Olympia E. Anastasiou

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.

Higher Thyroid-Stimulating Hormone, Triiodothyronine and Thyroxine Values Are Associated with Better Outcome in Acute Liver Failure.

Introduction Changes in thyroid hormone levels, mostly as non-thyroidal illness syndrome (NTIS), have been described in many diseases. However, the relationship between acute liver failure (ALF) and thyroid hormone levels has not yet been clarified. The present study evaluates potential correlations of select thyroid functional parameters with ALF. Methods 84 consecutively recruited ALF patients were grouped according to the outcome of ALF (spontaneous recovery: SR; transplantation or death: NSR). TSH, free thyroxine (fT4), free triiodothyronine (fT3), T4, and T3 were determined. Results More than 50% of patients with ALF presented with abnormal thyroid parameters. These patients had greater risk for an adverse outcome than euthyroid patients. SR patients had significantly higher TSH, T4, and T3 concentrations than NSR patients. Albumin concentrations were significantly higher in SR than in NSR. In vitro T3 treatment was not able to rescue primary human hepatocytes from acetaminophen induced changes in mRNA expression. Conclusions In patients with ALF, TSH and total thyroid hormone levels differed significantly between SR patients and NSR patients. This might be related to diminished liver-derived transport proteins, such as albumin, in more severe forms of ALF. Thyroid parameters may serve as additional indicators of ALF severity.

High ferritin levels are not only but mostly because of liver specific injury

To the Editor, The authors thank Dr. BritoAzevedo for his interest in our paper and the opportunity to look at our data from a different perspective (1,2). Haemophagocytic lymphohistiocytosis (HLH) is a rare condition, associated with defective termination of the immune system, leading to multiorgan failure. A possible manifestation includes acute liver failure (ALF) (3). Patients diagnosed with HLH present with ferritin concentrations up to 10.000 ng/mL (4). A ferritin concentration of more than 500 ng/mL is a diagnostic criterion for HLH. Other criteria include fever, splenomegaly, cytopenia (of at least two lineages), hypertriglyceridaemia and/ or hypofibrinogenaemia, haemophagocytosis in bone marrow, spleen, or lymph nodes, low or absent natural killercell activity and soluble CD25 ≥ 2.400U/mL (5). ALF was associated with high ferritin levels in our study (2). In our cohort, 75 of 102 patients had ferritin levels above 500 ng/mL (Table 1). Ferritin exceeded 10.000 ng/mL in 14 patients. Among the patients with very high ferritin levels (>10.000 ng/mL), viral hepatitis was the most frequent cause, 7 of 14 (43%) (HAV, n = 3; HBV, n = 3; HEV, n = 1), while three patients developed a drug induced ALF, one an autoimmune hepatitis induced ALF and in three patients the cause of ALF could not be determined. Concerning the other diagnostic criteria, cytopenia was rare: some patients had thrombocytopenia or anaemia but no one presented with leukopaenia. A few patients presented with splenomegaly or hypofibrinogenaemia, but no one qualified for the HLH diagnosis, using the existing criteria. That being said, bone marrow, spleen or lymph nodes cytology/histology were not available in any of our patient and natural killercell activity and soluble CD25 were not assessed. Unfortunately, because of the retrospective nature of the study, it is impossible to reevaluate our patient cohort for all HLH criteria. Furthermore, there might be a certain selection bias: HLH is a systemic disease and is often associated with multiorgan failure (3); while a common feature of the patient history in our cohort was the severe impairment of liver function, which then lead to impairment of other organ systems. HLH has been associated with infectious, autoimmune, metabolic and malignant diseases and immunosuppression (3). The disease is rare in the adult population with a high mortality rate. However, given the availability of efficient treatment with immunosuppressive agents

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.

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.

Corticosteroid Therapy Improves the Outcome of Autoimmune Hepatitis-Induced Acute Liver Failure

Background/Aims: Autoimmune hepatitis (AIH) is a relatively rare cause of liver dysfunction and may lead in some cases to acute liver failure (ALF). The aim of our study was to evaluate the clinical course and outcome of patients with AIH-induced ALF. Methods: We retrospectively enrolled 32 patients with AIH-induced ALF and 93 age- and sex-matched patients with chronic AIH (cAIH) who were enrolled at the University Clinic Essen from 1988 to 2014. All ALF patients were treated with corticosteroids after diagnosis. Results: Overweight, higher γ-globulin levels, the absence of anti-smooth muscle antibodies and human leukocyte antigen (HLA) B8 and the presence of anti-mitochondrial antibodies and HLA DR7 were risk factors for an ALF vs chronic hepatitis manifestation of AIH. Liver histology was significantly more often typical for AIH in an ALF setting than in cAIH. The spontaneous survival rate was 91% and 97% in ALF and cAIH patients, respectively, at 6 months after diagnosis and only 1 patient in the ALF group developed sepsis under therapy. Conclusion: Liver biopsy in an AIH-mediated ALF setting was both safe and effective in diagnosing AIH. Corticosteroid therapy was not associated with high mortality or sepsis. Our findings suggest that corticosteroid treatment of AIH-mediated ALF may improve the outcome.

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.