Genipin protects against acute liver injury by abrogating ferroptosis via modification of GPX4 and ALOX15-launched lipid peroxidation in mice

It is essential to further characterize liver injury aimed at developing novel therapeutic approaches. This study investigated the mechanistic basis of genipin against carbon tetrachloride (CCl4)-triggered acute liver injury concerning ferroptosis, a novel discovered modality of regulated cell death. All experiments were performed using hepatotoxic models upon CCl4 exposure in mice and human hepatocytes in vitro. Immunohistochemistry, immunoblotting, molecular docking, RNA-sequencing and ultra-high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) were conducted. CCl4 intoxication was manifested with lipid peroxidation-dictated ferroptotic cell death, together with changes in a cascade of ferroptosis-associated events and several regulatory pathways. Both the administration of genipin and ferrostatin-1 (Fer-1) significantly prevented this hepatotoxicity in response to CCl4 intoxication via upregulating GPX4 and xCT (i.e., critical regulators of ferroptosis). RNA-sequencing unraveled that arachidonic acid metabolism was considerably influenced upon genipin treatment. Accordingly, genipin treatment attenuated arachidonate 15-lipoxygenase (ALOX15)-launched lipid peroxidation in terms of UHPLC-MS/MS analysis and inflammation. In vitro, genipin supplementation rescued erastin-induced hepatocellular inviability and lipid ROS accumulation. The siRNA knockdown of GPX4 partially abrogated the protective effects of genipin on erastin-induced cytotoxicity, whereas the cytotoxicity was less severe in the presence of diminished ALOX15 expression in L-O2 cells. In conclusion, our findings uncovered that genipin treatment protects against CCl4-triggered acute liver injury by abrogating hepatocyte ferroptosis, wherein the pharmacological modification of dysregulated GPX4 and ALOX15-launched lipid peroxidation was responsible for underlying medicinal effects as molecular basis.

Association between serum trace elements and sleep disturbance in patients with decompensated cirrhosis

Background

Sleep disturbance and trace elements imbalance are common features in patients with decompensated cirrhosis, partially sharing similar mechanistic contributors and linking to adverse outcomes. However, there is a paucity of data concerning their relationship.

Objectives

To investigate the association between serum trace elements levels and sleep quality in the context of cirrhosis.

Design

Cross-sectional study.

Methods

We consecutively enrolled 160 patients with decompensated cirrhosis. The sleep disturbance was determined by the Pittsburgh Sleep Quality Index (PSQI > 5). Serum trace elements [magnesium, calcium, iron, copper (Cu), zinc (Zn), lead, and manganese] was measured by inductively coupled plasma mass spectrometry. Association of examined trace elements levels and sleep disturbance was analyzed by multiple linear (global PSQI scores) and multivariate logistic (dichotomized PSQI categories) regression models, respectively.

Results

In total, 91 patients (56.88%) represented PSQI-defined sleep disturbance, characterized by female preponderance, lower body mass index levels, and higher serum Cu levels (all p < 0.05). Looking into its clinical relevance with debilitating conditions, we showed that Cu/Zn ratio (CZr) is significantly higher in cirrhosis with poor sleep quality (1.77 versus 1.48, p = 0.003). Diagnostic performance analysis indicated CZr > 1.62 to exhibit better discrimination relative to respective Cu. Both multiple linear (β = 0.355, p < 0.001) and multivariate logistic regression (odds ratio = 2.364, p = 0.019) identified higher CZr as an independent risk factor associated with sleep disturbance.

Conclusion

Our findings implied an association between higher CZr and the presence of sleep disturbance in patients with decompensated cirrhosis.

Dissecting the Contributing Role of Divergent Adipose Tissue to Multidimensional Frailty in Cirrhosis

BACKGROUND AND AIMS

Emerging evidence has demonstrated that abnormal body composition may potentiate the development of frailty, whereas little work focuses on the role of divergent adipose tissue. Therefore, we aimed to determine the potential contribution of adipose tissue distribution to multidimensional frailty in decompensated cirrhosis.

METHODS

We conducted a retrospective cohort study. Divergent adipose tissues were assessed by computed tomography-derived subcutaneous adipose tissue index (SATI), visceral adipose tissue index (VATI) and total adipose tissue index (TATI), respectively. Frailty was identified by our validated self-reported Frailty Index. Multiple binary logistic models incorporating different covariates were established to assess the relationship between adipose tissue distribution and frailty.

RESULTS

The study cohort comprised 245 cirrhotic patients with 45.3% being male. The median Frailty Index, body mass index (BMI) and model for end-stage liver disease (MELD) score were 0.11, 24.3 kg/m² and 8.9 points, respectively. In both men and women, patients who were frail exhibited lower levels of SATI in comparison with nonfrail patients. SATI inversely correlated with Frailty Index in the entire cohort (r_s=-0.1361, p=0.0332). Furthermore, SATI or TATI was independently associated with frail phenotype in several multiple logistic regression models adjusting for age, BMI, presence of ascites, sodium, Child-Pugh class or MELD score in isolation.

CONCLUSIONS

In the context of decompensated cirrhosis, low SATI and concomitant TATI were associated with higher risk of being frail. These findings highlight the importance to further apply tissue-specific tools of body composition in place of crude metric like BMI.

Malnutrition according to the Global Leadership Initiative on Malnutrition criteria is associated with in-hospital mortality and prolonged length of stay in patients with cirrhosis

OBJECTIVES

Malnutrition is prevalent and negatively affects patients with cirrhosis, but a generally accepted consensus pertaining to its diagnosis is lacking. Recently, a framework called the Global Leadership Initiative on Malnutrition (GLIM) has been proposed to diagnose malnutrition, but there is scant evidence regarding its validity. We aimed to investigate associations of malnutrition according to the GLIM criteria, as well as its individual indicator with in-hospital adverse outcomes.

METHODS

This was a prospective, observational study of consecutively hospitalized patients with cirrhosis. The malnutrition diagnosis was built on a stepwise GLIM process with initial screening, followed by fulfillment of at least one phenotypic and one etiologic criterion. Patients were followed up for a combined endpoint of in-hospital mortality and prolonged length of stay (LOS). Covariates compromise malnutrition according to the GLIM criteria and its indicators in separation. Logistic regression analyses were implemented to determine predictive validity.

RESULTS

A total of 387 cirrhotic patients were assessed. Malnutrition was diagnosed in 28.7% of patients according to the GLIM criteria, and increased the risk of in-hospital mortality and prolonged LOS by 2.166 and 1.767 times, respectively, adjusting for age, sex, biochemical parameters, and clinical scores of disease severity. When analyzing separate criteria, all constituents were independently associated with in-hospital adverse outcomes, adjusting for model for end-stage liver disease sodium score.

CONCLUSIONS

Malnutrition according to the GLIM criteria was considerably prevalent among hospitalized patients with cirrhosis, and associated with approximately two times greater probability of in-hospital mortality and prolonged LOS. These diagnostic criteria may be implemented and disseminated during daily practice considering their predictive validity.

Low Levels of Serum Zinc Associate with Malnutrition Risk Assessed by the Royal Free Hospital-Nutritional Prioritizing Tool in Cirrhosis

We have clarified that malnutrition risk evaluated by the Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) is prevalent in patients with cirrhosis. Mineral elements (zinc, iron, magnesium, copper, manganese, and calcium) are micronutrients essential for versatile physiological processes and cellular bioactivities. However, the association between these trace elements and integral nutritional status is unclear in decompensated cirrhotics. We collected blood samples from hospitalized patients with cirrhosis, and serum trace element concentrations were examined by inductively coupled plasma mass spectrometry. Association of trace element levels with high malnutrition risk was determined by multivariate logistic regression model. Sera from 141 patients with decompensated cirrhosis were analyzed for a total of six trace element concentrations. No significant differences were observed between high and low/moderate RFH-NPT malnutrition risk groups with the exception of zinc. The serum zinc concentrations were significantly decreased in patients at high malnutrition risk when compared to low/moderate subjects (57.9 vs 68.1 μg/dL, P = 0.006). In terms of receiver operating characteristics curve, zinc < 64 μg/dL represented best discriminative capability with an area of 0.635 (95% CI: 0.542, 0.728). Patients in the group with zinc < 64 μg/dL had elevated RFH-NPT and MELD score, higher proportion of Child-Pugh class C and ascites, higher CRP, lower albumin and sodium than in the group with zinc ≥ 64 μg/dL. Zinc < 64 μg/dL was an independent risk factor for high malnutrition risk. Low levels of serum zinc referring to less than 64 μg/dL were associated with poor integral nutritional status in cirrhosis.

Associations of Multiple Serum Trace Elements with Abnormal Sleep Duration Patterns in Hospitalized Patient with Cirrhosis

The associations of circulating trace elements with sleep health have attracted increasing attention given their potential link. However, there is scant data on the relationship between serum trace elements and abnormal sleep duration patterns in cirrhosis. We aimed to investigate these associations with the purpose of identifying modifiable risk factors. The blood samples were collected from inpatients with cirrhosis, and serum levels of several trace elements were assessed by inductively coupled plasma mass spectrometry. Self-reported sleep duration was categorized to short- (< 7 h/night), optimal (7-8 h/night), and long-sleep duration (> 8 h/night). The dose-response trends and associations of trace elements levels with sleep duration were determined by restricted cubic splines (RCS) and logistic regression, respectively. Cirrhotic patients with optimal sleep duration experienced the highest levels of serum Zinc (Zn) and the lowest values of copper to zinc ratio (CZr). RCS model corroborated non-linear associations of serum Zn and CZr against sleep duration. Multiple regression analysis showed that both CZr (short vs optimal sleep duration: OR 4.785, P < 0.001; long vs optimal sleep duration: OR 4.150, P = 0.019) and serum Zn levels (short vs optimal sleep duration: OR 0.985, P = 0.040; long vs optimal sleep duration: OR 0.956, P = 0.008) serve as independent risk factors for sleep duration abnormalities. In conclusion, our findings unraveled a close relationship of serum Zn and CZr with sleep duration in cirrhosis. Further trace element-based therapy such as Zn supplementation may be novel approach to reverse this sleep problem.

Association of myosteatosis with various body composition abnormalities and longer length of hospitalization in patients with decompensated cirrhosis

Background

Myosteatosis is linked to dismal outcomes in the context of cirrhosis. However, the association of myosteatosis with various body composition abnormalities remains enigmatic. We aimed to clarify the determinants of myosteatosis and its relationship with other body composition profiles and length of hospitalization (LOH).

Methods

We retrospectively analyzed the data of 473 consecutive patients with cirrhosis hospitalized for decompensation. Computed tomography-based segmentation of the cross-sectional area at the third lumbar vertebra was used to evaluate body composition abnormalities. The categories of myosteatosis were built according to our previously outcome-based cutoffs for each gender.

Results

Totally, 83 patients (17.55%) were stratified as myosteatosis, of whom 85.54% had concomitant high visceral adiposity indicative of increased visceral adipose tissue index (VATI). The prevalence of sarcopenia showed no significant difference between the groups with and without myosteatosis. Multivariate analysis showed that advanced age [odds ratio (OR) = 1.097, p < 0.001], higher visceral to subcutaneous ratio of adipose tissue area (VSR; OR = 1.574, p = 0.032), and higher VATI (OR = 1.026, p < 0.001) are independently associated with myosteatosis. Correlation analyses revealed a positive relationship between intramuscular adipose tissue content (IMAC) and VATI (ρ = 0.48, p < 0.001), subcutaneous adipose tissue index (SATI) (ρ = 0.36, p < 0.001), and age (ρ = 0.36, p < 0.001). None of the skeletal muscle or adipose tissue indicators were significantly related to longer LOH.

Conclusion

Higher VSR, higher VATI, and advanced age are associated with myosteatosis among patients with cirrhosis at the decompensation phase. It is tempting to target divergent adipose tissue depots aimed at timely intervention/prevention of myosteatosis.

Regulating Nrf2-GPx4 axis by bicyclol can prevent ferroptosis in carbon tetrachloride-induced acute liver injury in mice

Hepatocellular death is a sensitive parameter for detecting acute liver injury (ALI) of toxic, viral, metabolic, and autoimmune origin. Ferroptosis has recently been implicated in carbon tetrachloride (CCl₄)-induced ALI. However, the underpinning mechanism and mechanistic basis remain elusive. In this study, bicyclol, a proprietary hepatoprotectant in China, and ferroptosis-specific inhibitor ferrostatin-1 (Fer-1) were administered in CCl₄-injured mice. A panel of ferroptosis-related markers, including mitochondria morphology, reactive oxygen species production, protein adducts in response to lipid peroxidation, and key modulators of ferroptotic process, was determined in vivo. Erastin-treated L-O2 hepatocytes were transfected with glutathione peroxidase 4 (GPx4) or nuclear factor erythroid 2-related factor 2 (Nrf2) siRNA to delineate the pathway of bicyclol against ferroptosis in vitro. As a result, CCl₄ led to iron accumulation, excessive reactive oxygen species production, enhanced lipid peroxidation, and characteristic morphological changes in mitochondria, along with a decrease in GPx4 and xCT protein levels in ALI mice liver, all of which were generally observed in ferroptosis. The use of Fer-1 further corroborated that ferroptosis is responsible for liver damage. Bicyclol exerted its hepatoprotection by preventing the aforesaid ferroptotic process. Furthermore, bicyclol alleviated erastin-induced cellular inviability, destruction, and lipid peroxidation in vitro. Knockdown of GPx4 diminished these protective activities against perturbations associated with ferroptosis in L-O2 hepatocytes. Additionally, Nrf2 silencing drastically reduced GPx4 levels, and further impeded the medicinal effects of bicyclol. In summary, positively regulating Nrf2-GPx4 axis by bicyclol can prevent ferroptosis in CCl₄-induced ALI in mice.

Sarcopenia and frailty combined increases the risk of mortality in patients with decompensated cirrhosis

Background:

Both sarcopenia and frailty are prevalent in patients with decompensated cirrhosis and associated with negative outcomes. However, few studies investigated the impact of their coexistence on mortality. We aimed to evaluate the role of sarcopenia and frailty on survival in a cohort of hospitalized cirrhotics.

Methods:

This was an observational cohort study including 221 patients hospitalized for decompensated events. The cutoff for low skeletal muscle index (SMI) at the third lumbar vertebra level on computed tomography built by our previous work (male: SMI <46.96 cm²/m²; female: SMI <32.46 cm²/m²) was used for the diagnosis of sarcopenia. Individuals with a Frailty Index >0.38 were considered frail. The sample was divided into four groups: sarcopenia and frailty (SF); sarcopenia and non-frailty (SN); non-sarcopenia and frailty (NF); and non-sarcopenia and non-frailty (NN). Follow-up for survival lasted 2 years.

Results:

Sarcopenia and frailty were present in 21.7% and 14.5% of the patients, respectively. The frequency of frailty in the group of sarcopenic patients was significantly higher than in the patients without sarcopenia (27.1% versus 11%, p = 0.009). In the survival analysis, the SF group showed a higher hazard ratio (2.604 in model 1; 4.294 in model 2) for mortality when compared with the NN group. In addition, the concurrence of those two conditions does give rise to incremental risk for mortality when compared with the group with each disturbance separately, namely, the SN/NF group.

Conclusion:

In conclusion, cirrhotic patients with sarcopenia and frailty combined showed higher mortality risk.

Visceral Adiposity Associates With Malnutrition Risk Determined by Royal Free Hospital-Nutritional Prioritizing Tool in Cirrhosis

Mounting evidence has suggested the clinical significance of body composition abnormalities in the context of cirrhosis. Herein, we aimed to investigate the association between visceral adiposity and malnutrition risk in 176 hospitalized patients with cirrhosis. The adiposity parameters were obtained by computed tomography (CT) as follows: total adipose tissue index (TATI), visceral adipose tissue index (VATI), subcutaneous adipose tissue index (SATI), and visceral to subcutaneous adipose tissue area ratio (VSR). Malnutrition risk was screened using Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT). Visceral adiposity was determined given a higher VSR based on our previously established cutoffs. Multivariate analysis implicated that male gender (OR = 2.884, 95% CI: 1.360–6.115, p = 0.006), BMI (OR = 0.879, 95% CI: 0.812–0.951, P = 0.001), albumin (OR = 0.934, 95% CI: 0.882–0.989, P = 0.019), and visceral adiposity (OR = 3.413, 95% CI: 1.344–8.670, P = 0.010) were independent risk factors of malnutrition risk. No significant difference was observed regarding TATI, SATI, and VATI among patients with low or moderate and high risk of malnutrition. In contrast, the proportion of male patients embracing visceral adiposity was higher in high malnutrition risk group compared with that in low or moderate group (47.27 vs. 17.86%, p = 0.009). Moreover, this disparity was of borderline statistical significance in women (19.05 vs. 5.88%, p = 0.061). Assessing adipose tissue distribution might potentiate the estimation of malnutrition risk in cirrhotics. It is pivotal to recognize visceral adiposity and develop targeted therapeutic strategies.

A predictive nomogram incorporating gait speed for all-cause mortality in hospitalized cirrhotics

OBJECTIVES

No tailored model incorporating physical frailty for 2-year mortality in cirrhosis is available for practitioners in general practice. Thus we aimed to develop a model based on laboratory results and physical frailty allowing clinicians for stratifying cirrhotics by using individual estimate.

METHODS

One hundred and thirteen cases were assigned to the primary cohort, and all other 76 patients were regarded as the validation cohort. Multivariate Cox regression was performed, and a nomogram including five-meter gait speed (5MGS) were generated. The performance of the proposed model was assessed by C-index, calibration curve, and decision curve analysis (DCA).

RESULTS

On multivariate analysis, the Model for End-Stage Liver Disease-Sodium, albumin and 5MGS were independent predictors for 2-year mortality in cirrhosis. A nomogram incorporating all these parameters achieved a C-index of 0.804 (95%CI, 0.731-0.877). The calibration curve implied optimal correspondence between the predicted survival and actual outcomes. Our model is useful in the clinical settings based on DCA. Similar results were observed in the validation cohort with a C-index of 0.796 (95%CI, 0.689-0.899). Moreover, 5MGS, as a surrogate of physical performance, significantly correlated with multiple domains of general frailty according to Frailty Index (our published data), including instrumental activities of daily living, self-reported health, social activity and falls.

CONCLUSION

In conclusion, the nomogram incorporating 5MGS may represent an individualized tool for predicting mortality in cirrhosis for primary care physicians.

A self-reported Frailty Index predicts long-term mortality in hospitalized patients with cirrhosis

Background

Frailty is a syndrome that diminishes the potential for functional recovery in liver cirrhosis (LC). However, its utility is limited due to sole reliance on physical performance, especially in hospitalized patients. We investigate the predictive value of a modified self-reported Frailty Index in cirrhotics, and identify which health deficits play more important roles.

Methods

Consecutive LC patients were assessed by our frailty scale. Outcomes of interest were mortality for 90-day, 1-year and 2-year. Independent predictors were identified by multivariate Cox regression. Receiver operating characteristic curve (ROC) was performed to evaluate discriminative ability. We used a combination of stepwise selection, best subset selection, and Akaike information criteria (AIC) to identify pivotal frailty components.

Results

The study cohort consisted of 158 patients, in which 37 expired during follow-up. Compared with non-frail groups, the frail group had higher 1- and 2-year mortality. The area under ROC of the Child-Turcotte-Pugh classification (CTP) and Frailty Index were 0.66 and 0.68, while 0.72 for CTP + Frailty Index (P=0.034), respectively. The optimal predictors comprised instrumental activities of daily living (IADL) limitation, falls and loss of weight (AIC =170, C-statistic =0.67).

Conclusions

It is plausible for incorporating Frailty Index to improve prognostication in cirrhotics. IADL limitation, falls and loss of weight play more crucial roles on mortality determination.

Myopenic obesity determined by visceral fat area strongly predicts long-term mortality in cirrhosis

BACKGROUND

The impact of changes in body composition has proved to correlate with outcomes in cirrhosis, however, numerous issues remain elusive. The present study aimed to investigate the prognostic value of myopenic obesity (MO) on long-term mortality in cirrhosis.

METHODS

We retrospectively analyzed 200 patients with cirrhosis. Body composition parameters including skeletal muscle index (SMI) and visceral fat area (VFA) were estimated by computed tomography images at the third lumbar vertebra level. We defined MO as a low SMI (male: SMI < 46.96 cm²/m² and female: SMI < 32.46 cm²/m²) with BMI ≥ 25 kg/m² or VFA ≥ 100 cm² according to our previous publication. Patients were categorized into one of four body composition groups in terms of the presence or absence of myopenia and obesity.

RESULTS

On the basis of VFA or BMI, the four group comparison demonstrated the prognosis was poor in MO, followed by myopenic/nonobesity (MN), nonmyopenic/obesity and nonmyopenic/nonobesity, in that order (log-rank test). Multivariate Cox analysis identified that MO (HR 2.498; 95% CI, 1.214-5.140; P = 0.013), MN (HR 2.763; 95% CI, 1.244-6.134; P = 0.013), age (HR 3.035; 95% CI, 1.904-4.839; P < 0.001), neutrophil-to-lymphocyte ratio (HR 1.142; 95% CI, 1.082-1.207; P < 0.001) and MELD (HR 1.140; 95% CI, 1.066-1.219; P = 0.001) were independently associated with 2-year mortality according to VFA classification.

CONCLUSIONS

MO was an independent predictor of higher long-term mortality in cirrhosis. Prevention strategies by reducing visceral fat obesity rather than BMI should be the optimal target for MO management.

The emerging role of ferroptosis in non-cancer liver diseases: hype or increasing hope?

Ferroptosis is an iron- and lipotoxicity-dependent form of regulated cell death (RCD). It is morphologically and biochemically distinct from characteristics of other cell death. This modality has been intensively investigated in recent years due to its involvement in a wide array of pathologies, including cancer, neurodegenerative diseases, and acute kidney injury. Dysregulation of ferroptosis has also been linked to various liver diseases and its modification may provide a hopeful and attractive therapeutic concept. Indeed, targeting ferroptosis may prevent the pathophysiological progression of several liver diseases, such as hemochromatosis, nonalcoholic steatohepatitis, and ethanol-induced liver injury. On the contrary, enhancing ferroptosis may promote sorafenib-induced ferroptosis and pave the way for combination therapy in hepatocellular carcinoma. Glutathione peroxidase 4 (GPx4) and system x_c⁻ have been identified as key players to mediate ferroptosis pathway. More recently diverse signaling pathways have also been observed. The connection between ferroptosis and other forms of RCD is intricate and compelling, where discoveries in this field advance our understanding of cell survival and fate. In this review, we summarize the central molecular machinery of ferroptosis, describe the role of ferroptosis in non-cancer hepatic disease conditions and discuss the potential to manipulate ferroptosis as a therapeutic strategy.

Therapeutic potential of genipin in various acute liver injury, fulminant hepatitis, NAFLD and other non-cancer liver diseases: More friend than foe

Genipin is an aglycone derived from the geniposide, the most abundant iridoid glucoside constituent of Gardenia jasminoides Ellis. For decades, genipin is the focus of studies as a versatile compound in the treatment of various pathogenic conditions. In particularly, Gardenia jasminoides Ellis has long been used in traditional Chinese medicine for the prevention and treatment of liver disease. Mounting experimental data has proved genipin possesses therapeutic potential for cholestatic, septic, ischemia/reperfusion-triggered acute liver injury, fulminant hepatitis and NAFLD. This critical review is a reflection on the valuable lessons from decades of research regarding pharmacological activities of genipin. Of note, genipin represents choleretic effect by potentiating bilirubin disposal and enhancement of genes in charge of the efflux of a number of organic anions. The anti-inflammatory capability of genipin is mediated by suppression of the production and function of pro-inflammatory cytokines and inflammasome. Moreover, genipin modulates various transcription factor and signal transduction pathway. Genipin appears to trigger the upregulation of several key genes encoding antioxidant and xenobiotic-metabolizing enzymes. Furthermore, the medicinal impact of genipin extends to modulation of regulated cell death, including autophagic cell death, apoptosis, necroptosis and pyroptosis, and modulation of quality of cellular organelle. Another crucial effect of genipin appears to be linked to dual role in targeting uncoupling protein 2 (UCP2). As a typical UCP2-inhibiting compound, genipin could inhibit AMP-activated protein kinase or NF-κB in circumstance. On the contrary, reactive oxygen species production and cellular lipid deposits mediated by genipin through the upregulation of UCP2 is observed in liver steatosis, suggesting the precise role of genipin is disease-specific. Collectively, we comprehensively summarize the mechanisms and pathways associated with the hepatoprotective activity of genipin and discuss potential toxic impact. Notably, our focus is the direct medicinal effect of genipin itself, whereas its utility as a crosslinking agent in tissue engineering is out of scope for the current review. Further studies are therefore required to disentangle these complicated pharmacological properties to confer this natural agent a far greater potency.

Bicyclol Attenuates Acute Liver Injury by Activating Autophagy, Anti-Oxidative and Anti-Inflammatory Capabilities in Mice

Bicyclol, a novel synthetic antihepatitis drug, has been shown to protect against liver injury via various pharmacological activities. The purpose of the current study was to further investigate the protective effect of bicyclol against carbon tetrachloride (CCl₄)-induced acute liver injury (ALI) and its underlying molecular mechanism, particularly autophagic machinery, anti-oxidative, and anti-inflammatory potentials. Our results found that treatment with bicyclol significantly reduced CCl₄-induced hepatotoxicity by alleviating histopathological liver changes, decreasing the alanine transaminase levels, promoting autophagic flux, attenuating the expression of inflammatory cytokines, and modulating oxidative markers. Furthermore, bicyclol efficiently induced the conversion of LC3 and enhanced the liver expressions of ATG7 and Beclin-1. Meanwhile, bicyclol induced the activation of nuclear factor erythroid 2-related factor 2 (Nrf2) and p62. These protective effects may be mediated by activation of AMP-activated protein kinase and inhibition of mTOR or MAPK signaling pathways. Taken together, our study firstly suggests that bicyclol has protective potential against CCl₄-induced hepatotoxicity, which might be closely associated with induction of autophagy, concomitant anti-oxidative stress, and anti-inflammatory response.

Low psoas muscle index associates with long-term mortality in cirrhosis: construction of a nomogram

Background

To develop a nomogram incorporating indicator of muscle waste to prognosticate long-term mortality in liver cirrhosis (LC), and identify the prognostic impact of psoas muscle index (PMI).

Methods

A total of 251 LC patients who underwent computed tomography were included in this study. Multiple Cox regression was performed, and sex-specific nomogram models incorporating PMI were developed. The utility of the proposed models were evaluated by Harrell’s concordance index (C-index), calibration curve and decision curve analysis. X-tile was used to determine optimal cutpoint for stratifying subjects with distinct outcomes. Subgroup analysis was implemented in terms of age and MELD score. The correlation between PMI and gait speed was also evaluated.

Results

On multiple analysis, independent predictors for 3-year all-cause mortality were age, BMI, PMI and MELD for males, and age, PMI and MELD for females. Both nomogram models gave rise to moderately strong discrimination, with a C-index of 0.792 (95% CI: 0.723–0.861) in males and 0.715 (95% CI: 0.637–0.793) in females, respectively. The calibration curve implied predicted survival corresponding optimally with the actual outcomes. The proposed models were feasible in clinical settings based on decision curve analysis. On subgroup analysis, PMI might confer valid predictive value on LC patients with MELD <15. Moreover, a definitely positive correlation between PMI and gait speed was revealed.

Conclusions

Our proposed nomogram embedding PMI rendered an individualized predictive tool for long-term mortality in LC. The diminishing value of PMI is likely indicative of muscle dysfunction.

The Efficacy of Proton Pump Inhibitor in Cirrhotics with Variceal Bleeding: A Systemic Review and Meta-Analysis

BACKGROUND AND AIMS

Proton pump inhibitor (PPI) was widely used in cirrhotic patients with variceal bleeding empirically rather than evidence-based practice. We aimed to evaluate the plausible indication of PPI use in variceal bleeding cirrhotic patients and figure out whether it can decrease the re-bleeding rate after endoscopic therapy. Furthermore, we also investigated the association between PPI and bleeding-related mortality in these patients.

METHODS

We have searched in PubMed, Medline, Web of Science, Google Scholar, Cochrane and Embase prior to May 2019. Pooled OR and 95% CI were calculated by random-effects model.

RESULTS

A total of 11 original articles including 1,818 cirrhotic patients were analyzed. The overall meta-analysis highlighted that PPI use may decrease the re-bleeding rate after endoscopic therapy (OR 0.52, 95% CI 0.35-0.77). The conclusion was irrespective of study methods, endoscopic purpose and hemorrhage sites. However, the conclusion speculated that PPI should be prescribed >1 month. Meanwhile, PPI use may not impact the bleeding-related mortality.

CONCLUSIONS

PPI, used for >1 month, can decrease re-bleeding rate after endoscopic therapy in cirrhotic patients for prophylaxis or emergency treatment purpose. No matter how long it takes, PPI use is not associated with bleeding-related mortality.

Acid suppression therapy and its association with spontaneous bacterial peritonitis incidence: A systemic review and meta-analysis

AIM

It is well known that the use of proton pump inhibitor (PPI) is widespread in patients with liver cirrhosis. PPI counteracts H₂ receptor inhibitor (H₂ RA) with its strong acid suppression effect. However, there is always a concern that PPI use may increase spontaneous bacteria peritonitis (SBP) development in cirrhotic patients. We aimed to investigate the association between acid suppression therapy (i.e. PPI or H₂ RA) and SBP through meta-analysis.

METHODS

We searched PubMed, Medline, Web of Science, Cochrane library, and Embase for relevant studies published up to April 2019. Pooled OR and 95% CI were calculated by a random-effects model. Funnel plots and Egger's tests were performed for the evaluation of publication bias. Non-parametric "trim-and-fill" tests were conducted for sensitivity analysis.

RESULTS

A total of 20 original articles including 9566 cirrhotic patients were analyzed. The overall meta-analysis highlighted that PPI use was associated with the risk of SBP (pooled OR 1.77, 95% CI 1.49-2.11). The conclusion was irrespective of study methods, whereas the result was inconsistent only in South America. However, the conclusion might not be stable enough and should be extrapolated with caution. Unlike PPI, we found H₂ RA was not associated with SBP (pooled OR 1.06, 95% CI 0.75-1.48).

CONCLUSIONS

In conclusion, PPI use, but not H₂ RA, will increase the incidence of SBP in cirrhotic patients. In addition, H₂ RA might be beneficial for patients who require long-term acid suppression therapy.

Genipin Ameliorates Carbon Tetrachloride-Induced Liver Injury in Mice via the Concomitant Inhibition of Inflammation and Induction of Autophagy

Genipin, as the most effective ingredient of various traditional medications, encompasses antioxidative, anti-inflammatory, and antibacterial capacities. More recently, it is suggested that genipin protects against septic liver damage by restoring autophagy. The purpose of the current study was to explore the protective effect of genipin against carbon tetrachloride- (CCl₄-) induced acute liver injury (ALI) and its underlying molecular machinery. Our results indicated that treatment with genipin significantly reduced CCl₄-induced hepatotoxicity by ameliorating histological liver changes, decreasing the aspartate aminotransferase and alanine transaminase levels, alleviating the secretion of inflammatory cytokines, and promoting autophagic flux. Moreover, genipin effectively induced the conversion of LC3 and inhibition of p62 accumulation. The liver expressions of ATG5, ATG7, and ATG12 were significantly increased by genipin pretreatment in the ALI mice model. This protective effect may be mediated by the inhibition of mTOR and the activation of p38 MAPK signaling pathways. Meanwhile, genipin attenuated CCl₄-induced inflammatory response by inhibiting the NF-κB and STAT3 signaling pathway. In addition, pretreatment with autophagy inhibitor 3-methyladenine (3-MA) or inhibition of p38 MAPK by SB203580 abolished the hepatoprotective effect of genipin. Taken together, our study implicates that genipin has a protective potential against CCl₄-induced hepatotoxicity, which might be strongly associated with the induction of autophagy and the attenuation of inflammatory response.

Prognostic impact of neutrophil-to-lymphocyte ratio in cirrhosis: A propensity score matching analysis with a prespecified cut-point

BACKGROUND & AIMS

An elevated neutrophil-to-lymphocyte ratio (NLR) has received attention as a prognostic surrogate across chronic liver diseases. However, an exact threshold has not been fully elucidated.

METHODS

A total number of 589 patients with cirrhosis (LC) were included. The value of NLR was calculated and its optimal cut-off was initially determined by X-tile program. Independent predictors of 90-day mortality were identified with Cox regression model. The Kaplan-Meier method was used to generate survival curves. To reduce influences of selection bias and possible confounders, a 1:2 propensity score matching (PSM) was performed.

RESULTS

The X-tile indicated that the difference in survival was most significant for NLR more than 8.9. Serum NLR > 8.9 was an independent indicator in the entire cohort and PSM subset (HR 4.268, 95% CI 2.211-8.238, P < .001; HR 4.209, 95% CI 1.448-12.238, P = .008 respectively). Subgroup analysis showed that NLR > 8.9 was an independent risk factor of 90-day mortality regardless of age, gender, CTP or MELD score.

CONCLUSIONS

The value of NLR more than 8.9 is a feasible cut-off across clinical settings among applicable population. The adding of NLR to other conventional predictive systems has the potential to provide incremental value without extra economic cost.

Increasing Diverticulosis in an Aging Population: A Colonoscopy-Based Study of 5-Year Trends in 26 463 Patients in Northern China

Background

Because such data are scarce in northern China, the purpose of this study was to determine trends in diverticulosis over the past 5 years.

Material/Methods

A total of 26 463 patients (27 558 examinations, including 1095 repeated colonoscopies) performed between January 2011 and December 2015 were reviewed respectively. The distributions of diverticulosis were recorded, which were classified as right-sided, left-sided, and bilateral type. The trends in diverticulosis were analyzed in terms of aging and yearly increase. Additionally, associations of the occurrence of diverticulosis with age (≤39, 40–59, and ≥60 years) and sex were determined using a logistic regression model.

Results

We identified 1045 patients with colonic diverticulosis, with an overall prevalence of 3.8% (1045/27 558). A preponderance of right-sided diverticulosis was demonstrated, accounting for 72.9% (693/951) of included subjects. The proportion of colonic diverticulosis increased significantly (P<0.001 for trend), from 2.78% (112/4028) in 2011 to 4.98% (309/6208) in 2015. The proportion of patients of all age groups with diverticulosis increased significantly (P<0.001 for trend) in correlation with yearly increase. There was a greater proportion of diverticulosis, regardless of the distribution, in patients aged ≥60 than in younger age groups (P<0.001 for trend). Multivariate analysis showed older age and male sex (P<0.001) were independent risk factor for diverticulosis.

Conclusions

Colonic diverticulosis has been increasing in northern China, where rapid aging is ongoing.

Sex differences in risk factors of uncomplicated colonic diverticulosis in a metropolitan area from Northern China

As the world’s most populated and rapidly aging country, there is limited information on sex-related differences in factors regarding uncomplicated colonic diverticulosis in China. We aimed to investigate sex differences in individual risk factor in a northern metropolis. Patients with colonic diverticulosis who underwent indicated colonoscopy were queried with respect to medical history and demographic features. Demographic information, life style factors and co-morbidities were retrieved from a prospective dataset. Multiple regression analyses were performed to determine precipitating factors of diverticula. Of 4,386 enrolled patients, colonic diverticulosis were detected in 218 cases (4.97%). Multiple logistic regression analysis implicated increasing age (OR = 1.05, 95%CI 1.03–1.06, P < 0.001), red meat ≥100 g/d (OR = 2.53, 95%CI 1.72–3.70, P < 0.001), smoking (OR = 2.14, 95%CI 1.05–4.33, P = 0.035), rheumatologic diseases (OR = 3.38, 95%CI 1.09–10.5, P = 0.035) and NSAIDs (OR = 2.11, 95%CI 1.12–3.97, P = 0.020) were significantly associated with diverticulosis in men, whilst advancing age (OR = 1.03, 95%CI 1.01–1.05, P = 0.013), BMI (OR = 1.12, 95%CI 1.04–1.19, P = 0.001), smoking (OR = 10.2, 95%CI 2.81–37.4, P < 0.001), rheumatologic diseases (OR = 8.04, 95%CI 3.05–21.2, P < 0.001), hypertension (OR = 1.76, 95%CI 1.01–3.06, P = 0.047), colonic polyps (OR = 3.12, 95%CI 1.82–5.36, P < 0.001) and antihypertensive medications (OR = 2.99, 95%CI 1.66–5.39, P < 0.001) in women. In conclusion, it is pivotal to take account of differentially sex-related factors in regard to the development of uncomplicated colonic diverticulosis.

Does neutrophil-to-lymphocyte ratio predict 1-year mortality in patients with primary biliary cholangitis? Results from a retrospective study with validation cohort

OBJECTIVES

Neutrophil-to-lymphocyte ratio (NLR) has been used to predict prognosis in various liver diseases, but its role in primary biliary cholangitis (PBC) is not clarified. We aimed to investigate the prognostic usefulness of NLR for 1-year mortality in PBC.

METHODS

The study recruited a retrospective cohort with 88 patients with PBC and a prospective validation cohort with 63 participants who were followed-up for 1 year. NLR and other laboratory measurements were analysed by multivariate regression model for identifying independent factors for early mortality. The cut-off threshold of NLR was determined by calculating the area under the receiver operating characteristics curve (AUROC) and used in a subsequent Kaplan-Meier survival analysis.

RESULTS

Univariate and multivariate analyses showed that Mayo Risk Score (MRS), serum creatinine and NLR were independent indicators for mortality. NLR yielded significantly higher AUROC (0.86) than those of platelet-to-lymphocyte ratio (0.58, p=0.03), but comparable with MRS (0.87, p=0.88). Spearman's correlation analysis represented a positive correlation between escalating NLR and aggravating Child-Pugh grade (r=0.44, p<0.001). Patients with NLR <2.18 exhibited higher survival (with 100% sensitivity and 67.1% specificity) within 1 year follow-up duration, and NLR ≥2.18 was indicative of higher mortality (log-rank test, p<0.001). In addition, these results were internally confirmed by a validation cohort.

CONCLUSION

NLR is closely related to short-term mortality in patients with PBC.

Analysis of the learning curve for peroral endoscopic myotomy for esophageal achalasia: Single-center, two-operator experience

BACKGROUND AND AIM

Peroral endoscopic myotomy (POEM) has emerged as an advanced technique for the treatment of achalasia, and defining the learning curve is mandatory.

METHODS

From August 2011 to June 2014, two operators in our institution (A&B) carried out POEM on 35 and 33 consecutive patients, respectively. Moving average and cumulative sum (CUSUM) methods were used to analyze the POEM learning curve for corrected operative time (cOT), referring to duration of per centimeter myotomy. Additionally, perioperative outcomes were compared among distinct learning curve phases.

RESULTS

Using the moving average method, cOT reached a plateau at the 29th case and at the 24th case for operators A and B, respectively. CUSUM analysis identified three phases: initial learning period (Phase 1), efficiency period (Phase 2) and mastery period (Phase 3). The relatively smooth state in the CUSUM graph occurred at the 26th case and at the 24th case for operators A and B, respectively. Mean cOT of distinct phases for operator A were 8.32, 5.20 and 3.97 min, whereas they were 5.99, 3.06 and 3.75 min for operator B, respectively. Eckardt score and lower esophageal sphincter pressure significantly decreased during the 1-year follow-up period. Data were comparable regarding patient characteristics and perioperative outcomes.

CONCLUSION

This single-center study demonstrated that expert endoscopists with experience in esophageal endoscopic submucosal dissection reached a plateau in learning of POEM after approximately 25 cases.