Stravitz RT, Sanyal AJ, Reisch J, Bajaj JS, Mirshahi F, Cheng J, Lee WM. Effects of N-acetylcysteine on cytokines in non-acetaminophen acute liver failure: potential mechanism of improvement in transplant-free survival.
Liver Int 2013;
33:1324-31. [PMID:
23782487 PMCID:
PMC4994536 DOI:
10.1111/liv.12214]
[Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Accepted: 05/05/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND
N-Acetylcysteine (NAC) improves transplant-free survival in patients with non-acetaminophen acute liver failure (ALF) when administered in early stages of hepatic encephalopathy. The mechanisms of this benefit are unknown.
AIM
To determine whether NAC improves transplant-free survival in ALF by ameliorating the surge of pro-inflammatory cytokines.
METHODS
Serum samples were obtained from 78 participants of the randomized, ALF Study Group NAC Trial with grade 1 or 2 hepatic encephalopathy on randomization. Concentrations of ten cytokines, chosen to represent a wide array of inflammatory responses, were determined by multiplex enzyme-linked immunosorbent assay ELISA.
RESULTS
In univariate analysis, predictors of transplant-free survival included NAC administration (P = 0.012), admission bilirubin (P = 0.003), international normalized ratio INR (P = 0.0002), grade 1 vs. grade 2 encephalopathy (P = 0.006) and lower admission interleukin (IL)-17 concentrations (P = 0.011). IL-17 levels were higher in patients with grade 2 vs. grade 1 encephalopathy on randomization (P = 0.007) and in those who progressed to grade 3 or grade 4 encephalopathy over the following 7 days (P ≤ 0.01). Stepwise multivariate logistic regression analysis identified only NAC administration and lower IL-17 concentrations as independent predictors of transplant-free survival. In patients with detectable IL-17 concentrations on admission, 78% of those who received NAC vs. 44% of those who received placebo had undetectable levels by day 3-5 (P = 0.042), and the mean decrease in IL-17 concentrations between admission and late samples was significantly greater in patients who received NAC vs. placebo (P = 0.045).
CONCLUSIONS
N-acetylcysteine (NAC) may improve transplant-free survival in patients with non-acetaminophen ALF by ameliorating the production of IL-17, which is associated with progression of hepatic encephalopathy and poor outcome.
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