The sex specific effect of alcohol consumption on circulating levels of CTRP3

The goal of this project was to establish the effect of alcohol consumption on the circulating levels of the adipose tissue derived protein C1q TNF Related Protein 3 (CTRP3). Adipose tissue secretes several adipokines, such as adiponectin and leptin, which exert a multitude of biological effects important for human health. However, adipose tissue is extremely sensitive to alcohol consumption, leading not only to disrupted fat storage, but also to disruptions in adipokine production. Changes to adipokine secretion could have widespread biological effects and potentially contribute to alcohol-induced ailments, such as alcoholic fatty liver disease (ALD). CTRP3 has been previously demonstrated to attenuate fatty liver disease, and suppression of CTRP3 with alcohol consumption could contribute to development of and progression to alcoholic fatty liver disease. To examine the effect of ethanol consumption on circulating adipokine levels, male and female mice were fed an ethanol containing diet (Lieber-DeCarli 5% (v/v) ethanol diet) for 10-days followed by a single gavage of 5 g/kg ethanol (the NIAAA model), or for 6-weeks with no binge added (chronic model). In female mice, adiponectin levels increased ~2-fold in both models of ethanol feeding, but in male mice increased adiponectin levels were only observed after chronic ethanol feeding. On the other hand, in female mice, circulating CTRP3 levels decreased by ~75% and ~50% in the NIAAA and chronic model, respectively, with no changes observed in the male mice in either feeding model. Leptin levels were unchanged with ethanol feeding regardless of model or sex of mice. Lastly, chronic ethanol feeding led to a significant increase in mortality (~50%) in female mice, with no difference in relative ethanol consumption. These findings indicate that ethanol consumption can dysregulate adipokine secretion, but that the effects vary by sex of animal, method of ethanol consumption, and adipokine examined. These findings also indicate that female mice are more sensitive to the chronic effects of ethanol than male mice. Notably, this is the first study to document the effects of ethanol consumption on the circulating levels of CTRP3. Understanding the impact of excessive alcohol consumption on adipokine production and secretion could identify novel mechanisms of alcohol-induced human disease. However, the mechanism responsible for the increased sensitivity remains elusive.

Steroids or pentoxifylline for alcoholic hepatitis (STOPAH): study protocol for a randomised controlled trial

BACKGROUND

Alcoholic hepatitis is the most florid presentation of alcohol-related liver disease. In its severe form, defined by a Maddrey's discriminant function (DF) ≥32, the 28-day mortality rate is approximately 35%. A number of potential treatments have been subjected to clinical trials, of which two, corticosteroids and pentoxifylline, may have therapeutic benefit. The role of corticosteroids is controversial as trial results have been inconsistent, whereas the role of pentoxifylline requires confirmation as only one previous placebo-controlled trial has been published.

METHODS/DESIGN

STOPAH is a multicentre, double-blind, factorial (2 × 2) trial in which patients are randomised to one of four groups:1. Group A: placebo / placebo2. Group B: placebo / prednisolone3. Group C: pentoxifylline / placebo4. Group D: pentoxifylline / prednisoloneThe trial aims to randomise 1,200 patients with severe alcoholic hepatitis, in order to provide sufficient power to determine whether either of the two interventions is effective. The primary endpoint of the study is mortality at 28 days, with secondary endpoints being mortality at 90 days and 1 year.

DISCUSSION

STOPAH aims to be a definitive study to resolve controversy around the existing treatments for alcoholic hepatitis. Eligibility criteria are based on clinical parameters rather than liver biopsy, which are aligned with standard clinical practice in most hospitals. The use of a factorial design will allow two treatments to be evaluated in parallel, with efficient use of patient numbers to achieve high statistical power.

TRIAL REGISTRATION

EudraCT reference number: 2009-013897-42 ISRCTN reference number: ISRCTN88782125.

Update on the management of alcoholic steatohepatitis

Among heavy drinkers with liver disease, the development of severe alcoholic hepatitis (AH) is a serious complication. Prognosis is grave and associated with a high mortality due to liver failure, hepatorenal syndrome or intractable sepsis. Clinically, AH presents as a syndrome of progressive inflammatory liver injury in patients with recent or ongoing heavy alcohol consumption. Although approximately 20% of alcoholics undergoing liver biopsy reveal histological features of AH, only a minority progress to severe AH with markedly elevated serum liver enzymes, jaundice and impaired liver function. To establish the diagnosis of AH, histology is recommended but not mandatory. Prognostic scores include the Maddrey's discriminant function, the model of end-stage liver disease, the Glasgow Alcoholic Hepatitis score, and the ABIC score. While the former scores identify patients at risk of death or the need for corticosteroids, the response to corticosteroid therapy can be assessed using the Lille model. Treatments include abstinence and enteral nutrition, while pharmacotherapy using corticosteroids either with or without N-acetylcysteine may be indicated for patients with severe AH. Pentoxifylline was found to reduce the risk of hepatorenal syndrome, but data on mortality are limited. Although considered a contraindication in most transplant centers, recent evidence indicates that carefully selected patients with AH could be good candidates for liver transplantation with a prognosis comparable to other indications.

Hepatic steatosis in response to acute alcohol exposure in zebrafish requires sterol regulatory element binding protein activation

Steatosis is the most common consequence of acute alcohol abuse and may predispose to more severe hepatic disease. Increased lipogenesis driven by the sterol response element binding protein (SREBP) transcription factors is essential for steatosis associated with chronic alcohol ingestion, but the mechanisms underlying steatosis following acute alcohol exposure are unknown. Zebrafish larvae represent an attractive vertebrate model for studying alcoholic liver disease (ALD), because they possess the pathways to metabolize alcohol, the liver is mature by 4 days post-fertilization (dpf), and alcohol can be simply added to their water. Exposing 4 dpf zebrafish larvae to 2% ethanol (EtOH) for 32 hours achieves approximately 80 mM intracellular EtOH and up-regulation of hepatic cyp2e1, sod, and bip, indicating that EtOH is metabolized and provokes oxidant stress. EtOH-treated larvae develop hepatomegaly and steatosis accompanied by changes in the expression of genes required for hepatic lipid metabolism. Based on the importance of SREBPs in chronic ALD, we explored the role of Srebps in this model of acute ALD. Srebp activation was prevented in gonzo larvae, which harbor a mutation in the membrane-bound transcription factor protease 1 (mbtps1) gene, and in embryos injected with a morpholino to knock down Srebp cleavage activating protein (scap). Both gonzo mutants and scap morphants were resistant to steatosis in response to 2% EtOH, and the expression of many Srebp target genes are down-regulated in gonzo mutant livers.

CONCLUSION

Zebrafish larvae develop signs of acute ALD, including steatosis. Srebp activation is required for steatosis in this model. The tractability of zebrafish genetics provides a valuable tool for dissecting the molecular pathogenesis of acute ALD.

Fibrosis progression occurs in a subgroup of heavy drinkers with typical histological features

BACKGROUND

Studies using consecutive liver biopsies constitute an attractive approach to gaining insight into the pathogenesis of alcoholic liver disease.

AIM

To analyse histological factors at baseline, which are predictive of fibrosis progression and recurrence of alcoholic hepatitis.

RESULTS

A total of 193 drinkers underwent consecutive biopsies at an interval of 4 years. At baseline, 20 had normal livers, 135 steatosis, five fibrosis and 33 alcoholic hepatitis. The fibrosis score increased from 1.07 +/- 0.07 to 1.7 +/- 0.94 (P < 0.001). In multivariate analysis, only steatosis (P = 0.04), alcoholic hepatitis (P = 0.0004) and stage of fibrosis (P < 0.0001) were independent predictive factors of the fibrosis score at the second biopsy. Cirrhosis developed more frequently in patients with steatosis (11%) and alcoholic hepatitis (39%) than in others (0%, P < 0.0001). Alcoholic hepatitis recurred more frequently in patients with alcoholic hepatitis at baseline: 58% vs. 15%, P < 0.0001. In multivariate analysis, alcoholic hepatitis at the first biopsy was the only predictive factor of its recurrence (P < 0.0001).

CONCLUSIONS

In a large cohort of drinkers with consecutive biopsies, steatosis, fibrosis stage and alcoholic hepatitis at baseline were independent predictive factors of fibrosis progression. In terms of mechanisms, we propose a novel concept of multiple hits of alcoholic hepatitis occurring in the same patient.

Clinical syndromes of alcoholic liver disease

BACKGROUND AND AIMS

Alcoholic liver disease continues to be a major health problem with respect to both morbidity and mortality. To understand the clinical syndromes of alcoholic liver disease, this review highlights the papers on both clinical and basic research of alcoholic liver disease, especially on steatosis, alcoholic hepatitis and fibrosis.

METHODS

The various forms of alcoholic liver disease are described, and knowledge about the clinical and pathophysiological features of different stages of alcoholic liver disease are summarized.

RESULTS

Clinical studies combined with basic research have established a spectrum of alcoholic liver disease from steatosis to steatohepatitis, fibrosis, and cirrhosis. New insights into the pathogenesis of alcoholic liver disease include the key roles of the excess production of cytokines, reactive oxygen species, and the shortage of protective mediators, including adiponectin.

CONCLUSION

These new insights will lead to new specific therapies for the treatment of alcoholic hepatitis and alcoholic liver fibrosis.

Prognosis of patients with a diagnosis of fatty liver--a registry-based cohort study

BACKGROUND/AIMS

There are very limited data available regarding the prognosis of patients with fatty liver. We examined the overall and cause-specific mortality of fatty liver patients in a large Danish cohort.

METHODOLOGY

In the Danish National Registry of Patients, we identified 7,372 patients discharged with a diagnosis of fatty liver from a Danish hospital between 1977 and 1993. Causes of death were identified in the Danish Death Registry. We estimated the standardized mortality ratio by comparing with the general population.

RESULTS

Most patients (76%) had alcoholic fatty liver. During follow-up, 2,914 (40%) died. The commonest cause of death was hepatobiliary disease (25% of deaths). Mortality was increased 5.4-fold (95% CI 5.2-5.6) in patients with alcoholic fatty liver, and 2.6-fold (95% CI 2.4-2.9) in patients with non-alcoholic or unspecified fatty liver. Overall, in the first year of follow-up, mortality was increased more than 7-fold, almost 5-fold in the second to fifth years, and more than 3-fold after that. Mortality was similar among genders and among diabetics and non-diabetics, and remained increased after censoring patients upon diagnosis of liver cirrhosis.

CONCLUSIONS

The mortality of patients with a hospital discharge diagnosis of fatty liver was higher than that of the general population.

In vitro interleukin-6 treatment prevents mortality associated with fatty liver transplants in rats

BACKGROUND & AIMS

Orthotopic liver transplantation is currently the only curative therapy for chronic end-stage liver disease and acute liver failure. However, a scarcity of cadaveric donors has led to a critical shortage of organs available for transplant. This is further complicated by the prevalence of steatosis in about 13%-50% of donor livers, which is associated with a high risk of dysfunction and primary nonfunction.

METHODS

Steatotic Zucker rat livers and livers from alcohol-fed rats were transplanted into lean control rats. Liver injury, activation of survival signals, and hepatic microcirculation were compared in nontreated and interleukin-6 (IL-6)-treated steatotic isografts.

RESULTS

IL-6 pretreatment of steatotic Zucker rat liver isografts dramatically reduces mortality and liver injury following transplantation. Reperfusion after transplantation induces significant sinusoidal endothelial cell necrapoptosis in steatotic Zucker rat liver isografts, which is prevented by in vitro IL-6 pretreatment. IL-6 treatment activates cell survival signal transducer and activator of transcription factor 3 (STAT3) in hepatocytes and sinusoidal endothelial cells. Laser Doppler imaging and microsphere analyses demonstrate that IL-6 treatment markedly improves hepatic microcirculation, which is impaired in steatotic Zucker rat liver transplants. Finally, in vitro IL-6 treatment of donor livers also markedly reduces mortality associated with fatty liver transplants from alcohol-fed rats.

CONCLUSIONS

IL-6 induces hepatoprotection of steatotic liver isografts via preventing sinusoidal endothelial cell necrapoptosis and consequent amelioration of hepatic microcirculation, and protecting against hepatocyte death. IL-6 pretreatment of steatotic livers may render such allografts useable for clinical transplantation.

Role of alcohol in traffic crashes involving women: passenger car fatalities in northern Sweden

OBJECTIVE

Since increased alcohol consumption and increased driving among women may lead to a growing mortality due to drunken driving among women, the study analyzed gender differences among traffic fatalities.

METHOD

Traffic fatalities (597 victims, 159 women) in northern Sweden were investigated, using autopsy and police reports, for a 10-year period, 1980-1989.

RESULTS

The incidence of inebriated female driver fatalities was 0.51 per 100 million km (men, 0.66). Eighty-six percent of the female inebriated drivers (98% of men) and 68% of female sober drivers (78% of men) initiated the crash. Blood alcohol was detected in 10% of the women (men, 32%) with a mean blood alcohol concentration of 1.1 g/kg (men, 1.9 g/kg). Of the women, 13% had liver steatosis (men, 28%). The proportion of victims with liver steatosis increased with increasing blood alcohol concentration. Only one case of liver cirrhosis was found (a man). The majority of the inebriated victims were killed from May through October (women, 73%; men, 76%), and from Fridays through Sundays (women, 87%; men, 70%). Only 27% of the inebriated women crashed between 9 PM and 6 AM, compared to 62% of the men. The body location of fatal trauma was similar in men and women and was not influenced by alcohol.

CONCLUSIONS

Female traffic fatalities differ from those of men in several respects. No evidence was found for an increase in the number of women in alcohol-related traffic fatalities in Sweden over the 10-year period studied. Drunken driving and alcohol abuse in traffic is still mainly a male problem.

Morphometry of liver parenchyma in needle biopsy specimens from patients with alcoholic liver disease: preliminary variables for the diagnosis and prognosis of cirrhosis

The diagnosis of liver cirrhosis depends on assessing fibrosis and architectural alterations of the liver. In a needle biopsy specimen the connective tissue is often inadequately sampled, which leads to an uncertain diagnosis. Parenchymal features alone are currently insufficient. We, therefore, carried out a comprehensive morphometric study to detect parenchymal structures that may be useful in the diagnosis and prognosis of cirrhosis. Five human liver biopsy specimens were selected from each of four alcoholic disease groups: fatty liver, alcoholic hepatitis, cirrhosis with greater-than-5-yr survival, and cirrhosis with less-than-2-yr survival. Volume fractions (Vv) and surface densities (Sv) were determined stereologically for parenchymal and hepatocellular compartments in electron micrographs. The differences between noncirrhosis and cirrhosis were (a) a doubling of the Vv of parenchymal interstitial space, (b) a nearly 25% increase in the Sv of hepatocyte plasma membrane, (c) a nearly 50% increase in the Sv of hepatocyte RER, and (d) a decrease in the Sv of the outer mitochondrial membrane. The significant difference between the greater than 5-yr and the less than 2-yr survivors of cirrhosis was the marked decrease in hepatocyte nuclear Vv in the latter group. Statistical analysis of our data showed that optimal sampling is achieved with as few as three micrographs from one block of tissue per biopsy specimen.

Mortality of alcohol abusing men prospectively assessed in relation to history of abuse and degree of liver injury

A prospective evaluation of mortality in relation to a broad range of alcoholic abuse and biopsy-assessed stage of alcoholic liver injury was carried out by following 315 men admitted to hospital for various medical disorders. During 10-13 years, 184 patients (58%) died, which, according to national mortality statistics, corresponds to a mortality ratio of 3.07. 43% of the excess mortality could be attributed to liver disease. Our results indicate that the alcohol abuse, irrespective of its magnitude and duration, is associated with a rather constant excess mortality and that the occurrence and severity of hepatic injury ranging from normal liver to active cirrhosis is directly associated with a subsequent liver-disease-related excess mortality.

Sudden death and hepatic fatty metamorphosis. A North Carolina survey

There is a generally unrecognized epidemic of sudden, nonviolent deaths among alcohol abusers, largely due to fatty liver--related sudden deaths (FLDs). Using data from the North Carolina Office of the Chief Medical Examiner, 411 cases of FLD were identified from 1972 through 1976. The 411 FLD deaths, in view of a low autopsy rate among nonviolent alcohol abuser deaths and the lack of awareness of FLD, suggest a FLD death rate of epidemic proportions. The FLD population characteristics mirror those of the underlying alcohol-abusing population. The increased incidence of low-level (1 to 50 mg/dL) blood ethanol levels among FLD as compared with "control" groups is consistent with several theories linking FLD to some form of acute or hyperacute ethanol withdrawal phenomenon.

Fatty liver and sudden death. A review

Alcoholism is associated with increased mortality from violent and nonviolent causes. The increase in nonviolent deaths is usually ascribed, at least in part, to "cirrhosis." In the majority of these deaths this implies fatty liver rather than true Laennec's cirrhosis. Studies of sudden nonviolent deaths illustrate the largely unrecognized and frequent occurrence of sudden death with autopsy findings limited solely to fatty liver. The mechanism(s) of these sudden fatty liver deaths is unknown. Several attractive theories attribute such deaths to ethanol withdrawal induced hypoglycemia or hypomagnesemia, pulmonary fat embolization from fatty liver, or other facets of the alcohol withdrawal syndrome, including ethanol dependent maladaptive derangements of neurotransmitters. All the theories of fatty liver death remain essentially untested, however, owing to uncontrolled postmortem conditions and the lack of awareness of fatty liver deaths within the scientific community.

Mortality among men alcoholics in Iceland, 1951--74

In close to 3000 alcoholics followed up from 4 to 24 years after first contact with a treatment facility, the death rate was more than double the expected rate; the rates of death due to accidents and suicides were 4 times the expected rates.