[Analysis of curative effect and short-term survival rate of plasma exchange and double plasma molecular adsorption combined with half-volume plasma exchange in the treatment of liver failure]

Objective: To investigate how plasma exchange (PE) and double plasma molecular adsorption combined with half-volume plasma exchange (DPMAS + half-volume PE) affect the curative effect and short-term survival rate in liver failure. Methods: Data from 181 cases of liver failure caused by different etiologies from January 1, 2017 to September 31, 2020, were selected. Patients were divided into a PE treatment alone group and a DPMAS + half-dose PE treatment group. The laboratory indicators with different models of artificial liver before and after treatment and the survival rates of 7, 14, 28, and 90 days after discharge were observed in the two groups. Measurement data were analyzed by t-tests and rank sum tests. Categorical data were analyzed by χ (2) test. Results: Non-biological artificial liver therapy with different models improved the liver and coagulation function in the two groups of patients with liver failure (P < 0.05 in PTA% intra-group). The coagulation function was significantly improved in the PE treatment alone group compared with that in the DPMAS + half-dose PE group [PT after treatment: (20.15 ± 0.88) s in the PE treatment alone group, (23.43 ± 1.02) s, t = -2.44, P = 0.016 in the DPMAS+half-dose PE group; PTA: 44.72% ± 1.75% in the PE treatment alone group, 35.62% ± 2.25%, t = 3.215 P = 0.002 in the DPMAS + half-dose PE group]. Bilirubin levels were significantly decreased in the DPMAS+half-dose PE group compared to the PE treatment alone group [total bilirubin after treatment: (255.30 ± 15.64) μmol/L in the PE treatment alone group, (205.46 ± 9.03) μmol/L, t = 2.74, P = 0.07 in the DPMAS + half-dose PE group; direct bilirubin after treatment: (114.74 ± 7.11) μmol/L in the PE treatment alone group, (55.33 ± 3.18) μmol/L, t = 7.54, P < 0.001) in the DPMAS + half-dose PE group]. However, there was no significant effect on leukocytes and neutrophils after treatment with different models of artificial liver (P > 0.05) in the two groups, and platelets decreased after treatment, with no statistically significant difference between the groups (t = -0.15, P = 0.882). The inflammatory indexes of the two groups improved after treatment with different models of artificial liver (P < 0.05], and the 28 and 90 d survival rates were higher in the DPMAS+half-dose PE group than those of the PE treatment alone group (28 d: 60.3% vs. 75.0%, χ (2) = 4.315, P = 0.038; 90 d: 56.2% vs. 72.5%. χ (2) = 10.355 P < 0.001). DPMAS + half-dose PE group plasma saving was 1385 ml compared with PE treatment alone group (Z = -7.608, P < 0.05). Conclusion: Both DPMAS+half-dose PE and PE treatment alone have a certain curative effect on patients with liver failure. In DPMAS+half-dose PE, the 28-day survival rate is superior to PE treatment alone, and it saves plasma consumption and minimizes blood use in clinic.

[Advances in anticoagulant therapy for cirrhosis combined with atrial fibrillation]

Relevant research in recent years has demonstrated that the atrial fibrillation occurrence rate is significantly higher in patients with cirrhosis. The most common indication for long-term anticoagulant therapy is chronic atrial fibrillation. The use of anticoagulant therapy greatly reduces the incidence rate of ischemic stroke. Patients with cirrhosis combined with atrial fibrillation have an elevated risk of bleeding and embolism during anticoagulant therapy due to cirrhotic coagulopathy. At the same time, the liver of such patients will go through varying levels of metabolism and elimination while consuming currently approved anticoagulant drugs, thereby increasing the complexity of anticoagulant therapy. This article summarizes the clinical studies on the risks and benefits of anticoagulant therapy in order to provide a reference for patients with cirrhosis combined with atrial fibrillation.

[Impact of NLR on atrial fibrillation recurrence after radiofrequency ablation in atrial fibrillation patients combined with heart failure]

Objective: To investigate the predictive value of neutrophils-to-lymphocytes ratio (NLR) for atrial fibrillation recurrence after radiofrequency ablation in atrial fibrillation patients combined with heart failure. Methods: This is a retrospective cohort study. Patients with atrial fibrillation and heart failure who received radiofrequency ablation in the First Affiliated Hospital of Zhengzhou University from January 2019 to June 2020 were included. Patient were followed up in the outpatient clinic at 3, 6, 9 and 12 months after radiofrequency ablation and were divided into recurrent and non-recurrent groups according to the absence or presence of atrial fibrillation. Demographic data, echocardiographic indices and inflammation-related indices including NLR were collected and compared between the two groups. Spearman rank correlation was performed to analyze the correlation of NLR with atrial fibrillation recurrence after radiofrequency ablation. Multivariate logistic regression analysis was used to determine independent risk factors of atrial fibrillation recurrence after radiofrequency ablation. The receiver operating characteristic (ROC) curve was used to evaluate the value of NLR in predicting the atrial fibrillation recurrence after radiofrequency ablation. Results: A total of 883 patients were included, of which 460 (52.1%) were male, mean age was (64.4±10.7) years old. There were 246 patients (27.9%) in the recurrence group and 637 patients (72.1%) in the non-recurrence group. Compared with the non-recurrent group, the duration of atrial fibrillation, NLR, neutrophil count, N-terminal B-type natriuretic peptide precursor (NT-proBNP) and body mass index levels were significantly higher, while lymphocyte count was significantly lower in the recurrence group than in the non-recurrent group (all P<0.05). Spearman rank correlation analysis showed that NLR was positively correlated with the atrial fibrillation recurrence (r=0.333, P<0.05). Multivariate logistic regression analysis showed that NLR was an independent risk factor for atrial fibrillation recurrence after radiofrequency ablation in atrial fibrillation patients combined heart failure (OR=1.634, P<0.001). The ROC curve showed that the area under the curve (AUC) of NLR in predicting the recurrence of atrial fibrillation after radiofrequency ablation was 0.715 (95%CI: 0.668-0.762, P<0.001), with a sensitivity of 55.61% and a specificity of 84.54%. Conclusion: NLR is a useful predictor of atrial fibrillation recurrence after radiofrequency ablation in atrial fibrillation patients combined with heart failure.

[Human chorionic gonadotropin-secreting gonadoblastomas in a girl of 45, X Turner syndrome: a case report and literature review]

Objective: To summarize the experience in diagnosis and treatment of 45, X Turner syndrome (TS) with gonadal Y chromosome mosaicism and bilateral gonadoblastoma (Gb) secreting human chorionic gonadotrophin(HCG). Methods: A female patient aged 5 years and 3 months was admitted to the hospital with a complaint of "enlarged breasts for 27 months, and elevated blood β-HCG for 8 months". The clinical data were summarized, and related literature up to March 2022 with the key words"Turner syndrome" "Gonadoblastoma" "Y chromosome" "human chorionic gonadotropin" "precocious" in PubMed, CNKI and Wanfang databases were reviewed. Results: The girl went to the local hospital for 2-month breast development at age of 3 years, and was found with a heart murmur diagnosed with "pulmonary venous malformation and atrial septal defect (secondary foramen type)". Surgical correction was performed. She experienced the progressive breast development, rapid linear growth and markedly advanced skeletal age, which cannot be explained by partial activation in the hypothalamic-pituitary-gonadal axis determined at the age of 3 years and 7 months in local hospital. Then whole-exome sequencing revealed chromosome number abnormality 45, X, which was confirmed by Karyotyping. At the age of 4 years and 6 months, serum β-HCG was found to be elevated (24.9 U/L) with no lesion found at the local hospital. On physical examination, she was found with breast development, pubic hair development and clitoromegaly with elevated serum testosterone (1.96 μg/L) and β-HCG (32.3 U/L). Sex determining region Y(SRY) gene was negative in peripheral blood sample. Thoracic and abdominal CT, head and pelvic magnetic resonance imaging were normal. Exploratory laparotomy confirmed the presence of a left adnexal tumor and a right fibrous streak gonad. During surgery, simultaneous samples of bilateral gonadal and peripheral venous blood were obtained and serum β-HCG, estradiol and testosteron concentrations was higher to lower from left gonadal venous blood, right gonadal venous blood, to peripheral venous blood. Bilateral gonadectomy was performed. Histopathology revealed bilateral gonadoblastomas. SRY was positive in bilateral gonadal tissues. After surgery, serum E₂, testerone and β-HCG returned to normal. So far 4 cases of HCG-secreting gonadoblastoma had been reported worldwide. The phenotypes of the 4 cases were all female, with virilization or amenorrhea, and the preoperative peripheral blood β-HCG concentrations were 74.4, 5.0, 40 456.0, and 42.4 U/L, respectively. Conclusions: There is a high risk of Gb in TS with Y chromosome components. Gb is infrequently presented with breast development, and Gb associated with HCG secretion is rare. Karyotyping should be performed in a phenotypic female with masculinization, and virilization in TS indicates the presence of Y chromosome material with concurrent androgen secreting tumors.

[Sero-epidemiological characteristics of the hepatitis D virus infection among hepatitis B virus infected-patients at a single center in Xinjiang region]

Objective: To investigate the sero-epidemiological characteristics of the hepatitis D virus (HDV) infection among hepatitis B virus (HBV)-infected patients in Xinjiang region. Methods: A single-center cross-sectional analysis method was used to select 264 cases of hepatitis B virus infection who were hospitalized in the Center for Infectious Diseases and Liver Diseases of the First Affiliated Hospital of Xinjiang Medical University from August 2021 to January 2022. All patients were tested for HDV Ag, HDV IgM, HDV IgG, and HDV RNA. The infection status of hepatitis D virus was analyzed by grouping according to their clinical type, HBV viral load, and HBsAg level. A paired t-test was used for data with measurement data conforming to normal distribution. A paired rank sum test was used for data that did not conform to normal distribution before and after treatment. Results: A total of 36 cases (13.64%) and 26 cases (9.85%) were positive for HDV serological markers and HDV RNA. According to clinical type grouping, the positive rates of HDV serum markers in patients with chronic hepatitis B, hepatitis B-related cirrhosis, liver cancer, and liver failure were 13.46%, 12.43%, and 20.83%, respectively, and there was no statistically significant difference among the three groups (χ²=0.86, P=0.649). The positive rates of HDV RNA were 11.54%, 8.11%, and 20.83%, respectively, and there was no statistically significant difference among the three groups (χ²=4.015, P=0.134). According to HBV viral load grouping, the positive rates of HDV serum markers among patients with viral loads <20, 20-2 000, and >2 000 IU/ml were 17.15%, 7.81%, and 6.67%, respectively, and the difference was not statistically significant among the three groups (χ²=4.846, P=0.089). The positive rates of HDV RNA were 9.47%, 10.94%, and 10%, respectively, and the difference was not statistically significant among the three groups (χ²=0.113, P=0.945). According to HBsAg level grouping, the positive rates of HDV serum markers in HBsAg<0.05, 0.05~250, and >250 IU/ml were 14.29%, 16.67%, and 10.85%, respectively, and there was no statistically significance between the three groups (χ²=1.745, P=0.418). The positive rates of HDV RNA were 4.76%, 8.77%, and 11.63%, respectively, and there was no statistically significant difference among the three groups (χ²=1.221, P=0.543). Clinical outcome, disease course, HBV DNA, serological markers of viral hepatitis, routine blood test, biochemical indicators, coagulation function, and other laboratory indicators were compared between HDV serum marker and/or nucleic acid positive and negative patients, and there was no statistically significant difference (P>0.05). Conclusion: The positive rate of HDV serological markers and HDV RNA is 13.64% and 9.85%, respectively, at a single center in the Xinjiang region, and there is still a high HDV infection rate among the HBV-infected patients with low levels of viral load and HBsAg.

[Analysis of clinical characteristics of 481 HBV-related liver cirrhotic patients with low viral load]

Objective: To analyze the clinical characteristics of HBV-related liver cirrhotic patients with low viral load. Methods: A retrospective analysis on 481 inpatients with HBV-related cirrhosis with low viral load [HBV DNA≤2 000 IU/ml (10(4) copies/ml)] general condition, virological indicators, liver function-related indicators, complications, and incidence of complications were analyzed. The t-test was used to compare the average measurement data, and the χ (2) test was used to compare the count data. Results: 481 cases were mainly male (male/female: 324/157), aged 20-83 (53.31 ± 11.67) years old. Han nationality accounted for 71.518%. 386 cases were HBsAg positive. 391 cases were HBeAg positive, and 140 cases were HBV DNA positive. The average value of bilirubin, albumin, alanine aminotransferase, aspartate aminotransferase, platelets, and prothrombin were 50.59 ± 91.25 (μmol/L), 33.68 ± 7.5 (g/L), and 60.66 ± 106.95(U/L), 63.37 ± 86.19(U/L), 106.65 ± 83.22(×10(9)/L), 68.82% ± 25.33%, respectively. CTP class A/B/C had 220/150/111 cases. The average values of CTP, MELD, APRI and FIB-4 were 7.61 ± 2.58, 10.98 ± 5.79, 2.34 ± 3.56, 6.91 ± 8.04, respectively. The overall incidence of complications in HBV-related cirrhotic patients with low viral load, HBV DNA negative, HBV DNA positive, HBsAg negative, and HBsAg positive were 80.0%, 82.7%, 73.6%, 85.3%, and 78.8%, respectively. Among them, 283 cases (58.84%), 197 cases (55.77%), 86 cases (61.43%), 52 cases (54.74%) and 231 cases (59.84%) were of hypersplenism, and 267 cases (55.51%), 197 cases (55.77%), 70 cases (50.00%), 56 cases (58.95%), and 211 cases (54.66%) were of esophagogastric varices. There were 59 cases (12.27%), 48 cases (14.08%), 11 cases (7.86%), 12 cases (12.63%), and 47 cases (12.18%) of rupture of esophageal and gastric varices, respectively. 202 cases (42.00%), 147 cases (43.11%), 55 cases (39.29%), 42 cases (44.21%), and 160 cases (41.45%) were of ascites, respectively. 17 cases (3.53%), 12 cases (3.52%), 5 cases (3.5%), 2 cases (2.11%), 15 (3.89%) cases were of hepatic encephalopathy, respectively. There were 6 cases (1.25%), 3 cases (0.88%), 3 cases (2.14%), 0 cases (0%), 6 cases (1.55%) of liver cancer. 29 cases (6.03%), 21 cases (6.16%), 8 cases (5.71%), 9 cases (9.47%) and 20 cases (5.18%) were of portal vein thrombosis. Compared with the overall incidence of complications, 341 HBV DNA-negative patients and 95 HBsAg-negative patients still had higher incidence of complications. The patients were grouped by age, and in < 40 years old, 40-50 years old, and > 50 years old, the overall complications were 80.8% in 42 cases, 76.8% in 116 cases and 81.7% in 227 cases, and the difference was not statistically significant. Conclusion: HBV infection patients with low viral load, and those whose HBsAg has disappeared, are still at risk of developing liver cirrhosis and even serious complications, and whether such population need antiviral therapy and benefit from it deserves further research.

[Efficacy and safety of IA regimen containing different doses of idarubicin in de-novo acute myeloid leukemia for adult patients]

目的

探讨含不同剂量去甲氧柔红霉素（IDA 8、10、12 mg/m²）的IA方案诱导治疗成人初发急性髓系白血病（AML）（非急性早幼粒细胞白血病）的临床疗效和安全性。

方法

采用多中心、单盲、非随机、临床对照研究，纳入2011年5月至2015年3月苏州大学附属第一医院及其他36家单位收治的1 215例成人初发AML患者，根据诱导化疗方案中IDA的剂量对患者进行分组，分析不同剂量IDA联合阿糖胞苷（100 mg/m²）组成的IA方案在成人初发AML诱导治疗中的完全缓解（CR）率、血液学及非血液学不良事件。

结果

可纳入缓解率分析的AML患者共1 207例，IDA 8 mg/m²、10 mg/m²和12 mg/m²组的CR率分别为73.6%（215/292）、84.1%（662/787）和86.7%（111/128），差异有统计学意义（P<0.001）；以IDA 8 mg/m²组为参照组，在调整了年龄、骨髓原始细胞比例、FAB分型、危险度分层后，IDA 10 mg/m²和IDA 12 mg/m²为影响患者CR的有利因素[OR=0.49（95% CI 0.34~0.70），P<0.001；OR=0.36（95%CI 0.18~0.71），P=0.003]。在中、低危组中三组CR率分别为76.5%（163/213）、86.9%（506/582）和86.1%（68/79），差异有统计学意义（P=0.007）；在调整了年龄、骨髓原始细胞比例、FAB分型因素后，IDA 10 mg/m²为影响患者CR的有利因素[OR=0.47（95% CI 0.31~0.71），P<0.001]。在高危组中，三组CR率分别为50.0%（18/36）、60.6%（43/71）和81.8%（18/22），差异无统计学意义（P=0.089），但在调整了年龄、骨髓原始细胞比例、FAB分型因素后，IDA 12 mg/m²为影响患者CR的有利因素[OR=0.22（95% CI 0.06~0.80），P=0.022]。8 mg/m²、10 mg/m²和12 mg/m²组中性粒细胞≤0.5×10⁹/L的中位持续时间分别为14（11~18）、15（11~20）和18（14~22）d，差异有统计学意义（P=0.012）；三组PLT≤20×10⁹/L的中位持续时间分别为14（7~17）、15（11~20）和17（15~21）d，差异有统计学意义（P=0.001）；三组肺部感染发生率分别为9.8%、13.5%和25.2%，差异有统计学意义（P<0.001）。

结论

在中国成人（18~60岁）初发AML中，建议中、低危组患者采用含IDA 10 mg/m²的IA方案进行诱导治疗；而高危组AML建议选择含IDA 12 mg/m²的IA方案进行诱导治疗。

[Effects of bone marrow mesenchymal stem cell transplantation on the expression of stromal cell-derived factor-1α and vascular endothelial growth factor in rats with acute hepatic failure]

Objective: To investigate the curative effect of bone marrow mesenchymal stem cells (BMSCs) transplantation on the expression of stromal cell-derived growth factor (SDF-1 α) and vascular endothelial growth factor (VEGF) in rats with acute hepatic failure, and to compare the effects of two transplantation pathways. Methods: Eighty-four rats with acute liver failure (ALF) induced by D-galactosamine combined with lipopolysaccharide were randomly divided into control group, tail vein and portal vein transplantation group. The latter two groups were injected allogenic BMSCs into the tail vein and portal vein. Blood samples and liver tissue samples were collected at 24, 72, 120, and 168h after transplantation to detect serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST). The improvement of liver function before and after BMSCs transplantation was compared. The expression of VEGF and SDF-1a in liver tissue was detected by immunofluorescence and Western blot. Data measurement between two groups was performed by analysis of variance and the correlation analysis was performed by Spearman's rank correlation coefficient. Results: Serum ALT and AST levels in the tail vein and portal vein transplantation group peaked at 24 h after transplantation, which were (134.60 ± 58.08 IU/L), (179.20 ± 86.68 IU/L), and (131.00 ± 54.47 IU/L), (173.50 ± 93.10 IU/L). In addition, 168h after transplantation it decreased to (46.10 ± 8.40 IU/L), (95.67 ± 13.80 IU/L) and (19.30 ± 1.30 IU/L), (54.30 ± 6.00 IU/L). After 120 and 168 hours of BMSCs transplantation, the levels of serum ALT and AST in tail vein and portal vein transplantation group were significantly higher than control group (F ≥ 12.51, P < 0.01). The results of western blot and immunofluorescence showed that the expression levels of SDF-1α and VEGF protein in the two BMSCs transplantation groups increased with the improvement of liver function, and the difference was statistically significant at 120 and 168 hours after transplantation (F ≥ 9.069, P < 0.05). There was no significant difference in the expression of SDF-1a and VEGF between the tail vein and portal vein transplantation groups (P > 0.05). Correlation analysis showed that the expression levels of SDF-1α and VEGF in liver tissues were positively correlated (r = 0.923, P < 0.05). Conclusion: BMSCs transplantation can promote the secretion of VEGF for recovery of liver function to reduce the degree of inflammation and necrosis in rats with ALF.

Use of bone mesenchymal stem cells to treat rats with acute liver failure

This study aimed to isolate mesenchymal stem cells from bone mesenchymal stem cells (BMSCs), determine their therapeutic potential for treating rats with acute liver failure (ALF), further explore the factors that induce liver failure mechanisms, and elucidate the role of bone marrow stem cell therapy and BMSCs on liver homing. We found that differentiation potential was present in BMSCs expressing high levels of CD29 and CD90. These cells improved liver functioning in vivo after transplantation into rat livers with D-galactosamine damage, as evidenced by the levels of alanine aminotransferase and aspartate aminotransferase returning to normal (low levels) in recipient ALF rats. A significant improvement in the liver functional test and histological findings was observed in the transplantation group after 120 and 168 h of transplantation (P < 0.05). Histological data revealed that hepatocyte cell apoptosis was lower in the transplantation group compared to the control groups (P < 0.05), and that the transplantation of BMSCs reduced liver inflammation, decreased hepatic denaturation and necrosis, and promoted liver regeneration. These ameliorations were not recorded in the control groups. The results of in situ hybridization, immunofluorescence staining, and Western blot confirmed the presence of transplanted BMSCs in recipient rat livers. Stromal cell derived factor-1 alpha and vascular endothelial growth factor were significantly upregulated after the intraportal transplantation of BMSCs, with significantly higher levels being found in the portal vein and the tail vein groups (P < 0.05). In conclusion, BMSCs have a therapeutic effect against ALF rats, evoke endogenous repair mechanisms in the liver, and may represent a novel form of therapeutic intervention for the disease. Furthermore, intraportal transplantation serves as a more effective pathway compared to tail vein transplantation.

Effect of bone marrow mesenchymal stem cell transplantation on expression of Caspase1 and IL-18 in rats with acute hepatic liver failure

AIM: To investigate the effect of bone marrow mesenchymal stem cell (BMSC) transplantation in the treatment of acute liver failure (ALF) in rats and optimize the administration route.

METHODS: D-galactosamine (D-GalN)/lipopolysaccharide (LPS) were used to make a rat model of experimental ALF. Seventy-two rats were randomly divided into an ALF group, a tail vein group, and a portal vein transplantation group. At different time points (24, 72, 120, and 168 h) after BMSC transplantation, serum ALT and AST were detected. TUNEL assay was applied to detect hepatocyte apoptosis. Immunohistochemistry and Western blot were performed to detect the expression of Caspase1 and IL-18 proteins in liver tissue.

RESULTS: Serum levels of ALT and AST in the ALF group were gradually increased with the progression of the disease. Compared with the ALF group, significant improvement of liver function parameters and histological findings was observed in the transplantation group 120 and 168 h after transplantation (P < 0.05 for both). The apoptosis indexes in the tail vein group and portal vein transplantation group (120 h: 28.17% ± 17.08%, 20.67% ± 12.68%; 168 h: 19.67 % ± 11.82%, 13.00 % ± 6.84% ) were significantly lower than those in the ALF group (P < 0.01 for all). The expression levels of Caspase1 and IL-18 proteins in the two transplantation groups were decreased significantly at 120 and 168 h compared with the ALF group (P < 0.05 for both). Both administration routes had a therapeutic effect against ALF in rats, but no significant difference was observed between them.

CONCLUSION: BMSCs can improve the liver function, inhibit hepatic apoptosis and reduce the levels of Caspase1 and IL-18 proteins in ALF rats. Caspase1 and IL-18 play an important role in the pathogenesis of ALF and are expected to be predictors of ALF and future therapeutic targets.