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Kaur B, Rosenblatt R, Sundaram V. Infections in Alcoholic Hepatitis. J Clin Transl Hepatol 2022; 10:718-725. [PMID: 36062291 PMCID: PMC9396323 DOI: 10.14218/jcth.2022.00024] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/11/2022] [Accepted: 04/21/2022] [Indexed: 12/04/2022] Open
Abstract
Severe alcoholic hepatitis (sAH) is defined by a modified discriminant function ≥32 or model for end-stage liver disease (MELD) >20. Patients with sAH are in an immunocompromised state attributed to cirrhosis-related immunoparesis and corticosteroid use. Individuals with sAH often develop severe infections that adversely impact short-term prognosis. Currently, the corticosteroid prednisolone is the only treatment with proven efficacy in sAH; however, the combination of corticosteroid treatment and altered host defense in sAH has been thought to increase the risk of acquiring of bacterial, opportunistic fungal, and viral infections. Newer studies have shown that corticosteroids do not increase occurrence of infections in those with sAH; unfortunately, the lack of response to corticosteroids may instead predispose to infection development. Prompt and appropriate antibiotic treatment is therefore essential to improving patient outcomes. This review highlights common infections and risk factors in patients with sAH. Additionally, current diagnostic, therapeutic, and prophylactic strategies in these patients are discussed.
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Affiliation(s)
- Bhupinder Kaur
- Internal Medicine Department, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Russell Rosenblatt
- Department of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY, USA
| | - Vinay Sundaram
- Department of Gastroenterology and Hepatology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Correspondence to: Vinay Sundaram, Department of Gastroenterology and Hepatology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, 8635W. Third Street, Suite 1060W, Los Angeles, CA 90048, USA. ORCID: https://orcid.org/0000-0002-1450-7756. Tel: +1-310-423-6000, Fax: +1-310-423-6086, E-mail:
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Van der Merwe S, Chokshi S, Bernsmeier C, Albillos A. The multifactorial mechanisms of bacterial infection in decompensated cirrhosis. J Hepatol 2021; 75 Suppl 1:S82-S100. [PMID: 34039494 DOI: 10.1016/j.jhep.2020.11.029] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/17/2020] [Accepted: 11/20/2020] [Indexed: 02/08/2023]
Abstract
Infections, due to a dysfunctional immune response, pose a great risk to patients with decompensated cirrhosis and herald the beginning of the terminal phase of this disease. Infections typically result from breaches in innate immune barriers and inadequate clearance by immune cells. This leads to bacterial and bacterial product translocation to the systemic circulation, which is already primed by ongoing hepatic inflammation in patients with cirrhosis, who are particularly prone to developing organ failure in the presence of an infection. Early identification of bacterial infection, along with the prompt use of appropriate antibiotics, have reduced the mortality associated with certain infections in patients with decompensated cirrhosis. Judicious use of antibiotic therapy remains imperative given the emergence of multidrug-resistant infections in the cirrhotic population. Important research over the last few years has identified molecular targets on immune cells that may enhance their function, and theoretically prevent infections. Clinical trials are ongoing to delineate the beneficial effects of targeted molecules from their off-target effects. Herein, we review the mechanisms that predispose patients with cirrhosis to bacterial infections, the clinical implications of infections and potential targets for the prevention or treatment of infections in this vulnerable population.
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Affiliation(s)
- Schalk Van der Merwe
- Department of Gastroenterology and Hepatology, University hospital, Leuven, Belgium; Laboratory of Hepatology, University of Leuven, Belgium.
| | - Shilpa Chokshi
- Institute of Hepatology, Foundation for Liver Research, London, UK; Division of Transplantation, Immunology and Mucosal Biology, Faculty of Life Sciences and Medicine, King's College, London, United Kingdom
| | - Christine Bernsmeier
- Department of Biomedicine, University of Basel, Switzerland; University Centre for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | - Agustin Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD, Universidad de Alcalá, Madrid, Spain
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3
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Chen J, Argemi J, Odena G, Xu MJ, Cai Y, Massey V, Parrish A, Vadigepalli R, Altamirano J, Cabezas J, Gines P, Caballeria J, Snider N, Sancho-Bru P, Akira S, Rusyn I, Gao B, Bataller R. Hepatic lipocalin 2 promotes liver fibrosis and portal hypertension. Sci Rep 2020; 10:15558. [PMID: 32968110 PMCID: PMC7512007 DOI: 10.1038/s41598-020-72172-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 08/11/2020] [Indexed: 12/13/2022] Open
Abstract
Advanced fibrosis and portal hypertension influence short-term mortality. Lipocalin 2 (LCN2) regulates infection response and increases in liver injury. We explored the role of intrahepatic LCN2 in human alcoholic hepatitis (AH) with advanced fibrosis and portal hypertension and in experimental mouse fibrosis. We found hepatic LCN2 expression and serum LCN2 level markedly increased and correlated with disease severity and portal hypertension in patients with AH. In control human livers, LCN2 expressed exclusively in mononuclear cells, while its expression was markedly induced in AH livers, not only in mononuclear cells but also notably in hepatocytes. Lcn2-/- mice were protected from liver fibrosis caused by either ethanol or CCl4 exposure. Microarray analysis revealed downregulation of matrisome, cell cycle and immune related gene sets in Lcn2-/- mice exposed to CCl4, along with decrease in Timp1 and Edn1 expression. Hepatic expression of COL1A1, TIMP1 and key EDN1 system components were elevated in AH patients and correlated with hepatic LCN2 expression. In vitro, recombinant LCN2 induced COL1A1 expression. Overexpression of LCN2 increased HIF1A that in turn mediated EDN1 upregulation. LCN2 contributes to liver fibrosis and portal hypertension in AH and could represent a new therapeutic target.
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Affiliation(s)
- Jiegen Chen
- Departments of Medicine and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Josepmaria Argemi
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Gemma Odena
- Departments of Medicine and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Ming-Jiang Xu
- Laboratory of Liver Diseases, National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institutes of Health, Bethesda, DM, 20892, USA
| | - Yan Cai
- Laboratory of Liver Diseases, National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institutes of Health, Bethesda, DM, 20892, USA
| | - Veronica Massey
- Departments of Medicine and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Austin Parrish
- Department of Pathology, Anatomy and Cell Biology, Daniel Baugh Institute for Functional Genomics and Computational Biology, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Rajanikanth Vadigepalli
- Department of Pathology, Anatomy and Cell Biology, Daniel Baugh Institute for Functional Genomics and Computational Biology, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Jose Altamirano
- Hepatology-Internal Medicine Department, Hospital Quironsalud Barcelona, Barcelona, Spain
| | - Joaquin Cabezas
- Gastroenterology and Hepatology Department, Research Institute Valdecilla (IDIVAL), University Hospital Marques de Valdecilla, Santander, Spain
| | - Pere Gines
- Hospital Clinic, Institut D'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), CIBER de Enfermedades Hepáticas Y Digestivas (CIBERehd), Barcelona, Catalonia, Spain
| | - Juan Caballeria
- Hospital Clinic, Institut D'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), CIBER de Enfermedades Hepáticas Y Digestivas (CIBERehd), Barcelona, Catalonia, Spain
| | - Natasha Snider
- Department of Cell Biology and Physiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Pau Sancho-Bru
- Hospital Clinic, Institut D'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), CIBER de Enfermedades Hepáticas Y Digestivas (CIBERehd), Barcelona, Catalonia, Spain
| | - Shizuo Akira
- Laboratory of Host Defense, Immunology Frontier Research Center, Osaka University, Suita, Osaka, Japan
| | - Ivan Rusyn
- Department of Veterinary Integrative Biosciences, Texas A&M University, College Station, TX, 77843, USA
| | - Bin Gao
- Laboratory of Liver Diseases, National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institutes of Health, Bethesda, DM, 20892, USA
| | - Ramon Bataller
- Departments of Medicine and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA.
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Furuya S, Cichocki JA, Konganti K, Dreval K, Uehara T, Katou Y, Fukushima H, Kono H, Pogribny IP, Argemi J, Bataller R, Rusyn I. Histopathological and Molecular Signatures of a Mouse Model of Acute-on-Chronic Alcoholic Liver Injury Demonstrate Concordance With Human Alcoholic Hepatitis. Toxicol Sci 2020; 170:427-437. [PMID: 30517762 DOI: 10.1093/toxsci/kfy292] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Human alcoholic hepatitis (AH) carries a high mortality rate. AH is an acute-on-chronic form of liver injury characterized by hepatic steatosis, ballooned hepatocytes, neutrophil infiltration, and pericellular fibrosis. We aimed to study the pathogenesis of AH in an animal model which combines chronic hepatic fibrosis with intragastric alcohol administration. Adult male C57BL6/J mice were treated with CCl4 (0.2 ml/kg, 2×weekly by intraperitoneal injections for 6 weeks) to induce chronic liver fibrosis. Then, ethyl alcohol (up to 25 g/kg/day for 3 weeks) was administered continuously to mice via a gastric feeding tube, with or without one-half dose of CCl4. Liver and serum markers and liver transcriptome were evaluated to characterize acute-on-chronic-alcoholic liver disease in our model. CCl4 or alcohol treatment alone induced liver fibrosis or steatohepatitis, respectively, findings that were consistent with expected pathology. Combined treatment resulted in a marked exacerbation of liver injury, as evident by the development of inflammation, steatosis, and pericellular fibrosis, pathological features of human AH. E. coli and Candida were also detected in livers of mice cotreated with CCl4 and alcohol, indicating pathogen translocation from gut to liver, similar to human AH. Importantly, liver transcriptomic changes specific to combined treatment group demonstrated close concordance with pathways perturbed in patients with severe AH. Overall, mice treated with CCl4 and alcohol displayed key molecular and pathological characteristics of human AH-pericellular fibrosis, increased hepatic bacterial load, and dysregulation of the same molecular pathways. This model may be useful for developing therapeutics for AH.
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Affiliation(s)
| | | | - Kranti Konganti
- Texas A&M Institute for Genome Sciences and Society, Texas A&M University, College Station, Texas 77843
| | - Kostiantyn Dreval
- Program in Cancer Genetics, Epigenetics and Genomics, Division of Molecular Medicine, Department of Internal Medicine, University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico 87102
| | - Takeki Uehara
- Laboratory of Veterinary Pathology, Osaka Prefecture University, Osaka, Japan
| | - Yuuki Katou
- Laboratory of Veterinary Pathology, Osaka Prefecture University, Osaka, Japan
| | | | - Hiroshi Kono
- First Department of Surgery, University of Yamanashi, Yamanashi, Japan
| | - Igor P Pogribny
- National Center for Toxicological Research, U.S. FDA, Jefferson, Arkansas 72079
| | - Josepmaria Argemi
- Department of Medicine, Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Ramon Bataller
- Department of Medicine, Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Ivan Rusyn
- Department of Veterinary Integrative Biosciences
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Li S, Wang N, Tan HY, Hong M, Yuen MF, Li H, Feng Y. Expansion of Granulocytic, Myeloid-Derived Suppressor Cells in Response to Ethanol-Induced Acute Liver Damage. Front Immunol 2018; 9:1524. [PMID: 30072984 PMCID: PMC6060237 DOI: 10.3389/fimmu.2018.01524] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 06/20/2018] [Indexed: 02/06/2023] Open
Abstract
The dual role of ethanol in regulating both pro-inflammatory and anti-inflammatory response has recently been reported. Myeloid-derived suppressor cells (MDSCs) are one of the major components in the immune suppressive network in both innate and adaptive immune responses. In this study, we aim to define the role of a population expressing CD11b+Ly6GhighLy6Cint with immunosuppressive function in response to ethanol-induced acute liver damage. We find this increased granulocytic-MDSCs (G-MDSCs) population in the blood, spleen, and liver of mice treated with ethanol. Depletion of these cells increases serum alanine aminotransferase and aspartate aminotransferase levels, while G-MDSCs population adoptive transfer can ameliorate liver damage induced by ethanol, indicating the protective role in the early stage of alcoholic liver disease. The significant changes of T-cell profiles after G-MDSCs populations adoptive transfer and anti-Gr1 injection signify that both cytotoxic T and T helper cells might be the targeted cells of G-MDSCs. In the in vitro study, we find that myeloid precursors preferentially generate G-MDSCs and improve their suppressive capacity via chemokine interaction and YAP signaling when exposed to ethanol. Furthermore, IL-6 serves as an important indirect factor in mediating the expansion of G-MDSCs populations after acute ethanol exposure. Collectively, we show that expansion of G-MDSCs in response to ethanol consumption plays a protective role in acute alcoholic liver damage. Our study provides novel evidence of the immune response to acute ethanol consumption.
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Affiliation(s)
- Sha Li
- Li Ka Shing Faculty of Medicine, School of Chinese Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Ning Wang
- Li Ka Shing Faculty of Medicine, School of Chinese Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Hor-Yue Tan
- Li Ka Shing Faculty of Medicine, School of Chinese Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Ming Hong
- Li Ka Shing Faculty of Medicine, School of Chinese Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Man-Fung Yuen
- Division of Gastroenterology and Hepatology, Queen Mary Hospital, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Huabin Li
- Guangdong Provincial Key Laboratory of Food, Nutrition and Health, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Yibin Feng
- Li Ka Shing Faculty of Medicine, School of Chinese Medicine, The University of Hong Kong, Pokfulam, Hong Kong
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Abstract
Alcoholic liver disease (ALD) is an escalating global problem accounting for more than 3 million deaths annually. Bacterial infections are diagnosed in 25-47% of hospitalized patients with cirrhosis and represent the most important trigger for acute decompensation, multi-organ failure, septic shock and death. Current guidelines recommend intensive antibiotic therapy, but this has led to the emergence of multi-drug resistant bacteria, which are associated with increased morbidity and mortality rates. As such, there is a pressing need to explore new paradigms for anti-infective therapy and host-directed immunomodulatory therapies are a promising approach. Paradoxically, cirrhotic patients are characterised by heightened immune activity and exacerbated inflammatory processes but are unable to contend with bacterial infection, demonstrating that whilst immune effector cells are primed, their antibacterial effector functions are switched-off, reflecting a skewed homeostatic balance between anti-pathogen immunity and host-induced immunopathology. Preservation of this equilibrium physiologically is maintained by multiple immune-regulatory checkpoints and these feedback receptors serve as pivotal regulators of the host immunity. Checkpoint receptor blockade is proving to be effective at rescuing deranged/exhausted immunity in pre-clinical studies for chronic viral infection and sepsis. This approach has also obtained FDA approval for restoring anti-tumor immunity, with improved response rates and good safety profiles. To date, no clinical studies have investigated checkpoint blockade in ALD, highlighting an area for development of host-targeted immunotherapeutic strategies in ALD, for which there are no current specific treatment options. This review aims at framing current knowledge on immune checkpoints and the possibility of their therapeutic utility in ALD-associated immune dysfunctions.
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Affiliation(s)
- Antonio Riva
- Institute of Hepatology London, Foundation for Liver Research, 111 Coldharbour Lane, London, SE5 9NT UK
- Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Shilpa Chokshi
- Institute of Hepatology London, Foundation for Liver Research, 111 Coldharbour Lane, London, SE5 9NT UK
- Faculty of Life Sciences and Medicine, King’s College London, London, UK
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LPS-TLR4 Pathway Mediates Ductular Cell Expansion in Alcoholic Hepatitis. Sci Rep 2016; 6:35610. [PMID: 27752144 PMCID: PMC5067590 DOI: 10.1038/srep35610] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 09/29/2016] [Indexed: 02/06/2023] Open
Abstract
Alcoholic hepatitis (AH) is the most severe form of alcoholic liver disease for which there are no effective therapies. Patients with AH show impaired hepatocyte proliferation, expansion of inefficient ductular cells and high lipopolysaccharide (LPS) levels. It is unknown whether LPS mediates ductular cell expansion. We performed transcriptome studies and identified keratin 23 (KRT23) as a new ductular cell marker. KRT23 expression correlated with mortality and LPS serum levels. LPS-TLR4 pathway role in ductular cell expansion was assessed in human and mouse progenitor cells, liver slices and liver injured TLR4 KO mice. In AH patients, ductular cell expansion correlated with portal hypertension and collagen expression. Functional studies in ductular cells showed that KRT23 regulates collagen expression. These results support a role for LPS-TLR4 pathway in promoting ductular reaction in AH. Maneuvers aimed at decreasing LPS serum levels in AH patients could have beneficial effects by preventing ductular reaction development.
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Abstract
Acute and chronic alcohol use leads to an impaired immune response and dysregulated inflammatory state that contributes to a markedly increased risk of infection. Via shared mechanisms of immune-mediated injury, alcohol can alter the clinical course of viral infections such as hepatitis B, hepatitis C, and human immunodeficiency virus. These effects are most evident in patients with alcoholic hepatitis and cirrhosis. This article provides an overview of alcohol's effect on the immune system and contribution to the risks and outcomes of specific infectious diseases.
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Affiliation(s)
- Christine Chan
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Chicago, IL 60611, USA
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Chicago, IL 60611, USA.
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