Jung Hee Kim

Low‐level viremia and the increased risk of hepatocellular carcinoma in patients receiving entecavir treatment

The long‐term clinical impact of low‐level viremia (LLV; <2,000 IU/mL) is not well understood. As a result, it is unclear whether the development of LLV during entecavir monotherapy requires a change in therapy. A retrospective cohort of 875 treatment‐naive chronic hepatitis B virus (HBV) monoinfected patients (mean age 47.7 years, male = 564 [65.5%], cirrhosis = 443 [50.6%]) who received entecavir monotherapy were analyzed for the development of hepatocellular carcinoma (HCC). The HCC risk was compared between patients who maintained virological response (MVR), defined by persistently undetectable HBV DNA (<12 IU/mL), and patients who experienced LLV, defined by either persistent or intermittent episodes of <2,000 IU/mL detectable HBV DNA. During a median 4.5 years of follow‐up (range 1.0‐8.7 years), HCC was diagnosed in 85 patients (9.7%). HCC developed more frequently in patients who experienced LLV than MVR (14.3% versus 7.5% at 5 years, P = 0.015). The hazard ratio comparing those with LLV to MVR was 1.98 (95% confidence interval = 1.28‐3.06, P = 0.002, adjusted for age, sex, hepatitis B e antigen, baseline HBV DNA levels, and cirrhosis). Among patients with cirrhosis, those with LLV exhibited a significantly higher HCC risk than those with MVR (HCC incidence rate at 5 years 23.4% versus 10.3%, adjusted hazard ratio = 2.20, 95% confidence interval 1.34‐3.60; P = 0.002). However, for patients without cirrhosis, there was no significant difference in the HCC risk between LLV and MVR. Conclusion: LLV observed during entecavir monotherapy was associated with a higher risk of HCC, especially for those with cirrhosis, indicating that LLV during potent antiviral therapy is consequential. (Hepatology 2017;66:335–343).

Proton pump inhibitors do not increase the risk for recurrent spontaneous bacterial peritonitis in patients with cirrhosis

The present study aimed to assess the real impact of proton pump inhibitor (PPI) use on incidence of recurrent spontaneous bacterial peritonitis (SBP) in a homogenous population composed of cirrhotic patients with a previous SBP where differences related with SBP incidence between PPI users and non‐users are less likely to exist.

A Case of Riata® Dual Coil Defibrillator Lead Failure in a Patient with Ventricular Fibrillation

A 50-year-old man, who underwent a procedure for an implantable cardioverter defibrillator (ICD), visited the outpatient department of our clinic after suffering multiple ICD shocks. The ICD interrogation revealed recurrent shock due to a high frequency of noise that is sensed by the device as ventricular fibrillation. Chest radiography revealed a significant split in the insulation of the lead allowing the inner wire to protrude. We considered the removal of the failed lead, but the removal of ICD lead is potentially a high risk procedure, so we cut and capped a proximal part of the failed lead and inserted a new lead. This is the first report of a St. Jude Riata® dual coil defibrillator lead failure with clinical and radiologic evidence of a defect in lead insulation in Korea.

Two new lignans from the roots of Pulsatilla koreana.

Two new lignans, (2 R,3 R)-2 β-(4-hydroxy-3-methoxybenzyl)-3 α-(4-hydroxy-3-methoxybenzyl)-γ-butyrolactone 2-O-( β-D-glucopyranoside) (1) and (1 S,2 R,3 S)-dimethyl-1,2,3,4-tetrahydro-3,6,7-trihydroxy-1-(3,4-dihydroxyphenyl)naphthalene-2,3-dicarboxylate (2) together with nine known compounds (3-11) were isolated from the ethyl acetate fraction of the roots of Pulsatilla koreana. Their chemical structures were established based on physicochemical and spectroscopic data analyses. All isolates were investigated for their inhibition effects against the classical pathway of the complement system. Among them, compound 6 showed significant inhibitory activity with an IC (50) value of 75.9 µM, compounds 8 and 9 had moderate effects with IC (50) values of 182.2 and 166.5 µM, respectively.

Hepatocellular Carcinoma Risk of Compensated Cirrhosis Patients with Elevated HBV DNA Levels according to Serum Aminotransferase Levels

Sometimes, hepatitis B virus (HBV)-related cirrhotic patients with normal aminotransferase levels are closely followed-up for the elevation of aminotransferase levels instead of prompt antiviral therapy (AVT). We analyzed the long-term hepatocellular carcinoma (HCC) risk according to the aminotransferase levels in a retrospective cohort of 1,468 treatment-naïve, HBV-related, compensated cirrhosis patients with elevated HBV DNA levels (≥2,000 IU/mL). Based on aminotransferase levels, patients were categorized into normal (< 40 U/L, n = 364) and elevated group (≥40 U/L, n = 1,104). During a median of 5.3 yr of follow-up (range: 1.0-8.2 yr), HCC developed in 296 (20%) patients. The 5-yr cumulative HCC incidence rate was higher in patients with elevated aminotransferase level, but was not low in normal aminotransferase level (17% vs. 14%, P = 0.004). During the follow-up, 270/364 (74%) patients with normal aminotransferase levels experienced elevation of aminotransferase levels, and AVT was initiated in 1,258 (86%) patients. Less patients with normal aminotransferase levels received AVT (70% vs. 91%, P < 0.001) and median time to start AVT was longer (17.9 vs. 2.4 months, P < 0.001). AVT duration was an independent factor associated with HCC, and median duration of AVT was shorter (4.0 vs. 2.6 yr, P < 0.001) in patients with normal aminotransferase levels. The HCC risk of compensated cirrhosis patients with normal aminotransferase level is not low, and AVT duration is associated with lowered HCC risk, indicating that prompt AVT should be strongly considered even for those with normal aminotransferase levels.

Insulin resistance and the risk of hepatocellular carcinoma in chronic hepatitis B patients: Insulin resistance and hepatitis B

We analyzed whether insulin resistance (IR) assessed by homeostasis model assessment (HOMA2‐IR) index can stratify hepatocellular carcinoma (HCC) risk in patients with chronic hepatitis B virus (HBV) infection.

The utility of gadoxetic acid-enhanced magnetic resonance imaging in the surveillance for postoperative recurrence of hepatocellular carcinoma

AbstractThis study aimed to investigate the utility of gadoxetic acid-enhanced magnetic resonance imaging (Gd-MRI) in surveillance for recurrent hepatocellular carcinoma (HCC) after hepatectomy.This retrospective study analyzed 147 patients who underwent surveillance with alternating multidetector computed tomography (MDCT) and Gd-MRI after hepatectomy for HCC. The patients were followed-up every 3 months during the first 2 years, and every 6 months thereafter. At each visit, MDCT was performed but once a year (every 12 months), Gd-MRI was performed instead of MDCT. Each HCC recurrence detection rate of MDCT and Gd-MRI was evaluated, and recurrent HCC characteristics were compared according to the detection test.A total of 63 patients had recurrent HCC. Among them, 9 were detected with Gd-MRI and 29 with MDCT. The baseline characteristics of patients with recurrent HCC showed no significant differences according to the detection test. The HCC recurrence detection rate of Gd-MRI and MDCT was 4.8% (9/180) and 4.3% (29/580), respectively, on the per test basis (Pu200a=u200a0.764). However, in the population with a follow-up period of ≥12 months, the detection rate of Gd-MRI and MDCT was 4.3% (7/150) and 1.5% (19/400), respectively (Pu200a=u200a0.035). Recurrent HCCs detected with Gd-MRI were smaller than those detected with MDCT (tumor sizeu200a<u200a2u200acm, 100% vs 65.5%, Pu200a=u200a0.040).Our data suggest that Gd-MRI has advantages in detecting recurrent HCC after hepatectomy. Surveillance with alternating MDCT and Gd-MRI may identify more recurrent HCC in an early stage than with MDCT alone in patients who received hepatectomy for HCC.

Insulin resistance assessment is useful in risk stratification of hepatocellular carcinoma in chronic hepatitis B patients

We analyzed whether insulin resistance (IR) assessed by homeostasis model assessment (HOMA2‐IR) index can stratify hepatocellular carcinoma (HCC) risk in patients with chronic hepatitis B virus (HBV) infection.

Lamivudine versus Entecavir for Newly Diagnosed Hepatitis B Virus-Related Hepatocellular Carcinoma

Background/Aims Antiviral therapy is a key component in the management of hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) patients. However, whether the potent drug entecavir is more effective than a less potent drug, such as lamivudine, in HBV-related HCC is not clear. Methods A retrospective cohort of 451 newly diagnosed, HBV-related HCC patients without antiviral therapy at diagnosis, who started antiviral therapy with either entecavir (n=249) or lamivudine (n=202), were enrolled. Results The median survival was longer for the entecavir group than for the lamivudine group, and lamivudine use (vs entecavir) was an independent factor for mortality (hazard ratio [HR], 1.49; p=0.002). Lamivudine use (vs entecavir) was an independent risk factor for new-onset hepatic decompensation (HR, 1.67; p=0.010) in 318 patients without previous hepatic decompensation, and it was also an independent risk factor for recurrence after curative therapy (HR, 1.84; p=0.002) in 117 patients who received curative therapy. The findings were similar in a propensity score-matched cohort. Conclusions Overall survival, decompensation-free survival, and recurrence-free survival were better in the entecavir-treated patients than in the lamivudine treated-patients, indicating that the potent antiviral drug should be the preferred choice in HBV-related HCC patients.

Novel Albumin–Bilirubin Grade-Based Risk Prediction Model for Patients with Hepatocellular Carcinoma Undergoing Chemoembolization

BackgroundRecently, albumin–bilirubin (ALBI) grade has been suggested as a better surrogate for hepatic functional reserve for patients with hepatocellular carcinoma (HCC).AimsWe developed and validated a novel prediction model to predict outcome for HCC patients who underwent transcatheter arterial chemoembolization (TACE) as a first-line therapy.MethodsFrom a multivariate Cox regression model for overall survival, five objective variables (ALBI grade), the Barcelona clinic liver cancer (BCLC) stage, response after the first TACE session, Alpha-fetoprotein level, and sex were chosen and the ABRAS score was developed from the derivation cohort (nxa0=xa0476) and scored to generate an 8-point risk prediction model. The model’s prognostic performance was assessed in the randomly assigned internal validation set (nxa0=xa0475) and external validation set (nxa0=xa0243).ResultsThe ALBI grade was able to stratify patient survival within the same Child–Pugh class. The time-dependent area under receiver operating characteristics curves (AUROCs) for overall survival at 1 and 3 years were 0.78 and 0.73 in the training set, 0.78 and 0.71 in the internal validation set, and 0.70 and 0.65 in the external validation set, respectively. When stratified by BCLC stage, ABRAS score at a cutoff point of more than 3, 4, and 5 for BCLC stage 0/A, B, and C could identify subset of patients with dismal prognosis.ConclusionABRAS score was useful in estimating prognosis for patients who underwent TACE as a first-line therapy. This score can be useful in planning and guiding treatment strategies with TACE, which warrants prospective validation.