16, 29 The data presented here suggest that
adjunctive CD25 blockade might be expected to improve outcomes in steroid-resistant AH but caution is required before translating this finding into the in vivo setting. However, there is clearly a need for new intervention strategies. In patients with AH, immunomodulators other Rapamycin ic50 than steroids have not been successful at improving outcome; a trial of high-dose infliximab (anti-tumor necrosis factor [TNF]) at 10 mg/kg was stopped early due to increased mortality in the treatment group43 and Etanacept44 has also been proven to be ineffective at enhancing immunosuppressive treatment and leads to a poorer outcome. Sharma et al.45 have recently reported improved MdF at 28 days in patients with SAH receiving one dose (5 mg/kg) of infliximab as monotherapy. In this particular study, a reduction in serum bilirubin at day 7 was significantly associated with a better outcome. However, even in the absence of steroid use in this study, the immunosuppressive profile of infliximab alone may inhibit its clinical use in AH. Overall, five patients in the study (26%) developed infection. Three patients recovered with treatment but two patients (10%) died (one with pneumonia INCB024360 cell line leading to sepsis and
the other of disseminated tuberculosis). The prospective study design, inclusion of consecutive cases, biopsy check details confirmation of the diagnosis, complete follow-up of all cases to 6 months, and the use of an objective primary outcome measure (survival at 6 months) represent strengths of the current study. In all cases the measurement of steroid resistance was performed before
the clinical outcome was known. Potential weaknesses include the lack of a strictly controlled treatment regime, but all subjects were treated at a single center where a standard treatment protocol exists, and the managing clinicians were unaware of the results of the steroid sensitivity measurement results. The overall mortality rate in the present cohort was high—around 50% at 6 months. However, it should be noted that many of these individuals survived their inpatient treatment (2/11; 18%) but died later of complications of decompensated liver disease either at home or during a subsequent hospital admission. A recent review of mortality in AH showed an overall mortality rate of 34.19%, with a median observation time of 160 days (range, 21-720). The three most common causes of death were hepatic failure, gastrointestinal bleeding, and infection.46 Rates of intrinsic (in vitro) steroid resistance within our cohort were also high, at 55% (Imax <60%), which contrasts with previous series rates of 25%-30% in other diseases.