Prognostic Scores in Acute Liver Failure Due to Viral Hepatitis

Silibinin alleviates acute liver failure by modulating AKT/GSK3β/Nrf2/GPX4 pathway

Silibinin (Sil) is a major bioactive component of silymarin, extracted from the fruit and seeds of Silybum marianum. Silibinin meglumine (SM) is a water-soluble derivative of silibinin that has shown significant potential in liver fibrosis. However, the potential effects and underlying mechanisms of SM on acute liver failure (ALF) are still not fully understood. This study aims to find the likely mechanism. An ALF mouse model and a cell model were established with GalN/LPS. SM was administered to mice via the tail vein or to a hepatocyte line (alpha mouse liver 12, AML12). The results showed that SM particularly lowered the mortality and improved liver pathological lesions in ALF mice. Meanwhile, SM improved the levels of GSH, SOD, TNF-α, IL-6, IL-1β, and IL-10 in the liver tissues and serum. Additionally, SM enhanced cell viability and reduced oxidative stress in vitro. In the AKT/GSK3β/Nrf2/GPX4 pathway, the subpathway of AKT/GSK3β was inhibited, and the subpathway of Nrf2/GPX4 was activated by SM both in vivo and in vitro. In addition, ferrostatin-1, a ferroptosis inhibitor, and the silencing of AKT using siRNA weakened the protective effect of SM, indicating that this process is mediated in an AKT-dependent manner. All the results suggested that SM inhibits inflammation and oxidative stress by modulating the AKT/GSK3β/Nrf2/GPX4 pathway.

Validation of prognostic scores for predicting acute liver failure and in-hospital death in patients with dengue-induced severe hepatitis

BACKGROUND

Acute liver failure (ALF) in dengue is rare but fatal. Early identification of patients who are at risk of ALF is the key strategy to improve survival.

AIM

To validate prognostic scores for predicting ALF and in-hospital mortality in dengue-induced severe hepatitis (DISH).

METHODS

We retrospectively reviewed 2532 dengue patients over a period of 16 years (2007-2022). Patients with DISH, defined as transaminases > 10 times the normal reference level and DISH with subsequent ALF, were included. Univariate regression analysis was used to identify factors associated with outcomes. Youden's index in conjunction with receiver operating characteristic (ROC) analysis was used to determine optimal cut-off values for prognostic scores in predicting ALF and in-hospital death. Area under the ROC (AUROC) curve values were compared using paired data nonparametric ROC curve estimation.

RESULTS

Of 193 DISH patients, 20 developed ALF (0.79%), with a mortality rate of 60.0%. International normalized ratio, bilirubin, albumin, and creatinine were independent predictors associated with ALF and death. Prognostic scores showed excellent performance: Model for end-stage liver disease (MELD) score ≥ 15 predicted ALF (AUROC 0.917, sensitivity 90.0%, specificity 88.4%) and ≥ 18 predicted death (AUROC 0.823, sensitivity 86.9%, specificity 89.1%); easy albumin-bilirubin (ALBI) score ≥ -30 predicted ALF and death (ALF: AUROC 0.835, sensitivity80.0%, specificity 72.2%; death: AUROC 0.808, sensitivity 76.9%, specificity 69.3%); ALBI score ≥ -2 predicted ALF and death (ALF: AUROC 0.806, sensitivity 80.0%, specificity 77.4%; death: AUROC 0.799, sensitivity 76.9%, specificity 74.3%). Platelet-ALBI score also showed good performance in predicting ALF and death (AUROC = 0.786 and 0.699, respectively). MELD and EZ-ALBI scores had similar performance in predicting ALF (Z = 1.688, P = 0.091) and death (Z = 0.322, P = 0.747).

CONCLUSION

MELD score is the best predictor of ALF and death in DISH patients. EZ-ALBI score, a simpler yet effective score, shows promise as an alternative prognostic tool in dengue patients.

A Case Report of Acute Liver Failure in a Child with Hepatitis a Virus and Epstein-Barr Virus Coinfection on the Background of Autoimmune Sclerosing Cholangitis

Background

Fulminant hepatitis is a rare and severe form of acute liver failure (ALF) characterized by rapid and massive destruction of liver cells and associated with a high mortality rate. Infectious factors, in particular viral hepatitis, take a prominent place in the etiology of ALF, however, the presence of chronic liver pathology can play a significant role in the disease progression and development of ALF.

Case Presentation

A 2-year-old child was hospitalized on the 4th day of the disease with manifestations of jaundice and general intoxication. The examination revealed markers of active hepatitis A virus infection and Epstein-Barr virus infection. From the seventh day of the disease, the child's condition began to progressively deteriorate due to manifestations of ALF. Despite the use of immunomodulatory and replacement therapy, the disease ended fatally on the 9th day. Pathohistological examination revealed manifestations of viral necrotic hepatitis on the background of autoimmune sclerosing cholangitis.

Conclusion

The case is novel as regards the occurrence of two viral hepatitis with different modes of transmission on a background of unidentified liver disease.

Viral hepatitis-induced acute liver failure

Viral hepatitis-induced acute liver failure (ALF) is a preventable cause for liver-related mortality worldwide. Viruses are the most common cause for ALF in developing nations in contrast to the west, where acetaminophen is largely responsible. Viruses may be hepatotropic or affect the liver secondary to a systemic infection. In tropical countries, infections such as leptospirosis, scrub typhus and malaria can mimic the symptoms of ALF. Differentiating these ALF mimics is crucial because they require etiology-specific therapy. Treatment of viral hepatitis-induced ALF is two-pronged and directed towards providing supportive care to prevent organ failures and antiviral drugs for some viruses. Liver transplantation (LT) is an effective modality for patients deteriorating despite adequate supportive care. Early referral and correct identification of patients who require a transplant are important. Liver support devices and plasma exchange have evolved into "bridging modalities" for LT. Preventive strategies such as hand hygiene, use of clean and potable water and inclusion of vaccines against viral hepatitis in the national program are simple yet very effective methods focusing on the preventive aspect of this disease.

The burden of HEV-related acute liver failure in Bangladesh, China and India: a systematic review and meta-analysis

BACKGROUND

Hepatitis E can potentially progress to HEV-related acute liver failure (HEV-ALF). East and South Asia bear a substantial burden of HEV infection, with Bangladesh, China, and India facing the most severe threat in this region. Therefore, we conducted a systematic review and meta-analysis to evaluate the burden of HEV-ALF in these three high-risk countries.

METHODS

A systematic literature search was performed utilizing PubMed, the Cochrane Library, Medline, Embase, and Web of Science databases. Studies in English or Chinese that reported data on the burden of HEV-ALF in Bangladesh, China and India were included. Outcomes were pooled with meta-analysis utilizing R software. Estimates were calculated with random-effects models, and subgroup analysis and sensitivity analysis were conducted to address heterogeneity. Egger's test and Begg's test were performed to assess publication bias.

RESULTS

A total of 20 eligible studies were included in this study. The pooled HEV-attributable proportion of viral-related acute liver failure was estimated to be 40.0% (95% CI: 0.28-0.52), 30.0% (95% CI: 0.18-0.44), and 61.0% (95% CI: 0.49-0.72) among non-pregnant individuals in India, China and Bangladesh, while in Indian pregnant females, it was 71.0% (95% CI: 0.62-0.79). The combined prevalence among non-pregnant HEV-infected participants was 28.0% (95% CI: 0.20-0.37) and 10.0% (95% CI: 0.01-0.28) in India and China, and it was 34.0% (95% CI: 0.27-0.42) in Indian pregnant females with HEV infection. The overall mortality of HEV-ALF was estimated to be 32.0% (95% CI: 0.23-0.42) and 64.0% (95% CI: 0.50-0.77) among the non-pregnant and the pregnant participants in India, and it was 23.0% (95% CI: 0.14-0.34) in Chinese non-pregnant participants.

CONCLUSIONS

The burden of HEV-ALF in Bangladesh, China, and India is non-negligible despite geographic and population heterogeneity. The prevention of HEV infection and early recognition of HEV-ALF are of great significance, especially in high-risk countries and populations.

REGISTRATION

PROSPERO registration ID is CRD42022382101.