51
|
Kaushal K, Gupta V, Goswami P, Agarwal S, Sharma S, Das P, Yadav R, Anand A, Sonika U, Gunjan D, Saraya A. Acute Variceal Bleed in Cirrhosis is Associated With Reversible Changes in Tight Junction Protein Expression in the Intestine: A Proof-of-Concept Study. J Clin Exp Hepatol 2022; 12:89-100. [PMID: 35068789 PMCID: PMC8766542 DOI: 10.1016/j.jceh.2021.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/23/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Tight junction proteins (TJPs) play an important role in gut-barrier dysfunction in cirrhosis and its complications such as acute variceal bleed (AVB). However, the dynamics of TJPs expression after AVB, its relation to bacterial translocation, and impact on clinical outcome is largely unknown. AIMS The aim of this study was to study the expression of TJPs in cirrhosis and assess its dynamic changes in AVB. In addition, the relation of TJP expression to endotoxemia and clinical outcomes was assessed. METHODS In this prospective pilot study, 17 patients of cirrhosis with AVB, 59 patients of cirrhosis without AVB (non-AVB cirrhosis), and 20 controls were assessed for claudin-2 and claudin-4 expression in the duodenal biopsy. In the AVB-cirrhosis group, additional biopsies were obtained after 3 weeks. Endotoxemia was assessed by measuring IgG anti-endotoxin antibody levels. Claudin expression was correlated with a 6-month survival. RESULTS Claudin-2 expression was downregulated in patients with AVB and non-AVB cirrhosis in villi (P < 0.001 and 0.013) and crypts (P < 0.001 and 0.012), respectively, compared with the controls. Claudin-4 expression was similar in villi (P = 0.079), but lower in crypts (P = 0.007) in patients with cirrhosis. Claudin-2 expression was upregulated on serial biopsies in both villi and crypts (P = 0.003 and 0.001, respectively) in AVB-cirrhosis with postbleed expression comparable with those with non-AVB cirrhosis. IgG anti-endotoxin antibody levels were elevated in cirrhosis with no correlation with claudin-2/4 expression. Claudin-2 expression independently predicted survival at 6 months. CONCLUSION Both claudin-2 and claudin-4 expression are downregulated in cirrhosis. AVB is associated with dynamic changes in TJPs expression. Gut-barrier dysfunction might predict outcomes independent of bacterial endotoxemia in cirrhosis.
Collapse
Key Words
- AVB, Acute Variceal Bleed
- DAB, 3,3′-Diaminobenzidine
- EBL, Endoscopic Band Ligation
- EGD, Esophagogastroduodenoscopy
- HRV, high-risk varices
- IHC, Immunohistochemistry
- NSBB, Non-selective Beta Blockers
- PAMP, Pathogen associated molecular patterns
- TJP, Tight Junction Protein
- TMB, 3, 3′, 5, 5′-tetramethylbenzidine
- acute variceal bleed
- claudin-2
- endotoxemia
- tight junction proteins
Collapse
|
52
|
Saraya A, Singh N, Gupta S, Rashid S. Association of inflammatory markers with the disease & mutation status in pancreatic cancer. Indian J Med Res 2022; 155:49-55. [PMID: 35859428 PMCID: PMC9552386 DOI: 10.4103/ijmr.ijmr_2238_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background & objectives: Inflammation has been studied to be an important contributory factor to carcinogenesis through pro-inflammatory markers such as interleukin (IL)-6 and C-reactive protein (CRP). Furthermore, K-ras mutation is an important genetic alteration in the pathogenesis of pancreatic cancer. This study aimed to compare these inflammatory markers in pancreatic ductal adenocarcinoma (PDAC) with the diseased and healthy controls (HCs) and to check for any association between IL-6 and CRP serum levels with the disease status, survival and K-ras mutation status of PDAC patients. Methods: The study included 135 PDAC, 25 chronic pancreatitis (CP) patients and 25 HCs. The serum levels of IL-6 and CRP were detected by enzyme-linked immunosorbent assay and K-ras mutations were detected by polymerase chain reaction-restriction fragment length polymorphism technique. Results: The serum levels of both these markers were elevated in PDAC cases than that in HCs. High IL-6 levels and higher CRP levels were found to be associated with locally advanced disease, lymphatic invasion, metastasis and advanced stage of the PDAC. In patients with unresectable PDAC, higher IL-6 levels were found to be associated with the presence of K-ras mutations. Interpretation & conclusions: Higher IL-6 and CRP levels in patients with advanced PDAC suggest an important role of these inflammatory markers in tumour progression. Furthermore, the association of mutations in the K-ras gene with serum IL-6 indicates cross-talks that may contribute to the progression of the PDAC.
Collapse
|
53
|
Kaushal K, Agarwal S, Sharma S, Goswami P, Singh N, Sachdev V, Poudel S, Das P, Yadav R, Kumar D, Pandey G, Gunjan D, Saraya A. Demonstration of Gut-Barrier Dysfunction in Early Stages of Non-alcoholic Fatty Liver Disease: A Proof-Of-Concept Study. J Clin Exp Hepatol 2022; 12:1102-1113. [PMID: 35814507 PMCID: PMC9257921 DOI: 10.1016/j.jceh.2022.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 01/17/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND/AIMS Gut-barrier dysfunction is well recognized in pathogenesis of both non-alcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD). However, comparison of components of this dysfunction between the two etiologies remains unexplored especially in early stages of NAFLD. METHODS Components of gut-barrier dysfunction like alterations in intestinal permeability (IP) by lactulose mannitol ratio (LMR) in urine, systemic endotoxemia (IgG and IgM anti-endotoxin antibodies), systemic inflammation (serum tumor necrosis factor alpha [TNF-α] and interleukin-1 [IL-1] levels), tight junction (TJ) proteins expression in duodenal biopsy and stool microbiota composition using Oxford Nanopore MinION device were prospectively evaluated in patients with NAFLD (n = 34) with no cirrhosis, ALD (n = 28) and were compared with disease free controls (n = 20). RESULTS Patients with ALD had more advanced disease than those with NAFLD (median liver stiffness -NAFLD:7.1 kPa [5.9-8.9] vs. ALD:14.3 kPa [9.6-24], P < 0.001]. Median LMR was significantly higher in NAFLD and ALD group when compared to controls (NAFLD 0.054 [0.037-0.17] vs. controls 0.027 [0.021-0.045] (P = 0.001)) and ALD 0.043 [0.03-0.068] vs. controls 0.027 [0.021-0.045] (P = 0.019)]. Anti-endotoxin antibody titer (IgM) (MMU/mL) was lowest in NAFLD 72.9 [3.2-1089.5] compared to ALD 120.6 [20.1-728]) (P = 0.042) and controls 155.3 [23.8-442.9]) (P = 0.021). Median TNF-α (pg/mL) levels were elevated in patients with NAFLD (53.3 [24.5-115]) compared to controls (16.1 [10.8-33.3]) (P < 0.001) and ALD (12.3 [10.1-42.7]) (P < 0.001). Expression of zonulin-1 and claudin-3 in duodenal mucosa was lowest in NAFLD. On principal co-ordinate analysis (PCoA), the global bacterial composition was significantly different across the three groups (PERMANOVA test, P < 0.001). CONCLUSION While remaining activated in both etiologies, gut-barrier dysfunction abnormalities were more pronounced in NAFLD at early stages compared to ALD despite more advanced disease in the latter.
Collapse
Key Words
- ALD, alcoholic liver disease
- ALT, alanine transaminase
- AST, aspartate transaminase
- IL-1, interleukin-1
- IP, intestinal permeability
- KFT, kidney function test
- LFT, liver function test
- LMR, lactulose mannitol ratio
- NAFLD, non-alcoholic fatty liver disease
- TNF, tumor necrosis factor
- alcoholic liver disease
- endotoxemia
- intestinal permeability
- non-alcoholic fatty liver disease
- tight junction protein
Collapse
|
54
|
Grover I, Singh N, Gunjan D, Pandey RM, Chandra Sati H, Saraya A. Comparison of Anthropometry, Bioelectrical Impedance, and Dual-energy X-ray Absorptiometry for Body Composition in Cirrhosis. J Clin Exp Hepatol 2022; 12:467-474. [PMID: 35535105 PMCID: PMC9077186 DOI: 10.1016/j.jceh.2021.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/29/2021] [Indexed: 12/12/2022] Open
Abstract
Background & aims This study was planned to evaluate triceps skinfold thickness (TSFT), mid-arm muscle circumference (MAMC) and bioelectrical impedance analysis (BIA) for assessing body composition using dual-energy X-ray absorptiometry (DEXA) (reference) and to predict fat mass (FM) and fat-free mass (FFM) in patients with cirrhosis. Methods FM and FFM were assessed by using DEXA and BIA. Skin-fold calliper was used for measuring TSFT, and MAMC was calculated. Bland-Altman plot was used to determine agreement and linear regression analysis for obtaining equations to predict FM and FFM. Results Patients with cirrhosis (n = 302, 241 male, age 43.7 ± 12.0 years) were included. Bland-Altman plot showed very good agreement between BIA and DEXA for the estimation of FM and FFM. Majority of patients were within the limit of agreement: FM (98%) and FFM (96.4%). BIA shows a positive correlation with DEXA:FM (r = 0.73, P ≤ 0.001) and FFM (r = 0.86, P ≤ 0.001). DEXA (FM and FFM) shows a positive correlation with TSFT (r = 0.69, P ≤ 0.01) and MAMC (r = 0.61, P ≤ 0.01). The mean difference between the observed and predicted value of FM and FFM by BIA in the developmental set was 0.01 and 0.05, respectively; whereas in the validation set, it was -0.13 and 0.86, respectively. The mean difference between the observed and predicted value of TSFT and MAMC in the developmental set was 0.43 and 0.07; whereas, in the validation set, it was 0.16 and 0.48, respectively. Conclusion Anthropometry (TSFT and MAMC) and BIA are simple and easy to use and can be a substitute of DEXA for FM and FFM assessment in routine clinical settings in patients with cirrhosis.
Collapse
Key Words
- ALP, alkaline phosphatise
- ALT, alanine aminotransferase
- ANA, anti-nuclear antibody
- ASMA, anti-smooth muscle antibody
- AST, aspartate aminotransferase
- BIA, bioelectrical impedance analysis
- BMC, bone mineral content
- BMI, body mass index
- CTP, Child–Turcotte–Pugh score
- DEXA, dual-energy X-ray absorptiometry
- FFM, fat-free mass
- FM, fat mass
- HBsAg, hepatitis B surface antigen
- MAMC, mid-arm muscle circumference
- TSFT, triceps skinfold thickness
- anthropometric measurements
- anti-HCV, anti-hepatitis C virus
- anti-LKM1, anti-liver kidney microsomal antibody type 1
- bioelectrical impedance analysis
- cirrhosis
- dual-energy X-ray absorptiometry
- nutritional assessment
Collapse
|
55
|
Mohta S, Sharma S, Saraya A. Improvement in adipocytic indices as a predictor of improved outcomes after TIPS: Right conclusion? Liver Int 2022; 42:253. [PMID: 34724317 DOI: 10.1111/liv.15091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/27/2021] [Indexed: 02/13/2023]
|
56
|
Anand A, Nambirajan A, Kumar V, Agarwal S, Sharma S, Mohta S, Gopi S, Kaushal K, Gunjan D, Singh N, Madhusudhan KS, Chauhan SS, Sharma MC, Bansal VK, Saraya A. Alterations in Autophagy and Mammalian Target of Rapamycin (mTOR) Pathways Mediate Sarcopenia in Patients with Cirrhosis. J Clin Exp Hepatol 2022; 12:510-518. [PMID: 35535114 PMCID: PMC9077178 DOI: 10.1016/j.jceh.2021.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/16/2021] [Indexed: 12/12/2022] Open
Abstract
Background and aims The pathophysiology of sarcopenia in cirrhosis is poorly understood. We aimed to evaluate the histological alterations in the muscle tissue of patients with cirrhosis and sarcopenia, and identify the regulators of muscle homeostasis. Methods Computed tomography images at third lumbar vertebral level were used to assess skeletal muscle index (SMI) in 180 patients. Sarcopenia was diagnosed based on the SMI cut-offs from a population of similar ethnicity. Muscle biopsy was obtained from the vastus lateralis in 10 sarcopenic patients with cirrhosis, and the external oblique in five controls (voluntary kidney donors during nephrectomy). Histological changes were assessed by hematoxylin and eosin staining and immunohistochemistry for phospho-FOXO3, phospho-AKT, phospho-mTOR, and apoptosis markers (annexin V and caspase 3). The messenger ribonucleic acid (mRNA) expressions for MSTN, FoxO3, markers of ubiquitin-proteasome pathway (FBXO32, TRIM63), and markers of autophagy (Beclin-1 and LC3) were also quantified. Results The prevalence of sarcopenia was 14.4%. Muscle histology in sarcopenics showed atrophic angulated fibers (P = 0.002) compared to controls. Immunohistochemistry showed a significant loss of expression of phospho-mTOR (P = 0.026) and an unaltered phospho-AKT (P = 0.089) in sarcopenic patients. There were no differences in the immunostaining for annexin-V, caspase-3, and phospho-FoxO3 between the two groups. The mRNA expressions of MSTN and Beclin-1 were higher in sarcopenics (P = 0.04 and P = 0.04, respectively). The two groups did not differ in the mRNA levels for TRIM63, FBXO32, and LC3. Conclusions Significant muscle atrophy, increase in autophagy, MSTN gene expression, and an impaired mTOR signaling were seen in patients with sarcopenia and cirrhosis.
Collapse
Key Words
- 4E-BP1, eukaryotic translation initiation factor 4E binding protein-1
- APASL, Asia Pacific Association for the study of the Liver
- BMI, body mass index
- CT, computed tomography
- EWGSOP, European Working Group on Sarcopenia in Older People
- Fox-O, forkhead O
- HCC, hepatocellular carcinoma
- HE, hepatic encephalopathy
- MSTN gene
- MuRF-1, muscle RING finger 1
- RNA, ribonucleic acid
- RT-PCR, real-time polymerase chain reaction
- SMI, skeletal muscle index
- autophagy
- cDNA, complementary deoxyribonucleic acid
- cirrhosis
- mRNA, messenger RNA
- mTOR, mammalian target of rapamycin
- qPCR, quantitative polymerase chain reaction
- sarcopenia
Collapse
|
57
|
Suyal G, Pandey P, Saraya A, Sharma R. Tumour suppressor role of microRNA-335-5p in esophageal squamous cell carcinoma by targeting TTK (Mps1). Exp Mol Pathol 2021; 124:104738. [PMID: 34953918 DOI: 10.1016/j.yexmp.2021.104738] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 12/14/2021] [Accepted: 12/17/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Esophageal cancer is an aggressive malignancy. miR-335-5p is reported to possess both tumour suppressor and tumour promoter activities in different cancers. OBJECTIVES We investigated the role of miR-335-5p in esophageal cancer by expression and functional studies. MATERIALS AND METHODS The role of miR-335-5p in ESCC was evaluated using MTT assay, cell cycle analysis, colony formation assay, scratch assay, matrigel invasion, and migration assay. RESULTS Our expression studies showed a significantly decreased expression of tissue and circulating miR-335-5p in esophageal cancer. Our results herein report a key tumour suppressive role of miR-335-5p in esophageal carcinogenesis by inhibiting proliferation, migration, and invasion in ESCC cells. Using RNA-seq and Insilico analysis we found TTK to be a newly identified direct target and confirmed it by using luciferase assay. CONCLUSION Overall, our expression and functional analysis results demonstrated herein point towards the potential role of miR-335-5p in esophageal tumorigenesis. Moreover, this is the first report showing TTK as a downstream target of miR-335-5p.
Collapse
|
58
|
Agarwal A, Sharma S, Saraya A. Letter to the Editor: Defining the Futility for Rescue Transjugular Intrahepatic Portosystemic Shunt Using the Model for End-Stage Liver Disease Score and Lactate in Variceal Bleed. Hepatology 2021; 74:3556-3557. [PMID: 34351005 DOI: 10.1002/hep.32093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
|
59
|
Nayak B, Lal G, Kumar S, Das CJ, Saraya A, Shalimar. Host Response to SARS-CoV2 and Emerging Variants in Pre-Existing Liver and Gastrointestinal Diseases. Front Cell Infect Microbiol 2021; 11:753249. [PMID: 34760721 PMCID: PMC8573081 DOI: 10.3389/fcimb.2021.753249] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/04/2021] [Indexed: 01/08/2023] Open
Abstract
Background Novel coronavirus SARS-CoV2 is evolving continuously with emergence of several variants of increasing transmission capabilities and pandemic potential. Generation of variants occurs through accumulation of mutations due to the RNA nature of viral genome, which is further enhanced by variable selection pressures of this ongoing pandemic. COVID-19 presentations of SARS-CoV2 are mainly pulmonary manifestations with or without mild gastrointestinal (GI) and hepatic symptoms. However, the virus has evolved beyond pulmonary manifestations to multisystem disorder due to systemic inflammation and cytokine storm. Definitive cause of acute or late onset of inflammation, infection in various organs, and host response to emerging variants lacks clarity and needs elucidation. Several studies have reported underlying diseases including diabetes, hypertension, obesity, cardio- and cerebrovascular disorders, and immunocompromised conditions as significant risk factors for severe form of COVID-19. Pre-existing liver and GI diseases are also highly predominant in the population, which can alter COVID-19 outcome due to altered immune status and host response. We aim to review the emerging variants of SARS-CoV2 and host response in patients with pre-existing liver and GI diseases. Methods In this review, we have elucidated the emergence and characteristic features of new SARS-CoV2 variants, mechanisms of infection and host immune response, GI and hepatic manifestation with radiologic features of COVID-19, and outcomes in pre-existing liver and GI diseases. Key Findings Emerging variants of concern (VOC) have shown increased transmissibility and virulence with severe COVID-19 presentation and mortality. There is a drastic swift of variants from the first wave to the next wave of infections with predominated major VOC including alpha (B.1.1.7, UK), beta (B.1.351, South Africa), gamma (B.1.1.28.1, Brazil), and delta (B1.1.617, India) variants. The mutations in the spike protein of VOC are implicated for increased receptor binding (N501Y, P681R) and immune escape (L452R, E484K/Q, T478K/R) to host response. Pre-existing liver and GI diseases not only have altered tissue expression and distribution of viral entry ACE2 receptor but also host protease TMPRSS2, which is required for both spike protein binding and cleavage to initiate infection. Altered immune status due to pre-existing conditions results in delayed virus clearance or prolonged viremia. Even though GI and hepatic manifestations of SARS-CoV2 are less severe, the detection of virus in patient’s stool indicates GI tropism, replication, and shedding from the GI tract. COVID-19-induced liver injury, acute hepatic decompensation, and incidences of acute-on-chronic liver failure may change the disease outcomes. Conclusions The changes in the spike protein of emerging variants, immunomodulation by viral proteins, and altered expression of host viral entry receptor in pre-existing diseases are the key determinants of host response to SARS-CoV2 and its disease outcome.
Collapse
|
60
|
Baloda V, Anand A, Yadav R, Mehra L, Rajeshwari M, Vishnubhatla S, Upadhyay AD, Dwivedi SN, Nayak B, Saraya A, Acharya SK, Datta Gupta S, Shalimar, Das P. Histologic Changes in Core-Needle Liver Biopsies From Patients With Acute-on-Chronic Liver Failure and Independent Histologic Predictors of 28-Day Mortality. Arch Pathol Lab Med 2021; 146:846-854. [PMID: 34705032 DOI: 10.5858/arpa.2021-0103-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— The histologic features in patients with acute-on-chronic liver failure (ACLF) are evolving and histologic indicators of patients' poor prognosis are not yet fully established. OBJECTIVE.— To evaluate the independent histologic predictors of 28-day mortality in ACLF patients on core-needle liver biopsies. DESIGN.— Core-needle biopsies from patients with a diagnosis of ACLF (n = 152) as per the European Association for the Study of the Liver criteria were included during 8 years. Liver biopsies from 98 patients with compensated chronic liver disease were included as disease controls for histologic comparison. Features of ongoing changes, such as hepatic necrosis, hepatic apoptosis, cholestasis, hepatocyte degeneration, bile ductular proliferation, Mallory Denk bodies, steatosis, and extent of liver fibrosis, were analyzed for predicting short-term mortality (28 days). A P value of <.05 was considered significant. RESULTS.— In our cohort of ACLF patients, the following etiologies for acute decompensation were identified: alcohol, 47 of 152 (30.9%); sepsis, 24 of 152 (15.7%); hepatotropic viruses, 20 of 152 (13.1%); drug-induced liver injury, 11 of 152 (7.2%); autoimmune flare, 9 of 152 (5.9%); mixed etiologies, 5 of 152 (3.2%); and cryptogenic, 36 of 152 (23.6%). On histologic examination, hepatic necrosis (P < .001), dense lobular inflammation (P = .03), cholestasis (P < .001), ductular reaction (P = .001), hepatocyte degeneration (P < .001), and absence of advanced fibrosis stages (P < .001) were identified significantly more in ACLF patients than in disease controls on univariate analysis. On multivariate Cox regression analysis, the absence of advanced Ishak histologic activity index fibrosis stages (P = .02) and the presence of dense lobular inflammation (P = .04) were associated with increased 28-day mortality in ACLF patients. After adjusting the clinical causes of acute decompensation, only dense lobular inflammation was found as an independent predictor of short-term mortality (P = .04) in ACLF patients. CONCLUSIONS.— Dense lobular necroinflammatory activity is a clinically independent histologic predictor of 28-day short-term mortality in patients with ACLF.
Collapse
|
61
|
Agarwal S, Sharma S, Kumar M, Venishetty S, Bhardwaj A, Kaushal K, Gopi S, Mohta S, Gunjan D, Saraya A, Sarin SK. Development of a machine learning model to predict bleed in esophageal varices in compensated advanced chronic liver disease: A proof of concept. J Gastroenterol Hepatol 2021; 36:2935-2942. [PMID: 34050561 DOI: 10.1111/jgh.15560] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/19/2021] [Accepted: 05/26/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Risk stratification beyond the endoscopic classification of esophageal varices (EVs) to predict first episode of variceal bleeding (VB) is currently limited in patients with compensated advanced chronic liver disease (cACLD). We aimed to assess if machine learning (ML) could be used for predicting future VB more accurately. METHODS In this retrospective analysis, data from patients of cACLD with EVs, laboratory parameters and liver stiffness measurement (LSM) were used to generate an extreme-gradient boosting (XGBoost) algorithm to predict the risk of VB. The performance characteristics of ML and endoscopic classification were compared in internal and external validation cohorts. Bleeding rates were estimated in subgroups identified upon risk stratification with combination of model and endoscopic classification. RESULTS Eight hundred twenty-eight patients of cACLD with EVs, predominantly related to non-alcoholic fatty liver disease (28.6%), alcohol (23.7%) and hepatitis B (23.1%) were included, with 455 (55%) having the high-risk varices. Over a median follow-up of 24 (12-43) months, 163 patients developed VB. The accuracy of machine learning (ML) based model to predict future VB was 98.7 (97.4-99.5)%, 93.7 (88.8-97.2)%, and 85.7 (82.1-90.5)% in derivation (n = 497), internal validation (n = 149), and external validation (n = 182) cohorts, respectively, which was better than endoscopic classification [58.9 (55.5-62.3)%] alone. Patients stratified high risk on both endoscopy and model had 1-year and 3-year bleeding rates of 31-43% and 64-85%, respectively, whereas those stratified as low risk on both had 1-year and 3-year bleeding rates of 0-1.6% and 0-3.4%, respectively. Endoscopic classification and LSM were the major determinants of model's performance. CONCLUSION Application of ML model improved the performance of endoscopic stratification to predict VB in patients with cACLD with EVs.
Collapse
|
62
|
Jagannath S, Agarwal A, Gunjan D, Mohindra S, Sharma V, Chowdhury SD, Sachdeva S, Saraswat VA, Kochhar R, Saraya A. Mandatory preprocedure testing for SARS-CoV-2 for all-comers may not be required for resuming endoscopic services amidst the ongoing COVID-19 pandemic. Gut 2021; 70:1805-1806. [PMID: 33158980 DOI: 10.1136/gutjnl-2020-323154] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 12/27/2022]
|
63
|
Anand A, Saraya A. Assessment of Sarcopenia in Chronic Liver Disease: Indian Perspective. Clin Liver Dis (Hoboken) 2021; 18:164-167. [PMID: 34691405 PMCID: PMC8518340 DOI: 10.1002/cld.1142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/12/2021] [Accepted: 05/18/2021] [Indexed: 02/04/2023] Open
|
64
|
Sharma S, Gunjan D, Saraya A. Letter to the Editor: Balloon-Occluded Retrograde Transvenous Obliteration for Prevention of Gastric Variceal Rebleeding: A Paradigm Shift? Hepatology 2021; 74:1721-1722. [PMID: 33745137 DOI: 10.1002/hep.31821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
|
65
|
Madhu D, Sharma S, Agarwal A, Saraya A. Special Considerations in the Management of Autoimmune Hepatitis in COVID-19 Hotspots: A Review. J Clin Transl Hepatol 2021; 9:568-575. [PMID: 34447687 PMCID: PMC8369025 DOI: 10.14218/jcth.2021.00001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/22/2021] [Accepted: 04/27/2021] [Indexed: 02/06/2023] Open
Abstract
The ongoing coronavirus disease-2019 (COVID-19) pandemic has necessitated special considerations in the management of diseases. The way presence of pre-existing diseases or treatment for it predisposes to, alters course of, and changes the management of COVID-19, is of relevance and is being extensively studied. Autoimmune hepatitis (AIH) is unique in that it is an autoimmune disease mandating treatment with immunosuppressive drugs, as well as a liver disease with potential for varying degrees of underlying fibrosis. The use of immunosuppressive drugs could alter the risk of acquiring COVID-19, the clinical course and severity of COVID-19 and the degree of underlying liver fibrosis could alter the clinical outcomes of patients with COVID-19. In this review, we try to summarize key areas relevant in understanding and improving the clinical care of patients with AIH in the current pandemic. Special considerations required in the management of patients with AIH in COVID-19 hotspots have been outlined based on the current evidence.
Collapse
|
66
|
|
67
|
Chauhan A, Madhu D, Sharma S, Saraya A. Fresh frozen plasma transfusion affects outcomes in acute variceal bleeding: Right conclusion? Liver Int 2021; 41:1976. [PMID: 34008259 DOI: 10.1111/liv.14965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 02/13/2023]
|
68
|
Sharma S, Chauhan A, Saraya A. Prediction of post TIPS hepatic encephalopathy: are we there yet? Hepatol Int 2021; 15:1027. [PMID: 34117618 DOI: 10.1007/s12072-021-10216-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 05/25/2021] [Indexed: 10/21/2022]
|
69
|
Anand A, Saraya A. A new diagnostic criterion for sarcopenia: The fallout of lack of consensus. Liver Int 2021; 41:1434. [PMID: 33788408 DOI: 10.1111/liv.14881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
|
70
|
Khetan K, Sahoo RK, Baloda V, Shalimar, Vishnubhatla S, Saraya A, Dash NR, Sharma A, DattaGupta S, Das P. Expression patterns and prognostic significances of RRM1 and ERCC1 in pancreatic carcinoma and cholangiocarcinoma. INDIAN J PATHOL MICR 2021; 64:S160-S165. [PMID: 34135160 DOI: 10.4103/ijpm.ijpm_537_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Aggressive pancreatobiliary tumors often require oxaliplatin-based therapies, instead of standard gemcitabine-based therapy and biomarker studies at diagnosis to decide the appropriate therapeutic regimen. The ribonucleotide Reductase catalytic subunit M1 (RRM1) and excision repair cross-complementing gene-1 (ERCC1) are related to DNA synthesis and repair and essential in this regard. However, apart from the therapeutic benefit, their prognostic implication is controversial. METHODS In this retrospective study, paraffin-embedded tissue from 51 cases of pancreatic cancer and 29 cases of cholangiocarcinoma were evaluated for RRM1 and ERCC1 expression by immunohistochemical technique along with 18 control pancreatic and biliary tissues. The semiquantitatively H score was calculated based on stain distribution and stain intensities. RESULTS Both RRM1 and ERCC1 expression were high in tumor epithelium than in controls (RRM1: the difference was statistically significant in cholangiocarcinoma (P = 0.008); ERCC1: the difference was statistically significant both in pancreatic and cholangiocarcinoma (P < 0.05)]. However, no correlation was noted between RRM1 and ERCC1-low and high tumors with histological markers of prognosis and overall survival in these patients. CONCLUSIONS The present study adds further evidence against the controversy that if RRM1 and ERCC1 expression in pancreatic and biliary carcinomas have any prognostic significance apart from their proven therapeutic benefits in these tumors.
Collapse
|
71
|
Anand A, Sharma S, Saraya A. Low skeletal muscle mass and significant fibrosis in non-alcoholic fatty liver disease: Cause or effect? Liver Int 2021; 41:1160. [PMID: 33249727 DOI: 10.1111/liv.14746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 02/13/2023]
|
72
|
Mohta S, Singh N, Gunjan D, Kumar A, Saraya A. Systematic review and meta-analysis: Is there any role for antioxidant therapy for pain in chronic pancreatitis. JGH OPEN 2021; 5:329-336. [PMID: 33732878 PMCID: PMC7936613 DOI: 10.1002/jgh3.12433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/29/2020] [Accepted: 10/04/2020] [Indexed: 12/19/2022]
Abstract
Chronic pancreatitis (CP) is an irreversible disease with increased oxidative stress. The therapeutic role of antioxidants for pain reduction in CP is debatable. A systematic review of articles in PubMed and Embase until February 2020 was performed. Only randomized controlled trials conducted on humans to evaluate the therapeutic effects of antioxidants for pain in CP were included. Studies of other design, nonhuman studies, and those that did not objectively assess pain were excluded. Twelve articles and four articles were eligible for qualitative and quantitative analysis, respectively. The four included studies had a total of 352 participants. Pain reduction as measured by a visual analog scale was not significantly different in the antioxidant group compared to placebo (standardized mean difference = -0.14 [95% confidence interval [CI] = -0.44 to 0.17]; P = 0.38). Number of pain-free participants was also similar (odds ratio [OR] = 1.59 [0.97-2.59]; P = 0.06). There was no difference in outcome when comparing different etiologies of CP or age group. The reduction in the number of analgesics used did not differ between both groups. Antioxidants were not associated with increased adverse events (OR = 2.59 [CI = 0.77-8.69]; P = 0.12). A qualitative analysis on the effect on quality of life did not suggest any significant improvement with antioxidants. There was no significant pain reduction or change in quality of life in CP patients with use of antioxidants. This makes their routine use in the management of CP questionable. However, further studies may identify a subgroup where they are more useful.
Collapse
|
73
|
Sharma S, Anand A, Saraya A. Underestimation of portal pressures by wedge hepatic venous pressures in patients with non-alcoholic steatohepatitis related cirrhosis- Possibilities and implications. J Hepatol 2021; 74:756-757. [PMID: 33358254 DOI: 10.1016/j.jhep.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/04/2022]
|
74
|
Sharma S, Saraya A, Das P, Gunjan D. Case of cholestatic jaundice associated with papillary carcinoma of thyroid: a multidisciplinary challenge. BMJ Case Rep 2021; 14:14/2/e236372. [PMID: 33547117 PMCID: PMC7871217 DOI: 10.1136/bcr-2020-236372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The report describes a patient with cholestatic jaundice who had incidentally detected parathyroid hormone-independent hypercalcaemia. The differential diagnosis for this presentation includes systemic granulomatous and infiltrative disorders, drug-induced liver injury and malignancy. As the initial investigations were non-contributory towards the aetiology, she was given steroids and later plasma exchange for symptomatic treatment. The differentials were revised again in view of no clinical and biochemical response. A repeat fine-needle aspiration cytology of the thyroid nodule (seen on positron emission tomography/CT) revealed papillary carcinoma of the thyroid. The patient underwent total thyroidectomy. There was a complete normalisation of liver function tests and serum calcium, and resolution of pruritus 3 months post surgery. She was retrospectively diagnosed as a case of papillary carcinoma of the thyroid with paraneoplastic manifestations-hypercalcaemia and cholestatic jaundice-which got resolved with treatment of the primary tumour.
Collapse
|
75
|
Nadda N, Paul SB, Yadav DP, Kumar S, Sreenivas V, Saraya A, Gamanagatti S, Acharya SK, Shalimar, Nayak B. Prognostic and Therapeutic Potentials of OncomiRs Modulating mTOR Pathways in Virus-Associated Hepatocellular Carcinoma. Front Oncol 2021; 10:604540. [PMID: 33614488 PMCID: PMC7890014 DOI: 10.3389/fonc.2020.604540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/16/2020] [Indexed: 01/07/2023] Open
Abstract
Background Dysregulated oncomiRs are attributed to hepatocellular carcinoma (HCC) through targeting mTOR signaling pathway responsible for cell growth and proliferation. The potential of these oncomiRs as biomarker for tumor response or as target for therapy needs to be evaluated. AIM Tumor response assessment by OncomiR changes following locoregional therapy (LRT) and targeting of these oncomiRs modulating pathway Methods All consecutive viral-HCC patients of BCLC stage-A/B undergoing LRT were included. OncomiRs (miR-21, -221, and -16) change in circulation and AFP-ratio at 1-month post-LRT to baseline was estimated to differentiate various categories of response as per mRECIST criteria. OncomiR modulating mTOR pathway was studied by generating miR-21 and miR-221 overexpressing Huh7 stable cell lines. Results Post-LRT tumor response was assessed in 90 viral-HCC patients (CR, 40%; PR, 31%, and PD, 29%). Significant increase of miRNA-21 and -221 expression was observed in PD (p = 0.040, 0.047) and PR patients (miR-21, p = 0.045). Fold changes of miR-21 can differentiate response in group (CR from PR+PD) at AUROC 0.718 (95% CI, 0.572–0.799) and CR from PD at AUROC 0.734 (95% CI, 0.595–0.873). Overexpression of miR-21 in hepatoma cell line had shown increased phosphorylation p70S6K, the downstream regulator of cell proliferation in mTOR pathway. Upregulation of AKT, mTOR, and RPS6KB1 genes were found significant (P < 0.005) and anti-miR-21 specifically reduced mTOR gene (P = 0.02) expression. Conclusions The miR-21 fold change correlates well with imaging in predicting tumor response. Overexpression of miR-21 has a role in HCC through mTOR pathway activation and can be targeted.
Collapse
|