L. Okolicsanyi

Effects of angiogenic factor overexpression by human and rodent cholangiocytes in polycystic liver diseases.

Liver involvement in autosomal dominant polycystic kidney disease (ADPKD) is characterized by altered remodeling of the embryonic ductal plate (DP) with presence of biliary cysts and aberrant portal vasculature. The genetic defect causing ADPKD has been identified, but mechanisms of liver cyst growth remain uncertain. To investigate the possible role of angiogenic mechanisms, we have studied the immunohistochemical expression of vascular endothelial growth factor (VEGF), angiopoietin–1 (Ang‐1), angiopoietin‐2 (Ang‐2) and their receptors (VEGFR‐1, VEGFR‐2, Tie‐2) in ADPKD, Carolis disease, normal and fetal livers. In ADPKD and control livers Ang‐1 and Ang‐2 gene expression was studied by real‐time‐PCR. Effects of VEGF on cholangiocyte proliferation were studied by PCNA Western Blot in isolated rat cholangiocytes and by MTS assay in cultured cholangiocytes isolated from ADPKD patients and from an ADPKD mouse model (Pkd2WS25/−). Cholangiocytes were strongly positive for VEGF, VEGFR‐1, VEGFR‐2 and Ang‐2 in ADPKD and Caroli, and also for Ang‐1 and Tie‐2 in ADPKD, similar to fetal ductal plate cells. VEGF stimulated proliferation in both normal and ADPKD cholangiocytes, but the effect was particularly evident in the latter. Ang‐1 alone had no effect, but was synergic to VEGF. VEGF expression on cholangiocytes positively correlated with microvascular density. In conclusion, consistent with the immature phenotype of the cystic epithelium, expression of VEGF, VEGFRs, Ang‐1 and Tie‐2 is strongly upregulated in cholangiocytes from polycystic liver diseases. VEGF and Ang‐1 have autocrine proliferative effect on cholangiocyte growth and paracrine effect on portal vasculature, thus promoting the growth of the cysts and their vascular supply. (HEPATOLOGY 2006;43:1001–1012.)

Silybin combined with phosphatidylcholine and vitamin E in patients with nonalcoholic fatty liver disease: A randomized controlled trial

The only currently recommended treatment for nonalcoholic fatty liver disease (NAFLD) is lifestyle modification. Preliminary studies of silybin showed beneficial effects on liver function. Realsil (RA) comprises the silybin phytosome complex (silybin plus phosphatidylcholine) coformulated with vitamin E. We report on a multicenter, phase III, double-blind clinical trial to assess RA in patients with histologically documented NAFLD. Patients were randomized 1:1 to RA or placebo (P) orally twice daily for 12 months. Prespecified primary outcomes were improvement over time in clinical condition, normalization of liver enzyme plasma levels, and improvement of ultrasonographic liver steatosis, homeostatic model assessment (HOMA), and quality of life. Secondary outcomes were improvement in liver histologic score and/or decrease in NAFLD score without worsening of fibrosis and plasma changes in cytokines, ferritin, and liver fibrosis markers. We treated 179 patients with NAFLD; 36 were also HCV positive. Forty-one patients were prematurely withdrawn and 138 patients analyzed per protocol (69 per group). Baseline patient characteristics were generally well balanced between groups, except for steatosis, portal infiltration, and fibrosis. Adverse events (AEs) were generally transient and included diarrhea, dysgeusia, and pruritus; no serious AEs were recorded. Patients receiving RA but not P showed significant improvements in liver enzyme plasma levels, HOMA, and liver histology. Body mass index normalized in 15% of RA patients (2.1% with P). HCV-positive patients in the RA but not the P group showed improvements in fibrogenesis markers. This is the first study to systematically assess silybin in NAFLD patients. Treatment with RA but not P for 12 months was associated with improvement in liver enzymes, insulin resistance, and liver histology, without increases in body weight. These findings warrant further investigation.

Changing trends in acute upper-GI bleeding: a population-based study.

BACKGROUND Advances in medical practice in recent decades have influenced the etiology and management of acute upper-GI bleeding (UGIB), but their impact on the incidence and mortality is unclear. OBJECTIVE To analyze the time trends of UGIB in 2 different management eras. DESIGN Prospective observational study. SETTING General university-affiliated hospital. PATIENTS AND INTERVENTIONS A total of 587 patients who presented with UGIB during the 1983-to-1985 period were compared with 539 patient in the 2002-to-2004 period. RESULTS The overall incidence of UGIB decreased from 112.5 to 89.8 per 100,000/y, which corresponds to a 35.5% decrease after adjustment for age (95% CI, 24.2%-46.8%). The age standardized incidence of ulcer bleeding decreased by 41.6% (95% CI, 27.2%-56%); the decrease occurred only in people younger than 70 years of age. The rate of history of peptic ulcer disease decreased from 32.7% in the 1983-to-1985 period versus 19.5% in the 2002-to-2004 period (P < .001). The mean age increased from 61.0 to 68.7 years (P < .001), and the male:female ratio decreased from 2.7 to 1.8 (P = .002). The comorbidities increased from 69% to 75% (P = .01), the use of nonsteroidal anti-inflammatory drugs from 40.0% to 46.4% (P = .03), and the cases of bleeding occurring during hospitalization from 10.4% to 17.1% (P < .001). In the 1983-to-1985 cohort, the endoscopy was solely diagnostic, and antisecretory therapy consisted of H2-antagonists drugs. In the second period, 39.3% of patients underwent endoscopic therapy, whereas proton pump inhibitors were administered in 47%. Rebleeding rates decreased from 32.5% to 7.4% (P < .001) and surgery from 10.2% to 2.0% (P < .001). Overall mortality decreased from 17.1 to 8.2 per 100,000/y, which corresponded to a 60.8% decrease after adjustment for age (95% CI, 46.5%-75.1%). The age standardized mortality rate for ulcer bleeding decreased by 56.5% (95% CI, 41.9%-71.1%). LIMITATIONS A single-center study and a potential lack of generalizability. CONCLUSIONS From the 1983-to-1985 period to the 2002-to-2004 period, major changes occurred in the incidence of UGIB, features of patients, management, and outcomes. The incidence and mortality of UGIB overall and ulcer bleeding decreased significantly, and the decline of incidence occurred only in patients younger than 70 years old.

Nuclear Expression of S100A4 Calcium-Binding Protein Increases Cholangiocarcinoma Invasiveness and Metastasization

Cholangiocarcinoma (CCA) carries a severe prognosis because of its strong invasiveness and early metastasization. In several patients, otherwise eligible for surgical resection, micrometastasis are already present at the time of surgery. The mechanisms responsible for CCA invasiveness are unclear. S100A4, a member of the S100 family of small Ca2+‐binding proteins, is expressed in mesenchymal cells, regulates cell motility in several cell types, and is expressed in some epithelial cancers. Thus, we aimed to study the role of S100A4 in CCA invasiveness and metastasization. The expression of S100A4 was studied by immunohistochemistry in 93 human liver samples of CCA patients undergoing surgical resection and correlated with metastases development (67 cases) and patient survival following surgery using log rank tests and multivariate analysis. S100A4 expression was studied in EGI‐1 and TFK‐1, human CCA cell lines with and without nuclear S100A4 expression, respectively. Metastatic properties of CCA cells were assessed by xenotransplantation in severe combined immunodeficiency (SCID) mice after transduction with lentiviral vectors encoding firefly luciferase gene. Proliferation, motility (wound healing), invasiveness (Boyden chamber), and metalloproteinases (MMPs) secretion were studied in CCA cells, with or without lentiviral silencing of S100A4. Nuclear expression of S100A4 by neoplastic ducts was a strong predictor of metastasization and reduced survival after resection (P < 0.01). EGI‐1 CCA cells showed stronger metastatic properties than TFK‐1 when xenotransplanted in SCID mice. S100A4‐silenced EGI‐1 cells showed significantly reduced motility, invasiveness, and MMP‐9 secretion in vitro, without changes in cell proliferation. Conclusion: Nuclear S100A4 identifies a subset of CCA patients with a poor prognosis after surgical resection. Nuclear expression of S100A4 increases CCA cells invasiveness and metastasization, indicating that S100A4 may also represent a potential therapeutic target. (HEPATOLOGY 2011; 54:890–899)

Epithelial expression of angiogenic growth factors modulate arterial vasculogenesis in human liver development

Intrahepatic bile ducts maintain a close anatomical relationship with hepatic arteries. During liver ontogenesis, the development of the hepatic artery appears to be modulated by unknown signals originating from the bile duct. Given the capability of cholangiocytes to produce angiogenic growth factors and influence peribiliary vascularization, we studied the immunohistochemical expression of vascular endothelial growth factor (VEGF), angiopoietin‐1, angiopoietin‐2, and their cognate receptors (VEGFR‐1, VEGFR‐2, Tie‐2) in fetal human livers at different gestational ages and in mice characterized by defective biliary morphogenesis (Hnf6−/−). The results showed that throughout the different developmental stages, VEGF was expressed by developing bile ducts and angiopoietin‐1 by hepatoblasts, whereas their cognate receptors were variably expressed by vascular cells according to the different maturational stages. Precursors of endothelial and mural cells expressed VEGFR‐2 and Tie‐2, respectively. In immature hepatic arteries, endothelial cells expressed VEGFR‐1, whereas mural cells expressed both Tie‐2 and Angiopoietin‐2. In mature hepatic arteries, endothelial cells expressed Tie‐2 along with VEGFR‐1. In early postnatal Hnf6−/− mice, VEGF‐expressing ductal plates failed to incorporate into the portal mesenchyma, resulting in severely altered arterial vasculogenesis. Conclusion: The reciprocal expression of angiogenic growth factors and receptors during development supports their involvement in the cross talk between liver epithelial cells and the portal vasculature. Cholangiocytes generate a VEGF gradient that is crucial during the migratory stage, when it determines arterial vasculogenesis in their vicinity, whereas angiopoietin‐1 signaling from hepatoblasts contributes to the remodeling of the hepatic artery necessary to meet the demands of the developing epithelium. (HEPATOLOGY 2008.)

Association of keratin 8 gene mutation with chronic pancreatitis

BACKGROUND Keratin 8 (K8) and 18 (K18) are the major components of the intermediate filament cytoskeleton of pancreatic acinar cells and play a relevant role in pancreatic exocrine homeostasis. Transgenic mice for K8 have shown to display progressive exocrine pancreas alterations, including dysplasia, loss of acinar architecture, redifferentiation of acinar to ductal cells, inflammation, fibrosis, and substitution of exocrine tissue by adipose tissue. AIM To investigate whether mutations in the keratin 8 gene are associated with chronic pancreatitis. METHODS Mutations in the keratin 8 gene were determined by polymerase chain reaction/restriction fragment length polymorphism in 67 chronic pancreatitis patients and 100 normal controls. Sequence analysis was performed when necessary. RESULTS Glycine-to-cysteine mutations at position 61 (G61C) of the keratin 8 gene were found in six patients (8.9 vs. 0%, p(c) < 0.003, odds ratio = 21.24, confidence interval = 2.74-164.42); none of the controls presented the mutation. No tyrosine-to-histidine mutations at position 53 (Y53H) were detected in any subject. CONCLUSION G61C mutation of the keratin 8 gene, together with other environmental factors and/or genetic factors, could predispose to chronic pancreatitis, by interfering with the normal organization of keratin filaments.

The Effect of Drugs on Bile Flow and Composition: An Overview

SummaryMany drugs are eliminated via the hepatobiliary route, after biotransformation in the liver. Some of them may affect bile flow and/or the hepatic secretion of biliary lipids such as bile acids, cholesterol and phospholipids.Bile acids are the most potent agents which increase bile flow, especially unconjugated bile acids. Other drugs which increase bile flow include phenobarbitone (phenobarbital), theophylline, glucagon and insulin. In contrast, ethacrynic acid, amiloride, ouabain, oestrogens and chlorpromazine are among those agents which decrease bile flow. Biliary bile acid secretion is altered by a variety of drugs, including cheno- and ursodeoxycholic acids (CDCA and UCDA), the bile acid sequestrants cholestyramine and colestipol, and ethinyloestradiol.The composition of bile can also be altered by drug therapy. Thus, clofibrate increases biliary cholesterol secretion, and reduces bile acid concentrations, without altering biliary phospholipid concentrations. However, other clofibrate derivatives may produce changes of a different pattern, suggesting that the risk of developing gallstones may differ for each derivative. Nicotinic acid and d-thyroxine also increase biliary cholesterol saturation, while CDCA and UDCA reduce biliary cholesterol concentration.The potential consequences of drug-induced changes in bile flow and composition extend to the liver, the gallbladder and the intestine. If adverse effects are to be avoided, further study in this often overlooked area is required.

Effect of age on single- and multiple-dose pharmacokinetics of erythromycin

SummaryThe effect of age on the pharmacokinetics of erythromycin was investigated by comparing its kinetic behaviour in eight young healthy adults and eight healthy elderly subjects after single and repeated oral doses of erythromycin stearate 1 g b.d. for 7 doses.The peak serum concentration and area under the serum concentration-time curve (AUC) were significantly greater in the elderly subjects than in the young controls after single and multiple doses. Accordingly, the apparent oral clearance was lower in the elderly subjects (0.31 vs 0.64 and 0.22 vs 0.69 l·h−1·kg−1 after the first and seventh administration, respectively). The mean elimination half-life was significantly longer in the elderly group only after multiple dosing (4.8 vs 2.3 h).No age-related difference was observed in the time to peak serum concentration and apparent volume of distribution. The multiple-dose regimen resulted in an almost two-fold accumulation of erythromycin in the older individuals and no accumulation in the young adults. Mean drug accumulation in elderly subjects at steady state was 43% greater than was predicted from the AUC after the first dose, suggesting a time-dependent reduction in both systemic and presystemic clearance.The results indicate that the metabolic elimination processes for erythromycin are impaired in normal elderly subjects and suggest that caution is required on administering a high dose of it to aged people.

Les complications de la laparoscopie en pathologie hépatique. Nécessité d’une révision de la classification des complications dans le diagnostic laparoscopique

RéSUMéLes auteurs rapportent les résultats d’une évaluation rétrospective des complications de la laparoscopie chez 2 400 malades atteints d’affection hépatique. Le taux global de complications est de 5,08 %. Les complications ont été couramment classées en majeures (0,58 %) et mineures (4,5 %).La plupart des complications majeures n’étaient pas liées à la laparoscopieen elle- même, mais à la prémédication préendoscopique, le pneumopéritoine et la biopsie hépatique.Si les complications dues à ces manœuvres sont éliminées, le taux d’incidents majeurs lié à la laparoscopie diminue (0,08 %). Néanmoins, les complications liées à la prémédication, le pneumopéritoine, ne peuvent pas être écartés puisque ces manœuvres font partie intégrante de l’examen laparoscopique. Le taux global de complications de la laparoscopie varie selon différentes études entre 1,3 et 7,8 %.Cette large variation dépend des critères choisis pour la classification des complications de la laparoscopie.Les auteurs suggèrent qu’à l’avenir, les complications soient toutes rapportées, sans tenir compte de la sévérité de l’état clinique ou des séquelles’résiduelles.SummaryThe authors report the results of a retrospective study of laparoscopie complications in 2 400 patients with liver disease. The overall rate of complications was 5.08 %. The complications are currently classified into major (0.58 %) and minor (4.5 %). Most of the major complications are not related to laparoscopy per se, but to preoperative medication, pneumoperitoneum and to liver biopsy.If the complications due to these procedures were eliminated, the rate of the laparoscopy-related major accidents would decline (0.08 %).However, the complications related to preoperative medication or pneumo-peritoneum cannot be disregarded, as these procedures are integral parts of the laparoscopie examination.The overall rate of laparoscopie complications, reported in different studies, varies greatly from 1.3 a 7.8 %.This large variation may depend on the currently adopted criteria for the classification of laparoscopie complications.The authors suggest that, in the future, complications should be reported, regardless of the severity of the clinical case and its resultant sequaelae.RESUMENLos autores aportan los resultados de una evaluación retrospectiva de las complicaciones de la laparoscopia en 2.400 pacientes afectados por un proceso hepàtico. La tasa global de complicaciones es del 5.08 %. Las complicaciones fueron clasificadas en mayores (0.58 %) y menores (4.5 %).La mayor parte de complicaciones mayores no estuvieron relacionadas con la laparoscopia, por sí misma, sino con la premedicación, neumoperitoneo y biopsia hepática. Si no tuvieramos en cuenta las complicaciones debidas a dichas maniobras las tasa de incidentes graves relacionados con la laparoscopia disminuiria al 0.08 %. Sin embargo, las complicaciones relativas a premedicación, neumoperitoneo y biopsia no pueden evitarse puesto que forman parte intégrante del examen laparoscópico. Las tasas globales de complicaciones de la laparoscopia varian según las series, entre el 1.3 y el 7.8 %. Esta gran variación dépende de los criterios escogidos en la clasificación de las complicaciones de la laparoscopia.Los autores sugieren que, en el futuro, se notifiquen todas las complicaciones, sin tener en cuenta su gravedad clinica o de las secuelas residuales.

Therapy of inflammatory bowel diseases in pregnancy and lactation.

Inflammatory bowel diseases (IBDs) are a group of disorders characterised by chronic or relapsing inflammation within the gastrointestinal tract of variable severity. A chronic medication is often needed and management of fertile women is a crucial point because of the possible adverse effects associated with the administered drugs and the disease itself. The risk of pregnancy-related complications and the disease behaviour during pregnancy depends mainly on disease activity at time of conception. So, it is very important to plan the pregnancy and reach and maintain a clinical remission of the disease before conception. Drugs usually used in IBD treatment include 5- aminosalicylic acid compounds, corticosteroids, azathioprine and 6-mercaptopurine, cyclosporine A, mesalazine, and antibiotics such as metronidazole and ciprofloxacin. Management of IBD in pregnancy at present is not standardised or supported by strong evidence. In this report, we summarise the available data, mainly derived from retrospective and case-control studies, about IBD management in pregnancy, focusing mostly on the safety of drugs during gestation and peripartum.