Human albumin solution for patients with cirrhosis and acute on chronic liver failure: Beyond simple volume expansion

Quality Evaluation of Guidelines for the Diagnosis and Treatment of Liver Failure

OBJECTIVES

This study aimed to systematically assess the methodological quality and key recommendations of the guidelines for the diagnosis and treatment of liver failure (LF), furnishing constructive insights for guideline developers and equipping clinicians with evidence-based information to facilitate informed decision-making.

DATA SOURCES

Electronic databases and manual searches from January 2011 to August 2023.

STUDY SELECTION

Two reviewers independently screened titles and abstracts, then full texts for eligibility. Fourteen guidelines were included.

DATA EXTRACTION AND SYNTHESIS

Two reviewers extracted data and checked by two others. Methodological quality of the guidelines was appraised using the Appraisal of Guidelines for Research and Evaluation II tool. Of the 14 guidelines, only the guidelines established by the Society of Critical Care Medicine and the American College of Gastroenterology (2023) achieved an aggregate quality score exceeding 60%, thereby meriting clinical recommendations. It emerged that there remains ample room for enhancement in the quality of the guidelines, particularly within the domains of stakeholder engagement, rigor, and applicability. Furthermore, an in-depth scrutiny of common recommendations and supporting evidence drawn from the 10 adult LF guidelines unveiled several key issues: controversy exists in the recommendation, the absence of supporting evidence and confusing use of evidence for recommendations, and a preference in evidence selection.

CONCLUSIONS

There are high differences in methodological quality and recommendations among LF guidelines. Improving these existing problems and controversies will benefit existing clinical practice and will be an effective way for developers to upgrade the guidelines.

Antibacterial and cytotoxicity studies of pyrrolo-based organic scaffolds and their binding interaction with bovine serum albumin

Two pyrrolo-based compounds, 1H-pyrrolo[3,2-b]pyridine-3-carboxylic acid (L1) and 1H-pyrrolo[3,2-c]pyridine-4-carboxylic acid (L2), were employed for the detection of bovine serum albumin (BSA) by UV-Vis and fluorescence spectroscopic methods in phosphate buffer solution (pH = 7). In the presence of L1 and L2, the fluorescence emission of BSA at 340 nm was quenched and concomitantly a red-shifted emission band appeared at 420 nm (L1)/450 nm (L2). The fluorescence spectral changes indicate the protein-ligand complex formation between BSA and L1/L2. An isothermal titration calorimetry (ITC) experiment was conducted to determine the binding ability between BSA and L1/L2. The binding constants are found to be 4.45 ± 0.22 × 104 M-1 for L1 and 2.29 ± 0.11 × 104 M-1 for L2, respectively. The thermodynamic parameters were calculated from ITC measurements (i.e. ∆rH = -40 ± 2 kcal/mol, ∆rG = -4.57 ± 0.22 kcal/mol and -T∆rS = 35.4 ± 1.77 kcal/mol), which indicated that the protein-ligand complex formation between L1/L2 with BSA is mainly due to the electrostatic interactions. The protein-ligand interactions were studied by performing molecular docking. Further, the antibacterial assay of L1 and L2 was conducted against gram-positive and gram-negative bacterial strains in an effort to address the difficulties caused by the co-occurrence of antimicrobial and multidrug-resistant bacteria. E. coli and S. aureus were significantly inhibited by L1 and L2. The L1 exhibits 13, 12 and 15 mm, whereas L2 exhibits a 2, 3 and 5 mm zone of inhibition against S. aureus, S. pyogenes and E. coli, respectively. In silico molecular docking of L1 and L2 was performed with bacterial DNA gyrase to establish the intermolecular interactions. Finally, the in vitro cytotoxicity activities of the ligands L1 and L2 have been carried out using drosophila.

European Society of Intensive Care Medicine clinical practice guideline on fluid therapy in adult critically ill patients. Part 1: the choice of resuscitation fluids

PURPOSE

This is the first of three parts of the clinical practice guideline from the European Society of Intensive Care Medicine (ESICM) on resuscitation fluids in adult critically ill patients. This part addresses fluid choice and the other two will separately address fluid amount and fluid removal.

METHODS

This guideline was formulated by an international panel of clinical experts and methodologists. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was applied to evaluate the certainty of evidence and to move from evidence to decision.

RESULTS

For volume expansion, the guideline provides conditional recommendations for using crystalloids rather than albumin in critically ill patients in general (moderate certainty of evidence), in patients with sepsis (moderate certainty of evidence), in patients with acute respiratory failure (very low certainty of evidence) and in patients in the perioperative period and patients at risk for bleeding (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than albumin in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using albumin rather than crystalloids in patients with cirrhosis (very low certainty of evidence). The guideline provides conditional recommendations for using balanced crystalloids rather than isotonic saline in critically ill patients in general (low certainty of evidence), in patients with sepsis (low certainty of evidence) and in patients with kidney injury (very low certainty of evidence). There is a conditional recommendation for using isotonic saline rather than balanced crystalloids in patients with traumatic brain injury (very low certainty of evidence). There is a conditional recommendation for using isotonic crystalloids rather than small-volume hypertonic crystalloids in critically ill patients in general (very low certainty of evidence).

CONCLUSIONS

This guideline provides eleven recommendations to inform clinicians on resuscitation fluid choice in critically ill patients.

Assessing resuscitation in burn patients with varying degrees of liver disease

We find minimal literature and lack of consensus among burn practitioners over how to resuscitate thermally injured patients with pre-existing liver disease. Our objective was to assess burn severity in patients with a previous history of liver disease. We attempted to stratify resuscitation therapy utilised, using it as an indicator of burn shock severity. We hypothesized that as severity of liver disease increased, more fluid therapy is needed. We retrospectively studied adult patients with a total body surface area (TBSA) of burn greater than or equal to 20% (n = 314). We determined the severity of liver disease by calculating admission Model for End-Stage Liver Disease (MELD) scores and measured resuscitation adequacy via urine output within the first 24 h. We performed stepwise, multivariable linear regression with backward selection to test our hypothesis with α = 0.05 defined a priori. After controlling for important confounders including age, TBSA, baseline serum albumin, total crystalloids, colloids, blood products, diuretics, and steroids given in first 24 h, we found a statistically significant reduction in urine output as MELD score increased (p < 0.000). In our study, severity of liver disease correlated with declining urine output during first 24-hour resuscitation more so than burn size or burn depth. While resuscitation is standardized for all patients, lack of urine output with increased liver disease suggests a new strategy is of benefit. This may involve investigation of alternate markers of adequacy of resuscitation, or developing modified resuscitation protocols for use in patients with liver disease. More investigation is necessary into how resuscitation protocols may best be modified.

Role of albumin infusion in cirrhosis-associated complications

Cirrhosis is an advanced-stage liver disease that occurs due to persistent physiological insults such as excessive alcohol consumption, infections, or toxicity. It is characterised by scar tissue formation, portal hypertension, and ascites (accumulation of fluid in the abdominal cavity) in decompensated cirrhosis. This review evaluates how albumin infusion ameliorates cirrhosis-associated complications. Since albumin is an oncotic plasma protein, albumin infusion allows movement of water into the intravascular space, aids with fluid resuscitation, and thereby contributes to resolving cirrhosis-induced hypovolemia (loss of extracellular fluid) seen in ascites. Thus, albumin infusion helps prevent paracentesis-induced circulatory dysfunction, a complication that occurs when treating ascites. When cirrhosis advances, other complications such as spontaneous bacterial peritonitis and hepatorenal syndrome can manifest. Infused albumin helps mitigate these by exhibiting plasma expansion, antioxidant, and anti-inflammatory functions. In hepatic encephalopathy, albumin infusion is thought to improve cognitive function by reducing ammonia concentration in blood and thereby tackle cirrhosis-induced hepatocyte malfunction in ammonia clearance. Infused albumin can also exhibit protective effects by binding to the cirrhosis-induced proinflammatory cytokines TNFα and IL6. While albumin administration has shown to prolong overall survival of cirrhotic patients with ascites in the ANSWER trial, the ATTIRE and MACHT trials have shown either no effect or limitations such as development of pulmonary oedema and multiorgan failure.  Thus, albumin infusion is not a generic treatment option for all cirrhosis patients. Interestingly, cirrhosis-induced structural alterations in native albumin (which lead to formation of different albumin isoforms) can be used as prognostic biomarkers because specific albumin isoforms indicate certain complications of decompensated cirrhosis.

Research Progress of Macromolecules in the Prevention and Treatment of Sepsis

Sepsis is associated with high rates of mortality in the intensive care unit and accompanied by systemic inflammatory reactions, secondary infections, and multiple organ failure. Biological macromolecules are drugs produced using modern biotechnology to prevent or treat diseases. Indeed, antithrombin, antimicrobial peptides, interleukins, antibodies, nucleic acids, and lentinan have been used to prevent and treat sepsis. In vitro, biological macromolecules can significantly ameliorate the inflammatory response, apoptosis, and multiple organ failure caused by sepsis. Several biological macromolecules have entered clinical trials. This review summarizes the sources, efficacy, mechanism of action, and research progress of macromolecular drugs used in the prevention and treatment of sepsis.

New look at the metabolism of nonsteroidal anti-inflammatory drugs: influence on human serum albumin antioxidant activity

Body's homeostasis is dependent on many factors, such as maintaining balance between free radicals formation and degradation. Human serum albumin (HSA) also plays an important role in homeostasis. The aim of this study was thermodynamic analysis of the interaction between ketoprofen (KET), naproxen (NPX), diclofenac (DIC) and HSA, as well as the effect of drug-albumin binding on HSA antioxidant activity using calorimetric and spectrophotometric techniques. Based on the calorimetric analysis it has been shown that accompanied by hydrophobic interaction drugs-albumin binding is an exoenergetic reaction. All analyzed drugs and HSA showed the ability to react with free radicals such as a radical cation, formed as a result of the reaction between 2,2'-Azino-bis(3-ethylbenzothiazoline-6-sulfonic acid) diammonium salt (ABTS) and potassium persulfate (K₂S₂O₈). Using ABTS assay a synergistic effect of ketoprofen (KET) and naproxen (NPX) on HSA antioxidant activity was observed while the effect of diclofenac (DIC) binding with albumin was probably additive. Because some medications including KET, NPX and DIC belong to over the counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs), it is necessary to understand their influence on HSA antioxidant activity.Communicated by Ramaswamy H. Sarma.

Molecularly Imprinted Polymer-Based Sensors for Protein Detection

The accurate detection of biological substances such as proteins has always been a hot topic in scientific research. Biomimetic sensors seek to imitate sensitive and selective mechanisms of biological systems and integrate these traits into applicable sensing platforms. Molecular imprinting technology has been extensively practiced in many domains, where it can produce various molecular recognition materials with specific recognition capabilities. Molecularly imprinted polymers (MIPs), dubbed plastic antibodies, are artificial receptors with high-affinity binding sites for a particular molecule or compound. MIPs for protein recognition are expected to have high affinity via numerous interactions between polymer matrices and multiple functional groups of the target protein. This critical review briefly describes recent advances in the synthesis, characterization, and application of MIP-based sensor platforms used to detect proteins.

Differentiation of HSA and BSA and Instantaneous Detection of HSO3 - Using Confined Space of Serum Albumins and Live Cell Imaging of Exogenous/Endogenous HSO3. ACS OMEGA 2023;8:2639-2647. [PMID: 36687064 PMCID: PMC9851030 DOI: 10.1021/acsomega.2c07163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

The limitations of prevailing probes for the detection of human serum albumin (HSA) and HSO3 - make it challenging to apprehend the cooperative effect of both HSA and HSO3 - in biological systems. Herein, we present a multi-responsive fluorescent probe MGTP, which distinguishes HSA from bovine serum albumin (BSA) through an ∼104-fold fluorescence enhancement at an emission maximum of 595 nm with HSA and only an ∼10-fold increase at an emission maximum of 615 nm with a shoulder at 680 nm with BSA. The absorbance spectrum of MGTP also discriminates HSA and BSA with the respective absorption maxima at 543 nm and at 580 nm. MGTP in the confined space of HSA or BSA undergoes instantaneous conjugate addition of HSO3 - and results in a ratiometric change in fluorescence intensity with diminishing of red fluorescence (600 nm) and emergence of green fluorescence (515 nm). MGTP in the absence of SAs does not react with HSO3 - in phosphate-buffered saline buffer and reacts sluggishly in the dimethyl sulfoxide-water 1:1 mixture. The limit of detection values for the detection of HSA and HSO3 - are 4 and 6.88 nM, respectively. The drug binding studies reveal that MGTP preferably confines itself at the bilirubin site of HSA. In MCF-7 cancer cells, MGTP is localized into mitochondria and reveals both exogenous and endogenous visualization of HSO3 - through a change in fluorescence from the red to green channel.

Effects of Albumin Supplements on In-Hospital Mortality in Patients with Sepsis or Septic Shock: A Systemic Review and Meta-Analysis

Objective

To explore the clinical effects of albumin supplements on the basis of crystalloid solution in patients with sepsis or septic shock.

Methods

The online databases including PubMed, Web of Science, Cochrane Library, and EMBASE were comprehensively searched from inception to June 28, 2021, with the keywords including “albumin,” “sepsis,” or “septic shock.” Retrospective cohort (RC) and randomized controlled trials (RCT) were included for analysis. Two authors independently searched and analyzed the literature. The in-hospital mortality at 7 days and 28 days, duration of mechanical ventilation, renal replacement therapy, length of ICU stay, and length of hospital stay were compared between patients with albumin supplements and crystalloid solution and those with crystalloid alone.

Results

A total of 10 studies with 6463 patients were eventually included for meta-analysis. The in-hospital mortality of patients at 7 days (OR = 1.00, 95% CI: 0.81–1.23) and 28 days (OR = 1.02, 95% CI: 0.91–1.13) did not show a significant difference between the two groups of patients. Also, the pooled results demonstrated no significant differences in duration of mechanical ventilation (OR = 0.29, 95% CI: −0.05–0.63), renal replacement therapy (WMD = 1.15, 95% CI: 0.98–1.35), length of ICU stay (WMD = −0.07, 95% CI: −0.62–0.48), and length of hospital stay (WMD = −0.09, 95% CI: −0.70–0.52) between patients receiving albumin plus crystalloid solution and those with crystalloid solution alone.

Conclusion

Albumin supplements on the basis of crystalloid solution did not improve the 7-day and 28-dayin-hospital mortality in patients with sepsis or septic shock compared with those with crystalloid solution alone.

Fluorescent turn-on sensing of albumin proteins (BSA and ovalbumin) using vitamin B6 cofactor derived Schiff base

The detection of albumin proteins with high accuracy by facile analytical approaches is important for the diagnosis of various diseases. This manuscript introduced an easy-to-prepare Schiff base L by condensing vitamin B₆ cofactor pyridoxal 5'-phosphate (PLP) with 2-aminothiophenol for the fluorescence turn-on sensing of bovine serum albumin (BSA) and ovalbumin (OVA). The weakly emissive L showed a significant fluorescence enhancement at 485 and 490 nm in the presence of OVA and BSA with an estimated sensitivity limit of 1.7 µM and 0.3 µM, respectively. The formation of protein-ligand complex restricted the free intramolecular rotation of L is expected to show the selective fluorescence enhancement. The molecular docking and molecular dynamics simulations were performed to examine the binding affinity and modes between BSA/OVA and L. The practical utility of L as a fluorescent turn-on sensor was validated by quantifying BSA and OVA in various real biological samples of milk, serum, egg white and urine with good recovery percentages.

Synthesis and preparation of vitamin A coupled butein-loaded solid lipid nanoparticles for liver fibrosis therapy in rats

The development of a therapeutic system for hepatic fibrosis has become a research hotspot to date. Butein, a simple chalcone derivative, displays anti-fibrotic effects through different pathways. However, impurities, low solubility, and low concentration in the target tissue hinder therapy with herbal ingredients. Hepatic stellate cells (HSCs), the vitamin A (VA) storage cells, as the main contributors to liver fibrogenesis, are not readily accessible to drugs owing to their anatomical location. Targeted delivery of therapeutics to the activated HSCs is therefore critical for successful treatment. For these reasons, the current study aimed at increasing butein delivery to the liver. Hence, high purity butein was synthesized in three steps. A novel VA-Myrj52 ester conjugate was also synthesized using all-trans retinoic acid and a hydrophilic emulsifier (Myrj52) as a targeting agent. Next, butein was encapsulated inside the novel VA-modified solid lipid nanoparticles (VA-SLNs) and studied in vitro and in vivo. According to our evaluations, negatively charged SLNs with a mean diameter of 150 nm and entrapment efficacy of 75 % were successful in liver fibrosis amelioration. Intraperitoneal (i.p.) injection of VA-SLNs in fibrotic rats, for four weeks long, reduced serum AST and ALT by 58% (P, 0.001) and 72% (P, 0.05), respectively, concerning the CCl₄ group. Additionally, histologic damage score decline and normalization of tissue oxidative stress markers collectively confirmed the efficacy of formulations in hepatic fibrosis and kidney damage amelioration.

Platelet-hemoglobin ratio predicts amputation in patients with below-knee peripheral arterial disease

BACKGROUND

Peripheral arterial disease (PAD) causes significant morbidity today. Atherosclerosis is evident in the pathophysiological process in most patients, so PAD has similar risk factors as coronary artery disease. Platelet-Hemoglobin ratio (PHR) has been proven to predict mortality in atherosclerotic heart disease. We aimed to determine the relationship between PHR and below-knee amputation.

METHODS

The study is a single-center retrospective study. Platelet count/hemoglobin amount formula was used for PHR. Only PAD patients with below-knee critical extremity ischemia and unsuitable for revascularization were included in the study.

RESULTS

235 patients were included in the study retrospectively. The mean age was 65.7 ± 9.9 years and 175(74.5%) of them were male. In the amputated group, white blood cell, neutrophil, platelet, creatinine, glucose, and PHR were higher (p = .031, p = .045, p = .011, p = .048 p = .018, p = .004, respectively). Only hemoglobin values were lower (p = .003). Multivariable regression analysis showed; age, albumin and PHR were determined as independent risk factors for amputation (Age; OR (95%CI): (1.094(1.040-1.152), p = .001) (Albumin; OR (95% CI): 1.950(1.623-1.799), p = .001) (PHR; OR (95% CI): 1.872(1.246-2.812), p = .003). Receiver operating characteristics analysis performed to determine the optimal cut-off value of PHR for amputation, the optimal value was found 2.08 (65.8% sensitivity, 67.5% specificity, p < .001).

CONCLUSIONS

PHR was a good predictor for BKA. Using the PHR, it may be possible to identify high-risk patients for amputation.

The patient with cirrhosis in the intensive care unit and the management of acute-on-chronic liver failure

Acute on chronic liver failure (ACLF) is a clinical syndrome characterised by acute hepatic decompensation, multi-organ failure and high mortality, in patients with cirrhosis.  Organ dysfunction in ACLF is often reversible and when necessary these patients should be considered appropriate candidates for admission to an intensive care unit (ICU). The yearly increase in numbers of patients with ACLF admitted to ICU has been matched with an improvement in survival.  ACLF has only been recently defined. In the absence of evidence-based guidelines we outline a systems-based approach to care which encompasses accepted ICU practice and evidence from trials in this cohort. We advocate for timely referral to specialist liver centres and consider the complexities of proceeding with liver transplantation. Equally, in a proportion of patients who continue to deteriorate, appropriate ceilings of care should be established.  Future clinical trials may change treatment paradigms but care of patients with ACLF is undoubtedly becoming an integral part of an intensivist's practice. We hope that this review is a welcome starting point when managing this complex clinical syndrome.

QCM-based assay designs for human serum albumin

Solid-phase synthesis is an elegant way to create molecularly imprinted polymer nanoparticles (nano-MIPs) comprising a single binding site, i.e. mimics of antibodies. When using human serum albumin (HSA) as the template, one achieves nano-MIPs with 53 ± 19 nm diameter, while non-imprinted polymer nanoparticles (nano-NIPs) reach 191 ± 96 nm. Fluorescence assays lead to Stern-Volmer plots revealing selective binding to HSA with selectivity factors of 1.2 compared to bovine serum albumin (BSA), 1.9 for lysozyme, and 4.1 for pepsin. Direct quartz crystal microbalance (QCM) assays confirm these results: nano-MIPs bind to HSA immobilized on QCM surfaces. This opens the way for competitive QCM-based assays for HSA: adding HSA to nanoparticle solutions indeed reduces binding to the QCM surfaces in a concentration-dependent manner. They achieve a limit of detection (LoD) of 80 nM and a limit of quantification (LoQ) of 244 nM. Furthermore, the assay shows recovery rates around 100% for HSA even in the presence of competing analytes.

Treatment of Severe Acute on Chronic Liver Failure: Management of Organ Failures, Investigational Therapeutics, and the Role of Liver Transplantation

Acute on chronic liver failure (ACLF) is a unique syndrome that afflicts patients with chronic liver disease and results in high short-term mortality, in the setting of organ system failures. Given this prognosis, there is an urgent need to understand risk factors for this condition, for appropriate medical management of organ failures, and for selection criteria for patients who may benefit from liver transplantation (LT). Although several definitions exist to identify ACLF, all of them are designed to identify patients with uniquely high mortality. Currently, management of severe ACLF relies on best supportive care for specific organ failures. Thromboelastography should guide the evaluation of coagulation pathways and hyperfibrinolysis in ACLF; prophylactic blood product transfusions and thrombopoetin agonists are not recommended. Combination therapy with terlipressin and albumin has been shown to be efficacious in the management of the hepatorenal syndrome but should be administered with caution in patients with ACLF-3. Recent data have characterized the role of beta-blockers and transjugular intrahepatic portosystemic shunt placement in the management of ACLF. Investigational therapies such as extracorporeal liver support and hepatocyte stem cell therapies have shown promise; larger scale studies may better define the subpopulations of patients with ACLF mostly likely to benefit from these evolving therapeutics. Regarding LT in ACLF, data suggest that even patients with 3 or more organ system failures may have a 1-year survival >80%. However, further efforts are needed to understand the predictors of post-LT survival to facilitate LT criteria for this condition.

Association Between Serum Albumin Levels and Obesity and Risk of Developing Chronic Kidney Disease Using Data from the Korean Multi-Rural Communities Cohort (MRCohort) Population Database

Background

The Multi-Rural Communities Cohort (MRCohort) was established as part of the Korean Genome and Epidemiology Study, which identified risk factors for cardiovascular diseases in the population between January 2005 and December 2011. This was a prospective study, aimed to investigate the association between serum albumin levels and the risk of developing chronic kidney disease (CKD) in obese patients using data from the MRCohort population database.

Material/Methods

For analysis, we selected a total of 9695 people from the MRCohort from 2004 to 2013: 3105 people from Goryeong, 3183 from Yangpyeong, and 3407 from Namwon, without previous history of myocardial infarction, cerebrovascular disease, cancer, and CKD, or missing values on confounders. As a result, 2300 metabolically healthy participants were studied as a whole, and then by body mass index of >23 kg/m². The groups were divided into 4 subgroups by albumin quartiles, and the effects of albumin levels compared to the lowest quartile were studied by Cox proportional hazard analysis, after adjusting for potential confounders.

Results

The results showed that the highest quartile of albumin, compared to the lowest quartile, was a protective factor of CKD development only in the overweight and obese group with adjusted hazard ratio (HR)=0.38 (95% confidence interval (CI) 0.16–0.95, p<0.05). In the normal-weight group, results were insignificant, with adjusted HR=0.54 (95% CI 0.24–1.25, not significant).

Conclusions

Data from the Korean MRCohort population database showed that obesity and increased serum albumin levels were protective factors for the development of CKD.

Gasdermin E-derived caspase-3 inhibitors effectively protect mice from acute hepatic failure

Programmed cell death (PCD), including apoptosis, apoptotic necrosis, and pyroptosis, is involved in various organ dysfunction syndromes. Recent studies have revealed that a substrate of caspase-3, gasdermin E (GSDME), functions as an effector for pyroptosis; however, few inhibitors have been reported to prevent pyroptosis mediated by GSDME. Here, we developed a class of GSDME-derived inhibitors containing the core structure of DMPD or DMLD. Ac-DMPD-CMK and Ac-DMLD-CMK could directly bind to the catalytic domains of caspase-3 and specifically inhibit caspase-3 activity, exhibiting a lower IC50 than that of Z-DEVD-FMK. Functionally, Ac-DMPD/DMLD-CMK substantially inhibited both GSDME and PARP cleavage by caspase-3, preventing apoptotic and pyroptotic events in hepatocytes and macrophages. Furthermore, in a mouse model of bile duct ligation that mimics intrahepatic cholestasis-related acute hepatic failure, Ac-DMPD/DMLD-CMK significantly alleviated liver injury. Together, this study not only identified two specific inhibitors of caspase-3 for investigating PCD but also, more importantly, shed light on novel lead compounds for treating liver failure and organ dysfunctions caused by PCD.

Body mass index (BMI) and alpha-fetoprotein (AFP) level correlate with the severity of HCV-induced fibrosis in a cohort of Egyptian patients with chronic HCV

Background

Viral hepatitis is the seventh leading cause of mortality globally, and half of this mortality is attributed to hepatitis C virus (HCV). Egypt has the highest HCV prevalence worldwide, with an estimated 14.7% of the population being HCV-positive. HCV infection is the primary cause of liver fibrosis, cirrhosis, and hepatocellular carcinoma. Liver fibrosis varies in severity during chronic HCV infection, and 10–20% of chronic hepatitis C (CHC) patients with severe fibrosis develop cirrhosis. The goal of this work was to assess the clinico-demographic predictors of severity of HCV-induced fibrosis in a cohort of Egyptian patients.

Results

A cohort of Egyptian patients with chronic HCV genotype 4a infection showed significant association between severe fibrosis stages and obesity, represented by a higher body mass index (BMI), low albumin level, high alpha-fetoprotein (AFP) level, low thyroid-stimulating hormone (TSH) level, and high alkaline phosphatase (ALP) level. Multivariate analysis delineated BMI, TSH, and ALP as independent significant variables that could predict the risk of fibrosis severity in HCV infections.

Conclusion

This study argues in favor of using the biomarker profile of CHC patients infected with HCV genotype 4a to identify patients at higher risk of developing severe fibrosis, which is a necessary first step towards precision medicine via patient stratification.

Pharmacological Interactions in the Elderly

Pharmacological therapy in the elderly is particularly complicated and challenging. Due to coexistence of three main predisposing factors (advanced age, multiple morbidity and polypharmacotherapy), this group of patients is prone to occurrence of drug interactions and adverse effects of incorrect drug combinations. Since many years patient safety during the treatment process has been one of key elements for proper functioning of healthcare systems around the world, thus different preventive measures have been undertaken in order to counteract factors adversely affecting the therapeutic effect. One of the avoidable medical errors is pharmacological interactions. According to estimates, one in six elderly patients may be at risk of a significant drug interaction. Hence the knowledge about mechanisms and causes of drug interactions in the elderly, as well as consequences of their occurrence are crucial for planning the process of pharmacotherapy. For the purpose of pharmacovigilance, a review of available methods and tools gives an insight into possible ways of preventing drug interactions. Additionally, recognizing the actual scale of this phenomenon in geriatric population around the world emphasizes the importance of a joint effort among medical community to improve quality of pharmacotherapy.

Low-energy extracorporeal shock wave therapy for a model of liver cirrhosis ameliorates liver fibrosis and liver function

Low-energy extracorporeal shock waves (LESW) have been studied as a new treatment for angina pectoris and several ischemic diseases because of its effect on angiogenesis and inhibition of fibrosis of the heart. The effect of LESW on fibrosis in liver cirrhosis has not been studied. The aim of this study was to verify the amelioration of liver fibrosis by LESW and elucidate its mechanisms in a rat model of drug-induced liver cirrhosis. Male Wistar rats aged 7 weeks were injected with carbon tetrachloride intraperitoneally twice a week for 12 weeks. Eight rats underwent LESW therapy (0.25 mJ/mm², 4 Hz, 1000 shots) under general anesthesia (shock wave group). Seven rats only underwent general anesthesia (control group). Quantitative analysis showed that the area of fibrosis in the shock wave group was significantly reduced compared with the control group (11,899.9 vs. 23,525.3 pixels per field, p < 0.001). In the shock wave group, the mRNA expression of transforming growth factor (TGF)-β1 was significantly suppressed (0.40-fold, p = 0.018) and vascular endothelial growth factor-B was significantly increased (1.77-fold, p = 0.006) compared with the control group. Serum albumin was significantly higher in the shock wave group than in the control group (3.0 vs. 2.4 g/dl, p = 0.025). Aspartate aminotransferase/alanine aminotransferase ratio decreased by LESW compared with the control group (1.49 vs. 2.04, p = 0.013). These results suggest that LESW therapy ameliorates liver fibrosis by reducing the expression of TGF-β1 and increasing the expression of angiogenic factors, and improves hepatic function.

Acute kidney injury spectrum in patients with chronic liver disease: Where do we stand?

Acute kidney injury (AKI) is a common complication of liver cirrhosis and is of the utmost clinical and prognostic relevance. Patients with cirrhosis, especially decompensated cirrhosis, are more prone to develop AKI than those without cirrhosis. The hepatorenal syndrome type of AKI (HRS–AKI), a spectrum of disorders in prerenal chronic liver disease, and acute tubular necrosis (ATN) are the two most common causes of AKI in patients with chronic liver disease and cirrhosis. Differentiating these conditions is essential due to the differences in treatment. Prerenal AKI, a more benign disorder, responds well to plasma volume expansion, while ATN requires more specific renal support and is associated with substantial mortality. HRS–AKI is a facet of these two conditions, which are characterized by a dysregulation of the immune response. Recently, there has been progress in better defining this clinical entity, and studies have begun to address optimal care. The present review synopsizes the current diagnostic criteria, pathophysiology, and treatment modalities of HRS–AKI and as well as AKI in other chronic liver diseases (non-HRS–AKI) so that early recognition of HRS–AKI and the appropriate management can be established.

Con: The Unclear Benefit of Albumin

Many studies have shown that 20% human albumin solution infusions improve circulatory function in patients with advanced liver disease, and this treatment is widely recommended and used by all hepatologists. However, it is more expensive than other crystalloids or colloids, and several countries suffer shortages of supply. This article examines whether other fluids might be considered for these patients.

Mycobacterium tuberculosis complex bacteremia among HIV and non-HIV patients in a Mexican tertiary care center

Objectives

To determine the factors associated with Mycobacterium tuberculosis complex-positive blood culture.

Methods

Case-control study. Sociodemographic, clinical and laboratory data were collected from 2000 to 2015.

Results

We reviewed medical records of 533 patients with culture-proven tuberculosis, of whom 27.2% (145/533) had blood culture available. Patients with mycobacteremia presented more frequently with abdominal tuberculosis, body mass index <18 kg/m², and had lower hemoglobin and albumin levels. No differences were observed regarding HIV status.

Conclusions

Few studies have reported on the characteristics associated with Mycobacterium tuberculosis complex bacteremia, especially among Human Immunodeficiency Virus-negative patients. Out of 145 tuberculosis-infected patients with blood culture results available, 21 turned out positive. Anemia, hypoalbuminemia, and a body mass index < 18 kg/m² were associated with mycobacteremia.

New Insights About Albumin and Liver Disease

Decompensated liver cirrhosis has a dismal prognosis, with an overall survival of 2-4 years, which is worse than for many oncological diseases. Albumin is an important tool in the management of patients with cirrhosis, since it decreases for less than half the risk for post-paracentesis cardiocirculatory dysfunction and mortality associated with spontaneous bacterial infection, as well as, it triplicates the response to terlipressin in patients with hepatorenal syndrome. Recently, research on albumin has been a hot topic, with important new insights such as the characterization of the pleiotropic effects of albumin (which surpass its oncotic properties) and the concept of effective albumin concentration. In fact, patients with liver cirrhosis present posttranslational modifications on albumin that compromises its function. Those modified albumin forms were proved to have prognostic value and its knowledge may change the paradigm of albumin treatment. In this review, we critically summarize the latest evidence on the potential benefits of albumin in patients with end-stage liver disease.

Development of a prognostic nomogram for cirrhotic patients with upper gastrointestinal bleeding

BACKGROUND AND AIM

Upper gastrointestinal bleeding (UGIB) is a complication with a high mortality rate in critically ill patients presenting with cirrhosis. Today, there exist few accurate scoring models specifically designed for mortality risk assessment in critically ill cirrhotic patients with upper gastrointestinal bleeding (CICGIB). Our aim was to develop and evaluate a novel nomogram-based model specific for CICGIB.

PATIENTS AND METHODS

Overall, 540 consecutive CICGIB patients were enrolled. On the basis of Cox regression analyses, the nomogram was constructed to estimate the probability of 30-day, 90-day, 270-day, and 1-year survival. An upper gastrointestinal bleeding-chronic liver failure-sequential organ failure assessment (UGIB-CLIF-SOFA) score was derived from the nomogram. Performance assessment and internal validation of the model were performed using Harrell's concordance index (C-index), calibration plot, and bootstrap sample procedures. UGIB-CLIF-SOFA was also compared with other prognostic models, such as CLIF-SOFA and model for end-stage liver disease, using C-indices.

RESULTS

Eight independent factors derived from Cox analysis (including bilirubin, creatinine, international normalized ratio, sodium, albumin, mean artery pressure, vasopressin used, and hematocrit decrease>10%) were assembled into the nomogram and the UGIB-CLIF-SOFA score. The calibration plots showed optimal agreement between nomogram prediction and actual observation. The C-index of the nomogram using bootstrap (0.729; 95% confidence interval: 0.689-0.766) was higher than that of the other models for predicting survival of CICGIB.

CONCLUSION

We have developed and internally validated a novel nomogram and an easy-to-use scoring system that accurately predicts the mortality probability of CICGIB on the basis of eight easy-to-obtain parameters. External validation is now warranted in future clinical studies.

Acute kidney injury in acute-on-chronic liver failure: where does hepatorenal syndrome fit?

Renal dysfunction occurs in 25% to 50% of patients with cirrhosis admitted to the hospital with an acute episode of hepatic decompensation and may be due to underlying chronic kidney disease, an acute deterioration, or both. An acute deterioration in renal function in cirrhotic patients is now collectively referred to as acute kidney injury (AKI), which has been subclassified into different grades of severity that identify prognostic groups. Acute-on-chronic liver failure is characterized by acute hepatic and/or extrahepatic organ failure driven by a dysregulated immune response and systemic inflammatory response. AKI is also one of the defining features of ACLF and a major component in grading the severity of acute-on-chronic liver failure. As such, the pattern of AKI now observed in patients admitted to the hospital with acutely decompensated liver disease is likely to be one of inflammatory kidney injury including acute tubular injury (referred in this review as non-hepatorenal syndrome [HRS]-AKI) rather than HRS. As the management and supportive treatment of non-HRS-AKI potentially differ from those of HRS, then from the nephrology perspective, it is important to distinguish between non-HRS-AKI and HRS-AKI when reviewing patients with acute-on-chronic liver failure and AKI, so that appropriate and early management can be instituted.

ZWIĄZKI WIĄŻĄCE SIĘ Z BIAŁKAMI OSOCZA U LUDZI. ZNACZENIE W TERAPII ORAZ METODY OZNACZANIA WOLNEJ FRAKCJI

Wiele substancji endogennych oraz egzogennych wykazuje zdolność do wiązania się z białkami osocza, głównie z ludzką albuminą surowicy oraz α-1-kwaśną glikoproteiną. Substancje te w krwioobiegu występują zarówno w formie wolnej jak i związanej z białkami. Białko posiada na swojej powierzchni miejsca wiązania charakterystyczne dla danego związku, różniące się wielkością, kształtem oraz powinowactwem. Wiązanie z białkami następuje w wyniku oddziaływań hydrofobowych, van der Waalsa oraz elektrostatycznych. Stopień związania z białkami osocza zależy od m.in. obecności stanu zapalnego, występowania chorób nerek i wątroby oraz wieku. Jedynie forma wolna związku jest aktywna biologicznie oraz jest zdolna do pokonywania barier biologicznych. W związku z tym duże znaczenie mają metody pomiaru stężenia frakcji niezwiązanej z białkami w osoczu. Najczęściej stosowana jest dializa równowagowa, uznawana za metodę referencyjną. Inne metody to m.in. ultrafiltracja, ultrawirowanie, mikrodializa, mikroekstrakcja, wysokosprawna analiza czołowa oraz ekstrakcja w punkcie zmętnienia.

Terlipressin plus albumin for treatment of type 1 hepatorenal syndrome: A meta-analysis

AIM

to assess the efficacy of terlipressin plus albumin in the treatment of hepatorenal syndrome (HRS).

METHODS

Cochrane strategy was used to identify randomized controlled trials published before July 2016 by searching PubMed, The Cochrane Library, Web of Science and LILACS, Medline, EMBASE, Chinese Biomedical Literature Database, Chongqing VIP Information Co., Ltd, China National Knowledge Internet Database, and Wanfang Data.

RESULTS

Six randomized controlled trials involving 542 cases were selected for this meta-analysis. The HRS remission rate and the survival rate were increased by terlipressin plus albumin, with OR = 5.25 (95%CI: 2.77-6.52) and 2.33 (95%CI: 1.11-4.88) compared with albumin alone, respectively. Blood creatinine was decreased by the combination treatment, and mean arterial pressure was increased significantly, while there was no difference in urine output. Side effects due to systemic circulation congestion and peripheral vasoconstriction were reported, such as stomach ache and extremity cyanosis. No fatal side effect was reported.

CONCLUSION

compared with albumin alone, terlipressin plus albumin is effective in the treatment of HRS, as demonstrated by increased remission rate and survival rate and no occurrence of fatal side effect.

Protective effects of Chinese traditional medicine against liver injury and liver fibrosis and mechanisms involved

Liver injury and liver fibrosis are clinically common, and there is currently a lack of ideal drugs for these conditions. Recent studies have indicated that the effective components of traditional Chinese medicine show certain efficacy in prevention and treatment of liver injury and liver fibrosis, and the mechanisms are related to the protection of liver cells, anti-oxidation and anti-inflammation. This paper discusses the protective effects of the effective components of traditional Chinese medicine against liver injury and liver fibrosis and the mechanisms involved, with an aim to promote the development of therapeutic drugs for liver injury and liver fibrosis.

A comprehensive validation of HBV-related acute-on-chronic liver failure models to assist decision-making in targeted therapeutics

This research utilized an external longitudinal dataset of hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) to compare and validate various predictive models that support the current recommendations to select the most effective predictive risk models to estimate short- and long-term mortality and facilitate decision-making about preferable therapeutics for HBV-ACLF patients. Twelve ACLF prognostic models were developed after a systematic literature search using the longitudinal data of 232 HBV-ACLF patients on the waiting list for liver transplantation (LT). Four statistical measures, the constant (A) and slope (B) of the fitted line, the area under the curve (C) and the net benefit (D), were calculated to assess and compare the calibration, discrimination and clinical usefulness of the 12 predictive models. According to the model calibration and discrimination, the logistic regression models (LRM2) and the United Kingdom model of end-stage liver disease(UKELD) were selected as the best predictive models for both 3-month and 5-year outcomes. The decision curve summarizes the benefits of intervention relative to the costs of unnecessary treatment. After the comprehensive validation and comparison of the currently used models, LRM2 was confirmed as a markedly effective prognostic model for LT-free HBV-ACLF patients for assisting targeted and standardized therapeutic decisions.