Serum keratin 18-M65 levels detect progressive forms of alcohol-associated liver disease in early noncirrhotic stages

BACKGROUND AND AIMS

The progression of alcohol-associated liver disease (ALD) in its early precirrhotic stages can be a silent process. Serum keratin 18 levels (K18-M65) predict severe events and mortality in advanced stages of ALD, but data on this biomarker in early stages are scarce. We evaluated the diagnostic accuracy of K18-M65 levels in identifying early forms of ALD.

METHODS

We prospectively evaluated two cohorts of actively drinking patients with alcohol use disorder (AUD) following a rehabilitation program (training (n = 162) and validation (n = 78)) and matched healthy controls (n = 21). Clinical, laboratory, and imaging data were used to distinguish AUD patients with simple steatosis (minimal ALD) and steatohepatitis/fibrosis (early ALD). We measured serum K18-M65 levels and assessed their ability to predict early ALD.

RESULTS

High levels of K18-M65 characterized AUD patients with early ALD, while levels in the minimal ALD group were similar to those in healthy controls. K18-M65 levels distinguished minimal liver disease from early ALD (AUROC = 0.8704; p < 0.0001) with an optimal cutoff at 265.9 U/L. K18-M65 levels strongly correlated with transaminases and predicted early ALD (OR 25.81; 95% CI 3.166-336.1; p < 0.0001), controlled attenuation parameter, and liver stiffness independently from transaminases and other potential confounders. K18-M65 levels did not discriminate between fibrosis and steatohepatitis but correlated with histological signs of hepatocellular injury and inflammation (all p < 0.05). The K18-M65 cutoff detected early ALD in the validation cohort with high accuracy (sensitivity 86.67%, specificity 96.67%) and a very high positive likelihood ratio (28.6; 95% CI 4.14-197.73).

CONCLUSIONS

Serum K18-M65 levels can be used as a biomarker to detect early ALD stages with excellent predictive value.

Mn-SOD alleviates methotrexate-related hepatocellular injury via GSK-3β affecting anti-oxidative stress of HO-1 and Drp1

OBJECTIVES

Methotrexate (MTX) is the most common therapeutic agent that may have the risk of drug-induced liver injury. Its pathogenic mechanism is related to oxidative stress caused by mitochondrial dysfunction. Superoxide dismutase (SOD), including manganese-containing SOD (Mn-SOD), can exert its effect of anti-oxidative stress by scavenging superoxide free radicals. Accordingly, this study is performed to explore the underlying molecular mechanism via observing whether Mn-SOD could affect the damage of MTX to hepatocytes.

METHODS

Human hepatocyte cell line L-02 was cultured in vitro and divided into 4 groups, including a blank group with the addition of the same volume of serum-free medium, a MTX group (40 μg/well MTX drug-treatment), a MTX+NC group (40 μg/well MTX drug-treatment+blank plasmid), and a MTX+SOD group (40 μg/well MTX drug-treatment+Mn-SOD plasmid). The levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), and microRNA-122 (miR-122) in the supernatant of cell culture were respectively detected by automatic biochemical analytical instrument and real-time RT-PCR to evaluate the degree of hepatocyte damage in each group. MitoSOX fluorescent probe was used to label intracellular superoxide in each group, and cell apoptosis was detected by flow cytometry. Meanwhile, the contents of glycogen synthase kinase-3 beta (GSK-3β), hemeoxygenase-1 (HO-1), mitochondrial fission-mediated protein of dynamin-related protein 1 (Drp1), and Mn-SOD were detected by Western blotting.

RESULTS

Compared with the blank group, the levels of ALT, AST, and miR-122 in the supernatant of hepatocyte culture of the MTX group and MTX+NC group were significantly elevated (all P <0.05), and that in the MTX+SOD group were significantly decreased ( P <0.05) and equivalent to that in the blank group. MitoSOX staining revealed that the MTX group and MTX+NC had the most abundant superoxide; and the amount was significantly reduced in the MTX+SOD group, without a significant difference when compared with the blank group. Furthermore, the results of flow cytometry indicated that compared with the blank group, the MTX group and MTX+NC group showed significantly increased cell apoptosis ( P <0.05); while there was obviously reduced cell apoptosis in the MTX+SOD group than that in the MTX group and MTX+NC group ( P <0.05). According to the results of Western blotting, the blank group and MTX+SOD group had higher expressions of Mn-SOD, p-GSK-3β, and HO-1; while the MTX group and MTX+NC group exhibited remarkably lower levels of Mn-SOD, p-GSK-3β, and HO-1 than those in the blank group ( P <0.05). Besides, a completely opposite trend was found in the expression of Drp1, which was highly expressed in the MTX group and MTX+NC group, but lowly expressed in the blank group and the MTX+SOD group.

CONCLUSIONS

MTX may induce hepatocyte damage, and one of the mechanisms may be due to the decrease of intracellular Mn-SOD level, which can cause the accumulation of superoxide, affect the levels of HO-1 and Drp1 through GSK-3β leading to mitochondrial damage and cell apoptosis. High expression of Mn-SOD intracellularly through exogenous introduction can scavenge drug-produced superoxide, affect HO-1 and Drp1 levels through GSK-3β, activate mitochondria, protect cells against damage from oxidative stress, and inhibit hepatocyte apoptosis eventually. So exogenous introduction of SOD may be a potential therapeutic approach to block or reverse MTX-related hepatocyte injury.

Regulatory effect of PINK1/Parkin axis on mitophagy in isoniazide-induced hepatocellular injury

OBJECTIVES

Patients with tuberculosis, who are treated with long-term high-dose combined use of anti-tuberculosis drugs, can cause many adverse reactions such as liver damage, but the mechanism is still unclear. Although phosphatase and tensin homolog induced kinase 1 (PINK1)/Parkin axis might participate in the process of liver damage through regulating mitochondrial autophagy and oxidative stress in liver cells. However, the association between the mitochondrial autophagy regulated by the PINK1/Parkin axis and the liver injury induced by anti-tuberculosis drugs is unknown. This study aims to explore the mechanism of PINK1/Parkin signal axis in regulating hepatocellular injury induced by anti-tuberculosis drugs through mitochondrial autophagy, and to provide new therapeutic targets for the patients with liver damage caused by anti-tuberculosis drugs.

METHODS

Mouse hepatocytes AML-12 were treated with isoniazide (INH) to induce liver injury. The mRNA and protein levels of PINK1, Parkin and autophagy associated factors were detected by real-time PCR and Western blotting in the normal AML-12 cells (control group), the AML-12 cells treated by INH (model group) and the AML-12 cells treated with INH and salidroside together (intervention group). Meantime, ELISA kit was used to detect the level of reactive oxygen species (ROS) in AML-12 cells, and the cell morphology and injury was observed by HE staining and transmission electron microscope (TEM).

RESULTS

Compared with the control group, the mRNA (all P <0.01) and protein levels (all P <0.05) of PINK1, Parkin and microtubule associated protein 1 light chain 3 (LC3) were significantly decreased, the ubiquitination level was significantly decreased ( P <0.05), and the ROS level was increased ( P <0.05), and the hepatocellular cell showed obvious damage in the model group. Compared with the model group, the expression of PINK1, Parkin and LC3 were significantly increased in the intervention group (all P <0.05), as well as the ubiquitination level was also increased ( P <0.05). The ROS level mediated by mitochondria was decreased ( P <0.05). The results of HE staining and TEM showed that the cell status was improved and the damage of hepatocytes was significantly attenuated.

CONCLUSIONS

In this study, the mechanism of mitochondrial autophagy mediated by PINK1/Parkin signal axis may be related to INH-induced injury in liver cells and it can regulate the damage state in vitro, indicating that Parkin is a potential molecular target for the prediction, diagnosis and treatment for liver injury induced by anti-tuberculosis drugs.

Liberal Intravenous Fluid Administration in a Rare Case of Severe Rhabdomyolysis Secondary to SARS-CoV-2

SARS-CoV-2 entered the world by storm when it made its appearance at the end of 2019 in Wuhan, China. The severity can range from asymptomatic infection, which occurs in approximately 33% of infected patients, to death. Worldwide deaths due to SARS-CoV-2 are currently approximated at 3.8 million people with close to 600,000 deaths in the United States alone, reiterating the significant impact this virus has on the population. SARS-CoV-2 can affect systems of the body such as respiratory, gastrointestinal tract, neurological, cardiac, renal, and even skeletal muscle tissue. A few cases of rhabdomyolysis are reported in SARS-CoV-2 infection, but the significant level of creatinine kinase in the hundreds of thousands is rare. Our case demonstrates the rarity of SARS-CoV-2 manifestation in a 33-year-old African American male with severe rhabdomyolysis with a creatinine kinase on the admission of 362,445 IU/L. The patient was treated aggressively with intravenous fluids, monitoring electrolytes, renal function, and respiratory status closely. His management includes liberal administration of fluid to treat his rhabdomyolysis, without compromising his respiratory status. He was subsequently discharged home after seven days of hospitalization. We strive to share this information in hopes to share our management for future similar cases.

Severe Liver Injury Associated With High-Dose Atorvastatin Therapy

Statins are recommended for first-line management of elevated cholesterol in the primary and secondary prevention of atherosclerotic cardiovascular disease. Statins may occasionally be associated with mild transaminase elevations but can also result in life-threatening liver injury. Atorvastatin is the most common cause of clinically significant liver injury in this drug class. We report a case of severe, asymptomatic liver injury in a hepatocellular pattern in a 71-year-old man occurring within 3 months of switching from simvastatin to high-intensity atorvastatin therapy. Hepatitis improved rapidly with cessation of atorvastatin and did not recur after resuming simvastatin.

Modulating NF-κB, MAPK, and PI3K/AKT signaling by ergothioneine attenuates iron overload-induced hepatocellular injury in rats

The liver is highly susceptible to iron overload-evoked oxidative injury. Ergothioneine is a thio-histidine amino acid that has exhibited strong antioxidant and metal chelating activities. This study aimed at exploring the potential modulating effects of ergothioneine on iron-triggered liver injury. The results showed that ergothioneine inhibited iron-evoked inflammation and apoptosis as demonstrated by a significant reduction in tumor necrosis factor-α and interleukin-6 levels and in caspase-3 activity. Ergothioneine significantly improved liver cell survival as indicated by modulating phosphatidylinositol 3-kinase/protein kinase B signaling. Consistent with reduced necrotic cell death, ergothioneine diminished the iron-evoked histopathological changes and decreased serum activity of the liver enzymes. Mechanistically, ergothioneine reduced nuclear translocation of nuclear factor kappa B p65 and modulated p38 mitogen-activated protein kinase/c-Fos signaling. In addition, it enhanced the liver tissue antioxidant potential and curbed hepatic iron load. Together, these results point out the modulatory effects of ergothioneine on iron-evoked liver cell injury that are possibly mediated via anti-inflammatory, antioxidant, and possible iron chelation capabilities.

Current and Potential Therapies Targeting Inflammation in NASH

Nonalcoholic steatohepatitis (NASH) is the advanced form of nonalcoholic fatty liver disease (NAFLD). It is characterized by hepatic steatosis, inflammation, hepatocellular injury, and fibrosis. Inflammation plays a key role in the progression of NASH and can be provoked by intrahepatic (e.g., lipotoxicity, immune responses, oxidative stress and cell death) and extrahepatic sources (adipose tissue or gut). The identification of triggers of inflammation is central to understanding the mechanisms in NASH development and progression and in designing targeted therapies that can halt or reverse the disease. In this review, we summarize the current and potential therapies targeting inflammation in NASH.

Meropenem-induced vanishing bile duct syndrome: A case report

Vanishing bile duct syndrome (VBDS) refers to a group of acquired disorders associated with progressive destruction and disappearance of the intrahepatic bile ducts. We report a case of meropenem-induced VBDS in a patient who had undergone surgical repair of a ruptured abdominal aortic aneurysm. Meropenem was used to treat Serratia marcescens isolated from blood, urine, sputum, and wound swab cultures. The patient developed severe mixed liver injury with no obstruction noted in radiological imaging. Because of the patient's increasing serum bilirubin level, VBDS was suspected and the meropenem was therefore changed to ciprofloxacin on postoperative day 18. Although the bilirubin level decreased, meropenem was restarted 3 days later because of clinical concerns regarding worsening fever and sepsis. Restarting meropenem was associated with an immediate increase in the serum bilirubin level. This further increase in bilirubin after reintroduction of meropenem strongly suggested meropenem-induced VBDS. The antibiotic therapy was changed from meropenem to ciprofloxacin and metronidazole, leading to a dramatic decrease in the bilirubin level to normal within a few weeks. In patients receiving meropenem, VBDS as a cause of deranged liver function and cholestasis should be considered after ruling out mechanical and other probable causes of liver injury.

Dose-dependent acute liver injury with hypersensitivity features in humans due to a novel microsomal prostaglandin E synthase 1 inhibitor

AIMS

LY3031207, a novel microsomal prostaglandin E synthase 1 inhibitor, was evaluated in a multiple ascending dose study after nonclinical toxicology studies and a single ascending dose study demonstrated an acceptable toxicity, safety and tolerability profile.

METHODS

Healthy subjects were randomized to receive LY3031207 (25, 75 and 275 mg), placebo or celecoxib (400 mg) once daily for 28 days. The safety, tolerability and pharmacokinetic and pharmacodynamic profiles of LY3031207 were evaluated.

RESULTS

The study was terminated when two subjects experienced drug-induced liver injury (DILI) after they had received 225 mg LY3031207 for 19 days. Liver biopsy from these subjects revealed acute liver injury with eosinophilic infiltration. Four additional DILI cases were identified after LY3031207 dosing had been stopped. All six DILI cases shared unique presentations of hepatocellular injury with hypersensitivity features and demonstrated a steep dose-dependent trend. Prompt discontinuation of the study drug and supportive medical care resulted in full recovery. Metabolites from metabolic activation of the imidazole ring were observed in plasma and urine samples from all subjects randomized to LY3031207 dosing.

CONCLUSIONS

This study emphasized the importance of careful safety monitoring and serious adverse events management in phase I trials. Metabolic activation of the imidazole ring may be involved in the development of hepatotoxicity of LY3031207.

Metoprolol-induced Severe Liver Injury and Successful Management with Therapeutic Plasma Exchange

Liver injury caused by metoprolol is very rare with current reports limited to an isolated elevation in transaminases. We report the first case of severe icteric liver injury leading to hepatic encephalopathy secondary to metoprolol use in a patient diagnosed with coronary heart disease. We also describe the histopathology of metoprolol-related liver injury, discuss mechanisms of injury with new insights on the immunological phenomenon, and shed light on the successful utility of early plasmapheresis as a salvage therapy in metoprolol-induced severe liver damage.

Graft-derived macrophage migration inhibitory factor correlates with hepatocellular injury in patients undergoing liver transplantation

Experimental studies suggest that macrophage migration inhibitory factor (MIF) mediates ischemia/reperfusion injury during liver transplantation. This study assessed whether human liver grafts release MIF during preservation, and whether the release of MIF is proportional to the extent of hepatocellular injury. Additionally, the association between MIF and early allograft dysfunction (EAD) after liver transplantation was evaluated. Concentrations of MIF, aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), and creatine kinase (CK) were measured in effluents of 38 liver grafts, and in serum of recipients. Concentrations of MIF in the effluent were greater than those in the recipients' serum before and after reperfusion (58 [interquartile range, IQR:23-79] μg/mL vs 0.06 [IQR:0.03-0.07] μg/mL and 1.3 [IQR:0.7-1.8] μg/mL, respectively; both P<.001). Effluent MIF concentrations correlated with effluent concentrations of the cell injury markers ALT (R=.51, P<.01), AST (R=.51, P<.01), CK (R=.45, P=.01), and LDH (R=.56, P<.01). Patients who developed EAD had greater MIF concentrations in effluent and serum 10 minutes after reperfusion than patients without EAD (Effluent: 80 [IQR:63-118] μg/mL vs 36 [IQR:20-70] μg/mL, P=.02; Serum: 1.7 [IQR:1.2-2.5] μg/mL vs 1.1 [IQR:0.6-1.7] μg/mL, P<.001).

CONCLUSION

Human liver grafts release MIF in proportion to hepatocellular injury. Greater MIF concentrations in effluent and recipient's serum are associated with EAD after liver transplantation.

Neurological Involvement and Hepatocellular Injury Caused by a Snake With Hematotoxin Envenomation

Venomous snakes with hematotoxin-Russell's viper (Daboia spp), Malayan pit viper (Calloselasma rhodostoma), and green pit viper (Cryptelytrops albolabris and C macrops, previously named Trimeresurus spp) are commonly found in Thailand. Coagulation factor activation, thrombocytopenia, hyperfibrinolysis, and disseminated intravascular coagulation are the main mechanisms of hemorrhaging from these snake bites. The neurological involvement and hepatocellular injury after Russell's viper bites were reported in Sri Lanka, but there is no report from Southeast Asia. This case was a 12-year-old hill tribe boy who had ptosis and exotropia of the left eye, respiratory distress, and prolonged venous clotting time, prothrombin time, and activated partial thromboplastin time; low fibrinogen and platelet count; and transaminitis after being bitten by a darkish-colored snake. He did not respond to antivenom for cobra, Malayan pit viper, or Russell's viper. However, his neurological abnormalities, respiratory failure, and hepatocellular injury improved, and coagulopathy was finally corrected after receiving antivenom for green pit viper. The unidentified snake with hematotoxin was alleged for all manifestations in this patient.

Increased serum heat-shock protein 70 levels reflect systemic inflammation, oxidative stress and hepatocellular injury in preeclampsia

It has been previously reported that serum levels of 70-kDa heat-shock protein (Hsp70) are elevated in preeclampsia. The aim of the present study was to examine whether increased serum Hsp70 levels are related to clinical characteristics and standard laboratory parameters of preeclamptic patients, as well as to markers of inflammation (C-reactive protein), endothelial activation (von Willebrand factor antigen) or endothelial injury (fibronectin), trophoblast debris (cell-free fetal DNA) and oxidative stress (malondialdehyde). Sixty-seven preeclamptic patients and 70 normotensive, healthy pregnant women were involved in this case-control study. Serum Hsp70 levels were measured with enzyme-linked immunosorbent assay (ELISA). Standard laboratory parameters (clinical chemistry) and C-reactive protein (CRP) levels were determined by an autoanalyzer using the manufacturer's kits. Plasma von Willebrand factor antigen (VWF:Ag) levels were quantified by ELISA, and plasma fibronectin concentration by nephelometry. The amount of cell-free fetal DNA in maternal plasma was determined by quantitative real-time polymerase chain reaction analysis of the sex-determining region Y gene. Plasma malondialdehyde levels were measured by the thiobarbituric acid-based colorimetric assay. Serum Hsp70 levels were increased in preeclampsia. Furthermore, serum levels of blood urea nitrogen, creatinine, bilirubin and CRP, serum alanine aminotransferase and lactate dehydrogenase (LDH) activities, as well as plasma levels of VWF:Ag, fibronectin, cell-free fetal DNA and malondialdehyde were also significantly higher in preeclamptic patients than in normotensive, healthy pregnant women. In preeclamptic patients, serum Hsp70 levels showed significant correlations with serum CRP levels (Spearman R = 0.32, p = 0.010), serum aspartate aminotransferase (R = 0.32, p = 0.008) and LDH activities (R = 0.50, p < 0.001), as well as with plasma malondialdehyde levels (R = 0.25, p = 0.043). However, there was no other relationship between serum Hsp70 levels and clinical characteristics (age, parity, body mass index, blood pressure, gestational age, fetal birth weight) and laboratory parameters of preeclamptic patients, including markers of endothelial activation or injury and trophoblast debris. In conclusion, increased serum Hsp70 levels seem to reflect systemic inflammation, oxidative stress and hepatocellular injury in preeclampsia. Nevertheless, further studies are required to determine whether circulating Hsp70 plays a causative role in the pathogenesis of the disease.