Reduction In Alkaline Phosphatase Levels Research Articles

Retrospective study on the diagnosis, treatment, and follow-up of 85 cases of hypophosphatemic rickets in children

To study the diagnosis, treatment, and complications of hypophosphatemic rickets (HR) in children, explore effectiveness evaluation indicators for the disease, and understand the pattern in height growth among these patients. A retrospective analysis of the initial clinical data and five-year follow-up data of 85 children with HR treated at Children's Hospital of Nanjing Medical University from January 2008 to December 2022. Among the 85 children with HR, there were 46 males (54%) and 39 females (46%). The age at initial diagnosis ranged from 6 months to 13 years and 9 months, with a median age of 2.75 years. The average height standard deviation score was -2.0±1.1. At initial diagnosis, children exhibited reduced blood phosphate levels and elevated alkaline phosphatase (ALP), with 99% (84/85) presenting with lower limb deformities. The positive rate for PHEX gene mutations was 93% (55/59). One year post-treatment, there was a significant reduction in ALP levels and the gap between the lower limbs (P<0.05). The fastest height growth occurred in the first year after treatment, at 8.23 cm/year, with a peak height velocity (PHV) phase lasting about two years during puberty. The height increased by 9-20 cm in male children during the PHV stage and 10-15 cm in female children. Major complications included nephrocalcinosis and hyperparathyroidism. The incidence rate of nephrocalcinosis in the first year after treatment was 55% (22/40), which increased with the duration of the disease (P<0.001); an increased urinary phosphate/creatinine ratio was positively associated with a higher risk of nephrocalcinosis (OR=1.740, P<0.001). The incidence of hyperparathyroidism in the first year after treatment was 64% (27/42). For children presenting with lower limb deformities, short stature, and slow growth, early testing for blood levels of phosphate, calcium, and ALP, along with imaging examinations of the lower limbs, can aid in the early diagnosis of HR. Genetic testing may be utilized for definitive confirmation when necessary. ALP combined with improvements in skeletal deformities and annual height growth can serve as indicators of therapeutic effectiveness for HR. Compared to normal children, children with HR demonstrate a lower height increase during the PHV phase, necessitating close follow-up and timely adjustment of treatment plans Citation:Chinese Journal of Contemporary Pediatrics, 2024, 26(7): 677-682.

Vascular adhesion protein-1 blockade in primary sclerosing cholangitis: Open-label, multicenter, single-arm, phase II trial.

Primary sclerosing cholangitis is a progressive inflammatory liver disease characterized by biliary and liver fibrosis. Vascular adhesion protein-1 (VAP-1) is important in the inflammatory process driving liver fibrosis. We evaluated the safety and efficacy of VAP-1 blockade with a monoclonal antibody (timolumab, BTT1023) in patients with primary sclerosing cholangitis. BUTEO was a prospective, single-arm, open-label, multicenter, phase II trial, conducted in 6 centers in the United Kingdom. Patients with primary sclerosing cholangitis aged 18-75 years had an alkaline phosphatase value of >1.5 times the upper limit of normal. The dose-confirmatory stage aimed to confirm the safety of timolumab through the incidence of dose-limiting toxicity and sufficient trough levels of circulating antibody to block VAP-1 function. The primary outcome of the dose-expansion portion of the trial was patient's response to timolumab at day 99, as measured by a reduction in serum alkaline phosphatase by 25% or more from baseline to day 99. Twenty-three patients were recruited: 7 into the initial dose-confirmatory stage and a further 16 into an expansion stage. Timolumab (8mg/kg) was confirmed to be safe for the duration of administration with sufficient circulating levels. Only 2 of the 18 evaluable patients (11.1%) achieved a reduction in alkaline phosphatase levels of 25% or more, and both the proportion of circulating inflammatory cell populations and biomarkers of fibrosis remained unchanged from baseline. The BUTEO trial confirmed 8mg/kg timolumab had no short-term safety signals and resulted in sufficient circulating levels of VAP-1 blocking timolumab. However, the trial was stopped after an interim assessment due to a lack of efficacy as determined by no significant change in serum liver tests.

Relationship of calcium-sensing receptor gene polymorphism CASR rs 1042636, CASR rs 1802757, and cinacalcet response among Egyptian hemodialysis patients with secondary hyperparathyroidism

Introduction: Secondary hyperparathyroidism (SHPT) is a common complication associated with morbidity and mortality among hemodialysis (HD) patients. Objectives: The current study aims to evaluate the frequency of CASR gene polymorphism variants related to parathyroid hormone (PTH) regulation (CASR rs1042636 and CASR rs1802757) and to test the hypothesis that single nucleotide polymorphisms (SNPs) in the CASR gene alter the response to cinacalcet among Egyptian HD patients with SHPT. Patients and Methods: A case-control study that included 50 HD patients with intact parathyroid hormone (iPTH) ≥300 pg/mL treated with cinacalcet for a 6-month duration and 40 healthy volunteers as a control group. Eligible patients were recruited from Ain Shams university hospitals. Blood samples were collected from patients and controls to assess allele frequencies of CASR gene polymorphism variants using real-time polymerase chain reaction (PCR), corrected calcium (Ca), phosphorus (P), Ca×P product, iPTH level, and alkaline phosphatase before and after treatment. HD patients were categorized into two groups based on the reduction percentage; responders’ patients (iPTH ≥20%) and non-responders to cinacalcet treatment. Results: Of 50 HD patients, 48 (96%) carried the rs1042636 AA wild gene, while only two (4%) carried the rs1042636 AG mutant gene, 42 (87.5%) carried the rs1802757 CC wild genotype, and 6 (12.5%) carried the CT mutant genotype. The minor alleles T and G were (6.3% and 2%) respectively, with no statistically significant difference between the patient and control groups regarding the CASR genotypes or alleles distribution. There was no significant difference between responders and non-responder’s patient groups regarding CASR genotypes or allele frequencies. Moreover, no significant correlation between CASR genotypes or alleles to delta change of Ca, P, Ca×P product, or PTH was seen. However, CASR rs1802757 CT mutant genotype was associated with a significant reduction in alkaline phosphatase levels after treatment. Conclusion: There is no significant association between the gene polymorphism CASR rs1042636 or CASR rs1802757 and the reduction in PTH levels as a response to cinacalcet treatment among Egyptian HD patients with SHPT.

Sex differences in the hepatotropic effects of antiulcer drugs and placenta cryoextract in an experimental rat liver injury model

Background/Aim: Sex-related variances in drug metabolism provide a foundation for refining treatment protocols for prevalent conditions based on the patient's sex. Tailoring treatment strategies based on sex is particularly noteworthy among patients with comorbid illnesses due to the potential for drug interactions and the impact of concurrent diseases on clinical outcomes. Aim of this study was to assess the hepatotropic effects of antiulcer drugs (esomeprazole, clarithromycin and metronidazole - E/C/M) and placenta cryoextract (CEP) within a simulated model of tetrachloromethane (CCl4 )-induced hepatitis combined with underlying ethanol-induced liver cirrhosis (EILC), with a focus on the role of subjects' sex. Methods: Using 112 male and female rats, the research explored the effects of different sex hormone levels. Chronic EILC was induced by administering a 50.0 % CCl4 oil solution (8 mL/kg) twice a week, combined with a 5.0 % ethanol solution, over 45 days. Total protein (TP) levels and alkaline phosphatase (AP) activity were measured spectrophotometrically. Results: The research findings indicate that the onset of EILC and the administration of E/C/M resulted in a significantly greater 10.8 % (p = 0.03) reduction in TP levels among females compared to males, without altering hormonal status. Introducing CEP led to a noteworthy (p &lt; 0.001) rise in TP levels, by 30.8 % in males and 33.9 % in females, in the context of EILC and E/C/M administration, while maintaining hormonal status. Among male rats, the most elevated AP activity was observed with excess testosterone propionate administration (5.0 [5.0; 5.9] mmol/L), while the lowest level was recorded in rats after testectomy, measuring 3.8 [2.5; 4.7] mmol/L, exhibiting a significant 20.8 % decrease (p &lt; 0.05) compared to male rats without hormonal status changes. In female rats, the study revealed that against the backdrop of EILC and E/C/M administration, the highest AP level was seen in ovariectomised females, reaching 5.8 [5.1; 6.2] mmol/L, reflecting a substantial 9.4 % increase compared to rats without hormonal status changes. Conclusions: The administration of CEP under similar experimental conditions led to the recovery of the liver's protein-synthesising function in both male and female rats. When female sex hormones were introduced to sham-operated female rats, a significant 20.8 % greater reduction in AP levels was observed. Additionally, gonadectomy led to a more pronounced decrease in this enzyme's levels in male rats compared to female rats, indicating the cytoprotective properties of female sex hormones.

Dexamethasone-Induced Derangement in Some Liver Function Parameters

Background: Dexamethasone is not only a potent glucocorticoid with several health benefits but is also associated with severe side effects, one of which is hepatotoxicity. L-Citrulline is known to possess antioxidant, antidiabetic, and antidyslipidemic effects, among others, of which hepatoprotection has not been extensively explored. We aimed to assess the effect of L-Citrulline on dexamethasone-induced derangement in liver enzymes and serum proteins in Wistar rats. Materials and Methods: Twenty-five male Wistar rats, weighing between 200 and 250 g, were randomly assigned into five groups of five rats each. While Group I received no intervention, dexamethasone intraperitoneally (1 mg/kg) was administered to the other groups for 7 days. Groups III, IV, and V were pretreated with 200, 400, and 800 mg/kg L-Citrulline daily for 21 days, respectively. Biochemical assessment was made after humanely sacrificing the animals. Values at P &lt; 0.05 were considered statistically significant compared to the dexamethasone group. Results: L-Citrulline significantly lowered the levels of aspartate transferase (AST), alanine transferase (ALT), gamma–glutamyltransferase, and serum total and conjugated bilirubin in a dose-dependent manner. The greatest reduction in alkaline phosphatase level by L-Citrulline was recorded at 200 mg/kg (13.96 ± 0.73 IU/L). Similarly, the total protein level was significantly increased by L-Citrulline 800 mg/kg (9.38 ± 0.39 g/dL), but the greatest increase in albumin level was at 400 mg/kg (4.20 ± 0.21 g/dL). In a dose-dependent manner, the AST: ALT ratios were markedly reduced while the albumin: globulin ratios were greatly increased following L-Citrulline supplementation. Conclusion: L-Citrulline supplementation confers hepatoprotective effect against dexamethasone-induced derangements in liver enzymes and serum proteins in Wistar rats.

Proof-of-concept study to evaluate the safety and efficacy of saroglitazar in patients with primary biliary cholangitis

Saroglitazar is a novel peroxisome proliferator-activated receptor (PPAR) agonist with dual agonistic properties (α/γ). Due to a strong mechanistic rationale, we aimed to test the safety and efficacy of saroglitazar in patients with primary biliary cholangitis (PBC) who were either ursodeoxycholic acid (UDCA) resistant or intolerant. In this double-blind, phase II proof-of-concept trial, 37 patients with PBC were randomized to saroglitazar 4 mg (n= 13), saroglitazar 2 mg (n= 14), or placebo (n= 10) daily for 16 weeks. The primary efficacy endpoint was the reduction in alkaline phosphatase (ALP) level at Week16. A significant reduction of mean ALP levels was observed at Week 16 relative to baseline in both the saroglitazar 4 mg (least-squares [LS] mean=-163.3 U/L, SE= 25.1, p <0.001) and 2 mg (LS mean=-155.8 U/L, SE= 24.4, p <0.001) groups, compared with placebo (LS mean=-21.1 U/L, SE= 28.9). Treatment with saroglitazar resulted in a rapid reduction of ALP concentration at Week 4 that was sustained through the study duration. At least 1 treatment-emergent adverse event occurred in 11 (84.6%) patients in the saroglitazar 4 mg group, in 12 (85.7%) patients in the 2 mg group and in 8 (80%) patients in the placebo group. Study drug was discontinued in 4 patients (3 patients in the 4 mg group and 1 patient in the 2 mg group) due to aminotransferase increases that promptly returned to baseline values after drug discontinuation. Saroglitazar at 2 mg and 4 mg daily was tolerated and resulted in rapid and sustained improvements in ALP. Further studies are underway at a daily dose of 2 mg and 1 mg due to the higher incidence of elevated liver enzymes observed with the 4 mg dose. CLINICALTRIALS. NCT03112681 LAY SUMMARY: Saroglitazar resulted in a rapid and sustained improvement in alkaline phosphatase levels in patients with primary biliary cholangitis. The mean percentage reductions in alkaline phosphatase levels were 49% and 51% in the saroglitazar 4 mg and 2 mg groups compared to 3% in the placebo group.

NGM282 for Treatment of Patients With Primary Biliary Cholangitis: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial.

Patients with primary biliary cholangitis (PBC) who had an inadequate response to ursodiol have few treatment options. Alkaline phosphatase (ALP) and bilirubin levels correlate with the risk of liver transplant or death in PBC patients. Fibroblast growth factor (FGF) 19 is a hormone that acts directly in the liver to regulate bile acid synthesis. We evaluated NGM282, an engineered analogue of FGF19, for the treatment of PBC. In this 28‐day, double‐blind, placebo‐controlled phase 2 trial, 45 PBC patients who had an inadequate response to ursodiol were randomly assigned 1:1:1 to receive subcutaneous daily doses of either NGM282 at 0.3 mg (n = 14), 3 mg (n = 16), or placebo (n = 15). The primary endpoint was a change in ALP from baseline after 28 days of treatment. At day 28, ALP was significantly reduced with NGM282 treatment at both 0.3 mg (least‐squares mean –51.0 IU/L [standard error (SE) 15.4]) and 3 mg (–66.0 IU/L [SE 16.0]) versus placebo (3.3 IU/L [SE 14.8]), with least‐squares mean differences of –54.3 IU/L (95% confidence interval –104.2 to –4.5; P = 0.0149) and –69.3 IU/L (95% confidence interval –120.5 to –18.3; P = 0.0030), respectively. Fifty percent (7 of 14) of patients receiving NGM282 0.3 mg and 46% (6 of 13) of those receiving NGM282 3mg achieved 15% or greater reduction in ALP levels from baseline, compared with 7% (1 of 15) of patients receiving placebo. NGM282 also significantly reduced serum concentrations of transaminases and immunoglobulins. Most adverse events were grade 1 (mild) to grade 2 (moderate) in severity, with gastrointestinal disorders more frequent in the NGM282 treatment groups. No worsening of pruritus was observed with NGM282 treatment. Conclusion: NGM282 administered for 28 days resulted in significant improvements in ALP and transaminase levels compared with placebo, with an acceptable safety profile in patients with PBC. (Hepatology Communications 2018; 00:000‐000)

Old and new treatments for primary biliary cholangitis.

Primary biliary cholangitis (formerly primary biliary cirrhosis) is a rare progressive cholestatic liver disease, whose hallmark features include a persistently elevated alkaline phosphatase level, presence of anti-mitochondrial antibodies and characteristic histology. Since 1998, ursodeoxycholic acid (UDCA), a bile acid, has been the only available therapeutic agent. Primary biliary cholangitis is associated with the development of end-stage liver disease, increased morbidity and mortality. UDCA has been shown to improve serum biochemistries, histology and delay the need for liver transplantation. The clinical issue is that approximately 25%-40% of patients do not respond to this standard therapy. In recent years, many trials have investigated alternative and adjunctive treatments, leading to the recent approval of obeticholic acid, an analogue of chenodeoxycholic acid, which has shown significant and sustained reductions in alkaline phosphatase levels in combination with UDCA. Obeticholic acid has rapidly been embraced as a new agent to improve the biochemical profile in refractory patients, in addition to being approved for use as monotherapy in patients who cannot tolerate UDCA. There are several other studies and targets which are being investigated. This review is intended to highlight the benefits of UDCA, educate the reader on the newly available obeticholic acid, and to summarize the many ongoing trials and therapeutic targets being investigated in attempts to control and cure primary biliary cholangitis.

Second hand tobacco smoke adversely affects the bone of immature rats

OBJECTIVES:To evaluate the influence of secondhand cigarette smoke exposure on longitudinal growth of the tibia of growing rats and some parameters of bone quality.METHODS:Forty female rats were randomly divided into four groups: control: rats were sham exposed; 30 days: rats were exposed to tobacco smoke for 30 days; 45 days: rats were exposed to tobacco smoke for 45 days; and 60 days: rats were exposed to tobacco smoke for 60 days. Blood samples were collected to evaluate the levels of cotinine and alkaline phosphatase. Both tibias were dissected and weighed; the lengths were measured, and the bones were then stored in a freezer for analysis of bone mineral content and mechanical resistance (maximal load and stiffness).RESULTS:Exposure of rats to tobacco smoke significantly compromised bone health, suggesting that the harmful effects may be time dependent. Harmful effects on bone growth were detected and were more pronounced at 60-day follow-ups with a 41.8% reduction in alkaline phosphatase levels (p<0.01) and a decrease of 11.25% in tibia length (p<0.001). Furthermore, a 41.5% decrease in bone mineral density was observed (p<0.001), leading to a 42.8% reduction in maximum strength (p<0.001) and a 56.7% reduction in stiffness (p<0.001).CONCLUSION:Second hand cigarette smoke exposure in rats affected bones that were weaker, deforming them and making them osteopenic. Additionally, the long bone was shorter, suggesting interference with growth. Such events seem to be related to time of exposure.

A network meta-analysis of the efficacy and side effects of UDCA-based therapies for primary sclerosing cholangitis.

Therapies for treatment of patients with primary sclerosing cholangitis (PSC) include administration of ursodeoxycholic acid (UDCA) alone, or combination with metronidazole (MTZ) or mycophenolate mofetil (MMF), respectively. However, the optimum regimen still remains inconclusive. We aimed to compare interventions in terms of patient mortality or liver transplantation (MOLT), progression of liver histological stage (POLHS), serum bilirubin, alkaline phosphatase (ALP) levels and adverse events (AE). We searched PubMed, Embase and the Cochrane Library for randomized controlled trials until 31, Jan 2015. We estimated hazard ratios (HRs), odds ratios (ORs) and mean difference (MD) between treatments on clinical outcomes. Sensitivity analyses based on the dose of UDCA, quality of trials or treatment duration were also performed. Ten RCTs were included. Compared with UDCA plus MTZ, UDCA (HR 0.28, 95%CI 0.01-3.41), UDCA plus MMF (HR 0.08, 95%CI 0.00-4.18), or OBS (HR 0.28, 95%CI 0.01-3.98) all provided an increased risk of MOLT. UDCA provided a significant reduction in bilirubin and ALP levels compared with OBS (MD -13.92, P < 0.001; MD -484.34, P < 0.001; respectively). With respect to POLHS, although differing not significantly, UDCA plus MTZ had a tendency to improve LHS more than UDCA (OR 1.33), UDCA plus MMF (OR 3.24) or OBS (OR 1.08). Additionally, UDCA plus MTZ (MD -544.66, P < 0.001) showed a significant reduction in ALP levels compared with OBS, but appeared to be associated with more AEs compared with UDCA (OR 5.09), UDCA plus MMF (OR 4.80) or OBS (OR 7.21). MTZ plus UDCA was the most effective therapy in survival rates and liver histological progression.

Microcarrier Culture for Efficient Expansion and Osteogenic Differentiation of Human Fetal Mesenchymal Stem Cells

Stirred microcarrier (MC) culture has been suggested as the method of choice for supplying large volumes of mesenchymal stem cells (MSCs) for bone tissue engineering. In this study, we show that in addition to the improvement in cell expansion capacity, MSCs propagated and harvested from MC culture also demonstrate higher osteogenic potency when differentiated in vivo or in vitro in three-dimensional (3D) scaffold cultures as compared with traditional monolayer (MNL) cultures. Cytodex 3 microcarrier-expanded human fetal MSC (hfMSC) cultures (MC-hfMSCs) achieved 12- to 16-fold expansion efficiency (6×105–8×105 cells/mL) compared to 4- to 6-fold (1.2×105–1.8×105 cells/mL) achieved by traditional MNL-expanded hfMSC culture (MNL-hfMSCs; p<0.05). Both MC-hfMSCs and MNL-hfMSCs maintained similar colony-forming capacity, doubling times, and immunophenotype postexpansion. However, when differentiated under in vitro two-dimensional (2D) osteogenic conditions, MC-hfMSCs exhibited a 45-fold reduction in alkaline phosphatase level and a 37.5% decrease in calcium deposition compared with MNL-hfMSCs (p<0.05). Surprisingly, when MC-hfMSCs and MNL-hfMSCs were seeded on 3D macroporous scaffold culture or subcutaneously implanted into nonobese diabetic/severe combined immunodeficient mice, MC-hfMSCs deposited 63.5% (p<0.05) more calcium and formed 47.2% (p<0.05) more bone volume, respectively. These results suggest that the mode of hfMSC growth in the expansion phase affects the osteogenic potential of hfMSCs differently in various differentiation platforms. In conclusion, MC cultures are advantageous over MNL cultures in bone tissue engineering because MC-hfMSCs have improved cell expansion capacity and exhibit higher osteogenic potential than MNL-hfMSCs when seeded in vitro into 3D scaffolds or implanted in vivo.

Hepatoprotective Effect of Parkia Biglobosa Stem Bark Methanolic Extract on Paracetamol Induced Liver Damage in Wistar Rats

This study was designed to investigate the effect of the methanolic extract of parkia biglobosa stem bark on a single daily dose of oral administration of 500 mg/kg BW of paracetamol (acetaminophen, PCM) induced hepatotoxicity in wistar rats. The rats were divided into (5 groups. The rats in group I served as control and received distilled water, group II were given orally a single daily dose of 500 mg/kg BW of paracetamol for 7 days. Group III, IV, and V received a single daily dose of 500 mg/kg BW of paracetamol and then treated orally with 140 mg/kg BW acetylcysteine, 100 mg/kg BW low dose and 200 mg/kg BW high dose of parkia biglobosa respectively for 21 days. The activities of liver function marker enzymes were determined in the serum of the rat liver homogenate. Paracetamol caused liver damage as evident by significant increased (p≤0.05) (49.63±1.99; 39.41±1.99; 78.58±1.72) in the serum levels of Alkaline phosphatase (AP), Aspartate transaminase (AST) and Alanine transaminase (ALT) respectively. Low dose 100mg/kg BW of Parkia biglobosa significantly increased (p≤0.05) serum AP levels (65.42±1.6) but significantly reduced serum levels of ALT and AST (43.80±2.4; 36.77±1.58) respectively. High dose 200 mg/kg BW of Parkia biglobosa significantly reduced (p≤0.05) serum levels of AP, ALT and AST (26.58±0.34; 33.68±2.02; 31.08±0.34) respectively. Acetylcysteine (standard reference drug) significantly reduced (p≤0.05) ALT and AST levels (43.46±1.67; 30.10±1.01) respectively, but the reduction in AP level (46.64±1.01) was not significant. The activity of parkia biglobosa is comparable with acetylcysteine, a known hepatoprotective drug. Thus, Parkia biglobosa exhibits hepatoprotective activity against paracetamol toxicity.

Farnesoid X Receptor Agonist for the Treatment of Liver and Metabolic Disorders: Focus on 6-ethyl-CDCA

6-ethyl-chedeoxycholic acid (6E-CDCA) is a farnesoid X receptor (FXR) ligand endowed with agonistic activity under development for treatment of cholestatic liver diseases including primary biliary cirrhosis (PBC) and liver-related metabolic disorders including non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). FXR is a bile sensor that acts in coordination with other nuclear receptors to regulate essential steps of bile acid uptake, metabolism and excretion. 6E-CDCA has been investigated in preclinical models of cholestasis, liver fibrosis and diet-induced atherosclerosis. In a phase II clinical trial in patients with PBC, 6E-CDCA met the primary endpoint of a reduction in alkaline phosphatase levels but safety data indicated that the drug exacerbated pruritus, one of the main symptoms of PBC, suggesting that 6E-CDCA or FXR are mediators of pruritus in humans. Treatment of patients with diabetes and liver steatosis resulted in amelioration of insulin sensitivity despite a reduction a slight reduction in HDL and increased levels of LDL were observed. These side effects on bile acids and lipid metabolism were all predicted by pre-clinical studies, suggesting that potent FXR ligands hold promise but potential side effects might limit their development.

Bone Marrow Cells Reduce Collagen Deposition in the Rat Model of Common Bile Duct Ligation

Background and Aim: Transplantation of bone marrow cells (BMC) was shown to improve liver function in animal models of cirrhosis. In this work we evaluated the effects of mononuclear BMC transplantation in rats submitted to bile duct ligation (BDL), a model of cholestatic liver disease. Methods: BDL was performed on Wistar rats, and two weeks later animals underwent a liver biopsy. At the same time, BMC group was injected with 1x106 mononuclear BMC and compared to untreated (BDL) and a fake-surgery (Sham) group. Animals were sacrificed two weeks later. Alkaline Phosphatase (ALP) and collagen deposition quantified by Sirius red staining were analyzed at both time points. MMP-9 expression assessed by immunohistochemistry and liver oxidative stress parameters (TBARS, SOD and catalase activity) was performed at four weeks. The effect of BMC-conditioned medium upon activated hepatic stellate cells was tested in vitro by MTT using GRX cells. Results: Treated animals showed a 25% decrease in ALP levels at four weeks. Collagen deposition in untreated group at 4 weeks had values 2-fold higher, compared to those found in the biopsy. In contrast, BMC-treated rats barely increased collagen deposition after treatment (p< 0.01). No difference was observed in MMP-9 expression nor in oxidative stress parameters. BMC-conditioned medium was able to induce cell death on GRX cells in vitro. Conclusions: A decrease in collagen deposition and a reduction in ALP levels suggest a better outcome in the treated group. The effect of BMC conditioned medium in vitro suggests a possible mechanism for the reduction of fibrosis observed in vivo.

Bezafibrate Treatment of Primary Biliary Cirrhosis Following Incomplete Response to Ursodeoxycholic Acid

Ursodeoxycholic acid (UDCA) is the only current pharmacologic treatment for primary biliary cirrhosis (PBC). However, some patients show persistent liver biochemical abnormalities even after 6 to 12 months treatment. Bezafibrate retard is a commonly used medication for hyperlipidemia. In Japanese studies, it was found to lower liver enzyme levels, apparently through its action on multiple drug resistance gene 3, a transport element of the ATP-dependent bile secretion system, and on peroxisome proliferator-activated receptor-alpha. The aim of this study was to evaluate the effect of adding bezafibrate to the treatment regimen in patients with PBC and a partial response to UDCA. The study group included 8 White patients, 7 women and 1 man, aged 52 to 76 years with PBC who had been treated at our Liver Institute with UDCA (900 mg/d to 1500 mg/d) for 2 to 11 years (mean, 5.7 y) with only a partial response (19% to 56% reduction in alkaline phosphatase level). Bezafibrate (400 mg/d) was added to UDCA and the patients were followed for 4 to 12 months. Alkaline phosphatase levels (normal range, 35 to 104 U/L) decreased in all patients, from 140 to 360 U/L (mean, 201.2) to 68 to 158 U/L (mean, 98.4), and normalized in 6 patients. In addition, levels of gamma-glutamyl transferase (normal range, 6 to 42 U/L) decreased from 70 to 192 U/L (mean, 130) to 41 to 122 U/L (mean, 71.8). These findings were maintained throughout follow-up. Combination therapy with bezafibrate and UDCA improves the biochemical profile of patients with PBC who respond only partially to UDCA. A larger controlled study is needed to evaluate the clinical implications of these findings.

Reply

We thank Walker and colleagues for their comments on our article showing that the extent of the biochemical response to ursodeoxycholic acid (UDCA) has a major impact on the prognosis of primary biliary cirrhosis (PBC), thus confirming previous data indicating that not only the fall in bilirubin levels but also in liver enzymes may have prognostic values in patients treated for PBC.1, 2 In this context, Walker and colleagues highlight the possible role of fibrates as new therapeutic agents for PBC. Indeed, they found in their cohort from Northeast England that the combination of fenofibrate and UDCA was able to markedly decrease both alkaline phosphatase and immunoglobulin M levels in patients with PBC with an incomplete response to UDCA, thus confirming recently published results from Iwasaki et al. in Japan.3 First, Iwasaki and colleagues showed that bezafibrate (400 mg/day) was as effective as UDCA (600 mg/day) in reducing liver enzymes. Second, they showed that the combination of bezafibrate and UDCA produces a higher reduction in alkaline phosphatase levels than does UDCA (600 mg/day) alone, but there were no significant differences in other biochemistries between the two therapeutic regimens. Fibrates derivatives have a 40-year history in the management of dyslipidemia. Their use led to the discovery of peroxisome proliferator-activated receptor (PPAR) genes. This class of drugs is generally well-tolerated; however, safety issues have arisen from their use. Their parsimonious use in Europe for the treatment of PBC came initially from the reports of Schaffner4 and Summerfield et al.,5 who showed that clofibrate could induce paradoxical hypercholesterolemia, intrahepatic, and choledocolithiasis in patients with PBC. There were further reports of cases of acute and chronic liver injuries described under the forms of acute cholestatic, autoimmune, chronic liver diseases and biliary tract diseases as well as acute pancreatitis mostly associated with gallstones.6-8 At the same time, occurrence of severe photosensitivity, cutaneous rash, rhabdomyolysis, polymyositis, and renal failure, in addition to the suspected possible role in human liver carcinogenesis, which was demonstrated in rodents, discouraged hepatologists from prescribing fibrates even in the case of dyslipidemia in their patients with PBC. We have a little experience of the use of fibrates for dyslipidemia in PBC. Following the reports from Japan, the review of these cases indeed suggests that fibrates may potentiate the effects of UDCA given at a daily dose of more than 13 mg/kg body weight on alkaline phosphatase and immunoglobulin M levels. We did not find the side-effects mentioned above with the combined therapy. Fibrates are PPAR alpha receptor activators, which are known to exert an array of effects on a myriad of genes including those involved in hepatic lipid metabolism, suppression of bile acid synthesis, increased biliary secretion of phospholipids and cholesterol, inflammation, and defense against oxidative stress, all of these being processes which possibly act in the pathobiology of PBC. As for UDCA over the last 20 years, it remains to be demonstrated that the effects of fibrates will not only be “cosmetic” but really effective in terms of progression toward end-stage disease. Lessons from the UDCA story will certainly be useful to achieve this goal. Raoul Poupon M.D.*, Olivier Chazouilleres M.D.*, Christophe Corpechot M.D.*, * UPMC Liver Center, INSERM, UMRS 893, Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Service d'Hépatologie, Hôpital Saint-Antoine, Assistance Publique–Hôpitaux de Paris, Paris.

Modulation of osteoblast behaviour by tenascin.

The extracellular matrix protein tenascin is secreted by osteoblasts but absent from mineralized bone matrix. The current study was undertaken to test the hypothesis that tenascin regulates osteoblast behaviour. Three osteoblast-like cell lines UMR-106, ROS-17/2.8 (rat) and SAOS-2 (human) were used to investigate the role of tenascin in osteoblast morphology, differentiation and proliferation. Two of three cell lines adhered specifically to tenascin, remaining round and failing to spread. Tenascin as a substratum stimulated alkaline phosphatase activity (a marker of osteoblast differentiation) in two of three cell lines. Moreover, anti-tenascin in the medium caused a reduction in alkaline phosphatase levels in all three cell lines. Anti-tenascin also inhibited collagen synthesis, an important osteoblast function. Since it seemed possible that tenascin may exert its effects on cell function through its ability to cause cell rounding, the ability of cell shape change alone to influence alkaline phosphatase levels was investigated. Cells were incubated in the presence of cytochalasin D and alkaline phosphatase levels assayed. Alkaline phosphatase activity was not elevated by cytochalasin D treatment, indicating that cell rounding alone is insufficient to mimic the effect of tenascin. Anti-tenascin caused a slight increase in proliferation of SAOS-2 cells, indicating that tenascin is itself inhibitory. In ROS 17/2.8 and UMR-106 cells, in contrast, proliferation was inhibited by anti-tenascin. The results presented here indicate that tenascin is able to stimulate osteoblastic differentiation and that endogenous tenascin helps to maintain the functional state of cultured osteoblast-like cells.