Terlipressin plus albumin was associated with greater improvement in renal function vs albumin alone in patients with cirrhosis and HRS-1. Patients had similar rates of HRS reversal with terlipressin as they did with albumin. ClinicalTrials.gov no: NCT01143246.

Background Hepatitis C virus (HCV) is the most common cause of mixed cryoglobulinemia syndrome (MCS). The efficacy and safety of all-oral directly-acting antiviral (DAA) therapy in HCV-associated MCS (HCV-MCS) is largely unknown. Methods Case series of patients with HCV-MCS who were treated with sofosbuvir-based regimens and historical controls treated with pegylated interferon and ribavirin in a single healthcare network. HCV-MCS was defined by circulating cryoglobulin associated with systemic vasculitis symptoms. Renal involvement (N=7) was established by kidney biopsy (N=5) or by ≥ 2 of the following clinical findings: reduced kidney function, proteinuria, or hematuria with other causes excluded (N=2). Results Twelve patients received DAA therapy between December 2013 and September 2014. Median age was 61 years, 58% male, 50% had cirrhosis. Median baseline serum creatinine was 0.97 mg/dL (range 0.7 – 2.47 mg/dL.) Four patients received Rituximab concurrent with DAA therapy. Sustained virological response rate at twelve weeks (SVR12) was 83% overall. Patients with glomerulonephritis who achieved SVR12 experienced an improvement in serum creatinine and reduction in proteinuria. Cryoglobulin levels decreased in 89% of patients, with median percent decreasing from 1.5% to 0.5%, and completely disappearing in 4 of 9 cases who had cryoglobulins measured after treatment. Serious adverse events were infrequent (17%). In contrast, the historical cohort treated with pegylated interferon and ribavirin experienced only 10% SVR12 rate with 100% experiencing at least one adverse event, and 50% experiencing premature discontinuation due to adverse events. Conclusion SVR12 rates for sofosbuvir-based direct acting antiviral regimens in HCV-MCS were 83%, significantly higher than historical controls treated with pegylated interferon and ribavirin. Patients with glomerulonephritis experienced improvement in renal function, including those not concomitantly treated with immunosuppression.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first emerged in the fall of 2019 and has since become a global pandemic. This virus, which causes coronavirus disease 2019 (COVID-19), has led to over 4.8 million infections and 316,000 deaths worldwide to date. 1 Prior studies have demonstrated advanced age, chronic cardiopulmonary diseases, immunosuppression and obesity as potential risk factors for worse clinical outcomes among patients with COVID-19-with mortality often driven by disease-associated cardiopulmonary failure. 2,3 While the virus primarily affects the lungs, experience from China and the USA also suggests that SARS-CoV-2 may impact extra-pulmonary systems, including the gastrointestinal and hepatobiliary systems. 4,5 Chronic liver disease (CLD), including non-alcoholic fatty liver disease (NAFLD), alcohol-related liver disease and chronic viral hepatitis, comprise a large global burden of disease. 6 Published reports indicate that up to half of adults hospitalized with COVID-19 have abnormal aminotransferase levels and 2%-11% have underlying liver conditions. 7-12 A meta-analysis of 11 observational studies of 2034 adults with COVID-19 from China revealed an overall CLD prevalence of 3%. 13 However, there are limited reports on the nature of liver disease among COVID-19 patients and it remains unclear how underlying CLD influences hepatic injury and clinical outcomes in these patients. Higher rates of liver dysfunction have been observed in patients with more severe cases of COVID-19 and among those requiring admission to the intensive care unit (ICU). 12,14 Given the high prevalence of NAFLD in the USA, as well as metabolic syndrome and

Gastrointestinal toxicities are among the leading causes of immune-related adverse effects of checkpoint blockade. These adverse events can be severe enough to require interruption or withdrawal of immune checkpoint blockade therapy. Patients with immune-related adverse effects require early recognition with an evaluation to rule out alternative etiologies and effective management to minimize complications. This article reviews the gastrointestinal and hepatic toxicities of the antibodies that target immune checkpoints CTLA-4 and PD-1/PD-L1 and provides an approach to their diagnosis and management.