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Systemic inflammation and portal vein thrombosis in cirrhotic patients with gastroesophageal varices. Eur J Gastroenterol Hepatol 2020; 32:401-405. [PMID: 31356372 DOI: 10.1097/meg.0000000000001526] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Cirrhotic patients with gastroesophageal varices and non-tumoral portal vein thrombosis have a higher risk of re-bleeding and poor prognosis. This study aimed to analyze inflammatory biomarkers and thromboelastography in cirrhotic patients with portal vein thrombosis. METHODS A total of 385 consecutive cirrhotic patients with gastroesophageal varices were prospectively enrolled between 1 December 2016, and 31 August 2017. Of these, 231 were eligible for analysis and were divided into portal vein thrombosis (n = 103) and non-portal vein thrombosis (n = 128) groups based on computerized tomography angiography findings. RESULTS Patients with portal vein thrombosis generally had higher Child-Pugh scores than those without portal vein thrombosis (6.38 ± 0.12 vs. 5.81 ± 0.09, P < 0.001). The serum albumin levels were significantly lower in patients with portal vein thrombosis (35.90 ± 0.52 vs. 38.52 ± 0.43, P < 0.001). The portal vein thrombosis group had significant higher serum levels of interleukin 6 [4.85 (3.15-6.99) vs. 3.09 (2.06-5.20) pg/ml, P < 0.001] and tumor necrosis factor alpha [10.70 (7.60-15.20) vs. 9.07 (7.03-11.60) pg/ml, P = 0.020]. The interleukin 6 level was 2.5-fold higher in patients with portal vein thrombosis (adjusted odds ratio: 2.574; 95% confidential interval: 1.248-5.310). Thromboelastography showed that TEG-R, the reaction time, was significantly lower in the portal vein thrombosis group [5.20 (4.80-6.30) vs. 6.00 (5.20-6.95), P = 0.009], indicating enhanced coagulation activity. CONCLUSION This study confirmed the important role of systemic inflammation in portal vein thrombosis. Interleukin 6, an important inflammatory cytokine, is independently associated with portal vein thrombosis. The correlation between the interleukin 6 level and portal vein thrombosis requires further investigation.
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Carnevale R, Raparelli V, Nocella C, Bartimoccia S, Novo M, Severino A, De Falco E, Cammisotto V, Pasquale C, Crescioli C, Scavalli AS, Riggio O, Basili S, Violi F. Gut-derived endotoxin stimulates factor VIII secretion from endothelial cells. Implications for hypercoagulability in cirrhosis. J Hepatol 2017; 67:950-956. [PMID: 28716745 DOI: 10.1016/j.jhep.2017.07.002] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 07/05/2017] [Accepted: 07/07/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Patients with cirrhosis display enhanced blood levels of factor VIII, which may result in harmful activation of the clotting system; however, the underlying mechanism is unknown. METHODS We performed a cross-sectional study in patients with cirrhosis (n=61) and matched controls (n=61) comparing blood levels of factor VIII, von Willebrand factor (vWf), lipopolysaccharide (LPS) and positivity for Escherichia coli DNA. Furthermore, we performed an in vitro study to investigate if LPS, in a concentration range similar to that found in the peripheral circulation of cirrhotic patients, was able to elicit factor VIII secretion from human umbilical vein endothelial cells (HUVEC). RESULTS Patients with cirrhosis displayed higher serum levels of LPS (55.8 [42.2-79.9] vs. 23.0 [7.0-34.0]pg/ml, p<0.001), factor VIII (172.0 [130.0-278.0] vs. 39.0 [26.0-47.0]U/dl, p<0.0001), vWf (265.0 [185.0-366.0] vs. 57.0 [48.0-65.0]U/dl, p<0.001) and positivity for Escherichia coli DNA (88% vs. 3%, p<0.001, n=34) compared to controls. Serum LPS correlated significantly with factor VIII (r=0.80, p<0.001) and vWf (r=0.63, p<0.001). Only LPS (beta-coefficient=0.70, p<0.0001) independently predicted factor VIII levels. The in vitro study showed that LPS provoked factor VIII and vWf release from HUVEC via formation and secretion of Weibel-Palade bodies, a phenomenon blunted by pre-treating HUVEC with an inhibitor of Toll-like receptor 4. CONCLUSIONS The study provides the first evidence that LPS derived from gut microbiota increases the systemic levels of factor VIII via stimulating its release by endothelial cells. Lay summary: Cirrhosis is associated with thrombosis in portal and systemic circulation. Enhanced levels of factor VIII have been suggested to play a role but the underlying mechanism is still unclear. Here we show that patients with cirrhosis display a concomitant increase of factor VIII and lipopolysaccharide (LPS) from Escherichia coli and suggest that LPS contributes to the release of factor VIII from endothelial cells.
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Affiliation(s)
- Roberto Carnevale
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Valeria Raparelli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Cristina Nocella
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Simona Bartimoccia
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Marta Novo
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Anna Severino
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Elena De Falco
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Vittoria Cammisotto
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Chiara Pasquale
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension, Sapienza-University of Rome, Rome, Italy
| | - Clara Crescioli
- Department of Movement, Human and Health Sciences, Section of Health Sciences, "Foro Italico" University of Rome, Rome, Italy
| | - Antonio Sili Scavalli
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Oliviero Riggio
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension, Sapienza-University of Rome, Rome, Italy
| | - Stefania Basili
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Francesco Violi
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy.
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Raparelli V, Basili S, Carnevale R, Napoleone L, Del Ben M, Nocella C, Bartimoccia S, Lucidi C, Talerico G, Riggio O, Violi F. Low-grade endotoxemia and platelet activation in cirrhosis. Hepatology 2017; 65:571-581. [PMID: 27641757 DOI: 10.1002/hep.28853] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 08/28/2016] [Indexed: 02/06/2023]
Abstract
UNLABELLED Patients with cirrhosis may display impaired or enhanced platelet activation, but the reasons for these equivocal findings are unclear. We investigated if bacterial lipopolysaccharide (LPS) is implicated in platelet activation. In a cross-sectional study, conducted in an ambulatory care clinic and hospital, comparing 69 cirrhosis patients and 30 controls matched for sex, age, and atherosclerotic risk factors, serum levels of LPS, soluble cluster of differentiation 40 ligand and p-selectin (two markers of platelet activation), and zonulin (a marker of gut permeability) were investigated. Ex vivo and in vitro studies were also performed to explore the effect of LPS on platelet activation. Compared to controls, cirrhosis patients displayed higher serum levels of LPS (6.0 [4.0-17.5] versus 57.4 [43.4-87.2] pg/mL, P < 0.0001), soluble cluster of differentiation 40 ligand (7.0 ± 2.2 versus 24.4 ± 13.3 ng/mL, P < 0.0001), soluble p-selectin (14.2 ± 4.05 versus 33.2 ± 15.2 ng/mL, P < 0.0001), and zonulin (1.87 ± 0.84 versus 2.54 ± 0.94 ng/mL, P < 0.006). LPS significantly correlated with zonulin (r = 0.45, P < 0.001). Ex vivo studies showed that platelets from cirrhosis patients were more responsive to the agonists independently from platelet count; this phenomenon was blunted by incubation with an inhibitor of Toll-like receptor 4. In vitro study by normal platelets showed that LPS alone (50-150 pg/mL) did not stimulate platelets but amplified platelet response to the agonists; Toll-like receptor 4 inhibitor blunted this effect. CONCLUSION LPS may be responsible for platelet activation and potentially contributes to thrombotic complications occurring in cirrhosis. (Hepatology 2017;65:571-581).
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Affiliation(s)
- Valeria Raparelli
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Stefania Basili
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Roberto Carnevale
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Laura Napoleone
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Maria Del Ben
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Cristina Nocella
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Simona Bartimoccia
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Cristina Lucidi
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Giovanni Talerico
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - Oliviero Riggio
- Department of Clinical Medicine, Center for the Diagnosis and Treatment of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Francesco Violi
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
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Violi F, Corazza GR, Caldwell SH, Perticone F, Gatta A, Angelico M, Farcomeni A, Masotti M, Napoleone L, Vestri A, Raparelli V, Basili S. Portal vein thrombosis relevance on liver cirrhosis: Italian Venous Thrombotic Events Registry. Intern Emerg Med 2016; 11:1059-1066. [PMID: 27026379 DOI: 10.1007/s11739-016-1416-8] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 02/17/2016] [Indexed: 02/07/2023]
Abstract
Portal vein thrombosis may occur in cirrhosis; nevertheless, its prevalence, and predictors are still elusive. To investigate this issue, the Italian Society of Internal Medicine undertook the "Portal vein thrombosis Relevance On Liver cirrhosis: Italian Venous thrombotic Events Registry" (PRO-LIVER). This prospective multicenter study includes consecutive cirrhotic patients undergoing Doppler ultrasound examination of the portal area to evaluate the prevalence and incidence of portal vein thrombosis over a 2-year scheduled follow-up. Seven hundred and fifty-three (68 % men; 64 ± 12 years) patients were included in the present analysis. Fifty percent of the cases were cirrhotic outpatients. Viral (44 %) etiology was predominant. Around half of the patients had a mild-severity disease according to the Child-Pugh score; hepatocellular carcinoma was present in 20 %. The prevalence of ultrasound-detected portal vein thrombosis was 17 % (n = 126); it was asymptomatic in 43 % of the cases. Notably, more than half of the portal vein thrombosis patients (n = 81) were not treated with anticoagulant therapy. Logistic step-forward multivariate analysis demonstrated that previous portal vein thrombosis (p < 0.001), Child-Pugh Class B + C (p < 0.001), hepatocellular carcinoma (p = 0.01), previous upper gastrointestinal bleeding (p = 0.030) and older age (p = 0.012) were independently associated with portal vein thrombosis. Portal vein thrombosis is a frequent complication of cirrhosis, particularly in patients with moderate-severe liver failure. The apparent undertreatment of patients with portal vein thrombosis is a matter of concern and debate, which should be addressed by planning interventional trials especially with newer oral anticoagulants. Clinicaltrials.gov identifier NCT01470547.
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Affiliation(s)
- Francesco Violi
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Gino Roberto Corazza
- First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Stephen Hugh Caldwell
- Division of Gastroenterology and Hepatology, Digestive Health Center, University of Virginia, Charlottesville, VA, USA
| | - Francesco Perticone
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Angelo Gatta
- Department of Medicine, University of Padova, Padua, Italy
| | - Mario Angelico
- Liver Unit, University Hospital Tor Vergata, Rome, Italy
| | - Alessio Farcomeni
- Department of Public Health and Infectious Disease, Sapienza-University of Rome, Rome, Italy
| | - Michela Masotti
- First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Laura Napoleone
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Annarita Vestri
- Department of Public Health and Infectious Disease, Sapienza-University of Rome, Rome, Italy
| | - Valeria Raparelli
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Stefania Basili
- I Clinica Medica, Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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