The main advantages of exploiting proteases are that both therape

The main advantages of exploiting proteases are that both therapeutics and assays can use specific chemical compounds that are far less expensive than antibodies.

FAP is predominantly associated with disease states, including liver and lung fibrosis, solid tumors, arthritis and atherosclerosis. Substrates of this protease include α-2-antiplasmin, collagen I and Neuropeptide Y. In a diet-induced obesity model, we have found that FAP gene knockout (gko) mice have improved glucose tolerance and liver histopathology, and less insulin resistance and fatty liver, compared R428 to wild type mice on this diet. FAP gko mice resist liver fibrosis. Using our recently published novel FAP activity assay (1), we observed that serum levels of FAP enzyme activity co-segregate with liver stiffness as a measure of fibrosis in two adult cohorts with NAFLD. Cohort 1 contained 108 patients with type 2 diabetes who had transient elastography and Cohort 2 contained 148 patients with morbid Vincristine research buy obesity with liver biopsies. In Cohort 1, serum FAP was an independent risk

factor for median liver stiffness ≥ 10.3 kPa. There was an 8-fold increased odds ratio of having a median liver stiffness of ≥10.3 kPa for those in the highest FAP tertile, compared with subjects in the lowest tertile (p = 0.01). A serum FAP level below 730 pmol AMC/min/mL had a negative Flavopiridol (Alvocidib) predictive value for significant fibrosis of 95%. In Cohort 2, the FAP level was added to the NAFLD fibrosis score (NFS) to correctly reclassify 49% of patients as low risk of severe fibrosis who by NFS had been classified as intermediate risk. Measuring FAP in serum is rapid and should thus become an inexpensive supplement to the NFS to avoid patients being sent for unnecessary further tests. Cell lines derived from FAP gko mice were engineered to express functional

FAP enzyme (FAPe+) vs inactive FAP (FAPe-). Proteomic analyses of these cells showed FAP-specific cleavage of many bioactive peptides. In vitro ‘wound healing’ found that cells with FAP activity exhibited greater cell migration but comparable proliferation and apoptosis. Conclusions: (1) FAP has an important role in glucose and lipid metabolism and in fibrosis progression. (2) Adding a FAP serum measurement to the existing clinical NFS algorithm may correctly diagnose as non-fibrotic about half of the patients who would otherwise receive an uncertain diagnosis and require further testing. (3) FAP enzyme activity causes increased cell migration and so may have roles in wound healing. 1. Keane FM, et al.

Indications for antiviral therapies for persistent HBV infection<

Indications for antiviral therapies for persistent HBV infection

are based on the need for treatment, related to a range of factors such as age, disease stage, degree of liver disease (inflammation and fibrosis), and risk of further progression to liver cirrhosis and/or HCC. The three key criteria that are currently used in determining whether to treat are histological progression, ALT levels and HBV DNA levels. In numerous reports on factors linked to antiviral therapeutic effects, ALT and HBV DNA levels have been shown to influence the progression of the disease, and are also noted as common factors associated with therapeutic effects for both IFN and NAs. Guidelines from the American Association for the Study of GSI-IX mw Liver JQ1 ic50 Diseases (AASLD),[27] the European Association for the Study of the Liver (EASL),[6] the Asia Pacific Association for the Study of the Liver (APASL),[7] and the Japanese Ministry of Health, Labour and Welfare (MHLW) research group[28] all nominate these

factors as patient selection criteria, as shown in Table 7. ALT and HBV DNA levels change over the natural course of the disease, and this must be taken into account when deciding when to initiate treatment. 2) 1–2 × ULN >40 years Family history of HCC liver biopsy 2) <1 × ULN liver biopsy 2) ≤2 × ULN >40 years liver biopsy 2) 1–2 × ULN >40 years Family history of HCC liver biopsy 2) <1 × ULN liver biopsy 2) ≤2 × ULN >40 years liver biopsy 4 (<4a) >1 × ULN (>2 × ULNa) Recently a link has been posited between HBsAg levels and carcinogenesis, with some reports claiming that patients with high HBsAg levels (even when the HBV DNA level is less than 4 log copies/mL following HBeAg seroconversion) have higher rates of further progression and cancinogenesis.[29] However there is still insufficient evidence on the link between HBsAg Dolutegravir research buy levels and long term outcomes, and further studies are required before HBsAg levels can be incorporated into the patient

selection criteria. Recommendations The three key criteria currently used to determine whether to treat persistent HBV infection are histological progression, ALT levels and HBV DNA levels. The question of whether HBsAg levels should be added to these criteria requires further studies. Indications for treatment for chronic hepatitis include abnormal ALT levels, high HBV DNA levels, and presence of histological liver disease. Treatment is therefore not indicated when ALT levels are within the normal range and histological disease is mild or absent altogether – in other words, for HBeAg positive asymptomatic carriers during the immune tolerance phase and inactive carriers following HBeAg seroconversion. Note that in cases of HBeAg-positive chronic hepatitis with elevated ALT levels, there is a 7–16% probability (in annual terms) of the HBeAg seroconversion over the natural course of the disease.

3) Expression of wildtype OCT1 induced quinine-sensitive TEA upt

3). Expression of wildtype OCT1 induced quinine-sensitive TEA uptake by HCC and CGC cells (Fig. 4A-C). This ability was also

observed in S14F, L160F, G401S, and P197S variants, whereas it was partly or completely lost in the rest of detected variants. To validate this transport assay, wildtype OCT1 was also expressed in frog oocytes. This maneuver markedly enhanced their ability to take up, in a quinine-sensitive manner, both TEA (Fig. 4D) and sorafenib (Fig. 4E). Moreover, the expression of the novel variants in this model also confirmed the lack of ability of R61S fs*10 and C88A fs*16 to transport sorafenib, which this website was maintained in P197S (Fig. 4E). The effect of SNPs on the targeting to the plasma membrane was investigated by immunodetection of the V5-tag placed in the constructs. In this set of experiments, we also included C88R

and S189L, whose effects on protein targeting were not known, and G465R, whose functional consequences are controversial. Although G465R has been described as a loss-of-function variant,[24] our results indicate that when expressed in HCC and CGC cells this variant has a reduced, but not abolished, OCT1-mediated transport (Fig. 4A-C). When G465R was investigated in Alexander cells, similarly to wildtype OCT1, it was targeted to the plasma membrane (Fig. 5). In contrast, both C88R and S189L were mainly localized intracellularly BAY 73-4506 molecular weight (Fig. 5). This was consistent with the abolished ability of the latter two variants to mediate TEA uptake (Fig. 4). Regarding the novel OCT1 variants, both R61S fs*10 and C88A fs*16, which encode truncated proteins (Fig. 2B), resulted in impaired targeting to the plasma membrane (Fig. 5) and lack of the Farnesyltransferase ability to mediate sorafenib uptake by oocytes (Fig. 4E) and TEA uptake by transfected cells (Fig. 4A-C). In contrast, the functional variant P197S resulted in an entire OCT1 protein targeted to the plasma membrane (Fig. 5). Based on studies addressing the dose- (Fig. 3) and time- (Supporting Fig. 1) dependent sensitivity of Alexander cells to sorafenib, short-term (6 hours) exposure

of HCC and CGC cells to sorafenib was carried out (Fig. 6). Under these conditions only OCT1 variants with a relatively well-preserved ability to mediate TEA transport (Fig. 4) were able to induce sensitivity to sorafenib in all cells assayed (Fig. 6). Regarding the SNPs identified here, P197S, but not R61S fs*10 or C88A fs*16, enhanced the sensitivity to sorafenib in cells expressing these variants (Fig. 6). Interestingly, OCT1 inhibition with quinine reduced, in a dose-dependent manner, the sensitivity to sorafenib due to the expression of functional variants of this transporter. Selective identification of loss-of-function SNPs was performed by RT-QPCR in a larger series of HCC and CGC biopsies (Table 2). The abundance of each variant was normalized by the abundance of total OCT1 mRNA.

21 In conclusion, the more potent effects of PAS compared to OCT

21 In conclusion, the more potent effects of PAS compared to OCT on hepatorenal cystogenesis observed in this study are likely related to a combination of features of both the drug and the cystic cell phenotype including: (1) a broader range of SSTRs targeted by PAS; (2) a higher affinity of PAS

to SSTR3 and SSTR5 (expression of which in cystic cholangiocytes is unchanged compared to control); and (3) the extended half-life CT99021 in vivo of PAS. Our data suggest that PAS may be more effective for the treatment of PLD and PKD than OCT. A clinical trial (NCT01670110) to assess the effectiveness of PAS in hepatorenal cystogenesis in patients with ADPKD and ADPLD is now under way at our institution. Additional Supporting Information may be found in the online version of this article. “
“MicroRNA-122 (miR-122) is a liver-specific microRNA whose expression is specifically turned on in the mouse liver during embryogenesis, thus it is expected to be involved in liver development. However, the role of miR-122 in liver development and its potential underlying

mechanism remain unclear. Here, we show that the expression of miR-122 is closely correlated with four liver-enriched transcription factors (LETFs)—hepatocyte nuclear factor (HNF) 1α, HNF3β, HNF4α, and CCAAT/enhancer-binding protein (C/EBP) α—in the livers of developing mouse embryos and in human hepatocellular carcinoma (HCC) cell lines. Correspondingly, promoter analysis revealed that these

LETFs are coordinately involved in the transcriptional regulation of miR-122, and three HNFs directly bind to the miR-122 promoter CP-690550 manufacturer as transcriptional activators. Using a luciferase reporter system, we identified a group of miR-122 targets involved in proliferation and differentiation regulation. Among these targets, the most prominently repressed target was CUTL1, a transcriptional repressor of genes specifying terminal differentiation in multiple cell lineages, including hepatocytes. We show that CUTL1 expression is gradually silenced at the posttranscriptional level during mouse liver development. Overexpression and knockdown studies both showed that miR-122 repressed CUTL1 protein expression in HCC cell lines. Finally, we show that the stable restoration of miR-122 in HepG2 cells suppresses cellular proliferation and activates SB-3CT the expression of three hepatocyte functional genes, including the cholesterol-7α hydroxylase gene (CYP7A1), a known target of CUTL1 in hepatocytes. Conclusion: Our study provides a model in which miR-122 functions as an effector of LETFs and contributes to liver development by regulating the balance between proliferation and differentiation of hepatocytes, at least by targeting CUTL1. HEPATOLOGY 2010 MicroRNAs (miRNAs) are a family of small, noncoding RNAs that have emerged as posttranscriptional regulators of gene expression in animals and plants.

Platelet, prothrombin time

Platelet, prothrombin time SCH772984 (PT), activated partial prothrombin time (APTT) and fibrinogen were measured. Also, plasma samples from the patients were

analyzed for the levels of antithrombin III (AT-III), protein C (PC), protein S (PS), D-dimer, tissue-type plasminogen activator as well as plasminogen activator inhibitor-1. Statistical analyses were carried out to evaluate the correlation of specific variations with the disease status. Results:  In general, the higher Child-Pugh scores, indicating the aggravation of hepatic impairment of the patients, correlated well with the prolonged PT/APTT and increased D-dimer, as well as decreased platelet, fibrinogen, PC and AT-III levels in the serum. Furthermore, we found that the PC, PS and D-dimer levels in PVT patients were 2.32 ± 0.72 mg/L, 17.14 ± 3.62 mg/L and 0.99 ± 0.36 mg/L, respectively, both representing a significant difference compared with those in the control group without PVT. Logistic regression model shows that the odds ratio value of one unit of Alvelestat increase of PC and D-dimer were 0.48 and 15.57. Conclusions:  Cirrhotic patients displayed dysfunctions in the coagulation, anti-coagulation and fibrolytic systems. The

development of PVT in these patients may be independently associated with the decrease of PC, PS and D-dimer. Furthermore, decreasing PC and increasing D-dimer may be risk factors inducing PVT in cirrhotic patients. “
“In mammals, circadian rhythms are essential for coordinating the timing of various metabolic processes. The Clock gene regulates diurnal plasma triglyceride fluctuation through nuclear receptor small heterodimer partner (Shp, Nr0b2). Given that SHP is a critical regulator of metabolism in the liver, it is unknown whether SHP is necessary to coordinate metabolism and circadian rhythms. Methods: Shp+/+ and Shp−/− mice on a C57BL/6 background (n=3-5/group) were fed a standard chow diet and water ad libitum. Serum and livers were collected

at zeitgeber time (ZT) 2, 6, 10, 14, 18 and 22. In vivo and in vitro assays include: RNA-sequencing (RNA-seq), qPCR, VLDL production, adenovirus overexpression and siRNA knockdown, serum parameters, circadian locomotor Bcl-w activity, oil-red O staining, transient transfection, luciferase reporter assay, ChIP assay, gel-shift assay, Co-IP, Western blots. Results: Shp-deficiency had a robust global impact on major liver metabolic genes. Several components of the liver clock including Pgc-1α, Npas2 and Rorα/γ were sharply induced in Shp-/- liver. At the molecular level, SHP inhibited Npas2 gene transcription and promoter activity through interaction with Rorγ to repress Rorγ transactivation and by interacting with Rev-erbα to enhance its inhibition of Rorα activity. Conversely, Npas2 controlled the circadian rhythm of Shp expression by binding rhythmically to the Shp promoter, which was enhanced by NADH, but not NADPH.

H2O2 also stimulated expression of Gadd45b in cultured cells Con

H2O2 also stimulated expression of Gadd45b in cultured cells. Conclusion: PPARα indirectly induces the Gadd45b gene in liver through promoting degradation of the repressor STAT3 as a result of elevated oxidative stress. (Hepatology 2014;59:695–704) “
“Controlled attenuation parameter (CAP) is a novel ultrasound-based

elastography method for detection of steatosis severity. This meta-analysis aimed to assess the performance of CAP. PubMed, the Cochrane Library, and the Web of Knowledge were searched to find studies, published in English, relating to accuracy evaluations of CAP for detecting stage 1 (S1), stage 2 (S2), or stage 3 (S3) hepatic steatosis which was diagnosed by Cobimetinib price liver biopsy. Sensitivities, specificities, and hierarchical summary receiver operating characteristic (HSROC) curves were used to examine CAP performance. The clinical utility of CAP was also evaluated. Nine studies, with 11 cohorts were analyzed. The summary sensitivities and specificities values were 0.78 (95% confidence interval [CI], 0.69–0.84) and 0.79 (95% CI, 0.68–0.86) for ≥ S1, 0.85 (95% CI, 0.74–0.92) and 0.79 (95% CI, 0.71–0.85) for ≥ S2, and 0.83 (95% CI, 0.76–0.89) and 0.79 (95% CI, 0.68–0.87) for ≥ S3. The HSROCs were 0.85 (95% CI, 0.81–88) for ≥ S1, 0.88 (95% CI, 0.85–0.91) for ≥ S2, and 0.87 (95% CI, 0.84–0.90) for ≥ S3. Following a “positive” measurement (over the threshold value) for

≥ S1, ≥ S2, and ≥ S3, the corresponding post-test probabilities for the presence of steatosis (pretest probability was 50%) were 78%, 80% and 80%, respectively; if the values were below these thresholds (“negative”

results), the post-test probabilities Selleckchem Rapamycin were 22%, 16%, and 17%, respectively. CAP has good sensitivity and specificity for detecting hepatic steatosis; however, based Selleckchem Idelalisib on a meta-analysis, CAP was limited in their accuracy of steatosis, which precluded widespread use in clinical practice. “
“It is known that plasma phospholipid transfer protein (PLTP) activity influences lipoprotein metabolism. The liver is one of the major sites of lipoprotein production and degradation, as well as of PLTP expression. To address the impact of liver-expressed PLTP on lipoprotein metabolism, we created a mouse model that expresses PLTP in the liver acutely and specifically, with a PLTP-null background. This approach in mouse model preparations can also be used universally for evaluating the function of many other genes in the liver. We found that liver PLTP expression dramatically increases plasma levels of non–high-density lipoprotein (HDL) cholesterol (2.7-fold, P < 0.0001), non-HDL phospholipid (2.5-fold, P < 0.001), and triglyceride (51%, P < 0.01), but has no significant influence on plasma HDL lipids compared with controls. Plasma apolipoprotein (apo)B levels were also significantly increased in PLTP-expressing mice (2.2-fold, P < 0.001), but those of apoA-I were not.

Each sequence is identified by means of its sample tag and assign

Each sequence is identified by means of its sample tag and assigned to the file corresponding to the sample of origin by PyroClass. PyroMute then uses a number of quality filters to eliminate unreliable sequences. Sequence portions with a low Phred quality

score are removed.[21] Too-short sequences (<50 bp), including those generated by the previous filtering step, are also eliminated. Sequences are then aligned by means of a modified version of Smith-Waterman's algorithm,[22] in which the resolution of alignment matrices is accelerated and the identification of insertions and deletions (so-called indels) and the correction of length errors in homopolymeric sequences are improved. Quality filters subsequently remove Palbociclib purchase sequences with an identity score <80% relative to

the consensus sequence of the patient’s baseline sample. In the next step, an array of nucleotide substitutions and corresponding Phred quality scores is built and tested by means of a modified statistical test based on the binomial law[23] to eliminate sequences that are too rare and/or of poor quality, likely the result of sequencing errors. Finally, the remaining nucleotide sequences, considered reliable, BMN673 are converted into amino acid sequences and their respective frequencies are calculated. Each amino acid change is ascribed to its sequence of origin to subsequently analyze linkages between substitutions. PyroDyn uses data generated by PyroMute to detect and quantify increases or decreases in amino acid substitutions through mathematical modeling of their variations and correlation with an exponential growth model, which provided the best fit with the observed data. Briefly, in every patient, the frequency of each amino acid at each position is established at each time point. Assuming that HBV resistance is governed Meloxicam by exponential outgrowth of selected resistant variants, the best-fit curve is automatically drawn for each substitution

in each patient. Combined cut-off values have been established (r2 > 0.8 and growth rate > mean of the growth rates of all substitutions at all positions plus 2 standard deviations [SDs]) to differentiate significant exponential changes from polymorphism fluctuations. Finally, PyroLink has been designed to analyze genetic linkages between amino acid substitutions that have been selected by PyroDyn and to characterize the dynamics of viral populations bearing one or several amino acid substitutions over time. Briefly, linkages are automatically sought for every substitution identified with PyroDyn as exponentially growing or decreasing over time. Then, sequences that span all of the identified substitutions are extracted from PyroMute data and, when more than 100 such sequences are available, the proportion of sequences bearing no (WT), one, two, three, and so on, substitutions is calculated and used for subsequent analyses.

Disclosures: Hidemi Goto – Grant/Research Support: MSD, Roche, Ba

Disclosures: Hidemi Goto – Grant/Research Support: MSD, Roche, Bayer, Bristol-Myers, Eisai, Ajinomoto, Otsuka, Astra, Tanabe The following people have nothing to disclose: Takashi Honda, Masatoshi

Ishi-gami, Fangqiong Luo, Yoji Ishizu, Teiji Kuzuya, Kazuhiko Hayashi, Yoshiharu Shimomura Non-alcoholic steatohepatitis (NASH) is a severe form of non-alcoholic fatty liver disease characterized by lobular inflammation, hepatocellular ballooning and fibrosis with an inherent risk for progression to cirrhosis and hepatocellular carcinoma (HCC). Mitochondrial dysfunction appears to play a role in the progression from simple steatosis to NASH. L-carnitine (L-b-hydroxy-g-N-trimethylaminobutyric acid), an essential nutrient that converts fat into energy in mitochondria, has been shown to ameliorate liver damage. The aim of the present study was to explore the preventive and therapeutic effect of L-carni-tine in selleck NASH Selleck Roxadustat model mice. Eight-week-old male STAM mice, a NASH-cirrhosis-hepatocarcinogenic model, were divided into 3 experimental groups and fed as follows: 1) high-fat diet (HFD) (control group); 2) HFD mixed with 0.28% L-carnitine (L-carnitine group); and 3) HFD mixed with 0.01% a-tocopherol (a-tocopherol group). After 4 or 8 weeks, the mice were killed. Blood samples and livers were collected, and hepatic tumors were counted

and measured. Livers were subjected to histological study, immunohistochemical staining of 4-hydroxynonenal and ferritin, determination of 8-OHdG levels, RT-PCR for multiple genes, not and metabolomic analysis. The intestinal microbiome was also analyzed. L-carnitine increased hepatic expression of genes related to long-chain fatty acid transport, mitochondrial β-oxidation

and antioxidant enzymes following suppression of hepatic oxidative stress markers and inflammatory cytokines in NASH, and mice treated with L-carnitine developed fewer liver tumors. Although a-tocopherol resulted in NASH improvement in the same manner as L-carnitine, it increased periodontitis-related microbiotic changes and hepatic iron transport-related gene expression and led to more extensive hepatocarcinogenesis. Conclusion: L-carnitine prevents progression of non-alcoholic steatohepatitis in a mouse model by upregulating the mitochondrial β-oxidation and redox system. Disclosures: Kazuhide Yamamoto – Advisory Committees or Review Panels: Shionogi Pharmaceutical Co; Grant/Research Support: Tanabe Mitsubishi Co, MSD, Chugai Pharmaceutical Co, Esai Co The following people have nothing to disclose: Hisashi Ishikawa, Akinobu Takaki Background: Non-alcoholic steatohepatitis (NASH) is a progressive liver disease leading to liver cirrhosis. NASH is a hepatic representation of metabolic syndrome, which is characterized by obesity, diabetes, hyperlipidemia, and hypertension.

The main contribution of this work, as discussed below, is the id

The main contribution of this work, as discussed below, is the identification of a new tool, the determination of MMN area, that is useful to diagnose and follow the course of attention deficits and MHE in patients with liver cirrhosis. The data reported also show that patients who do not show MHE, as detected using the PHES, already have some psychomotor slowing,

as reflected ERK inhibitor by the reduced number of words and colors in the congruent and neutral tasks of the Stroop and increased time in the bimanual coordination test. This indicates that there are some mild neurological alterations not detected with the PHES and are detected by other procedures. This agrees with a report38 showing that ataxia, tremor, and slowing of finger movements are early markers for cerebral dysfunction in cirrhotic patients, even before alterations in performance in the PHES become detectable. This suggests that the PHES battery detects some “subtypes of MHE,” but not others. Patients with MHE show much stronger alterations in the Stroop tasks and in bimanual coordination

than patients without MHE. Moreover, they show other alterations not present in patients without MHE, including reduced area in the MMN wave, reduced performance in Map Search selleck chemicals and elevator tests, indicating impairment of selective and sustained attention, respectively, and reduced performance in the visuomotor coordination test. This supports that

patients with O-methylated flavonoid MHE have remarkable attention deficits. Reduction of MMN area in patients with MHE is specifically associated with reduced performance in attention tests, but not with other alterations, such as motor coordination. This is supported by the results of patients who improved or worsened in the follow-up study. Patients PR51, A41, and A28 had MHE, mainly the result of impairment of attention (mainly NCT-B; Table 4). In the follow-up, they improved in attention tests, resulting in resolution of MHE and normalization of MMN area, which increased from 49 ± 3 to 130 ± 25. In contrast, patient PR27 did not show impairment in attention tests or in the MMN area (108.5) in the first study, and MHE was caused by impaired motor coordination, of which improvement led to resolution of MHE in the second study without changes in MMN area. This supports that reduction of MMN area in patients with MHE is associated with reduced performance in attention tests, but not with other alterations, such as motor coordination. Moreover, in the second study, MMN area was reduced in those patients (A40, PR41, A49, and A23) showing worsened performance in attention tests (Table 4; Fig. 4). MMN area selectively predicts performance in attention tests and MHE, as shown by logistic regression analyses.

All patients with haemophilia A/B and persistent inhibitors shoul

All patients with haemophilia A/B and persistent inhibitors should therefore be offered immune tolerance induction (ITI) EMD 1214063 research buy to eliminate the inhibitor and to restore normal clinical responsiveness

to FVIII [5]. Immune tolerance induction (ITI) should be started soon after inhibitor development, but should be delayed until the titre has fallen below 10 BU mL−1. Inhibitor titre <10 at the start of ITI was the most powerful predictor of successful ITI in both the NAITI and IITI studies [6,7] and the inhibitor takes a median of 5 months to fall to this level from the time of diagnosis [8]. The NAITI showed that response to ITI did not fall off until 5 years after inhibitor diagnosis [6]. Inhibitors that fail to fall to Crizotinib order this level over 12–24 months respond poorly to ITI. Regimens in which the start has been delayed until the inhibitor titre has fallen to <10 BU mL−1 have been notably successful [9–11]. A central venous access device (CVAD) is usually inserted to facilitate ITI [8]. Some centres attempt ITI without the use of a CVAD, since infection has been

reported to adversely affect the outcome of ITI. Recent results from the IITI study suggest that infection has no effect on either the proportion achieving tolerance or the time taken to become tolerant, at least in good-risk patients [8]. Implantable CVADS are significantly less likely to become infected than external lines such as Hickman or Broviac catheters [8,12,13]. Immune tolerance is usually initiated using the product used by the patient at the time of inhibitor development. Uncontrolled data have suggested low-purity pdFVIII may induce tolerance more effectively than rFVIII [14–17]. However, the reported success-rates for ITI do not appear to be influenced by the product-type used [18–20]. A randomized comparison of high-dose pdFVIII vs. rFVIII for ITI in poor-risk patients

is in progress [17]. The choice of optimal ITI regimen remains problematic. The IITI and NAITI suggest that poor-risk patients (Peak titre >200 BU, Starting titre >10 BU) are best tolerized using a high-dose regimen (100–200 IU kg−1 Cyclin-dependent kinase 3 FVIII) [6,7]. These registries and the ITI study suggest that high-dose and low-dose (50 IU kg−1 3 X weekly) regimens are equally effective in inducing tolerance [6–8,21,22]. There is no evidence that 200 IU kg−1 day−1 are superior to 100 IU kg−1 day−1. Low-dose ITI takes longer to achieve a negative Bethesda titre, however [6,8], and is associated with significantly greater intercurrent bleeding in early ITI, before the Bethesda titre becomes negative, when 85% of intercurrent bleeding on ITI takes place [8]. Many clinicians may consider that all patients requiring ITI should be started with high-dose to minimize intercurrent bleeding. Once the Bethesda titre has become negative, it may be argued that the dosing could be tailed down in stages to a low-dose regimen.