Entre el 13 y 17 de abril del 2016, se realizó en Barcelona “The International Liver Congress” de la EASL. En esta oportunidad se presentaron 26 trabajos científicos de Latinoamérica. Brasil presentó 18 trabajos, Argentina 3, México 3, Perú 1. Chile, Argentina y Uruguay participaron en uno. Los resúmenes de los trabajos se presentan a continuación:
HEPATOTOXICITY ASSOCIATED WITH NON-STEROIDAL ANTIINFLAMMATORY DRUGS. A COMPARATIVE ANALYSIS AMONG IBUPROFEN, DICLOFENAC AND NIMESULIDE FROM THE SPANISH AND LATIN-AMERICAN DILI REGISTRIES
A. Gonzalez-Jimenez1,2, I. Medina-Cáliz1,2, M. Robles-Díaz1,2, M.E. Zoubek1 , P. Díaz-Jimenez1 , M.R. Cabello1,2, A. Ortega-Alonso1,2, M. García-Cortes1,2, B. García-Muñoz1,2, M.C. Fernandez3 , M. Slim1,2, M. Romero-Gómez2,4, F. Bessone5 , N. Hernandez6 , M. Arrese7 , E. Montane8 , H. Hallal9 , J.A. Sanabria-Cabrera1,2, R. Sanjuan-Jimenez1,2, M.I. Lucena1,2, R.J. Andrade1,2. 1 IBIMA, H. Virgen de la Victoria, Universidad de Málaga, Malaga; 2 CIBERehd, Barcelona; 3 Hospital Torrecárdenas, Almeria; 4 UCM Digestive Diseases, Hospital Virgen del Rocio, Sevilla, Spain; 5 Hospital Provincial del Centenario, Rosario, Argentina; 6 Hospital de Clínicas, Montevideo, Uruguay; 7 Pontificia Universidad Católica de Chile, Santiago de Chile, Chile; 8 Hospital Germans Trias i Pujol, Badalona; 9 Hospital Morales Meseguer, Murcia, Spain E-mail: firstname.lastname@example.org Background and Aims: Non-steroidal anti-inflammatory (NSAIDs) drugs are the second therapeutic class more frequently associated with drug-induced liver injury (DILI) in the Spanish and LatinAmerican DILI Registries. We aimed to analyze the differences in clinical presentation and outcome in NSAIDs-DILI cases. Methods: Demographic, clinical and biochemical parameters in NSAIDs cases included in the Spanish (73/867, 8%) and LatinAmerican (29/200, 14%) DILI Registries were analyzed. DILI cases attributed to a single culprit drug and assessed as possible, probable or definite based on the CIOMS scale were included. Results: A total of 102 (9.5%) of 1067 cases from both registries were attributed to NSAIDs. Out of them, 26 (25%) were attributed to ibuprofen, 23 (22%) to diclofenac, 20 (20%) to nimesulide and 33 (32%) to other NSAIDs (piroxicam, naproxen, ketoprofen). Female gender predominated in nimesulide cases (85%) as compared to diclofenac (48%), ibuprofen (50%) and other NSAIDs (55%), ( p = 0.03). The presence of autoantibodies was higher in diclofenac, ibuprofen and nimesulide DILI cases (30%, 27%, 29%, respectively) compared to other NSAIDs (20%). Hypersensitivity features were more frequent in ibuprofen (50%) and nimesulide DILI cases (45%) as compared to diclofenac (39%) and other NSAIDs (36%). Hepatocellular damage was predominant in all groups, being 87% in diclofenac, 69% in ibuprofen, 65% in nimesulide and 54% in other NSAIDs. Total bilirubin mean values were significantly higher in nimesulide-induced cases (14 × ULN) as compared to ibuprofen (5.7 × ULN), diclofenac (4.1 × ULN) and other NSAIDs (5.4 × ULN) ( p = 0.002). Similarly, AST and ALP mean values were significantly higher in nimesulide cases (25 and 2.6xULN) ( p = 0.047, p = 0.049) as compared to the other groups (ibuprofen 14 and 2.3 × ULN, diclofenac 14 and 1.7 × ULN and other NSAIDs 16 and 2.2 × ULN). Severity differed significantly among groups, with 4 (20%) fatal and 3 (15%) severe cases in nimesulide, 3 (12%) fatal cases in ibuprofen, 3 (9%) severe cases in others NSAIDs and neither fatal nor severe cases related to diclofenac ( p = 0.008). Conclusions: NSAID-induced liver injury offers a wide range of clinical phenotypes, and severity. Nimesulide cases showed the highest severity among the NSAIDs. Ibuprofen-induced liver injury were the most prevalent showing a hepatotoxicity potential that could lead to acute liver failure. Funding: AEMPS, FIS (PI12-00620, AC-0073-2013). Fondo Europeo de Desarrollo Regional (FEDER). CIBERehd by Instituto de Salud Carlos III.
EXERCISE CAPACITY AND SURVIVAL AFTER LIVER TRANSPLANT IN CIRRHOTIC WITH HEPATOPULMONARY SYNDROME
C.A. Marroni1 , J.L.F. Pereira1 , L.H. Galant1 , L.H.T. da Rosa1 , E. Garcia2 , A.B. de Mello Brandão1 . 1 Hepatology; 2 Universidade Federal De Ciencias Da Saude De Porto Alegre, Porto Alegre, Brazil E-mail: email@example.com Background and Aims: The Hepatopulmonary Syndrome, defined by a triad involving liver disease and/or portal hypertension, pulmonary vascular dilatation and abnormalities of arterial oxygenation, is one of the complications associated with cirrhosis which may contribute to worsening of exercise capacity and poor survival after liver transplantation. Thus this study aimed to compare the survival two years after liver transplantation between cirrhotic patients diagnosed with HPS and cirrhotic patients without this diagnosis, and identify independent predictors for this outcome. Methods: A prospective cohort of four years, consisting of 178 patients (92 with and 86 without HPS) who had a diagnosis of cirrhosis and were potential candidates for liver transplantation. All patients previously underwent a physical evaluation consisting of the walk test of six minutes, stress testing and manometer. Statistical analysis was performed using the Kolmogorov-Smirnov test and the Student t test, linear association square test, the Kaplan Meier survival curve and Cox regression. The data were analyzed using SPSS 16 o’clock being considered significant p < 0.05. Results: The cirrhotic group without diagnosis of HPS showed greater survival in a period of 2 years after transplantation (p = 0.01). There was a 17% higher survival rate with increasing distance in the walk test of six minutes (HR = 0.83, CI95% = 0.73–0.94, p = 0.003), as well as improved Peak Oxygen Consumption increased by up to 30% survival (HR = 0.70CI95% 0.57–0.82, p = 0.001) and a higher maximum inspiratory pressure increased by 15% patient survival (HR = 0.85 95% CI 0.75–0.92, p = 0.002). Conclusions: The group of cirrhotic patients without a diagnosis of HPS had a higher survival rate over a period of two years after liver transplantation. The walk test of six minutes the peak oxygen uptake and maximal inspiratory pressure were considered independent predictors for this outcome in this population.
CLINICAL TRIAL TO EVALUATE THE EFFICACY OF PRIMARY PROPHYLAXIS WITH L-ORNITHINE L-ASPARTATE TO PREVENT THE DEVELOPMENT OF OVERT HEPATIC ENCEPHALOPATHY IN PATIENTS WITH CIRRHOSIS AND ACUTE VARICEAL BLEEDING
F. Higuera-de la Tijera1 , A.I. Servín-Caamaño2 , F. Salas-Gordillo1 , J.M. Abdo-Francis1 , J. Camacho-Aguilera2 , J.L. Pérez-Hernández1 , F. Jiménez-Ponce3 . 1 Gastroenterology/Hepatology; 2 Internal Medicine, Hospital General de México; 3 Research Department, ISSSTE, Mexico City, Mexico E-mail: firstname.lastname@example.org Background and Aims: Variceal bleeding (VB) is one of the most important precipitating factors of overt hepatic encephalopathy (OHE). L-ornithine L-aspartate (LOLA), an anti-ammonia therapy, has never been evaluated as primary prophylaxis to prevent the development of OHE in cirrhotic patients after an acute episode of VB. The aim of this study was to evaluate if primary prophylaxis with LOLA is effective to prevent the development of OHE after VB. Methods: A randomized, double-blind, placebo-controlled clinical trial, approved by Ethics and Research Committees from México’s General Hospital, it included cirrhotic patients with VB and without OHE according to West-Haven criteria (WHC), and without minimal hepatic encephalopathy (MHE) assessed by the Psychometric Hepatic Encephalopathy Score (PHES) and critical flicker fusion (CFF) at admission-time. Sample size was calculated considering a onetailed 5% type I error, a statistic power of 80%, a difference between groups of 26%, and considering an additional 20% of patients for possible losses. Group 1 (22 patients) received a 24-hour intravenous infusion of 500 mL of 0.9% saline solution containing 10 mg of LOLA during 7 days. Group 2 (22 patients) received placebo. All patients were daily evaluated searching for signs of OHE according with WHC. Acute VB was treated according with recommendations from Baveno V consensus. Results: There were no differences between groups regard to demographic, clinical and biochemical basal characteristics. Patients in the placebo group had a greater frequency regard to the development of OHE compared with LOLA group (54.5% vs. 22.7%, p = 0.03). In those who developed OHE, the grade according to WHC was worst in the group receiving placebo (median 3, range 2-4) than in those receiving LOLA (median 1, range 1–2), ( p = 0.004) The time in days for the development of OHE has a median of 2 days (range 1–4) and 3 days (range 1–3) for placebo and LOLA groups respectively ( p = 0.65). There were no adverse effects or deaths. One patient receiving placebo developed spontaneous bacterial peritonitis despite antibiotic prophylaxis, however, he had a good response when antibiotic was adjusted according to the ascites culture result. Conclusions: This is the first study that demonstrates that LOLA is an effective therapy for primary prophylaxis in cirrhotic patients with VB to prevent the development of OHE; this therapy also was well tolerated and was free of adverse effects.
USE OF NON-SELECTIVE BETA BLOCKERS (NSBB) IN CIRRHOTIC PATIENTS WITH BACTERIAL INFECTIONS IS ASSOCIATED WITH LOWER FREQUENCY OF SEPSIS, BUT NOT OF ACUTE-ON-CHRONIC LIVER FAILURE (ACLF) OR SURVIVAL. RESULTS OF A PROSPECTIVE STUDY
G.H. Pereira1 , C. Baldin1 , L. Victor1 , J. Piedade1 , L. Guimarães1 , T. Rocha1 , Z. Veiga1 , F. Fernandes1 , E. Ahmed1 , J.L. Pereira1 . 1 Liver Unit, Bonsucesso General Hospital, Rio de Janeiro, Brazil E-mail: email@example.com Background and Aims: Use of NSBB has deleterious effects in decompensated cirrhosis. Bacterial infections are associated with Sepsis and ACLF, and NSBB trough reduction in systemic inflammatory response, could have beneficial effects. There are few data respect use of NSBB in patients with bacterial infections and their correlation with SIRS and ACLF. Our objective was to evaluate the frequency of complications of cirrhosis, incidence and clinical course of ACLF and SIRS in patients with and without NSSB use. Methods: Cirrhotic patients prospectively included in a large database were analyzed. Bacterial infections and sepsis were diagnosed at hospitalization. ACLF was diagnosed and staged according to CLIF C OF score. Dose and type of NSSBB used within last 3 months was recorded. Frequency of complications of cirrhosis, sepsis and ACLF were compared between groups. Results: 163 patients were included (57 ± 12 years, 64% male, MELD 18 ± 6, child C 54%). The most common type of infection was SBP and skin infections (37 and 38 patients). One hundred four patients were currently using NSSB. Patients taking NSBB more commonly had previous variceal bleeding, ascites and hepatic encephalopathy. At study inclusion, prevalence of complications of cirrhosis, liver and kidney function parameters were similar between patients taking NSBB or not. However, the frequency of ascites and hepatic encephalopathy throughout hospital stay was higher in patients taking NSBB (90 vs. 79%, 60 vs. 43%, p < 0.05). Use of NSBB was associated with lower heart rate (76 ± 12 vs.85 ± 15, p < 0.001), leukocyte count (7.5 ± 4.5 vs. 9.7 ± 7.6, p = 0.04) and frequency of sepsis (21 vs. 42%, p = 0.03). Frequency of ACLF was similar between groups (38 vs. 27%, p = 0.2), as well as CLIF-CF OF score and frequency of grade 2–3 ACLF. Patients taking NSBB had lower frequency of liver and coagulation failure, but higher frequency of kidney and cerebral failure. In –hospital and 3-month survival for patients taking NSBB and not was 67 and 59% versus 69 and 63% (p = ns). Conclusions: In patients hospitalized with bacterial infections, NSBB use is associated with higher frequency of complications of cirrhosis. Patients with NSBB had a blunted inflammatory response, as evidenced by lower frequency of sepsis. NSBB does not reduce ACLF frequency or severity, but their use correlates with distinct types of organ failure. Use of NSBB in cirrhotic patients with bacterial infections does not modify prognosis.
SPONTANEOUS BACTEREMIA IN PATIENTS WITH CIRRHOSIS: CHARACTERISTICS AND OUTCOMES
S. Marciano1 , C. Bermudez1 , N. Sobenko1 , L. Haddad1 , F.G. Bert1 , L. Barcán2 , A. Smud2 , M.L. Posadas-Martinez3 , D. Giunta3 , A. Gadano1 . 1 Liver Unit; 2 Infectious Diseases Section; 3 Department of Research, Hospital Italiano, Buenos Aires, Argentina E-mail: firstname.lastname@example.org Background and Aims: Spontaneous bacteremia (SB) accounts for approximately 10% of infections in patients with cirrhosis. Outcomes of SB are not widely reported. We aimed to describe characteristics of SB and to compare patient’s outcomes after a first episode of SB and a first episode of spontaneous bacterial peritonitis (SBP). Methods: We performed a single center retrospective cohort study of all consecutive episodes of SB in patients with cirrhosis (June/2003- Dec/2014). Spontaneous bacteremia: positive blood culture/s (excluding contaminants) without an infection source. A control group of consecutive patients with a first episode of SBP (>250 PMN in ascitic fluid, without an evident source of infection) matched for severity of liver disease was used to compare survival. We modeled the cumulative incidence of death in the presence of the competing event liver transplantation according to the type of infection (EB vs SBP). Factors associated with mortality by type of infection were estimated with competitive risk regression. The crude and adjusted hazard ratios (HR) were reported. Results: One hundred and seventeen episodes of SB in 94 patients were included, of whom 77 correspond to the first episode of spontaneous infection. Median MELD at the moment of SB was 19 (IQR 15–25); CHILD A/B/C: 5 (4%), 27 (23%), 85 (73%). SIRS and acute-on-chronic liver failure occurred in 64 (56%) and 72 (61%) episodes, respectively. Characteristics of SB: Gram negative and positive strains were isolated in 63 (54%) and 54 (46%) episodes, respectively. infections were nosocomial or healthcare related in 89 (76%) episodes. Multiresistant strains were isolated in 12% of the episodes. In 14% of the episodes, an inadequate initial antibiotic regimen was indicated. Mortality of the 77 patients with a first episode of SB was compared with 45 patients with a first episode of SBP. Overall, 55 (45%) died, 40 (43%) survived, and 27 (22%) were transplanted during the follow up. There was no statistical difference in the cumulative mortality in patients with SB and SBP: 27% vs 23% at 30 days, and 29% vs 35% at 90 days, respectively (p = 0.43). In the bivariate analyses, age, leucocytes, creatinine and sodium were associated with an increase risk of death in patients with SB; in the multivariate analyses all maintained significance except for creatinine. Conclusions: Mortality at 30 and 90 days in patients with SB is as high as in patients with SBP. Strategies for prevention and early diagnosis of SB should be developed and implemented.
PHARMACOKINETICS OF THE ANTIFIBROTIC DRUG PIRFENIDONE IN CHILD PUGH A AND B CIRRHOTIC PATIENTS COMPARED TO HEALTHY AGE-MATCHED CONTROLS
J.L. Poo1 , R. Bernal1 , J.R. Aguilar1 , R. Alonso1 , R. Balderas1 , E. Piñeyro2 , M. Gómez2 , J. Escobar3 , C. Mora4 , N. Hernandez5 , R. Magaña3 , P. Peña6 . 1 Pharma Research Unit, AMIC, Pachuca; 2 Pharma Research Unit, IPHARMA, Monterrey; 3 Clinical Research Unit; 4 Clinica Research Unit; 5 Drug Development Unit, Cellpharma; 6 Clinical Research Unit, Cellpharma, Mexico City, Mexico E-mail: email@example.com Background and Aims: Pirfenidone (PF) has demonstrated antiinflammatory and anti-fibrogenic effects in experimental models of cirrhosis and also in open trials with humans affected with hepatic fibrosis caused by different etiologies. Since the EMA and FDA authorization for PF usage in the treatment of patients with Idiopathic Pulmonary Fibrosis, this novel antifibrotic agent is currently in phase II and III clinical development for the treatment of other fibrotic diseases including liver, skin, renal, cardiac and multiple sclerosis. Considering the wide variation in liver function in patients with cirrhosis we aimed to evaluate PF pharmacokinetics. Methods: A total of 24 subjects (9 men and 15 non pregnant women), aged 58 ± 12 entered the trial; 8 subjects had cirrhosis Child Pugh A, and 8 Child Pugh B and 8 were age-matched healthy volunteers, with no fibrosis result (F0) by using a non invasive validated serologic test (Fibrotest™, Bio Predictive). All volunteers received orally two 600 mg tablets of a slow release formulation of PF, in the morning and in fasted state. Subjects remained in a phase I clinical study unit throughout treatment and for 36 hours after PF administration. Serial blood samples were collected prior to dosing (0 hour) and at 1, 2, 2.5, 3, 3.5, 4, 4.5, 5, 6, 8, 12, 24, 30 and 36 hours after dosing. Analysis was done with mass spectrometry. Results: Cirrhosis was alcohol related in 6, HCV in 6, Autoimmune in 2 and NASH related in 2 patients. Main pharmacokinetic parameters per group revealed the following results: PK parameters Non Cirrotics (Healthy-F0) N=8 Child Pugh A Cirrhotics (N = 8) Child Pugh B Cirrhotics (N = 8) AUC 0-t (μg/mL*h) 57.8 ± 24.0 210.6 ± 43.2 205.4 ± 60.0 AUC 0-α (μg/mL*h) 62.1 ± 23.3 231.6 ± 59.3 287.2 ± 165.5 C max (μg/mL) 6.6 ± 2.6 12.4 ± 0.9 11.7 ± 3.3 T max (h) 4.1 ± 0.8 5.0 ± 0.7 4.4 ± 0.3 T ½ (h) 4.8 ± 0.7 8.6 ± 2.1 7.4 ± 3.6 PF was well tolerated since there were no withdrawals and no serious adverse events in this study. Overall, 7 of the 24 subjects (29.1%) reported at least 1 adverse event which generally occurred 2 hours after fasted oral administration of PF. Most of the adverse events were mild in intensity and required no intervention, the most frequent being nausea (20.8%) and vomiting (8.3%). Conclusions: PK parameters of a slow release PF formulation are modified by the degree of liver function impairment allowing a twice day formulation to maintain sufficient drug exposure with similar AUC, Cmax, and T ½ values between Child Pugh grade A and grade B cirrhosis.
ANTI-INFLAMMATORY ACTION OF GLUTAMINE IN ACUTE LIVER FAILURE INDUCED BY THIOACETAMIDE IN RATS
E.G. Schemitt1 , J.R. Colares2 , R.M. Hartmann1 , F. Licks1 , M. Do Couto Soares1 , J. De Oliveira Salvi2 , C.A. Marroni3 , N.A.P. Marroni4 . 1 Universidade Federal do Rio Grande do Sul, Porto Alegre; 2 Universidade Luterana do Brasil, Canoas; 3 Postgraduate Program in Liver Diseases, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre; 4 Postgraduate Program in Cell and Molecular Biology Applied to Health, Universidade Luterana do Brasil, Canoas, Brazil E-mail: firstname.lastname@example.org Background and Aims: Severe acute liver failure (SALF) is a syndrome which leads to functional impairment of the liver. The thioacetamide (TAA) is a xenobiotic that causes liver damage. Glutamine (G) is an amino acid involved in the synthesis of glutathione. The aim of this study was to assess the hepatotoxic effect of thioacetamide and the anti-inflammatory action of glutamine. Methods: CEUA project/HCPA: 12-0116. 28 rats were divided into 4 groups: control (CO), Glutamine (G), Thioacetamide (TAA), Glutamine + thioacetamide (TAA + G). TAA doses were administered (400 mg/kg ip) with an interval of eight hours. Glutamine (25 mg/kg ip) was administered 30 minutes after the last dose of TAA. 24 hours after the beginning of the experiment, the animals were anesthetized and killed. Blood samples were collected to assess the levels of AST, ALT and AP. The liver was removed for analysis interleukins (Assay kits using Luminex® technology by Invitrogen™) and immunohistochemical evaluation of NF-kB, TNF-α and iNOS. Statistical analysis was ANOVA + Student-Newman-Keuls test (mean ± SE) being significant p < 0.05. Results: There was an increase in AST, ALT and AP levels in TAA group (598.8 ± 39.4, 298.4 ± 9.1 and 58.7 ± 2.6 U/L, respectively) relative to groups CO (42.0 ± 9.2, 24.2 ± 2.5 and 15.4 ± 0.9 U/L, respectively) and G (48.5 ± 5.5, 29.8 ± 3.6 and 16.8 ± 1 U/L, respectively) and a decrease in the TAA + G group (249.7 ± 24.9, 54.5 ± 5.1 and 19.6 ± 1.2 U/L respectively) (p < 0.001). IL-1β increased in TAA group (465.9 ± 15.9 pg/mL) relative to groups CO (61.1 ± 1.8 pg/mL) and G (62.1 ± 1.3 pg/mL) and decreased in the group TAA + G (104 ± 8.5 pg/mL) (p < 0.001). IL-6 increased in TAA group (359.4 ± 12.6 pg/mL) relative to groups CO (73.2 ± 0.9 pg/mL) and G (78.0 ± 0.8 pg/mL) and decreased in the group TAA + G (155.9 ± 6.9 pg/mL) (p < 0.01). An increase in IL-10 was observed in the TAA group (58.2 ± 4.5 pg/mL) when compared to the CO group (8.6 ± 0.9 pg/mL) and G (13.2 ± 1.2 pg/mL) and a decrease in TAA + G group (21.3 ± 3.1 pg/mL) (p < 0.01). Immunohistochemical expression of NF-kB, TNF-α and iNOS in animals exposed to TAA showed the highest staining for all proteins when compared to the control groups. Glutamine treatment led to decreased expression of the protein in the significantly TAA + G group. Conclusions: TAA causes alterations in biochemical and inflammatory parameters. Glutamine has been shown to have antiinflammatory effects against liver damage generated by this experimental model thioacetamide.
THE XENOGRAFT OF ADIPOSE DERIVED-HUMAN MESENCHYMAL STEM CELLS ATTENUATES HEPATIC DAMAGE IN RATS WITH CHRONIC LIVER INJURY N.
Enciso1 , J. Amiel2 , J. Pando1,3, N. Rojas4 , C. Cisneros1 , E. Nava4 , F. Fabian1 , J. Enciso1 . 1 Laboratorio de Cultivo Celular; 2 Instituto de Medicina Regenerativa, Universidad Cientifica Del Sur. Lima.Perù; 3 Instituto de Criopreservaciòn y Terapia Celular; 4 Facultad de Medicina, Universidad nacional Mayor de San Marcos, Lima, Peru E-mail: email@example.com Background and Aims: Liver transplantation for chronic liver failure is limited by the availability of donor organs. Transplantation of adipose derived-mesenchymal stem cells has been tested in rats with acute liver damage. The aim of this study was to evaluate the effectiveness of adipose derived-human mesenchymal stem cells (Ad-hMSC) on rats with chronic liver injury. Methods: After chronic liver injury induced by 24 doses of 200 mg/kg intraperitoneally of thyoacetamide to Holtzman rats, Ad-hMSC or control vehicle was administered intravenously. After 8 weeks of infusion Ad-HMSC, the rats were sacrificed. Complete blood count, hepatic levels of GOT, GPT, AP and kidney urea and creatinine levels were determined as markers of liver and renal function; the population of Kupffer cells and hepatic stellate cells (Hito Cells) and collagen type I producing cells as fibrogenesis markers was also evaluated. Results: Xenotransplantation without immunosuppression of Ad-hMSCs attenuated to liver injury by thyoacetamide in rats, which is expressed by drastic reduction of GOT by at least 15 days after infusion but no remains at week 8 after infusion, however lymphopenia occurred in both periods. While the architecture of the liver showed decreased macronodules and micronodules (Figure 1. A pre,C post), decreased fibrous tissue and populations of Kupffer cells and stellate cells and collagen type I producing cells (Figure 1. B pre, Dpost), not observed impaired renal function at 8 weeks after infusion. Conclusions: Xenotransplantation Ad-hMSCs reduces chronic liver injury caused by thioacetamide to initially improve its function and structure subsequently by reducing Kupffer cells, stellate cells and collagen type I producing cells.
MELATONIN MITIGATES THE NUTRITIONAL AND MORPHOLOGICAL CHANGES OF RAT TONGUE WITH SECONDARY BILIARY CIRRHOSIS INDUCED BY LIGATION OF THE COMMON BILE DUCT
N.A.P. Marroni1 , J.R. Colares2 , E.G. Schemitt3 , R.M. Hartmann3 , F. Licks3 , M. Do Couto Soares3 , S. Fernandes4 , C.A. Marroni4 . 1 Postgraduate Program in Cell and Molecular Biology Applied to Health; 2 Universidade Luterana do Brasil, Canoas; 3 Universidade Federal do Rio Grande do Sul; 4 Postgraduate Program in Liver Diseases, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil E-mail: firstname.lastname@example.org Background and Aims: Hepatic cirrhosis is characterized by the appearance of septa and fibrotic nodules. Most cirrhotics patients are malnourished and present characteristic sarcopenia, being the degree of those associated to the disease severity. Several factors may be related to this framework such as inadequate food intake and poor absorption of nutrients. Changes in taste may be related to changes in the morphology of the tongue. Prolonged obstruc-tion of the bile duct in rats is an effective experimental model for inducing secondary biliary cirrhosis and fibrosis. Melatonin (Mel) is a hormone produced by the pineal gland and synthesized from serotonin and derived from the amino acid tryptophan. Aim: To investigate the effects of Mel in the nutritional alterations observed in rats with secondary biliary cirrhosis induced by bile duct ligation (BDL). Methods: 32 Wistar rats weighing ±300 g each, divided into four groups: CO, CO + Mel, BDL and BDL + Mel. Mice were treated with Mel (20 mg/kg) from the 15th day after the BDL, until the 28th day. At that time, the animals were weighed and evaluated by the technique of bioelectrical impedance. After, their tongue was collected for histological analysis and liver analysis for lipid peroxidation (LPO). Results: The animals of CO and CO + Mel groups had a weight gain of 24% and 29%, respectively, in the BDL group was 8% and in the BDL + Mel group we observed a 21% weight gain. The CO, CO + Mel and BDL + Mel groups showed a phase angle of 22%, 20% and 17%, respectively, and the BDL group showed a phase angle of 5%, suggesting changes in the cell membranes. When assessing the LPO, there was an increase in BDL group when compared to the control groups (p < 0.001) and a reduction in BDL + Mel group (p < 0.001). In animal tongue assessment can be seen that filiform papillae and taste buds are normal in CO and CO + Mel groups; but in the BDL group we observed a destruction of filiform and a commitment of keratinization; in the animals of BDL + Mel group these standards are close to those of controls. Conclusions: To judge by the results obtained, we can suggest that the morphological and histological changes of the tongue may be related to nutritional changes. Mel appears to have a regenerative action on these structures studied.
VARIANTS ASSOCIATED WITH VITAMIN D METABOLISM AND PROGRESSION TO HEPATOCELLULAR CARCINOMA IN CHRONIC HEPATITIS C: DBGAP DATA FROM HALT-C TRIAL
L.A. De Azevedo1 , U.D.S. Matte1 , T.R. Silveira1 , M.R. Alvares-da-Silva2 . 1 Universidade Federal do Rio Grande do Sul (UFRGS)/ Hospital de Clinicas de Porto Alegre, Porto Alegre; 2 GI-Hepatology Division, Universidade Federal do Rio Grande do Sul (UFRGS)/ Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil E-mail: email@example.com Background and Aims: Vitamin D status has been associated to progression of chronic liver disease, but data are somehow controversial. In this study, we evaluated 24 polymorphisms related to vitamin D metabolism pathway and their relationship with hepatocellular carcinoma (HCC) in chronically hepatitis C virus (HCV) infected patients. Methods: Data are from the 4-year follow-up of Hepatitis C Antiviral Long-term Treatment Against Cirrhosis cohort and access to datasets were obtained from dbGaP (phs000430.v1.p1). Patients were originally genotyped for 601,273 polymorphisms in Illumina Human610_Quadv1_B platform. Twenty four SNPs from candidate genes related to vitamin D metabolism were selected and entered the analysis (DHCR7, GC, CYP2R1, CYP27B1, CYP24A1, VDR, TGF, and SMAD3). The SNPs not genotyped in the platform were imputed with Mach-Admix package using 1000 Genomes Phase 3 v.5 as reference panel. Outcome of interest was development of HCC during the 4-year follow-up. Logistic regression was employed in the association analysis. Age, sex, and race were used as covariates. Quality control and statistical analysis were computed in Plink software, v. 1.07. Results: Of the 24 studied polymorphisms, only CYP2R1 rs1562902 T/C significantly affected development of HCC. Homozygosity for allele C was present in 31% of HCC cases and in 19.5% of non-HCC (OR = 1.912, P = 0.03838). Conclusions: The only genotype related to HCC in this cohort (CYP2R1) is responsible for higher levels of vitamin D, according to the literature. Thus, this may suggest vitamin D levels would not have an impact in progression to HCC in HCV infected patients.
QUANTIFICATION OF HBSAG IN HBV PATIENTS WITH CHRONIC KIDNEY DISEASE: RELATIONSHIP WITH VIRAL LOAD AND HISTOLOGICAL FINDINGS
A.S.N. Lima1 , C.S. Ferreira1 , I.R.D. de Castro1 , J.S. Bernardino1 , R. Alves1 , G.A. Silva1 , C.T. Emori1 , S.N. Uehara1 , I.M. Carvalho-Mello1 , V.P. Lanzoni2 , A.C.A. Feldner1 , I.S.S. Silva1 , A.E.B. Silva1 , M.L.G. Ferraz1 , R. Carvalho-Filho1 . 1 Gastroenterology; 2 Pathology, Federal University of São Paulo, Sao Paulo, Brazil E-mail: firstname.lastname@example.org Background and Aims: Patients with chronic kidney disease (CKD) under haemodialysis are at elevated risk of hepatitis B virus (HBV) infection and its complications. Quantification of hepatitis B surface antigen (HBsAg) serum levels can be useful for early identification of HBV inactive carriers, for predicting response to interferon, and for estimating the severity of liver disease in HBV patients with preserved kidney function. The aims of this study were a) to evaluate the relationship between HBsAg serum levels, HBV viral load, and fibrosis staging in HBV patients with CKD on haemodialysis (CKD-HD); b) to assess the influence of the haemodialysis procedure on HBsAg measurements; and c) to compare HBsAg levels between CKD-HD and kidney transplant recipients (KTR) in relation to HBV viral load, HBV genotyping and fibrosis staging. Methods: Cross-sectional study including 3 groups: 1) CKD-HD; 2) KTR; and 3) HBV patients with preserved kidney function (controls). HBsAg, HBV DNA, and HBV genotype were investigated using commercial diagnostic assays and liver histology was scored using the METAVIR system. Results: 165 patients were included, with 55, 60 and 50 subjects in groups 1), 2) and 3), respectively. HBsAg serum levels were similar in these groups (irrespectively of HBeAg status), as well as the prevalence of advanced liver fibrosis (METAVIR F3/F4). Overall, there was a positive and moderate correlation between HBsAg level and HBV DNA (r = 0.446; p < 0.001), both in HBeAg-positive (r = 0.256; p = 0.025), and HBeAg-negative individuals (r = 0.353; p = 0.002). In each of the 3 groups, positive correlations were observed between HBsAg and HBV DNA levels. HBeAg-positive patients with F3/F4 fibrosis stages exhibited lower HBsAg levels, but this association was not observed in HBeAg-negative subjects. Haemodialysis and HBV genotype showed no impact on HBsAg measurement. Conclusions: In HBV patients with CKD on haemodialysis, there is a positive and significant correlation between HBsAg and HBV viral load, as well as a significant association between HBsAg and advanced liver fibrosis. Measurement of HBsAg level is not influenced by the haemodialysis procedure. Quantification of serum HBsAg seems to have similar potential for clinical applicability, as compared to subjects with normal renal function.
APPLICABILITY OF DRIED BLOOD SAMPLES FOR HEPATITIS C VIRUS DETECTION AND QUANTIFICATION
L.M. Villar1 , B.L.C. Marques1 , M.P. Espírito-Santos1 , V.A. Marques1 , C.A. Villela-Nogueira2 , L.L. Lewis-Ximenez1 , E. Lampe1 . 1 Viral Hepatitis Laboratory, FIOCRUZ; 2 Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil E-mail: email@example.com Background and Aims: Dried blood spots (DBS) could be an excellent alternative for HCV diagnosis, since it is less invasive and can be stored and transported without refrigeration. The aim of this study was to optimize quantitative and qualitative methods for HCV detection in DBS. Methods: A total of 99 subjects gave DBS and serum samples for antiHCV testing. Reactive anti-HCV samples were submitted to in house quantitative RT-PCR (qRT-PCR) for amplification of 5’ non coding region of HCV using Taqman methodology. For optimization of quantitative real time PCR in DBS, RNA extraction, number of cycles of reaction, and concentration of cDNA and reverse transcriptase were evaluated. A qualitative PCR for amplification of NS5B region of HCV was also used to determine HCV genotype. Sensitivity, specificity, kappa statistic, reproducibility and presence of inhibitors in qRT-PCR were also determined. Results: For anti-HCV, the sensitivity of DBS was 94.9%, specificity was 100%, and Kappa was 0.93. In house qRT-PCR showed good correlation to commercial assay for HCV viral measurement in serum. To quantify HCV RNA in DBS, a commercial method was choosen for HCV RNA extraction (Qiamp DNA mini kit). In addition, reverse transcriptase and cDNA concentration were increased. Among 44 HCV RNA reactive serum samples by quantitative PCR, HCV RNA was also quantified among 35 DBS samples (median viral load of 5.38 log10 copies/mL). Real time PCR for HCV RNA quantification in DBS demonstrated 65.9% of sensitivity, 100% of specificity and kappa statistic of 0.65. Among 59 anti-HCV reactive serum samples, HCV RNAwas detected by qualitative PCR in 45 sera and 15 DBS specimens. Nucleotide sequences were obtained for 43 sera and 11 DBS samples. Among 11 individuals that presented HCV RNA in serum and DBS, all of them belonged to genotype 1. Conclusions: Quantitative real time PCR was developed for HCV RNA quantification in serum and DBS and DBS could be used to determine HCV genotype demonstrating the usefulness of these samples for viral load determination and molecular epidemiology studies of HCV.
ALLOPURINOL IS SAFE AND EFFECTIVE TO ACHIEVE BIOCHEMICAL AND HISTOLOGICAL REMISSION IN PATIENTS WITH AUTOIMMUNE HEPATITIS WITH INCOMPLETE THERAPEUTIC RESPONSE
D.R. Terrabuio1 , L.T. De Moraes Falcao1 , S.K. Ono1 , M.A. Diniz1 , F.J. Carrilho1 , E. Cancado1,2. 1 Gastroenterology, University of Sao Paulo School of Medicine; 2 Laboratory of Medical Investigation 6, Institute of Tropical Medicine of Univesity of Sao Paulo, Sao Paulo, Brazil E-mail: firstname.lastname@example.org Background and Aims: Measurement of thiopurine metabolites is controversial in AIH treatment. Low and high levels of 6-thioguanine (6TGN) are related to low immunosuppressive activity or myelotoxicity respectively. High levels of 6-methylmercaptopurine (6MMP) are associated with hepatotoxicity. Co-administration of allopurinol (ALLO) redirects thiopurine metabolism to 6TGN instead of 6MMP. The aims of this study were to evaluate the efficacy and safety of ALLO and azathioprine (AZA) to induce biochemical and/or histological remission in AIH patients. Methods: 27 patients (23 females), ([85.2% AIH-1, 29.2% anti-SLA]; 60.9% with advanced fibrosis [F3/4]) with a mean age of 35 ± 17.3 y were selected to receive ALLO-AZAwith varying doses of prednisone. The reasons for ALLO indication were 6MMP levels above 5700 pmol/ 8 × 108 RBC in 18 and low levels of 6TGN with high doses of AZA in 9, without biochemical or histological remissions. At inclusion only 4 out of 27 patients had previous histological remissions and 16 had biochemical but not histological remission. They received 100 mg/ day ALLO with a reduction of 50–75% of AZA dose; they performed weekly complete blood count in the first month, AZA metabolites at least 4 weeks after ALLO and assessment of liver enzymes and function. After 18 months of biochemical remission, liver biopsies were performed to evaluate histological remission. Simple and multiple generalized estimating equations were performed to describe data considering an autoregressive correlation structure. Results: AZA dose and the levels of 6TGN and 6MMP pre-ALLO were respectively 112.5 ± 34.5 mg/day, 275 ± 20.1 and 6854 ± 1049 pmol/ 8 × 108 RBC. After ALLO, 6TGN levels increased to 782 ± 131.6 (p < 0.001), and 6MMP levels reduced to 2383 ± 1229 (p < 0.001), while AZA dose was reduced to 48.1 ± 11.3 mg/d. There were no significant drops in leukocytes, neutrophils, platelets and erythrocytes counts. Six/27 (22.2%) stopped ALLO (1 gastrointestinal side effects, 4 pregnancies with AZAwithdrawal and 1 inclusion in liver transplant list). After ALLO 6 other patients went into biochemical remission; 16/22 underwent liver biopsies that revealed histological remissions in 10 (62.5% or 37% of all patients using ALLO). 6TGN levels were 624 ± 545 in those who achieved histological remission compared to 1235 ± 821.3 in those who did not (p = 0.23). Conclusions: Co-administration of ALLO with lower AZA dose is safe and effective for histological remission in AIH patients with incomplete response due to an unfavorable AZA metabolite profile. AGE-STANDARDIZED LIVER-RELATED MORTALITY IN BRAZIL FROM 2008 TO 2012: A NATIONWIDE ANALYSIS OF MORE THAN 270,000 LIVER DEATHS H. Perazzo1 , A. Pacheco2 , J. Fittipaldi1 , C. Rigolon1 , S. Cardoso1 , V. Veloso1 , B. Grinsztejn1 . 1 LaPClin, National Institute of Infectious Diseases/FIOCRUZ; 2 PROCC, FIOCRUZ, Rio de Janeiro, Brazil E-mail: email@example.com Background and Aims: Chronic liver diseases have emerged as major causes of global health burden and have been leading to an economic impact in health care systems. Liver-related mortality has been increasing worldwide and we aimed to evaluate its burden in Brazil from 2008 to 2012. Methods: The Brazilian National Death Registry was analyzed from 2008 to 2012. A liver-related death was defined as the presence of any of the following ICD-10 codes in contributing or underlying causes of death in the death certificate (DC): viral hepatitis due to virus B [B16.2; B16.9], C [B17.1; B18.2] or Delta [B16.0; B16.1; B17.0; B18.0]; liver cancer [C22]; alcoholic liver disease (ALD) [K70] and liver fibrosis and cirrhosis [I85, K73, K74]. Population estimation was provided by the Brazilian Institute of Geography and Statistics (IBGE). The World Standard population (2000–2025) proposed by the WHO was used to adjust the mortality rates by age applying the direct standardization method. Age-adjusted liver-related mortality rates [expressed per 100.000 inhabitants] were estimated in Brazilian macro and micro-regions (states). Results: A total of 270,838 deaths with liver diseases mentioned in their DC [70% male, median age = 58 (48–70) yrs] occurred from 2008 to 2012. The age-adjusted liver-related mortality rate (95% CI) was 25.74 (25.64–25.83) in Brazil. The age-adjusted mortality rates of specific liver diseases were: 2.12 (2.09–2.014) for viral hepatitis; 4.04 (4.00–4.08) for liver cancer; 5.26 (5.22–5.30) for ALD and 10.41 (10.35–10.47) for cirrhosis. The South region had the highest mortality rates for viral hepatitis [3.22 (3.13–3.30)], liver cancer [4.37 (4.27–4.47)] and cirrhosis [9.83 (9.68–9.98)] as well as the Northeast region for ALD [5.93 (5.84–6.02)]. Two Brazilian states localized in the North region had the highest age-adjusted mortality rates: (i) the state of Acre for viral hepatitis [11.51 (10.24–12.78); more than double of the second top ranking state] and cirrhosis [18.46 (16.75–19.93)]; and (ii) the state of Roraima for liver cancer [7.04 (5.51–8.57)]. Pernambuco, a state of the Northeast region, had the highest rate for ALD [8.89 (8.32–9.17)]. The highest mortality rates for hepatitis B [4.58 (3.79–5.38)], C [6.32 (5.35–7.29)] and Delta [1.29 (0.89–1.69)] were observed in the state of Acre. Conclusions: Liver diseases remain as a major public health issue in Brazil. Further urgent research is needed to prioritize health policies for the most frequent liver diseases across different regions of the country.
A NATIONWIDE ANALYSIS OF AGE-STANDARDIZED CIRRHOSIS MORTALITY RATES IN BRAZIL FROM 2000 TO 2012
H. Perazzo1 , A. Pacheco2 , R. De Boni1 , P. Luz1 , J. Fittipaldi1 , S. Cardoso1 , B. Grinsztejn1 , V. Veloso1 . 1 LaPClin, National Institute of Infectious Disease/FIOCRUZ, Rio de Janeiro; 2 PROCC, FIOCRUZ, Rio de Janeior, Brazil E-mail: firstname.lastname@example.org Background and Aims: Mortality rates related to liver cirrhosis has been decreasing worldwide. However, cirrhosis remains the most frequent liver-related cause of death. This study aimed to evaluate the burden of cirrhosis mortality in Brazil from 2000 to 2012. Methods: The Brazilian National Death Registry (SIM – Sistema de Informação de Mortalidade) was analyzed from 2000 to 2012. SIM is an open-source and web available (www.datasus.gov.br) database provided by the Brazilian Ministry of Health, which contains data from all deaths registered, based on the death certificate (DC), in Brazil since 1979. Death by cirrhosis was defined by the presence of I85, K73 and/or K74 ICD-10 codes in contributing or underlying causes of death on the DC. Estimation of population was provided by the Brazilian Institute of Geography and Statisitcs (IBGE). Crude mortality rates were calculated by the ratio between the absolute number of deaths and the estimated population. Mortality rates were age-adjusted by the direct standardization method using the WHO standard population. Crude and age-standardized mortality rates [expressed per 100,000 inhabitants] were calculated for Brazil and its macro-regions. Results: A total of 265,180 deaths where cirrhosis is mentioned on their DC [77% male, aged 56 years] occurred from 2000 to 2012. Cirrhosis codes were present in 46% of liver-related deaths and 2% of all deaths in this period. Despite an increase in the absolute number of deaths (n = 18,245 to 22,340), the age-standardized mortality rates (95%CI) decreased from 13.32 (13.16–13.48) to 11.71 (11.59–11.83) per 100,000 inhabitants from 2000 to 2012. This trend was not uniform across the country, with decreases in death rates in the South [14.46 (14.07–14.87) to 10.89 (10.59–11.19)] and Southeast [15.85 (15.6– 16.09) to 12.52 (12.34–12.70)] and increases in the North [8.84 (8.24– 9.43) to 11.53 (11.08–11.99)] and Northeast [9.41 (9.13–9.69) to 10.93 (10.68–11.17)]. Conclusions: Cirrhosis was mentioned in more than 20,000 deaths/ year in the last decade. Despite the reduction in age-adjusted mortality rates, cirrhosis remains a major public health issue in Brazil.
INEQUALITY AND ECONOMIC FACTORS IMPACT ON THE WEIGHT OF ALCOHOL IN CIRRHOSIS BURDEN AND DEATH RATE: A WORLDWIDE STUDY
M. Cruz-Lemini1,2, E. Stein3 , J.G. Abraldes4 , R. Bataller3,5, J. Altamirano1,5. 1 Vall d’Hebrón Institut de Recerca, Barcelona, Spain; 2 Fetal Medicine and Surgery Research Unit, Fetal Medicine Mexico, Neurodevelopmental Research Unit “Dr. Augusto Fernández Guardiola”, Neurobiology Institute, Universidad Nacional Autónoma de México (UNAM) Campus Juriquilla, Querétaro, Mexico; 3 Division of Gastroenterogy & Hepatology, Department of Medicine; Division of Biochemistry, Department of Nutrition, University of North Carolina, Chapel Hill, United States; 4 Cirrhosis Care Clinic (CCC), Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Canada; 5 Institut d’Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain E-mail: email@example.com Background and Aims: Approximately 6% of global deaths are caused by alcohol consumption, with a major contribution from alcoholic cirrhosis. We have previously reported on global consumption patterns and their prediction of the alcohol attributable fraction (AAF) and age-standardized death rate (ASDR) from cirrhosis. Most studies assessing these outcomes focus on alcohol consumption as risk factors for alcoholic cirrhosis, however inequality and economic data, and its influence on the cirrhosis burden, have not been evaluated globally. The aim of this study is to investigate the influence of country inequality and economic factors on the cirrhosis burden worldwide. Methods: We performed a comprehensive analysis of the following global databases: WHO Global Information System on Alcohol and Health, WHO Global Health Observatory, World Bank, International Labor Organization (United Nations) and the United Nations Development Programme Human Development Reports, to include surrogate inequality and economic parameters from 193 countries. We focused on the gross domestic product (GDP), Human Development Index (HDI), Inequality-adjusted HDI (IHDI), Total Health Expenditure (THE) and Knowledge Economy Index (KEI) as parameters reflecting inequality and the economy of each country. Uni- and multivariate models were fitted to determine the influence of these parameters and the outcome measures of AAF and ASDR, adjusting for other cofactors such as the prevalence of viral hepatitis. Results: From 193 countries, evaluated factors were available in 183. Univariate analysis showed a positive association of GDP ( p = 0.012) and inequality parameters with AAF. In contrast, all parameters with exception of health expenditure ( p = 0.109), showed significant negative associations with ASDR ( p < 0.001). Multivariate analyses showed inequality parameters maintained their positive association with AAF, suggesting that the cirrhosis burden due to alcohol is associated with greater national health expenditure and a higher development level (Table 1). IHDI was the only independent parameter that remained inversely associated with ASDR, when adjusted by the other cofactors ( p = 0.035, Table 2). Conclusions: Country inequality and economic status independently influence the weight of alcohol in the cirrhosis burden and standardized death rate from cirrhosis, and should be considered as important factors when developing public health policies addressing alcoholic liver disease.
HEPATOCELLULAR CARCINOMA IN NON-ALCHOLIC STEATOHEPATITIS – HISTOPATHOLOGICAL ASPECTS
P.B. de Campos1 , C.P. Oliveira1 , L. Kikuchi1 , J.T. Stefano1 , A.L. Chagas1 , P. Herman2 , L.C. D’albuquerque2 , M.R. Alvares da Silva3 , F.J. Carrilho1 , V.A. F. Alves4 . 1 Gastroenterology (LIM-07); 2 Division of Liver and Gastrointestinal Transplant (LIM-37), Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo; 3 Division of Gastroenterology, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre; 4 Pathology (LIM-14), University of São Paulo School of Medicine, São Paulo, Brazil E-mail: firstname.lastname@example.org Background and Aims: Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver. The raise in incidence has been ascribed to the increase in obesity, diabetes and non-alcoholic fat liver disease (NAFLD). The aim of this study is to evaluate the pathological and clinical aspects in patients with HCC secondary to NAFLD. Methods: We evaluated 28 HCC specimens from 18 patients diagnosed with NAFLD undergoing liver resection (10 patients) or liver transplantation (8 patients) from 2005 to 2015. We compared histological features, clinical aspects, imaging findings, demographic and biochemical data, as well as their survival. Results: A total of 30 nodules were detected in 18 patients. Since 2 nodules were necrotic, 28 HCC nodules were studied herein. Cirrhosis was present in eleven cases, (8 F4A × 11 F4B × 1F4C according to Laennec Staging) harboring 20 HCC nodules, whereas 8 HCC nodules (28%) were found in 7 patients without cirrhosis (NASH staging: F2: 5pts, F3 = 3pts). Ages ranged from 58 to 77 years and 13 patients were male (72%). Thirteen patients (72%) had diabetes mellitus (23 HCC nodules), 13 patients (72%) had arterial hypertension (20 HCC nodules), and 14 patients (77%) had BMI above 25 (23 HCC nodules). Only 6 patients (33%) had dyslipidemia (8 HCC nodules). HCC occurred in 7 patients Child A, 4 Child B and in 7 patients without cirrhosis. As the performance status, 16 patients had a good performance status (PS) with ECOG 0 (26 HCC nodules). Alphafetoprotein level was normal in 12 patients (18 HCC nodules). The dimensions of the HCC nodules ranged from 0.8 cm (single nodule) to 15 cm in diameter and the predominant macroscopic pattern was nodular (93% – 26 HCC nodules). The predominant microscopic pattern was trabecular (46% > 13 HCC nodules). Major histological features of HCC are depicted at Table 1. Of all the patients, 11 evolved to death, 8 cases in patients who underwent resection and 3 cases who underwent liver transplantation. The causes of death were primary nonfunction, infection, acute rejection and palliative care caused by the evolution of HCC. Conclusions: HCC secondary to NAFLD can arise in patients without cirrhosis with normal level of alpha-fetoprotein. Histological markers of “steato-hepatitic HCC” and high architectural and nuclear degrees (g.3) were prevalent. The survival rate was low, especially in patients who underwent resection, despite the good performance status.
QUANTIFICATION OF LIVER STEATOSIS USING THE NEW SCORE ULTRASOUND FLI (FATTY LIVER INDEX) AND CAP (CONTROLLED ATTENUATED PARAMETER): A COMPARATIVE ANALYSIS
F.V. Calcado1 , R. Luz1 , R. Leite1 , N. Leite1 , H. Coelho1 , C.V. Nogueira1 . 1 Hepatology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil E-mail: email@example.com Background and Aims: Ultrasound FLI (US-FLI) is a new scoring system ranging 2–8 based on the intensity of liver/kidney contrast (0–3), posterior attenuation of ultrasound beam (0–1), vessel blurring (0–1), difficult visualization of gallbladder wall (0–1), difficult visualization of the diaphragm (0–1) and areas of focal sparing (0–1). So far, US-FLI was correlated with severity and the presence NASH assessed histologically. The association between US-FLI and CAP values has not been described. The aim of this study was to compare the US-FLI with CAP in detection and quantification of liver steatosis and correlated with clinical, anthropometric and laboratory parameters. Methods: We studied patients with metabolic syndrome or type 2 diabetes mellitus in outpatients from october 2013 to august 2014. Other liver diseases, alcohol consuption ≥20 g/day and use of drugs associated with liver steatosis were excluded. Were evaluated: US-FLI (medical operator was blinded both to clinical information and to CAP value), liver elastography with CAP, weight, BMI, waist circumference, glycated hemoglobin, total cholesterol, LDL, HDL, triglycerides, GGT, platelet. The US-FLI was categorized as < 0.001). The sensitivity (S), specificity (SP), positive predictive value (PPV), negative predictive value (NPV) of US-FLI ≥4 for steatosis ≥66% by CAP were: 88%, 72%, 73% and 88%. The AUROC of US-FLI ≥4 for steatosis ≥66% by CAP was 0.86. The agreement between the US FLI ≥4 with CAP ≥ 66% steatosis was significantly (p < 0.001; k = 0.59). US FLI ≥4 obtained S = 92%, E = 80% PPV = 85% and NPV = 89% in the detection of CAP ≥279, with highest concordance (p < 0.001; k = 0, 73) and highest AUROC (0.90). Conclusions: US-FLI have good accuracy in detecting severe steatosis and was as effective as the CAP. As the ultrasound tool easily accessible, the US-FLI should be better studied for diagnosis and quantification of liver steatosis.
CORONARY ARTERY CALCIUM SCORE AND FRAMINGHAM SCORE IN EVALUATION OF CARDIOVASCULAR RISK AFTER LIVER TRANSPLANTATION
L. Carone1 , C.P. Oliveira1 , M.R. Alvares-da-Silva2 , J.T. Stefano1 , D.R.B. Terrabuio1 , E. Abdala1 , F.J. Carrilho1 , A.Q. Farias1 , L.A.C. D’Albuquerque1 . 1 Gastroenterology, Hepatologiy and Liver Transplantation, University of São Paulo School of Medicine, Sao Paulo; 2 Gastroenterology, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil E-mail: firstname.lastname@example.org Background and Aims: Cardiovascular (CV) disease is a common complication following orthotopic liver transplantation (OLT). Coronary artery calcium score (CACS) is considered a robust tool to assess cardiovascular risk (CVR). We hypothesized that liver transplantation aggravates MS and CVR along time. The aim of the present study is to register the prevalence of MS and related diseases among OLT recipients and to know how that impacts on their CVR stratification, using FRS and CACS. Also, we want to determine whether CACS has additive value to FRS in CVR classification. Methods: Forty consecutive adult patients who underwent OLT were evaluated during outpatient clinic visits in the following four years. Anthropometric and clinical data, Framingham score (FS) and blood biomarkers of atherosclerosis after one and four years of OLT were analyzed. CACS was performed at the end of the follow-up. Results: There were 25 (62.5%) male patients, mean age of 53.8 years and mean body mass index (BMI) of 26.9 kg/m2 at the final evaluation. Prevalence of hypertension, dyslipidemia and metabolic syndrome (MS) significantly increased over time, from 37.5% to 65%, 30% to 60% and 22.5% to 47.5%, respectively. The median FS increased from 7.5% to 21% (p = 0.0354), demonstrating that the 10-year CVR changed from low to high. According to CACS, 27.5% of patients had moderate/severe calcification. Five patients (12.5%) presented at least one CV event after OLT. Patients with previous CV event had higher values of CACS when compared with patients who did not have a history of CV morbidity (median 140.0 × 0; p = 0.001). A significant correlation between CACS and FS, age, alcohol, glucose, glycosylated hemoglobin and triglycerides was found. Levels of blood biomarkers of atherosclerosis did not correlated with MS, FS or CACS. Conclusions: We concluded that the prevalence of MS and the CVR have a great increase fours years after OLT, which is known to impact on late survival. CACS is a useful tool in evaluating liver transplant recipients, and probably can enhance CVR stratification and help prevent CV events in the future.
COMBINATION OF 4-METHYLUMBELLIFERONE AND ADENOVIRAL GENE TRANSFER OF INTERLEUKIN-12 REDUCED THE EXPRESSION OF CANCER STEM CELLS MARKERS, AND SHOWED A POTENT ANTITUMOR EFFECT IN AN EXPERIMENTAL HEPATOCELLULAR CARCINOMA MODEL WITH FIBROSIS
M.M. Rodriguez1 , M. Malvicini1 , E. Fiore1 , S.G. Bustillo1 , F. Piccioni1 , E. Peixoto1 , C. Atorrasagasti1 , M. Garcia1 , L. Alaniz2 , G. Mazzolini1 . 1 Gene Therapy Lab, Universidad Austral, Buenos Aires; 2 CIT NOBA, Junin, Argentina E-mail: email@example.com Background and Aims: The incidence of hepatocellular carcinoma (HCC) has grown significantly in the last decade. Curative treatments for HCC can only be applied in less than 30% of cases. Therefore, new therapeutic options are needed. We have demonstrated that HCC overexpressed an essential ECM component, hyaluronic acid (HA) and HA synthesis inhibition using a selective inhibitor 4- methylumbelliferone (4Mu) demonstrated anti-fibrotic and antitumor activity in a murine model of HCC associated with liver fibrosis. The aim of this work was to study the use of 4Mu in combination with gene therapy of interleukin 12 mediated by an adenovirus (AdIL-12) in a murine model of HCC associated with advanced fibrosis induced by thioacetamide (TAA). Methods: After 4 weeks of TAA administration (200 mg/kg) male C3H mice received intrahepatic injection of 1,25 × 10e5 Hepa 129 cells (day 0). On day 5 mice were distributed in experimental groups (n = 8/ group): i) saline (control); ii) 4Mu 200 mg/Kg, drinking water (day 5); iii) AdIL-12 1 × 10e9 DICT50/mL, i.v (day 9); iv) 4Mu + Adβ-gal 1 × 10e9 DICT50/mL, i.v (day 9); v) 4Mu + AdIL-12 1 × 10e9 DICT50/mL, i. v. Tumor volume was measured and survival studies were carried out. Tumor samples were taken to determine levels of CSCs. Results: Administration of 4 Mu or AdIL-12 alone induced a slightly reduction of liver tumor volume respect to saline group. Interestingly, combined treatment induced a significant reduction of HCC size (p < 0.05), reduced the number of tumor satellites, and increased animal survival (p < 0.05). Analysis by flow cytometry showed that the number of CD133 + cells the within liver and in HCC was reduced in 4Mu and 4Mu + AdIL-12 groups (p < 0.001). Combined therapy was also able to decrease the hepatic mRNA levels of CSCs markers CD133, CD90, EpCAM and CD44 (p < 0.01). No signs of toxicity were observed in mice treated with the combination strategy. Conclusions: Our results suggest that the combination of 4Mu and AdIL-12 reduced the expression of cancer stem cells markers and showed a potent antitumor efficacy in mice with HCC associated with liver fibrosis.
MELATONIN’S EFFECT ON THE SECONDARY BILIARY CIRRHOSIS INDUCED BY LIGATION OF BILIARY DUCT
N.A.P. Marroni1 , J.R. Colares2 , E.G. Schemitt3 , R.M. Hartmann3 , F. Licks3 , M. Do Couto Soares3 , A. DalBosco4 . 1 Postgraduate Program in Cell and Molecular Biology Applied to Health; 2 Universidade Luterana do Brasil, Canoas; 3 Universidade Federal do Rio Grande do Sul, Porto Alegre; 4 Postgraduate Program in Medical Sciences: Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil E-mail: firstname.lastname@example.org Background and Aims: Hepatic cirrhosis is characterized by the appearance of septa and fibrotic nodules, as well changes in liver function and structures. Prolonged obstruction of the bile duct in rats is an effective experimental model for inducing secondary biliary cirrhosis and fibrosis. Studies show the participation of reactive oxygen species in the pathophysiology of cirrhosis caused by secondary biliary steatosis. Melatonin is a lipophilic indolamine synthesized from serotonin and derived from the amino acid tryptophan. Aim: To investigate the effects of melatonin in secondary biliary cirrhosis induced by bile duct ligation (BDL). Methods: 32 Wistar rats were used (±30 0g), divided into four groups: CO, CO + Mel, BDL and BDL + Mel. Mice were treated with Mel (20 mg/kg) from the 15th day after the BDL until the 28° day. On the 29th day, spleen and liver were collected for evaluation of hepatosomatic ratio (RHS) and esplenosomatic (RES), and liver tissue for histological analysis and oxidative stress. Results: Results: The RHS and RES showed an increase in the BDL group when compared to the CO and CO + Mel group (p < 0.001), also, a decrease in the BDL + Mel group when compared to the BDL group (p < 0.001). In the evaluation of lipid peroxidation, there was a statistical difference in the BDL group when compared to the control groups (p < 0.001) and a reduction in BDL + Mel group (p < 0.001). The catalase and superoxide dismutase enzymes decreased in the LDB group when compared to controls and when administered Mel we observed a significant increase (p < 0.01) in the BDL + Mel group. In the histological analysis of liver tissue (HE and sirius red), we observed no deposition of collagen in liver parenchyma in the control groups, in the BDL group we observed tissue disorganization, presence of inflammatory infiltrate and fibrosis and when administered Mel in BDL + Mel group observed a reorganization of parenchymal fibrosis and decreased. Conclusions: The results suggest a protective effect of melatonin when administered in rats with secondary biliary cirrhosis induced by ligation of bile duct.
THE IL10-819C/T IS ASSOCIATED WITH MAJOR DEPRESSIVE DISORDER IN PATIENTS WITH CHRONIC HEPATITIS C
L.R. Cunha1 , D.A. Vieira1 , Y.G. Giampietro1 , A.D. Gomes2 , C. Faria, Jr 2 , R. Teixeira1,3, O.A. Martins Filho4 , F.S. Neves5 , G.A. Rocha2 , D.M. Queiroz2 , L.D. Silva3,6. 1 Viral Hepatitis Ambulatory, Instituto Alfa de Gastroenterologia, Hospital das Clínicas, Universidade Federal de Minas Gerais; 2 Laboratory of Research in Bacteriology; 3 Internal Medicine, Faculdade De Medicina Da Universidade Federal De Minas Gerais; 4 Diagnoses and Monitoring Biomarkers Laboratory, Instituto René Rachou, Fundação Oswaldo Cruz; 5 Mental Health, Faculdade de Medicina da Universidade Federal de Minas Gerais; 6 Viral Hepatitis Ambulatory, Instituto Alfa de Gastroenterologia, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil E-mail: email@example.com Background and Aims: Depressive disorder has high prevalence in chronic hepatitis C (CHC), however the pathophysiology of HCVrelated neuropsychiatric symptoms remains poorly understood. Both CHC and major depressive disorder (MDD) have been associated with increased levels of pro-inflammatory cytokines. Single nucleotide polymorphism (SNP) can affect inflammation and immune regulation and, as consequence, the development of illness. Therefore, we aimed to investigate whether IL6-174G/C and IL10- 819C/T polymorphisms are associated with MDD in patients with CHC. Since these polymorphisms are functional, further we aimed to test whether significant associations in the first analysis had relevance in plasma levels of target cytokines. Methods: 139 consecutive CHC patients (46 with MDD and 93 without MDD) were prospectively enrolled. MDD was diagnosed by using Mini-International Neuropsychiatry Interview, Hamilton Depression Rating Scale and Hospital Anxiety and Depression Scale. Clinical, laboratory and sociodemographic variables were evaluated in CHC patients with and without MDD. Cytokine genotyping was carried out by PCR. Plasma cytokine levels (pg/mL) were measured by Cytometric Bead Array method. The study was approved by Ethics Committee of UFMG. Results: In multivariate analysis, previous history of MDD (OR = 2.96; CI95% 1.08-8.10; p = 0.03), diabetes mellitus (OR = 2.77; CI95% 1.03- 7.47; p = 0.04), IL10-819C/T polymorphism (OR = 2.45 CI95% 1.06- 5.69; p = 0.04) were associated with current MDD. IL6-174G/C ( p = 0.27) and IL10-819C/T ( p = 1) were in Hardy Weinberg equilibrium. In the group of patients with current MDD, IL10-819*T carriers [median (IQR) 4.1 (0.6) vs. 3.9 (0.5), p = 0.04] had significant higher plasma levels of TNF-α than IL10-819*C carriers. Although IL6-174G/C was not associated with MDD, IL6-174*C carriers had significant lower plasma levels [median (IQR) 3.7 (0.7) vs. 4.0 (0.5), p = 0.01) of IL-4 than IL6- 174*G carriers. Conclusions: This is the first study to show that IL10-819C/T carrier is associated with MDD in patients with CHC. We also demonstrated that the polymorphism interfere with plasma levels of TNF-α.
IMPAIRED ANTI-HBV VACCINE RESPONSE IN NON-CIRRHOTIC CHRONIC HCV PATIENTS IS NOT OVERCOME BY DOUBLE DOSE REGIMEN: A RANDOMIZED CONTROL TRIAL
M.G. Pessoa1 , R. Porto1 , D. Mazo1 , C.P. Oliveira1 , N. Terrault2 , J. Dodge2 , P.M. Zitelli1 , J.R. Pinho1 , M. Lopes1 , F.J. Carrilho1 . 1 University of Sao Paulo School of Medicine, Sao Paulo, Brazil; 2 University of California San Francisco, Sao Francisco, United States E-mail: firstname.lastname@example.org Background and Aims: Some immunogenicity studies of anti-HBV vaccine in patients with chronic HCV infection have demonstrated a diminished anti-HBs response ranging from 63.6% to 72.9%, compared to 90.9% to 93.9% in healthy controls. To evaluate the anti-HBs response to standard compared to double dose HBV vaccination (Butang®; Butantã Institute, São Paulo) in treatment naive chronic HCV patients without cirrhosis. Methods: 140 adults with chronic HCV without cirrhosis were randomized to receive HBV vaccination at double dose (40 ug at 0, 1 and 6 months) or standard dose (20 ug at 0, 1 and 6 months). Response to vaccination was measured by titers of anti-HBs at 1 month after the last dose of HBV vaccine. 59 healthy controls were also evaluated (negative to anti-HCV, anti-HBc, HBsAg and anti-HBs antibodies) who received standard dosing (20 ug at intervals of 0, 1 and 6 months). Vaccine response (seroconversion) was defined by anti-HBs ≥10 U/L. Results: 129 patients (61 standard dose; 68 double dose) completed the study, with no dropouts due to adverse events. Completed patients were of median age 51 yrs, 61% female, 52% White, 40% F2-3, and 75% genotype 1 with median 6 log10 HCV RNA. The overall seroconversion rate was 76.3% (95% CI 65–87%) in standard dose and 73.1% (63–84%) in double dose groups compared to 91.5% (84–99%) in non-HCV controls (p = 0.02 and 0.008, respectively). Among HCVinfected patients, seroconversion were not significantly different in the double dose vs. standard dose HBV vaccination regimen (p = 0.69). Among responders, median anti-HBs titers in the double dose and standard dose vaccine groups were not significantly different from controls (205 vs 432 UI/L, p = 0.66). In a logistic regression model evaluating the association between vaccine group (standard versus double dose) and anti-HBs seroconversion, vaccine regimen was not an independent predictor of response (OR = 0.85, p = 0.69). In multivariate analysis, controlling for potential confounders including age, sex, ethnicity, and HCV genotype, only older age (OR = 0.92, p < 0.001) and HCV genotype 1 (vs others) (OR = 0.12, p = 0.005) were associated with a decreased likelihood of anti-HBs response in HCVinfected patients. Conclusions: In HCV-infected patients without cirrhosis, responses to HBV vaccination are significantly impaired and this reduced response cannot be overcome by the use double dose HBV vaccination. Other adjuvant measures need to be explored to enhance seroconversion rates in this “high need” group of patients.
RESCUE WITH STEROIDS IN PATIENTS WITH AUTOIMMUNE ACUTE JAUNDICED HEPATITIS
V. Cervera1 , M.E. Serio1 , V. Descalzi1 , S. Raffa1 . 1 Hepatology Unit, Fundacion Favaloro, Buenos Aires, Argentina E-mail: email@example.com Background and Aims: Autoimmune hepatitis (AIH) has a wide spectrum of clinical manifestations, being jaundice a significant marker of severity. The decision to start steroids treatment in this population is difficult in clinical practice. Aims: to evaluate the degree of response, clinical predictors of outcome and survival in acute jaundiced AIH. Methods: Thirty three consecutive patientes (pts) with acute jaundiced AIH seen at our center in the last 5 years were included in the study. Inclusion criteria were: bilirrubin >2.5 mg/dL, naïve to treatment, older than 15 years old and AIH diagnosis according to the international group score. In those pts treated with steroid, response was defined as complete, partial or treatment failure in concurrence to 2010 AASLD Guideline. Clinical, biochemical and histological variables associated with treatment failure were analyzed by nonparametric tests (Chi square and U Mann-Whitney). Overall survival and free liver transplant (LT) survival were assessed by Kaplan-Meier curves, performing a sub analysis by MELD 25) in which the efficacy and tolerability of steroids is lower, we still found an excellent overall survival.
URINARY BIOMARKER NGAL IN PATIENTS WITH CIRRHOSIS AND BACTERIAL INFECTIONS: ACCURACY STUDY IN ACUTE KIDNEY INJURY PREDICTION DEFINED BY KDIGO CRITERIA
R.O. Ximenes1 , C. Helou2,3, M. Diniz1 , D. Barbeiro4 , H. Souza4 , L.A. D’Albuquerque1 , F. Carrilho1 , A. Farias1 . 1 Gastroenterology Department; 2 Nephrology Department; 3 LIM 12; 4 Emergency Derpartment, University of Sao Paulo School of Medicine, Sao Paulo – SP, Brazil E-mail: firstname.lastname@example.org Background and Aims: Acute kidney injury (AKI) is a frequent complication of bacterial infections in patients with cirrhosis, occurring in 30% of cases. Serum creatinine (SCr) has limited diagnostic accuracy, taking up to 48 h to raise. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) is a more accurate AKI biomarker, because it raises earlier than SCr. We have demonstrated previously that uNGAL measured in the first hours of hospital admission can identify cirrhotic patients with bacterial infections who will develop AKI during hospital stay defined by traditional criteria in cirrhosis (i.e., raise of SCr of 50% from baseline to a final value above 1.5 mg/dL). The aim of this study was to test if uNGAL could predict AKI development defined by KDIGO criteria in patients with cirrhosis admitted with bacterial infections. Methods: Prospective study conducted at a university hospital from June 2013 to July 2014. Inclusion criteria: a) diagnosis of cirrhosis; b) presence of ascites and/or hepatic hydrothorax; c) age greater than 18 years old; d) concordance to participate in the study; e) bacterial infection without AKI at admission. Exclusion criteria: a) severe systemic comorbidities; b) shock; c) chronic kidney disease; d) intrinsic nephropathy; e) nephrotoxic drugs use; f ) previous dialysis; g) liver transplantation. Blood and urine samples were collected for urinary NGAL, serum catecholamines and renin plasmatic activity at the inclusion of patients in the study. SCr was measured daily to determine AKI development according to KDIGO criteria (i.e., raise of 0.3 mg/dL within 48 hours or 50% from baseline within 7 days). Results: Forty two patients were included, of which 16 (38.1%) developed AKI during hospital stay. The main parameters associated with AKI development were urinary NGAL, hepatic encephalopathy and diastolic arterial pressure (Table 1). Urinary NGAL had an accuracy of 0.74 (0.57–0.91) to predict AKI development, with the best cut-off value >86.3 μg/L. With this cut-off, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio were respectively 0.87 (0.6–0.98), 0.62 (0.41–0.8), 0.57 (0.36–0.92), 0.89 (0.64–0.95), 2.25 (1.33–3.81) and 0.22 (0.06–0.82). Conclusions: Urinary NGAL measurement at hospital admission is useful to identify patients with cirrhosis and bacterial infections who will develop AKI defined by KDIGO criteria during hospital stay.
URINARY BIOMARKER NGAL IN PATIENTS WITH HEPATORENAL SYNDROME: ACCURACY STUDY IN PREDICTION OF NO RESPONSE TO THERAPY WITH ALBUMIN AND TERLIPRESSIN
R.O. Ximenes1 , C. Helou2,3, M. Diniz1 , D. Barbeiro4 , H. Souza4 , L.A. D’Albuquerque1 , F. Carrilho1 , A. Farias1 . 1 Gastroenterology Department; 2 Nephrology Department; 3 LIM 12; 4 Emergency Derpartment, University of Sao Paulo School of Medicine, Sao Paulo – SP, Brazil E-mail: email@example.com Background and Aims: Acute kidney injury (AKI) etiology in patients with cirrhosis is variable, including pre-renal azotemia, acute tubular necrosis (ATN) and hepatorenal syndrome (HRS). HRS diagnosis is based on the exclusion of other causes of AKI. With current diagnostic criteria, some patients with ATN are misdiagnosed as HRS cases. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) is a biomarker of renal tubular injury and its levels vary according to the etiology of AKI. Therefore, we hypothesized that uNGAL would identify patients with HRS diagnosis who have significant tubular injury and will not respond to treatment with albumin and terlipressin. The aim of the study was to test if uNGAL is clinically useful to predict no response to albumin and terlipressin treatment in patients with HRS diagnosis. Methods: Prospective study conducted at a university hospital from June 2013 to July 2014. Inclusion criteria: a) diagnosis of cirrhosis; b) age greater than 18 years old; c) HRS diagnosis according to International Club of Ascites criteria; d) concordance to participate in the study. Exclusion criteria: a) severe systemic comorbidities; b) shock; c) chronic kidney disease; d) intrinsic nephropathy; e) nephrotoxic drugs use; f ) previous dialysis; g) liver transplantation. Blood and urine samples were collected for urinary NGAL, serum catecholamines and renin plasmatic activity within 6 hours of HRS diagnosis. Patients received standard treatment with albumin and terlipressin up to 14 days. Results: Twenty eight patients were included, of which 11 (39.3%) did not respond to treatment with albumin and terlipressin. Parameters associated with no response were serum noradrenaline, albumin and fractional excretion of urea (Table 1). Although uNGAL levels were higher in non-responders (747.4 μg/L × 182.9 μg/L), this difference did not reach statistical significance (p = 0.083). Urinary NGAL had an accuracy of 0.71 (0.5–0.92) to predict no response to combined treatment, with the best cut-off value >214.4 μg/L. With this cut-off, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio were respectively 0.9 (0.55–1), 0.53 (0.27–0.79), 0.56 (0.29–0.98), 0.89 (0.53–0.96), 1.93 (1.08–3.44) and 0.19 (0.03–1.28). Conclusions: Urinary NGAL had a moderate accuracy to identify patients with HRS diagnosis with no response to combined treatment with albumin and terlipressin. Further studies with a higher number of patients are warranted.