Letters to the Editor 363
Recently, the JAK2 V617F gene mutation has also been reported in 17–35% of PVT patients without any known underlying disease [6,7]. Nevertheless, JAK2 exon 12 mutation has not been reported as being associated with splanchnic vein thrombosis (SVT) in noncirrhotic patients [8]. However, the prevalence of JAK2 mutations (JAK2 V617F or JAK2 exon 12 mutations) among cirrhotic PVT patients is largely unknown. We have previously investigated the link between JAK2 V617F and pretransplant PVT in a cohort of liver transplant recipients but found no relation [9]. Therefore, we addressed the prevalence of JAK2 exon 12 mutations in a cohort of liver transplant recipients both with and without pretransplant SVT, which include PVT and thrombosis of the hepatic veins causing Budd–Chiari syndrome (BCS). We reported JAK2 exon 12 mutation results for 271 primary liver transplantation recipients and found liver cirrhosis present in 72.6% of cases. The primary cause of liver disease was: hepatitis B virus (HBV) in 21 recipients, hepatitis C virus (HCV) in 57 recipients, ethanol in 50 recipients, autoimmunity in nine recipients, toxicity in six recipients, tumor in 17 recipients, HBV or HCV and ethanol in 22 recipients, HBV or HCV and tumor in 51 recipients, vascular in two recipients, a1 antitrypsin deficits or biliary atresia in 28 recipients, and cryptogenetic in eight recipients. The study was approved by our Institutional Review Board and all patients gave their consent for blood samples to be further processed. The inclusion criteria for this retrospective study were: (a) recipients of liver graft with or without SVT; (b) available DNA for molecular testing; and (c) patient informed consent obtained in accordance with the Declaration of Helsinki. It should be noted that associated malignancy or cirrhosis was not excluded. PVT was diagnosed, previously or at the time of transplant, in the presence of endoluminal material and absence of flow in the portal vein, or cavernous transformation of the vein as shown by duplex-Doppler ultrasound, or contrast-enhanced computed tomography scan or MRI. We analyzed peripheral blood DNA samples and detection of JAK2 exon 12 mutations was performed using high-resolution melting methods as previously described [10]. The sensitivity of this method was between 1 and 5%. Bidirectional sequencing analysis was also carried out to confirm JAK2 mutations in exon 12. At the time of liver transplant, PVT was observed in 50 recipients (18.45%). Two cases presented BCS. No JAK2 exon 12 mutations were found in recipients with or without pretransplant PVT. As previously reported [9], JAK2 V617F was detected in four recipients (1.5%): one patient previously diagnosed
with polycythemia vera who presented BCS, another diagnosed with BCS and features of myeloproliferative neoplasia, and two others with neither thrombotic complications nor myeloproliferative neoplasia features. No JAK2 exon 12 mutations were found in liver transplant recipients, including cirrhotic PVT patients, either with or without pretransplant PVT. Therefore, routine screening of JAK2 exon 12 mutations in cirrhotic PVT patients is not indicated.
Acknowledgements This work was supported by a grant from Foundation ˜a del Automovil. Mutua Madrilen Conflicts of interest
There are no conflicts of interest.
References 1
Francoz C, Belghiti J, Vilgrain V, Sommacale D, Paradis V, Condat B, et al. Splanchnic vein thrombosis in candidates for liver transplantation: usefulness of screening and anticoagulation. Gut 2005; 54:691–697. 2 Gimeno FA, Calvo J, Loinaz C, Meneu JC, Perez B, Gomez R, et al. Comparative analysis of the results of orthotopic liver transplantation in patients with and without portal vein thrombosis. Transplant Proc 2005; 37:3899–3903. 3 Janssen HL, Wijnhoud A, Haagsma EB, van Uum SH, van Nieuwkerk CM, Adang RP, et al. Extrahepatic portal vein thrombosis: aetiology and determinants of survival. Gut 2001; 49:720–724. 4 Plessier A, Darwish-Murad S, Hernandez-Guerra M, Consigny Y, Fabris F, Trebicka J, et al. Acute portal vein thrombosis unrelated to cirrhosis: a prospective multicenter follow-up study. Hepatology 2010; 51:210–218. 5 Plessier A, Rautou PE, Valla DC. Management of hepatic vascular diseases. J Hepatol 2012; 56 (Suppl 1):S25–S38. 6 De Stefano V, Fiorini A, Rossi E, Za T, Farina G, Chiusolo P, et al. Incidence of the JAK2 V617F mutation among patients with splanchnic or cerebral venous thrombosis and without overt chronic myeloproliferative disorders. J Thromb Haemost 2007; 5:708–714. 7 Primignani M, Barosi G, Bergamaschi G, Gianelli U, Fabris F, Reati R, et al. Role of the JAK2 mutation in the diagnosis of chronic myeloproliferative disorders in splanchnic vein thrombosis. Hepatology 2006; 44:1528–1534. 8 Kiladjian JJ, Cervantes F, Leebeek FW, Marzac C, Cassinat B, Chevret S, et al. The impact of JAK2 and MPL mutations on diagnosis and prognosis of splanchnic vein thrombosis: a report on 241 cases. Blood 2008; 111:4922–4929. 9 Ayala R, Grande S, Bustelos R, Ribera C, Garcia-Sesma A, Jimenez C, et al. Obesity is an independent risk factor for pre-transplant portal vein thrombosis in liver recipients. BMC Gastroenterol 2012; 12:114. 10 Rapado I, Grande S, Albizua E, Ayala R, Hernandez JA, Gallardo M, et al. High resolution melting analysis for JAK2 exon 14 and exon 12 mutations: a diagnostic tool for myeloproliferative neoplasms. J Mol Diagn 2009; 11:155–161.
Hematocrit levels and red blood cell indices in patients with nonalcoholic fatty liver disease Danny Issaa, Mazen Albeldawib, Rocio Lopezc and Naim Alkhourib,d, a Department of Internal Medicine, Fairview Hospital, bDigestive Disease Institute, c Quantitative Health Sciences and dDepartment of Pediatric Gastroenterology, Cleveland Clinic, Cleveland, Ohio, USA Correspondence to Naim Alkhouri, MD, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA Tel: + 1 216 444 9000; fax: + 1 216 444 2974; e-mail: [email protected] Received 25 November 2013 Accepted 27 November 2013
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
364 European Journal of Gastroenterology & Hepatology 2014, Vol 26 No 3
Table 1
Red blood cell indices and liver histology in nonalcoholic fatty liver disease Steatosis
Factor Hb Hct RBC RDW
r (95% CI) 0.17 0.16 0.15 – 0.10
(– 0.03, (– 0.05, (– 0.06, (– 0.30,
0.37) 0.36) 0.35) 0.11)
Inflammation P-value 0.1 0.13 0.16 0.34
r (95% CI) – 0.00 0.05 0.05 0.13
(– 0.21, (– 0.15, (– 0.15, (– 0.08,
Ballooning P-value
0.20) 0.26) 0.26) 0.33)
0.99 0.61 0.6 0.22
r (95% CI) – 0.01 0.04 0.02 0.06
Fibrosis r (95% CI)
P-value
(– 0.22, 0.19) (– 0.17, 0.25) (– 0.19, 0.22) (– 0.15, 0.26)
0.92 0.7 0.88 0.57
0.07 0.10 0.07 0.11
(– 0.13, (– 0.10, (– 0.13, (– 0.10,
0.28) 0.31) 0.28) 0.31)
P-value 0.49 0.33 0.48 0.3
CI, confidence interval; Hb, hemoglobin; Hct, hematocrit; RBC, red blood cell; RDW, red cell distribution width.
We read with great interest the articles by Li et al. [1] and Yang et al. [2] reporting significant associations of hematocrit (Hct) levels and red cell distribution width (RDW) with fibrosis, as well as the histologic severity of nonalcoholic fatty liver disease (NAFLD). The most plausible explanations for these associations are chronic inflammation, oxidative stress, and hypoxia, which can lead to an elevation in Hct levels and RDW and may play a role in NAFLD pathogenesis [3,4]. We aimed to further investigate these associations in our cohort of patients. Our study consisted of 95 patients who underwent a liver biopsy for clinically suspected NAFLD. We evaluated the levels of Hct and hemoglobin, the red blood cell count, and RDW. The histologic features of nonalcoholic steatohepatitis (NASH) were scored including steatosis, inflammation, and ballooning. Fibrosis stage was also scored. The diagnosis of NASH was based on Brunt’s criteria. Spearman’s correlation coefficients were computed to assess the correlation between red blood cell indices and the histological features of liver biopsy.
P = 0.14). No significant association was found between Hct level and any of the main histologic features of NAFLD (steatosis, inflammation, ballooning, fibrosis) or the NAFLD activity score. Similarly, no significant correlations were found between RDW, hemoglobin level, or red blood cell count and liver histology, as shown in Table 1. In conclusion, Hct levels and RDW are not significantly associated with the severity of liver histology in NAFLD. Our findings argue against using red blood cell indices as biomarkers of NAFLD severity.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
2
Our results showed that 47 patients had biopsy-proven NASH, whereas 30 patients had simple steatosis and 18 had normal liver biopsies (mean age 49.1±10.7 years, 47.2% female). Mean Hct levels were not significantly different between patients with NASH (43.3±3.6), steatosis (43.5±3.4), and normal biopsies (41.5±3.9;
3
4
Li Y, Liu L, Wang B, Wang J, Chen D. Hematocrit is associated with fibrosis in patients with nonalcoholic steatohepatitis. Eur J Gastroenterol Hepatol 2014; 26:332–338. Yang W, Huang H, Wang Y, Yu X, Yang Z. High red blood cell distribution width is closely associated with nonalcoholic fatty liver disease. Eur J Gastroenterol Hepatol 2013 [Epub ahead of print]. Kim HM, Kim BS, Cho YK, Kim BI, Sohn CI, Jeon WK, et al. Elevated red cell distribution width is associated with advanced fibrosis in NAFLD. Clin Mol Hepatol 2013; 19:258–265. Tessari P, Coracina A, Cosma A, Tiengo A. Hepatic lipid metabolism and non-alcoholic fatty liver disease. Nutr Metab Cardiovasc Dis 2009; 19: 291–302.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Recently, the JAK2 V617F gene mutation has also been reported in 17–35% of PVT patients without any known underlying disease [6,7]. Nevertheless, JAK2 exon 12 mutation has not been reported as being associated with splanchnic vein thrombosis (SVT) in noncirrhotic patients [8]. However, the prevalence of JAK2 mutations (JAK2 V617F or JAK2 exon 12 mutations) among cirrhotic PVT patients is largely unknown. We have previously investigated the link between JAK2 V617F and pretransplant PVT in a cohort of liver transplant recipients but found no relation [9]. Therefore, we addressed the prevalence of JAK2 exon 12 mutations in a cohort of liver transplant recipients both with and without pretransplant SVT, which include PVT and thrombosis of the hepatic veins causing Budd–Chiari syndrome (BCS). We reported JAK2 exon 12 mutation results for 271 primary liver transplantation recipients and found liver cirrhosis present in 72.6% of cases. The primary cause of liver disease was: hepatitis B virus (HBV) in 21 recipients, hepatitis C virus (HCV) in 57 recipients, ethanol in 50 recipients, autoimmunity in nine recipients, toxicity in six recipients, tumor in 17 recipients, HBV or HCV and ethanol in 22 recipients, HBV or HCV and tumor in 51 recipients, vascular in two recipients, a1 antitrypsin deficits or biliary atresia in 28 recipients, and cryptogenetic in eight recipients. The study was approved by our Institutional Review Board and all patients gave their consent for blood samples to be further processed. The inclusion criteria for this retrospective study were: (a) recipients of liver graft with or without SVT; (b) available DNA for molecular testing; and (c) patient informed consent obtained in accordance with the Declaration of Helsinki. It should be noted that associated malignancy or cirrhosis was not excluded. PVT was diagnosed, previously or at the time of transplant, in the presence of endoluminal material and absence of flow in the portal vein, or cavernous transformation of the vein as shown by duplex-Doppler ultrasound, or contrast-enhanced computed tomography scan or MRI. We analyzed peripheral blood DNA samples and detection of JAK2 exon 12 mutations was performed using high-resolution melting methods as previously described [10]. The sensitivity of this method was between 1 and 5%. Bidirectional sequencing analysis was also carried out to confirm JAK2 mutations in exon 12. At the time of liver transplant, PVT was observed in 50 recipients (18.45%). Two cases presented BCS. No JAK2 exon 12 mutations were found in recipients with or without pretransplant PVT. As previously reported [9], JAK2 V617F was detected in four recipients (1.5%): one patient previously diagnosed
with polycythemia vera who presented BCS, another diagnosed with BCS and features of myeloproliferative neoplasia, and two others with neither thrombotic complications nor myeloproliferative neoplasia features. No JAK2 exon 12 mutations were found in liver transplant recipients, including cirrhotic PVT patients, either with or without pretransplant PVT. Therefore, routine screening of JAK2 exon 12 mutations in cirrhotic PVT patients is not indicated.
Acknowledgements This work was supported by a grant from Foundation ˜a del Automovil. Mutua Madrilen Conflicts of interest
There are no conflicts of interest.
References 1
Francoz C, Belghiti J, Vilgrain V, Sommacale D, Paradis V, Condat B, et al. Splanchnic vein thrombosis in candidates for liver transplantation: usefulness of screening and anticoagulation. Gut 2005; 54:691–697. 2 Gimeno FA, Calvo J, Loinaz C, Meneu JC, Perez B, Gomez R, et al. Comparative analysis of the results of orthotopic liver transplantation in patients with and without portal vein thrombosis. Transplant Proc 2005; 37:3899–3903. 3 Janssen HL, Wijnhoud A, Haagsma EB, van Uum SH, van Nieuwkerk CM, Adang RP, et al. Extrahepatic portal vein thrombosis: aetiology and determinants of survival. Gut 2001; 49:720–724. 4 Plessier A, Darwish-Murad S, Hernandez-Guerra M, Consigny Y, Fabris F, Trebicka J, et al. Acute portal vein thrombosis unrelated to cirrhosis: a prospective multicenter follow-up study. Hepatology 2010; 51:210–218. 5 Plessier A, Rautou PE, Valla DC. Management of hepatic vascular diseases. J Hepatol 2012; 56 (Suppl 1):S25–S38. 6 De Stefano V, Fiorini A, Rossi E, Za T, Farina G, Chiusolo P, et al. Incidence of the JAK2 V617F mutation among patients with splanchnic or cerebral venous thrombosis and without overt chronic myeloproliferative disorders. J Thromb Haemost 2007; 5:708–714. 7 Primignani M, Barosi G, Bergamaschi G, Gianelli U, Fabris F, Reati R, et al. Role of the JAK2 mutation in the diagnosis of chronic myeloproliferative disorders in splanchnic vein thrombosis. Hepatology 2006; 44:1528–1534. 8 Kiladjian JJ, Cervantes F, Leebeek FW, Marzac C, Cassinat B, Chevret S, et al. The impact of JAK2 and MPL mutations on diagnosis and prognosis of splanchnic vein thrombosis: a report on 241 cases. Blood 2008; 111:4922–4929. 9 Ayala R, Grande S, Bustelos R, Ribera C, Garcia-Sesma A, Jimenez C, et al. Obesity is an independent risk factor for pre-transplant portal vein thrombosis in liver recipients. BMC Gastroenterol 2012; 12:114. 10 Rapado I, Grande S, Albizua E, Ayala R, Hernandez JA, Gallardo M, et al. High resolution melting analysis for JAK2 exon 14 and exon 12 mutations: a diagnostic tool for myeloproliferative neoplasms. J Mol Diagn 2009; 11:155–161.
Hematocrit levels and red blood cell indices in patients with nonalcoholic fatty liver disease Danny Issaa, Mazen Albeldawib, Rocio Lopezc and Naim Alkhourib,d, a Department of Internal Medicine, Fairview Hospital, bDigestive Disease Institute, c Quantitative Health Sciences and dDepartment of Pediatric Gastroenterology, Cleveland Clinic, Cleveland, Ohio, USA Correspondence to Naim Alkhouri, MD, Digestive Disease Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA Tel: + 1 216 444 9000; fax: + 1 216 444 2974; e-mail: [email protected] Received 25 November 2013 Accepted 27 November 2013
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
364 European Journal of Gastroenterology & Hepatology 2014, Vol 26 No 3
Table 1
Red blood cell indices and liver histology in nonalcoholic fatty liver disease Steatosis
Factor Hb Hct RBC RDW
r (95% CI) 0.17 0.16 0.15 – 0.10
(– 0.03, (– 0.05, (– 0.06, (– 0.30,
0.37) 0.36) 0.35) 0.11)
Inflammation P-value 0.1 0.13 0.16 0.34
r (95% CI) – 0.00 0.05 0.05 0.13
(– 0.21, (– 0.15, (– 0.15, (– 0.08,
Ballooning P-value
0.20) 0.26) 0.26) 0.33)
0.99 0.61 0.6 0.22
r (95% CI) – 0.01 0.04 0.02 0.06
Fibrosis r (95% CI)
P-value
(– 0.22, 0.19) (– 0.17, 0.25) (– 0.19, 0.22) (– 0.15, 0.26)
0.92 0.7 0.88 0.57
0.07 0.10 0.07 0.11
(– 0.13, (– 0.10, (– 0.13, (– 0.10,
0.28) 0.31) 0.28) 0.31)
P-value 0.49 0.33 0.48 0.3
CI, confidence interval; Hb, hemoglobin; Hct, hematocrit; RBC, red blood cell; RDW, red cell distribution width.
We read with great interest the articles by Li et al. [1] and Yang et al. [2] reporting significant associations of hematocrit (Hct) levels and red cell distribution width (RDW) with fibrosis, as well as the histologic severity of nonalcoholic fatty liver disease (NAFLD). The most plausible explanations for these associations are chronic inflammation, oxidative stress, and hypoxia, which can lead to an elevation in Hct levels and RDW and may play a role in NAFLD pathogenesis [3,4]. We aimed to further investigate these associations in our cohort of patients. Our study consisted of 95 patients who underwent a liver biopsy for clinically suspected NAFLD. We evaluated the levels of Hct and hemoglobin, the red blood cell count, and RDW. The histologic features of nonalcoholic steatohepatitis (NASH) were scored including steatosis, inflammation, and ballooning. Fibrosis stage was also scored. The diagnosis of NASH was based on Brunt’s criteria. Spearman’s correlation coefficients were computed to assess the correlation between red blood cell indices and the histological features of liver biopsy.
P = 0.14). No significant association was found between Hct level and any of the main histologic features of NAFLD (steatosis, inflammation, ballooning, fibrosis) or the NAFLD activity score. Similarly, no significant correlations were found between RDW, hemoglobin level, or red blood cell count and liver histology, as shown in Table 1. In conclusion, Hct levels and RDW are not significantly associated with the severity of liver histology in NAFLD. Our findings argue against using red blood cell indices as biomarkers of NAFLD severity.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
2
Our results showed that 47 patients had biopsy-proven NASH, whereas 30 patients had simple steatosis and 18 had normal liver biopsies (mean age 49.1±10.7 years, 47.2% female). Mean Hct levels were not significantly different between patients with NASH (43.3±3.6), steatosis (43.5±3.4), and normal biopsies (41.5±3.9;
3
4
Li Y, Liu L, Wang B, Wang J, Chen D. Hematocrit is associated with fibrosis in patients with nonalcoholic steatohepatitis. Eur J Gastroenterol Hepatol 2014; 26:332–338. Yang W, Huang H, Wang Y, Yu X, Yang Z. High red blood cell distribution width is closely associated with nonalcoholic fatty liver disease. Eur J Gastroenterol Hepatol 2013 [Epub ahead of print]. Kim HM, Kim BS, Cho YK, Kim BI, Sohn CI, Jeon WK, et al. Elevated red cell distribution width is associated with advanced fibrosis in NAFLD. Clin Mol Hepatol 2013; 19:258–265. Tessari P, Coracina A, Cosma A, Tiengo A. Hepatic lipid metabolism and non-alcoholic fatty liver disease. Nutr Metab Cardiovasc Dis 2009; 19: 291–302.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
