Endotoxin Metabolism Reflects Hepatic Functional Reserve in End-Stage Liver Disease

Scoring models and test indexes for diagnosis and prognosis of hepatitis B virus-related acute-on-chronic liver failure

Hepatitis B virus-associated acute-on-chronic liver failure (HBV-ACLF) is a common type of liver failure, which can occur in the context of chronic hepatitis B or cirrhosis compensatory period or decompensated period. HBV-ACLF progresses rapidly, is often complicated with multiple organ failure syndrome involving the liver, brain, heart, kidney, etc., and is associated with an extremely high short-term mortality rate. The American College of Gastroenterology (ACG) defines HBV-ACLF as a potentially reversible disease, and early diagnosis and standardized treatment will affect its prognosis. In recent years, the clinical application of some new scoring models and biomarkers has effectively improved the diagnosis and prognosis of HBV-ACLF. This article reviews some scoring models and test indexes recently used in the clinical treatment and explores their value in the diagnosis and prognosis of HBV-ACLF.

Pulse oximetry-based capillary refilling evaluation predicts postoperative outcomes in liver transplantation: a prospective observational cohort study

Background

Capillary refill time (CRT) is a non-invasive technique to evaluate tissue perfusion, and quantitative CRT (Q-CRT) adapted to pulse oximetry was developed with patients with sepsis and compared to blood lactate and sepsis scores. In post liver transplantation, large amounts of fluid administration are necessary for maintaining tissue perfusion to grafted liver against intravascular hypovolemia. This study aimed to evaluate whether Q-CRT can predict poor outcomes by detecting peripheral tissue perfusion abnormality in patients with liver transplantations who were treated with massive fluid administration.

Methods

In this single-center prospective cohort study, we enrolled adult patients with liver transplantations between June 2018 and July 2019. Measurement of Q-CRT was conducted at intensive care units (ICU) admission and postoperative day 1 (POD1).

Results

A total of 33 patients with liver transplantations were enrolled. Significant correlations of Q-CRT and ΔA_b, a tissue oxygen delivery parameter calculated by pulse oximetry data, at ICU admission with the postoperative outcomes such as length of ICU and hospital stay and total amount of ascitic fluid discharge were observed. Quantitative CRT and ΔA_b at ICU admission were significantly associated with these postoperative outcomes, even after adjusting preoperative and operative factors (MELD score and bleeding volume, respectively). However, quantitative CRT and ΔA_b at POD1 and changes from ICU admission to POD1 failed to show significant associations.

Conclusions

Q-CRT values were significantly associated with postoperative outcomes in liver transplantation. Although the mechanisms of this association need to be clarified further, Q-CRT may enable identification of high-risk patients that need intensive postoperative managements.

Postprandial Endotoxin Transporters LBP and sCD14 Differ in Obese vs. Overweight and Normal Weight Men during Fat-Rich Meal Digestion

Circulating levels of lipopolysaccharide-binding protein (LBP) and soluble cluster of differentiation 14 (sCD14) are recognized as clinical markers of endotoxemia. In obese men, postprandial endotoxemia is modulated by the amount of fat ingested, being higher compared to normal-weight (NW) subjects. Relative variations of LBP/sCD14 ratio in response to overfeeding are also considered important in the inflammation set-up, as measured through IL-6 concentration. We tested the hypothesis that postprandial LBP and sCD14 circulating concentrations differed in obese vs. overweight and NW men after a fat-rich meal. We thus analyzed the postprandial kinetics of LBP and sCD14 in the context of two clinical trials involving postprandial tests in normal-, over-weight and obese men. In the first clinical trial eight NW and 8 obese men ingested breakfasts containing 10 vs. 40 g of fat. In the second clinical trial, 18 healthy men were overfed during 8 weeks. sCD14, LBP and Il-6 were measured in all subjects during 5 h after test meal. Obese men presented a higher fasting and postprandial LBP concentration in plasma than NW men regardless of fat load, while postprandial sCD14 was similar in both groups. Irrespective of the overfeeding treatment, we observed postprandial increase of sCD14 and decrease of LBP before and after OF. In obese individuals receiving a 10 g fat load, whereas IL-6 increased 5h after meal, LBP and sCD14 did not increase. No direct association between the postprandial kinetics of endotoxemia markers sCD14 and LBP and of inflammation in obese men was observed in this study.

Importance of Endotoxin Clearance in Endotoxemic Septic Shock: An Analysis From the Evaluating Use of PolymyxinB Hemoperfusion in a Randomized Controlled Trial of Adults Treated for Endotoxemic Septic Shock (EUPHRATES) Trial

To investigate the relationship between survival and treatment-related reduction in endotoxin activity for patients in the Evaluating Use of PolymyxinB Hemoperfusion in a Randomized controlled trial of Adults Treated for Endotoxemia and Septic shock trial with baseline endotoxin activity assay greater than or equal to 0.60 to less than 0.90 units.

Design

Post hoc analysis of a multicenter randomized controlled clinical trial.

Setting

Fifty-five tertiary hospitals in North America.

Patients

Patients with septic shock and endotoxin activity assay level greater than or equal to 0.60 to less than 0.90 and multiple organ dysfunction syndrome greater than 9.

Interventions

Two polymyxin B hemoperfusion treatments or Sham.

Measurements and Main Results

One-hundred ninety-four patients were included (88 polymyxin B and 106 Sham). We evaluated the impact of changes in endotoxin activity assay based on comparison to the median reduction from baseline to day 3 and a second method where a target post-treatment endotoxin activity assay level (day 3) was established. The population median reduction in endotoxin activity assay level was 10.4%. In patients with a greater than median reduction, there was trend toward lower mortality with polymyxin B (17.1% vs 33.3%; p = 0.07) and a significant increase in mechanical ventilation-free days (20 vs 13.5; p = 0.04). The pressure adjusted heart rate showed a significant improvement in the polymyxin B group (p = 0.02). For patients who achieved an endotoxin activity assay of less than 0.65 at day 3, the polymyxin B treated group had a trend toward a mortality reduction compared to Sham (16% vs 33%;p = 0.06) and a significant increase in ventilation-free day (20 vs 16; p = 0.05). Kaplan-Meier analysis showed a 17% reduction in mortality with polymyxin B (p = 0.04).

Conclusions

These findings suggest that reducing endotoxin activity assay levels with polymyxin B as measured by comparison to a median reduction or when a treatment target is established, may result in improvements in mortality and organ function outcomes. This article is the first to report endotoxin activity assay measurements in response to polymyxin B use versus Sham in patients with septic shock and elevated endotoxin activity assay. These findings are considered to be hypothesis generating and will need to be prospectively validated.