Management of Hepatic Sarcoidosis.

BACKGROUND AND AIMS: Liver involvement in sarcoidosis may occur in up to 60% of all patients. As many patients experience only minor symptoms, a high number of undiagnosed cases must be assumed. In order to successfully identify patients with hepatic sarcoidosis, a throughout characterization of these patients and their course of disease is necessary. METHODS: We collected 40 patients from four German centers to evaluate current treatment standards and course of disease. All of our patients underwent liver biopsy with histologically proven granulomatous hepatitis. RESULTS: Detailed characterization of our patients showed an overall benign course of disease. Treatment was very diverse with glucocorticoids for 1 year in 55% (22/40), 5-10 years in 18% (7/40), and permanently in 18% (7/40). Other treatments included disease-modifying anti-rheumatic drugs (DMARDs), the conventional non-biological type in 53% of all patients (of these 81% received azathioprine, 46% metotrexate, 10% hydroxychloroquine, 10% mycophenolate mofetil and 10% cyclophosphamide and biologicals in 8%. Despite these very diverse treatments, patients generally showed slow progression of the disease. Two patients died. None of our patients received a liver transplantation. CONCLUSIONS: Patients received diverse treatments and generally showed slow progression of the disease. Based on our experience, we proposed a diagnostic work up and surveillance strategy as a basis for future, prospective register studies.

Autoimmune Hepatitis: a Review of Established and Evolving Treatments.

Autoimmune hepatitis (AIH) is a necroinflammatory liver disease commonly presenting with a fluctuating course of activity, presence of circulating autoantibodies, hyperglobulinemia of IgG, and/or response to immunosuppressive drugs. However, the disease displays a considerable heterogeneity. No single clinical or biochemical test may establish diagnosis of AIH. Thus, diagnosis still requires extensive clinical evaluation and experience. Prednisolone and azathioprine are considered standard treatment leading to remission in most patients. However, this standard treatment may not be effective in some patients or not be feasible due to one of these drugs. Over the past two decades additional immunosuppressant drugs for the treatment of AIH have been evaluated and have significantly extended the therapeutic spectrum. Among those novel drugs are mycophenolate mofetil, tacrolimus, everolimus, 6-mercaptopurine, infliximab, rituximab and several others. In this review we summarize the current standard of therapy but also efforts of providing novel therapeutic strategies to AIH patients.

Response of advanced HCC to pembrolizumab and lenvatinib combination therapy despite monotherapy failure.

In recent years, immune checkpoint inhibitors (ICIs) were successfully introduced to cancer therapy, and these drugs have already become essential for the treatment of various noncurable tumors. However, monotherapy in advanced hepatocellular carcinoma (aHCC) failed to show statistically significant improvement.Recently, the combination of atezolizumab and bevacizumab demonstrated efficacy of combining ICI and VEGF inhibition, further substantiating previous data on synergistic mechanisms among respective substance classes.As TKI treatment is currently standard of care for aHCC, and ICIs are approved by the FDA and available in many areas of the world, numerous patients may have been treated with monotherapy of those drugs. However, it remains unclear if failure to monotherapy has an impact on combination therapy. We therefore report a patient well responding to combination therapy despite previous failures to TKI and ICI monotherapy.

Pharmacological treatment of hepatocellular carcinoma with cavoatrial tumor thrombus - case series and literature review.

Hepatocellular carcinomas (HCC) that extend into the vena cava and the right atrium have a poor prognosis. Surgical approaches including partial hepatectomy and thrombectomy are the most frequently reported treatment options. However, most patients with advanced HCC are not eligible for complex surgical interventions due to reduced liver function, comorbidities, and metastases. At the same time, systemic treatment options of HCC have expanded in recent years. Here, we report 3 cases of patients with advanced HCC who developed a cavoatrial tumor thrombus (CATT) after initial surgical or interventional therapy. The patients were consequently treated with sorafenib or nivolumab. In all cases, the tumor responded to systemic treatment with disease stabilization or partial regression. Overall survival after diagnosis of CATT was 3 and 17 months for sorafenib and 7 + months for nivolumab. Compared to survival rates of alternative treatment options, systemic therapies demonstrated comparable outcomes. In summary, pharmacotherapy is an efficient and well worth option to treat patients with HCC and CATT and should be an integral part of a multimodal therapy concept.

Bariatric Surgery as an Efficient Treatment for Non-Alcoholic Fatty Liver Disease in a Prospective Study with 1-Year Follow-up : BariScan Study.

BACKGROUND: Bariatric surgery gains attention as a potential treatment for non-alcoholic fatty liver disease (NAFLD). The present study aimed to evaluate improvement of NAFLD after the two most common bariatric procedures with validated non-invasive instruments. MATERIAL AND METHODS: N = 100 patients scheduled for laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB) were included. NAFLD was evaluated preoperatively and postoperatively with liver stiffness measurement by transient elastography and laboratory-based fibrosis scores. Clinical data included body mass index (BMI), total weight loss (%TWL), excess weight loss (%EWL), age, gender, comorbidities, and the Edmonton obesity staging system (EOSS). RESULTS: There were significant improvements of BMI, %TWL, %EWL, and EOSS after bariatric surgery. Liver stiffness was significantly improved from pre- to postoperative (12.9 ± 10.4 vs. 7.1 ± 3.7 kPa, p < 0.001) at median follow-up of 12.5 months. Additionally, there were significant improvements of liver fibrosis scores (aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio 0.8 ± 0.3 vs. 1.1 ± 0.4, p < 0.001; NAFLD fibrosis score - 1.0 ± 1.8 vs. - 1.7 ± 1.3, p < 0.001; APRI score 0.3 ± 0.2 vs. 0.3 ± 0.1, p = 0.009; BARD score 2.3 ± 1.2 vs. 2.8 ± 1.1, p = 0.008) and laboratory parameters (ALT, AST, and GGT). After adjustment for baseline liver stiffness, RYGB showed higher improvements than LSG, and there was no gender difference. Improvement of liver stiffness was not correlated to improvement of BMI, %TWL, %EWL, or EOSS. CONCLUSIONS: NAFLD seems to be improved by bariatric surgery as measured by validated non-invasive instruments. Furthermore, it appears that RYGB is more effective than LSG. No correlation could be detected between NAFLD and weight loss. The present study highlights the potential of bariatric surgery for successful treatment of NAFLD. Further research is required to understand the exact mechanisms.

Rapid change of liver stiffness after variceal ligation and TIPS implantation.

Liver stiffness (LS) as measured by transient elastography is widely used to screen for liver fibrosis. However, LS also increases in response to pressure changes like congestion but no data on portal pressure are available. We study here the effect of rapid portal pressure changes on LS. Therefore, LS was assessed directly prior and after ligation of esophageal varices ( n = 11) as well as transjugular intrahepatic portosystemic shunt (TIPS) implantation in patients with established cirrhosis ( n = 14). Additionally, we retrospectively analyzed changes in LS and variceal size in patients with sequential gastroscopic monitoring and LS measurements ( n = 14). To study LS and portal pressure in healthy livers, LS (µFibroscan; Echosens, Paris, France) and invasive pressures (Powerlab, AD Instruments, New Zealand) were assessed in male Wistar rats after ligation of single liver lobes. Ligation of esophageal varices caused an immediate and significant increase of LS from 40.3 ± 19.0 to 56.1 ± 21.5 kPa. Likewise, LS decreased significantly from 53.1 ± 16.6 to 43.8 ± 17.3 kPa after TIPS placement, which correlated significantly with portal pressure ( r = 0.558). In the retrospective cohort, the significant LS decrease from 54.9 ± 23.5 to 47.9 ± 23.8 kPa over a mean observation interval of 4.3 ± 3 mo was significantly correlated with a concomitant increase of variceal size ( r = -0.605). In the animal model, LS and portal pressure increased significantly after single lobe ligation without changes of arterial or central venous pressure. In conclusion, rapid changes of portal pressure are a strong modulator of LS in healthy and cirrhotic organs. In patients with stable cirrhosis according to the model for end-stage liver disease (MELD), a decrease of LS may be indicative for enlarging varices. NEW & NOTEWORTHY Liver stiffness (LS) immediately increases after variceal ligation while it decreases after transjugular intrahepatic portosystemic shunt (TIPS) implantation due to portal pressure changes. LS and portal pressure rapidly increase after single lobe ligation in Wistar rats without changes of arterial or central venous pressure. Collateral formation may be one cause for a transient decrease in LS in the absence of other confounders. Such pressure changes should be considered when interpreting LS in clinical practice.

Human oxidation-specific antibodies reduce foam cell formation and atherosclerosis progression.

OBJECTIVES: We sought to assess the in vivo importance of scavenger receptor (SR)-mediated uptake of oxidized low-density lipoprotein (OxLDL) in atherogenesis and to test the efficacy of human antibody IK17-Fab or IK17 single-chain Fv fragment (IK17-scFv), which lacks immunologic properties of intact antibodies other than the ability to inhibit uptake of OxLDL by macrophages, to inhibit atherosclerosis. BACKGROUND: The unregulated uptake of OxLDL by macrophage SR contributes to foam cell formation, but the importance of this pathway in vivo is uncertain. METHODS: Cholesterol-fed low-density lipoprotein receptor knockout (LDLR(-/-)) mice were treated with intraperitoneal infusion of human IK17-Fab (2.5 mg/kg) 3 times per week for 14 weeks. Because anti-human antibodies developed in these mice, LDLR(-/-)/low-density lipoprotein receptor Rag 1 double-knockout mice (lacking the ability to make immunoglobulins due to loss of T- and B-cell function) were treated with an adenoviral vector encoding adenovirus expressed (Adv)-IK17-scFv or control adenovirus-enhanced green fluorescent protein vector intravenously every 2 weeks for 16 weeks. RESULTS: In LDLR(-/-) mice, infusion of IK17-Fab was able to sustain IK17 plasma levels for the first 8 weeks, but these diminished afterward due to increasing murine anti-IK17 antibody titers. Despite this, after 14 weeks, a 29% decrease in en face atherosclerosis was noted compared with phosphate-buffered saline-treated mice. In LDLR(-/-)/low-density lipoprotein receptor Rag 1 double-knockout mice, sustained levels of plasma IK17-scFv was achieved by Adv-IK17-scFv-mediated hepatic expression, which led to a 46% reduction (p < 0.001) in en face atherosclerosis compared with adenovirus-enhanced green fluorescent protein vector. Importantly, peritoneal macrophages isolated from Adv-IK17-scFv treated mice had decreased lipid accumulation compared with adenovirus-enhanced green fluorescent protein-treated mice. CONCLUSIONS: These data support an important role for SR-mediated uptake of OxLDL in the pathogenesis of atherosclerosis and demonstrate that oxidation-specific antibodies reduce the progression of atherosclerosis, suggesting their potential in treating cardiovascular disease in humans.

Eosinophilic meningitis due to Angiostrongylus cantonensis in Germany.

We report a case of eosinophilic meningitis due to Angiostrongylus cantonensis in a patient who returned from Thailand. The presence of a compatible epidemiologic history and eosinophilia in cerebrospinal fluid (CSF) lead to the diagnosis, which was confirmed by detection of specific antibodies. After treatment with albendazole and corticosteroids he recovered completely.

Neurocysticercosis with a single brain lesion in Germany: a case report.

Neurocysticercosis is rare in Western Europe and a high degree of physician awareness is necessary for diagnosis. We describe a case of Neurocysticercosis with a single brain lesion acquired in Germany in which only surgical removal and subsequent histological examination allowed diagnosis whereas diagnostic investigation yielded no pathological findings.