Cirrhosis development probably arises from chronic micro-vascular ischemia

Budd-Chiari Syndrome Management: Controversies and Open Issues

Budd-Chiari Syndrome (BCS) is due to thrombosis of hepatic veins (HVs), inferior vena cava (IVC) or both, leading to impaired hepatic venous outflow [...].

The Role of von Willebrand Factor Antigen in Predicting Survival of Patients with HBV-Related Cirrhosis

OBJECTIVE

The model for end-stage liver disease (MELD) scoring system cannot be used to assess the deterioration of patients with liver cirrhosis caused by infection and portal hypertension. Elevated von Willebrand factor antigen (vWF-Ag) in plasma is associated with portal pressure and complications in patients with liver cirrhosis. We aimed to evaluate whether the addition of vWF-Ag can improve the risk prediction ability of the MELD scoring system.

METHODS

A total of 228 patients with hepatitis B virus (HBV)-related liver cirrhosis were eligible for inclusion in this retrospective study. The vWF-Ag level was assessed by enzyme-linked immunosorbent assay (ELISA). The endpoint of this study was defined as the time to liver transplantation or death. Univariate and multivariate analyses were performed to assess the risk factors associated with transplant-free mortality. Receiver operating characteristic (ROC) curve analysis was used to assess potential discriminatory variables for transplant-free mortality.

RESULTS

During a median follow-up interval of 30.23 months, 124 patients (54.4%) reached the endpoint of this study. Patients who died or underwent liver transplantation had elevated levels of MELD and vWF-Ag. Moreover, vWF-Ag and MELD showed comparable predictive potential for transplant-free survival (area under the curve [AUC], vWF-Ag = 0.71; AUC, MELD = 0.73). Ultimately, vWF-Ag can significantly improve the predictive potential of MELD in determining transplant-free mortality (AUC, MELD-vWF-Ag = 0.79, P = 0.006).

CONCLUSION

An elevated vWF-Ag level was independently associated with transplant-free mortality in patients with liver cirrhosis. The inclusion of vWF-Ag in the MELD scoring system can improve mortality predictions in patients with liver cirrhosis.

Systematic review: role of elevated plasma von-Willebrand factor as predictor of mortality in patients with chronic liver disease

In this systematic review, we aimed to assess role of plasma von-Willebrand factor (vWF), an endothelial activation marker, as prognostic marker in patients with chronc liver disease [cirrhosis and acute-on-chronic liver failure (ACLF)]. We searched published databases using predefined keywords to identify all studies up to June 2018, in which plasma vWF (antigen or activity assay) was used as prognostic marker predicting mortality in patients with chronic liver disease. Relevant extracted data from selected studies were narratively summarized. The individual study's area under ROC curve for plasma vWF as a predictor of mortality was pooled and meta-analyzed. Six studies (cirrhosis: 5; ACLF: 1) with an aggregate data of 765 patients (cirrhosis: 715 patients; ACLF: 50 patients) were included. Baseline plasma vWF-antigen was an independent predictor of medium-term mortality in patients with cirrhosis (summary area under the curve: 0.74; 95% confidence interval: 0.70-0.79) with an optimal cutoff of 318% (216-390%; median, range) over a period of 25.6 months (23.6-33 months). Plasma vWF also predicted short-term (over 7 days) mortality in patients with ACLF. Plasma vWF levels correlated with Child's score, model for end-stage liver disease (MELD) score and hepatic venous pressure gradient and performed as well as MELD score in predicting mortality in patients with cirrhosis and ACLF. Baseline plasma vWF level predicts mortality over a medium term (1-3 years) in cirrhosis and over a short term (1 week) in ACLF patients. The marked elevation of baseline plasma vWF levels in ACLF patients was associated with drastic truncation of survival when compared with cirrhosis patients.

The relationship between serum hepatitis B virus DNA level and liver histology in patients with chronic HBV infection

BACKGROUND

There is no consensus regarding the relationship between HBV DNA and liver fibrosis, and the relationship between HBV DNA and the degree of liver cirrhosis has not been reported in patients with chronic HBV infection.

METHODS

From January 2011 to December 2016, liver biopsies were performed on 396 patients with chronic hepatitis B and cirrhosis. Assessments of liver fibrosis and cirrhosis were based on the Laennec staging system.

RESULTS

Serum levels of HBV DNA were correlated with fibrosis and cirrhosis (KW = 73.946, P<0.001). Serum HBV DNA level was correlated with mild fibrosis, moderate to severe fibrosis and cirrhosis (P = 0.009, P<0.001, and P<0.001, respectively). The HBeAg-positive group and HBeAg-negative group showed significant differences in HBV DNA levels, and the rates of mild fibrosis, severe fibrosis and cirrhosis were significantly different between these two groups (F = 17.585, P<0.001 and F = 6.017, P = 0.003, respectively). The replication status of the serum HBV DNA affected fibrosis formation as well as cirrhosis (χ2 = 53.76, P<0.001). In the HBeAg-positive group, the sensitivity, specificity and AUC values of HBV DNA as a predictor for mild fibrosis and cirrhosis were 64.3%, 78.94% and 0.818, respectively, and 81.0%, 69.2%, and 0.871, respectively. In the HBeAg-negative group, the sensitivity, specificity and AUC values of HBV DNA for liver sclerosis prediction were 48%, 76.8% and 0.697, respectively.

CONCLUSIONS

Different HBV DNA levels had different effects on the formation of fibrosis and sclerosis in liver tissues. HBV DNA levels can predict mild fibrosis and cirrhosis in liver tissue, which is enhanced in HBeAg-positive patients.

Timing of Transjugular Intrahepatic Portosystemic Shunt for Budd-Chiari Syndrome: An Italian Hepatologist's Perspective

Budd-Chiari syndrome (BCS) management flow-chart is derived from experts' opinion and is not evidence-based. Guidelines suggest BCS management should follow a stepwise strategy: medical therapy as first-line treatment, revascularization or transjugular intrahepatic portosystemic shunt (TIPS) if no response to medical therapy, and liver transplant as rescue therapy. Recent evidence suggests that only medical therapy results in a bad long-term outcome. The biggest criticism of guidelines is the indication that BCS should receive further treatment only when hemodynamic consequences of portal hypertension become clinically evident. Recent data support that in BCS liver fibrosis could arise from chronic microvascular ischemia. A reasoning model of BCS physiopathology is that impaired hepatic vein outflow has hemodynamic consequences on portal hypertension development and causes hepatic fibrosis and liver failure through chronic ischemic damage. On this assumption is the concept that relieving liver congestion could ameliorate liver function and prevent development of BCS complications. Recently, early interventional treatment with TIPS for BCS has been reported to be effective. Early TIPS seems to be the best option for BCS management. Future multicenter controlled studies should compare the outcome of BCS treated with early interventional treatment compared with stepwise strategy.

Effects of aspirin and enoxaparin in a rat model of liver fibrosis

AIM

To examine the effects of aspirin and enoxaparin on liver function, coagulation index and histopathology in a rat model of liver fibrosis.

METHODS

Forty-five male Sprague-Dawley rats were randomly divided into the control group (n = 5) and model group (n = 40). Thioacetamide (TAA) was used to induce liver fibrosis in the model group. TAA-induced fibrotic rats received TAA continuously (n = 9), TAA + low-dose aspirin (n = 9), TAA + high-dose aspirin (n = 9) or TAA + enoxaparin (n = 9) for 4 wk. All rats were euthanized after 4 wk, and both hematoxylin-eosin and Masson staining were performed to observe pathological changes in liver tissue.

RESULTS

Liver fibrosis was assessed according to the METAVIR score. Compared with untreated cirrhotic controls, a significant improvement in fibrosis grade was observed in the low-dose aspirin, high-dose aspirin and enoxaparin treated groups, especially in the high-dose aspirin treated group. Alanine aminotransferase and total bilirubin were higher, albumin was lower and both prothrombin time and international normalized ratio were prolonged in the four treatment groups compared to controls. No significant differences among the four groups were observed.

CONCLUSION

Aspirin and enoxaparin can alleviate liver fibrosis in this rat model.

Management of portal vein thrombosis in cirrhosis: an update

BACKGROUND

Portal vein thrombosis (PVT) is a complication of cirrhosis. However, whether PVT worsens cirrhosis outcome is a debated issue.

AIM

To report an update on the management of PVT.

METHODS

A review was performed on the outcome, prevention, and treatment of PVT.

RESULTS

Some studies suggest that PVT could worsen the rate of hepatic decompensation and survival of cirrhosis, whereas others report a non-negative impact of PVT in the outcome of cirrhosis. Therefore, the prognostic value of PVT in cirrhosis remains a gray zone. One single randomized-controlled trial reported that enoxaparin could prevent PVT, delay the occurrence of hepatic decompensation, and improve survival. However, no further study data confirmed this assumption and the issue is not actually generalizable. Numerous studies report that anticoagulation determines a relatively high rate of portal vein recanalization in cirrhotics PVT. However, further data are warranted to confirm the risk-to-benefit of anticoagulation, especially bleeding. Transjugular intrahepatic portosystemic shunt (TIPS) has been reported to be effective as a treatment of PVT in cirrhosis, with the advantage of avoiding the risk of bleeding linked to anticoagulation. However, there are no data comparing TIPS with anticoagulation as a treatment of PVT in cirrhosis. Furthermore, there is no evidence on whether both anticoagulation and TIPS improve survival.

CONCLUSION

It is uncertain whether PVT affects cirrhosis outcome. Further data are needed to weigh the risk/benefit ratio of enoxaparin for the prevention of PVT in cirrhosis. Anticoagulation or TIPS should probably be indicated in liver transplantation candidates, but avoided in patients not suitable for liver transplantation and with an otherwise poor prognosis. Future studies should evaluate which subgroup of cirrhotics with PVT may benefit from treatment. Management of PVT in cirrhosis should be personalized.

The ischemic liver cirrhosis theory and its clinical implications

The canonical pathway theory of cirrhosis addresses inflammation as the main driver of hepatic fibrogenesis in hepatitis, so needing a further hypothesis for etiologies missing inflammation, for which parenchymal extinction is postulated. The present paper reports an alternative hypothesis suggesting a central role of micro-vascular ischemia in fibrogenesis and cirrhosis development, whatever is the aetiology of liver chronic injury. In fact, since chronic liver injury could finally result in endothelial damage and micro-vascular thrombosis, leading to a trigger of inappropriate hepatocyte proliferation and fibrosis, finally cirrhosis development could arise from chronic micro-vascular ischemia. Recently, some important confirmation of this hypothesis has been reported. In fact, in a murine experimental model of congestive hepatopathy, it was found that chronic hepatic congestion leads to sinusoidal thrombosis and strain, which in turn promote hepatic fibrosis. Furthermore, a study on a murine model of cirrhosis reported enoxaparin to reduce hepatic vascular resistance and portal pressure by having a protective role against fibrogenesis. In conclusion, the hypothesis giving a central role of micro-vascular ischemia in fibrogenesis and cirrhosis development could change the clinical scenario of chronic liver disease and have several main implications on management of various liver disease.

An update on the management of Budd-Chiari syndrome: the issues of timing and choice of treatment

Because of the rarity of Budd-Chiari syndrome (BCS), the flow chart of management comes from expert opinion and is not evidence based. To report an update on the management of BCS. I performed a review on published papers on BCS in an attempt to speculate in particular on the timing and the choice of treatment. Some authors suggest that the management of BCS should follow a step-wise strategy. Anticoagulation and medical therapy should be the first-line treatment. Revascularization or transjugular intrahepatic portosystemic shunt should be performed in case of no response to medical therapy. Orthotopic liver transplant should be used as a rescue therapy. The biggest criticism of this flow chart is that it is based on the assumption that patients with BCS should receive further treatment only when hemodynamic effects on portal hypertension become clinically evident, thus paying little attention to the chronic ischemic liver damage effects on hepatic function and to the possibility of preventing liver failure by relieving impaired hepatic veins outflow. Recently, I presented a proposal of a new algorithm for the management of BCS, in which medical therapy alone is suggested only for patients without any sign of portal hypertension, irrespective of whether early interventional treatment is suggested when either any symptoms or signs of portal hypertension appear, with the aim of preventing hepatic fibrosis development, disease progression, and finally improving outcome. Given that the benefit of treatments for BCS is not under debate, guidelines for the management of BCS should be re-evaluated and updated, with particular attention to both the timing and the choice of treatment.