Review article: depression and the use of antidepressants in patients with chronic liver disease or liver transplantation

Antidepressants in People With Chronic Liver Disease and Depression: When Are They Warranted and How to Choose the Suitable One?

Most chronic medical illnesses are associated with significant psychiatric comorbidity, especially in the form of depression, anxiety, and suicidality. Chronic liver disease (CLD) is no exception to this and rather is placed uniquely as compared to other diseases because of its intersection with alcohol use disorder and other substance use, which in itself is a mental illness. Patients with CLD may have comorbid psychiatric illnesses; the pharmacokinetic concerns arising out of hepatic dysfunction which affects pharmacotherapy for depression and vice versa. The high prevalence of medical comorbidities with CLD may further complicate the course and outcome of depression in such patients, and diagnostic and management issues arise from special situations like transplant evaluation, alcohol use disorder, and hepatic encephalopathy or multifactorial encephalopathy seen in a disoriented or agitated patient with CLD. For this narrative review, we carried out a literature search in PubMed/PubMed Central and in Google Scholar (1980-2023) with the keywords "depression in cirrhosis", "antidepressants in liver disease", "anxiety in liver disease", "depression in liver transplantation", and "drug interactions with antidepressants". This review presents a comprehensive view of the available research on the use of antidepressants in patients with CLD, including deciding to use them, choosing the right antidepressant, risks, drug interactions, and adverse reactions to expect, and managing the same. In addition, liver transplant fitness and the overlap of hepatic encephalopathy with neuropsychiatric illness will be discussed.

Dietary sulforaphane glucosinolate mitigates depression-like behaviors in mice with hepatic ischemia/reperfusion injury: A role of the gut-liver-brain axis

Nutrition has been increasingly recognized for its use in mental health. Depression is commonly observed in patients with chronic liver disease (CLD). Building on our recent findings of depression-like behaviors in mice with hepatic ischemia/reperfusion (HI/R) injury, mediated by the gut-liver-brain axis, this study explored the potential influence of dietary sulforaphane glucosinolate (SGS) on these behaviors. Behavioral assessments for depression-like behaviors were conducted 7 days post either sham or HI/R injury surgery. Dietary intake of SGS significantly prevented splenomegaly, systemic inflammation, depression-like behaviors, and downregulation of synaptic proteins in the prefrontal cortex (PFC) of HI/R-injured mice. Through 16S rRNA analysis and untargeted metabolomic analyses, distinct bacterial profiles and metabolites were identified between control + HI/R group and SGS + HI/R group. Correlations were observed between the relative abundance of gut microbiota and both behavioral outcomes and blood metabolites. These findings suggest that SGS intake could mitigate depression-like phenotypes in mice with HI/R injury, potentially through the gut-liver-brain axis. Additionally, SGS, found in crucial vegetables like broccoli, could offer prophylactic nutritional benefits for depression in patients with CLD.

The ameliorating effect of Rutin on hepatotoxicity and inflammation induced by the daily administration of vortioxetine in rats

BACKGROUND

Vortioxetine (VORTX) is a potent and selective type of selective serotonin reuptake inhibitor (SSRI) that is mainly prescribed for treating major depression along with mood disorders as the first drug of choice. Limited previous findings have indicated evidence of liver injury and hepatotoxicity associated with daily VORTX treatment. Rutin (RUT), which is known for its antioxidant properties, has demonstrated several beneficial health actions, including hepatoprotection. Therefore the current study aimed to evaluate and assess the ameliorative effect of RUT against the hepatotoxic actions of daily low and high-dose VORTX administration.

METHODS

The experimental design included six groups of rats, each divided equally. Control, rats exposed to RUT (25 mg/kg), rats exposed to VORTX (28 mg/kg), rats exposed to VORTX (28 mg/kg) + RUT (25 mg/kg), rats exposed to VORTX (80 mg/kg), and rats exposed to VORTX (80 mg/kg) + RUT (25 mg/kg). After 30 days from the daily exposure period, assessments were conducted for serum liver enzyme activities, hepatotoxicity biomarkers, liver antioxidant endogenous enzymes, DNA fragmentation, and histopathological studies of liver tissue.

RESULTS

Interestingly, the risk of liver damage and hepatotoxicity related to VORTX was attenuated by the daily co-administration of RUT. Significant improvements were observed among all detected liver functions, oxidative stress, and inflammatory biomarkers including aspartate aminotransferase (AST), alanine transaminase (ALT), lactate dehydrogenase (LDH), albumin, malondialdehyde (MDA), superoxide dismutase (SOD), glutathione (GSH), glutathione S-transferase (GST), total protein, acid phosphatase, N-Acetyl-/β-glucosaminidase (β-NAG), β-Galactosidase (β-Gal), alpha-fetoprotein (AFP), caspase 3, and cytochrom-C along with histopathological studies, compared to the control and sole RUT group.

CONCLUSION

Thus, RUT can be considered a potential and effective complementary therapy in preventing hepatotoxicity and liver injury induced by the daily or prolonged administration of VORTX.

Anxiety and Somatoform Syndromes Predict Transplant-Focused Internet Use in the Course of an Organ Transplantation

Background: e-Health interventions are increasing in the field of organ transplantations; however, the literature lacks evidence regarding needs, attitudes, and preferences of organ recipients and donors during the course of an organ transplantation. Methods: In a cross-sectional study, 70 subjects were assessed using self-rated and validated questionnaires, such as the PRIME MD Patient Health Questionnaire (PHQ-D) and the Essen Resource Inventory (ERI). Group differences and a multiple linear regression were also applied. Results: Organ recipients had significantly higher scores for depression (U = 245.00, z = -2.65, p = 0.008, Cohen's d = 0.32), somatoform (U = 224.50, z = -2.99, p = 0.003, Cohen's d = 0.37), and stress syndromes (U = 266.00, z = -2.25, p = 0.008, Cohen's d = 0.27). They also named the internet and apps as resources to find information regarding organ transplants (U = 177.50, z = -2.07, p = 0.017, Cohen's d = 0.28; Z = -2.308, p = 0.021) and preferred to use apps to monitor the physical condition (Z = -2.12, p = 0.034) significantly more than organ donors. Anxiety and somatoform syndromes were significant predictors to search for information regarding the transplant process (F[6,38] = 3.98, p < 0.001; R2 = 0.386). Conclusions: e-Health interventions are promising in accompanying the course of an organ transplant for patients to be informed and educated. Predominantly, potential organ recipients might benefit from apps to record physical parameters. However, anxiety syndromes might hinder patients from searching for information about the transplant process, while somatoform syndromes might enable patients who are searching for such information.

Depression-like phenotypes in mice following common bile duct ligation: Insights into the gut-liver-brain axis via the vagus nerve

Depression frequently occurs in patients with liver cirrhosis, yet the reasons for this correlation are not fully understood. Dysbiosis of gut microbiota has been implicated in depression through the gut-brain axis via the vagus nerve. This study explored the potential role of the gut-liver-brain axis via the vagus nerve in depression-like phenotypes in mice with liver cirrhosis. These mice underwent common bile duct ligation (CBDL), a method used to stimulate liver cirrhosis. To assess depression-like behaviors, behavioral tests were conducted 10 days following either sham or CBDL surgeries. The mice with CBDL displayed symptoms such as splenomegaly, elevated plasma levels of interleukin-6 and tumor necrosis factor-α, depression-like behaviors, decreased levels of synaptic proteins in the prefrontal cortex (PFC), disrupted gut microbiota balance, and changes in blood metabolites (or lipids). Additionally, there were positive or negative correlations between the relative abundance of microbiome and behavioral data or blood metabolites (or lipids). Significantly, these changes were reversed in CBDL mice by performing a subdiaphragmatic vagotomy. Intriguingly, depression-like phenotypes in mice with CBDL were improved after a single injection of arketamine, a new antidepressant. These results suggest that CBDL-induced depression-like phenotypes in mice are mediated through the gut-liver-brain axis via the subdiaphragmatic vagus nerve, and that arketamine might offer a new treatment approach for depression in liver cirrhosis patients.

Depression-like phenotypes in mice with hepatic ischemia/reperfusion injury: A role of gut-microbiota-liver-brain axis via vagus nerve

Depression is a frequent symptom in patients with chronic liver disease; however, the mechanisms underlying this association remain unclear. Dysbiosis of gut microbiota plays a critical role in depression through the gut-brain axis via the vagus nerve. In this study, we investigated whether the gut-microbiota-liver-brain axis plays a role in depression-like phenotypes in mice with hepatic ischemia/reperfusion (HI/R) injury via the vagus nerve. Behavioral tests for depression-like behaviors were performed 7 days after sham or HI/R injury surgery. Mice with HI/R injury exhibited splenomegaly, systemic inflammation, depression-like behaviors, reduced expression of synaptic proteins in the prefrontal cortex (PFC), abnormal composition of gut microbiota, and altered blood metabolites and lipids. Furthermore, there were positive or negative correlations between the relative abundance of microbiome and behavioral data or blood metabolites (or lipids). Moreover, subdiaphragmatic vagotomy significantly blocked these changes in mice with HI/R injury. Notably, depression-like phenotypes in mice with HI/R injury were ameliorated after subsequent single injection of the new antidepressant arketamine. The current findings suggest that HI/R injury induces depression-like phenotypes in mice through the gut-microbiota-liver-brain axis via the subdiaphragmatic vagus nerve. Furthermore, arketamine may have therapeutic potential in the treatment of depression in patients with chronic liver disease.

Neuropsychiatric sequelae after liver transplantation and their possible mechanism via the microbiota-gut-liver-brain axis

Patients after liver transplantation are often impacted by mental and even neuropsychiatric disorders, including depression, sleep disorders, anxiety, and post-traumatic stress disorder. Neuropsychiatric sequelae have an adverse impact on rehabilitation and can even incapacitate people, reducing their quality of life. Despite screening tools and effective treatments, neuropsychiatric sequelae after liver transplantation (NSALT) have not been fully diagnosed and treated. Current research suggests that NSALT may be partly related to intestinal microbial variation, but the detailed mechanism remains unclear. In this review, we describe the clinical and diagnostic features, prevalence, prediction, clinical course and outcome, management, and treatment of NSALT; we also summarize their mechanisms through the microbiota-gut-liver-brain axis. Finally, we propose to improve NSALT on the basis of adjusting the gastrointestinal flora, immune inflammation or vagus nerve (VN), providing a novel strategy for clinical prevention and treatment.

Sex differences in the relationship between hepatic steatosis, mood and anxiety disorders

OBJECTIVE

To investigate the association between non-alcoholic fatty liver disease (NAFLD), alcoholic liver disease (ALD), mental symptoms (mood, anxiety disorders and distress) by sex.

METHODS

This a cross-sectional study performed in working-age adults from a Health Promotion Center (primary care) in São Paulo, Brazil. Self-reported mental symptoms from rating scales (21-item Beck Anxiety Inventory, Patient Health Questionnaire-9, and K6 distress scale) were evaluated by hepatic steatosis (NAFLD and ALD). Logistic regression models estimated the association between hepatic steatosis subtypes and mental symptoms by Odds ratios (OR) adjusted by confounders in the total sample and sex stratified.

RESULTS

Among 7241 participants (70.5% men, median age: 45 years), the frequency of steatosis was of 30.7% (25.1% NAFLD), being higher in men than women (70.5% vs. 29.5%, p < 0.0001), regardless of the steatosis subtype. Metabolic risk factors were similar in both subtypes of steatosis, but not mental symptoms. Overall, NAFLD was inversely associated with anxiety (OR = 0.75, 95%CI 0.63-0.90) and positively associated with depression (OR = 1.17, 95%CI 1.00-1.38). On the other hand, ALD was positively associated with anxiety (OR = 1.51; 95%CI 1.15-2.00). In sex-stratified analyses, only men presented an association of anxiety symptoms with NAFLD (OR = 0.73; 95%CI 0.60-0.89) and ALD (OR = 1.60; 95%CI 1.18-2.16).

CONCLUSIONS

The complex association between different types of steatosis (NAFLD and ALD), mood and anxiety disorders indicates the need for a deeper understanding of their common causal pathways.

Gut microbiome-brain-cirrhosis axis

Cirrhosis is characterized by inflammation, degeneration, and fibrosis of liver tissue. Along with being the most common cause of liver failure and liver transplant, cirrhosis is a significant risk factor for several neuropsychiatric conditions. The most common of these is HE, which is characterized by cognitive and ataxic symptoms, resulting from the buildup of metabolic toxins with liver failure. However, cirrhosis patients also show a significantly increased risk for neurodegenerative diseases such as Alzheimer and Parkinson diseases, and for mood disorders such as anxiety and depression. In recent years, more attention has been played to communication between the ways the gut and liver communicate with each other and with the central nervous system, and the way these organs influence each other's function. This bidirectional communication has come to be known as the gut-liver-brain axis. The gut microbiome has emerged as a key mechanism affecting gut-liver, gut-brain, and brain-liver communication. Clinical studies and animal models have demonstrated the significant patterns of gut dysbiosis when cirrhosis is present, both with or without concomitant alcohol use disorder, and have provided compelling evidence that this dysbiosis also influences the cognitive and mood-related behaviors. In this review, we have summarized the pathophysiological and cognitive effects associated with cirrhosis, links to cirrhosis-associated disruption of the gut microbiome, and the current evidence from clinical and preclinical studies for the modulation of the gut microbiome as a treatment for cirrhosis and associated neuropsychiatric conditions.

Impact of depression and antidepressant use on clinical outcomes of hepatitis B and C: a population-based study

BACKGROUND

Depression is common in patients with chronic viral hepatitis. We evaluated the impact of major depressive disorder (MDD) and antidepressant use on survival among patients with HBV and HCV.

METHODS

We used The Health Improvement Network database, the largest medical database in the UK, to identify incident HBV (n=1401) and HCV (n=1635) in patients between 1986 and 2017. Our primary composite outcome was the development of decompensated cirrhosis or death. MDD and each class of antidepressants were assessed in multivariate Cox proportional hazards models. Models were adjusted for age, sex, and clinical comorbidities.

RESULTS

The prevalence of MDD among HCV patients was higher compared with HBV patients (23.5% vs. 9.0%, p<0.001, respectively). Similarly, HCV patients were more likely to use antidepressants (59.6%) compared with HBV patients (27.1%), p>0.001. MDD was not an independent predictor for decompensated cirrhosis-free survival or mortality. However, the use of tricyclic and tetracyclic antidepressants (TCAs) was associated with poor decompensated cirrhosis-free survival in HBV and HCV cohorts (adjusted HR: 1.80, 95% CI, 1.00-3.26 and 1.56, 95% CI, 1.13-2.14, respectively). Both TCAs in the HBV cohort and selective serotonin reuptake inhibitors among the HCV cohort were associated with poor overall survival (adjusted HR: 2.18, 95% CI, 1.16-4.10; 1.48, 95% CI, 1.02-2.16, respectively).

CONCLUSIONS

Although prevalent among viral hepatitis patients, MDD did not affect disease progression or survival in either HBV or HCV cohorts. TCA use was associated with poor decompensated cirrhosis-free survival. Therefore, its use should be further studied among viral hepatitis patients.

The incidence of new mental health disorders after acute pancreatitis: A large, propensity-matched, observational study

INTRODUCTION

The prevalence of acute pancreatitis (AP) and mental health disorders (MHDs) are rising. While the association between chronic pancreatitis (CP) and MHDs is established, it is unknown whether there is a risk of MHDs after an index episode of AP. The aim of this study was to evaluate the incidence of MHDs and pharmacotherapy use after an episode of AP.

METHODS

This was a large observational study using the TriNetX research network, an electronic health record dataset containing inpatient and outpatient data from more than 50 healthcare organizations. Patients with AP from 2015-2020 were identified. Four cohorts were created: acute necrotizing pancreatitis (ANP), acute pancreatitis without necrosis (AP-WON), acute appendicitis, and healthy controls without pancreatitis. The cohorts were matched by age, sex, race, ethnicity, and nicotine and alcohol use. The primary outcome was new composite MHDs at one-year. Secondary outcomes included stratified MHDs, psychiatric medication use, opioid analgesic use, and all-cause mortality.

RESULTS

The ANP, AP-WON, appendicitis, and healthy control cohorts contained 11,806, 177,266, 27,187, and 561,833 patients, respectively. Patients with AP-WON had significantly higher rates of composite MHDs compared with those hospitalized for appendicitis (9.7% vs 4.7%, HR 1.9, 95% CI 1.7-1.9). This association was augmented when comparing ANP to appendicitis (12.8% vs 5.2%, HR 2.4, 95% CI 2.1-2.7). All secondary outcomes were observed at significantly higher rates in the AP-WON cohort when compared to appendicitis. Again, these associations were augmented comparing ANP to appendicitis.

CONCLUSION

Compared with controls, patients with AP had significantly higher rates of new MHDs and their associated pharmacotherapies at one-year, suggesting that a single episode of AP may independently place patients at risk for developing MHDs irrespective of whether they go on to develop CP.

Contemporary management of pain in cirrhosis: Toward precision therapy for pain

Chronic pain is highly prevalent in patients with cirrhosis and is associated with poor health-related quality of life and poor functional status. However, there is limited guidance on appropriate pain management in this population, and pharmacologic treatment can be harmful, leading to adverse outcomes, such as gastrointestinal bleeding, renal injury, falls, and hepatic encephalopathy. Chronic pain can be categorized mechanistically into three pain types: nociceptive, neuropathic, and nociplastic, each responsive to different therapies. By discussing the identification, etiology, and treatment of these three mechanistic pain descriptors with a focus on specific challenges in patients with cirrhosis, we provide a framework for better tailoring treatments, including nonpharmacologic therapies, to patients' needs.

Safety and effectiveness of vortioxetine for major depressive disorder: Real-world evidence from a population-based study in South Korea

Background

A post-marketing surveillance study was conducted to assess the real-world safety and effectiveness of vortioxetine for the treatment of major depressive disorder (MDD) in South Korea.

Methods

Adult patients aged 19-94 years receiving vortioxetine for MDD at 72 hospitals and clinics in South Korea between 19^th August 2014 and 18^th August 2020 were included. Patients were followed for up to 24±2 weeks, at up to three visits. Adverse events (AEs) and effectiveness, assessed by both clinician and patient-reported measures, were analyzed.

Results

A total of 3,263 patients (mean age: 51.28 years) were included in the safety set; 1,095 were aged ≥65 years. The majority of the safety set (61.97%) were female. The overall rate of any AEs and serious AEs were 17.13 and 1.56%, respectively. The majority of AEs were mild (88.32%). The rates of AEs did not differ statistically by age (≥65 years: 16.89% [185/1,095] versus <65 years: 17.25% [374/2,168)], p=0.7989), sex (male: 15.95% [198/1,241] versus female: 17.85% [361/2,022], p=0.1623), or liver impairment (with liver impairment: 20.90% [14/67] versus without liver impairment: 17.05% [545/3,196], p=0.4087). Effectiveness was assessed in 1,918 patients. By 24±2 weeks, there were significant clinical improvements from baseline, assessed by change in Montgomery-Asberg Depression Rating Scale total score (mean±standard deviation [SD]: -10.49±9.42 points, p <0.0001), the proportion of patients with improved symptoms using the Clinical Global Impression - Improvement scores (79.29%), and in both patient-reported measures, with a significant improvement in the Korean Version of the Perceived Deficits Questionnaire-Depression (mean±SD: -6.06±13.23, p <0.0001) and Digit Symbol Substitution Test (mean±SD: 4.83±9.81, p <0.0001) total scores from baseline. Similar to the safety profiles, the proportions of patients with improved symptoms compared with baseline using the Clinical Global Impression - Improvement scores did not differ by age (≥65 years: 82.09% versus <65 years: 78.32%, p=0.0511), sex (male: 77.45% versus female: 81.01%, p=0.0587), or liver impairment (with liver impairment: 67.57% versus without liver impairment: 79.85%, p=0.0663).

Conclusion

Vortioxetine appears to be well-tolerated and effective for treating MDD patients in the real-world setting in South Korea, irrespective of age, sex, and liver impairment, reflecting the known profile of vortioxetine based on studies worldwide.

Narrative review of migraine management in patients with renal or hepatic disease

OBJECTIVES/BACKGROUND

Treatment of migraine in the setting of either renal or hepatic disease can be daunting for clinicians. Not only does the method of metabolism have to be considered, but also the method of elimination/excretion of the parent drug and any active or toxic metabolites. Furthermore, it is difficult to think about liver or kidney disease in isolation, as liver disease can sometimes contribute to impaired renal function and renal disease can sometimes impair hepatic metabolism, through the cytochrome P450 system.

METHODS

A detailed search for terms related to liver disease, renal disease, and migraine management was performed in PubMed, Ovid Medline, Embase, and the Cochrane Library.For each medication, product labels were retrieved and reviewed using the US FDA website, with additional review of IBM Micromedex, LiverTox, and the Renal Drug Handbook.

RESULTS

This manuscript provides an overview of migraine drug metabolism and how it can be affected by liver and renal impairment. It reviews the standard terminology recommended by the US Food and Drug Administration for the different stages of hepatic and renal failure. The available evidence regarding the use of abortive and preventative medicines in the setting of organ failure is discussed in detail, including more recent therapies such as lasmiditan, gepants, and calcitonin gene-related peptide antibodies.

CONCLUSIONS

For acute therapy, the use of NSAIDS should be limited, as these carry risk for both severe hepatic and renal disease. Triptans can be selectively used, often with dose guideline adjustments. Ubrogepant may be used in severe hepatic disease with dose adjustment and lasmiditan can be used in end stage renal disease. Though non-medicine strategies may be the most reasonable initial approach, many preventative medications can be used in the setting of hepatic and renal disease, often with dose adjustment. This review provides tables of guidelines, including reduced dosing recommendations, for the use of abortive and preventative migraine medications in hepatic and renal failure.

Overlooked Symptoms in Autoimmune Hepatitis Negatively Impact Many Facets of Life

BACKGROUND

Significant reduction in quality of life among patients with autoimmune hepatitis (AIH) patients has been observed in several studies. While acute symptoms associated with AIH have been well described, little is known about the overall impact of living with AIH on patients' quality of life. The aim of this qualitative descriptive study was to describe the impact of AIH and associated symptoms on quality of life from the perspectives of patients living with AIH.

METHODS

Patients from Autoimmune Hepatitis Association support groups were recruited to participate in one of five online focus groups conducted between August and September 2020. After enrollment, patients were asked to complete a brief demographic and disease history questionnaire. A single moderator conducted interviews with each group guided by seven questions focused on the impact of AIH on the participants' quality of life. Each session was recorded, transcribed, and verified. Content analysis was used to summarize the participants' responses.

RESULTS

The participants' discussed three overarching topics: (a) symptoms of AIH and medication side effects, (b) the impact the disease and symptoms/side effects on five domains of quality of life (work life, relationships with friends and family, social life, leisure activities, and diet and exercise) and (c) interactions with healthcare providers and recommendations for future research.

CONCLUSIONS

Living with AIH can have profound effects on patients' quality of life in several domains. Healthcare providers and the AIH research community should focus on developing further strategies that can improve the quality of life in persons suffering from AIH.

Polystyrene microplastics up-regulates liver glutamine and glutamate synthesis and promotes autophagy-dependent ferroptosis and apoptosis in the cerebellum through the liver-brain axis

Microplastics (MPs), which are emerging environmental pollutants, remain uncertainties in their toxic mechanism. MPs have been linked to severe liver metabolic disorders and neurotoxicity, but it is still unknown whether the abnormal metabolites induced by MPs can affect brain tissue through the liver-brain axis. Exposed to MPs of chickens results in liver metabolic disorders and increased glutamine and glutamate synthesis. The relative expression of glutamine in the C group was -0.862, the L-PS group was 0.271, and the H-PS group was 0.592. The expression of tight junction proteins in the blood-brain barrier (BBB) was reduced by PS-MPs. Occludin protein expression decreased by 35.8%-41.2%. Claudin 3 decreased by 19.6%-42.3%, and ZO-1 decreased by 28.3%-44.6%. Excessive glutamine and glutamate cooperated with PS-MPs to inhibit the Nrf2-Keap1-HO-1/NQO1 signaling pathway and triggered autophagy-dependent ferroptosis and apoptosis. GPX protein expression decreased by 30.9%-38%. LC3II/LC3I increased by 54%, and Caspase 3 increased by 45%. Eventually, the number of Purkinje cells was reduced, causing neurological dysfunction. In conclusion, this study provides new insights for revealing the mechanism of nervous system damaged caused by PS-MPs exposed in chickens.

Multivariate genome-wide association study of depression, cognition, and memory phenotypes and validation analysis identify 12 cross-ethnic variants

To date, little is known about the pleiotropic genetic variants among depression, cognition, and memory. The current research aimed to identify the potential pleiotropic single nucleotide polymorphisms (SNPs), genes, and pathways of the three phenotypes by conducting a multivariate genome-wide association study and an additional pleiotropy analysis among Chinese individuals and further validate the top variants in the UK Biobank (UKB). In the discovery phase, the participants were 139 pairs of dizygotic twins from the Qingdao Twins Registry. The genome-wide efficient mixed-model analysis identified 164 SNPs reaching suggestive significance (P < 1 × 10-5). Among them, rs3967317 (P = 1.21 × 10-8) exceeded the genome-wide significance level (P < 5 × 10-8) and was also demonstrated to be associated with depression and memory in pleiotropy analysis, followed by rs9863698, rs3967316, and rs9261381 (P = 7.80 × 10-8-5.68 × 10-7), which were associated with all three phenotypes. After imputation, a total of 457 SNPs reached suggestive significance. The top SNP chr6:24597173 was located in the KIAA0319 gene, which had biased expression in brain tissues. Genes and pathways related to metabolism, immunity, and neuronal systems demonstrated nominal significance (P < 0.05) in gene-based and pathway enrichment analyses. In the validation phase, 12 of the abovementioned SNPs reached the nominal significance level (P < 0.05) in the UKB. Among them, three SNPs were located in the KIAA0319 gene, and four SNPs were identified as significant expression quantitative trait loci in brain tissues. These findings may provide evidence for pleiotropic variants among depression, cognition, and memory and clues for further exploring the shared genetic pathogenesis of depression with Alzheimer's disease.

Immunological Tolerance in Liver Transplant Recipients: Putative Involvement of Neuroendocrine-Immune Interactions

The transplantation world changed significantly following the introduction of immunosuppressants, with millions of people saved. Several physicians have noted that liver recipients that do not take their medication for different reasons became tolerant regarding kidney, heart, and lung transplantations at higher frequencies. Most studies have attempted to explain this phenomenon through unique immunological mechanisms and the fact that the hepatic environment is continuously exposed to high levels of pathogen-associated molecular patterns (PAMPs) or non-pathogenic microorganism-associated molecular patterns (MAMPs) from commensal flora. These components are highly inflammatory in the periphery but tolerated in the liver as part of the normal components that arrive via the hepatic portal vein. These immunological mechanisms are discussed herein based on current evidence, although we hypothesize the participation of neuroendocrine-immune pathways, which have played a relevant role in autoimmune diseases. Cells found in the liver present receptors for several cytokines, hormones, peptides, and neurotransmitters that would allow for system crosstalk. Furthermore, the liver is innervated by the autonomic system and may, thus, be influenced by the parasympathetic and sympathetic systems. This review therefore seeks to discuss classical immunological hepatic tolerance mechanisms and hypothesizes the possible participation of the neuroendocrine-immune system based on the current literature.

Assessment of mental health in patients with chronic liver disease

Content available: Audio Recording.

Association between depression and quality of life in stroke patients: The Korea National Health and Nutrition Examination Survey (KNHANES) IV–VII (2008–2018)

Background

Stroke and depression are common diseases that affect quality of life (QoL). Although some recent studies have investigated the association between the two diseases, studies that examined the association between stroke, depression, and QoL are rare, with large-scale national-level studies lacking. We aimed to investigate the association between depression and QoL in stroke patients.

Methods

Data from the Korea National Health and Nutrition Examination Survey (KNHANES) IV–VII conducted in 2008–2018 were used, and 45,741 adults who were aged >40 years and had no missing data for stroke and depression were included in the analysis. The participants were first grouped by prevalence of stroke, and further divided by prevalence of depression.

Results

The overall prevalence of stroke was 3.2%, and the incidence was 9% higher in men than in women. Multiple logistic regression was performed after adjusting for demographic factors, health-related factors, and disease-related factors. The results confirmed that the stroke group with depression had a lower overall health-related quality of life, measured using EQ-5D, score compared to the stroke group without depression (-0.15). Moreover, the concurrent stroke and depression treatment group had the highest OR of 7.28 (95% CI 3.28–16.2) for the anxiety/depression domain.

Conclusion

Depression was strongly associated with QoL in stroke patients. This association was more evident in stroke patients undergoing treatment for depression. Thus, clinical approaches that take QoL into consideration are needed for stroke patients with depression.

Symptom Management in Patients with Cirrhosis: a Practical Guide

Purpose of the review

Though it is well known that cirrhosis is associated with significant morbidity and mortality, management of symptoms in cirrhosis can be difficult. This review serves to offer practical guidance in the management of liver-specific symptoms of cirrhosis as well as other symptoms with special hepatic considerations.

Recent findings

We discuss liver-specific symptoms and management, including ascites and refractory ascites, hepatic encephalopathy, pruritus, and muscle cramping. We also discuss the challenges of treating more generalized symptoms in cirrhosis, including pain, depression/anxiety, appetite, and fatigue. Medication management is, especially complex in this population given the altered metabolism of drugs, and we consider some strategies to approach this.

Summary

With the right tools, provided throughout this review, hepatologists should be well equipped to manage the nuanced liver-specific and generalized symptoms in patients with cirrhosis.

Treatment of Mental Health in Patients With Chronic Liver Disease

Content available: Author Interview and Audio Recording.

Anxiety in cirrhosis: a prospective study on prevalence and development of a practical screening nomogram

OBJECTIVES

The prevalence and effects of anxiety on health-related quality of life and clinical outcomes in cirrhosis are not well understood. This is increasingly relevant during COVID-19. Our aim was to use the Mini-International Neuropsychiatric Interview (MINI) to determine the prevalence of anxiety, its association with clinical outcomes in cirrhosis and to develop a rapid cirrhosis-specific anxiety screening nomogram.

METHODS

Adults with a diagnosis of cirrhosis were prospectively recruited as outpatients at three tertiary care hospitals across Alberta and followed for up to 6 months to determine the association with unplanned hospitalization/death. The Hospital Anxiety and Depression scale (HADS) was used as a screening tool as it is free of influence from somatic symptoms. Anxiety was diagnosed using the MINI.

RESULTS

Of 304 patients, 17% of patients had anxiety by the MINI and 32% by the HADS. Anxious patients had lower health-related quality of life as assessed by the chronic liver disease questionnaire (P < 0.001) and EuroQol Visual Analogue Scale (P < 0.001), and also had higher levels of frailty using the Clinical Frailty score (P = 0.004). Multivariable analysis revealed smoking and three HADS subcomponents as independent predictors of anxiety. These were used to develop a rapid screening nomogram.

CONCLUSION

A formal diagnosis of anxiety was made in approximately one in five patients with cirrhosis, and it was associated with worse HrQoL and frailty. The use of a 4-question nonsomatic symptom-based nomogram requires validation but is promising as a rapid screen for anxiety in cirrhosis.

Gut-derived systemic inflammation as a driver of depression in chronic liver disease

Depression and chronic liver disease (CLD) are important causes of disability, morbidity and mortality worldwide and their prevalence continues to rise. The rate of depression in CLD is high compared to that of the general population and is comparable to the increased rates observed in other medical comorbidities and chronic inflammatory conditions. Notably, a comorbid diagnosis of depression has a detrimental effect on outcomes in cirrhosis. Systemic inflammation is pivotal in cirrhosis-associated immune dysfunction - a phenomenon present in advanced CLD (cirrhosis) and implicated in the development of complications, organ failure, disease progression, increased infection rates and poor outcome. The presence of systemic inflammation is also well-documented in a cohort of patients with depression; peripheral cytokine signals can result in neuroinflammation, behavioural change and depressive symptoms via neural mechanisms, cerebral endothelial cell and circumventricular organ signalling, and peripheral immune cell-to-brain signalling. Gut dysbiosis has been observed in both patients with cirrhosis and depression. It leads to intestinal barrier dysfunction resulting in increased bacterial translocation, in turn activating circulating immune cells, leading to cytokine production and systemic inflammation. A perturbed gut-liver-brain axis may therefore explain the high rates of depression in patients with cirrhosis. The underlying mechanisms explaining the critical relationship between depression and cirrhosis remain to be fully elucidated. Several other psychosocial and biological factors are likely to be involved, and therefore the cause is probably multifactorial. However, the role of the dysfunctional gut-liver-brain axis as a driver of gut-derived systemic inflammation requires further exploration and consideration as a target for the treatment of depression in patients with cirrhosis.

Network Pharmacology-Based and Experimental Identification of the Effects of Paeoniflorin on Major Depressive Disorder

Objective: Major depressive disorder (MDD) is one of the most common psychiatric disorders, the diagnosis and treatment of MDD are major clinical issues. However, there is a lack of effective biomarkers and drugs diagnosis and therapeutics of MDD. In the present study, bioinformatics analysis combined with an experimental verification strategy was used to identify biomarkers and paeoniflorin targets for MDD diagnosis and treatment.

Methods: Based on network pharmacology, we obtained potential targets and pathways of paeoniflorin as an antidepressant through multiple databases. We then constructed a protein-protein interaction network and performed enrichment analyses. According to the results, we performed in vivo and in vitro experimental validation.

Results: The results showed that paeoniflorin may exert an antidepressant effect by regulating cell inflammation, synaptic function, NF-κB signaling pathway, and intestinal inflammation.

Conclusion: NPM1, HSPA8, HSPA5, HNRNPU, and TNF are the targets of paeoniflorin treatment. In addition, we demonstrated that paeoniflorin inhibits inflammatory cytokine production via the p38MAPK/NF-κB pathway and has neuroprotective effects on the synaptic structure. Our findings provide valuable evidence for the diagnosis and treatment of MDD.

Binge-eating disorder is associated with an unfavorable body mass composition in patients with non-alcoholic fatty liver disease

The interaction between eating disorders and non-alcoholic fatty liver disease (NAFLD) remains unexplored, especially with regards to binge-eating disorder (BED). Our team conducted a service evaluation project in order to assess risk factors for the presence of BED among patients with NAFLD and the impact of BED on body mass composition. The overall prevalence of patients screening positive to BED Screener-7 (BEDS-7) was 28.4%, while a previous diagnosis of depression and marital status (as single or separated) were independently associated with positive BED. Furthermore, patients with positive BEDS-7 had higher BMI, with greater visceral component and overall lower muscle mass. There was no difference in terms of liver disease severity as assessed by noninvasive markers of fibrosis. However, as body mass composition and sarcopenia have been shown to be associated to disease progression in patients with NAFLD, further studies are required to ascertain the long-term impact of BED in these patients. Moreover, further work is warranted to identify to implement multidisciplinary approach within clinical psychology for the management of patients with BED, who may be particularly challenging in terms of achieving lifestyle modifications. As a hepatology community, we should address NAFLD with a more holistic approach.

Hepatic encephalopathy and depression in chronic liver disease: is the common link systemic inflammation?

Hepatic encephalopathy and depression share a number of clinical features, such as cognitive impairment and psychomotor retardation, and are highly prevalent in patients with chronic liver disease. Both conditions signify a poor prognosis, carry an increased mortality and are major determinants of reduced health related quality of life. The pathophysiology of hepatic encephalopathy is complex. Whilst cerebral accumulation of ammonia is well-recognised as being central to the development of hepatic encephalopathy, systemic inflammation, which acts in synergy with hyperammonaemia, is emerging as a key driver in its development. The pro-inflammatory state is also widely documented in depression, and peripheral to brain communication occurs resulting in central inflammation, behavioural changes and depressive symptoms. Gut dysbiosis, with a similar reduction in beneficial bacteria, increase in pathogens and decreased bacterial diversity, has been observed in both hepatic encephalopathy and depression, and it may be that the resultant increased bacterial translocation causes their shared inflammatory pathophysiology. Whilst the literature on a positive association between hepatic encephalopathy and depression in cirrhosis remains to be substantiated, there is evolving evidence that treatment with psychobiotics may be of dual benefit, improving cognition and mood in cirrhosis.

Impact of major depression and antidepressant use on alcoholic and non-alcoholic fatty liver disease: A population-based study

BACKGROUND AND AIMS

The effect of major depression and antidepressant use on patient survival in chronic liver disease is unknown. We evaluated the impact of major depressive disorder (MDD) and antidepressants on survival among patients with alcoholic liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD).

METHODS

The Health Improvement Network database, the largest medical database in the United Kingdom, was used to identify incident ALD (n = 4148) and NAFLD (n = 19 053) in patients between 1986 and 2017. Our primary outcome was development of decompensated cirrhosis or death. MDD and each class of antidepressants were assessed in multivariate Cox proportional hazards models as time-varying covariates. Models were adjusted for age, sex, socio-economic status and comorbidities.

RESULTS

MDD rate was higher among patients with ALD (22.8%) compared to those with NAFLD (16.1%), P < .01. Antidepressant usage was common in patients with ALD (47.4%) and NAFLD (40.8%). After adjusting for covariates, MDD (adjusted hazard ratio [AHR]: 0.80, 95% CI: 0.63-1.02 for NAFLD; and AHR 1.01, 0.88-1.15 for ALD) was not associated with improved decompensated cirrhosis-free survival. The antidepressant mirtazapine was associated with worse decompensated cirrhosis-free survival among NAFLD (AHR 2.16, 95% CI: 1.32-3.52) and ALD (AHR 1.53, 1.09-2.15) cohorts. Similarly, mirtazapine was associated with mortality in both cohorts.

CONCLUSIONS

MDD was not associated with worse outcomes for ALD or NAFLD. Mirtazapine was associated with an increased risk of decompensated cirrhosis or death, which was not observed with other antidepressants. Prospective studies are warranted to confirm these findings.

Anxiety and Depression in Patients with Primary Biliary Cholangitis: Current Insights and Impact on Quality of Life

Primary biliary cholangitis (PBC), formerly known as primary biliary cirrhosis, is a chronic cholestatic immune-mediated liver disease characterized by injury to intrahepatic bile ducts that may ultimately progress to cirrhosis and liver failure and result in the need for liver transplant or death without treatment. Ursodeoxycholic acid (UDCA) and obeticholic acid (OCA) are approved therapies for PBC and are associated with a reduced risk of progression of disease, although patients may continue to experience significant symptoms of pruritus and fatigue independent of liver disease. The two most commonly reported symptoms among patients with PBC are fatigue and pruritus which may be debilitating, and negatively impact physical, mental, emotional, and social wellbeing. Intense symptom burden has been associated with depressive symptoms, cognitive defects, poor sleep schedules, and social isolation. This literature review explores the presence of anxiety and depressive symptoms in chronic liver disease, the impact of symptom burden on patients' wellbeing, and available pharmaceutical and natural therapies.

Correlation between anxiety-depression symptoms and immune characteristics in inpatients with 2019 novel coronavirus in Wuhan, China

BACKGROUND

Coronavirus disease 2019 (COVID-19) is widely acknowledged as a severe traumatic event, and depression, anxiety, and psychological distress are common in diagnosed patients. However, the correlations of biological indicators with emotion are rarely reported. The primary objective of this study was to explore the dysfunction of immune-inflammatory characteristics in patients with depression-anxiety symptoms.

METHODS

We investigated the mental status of inpatients with COVID-19 in Wuhan and compared the differences in cytokines and lymphocytes between patients with and without depression-anxiety symptoms at admission. After two weeks of treatment, we evaluated the mental conditions and measured the cytokines and lymphocytes of the patients with depression and anxiety symptoms and explored the changes and their associations.

RESULTS

Approximately half of the patients with COVID-19 had depression and anxiety symptoms, and the symptoms were related to the ratio of CD4+/CD8+ and the level of CD4⁺T lymphocytes. When compared with patients without depression-anxiety symptoms, CD4⁺T lymphocytes level was significantly higher in COVID-19 patients with depression-anxiety symptoms.

CONCLUSION

This study provided novel evidence regarding the association between depression and anxiety symptoms and immune characteristics, especially CD4⁺T lymphocyte levels, in COVID-19 patients. We emphasized the importance of paying attention to the dynamic immune process of patients diagnosed with COVID-19 with depression/anxiety.

Health-related quality of life in outpatients with chronic liver disease: a cross-sectional study

Background

The symptoms and complications related to chronic liver disease (CLD) have been shown to affect patient well-being. Currently there is limited research data on how CLD severity may affect both health-related quality of life (HRQOL) and the development of depressive symptoms in CLD patients. Moreover, the ongoing advances in CLD treatment, and its effect on HRQOL, highlight the need for further studies. Therefore, the aim of the present study was to evaluate if the CLD severity may affect the HRQOL and the development of depressive symptoms.

Methods

A cross-sectional study was conducted. Patients with CLDs were identified at their regular visits to the outpatient clinic of the Sant’Orsola-Malpighi Hospital in Bologna, between September 2016 and July 2017. HRQOL was measured with Short Form 12 (SF-12) and Nottingham Health Profile (NHP) questionnaires; depressive symptoms were measured with Beck Depression Inventory-II (BDI). CLD severity was measured using the MELD score and the sample was stratified into five classes according to it. Group comparisons were conducted using the Kruskal–Wallis test.

Results

Two hundred and fifty-four patients were included. Mean age was 62.84 years (SD 11.75) and 57.9% were male. Most participants were affected by compensated cirrhosis (140.2%) and chronic hepatitis (40.2%), with a disease duration ≥ 5 years (69.3%). Regarding the MELD score, 67.7% of patients belonged to Class I, 29.9% to Class II, and 2.4% to Class III. There were not patients belonging to the Classes IV and V.

No statistically significant differences were found in all SF-12 and NHP domains between the MELD classes, except for CLD impact on sexual life and holidays (p = 0.037 and p = 0.032, respectively). A prevalence rate of 26% of depressive symptoms was reported, no statistically significant differences were found in BDI-II total scores between the three MELD classes.

Conclusions

All domains of HRQOL and depression were altered in CLDs patients, nevertheless CLD severity was not confirmed as an affecting factor for HRQOL.

Risk factors for poorer health literacy in patients with liver cirrhosis

BACKGROUND

Health literacy is a concept that refers to patients' ability to manage their disease and the health system's ability to guarantee access to services. There is evidence that health literacy impacts the health outcomes of patients with chronic diseases, but detailed information on this topic in patients with liver cirrhosis is scarce. It was the aim of this study to identify risk factors for poorer health literacy in patients with liver cirrhosis.

METHODS

89 patients with liver cirrhosis were enrolled in this study and health literacy was measured using the Health Literacy Questionnaire (HLQ). Covert hepatic encephalopathy (CHE) was diagnosed clinically according to the West-Haven Criteria (HE grade 1) and the PHES (minimal HE). Depressive symptoms were assessed using the Hamilton Depression Rating Scale (HDRS). Based on the nine subscales of the HLQ, risk factors for poor health literacy were identified using linear regression models.

RESULTS

Normalized HLQ scores ranged between 65-76%, while appraisal of health information had lowest score (65%) and ability to actively engage with healthcare providers had highest score (76%). Multivariable regression analyses revealed an association of poorer health literacy and liver function as determined by MELD score and complications of liver cirrhosis such as a history of ascites or CHE. Additionally, we identified modifiable or preventable factors such as depressive symptoms, a history of falls, and active smoking as risk factors for poorer health literacy.

CONCLUSION

Multiple factors seem to impact on health literacy in patients with liver cirrhosis. Addressing modifiable and preventable factors may improve health literacy.

Endoscopic management of multiple broken scalpel blades in the gastrointestinal tract: a case report

The entry of multiple broken scalpel blades into the gastrointestinal tract with involvement of the stomach, ileum, and colon is rare; no such cases have been reported to date. Whether management of multiple sharp foreign bodies is more effective by endoscopy or surgery remains controversial in clinical practice. We herein describe a 23-year-old man with depression who was admitted to our department 36 hours after swallowing multiple scalpel blades. The patient reported abdominal pain and bloody vomit. A radiograph revealed irregular blade-shaped foreign bodies in the abdomen, and computed tomography confirmed foreign bodies in the stomach, mid-distal segment of the ileum, proximal segment of the ascending colon, liver area of the transverse colon, and lumen of the sigmoid colon. Surgery was immediately suggested as the first-choice treatment, but endoscopy was instead performed after a thorough multidisciplinary discussion. All broken scalpel blades were successfully removed with combined gastroscopy and colonoscopy, and the patient’s postoperative recovery was uneventful. This case demonstrates the vital importance of multidisciplinary management and endoscopy as an appropriate treatment approach even for multiple sharp foreign bodies in patients without perforation or peritonitis.

Cirrhosis: An evidence-based approach

ABSTRACT

The role of nurses in managing patients with cirrhosis is increasing due to the growing prevalence of the disease. This article reviews the pathophysiology, diagnosis, complications, and management of patients with cirrhosis, with an emphasis on interdisciplinary collaboration and evidence-based practice.

Selective serotonin reuptake inhibitors use and hepatocellular carcinoma in patients with alcohol use disorder

BACKGROUND

Research has proposed that selective serotonin reuptake inhibitors (SSRIs) were associated with a reduction of the risk of hepatocellular carcinoma (HCC). The objective of this study is to investigate whether SSRIs use is associated with decreased risk of HCC in patients with alcohol use disorder (AUD).

PATIENTS AND METHODS

We conducted a retrospective population-based cohort study using Taiwan's National Health Insurance Research Database (NHIRD) from 1997 to 2013 and enrolled patients with newly diagnosed AUD. After propensity scores matching at a ratio 1:4, total of 4945 SSRI users and 19,785 non-SSRI users were included in the matched cohort. Patients were followed up from the 365th day after the date of first exposure to SSRIs to occurrence of HCC, the date of death, or the end of 2013. Cox proportional hazard regressions were performed to evaluate hazard ratio (HRs) for HCC in SSRI-exposed patients compared with unexposed patients.

RESULTS

In the main study cohort, SSRI use was associated with significant lower risk of HCC compared to the non-SSRI users after adjusting for age, sex, income, urbanization, alcoholic fatty liver, alcoholic hepatitis and diabetes (adjusted hazard ratio [aHR] = 0.31, 95 % CI = 0.24-0.39). The negative association of SSRI use and HCC was replicated in the matched cohort (aHR = 0.58, 95 % CI = 0.44-0.77). The effect of SSRI use on HCC was dose-related in both cohorts (p for trend < 0.0001).

CONCLUSIONS

This study showed that SSRIs use was associated with a reduction risk of HCC among AUD patients in a cumulative dose effect manner.

The Role of Intestinal Bacteria and Gut-Brain Axis in Hepatic Encephalopathy

Hepatic encephalopathy (HE) is a neurological disorder that occurs in patients with liver insufficiency. However, its pathogenesis has not been fully elucidated. Pharmacotherapy is the main therapeutic option for HE. It targets the pathogenesis of HE by reducing ammonia levels, improving neurotransmitter signal transduction, and modulating intestinal microbiota. Compared to healthy individuals, the intestinal microbiota of patients with liver disease is significantly different and is associated with the occurrence of HE. Moreover, intestinal microbiota is closely associated with multiple links in the pathogenesis of HE, including the theory of ammonia intoxication, bile acid circulation, GABA-ergic tone hypothesis, and neuroinflammation, which contribute to cognitive and motor disorders in patients. Restoring the homeostasis of intestinal bacteria or providing specific probiotics has significant effects on neurological disorders in HE. Therefore, this review aims at elucidating the potential microbial mechanisms and metabolic effects in the progression of HE through the gut–brain axis and its potential role as a therapeutic target in HE.

Antidepressants- and antipsychotics-induced hepatotoxicity

Drug-induced liver injury (DILI) is a serious health burden. It has diverse clinical presentations that can escalate to acute liver failure. The worldwide increase in the use of psychotropic drugs, their long-term use on a daily basis, common comorbidities of psychiatric and metabolic disorders, and polypharmacy in psychiatric patients increase the incidence of psychotropics-induced DILI. During the last 2 decades, hepatotoxicity of various antidepressants (ADs) and antipsychotics (APs) received much attention. Comprehensive review and discussion of accumulated literature data concerning this issue are performed in this study, as hepatotoxic effects of most commonly prescribed ADs and APs are classified, described, and discussed. The review focuses on ADs and APs characterized by the risk of causing liver damage and highlights the ones found to cause life-threatening or severe DILI cases. In parallel, an overview of hepatic oxidative stress, inflammation, and steatosis underlying DILI is provided, followed by extensive review and discussion of the pathophysiology of AD- and AP-induced DILI revealed in case reports, and animal and in vitro studies. The consequences of some ADs and APs ability to affect drug-metabolizing enzymes and therefore provoke drug–drug interactions are also addressed. Continuous collecting of data on drugs, mechanisms, and risk factors for DILI, as well as critical data reviewing, is crucial for easier DILI diagnosis and more efficient risk assessment of AD- and AP-induced DILI. Higher awareness of ADs and APs hepatotoxicity is the prerequisite for their safe use and optimal dosing.

COVID-19 Pandemic Stress-Induced Somatization in Transplant Waiting List Patients

Background: The coronavirus disease 2019 (COVID-19) pandemic has resulted in widespread socioeconomic restrictions including quarantine, social distancing and self-isolation. This is the first study investigating the psychological impact of the pandemic on patients waiting for liver or kidney transplantation, a particularly vulnerable group. Methods: Twenty-seven patients on the transplantation waiting list and 43 healthy controls took part in an online survey including the Beck Depression Inventory (BDI-2), the Brief Symptom Inventory-18 (BSI-18), the Pittsburgh Sleep Quality Index (PSQI), the Alcohol Use Identification Test (AUDIT-C), the 12-item Operationalized Psychodynamic Diagnosis Structure Questionnaire (OPD-SQS) and a questionnaire to determine cognitions and beliefs, attitude and fear related to COVID-19. Results: BSI-18 Somatization was increased in waiting list patients compared to controls. Correlation analyses indicated a relationship between Somatization and the fear of contracting the coronavirus in the patient group; however this association was weak. In patients and controls, other psychologicial symptoms (depression, anxiety) correlated highly with emotional distress due to social distancing. There were no differences between patients and controls in depression scores and sleep disturbances. Alcohol consumption and personality structure were not related to COVID-19 fears. Conclusion: In times of the first lockdown during the COVID-19 pandemic, patients on the transplantation waiting list have high somatization symptoms associated with COVID-19 fears. As vulnerable group, they need psychological counseling to improve mental well-being during times of crisis.

Association between vitamin D status and depression in children with chronic liver disease

Background

Deficiency of vitamin D and depression are commonly occurring in patients with chronic liver diseases. This study aimed to determine the association between 25-OH-vitamin D status and depressive symptoms among children with chronic liver diseases. Eighty children were enrolled and divided into 2 groups: the patients’ group (60 children with chronic hepatitis) and the control group (20 healthy children). All children have been analyzed for their clinical, biochemical features, histological profile, serum 25-OH-vitamin D levels, and assessment of childhood depression using Arabic form based on Kovacs Children’s Depression Inventory.

Results

Serum level of 25(OH) D was significantly lower in the hepatic group than the control group [17 (5–52) ng/ml, 45 (13–95) ng/ml, p = <0001 respectively]. Depression score was significantly higher in the hepatic group as 30% of the control group had mild depression, while 36.7% of the hepatic group had mild depression, 16.7% had moderate depression, and 10% had severe depression. There was a statistically significant difference between children with depressive symptoms and non-depressive symptoms as regards the level of serum vitamin D as it was lower in children with depressive symptoms [median (range) 17 (5–40) ng/ml, 27.5 (8–52) ng/ml, p = 0.04 respectively]. There were statistically significant differences between the serum level of 25(OH) D and depression as it decreases with increasing severity of depression.

Conclusion

Children with chronic liver disease who had depressive symptoms showed significantly lower levels of vitamin D when compared with those without depressive symptoms; also, vitamin D had an inverse correlation with depression scores in these children.

The Antidepressant Mirtazapine Activates Hepatic Macrophages, Facilitating Pathogen Clearance While Limiting Tissue Damage in Mice

Background and Aims

Mirtazapine is an atypical antidepressant with antagonist activity for serotonin and histamine receptors. Clinical and experimental evidence suggests that, in addition to treating depression, mirtazapine also alters liver innate immunity and suppresses immune-driven hepatic macrophage activation. Liver macrophages, Kupffer cells, represent the largest collection of fixed macrophages in the body and are critical in regulating hepatic immunity. In addition to their capacity to regulate inflammation, Kupffer cells are key sentinels for clearing blood-borne pathogens, preventing their dissemination within the body. This process involves pathogen capture, phagocytosis, and activation-induced killing via reactive oxygen species (ROS) production. Therefore, we speculated that mirtazapine might adversely alter Kupffer cell pathogen-associated activation and killing.

Methods

Mice were treated with mirtazapine and time-dependent changes in Kupffer cells were characterized using intravital microscopy. Macrophage and neutrophil responses, bacterial dissemination, and liver damage were assessed following i.v. infection with a pathogenic strain of S. aureus.

Results

Mirtazapine rapidly (within 1.5 h) activates Kupffer cells, indicated by a loss of elongated shape with cellular rounding. However, this shape change did not result in impaired pathogen capture function, and, in fact, generated enhanced ROS production in response to S. aureus-induced sepsis. Neutrophil dynamics were altered with reduced cellular recruitment to the liver following infection. Bacterial dissemination post-intravenous administration was not altered by mirtazapine treatment; however, hepatic abscess formation was significantly reduced.

Conclusions

Mirtazapine rapidly activates Kupffer cells, associated with preserved bacterial capture functions and enhanced ROS generation capacity. Moreover, these changes in Kupffer cells were linked to a beneficial reduction in hepatic abscess size. In contrast to our initial speculation, mirtazapine may have beneficial effects in sepsis and warrants further exploration.

Cirrhosis: An evidence-based treatment approach

The NP's role in managing cirrhosis is increasing due to the growing prevalence of the disease. The purpose of this article is to review the pathophysiology, diagnosis, and management of patients with cirrhosis with an emphasis on interdisciplinary collaboration and evidence-based practice. Cirrhosis complications are also discussed.

Quantitative proteomic analysis of the liver reveals antidepressant potential protein targets of Sinisan in a mouse CUMS model of depression

In traditional Chinese medicine, the role of the liver in depression is highly valued, and liver-relieving drugs, such as Sinisan, are often used to treat depression; however, the mechanism whereby these drugs work remains unclear. The present study aimed to reveal possible antidepressant mechanisms of Sinisan (SNS) by analyzing hepatic proteomics in chronic unpredictable mild stress (CUMS) mice. Using the CUMS mouse model of depression, the antidepressant effects of SNS were assessed by the sucrose preference test (SPT) and forced swimming test (FST). Hepatic differentially expressed proteins (DEPs) after SNS treatment were investigated by tandem mass tag (TMT) based quantitative proteomics analysis. Then, a bioinformatics analysis of DEPs was conducted through hierarchical clustering, Venn analysis, Gene Ontology (GO) annotation enrichment, and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment. DEP genes were further validated by quantitative real-time polymerase chain reaction (qRT-PCR) analysis and western blotting. Behavioral results demonstrated that SNS significantly increased sucrose intake in SPT and shortened the immobility time in FST in model mice. Eighty-two DEPs were identified, including 37 upregulated and 45 downregulated proteins, between model and SNS groups. Enrichment analysis of GO annotations indicated that SNS primarily maintained cellular iron ion homeostasis by iron ion transportation and regulated expression of some extracellular structural proteins for oxidation-reduction processes. KEGG and Venn analysis showed that mineral absorption, steroid hormone biosynthesis and metabolism might be the principal pathways through which SNS acts on depression. Furthermore, several proteins involved in the biosynthesis and metabolism of steroid hormone pathways were significantly up/downregulated by SNS, including CYP2B19, CYP7B1 (validated by qRT-PCR) and HSD3b5 (validated by qRT-PCR and western blotting). Our results indicate that SNS plays important roles in antidepressant actions by restoring DEPs, resulting in the biosynthesis and metabolism of steroid hormones. The current results provide novel perspectives for revealing potential protein targets of SNS in depression.

Anxiety and depression on the liver transplant waiting list: a case for psychological prehabilitation?

Introduction:

Anxiety and depression in patients awaiting liver transplantation are associated with worse clinical outcomes. However, optimising patient mental health is not routinely addressed in pre-transplant care.

Aims:

To understand the prevalence of anxiety and depression in patients awaiting transplantation and their access to pharmacological and psychological therapies.

Methods:

Patients awaiting transplantation were offered screening for anxiety and depression using the Hospital Anxiety and Depression Screening (HADS) tool. Data pertaining to patient demographics and previous treatment for anxiety and depression were recorded and analysed.

Findings:

Over 50% of patients recorded abnormal scores for anxiety and depression. Of the 19 patients screened, 42% had received treatment for either disorder, and most found the intervention unhelpful due to lack of follow-up appointments and limited understanding of their underlying chronic liver disease. There was a significant association between female sex and screening positive for depression.

Conclusion:

Anxiety and depression are prevalent in patients awaiting liver transplantation. The integration of a psychologist into the transplantation multidisciplinary team may improve patient outcomes.

Quality of life after liver transplantation

Liver transplantation (LT) enables rapid transition from critical illness and poor prognosis back to health. After LT, health-related quality of life (HRQoL) generally becomes comparable to that of the general population, although some deficits in mainly physical domains are frequent. However, recipients continue to have symptoms related to immunosuppression, complications, and other things, which impact HRQoL and the recipient's ability to regain independence and re-establish function in everyday life. Less than half of LT recipients return to work. Reportedly, HRQoL seems to deteriorate slightly over the long-term, but still remains satisfactory. Physical fatigue is common, but recent studies show that structured exercise programs improve both fatigue and HRQoL. Emerging evidence also suggests that continued patient information, structured psychosocial support systems, and caregiver involvement might further help improve long-term HRQoL. More research is needed to gain better understanding of the factors affecting long-term HRQoL, and how to best improve HRQoL.

Studies on the potential link between antidepressant effect of Xiaoyao San and its pharmacological activity of hepatoprotection based on multi-platform metabolomics

ETHNOPHARMACOLOGICAL RELEVANCE

In traditional Chinese medicine (TCM) theory, depression is considered to be "liver qi stagnation", and relieving "liver qi stagnation" is regarded as an effective method for treating depression. Xiaoyao San (XYS) is a well-known TCM formula for the treatment of depression by relieving "liver qi stagnation". This formula consists of Radix Paeoniae Alba (Paeonia lactiflora Pall.), Radix Bupleuri (Bupleurum chinense DC.), Poria (Poria cocos (Schw.) Wolf), Rhizoma Atractylodis Macrocephalae (Atractylodes macrocephala Koidz.), Radix Angelicae Sinensis (Angelica sinensis (Oliv.) Diels), Radix Glycyrrhizae (Glycyrrhiza uralensis Fisch.), Rhizoma Zingiberis Recens (Zingiber officinale Roscoe) and Herba Menthae Haplocalycis (Mentha haplocalyx Briq.).

AIM OF THE STUDY

Several studies have suggested that depression is associated with liver injury. XYS was a well-known TCM formula for the treatment of depression and liver stagnancy. However, it was still unknown whether the antidepressant effect of XYS is related to the pharmacological activity of hepatoprotection. The aim of this study was to elucidate the potential link between the antidepressant and hepatoprotective effect of XYS.

MATERIALS AND METHODS

A depression rat model was established by the CUMS (chronic unpredictable mild stress) procedure. The antidepressant effect of XYS was assessed by the behavioral indicators, and the hepatoprotective effect of XYS was evaluated through biochemical assays. ¹H-NMR and LC/MS-based liver metabolomics were performed to discover key metabolic pathways involved in the antidepressant and hepatoprotective effects of XYS. Further, the key pathway was validated using commercial kits.

RESULTS

The results demonstrated that XYS pretreatment could significantly improve the depressive symptom induced by CUMS. More importantly, the results demonstrated that liver injury was observed in the CUMS model rats, and XYS had a hepatoprotective effect by reducing the activities of AST and ALT in serum, increasing the levels of SOD and GSH-Px and reducing the contents of MDA, IL-6, and IL-1β in the liver. In addition, the NMR and LC/MS-based metabolomics results indicated that XYS improved 23 of the 35 perturbed potential liver biomarkers that were induced by CUMS. Among them, 9 biomarkers were significantly correlated with both depression and liver pathology, according to Pearson correlation analysis. Metabolic pathway analyses of these 9 biomarkers showed that glutamine and glutamate metabolism were the most important metabolic pathways. Furthermore, to verify glutamine and glutamate metabolism, the levels of glutamine and glutamate, and the activity of glutamine synthetase (GS) and glutaminase (GLS) were quantitatively determined in the liver by commercial kits, and these results were consistent with the metabolomics results.

CONCLUSIONS

XYS could significantly improve the depressive and liver injury symptoms induced by CUMS. The metabolomics results indicate that the regulation of glutamine and glutamate metabolism to maintain the balance of ammonia and promote energy metabolism is a potential junction between the antidepressant and hepatoprotective effects of XYS.

Nutrition in Chronic Liver Disease: A Point-of-Care Review

Patients with chronic liver disease have a very high lifetime risk of malnourishment. It has been increasingly identified in literature that the severity of liver disease affects severity of malnutrition and vice versa. The objective of this review article is to recognize the severity of complications associated with malnutrition in patients with cirrhosis and ways to overcome these obstacles.

Depressive-like behaviors are induced by chronic liver injury in male and female mice

Depression is a highly prevalent mental disease and increasingly become a global public health problem. Recent studies have shown that the dysfunction of liver was associated with depression. However, the previous studies have not been fully explained the relationship between depression and liver injury. The present study was aimed to investigate whether chronic liver injury could induce depressive-like behavior. Chronic liver injury was induced by intraperitoneal injection of carbon (CCl₄), D-galactosamine (D-GalN) and thioacetamide (TAA), respectively. And the results showed that the serum activities of ALT in CCl₄, D-GalN and TAA groups were significantly increased in both male and female mice compared with the control group, while the activities of AST increased only in CCl₄ group. Meanwhile, H&E staining showed that CCl₄, D-GalN and TAA induced hepatocytes injury in both male and female mice. Moreover, the sucrose preference was significantly decreased and the immobility time in forced swimming test and tail suspension test were significantly prolonged in CCl₄ and D-GalN group compared with control group. Our findings demonstrated that chronic liver injury induced by CCl₄ and D-GalN could induce depressive-like behaviors in mice.