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Halder P, Roy S, Banerjee S, Mandal S, Das K, Chowdhury A, Mahiuddin Ahammed S. Clinical Profile and Prognostic Markers of Acute on Chronic Liver Failure (ACLF): A Single-center Experience from East India. J Clin Exp Hepatol 2023; 13:1017-1024. [PMID: 37975045 PMCID: PMC10643518 DOI: 10.1016/j.jceh.2023.06.010] [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: 03/30/2023] [Accepted: 06/24/2023] [Indexed: 11/19/2023] Open
Abstract
Aim The aim of the study was to study the clinical profile of acute on chronic liver failure (ACLF) and establish Cell-free DNA (Cf DNA) as a predictor of the outcome of ACLF. Methods In this prospective study, those patients who fulfilled EASL criteria were included. Cf DNA was estimated in 30 patients and compared with the CLIF-C ACLF score. Results The median age of 132 consecutive ACLF patients was 40 years. The most common acute insult were sepsis (30.3%) and alcohol (22%). While alcohol (35.6%) and chronic HBV (14.3%) were the most common etiologies of cirrhosis. The overall mortality was 45.5% and 71.2% at 28 days and 90 days, respectively. Multiple regression analysis using the Cox proportional hazard model showed that heart rate (HR 1.06, 95% CI 1.04-1.08 P = 0.001), lung failure (HR 2.82, 95% CI 1.24-6.44, P = 0.02), and cell-free DNA (HR 2.70, 95% CI 1.17-6.24, P = 0.02) were independent predictors of mortality When Cf DNA was used to predict 28-day mortality, Cf DNA was found to have a higher AUC (AUROC 0.84, 95% CI 0.70-0.98, P = 0.001) than the CLIF-C-ACLF score (AUROC 0.81, 95% 0.66-0.97, P = 0.003). However, when 90-day mortality was compared, CLIF-C-ACLF score had a higher area under the curve (AUROC 0.93, 95% CI 0.83-1.00, P = 0.0001) than Cf DNA (AUROC 0.89, 95% CI 0.77-1.00, P = 0.0001). Conclusions Alcohol and sepsis remain the most common causes of acute insult. Cf DNA is a better predictor of 28-day mortality, whereas CLIF-C ACLF is more accurate to predict 90-day mortality.
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Affiliation(s)
- Prasenjit Halder
- Department of Hepatology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, Kolkata
| | - Susree Roy
- Center for Liver Research, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, Kolkata
| | - Soma Banerjee
- Center for Liver Research, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, Kolkata
| | - Syamsundar Mandal
- Department of Epidemiology & Biostatistics, Chittaranjan National Cancer Institute, Kolkata
| | - Kausik Das
- Department of Hepatology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, Kolkata
| | - Abhijit Chowdhury
- Department of Hepatology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, Kolkata
| | - Sk Mahiuddin Ahammed
- Department of Hepatology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, Kolkata
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Pal S, Dey D, Chakraborty BC, Nandi M, Khatun M, Banerjee S, Santra A, Ghosh R, Ahammed SM, Chowdhury A, Datta S. Diverse facets of MDSC in different phases of chronic HBV infection: Impact on HBV-specific T-cell response and homing. Hepatology 2022; 76:759-774. [PMID: 35000202 DOI: 10.1002/hep.32331] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 11/03/2021] [Accepted: 01/03/2022] [Indexed: 12/08/2022]
Abstract
BACKGROUND AND AIMS Chronic HBV infection (CHI) is associated with a diverse natural history that includes immune-tolerant (IT), HBeAg-positive chronic hepatitis B (CHB) (EP-CHB), inactive carrier, and HBeAg-negative CHB (EN-CHB) phases. A hallmark of CHI is impairment of HBV-specific T-cell response. Recently, myeloid-derived suppressor cells (MDSCs) have emerged as key regulator of T cells, and their properties are sculpted by their microenvironment. Here, we investigated the distinctive features of MDSCs during CHI, identified factors responsible for their functional discrepancies, and studied their impact on HBV-specific T-cell response and homing. Influence of antiviral therapy on MDSC profile and T-cell response was also assessed. APPROACH AND RESULTS Flow cytometric analysis indicated that MDSCs in EP-CHB/EN-CHB patients had profound suppressive ability, expressing arginase 1 (Arg1)/inducible nitric oxide synthase (iNOS)/programmed death ligand 1 (PD-L1)/cytotoxic T lymphocyte-associated protein 4 (CTLA-4)/CD40 at significantly greater levels relative to healthy controls (HC). However, in IT, only Arg1+ MDSCs and in inactive carrier, iNOS+ and PD-L1+ MDSCs were higher than HC. In vitro assays demonstrated that high HBsAg titer in IT/CHB induced Arg1+ MDSC. Furthermore, elevated serum TNF-α and IL-4 in CHB potentiated Arg1/PD-L1/CD40/CTLA-4 expression, whereas increased IL-1β in CHB/IC triggered the expansion of PD-L1+ MDSCs and iNOS+ MDSCs. MDSCs, sorted from CHB/IC, greatly attenuated IL-2/interferon gamma (IFN-γ) production by HBV-specific CD8+ /CD4+ T cells, the effect being more pronounced in CHB. However, MDSCs of IT minimally affected the cytokine production by T cells. Adding Arg1-/iNOS-inhibitor restored only IFN-γ production, while neutralizing PD-L1 recovered both IL-2 and IFN-γ secretion by T cells. Moreover, MDSCs from IT/CHB disrupted virus-specific T-cell trafficking by down-regulating chemokine receptor type 5 on them via TGF-β signaling. One year of tenofovir therapy failed to normalize MDSC phenotype and HBV-specific T-cell response. CONCLUSIONS Diversity of MDSCs during CHI affects HBV-specific T-cell response and homing. Hence, therapeutic targeting of MDSCs could boost anti-HBV immunity.
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Affiliation(s)
- Sourina Pal
- Center for Liver Research, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Debangana Dey
- Center for Liver Research, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Bidhan Chandra Chakraborty
- Multidisciplinary Research Unit, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Madhuparna Nandi
- Center for Liver Research, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Mousumi Khatun
- Center for Liver Research, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Soma Banerjee
- Center for Liver Research, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Amal Santra
- John C Martin Center for Liver Research and Innovation, Kolkata, India
| | - Ranajoy Ghosh
- Division of Pathology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, Kolkata, India
| | - Sk Mahiuddin Ahammed
- Department of Hepatology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Abhijit Chowdhury
- Department of Hepatology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Simanti Datta
- Center for Liver Research, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, Kolkata, India
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Abutaleb A, Khatun M, Clement J, Baidya A, Singh P, Datta S, Ahammed SM, George K, Mukherjee P, Santra A, Neogi S, Parikh S, Pillai V, Kottilil S, Chowdhury A. A Model of Care Optimized for Marginalized Remote Population Unravels Migration Pattern in India. Hepatology 2020; 73:1261-1274. [PMID: 32659859 PMCID: PMC7883670 DOI: 10.1002/hep.31461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 05/05/2020] [Accepted: 06/12/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Access to basic health needs remains a challenge for most of world's population. In this study, we developed a care model for preventive and disease-specific health care for an extremely remote and marginalized population in Arunachal Pradesh, the northeasternmost state of India. APPROACH AND RESULTS We performed patient screenings, performed interviews, and obtained blood samples in remote villages of Arunachal Pradesh through a tablet-based data collection application, which was later synced to a cloud database for storage. Positive cases of hepatitis B virus (HBV) were confirmed and genotyped in our central laboratory. The blood tests performed included liver function tests, HBV serologies, and HBV genotyping. HBV vaccination was provided as appropriate. A total of 11,818 participants were interviewed, 11,572 samples collected, and 5,176 participants vaccinated from the 5 westernmost districts in Arunachal Pradesh. The overall hepatitis B surface antigen (HBsAg) prevalence was found to be 3.6% (n = 419). In total, 34.6% were hepatitis B e antigen positive (n = 145) and 25.5% had HBV DNA levels greater than 20,000 IU/mL (n = 107). Genotypic analysis showed that many patients were infected with HBV C/D recombinants. Certain tribes showed high seroprevalence, with rates of 9.8% and 6.3% in the Miji and Nishi tribes, respectively. The prevalence of HBsAg in individuals who reported medical injections was 3.5%, lower than the overall prevalence of HBV. CONCLUSIONS Our unique, simplistic model of care was able to link a highly resource-limited population to screening, preventive vaccination, follow-up therapeutic care, and molecular epidemiology to define the migratory nature of the population and disease using an electronic platform. This model of care can be applied to other similar settings globally.
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Affiliation(s)
- Ameer Abutaleb
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland, Baltimore, MD,Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland, Baltimore, MD
| | - Mousumi Khatun
- Department of Hepatology and Centre for Liver Research, School of Digestive and Liver Diseases, Institute of Post-Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Jean Clement
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland, Baltimore, MD
| | - Ayana Baidya
- Department of Hepatology and Centre for Liver Research, School of Digestive and Liver Diseases, Institute of Post-Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Pratibha Singh
- Baptist Christian Hospital, Tezpur (Emanuel Hospital Association), Tezpur, Assam, India
| | - Simanti Datta
- Department of Hepatology and Centre for Liver Research, School of Digestive and Liver Diseases, Institute of Post-Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Sk Mahiuddin Ahammed
- Department of Hepatology and Centre for Liver Research, School of Digestive and Liver Diseases, Institute of Post-Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Koshy George
- Baptist Christian Hospital, Tezpur (Emanuel Hospital Association), Tezpur, Assam, India
| | - ParthaSarathi Mukherjee
- Indian Institute of Liver and Digestive Sciences, Sonarpur, Kolkata, India,John C. Martin Centre for Liver Research and Innovations, Liver Foundation, Sonarpur, Kolkata, West Bengal, India
| | - Amal Santra
- Department of Hepatology and Centre for Liver Research, School of Digestive and Liver Diseases, Institute of Post-Graduate Medical Education and Research, Kolkata, West Bengal, India,John C. Martin Centre for Liver Research and Innovations, Liver Foundation, Sonarpur, Kolkata, West Bengal, India
| | - Suvadip Neogi
- John C. Martin Centre for Liver Research and Innovations, Liver Foundation, Sonarpur, Kolkata, West Bengal, India
| | - Sachin Parikh
- John C. Martin Centre for Liver Research and Innovations, Liver Foundation, Sonarpur, Kolkata, West Bengal, India,CTIS, Inc., Rockville, MD
| | - Vivek Pillai
- John C. Martin Centre for Liver Research and Innovations, Liver Foundation, Sonarpur, Kolkata, West Bengal, India,CTIS, Inc., Rockville, MD
| | - Shyam Kottilil
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland, Baltimore, MD
| | - Abhijit Chowdhury
- Department of Hepatology and Centre for Liver Research, School of Digestive and Liver Diseases, Institute of Post-Graduate Medical Education and Research, Kolkata, West Bengal, India,Indian Institute of Liver and Digestive Sciences, Sonarpur, Kolkata, India,John C. Martin Centre for Liver Research and Innovations, Liver Foundation, Sonarpur, Kolkata, West Bengal, India
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Ahammed SM, Das K, Sarkar R, Dasgupta J, Bandopadhyay S, Dhali GK. Patient-posture and Ileal-intubation during colonoscopy (PIC): a randomized controlled open-label trial. Endosc Int Open 2014; 2:E105-10. [PMID: 26135254 PMCID: PMC4423309 DOI: 10.1055/s-0034-1365541] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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: 06/16/2013] [Accepted: 01/31/2014] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND AND AIMS Patient's posture change is commonly employed by a colonoscopist to achieve complete examination. We studied whether patient's posture (left-lateral decubitus vs supine) influenced the success rate of ileal intubation. PATIENTS AND METHODS In this prospective open-label randomized study performed in the Endoscopy Suite of a tertiary-care center, all adult outpatients referred for colonoscopy, in whom cecal intubation was achieved and who satisfied predefined inclusion criteria, were randomized to undergo ileal intubation in either of the above two postures. Colonoscopy (EC-201 WL, Fujinon) was performed after overnight poly-ethylene-glycol preparation, under conscious sedation and continuous pulse-oxymetry monitoring. After confirming cecal intubation, patients were randomized for ileal intubation. Success was defined by visualization of ileal mucosa or villi (confirmed by digital photography) and was attempted until limited by pain and/or time of ≥ 6 min. RESULTS Of 320 eligible patients, 217 patients (150 males) were randomized, 106 to left-lateral decubitus and 111 to supine posture. At baseline, the two groups were evenly matched. Successful ileal intubation was achieved in 145 (66.8 %) patients overall, significantly higher in the supine posture (74.8 % versus 58.5 %; P = 0.014). On multivariate analysis, supine posture (P = 0.02), average/good right-colon preparation (P < 0.01), non-thin-lipped ileocecal (IC) valve (P < 0.001) and younger age (P = 0.02) were independent predictors of success. Positive ileal findings were recorded in 13 (9 %) patients. CONCLUSION Ileoscopy is more successful in supine than in left-lateral decubitus posture. Age, bowel preparation and type of IC valve also determine success.
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Affiliation(s)
- Sk Mahiuddin Ahammed
- Division of Gastroenterology, School of Digestive and Liver Diseases, IPGME and R, Kolkata, West Bengal, India
| | - Kshaunish Das
- Division of Gastroenterology, School of Digestive and Liver Diseases, IPGME and R, Kolkata, West Bengal, India
| | - R. Sarkar
- Division of Gastroenterology, School of Digestive and Liver Diseases, IPGME and R, Kolkata, West Bengal, India
| | - J. Dasgupta
- Division of Gastroenterology, School of Digestive and Liver Diseases, IPGME and R, Kolkata, West Bengal, India
| | - S. Bandopadhyay
- Division of Gastroenterology, School of Digestive and Liver Diseases, IPGME and R, Kolkata, West Bengal, India
| | - G. K. Dhali
- Division of Gastroenterology, School of Digestive and Liver Diseases, IPGME and R, Kolkata, West Bengal, India
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