Albumin: pathophysiologic basis of its role in the treatment of cirrhosis and its complications

Predictive model of mortality in patients with spontaneous bacterial peritonitis

BACKGROUND

Hospital mortality in patients with spontaneous bacterial peritonitis (SBP) is high despite albumin treatment, particularly in those with worse liver and/or renal function.

AIM

To determine the independent predictive factors of in-hospital mortality and to create and validate a predictive model of mortality in patients with SBP.

METHODS

We analysed all cirrhotic patients with high-risk SBP (serum urea ≥11 mmol/L and/or serum bilirubin ≥68 μmol/L) between 2001 and 2011. We developed a predictive model of in-hospital mortality and validated this in a different cohort.

RESULTS

We included 118 high-risk SBP episodes treated with antibiotics and albumin. In-hospital mortality was 33/118 (28%). The independent predictive factors of in-hospital mortality at SBP diagnosis were serum urea, blood leucocyte count, Child-Pugh score and mean arterial pressure. A predictive model including these four variables showed a discrimination accuracy (AUC) of 0.850, 95% CI 0.777-0.922. A cut-off point of 0.245 showed a sensitivity of 0.85 and specificity of 0.75. The in-hospital mortality was 28/49 (57.1%) in patients with a model value ≥0.245, and 5/69 (7.2%) in patients with a model value <0.245 (P < 0.001). The validation series included 161 patients with an in-hospital mortality of 40/161 (24.8%), 30/77 (39.0%) in patients with a model value ≥0.245, and 10/84 (11.9%) in those with a model value <0.245 (P < 0.001).

CONCLUSIONS

We developed and validated a predictive model of mortality that includes serum urea, blood leucocyte count, Child-Pugh score and mean arterial pressure in high-risk patients with spontaneous bacterial peritonitis. These findings may help to identify patients who would benefit from additional therapeutic strategies.

Equine Mesenchymal Stromal Cells from Different Sources Efficiently Differentiate into Hepatocyte-Like Cells

Adult equine hepatocytes have proven challenging to culture long term in vitro as they rapidly lose their morphology and functionality, thus limiting studies on liver function and response to disease. In this study, we describe for the first time the differentiation of equine mesenchymal stromal cells (MSC) from a variety of sources into functional hepatocyte-like cells (HLC). First, we differentiated equine umbilical cord blood (UCB)-derived MSC into HLC and found that these cells exhibited a distinct polygonal morphology, stored glycogen as visualized by periodic acid Schiff's reagent staining, and were positive for albumin and other hepatocyte-specific genes. Second, we demonstrated that UCB-HLC could be revived following cryopreservation and retained their phenotype for at least 10 days. Third, we differentiated three sets of MSC from bone marrow (BM), adipose tissue (AT), and peripheral blood (PB), matched within the same horse. We achieved a 100% differentiation success rate with BM, 0% with AT, and 66% with PB. An additional set of nine PB-MSC samples resulted in an overall success rate of 42% (n = 12), and age or gender did not seem to have an effect on the success of hepatic differentiation from that source. In a final set of experiments, we evaluated the use of these HLC as tools in different fields of biomedical research like virology, to study viral growth, and toxicology, to study chemicals with hepatic toxicity. Equine HLC were found susceptible for infection with the equine herpesviruses type 1 (EHV-1), -2, and -5, and exhibited a more sensitive dose-dependent response to arsenic toxicity than the commonly used human hepatocellular cell line HepG2. Taken together, these data indicate that equine MSC can be efficiently differentiated into HLC and these equine HLC could be a useful tool for in vitro studies.

The Roche Immunoturbidimetric Albumin Method on Cobas c 501 Gives Higher Values Than the Abbott and Roche BCP Methods When Analyzing Patient Plasma Samples

BACKGROUND

Serum/plasma albumin is an important and widely used laboratory marker and it is important that we measure albumin correctly without bias. We had indications that the immunoturbidimetric method on Cobas c 501 and the bromocresol purple (BCP) method on Architect 16000 differed, so we decided to study these methods more closely.

METHOD

A total of 1,951 patient requests with albumin measured with both the Architect BCP and Cobas immunoturbidimetric methods were extracted from the laboratory system. A comparison with fresh plasma samples was also performed that included immunoturbidimetric and BCP methods on Cobas c 501 and analysis of the international protein calibrator ERM-DA470k/IFCC.

RESULTS

The median difference between the Abbott BCP and Roche immunoturbidimetric methods was 3.3 g/l and the Roche method overestimated ERM-DA470k/IFCC by 2.2 g/l. The Roche immunoturbidimetric method gave higher values than the Roche BCP method: y = 1.111x - 0.739, R² = 0.971.

CONCLUSION

The Roche immunoturbidimetric albumin method gives clearly higher values than the Abbott and Roche BCP methods when analyzing fresh patient samples. The differences between the two methods were similar at normal and low albumin levels.

Atrial fibrillation in patients with cirrhosis

BACKGROUND & AIMS

Few information is available regarding atrial fibrillation in cirrhotic patients. The aim of this study was to investigate the occurrence and clinical impact of atrial fibrillation in these patients.

METHODS

Three hundred and thirty-five cirrhotic patients (219 males; mean age 65 ± 10.85 years; 196 Child-Pugh class A, 104 class B and 35 class C) were consecutively analysed and followed up for 24 months. Electrocardiograms were available for all patients before starting the study, at basaltime and during the follow-up. Echocardiography was performed in individuals with atrial fibrillation and in 100 randomly chosen patients without it.

RESULTS

Atrial fibrillation was observed in 21/335 cirrhotics (mean age 75 ± 7 years, 13 male), six of whom had permanent and 15 had paroxysmal atrial fibrillation. At univariate analysis, atrial fibrillation significantly correlated with older age, history of coronary heart disease, Child-Pugh score, serum albumin, hepatic encephalopathy, treatment with furosemide, QTc prolongation, atrial section areas, increased PAPs and thickness of interventricular septum. Age [odd ratio 1.12, 95% CI (1.05-1.2), P = 0.001], history of coronary heart disease [odd ratio 4.93, 95% CI (1.04-23.54), P = 0.04] and PAPs [odd ratio 1.12, 95% CI (1.02-1.2), P = 0.01] maintained statistical significance at multivariate analysis. Fifty-one of the 335 patients died during the follow-up. At Cox regression analysis, advanced Child-Pugh score [hazard ratio 1.546, 95% CI (1.357-1.762), P = 0.037] and increased heart rate [hazard ratio 1.117, 95% CI (1.021-1.223), P = 0.016] were significantly associated with mortality which was independent of atrial fibrillation occurrence.

CONCLUSIONS

Cirrhosis is not a predisposing factor of atrial fibrillation, which in turn has no impact on mortality in cirrhotic patients.

Studies on oxidants and antioxidants with a brief glance at their relevance to the immune system

Free radical generation occurs continuously within cells as a consequence of common metabolic processes. However, in high concentrations, whether from endogenous or exogenous sources, free radicals can lead to oxidative stress; a harmful process that cause serious damages to all biomolecules in our body hence impairs cell functions and even results in cell death and diseased states. Oxidative injuries accumulate over time and participate in cancer development, cardiovascular and neurodegenerative disorders as well as aging. Nature has bestowed the human body with a complex web of antioxidant defense system including enzymatic antioxidants like glutathione peroxidase and glutathione reductase, catalase and superoxide dismutase as well as non-enzymatic antioxidants such as thiol antioxidants, melatonin, coenzyme Q, and metal chelating proteins, which are efficient enough to fight against excessive free radicals. Also, nutrient antioxidants such as vitamin C, vitamin E, carotenoids, polyphenols, and trace elements are known to have high antioxidant potency to assist in minimizing harmful effects of reactive species. The immune system is also extremely vulnerable to oxidant and antioxidant balance as uncontrolled free radical production can impair its function and defense mechanism. The present paper reviews the ways by which free radicals form in the body and promote tissue damage, as well as the role of the antioxidants defense mechanisms. Finally, we will have a brief glance at oxidants and antioxidants relevance to the immune system.

AISF-SIMTI Position Paper: The appropriate use of albumin in patients with liver cirrhosis

The use of human albumin is common in hepatology since international scientific societies support its administration to treat or prevent severe complications of cirrhosis, such as the prevention of post-paracentesis circulatory dysfunction after large-volume paracentesis and renal failure induced by spontaneous bacterial peritonitis, and the treatment of hepatorenal syndrome in association with vasoconstrictors. However, these indications are often disregarded, mainly because the high cost of human albumin leads health authorities and hospital administrations to restrict its use. On the other hand, physicians often prescribe human albumin in patients with advanced cirrhosis for indications that are not supported by solid scientific evidence and/or are still under investigation in clinical trials. In order to implement appropriate prescription of human albumin and to avoid its futile use, the Italian Association for the Study of the Liver (AISF) and the Italian Society of Transfusion Medicine and Immunohaematology (SIMTI) nominated a panel of experts, who reviewed the available clinical literature and produced practical clinical recommendations for the use of human albumin in patients with cirrhosis.

Factors Affecting Mortality and Morbidity of Patients With Cirrhosis Hospitalized for Spontaneous Bacterial Peritonitis

OBJECTIVES

Spontaneous bacterial peritonitis, unless originating from surgery or an intra-abdominal source, is an infection diagnosed by neutrophil counts greater than 250/mm³ in ascites. Spontaneous bacterial peritonitis is the most common infection among patients hospitalized with cirrhosis, with a prevalence of 9% and a risk of development among all patients with cirrhosis within 1 year of 10%. No valid parameters have been defined to predict the mortality related to spontaneous bacterial peritonitis. Unless it is treated, the mortality rate as a result of spontaneous bacterial peritonitis is 50%, and serious complications may arise.

MATERIALS AND METHODS

Medical records from 29 patients on the deceased-donor transplant waiting list and receiving treatment at the Başkent University Hospital Gastroenterology Clinic for cirrhotic ascites infection between 1996 and 2013 were analyzed. Demographic information, paracentesis findings, clinical follow-up, and treatment results were reviewed and collected from patient medical records, with data recorded to the research form.

RESULTS

In our patient group, 72.4% were men and the average age was 46.6 years. Most of our patients were at advanced stage, with 55.2% having a Child-Pugh score of C and an average Model for End-Stage Liver Disease score of 17 ± 4.1. We found that 34.5% of the patients received prophylactic treatment for spontaneous bacterial peritonitis, 72.4% received a proton pump inhibitor, and 82.8% had treatment with intravenous albumin support at the time of diagnosis. Albumin treatment showed no effect on mortality. Mortality rate among patients with Child-Pugh score of C was 81.3%.

CONCLUSIONS

Existence of chronic renal failure, liver graft surgery, and hepatocellular cancer did not seem to have a significant effect on patient mortality. The albumin treatment protocol showed no significant difference despite common belief among physicians.

Albumin Levels in Patients With Chronic Rhinosinusitis With Nasal Polyp

OBJECTIVES

We aim to provide useful evidence on the relationship between the albumin levels and chronic rhinosinusitis with nasal polyp (CRSwNP) and its potential use as an inexpensive, reliable, and independent prognostic marker of CRSwNP.

MATERIALS AND METHODS

Forty-five patients with CRSwNP and 45 healthy individuals were included in the study. Serum albumin levels were determined. The serum albumin levels of the study and control groups were compared to determine whether there is a statistically significant difference.

RESULTS

The mean albumin level of the study group was 4.65 ± 0.38, the median value was 4.70. The mean albumin level of the control group was 4.84 ± 0.39, the median value was 4.90. There was a statistically significant difference between the albumin levels of the study and control groups (P = 0.045, P < 0.05).

CONCLUSION

The albumin levels were found to be statistically significantly lower in patients with CRSwNP. This result may contribute to the diagnosis of CRSwNP and identifying its prognosis.

Albumin treatment regimen for type 1 hepatorenal syndrome: a dose-response meta-analysis

BACKGROUND

Recommended treatment for type 1 hepatorenal syndrome consists of albumin and vasoconstrictor. The optimal albumin dose remains poorly characterized. This meta-analysis aimed to determine the impact of albumin dose on treatment outcomes.

METHODS

Clinical studies of type 1 hepatorenal syndrome treatment with albumin and vasoconstrictor were sought. Search terms included: hepatorenal syndrome; albumin; vasoconstrictor; terlipressin; midodrine; octreotide; noradrenaline; and norepinephrine. A meta-analysis was performed of hepatorenal syndrome reversal and survival in relation to albumin dose.

RESULTS

Nineteen clinical studies with 574 total patients were included, comprising 8 randomized controlled trials, 8 prospective studies and 3 retrospective studies. The pooled percentage of patients achieving hepatorenal syndrome reversal was 49.5% (95% confidence interval, 40.0-59.1%). Increments of 100 g in cumulative albumin dose were accompanied by significantly increased survival (hazard ratio, 1.15; 95% confidence interval, 1.02-1.31; p = 0.023). A non-significant increase of similar magnitude in hepatorenal syndrome reversal was also observed (odds ratio, 1.15; 95% confidence interval, 0.97-1.37; p = 0.10). Expected survival rates at 30 days among patients receiving cumulative albumin doses of 200, 400 and 600 g were 43.2% (95% confidence interval, 36.4-51.3%), 51.4% (95% confidence interval, 46.3-57.1%) and 59.0% (95% confidence interval, 51.9-67.2), respectively. Neither survival nor hepatorenal syndrome reversal was significantly affected by vasoconstrictor dose or type, treatment duration, age, baseline serum creatinine, bilirubin or albumin, baseline mean arterial pressure, or study design, size or time period.

CONCLUSIONS

This meta-analysis suggests a dose-response relationship between infused albumin and survival in patients with type 1 hepatorenal syndrome. The meta-analysis provides the best current evidence on the potential role of albumin dose selection in improving outcomes of treatment for type 1 HRS and furnishes guidance for the design of future dose-ranging studies.

The effect and mechanism of bufalin on regulating hepatocellular carcinoma cell invasion and metastasis via Wnt/β-catenin signaling pathway

Hepatocellular carcinoma (HCC) is a highly malignant tumor with an extremely poor prognosis. Our preliminary study indicated that bufalin could restrain the proliferation of human hepatoma BEL-7402 cells in a time- and dose-dependent manner. In the present study, the colony formation assay, the Transwell invasion assay, the western blot analysis and the immunofluorescence method were respectively used to investigate the effect and mechanism of bufalin against HCC cell invasion and metastasis. We found that: i) bufalin had significant inhibitory effect on the cell proliferation of BEL-7402 cells; ii) bufalin markedly inhibited the migration and invasion of BEL-7402 cells; iii) bufalin could suppress the phosphorylation of GSK-3β Ser9 site in BEL-7402 cells, decrease the expression of β-catenin, cyclin D1, metalloproteinases-7 (MMP-7) and cyclooxygenase-2 (COX-2) in the cytoplasm, and increase the expression of E-cadherin and β-catenin on the cell membrane; and iv) the expression of α-fetoprotein significantly decreased and the expression of albumin increased in BEL-7402 cells after bufalin was used. Our results indicate that: i) bufalin can regulate the expression of associated factors in Wnt/β-catenin signaling pathway of BEL-7402 cells through suppressing the phosphorylation of GSK-3β Ser9 site; ii) bufalin can strengthen intercellular E-cadherin/β-catenin complex to control epithelial-mesenchymal transition; and iii) bufalin can reverse the malignant phenotype and promote the differentiation and maturation by regulating the AFP and ALB expression in BEL-7402 cells. These are very important mechanisms of bufalin on the inhibition of the invasion and metastasis of HCC cells.

Safety, complications and outcome of large volume paracentesis with or without albumin therapy in children with severe ascites due to liver disease

BACKGROUND & AIMS

There are currently no published data on post-paracentesis circulatory dysfunction (PPCD) or its prevention in children. Our study was aimed to analyze the safety and complications of large volume paracentesis (LVP) in children with severe ascites due to chronic liver disease with or without albumin therapy.

METHODS

A prospective longitudinal observational study enrolled children with severe ascites who underwent single time LVP at admission. They were divided into albumin infused (AI) and albumin non-infused (ANI) groups. Hemodynamic monitoring and laboratory parameters including plasma renin activity (PRA) were compared between baseline, 48 h and day 6 of LVP. Their outcome at 3 months and maximal follow-up were noted.

RESULTS

32 children (AI, n=17; ANI, n=15) had comparable baseline characteristics and 90.6% had high PRA at onset. The incidence of PPCD was 37.5% (ANI: 67%; AI: 12%, p=0.003), occurred if ascitic fluid extraction was >197.5 ml/kg (sensitivity: 90%; specificity: 50%, p=0.01) and if flow rate was higher in ANI group (1224 ± 476 vs. 678 ± 214 ml/h, p=0.009). ANI patients were susceptible to asymptomatic, persistent hyponatremia (baseline vs. day 6, 131 ± 4 vs. 128 ± 6 mEq/L; p=0.04) and had higher rates of recurrent ascites (42%) and hospital readmission (67%) within 3 months. No survival benefit among the AI or non-PPCD groups was demonstrated.

CONCLUSIONS

LVP is safe in all age groups, best performed under albumin cover to overcome the problems of PPCD and hyponatremia. It is prudent to restrict volume extraction to less than 200 ml/kg actual dry weight for all and flow rate of 680 ml/h in ANI.

Ischaemia-modified albumin: a marker of bacterial infection in hospitalized patients with cirrhosis

BACKGROUND & AIMS

Patients with cirrhosis present structural changes of human serum albumin (HSA) affecting non-oncotic functions. Ischaemia-modified albumin (IMA), which reflects the capacity to bind cobalt, has been associated to patient mortality during acute-on-chronic liver failure. This study aimed to assess whether circulating IMA is elevated in advanced cirrhosis and its relationship with severity of cirrhosis and specific complications.

METHODS

A total of 127 cirrhotic patients hospitalized for an acute complication of the disease and 44 healthy controls were enrolled. Plasma IMA and IMA to albumin ratio (IMAr) were measured with a cobalt-binding assay. HSA isoforms carrying post-transcriptional molecular changes were assessed with HPLC-ESI-MS. The effect of endotoxemia on IMA was evaluated in rats with CCl4 -cirrhosis.

RESULTS

IMA/IMAr is significantly higher in cirrhotic patients than in controls, but no correlations were found with prognostic scores. IMA did not correlate with the altered HSA isoforms. Ascites, renal impairment and hepatic encephalopathy did not influence IMA/IMAr levels. In contrast, IMA/IMAr is significantly higher in infected than non-infected patients. ROC curves showed that IMA/IMAr had similar discriminating performances for bacterial infection as C-reactive protein (CRP). Moreover, CRP and IMA were independently associated with bacterial infection. Consistently, endotoxin injection significantly increased IMA in cirrhotic, but not in healthy rats.

CONCLUSIONS

IMA is elevated in patients with advanced cirrhosis. The IMA level does not correlate with disease severity scores, but it is specifically associated to bacterial infection, showing a discriminating performance similar to CRP. Further investigations to assess IMA as a novel diagnostic test for bacterial infection are advocated.

Mechanisms of decompensation and organ failure in cirrhosis: From peripheral arterial vasodilation to systemic inflammation hypothesis

The peripheral arterial vasodilation hypothesis has been most influential in the field of cirrhosis and its complications. It has given rise to hundreds of pathophysiological studies in experimental and human cirrhosis and is the theoretical basis of life-saving treatments. It is undisputed that splanchnic arterial vasodilation contributes to portal hypertension and is the basis for manifestations such as ascites and hepatorenal syndrome, but the body of research generated by the hypothesis has revealed gaps in the original pathophysiological interpretation of these complications. The expansion of our knowledge on the mechanisms regulating vascular tone, inflammation and the host-microbiota interaction require a broader approach to advanced cirrhosis encompassing the whole spectrum of its manifestations. Indeed, multiorgan dysfunction and failure likely result from a complex interplay where the systemic spread of bacterial products represents the primary event. The consequent activation of the host innate immune response triggers endothelial molecular mechanisms responsible for arterial vasodilation, and also jeopardizes organ integrity with a storm of pro-inflammatory cytokines and reactive oxygen and nitrogen species. Thus, the picture of advanced cirrhosis could be seen as the result of an inflammatory syndrome in contradiction with a simple hemodynamic disturbance.

Acute-on-chronic liver failure

Acute-on-chronic liver failure combines an acute deterioration in liver function in an individual with pre-existing chronic liver disease and hepatic and extrahepatic organ failures, and is associated with substantial short-term mortality. Common precipitants include bacterial and viral infections, alcoholic hepatitis, and surgery, but in more than 40% of patients, no precipitating event is identified. Systemic inflammation and susceptibility to infection are characteristic pathophysiological features. A new diagnostic score, the Chronic Liver Failure Consortium (CLIF-C) organ failure score, has been developed for classification and prognostic assessment of patients with acute-on-chronic liver failure. Disease can be reversed in many patients, and thus clinical management focuses upon the identification and treatment of the precipitant while providing multiorgan-supportive care that addresses the complex pattern of physiological disturbance in critically ill patients with liver disease. Liver transplantation is a highly effective intervention in some specific cases, but recipient identification, organ availability, timing of transplantation, and high resource use are barriers to more widespread application. Recognition of acute-on-chronic liver failure as a clinically and pathophysiologically distinct syndrome with defined diagnostic and prognostic criteria will help to encourage the development of new management pathways and interventions to address the unacceptably high mortality.

Albumin in chronic liver disease: structure, functions and therapeutic implications

Human serum albumin is a critical plasma protein produced by the liver with a number of accepted clinical indications in chronic liver disease including management of circulatory and renal dysfunction in patients with ascites. Advanced cirrhosis is characterised by reduced albumin concentration as well as impaired albumin function as a result of specific structural changes and oxidative damage. Traditionally, the biologic and therapeutic role of albumin in liver disease was attributed to its oncotic effects but it is now understood that albumin has a wide range of other important physiologic functions such as immunomodulation, endothelial stabilisation, antioxidant effects and binding multiple drugs, toxins and other molecules. This review discusses the multifunctional properties of albumin and, in particular, the biologic and clinical implications of structural and functional changes of albumin that are associated with cirrhosis. Based on these insights, we explore the current and potential future therapeutic uses of albumin in liver disease.

Extracorporeal liver assist device to exchange albumin and remove endotoxin in acute liver failure: Results of a pivotal pre-clinical study

BACKGROUND & AIMS

In acute liver failure, severity of liver injury and clinical progression of disease are in part consequent upon activation of the innate immune system. Endotoxaemia contributes to innate immune system activation and the detoxifying function of albumin, critical to recovery from liver injury, is irreversibly destroyed in acute liver failure. University College London-Liver Dialysis Device is a novel artificial extracorporeal liver assist device, which is used with albumin infusion, to achieve removal and replacement of dysfunctional albumin and reduction in endotoxaemia. We aimed to test the effect of this device on survival in a pig model of acetaminophen-induced acute liver failure.

METHODS

Pigs were randomised to three groups: Acetaminophen plus University College London-Liver Dialysis Device (n=9); Acetaminophen plus Control Device (n=7); and Control plus Control Device (n=4). Device treatment was initiated two h after onset of irreversible acute liver failure.

RESULTS

The Liver Dialysis Device resulted in 67% reduced risk of death in acetaminophen-induced acute liver failure compared to Control Device (hazard ratio=0.33, p=0.0439). This was associated with 27% decrease in circulating irreversibly oxidised human non-mercaptalbumin-2 throughout treatment (p=0.046); 54% reduction in overall severity of endotoxaemia (p=0.024); delay in development of vasoplegia and acute lung injury; and delay in systemic activation of the TLR4 signalling pathway. Liver Dialysis Device-associated adverse clinical effects were not seen.

CONCLUSIONS

The survival benefit and lack of adverse effects would support clinical trials of University College London-Liver Dialysis Device in acute liver failure patients.

Impact of preoperative serum albumin on 30-day mortality following surgery for colorectal cancer: a population-based cohort study

Objective

Surgery is the only potentially curable treatment for colorectal cancer (CRC), but it is hampered by high mortality. Human serum albumin (HSA) below 35 g/L is associated with poor overall prognosis in patients with CRC, but evidence regarding the impact on postoperative mortality is sparse.

Methods

We performed a population-based cohort study including patients undergoing CRC surgery in North and Central Denmark (1997–2011). We categorised patients according to HSA concentration measured 1–30 days prior to surgery date. We used the Kaplan-Meier method to compute 30-day mortality and Cox regression model to compute HRs as measures of the relative risk of death, controlling for potential confounders. We further stratified patients by preoperative conditions, including cancer stage, comorbidity level, and C reactive protein concentration.

Results

Of the 9339 patients undergoing first-time CRC surgery with preoperative HSA measurement, 26.4% (n=2464) had HSA below 35 g/L. 30-day mortality increased from 4.9% among patients with HSA 36–40 g/L to 26.9% among patients with HSA equal to or below 25 g/L, compared with 2.0% among patients with HSA above 40 g/L. The corresponding adjusted HRs increased from 1.75 (95% CI 1.25 to 2.45) among patients with HSA 36–40 g/L to 7.59 (95% CI 4.95 to 11.64) among patients with HSA equal to or below 25 g/L, compared with patients with HSA above 40 g/L. The negative impact associated with a decrement of HSA was found in all subgroups.

Conclusions

A decrement in preoperative HSA concentration was associated with substantial concentration-dependent increased 30-day mortality following CRC surgery.

Serum Albumin Can Identify Patients With Compensated Cirrhosis With a Good Prognosis

BACKGROUND

Many prognostic studies in cirrhosis were performed without distinguishing between compensated and decompensated patients and/or have evaluated the prognostic role of variables that are not routinely used. The aim was to evaluate predictors of survival in compensated and decompensated cirrhosis separately but in a concurrent cohort and focused on routine clinical variables.

METHODS

Secondary analysis of a prospective cohort with cirrhosis collected in a tertiary center between August 2000 and May 2002 and followed until death or April 2006. Univariate, stratified univariate analysis, and multivariate Cox regression analysis were performed. Receiving operating characteristics curves were used to identify the best cutoff of variables predictive of death.

RESULTS

A total of 242 patients were included (122 compensated, 120 decompensated). In a median follow-up of 30 months (range, 6 to 50 mo), 62 (26%) deaths occurred, 24 (20%) in the compensated and 38 (32%) in the decompensated group. In the whole cohort, decompensation was the strongest predictor of death. In the compensated group, age, albumin, and platelets and in the decompensated group model for end-stage liver disease, platelets, and albumin were identified as independent predictors of death. A serum albumin of 4 g/dL was the best cutoff to identify patients at risk for death in the compensated group with a hazard ratio of 13.3 [95% confidence interval, 1.8-98.8] in those with an albumin of <4.0 g/dL.

CONCLUSIONS

Albumin is a predictor of death in compensated and decompensated cirrhosis. In compensated cirrhosis a subset patients with particularly good prognosis can be identified. Different predictors were observed in both stages, confirming that compensated and decompensated cirrhosis are 2 separate disease stages.

A Model for Predicting Development of Overt Hepatic Encephalopathy in Patients With Cirrhosis

BACKGROUND & AIMS

Overt hepatic encephalopathy (HE) affects patients' quantity and quality of life and places a burden on families. There is evidence that overt HE might be prevented pharmacologically, but prophylaxis would be justified and cost effective only for patients at risk. We aimed to identify patients with cirrhosis at risk for overt HE.

METHODS

We collected data from October 2009 through December 2012 for 216 consecutive patients with cirrhosis (based on liver biopsy, 96 patients with minimal HE), admitted to the Gastroenterology Unit at the University of Rome. Patients were followed up and evaluated for an average of 14.7 ± 11.6 months; development of overt HE was recorded. We analyzed end-stage liver disease scores, shunt placement, previous overt or minimal HE, psychometric hepatic encephalopathy score (PHES), and levels of albumin, bilirubin, creatinine, and sodium to develop a prediction model. We validated the model in 112 patients with cirrhosis seen at the University of Padua and followed up for 12 ± 9.5 months.

RESULTS

During the follow-up period, 68 patients (32%) developed at least 1 episode of overt HE. Based on multivariate analysis, the development of overt HE was associated with previous HE, minimal HE (based on PHES), and level of albumin less than 3.5 g/dL (area under curve [AUC], 0.74). A model that excluded minimal HE but included albumin level and previous HE also identified patients who would develop overt HE (AUC, 0.71); this difference in AUC values was not statistically significant (P = .104). Both models were validated in the independent group of patients (3 variables: AUC, 0.74; 95% confidence interval, 0.66-0.83; and 2 variables: AUC, 0.71; 95% confidence interval, 0.63-0.78).

CONCLUSIONS

We developed and validated a model to identify patients with cirrhosis at risk for overt HE based on previous HE, albumin levels, and PHES. If PHES was not available, previous HE and albumin levels still can identify patients at risk. Psychometric evaluation is essential for patients with no history of HE. These findings should aid in planning studies of pharmacologic prevention of overt HE.

Treatment to improve acute kidney injury in cirrhosis

OPINION STATEMENT

Acute kidney injury (AKI) is an ominous complication of decompensated cirrhosis, which can be fatal if not treated promptly. It is important that clinicians recognize that AKI has occurred and institute timely treatment. Recent establishment of diagnostic criteria and treatment guidelines are most useful, and these will be further refined as treatments are being modified to improve patient outcome. To manage such a patient, firstly, the cause of the AKI needs to be identified and any precipitating factors corrected. Bacterial infections are a common cause of AKI in cirrhosis, and it is recommended to offer empirical antibiotics in cases of suspicious bacterial infection until all the cultures are negative. Patients should be given albumin infusion in doses of 1 g/kg of body weight for at least 2 days. This can improve the filling of the central circulation, and also absorb many of the bacterial products or inflammatory cytokines that play a role in mediating the renal dysfunction. Often, albumin infusion alone may be sufficient to reverse the AKI. For patients who have acute or type 1 hepatorenal syndrome (HRS1), which is a special form of AKI, pharmacotherapy in the form of vasoconstrictor will be needed. The vasoconstrictor can be terlipressin, norepinephrine, or midodrine, depending on the local availability of drugs or facilities. Currently, approximately 40 % of patients will respond to a combination of vasoconstrictor and albumin. All patients with HRS1 should be assessed for liver transplant. If accepted for liver transplantation, those patients who do not respond to vasocontrictors and albumin need to be started on renal replacement therapy, which otherwise has no place in the treatment of HRS1. Once listed, liver transplantation should occur promptly, preferable under 2 weeks. Otherwise, the chances for renal recovery after liver transplant are significantly reduced, necessitating a renal transplant at the future date.

Methods to determine intestinal permeability and bacterial translocation during liver disease

Liver disease is often times associated with increased intestinal permeability. A disruption of the gut barrier allows microbial products and viable bacteria to translocate from the intestinal lumen to extraintestinal organs. The majority of the venous blood from the intestinal tract is drained into the portal circulation, which is part of the dual hepatic blood supply. The liver is therefore the first organ in the body to encounter not only absorbed nutrients, but also gut-derived bacteria and pathogen associated molecular patterns (PAMPs). Chronic exposure to increased levels of PAMPs has been linked to disease progression during early stages and to infectious complications during late stages of liver disease (cirrhosis). It is therefore important to assess and monitor gut barrier dysfunction during hepatic disease. We review methods to assess intestinal barrier disruption and discuss advantages and disadvantages. We will in particular focus on methods that we have used to measure increased intestinal permeability and bacterial translocation in experimental liver disease models.

Effect of albumin in cirrhotic patients with infection other than spontaneous bacterial peritonitis. A randomized trial

BACKGROUND & AIMS

Albumin infusion improves renal function and survival in cirrhotic patients with spontaneous bacterial peritonitis (SBP) but its efficacy in other types of infections remains unknown. We investigated this issue through a multicenter randomized controlled trial.

METHODS

A total of 193 cirrhotic patients with a Child-Pugh score greater than 8 and sepsis unrelated to SBP were randomly assigned to receive antibiotics plus albumin (1.5 g/kg on day 1 and 1g/kg on day 3; albumin group [ALB]: n=96) or antibiotics alone (control group [CG]: n=97). The primary endpoint was the 3-month renal failure rate (increase in creatinine ⩾50% to reach a final value ⩾133 μmol/L). The secondary endpoint was 3-month survival rate.

RESULTS

Forty-seven (24.6%) patients died (ALB: n=27 vs. CG: n=20; 3-month survival: 70.2% vs. 78.3%; p=0.16). Albumin infusion delayed the occurrence of renal failure (mean time to onset, ALB: 29.0 ± 21.8 vs. 11.7 ± 9.1 days, p=0.018) but the 3-month renal failure rate was similar (ALB: 14.3% vs. CG: 13.5%; p=0.88). By multivariate analysis, MELD score (p<0.0001), pneumonia (p=0.0041), hyponatremia (p=0.031) and occurrence of renal failure (p<0.0001) were predictors of death. Of note, pulmonary edema developed in 8/96 (8.3%) patients in the albumin group of whom two died, one on the day and the other on day 33 following albumin infusion.

CONCLUSIONS

In cirrhotic patients with infections other than SBP, albumin infusion delayed onset of renal failure but did not improve renal function or survival at 3 months. Infusion of large amounts of albumin should be cautiously administered in the sickest cirrhotic patients.

Immunomodulatory and antioxidant function of albumin stabilises the endothelium and improves survival in a rodent model of chronic liver failure

BACKGROUND & AIMS

Liver failure is characterized by endothelial dysfunction, which results in hemodynamic disturbances leading to renal failure. Albumin infusion improves hemodynamics and prevents renal dysfunction in advance liver failure. These effects are only partly explained by the oncotic properties of albumin. This study was designed to test the hypothesis that albumin exerts its beneficial effects by stabilising endothelial function.

METHODS

In vivo: systemic hemodynamics, renal function, markers of endothelial dysfunction (ADMA) and inflammation were studied in analbuminaemic and Sprague-Dawley rats, 6-weeks after sham/bile duct ligation surgery. In vitro: human umbilical vein endothelial cells were stimulated with LPS with or without albumin. We studied protein expression and gene expression of adhesion molecules, intracellular reactive oxygen species, and cell stress markers.

RESULTS

Compared to controls, analbuminaemic rats had significantly greater hemodynamic deterioration after bile duct ligation, resulting in worse renal function and shorter survival. This was associated with significantly greater plasma renin activity, worse endothelial function, and disturbed inflammatory response. In vitro studies showed that albumin was actively taken up by endothelial cells. Incubation of albumin pre-treated endothelial cells with LPS was associated with significantly less activation compared with untreated cells, decreased intracellular reactive oxygen species, and markers of cell stress.

CONCLUSIONS

These results show, for the first time, that absence of albumin is characterised by worse systemic hemodynamics, renal function and higher mortality in a rodent model of chronic liver failure and illustrates the important non-oncotic properties of albumin in protecting against endothelial dysfunction.

Pathogenesis of hepatic encephalopathy: role of ammonia and systemic inflammation

The syndrome we refer to as Hepatic Encephalopathy (HE) was first characterized by a team of Nobel Prize winning physiologists led by Pavlov and Nencki at the Imperial Institute of Experimental Medicine in Russia in the 1890's. This focused upon the key observation that performing a portocaval shunt, which bypassed nitrogen-rich blood away from the liver, induced elevated blood and brain ammonia concentrations in association with profound neurobehavioral changes. There exists however a spectrum of metabolic encephalopathies attributable to a variety (or even absence) of liver hepatocellular dysfunctions and it is this spectrum rather than a single disease entity that has come to be defined as HE. Differences in the underlying pathophysiology, treatment responses and outcomes can therefore be highly variable between acute and chronic HE. The term also fails to articulate quite how systemic the syndrome of HE can be and how it can be influenced by the gastrointestinal, renal, nervous, or immune systems without any change in background liver function. The pathogenesis of HE therefore encapsulates a complex network of interdependent organ systems which as yet remain poorly characterized. There is nonetheless a growing recognition that there is a complex but influential synergistic relationship between ammonia, inflammation (sterile and non-sterile) and oxidative stress in the pathogenesis HE which develops in an environment of functional immunoparesis in patients with liver dysfunction. Therapeutic strategies are thus moving further away from the traditional specialty of hepatology and more towards novel immune and inflammatory targets which will be discussed in this review.

Treatment and management of ascites and hepatorenal syndrome: an update

Ascites and renal dysfunction are frequent complications experienced by patients with cirrhosis of the liver. Ascites is the pathologic accumulation of fluid in the peritoneal cavity, and is one of the cardinal signs of portal hypertension. The diagnostic evaluation of ascites involves assessment of its granulocyte count and protein concentration to exclude complications such as infection or malignoma and to allow risk stratification for the development of spontaneous peritonitis. Although sodium restriction and diuretics remain the cornerstone of the management of ascites, many patients require additional therapy when they become refractory to this treatment. In this situation, the treatment of choice is repeated large-volume paracentesis. Alteration in splanchnic hemodynamics is one of the most important changes underlying the development of ascites. Further splanchnic dilation leads to changes in systemic hemodynamics, activating vasopressor agents and leading to decreased renal perfusion. Small alterations in renal function influence the prognosis, which depends on the cause of renal failure. Prerenal failure is evident in about 70% of patients, whereas in about 30% of patients the cause is hepatorenal syndrome (HRS), which is associated with a worse prognosis. Therefore, effective therapy is of great clinical importance. Recent data indicate that use of the new definition of acute kidney injury facilitates the identification and treatment of patients with renal insufficiency more rapidly than use of the current criteria for HRS. In this review article, we evaluate approaches to the management of patients with ascites and HRS.

Serum hypoalbuminemia predicts late mortality on the liver transplant waiting list

BACKGROUND

The reduction of liver transplant wait list mortality remains a priority for transplant programs and depends on the accurate stratification of patients by mortality risk. Although estimation of 90-day mortality by Model for End-Stage Liver Disease (MELD) score has improved wait list survival, it is unclear how contemporary wait list mortality can best be diminished given the preponderance of listed patients with low MELD scores and long wait times.

METHODS

In this intention-to-treat analysis of 289 consecutively listed patients with over 5 years of follow-up, we aimed to determine the contribution of late mortality to overall wait list outcome and identify clinical predictors that would help discriminate long-term survivors from fatalities.

RESULTS

Seventy percent of wait list deaths occurred in patients listed with MELD scores less than 20, and 40% of deaths occurred in patients waiting longer than 1 year. Hypoalbuminemia at listing was a significant predictor of late mortality in all patients in both univariate and multivariate analyses, and it was most discriminatory among patients with MELD scores of 20 or less.

CONCLUSION

Our data suggest that hypoalbuminemia at listing reveals a vulnerable population of low MELD patients who are underserved by their MELD score over time. Such patients comprise almost 40% of the contemporary wait list and contribute substantially to list mortality given their poor access to transplantation. Targeting these at-risk patients with grafts from living or extended criteria donors may thus significantly diminish overall list mortality, and future initiatives to decrease overall wait list mortality must focus on improved risk stratification for low MELD patients.

Hepatic encephalopathy in patients with acute decompensation of cirrhosis and acute-on-chronic liver failure

Hepatic encephalopathy in a hospitalized cirrhotic patient is associated with a high mortality rate and its presence adds further to the mortality of patients with acute-on-chronic liver failure (ACLF). The exact pathophysiological mechanisms of HE in this group of patients are unclear but hyperammonemia, systemic inflammation (including sepsis, bacterial translocation, and insulin resistance) and oxidative stress, modulated by glutaminase gene alteration, remain as key factors. Moreover, alcohol misuse, hyponatremia, renal insufficiency, and microbiota are actively explored. HE diagnosis requires exclusion of other causes of neurological, metabolic and psychiatric dysfunction. Hospitalization in the ICU should be considered in every patient with overt HE, but particularly if this is associated with ACLF. Precipitating factors should be identified and treated as required. Evidence-based specific management options are limited to bowel cleansing and non-absorbable antibiotics. Ammonia lowering drugs, such as glycerol phenylbutyrate and ornithine phenylacetate show promise but are still in clinical trials. Albumin dialysis may be useful in refractory cases. Antibiotics, prebiotics, and treatment of diabetes reduce systemic inflammation. Where possible and not contraindicated, large portal-systemic shunts may be embolized but liver transplantation is the most definitive step in the management of HE in this setting. HE in patients with ACLF appears to be clinically and pathophysiologically distinct from that of acute decompensation and requires further studies and characterization.

Albumin infusion improves renal blood flow autoregulation in patients with acute decompensation of cirrhosis and acute kidney injury

BACKGROUND & AIMS

In cirrhotic patients with renal failure, renal blood flow autoregulation curve is shifted to the right, which is consequent upon sympathetic nervous system activation and endothelial dysfunction. Albumin infusion improves renal function in cirrhosis by mechanisms that are incompletely understood. We aimed to determine the effect of albumin infusion on systemic haemodynamics, renal blood flow, renal function and endothelial function in patients with acute decompensation of cirrhosis and acute kidney injury.

METHODS

Twelve patients with refractory ascites and 10 patients with acute decompensation of cirrhosis and acute kidney injury were studied. Both groups were treated with intravenous albumin infusion, 40-60 g/days over 3-4 days. Cardiac and renal haemodynamics were measured. Endothelial activation/dysfunction was assessed using von Willebrand factor and serum nitrite levels. F2α Isoprostanes, resting neutrophil burst and noradrenaline levels were quantified as markers of oxidative stress, endotoxemia and sympathetic activation respectively.

RESULTS

Albumin infusion leads to a shift in the renal blood flow autoregulation curve towards normalization, which resulted in a significant increase in renal blood flow. Accordingly, improvement of renal function was observed. In parallel, a significant decrease in sympathetic activation, inflammation/oxidative stress and endothelial activation/dysfunction was documented. Improvement of renal blood flow correlated with improvement in endothelial activation (r = 0.741, P < 0.001).

CONCLUSIONS

The data suggest that albumin infusion improves renal function in acutely decompensated cirrhotic patients with acute kidney injury by impacting on renal blood flow autoregulation. This is possibly achieved through endothelial stabilization and a reduction in the sympathetic tone, endotoxemia and oxidative stress.

Diagnosis and treatment of spontaneous bacterial peritonitis in cirrhotic patients

Spontaneous bacterial peritonitis (SBP) is a common complication in liver cirrhotic patients with ascites. Polymorphonuclear cells > 250/mL and bacterial cultures of ascitic fluid are main means for diagnosis of SBP. Leukocyte esterase isozyme, pH value, procalcitonin, lactoferrin, granulocyte elastase and phagocytized bacterial DNA in leukocytes from ascitic fluid also play a role in the diagnosis of SBP. Third-generation cephalosporins (especially cefotaxime) are the most appropriate antibiotics for the treatment of SBP. Albumin infusion can prevent renal impairment and reduce mortality among patients with SBP.

Conjugated bilirubin triggers anemia by inducing erythrocyte death

Hepatic failure is commonly associated with anemia, which may result from gastrointestinal bleeding, vitamin deficiency, or liver-damaging diseases, such as infection and alcohol intoxication. At least in theory, anemia during hepatic failure may result from accelerated clearance of circulating erythrocytes. Here we show that bile duct ligation (BDL) in mice leads to severe anemia despite increased reticulocyte numbers. Bilirubin stimulated suicidal death of human erythrocytes. Mechanistically, bilirubin triggered rapid Ca(2+) influx, sphingomyelinase activation, formation of ceramide, and subsequent translocation of phosphatidylserine to the erythrocyte surface. Consistent with our in vitro and in vivo findings, incubation of erythrocytes in serum from patients with liver disease induced suicidal death of erythrocytes in relation to their plasma bilirubin concentration. Consistently, patients with hyperbilirubinemia had significantly lower erythrocyte and significantly higher reticulocyte counts compared to patients with low bilirubin levels.

CONCLUSION

Bilirubin triggers suicidal erythrocyte death, thus contributing to anemia during liver disease.

Posttranscriptional changes of serum albumin: clinical and prognostic significance in hospitalized patients with cirrhosis

Beside the regulation of fluid distribution, human serum albumin (HSA) carries other activities, such as binding, transport, and detoxification of many molecules. In patients with cirrhosis, HSA exhibits posttranscriptional alterations that likely affect its functions. This study aimed at identifying the structural HSA alterations occurring in cirrhosis and determining their relationship with specific clinical complications and patient survival. One hundred sixty-eight patients with cirrhosis, 35 with stable conditions and 133 hospitalized for acute clinical complications, and 94 healthy controls were enrolled. Posttranscriptional HSA molecular changes were identified and quantified by using a high-performance liquid chromatography/electrospray ionization mass spectrometry technique. Clinical and biochemical parameters were also recorded and hospitalized patients were followed for up to 1 year. Seven HSA isoforms carrying one or more posttranscriptional changes were identified. Altered HSA isoforms were significantly more represented in patients than in healthy controls. Conversely, the native, unchanged HSA isoform was significantly reduced in cirrhosis. Native HSA and most altered isoforms correlated with both Child-Pugh and Model for End-Stage Liver Disease scores. In hospitalized patients, oxidized and N-terminal truncated isoforms were independently associated with ascites, renal impairment, and bacterial infection. Finally, the native HSA and cysteinylated/N-terminal truncated isoforms were predictors of 1-year survival, with greater prognostic accuracy than total serum albumin concentration.

CONCLUSIONS

Extensive posttranscriptional changes of HSA, involving several molecular sites and increasing in parallel with disease severity, occur in patients with cirrhosis. Altered isoforms are independently associated with specific clinical complications, whereas the residual, native HSA isoform independently predicts patient survival. These findings support the concept of the "effective albumin concentration," which implies that the global HSA function is related not only to its serum concentration, but also to the preservation of its structural integrity.

Role of human albumin in the management of complications of liver cirrhosis

Albumin is a negatively charged, relatively small protein synthesized by liver cells. Is the most abundant protein in extracellular fluid and accounts for about 70% of the plasma colloid osmotic pressure. Therefore it plays a crucial role in regulating fluid distribution in the body. In addition, albumin possesses functional domains with important non-oncotic properties, such as potent anti-oxydant and scavenging activities, binding of highly toxic reactive metal species and a great amount of endogenous and exogenous substances. We have recently learned that albumin in cirrhosis undergoes a number of post-transcriptional changes that greatly impair its non-oncotic properties. The overall assessment of these changes clearly shows that the relative abundance of the native form of albumin is significantly reduced in hospitalized patients with cirrhosis and that these abnormalities worsen in parallel with the increasing severity of the disease. Thus, it is time to abandon the concept of serum albumin concentration and refer to the effective albumin concentration, that is the native intact albumin. Given the pathophysiological context in which we use human albumin in patients with cirrhosis, who are characterized by peripheral vasodilation and a low-grade but sustained inflammatory state, the use of albumin in patients with cirrhosis should aim at enhancing effective hypovolemia and exploiting its antioxidant and scavenging activities. The indications for the use of albumin in cirrhosis that clearly emerge from evidence-based medicine are represented by conditions characterized by an acute aggravation of effective hypovolemia and inflammation, such as such post-paracentesis circulatory dysfunction, spontaneous bacterial peritonitis, and hepatorenal syndrome. Other indications to the use of albumin that still require further studies are represented by bacterial infections other than spontaneous bacterial peritonitis, hepatic encephalopathy and long-term treatment of ascites, which has been debated for the last half-century.

Role of vaptans in the management of hydroelectrolytic imbalance in liver cirrhosis

Ascites and hyponatremia are the most common complications in patients with liver cirrhosis and develop as a consequence of a severe impairment of liver function and portal hypertension. Increasing evidences support the central role of renal function alterations in the pathogenesis of hydroelectrolytic imbalances in cirrhotic patients, thus implying a dense cross-talk between liver and kidney in the systemic and splanchnic vascular homeostasis in such subjects. Since Arginin Vasopressin (AVP) hyperincretion occurs at late stage of cirrhosis and plays an important role in the development of refractory ascites, dilutional hyponatremia and finally hepato-renal syndrome, selective antagonists of AVP receptors V2 (vaptans) have been recently introduced in the therapeutic algorithm of advanced cirrhotic patients. Despite the promising results of earlier phase-two studies, randomized controlled trials failed to find significant results in terms of efficacy of such drugs both in refractory ascites and hyponatremia. Moreover, concerns on their safety profile arise, due to the number of potentially severe side effects of vaptans in the clinical setting, such as hypernatremia, dehydration, renal impairment, and osmotic demyelination syndrome. More robust data from randomized controlled trials are needed in order to confirm the potential role of vaptans in the management of advanced cirrhotic patients.

Assessment of toxic effects of the methanol extract of Citrus macroptera Montr. Fruit via biochemical and hematological evaluation in female Sprague-Dawley rats

Citrus macroptera Montr. (C. macroptera) is locally known as Satkara. The fruit of this plant is used as appetite stimulant and in the treatment of fever. This study therefore aimed to evaluate the toxic effects of the fruit extract using some biochemical and hematological parameters in rat model. The effects of methanol extract of Citrus macroptera Montr. fruit administered at 250, 500 and 1000 mg/kg body weight were investigated on hematological and biochemical parameters in Sprague-Dawley female rats. Moreover, histopathological study was performed to observe the presence of pathological lesions in primary body organs. The extract presented no significant effect on body weight, percent water content, relative organ weight and hematological parameters in rat. Significant decrease from control group was observed in the levels of triglyceride, total cholesterol, low density lipoprotein and very low density lipoprotein; thus leading to significant decrease of cardiac risk ratio, castelli's risk index-2, atherogenic coefficient and atherogenic index of plasma at all doses. 500 mg/kg dose significantly decreased alkaline phosphatase (P<0.05), 1000 mg/kg dose significantly increased high density lipoprotein cholesterol (P<0.05) and 250 mg/kg dose significantly decreased the level of glycated hemoglobin (P<0.05) from the control group. There were no significant alterations observed with other serum biochemical parameters. Histopathological study confirmed the absence of inflammatory and necrotic features in the primary body organs. Study results indicate that methanolic fruit extract is unlikely to have significant toxicity. Moreover, these findings justified the cardio-protective, moderate hepato-protective and glucose controlling activities of the fruit extract.

Promoterless gene targeting without nucleases ameliorates haemophilia B in mice

Site-specific gene addition can allow stable transgene expression for gene therapy. When possible, this is preferred over the use of promiscuously integrating vectors, which are sometimes associated with clonal expansion and oncogenesis. Site-specific endonucleases that can induce high rates of targeted genome editing are finding increasing applications in biological discovery and gene therapy. However, two safety concerns persist: endonuclease-associated adverse effects, both on-target and off-target; and oncogene activation caused by promoter integration, even without nucleases. Here we perform recombinant adeno-associated virus (rAAV)-mediated promoterless gene targeting without nucleases and demonstrate amelioration of the bleeding diathesis in haemophilia B mice. In particular, we target a promoterless human coagulation factor IX (F9) gene to the liver-expressed mouse albumin (Alb) locus. F9 is targeted, along with a preceding 2A-peptide coding sequence, to be integrated just upstream to the Alb stop codon. While F9 is fused to Alb at the DNA and RNA levels, two separate proteins are synthesized by way of ribosomal skipping. Thus, F9 expression is linked to robust hepatic albumin expression without disrupting it. We injected an AAV8-F9 vector into neonatal and adult mice and achieved on-target integration into ∼0.5% of the albumin alleles in hepatocytes. We established that F9 was produced only from on-target integration, and ribosomal skipping was highly efficient. Stable F9 plasma levels at 7-20% of normal were obtained, and treated F9-deficient mice had normal coagulation times. In conclusion, transgene integration as a 2A-fusion to a highly expressed endogenous gene may obviate the requirement for nucleases and/or vector-borne promoters. This method may allow for safe and efficacious gene targeting in both infants and adults by greatly diminishing off-target effects while still providing therapeutic levels of expression from integration.

Multi-resistant bacteria in spontaneous bacterial peritonitis: a new step in management?

Spontaneous bacterial peritonitis (SBP) is the most typical infection observed in cirrhosis patients. SBP is responsible for an in-hospital mortality rate of approximately 32%. Recently, pattern changes in the bacterial flora of cirrhosis patients have been observed, and an increase in the prevalence of infections caused by multi-resistant bacteria has been noted. The wide-scale use of quinolones in the prophylaxis of SBP has promoted flora modifications and resulted in the development of bacterial resistance. The efficacy of traditionally recommended therapy has been low in nosocomial infections (up to 40%), and multi-resistance has been observed in up to 22% of isolated germs in nosocomial SBP. For this reason, the use of a broad empirical spectrum antibiotic has been suggested in these situations. The distinction between community-acquired infectious episodes, healthcare-associated infections, or nosocomial infections, and the identification of risk factors for multi-resistant germs can aid in the decision-making process regarding the empirical choice of antibiotic therapy. Broad-spectrum antimicrobial agents, such as carbapenems with or without glycopeptides or piperacillin-tazobactam, should be considered for the initial treatment not only of nosocomial infections but also of healthcare-associated infections when the risk factors or severity signs for multi-resistant bacteria are apparent. The use of cephalosporins should be restricted to community-acquired infections.

Clinical effects of exogenous albumin in critically ill patients with gastrointestinal diseases

AIM: To investigate the clinical effects of exogenous albumin in acute and critically ill patients with gastrointestinal diseases.

METHODS: Eighty-eight critically ill patients with gastrointestinal diseases treated in our hospital ICU from April 2010 to February 2013 were randomly divided into either a study group or a control group, with 44 patients in each group. Both groups underwent conventional symptomatic treatment and nutritional support therapy, and the study group was additionally given exogenous albumin. The times to recovery of bowel sounds and flatus were compared between the two groups.

RESULTS: The study group had significantly shorter times to recovery of bowel sounds and flatus compared with the control group (58.0 h ± 7.7 h vs 69.6 h ± 11.5 h, 76.8 h ± 9.4 h vs 95.6 h ± 13.5 h, P < 0.05 for both). Before treatment, the two groups showed no significant difference in serum albumin (P > 0.05); after treatment, the study group had significantly higher serum albumin (34.8 g/L ± 4.0 g/L vs 28.5 g/L ± 3.1 g/L, P < 0.05).

CONCLUSION: Exogenous albumin can improve the nutritional status of critically ill patients with gastrointestinal diseases and promote the recovery of gastrointestinal function.

Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013

Bacterial infections are very common and represent one of the most important reasons of progression of liver failure, development of liver-related complications, and mortality in patients with cirrhosis. In fact, bacterial infections may be a triggering factor for the occurrence of gastrointestinal bleeding, hypervolemic hyponatremia, hepatic encephalopathy, kidney failure, and development of acute-on-chronic liver failure. Moreover, infections are a very common cause of repeated hospitalizations, impaired health-related quality of life, and increased healthcare costs in cirrhosis. Bacterial infections develop as a consequence of immune dysfunction that occurs progressively during the course of cirrhosis. In a significant proportion of patients, infections are caused by gram-negative bacteria from intestinal origin, yet gram-positive bacteria are a frequent cause of infection, particularly in hospitalized patients. In recent years, infections caused by multidrug-resistant bacteria are becoming an important clinical problem in many countries. The reduction of the negative clinical impact of infections in patients with cirrhosis may be achieved by a combination of prophylactic measures, such as administration of antibiotics, to reduce the occurrence of infections in high-risk groups together with early identification and management of infection once it has developed. Investigation on the mechanisms of altered gut microflora, translocation of bacteria, and immune dysfunction may help develop more effective and safe methods of prevention compared to those that are currently available. Moreover, research on biomarkers of early infection may be useful in early diagnosis and treatment of infections. The current manuscript reports an in-depth review and a position statement on bacterial infections in cirrhosis.

Liver dialysis in acute-on-chronic liver failure: current and future perspectives

Patients with acute-on-chronic liver failure (ACLF) are known to have a very high mortality rate as the majority of these patients succumb to multiorgan failure. Liver transplant remains the only option for these patients; however, there are problems with its availability, cost and also the complications and side effects associated with immunosuppression. Unlike advanced decompensated liver disease, there is a potential for hepatic regeneration and recovery in patients with ACLF. A liver support system, cell or non-cell based, logically is likely to provide temporary functional support until the donor liver becomes available or the failing liver survives the onslaught of the acute insult and spontaneously regenerates. Understanding the pathogenesis of liver failure and regeneration is essential to define the needs for a support system. Removal of hepatotoxic metabolites and inhibitors of hepatic regeneration by liver dialysis, a non-cell-based hepatic support, could help to provide a suitable microenvironment and support the failing liver. The current systems, i.e., MARS and Prometheus, have failed to show survival benefits in patients with ACLF based on which newer devices with improved functionality are currently under development. However, larger randomized trials are needed to prove whether these devices can enable restoration of the complex dysregulated immune system and impact organ failure and mortality in these patients.

Immunosuppression in acutely decompensated cirrhosis is mediated by prostaglandin E2

Liver disease is one of the leading causes of death worldwide. Patients with cirrhosis display an increased predisposition to and mortality from infection due to multimodal defects in the innate immune system; however, the causative mechanism has remained elusive. We present evidence that the cyclooxygenase (COX)-derived eicosanoid prostaglandin E2 (PGE2) drives cirrhosis-associated immunosuppression. We observed elevated circulating concentrations (more than seven times as high as in healthy volunteers) of PGE2 in patients with acute decompensation of cirrhosis. Plasma from these and patients with end-stage liver disease (ESLD) suppressed macrophage proinflammatory cytokine secretion and bacterial killing in vitro in a PGE2-dependent manner via the prostanoid type E receptor-2 (EP2), effects not seen with plasma from patients with stable cirrhosis (Child-Pugh score grade A). Albumin, which reduces PGE2 bioavailability, was decreased in the serum of patients with acute decompensation or ESLD (<30 mg/dl) and appears to have a role in modulating PGE2-mediated immune dysfunction. In vivo administration of human albumin solution to these patients significantly improved the plasma-induced impairment of macrophage proinflammatory cytokine production in vitro. Two mouse models of liver injury (bile duct ligation and carbon tetrachloride) also exhibited elevated PGE2, reduced circulating albumin concentrations and EP2-mediated immunosuppression. Treatment with COX inhibitors or albumin restored immune competence and survival following infection with group B Streptococcus. Taken together, human albumin solution infusions may be used to reduce circulating PGE2 levels, attenuating immune suppression and reducing the risk of infection in patients with acutely decompensated cirrhosis or ESLD.

Review article: advances in the management of patients with cirrhosis and portal hypertension-related renal dysfunction

BACKGROUND

In cirrhosis, portal hypertension is associated with a spectrum of renal dysfunction that has significant implications for morbidity and mortality.

AIM

To discuss recent progress in the patho-physiological mechanisms and therapeutic options for portal hypertension-related renal dysfunction.

METHODS

A literature search using Pubmed was performed.

RESULTS

Portal hypertension-related renal dysfunction occurs in the setting of marked neuro-humoral and circulatory derangement. A systemic inflammatory response is a pathogenetic factor in advanced disease. Such physiological changes render the individual vulnerable to further deterioration of renal function. Patients are primed to develop acute kidney injury when exposed to additional 'hits', such as sepsis. Recent progress has been made regarding our understanding of the aetiopathogenesis. However, treatment options once hepatorenal syndrome develops are limited, and prognosis remains poor. Various strategies to prevent acute kidney injury are suggested.

CONCLUSION

Prevention of acute kidney injury in high risk patients with cirrhosis and portal hypertension-related renal dysfunction should be a clinical priority.