Characterization of acute-on-chronic liver failure and prediction of mortality in Asian patients with active alcoholism

An artificial intelligence-generated model predicts 90-day survival in alcohol-associated hepatitis: A global cohort study

BACKGROUND AND AIMS

Alcohol-associated hepatitis (AH) poses significant short-term mortality. Existing prognostic models lack precision for 90-day mortality. Utilizing artificial intelligence in a global cohort, we sought to derive and validate an enhanced prognostic model.

APPROACH AND RESULTS

The Global AlcHep initiative, a retrospective study across 23 centers in 12 countries, enrolled patients with AH per National Institute for Alcohol Abuse and Alcoholism criteria. Centers were partitioned into derivation (11 centers, 860 patients) and validation cohorts (12 centers, 859 patients). Focusing on 30 and 90-day postadmission mortality, 3 artificial intelligence algorithms (Random Forest, Gradient Boosting Machines, and eXtreme Gradient Boosting) informed an ensemble model, subsequently refined through Bayesian updating, integrating the derivation cohort's average 90-day mortality with each center's approximate mortality rate to produce posttest probabilities. The ALCoholic Hepatitis Artificial INtelligence Ensemble score integrated age, gender, cirrhosis, and 9 laboratory values, with center-specific mortality rates. Mortality was 18.7% (30 d) and 27.9% (90 d) in the derivation cohort versus 21.7% and 32.5% in the validation cohort. Validation cohort 30 and 90-day AUCs were 0.811 (0.779-0.844) and 0.799 (0.769-0.830), significantly surpassing legacy models like Maddrey's Discriminant Function, Model for End-Stage Liver Disease variations, age-serum bilirubin-international normalized ratio-serum Creatinine score, Glasgow, and modified Glasgow Scores ( p < 0.001). ALCoholic Hepatitis Artificial INtelligence Ensemble score also showcased superior calibration against MELD and its variants. Steroid use improved 30-day survival for those with an ALCoholic Hepatitis Artificial INtelligence Ensemble score > 0.20 in both derivation and validation cohorts.

CONCLUSIONS

Harnessing artificial intelligence within a global consortium, we pioneered a scoring system excelling over traditional models for 30 and 90-day AH mortality predictions. Beneficial for clinical trials, steroid therapy, and transplant indications, it's accessible at: https://aihepatology.shinyapps.io/ALCHAIN/ .

Bacterial Infections in Acute-on-chronic Liver Failure: Epidemiology, Diagnosis, Pathogenesis, and Management

Acute-on-chronic liver failure (ACLF) is a distinct condition characterized by the abrupt exacerbation of pre-existing chronic liver disease, often leading to multi-organ failures and significant short-term mortalities. Bacterial infection is one of the most frequent triggers for ACLF and a common complication following its onset. The impact of bacterial infections on the clinical course and outcome of ACLF underscores their critical role in the pathogenesis of systemic inflammation and organ failures. In addition, the evolving epidemiology and increasing prevalence of multidrug-resistant bacteria in cirrhosis and ACLF highlight the importance of appropriate empirical antibiotic use, as well as accurate and prompt microbiological diagnosis. This review provided an update on recent advances in the epidemiology, diagnosis, pathogenesis, and management of bacterial infections in ACLF.

Impact of Diabetes, Drug-Induced Liver Injury, and Sepsis on Outcomes in Metabolic Dysfunction Associated Fatty Liver Disease-Related Acute-on-Chronic Liver Failure

INTRODUCTION

The prevalence of metabolic dysfunction-associated fatty liver disease (MAFLD) and its complication, MAFLD-related acute-on-chronic liver failure (MAFLD-ACLF), is rising. Yet, factors determining patient outcomes in MAFLD-ACLF remain understudied.

METHODS

Patients with MAFLD-ACLF were recruited from the Asian Pacific Association for the Study of the Liver-ACLF Research Consortium (AARC registry). The diagnosis of MAFLD-ACLF was made when the treating unit had identified the etiology of chronic liver disease as MAFLD (or previous nomenclature such as non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, or non-alcoholic steatohepatitis-cirrhosis). Patients with coexisting other etiologies of chronic liver disease (such as alcohol, hepatitis B virus, hepatitis C virus, etc.) were excluded. Data were randomly split into derivation (n = 258) and validation (n = 111) cohorts at a 70:30 ratio. The primary outcome was 90-day mortality. Only the baseline clinical, laboratory features and severity scores were considered.

RESULTS

The derivation group had 258 patients; 60% were male, with a mean age of 53. Diabetes was noted in 27% and hypertension in 29%. The dominant precipitants included viral hepatitis (hepatitis A virus and hepatitis E virus, 32%), drug-induced injury (drug-induced liver injury, 29%), and sepsis (23%). Model for End-Stage Liver Disease-Sodium (MELD-Na) and AARC scores on admission averaged 32 ± 6 and 10.4 ± 1.9. At 90 days, 51% survived. Nonviral precipitant, diabetes, bilirubin, international normalized ratio, and encephalopathy were independent factors influencing mortality. Adding diabetes and precipitant to MELD-Na and AARC scores, the novel MAFLD-MELD-Na score (+12 for diabetes, +12 for nonviral precipitant), and MAFLD-AARC score (+5 for each) were formed. These outperformed the standard scores in both cohorts.

DISCUSSION

Almost half of patients with MAFLD-ACLF die within 90 days. Diabetes and nonviral precipitants such as drug-induced liver injury and sepsis lead to adverse outcomes. The new MAFLD-MELD-Na and MAFLD-AARC scores provide reliable 90-day mortality predictions for patients with MAFLD-ACLF.

Determining Prognosis of ALD and Alcohol-associated Hepatitis

Alcohol-associated hepatitis has a poor prognosis in terms of short-term mortality and often presents with symptoms, such as jaundice, acute renal failure, and ascites. There are many prognostic models that have been developed to predict short-term and long-term mortality in these patients. Current prognostic models can be divided into static scores, which are measured at admission, and dynamic models, which measure baseline and after a certain amount of time. The efficacy of these models in predicting short-term mortality is disputed. Numerous studies across the world have compared prognostic models, such as the Maddrey's discriminant function, the model for end-stage liver disease score, model for end-stage liver disease score-Na, Glasgow alcohol-associated hepatitis score, and the age-bilirubin-international normalized ratio-creatinine (ABIC) score, to each other to determine which score is more useful for a particular context. There are also prognostic markers such as liver biopsy, breath biomarkers, and acute kidney injury that are able to predict mortality. The accuracy of these scores is a key to determining when treatment with corticosteroids is futile since there is an increased risk of infection in those treated with it. Furthermore, although these scores are helpful in predicting short-term mortality, the only factor that is able to predict long-term mortality in patients with alcohol-related liver disease is abstinence. Numerous studies have proven that even though corticosteroids provide a treatment for alcohol-associated hepatitis, it is a temporary one, at best. The purpose of this paper is to compare the historical models to current ones in their ability to predict mortality in patients with alcohol-related liver disease by analyzing multiple studies that have examined these prognostic markers. This paper also isolates the knowledge gaps in the ability to delineate which patients would benefit from corticosteroids and patients who would not and provides potential models for the future that could narrow this gap.

The progress to establish optimal animal models for the study of acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) defines a complicated and multifaceted syndrome characterized by acute liver dysfunction following an acute insult on the basis of chronic liver diseases. It is usually concurrent with bacterial infection and multi-organ failure resulting in high short-term mortality. Based on the cohort studies in ACLF worldwide, the clinical course of ACLF was demonstrated to comprise three major stages including chronic liver injury, acute hepatic/extrahepatic insult, and systemic inflammatory response caused by over-reactive immune system especially bacterial infection. However, due to the lack of optimal experimental animal models for ACLF, the progress of basic study on ACLF is limping. Though several experimental ACLF models were established, none of them can recapitulate and simulate the whole pathological process of ACLF patients. Recently, we have developed a novel mouse model for ACLF combining chronic liver injury [injection of carbon tetrachloride (CCl₄) for 8 weeks], acute hepatic insult (injection of a double dose CCl₄), and bacterial infection (intraperitoneal injection of Klebsiella pneumoniae), which could recapitulate the major clinical features of patients with ACLF worsened by bacterial infection.

Catecholamine induces Kupffer cell apoptosis via growth differentiation factor 15 in alcohol-associated liver disease

Chronic alcohol consumption often induces hepatic steatosis but rarely causes severe inflammation in Kupffer cells (KCs) despite the increased hepatic influx of lipopolysaccharide (LPS), suggesting the presence of a veiled tolerance mechanism. In addition to LPS, the liver is affected by several gut-derived neurotransmitters through the portal blood, but the effects of catecholamines on KCs have not been clearly explored in alcohol-associated liver disease (ALD). Hence, we investigated the regulatory roles of catecholamine on inflammatory KCs under chronic alcohol exposure. We discovered that catecholamine levels were significantly elevated in the cecum, portal blood, and liver tissues of chronic ethanol-fed mice. Increased catecholamines induced mitochondrial translocation of cytochrome P450 2E1 in perivenous hepatocytes expressing the β2-adrenergic receptor (ADRB2), leading to the enhanced production of growth differentiation factor 15 (GDF15). Subsequently, GDF15 profoundly increased ADRB2 expression in adjacent inflammatory KCs to facilitate catecholamine/ADRB2-mediated apoptosis. Single-cell RNA sequencing of KCs confirmed the elevated expression of Adrb2 and apoptotic genes after chronic ethanol intake. Genetic ablation of Adrb2 or hepatic Gdf15 robustly decreased the number of apoptotic KCs near perivenous areas, exacerbating alcohol-associated inflammation. Consistently, we found that blood and stool catecholamine levels and perivenous GDF15 expression were increased in patients with early-stage ALD along with an increase in apoptotic KCs. Our findings reveal a novel protective mechanism against ALD, in which the catecholamine/GDF15 axis plays a critical role in KC apoptosis, and identify a unique neuro-metabo-immune axis between the gut and liver that elicits hepatoprotection against alcohol-mediated pathogenic challenges.

Extracts of Dracocephalum tanguticum Maxim Ameliorate Acute Alcoholic Liver Disease via Regulating Transcription Factors in Mice

Alcoholic liver disease (ALD) caused by excessive drinking is a health and economic concern worldwide. Given the high morbidity, mortality, and the progressive nature of ALD, finding effective interventions is essential. Previous studies have confirmed that edible food plants and their bioactive compounds exert a protective effect against ALD. Dracocephalum tanguticum Maxim (DTM) is one of the important traditional Tibetan medicines in China with the effect of clearing away liver heat, used for the treatment of hepatitis. In this study, the DTM chloroform extract (DtM-C), ethyl acetate extract (DtM-E), and n-butanol extract (DtM-B) were obtained by ethanol extraction combined with fractional extraction. Acute ALD was induced in mice given intragastric ethanol. Serum and liver biochemical markers were detected by ELISA. Liver histological observation, Oil Red O, and Masson's trichrome staining were performed. Liver injury cells were induced by ethanol. The cell vitality was detected by using MTT colorimetry. The expressions of Nrf2, NF-κB, STAT3, AP-1, CREB, HIF-1α, HO-1, NQO-1, GSTA1, IKB2, and Keap1 were detected by real-time polymerase chain reaction (PCR) to elucidate the mechanism of hepatoprotective effect, and the results were verified by using Western blot. The results of serum liver function indicators (ALT, AST, and ADH), serum hepatic lipid indicators (TC, TG, HDL-C, and LDL-C), and lipid peroxidation indicators (ADH, MDA, SOD, CAT, and GSH-Px) in liver tissue and liver histological observation showed that DtM-E could improve liver function, alleviate fatty degeneration, edema, cell necrosis, and liver fibrosis caused by alcohol. DtM-E also increased the vitality of EtOH-induced liver injury cells, upregulated the mRNA expression of Nrf2, HO-1, NQO-1, and GSTA1, while downregulated the expression of Keap-1, p65, and NF-κB. Western blot results were consistent with PCR. The results suggest that DtM-E has a protective effect against ALD in vitro and in vivo, and its mechanism of action may be related to the activation of Nrf2/Keap-1 and inhibition of the P65/NF-κB signaling pathways.

N-acetyl cysteine versus standard of care for non-acetaminophen induced acute liver injury: a systematic review and meta-analysis

The role of N-acetylcysteine (NAC) in the treatment of acetaminophen induced acute liver injury (ALI) is well established but its role in non-acetaminophen induced ALI is still elusive. We conducted this meta-analysis to evaluate the role of NAC in non-acetaminophen induced ALI. We searched electronic databases for studies published till Oct 25, 2020. We used RevMan v5.4 software to analyze the data extracted from selected studies by using Covidence systematic review software. Outcome estimation was done using Odds Ratio (OR) with 95% confidence interval (CI). The heterogeneity in various studies was determined using the I² test. A total of 11 studies were included in quantitative analysis. Use of NAC in non-acetaminophen induced ALI showed 53% reduction in mortality compared to standard of care (OR, 0.47; CI, 0.29-0.75) and reduced mean duration of hospital stay by 6.52 days (95% CI, -12.91 to -0.13). Similarly, the rate of encephalopathy was 59% lower in the treatment group (OR, 0.41; CI, 0.20-0.83). However, the risk of developing nausea and vomiting (OR, 3.99; CI, 1.42-11.19), and the need for mechanical ventilation (OR 3.88; CI, 1.14-13.29) were significantly higher in the treatment group. These findings conclude use of NAC decreases mortality and hepatic encephalopathy compared to standard of care in patients with non-acetaminophen induced ALI. Although there is an increased risk of nausea and vomiting with the use of NAC, the majority of adverse events are transient and minor.

Characterizing a cohort of Egyptian patients with acute-on-chronic liver failure

BACKGROUND AND AIM

Several studies performed in Western countries and Asia have shown that acute-on-chronic liver failure (ACLF) is an acute decompensation of cirrhosis characterized by organ system failures and high short-term mortality. However, the characteristics of Egyptian patients with ACLF have not yet been described. The aim of this study was to assess Egyptian patients with cirrhosis hospitalized for an acute decompensation using criteria and scores developed by the EASL-CLIF Consortium.

PATIENTS AND METHODS

One hundred and twenty patients with acutely decompensated cirrhosis nonelectively admitted to two tertiary hospitals were prospectively included. Ninety-three percent of patients had hepatitis C virus-related liver disease.

RESULTS

Of the 120 patients, 40 had ACLF; of these 45% had ACLF-1, 33% ACLF-2, and the remaining 22% had ACLF-3. None of the patients with ACLF had received direct-antiviral agents (DAAs) while 30% of patients without ACLF were treated with these agents. The prevalence of prior episodes of decompensation was significantly higher in patients with ACLF (60% vs. 28%). The prevalence of precipitating events such as bacterial infection alone or combined with gastrointestinal hemorrhage was higher in patients with ACLF than in those without. Systemic inflammation, assessed with white blood-cell count and plasma C reactive levels, was more intense in ACLF.

CONCLUSION

Among Egyptian patients with acutely decompensated cirrhosis nonelectively admitted to the hospital, those with ACLF were distinct from those without ACLF, not only by the presence of organ failures, but also the absence DAA therapy, more frequent prior episodes of decompensation, more frequent bacterial infections as a precipitant, and more intense systemic inflammation.

Comparing Eight Prognostic Scores in Predicting Mortality of Patients with Acute-On-Chronic Liver Failure Who Were Admitted to an ICU: A Single-Center Experience

Limited data is available on long-term outcome predictions for patients with acute-on-chronic liver failure (ACLF) in an intensive care unit (ICU) setting. Assessing the reliability and accuracy of several mortality prediction models for these patients is helpful. Two hundred forty-nine consecutive patients with ACLF and admittance to the liver ICU in a single center in northern Taiwan between December 2012 and March 2015 were enrolled in the study and were tracked until February 2017. Ninety-one patients had chronic hepatitis B-related cirrhosis. Clinical features and laboratory data were collected at or within 24 h of the first ICU admission course. Eight commonly used clinical scores in chronic liver disease were calculated. The primary endpoint was overall survival. Acute physiology and chronic health evaluation (APACHE) III and chronic liver failure consortium (CLIF-C) ACLF scores were significantly superior to other models in predicting overall mortality as determined by time-dependent receiver operating characteristic (ROC) curve analysis (area under the ROC curve (AUROC): 0.817). Subgroup analysis of patients with chronic hepatitis B-related cirrhosis displayed similar results. CLIF-C organ function (OF), CLIF-C ACLF, and APACHE III scores were statistically superior to the mortality probability model III at zero hours (MPM0-III) and the simplified acute physiology (SAP) III scores in predicting 28-day mortality. In conclusion, for 28-day and overall mortality prediction of patients with ACLF admitted to the ICU, APACHE III, CLIF-OF, and CLIF-C ACLF scores might outperform other models. Further prospective study is warranted.

Point shear wave elastography predicts fibrosis severity and steatohepatitis in alcohol-related liver disease

BACKGROUND

Point shear wave elastography (pSWE) is a convenient noninvasive tool for assessing liver fibrosis in chronic liver disease. However, there is little information on the correlation between pSWE and the histological findings of alcohol-related liver disease (ALD). Thus, we investigated the diagnostic performance of pSWE in discriminating the fibrosis stage of patients with ALD.

METHODS

A total of 251 Korean patients with ALD were prospectively enrolled. The diagnostic performance of pSWE was evaluated on the basis of histological fibrosis severity according to Kleiner/Brunt et al.'s criteria and the Laennec classification.

RESULTS

Median liver stiffness on pSWE significantly increased as liver fibrosis stage increased (p < 0.001). Liver stiffness measurement proved to be an excellent diagnostic indicator in the evaluation of a ≥ F2 stage (area under the receiver operating characteristics curve [AUROC] 0.93; cutoff > 1.46 m/s), ≥ F3 stage (AUROC 0.90; cutoff > 1.47 m/s), and F4 stage (AUROC 0.91; cutoff > 1.66 m/s). Compared with noninvasive serum fibrosis tests, pSWE had the highest AUROC for predicting ≥ F2, ≥ F3, and = F4 stages and the highest Obuchowski index (0.931 ± 0.007; all p < 0.001). The AUROC for discriminating steatohepatitis from simple steatosis was 0.93 (> 1.49 m/s) and the AUROC for discriminating cirrhosis with steatohepatitis from cirrhosis without steatohepatitis was 0.92 (> 2.52 m/s).

CONCLUSION

pSWE not only gives an accurate indication of liver fibrosis stage in ALD, but also can allow patients with severe alcoholic steatohepatitis to begin corticosteroid treatment without exposing them to the risks of liver biopsy.

CLINICAL TRIAL REGISTRATION

Clincialtrials.gov Identifier NCT01943318.

Establishment of prognostic scoring models for different etiologies of acute decompensation in hospitalized patients with cirrhosis

Objective

Acute decompensation (AD) in liver cirrhosis has high mortality. We assessed prognostic scoring models and established prediction models for different etiologies of AD.

Methods

This retrospective analysis included 732 patients hospitalized with acute decompensated cirrhosis without acute-on-chronic liver failure. We performed logistic regression analysis of risk factors for mortality associated with different etiologies, to establish predictive models.

Results

Patients with different etiologies, scored using different scoring systems and various impact factors, exhibited differences with respect to mortality. MELD, CLIF-C-AD, MELD-Na, and AARC-ACLF scores exhibited adequate predictive ability for mortality. Area under the receiver operating characteristic curve for 28-day mortality for MELD, CLIF-C-AD, MELD-Na, AARC-ACLF, and the newly developed AD scores was 0.663, 0.673, 0.657, 0.662, and 0.773, respectively, in the hepatitis B virus group (HBV-AD score =−5.51 + 0.07*WBC count (109/L) +0.7*AD sum+0.4*AARC-ACLF score); 0.731, 0.737, 0.735, 0.689, and 0.778, respectively, in the alcoholic liver disease group (ALD-AD score =−4.55 +0.08* WBC count (109/L) +1.34* AD sum); and 0.765, 0.767, 0.814, 0.720, and 0.814, respectively, in the Others group (OTHERS-AD score =−2.14 + 1.24*MELD-Na score +4.49*AD sum).

Conclusions

The newly developed scoring models for short-term mortality were superior to the other scoring systems in predicting prognosis of acute decompensated cirrhosis in hospitalized patients.

HINT: a novel prognostic model for patients with hepatitis B virus-related acute-on-chronic liver failure

BACKGROUND

HBV-related acute-on-chronic liver failure (HBV-ACLF) deteriorates rapidly in the short term, which necessitates accurate initial clinical decision making.

AIMS

To develop a novel prognostic score for patients with HBV-ACLF and clarify the role of thyroid hormones in HBV-ACLF.

METHODS

A retrospective cohort of 635 HBV-ACLF patients was enrolled to develop and validate a novel prognostic score for HBV-ACLF. Additionally, a cross-sectional cohort (n = 199) and a prospective longitudinal HBV-ACLF cohort (n = 56) were recruited to clarify the association between thyroid hormone status and the 30-day mortality of HBV-ACLF.

RESULTS

HINT, a novel prognostic score based on hepatic encephalopathy, INR, neutrophil count, and thyroid-stimulating hormone (TSH) using the deriving cohort (n = 426), was significantly higher in non-survivors than survivors (1.17 ± 2.38 vs -1.87 ± 1.26, P < 0.0001). The AUROC of HINT for 30-day mortality was 0.889, which was significantly higher than that of the Child-Pugh, MELD, CLIF-SOFA, CLIF-C ACLF, and COSSH-ACLF scores (all P < 0.05). These results were confirmed in the validation cohort (n = 209), except that the AUROC of HINT was comparable to that of COSSH-ACLF (P = 0.357). Among thyroid hormones, only the TSH level on admission was significantly lower in non-survivors than in survivors (P = 0.01). During the 14-day longitudinal observation, TSH levels increased significantly in the improvement group (P < 0.001) but did not change in the deterioration or fluctuation groups, and gradually increased in survivors (P < 0.001) but not in non-survivors.

CONCLUSIONS

HINT, as a prognostic score for HBV-ACLF, is simpler than and superior to the Child-Pugh, MELD, CLIF-SOFA, and CLIF-C ACLF scores and at least comparable with the COSSH-ACLF score. Sequential TSH measurements may facilitate prediction of the clinical course of ACLF.

Acute-on-chronic liver failure: a time to step forward

Acute-on-chronic liver failure (ACLF) is defined as a syndrome characterized by acute deterioration of liver function on a chronic liver disease, associated with extrahepatic organ failure and high short-term mortality (≥ 15%). This concept represents a disruption in the traditional spectrum of liver diseases, particularly in liver cirrhosis. ACLF may appear during liver disease ranging from compensated to long-standing cirrhosis. Despite the heterogeneity of definitions, it is clear that ACLF results from different types of precipitants in patients with underlying chronic liver disease, mimicking the prognosis of acute liver failure. In this scenario, some new prognostic scores have been proposed instead of MELD or Child-Pugh scores. In the current issue, a retrospective Portuguese study (N = 177) carried out by Barosa et al. explored the usefulness of CLIF scores identifying high mortality rates among cirrhotic patients suffering from ACLF5.

Validation of prognostic scores to predict short-term mortality in patients with acute-on-chronic liver failure

BACKGROUND AND AIM

The aim of this study was to validate the chronic liver failure-sequential organ failure assessment score (CLIF-SOFAs), CLIF consortium organ failure score (CLIF-C OFs), CLIF-C acute-on-chronic liver failure score (CLIF-C ACLFs), and CLIF-C acute decompensation score in Korean chronic liver disease patients with acute deterioration.

METHODS

Acute-on-chronic liver failure was defined by either the Asian Pacific Association for the study of the Liver ACLF Research Consortium (AARC) or CLIF-C criteria. The diagnostic performances for short-term mortality were compared by the area under the receiver operating characteristic curve.

RESULTS

Among a total of 1470 patients, 252 patients were diagnosed with ACLF according to the CLIF-C (197 patients) or AARC definition (95 patients). As the ACLF grades increased, the survival rates became significantly lower. The areas under the receiver operating characteristic of the CLIF-SOFAs, CLIF-C OFs, and CLIF-C ACLFs were significantly higher than those of the Child-Pugh, model for end-stage liver disease, and model for end-stage liver disease-Na scores in ACLF patients according to the CLIF-C definition (all P < 0.05), but there were no significant differences in patients without ACLF or in patients with ACLF according to the AARC definition. The CLIF-SOFAs, CLIF-C OFs, and CLIF-C ACLFs had higher specificities with a fixed sensitivity than liver specific scores in ACLF patients according to the CLIF-C definition, but not in ACLF patients according to the AARC definition.

CONCLUSIONS

The CLIF-SOFAs, CLIF-C OFs, and CLIF-C ACLFs are useful scoring systems that provide accurate information on prognosis in patients with ACLF according to the CLIF-C definition, but not the AARC definition.

Impairment of Hematopoietic Precursor Cell Activation during the Granulopoietic Response to Bacteremia in Mice with Chronic-Plus-Binge Alcohol Administration

Alcohol abuse impairs immune defense. To study the effect of chronic-plus-binge alcohol exposure on the granulopoietic response, acute alcohol intoxication (intraperitoneal injection of 5 g alcohol/kg body weight) was introduced to mice chronically fed on the Lieber-DeCarli low-fat liquid alcohol diet for 5 weeks. Bacteremia was induced by intravenous injection of Escherichia coli Bacteremia caused a remarkable increase in marrow lin^- c-kit⁺ Sca-1⁺ cells. Activation of cell proliferation supported the increase in marrow lin^- c-kit⁺ Sca-1⁺ cells. Alcohol administration inhibited this activation of lin^- c-kit⁺ Sca-1⁺ cells. The bone marrow of pair-fed control mice receiving intraperitoneal saline stored a large number of mature granulocytes expressing a high level of Gr1 (Gr1^hi cells). The proportion of Gr1^hi cells and the total number of Gr1⁺ cells were markedly reduced in the bone marrow, along with an increase in the ratio of Gr1⁺ granulocytes in peripheral white blood cells following bacteremia. E. coli infection stimulated proliferation of granulopoietic precursor cells, resulting in a marked increase in the ratio of immature Gr1^lo cells in the bone marrow. Alcohol administration itself triggered marrow release of Gr1⁺ cells, resulting in reduction of the marrow granulocyte reserve with an elevation of granulocytes in the circulation. Alcohol also impaired activation of granulopoietic precursor proliferation following bacteremia. Alcohol disrupted lipopolysaccharide (LPS)-TLR4-ERK1/2-cyclin D1 signaling and inhibited upregulation of Sca-1 and C/EBPβ expression by lineage-negative marrow cells in response to bacteremia. These results indicate that chronic-plus-binge alcohol exposure inhibits the granulopoietic response by disrupting key cell signaling for hematopoietic precursor cell activation and commitment to granulocyte lineage development.

Elevated serum prostaglandin E2 predicts the risk of infection in hepatitis B virus-related acute-on-chronic liver failure patients

OBJECTIVE

To evaluate the serum Prostaglandin E2 (PGE2) level in Acute-on-chronic liver failure (ACLF) and determine its predicative value for infection.

METHODS

From April 2014 to April 2015, ninety-one patients with hepatitis B virus and ACLF but without infection were enrolled into this prospective study that was carried out at our Hospital. Twenty patients with stable chronic hepatitis B were enrolled from the outpatient department and twenty healthy control subjects without any disease were enrolled from hospital staff. Serum PGE2 levels were determined using ELISA at enrollment. Clinical and laboratory parameters were collected. Receiver operating characteristic (ROC) curves were used to determine optimal cut-off values to predict infection.

RESULTS

Significantly higher PGE2 levels were found in patients with ACLF in comparison with healthy controls and patients with stable CHB (P < 0.0001). In ACLF patients, PGE2 levels were significantly higher in patients that eventually developed infection than those without this complication (P < 0.0001). ROC analysis showed that serum PGE2 (area under the ROC curve, 0.83) could predict infection in patients with ACLF with sensitivity of 78.4% and specificity of 81.5% using a threshold of 141 pg/mL.

CONCLUSIONS

Serum PGE2 is associated with the susceptibility to secondary infections for patients with ACLF. Increased PGE2 serum levels may serve as a potential biomarker for developing infections in ACLF patients.

Acute-on-chronic liver failure: recent update

Acute on chronic liver failure (ACLF) was first described in 1995 as a clinical syndrome distinct to classic acute decompensation. Characterized by complications of decompensation, ACLF occurs on a background of chronic liver dysfunction and is associated with high rates of organ failure and significant short-term mortality estimated between 45% and 90%. Despite the clinical relevance of the condition, it still remains largely undefined with continued disagreement regarding its precise etiological factors, clinical course, prognostic criteria and management pathways. It is concerning that, despite our relative lack of understanding of the condition, the burden of ACLF among cirrhotic patients remains significant with an estimated prevalence of 30.9%. This paper highlights our current understanding of ACLF, including its etiology, diagnostic and prognostic criteria and pathophysiology. It is evident that further refinement of the ACLF classification system is required in order to detect high-risk patients and improve short-term mortality rates. The field of metabolomics certainly warrants investigation to enhance diagnostic and prognostic parameters, while the use of granulocyte-colony stimulating factor is a promising future therapeutic intervention for patients with ACLF.

Validation of prognostic scores to predict short-term mortality in patients with HBV-related acute-on-chronic liver failure: The CLIF-C OF is superior to MELD, CLIF SOFA, and CLIF-C ACLF

Acute-on-chronic liver failure (ACLF) in chronic hepatitis B (CHB) patients has a high short-term mortality. Identification of effective models to predict the short-term mortality may enable early intervention and improve patients' prognosis. We aim to assess the performance of the CLIF Consortium Organ Failure score (CLIF-C OFs), CLIF sequential organ failure assessment score (CLIF-SOFAs), CLIF Consortium ACLF score (CLIF-C ACLFs), ACLF grade, and model for end-stage liver disease score (MELDs) in predicting the short-term mortality in CHB patients with ACLF.Among the 155 consecutive adult patients with liver failure as a discharge diagnosis were screened, and all the patients were treated at the Department of Infectious Diseases, Huashan Hospital, Fudan University (Shanghai, China) from January 2010 to February 2016. The diagnosis of ACLF was based on the criteria formalized by the ACLF consensus recommendations of the Asian Pacific Association for the Study of the Liver (APASL). Diagnostic accuracy for predicting short-term (28-day) mortality was calculated for CLIF-C OFs, CLIF-SOFAs, CLIF-C ACLFs, ACLF grade, and MELDs in all patients.One hundred fifty-five consecutive adult liver failure patients were screened and 85 patients including 73 males and 12 females were enrolled. Overall, the 28-day transplant-free mortality was 32% in all patients, and 100% in those with severe early course (ACLF-3). The area under the receiver operating characteristic curve (AUROC) of CLIF-C OFs (AUROC: 0.906, P = .0306, compared with MELDs) was higher than those of CLIF-SOFAs (AUROC: 0.876), CLIF-C ACLFs (AUROC: 0.858), ACLF grade (AUROC: 0.857), and MELDs (AUROC: 0.838) for predicting short-term mortality. The cut-point for baseline CLIF-C OFs in predicting death was 8.5, with 67% sensitivity, 90% specificity, and AUROC of 0.906 (95% CI: 0.8450-0.9679).The results indicate that short-term mortality is high in patients with ACLF and CLIF Consortium Organ Failure score is superior to MELD, CLIF SOFA, and CLIF-C ACLF in predicting its short-term mortality.

Plasma von Willebrand factor levels predict in-hospital survival in patients with acute-on-chronic liver failure

BACKGROUND AND AIMS

Circulating levels of von Willebrand factor (vWF) predict mortality in patients with cirrhosis. We hypothesized that systemic inflammation in acute-on-chronic liver failure (ACLF) will stimulate endothelium, increase vWF levels, and promote platelet microthrombi causing organ failure.

METHODS

In this prospective study, we correlated plasma vWF levels with organ failure, liver disease severity, sepsis, and systemic inflammatory response syndrome (SIRS) and also analyzed if vWF levels predicted in-hospital composite poor outcome (i.e. death/discharged in terminal condition/liver transplantation) in consecutive ACLF patients.

RESULTS

Twenty-one of the 50 ACLF patients studied had composite poor outcome. ACLF patients had markedly elevated vWF antigen and activity (sevenfold and fivefold median increase, respectively) on days 1 and 3. Median ratio of vWF to a disintegrin and metalloprotease with thrombospondin type 1 motif, member 13 (ADAMTS13) activity on day 1 was significantly higher in ACLF patients (11.2) compared to 20 compensated cirrhosis patients (3.3) and healthy volunteers (0.9). On day 1, area under ROC curve (AUROC) to predict composite poor outcome of hospital stay for ACLF patients for vWF antigen, vWF activity, and model for end-stage liver disease (MELD) score were 0.63, 0.68, and 0.74, respectively. vWF activity correlated better with liver disease severity (MELD score, ACLF grade) and organ failure (Sequential Organ Failure Assessment [SOFA] score) than vWF antigen; in contrast, neither vWF antigen nor activity correlated with platelet count, sepsis, or SIRS.

CONCLUSIONS

vWF levels are markedly elevated, correlate with organ failure, and predict in-hospital survival in ACLF patients. This data provides a mechanistic basis for postulating that vWF-reducing treatments such as plasma exchange may benefit ACLF patients.

Acute-on-chronic liver failure in cirrhosis

The definition of acute-on-chronic liver failure (ACLF) remains contested. In Europe and North America, the term is generally applied according to the European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) Consortium guidelines, which defines this condition as a syndrome that develops in patients with cirrhosis and is characterized by acute decompensation, organ failure and high short-term mortality. One-third of patients who are hospitalized for acute decompensation present with ACLF at admission or develop the syndrome during hospitalization. ACLF frequently occurs in a closed temporal relationship to a precipitating event, such as bacterial infection or acute alcoholic, drug-induced or viral hepatitis. However, no precipitating event can be identified in approximately 40% of patients. The mechanisms of ACLF involve systemic inflammation due to infections, acute liver damage and, in cases without precipitating events, probably intestinal translocation of bacteria or bacterial products. ACLF is graded into three stages (ACLF grades 1-3) on the basis of the number of organ failures, with higher grades associated with increased mortality. Liver and renal failures are the most common organ failures, followed by coagulation, brain, circulatory and respiratory failure. The 28-day mortality rate associated with ACLF is 30%. Depending on the grade, ACLF can be reversed using standard therapy in only 16-51% of patients, leaving a considerable proportion of patients with ACLF that remains steady or progresses. Liver transplantation in selected patients with ACLF grade 2 and ACLF grade 3 increases the 6-month survival from 10% to 80%.