Johannes Korth

Low transferrin and high ferritin concentrations are associated with worse outcome in acute liver failure.

Serum ferritin and transferrin have been identified as prognostic markers in patients with chronic diseases. In this study, we investigated if these parameters can predict outcome in patients with acute liver failure.

Performance and Utility of Transient Elastography and Non-Invasive Markers of Liver Fiibrosis in Patients with Autoimmune Hepatitis: A Single Centre Experience

Objectives Autoimmune hepatitis (AIH) is a relatively rare cause of hepatic dysfunction, which can lead to acute liver failure (ALV) and cirrhosis if not treated. The performance of transient elastography (TE) compared to liver biopsy has been evaluated in many liver diseases. The aim of the present study was to evaluate the performance of TE and other non-invasive markers for liver fiibrosis in patients with biopsy-proven AIH. Methods Fifty-three patients who were treated at the department of gastroenterology and hepatology of the University Clinic Essen from 2008 to 2013 included in this retrospective study. Laboratory parameters were used to calculate non-invasive markers for liver fiibrosis. Every patient underwent a liver biopsy within 6 months of the liver stiffness measurement. Results Transient elastography score, non-alcoholic fatty liver disease (NAFLD) fiibrosis score, Fiibrosis 4 score (FIB-4), and FibroQ were associated with the stage of fiibrosis, whereas other non-invasive markers of liver fiibrosis (aspartate transaminase (AST) to alanine transaminase (ALT) ratio, and AST to platelet ratio index (APRI)) did not demonstrate a significant correlation. NAFLD fiibrosis score and FibroQ performed slightly better in ROC curve analysis than TE in differentiating mild to moderate from severe fiibrosis (AUC 0.895 and 0.773 vs. 0.739; P < 0.001 and = 0.01, respectively), while TE performed slightly better, but still not adequate, in differentiating mild from all other stages of fiibrosis compared to NAFLD fiibrosis score and FibroQ (AUC 0.779 vs. 0.752 and 0.684; P = 0.051 and 0.009). Conclusions Transient elastography, NAFLD fiibrosis score, and FibroQ are valuable non-invasive markers for the evaluation of liver fiibrosis in autoimmune hepatitis but they cannot replace liver biopsy, especially in differentiating mild from more advanced stages of fiibrosis.

Clinical course and core variability in HBV infected patients without detectable anti-HBc antibodies

BACKGROUND The presence of anti-HBc antibodies indicates direct encounter of the immune system with hepatitis B virus (HBV). OBJECTIVES Aim of our study was to seek for anti-HBc negative but HBV replicating patients and analyze their clinical course and preconditions. STUDY DESIGN From 1568 HBV-DNA positive patients, 29 patients (1.85%) tested negative for anti-HBc. The absence of anti-HBc could be confirmed in 19 patients using an alternative assay. In 16 of 19 cases, a partial or full HBV genome analysis was performed with NGS sequencing to evaluate if specific mutations were associated with anti-HBc absence. As a control group samples from 32 matched HBV infected patients with detectable anti-HBc were sequenced. RESULTS Patients with detectable HBV-DNA and sequenced HBV core region in the confirmed absence of anti-HBc were diagnosed with acute HBV infection (n=3), HBV reactivation (n=9) and chronic hepatitis B (n=4). Most patients (12/16) were immunosuppressed: 3/16 patients had an HIV coinfection, 7/16 patients suffered from a malignant disease and 4/16 patients underwent solid organ transplantation (from which 2/4 had a malignant disease). Compared to the control cohort, HBV variants from anti-HBc negative patients showed less variability in the core region. CONCLUSIONS In the absence of anti-HBc, HBV-DNA was most often found in immunocompromised hosts. Distinct mutations or deletions in the core region did not explain anti-HBc negativity. It would be advisable not to rely only on a single result of anti-HBc negativity to exclude HBV infection in immunocompromised hosts, but to measure anti-HBc repeatedly or with different methods.

Clinical patterns associated with the concurrent detection of anti‐HBs and HBV DNA

Simultaneous detection of anti‐HBs and HBV DNA is a rare serological combination and has been described in acute and chronic HBV infection. To scrutinize viral and clinical patterns associated with concurrent detection of anti‐HBs and HBV DNA. Simultaneous detection of anti‐HBs and HBV DNA was observed in 64/1444 (4.4%) patients treated for HBV infection at the University Hospital of Essen from 2006 to 2016 (8 with acute, 20 with reactivated, and 36 chronic HBV infection). Clinical data and laboratory parameters were analyzed. Regions of the small hepatitis B surface antigen (SHB) and the reverse transcriptase (RT) were sequenced using next generation sequencing (NGS). Among the 64 patients with detectable HBV DNA and anti‐HBs, 17 were HBsAg negative (HBsAg[−]), and two had acute liver failure. Patients with acute HBV infection had fewer genotype specific amino acid substitutions in the SHB region than patients with reactivated HBV infection (4 [4.5] vs 9 [16.25], P = 0.043). However, we could observe a significantly higher number of mutations in the a‐determinant region when comparing chronically infected patients to patients with acute infection (0 [1] vs 1 [1], P = 0.044). The ratio of nonsynonymous to synonymous mutations (Ka/Ks) was on average >1 for the SHB region and <1 for the RT region. The Ka/Ks ratio (>1) in the SHB region indicates that anti‐HBs might have exerted selection pressure on the HBsAg. In three cases the diagnosis of acute HBV infection would have been at least delayed by only focusing on HBsAg testing.

Role of BK polyomavirus (BKV) and Torque teno virus (TTV) in liver transplant recipients with renal impairment

Purpose. Renal impairment is a common complication after liver transplantation (LT). While BK polyomavirus (BKV) has been linked to renal failure in kidney transplant recipients, Torque teno virus (TTV) is a surrogate marker for immunosuppression that does not have a clear association with any human disease. The impact of BKV and TTV on renal impairment after LT is unknown. Methodology. In this retrospective study, urine and serum samples from 136 liver transplant recipients were screened for BKV and TTV by quantitative PCR. In addition, serum was screened for BKV‐specific antibodies and the VP1 typing region was sequenced for BKV genotyping. All parameters were correlated with clinical data. Results/Key findings. BK viruria was detected up to 21 years after transplantation in 16.9 % of cases. BK viraemia was detected in 8.7 % of patients with BK viruria up to 4 years after LT. BKV‐specific antibodies were detected in 93.6 % of all LT recipients and correlated with BKV viral load in urine. There was no correlation between renal impairment and the detection of BK DNA in urine (OR 0.983). TTV DNA was detected in 84.6 % of serum samples and in 66.6 % of urine samples. The TTV viral load in serum correlated with the BKV viral load but had no impact on renal impairment. Conclusion. Our data indicate that the detection of BKV and TTV is not a risk factor for renal impairment after LT. A correlation of TTV and BKV viral load seems to be an indicator for the immune status of the host.

T-Track-CMV and QuantiFERON-CMV assays for prediction of protection from CMV reactivation in kidney transplant recipients

BACKGROUND Assays detecting CMV-specific cell-mediated immunity (CMI) may support the current management of CMV infection in solid-organ transplant (SOT) recipients, by allowing a better risk assessment and adjusting antiviral treatment. OBJECTIVES The primary endpoint was the performance of two tests measuring CMV-specific interferon-gamma production, both approved for commercial use in clinical settings. Secondarily, we determined a cut-off for the cellular immune response, which protects against CMV reactivation/infection. STUDY DESIGN Thirty kidney transplant (KTx) patients were stratified according to their CMV-IgG status pre-transplantation (Tx) and were divided into two groups: pre-emptive (donor-/recipient+, donor+/recipient+) and prophylaxis (donor+/recipient-). An ELISpot (T-Track-CMV) was performed at month 1 post-Tx (pre-emptive group) and end of prophylaxis and one month thereafter (prophylaxis group). An ELISA (QuantiFERON-CMV) was performed every 2-4 weeks (pre-emptive) or monthly (prophylaxis), in parallel to the CMV viral load (PCR). RESULTS A good positive agreement was obtained between the QuantiFERON-CMV or T-Track-CMV and the CMV-IgG (kappa = 0.839 and 0.824, respectively). A cut-off of 19.5 spot forming units (SFU)/200,000 lymphocytes for the T-Track-CMV IE-1 (AUC = 0.802, sensitivity 45%, specificity 100%) and 495 SFU/200,000 lymphocytes for the T-Track-CMV pp65 (AUC = 0.617, sensitivity 11%, specificity 100%) was defined to assess protection against reactivation. The QuantiFERON-CMV performed modestly (AUC = 0.477, cut-off 85.1 IU/ml). CONCLUSIONS The QuantiFERON-CMV and T-Track-CMV enable the functional assessment of CMV-specific CMI in KTx recipients. In combination with CMV viral load monitoring, T-Track-CMV results could stratify patients at risk of CMV reactivation/infection.

Clinical outcome and viral genome variability of hepatitis B virus induced acute liver failure (HEP-18-0579)

Acute hepatitis B virus (HBV) infection remains a frequent cause of acute liver failure (ALF) worldwide. ALF occurs in 0.1%‐0.5% of infected patients. The aim of this study was to scrutinize the outcome of patients with HBV‐induced ALF and mutational patterns of HBV variants, which might contribute to ALF. From 2005 to 2016, 42 patients were treated for HBV‐induced ALF in the University Hospital Essen, Germany. Clinical and virological data from these patients were collected. As a control, 38 patients with acute hepatitis B (AHB) without liver failure were included. The HBV genome was sequenced by next‐generation sequencing (NGS). Mutations that were found by NGS were analyzed in vitro. Of 42 patients, 8 had ALF without spontaneous recovery (NSR): Seven patients underwent liver transplantation (LT) and one patient died before LT. Of 42 patients, 34 (81%) had spontaneous recovery (SR) and cleared the infection, achieving either anti‐HBs seroconversion or hepatitis B surface antigen (HBsAg) loss. HBV genotype (GT)‐D was the most frequent GT in patients with ALF. Mutations in HBV core, preS2, and small hepatitis B surface antigen (SHB) were more frequent in patients with ALF‐NSR compared with those with ALF‐SR or AHB. Amino acid deletions (del; 16‐22 and 20‐22) in preS2 and SHB mutation L49R were exclusively detected in patients with ALF‐NSR. In vitro analyses reveal that these mutations did not influence HBsAg secretion or infectivity. Conclusion: HBV GT‐D and increased variability in HBV core, preS2 region, and SHB are associated with a worse clinical outcome of acute HBV infection.

The Donor Major Histocompatibility Complex Class I Chain-Related Molecule A Allele rs2596538 G Predicts Cytomegalovirus Viremia in Kidney Transplant Recipients

The interaction of major histocompatibility complex class I chain-related protein A (MICA) and its cognate activating receptor natural killer (NK) group 2 member D (NKG2D) receptor plays a significant role in viral immune control. In the context of kidney transplantation (KTx), cytomegalovirus (CMV) frequently causes severe complications. Hypothesizing that functional polymorphisms of the MICA/NKG2D axis might affect antiviral NK and T cell responses to CMV, we explored the association of the MICA-129 Met/Val single nucleotide polymorphism (SNP) (affecting the binding affinity of MICA with the NKG2D receptor), the MICA rs2596538 G/A SNP (influencing MICA transcription), and the NKG2D rs1049174 G/C SNP (determining the cytotoxic potential of effector cells) with the clinical outcome of CMV during the first year after KTx in a cohort of 181 kidney donor-recipients pairs. Univariate analyses identified the donor MICA rs2596538 G allele status as a protective prognostic determinant for CMV disease. In addition to the well-known prognostic factors CMV high-risk sero-status of patients and the application of lymphocyte-depleting drugs, the donor MICA rs2596538 G allele carrier status was confirmed by multivariate analyses as novel-independent factor predicting the development of CMV infection/disease during the first year after KTx. The results of our study emphasize the clinical importance of the MICA/NKG2D axis in CMV control in KTx and point out that the potential MICA transcription in the donor allograft is of clinically relevant importance for CMV immune control in this allogeneic situation. Furthermore, they provide substantial evidence that the donor MICA rs2596538 G allele carrier status is a promising genetic marker predicting CMV viremia after KTx. Thus, in the kidney transplant setting, donor MICA rs2596538 G may help to allow the future development of personal CMV approaches within a genetically predisposed patient cohort.

Pro-inflammatory Th1 and Th17 cells are suppressed during human experimental endotoxemia whereas anti-inflammatory IL-10 producing T-cells are unaffected

Objective Sepsis is one of the leading causes of the deaths in hospitals. During sepsis, patients are exposed to endotoxemia, which may contribute to the dysregulation of the immune system frequently observed in sepsis. This dysregulation leads to impaired pro-inflammatory responses and may increase the risk for secondary infections in sepsis. The experimental human endotoxemia model is widely used as a model system to study the acute effects of endotoxemia. Under physiological circumstances, the immune system is tightly regulated. Effector T-cells exert pro-inflammatory function and are restrained by regulatory T-cells (Tregs), which modulate pro-inflammatory effector responses. Endotoxemia may induce inadequate Treg activity or render effector T-cells dysfunctional. It was the aim of the study to investigate effector T-cell and Treg responses in an experimental human endotoxemia model. Methods In a cross-over designed placebo-controlled study, 20 healthy male volunteers received an intravenous injection of either lipopolysaccharide (LPS) (0.8 ng/kg body weight) or a placebo (saline 0.9%). CD3+ T-cells, CD4+ T-cells, CD8+ T-cells, and intracellular cytokine profiles were measured with flow cytometry at baseline and at repeated points after LPS/placebo injection. Complete blood cell counts were obtained with an automated hematology analyzer and cytokines were quantified by ELISA. Results Circulating neutrophils were significantly increased 2 h after LPS injection (p < 0.001) while absolute number of CD3+ T-cells, CD4+ T-cells, and CD8+ T-cells decreased (p < 0.001). Effector T-helper-cells (THs) showed a significant—but transient—decrease of pro-inflammatory IFNγ, interleukin (IL)-2, TNFα, and IL-17A production after LPS injection (p < 0.001). In contrast, the frequency of Treg and the capacity to produce IL-10 were unchanged (p = 0.21). Conclusion Effector THs fail to produce pro-inflammatory Th1-/Th17-associated cytokines after LPS challenge. In contrast, IL-10 production by Treg is not affected. Thus, endotoxemia-induced suppression of pro-inflammatory THs might be considered as a contributing factor to immunoparalysis in sepsis.

Impact of immune suppressive agents on the BK-Polyomavirus non coding control region

Background: Reactivation of the BK‐Polyomavirus (BKPyV) can cause a polyomavirus associated nephropathy in approx. 10% of kidney transplant recipients. In these cases, current therapy is based on the reduction of immunosuppression. Since BKPyV‐transcription is driven by the Non‐Coding‐Control‐Region (NCCR) we were interested whether NCCR‐activity is affected by immunosuppressive agents. Methods: Plasma samples from 45 BKPyV‐positive patients after renal transplantation were subjected to PCR‐analysis. NCCR‐amplicons were cloned into a plasmid that allows the quantification of early and late NCCR‐activity by tdTomato and eGFP expression, respectively. HEK293T‐cells were transfected with the reporter‐plasmids, treated with immunosuppressive agents, and subjected to FACS‐analysis. In addition, H727‐cells were infected with patient derived BKPyV, treated with mTOR‐inhibitors, and NCCR activity was analysed using qRT‐PCR. Results: While tacrolimus and cyclosporine‐A did not affect NCCR‐promoter‐activity, treatment with mTOR1‐inhibitor rapamycin resulted in the reduction of early, but not late‐NCCR‐promoter‐activity. Treatment with dual mTOR1/2 inhibitors (INK128 or pp242) led to significant inhibition of early, however, concomitantly enhanced late‐promoter‐activity. In BKPyV infected cells both rapamycin and INK128 reduced early expression, however, INK128 resulted in higher late‐mRNA levels when compared to rapamycin treatment. Conclusions: Our results demonstrate that mTOR1‐inhibitors are able to reduce early‐expression of wildtype and rearranged NCCRs, which might contribute to previously described inhibition of BKPyV‐replication. Dual mTOR1/2‐inhibitors, however, additionally might shift viral early into late‐expression promoting synthesis of viral structural proteins and particle production. HighlightsA dual fluorescence reporter was constructed to quantify the non‐coding‐control‐region (NCCR) driven BKPyV gene expression.NCCRs from patient material obtained after kidney transplantation were amplified and cloned into the reporter plasmid.The impact of immunosuppressive drugs on the bidirectional BKPyV‐promoter activity was analysed.mTOR1‐inhibitors were able to reduce early‐expression of archetypical and rearranged NCCRs.Dual mTOR1/2‐inhibitors, however, shifted viral early‐into late‐expression.