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Abstract
Chronic liver disease (CLD) is a persistent public health burden, with over one billion cases reported worldwide. In most cases, the progression of CLD is slow and undulating with end-stage liver disease developing at variable time points depending on the underlying etiology of the disease. The concept of reversibility or halting progression to end stage liver disease is recent and various medications are in the pipeline which influence the progression of CLD. Non-invasive tests for monitoring of CLD may have the potential to avoid the morbidity and mortality related to invasive procedures. However, their applicability and validation in pediatrics requires further development and a coordinated effort by large pediatric liver centres. Recent advances in metabolomics and modern molecular technologies have led to an understanding of the interaction between gut microbiome liver axis and gut dysbiosis contributing to liver diseases. In the future, modifying the gut microbiome has the potential to change the outcome and significantly reduce the morbidity associated with CLD. This article focuses on newer modalities and concepts in the management of CLD, which may help develop strategies to prevent its progression to end-stage liver disease and associated morbidity/mortality.
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Affiliation(s)
- Ezyana Effandie
- Liver Unit (Including Small Bowel Transplantation), Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Girish L Gupte
- Liver Unit (Including Small Bowel Transplantation), Birmingham Women's and Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK.
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2
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Zhang Z, Yuan Q, Hu X, Liao J, Kuang J. Rifaximin protects SH-SY5Y neuronal cells from iron overload-induced cytotoxicity via inhibiting STAT3/NF-κB signaling. Cell Biol Int 2022; 46:1062-1073. [PMID: 35143099 DOI: 10.1002/cbin.11776] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 01/10/2022] [Accepted: 02/09/2022] [Indexed: 11/06/2022]
Abstract
Acute or chronic liver disease-caused liver failure is the cause of hepatic encephalopathy (HE), characterized by neuropsychiatric manifestations. Liver diseases potentially lead to peripheral iron metabolism dysfunction and surges of iron concentration in the brain, contributing to the pathophysiological process of degenerative disorders of the central nervous system. In this study, the mechanism of rifaximin treating hepatic encephalopathy was investigated. Ferric ammonium citrate (FAC)-induced iron overload significantly reduced the proliferation and boosted the apoptosis in SH-SY5Y cells through increasing reactive oxygen species (ROS) levels and inducing iron metabolism disorder. Rifaximin treatment could rectify the FAC-induced iron overload and lipopolysaccharide (LPS)-induced iron deposition, therefore effectively protecting SH-SY5Y cells from ROS-induced cell injury and apoptosis. Signal transducer and activator of transcription 3 (STAT3)/nuclear factor-kappaB (NF-κB) signaling is involved in the protective function of rifaximin against LPS-induced iron deposition. The therapeutic effect of rifaximin on HE associated with acute hepatic failure in mouse model was ascertained. In conclusion, Rifaximin could effectively protect SH-SY5Y cells against injury caused by iron overload through the rectification of the iron metabolism disorder via the STAT3/NF-κB signaling pathway. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Zheng Zhang
- Department of Hepatopathy, The Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005, China
| | - Qi Yuan
- Department of Hepatopathy, The Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005, China
| | - Xiaoxuan Hu
- Department of Hepatopathy, The Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005, China
| | - Jinmao Liao
- Department of Hepatopathy, The Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005, China
| | - Jia Kuang
- Department of Hepatopathy, The Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005, China
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Chela HK, Basra N, Naqvi SH. Hepatic Encephalopathy in the Hospitalized Patient: A Review for Hospitalists. MISSOURI MEDICINE 2019; 116:308-312. [PMID: 31527980 PMCID: PMC6699823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Hepatic encephalopathy is a well-recognized complication of decompensated cirrhosis. It is a reversible state of neurocognitive decline, the etiology of which is multifactorial. Diagnosis is predominantly clinical and usually a diagnosis of exclusion. The identification of precipitating factors and their correction is an essential part of the management along with medical therapies such as lactulose and rifaxmin.
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Affiliation(s)
- Harleen Kaur Chela
- Harleen Kaur Chela, MD, and S. Hasan Naqvi, MD, are in the Department of Medicine, Division of Hospital Medicine, University of Missouri - Columbia. Nishchayjit Basra, DO, is in the Department of Medicine, Internal Medicine Residency Program, University of Missouri - Columbia, Columbia, Mo
| | - Nishchayjit Basra
- Harleen Kaur Chela, MD, and S. Hasan Naqvi, MD, are in the Department of Medicine, Division of Hospital Medicine, University of Missouri - Columbia. Nishchayjit Basra, DO, is in the Department of Medicine, Internal Medicine Residency Program, University of Missouri - Columbia, Columbia, Mo
| | - S Hasan Naqvi
- Harleen Kaur Chela, MD, and S. Hasan Naqvi, MD, are in the Department of Medicine, Division of Hospital Medicine, University of Missouri - Columbia. Nishchayjit Basra, DO, is in the Department of Medicine, Internal Medicine Residency Program, University of Missouri - Columbia, Columbia, Mo
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Kockerling D, Nathwani R, Forlano R, Manousou P, Mullish BH, Dhar A. Current and future pharmacological therapies for managing cirrhosis and its complications. World J Gastroenterol 2019; 25:888-908. [PMID: 30833797 PMCID: PMC6397723 DOI: 10.3748/wjg.v25.i8.888] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/17/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
Abstract
Due to the restrictions of liver transplantation, complication-guided pharmacological therapy has become the mainstay of long-term management of cirrhosis. This article aims to provide a complete overview of pharmacotherapy options that may be commenced in the outpatient setting which are available for managing cirrhosis and its complications, together with discussion of current controversies and potential future directions. PubMed/Medline/Cochrane Library were electronically searched up to December 2018 to identify studies evaluating safety, efficacy and therapeutic mechanisms of pharmacological agents in cirrhotic adults and animal models of cirrhosis. Non-selective beta-blockers effectively reduce variceal re-bleeding risk in cirrhotic patients with moderate/large varices, but appear ineffective for primary prevention of variceal development and may compromise renal function and haemodynamic stability in advanced decompensation. Recent observational studies suggest protective, haemodynamically-independent effects of beta-blockers relating to reduced bacterial translocation. The gut-selective antibiotic rifaximin is effective for secondary prophylaxis of hepatic encephalopathy; recent small trials also indicate its potential superiority to norfloxacin for secondary prevention of spontaneous bacterial peritonitis. Diuretics remain the mainstay of uncomplicated ascites treatment, and early trials suggest alpha-adrenergic receptor agonists may improve diuretic response in refractory ascites. Vaptans have not demonstrated clinical effectiveness in treating refractory ascites and may cause detrimental complications. Despite initial hepatotoxicity concerns, safety of statin administration has been demonstrated in compensated cirrhosis. Furthermore, statins are suggested to have protective effects upon fibrosis progression, decompensation and mortality. Evidence as to whether proton pump inhibitors cause gut-liver-brain axis dysfunction is conflicting. Emerging evidence indicates that anticoagulation therapy reduces incidence and increases recanalisation rates of non-malignant portal vein thrombosis, and may impede hepatic fibrogenesis and decompensation. Pharmacotherapy for cirrhosis should be implemented in accordance with up-to-date guidelines and in conjunction with aetiology management, nutritional optimisation and patient education.
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Affiliation(s)
- David Kockerling
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Rooshi Nathwani
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Roberta Forlano
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Pinelopi Manousou
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Benjamin H Mullish
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
| | - Ameet Dhar
- Liver Unit/Division of Integrative Systems Medicine and Digestive Disease, Imperial College London, London W2 1NY, United Kingdom
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New concepts on intestinal microbiota and the role of the non-absorbable antibiotics with special reference to rifaximin in digestive diseases. Dig Liver Dis 2018; 50:741-749. [PMID: 29807873 DOI: 10.1016/j.dld.2018.04.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 04/16/2018] [Accepted: 04/17/2018] [Indexed: 12/11/2022]
Abstract
Digestive diseases are a broad range of chronic disorders that substantially and negatively impact the patients' quality of life. Here, we review our current understanding on the pathophysiology of hepatic encephalopathy, irritable bowel syndrome, and diverticular disease, with a special focus on the gut microbiota composition associated with these disorders. Furthermore, we review the current clinical practice for their therapeutic treatments, including probiotics, diet change, non-adsorbable disaccharides, and antibiotics. We highlight that broad-spectrum non-adsorbable antibiotics, such as rifaximin, are quite effective and safe for the treatment of all essayed digestive diseases.
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Gasteiger L, Eschertzhuber S, Tiefenthaler W. Perioperative management of liver surgery-review on pathophysiology of liver disease and liver failure. Eur Surg 2018; 50:81-86. [PMID: 29875796 PMCID: PMC5968074 DOI: 10.1007/s10353-018-0522-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 03/23/2018] [Indexed: 12/17/2022]
Abstract
An increasing number of patients present for liver surgery. Given the complex pathophysiological changes in chronic liver disease (CLD), it is pivotal to understand the fundamentals of chronic and acute liver failure. This review will give an overview on related organ dysfunction as well as recommendations for perioperative management and treatment of liver failure-related symptoms.
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Affiliation(s)
- Lukas Gasteiger
- Department of Anaesthesia and Intensive Care, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Stephan Eschertzhuber
- Department of Anaesthesia and Intensive Care, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
- Department of Anaesthesia and Intensive Care, General Hospital Hall in Tirol, Hall in Tirol, Austria
| | - Werner Tiefenthaler
- Department of Anaesthesia and Intensive Care, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
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Ning Z, Shuangnan Z, Xiaohe X, Zhen W, Yunfeng B, Tingting H, Chao Z, Yao W, Zhou K, Zhongxia W, Bing L, Prokop LJ, Hernandez MC, Jun L, Man G. Rhubarb-based Chinese herbal formulae for hepatic encephalopathy: a systematic review and Meta-analysis. J TRADIT CHIN MED 2017. [DOI: 10.1016/s0254-6272(18)30035-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Abstract
Chronic injury to the liver from a variety of different sources can result in irreversible scarring of the liver, known as cirrhosis. Cirrhosis is a major cause of morbidity and mortality in the USA, and according to the Centers for Disease Control and Prevention was responsible for 31,903 deaths in 2010 alone. It is thus of the utmost importance to appropriately manage these patients in the inpatient and outpatient setting to improve morbidity and mortality. In this review, we address four major areas of cirrhosis management: outpatient management of portal hypertension with decompensation, hepatic encephalopathy, hepatorenal syndrome, and bleeding/coagulation issues. Outpatient management covers recommendations for health care maintenance and screening. Hepatic encephalopathy encompasses a brief review of pathophysiology, treatment in the acute setting, and long-term prevention. Hepatorenal syndrome is discussed in regards to pathophysiology and treatment in the hospital setting. Finally, a discussion of the assessment of coagulation profiles in cirrhosis and recommendations for bleeding and thrombosis complications is included. These topics are not all encompassing with regard to this complicated population, but rather an overview of a few medical problems that are commonly encountered in their care.
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Affiliation(s)
- Neeral L Shah
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | | | | | - Scott L Cornella
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
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Courson A, Jones GM, Twilla JD. Treatment of Acute Hepatic Encephalopathy: Comparing the Effects of Adding Rifaximin to Lactulose on Patient Outcomes. J Pharm Pract 2015; 29:212-7. [PMID: 25586470 DOI: 10.1177/0897190014566312] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Rifaximin is approved for the reduction of hepatic encephalopathy (HE) recurrence in patients with chronic liver disease (CLD); however, few studies have evaluated the benefit of adding rifaximin to lactulose for treatment of acute HE. The aim of this study was to determine the impact of combination therapy with lactulose and rifaximin on hospital length of stay (LOS) and readmission rates. METHODS A retrospective study of patients admitted to an adult hospital within the Methodist LeBonheur Healthcare (MLH) System in Memphis, Tennessee, between 2007 and 2012 was conducted. Patients were identified via International Classification of Diseases, Ninth Revision (ICD-9) coding for liver cirrhosis. RESULTS Of the 173 patients included, 87 (50%) received lactulose monotherapy and 62 (36%) combination therapy, while 24 (14%) underwent therapy escalation. Median LOS was 6 days in monotherapy group and 8 days in combination group (P = .9). At 180 days, patients receiving combination therapy had fewer readmissions for HE than those receiving monotherapy (2.4% vs 16.2%, P = .02). CONCLUSION Addition of rifaximin to lactulose for treatment of acute HE did not reduce hospital LOS; however, it did result in lower readmission rates for HE at 180 days.
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Affiliation(s)
- Alesa Courson
- New York Presbyterian Hospital, Department of Pharmacy, New York, NY, USA
| | - G Morgan Jones
- Methodist University Hospital, Department of Pharmacy, Memphis, TN, USA University of Tennessee Health Science Center, College of Pharmacy, Memphis, TN, USA
| | - Jennifer D Twilla
- Methodist University Hospital, Department of Pharmacy, Memphis, TN, USA University of Tennessee Health Science Center, College of Pharmacy, Memphis, TN, USA
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Rifaximin: A Review of Its Use in Reducing Recurrence of Overt Hepatic Encephalopathy Episodes. Drugs 2014; 74:2153-60. [DOI: 10.1007/s40265-014-0300-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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