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Singh J, Ebaid M, Saab S. Advances in the management of complications from cirrhosis. Gastroenterol Rep (Oxf) 2024; 12:goae072. [PMID: 39104730 PMCID: PMC11299547 DOI: 10.1093/gastro/goae072] [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] [Received: 03/21/2024] [Revised: 05/29/2024] [Accepted: 06/15/2024] [Indexed: 08/07/2024] Open
Abstract
Cirrhosis with complications of liver decompensation and hepatocellular carcinoma (HCC) constitute a leading cause of morbidity and mortality worldwide. Portal hypertension is central to the progression of liver disease and decompensation. The most recent Baveno VII guidance included revision of the nomenclature for chronic liver disease, termed compensated advanced chronic liver disease, and leveraged the use of liver stiffness measurement to categorize the degree of portal hypertension. Additionally, non-selective beta blockers, especially carvedilol, can improve portal hypertension and may even have a survival benefit. Procedural techniques with interventional radiology have become more advanced in the management of refractory ascites and variceal bleeding, leading to improved prognosis in patients with decompensated liver disease. While lactulose and rifaximin are the preferred treatments for hepatic encephalopathy, many alternative treatment options may be used in refractory cases and even procedural interventions such as shunt embolization may be of benefit. The approval of terlipressin for the treatment of hepatorenal syndrome (HRS) in the USA has improved the way in which HRS is managed and will be discussed in detail. Malnutrition, frailty, and sarcopenia lead to poorer outcomes in patients with decompensated liver disease and should be addressed in this patient population. Palliative care interventions can lead to improved quality of life and clinical outcomes. Lastly, the investigation of systemic therapies, in particular immunotherapy, has revolutionized the management of HCC. These topics will be discussed in detail in this review.
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Affiliation(s)
- Jasleen Singh
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Mark Ebaid
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Sasaki T, Kakisaka K, Kuroda H, Matsumoto T. Nutritional management for acute liver failure. Hepatol Res 2024; 54:736-744. [PMID: 38949571 DOI: 10.1111/hepr.14090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 06/04/2024] [Accepted: 06/14/2024] [Indexed: 07/02/2024]
Abstract
Acute liver failure (ALF) induces increased energy expenditure and disrupts the metabolism of essential nutrients. Hepatic encephalopathy is a complication of ALF with a poor prognosis and mainly involves the metabolic disturbance of amino acids in its pathogenesis. In this review, we discuss the nutritional management for ALF in consideration of the pathophysiology of ALF with respect to the impairment of hepatocyte function. It is known that enteral nutrition is recommended for patients with ALF, while parenteral nutrition is recommended for patients who cannot tolerate enteral nutrition. As ALF leads to a hypermetabolic state, the energy intake is recommended to cover 1.3 times the resting energy expenditure. Because of the high risk of hypoglycemia associated with disturbances in glucose metabolism, substantial glucose intake is recommended. Along with the deterioration of glucose metabolism, protein metabolism is also disrupted. As patients with ALF have increased systemic protein catabolism together with decreased protein synthesis, appropriate amounts of amino acids or protein under monitoring serum ammonia levels are recommended. In conclusion, nutritional management based on the understanding of nutritional pathophysiology is a pivotal therapeutic approach for patients with ALF. The approach should be individualized in the acute phase, the recovery phase, and the pretransplant phase.
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Affiliation(s)
- Tokio Sasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, School of Medicine, Yahaba, Japan
| | - Keisuke Kakisaka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, School of Medicine, Yahaba, Japan
| | - Hidekatsu Kuroda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, School of Medicine, Yahaba, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, School of Medicine, Yahaba, Japan
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Singh J, Ibrahim B, Han SH. Nontraditional Treatment of Hepatic Encephalopathy. Clin Liver Dis 2024; 28:297-315. [PMID: 38548441 DOI: 10.1016/j.cld.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
The pathophysiology of hepatic encephalopathy (HE) is complex, with hyperammonemia playing a central role in its development. Traditional therapies for HE have targeted ammonia and include medications such as lactulose and rifaximin. Although these agents are considered standard of care, nontraditional treatments seek to affect other factors in the pathogenesis of HE. Finally, procedural therapies include albumin dialysis, shunt closure, and the ultimate cure for HE, which is liver transplant. The treatments discussed provide alternative options for patients who have failed standard of care. However, more high-quality studies are needed to routinely recommend many of these agents.
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Affiliation(s)
- Jasleen Singh
- Department of Medicine, University of California at Los Angeles; Los Angeles, CA, USA.
| | - Brittney Ibrahim
- Department of Surgery, University of California at Los Angeles; Los Angeles, CA, USA
| | - Steven-Huy Han
- Department of Medicine, University of California at Los Angeles; Los Angeles, CA, USA; Department of Surgery, University of California at Los Angeles; Los Angeles, CA, USA
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Ilie OD, Duta R, Nita IB, Dobrin I, Gurzu IL, Girleanu I, Huiban L, Muzica C, Ciobica A, Popescu R, Cianga P, Stanciu C, Cimpoesu D, Trifan A. A Comprehensive Overview of the Past, Current, and Future Randomized Controlled Trials in Hepatic Encephalopathy. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2143. [PMID: 38138246 PMCID: PMC10744451 DOI: 10.3390/medicina59122143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/01/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023]
Abstract
Background: Hepatic encephalopathy (HE) caused by cirrhosis has severe consequences on an individual's lifespan, leading to long-term liver complications and potentially life-threatening outcomes. Despite recent interest in this condition, the effectiveness of secondary prophylaxis involving rixafimin, lactulose, or L-ornithine L-aspartate (LOLA) may be hindered by the unique microbial profiles each patient possesses. Methods: Thus, in this manuscript, we aimed to search, identify, and gather all randomized controlled trials (RCTs) published between 2000-2023 (November) in four major academic databases such as PubMed, ISI Web of Science, Scopus, and ScienceDirect by using a controlled terminology and web strings that reunite six main keywords. We complementarily retrieved data on the ongoing RCTs. Results: Regardless of the relatively high number of results displayed (n = 75), 46.66% (n = 35) were initially deemed eligible after the first evaluation phase after removing duplicates, n = 40 (53.34%). At the second assessment stage, we eliminated 11.42% (n = 4) studies, of which n = 22 finally met the eligibility criteria to be included in the main body of the manuscript. In terms of RCTs, otherwise found in distinct stages of development, n = 3 target FMT and n = 1 probiotics. Conclusions: Although we benefit from the necessary information and technology to design novel strategies for microbiota, only probiotics and synbiotics have been extensively studied in the last decade compared to FMT.
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Affiliation(s)
- Ovidiu-Dumitru Ilie
- Gastroenterology Group, CENEMED Platform for Interdisciplinary Research, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
| | - Raluca Duta
- Gastroenterology Group, CENEMED Platform for Interdisciplinary Research, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
| | - Ilinca-Bianca Nita
- Department of Medicine III, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
| | - Irina Dobrin
- Department of Medicine III, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
- Institute of Psychiatry “Socola”, Bucium Street No. 36, 700282 Iasi, Romania
| | - Irina-Luciana Gurzu
- Department of Preventive Medicine and Interdisciplinarity, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
| | - Irina Girleanu
- Department of Gastroenterology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” County Emergency Clinical Hospital, Independence Avenue No. 1, 700111 Iasi, Romania
| | - Laura Huiban
- Department of Gastroenterology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” County Emergency Clinical Hospital, Independence Avenue No. 1, 700111 Iasi, Romania
| | - Cristina Muzica
- Department of Gastroenterology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” County Emergency Clinical Hospital, Independence Avenue No. 1, 700111 Iasi, Romania
| | - Alin Ciobica
- Department of Biology, Faculty of Biology, “Alexandru Ioan Cuza” University, Carol I Avenue No. 20A, 700505 Iasi, Romania
- Centre of Biomedical Research, Romanian Academy, Carol I Avenue No. 8, 700506 Iasi, Romania
- Academy of Romanian Scientists, Splaiul Independentei No. 54, Sector 5, 050094 Bucharest, Romania
- Preclinical Department, “Apollonia” University, Păcurari Street No. 11, 700511 Iasi, Romania
| | - Roxana Popescu
- Department of Medical Genetics, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
- Department of Medical Genetics, “Saint Mary” Emergency Children’s Hospital, Vasile Lupu Street No. 62, 700309 Iasi, Romania
| | - Petru Cianga
- Department of Immunology, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
| | - Carol Stanciu
- Centre of Biomedical Research, Romanian Academy, Carol I Avenue No. 8, 700506 Iasi, Romania
| | - Diana Cimpoesu
- Gastroenterology Group, CENEMED Platform for Interdisciplinary Research, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
- Department of Emergency Medicine, “St. Spiridon” County Emergency Clinical Hospital, Independence Avenue No. 1, 700111 Iasi, Romania
| | - Anca Trifan
- Department of Gastroenterology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street No. 16, 700115 Iasi, Romania
- Institute of Gastroenterology and Hepatology, “St. Spiridon” County Emergency Clinical Hospital, Independence Avenue No. 1, 700111 Iasi, Romania
- Centre of Biomedical Research, Romanian Academy, Carol I Avenue No. 8, 700506 Iasi, Romania
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Qi W, Ge Y, Wang X, Li Z, Li X, Wang N, He H, Luo X, Ma W, Chen L, Liu Y, Zhang T. Ameliorative Effect of Chitosan Oligosaccharides on Hepatic Encephalopathy by Reshaping Gut Microbiota and Gut-Liver Axis. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2022; 70:13186-13199. [PMID: 36194761 DOI: 10.1021/acs.jafc.2c01330] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
This study investigated the influence of chitosan oligosaccharides (COSs) on a thioacetamide-induced hepatic encephalopathy (HE) Wistar rat model. COS treatment statistically reduced the false neurotransmitters and blood ammonia in HE rats, along with the suppression of oxidative stress and inflammation. The disbalanced gut microbiota was detected in HE rats by 16S rDNA sequencing, but the abundance alterations of some intestinal bacteria at either the phylum or genus level were at least partly restored by COS treatment. According to metabolomics analysis of rat feces, six metabolism pathways with the greatest response to HE were screened, several of which were remarkably reversed by COS. The altered metabolites might serve as a bridge for the alleviated HE rats treated with COS and the enhanced intestinal bacterial structure. This study provides novel guidance to develop novel food or dietary supplements to improve HE diseases due to the potential beneficial effect of COS on gut-liver axis.
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Affiliation(s)
- Wei Qi
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Yanyan Ge
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Xinyue Wang
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Zihan Li
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Xiaoxue Li
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Nan Wang
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Hongpeng He
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Xuegang Luo
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Wenjian Ma
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Liehuan Chen
- New Youlan Healthy Technology Co., Ltd., Guangzhou 510530, Guangdong, P. R. China
| | - Yihan Liu
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
| | - Tongcun Zhang
- Key Laboratory of Industrial Fermentation Microbiology, Ministry of Education, Tianjin Key Laboratory of Industrial Microbiology, The College of Biotechnology, Tianjin University of Science and Technology, Tianjin 300457, P. R. China
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