Low Transthyretin Levels Predict Poor Prognosis in Cancer Patients in Palliative Care Settings

Integrated study reveals mechanism of Tripterygium Wilfordii against cholangiocarcinoma based on bioinformatics approaches and molecular dynamics simulation

BACKGROUND

Tripterygium wilfordii Hook. f. (TW) shows anticancer activity, and no study has comprehensively investigated the effects of TW in treating cholangiocarcinoma (CHOL). This study was designed to identify the therapeutic role and the mechanism of TW against CHOL to obtain anti-CHOL candidate components and targets.

METHODS

Ingredients of TW were collected from the Traditional Chinese Medicine System Pharmacology Database and literature. Limma package and weighted gene co-expression network analysis were used to identify the genes related to CHOL. Enrichment analysis of Kyoto Encyclopedia of Genes and Genomes (KEGG) and Gene Ontology (GO) was performed by R package Cluster-Profiler and Metascape, respectively. Protein-Protein Interaction (PPI) network was used to select core genes in the treatment of CHOL by TW, followed by GEPIA2, UALCAN database, and ROC curves to assess their diagnostic and prognostic capability. Molecular docking and molecular dynamics simulation were applied to explore the binding affinity and stability of the complex between the bioactive ingredients in TW and core targets.

RESULTS

A total of 67 ingredients in TW were collected, and 495 genes were obtained as genes of CHOL. 55 common TW-CHOL targets were identified. 171 biological process terms and 100 KEGG pathways were enriched. 12 genes were regarded as core genes through PPI analysis, such as CYP3A4, CES1, GC, and PLG, whose good diagnostic and prognostic capability were identified. Ten ingredients were selected through the construction of Herb-Components-Targets-Disease network. Molecular docking and molecular dynamics simulation both confirmed the good binding affinity and stability of the ligand-protein complexes.

CONCLUSION

This study identified the therapeutic role and predicted the mechanism of TW against CHOL, where TW may combat CHOL through the regulation of metabolic conditions of the body, bile acid secretion, xenobiotics metabolism, and the inflammatory response. Celastrol, triptonide, triptolide and wilforlide A emerged as promising anti-CHOL candidates. So, this study offered a reference for the treatment of CHOL and the development of anti-CHOL drugs.

Plasma transthyretin is a nutritional biomarker in human morbidities

Transthyretin (TTR) is a small liver-secreted plasma protein that shows close correlations with changes in lean body mass (LBM) during the entire human lifespan and agglomerates the bulk of nitrogen (N)-containing substrates, hence constituting the cornerstone of body building. Amino acids (AAs) dietary restriction causes inhibition of TTR production and impairs the accretion of LBM reserves. Inflammatory disorders result in cytokine-induced abrogation of TTR synthesis and urinary leakage of nitrogenous catabolites. Taken together, the data indicate that malnutrition and inflammation may similarly suppress the production of TTR through distinct and unrelated pathophysiological mechanisms while operating in concert to downsize LBM stores. The hepatic synthesis of TTR integrates both machineries, acting as a marker of reduced LBM resources still available for defense and repair processes. TTR operates as a universal surrogate analyte that allows for the grading of residual LBM capacity to reflect disease burden. Measurement of TTR is a simple, rapid, and inexpensive micro-method that may be reproduced on a daily basis, hence ideally suited for the follow-up of the most intricated clinical situations and as a reliable predictor of any morbidity outcome.

Difficulties in Addressing Artificial Hydration and Nutrition Therapy for Terminal Cancer Patients: What to do if Patients/Families' Wishes Differ From the Medically Appropriate Treatment Plans?

PURPOSE

Artificial hydration and nutrition therapy (AHNT) initiated by patients/families sometimes differs from medically appropriate treatment plans. We aimed to identify the causes of these differences and examine the ensuing responses and outcomes.

METHODS

Of 133 adult cancer patients receiving end-of-life care in the last 2 years, these discrepancies occurred in 41 patients. We retrospectively examined the following issues: (1) The reason why these discrepancies occurred. (2) Based on the causes identified in (1), the following actions were taken: 1) If the consent to change to medically appropriate AHNT was obtained, physical findings using Japan Palliative Oncology Study (JPOS) group and Edmonton Symptom Assessment System (ESAS) were compared before and 1 week after the intervention. 2) If consent was not obtained, time-limited trial (TLT) was conducted, and these results were compared. (3) The communication between patients/families and medical professionals was compared using Support Team Assessment Schedule.

RESULTS

(1) Causes: a) the lack of understanding of the disease condition in 26 cases and b) faulty expectation of AHNT in 15 cases. (2) In 30 cases of 1) (20 of a) and 10 of b)) and 11 of 2) in which TLT was performed, JPOS and ESAS improved significantly. (3) The communication above was improved significantly in 1) and 2) (P = .0027 and .0039, respectively).

CONCLUSION

Providing medically appropriate AHNT with the consent of patients/families is expected to not only alleviate distressing symptoms but also improve the communication between patients/families and medical professionals, as well as improve the quality of palliative care.

Differential Diagnosis of Cachexia and Refractory Cachexia and the Impact of Appropriate Nutritional Intervention for Cachexia on Survival in Terminal Cancer Patients

Cancer cachexia subsequently shifts to refractory cachexia, however, it is not easy to properly differentiate them in clinical settings. Patients considered refractory cachexia may include cachectic patients with starvation. This study aimed to identify these cachectic patients and to evaluate the effect of nutritional intervention for them. Study subjects were terminal cancer patients admitted for palliative care and were judged refractory cachexia in the last five years. We retrospectively examined to find useful indices for identifying such cachectic patients and for evaluating the effect of nutritional intervention. Out of 223 patients in refractory cachexia, 26 were diagnosed cachexia with starvation after symptom management. Comparing before and one week after this management, Palliative Performance Scale (PPS) and transthyretin significantly improved (p < 0.0001, p = 0.0002, respectively) Then, we started nutritional intervention for these cachectic patients and divided into effective group (n = 17) and non-effective group (n = 9) using the criteria for cachexia. Comparing between the two groups, PPS significantly improved2 weeks after intervention in effective group (p = 0.006). Survival time was significantly longer in effective group (p = 0.008). PPS and transthyretin were useful for differential diagnosis of cachexia and refractory cachexia. PPS was useful for evaluating nutritional intervention for cachectic patients. Appropriate nutritional intervention improved survival.