European Association For The Study Of Liver Research Articles

Drug-induced liver injury in children: A nationwide cohort study from China

Background & AimsCurrently, there is limited knowledge on the clinical profile of drug induced liver injury (DILI) in Chinese children. We aimed to assess the clinical characteristics, suspected drugs, and outcomes associated with pediatric DILI in China. MethodsThis nationwide, multi-center, retrospective study, conducted between 2012 and 2014, analyzed 25,927 cases of suspected DILI at 308 medical centers using the inpatient medical register system. Utilizing the Roussel Uclaf Causality Assessment Method (RUCAM) score, only patients with scores>6 or diagnosed with DILI by at least two experts after scoring <6 were included in the analysis. Among them, 460 cases met the European Association for the Study of Liver (EASL) biochemical criteria. The study categorized children into three age groups: toddlers (≥30 days to <6 years old), school-age children (6 to <12 years old), and adolescents (12 to <18 years old). ResultsHepatocellular injury was the predominant clinical classification, accounting for 63% of cases, with 34% of these cases meeting Hy's law criteria. Adolescents comprised the majority of children with moderate/severe DILI (65%). Similarly, adolescents faced a significantly higher risk of severe liver injury compared to younger children (adjusted odd ratio [aOR]=4.75, p =.002). The top three most frequently prescribed drug classes across all age groups were antineoplastic agents (25.9%), antimicrobials (21.5%), and traditional Chinese medicine (TCM, 13.7%). For adolescents, the most commonly suspected drugs were antituberculosis drugs (22%) and TCM (23%). ConclusionAdolescents are at a greater risk of severe and potentially fatal liver injury compared to younger children. Recognizing the risk of pediatric DILI is crucial for ensuring safe medical practices.

Review of the European Association for Study of the Liver (EASL) Congress 2023

Review of the European Association for Study of the Liver (EASL) Congress 2023

HCV Management: Recent Updates

Background: Hepatitis C virus (HCV) has been a major public health threatboth worldwide and in Bangladesh due to itsconsiderable disease burden, morbidities, and death. An individualized, cost-effective, standard treatment regimen can help combat and eliminate HCV once and for all. Methods: This is an executive summary of the latest EASL (European Association for the Study of the Liver) recommendationsbased on existing literature, and clinical expertise from a panel of specialists chosen by the EASL Governing Board. Additionally, author’s clinical experience is undertaken for considering country level context. Results: HCV infection requires personalized treatment, based on factors such as genotype, liver fibrosis stage, and comorbidities. Direct-acting antiviral (DAA) regimens have replaced interferon, and are recommended as the first-line treatment for all patients with chronic HCV infection, irrespective of genotype. It is recommended to initiate treatment as soon as possible to prevent the progression of liver disease, and associated complications. For patients with decompensated cirrhosis, liver transplantation should be considered as a treatment option after weighing risk-benefit. Additionally, the management of special populations such as children, pregnant women, lactating mother, HCVpatients co-infected with HIV, HBV or SARS-CoV-2, patients with renal impairment, haemoglobin-opathies or bleeding disorders require special attention. Monitoring patients during and after treatment is recommended to ensure sustained virologic response (SVR), to detect any potential complication, and to check potential HCV reinfection. Conclusion: The EASL recommendations provide a comprehensive overview on personalized treatment of HCV, and monitoring for optimal patient outcomes, ushering high hopes for HCV elimination in the future. Bangladesh J Medicine 2023; Vol. 34, No. 2(1) Supplement: 188

Evaluation of Drug Interactions in Patients Treated with DAAs for Hepatitis C Therapy with Comorbidities and Cardiovascular Issues—A Delphi Consensus Project

Orally administered direct-acting antivirals (DAAs) have dramatically changed the possibility of curing HCV (hepatitis C virus) infection, with the two principal HCV regimens based on the combination of glecaprevir + pibrentasvir (GLE-PIB) and sofosbuvir + velpatasvir (SOF-VEL). A combination of drugs containing NS3/4A protease inhibitors, as well as the fact that almost all HCV patients can be treated at present, may expose patients to a higher rate of drug-drug interactions (DDIs). The hepatitis C treatment recommendations from the EASL (European Association for the Study of the Liver) state that, prior to starting treatment with a DAA, a detailed drug history should be taken; yet, the decision on managing the potential DDIs is not always clear. For this reason, a group of Italian cardiologists and hepatologists promoted a survey among colleagues to assess the controversial issues when treating patients with chronic hepatitis C taking concomitant cardiovascular drugs, aiming to reach a consensus on the best practice to apply when treating a patient with chronic hepatitis C who is taking concomitant drugs for cardiovascular diseases. Two consecutive questionnaires were proposed between June and July 2022 to a qualitative Expert Panel (EP) of 14 gastroenterologists, infectologists, hepatologists, and internists, with statistical analyses performed on 100% of the responses for both questionnaires. Agreement among experts was assessed following the Delphi method as developed by the RAND Corporation. The interviewed experts consider DDIs a critical clinical problem to be evaluated in HCV patients. Therefore, dose changes, drug substitution, and discontinuation of concomitant cardiovascular drugs should be discouraged, even if planned for a relatively short period. Since oral DAAs have different DDIs profiles, hepatologists should prefer the antiviral DAA combination presenting the lowest instance of potential interactions.

Spontaneous Bacterial Peritonitis in Alcoholic Cirrhosis

Background: Spontaneous bacterial peritonitis (SBP) is one of the most common complications in cirrhosis with ascites, which is associated with a high mortality. Various studies have shown that the prevalence of PBS ranges from 20-30% in patients with cirrhosis and ascites. Not in all cases it is accompanied by obvious symptoms, which makes early diagnosis difficult. Aim: The aims of this study were to assess the prevalence and the risk factors of PBS in alcohoolic liver cirrhosis. Methodology: This is a retrospective study, which considers all cases diagnosed with PBS admitted to our hospital during 2018-2021. Diagnosis is based on the European Association for the Study of Liver (EASL) guidelines. The patients were divided into two groups, alcohoolic cirrhosis with PBS, and without PBS. Data collection consists of filling out a standard form for each patient,which contained information about the diagnosis, the degree of liver function damage evaluated by Child-Pough score and MELD score, clinical and laboratory indicators and complications associated with cirrhosis with PBS, ascitic fluid analyses. All categorical variables were analised by using SPSS version 25, and t-test were used for continuous date. Results: The average age of the patients included in the study was 54.15 ± 12.5 years, while according to gender, there were 112 males (97.3%) and 3 females (2.7%). According to the evaluation of MELD, it was seen to be higher in the group with PBS than those without PBS (p &lt; 0.05). The most frequent complications accompanying PBS were Encephalopathy (p &lt; 0.004), hepatorenal syndrome (p &lt; 0.004), gastro\intestinal hemorrhage (p &lt; 0.004). From laboratory data, platelets (p &lt; 0.015), creatinine (p &lt; 0.006), bilirubin (p &lt; 0.002), INR (p &lt; 0.049) and prothrombin level (p &lt; 0.002) were seen as predictive factors. Conclusions: The most probable predictive factors in the case of PBS in alcoholic cirrhosis were found the low level of platelets, prolonged level of INR and prothrombin, increased level of creatinine. While the most frequent associated complications were hepatic encephalopathy, HRS, G\I hemorrhage, jaundice.

Simplifying Treatment Criteria in Chronic Hepatitis B: Reducing Barriers to Elimination.

Early, sustained hepatitis B virus (HBV) DNA suppression reduces long-term risks of hepatocellular carcinoma. Chronic hepatitis B (CHB) treatment criteria are complex. Simplifying criteria will improve timely linkage to therapy. We evaluated treatment eligibility patterns among US patients with CHB and propose stepwise simplification of CHB treatment criteria. Using 2016-2020 Quest Diagnostics data, we evaluated treatment eligibility among patients with CHB (2 positive HBV tests [HBV surface antigen, HBV e antigen, or HBV DNA] ≥6 months apart) using American Association for the Study of Liver Disease (AASLD), European Association for Study of the Liver (EASL), Asian Pacific Association for Study of the Liver (APASL), and Asian American Treatment Algorithm (AATA) criteria. Among 84 916 patients with CHB, 6.7%, 6.2%, 5.8%, and 16.4% met AASLD, EASL, APASL, and AATA criteria, respectively. Among treatment-ineligible patients with CHB, proportion with significant fibrosis (aspartate aminotransferase platelet ratio index >0.5) were 10.4%, 10.4%, 10.8%, and 7.7% based on AASLD, EASL, APASL, and AATA, respectively. In the proposed treatment simplification, the proportion of patients with CHB eligible for therapy increased from 10.3% for step 1 (HBV DNA >20 000 IU/mL, elevated alanine aminotransferase [ALT] level) to 14.1% for step 2 (HBV >2000 IU/mL, elevated ALT level), 33.5% for step 3 (HBV DNA >2000 IU/mL, any ALT level), and 87.2% for step 4 (detectable HBV DNA, any ALT level). A large proportion of patients with CHB not meeting established treatment criteria have significant fibrosis. Simplifying criteria to treat all patients with detectable HBV DNA will reduce complexity and heterogeneity in assessing treatment eligibility, improving treatment rates and progress toward HBV elimination.

The Negative Bidirectional Interaction Between Climate Change and the Prevalence and Care of Liver Disease: A Joint BSG, BASL, EASL, and AASLD Commentary

The Negative Bidirectional Interaction Between Climate Change and the Prevalence and Care of Liver Disease: A Joint BSG, BASL, EASL, and AASLD Commentary

Therapeutic plasma exchange in children with acute liver failure (ALF): is it time for incorporation into the ALF armamentarium?

Paediatric acute liver failure (PALF) is a rare but devastating condition with high mortality. An exaggerated inflammatory response is now recognised as pivotal in the pathogenesis and prognosis of ALF, with cytokine spill from the liver to systemic circulation implicated in development of multi-organ failure associated with ALF. With advances in medical management, especially critical care, there is an increasing trend towards spontaneous liver regeneration, averting the need for emergency liver transplantation or providing stability to the patient awaiting a graft. Hence, research is ongoing for therapies, including extracorporeal liver support devices, that can bridge patients to transplant or spontaneous liver recovery. Considering the immune-related pathogenesis and inflammatory phenotype of ALF, plasma exchange serves as an ideal liver assist device as it performs both the excretory and synthetic functions of the liver and, in addition, works as an immunomodulatory therapy by suppressing the early innate immune response in ALF. After a recent randomised controlled trial in adults demonstrated a beneficial effect of high-volume plasma exchange on clinical outcomes, this therapy was incorporated in European Association for the Study of Liver (EASL) recommendations for managing adult patients with ALF, but no guidelines exist for PALF. In this review, we discuss rationale, timing, practicalities, and existing evidence regarding the use of plasma exchange as an immunomodulatory treatment in PALF. We discuss controversies in delivery of this therapy as an extracorporeal device, and practicalities of use of plasma exchange as a ‘hybrid’ therapy alongside other extracorporeal liver assist devices, before finally reviewing outstanding research questions for the future.

Prevalence of drug-drug interactions with pangenotypic direct-acting antivirals for hepatitis C and real-world care management in the United States: a retrospective observational study.

BACKGROUND: Direct-acting antiviral (DAA) regimens for hepatitis C virus (HCV) have varying potentials for drug-drug interactions (DDIs). OBJECTIVES: To (1) identify prevalence of potential DDI with glecaprevir-pibrentasvir (GLE-PIB) and sofosbuvir-velpatasvir (SOF-VEL) and (2) describe health care provider actions in response to pharmacist recommendations based on potential interactions with GLE-PIB or SOF-VEL, using 2 complementary data sources. METHODS: Possible interacting drugs were identified among adult patients in a United States electronic medical record database covering 21 health care organizations and 26 million patients in 2018. DDIs were categorized as potential weak interaction (Level 1), potential interaction (Level 2), or contraindicated (Level 3). Real-world recommendations and resultant actions regarding DDIs with GLE-PIB and SOF-VEL were obtained from a specialty pharmacy database. Categorical variable comparisons were done via chi-square analysis with subsequent z-tests of column proportions. RESULTS: DDI prevalence was higher for patients prescribed GLE-PIB (317/769 [41%]) compared with those prescribed SOF-VEL (170/633 [27%]), and the prevalence of a Level 3 (contraindicated) interaction was higher with GLE-PIB than SOF-VEL (61/769 [8%] vs 2/633 [< 1%]). Across all DDI levels, analgesics (139/317 [44%]), proton-pump inhibitors (129/317 [41%]), and lipid-lowering agents (59/317 [19%]) were the top drug classes for the GLE-PIB group with potential for DDI. For SOF-VEL prescribed patients, the top drug classes were proton-pump inhibitors (83/170 [49%]), histamine-2 blockers (42/170[25%]), and lipid-lowering agents (42/170 [25%]). In real-world care management, the overall prevalence of pharmacist recommendations regarding DDIs was significantly lower for SOF-VEL (28/419 [7%]) relative to GLE-PIB (151/1,216 [12%]). Recommended guidance from pharmacists was not followed for 39% (69/179) of patients, 36% (54/151) for GLE-PIB, and 54% (15/28) for SOF-VEL. CONCLUSIONS: The potential for DDIs with pangenotypic HCV DAAs is frequent and may be more frequent with GLE-PIB than SOF-VEL. Physician responses to pharmacist alerts regarding potential interaction can be highly variable, even in cases of contraindication. DISCLOSURES: Funding for this study was provided by Gilead Sciences, Inc. Trio Health Analytics received funding from Gilead Sciences, Inc., to conduct research for this study. Tsai consults for and has received grants and honoraria from Gilead, AbbVie, Merck, and Bristol Myers Squibb; he has also received lecture fees from Gilead and AbbVie. Curry consults for Trio Health Analytics and Gilead and has also consulted for and received grants from Mallinckrodt. Flamm consults for and has received lecture fees from Gilead and AbbVie; he has also received grants from Gilead and AbbVie. Milligan and Wick are employed by Trio Health Analytics and have received research support from Gilead, Merck, and AbbVie. Younossi has received grants from Gilead, Intercept, Bristol Myers Squibb, GlaxoSmithKline, and Novo Nordisk. Afdhal is a paid consultant/advisory board member for Gilead, Echosens, Ligand, Shionogi, and Trio Health; owns stock in Spring-Bank and Allurion and has stock options in SpringBank; receives royalty income from UpToDate; and is on the board of directors for the nonprofit Liver Institute for Education and Research. Data from this study were presented at the American Association for the Study of Liver Disease (AASLD) Liver Meeting 2019; November 8-12, 2019; Boston, MA, and the European Association for Study of the Liver (EASL) International Liver Congress 2020; August 27-29, 2020; virtual.

COVID-19 in Chronic Liver Disease and Liver Transplantation: A Clinical Review.

The coronavirus disease 2019 (COVID-19) pandemic has brought challenges to clinicians caring for patients with chronic liver disease. In the past 6 months, COVID-19 has led to over 150,000 deaths in the United States and over 660,000 deaths around the world. Mounting evidence suggests that chronic liver diseases can have an adverse effect on the clinical outcomes of patients with COVID-19. We present a comprehensive review of the latest literature on preexisting liver diseases and its interrelationship with COVID-19 infection in cirrhosis, hepatocellular carcinoma, nonalcoholic fatty liver disease, autoimmune hepatitis, and viral hepatitis B. As social distancing and telemedicine gain new footing, we synthesize recommendations from 3 major hepatology societies [American Association for the Study of Liver Disease (AASLD), the European Association for the Study of Liver (EASL), and the Asian Pacific Association for the Study of Liver (APASL)] to present the best approaches for caring for patients with liver diseases as well as those requiring liver transplantation.

Prediction of overall survival in patients with hepatocellular carcinoma treated with Y-90 radioembolization by imaging response criteria

PurposeTo evaluate the potential of imaging criteria in predicting overall survival of patients with hepatocellular carcinoma (HCC) after a first transcatheter arterial yttrium-90 radioembolization (TARE) Materials and methodsFrom October 2013 to July 2017, 37 patients with HCC were retrospectively included. There were 34 men and 3 women with a mean age of 60.5±10.2 (SD) years (range: 32.7–78.9 years). Twenty-five patients (68%) were Barcelona Clinic Liver Cancer (BCLC) C and 12 (32%) were BCLC B. Twenty-four primary index tumors (65%) were>5cm. Three radiologists evaluated tumor response on pre- and 4–7 months post-TARE magnetic resonance imaging or computed tomography examinations, using Response Evaluation Criteria in Solid Tumors (RECIST) 1.1, modified RECIST (mRECIST), European Association for Study of the Liver (EASL), volumetric RECIST (vRECIST), quantitative EASL (qEASL) and the Liver Imaging Reporting and Data System treatment response algorithm. Kaplan–Meier survival curves were used to compare responders and non-responders for each criterion. Univariate and multivariate Cox proportional hazard ratio (HR) analysis were used to identify covariates associated with overall survival. Fleiss kappa test was used to assess interobserver agreement. ResultsAt multivariate analysis, RECIST 1.1 (HR: 0.26; 95% confidence interval [95% CI]: 0.09–0.75; P=0.01), mRECIST (HR: 0.22; 95% CI: 0.08–0.59; P=0.003), EASL (HR: 0.22; 95% CI: 0.07–0.63; P=0.005), and qEASL (HR: 0.30; 95% CI: 0.12–0.80; P=0.02) showed a significant difference in overall survival between responders and nonresponders. RECIST 1.1 had the highest interobserver reproducibility. ConclusionRECIST and mRECIST seem to be the best compromise between reproducibility and ability to predict overall survival in patients with HCC treated with TARE.

Chronic hepatitis B in children, report of a single-centre longitudinal study on 152 children.

The aims of this prospective study were as follows: (1) to describe the natural history of chronic hepatitis B virus (HBV) infection in a large cohort of untreated children followed at a single centre and (2) to evaluate whether or not the new European Association for the Study of Liver (EASL) classification for the phases of HBV infection in adults can be used for children. All children who presented at the Liver Unit of our hospital from 1 January 1987 to 31 December 2019 and were diagnosed with chronic HBV infection were enrolled. The final sample consisted of 152 children. The median duration of the follow-up was 83months (range 7-232). At baseline, 125 patients (82.2%) were HBeAg positive (85.3% abnormal alanine aminotransferase (ALT) levels), and 24 (15.8%) were HBeAg-negative (93.3% abnormal ALT). At the end of the observation period, 62 of the HBeAg-positive patients (40.7%) achieved HBeAg seroconversion (median age 9.45years, range 0.8-19) and 2 (1.4%) achieved HBsAg seroconversion. Elevated ALT serum levels at baseline (P=.011), lower baseline HBV DNA levels (P<.001) and Asian ethnicity (P=.0001) were identified as predisposing factors towards HBeAg seroconversion. EASL criteria could not be applied to 43.3% and 43.5% of the children at baseline and at end of observation, respectively, that were grouped into an undetermined phenotype category. According to the results of the present study, the new EASL guidelines for adults with HBV infection cannot be applied in a satisfactory manner in children.

Spontaneous Bacterial Peritonitis: We Are Still Behind.

Spontaneous bacterial peritonitis (SBP) is an infection in the ascitic fluid. Despite published guidelines, an inappropriate diagnosis of SBP is frequent. In this study, we aim to evaluate guideline adherence in diagnosing SBP. This is a retrospective study conducted between January 2015 and January 2018. Based on the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of Liver (EASL), two authors judged guideline adherence in SBP diagnosis and management. One hundred and six patients were included in the study, and 93% were hospitalized. The mean age was 56.9 years, and 62 patients were males. In addition, Caucasians were the most common ethnicity (86.8%). The authors judged that only 52.4% of patients were appropriately diagnosed, and only 67.3% were managed with proper treatment. Inpatient mortality was documented in five patients, and the readmission rate within 30-days after discharge was 29.3%. In conclusion, SBP is a common complication of cirrhosis, which can be managed with adherence to published guidelines. In our population, guidelines were not implemented in diagnosing nearly half the SBP patients, mostly due to misdiagnosis of SBP with secondary peritonitis or non-neutrocytic bacteriascites, starting antibiotics before performing the paracentesis, and even giving broad-coverage antibiotics when not indicated. Further efforts are needed to enhance adherence to guidelines in clinical practice.

TREATMENT OF HEPATITIS C IN SELECTED CLINICAL SETTINGS

This article aims to review the treatment strategy of Hepatitis C in compelling indications and provide the literature update, mainly discussing the EASL (European Association for the Study of the Liver) recommendations, which described the current optimal management of patients with acute and chronic HCV infections. The review will focus on HCV infection in selected clinical settings including patients with immune complex-mediated manifestations of chronic hepatitis C, patients with chronic kidney disease (CKD) or renal end-stage renal disease (ESRD), and solid organ transplant recipients.

APPROACH TO A PATIENT WITH HEPATITIS C: DIAGNOSIS AND PRETREATMENT ASSESSMENT

Chronic infection with hepatitis virus C affects more than 70 million individuals worldwide. Hepatitis C infection is the leading cause of end-stage liver disease, hepatocellular carcinoma, and multiple extrahepatic manifestations associated with immune system disorders and chronic inflammation. In the era of interferon-free anti-HCV regimens, clinical care for patients with HCV-related liver disease and extrahepatic complications has advanced significantly because of improvements in therapy and prevention. The antiviral capacity of a new generation of direct-acting agents provide high rates of sustained virological response, and it is expected to improve clinical outcomes in these patient populations. The article aims to review published data on the treatment strategy of hepatitis C, including the EASL (European Association for the Study of the Liver) recommendations.

Complications constitute a major risk factor for mortality in hepatitis B virus-related acute-on-chronic liver failure patients: a multi-national study from the Asia-Pacific region.

Cirrhosis is a controversial determinant of mortality in HBV-related acute-on-chronic liver failure (HBV-ACLF). The present study aimed to explore the effects of cirrhosis and the associated risk factors, especially its complications, on the outcome of HBV-ACLF. A prospective-retrospective cohort of 985 patients was identified from the APASL-ACLF Research Consortium (AARC) database and the Chinese Study Group. Complications of ACLF (ascites, infection, hepatorenal syndrome, hepatic encephalopathy, upper gastrointestinal bleeding) as well as cirrhosis and the current main prognostic models were measured for their predictive ability for 28- or 90-day mortality. A total of 709 patients with HBV-ACLF as defined by the AARC criteria were enrolled. Among these HBV-ACLF patients, the cirrhotic group showed significantly higher mortality and complications than the non-cirrhotic group. A total of 36.1% and 40.1% of patients met the European Association for the Study of Liver (EASL)-Chronic Liver Failure consortium (CLIF-C) criteria in the non-cirrhotic and cirrhotic groups, respectively; these patients had significantly higher rates of mortality and complications than those who did not satisfy the CLIF-C criteria. Furthermore, among patients who did not meet the CLIF-C criteria, the cirrhotic group exhibited higher mortality and complication rates than the non-cirrhotic group, without significant differences in organ failure. The Tongji prognostic predictor model score (TPPMs), which set the number of complications as one of the determinants, showed comparable or superior ability to the Chinese Group on the Study of Severe Hepatitis B-ACLF score (COSSH-ACLFs), APASL-ACLF Research Consortium score (AARC-ACLFs), CLIF-C organ failure score (CLIF-C OFs), CLIF-C-ACLF score (CLIF-C-ACLFs), Model for End-Stage Liver Disease score (MELDs) and MELD-sodium score (MELD-Nas) in HBV-ACLF patients, especially in cirrhotic HBV--ACLF patients. Patients with two (OR 4.70, 1.88) or three (OR 8.27, 2.65) complications had a significantly higher risk of 28- or 90-day mortality, respectively. The presence of complications is a major risk factor for mortality in HBV-ACLF patients. TPPM possesses high predictive ability in HBV-ACLF patients, especially in cirrhotic HBV-ACLF patients.

1115 Spontaneous Bacterial Peritonitis: We Are Still Behind

INTRODUCTION: Spontaneous bacterial peritonitis (SBP) is an infection in the ascitic fluid when there is no evidence of intra-abdominal surgically treatable source of infection. It has an estimated in-hospital mortality rate of 20%. Despite the published guidelines, inappropriate diagnosis of SBP is frequent. In this study, we aim to measure the percentage of inappropriate diagnosis and treatment of SBP. METHODS: A retrospective study was conducted between Jan-2015 and Jan-2018. Based on the American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of Liver (EASL) two authors judged the adherence to the guidelines in diagnosis and management of SBP. A third author resolved conflicts. Data was analyzed by chi-square analysis/Mann Whitney U Tests, ANOVA, and t-tests. RESULTS: One hundred six patients were included in the study. 93.3% (98/106) of them were hospitalized. Mean age was 56.9 years (range 32-87). 58.5% (62/106) of the patients were males. Caucasian was the most common ethnicity, with 86.8% (92/106). Smoking use was present in 41.5%, and alcohol use was present in 28.3% of our sample. Alcohol was the most common cause of cirrhosis in 50% of the patients, and viral hepatitis was the second (21.7%). Prior SBP was found in 24.5% of the population. Mean WBC 11.1, Mean MELD-Na score 23.5 (range 8-42), and mean Albumin 2.8 (1.6-4.9). Polymorphonuclear neutrophils (PMN) was neutrocytic (&gt;250) in 54.8% (46/106). 81.8% of the ascitic cultures were negative. 16.2% of the cultures grew one organism, and 1.9% of them were polymicrobial. Albumin was given in 62.1%, and 52.4% on day 1 and day 3, respectively. Hepatology was consulted on 80.2% of the patients. Authors judged that only 52.4% of patients were appropriately diagnosed, and only 67.3% were managed with appropriate treatment. Inpatient mortality documented in 5 patients. The readmission rate was 29.3%. CONCLUSION: SBP is a common complication of cirrhosis, that can be easily managed if we adhere to the published guidelines. In our population, nearly half of the patients were diagnosed and treated inappropriately; this was mostly due to misdiagnosis of SBP with secondary peritonitis or non-neutrocytic bacteriascites, starting antibiotics before performing the paracentesis, and even given broader antibiotics when it is not needed. Further efforts should stress to adopt the guidelines in clinical practice.

Tumor Response Criteria in Oncoimaging: RECIST Criteria and beyond—Part 2

AbstractThe rapid recent advances in oncology have made the dream of precision oncology a reality, with targeted therapy available for various tumors depending on the molecular genotype. This has led to the corresponding development of personalized radiology as well, with various tumor response criteria used to characterize disease response/progression depending on chemotherapy used. In these two review articles, we review the various tumor response criteria widely applied in both research and clinical settings. These include the classic size-based criteria such as RECIST (Response Evaluation Criteria In Solid Tumors) 1.1 and the WHO (World Health Organization) criteria, as also various other criteria such as Choi and modified Choi criteria for tumors treated by targeted therapy, EASL (European Association for the Study of the Liver) and modified RECIST (mRECIST) criteria for hepatocellular carcinomas, immune-related response criteria (irRC) and immune RECIST (iRECIST) for patients on immunotherapy. Other clinically important criteria such as PERCIST (PET Response Criteria In Solid Tumors) for positron emission tomography–computed tomography (PET-CT), and the MD Anderson criteria for evaluating bone metastases are also highlighted.

Correlation of polymorphous variants (ApaI, TagI, BsmI) of the VDR receptor gene with the vitamin D level and liver fibrosis in children with autoimmune hepatitis

The aim. To study the correlation of the frequency distribution of alleles, genotypes and their combinations for the allelic variants of ApaI, TagI, BsmI of the Vitamin D receptor gene (VDR) with the vitamin D levels and the stage of fibrosis in children with autoimmune hepatitis.Materials and methods. 51 children with autoimmune hepatitis were examined between 2016 and 2018. In all children, the diagnosis was confirmed in accordance with the International Guidelines for the study of liver diseases (European Association for the Study of Liver (EASL) Clinical Practice Guidelines: Autoimmune Hepatitis, 2015). In the examined children, the elastography of the liver parenchyma was performed by the shear wave method. Needle biopsy of the liver with histological examination of the specimens was performed in 42 children. The disease activity was determined using the histological activity index (HAI) by Knodell based on the results of a morphological study of the liver biopsy and biochemical parameters. The stage of the disease was evaluated by the histological index of fibrosis using the METAVIR scoring system and semi-quantitatively using the share wave elastography of liver parenchyma. A level of 25(OH)D was determined in the blood serum. The determination of the ApaI, TagI, BsmI polymorphic loci of vitamin D receptor (VDR) was carried out using the molecular-genetic method. The association of polymorphic variants of the VDR gene with the level of vitamin D and the stage of liver fibrosis in children with autoimmune hepatitis has been evaluated.Results. 72.0 % of the examined children had advanced severe liver fibrosis (F3-4 by the METAVIR score), among them 34.0 % of children had signs of liver cirrhosis. Children with advanced severe fibrosis (F3–4 by the METAVIR score) had the CC genotype of the polymorphic version of the TagI of the VDR gene significantly more often (χ2 = 3.953; P &lt; 0.05), and the genotype AA/CC/AA according to the investigated allelic variants of the VDR gene (χ2 = 3.953; P &lt; 0.05). In 72.5 % of the examined children, there was a deficiency of vitamin D. In children with severe fibrosis (F3–4 by the METAVIR score) vitamin D deficiency was significantly more frequent as compared to children with less severe fibrosis (F1–2 by the METAVIR score) (χ2 = 5,207; P = 0.023). The genotype GA of the BsmI polymorphic variant was associated with a decrease in serum vitamin D levels (P &lt; 0.05). At the AC/TC/GA combination of the ApaI, TagI and BsmI allelic variants of the VDR gene, vitamin D deficiency was registered significantly more frequently (P &lt; 0.05).Conclusions. The level of vitamin D in children with autoimmune hepatitis was dependent on the stage of fibrosis. Children with severe fibrosis had a genetically determined vitamin D deficiency significantly more often. Vitamin D deficiency was associated with the CC genotype presence of the TagI polymorphic variant of the VDR gene in patients as well as the GA genotype of the BsmI polymorphic variant and the AC/TC/GA genotype of the three allelic variants of the gene studied.

Clinical presentations of Hepatitis E: A clinical review with representative case histories

SummaryHepatitis E virus (HEV) typically causes an acute, self-limiting hepatitis and is among the commonest cause of such presentations. Hepatitis E viral infection is also increasingly recognized as a cause of chronic hepatitis amongst the immunocompromised, particularly amongst solid organ transplant recipients. Chronic HEV infection remains an underdiagnosed disease and chronic infection can lead to rapidly progressive liver fibrosis and cirrhosis. This review examines current understanding of the HEV. We illustrate typical clinical presentations, management strategies [(based upon guidelines from both the British Transplant Society (BTS) and European Association for the study of liver (EASL)] and outcomes of HEV infection in different cohorts of patients by highlighting select transplant and non-transplant patient cases, from one of the largest tertiary Hepatology centres in Europe.