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Sauerbruch T, Hennenberg M, Trebicka J, Schierwagen R. Beta-blockers in patients with liver cirrhosis: Pragmatism or perfection? Front Med (Lausanne) 2023; 9:1100966. [PMID: 36743678 PMCID: PMC9891090 DOI: 10.3389/fmed.2022.1100966] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
With increasing decompensation, hyperdynamic circulatory disturbance occurs in liver cirrhosis despite activation of vasoconstrictors. Here, the concept of a therapy with non-selective beta-blockers was established decades ago. They lower elevated portal pressure, protect against variceal hemorrhage, and may also have pleiotropic immunomodulatory effects. Recently, the beneficial effect of carvedilol, which blocks alpha and beta receptors, has been highlighted. Carvedilol leads to "biased-signaling" via recruitment of beta-arrestin. This effect and its consequences have not been sufficiently investigated in patients with liver cirrhosis. Also, a number of questions remain open regarding the expression of beta-receptors and its intracellular signaling and the respective consequences in the intra- and extrahepatic tissue compartments. Despite the undisputed role of non-selective beta-blockers in the treatment of liver cirrhosis, we still can improve the knowledge as to when and how beta-blockers should be used in which patients.
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Affiliation(s)
- Tilman Sauerbruch
- Department of Internal Medicine I, University of Bonn, Bonn, Germany,*Correspondence: Tilman Sauerbruch,
| | - Martin Hennenberg
- Department of Urology, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Jonel Trebicka
- Department of Internal Medicine B, University of Münster, Münster, Germany,European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Robert Schierwagen
- Department of Internal Medicine B, University of Münster, Münster, Germany
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2
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Wang J, Wang Z, Chen M, Xiao Y, Chen S, Wu L, Yao L, Jiang X, Li J, Xu M, Lin M, Zhu Y, Luo R, Zhang C, Li X, Yu H. An interpretable artificial intelligence system for detecting risk factors of gastroesophageal variceal bleeding. NPJ Digit Med 2022; 5:183. [PMID: 36536039 PMCID: PMC9763258 DOI: 10.1038/s41746-022-00729-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
Bleeding risk factors for gastroesophageal varices (GEV) detected by endoscopy in cirrhotic patients determine the prophylactical treatment patients will undergo in the following 2 years. We propose a methodology for measuring the risk factors. We create an artificial intelligence system (ENDOANGEL-GEV) containing six models to segment GEV and to classify the grades (grades 1-3) and red color signs (RC, RC0-RC3) of varices. It also summarizes changes in the above results with region in real time. ENDOANGEL-GEV is trained using 6034 images from 1156 cirrhotic patients across three hospitals (dataset 1) and validated on multicenter datasets with 11009 images from 141 videos (dataset 2) and in a prospective study recruiting 161 cirrhotic patients from Renmin Hospital of Wuhan University (dataset 3). In dataset 1, ENDOANGEL-GEV achieves intersection over union values of 0.8087 for segmenting esophageal varices and 0.8141 for gastric varices. In dataset 2, the system maintains fairly accuracy across images from three hospitals. In dataset 3, ENDOANGEL-GEV surpasses attended endoscopists in detecting RC of GEV and classifying grades (p < 0.001). When ranking the risk of patients combined with the Child‒Pugh score, ENDOANGEL-GEV outperforms endoscopists for esophageal varices (p < 0.001) and shows comparable performance for gastric varices (p = 0.152). Compared with endoscopists, ENDOANGEL-GEV may help 12.31% (16/130) more patients receive the right intervention. We establish an interpretable system for the endoscopic diagnosis and risk stratification of GEV. It will assist in detecting the first bleeding risk factors accurately and expanding the scope of quantitative measurement of diseases.
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Affiliation(s)
- Jing Wang
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhengqiang Wang
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Mingkai Chen
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yong Xiao
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shi Chen
- Department of Gastroenterology, Wuhan Puren Hospital, Wuhan, China
| | - Lianlian Wu
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Liwen Yao
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiaoda Jiang
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jiao Li
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Ming Xu
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Mengjuan Lin
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yijie Zhu
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Renquan Luo
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Chenxia Zhang
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xun Li
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
| | - Honggang Yu
- grid.412632.00000 0004 1758 2270Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China ,grid.412632.00000 0004 1758 2270Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
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Hsin F, Hsu YC, Tsai YF, Lin SW, Liu HM. The transmembrane serine protease hepsin suppresses type I interferon induction by cleaving STING. Sci Signal 2021; 14:14/687/eabb4752. [PMID: 34131022 DOI: 10.1126/scisignal.abb4752] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Many viral proteases mediate the evasion of antiviral innate immunity by cleaving adapter proteins in the interferon (IFN) induction pathway. Host proteases are also involved in innate immunity and inflammation. Here, we report that the transmembrane protease hepsin (also known as TMPRSS1), which is predominantly present in hepatocytes, inhibited the induction of type I IFN during viral infections. Knocking out hepsin in mouse embryonic fibroblasts (MEFs) increased the viral infection-induced expression of Ifnb1, an Ifnb1 promoter reporter, and an IFN-sensitive response element promoter reporter. Ectopic expression of hepsin in cultured human hepatocytes and HEK293T cells suppressed the induction of IFNβ during viral infections by reducing the abundance of STING. These effects depended on the protease activity of hepsin. We identified a putative hepsin target site in STING and showed that mutating this site protected STING from hepsin-mediated cleavage. In addition to hepatocytes, several hepsin-producing prostate cancer cell lines showed reduced STING-mediated type I IFN induction and responses. These results reveal a role for hepsin in suppressing STING-mediated type I IFN induction, which may contribute to the vulnerability of hepatocytes to chronic viral infections.
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Affiliation(s)
- Fu Hsin
- Department of Biochemistry and Molecular Biology, College of Medicine, National Taiwan University, Taipei City, Taiwan.,Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Yu-Chen Hsu
- Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University, Taipei City, Taiwan.,Liver Disease Prevention and Treatment Research Foundation, Taipei City, Taiwan
| | - Yu-Fei Tsai
- Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Shu-Wha Lin
- Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University, Taipei City, Taiwan
| | - Helene Minyi Liu
- Department of Biochemistry and Molecular Biology, College of Medicine, National Taiwan University, Taipei City, Taiwan.
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4
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Mac-2 Binding Protein Glycosylation Isomer for Screening High-Risk Esophageal Varices in Liver Cirrhotic Patient. LIVERS 2021. [DOI: 10.3390/livers1020006] [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] [Indexed: 10/21/2022] Open
Abstract
Background: Esophageal varices occur at middle to advanced stages of cirrhosis and are associated with increased mortality due to their potential for rupture and bleeding. The aim of this study is to examine the accuracy of a surrogate marker, Mac-2 binding protein glycosylation isomer (M2BPGi), for screening high-risk esophageal varices in cirrhotic patients. Methods: Ninety-four cirrhotic patients who underwent endoscopy screening at Cipto Mangunkusumo Hospital, Jakarta, Indonesia were included. Patients with a history of ligation, portal vein thrombosis, or hepatocellular carcinoma were excluded. All enrolled patients underwent ultrasonography, transient elastography, and laboratory tests. The HISCL-5000 Sysmex analyzer was used to measure M2BPGi levels. Results: Of these 94 patients, 27 had high-risk esophageal varices and 67 had non-high-risk esophageal varices. M2BPGi levels were higher in patients with high-risk esophageal varices compared with those with non-high-risk esophageal varices (cutoff index (COI) of 11.4 vs. 3.7, p < 0.001). The sensitivity, specificity, positive predictive value, and negative predictive value of M2BPGi with a cutoff value of 5 COI was 92.6%, 70.1%, 55.6%, and 95.9%, respectively. Conclusions: M2BPGi could be used as a non-invasive surrogate marker for ruling out high-risk esophageal varices in cirrhotic patients. This method is cheap and non-invasive and could be used as a screening tool in resource-limited settings.
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Garbuzenko DV, Arefyev NO. Primary prevention of bleeding from esophageal varices in patients with liver cirrhosis: An update and review of the literature. J Evid Based Med 2020; 13:313-324. [PMID: 33037792 DOI: 10.1111/jebm.12407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/19/2020] [Indexed: 12/12/2022]
Abstract
All patients with liver cirrhosis and portal hypertension should be stratified by risk groups to individualize different therapeutic strategies to increase the effectiveness of treatment. In this regard, the development of primary prophylaxis of variceal bleeding and its management according to the severity of portal hypertension may be promising. This paper is to describe the modern principles of primary prophylaxis of esophageal variceal bleeding in patients with liver cirrhosis. The PubMed and EMbase databases, Web of Science, Google Scholar, and the Cochrane Database of Systematic Reviews were used to search for relevant publications from 1999 to 2019. The results suggested that depending on the severity of portal hypertension, patients with cirrhosis should be divided into those who need preprimary prophylaxis, which aims to prevent the formation of esophageal varices, and those who require measures that aim to prevent esophageal variceal bleeding. In subclinical portal hypertension, therapy should be etiological and pathogenetic. Cirrhosis with clinically significant portal hypertension should receive nonselective β-blockers if they have small esophageal varices and risk factors for variceal bleeding. Nonselective β-blockers are the first-line drugs for the primary prevention of bleeding from medium to large-sized esophageal varices. Endoscopic band ligation is indicated for the patients who are intolerant to nonselective β-blockers or in the case of contraindications to pharmacological therapy. In summary, the stratification of cirrhotic patients by the severity of portal hypertension and an individual approach to the choice of treatment may increase the effectiveness of therapy as well as improve survival rate of these patients.
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Affiliation(s)
| | - Nikolay Olegovich Arefyev
- Department of Pathological Anatomy and Forensic Medicine, South Ural State Medical University, Chelyabinsk, Russia
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6
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Abstract
Hepatitis B virus (HBV) infection causes chronic hepatitis and has long term complications. Individuals ever infected with HBV are at risk of viral reactivation under certain circumstances. This review summarizes studies on HBV persistence and reactivation with a focus on the definitions and mechanisms. Emphasis is placed on the interplay between HBV replication and host immunity as this interplay determines the patterns of persistence following viral acquisition. Chronic infections exhibit as overt persistence when a defective immune response fails to control the viral replication. The HBV genome persists despite an immune response in the form of covalently closed circular DNA (cccDNA) and integrated DNA, rendering an occult state of viral persistence in individuals whose infection appears to have been resolved. We have described HBV reactivation that occurs because of changes in the virus or the immune system. This review aims to raise the awareness of HBV reactivation and to understand how HBV persists, and discusses the risks of HBV reactivation in a variety of clinical settings.
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Affiliation(s)
- Yu Shi
- The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital of School of Medicine, Zhejiang University, Hangzhou, China
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
- National Clinical Research Center for Infectious Diseases, China
| | - Min Zheng
- The State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital of School of Medicine, Zhejiang University, Hangzhou, China
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
- National Clinical Research Center for Infectious Diseases, China
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7
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Lee SW, Uchiyama K. A commentary on “Laparoscopic vs. open splenectomy and oesophagogastric revascularisation for liver cirrhosis and portal hypertension: A retrospective cohort study”. Int J Surg 2020; 81:83. [DOI: 10.1016/j.ijsu.2020.07.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/17/2020] [Indexed: 12/13/2022]
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8
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Fabrellas N, Carol M, Palacio E, Aban M, Lanzillotti T, Nicolao G, Chiappa MT, Esnault V, Graf‐Dirmeier S, Helder J, Gossard A, Lopez M, Cervera M, Dols LL, Pose E, Caraceni P, Vargas V, Alessandria C, Beuers U, Trebicka J, Durand F, Mookerjee R, Angeli P, Korenjak M, Abraldes JG, Watson H, Kamath PS, Ginès P. Nursing Care of Patients With Cirrhosis: The LiverHope Nursing Project. Hepatology 2020; 71:1106-1116. [PMID: 31944340 PMCID: PMC7154704 DOI: 10.1002/hep.31117] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 01/07/2020] [Indexed: 12/16/2022]
Abstract
Cirrhosis is a complex disease that is associated with disturbances in different organs besides the liver, including kidneys, heart, arterial circulation, lungs, gut, and brain. As a consequence, patients develop a number of complications that result in frequent hospital admissions and high morbidity and mortality. Patients with cirrhosis require constant and rigorous monitoring both in and outside the hospital. In this context, the role of nurses in the care of patients with cirrhosis has not been sufficiently emphasized and there is very limited information about nursing care of patients with cirrhosis compared with other chronic diseases. The current article provides a review of nursing care for the different complications of patients with cirrhosis. Nurses with specific knowledge on liver diseases should be incorporated into multidisciplinary teams managing patients with cirrhosis, both inpatient and outpatient. Conclusion: Nurses play an important role in the management and prevention of complications of the disease and improvement in patients' quality of life and bridge the gap between clinicians and families, between primary care and hospital care, and provide medical education to patients and caregivers.
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Affiliation(s)
- Núria Fabrellas
- Faculty of Medicine and Health SciencesUniversity of BarcelonaBarcelonaSpain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y DigestivasBarcelonaSpain
| | - Marta Carol
- Faculty of Medicine and Health SciencesUniversity of BarcelonaBarcelonaSpain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y DigestivasBarcelonaSpain
| | | | | | | | | | | | | | - Sabine Graf‐Dirmeier
- Department of Internal Medicine IUniversity Clinic FrankfurtFrankfurt am MainGermany
| | | | - Andrea Gossard
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMN
| | - Mireia Lopez
- Faculty of Medicine and Health SciencesUniversity of BarcelonaBarcelonaSpain
| | - Marta Cervera
- Faculty of Medicine and Health SciencesUniversity of BarcelonaBarcelonaSpain,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y DigestivasBarcelonaSpain
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Perera K, Kodisinghe SK, Ediriweera DS, Moratuwagama D, Williams S, Pathmeswaran A, Niriella MA, de Silva HJ. Percentage of small platelets on peripheral blood smear and Child-Turcott-Pugh class can predict the presence of oesophageal varices in newly diagnosed patients with cirrhosis: development of a prediction model for resource limited settings. BMC Gastroenterol 2019; 19:134. [PMID: 31349807 PMCID: PMC6660923 DOI: 10.1186/s12876-019-1054-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/21/2019] [Indexed: 12/19/2022] Open
Abstract
Background In cirrhosis upper-gastrointestinal-endoscopy (UGIE) identifies oesophageal varices (OV). UGIE is unavailable in most resource-limited settings. Therefore, we assessed prediction of presence of OV using hematological parameters (HP) and Child-Turcott-Pugh (CTP) class. Methods A prospective study was carried out on consecutive, consenting, newly-diagnosed patients with cirrhosis, in the University Medical Unit, Colombo North Teaching Hospital, Ragama, Sri Lanka from April 2014–April 2016. All patients had UGIE to evaluate presence and degree of OV, prior to appropriate therapy. HP (full blood count with indices using automated analyzer and peripheral blood smear using Leishmann stain) and CTP class were assessed on admission. Linear logistic regression model was developed to predict OV using HP and CTP class. Results 54-patients with cirrhosis were included [14(26%), 24(44%) and 16(30%) belonged to CTP class A, B and C respectively]. 37 had varices [CTP-A 4/14(26.6%), CTP-B 19/24(79.2%), CTP-C 14/16(87.5%)] on UGIE. Generalized linear model fitting showed decreasing percentage of small platelets (%SP) (P = 0.002), CTP-B (P = 0.003) and CTP-C (P = 0.003) compared to CTP-A had higher probability of having OV. The model predicts the log odds for having OV = − 0.189 – (0.046*%SP) + 2.9 [if CTP-B] + 3.7 [if CTP-C]. Based on receiver operating characteristic (ROC) analysis, a model value > − 0.19 was selected as the cutoff point to predict OV with 89%-sensitivity, 76%-specificity, 89%-positive predictive value and 76%-negative predictive value. Conclusions We constructed a model using %SP on peripheral blood smear and CTP class. This model may be used to predict the presence of OV, in newly diagnosed patients with cirrhosis, with acceptable sensitivity and specificity, to prioritize the patients who deserve early UGIE in limited resource settings. Electronic supplementary material The online version of this article (10.1186/s12876-019-1054-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- K Perera
- Colombo North Teaching Hospital, Ragama, Sri Lanka
| | | | - D S Ediriweera
- Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - D Moratuwagama
- Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - S Williams
- Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - A Pathmeswaran
- Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - M A Niriella
- Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka.
| | - H J de Silva
- Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
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Abstract
Portal hypertension is one cause and a part of a dynamic process triggered by chronic liver disease, mostly induced by alcohol or incorrect nutrition and less often by viral infections and autoimmune or genetic disease. Adequate staging - continuously modified by current knowledge - should guide the prevention and treatment of portal hypertension with defined endpoints. The main goals are interruption of etiology and prevention of complications followed, if necessary, by treatment of these. For the past few decades, shunts, mostly as intrahepatic stent bypass between portal and hepatic vein branches, have played an important role in the prevention of recurrent bleeding and ascites formation, although their impact on survival remains ambiguous. Systemic drugs, such as non-selective beta-blockers, statins, or antibiotics, reduce portal hypertension by decreasing intrahepatic resistance or portal tributary blood flow or by blunting inflammatory stimuli inside and outside the liver. Here, the interactions among the gut, liver, and brain are increasingly examined for new therapeutic options. There is no general panacea. The interruption of initiating factors is key. If not possible or if not possible in a timely manner, combined approaches should receive more attention before considering liver transplantation.
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Affiliation(s)
| | | | - Jonel Trebicka
- Department of Internal Medicine, University of Bonn, Bonn, Germany.,European Foundation for Study of Chronic Liver Failure, Barcelona, Spain
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11
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Activation of Stimulator of Interferon Genes in Hepatocytes Suppresses the Replication of Hepatitis B Virus. Antimicrob Agents Chemother 2017; 61:AAC.00771-17. [PMID: 28717041 DOI: 10.1128/aac.00771-17] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 07/11/2017] [Indexed: 12/12/2022] Open
Abstract
Induction of interferon and proinflammatory cytokines is a hallmark of the infection of many different viruses. However, hepatitis B virus (HBV) does not elicit a detectable cytokine response in infected hepatocytes. In order to investigate the molecular mechanism underlying the innate immune evasion, a functional cyclic GMP-AMP (cGAMP) synthase (cGAS)-stimulator of interferon genes (STING) pathway was reconstituted in a human hepatoma cell line supporting tetracycline-inducible HBV replication. It was demonstrated that induction of HBV replication neither activated nor inhibited this cytosolic DNA sensing pathway. However, human hepatoma cells, as well as immortalized mouse hepatocytes, express low levels of STING, which upon activation by cGAMP, the natural ligand of STING, led to induction of a proinflammatory cytokine response. Treatment of immortalized mouse hepatocytes supporting HBV replication with either cGAMP or a small molecule pharmacologic STING agonist significantly reduced viral DNA in a STING- and Janus kinase 1-dependent manner. Moreover, cGAMP treatment was able to induce inflammatory cytokine gene expression and inhibit the transcription of covalently closed circular DNA in HBV-infected human hepatoma cells expressing sodium taurocholate cotransporting polypeptide, an essential receptor for HBV infection of hepatocytes. The studies reported here and previously (F. Guo et al., Antimicrob Agents Chemother 59:1273-1281, 2015, https://doi.org/10.1128/AAC.04321-14) thus support the notion that pharmacological activation of STING in macrophages and hepatocytes induces host innate responses that can efficiently control HBV replication. Hence, despite not playing a significant role in host innate immune response to HBV infection of hepatocytes, STING is potentially a valuable target for immunotherapy of chronic hepatitis B.
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