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Li X, Liu S, Guo Y, Zu H, Xiang H, Yang S, Zhang X, Meng F, Bianba Y, Li J, Liu F, Lei C, Lv J, Yang Q, Fu W, Ye W, Chen J, Gao Y, Wu C, Wang N, Zheng Q, Wang F, Yu J, Wang J, Yang X, Wang X, Liu Y, Zhao X, Wu C, Gou W, Bajaj JS, Wang F, Fu J, Qi X. Detection of minimal hepatic encephalopathy in patients with cirrhosis based on the Stroop-CN model (NCRCID-CHESS 2106): a prospective multicenter study. MedComm (Beijing) 2024; 5:e627. [PMID: 39015557 PMCID: PMC11247336 DOI: 10.1002/mco2.627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 05/21/2024] [Accepted: 05/23/2024] [Indexed: 07/18/2024] Open
Abstract
Minimal hepatic encephalopathy (MHE) has a substantial impact on the clinical outcomes and quality of life (QOL) of patients with cirrhosis. However, timely diagnosis and intervention are challenging due to sophisticated diagnostic methods. In this study, 673 healthy controls and 905 patients with cirrhosis were screened, and 660 healthy controls and 757 patients with cirrhosis, divided into the test (292 patients) and validation (465 patients) cohort, were analyzed after screening. A diagnostic model of the Stroop test (Stroop-CN) was constructed by multivariate linear regression based on the results of healthy controls. The prevalence of MHE and the comparison results with psychometric hepatic encephalopathy score through the Stroop-CN model were stable in the test and validation cohorts. Moreover, the prevalence of MHE remained significantly higher in patients with worse disease conditions marked as high Child-Pugh grades and the Model for End-stage Liver Disease and Sodium (MELD-Na) scores in the test and validation cohort. The EuroQol 5-D questionnaire revealed that patients with MHE had a worse QOL than those without MHE both in the test and validation cohort. In conclusion, an easy and practical Stroop-CN model for MHE diagnosis based on the EncephalApp is established. It is found that a considerable number of Chinese patients with cirrhosis experience MHE, which significantly impacts their QOL.
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Affiliation(s)
- Xiaoyan Li
- Medical School of Chinese PLABeijingChina
- Senior Department of Infectious DiseasesThe Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious DiseasesBeijingChina
| | - Shanghao Liu
- Center of Portal HypertensionDepartment of RadiologyZhongda Hospital, Medical School, Southeast University, Nurturing Center of Jiangsu Province for State Laboratory of AI Imaging & Interventional Radiology (Southeast University)NanjingChina
- Basic Medicine Research and Innovation Center of Ministry of EducationZhongda HospitalSoutheast UniversityNanjingChina
- State Key Laboratory of Digital Medical EngineeringNanjingChina
| | - Ying Guo
- Department of HepatologyThe Third People's Hospital of TaiyuanTaiyuanChina
| | - Hongmei Zu
- Department of GastroenterologyThe Fourth People's Hospital of Qinghai ProvinceXiningChina
| | - Huiling Xiang
- Department of Gastroenterology and HepatologyTianjin Third Central Hospital, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Institute of Hepatobiliary DiseaseTianjinChina
| | - Shaoqi Yang
- Department of GastroenterologyThe General Hospital of Ningxia Medical UniversityYinchuanChina
| | - Xiaoning Zhang
- Senior Department of Infectious DiseasesThe Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious DiseasesBeijingChina
| | - Fanping Meng
- Senior Department of Infectious DiseasesThe Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious DiseasesBeijingChina
| | - Yangzhen Bianba
- Department of HepatologyThe Third People's Hospital of Tibet Autonomous RegionLhasaChina
| | - Jie Li
- Department of Infectious DiseasesNanjing Drum Tower Hospital, The Affiliated Hospital of Medical SchoolNanjing UniversityNanjingChina
| | - Fei Liu
- Department of Infectious DiseasesHunan Key Laboratory of Viral HepatitisXiangya HospitalCentral South UniversityChangshaChina
| | - Chuang Lei
- Department of Infectious DiseasesThe First People's Hospital of Changde CityChangdeChina
| | - Jiaojian Lv
- Department of Infectious DiseaseLishui City People's HospitalLishuiChina
| | - Qiao‐hua Yang
- Hepatology Department of Infectious Diseases CenterThe First People's Hospital of HuaihuaHuaihuaChina
| | - Wei Fu
- Department of HepatologyShenyang 739 HospitalShenyangChina
| | - Wei Ye
- Liver Cirrhosis Treatment CenterNanjing Hospital Affiliated to Nanjing University of Traditional Chinese MedicineNanjingChina
| | - Jiafang Chen
- Department of GastroenterologyDatong City Fourth People's HospitalDatongChina
| | - Yanjing Gao
- Department of GastroenterologyQilu Hospital of Shandong UniversityJinanChina
| | - Caiyun Wu
- Department of HepatologyThird People′s Hospital of Linfen CityLinfenChina
| | - Ningning Wang
- Department of GastroenterologyThe First Hospital of China Medical UniversityShenyangChina
| | - Qi Zheng
- Department of HepatologyHepatology Research InstituteThe First Affiliated HospitalFujian Medical UniversityFuzhouChina
| | - Fang Wang
- Department of HepatologyShenzhen Third People's Hospital, National Clinical Research Center for Infectious Disease, The Second Affiliated Hospital, School of Medicine, Southern University of Science and TechnologyShenzhenChina
| | - Jiali Yu
- Department of GastroenterologyThe First Affiliated Hospital of Dalian Medical UniversityDalianChina
| | - Jing Wang
- Department of GastroenterologyThe Second Affiliated Hospital of Baotou Medical CollegeBaotouChina
| | - Xiaoting Yang
- Department of GastroenterologyWuzhong People's HospitalWuzhongChina
| | - Xiangmei Wang
- Department of Severe HepatologyMengchao Hepatobiliary Hospital of Fujian Medical UniversityFuzhouChina
| | - Yayuan Liu
- Department of GastroenterologyCentral hospital of DandongDandongChina
| | - Xuelan Zhao
- Department of Gastroenterology Liver DiseasesChongqing Public Health Medical CenterChongqingChina
| | - Chenxi Wu
- Liver Disease Diagnosis and Treatment CenterYiyang Fourth People's HospitalYiyangChina
| | - Wei Gou
- Qingdao Sixth People's HospitalQingdaoChina
| | - Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology and NutritionVirginia Commonwealth University and Central Virginia Veterans Healthcare SystemRichmondVirginiaUSA
| | - Fu‐Sheng Wang
- Medical School of Chinese PLABeijingChina
- Senior Department of Infectious DiseasesThe Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious DiseasesBeijingChina
| | - Junliang Fu
- Medical School of Chinese PLABeijingChina
- Senior Department of Infectious DiseasesThe Fifth Medical Center of Chinese PLA General Hospital, National Clinical Research Center for Infectious DiseasesBeijingChina
| | - Xiaolong Qi
- Center of Portal HypertensionDepartment of RadiologyZhongda Hospital, Medical School, Southeast University, Nurturing Center of Jiangsu Province for State Laboratory of AI Imaging & Interventional Radiology (Southeast University)NanjingChina
- Basic Medicine Research and Innovation Center of Ministry of EducationZhongda HospitalSoutheast UniversityNanjingChina
- State Key Laboratory of Digital Medical EngineeringNanjingChina
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Sørensen M, Lauridsen MM, Montagnese S. The social and psychological impact of hepatic encephalopathy. Metab Brain Dis 2024:10.1007/s11011-024-01384-x. [PMID: 39009929 DOI: 10.1007/s11011-024-01384-x] [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: 05/05/2024] [Accepted: 07/06/2024] [Indexed: 07/17/2024]
Abstract
Hepatic encephalopathy (HE) is a brain dysfunction caused by liver insufficiency with symptoms ranging from slight cognitive changes detectable only by neuropsychiatric testing to coma. Up to 60% of patients with cirrhosis have mild forms of HE and 35% will at some point experience overt HE. Even in its milder forms, HE impacts the patient's daily routines, self-sufficiency, quality of life, and, thereby, socio-economic status. HE is a condition affecting the whole household including formal and informal caregivers, who carry a heavy burden. Early identification, prophylaxis, and treatment of HE are essential for relieving patients and informal caregivers.
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Affiliation(s)
- Michael Sørensen
- Department of Internal Medicine, Viborg Regional Hospital, Viborg, Denmark.
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.
| | - Mette Munk Lauridsen
- Department of Gastroenterology & Hepatology, Institute for Regional Health Research, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Sara Montagnese
- Department of Medicine (DIMED), University of Padova, Padova, Italy
- Chronobiology, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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Sultanik P, Kheloufi L, Leproux A, Bouzbib C, Mouri S, Santiago A, Galanaud D, Navarro V, Sakka M, Rudler M, Weiss N, Thabut D. Other causes of neurocognitive impairment than covert hepatic encephalopathy (CHE) are very frequent, either alone or associated with CHE, in cirrhotic patients with cognitive complaints. Aliment Pharmacol Ther 2024. [PMID: 38973133 DOI: 10.1111/apt.18148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 05/27/2024] [Accepted: 06/22/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND/AIMS Although it is well admitted that cirrhotic patients display various causes of neurocognitive impairment (NI) hampering the diagnosis of covert hepatic encephalopathy (CHE), those are almost never investigated per se. The aims of this study were, in cirrhotic patients displaying cognitive complaints explored by a complete multimodal work-up, to assess: (1) the prevalence of CHE and/or that of other causes of NI and (2) their outcomes, according to the cause of NI. METHODS Prospective cohort of cirrhotic patients referred in a dedicated clinic because of cognitive complaints. Work-up included a complete neuropsychological assessment, electroencephalogram (EEG) and brain magnetic resonance imaging with spectroscopy. The diagnosis of CHE was made by an adjudication committee involving the physicians/neuropsychologist. RESULTS One hundred and twenty-three patients were included (alcohol/MASLD/virus in 63/53/14%, MELD = 11). Sixty-six per cent of them were diagnosed with CHE; among them, 73% exhibited also other causes of NI, mainly cerebrovascular diseases/psychiatric. Among patients without CHE, 48% and 59% displayed pathological Psychometric Hepatic Encephalopathy Score and animal naming test, respectively. Clinical improvement was observed in 77% of the patients re-evaluated after specific management. CHE, but not the other causes of NI, was independently associated with OHE occurrence. CONCLUSION Other causes of NI than CHE are frequent in patients with cirrhosis, and not ruled-out by the classical tests dedicated to CHE. Prognosis was influenced by the cause of NI. The management of patients even without CHE led to clinical improvement, underlining the need for a multifaceted approach of cirrhotic patients with cognitive complaints.
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Affiliation(s)
- Philippe Sultanik
- Liver Intensive Care Unit, Hepatogastroenterology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Lyes Kheloufi
- Liver Intensive Care Unit, Hepatogastroenterology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
- INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, biliaires et fibro-inflammatoire du foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Apolline Leproux
- Liver Intensive Care Unit, Hepatogastroenterology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Charlotte Bouzbib
- Liver Intensive Care Unit, Hepatogastroenterology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Sarah Mouri
- Liver Intensive Care Unit, Hepatogastroenterology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Antoine Santiago
- Liver Intensive Care Unit, Hepatogastroenterology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Damien Galanaud
- Neuroradiology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Vincent Navarro
- Neurology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Mehdi Sakka
- Biochemistry Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Marika Rudler
- Liver Intensive Care Unit, Hepatogastroenterology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
- INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, biliaires et fibro-inflammatoire du foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Nicolas Weiss
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
- INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, biliaires et fibro-inflammatoire du foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
- Neurology Intensive Care Unit, Neurology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Dominique Thabut
- Liver Intensive Care Unit, Hepatogastroenterology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
- INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, biliaires et fibro-inflammatoire du foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
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4
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Nourbakhsh S, Ferrando SJ. Primary versus secondary psychosis in a patient with congenital liver disease. BMJ Case Rep 2024; 17:e259623. [PMID: 38960424 PMCID: PMC11227732 DOI: 10.1136/bcr-2024-259623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2024] [Indexed: 07/05/2024] Open
Abstract
In this article we report the case of a man with congenital liver disease who later developed psychotic illness and was diagnosed with schizophrenia. We illustrate how decompensation in liver function was associated with the exacerbation of psychotic symptoms. We discuss differential diagnostic challenges, and the possible overlapping neuropathology in these two conditions that may converge on glutamate/N-methyl-D-aspartate dysfunction. This patient's case underscores the need for further research to elucidate the possible underlying mechanisms linking congenital liver disease and psychosis.
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Affiliation(s)
- Sormeh Nourbakhsh
- Psychiatry, Westchester Medical Center, Valhalla, New York, USA
- New York Medical College, Valhalla, New York, USA
| | - Stephen J Ferrando
- Westchester Medical Center Health Network, Valhalla, New York, USA
- New York Medical College School of Medicine, Valhalla, New York, USA
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5
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Sasaki T, Kakisaka K, Kuroda H, Matsumoto T. Nutritional management for acute liver failure. Hepatol Res 2024. [PMID: 38949571 DOI: 10.1111/hepr.14090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 06/04/2024] [Accepted: 06/14/2024] [Indexed: 07/02/2024]
Abstract
Acute liver failure (ALF) induces increased energy expenditure and disrupts the metabolism of essential nutrients. Hepatic encephalopathy is a complication of ALF with a poor prognosis and mainly involves the metabolic disturbance of amino acids in its pathogenesis. In this review, we discuss the nutritional management for ALF in consideration of the pathophysiology of ALF with respect to the impairment of hepatocyte function. It is known that enteral nutrition is recommended for patients with ALF, while parenteral nutrition is recommended for patients who cannot tolerate enteral nutrition. As ALF leads to a hypermetabolic state, the energy intake is recommended to cover 1.3 times the resting energy expenditure. Because of the high risk of hypoglycemia associated with disturbances in glucose metabolism, substantial glucose intake is recommended. Along with the deterioration of glucose metabolism, protein metabolism is also disrupted. As patients with ALF have increased systemic protein catabolism together with decreased protein synthesis, appropriate amounts of amino acids or protein under monitoring serum ammonia levels are recommended. In conclusion, nutritional management based on the understanding of nutritional pathophysiology is a pivotal therapeutic approach for patients with ALF. The approach should be individualized in the acute phase, the recovery phase, and the pretransplant phase.
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Affiliation(s)
- Tokio Sasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, School of Medicine, Yahaba, Japan
| | - Keisuke Kakisaka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, School of Medicine, Yahaba, Japan
| | - Hidekatsu Kuroda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, School of Medicine, Yahaba, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, School of Medicine, Yahaba, Japan
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6
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Zhang Y, Zhan L, Zhang L, Shi Q, Li L. Branched-Chain Amino Acids in Liver Diseases: Complexity and Controversy. Nutrients 2024; 16:1875. [PMID: 38931228 PMCID: PMC11206364 DOI: 10.3390/nu16121875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/11/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
Branched-chain amino acids (BCAAs), as essential amino acids, engage in various physiological processes, such as protein synthesis, energy supply, and cellular signaling. The liver is a crucial site for BCAA metabolism, linking the changes in BCAA homeostasis with the pathogenesis of a variety of liver diseases and their complications. Peripheral circulating BCAA levels show complex trends in different liver diseases. This review delineates the alterations of BCAAs in conditions including non-alcoholic fatty liver disease, hepatocellular carcinoma, cirrhosis, hepatic encephalopathy, hepatitis C virus infection, and acute liver failure, as well as the potential mechanisms underlying these changes. A significant amount of clinical research has utilized BCAA supplements in the treatment of patients with cirrhosis and liver cancer. However, the efficacy of BCAA supplementation in clinical practice remains uncertain and controversial due to the heterogeneity of studies. This review delves into the complicated relationship between BCAAs and liver diseases and tries to untangle what role BCAAs play in the occurrence, development, and outcomes of liver diseases.
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Affiliation(s)
- Yaqi Zhang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou 310003, China
| | - Luqi Zhan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou 310003, China
| | - Lingjian Zhang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou 310003, China
- Affiliated Hangzhou First People’s Hospital, School of Medicine, Westlake University, Hangzhou 310024, China
| | - Qingmiao Shi
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou 310003, China
| | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd., Hangzhou 310003, China
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7
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Ma L, Ma J, Zhang W, Yu J, Zhang Z, Yang M, Zhou Y, Ju S, Gu G, Luo J, Yan Z. Reduced risk of overt hepatic encephalopathy and death after transjugular intrahepatic portosystemic shunt in patients with hepatic venovenous communications. Eur J Radiol 2024; 177:111554. [PMID: 38850724 DOI: 10.1016/j.ejrad.2024.111554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/31/2024] [Accepted: 06/04/2024] [Indexed: 06/10/2024]
Abstract
PURPOSE Hepatic venovenous communications (HVVC) is detectable in more than one-third of cirrhotic patients, where portal hypertension (PHT) tends to present more severely. We aimed to explore the prognostic implications of HVVC in patients with sinusoidal PHT treated by transjugular intrahepatic portosystemic shunt (TIPS). METHOD The multicenter data of patients (2020-2022) undergoing balloon-occluded hepatic venography during TIPS were retrospectively analyzed. Pre-TIPS total bile acids (TBA) levels in portal, hepatic and peripheral veins were compared between groups. The primary endpoint was the development of overt hepatic encephalopathy (HE) within one year after TIPS. RESULTS 183 patients were eligible and classified by the presence (n = 69, 37.7 %) or absence (n = 114, 62.3 %) of HVVC. The agreement between wedged hepatic venous pressure and portal venous pressure was poor in HVVC group (intraclass correlation coefficients [ICC]: 0.141, difference: 13.4 mmHg, p < 0.001), but almost perfect in non-HVVC group (ICC: 0.877, difference: 0.4 mmHg, p = 0.152). At baseline, patients with HVVC had lower Model for end-stage liver disease scores (p < 0.001), blood ammonia levels (p < 0.001), TBA concentrations in the hepatic (p = 0.011) and peripheral veins (p = 0.049) rather than in the portal veins (p = 0.516), and a higher portosystemic pressure gradient (p = 0.035), suggesting more effective intrahepatic perfusion in this group. Within 1-year post-TIPS, HVVC group had a lower incidence of overt HE (11.7 % vs. 30.5 %, p = 0.004, HR: 0.34, 95 % CI: 0.16-0.74, absolute risk difference [ARD]: -17.4) and an improved liver transplantation-free survival rate (97.1 % vs. 86.8 %, p = 0.021, HR: 0.16, 95 % CI: 0.05-0.91, ARD: -10.3). CONCLUSIONS For patients with sinusoidal PHT treated by TIPS, the presence of HVVC was associated with a reduced risk of overt HE and a potential survival benefit.
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Affiliation(s)
- Li Ma
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jingqin Ma
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen Zhang
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiaze Yu
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zihan Zhang
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Minjie Yang
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yongjie Zhou
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shuai Ju
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China
| | - Guoqiang Gu
- Department of Radiology, Minhang Hospital, Fudan University, Shanghai, China
| | - Jianjun Luo
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China; Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.
| | - Zhiping Yan
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China; Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.
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8
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Jhajharia A, Singh S, Jana S, Ashdhir P, Nijhawan S. Intravenous versus oral 'L-ornithine-L-aspartate' in overt hepatic encephalopathy: a randomized comparative study. Sci Rep 2024; 14:11862. [PMID: 38789596 PMCID: PMC11126676 DOI: 10.1038/s41598-024-62293-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
Hepatic encephalopathy (HE), a morbid ordeal affecting chronic liver disease patients always insists for the search of a rational, superior & infallible agent beyond the time-proven standards i.e., Lactulose & Rifaximin. In this RCT, we compared the efficacy of intravenous (IV) L-ornithine-L-aspartate(LOLA) versus Oral LOLA in patients with chronic liver disease(CLD) enduring overt Hepatic Encephalopathy(OHE). 40 CLD patients with OHE were randomly assigned IV or oral LOLA in a 1:1 ratio. Patients were graded for HE and monitored for serum ammonia levels from day 1 to day 5. The aim was to compare IV versus oral LOLA efficacy in HE grades improvement and its correlation with ammonia levels. The study was registered with clinical trials registry-India, CTRI/2020/12/029943. Baseline characteristics of patients in both groups were similar. The mean difference in ammonia levels from day 1 to day 5 was 55.4 ± 32.58 µmol/L in the IV LOLA group and 60.75 ± 13.82 µmol/L in the oral LOLA group (p = 0.511). Significant reductions in ammonia levels were observed from day 1 to day 5 within each group (p < 0.001). HE grade & ammonia correlated positively in both groups. LOLA, regardless of administration route, has demonstrated efficacy in OHE.
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Affiliation(s)
- Ashok Jhajharia
- Department of Gastroenterology, SMS Medical College & Hospital, Jaipur, Rajasthan, 302004, India.
- , House No. 109, Shiv Vihar, VKI, Infront of road number 5, Sikar Road, Jaipur, 302039, India.
| | - Shashank Singh
- Department of Gastroenterology, SMS Medical College & Hospital, Jaipur, Rajasthan, 302004, India
| | - Sangeeta Jana
- Department of Gastroenterology, SMS Medical College & Hospital, Jaipur, Rajasthan, 302004, India
| | - Prachis Ashdhir
- Department of Gastroenterology, SMS Medical College & Hospital, Jaipur, Rajasthan, 302004, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, SMS Medical College & Hospital, Jaipur, Rajasthan, 302004, India
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Kulkarni AV, Avadhanam M, Karandikar P, Rakam K, Gupta A, Simhadri V, Premkumar M, Zuberi AA, Gujjarlapudi D, Narendran R, Shaik S, Sharma M, Iyengar S, Alla M, Venishetty S, Reddy DN, Rao PN. Antibiotics With or Without Rifaximin for Acute Hepatic Encephalopathy in Critically Ill Patients With Cirrhosis: A Double-Blind, Randomized Controlled (ARiE) Trial. Am J Gastroenterol 2024; 119:864-874. [PMID: 37942950 DOI: 10.14309/ajg.0000000000002575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 10/10/2023] [Indexed: 11/10/2023]
Abstract
INTRODUCTION Critically ill patients with cirrhosis admitted to the intensive care unit (ICU) are usually on broad-spectrum antibiotics because of suspected infection or as a hospital protocol. It is unclear if additional rifaximin has any synergistic effect with broad-spectrum antibiotics in ICU patients with acute overt hepatic encephalopathy (HE). METHODS In this double-blind trial, patients with overt HE admitted to ICU were randomized to receive antibiotics (ab) alone or antibiotics with rifaximin (ab + r). Resolution (or 2 grade reduction) of HE, time to resolution of HE, in-hospital mortality, nosocomial infection, and changes in endotoxin levels were compared between the 2 groups. A subgroup analysis of patients with decompensated cirrhosis and acute-on-chronic liver failure was performed. RESULTS Baseline characteristics and severity scores were similar among both groups (92 in each group). Carbapenems and cephalosporin with beta-lactamase inhibitors were the most commonly used ab. On Kaplan-Meier analysis, 44.6% (41/92; 95% confidence interval [CI], 32-70.5) in ab-only arm and 46.7% (43/92; 95% CI, 33.8-63) in ab + r arm achieved the primary objective ( P = 0.84).Time to achieve the primary objective (3.65 ± 1.82 days and 4.11 ± 2.01 days; P = 0.27) and in-hospital mortality were similar among both groups (62% vs 50%; P = 0.13). Seven percent and 13% in the ab and ab + r groups developed nosocomial infections ( P = 0.21). Endotoxin levels were unaffected by rifaximin. Rifaximin led to lower in-hospital mortality (hazard ratio: 0.39 [95% CI, 0.2-0.76]) in patients with decompensated cirrhosis but not in patients with acute-on-chronic liver failure (hazard ratio: 0.99 [95% CI, 0.6-1.63]) because of reduced nosocomial infections. DISCUSSION Reversal of overt HE in those on ab was comparable with those on ab + r.
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Affiliation(s)
| | | | | | - Kalyan Rakam
- Department of Critical Care Medicine, AIG Hospitals, Hyderabad, India
| | - Anand Gupta
- Department of Critical Care Medicine, AIG Hospitals, Hyderabad, India
| | - Venu Simhadri
- Department of Basic Sciences, Asian Healthcare Foundation, Hyderabad, India
| | | | | | | | | | - Sameer Shaik
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Mithun Sharma
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Sowmya Iyengar
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Manasa Alla
- Department of Hepatology, AIG Hospitals, Hyderabad, India
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10
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Shetty A, Saab EG, Choi G. Social Impact of Hepatic Encephalopathy. Clin Liver Dis 2024; 28:273-285. [PMID: 38548439 DOI: 10.1016/j.cld.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Hepatic encephalopathy is a medical condition that stems from liver dysfunction, leading to the accumulation of toxins in the bloodstream. This can result in cognitive impairments, mood changes, and motor dysfunction. Its social impact includes challenges in employment, relationships, and daily functioning for affected individuals. Stigma and misunderstanding around the condition can further exacerbate the difficulties faced by both patients and their caregivers. Efforts to raise awareness, improve medical management, and provide support systems can help mitigate the social impact of hepatic encephalopathy.
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Affiliation(s)
- Akshay Shetty
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA.
| | - Elena G Saab
- School of Medicine, Wake Forest University, Winston Salem, NC, USA
| | - Gina Choi
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
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11
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He Q, Mao C, Chen Z, Zeng Y, Deng Y, Hu R. Efficacy of L-ornithine L-aspartate for minimal hepatic encephalopathy in patients with cirrhosis: A meta-analysis of randomized controlled trials. Arab J Gastroenterol 2024; 25:84-92. [PMID: 38403493 DOI: 10.1016/j.ajg.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/12/2023] [Accepted: 01/06/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND AND STUDY AIMS Minimal hepatic encephalopathy (MHE) is an early stage of hepatic encephalopathy (HE) and is highly prevalent. The efficacy of L-ornithine L-aspartate (LOLA) for the treatment of HE is well known but its role in MHE remains uncertain. The objectives of the current study were to evaluate the efficacy of LOLA for the treatment of MHE in patients with cirrhosis. METHODS The Cochrane Library, PubMed, EMBASE, Web of Science and Ovid databases were searched. Only randomized controlled trials (RCTs) that compared the efficacy of LOLA with placebo or no intervention for the treatment of MHE in patients with cirrhosis were included from inception to January 2023. The primary outcomes were reversal of MHE and development of overt hepatic encephalopathy (OHE). RESULTS Overall, six RCTs comprising 292 patients were included. Compared with placebo or no intervention, LOLA was more effective in reversing MHE (RR = 2.264, 95 % CI = 1.528, 3.352, P = 0.000, I2 = 0.0 %) and preventing progression of OHE (RR = 0.220, 95 % CI = 0.076, 0.637, P = 0.005, I2 = 0.0 %). Based on subgroup analyses, oral LOLA treatment appeared more likely to reverse MHE (RR = 2.648, 95 % CI = 1.593, 4.402, P = 0.000, I2 = 0.0 %), intravenous LOLA treatment yielded a similar probability of reversing MHE (RR = 1.669, 95 % CI = 0.904, 3.084, P = 0.102, I2 = 0.0 %). LOLA did not show a superior possibility in reducing mortality (RR = 0.422, 95 % CI = 0.064, 2.768, P = 0.368, I2 = 0.0 %) and ammonia levels (SMD = 0.044, 95 % CI = -0.290, 0.379, P = 0.795, I2 = 0.0 %) compared with placebo or no intervention. CONCLUSIONS LOLA has significant beneficial effects on reversal of MHE and prevention of OHE in patients with cirrhosis compared with placebo or no intervention.
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Affiliation(s)
- Qiufeng He
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Chuangjie Mao
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Zhili Chen
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Yilan Zeng
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Yang Deng
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Rong Hu
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China.
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12
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Singh J, Ibrahim B, Han SH. Nontraditional Treatment of Hepatic Encephalopathy. Clin Liver Dis 2024; 28:297-315. [PMID: 38548441 DOI: 10.1016/j.cld.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
The pathophysiology of hepatic encephalopathy (HE) is complex, with hyperammonemia playing a central role in its development. Traditional therapies for HE have targeted ammonia and include medications such as lactulose and rifaximin. Although these agents are considered standard of care, nontraditional treatments seek to affect other factors in the pathogenesis of HE. Finally, procedural therapies include albumin dialysis, shunt closure, and the ultimate cure for HE, which is liver transplant. The treatments discussed provide alternative options for patients who have failed standard of care. However, more high-quality studies are needed to routinely recommend many of these agents.
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Affiliation(s)
- Jasleen Singh
- Department of Medicine, University of California at Los Angeles; Los Angeles, CA, USA.
| | - Brittney Ibrahim
- Department of Surgery, University of California at Los Angeles; Los Angeles, CA, USA
| | - Steven-Huy Han
- Department of Medicine, University of California at Los Angeles; Los Angeles, CA, USA; Department of Surgery, University of California at Los Angeles; Los Angeles, CA, USA
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13
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de Wit K, van Doorn DJ, Mol B, van Vught LA, Nevens F, Beuers U, Ponsioen CY, Teunissen CE, Takkenberg RB. Neurofilament light chain but not glial fibrillary acidic protein is a potential biomarker of overt hepatic encephalopathy in patients with cirrhosis. Ann Hepatol 2024; 29:101496. [PMID: 38460714 DOI: 10.1016/j.aohep.2024.101496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/04/2023] [Accepted: 01/04/2024] [Indexed: 03/11/2024]
Abstract
INTRODUCTION AND OBJECTIVES Hepatic encephalopathy (HE) is a frequent complication of cirrhosis and may cause cerebral damage. Neurodegenerative diseases can induce the release of neuroproteins like neurofilament light chain (NfL) and glial fibrillary acidic protein (GFAP) in body fluids, including blood plasma. We investigated whether NfL and GFAP could serve as potential diagnostic plasma biomarkers for overt HE (oHE). MATERIALS AND METHODS We included 85 patients from three prospective cohorts with different stages of liver disease and HE severity. The following patients were included: 1) 34 patients with primary sclerosing cholangitis (PSC) with compensated disease; 2) 17 patients with advanced liver disease without oHE before elective transjugular intrahepatic portosystemic shunt (TIPS) placement; 3) 17 intensive care unit (ICU) patients with oHE and 17 ICU patients without cirrhosis or oHE. Plasma NfL and GFAP were measured using single molecule assays. RESULTS ICU oHE patients had higher NfL concentrations compared to pre-TIPS patients or ICU controls (p < 0.05, each). Median GFAP concentrations were equal in the ICU oHE and pre-TIPS patients or ICU controls. Plasma NfL and GFAP concentrations correlated with Model for End-Stage Liver Disease (MELD) scores (R = 0.58 and R = 0.40, p < 0.001, each). CONCLUSIONS Plasma NfL deserves further evaluation as potential diagnostic biomarker for oHE and correlates with the MELD score.
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Affiliation(s)
- Koos de Wit
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Diederick J van Doorn
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Bregje Mol
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Lonneke A van Vught
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Center of Experimental and Molecular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospitals KU Leuven, Leuven, Belgium
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Charlotte E Teunissen
- Neurochemistry Laboratory, Department of Clinical Chemistry, Amsterdam Neuroscience, Neurodegeneration, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - R Bart Takkenberg
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands.
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14
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Amodio P, Montagnese S. No Solid Reasons Not to Measure Ammonia. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00395-1. [PMID: 38692556 DOI: 10.1016/j.cgh.2024.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 03/26/2024] [Indexed: 05/03/2024]
Affiliation(s)
- Piero Amodio
- Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Sara Montagnese
- Department of Medicine (DIMED), University of Padova, Padova, Italy
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15
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Tonon M, D'Ambrosio R, Calvino V, Tosetti G, Barone A, Incicco S, Gambino C, Gagliardi R, Borghi M, Zeni N, Piano S, Lampertico P, Angeli P. A new clinical and prognostic characterization of the patterns of decompensation of cirrhosis. J Hepatol 2024; 80:603-609. [PMID: 38110003 DOI: 10.1016/j.jhep.2023.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/21/2023] [Accepted: 12/04/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND & AIMS The prognostic impact of acute decompensation (AD), i.e. the development of complications that require hospitalization, has recently been assessed. However, complications of cirrhosis do not necessarily require hospitalization and can develop progressively, as in the recently defined non-acute decompensation (NAD). Nevertheless, there is no data regarding the incidence and prognostic impact of NAD. The aim of the study was to evaluate the incidence and the prognostic impact of NAD and AD in outpatients with cirrhosis. METHODS A total of 617 outpatients with cirrhosis from two Italian tertiary centers (Padua and Milan) were enrolled from January 2003 to June 2021 and followed prospectively until the end of the study, death or liver transplantation. The complications registered during follow-up were considered as AD if they required hospitalization, or NAD if managed at the outpatient clinic. RESULTS During follow-up, 154 patients (25.0% of total patients) developed complications, 69 patients (44.8%) developed NAD and 85 (55.2%) developed AD, while 29 patients with NAD (42.0%) developed a further episode of AD during follow-up. Sixty-month survival was significantly higher in patients with no decompensation than in patients with NAD or AD. On multivariable analysis, AD (hazard ratio [HR] 21.07, p <0.001), NAD (HR 7.13, p <0.001), the etiological cure of cirrhosis (HR 0.38, p <0.001) and model for end-stage liver disease score (HR 1.12, p = 0.003) were found to be independent predictors of mortality. CONCLUSIONS The first decompensation is non-acute in almost 50% of outpatients, though such events are still associated with decreased survival compared to no decompensation. Patients who develop NAD must be treated with extreme care and monitored closely to prevent the development of AD. IMPACT AND IMPLICATIONS This multicenter study is the first to investigate the role of non-acute decompensation (NAD) in patients with cirrhosis. In fact, while the unfavorable impact of acute decompensation is well known, there is currently a dearth of evidence on NAD, despite it being a common occurrence in clinical practice. Our data show that almost half of decompensations in patients with cirrhosis can be considered NAD and that such events are associated with a higher risk of mortality than no decompensation. This study has important clinical implications because it highlights the need to carefully consider patients who develop NAD, in order to prevent further decompensation and reduce mortality.
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Affiliation(s)
- Marta Tonon
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Roberta D'Ambrosio
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Calvino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Giulia Tosetti
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Barone
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Simone Incicco
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Carmine Gambino
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Roberta Gagliardi
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Marta Borghi
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Zeni
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy
| | - Pietro Lampertico
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; CRC "A. M. and A. Migliavacca" Centre for Liver Disease, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine (DIMED), University of Padova, Italy.
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16
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Weiss N, Tripon S, Mallet M, Imbert-Bismut F, Sakka M, Bonnefont-Rousselot D, Sultanik P, Mouri S, Rudler M, Thabut D. Protein-S-100-beta is increased in patients with decompensated cirrhosis admitted to ICU. JOURNAL OF INTENSIVE MEDICINE 2024; 4:222-230. [PMID: 38681783 PMCID: PMC11043635 DOI: 10.1016/j.jointm.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/09/2023] [Accepted: 08/16/2023] [Indexed: 05/01/2024]
Abstract
Background Hepatic encephalopathy (HE) is highly prevalent in patients with liver diseases. The pathophysiology of HE is centered on the synergic role of hyperammonemia and systemic inflammation. However, some data suggest altered functioning of the blood-brain barrier (BBB). Assessing BBB function is challenging in clinical practice and at the bedside. Protein-S-100 Beta (PS100-Beta) could be a useful peripheral marker of BBB permeability in HE. This study aimed to assess plasmatic PS100-Beta levels in a prospective cohort of patients admitted to the intensive care unit (ICU) with decompensated cirrhosis with and without overt HE. Methods We retrospectively evaluated a prospective cohort of cirrhotic patients admitted to the ICU from October 2013 to September 2015 that had an available plasmatic PS100-Beta measurement. Patients with previous neurological impairment or limitation of intensive or resuscitative measures were excluded. Overt HE was defined as West-Haven grades 2 to 4. The patients were compared to a control cohort of outpatient clinic cirrhotic and non-cirrhotic patients explored for isolated elevation of liver enzymes. After ICU discharge, the patients were followed for at least 3 months for the occurrence of overt HE. Adverse outcomes (liver transplantation or death) were collected. The ability of PS100-Beta - in combination with other factors - to predict overt HE was evaluated in a multivariate analysis using logistic regression. Likelihood ratios were used to determine the effects and calculate odds ratios (OR). Survival analysis was performed by using the Kaplan-Meier method and survival between groups was compared using a Log-rank test. Results A total of 194 ICU patients and 207 outpatients were included in the study. Increased levels of plasmatic PS100-Beta were detected in the ICU decompensated cirrhotic patients compared with the outpatients ([0.15±0.01] mg/L vs. [0.08±0] mg/L, P <0.001). ICU patients with overt HE had higher levels of PS100-Beta ([0.19±0.03] mg/L) compared with the ICU patients without overt HE ([0.13±0.01] mg/L) (P=0.003). PS100-Beta levels did not differ in outpatients with F 0-3 compared to F 4 fibrosis (P=0.670). PS100-Beta values were correlated with Child-Pugh score (P <0.001), Model for End-Stage Liver Disease (MELD) score (P=0.004), C-reactive protein (P <0.001), ammonemia (P <0.001), and chronic liver failure consortium (CLIF-C) organ failure (P <0.001) and CLIF-C acute-on-chronic (P=0.038) scores, but not with leukocytes (P=0.053), procalcitonin (PCT) (P=0.107), or the lymphocyte-to-neutrophil ratio in ICU patients (P=0.522). In a multivariate model including age, ammonemia, PS100-Beta, PCT, MELD, presence of transjugular portosystemic shunt, and sodium level, the diagnostic performance was 0.765 for the diagnosis of overt HE. Patients with a PS100-Beta level <0.12 mg/L had a better overall survival (P=0.019) and a better survival without liver transplantation (P=0.013). Conclusions Serum levels of PS100-Beta are elevated in ICU patients with decompensated cirrhosis, and even more so in those displaying overt HE, and the levels are correlated with outcome. This suggests an increase in the permeability of the BBB in these patients.
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Affiliation(s)
- Nicolas Weiss
- Sorbonne Université, AP-HP.Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Département de Neurologie, Unité de Médecine Intensive Réanimation à Orientation Neurologique, Paris, France
- Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, Biliaires et Fibro-Inflammatoire du Foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
- Groupe de Recherche Clinique en REanimation et Soins intensifs du Patient en Insuffisance Respiratoire aiguE (GRC-RESPIRE) Sorbonne Université, Paris, France
| | - Simona Tripon
- Sorbonne Université, AP-HP.Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Département de Neurologie, Unité de Médecine Intensive Réanimation à Orientation Neurologique, Paris, France
- Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, Biliaires et Fibro-Inflammatoire du Foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
- Assistance Publique-Hôpitaux de Paris, AP-HP.Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Service d'hépato-Gastroentérologie, Unité de Soins Intensifs d'Hépatologie, Paris, France
| | - Maxime Mallet
- Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, Biliaires et Fibro-Inflammatoire du Foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
- Assistance Publique-Hôpitaux de Paris, AP-HP.Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Service d'hépato-Gastroentérologie, Unité de Soins Intensifs d'Hépatologie, Paris, France
| | - Françoise Imbert-Bismut
- Assistance Publique-Hôpitaux de Paris, AP-HP.Sorbonne Université, Service de Biochimie Métabolique, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix, DMU BioGeM, Paris F-75013, France
| | - Mehdi Sakka
- Assistance Publique-Hôpitaux de Paris, AP-HP.Sorbonne Université, Service de Biochimie Métabolique, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix, DMU BioGeM, Paris F-75013, France
| | - Dominique Bonnefont-Rousselot
- Assistance Publique-Hôpitaux de Paris, AP-HP.Sorbonne Université, Service de Biochimie Métabolique, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix, DMU BioGeM, Paris F-75013, France
- Université Paris Cité, UFR de Pharmacie, CNRS, Inserm, UTCBS, Paris, France
| | - Philippe Sultanik
- Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, Biliaires et Fibro-Inflammatoire du Foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
- Assistance Publique-Hôpitaux de Paris, AP-HP.Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Service d'hépato-Gastroentérologie, Unité de Soins Intensifs d'Hépatologie, Paris, France
| | - Sarah Mouri
- Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, Biliaires et Fibro-Inflammatoire du Foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
- Assistance Publique-Hôpitaux de Paris, AP-HP.Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Service d'hépato-Gastroentérologie, Unité de Soins Intensifs d'Hépatologie, Paris, France
| | - Marika Rudler
- Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, Biliaires et Fibro-Inflammatoire du Foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
- Assistance Publique-Hôpitaux de Paris, AP-HP.Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Service d'hépato-Gastroentérologie, Unité de Soins Intensifs d'Hépatologie, Paris, France
| | - Dominique Thabut
- Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, Biliaires et Fibro-Inflammatoire du Foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
- Assistance Publique-Hôpitaux de Paris, AP-HP.Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Service d'hépato-Gastroentérologie, Unité de Soins Intensifs d'Hépatologie, Paris, France
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17
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Hui Y, Wang H, Guo G, Yang W, Zhang X, Yang J, Yang F, Wang X, Fan X, Cui B, Chen X, Jiao H, Sun C. Association Between Quality of Life Defined by EuroQol Group 5 Dimension and Composite Inferior Outcome Among Inpatients with Cirrhosis. Clin Interv Aging 2024; 19:551-560. [PMID: 38528882 PMCID: PMC10962662 DOI: 10.2147/cia.s444842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/13/2024] [Indexed: 03/27/2024] Open
Abstract
Purpose The utility of the EuroQol Group 5 Dimension (EQ-5D) measuring health-related quality of life (HRQoL) has been verified; however, knowledge gaps remain concerning predictive performance in cirrhosis. We aimed to identify the optimal threshold for risk stratification and the pronounced domain in the EQ-5D linked to inferior outcomes. Patients and Methods The X-tile project was used to obtain a threshold, considering the composite outcome of 1-year all-cause mortality or readmission. A restricted cubic spline (RCS) was performed to test the non-linear relationship between the EQ-5D utility value and the primary outcome. Six multivariate Cox regression models incorporating EQ-5D utility value and each of the five domains were constructed. Setting/Participants Totally, 420 patients with cirrhosis were recruited. Results The median utility value of the study population was 0.77 and 59.8% reported impairment in minimal one EQ-5D domain. RCS indicated a linear relationship between the utility value and composite inferior outcome. X-tile pinpointed a utility value of 0.59 stratifying populations into high- and low-risk groups based on the outcome. Inpatients with cirrhosis and deteriorated HRQoL (utility value ≤0.59) were at higher risk of death or readmission (adjusted HR: 2.18, P < 0.001). Furthermore, mobility and usual activities were the most pronounced domains associated with composite inferior outcome. Conclusion A utility value ≤0.59 can identify cirrhotic inpatients exhibiting compromised HRQoL and mortality/readmission risk. It is tempting to reverse the decreased HRQoL by applying longitudinal measurements and keeping surveillance on utility value, while interventions appear to mainly focus on improving mobility and usual activities.
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Affiliation(s)
- Yangyang Hui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Han Wang
- Department of Health Management, Tianjin Hospital, Tianjin, People’s Republic of China
| | - Gaoyue Guo
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Wanting Yang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Xuqian Zhang
- Department of Gastroenterology and Hepatology, China Aerospace Science & Industry Corporation 731 Hospital, Beijing, People’s Republic of China
| | - Jie Yang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Fang Yang
- Department of Digestive System, Baodi Clinical College of Tianjin Medical University, Tianjin, People’s Republic of China
| | - Xiaoyu Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Xiaofei Fan
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Binxin Cui
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin Airport Economic Area, Tianjin, People’s Republic of China
| | - Xin Chen
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Huanli Jiao
- Department of Health Management, Tianjin Hospital, Tianjin, People’s Republic of China
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin Airport Economic Area, Tianjin, People’s Republic of China
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Xiao Y, Wang W, Peng S, Lu Y, Du J, Cai W. Farnesoid X receptor agonist tropifexor detoxifies ammonia by regulating the glutamine metabolism and urea cycles in cholestatic livers. Eur J Pharmacol 2024; 966:176334. [PMID: 38286357 DOI: 10.1016/j.ejphar.2024.176334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/14/2023] [Accepted: 01/16/2024] [Indexed: 01/31/2024]
Abstract
Hyperammonemia refers to elevated levels of ammonia in the blood, which is an important pathological feature of liver cirrhosis and hepatic failure. Preclinical studies suggest tropifexor (TXR), a novel non-bile acid agonist of Farnesoid X Receptor (FXR), has shown promising effects on reducing hepatic steatosis, inflammation, and fibrosis. This study evaluates the impact of TXR on hyperammonemia in a piglet model of cholestasis. We here observed blood ammonia significantly elevated in patients with biliary atresia (BA) and was positively correlated with liver injury. Targeted metabolomics and immunblotting showed glutamine metabolism and urea cycles were impaired in BA patients. Next, we observed that TXR potently suppresses bile duct ligation (BDL)-induced injuries in liver and brain with improving the glutamine metabolism and urea cycles. Within the liver, TXR enhances glutamine metabolism and urea cycles by up-regulation of key regulatory enzymes, including glutamine synthetase (GS), carbamoyl-phosphate synthetase 1 (CPS1), argininosuccinate synthetase (ASS1), argininosuccinate lyase (ASL), and arginase 1 (ARG1). In primary mice hepatocytes, TXR detoxified ammonia via increasing ureagenesis. Mechanically, TXR activating FXR to increase express enzymes that regulating ureagenesis and glutamine synthesis through a transcriptional approach. Together, these results suggest that TXR may have therapeutic implications for hyperammonemic conditions in cholestatic livers.
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Affiliation(s)
- Yongtao Xiao
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Division of Pediatric Gastroenterology and Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Pediatric Research, Shanghai, China; Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China.
| | - Weipeng Wang
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Shicheng Peng
- Shanghai Institute of Pediatric Research, Shanghai, China; Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Ying Lu
- Shanghai Institute of Pediatric Research, Shanghai, China; Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Jun Du
- Shanghai Institute of Pediatric Research, Shanghai, China; Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Wei Cai
- Department of Pediatric Surgery, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Division of Pediatric Gastroenterology and Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Pediatric Research, Shanghai, China; Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China.
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19
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Kibble H, Shawcross DL. The assessment and management of cirrhotic patients with encephalopathy. United European Gastroenterol J 2024; 12:187-193. [PMID: 38180440 PMCID: PMC10954429 DOI: 10.1002/ueg2.12530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/24/2023] [Indexed: 01/06/2024] Open
Abstract
Hepatic encephalopathy (HE) is a debilitating complication associated with both acute and chronic liver injury. It is associated with a greater risk of death than any other significant hepatic decompensation event. It manifests as a wide spectrum of neuropsychological abnormalities ranging from subtle impairments in higher cognitive function, to confusion and coma. The pathophysiological role of ammonia in the development of HE is well known, but there is increasing recognition that the gut microbiome, gut-derived systemic inflammation and development of infection can serve as drivers of HE in patients with cirrhosis. The development of HE portents to the severity of cirrhosis and the prognosis is poor without liver transplantation. A referral for liver transplantation should therefore be considered early in those who are eligible. This review covers the pragmatic assessment of HE in patients with cirrhosis, as well as the current evidence base for the best practice management of HE in such patients.
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Affiliation(s)
- H Kibble
- Institute of Liver Studies, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Debbie L Shawcross
- Institute of Liver Studies, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
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20
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Cai W, Lin X, Guo Y, Lin X, Chen C. A nomogram for predicting prognosis in patients with transjugular intrahepatic portosystemic shunt creation based on deep learning-derived spleen volume-to-platelet ratio. Br J Radiol 2024; 97:600-606. [PMID: 38288507 DOI: 10.1093/bjr/tqad064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 11/09/2023] [Accepted: 12/21/2023] [Indexed: 03/01/2024] Open
Abstract
OBJECTIVES The objective of our study was to develop a nomogram to predict post-transjugular intrahepatic portosystemic shunt (TIPS) survival in patients with cirrhosis based on CT images. METHODS This retrospective cohort study included patients who had received TIPS operation at the Wenzhou Medical University First Affiliated Hospital between November 2013 and April 2017. To predict prognosis, a nomogram and Web-based probability were developed to assess the overall survival (OS) rates at 1, 3, and 5 years based on multivariate analyses. With deep learning algorithm, the automated measurement of liver and spleen volumes can be realized. We assessed the predictive accuracy and discriminative ability of the nomogram using the concordance index (C-index), receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA). RESULTS Age, total bilirubin, and spleen volume-to-platelet ratio (SVPR) were identified as the independent risk factors for OS. The nomogram was constructed based on the above risk factors. The C-index (0.80, 0.74, 0.70), ROC curve (area under curve: 0.828, 0.761, 0.729), calibration curve, and DCA showed that nomogram good at predictive value, stability, and clinical benefit in the prediction of 1-, 3-, 5-year OS in patients with TIPS creation. CONCLUSIONS We constructed a nomogram for predicting prognosis in patients with TIPS creation based on risk factors. The nomogram can help clinicians in identifying patients with poor prognosis, eventually facilitating earlier treatment and selecting suitable patients before TIPS. ADVANCES IN KNOWLEDGE This study developed the first nomogram based on SVPR to predict the prognosis of patients treated with TIPS. The nomogram could help clinician in non-invasive decision-making.
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Affiliation(s)
- Weimin Cai
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Xinran Lin
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Yu Guo
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Xiuqing Lin
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Chao Chen
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
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21
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Zhang P, Gan D, Chi X, Mao D, Gao Y, Li Y, Zhou D, Li Q, Zhang M, Lu B, Li F, Xue J, Wang X, Du H, Li X, Liang Y, Ye Y. Regression-based Chinese norms of number connection test A and digit symbol test for diagnosing minimal hepatic encephalopathy. Sci Rep 2024; 14:4005. [PMID: 38369632 PMCID: PMC10874952 DOI: 10.1038/s41598-024-54696-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 02/15/2024] [Indexed: 02/20/2024] Open
Abstract
Number connection test A (NCT-A) and digit symbol test (DST), the preferential neuropsychological tests to detect minimal hepatic encephalopathy (MHE) in China, haven't been standardized in Chinese population. We aimed to establish the norms based on a multi-center cross-sectional study and to detect MHE in cirrhotic patients. NCT-A and DST were administered to 648 healthy controls and 1665 cirrhotic patients. The regression-based procedure was applied to develop demographically adjusted norms for NCT-A and DST based on healthy controls. Age, gender, education, and age by education interaction were all predictors of DST, while age, gender, and education by gender interaction were predictors of log10 NCT-A. The predictive equations for expected scores of NCT-A and DST were established, and Z-scores were calculated. The norm for NCT-A was set as Z ≤ 1.64, while the norm for DST was set as Z ≥ - 1.64. Cirrhotic patients with concurrent abnormal NCT-A and DST results were diagnosed with MHE. The prevalence of MHE was 8.89% in cirrhotic patients, and only worse Child-Pugh classification (P = 0.002, OR = 2.389) was demonstrated to be the risk factor for MHE. The regression-based normative data of NCT-A and DST have been developed to detect MHE in China. A significant proportion of Chinese cirrhotic patients suffered from MHE, especially those with worse Child-Pugh classification.
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Affiliation(s)
- Peng Zhang
- Institute of Liver Disease, Beijing University of Chinese Medicine, Beijing, China
- Department of Gastroenterology and Hepatology, Beijing University of Chinese Medicine Affiliated Dongfang Hospital, Beijing, China
| | - Danan Gan
- Institute of Liver Disease, Beijing University of Chinese Medicine, Beijing, China
- Department of Gastroenterology and Hepatology, Institute of Liver Disease, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
| | - Xiaoling Chi
- Department of Hepatology, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, China
| | - Dewen Mao
- Department of Hepatology, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, Guangxi Province, China
| | - Yueqiu Gao
- Department of Hepatology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yong Li
- Department of Hepatology, The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, China
| | - Daqiao Zhou
- Department of Hepatology, Shenzhen Hospital of Traditional Chinese Medicine, Shenzhen, Guangdong Province, China
| | - Qin Li
- The Fourth Ward, Fuzhou Infectious Disease Hospital, Fuzhou, Fujian Province, China
| | - Mingxiang Zhang
- Department of Integrated Traditional and Western Medicine on Liver Diseases, Shenyang Infectious Disease Hospital, Shenyang, Liaoning Province, China
| | - Bingjiu Lu
- Department of Hepatology, The Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, Shenyang, Liaoning Province, China
| | - Fengyi Li
- Treatment and Research Center of Infectious Disease, The Fifth Medical Center of the General Hospital of the People's Liberation Army, Beijing, China
| | - Jingdong Xue
- Department of Hepatology, Shanxi Hospital of Traditional Chinese Medicine, Xi'an, Shanxi Province, China
| | - Xianbo Wang
- Department of Hepatology, Beijing Ditan Hospital, Beijing, China
| | - Hongbo Du
- Institute of Liver Disease, Beijing University of Chinese Medicine, Beijing, China
- Department of Gastroenterology and Hepatology, Institute of Liver Disease, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
| | - Xiaoke Li
- Institute of Liver Disease, Beijing University of Chinese Medicine, Beijing, China
- Department of Gastroenterology and Hepatology, Institute of Liver Disease, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
| | - Yijun Liang
- Institute of Liver Disease, Beijing University of Chinese Medicine, Beijing, China
- Department of Gastroenterology and Hepatology, Institute of Liver Disease, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
| | - Yongan Ye
- Institute of Liver Disease, Beijing University of Chinese Medicine, Beijing, China.
- Department of Gastroenterology and Hepatology, Institute of Liver Disease, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China.
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22
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Sonderup MW, Kamath PS, Awuku YA, Desalegn H, Gogela N, Katsidzira L, Tzeuton C, Bobat B, Kassianides C, Spearman CW. Managing cirrhosis with limited resources: perspectives from sub-Saharan Africa. Lancet Gastroenterol Hepatol 2024; 9:170-184. [PMID: 38215781 DOI: 10.1016/s2468-1253(23)00279-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/05/2023] [Accepted: 08/14/2023] [Indexed: 01/14/2024]
Abstract
Cirrhosis represents the end stage of chronic liver disease. Sub-Saharan Africa, a resource-constrained region, has a high burden of chronic liver disease, with causes including chronic viral hepatitis, excessive alcohol use, and metabolic dysfunction-associated steatotic liver disease (MASLD), the risk of which is burgeoning. The development of liver cirrhosis predicts for morbidity and mortality, driven by both liver dysfunction and the consequences of portal hypertension. Compensated cirrhosis portends a better prognosis than decompensated cirrhosis, highlighting the need for the early diagnosis of cirrhosis and its causes. With resource challenges, the diagnosis and management of cirrhosis is demanding, but less costly and less invasive interventions with substantial benefits, ranging from simple blood tests to transient elastography, are feasible in such settings. Simple interventions are also available to manage the complex manifestations of decompensation, such as β blockers in variceal bleeding prophylaxis, salt restriction and appropriate diuretic use in ascites, and lactulose and generic rifaximin in hepatic encephalopathy. Ultimately, managing the underlying causative factors of liver disease is key in improving prognosis. Management demands expanded policy interventions to increase screening and treatment for hepatitis B and C and reduce alcohol use and the metabolic factors driving MASLD. Furthermore, the skills needed for more specialised interventions, such as transjugular intrahepatic portosystemic shunt procedures and even liver transplantation, warrant planning, increased capacity, and support for regional centres of excellence. Such centres are already being developed in sub-Saharan Africa, demonstrating what can be achieved with dedicated initiatives and individuals.
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Affiliation(s)
- Mark W Sonderup
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
| | | | - Yaw A Awuku
- Department of Medicine, School of Medicine, University of Health and Allied Sciences, Ho, Ghana
| | - Hailemichael Desalegn
- Department of Internal Medicine, St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Neliswa Gogela
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Leolin Katsidzira
- Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Christian Tzeuton
- Faculty of Medicine and Pharmaceutical Sciences of Douala, University of Douala, Douala, Cameroon
| | - Bilal Bobat
- Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand and Wits Donald Gordon Medical Centre, Johannesburg, South Africa
| | - Chris Kassianides
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - C Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
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23
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Fortuny M, Sarrias MR, Torner M, Iborra I, Clos A, Ardèvol A, Bartolí R, Morillas RM, Domènech E, Masnou H. Systematic review of the role of calprotectin in cirrhosis. Eur J Clin Invest 2024; 54:e14111. [PMID: 37849372 DOI: 10.1111/eci.14111] [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: 05/17/2023] [Revised: 09/16/2023] [Accepted: 09/23/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Calprotectin is a calcium-binding-S100-protein synthetized mainly in neutrophils which has been demonstrated to be an accurate biomarker of the presence of these cells. Gut barrier dysfunction in patients with advanced chronic liver disease (ACLD), in addition to the lack of noninvasive tools for diagnosis and prognosis of cirrhosis decompensations, has raised interest in this biomarker. AIMS Our aim is to summarize the current evidence regarding the role of calprotectin in terms of its diagnostic and prognostic utility in ACLD. METHODS We performed a systematic search (PROSPERO registration no. CRD42023389069) of original articles published without any restrictions on the publication date until January 2023 providing information about calprotectin for the prognosis or diagnosis of ACLD and its decompensations in adult patients. RESULTS A total 227 articles were identified, and 26 observational studies finally met the inclusion criteria. In 14 studies, calprotectin was measured in ascitic fluid, all of which reported higher calprotectin values in spontaneous bacterial peritonitis, while cut-off points for its diagnosis were proposed in nine studies. Three studies reported higher faecal calprotectin levels in patients with hepatic encephalopathy and portal hypertension. Four studies evaluated faecal calprotectin and one plasma calprotectin as biomarkers for gut barrier integrity and bacterial translocation. CONCLUSIONS Calprotectin is emerging as a promising biomarker in ACLD, particularly for the management of bacterial infections and alcohol-related liver disease. Further research with better study designs should help to determine the feasibility of calprotectin measurement in routine clinical practice.
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Affiliation(s)
- Marta Fortuny
- Hepatology Unit, Hospital Germans Trias i Pujol, Badalona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria-Rosa Sarrias
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Germans Trias i Pujol Research Institute (IGTP), Badalona, Spain
| | - Maria Torner
- Hepatology Unit, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Ignacio Iborra
- Hepatology Unit, Hospital Germans Trias i Pujol, Badalona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ariadna Clos
- Hepatology Unit, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Alba Ardèvol
- Hepatology Unit, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Ramon Bartolí
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Germans Trias i Pujol Research Institute (IGTP), Badalona, Spain
| | - Rosa M Morillas
- Hepatology Unit, Hospital Germans Trias i Pujol, Badalona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Eugeni Domènech
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- IBD Unit, Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Helena Masnou
- Hepatology Unit, Hospital Germans Trias i Pujol, Badalona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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Huang CH, Yu TY, Tseng WEJ, Huang YT, Chang SH, Hsieh SY, Chien RN, Amodio P. Animal naming test is a simple and valid tool for detecting covert hepatic encephalopathy and predicting outcomes in Chinese-speaking regions: a preliminary study. Ann Med 2023; 55:2236013. [PMID: 37494454 PMCID: PMC10373624 DOI: 10.1080/07853890.2023.2236013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/19/2023] [Accepted: 07/09/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND AND AIMS Hepatic encephalopathy (HE) implies high morbidity and mortality. The assessment of covert HE (CHE) [i.e. minimal HE (MHE) plus grade 1 HE] is often neglected in Taiwan. Therefore, the aim was to investigate the potential of the animal naming test (ANT1 and simplified ANT1 (S-ANT1)) for assessing CHE in Chinese-speaking regions, specifically Taiwan. METHODS A prospective cohort study was conducted, comprising 65 cirrhotic patients and 29 healthy controls (relatives of the patients). Patients were followed up every three months and censored after two years or until death. Hospitalization for overt HE (OHE) and mortality were considered. All subjects underwent ANT1, psychometric HE score (PHES), and mini-mental state examination (MMSE). The patients underwent an electroencephalogram (EEG) to detect slowing indicative of MHE. Cut-off values for ANT1 and S-ANT1 were assessed by ROC analysis and Youden's index, considering CHE as a reference. The prognostic values for OHE and OHE-free survival were assessed. RESULTS Preliminary analysis confirmed that PHES ≤-4 is a good discriminant point for abnormal results. CHE was found in 29 patients: 9 had MHE (PHES ≤ -4 or altered EEG) and 20 had grade 1 HE. ANT1 and S-ANT1 were found to have diagnostic values for CHE: AUC = 0.807, 0.786; cut off: 18 and 19, respectively. ANT1 and S-ANT1 were found to have prognostic value for OHE, number of hospitalization episodes for OHE, and OHE recurrence-free survival. CONCLUSIONS ANT1 shows promise as a tool for CHE detection, quantification, and follow-up in Taiwan and other Chinese-speaking regions.Key messagesThe animal naming test (ANT1) is a simple and valid semantic fluency test that can be easily performed in outpatient or bedside settings in one minute and can also be used as a tool for covert hepatic encephalopathy (CHE) detection, quantification, and follow-up in Taiwan, other Chinese-speaking regions, and many other countries.The diagnostic value of ANT1 and S-ANT1 for CHE were found to be significant, with area under the receiver operating characteristic curve (AUROC) values of 0.807 and 0.786 respectively, and cut-off scores of 18 and 19.ANT1 and S-ANT1 have prognostic value for the first breakthrough of overt hepatic encephalopathy (OHE), number of hospitalization episodes for OHE, and OHE recurrence-free survival, independent of the MELD score.
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Affiliation(s)
- Chien-Hao Huang
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Tung-Yang Yu
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Wei-En Johnny Tseng
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yu-Tung Huang
- Center for Big Data Analytics and Statistics, Department of Medical Research and Development, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Shang-Hung Chang
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
- Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan
- Cardiovascular Division, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
| | - Sen-Yung Hsieh
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Rong-Nan Chien
- Division of Hepatology, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
- College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Piero Amodio
- Department of Medicine, University of Padova, Padova, Italy
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Yao C, Huang L, Wang M, Mao D, Wang M, Zheng J, Long F, Huang J, Liu X, Zhang R, Xie J, Cheng C, Yao F, Huang G. Establishment and validation of a nomogram model for riskprediction of hepatic encephalopathy: a retrospective analysis. Sci Rep 2023; 13:19544. [PMID: 37945916 PMCID: PMC10636098 DOI: 10.1038/s41598-023-47012-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 11/08/2023] [Indexed: 11/12/2023] Open
Abstract
To establish a high-quality, easy-to-use, and effective risk prediction model for hepatic encephalopathy, to help healthcare professionals with identifying people who are at high risk of getting hepatic encephalopathy, and to guide them to take early interventions to reduce the occurrence of hepatic encephalopathy. Patients (n = 1178) with decompensated cirrhosis who attended the First Affiliated Hospital of Guangxi University of Chinese Medicine between January 2016 and June 2022 were selected for the establishment and validation of a nomogram model for risk prediction of hepatic encephalopathy. In this study, we screened the risk factors for the development of hepatic encephalopathy in patients with decompensated cirrhosis by univariate analysis, LASSO regression and multifactor analysis, then established a nomogram model for predicting the risk of getting hepatic encephalopathy for patients with decompensated cirrhosis, and finally performed differentiation analysis, calibration analysis, clinical decision curve analysis and validation of the established model. A total of 1178 patients with decompensated cirrhosis who were hospitalized and treated at the First Affiliated Hospital of Guangxi University of Chinese Medicine between January 2016 and June 2022 were included for modeling and validation. Based on the results of univariate analysis, LASSO regression analysis and multifactor analysis, a final nomogram model with age, diabetes, ascites, spontaneous peritonitis, alanine transaminase, and blood potassium as predictors of hepatic encephalopathy risk prediction was created. The results of model differentiation analysis showed that the AUC of the model of the training set was 0.738 (95% CI 0.63-0.746), while the AUC of the model of the validation set was 0.667 (95% CI 0.541-0.706), and the two AUCs indicated a good discrimination of this nomogram model. According to the Cut-Off value determined by the Jorden index, when the Cut-Off value of the training set was set at 0.150, the sensitivity of the model was 72.8%, the specificity was 64.8%, the positive predictive value was 30.4%, and the negative predictive value was 91.9%; when the Cut-Off value of the validation set was set at 0.141, the sensitivity of the model was 69.7%, the specificity was 57.3%, the positive predictive value was 34.5%, and the negative predictive value was 84.7%. The calibration curve and the actual events curve largely overlap at the diagonal, indicating that the prediction with this model has less error. The Hosmer-Lemeshow test for goodness of fit was also applied, and the results showed that for the training set, χ2 = 1.237587, P = 0.998, and for the validation set, χ2 = 31.90904, P = 0.0202, indicating that there was no significant difference between the predicted and actual observed values. The results of the clinical decision curve analysis showed that the model had a good clinical benefit, compared with the two extreme clinical scenarios (all patients treated or none treated), and the model also had a good clinical benefit in the validation set. This study showed that aged over 55 years, complications of diabetes, ascites, and spontaneous bacterial peritonitis, abnormal glutamate aminotransferase and abnormal blood potassium are independent risks indicators for the development of hepatic encephalopathy in patients with decompensated cirrhosis. The nomogram model based on the indicators mentioned above can effectively and conveniently predict the risk of developing hepatic encephalopathy in patients with decompensated cirrhosis. The nomogram model established on this study can help clinical healthcare professionals to timely and early identify patients with high risk of developing hepatic encephalopathy.
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Affiliation(s)
- Chun Yao
- Guangxi University of Chinese Medicine, Nanning, 530001, Guangxi, People's Republic of China
| | - Liangjiang Huang
- Guangxi University of Chinese Medicine, Nanning, 530001, Guangxi, People's Republic of China
| | - Meng Wang
- First Affiliated Hospital of Guangxi University of Chinese Medicine, 89-9 Dongge Road, Nanning, 530001, Guangxi, People's Republic of China
| | - Dewen Mao
- First Affiliated Hospital of Guangxi University of Chinese Medicine, 89-9 Dongge Road, Nanning, 530001, Guangxi, People's Republic of China
| | - Minggang Wang
- First Affiliated Hospital of Guangxi University of Chinese Medicine, 89-9 Dongge Road, Nanning, 530001, Guangxi, People's Republic of China
| | - Jinghui Zheng
- Guangxi University of Chinese Medicine, Nanning, 530001, Guangxi, People's Republic of China
| | - Fuli Long
- First Affiliated Hospital of Guangxi University of Chinese Medicine, 89-9 Dongge Road, Nanning, 530001, Guangxi, People's Republic of China
| | - Jingjing Huang
- First Affiliated Hospital of Guangxi University of Chinese Medicine, 89-9 Dongge Road, Nanning, 530001, Guangxi, People's Republic of China
| | - Xirong Liu
- First Affiliated Hospital of Guangxi University of Chinese Medicine, 89-9 Dongge Road, Nanning, 530001, Guangxi, People's Republic of China
| | - Rongzhen Zhang
- First Affiliated Hospital of Guangxi University of Chinese Medicine, 89-9 Dongge Road, Nanning, 530001, Guangxi, People's Republic of China
| | - Jiacheng Xie
- Guangxi University of Chinese Medicine, Nanning, 530001, Guangxi, People's Republic of China
| | - Chen Cheng
- First Affiliated Hospital of Guangxi University of Chinese Medicine, 89-9 Dongge Road, Nanning, 530001, Guangxi, People's Republic of China
| | - Fan Yao
- First Affiliated Hospital of Guangxi University of Chinese Medicine, 89-9 Dongge Road, Nanning, 530001, Guangxi, People's Republic of China
| | - Guochu Huang
- First Affiliated Hospital of Guangxi University of Chinese Medicine, 89-9 Dongge Road, Nanning, 530001, Guangxi, People's Republic of China.
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Dong JJ, Zhang QY, Cai YJ. Letter: Exploring the clinical utility of ammonia in critically ill patients with cirrhosis: More to do? Aliment Pharmacol Ther 2023; 58:960-961. [PMID: 37831532 DOI: 10.1111/apt.17698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
LINKED CONTENTThis article is linked to Cardoso et al papers. To view these articles, visit https://doi.org/10.1111/apt.17650 and https://doi.org/10.1111/apt.17725
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Affiliation(s)
- Jia-Jia Dong
- Department of Ultrasonography, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Qiong-Ying Zhang
- Department of Pathology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yi-Jing Cai
- Department of Infectious Diseases, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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Tagliaro I, Musile G, Caricato P, Dorizzi RM, Tagliaro F, Antonini C. Chitosan Film Sensor for Ammonia Detection in Microdiffusion Analytical Devices. Polymers (Basel) 2023; 15:4238. [PMID: 37959918 PMCID: PMC10650627 DOI: 10.3390/polym15214238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Chitosan films have attracted increased attention in the field of sensors because of chitosan's unique chemico-physical properties, including high adsorption capacity, filmability and transparency. A chitosan film sensor was developed through the dispersion of an ammonia specific reagent (Nessler's reagent) into a chitosan film matrix. The chitosan film sensor was characterized to assess the film's properties by Fourier transform infrared spectroscopy (FTIR), thermogravimetric analysis (TGA), scanning electron microscopy (SEM) and differential scanning calorimetry (DSC). A gas diffusion device was prepared with the chitosan film sensor, enabling the collection and detection of ammonia vapor from biological samples. The chitosan film sensor color change was correlated with the ammonia concentration in samples of human serum and artificial urine. This method enabled facile ammonia detection and concentration measurement, making the sensor useful not only in clinical laboratories, but also for point-of-care devices and wherever there is limited access to modern laboratory facilities.
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Affiliation(s)
- Irene Tagliaro
- Department of Materials Science, University of Milano, via Cozzi 55, 20131 Milano, Italy;
| | - Giacomo Musile
- Unit of Forensic Medicine, Department of Diagnostics and Public Health, University of Verona, Piazzale L. A. Scuro, 10, 37134 Verona, Italy; (R.M.D.); (F.T.)
| | - Paolo Caricato
- Directorate-General for Health and Food Safety G5, Food Hygiene, Feed and Fraud 03/104, 1049 Brussels, Belgium;
| | - Romolo M. Dorizzi
- Unit of Forensic Medicine, Department of Diagnostics and Public Health, University of Verona, Piazzale L. A. Scuro, 10, 37134 Verona, Italy; (R.M.D.); (F.T.)
| | - Franco Tagliaro
- Unit of Forensic Medicine, Department of Diagnostics and Public Health, University of Verona, Piazzale L. A. Scuro, 10, 37134 Verona, Italy; (R.M.D.); (F.T.)
| | - Carlo Antonini
- Department of Materials Science, University of Milano, via Cozzi 55, 20131 Milano, Italy;
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Testino G, Bottaro LC, Andorno E, Bandini F, Balbinot P, Beltramini S, Bottino S, Caltabellotta M, Caputo F, Caviglia E, Curone P, DI Biagio A, Gagliano C, Gandolfo N, Pestarino L, Rollero A, Romairone E, Sampietro L, Torre E, Zuccarelli S, Pellicano R. Hepatic encephalophathy: management and diagnostic therapeutic assistance path of Ligurian Local Health Company 3 (ASL3). Minerva Med 2023; 114:698-718. [PMID: 36952221 DOI: 10.23736/s0026-4806.22.08408-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Hepatic encephalophathy (HE) is a neuropsychiatric syndrome with a prevalence in the cirrhotic population ranging from 20 to 80%. HE is a cause of inappropriate hospitalization, caregiver burdening and increased social costs. There is need to create dedicated care pathways to better manage patients and support family caregivers. The data used for the preparation of this diagnostic therapeutic assistance path (DTAP) are based on a detailed analysis of the scientific literature published before June 30, 2022 (PubMed, Web of Science, Scopus, Google Scholar). Furthermore, in the process of developing this work, we consulted in particular the guidelines/ position papers of International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN), Italian Association for the Study of the Liver (AISF), European Association for the Study of the Liver (EASL), American Association for the Study of Liver Diseases (AASLD), Italian Society on Alcohol (Società Italiana di Alcologia [SIA]) and other relevant papers. DTAP was created based on the most recent recommendations of the international scientific literature. The present DTAP highlight the need for a multidisciplinary activity integrated with territorial medicine in close connection with caregivers. This guarantees improved therapeutic adherence, hospital readmission reduction, improved quality of life for patients and caregivers and a significant reduction in costs.
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Affiliation(s)
- Gianni Testino
- Addiction and Hepatology Unit/Alcohological Regional Centre and Study Centre "Self Help, Community Program and Caregiver Training" ASL3, Genoa, Italy -
| | | | - Enzo Andorno
- Liver Transplantation Unit, San Martino Polyclinic Hospital, Genoa, Italy
| | | | - Patrizia Balbinot
- Addiction and Hepatology Unit/Alcohological Regional Centre and Study Centre "Self Help, Community Program and Caregiver Training" ASL3, Genoa, Italy
| | | | | | | | - Fabio Caputo
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Center for the Study and Treatment of Chronic Inflammatory Intestinal Diseases (IBD) and Gastroenterological Manifestations of Rare Diseases, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Center for the Study and Treatment of Alcohol-Related Diseases, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Internal Medicine, Santissima Annunziata Hospital, University of Ferrara, Ferrara, Italy
| | | | | | - Antonio DI Biagio
- Department of Health Sciences, Infectious Diseases Clinic, IRCCS San Martino Polyclinic Hospital, University of Genoa, Genoa, Italy
| | | | | | | | | | | | | | - Enrico Torre
- Unit of Endocrinology, Metabolic Diseases and Diabetology, ASL3 Liguria, Genoa, Italy
| | | | - Rinaldo Pellicano
- Unit of Gastroenterology, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
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Liao Y, Zhang L, Wang JT, Yue ZD, Fan ZH, Wu YF, Zhang Y, Dong CB, Wang XQ, Cui T, Meng MM, Bao L, Chen SB, Liu FQ, Wang L. A novel nomogram predicting overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in portal hypertension patients. Sci Rep 2023; 13:15244. [PMID: 37709823 PMCID: PMC10502141 DOI: 10.1038/s41598-023-42061-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 09/05/2023] [Indexed: 09/16/2023] Open
Abstract
We aim to develop a nomogram to predict overt hepatic encephalopathy (OHE) after transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension, according to demographic/clinical indicators such as age, creatinine, blood ammonia, indocyanine green retention rate at 15 min (ICG-R15) and percentage of Portal pressure gradient (PPG) decline. In this retrospective study, 296 patients with portal hypertension who received elective TIPS in Beijing Shijitan Hospital from June 2018 to June 2020 were included. These patients were randomly divided into a training cohort (n = 207) and a validation cohort (n = 89). According to the occurrence of OHE, patients were assigned to OHE group and non-OHE group. Both univariate and multivariate analyses were performed to determine independent variables for predicting OHE after TIPS. Accordingly, receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to compare the accuracy and superiority of a novel model with conventional Child-Pugh and MELD scoring model. Age (OR 1.036, 95% CI 1.002-1.070, p = 0.037), Creatinine (OR 1.011, 95% CI 1.003-1.019, p = 0.009), Blood ammonia (OR 1.025, 95% CI 1.006-1.044, p = 0.011), ICG-R15 (OR 1.030, 95% CI 1.009-1.052, p = 0.004) and Percentage decline in PPG (OR 1.068, 95% CI 1.029-1.109, p = 0.001) were independent risk factors for OHE after TIPS using multifactorial analysis. A nomogram was constructed using a well-fit calibration curve for each of these five covariates. When compared to Child-Pugh and MELD score, this new nomogram has a better predictive value (C-index = 0.828, 95% CI 0.761-0.896). Consistently, this finding was reproduceable in validation cohort and confirmed with DCA. A unique nomogram was developed to predict OHE after TIPS in patients with PHT, with a high prediction sensitivity and specificity performance than commonly applied scoring systems.
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Affiliation(s)
- Yong Liao
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
- Department of Hepatobiliary Interventional Therapy, Beijing Tsinghua Changgung Hospital, Beijing, China
- School of Clinical Medicine, Tsinghua University, Beijing, 100038, People's Republic of China
- Department of Hepatobiliary Surgery, Xingtai People's Hospital of Hebei Medical University, Xingtai, 054001, Hebei, People's Republic of China
| | - Lin Zhang
- Department of Hepatobiliary Interventional Therapy, Beijing Tsinghua Changgung Hospital, Beijing, China
- School of Clinical Medicine, Tsinghua University, Beijing, 100038, People's Republic of China
| | - Ji-Tao Wang
- Department of Hepatobiliary Surgery, Xingtai People's Hospital of Hebei Medical University, Xingtai, 054001, Hebei, People's Republic of China
| | - Zhen-Dong Yue
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Zhen-Hua Fan
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Yi-Fan Wu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Yu Zhang
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Cheng-Bin Dong
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Xiu-Qi Wang
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Ting Cui
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Ming-Ming Meng
- Department of Gastroenterology, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, People's Republic of China
| | - Li Bao
- Department of Pharmacy, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, People's Republic of China
| | - Shu-Bo Chen
- Department of Hepatobiliary Surgery, Xingtai People's Hospital of Hebei Medical University, Xingtai, 054001, Hebei, People's Republic of China
| | - Fu-Quan Liu
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China.
| | - Lei Wang
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tie Yi Road, Yangfangdian, Haidian District, Beijing, 100038, China.
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Schwarz M, Schwarz C, Burghart L, Pfisterer N, Bauer D, Hübl W, Mandorfer M, Gschwantler M, Reiberger T. Late-stage presentation with decompensated cirrhosis is alarmingly common but successful etiologic therapy allows for favorable clinical outcomes. PLoS One 2023; 18:e0290352. [PMID: 37616205 PMCID: PMC10449133 DOI: 10.1371/journal.pone.0290352] [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: 02/14/2023] [Accepted: 08/04/2023] [Indexed: 08/26/2023] Open
Abstract
INTRODUCTION Liver cirrhosis accounts for considerable morbidity and mortality worldwide and late presentation limits therapeutic options. We aimed to assess characteristics of patients with liver cirrhosis at the time of first presentation and during their clinical course. METHODS Patients with cirrhosis as evident by presence of varices at endoscopy, liver stiffness ≥15kPa at elastography, or ascites requiring paracentesis between Q1/2015-Q2/2020 were retrospectively included. Clinical, laboratory, and imaging data were collected from medical records at presentation and last follow-up. RESULTS 476 patients were included (alcohol-related liver disease, ALD: 211, 44.3%; viral hepatitis: 163, 34.2%). Of these, 106 patients (22.3%) and 160 patients (33.6%) presented already with Child-Pugh C and MELD >15, respectively, and decompensation events were registered in 50% (238 patients) at baseline, and even in 75.4% of ALD patients. During a median follow-up of 11.0 (IQR 4-24) months, 116 patients died. Two-year survival was worse for patients with ALD than for viral hepatitis (71.1% vs. 90.2%, log rank p<0.001). We observed the highest percentage of portal-vein thrombosis (30.0%), hepatocellular carcinoma (15.0%), and death (45.0%) in the MAFLD group (n = 20). Patients cured from hepatitis C showed significant improvements in platelet count (147 to 169 G/L, p<0.001) and liver stiffness (26.2 to 17.7 kPa, p<0.001), while ALD patients improved in Child-Pugh score (8.6 to 7.6, p<0.001) during follow-up. With increasing Child Pugh score and MELD, we found increasing serum concentrations of CRP (p<0.001) and an inverse correlation with serum HDL (Spearman's ρ = -0.573 and -0.529, respectively, p<0.001). CONCLUSION Half of the patients with cirrhosis had decompensated cirrhosis at presentation. This calls for increased awareness and strategies for earlier diagnosis of chronic liver disease and cirrhosis.
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Affiliation(s)
- Michael Schwarz
- Department of Internal Medicine IV, Department for Gastroenterology and Hepatology, Klinik Ottakring, Vienna, Austria
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Caroline Schwarz
- Department of Internal Medicine IV, Department for Gastroenterology and Hepatology, Klinik Ottakring, Vienna, Austria
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Lukas Burghart
- Department of Internal Medicine IV, Department for Gastroenterology and Hepatology, Klinik Ottakring, Vienna, Austria
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Nikolaus Pfisterer
- Department for Gastroenterology and Hepatology, Department of Internal Medicine IV, Klinik Landstraße, Vienna, Austria
| | - David Bauer
- Department of Internal Medicine IV, Department for Gastroenterology and Hepatology, Klinik Ottakring, Vienna, Austria
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Hübl
- Klinik Ottakring, Institute for Laboratory Medicine, Vienna, Austria
| | - Mattias Mandorfer
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Michael Gschwantler
- Department of Internal Medicine IV, Department for Gastroenterology and Hepatology, Klinik Ottakring, Vienna, Austria
- Sigmund Freud University, Vienna, Austria
| | - Thomas Reiberger
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
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31
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Bai Z, Méndez-Sánchez N, Romeiro FG, Mancuso A, Philips CA, Tacke F, Basaranoglu M, Primignani M, Ibrahim M, Wong YJ, Nery FG, Teschke R, Ferreira CN, Muñoz AE, Pinyopornpanish K, Thevenot T, Singh SP, Mohanty A, Satapathy SK, Ridola L, Maruyama H, Cholongitas E, Levi Sandri GB, Yang L, Shalimar, Yang Y, Villa E, Krag A, Wong F, Jalan R, O’Brien A, Bernardi M, Qi X. Use of albumin infusion for cirrhosis-related complications: An international position statement. JHEP Rep 2023; 5:100785. [PMID: 37456673 PMCID: PMC10339261 DOI: 10.1016/j.jhepr.2023.100785] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/06/2023] [Accepted: 04/18/2023] [Indexed: 07/18/2023] Open
Abstract
Background & Aims Numerous studies have evaluated the role of human albumin (HA) in managing various liver cirrhosis-related complications. However, their conclusions remain partially controversial, probably because HA was evaluated in different settings, including indications, patient characteristics, and dosage and duration of therapy. Methods Thirty-three investigators from 19 countries with expertise in the management of liver cirrhosis-related complications were invited to organise an International Special Interest Group. A three-round Delphi consensus process was conducted to complete the international position statement on the use of HA for treatment of liver cirrhosis-related complications. Results Twelve clinically significant position statements were proposed. Short-term infusion of HA should be recommended for the management of hepatorenal syndrome, large volume paracentesis, and spontaneous bacterial peritonitis in liver cirrhosis. Its effects on the prevention or treatment of other liver cirrhosis-related complications should be further elucidated. Long-term HA administration can be considered in specific settings. Pulmonary oedema should be closely monitored as a potential adverse effect in cirrhotic patients receiving HA infusion. Conclusions Based on the currently available evidence, the international position statement suggests the potential benefits of HA for the management of multiple liver cirrhosis-related complications and summarises its safety profile. However, its optimal timing and infusion strategy remain to be further elucidated. Impact and implications Thirty-three investigators from 19 countries proposed 12 position statements on the use of human albumin (HA) infusion in liver cirrhosis-related complications. Based on current evidence, short-term HA infusion should be recommended for the management of HRS, LVP, and SBP; whereas, long-term HA administration can be considered in the setting where budget and logistical issues can be resolved. However, pulmonary oedema should be closely monitored in cirrhotic patients who receive HA infusion.
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Affiliation(s)
- Zhaohui Bai
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Nahum Méndez-Sánchez
- Liver Research Unit, Medica Sur Clinic and Foundation, National Autonomous University of Mexico, Mexico City, Mexico
| | | | - Andrea Mancuso
- Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico-Di Cristina-Benfratelli, Palermo, Italy
| | - Cyriac Abby Philips
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, India
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Metin Basaranoglu
- Division of Gastroenterology, Department of Internal Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Massimo Primignani
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mostafa Ibrahim
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Filipe Gaio Nery
- Serviço de Cuidados Intensivos, Unidade de Cuidados Intermédios Médico-Cirúrgica, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Germany
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria-Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Alberto E. Muñoz
- Sección Hepatología, Hospital Dr. Carlos B. Udaondo. Ciudad Autónoma de Buenos Aires, Argentina
| | - Kanokwan Pinyopornpanish
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Thierry Thevenot
- Centre Hospitalier Universitaire de Besançon, Hôpital Jean Minjoz, Service d’Hépatologie et de Soins Intensifs Digestifs, Besançon, France
| | | | - Arpan Mohanty
- Section of Gastroenterology, Boston Medical Center, Boston, MA, USA
| | - Sanjaya K. Satapathy
- Department of Internal Medicine, Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases & Transplantation, Donald and Barbara Zucker School of Medicine for Hofstra/Northwell Health, Manhasset, New York, USA
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Hitoshi Maruyama
- Department of Gastroenterology, Juntendo University, Hongo, Bunkyo-ku, Tokyo, Japan
| | - Evangelos Cholongitas
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Li Yang
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Yongping Yang
- Senior Department of Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Erica Villa
- Department of Gastroenterology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy
| | - Aleksander Krag
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, University College London, London, UK
| | | | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - the Liver Cirrhosis-related Complications (LCC)-International Special Interest Group
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
- Liver Research Unit, Medica Sur Clinic and Foundation, National Autonomous University of Mexico, Mexico City, Mexico
- Internal Medicine Department, Botucatu Medical School, São Paulo, Brazil
- Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico-Di Cristina-Benfratelli, Palermo, Italy
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, India
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Division of Gastroenterology, Department of Internal Medicine, Bezmialem Vakif University, Istanbul, Turkey
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- Serviço de Cuidados Intensivos, Unidade de Cuidados Intermédios Médico-Cirúrgica, Centro Hospitalar Universitário do Porto, Porto, Portugal
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Germany
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria-Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
- Sección Hepatología, Hospital Dr. Carlos B. Udaondo. Ciudad Autónoma de Buenos Aires, Argentina
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Centre Hospitalier Universitaire de Besançon, Hôpital Jean Minjoz, Service d’Hépatologie et de Soins Intensifs Digestifs, Besançon, France
- Kalinga Gastroenterology Foundation, Odisha, India
- Section of Gastroenterology, Boston Medical Center, Boston, MA, USA
- Department of Internal Medicine, Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases & Transplantation, Donald and Barbara Zucker School of Medicine for Hofstra/Northwell Health, Manhasset, New York, USA
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome, Italy
- Department of Gastroenterology, Juntendo University, Hongo, Bunkyo-ku, Tokyo, Japan
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
- Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
- Senior Department of Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Gastroenterology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Liver Failure Group, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, University College London, London, UK
- Division of Medicine, Royal Free Campus, London, UK
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Pandico F, Citarella A, Cammarota S, Bernardi FF, Claar E, Coppola C, Cozzolino M, De Rosa F, Di Gennaro M, Fogliasecca M, Giordana R, Pacella D, Russo A, Salerno V, Scafa L, Trama U. Rifaximin Use, Adherence and Persistence in Patients with Hepatic Encephalopathy: A Real-World Study in the South of Italy. J Clin Med 2023; 12:4515. [PMID: 37445550 DOI: 10.3390/jcm12134515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
Real-world data on the therapeutic management of hepatic encephalopathy (HE) patients are limited. The aim of this study was to evaluate the HE medications prescribed in an Italian cohort of HE patients post-discharge and to assess the real-world rifaximin adherence and persistence over 1 year. An observation retrospective study was conducted using data retrieved from outpatient pharmaceutical databases and hospital discharge records of the Campania region. For all subjects hospitalized for HE during 2019 (cohort 1), the HE medications prescribed within 60 days after discharge were evaluated. Adherence (proportion of days covered, PDC) and persistence were estimated for rifaximin 550 mg incident users over 1 year (cohort 2). Patients with PDC ≥80% were considered adherents. Persistence was defined as the period of time from the first rifaximin prescription to the date of discontinuation. Discontinuation was assessed using the permissible gap method. In cohort 1, 544 patients were identified; 58.5% received rifaximin while 15.6% only received non-absorbable disaccharides and 25.9% did not receive any HE medications. In cohort 2, 650 users were selected; only 54.5% were adherents and 35% were persistent users at 1 year. This real-world study highlights that quality improvement in therapeutic management is needed to potentially improve the outcomes of HE patients.
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Affiliation(s)
- Fulvio Pandico
- Department of Territorial Pharmaceuticals, Local Health Authority of Caserta, 81100 Caserta, Italy
| | - Anna Citarella
- LinkHealth Health Economics, Outcomes & Epidemiology S.R.L., 80143 Naples, Italy
| | - Simona Cammarota
- LinkHealth Health Economics, Outcomes & Epidemiology S.R.L., 80143 Naples, Italy
| | | | - Ernesto Claar
- Internal Medicine and Hepatology Unit, Ospedale Evangelico Betania, 80147 Naples, Italy
| | - Carmine Coppola
- Unit of Hepatology and Interventional Ultrasonography, Department of Internal Medicine, OORR Area Stabiese, 80054 Gragnano, Italy
| | - Marianna Cozzolino
- Department of Territorial Pharmaceuticals, Local Health Authority of Caserta, 81100 Caserta, Italy
| | - Federica De Rosa
- Postgraduate School in Clinical Pharmacology and Toxicology, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, 84081 Baronissi, Italy
| | - Massimo Di Gennaro
- Innovation and Data Analytics (So.Re.Sa), Campania Region, 80143 Naples, Italy
| | - Marianna Fogliasecca
- LinkHealth Health Economics, Outcomes & Epidemiology S.R.L., 80143 Naples, Italy
| | - Roberta Giordana
- Monitoring of Public Healthcare System (So.Re.Sa), Campania Region, 80143 Naples, Italy
| | - Daniela Pacella
- Department of Public Health, University of Naples Federico II, 80131 Naples, Italy
| | - Alessandro Russo
- Monitoring of Public Healthcare System (So.Re.Sa), Campania Region, 80143 Naples, Italy
| | - Vito Salerno
- Monitoring of Public Healthcare System (So.Re.Sa), Campania Region, 80143 Naples, Italy
| | - Luca Scafa
- Monitoring of Public Healthcare System (So.Re.Sa), Campania Region, 80143 Naples, Italy
| | - Ugo Trama
- Regional Pharmaceutical Unit, Campania Region, 80143 Naples, Italy
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Thomsen KL, Eriksen PL, Kerbert AJC, De Chiara F, Jalan R, Vilstrup H. Role of ammonia in NAFLD: An unusual suspect. JHEP Rep 2023; 5:100780. [PMID: 37425212 PMCID: PMC10326708 DOI: 10.1016/j.jhepr.2023.100780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 07/11/2023] Open
Abstract
Mechanistically, the symptomatology and disease progression of non-alcoholic fatty liver disease (NAFLD) remain poorly understood, which makes therapeutic progress difficult. In this review, we focus on the potential importance of decreased urea cycle activity as a pathogenic mechanism. Urea synthesis is an exclusive hepatic function and is the body's only on-demand and definitive pathway to remove toxic ammonia. The compromised urea cycle activity in NAFLD is likely caused by epigenetic damage to urea cycle enzyme genes and increased hepatocyte senescence. When the urea cycle is dysfunctional, ammonia accumulates in liver tissue and blood, as has been demonstrated in both animal models and patients with NAFLD. The problem may be augmented by parallel changes in the glutamine/glutamate system. In the liver, the accumulation of ammonia leads to inflammation, stellate cell activation and fibrogenesis, which is partially reversible. This may be an important mechanism for the transition of bland steatosis to steatohepatitis and further to cirrhosis and hepatocellular carcinoma. Systemic hyperammonaemia has widespread negative effects on other organs. Best known are the cerebral consequences that manifest as cognitive disturbances, which are prevalent in patients with NAFLD. Furthermore, high ammonia levels induce a negative muscle protein balance leading to sarcopenia, compromised immune function and increased risk of liver cancer. There is currently no rational way to reverse reduced urea cycle activity but there are promising animal and human reports of ammonia-lowering strategies correcting several of the mentioned untoward aspects of NAFLD. In conclusion, the ability of ammonia-lowering strategies to control the symptoms and prevent the progression of NAFLD should be explored in clinical trials.
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Affiliation(s)
- Karen Louise Thomsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
- UCL Institute of Liver and Digestive Health, University College London, United Kingdom
| | - Peter Lykke Eriksen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | - Annarein JC. Kerbert
- UCL Institute of Liver and Digestive Health, University College London, United Kingdom
| | - Francesco De Chiara
- UCL Institute of Liver and Digestive Health, University College London, United Kingdom
| | - Rajiv Jalan
- UCL Institute of Liver and Digestive Health, University College London, United Kingdom
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
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Claeys W, Van Hoecke L, Lernout H, De Nolf C, Van Imschoot G, Van Wonterghem E, Verhaege D, Castelein J, Geerts A, Van Steenkiste C, Vandenbroucke RE. Experimental hepatic encephalopathy causes early but sustained glial transcriptional changes. J Neuroinflammation 2023; 20:130. [PMID: 37248507 DOI: 10.1186/s12974-023-02814-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/21/2023] [Indexed: 05/31/2023] Open
Abstract
Hepatic encephalopathy (HE) is a common complication of liver cirrhosis, associated with high morbidity and mortality, for which no brain-targeted therapies exist at present. The interplay between hyperammonemia and inflammation is thought to drive HE development. As such, astrocytes, the most important ammonia-metabolizing cells in the brain, and microglia, the main immunomodulatory cells in the brain, have been heavily implicated in HE development. As insight into cellular perturbations driving brain pathology remains largely elusive, we aimed to investigate cell-type specific transcriptomic changes in the HE brain. In the recently established mouse bile duct ligation (BDL) model of HE, we performed RNA-Seq of sorted astrocytes and microglia at 14 and 28 days after induction. This revealed a marked transcriptional response in both cell types which was most pronounced in microglia. In both cell types, pathways related to inflammation and hypoxia, mechanisms commonly implicated in HE, were enriched. Additionally, astrocytes exhibited increased corticoid receptor and oxidative stress signaling, whereas microglial transcriptome changes were linked to immune cell attraction. Accordingly, both monocytes and neutrophils accumulated in the BDL mouse brain. Time-dependent changes were limited in both cell types, suggesting early establishment of a pathological phenotype. While HE is often considered a unique form of encephalopathy, astrocytic and microglial transcriptomes showed significant overlap with previously established gene expression signatures in other neuroinflammatory diseases like septic encephalopathy and stroke, suggesting common pathophysiological mechanisms. Our dataset identifies key molecular mechanisms involved in preclinical HE and provides a valuable resource for development of novel glial-directed therapeutic strategies.
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Affiliation(s)
- Wouter Claeys
- Hepatology Research Unit, Department of Internal Medicine and Paediatrics, Ghent University, 9000, Ghent, Belgium
- Liver Research Center Ghent, Ghent University Hospital, Ghent University, 9000, Ghent, Belgium
- Barriers in Inflammation, VIB Center for Inflammation Research, VIB, Technologiepark-Zwijnaarde 71, 9052, Ghent, Belgium
- Department of Biomedical Molecular Biology, Ghent University, 9000, Ghent, Belgium
| | - Lien Van Hoecke
- Barriers in Inflammation, VIB Center for Inflammation Research, VIB, Technologiepark-Zwijnaarde 71, 9052, Ghent, Belgium
- Department of Biomedical Molecular Biology, Ghent University, 9000, Ghent, Belgium
| | - Hannah Lernout
- Barriers in Inflammation, VIB Center for Inflammation Research, VIB, Technologiepark-Zwijnaarde 71, 9052, Ghent, Belgium
- IBD Research Unit, Department of Internal Medicine and Paediatrics, Ghent University, 9000, Ghent, Belgium
| | - Clint De Nolf
- Barriers in Inflammation, VIB Center for Inflammation Research, VIB, Technologiepark-Zwijnaarde 71, 9052, Ghent, Belgium
- Department of Biomedical Molecular Biology, Ghent University, 9000, Ghent, Belgium
- Department of Internal Medicine and Paediatrics, Ghent University, 9000, Ghent, Belgium
| | - Griet Van Imschoot
- Barriers in Inflammation, VIB Center for Inflammation Research, VIB, Technologiepark-Zwijnaarde 71, 9052, Ghent, Belgium
- Department of Biomedical Molecular Biology, Ghent University, 9000, Ghent, Belgium
| | - Elien Van Wonterghem
- Barriers in Inflammation, VIB Center for Inflammation Research, VIB, Technologiepark-Zwijnaarde 71, 9052, Ghent, Belgium
- Department of Biomedical Molecular Biology, Ghent University, 9000, Ghent, Belgium
| | - Daan Verhaege
- Barriers in Inflammation, VIB Center for Inflammation Research, VIB, Technologiepark-Zwijnaarde 71, 9052, Ghent, Belgium
- Department of Biomedical Molecular Biology, Ghent University, 9000, Ghent, Belgium
| | - Jonas Castelein
- Barriers in Inflammation, VIB Center for Inflammation Research, VIB, Technologiepark-Zwijnaarde 71, 9052, Ghent, Belgium
- Department of Biomedical Molecular Biology, Ghent University, 9000, Ghent, Belgium
| | - Anja Geerts
- Hepatology Research Unit, Department of Internal Medicine and Paediatrics, Ghent University, 9000, Ghent, Belgium
- Liver Research Center Ghent, Ghent University Hospital, Ghent University, 9000, Ghent, Belgium
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Christophe Van Steenkiste
- Department of Gastroenterology and Hepatology, Antwerp University, Antwerp, Belgium
- Department of Gastroenterology and Hepatology, Maria Middelares Hospital, Ghent, Belgium
| | - Roosmarijn E Vandenbroucke
- Barriers in Inflammation, VIB Center for Inflammation Research, VIB, Technologiepark-Zwijnaarde 71, 9052, Ghent, Belgium.
- Department of Biomedical Molecular Biology, Ghent University, 9000, Ghent, Belgium.
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35
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Gitto S, Vizzutti F, Baldi S, Campani C, Navari N, Falcini M, Venturi G, Montanari S, Roccarina D, Arena U, Pallecchi M, Di Bonaventura C, Bartolucci G, Ramazzotti M, Citone M, Fanelli F, Amedei A, Marra F. Transjugular intrahepatic Porto-systemic shunt positively influences the composition and metabolic functions of the gut microbiota in cirrhotic patients. Dig Liver Dis 2023; 55:622-628. [PMID: 36529635 DOI: 10.1016/j.dld.2022.11.017] [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: 07/14/2022] [Revised: 10/17/2022] [Accepted: 11/21/2022] [Indexed: 04/29/2023]
Abstract
BACKGROUND & AIMS Cirrhosis and its complications may affect gut microbiota (GM) composition. Transjugular intrahepatic portosystemic shunt (TIPS) represents the most effective treatment for portal hypertension (PH). We aimed to evaluate whether TIPS placement modifies GM composition and metabolic function. METHODS A compositional and functional GM analysis was prospectively performed in 13 cirrhotic patients receiving TIPS. Patients receiving systemic or non-absorbable antibiotics for any indications were excluded. Fecal samples were collected before and three months after TIPS. GM was analyzed by 16S ribosomal RNA sequencing. Small- and medium-chain fatty acids (SCFAs and MCFAs, respectively) were measured by gas chromatography/mass spectrometry. RESULTS TIPS placement resulted in a mean 48% reduction in portal-caval pressure gradient. No recurrence of PH related complications was observed. After TIPS, increased levels of Flavonifractor spp. (p = 0.049), and decreased levels of Clostridiaceae (p = 0.024), these latter linked to abdominal infections in cirrhotic patients, were observed. No differences were found in the SCFAs signature while analysis of MCFA profiles showed a decreased abundance of pro-inflammatory isohexanoic (p<0.01), 2-ethylhexanoic (p<0.01) and octanoic acids (p<0.01) after TIPS. CONCLUSION Correction of PH following TIPS results in modifications of GM composition which could be potentially beneficial and reduces the levels of fecal pro-inflammatory MCFAs.
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Affiliation(s)
- Stefano Gitto
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Simone Baldi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Claudia Campani
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Nadia Navari
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Margherita Falcini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giulia Venturi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Stanislao Montanari
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Davide Roccarina
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Umberto Arena
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marco Pallecchi
- Department of Neurosciences, Psychology, Drug Research and Child Health Section of Pharmaceutical and Nutraceutical Sciences, University of Florence, Italy
| | - Chiara Di Bonaventura
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianluca Bartolucci
- Department of Neurosciences, Psychology, Drug Research and Child Health Section of Pharmaceutical and Nutraceutical Sciences, University of Florence, Italy
| | - Matteo Ramazzotti
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Michele Citone
- Interventional Radiology Unit, Careggi Hospital, Florence, Italy
| | - Fabrizio Fanelli
- Interventional Radiology Unit, Careggi Hospital, Florence, Italy
| | - Amedeo Amedei
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Center for Research, High Education and Transfer DENOThe, University of Florence, Florence, Italy.
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36
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Bowman CA, Zhang J, Grinspan LT. What guidelines?: Attitudes and behaviors for prescribing prophylactic hepatic encephalopathy medications. Clin Liver Dis (Hoboken) 2023; 21:147-150. [PMID: 37274948 PMCID: PMC10238048 DOI: 10.1097/cld.0000000000000049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 04/10/2023] [Indexed: 06/07/2023] Open
Affiliation(s)
- Chip A. Bowman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joyce Zhang
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lauren T. Grinspan
- Department of Medicine, Division of Liver Diseases, Recanati/Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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37
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Zhang Z, Wang J, Han W, Zhao L. Using machine learning methods to predict 28-day mortality in patients with hepatic encephalopathy. BMC Gastroenterol 2023; 23:111. [PMID: 37024814 PMCID: PMC10077693 DOI: 10.1186/s12876-023-02753-z] [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: 09/02/2022] [Accepted: 03/29/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Hepatic encephalopathy (HE) is associated with marked increases in morbidity and mortality for cirrhosis patients. This study aimed to develop and validate machine learning (ML) models to predict 28-day mortality for patients with HE. METHODS A retrospective cohort study was conducted in the Medical Information Mart for Intensive Care (MIMIC)-IV database. Patients from MIMIC-IV were randomized into training and validation cohorts in a ratio of 7:3. Training cohort was used for establishing the model while validation cohort was used for validation. The outcome was defined as 28-day mortality. Predictors were identified by recursive feature elimination (RFE) within 24 h of intensive care unit (ICU) admission. The area under the curve (AUC) and calibration curve were used to determine the predictive performance of different ML models. RESULTS In the MIMIC-IV database, 601 patients were eventually diagnosed with HE. Of these, 112 (18.64%) experienced death within 28 days. Acute physiology score III (APSIII), sepsis related organ failure assessment (SOFA), international normalized ratio (INR), total bilirubin (TBIL), albumin, blood urea nitrogen (BUN), acute kidney injury (AKI) and mechanical ventilation were identified as independent risk factors. Validation set indicated that the artificial neural network (NNET) model had the highest AUC of 0.837 (95% CI:0.774-0.901). Furthermore, in the calibration curve, the NNET model was also well-calibrated (P = 0.323), which means that it can better predict the 28-day mortality in HE patients. Additionally, the performance of the NNET is superior to existing scores, including Model for End-Stage Liver Disease (MELD) and Model for End-Stage Liver Disease-Sodium (MELD-Na). CONCLUSIONS In this study, the NNET model demonstrated better discrimination in predicting 28-day mortality as compared to other models. This developed model could potentially improve the early detection of HE with high mortality, subsequently improving clinical outcomes in these patients with HE, but further external prospective validation is still required.
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Affiliation(s)
- Zhe Zhang
- Department of Gastroenterology, Tangdu Hospital, Fourth Military Medical University, No. 1 Xinsi Road, Xi'an, 710038, China
| | - Jian Wang
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, No. 1 Xinsi Road, Xi'an, China
| | - Wei Han
- Department of Gastroenterology, Tangdu Hospital, Fourth Military Medical University, No. 1 Xinsi Road, Xi'an, 710038, China
| | - Li Zhao
- Department of Gastroenterology, Tangdu Hospital, Fourth Military Medical University, No. 1 Xinsi Road, Xi'an, 710038, China.
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38
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Thabut D, Bouzbib C, Meunier L, Haas M, Weiss N, Louvet A, Imbert-Bismut F, Mochel F, Nadjar Y, Santiago A, Thevenot T, Duhalde V, Oberti F, Francoz C, Coilly A, Hilleret MN, Lebray P, Liou-Schischmanoff A, Barbier L, Duvoux C, Pageaux GP, Bismuth M, Galanaud D, Broucker TD, Cadranel JF, Leroy V, Di Martino V, Larrey D, Camus C, Scatton O, De Ledinghen V, Mallat A, Rudler M, Bureau C. Diagnosis and management of hepatic encephalopathy: The French recommendations. Liver Int 2023; 43:750-762. [PMID: 36625084 DOI: 10.1111/liv.15510] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/27/2022] [Accepted: 12/31/2022] [Indexed: 01/11/2023]
Abstract
Hepatic encephalopathy (HE) is a frequent and severe complication of liver disease with poor patient outcomes. However, it is a poorly understood complication, with no consensus for diagnosis. Therefore, HE is often underdiagnosed. Differential diagnosis may be cumbersome because of non-specific symptoms, such as confusion, cognitive disorders, the aetiological factors of cirrhosis and comorbidities, which are often observed in cirrhotic patients. Therefore, an overt or covert form of HE should be systematically investigated. Advice is provided to drive patient work-up. Effective treatments are available to prevent or treat HE bouts, but the issue of single or combination therapy has not been resolved. Transjugular intrahepatic portosystemic shunt (TIPS) placement largely improved the prognosis of cirrhotic patients, but HE occurrence of HE is often a fear, even when post-TIPS HE can be avoided by a careful selection of patients and preventive treatment. HE is an indication of liver transplantation. However, its reversibility post-transplantation and the consequences of transplantation in patients with other causes of neurological disorders remain controversial, which supports the performance of an extensive work-up in expert centres for this subset of patients. The present guidelines assist clinicians in the diagnosis of the overt or covert form of HE to implement curative and preventive treatments and clarify which patients require referral to expert centres for consideration for liver transplantation. These guidelines are very clinically oriented and address different frequent clinical issues to help physicians make bedside decisions.
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Affiliation(s)
- Dominique Thabut
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Charlotte Bouzbib
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Lucy Meunier
- Service d'hépato-gastroentérologie A et Transplantation, Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France
| | - Manon Haas
- APHP-Paris Saclay, Centre Hépato-Biliaire, Hôpital Paul Brousse, Université Paris-saclay, Villejuif, France
| | - Nicolas Weiss
- APHP-Sorbonne Université, Service de réanimation neurologique, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Alexandre Louvet
- Services des maladies de l'appareil digestif, CHRU de Lille, Lille, France
| | - Francois Imbert-Bismut
- APHP-Sorbonne Université, Service de biochimie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Fanny Mochel
- APHP-Sorbonne Université, Service de génétique, Hôpital Pitié-Salpêtrière, Paris, France
| | - Yann Nadjar
- APHP-Sorbonne Université, Service de neurologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Antoine Santiago
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Thierry Thevenot
- Service d'hépatologie, Hôpital Jean Minjoz, CHU de Besançon, Besançon, France
| | - Véronique Duhalde
- Service de pharmacie, Hôpital Rangueil, CHU de Toulouse, Toulouse, France
| | - Frédéric Oberti
- Laboratoire HIFIH, UPRES-EA2170, Faculté de Médecine, Service d'hépato-gastroentérologie, CHU ANGERS, Angers, France
| | - Claire Francoz
- APHP-Hôpital Beaujon, Service d'hépatologie, Clichy, France
| | - Audrey Coilly
- APHP-Paris Saclay, Centre Hépato-Biliaire, Hôpital Paul Brousse, Université Paris-saclay, Villejuif, France
| | | | - Pascal Lebray
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | | | - Louise Barbier
- Service de chirurgie hépatique et transplantation, CHU de Tours, Tours, France
| | | | - Georges-Philippe Pageaux
- Service d'hépato-gastroentérologie A et Transplantation, Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France
| | - Michael Bismuth
- Service d'hépato-gastroentérologie B, Hôpital Saint Eloi, CHU de Montpellier, Montpellier, France
| | - Damien Galanaud
- APHP-Sorbonne Université, Service de neuro-radiologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Thomas De Broucker
- Service de Neurologie Hôpital Pierre Delafontaine, Centre Hospitalier de Saint-Denis, Saint-Denis, France
| | - Jean-François Cadranel
- Service d'hépato-gastroentérologie de nutrition et d'Alcoologie-GHPSO site de Creil, Creil, France
| | - Vincent Leroy
- APHP Hôpital Henri-Mondor, Service d'hépatologie, Créteil, France
| | - Vincent Di Martino
- Service d'hépatologie, Hôpital Jean Minjoz, CHU de Besançon, Besançon, France
| | - Dominique Larrey
- Service d'hépato-gastroentérologie A et Transplantation, Hôpital Saint-Eloi, CHU de Montpellier, Montpellier, France
| | - Christophe Camus
- Service de réanimation Médicale, Hôpital Pontchaillou, CHU de Rennes, Rennes, France
| | - Olivier Scatton
- APHP-Sorbonne Université, Service de chirurgie et transplantation hépatique, Hôpital Pitié-Salpêtrière, Paris, France
| | - Victor De Ledinghen
- Service d'hépato-gastroentérologie, Hôpital du Haut-Lévêque, CHU de Bordeaux, Bordeaux, France
| | - Ariane Mallat
- APHP Hôpital Henri-Mondor, Service d'hépatologie, Créteil, France
| | - Marika Rudler
- APHP-Sorbonne Université, Service d'hépato-gastroentérologie, Hôpital Pitié-Salpêtrière. INSERM, Centre de Recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN). Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Christophe Bureau
- Service d'hépatologie, Hôpital Rangueil, CHU de Toulouse, Toulouse, France
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Zheng X, Bai Z, Wang T, Romeiro FG, Mancuso A, Philips CA, Wong YJ, Nery FG, Qi X. Human Albumin Infusion for the Management of Liver Cirrhosis and Its Complications: An Overview of Major Findings from Meta-analyses. Adv Ther 2023; 40:1494-1529. [PMID: 36697778 DOI: 10.1007/s12325-023-02430-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/06/2023] [Indexed: 01/27/2023]
Abstract
INTRODUCTION The role of human albumin (HA) infusion in cirrhotic patients has been increasingly recognized. This paper aims to summarize the evidence from meta-analyses regarding HA infusion for the management of cirrhosis and its complications. METHODS A systematic search in the PubMed, EMBASE, and Cochrane library databases, and in reference lists was conducted. All relevant meta-analyses were identified and their findings were reviewed. The Assessment of Multiple Systematic Reviews 2 (AMSTAR-2) checklist was used to evaluate the methodological quality and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system to assess the quality of evidence for significant outcomes. RESULTS Among 300 papers initially identified, 18 meta-analyses have been included. Short- and long-term HA infusion at high doses decreased the mortality of patients with decompensated cirrhosis. In cirrhotic patients with ascites, long-term HA infusion reduced the recurrence of ascites, but not mortality. In cirrhotic patients undergoing large-volume paracentesis (LVP), HA infusion reduced the incidence of post-paracentesis circulatory dysfunction and hyponatremia, but not mortality or renal impairment. In cirrhotic patients with overt hepatic encephalopathy (HE), HA infusion improved the severity of overt HE, but not overall mortality. In cirrhotic patients with spontaneous bacterial peritonitis (SBP), but not those with non-SBP infections, HA infusion reduced the mortality and renal impairment. In cirrhotic patients with type-1 hepatorenal syndrome (HRS), an increment of 100 g in cumulative HA dose increased 1.15-fold survival, but not HRS reversal. In these meta-analyses, the quality of methodology was low or critically low, and that of the evidence was from very low to moderate. CONCLUSIONS Based on the limited evidence from these meta-analyses, HA infusion appears to be beneficial in cirrhotic patients with ascites, overt HE, and SBP and in those undergoing LVP, but not in those with non-SBP infections.
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Affiliation(s)
- Xiaojie Zheng
- Department of Gastroenterology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenyang, 110840, Liaoning, China
- Postgraduate College, China Medical University, Shenyang, China
| | - Zhaohui Bai
- Department of Gastroenterology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenyang, 110840, Liaoning, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Ting Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenyang, 110840, Liaoning, China
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China
| | - Fernando G Romeiro
- Internal Medicine Department, Botucatu Medical School, São Paulo, Brazil
| | - Andrea Mancuso
- Medicina Interna 1, Azienda di Rilievo Nazionale ad Alta Specializzazione Civico-Di Cristina-Benfratelli, Palermo, Italy
| | - Cyriac A Philips
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, India
| | - Yu J Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
- Duke-NUS Medical School, SingHealth, Singapore, Singapore
| | - Filipe G Nery
- Serviço de Cuidados Intensivos, Unidade de Cuidados Intermédios Médico-Cirúrgica, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenyang, 110840, Liaoning, China.
- Postgraduate College, China Medical University, Shenyang, China.
- Department of Life Sciences and Biopharmaceutics, Shenyang Pharmaceutical University, Shenyang, China.
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Ma L, Ma J, Zhang W, Liu Q, Zhang Z, Yang M, Yu J, Zhou X, Chen S, Wang J, Luo J, Yan Z. Predictive power of portal pressure gradient remeasured shortly after transjugular intrahepatic portosystemic shunt. Hepatol Int 2023; 17:417-426. [PMID: 36322301 DOI: 10.1007/s12072-022-10440-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/09/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND AIMS The portal pressure gradient (PPG) measured at the time of transjugular intrahepatic portosystemic shunt (TIPS) completion (immediate PPG) is easily disturbed by many factors. This study aimed to assess the diagnostic value of PPG remeasured 2-4 days after TIPS (delayed PPG) by comparison with immediate PPG. METHODS We retrospectively analyzed cirrhotic patients aged 18-75 years who received TIPS for preventing variceal rebleeding and pressure measurements at different time points. RESULTS Of 154 eligible patients, 60 (39.0%), 62 (40.3%), and 32 (20.8%) were categorized into group LL (both immediate and delayed PPG < 12 mmHg), LH (immediate PPG < but delayed PPG ≥ 12 mmHg) and HH (both immediate and delayed PPG ≥ 12 mmHg), respectively. Mean immediate and delayed PPG were 9.2 mmHg and 12.8 mmHg (p < 0.001). During a median follow-up of 22 months, the 1-year probability of variceal rebleeding was significantly lower in group LL (1.7%) compared to LH (9.8%, absolute risk difference [ARD]: - 8.2%, p = 0.028) and HH (12.6%, ARD: - 11.1%, p = 0.014), but was not significantly different between groups LH and HH (ARD: - 2.9%, p = 0.671). Delayed PPG (p < 0.001) was identified as an independent predictor of variceal rebleeding in multivariable Cox regression analysis. The area under curves of delayed and immediate PPG in predicting variceal rebleeding were 0.837 and 0.693 for all patients (p = 0.031), and 0.936 and 0.694 for patients without shunt dysfunction (p < 0.001). CONCLUSIONS In cirrhotic patients with variceal bleeding, delayed PPG has higher predictive power for variceal rebleeding than immediate PPG.
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Affiliation(s)
- Li Ma
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jingqin Ma
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen Zhang
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qingxin Liu
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zihan Zhang
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Minjie Yang
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiaze Yu
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin Zhou
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shiyao Chen
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian Wang
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianjun Luo
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China.
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China.
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.
| | - Zhiping Yan
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China.
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China.
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China.
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.
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Schult D, Rasch S, Schmid RM, Lahmer T, Mayr U. EASIX Is an Accurate and Easily Available Prognostic Score in Critically Ill Patients with Advanced Liver Disease. J Clin Med 2023; 12:jcm12072553. [PMID: 37048641 PMCID: PMC10094870 DOI: 10.3390/jcm12072553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/18/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) is associated with high mortality. Objective prognostic scores are important for treatment decisions. EASIX (Endothelial Activation and Stress Index) is a simple biomarker consisting of LDH, platelets, and creatinine, reflecting endothelial dysfunction after allogeneic stem cell transplantation. Considering endothelial dysfunction in the pathogenesis of ACLF, this study aimed to test the discriminative ability of EASIX in advanced liver disease. We retrospectively analysed the prognostic potential of EASIX to predict 28-day and 3-month mortality in a total of 188 liver cirrhotic patients requiring treatment at the intensive care unit. We evaluated the ability of EASIX to rule out early infections and predict the need for hemodialysis. EASIX performed moderately better than established scores in predicting 28-day mortality (AUC = 0.771) and was nearly equivalent (AUC = 0.791) to SOFA and APACHE-II in the prediction of 3-month mortality. Importantly, EASIX showed better diagnostic potential in ruling out clinically apparent infections than common proinflammatory markers (AUC = 0.861, p < 0.001) and showed suitable accuracy in predicting the need for hemodialysis (AUC = 0.833). EASIX is an accurate, objective and easily assessable biomarker for predicting mortality and complications in patients with advanced liver disease.
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Zhang L, Wei B, Wang Z, Tong H, Wu H. Treatment of refractory hepatic encephalopathy induced by spontaneous portosystemic shunt: Selective splenic vein embolization versus shunt embolization. Dig Liver Dis 2023; 55:381-386. [PMID: 36175324 DOI: 10.1016/j.dld.2022.08.041] [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: 07/02/2022] [Revised: 08/27/2022] [Accepted: 08/30/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Spontaneous portosystemic shunt (SPSS) can cause refractory hepatic encephalopathy (HE) in cirrhotic patients. The embolization of the shunt (ES) can resolve the HE, while the selective embolization of the splenic vein (SESV) can treat splenorenal shunts related HE. The aim of this study was to compare the clinical outcomes of ES and SESV when applied for the treatment of SPSS-induced refractory HE in cirrhotic patients. METHODS Patients with refractory HE who were treated with ES or SESV were retrospectively identified. The clinical outcomes were compared and analyzed. RESULTS The 6-month mortality after the ES procedure was significantly higher than that after the SESV procedure. During the 6-month follow-up, both the white blood cell and the platelet counts were significantly lower after the ES procedure than after the SESV procedure. There was a significant increase in aspartate aminotransferase levels after ES. However, the albumin levels as well as the Child-Pugh score and grade were found to be significantly improved at 6 months after the undertaking of an SESV (as compared with baseline). CONCLUSION The 6-month mortality was improved after SESV (as compared with ES) in the treatment of SPSS-induced refractory HE. A prospective multicenter study for validation is warranted.
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Affiliation(s)
- Linhao Zhang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Bo Wei
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Zhidong Wang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Huan Tong
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Hao Wu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China.
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de Wit K, Beuers U, Mukha A, Stigter ECA, Gulersonmez MC, Ramos Pittol JM, Middendorp S, Takkenberg RB, van Mil SWC. Rifaximin stimulates nitrogen detoxification by PXR-independent mechanisms in human small intestinal organoids. Liver Int 2023; 43:649-659. [PMID: 36463417 DOI: 10.1111/liv.15491] [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: 08/18/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND AND AIMS Recurrent hepatic encephalopathy (HE) is characterized by hyperammonaemia in combination with neuropsychiatric abnormalities and is treated with lactulose and rifaximin. Rifaximin is a pregnane X receptor (PXR) agonist with low systemic and high intestinal bioavailability. The mechanisms by which it alleviates HE are unclear. We used human small intestinal (hSI) organoids to study whether rifaximin, via PXR activation, affects the epithelial biotransformation machinery, and to gain understanding of its low systemic availability. METHODS We generated PXR knockdown hSI organoids via lentiviral delivery of short hairpin RNAs. Organoids were cultured for 24 h with rifaximin or rifampicin. RNA-sequencing and metabolomics were performed to analyse gene expression and amino acid metabolism. Luminal rifaximin was quantified by photospectrometry. RESULTS Treatment of wild-type hSI organoids with rifaximin resulted in >twofold differential expression of 131 genes compared to DMSO. These effects were largely PXR independent and related to amino acid metabolism. Rifaximin decreased expression of glutaminase-2 and increased expression of asparagine synthetase and solute carrier 7A11, thereby increasing intracellular glutamine and asparagine concentrations, indicating active ammonia detoxification. Rifaximin was apically excreted into the lumen in an ATP binding cassette B1 (ABCB1)-dependent manner. CONCLUSIONS Rifaximin-after uptake into enterocytes-stimulates intracellular nitrogen detoxification by PXR-independent mechanisms. Active apical excretion of rifaximin by ABCB1 into the intestinal lumen explains its low systemic bioavailability. Our study implies that rifaximin, next to modulation of the microbiome, has direct effects on ammonia scavenging in the human small intestinal epithelium.
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Affiliation(s)
- Koos de Wit
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Anna Mukha
- Center for Molecular Medicine, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Edwin C A Stigter
- Center for Molecular Medicine, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - M Can Gulersonmez
- Center for Molecular Medicine, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jose M Ramos Pittol
- Center for Molecular Medicine, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sabine Middendorp
- Division of Paediatric Gastroenterology, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht University, Utrecht, The Netherlands.,Regenerative Medicine Center Utrecht, Utrecht, The Netherlands
| | - R Bart Takkenberg
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Saskia W C van Mil
- Center for Molecular Medicine, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
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Low adipose tissue index as an indicator of hepatic encephalopathy in cirrhotic patients following transjugular intrahepatic portosystemic shunt. ABDOMINAL RADIOLOGY (NEW YORK) 2023; 48:1454-1467. [PMID: 36735033 DOI: 10.1007/s00261-023-03813-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/10/2023] [Accepted: 01/10/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE We aimed to investigate the predictive value of body compositions measured by CT, including skeletal muscle and adipose tissue, for hepatic encephalopathy (HE) in cirrhotic patients following transjugular intrahepatic portosystemic shunt (TIPS). METHODS Patients who underwent TIPS between November 2015 and April 2021 were included in this retrospective study. CT images taken at L3 were quantified for three body composition indexes (cm2/m2), visceral fat area index (VFAI), subcutaneous fat area index (SFAI), and skeletal muscle index (SMI) at baseline. Multivariable logistic regression models were conducted to assess associations between post-TIPS HE and body compositions. Nomograms based on the multivariable logistic regression models were developed and were evaluated from Calibration curves. RESULTS Male patients had greater SMI, whereas SFAI and VFAI were higher in females (p < 0.001 for each). In sex stratified multivariate analyses after adjustment for other confounding variables, VFAI in males (p = 0.033) and SFAI in females (p = 0.003) were significant predictors of post-TIPS HE. Male patients with low VFAI (< 53.52 cm2/m2) (OR 6.44; 95% CI 1.72-23.59; p = 0.006) and female patients with low SFAI (< 70.05 cm2/m2) (OR 10.55; 95% CI 2.36-46.23; p = 0.002) had a higher risk of post-TIPS HE. Risk factors in the nomogram contributing to the male model included age, height, Child-Pugh score, and low VFAI; pre-albumin and low SFAI were contributed to female model. CONCLUSION Body compositions could not only be noninvasively used for nutritional assessment, but also be utilized to predict HE risk of cirrhotic patients after TIPS.
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Banc-Husu AM, Shiau H, Dike P, Shneider BL. Beyond Varices: Complications of Cirrhotic Portal Hypertension in Pediatrics. Semin Liver Dis 2023; 43:100-116. [PMID: 36572031 DOI: 10.1055/s-0042-1759613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Complications of cirrhotic portal hypertension (PHTN) in children are broad and include clinical manifestations ranging from variceal hemorrhage, hepatic encephalopathy (HE), ascites, spontaneous bacterial peritonitis (SBP), and hepatorenal syndrome (HRS) to less common conditions such as hepatopulmonary syndrome, portopulmonary hypertension, and cirrhotic cardiomyopathy. The approaches to the diagnosis and management of these complications have become standard of practice in adults with cirrhosis with many guidance statements available. However, there is limited literature on the diagnosis and management of these complications of PHTN in children with much of the current guidance available focused on variceal hemorrhage. The aim of this review is to summarize the current literature in adults who experience these complications of cirrhotic PHTN beyond variceal hemorrhage and present the available literature in children, with a focus on diagnosis, management, and liver transplant decision making in children with cirrhosis who develop ascites, SBP, HRS, HE, and cardiopulmonary complications.
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Affiliation(s)
- Anna M Banc-Husu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Henry Shiau
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Peace Dike
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Benjamin L Shneider
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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Trivedi S, Lam K, Ganesh A, Hasnain Y, Hassan W, Herren J, Gaba RC. Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation. Semin Intervent Radiol 2023; 40:9-14. [PMID: 37152788 PMCID: PMC10159723 DOI: 10.1055/s-0043-1764282] [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: 05/09/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) creation is effective in treating the sequelae of decompensated liver cirrhosis-including medically refractory ascites and variceal bleeding-by decompressing the portal venous system through a manmade portosystemic conduit within the liver. However, the altered physiology in which splenomesenteric blood bypasses intrahepatic portal venous perfusion can precipitate varying degrees of hepatic encephalopathy (HE). While the majority of post-TIPS HE cases can be treated medically, some require escalated management strategies, including endovascular interventions to modify the indwelling TIPS and/or occlude competitive physiologic spontaneous portosystemic shunts. This review article details the epidemiology, risk factors, diagnosis, classification, and treatment of post-TIPS HE.
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Affiliation(s)
- Surbhi Trivedi
- Department of Radiology, University of Illinois at Chicago College of Medicine, Chicago, Illinois
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Katie Lam
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Ashwin Ganesh
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Yasir Hasnain
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Wassim Hassan
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Josi Herren
- Department of Radiology, University of Illinois at Chicago College of Medicine, Chicago, Illinois
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Ron C. Gaba
- Department of Radiology, University of Illinois at Chicago College of Medicine, Chicago, Illinois
- University of Illinois at Chicago College of Medicine, Chicago, Illinois
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Moon AM, Kim HP, Jiang Y, Lupu G, Bissram JS, Barritt AS, Tapper EB. Systematic Review and Meta-Analysis on the Effects of Lactulose and Rifaximin on Patient-Reported Outcomes in Hepatic Encephalopathy. Am J Gastroenterol 2023; 118:284-293. [PMID: 36730910 PMCID: PMC9904367 DOI: 10.14309/ajg.0000000000002008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/09/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Patients with hepatic encephalopathy (HE) suffer from significant symptoms and impaired quality of life. Improved understanding on the potential benefits of first-line HE therapies may aid patient-provider discussions regarding expected benefits of HE treatments. We aimed to perform a systematic review to assess the effects of lactulose and rifaximin on patient-reported outcomes (PROs). METHODS We searched MEDLINE, EMBASE, and Cochrane Library databases for randomized trials or prospective cohort studies using lactulose and/or rifaximin for the management of HE and assessing changes in PRO using PRO instruments. Physician reviewers independently reviewed titles, abstracts, and full texts and extracted data independently. We performed random-effects meta-analyses to examine the effects of lactulose and rifaximin on PROs. RESULTS We identified 16 studies representing 1,376 patients that met inclusion criteria. Most studies assessed treatment of covert HE. In patients with covert HE, lactulose significantly improved overall patient-reported health-related quality of life measured by the Sickness Impact Profile with an estimated pooled mean difference of 6.92 (95% confidence interval: 6.66-7.18) and showed improvements in several subscales. Conversely, rifaximin demonstrated a nonstatistically significant mean difference in the total Sickness Impact Profile of 4.76 (95% confidence interval: -4.23 to 13.76), with strong evidence of heterogeneity between these studies. Studies examining other PRO instruments showed improvements in overall health-related quality of life, social functioning, and sleep from both lactulose and rifaximin. DISCUSSION Patients with HE treated with lactulose or rifaximin reported improvements in important PROs. These results may inform provider-patient communication and help manage patient expectations regarding the potential benefits of HE therapies.
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Affiliation(s)
- Andrew M Moon
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Hannah P Kim
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Yue Jiang
- Department of Statistical Science, Duke University, Durham, North Carolina, USA
| | - Gabriel Lupu
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jennifer S Bissram
- Health Sciences Library, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - A Sidney Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Improvement of sarcopenia is beneficial for prognosis in cirrhotic patients after TIPS placement. Dig Liver Dis 2023:S1590-8658(23)00003-8. [PMID: 36682922 DOI: 10.1016/j.dld.2023.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 12/14/2022] [Accepted: 01/01/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND The relationship between the improvement of sarcopenia and post-TIPS prognosis has not been fully investigated. AIMS To assess what level of sarcopenia improvement is required for potential benefits to post-TIPS prognosis. METHODS In this retrospective study, 109 cirrhotic patients with sarcopenia who underwent TIPS between February 2016 and January 2021 were included. The change in skeletal muscle index (SMI) at 6 months post-TIPS was assessed and the correlations of SMI improvement with clinical outcomes were analyzed. RESULTS During follow up, 59 (65.6%) patients reversed from sarcopenic to non-sarcopenic, and the cumulative mortality (8.5 % vs. 26.0%, log rank P = 0.013) and incidence of overt hepatic encephalopathy (OHE) (18.6% vs. 44.0%, log rank P = 0.004) in patients who reversed were significantly lower than who did not. SMI improvement rate was identified as an independent risk factor for mortality and OHE. In addition, the cumulative survival rate of patients with sarcopenia reversal or SMI improvement rate > 10.4% was significantly higher than that of patients with an SMI improvement rate ≤ 10.4% (92.5% vs. 58.6%, log rank P < 0.001). CONCLUSION Reversal of sarcopenia or significant SMI improvement by TIPS could reduce the risk of death and OHE.
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Kim MJ, Kim JH, Jung JH, Kim SE, Kim HS, Jang MK, Park SH, Lee MS, Suk KT, Kim DJ, Choi EK, Park JW. Serum S100B Levels in Patients with Liver Cirrhosis and Hepatic Encephalopathy. Diagnostics (Basel) 2023; 13:diagnostics13030333. [PMID: 36766438 PMCID: PMC9914222 DOI: 10.3390/diagnostics13030333] [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: 12/05/2022] [Revised: 01/08/2023] [Accepted: 01/13/2023] [Indexed: 01/18/2023] Open
Abstract
Hepatic encephalopathy (HE) is one of the main complications of liver cirrhosis (LC) and is classified into minimal hepatic encephalopathy (MHE) and overt hepatic encephalopathy (overt HE). S100B is expressed mainly in astrocytes and other glial cells, and S100B has been reported to be associated with various neurological disorders. The present study aimed to investigate the diagnostic ability of serum S100B to discriminate the grade of HE and the parameters correlated with serum S100B levels. Additionally, we investigated whether serum S100B levels can be used to predict 1-year mortality in cirrhotic patients. In total, 95 cirrhotic patients were consecutively enrolled and divided into the following three groups: (i) without any types of HEs; (ii) with MHE; and (iii) with overt HE. The diagnosis of MHE was made by the Mini-Mental State Examination (MMSE) and Psychometric Hepatic Encephalopathy Score (PHES). Among the three groups, there were no significant differences in serum S100B levels regardless of HE severity. The clinical parameters correlated with serum S100B levels were age, serum bilirubin, and creatinine levels. The Model for End-Stage Liver Disease (MELD) score showed a significant positive correlation with serum S100B levels. The relationship between serum S100B levels and MELD score was maintained in 48 patients without any type of HE. Additionally, hyperammonemia, low cholesterol levels, and the combination of serum S100B levels ≥ 35 pg/mL with MELD score ≥ 13 were factors for predicting 1- year mortality. In conclusion, serum S100B level was not useful for differentiating the severity of HE. However, we found that serum S100B levels can be affected by age, serum bilirubin, and creatinine in cirrhotic patients and are associated with MELD scores. Additionally, serum S100B levels showed the possibility of predicting 1-year mortality in cirrhotic patients. These findings suggest that serum S100B levels may reflect liver dysfunction and prognosis in liver disease.
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Affiliation(s)
- Mo-Jong Kim
- Ilsong Institute of Life Science, Hallym University, Seoul 07247, Republic of Korea
- Department of Biomedical Gerontology, Graduate School of Hallym University, Chuncheon-si 24252, Republic of Korea
| | - Jung-Hee Kim
- Department of Internal Medicine, Dongtan Sacred Heart Hospital of Hallym University Medical Center, 7, Keunjaebong-gil, Hwaseong-si 18450, Republic of Korea
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
| | - Jang-Han Jung
- Department of Internal Medicine, Dongtan Sacred Heart Hospital of Hallym University Medical Center, 7, Keunjaebong-gil, Hwaseong-si 18450, Republic of Korea
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
| | - Sung-Eun Kim
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Hallym University Sacred Heart Hospital of Hallym University Medical Center, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang-si 14068, Republic of Korea
| | - Hyoung-Su Kim
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Kangdong Sacred Heart Hospital of Hallym University Medical Center, 18, Cheonho-daero 173-gil, Gangdong-gu, Seoul 05355, Republic of Korea
| | - Myoung-Kuk Jang
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Kangdong Sacred Heart Hospital of Hallym University Medical Center, 18, Cheonho-daero 173-gil, Gangdong-gu, Seoul 05355, Republic of Korea
| | - Sang-Hoon Park
- Department of Internal Medicine, Kangnam Sacred Heart Hospital of Hallym University Medical Center, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Myung-Seok Lee
- Department of Internal Medicine, Kangnam Sacred Heart Hospital of Hallym University Medical Center, 1, Singil-ro, Yeongdeungpo-gu, Seoul 07441, Republic of Korea
| | - Ki Tae Suk
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital of Hallym University Medical Center, 77, Sakju-ro, Chuncheon-si 24253, Republic of Korea
| | - Dong Joon Kim
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital of Hallym University Medical Center, 77, Sakju-ro, Chuncheon-si 24253, Republic of Korea
| | - Eun-Kyoung Choi
- Ilsong Institute of Life Science, Hallym University, Seoul 07247, Republic of Korea
- Department of Biomedical Gerontology, Graduate School of Hallym University, Chuncheon-si 24252, Republic of Korea
| | - Ji-Won Park
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon-si 24252, Republic of Korea
- Department of Internal Medicine, Hallym University Sacred Heart Hospital of Hallym University Medical Center, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang-si 14068, Republic of Korea
- Correspondence: ; Tel.: +82-31-380-3705
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50
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Sano T, Amano K, Ide T, Yokoyama K, Noguchi K, Nakamura H, Isoda H, Ohno M, Shirachi M, Morita Y, Yano Y, Sumie S, Kawaguchi T, Kuwahara R, Arinaga-Hino T, Takahashi H, Shakado S, Hirai F, Kawaguchi T. A combination of hepatic encephalopathy and body mass index was associated with the point of no return for improving liver functional reserve after sofosbuvir/velpatasvir treatment in patients with hepatitis C virus-related decompensated cirrhosis. Hepatol Res 2023; 53:26-34. [PMID: 36066400 DOI: 10.1111/hepr.13837] [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: 07/12/2022] [Revised: 08/31/2022] [Accepted: 09/04/2022] [Indexed: 01/03/2023]
Abstract
AIMS The real-world efficacy of sofosbuvir/velpatasvir treatment for patients with hepatitis C virus-related decompensated cirrhosis is unclear. We aimed to identify factors that improve liver functional reserve after treatment. METHODS This was a multicenter retrospective study of 12-week sofosbuvir/velpatasvir treatment. A total of 48 patients with Child-Pugh (CP) class B or C were enrolled at 11 institutions. We evaluated changes in liver functional reserve at 24 weeks post-treatment. RESULTS At baseline, 40 and eight patients were CP class B and C, respectively. The overall rate of sustained virologic response 12 weeks post-treatment was 95.8% (46/48). Serum albumin, alanine aminotransferase and α-fetoprotein levels, and the FIB-4 index were significantly improved post-treatment (P < 0.05). Among patients who achieved sustained virologic response 12 weeks post-treatment, those with CP class A increased from 0 to 24 patients (56%) at 24 weeks post-treatment. In multivariate analysis, body mass index (BMI) ≥25 was an independent factor that inhibited CP class improvement (P < 0.05). In decision tree analysis, after treatment, the initial divergent variable for CP class improvement was hepatic encephalopathy, followed by serum sodium level and BMI. CONCLUSION Sofosbuvir/velpatasvir treatment improved the liver functional reserve in patients with hepatitis C virus-related decompensated cirrhosis at 24 weeks post-treatment. However, BMI ≥25 inhibited improvement in CP class. Additionally, decision tree analysis revealed that a combination of hepatic encephalopathy, serum sodium levels, and BMI were diversity profiles associated with no improvement in liver functional reserve after the treatment.
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Affiliation(s)
- Tomoya Sano
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Keisuke Amano
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Tatsuya Ide
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan.,Kurume University Medical Center, Fukuoka, Japan
| | - Keiji Yokoyama
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | | | | | - Hiroshi Isoda
- Liver Center, Faculty of Medicine, Saga University, Saga, Japan
| | | | | | | | | | | | | | - Reiichiro Kuwahara
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Teruko Arinaga-Hino
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | | | - Satoshi Shakado
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Fumihito Hirai
- Department of Gastroenterology and Medicine, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Takumi Kawaguchi
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan
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