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Faillaci F, Marzi L, Critelli R, Milosa F, Schepis F, Turola E, Andreani S, Vandelli G, Bernabucci V, Lei B, D'Ambrosio F, Bristot L, Cavalletto L, Chemello L, Sighinolfi P, Manni P, Maiorana A, Caporali C, Bianchini M, Marsico M, Turco L, de Maria N, Del Buono M, Todesca P, di Lena L, Romagnoli D, Magistri P, di Benedetto F, Bruno S, Taliani G, Giannelli G, Martinez‐Chantar M, Villa E. Liver Angiopoietin-2 Is a Key Predictor of De Novo or Recurrent Hepatocellular Cancer After Hepatitis C Virus Direct-Acting Antivirals. Hepatology 2018; 68:1010-1024. [PMID: 29604220 PMCID: PMC6175123 DOI: 10.1002/hep.29911] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/19/2018] [Accepted: 03/25/2018] [Indexed: 12/14/2022]
Abstract
Recent reports suggested that direct acting antivirals (DAAs) might favor hepatocellular carcinoma (HCC). In study 1, we studied the proangiogenic liver microenvironment in 242 DAA-treated chronic hepatitis C patients with advanced fibrosis. Angiopoietin-2 (ANGPT2) expression was studied in tissue (cirrhotic and/or neoplastic) from recurrent, de novo, nonrecurrent HCC, or patients never developing HCC. Circulating ANGPT2,vascular endothelial growth factor (VEGF), and C-reactive protein (CRP) were also measured. In study 2, we searched for factors associated with de novo HCC in 257 patients with cirrhosis of different etiologies enrolled in a dedicated prospective study. Thorough biochemical, clinical, hemodynamic, endoscopic, elastographic, and echo-Doppler work-up was performed in both studies. In study 1, no patients without cirrhosis developed HCC. Of 183 patients with cirrhosis, 14 of 28 (50.0%) with previous HCC recurred whereas 21 of 155 (13.5%) developed de novo HCC. Patients with recurrent and de novo HCCs had significantly higher liver fibrosis (LF) scores, portal pressure, and systemic inflammation than nonrecurrent HCC or patients never developing HCC. In recurrent/de novo HCC patients, tumor and nontumor ANGPT2 showed an inverse relationship with portal vein velocity (PVv; r = -0.412, P = 0.037 and r = -0.409, P = 0.047 respectively) and a positive relationship with liver stiffness (r = 0.526, P = 0.007; r = 0.525, P = 0.003 respectively). Baseline circulating VEGF and cirrhotic liver ANGPT2 were significantly related (r = 0.414, P = 0.044). VEGF increased during DAAs, remaining stably elevated at 3-month follow-up, when it significantly related with serum ANGPT2 (r = 0.531, P = 0.005). ANGPT2 expression in the primary tumor or in cirrhotic tissue before DAAs was independently related with risk of HCC recurrence (odds ratio [OR], 1.137; 95% confidence interval [CI], 1.044-1.137; P = 0.003) or occurrence (OR, 1.604; 95% CI, 1.080-2.382; P = 0.019). In study 2, DAA treatment (OR, 4.770; 95% CI, 1.395-16.316; P = 0.013) and large varices (OR, 3.857; 95% CI, 1.127-13.203; P = 0.032) were independent predictors of de novo HCC. CONCLUSION Our study indicates that DAA-mediated increase of VEGF favors HCC recurrence/occurrence in susceptible patients, that is, those with more severe fibrosis and splanchnic collateralization, who already have abnormal activation in liver tissues of neo-angiogenetic pathways, as shown by increased ANGPT2. (Hepatology 2018; 00:000-000).
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Affiliation(s)
- Francesca Faillaci
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Luca Marzi
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
| | - Rosina Critelli
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Fabiola Milosa
- National Institute of Gastroenterology, “S. de Bellis” Research HospitalCastellana GrotteBariItaly
- WomenInHepatology Network
| | - Filippo Schepis
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
| | - Elena Turola
- National Institute of Gastroenterology, “S. de Bellis” Research HospitalCastellana GrotteBariItaly
- WomenInHepatology Network
| | - Silvia Andreani
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
| | - Gabriele Vandelli
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
| | - Veronica Bernabucci
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Barbara Lei
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Federica D'Ambrosio
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Laura Bristot
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Luisa Cavalletto
- Department of MedicineUniversity of PaduaPaduaItaly
- WomenInHepatology Network
| | - Liliana Chemello
- Department of MedicineUniversity of PaduaPaduaItaly
- WomenInHepatology Network
| | - Pamela Sighinolfi
- Department of PathologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Paola Manni
- Department of PathologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Antonino Maiorana
- Department of PathologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Cristian Caporali
- Department of RadiologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Marcello Bianchini
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
| | - Maria Marsico
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Laura Turco
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Nicola de Maria
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
| | - Mariagrazia Del Buono
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Paola Todesca
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Luca di Lena
- National Institute of Gastroenterology, “S. de Bellis” Research HospitalCastellana GrotteBariItaly
| | - Dante Romagnoli
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
| | - Paolo Magistri
- Liver and Multivisceral Transplant CenterUniversity of Modena and Reggio EmiliaModenaItaly
| | - Fabrizio di Benedetto
- Liver and Multivisceral Transplant CenterUniversity of Modena and Reggio EmiliaModenaItaly
| | - Savino Bruno
- Humanitas University and Humanitas Research Hospital RozzanoMilanItaly
| | - Gloria Taliani
- Department of Clinical MedicineUniversity of Rome ‘La Sapienza’RomeItaly
- WomenInHepatology Network
| | - Gianluigi Giannelli
- National Institute of Gastroenterology, “S. de Bellis” Research HospitalCastellana GrotteBariItaly
| | - Maria‐Luz Martinez‐Chantar
- CIC bioGUNE, Centro de Investigación Cooperativa en Biociencias. Technology Park of Bizkaia, Bizkaia, Spain. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)Instituto de Salud Carlos IIIMadridSpain
- WomenInHepatology Network
| | - Erica Villa
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
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Cardiopulmonary hemodynamics and C-reactive protein as prognostic indicators in compensated and decompensated cirrhosis. J Hepatol 2018; 68:949-958. [PMID: 29331339 DOI: 10.1016/j.jhep.2017.12.027] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 12/25/2017] [Accepted: 12/26/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS The main stages of cirrhosis (compensated and decompensated) have been sub-staged based on clinical, endoscopic, and portal pressure (determined by the hepatic venous pressure gradient [HVPG]) features. Vasodilation leading to a hyperdynamic circulatory state is central in the development of a late decompensated stage, with inflammation currently considered a key driver. We aimed to assess hepatic/systemic hemodynamics and inflammation (by C-reactive protein [CRP]) among the different sub-stages of cirrhosis and to investigate their interrelationship and prognostic relevance. METHODS A single center, prospective cohort of patients with cirrhosis undergoing per protocol hepatic and right-heart catheterization and CRP measurement, were classified into recently defined prognostic stages (PS) of compensated (PS1: HVPG ≥6 mmHg but <10 mmHg; PS2: HVPG ≥10 mmHg without gastroesophageal varices; PS3: patients with gastroesophageal varices) and decompensated (PS4: diuretic-responsive ascites; PS5: refractory ascites) disease. Cardiodynamic states based on cardiac index (L/min/m2) were created: relatively hypodynamic (<3.2), normodynamic (3.2-4.2) and hyperdynamic (>4.2). RESULTS Of 238 patients, 151 were compensated (PS1 = 25; PS2 = 36; PS3 = 90) and 87 were decompensated (PS4 = 48; PS5 = 39). Mean arterial pressure decreased progressively from PS1 to PS5, cardiac index increased progressively from PS1-to-PS4 but decreased in PS5. HVPG, model for end-stage liver disease (MELD), and CRP increased progressively from PS1-to-PS5. Among compensated patients, age, HVPG, relatively hypodynamic/hyperdynamic state and CRP were predictive of decompensation. Among patients with ascites, MELD, relatively hypodynamic/hyperdynamic state, post-capillary pulmonary hypertension, and CRP were independent predictors of death/liver transplant. CONCLUSIONS Our study demonstrates that, in addition to known parameters, cardiopulmonary hemodynamics and CRP are predictive of relevant outcomes, both in patients with compensated and decompensated cirrhosis. LAY SUMMARY There are two main stages in cirrhosis, compensated and decompensated, each with a main relevant outcome. In compensated cirrhosis the main relevant outcome is the development of ascites, while in decompensated cirrhosis it is death. Major roles of cardiac dysfunction and systemic inflammation have been hypothesized in the evolution of the disease in decompensated patients. In this study, we have shown that these factors were also involved in the progression from compensated to decompensated stage.
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Unger LW, Berlakovich GA, Trauner M, Reiberger T. Management of portal hypertension before and after liver transplantation. Liver Transpl 2018; 24:112-121. [PMID: 28752925 DOI: 10.1002/lt.24830] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 07/23/2017] [Accepted: 07/25/2017] [Indexed: 12/19/2022]
Abstract
Orthotopic liver transplantation (OLT) represents a curative treatment option for end-stage liver disease (ESLD). Although epidemiology of ESLD has recently changed due to the rising prevalence of nonalcoholic fatty liver disease and the decreased burden of hepatitis C virus infections due to highly effective antiviral regimens, the management of portal hypertension (PHT) remains a clinical challenge in the pre- and post-OLT setting. The measurement of the hepatic venous pressure gradient represents the most reliable but invasive tool for assessment of the severity of PHT. Although novel liver ultrasound and magnetic resonance-based elastography methods have been developed, their value to screen for liver fibrosis and PHT in transplanted patients remains to be established. Nonselective beta-blockers represent the cornerstone of medical treatment of PHT, but more studies on their effects on clinical endpoints after OLT are needed. Statins are widely used to treat hyperlipidemia, which is a common condition after OLT. Although a growing body of evidence suggests that statins decrease portal pressure and PHT-related complications in ESLD, studies on potential benefits of statins after OLT are lacking. Finally, transjugular intrahepatic portosystemic shunts (TIPS) are effective in decreasing PHT and seem to decrease mortality on the OLT waiting list. Moreover, TIPS does not have an impact on liver function nor complicate the transplant surgical procedures. TIPS may also be used after OLT, but the evidence is limited. In conclusion, whereas the management of PHT in patients with ESLD is based on strong evidence, further data on the value of noninvasive monitoring tools as well as on medical and invasive treatment options in the post-OLT setting are needed to improve management strategies in patients with recurrent PHT after liver transplantation. Liver Transplantation 24 112-121 2018 AASLD.
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Affiliation(s)
| | | | - Michael Trauner
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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Zardi EM, Zardi DM, Chin D, Sonnino C, Dobrina A, Abbate A. Cirrhotic cardiomyopathy in the pre- and post-liver transplantation phase. J Cardiol 2015; 67:125-30. [PMID: 26074443 DOI: 10.1016/j.jjcc.2015.04.016] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 03/24/2015] [Accepted: 04/16/2015] [Indexed: 12/23/2022]
Abstract
Patients with advanced liver cirrhosis may develop a clinical syndrome characterized by a blunted contractile responsiveness to stress and/or altered diastolic relaxation, called "cirrhotic cardiomyopathy." This syndrome, which is initially asymptomatic, is often misdiagnosed due to the presence of symptoms that characterize other disorders present in patients with advanced liver cirrhosis, such as exercise intolerance, fatigue, and dyspnea. Stress and other conditions such as liver transplantation and transjugular intrahepatic portosystemic shunt (TIPS) may unmask this syndrome. Liver transplantation in this group of patients results in a clinical improvement and can be a cure for the cardiomyopathy. However, post-transplant prognosis depends on the identification of cirrhotics with cardiomyopathy in the pre-transplant phase; an early diagnosis of cirrhotic cardiomyopathy in the pre-transplant phase may avoid an acute onset or worsening of cardiac failure after liver transplantation. Since a preserved left ventricular ejection fraction may mask the presence of cirrhotic cardiomyopathy, the use of newer noninvasive diagnostic techniques (i.e. tissue Doppler, myocardial strain) is necessary to identify cirrhotics with this syndrome, in the pre-transplant phase. A pre-transplant treatment of heart failure in cirrhotics with cardiomyopathy improves the quality of life in this phase and reduces the complications during and immediately after liver transplantation. Since specific therapies for cirrhotic cardiomyopathy are lacking, due to the absence of a clear understanding of the pathophysiology of the cardiomyopathy, further research in this field is required.
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Affiliation(s)
- Enrico Maria Zardi
- Department of Clinical Medicine, University Campus Bio-Medico, Rome, Italy.
| | - Domenico Maria Zardi
- Department of Cardiology, II School of Medicine, University La Sapienza, Ospedale Sant'Andrea, Rome, Italy
| | - Diana Chin
- Department of Cardiology, II School of Medicine, University La Sapienza, Ospedale Sant'Andrea, Rome, Italy
| | - Chiara Sonnino
- Virginia Commonwealth University-VCU Pauley Heart Center, Richmond, VA, USA
| | - Aldo Dobrina
- Department of Physiology and Pathology, University of Trieste, Trieste, Italy
| | - Antonio Abbate
- Virginia Commonwealth University-VCU Pauley Heart Center, Richmond, VA, USA
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Seiberlich E, Sanches MD, Morais BS, Maciel JF. Influence of preoperative propranolol on cardiac index during the anhepatic phase of liver transplantation. Braz J Anesthesiol 2015; 65:170-6. [PMID: 25925027 DOI: 10.1016/j.bjane.2014.02.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 02/05/2014] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION Liver transplantation is the best therapeutic option for end-stage liver disease. Non-selective beta-blocker medications such as propranolol act directly on the cardiovascular system and are often used in the prevention of gastrointestinal bleeding resulting from HP. The effects of propranolol on cardiovascular system of cirrhotic patients during liver transplantation are not known. OBJECTIVE Evaluate the influence of propranolol used preoperatively on cardiac index during the anhepatic phase of liver transplantation. METHOD 101 adult patients (73 male [72.2%]) who underwent cadaveric donor orthotopic liver transplantation by piggyback technique with preservation of the retrohepatic inferior vena cava performed at Hospital das Clinicas, Federal University of Minas Gerais were evaluated. There was no difference in severity between groups by the MELD system, p=0.70. The preoperative use of propranolol and the cardiac index outcome were compared during the anhepatic phase of liver transplantation in 5 groups (I: increased cardiac index, II: cardiac index reduction lower than 16%, III: cardiac index reduction equal to or greater than 16% and less than 31%, IV: cardiac index reduction equal to or greater than 31% and less than 46%, V: cardiac index reduction equal to or greater than 46%). RESULTS Patients in group I (46.4%) who received propranolol preoperatively were statistically similar to groups II (60%), III (72.7%), IV (50%) and V (30.8%), p=0.57. CONCLUSION The use of propranolol before transplantation as prophylaxis for gastrointestinal bleeding may be considered safe, as it was not associated with worsening of cardiac index in anhepatic phase of liver transplantation.
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Affiliation(s)
- Emerson Seiberlich
- Department of Surgery, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil.
| | - Marcelo D Sanches
- Department of Surgery, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | | | - Jader F Maciel
- Department of Surgery, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
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