Questionnaire PLD-complaint-specific assessment identifies need for therapy in polycystic liver disease: A multi-centric prospective study.

BACKGROUND AND AIMS: Polycystic liver disease (PLD) can lead to extensive hepatomegaly. Symptom relief is the primary goal of the treatment. The role of the recently developed disease-specific questionnaires for identification of the thresholds and the assessment of therapy needs further investigation. METHODS: A five-year prospective multi-centric observational study in 21 hospitals in Belgium gathered a study population of 198 symptomatic PLD-patients of whom the disease-specific symptom questionnaire PLD-complaint-specific assessment (POLCA) scores were calculated. The thresholds of the POLCA score for the need for volume reduction therapy were analyzed. RESULTS: The study group consisted of mostly (82.8%) women with baseline mean age of 54.4 years ±11.2, median liver volume expressed as height-adjusted total liver volume(htLV) of 1994 mL (interquartile range [IQR] 1275; 3150) and median growth of the liver of +74 mL/year (IQR +3; +230). Volume reduction therapy was needed in 71 patients (35.9%). A POLCA severity score (SPI) ≥ 14 predicted the need for therapy both in the derivation (n = 63) and the validation cohort (n = 126). The thresholds to start somatostatin analogues (n = 55) or to consider liver transplantation (n = 18) were SPI scores of ≥14 and ≥ 18 and the corresponding mean htLVs were 2902 mL (IQR 1908; 3964) and 3607 mL (IQR 2901; 4337), respectively. Somatostatin analogues treatment resulted in a decrease in the SPI score -6.0 versus + 4.5 in patients without somatostatin analogues (p < 0.01). Changes in the SPI score were significantly different between the liver transplantation group and no liver transplantation group, +4.3 ± 7.1 versus -1.6 ± 4.9, respectively, (p < 0.01). CONCLUSION: A polycystic liver disease-specific questionnaire can be used as a guide on when to start a volume reduction therapy and to assess the effect of treatment.

Caucasian Ethnicity, but Not Treatment Cessation is Associated with HBsAg Loss Following Nucleos(t)ide Analogue-Induced HBeAg Seroconversion.

It is well appreciated that ethnicity influences the natural history and immune responses during a chronic hepatitis B infection. In this study, we explore the effect of ethnicity and treatment cessation on Hepatitis B surface Antigen (HBsAg) seroclearance in patients with Nucleos(t)ide Analogue (NA)-induced Hepatitis B e Antigen (HBeAg) seroconversion. We performed a multi-ethnic, multicentric observational cohort study. The analyzed cohort consisted of 178 mono-infected, predominantly male (75.3%) chronic hepatitis B patients of mixed ethnicity (44.4% Asians, 48.9% Caucasians) with nucleos(t)ide analogue-induced HBeAg seroconversion. Treatment was withdrawn in 105 patients and continued in 73, leading to HBsAg loss in 14 patients off- and 16 patients on-treatment, respectively. Overall, HBsAg loss rates were not affected by treatment cessation (hazard ratio 1.45, p = 0.372), regardless of consolidation treatment duration. Caucasian ethnicity was associated with an increased chance of HBsAg loss (hazard ratio 6.70, p = 0.001), but hepatitis B virus genotype was not (p = 0.812). In conclusion, ethnicity is the most important determinant for HBsAg loss after NA-induced HBeAg seroconversion, with up to six-fold higher HBsAg loss rates in Caucasians compared to Asians, irrespective of treatment cessation and consolidation treatment duration.

Protein tolerance to standard and high protein meals in patients with liver cirrhosis.

AIM: To investigate the plasma amino acid response and tolerance to normal or high protein meals in patients with cirrhosis. METHODS: The plasma amino acid response to a 20 g mixed protein meal was compared in 8 biopsy-proven compensated cirrhotic patients and 6 healthy subjects. In addition the response to a high protein meal (1 g/kg body weight) was studied in 6 decompensated biopsy-proven cirrhotics in order to evaluate their protein tolerance and the likelihood of developing hepatic encephalopathy (HE) following a porto-caval shunt procedure. To test for covert HE, the "number connection test" (NCT) was done on all patients, and an electroencephalogram was recorded in patients considered to be at Child-Pugh C stage. RESULTS: The changes in plasma amino acids after a 20 g protein meal were similar in healthy subjects and in cirrhotics except for a significantly greater increase (P < 0.05) in isoleucine, leucine and tyrosine concentrations in the cirrhotics. The baseline branched chain amino acids/aromatic amino acids (BCAA/AAA) ratio was higher in the healthy persons and remained stable-but it decreased significantly after the meal in the cirrhotic group. After the high protein meal there was a marked increase in the levels of most amino acids, but only small changes occurred in the levels of taurine, citrulline, cysteine and histidine.The BCAA/AAA ratio was significantly higher 180 and 240 min after the meal. Slightly elevated basal plasma ammonia levels showed no particular pattern. Overt HE was not observed in any patients. CONCLUSION: Patients with stable liver disease tolerate natural mixed meals with a standard protein content. The response to a high protein meal in decompensated cirrhotics suggests accumulation of some amino acids but it did not precipitate HE. These results support current nutritional guidelines that recommend a protein intake of 1.2-1.5 g/kg body weight/day for patients with cirrhosis.

Spontaneous dissection of the celiac trunk: a rare cause of abdominal pain--case report and review of the literature.

Spontaneous dissection of the celiac trunk is uncommon and rarely considered in patients presenting with acute onset of epigastric pain. We report the case of a 48-year old male, diagnosed with a spontaneous dissection of the celiac trunk extending towards the common hepatic artery. He was treated conservatively and remained asymptomatic after two years of follow-up. Conservative treatment seems justified in the absence of bowel ischemia or signs of hemorrhage. Initial Computed Tomography angiography revealed the presence of a dissection with a pseudoaneurysm that remained stable and regressed towards a normal Computed Tomography angiography after 7 months of follow-up. Radiologic follow-up is warranted as progression of the dissection and/or total occlusion with or without symptoms can occur. The risk factors, the natural course and optimal treatment remain unclear due to the rarity of the disorder. Our patient had no predisposing cardiovascular risk factors. Nevertheless, we observed a hypertrophic ligamentum arcuatum on Computed Tomography, possibly facilitating the evolution towards a dissection. Next to the case report, we provide a review of the available literature.

Hepatitis B virus and hepatitis C virus infections in Belgium: similarities and differences in epidemics and initial management.

INTRODUCTION: Nationwide studies comparing patients with hepatitis B and C virus (HBV and HCV) infections are mandatory for assessing changes in epidemiology. AIM: The aim of this study was to compare epidemiological data and initial management of newly diagnosed patients with persistent HBV (HBsAg positive) or HCV (detectable HCV RNA) infection in Belgium. PATIENTS AND METHODS: Data were extracted from two Belgian observational databases. RESULTS: A total of 655 patients (387 HBV and 268 HCV) were included. Compared with HCV patients, HBV patients were younger, more frequently men, more often of Asian or African origin (43 vs. 10%, P<0.0001), and less frequently contaminated by transfusion or intravenous drug use (9 and 6% vs. 34 and 44%, P<0.0001). Viral replication was assessed in 89% of HBV patients. Compared with HCV patients, HBV patients more frequently had normal alanine aminotransferase (ALT) levels (65 vs. 29%, P<0.0001), less frequently underwent liver biopsy (29 vs. 67%, P<0.0001), and were less often considered for antiviral therapy (25 vs. 54%, P<0.0001). When taking only HBV patients with detectable viral replication into consideration, results remained unchanged. During the multivariate analysis, ALT was a major factor for performing liver biopsy or considering antiviral therapy in both groups. CONCLUSION: HBV and HCV screening policies should be targeted toward immigrants and intravenous drug users, respectively. Guidelines recommending systematic search for viral replication should be reinforced in HBV patients. HBV patients less frequently underwent liver biopsy and were less often considered for antiviral therapy compared with HCV patients. Despite the lack of sensitivity and specificity, ALT remains a pivotal decision-making tool for liver biopsy and antiviral therapy in both infections.

HBV infection in Belgium: results of the BASL observatory of 1,456 HBsAg carriers.

INTRODUCTION: Nationwide studies are mandatory to assess changes in the epidemiology of HBV infection in Europe. AIM: To describe epidemiological characteristics of HBsAg-positive patients, especially inactive carriers, and to evaluate how practitioners manage HBV patients in real life. METHODS: Belgian physicians were asked to report all chronically infected HBV patients during a one-year period. RESULTS: Among 1,456 patients included, 1,035 (71%) were classified into one of four phases of chronic infection: immune tolerance (n = 10), HBeAg-positive hepatitis (n = 248), HBeAg-negative hepatitis (n = 420) and inactive carrier state (n = 357 HBeAg-negative patients with ALT

A pilot study of therapeutic vaccination with envelope protein E1 in 35 patients with chronic hepatitis C.

New treatments are needed for chronic hepatitis C patients in whom viral clearance cannot be achieved. Thirty-five chronic hepatitis C patients (genotype 1) were randomized to receive 20 mug of recombinant HCV E1 (E1) (n = 26) or placebo (n = 9) intramuscularly at weeks 0, 4, 8, 12, and 24. Thirty-four then received open-label E1 vaccine at weeks 50, 53, 56, 59, 62, and 65. Twenty-four patients (12 men, 12 women; mean age, 52 y; 18 interferon-based treatment failures; mean baseline alanine aminotransferase [ALT] level, 118 IU/L) underwent a biopsy before and after 2 courses of E1, 17 months later. Liver histology was scored by 2 blinded pathologists according to the Ishak and Metavir systems. Postinjection reactions were similar to placebo (alum only). Nine of 24 patients (38%) had improvement of 2 points or more, 10 (41%) remained stable, and 5 (21%) showed worsening in total Ishak score. Nine patients (38%) improved both on Ishak and Metavir fibrosis scores. Plasma HCV-RNA levels remained unchanged, whereas ALT levels showed a trend toward a decrease during treatment. All but 3 patients developed a significant de novo E1-specific T-cell response. The increase in anti-E1 antibody levels correlated with the decrease in total Ishak score and with the relative decreases in both Ishak fibrosis score and ALT level (all P < or =.01). In conclusion, E1 therapeutic vaccination is well tolerated and the observed effects warrant further study.

The BCAA/AAA ratio of plasma amino acids in three different groups of cirrhotics

Con el objeto de investigar las diferencias en el perfil de aminoácidos en plasma y reevaluar el uso de la razón AACR/AAA (aminoácidos de cadena ramificada/aminoácidos aromáticos) (valina+isoleucina+leucina/fenilalanina+tirosina) para la valoración del grado de deterioro hepático, se estudió la concentración de aminoácidos plasmáticos en tres grupos de pacientes cirróticos: cirróticos compensados (estables), cirróticos descompensados y cirróticos con encefalopatía portosistémica (EPS) agudo, comparados con un grupo de sujetos normales (control). Los cirróticos estables mostraron concentraciones de aminoácidos similares al grupo control; la razón AACR/AAA en los cirróticos estables (2.9 +- 0.2) fue significativamente menor que en el grupo control (3.9+-0.3) (p<0.05). Los cirróticos descompensados mostraron diferencias en los aminoácidos plasmáticos y la razón AACR/AAA (1.7+-0.3) fue significativamente menor comparados con los cirróticos estables y con el grupo control, respectivamente (p<0.005 y p<0.01). Los pacientes con EPS aguda mostraron una elevación externa en la mayoría de los aminoácidos comparados con los otros grupos y la razón AARC/AAA (0.8+-0.07)fue la menor de los cuatro grupos (p<0.001 comparado con el grupo control). Se concluye que es posible detectar diferencias en las concentraciones de aminoácidos plasmáticos en diferentes grupos de cirróticios con diferentes grados de daño hepático y que la razón AACR/AAA es un índice útil en la valoración del grado de deterioro en la función hepática. Se propone el uso de este índice en el seguimiento de pacientes cirróticos seleccionados, tales como aquellos pacientes candidatos a cirugía mayor y trasplante hepático en quienes se podría utilizar este índice para precisar el momento más apropiado para el trasplante.