Management of alcoholic hepatitis: A clinical perspective

Prognostic challenges in alcoholic hepatitis: From scoring systems to clinical predictors

In this article, we discuss the recently published article by Yang et al. This retrospective analysis, which was conducted at a large urban tertiary care center, focused on comparing Lille model scores at days 3 and 7 with established scoring systems and identifying critical clinical predictors, such as renal dysfunction, nutritional status, and underlying cirrhosis. Alcoholic hepatitis (AH), a severe manifestation of alcohol-related liver disease, is associated with high morbidity and mortality, necessitating accurate prognostic tools and comprehensive clinical assessments. Prognostic tools are invaluable for early risk stratification, but they must be contextualized within the multifactorial nature of AH. Acute renal dysfunction and poor nutritional status, for example, are not just complications but pivotal markers of disease severity and systemic impact. Addressing these factors requires a holistic approach that extends beyond scoring systems to include targeted interventions and comprehensive patient care. This editorial emphasizes the need for a paradigm shift in AH management, where prognostic models are complemented by a deeper understanding of patient-specific factors. Such an approach can guide clinicians in tailoring therapies and improving outcomes for this high-risk population.

Suboptimal use of inpatient palliative care consultation in alcoholic hepatitis hospitalizations may lead to higher readmissions

AIMS

Alcoholic hepatitis (AH), a clinical syndrome precipitated by chronic alcohol consumption, constitutes about 0.9 % of total admissions in the United States. It presents a wide severity spectrum, from mild disease to severe cases associated with high mortality. Palliative care (PC) is a specialized medical approach focused on enhancing the quality of life for patients with serious or life-threatening illnesses. This study aims to investigate the national trends of palliative care (PC) utilization in AH hospitalizations and its impact on resource utilization.

METHODS

We identified adult AH hospitalizations from the Nationwide Readmission Database, further categorized based on PC utilization. Multivariate regression analysis was employed to evaluate the impact of PC on the 90-day readmission rate.

RESULTS

Among the 68,062 AH patients, 3,784 (5.56 %) utilized PC services. PC utilization in AH hospitalizations was associated with a significantly lower 90-day readmission rate (adjusted hazard ratio (aHR) 0.45, P = 0.02). 90-day readmission benefits with PC were persistent on analysis of severe (North American Consortium for the Study of End-Stage Liver Disease-Acute-on-Chronic Liver Failure [NACSELD-ACLF] score ≥1) AH population as well (aHR 0.46, P < 0.01). Trend analysis of PC utilization in AH hospitalizations revealed a non-significant change from 5.39 % in 2016 to 5.69 % in 2020 (P = 0.07).

CONCLUSION

This study shows that PC utilization in AH hospitalizations reduces readmissions and healthcare burden. We advocate integrating PC into the comprehensive management of AH. Further research is needed to determine the optimal timing and components of PC interventions for AH patients.

Molecular mechanisms in liver repair and regeneration: from physiology to therapeutics

Liver repair and regeneration are crucial physiological responses to hepatic injury and are orchestrated through intricate cellular and molecular networks. This review systematically delineates advancements in the field, emphasizing the essential roles played by diverse liver cell types. Their coordinated actions, supported by complex crosstalk within the liver microenvironment, are pivotal to enhancing regenerative outcomes. Recent molecular investigations have elucidated key signaling pathways involved in liver injury and regeneration. Viewed through the lens of metabolic reprogramming, these pathways highlight how shifts in glucose, lipid, and amino acid metabolism support the cellular functions essential for liver repair and regeneration. An analysis of regenerative variability across pathological states reveals how disease conditions influence these dynamics, guiding the development of novel therapeutic strategies and advanced techniques to enhance liver repair and regeneration. Bridging laboratory findings with practical applications, recent clinical trials highlight the potential of optimizing liver regeneration strategies. These trials offer valuable insights into the effectiveness of novel therapies and underscore significant progress in translational research. In conclusion, this review intricately links molecular insights to therapeutic frontiers, systematically charting the trajectory from fundamental physiological mechanisms to innovative clinical applications in liver repair and regeneration.

Metabolic Dysregulation and Metabolite Imbalances in Acute-on-chronic Liver Failure: Impact on Immune Status

Liver failure encompasses a range of severe clinical syndromes resulting from the deterioration of liver function, triggered by factors both within and outside the liver. While the definition of acute-on-chronic liver failure (ACLF) may vary by region, it is universally recognized for its association with multiorgan failure, a robust inflammatory response, and high short-term mortality rates. Recent advances in metabolomics have provided insights into energy metabolism and metabolite alterations specific to ACLF. Additionally, immunometabolism is increasingly acknowledged as a pivotal mechanism in regulating immune cell functions. Therefore, understanding the energy metabolism pathways involved in ACLF and investigating how metabolite imbalances affect immune cell functionality are crucial for developing effective treatment strategies for ACLF. This review methodically examined the immune and metabolic states of ACLF patients and elucidated how alterations in metabolites impact immune functions, offering novel perspectives for immune regulation and therapeutic management of liver failure.

Bacterial Infection Features in Alcohol-Associated Hepatitis: Review of a 2016-2021 Cohort

Background/Objectives: Bacterial infections (BI) are a major cause of mortality in patients with alcohol-associated hepatitis (AH); however, only a few studies have investigated BI in AH in the last decade. Therefore, we aimed to assess the features and outcomes of BI in patients with AH. Methods: This observational descriptive study included patients with AH admitted to a tertiary academic hospital between 2016 and 2021. Clinical and complete microbiological data were recorded and complications, including acute-on-chronic liver failure (ACLF), and mortality over 90-days were compared between infected and noninfected patients. Results: Overall, 115 patients with AH were recruited and 75 had severe AH; among them, 66 started corticosteroid treatment. We identified 69 cases of BI in 44 patients; the incidence of BI upon hospital discharge was 32.2%, which reached 38.2% at 90 days. The predominant infection site was the chest (35%). Among the identified bacteria (52.1%), half were gram positive and half gram negative. A low rate of multidrug-resistant bacteria (14%) was also noted. Infected patients during hospitalization (n = 37) exhibited higher rates of hepatic decompensation and ACLF (p = 0.001) and lower survival (81.8% vs. 95.8%, p = 0.015) than did noninfected patients (n = 78). In-hospital infected patients (n = 22) exhibited worse survival (72.7%) than did those infected upon admission (93.3%) or noninfected patients (94.9%) (p = 0.009). Corticosteroid-treated patients displayed a nonsignificant increase in the total number of BI; however, without greater mortality. Conclusions: BI were common in our cohort of patients with AH. Patients with in-hospital infections commonly experienced serious complications, including high ACLF and death rates. Infections diagnosed upon admission were treated without affecting survival.

Water decoction of Pericarpium citri reticulatae and Amomi fructus ameliorates alcohol-induced liver disease involved in the modulation of gut microbiota and TLR4/NF-κB pathway

Introduction

Alcohol consumption alters the diversity and metabolic activities of gut microbiota, leading to intestinal barrier dysfunction and contributing to the development of alcoholic liver disease (ALD), which is the most prevalent cause of advanced liver diseases. In this study, we investigated the protective effects and action mechanism of an aqueous extraction of Pericarpium citri reticulatae and Amomi fructus (PFE) on alcoholic liver injury.

Methods

C57BL/6 mice were used to establish the mouse model of alcoholic liver injury and orally administered 500 and 1,000 mg/kg/d of PFE for 2 weeks. Histopathology, immunohistochemistry, immunofluorescence, Western blotting, qRT-PCR, and 16S rDNA amplicon sequencing were used to analyze the mechanism of action of PFE in the treatment of alcohol-induced liver injury.

Results

Treatment with PFE significantly improved alcohol-induced liver injury, as illustrated by the normalization of serum alanine aminotransferase, aspartate aminotransferase, total triglyceride, and cholesterol levels in ALD mice in a dose-dependent manner. Administration of PFE not only maintained the intestinal barrier integrity prominently by upregulating mucous production and tight junction protein expressions but also sensibly reversed the dysregulation of intestinal microecology in alcohol-treated mice. Furthermore, PFE treatment significantly reduced hepatic lipopolysaccharide (LPS) and attenuated oxidative stress as well as inflammation related to the TLR4/NF-κB signaling pathway. The PFE supplementation also significantly promoted the production of short-chain fatty acids (SCFAs) in the ALD mice.

Conclusion

Administration of PFE effectively prevents alcohol-induced liver injury and may also regulate the LPS-involved gut-liver axis; this could provide valuable insights for the development of drugs to prevent and treat ALD.

Non-cirrhotic Ascites: A Case of Severe Alcoholic Hepatitis

This case report presents a unique instance of ascites in acute alcoholic hepatitis (AH) occurring in a non-cirrhotic patient. Comprehensive diagnostic evaluation excluded alternative etiologies, pinpointing sinusoidal non-cirrhotic portal hypertension. Present therapeutic modalities for AH, including steroids and pentoxifylline, offer limited efficacy, necessitating ongoing investigation. Liver transplantation may be contemplated in refractory cases. This case underscores the intricate nature of AH presentations and the challenges in their management, emphasizing the imperative need for continued research to delineate optimal therapeutic strategies. Early intervention remains pivotal in addressing AH complications, underscoring the need for heightened clinical vigilance and proactive treatment approaches in such cases.

Circulating myeloid populations have prognostic utility in alcohol-related liver disease

Introduction

Alcohol-related liver disease (ARLD) accounts for over one third of all deaths from liver conditions, and mortality from alcohol-related liver disease has increased nearly five-fold over the last 30 years. Severe alcohol-related hepatitis almost always occurs in patients with a background of chronic liver disease with extensive fibrosis or cirrhosis, can precipitate 'acute on chronic' liver failure and has a high short-term mortality. Patients with alcohol-related liver disease have impaired immune responses, and increased susceptibility to infections, thus prompt diagnosis of infection and careful patient management is required. The identification of early and non-invasive diagnostic and prognostic biomarkers in ARLD remains an unresolved challenge. Easily calculated predictors of infection and mortality are required for use in patients who often exhibit variable symptoms and disease severity and may not always present in a specialized gastroenterology unit.

Methods

We have used a simple haematological analyser to rapidly measure circulating myeloid cell parameters across the ARLD spectrum.

Results and Discussion

We demonstrate for the first time that immature granulocyte (IG) counts correlate with markers of disease severity, and our data suggests that elevated counts are associated with increased short-term mortality and risk of infection. Other myeloid populations such as eosinophils and basophils also show promise. Thus IG count has the potential to serve alongside established markers such as neutrophil: lymphocyte ratio as a simply calculated predictor of mortality and risk of infectious complications in patients with alcohol-related hepatitis. This would allow identification of patients who may require more intensive management.

Prevalence of Bruxism in alcohol abusers: a systematic review conducted according to PRISMA guidelines and the cochrane handbook for systematic reviews of interventions

BACKGROUND

Bruxism, a common oral parafunctional behavior characterized by the grinding or clenching of teeth, is a multifactorial condition with potentially detrimental effects on oral health and overall well-being. In recent years, there has been growing interest in understanding the relationship between bruxism and alcohol abuse, as both are prevalent issues that may share underlying factors and exacerbate each other. This systematic review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, aims to evaluate the frequency of bruxism among individuals with alcohol abuse.

METHODS

A comprehensive search of electronic databases, including PubMed, Lilacs, Scopus and Web of Science, will be conducted to identify relevant studies published up to the knowledge cutoff date in January 2023. The search strategy will include keywords related to bruxism, alcohol abuse, and their synonyms. Inclusion criteria will encompass original research studies, such as observational, cross-sectional, cohort, and case-control studies, as well as clinical trials, that examine the relationship between bruxism and alcohol abuse. Two independent reviewers will perform the study selection, data extraction, and quality assessment, with discrepancies resolved by consensus.

RESULTS

The systematic review will present a summary of the identified studies, including the study design, characteristics of the study populations, and key findings related to the association between bruxism and alcohol abuse. The potential mechanisms underlying this relationship will also be explored. Subgroup analyses and the quality of evidence will be assessed. Finally, the implications of this association for clinical practice and further research will be discussed.

CONCLUSIONS

This systematic review will contribute to a better understanding of the interplay between bruxism and alcohol abuse, shedding light on potential risk factors, mechanisms, and clinical implications. The findings may have significant implications for the prevention, management, and treatment of bruxism, particularly in individuals with a history of alcohol abuse.