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Lu H, Zhang H, Wu Z, Li L. Microbiota-gut-liver-brain axis and hepatic encephalopathy. MICROBIOME RESEARCH REPORTS 2024; 3:17. [PMID: 38841407 PMCID: PMC11149093 DOI: 10.20517/mrr.2023.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 01/16/2024] [Accepted: 01/19/2024] [Indexed: 06/07/2024]
Abstract
Hepatic encephalopathy (HE) is a clinical manifestation of neurological and psychiatric abnormalities that are caused by complications of liver dysfunction including hyperammonemia, hyperuricemia, and portal hypertension. Accumulating evidence suggests that HE could be reversed through therapeutic modifications of gut microbiota. Multiple preclinical and clinical studies have indicated that gut microbiome affects the physiological function of the liver, such as the regulation of metabolism, secretion, and immunity, through the gut-liver crosstalk. In addition, gut microbiota also influences the brain through the gut-brain crosstalk, altering its physiological functions including the regulation of the immune, neuroendocrine, and vagal pathways. Thus, key molecules that are involved in the microbiota-gut-liver-brain axis might be able to serve as clinical biomarkers for early diagnosis of HE, and could be effective therapeutic targets for clinical interventions. In this review, we summarize the pathophysiology of HE and further propose approaches modulating the microbiota-gut-liver-brain axis in order to provide a comprehensive understanding of the prevention and potential clinical treatment for HE with a microbiota-targeted therapy.
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Affiliation(s)
| | | | | | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang, China
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Ye Q, Yan Y, Li L. Letter: de novo infection in hepatic encephalopathy-the culprit or the victim? Aliment Pharmacol Ther 2022; 55:1230. [PMID: 35429029 DOI: 10.1111/apt.16855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Qiaoxia Ye
- The 910th Hospital of Chinese People's Liberation Army, Quanzhou, China
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Quality of life as a therapeutic objective in the management of hepatic encephalopathy and the potential role of rifaximin-α. Eur J Gastroenterol Hepatol 2021; 33:e1032-e1038. [PMID: 34402475 PMCID: PMC8734632 DOI: 10.1097/meg.0000000000002273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Quality of life (QoL) is impaired in patients with hepatic encephalopathy and rifaximin-α can improve QoL within 6 months. This study assessed the importance of QoL as a therapeutic objective in hepatic encephalopathy management; whether QoL is routinely assessed in hepatic encephalopathy patients in clinical practice and the role of rifaximin-α in this context. METHODS A survey was conducted of healthcare professionals (HCPs) from Europe and Australia involved in hepatic encephalopathy management. HCPs rated the importance of a range of therapeutic objectives on a 1-7 Likert scale (1 = not at all important; 7 = extremely important). HCPs were also required to provide three patient record forms (PRFs) based on their last three hepatic encephalopathy patients. RESULTS There were 218 HCP respondents, who provided 654 PRFs (patients treated with rifaximin-α, n = 347; patients not treated with rifaximin-α, n = 307). The mean Likert score was highest for the therapeutic objective 'improving a patient's QoL' (6.4), which was rated significantly more highly than all other therapeutic objectives, including 'reducing the patient's likelihood of hospital readmission' (6.1; P < 0.001) and 'preventing death of the patient' (6.1; P < 0.001). Despite this, only 28.3% of PRFs documented specific QoL data assessment. Patients receiving rifaximin-α were treated later in their disease course than those not receiving rifaximin-α. CONCLUSIONS HCPs consider QoL improvement the main therapeutic objective in hepatic encephalopathy management, but most do not explicitly assess QoL. Earlier introduction of rifaximin-α may safeguard QoL improvement even when QoL monitoring is not possible.
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Timmer C, Davids M, Nieuwdorp M, Levels JHM, Langendonk JG, Breederveld M, Ahmadi Mozafari N, Langeveld M. Differences in faecal microbiome composition between adult patients with UCD and PKU and healthy control subjects. Mol Genet Metab Rep 2021; 29:100794. [PMID: 34527515 PMCID: PMC8433284 DOI: 10.1016/j.ymgmr.2021.100794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 08/19/2021] [Indexed: 01/07/2023] Open
Abstract
Urea cycle disorders (UCDs) are a group of rare inherited metabolic diseases causing hyperammonemic encephalopathy. Despite intensive dietary and pharmacological therapy, outcome is poor in a subset of UCD patients. Reducing ammonia production by changing faecal microbiome in UCD is an attractive treatment approach. We compared faecal microbiome composition of 10 UCD patients, 10 healthy control subjects and 10 phenylketonuria (PKU) patients. PKU patients on a low protein diet were included to differentiate between the effect of a low protein diet and the UCD itself on microbial composition. Participants were asked to collect a faecal sample and to fill out a 24 h dietary journal. DNA was extracted from faecal material, taxonomy was assigned and microbiome data was analyzed, with a focus on microbiota involved in ammonia metabolism.In this study we show an altered faecal microbiome in UCD patients, different from both PKU and healthy controls. UCD patients on dietary and pharmacological treatment had a less diverse faecal microbiome, and the faecal microbiome of PKU patients on a protein restricted diet with amino acid supplementation showed reduced richness compared to healthy adults without a specific diet. The differences in the microbiome composition of UCD patients compared to healthy controls were in part related to lactulose use. Other genomic process encodings involved in ammonia metabolism, did not seem to differ. Since manipulation of the microbiome is possible, this could be a potential treatment modality. We propose as a first next step, to study the impact of these faecal microbiome alterations on metabolic stability. TAKE HOME MESSAGE The faecal microbiome of UCD patients was less diverse compared to PKU patients and even more compared to healthy controls.
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Key Words
- 16S rRNA, taxonomic marker genes, common to all bacteria
- ADI, Arginine Deimination. Bacteria derive energy from the deamination of arginine to citrulline and citrulline cleavage to ornithine plus carbamoyl phosphate. The latter is then converted into ATP and carbon dioxide, or used for pyrimidine biosynthesis. This route also generates two moles of ammonia (one from the arginine-citrulline conversion, the second from carbamoyl phosphate hydrolysis)
- ARG1d, arginase 1 (ARG1) deficiency
- ASLd, argininosuccinate lyase (ASL) deficiency
- ASSd, argininosuccinate synthetase (ASS) deficiency
- ASV, Amplified Sequence Variant. A specific nucleotide sequence representing a bacterial lineage
- Alpha Diversity, the species diversity in a microbial sample. Used to represent the taxonomic diversities of individual samples
- Ammonium scavengers, agents developed for the reduction of blood ammonia concentration used for the treatment of patients with urea cycle disorders. Sodiumbenzoate and phenylbutyrate are ammonium scavengers
- BCAA, branched chain amino acids: isoleucine, leucine and valine
- DEGs, differentially expressed genes
- DESeq, an R package to analyse count data from high-throughput sequencing assays such as RNA-Seq and test for differential expression
- EAA supplement, essential amino acids supplement containing L-histidine, L-isoleucine, L-leucine, l-lysine, L-methionine, L-phenylalanine, L-threonine, L-tryptofaan and L-valine with optional L-cystine and L-tyrosine added (depending on what product is used)
- FPD, Faiths Phylogenetic Diversity, alpha diversity metric accounting for genetic diversity
- Faecal
- Genus, a taxonomic rank
- Gut
- Hyperammonemia
- Metagenome, microbiome collective genome
- Microbiome
- OTCd, ornithine transcarbamylase deficiency
- PCoA, Principal Coordinate Analysis. PCoA is aimed at graphically representing a resemblance matrix between p elements (individuals, variables, objects, among others). By using PCoA we can visualize individual and/or group differences. Individual differences can be used to show outliers
- PFAA, precursor free amino acid supplement, in this case phenylalanine free
- PKU, Phenylketonuria
- Phenylketonuria
- Proteolytic capacity, the capacity to break proteins down into smaller polypeptides or amino acids. In this study: enzymes involved in protein degradation
- RT-qPCR, real-time quantitative polymerase chain reaction
- Sodium BPA, sodium phenylbutyrate
- UCD, urea cycle defect
- Urea cycle defect
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Affiliation(s)
- C Timmer
- Department of Dietetics and Nutritional science and Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - M Davids
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - M Nieuwdorp
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - J H M Levels
- Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - J G Langendonk
- Department of Dietetics and Department of Internal Medicine, Center of Lysosomal and Metabolic Diseases, Erasmus University Medical Center, Erasmus MC, Rotterdam, the Netherlands
| | - M Breederveld
- Department of Dietetics and Department of Internal Medicine, Center of Lysosomal and Metabolic Diseases, Erasmus University Medical Center, Erasmus MC, Rotterdam, the Netherlands
| | - N Ahmadi Mozafari
- Department of Dietetics and Department of Internal Medicine, Center of Lysosomal and Metabolic Diseases, Erasmus University Medical Center, Erasmus MC, Rotterdam, the Netherlands
| | - M Langeveld
- Department of Dietetics and Nutritional science and Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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Wallon G, Guth C, Guichon C, Thevenon S, Gazon M, Viale JP, Schoeffler M, Duperret S, Aubrun F. Extracorporeal Albumin Dialysis in Liver Failure with MARS and SPAD: A Randomized Crossover Trial. Blood Purif 2021; 51:243-250. [PMID: 34139706 DOI: 10.1159/000515825] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/11/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Liver failure is associated with hepatic and extrahepatic organ failure leading to a high short-term mortality rate. Extracorporeal albumin dialysis (ECAD) aims to reduce albumin-bound toxins accumulated during liver failure. ECAD detoxifies blood using albumin dialysis through an artificial semipermeable membrane with recirculation (molecular adsorbent recirculating system, MARS) or without (single-pass albumin dialysis, SPAD). METHODS We performed a randomized crossover open trial in a surgical intensive care unit. The primary outcome of the study was total bilirubin reduction during MARS and during SPAD therapies. The secondary outcomes were conjugated bilirubin and bile acid level reduction during MARS and SPAD sessions and tolerance of dialysis system devices. Inclusion criteria were adult patients presenting liver failure with factor V activity <50% associated with bilirubin ≥250 μmol/L and a complication (either hepatic encephalopathy, severe pruritus, or hepatorenal syndrome). For MARS and SPAD, the dialysis flow rate was equal to 1,000 mL/h. RESULTS Twenty crossovers have been performed. Baseline biochemical characteristics (bilirubin, ammonia, bile acids, creatinine, and urea) were not statistically different between MARS and SPAD. Both ECAD have led to a significant reduction in total bilirubin (-83 ± 67 μmol/L after MARS; -122 ± 118 μmol/L after SPAD session), conjugated bilirubin (-82 ± 61 μmol/L after MARS; -105 ± 96 μmol/L after SPAD session), and bile acid levels (-64 ± 75 μmol/L after MARS; -56 ± 56 μmol/L after SPAD session), all nondifferent comparing MARS to SPAD. CONCLUSION A simple-to-perform SPAD therapy with equal to MARS dialysate flow parameters provides the same efficacy in bilirubin and bile acid removal. However, clinically relevant endpoints have to be evaluated in randomized trials to compare MARS and SPAD therapies and to define the place of SPAD in the liver failure care program.
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Affiliation(s)
- Grégoire Wallon
- Département d'Anesthésie-Réanimation, Centre Léon Bérard, Lyon, France
| | - Cécile Guth
- Département d'Anesthésie-Réanimation, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Céline Guichon
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Sylvie Thevenon
- Centre de Recherche Clinique, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Mathieu Gazon
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Jean-Paul Viale
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Mathieu Schoeffler
- Département d'Anesthésie-Réanimation, Centre Hospitalier de Montélimar, Montélimar, France
| | - Serge Duperret
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Frédéric Aubrun
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
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Gut Microbiota at the Intersection of Alcohol, Brain, and the Liver. J Clin Med 2021; 10:jcm10030541. [PMID: 33540624 PMCID: PMC7867253 DOI: 10.3390/jcm10030541] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/20/2021] [Accepted: 01/26/2021] [Indexed: 12/12/2022] Open
Abstract
Over the last decade, increased research into the cognizance of the gut-liver-brain axis in medicine has yielded powerful evidence suggesting a strong association between alcoholic liver diseases (ALD) and the brain, including hepatic encephalopathy or other similar brain disorders. In the gut-brain axis, chronic, alcohol-drinking-induced, low-grade systemic inflammation is suggested to be the main pathophysiology of cognitive dysfunctions in patients with ALD. However, the role of gut microbiota and its metabolites have remained unclear. Eubiosis of the gut microbiome is crucial as dysbiosis between autochthonous bacteria and pathobionts leads to intestinal insult, liver injury, and neuroinflammation. Restoring dysbiosis using modulating factors such as alcohol abstinence, promoting commensal bacterial abundance, maintaining short-chain fatty acids in the gut, or vagus nerve stimulation could be beneficial in alleviating disease progression. In this review, we summarize the pathogenic mechanisms linked with the gut-liver-brain axis in the development and progression of brain disorders associated with ALD in both experimental models and humans. Further, we discuss the therapeutic potential and future research directions as they relate to the gut-liver-brain axis.
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Jin X, Chen D, Wu F, Zhang L, Huang Y, Lin Z, Wang X, Wang R, Xu L, Chen Y. Hydrogen Sulfide Protects Against Ammonia-Induced Neurotoxicity Through Activation of Nrf2/ARE Signaling in Astrocytic Model of Hepatic Encephalopathy. Front Cell Neurosci 2020; 14:573422. [PMID: 33192318 PMCID: PMC7642620 DOI: 10.3389/fncel.2020.573422] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/15/2020] [Indexed: 12/13/2022] Open
Abstract
Objective: Hepatic encephalopathy (HE) characterized by neuropsychiatric abnormalities is a major complication of cirrhosis with high mortality. However, the pathogenesis of HE has not been fully elucidated. This study aimed to determine endogenous hydrogen sulfide (H2S) in the blood of HE patients and investigate the role of H2S in an astrocytic model of HE. Methods: Patients with and without HE were recruited to determine plasma H2S levels and blood microbial 16S rRNA gene. Rat astrocytes were employed as a model of HE by treatment of NH4Cl. Exogenous H2S was preadded. Cell viability was measured by Cell Counting Kit-8 (CCK-8) assay, and cell death was evaluated by lactate dehydrogenase (LDH) release. Apoptosis was determined by Hoechst 33342/Propidium Iodide (PI) Double Staining and Western blot analysis of apoptosis-related protein expression. Intracellular reactive oxygen species (ROS) levels were assessed by flow cytometer. Expressions of Nrf2 and its downstream regulated genes were examined by immunofluorescence staining and Western blot, respectively. Nrf2 gene knockdown was performed by antisense shRNA of Nrf2 gene. Results: There was a significant decrease in H2S levels in cirrhotic patients with HE compared with without HE. Blood microbiota analyses revealed that certain strains associated with H2S production were negatively correlated with HE. In vitro, H2S markedly attenuated NH4Cl-induced cytotoxicity, oxidative stress, and apoptosis. This effect was mediated by Nrf2/ARE signaling, and knockdown of Nrf2 expression abolished the antagonistic effect of H2S on NH4Cl-induced neurotoxicity in astrocytes. Conclusion: Levels of H2S and bacteria associated with H2S production are decreased in HE, and H2S functions as the neuroprotector against NH4Cl-induced HE by activating Nrf2/ARE signaling of astrocytes.
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Affiliation(s)
- Xiaozhi Jin
- Department of Infectious Diseases, Wenzhou Key Laboratory of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Hepatology Institute of Wenzhou Medical University, Zhejiang Provincial Key Laboratory for Accurate Diagnosis and Treatment of Chronic Liver Diseases, Wenzhou, China
| | - Dazhi Chen
- Department of Gastroenterology, The First Hospital of Peking University, Beijing, China
| | - Faling Wu
- Department of Infectious Diseases, Wenzhou Key Laboratory of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Hepatology Institute of Wenzhou Medical University, Zhejiang Provincial Key Laboratory for Accurate Diagnosis and Treatment of Chronic Liver Diseases, Wenzhou, China
| | - Lei Zhang
- Department of Infectious Diseases, Wenzhou Key Laboratory of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Hepatology Institute of Wenzhou Medical University, Zhejiang Provincial Key Laboratory for Accurate Diagnosis and Treatment of Chronic Liver Diseases, Wenzhou, China
| | - Yu Huang
- Department of Infectious Diseases, Wenzhou Key Laboratory of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Hepatology Institute of Wenzhou Medical University, Zhejiang Provincial Key Laboratory for Accurate Diagnosis and Treatment of Chronic Liver Diseases, Wenzhou, China
| | - Zhuo Lin
- Department of Infectious Diseases, Wenzhou Key Laboratory of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Hepatology Institute of Wenzhou Medical University, Zhejiang Provincial Key Laboratory for Accurate Diagnosis and Treatment of Chronic Liver Diseases, Wenzhou, China
| | - Xiaodong Wang
- Department of Infectious Diseases, Wenzhou Key Laboratory of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Hepatology Institute of Wenzhou Medical University, Zhejiang Provincial Key Laboratory for Accurate Diagnosis and Treatment of Chronic Liver Diseases, Wenzhou, China
| | - Rui Wang
- Department of Infectious Diseases, Wenzhou Key Laboratory of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Hepatology Institute of Wenzhou Medical University, Zhejiang Provincial Key Laboratory for Accurate Diagnosis and Treatment of Chronic Liver Diseases, Wenzhou, China
| | - Lanman Xu
- Department of Infectious Diseases and Liver Diseases, Ningbo Medical Center Lihuili Hospital, Ningbo, China.,Department of Infectious Diseases and Liver Diseases, The Affiliated Lihuili Hospital of Ningbo University, Ningbo, China
| | - Yongping Chen
- Department of Infectious Diseases, Wenzhou Key Laboratory of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Hepatology Institute of Wenzhou Medical University, Zhejiang Provincial Key Laboratory for Accurate Diagnosis and Treatment of Chronic Liver Diseases, Wenzhou, China
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Sepehrinezhad A, Zarifkar A, Namvar G, Shahbazi A, Williams R. Astrocyte swelling in hepatic encephalopathy: molecular perspective of cytotoxic edema. Metab Brain Dis 2020; 35:559-578. [PMID: 32146658 DOI: 10.1007/s11011-020-00549-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 02/12/2020] [Indexed: 02/06/2023]
Abstract
Hepatic encephalopathy (HE) may occur in patients with liver failure. The most critical pathophysiologic mechanism of HE is cerebral edema following systemic hyperammonemia. The dysfunctional liver cannot eliminate circulatory ammonia, so its plasma and brain levels rise sharply. Astrocytes, the only cells that are responsible for ammonia detoxification in the brain, are dynamic cells with unique phenotypic properties that enable them to respond to small changes in their environment. Any pathological changes in astrocytes may cause neurological disturbances such as HE. Astrocyte swelling is the leading cause of cerebral edema, which may cause brain herniation and death by increasing intracranial pressure. Various factors may have a role in astrocyte swelling. However, the exact molecular mechanism of astrocyte swelling is not fully understood. This article discusses the possible mechanisms of astrocyte swelling which related to hyperammonia, including the possible roles of molecules like glutamine, lactate, aquaporin-4 water channel, 18 KDa translocator protein, glial fibrillary acidic protein, alanine, glutathione, toll-like receptor 4, epidermal growth factor receptor, glutamate, and manganese, as well as inflammation, oxidative stress, mitochondrial permeability transition, ATP depletion, and astrocyte senescence. All these agents and factors may be targeted in therapeutic approaches to HE.
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Affiliation(s)
- Ali Sepehrinezhad
- Department of Neuroscience, Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Asadollah Zarifkar
- Shiraz Neuroscience Research Center and Department of Physiology, Shiraz University of Medical Sciences (SUMS), Shiraz, Iran
| | - Gholamreza Namvar
- Department of Neuroscience and Cognition, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Shahbazi
- Department of Neuroscience, Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran.
- Cellular and Molecular Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran.
| | - Roger Williams
- The Institute of Hepatology London and Foundation for Liver Research, 111 Coldharbour Lane, London, SE5 9NT, UK.
- Faculty of Life Sciences & Medicine, King's College London, London, UK.
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Abstract
A consolidated overview of evidence for the effectiveness and safety/tolerability of hepatic encephalopathy (HE) treatment over the long term is currently lacking. We identified and assessed published evidence for the long-term (≥6 months) pharmacological management of HE with lactulose and/or rifaximin. A literature search was conducted in PubMed (cutoff date 05 March 2018) using the search terms 'hepatic encephalopathy+rifaximin' and 'hepatic encephalopathy+lactulose'. All articles containing primary clinical data were manually assessed to identify studies in which long-term (≥6 months) effectiveness and/or safety/tolerability end points were reported for lactulose and/or rifaximin. Long-term effectiveness outcomes were reported in eight articles for treatment with lactulose alone and 19 articles for treatment with rifaximin, alone or in combination with lactulose. Long-term safety/tolerability outcomes were reported in six articles for treatment with lactulose alone and nine articles for treatment with rifaximin, alone or in combination with lactulose. These studies showed that lactulose is effective for the prevention of overt HE recurrence over the long term and that the addition of rifaximin to lactulose significantly reduces the risk of overt HE recurrence and HE-related hospitalization, compared with lactulose therapy alone, without compromising tolerability. Current evidence therefore supports recommendations for the use of lactulose therapy for the prevention of overt HE recurrence over the long term, and for the additional benefit of adding rifaximin to lactulose therapy. Addition of rifaximin to standard lactulose therapy may result in substantial reductions in healthcare resource utilization over the long term, by reducing overt HE recurrence and associated rehospitalization.
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Clayton M. Hepatic encephalopathy: causes and health-related burden. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2018; 27:S4-S6. [PMID: 29411993 DOI: 10.12968/bjon.2018.27.sup3.s4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Patients with cirrhosis are at risk of hepatic encephalopathy (HE). While its pathogenesis is not fully understood, the circulation of increased levels of ammonia through the bloodstream to the brain is thought to be a key causative factor. The ammonia penetrates the blood-brain barrier, ultimately leading to cerebral oedema. This can result in cognitive impairments, which can exhibit in multiple ways, adversely affecting quality of life for both patients and their families. The need for hospitalisation and longer hospital stays associated with HE has cost implications for the health service. Treatment revolves around the reduction of ammonia levels in the bloodstream.
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Affiliation(s)
- Michelle Clayton
- Lecturer in Liver Care, School of Healthcare, University of Leeds and Liver Nurse Educator, Leeds Liver Unit, St James's University Hospital, Leeds
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Krag A, Schuchmann M, Sodatonou H, Pilot J, Whitehouse J, Strasser SI, Hudson M. Design of the Prospective Real-world Outcomes Study of hepatic encephalopathy Patients' Experience on Rifaximin-α (PROSPER): an observational study among 550 patients. HEPATOLOGY, MEDICINE AND POLICY 2018; 3:4. [PMID: 30288327 PMCID: PMC5918574 DOI: 10.1186/s41124-017-0029-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 12/19/2017] [Indexed: 12/16/2022]
Abstract
Background Hepatic encephalopathy (HE) is one of the most important severe complications of liver cirrhosis. Thought to be caused by elevated blood levels of gut-derived neurotoxins (particularly ammonia) entering the brain, HE manifests as a wide range of neurological or psychiatric abnormalities, which increase the risk of mortality, result in substantial morbidity and negatively affect the quality of life (QoL) of both patients and their caregivers. HE is also associated with a substantial economic burden. Rifaximin-α 550 mg is a locally acting oral antibiotic that reduces the effects of ammonia-producing intestinal flora, and which is used to help reduce the recurrence of overt HE. The efficacy of rifaximin-α 550 mg was established in a randomised controlled trial and long-term extension study. However, ‘real-world’ evidence is also required to assess how this efficacy may translate into effectiveness in clinical practice, including the potential impact of treatment on healthcare resource utilisation. Methods The Prospective Real-world Outcomes Study of HE Patients’ Experience on Rifaximin-α 550 mg (PROSPER) is a multinational, multicentre, observational study that will be conducted under real-world clinical practice conditions. Comprising a retrospective phase (up to 12 months) and a prospective phase (up to 24 months), and employing a robust statistical methodology, PROSPER has been specifically designed to minimise the bias associated with observational studies. The primary endpoint will be the effect of rifaximin-α 550 mg treatment on HE- and liver-related hospitalisation rate and duration of hospitalisation. Secondary endpoints will include comprehensive assessments of the impact of treatment on the QoL and workplace productivity of patients and caregivers, a global assessment of treatment effectiveness and safety/tolerability. Approximately 550 patients will be enrolled. Conclusions PROSPER will provide valuable real-world information on the effectiveness of rifaximin-α 550 mg in reducing the recurrence of HE, and its impact on the QoL and work productivity of patients and their caregivers. By providing data on both the direct costs (e.g., hospitalisation rate, duration of hospitalisation) and indirect costs (such as work productivity) of HE, PROSPER should help confirm whether rifaximin-α 550 mg treatment represents a good use of economic resources. Trial registration ClinicalTrials.gov identifier NCT02488993.
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Affiliation(s)
- Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Marcus Schuchmann
- Department of Internal Medicine, Constance Medical Centre, Constance, Germany
| | - Hanna Sodatonou
- 3Norgine Ltd Clinical Development & Medical Affairs, Harefield, UK
| | - Jeff Pilot
- 3Norgine Ltd Clinical Development & Medical Affairs, Harefield, UK
| | | | - Simone I Strasser
- 5AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia
| | - Mark Hudson
- Liver Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust and Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Novel Indications for Fecal Microbial Transplantation: Update and Review of the Literature. Dig Dis Sci 2017; 62:1131-1145. [PMID: 28315032 DOI: 10.1007/s10620-017-4535-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 03/08/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Fecal microbial transplantation (FMT) is an established successful treatment modality for recurrent Clostridium difficile infection (CDI). The safety profile and potential therapeutic advantages of FMT for diseases associated with dysbiosis and immune dysfunction have led to many publications, mainly case series, and while many studies and reviews have been published on the use of FMT for inflammatory bowel disease (IBD), its potential use for other disease conditions has not been thoroughly reviewed. The aim of this review was to investigate the evidence surrounding the use of FMT in conditions other than IBD and CDI. METHODS A PubMed search was performed using the terms "Fecal microbiota transplantation" OR "FMT" OR "Bacteriotherapy." RESULTS A total of 26 articles describing the use of FMT in a variety of both intra-and extraintestinal disease conditions including gastrointestinal, hematologic, neurologic, metabolic, infectious, and autoimmune disorders have been included in this review and have demonstrated some positive results. The studies included were case reports, case series, controlled trials, and cohort studies. CONCLUSIONS The findings of these studies demonstrate that FMT, particularly in conditions associated with gastrointestinal dysbiosis, shows promise to provide another effective tool in the therapeutic armament of the practicing physician. FMT was found to be possibly effective in various diseases, mostly associated with enteric dysbiosis or with immune dysfunction. Randomized clinical studies on large populations should be performed to explore the effectiveness of this therapy, and basic research studies should be designed to gain understanding of the mechanisms through which impact these disorders.
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Souto PA, Marcotegui AR, Orbea L, Skerl J, Perazzo JC. Hepatic encephalopathy: Ever closer to its big bang. World J Gastroenterol 2016; 22:9251-9256. [PMID: 27895414 PMCID: PMC5107690 DOI: 10.3748/wjg.v22.i42.9251] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 09/15/2016] [Accepted: 10/19/2016] [Indexed: 02/06/2023] Open
Abstract
Hepatic encephalopathy (HE) is a neuropsychiatric disorder that commonly complicates the course of patients with liver disease. Despite the fact that the syndrome was probably first recognized hundreds of years ago, the exact pathogenesis still remains unclear. Minimal hepatic encephalopathy (MHE) is the earliest form of HE and is estimated to affect more that 75% of patients with liver cirrhosis. It is characterized by cognitive impairment predominantly attention, reactiveness and integrative function with very subtle clinical manifestations. The development of MHE is associated with worsen in driving skills, daily activities and the increase of overall mortality. Skeletal muscle has the ability to shift from ammonia producer to ammonia detoxifying organ. Due to its large size, becomes the main ammonia detoxifying organ in case of chronic liver failure and muscular glutamine-synthase becomes important due to the failing liver and brain metabolic activity. Gut is the major glutamine consumer and ammonia producer organ in the body. Hepatocellular dysfunction due to liver disease, results in an impaired clearance of ammonium and in its inter-organ trafficking. Intestinal bacteria, can also represent an extra source of ammonia production and in cirrhosis, small intestinal bacterial overgrowth and symbiosis can be observed. In the study of HE, to get close to MHE is to get closer to its big bang; and from here, to travel less transited roads such as skeletal muscle and intestine, is to go even closer. The aim of this editorial is to expose this road for further and deeper work.
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Kovács DÁ, Al Huurman V, Wojcicki M, Soonowala D, Baranski A. Excessively Long Duodenum of the Pancreatic Graft Segment as a Rare Cause of Hyperammonemia After Simultaneous Pancreas-Kidney Transplant. EXP CLIN TRANSPLANT 2016; 16:499-501. [PMID: 27447174 DOI: 10.6002/ect.2016.0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Simultaneous pancreas-kidney transplant is currently standard therapy to achieve long-term insulin-free euglycemia in patients with type 1 diabetes mellitus and concomitant end-stage kidney failure. A patient with symptoms of encephalopathy caused by hyperammonemia and with new-onset iron deficiency anemia was admitted to our institution 20 months after a simultaneous pancreas-kidney transplant. Detailed screening did not reveal any specific cause for the hyperammonemia, and despite standard treatment, hyperammonemia did not resolve. An abdominal computed tomographic scan was performed, which showed a distended duodenal segment of the pancreas graft. This was confirmed during exploratory laparotomy when the anastomosis between duodenum and ileum was dismantled and found not to be stenotic. The excessively long stumps of the duodenum were then dissected and shortened, and a new anastomosis between graft-duodenum and recipient-ileum was created. The operation was followed by an uncomplicated postoperative course in which the serum ammonia normalized on the first postoperative day and remained normal afterwards. An excessively long segment of the duodenum of the pancreatic graft may lead to encephalopathy with hyperammonemia after a simultaneous pancreas-kidney transplant. This emphasizes the need for meticulous preparation of the graft to avoid this complication.
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Affiliation(s)
- Dávid Ágoston Kovács
- From the Leiden University Medical Centre, Department of Surgery, Division of Transplantation, Hungary
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Haque TR, Barritt AS. Intestinal microbiota in liver disease. Best Pract Res Clin Gastroenterol 2016; 30:133-42. [PMID: 27048904 DOI: 10.1016/j.bpg.2016.02.004] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/05/2016] [Accepted: 02/02/2016] [Indexed: 02/07/2023]
Abstract
The intestinal microbiota have emerged as a topic of intense interest in gastroenterology and hepatology. The liver is on the front line as the first filter of nutrients, toxins and bacterial metabolites from the intestines and we are becoming increasingly aware of interactions among the gut, liver and immune system as important mediators of liver health and disease. Manipulating the microbiota with therapeutic intent is a rapidly expanding field. In this review, we will describe what is known about the contribution of intestinal microbiota to liver homeostasis; the role of dysbiosis in the pathogenesis of liver disease including alcoholic and non-alcoholic fatty liver disease, cirrhosis and hepatocellular carcinoma; and the therapeutic manifestations of altering intestinal microbiota via antibiotics, prebiotics, probiotics and fecal microbiota transplantation.
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Affiliation(s)
- Tanvir R Haque
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA.
| | - A Sidney Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA.
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Kao D, Roach B, Park H, Hotte N, Madsen K, Bain V, Tandon P. Fecal microbiota transplantation in the management of hepatic encephalopathy. Hepatology 2016; 63:339-40. [PMID: 26264779 DOI: 10.1002/hep.28121] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 08/10/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Dina Kao
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Brandi Roach
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Heekuk Park
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Naomi Hotte
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Karen Madsen
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Vince Bain
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Puneeta Tandon
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Weingarten MA, Sande AA. Acute liver failure in dogs and cats. J Vet Emerg Crit Care (San Antonio) 2015; 25:455-73. [PMID: 25882813 DOI: 10.1111/vec.12304] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 01/26/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To define acute liver failure (ALF), review the human and veterinary literature, and discuss the etiologies and current concepts in diagnostic and treatment options for ALF in veterinary and human medicine. ETIOLOGY In veterinary medicine ALF is most commonly caused by hepatotoxin exposure, infectious agents, inflammatory diseases, trauma, and hypoxic injury. DIAGNOSIS A patient may be deemed to be in ALF when there is a progression of acute liver injury with no known previous hepatic disease, the development of hepatic encephalopathy of any grade that occurs within 8 weeks after the onset of hyperbilirubinemia (defined as plasma bilirubin >50 μM/L [>2.9 mg/dL]), and the presence of a coagulopathy. Diagnostic testing to more specifically characterize liver dysfunction or pathology is usually required. THERAPY Supportive care to aid the failing liver and compensate for the lost functions of the liver remains the cornerstone of care of patients with ALF. Advanced therapeutic options such as extracorporeal liver assist devices and transplantation are currently available in human medicine. PROGNOSIS The prognosis for ALF depends upon the etiology, the degree of liver damage, and the response to therapy. In veterinary medicine, the prognosis is generally poor.
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Henao-Mejia J, Elinav E, Thaiss CA, Licona-Limon P, Flavell RA. Role of the intestinal microbiome in liver disease. J Autoimmun 2013; 46:66-73. [PMID: 24075647 DOI: 10.1016/j.jaut.2013.07.001] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 07/02/2013] [Indexed: 02/06/2023]
Abstract
The liver integrates metabolic outcomes with nutrient intake while preventing harmful signals derived from the gut to spread throughout the body. Direct blood influx from the gastrointestinal tract through the portal vein makes the liver a critical firewall equipped with a broad array of immune cells and innate immune receptors that recognize microbial-derived products, microorganisms, toxins and food antigens that have breached the intestinal barrier. An overwhelming amount of evidence obtained in the last decade indicates that the intestinal microbiota is a key component of a wide variety of physiological processes, and alterations in the delicate balance that represents the intestinal bacterial communities are now considered important determinants of metabolic syndrome and immunopathologies. Moreover, it is now evident that the interaction between the innate immune system and the intestinal microbiota during obesity or autoimmunity promotes chronic liver disease progression and therefore it might lead to novel and individualized therapeutic approaches. In this review, we discuss a growing body of evidence that highlights the central relationship between the immune system, the microbiome, and chronic liver disease initiation and progression.
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Affiliation(s)
- Jorge Henao-Mejia
- Department of Immunobiology, Yale University School of Medicine, CT 06520, USA
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Ziada DH, Soliman HH, El Yamany SA, Hamisa MF, Hasan AM. Can Lactobacillus acidophilus improve minimal hepatic encephalopathy? A neurometabolite study using magnetic resonance spectroscopy. Arab J Gastroenterol 2013; 14:116-22. [PMID: 24206740 DOI: 10.1016/j.ajg.2013.08.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 08/20/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND STUDY AIMS Minimal hepatic encephalopathy (MHE) is diagnosed when hepatic patients perform worse on psychometric tests compared to healthy controls. This study aimed to evaluate probiotics as alternative therapy in MHE. PATIENTS AND METHODS This is an open-label randomised controlled trial, performed in the Department of Tropical Medicine and Infectious Diseases, Tanta University Hospitals, from March 2010 to January 2012. A total of 90 patients with MHE were allocated by simple randomisation to three parallel equal groups. Group A received lactulose, group B a probiotic (Lactobacillus acidophilus) and group C served as the control. After informed consent, patients were tested for gut micrecology, fasting blood ammonia, liver functions and magnetic resonance spectroscopy (MRS) examination to study brain metabolites, mainly choline (Cho), myo-inositol (mI), glutamine+glutamate (Glx) and creatinin (Cre). Patients who developed overt encephalopathy were excluded from analysis. The whole battery of investigations was repeated in the same order after 4weeks. RESULTS The probiotic was better tolerated than lactulose. The relative risk reduction (RRR) of developing overt encephalopathy was 60% in the case of lactulose and 80% in the case of probiotic, with a number needed to treat (NNT) of 2.4 and 2.3, respectively. The differential but not total microecology count was significantly shifted towards saccharolytic rather than proteolytic bacteria. The mI/Cre and (Cho+mI)/Glx ratios were significantly increased and the Glx/Cre ratio was significantly reduced after 1month-follow-up in the probiotic group compared to the lactulose group and in both treatment groups compared to the control group. CONCLUSION Both probiotic and lactulose therapy can improve blood ammonia and psychometric tests in MHE and reduce the risk of developing overt encephalopathy. MRS showed more improvement in the levels of brain neurometabolites in the probiotic group.
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Affiliation(s)
- Dina H Ziada
- Tropical Medicine and Infectious Disease Department, Faculty of Medicine, Tanta University, Tanta, Al Gharbia, Egypt.
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Prakash RK, Kanna S, Mullen KD. Evolving Concepts: The Negative Effect of Minimal Hepatic Encephalopathy and Role for Prophylaxis in Patients With Cirrhosis. Clin Ther 2013; 35:1458-73. [DOI: 10.1016/j.clinthera.2013.07.421] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 07/10/2013] [Accepted: 07/22/2013] [Indexed: 12/18/2022]
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Cichoż-Lach H, Michalak A. Current pathogenetic aspects of hepatic encephalopathy and noncirrhotic hyperammonemic encephalopathy. World J Gastroenterol 2013; 19:26-34. [PMID: 23326159 PMCID: PMC3545226 DOI: 10.3748/wjg.v19.i1.26] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 07/25/2012] [Accepted: 07/28/2012] [Indexed: 02/06/2023] Open
Abstract
Hepatic encephalopathy is a medical phenomenon that is described as a neuropsychiatric manifestation of chronic or acute liver disease that is characterized by psychomotor, intellectual and cognitive abnormalities with emotional/affective and behavioral disturbances. This article focuses on the underlying mechanisms of the condition and the differences between hepatic encephalopathy and noncirrhotic hyperammonemic encephalopathy. Hepatic encephalopathy is a serious condition that can cause neurological death with brain edema and intracranial hypertension. It is assumed that approximately 60%-80% of patients with liver cirrhosis develop hepatic encephalopathy. This review explores the complex mechanisms that lead to hepatic encephalopathy. However, noncirrhotic hyperammonemic encephalopathy is not associated with hepatic diseases and has a completely different etiology. Noncirrhotic hyperammonemic encephalopathy is a severe occurrence that is connected with multiple pathogeneses.
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Abstract
Recent evidence indicates that the intestinal microflora plays a critical role in physiological and pathological processes; in particular, it is now considered a key determinant of immune pathologies and metabolic syndrome. Receiving the majority of its blood supply from the portal vein, the liver represents the first line of defense against food antigens, toxins, microbial-derived products, and microorganisms. Moreover, the liver is critically positioned to integrate metabolic outcomes with nutrient intake. To accomplish this function, the liver is equipped with a broad array of immune networks. It is now evident that, during pathological processes associated with obesity, alcohol-intake, or autoimmunity, the interaction between these immune cell populations and the intestinal microbiota promotes chronic liver disease progression and therefore they represent a novel therapeutic target. Herein, we highlight recent studies that have shed new light on the relationship between the microbiome, the innate immune system, and chronic liver disease progression.
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Probiotics, prebiotics, and synbiotics: gut and beyond. Gastroenterol Res Pract 2012; 2012:872716. [PMID: 23049548 PMCID: PMC3459241 DOI: 10.1155/2012/872716] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Accepted: 07/20/2012] [Indexed: 12/14/2022] Open
Abstract
The human intestinal tract has been colonized by thousands of species of bacteria during the coevolution of man and microbes. Gut-borne microbes outnumber the total number of body tissue cells by a factor of ten. Recent metagenomic analysis of the human gut microbiota has revealed the presence of some 3.3 million genes, as compared to the mere 23 thousand genes present in the cells of the tissues in the entire human body. Evidence for various beneficial roles of the intestinal microbiota in human health and disease is expanding rapidly. Perturbation of the intestinal microbiota may lead to chronic diseases such as autoimmune diseases, colon cancers, gastric ulcers, cardiovascular disease, functional bowel diseases, and obesity. Restoration of the gut microbiota may be difficult to accomplish, but the use of probiotics has led to promising results in a large number of well-designed (clinical) studies. Microbiomics has spurred a dramatic increase in scientific, industrial, and public interest in probiotics and prebiotics as possible agents for gut microbiota management and control. Genomics and bioinformatics tools may allow us to establish mechanistic relationships among gut microbiota, health status, and the effects of drugs in the individual. This will hopefully provide perspectives for personalized gut microbiota management.
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Sanyal A, Younossi ZM, Bass NM, Mullen KD, Poordad F, Brown RS, Vemuru RP, Mazen Jamal M, Huang S, Merchant K, Bortey E, Forbes WP. Randomised clinical trial: rifaximin improves health-related quality of life in cirrhotic patients with hepatic encephalopathy - a double-blind placebo-controlled study. Aliment Pharmacol Ther 2011; 34:853-61. [PMID: 21848797 DOI: 10.1111/j.1365-2036.2011.04808.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatic encephalopathy (HE) is a brain disorder that often results from cirrhosis due to viral hepatitis, metabolic and alcohol-related liver disease, and is characterised by cognitive, psychiatric and motor impairments. Recurrent bouts of overt HE negatively impact daily functioning and quality of life. AIM To evaluate the effect of rifaximin on health-related quality of life (HRQL) in cirrhotic patients with HE. METHODS Patients with cirrhosis in remission from HE (Conn score = 0 or 1) and a documented history of recurrent HE episodes (≥2 within 6 months of screening) were randomised to rifaximin 550 mg twice daily (N = 101) or placebo (N = 118) for 6 months. Concomitant lactulose was permitted during the study. The Chronic Liver Disease Questionnaire (CLDQ) was administered every 4 weeks, and time for occurrence of HE breakthrough was recorded. A longitudinal analysis using time-weighted averages of the CLDQ scores normalised by days on study therapy was used to evaluate the effect of treatment on HRQL, and between HE outcomes (HE recurrence, yes/no) irrespective of treatment. RESULTS The time-weighted averages of the overall CLDQ score and each domain score were significantly higher in the rifaximin group vs. placebo (P-values ranged from 0.0087 to 0.0436); and were significantly lower in patients who experienced HE breakthrough compared to those who remained in remission (P-values were <0.0001). CONCLUSION Rifaximin significantly improved HRQL in patients with cirrhosis and recurrent hepatic encephalopathy. A lower HRQL may predict recurrence of hepatic encephalopathy.
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Affiliation(s)
- A Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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Bercik P, Denou E, Collins J, Jackson W, Lu J, Jury J, Deng Y, Blennerhassett P, Macri J, McCoy KD, Verdu EF, Collins SM. The intestinal microbiota affect central levels of brain-derived neurotropic factor and behavior in mice. Gastroenterology 2011; 141:599-609, 609.e1-3. [PMID: 21683077 DOI: 10.1053/j.gastro.2011.04.052] [Citation(s) in RCA: 1113] [Impact Index Per Article: 85.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 03/28/2011] [Accepted: 04/15/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Alterations in the microbial composition of the gastrointestinal tract (dysbiosis) are believed to contribute to inflammatory and functional bowel disorders and psychiatric comorbidities. We examined whether the intestinal microbiota affects behavior and brain biochemistry in mice. METHODS Specific pathogen-free (SPF) BALB/c mice, with or without subdiaphragmatic vagotomy or chemical sympathectomy, or germ-free BALB/c mice received a mixture of nonabsorbable antimicrobials (neomycin, bacitracin, and pimaricin) in their drinking water for 7 days. Germ-free BALB/c and NIH Swiss mice were colonized with microbiota from SPF NIH Swiss or BALB/c mice. Behavior was evaluated using step-down and light preference tests. Gastrointestinal microbiota were assessed using denaturing gradient gel electrophoresis and sequencing. Gut samples were analyzed by histologic, myeloperoxidase, and cytokine analyses; levels of serotonin, noradrenaline, dopamine, and brain-derived neurotropic factor (BDNF) were assessed by enzyme-linked immunosorbent assay. RESULTS Administration of oral antimicrobials to SPF mice transiently altered the composition of the microbiota and increased exploratory behavior and hippocampal expression of BDNF. These changes were independent of inflammatory activity, changes in levels of gastrointestinal neurotransmitters, and vagal or sympathetic integrity. Intraperitoneal administration of antimicrobials to SPF mice or oral administration to germ-free mice did not affect behavior. Colonization of germ-free BALB/c mice with microbiota from NIH Swiss mice increased exploratory behavior and hippocampal levels of BDNF, whereas colonization of germ-free NIH Swiss mice with BALB/c microbiota reduced exploratory behavior. CONCLUSIONS The intestinal microbiota influences brain chemistry and behavior independently of the autonomic nervous system, gastrointestinal-specific neurotransmitters, or inflammation. Intestinal dysbiosis might contribute to psychiatric disorders in patients with bowel disorders.
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Affiliation(s)
- Premysl Bercik
- The Farncombe Family Digestive Health Institute, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
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Minuk GY, Hawkins K, Kaita KDE, Wong S, Renner E, Minuk L, Uhanova J. Daily ciprofloxacin treatment for patients with advanced liver disease awaiting liver transplantation reduces hospitalizations. Dig Dis Sci 2011; 56:1235-41. [PMID: 21057977 DOI: 10.1007/s10620-010-1456-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 10/05/2010] [Indexed: 12/09/2022]
Abstract
BACKGROUND Progressive deterioration in liver function is a common cause of hepatic decompensation and indication for liver transplantation in patients with advanced liver disease. Previous studies in animal models of acute and chronic liver disease revealed that daily ciprofloxacin improves biochemical parameters of hepatic function. AIMS The primary objective of this study was to determine whether hepatic function improves in patients with advanced liver disease after 1 month of daily ciprofloxacin therapy. A secondary objective was to determine whether ciprofloxacin treatment for 1 or 3 months results in fewer hospitalizations for decompensated liver disease. METHODS Forty-four patients with advanced liver disease awaiting liver transplantation received oral ciprofloxacin (250 or 500 mg twice daily) or placebo for 1 (n=22/group) or 3 (n=10 ciprofloxacin, 14 placebo) months. RESULTS Compared to placebo recipients, ciprofloxacin-treated patients had mild improvements in serum albumin levels (+1.5 versus -3.4%, p=0.026) while bilirubin and international normalized ratios (INR) of prothrombin times remained unchanged. Overall, fewer hospitalizations occurred in ciprofloxacin-treated patients (1/22, 5% versus 7/22, 32%, respectively, p=0.02) during the study period. Treatment was well tolerated and no resistant infections occurred in either cohort. CONCLUSIONS The results of this study suggest that daily ciprofloxacin may result in fewer hospitalizations for patients with advanced liver diseases awaiting liver transplantation but not by enhancing hepatic function.
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Affiliation(s)
- G Y Minuk
- Section of Hepatology, Department of Medicine, University of Manitoba, 803F John Buhler Research Centre, 715 McDermot Avenue, Winnipeg, Manitoba, R3E 3P4, Canada.
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Lu H, Wu Z, Xu W, Yang J, Chen Y, Li L. Intestinal microbiota was assessed in cirrhotic patients with hepatitis B virus infection. Intestinal microbiota of HBV cirrhotic patients. MICROBIAL ECOLOGY 2011; 61:693-703. [PMID: 21286703 DOI: 10.1007/s00248-010-9801-8] [Citation(s) in RCA: 160] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Accepted: 12/29/2010] [Indexed: 02/07/2023]
Abstract
To unravel the profile of intestinal microecological parameters in Chinese patients with asymptomatic carriage of hepatitis B virus (HBV), chronic hepatitis B, decompensated HBV cirrhosis, and health controls and to establish their correlation with liver disease progression, we performed quantitative PCR and immunological techniques to investigate fecal parameters, including population of fecal predominant bacteria and the abundance of some virulence genes derived from Escherichia coli, Bacteroides fragilis, Clostridium difficile, and Clostridium perfringens in fecal crude DNA and some immunological parameters in extracts of all fecal samples. Data analysis indicated that 16S rRNA gene copy numbers for Faecalibacterium prausnitzii, Enterococcus faecalis, Enterobacteriaceae, bifidobacteria, and lactic acid bacteria (Lactobacillus, Pediococcus, Leuconostoc, and Weissella) showed marked variation in the intestine of HBV cirrhotic patients. The Bifidobacteria/Enterobacteriaceae (B/E) ratio, which may indicate microbial colonization resistance of the bowel, was decreased significantly in turn from 1.15 ± 0.11 in healthy controls, 0.99 ± 0.09 in asymptomatic carriers, and 0.76 ± 0.08 in patients with chronic hepatitis B to 0.64 ± 0.09 in patients with decompensated HBV cirrhosis (for all, P < 0.01). This suggests that B/E ratio is useful for following the level of intestinal microecological disorder in the course of liver disease progression. The data for virulence gene abundance suggested increased diversity of virulence factors during liver disease progression. Fecal secretory IgA and tumor necrosis factor-α in decompensated HBV cirrhotic patients were present at higher levels than in other groups, which indicates that a complicated autoregulatory system tries to achieve a new intestinal microecological balance.
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Affiliation(s)
- Haifeng Lu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, People's Republic of China
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Abstract
Hepatic encephalopathy is a complex and potentially reversible neuropsychiatric syndrome complicating acute or chronic liver disease. Clinical manifestations are multiple and varied, ranging from minimal neurological changes to coma. Ammonia is the main toxic substance involved in the pathogenesis of hepatic encephalopathy, although other mechanisms, such as modifications of the blood-brain barrier, disruptions in neurotransmission and abnormalities in GABAergic and benzodiazepine pathways may also play a role. The identification and treatment of precipitating factors is crucial in the management of patients with hepatic encephalopathy. Current treatments are based on reducing intestinal ammonia load by agents such as antibiotics or disaccharides, although their efficacy is yet to be clearly established.
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Abstract
Hepatic encephalopathy (HE) is a complication of cirrhosis, the severity of which can range from subtle, neurocognitive dysfunction (minimal HE) to more apparent and severe cognitive and motor manifestations with increasing grades of the condition (overt HE). Current treatment options are targeted at reducing the levels of ammonia and other gut-derived toxins, the purported culprits behind the pathogenesis of HE. One of these therapeutic options, the nonsystemic antibiotic rifaximin, is efficacious for the treatment of minimal and overt HE. However, HE may be a cyclic condition in which patients with overt HE enter remission following treatment and then relapse. Thus, safe, effective and well-tolerated treatments are needed to maintain HE remission. Rifaximin maintained HE remission more effectively than placebo in a large, randomized controlled trial. Rifaximin is safe and well-tolerated for the treatment of minimal and overt HE and for the maintenance of HE remission.
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Affiliation(s)
- Kevin Mullen
- Division of Gastroenterology, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
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Collins SM, Bercik P. The relationship between intestinal microbiota and the central nervous system in normal gastrointestinal function and disease. Gastroenterology 2009; 136:2003-14. [PMID: 19457424 DOI: 10.1053/j.gastro.2009.01.075] [Citation(s) in RCA: 377] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2008] [Revised: 01/13/2009] [Accepted: 01/25/2009] [Indexed: 12/14/2022]
Abstract
Although many people are aware of the communication that occurs between the gastrointestinal (GI) tract and the central nervous system, fewer know about the ability of the central nervous system to influence the microbiota or of the microbiota's influence on the brain and behavior. Within the GI tract, the microbiota have a mutually beneficial relationship with their host that maintains normal mucosal immune function, epithelial barrier integrity, motility, and nutrient absorption. Disruption of this relationship alters GI function and disease susceptibility. Animal studies suggest that perturbations of behavior, such as stress, can change the composition of the microbiota; these changes are associated with increased vulnerability to inflammatory stimuli in the GI tract. The mechanisms that underlie these alterations are likely to involve stress-induced changes in GI physiology that alter the habitat of enteric bacteria. Furthermore, experimental perturbation of the microbiota can alter behavior, and the behavior of germ-free mice differs from that of colonized mice. Gaining a better understanding of the relationship between behavior and the microbiota could provide insight into the pathogenesis of functional and inflammatory bowel disorders.
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Affiliation(s)
- Stephen M Collins
- The Farncombe Family Digestive Health Research Institute, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
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Bajaj JS, Saeian K, Christensen KM, Hafeezullah M, Varma RR, Franco J, Pleuss JA, Krakower G, Hoffmann RG, Binion DG. Probiotic yogurt for the treatment of minimal hepatic encephalopathy. Am J Gastroenterol 2008; 103:1707-15. [PMID: 18691193 DOI: 10.1111/j.1572-0241.2008.01861.x] [Citation(s) in RCA: 184] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Minimal hepatic encephalopathy (MHE), the preclinical stage of overt hepatic encephalopathy (OHE), is a significant condition affecting up to 60% of cirrhotics. All MHE therapies modify gut microflora, but consensus regarding MHE treatment and long-term adherence studies is lacking. The aim was to determine the effect of probiotic supplementation in the form of a food item, probiotic yogurt, on MHE reversal and adherence. METHODS Nonalcoholic MHE cirrhotics (defined by a standard psychometric battery) were randomized with unblinded allocation to receive probiotic yogurt (with proven culture stability) or no treatment (no Rx) for 60 days in a 2:1 ratio. Quality of life (short form [SF]-36), adherence, venous ammonia, model of end-stage liver disease (MELD) scores, and inflammatory markers (tumor necrosis factor [TNF]-alpha, interleukin [IL]-6) were also measured. Outcomes were MHE reversal using blinded scoring, OHE development, and adherence. RESULTS Twenty-five patients (17 yogurt, 8 no Rx; 84% Child class A) were enrolled. A significantly higher percentage of yogurt patients reversed MHE compared to no Rx patients (71%vs 0%, P= 0.003, intention-to-treat). Yogurt patients demonstrated a significant improvement in number connection test-A (NCT-A), block design test (BDT), and digit symbol test (DST) compared to baseline/no Rx group. Twenty-five percent of no Rx versus 0% of yogurt patients developed OHE during the trial. Eighty-eight percent of yogurt patients were adherent. No adverse effects or change in covariates were observed. All patients who completed the yogurt arm were agreeable to continue yogurt for 6 months if needed. CONCLUSIONS This trial demonstrated a significant rate of MHE reversal and excellent adherence in cirrhotics after probiotic yogurt supplementation with potential for long-term adherence.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI 53226, USA
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Mullen KD. Review of the final report of the 1998 Working Party on definition, nomenclature and diagnosis of hepatic encephalopathy. Aliment Pharmacol Ther 2007; 25 Suppl 1:11-6. [PMID: 17295847 DOI: 10.1111/j.1746-6342.2006.03216.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The heterogeneity and variability of the manifestations of hepatic encephalopathy among patients and in individual patients over time make the condition difficult to diagnose and to categorize with respect to severity. Recognizing these challenges, the World Congress of Gastroenterology formed a Working Party of hepatologists, neurologists and basic scientists in 1998 to develop consensus recommendations regarding key issues relevant to the diagnosis and grading of hepatic encephalopathy in clinical research and practice. This paper discusses the Working Party recommendations, which warrant re-examination in the context of the absolute need for consistency in diagnosis and grading of hepatic encephalopathy and in approaches to its clinical study. The Working Party recommendations provide a framework for achieving this consistency and can serve as a springboard for further refinements in diagnostic tests and procedures and in clinical-trial methodology.
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Affiliation(s)
- K D Mullen
- Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH 44109, USA.
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