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Idalsoaga F, Díaz LA, Fuentes-López E, Ayares G, Valenzuela F, Meza V, Manzur F, Sotomayor J, Rodriguez H, Chianale F, Villagrán S, Schalper M, Villafranca P, Veliz MJ, Uribe P, Puebla M, Bustamante P, Aguirre H, Busquets J, Roblero JP, Mezzano G, Hernandez-Tejero M, Arrese M, Arab JP. Active alcohol consumption is associated with acute-on-chronic liver failure in Hispanic patients. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:562-573. [PMID: 37778718 DOI: 10.1016/j.gastrohep.2023.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/16/2023] [Accepted: 09/18/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is a severe clinical entity associated with elevated short-term mortality. We aimed to characterize patients with decompensated cirrhosis according to presence of ACLF, their association with active alcohol intake, and long-term survival in Latin America. METHODS Retrospective cohort study of decompensated cirrhotic in three Chilean university centers (2017-2019). ACLF was diagnosed according EASL-CLIF criteria. We assessed survival using competing-risk and time-to-event analyses. We evaluated the time to death using accelerated failure time (AFT) models. RESULTS We included 320 patients, median age of 65.3±11.7 years old, and 48.4% were women. 92 (28.7%) patients met ACLF criteria (ACLF-1: 29.3%, ACLF-2: 27.1%, and ACLF-3: 43.4%). The most common precipitants were infections (39.1%), and the leading organ failure was kidney (59.8%). Active alcohol consumption was frequent (27.7%), even in patients with a prior diagnosis of non-alcoholic fatty liver disease (NAFLD) (16.2%). Ninety-two (28.7%) patients had ACLF (ACLF-1: 8.4%, ACLF-2: 7.8%, and ACLF-3: 12.5%). ACLF patients had a higher MELD-Na score at admission (27 [22-31] versus 16 [12-21], p<0.0001), a higher frequency of alcohol-associated liver disease (36.7% versus 24.9%, p=0.039), and a more frequent active alcohol intake (37.2% versus 23.8%, p=0.019). In a multivariate model, ACLF was associated with higher mortality (subdistribution hazard ratio 1.735, 95%CI: 1.153-2.609; p<0.008). In the AFT models, the presence of ACLF during hospitalization correlated with a shorter time to death: ACLF-1 shortens the time to death by 4.7 times (time ratio [TR] 0.214, 95%CI: 0.075-0.615; p<0.004), ACLF-2 by 4.4 times (TR 0.224, 95%CI: 0.070-0.713; p<0.011), and ACLF-3 by 37 times (TR 0.027, 95%CI: 0.006-0.129; p<0.001). CONCLUSIONS Patients with decompensated cirrhosis and ACLF exhibited a high frequency ofactive alcohol consumption. Patients with ACLF showed higher mortality and shorter time todeath than those without ACLF.
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Affiliation(s)
- Francisco Idalsoaga
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis Antonio Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo Fuentes-López
- Departamento de Ciencias de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gustavo Ayares
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Valenzuela
- Departamento de Medicina Interna, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Victor Meza
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Franco Manzur
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Joaquín Sotomayor
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Hernán Rodriguez
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Franco Chianale
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sofía Villagrán
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | | | | | - Paz Uribe
- Escuela de Medicina, Universidad de Chile, Santiago, Chile
| | | | - Pablo Bustamante
- Departamento de Medicina, Sección Gastroenterología, Hospital Clínico Universidad de Chile, Universidad de Chile, Santiago, Chile
| | - Herman Aguirre
- Departamento de Medicina, Sección Gastroenterología, Hospital Clínico Universidad de Chile, Universidad de Chile, Santiago, Chile
| | - Javiera Busquets
- Departamento de Medicina, Sección Gastroenterología, Hospital Clínico Universidad de Chile, Universidad de Chile, Santiago, Chile
| | - Juan Pablo Roblero
- Departamento de Medicina, Sección Gastroenterología, Hospital Clínico Universidad de Chile, Universidad de Chile, Santiago, Chile
| | - Gabriel Mezzano
- Sección de Gastroenterología, Hospital del Salvador, Santiago, Chile; Centro de Enfermedades Digestivas, Universidad de los Andes, Santiago, Chile
| | - Maria Hernandez-Tejero
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA; Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Marco Arrese
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan Pablo Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada.
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2
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Sasaki K, Rooge S, Gunewardena S, Hintz JA, Ghosh P, Pulido Ruiz IA, Yuquimpo K, Schonfeld M, Mehta H, Stevenson HL, Saldarriaga OA, Arroyave E, Tikhanovich I, Wozniak AL, Weinman SA. Kupffer cell diversity maintains liver function in alcohol-associated liver disease. Hepatology 2024:01515467-990000000-00871. [PMID: 38687563 DOI: 10.1097/hep.0000000000000918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 04/12/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND AND AIMS Liver macrophages are heterogeneous and play an important role in alcohol-associated liver disease (ALD) but there is limited understanding of the functions of specific macrophage subsets in the disease. We used a Western diet alcohol (WDA) mouse model of ALD to examine the hepatic myeloid cell compartment by single cell RNAseq and targeted KC ablation to understand the diversity and function of liver macrophages in ALD. APPROACH AND RESULTS In the WDA liver, KCs and infiltrating monocytes/macrophages each represented about 50% of the myeloid pool. Five major KC clusters all expressed genes associated with receptor-mediated endocytosis and lipid metabolism, but most were predicted to be noninflammatory and antifibrotic with 1 minor KC cluster having a proinflammatory and extracellular matrix degradation gene signature. Infiltrating monocyte/macrophage clusters, in contrast, were predicted to be proinflammatory and profibrotic. In vivo, diphtheria toxin-based selective KC ablation during alcohol exposure resulted in a liver failure phenotype with increases in PT/INR and bilirubin, loss of differentiated hepatocyte gene expression, and an increase in expression of hepatocyte progenitor markers such as EpCAM, CK7, and Igf2bp3. Gene set enrichment analysis of whole-liver RNAseq from the KC-ablated WDA mice showed a similar pattern as seen in human alcoholic hepatitis. CONCLUSIONS In this ALD model, KCs are anti-inflammatory and are critical for the maintenance of hepatocyte differentiation. Infiltrating monocytes/macrophages are largely proinflammatory and contribute more to liver fibrosis. Future targeting of specific macrophage subsets may provide new approaches to the treatment of liver failure and fibrosis in ALD.
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Affiliation(s)
- Kyo Sasaki
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Sheetalnath Rooge
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Sumedha Gunewardena
- Department of Cell Biology and Physiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Janice Averilla Hintz
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Priyanka Ghosh
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Kyle Yuquimpo
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Michael Schonfeld
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Heer Mehta
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Heather L Stevenson
- Department of Pathology, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Omar A Saldarriaga
- Department of Pathology, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Esteban Arroyave
- Department of Pathology, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Irina Tikhanovich
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Ann L Wozniak
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Steven A Weinman
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
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3
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Khan R, Salman S, Harford L, Sheriff L, Hazeldine J, Rajoriya N, Newsome PN, Lalor PF. Circulating myeloid populations have prognostic utility in alcohol-related liver disease. Front Immunol 2024; 15:1330536. [PMID: 38545104 PMCID: PMC10965684 DOI: 10.3389/fimmu.2024.1330536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/23/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction Alcohol-related liver disease (ARLD) accounts for over one third of all deaths from liver conditions, and mortality from alcohol-related liver disease has increased nearly five-fold over the last 30 years. Severe alcohol-related hepatitis almost always occurs in patients with a background of chronic liver disease with extensive fibrosis or cirrhosis, can precipitate 'acute on chronic' liver failure and has a high short-term mortality. Patients with alcohol-related liver disease have impaired immune responses, and increased susceptibility to infections, thus prompt diagnosis of infection and careful patient management is required. The identification of early and non-invasive diagnostic and prognostic biomarkers in ARLD remains an unresolved challenge. Easily calculated predictors of infection and mortality are required for use in patients who often exhibit variable symptoms and disease severity and may not always present in a specialized gastroenterology unit. Methods We have used a simple haematological analyser to rapidly measure circulating myeloid cell parameters across the ARLD spectrum. Results and Discussion We demonstrate for the first time that immature granulocyte (IG) counts correlate with markers of disease severity, and our data suggests that elevated counts are associated with increased short-term mortality and risk of infection. Other myeloid populations such as eosinophils and basophils also show promise. Thus IG count has the potential to serve alongside established markers such as neutrophil: lymphocyte ratio as a simply calculated predictor of mortality and risk of infectious complications in patients with alcohol-related hepatitis. This would allow identification of patients who may require more intensive management.
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Affiliation(s)
- Reenam Khan
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, Birmingham, United Kingdom
| | - Shees Salman
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Laura Harford
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, Birmingham, United Kingdom
| | - Lozan Sheriff
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, Birmingham, United Kingdom
| | - Jon Hazeldine
- Institute of Inflammation and Ageing, University of Birmingham, and Birmingham National Institute for Health Research (NIHR), Biomedical Research Centre, Birmingham, United Kingdom
| | - Neil Rajoriya
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Philip N. Newsome
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, and Birmingham National Institute for Health Research (NIHR), Biomedical Research Centre, Birmingham, United Kingdom
| | - Patricia F. Lalor
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, Birmingham, United Kingdom
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Mitri J, Almeqdadi M, Karagozian R. Prognostic and diagnostic scoring models in acute alcohol-associated hepatitis: A review comparing the performance of different scoring systems. World J Hepatol 2023; 15:954-963. [PMID: 37701919 PMCID: PMC10494564 DOI: 10.4254/wjh.v15.i8.954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/24/2023] [Accepted: 07/25/2023] [Indexed: 08/22/2023] Open
Abstract
Alcohol-associated hepatitis (AAH) is a severe form of liver disease caused by alcohol consumption. In the absence of confounding factors, clinical features and laboratory markers are sufficient to diagnose AAH, rule out alternative causes of liver injury and assess disease severity. Due to the elevated mortality of AAH, assessing the prognosis is a radical step in management. The Maddrey discriminant function (MDF) is the first established clinical prognostic score for AAH and was commonly used in the earliest AAH clinical trials. A MDF > 32 indicates a poor prognosis and a potential benefit of initiating corticosteroids. The model for end stage liver disease (MELD) score has been studied for AAH prognostication and new evidence suggests MELD may predict mortality more accurately than MDF. The Lille score is usually combined to MDF or MELD score after corticosteroid initiation and offers the advantage of assessing response to treatment a 4-7 d into the course. Other commonly used scores include the Glasgow Alcoholic Hepatitis Score and the Age Bilirubin international normalized ratio Creatinine model. Clinical AAH correlate adequately with histologic severity scores and leave little indication for liver biopsy in assessing AAH prognosis. AAH presenting as acute on chronic liver failure (ACLF) is so far prognosticated with ACLF-specific scoring systems. New artificial intelligence-generated prognostic models have emerged and are being studied for use in AAH. Acute kidney injury (AKI) is one possible complication of AAH and is significantly associated with increased AAH mortality. Predicting AKI and alcohol relapse are important steps in the management of AAH. The aim of this review is to discuss the performance and limitations of different scoring models for AAH mortality, emphasize the most useful tools in prognostication and review predictors of recurrence.
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Affiliation(s)
- Jad Mitri
- Department of Medicine, Saint Elizabeth's Medical Center, Boston, MA 02135, United States
| | - Mohammad Almeqdadi
- Division of Transplant and Hepatobiliary Disease, Tufts Medical Center, Boston, MA 02111, United States
| | - Raffi Karagozian
- Division of Gastroenterology & Hepatology, Tufts Medical Center, Boston, MA 02111, United States.
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5
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Reddy GS, Singh SP, Shasthry S. Successful Recovery from Severe Alcoholic Hepatitis (SAH) for Third Time. J Clin Exp Hepatol 2023; 13:713-715. [PMID: 37440953 PMCID: PMC10333933 DOI: 10.1016/j.jceh.2022.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 12/28/2022] [Indexed: 07/15/2023] Open
Abstract
Alcoholic hepatitis is a clinical syndrome with or without pre-existing chronic liver disease (CLD), and the majority of patients present with acute-on-chronic liver failure (ACLF) having a high 28-day mortality. The treatment of alcoholic hepatitis is suboptimal with corticosteroid having one 1month survival benefit but not translated to a survival benefit beyond six months. Survival benefit has been observed in only about 50-60% of treated patients. Long-term survival depends on underlying liver function and abstinence from alcohol. Relapse is reported in nearly half of the patients who recover from alcoholic hepatitis and even up to 17% after liver transplant. The data on repeated episodes of severe alcoholic hepatitis due to relapse and response to therapy are largely unknown. Here, we report a case of alcoholic hepatitis on three occasions in a period of 2 years follow-up and each time treated with steroids and had complete clinical recovery.
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Affiliation(s)
- Golamari S. Reddy
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Satender P. Singh
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - S.M. Shasthry
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
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6
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Affiliation(s)
- Ashwani K. Singal
- Address for correspondence: Ashwani K. Singal, University of South Dakota Sanford School of Medicine, University of South Dakota, Vermillion, SD, USA.
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7
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Mei X, Zou J, Shi B, Qian Z, Yi Z. High-Resolution Genomic Profiling of a Genotype 3b Hepatitis C Virus from a Flare of an Occult Hepatitis Patient with Acute-on-Chronic Liver Failure. Viruses 2023; 15:v15030634. [PMID: 36992343 PMCID: PMC10059314 DOI: 10.3390/v15030634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/22/2023] [Accepted: 02/24/2023] [Indexed: 03/03/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) is defined as a syndrome of acutely decompensated cirrhosis in patients with chronic liver disease (CLD). Here we report an ACLF case caused by a flare of occult hepatitis C infection. This patient was infected with hepatitis C virus (HCV) more than a decade ago and hospitalized due to alcohol-associated CLD. Upon admission, the HCV RNA in the serum was negative and the anti-HCV antibody was positive, whereas the viral RNA in the plasma dramatically increased during hospitalization, which suggests an occult hepatitis C infection. Overlapped fragments encompassing the nearly whole HCV viral genome were amplified, cloned, and sequenced. Phylogenetic analysis indicated an HCV genotype 3b strain. Sanger sequencing to 10-fold coverage of the 9.4-kb nearly whole genome reveals high diversity of viral quasispecies, an indicator of chronic infection. Inherent resistance-associated substitutions (RASs) in the NS3 and NS5A but not in the NS5B regions were identified. The patient developed liver failure and accepted liver transplantation, followed by direct-acting antiviral (DAA) treatment. The hepatitis C was cured by the DAA treatment despite the existence of RASs. Thus, care should be taken for occult hepatitis C in patients with alcoholic cirrhosis. The analysis of viral genetic diversity may help to identify an occult hepatitis C virus infection and predict the efficacy of anti-viral treatment.
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Affiliation(s)
- Xue Mei
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Jingyi Zou
- Key Laboratory of Medical Molecular Virology (MOE/NHC/CAMS), School of Basic Medical Sciences, Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai 200032, China
| | - Bisheng Shi
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Zhiping Qian
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Zhigang Yi
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
- Key Laboratory of Medical Molecular Virology (MOE/NHC/CAMS), School of Basic Medical Sciences, Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai 200032, China
- Correspondence:
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8
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Mirijello A, Sestito L, Antonelli M, Gasbarrini A, Addolorato G. Identification and management of acute alcohol intoxication. Eur J Intern Med 2023; 108:1-8. [PMID: 35985955 DOI: 10.1016/j.ejim.2022.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/03/2022] [Accepted: 08/11/2022] [Indexed: 02/07/2023]
Abstract
Acute alcohol intoxication (AAI) is a harmful clinical condition, potentially life-threatening, secondary to the intake of large amounts of alcohol. Clinical manifestations of AAI are characterized by behavioural and neurological symptoms, even if its effects involve several organs and apparatus. Moreover, severe alcohol intoxication can produce a global neurological impairment leading to autonomic dysfunction, respiratory depression, coma and cardiac arrest. The evaluation of blood alcohol concentrations (BAC) is useful to confirm the suspicion of intoxication, both for clinical and legal reasons. Most of patients with AAI are referred to Emergency Departments due to behavioural, social, traumatic or clinical complications. Patient's stabilization is the first step in the management of AAI, in order to support vital functions and to prevent complications. Metadoxine represents a useful drug to increase ethanol metabolism and elimination. Given that AAI could represent a sentinel event of chronic alcohol abuse, patients presenting with acute intoxication should be screened for the presence of an underlying alcohol use disorder and referred to and an alcohol addiction unit to start a multidisciplinary treatment to achieve long term alcohol abstinence. The present review will focus on clinical features, diagnostic criteria and treatment strategies of AAI.
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Affiliation(s)
- Antonio Mirijello
- Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Luisa Sestito
- Department of Medical Sciences, Hepatology and Gastroenterology Unit, Catholic University of Rome, Italy
| | - Mariangela Antonelli
- Department of Medical Sciences, Hepatology and Gastroenterology Unit, Catholic University of Rome, Italy
| | - Antonio Gasbarrini
- Department of Medical Sciences, Hepatology and Gastroenterology Unit, Catholic University of Rome, Italy
| | - Giovanni Addolorato
- Department of Medical Sciences, Hepatology and Gastroenterology Unit, Catholic University of Rome, Italy.
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