Acute-on-chronic liver failure: an update

Fibroblast growth factors 19 and 21 in acute liver damage

Currently there are very few pharmacological options available to treat acute liver injury. Because its natural exposure to noxious stimuli the liver has developed a strong endogenous hepatoprotective capacity. Indeed, experimental evidence exposed a variety of endogenous hepatic and systemic responses naturally activated to protect the hepatic parenchyma and to foster liver regeneration, therefore preserving individual's survival. The fibroblast growth factor (FGF) family encompasses a range of polypeptides with important effects on cellular differentiation, growth survival and metabolic regulation in adult organisms. Among these FGFs, FGF19 and FGF21 are endocrine hormones that profoundly influence systemic metabolism but also exert important hepatoprotective activities. In this review, we revisit the biology of these factors and highlight their potential application for the clinical management of acute liver injury.

Acute-on-chronic liver failure 2018: a need for (urgent) liver biopsy?

'Acute-on-Chronic-Liver Failure (ACLF)' entered hepatology practice by the end of the 20th century. Although we lack precise and universally agreed definitions, acute decompensation of chronic liver disease with jaundice and deranged clotting, multi-organ failure and high, short-term mortality are hallmarks of the syndrome. Timely recognition and and treatment, including urgent liver transplantation, may save the life of certain patients. The diagnosis and management are mostly based on clinical features, but some have suggested to incorporate histopathology (liver biopsy). This may add to the differentiation between acute and chronic disease, primary and concomitant etiologies, and identify prognostic determinants. Areas covered: A review of the literature on ACLF and the outcome of the discussions at a topical international meeting on specific histopathological aspects of diagnosis and prognosis of the syndrome. Expert commentary: There is a lack of standardized descriptions of histopathological features and there is limited prospective experience with the role of pathology of ACLF. It is important for the clinical hepatologist to understand the potential and limitations of (transjugular) liver biopsy in ACLF and for the pathologist to help address the clinical question and recognise the histopathological features that help to characterize ACLF, both in terms of diagnosis and prognosis.

Novel use of Cytosorb™ haemadsorption to provide biochemical control in liver impairment

We describe the use of Cytosorb™, a synthetic extracorporeal haemoperfusion adsorption column, in the management of two patients with drug induced cholestasis and a third with alcoholic hepatitis and subsequent acute on chronic liver failure. Cytosorb was used in these patients to remove bilirubin and bile acids by supporting impaired excretory hepatic function, alleviating symptoms with the intention of serving as a bridge to endogenous recovery. The first two cases demonstrate favourable biochemical and symptomatic responses; the third case demonstrated a good biochemical response but subsequently died from the complications of multiple organ failure. These cases suggest Cytosorb™ be evaluated as an adjunct to support liver excretory functions in other arenas, such as acute liver failure or overdose. It remains unclear whether extracorporeal therapies removing liver toxins allow faster or more complete spontaneous recovery of endogenous function.

Managing portal hypertension in patients with liver cirrhosis

Portal hypertension is one cause and a part of a dynamic process triggered by chronic liver disease, mostly induced by alcohol or incorrect nutrition and less often by viral infections and autoimmune or genetic disease. Adequate staging - continuously modified by current knowledge - should guide the prevention and treatment of portal hypertension with defined endpoints. The main goals are interruption of etiology and prevention of complications followed, if necessary, by treatment of these. For the past few decades, shunts, mostly as intrahepatic stent bypass between portal and hepatic vein branches, have played an important role in the prevention of recurrent bleeding and ascites formation, although their impact on survival remains ambiguous. Systemic drugs, such as non-selective beta-blockers, statins, or antibiotics, reduce portal hypertension by decreasing intrahepatic resistance or portal tributary blood flow or by blunting inflammatory stimuli inside and outside the liver. Here, the interactions among the gut, liver, and brain are increasingly examined for new therapeutic options. There is no general panacea. The interruption of initiating factors is key. If not possible or if not possible in a timely manner, combined approaches should receive more attention before considering liver transplantation.

Administration of Albumin Solution Increases Serum Levels of Albumin in Patients With Chronic Liver Failure in a Single-Arm Feasibility Trial

BACKGROUND & AIMS

Infections are life-threatening to patients with acute decompensation and acute-on-chronic liver failure (AD/ACLF). Patients with AD/ACLF have prostaglandin E2-mediated immune suppression, which can be reversed by administration of albumin; infusion of 20% human albumin solution (HAS) might improve outcomes of infections. We performed a feasibility study to determine optimal trial design, assess safety, and validate laboratory assessments of immune function to inform design of a phase 3 trial.

METHODS

We performed a prospective multicenter, single-arm, open-label trial of 79 patients with AD/ACLF and levels of albumin lower than 30 g/L, seen at 10 hospitals in the United Kingdom from May through December 2015. Patients were given daily infusions of 20% HAS, based on serum levels, for 14 days or until discharge from the hospital. Rates of infection, organ dysfunction, and in-hospital mortality were recorded. The primary end point was daily serum albumin level during the treatment period. Success would be demonstrated if 60% achieved and maintained serum albumin levels at or above 30 g/L on at least one third of days with recorded levels.

RESULTS

The patients' mean model for end-stage disease score was 20.9 ± 6.6. The primary end point (albumin ≥30 g/L on at least one third of days recorded) was achieved by 68 of the 79 patients; 75% of administrations were in accordance with suggested dosing regimen. Mean treatment duration was 10.3 days (104 ± 678 mL administered). There were 8 deaths and 13 serious adverse events, considered by the independent data-monitoring committee to be consistent with those expected. Twelve of 13 patients that developed either respiratory or cardiovascular dysfunction (based on ward-based clinical definitions) as their only organ dysfunction were alive at 30 days compared with 1 of 3 that developed renal dysfunction. Only 1 case of brain dysfunction was recorded.

CONCLUSIONS

In a feasibility trial, we found that administration of HAS increased serum levels of albumin in patients with AD/ACLF. The dosing regimen was acceptable at multiple sites and deemed safe by an independent data-monitoring committee. We also developed a robust system to record infections. The poor prognosis for patients with renal dysfunction was confirmed. However, patients with cardiovascular or respiratory dysfunction had good outcomes, which is counterintuitive. Severe encephalopathy appeared substantially under-reported, indicating that ward-based assessment of these parameters cannot be recorded with sufficient accuracy for use as a primary outcome in phase 3 trials. Trial registration no: EudraCT 2014-002300-24 and ISRCTN14174793.

Liver-enriched transcription factor expression relates to chronic hepatic failure in humans

The mechanisms by which the liver fails in end-stage liver disease remain elusive. Disruption of the transcription factor network in hepatocytes has been suggested to mediate terminal liver failure in animals. However, this hypothesis remains unexplored in human subjects. To study the relevance of transcription factor expression in terminal stages of chronic liver failure in humans, we analyzed the expression of liver-enriched transcription factors (LETFs) hepatocyte nuclear factor (HNF)4α, HNF1α, forkhead box protein A2 (FOXA2), CCAAT/enhancer-binding protein (CEBP)α, and CEBPβ. We then selected downstream genes responsible for some hepatic functions (ornithine transcarbamylase [OTC], cytochrome P450 3A4 [CYP3A4], coagulation factor VII [F7], cadherin 1 [CDH1], phospho-ezrin (Thr567)/radixin (Thr564)/moesin (Thr558) [p-ERM], phospho-myosin light chain [p-MLC], low-density lipoprotein receptor-related protein 1 [LRP1]) in liver tissue from patients at different stages of decompensated liver function based upon Child-Pugh classification, Model for End-Stage Liver Disease score, and degree of inflammatory activity/fibrosis. We first examined differential expression of LETF and determined whether a relationship exists between transcript and protein expression, and liver function. We found HNF4α expression was down-regulated and correlated well with the extent of liver dysfunction (P = 0.001), stage of fibrosis (P = 0.0005), and serum levels of total bilirubin (P = 0.009; r = 0.35), albumin (P < 0.001; r = 0.52), and prothrombin time activity (P = 0.002; r = 0.41). HNF4α expression also correlated with CYP3A4, OTC, and F7 as well as CDH1 RNA levels. The Rho/Rho-associated protein kinase pathways, which have been implicated in the regulation of HNF4α, were also differentially expressed, in concert with LRP1, a reported upstream regulator of RhoA function. Conclusion: HNF4α and other members of the LETFs appear to be important regulators of hepatocyte function in patients with chronic hepatic failure. (Hepatology Communications 2018;2:582-594).

Non-Intensive Care Unit Management of Acute Liver Failure

Acute liver failure (ALF) is an uncommon syndrome with a highly variable and unpredictable clinical course. The initial diagnostic evaluation is typically performed in a non-intensive care unit (ICU) setting, like the emergency department or general hospital ward. Prompt restoration of intravascular volume with intravenous fluids and correction of electrolyte, metabolic, and acid-base disturbances are important initial interventions in the management of ALF and can be safely accomplished in non-ICU settings in many patients. Similarly, therapies such as administration of N-acetylcysteine for acetaminophen-induced ALF and other cause-specific interventions can also be administered in non-ICU settings, thus minimizing delay.

The Pathology of Acute Liver Failure

Varied injuries may manifest clinically as acute liver failure. The pathologic features include variable amounts of necrosis and regeneration. This article reviews pathologic classification of patterns of necrosis and associated inflammatory and regenerative responses in specimens from patients with acute liver failure. Detailed pathologic examination of these specimens with clinical pathologic correlation can give the multidisciplinary team vital information regarding etiology and timing as well as extent of injury, and regenerative response. Pathologists are a vital component of the health care team for patients with acute liver failure.

Cellular Mechanisms of Hepatoprotection Mediated by M2-Like Macrophages

BACKGROUND Acute liver injury in the setting of hepatic fibrosis is an intriguing and still unsettled issue. We previously have demonstrated the protective effects conferred by M2-like macrophages in the fibrotic liver. In the present work, we further decipher the cellular mechanisms governing this hepatoprotection. MATERIAL AND METHODS Macrophages were isolated from control mice (M0 macrophages), then polarized into M1 or M2 phenotype using IFN-γ or IL-4, respectively. Conditioned media (CM) from M0, M1, and M2 macrophages were harvested and applied to M1 macrophages. Cell apoptosis was evaluated by immunostaining and real-time PCR. Similarly, human monocyte-derived macrophages were isolated and polarized, then M0, M1, and M2 CM were applied to HL-7702 or HepG2 cells followed by apoptosis induction. Cell apoptosis was assessed by flow cytometry. RESULTS For the mouse conditioned medium experiment, stronger expression of cleaved caspase 3 and higher Bax/Bcl-2 mRNA ratio were found in M1 macrophages pretreated with M2 CM compared to those in M1 macrophages pretreated with M0 or M1 CM. Similarly, exposure of HL-7702 and HepG2 cells to either M0 or M1 CM had no significant effect on cell apoptosis. Nevertheless, the frequency of hepatocyte apoptosis was substantially reduced in HL-7702 (from 32.23±2.99 to 15.37±0.69 for Annexin V+/PI+ staining, p<0.01) and HepG2 cells (from 36.1±7.26 to 15.2±1.2 for Annexin V+/PI+ staining, p<0.01) with M2 CM pretreatment. CONCLUSIONS M2-like macrophages exert their hepatoprotective effect by promoting M1-like macrophage apoptosis but protecting against hepatocyte apoptosis.

Good Tolerance of Citrate Accumulation due to Plasma Exchange among Patients with Acute-on-Chronic Liver Failure: A Prospective, Observational Study

Aim

To assess the tolerance of citrate accumulation due to plasma exchange (PE) among patients with acute-on-chronic liver failure (ACLF).

Methods

A prospective, observational study was conducted among patients with ACLF who received heparin anticoagulation during PE-centered therapy without filtration and dialysis. Citrate accumulation was defined as the value of total calcium (Catot) to ionized calcium (Caion) ratio (Catot/Caion) greater than or equal to 2.5 (Catot/Caion ≥ 2.5).

Results

Fifty-four patients were enrolled. The mean age and MELD score were 50.0 ± 11.3 years old and 25 ± 7, respectively. Thirty-three patients had liver cirrhosis. The total 3-month survival rate was 57.4% (31/54). The mean Catot/Caion at the time before PE was 2.05 ± 0.14. Catot/Caion ≥ 2.5 occurred in 100.0% (54/54) and 29.6% (16/54) of patients with mean Catot/Caion of 4.34 ± 1.52 and 2.36 ± 0.32 immediately after PE and 1 hour after PE, respectively, and these levels were much higher than those before PE (p < 0.01). However, all values returned to lower than 2.5 by the next morning with no difference from those before PE (2.10 ± 0.14 versus 2.05 ± 0.14, p > 0.05). Hypocalcemia (ionized calcium) and mild alkalosis were the main metabolic alterations. No symptoms associated with hypocalcemia occurred.

Conclusions

Citrate accumulation is well tolerated by patients with ACLF who receive PE-centered therapy without filtration and dialysis. This study is regeristed with ChiCTR-OOC-17013618.

Acute-on-chronic liver failure: a time to step forward

Acute-on-chronic liver failure (ACLF) is defined as a syndrome characterized by acute deterioration of liver function on a chronic liver disease, associated with extrahepatic organ failure and high short-term mortality (≥ 15%). This concept represents a disruption in the traditional spectrum of liver diseases, particularly in liver cirrhosis. ACLF may appear during liver disease ranging from compensated to long-standing cirrhosis. Despite the heterogeneity of definitions, it is clear that ACLF results from different types of precipitants in patients with underlying chronic liver disease, mimicking the prognosis of acute liver failure. In this scenario, some new prognostic scores have been proposed instead of MELD or Child-Pugh scores. In the current issue, a retrospective Portuguese study (N = 177) carried out by Barosa et al. explored the usefulness of CLIF scores identifying high mortality rates among cirrhotic patients suffering from ACLF5.

Development of an alpha-fetoprotein and Golgi protein 73 multiplex detection assay using xMAP technology

AIM OF THE STUDY

Development of a new method to simultaneously detect Alpha-fetoprotein (AFP) and Golgi protein 73 (GP73) from peripheral blood.

MATERIAL AND METHODS

Anti human AFP and GP73 monoclonal antibodies was used to develop a sandwich immunity reaction using xMAP technology for the simultaneous detection of plasma AFP and GP73. The assay evaluated the sensitivity, cross reactivity, range of detection, precision, recovery and linearity dilution effect. The assay utilized plasma samples and compared its performance with commercially available Enzyme Linked Immunosorbent Assay (ELISA) kits.

RESULTS

The assay was successful in detecting AFP and GP73 simultaneously. Validation experiments demonstrated the limit of detection was AFP 0.006 μg/l and GP73 0.482 μg/l. The functional sensitivity was AFP 0.010 μg/l and GP73 0.640 μg/l. The range of detection was AFP 0.01-50 μg/l and GP73 0.64-100 μg/l. No cross reactivity was observed. The intra- and inter-assay variation for AFP was 0.19-3.46% and 3.1-5.8% and for GP73 was 1.5-3.2% and 1.1-7.6% respectively. The recovery for AFP was 96-106% and GP73 was 89-110%. 80 clinical plasma samples from healthy controls, and patients with liver cirrhosis and Hepatocellular Carcinoma (HCC) were evaluated. For healthy controls (n = 25), the AFP was 2.40 (1.55, 3.30) μg/l and GP73 was 42.60 (39.10, 57.40) μg/l. For patients with liver cirrhosis (n = 19), the AFP was 2.60 (1.70, 4.20) μg/l and GP73 was 136.10 (92.10, 261.70) μg/l, and for HCC patients (n = 36), the AFP was 13.65 (3.35, 158.88) μg/l and GP73 was 186.25 (96.73, 262.03) μg/l. The new assay demonstrated a good correlation with commercially available ELISA kits (correlation coefficients (r) were 0.997 (AFP, p < 0.001) and 0.959 (GP73, p < 0.001).

CONCLUSIONS

The method demonstrated a sensitive, effective and accurate method for the simultaneous detection of AFP and GP73, and could be used clinically for routine detection and monitoring of patients with chronic hepatitis B.

Prediction of Fungal Infection Development and Their Impact on Survival Using the NACSELD Cohort

OBJECTIVES

Bacterial infections are associated with negative outcomes in cirrhosis but fungal infections are being increasingly recognized. The objective of this study is to define risk factors for fungal infection development and impact on 30-day survival.

METHODS

In a large, multi-center cirrhotic inpatient cohort, demographics, cirrhosis details, intensive care unit (ICU), organ failures/acute-on-chronic liver failure (ACLF), and 30-day survival were compared between patients without infections and with bacterial infections alone, with those with fungal infections. Variables associated with fungal infection development were determined using multi-variable regression. Ordinal variables (0=no infection, 1=community-acquired bacterial infection, 2=nosocomial bacterial, and 3=fungal infection) were input into a 30-day survival model.

RESULTS

A total of 2,743 patients (1,691 no infection, 918 bacterial, and 134 fungal infections) were included. Patients with fungal infection, all of which were nosocomial, were more likely to be admitted with bacterial infections, on spontaneous bacterial peritonitis prophylaxis, and have diabetes and advanced cirrhosis. Bacterial infection types did not predict risk for fungal infections. Multi-variable analysis showed male gender to be protective, whereas diabetes, longer stay, ICU admission, acute kidney injury (AKI), and admission bacterial infection were associated with fungal infection development (area under the curve (AUC)=0.82). Fungal infections were associated with significantly higher ACLF, inpatient stay, ICU admission, and worse 30-day survival. The case fatality rate was 30% with most fungal infections but >50% for fungemia and fungal peritonitis. On a multi-variable analysis, age, AKI, model for end-stage liver disease, ICU admission, and ordinal infection variables impaired survival (P<0.0001, AUC=0.83).

CONCLUSIONS

Fungal infections are associated with a poor 30-day survival in hospitalized cirrhotic patients compared with uninfected patients, and those with bacterial infections. Patients with diabetes, AKI, and those with an admission bacterial infection form a high-risk subgroup.

Bacterial infection-triggered acute-on-chronic liver failure is associated with increased mortality

BACKGROUND & AIMS

Acute-on-chronic liver failure (ACLF) is characterized by an acute deterioration of liver function in patients with cirrhosis in combination with recently defined organ failures. Our aim was to independently validate the prognostic value of the recently established EASL-CLIF-Consortium definition of ACLF and to identify new predictors of short-term mortality.

METHODS

Patients with cirrhosis and the International Classification of Diseases, Tenth Revision diagnosis of (sub)acute liver failure were retrospectively categorized according to the EASL-CLIF-Consortium definition. Logistic regression analyses were performed to identify clinical and epidemiological predictors of 30- and 90-day mortality.

RESULTS

From 2008 to 2015, 257 patients were included. Overall, 173 (67%) patients met the EASL criteria for ACLF (grade 1: n = 43 [25%], grade 2: n = 52 [30%], grade 3: n = 79 [45%]). Mortality within 30 days in patients without ACLF was 3.6%, and 18.6%, 37.3% and 62.0% in patients with ACLF grades 1, 2 and 3 respectively. Outcome of patients with bacterial infection-triggered ACLF was distinct from non-infection-triggered ACLF (71.6% vs 33.8% 30-day survival, P < .001), and infection-triggered ACLF was independently associated with increased mortality (odds ratio [OR] = 4.28, P < .001). Pneumonia was a particularly frequent infection and burdened with high mortality. In addition, infections with multidrug-resistant organisms were frequent and independently associated with mortality (P = .030, OR = 4.41), as was glycopeptide antibiotic therapy as initial empirical antibiotic therapy (P = .005).

CONCLUSIONS

This study confirmed the EASL-CLIF-Consortium definition of ACLF as strong predictor of mortality in patients with acute decompensation of cirrhosis. However, we have observed a remarkably higher mortality in infection-triggered ACLF compared to other precipitating events.

The pathophysiology of arterial vasodilatation and hyperdynamic circulation in cirrhosis

Patients with cirrhosis and portal hypertension often develop complications from a variety of organ systems leading to a multiple organ failure. The combination of liver failure and portal hypertension results in a hyperdynamic circulatory state partly owing to simultaneous splanchnic and peripheral arterial vasodilatation. Increases in circulatory vasodilators are believed to be due to portosystemic shunting and bacterial translocation leading to redistribution of the blood volume with central hypovolemia. Portal hypertension per se and increased splanchnic blood flow are mainly responsible for the development and perpetuation of the hyperdynamic circulation and the associated changes in cardiovascular function with development of cirrhotic cardiomyopathy, autonomic dysfunction and renal dysfunction as part of a cardiorenal syndrome. Several of the cardiovascular changes are reversible after liver transplantation and point to the pathophysiological significance of portal hypertension. In this paper, we aimed to review current knowledge on the pathophysiology of arterial vasodilatation and the hyperdynamic circulation in cirrhosis.

Clinical states of cirrhosis and competing risks

The clinical course of cirrhosis is mostly determined by the progressive increase of portal hypertension, hyperdynamic circulation, bacterial translocation and activation of systemic inflammation. Different disease states, encompassing compensated and decompensated cirrhosis and a late decompensated state, are related to the progression of these mechanisms and may be recognised by haemodynamic or clinical characteristics. While these disease states do not follow a predictable sequence, they correspond to varying mortality risk. Acute-on-chronic liver failure may occur either in decompensated or in compensated cirrhosis and is always associated with a high short-term mortality. The increasing severity of these disease states prompted the concept of clinical states of cirrhosis. A multistate approach has been considered to describe the clinical course of the disease. Such an approach requires the assessment of the probabilities of different outcomes in each state, which compete with each other to occur first and mark the transition towards a different state. This requires the use of competing risks analysis, since the traditional Kaplan-Meier analysis should only be used in two-state settings. Accounting for competing risks also has implications for prognosis and treatment efficacy research. The aim of this review is to summarise relevant clinical states and to show examples of competing risks analysis in multistate models of cirrhosis.

Comparison of five different scoring models for predicting short-term mortality in patients with alcohol-related acute-on-chronic liver failure

AIM

To compare the performance of age, bilirubin, INR, and creatinine (ABIC), Maddrey's discriminant function (MDF), model for end-stage liver disease (MELD), chronic liver failure-sequential organ failure assessment (CLIF-SOFA), and Child-Turcotte-Pugh (CTP) in predicting short-term mortality in patients with alcohol-related acute-on-chronic liver failure (ACLF).

METHODS

There were 462 consecutive patients with live failure treated from August 2005 to June 2017 at Tianjin Third Central Hospital, of whom 152 with alcohol-related ACLF were finally enrolled in this study according to the inclusion criteria and exclusion criteria. We divided patients into either group A or group B. Patients in group A met the criteria of Asian Pacific Association for the Study of the Liver but did not met the criteria of European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF), and patients in group B met the criteria of EASL-CLIF on admission. The performance of different scoring models in predicting short-term mortality was assessed using the area under the receiver operating characteristic curve (AUC-ROC).

RESULTS

The 28-d mortality rate was 19% in group A and 50% in group B (P = 0.002). In group A, the AUC of CLIF-SOFA for predicting the 28-d mortality was highest (0.889), followed by MELD (0.761), MDF (0.738), ABIC (0.718), and CTP (0.671), and there was a significant difference between CTP and the others. In group B, the AUC of CLIF-SOFA was 0.916, followed by MELD (0.804), MDF (0.770), ABIC (0.729), and CTP (0.647), and there was a significant difference between CLIF-SOFA and the others and between CTP and the others.

CONCLUSION

The five scoring systems could all predict the short-term prognosis of the two groups of patients. However, CLIF-SOFA performs well compared to the others, regardless of patients in group A or group B.

Disruption of the gut-liver axis in the pathogenesis of acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is characterized by organ failure mediated by acute decompensation of cirrhosis. Recent studies have highlighted the importance of the gut-liver axis (GLS) and its association with ACLF pathogenesis. In this review, we discuss the mechanisms related to the alteration of the GLA and their involvement in ACLF pathogenesis and suggest some possible therapeutic options that could modulate the GLA dysfunction. This knowledge may provide information useful for the design of therapeutic strategies for gut dysbiosis and its complications in ACLF.

Characteristics of systemic inflammation in hepatitis B-precipitated ACLF: Differentiate it from No-ACLF

BACKGROUND & AIMS

Patients with severe exacerbation of chronic hepatitis B (SE-CHB) are at risk of developing acute-on-chronic liver failure (ACLF). Systemic inflammation (SI) is a major driver of ACLF. The aim of this study was to identify characteristics of SI in hepatitis B-precipitated-ACLF (HB-ACLF), which may be distinct from No-ACLF patients with SE-CHB.

METHODS

Two cohorts of patients with SE-CHB were enrolled in two tertiary hospitals. The associations between circulating leucocyte counts/subsets and ACLF progression and prognoses were analysed in Cohort A. Cytokine measurements, leucocyte phenotyping and whole blood transcriptomic analyses were performed using peripheral blood samples obtained from patients in Cohort B.

RESULTS

Circulating leucocyte counts were higher in the HB-ACLF patients than in the No-ACLF patients (P < .001). Peripheral neutrophilic leucocytosis and monocytosis were associated with lymphopenia. The neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-lymphocyte ratio (MLR) were correlated with risk of death in patients with SE-CHB. NLR independently predicted progression to ACLF in patients without ACLF at enrolment and short-term mortality in ACLF patients. Plasma IL-6, IL-10, G-CSF and GM-CSF levels were higher in ACLF patients (P < .05). Blood transcriptome analyses showed that genes associated with cell migration and mobility and responses to wounding and bacteria were expressed at higher levels while genes involved in lymphocyte-mediated immunity were expressed at lower levels in HB-ACLF patients than in No-ACLF patients.

CONCLUSIONS

Systemic inflammation in HB-ACLF was characterized by an excessive innate immune response, which was associated with disease progression and mortality.

Matrix metalloproteinases and liver fibrosis (translational aspects)

Liver fibrosis, a reversible wound-healing response to chronic cellular injury, reflects a balance between liver repair and progressive substitution of the liver parenchyma by scar tissue. Complex mechanisms that underlie liver fibrogenesis are summarized to provide the basis for generating targeted therapies to reverse fibrogenesis and improve the outcomes of patients with chronic liver disease. This minireview presents some pathophysiological aspects of liver fibrosis as a dynamic process and elucidates matrix metalloproteinases (MMPs) and their role within as well as beyond matrix degradation. Open questions remain, whether inhibition of fibrogenesis or induction of fibrolysis is the key mechanism to resolve fibrosis. And a point of principle might be whether regeneration of liver cirrhosis is possible. Will we ever cure fibrosis?

A nomogram for predicting prognostic value of inflammatory biomarkers in patients with acute-on-chronic liver failure

BACKGROUND

Hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF) in china is a critical clinical syndrome with a high short-term mortality. This study aimed to construct and validate a model for neutrophil to lymphocyte ratio (NLR)-based nomogram for 3-month mortality estimation for patients with ACLF.

METHODS

The nomogram was based on a retrospectively study of 96 patients with ACLF. The predictive accuracy and discriminative ability of nomogram were evaluated by a concordance index (C-index), and calibration curve, comparing with model for end-stage liver disease (MELD) score. The results were validated using bootstrap resampling and an external cohort of 88 patients.

RESULTS

A total of 184 patients with ACLF were enrolled, with 3-month mortality of 40.76%. The cut-off value for NLR was 5.7 using X-tile program. Patients with NLR>5.7 had significantly higher mortality (p<0.001). On multivariate analysis of the training cohort, independent factors for survival were age, NLR and total bilirubin, which were all selected into the nomogram. The calibration curve for probability of survival showed optimal agreement between prediction by nomogram and actual observation. The C-index of nomogram was higher than that of MELD score for predicting survival (0.72 vs 0.56). The results were confirmed in validation cohort.

CONCLUSIONS

The proposed nomogram with NLR resulted in more accurate prognostic prediction for patients with HBV-related ACLF.

Serum osteopontin is a predictor of prognosis for HBV-associated acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is a syndrome with a high rate of short-term mortality, and clinically it is important to identify patients at high risk of mortality. The present study evaluated the value of osteopontin (OPN) in the prediction of 90-day mortality in patients with ACLF. A total of 54 patients with HBV-associated ACLF were enrolled, and serum OPN levels were determined in a prospective, observational study design. Survival analysis was performed using Kaplan-Meier curves, and multivariate Cox proportional hazards regression was used to analyze independent risk factors of mortality. Serum OPN was significantly higher in HBV-ACLF patients compared with patients with chronic hepatitis B and healthy controls (both P<0.01), and furthermore, was higher in those patients who succumbed to HBV-ACLF compared with surviving patients (P<0.05). OPN level positively correlated with total bilirubin (r=0.554, P<0.001), Model for End-Stage Liver Disease (MELD) score (r=0.234, P=0.038), MELD-Na score (r=0.379, P=0.005) and monocyte count (r=0.282, P=0.039), and OPN was an independent risk factor for 90-day mortality in ACLF (P=0.021, odds ratio=1.104, 95% confidence interval: 1.003-1.116). Furthermore, ACLF patients were stratified into three groups according to serum OPN levels (low mortality risk: <6,135 ng/ml; intermediate risk: 6,135-9,043 ng/ml; and high risk: >9,043 ng/ml), for which the 90-day mortality rates were 27.78 (5/18), 52.94 (9/17) and 73.68% (14/19), respectively, and those in the high risk had a poorer prognosis compared with the low risk group (P=0.009). In conclusion, serum OPN may be an independent risk factor associated with HBV-ACLF prognosis.

A novel dynamic model for predicting outcome in patients with hepatitis B virus related acute-on-chronic liver failure

AIM

It is challenging to predict the outcome of patients with hepatitis B virus related acute-on-chronic liver failure (HBV-ACLF) through existing prognostic models. Our aim was to establish a novel dynamic model to improve the predictive efficiency of 30-day mortality in HBV-ACLF patients.

METHODS

305 patients who were diagnosed as HBV-ACLF (derivation cohort, n=211; validation cohort, n=94) were included in this study. The HBV-ACLF dynamic (HBV-ACLFD) model was constructed based on the daily levels of predictive variables in 7 days after diagnosis combined with baseline risk factors by multivariate logistic regression analysis. The HBV-ACLFD model was compared with the Child-Turcotte-Pugh (CTP) score, end-stage liver disease (MELD) score, and MELD within corporation of serum sodium (MELD-Na) score by the area under the receiver-operating characteristic curves (AUROC).

RESULTS

The HBV-ACLFD model demonstrated excellent discrimination with AUROC of 0.848 in the derivation cohort and of 0.813 in the validation cohort (p=0.620). The performance of the HBV-ACLFD model appeared to be superior to MELD score, MELD-Na score and CTP score (P<0.0001).

CONCLUSION

The HBV-ACLFD model can accurately predict 30-day mortality in patients with HBV-ACLF, which is helpful to select appropriate clinical procedures, so as to relieve the social and economic burden.

Nutrition and Muscle in Cirrhosis

As the cirrhosis progresses, development of complication like ascites, hepatic encephalopathy, variceal bleeding, kidney dysfunction, and hepatocellular carcinoma signify increasing risk of short term mortality. Malnutrition and muscle wasting (sarcopenia) is yet other complications that negatively impact survival, quality of life, and response to stressors, such as infection and surgery in patients with cirrhosis. Conventionally, these are not routinely looked for, because nutritional assessment can be a difficult especially if there is associated fluid retention and/or obesity. Patients with cirrhosis may have a combination of loss of skeletal muscle and gain of adipose tissue, culminating in the condition of "sarcopenic obesity." Sarcopenia in cirrhotic patients has been associated with increased mortality, sepsis complications, hyperammonemia, overt hepatic encephalopathy, and increased length of stay after liver transplantation. Assessment of muscles with cross-sectional imaging studies has become an attractive index of nutritional status evaluation in cirrhosis, as sarcopenia, the major component of malnutrition, is primarily responsible for the adverse clinical consequences seen in patients with liver disease. Cirrhosis is a state of accelerated starvation, with increased gluconeogenesis that requires amino acid diversion from other metabolic functions. Protein homeostasis is disturbed in cirrhosis due to several factors such as hyperammonemia, hormonal, and cytokine abnormalities, physical inactivity and direct effects of ethanol and its metabolites. New approaches to manage sarcopenia are being evolved. Branched chain amino acid supplementation, Myostatin inhibitors, and mitochondrial protective agents are currently in various stages of evaluation in preclinical studies to prevent and reverse sarcopenia, in cirrhosis.

Gamma-glutamyl transpeptidase-to-platelet ratio predicts the prognosis in HBV-associated acute-on-chronic liver failure

BACKGROUND

The gamma-glutamyl transpeptidase-to-platelet ratio (GPR) is a new noninvasive marker for assessing liver fibrosis. We aimed to evaluate the performance of GPR for prediction of 90-day mortality in patients with acute-on-chronic liver failure (ACLF).

METHODS

A total of 355 patients with HBV-associated ACLF were enrolled from two clinical centers and divided into training group (n=210) and validation group (n=145). Potential risk factors for 90-day mortality were analyzed.

RESULTS

Age, MELD score and GPR were independent risk factors associated with ACLF prognosis. A new scoring system (MELD-GPR) was developed. MELD-GPR=9.211-0.029×age-0.290×MELD-0.460×GPR. For ACLF patients with liver cirrhosis, the area under the receiver operating characteristic curve (AUROC) of MELD-GPR was 0.788, which was significantly higher than that of MELD and MELD-Na (0.706 and 0.666, respectively). Patients were stratified into three groups according to MELD-GPR scores (high risk: <-0.19, intermediate risk: -0.19-0.95, and low risk: >0.95), and the high-risk group (MELD-GPR<-0.19) had a poor prognosis (P<0.01). For ACLF patients without liver cirrhosis, MELD-GPR<0.95 predicted a poor prognosis.

CONCLUSIONS

Incorporating GPR into MELD may provide more accurate survival prediction in patients with HBV-ACLF.

Cholemic nephropathy - Historical notes and novel perspectives

Acute kidney injury is common in patients with liver disease and associated with significant morbidity and mortality. Besides bacterial infections, fluid loss, and use of nephrotoxic drugs AKI in liver disease may be triggered by tubular toxicity of cholephiles. Cholemic nephropathy, also known as bile cast nephropathy, supposedly represents a widely underestimated but important cause of renal dysfunction in cholestasic or advanced liver diseases with jaundice. Cholemic nephropathy describes impaired renal function along with characteristic histomorphological changes consisting of intratubular cast formation and tubular epithelial cell injury directed towards distal nephron segments. The underlying pathophysiologic mechanisms are not entirely understood and clear defined diagnostic criteria are still missing. This review aims to summarize (i) the present knowledge on clinical and morphological characteristics of cholemic nephropathy, (ii) available preclinical models, (iii) potential pathomechanisms especially the potential role of bile acids, and (iv) future diagnostic and therapeutic strategies for cholemic nephropathy. This article is part of a Special Issue entitled: Cholangiocytes in Health and Disease edited by Jesus Banales, Marco Marzioni, Nicholas LaRusso and Peter Jansen.