BACKGROUND AND AIMS:Hepatic encephalopathy is a frequent complication of cirrhosis. Rifaximin-α has been included in guidelines for secondary prevention of hepatic encephalopathy, but there are few real-world data on its efficacy and impact on healthcare utilization. In this study, we aimed to assess the effect of rifaximin-α on healthcare utilization. METHOD:We conducted a cohort analysis in patients from seven hospitals in the Netherlands, who received rifaximin-α as secondary prophylaxis for hepatic encephalopathy. Data were compared 6 months before and 6 months after the prescription of rifaximin-α. The primary endpoint was the effect of rifaximin-α on healthcare utilization. Secondary endpoint was the effect of rifaximin-α on healthcare costs. RESULTS:We included 126 patients (65% male; median age 68) with a median Model for End-stage Liver Disease score of 15. The mean number of hepatic encephalopathy episodes after starting rifaximin-α was lower than before starting rifaximin-α (0.9 vs. 2.2; p < 0.001). Mean healthcare utilization decreased from 6.1 contacts in the 6 months before rifaximin-α to 3.3 contacts in the 6 months after starting rifaximin-α (p < 0.001). The mean number of hospital admissions decreased from 1.7 admissions per patient to 1.0 admissions after starting rifaximin-α (p < 0.001). The mean number of outpatient visits also decreased after starting rifaximin-α (2.4 visits per patient to 1.7; p = 0.001). Annual costs per patient before starting rifaximin-α were €13,320. This was similar to the costs after rifaximin-α was prescribed (€13,120). CONCLUSION:Rifaximin-α significantly reduced the number of episodes of hepatic encephalopathy, the number of hospital admissions as well as the number of outpatient and emergency department visits, contributing to a reduction in healthcare utilization. There was no reduction in overall costs.

AbstractBackground & AimsAlterations in the glycosylation of blood proteins affect protein functionality and have been linked to various diseases. Metabolic dysfunction- associated steatotic liver disease (MASLD) is a silent disease, of which progression to advanced disease stages including metabolic dysfunction-associated steatohepatitis (MASH), fibrosis and cirrhosis often goes unnoticed. As current non- invasive diagnostic tests lack specificity, the purpose of this work was to study total blood proteinN-glycosylation in individuals with MASLD and various degrees of fibrosis as compared to healthy controls.MethodsIn two independent cross-sectional cohort studies, bloodN-glycosylation analysis was performed by mass spectrometry on released glycans of overall 132 MASLD patients and 99 age- and sex-matched healthy controls. Relationships between glycosylation traits and the disease spectrum of MASLD including fibrotic MASLD were investigated in comparison to healthy controls. Furthermore, publicly available transcriptomics datasets were used to explore glycosyltransferase expression in patients with MASLD.ResultsGlobally lower α2,3-sialylation distinguished MASLD from healthy controls (OR [CI]=0.36; [0.18-0.67];p-value=0.019, and 0.11 [0.04-0.24];p-value<0.000001), as well as non-fibrotic MASLD from its fibrotic counterparts (OR: 0.13 [0.06-0.26];p- value<0.0001), but showed no association with steatohepatitis activity. HepaticST3GAL6, a sialyltransferase responsible forN-glycan α2,3-sialylation, negatively associated with fibrosis progression, similar to the observed glycomic signature. Both glycomic and transcriptomic signatures were replicated in independent cohorts.ConclusionsFibrotic MASLD is characterized by a global decrease of blood protein α2,3-sialylation and according decrease in hepatic α2,3-sialyltransferase expression, associating with disease progression. These findings suggest alterations in theN- glycan biosynthetic pathway and are potentially useful in the early diagnosis of fibrosis in MASLD.Lay SummaryNon-invasive markers of fibrotic MASLD perform suboptimal. This research identified that changes in blood protein glycosylation coincide with fibrosis development, offering blood-based markers that could potentially replace a liver biopsy.What You Need to KnowBACKGROUND AND CONTEXTThe majority of the plasma glycoproteins is synthesized in the liver and changes to their glycosylation are known to affect their function and to associate with liver disorders.NEW FINDINGSMASLD patients exhibit lower α2,3-sialylation on the complete range of their blood protein N-glycans, which coincides with the histological appearance of fibrosis, mediated likely via downregulation of hepaticST3GAL6.LIMITATIONSWhile the findings of this study has could have implications for diagnosing fibrotic MASLD, the identified glycomic signature needs to be confirmed in a larger, ideally prospective patient cohort.CLINICAL RESEARCH RELEVANCEBy identifying specific signatures in the blood protein N-glycome, this research offers potential non-invasive markers for early diagnosis and monitoring of fibrosis in MASLD. Non-invasive diagnosis could potentially lessen the need for liver biopsies, and allow for timely intervention and improved disease management, ultimately leading to improvement of patient outcomes and the reduction of liver-related morbidity and mortality.BASIC RESEARCH RELEVANCEThe observed glycomic and transcriptomic signatures offer molecular-level insights into fibrosis development in MASLD. This paves the way for future research at the intersection of glycoscience and hepatology, that will offer deeper insights into the pathophysiology of this liver disease.

Abstract Background Currently, the standard therapy for autoimmune hepatitis (AIH) consists of a combination of prednisolone and azathioprine. However, 15% of patients are intolerant to azathioprine which necessitates cessation of azathioprine or changes in therapy. In addition, not all patients achieve complete biochemical response (CR). Uncontrolled data indicate that mycophenolate mofetil (MMF) can induce CR in a majority of patients. Better understanding of first-line treatment and robust evidence from randomised clinical trials are needed. The aim of this study was to explore the potential benefits of MMF as compared to azathioprine, both combined with prednisolone, as induction therapy in a randomised controlled trial in patients with treatment-naive AIH. Methods CAMARO is a randomised (1:1), open-label, parallel-group, multicentre superiority trial. All patients with AIH are screened for eligibility. Seventy adult patients with AIH from fourteen centres in the Netherlands and Belgium will be randomised to receive MMF or azathioprine. Both treatment arms will start with prednisolone as induction therapy. The primary outcome is biochemical remission, defined as serum levels of alanine aminotransferase and immunoglobulin G below the upper limit of normal. Secondary outcomes include safety and tolerability of MMF and azathioprine, time to remission, changes in Model For End-Stage Liver Disease (MELD)-score, adverse events, and aspects of quality of life. The study period will last for 24 weeks. Discussion The CAMARO trial investigates whether treatment with MMF and prednisolone increases the proportion of patients in remission compared with azathioprine and prednisolone as the current standard treatment strategy. In addition, we reflect on the challenges of conducting a randomized trial in rare diseases. Trial registration EudraCT 2016-001038-91 . Prospectively registered on 18 April 2016. Graphical Abstract

Background: Recommendations for drug withdrawal in patients with autoimmune hepatitis (AIH) in longstanding remission are conflicting and rely on retrospective data. We prospectively investigated the predictive value of histological normalisation for successful treatment withdrawal in AIH patients. Methods: Non-cirrhotic patients with established AIH and complete biochemical remission (normalisation of serum alanine aminotransferase [ALT] or aspartate aminotransferase [AST] and immunoglobulin G [IgG]) of at least 2 years were biopsied. Immunosuppressive therapy was only withdrawn in patients with histological normalisation (histological activity index [HAI] <= 3) with a minimum follow-up of 12 months. Results: A total of 17 patients in biochemical remission for at least 2 years were included. Persistent histological inflammatory activity (HAI >3) precluded drug withdrawal in five patients. These had higher values of ALT (25 vs. 16 U/L; p = 0.01) and AST (26 vs. 22 U/L; p = 0.01) compared with patients in histological remission. Immunosuppressive medication was withdrawn in 12 patients; eight (67%, C.I. 40-93% p = 0.4) remained in remission during a median follow-up of 62 months (range: 13-75 months); and four (33%, C.I. 7-60% p = 0.4) required reinstitution of therapy after 1, 6, 11, and 40 months, all without clinical signs of disease progression or hepatic decompensation. No predictors of relapse were identified. Conclusion: Two-thirds of the patients who prove to have histological normalisation after at least 2 years of biochemical remission achieve treatment-free remission. Although patient numbers were small and results should be interpreted with caution, these findings support a liver biopsy prior to drug withdrawal.

NAFLD is closely related with the metabolic syndrome (MetS) and increased risk of cardiovascular disease. Liver fat associates with post‐prandial hypertriglyceridemia, potentially contributing to triglyceride‐enrichment of high‐density lipoproteins (HDL‐TG), and subsequent HDL dysfunction. We assessed liver fat by MR spectroscopy, and its association with HDL physiochemical properties, and endothelial function, measured as flow‐mediated dilation (FMD), before and following three consecutive meals, in 36 men with type 2 diabetes mellitus (T2DM), with the MetS, and controls. Plasma triglycerides increased significantly following the meals ( P < .001). Fasting HDL‐TG was highest in T2DM, relative to MetS and controls ( P = .002), and increased post‐prandially in all groups ( P < .001). HDL function was negatively associated with HDL‐TG following three meals ( r = −.32, P <.05). Liver fat associated with HDL‐TG after three meals ( r = .65, P < .001). HDL‐TG was independently associated with FMD following three consecutive meals ( r = −.477, P = .003). We conclude liver fat is associated with post‐prandial HDL‐TG enrichment which was closely related with endothelial and HDL dysfunction.

ObjectiveType 2 diabetes mellitus is a metabolic disorder characterized by insulin resistance. Previous studies in patients demonstrated that plasma levels of cathepsin D (CTSD), which is optimally active in the acidic environment of lysosomes, correlate with insulin resistance. As plasma pH is slightly reduced in type 2 diabetic patients and we have previously shown that plasma CTSD activity is causally linked to insulin levels in vivo, it is likely that the activity of CTSD in plasma will be increased in type 2 diabetes compared to healthy individuals. However, so far the interaction between CTSD activity and levels to postprandial metabolic derangements in type 2 diabetes is not known.MethodsEighteen type 2 diabetes and 16 age-matched healthy males were given 2 consecutive standardized mixed meals, after which blood samples were collected. Plasma metabolic parameters as well as CTSD levels and activity were measured, and changes in plasma pH was assessed.ResultsIn line with the elevation of plasma free fatty acids (FFA) levels in male type 2 diabetics patients, plasma pH in type 2 diabetic individuals was decreased compared to male healthy individuals. While plasma CTSD levels were similar, plasma CTSD activity was increased in male type 2 diabetic compared to male healthy individuals. Besides, plasma CTSD activity rather than levels significantly correlated with indicators of type 2 diabetes (HbA1c, HOMA-IR and glucose). Furthermore, FFA was also independently associated with plasma CTSD activity (standardized β = 0.493, p = 0.007).ConclusionsDespite similar plasma CTSD levels, type 2 diabetic male individuals showed increased plasma CTSD activity compared to healthy males, which was independently linked to plasma FFA levels. Our data therefore point toward plasma CTSD as a metabolic regulator in male type 2 diabetes.

Background: Few studies with diverging results and a small sample size have compared autoimmune hepatitis (AIH) in the elderly to younger patients. Aim: To unbiasedly investigate the role of age in behaviour and treatment outcome of AIH. Methods: All patients with probable or definite AIH type 1 in four tertiary academic centres were included in this retrospective- and since 2006 prospective-cohort study. Influence of age on presentation, remission and outcome of AIH were investigated. Results: 359 patients were included. Presence of cirrhosis at AIH diagnosis around 30% was independent of age. ALAT was higher at age 30-60 years on AIH diagnosis, and above age 60 there were less acute onset, less jaundice and more concurrent autoimmune disease. Remission was reached in 80.2%, incomplete remission in 18.7%, only 1.1% (all aged 50-65) was treatment-refractory. Age was not an independent predictor of remission, while cirrhosis was. Above age 45 there was more diabetes, above age 60 more loss of remission. Rate of progression to cirrhosis was 10% in the 10 years after diagnosis and unrelated to age at AIH diagnosis. With onset below age 30, there was more development of decompensated cirrhosis over time. With higher age at AIH diagnosis there was a lower survival free of liver-related death or liver transplantation. Conclusions: AIH presents at all ages. Age influences features at diagnosis, but not response to treatment, while survival without liver-related death or liver transplantation decreases with higher age at diagnosis.

Summary Background Azathioprine ( AZA ) and mercaptopurine ( MP ) are the cornerstone of steroid‐sparing strategies in autoimmune hepatitis ( AIH ). Up to 20% of patients do not tolerate or respond to these regimens. Aim To evaluate retrospectively the tolerability and efficacy of tioguanine (thioguanine) (TG) therapy in selected patients with AIH and AIH variant syndromes. Methods Records of 52 patients who received TG therapy were retrieved from nine hospitals in the Netherlands. Indications for TG treatment were intolerable side effects on AZA or MP (n = 38), insufficient response (n = 11) or first‐line treatment (n = 3). Treatment efficacy was defined as normalisation of serum aminotransferases and serum immunoglobulin G. Results No serious adverse events occurred in patients treated with TG during a median follow‐up of 18 months (range 1‐194). Treatment was well tolerated in 41 patients (79%), whereas four had tolerable (8%) and seven (13%) intolerable side effects. Thirty‐eight patients were treated with TG after intolerable side effects on AZA or MP ; 29 patients continued TG therapy of whom 24 (83%) achieved complete biochemical remission, four (14%) had incomplete and one (3%) had no response; nine discontinued treatment. Seven of 11 patients with insufficient response to AZA or MP were responsive to TG , three with complete and four with incomplete biochemical remission; four discontinued due to intolerance (n = 2) and non‐response (n = 2). TG was effective in all AIH patients as first‐line maintenance treatment. Conclusion In our retrospective review of TG therapy in selected patients with AIH or AIH variants who previously failed on AZA or MP , TG appeared tolerable with biochemical efficacy.

acute liver injury, the mice were pre-injected intravenously with 15mg/kg ROCK inhibitor, fasudil, fifteen minuetes ahead of Con A injection.Serum and liver tissue from individual mouse was collected.Serum alanine aminotransferase (ALT), aspartate animotransferase(AST) activities were measured.Inflammatory gene expression was determinated by real-time quantitative-RT-PCR.Liver inflammation was analyzed with H&E staining.F4/80,the marker of hepatic macrophages was detected by immunohistochemical staining.Hepatic CD4+T cells were isolated from liver tissue and followed by flow cytometry assay.Results: In the acute liver injury mice model induced by Con A, the ALT and AST level statistically decreased from 2356.57±1247.30U/L and 1972.00±707.84U/L in the Con A group to 221.71± 250.45U/L and 370.29±335.15U/L in the ConA/Fasudil group.Con A induced liver inflammatory gene expression (Tnfα, IFNγ, Cxcl10) and the RhoA/ROCK signaling activation, whereas intravenous pre-injection with ROCK inhibitor, fasudil abolished these phenotypes.Liver inflammation, the activation and proliferation of hepatic macrophages and CD4+ T cells were also suppressed by ROCK inhibitor.Conclusions

BACKGROUND AND AIMS:Epidemiological data on autoimmune hepatitis (AIH) are scarce. In this study, we determined the clinical and epidemiological characteristics of AIH patients in the Netherlands (16.7 million inhabitants).METHODS:Clinical characteristics were collected from 1313 AIH patients (78% females) from 31 centers, including all eight academic centers in the Netherlands. Additional data on ethnicity, family history and symptoms were obtained by the use of a questionnaire.RESULTS:The prevalence of AIH was 18.3 (95% confidential interval [CI]: 17.3-19.4) per 100,000 with an annual incidence of 1.1 (95% CI: 0.5-2) in adults. An incidence peak was found in middle-aged women. At diagnosis, 56% of patients had fibrosis and 12% cirrhosis in liver biopsy. Overall, 1% of patients developed HCC and 3% of patients underwent liver transplantation. Overlap with primary biliary cirrhosis and primary sclerosing cholangitis was found in 9% and 6%, respectively. The clinical course did not differ between Caucasian and non-Caucasian patients. Other autoimmune diseases were found in 26% of patients. Half of the patients reported persistent AIH-related symptoms despite treatment with a median treatment period of 8 years (range 1-44 years). Familial occurrence was reported in three cases.CONCLUSION:This is the largest epidemiological study of AIH in a geographically defined region and demonstrates that the prevalence of AIH in the Netherlands is uncommon. Although familial occurrence of AIH is extremely rare, our twin data may point towards a genetic predisposition. The high percentage of patients with cirrhosis or fibrosis at diagnosis urges the need of more awareness for AIH.

BACKGROUND & AIMS Autoimmune hepatitis (AIH) is an uncommon autoimmune liver disease of unknown etiology. We used a genome-wide approach to identify genetic variants that predispose individuals to AIH. METHODS We performed a genome-wide association study of 649 adults in The Netherlands with AIH type 1 and 13,436 controls. Initial associations were further analyzed in an independent replication panel comprising 451 patients with AIH type 1 in Germany and 4103 controls. We also performed an association analysis in the discovery cohort using imputed genotypes of the major histocompatibility complex region. RESULTS We associated AIH with a variant in the major histocompatibility complex region at rs2187668 (P = 1.5 × 10(-78)). Analysis of this variant in the discovery cohort identified HLA-DRB1*0301 (P = 5.3 × 10(-49)) as a primary susceptibility genotype and HLA-DRB1*0401 (P = 2.8 × 10(-18)) as a secondary susceptibility genotype. We also associated AIH with variants of SH2B3 (rs3184504, 12q24; P = 7.7 × 10(-8)) and CARD10 (rs6000782, 22q13.1; P = 3.0 × 10(-6)). In addition, strong inflation of association signal was found with single-nucleotide polymorphisms associated with other immune-mediated diseases, including primary sclerosing cholangitis and primary biliary cirrhosis, but not with single-nucleotide polymorphisms associated with other genetic traits. CONCLUSIONS In a genome-wide association study, we associated AIH type 1 with variants in the major histocompatibility complex region, and identified variants of SH2B3and CARD10 as likely risk factors. These findings support a complex genetic basis for AIH pathogenesis and indicate that part of the genetic susceptibility overlaps with that for other immune-mediated liver diseases.

Background & Aims: Current treatment strategies in autoimmune hepatitis (AIH) include long-term treatment with corticosteroids and/or azathioprine. Here we determined the risk of relapse after drug withdrawal in patients in long-term remission and factors associated with such a relapse.Methods: A total of 131 patients (out of a cohort including 844 patients) from 7 academic and 14 regional centres in the Netherlands were identified in whom treatment was tapered after at least 2 years of clinical and biochemical remission. Relapse was defined as alanine-aminotransferase levels (ALT) three times above the upper limit of normal and loss of remission as a rising ALT necessitating the reinstitution of drug treatment.Results: During follow-up, 61 (47%) patients relapsed and 56 (42%) had a loss of remission. In these 117 patients, 60 patients had fully discontinued medication whereas 57 patients were still on a withdrawal scheme. One year after drug withdrawal, 59% of the patients required retreatment, increasing to 73% and 81% after 2 and 3 years, respectively. Previous combination therapy of corticosteroids and azathioprine, a concomitant autoimmune disease and younger age at time of drug withdrawal were associated with an increased risk of relapse. Subsequent attempts for discontinuation after initial failure in 32 patients inevitably resulted in a new relapse.Conclusions: This retrospective analysis indicates that loss of remission or relapse occurs in virtually all patients with AIH in long-term remission when immunosuppressive therapy is discontinued. These findings indicate a reluctant attitude towards discontinuation of immunosuppressive treatment in AIH patients. (C) 2012 Published by Elsevier B.V. on behalf of the European Association for the Study of the Liver.

for for PSC.After adjusting for hepatobiliary cancer, standardized morbidity ratios for malignancy were 2.08 (95% CI 1.35-3.07)for AIH, 1.01 (95% CI 0.41-2.07)for for PSC.Conclusion: This is the first mortality analysis comparing population-based AIH, PBC and PSC cohorts from the same region.PSC had the worst outcome.The standardized mortality ratios for all three cohorts were significantly higher than those of the general population, suggesting that better treatment strategy is desperately needed for these conditions.AIH and PSC were associated with significantly more cases of malignancy, even after adjusting for hepatobiliary cancer.

Autoimmune hepatitis (AIH) is a progressive, chronic form of hepatitis of unknown cause that occurs in people of all ages. The diagnosis is based on characteristic clinical and biochemical abnormalities, absence of other causes of hepatitis and histopathological characteristics. The variety of symptoms that AIH patients may have and the importance of considering the disease is illustrated in three case studies. The first was a 22-year-old woman with fulminant hepatitis and jaundice. Corticosteroid and azathioprine treatment resulted in prolonged remission. The second patient, a 48-year-old woman, had hepatocellular carcinoma in a cirrhotic liver, based on AIH. Radiofrequency ablation was planned, after which the patient would be put on the waiting list for transplantation. The third patient was an 81-year-old man with impaired liver function and cirrhosis. His treatment was the same as in the first patient and resulted in remission as well. No curative therapy for AIH is yet available, but appropriate management of the disease can prolong survival, improve the quality of life, and avoid the need for liver transplantation.

Autoimmune hepatitis (AIH) is a progressive, chronic form of hepatitis of unknown cause that occurs in people of all ages. The diagnosis is based on characteristic clinical and biochemical abnormalities, absence of other causes of hepatitis and histopathological characteristics. The variety of symptoms that AIH patients may have and the importance of considering the disease is illustrated in three case studies. The first was a 22-year-old woman with fulminant hepatitis and jaundice. Corticosteroid and azathioprine treatment resulted in prolonged remission. The second patient, a 48-year-old woman, had hepatocellular carcinoma in a cirrhotic liver, based on AIH. Radiofrequency ablation was planned, after which the patient would be put on the waiting list for transplantation. The third patient was an 81-year-old man with impaired liver function and cirrhosis. His treatment was the same as in the first patient and resulted in remission as well. No curative therapy for AIH is yet available, but appropriate management of the disease can prolong survival, improve the quality of life, and avoid the need for liver transplantation.