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How can EASL support your liver research?Find out about the different EASL programs, events, and tools that will take your understanding of the liver to a new level.
The EASL Fellowship programmes, aim to enhance the mobility of investigators within different European institutions by actively promoting scientific exchange among research units in Hepatology. As a major European Association dedicated to the liver and liver disease, EASL promotes research and education through the sharing of research findings in Hepatology.
They define the use of diagnostic, therapeutic and preventive modalities, including non-invasive and invasive procedures, in the management of patients with various liver diseases. The Journal of Hepatology is the official journal of EASL publishing original papers, reviews and letters to the editor concerned with clinical and basic research in the field of Hepatology.
EASL supports Young Investigators by attributing 200 travel bursaries each year together with one year’s free EASL Membership to the presenting authors of the best scored abstracts.
Every year EASL hosts three schools for young hepatologists which provide teaching in an intimate environment to facilitate exchange between expert and trainee. This new educational platform centralizes and organizes thousands of EASL educational materials published over the past eight years. EASL Clinical Practice Guidelines (CPGs) assist physicians and other healthcare providers as well as patients and those interested in the clinical decision-making process by describing a range of generally accepted approaches for the diagnosis, treatment and prevention of specific liver diseases. LT should be considered in any patient with end-stage liver disease, in whom the LT would extend life expectancy beyond what the natural history of underlying liver disease would predict or in whom LT is likely to improve the quality of life (QoL). LT is indicated in patients with end-stage liver disease, in patients with the development of hepatocellular carcinoma (HCC) and in patients with acute liver failure.
In recent years, an extension of indications has been observed, but in contrast, the transplant community is currently facing organ shortages. The timing of LT is crucial since patients who should be transplanted for end-stage liver disease need to undergo surgery before life-threatening systemic complications occur.
Priority on the waiting list was based in the past by the waiting time, and severity of liver disease.
In patients with MELD ?14, 1-year survival was lower with rather than without transplantation [11].
In very sick patients with MELD >30 the risk of mortality and morbidity after transplantation should be addressed. MELD does not reflect the impact of complications such as refractory ascites and recurrent encephalopathy in the risk of mortality without transplantation. In fact, there are several exceptions to MELD, including pulmonary complications of cirrhosis, hepatic encephalopathy, amiloidosis, primary hyperoxaluria, etc. Serum sodium (MELD-Na), serum sodium and age (integrated MELD) scores have been proposed to improve the predictive value of MELD [14].
The management of a patient in the waiting list aims at eliminating not only contraindications of surgery, but also contraindications to taking long-term immunosuppressive treatment.
Evaluating and selecting a good recipient for LT thus requires the collaboration of several specialists, who account for all comorbidities.
The indication of decompensated HBV cirrhosis is declining probably due to the outcome of HBV vaccination and advent of oral antiviral agents. Scoring system developed at the 8th International Meeting on Wilson's disease, Leipzig 2001 [44]. Although a disease of copper overload, the total serum copper (which includes copper incorporated in ceruloplasmin) in Wilson's disease is usually decreased in proportion to the decreased ceruloplasmin in the circulation. The amount of copper excreted in the urine in a 24-hour period may be helpful for diagnosing Wilson's disease and for monitoring treatment. Urinary copper excretion with D-penicillamine administration was thought to be a useful diagnostic test. The penicillamine challenge test has been used in adults, but many of the reported results of this test utilized different dosages and timing for administration of the D-penicillamine [[12], [53], [56]].
For diagnostic purposes, a liver biopsy is only required if the clinical signs and noninvasive tests do not allow a final diagnosis or if there is suspicion of other or additional liver pathologies [62].
The earliest histologic abnormalities in the liver include mild steatosis (both microvesicular and macrovesicular), glycogenated nuclei in hepatocytes, and focal hepatocellular necrosis [[62], [63]].
Ultrastructural analysis of liver specimens at the time steatosis is present reveals specific mitochondrial abnormalities [66].
Neurologic evaluation should be performed also on patients with presymptomatic and hepatic Wilson's disease. Neurologic disease may manifest as motor abnormalities with Parkinsonian characteristics of dystonia, hypertonia and rigidity, choreic or pseudosclerotic, with tremors and dysarthria.
Magnetic resonance imaging (MRI) or computerized tomography of the brain may detect structural abnormalities in the basal ganglia [69].
Other neuroimaging techniques as magnetic resonance spectroscopy [70] and single-photon emission computed tomography (SPECT) might be useful in detecting early brain damage in Wilson's disease, not only in the perspective of assessing and treating motor impairment but also in better evaluating the less investigated disorders in the cognitive domain [73]. Auditory-evoked brainstem potentials are helpful to document the degree of functional impairment and the improvement by treatment [[76], [77]]. Direct molecular-genetic diagnosis is difficult because of more than 500 possible mutations; except for a few more frequent mutations, each of which is rare [78].
By contrast, allele-specific probes allow direct identification of a mutation and this can be rapid and clinically very helpful. The most challenging aspect is the diagnosis of acute liver failure due to Wilson's disease, since mortality without emergency liver transplantation is very high. Recurrence of the underlying liver disease, in particular hepatitis C infection, is a significant growing cause of late allograft dysfunction. When eradication of HCV is not feasible before LT, the graft becomes infected universally and immediately after the procedure. Antiviral therapy after the graft becomes infected can be initiated at early stages (pre-emptive therapy) or once liver damage has already been established [386]. Currently, all HCV-infected liver transplant patients should undergo treatment with IFN-free regimens, if available. The safety and efficacy of sofosbuvir plus RBV administered for 24?weeks was investigated in a phase II pilot single-arm study in 40 patients (naive or treatment-experienced) with hepatitis C recurrence at least 6?months after LT [392].
Preliminary data from an ongoing clinical trial assessing the efficacy and safety of the fixed-dose combination of sofosbuvir and ledipasvir with RBV for 12 or 24?weeks were recently presented.
Data from real-life cohorts with a combination of sofosbuvir and simeprevir with or without RBV for 12?weeks were recently reported. The Goal of Cities for Life: To help community groups and primary care providers create an environment that facilitates and.
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Patients should be selected if expected survival in the absence of transplantation is one year or less, or if the patient had an unacceptable QoL because of liver disease. Viruses (especially hepatitis viruses A and B), drugs (acetaminophen), and toxic agents are the most common causes of acute liver failure, with the proportions varying between countries. Actually, limited organ availability and an increasing demand for organ transplantation has extended transplant waiting times and thus increased morbidity and mortality for potential recipients on these waiting lists.
They should not be transplanted too early since the advantage of transplant might be unbalanced by the risk of surgery and immunosuppression for all life. The Child-Pugh-Turcotte classification and since 2002 also the model of end-stage liver disease (MELD) score (based on objective measures such as creatinine, bilirubin and international normalized ratio) are used for patient priority [9]. Consequently, a MELD score ?15 is recommended to list patients with end-stage liver disease. Delta MELD (?MELD), meaning the change of MELD over time, might also be a better predictor of mortality [[15], [16]].
Waiting list time-dependent points can be added to laboratory MELD to give priority to patients with HCC.
The final decision should be made, within each expert centre, among a multidisciplinary group of staff including transplant hepatologist, transplant surgeon, anaesthetist, intensivist, cardiologist, etc., that considers the benefit and risk for each recipient.
When Kayser–Fleischer rings are not present (as is common in the hepatic manifestation of Wilson's disease), ceruloplasmin levels are not always reliable because they may be low for reasons other than Wilson's disease (e.g. It contains six copper atoms per molecule (holoceruloplasmin) but may be present just as the protein without the copper (apoceruloplasmin). In patients with severe liver injury, serum copper may be within the normal range, independent of whether serum ceruloplasmin levels are elevated or low. In untreated patients, the 24-hour urinary excretion of copper reflects the amount of non-ceruloplasmin-bound copper in the circulation. This test has only been standardized in a pediatric population in which 500?mg of D-penicillamine was administered orally at the beginning and again 12?h later during the 24-hour urine collection, irrespective of body weight [58]. However, specific stains like rhodamine or orcein reveal focal copper stores in less than 10% of patients because they detect only lysosomal copper depositions. Frequently, these changes are misdiagnosed as nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH). Especially in early stages of the disease, copper is mainly present in the cytoplasm bound to metallothionein and is not histochemically detectable [65]. Typical findings include variability in size and shape, increased density of the matrix material, and numerous inclusions including lipid and fine granular material that may be copper.
Consultation with a neurologist should be sought for evaluation of patients with evident neurologic symptoms before treatment or soon after treatment is initiated. Due to the great variability of neurological signs, differences in their severity and concomitant presence of different signs in one patient, clinical description is very difficult.
The most frequent findings are an increased density on computerized tomography or hyperintensity on T2 MRI in the region of the basal ganglia. Transcranial brain parenchyma sonography (TCS) detects lenticular nucleus hyperechogenicity even when in MRI no abnormalities are observed [74], but it must be confirmed in further studies [75].
However, this can only be accomplished if a mutation occurs with a reasonable frequency in the population (e.g. Readily available laboratory tests, including alkaline phosphatase (AP), bilirubin, and serum aminotransferases, provide the most rapid and accurate method for diagnosis of acute liver failure due to Wilson's disease [85]. The prevalence of acute and chronic rejection has been constantly declining over the previous years, mainly due to new potent immunosuppressive regimens.
Progression of hepatitis C is accelerated after LT and HCV-infected recipients have a reduced graft and patient survival when compared to HCV negative recipients [381]. HCV infection after LT is characterized by an accelerated fibrotic progression towards chronic hepatitis and cirrhosis. During the first months following LT, patients are still under strong immunosuppression, at risk of opportunistic infections or surgical complications and undergoing treatment with multiple drugs. The study included treatment-naive and treatment-experienced patients with genotype 1 or 4 infection, with all fibrosis stages (F0 to F4) including patients with Child-Pugh B and C decompensated cirrhosis [395]. The USPSTF calcium und diabetes victoza zwischenbericht recommends screening for gestational diabetes mellitus (GDM) in Women with GDM are at increased risk for maternal and infant complications.
Patients should be referred to transplant centres when major complications of cirrhosis, such as variceal haemorrhage, ascites, hepatorenal syndrome and encephalopathy occur.
Seronegative hepatitis is also an important cause of LT for acute liver failure, being the most common indication for LT in acute liver failure in the UK [8].
The MELD was developed to determine the short-term prognosis for patients undergoing TIPS after gastrointestinal bleeding [10], and then proposed for predicting 3-month mortality in patients with end-stage liver disease. However, it does not provide a prediction of mortality following LT except for those patients with very high MELD scores over 35 [12]. In these cases, extra points could be attributed to patients in order to give them priority to transplantation [13].
Additional points can be added depending on the type of tumour (size, number of nodules, alpha fetoprotein [AFP] level, waiting time, response to downstaging procedures). Contraindications to LT are dynamic, changing over time and may vary among liver transplant centres, depending on their local expertise.
In addition, it is essential to know the precise HBV status of the patient and in particular the existence of HBV replication. In the setting of acute liver failure due to Wilson's disease, levels of serum copper may even be markedly elevated due to the sudden release of the metal from liver tissue stores.
The exact urine volume and the total creatinine excretion per 24?h are important for accurate determination of urinary copper excretion. Thus, hepatic copper overload cannot be excluded by histochemical evaluation of a liver biopsy alone.
The liver biopsy may show classic histologic features of autoimmune hepatitis (the so-called “chronic active hepatitis” picture). The amount of copper varies from nodule to nodule in the cirrhotic liver and may vary from cell to cell in pre-cirrhotic stages.
The most striking alteration is increased intracristal space with dilatation of the tips of the cristae, creating a cystic appearance [66]. There is not yet a commonly accepted scale which describes neurological signs and their severity. Infections, intra- and perioperative surgical complications account for almost 60% of deaths or graft losses in the first operative year, whereas de novo malignancies and cardiovascular diseases are the major reasons for deaths thereafter. Approximately 15–30% of LT recipients develop one or more episodes of acute cellular rejection, which can be successfully treated with increased immunosuppression in almost all patients. Around one third of HCV-infected LT recipients will suffer an aggressive HCV recurrence after LT and are at risk of clinical decompensation and graft loss [[28], [382]].
Fibrosis is the main consequence of an imbalanced repair process occurring in the liver in response to the viral injury. Several trials assessing pre-emptive therapies with PegIFN and RBV in early phases after LT reported very poor efficacies and poor tolerability due to the presence of renal impairment, infections and cytopenia. Betty Crocker’s Diabetes Cook book by Betty Crocker teaches you easy everyday foods that you could get ready for a person suffering from diabetes.
Purina Busy Bones list sugar and white rice in the gestational diabetes mellitus normal value history ulcer diabetic first ten ingredients. Prognosis is essentially determined by neurological status, but is also rapidly affected by damage to other organs.
Since a successful outcome requires optimal patient selection and timing, the issue of which patients to list for LT and when to transplant cirrhotic patients has generated great interest as well as considerable controversy. Whatever the level of HBV DNA, if detectable, antiviral treatment with entecavir or tenofovir should be started as soon as possible [17].
On the other hand, inflammation in the liver or elsewhere may cause the ceruloplasmin concentration to rise to normal levels, reflecting its identity as an acute phase protein.
Levels of serum ceruloplasmin may be measured enzymatically by its copper-dependent oxidase activity towards specific substrates, or by antibody-dependent assays such as radioimmunoassay, radial immunodiffusion, or nephelometry. Normal or elevated serum copper levels, in the face of decreased levels of ceruloplasmin, indicate an increase in the concentration of copper which is not bound to ceruloplasmin in the blood (non-ceruloplasmin-bound copper). A reassessment of this test in paediatric patients reconfirmed the value in the diagnosis of Wilson's disease with active liver disease, but was unreliable to exclude the diagnosis in asymptomatic siblings [59]. Therefore, the measurement of hepatic parenchymal copper concentration is the method of choice for the diagnosis of Wilson's disease. In the absence of cholestasis, these changes are considered to be essentially pathognomonic of Wilson's disease. Abnormal findings are not limited to this region, and other abnormalities have been described. Comprehensive molecular-genetic screening takes several months, which makes this an impractical method. In contrast, chronic (ductopenic) rejection can be effectively treated only in early cases and may lead to graft loss. Follow-up of patients with recurrent hepatitis C is usually performed with protocol liver biopsies, which are used to assess the degree of necroinflammation and the fibrosis stage, as well as to exclude other potential causes of graft damage (rejection, drug toxicity).
To date, the most common and classical approach to treat hepatitis C after LT has been to start antiviral therapy once histological damage is confirmed [[27], [28]]. Despite the small sample size the safety profile was good and most reported side effects were mild.


There were no differences in efficacy between 12 and 24?weeks of therapy and the combination had an excellent safety profile.
Immunologic assays may overestimate ceruloplasmin concentrations since they do not discriminate between apoceruloplasmin and holoceruloplasmin. In comparison to children with other liver diseases, the D-penicillamine test had only a sensitivity of 12.5%. Biopsies for quantitative copper determination should be placed dry in a copper-free container. Lysosomal copper complexes can be stained by various methods, including the rhodanine or orcein stain. A characteristic finding in Wilson's disease is the “face of the giant panda” sign [[70], [71]], but is found only in a minority of patients. Nevertheless, it is reasonable to perform molecular analysis of the ATP7B gene in any patient who has a provisional diagnosis of Wilson's disease, both for confirmation purposes and to facilitate the subsequent screening of family members.
In those cases, identification of a mutation can support the diagnosis, while identification of two mutations will confirm the diagnosis. Therefore, these parameters should be considered in case acute Wilson's disease is suspected, but should be used in combination with other signs and symptoms suggesting Wilson's disease. However, the rate of graft loss due to ductopenic rejection has significantly decreased to less than 2%.
Early identification of patients with progressive hepatitis C is crucial and liver biopsy, hepatic venous pressure gradient (HVPG) measurement or transient elastography (TE) performed one year after LT have shown an excellent ability to identify “rapid fibrosers” [[383], [384], [385]].
Overall SVR rates with PegIFN plus RBV have been shown to be low (30–40%) after transplantation, mainly explained by the high rates of treatment discontinuation (20–38%), dose drug reductions (66–73%) and poor tolerance observed in these patients.
Similarly, a compassionate use program of sofosbuvir plus RBV in patients with severe hepatitis C recurrence after LT was initiated in 2013. MELD scores at week 4 post-treatment improved in the majority of Child-Pugh A and B patients who achieved viral clearance.
Thus, for many patients, a combination of tests reflecting disturbed copper metabolism may be needed.
The serum non-ceruloplasmin-bound copper concentration has been proposed as a diagnostic test for Wilson's disease [53].
Shipment for quantitative copper determination does not require special precautions like freezing. There are a few older patients with Wilson's disease who do not have cirrhosis or even signs of liver disease [[5], [12]]. Besides this sign, hyperintensities in tectal-plate and central pons (CPM-like), and simultaneous involvement of basal ganglia, thalamus, and brainstem are virtually pathognomonic of Wilson's disease [72]. With the advancement of DNA-based diagnostics, such as the development of a single chip that is able to identify the most common mutations, these recommendations may change. The combination of clinical symptoms and the conventional Wilson's disease diagnostic parameters (ceruloplasmin, serum or urinary copper) are less sensitive and specific but important for the diagnosis [86]. Therefore, acute or chronic rejections are uncommon complications leading to allograft dysfunction or death.
Indeed, the presence of significant fibrosis (F ?2 METAVIR), portal hypertension (HVPG ?6?mmHg) or high TE values (>8.6?kPa) one year after LT are excellent predictors of graft loss.
Results from the first 104 patients (including some with fibrosing cholestatic hepatitis) were reported recently [393] and indicated SVR12 rates higher than 50%. Mild Hypoglycemia In the earl stages of Hypoglycemia you may feel all some or in some cases none of these signs and symptoms. Since interferon (IFN) is contraindicated in patients with decompensated cirrhosis, the only choice for these patients is treatment with NUCs. Not a single test is per se specific and, thus, a range of tests has to be applied (Table 4).
In general, the accuracy of measurement is improved with adequate specimen size: at least 1?cm of biopsy core length should be submitted for analysis [62]. In the setting of acute liver failure due to Wilson's disease, there is a marked hepatocellular degeneration and parenchymal collapse, typically on the background of cirrhosis. Significant abnormalities on brain imaging may even be present in some individuals prior to the onset of symptoms [69].
The diagnosis has to be ascertained by liver biopsy if possible or at least after transplantation (hepatic copper content, mutation analysis) to enable screening of asymptomatic siblings. Although the risk of rejection is not high, it has been reported to occur in ?5% of IFN-treated patients.
Lamivudine first and adefovir [19] have been widely used to treat hepatitis B in patients awaiting LT. A diagnostic score based on all available tests was proposed by the Working Party at the 8th International Meeting on Wilson's disease, Leipzig 2001 [44] (Table 5). Serum ceruloplasmin concentrations are elevated by acute inflammation, in states associated with hyperestrogenemia such as pregnancy and estrogen supplementation. The serum non-ceruloplasmin copper concentration may be elevated in acute liver failure of any etiology, in chronic cholestasis [54], and in cases of copper intoxication. The problems of measuring 24-hour copper excretion include incomplete urine collection, and, on the other hand, copper contamination of the collection device (this being less problematic with the advent of disposable containers). Paraffin-embedded specimens may also be analyzed for copper content, but may be less reliable if the specimen is small. TE can be repeated over time to assess fibrosis progression without the need to use an invasive test.
Different series have evaluated the safety and efficacy of triple therapy with first generation protease inhibitors (telaprevir or boceprevir) in over 300 HCV-infected liver transplant recipients [[387], [388], [389]]. Both viral clearance and clinical improvement were significantly higher in individuals with early severe recurrence (diagnosed during the first year after LT) than in those with advanced cirrhosis years after LT.
However, tenofovir and entecavir are currently the first-line drugs in patients with chronic hepatitis B, which have a greater potency and higher barriers to resistance [17]. Serum ceruloplasmin is typically decreased in patients with neurologic Wilson's disease, but may be in the low normal range in about half of patients with active Wilson's liver disease. The major problem with non-ceruloplasmin-bound copper as a diagnostic test for Wilson's disease is that it is dependent on the adequacy of the methods for measuring both serum copper and ceruloplasmin.
Interpreting 24-hour urinary copper excretion can be difficult due to the overlap with findings in other types of liver disease (e.g.
Most of these patients had already significant fibrosis in the graft (?F2) or fibrosing cholestatic hepatitis at time of treatment initiation and around half of them were already treatment-experienced after LT. These results can be considered excellent taking into account the poor outcomes of the disease. On the other hand, serum ceruloplasmin may be low in other conditions with marked renal or enteric protein loss, malabsorption syndromes or with severe end-stage liver disease of any etiology. It is of more value in monitoring pharmacotherapy than in the diagnosis of Wilson's disease. Approximately 20% of heterozygotes have decreased levels of serum ceruloplasmin [[1], [47]].
Heterozygotes may also have higher copper excretion than controls, rarely exceeding the normal range levels [57]. Nevertheless, the rate of SAEs leading to treatment discontinuation (13–26%) was high; anaemia was the most frequent adverse event and the use of erythropoietin and the need for RBV dose reduction were almost universal. Patients with aceruloplasminemia lack the protein entirely due to mutations in the ceruloplasmin gene on chromosome 3. The major problem with hepatic parenchymal copper concentration is the inhomogeneous distribution of copper within the liver in later stages of Wilson's disease. Only one prospective study has evaluated the safety and efficacy of triple therapy with telaprevir in genotype 1-infected patients with less severe recurrence: final results suggest a good safety profile and improved efficacy, with an SVR12 of 72% (53 of 74 patients) [390].
Since telaprevir and boceprevir are substrates and inhibitors of the CYP3A4 system (as well as P-glycoprotein transporter), patients need significant adjustments of CsA and Tac doses; drug levels need to be monitored closely when treatment is initiated as well as when the protein inhibitors are interrupted [391].
Thus, serum ceruloplasmin alone is not sufficient to diagnose or to exclude Wilson's disease. A prospective study on serum ceruloplasmin, as a screening test for Wilson's disease in patients referred with liver disease, showed that subnormal ceruloplasmin had a positive predictive value of only 6%.
In a pediatric study, sampling error was sufficiently common to render this test unreliable in patients with cirrhosis [60]. In children with Wilson's disease, 15–36% had ceruloplasmin in the normal range [[14], [49]].
On the other hand, in long-standing cholestatic disorders, hepatic copper content may also be increased. In one series, 12 out of 55 Wilson's disease patients had normal ceruloplasmin and no Kayser–Fleischer rings [12].
Markedly elevated levels of hepatic copper may also be found in idiopathic copper toxicosis syndromes such as Indian childhood cirrhosis [61].
The predictive value of ceruloplasmin for diagnosis of Wilson's disease in acute liver failure is poor [50]. In one recently published study, measurement of serum ceruloplasmin oxidase activity was superior to immunologic assays for diagnosing Wilson's disease, but these assays are generally not available in routine labs [51].




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