3%. Likewise

the AUROC of vascular diverging angle for discriminating advanced liver fibrosis from mild to moderate liver fibrosis was 0.873 with sensitivity of 94.1% and specificity of 75.0%. Conclusions: The present results indicated that Superb Micro-vascular Imaging potentially predicts hepatic fibrosis by detecting fine vessels present in the vicinity of liver surface, even though further investigation is needed in a large number of patients. Disclosures: Takeshi Sato – Employment: Toshiba Medical Systems Corporation The following people have nothing to disclose: Nobuko Koyama, Jiro Hata, Noriaki Manabe, Hiroshi Imamura, Ken Haruma, Keisuke Hino Background: Liver biopsy is the gold standard used to diagnose hepatic fibrosis/steatosis. Transient elastography which is used in some centers is a non-invasive test selleck chemicals preferred by patients. We investigated the use of a novel technique called shear wave elastography (SWE). Aims:To determine the optimal location for obtaining SWE measurements, compare it with liver biopsy and to investigate the accuracy of grayscale sonography hepatorenal index (HRI) in screening for hepatic steatosis. Methods:100 consecutive patients undergoing percutaneous liver biopsy between Feb 2014 and May 2014 were recruited from the outpatient clinics of Ochsner Medical Center. SWE measurements were obtained in hepatic segments V/VI and VII/

VIII. HRI beta-catenin inhibitor was calculated at the midportion of the right kidney. A single liver pathologist determined liver fibrosis (METAVIR) and steatosis. Analysis of Variance (ANOVA) was employed to analyze the degree of fibrosis and SWE measurements and Student’s t-test was used to analyze HRI and degree of steatosis. Results: Patient characteristics: We investigated 57 males and 43 females- (40 OLT recipients). 54 patients had HCV infection, 14 had hepatomegaly alone and 32 had a variety of autoimmune liver diseases. SWE measurements: There was no correlation found between SWE measurements and age, gender, AST/ALT, bilirubin and the presence of steatosis. There was however, a statistically significant difference in the mean SWE seen in patients with a BMI<40 vs BMI>40 (p<0.0001).

OLT patients had similar SWE values to non-OLT patients. There was no statistically significant SSR128129E inter-observer variation (3 technologists). SWE measurements and fibrosis: Segment VII/VIII SWE was able to distinguish normal liver (p< 0.01) and stage 1 fibrosis (0.008) from stage 4 fibrosis. Similar results were seen with segment V/VI SWE. When SWE measurements for both areas were combined, there was a significant difference between stage 1 vs stage 3 (p<0.011), stage 1 vs stage 4 (p< 0.005) and stage 0 vs stage 4 (p< 0.033). HRI measurements: HRI measurements for patients with <5% steatosis vs those with >5% steatosis were different (P<0.0002). Summary: a) SWE can distinguish normal liver/mild fibrosis from cirrhosis in both non-OLT and OLT patents. b) BMI>40 may affect SWE measurements.

Most subjects included in the study were Caucasian. The study was approved by the local ethics committee, and all patients in the study gave informed consent before tissue donation. Peripheral blood mononuclear cells (PBMCs) were isolated GSK3235025 mw via Ficoll density gradient centrifugation. Single cell suspensions from TFL and tumor were obtained via tissue digestion. Briefly, fresh tissue was cut into small pieces and digested with 0.5 mg/mL of collagenase (Sigma-Aldrich, St. Louis, MO) and 0.1 mg/mL of DNase I (Roche, Indianapolis, IN) for 30 minutes at 37°C. Cell

suspensions were filtered through cell strainers and mononuclear cells (MNCs) were obtained by Ficoll density gradient centrifugation. Viability was determined by trypan blue exclusion. Formalin-fixed, paraffin-embedded sections (6 μm) from liver tissues were used for immunohistochemistry. Deparaffinized sections were boiled for 10 minutes in Tris (10 mM)/ethylene

diamine tetraacetic acid (1 mM) (pH 9.0) buffer for antigen retrieval. The sections were labeled with 10 μg/mL of anti-FoxP3 antibody (clone 236A/E7; AbCAM, Cambridge, buy DZNeP UK). Endogenous peroxidase blockage and the secondary reagent used to detect the primary antibody were from the EnVision+ System-HRP kit (Dako, Denmark). Tissue sections were counterstained with hematoxylin. PBMCs and MNCs isolated from TFL or tumor were analyzed for expression of surface and intracellular markers using the following anti-human antibodies: anti-ICOS, anti-GITR, anti-Ki67, anti-CD25, anti-CTLA-4, anti-granzyme B, anti-Perforin, anti-CD8, anti-HLA-DR, anti-FoxP3, anti–TNF-α, anti-CD4, anti-CD3, anti-CD56, anti-CD45, and anti-CD25 (see Supporting Information for details). Cells were analyzed in a FACSCanto II system (BD Biosciences, San Diego, CA). Tumor lysates were generated from freshly dissected tumors by five cycles of freezing and BCKDHA thawing in phosphate-buffered saline, followed by filtration (0.2 μm), and normal liver (NL) lysates were made by the same method from TFLT tissue. Myeloid dendritic cells (mDCs) were isolated from PBMCs by positive selection (BDCA-1 dendritic cell isolation kit, Miltenyi

Biotec, Germany). mDCs were cultured overnight with media or 10 μg/mL autologous tumor lysate (TL), NL, or cytomegalovirus (CMV) antigens (Microbix Biosystems, Mississauga, Ontario, Canada) in the presence of 10 ng/mL of granulocyte-macrophage colony-stimulating factor (GM-CSF) (Miltenyi Biotec) and 0.1 μg/mL of polyinosinic:polycytidylic acid (InvivoGen, San Diego, CA). CD4+CD25− cells were isolated from PBMCs or TILs that were kept overnight at 4°C in medium supplemented with 10% fetal bovine serum, by magnetic sorting (Miltenyi Biotec). CD4+CD25− T cells were labeled with 0.1 μM carboxyfluorescein diacetate succinimidyl ester (CFSE, Invitrogen) and cocultured with autologous mDCs, pulsed with media, TL, NL, or CMV, at a ratio of 1:10 for 5 days in round-bottom 96-well plates with at least 5 × 104 CD4+CD25− T cells.

Huh7.5.1 cells, a human hepatocyte cell line that supports replication of HCV in vitro, were a gift from Apath (Brooklyn,

NY). Huh7.5.1 cells were grown in RPMI 1640 medium (Invitrogen, Carlsbad, CA) supplemented with 10% fetal bovine serum (FBS), L-glutamine, penicillin, and streptomycin. Cryopreserved primary human hepatocytes (PHHs) from six individual donors were purchased from ZenBio (Research Triangle Park, NC) and used in the current study. Peripheral blood was collected in BD Vacutainer tubes Dorsomorphin chemical structure (containing 143 USP units of sodium

heparin per 10-mL tube, BD, Franklin Lakes, NJ) from patients chronically infected with HCV or from healthy donors. Plasma was separated from blood cells by centrifugation and then stored at −80°C until use. Plasma HCV viral loads were measured using the COBAS TaqMan HCV Test (Roche, Pleasanton, CA) in a certified clinical laboratory. Anti-HCV E2 Abs in these plasma samples were titrated by an enzyme-linked immunosorbent assay (ELISA) assay modified from a previous report19 (and Supporting Material). MI-503 cost Informed consent was obtained from each participant and all investigational protocols were approved by Institutional Review Boards for Human Research at the Indiana University School of Medicine (Indianapolis, IN). JFH-1, a unique HCV genotype 2a replicon derived from a viral isolate of a patient with

fulminant HCV, was a gift from Apath (Brooklyn, NY). JFH-1 was inoculated into Huh7.5.1 cells at a multiplicity of infection (MOI) of 1. On day 5 of incubation cell-free supernatants were collected by Tyrosine-protein kinase BLK a centrifugation at 15,000 rpm at 4°C for 10 minutes and then filtered through a 0.2-μm-pore-size filter, followed by virus purification using 20% versus 60% two-layer sucrose gradient ultracentrifugation as described.12 Four fractions collected by aspiration from the top were subjected to: (1) ELISA for measuring HCV core concentration, (2) real-time quantitative reverse-transcription polymerase chain reaction (qPCR) for measuring viral RNA copies, and (3) western blot for measuring CD59. Fraction 3 was also subjected to HCV capture.

0.34 A recent Selleck Navitoclax hospital-based

study in Sri Lanka reported an incidence of UC of 0.6935 and CD of 0.09. No IBD incidence data are currently available from Singapore. In the West, the incidence of CD has overtaken that of UC in a number of studies.8–12 Traditionally in low incidence areas UC emerges first followed by CD, but over time the incidence of CD ultimately matches, and may eventually overtake, the incidence of UC.2,44 A recent review from China compared the crude incidence for CD and UC in the Chinese medical literature over two time periods: 1989 to 2003 and 2004 to 2007. In both periods, there were more cases of UC, but a relative increase in CD was seen, with the UC to CD ratio dropping from 41 to 15 over time.45 Similarly, a study from South Korea has reported a higher incidence of UC than CD, but the rise in incidence of CD between 1986 and 2005 was more rapid than that of UC, with the ratio of the incidence of UC to CD dropping from 6.8 to 2.3 between 1986 Quizartinib purchase and 2005.13 A recent pediatric study from Korea demonstrated that a rising incidence of IBD diagnosis was more marked for CD, with a new patient CD : UC ratio of 3.4 : 1.46 Overall,

incidence rates of IBD in Asia are still low compared to recent figures from Western countries such as North America, Canada, New Zealand and Australia, where incidence rates for CD and UC range from 14.6 to 17.4 and 7.6 to 14.3, respectively.9–12 Prevalence.  A rise in the prevalence of UC in Japan from 7.85 to 63.6 per 100 000 population has been reported across three different studies between 1984 to 2005.14,16,28 Data from the national register have demonstrated the CD prevalence rise from 2.9 to 13.5 between 1986 and 1998.15 A separate study from Japan documented CD prevalence to be 21.2 in 2005.16 In Hong Kong the prevalence of UC appears to have almost tripled from 2.3 to 6.3 over the period 1997 to 2006.25 There are very few reports of prevalence of CD in Hong Kong or China. One review, which extrapolated

the crude prevalence rate based on 55 years of research in China (which included the Chinese literature), calculated the prevalence of CD to be 2.29;27 this figure has increased from the estimate of 1.3 in a hospital based study in 1994.23 There has been a substantial rise in UC prevalence in Korea from 7.6 in MTMR9 1997 to 30.9 in 2005.13,47 In 2005 CD prevalence was reported to be 11.2.13 A selective report in 19-year-old males having a health assessment for military service in Korea identified a striking increase of more than threefold over the period 2006 to 200948 Although no diagnostic criteria were reported, the latter report supports a likely major increase in IBD prevalence in this country over the last one or two decades. In studies from Singapore, UC and CD prevalence has risen from 6.0 to 8.6,31,32and from,1.3 to 7.2,31–33 respectively.

2. Aralia Chinesis L simultaneously suppress the proliferation of collagen fibers in the liver tissue in order to reduce the degree of liver fibrosis in rats. and at the same time with the suppression of protein expression of a-SMA. Key Word(s): 1. Aralia Chinesis L; 2. Hepatic fibrosis; 3. cytokines; 4. Apoptosis; Presenting Author: GANG ZHAO selleck inhibitor Additional Authors: LEI DONG, HONG LI, HAITAO SHI, XIAOLAN LU Corresponding Author: GANG ZHAO Affiliations: Xi′an Jiaotong University; [email protected] Objective: To observe the expression of fatty acid synthase (FASN) in alcohol-induced liver injury in mice, and investigate the possible mechanism of

EGFR in the process. Methods: Primary mice hepatocytes were cultured conventionally.

Four groups included normal group (saline group), ethanol group, ethanol plus EGFR tyrosine kinase inhibitor (Gefitinib) group and Gefitinib alone group were set up randomly. Total RNA and protein from liver cells were extracted, and real time-PCR and western-blot were applied to measure the gene and protein expression of FASN, Sterol regulatory element binding proteins (SREBP-1c) and EGFR. Results: Normal liver cells only slightly expression of FASN. After treated with Gefitinib, FASN expression in liver cells was no significant difference between normal liver cells. After treated with ethanol, FASN, SREBP-1c and EGFR expression both in gene and protein levels Selleck Alpelisib were significantly increased in liver Cediranib (AZD2171) cells. In ethanol plus Gefitinib group, expression levels of FASN and SREBP-1c were significantly lower, EGFR mRNA expression was still in the high value, while its protein expression was significantly decreased.

Conclusion: FASN slightly expresses in normal liver cells, but has a high abundance expression in alcohol-induced liver injury, maybe EGFR signaling pathway plays an important role during the process. Key Word(s): 1. EGFR; 2. Liver injury; 3. Fatty acid synthase; 4. TKI; Presenting Author: JOHNC HSIANG Additional Authors: WAYNE BAI, ARLO UPTON, ED GANE, STEPHEN GERRED Corresponding Author: JOHNC HSIANG Affiliations: Middlemore Hospital Objective: Local guidelines recommend six monthly hepatic ultrasound (US) and alpha –fetoprotein (AFP) testing for patients with a high risk of developing hepatocellular carcinomna (HCC). To assess the adherence to HCC surveillance guidelines at our institution. Methods: Patients with a high risk of HCC between 2007 and 2011 were identified from our clinic database. A retrospective review of electronic records was undertaken to record clinic attendance and adherence to six monthly AFP and US surveillance. Results: A total of 460 patients were identified. Cirrhosis was present in 409, severe hepatic fibrosis in 38, chronic hepatitis B and a family history of HCC in 13.

The homo-deletion of TAT gene was further confirmed by southern blot analysis (Fig. 1C) using a full-length TAT probe. Compared with the TAT learn more band detected in paired nontumor liver tissue, a very weak band was detected in HCC tissues in H12 and H36. To identify the homo-deleted region, five sets of primers

were designed to amplify TAT, GST3 (≈30 kb from the 3′ of TAT) and K2F gene (≈90 kb from the 3′ of TAT, Fig. 1D). PCR results indicated that the homo-deletion region in H12 was from exon 4 to 11 of TAT, whereas the deleted region in H36 was from exon 4 of TAT to GST3 (Fig. 1D). Semiquantitative reverse-transcription PCR (RT-PCR) was used to investigate the expression status of TAT in 50 pairs of primary HCCs. Compared with their paired nontumor liver tissues, down-regulation of TAT was detected in 28/50 (56%) of HCCs (Fig. 2A; Table 1). The results were further confirmed by qPCR (Fig. 2B) and northern blot analysis. Down-regulation of TAT was detected in all seven tested cases including absent expression of TAT in six cases (Fig. 2C). Down-regulation of TAT was also detected in 3/6 (50%) of HCC cell lines compared with that in MIHA, an immortalized liver cell line (Fig. 2D).

TAT protein expression status was further studied in 148 primary HCCs by IHC using a tissue microarray. Compared with their paired nontumor Alvelestat datasheet liver tissues, down-regulation of TAT protein was observed in 77/138 (55.8%) of informative HCCs (Fig. 2E). To determine whether the down-regulation of TAT was associated with aberrant methylation, the HCC cell line QGY-7703 was treated with 5-Aza, a DNA methyltransferase inhibitor. After

5-Aza treatment, TAT expression levels were dramatically increased, indicating that methylation of the TAT was associated with the down-regulation of TAT in HCC (Fig. 3A). The upstream sequence Oxalosuccinic acid of TAT gene (−1-6761) was analyzed using the CpG-island finder and plotting tool (http://www.ebi.ac.uk/Tools/sequence.html) and one CpG-island (CGI) at −4888-5396 (a total of 23 CpG sites in a 509-basepair region) was found (Fig. 3B). To determine whether epigenetic silencing of TAT in HCC cells is regulated by this 5′-CGI, MSP using methylation- or unmethylation-specific primers was performed in HCC cell lines and primary HCCs to investigate the methylation status of TAT. In three HCC cell lines (QGY-7703, BEL7402, and Hep3B) with absent expression of TAT, only the methylated allele of TAT was detected (Fig. 3C). Both methylated and unmethylated alleles were found in 7701 cells with weak TAT expression. In contrast, no methylated allele was observed in one immortalized liver cell line (MIHA) and two HCC cell lines (HepG2 and PLC8024) with TAT expression (Fig. 3C). These data indicated that promoter methylation might be required for the tissue-restricted TAT expression. We next investigated the methylation frequency of TAT in 50 primary HCC tumors and their paired nontumorous tissues by MSP.

[16, 17] RFA is one of the most recent local ablative therapies for small HCC[13, 14, 18], which can be performed by percutaneous or surgical approach.[19-21] For small HCC nodules (less than 3 cm), there is still some controversy regarding to the long-term effectiveness between the two treatment modalities, such MG-132 as overall survive time, disease-free time, and the tumor recurrence rate.[13, 22] The aim of

this randomized study was to determine which treatment modality, hepatectomy, or percutaneous RFA is more beneficial for patients with small HCC in terms of long-term outcomes. One hundred twenty patients with HCC ≤ 3 cm between January 1, 2000 and December 30, 2012 were randomized into either percutaneous RFA therapy or hepatectomy group, as initial treatment BMN 673 cost in Sir Run Run Shaw Hospital. Sixty patients who received hepatectomy were treated at Department of General Surgery, and 60 patients who received

RFA were treated in Department of Medical Oncology. The treatment and data collection were approved by Ethical Committee of our institution. HCC diagnosis was based on the criteria used by the European Association for the Study of the Liver, confirmed by a core biopsy before therapy. This study included 88 men and 32 women with a median age of 53.4 ± 10.9 years (range: 18–71). All patients were Chinese. Inclusion criteria as follows: (i) ≥ 18 years; (ii) any solitary HCC ≤ 3 cm in diameter and no more than three tumor nodules; (iii) no extrahepatic metastasis at diagnosis; (iv)

no radiologic evidence of major portal/hepatic vein branches invasion; (v) liver function equal or better than Pugh–Child Class B, with no history of encephalopathy, ascites refractory to diuretics or variceal bleeding (Patients with Pugh–Child Class C could be enrolled after the liver function was improved to B with the treatment options, including Edoxaban albumin infusion, diuretics, and non-steroidal anti-inflammatory drugs); and (vi) platelet count > 50 × 109/L without clinical significant portal hypertension and esophageal varices. We compared the randomized analysis based on the clinical characteristics, including age, sex, Child–Pugh classification, hepatic cirrhosis, tumor anatomical location, and HBV infection. Sixty patients underwent hepatectomy for HCC. Hepatectomy procedures were performed based on the position of HCC under general anesthesia, including nonanatomic hepatectomy in 38 patients, right hepatectomy in 13 patients, and left hepatectomy in 9 patients. A nonanatomic resection aiming at a resection margin of at least 2 cm was performed.

The Use of probiotics prior to liver transplant should be considered as a part of the transplant protocol. Disclosures: The following people have nothing to disclose: Tarek Sawas, Shadi Al Halabi, Mubarak W. Sayyar, Won Kyoo Cho Several factors have been reported

to influence the survival outcome following liver transplantation. The principal six identified variables that influence outcomes are the transplant center’s experience and outcome statistics, recipient age, donor age, gender, MELD score, and liver disease etiology. The aim of this study was to compare the most recent outcome data from United States liver transplant centers which have performed at least 50 Liver Transplants (LT) per year. Methods/Results: Data were collected from the Scientific Selleck PLX3397 Registry see more of Transplant Recipients (www.SRTR.org) and the data was compared between the liver transplant centers in the US. The parameters assessed included but were not limited to: 3-year graft survival, 3-year patient survival, wait list mortality, composite 3-year mortality. Despite adjusting for all of the main variables, it was apparent that major differences in the three-year patient survival at liver transplant centers in the

US varied widely and ranged from 60-94% with a national average of approximately 79%. Wait list mortality also varied (10 folds) from a value 0.04% at the better performing LT centers to 0.40% in the poorer performing centers. Furthermore, the composite 3-year mortality rate range varied from 17.6- 67.0%. This Inositol monophosphatase 1 large variation in 3-year patient survival outcome between US LT centers performing more than 50 LT per year could not be explained after adjusting for the identified predictive variables and was not related to the level of competitiveness between centers or the centers’ access to organs. Importantly, performing < 50 liver transplantation per year was not found to correlate negatively with the 3-year patient survival data. Based upon these data obtained from the SRTR, it can be concluded that: 1) post- transplant survival varies widely between US liver transplant centers; 2) a favorable outcome is not predicted by: a) the

number of liver transplants performed, b) the various patient and donor characteristics examined, c) the MELD score, or d) the availability of organs for the individual transplant center. 3) The practice of substituting less toxic immunosuppressive agents at some centers was positively associated with a better overall 3-year survival outcome. These data suggest that the hospital and transplant team skills are the most important factors that contribute to the marked variation in adjusted post- LT survival between centers. Factors that may reduce this variation between centers in the future potentially consist of: 1) Standardization of the protocols used for the management of pre- and post-LT care. 2) Consideration for the use of less toxic and lower doses of immunosuppression.

Of selleck screening library the tumor markers assessed, NX-PVKA was the only significant predictor of prognosis (hazard ratio, 81.32; P < 0.0001). Patients with NX-PVKA level ≥ 100 mAU/mL showed significantly lower survival rates (P < 0.0001).

NX-PVKA level was also significantly associated with platelet count, prothrombin time, C-reactive protein, sex, maximum tumor size, number of nodules, and portal venous invasion by HCC. Finally, using NX-PVKA level and other clinical parameters, we established a prognostic model to estimate patient survival time. NX-PVKA offers the best marker of tumor prognosis among HCC patients, and is strongly associated with tumor factors and hepatic functional reserve. NX-PVKA could be useful for clinical evaluation of tumor severity, as well as the estimated duration of survival among patients with HCC. “
“Crohn’s disease is a chronic inflammatory bowel disease. Oridonin is an effective component isolated from Rabdosia rubescens. It can inhibit the activation of transcription factor nuclear factor-kappa B and suppress the over expression of cytokines. We postulated that oridonin may be a potential therapeutic candidate for Crohn’s disease. To confirm the postulation, we

investigated clinical and immunologic modulations of oridonin in a mouse model of trinitrobenzene Selleck MK-2206 sulfonic acid-induced colitis. It was found that oridonin attenuated trinitrobenzene sulfonic acid -induced colitis as represented by a reduction in colonic IFN-γ/IL-17 secretion and a decrement in splenic Th1/Th17 cells and effector memory CD4+ T cells. Oridonin treatment inhibited the proliferation of CD4+ T cells and up-regulated the apoptosis of lymphocytes by inhibiting nuclear translocation of transcription factor nuclear factor-kappa B. Oridonin is a potential modulator for trinitrobenzene sulfonic acid-induced colitis and other Th1/Th17 mediated inflammatory diseases. “
“Background and Aims:  Although the metabolic risk factors for non-alcoholic fatty

liver disease (NAFLD) progression have been recognized, the role of genetic susceptibility remains a field to be explored. The aim of this study was to examine NADPH-cytochrome-c2 reductase the frequency of two polymorphisms in Brazilian patients with biopsy-proven simple steatosis or non-alcoholic steatohepatitis (NASH): −493 G/T in the MTP gene, which codes the protein responsible for transferring triglycerides to nascent apolipoprotein B, and −129 C/T in the GCLC gene, which codes the catalytic subunit of glutamate-cystein ligase in the formation of glutathione. Methods:  One hundred and thirty-one biopsy-proven NAFLD patients (n = 45, simple steatosis; n = 86, NASH) and 141 unrelated healthy volunteers were evaluated. Genomic DNA was extracted from peripheral blood cells, and the −129 C/T polymorphism of the GCLC gene was determined by restriction fragment length polymorphism (RFLP). The −493 G/T polymorphism of the MTP gene was determined by direct sequencing of the polymerase chain reaction products.

This has not been tested in a controlled trial but has been reported to be successful in small series [9]. There has been little published on

the eradication of low titre inhibitors click here (peak titre <5 BU) but experience suggests that these are usually readily tolerized using a low-dose regimen. Progress on ITI is usually monitored firstly by measuring the inhibitor titre monthly and then, when the Bethesda titre is consistently negative, measuring the FVIII recovery monthly, without a washout. Once this has normalized (>66%), the half-life is usually measured after a 3-day washout every 3 months until normal [8]. A truncated half-life is probably adequate for this purpose and the ITI data are being re-analysed to determine whether the approach of Bjorkman to half-life estimation [23], which minimizes sample requirement may be appropriate. When all three of these parameters are normal, the patient is considered tolerant [8]. Most patients achieve tolerance within 6–12 months but a minority may take 1–3 years or more. ITI can be abandoned in such patients after 6–9 months RO4929097 supplier and

rescue therapy introduced if there is no evidence of a significant decline in inhibitor titre. ITI is also often stopped for logistic reasons, because of failure of venous access and/or repeated CVAD infection. Long interruptions in ITI are to be avoided because they are significantly associated with a poor outcome [24]. Patients whose inhibitor titres rise >500 BU are unlikely to succeed. Similarly patients whose titres fail to decline or continue to rise over a 6 month period are unlikely to be successfully tolerized and consideration should be given to either changing the regimen or stopping ITI. It is a matter of individual judgement when to consider Amino acid that the patient has failed ITI or should be changed to a different regimen. Options for rescue therapy in unresponsive patients are limited and there is insufficient data to recommend any specific strategy. The

alternatives include the use of a higher dose regimen, changing to pdFVIII with a high VWF content, adding immunosuppression such as Rituximab or both. Patients with mild haemophilia A who develop an inhibitor respond less well to immune tolerance than those with severe haemophilia [25] though these patients had a median age of 32 and inhibitors presenting earlier in life may be more likely to respond. Immune tolerance induction, ITI for haemophilia B must be carefully considered because of the relatively poor overall success rate (25%) and the risk of anaphylaxis and potentially irreversible nephrotic syndrome [5,6]. Regimens analogous to haemophilia A have been used including low- and high-dose FIX and a modified Malmo regimen [26]. The NAITR reported 31% success with a median dose of 100 U−1 kg−1 day−1 and 6/7 patients were successfully tolerized using the Malmo regimen [26].