Coleman I. Smith

Sources of fatty acids stored in liver and secreted via lipoproteins in patients with nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is characterized by the accumulation of excess liver triacylglycerol (TAG), inflammation, and liver damage. The goal of the present study was to directly quantify the biological sources of hepatic and plasma lipoprotein TAG in NAFLD. Patients (5 male and 4 female; 44 +/- 10 years of age) scheduled for a medically indicated liver biopsy were infused with and orally fed stable isotopes for 4 days to label and track serum nonesterified fatty acids (NEFAs), dietary fatty acids, and those derived from the de novo lipogenesis (DNL) pathway, present in liver tissue and lipoprotein TAG. Hepatic and lipoprotein TAG fatty acids were analyzed by gas chromatography/mass spectrometry. NAFLD patients were obese, with fasting hypertriglyceridemia and hyperinsulinemia. Of the TAG accounted for in liver, 59.0% +/- 9.9% of TAG arose from NEFAs; 26.1% +/- 6.7%, from DNL; and 14.9% +/- 7.0%, from the diet. The pattern of labeling in VLDL was similar to that in liver, and throughout the 4 days of labeling, the liver demonstrated reciprocal use of adipose and dietary fatty acids. DNL was elevated in the fasting state and demonstrated no diurnal variation. These quantitative metabolic data document that both elevated peripheral fatty acids and DNL contribute to the accumulation of hepatic and lipoprotein fat in NAFLD.

Effectiveness of Simeprevir Plus Sofosbuvir, with or Without Ribavirin, in Real-World Patients with HCV Genotype 1 Infection

BACKGROUND & AIMS The interferon-free regimen of simeprevir plus sofosbuvir was recommended by professional guidelines for certain patients with hepatitis C virus (HCV) genotype 1 infection based on the findings of a phase 2 trial. We aimed to evaluate the safety and efficacy of this regimen in clinical practice settings in North America. METHODS We collected demographic, clinical, and virologic data, as well as reports of adverse outcomes, from sequential participants in HCV-TARGET--a prospective observational cohort study of patients undergoing HCV treatment in routine clinical care settings. From January through October 2014, there were 836 patients with HCV genotype 1 infection who began 12 weeks of treatment with simeprevir plus sofosbuvir (treatment duration of up to 16 weeks); 169 of these patients received ribavirin. Most patients were male (61%), Caucasian (76%), or black (13%); 59% had cirrhosis. Most patients had failed prior treatment with peginterferon and ribavirin without (46%) or with telaprevir or boceprevir (12%). The primary outcome was sustained virologic response (SVR), defined as the level of HCV RNA below quantification at least 64 days after the end of treatment (beginning of week 12 after treatment--a 2-week window). Logistic regression models with inverse probability weights were constructed to adjust for baseline covariates and potential selection bias. RESULTS The overall SVR rate was 84% (675 of 802 patients, 95% confidence interval, 81%-87%). Model-adjusted estimates indicate patients with cirrhosis, prior decompensation, and previous protease inhibitor treatments were less likely to achieve an SVR. The addition of ribavirin had no detectable effects on SVR. The most common adverse events were fatigue, headache, nausea, rash, and insomnia. Serious adverse events and treatment discontinuation occurred in only 5% and 3% of participants, respectively. CONCLUSIONS In a large prospective observational cohort study, a 12-week regimen of simeprevir plus sofosbuvir was associated with high rates of SVR and infrequent treatment discontinuation. ClinicalTrials.gov: NCT01474811.

Comparison of three doses of ursodeoxycholic acid in the treatment of primary biliary cirrhosis: a randomized trial

BACKGROUND/AIM Ursodeoxycholic acid in doses of 13-15 mg x kg(-1) x day(-1), is a safe and cost-effective treatment for patients with primary biliary cirrhosis. However, very limited information exists regarding the most appropriate dose of ursodeoxycholic acid. The aim of the study was to compare three dosages of ursodeoxycholic acid with respect to changes in liver biochemistries, Mayo risk score, biliary enrichment with ursodeoxycholic acid and side effects over at least a 1-year period. METHODS A total of 155 patients were randomized to receive low- (5-7 mg x kg(-1) x day(-1)), standard-(13-15 mg x kg(-1) x day(-1)), and high- (23-25 mg x kg(-1) x day(-1)) doses of ursodeoxycholic acid. RESULTS The improvements in alkaline phosphatase (p = 0.0001), aspartate aminotransferase (p = 0.0001), Mayo risk score (p = 0.002), and ursodeoxycholic acid enrichment (p = 0.0001) were significantly greater in the standard- and high-dose groups compared to the low-dose group, but not between the standard- and high-dose groups. Changes in serum bilirubin were similar between the three groups (p = 0.07). No significant effects on symptoms were noted with any dose. No patients discontinued ursodeoxycholic acid because of side effects or toxicity. CONCLUSIONS Ursodeoxycholic acid in doses of 5-25 mg x kg(-1) x day(-1) is safe and well tolerated. The dose of 13-15 mg x kg(-1) x day(-1) appears to be the preferred dose for patients with primary biliary cirrhosis.

Hepatitis B Virus–Specific and Global T-Cell Dysfunction in Chronic Hepatitis B

BACKGROUND & AIMS T cells play a critical role in viral infection. We examined whether T-cell effector and regulatory responses can define clinical stages of chronic hepatitis B (CHB). METHODS We enrolled 200 adults with CHB who participated in the National Institutes of Health-supported Hepatitis B Research Network from 2011 through 2013 and 20 uninfected individuals (controls). Peripheral blood lymphocytes from these subjects were analyzed for T-cell responses (proliferation and production of interferon gamma and interleukin 10) to overlapping hepatitis B virus (HBV) peptides (preS, S, preC, core, and reverse transcriptase), influenza matrix peptides, and lipopolysaccharide. T-cell expression of regulatory markers FOXP3, programmed death-1, and cytotoxic T lymphocyte-associated antigen-4 was examined by flow cytometry. Immune measures were compared with clinical parameters, including physician-defined immune-active, immune-tolerant, or inactive CHB phenotypes, in a blinded fashion. RESULTS Compared with controls, patients with CHB had weak T-cell proliferative, interferon gamma, and interleukin 10 responses to HBV, with increased frequency of circulating FOXP3(+)CD127(-) regulatory T cells and CD4(+) T-cell expression of programmed death-1 and cytotoxic T lymphocyte-associated antigen-4. T-cell measures did not clearly distinguish between clinical CHB phenotypes, although the HBV core-specific T-cell response was weaker in hepatitis B e antigen (HBeAg)(+) than HBeAg(-) patients (percent responders: 3% vs 23%; P = .00008). Although in vitro blockade of programmed death-1 or cytotoxic T lymphocyte-associated antigen-4 increased T-cell responses to HBV, the effect was weaker in HBeAg(+) than HBeAg(-) patients. Furthermore, T-cell responses to influenza and lipopolysaccharide were weaker in CHB patients than controls. CONCLUSIONS HBV persists with virus-specific and global T-cell dysfunction mediated by multiple regulatory mechanisms, including circulating HBeAg, but without distinct T-cell-based immune signatures for clinical phenotypes. These findings suggest additional T-cell-independent or regulatory mechanisms of CHB pathogenesis that warrant further investigation.

Sofosbuvir plus ledispasvir for recurrent hepatitis C in liver transplant recipients.

Hepatitis C virus (HCV) recurrence after liver transplantation (LT) is associated with worse outcomes. The combination of ledipasvir (LDV) and sofosbuvir (SOF) has been approved for HCV treatment after LT, but there are limited data on the effectiveness and safety of LDV/SOF in the “real‐world” setting. This multicenter study is the largest report to date on the effectiveness and safety of LDV/SOF in the post‐LT setting. A total of 204 patients (72% male, 68% Caucasian, 66% genotype [GT] 1a, 21% METAVIR F3‐F4, 49% treatment‐experienced) were treated with LDV/SOF. The mean duration from LT to treatment initiation was 4.8 years. The overall sustained virological response rate 12 weeks after completion of therapy (SVR12) was 96%. Patients treated with 8 or 12 weeks of LDV/SOF without RBV experienced an SVR12 rate of 100% and 96%, respectively. Calcineurin inhibitors were used in 89% of patients, and 32% of patients underwent adjustment in immunosuppression during treatment. One episode of mild rejection, responsive to an increase in immunosuppression dosage, was observed. There was no graft loss attributed to HCV treatment. Four deaths occurred unrelated to HCV treatment, and no significant serious adverse events were documented. In conclusion, SOF and LDV with or without RBV for 8, 12, or 24 weeks in post‐LT patients was effective and safe with a high SVR12 rate across a spectrum of GTs and stages of fibrosis. Liver Transplantation 22 1536–1543 2016 AASLD.

Diabetes and prediabetes in patients with hepatitis B residing in North America

Diabetes is associated with liver disease progression and increased hepatocellular carcinoma risk, but factors associated with diabetes in patients with chronic hepatitis B virus (HBV) infection in North America are unknown. We aimed to determine factors predictive of diabetes and impaired fasting glucose (IFG) in a large HBV‐infected multiethnic cohort. Adults with chronic HBV not receiving antiviral therapy were enrolled from 21 centers in North America. Diabetes was defined by history/medication use or fasting glucose ≥126 mg/dL and IFG as fasting glucose 100‐125 mg/dL. Of 882 patients included, 47.2% were female, 71.3% Asian, 83.7% foreign born, median age was 44 years, and median body mass index BMI 24.3 kg/m2. In this cohort, 26.0% were hepatitis B envelope antigen (HBeAg) positive, 43.9% had HBV DNA ≥20,000 IU/mL, and 26.7% alanine aminotransferase (ALT) ≥2× upper limit of normal (≥40 U/L women, ≥60 U/L men). Overall, 12.5% had diabetes and 7.8% IFG. The combined prevalence of diabetes or IFG was highest among blacks (36.7%) and those either born in the United States/Canada or foreign born with migration >20 years ago (25.5%). Obesity (odds ratio [OR]: 2.13), hyperlipidemia (OR, 4.13), hypertension (OR, 3.67), high ALT level (OR, 1.86), and family history of diabetes (OR, 3.43) were associated with diabetes. Factors associated with IFG were obesity (OR, 4.13) and hypertension (OR, 3.27), but also HBeAg positivity (OR, 0.39). Recent migration was negatively associated with diabetes among non‐Asians (OR, 0.30). Conclusions: Diabetes is more prevalent in HBV‐infected North American adults than the general population and is associated with known metabolic risk factors and liver damage, as determined by ALT levels. Among the foreign born, longer duration of North America residence predicted diabetes risk in non‐Asians. These results highlight the opportunities for interventions to prevent diabetes especially among at‐risk ethnic groups with HBV. (Hepatology 2015;62:1364–1374)

Ledipasvir/sofosbuvir is effective and well tolerated in postkidney transplant patients with chronic hepatitis C virus

Patients with end‐stage renal diseases on hemodialysis have a high prevalence of hepatitis C infection (HCV). In most patients, treatment for HCV is delayed until postrenal transplant. We assessed the effectiveness and tolerance of ledipasvir/sofosbuvir (LDV/SOF) in 32 postkidney transplant patients infected with HCV. The group was composed predominantly of treatment‐naïve (75%) African American (68.75%) males (75%) infected with genotype 1a (62.5%). Most patients received a deceased donor kidney graft (78.1%). A 96% sustained viral response (SVR) was reported (27/28 patients). One patient relapsed. One patient with baseline graft dysfunction developed borderline rejection. No graft loss was reported. Six HIV‐coinfected patients were included in our analysis. Five of these patients achieved SVR 12. There were four deaths, and one of the deaths was in the HIV group. None of the deaths were attributed to therapy. Coinfected patients tolerated therapy well with no serious adverse events. Serum creatinine remained stable at baseline, end of therapy, and last follow‐up, (1.351±.50 mg/dL; 1.406±.63 mg/dL; 1.290±.39 mg/dL, respectively). In postkidney transplant patients with HCV infection with or without coinfection with HIV, a combination of LDV/SOF was well tolerated and effective.

NS5A: A new target for antiviral drugs in the treatment of hepatitis C virus infection

H epatitis C virus (HCV) is a major cause of liver disease and mortality affecting 170 million people worldwide. Chronic infection with HCV can lead to liver fibrosis, cirrhosis, and hepatocellular carcinoma and is the most common reason for liver transplantation in the United States. HCV is an enveloped single-strand RNA virus that belongs to the flaviviridae family. It has a 9.6-kb RNA genome encoding a single polyprotein of 3,010 amino acids. This polyprotein is composed of structural and nonstructural proteins. HCV entry into hepatocytes is mediated by the structural proteins, including glycoproteins E1 and E2, which interact with cellular receptors. Once HCV enters the host cell, replication of its genome is orchestrated by the nonstructural proteins, including proteases (NS2-3, NS3-4A), helicases (NS3), polymerases (NS5B), and NS5A, a protein with no known enzymatic activity. NS5A is essential to the replication machinery of the virus and critical in the assembly of infectious viral particles. However, its specific role remains unclear. A number of properties of this viral protein have been described. NS5A interacts with a variety of host proteins, including some which modulate host cellular signaling pathways. Studies have demonstrated that NS5A interacts with p53 and p21, affecting cell cycle control. More recently, NS5A was found to interact with proteins related to focal adhesions, gap-junction, and host signaling pathways. NS5A also interacts with other nonstructural viral proteins. During HCV viral replication, NS5A interacts with the RNAdependent RNA-polymerase NS5B, which is essential to maintain HCV replication in cell culture. Through its domain 1 NS5A has RNA-binding capacity, a property that can be critical for RNA replication. In addition to being involved in HCV replication, NS5A is involved in the assembly of the virus by forming stable complexes with NS2, the main protein involved in HCV assembly. NS5A attracted attention due to its interferon-alpha sensitivity determining region (ISDR), which can confer resistance to interferon treatment. Moreover, NS5A has an effect on interferon activity by up-regulating interleukin (IL)-8, which has been reported to attenuate the antiviral properties of interferon. These observations suggest that NS5A plays a critical role in many aspects of the life cycle of HCV and is therefore an attractive target for antiviral therapy (Fig. 1). Until recently, the standard treatment for HCV infection has been pegylated interferon-alpha and ribavirin. These drugs have significant and often serious side effects. Moreover, in patients with genotype 1 (the most prevalent HCV genotype), sustained viral clearance is achieved in less than 50% of cases. In recent years, several viral inhibitors targeting nonstructural proteins of HCV have been developed (direct-acting antiviral agents [DAA]). Most of the research has been focused on inhibitors of the NS3-NS4A and NS5B proteins, mainly because of a better understanding of the role of these proteins. A variety of NS3-NS4A and NS5B inhibitors are currently in various stages of development in preclinical and clinical studies. Telaprevir and boceprevir, which are both inhibitors of the NS3-NS4A serine protease, have recently been approved for use in combination with pegylated interferon and ribavirin in patients with genotype 1 HCV infection. Treatment with pegylated interferon, ribavirin, and either of these protease inhibitors results in improved rates of viral eradication (both in previously untreated and in those who have failed prior treatment). However, the recommended treatment regimens are complex and are associated with significant side effects from interferon and ribavirin, as well as adverse events from the protease inhibitors. Furthermore, these protease inhibitors need to be administered every 8 hours with food and there is also a very real problem of interaction with other drugs. In addition, the rapid replication of HCV makes the Abbreviations: DAA, direct-acting antiviral agents; HCV, hepatitis C virus; ISDR, interferon-alpha sensitivity determining region. Address reprint requests to: Coleman I. Smith, M.D., Department of Medicine, Division of Gastroenterology and Hepatology, University of Minnesota, 420 Delaware Street SE, MMC-36, Minneapolis, MN 55455. E-mail: smith136@umn.edu. CopyrightVC 2012 by the American Association for the Study of Liver Diseases. View this article online at wileyonlinelibrary.com. DOI 10.1002/hep.25696 Potential conflict of interest: Dr. Smith is on the speakers’ bureau of, consults for, and received grants from Gilead and Vertex. He received grants from Mochida, Abbott, and Jannsen. He received grants from and is on the speakers’ bureau of Merck. He is on the speakers’ bureau of and consults for Bayer. He also consults for Bristol-Myers Squibb.

Diet and Activity Programs Are Ineffective in Nonalcoholic Steatohepatitis

To the Editor: With the continued international increase in the prevalence of overweight and obese individuals, the recent review by Spengler and Loomba of nonalcoholic fatty liver disease (NAFLD) and the subset of individuals with nonalcoholic steatohepatitis (NASH), as defined by liver histology, is a very important topic. In the United States, NASH is the second most common indication for liver transplant, and the rate of liver transplant procedures is increasing. Prevention and treatment to reduce the rate of liver transplant is therefore a major issue in this field. We certainly agree with the authors’ statement that weight loss is the cornerstone of NAFLD treatment. We disagree, however, with their approach to weight loss. The authors state that it may be worthwhile to encourage patients to seek training on a structured weight loss regimen. This approach will clearly be too little (ie, weight loss) and not long enough (ie, inadequate maintenance of weight loss). A mean weight loss of only 6.4 kg has been reported from a metaanalysis of 19 studies of individuals with class 1 (body mass index [calculated as the weight in kilograms divided by the height in meters squared], 3034.9 kg/m) or class 2 (body mass index, 35-39.9 kg/m) obesity who participated in weight reduction programs that included dietary changes and physical activity. A recent study of an activity and dietary program for treatment of NAFLD found that only 10% of participants were able to lose the goal of more than 10% of their total body weight. Although this 10% of participants had a 90% rate of resolution of NASH, the study did not

Human leukocyte antigen DR markers as predictors of progression to liver transplantation in patients with chronic hepatitis C

Abstract OBJECTIVE: Because many patients with chronic viral hepatitis do not progress to end-stage liver disease, it is possible that host factors such as human leukocyte antigen (HLA) differences are important. Our aims were to determine HLA marker-specific rates of progression to liver transplantation among patients with chronic hepatitis C; and to determine if polymerase chain reaction (PCR)-based HLA DRB1 typing can be performed on stored serum samples. METHODS: Forty-two hepatitis C virus RNA-positive liver transplant patients and 87 untransplanted patients were included in a Cox proportional hazards model to test whether the occurrence of certain HLA DRB1 markers were associated with progression to liver transplantation. HLA DRB1 typing was performed on stored serum samples using a PCR method. RESULTS: There were no differences among the HLA DRB1 markers with regard to the HLA marker-specific rate of progression to transplantation among patients with chronic hepatitis C. CONCLUSIONS: HLA DRB1 markers do not appear to be associated with progression of disease in chronic viral hepatitis C. It is possible to perform PCR-based HLA DRB1 typing on stored frozen serum samples.