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Liver fibrosis, cirrhosis, and portal hypertension

Stem cell exosomes: new hope and future potential for relieving liver fibrosis
Lihua Li, Yongjie Liu, Kunpeng Wang, Jinggang Mo, Zhiyong Weng, Hao Jiang, Chong Jin
Clin Mol Hepatol 2025;31(2):333-349.
Published online November 7, 2024
DOI: https://doi.org/10.3350/cmh.2024.0854
Liver fibrosis is a chronic liver injury resulting from factors like viral hepatitis, autoimmune hepatitis, non-alcoholic steatohepatitis, fatty liver disease, and cholestatic liver disease. Liver transplantation is currently the gold standard for treating severe liver diseases. However, it is limited by a shortage of donor organs and the necessity for lifelong immunosuppressive therapy. Mesenchymal stem cells (MSCs) can differentiate into various liver cells and enhance liver function when transplanted into patients due to their differentiation and proliferation capabilities. Therefore, it can be used as an alternative therapy for treating liver diseases, especially for liver cirrhosis, liver failure, and liver transplant complications. However, due to the potential tumorigenic effects of MSCs, researchers are exploring a new approach to treating liver fibrosis using extracellular vesicles (exosomes) secreted by stem cells. Many studies show that exosomes released by stem cells can promote liver injury repair through various pathways, contributing to the treatment of liver fibrosis. In this review, we focus on the molecular mechanisms by which stem cell exosomes affect liver fibrosis through different pathways and their potential therapeutic targets. Additionally, we discuss the advantages of exosome therapy over stem cell therapy and the possible future directions of exosome research, including the prospects for clinical applications and the challenges to be overcome.

Citations

Citations to this article as recorded by  Crossref logo
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Original Articles

Auranofin attenuates hepatic steatosis and fibrosis in nonalcoholic fatty liver disease via NRF2 and NF- κB signaling pathways
Seung Min Lee, Dong Hee Koh, Dae Won Jun, Yoon Jin Roh, Hyeon Tae Kang, Ju Hee Oh, Hyun Sung Kim
Clin Mol Hepatol 2022;28(4):827-840.
Published online June 22, 2022
DOI: https://doi.org/10.3350/cmh.2022.0068
Background/Aims
We aim to evaluate the effects of auranofin, a known antioxidant, on hepatic steatosis, inflammation, and fibrosis, contributing to non-alcoholic steatohepatitis (NASH) development in vivo and in vitro.
Methods
Transcriptome analysis of LX-2 cells was that expression patterns of genes changed by auranofin, and their related pathways were estimated. We used the gene set enrichment analysis (GSEA) program to determine the pathway involved in overall genetic change. In vitro, LX-2 and HepG2 cells were treated with transforming growth factor (TGF)-β1 and palmitic acid (PA), respectively, and the antifibrotic and antiadipogenic effect function of auranofin was evaluated.
Results
Transcriptome analysis revealed that auranofin decreased the expression of 15 genes, including thrombospondin 1, endothelin 1 (ET-1), fibronectin 1, and LOX. The molecular functions of these genes are involved in collagen binding. GSEA of the overall gene expression pattern revealed that many genes increased in the reactive oxygen species pathway and decreased in the inflammatory response. Auranofin decreased nuclear factor kappa B (NF-κB) and IκBα in TGF-β1-induced LX-2 cells, thereby reducing ET-1 and fibrosis. Furthermore, increased pNRF2 in PA-induced HepG2 cells led to increased antioxidant marker expression and decreased lipid accumulation. In the bile duct ligation model mice, auranofin reduced the fibrosis area and increased the survival rate. Auranofin reduced liver fibrosis and lipid accumulation in NASH model mice fed on a Western diet.
Conclusions
Auranofin inhibits lipogenesis and fibrosis formation and is a proposed candidate for NASH treatment.

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Negligible risks of hepatocellular carcinoma during biomarker-defined immune-tolerant phase for patients with chronic hepatitis B
Mi Young Jeon, Beom Kyung Kim, Jae Seung Lee, Hye Won Lee, Jun Yong Park, Do Young Kim, Sang Hoon Ahn, Kwang-Hyub Han, Seung Up Kim
Clin Mol Hepatol 2021;27(2):295-304.
Published online December 3, 2020
DOI: https://doi.org/10.3350/cmh.2020.0216
Background/Aims
The immune-tolerant (IT) phase of chronic hepatitis B (CHB) patients is not generally indicative of antiviral therapy (AVT). We assessed and compared the risk of hepatocellular carcinoma (HCC) during the IT-phase stringently defined by a low fibrosis-4 (FIB-4) index, compared to that in patients undergoing AVT.
Methods
Among 125 untreated patients that were hepatitis B e-antigen positive, hepatitis B virus-DNA >20,000 IU/mL, with normal alanine aminotransferase level from 2012 to 2018, those with a FIB-4 index of <1.45 were classified into the IT-group. The cumulative probability of HCC was estimated using Kaplan-Meier analysis. All patients were assessed until HCC development (intention-to-treat [ITT] analysis), whereas those suspected of experiencing CHB phase switch were assessed using the per-protocol (PP) and censored at the time of phase switch.
Results
The cumulative probability of HCC at 1-, 3-, and 5-years among the IT-group was zero, compared to AVT-treated patients with FIB-4 indices <1.45 during the same period: 0.2%, 0.6%, and 1.4%, respectively (P=0.264 for ITT and P=0.533 for PP). Among the initially screened 125 untreated patients, those with a FIB-4 index of ≥1.45 had a higher risk of HCC compared to the IT-group (P=0.005). Furthermore, among AVT-treated patients, those with a FIB-4 index of ≥1.45 had a higher risk of HCC compared to their counterpart (P<0.001).
Conclusions
The risk of HCC was negligible in the IT-group stringently defined by a low FIB-4 index. However, given that a higher HCC risk exists among untreated patients with higher FIB-4, appropriate criteria for AVT should be established.

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Liver fibrosis, cirrhosis, and portal hypertension

Inhibition of hepatic stellate cells by bone marrow-derived mesenchymal stem cells in hepatic fibrosis
Yoon Ok Jang, Baek Gyu Jun, Soon Koo Baik, Moon Young Kim, Sang Ok Kwon
Clin Mol Hepatol 2015;21(2):141-149.
Published online June 26, 2015
DOI: https://doi.org/10.3350/cmh.2015.21.2.141
Background/Aims

Therapies involving bone-marrow-derived mesenchymal stem cells (BM-MSCs) have considerable potential in the management of hepatic disease. BM-MSCs have been investigated in regenerative medicine due to their ability to secrete various growth factors and cytokines that regress hepatic fibrosis and enhance hepatocyte functionality. The aim of this study was to determine the antifibrosis effect of BM-MSCs on activated hepatic stellate cells (HSCs) and the mechanism underlying how BM-MSCs modulate the function of activated HSCs.

Methods

We used HSCs in both direct and indirect co-culture systems with BM-MSCs to evaluate the antifibrosis effect of BM-MSCs. The cell viability and apoptosis were evaluated by a direct co-culture system of activated HSCs with BM-MSCs. The activations of both HSCs alone and HSCs with BM-MSCs in the direct co-culture system were observed by immunocytochemistry for alpha-smooth muscle actin (α-SMA). The levels of growth factors and cytokines were evaluated by an indirect co-culture system of activated HSCs with BM-MSCs.

Results

The BM-MSCs in the direct co-culture system significantly decreased the production of α-SMA and the viability of activated HSCs, whereas they induced the apoptosis of activated HSCs. The BM-MSCs in the indirect co-culture system decreased the production of transforming growth factor-β1 and interleukin (IL)-6, whereas they increased the production of hepatocyte growth factor and IL-10. These results confirmed that the juxtacrine and paracrine effects of BM-MSCs can inhibit the proliferative, fibrogenic function of activated HSCs and have the potential to reverse the fibrotic process by inhibiting the production of α-SMA and inducing the apoptosis of HSCs.

Conclusions

These results have demonstrated that BM-MSCs may exert an antifibrosis effect by modulating the function of activated HSCs.

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Viral hepatitis

The factors associated with longitudinal changes in liver stiffness in patients with chronic hepatitis B
In Ku Yo, Oh Sang Kwon, Jin Woong Park, Jong Joon Lee, Jung Hyun Lee, In Sik Won, Sun Young Na, Pil Kyu Jang, Pyung Hwa Park, Duck Joo Choi, Yun Soo Kim, Ju Hyun Kim
Clin Mol Hepatol 2015;21(1):32-40.
Published online March 25, 2015
DOI: https://doi.org/10.3350/cmh.2015.21.1.32
Background/Aims

Liver stiffness (LS) as assessed by transient elastography (TE) can change longitudinally in patients with chronic hepatitis B (CHB). The aim of this study was to identify the factors that improve LS.

Methods

Between April 2007 and December 2012, 151 patients with CHB who underwent two TE procedures with an interval of about 2 years were enrolled. Ninety-six of the 151 patients were treated with nucleos(t)ide analogues [the antiviral therapy (+) group], while the remaining 55 patients were not [the antiviral therapy (-) group]. The two groups of patients were stratified according to whether they exhibited an improvement or a deterioration in LS during the study period (defined as an LS change of ≤0 or >0 kPa, respectively, over a 1-year period), and their data were compared.

Results

No differences were observed between the antiviral therapy (+) and (-) groups with respect to either their clinical characteristics or their initial LS. The observed LS improvement was significantly greater in the antiviral therapy (+) group than in the antiviral therapy (-) group (-3.0 vs. 0.98 kPa, P=0.011). In the antiviral therapy (+) group, the initial LS was higher in the LS improvement group (n=63) than in the LS deterioration group (n=33; 7.9 vs. 4.8 kPa, P<0.001). However, there were no differences in any other clinical characteristic. In the antiviral therapy (-) group, the initial LS was also higher in the LS improvement group (n=29) than in the LS deterioration group (n=26; 8.3 vs. 6.5 kPa, P=0.021), with no differences in any other clinical characteristic.

Conclusions

A higher initial LS was the only factor associated with LS improvement in patients with CHB in this study.

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Review

NADPH oxidase mediated oxidative stress in hepatic fibrogenesis
Yong-Han Paik, David A. Brenner
Korean J Hepatol 2011;17(4):251-257.
Published online December 26, 2011
DOI: https://doi.org/10.3350/kjhep.2011.17.4.251

NADPH oxidase (NOX) is a multicomponent enzyme complex that generates reactive oxygen species (ROS) in response to a wide range of stimuli. ROS is involved as key secondary messengers in numerous signaling pathways, and NADPH oxidases complex has been increasingly recognized as key elements of intracellular signaling of hepatic fibrogenesis. In the liver, NADPH oxidase is functionally expressed both in the phagocytic form and in the non-phagocytic form. The non-phagocytic NADPH oxidase complex is structurally and functionally similar to the phagocytic NADPH, resulting in reduction of molecular oxygen to generate superoxide. There are six homologous NOX proteins in the non-phagocytic forms of NADPH oxidase. An emerging concept is that both phagocytic and nonphagocytic NADPH oxidase components in hepatic stellate cells (HSCs) mediate hepatic fibrosis, suggesting its potential role as a pharmacological target for anti-fibrotic therapy. The molecular components and signaling pathways of various NADPH oxidase homologues that are critical for the fibrotic activity in HSCs need to be more clearly identified.

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Original Article

Serum hyaluronic acid Level: Correlation with quantitative measurement of hepatic fibrosis in a cirrhotic rat model
Moon Young Kim, M.D., Soon Koo Baik, M.D., Yoon Ok Jang, M.D., Ki Tae Suk, M.D., Jae Woo Kim, M.D., Hyun Soo Kim, M.D., Mi Yun Cho, M.D.1, Sun Joo Choi, M.D.2, Soon Ho Um, M.D.3, Kwang-Hyub Han, M.D.4
Korean J Hepatol 2008;14(2):159-167.
Published online June 20, 2008
DOI: https://doi.org/10.3350/kjhep.2008.14.2.159
Backgrounds/Aims
The serum level of hyaluronic acid (HA) has been suggested as a useful serologic marker for hepatic fibrosis. However, the relationship between serum HA levels and quantitative markers of fibrosis from liver tissue has not been reported. The aim of this study was to determine the correlation between serum HA level and quantitative measurement of hepatic fibrosis in a cirrhotic rat model. Methods: Cirrhosis was produced by common bile duct ligation (BDL) in adult Sprague-Dawley rats. The animals were classified into four groups: (1) G1, sham operated (n=5); (2) G2, BDL for 2 weeks (n=6); (3) G3, BDL for 3 weeks (n=6); and (4) G4, BDL for 4 weeks (n=6). Hepatic fibrosis was analyzed histomorphologically using the Batts and Ludwig scoring system. Serum HA level and hepatic hydroxyproline content were quantified. The gene expressions in the liver of procollagen, collagen, and transforming growth factor-β (TGF-β) were measured by reverse transcriptase-polymerase chain reaction. Results: In groups G1, G2, G3, and G4, the Batts and Ludwig scores (mean±SD) were 0, 1.3±0.5, 2.6±0.5, and 3.4±0.5, respectively (P<0.05), serum HA levels were 12.5±3.2, 30.0±4.3, 228.6±157.7, and 391.3±207.7 ng/mL (P<0.05), and the concentration of hydroxyproline was 12.4±2.8, 17.6±3.8, 17.9±2.4, and 33.4±3.4 μg/g liver tissue, and it was significantly higher in group G4 than in the other groups (P<0.05). The gene expressions of collagen, procollagen, and TGF-β1 in the liver were also significantly higher in group G4 compared with the other groups (P<0.05). Direct linear correlations were observed between serum HA level and hepatic hydroxyproline content, hepatic gene expressions of collagen, procollagen, TGF-β1, and histomorphological grade of hepatic fibrosis (P<0.001).
Conclusions
These results indicate that serum HA is a useful and noninvasive serologic marker for the evaluation of advanced hepatic fibrosis. (Korean J Hepatol 2008;14:159-167)

Citations

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    Xiang-lan Wei, Ru-tang Fang, Yong-hua Yang, Xue-yuan Bi, Guo-xia Ren, A-li Luo, Ming Zhao, Wei-jin Zang
    BMC Complementary and Alternative Medicine.2015;[Epub]     CrossRef
  • Evaluation of Automated Assays for Measuring Serum Hyaluronic Acid: For the Diagnosis of Rheumatoid Arthritis
    Mi-Soon Han, Yongjung Park, Hyon-Suk Kim
    Laboratory Medicine Online.2014; 4(2): 98.     CrossRef
  • Histological subclassification of cirrhosis using the Laennec fibrosis scoring system correlates with clinical stage and grade of portal hypertension
    Moon Young Kim, Mee Yon Cho, Soon Koo Baik, Hong Jun Park, Hyo Keun Jeon, Chong Kun Im, Chan Sik Won, Jae Woo Kim, Hyun Soo Kim, Sang Ok Kwon, Min Seob Eom, Seung Hwan Cha, Young Ju Kim, Sei Jin Chang, Samuel S. Lee
    Journal of Hepatology.2011; 55(5): 1004.     CrossRef
  • Diagnostic value of multiple biomarker panel for prediction of significant fibrosis in chronic hepatitis C
    Seung Ha Park, Chang Hoon Kim, Dong Joon Kim, Ki Tae Suk, Jong Ha Park, Jae Youn Cheong, Sung Won Cho, Seong Gyu Hwang, Youn Jae Lee, Mong Cho, Jin Mo Yang, Ha Young Park, Young Bae Kim
    Clinical Biochemistry.2011; 44(17-18): 1396.     CrossRef
  • The value of serum retinol-binding protein 4 levels for determining disease severity in patients with chronic liver disease
    Jung Hyun Kwon, Seong Tae Park, Gi Dae Kim, Chan Ran You, Jin Dong Kim, Hyun Young Woo, Jeong Won Jang, Chang Wook Kim, Si Hyun Bae, Jong Young Choi, Seung Kew Yoon
    The Korean Journal of Hepatology.2009; 15(1): 59.     CrossRef
  • Effects of silymarin and pentoxifylline on matrix metalloproteinase-1 and -2 expression and apoptosis in experimental hepatic fibrosis
    Eray Kara, Teoman Coşkun, Yavuz Kaya, Okan Yumuş, Seda Vatansever, Ahmet Var
    Current Therapeutic Research.2008; 69(6): 488.     CrossRef
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  • Crossref

Editorial

Pharmacologic Therapy of Hepatic Fibrosis
Dong Joon Kim
Korean J Hepatol 2001;7(1):6-11.
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Original Articles

Protective Effect of Pentoxifylline and Ciprofloxacin on Dimethylnitrosamine-induced Hepatic Fibrosis in Rats
Kang Suek Suh,Chang Hun Lee,Mee Young Sol,Sun Kyung Lee
Korean J Hepatol 2001;7(1):34-46.
Background/Aims
Hepatic fibrosis is known to be a predisposing condition of cirrhosis for which there is no proven effective therapy. The aim of this study was to investigate the effect of pentoxifylline and ciprofloxacin on biochemical and histological features of rat hepatic fibrosis induced by dimethylnitrosamine (DMN). Methods: Seventy male Sprague-Dawley rats were divided into four groups including control (n = 10), DMN (n = 20), DMN plus pentoxifylline (n = 20) and DMN plus ciprofloxacin (n = 20). The rats were injected intraperitoneally with normal saline in the control group and the aforementioned chemicals in the study groups three times a week for 3 weeks. Two rats of the control group, and fives of each study group were sacrificed weekly after the beginning of experiment. From sacrified rats the following parameters of hepatic fibrosis were determined: AST, ALT, cytokines IL-1β, TNF-α and INF-γ, and histological features of hepatic tissue. Result: Rat weight, serological and histological findings were distinctively improved in two treated groups compared with untreated DMN group(p<0.05), The antifibrogenic activity between treated groups was rather better in the group treated with pentoxifylline than in the group treated with ciprofloxacin. During the first and second weeks after experiment the distribution of hepatic stellate cells in treated groups was limited, whereas DMN group showed their diffuse distribution. At the third week DMN group displayed micronodular cirrhosis, but treated groups showed only mild centrilobular fibrotic areas without developing cirrhosis. Conclusion: Our results indicate that pentoxifylline and cirprofloxacin may be protective against DMN induced rat hepatic fibrogenesis, while accompanying the inhibition of hepatic stellate cells during the early stage of hepatic fibrogenesis.(Korean J Hepatol 2001;7:34-46)
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Changes of Propranolol Pharmacokinetic Parameters According to Hepatic Fibrotic Severity in CCl4-Treated Rats
Mun Su Kang, M.D., Chang Ok Yoon, M.D., Jai Won Byun, M.D., Oh Young Lee, M.D. Byung Chul Yoon, M.D., Joon Soo Hahm, M.D., Ju Seop Kang, M.D.*, Min Ho Lee, M.D.
Korean J Hepatol 2001;7(2):181-188.
Background/Aims
This study was designed to determine the effect of hepatic fibrotic severity on pharmacokinetics of propranolol in CCl4-treated rats.Methods:1 mL/kg of 10% CCl4 in olive oil was injected intramuscularly to rats twice weekly for 4, 6, 8 and 10 weeks, respectively(n=6). Control(n=6) was a sham-injected equal dose of olive oil for 10 weeks. After intravenous bolus injection of 2 mg/kg propranolol to rats, the serum propranolol concentrations were analyzed for 4 hours at various time points by a HPLC-fluorimetric system, and pharmacokinetic parameters such as C0, MRT, AUC, Vdss, t1/2(β) and CLp were determined. Then, a small amount of hepatic tissue was obtained and subjected to determination of the hepatic 4-hydroxyproline content, which confirmed the hepatic fibrotic severity. Results:The serum concentrations of propranolol at 0.5, 1, 2 and 4 hours were significantly increased in CCl4-treated rats(p<0.01). In proportion to the duration of CCl4 treatment, C0 and AUC were significantly increased, and Vdss and CLp were significantly decreased(p<0.001). But MRT and t1/2(β) were not significantly changed. The hepatic 4-hydroxyproline content was gradually increased in CCl4-treated rats(p<0.001).Conclusion:Gradual changes in pharmacokinetic parameters of propranolol were seen to be dependent on the hepatic fibrotic severity. We suggest that gradual dosage modification, according to their hepatic fibrotic severity, is necessary for many drugs administered to patients with chronic liver disease.(Korean J Hepatol 2001;7:181-188)
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Lipid Peroxidation in Chronic Liver Diseases Type B
Kyung Chul Kim , Kwan Sik Lee , Kwang Hyub Han , Won Choi , Chae Yoon Chon , Sang In Lee , Young Myung Moon , Jin Kyung Kang , In Suh Park , Hye Young Kim
Korean J Hepatol 1997;3(1):40-49.
Background/Aims
.' Oxidative stress is known to play a role in the pathogenesis of a certain liver diseases such as alcoholic liver disease, metal storage disease, and ischemia/reperfusion injury. Recently oxidative stress(lipid peroxidation) has also been implicated in hepatic fibrosis, which is now regarded as a common response to chronic liver injury regardless of its nature. Development of fibrosis and cirrhosis are the major complications of chronic hepatitits B. So we aimed to detect lipid peroxidation in chronic hepatitis B and to investigate its potential role in the pathophysiology of the disease. Methods .' The subjects were histologically-proven 56 patients, including fatty liver(FL, n=8), healthy HBsAg carrier(n=6), chronic persistent hepatitis(CPH, n=8), mild chronic active hepatitis(CAH- m, n=10), severe CAH(CAH-s, n=16), and liver cirrhosis(LC, n=8). All patients were serologically HBsAg-positive except those with FL. Lipid peroxidation was detected in serum and liver specimen with TBARS(thiobarbituric acid-reacting substances) assay. Western blot and immunohistochemical stain of liver specimen were also performed, using polyclonal antibody against malondialdehyde (MDA). Results '. 1. There were no significant differences in serum TBARS levels among groups(p= 0.24). 2. The mean tissue TBARS level(nmol/g) was significantly higher in CAH-s group(175.4+ 41.5) than in other groups(FL 54.0+ 6.4, Carrier 51.1+ 15.9, CPH 63.9+ 2.9, CAH-m 68.9+ 7.9, LC 22.6+ 5.1) (p<0.05). 3. Tissue TBARS levels correlated with serum ALT levels(r=0.5934, p<0.05). 4. Western blot showed MDA bands only in CAH-s group. 5. Immunohistochemistry showed a strong MDA stain around portal and periportal area in CAH-s group, but weak or no stain in other groups. Conclusions . This study shows that lipid peroxidation can be detected in situ and commonly occurs in severe chronic hepatitis B. Oxidative stress may be related to active necroinflammatory change of the liver and contribute to the progression of the disease in chronic hepatitis B.
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Case Report

Two Cases of Congenital Hepatic Fibrosis with Polycystic Kidney Disease
Dong Hyun Lee,Ok Nyu Kong,Ji Young Kim,Chan Won Park,Jae Hyeon Moon,Dae Gun Nam,Hyung Jun Chu,Dae Hwan Kang,Geun Am Song,Mong Cho,Ung Suk Yang
Korean J Hepatol 2001;7(4):485-490.
Congenital hepatic fibrosis(CHF) is a rare development abnormality, which is characterized pathologically by periportal fibrosis with irregularly shaped proliferating bile ducts. In most, if not all. cases CHF is associated with autosomal recessive polycystic kidney disease. Recently, we experienced two cases, confirmed by percutaneous needle liver biopsy, of CHF with polycystic kidney disease. The first patient was a 19-year-old man and presented with hematemesis and hepatosplenomegaly. Esophageal varix was noted by an endoscopic examination and an endoscopic variceal ligation was performed. Abdominal CT scanning revealed innumerable cysts of both kidneys. The patient also had cystic dilation of subarchnoid space in the basal ciatern and posterrior fossa detected through brain MRI. The second patient was a 24-year-old man admitted for an evaluation of splenomegaly. Ha had no esophageal varix but, splenic varix and splenorenal shunt were detected through an abdominal CT scanning. Innumerable renal cysts were also present. The diagnosis of CHF was confirmed in both cases by its typical histologic features. We report these cases with a review of the relevant literatures. (Korean J Hepatol 2001;7 :485 - 490)
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Original Article

The Diagnostic Value of Serum Hyaluronic Acid, 7S Domain of Type IV Collagen and AST/ALT Ratio as Markers of Hepatic Fibrosis in Chronic Hepatitis B and Cirrhosis Patients
Jin Hyung Park, M.D., Chang Kun Park, M.D., Eun Soo Kim, M.D., Soo Young Park, M.D., Chang Min Jo, M.D., Won Young Tak, M.D., Young Oh Kweon, M.D., Sung Kook Kim, M.D. and Yong Whan Choi, M.D.
Korean J Hepatol 2003;9(2):79-88.
Background/Aims
The prognosis of chronic liver disease is closely related to the development of hepatic fibrosis. Liver biopsy is the gold standard method to assess inflammatory activity and fibrosis stage, but this is associated with morbidity and mortality. This study aimed to evaluate the diagnostic value of serum hyaluronic acid, 7S domain of type IV collagen and AST/ALT ratio as markers of hepatic fibrosis in chronic hepatitis B and cirrhosis. Methods: This study included 100 patients with chronic hepatitis B and cirrhosis. Liver biopsy and histopathologic classification were done. Serum hyaluronic acid and 7S domain of type IV collagen were measured by one step sandwich binding protein assay and radioimmunoassay using polyclonal antibody to 7S domain of type IV collagen, respectively. Results: The serum concentrations of hyaluronic acid, 7S domain of type IV collagen and AST/ALT ratio in the cirrhosis group (139±98.4 ng/mL, 6.9±3.5 ng/mL, 1.6±1.5) were significantly higher (p<0.01) than those in the normal and fatty liver group (20.2±12.5 ng/mL, 3.5±0.5 ng/mL, 0.7±0.3), mild hepatitis group (32.3±52.7 ng/mL, 3.9±1.4 ng/mL, 0.7±0.4), and moderate to severe hepatitis group (68.2±72.3 ng/mL, 5.3±2.4 ng/mL, 0.8 type IV collagen and 0.62 for AST/ALT ratio, the sensitivities were 81.8%, 63.6%, 90.9% and specificities were 87.3%, 88.6%, 53.1% for discriminating cirrhosis (fibrosis score: 4) from the mild to severe fibrosis (fibrosis score: 0-3). Conclusions: Serum hyaluronic acid, 7S domain of type IV collagen and AST/ALT ratio measurement may be clinically useful as markers of hepatic fibrosis in chronic hepatitis B and cirrhosis.(Korean J Hepatol 2003;9:79-88)
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Review

Clinical Application of Non-invasive Diagnosis for Hepatic Fibrosis
Sung Won Cho , Jae Youn Cheong
Korean J Hepatol 2007;13(2):129-137.
Progressive hepatic fibrosis with development of cirrosis is a feature of chronic liver disease. Assessing fibrosis is important for predicting disease progression and patient management. Liver biopsy is the current gold standard for the diagnosis of liver fibrosis. However, liver biopsy is an invasive procedure. Alternative non-invasive methods have been developed. Serum markers are useful in predicting liver cirrhosis, but accuracy of serum markers is not satisfactory in the assessment of fibrosis. Newly developed transient elastography (Fibroscan) is a non-invasive method of measuring liver stiffness. Fibroscan has been reported to be superior in early detection of cirrhosis to serum markers. Factors influencing it’s performance are not fully investigated. The evaluation of new tests should be continued to perform. (Korean J Hepatol 2007;13:129-137)
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Original Article

The Clinical Significance of Serum Hyaluronic Acid and Type IV Collagen Level in Chronic Hepatitis and Early Liver Cirrhosis
Joo Hyun Sohn, M.D., Young Woo Sohn, M.D., Dong Soo Han, M.D. Yong Cheol Jeon, M.D., Choon Suhk Kee, M.D., Won Mi Lee*, M.D. Se Jin Jang*, M.D. and Yong Wook Park*, M.D.
Korean J Hepatol 1999;5(3):190-199.
Background/Aims
Liver biopsy has been used to evaluate the degree of hepatic fibrosis in patients with chronic liver diseases. It is important to assess liver fibrosis when following the course of chronic liver diseases. Histopathological examination of percutaneous biopsy specimens is invasive and is also of questionable value because of the heterogenous distribution of pathological changes in the liver. Therefore, non-invasive methods to determine the progress of liver fibrosis are needed. Serum hyaluronic acid and type IV collagen are known to be related to hepatic fibrosis. This study was performed to evaluate the clinical usefulness of serum hyaluronic acid and type IV collagen measurement as a differential point in patients with chronic liver diseases and early cirrhosis. Methods: This study included 109 patients with chronic liver diseases caused by various etiologies. Liver biopsy and histopathological classification were done in all patients. Serum hyaluronic acid and type IV collagen were measured by one-step sandwich binding protein assay and one-step sandwich enzyme immunoassay. Results: The concentrations of hyaluronic acid and type IV collagen in the early cirrhosis group (208.5±186.4 ng/mL, 242.1±162.8 ng/mL) were significantly higher (p<0.01) than those in the normal and fatty liver group (26.3±21.7 ng/mL, 79.2±28.8 ng/mL), mild chronic hepatitis group (22.8±15.4 ng/mL, 125.5±79.7 ng/mL), moderate to severe hepatitis group (66.3±60.5 ng/mL, 148.5±78.7 ng/mL). At the cutoff value of 100 ng/mL for hyaluronic acid and 200 ng/mL for type IV collagen, the sensitivities were 66.7% and 55.6%, and specifities were 82.9% and 89%, and diagnostic efficiencies were 78.9% and 80.7% respectively for discriminating patients with cirrhosis (4 points) from the mild to severe fibrosis (0∼3 points). Conclusions: The serum levels of hyaluronic acid and type IV collagen may be sensitive markers of fibrotic process in chronic liver diseases and useful biochemical markers in differentiation of the patients with early cirrhosis from those with chronic liver diseases.(Korean J Hepatol 1999;5:190-199)
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Review

Hepatic fibrosis and cirrhosis are the consequences of many types of chronic liver disease. The precise quantification of fibrosis is important to predict the prognosis and monitor the response of treatment modality. The liver biopsy has a role to estimate the stage of fibrosis. However, its sensitivity is below 80%. Its use is limited by sampling errors, inter- and intraobserver variability and possible morbidity and mortality. There is increasing attention to developing clinical algorithms and new noninvasive alternative techniques to predict the stage of fibrosis. However none of these can replace the utility of liver biopsy in the intermediate stage of hepatic fibrosis. Therefore, the liver biopsy is still the “gold standard” to assess the precise stage of hepatic fibrosis. (Korean J Hepatol 2007;13:138-145)
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Hepatology Elsewhere
최근 간섬유화의 resolution phase에서 활성화된 간 성상세포(hepatic stellate cell)의 수가 줄어드는 기전으로 세포사멸(apoptosis)가 중요한 역할을 담당함이 알려지고 있다. 이러한 사실은 활성화된 간 성상세포가 휴지기에 있을 때보다 세포사멸을 일으키는 자극에 더 민감하다는 것을 암시한다. 이미 다른 종류의 세포들이 휴지 상태보다 활성화된 상태에서 TRAIL (tumor necrosis factor-related apoptosis-inducing ligand)에 의한 세포사멸에 더 민감하다는 사실이 알려진 바 있기 때문에 본 연구자들은 이번 연구에서 점진적인 활성화 단계를 거치는 간 성상세포에서 단계별 TRAIL 사망 수용체(death receptor)의 발현과 TRAIL에 의한 세포 독성에 대한 민감도를 밝히고자 하였다. 자연적으로 불멸화된 인간 간 성상세포주인 LX-2 세포를 14일간 플라스틱 용기에서 배양하며 분석한 결과, 14일 후 간 성상세포 활성화의 지표인 α-smooth muscle actin (α-SMA)과 β-crystalline의 messenger RNA (mRNA)의 양이 각각 7배와 5배 증가하였으며, 같은 기간동안 TRAIL-R1/DR4와 TRAIL-R2/DR5 mRNA 발현은 각각 18배와 17.6배 증가하였다. 양적으로 보았을 때에는 TRAIL-R2/DR5의 발현이 TRAIL-R1/ DR4보다 103배 높았다. 아울러 TRAIL-R2/DR5 단백 발현과 TRAIL 유도 세포사멸에 대한 민감플라스틱 용기에서 활성화 과정을 거치는 동안 도에서도 동일한 양상의 변화가 관찰되었으며, 설치류의 간으로부터 일차배양한 간 성상세포 역시 유사한 변화를 보였다. 결론적으로 간 성상세포는 활성화되어감에 따라 TRAIL-R2/DR5 발현이 증가하고 TRAIL 유도 세포사멸에 민감해짐을 알 수 있었다. 따라서 임상적으로 TRAIL-R2/DR5 agonist가 생체 내에서 선택적으로 간 성상세포의 세포사멸을 유도하여 간섬유화를 줄이는데 유용하게 이용될 수 있을 것으로 기대된다.
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