Clinical Case Summary

We report a case of Intrahepatic Cholestasis of Pregnancy (ICP) leading to a rejections of a living, related donor liver two years after the liver transplantation (LT). The 36yo patient underwent LT in November 2021 in Mongolia due to a HBV/HDV related liver cirrhosis. Until August 2024, she had normal test results when she presented with severe pruritus and jaundice at 16-17th week of her second pregnancy. The ICP was diagnosed after elevated total bile acids were detected. A medical pregnancy termination was induced with subsequent three sessions of plasmapheresis. The patient's condition deteriorated further before she received her second living, unrelated donor LT in December 2024.
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	2023.07.03- prior to pregnancy	2024.08.18- during the pregnancy	2024.09.30- A month after termination	2024.11.04	2025.02.02- Two months after re-transplantation
Total bilirubin (mg/dL) /norm 0-1.2/	1.5 N	17.6 H	20.2 H	40.6 H	0.73 N
GOT/GPT (IU/mL) /norm 0-40/	11.3/18.3 N	265.3/196.1 H	79.5/77.1 H	262.5/113.1 H	6.2/7.6 N
Total bile acids (umol/mL) /norm 0-10/		170.2 H	332 H		7 N

The explant histology stated a massive hepatocellular necrosis (fulminant), total bile duct loss, massive cholestasis (canalicular and intracellular), allograft arteriopathy: Foamy histiocytes in the intimal artery, Arteriosclerosis and Lumen narrowing. No genetic test was performed , either prior or after the LTs. The final diagnosis: An Intrahepatic Cholestasis of Pregnancy leading to a liver graft rejection.
The ICP is a relatively common pregnancy related condition (0.2-2% of pregnancies in Europe and Americas¹) that presents with jaundice and pruritus. The condition usually improves after delivery/termination. In rare cases elevated serum bile acid levels lead to fetal abnormalities or loss of pregnancy. Since the patients condition did not improve after the pregnancy termination in September, 2024, Progressive Familial Intrahepatic Cholestasis (PFIC) was suspected when she admitted her first pregnancy was also complicated by ICP. Better history taking is needed to prevent graft rejection due to bile acid transport dysfunction.

References

1- Williamson, C. and V. Geenes, Intrahepatic cholestasis of pregnancy. Obstet Gynecol, 2014. 124(1): p. 120-133

Introduction

Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) have demonstrated metabolic and cardiovascular benefits in patients with type 2 diabetes (T2D). However, their potential effect on pancreatic cancer (PC) risk remains unclear.

Aims & Methods

We aimed to examine the association between SGLT-2i use and PC risk in T2D patients prescribed metformin. We conducted a retrospective cohort study using a territory-wide electronic healthcare database, retrieving adult patients (≥18 years) with T2D who initiated metformin between 2015 and 2022. The index date was the first metformin prescription during the study period. Patients were observed until PC, pancreatectomy, death, or study end date (December 31, 2022). Exclusion criteria included prior history of PC, IgG4 disease, pancreatectomy, or fewer than two HbA1c measurements during follow-up. The outcome and exposure of interest was PC and SGLT-2i use (including dapagliflozin, empagliflozin, canagliflozin and ertugliflozin), respectively. SGLT-2i exposure was defined as continuous use during 90-day entry period following the index date. Cox proportional hazards model with propensity score (PS) matching (1:2) on 28 covariates – age, sex, smoking, alcohol use, body mass index (BMI), diabetes duration and complications, glycemic control (in terms of time-weighted mean HbA1c), history of pancreatitis and cholangitis, comorbidities, and concomitant medication use (aspirin, statins, and other antidiabetic medications) – were used to estimate hazard ratios (HRs). Sensitivity analysis by treating medication use as time-varying variable was conducted to address immortal time bias.

Results

Among 144,468 matched patients (mean age:59.3±11.2 years; male:58.3%; 48,156 SGLT-2i users and 96,312 SGLT-2i non-users), 441 (0.31%) developed PC during a mean follow-up of 6.6±2.0years. The mean duration of SGLT-2i use was 2.1±1.6 years. SGLT-2i use was associated with lowered PC risk (aHR:0.43; 95% CI:0.34-0.55), irrespective of empagliflozin (aHR0.43; 95%CI: 0.33-0.57) or dapagliflozin use (aHR:0.33; 95% CI:0.22-0.49). When drug use was modelled as time-varying variables, the protective effect remained significant (aHR:0.35; 95% CI:0.15-0.78). Furthermore, a dose- and duration-dependent relationship was observed. The aHR was 0.88 (95% CI:0.84-0.92) per 100-cumulative defined daily dose (cDDD) increase in use, and 0.66 (95% CI:0.59-0.75) per 1-year increase in use. Subgroup analysis showed beneficial effects persistent regardless of age (cutoff of 65 years), sex, BMI (cutoff of 25 kg/m²), diabetes complications, usage of other medications (aspirin, statins, and insulin).

Conclusion

SGLT-2i use was associated with a lower risk of PC in a dose- and duration-dependent manner, which was independent of glycemic control, among T2D patients treated with metformin. These findings provide insights into informing the choice of second-line anti-diabetic drug in lowering PC risk in T2D metformin users.

Introduction

Autoimmune pancreatitis (AIP) is a rare, immune-mediated form of chronic pancreatitis, classified into three subtypes. Type 1 AIP, the pancreatic manifestation of IgG4-related disease, often presents with multisystem involvement and frequent relapse (1,2). Type 2 AIP is pancreas-limited, tends to affect younger individuals, and is commonly associated with inflammatory bowel disease (IBD) (2,3). A third form—checkpoint inhibitor-related pancreatitis (CIP or Type 3 AIP)—has been recently described in patients receiving immune checkpoint inhibitors, typically asymptomatic but may result in pancreatic atrophy (4).
Precise subtyping is critical due to differences in clinical behavior, relapse risk, and treatment response (1,2,3). We present a single-center series comparing clinical, radiologic, and histopathologic characteristics of Type 1 and Type 2 AIP.

Aims & Methods

We retrospectively reviewed 20 patients diagnosed with AIP between 2020–2024 at a tertiary center. Classification followed International Consensus Diagnostic Criteria (1). Diagnostic evaluation included endoscopic ultrasound (EUS), serum IgG4 levels, and contrast-enhanced CT/MRI/MRCP (1,2). EUS-guided fine-needle biopsy (FNB) was performed where malignancy could not be excluded. Histopathology differentiated lymphoplasmacytic sclerosing pancreatitis (LPSP, Type 1) from idiopathic duct-centric pancreatitis (IDCP, Type 2) (2). Data on extra-pancreatic involvement, steroid response, and relapse were collected.

Results

Fifteen patients were diagnosed with Type 1 AIP and five with Type 2. Type 1 patients had a mean age of 63 years and were predominantly male (80%). Obstructive jaundice was the most common presentation. All had elevated serum IgG4. EUS revealed diffusely hyperechoic parenchyma and long-segment ductal narrowing. Histology confirmed LPSP. Extra-pancreatic involvement was observed in 60%, most commonly IgG4 cholangitis. All responded to corticosteroids; 40% relapsed within one year and received rituximab (5).
Type 2 patients had a mean age of 38, with equal gender distribution. Presenting symptoms included abdominal pain and acute pancreatitis. Serum IgG4 was normal in all cases. EUS revealed focal hypoechoic lesions with short-segment narrowing. Histology confirmed IDCP. Two patients (40%) had ulcerative colitis. All achieved remission with steroids, and no relapses were observed (2,3).

Conclusion

This series emphasizes the distinct clinical courses of AIP subtypes. Type 1 AIP represents a systemic IgG4-related disease with high relapse risk, often requiring long-term immunosuppression (5). Type 2 AIP affects younger patients, remains confined to the pancreas, and shows sustained remission after steroid therapy (2,3). Accurate classification using EUS, MRCP, IgG4, and histology is crucial for appropriate management and long-term outcomes (1,2).

References

1. Hart PA, Zen Y, Chari ST. Recent Advances in Autoimmune Pancreatitis. Gastroenterology. 2015;149(1):39–51.

2. de Pretis N, Crinò SF, Amodio A, et al. Type 2 autoimmune pancreatitis: Clinical features and long-term follow-up in an Italian cohort. United European Gastroenterol J. 2024;12(1):50–59.
   

3. Lohr JM, Dominguez-Munoz E, Rosendahl J, et al. United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis (HaPanEU). United European Gastroenterol J.2017;5(2):153–199.

4. Lamarca A, Dhani N, Hubner RA, et al. Immune checkpoint inhibitor-induced autoimmune pancreatitis (Type 3 AIP): Emerging entity with distinct features. Ann Oncol. 2023;34(3):385–393.
   

5. Ghazale A, Chari ST, Zhang L, et al. Treatment of relapsing autoimmune pancreatitis with immunomodulators and rituximab: The Mayo Clinic experience. Clin Gastroenterol Hepatol. 2012;10(6):640–646.

Introduction

Gene therapy holds great promise for the treatment of various diseases. AAVpan mediated SPINK1 overexpression has shown considerable promise in alleviating pancreatitis ^[1]. However, in the case of severe pancreatitis induced by high-dose caerulein administration, the protective effect was not markedly evident possibly due to the insufficient expression of SPINK1. To ensure therapeutic levels of hSPINK1 expression within the safe dosage range of AAV, we introduced the short intron 1 (mini intron1) sequence of hSPINK1 gene to explore whether mini-intron could enhance hSPINK1 expression, and validated the therapeutic efficacy of the AAVpan-hSPINK1-mini intron1 in pancreatitis models.

Aims & Methods

The first intron of human SPINK1 (1.8 kb) conforms to significantly enhance gene expression ^[2]. Considering limited packaging capacity of AAV (4.7 kb), we introduce the first and last 50 base pairs (which do not affect splicing) into hSPINK1 cDNA to construct hSPINK1-mini intron1. First, we investigated whether mini intron could enhance hSPINK1 overexpression: the hSPINK1 expression levels in AAVpan-hSPINK1 and AAVpan-hSPINK1-mini intron1 group were compared using qRT-PCR, Western blot, and trypsin-inhibition assays. The stability of hSPINK1 mRNA in both groups were evaluated following in vitro transcriptional inhibition with actinomycin D. Then, we evaluated the safety of mini intron-mediated hSPINK1 overexpression by detecting hepatic and renal function as well as pancreatic histology. Further, we constructed cerulein-induced severe acute pancreatitis model (250 μg/kg/h) to determine the protective effectiveness of mini intron-mediated overexpression.

Results

The AAVpan-hSPINK1-mini intron1 demonstrated substantially enhanced hSPINK1 expression compared to the AAVpan-hSPINK1. Quantitative analysis revealed a remarkable 30-fold increase in hSPINK1 mRNA levels, 7-fold elevation in protein expression, and 1.5-fold improvement in trypsin-inhibition activity in the AAVpan-hSPINK1-mini intron1 group than those in AAVpan-hSPINK1 group. The addition of actinomycin D resulted in continuous decay of hSPINK1 mRNA in AAVpan-hSPINK1 group, whereas the hSPINK1 mRNA levels in AAVpan-hSPINK1-mini intron1 group remained stable, indicating that mini intron1 effectively stabilized hSPINK1 mRNA. In safety analysis, the histological analysis of liver and pancreas, hepatic and renal function, as well as serum amylase remained within normal levels in both groups for up to 8 weeks post-injection. In the AAVpan-hSPINK1 group, mice with high-dose caerulein-induced SAP exhibited typical pancreatitis phenotypes. In contrast, the AAVpan-hSPINK1-mini intron1 attenuated SAP, implying a dose-dependently protective effect of hSPINK1 overexpression.

Conclusion

The enhanced mini intron could safely enhanced hSPINK1 expression level and trypsin-inhibition activity by improving mRNA stability, representing a promising strategy for optimizing transgene expression and opening up new possibilities for the treatment of severe pancreatitis and potentially other diseases in the field of gene therapy.

References

[1] Wang YC, Mao XT, Sun C, et al. Pancreas-directed AAV8-hSPINK1 gene therapy safely and effectively protects against pancreatitis in mice [J]. Gut, 2024, 73(7): 1142-55.
[2] Kereszturi E, Király O, Sahin-Tóth M. Minigene analysis of intronic variants in common SPINK1 haplotypes associated with chronic pancreatitis [J]. Gut, 2009, 58(4):545-9.

Introduction

Alcohol-induced acute pancreatitis (AP) is a common form of AP, while alcoholic hepatitis (AH) is a severe complication of alcoholic liver disease. Maléth et al. demonstrated that ethanol and fatty acids reduce cystic fibrosis transmembrane conductance regulator (CFTR) expression and activity, worsening alcohol-induced AP. Previously, we showed that ethanol and fatty acids disturb the CFTR-PMCA interaction, leading to disruped intracellular Ca²⁺ balance, exacerbating pancreatitis and potentially hepatitis. Previously Berrocal et al. described that MB reverses the inhibitory effect of Tau on PMCA, suggesting that its beneficial effect is based on the preservation of endogenous Ca²⁺-ATPase activity. Methylene blue (MB) is known for its antioxidant and mitochondrial protective properties, which can also influence intracellular Ca²⁺ regulation. Here we hypothesize that potentiating PMCA with methylene blue could have a protective effect in alcohol-induced AP and AH.

Aims & Methods

This study investigates MB’s effect on alcohol-induced AP severity and its underlying protective mechanisms in alcohol-related diseases. The effects of MB were assessed in mouse pancreatic (MPO), mouse liver (MLO), and human pancreatic ductal organoid (HPO) cultures. Microfluorimetric measurements were performed using an inverted fluorescence microscope. The polarized expression of ion channels was analyzed via immunofluorescence (IF). Gene expression changes were examined using qPCR, while mitochondrial membrane potential was assessed with TMRM and JC-10 staining. Cytotoxicity was evaluated using the CellTiter-Glo® 3D assay. Alcohol-induced AP and AH were modeled in wild-type FVB/N mice. AP was induced by repeated ethanol (EtOH) and palmitoleic acid (POA) injections, while AH was provoked using a 5% ethanol-fed Lieber-DeCarli diet.

Results

Fluorescent Ca²⁺ measurements showed that MB significantly potentiated PMCA activity following EtOH and PA exposure in MPOs, MLOs, and HPOs compared to EtOH-PA-treated groups. Mitochondrial membrane potential measurements confirmed MB’s protective effect. Gene expression analysis revealed no significant differences in CFTR, PMCA4, or ORAI1 expression between EtOH-PA and MB-treated groups. IF staining of PMCA4 demonstrated a defined apical localization in EtOH-PA + MB-treated groups. In experimental AH, MB’s effects were evaluated using Oil Red O and Trichrome staining, along with serum ALAT, ASAT, and triglyceride (TG) levels. In alcohol-induced AP, MB treatment significantly reduced serum amylase levels, oedema, leukocyte infiltration, and necrosis scores compared to the EtOH-POA group.

Conclusion

MB treatment mitigates the harmful effects of EtOH and PA exposure by enhancing PMCA activity, preserving mitochondrial function, and promoting PMCA4’s apical localization. Although no significant changes were observed in CFTR, PMCA4, or ORAI1 gene expression, histological and biochemical analyses highlight MB’s potential in alleviating alcohol-induced AP, as evidenced by reduced oedema, leukocyte infiltration, necrosis scores, and serum amylase levels. These findings suggest MB as a promising therapeutic candidate for protecting cellular and mitochondrial integrity in alcohol-related diseases.

Disclosure

I declare no conflict of interest