Lili Kazemi-Shirazi

Expanded allogeneic adipose-derived mesenchymal stem cells (Cx601) for complex perianal fistulas in Crohn's disease: a phase 3 randomised, double-blind controlled trial

BACKGROUND Complex perianal fistulas in Crohns disease are challenging to treat. Allogeneic, expanded, adipose-derived stem cells (Cx601) are a promising new therapeutic approach. We aimed to assess the safety and efficacy of Cx601 for treatment-refractory complex perianal fistulas in patients with Crohns disease. METHODS We did this randomised, double-blind, parallel-group, placebo-controlled study at 49 hospitals in seven European countries and Israel from July 6, 2012, to July 27, 2015. Adult patients (≥18 years) with Crohns disease and treatment-refractory, draining complex perianal fistulas were randomly assigned (1:1) using a pre-established randomisation list to a single intralesional injection of 120 million Cx601 cells or 24 mL saline solution (placebo), with stratification according to concomitant baseline treatment. Treatment was administered by an unmasked surgeon, with a masked gastroenterologist and radiologist assessing the therapeutic effect. The primary endpoint was combined remission at week 24 (ie, clinical assessment of closure of all treated external openings that were draining at baseline, and absence of collections >2 cm of the treated perianal fistulas confirmed by masked central MRI). Efficacy was assessed in the intention-to-treat (ITT) and modified ITT populations; safety was assessed in the safety population. This study is registered with ClinicalTrials.gov, number NCT01541579. FINDINGS 212 patients were randomly assigned: 107 to Cx601 and 105 to placebo. A significantly greater proportion of patients treated with Cx601 versus placebo achieved combined remission in the ITT (53 of 107 [50%] vs 36 of 105 [34%]; difference 15·2%, 97·5% CI 0·2-30·3; p=0·024) and modified ITT populations (53 of 103 [51%] vs 36 of 101 [36%]; 15·8%, 0·5-31·2; p=0·021). 18 (17%) of 103 patients in the Cx601 group versus 30 (29%) of 103 in the placebo group experienced treatment-related adverse events, the most common of which were anal abscess (six in the Cx601 group vs nine in the placebo group) and proctalgia (five vs nine). INTERPRETATION Cx601 is an effective and safe treatment for complex perianal fistulas in patients with Crohns disease who did not respond to conventional or biological treatments, or both. FUNDING TiGenix.

The relation of iron status and hemochromatosis gene mutations in patients with chronic hepatitis C

BACKGROUND & AIMS Elevated hepatic iron concentration may affect the response to antiviral therapy in chronic hepatitis C. This study explored the contribution of genetic hemochromatosis to iron accumulation in chronic hepatitis C. METHODS HFE mutations (C282Y and H63D) were assessed in 184 patients with chronic hepatitis C virus and 487 controls. Liver biopsy specimens were available in 149 patients. Hepatic iron content was measured in 114 patients by atom-absorption spectrophotometry. RESULTS The C282Y and H63D allele frequencies were 7.06 and 11.6 in patients and 4.83 and 11.09 in controls, respectively. Eight patients were homozygotes (5 C282Y [2.7%] and 3 H63D [1.6%]), 2 compound heterozygotes (1%), and 49 heterozygotes (14 C282Y [7.6%] and 35 H63D [19%]). Biochemical evidence of iron overload was more common in patients with HFE mutations (28 of 47) than in those without (34 of 102; P = 0.0045). Histological iron grading and hepatic iron content overlapped among patients with or without mutations. A hepatic iron index of >1.9 was observed only in 1 of the 4 C282Y homozygotes and 1 of the 3 H63D homozygotes. CONCLUSIONS HFE mutations contribute to but do not fully explain hepatic iron accumulation in chronic hepatitis C. Furthermore, C282Y or H63D homozygosity in chronic hepatitis C is not necessarily associated with a high hepatic iron content.

Differentiation of nonalcoholic from alcoholic steatohepatitis : are routine laboratory markers useful?

ZusammenfassungHINTERGRUND: Spezifische Marker für die Differenzierung der nicht alkoholischen (NASH) von der alkoholischen Steatohepatitis (ASH) fehlen. Wir untersuchten den Stellenwert von routinemäßig eingesetzten Laborparametern in der Differenzierung von NASH von ASH. METHODEN: Leberbiopsien, die über einen Zeitraum von 10 Jahren in unserem Krankenhaus durchgeführt wurden, wurden nochmals durchgesehen, 95 Patienten mit Steatohepatitis identifiziert und Ihre Daten zum Zeitpunkt der Biopsie reevaluiert. Basierend auf Ergebnisse der Leberbiopsie und Anamnese von Alkoholkonsum (< 140 g/Woche) wurde die Diagnose NASH oder ASH zugeteilt (andere Lebererkrankungen ausgeschlossen). Die Analyse erfolgte mittels logistischer Regression. ERGEBNISSE: NASH wurde bei 58 (61%; 30 w) und ASH bei 37 (39%; 9 w) Patienten diagnostiziert. Höhergradige Fibrose (59% vs. 19%, p < 0,0001) und AST/ALT Ratio > 1 (54,1% vs 20,7%, p = 0,0008) waren häufiger bei ASH zu finden. MCV war bei 53% der ASH Patienten erhöht and bei allen NASH Patienten (p < 0,0001) im Normbereich. Die multivariate Analyse identifizierte MCV (p = 0,0013), AST/ALT Ratio (p = 0,011) und Geschlecht (p = 0.0029) als die relevanten Regressoren (aROC = 0,92). AST/ALT Ratio (p < 0,0001) and Alter (p = 0,00049) waren unabhängige Prädiktoren für höhergradige Fibrose. Die Unterschiede bei MCV waren deutlicher bei höhergradiger Fibrose. SCHLUSSFOLGERUNGEN: Höheres MCV und AST/ALT Ratio bei ASH reflektieren den Schweregrad der zugrunde liegenden Lebererkrankung und können nicht zur Unterscheidung von ASH von NASH beitragen. Statt dessen könnten sich diese Marker als nützlich für die Patientenselektion für Leberbiopsie und in der Therapieplanung erweisen.SummaryBACKGROUND/AIMS: Specific markers for differentiation of nonalcoholic (NASH) from alcoholic steatohepatitis (ASH) are lacking. We investigated the role of routine laboratory parameters in distinguishing NASH from ASH. METHODS: Liver biopsies performed at our hospital over a 10-year period were reviewed, 95 patients with steatohepatitis identified and their data prior to biopsy reevaluated. The diagnosis NASH or ASH was assigned (other liver diseases excluded) on the basis of the biopsy and history of alcohol consumption (< 140 g/week). Logistic regression models were used for analysis. RESULTS: NASH was diagnosed in 58 patients (61%; 30 f) and ASH in 37 (39%; 9 f). High-grade fibrosis (59% vs. 19%, P < 0.0001) and an AST/ALT ratio > 1 (54.1% vs 20.7%, P = 0.0008) were more common in ASH. The MCV was elevated in 53% of ASH patients and normal in all NASH patients (P < 0.0001). Multivariate analysis identified the MCV (P = 0.0013), the AST/ALT ratio (P = 0.011) and sex (P = 0.0029) as relevant regressors (aROC = 0.92). The AST/ALT ratio (P < 0.0001) and age (P = 0.00049) were independent predictors of high-grade fibrosis. Differences in MCV were more marked in high-grade fibrosis. CONCLUSIONS: Higher MCVs and AST/ALT ratios in ASH reflect the severity of underlying liver disease and do not differentiate NASH from ASH. Instead, these biomarkers might prove useful in guiding selection of patients for liver biopsy and in targeting therapy.

Cystic fibrosis related liver disease--another black box in hepatology.

Due to improved medical care, life expectancy in patients with cystic fibrosis (CF) has veritably improved over the last decades. Importantly, cystic fibrosis related liver disease (CFLD) has become one of the leading causes of morbidity and mortality in CF patients. However, CFLD might be largely underdiagnosed and diagnostic criteria need to be refined. The underlying pathomechanisms are largely unknown, and treatment strategies with proven efficacy are lacking. This review focuses on current invasive and non-invasive diagnostic standards, the current knowledge on the pathophysiology of CFLD, treatment strategies, and possible future developments.

Therapeutic Role of Bile Acids and Nuclear Receptor Agonists in Fibrosing Cholangiopathies

Chronic inflammatory bile duct diseases such as primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) result in progressive fibrosis of the biliary tract and ultimately cirrhosis of the liver. Since the etiology and pathogenesis of these fibrosing cholangiopathies are still poorly understood, therapeutic options are rather limited at present. Ursodeoxycholic acid (UDCA) is the paradigm therapeutic bile acid and established standard treatment for PBC, but its role for medical therapy of PSC is still under debate. Promising novel bile acid-based therapeutic options include 24-norursodeoxycholic acid, a side chain-shortened C23 homologue of UDCA, and bile acid receptor/farnesoid X receptor agonists (e.g. obeticholic acid) which currently undergo clinical development for fibrosing cholangiopathies such as PBC and PSC. Other nuclear receptors such as vitamin D receptor and fatty acid-activated peroxisome proliferator-activated receptors are also of considerable interest. This review article is a summary of an overview talk given at Falk Symposium 191 on Advances in Pathogenesis and Treatment of Liver Diseases held in London, October 3-4, 2013, and summarizes the recent progress with novel therapeutic bile acids and bile acid derivatives as novel therapies for fibrosing cholangiopathies such as PBC and PSC.

Challenges and Management of Liver Cirrhosis: Practical Issues in the Therapy of Patients with Cirrhosis due to NAFLD and NASH.

Nonalcoholic fatty liver disease (NAFLD) is the hepatic manifestation of the metabolic syndrome and comprises a liver disease spectrum ranging from steatosis to nonalcoholic steatohepatitis (NASH) with risk of progression to liver cirrhosis and hepatocellular carcinoma (HCC). Associated metabolic conditions and comorbidities such as obesity, diabetes and cardiovascular diseases are common and require concerted management. Adiponutrin (PNPLA3) variants may help to identify NAFLD patients at higher risk for liver disease progression towards advanced fibrosis and HCC. The therapeutic options in NAFLD/NASH include lifestyle modification, pharmacological treatment, bariatric surgery for patients with morbid obesity and treatment of complications of liver cirrhosis and HCC, including liver transplantation. Insulin sensitizers and antioxidative treatment strategies with vitamin E are among the best-established pharmacological approaches, but both drugs have long-term safety issues and there is limited evidence in cirrhotic patients. Treatment of concomitant/underlying metabolic conditions with statins or metformin may also have beneficial effects on portal hypertension, complications of liver cirrhosis and HCC prevention. The bile acid receptor FXR may be a promising novel therapeutic target for the treatment of NAFLD/NASH, fibrosis and portal hypertension, but the prognostic implications of associated changes in low- and high-density lipoprotein cholesterol require further studies. Morbidly obese NASH patients can benefit from bariatric surgery which may reduce liver fibrosis but carries a risk of decompensation in patients with advanced liver cirrhosis. When carefully selected, patients with NASH cirrhosis undergoing liver transplantation have a good outcome. This review summarizes recent progress in the management of patients with liver cirrhosis due to NASH.

S-ibuprofen effectively inhibits thromboxane B2 levels and platelet function in an experimental model of lipopolysaccharide-stimulated and non-stimulated whole blood.

Objective: The present study aimed at testing the effect of S- and R-ibuprofen on thromboxane B2 (TXB2), collagen-epinephrine closure time (CEPI-CT) and collagen-adenosine 5′-diphosphate closure time (CADP-CT) in lipopolysaccharide (LPS)-stimulated and non-stimulated human whole blood. Materials and Methods: Whole blood was incubated with S- or R-ibuprofen with and without prior stimulation with LPS. To verify ibuprofen’s potential effects on TXB2, varying ratios of concentrations of S- and R-ibuprofen ranging from 0 to 100% were used. TXB2 levels were measured by ELISA. The effects of S- and R-ibuprofen enantiomers on platelet aggregability were tested utilizing a PFA-100 apparatus. Results: In non-stimulated and LPS-stimulated whole blood, S-ibuprofen markedly decreased TXB2 levels at concentrations ranging from 10 to 200 µg/ml. R-ibuprofen showed its inhibiting effect at concentrations >100 µg/ml. In inflammatory and non-inflammatory conditions, CEPI-CT was prolonged at concentrations of 12.5 and 75 µg/ml for S-ibuprofen and at a concentration of 150 µg/ml of combined R- and S-ibuprofen. S-ibuprofen was significantly more effective than R-ibuprofen (p < 0.05). The combined use of S- and R-ibuprofen did not additively or synergistically prolong CEPI-CTs. CADP-CTs remained unaffected by both enantiomers. Conclusions: S-ibuprofen was more effective than the R-ibuprofen enantiomer in inhibiting TXB2 plasma levels and aggregability of thrombocytes in non-inflammatory and inflammatory conditions.

Impact of nutritional status on pulmonary function after lung transplantation for cystic fibrosis

Background Nutritional status is an important prognostic factor in patients with cystic fibrosis (CF) prior to lung transplantation. Objective To investigate the impact of nutritional status on pulmonary function in CF transplant recipients. Methods Adult double lung transplanted CF patients were consecutively included. The predictive value of nutritional status on lung function – measured by spirometry – was longitudinally assessed by body composition serially evaluated by a three-compartment model bioelectrical impedance analysis (BIA) in comparison to body mass index (BMI). Results Overall, 147 spirometries and 147 BIAs were performed in 58 patients (59% female, median age: 30.1 years, median BMI: 19.6 kg/m2). Malnourished patients (BMI < 18.5 kg/m2; 27.6%) had a significantly reduced lung function compared to normal/overweight patients (forced expiratory volume in 1 second in percent (FEV1%pred), 57% vs 77%; p = 0.024). BMI, as well as the BIA parameters phase angle, total body water, fat free mass, body cell mass (BCM) and extracellular mass (ECM)/BCM ratio, were univariate predictors of FEV1%pred. When included in a linear mixed model, ECM/BCM ratio remained the only significant predictor of lung function (p = 0.012). Conclusion Nutritional status assessed by BIA predicted lung function in CF transplant recipients. Serial BIA measurements to monitor patients’ nutritional status might help to improve or maintain lung function.

The Efficacy of MRI in the diagnostic workup of cystic fibrosis-associated liver disease: A clinical observational cohort study

PurposeTo identify independent imaging features and establish a diagnostic algorithm for diagnosis of cystic fibrosis (CF)-associated liver disease (CFLD) in CF patients compared to controls using gadoxetic acid-enhanced MRI.MethodsA total of 90 adult patients were enrolled: 50 with CF, 40 controls. The CF group was composed of two subgroups: a retrospective test subgroup (n = 33) and a prospective validation subgroup (n = 17). Controls (patients with normal liver enzymes and only benign focal liver lesions) were divided accordingly (27:13). MRI variables, including quantitative and qualitative parameters, were used to distinguish CFLD from controls using clinical symptoms, laboratory tests and Debray criteria. Disease severity was classified according to Child-Pugh and Albumin-Bilirubin (ALBI) scores. Fifteen qualitative single-lesion CF descriptors were defined. Two readers independently evaluated the images. Univariate statistical analysis was performed to obtain significant imaging features that differentiate CF patients from controls. Through multivariate analysis using chi-squared automatic interaction detector (CHAID) methodology the most important descriptors were identified. Diagnostic performance was assessed by receiver-operating characteristic (ROC) analysis.ResultsThree independent imaging descriptors distinguished CFLD from controls: (1) presence of altered gallbladder morphology; (2) periportal tracking; and (3) periportal fat deposition. Prospective validation of the classification algorithm demonstrated a sensitivity of 94.1% and specificity of 84.6% for discriminating CFLD from controls. Disease severity was well associated with the imaging features.ConclusionsA short unenhanced MRI protocol can identify the three cardinal imaging features of CFLD. The hepatobiliary phase of gadoxetic acid-enhanced MRI can define CFLD progression.Key Points• Using a multivariate classification analysis, we identified three independent imaging features, altered gallbladder morphology (GBAM), periportal tracking (PPT) and periportal fat deposition (PPFD), that could diagnose CFLD with high sensitivity, 94.1 % (95% CI: 71.3–99.9) and moderate specificity, 84.6 % (95% CI: 54.6–98.1).• Based upon the results of this study, gadoxetic acid-enhanced MRI with DWI is able to diagnose early-stage CFLD, as well as its progression.

Difficult case of Cronkhite-Canada syndrome with small intestinal bacterial overgrowth, Clostridium difficile infection and polymyalgia rheumatica

A 64-year-old woman presented with heavy diarrhoea, nausea and weight loss accompanied by alopecia and dystrophic fingernails and toenails. The preceding diagnosis of an inflammatory bowel disease, a common pitfall, was excluded by endoscopic work up. Instead, Cronkhite-Canada syndrome (CCS), a rare polyposis condition, was identified as the reason for this almost pathognomonic combination of diagnostic findings including various polyps throughout the entire intestine and ectodermal abnormalities. This case exemplifies common risks and complications in terms of gastrointestinal malabsorption, infections and small intestinal bacterial overgrowth (SIBO), including its treatment as well as a hereto unreported association with polymyalgia rheumatica. In CCS, long-term immunosuppressive therapy and close endoscopic cancer screening of the patient is essential. The treatment of vitamin deficiency and recurring SIBO helps to reduce symptoms.