1
|
Kazankov K, Nixon-Hill M, Kumar R, Amin A, Alabsawy E, Chikhlia A, Leung TS, Mookerjee RP. A novel smartphone scleral-image based tool for assessing jaundice in decompensated cirrhosis patients. J Gastroenterol Hepatol 2023; 38:330-336. [PMID: 36574965 PMCID: PMC10107452 DOI: 10.1111/jgh.16093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/12/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIM Serum bilirubin is an established marker of liver disease. Reliable tools for non-invasive assessment of jaundice in cirrhosis patients, at risk of clinical decompensation, are highly desirable. While smartphone-based imaging has been described in neonatal jaundice, it has not been investigated in advanced cirrhosis patients. METHODS We included 46 hospitalized patients with acute cirrhosis decompensation and jaundice. Scleral images using an Android smartphone were taken to derive "Scleral Color Values (SCV)," which were matched with same day serum bilirubin measurements. In 29 patients, repeat SCV and bilirubin measurements were performed over time. We analyzed the relationship of SCV and its dynamics with serum bilirubin, clinical scores, and patient outcomes. RESULTS Of 46 patients, 26 (57%) had alcoholic hepatitis as the decompensation precipitant. Seven patients died during admission; a further 12 following hospital discharge. SCV had an excellent linear correlation with serum bilirubin (rho = 0.90, P < 0.001); changes in SCV and serum bilirubin across different time points, were also closely associated (rho = 0.77, P < 0.001). SCV correlated significantly with CLIF Consortium Acute Decompensation score (rho = 0.38, P < 0.001) and grade of Acute-on-Chronic Liver Failure (rho = 0.42, P = 0.039). SCV was higher in patients who died, however, not significantly (86.1 [IQR 83.0-89.7] vs 82.3 [IQR 78.5-83.3], P = 0.22). The associations of SCV with clinical parameters mirrored those of serum bilirubin. CONCLUSION Smartphone-based assessment of jaundice shows excellent concordance with serum bilirubin and is associated with clinical parameters in acute cirrhosis decompensation. This approach offers promise for remote assessment of cirrhosis patients at-risk of decompensation, post hospital discharge.
Collapse
Affiliation(s)
- Konstantin Kazankov
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK.,Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Miranda Nixon-Hill
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Rahul Kumar
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Ahmed Amin
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Eman Alabsawy
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Anmol Chikhlia
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Terence S Leung
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Rajeshwar P Mookerjee
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK.,Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
2
|
Alabsawy E, Shalimar, Jalan R. Letter: de novo infection in hepatic encephalopathy-The culprit or the victim? Authors' reply. Aliment Pharmacol Ther 2022; 55:1231-1232. [PMID: 35429039 DOI: 10.1111/apt.16906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Eman Alabsawy
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK.,Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
| |
Collapse
|
3
|
Alabsawy E, Shalimar, Sheikh MF, Ballester MP, Acharya SK, Agarwal B, Jalan R. Overt hepatic encephalopathy is an independent risk factor for de novo infection in cirrhotic patients with acute decompensation. Aliment Pharmacol Ther 2022; 55:722-732. [PMID: 35106777 PMCID: PMC9303427 DOI: 10.1111/apt.16790] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/30/2021] [Accepted: 01/12/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The occurrence of overt hepatic encephalopathy (OHE) is associated with increased mortality. HE is commonly precipitated by infection, but whether HE predisposes to new infection is unclear. This study aimed to test if OHE predisposes to de novo infection during hospitalisation and its association with short-term mortality. AIMS AND METHODS Seven hundred and fifty-nine consecutive patients were identified at two institutions from prospectively maintained clinical databases of cirrhotic patients admitted with acute decompensation (AD). Infection and HE data were collected on the day of admission, and the occurrence of de novo infections was assessed for 28 days after admission. EASL-CLIF organ failure criteria were used to determine the presence of organ failures. Multivariable analysis using the logistic regression model was used to assess predictors of 28-day mortality and de novo infection. RESULTS Patients were divided into four groups; no baseline OHE or infection (n = 352); OHE with no baseline Infection (n = 221); no OHE but baseline infection (n = 100) and OHE with baseline infection (n = 86). On multivariate analyses, OHE (OR, 1.532 [95% CI, 1.061-2.300, P = 0.024]), and admission to ITU (OR, 2.303 [95% CI, 1.508-3.517, P < 0.001]) were independent risk factors for de novo infection. 28-day mortality was 25.3%, 60.2%, 55.0% and 72.1% in the 4-groups respectively. Age, INR and creatinine were independently predictive of mortality. The presence of overt HE, infection, coagulation, kidney, circulatory, respiratory and liver failures were significantly associated with higher mortality. CONCLUSION OHE is an independent risk factor for de novo infection in cirrhotic patients with AD.
Collapse
Affiliation(s)
- Eman Alabsawy
- Liver Failure Group, Institute for Liver and Digestive HealthUniversity College LondonLondonUK,Faculty of MedicineAlexandria UniversityAlexandriaEgypt
| | - Shalimar
- Department of GastroenterologyAll India Institute of Medical SciencesNew DelhiIndia
| | - Mohammed Faisal Sheikh
- Liver Failure Group, Institute for Liver and Digestive HealthUniversity College LondonLondonUK
| | - Maria Pilar Ballester
- Digestive Disease DepartmentHospital Clínico Universitario de ValenciaValenciaSpain,INCLIVA Biomedical Research InstituteValenciaSpain
| | - Subrat Kumar Acharya
- Department of GastroenterologyAll India Institute of Medical SciencesNew DelhiIndia,KIIT UniversityBhubaneshwarOdishaIndia
| | - Banwari Agarwal
- Liver Failure Group, Institute for Liver and Digestive HealthUniversity College LondonLondonUK,Intensive Care UnitRoyal Free HospitalLondonUK
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive HealthUniversity College LondonLondonUK
| |
Collapse
|
4
|
Alabsawy E, Shalimar, Jalan R. Editorial: infections and hepatic encephalopathy-does the chicken or the egg come first? A novel perspective at the horizon. Authors' reply. Aliment Pharmacol Ther 2022; 55:746-747. [PMID: 35245963 DOI: 10.1111/apt.16829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Eman Alabsawy
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK.,Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
| |
Collapse
|
5
|
Kerbert AJC, Gupta S, Alabsawy E, Dobler I, Lønsmann I, Hall A, Nielsen SH, Nielsen MJ, Gronbaek H, Amoros À, Yeung D, Macnaughtan J, Mookerjee RP, Macdonald S, Andreola F, Moreau R, Arroyo V, Angeli P, Leeming DJ, Treem W, Karsdal MA, Jalan R. Biomarkers of extracellular matrix formation are associated with acute-on-chronic liver failure. JHEP Rep 2021; 3:100355. [PMID: 34805815 PMCID: PMC8581571 DOI: 10.1016/j.jhepr.2021.100355] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/03/2021] [Accepted: 08/17/2021] [Indexed: 12/24/2022]
Abstract
Background & Aims Acute-on-chronic liver failure (ACLF) is characterised by organ failure(s), high short-term mortality, and, pathophysiologically, deranged inflammatory responses. The extracellular matrix (ECM) is critically involved in regulating the inflammatory response. This study aimed to determine alterations in biomarkers of ECM turnover in ACLF and their association with inflammation, organ failures, and mortality. Methods We studied 283 patients with cirrhosis admitted for acute decompensation (AD) with or without ACLF, 64 patients with stable cirrhosis, and 30 healthy controls. A validation cohort (25 ACLF, 9 healthy controls) was included. Plasma PRO-C3, PRO-C4, PRO-C5, PRO-C6, and PRO-C8 (i.e. collagen type III–VI and VIII formation) and C4M and C6M (i.e. collagen type IV and VI degradation) were measured. Immunohistochemistry of PRO-C6 was performed on liver biopsies (AD [n = 7], ACLF [n = 5]). A competing-risk regression analysis was performed to explore the prognostic value of biomarkers of ECM turnover with 28- and 90-day mortality. Results PRO-C3 and PRO-C6 were increased in ACLF compared to AD (p = 0.089 and p <0.001, respectively), whereas collagen degradation markers C4M and C6M were similar. Both PRO-C3 and PRO-C6 were strongly associated with liver function and inflammatory markers. Only PRO-C6 was associated with extrahepatic organ failures and 28- and 90-day mortality (hazard ratio [HR; on log-scale] 6.168, 95% CI 2.366–16.080, p <0.001, and 3.495, 95% CI 1.509–8.093, p = 0.003, respectively). These findings were consistent in the validation cohort. High PRO-C6 expression was observed in liver biopsies of patients with ACLF. Conclusions This study shows, for the first time, evidence of severe net interstitial collagen deposition in ACLF and makes the novel observation of the association between PRO-C6 and (extrahepatic) organ failures and mortality. Further studies are needed to define the pathogenic significance of these observations. Lay summary This study describes a disrupted turnover of collagen type III and VI in Acute-on-chronic liver failure (ACLF). Plasma biomarkers of these collagens (PRO-C3 and PRO-C6) are associated with the severity of liver dysfunction and inflammation. PRO-C6, also known as the hormone endotrophin, has also been found to be associated with multi-organ failure and prognosis in acute decompensation and ACLF. Collagen type III and VI formation is increased in ACLF compared to AD. PRO-C3 and PRO-C6 correlate with the severity of liver dysfunction and inflammation in AD and ACLF. High PRO-C6 levels were found to be indicative for the presence of multi-organ failure and worse survival.
Collapse
Key Words
- ACLF, acute-on-chronic liver failure
- AD, acute decompensation
- CLIF-C ACLF, CLIF Consortium Acute-on-Chronic Liver
- CLIF-C AD, CLIF Consortium Acute Decompensation
- CLIF-C OF, CLIF Consortium Organ Failure
- CPE, concordance probability estimate
- Collagen
- DAMP, danger-associated molecular pattern
- ECM, extracellular matrix
- HC, healthy control
- HR, hazard ratio
- HSC, hepatic stellate cell
- IHC, immunohistochemistry
- INR, international normalised ratio
- K18, keratin 18
- Liver cirrhosis
- MELD, model for end-stage liver disease
- MMP, matrix metalloproteinase
- Multi-organ failure
- NGAL, neutrophil gelatinase-associated lipocalin
- NIS, noninterventional Study
- PAMP, pathogen-associated molecular pattern
- Prognosis
- ROC, receiver operating characteristic
- SC, stable cirrhosis
- TLR, toll-like receptor
- UCL, University College London
- UCLH, University College London Hospitals
- WCC, white cell count
- cK18, caspase-cleaved keratin 18
- α-SMA, alpha-smooth muscle actin
Collapse
Affiliation(s)
- Annarein J C Kerbert
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
| | - Saurabh Gupta
- Translational and Biomarker Research, GI-DDU, Takeda Pharmaceuticals International Co., Cambridge, MA, USA
| | - Eman Alabsawy
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK.,Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Iwona Dobler
- Statistical and Quantitative Sciences, Takeda Pharmaceuticals International Co., Cambridge, MA, USA
| | - Ida Lønsmann
- Biomarkers and Research, Nordic Bioscience, Herlev, Denmark
| | - Andrew Hall
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
| | - Signe Holm Nielsen
- Biomarkers and Research, Nordic Bioscience, Herlev, Denmark.,Department of Biomedicine and Biotechnology, Technical University of Denmark, Lyngby, Denmark
| | | | - Henning Gronbaek
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Àlex Amoros
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Dave Yeung
- Translational and Biomarker Research, GI-DDU, Takeda Pharmaceuticals International Co., Cambridge, MA, USA
| | - Jane Macnaughtan
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
| | - Rajeshwar P Mookerjee
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK.,Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Stewart Macdonald
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
| | - Fausto Andreola
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
| | - Richard Moreau
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.,Inserm and Université de Paris, Centre de Recherche sur l'Inflammation (CRI), Paris, France.,Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Vicente Arroyo
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, DIMED, University of Padova, Padua, Italy
| | | | - William Treem
- Clinical Science, GI-TAU, Takeda Pharmaceuticals International Co., Cambridge, MA, USA
| | | | - Rajiv Jalan
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
| |
Collapse
|
6
|
Alabsawy E, Serry Y, Kotha S, Berry P, Tritto G. Hepatopulmonary syndrome as the first and only manifestation of cirrhosis in a patient with hypopituitarism. BMJ Case Rep 2021; 14:e244805. [PMID: 34544714 PMCID: PMC8454452 DOI: 10.1136/bcr-2021-244805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 11/04/2022] Open
Abstract
Hepatopulmonary syndrome (HPS) is characterised by the development of intrapulmonary arteriovenous blood shunts and vascular dilatation with consequent hypoxaemia, usually in the context of end-stage liver disease (ESLD). The estimated incidence of HPS in ESLD has been reported to be 13%-47%. Chronic liver disease has been described in patients with hypothalamic-pituitary dysfunction, mainly in the form of non-alcoholic fatty liver disease due to metabolic syndrome, with occasional progression to cirrhosis. We report a challenging case of a 27-year-old man with a background of hypopituitarism with no known liver disease who presented with progressive dyspnoea and hypoxaemia and was eventually diagnosed with severe HPS.
Collapse
Affiliation(s)
- Eman Alabsawy
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Yassen Serry
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sreelakshmi Kotha
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Philip Berry
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Giovanni Tritto
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
7
|
Putignano A, Figorilli F, Alabsawy E, Agarwal B, Jalan R. Long-term outcome in patients with acute liver failure. Liver Int 2018; 38:2228-2238. [PMID: 29927051 DOI: 10.1111/liv.13914] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 06/09/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Acute liver failure patients who meet poor prognostic criteria have high early mortality without emergency liver transplantation. A recent study however, reported that patients that survive spontaneously have a poorer outcome compared with patients undergoing transplantation. In this single centre study, we aimed to confirm or refute this observation. METHODS Early survivors (acute liver failure patients who survived 90 days after the ICU admission) were assessed for long-term outcomes in four distinctive cohorts, incorporating aetiology (Acetaminophen overdose or non-Acetaminophen overdose), and management strategy (conservative or liver transplantation). Chi Squared or Fisher test were used to compare outcomes among the four cohorts (P < 0.05) and Kaplan-Meier curve (Log Rank test) to represent cumulative survival. RESULTS Two hundred consecutive acute liver failure patients between 1990 and 2014 were included; mean age 38.3, ±12.8, male 70, 35%. 124/200 (62%) early survivors were identified; 13/124 (10.5%) acetaminophen patients underwent transplantation and 48/124 (38.7%) survived spontaneously; 36/124 (29.0%) non-acetaminophen underwent transplantation and 27/124 (21.8%) survived spontaneously. A total of 11/124 (8.9%) died subsequently (median survival 5.3± IQR 9.1), three spontaneous survivors and eight transplanted patients (P = 0.025); of the eight transplanted patients, six died of transplant related complications and two of suicide. CONCLUSION The results of this study suggest that although liver transplantation is a life-saving procedure for acute liver failure patients, they have a worse long-term outcome compared with spontaneous survivors. Novel therapies to increase the percentage of spontaneous survivors are urgently needed.
Collapse
Affiliation(s)
- Antonella Putignano
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, UK.,Intensive Care Unit, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Francesco Figorilli
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, UK
| | - Eman Alabsawy
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, UK
| | - Banwari Agarwal
- Intensive Care Unit, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, UK
| |
Collapse
|