Liver failure

Serum wnt5a is a predictor for the prognosis of acute on chronic hepatitis B liver failure

OBJECTIVES

To find a biomarker to predict the prognosis of acute on chronic hepatitis B liver failure (ACHBLF).

METHODS

Expression gene profiles in wnt pathway were determined in serum from 63 patients with ACHBLF, 60 patients with chronic hepatitis B (CHB) and 30 healthy controls (HCs).

RESULTS

Serum wnt5a concentration of 1.553 ng/ml showed a poor prognosis with a sensitivity of 69.23% and a specificity of 83.33% in ACHBLF patients.

CONCLUSIONS

Serum wnt5a gene expression might be a potential biomarker for predicting the prognosis of ACHBLF.

Cross-sectional and dynamic change of serum metabolite profiling for Hepatitis B-related acute-on-chronic liver failure by UPLC/MS

Summary Acute-on-chronic liver failure(ACLF) is an increasingly recognized entity encompassing an acute deterioration of liver function and results in the failure of one or more organs with high short-term mortality. The focus of this study was to discover noninvasive and reliable biomarkers for the diagnosis and prognosis of hepatitis B-related ACLF. Ultra-performance liquid chromatography-mass spectrometry (UPLC/MS) was used to analyse serum metabolites of 28 patients with hepatitis B-related ACLF, 35 patients with Child-Pugh A cirrhosis, 30 patients with chronic hepatitis B and 35 healthy volunteers (HS). Characteristic metabolites were screened, identified and dynamically tracked to investigate their value for diagnosis and prognosis. After comparing serum metabolic profile of hepatitis B-related ACLF and Child-Pugh A cirrhosis, 99 characteristic metabolites were selected, and 38 of them were identified. Dynamic tracking model demonstrated that 17 metabolites were related to prognosis of hepatitis B-related ACLF, and there were also 11 metabolites which improved with treatment in the survival group. The correlations between these characteristic metabolites and the model for end-stage liver disease score were strong. These observations contributed to the investigation of the mechanisms of hepatitis B-related ACLF manifestation and progression on the metabolic level, and they provided information for the identification of biomarkers for the diagnosis and prognosis of hepatitis B-related ACLF.

Liver histology as predictor of outcome in patients with acute-on-chronic liver failure (ACLF)

There is paucity of literature on liver histological spectrum of acute-on-chronic liver failure (ACLF). The aims of this study are to (a) to characterize the liver histological features in ACLF, (b) to correlate histological parameters with prognosis, and (c) to investigate whether etiology influences prognosis. We retrospectively studied liver biopsies of patients with ACLF. The histological findings were correlated with the clinical outcome. Fifty cases (median age, 39 years [10-69 years]; M/F, 3:1) were included. Etiology of acute insult was viral or alcohol in majority of the cases. Twenty-five patients survived (good outcome, 50%) and 25 died (poor outcome, 50%). On a univariate analysis, the outcome correlated with fibrosis, ballooning, eosinophilic degeneration, ductular proliferation, pericellular fibrosis, Mallory's hyaline, foci of confluent necrosis and/or bridging necrosis (CN/BN), cholestasis, apoptosis (present), and parenchyma left. However, on a multivariate analysis, only fibrosis, ballooning, ductular proliferation, apoptosis, and parenchyma left were found to be independently associated with outcome. Two distinct patterns of liver histology were observed: pattern I, observed in cases with poor outcome, showing marked ductular proliferation, coarse inspissated ductular bile plugs, eosinophilic degeneration of hepatocytes, foci of CN/BN, higher apoptosis, pericellular fibrosis, Mallory's hyaline, and higher stage of fibrosis. Pattern II is seen in cases with good outcome, show prominent hepatocyte ballooning with lesser parenchymal involvement by fibrosis and necrosis. Histological features of liver biopsy are: extent of fibrosis, ballooning, ductular proliferation, apoptosis, and lesser degree of parenchymal replacement by fibrosis or necrosis which correlates with the outcome in patients with ACLF. Two distinct patterns of liver histology are seen which help in prognostication.

Liver histology as predictor of outcome in patients with acute-on-chronic liver failure (ACLF)

There is paucity of literature on liver histological spectrum of acute-on-chronic liver failure (ACLF). The aims of this study are to (a) to characterize the liver histological features in ACLF, (b) to correlate histological parameters with prognosis, and (c) to investigate whether etiology influences prognosis. We retrospectively studied liver biopsies of patients with ACLF. The histological findings were correlated with the clinical outcome. Fifty cases (median age, 39 years [10-69 years]; M/F, 3:1) were included. Etiology of acute insult was viral or alcohol in majority of the cases. Twenty-five patients survived (good outcome, 50%) and 25 died (poor outcome, 50%). On a univariate analysis, the outcome correlated with fibrosis, ballooning, eosinophilic degeneration, ductular proliferation, pericellular fibrosis, Mallory's hyaline, foci of confluent necrosis and/or bridging necrosis (CN/BN), cholestasis, apoptosis (present), and parenchyma left. However, on a multivariate analysis, only fibrosis, ballooning, ductular proliferation, apoptosis, and parenchyma left were found to be independently associated with outcome. Two distinct patterns of liver histology were observed: pattern I, observed in cases with poor outcome, showing marked ductular proliferation, coarse inspissated ductular bile plugs, eosinophilic degeneration of hepatocytes, foci of CN/BN, higher apoptosis, pericellular fibrosis, Mallory's hyaline, and higher stage of fibrosis. Pattern II is seen in cases with good outcome, show prominent hepatocyte ballooning with lesser parenchymal involvement by fibrosis and necrosis. Histological features of liver biopsy are: extent of fibrosis, ballooning, ductular proliferation, apoptosis, and lesser degree of parenchymal replacement by fibrosis or necrosis which correlates with the outcome in patients with ACLF. Two distinct patterns of liver histology are seen which help in prognostication.

Serum peptide profiles during progression of chronic hepatitis B virus infection to liver failure

Chronic hepatitis B virus (HBV)-infected patients with liver failure have a poor prognosis, and no satisfactory biomarkers are available for diagnosis before the end-stage. We explored serum peptide profiling for diagnosis and prediction of progression to liver failure in HBV-infected patients. Serum samples (164) from healthy subjects (n = 20), or subjects with chronic hepatitis B without cirrhosis and liver failure [chronic hepatitis B subjects without cirrhosis and liver failure (CHB); n = 33], with compensated liver cirrhosis (compensated liver cirrhosis (LC); n = 35), with acute-on-chronic liver failure [acute-on-chronic liver failure (ACLF); n = 38] or with chronic liver failure [chronic liver failure (CLF), n = 38] were applied to ClinProt magnetic beads, and bound peptides/proteins were analyzed by matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry. Our classification diagnostic models of liver disease were generated based on the Genetic Algorithm (GA) and Quick Classifier Algorithm (QC). Differentially expressed peptides were found among all test groups, with patterns of difference that readily distinguished between healthy and various HBV-associated liver disease samples. The model generated seven characteristic peptide peaks at 4053 m/z, 3506 m/z, 4963 m/z, 9289 m/z, 2628 m/z, 3193 m/z and 6432 m/z, giving overall predictive capability of 54.27%. Two-way comparisons of LC, ACLF or CLF vs CHB had predictive capabilities of 79.8%, 91.41% and 97.99%, respectively. Comparisons of ACLF or CLF vs LC were predictive at 87.72% and 82.18%, respectively and ACLF vs CLF was predictive at 75.05%. These classification diagnostic models generated by different peptide peaks were further validated in blinded tests with 67-100% accuracy. Serum peptide patterns vary during progression of chronic HBV infection to liver failure and may be used to distinguish different stages of the disease.

Extracorporeal liver support therapy with Prometheus in patients with liver failure in the intensive care unit

Acute liver failure (ALF) and acute-on-chronic liver failure (AoCLF) are associated with a high mortality. In these patients an accumulation of both water-soluble and water-insoluble, protein-bound, metabolic waste products occurs. Conventional extracorporeal blood purification techniques based on diffusion and/or convection such as hemodialysis or hemofiltration may only eliminate small molecular weight, water-soluble compounds. In recent years, fractionated plasma separation and adsorption (FPSA) with the Prometheus system has been introduced for extracorporeal liver support therapy. To date, however, only limited data is available regarding the effect of this treatment on mortality and outcome of patients with advanced liver disease. Here we report on our experience with 23 patients with severe liver failure who were treated with Prometheus in our medical intensive care unit. Fourteen patients had AoCLF, and nine patients experienced ALF. The median bilirubin level at the start of Prometheus therapy was 30.5 mg/dL and the median Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 26. During 40 individual treatment sessions lasting 5-6 h, Prometheus therapy reduced serum bilirubin levels from 23.7 mg/dL to 15.0 mg/dL (median values) (P < 0.001), and the overall survival was 26%. ALF patients had a better survival compared to AoCLF patients (44% vs. 22%; P = 0.022). Apart from one patient who developed hemodynamic instability during a treatment session, Prometheus therapy was well tolerated without relevant side-effects. In conclusion, extracorporeal liver support therapy with Prometheus is a novel and safe treatment option in patients with severe liver failure. In this series, patients with ALF showed a significantly better outcome with Prometheus therapy compared to AoCLF patients.

Albumin dialysis in liver failure: comparison of molecular adsorbent recirculating system and single pass albumin dialysis--a retrospective analysis

Despite improvement in critical care, liver failure is still associated with high mortality. Therapeutic concepts are aimed at restoring endogenous liver function or to bridge the time to liver transplantation. In addition to standard medical treatment, extracorporeal liver support with albumin dialysis is used for this purpose. The aim of this study was to analyze the efficacy of single pass albumin dialysis (SPAD) in comparison to the molecular adsorbent recirculating system (MARS) in patients treated at our university hospital intensive care unit between July 2004 and August 2008. In this retrospective analysis we studied patients presenting with liver failure who were treated with albumin dialysis. Laboratory parameters, daily health scoring, the number of transfusions, and mortality were recorded. The (paired) t-test, Mann-Whitney U-test, and Wilcoxon test were used for statistical analysis. In all, 163 albumin dialysis treatments, 126 with MARS and 37 with SPAD, in 57 patients were performed. MARS resulted in a significant decrease in bilirubin (-38 +/- 66.5 micromol/L from a baseline of 301 +/- 154.6 micromol/L), gamma-glutamyltransferase (gamma-GT), alanine aminotransferase, creatinine, and urea. SPAD resulted in a significant decrease in bilirubin (-41 +/- 111.2 micromol/L from a baseline of 354 +/- 189.4 micromol/L) and gamma-GT, while lactate levels increased. No differences in the need for blood transfusion, health scoring, or mortality between the two treatment modalities were detected. This retrospective analysis suggests equal efficacy of MARS and SPAD; however, prospective assessment to further define the role of SPAD in the treatment of acute or acute-on-chronic liver failure is needed.

Clinical features and predictors of outcome in acute hepatitis A and hepatitis E virus hepatitis on cirrhosis

BACKGROUND AND OBJECTIVES

Acute hepatitis A and E are recognized triggers of hepatic decompensation in patients with cirrhosis, particularly from the Indian subcontinent. However, the resulting acute-on-chronic liver failure (ACLF) has not been well characterized and no large studies are available. Our study aimed to evaluate the clinical profile and predictors of 3-month mortality in patients with this distinctive form of liver failure.

METHODS

ACLF was diagnosed in patients with acute hepatitis A or E [abrupt rise in serum bilirubin and/or alanine aminotransferase with positive immunoglobulin M anti-hepatitis A virus (HAV)/anti-hepatitis E virus (HEV)] presenting with clinical evidence of liver failure (significant ascites and/or hepatic encephalopathy) and clinical, biochemical, endoscopic (oesophageal varices at least grade II in size), ultrasonographical (presence of nodular irregular liver with porto-systemic collaterals) or histological evidence of cirrhosis. Clinical and laboratory profile were evaluated, predictors of 3-month mortality were determined using univariate and multivariate logistic regression and a prognostic model was constructed. Receiver-operating curves were plotted to measure performance of the present prognostic model, model for end-stage liver disease (MELD) score and Child-Turcotte-Pugh (CTP) score.

RESULTS

ACLF occurred in 121 (3.75%) of 3220 patients (mean age 36.3+/-18.0 years; M:F 85:36) with liver cirrhosis admitted from January 2000 to June 2006. It was due to HEV in 80 (61.1%), HAV in 33 (27.2%) and both in 8 (6.1%). The underlying liver cirrhosis was due to HBV (37), alcohol (17), Wilson's disease (8), HCV (5), autoimmune (6), Budd-Chiari syndrome (2), haemochromatosis (2) and was cryptogenic in the rest (42). Common presentations were jaundice (100%), ascites (78%) and hepatic encephalopathy (55%). Mean (SD) CTP score was 11.4+/-1.6 and mean MELD score was 28.6+/-9.06. Three-month mortality was 54 (44.6%). Complications seen were sepsis in 42 (31.8%), renal failure in 45 (34%), spontaneous bacterial peritonitis in 27 (20.5%), UGI bleeding in 15(11%) and hyponatraemia in 50 (41.3%). On univariate analysis, ascites, hepatic encephalopathy, renal failure, GI bleeding, total bilirubin, hyponatraemia and coagulopathy were significant predictors of mortality. Multivariate analysis revealed grades 3 and 4 HE [odds ratio (OR 32.1)], hyponatraemia (OR 9.2) and renal failure (OR 16.8) as significant predictors of 3-month mortality and a prognostic model using these predictors was constructed. Areas under the curve for the present predicted prognostic model, MELD, and CTP were 0.952, 0.941 and 0.636 respectively.

CONCLUSIONS

ACLF due to hepatitis A or E super infection results in significant short-term mortality. The predictors of ominous outcome include grades 3 and 4 encephalopathy, hyponatraemia and renal failure. Present prognostic model and MELD scoring system were better predictors of 3-month outcome than CTP score in these patients. Early recognition of those with dismal prognosis may permit timely use of liver replacement/supportive therapies.

Evaluation of mannitol effect in patients with acute hepatic failure and acute-on-chronic liver failure using conventional MRI, diffusion tensor imaging and in-vivo proton MR spectroscopy

AIM: To evaluate the effect of an intravenous bolus of mannitol in altering brain metabolites, brain water content, brain parenchyma volume, cerebrospinal fluid (CSF) volume and clinical signs in controls and in patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF), by comparing changes in conventional magnetic resonance imaging (MRI), in vivo proton magnetic resonance spectroscopy (PMRS) and diffusion tensor imaging (DTI) before and after its infusion.

METHODS: Five patients each with ALF and ACLF in grade 3 or 4 hepatic encephalopathy and with clinical signs of raised intracranial pressure were studied along with five healthy volunteers. After baseline MRI, an intravenous bolus of 20% mannitol solution was given over 10 min in controls as well as in patients with ALF and ACLF. Repeat MRI for the same position was acquired 30 min after completing the mannitol injection.

RESULTS: No statistically significant difference was observed between controls and patients with ALF and ACLF in metabolite ratios, DTI metrics and brain volume or CSF volume following 45 min of mannitol infusion. There was no change in clinical status at the end of post-mannitol imaging.

CONCLUSION: The osmotic effect of mannitol did not result in significant reduction of brain water content, alteration in metabolite ratios or any change in the clinical status of these patients during or within 45 min of mannitol infusion.

Isolation and characterization of a novel population of progenitor cells from unmanipulated rat liver

Widespread use of liver transplantation in the treatment of hepatic diseases is restricted by the limited availability of donated organs. One potential solution to this problem would be isolation and propagation of liver progenitor cells or stem cells. Here, we report on the isolation of a novel progenitor cell population from unmanipulated (that is, no prior exposure to chemicals and no injury) adult rat liver. Rat liver cells were cultured following a protocol developed in our laboratory to generate a unique progenitor cell population called liver-derived progenitor cells (LDPCs). LDPCs were analyzed by fluorescence-activated cell sorting, real-time polymerase chain reaction (RT-PCR), immunostaining and microarray gene expression. LDPCs were also differentiated into hepatocytes and biliary epithelium in vitro and examined for mature hepatic markers and urea and albumin production. These analyses showed that, LDPCs expressed stem cell markers such as cluster domain (CD)45, CD34, c-kit, and Thy 1, similar to hematopoietic stem cells, as well as endodermal/hepatic markers such as hepatocyte nuclear factor (HNF)3beta, hematopoietically-expressed homeobox gene-1, c-met, and transthyretin. LDPCs were negative for OV-6, cytokeratins (CKs), albumin, and HNF1alpha. The microarray gene expression profile demonstrated that they showed some similarities to known liver progenitor/stem cells such as oval cells. In addition, LDPCs differentiated into functional hepatocytes in vitro as shown by albumin expression and urea production. In conclusion, LDPCs are a population of unique liver progenitors that can be generated from unmanipulated adult liver, which makes them potentially useful for clinical applications, especially for cell transplantation in the treatment of liver diseases.

Impact of Pretransplant MELD Score on Posttransplant Outcome in Orthotopic Liver Transplantation for Patients with Acute-on-Chronic Hepatitis B Liver Failure

This study was performed to evaluate the usefulness of the model for end-stage liver disease (MELD) score in comparison with the Child-Turcotte-Pugh (CTP) score to predict short-term postoperative survival and 3-month morbidity among patients with acute-on-chronic hepatitis B liver failure undergoing orthotopic liver transplantation.

METHODS

We retrospectively analyzed data from all patients undergoing orthotopic liver transplantation in our unit from December 1999 to November 2005, on the admission day MELD and CTP scores were calculated for each patient according to the original formula. We evaluated the accuracy of MELD and CTP to predict postoperative short-term survival and 3-month morbidity using receiver operating characteristic (ROC) analysis and Kaplan-Meier analysis, respectively.

RESULTS

Seven of 42 patients died within 3-months follow-up. The MELD scores for nonsurvivors (32.97 +/- 7.11) were significantly higher than those for survivors (24.90 +/- 4.96; P < .05), CTP scores were significantly higher, too (12.57 +/- 0.98, 11.51 +/- 1.17; P < .05). ROC analysis identified the MELD best cut-off point to be 25.67 to predict postoperative morbidity (area under the curve [AUC] = 0.841; sensitivity = 85.7%; specificity = 60.0%), and the CTP best cut-off point was 11.5 (AUC = 0.747; sensitivity = 85.7%; specificity = 54.3%). MELD score was superior to CTP score to predict postoperative short-term survival and 3-month morbidity among patients with acute-on-chronic hepatitis B liver failure undergoing orthotopic liver transplantation.

CONCLUSION

MELD score was an objective predictive system and more efficient than CTP score to evaluate the risk of 3-month morbidity and short-term prognosis in patients with acute-on-chronic hepatitis B liver failure undergoing orthotopic liver transplantation.

Economic evaluation of the artificial liver support system MARS in patients with acute-on-chronic liver failure

Background

Acute-on-chronic liver failure (ACLF) is a life threatening acute decompensation of a pre-existing chronic liver disease. The artificial liver support system MARS is a new emerging therapeutic option possible to be implemented in routine care of these patients. The medical efficacy of MARS has been demonstrated in first clinical studies, but economic aspects have so far not been investigated. Objective of this study was to estimate the cost-effectiveness of MARS.

Methods

In a clinical cohort trial with a prospective follow-up of 3 years 33 ACLF-patients treated with MARS were compared to 46 controls. Survival, health-related quality of life as well as direct medical costs for in- and outpatient treatment from a health care system perspective were determined. Based on the differences in outcome and indirect costs the cost-effectiveness of MARS expressed as incremental costs per life year gained and incremental costs per QALY gained was estimated.

Results

The average initial intervention costs for MARS were 14600 EUR per patient treated. Direct medical costs over 3 years follow up were overall 40000 EUR per patient treated with MARS respectively 12700 EUR in controls. The 3 year survival rate after MARS was 52% compared to 17% in controls. Kaplan-Meier analysis of cumulated survival probability showed a highly significant difference in favour of MARS. Incremental costs per life-year gained were 31400 EUR; incremental costs per QALY gained were 47200 EUR.

Conclusion

The results after 3 years follow-up of the first economic evaluation study of MARS based on empirical patient data are presented. Although high initial treatment costs for MARS occur the significantly better survival seen in this study led to reasonable costs per live year gained. Further randomized controlled trials investigating the medical efficacy and the cost-effectiveness are recommended.