1
|
Wakil A, Niazi M, Lunsford KE, Pyrsopoulos N. Future Approaches and Therapeutic Modalities for Acute-on-Chronic Liver Failure. Clin Liver Dis 2023; 27:777-790. [PMID: 37380297 DOI: 10.1016/j.cld.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Acute-on-chronic liver failure (ACLF) results from an acute decompensation of cirrhosis due to exogenous insult. The condition is characterized by a severe systemic inflammatory response, inappropriate compensatory anti-inflammatory response, multisystem extrahepatic organ failure, and high short-term mortality. Here, the authors evaluate the current status of potential treatments for ACLF and assess their efficacy and therapeutic potential.
Collapse
Affiliation(s)
- Ali Wakil
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers New Jersey Medical School, 185 South Orange Avenue, MSB H536, Newark, NJ 07103, USA
| | - Mumtaz Niazi
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers New Jersey Medical School, 185 South Orange Avenue, MSB H536, Newark, NJ 07103, USA
| | - Keri E Lunsford
- Department of Surgery, Division of Liver Transplant and HPB Surgery, Rutgers New Jersey Medical School, 185 South Orange Avenue, MSB H536, Newark, NJ 07103, USA
| | - Nikolaos Pyrsopoulos
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers New Jersey Medical School, 185 South Orange Avenue, MSB H536, Newark, NJ 07103, USA.
| |
Collapse
|
2
|
Papamichalis P, Oikonomou KG, Valsamaki A, Xanthoudaki M, Katsiafylloudis P, Papapostolou E, Skoura AL, Papamichalis M, Karvouniaris M, Koutras A, Vaitsi E, Sarchosi S, Papadogoulas A, Papadopoulos D. Liver replacement therapy with extracorporeal blood purification techniques current knowledge and future directions. World J Clin Cases 2023; 11:3932-3948. [PMID: 37388799 PMCID: PMC10303607 DOI: 10.12998/wjcc.v11.i17.3932] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/04/2023] [Accepted: 05/11/2023] [Indexed: 06/12/2023] Open
Abstract
Clinically, it is highly challenging to promote recovery in patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF). Despite recent advances in understanding the underlying mechanisms of ALF and ACLF, standard medical therapy remains the primary therapeutic approach. Liver transplantation (LT) is considered the last option, and in several cases, it is the only intervention that can be lifesaving. Unfortunately, this intervention is limited by organ donation shortage or exclusion criteria such that not all patients in need can receive a transplant. Another option is to restore impaired liver function with artificial extracorporeal blood purification systems. The first such systems were developed at the end of the 20th century, providing solutions as bridging therapy, either for liver recovery or LT. They enhance the elimination of metabolites and substances that accumulate due to compromised liver function. In addition, they aid in clearance of molecules released during acute liver decompensation, which can initiate an excessive inflammatory response in these patients causing hepatic encephalopathy, multiple-organ failure, and other complications of liver failure. As compared to renal replacement therapies, we have been unsuccessful in using artificial extracorporeal blood purification systems to completely replace liver function despite the outstanding technological evolution of these systems. Extracting middle to high-molecular-weight and hydrophobic/protein-bound molecules remains extremely challenging. The majority of the currently available systems include a combination of methods that cleanse different ranges and types of molecules and toxins. Furthermore, conventional methods such as plasma exchange are being re-evaluated, and novel adsorption filters are increasingly being used for liver indications. These strategies are very promising for the treatment of liver failure. Nevertheless, the best method, system, or device has not been developed yet, and its probability of getting developed in the near future is also low. Furthermore, little is known about the effects of liver support systems on the overall and transplant-free survival of these patients, and further investigation using randomized controlled trials and meta-analyses is needed. This review presents the most popular extracorporeal blood purification techniques for liver replacement therapy. It focuses on general principles of their function, and on evidence regarding their effectiveness in detoxification and in supporting patients with ALF and ACLF. In addition, we have outlined the basic advantages and disadvantages of each system.
Collapse
Affiliation(s)
| | - Katerina G Oikonomou
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Thessaly, Greece
| | - Asimina Valsamaki
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Thessaly, Greece
| | - Maria Xanthoudaki
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Thessaly, Greece
| | | | | | - Apostolia-Lemonia Skoura
- Department of Transfusion Medicine, University Hospital of Larissa, Larissa 41110, Thessaly, Greece
| | - Michail Papamichalis
- Department of Cardiology, University Hospital of Larissa, Larissa 41110, Thessaly, Greece
| | | | - Antonios Koutras
- 1st Department of Obstetrics and Gynecology, General Hospital of Athens “ALEXANDRA”, National and Kapodistrian University of Athens, Athens 11528, Greece
| | - Eleni Vaitsi
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Thessaly, Greece
| | - Smaragdi Sarchosi
- Department of Anesthesiology, University Hospital of Larissa, Larissa 41110, Thessaly, Greece
| | | | | |
Collapse
|
3
|
Biasoto HP, Hebeda CB, Farsky SHP, Pessoa A, Costa-Silva TA, Monteiro G. Extracellular expression of Saccharomyces cerevisiae's L-asparaginase II in Pichia pastoris results in novel enzyme with better parameters. Prep Biochem Biotechnol 2022; 53:511-522. [PMID: 35981094 DOI: 10.1080/10826068.2022.2111582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
L-asparaginase (ASNase) is an efficient inhibitor of tumor development, used in chemotherapy sessions against acute lymphoblastic leukemia (ALL) tumor cells; its use results in 80% complete remission of the disease in treated patients. Saccharomyces cerevisiae's L-asparaginase II (ScASNaseII) has a high potential to substitute bacteria ASNase in patients that developed hypersensitivity, but the endogenous production of it results in hypermannosylated immunogenic enzyme. Here we describe the genetic process to acquire the ScASNaseII expressed in the extracellular medium. Our strategy involved a fusion of mature sequence of protein codified by ASP3 (amino acids 26-362) with the secretion signal sequence of Pichia pastoris acid phosphatase enzyme; in addition, this DNA construction was integrated in P. pastoris Glycoswitch® strain genome, which has the cellular machinery to express and secrete high quantity of enzymes with humanized glycosylation. Our data show that the DNA construction and strain employed can express extracellular asparaginase with specific activity of 218.2 IU mg-1. The resultant enzyme is 40% more stable than commercially available Escherichia coli's ASNase (EcASNaseII) when incubated with human serum. In addition, ScASNaseII presents 50% lower cross-reaction with anti-ASNase antibody produced against EcASNaseII when compared with ASNase from Dickeya chrysanthemi.
Collapse
Affiliation(s)
- Henrique P Biasoto
- Departamento de Tecnologia Bioquímico-Farmacêutica, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, Brazil
| | - Cristina B Hebeda
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, Brazil
| | - Sandra H P Farsky
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, Brazil
| | - Adalberto Pessoa
- Departamento de Tecnologia Bioquímico-Farmacêutica, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, Brazil
| | - Tales A Costa-Silva
- Centro de Ciencias Naturais e Humanas, Universidade Federal do ABC, Santo André, SP, Brazil
| | - Gisele Monteiro
- Departamento de Tecnologia Bioquímico-Farmacêutica, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|
4
|
García Martínez JJ, Bendjelid K. Artificial liver support systems: what is new over the last decade? Ann Intensive Care 2018; 8:109. [PMID: 30443736 PMCID: PMC6238018 DOI: 10.1186/s13613-018-0453-z] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 11/07/2018] [Indexed: 12/16/2022] Open
Abstract
The liver is a complex organ that performs vital functions of synthesis, heat production, detoxification and regulation; its failure carries a highly critical risk. At the end of the last century, some artificial liver devices began to develop with the aim of being used as supportive therapy until liver transplantation (bridge-to-transplant) or liver regeneration (bridge-to-recovery). The well-recognized devices are the Molecular Adsorbent Recirculating System™ (MARS™), the Single-Pass Albumin Dialysis system and the Fractionated Plasma Separation and Adsorption system (Prometheus™). In the following years, experimental works and early clinical applications were reported, and to date, many thousands of patients have already been treated with these devices. The ability of artificial liver support systems to replace the liver detoxification function, at least partially, has been proven, and the correction of various biochemical parameters has been demonstrated. However, the complex tasks of regulation and synthesis must be addressed through the use of bioartificial systems, which still face several developmental problems and very high production costs. Moreover, clinical data on improved survival are conflicting. This paper reviews the progress achieved and new data published on artificial liver support systems over the past decade and the prospects for these devices.
Collapse
Affiliation(s)
- Juan José García Martínez
- Intensive Care Unit, Geneva University Hospitals, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland. .,Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Karim Bendjelid
- Intensive Care Unit, Geneva University Hospitals, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland
| |
Collapse
|
5
|
Costa IM, Schultz L, de Araujo Bianchi Pedra B, Leite MSM, Farsky SHP, de Oliveira MA, Pessoa A, Monteiro G. Recombinant L-asparaginase 1 from Saccharomyces cerevisiae: an allosteric enzyme with antineoplastic activity. Sci Rep 2016; 6:36239. [PMID: 27824095 PMCID: PMC5099943 DOI: 10.1038/srep36239] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 10/12/2016] [Indexed: 01/16/2023] Open
Abstract
L-asparaginase (L-ASNase) (EC 3.5.1.1) is an important enzyme for the treatment of acute lymphoblastic leukaemia. Currently, the enzyme is obtained from bacteria, Escherichia coli and Erwinia chrysanthemi. The bacterial enzymes family is subdivided in type I and type II; nevertheless, only type II have been employed in therapeutic proceedings. However, bacterial enzymes are susceptible to induce immune responses, leading to a high incidence of adverse effects compromising the effectiveness of the treatment. Therefore, alternative sources of L-ASNase may be useful to reduce toxicity and enhance efficacy. The yeast Saccharomyces cerevisiae has the ASP1 gene responsible for encoding L-asparaginase 1 (ScASNase1), an enzyme predicted as type II, like bacterial therapeutic isoforms, but it has been poorly studied. Here we characterised ScASNase1 using a recombinant enzyme purified by affinity chromatography. ScASNase1 has specific activity of 196.2 U/mg and allosteric behaviour, like type I enzymes, but with a low K0.5 = 75 μM like therapeutic type II. We showed through site-directed mutagenesis that the T64-Y78-T141-K215 residues are involved in catalysis. Furthermore, ScASNase1 showed cytotoxicity for the MOLT-4 leukemic cell lineage. Our data show that ScASNase1 has characteristics described for the two subfamilies of l-asparaginase, types I and II, and may have promising antineoplastic properties.
Collapse
Affiliation(s)
- Iris Munhoz Costa
- Department of Biochemical and Pharmaceutical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo/SP 05508-000, Brazil
| | - Leonardo Schultz
- Biosciences Institute, São Paulo State University - UNESP, Coastal Campus, São Vicente/SP 11330-900, Brazil
| | - Beatriz de Araujo Bianchi Pedra
- Department of Biochemical and Pharmaceutical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo/SP 05508-000, Brazil
| | - Mariana Silva Moreira Leite
- Department of Biochemical and Pharmaceutical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo/SP 05508-000, Brazil
| | - Sandra H P Farsky
- Department of Clinical and Toxicological Analysis School of Pharmaceutical Sciences, University of São Paulo, São Paulo/SP 05508-000, Brazil
| | - Marcos Antonio de Oliveira
- Biosciences Institute, São Paulo State University - UNESP, Coastal Campus, São Vicente/SP 11330-900, Brazil
| | - Adalberto Pessoa
- Department of Biochemical and Pharmaceutical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo/SP 05508-000, Brazil
| | - Gisele Monteiro
- Department of Biochemical and Pharmaceutical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo/SP 05508-000, Brazil
| |
Collapse
|
6
|
Shen Y, Wang XL, Wang B, Shao JG, Liu YM, Qin Y, Wang LJ, Qin G. Survival Benefits With Artificial Liver Support System for Acute-on-Chronic Liver Failure: A Time Series-Based Meta-Analysis. Medicine (Baltimore) 2016; 95:e2506. [PMID: 26817889 PMCID: PMC4998263 DOI: 10.1097/md.0000000000002506] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The artificial liver support system (ALSS) offers the potential to improve the prognosis of patients with acute-on-chronic liver failure (ACLF). However, the literature has been inconsistent on its survival benefits. We aimed to conduct a time series-based meta-analysis of randomized clinical trials (RCTs) and observational studies which examined differences in mortality in ACLF patients treated with ALSS or not.MEDLINE, EMBASE, OVID, and COCHRANE library database were systemically searched up to December 2014. Quality of included studies was evaluated using the Jadad score. The outcome measure was mortality at different follow-up endpoints. Odds ratios (ORs) and survival curve data were pooled for analysis.Ten studies, 7 RCTs, and 3 controlled cohorts were enrolled, involving a total of 1682 ACLF patients, among whom 842 were treated with ALSS. ALSS was found to reduce the risk of short-term (1-month and 3-month) mortality for patients with ACLF by nearly 30%. Randomized trials and observational studies provided good internal and external validity respectively. The combined Kaplan-Meier curves showed a consistent pattern of findings. Meta-analysis also suggested that ALSS might reduce medium-term (6-month and 1-year) mortality risk by 30% and long-term (3-year) mortality risk by 50% in ACLF patients.ALSS therapy could reduce short-term mortality in patients with ACLF. Meanwhile, its impacts on medium- and long-term survival seem to be promising but remained inconclusive. Clinical utility of this system for survival benefit may be implied.
Collapse
Affiliation(s)
- Yi Shen
- From the Department of Epidemiology and Medical Statistics (YS, X-LW, Y-ML); Center for Liver Diseases, Nantong Third People's Hospital, Nantong University, China (BW, J-GS, L-JW, GQ); and Department of Internal Medicine, Singapore General Hospital, Singapore (YQ)
| | | | | | | | | | | | | | | |
Collapse
|
7
|
Anishkin A, Vanegas JM, Rogers DM, Lorenzi PL, Chan WK, Purwaha P, Weinstein JN, Sukharev S, Rempe SB. Catalytic Role of the Substrate Defines Specificity of Therapeutic l-Asparaginase. J Mol Biol 2015; 427:2867-85. [DOI: 10.1016/j.jmb.2015.06.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 05/20/2015] [Accepted: 06/26/2015] [Indexed: 12/23/2022]
|
8
|
Bjerring PN, Hauerberg J, Frederiksen HJ, Nielsen HB, Clemmesen JO, Larsen FS. The effect of fractionated plasma separation and adsorption on cerebral amino acid metabolism and oxidative metabolism during acute liver failure. J Hepatol 2012; 57:774-9. [PMID: 22691571 DOI: 10.1016/j.jhep.2012.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 05/21/2012] [Accepted: 06/04/2012] [Indexed: 01/13/2023]
Abstract
BACKGROUND & AIMS Patients with acute liver failure have a disturbed amino acid metabolism and a compromised oxidative metabolism in the brain. A limited number of clinically neuroprotective interventions are available. This study aimed at assessing the effect of fractionated plasma separation and adsorption (FPSA), an extracorporeal liver support system, on cerebral amino acids and lactate to pyruvate ratio. METHODS Seven patients with acute liver failure and high risk of intracranial hypertension were included for cerebral microdialysis and intracranial pressure monitoring. Microdialysate, arterial blood, and venous blood from the jugular bulb were sampled, before and after an FPSA session, and the content of nineteen amino acids, lactate, and pyruvate was determined. RESULTS The total amino acid concentration in arterial plasma was not significantly reduced by FPSA (11.2 mM (3.0-26.0 mM) vs. 9.7 mM (2.7-13.6 mM); median with range). The total amino acid content in the microdialysate was 5.6 mM both before and after FPSA and no change in glutamine content was observed in plasma or microdialysate. The content of aromatic amino acids in arterial plasma, but not in microdialysate, was marginally reduced (p<0.05). Arterial lactate concentration and lactate to pyruvate ratio in the microdialysate did not change following FPSA. CONCLUSIONS One single treatment session with FPSA had a marginal effect on plasma amino acid composition. We found minimal changes in the amino acids content in the microdialysate, and the lactate to pyruvate ratio was unaffected.
Collapse
|
9
|
Kribben A, Gerken G, Haag S, Herget-Rosenthal S, Treichel U, Betz C, Sarrazin C, Hoste E, Van Vlierberghe H, Escorsell A, Hafer C, Schreiner O, Galle PR, Mancini E, Caraceni P, Karvellas CJ, Salmhofer H, Knotek M, Ginès P, Kozik-Jaromin J, Rifai K. Effects of fractionated plasma separation and adsorption on survival in patients with acute-on-chronic liver failure. Gastroenterology 2012; 142:782-789.e3. [PMID: 22248661 DOI: 10.1053/j.gastro.2011.12.056] [Citation(s) in RCA: 245] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 12/15/2011] [Accepted: 12/29/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Fractionated plasma separation and adsorption (FPSA) is an extracorporeal procedure that supports liver function by removing endogenous toxins that cause complications from acute-on-chronic liver failure (AOCLF). We performed a randomized trial to investigate survival of patients with AOCLF treated with FPSA. METHODS Patients with AOCLF were randomly assigned to groups given a combination of FPSA and standard medical therapy (SMT) (FPSA group, n = 77) or only SMT (SMT group, n = 68). The Prometheus liver support system was used to provide 8 to 11 rounds of FPSA (minimum of 4 hours each) for 3 weeks. Primary end points were survival probabilities at days 28 and 90, irrespective of liver transplantation. RESULTS Baseline clinical parameters and number of transplant patients were similar between study arms. Serum bilirubin level decreased significantly in the FPSA group but not in the SMT group. In an intention-to-treat analysis, the probabilities of survival on day 28 were 66% in the FPSA group and 63% in the SMT group (P = .70); on day 90, they were 47% and 38%, respectively (P = .35). Baseline factors independently associated with poor prognosis were high SOFA score, bleeding, female sex, spontaneous bacterial peritonitis, intermediate increases in serum creatinine concentration, and combination of alcoholic and viral etiology of liver disease. There were no differences between the 2 groups in the incidence of side effects. CONCLUSIONS Among all patients with AOCLF, extracorporeal liver support with FPSA does not increase the probability of survival. Further studies are needed to assess whether therapy might be beneficial in specific subsets of patients.
Collapse
Affiliation(s)
- Andreas Kribben
- Department of Nephrology, University Duisburg-Essen, Essen, Germany.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Abstract
In this Editor's Review, articles published in 2010 are organized by category and briefly summarized. As the official journal of The International Federation for Artificial Organs, The International Faculty for Artificial Organs, and the International Society for Rotary Blood Pumps, Artificial Organs continues in the original mission of its founders "to foster communications in the field of artificial organs on an international level."Artificial Organs continues to publish developments and clinical applications of artificial organ technologies in this broad and expanding field of organ Replacement, Recovery, and Regeneration from all over the world. We take this time also to express our gratitude to our authors for offering their work to this journal. We offer our very special thanks to our reviewers who give so generously of time and expertise to review, critique, and especially provide such meaningful suggestions to the author's work whether eventually accepted or rejected and especially to those whose native tongue is not English. Without these excellent and dedicated reviewers the quality expected from such a journal could not be possible. We also express our special thanks to our Publisher, Wiley-Blackwell, for their expert attention and support in the production and marketing of Artificial Organs. In this Editor's Review, that historically has been widely received by our readership, we aim to provide a brief reflection of the currently available worldwide knowledge that is intended to advance and better human life while providing insight for continued application of technologies and methods of organ Replacement, Recovery, and Regeneration. We look forward to recording further advances in the coming years.
Collapse
|