[First data concerning the medical supply of patients with non-alcoholic fatty liver disease in Germany - a survey in university hospital centers of hepatology]. / Erste Daten zur Versorgungssituation von Patienten mit nicht alkoholischer Fettlebererkrankung (NAFLD) in Deutschland - Eine Umfrage an universitären hepatologischen Zentren.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) currently is one oft the most common reasons for chronic liver injury in the western world. In the European and American population the prevalence is up to 30 %. The medical supply of German patients with NAFLD is variable and has not been analyzed to date. METHODS: We sent questionnaires to all university liver centers in Germany (11 questions) concerning the medical supply of patients with NAFLD. Questions included the rate of patients with fatty liver disease in the outpatient clinics, metabolic comorbidities and the kind of assignment. Besides that, individual clinical standards were documented. We compared longitudinal changes between 2008 and 2013. RESULTS: The return rate of questionnaires was 65 % (n = 20). Analysis showed that the portion of NAFLD patients in the university outpatient clinics had increased between 2008 and 2013 with the predominant part of patients being assigned from external practitioners and not from internal departments of the hospital. Only few patients were assigned by diabetologists or endocrinologists, but on the other hand most liver outpatient clinics investigated their NAFLD patients for metabolic disorders. Cooperation between liver outpatient clinics and other medical services was moderate and was rated average, joint conferences were held rarely. Follow-up visits of patients with NAFLD take place regularly in all centers, however based on different criterions. A consistent algorithm concerning risk assessment and invasive workup does not exist. CONCLUSION: The awareness concerning patients with NAFLD seems to have grown in recent years. Nevertheless, the medical supply of these patients is quite heterogenous and consistent standards do not exist. Therefore, a common guidline is urgently required.

[Actors in liver transplantation advocate greater transparency and systematic evaluations of transplant centres]. / Akteure der Lebertransplantation befürworten größere Transparenz und systematische Evaluationen der Transplantationszentren.

BACKGROUND: Following the introduction of the MELD score, the survival rates have worsened after liver transplantation (LTX) in Germany. Existing organ shortages, shorter survival rates after LTX, and failures in the liver allocation process provide true challenges. Facilitated by a structured questionnaire, the appropriate German liver transplantation actors were approached with regard to these challenges for the first time. The aim was to provide a balanced experts' view in an anonymous fashion thereby identifying areas for potential improvement. METHOD: Data collection was performed by a structured, standardised, anonymous survey of all LTX centres in Germany. RESULTS: We received 75 % replies of the questionnaires, 35 of 36 participants responded to more than 75 % of all questions. The following key points were highlighted. A minimum amount of LTX per centre was deemed important and monetary incentives must not exist. The ultimate goal of LTX is a prolongation of life and social as well as occupational reintegration. Quality management and transparent LTX registers are prerequisites for both adequate organ allocation and distribution of resources in order to achieve the best possible transplant outcomes. CONCLUSION: The German liver transplant experts consider transparency of organ allocation and systematic evaluation of the quality of transplant centres and the transplantation process itself to be mandatory, however, executed in a participatory way. A scoring system to facilitate the decision making process in order to predict the likelihood of satisfactory LTX outcome thereby circumventing some of the ethical and constitutional doubts would be highly appreciated.

[NASH (non-alcoholic steatohepatitis): fatty liver or fatal liver disease?]. / NASH (nicht alkoholische Steatohepatitis): Fettleber oder fatale Lebererkrankung?

INTRODUCTION: Non-alcoholic steatohepatitis (NASH) was first described in 1980 and has emerged from an anecdotal disease to a widely distributed liver disease in the current decade. METHODS: This review is based on publications in PubMed and our own experiences and deals with basic pathophysiological aspects, diagnostic, and therapeutic tools as well as with the modern management of this serious liver disease. RESULTS: For a long time the potenial for serious liver destruction and enhanced liver mortality by NASH has been observed. The recognition of the metabolic origin of NASH has contributed to diagnostic as well as therapeutic approaches. Since then patients with metabolic syndrome are often screened for liver disease. NASH might worsen other chronic liver diseases but should be judged as an independent illness rather than the exclusion of other potential liver diseases. Furthermore, non-alcoholic steatohepatitis has systemic consequences concerning insulin resistance, metabolic complications and cardiovascular diseases. PERSPECTIVES: Future research should concentrate on non-invasive screening strategies, identification of risk factors, evaluation of hepatocellular carcinogenesis and new therapeutic targets.

[Hepatocellular carcinoma - current aspects of screening, surveillance and therapeutic strategies (revised EASL-EORTC recommendations)]. / Hepatozelluläres Karzinom - Aktuelles zu Screening, Surveillance und Therapiestrategien (aktualisierte EASL-EORTC-Empfehlungen).

With an incidence of 523 000 new cases a year hepatocellular carcinomas (HCCs) belong to the most frequent cancer entities worldwide. Diagnostic and therapeutic procederes have been improved during the last years. Surveillance of patients with high risk factors leads to an early diagnosis. Up to now the detection of early HCCs represents the best prerequisite for any curative therapy. The present synopsis summarises the current guidelines of the European Association for the Study of the Liver (EASL) and the European Organisation for Research and Treatment of Cancer (EORTC) with a special focus on screening and surveillance of risk groups.

[A 75-year-old female patient with pleural effusion and gastric metastases of a poorly differentiated carcinoma]. / 75-jährige Patientin mit Pleuraerguss und gastralen Metastasen eines wenig differenzierten Karzinoms.

A 75-year-old woman was found to have left-sided pleural effusion and endoscopy revealed the rare entity of adenoid cystic carcinoma metastases in the gastric mucosa. Approximately 20% of patients with this carcinoma suffer from distant metastases. For the initial staging detection of adenoid cystic carcinoma metastasis with positron emission tomography (PET) or PET computed tomography (CT) is recommended. The recurrent t(6;9)(q22-23;p23-24) translocation that results in a fusion of the two transcription factor genes MYB and NFIB is detectable in half of the cases. As in our case molecular pathology can confirm the correct diagnosis and identification of the localization of the primary tumor.

Profile of gastrointestinal involvement in patients with systemic sclerosis.

Systemic sclerosis (SSc) is a chronic autoimmune connective tissue disease. Of the numerous organ manifestations, involvement of the upper and lower gastrointestinal tract (GIT) appears to be the most frequent with regard to the clinical symptoms. However, as the frequency and clinical relevance of GI involvement in patients with SSc are not known in detail, the German network of the systemic sclerosis (DNSS) has developed a detailed questionnaire to evaluate the extent and profile of gastrointestinal involvement in SSc patients. The multi-symptom questionnaire was used at baseline and after 1 year in registered patients of the DNSS. In addition, the results were compared with gastrointestinal disorders in patients with SSc and other rheumatic diseases, as well as with the medical history of the patients. In total, 90 patients were included in the study. The results of the study show that in reality, a much higher (nearly all) percentage of (98,9%) patients than expected suffer from GI-symptoms, regardless of the stage of their disease. Of these, meteorism (87,8%) was the most common followed by coughing/sore voice (77,8%), heartburn (daytime 68,9%, nighttime 53,3%), diarrhea (67,8%), stomach ache (68,9%) and nausea (61,1%). Although SSc patients were treated according to the respective recommendations, only limited improvements with regard to GI-symptoms could be achieved after 1 year of follow-up. In addition, the study revealed that the multi-symptom questionnaire is a useful tool to contribute to identify the gastrointestinal sequelae in systemic sclerosis.

[Matrix metalloproteinases in inflammatory bowel disease - from basic research to clinical significance]. / Matrix-Metalloproteinasen bei chronisch-entzündlichen Darmerkrankungen - von der Grundlagenforschung zur klinischen Bedeutung.

Matrix Metalloproteinases (MMPs) are a family of Zn (2 +)-dependent endopeptidases that are considered to be the most potent proteases in the turnover of the extracellular matrix (ECM). In addition to their capability for degradating virtually all protein components of the ECM, MMPs regulate a variety of non-matrix substrates such as chemokines, cytokines and growth factors. Therefore MMPs play a central role in a variety of physiological and pathological processes such as angiogenesis, wound healing and inflammatory response including mucosal inflammation associated with inflammatory bowel disease (IBD). Apart from mucosal destruction in IBD, recent studies have identified several new functions of MMPs for the pathophysiology of the healthy and inflamed intestine. This article summarises the main activities of MMPs in IBD with emphasis on their pathophysiological relevance and potential clinical implications based on the expression and regulation patterns of these enzymes.

MMP-9-hemopexin domain hampers adhesion and migration of colorectal cancer cells.

Matrix metalloproteinases (MMPs), in particular MMP-2 and MMP-9, are involved in colon cancer progression and metastasis due to their ability to degrade extracellular matrix (ECM) components. In previous studies we described the MMP-9 hemopexin like domain (MMP-9-PEX) as an MMP-9 antagonist. In the present study it was examined whether recombinant MMP-9-PEX has an inhibitory effect on migration and adhesion of colorectal carcinoma cells. Furthermore, we searched for MMP-9 substrate binding sites within the MMP-9-PEX by surface plasmon resonance. Migration of SW620 and LS174 cells was investigated in a modified Boyden chamber assay. In the presence of 0.2 microg/ml MMP-9-PEX migration of SW620 was decreased by 34%, while addition of 0.4 microg/ml diminished migration by 56%. Migration of LS174 cells was not affected by MMP-9-PEX. Adhesion studies were performed on 96-well plates coated with gelatin, collagen type I, and laminin, respectively. In the presence of MMP-9-PEX, adhesion of SW620 cells to these coating substrates was significantly inhibited. Surface plasmon resonance studies revealed binding of collagen type I and IV, elastin, and fibrinogen to proMMP-9 as well as to MMP-9-PEX. However, equilibrium constants (Kd) indicated a higher affinity of proMMP-9 to the matrix proteins. This could indicate that there is more than one binding site for matrix components within the entire proMMP-9 molecule. Since migration and adhesion of metastatic colorectal carcinoma cells were reduced by MMP-9-PEX, this recombinant MMP-9 antagonist might be of therapeutical interest.

Mechanisms of fibrinolysis in chronic liver injury (with special emphasis on MMPs and TIMPs).

Regeneration from liver fibrosis is characterized by four essential events: 1. eradication of pathological agents, 2. apoptosis of activated hepatic stellate cells, 3. remodeling of extracellular matrix, and 4. regeneration of parenchyma and liver function. The temporal and spatial regulation of matrix metalloproteinase (MMP) activity and expression of their specific inhibitors, the tissue inhibitors of metalloproteinases (TIMPs), play a pivotal role in matrix remodeling during hepatic fibrogenesis and recovery. According to current knowledge, the main topics and mechanisms in regeneration from hepatic fibrosis with special emphasis on MMPs and TIMPs are presented. MMP and TIMP expression patterns during hepatic fibrogenesis and fibrolysis, specific characteristics like regulation, expression of cell types, gene expression (RNA/protein), and the underlying disease are summarized. Studies presenting a time course for MMP and TIMP expression during recovery from hepatic fibrosis were taken into consideration to point out a synchronizing behavior in the expression pattern.