The relationship between liver function and portal pressure: what comes first, the chicken or the egg?

Remodeling liver microenvironment by L-arginine loaded hollow polydopamine nanoparticles for liver cirrhosis treatment

Liver cirrhosis is a liver disease with a high mortality rate worldwide, and antifibrotic drugs are commonly used clinically to alleviate the symptoms, but there are still many challenges. Many studies have shown that excessive reactive oxygen species (ROS) in the microenvironment of liver lesions is an important factor leading to the development of liver cirrhosis. Herein, a nanomedicine-mediated antioxidant therapy was utilized to remodel liver microenvironment and hence reverse the process of cirrhosis from the root. Firstly, L-arginine (L-Arg) loaded and pPB peptide modified PEGylated hollow polydopamine (HPDA) nanoparticles (L-Arg@HPDA-PEG-pPB, L@HPp) were prepared successfully. The in vitro and in vivo experiment showed that L@HPp significantly inhibited oxidative stress and inflammatory reaction, reduced the activation of hepatic stellate cells (HSCs), inhibited the pro-fibrosis molecular pathway, and reduced the deposition of extracellular matrix (ECM), thereby effectively inhibiting liver fibrosis. The pPB peptide modification increased the targeting effect to HSCs. In addition, the oxidative microenvironment in liver cirrhosis promoted the transformation of the loaded L-Arg to nitric oxide (NO), and the latter one caused vascular dilation and further relieved portal hypertension, a typical complication of liver cirrhosis. Therefore, L@HPp had a good prospect of clinical application in the treatment of liver cirrhosis and its complications.

Is there any vindication for low dose nonselective β-blocker medication in patients with liver cirrhosis?

Background/Aims

Nonselective β-blockers (NSBBs), such as propranolol, reportedly exert a pleiotropic effect in liver cirrhosis. A previous report suggested that survival was higher in patients receiving adjusted doses of NSBBs than in ligation patients. This study investigated whether low-dose NSBB medication has beneficial effects in patients with liver cirrhosis, especially in terms of overall survival.

Methods

We retrospectively studied 273 cirrhotic patients (199 males; age 53.6±10.2 years, mean±SD) who visited our institution between March 2003 and December 2007; follow-up data were collected until June 2011. Among them, 138 patients were given a low-dose NSBB (BB group: propranolol, 20-60 mg/day), and the remaining 135 patients were not given an NSBB (NBB group). Both groups were stratified randomly according to Child-Turcotte-Pugh (CTP) classification and age.

Results

The causes of liver cirrhosis were alcohol (n=109, 39.9%), hepatitis B virus (n=125, 45.8%), hepatitis C virus (n=20, 7.3%), and cryptogenic (n=19, 7.0%). The CTP classes were distributed as follows: A, n=116, 42.5%; B, n=126, 46.2%; and C, n=31, 11.4%. Neither the overall survival (P=0.133) nor the hepatocellular carcinoma (HCC)-free survival (P=0.910) differed significantly between the BB and NBB groups [probability of overall survival at 4 years: 75.1% (95% CI=67.7-82.5%) and 81.2% (95% CI=74.4-88.0%), respectively; P=0.236]. In addition, the delta CTP score did not differ significantly between the two groups.

Conclusions

Use of low-dose NSBB medication in patients with liver cirrhosis is not indicated in terms of overall and HCC-free survival.

Management of varices in cirrhosis

INTRODUCTION

Acute variceal bleeding is a medical emergency and one of the main causes of mortality in patients with cirrhosis. Timely and effective treatment of the acute bleeding episode results in increased survival, and appropriate prophylactic treatment can prevent bleeding or rebleeding from varices.

AREAS COVERED

We discuss the prevention of development and growth of varices, the primary and secondary prophylaxis of bleeding, the treatment of acute bleeding, and the management of gastric varices. We systematically reviewed studies, without time limits, identified through Medline and searches of reference lists, and provide an overview of the evidence underlying the -treatment options in the management of varices in cirrhosis.

EXPERT OPINION

The management of variceal hemorrhage relies on nonspecific interventions (e.g., adequate fluid resuscitation, airway protection) and on specific interventions. These are routine prophylactic antibiotics, vasoactive drugs and endoscopic treatment. Procedures such as the placement of a Sengstaken-Blakemore tube or a transjugular intrahepatic portosystemic shunt (TIPS) can be lifesaving. The primary and secondary prophylaxis of bleeding is based on nonselective beta-blockers and endoscopy, even though TIPS or, less frequently, surgery have a role in selected cases.

beta-Blockers protect against spontaneous bacterial peritonitis in cirrhotic patients: a meta-analysis

INTRODUCTION

Bacterial infections have been hypothetized to be a trigger of variceal bleeding in cirrhotic patients and beta-blockers may have a protective effect by decreasing bacterial translocation, reducing portal pressure. The aim of our study was to evaluate the possible role of beta-blockers in preventing spontaneous bacterial peritonitis (SBP) in patients with liver cirrhosis and ascites.

MATERIALS AND METHODS

Extensive search of the literature including randomized controlled trial (RCT) and non-RCT of primary and secondary prophylaxis for variceal bleeding in cirrhotics using beta-blockers were evaluated. We performed a meta-analysis using the occurrence of SBP as endpoint in all the studies, using the random effect model.

RESULTS

Three RCT and three retrospective studies in which beta-blockers were evaluated against no treatment for the prevention of SBP in ascitic cirrhotics were included. There was a statistically significant difference of 12.1%, P<0.001 in favour of propranolol in preventing SBP, which was confirmed by sensitivity analysis evaluating only RCTs (7.8% difference). The effect was still present when haemodynamic responders were compared with non-responders.

CONCLUSIONS

This analysis suggests a role of beta-blockers in preventing SBP in ascitic cirrhotics, independent of haemodynamic response. Further formal RCTs are needed to confirm this finding.

Review article: the therapeutic and prognostic benefit of portal pressure reduction in cirrhosis

BACKGROUND

Hepatic venous pressure gradient (HVPG) measurement is not a routinely used technique, despite its therapeutic and prognostic value.

AIM

To review the role of HVPG from published literature.

METHODS

Systematic literature review.

RESULTS

In acute variceal bleeding, HVPG is prognostic identifying 'difficult to treat' group, which now has defined clinical correlations. In secondary prevention of portal hypertensive bleeding, a reduction to < or = 12 mmHg confers near complete protection against rebleeding. The target of > or = 20% HVPG reduction from baseline needs prospective assessment to test a change of therapy, if no reduction occurs. The acute HVPG response to beta-blockade needs further assessment. In primary prevention, the cost-effectiveness of HVPG measurement is not favourable given the efficacy of medical therapy. In chronic liver disease, wedge hepatic venous pressure (WHVP) is prognostic for survival. Pharmacological reduction in portal pressure decreases complications and improves survival, possibly independent of a concomitant improvement in liver function. This latter requires urgent confirmation as it is clinically very relevant. HVPG monitoring can be used to assess anti-viral therapy particularly in cirrhosis, ergonomically combined with transjugular biopsy.

CONCLUSIONS

The prognostic and therapeutic value of HVPG is established beyond portal hypertensive bleeding for which there are some clinical surrogates. HVPG measurement should now be part of everyday clinical practice.

The transjugular route: the key hole to the liver world

Portal hypertensive complications are major causes of morbidity and mortality in patients with liver cirrhosis. The advent of the transjugular route with its minimal access allows non-surgical management of portal hypertension, therapy of venous complications of liver transplantation, monitoring of therapy for portal hypertension, hepatic venous pressure gradient and is also the major route to treat hepatic venous obstruction syndromes. In addition, the transjugular route is a safe route to perform a liver biopsy (transjugular liver biopsy) and allows retrograde evaluation of the portal vein. All these procedures can be combined in the same session. These hepatic interventional radiological skills should be incorporated into the expertise of the liver team in specialised hepatological centres, particularly in liver transplant centres as they are especially useful in improving outcomes of cirrhotic patients on the liver transplantation waiting list. A limitation in achieving this goal, could be the number of experienced radiologists, but hepatologists can be trained, at least for the most simple procedures (transjugular liver biopsy and hepatic venous pressure gradient). This would allow wider applicability and use of these diagnostic and therapeutic techniques, all through a 2 mm hole in the neck--the key hole to the liver world.