Decreasing interleukin-6 levels after TIPS predict outcomes in decompensated cirrhosis

Background & Aims

Transjugular intrahepatic portosystemic shunt (TIPS) effectively treats complications of cirrhosis. Systemic inflammation (SI) is linked to acute-on-chronic liver failure (ACLF) and liver-related death. We aimed to assess the trajectory and clinical impact of SI parameters after TIPS implantation.

Methods

Consecutive patients undergoing elective implantation of covered TIPS for recurrent/refractory ascites or portal-hypertensive bleeding at the Medical University Vienna (NCT03409263; n = 58) and at the Hannover Medical School (NCT04801290, n = 51) were included. IL-6 was assessed at baseline (BL), 3 months (M3) and up to 6 (M6; Hannover cohort) or 9 months (M9; Vienna cohort) of follow-up; C-reactive protein (CRP) and lipopolysaccharide-binding protein (LBP) were assessed in the Vienna cohort only.

Results

In 109 patients (66.1% male, median age 57 years) receiving TIPS mainly (72.4%) by indication ascites the median BL IL-6 levels were 10.5 pg/ml; and 41.3% (n = 45/109) patients exhibiting IL-6 ≥14 pg/ml. From BL to M3, IL-6 decreased in 63.8% (n = 37/58; Vienna cohort) and in 68.6% (n = 35/51; Hannover cohort) of patients, respectively. Similar rates of decreases were observed also for CRP (in 62.1%) and for LBP (in 77.4%). A considerable IL-6 reduction (≥50% of baseline) was noted in 41 (37.6%) patients during follow-up. Competing risk regression in the combined cohort adjusted for age, albumin, and model for end-stage liver disease revealed that IL-6 decrease at M3 was an independently protective factor for the development of ACLF (adjusted subdistribution hazard ratio [asHR]: 0.26; 95% CI: 0.09-0.77; p = 0.016) and liver-related death (asHR: 0.26; 95% CI: 0.07-0.95; p = 0.042).

Conclusions

TIPS leads to a sustained reduction of SI and bacterial translocation in patients with decompensated cirrhosis. Decreasing IL-6 levels three months after TIPS implantation indicate a lower risk of ACLF and liver-related death in patients with cirrhosis.

Impact and implications

Systemic inflammation is a major driver of disease progression in patients with decompensated advanced chronic liver disease (dACLD). This study demonstrates that systemic inflammation (i.e. interleukin-6 [IL-6]) effectively and sustainedly decreases after transjugular intrahepatic portosystemic shunt (TIPS) implantation. A decrease of IL-6 3 months after TIPS implantation is a protective factor for acute-on-chronic liver failure and liver-related death. Thus, our results suggest that TIPS reduces systemic inflammation in a clinically meaningful way.

Pancreatic Stone Protein in patients with liver failure: A prospective pilot cohort study

BACKGROUND

Pancreatic Stone Protein (PSP) seems to have higher accuracy for sepsis detection compared to other biomarkers. As PSP has never been studied in patients with liver failure (LF), our purpose was to assess its accuracy for diagnosis of infection and prognosis in this population.

METHODS

We conducted a prospective pilot cohort study on patients with LF consecutively admitted to the Intensive Care Unit of a liver transplant center in 2021-2023. Ongoing overt infection was an exclusion criterion. Daily measurements of biomarkers were performed until discharge, death, or for 21 days. Analysis was performed by adjusting the baseline for the first infection episode (median on D3), which was the reference for those non-infected.

RESULTS

Sixteen patients were included, 7 with acute and 9 with acute-on-chronic LF. Median age was 54 (interquartile range 42-64) years, half were female, with admission SOFA score of 10 (IQR 8-12). Hospital mortality was 43.8% (n = 7). An infection was observed in 8 patients, who presented non-significantly higher levels of PSP than non-infected ones during follow-up. Levels were higher in non-survivors than survivors (p < 0.05 from D4 on and since the day of infection considering only infected patients). Similarly, patients under renal replacement therapy had higher PSP levels than others (p < 0.05, D2 to D7 after admission).

CONCLUSION

This pilot study provides early insights into PSP kinetics, suggesting a potential role for prognosis in patients with LF. PSP rises in both ALF and ACLF to levels sustainably higher than those expected for healthy adults. Further research is needed to reassess its diagnostic accuracy for infection and redefine cut-offs in this population.

Clinical trials and young adults with inflammatory bowel disease

Young adults (approximately 18-35 years) with inflammatory bowel disease (IBD) represent a distinct demographic with unique developmental and physiological characteristics, yet they are underrepresented in clinical trials. This commentary synthesizes insights from a roundtable discussion facilitated by the Crohn's and Colitis Young Adults Network (CCYAN) between young adult patients with IBD and medical professionals, including physicians, nurses, psychologists, and trainees/medical students. Themes include defining young adults as a distinct demographic in research, improving outcomes for young adults with IBD through age-specific data disaggregation, barriers for participation and post-trial responsibilities, as well as regulatory and legislative policy opportunities to enhance young adult representation in clinical trials.

Liver transplantation improves prognosis across all grades of acute-on-chronic liver failure patients: A systematic review and meta-analysis

BACKGROUND

Liver transplantation (LT) is recognized as an effective approach that offers survival benefits for patients with acute-on-chronic liver failure (ACLF). However, controversies remain regarding the LT selection criteria, and meta-analyses reporting overall survival outcomes across different ACLF severity grades are lacking.

AIM

To depict a comprehensive postoperative picture of patients with ACLF of varying severity and contribute to updating LT selection.

METHODS

Systematic searches in Web of Science, EMBASE, PubMed, and Cochrane databases were performed, from inception to December 26, 2023, for studies exploring post-transplant outcomes among ACLF patients, stratified by severity grades as identified by the European Association for the Study of the Liver-Chronic Liver Failure criteria. The primary outcome of interest was the survival rate within one year, with post-transplant complications as secondary outcomes. Additionally, the subgroup analysis examined region-specific one-year survival rates.

RESULTS

A total of 17 studies involving 28025 participants were included. Patients with ACLF-1 and ACLF-2 have favorable survival within one year, with survival rates reaching 87% [95% confidence interval (CI): 84%-91%] and 86% (95%CI: 81%-91%), respectively. Despite the relatively lower survival (73%, 95%CI: 66%-80%) and higher incidence of infection (48%, 95%CI: 29%-67%) observed in ACLF-3 patients, their survival exceeds that of those who do not undergo LT. Moreover, post-transplant survival was highest in North America across all ACLF grades.

CONCLUSION

LT can provide survival advantages for ACLF patients. To optimize the utilization of scarce donor organs and improve prognosis, comprehensive preoperative health evaluations are essential, especially for ACLF-3 patients.

Hepatic cirrhosis and decompensation: Key indicators for predicting mortality risk

Liver cirrhosis represents the final stage of liver diseases. The transition from the compensated to the decompensated form is a critical phase, as it is associated with a negative impact on patient prognosis. Therefore, having a tool to identify patients at higher risk of complications and mortality is an ideal goal. Currently, the validated scores for this purpose are the model for end-stage liver disease score and the Child-Pugh score. However, these scores have limitations, as they do not account for other factors associated with liver cirrhosis that are equally relevant from a prognostic perspective. Among these, alterations in body composition, particularly sarcopenia, increase the risk of mortality and should therefore be considered in the comprehensive assessment of patients with liver cirrhosis.

Exploring the next frontier in diagnosing spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis (SBP) is a common complication of liver failure. It is an acute bacterial infection of the ascitic fluid in patients with liver cirrhosis. SBP presents a significant challenge for hepatologists owing to its associated complications. While diagnostic paracentesis with polymorphonuclear count is highly accurate, it can be troublesome for some patients as it is an invasive procedure with associated risks. Several studies have proposed new diagnostic methods to improve current practices, many of which remain invasive. Although some serum tests show promise in the diagnosis of SBP, the results are still preliminary. Recent advancements in artificial intelligence and machine learning have introduced predictive models and scoring systems for diagnosis. However, these models still lack sufficient sensitivity, specificity, and the ability to effectively assess treatment response.

Relationship between coagulopathy score and survival in critically ill patients with liver cirrhosis and sepsis: a retrospective study

BACKGROUND

This research focused on exploring the association between coagulopathy scores and the survival outcomes, both short-term and long-term, in individuals diagnosed with liver cirrhosis complicated by sepsis.

METHODS

This study retrospectively analyzed data from individuals with liver cirrhosis and sepsis who were admitted to the intensive care unit (ICU) at Beth Israel Deaconess Medical Center between 2008 and 2022. The main outcome of interest was all-cause mortality within 28 days post-admission, while the secondary outcome assessed mortality within 90 days. We used the Kaplan-Meier analysis to compare the mortality risk among the different groups. To evaluate the relationship between coagulopathy score and mortality risk in patients with liver cirrhosis and sepsis, a multivariate Cox proportional hazards regression analysis was performed. The predictive performance of the coagulopathy score for short- and long-term all-cause mortality was assessed using receiver operating characteristic (ROC) curve analysis, which included evaluation of its sensitivity, specificity, and area under the curve. Subgroup analyses were performed to evaluate the relationship between coagulopathy score and survival across different groups.

RESULTS

The study included a total of 2,278 patients. Kaplan-Meier survival analysis demonstrated that individuals with elevated coagulopathy scores exhibited markedly higher rates of ICU mortality, in-hospital mortality, as well as 28-day and 90-day mortality, with all log-rank tests yielding P-values of less than 0.001. The results of the multivariate Cox regression analysis showed that an elevated coagulopathy score was independently linked to higher 28-day and 90-day all-cause mortality, both before and after controlling for potential confounders. ROC curve analysis showed that although the coagulopathy score was slightly less predictive of prognosis than the Model for End-stage Liver Disease score, it significantly outperformed the Sequential Organ Failure Assessment score and the Sepsis-induced Coagulopathy score. Subgroup analysis revealed no significant interaction between the coagulopathy score and survival across the different subgroups.

CONCLUSIONS

Higher coagulopathy scores in critically ill patients with liver cirrhosis and sepsis were independently associated with poor prognosis. Due to its simplicity and potential predictive value, the coagulopathy score can serve as an effective complement to existing clinical tools for managing critically ill patients with liver cirrhosis and sepsis.

Evaluation of the incidence and risk factors for the development of acute-on-chronic liver failure in outpatients with cirrhosis

OBJECTIVE

Acute decompensation of cirrhosis is associated with high mortality, and acute-on-chronic liver failure is at the extreme of its spectrum of severity. This study aimed to evaluate the incidence and risk factors for the development of acute-on-chronic liver failure in outpatients with cirrhosis.

METHODS

This is a retrospective cohort study of consecutive patients with cirrhosis attending an outpatient clinic at a referral hospital in southern Brazil. Clinical, laboratory, and imaging data at the first outpatient visit were collected. The primary outcome of interest was the development of acute-on-chronic liver failure.

RESULTS

Three hundred patients with cirrhosis were included in the study. During a median follow-up of 56.5 months, 41 developed acute-on-chronic liver failure. The incidence of acute-on-chronic liver failure was 3.9% at 12 months, 7.0% at 24 months, 8.8% at 36 months, and 12.7% at 60 months. The cumulative incidence of acute-on-chronic liver failure was 23.0% at 84 months. Multivariate Cox regression analysis showed that baseline hemoglobin (hazard ratio of 0.78, 95% confidence interval: 0.67-0.90) and Child-Pugh score (hazard ratio of 1.70, 95% confidence interval: 1.44-2.00) were independently associated with the development of acute-on-chronic liver failure.

CONCLUSIONS

Nearly one-fourth of outpatients with cirrhosis developed acute-on-chronic liver failure during follow-up, which was independently associated with low hemoglobin levels and poor liver function according to the Child-Pugh score at baseline.

Acute-on-Chronic Liver Failure: Steps Towards Consensus

Acute-on-chronic liver failure (ACLF) is a clinical syndrome characterized by organ failure and high short-term mortality. Since its first definition in 2013, many international organizations have defined this syndrome and, till now, there has been no agreement regarding definitions and diagnostic criteria. Although the precise mechanism of ACLF is unknown, precipitant factors and the systemic inflammation response play a major role. Specific management of this high-mortality syndrome is still under development, but a general consensus in the diagnosis and management of ACLF is needed.

Liver Cirrhosis: ancient disease, new challenge

Liver cirrhosis is a common cause of morbidity and mortality worldwide. Excessive alcohol consumption and metabolic associated steatotic liver disease are the most common etiological factors of cirrhosis in our region. Cirrhosis occurs in two well-differentiated phases, compensated and decompensated, depending on the absence or presence of complications, respectively. Current therapeutic strategies are aimed at controlling these complications (such as ascites, hepatic encephalopathy, bacterial infections, or digestive hemorrhage, among others) or performing a liver transplant if there are no contraindications. However, it is important to eliminate the etiological factor responsible for the disease, as this can lead to the disappearance of complications, a state known as recompensation. This article proposes an updated review of the epidemiology of cirrhosis and its main causes, and offers an overview of the clinical features and treatment of the disease's complications, in addition to outlining future lines of research in this field.

Early prediction of invasive fungal infection risk in acute-on-chronic liver failure: a prediction model based on admission indicators

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a severe clinical syndrome, and the incidence of invasive fungal infection (IFI) among hospitalized patients with ACLF is steadily increasing. The aim of this study is to develop a diagnostic nomogram to assist in the identification of IFI in these patients.

METHODS

A retrospective study included 705 patients from January 1, 2019, to October 31, 2023, randomly divided into training (n = 493) and validation (n = 212) cohorts. The diagnosis of IFI includes proven diagnosis and probable diagnosis. Kaplan analysis was performed to analyze the survival prognosis of ACLF patients with and without IFI. A nomogram was developed based on a logistic regression model derived through least absolute shrinkage and selection operator (LASSO) regression. The discrimination, accuracy, and clinical utility of the model were assessed using receiver operating characteristic curves, Hosmer-Lemeshow tests, calibration plots, and decision curve analysis.

RESULTS

Kaplan-Meier survival analysis confirmed that the median survival time of ACLF patients with IFI was significantly lower (by 68 days) than that of ACLF patients without IFI, and there were significant differences in the 90-day, 180-day, and 360-day survival rates between the two groups (P < 0.05). Based on LASSO regression, the following factors were identified as significant risk factors for predicting IFI: aminotransferase levels, prothrombin activity, hemoglobin, neutrophil-to-lymphocyte ratio, and serum total bilirubin. A nomogram was constructed incorporating these variables. The nomogram demonstrated good discriminative ability, with an area under the receiver operating characteristic curve (AUC) of 0.78 (95% confidence interval [CI]: 0.72-0.84) in the training cohort and 0.79 (95% CI: 0.70-0.87) in the validation cohort. Decision curve analysis further validated the clinical applicability of the nomogram.

CONCLUSION

ACLF patients with IFI have lower survival time than those without IFI. A nomogram was developed and validated to assist clinicians in the early prediction of IFI in hospitalized patients with ACLF.

CLINICAL TRIAL NUMBER

Not applicable.

Role of Rifaximin in the Prognosis of Critically Ill Patients with Liver Cirrhosis

Background/Objectives: Critically ill patients with liver cirrhosis impose a substantial health burden on the world. Rifaximin is a potential treatment option for such patients. Methods: We extracted critically ill patients with liver cirrhosis from the Medical Information Mart for Intensive Care (MIMIC) IV database. Based on study outcomes, the current study included prevention and treatment cohorts. A 1:1 propensity score matching (PSM) analysis was performed to match the characteristics of patients. The risk of ICU admission and intensive care unit (ICU), in-hospital, 90-day, and 180-day death were explored. Cox regression analyses were conducted, and hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. Kaplan-Meier curves were further drawn to demonstrate the cumulative 90-day and 180-day survival rate. Results: Overall, 5381 critically ill patients with liver cirrhosis were included. In the prevention cohort, rifaximin could decrease the risk of ICU admission (HR = 0.427, 95%CI: 0.338-0.539, p < 0.001). In the treatment cohort, rifaximin could decrease the risk of ICU (HR = 0.530, 95%CI: 0.311-0.902, p = 0.019) and in-hospital death (HR = 0.119, 95%CI: 0.033-0.429, p = 0.001) in critically ill patients with liver cirrhosis. However, rifaximin could not decrease the risk of 90-day (HR = 0.905, 95%CI: 0.658-1.245, p = 0.541) and 180-day (HR = 1.043, 95%CI: 0.804-1.353, p = 0.751) death in critically ill patients with liver cirrhosis. Kaplan-Meier curve analyses also showed that rifaximin could not significantly decrease the 90-day (p = 0.570) and 180-day (p = 0.800) cumulative mortality. Conclusions: This study suggests that rifaximin can significantly decrease the risk of ICU admission and improve short-term survival but does not impact long-term survival in critically ill patients with liver cirrhosis.

Global, regional, and national burden of liver cancer in adolescents and young adults from 1990 to 2021: an analysis of the global burden of disease study 2021 and forecast to 2040

Background

The global burden of liver cancer among adolescents and young adults (AYAs) has often been underestimated, despite significant shifts in its etiology. This study analyzes the disease burden of liver cancer in AYAs from 1990 to 2021 and forecasts trends up to 2040 using data from the Global Burden of Disease Study 2021. Our goal is to provide insights that can inform resource allocation and policy planning.

Methods

Incidence, mortality, and disability-adjusted life years (DALYs) data were extracted and estimated annual percentage changes calculated to assess trends. Correlation between age-standardized rates and sociodemographic index (SDI) was analyzed using Spearman correlation, and future trends were predicted using the Bayesian age-period-cohort model.

Findings

Globally, there were 24,348 new liver cancer cases and 19,270 deaths among AYAs in 2021, with decreases in age-standardized rates for incidence, mortality, and DALYs from 1990 to 2021. East Asia bears the highest burden, with males experiencing significantly higher rates than females. The burden increases with age, peaking at 35-39 years. Higher SDI is associated with lower incidence, mortality, and DALYs. While HBV remains the leading cause, NASH is the fastest-growing contributor to liver cancer incidence and mortality. Projections indicate a continued decline in liver cancer burden among AYAs, though female cases are expected to rise.

Interpretation

Despite a gradual decline in liver cancer burden among AYAs, NASH is emerging as a significant and rising cause of incidence and mortality. Regional and gender disparities persist, highlighting the need for tailored prevention and healthcare strategies to alleviate the liver cancer AYA's burden globally.

Multicenter analysis on the correlation between the anatomical characteristics of hepatic veins and hepatic venous wedge pressure

BACKGROUND

Wedged hepatic venous pressure (WHVP) is a crucial variable for accurately assessing the hepatic venous pressure gradient (HVPG) and is vital for the diagnosis and prognostic evaluation of patients with portal hypertension (PH).

AIM

To investigate the anatomical characteristics of balloon-occluded hepatic venous angiography in patients with PH and analyze the relationship between the WHVP and portal venous pressure (PVP).

METHODS

This retrospective study included 877 patients with PH who met the inclusion criteria from January 2020 to June 2024. Routine and innovative hepatic venous angiography was performed during transjugular intrahepatic portosystemic shunt procedures to measure hepatic venous and PVPs. All patients' angiographic images were collected for analysis. The associations between WHVP and PVP in each group were analyzed via linear regression analysis, and a predictive model was established.

RESULTS

The 877 patients had a mean age of 52.6 ± 13.0 years, with 582 males and 295 females. Patients were categorized into four groups on the basis of their anatomical structure. All groups showed strong correlations between WHVP and PVP. The regression coefficient between the WHVP and PVP in the hepatic right vein-portal venous angiography group was 0.884 (P < 0.05); in the hepatic right vein-accessory hepatic venous angiography group, it was 0.721 (P < 0.05); in the hepatic right vein-middle hepatic venous angiography group, it was 0.344 (P < 0.05); and in the hepatic right vein-nonangiography group, it was 0.293 (P < 0.05).

CONCLUSION

The presence and anatomical classification of hepatic venous collaterals are key factors influencing the relationship between WHVP with and PVP. Based on the different anatomical classifications of hepatic veins, WHVP can be used to estimate PVP, improving the accuracy of PVP prediction.

Clinical and pathophysiological characteristics of non-acute decompensation of cirrhosis

BACKGROUND & AIMS

The heterogenous presentation patterns in decompensated cirrhosis confer variable outcomes. While acute decompensation (AD) is well-characterized, the presentation patterns and outcomes of non-acute decompensation (NAD) remain unclear. The aim of this study was to characterize clinical and pathophysiological features of NAD and identify predictors of progression in NAD.

METHODS

In this prospective study, patients across the cirrhosis spectrum were enrolled from two centers in India between 2020-2023: compensated cirrhosis (CC; n = 29), NAD (n = 311), AD (n = 201), and healthy controls (n = 10). Clinical and laboratory parameters, cytokine levels (IL-6, TNF, IL-10, MCP-1) and cell death markers (M30, M65, Gasdermin-D, RIPK3, MLKL) were assessed at baseline. Twelve-month overall survival was assessed in all patients. The predictors of progression to AD and mortality were evaluated in patients with NAD.

RESULTS

Survival was lower in patients with NAD (81.7%) than in those with CC (100%), but higher than in those with AD (31.2%) (p <0.001). Despite no significant systemic inflammation, patients with NAD exhibited elevated levels of cell death markers, particularly Gasdermin-D and RIPK3, compared to healthy controls and patients with CC. Both inflammatory and cell death markers were most pronounced in AD. Over 12 months, the cumulative incidence of progression to AD among those with NAD was 55.1%, significantly reducing their survival (68.2% vs. 95.3%, p <0.001). Predictors of such progression to AD included severe ascites, lower IGF-1, albumin, BMI, and higher bilirubin, Gasdermin-D, and RIPK3 levels, as well as higher CTP and MELD scores.

CONCLUSIONS

NAD represents a clinically, prognostically and pathophysiologically distinct entity in cirrhosis. Patients with NAD express elevated cell death markers and remain at risk of progression to AD and mortality. Identifying such high-risk patients should prompt interventions to prevent progression. Modulation of cell death is a potentially disease-modifying target in cirrhosis.

IMPACT AND IMPLICATIONS

This study highlights non-acute decompensation as a clinically, prognostically and pathophysiologically distinct subset of cirrhosis, underscoring the importance of understanding its progression dynamics. Identifying key predictors of acute decompensation, including ascites severity, low IGF-1 levels, and elevated cell death markers, such as Gasdermin-D and RIPK3, potentially uncovers new therapeutic avenues. These findings are crucial for helping hepatologists and researchers to risk stratify patients and optimize transplant candidacy. Interventions targeting necroptosis and pyroptosis pathways may improve outcomes, providing a significant shift towards precision medicine in cirrhosis care.

Hepatic encephalopathy: risk identification and prophylaxis approaches

Hepatic encephalopathy (HE) is a debilitating neurological condition associated with cirrhosis, characterized by cognitive impairment ranging from minimal to overt symptoms. It significantly impacts patients' quality of life and substantially burdens healthcare systems. This review examines current prophylactic strategies for HE, focusing on established treatments, emerging therapies, and predictive tools to identify high-risk patients. Traditional treatments such as lactulose and rifaximin remain the cornerstone of HE management, effectively reducing ammonia levels and preventing recurrence. However, novel approaches like L-ornithine L-aspartate, albumin infusions, and antioxidants like resveratrol show promise in further improving outcomes by addressing underlying pathophysiological mechanisms, including systemic inflammation and gut dysbiosis. Developing predictive models, such as the AMMON-OHE score and clinical-genetic risk assessments, enhances the ability to tailor preventive interventions to individual patient profiles. These advancements are crucial in mitigating the incidence of overt HE, reducing hospital admissions, and improving patient survival rates. The future of HE management lies in personalized medicine, targeting specific inflammatory and metabolic pathways, with the potential integration of genetic manipulation. Continued research is essential to refine these strategies, ultimately aiming to improve the prognosis and quality of life for cirrhotic patients at risk of HE.

COVID-19 lockdown-related treatment modifications did not impact the outcome of digestive cancers: the Clin-COVIDICA prospective study

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) pandemic modified the organization of cancer care pathways worldwide. Few prospective long-term data assessing these therapeutic modifications are available.

METHODS

Clin-COVIDICA was a prospective cohort aiming at determining the clinical impact of COVID-19-related therapeutic modifications in patients with digestive cancer in our center. All consecutive patients undergoing an oncologic treatment for a digestive cancer from March 1 to April 30, 2020, were enrolled in the cohort and followed-up for 24 months. The primary endpoint was progression-free survival (PFS). Secondary endpoints included COVID-19 rate, adverse events (AE) and overall survival (OS). Survival curves were estimated using the Kaplan-Meier method and compared by the log-rank test.

RESULTS

Of the 401 patients included, 39.6% were female, mean age was 68 years old and most frequent tumor were colorectal (50.0%) and pancreatic (17.9%) cancers. All in all, 55 patients (13.7%) have undergone therapeutic modifications. The most frequent were a switch to an oral drug (capecitabine, 30.9%), treatment holidays (29.1%) and treatment cancellation (18.2%). Considering patients with palliative treatment (n = 339), there was a non-significant trend for longer OS (52.0 months versus 36.4 months, p = 0.07) and a significant longer PFS (15.4 months versus 6.2 months, p = 0.009) in patients with therapeutic modifications. There were more all grades AEs in patients without therapeutic modifications (84.4% vs. 65.5%, p = < 0.001), but more severe AEs (grade 3-5) among patients with therapeutic modifications (18.2% versus 8.7%, p = 0.048), especially for patients with a switch to an oral drug, which resulted in 8 severe adverse events and one death. Six patients (1.5%) had a COVID-19, with one COVID-19-related death and one definitive cancellation of a curative surgery due to the consequences of COVID-19.

DISCUSSION

We observed no negative survival impact of therapeutic modifications due to the COVID-19 pandemic in digestive cancer management. This may be due to the selection of patients with less aggressive disease. More severe AEs were observed upon therapeutic modifications, especially switching to oral capecitabine.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT04389684; date of registration (15/05/2020).

Role of Intestinal Barrier Disruption to Acute-on-Chronic Liver Failure

Acute-on-chronic liver failure (ACLF) is a severe condition in patients with decompensated liver cirrhosis, marked by high short-term mortality. Recent experimental and clinical evidence has linked intestinal dysfunction to both the initiation of ACLF as well as disease outcome. This review discusses the significant role of the gut-liver axis in ACLF pathogenesis, highlighting recent advances. Gut mucosal barrier disruption, gut dysbiosis, and bacterial translocation emerge as key factors contributing to systemic inflammation in ACLF. Different approaches of therapeutically targeting the gut-liver axis via farnesoid X receptor agonists, nonselective beta receptor blockers, antibiotics, and probiotics are discussed as potential strategies mitigating ACLF progression. The importance of understanding the distinct pathophysiology of ACLF compared with other stages of liver cirrhosis is highlighted. In conclusion, research findings suggest that disruption of intestinal integrity may be an integral component of ACLF pathogenesis, paving the way for novel diagnostic and therapeutic approaches to manage this syndrome more effectively.

Potential therapies for acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is a syndrome that develops in approximately 30% of patients hospitalised with cirrhosis and is characterised by an acute decompensation of liver function associated with extra-hepatic organ failures and a high short-term mortality. At present, no specific therapies are available for ACLF, and current management is limited to treatment of the precipitating event and organ support. Given the high prevalence and high mortality of this severe liver disease, there is an urgent need for targeted treatments. There is increasing evidence of the important role played by systemic inflammation and immune dysfunction in the pathophysiology of ACLF and a better understanding of these immune processes is resulting in new therapeutic targets. The aim of this review is to present an overview of ongoing studies of potentially promising therapies and how they could be utilised in the management of ACLF.

Rational design of peptides to overcome drug resistance by metabolic regulation

Chemotherapy is widely used clinically, however, its efficacy is often compromised by the development of drug resistance, which arises from prolonged administration of drugs or other stimuli. One of the driven causes of drug resistance in tumors or bacterial infections is metabolic reprogramming, which alters mitochondrial metabolism, disrupts metabolic pathways and causes ion imbalance. Bioactive peptide materials, due to their biocompatibility, diverse bioactivities, customizable sequences, and ease of modification, have shown promise in overcoming drug resistance. This review provides an in-depth analysis of metabolic reprogramming and associated microenvironmental changes that contribute to drug resistance in common tumors and bacterial infections, suggesting potential therapeutic targets. Additionally, we explore peptide-based materials for regulating metabolism and their potential synergic effect with other therapies, highlighting the mechanisms by which these peptides reverse drug resistance. Finally, we discuss future perspectives and the clinical challenges in peptide-based treatments, aiming to offer insights for overcoming drug-resistant diseases.

Acute and non-acute decompensation of liver cirrhosis (47/130)

In the traditional view, the occurrence of cirrhosis-related complications, such as hepatic encephalopathy, formation of ascites or variceal haemorrhage, marks the transition to the decompensated stage of cirrhosis. Although the dichotomous stratification into a compensated and decompensated state reflects a prognostic water-shed moment and remains to hold its prognostic validity, it represents an oversimplification of clinical realities. A broadening understanding of pathophysiological mechanisms underpinning decompensation have led to the identification of distinct prognostic subgroups, associated with different clinical courses following decompensation. Data provided by the PREDICT study uncovered three distinct sub-phenotypes of acute decompensation (AD). Moreover, acute-on-chronic liver failure (ACLF) has been established as a distinct clinical entity for many years, which is associated with a high short-term mortality. Recently, non-acute decompensation (NAD) has been proposed as a distinct pathway of decompensation, complementing current concepts of the spectrum of decompensation. In contrast to AD, NAD is characterized by a slow and progressive development of complications, which are often presented at first decompensation and/or in patients in an earlier stage of chronic liver disease. Successful treatment of AD or NAD may lead to a clinical stabilization or even the concept of recompensation. This review aims to provide an overview on current concepts of decompensation and to delineate recent advances in our clinical and pathophysiological understanding.

Organ dysfunction and failure in liver disease

Acute-on-chronic liver failure (ACLF) is a complex syndrome defined by the existence of different organ failures (OFs) in patients with chronic liver disease, mainly cirrhosis. Several definitions have been proposed to define the syndrome, varying in the grade of the subjacent liver disease, the type of precipitants and the organs considered in the definition. Liver, coagulation, brain, kidney, circulatory and pulmonary are the six types of OFs proposed in the different classifications, with different prevalence worldwide. Irrespective of the definition used, patients who develop ACLF present a hyperactive immune system, profound haemodynamic disturbances and several metabolic alterations that finally lead to organ dysfunction. These disturbances are triggered by different factors such as bacterial infections, alcoholic hepatitis, gastrointestinal bleeding or hepatitis B virus flare, among others. Because patients with ACLF present high short-term mortality, a prompt recognition is needed to start treatment of the trigger event and specific organ support. Liver transplantation is also feasible in carefully selected patients and should be evaluated.

Mechanisms and treatment approaches for ACLF

Acute-on-chronic liver failure (ACLF) is a life-threatening syndrome characterized by decompensation of cirrhosis, severe systemic inflammation and organ failures. ACLF is frequently triggered by intra- and/or extrahepatic insults, such as bacterial infections, alcohol-related hepatitis or flares of hepatic viruses. The imbalance between systemic inflammation and immune tolerance causes organ failures through the following mechanisms: (i) direct damage of immune cells/mediators; (ii) worsening of circulatory dysfunction resulting in organ hypoperfusion and (iii) metabolic alterations with prioritization of energetic substrates for inflammation and peripheral organ 'energetic crisis'. Currently, the management of ACLF includes the support of organ failures, the identification and treatment of precipitating factors and expedited assessment for liver transplantation (LT). Early LT should be considered in patients with ACLF grade 3, who are unlikely to recover with the available treatments and have a mortality rate > 70% at 28 days. However, the selection of transplant candidates and their prioritization on the LT waiting list need standardization. Future challenges in the ACLF field include a better understanding of pathophysiological mechanisms leading to inflammation and organ failures, the development of specific treatments for the disease and personalized treatment approaches. Herein, we reviewed the current knowledge and future perspectives on mechanisms and treatment of ACLF.

Comprehensive toolkit integrating lifestyle and clinical questionnaires with gut microbiota profiling via rectal swabs: application in intensive care cirrhotic patients

Introduction. The study of gut microbiota is now an essential dimension in many clinical studies. For instance, microbiota diversity investigation can help us to better manage cirrhotic patients by the identification of markers of severity and the identification of possible sources of pathogens.Hypothesis/Gap Statement. Conducting clinical research on gut microbiota for fragile patients in intensive care units, such as cirrhotic patients, poses significant challenges.Aim. In this study, we developed a comprehensive toolkit for investigating gut microbiota in fragile patients using rectal swabbing combined with straightforward lifestyle and clinical questionnaires.Methodology . We applied this prospective approach to 49 well-phenotyped cirrhotic patients as a function of their compensation status (compensated patients with outpatients' recruitment vs decompensated patients in intensive care units).Results . Our results, consistent with the literature, showed that liver function impairment is associated with lower microbiota diversity. Additionally, we monitored aerobic microbiota in decompensated cirrhotic patients, observing the invasion of extended spectrum beta-lactamase (ESBL)-producing Escherichia coli in the gut's aerobic microbiota prior to severe infection caused by these pathogens.Conclusion. We propose this pragmatic methodology for larger cohort studies, aiming to enhance the monitoring of immunocompromised patients by using microbiota analysis as a predictive tool for the severity of associated pathologies and the identification of agents responsible for severe infections.

Prognosis algorithms for acute decompensation of cirrhosis and ACLF

Accurate prediction of survival in patients with cirrhosis is crucial, as patients who are unlikely to survive in the short-term need to be oriented to liver transplantation and to novel therapeutic approaches. Patients with acute decompensation of cirrhosis without or with organ dysfunction/failure, the so-called acute-on-chronic liver failure (ACLF), have a particularly high short-term mortality. Recognizing the specificity of this clinical situation, dedicated classifications and scores have been developed over the last 15 years, including variables (e.g. organ failures and systemic inflammation) not part of the formerly available cirrhosis severity scores, namely Child-Pugh score or MELD. For patients with acute decompensation of cirrhosis, it led to the development of a dedicated score, the Clif-C-AD score, independently validated. For more severe patients, three different scoring systems have been proposed, by European, Asian and North American societies namely Clif-C-ACLF, AARC score and NASCELD-ACLF respectively. These scores have been validated, and are widely used across the world. The differences and similarities between these scores, as well as their validation and limitations are discussed here. Even if these scores and classifications have been a step forward in favouring homogeneity between studies, and in helping making decisions for individual patients, their predictive value for mortality can still be improved as their area under the ROC curve does not exceed .8. Novel scores including biomarkers reflecting the pathophysiology of acute decompensation of cirrhosis might help reach that goal.

Optimizing treatment outcomes in acute-on-chronic liver failure: The role of T2 candida panel in detecting invasive candidiasis

INTRODUCTION

Acute-on-Chronic Liver Failure(ACLF) is a syndrome characterized by organ dysfunction and high mortality in cirrhotic patients. ACLF has multiple triggers but those precipitated by fungal infection have higher mortality. Early detection and treatment of candidemia have shown mortality benefits in ACLF. The sensitivity of blood cultures ranged from 21 % - 71 %. Given the increase in mortality, it is vital to have a quick yet reliable diagnostic test for the detection of candida. This study examines the risk of developing ACLF and its impact on survival in hospitalized cirrhotic patients with invasive fungal infection via a positive T2 Candida Panel. We also examine the effects of earlier treatment on mortality in those with a positive T2 Candida Panel.

METHODS

We performed a retrospective study and included cirrhotic patients admitted from 2017 to 2021. Data collected includes baseline characteristics, labs, progression to ACLF, and mortality outcomes. The stages of ACLF were determined through the use of the CLIF-Consortium ACLF score.

RESULTS

Of the 489 patients sampled, 95 patients developed ACLF during the time of the T2 panel collection, of which 60 (63.2 %) (p ≤ 0.001) patients had a positive T2 Candida Panel. The data also demonstrates that patients who had earlier antifungal initiation had a decrease in mortality (6.15 ± 5.23 versus 13.53 ± 11.42)(p ≤ 001).

CONCLUSION

Our study shows that a positive T2 Panel leads to more frequent progression of ACLF and worsening survival outcomes. This study shows that earlier treatment of candidiasis via the T2 Panel leads to mortality benefits.

Definition, diagnosis and epidemiology of acute-on-chronic liver failure

This narrative review addresses the definition of acute-on-chronic liver failure, a condition associated with high short-term mortality in patients with chronic liver disease and/or cirrhosis. We provide two major points of view: the East and the West perspective. Both definitions vary regarding the underlying patient population and organ failure(s) definition. Nevertheless, all the definitions have their clinical utility: from the core concept of having the "liver" as a conditio sine qua non, the syndrome cannot exist (Asian Pacific Association for the Study of the Liver); a data-driven, robust definition (European Association for the Study of the Liver); a bedside tool that can quickly identify patients at high risk of dying (North American Consortium for the Study of End-stage Liver Disease [NACSELD]). In each section, we provide the overall definitions, the criteria of organ failure(s), and some epidemiological data illustrating how these apply in each area of the world.

Management of the acute on chronic liver failure in the intensive care unit

Acute on chronic liver failure (ACLF) reflects the development of organ failure(s) in a patient with cirrhosis and is associated with high short-term mortality. Given that ACLF has many different 'phenotypes', medical management needs to take into account the relationship between precipitating insult, organ systems involved and underlying physiology of chronic liver disease/cirrhosis. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (e.g. infection, severe alcoholic hepatitis and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo liver transplantation or recovery. Management of these patients is complex since they are prone to develop new organ failures and infectious or bleeding complications. ICU therapy parallels that applied in the general ICU population in some complications but differs in others. Given that liver transplantation in ACLF is an emerging and evolving field, multidisciplinary teams with expertise in critical care and transplant medicine best accomplish management of the critically ill ACLF patient. The focus of this review is to identify the common complications of ACLF and to describe the proper management in critically ill patients awaiting liver transplantation in our centres, including organ support, prognostic assessment and how to assess when recovery is unlikely.

Noninvasive assessment of hepatic decompensation

Noninvasive tests (NITs) are used in all aspects of liver disease management. Their most prominent break-through since the millennium has been in advancing early detection of liver fibrosis, but their use is not limited to this. In contrast to the symptom-driven assessment of decompensation in patients with cirrhosis, NITs provide not only opportunities for earlier diagnoses but also accurate prognostication, targeted treatment decisions, and a means of monitoring disease. NITs can inform disease management and decision-making based on validated cutoffs and standardized interpretations as a valuable supplement to clinical acumen. The Baveno VI and VII consensus meetings resulted in tangible improvements to pathways of care for patients with compensated and decompensated advanced chronic liver disease, including the combination of platelet count and transient elastography to diagnose clinically significant portal hypertension. Furthermore, circulating NITs will play increasingly important roles in assessing the response to interventions against ascites, variceal bleeding, HE, acute kidney injury, and infections. However, due to NITs' wide availability, there is a risk of inaccurate use, leading to a waste of resources and flawed decisions. In this review, we describe the uses and pitfalls of NITs for hepatic decompensation, from risk stratification in primary care to treatment decisions in outpatient clinics, as well as for the in-hospital management of patients with acute-on-chronic liver failure. We summarize which NITs to use when, for what indications, and how to maximize the potential of NITs for improved patient management.

The clinical relevance of acute-on-chronic liver failure in medical procedures: Endoscopy, interventions and surgery

Acute-on-chronic liver failure (ACLF) is a specific, but complex and multifactorial form of acute decompensation (AD) of cirrhosis and is characterized by an extraordinary dynamic natural course, rapidly evolving organ failure and high short-term mortality. In daily clinical practice, patients with liver cirrhosis and decompensation have indications for different medical procedures such as endoscopies, interventional treatments like transjugular intrahepatic portosystemic shunt (TIPS) or even surgical procedures. In these situations, clinicians often need to balance the expected benefits of such procedures with the risks of causing acute decompensation or ACLF. This review summarizes the evidence of medical procedures and their role in precipitating or preventing ACLF and highlights the aspects to consider during patient selection.

Omics in acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is a critical syndrome that develops in patients with chronic liver disease and is characterized by acute decompensation, single- or multiple-organ failure and high short-term mortality. Over the past few decades, ACLF has been progressively recognized as an independent clinical entity, and several criteria and prognostic scores have been proposed and validated by different scientific societies. However, controversies still exist in some aspects across regions, which mainly involve whether the definition of underlying liver diseases should include cirrhosis and non-cirrhosis. The pathophysiology of ACLF is complicated and remains unclear, although accumulating evidence based on different aetiologies of ACLF shows that it is closely associated with intense systemic inflammation and immune-metabolism disorder, which result in mitochondrial dysfunction and microenvironment imbalance, leading to disease development and organ failure. In-depth insight into the biological pathways involved in the mechanisms of ACLF and potential mechanistic targets that improve patient survival still needs to be investigated. Omics-based analytical techniques, including genomics, transcriptomics, proteomics, metabolomics and microbiomes, have developed rapidly and can offer novel insights into the essential pathophysiologic process of ACLF. In this paper, we briefly reviewed and summarized the current knowledge and recent advances in the definitions, criteria and prognostic assessments of ACLF; we also described the omics techniques and how omics-based analyses have been applied to investigate and characterize the biological mechanisms of ACLF and identify potential predictive biomarkers and therapeutic targets for ACLF. We also outline the challenges, future directions and limitations presented by omics-based analyses in clinical ACLF research.

Mechanisms of immunity in acutely decompensated cirrhosis and acute-on-chronic liver failure

The identification of systemic inflammation (SI) as a central player in the orchestration of acute-on-chronic liver failure (ACLF) has opened new avenues for the understanding of the pathophysiological mechanisms underlying this disease condition. ACLF, which develops in patients with acute decompensation of cirrhosis, is characterized by single or multiple organ failure and high risk of short-term (28-day) mortality. Its poor outcome is closely associated with the severity of the systemic inflammatory response. In this review, we describe the key features of SI in patients with acutely decompensated cirrhosis and ACLF, including the presence of a high blood white cell count and increased levels of inflammatory mediators in systemic circulation. We also discuss the main triggers (i.e. pathogen- and damage-associated molecular patterns), the cell effectors (i.e. neutrophils, monocytes and lymphocytes), the humoral mediators (acute phase proteins, cytokines, chemokines, growth factors and bioactive lipid mediators) and the factors that influence the systemic inflammatory response that drive organ failure and mortality in ACLF. The role of immunological exhaustion and/or immunoparalysis in the context of exacerbated inflammatory responses that predispose ACLF patients to secondary infections and re-escalation of end-organ dysfunction and mortality are also reviewed. Finally, several new potential immunogenic therapeutic targets are debated.

Prevalence of multidrug-resistant bacteria in healthcare and community settings in West Africa: systematic review and meta-analysis

BACKGROUND

Multidrug-resistant (MDR) bacteria are a global health threat, notably in low- and middle-income countries. The aim of this review was to estimate the prevalence of multidrug-resistant bacteria in healthcare and community settings in West Africa.

METHODS

In accordance with PRISMA guidelines, we searched PubMed, CINAHL, African Index Medicus, and other databases for studies published from 2010 onward. Data on MDR bacterial prevalence, study characteristics, and infection types were extracted and analyzed via R software. Subgroup analyses were performed to explore differences in prevalence across infection settings and sample types.

RESULTS

Out of the 5,320 articles identified, 50 studies from 13 West African countries met the inclusion criteria, with the majority from Nigeria (34%) and Ghana (22%). Among the 35,820 bacteria isolated in these studies, gram-negative bacteria (GNB), particularly Escherichia coli and Klebsiella sp., were the most frequently isolated species, accounting for 63.3% of the bacteria. The overall prevalence of MDR bacteria was 59% (95% CI: 48-69%), with significant heterogeneity between studies (I² = 98%, p < 0.001). Subgroup analysis revealed a 7% increase in MDR bacteria prevalence from the first five-year period to the last two five-year periods, and a greater prevalence of MDR bacteria in nosocomial infections (65%, 95% CI: 45-81%) than in community-acquired infections (53%, 95% CI: 31-74%). The prevalence of MDR bacteria in mixed infection settings was 58% (95% CI: 44-71%). The MDR prevalence was highest in the urine samples (72%, 95% CI: 57-84%) and superficial skin samples (69%, 95% CI: 29-92%), whereas it was lowest in the nasopharyngeal samples (26%, 95% CI: 21-33%).

CONCLUSION

The high prevalence of MDR bacteria in West Africa underscores the need for strengthened infection control measures, improved surveillance, and stricter antibiotic use policies. Enhanced regional collaboration is essential to mitigate the spread of AMR in both healthcare and community settings.

PROSPERO REGISTRATION NUMBER

CRD42023470363.

Pharmacological Treatment of Ascites: Challenges and Controversies

Ascites is the most common complication from cirrhosis related to portal hypertension and depicts the onset of hepatic decompensation. Ranging from uncomplicated to refractory ascites, the progression carries prognostic value by reflecting the deterioration of underlying cirrhosis and portal hypertension. Diuretics have been the mainstay of treatment to control ascites, but the side effects heighten when the dosage is escalated. Non-selective beta-blockers (NSBBs) are widely used nowadays to prevent hepatic decompensation and variceal hemorrhage. However, with worsening systemic vasodilation and inflammation when ascites progresses, patients on NSBBs are at risk of hemodynamic collapse leading to renal hypoperfusion and thus hepatorenal syndrome. Long-term albumin infusion was studied to prevent the progression of ascites. However, the results were conflicting. Sodium-glucose cotransporter-2 inhibitors are under investigation to control refractory ascites. With that, patients with refractory ascites may require regular large-volume paracentesis. With an aging population, more patients are put on anti-thrombotic agents and their risks in decompensated cirrhosis and invasive procedures have to be considered. In general, decompensated cirrhosis with ascites poses multiple issues to pharmacological treatment. In the present review, we discuss the challenges and controversies in the pharmacological treatment of ascites.

Gene score to quantify systemic inflammation in patients with acutely decompensated cirrhosis

BACKGROUND AND AIMS

Quantifying systemic inflammation (SI) in acutely decompensated cirrhosis (ADC) is of major importance because SI is a driver of the most severe forms of ADC, including acute-on-chronic liver failure (ACLF). Blood biomarkers of SI already evaluated in ADC failed to appropriately assess SI in ADC. We aimed to investigate whether gene expression related to circulating immune cells could quantify SI in ADC.

METHODS

Standard biomarkers (white cell count, C reactive protein, cytokines) and genome-wide RNA expression (RNA-sequencing) were obtained in blood from 700 patients with ADC at the time of their hospital admission. A composite score based on standard biomarkers of SI (Chronic Liver Failure-Standard Biomarkers Composite (CLIF-SBC) score) and a gene score (CLIF-Systemic Inflammation Gene (SIG) score) composed of the 28 top differentially expressed immune cell-related genes in the comparison between high-severity and low-severity clinical phenotypes were computed. Among the 700 patients, the CLIF-SIG score was repeated once during follow-up in 375 patients, and 3 times or more in 46 patients.

RESULTS

The CLIF-SIG score was more accurate in reflecting clinical severity induced by SI than the CLIF-SBC score (area under the curve 0.803 vs 0.658). A CLIF-SIG score of 0.386 (Youden Index) was the best cut-off level discriminating patients with poor outcomes from the others, in all clinical scenarios. Sequential measurement of the CLIF-SIG score showed that 78% of patients were admitted at the peak or descending part of the SI-wave. ACLF developed during hospitalisation in 80% of patients with a CLIF-SIG score >0.386 on admission.

CONCLUSIONS

In patients with ADC, the CLIF-SIG score is an accurate estimator of SI, clinical course severity and prognosis.

Colitis-Associated Dysplasia in Inflammatory Bowel Disease: Features and Endoscopic Management

Patients with long-standing inflammatory bowel disease (IBD) involving the colon are at higher risk of developing colorectal dysplastic or neoplastic lesions. While from sporadic colorectal cancer follows an "adenoma-carcinoma" sequence, IBD colitis-associated carcinogenesis is mainly related to an "inflammation-dysplasia-carcinoma" sequence. Currently, specific endoscopic surveillance strategies involving dye spray and virtual chromoendoscopy have been standardized, aiming for early CRC diagnosis. When detected, colitis-associated dysplasia should be classified according to standard classification, thus allowing for better treatment. Indeed, most IBD-associated dysplastic lesions can be treated with endoscopic resection, even though available procedures are usually more challenging than those in the general population. The higher frequency of severe submucosal fibrosis and the difficulty in the definition of lesions' margins account for this issue. Current endoscopic resection techniques include polypectomy, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Recent evidence suggests the relevance of en bloc resection, as this may be associated with lower rates of recurrence. Therefore, particularly for larger (>20 mm) lesions, ESD should be preferred, even though it is considered the most difficult technique due to frequent severe submucosal fibrosis. Considering the growing number of new endoscopic resective techniques, including underwater EMR or ESD, which in the general population have been suggested to lower procedure-related risks and may also allow a larger spread of advanced endoscopic resection in IBD. However, additional data are needed to assess the medium- and long-term efficacy of endoscopic resection of visible dysplasia in IBD patients, which are burdened by a high risk of local and, more importantly, metachronous recurrence.

The prognostic nutritional index is an effective prognostic and nutritional status indicator for cirrhosis

BACKGROUND AND AIM

Malnutrition is an important clinical feature of cirrhotic patients and is closely associated with prognosis. The prognostic nutritional index (PNI) is a measure of nutritional status. This study was conducted to clarify whether the PNI is related to the severity and prognosis of cirrhosis.

METHODS

In this study, we retrospectively analysed the clinical data of patients who were hospitalized with a primary diagnosis of liver cirrhosis from January 2020 to December 2023 at Tianmen Hospital affiliated with Wuhan University of Science and Technology. Cox regression was used to analyse the independent risk factors for prognosis in patients with decompensated cirrhosis, and the predictive value of the PNI for assessing cirrhosis severity and prognosis was analysed via receiver operating characteristic (ROC) curves.

RESULTS

A total of 513 patients with cirrhosis were included in the study. The patients were divided according to disease severity into compensated (28) and decompensated (485) groups, where the decompensated group consisted of the ascites-only group (63), the complications group (381), and the death group (41). The PNI [hazard ratio (HR) = 0.925, 95% confidence interval (CI): 0.858-0.997, P = 0.041] and platelet count (HR = 1.006, 95% CI: 1.002-1.01, P = 0.002) were found to be independent factors influencing poor prognosis in patients with decompensated cirrhosis. The PNI has predictive value for mortality in decompensated cirrhosis patients. Moreover, a significant disparity was observed in the PNI between the compensated and decompensated groups, and the PNI in the compensated group [47.03(42.85,51.50)] was markedly greater than that in the decompensated group [34.15(30.05,37.93)]. As the severity of the disease increased, the PNI progressively decreased in the ascites-only group [36.40 (32.15, 40.80)], the complication group [34.05 (30.08, 37.80)], and the death group [30.15 (27.05, 35.58)].The ROC curves revealed that the PNI had a high predictive value for decompensated cirrhosis [area under the curve (AUC) = 0.897] and the highest predictive value for mortality outcome (AUC = 0.943). This research also demonstrated that the PNI is strongly correlated with the occurrence and number of complications.

CONCLUSION

The prognostic nutritional index is a good indicator of the severity and prognosis of cirrhotic disease and warrants clinical promotion.

Association between lactate-to-albumin ratio and all-cause mortality in cirrhosis patients: Analysis of the MIMIC-IV database

OBJECTIVE

This study evaluates the predictive value of the lactate/albumin ratio (LAR) for all-cause mortality in cirrhosis patients.

DESIGN

Retrospective observational study.

SETTING

Intensive care unit (ICU).

PATIENTS OR PARTICIPANTS

626 first-time ICU-admitted cirrhosis patients in the USA (MIMIC-IV v2.2).

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

LAR index, 28-day, and 90-day all-cause mortality.

RESULTS

Of 626 patients (60.86% male), 27.80% and 39.14% died within 28 and 90 days, respectively. Multivariate Cox analysis showed a significant association between higher LAR and mortality. Adjusted for confounders, elevated LAR increased the 28-day mortality risk [HR: 1.31 (1.21-1.42), P < 0.001]. A restricted cubic spline analysis revealed non-linear relationships between LAR and mortality. For 28-day mortality, the inflection point was 1.583: below this, HR was 2.29 (95% CI: 1.61-3.27, P < 0.001); above, HR was 1.16 (95% CI: 1.02-1.31, P = 0.021; P = 0.002). For 90-day mortality, the inflection point was 1.423: below, HR was 1.60 (95% CI: 1.04-2.47, P = 0.033); above, HR was 0.94 (95% CI: 0.75-1.16, P = 0.542; P = 0.012).

CONCLUSIONS

LAR predicts 28-day and 90-day mortality with a segmented effect. An LAR ≥1.583 signals high 28-day mortality risk, necessitating intensified monitoring and potential ICU admission. For 90-day mortality, LAR near 1.423 serves as an early warning for high-risk patients and guides interventions. Continuous LAR monitoring aids management, but prospective studies are needed to confirm clinical utility.

Dysplasia in Pediatric Patients with Inflammatory Bowel Disease Shows Distinct Clinicopathologic Features Compared to that in Adult Patients

Due to its rarity, there is limited information on the clinicopathologic features of dysplasia in pediatric patients with inflammatory bowel disease (IBD). The existing surveillance guidelines for these patients do not include dysplasia as a potential risk factor for colorectal cancer (CRC), and there is no clear guidance on the optimal strategy for detecting dysplasia. As such, we analyzed the clinicopathologic features of 20 IBD patients who developed at least one instance of dysplasia (n = 56) before the age of 21 years. The results were then compared with data from a previously published adult cohort, which included 315 dysplastic lesions from 167 consecutive adult IBD patients. The study group consisted of 11 males and 9 females, with a mean age of 11 years at the time of IBD diagnosis. The mean age at the time of the first dysplasia diagnosis was 18 years for the study group compared to 54 years for the adult group. The study group had a lower incidence of ulcerative colitis (65% vs. 92% in the adult group, p < 0.001), but the proportion of patients with concurrent primary sclerosing cholangitis (PSC) was nearly double that of the adult group (25% vs. 13%, p = 0.129). Dysplasia in the study group was more likely to be nonconventional (38%, p = 0.047) and invisible or flat (50%, p < 0.001) compared to the adult group (25% and 24%, respectively). High-risk nonconventional dysplastic subtypes, including crypt dysplasia (13%, p = 0.016), goblet cell-deficient dysplasia (11%, p = 0.010), and hypermucinous dysplasia (9%, p = 0.009), were more common in the study group compared to the adult group (4%, 3%, and 2%, respectively). The mean duration from IBD diagnosis to the first dysplasia diagnosis was significantly shorter in the study group (8 years) than in the adult group (16 years) (p = 0.005). While dysplastic lesions in the adult group were more likely to present as high-grade dysplasia (HGD) at initial diagnosis (17% vs. 4% in the study group, p = 0.008), the rate of advanced neoplasia (HGD or CRC) on follow-up was similar between the two groups (26% in the adult group vs. 22% in the study group, p = 1.000). In conclusion, dysplasia in pediatric IBD patients is often associated with nonconventional features (including the high-risk subtypes), an invisible/flat appearance, concurrent PSC, and early development (within 8 years of IBD diagnosis).

The Composition of the Fecal and Mucosa-adherent Microbiota Varies Based on Age and Disease Activity in Ulcerative Colitis

BACKGROUND

Pediatric-onset ulcerative colitis (pUC) represents a more aggressive disease phenotype compared with adult-onset UC. We hypothesized that this difference can, in part, be explained by the composition of the microbiota.

METHODS

In a prospective, longitudinal study, we included pediatric (N = 30) and adult (N = 30) patients with newly or previously (>1 year) diagnosed UC. We analyzed the microbiota composition in the mucosa-adherent microbiota at baseline, using 16S rRNA gene sequencing, and the fecal microbiota at baseline and at 3-month intervals, using shotgun metagenomics.

RESULTS

For fecal samples, the bacterial composition differed between pUC and aUC in newly diagnosed patients (β-diversity, Bray Curtis: R2 = 0.08, P = .02). In colon biopsies, microbial diversity was higher in aUC compared with pUC (α-diversity, Shannon: estimated difference 0.54, P = .006). In the mucosa-adherent microbiota, Alistipes finegoldii was negatively associated with disease activity in pUC while being positively associated in aUC (estimate: -0.255 and 0.098, P = .003 and P = .02 in pUC and aUC, respectively). Finally, we showed reduced stability of the fecal microbiota in pediatric patients, evidenced by a different composition of the fecal microbiota in newly and previously diagnosed pUC, a pattern not found in adults.

CONCLUSIONS

Our results indicate that pediatric UC patients have a more unstable fecal microbiota and a lower α diversity than adult patients and that the microbiota composition differs between aUC and pUC patients. These findings offer some explanation for the observed differences between pUC and aUC and indicate that individualized approaches are needed if microbiota modifications are to be used in the future treatment of UC.

[Acute management of bleeding complications and coagulation disorders in critically ill patients with liver cirrhosis]

Critically ill patients with liver cirrhosis exhibit complex alterations in coagulation that should be considered in clinical acute management. As routine laboratory tests (e.g., INR, aPTT, platelet count) cannot always adequately reflect the coagulation status of critically ill patients with liver cirrhosis, functional hemostatic tests, such as viscoelastic tests, should also be used to assess coagulation disorders in these patients. If invasive procedures are planned, hemostatic interventions to prevent bleeding and measures to stabilize coagulation disorders should be considered depending on the risk of procedure-associated bleeding, while a prophylactic routine correction of abnormal laboratory coagulation parameters should be avoided. If an acute bleeding complication manifests in critically ill patients with liver cirrhosis, an individualized correction of hemostatic changes is indicated in addition to prompt identification of the source of bleeding. This review article describes the pathophysiological changes underlying the altered hemostatic system in critically ill patients with liver cirrhosis and provides an overview of diagnostic and therapeutic options for hemostatic complications.

Proteomics-guided Biomarker Discovery, Validation, and Pathway Perturbation in Infection-related Acute Decompensation of Cirrhosis

BACKGROUND & AIMS

Inappropriate treatment of infections fuels drug resistance, organ failures, and costs in cirrhosis. We explored proteomics to improve infection diagnosis and management in acutely decompensated (AD) cirrhosis.

METHODS

We enrolled 391 patients with AD cirrhosis (92% males, median-age: 41 years), 84 in the discovery cohort (54 infected, 30 non-infected), 147 in the validation cohort I (106 infected, 41 non-infected), and 160 in the validation cohort II (108 infected, 52 non-infected). High-throughput proteomics identified biomarkers in the discovery cohort, validated through enzyme-linked immunoassay in subsequent cohorts. A model for infection was evaluated through discrimination, calibration, and decision curves and was externally validated.

RESULTS

Infected patients exhibited higher leucocyte counts, procalcitonin, organ failures, Model for End-stage Liver Disease scores, and 30-day mortality (P < .001 each). Proteomics identified 516 proteins, 27 upregulated and 38 downregulated, in infections. LGALS3BP, PLTP, CFP, and GPX3 were independently linked to infections (adjusting for severity and systemic inflammatory response syndrome), with composite area under the receiver operating characteristic curve (AUC) of 0.854 (95% confidence interval [CI], 0.787-0.922) in validation cohort I. A PACIFY model (LGALS3BP + procalcitonin + CLIF-COF + lactate) predicted infections with AUC of 0.965 (95% CI, 0.933-0.997) and 0.906 (95% CI, 0.860-0.952) in validation cohorts I and II, outperforming procalcitonin, systemic inflammatory response syndrome, white blood cell, neutrophil-to-lymphocyte ratio, neutrophil %, and composite models (P < .001). The model demonstrated fair calibration, with decision curves indicating a net benefit of the model in treating infections and reducing unnecessary antimicrobial use. Consistent findings were observed on external validation (AUC, 0.949; 95% CI, 0.916-0.982), re-enforcing the accuracy and clinical utility of the model. A deployable app was developed for infection risk estimation, enhancing practical applicability. Impaired phagocytosis, complement functions, hypocoagulation, hypofibrinolysis, dysregulated carbohydrate metabolism, autophagy, heightened cell death, and proteolysis were key perturbed pathways in infections.

CONCLUSION

The study identifies novel protein signatures and pathways linked with infections in AD cirrhosis. A biomarker-guided treatment of infections can limit unnecessary antimicrobial use and the burden of drug resistance in cirrhosis.

Diagnostic interval of inflammatory bowel disease in Chinese children and its relationship with growth parameters: a retrospective study

Background

Delayed diagnosis of inflammatory bowel disease (IBD) is common in Europe and North America, with limited research in Asia. We aimed to investigate factors influencing delayed diagnosis of IBD in Chinese children and the impact of delayed diagnosis on growth.

Methods

This was a retrospective study. Clinical data on children with IBD were collected through electronic medical records. The diagnostic interval includes the time from symptom onset to hospital admission and admission to diagnosis. Diagnostic delay was defined as the upper quartile of the time interval from the first symptom to the diagnosis of IBD. For the effect on growth indicators, the length of follow-up was at least 3 months from diagnosis.

Results

This study included 222 children with IBD, predominantly with Crohn's disease (86.0%). Approximately one-quarter of children require more than 366 days to be diagnosed with IBD, primarily due to the extended interval between the onset of initial symptoms and hospital admission. Multivariate logistic regression models showed that fever was associated with a prolonged time interval from first symptom onset to admission and the odds ratio (OR) was 0.45 [95% confidence interval (CI) 0.22-0.94]. Age and bloody stools were associated with prolonged intervals from admission to diagnosis, with ORs of 0.84 (95% CI 0.77-0.92) and 0.36 (95% CI 0.14-0.94), respectively. Delayed diagnosis was associated with height at first admission and follow-up. Children with a delayed diagnosis had a 5.87-fold higher chance of growth retardation upon initial admission compared to children without a delayed diagnosis (95% CI 1.59-24.05). After 15.7 months of follow-up, this elevated risk remained (OR 3.28, 95% CI 1.00-10.50).

Conclusion

Delayed diagnosis is common in Chinese children with IBD and is associated with persistent height impairment.

Freiburg index of post-TIPS survival (FIPS) identifies patients at risk of further decompensation and ACLF after TIPS

BACKGROUND & AIMS

The Freiburg index of post-TIPS survival (FIPS) defines a high-risk group of patients with significantly reduced survival following transjugular intrahepatic portosystemic shunt (TIPS) implantation. However, the clinical hallmarks responsible for these patients' unfavorable outcome remain to be identified. Therefore, the present study aimed to characterize the clinical course after TIPS implantation according to the FIPS.

METHODS

A total of 1,359 patients with cirrhosis allocated to TIPS implantation for treatment of recurrent or refractory ascites or secondary prophylaxis of variceal bleeding from eight tertiary centers were retrospectively included. The patients' clinical course following TIPS placement was analyzed, stratified according to the FIPS. The primary study outcome was further decompensation within 90 days after TIPS; secondary outcomes were acute-on-chronic liver failure (ACLF) within 90 days and 1-year transplant-free survival.

RESULTS

Further decompensation after TIPS implantation was significantly more frequent in FIPS high-risk patients compared to low-risk patients (cumulative incidence function 0.58 vs. 0.38, p <0.001). Moreover, FIPS high-risk patients developed ACLF significantly more often (0.18 vs. 0.08; p = 0.008). Uni- and multivariable competing risk regression analyses confirmed that high-risk FIPS independently predicted further decompensation (subdistribution hazard ratio 1.974; 95% CI 1.531-2.544; p <0.001) and ACLF (subdistribution hazard ratio 2.586; 95% CI 1.449-4.616; p = 0.001) after TIPS. Importantly, further decompensation and ACLF after TIPS were associated with significantly reduced transplant-free survival.

CONCLUSIONS

The present study reveals that the FIPS predicts development of further decompensation and ACLF after TIPS implantation. These events are responsible for impaired transplant-free survival in FIPS high-risk patients. These results pave the way for the development of tailored clinical management strategies.

IMPACT AND IMPLICATIONS

Prognostication after transjugular intrahepatic portosystemic shunt (TIPS) implantation is challenging. Several clinical scores have been proposed in this context, such as the Freiburg index of post-TIPS survival (FIPS). The FIPS can identify a high-risk group of patients with significantly reduced survival after TIPS. However, to understand the reasons for these patients' unfavorable outcome, their clinical course after TIPS needs to be characterized. This study reveals that the FIPS predicts development of further decompensation and acute-on-chronic liver failure after TIPS implantation, which are responsible for the poor prognosis of FIPS high-risk patients. Therefore, the present results may be useful for tailored decision making in patients allocated to TIPS implantation.

Angel or devil: the dual roles of 2,3,5,4'-tetrahydroxystilbene-2-O-β-D-glucopyranoside in the development of liver injury based on integrating pharmacological techniques: a systematic review

Background and purpose

2,3,5,4'-tetrahydroxystilbene-2-O-β-D-glucoside (TSG) exhibits a dualistic pharmacological profile, acting as both a hepatoprotective and hepatotoxic agent, which is intricately linked to its interaction with multiple signaling pathways and its stereoisomeric forms, namely, cis-SG and trans-SG. The purpose of this study is to evaluate both the hepatoprotective and hepatotoxic effects of TSG and give therapeutic guidance.

Methods

This study performed a systematic search of eight databases to identify preclinical literature up until March 2024. The CAMARADES system evaluated evidence quality and bias. STATA and Python were used for statistical analysis, including dose-effect maps, 3D maps and radar charts to show the dose-time-effect relationship of TSG on hepatoprotection and hepatotoxicity.

Results

After a rigorous screening process, a total of 24 studies encompassing 564 rodents were selected for inclusion in this study. The findings revealed that TSG exhibited bidirectional effects on the levels of ALT and AST, while also regulating the levels of ALT, AST, TNF-α, IL-6, serum TG, serum TC, SOD, MDA, IFN-γ, and apoptosis rate. The histological analysis of liver tissue confirmed the regulatory effects of TSG, and a comprehensive analysis revealed the optimal protective dosage range was 27.27-38.81 mg/kg/d and the optimal toxic dosage range was 51.93-76.07 mg/kg/d. TSG exerts the dual effects on liver injury (LI) through the network of Keap1/Nrf2/HO-1/NQO1, NF-κB, PPAR, PI3K/Akt, JAK/STAT and TGF-β pathways.

Conclusion

TSG could mediate the pathways of oxidation, inflammation, and metabolism to result in hepatoprotection (27.27-38.81 mg/kg/d) and hepatotoxicity (51.93-76.07 mg/kg/d).

Bowel Colonization With Carbapenem-Resistant Bacteria Is Associated With Short-Term Outcomes in Patients With Acute-On-Chronic Liver Failure

BACKGROUND

Bowel colonization with antimicrobial-resistant bacteria has been associated with worse clinical outcomes in patients with cirrhosis; however, it has not been studied in patients with acute-on-chronic liver failure (ACLF). We evaluated whether fecal isolation of carbapenem-resistant gram-negative bacteria (CR-GNB) among patients with ACLF affects short-term outcomes.

METHODS

Patients of APASL-ACLF (n = 339) were screened between June 2020 and December 2021, and 150 were included. Stool cultures were carried out at baseline and every 5 days thereafter until discharge or death. All surviving patients were followed until 60 days after discharge.

RESULTS

Mean age was 44.8 (8.8) years, with 86% males and alcohol as etiology in 66%. CR-GNB organisms were isolated from stool in 42% of hospitalized ACLF patients, with E. coli and Klebsiella pneumoniae as the most common species. Patients with CR-GNB fecal carriage were associated with higher CTP, MELD, and DF scores but not with recent antibiotics, proton pump inhibitors, or lactulose use. Extraintestinal infections developed in 59.3% overall, most commonly UTI, pneumonia, and SBP. Infectious complications developed in 57.3% and 19.7% with and without CR-GNB in the stool (RR: 5.5; p < 0.001). Peripheral cultures were positive in 60.7% with infections, with species concordant with the fecal isolates found in 90.7%. Isolation of CR-GNB from stool and high bilirubin were independently associated with both in-hospital mortality and 60-day mortality (p = 0.05).

CONCLUSIONS

Hospitalized ACLF patients with CR-GNB in the stool have a significantly higher risk of extraintestinal infections, in-hospital mortality, and short-term mortality up to 60 days.

TRIAL NUMBER

[NCT04383106].

Artificial intelligence for dysplasia detection during surveillance colonoscopy in patients with ulcerative colitis: A cross-sectional, non-inferiority, diagnostic test comparison study

BACKGROUND AND STUDY AIM

High-definition virtual chromoendoscopy, along with targeted biopsies, is recommended for dysplasia surveillance in ulcerative colitis patients at risk for colorectal cancer. Computer-aided detection (CADe) systems aim to improve colonic adenoma detection, however their efficacy in detecting polyps and adenomas in this context remains unclear. This study evaluates the CADe Discovery™ system's effectiveness in detecting colonic dysplasia in ulcerative colitis patients at risk for colorectal cancer.

PATIENTS AND METHODS

A prospective cross-sectional, non-inferiority, diagnostic test comparison study was conducted on ulcerative colitis patients undergoing colorectal cancer surveillance colonoscopy between January 2021 and April 2021. Patients underwent virtual chromoendoscopy (VCE) with iSCAN 1 and 3 with optical enhancement. One endoscopist, blinded to CADe Discovery™ system results, examined colon sections, while a second endoscopist concurrently reviewed CADe images. Suspicious areas detected by both techniques underwent resection. Proportions of dysplastic lesions and patients with dysplasia detected by VCE or CADe were calculated.

RESULTS

Fifty-two patients were included, and 48 lesions analyzed. VCE and CADe each detected 9 cases of dysplasia (21.4% and 20.0%, respectively; p=0.629) in 8 patients and 7 patients (15.4% vs. 13.5%, respectively; p=0.713). Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy for dysplasia detection using VCE or CADe were 90% and 90%, 13% and 5%, 21% and 2%, 83% and 67%, and 29.2% and 22.9%, respectively.

CONCLUSIONS

The CADe Discovery™ system shows similar diagnostic performance to VCE with iSCAN in detecting colonic dysplasia in ulcerative colitis patients at risk for colorectal cancer.

Acute-on-chronic liver failure (ACLF): the ‘Kyoto Consensus’—steps from Asia

Acute-on-chronic liver failure (ACLF) is a condition associated with high mortality in the absence of liver transplantation. There have been various definitions proposed worldwide. The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set in 2004 on ACLF was published in 2009, and the “APASL ACLF Research Consortium (AARC)” was formed in 2012. The AARC database has prospectively collected nearly 10,500 cases of ACLF from various countries in the Asia–Pacific region. This database has been instrumental in developing the AARC score and grade of ACLF, the concept of the ‘Golden Therapeutic Window’, the ‘transplant window’, and plasmapheresis as a treatment modality. Also, the data has been key to identifying pediatric ACLF. The European Association for the Study of Liver-Chronic Liver Failure (EASL CLIF) and the North American Association for the Study of the End Stage Liver Disease (NACSELD) from the West added the concepts of organ failure and infection as precipitants for the development of ACLF and CLIF-Sequential Organ Failure Assessment (SOFA) and NACSELD scores for prognostication. The Chinese Group on the Study of Severe Hepatitis B (COSSH) added COSSH-ACLF criteria to manage hepatitis b virus-ACLF with and without cirrhosis. The literature supports these definitions to be equally effective in their respective cohorts in identifying patients with high mortality. To overcome the differences and to develop a global consensus, APASL took the initiative and invited the global stakeholders, including opinion leaders from Asia, EASL and AASLD, and other researchers in the field of ACLF to identify the key issues and develop an evidence-based consensus document. The consensus document was presented in a hybrid format at the APASL annual meeting in Kyoto in March 2024. The ‘Kyoto APASL Consensus’ presented below carries the final recommendations along with the relevant background information and areas requiring future studies.