Review article: the reversibility of cirrhosis

Advances in Noninvasive Molecular Imaging Probes for Liver Fibrosis Diagnosis

Liver fibrosis is a wound-healing response to chronic liver injury, which may lead to cirrhosis and cancer. Early-stage fibrosis is reversible, and it is difficult to precisely diagnose with conventional imaging modalities such as magnetic resonance imaging, positron emission tomography, single-photon emission computed tomography, and ultrasound imaging. In contrast, probe-assisted molecular imaging offers a promising noninvasive approach to visualize early fibrosis changes in vivo, thus facilitating early diagnosis and staging liver fibrosis, and even monitoring of the treatment response. Here, the most recent progress in molecular imaging technologies for liver fibrosis is updated. We start by illustrating pathogenesis for liver fibrosis, which includes capillarization of liver sinusoidal endothelial cells, cellular and molecular processes involved in inflammation and fibrogenesis, as well as processes of collagen synthesis, oxidation, and cross-linking. Furthermore, the biological targets used in molecular imaging of liver fibrosis are summarized, which are composed of receptors on hepatic stellate cells, macrophages, and even liver collagen. Notably, the focus is on insights into the advances in imaging modalities developed for liver fibrosis diagnosis and the update in the corresponding contrast agents. In addition, challenges and opportunities for future research and clinical translation of the molecular imaging modalities and the contrast agents are pointed out. We hope that this review would serve as a guide for scientists and students who are interested in liver fibrosis imaging and treatment, and as well expedite the translation of molecular imaging technologies from bench to bedside.

The LIDPAD Mouse Model Captures the Multisystem Interactions and Extrahepatic Complications in MASLD

Metabolic dysfunction-associated steatotic liver disease (MASLD) represents an impending global health challenge. Current management strategies often face setbacks, emphasizing the need for preclinical models that faithfully mimic the human disease and its comorbidities. The liver disease progression aggravation diet (LIDPAD), a diet-induced murine model, extensively characterized under thermoneutral conditions and refined diets is introduced to ensure reproducibility and minimize species differences. LIDPAD recapitulates key phenotypic, genetic, and metabolic hallmarks of human MASLD, including multiorgan communications, and disease progression within 4 to 16 weeks. These findings reveal gut-liver dysregulation as an early event and compensatory pancreatic islet hyperplasia, underscoring the gut-pancreas axis in MASLD pathogenesis. A robust computational pipeline is also detailed for transcriptomic-guided disease staging, validated against multiple harmonized human hepatic transcriptomic datasets, thereby enabling comparative studies between human and mouse models. This approach underscores the remarkable similarity of the LIDPAD model to human MASLD. The LIDPAD model fidelity to human MASLD is further confirmed by its responsiveness to dietary interventions, with improvements in metabolic profiles, liver histopathology, hepatic transcriptomes, and gut microbial diversity. These results, alongside the closely aligned changing disease-associated molecular signatures between the human MASLD and LIDPAD model, affirm the model's relevance and potential for driving therapeutic development.

Shining a light on liver health: advancements in fluorescence-enhanced enzyme biosensors for early disease detection

Early detection of liver diseases holds paramount importance in optimizing treatment outcomes and prognosis, thereby significantly enhancing the likelihood of recovery while mitigating the risk of progression to liver cancer. Liver diseases encompass a spectrum of conditions, each potentially manifesting distinct enzymatic profiles. Monitoring these enzymes in situ facilitates timely intervention and therapeutic management. In recent years, the field of biosensor technology has witnessed remarkable advancement, owing to strides in biomedicine and computational sciences. Biosensors have garnered widespread utility across medical and biological domains, spanning the detection of disease biomarkers, drug release tracking, ion imaging, and fluorescence imaging within living organisms. These applications have markedly enhanced imaging resolution and have the potential to refine disease diagnosis accuracy for clinicians. A pivotal aspect in the successful application of this technology lies in the construction of fluorescence probes adept at swiftly and selectively identifying target enzymes by amalgamating liver disease enzymes with fluorescence probe technology. However, research in this niche area remains relatively scarce. Building upon this foundational understanding, the present review delineates the utilization of biosensors in the early diagnosis of liver disease. Serving as a theoretical framework, this review envisages the development of high-performance biosensors tailored for the early detection of liver cancer. Furthermore, it offers insights into the potential of biosensor technology to progress and broaden its practical applications, thus contributing to the advancement of diagnostic methodologies in liver disease management.

Keeping an eye on the nutrition: The importance of nutrition management on cardiometabolic risk factors in cirrhotic patients

Chronic liver diseases, especially cirrhosis, are associated with significant morbidity and mortality. Besides predisposing to chronic liver disease per se, diabetes, hypertension, and dyslipidemia worsen the prognosis of patients with cirrhosis induced by other causes. There is no standard of care in the management of these factors in patients with cirrhosis. Also, in particular, it is not known whether nutritional interventions in the modification of cardiometabolic factors can improve the course of cirrhosis or not. This narrative review aimed to investigate the clinical significance of diabetes, hypertension, and dyslipidemia and appropriate nutritional interventions in cirrhotic patients. A comprehensive literature search of the published data was performed in regard to the association of cirrhosis with cardiometabolic factors and the management of cirrhosis and its complications. There is limited evidence on the association of cirrhosis with cardiometabolic risk factors. Cirrhotic cardiometabolic abnormalities are associated with an increased risk of complications, such that the coexistence of diabetes, hypertension, and dyslipidemia increases the risk of clinical decompensation in cirrhosis. Dietary management of cirrhotic patients with risk factors such as diabetes, hypertension, or dyslipidemia does not seem to be considerably different from non-cirrhotic patients.

Tolerance of repeated toxic injuries of murine livers is associated with steatosis and inflammation

The human liver has a remarkable capacity to regenerate and thus compensate over decades for fibrosis caused by toxic chemicals, drugs, alcohol, or malnutrition. To date, no protective mechanisms have been identified that help the liver tolerate these repeated injuries. In this study, we revealed dysregulation of lipid metabolism and mild inflammation as protective mechanisms by studying longitudinal multi-omic measurements of liver fibrosis induced by repeated CCl₄ injections in mice (n = 45). Based on comprehensive proteomics, transcriptomics, blood- and tissue-level profiling, we uncovered three phases of early disease development-initiation, progression, and tolerance. Using novel multi-omic network analysis, we identified multi-level mechanisms that are significantly dysregulated in the injury-tolerant response. Public data analysis shows that these profiles are altered in human liver diseases, including fibrosis and early cirrhosis stages. Our findings mark the beginning of the tolerance phase as the critical switching point in liver response to repetitive toxic doses. After fostering extracellular matrix accumulation as an acute response, we observe a deposition of tiny lipid droplets in hepatocytes only in the Tolerant phase. Our comprehensive study shows that lipid metabolism and mild inflammation may serve as biomarkers and are putative functional requirements to resist further disease progression.

Research progress of metformin in the treatment of liver fibrosis

Liver fibrosis is a disease with significant morbidity and mortality. It is a chronic pathological process characterized by an imbalance of extracellular matrix production and degradation in liver tissue. Metformin is a type of hypoglycemic biguanide drug, which can be used in the treatment of liver fibrosis, but its anti-fibrotic effect and mechanism of action are unclear. The purpose of this article is to review the research progress of metformin in the treatment of liver fibrosis and to provide a theoretical basis for its application in the treatment of liver fibrosis.

Diagnostic accuracy of magnetic resonance elastography and point-shear wave elastography for significant hepatic fibrosis screening: Systematic review and meta-analysis

The hepatic diseases are extremely common in clinical practice. The correct classification of liver fibrosis is extremely important, as it influences therapy and predicts disease outcomes. The purpose of this study is to compare the diagnostic performance of point-shear wave elastography (pSWE) and magnetic resonance elastography (MRE) in the hepatic fibrosis diagnostic. A meta-analysis was carried out based on articles published until October 2020. The articles are available at following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scientific Electronic Library Online, LILACS, Scopus, and CINAHL. Diagnostic performances were analyzed per METAVIR F2, using 3.5kPa as target fibrosis. Assessment of the methodological quality of the incorporated papers by the QUADAS-2 tool for pSWE and MRE. A total 2,153 studies articles were evaluated and 44 studies, comprising 6,081 patients with individual data, were included in the meta-analysis: 28 studies for pSWE and 16 studies for MRE. The pooled sensitivity and specificity were 0.86 (95%CI 0.80-0.90) and 0.88 (95%CI 0.85-0.91), respectively, for pSWE, compared with 0.94 (95%CI 0.89-0.97) and 0.95 (95%CI 0.89-0.98) respectively, for MRE. The pooled SROC curve for pSWE shows in the area under the curve (AUC) of 0.93 (95%CI 0.90-0.95), whereas the AUC for MRE was 0.98 (95%CI 0.96-0.99). The diagnostic odds ratio for pSWE and MRE were 41 (95%CI 24-72) and 293 (95%CI 86-1000), respectively. There was statistically significant heterogeneity for pSWE sensitivity (I² = 85.26, P<0.001) and specificity (I² = 89.46, P<0.001). The heterogeneity for MRE also was significant for sensitivity (I² = 73.28, P<0.001) and specificity (I² = 87.24, P<0.001). Therefore, both pSWE and MRE are suitable modalities for assessing liver fibrosis. In addition, MRE is a more accurate imaging technique than pSWE and can be used as alternative to invasive biopsy.

Therapeutic interventions of acute and chronic liver disorders: A comprehensive review

Liver disorders are one of the most common pathological problems worldwide. It affects more than 1.5 billion worldwide. Many types of hepatic cells have been reported to be involved in the initiation and propagation of both acute and chronic liver diseases, including hepatocytes, Kupffer cells, sinusoidal endothelial cells, and hepatic stellate cells (HSCs). In addition, oxidative stress, cytokines, fibrogenic factors, microRNAs, and autophagy are also involved. Understanding the molecular mechanisms of liver diseases leads to discovering new therapeutic interventions that can be used in clinics. Recently, antioxidant, anti-inflammatory, anti-HSCs therapy, gene therapy, cell therapy, gut microbiota, and nanoparticles have great potential for preventing and treating liver diseases. Here, we explored the recent possible molecular mechanisms involved in the pathogenesis of acute and chronic liver diseases. Besides, we overviewed the recent therapeutic interventions that targeted liver diseases and summarized the recent studies concerning liver disorders therapy.

Association between metabolic syndrome, C-reactive protein, and the risk of primary liver cancer: a large prospective study

Background and aims

High-sensitivity C-reactive protein (hs-CRP) levels and metabolic syndrome (MetS) are known to be associated with an increased incidence of different cancers. We aimed to evaluate the effect of MetS combined with high hs-CRP levels on the risk of primary liver cancer (PLC).

Methods

Participants were recruited from the Kailuan cohort study and were classified into four groups according to the presence or absence of MetS and inflammation (hs-CRP ≥ 3 or < 3 mg/L). The associations of MetS and inflammation with the risk of PLC were assessed using Cox proportional hazards models.

Results

This study included 92,770 participants. The mean age was 51.4 years old. Over a median follow-up of 13.02 years, 395 participants were diagnosed as PLC. Compared to the control participants without inflammation (hs-CRP < 3 mg/L) and MetS (n = 69,413), participants with high hs-CRP levels combined with MetS (n = 2,269) had a higher risk of PLC [hazard ratios (HR) 2.91; 95% confidence interval (CI), 1.77–4.81], and participants with high hs-CRP levels and without MetS (n = 14,576) had the same trend (HR, 1.36; 95%CI, 1.05–1.75). However, participants with low hs-CRP levels and MetS (n = 6,512) had no significant association with an elevated risk of PLC (HR, 1.18; 95%CI, 0.76–1.82). After excluding participants who had cancer during the first year of follow-up, sensitivity analysis showed the same trend. In addition, co-occurrence of MetS and high hs-CRP levels had significant interactive effects on the risk of PLC between the sexes (P < 0.001) and the patients with HBV infection (P = 0.012).

Conclusions

Participants with co-occurrence of MetS and high hs-CRP levels have an elevated risk of PLC.

Trial registration

Kailuan study, ChiCTR–TNRC–11001489. Registered 24 August, 2011-Retrospectively registered, http://www.chictr.org.cn/showprojen.aspx?proj=8050

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09939-w.

Deep learning supports the differentiation of alcoholic and other-than-alcoholic cirrhosis based on MRI

Although CT and MRI are standard procedures in cirrhosis diagnosis, differentiation of etiology based on imaging is not established. This proof-of-concept study explores the potential of deep learning (DL) to support imaging-based differentiation of the etiology of liver cirrhosis. This retrospective, monocentric study included 465 patients with confirmed diagnosis of (a) alcoholic (n = 221) and (b) other-than-alcoholic (n = 244) cirrhosis. Standard T2-weighted single-slice images at the caudate lobe level were randomly split for training with fivefold cross-validation (85%) and testing (15%), balanced for (a) and (b). After automated upstream liver segmentation, two different ImageNet pre-trained convolutional neural network (CNN) architectures (ResNet50, DenseNet121) were evaluated for classification of alcohol-related versus non-alcohol-related cirrhosis. The highest classification performance on test data was observed for ResNet50 with unfrozen pre-trained parameters, yielding an area under the receiver operating characteristic curve of 0.82 (95% confidence interval (CI) 0.71–0.91) and an accuracy of 0.75 (95% CI 0.64–0.85). An ensemble of both models did not lead to significant improvement in classification performance. This proof-of-principle study shows that deep-learning classifiers have the potential to aid in discriminating liver cirrhosis etiology based on standard MRI.

Cirrhosis

Cirrhosis is a chronic condition resulting from inflammation and fibrosis of the liver. Patients with cirrhosis may have a myriad of physical examination findings that reflect the severity of the underlying liver disease. Although many signs and symptoms related to cirrhosis are nonspecific, such as abdominal pain, nausea, and malaise, some findings are more specific and point to complications of liver disease. In this article, key physical findings in patients with cirrhosis, including hepatomegaly, splenomegaly, jaundice, ascites, encephalopathy, dilated abdominal wall veins, spider nevi, palmar erythema, and others, are discussed.

Intraindividual comparison of MRI-derived liver surface nodularity score at 1.5 T and 3 T

PURPOSE

To compare the MRI-derived liver surface nodularity (LSN) scores acquired on both 1.5 T and 3 T.

MATERIALS AND METHODS

Forty chronic liver disease patients who underwent gadoxetic acid-enhanced MRI at both 1.5 and 3 T were included. Axial hepatobiliary phase images with the same voxel size were used to calculate the LSN score in both liver lobes with a quantitative software. Rank correlation, Wilcoxon test, and Bland-Altman limits of agreement were used for statistical analysis.

RESULTS

There was a weak correlation between the right and left liver lobe on 1.5 T (r_s = 0.331, p = 0.037) and 3 T (r_s = 0.381, p = 0.015). The correlation between 1.5 T and 3 T on both liver lobes showed a very strong correlation (right, r_s = 0.927, p < 0.001; left, r_s = 0.845, p < 0.001). LSN scores differed significantly between both lobes on 1.5 T (median, 1.201 vs. 0.674, right vs. left) and 3 T (1.076 vs. 0.592) (all p < 0.001). LSN scores differed significantly between 1.5 T and 3 T on both lobes (all p < 0.001). The Bland-Altman plot comparing 1.5 T and 3 T on right and left liver lobes showed a systemic bias of 0.08 and 0.07, respectively.

CONCLUSIONS

LSN scores differed significantly on 1.5 T vs. 3 T and right vs. left liver lobe. Caution should be made when comparing LSN scores derived from different field strengths or the hepatic lobe. Interplatform, interlobar reproducibility should be resolved to use LSN scores, which is relatively easy to perform without additional hardware or images.

Comparison of diffusion-weighted imaging and MR elastography in staging liver fibrosis: a meta-analysis

PURPOSE

To compare the diagnostic performance of diffusion-weighted imaging (DWI), gradient-recalled echo-based magnetic resonance elastography (GRE-MRE), and spin-echo echo-planar imaging-based MRE (SE-EPI-MRE) in liver fibrosis staging.

METHODS

A systematic literature search was done to collect studies on the performance of DWI, GRE-MRE, and SE-EPI-MRE for diagnosing liver fibrosis. Pooled sensitivity, specificity, diagnostic odds ratio, positive and negative likelihood ratio, and a summary receiver operating characteristic (ROC) curve were estimated with a bivariate random effects model. Subgroup analyses on various study characteristics were performed.

RESULTS

Sixty studies with a total of 6620 patients were included in the meta-analysis. Pooled sensitivity and specificity of GRE-MRE and SE-EPI-MRE showed high diagnostic accuracy and did not differ significantly. The area under the summary ROC curve for all stages of fibrosis differed significantly between DWI (0.83-0.88) and either GRE-MRE (0.95-0.97) or SE-EPI-MRE (0.95-0.99). Substantial heterogeneity was detected for all three imaging methods.

CONCLUSIONS

Both GRE-MRE and SE-EPI-MRE are highly accurate for detection of each liver fibrosis stage, with high potential to replace liver biopsy. Although DWI had a moderate accuracy in distinguishing liver fibrosis, it could be regarded as an alternative to MRE, since it is widely available and easily implemented in routine liver MRI.

Interaction of non‑parenchymal hepatocytes in the process of hepatic fibrosis (Review)

Hepatic fibrosis (HF) is the process of fibrous scar formation caused by chronic liver injury of different etiologies. Previous studies have hypothesized that the activation of hepatic stellate cells (HSCs) is the central process in HF. The interaction between HSCs and surrounding cells is also crucial. Additionally, hepatic sinusoids capillarization, inflammation, angiogenesis and fibrosis develop during HF. The process involves multiple cell types that are highly connected and work in unison to maintain the homeostasis of the hepatic microenvironment, which serves a key role in the initiation and progression of HF. The current review provides novel insight into the intercellular interaction among liver sinusoidal endothelial cells, HSCs and Kupffer cells, as well as the hepatic microenvironment in the development of HF.

Rapid Two-Photon Fluorescence Imaging of Monoamine Oxidase B for Diagnosis of Early-Stage Liver Fibrosis in Mice

Liver fibrosis could induce cirrhosis and liver cancer, causing serious damages to liver function and even death. Early diagnosis of fibrosis is extremely requisite for optimizing treatment schedule to improve cure rate. In early-stage fibrosis, overexpressed monoamine oxidase B (MAO-B) can serve as a biomarker, which greatly contributes to the diagnosis of early liver fibrosis. However, there is still a lack of desired strategy to precisely monitor MAO-B in situ. In this work, we established a two-photon fluorescence imaging method for in vivo detection of MAO-B activity counting on a simply prepared probe, BiPhAA. The BiPhAA could be activated by MAO-B within 10 min and fluoresced brightly. To our knowledge, this BiPhAA-based imaging platform for MAO-B is more rapid than other current detection methods. Furthermore, BiPhAA allowed the dynamic observation of endogenous MAO-B level changes in hepatic stellate cells (LX-2). Through two-photon fluorescence imaging, we observed six times higher fluorescence brightness in the liver tissue of fibrosis mice than that of normal mice, thus successfully distinguishing mice with liver fibrosis from normal mice. Our work offers a simple, fast, and highly sensitive approach for imaging MAO-B in situ and paves a way to the diagnosis of early liver fibrosis with accuracy.

The global, regional, and national burden of cirrhosis by cause in 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

Cirrhosis and other chronic liver diseases (collectively referred to as cirrhosis in this paper) are a major cause of morbidity and mortality globally, although the burden and underlying causes differ across locations and demographic groups. We report on results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 on the burden of cirrhosis and its trends since 1990, by cause, sex, and age, for 195 countries and territories.

METHODS

We used data from vital registrations, vital registration samples, and verbal autopsies to estimate mortality. We modelled prevalence of total, compensated, and decompensated cirrhosis on the basis of hospital and claims data. Disability-adjusted life-years (DALYs) were calculated as the sum of years of life lost due to premature death and years lived with disability. Estimates are presented as numbers and age-standardised or age-specific rates per 100 000 population, with 95% uncertainty intervals (UIs). All estimates are presented for five causes of cirrhosis: hepatitis B, hepatitis C, alcohol-related liver disease, non-alcoholic steatohepatitis (NASH), and other causes. We compared mortality, prevalence, and DALY estimates with those expected according to the Socio-demographic Index (SDI) as a proxy for the development status of regions and countries.

FINDINGS

In 2017, cirrhosis caused more than 1·32 million (95% UI 1·27-1·45) deaths (440 000 [416 000-518 000; 33·3%] in females and 883 000 [838 000-967 000; 66·7%] in males) globally, compared with less than 899 000 (829 000-948 000) deaths in 1990. Deaths due to cirrhosis constituted 2·4% (2·3-2·6) of total deaths globally in 2017 compared with 1·9% (1·8-2·0) in 1990. Despite an increase in the number of deaths, the age-standardised death rate decreased from 21·0 (19·2-22·3) per 100 000 population in 1990 to 16·5 (15·8-18·1) per 100 000 population in 2017. Sub-Saharan Africa had the highest age-standardised death rate among GBD super-regions for all years of the study period (32·2 [25·8-38·6] deaths per 100 000 population in 2017), and the high-income super-region had the lowest (10·1 [9·8-10·5] deaths per 100 000 population in 2017). The age-standardised death rate decreased or remained constant from 1990 to 2017 in all GBD regions except eastern Europe and central Asia, where the age-standardised death rate increased, primarily due to increases in alcohol-related liver disease prevalence. At the national level, the age-standardised death rate of cirrhosis was lowest in Singapore in 2017 (3·7 [3·3-4·0] per 100 000 in 2017) and highest in Egypt in all years since 1990 (103·3 [64·4-133·4] per 100 000 in 2017). There were 10·6 million (10·3-10·9) prevalent cases of decompensated cirrhosis and 112 million (107-119) prevalent cases of compensated cirrhosis globally in 2017. There was a significant increase in age-standardised prevalence rate of decompensated cirrhosis between 1990 and 2017. Cirrhosis caused by NASH had a steady age-standardised death rate throughout the study period, whereas the other four causes showed declines in age-standardised death rate. The age-standardised prevalence of compensated and decompensated cirrhosis due to NASH increased more than for any other cause of cirrhosis (by 33·2% for compensated cirrhosis and 54·8% for decompensated cirrhosis) over the study period. From 1990 to 2017, the number of prevalent cases more than doubled for compensated cirrhosis due to NASH and more than tripled for decompensated cirrhosis due to NASH. In 2017, age-standardised death and DALY rates were lower among countries and territories with higher SDI.

INTERPRETATION

Cirrhosis imposes a substantial health burden on many countries and this burden has increased at the global level since 1990, partly due to population growth and ageing. Although the age-standardised death and DALY rates of cirrhosis decreased from 1990 to 2017, numbers of deaths and DALYs and the proportion of all global deaths due to cirrhosis increased. Despite the availability of effective interventions for the prevention and treatment of hepatitis B and C, they were still the main causes of cirrhosis burden worldwide, particularly in low-income countries. The impact of hepatitis B and C is expected to be attenuated and overtaken by that of NASH in the near future. Cost-effective interventions are required to continue the prevention and treatment of viral hepatitis, and to achieve early diagnosis and prevention of cirrhosis due to alcohol-related liver disease and NASH.

FUNDING

Bill & Melinda Gates Foundation.

Utility of N-acetylcysteine in ischemic hepatitis in cirrhotics with acute variceal bleed: a randomized controlled trial

BACKGROUND AND AIMS

Ischemic hepatitis (IH) following acute variceal bleed (AVB) carries an ominous prognosis. N-Acetylcysteine (NAC), a potent anti-oxidant, may prevent IH by improving tissue oxygen delivery and improving hepatic hypoxia.

METHODS

Consecutive cirrhotics with AVB were prospectively randomized to receive either standard of care (SOC) plus NAC intravenously for 72 h(at 150 mg/kg/h for 1 h followed by 12.5 mg/kg/h for 4 h, followed by 6.25 mg/kg for 67 h) (Group A, n = 107) or SOC alone (Group B, n = 107).

RESULTS

Baseline characteristics were comparable. IH developed more frequently in Gr.B 25(23%) than A-15(14%); p = 0.08). Incidence of IH increased with severity of liver disease. Binary logistic regression analysis showed reduced incidence of IH in Gr.A than B [odds ratio (OR) 0.33, 0.11-0.93] patients after controlling for other significant factors. The incidence of acute kidney injury (AKI) was also reduced in Gr.A [OR 0.34, 0.15-0.75]. Development of IH was significantly associated with increased deaths due to liver failure at 6 weeks [subdistribution hazard ratio (SHR) 21.6, 7.4-62.8]. On multivariate competing risk analysis, significantly lower deaths due to liver failure (SHR 0.33, 0.11-0.97) were noted in Gr.A than B.

CONCLUSIONS

One in five patients with acute variceal bleed develops ischemic hepatitis which is associated with worse outcomes. NAC therapy averts deaths due to liver failure by preventing IH and reduces AKI and is, therefore, recommended for cirrhotics with acute variceal bleed.

TRIAL REGISTRATION

Clinicaltrials.gov no: NCT02015403.

Quantitative Evaluation of Liver Fibrosis on T1 Relaxometry in Comparison with Fibroscan

Purpose

This study was performed to determine whether the T1 relaxation time of gadoxetic acid-enhanced liver MR imaging is useful for detecting and staging liver fibrosis in patients with chronic liver disease.

Materials and Methods

One hundred and three patients with suspected focal liver lesion underwent MR imaging and Fibroscan. Fibroscan was chosen as the reference standard for classifying liver fibrosis. T1 relaxation times were acquired before (preT1), 20 minutes after (postT1) contrast administration, and reduction rate of T1 relaxation time (rrT1) on transverse 3D VIBE (volumetric interpolated breath-hold examination) sequence using 3T MR imaging. The optimal cut-off values for the fibrosis staging were determined with ROC analysis.

Results

PreT1 and postT1 increased and rrT1 decreased constantly with increasing severity of liver fibrosis according to the METAVIR score (F0–F4). There were statistically significant differences between F2 and F3 in preT1 (F2, 836.0 ± 74.7 ms; F3, 888.6 ± 77.5 ms, p < 0.05) and between F3 and F4 in postT1 (F3, 309.0 ± 80.2 ms; F4, 406.6 ± 147.7 ms, p < 0.05) and rrT1 (F3, 65.4 ± 7.7%; F4, 57.3 ± 11.4%, p < 0.05). ROC analysis revealed that combination test (preT1 + postT1) was the best test for predicting liver fibrosis.

Conclusion

PreT1 and postT1 increased constantly with increasing severity of liver fibrosis. T1 mapping in gadoxetic acid-enhanced liver MR imaging could be a helpful complementary sequence to determine the liver fibrosis stage.

Hepatic disease and the risk of mortality of Vibrio vulnificus necrotizing skin and soft tissue infections: A systematic review and meta-analysis

Background

Vibrio vulnificus necrotizing skin and soft tissue infections (VNSSTIs) are associated with a high mortality rate that varies remarkably with host susceptibility. Hepatic disease (HD) is considered the key risk factor for high VNSSTIs incidence and mortality; however, there is limited evidence in the literature to support this observation.

Methodology

We examined all reported cases of VNSSTIs and associated mortality rates between 1966 and mid-2018. The PubMed, Medline and Cochrane Library databases were systematically searched for observational studies on patients with VNSSTIs. Twelve studies with 1157 total patients with VNSSTIs were included in the analysis. From the pooled dataset, nearly half (46.8%) of the patients with VNSSTIs had HD. The mortality rate in HD patients with VNSSTIs was 53.9% (n = 292/542), which was considerably higher than the mortality rate of 16.1% (n = 99/615) in non-HD patients. Patients with HD contracted VNSSTIs were found to be two or more times (RR = 2.61, 95% CI = 2.14–3.19) as likely to die compared with those without HD. Besides, liver cirrhosis (LC), the end-stage HD, was confirmed to be a significant risk factor, with risk ratios of 1.84 (95% CI 1.21–2.79) and 2.00 (95% CI 1.41–2.85) when compared to non-LC and non-HD, respectively.

Conclusions

HD with or without LC can be associated with infections and complications from V. vulnificus. Clinicians should aggressively approach care and management of acutely and/or critically ill patients with VNSSTIs.

MicroRNA Expression in Focal Nodular Hyperplasia in Comparison with Cirrhosis and Hepatocellular Carcinoma

The liver disease focal nodular hyperplasia (FNH) has several histological features that resemble hepatic cirrhosis. Since cirrhosis may develop further into hepatocellular carcinoma (HCC) contrary to FNH, the aim of the present study was to identify microRNAs (miRNA), which, by their altered expression levels, may be associated with the benign, tumor-like nature of FNH. Altogether 106 surgically removed formalin-fixed paraffin-embedded liver samples were selected, including 22 FNH, 45 cirrhosis, 24 HCC and 15 normal liver tissues. Etiology of the cases of cirrhosis and HCC includes hepatitis C and alcoholism and the HCC cases developed in cirrhotic livers. Relative expression levels of 14 miRNAs were determined using TaqMan MicroRNA Assays. In comparison to normal liver, the levels of miR-34a and miR-224 were elevated not only in FNH but also in cirrhosis and HCC, while the expression of miR-17-5p, miR-18a and miR-210 was decreased in FNH. Further, the levels of miR-21 and miR-222 were increased in cirrhosis and HCC but were decreased in FNH and the expression of miR-17-5p, miR-18a, miR-195 and miR-210 was decreased in FNH as compared with cirrhosis and/or HCC. In conclusion, the elevation of miR-34a and miR-224 may be associated with both benign and malignant proliferative processes, nevertheless the increased expression of oncomiRs miR-21 and miR-222 in cirrhosis and HCC but not in FNH may be related to malignant processes of the liver. The decreased levels of miR-18a, miR-195 and miR-210 may further differentiate FNH from cirrhosis, reflecting the different pathogenesis of these two entities contrary to some histologically similar features.

Intra-individual comparison of hepatocellular carcinoma imaging features on contrast-enhanced computed tomography, gadopentetate dimeglumine-enhanced MRI, and gadoxetic acid-enhanced MRI

Background Gadoxetic acid is being widely used for detection and characterization of hepatic nodules. However, there are no data regarding intra-individual comparison of imaging features of hepatocellular carcinoma (HCC) on dynamic computed tomography (CT), gadopentetate dimeglumine-enhanced magnetic resonance imaging (Gd-DTPA-MRI), and gadoxetic acid-enhanced MRI (Gd-EOB-MRI). Purpose To evaluate typical imaging features of HCC and capsule appearance with dynamic CT, Gd-DTPA-MRI, and Gd-EOB-MRI. Material and Methods We retrospectively reviewed 56 HCCs in 49 patients. Lesion attenuation/signal intensity was graded using a five-point scale based on dynamic phase and hepatobiliary phase (HBP) imaging. Subjective washout and capsule appearance were evaluated on portal venous phase (PVP) or delayed/transitional phase (DP/TP) imaging. The tumor-to-liver contrast ratio (TLCR) was calculated. Results Gd-DTPA-MRI and Gd-EOB-MRI was graded higher than CT on arterial phase ( P < 0.001). Gd-EOB-MRI was graded lower than Gd-DTPA-MRI on PVP and DP/TP ( P < 0.05). The detection rate of subjective washout and capsule appearance did not differ among the three imaging studies on either PVP or DP/TP. TLCR of Gd-EOB-MRI was lower than CT on PVP ( P = 0.004) and was lower than Gd-DTPA-MRI on DP/TP ( P = 0.001). Conclusion Arterial phase hyperenhancement and washout appearance of HCC were well demonstrated in Gd-EOB-MRI. The detection of capsule appearance using Gd-EOB-MRI was not inferior to Gd-DTPA-MRI or CT.

Mechanotransduction-modulated fibrotic microniches reveal the contribution of angiogenesis in liver fibrosis

The role of pathological angiogenesis on liver fibrogenesis is still unknown. Here, we developed fibrotic microniches (FμNs) that recapitulate the interaction of liver sinusoid endothelial cells (LSECs) and hepatic stellate cells (HSCs). We investigated how the mechanical properties of their substrates affect the formation of capillary-like structures and how they relate to the progression of angiogenesis during liver fibrosis. Differences in cell response in the FμNs were synonymous of the early and late stages of liver fibrosis. The stiffness of the early-stage FμNs was significantly elevated due to condensation of collagen fibrils induced by angiogenesis, and led to activation of HSCs by LSECs. We utilized these FμNs to understand the response to anti-angiogenic drugs, and it was evident that these drugs were effective only for early-stage liver fibrosis in vitro and in an in vivo mouse model of liver fibrosis. Late-stage liver fibrosis was not reversed following treatment with anti-angiogenic drugs but rather with inhibitors of collagen condensation. Our work reveals stage-specific angiogenesis-induced liver fibrogenesis via a previously unrevealed mechanotransduction mechanism which may offer precise intervention strategies targeting stage-specific disease progression.

Comparison of gradient-recalled echo and spin-echo echo-planar imaging MR elastography in staging liver fibrosis: a meta-analysis

OBJECTIVES

To compare the diagnostic performance of gradient-recalled echo-based magnetic resonance elastography (GRE-MRE) and spin-echo echo-planar imaging-based MRE (SE-EPI-MRE) in liver fibrosis staging.

METHODS

A systematic literature search was performed to identify studies involving the performance of MRE for the diagnosis of liver fibrosis. Pooled sensitivity, specificity, positive and negative likelihood ratios, the diagnostic odds ratio, and a summary receiver operating characteristic (ROC) curve were estimated by using a bivariate random effects model. Subgroup analyses were performed between different study characteristics.

RESULTS

Twenty-six studies with a total of 3,200 patients were included in the meta-analysis. Pooled sensitivity and specificity of GRE-MRE and SE-EPI-MRE did not differ significantly. The area under the summary ROC curve for stage diagnosis of any (F ≥ 1), significant (F ≥ 2), advanced (F ≥ 3), and cirrhosis (F = 4) on GRE-MRE and SE-EPI-MRE were 0.93 versus 0.94, 0.95 versus 0.94, 0.94 versus 0.95, and 0.92 versus 0.93, respectively. Substantial heterogeneity was detected for both sequences.

CONCLUSION

Both GRE and SE-EPI-MRE show high sensitivity and specificity for detection of each stage of liver fibrosis, without significant differences. Magnetic resonance elastography (MRE) may be useful for noninvasive evaluation of liver fibrosis in chronic liver disease.

KEY POINTS

• Pooled sensitivity and specificity of GRE-MRE and SE-EPI-MRE did not differ significantly. • GRE-MRE and SE-EPI-MRE were highly accurate for detecting all stages of fibrosis. • Due to better agreement and repeatability, GRE-MRE should be used first. • In case of failure on GRE-MRE, SE-EPI-MRE should be used.

Improving Quality of Care in Patients with Liver Cirrhosis

Liver cirrhosis is a major chronic disease in the field of digestive diseases. It causes more than one million deaths per year. Despite established evidence based guidelines, the adherence to standard of care or quality indicators are variable. Complete adherence to the recommendations of guidelines is less than 50%. To improve the quality of care in patients with cirrhosis, we need a more holistic view. Because of high rate of death due to cardiovascular disease and neoplasms, the care of comorbid conditions and risk factors such as smoking, hypertension, high blood sugar or cholesterol, would be important in addition to the management of primary liver disease. Despite a holistic multidisciplinary approach for this goal, the management of such patients should be patient centered and individualized. The diagnosis of underlying etiology and its appropriate treatment is the most important step. Definition and customizing the quality indicators for quality measure in patients are needed. Because most suggested quality indicators are designed for measuring the quality of care in decompensated liver cirrhosis, we need special quality indicators for compensated and milder forms of chronic liver disease as well. Training the patients for participation in their own management, design of special clinics with dedicated health professionals in a form of chronic disease model, is suggested for improvement of quality of care in this group of patients. Special day care centers by a dedicated gastroenterologist and a trained nurse may be a practical model for better management of such patients.

Polaprezinc inhibits liver fibrosis and proliferation in hepatocellular carcinoma

Hepatic fibrosis is defined as a pathological process, and activation of hepatic stellate cells (HSCs) is believed to be the key event of liver fibrosis. Additionally, activated HSCs may participate in the formation of the tumor microenvironment. Polaprezinc, a protector of the gastric mucosa, has been recently demonstrated to be an inhibitor of liver fibrosis in a mouse model. Proliferation and colony formation assays were performed to determine the inhibitory effects of polaprezinc on the growth of LX‑2 and hepG2 cells. A migration assay was used to evaluate the change in mobility of LX‑2 cells and quantitative polymerase chain reaction was performed to detect the expression levels of key markers of fibrosis. Finally, a gene chip assay for polaprezinc‑treated hepG2 cells was performed to evaluate the effect of polaprezinc on the hepG2 gene expression profile. The proliferation assay indicated that polaprezinc may inhibit the LX‑2 cell proliferation and the migration assays confirmed the inhibition of mobility. The expression levels of fibrotic markers such as collagen I, fibronectin and α‑smooth muscle actin were downregulated following polaprezinc treatment. The proliferation activity of polaprezinc‑treated hepG2 cells was reduced and the gene chip assay indicated that series of gene expression changes associated with cancer migration, cell skeletal organization and proliferation had occurred. In conclusion, polaprezinc treatment mayinhibit the proliferation of hepatocellular carcinoma cells and reverse liver fibrosis by deactivating HSCs. The present findings suggest that polaprezinc provides a novel treatment for patients with gastritis complicated with cirrhosis.

Validation of the prognostic value of histologic scoring systems in primary sclerosing cholangitis: An international cohort study

Histologic scoring systems specific for primary sclerosing cholangitis (PSC) are not validated. We recently determined the applicability and prognostic value of three histological scoring systems in a single PSC cohort. The aim of this study was to validate their prognostic use and reproducibility across a multicenter PSC cohort. Liver biopsies from PSC patients were collected from seven European institutions. Histologic scoring was performed using the Nakanuma, Ishak, and Ludwig scoring systems. Biopsies were independently scored by six liver pathologists for interobserver agreement. The prognostic value of clinical, biochemical, and all three histologic scoring systems on predicting composite endpoints 1 (PSC-related death and liver transplantation), 2 (liver transplantation), and 3 (liver-related events), was assessed using univariable and multivariable Cox proportional hazards modeling. A total of 119 PSC patients were identified, and the median follow-up was 142 months. During follow-up, 31 patients died (20 PSC-related deaths), 31 patients underwent liver transplantation, and 35 patients experienced one or more liver-related events. All three staging systems were independent predictors of endpoints 2 and 3 (Nakanuma system: hazard ratio [HR], 3.16 [95% confidence interval (CI), 1.49-6.68] for endpoint 2 and HR, 2.05 [95% CI, 1.17-3.57] for endpoint 3; Ishak system: HR, 1.55 [95% CI, 1.10-2.18] for endpoint 2 and HR, 1.43 [95% CI, 1.10-1.85] for endpoint 3; Ludwig system: HR, 2.62 [95% CI, 1.19-5.80] for endpoint 2 and HR, 2.06 [95% CI, 1.09-3.89] for endpoint 3). Only the Nakanuma staging system was independently associated with endpoint 1: HR, 2.14 (95% CI, 1.22-3.77). Interobserver agreement was moderate for Nakanuma stage (κ = 0.56) and substantial for Nakanuma component fibrosis (κ = 0.67), Ishak stage (κ = 0.64), and Ludwig stage (κ = 0.62).

CONCLUSION

We confirm the independent prognostic value and demonstrate for the first time the reproducibility of staging disease progression in PSC using the Nakanuma, Ishak, and Ludwig staging systems. The Nakanuma staging system-incorporating features of chronic biliary disease-again showed the strongest predictive value. (Hepatology 2017;65:907-919).

Quantitative Liver Function Analysis: Volumetric T1 Mapping with Fast Multisection B1 Inhomogeneity Correction in Hepatocyte-specific Contrast-enhanced Liver MR Imaging

Purpose To determine whether B₁ inhomogeneity-corrected volumetric T1 maps of gadoxetic acid-enhanced liver magnetic resonance (MR) imaging are able to demonstrate global liver function and functional heterogeneity in patients with cirrhosis and to investigate their relationship with the development of hepatic insufficiency and decompensation. Materials and Methods This institutional review board-approved retrospective study with waiver of informed consent included 234 consecutive patients who underwent gadoxetic acid-enhanced liver MR imaging, including B₁ inhomogeneity-corrected volumetric T1 mapping. For all patients, T1 relaxation times of the liver and liver volumes were measured on T1 maps. Liver T1 and functional liver volume-to-weight ratio (liver volume divided by liver T1 and the patient's weight) were compared between Child-Pugh class A and class B cirrhosis. Associations between serum markers, MR parameters, hepatic insufficiency, and decompensation were investigated by using Cox proportional hazards analysis. Results Patients with Child-Pugh class B disease showed significantly longer liver T1 (548.2 msec ± 257.7 vs 372.2 msec ± 77.5, P < .0001) and lower kurtosis of liver T1 (29.1 ± 39.6 vs 43.9 ± 64.9, P = .016) than patients with Child-Pugh class A disease. Prolonged liver T1 (≥462 msec) (hazard ratio [HR], 5.9; 95% confidence interval [CI]: 1.1, 62.8) and an albumin level of less than 3.5 g/dL (HR, 20.7; 95% CI: 3.9, 221.9) were independently associated with the development of hepatic insufficiency. Functional liver volume-to-weight ratio was associated with the development of hepatic decompensation in patients with Child-Pugh class A disease (HR, 0.03; 95% CI: 0.004, 0.23). Conclusion B₁ inhomogeneity-corrected volumetric T1 mapping provided information on global liver function and demonstrated functional heterogeneity. In addition, prolonged liver T1 (≥462 msec) was associated with the development of hepatic insufficiency, and functional liver volume-to-weight ratio was negatively related with the development of decompensation in compensated cirrhosis. ^© RSNA, 2016 Online supplemental material is available for this article.

Fibronectin expression is critical for liver fibrogenesis in vivo and in vitro

Increased fibronectin (FN) expression has an important role during liver fibrosis. The present study examined FN expression in rats subjected to carbon tetrachloride (CCl4)‑induced liver fibrosis. In addition, the potential mechanisms underlying fibrogenesis were investigated by exposing hepatic stellate cells (HSCs) to transforming growth factor‑β (TGF‑β), which is a known inducer of myofibroblastic transformation of HSCs. Briefly, a rat model of liver fibrosis was created by administering intraperitoneal injections of CCl4. Furthermore, HSC‑T6 cells were stimulated with increasing doses of recombinant TGF‑β over 24 h. Hepatic fibrosis gradually increased following CCl4 administration in vivo. Western blotting and immunohistochemistry demonstrated that fibronectin (FN), TGF‑β and α‑smooth muscle actin (SMA) expression was increased following CCl4 injection, and the maximum expression levels were observed at 8 weeks. Once CCl4 treatment had been terminated, the expression levels of FN, TGF‑β and α‑SMA progressively declined to near baseline levels. Western blotting and quantitative polymerase chain reaction demonstrated that FN expression was gradually increased in response to TGF‑β‑stimulation of HSCs; maximum expression was achieved 12 h post‑treatment (P<0.01 vs. the baseline). In conclusion, these findings indicated that FN expression is an early and progressive event that occurs during liver fibrogenesis in vivo and in vitro.

Autoimmune hepatitis unmasked by nimesulide

A 49-year-old woman presented at the emergency department, with acute hepatic failure, 2 weeks after taking nimesulide. Presenting with a MELD score of 25.0, the patient was transferred to a specialised liver transplant unit, with the probable diagnosis of toxic hepatitis. After a clinical improvement with supportive care and acetylcysteine, a liver biopsy was executed. The histology revealed micronodular cirrhosis associated with acute hepatitis, with features suggestive of autoimmune hepatitis. The patient was then started on azathioprine 50 mg/day and prednisolone 30 mg/day, and tapering of prednisolone was carried out in the following months. Twenty eight months after treatment, another liver biopsy was performed, showing almost full remission of the disease, with only mild fibrosis and no significant inflammatory infiltrate.

Quantitative morphometric and immunohistochemical analysis and their correlates in cirrhosis--A study on explant livers

BACKGROUND

Reproducible structural analysis was made on cirrhotic human liver samples in order to reveal potential connections between morphological and laboratory parameters.

MATERIAL AND METHODS

Large histological samples were taken from segment VII of 56 cirrhotic livers removed in connection with liver transplantation. Picro Sirius red and immunohistochemically (smooth muscle actin [SMA], cytokeratin 7 [CK7], Ki-67) stained sections were digitalized and morphometric evaluation was performed.

RESULTS

The Picro Sirius-stained fibrotic area correlated with the average thickness of the three broadest septa, extent of SMA positivity, alkaline phosphatase (ALP) values and it was lower in the viral hepatitis related cirrhoses than in samples with non-viral etiology. The extent of SMA staining increased with the CK7-positive ductular reaction. The proliferative activity of the hepatocytes correlated positively with the Ki-67 labeling of the ductular cells and inversely with the septum thickness. These data support the potential functional connection among different structural components, for example, myofibroblasts, ductular reaction and fibrogenesis but challenges the widely proposed role of ductular cells in regeneration.

CONCLUSION

Unbiased morphological characterization of cirrhotic livers can provide valuable, clinically relevant information. Similar evaluation of routine core biopsies may increase the significance of this 'Gold Standard' examination.

Intraportal Infusion of Bone Marrow Mononuclear or CD133+ Cells in Patients With Decompensated Cirrhosis: A Double-Blind Randomized Controlled Trial

The present study assessed the effects of intraportal infusions of autologous bone marrow-derived mononuclear cells (MNCs) and/or CD133+ cells on liver function in patients with decompensated cirrhosis. We randomly assigned 27 eligible patients to a placebo, MNCs, and/or CD133+ cells. Cell infusions were performed at baseline and month 3. We considered the absolute changes in the Model for End-Stage Liver Disease (MELD) scores at months 3 and 6 after infusion as the primary outcome. The participants and those who assessed the outcomes were unaware of the treatment intervention assignments. After 6 months, 9 patients were excluded because of liver transplantation (n=3), hepatocellular carcinoma (n=1), loss to follow-up (n=3), and death (n=2). The final analysis included 4 patients from the CD133+ group, 8 from the MNC group, and 6 from the placebo group. No improvement was seen in the MELD score at month 6 using either CD133+ cells or MNC infusions compared with placebo. However, at month 3 after infusion, a trend was seen toward a higher mean absolute change in the MELD score in patients who had received CD133+ cells compared with placebo (-2.00±1.87 vs. -0.13±1.46; p=.08). No significant adverse events occurred in the present study. A transient improvement in the MELD score was observed in subjects treated with CD133+ cells but not in the MNC or placebo group. Although the study was not powered to make definitive conclusions, the data justify further study of CD133+ therapy in cirrhotic patients.

SIGNIFICANCE

Cell therapy is a new approach in liver disease. Several clinical experiments have been reported on the safety of bone marrow-derived stem cells to treat liver disorders. However, the effectiveness of these approaches in the long-term follow-ups of patients initiated controversial discussions among the scientific community. A double-blind randomized controlled trial was designed to address this concern scientifically. A transient improvement in the patients' signs occurred; however, for a sustainable result, more work is needed. The results of multiple administrations of cells reported in the present study can be compared with the results from other single-injection studies.

Preventive effects of phenylethanol glycosides from Cistanche tubulosa on bovine serum albumin-induced hepatic fibrosis in rats

BACKGROUND

Cistanche tubulosa is a traditional Chinese herbal medicine that is widely used for regulating immunity. Phenyl ethanol glycosides (CPhGs) from this plant are the primarily efficacious materials. This aim of this study was to evaluate the preventive and therapeutic effects of CPhGs on BSA-induced hepatic fibrosis in rats and related molecular mechanisms involving hepatic stellate cells. Biejiarangan (BJRG), another traditional Chinese herbal medicine, was used as a positive control.

METHODS

In in vivo experiments, 75 SD rats were randomly divided into 6 groups: normal (distilled water-treated), model (BSA-treated), positive drug (BSA-treated + BJRG 600 mg/kg/day), and BSA-treated + CPhGs (125, 250, and 500 mg/kg/day) groups. The liver and spleen indices, serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), hexadecenoic acid (HA), laminin (LN), type III procollagen (PCIII), type IV collagen (IV-C), hydroxyproline (Hyp), and transforming growth factor β 1 (TGF-β 1) were measured in rat livers. Histopathological grades for liver fibrosis were assessed for each group using H&E and Masson's trichrome staining. The expression of TGF-β 1, collagen I (Col-I) and collagen III (Col-III) were determined by an immunohistochemical staining method. These effects were further evaluated in vitro by determining expression levels of NF-κB p65 and Col-I by quantitative real-time PCR analyses. Col-I protein expression was also examined by western blotting.

RESULTS

All dose groups (125, 250, and 500 mg/kg/day) of CPhGs significantly reduced the liver and spleen index, decreased ALT, AST, HA, LN, PCIII, IV-C serum levels, TGF-β 1 content (P < 0.01, P < 0.01, and P < 0.01), and Hyp content. CPhGs also markedly alleviated the swelling of liver cells and effectively prevented hepatocyte necrosis and inflammatory cell infiltration. Immunohistochemical results showed that CPhGs significantly reduced the expression of TGF-β 1 (P < 0.01, P < 0.01, and P < 0.01), Col- I, and Col-III. The in vitro effects of CPhGs (100, 75, 50, and 25 ug/ml) on HSC-T6 showed that CPhGs significantly reduced mRNA expression of NF-κB p65 and Col-I, and CPhGs also downregulated Col-I protein expression.

CONCLUSIONS

CPhGs have a significant anti-hepatic fibrosis effect, and may be used as hepatoprotective agents for treatment of hepatic fibrosis.

Hepatocyte buds derived from progenitor cells repopulate regions of parenchymal extinction in human cirrhosis

Repair of cirrhotic livers occurs, in part, by repopulation with hepatocytes through the stem/progenitor pathway. There remain many uncertainties regarding this pathway. Hepatocyte "buds" occurring in broad septa are hypothesized to be the anatomic manifestation of this pathway. Our purpose was to define a morphologic sequence of bud maturation to allow a quantitative measure of the importance of the stem/progenitor pathway in humans. Histologic sections from 37 liver resection specimens were stained with trichrome, epithelial cell adhesion molecule (EpCAM), K19, CD34, glutamine synthetase (GS), and Ki-67. Specimens were stratified by etiology (10 biliary, 22 nonbiliary, five controls) and stage. Buds were defined as clusters of hepatocytes within septa. Five levels of bud maturation (0-4) were defined by the progressive increase in hepatocyte progeny relative to cholangiocytes. Level 0 single-cell buds are K19(+) /GS(+) /EpCAM(+) /Heppar1(-) . In level 1, the progeny are morphologically hepatocytes (K19(-) /GS(+) /EpCAM(+) /Heppar1(+) ). In level 2-4 buds, hepatocytes increase and become progressively GS(-) and EpCAM(-) . Associated endothelium is CD34(+) in level 1-2 buds and becomes CD34(-) near hepatic veins in level 3-4 buds. Progeny of the bud sequence may represent up to 70% of hepatocytes (immaturity index of 70%). In biliary disease, bud number is reduced in association with duct loss and cholestatic destruction of nascent buds.

CONCLUSIONS

The stem/progenitor pathway, manifested anatomically by the bud sequence, is a major mechanism for repopulation of cirrhotic livers. The bud sequence reveals some critical features of hepatic morphogenesis, including that 1) the majority of distal cholangiocytes have stem-like properties, and 2) availability of bile ducts and/or venous drainage are limiting factors for regeneration.

Resolution of chronic bacterial-induced prostatic inflammation reverses established fibrosis

BACKGROUND

Prostatic inflammation has been suggested to contribute to the etiology of lower urinary tract symptoms by inducing fibrosis. We previously used a well-characterized mouse model of bacterial-induced prostate inflammation to demonstrate that chronic prostatic inflammation induces collagen deposition. Here, we examined stability of the newly synthesized collagen in bacterial-induced prostatic inflammation and the reversibility of fibrosis after resolution of infection and inflammation.

METHODS

Uropathogenic Escherichia coli 1677 was instilled transurethrally into adult C3H/HeOuJ male mice to induce chronic prostatic inflammation. Collagen was labeled by (3) H-proline administration for 28 days post-inoculation and (3) H-hydroxyproline incorporation measured to determine stability of the newly synthesized collagen. Inflammation score was graded using a previously established system and total collagen content was measured by picrosirius red staining quantitation and hydroxyproline content. Resolution of inflammation and reversal of collagen deposition was assessed after treatment with antibiotic enrofloxacin for 2 weeks on day 28 post-inoculation followed by an 8-week recovery period.

RESULTS

Decay analysis of incorporated (3) H-hydroxyproline revealed the half-life of newly synthesized collagen to be significantly shorter in infected/inflamed prostates than in controls. Treatment with antibiotic enrofloxacin completely eradicated bacterial infection and allowed resolution of inflammation. This was followed by marked attenuation of collagen content and correlation analysis verified a positive association between the resolution of inflammation and the reversal of collagen deposition.

CONCLUSIONS

These data demonstrate, for the first time, that inflammation-induced prostatic fibrosis is a reversible process.

Dynamics of allograft fibrosis in pediatric liver transplantation

Progressive liver allograft fibrosis (LAF) is well known to occur long term, as shown by its high prevalence in late posttransplant liver biopsies (LBs). To evaluate the influence of clinical variables and immunosuppression on LAF progression, LAF dynamic was assessed in 54 pediatric liver transplantation (LT) recipients at 6 months, 3 and 7 years post-LT, reviewing clinical, biochemical data and protocol LBs using METAVIR and the liver allograft fibrosis score, previously designed and validated specifically for LAF assessment. Scoring evaluations were correlated with fibrosis quantification by morphometric analysis. Progressive LAF was found in 74% of long-term patients, 70% of whom had unaltered liver enzymes. Deceased grafts showed more fibrosis than living-related grafts (p = 0.0001). Portal fibrosis was observed in correlation with prolonged ischemia time, deceased grafts and lymphoproliferative disease (p = 0.001, 0.006 and 0.012, respectively). Sinusoidal fibrosis was correlated with biliary complications (p = 0.01). Centrilobular fibrosis was associated with vascular complications (p = 0.044), positive autoantibodies (p = 0.017) and high gamma-globulins levels (p = 0.028). Steroid therapy was not associated with reduced fibrosis (p = 0.83). LAF could be viewed as a dynamic process with mostly progression along the time. Peri- and post-LT-associated factors may condition fibrosis development in a specific area of the liver parenchyma.

Endostar, a novel human recombinant endostatin, attenuates liver fibrosis in CCl4-induced mice

Decreasing hepatic fibrosis remains one of the major therapeutic challenges in hepatology. The present study aims to evaluate the effect of Endostar on both CCl4-induced liver fibrosis in mice and a hepatic stellate cell (HSC) line. Two main models were studied: (i) a liver fibrosis model was induced in BALB/c mice using CCl4 by intraperitoneal injection for six weeks. Six animal groups were studied: group 1: normal animals; group 2: CCl4-induced liver fibrosis; group 3: CCl4 + Endostar 20 mg/kg/d, six weeks; group 4: CCl4 + Endostar 10 mg/kg/d, six weeks; group 5: CCl4 + Endostar 20 mg/kg/d, four weeks; group 6: CCl4 + Endostar 10 mg/kg/d, four weeks corresponded to different Endostar doses and duration of administration. Liver fibrosis was evaluated by histopathological staining and liver hydroxyproline content. Expressions of collagen type I, α-smooth muscle actin ( α-SMA), TGF-β1 and VEGFR were measured by real-time polymerase chain reaction (PCR). (ii) A liver cell model. HSC-T6 cells were cultured with or without Endostar for 12 h or 24 h. Expressions of collagen type I, α-SMA, and TGF-β1 were measured by real-time PCR. Collagen I and transforming growth factor β1 (TGF-β1) contents in cell supernatant were measured by enzyme-linked immunosorbent assay. As compared to the group without Endostar, liver fibrosis scores and hydroxyproline content were decreased in both Endostar groups ( P < 0.05). Moreover, Endostar inhibited the hepatic expression of α-SMA, TGF-β1, Collagen-1, VEGFR1, and VEGFR2 mRNA ( P < 0.05). In the HSC-T6 cell line model, Endostar profoundly inhibited the expression of α-SMA, Collagen-1, and TGF-β1 mRNA. Expressions of Collagen-1 and TGF-β1 protein were decreased in the Endostar group as compared to the normal controls in the supernatant of HSC-T6 cells ( P < 0.05). Endostar decreased both liver fibrosis in CCl4-induced mice and collagen synthesis in HSCs in vitro. Therefore, this recombinant human endostatin is a promising compound for counteracting liver fibrosis.

Protective effects of L-carnitine, N-acetylcysteine and genistein in an experimental model of liver fibrosis

AIM

Liver fibrosis is a reversible wound-healing response that occurs following liver injury. In this study, we aimed to investigate the possible protective effects of L-carnitine, N-acetylcysteine and genistein in liver fibrosis induced by carbon tetrachloride (CCl4). In addition, the effects of these agents were compared in the same study.

METHODS

In this study, rats were randomly allocated into 8 groups, consisting of 10 rats each, as follows: a control group, CCl4, L-carnitine, N-acetylcysteine, genistein, CCl4 and L-carnitine, CCl4 and N-acetylcysteine, and CCl4 and genistein. At the end of 6 weeks, blood and liver tissue specimens were collected. Alanine aminotransferase (ALT); aspartate aminotransferase (AST); complete blood count, tumor necrosis factor-α (TNF-α); platelet-derived growth factor-BB (PDGF-BB); interleukin-6 (IL-6); liver glutathione level; oxidant/antioxidant status; scores of hepatic steatosis, necrosis, inflammation, and fibrosis; and the expression of α-smooth muscle actin were studied.

RESULTS

Although the ALT and AST values in the group administered CCl4 were significantly higher than in all the other groups (P<0.05), there was no significant difference between the control group and the groups administered CCl4 combined with L-carnitine, N-acetylcysteine and genistein (P>0.05). There were significant differences in the levels of TNF-α, PDGF-BB and IL-6 (P<0.05) between the CCl4 group and the groups with L-carnitine, N-acetylcysteine and genistein added to CCl4. N-acetylcysteine and genistein had positive effects on the oxidant/antioxidant status and on liver necrosis and fibrosis scores.

CONCLUSIONS

In our study, L-carnitine, N-acetylcysteine and genistein showed significant protective effects in liver fibrosis induced by CCl4.

Determinants of long-term outcome in severe alcoholic hepatitis

BACKGROUND

Although short-term outcome in severe alcoholic hepatitis (SAH) is well described, its long-term course remains uncharacterised.

AIM

To assess determinants of long-term outcome in SAH.

METHODS

Data were recorded from a cohort with SAH (admission Discriminant Function (DF) ≥32). Kaplan-Meier (KM) and Cox proportional hazards survival analyses were performed to determine predictors of outcome.

RESULTS

One hundred and nine patients were included; 63.3% male, aged 49.6 ± 9.4 years with median follow-up of 40.7 months (95% CI 37.2-44.3). Median DF was 58, 86.2% had cirrhosis and 65.1% received corticosteroids and/or pentoxifylline. Overall mortality was 57.8%, 96.8% of deaths being liver-related and 65.1% occurring after the index hospitalisation. Estimated 5-year survival was 31.8%. Hepatorenal syndrome was the only baseline factor independently associated with mortality (HR 3.78, 95% CI 1.98-7.19, P < 0.0001), although it predicted short-term, rather than long-term outcome (median survival 0.52 months, 95% CI 0.43-0.61). Of the 87 patients (79.8%) who survived index hospitalisation, 65.1% experienced recidivism. Abstinence at last follow-up remained the only independent predictor of survival in multivariate analysis (HR 0.370, 95% CI 0.168-0.818, P = 0.014). Five-year survival was higher in abstainers (75.3%) compared with relapsed and continued drinkers (26.8% and 21.0%, respectively, P = 0.005). However, the survival benefit from abstinence only became statistically significant at 18 months postdischarge (HR 2.714, 95% CI 0.995-7.404, P = 0.051).

CONCLUSIONS

Estimated 5-year survival after index hospitalisation with SAH is 31.8% with alcohol relapse occurring in two-thirds of patients. Abstinence remains the only independent predictor of long-term survival. Novel strategies to improve abstinence after admission with SAH are urgently needed.

Recombinant human histidine triad nucleotide-binding protein 1 attenuates liver fibrosis induced by carbon tetrachloride in rats

It is currently thought that the transforming growth factor-β (TGF-β)/Smad signaling pathway acts as a central pathway leading to liver fibrosis, and that the aberrant Wnt/β-catenin signaling pathway also plays a vital role in the development of liver fibrosis. There is evidence that the histidine triad nucleotide-binding protein 1 (Hint1) was capable of inhibiting these two pathways. However, little data regarding the effects of Hint1 on liver fibrosis exists. Thus, we sought to investigate whether the recombinant human Hint1 protein (rhHint1) was capable of attenuating liver fibrosis induced by carbon tetrachloride (CCl4) in rats and the possible underlying mechanism(s) of action. In the present study, purified rhHint1 was obtained using genetic engineering technology. Liver fibrosis was induced in male Sprague-Dawley (SD) rats by the subcutaneous injection of CCl4. The rats were randomly divided into the normal control, the liver fibrosis model and the rhHint1 (doses, 50 and 100 µg/kg)‑treated groups. Following four weeks of treatment, the rhHint1-treated rats exhibited significantly reduced liver fibrosis upon histopathological analysis and lower levels of hydroxyproline. Furthermore, rhHint1 inhibited the expression of α-smooth muscle actin (α-SMA) in the liver tissues. Additionally, rhHint1 lowered the gene expression levels of TGF-β1/Smad3 and β-catenin/cyclin D1, whereas it increased the gene expression levels of Smad7. In conclusion, the results of this study indicated that rhHint1 is capable of attenuating CCl4-induced liver fibrosis by simultaneously targeting multiple pathogenic pathways, which may be developed as a new treatment for liver fibrosis.