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Smith ML, Wade JB, Wolstenholme J, Bajaj JS. Gut microbiome-brain-cirrhosis axis. Hepatology 2024; 80:465-485. [PMID: 36866864 PMCID: PMC10480351 DOI: 10.1097/hep.0000000000000344] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/10/2023] [Indexed: 03/04/2023]
Abstract
Cirrhosis is characterized by inflammation, degeneration, and fibrosis of liver tissue. Along with being the most common cause of liver failure and liver transplant, cirrhosis is a significant risk factor for several neuropsychiatric conditions. The most common of these is HE, which is characterized by cognitive and ataxic symptoms, resulting from the buildup of metabolic toxins with liver failure. However, cirrhosis patients also show a significantly increased risk for neurodegenerative diseases such as Alzheimer and Parkinson diseases, and for mood disorders such as anxiety and depression. In recent years, more attention has been played to communication between the ways the gut and liver communicate with each other and with the central nervous system, and the way these organs influence each other's function. This bidirectional communication has come to be known as the gut-liver-brain axis. The gut microbiome has emerged as a key mechanism affecting gut-liver, gut-brain, and brain-liver communication. Clinical studies and animal models have demonstrated the significant patterns of gut dysbiosis when cirrhosis is present, both with or without concomitant alcohol use disorder, and have provided compelling evidence that this dysbiosis also influences the cognitive and mood-related behaviors. In this review, we have summarized the pathophysiological and cognitive effects associated with cirrhosis, links to cirrhosis-associated disruption of the gut microbiome, and the current evidence from clinical and preclinical studies for the modulation of the gut microbiome as a treatment for cirrhosis and associated neuropsychiatric conditions.
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Affiliation(s)
- Maren L Smith
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia, USA
- Alcohol Research Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - James B Wade
- Department of Psychiatry, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jennifer Wolstenholme
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, Virginia, USA
- Alcohol Research Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
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Chen X, Huang M, Yu X, Chen J, Xu C, Jiang Y, Li Y, Zhao Y, Duan C, Luo Y, Zhang J, Lv W, Li Q, Luo J, Dong D, An T, Lu L, Fu S. Hepatic-associated vascular morphological assessment to predict overt hepatic encephalopathy before TIPS: a multicenter study. Hepatol Int 2024; 18:1238-1248. [PMID: 38833138 PMCID: PMC11297904 DOI: 10.1007/s12072-024-10686-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 04/21/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND To provide patients the chance of accepting curative transjugular intrahepatic portosystemic shunt (TIPS) rather than palliative treatments for portal hypertension-related variceal bleeding and ascites, we aimed to assess hepatic-associated vascular morphological change to improve the predictive accuracy of overt hepatic encephalopathy (HE) risks. METHODS In this multicenter study, 621 patients undergoing TIPS were subdivided into training (413 cases from 3 hospitals) and external validation datasets (208 cases from another 3 hospitals). In addition to traditional clinical factors, we assessed hepatic-associated vascular morphological changes using maximum diameter (including absolute and ratio values). Three predictive models (clinical, hepatic-associated vascular, and combined) were constructed using logistic regression. Their discrimination and calibration were compared to test the necessity of hepatic-associated vascular assessment and identify the optimal model. Furthermore, to verify the improved performance of ModelC-V, we compared it with four previous models, both in discrimination and calibration. RESULTS The combined model outperformed the clinical and hepatic-associated vascular models (training: 0.814, 0.754, 0.727; validation: 0.781, 0.679, 0.776; p < 0.050) and had the best calibration. Compared to previous models, ModelC-V showed superior performance in discrimination. The high-, middle-, and low-risk populations displayed significantly different overt HE incidence (p < 0.001). Despite the limited ability of pre-TIPS ammonia to predict overt HE risks, the combined model displayed a satisfactory ability to predict overt HE risks, both in the low- and high-ammonia subgroups. CONCLUSION Hepatic-associated vascular assessment improved the predictive accuracy of overt HE, ensuring curative chances by TIPS for suitable patients and providing insights for cirrhosis-related studies.
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Affiliation(s)
- Xiaoqiong Chen
- Zhuhai Interventional Medical Centre, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
| | - Mingsheng Huang
- Department of Interventional Radiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiangrong Yu
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
- Department of Radiology, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), Zhuhai, China
| | - Jinqiang Chen
- Zhuhai Interventional Medical Centre, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
| | - Chunchun Xu
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Yunzheng Jiang
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Yiting Li
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Yujie Zhao
- Zhuhai Interventional Medical Centre, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
| | - Chongyang Duan
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Yixin Luo
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Jiawei Zhang
- Zhuhai Interventional Medical Centre, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
| | - Weifu Lv
- Interventional Radiology Department, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Qiyang Li
- Department of Interventional Radiology, Shenzhen People's Hospital, Shenzhen, China
| | - Junyang Luo
- Department of Interventional Radiology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Dandan Dong
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China
- Department of Radiology, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), Zhuhai, China
| | - Taixue An
- Department of Laboratory Medicine, Nanfang Hospital, Southern Medical University, No. 1023-1063 Shatai Road, Guangzhou, 510515, Guangdong Province, China.
| | - Ligong Lu
- Zhuhai Interventional Medical Centre, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China.
- Guangdong Provincial Key Laboratory of Tumor Interventional Diagnosis and Treatment, Zhuhai Institute of Translational Medicine, Zhuhai, China.
| | - Sirui Fu
- Zhuhai Interventional Medical Centre, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China.
- Zhuhai Engineering Technology Research Center of Intelligent Medical Imaging, Zhuhai Clinical Medical College of Jinan University (Zhuhai People's Hospital), No. 79 Kangning Road, Zhuhai, 519000, Guangdong Province, China.
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Chen X, Han L, Xu W. Dissecting causal relationships between gut microbiota, blood metabolites, and glioblastoma multiforme: a two-sample Mendelian randomization study. Front Microbiol 2024; 15:1403316. [PMID: 39021629 PMCID: PMC11251919 DOI: 10.3389/fmicb.2024.1403316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 06/18/2024] [Indexed: 07/20/2024] Open
Abstract
Background Given the increasing interest in the role of gut microbiota in glioblastoma multiforme (GBM), our objective was to examine the potential causal relationship between gut microbiota and GBM, as well as the mediating effects of specific metabolites. Methods A bidirectional two-sample Mendelian randomization (MR) analysis was conducted to investigate the associations between 196 microbial taxa and GBM. A two-step MR technique was used to identify significant mediators in this relationship. Subsequently, a mediation analysis was performed to explore and quantify the mediating effects of specific metabolites on the causal relationship between gut microbiota and GBM. Results Five taxa showed significant associations with GBM. Among them, family Victivallaceae [odds ratio (OR): 1.95; 95% confidence interval (CI): 1.21, 3.13; p = 0.005] and genus Lactococcus (OR: 1.81; 95% CI: 1.04, 3.15; p = 0.036) were positively correlated with the risk of GBM, while phylum Cyanobacteria had a protective effect against GBM (OR: 0.45; 95% CI: 0.22, 0.89; p = 0.021). The mediation analysis revealed that the connections among family Victivallaceae, genus Lactococcus, phylum Cyanobacteria and GBM were mediated by Methyl-4-hydroxybenzoate sulfate, phosphoethanolamine and dehydroepiandrosterone sulfate. Each of these accounted for 7.27, 7.98, and 8.65%, respectively. Conclusion Our study provides evidence supporting a potential causal association between certain gut microbiota taxa and GBM. The study highlights the central role of gut microbiota in GBM pathogenesis and their interactions with vital serum metabolites. This paves the way for potential novel therapeutic interventions in GBM management.
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Affiliation(s)
- Xuan Chen
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Jinan, China
| | - Lihui Han
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Jinan, China
| | - Wenzhe Xu
- Department of Neurosurgery, Qilu Hospital of Shandong University and Institute of Brain and Brain-Inspired Science, Shandong University, Jinan, China
- Shandong Key Laboratory of Brain Function Remodeling, Jinan, China
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Cullaro G, Allegretti AS, Patidar KR, Verna EC, Lai JC. Applying Metabolomics and Aptamer-based Proteomics to Determine Pathophysiologic Differences in Decompensated Cirrhosis Patients Hospitalized with Acute Kidney Injury. RESEARCH SQUARE 2024:rs.3.rs-4344179. [PMID: 38765962 PMCID: PMC11100905 DOI: 10.21203/rs.3.rs-4344179/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
A case-control study of 97 patients hospitalized at our institution. We performed aptamer-based proteomics and metabolomics on serum biospecimens obtained within 72 hours of admission. We compared the proteome and metabolome by the AKI phenotype (i.e., HRS-AKI, ATN) and by AKI recovery (decrease in sCr within 0.3 mg/dL of baseline) using ANCOVA analyses adjusting for demographics and clinical characteristics. We completed Random Forest (RF) analyses to identify metabolites and proteins associated with AKI phenotype and recovery. Lasso regression models were developed to highlight metabolites and proteins could improve diagnostic accuracy. Results: ANCOVA analyses showed no metabolomic or proteomic differences by AKI phenotype while identifying differences by AKI recovery status. Our RF and Lasso analyses showed that metabolomics can improve the diagnostic accuracy of both AKI diagnosis and recovery, and aptamer-based proteomics can enhance the diagnostic accuracy of AKI recovery. Discussion: Our analyses provide novel insight into pathophysiologic pathways, highlighting the metabolomic and proteomic similarities between patients with cirrhosis with HRS-AKI and ATN while also identifying differences between those with and without AKI recovery.
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Affiliation(s)
| | | | - Kavish R Patidar
- Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center
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Wu P, Lee PC, Chang TE, Hsieh YC, Chiou JJ, Lin CH, Huang YL, Lin YT, Huo TI, Schnabl B, Lee KC, Hou MC. Fecal Carriage of Multidrug-Resistant Organisms Increases the Risk of Hepatic Encephalopathy in Cirrhotic Patients: Insights from Gut Microbiota and Metabolite Features. RESEARCH SQUARE 2024:rs.3.rs-4328129. [PMID: 38766152 PMCID: PMC11100873 DOI: 10.21203/rs.3.rs-4328129/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Background Impact of fecal colonization by multidrug-resistant organisms (MDROs) on changes in gut microbiota and associated metabolites, as well as its role in cirrhosis-associated outcomes, has not been thoroughly investigated. Methods Eighty-eight cirrhotic patients and 22 healthy volunteers were prospectively enrolled with analysis conducted on plasma metabolites, fecal MDROs, and microbiota. Patients were followed for a minimum of one year. Predictive factors for cirrhosis-associated outcomes were identified using Cox proportional hazards regression models, and risk factors for fecal MDRO carriage were assessed using logistic regression model. Correlations between microbiota and metabolic profiles were evaluated through Spearman's rank test. Results Twenty-nine (33%) cirrhotic patients exhibited MDRO carriage, with a notably higher rate of hepatic encephalopathy (HE) in MDRO carriers (20.7% vs. 3.2%, p = 0.008). Cox regression analysis identified higher serum lipopolysaccharide levels and fecal MDRO carriage as predictors for HE development. Logistic regression analysis showed that MDRO carriage is an independent risk factor for developing HE. Microbiota analysis showed a significant dissimilarity of fecal microbiota between cirrhotic patients with and without MDRO carriage (p = 0.033). Thirty-two metabolites exhibiting significantly different expression levels among healthy controls, cirrhotic patients with and without MDRO carriage were identified. Six of the metabolites showed correlation with specific bacterial taxa expression in MDRO carriers, with isoaustin showing significantly higher levels in MDRO carriers experiencing HE compared to those who did not. Conclusion Fecal MDRO carriage is associated with altered gut microbiota, metabolite modulation, and an elevated risk of HE occurrence within a year.
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Affiliation(s)
| | | | | | | | | | | | - Yi-Long Huang
- National Yang Ming Chiao Tung University - Yangming Campus
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Lin L, Huang ZY, Liu K, Tong XC, Zhang ZX, Xue Y. The Free Triiodothyronine, Gamma-Glutamyl Transpeptidase and Spontaneous Bacterial Peritonitis Index: A Novel Model for Predicting 1-Year Mortality in Patients with HBV-Related Hepatic Encephalopathy. Hepat Med 2024; 16:1-9. [PMID: 38283915 PMCID: PMC10819082 DOI: 10.2147/hmer.s450638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 01/12/2024] [Indexed: 01/30/2024] Open
Abstract
Background and Aims Hepatic encephalopathy (HE) is characterized by neuropsychiatric manifestations in patients with decompensated cirrhosis (DC) and/or liver failure. This study aimed to investigate the predictive value of thyroid hormone in patients with HE. Methods Patients with DC and HE were enrolled, and multivariate logistic analysis was conducted to analyze the risk factors for 1-year mortality. Results Among the 81 patients with HBV-related DC and HE, 9 (11.1%) died within 3 months, and 15 (18.5%) died within the first year. More patients with FT3 < 3.5pmol/L had ascites (33.3% vs 8.9%, P<0.01) and higher model for end-stage liver disease (MELD) (Z=3.669, P<0.01). Additionally, free triiodothyronine (FT3) levels were lower in the non-survivor group (P<0.01). FT3 exhibited a negative correlation with international normalized ratio and MELD (both P<0.05). Multivariate analysis revealed that FT3, gamma-glutamyl transpeptidase (GGT), and spontaneous bacterial peritonitis (SBP) were independent risk factors for 1-year mortality of HE. A new model incorporating FT3, GTT, and SBP demonstrated superiority to MELD based on the AUROC (0.9 and 0.752, P=0.04). Conclusion Low FT3, but not thyroid-stimulating hormone and free tetraiodothyronine, was identified as an independent risk factor for 1-year mortality in patients with DC and HE. The newly proposed prognostic model, which includes FT3, GTT, and SBP, holds significant predictive value.
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Affiliation(s)
- Lin Lin
- Institute of Hepatology, The Third People’s Hospital of Changzhou, Changzhou, People’s Republic of China
- Department of Pharmacy, The Third People’s Hospital of Changzhou, Changzhou Medical Center, Nanjing Medical University, Changzhou, People’s Republic of China
| | - Ze-yu Huang
- Institute of Hepatology, The Third People’s Hospital of Changzhou, Changzhou, People’s Republic of China
| | - Kai Liu
- Institute of Hepatology, The Third People’s Hospital of Changzhou, Changzhou, People’s Republic of China
- Department of Infectious Diseases, The Third People’s Hospital of Changzhou, Changzhou Medical Center, Nanjing Medical University, Changzhou, People’s Republic of China
| | - Xue-cheng Tong
- Institute of Hepatology, The Third People’s Hospital of Changzhou, Changzhou, People’s Republic of China
- Department of Infectious Diseases, The Third People’s Hospital of Changzhou, Changzhou Medical Center, Nanjing Medical University, Changzhou, People’s Republic of China
| | - Zhi-xin Zhang
- Department of Pulmonary Diseases, The Third People’s Hospital of Changzhou, Changzhou Medical Center, Nanjing Medical University, Changzhou, People’s Republic of China
| | - Yuan Xue
- Institute of Hepatology, The Third People’s Hospital of Changzhou, Changzhou, People’s Republic of China
- Department of Infectious Diseases, The Third People’s Hospital of Changzhou, Changzhou Medical Center, Nanjing Medical University, Changzhou, People’s Republic of China
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Badal BD, Cox IJ, Bajaj JS. Are we ready to translate metabolomics into clinical practice for ACLF prediction and diagnosis? J Hepatol 2023; 79:1082-1084. [PMID: 37734684 DOI: 10.1016/j.jhep.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Bryan D Badal
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA
| | - I Jane Cox
- The Roger Williams Institute of Hepatology, Foundation for Liver Research, London, UK; Faculty of Life Sciences & Medicine, King's College London, United Kingdom
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA.
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Kulkarni AV, Vora M, Ramagundam R, Sharma M, Reddy DN, Rao P. Thyroxine Levels Predict the Development of Brain Failure in Patients With Cirrhosis in Indian Population. GASTRO HEP ADVANCES 2023; 3:55-57. [PMID: 39132184 PMCID: PMC11307603 DOI: 10.1016/j.gastha.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/12/2023] [Indexed: 08/13/2024]
Affiliation(s)
| | - Moiz Vora
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | | | - Mithun Sharma
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | | | - P.N. Rao
- Department of Hepatology, AIG Hospitals, Hyderabad, India
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Badal BD, Bajaj JS. Hepatic Encephalopathy in Acute-on-Chronic Liver Failure. Clin Liver Dis 2023; 27:691-702. [PMID: 37380292 DOI: 10.1016/j.cld.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is characterized by the presence of chronic liver disease and extrahepatic organ failure and is associated with a high rate of short-term mortality. International societies have sought to define the criteria for ACLF and differ on definitions. Encephalopathy is an important organ failure in ACLF cases and is included as a marker of ACLF across society definitions. Both brain failure and ACLF commonly occur in the presence of a triggering event and in the setting of the large amount of inflammation that ensues. The presence of encephalopathy as a part of ACLF not only increases the chances of mortality but also provides unique challenges in that the patient will be limited in conversations around major decisions such as need for advanced level of care, liver transplant, or even end-of-life decisions. Many decisions need to be made quickly and occur in parallel in the care of patients with encephalopathy and ACLF and include stabilizing the patient, identifying precipitants or alternative diagnoses, and medical management. Infections has emerged as a major trigger for both ACLF and encephalopathy, and special attention should be given to identifying and treating infections as they occur.
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Affiliation(s)
- Bryan D Badal
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, 1201 Broad Rock Boulevard, Richmond, VA, USA
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, 1201 Broad Rock Boulevard, Richmond, VA, USA.
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Weiss E, de la Peña-Ramirez C, Aguilar F, Lozano JJ, Sánchez-Garrido C, Sierra P, Martin PIB, Diaz JM, Fenaille F, Castelli FA, Gustot T, Laleman W, Albillos A, Alessandria C, Domenicali M, Caraceni P, Piano S, Saliba F, Zeuzem S, Gerbes AL, Wendon JA, Jansen C, Gu W, Papp M, Mookerjee R, Gambino CG, Jiménez C, Giovo I, Zaccherini G, Merli M, Putignano A, Uschner FE, Berg T, Bruns T, Trautwein C, Zipprich A, Bañares R, Presa J, Genesca J, Vargas V, Fernández J, Bernardi M, Angeli P, Jalan R, Claria J, Junot C, Moreau R, Trebicka J, Arroyo V. Sympathetic nervous activation, mitochondrial dysfunction and outcome in acutely decompensated cirrhosis: the metabolomic prognostic models (CLIF-C MET). Gut 2023; 72:1581-1591. [PMID: 36788015 PMCID: PMC10359524 DOI: 10.1136/gutjnl-2022-328708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/25/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND AND AIMS Current prognostic scores of patients with acutely decompensated cirrhosis (AD), particularly those with acute-on-chronic liver failure (ACLF), underestimate the risk of mortality. This is probably because systemic inflammation (SI), the major driver of AD/ACLF, is not reflected in the scores. SI induces metabolic changes, which impair delivery of the necessary energy for the immune reaction. This investigation aimed to identify metabolites associated with short-term (28-day) death and to design metabolomic prognostic models. METHODS Two prospective multicentre large cohorts from Europe for investigating ACLF and development of ACLF, CANONIC (discovery, n=831) and PREDICT (validation, n=851), were explored by untargeted serum metabolomics to identify and validate metabolites which could allow improved prognostic modelling. RESULTS Three prognostic metabolites strongly associated with death were selected to build the models. 4-Hydroxy-3-methoxyphenylglycol sulfate is a norepinephrine derivative, which may be derived from the brainstem response to SI. Additionally, galacturonic acid and hexanoylcarnitine are associated with mitochondrial dysfunction. Model 1 included only these three prognostic metabolites and age. Model 2 was built around 4-hydroxy-3-methoxyphenylglycol sulfate, hexanoylcarnitine, bilirubin, international normalised ratio (INR) and age. In the discovery cohort, both models were more accurate in predicting death within 7, 14 and 28 days after admission compared with MELDNa score (C-index: 0.9267, 0.9002 and 0.8424, and 0.9369, 0.9206 and 0.8529, with model 1 and model 2, respectively). Similar results were found in the validation cohort (C-index: 0.940, 0.834 and 0.791, and 0.947, 0.857 and 0.810, with model 1 and model 2, respectively). Also, in ACLF, model 1 and model 2 outperformed MELDNa 7, 14 and 28 days after admission for prediction of mortality. CONCLUSIONS Models including metabolites (CLIF-C MET) reflecting SI, mitochondrial dysfunction and sympathetic system activation are better predictors of short-term mortality than scores based only on organ dysfunction (eg, MELDNa), especially in patients with ACLF.
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Affiliation(s)
- Emmanuel Weiss
- Centre de Recherchesurl' Inflammation (CRI), Universite Paris Diderot, Paris, Île-de-France, France
- INSERM UMR_S1149, University Paris Cite, Paris, France
- Department of Anesthesiology and Critical Care, Hopital Beaujon, Clichy, France
| | | | | | | | | | | | | | | | | | | | - Thierry Gustot
- Department of Hepato Gastroenterology, Erasme Hospital, Université Libre de Bruxelles, Bruxelles, Bruxelles, Belgium
| | - Wim Laleman
- Division of Liver and Biliopanreatic Disorders, KU Leuven, University of Leuven, Leuven, Belgium
| | - Agustín Albillos
- Department of Gastroenterology, Hospital Ramon y Cajal, Madrid, Spain
- Universidad de Alcala de Henares, Madrid, Spain
| | | | - Marco Domenicali
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Center for Applied Biomedical Research (CRBA), S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Paolo Caraceni
- IRCCS Azienda-Ospedaliera Universitaria di Bologna, Department of Medical and Surgical Science - University of Bologna, Bologna, Italy
| | - Salvatore Piano
- Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Faouzi Saliba
- Centre Hepato-Biliare, Hopital Paul Brousse, Villejuif, France
| | - Stefan Zeuzem
- Department of Gastroenterology and Hepatology, J. W. Goethe-University Hospital, Frankfurt am Main, Hessen, Germany
| | | | - Julia A Wendon
- Institute of Liver Studies, King's College Hospital, London, UK
| | | | - Wenyi Gu
- Department of Internal Medicine B, University of Münster, Munster, Nordrhein-Westfalen, Germany
| | - Maria Papp
- Department of Internal Medicine, Division of Gastroenterology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Raj Mookerjee
- Institute of Liver and Digestive Health, University College London Medical School, London, UK
| | - Carmine Gabriele Gambino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine - DIMED, University of Padua, Padova, Veneto, Italy
| | | | - Ilaria Giovo
- Azienda Ospedaliero Universitaria Citta della Salute e della Scienza di Torino, Torino, Italy
| | - Giacomo Zaccherini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-related Diseases, University of Bologna Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Manuela Merli
- II Department of Gastroenterology, "La Sapienza" University, Rome, Italy
| | - Antonella Putignano
- Division of Gastroenterology and Gastrointestinal Endoscopy. Vita-Salute San Raffaele University - Scientific Institute San Raffaele, Milan, Italy
| | | | - Thomas Berg
- Medizinische Klinik, Gastroenterologie und Hepatologie, Berlin, Germany
| | - Tony Bruns
- Department of Medicine III, University Hospital Aachen, Aachen, Germany
| | - Christian Trautwein
- Deptartment of Internal Medicine III, University Hospital Aachen Department of Gastroenterology Metabolic Disorders and Intensive Medicine, Aachen, Germany
| | - Alexander Zipprich
- Department of Internal Medicine IV, Jena University Hospital, Jena, Germany
| | - Rafael Bañares
- Gastroenterology, IRYCIS, Hospital General Universitario Gregorio Marañón, Madrid, Madrid, Spain
| | | | - Joan Genesca
- Internal Medicine-Liver Unit, Hospital Universitari Vall d'Hebron, Barcelona, Barcelona, Spain
- Spain
| | - Victor Vargas
- Liver Unit, Hospital Vall d'Hebron, Barcelona, Barcelona, Spain
| | | | | | - Paolo Angeli
- Department of Clinical and Experimental Medicine, University of Padova, Padova, Italy
| | | | - Joan Claria
- Department of Biochemistry/Molecular Genetics, Hospital Clínic/University of Barcelona, Barcelona, Spain
| | | | - Richard Moreau
- Centre de Recherchesurl' Inflammation (CRI), Universite Paris Diderot, Paris, Île-de-France, France
- EF Clif, Barcelona, Catalunya, Spain
- Hepatology, Hôpital Beaujon, Clichy, France
| | - Jonel Trebicka
- EF Clif, Barcelona, Catalunya, Spain
- Translational Hepatology Department of Internal Medicine I, Goethe-Universitat Frankfurt am Main, Frankfurt am Main, Germany
- Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Vicente Arroyo
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
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11
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Abstract
Patients with cirrhosis frequently require admission to the intensive care unit (ICU). Common indications for admission to ICU include one or more reasons of sepsis, shock due to any cause, acute gastrointestinal bleeding, and altered mentation either due to hepatic encephalopathy, alcohol withdrawal/intoxication, or metabolic encephalopathy. The appropriate critical care of an individual can determine the outcomes of these sick patients. The Airway, Breathing, Circulation, Disability (ABCD) approach to a patient admitted to ICU includes airway, breathing, circulation, and disability management. In this review, the authors discuss the common indications for ICU admission in a patient with cirrhosis and also their management.
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Affiliation(s)
- Mahathi Avadhanam
- Department of Emergency Medicine, Queen Elizabeth hospital, London, UK
| | - Anand V Kulkarni
- Department of Hepatology, AIG Hospitals, Gachibowli, Hyderabad, India-500032.
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12
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Langer MM, Bauschen A, Guckenbiehl S, Klauss S, Lutz T, Denk G, Zwanziger D, Moeller LC, Lange CM. Evolution of non-thyroidal illness syndrome in acute decompensation of liver cirrhosis and acute-on-chronic liver failure. Front Endocrinol (Lausanne) 2023; 14:1104388. [PMID: 36755907 PMCID: PMC9899974 DOI: 10.3389/fendo.2023.1104388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/06/2023] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND AND AIMS Non-thyroidal illness syndrome (NTIS) is frequent in critically ill patients and associated with adverse outcomes. We aimed to characterize the evolution of NTIS in patients with acute decompensation (AD) of cirrhosis and acute-on-chronic liver failure (ACLF), since NTIS is not well described in these newly defined syndromes. METHODS Thyroid hormones (TH) were quantified at baseline in consecutive patients with cirrhosis. In addition, 76 inflammatory mediators were quantified by proximity extension analysis assay in a subgroup of patients. Associations between TH, cirrhosis stage, mortality and inflammation were assessed. RESULTS Overall, 437 patients were included, of whom 165 (37.8%), 211 (48.3%), and 61 (14%) had compensated cirrhosis (CC), AD, and ACLF. FT3 concentrations were lower in AD versus CC, and further decreased in ACLF. Importantly, NTIS was present in 83 (39.3%) patients with AD and in 44 (72.1%) patients with ACLF (P<0.001). Yet, TSH and TSH-based indexes (TSH/FT3-ratio, thyroid index) showed an U-shaped evolution during progression of cirrhosis, suggesting a partially preserved responsiveness of the hypothalamus and pituitary in AD. Infections were associated with lower FT3 concentrations in AD, but not in ACLF. Low FT3 concentrations correlated significantly with 90-day mortality. Both, AD/ACLF and NTIS, were associated with signatures of inflammatory mediators, which were partially non-overlapping. CONCLUSION NTIS is frequent already in AD and therefore precedes critically illness in a subgroup of patients with decompensated cirrhosis. This might constitute a new paradigm of TH signaling in cirrhosis, offering opportunities to explore preventive effects of TH in AD.
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Affiliation(s)
- Mona-May Langer
- Department for Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- Department of Internal Medicine II, Ludwig-Maximilians University (LMU) University Hospital Munich, Munich, Germany
| | - Alina Bauschen
- Department for Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Sabrina Guckenbiehl
- Department for Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Sarah Klauss
- Department of Internal Medicine II, Ludwig-Maximilians University (LMU) University Hospital Munich, Munich, Germany
| | - Teresa Lutz
- Department of Internal Medicine II, Ludwig-Maximilians University (LMU) University Hospital Munich, Munich, Germany
| | - Gerald Denk
- Department of Internal Medicine II, Ludwig-Maximilians University (LMU) University Hospital Munich, Munich, Germany
| | - Denise Zwanziger
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Lars C. Moeller
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Christian M. Lange
- Department for Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- Department of Internal Medicine II, Ludwig-Maximilians University (LMU) University Hospital Munich, Munich, Germany
- *Correspondence: Christian M. Lange,
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13
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Bajaj JS, Reddy KR, Tandon P, Garcia-Tsao G, Kamath PS, O’Leary JG, Wong F, Lai J, Vargas H, Thuluvath PJ, Subramanian RM, Pena-Rodriguez M, Sikaroodi M, Thacker LR, Gillevet PM. Association of serum metabolites and gut microbiota at hospital admission with nosocomial infection development in patients with cirrhosis. Liver Transpl 2022; 28:1831-1840. [PMID: 36017804 PMCID: PMC11097235 DOI: 10.1002/lt.26552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/02/2022] [Accepted: 07/18/2022] [Indexed: 02/07/2023]
Abstract
Cirrhosis is complicated by a high rate of nosocomial infections (NIs), which result in poor outcomes and are challenging to predict using clinical variables alone. Our aim was to determine predictors of NI using admission serum metabolomics and gut microbiota in inpatients with cirrhosis. In this multicenter inpatient cirrhosis study, serum was collected on admission for liquid chromatography-mass spectrometry metabolomics, and a subset provided stool for 16SrRNA analysis. Hospital course, including NI development and death, were analyzed. Metabolomic analysis using analysis of covariance (ANCOVA) (demographics, Model for End-Stage Liver Disease [MELD] admission score, white blood count [WBC], rifaximin, and infection status adjusted) and random forest analyses for NI development were performed. Additional values of serum metabolites over clinical variables toward NI were evaluated using logistic regression. Stool microbiota and metabolomic correlations were compared in patients with and without NI development. A total of 602 patients (231 infection admissions) were included; 101 (17%) developed NIs, which resulted in worse inpatient outcomes, including intensive care unit transfer, organ failure, and death. A total of 127 patients also gave stool samples, and 20 of these patients developed NIs. The most common NIs were spontaneous bacterial peritonitis followed by urinary tract infection, Clostridioides difficile, and pneumonia. A total of 247 metabolites were significantly altered on ANCOVA. Higher MELD scores (odds ratio, 1.05; p < 0.0001), admission infection (odds ratio, 3.54; p < 0.0001), and admission WBC (odds ratio, 1.05; p = 0.04) predicted NI (area under the curve, 0.74), which increased to 0.77 (p = 0.05) with lower 1-linolenoyl-glycerolphosphocholine (GPC) and 1-stearoyl-GPC and higher N-acetyltryptophan and N-acetyl isoputreanine. Commensal microbiota were lower and pathobionts were higher in those who developed NIs. Microbial-metabolite correlation networks were complex and dense in patients with NIs, especially sub-networks centered on Ruminococcaceae and Pseudomonadaceae. NIs are common and associated with poor outcomes in cirrhosis. Admission gut microbiota in patients with NIs showed higher pathobionts and lower commensal microbiota. Microbial-metabolomic correlations were more complex, dense, and homogeneous among those who developed NIs, indicating greater linkage strength. Serum metabolites and gut microbiota on admission are associated with NI development in cirrhosis.
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Affiliation(s)
- Jasmohan S. Bajaj
- Department of Medicine, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - K. Rajender Reddy
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Patrick S. Kamath
- Department of Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | | | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Lai
- Department of Medicine, University of California, San Francisco, California, USA
| | - Hugo Vargas
- Department of Medicine, Mayo Clinic, Phoenix, Arizona, USA
| | - Paul J. Thuluvath
- Department of Medicine, Mercy Medical Center, Baltimore, Maryland, USA
| | - Ram M. Subramanian
- Department of Medicine, Emory University Medical Center, Atlanta, Georgia, USA
| | | | - Masoumeh Sikaroodi
- Microbiome Analysis Center, George Mason University, Manassas, Virginia, USA
| | - Leroy R. Thacker
- Department of Medicine, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - Patrick M. Gillevet
- Microbiome Analysis Center, George Mason University, Manassas, Virginia, USA
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