Controversies in the management of alcoholic liver disease

Evaluation of Dental Health in Terminally Ill Patients

Dental health plays an imperative role in the general health and well-being of an individual. Terminally ill patients due to a compromised immune response are susceptible to a wide array of oral complications, which may affect their ability to speak and chew, leading to malnutrition. The present study was conducted to evaluate dental health and various oral manifestations in terminally ill patients. One hundred twenty terminally ill patients hospitalized with diseases of the respiratory tract, gastrointestinal tract, circulatory system, liver, and endocrinal disorders were included in the study. The evaluation of oral manifestations and their prevalence was done by a single examiner. The oral health was evaluated according to symptoms exhibited by the patients and clinical presentation. Of the patients included in the study, 78 were male, and 42 were female. All the individuals were adults between 25 to 55 years of age. Out of 120 admitted terminally ill patients, 27 subjects had respiratory diseases, 17 had gastrointestinal disorders, 5 had disorders of the circulatory system, 39 had liver disorders, and 32 had endocrine disorders. A need for added comprehension is mandatory to link the inter-relationships between dentistry and medicine to further perk up the management of the overall health of patients, which will further reinforce the partnership between dental and medical communities.

Treatment options for alcoholic and non-alcoholic fatty liver disease: A review

Alcoholic liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD) are serious health problems worldwide. These two diseases have similar pathological spectra, ranging from simple steatosis to hepatitis to cirrhosis and hepatocellular carcinoma. Although most people with excessive alcohol or calorie intake display abnormal fat accumulation in the liver (simple steatosis), a small percentage develops progressive liver disease. Despite extensive research on understanding the pathophysiology of both these diseases there are still no targeted therapies available. The treatment for ALD remains as it was 50 years ago: abstinence, nutritional support and corticosteroids (or pentoxifylline as an alternative if steroids are contraindicated). As for NAFLD, the treatment modality is mainly directed toward weight loss and co-morbidity management. Therefore, new pathophysiology directed therapies are urgently needed. However, the involvement of several inter-related pathways in the pathogenesis of these diseases suggests that a single therapeutic agent is unlikely to be an effective treatment strategy. Hence, a combination therapy towards multiple targets would eventually be required. In this review, we delineate the treatment options in ALD and NAFLD, including various new targeted therapies that are currently under investigation. We hope that soon we will be having an effective multi-therapeutic regimen for each disease.

Sequential therapy consisting of glucocorticoid infusions followed by granulocyte-monocyte absorptive apheresis in patients with severe alcoholic hepatitis

BACKGROUND

Activated leukocytes infiltrating the liver contribute to the provocation of alcoholic hepatitis. Glucocorticoid induces the demargination of leukocytes from the hepatic sinusoids, whereas granulocyte-monocyte absorptive apheresis (GMA) removes leukocytes from the circulation. Thus, the usefulness of a sequential therapy consisting of glucocorticoid infusions followed by GMA was evaluated in patients with severe alcoholic hepatitis.

METHODS

Patients with severe alcoholic hepatitis received intravenous injections of methylprednisolone (1,000 mg/day) for 3 or 4 days, and then GMA was performed every day for 3 days. Responders were defined as those with attenuated serum C-reactive protein (CRP) levels during the GMA procedures.

RESULTS

Ten consecutive patients were enrolled. At the baseline, the Japan alcoholic hepatitis scores were 9 in two patients and 10 or more in eight patients, and the Model for End-Stage Liver Disease scores ranged from 22 to 43. In all the patients, the peripheral neutrophil counts increased and the serum levels of CRP, aspartate aminotransferase, IL-6, IL-8, TNF-α, and intercellular adhesion molecule 1 decreased immediately after the glucocorticoid infusions. However, a rebound increase in the serum CRP levels was observed in all patients after discontinuation of glucocorticoid infusions, but the maximal values during the GMA procedures were lower than the baseline values. Six patients were rescued, whereas the remaining four patients died because of sepsis, pneumonia, pancreatitis, and renal failure.

CONCLUSIONS

Sequential therapy combining glucocorticoid infusion and GMA was useful for attenuating liver injuries in patients with severe alcoholic hepatitis by preventing rebound increases in inflammatory reactions after discontinuation of glucocorticoid infusions, except in patients with bacterial infections and/or multiple organ failure.

酒精性肝病研究进展

酒精性肝病(alcoholic liver disease, ALD)是一种慢性肝脏疾病, 包括肝脂肪变性、酒精性脂肪性肝炎、肝硬化、肝细胞癌和肝衰竭. 许多因素被认为能促进ALD的发展, 特别是氧化应激, 在酒精代谢期间活性氧物质的产生, 来自内脏脂肪组织的脂肪因子和来自肠道的内毒素等. 目前, ALD的发病机制已被广泛研究, 精确的机制尚待阐明. 在我国随着人类生活水平提高和生活方式的改变, 人群中的嗜酒者的比率逐年上升, 乙醇也已成为导致肝脏损害的第二大原因. 因此, ALD相关治疗也受到人们的广泛关注. 在本文中, 我们就ALD的发病机制、治疗等方面的最新研究进展作一综述.

Risk of alcohol use relapse after liver transplantation for alcoholic liver disease

AIM

To investigate factors, including psychosocial factors, associated with alcoholic use relapse after liver transplantation (LT) for alcoholic liver disease (ALD).

METHODS

The clinical records of 102 patients with ALD who were referred to Nagoya University Hospital for LT between May 2003 and March 2015 were retrospectively evaluated. History of alcohol intake was obtained from their clinical records and scored according to the High-Risk Alcoholism Relapse scale, which includes duration of heavy drinking, types and amount of alcohol usually consumed, and previous inpatient treatment history for alcoholism. All patients were assessed for eligibility for LT according to comprehensive criteria, including Child-Pugh score, Model for End-Stage Liver Disease score, and psychosocial criteria.

RESULTS

Of the 102 patients with ALD referred for LT, seven (6.9%) underwent LT. One (14.3%) of these seven patients returned to heavy drinking, but that patient was able to successfully quit drinking following an immediate intervention, consisting of psychotherapeutic education and supportive psychotherapy, by a psychiatrist. A comparison between the transplantation/registration (T/R) group, consisting of the seven patients who underwent LT and 10 patients listed for deceased donor LT, and 50 patients who did not undergo LT and were not listed for deceased donor LT (non-T/R group), showed statistically significant differences in duration of abstinence period (P < 0.01), duration of heavy drinking (P < 0.05), adherence to medical treatment (P < 0.01), and declaration of abstinence (P < 0.05).

CONCLUSION

Patients with ALD referred for LT require comprehensive evaluation, including evaluation of psychosocial criteria, to prevent alcoholic recidivism.

The dilemma of liver transplant allocation for alcoholic patients

Liver transplantation for alcoholic liver disease (ALD) has been, and continues to be, a subject of great controversy. Although ALD is one of the most common causes of cirrhosis of the liver and one of the most prominent indications for orthotopic liver transplantation, arguments arise regarding liver transplantation as a suitable treatment for this disease. In many documented studies, the rate of alcoholic recidivism and rates of noncompliance with antirejection regimens have been examined. Many of these studies demonstrate that the rate of recidivism is high and medication compliance is low. Now is a time in which medicine is experiencing an increased need for organ allografts with a profound shortage of suitable matches for patients in need. Therefore, transplanting viable and vital liver allografts into patients with ALD, considering high rates of alcoholic recidivism and noncompliance, is more ethically controversial than ever. It is the responsibility of the medical personnel-including nurses-who sit on ethical advisory boards to distribute an exceptional gift of liver transplants. Also, it is the duty of nurses who are involved with the care of transplant recipients to help the patients assume full respect and treat their liver well. This article discusses the ethical implications and ethical obligations of medical staff when continuing to consider ALD appropriate grounds for liver transplantation.

Life Experiences of People Affected by Crohn's Disease and Their Support Networks: Scoping Review

This scoping review identifies and describes relevant studies related to the evidence published on life experiences and perceived social support of people affected by Crohn's disease. Twenty-three studies were definitely selected and analyzed for the topics explored. The overall findings show patients' needs and perceptions. There is a lack of evidence about patients' perceived needs as well as the understanding of social support that has contributed to improve their life experiences with that chronic illness. Lack of energy, loss of body control, body image damaged due to different treatments and surgeries, symptoms related to fear of disease, feeling burdened loss related to independence, and so on are some of the concerns with having to live with those affected by the Crohn. To underline those experiences through this scoping review provides valuable data for health care teams, especially for the nursing profession, considered by those affected as one of the main roles along the whole pathological process. This review provides the basis for developing broader research on the relatively underexplored topics and consequently improves specific programs that could address patients' needs.

Chronic liver inflammation: Clinical implications beyond alcoholic liver disease

Chronic alcohol exposure can lead to alcoholic liver disease, including hepatitis, cirrhosis and hepatocellular carcinoma, and chronic inflammation can simultaneously cause systemic medical illness. Recent evidence suggests that alcoholic liver disease is a predictor for liver-related diseases, cardiovascular disease, immunologic disease, and bone disease. Chronic inflammation in alcoholic liver disease is mediated by a direct inflammatory cascade from the alcohol detoxification process and an indirect inflammatory cascade in response to gut microflora-derived lipopolysaccharides (LPS). The pathophysiology of alcoholic liver disease and its related systemic illness is characterized by oxidative stress, activation of the immune cascade, and gut-liver interactions. Integrative therapeutic strategies for alcoholic liver disease include abstaining from alcohol consumption; general anti-inflammatories such as glucocorticoid, pentoxifylline, and tumour necrosis factor-α antagonist; antioxidants such as N- acetylcysteine; gut microflora and LPS modulators such as rifaximin and/or probiotics. This review focuses on the impact of chronic liver inflammation on systemic health problems and several potential therapeutic targets.

Elevated expression of tumour necrosis factor-α-induced protein 8 (TNFAIP8)-like 2 mRNA in peripheral blood mononuclear cells is associated with disease progression of acute-on-chronic hepatitis B liver failure

Aberrant immunity response contributes to the pathogenesis of acute-on-chronic hepatitis B liver failure. Tumour necrosis factor-α-induced protein-8 like-2 (TIPE2) is a recently identified molecular to maintain immune homoeostasis, but its role in acute-on-chronic hepatitis B liver failure (ACHBLF) is unknown. We detected TIPE2 mRNA levels in peripheral blood mononuclear cells (PBMCs) from 56 patients with ACHBLF, 60 chronic hepatitis B patients, 24 healthy controls and analysed its role in disease severity and prognosis. TIPE2 mRNA expression in patients with ACHBLF was higher than that of patients with chronic infection or healthy controls. In patients with ACHBLF, TIPE2 mRNA level was positively correlated with serum total bilirubin, international normalized ratio and model for end-stage liver disease scores. Furthermore, the level of TIPE2 mRNA was significantly higher in nonsurvivors than survivors in patients with ACHBLF. The mRNA level of TIPE2 gradually decreased week by week in survivors accompanied by recovery from patients with ACHBLF, while its expression sustained at high levels in nonsurvivors. TIPE2 mRNA level after lipopolysaccharide (LPS) stimulation ex vivo in patients with ACHBLF was higher compared with controls and patients with chronic infection. Meanwhile, cytokines ex vivo secreted were measured as a marker of immune activation. After LPS stimulation, interleukin (IL)-6 and tumour necrosis factor (TNF)-α mRNA expression were reduced in patients with ACHBLF, and a significantly negative correlation was found between TIPE2 and TNF-α mRNA levels. In conclusion, our results identified the potential role of TIPE2 in predicting disease progression and prognosis in patients with ACHBLF by negative regulating of cell-mediated immunity.

Alkaline phosphatase: the next independent predictor of the poor 90-day outcome in alcoholic hepatitis

AIM

Determination of risk factors relevant to 90-day prognosis in AH. Comparison of the conventional prognostic models such as Maddrey's modified discriminant function (mDF) and Child-Pugh-Turcotte (CPT) score with newer ones: the Glasgow Alcoholic Hepatitis Score (GAHS); Age, Bilirubin, INR, Creatinine (ABIC) score, Model for End-Stage Liver Disease (MELD), and MELD-Na in the death prediction.

PATIENTS AND METHODS

The clinical and laboratory variables obtained at admission were assessed. The mDF, CPT, GAHS, ABIC, MELD, and MELD-Na scores' different areas under the curve (AUCs) and the best threshold values were compared. Logistic regression was used to assess predictors of the 90-day outcome.

RESULTS

One hundred sixteen pts fulfilled the inclusion criteria. Twenty (17.4%) pts died and one underwent orthotopic liver transplantation (OLT) within 90 days of follow-up. No statistically significant differences in the models' performances were found. Multivariate logistic regression identified CPT score, alkaline phosphatase (AP) level higher than 1.5 times the upper limit of normal (ULN), and corticosteroids (CS) nonresponse as independent predictors of mortality.

CONCLUSIONS

The CPT score, AP > 1.5 ULN, and the CS nonresponse had an independent impact on the 90-day survival in AH. Accuracy of all studied scoring systems was comparable.

Long-term management of alcoholic liver disease

Alcoholic liver disease is a major cause of morbidity and mortality worldwide. Patients with cirrhosis caused by alcohol are at risk for developing complications associated with a failing liver. The long-term management of alcoholic liver disease stresses the following: (1) Abstinence of alcohol (Grade 1A), with referral to an alcoholic rehabilitation program; (2) Adequate nutritional support (Grade 1B), emphasizing multiple feedings and a referral to a nutritionist; (3) Routine screening in alcoholic cirrhosis to prevent complications; (4) Timely referral to a liver transplant program for those with decompensated cirrhosis; (5) Avoid pharmacologic therapies, as these medications have shown no benefit.

Diagnosis and management of alcoholic hepatitis

Alcoholic hepatitis is a form of severe, cholestatic liver disease that results from consumption of large amount of alcohol during a sustained period of time in a subset of alcoholics. Symptoms could be mild and nonspecific to more severe. The diagnosis of alcoholic hepatitis can be made with a thorough history, physical examination, and review of laboratory results. Liver biopsy is confirmatory but generally not indicated for the diagnosis. Abstinence is the key form of therapeutic intervention. Despite variable results in clinical trials, corticosteroids and pentoxifylline seem to provide moderate survival benefit. Liver transplantation in acute alcoholic hepatitis is contentious.

Evaluation and selection of the patient with alcoholic liver disease for liver transplant

Alcoholic liver cirrhosis is the second most common indication for liver transplantation in the United States. Studies have shown that these patients do as well as those transplanted for nonalcoholic liver disease. Recently, transplantation of patients with alcoholic liver disease has come under closer scrutiny following an article in the New England Journal of Medicine demonstrating comparable outcomes and survival in patients transplanted for acute alcoholic hepatitis. This article reviews the literature and data on the evaluation and selection of patients with alcoholic cirrhosis for liver transplant, and discusses the most recent indication (once a contraindication), acute alcoholic hepatitis.

Inflammation in alcoholic liver disease

Frank Burr Mallory's landmark observation in 1911 on the histopathology of alcoholic liver disease (ALD) was the first identification of a link between inflammation and ALD. In this review, we summarize recent advances regarding the origins and roles of various inflammatory components in ALD. Metabolism of ethanol generates a number of metabolites, including acetate, reactive oxygen species, acetaldehyde, and epigenetic changes, that can induce inflammatory responses. Alcohol and its metabolites can also initiate and aggravate inflammatory conditions by promoting gut leakiness of microbial products, by sensitizing immune cells to stimulation, and by activating innate immune pathways, such as complement. Chronic alcohol consumption also sensitizes nonimmune cells, e.g., hepatocytes, to inflammatory signals and impairs their ability to respond to protective signals. Based on these advances, a number of inflammatory targets have been identified with potential for therapeutic intervention in ALD, presenting new opportunities and challenges for translational research.

Care of chronic liver disease

Regardless of etiology, chronic liver disease generally involves a process of progressive destruction and regeneration of the liver parenchyma, leading to fibrosis and cirrhosis. At an early stage, most patients are asymptomatic and can easily go undiagnosed and untreated. Primary care physicians can often make the diagnosis but may offer little treatment. Better understanding about treatment is the key for primary care providers to provide better care for this group of patients. This review focuses on the treatment of the most common causes of chronic liver disease, including hepatitis B, hepatitis C, alcoholic cirrhosis, nonalcoholic fatty liver disease, and hemochromatosis.

Corticosteroids or non-corticosteroids: a fresh perspective on alcoholic hepatitis treatment

BACKGROUND

Alcoholic hepatitis (AH) is a necrotizing inflammatory process caused by alcoholic liver injury. It carries a significant short-term mortality. The management of AH is challenging. Although corticosteroids have been demonstrated to exert anti-inflammatory and antifibrotic effects, their efficacy for the treatment of AH remains debatable.

DATA SOURCES

A literature search was performed of MEDLINE, ScienceDirect, SpringerLink and Wiley InterScience using the keywords "alcoholic hepatitis", "alcoholic liver disease", and "corticosteroids". The available data reported in the relevant literature were analyzed.

RESULTS

More than 17 controlled trials and at least 13 meta-analyses have reported the efficacy of corticosteroids in the treatment of AH in the past 40 years. Many were poorly designed and used different inclusion/exclusion criteria, making it difficult to reach a consensus. In this review, we summarized all the controversial data in the past decade and analyzed the potential causes for the varying therapeutic effects of corticosteroids in AH. The focus of the controversy has changed from "whether steroids are beneficial or harmful for AH patients" to "how to accurately identify responders to steroids early and rationalize corticosteroid treatment". An early response to glucocorticoids, as determined by calculating the Lille score after 7 days of treatment, has been shown to be a clinically useful indicator. Moreover, down-regulation of steroid sensitivity, risk of infection, and a rational therapeutic strategy of corticosteroids in AH patients are all crucial for therapeutic effect.

CONCLUSIONS

An early and accurate determination of steroid sensitivity is important. Besides, we need to overcome the down-regulation of steroid sensitivity, reduce the infection risk and rationalize the therapeutic strategy of corticosteroids. A fresh perspective is needed on the use of corticosteroids in AH patients.

Management of alcoholic liver disease: an update

Treatment of alcoholic liver disease is for the most part based on the stage of the disease and the pathogenic event that is being targeted. The primary treatment modalities that are considered in the treatment of alcoholic liver disease include abstinence, agents that suppress inflammation, anticytokine therapy, nutritional support, modifiers of alcohol metabolism, anti-oxidants, and inhibitors of hepatic fibrosis. Future therapeutic options include exploration of new pathways such as the patatin-like phospholipase domain containing 3 protein (PNPLA-3).

Treatment of alcoholic liver disease

Alcoholic liver disease (ALD) remains a major cause of liver-related mortality in the US and worldwide. The correct diagnosis of ALD can usually be made on a clinical basis in conjunction with blood tests, and a liver biopsy is not usually required. Abstinence is the hallmark of therapy for ALD, and nutritional therapy is the first line of therapeutic intervention. The role of steroids in patients with moderate to severe alcoholic hepatitis is gaining increasing acceptance, with the caveat that patients be evaluated for the effectiveness of therapy at 1 week. Pentoxifylline appears to be especially effective in ALD patients with renal dysfunction/hepatorenal syndrome. Biologics such as specific anti-TNFs have been disappointing and should probably not be used outside of the clinical trial setting. Transplantation is effective in patients with end-stage ALD who have stopped drinking (usually for ≥6 months), and both long-term graft and patient survival are excellent.