Entecavir Improves Liver Function and Fibrosis in Hepatitis B Virus-Associated Cirrhosis: A 6Years-Multicenter Study

( Seung Kak Shin ),( Oh Sang Kwon ),( Jeong Han Kim ),( Chan Uk Lee ),( Jong Eun Yeon ),( Sang Jun Suh ),( Young Kul Jung ),( Hyung Joon Yim ),( Duck Joo Choi ),( Yun Soo Kim ),( Ju Hyun Kim ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: Previously we reported that entecavir (ETV) improves liver function and non-invasive fibrosis markers in patients with HBV-associated cirrhosis after 2 years of treatment (Shin et al. JGH, 2016). This study extended observational period (6 years) and aimed to verify same objects after 6 years of ETV treat-ment. Methods: Among 370 patients who were enrolled in 2 years-study of ETV, a total 283 naïve patients with HBV associated-cirrhosis was treated by ETV for at least 6 years in 4 tertiary institutions. For the evaluation of liver function or fibrosis, laboratory findings, model for end stage liver disease (MELD) score, Child-Pugh (CP) class, AST platelet ratio index (APRI), FIB- 4 index, fibrosis index (FI), and liver stiffness measurement (LSM) value were compared between the baseline and 6 years after ETV treatment. Results: The final 205 patients (mean age of 50±9 years; 64.2% male; 50.2% HBeAg-positive) were enrolled. The baseline ALT and HBV DNA levels were 139±205 IU/L and 6.9±1.2 log10 copies/mL, respectively. The ALT normalization and the undetectable HBV DNA rate after 6 years of ETV treatment were 87.3% and 99.0%, respectively. Changes in total bilirubin (1.9±2.7 to 1.1±0.6 mg/dL, P<0.001), albumin (3.7±0.6 to 4.2±0.4 g/dL, P<0.001), platelet count (105±44 to 124±53Í103/ mm3, P<0.001), and MELD score (8.5±4.6 to 5.9±4.6, P<0.001) were observed. The change of distribution in CP class (A:74.1%, B:21.0%, C:4.9% at baseline to A:96.1%, B:3.4%, C:0.5% at 6 years after ETV treatment) was observed. The changes in APRI score, FIB-4 index, and FI were from 3.7±5.4 to 0.8±0.7 (P<0.001), from 6.4±6.3 to 3.5±2.7 (P<0.001), and from 3.2±0.9 to 2.6±0.9 (P<0.001), respectively. The change in LSM value (n=55) was from 26.5±17.7 to 12.4±8.0 kPa (P<0.001). Conclusions: Long-term treatment with ETV improves liver function and fibrosis in patients with HBV-associated cirrhosis.

Efficacy of Daclatasvir and Asunaprevir Treatment in Genotype 1b HCV Infected Patients: A Real Life and Multicenter Study

( Seung Kak Shin ),( Oh Sang Kwon ),( Chang Hwi Yoon ),( Young-joo Jin ),( Jin-woo Lee ),( Sangheun Lee ),( Ki Jun Han ),( Young Nam Kim ),( Tae Hun Kim ),( Yun Soo Kim ),( Duck Joo Choi ),( Ju Hyun K 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims: Combination of daclatasvir (DCV) and asunaprevir (ASV) has been approved in Korea for the treatment of genotype 1b (GT1b) hepatitis C virus (HCV) infected patients. The efficacy in virologic response, improvement of liver function and non-invasive fibrosis marker in liver cirrhosis (LC) were investigated. Methods: All HCV GT1b patients who were treated with DCV and ASV for at least 4 weeks from August 2015 to January 2017, were retrospectively enrolled. Virologic response was measured at 4 weeks (rapid virologic response, RVR), at 24 weeks (end of treatment response, ETR), and at 12 weeks after the end of treatment (sustained virologic response, SVR12). Liver function, aspartate transaminase to platelet ratio index (APRI), FIB-4 index, and fibrosis index (FI) were compared between before and after treatment (SVR12). Results: Patients with GT1b patients (n=474) were examined for resistance associated variants (RAVs). Sixty-seven patients had RAV. A total of 290 RAV-negative patients were treated with DCV and ASV for at least 4 weeks. Baseline characteristics were obtained: age (54±11 years), gender (male: 50.3%), LC (29.0%), treatment-naïve (74.8%), ALT (58.5±49.2 IU/L), HCV RNA (1,915,001±4,969,456 IU/mL). RVR (255/277, 92.1%), ETR (190/195, 97.4%), and SVR (146/152, 96.1%) rates were obtained. SVR rates were not significantly different between non-LC (102/104, 98.1%) and LC patients (44/48, 91.7%) (p=0.080). SVR rates were not significantly different between treatment- naïve (103/106, 97.2%) and treatment-experienced patients (43/46, 93.5%) (p=0.368). In LC patients (n=48), there were significant changes of albumin (3.8±0.8 to 4.0±0.5 g/dL, p=0.036), platelet count (109.6±52.6 to 120.3±58.5 x103/mm3, p=0.004), APRI (2.6±3.1 to 0.8±0.6, p=0.001), FIB-4 (7.6±6.5 to 2.9±1.6, p<0.001), and FI (3.1±1.1 to 2.9±1.2, p=0.058) after treatment. Conclusions: DCV and ASV treatment for HCV GT1b infected Korean subjects without RAV achieved high SVR rates. In addition, improvement of liver function and non-invasive fibrosis marker were noted in patients with LC.

Exogenous 8-Hydroxydeoxyguanosine Prevents Liver Fibrosis through the Inhibition of Rac1-NADPH oxidase Signaling in a Nonalcoholic Steatohepatitis Model

( Seung Kak Shin ),( Hye Jeong Cho ),( Hyosang Hwang ),( Dong Hae Chung ),( Oh Sang Kwon ),( Yun Soo Kim ),( Ju Hyun Kim ) 대한간학회 2021 춘·추계 학술대회 (KASL) Vol.2021 No.1

Partial Virological Response after 2 Years of Entecavir Therapy Increases the Risk of Hepatocellular Carcinoma in Patients with Hepatitis B Virus-Associated Cirrhosis

( Seung Kak Shin ),( Hyung Joon Yim ),( Jeong Han Kim ),( Chan Uk Lee ),( Jong Eun Yeon ),( Sang Jun Suh ),( Young Kul Jung ),( Yun Soo Kim ),( Ju Hyun Kim ),( Oh Sang Kwon ) 대한간학회 2021 Gut and Liver Vol.15 No.3

Background/Aims: The clinical significance of partial virological response (PVR) in patients undergoing antiviral therapy is not well known. This study investigated whether PVR after 2 years of entecavir (ETV) therapy is associated with hepatocellular carcinoma (HCC) development in cirrhotic patients. Methods: A total of 472 naïve patients with hepatitis B virus (HBV)-associated cirrhosis who were treated with ETV for at least 2 years were retrospectively enrolled. Clinical characteristics, laboratory data, PVR, and noninvasive fibrosis markers (aspartate aminotransferase to platelet ratio and FIB-4 index) at 2 years after ETV commencement were analyzed for HCC risk. Results: After excluding those who developed HCC within 2 years of ETV therapy, 359 patients (mean age, 51±10 years; male 64.3%) were examined. During a median follow-up of 82 months, 80 patients developed HCC. In the univariate analysis, older age (hazard ratio [HR], 1.056; p<0.001), PVR (HR, 2.536; p=0.002), higher aspartate aminotransferase (HR, 1.018; p=0.005), lower albumin level (HR, 0.463; p<0.001), lower platelet count (HR, 0.993; p=0.01), and higher FIB-4 index (HR, 1.141; p<0.001) at 2 years after ETV commencement were risk factors for HCC. In the multivariate analysis, older age (HR, 1.046; 95% confidence interval [CI], 1.022 to 1.072; p<0.001), PVR (HR, 2.358; 95% CI, 1.310 to 4.245; p=0.004), and higher FIB-4 index (HR, 1.103; 95% CI, 1.035 to 1.177; p=0.003) were independent risk factors. Conclusions: PVR and higher FIB-4 index after 2 years of ETV therapy were independent risk factors for HCC. Therefore, efforts to accomplish a complete virological response and reduce the FIB-4 index should be made. (Gut Liver 2021;15:430-439)

Clinical Significance of the Peritumoral Decreased Uptake Area on Hepatobiliary Phase of Gadoxetic Acid-enhanced MRI in Hepatocellular Carcinoma

( Seung Kak Shin ),( Yun Soo Kim ),( Young Sup Shim ),( Seung Joon Choi ),( So Hyun Park ),( Dong Hae Jung ),( Oh Sang Kwon ),( Duck Joo Choi ),( Ju Hyun Kim ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: Vascular invasion is the most important predictive factor of tumor recurrence after resection in hepatocellular carcinoma (HCC). Recently, it has been suggested that the peritumoral decreased uptake area (PDUA) on hepatobiliary phase of gadoxetic acid-enhanced MRI could be shown in cases of the impaired hepatocyte function induced by decreased portal flow, and was associated with vascular invasion in HCC. The aims of our study were to clarify the clinicopathological characteristics of PDUA on hepatobiliary phase and to elucidate the predictability of the PDUA on tumor recurrence after resection. Methods: We retrospectively analyzed the clinicopathological and radiological data from 194 consecutive HCC patients who underwent preoperative gadoxetic acid-enhanced MRI and surgical resection between January 2008 and January 2016. The presence of a faint and hypointense area around the tumor in the hepatobiliary phase was defined as PDUA. Results: Of 194 HCCs, PDUA on hepatobiliary phase was observed in 25 cases (12.9%). Of 42 HCCs with microvascular invasion, PDUA was observed in 16 cases (38.1%) and of 16 HCCs with macrovascular invasion, PDUA was observed in 8 cases (50.0%). In multivariate analysis, tumor size (>5 cm) and microvascular invasion were significantly associated with PDUA. After a median follow-up period of 17.5 months, 17 of the 25 patients with PDUA (68.0%) suffered from tumor recurrence. The recurrent-free survival in group with PDUA after resection by Kaplan-Meier method with the log-rank test was significantly worse than that in group without PDUA (P=0.003). In addition, multivariate survival analysis using Cox``s regression identified that PDUA (HR =4.2; 95% CI 1.8-9.7; P=0.001) was an independent risk factor for recurrence after resection of HCCs less than 5 cm. Conclusions: PDUA on hepatobiliary phase of gadoxetic acid-enhanced MRI could be a useful preoperative predictor of microvascular invasion and prognosis factor after surgical resection in HCC.

Antifibrotic Effects of 8-Hydroxydeoxyguanosine by Inhibiting NOX Derived Oxidative Stress in Vitro and in Vivo Models of Liver Fibrosis

( Seung Kak Shin ),( Oh Sang Kwon ),( Jong Joon Lee ),( Duck Joo Choi ),( Yun Soo Kim ),( Ju Hyun Kim ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims: NADPH oxidase (NOX)-derived reactive oxygen species (ROS) is implicated in liver fibrosis. 8-hydroxydeoxyguanosine (8-OHdG) can have antioxidant effects by inhibiting Rac1. Rac1 is a known activator of NOX enzymes. The aim of this study was to investigate the role of NOX and the antifibrotic effects of 8-OHdG in vitro and in vivo models of liver fibrosis. Methods: Adult Sprague-Dawley rats were allocated to 3 groups: sham-operated rats (n=7), rats underwent bile duct ligation (BDL) (n=6), and BDL rats treated with 8-OHdG (60 mg/kg/day by gavage feeding) (n=6). All rats were sacrificed on day 21. Hepatic fibrosis in liver tissue was assessed. In vitro, human stellate cell line LX-2 was stimulated by angiotensin II (10uM). The ROS production was measured by confocal microscopy. The mRNA expressions in liver tissue and LX-2 cell were analyzed by quantitative real-time PCR. Results: 8-OHdG significantly attenuated the hydroxyproline level (620.6±169.1 vs 1110.3±357.9 ug/g liver tissue, p=0.019) and the degrees of collagen stain (2.04±0.86 vs 5.11±0.26 %, p<0.001). The NOX1 and NOX2 protein expression in liver tissue by immunofluorescence was attenuated in 8-OHdG treatment groups. 8-OHdG significantly attenuated the mRNA expression of NOX1 (7.3 vs 2.7 folds, p=0.022), NOX2 (10.5 vs 3.9 folds, p=0.001), α-SMA (6.2 vs 2.6 folds, p=0.017), TGF-β (7.7 vs 3.4 folds, p=0.001) collagen Iα (25.7 vs 9.0 folds, p<0.001). Angiotensin II induced increase of the DCF fluorescence intensity in LX-2 cells was attenuated by 8-OHdG. 8-OHdG significantly attenuated the mRNA expression of α-SMA (6.2 vs 1.2 folds, p=0.001) TGF-β (7.8 vs 1.5 folds, p<0.001) collagen Iα (13.3 vs 0.74 folds, p<0.001) in LX-2 cells treated with angiotensin II for 72 hours. Conclusions: NOX-derived ROS is a critical role in vitro and in vivo models of liver fibrosis. 8-OHdG ameliorates the liver fibrosis through the inhibition of NOX-derived oxidative stress.

Role of FIB-4 Predicting Clinical Outcomes after HBsAg Seroclearance in Patients with Chronic Hepatitis B

( Seung Kak Shin ),( Ju Hyun Kim ),( Oh Sang Kwon ),( Duck Joo Choi ),( Yun Soo Kim ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: The long term clinical outcomes, including development of liver cirrhosis (LC) and hepatocellular carcinoma (HCC) after hepatitis B surface antigen (HBsAg) seroclearance in patients with high FIB-4 index remains unclear. This study aimed to determine the correlations between clinical outcomes after HBsAg seroclearance and high FIB-4 index at the time of HBsAg seroclearance in patients with chronic hepatitis B. Methods: Between November 2000 and January 2016, a total of 117 patients who achieved HBsAg seroclearance (n=96, non-cirrhotic; n=21, cirrhotic) were retrospectively reviewed. FIB-4 index was used to evaluate the liver fibrosis. LC was diagnosed based on clinical and radiological assessments. Results: The mean age at the time of HBsAg seroclearance was 50.1±10.5 years. Among 96 patients without evidence of cirrhosis at the time of HBsAg seroclearance, 11 (11.5%) patients developed LC. The median interval from HBsAg seroclearance to development of LC was 33 months (rage from 22 to 99 months). In univariate Cox regression analysis, platelet count (<150 x 103/mm3; HR 4.71; 95% CI 1.17-18.92; P=0.029) and FIB-4 index (≥1.70; HR 9.12; 95% CI 2.29-36.28; P=0.002) at the time of HBsAg seroclearance were significant predictive factors for development of LC after HBsAg seroclearance. During a median follow-up of 36 months after HBsAg seroclearance, HCC developed in 6 patients (5.1%) (n=3, cirrhotic; n=3, non-cirrhotic) and the 1-, 3-, and 6-year cumulative incidences of HCC were 0.9%, 2.6%, and 7.3%, respectively. The log-rank test revealed that the occurrence rate of HCC was significantly higher in the high FIB-4 index group (≥1.70) compared with that in the low FIB-4 index group (<1.70) (P=0.027). Conclusions: Patients with a high FIB-4 index at the time of HBsAg seroclearance are at risk of development of LC and HCC, and these patients require more careful surveillance after HBsAg seroclearance.

Usefulness of Linear Type Wireless Hand-Held Ultrasound for the Evaluation of Liver Surface Nodularity in Patents with Liver Cirrhosis

( Seung Kak Shin ),( Yun Soo Kim ),( Hannah Ra ),( Sangho Jeong ),( Hyung Nam Kim ),( Oh Sang Kwon ),( Duck Joo Choi ),( Ju Hyun Kim ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: Sonographic liver surface nodularity (LSN) is a useful parameter for diagnosis of liver cirrhosis (LC). Recently, easy-to-use linear type wireless hand-held ultrasound (wireless US) has been introduced. We aimed to assess the performance of wireless US compared to conventional ultrasound system (conventional US) in evaluating the LSN, and to verify the usefulness of LSN measured by wireless US in diagnosing LC. Methods: We enrolled 104 patients who underwent wireless US (SONON 300L, 10 MHz linear transducer, Healcerion), conventional US (Logic E9, 9 MHz linear transducer, GE) and Fibroscan for evaluation of liver diseases between March 2017 and January 2018. LSN measurement (LSNM, defined as the length of curve line in liver surface matching the 2-cm linear segment in left lateral segment) was used to objectively evaluate the LSN. Diagnosis of LC was based on clinical criteria, and was compared with fibroscan results. Results: Among 104 patients, 54 (51.9%) patients were diagnosed with LC. The mean liver stiffness measurement (LSM) on fibroscan (28.1±22.3 vs. 6.7±4.8, P<0.001) and LSNM on conventional US (2.075±0.459 vs. 2.028±0.119, P<0.001) were significantly different between LC and non-LC group. The mean LSNMs (2.051±0.034 vs. 2.052±0.041, P=0.13) on between wireless and conventional US by paired t-test were not significantly different. The sensitivity, specificity, positive predictive value, and negative predictive value of high LSNMs (≥ 2.04) on wireless US in diagnosing LC were 88.9%, 90.0%, 90.6%, and 88.2%, respectively. The mean LSMs (25.7±22.8 vs. 9.6±10.6 kPa, P<0.001) were significantly different between high LSNMs (≥ 2.04) and low LSNMs (<2.04) group. Conclusions: The ability of liver surface nodularity evaluation with wireless US was not inferior to conventional US. Linear type wireless hand-held ultrasound can be a useful tool to easily identify the liver surface nodularity for diagnosis of LC.

Overexpressions of P21 Activated Kinases and Snail in Patients with Advanced Hepatocellular Carcinoma

( Seung Kak Shin ),( Ho Kyung Kim ),( Seo Jun Bae ),( Sung Min Lee ),( Seung Yeon Ha ),( Oh Sang Kwon ),( Yun Soo Kim ),( Ju Hyun Kim ) 대한간학회 2020 춘·추계 학술대회 (KASL) Vol.2020 No.1

Aims: Epithelial-to-mesenchyme transition (EMT) has been implicated in cancer progression, invasion and metastasis. It is known that P21 activated kinases (PAKs) and Snail are associated with EMT in various cancers. Recent report suggested that Snail’s regulation may involve Rac1 signaling. The aims of study were to determine whether PAKs, Snail and Rac1 were overexpressed in patients with advanced hepatocellular carcinoma (HCC) and to identify mechanisms that can effectively inhibit PAKs and Snail in vitro study. Methods: Fresh-frozen HCC samples and their adjacent normal hepatic tissues from 30 patients (men: 73.3%; mean age: 58.0±9.7 years) underwent surgical resection were provided by the Gachon University Gil Medical Center Biobank. Hep3B cells were transfected with control or Rac1-specific siRNAs for 72hrs. The expressions of PAK1, PAK2, Snail, Rac1 and GAPDH in HCC samples compared with adjacent tissues or cells were analyzed by immunoblotting. Cell migration was measured using transwell migration assay Results: Among 30 patients with HCC, 63.3%, 23.3%, and 13.3% of the patients were stage I, II, and III, based on eighth edition AJCC TNM-staging, respectively. 80% of the patients tested positive for the hepatitis B surface antigen. The PAK1, PAK2, Snail, and Rac1 were all overexpressed in 5.3% of patients with TNM stage I, 42.9% of patients with TNM stage II, and 75% of patients with TNM stage III HCC, respectively (P=0.004). The PAK1, PAK2, and Snail were all overexpressed in 66.7% of HCCs with vascular invasion and in 4.8% of HCCs without vascular invasion (P=0.001). Rac1 knockdown significantly decreased the expression of PAK1, PAK2 and Snail in Hep3B cell. Rac1 knockdown suppressed the migration of Hep3B cells. Conclusions: Overexpressions of PAKs, Snail, and Rac1 in patients with HCC were associated with advanced tumor stage and vascular invasion. Inhibition of Rac1 might reduce the expression of PAKs and Snail in HCC.

PE-098: Effect of Rifaximin on the Hepatic Fibrosis in Bile Duct Ligated-rat Model

( Seung Kak Shin ),( Oh Sang Kwon ),( Jong Joon Lee ),( Duck Joo Choi ),( Yun Soo Kim ),( Ju Hyun Kim ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: Several recent studies suggest that the nonabsorbable antibiotic rifaximin could reduce endotoxemia and ameliorate hepatic fibrosis. The aim of this study was to investigate the effect of rifaximin on the hepatic fibrosis in animal model. Methods: Adult Sprague-Dawley rats were allocated to 6 groups: sham-operated rats [G1 (n=6) and G4 (n=7)], rats underwent bile duct ligation (BDL) [G2 (n=4) and G5 (n=6)], and BDL rats treated with rifaximin (50 mg/kg/day by gavage feeding) [G3 (n=9) and G6 (n=5)]. G1, G2 and G3 were sacrificed on day 9. G4, G5 and G6 were sacrificed on day 21. Liver tissue was stored in -70°C refrigerator or fixed in formalin. Hepatic fibrosis was assessed by hydroxyproline assay and quantified by Sirius red staining with image analysis. Results: The concentrations of hydroxyproline (μg/g liver tissue) were 236.4±103.1 in G1, 444.8±114.4 in G2, and 312.5±131.6 in G3. The concentration was higher in G2 than in G1 (p=0.025). However, there was no difference between G2 and G3. The degrees of collagen stain (%) were 0.22±0.04 in G1, 1.64±0.53 in G2, and 1.66±0.44 in G3. The degree was higher in G2 than in G1 (p=0.001). However, there was no difference between G2 and G3. The concentrations of hydroxyproline were 311.5±72.9 in G4, 1110.3±357.9 in G5, and 944.3±209.3 in G6. The concentration was higher in G5 than in G4 (p<0.001). However, there was no difference between G5 and G6. The degrees of collagen stain (%) were 0.19±0.03 in G4, 5.04±0.18 in G5, and 4.42±0.68 in G6. The degree was higher in G5 than in G4 (p<0.001). However, there was no difference between G5 and G6.