A cross-sectional study of the public health response to non-alcoholic fatty liver disease in Europe

Background & Aims: Non-alcoholic fatty liver disease (NAFLD) is a growing public health problem worldwide and has become an important field of biomedical inquiry. We aimed to determine whether European countries have mounted an adequate public health response to NAFLD and non-alcoholic steatohepatitis (NASH). Methods: In 2018 and 2019, NAFLD experts in 29 European countries completed an English-language survey on policies, guidelines, awareness, monitoring, diagnosis and clinical assessment in their country. The data were compiled, quality checked against existing official documents and reported descriptively. Results: None of the 29 participating countries had written strategies or action plans for NAFLD. Two countries (7%) had mentions of NAFLD or NASH in related existing strategies (obesity and alcohol). Ten (34%) reported having national clinical guidelines specifically addressing NAFLD and, upon diagnosis, all included recommendations for the assessment of diabetes and liver cirrhosis. Eleven countries (38%) recommended screening for NAFLD in all patients with either diabetes, obesity and/or metabolic syndrome. Five countries (17%) had referral algorithms for follow-up and specialist referral in primary care, and 7 (24%) reported structured lifestyle programmes aimed at NAFLD. Seven (24%) had funded awareness campaigns that specifically included prevention of liver disease. Four countries (14%) reported having civil society groups which address NAFLD and 3 countries (10%) had national registries that include NAFLD. Conclusions: We found that a comprehensive public health response to NAFLD is lacking in the surveyed European countries. This includes policy in the form of a strategy, clinical guidelines, awareness campaigns, civil society involvement, and health systems organisation, including registries. Lay summary: We conducted a survey on non-alcoholic fatty liver disease with experts in European countries, coupled with data extracted from official documents on policies, clinical guidelines, awareness, and monitoring. We found a general lack of national policies, awareness campaigns and civil society involvement, and few epidemiological registries.International Liver Foundation through grants from Gilead Sciences Europe Ltd., Allergan Pharmaceutical International Ltd., Bristol-Myers-Squibb Company, Pfizer Inc., and Resoundant Inc. JVL is a Miguel Servet-funded researcher at ISGlobal, Hospital Clínic, University of Barcelona. QMA and VR are members of the EPoS (Elucidating Pathways of Steatohepatitis) consortium funded by the Horizon 2020 Framework Program of the European Union under Grant Agreement 634413. QMA, VR, HCP, ME, MRG, HCP are members of the LITMUS (Liver Investigation: Testing Marker Utility in Steatohepatitis) consortium funded by the IMI2 Program of the European Union under Grant Agreement 777377. QMA is a Newcastle NIHR Biomedical Research Centre investigator

Aplastic anemia associated with interferon alpha 2a in a patient with chronic hepatitis C virus infection: a case report

<p>Abstract</p> <p>Introduction</p> <p>Hepatitis-associated aplastic anemia is a common syndrome in patients with bone marrow failure. However, hepatitis-associated aplastic anemia is an immune-mediated disease that does not appear to be caused by any of the known hepatitis viruses including hepatitis C virus. In addition, to the best of our knowledge there are no reported cases of patients with chronic hepatitis C virus infection developing aplastic anemia associated with pegylated interferon alpha 2a treatment.</p> <p>Case presentation</p> <p>We report the case of a 46-year-old Greek man who developed severe aplastic anemia during treatment with pegylated interferon alpha 2a for chronic hepatitis C virus infection. He presented with generalized purpura and bruising, as well as pallor of the skin and mucous membranes. His blood tests showed pancytopenia. He underwent allogeneic bone marrow transplantation after completing two courses of immunosuppressive therapy with antithymocyte globulin and cyclosporin A.</p> <p>Conclusions</p> <p>The combination of a specific environmental precipitant represented by the hepatitis C virus infection, an altered metabolic detoxification pathway due to treatment with pegylated interferon alpha 2a and a facilitating genetic background such as polymorphism in metabolic detoxification pathways and specific human leukocyte antigen genes possibly conspired synergistically in the development of aplastic anemia in this patient. Our case clearly shows that the causative role of pegylated interferon alpha 2a in the development of aplastic anemia must not be ignored.</p

Who to Test for Hepatitis C Virus in the Middle East and North Africa?: Pooled Analyses of 2,500 Prevalence Measures, Including 49 Million Tests.

Expanding hepatitis C virus (HCV) treatment coverage is challenged by limited testing and diagnosis. This study assessed the risk of exposure, for the Middle East and North Africa, by population, yields of testing, and program efficiency of testing strategies. A standardized and systematically assembled database of 2,542 HCV antibody prevalence studies on 49 million individuals was analyzed. Random effects meta-analyses were conducted to estimate pooled measures for risk of exposure, risk ratio (RR) of exposure, and yields of testing. Program expansion path curves were calculated to assess program efficiency. Countries clustered into two patterns: generalized versus concentrated epidemics. In generalized epidemics (Egypt and Pakistan) relative to general populations, RR of exposure was 6.8 for people who inject drugs (PWID), 6.7 for populations with liver conditions, and 5.0 for populations with high-risk health care exposures. In concentrated epidemics (remaining countries), corresponding RRs were 97.2, 45.1, and 22.2, respectively. In generalized epidemics, the number of tests needed to identify a chronic infection was 2.5 for PWID, 2.4 for populations with liver conditions, 2.7 for populations with high-risk health care exposures, and 14.2 for general populations. In concentrated epidemics, corresponding numbers were 2.8, 8.6, 5.1, and 222.2, respectively. Program expansion path curves demonstrated major gains in program efficiency by targeting specific populations. Risk of exposure varies immensely by population and shows a distinctive hierarchy, particularly in concentrated epidemics. Testing strategies can be much more efficient through population prioritization by risk of exposure. General population testing is not programmatically efficient in concentrated epidemics

Age-dependent glycosylation of the sodium taurocholate co-transporte polypeptide: from neonates to adult human primary hepatocytes

Background and Aims: The sodium taurocholate cotransporter polypeptide (NTCP) is the major hepatobiliary transporter responsible for bile acids portal vein re-uptake in hepatocytes. In humans, NTCP ontogeny has not been sufficiently investigated because of limited access to human tissue. Based on rodent models, NTCP glycosylation requires four weeks to be completed (Hardikar et al., 1995; Gao et al., 2004). Therefore, the aim of this study was to examine in humans the maturational profile of NTCP glycosylation levels from birth up to adulthood. Methods: Adult and neonatal primary human hepatocytes (PHH) were obtained from UCL-St Luc biobank with ethical consent for research purposes. PHH were isolated by a one stage collagenase perfusion and cryopreserved in liquid nitrogen (Ref). Donors were selected and approved by the medical ethical committee of our institution. Two groups of PHH were established: PHH donors younger than 1 year old were considered as early infants, whereas, PHH donors older than 1 years were considered as mature hepatocytes. The two groups were tested for NTCP transcriptional, translational and glycosylation age-dependent modulation levels by RT-qPCR and SDS-PAGE analysis. Characterization of NTCP glycosylation bands was conducted with PNGase F de-glycosylation treatment. Results: As a result, we show that NTCP mature complex-glycosylated form (55 kDa) was significantly increased in an age-dependent manners as compared to non-glycosylated NTCP (38 kDa) approximately at one year of age, whereas, NTCP mRNA and native protein levels were not significantly regulated, but had a slight tendency to increase with age. The complete deglycosylation of NTCP allowed us to then quantify the amount of de-glycosylated NTCP that shift at 38 kDa band. Here we show that NTCP 38 kDa band in adults was significantly increased by PNGase F treatment as compared to non treated, whereas in infants, no significant difference was shown. Conclusions: In conclusion, our data suggests that in human neonates, NTCP complex-glycosylation maturation process requires several months to up to one year to be completed,whereas, trascriptional and translational profiles were less influenced by age

High liver expression of SPINK-1 is associated with progenitor cell and hepatocyte proliferation and determines MELD score improvement in decompensated alcoholic liver disease

Background and aims: The prognostic significance of liver progenitor cell (LPC) and macrophage expansion in the regeneration of decompensated alcoholic liver disease (ALD) remain ill defined. In a well-characterized population of patients with acutely decompensated ALD (Hepatology 2011, A62), we analysed macrophage infiltration, proliferative LPC and differential expression of hepatic genes at baseline in relation to outcome at 3 months follow up. Methods: Fifty-eight patients (MELD 20) were included. Liver biopsy at inclusion was used for (1) immunohistological analysis of proliferative LPC (MIB1+/CK7+), proliferative hepatocytes (MIB1+/CK7- parenchymal cells), morphometric analysis of macrophage infiltration (CD68) and LPC expansion (CK7), and (2) transcriptome profiling using Affymetrix GeneChip Human arrays. Serum levels of HGF were determined by immunoassay. A ≥ 3 points decrease in MELD at 3 months as compared to baseline defined the improvers. Fifteen abstinent cirrhotics served as controls. CD68 and SPINK3 mRNA expression was determined in various mice models of liver injury. Results: At baseline, patients with decompensated ALD presented a significant expansion of CD68+ macrophages and CK7+ cells compared to abstinent cirrhotics. Patients who will improve (n=34) were characterized at baseline by a higher number of CK7+/MIB1+ cells (1.9 ± 1.5 versus 0.9 ± 0.9 cells/field, p<0.01), MIB1+ hepatocytes (4.1 ± 3.6 versus 1.8 ± 1.4 cells/field, p<0.01), an increased expansion of liver macrophages (4.4% versus 3.3% of surface area, p<0.05) and a higher level of serum HGF (p<0.05), compared to those who will not (n=24). Transcriptome analysis revealed that the first pathways upregulated in improvers were related to cell cycle and a 7-fold increase of liver serine peptidase inhibitor Kazal type I (SPINK1) compared with non-improvers (p=0.005). SPINK1 liver expression positively correlated with CD68 (r=0.46) and cyclinE1 (r=0.6). In mice, a 20-fold increase in liver SPINK3 expression, the homolog of human SPINK1, was evidenced following partial hepatectomy, concurrent with hepatocyte proliferation. Conclusions: Baseline markers of liver macrophages and liver cell proliferation predict the clinical outcome in decompensated ALD. This study reveals an unexpected implication of SPINK1, an acute phase reactant, in liver regeneration and human ALD

Impact of Kupffer cells on high fat induced insulin resistance and liver fetuin-A expression.

Backgroun and aims: Hepatokines (liver secreted proteins with possible distant action) are emerging potential players in insulin resistance in type 2 diabetic patients. Here, we explore the effect of a high fat diet on the expression of fetuin-A, one of those candidate liver proteins, and its relation with liver macrophage (Kupffer cell) activation. Methods: Male mice of 5 weeks of age were fed a normal diet (ND) or a high fat diet (HFD) for 3 days, known to initiate steatosis and insulin resistance. A preventive Kupffer cell (KC) depletion was obtained by intravenous injection of clodronate loaded liposomes and compared with PBS liposomes. The mRNA and protein expression of fetuin-A was evaluated by RT-PCR, Western-blot and immunofluorescence (IF) on different insulin-sensitive tissues (liver, adipose tissue and muscle). Results: Short term HFD induced steatosis, KC activation and insulin resistance together with a significant increased expression of liver fetuin-A mRNA (1.5 fold, p<0.01). However, liver fetuin-A protein expression remained unchanged under short term HFD. This increase in fetuin-A under high fat diet was not evidenced in the peripheral insulin sensitive tissues (skeletal muscle and adipose tissue) whether at the mRNA or at the protein level. Kupffer cell depletion in this setting did not reduce hepatic steatosis but significantly ameliorated insulin sensitivity proved by clamp studies. This amelioration in insulin sensitivity in KC-depleted mice was associated with a significant decrease in fetuin-A mRNA expression (0.7 fold, p<0.01) compared to animals with KC. On immunofluorescence, fetuin-A was mostly expressed in centrilobular hepatocytes. Interestingly, while selectively depleting liver macrophages without affecting adipose tissue macrophage infiltration, intravenous clodronate injection was associated with a significant reduction in epididymal adipose tissue expansion compared to PBS injection (1.1% of body weight versus 1.6% of body weight, p<0.001). Conclusion: This study demonstrates liver fetuin-A overexpression at the initiation of HFD feeding, concurrent with hepatic steatosis and insulin resistance. Targeting KC in this setting improved insulin sensitivity and was associated with a decreased adiposity and a reduced liver fetuin-A expression suggesting that fetuin-A acts as an hepatokine with pro-adiposity and pro-insulin resistance effects

Antibiotics induce remission in pediatric PSC-AIH overlap syndrome allowing corticosteroid-free therapy

Background and Aims: Concomitant presence of autoimmune hepatitis (AIH) and primary sclerosing cholangitis (PSC) is labelled as AIH-PSC overlap syndrome or autoimmune sclerosing cholangitis (ASC). Treatment of AIH with corticosteroids and azathioprine; and of the PSC component with ursodeoxycholic acid (UDCA) is the standard practice. Antibiotics are increasingly being shown to have benefit in PSC but their role in paediatric ASC is not well evaluated. We investigated the response to oral antibiotics as initial or subsequent therapy in children with ASC. Methods: Patients diagnosed with ASC on basis of biochemical, liver biopsy and radiology findings were included. They received metronidazole or vancomycin for 14 days [10-220] either at diagnosis (i.e. initial therapy) or during their maintenance period. When antibiotics were administered as initial therapy, steroid free induction regime was adopted. In children during the maintenance phase antibiotics were administered if they had not achieved biochemical remission with their standard treatment of steroids, azathioprine and UDCA. The outcome parameters to assess the efficacy of antibiotics were achievement of biochemical remission and additionally steroid avoidance when given in the initial therapy. Results: Ten children with ASC were included, of which 6 received oral antibiotics (4 metronidazole, 2 vancomycin) at diagnosis and 4 received metronidazole during the maintenance period. All patients showed a significant decrease in their AST (-55%, p=0,005), ALT (-84%, p=0,003) and GGT (-53%, p=0,003), without significant difference across the two groups. All six children in the initial therapy group did not need corticosteroids and continued to be in remission until last follow up duration of 400 days [216-888]. Among the four children administered antibiotics in the maintenance phase, two showed biochemical remission and steroids could be tapered; while two did not show any benefit. There was transient biochemical relapse after stopping antibiotics in one responder, for which they were restarted and continued until last follow up while continuing to be in remission. Conclusions: We demonstrate the benefit of antibiotics in ASC by achieving steroid free treatment when given at diagnosis as induction regime. When given in the maintenance phase they assist in achieving long term biochemical remission in an otherwise uncontrolled ASC