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Callum J, Skubas NJ, Bathla A, Keshavarz H, Clark EG, Rochwerg B, Fergusson D, Arbous S, Bauer SR, China L, Fung M, Jug R, Neill M, Paine C, Pavenski K, Shah PS, Robinson S, Shan H, Szczepiorkowski ZM, Thevenot T, Wu B, Stanworth S, Shehata N. Use of Intravenous Albumin: A Guideline From the International Collaboration for Transfusion Medicine Guidelines. Chest 2024:S0012-3692(24)00285-X. [PMID: 38447639 DOI: 10.1016/j.chest.2024.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Albumin is used commonly across a wide range of clinical settings to improve hemodynamics, to facilitate fluid removal, and to manage complications of cirrhosis. The International Collaboration for Transfusion Medicine Guidelines developed guidelines for the use of albumin in patients requiring critical care, undergoing cardiovascular surgery, undergoing kidney replacement therapy, or experiencing complications of cirrhosis. METHODS Cochairs oversaw the guideline development process and the panel included researchers, clinicians, methodologists, and a patient representative. The evidence informing this guideline arises from a systematic review of randomized clinical trials and systematic reviews, in which multiple databases were searched (inception through November 23, 2022). The panel reviewed the data and formulated the guideline recommendations using Grading of Recommendations Assessment, Development and Evaluation methodology. The guidelines were revised after public consultation. RESULTS The panel made 14 recommendations on albumin use in adult critical care (three recommendations), pediatric critical care (one recommendation), neonatal critical care (two recommendations), cardiovascular surgery (two recommendations), kidney replacement therapy (one recommendation), and complications of cirrhosis (five recommendations). Of the 14 recommendations, two recommendations had moderate certainty of evidence, five recommendations had low certainty of evidence, and seven recommendations had very low certainty of evidence. Two of the 14 recommendations suggested conditional use of albumin for patients with cirrhosis undergoing large-volume paracentesis or with spontaneous bacterial peritonitis. Twelve of 14 recommendations did not suggest albumin use in a wide variety of clinical situations where albumin commonly is transfused. CONCLUSIONS Currently, few evidence-based indications support the routine use of albumin in clinical practice to improve patient outcomes. These guidelines provide clinicians with actionable recommendations on the use of albumin.
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Affiliation(s)
- Jeannie Callum
- Department of Pathology and Molecular Medicine, Queen's University and Kingston Health Sciences Centre, Kingston.
| | - Nikolaos J Skubas
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland
| | | | | | - Edward G Clark
- Division of Nephrology, University of Ottawa, Ottawa Hospital Research Institute, Ottawa
| | - Bram Rochwerg
- Department of Medicine and Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton
| | - Dean Fergusson
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa
| | - Sesmu Arbous
- Department of Critical Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland
| | - Louise China
- Department of Hepatology and ILDH, The Royal Free NHS Trust and University College London, London
| | - Mark Fung
- Department of Pathology and Laboratory Medicine, University of Vermont Medical Center, Burlington, VT
| | - Rachel Jug
- University of Cincinnati College of Medicine, Cincinnati, OH
| | | | - Cary Paine
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, Mount Sinai Hospital, Toronto, ON
| | - Prakesh S Shah
- Institute of Health Policy, Management, and Evaluation, Mount Sinai Hospital, Toronto, ON; Department of Pediatrics, Mount Sinai Hospital, Toronto, ON
| | - Susan Robinson
- Department of Clinical Haematology, Guy's and St Thomas' NHS Foundation Trust, London
| | - Hua Shan
- Department of Pathology, Stanford University School of Medicine, Palo Alto
| | | | - Thierry Thevenot
- Service d'Hépatologie, Centre Hospitalier Régional et Universitaire de Besançon, Besançon, France
| | - Bovey Wu
- Department of Internal Medicine, Graduate Medical Education, Loma Linda University, Loma Linda, CA
| | - Simon Stanworth
- NHS Blood and Transplant, Oxford, England; Radcliffe Department of Medicine, University of Oxford, Oxford, England; John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Nadine Shehata
- Department of Medicine, University of Toronto, Mount Sinai Hospital, Toronto, ON; Transfusion Medicine Laboratory, Mount Sinai Hospital, Toronto, ON
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Deltenre P, Payancé A, Elkrief L, Mura VL, Artru F, Baiges A, Cervoni JP, China L, Colle I, Lemaitre E, Procopet B, Schiller D, Bureau C, Goria O, Ollivier I, Nuzzo A, Rautou PE, Plessier A. Splanchnic vein thrombosis associated with SARS-CoV-2 infection: A VALDIG case-control study. JHEP Rep 2023; 5:100894. [PMID: 37841638 PMCID: PMC10570588 DOI: 10.1016/j.jhepr.2023.100894] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/28/2023] [Accepted: 08/14/2023] [Indexed: 10/17/2023] Open
Abstract
Background & Aims Whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is a risk factor for splanchnic vein thrombosis (SVT) is unknown. This study aims to assess the impact of SARS-CoV-2 infection on the presentation and prognosis of recent SVT and to identify specific characteristics of SARS-CoV-2-associated SVT. Methods This is a retrospective study collecting health-related data of 27 patients presenting with recent SVT in the context of SARS-CoV-2 infection in 12 Vascular Liver Disease Group (VALDIG) centres and in comparison with 494 patients with recent SVT before the SARS-CoV-2 pandemic. Results Twenty-one patients with SARS-CoV-2 had portal vein thrombosis with or without thrombosis of another splanchnic vein, two had superior mesenteric vein thrombosis, one had splenic vein thrombosis, and three had hepatic vein thrombosis. Diagnosis of SVT was made 10 days (95% CI 0-24 days) after the diagnosis of SARS-CoV-2 infection. Fever (52 vs. 15%; p <0.001) and respiratory symptoms (44 vs. 0%; p <0.001) were more frequent, and median lymphocyte count was lower (1.1 × 103/mm3vs. 1.6 × 103/mm3; p = 0.043) in patients with infection than in those without SARS-CoV-2 infection. A prothrombotic condition was identified in 44 and 52% of patients with and without SARS-CoV-2 infection, respectively (p = 0.5). All patients with SARS-CoV-2 received anticoagulation therapy. During a median follow-up of 250 days, three SARS-CoV-2-infected patients (11%) required intestinal resection for infarction 1 to 3 months after diagnosis of SVT compared with 13 (2.6%) controls (p = 0.044). Partial or complete recanalisation of the thrombosed splanchnic vein was performed in 33% of patients with SARS-CoV-2. Conclusions SARS-CoV-2 infection can be associated with recent SVT. Intestinal infarction leading to intestinal resection might be more frequent in patients with SARS-CoV-2. Impact and implications SARS-CoV-2 infection can be associated with recent SVT. SVT occurring during SARS-CoV-2 infection is characterised by a higher frequency of respiratory symptoms and a lower lymphocyte count. Intestinal infarction leading to intestinal resection appears to occur more frequently in patients with SARS-CoV-2.
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Affiliation(s)
- Pierre Deltenre
- CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Clinique St Luc, Bouge, Belgium
- CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Audrey Payancé
- Université de Paris, AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, VALDIG Group, Centre de recherche sur l'inflammation, Inserm, UMR 1149, Paris, France
| | - Laure Elkrief
- Hôpital Trousseau, CHU de Tours, FILFOIE, ERN RARE-LIVER, VALDIG Group, Tours, France
| | - Vincenzo La Mura
- IRCCS Fondazione Ca' Granda – Ospedale Maggiore Policlinico, ERN RARE-LIVER, VALDIG Group, Milan, Italy
| | - Florent Artru
- Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Anna Baiges
- Barcelona Hepatic Hemodynamic Lab, Clinic Barcelona Hospital, CIBEREHD, IDIBAPS, Universitat de Barcelona, ERN RARE-LIVER, VALDIG Group, Barcelona, Spain
| | | | | | | | | | - Bogdan Procopet
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | | | - Christophe Bureau
- Hôpital Universitaire Rangueil Toulouse, FILFOIE, ERN RARE-LIVER, VALDIG Group, Toulouse, France
| | - Odile Goria
- Hôpital Universitaire Charles Nicolle de Rouen, Rouen, France
| | - Isabelle Ollivier
- Hôpital Universitaire Côte de la Nacre, FILFOIE, ERN RARE-LIVER, VALDIG Group, Caen, France
| | - Alexandre Nuzzo
- Paris Cité University, AP-HP, Beaujon Hospital, Intestinal Stroke Center, Gastroenterology, IBD, Intestinal Failure Department, Inserm, UMR 1148, Paris, France
| | - Pierre-Emmanuel Rautou
- Université de Paris, AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, VALDIG Group, Centre de recherche sur l'inflammation, Inserm, UMR 1149, Paris, France
| | - Aurélie Plessier
- Université de Paris, AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, VALDIG Group, Centre de recherche sur l'inflammation, Inserm, UMR 1149, Paris, France
| | - for VALDIG, an EASL consortium
- CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Clinique St Luc, Bouge, Belgium
- CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
- Université de Paris, AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, VALDIG Group, Centre de recherche sur l'inflammation, Inserm, UMR 1149, Paris, France
- Hôpital Trousseau, CHU de Tours, FILFOIE, ERN RARE-LIVER, VALDIG Group, Tours, France
- IRCCS Fondazione Ca' Granda – Ospedale Maggiore Policlinico, ERN RARE-LIVER, VALDIG Group, Milan, Italy
- Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
- Barcelona Hepatic Hemodynamic Lab, Clinic Barcelona Hospital, CIBEREHD, IDIBAPS, Universitat de Barcelona, ERN RARE-LIVER, VALDIG Group, Barcelona, Spain
- CHU, Besançon, France
- Royal Free Hospital, London, UK
- Algemeen Stedelijk Ziekenhuis ASZ, Aalst, Belgium
- CHU, Lille, France
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
- Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
- Hôpital Universitaire Rangueil Toulouse, FILFOIE, ERN RARE-LIVER, VALDIG Group, Toulouse, France
- Hôpital Universitaire Charles Nicolle de Rouen, Rouen, France
- Hôpital Universitaire Côte de la Nacre, FILFOIE, ERN RARE-LIVER, VALDIG Group, Caen, France
- Paris Cité University, AP-HP, Beaujon Hospital, Intestinal Stroke Center, Gastroenterology, IBD, Intestinal Failure Department, Inserm, UMR 1148, Paris, France
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China L, Tittanegro T, Crocombe D, Forrest E, Kallis Y, Ryder SD, Wright G, Freemantle N, O'Brien A. Investigating potential confounding by indication when considering the association between proton pump inhibitor use, infection, hepatic encephalopathy and mortality in hospitalised decompensated cirrhosis: a post-hoc analysis of the ATTIRE trial. EClinicalMedicine 2023; 58:101924. [PMID: 37090442 PMCID: PMC10119493 DOI: 10.1016/j.eclinm.2023.101924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/25/2023] [Accepted: 03/08/2023] [Indexed: 04/25/2023] Open
Abstract
Background Proton pump inhibitors (PPIs) are commonly prescribed to prevent and treat upper gastrointestinal ulceration and bleeding. Studies have identified increased incidence of spontaneous bacterial peritonitis and hepatic encephalopathy (HE) in cirrhosis patients taking PPIs. However, results are conflicting, and as PPIs are prescribed for variceal bleeding, a major risk factor for infection and HE, it is challenging to discern whether these associations are causal. Methods In this post-hoc analysis of the ATTIRE trial, we pooled all patient data to investigate the effects of PPI use on clinical outcomes. ATTIRE was a multicentre, open-label, randomised trial of targeted 20% human albumin solution (HAS) daily infusions versus standard care involving 777 adults with decompensated cirrhosis hospitalised with acute complications and albumin <30 g/L. Study recruitment was between Jan 25, 2016, and June 28, 2019, at 35 hospitals across England, Scotland, and Wales. Key exclusion criteria were advanced hepatocellular carcinoma with life expectancy <8 weeks and patients receiving palliative care. In ATTIRE, patients were grouped by PPI use at trial entry. We studied infection and HE at baseline and incidence of hospital acquired infection, new onset HE, renal dysfunction and mortality. We attempted with propensity score matching to account for differences in disease severity. Findings Overall PPI use at baseline was not associated with increased incidence of infection, renal dysfunction or mortality, but was associated with significantly increased incidence of grade III/IV HE during hospital stay (P = 0.011). This was only significant for those taking intravenous PPIs and these patients had >10 times the incidence of variceal bleeding and near double the 28-day mortality compared to non-PPI patients. However, propensity score matching was not possible as there was such a strong selection of patients for PPI use, that we could not find sufficient non-PPI patients to match to. We found no impact of PPI use on plasma markers of bacterial translocation, infection or systemic inflammation. Interpretations Our real-world data from a completed randomised trial show that PPIs are widely prescribed in the UK and judicious use appears safe in patients hospitalised with decompensated cirrhosis. However, patients prescribed PPIs had fundamentally different phenotypes to those not prescribed PPIs, a form of confounding by indication, which should be strongly considered when interpreting studies and making recommendations about their use. Funding Wellcome Trust and Department of Health and Social Care.
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Affiliation(s)
- Louise China
- Institute of Liver and Digestive Health, University College London, United Kingdom
| | - Thais Tittanegro
- Institute of Liver and Digestive Health, University College London, United Kingdom
| | - Dominic Crocombe
- Institute of Liver and Digestive Health, University College London, United Kingdom
| | - Ewan Forrest
- Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Yiannis Kallis
- Barts and the London School of Medicine and Dentistry Queen Mary University of London, United Kingdom
| | - Stephen D. Ryder
- National Institute for Health Research Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Centre, Nottingham, United Kingdom
| | - Gavin Wright
- Mid and South Essex NHS Foundation Trust, Basildon & Thurrock University Hospitals NHS Foundation Trust, Gastroenterology, Hepatology and Hepatobiliary Medicine, The Royal Free Hospital, University College London, Kings College London, United Kingdom
| | - Nick Freemantle
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
| | - Alastair O'Brien
- Institute of Liver and Digestive Health, University College London, United Kingdom
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
- Corresponding author. UCL Institute for Liver and Digestive Health, Upper 3rd Floor, Division of Medicine, Royal Free Campus, Rowland Hill Street London, NW3 2PF, United Kingdom. a.o'
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Tittanegro T, China L, Forrest E, Kallis Y, Ryder SD, Wright G, Freemantle N, O'Brien A. Use of non-selective B-blockers is safe in hospitalised decompensated cirrhosis patients and exerts a potential anti-inflammatory effect: Data from the ATTIRE trial. EClinicalMedicine 2023; 55:101716. [PMID: 36407574 PMCID: PMC9672423 DOI: 10.1016/j.eclinm.2022.101716] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Nonselective B-blockers (NSBBs) are believed to have pleiotropic effects beyond reducing portal pressure. However, studies also report potential harm in patients hospitalized with cirrhosis and ascites. We therefore investigated whether NSBB use at ATTIRE trial entry (Albumin to prevent infection in chronic liver failure, 2016-19) was associated with increased renal or cardiovascular dysfunction, compared the incidence of infection and plasma markers of systemic inflammation, and examined mortality at 28-days, 3 and 6-months. METHODS In ATTIRE patients grouped by NSBB use at trial entry, we studied infection at baseline, hospital acquired infection and organ dysfunction during trial treatment period and mortality, with propensity score matching to account for differences in disease severity. FINDINGS There were no differences in renal or cardiovascular dysfunction between patients treated with NSBBs or not, during days 3-15 of hospitalization, despite elevated serum creatinine in NSBB patients at hospitalisation. Use of NSBBs was associated with a significant reduction in infection at hospitalization (p = 0.006), lower white cell counts throughout hospital stay (p < 0.001) and reduced plasma procalcitonin (p = 0.009) and interlukin-8 levels (p = 0.04) at baseline, but markers of bacterial translocation and systemic inflammation were the same in treatment groups. There was no reduction in hospital acquired infections in patients taking NSBBs and no beneficial impact on mortality at 28-days, 3 and 6-months. INTERPRETATIONS Our real-world data from a completed randomised trial show that use of NSBBs in decompensated cirrhosis patients is safe during hospitalisation. We also show a potential anti-inflammatory role for NSBBs which may be mediated by a downregulation of IL-8 induced leucocytosis, that was associated with reduced infection at baseline but not a survival benefit. FUNDING Wellcome Trust and Department of Health and Social Care.
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Affiliation(s)
- Thais Tittanegro
- Institute of Liver and Digestive Health, University College London, United Kingdom
| | - Louise China
- Institute of Liver and Digestive Health, University College London, United Kingdom
| | - Ewan Forrest
- Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Yiannis Kallis
- Barts and the London School of Medicine and Dentistry Queen Mary University of London, United Kingdom
| | - Stephen D. Ryder
- National Institute for Health Research Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust, and the University of Nottingham, Queens Medical Centre, Nottingham, United Kingdom
| | - Gavin Wright
- Mid and South Essex NHS Foundation Trust, Basildon & Thurrock University Hospitals NHS Foundation Trust, The Royal Free Hospital, University College London, Kings College London, United Kingdom
| | - Nick Freemantle
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
| | - Alastair O'Brien
- Institute of Liver and Digestive Health, University College London, United Kingdom
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
- Corresponding author. UCL Institute for Liver and Digestive Health, Upper 3rd Floor, Division of Medicine, Royal Free Campus, Rowland Hill Street London NW3 2PF, United Kingdom. a.o'
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Crocombe D, Ahmed N, Balakrishnan I, Bordea E, Chau M, China L, Corless L, Danquah V, Dehbi HM, Dillon JF, Forrest EH, Freemantle N, Gear DP, Hollywood C, Hunter R, Jeyapalan T, Kallis Y, McPherson S, Munteanu I, Portal J, Richardson P, Ryder SD, Virk A, Wright G, O'Brien A. ASEPTIC: primary antibiotic prophylaxis using co-trimoxazole to prevent SpontanEous bacterial PeritoniTIs in Cirrhosis-study protocol for an interventional randomised controlled trial. Trials 2022; 23:812. [PMID: 36167573 PMCID: PMC9513307 DOI: 10.1186/s13063-022-06727-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bacterial infection is a major cause of mortality in patients with cirrhosis. Spontaneous bacterial peritonitis (SBP) is a serious and common infection in patients with cirrhosis and ascites. Secondary prophylactic antibiotic therapy has been shown to improve outcomes after an episode of SBP but primary prophylaxis to prevent the first episode of SBP remains contentious. The aim of this trial is to assess whether primary antibiotic prophylaxis with co-trimoxazole improves overall survival compared to placebo in adults with cirrhosis and ascites. METHODS The ASEPTIC trial is a multicentre, placebo-controlled, double-blinded, randomised controlled trial (RCT) in England, Scotland, and Wales. Patients aged 18 years and older with cirrhosis and ascites requiring diuretic treatment or paracentesis, and no current or previous episodes of SBP, are eligible, subject to exclusion criteria. The trial aims to recruit 432 patients from at least 30 sites. Patients will be randomised in a 1:1 ratio to receive either oral co-trimoxazole 960 mg or an identical placebo once daily for 18 months, with 6 monthly follow-up visits thereafter (with a maximum possible follow-up period of 48 months, and a minimum of 18 months). The primary outcome is overall survival. Secondary outcomes include the time to the first incidence of SBP, hospital admission rates, incidence of other infections (including Clostridium difficile) and antimicrobial resistance, patients' health-related quality of life, health and social care resource use, incidence of cirrhosis-related decompensation events, liver transplantation, and treatment-related serious adverse events. DISCUSSION This trial will investigate the efficacy, safety, and cost-effectiveness of co-trimoxazole for patients with liver cirrhosis and ascites to determine whether this strategy improves clinical outcomes. Given there are no treatments that improve survival in decompensated cirrhosis outside of liver transplant, if the trial has a positive outcome, we anticipate widespread adoption of primary antibiotic prophylaxis. TRIAL REGISTRATION ClinicalTrials.gov NCT043955365 . Registered on 18 April 2020. Research ethical approval was granted by the Research Ethics Committee (South Central - Oxford B; REC 19/SC/0311) and the Medicines and Healthcare products Regulatory Agency (MHRA).
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Affiliation(s)
- Dominic Crocombe
- UCL Institute of Liver and Digestive Health, Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
| | - Norin Ahmed
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Indran Balakrishnan
- Royal Free London NHS Foundation Trust, University College London, London, UK
| | - Ekaterina Bordea
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Marisa Chau
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Louise China
- UCL Institute of Liver and Digestive Health, Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
| | | | - Victoria Danquah
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Hakim-Moulay Dehbi
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - John F Dillon
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Ewan H Forrest
- Gastroenterology Unit, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
| | - Nick Freemantle
- University College London Comprehensive Clinical Trials Unit, London, UK
| | | | - Coral Hollywood
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Rachael Hunter
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Tasheeka Jeyapalan
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Yiannis Kallis
- The Blizard Institute, Queen Mary University of London, London, UK
| | - Stuart McPherson
- Liver Unit, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, The Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Iulia Munteanu
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Jim Portal
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Paul Richardson
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Stephen D Ryder
- NIHR Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - Amandeep Virk
- University College London Comprehensive Clinical Trials Unit, London, UK
| | - Gavin Wright
- Mid & South Essex NHS Foundation Trust, Basildon, UK
| | - Alastair O'Brien
- UCL Institute of Liver and Digestive Health, Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK. a.o'.,University College London Comprehensive Clinical Trials Unit, London, UK. a.o'.,University College London Hospitals NHS Foundation Trust, London, UK. a.o'
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6
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China L, Becares N, Rhead C, Tittanegro T, Freemantle N, O'Brien A. Targeted Albumin Infusions Do Not Improve Systemic Inflammation or Cardiovascular Function in Decompensated Cirrhosis. Clin Transl Gastroenterol 2022; 13:e00476. [PMID: 35333783 PMCID: PMC9132514 DOI: 10.14309/ctg.0000000000000476] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/09/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Albumin is recommended in decompensated cirrhosis, and studies have shown potential immunomodulatory effects. However, 2 large trials of repeated albumin infusions demonstrated contrasting results between outpatients and hospitalized patients. We investigated markers of systemic inflammation, immune function, albumin binding, and cardiovascular function using samples from Albumin To prevenT Infection in chronic liveR failurE (ATTIRE) taken at baseline, day 5, and day 10 of the trial to identify why targeted albumin infusions had no effect in hospitalized patients. METHODS Plasma samples were analyzed from 143 patients (n = 71 targeted albumin; n = 72 standard care at baseline) for cytokines, cardiovascular markers, prostaglandin E2, the effect of plasma on macrophage function, and albumin radioligand binding and oxidation status. The sample size was based on our feasibility study, and samples were selected by a trial statistician stratified by the serum albumin level and the presence of infection at randomization and analyses performed blinded to the study arm. Data were linked to 3-month mortality and treatment groups compared. RESULTS Increased baseline model for end-stage liver disease score, white cell count, calprotectin, CD163, tumor necrosis factor, renin, atrial natriuretic peptide, and syndecan-1 were associated with 3-month mortality. Despite infusing substantially differing volumes of albumin, there were no significant differences in inflammatory markers, albumin-prostaglandin E2 binding, or cardiovascular markers between treatment arms. DISCUSSION Contrary to many preclinical studies, targeted intravenous albumin therapy in hospitalized decompensated cirrhosis had no effect across a broad range of systemic inflammation, albumin function, and cardiovascular mediators and biomarkers compared with standard care, consistent with the null clinical findings.
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Affiliation(s)
- Louise China
- UCL Institute for Liver and Digestive Health, London, UK
| | | | - Camilla Rhead
- UCL Institute for Liver and Digestive Health, London, UK
| | | | - Nick Freemantle
- Comprehensive Clinical Trials Unit, University College London, London, UK
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Colwill M, Lake L, El-Sayed A, King J, Kader R, Shakweh E, Caracostea A, China L, Maurice J. Unlocking the benefits of the Baveno VI guidance when screening for varices: an audit of clinical practice across London. Future Healthc J 2022; 9:41-44. [PMID: 35372760 PMCID: PMC8966789 DOI: 10.7861/fhj.2021-0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Baveno VI consensus identifies patients with compensated advanced chronic liver disease (cACLD) who can safely avoid screening endoscopy. However, concordance in clinical practice with this guidance is unknown. We audited clinical practice and the provision of transient elastography (TE) aiming to identify potential cost savings and benefits. METHODS Retrospective data collection from 12 sites across London over 6 months by reviewing oesophagogastroduodenoscopy (OGD) reports, platelet count and TE results as well as information on site-specific provision of TE. RESULTS Three-hundred and fifty-one screening procedures were identified; 177 (50.43%) had a TE test performed within the preceding 12 months; 142 (80.23%) patients with a recent TE test did not meet criteria for screening OGD. TE provision varied widely between sites. CONCLUSION Improving concordance with the Baveno criteria through improved provision of TE would have benefits for patients, healthcare systems and the environment and would help to address the challenges of moving on from the COVID-19 pandemic.
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Affiliation(s)
- Michael Colwill
- AEpsom and St Helier University Hospitals NHS Trust, London, UK
- Address for correspondence: Dr Michael Colwill, St Helier Hospital, Wrythe Lane, Carshalton, London SM5 1AA, UK. m
| | | | - Ahmed El-Sayed
- CLondon North West University Healthcare NHS Trust, London, UK
| | | | | | | | | | - Louise China
- HRoyal Free London NHS Foundation Trust, London, UK
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Maini AA, Becares N, China L, Tittanegro TH, Patel A, De Maeyer RPH, Zakeri N, Long TV, Ly L, Gilroy DW, O'Brien A. Monocyte dysfunction in decompensated cirrhosis is mediated by the prostaglandin E2-EP4 pathway. JHEP Rep 2021; 3:100332. [PMID: 34825153 PMCID: PMC8603213 DOI: 10.1016/j.jhepr.2021.100332] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/12/2021] [Accepted: 07/17/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Infection is a major problem in advanced liver disease secondary to monocyte dysfunction. Elevated prostaglandin (PG)E2 is a mediator of monocyte dysfunction in cirrhosis; thus, we examined PGE2 signalling in outpatients with ascites and in patients hospitalised with acute decompensation to identify potential therapeutic targets aimed at improving monocyte dysfunction. METHODS Using samples from 11 outpatients with ascites and 28 patients hospitalised with decompensated cirrhosis, we assayed plasma levels of PGE2 and lipopolysaccharide (LPS); performed quantitative real-time PCR on monocytes; and examined peripheral blood monocyte function. We performed western blotting and immunohistochemistry for PG biosynthetic machinery expression in liver tissue. Finally, we investigated the effect of PGE2 antagonists in whole blood using polychromatic flow cytometry and cytokine production. RESULTS We show that hepatic production of PGE2 via the cyclo-oxygenase 1-microsomal PGE synthase 1 pathway, and circulating monocytes contributes to increased plasma PGE2 in decompensated cirrhosis. Transjugular intrahepatic sampling did not reveal whether hepatic or monocytic production was larger. Blood monocyte numbers increased, whereas individual monocyte function decreased as patients progressed from outpatients with ascites to patients hospitalised with acute decompensation, as assessed by Human Leukocyte Antigen (HLA)-DR isotype expression and tumour necrosis factor alpha and IL6 production. PGE2 mediated this dysfunction via its EP4 receptor. CONCLUSIONS PGE2 mediates monocyte dysfunction in decompensated cirrhosis via its EP4 receptor and dysfunction was worse in hospitalised patients compared with outpatients with ascites. Our study identifies a potential drug target and therapeutic opportunity in these outpatients with ascites to reverse this process to prevent infection and hospital admission. LAY SUMMARY Patients with decompensated cirrhosis (jaundice, fluid build-up, confusion, and vomiting blood) have high infection rates that lead to high mortality rates. A white blood cell subset, monocytes, function poorly in these patients, which is a key factor underlying their sensitivity to infection. We show that monocyte dysfunction in decompensated cirrhosis is mediated by a lipid hormone in the blood, prostaglandin E2, which is present at elevated levels, via its EP4 pathway. This dysfunction worsens when patients are hospitalised with complications of cirrhosis compared with those in the outpatients setting, which supports the EP4 pathway as a potential therapeutic target for patients to prevent infection and hospitalisation.
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Key Words
- ACLF, acute-on-chronic liver failure
- AD, acute decompensation
- CAID, cirrhosis-associated immune dysfunction
- CM, classical monocytes
- COX, cyclooxygenase
- CRP, C-reactive protein
- Cyclo-oxygenase 1
- DSS, downstream synthases
- Decompensated cirrhosis
- EIA, enzyme immune assay
- FACS, polychromatic flow cytometric analysis
- HLA DR, human leukocyte antigen – DR isotype
- HLA-DR
- HPGD, 15-hydroxyprostaglandin dehydrogenase
- HVs, healthy volunteers
- IL6
- LC-MS/MS, liquid chromatography-tandem mass spectrometry
- LPS
- LPS, lipopolysaccharide
- MDMs, monocyte-derived macrophages
- MFI, mean fluorescence intensity
- Microsomal PGE synthase 1
- NASH, non-alcoholic steatohepatitis
- OPD, patients with refractory ascites attending hospital outpatient department for day case paracentesis
- PGE2, prostaglandin E2
- TIPS, transjugular intrahepatic portosystemic shunt insertion
- TNF
- TNFα, tumour necrosis factor alpha
- cPGES, cytosolic PGE synthase
- mPGES1, microsomal PGE synthase 1
- qPCR, quantitative PCR
- sCD14, soluble CD14
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Affiliation(s)
- Alexander A Maini
- Institute of Liver and Digestive Health, University College London, London, UK
| | - Natalia Becares
- Institute of Liver and Digestive Health, University College London, London, UK
| | - Louise China
- Institute of Liver and Digestive Health, University College London, London, UK
| | - Thais H Tittanegro
- Institute of Liver and Digestive Health, University College London, London, UK
| | - Amit Patel
- Division of Medicine, University College London, London, UK
| | | | - Nekisa Zakeri
- Institute of Liver and Digestive Health, University College London, London, UK
| | | | - Lucy Ly
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Derek W Gilroy
- Division of Medicine, University College London, London, UK
| | - Alastair O'Brien
- Institute of Liver and Digestive Health, University College London, London, UK
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China L, Freemantle N, Forrest E, Kallis Y, Ryder SD, Wright G, Portal AJ, Becares Salles N, Gilroy DW, O'Brien A. A Randomized Trial of Albumin Infusions in Hospitalized Patients with Cirrhosis. N Engl J Med 2021; 384:808-817. [PMID: 33657293 DOI: 10.1056/nejmoa2022166] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Infection and increased systemic inflammation cause organ dysfunction and death in patients with decompensated cirrhosis. Preclinical studies provide support for an antiinflammatory role of albumin, but confirmatory large-scale clinical trials are lacking. Whether targeting a serum albumin level of 30 g per liter or greater in these patients with repeated daily infusions of 20% human albumin solution, as compared with standard care, would reduce the incidences of infection, kidney dysfunction, and death is unknown. METHODS We conducted a randomized, multicenter, open-label, parallel-group trial involving hospitalized patients with decompensated cirrhosis who had a serum albumin level of less than 30 g per liter at enrollment. Patients were randomly assigned to receive either targeted 20% human albumin solution for up to 14 days or until discharge, whichever came first, or standard care. Treatment commenced within 3 days after admission. The composite primary end point was new infection, kidney dysfunction, or death between days 3 and 15 after the initiation of treatment. RESULTS A total of 777 patients underwent randomization, and alcohol was reported to be a cause of cirrhosis in most of these patients. A median total infusion of albumin of 200 g (interquartile range, 140 to 280) per patient was administered to the targeted albumin group (increasing the albumin level to ≥30 g per liter), as compared with a median of 20 g (interquartile range, 0 to 120) per patient administered to the standard-care group (adjusted mean difference, 143 g; 95% confidence interval [CI], 127 to 158.2). The percentage of patients with a primary end-point event did not differ significantly between the targeted albumin group (113 of 380 patients [29.7%]) and the standard-care group (120 of 397 patients [30.2%]) (adjusted odds ratio, 0.98; 95% CI, 0.71 to 1.33; P = 0.87). A time-to-event analysis in which data were censored at the time of discharge or at day 15 also showed no significant between-group difference (hazard ratio, 1.04; 95% CI, 0.81 to 1.35). More severe or life-threatening serious adverse events occurred in the albumin group than in the standard-care group. CONCLUSIONS In patients hospitalized with decompensated cirrhosis, albumin infusions to increase the albumin level to a target of 30 g per liter or more was not more beneficial than the current standard care in the United Kingdom. (Funded by the Health Innovation Challenge Fund; ATTIRE EudraCT number, 2014-002300-24; ISRCT number, N14174793.).
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Affiliation(s)
- Louise China
- From the Institute for Liver and Digestive Health (L.C., N.B.S., A.O.), the Comprehensive Clinical Trials Unit (N.F.), and the Division of Medicine, University College London (D.W.G.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London (Y.K.), London, the Glasgow Royal Infirmary and the University of Glagow, Glasgow (E.F.), the National Institute for Health Research Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Centre, Nottingham (S.D.R.), the Mid and South Essex NHS Foundation Trust and the Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon (G.W.), and the Bristol Royal Infirmary, Bristol (A.J.P.) - all in the United Kingdom
| | - Nick Freemantle
- From the Institute for Liver and Digestive Health (L.C., N.B.S., A.O.), the Comprehensive Clinical Trials Unit (N.F.), and the Division of Medicine, University College London (D.W.G.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London (Y.K.), London, the Glasgow Royal Infirmary and the University of Glagow, Glasgow (E.F.), the National Institute for Health Research Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Centre, Nottingham (S.D.R.), the Mid and South Essex NHS Foundation Trust and the Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon (G.W.), and the Bristol Royal Infirmary, Bristol (A.J.P.) - all in the United Kingdom
| | - Ewan Forrest
- From the Institute for Liver and Digestive Health (L.C., N.B.S., A.O.), the Comprehensive Clinical Trials Unit (N.F.), and the Division of Medicine, University College London (D.W.G.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London (Y.K.), London, the Glasgow Royal Infirmary and the University of Glagow, Glasgow (E.F.), the National Institute for Health Research Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Centre, Nottingham (S.D.R.), the Mid and South Essex NHS Foundation Trust and the Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon (G.W.), and the Bristol Royal Infirmary, Bristol (A.J.P.) - all in the United Kingdom
| | - Yiannis Kallis
- From the Institute for Liver and Digestive Health (L.C., N.B.S., A.O.), the Comprehensive Clinical Trials Unit (N.F.), and the Division of Medicine, University College London (D.W.G.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London (Y.K.), London, the Glasgow Royal Infirmary and the University of Glagow, Glasgow (E.F.), the National Institute for Health Research Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Centre, Nottingham (S.D.R.), the Mid and South Essex NHS Foundation Trust and the Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon (G.W.), and the Bristol Royal Infirmary, Bristol (A.J.P.) - all in the United Kingdom
| | - Stephen D Ryder
- From the Institute for Liver and Digestive Health (L.C., N.B.S., A.O.), the Comprehensive Clinical Trials Unit (N.F.), and the Division of Medicine, University College London (D.W.G.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London (Y.K.), London, the Glasgow Royal Infirmary and the University of Glagow, Glasgow (E.F.), the National Institute for Health Research Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Centre, Nottingham (S.D.R.), the Mid and South Essex NHS Foundation Trust and the Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon (G.W.), and the Bristol Royal Infirmary, Bristol (A.J.P.) - all in the United Kingdom
| | - Gavin Wright
- From the Institute for Liver and Digestive Health (L.C., N.B.S., A.O.), the Comprehensive Clinical Trials Unit (N.F.), and the Division of Medicine, University College London (D.W.G.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London (Y.K.), London, the Glasgow Royal Infirmary and the University of Glagow, Glasgow (E.F.), the National Institute for Health Research Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Centre, Nottingham (S.D.R.), the Mid and South Essex NHS Foundation Trust and the Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon (G.W.), and the Bristol Royal Infirmary, Bristol (A.J.P.) - all in the United Kingdom
| | - Andrew J Portal
- From the Institute for Liver and Digestive Health (L.C., N.B.S., A.O.), the Comprehensive Clinical Trials Unit (N.F.), and the Division of Medicine, University College London (D.W.G.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London (Y.K.), London, the Glasgow Royal Infirmary and the University of Glagow, Glasgow (E.F.), the National Institute for Health Research Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Centre, Nottingham (S.D.R.), the Mid and South Essex NHS Foundation Trust and the Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon (G.W.), and the Bristol Royal Infirmary, Bristol (A.J.P.) - all in the United Kingdom
| | - Natalia Becares Salles
- From the Institute for Liver and Digestive Health (L.C., N.B.S., A.O.), the Comprehensive Clinical Trials Unit (N.F.), and the Division of Medicine, University College London (D.W.G.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London (Y.K.), London, the Glasgow Royal Infirmary and the University of Glagow, Glasgow (E.F.), the National Institute for Health Research Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Centre, Nottingham (S.D.R.), the Mid and South Essex NHS Foundation Trust and the Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon (G.W.), and the Bristol Royal Infirmary, Bristol (A.J.P.) - all in the United Kingdom
| | - Derek W Gilroy
- From the Institute for Liver and Digestive Health (L.C., N.B.S., A.O.), the Comprehensive Clinical Trials Unit (N.F.), and the Division of Medicine, University College London (D.W.G.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London (Y.K.), London, the Glasgow Royal Infirmary and the University of Glagow, Glasgow (E.F.), the National Institute for Health Research Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Centre, Nottingham (S.D.R.), the Mid and South Essex NHS Foundation Trust and the Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon (G.W.), and the Bristol Royal Infirmary, Bristol (A.J.P.) - all in the United Kingdom
| | - Alastair O'Brien
- From the Institute for Liver and Digestive Health (L.C., N.B.S., A.O.), the Comprehensive Clinical Trials Unit (N.F.), and the Division of Medicine, University College London (D.W.G.), Barts and the London School of Medicine and Dentistry, Queen Mary University of London (Y.K.), London, the Glasgow Royal Infirmary and the University of Glagow, Glasgow (E.F.), the National Institute for Health Research Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and the University of Nottingham, Queens Medical Centre, Nottingham (S.D.R.), the Mid and South Essex NHS Foundation Trust and the Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon (G.W.), and the Bristol Royal Infirmary, Bristol (A.J.P.) - all in the United Kingdom
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Aithal GP, Palaniyappan N, China L, Härmälä S, Macken L, Ryan JM, Wilkes EA, Moore K, Leithead JA, Hayes PC, O'Brien AJ, Verma S. Guidelines on the management of ascites in cirrhosis. Gut 2021; 70:9-29. [PMID: 33067334 PMCID: PMC7788190 DOI: 10.1136/gutjnl-2020-321790] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/27/2020] [Accepted: 09/04/2020] [Indexed: 12/15/2022]
Abstract
The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver has prepared this document. The aim of this guideline is to review and summarise the evidence that guides clinical diagnosis and management of ascites in patients with cirrhosis. Substantial advances have been made in this area since the publication of the last guideline in 2007. These guidelines are based on a comprehensive literature search and comprise systematic reviews in the key areas, including the diagnostic tests, diuretic use, therapeutic paracentesis, use of albumin, transjugular intrahepatic portosystemic stent shunt, spontaneous bacterial peritonitis and beta-blockers in patients with ascites. Where recent systematic reviews and meta-analysis are available, these have been updated with additional studies. In addition, the results of prospective and retrospective studies, evidence obtained from expert committee reports and, in some instances, reports from case series have been included. Where possible, judgement has been made on the quality of information used to generate the guidelines and the specific recommendations have been made according to the 'Grading of Recommendations Assessment, Development and Evaluation (GRADE)' system. These guidelines are intended to inform practising clinicians, and it is expected that these guidelines will be revised in 3 years' time.
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Affiliation(s)
- Guruprasad P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Naaventhan Palaniyappan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Louise China
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Suvi Härmälä
- Institute of Health Informatics, University College London, London, UK
| | - Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Jennifer M Ryan
- Institute of Liver Disease and Digestive Health, University College London, London, UK
- Royal Free London NHS Foundation Trust, London, UK
| | - Emilie A Wilkes
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kevin Moore
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Joanna A Leithead
- Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Peter C Hayes
- Hepatology Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alastair J O'Brien
- Institute of Liver Disease and Digestive Health, University College London, London, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Becares N, Härmälä S, China L, Colas RA, Maini AA, Bennet K, Skene SS, Shabir Z, Dalli J, O’Brien A. Immune Regulatory Mediators in Plasma from Patients With Acute Decompensation Are Associated With 3-Month Mortality. Clin Gastroenterol Hepatol 2020; 18:1207-1215.e6. [PMID: 31446184 PMCID: PMC7196929 DOI: 10.1016/j.cgh.2019.08.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/30/2019] [Accepted: 08/09/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Infection is a common cause of death in patients with cirrhosis. We investigated the association between the innate immune response and death within 3 months of hospitalization. METHODS Plasma samples were collected on days 1, 5, 10, and 15 from participants recruited into the albumin to prevent infection in chronic liver failure feasibility study. Patients with acute decompensated cirrhosis were given albumin infusions at 10 hospitals in the United Kingdom. Data were obtained from 45 survivors and 27 non-survivors. We incubated monocyte-derived macrophages from healthy individuals with patients' plasma samples and measured activation following lipopolysaccharide administration, determined by secretion of tumor necrosis factor and soluble mediators of inflammation. Each analysis included samples from 4 to 14 patients. RESULTS Plasma samples from survivors vs non-survivors had different inflammatory profiles. Levels of prostaglandin E2 were high at times of patient hospitalization and decreased with albumin infusions. Increased levels of interleukin 4 (IL4) in plasma collected at day 5 of treatment were associated with survival at 3 months. Incubation of monocyte-derived macrophages with day 5 plasma from survivors, pre-incubated with a neutralizing antibody against IL4, caused a significant increase in tumor necrosis factor production to the level of non-survivor plasma. Although baseline characteristics were similar, non-survivors had higher white cell counts and levels of C-reactive protein and renal dysfunction. CONCLUSIONS We identified profiles of inflammatory markers in plasma that are associated with 3-month mortality in patients with acute decompensated cirrhosis given albumin. Increases in prostaglandin E2 might promote inflammation within the first few days after hospitalization, and increased levels of plasma IL4 at day 5 are associated with increased survival. Clinicaltrialsregister.eu: EudraCT 2014-002300-24.
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Affiliation(s)
- Natalia Becares
- Centre for Clinical Pharmacology and Therapeutics, Division of Medicine, University College London, London, United Kingdom.
| | - Suvi Härmälä
- Institute of Health Informatics, University College London, London, United Kingdom
| | - Louise China
- Centre for Clinical Pharmacology and Therapeutics, Division of Medicine, University College London, London, United Kingdom
| | - Romain A. Colas
- Lipid Mediator Unit, Center for Biochemical Pharmacology, William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, Charterhouse Square, London, United Kingdom
| | - Alexander A. Maini
- Centre for Clinical Pharmacology and Therapeutics, Division of Medicine, University College London, London, United Kingdom
| | - Kate Bennet
- Comprehensive Clinical Trials Unit, University College London, London, United Kingdom
| | - Simon S. Skene
- Comprehensive Clinical Trials Unit, University College London, London, United Kingdom
| | - Zainib Shabir
- Comprehensive Clinical Trials Unit, University College London, London, United Kingdom
| | - Jesmond Dalli
- Lipid Mediator Unit, Center for Biochemical Pharmacology, William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, Charterhouse Square, London, United Kingdom
| | - Alastair O’Brien
- Centre for Clinical Pharmacology and Therapeutics, Division of Medicine, University College London, London, United Kingdom
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Maida M, Alrubaiy L, Bokun T, Bruns T, Castro V, China L, Conroy G, Trabulo D, Van Steenkiste C, Voermans RP, Burisch J, Ianiro G. Current challenges and future needs of clinical and endoscopic training in gastroenterology: a European survey. Endosc Int Open 2020; 8:E525-E533. [PMID: 32258375 PMCID: PMC7089798 DOI: 10.1055/a-1093-0877] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 11/04/2019] [Indexed: 12/19/2022] Open
Abstract
Background and study aims A universal European training program in gastroenterology and hepatology is currently not available. The European Board of Gastroenterology and Hepatology (EBGH) has produced guidance regarding expected competencies for European gastroenterology trainees but it is unclear whether these have been incorporated in national curricula. The aim of this study was to provide an in-depth assessment of training and research opportunities, professional activities and of socioeconomic aspects of gastroenterology training across Europe through a web-based 90-point questionnaire. Materials and methods Physicians in their last year or who had recently finished their training, from 16 European countries, were invited to answer the questionnaire. Results A total of 144 physicians answered the survey. A minimum number of procedures is required before completing training in nine of 16 countries (56 %). Overall, European trainees dedicate a median of 12 months (IQR 6-25) of their training period to endoscopy and a median of 3 months (IQR 0-6) to ultrasound. Training in interventional endoscopy was not always exhaustive, as about 50 % of participants performed fewer of several interventional procedures than was recommended by EBGH, most participants did not perform endoscopic hemostasis or endoscopic mucosal resection, and nearly a half of participants had no access to pancreatobiliary endoscopy training. Finally, up to 13 % of residents complete their training without the supervision of a mentor. Conclusion In this large European survey, deep gaps and considerable differences in several gastroenterology training activities were found both among and within 16 European countries. Homogenization of educational programs and training opportunities across Europe is therefore necessary.
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Affiliation(s)
- Marcello Maida
- Department of Gastroenterology, S.Elia - Raimondi Hospital, Caltanissetta, Italy
| | - Laith Alrubaiy
- Department of Gastroenterology, St Mark’s Hospital, London, UK
| | - Tomislav Bokun
- Department of Gastroenterology, Hepatology and clinical nutrition, University Hospital Dubrava, University of Zagreb, Zagreb, Yugoslavia
| | - Tony Bruns
- Department of Medicine III, University Hospital RWTH Aachen, Germany
| | - Valeria Castro
- Department of Internal Medicine, Gastroenterology and Hepatology Unit, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Louise China
- Metabolism and Experimental Therapeutics, Division of Medicine, University College London, London, UK
| | - Guillaume Conroy
- Department of Hepatology and Gastroenterology, Mercy Hospital, Metz, France
| | - Daniel Trabulo
- Gastroenterology department, Hospital de Cascais, Hospital da Luz Setúbal, Portugal
| | | | - Rogier P. Voermans
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam
| | - Johan Burisch
- Digestive Disease Centre, Medical Section, Herlev University Hospital, Copenhagen, Denmark
| | - Gianluca Ianiro
- Digestive Disease Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Woodhouse CA, Patel VC, Goldenberg S, Sanchez-Fueyo A, China L, O'Brien A, Flach C, Douiri A, Shawcross D. PROFIT, a PROspective, randomised placebo controlled feasibility trial of Faecal mIcrobiota Transplantation in cirrhosis: study protocol for a single-blinded trial. BMJ Open 2019; 9:e023518. [PMID: 30772848 PMCID: PMC6398649 DOI: 10.1136/bmjopen-2018-023518] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Patients with advanced cirrhosis have enteric bacterial dysbiosis and translocation of bacteria and their products across the gut epithelial barrier. This culminates in systemic inflammation and endotoxaemia, inducing innate immune dysfunction which predisposes to infection, and development of complications such as bleeding, sepsis and hepatic encephalopathy. This feasibility study aims to assess the safety of administering faecal microbiota transplantion to patients with cirrhosis and explore the effect of the intervention on their prognosis by achieving restoration of a healthy gut microbiome. METHODS AND ANALYSIS A PROspective, randomised placebo controlled feasibility trial of Faecal mIcrobiota Transplantation is a single-centre, randomised, single-blinded, placebo-controlled study evaluating faecal microbiota transplantation (FMT) against placebo. Patients with advanced but stable cirrhosis with a Model for End-Stage Liver Disease score between 10 and 16 will be recruited. Twenty-four patients will be randomised to FMT plus standard of care (as per our institutional practice) and eight patients to placebo in a ratio of 3:1. Patients will be evaluated at baseline before the study intervention is administered and at 7, 30 and 90 days post-intervention to assess safety and adverse events. FMT/placebo will be administered into the jejunum within 7 days of baseline. The primary outcome measure will be safety and feasibility as assessed by recruitment rates, tolerability and safety of FMT treatment. Results will be disseminated via peer-reviewed journals and international conferences. The recruitment of the first patient occurred on 23 May 2018. ETHICS AND DISSEMINATION Research Ethics approval was given by the London South East Research Ethics committee (ref 17/LO/2081). TRIAL REGISTRATION NUMBER NCT02862249 and EudraCT 2017-003629-13.
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Affiliation(s)
- Charlotte Alexandra Woodhouse
- James Black Centre, School of Immunology & Microbial Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Vishal C Patel
- James Black Centre, School of Immunology & Microbial Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Simon Goldenberg
- Department of Microbiology, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Alberto Sanchez-Fueyo
- James Black Centre, School of Immunology & Microbial Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Louise China
- Division of Medicine, University College London, London, UK
| | | | - Clare Flach
- School of Population Health & Environmental Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Abdel Douiri
- School of Population Health & Environmental Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Debbie Shawcross
- James Black Centre, School of Immunology & Microbial Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
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McFarlane M, Bhala N, China L, Alrubaiy L, Chedgy F, Disney BR, Farmer AD, Fogden E, Sadler G, Hull MA, McLaughlin J, Ellison H, Solomon J, Brookes MJ. Attitudes to out-of-programme experiences, research and academic training of gastroenterology trainees between 2007 and 2016. Frontline Gastroenterol 2019; 10:57-66. [PMID: 30651959 PMCID: PMC6319145 DOI: 10.1136/flgastro-2018-100993] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 05/23/2018] [Accepted: 05/27/2018] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Academic medical training was overhauled in 2005 after the Walport report and Modernising Medical Careers to create a more attractive and transparent training pathway. In 2007 and 2016, national web-based surveys of gastroenterology trainees were undertaken to determine experiences, perceptions of and perceived barriers to out-of-programme research experience (OOP-R). DESIGN SETTING AND PATIENTS Prospective, national web-based surveys of UK gastroenterology trainees in 2007 and 2016. MAIN OUTCOME MEASURE Attitudes to OOP-R of two cohorts of gastroenterology trainees. RESULTS Response rates were lower in 2016 (25.8% vs 56.7%) (p<0.0001), although female trainees' response rates increased (from 28.8% to 37.6%) (p=0.17), along with higher numbers of academic trainees. Over 80% of trainees planned to undertake OOP-R in both surveys, with >50% having already undertaken it. Doctor of Philosophy/medical doctorate remained the most popular OOP-R in both cohorts. Successful fellowship applications increased in 2016, and evidence of gender inequality in 2007 was no longer evident in 2016. In the 2016 cohort, 91.1% (n=144) felt the development of trainee-led research networks was important, with 74.7% (n=118) keen to get involved. CONCLUSIONS The majority of gastroenterology trainees who responded expressed a desire to undertake OOP-R, and participation rates in OOP-R remain high. Despite smaller absolute numbers responding than in 2007, 2016 trainees achieved higher successful fellowship application rates. Reassuringly more trainees in 2016 felt that OOP-R would be important in the future. Efforts are needed to tackle potential barriers to OOP-R and support trainees to pursue research-active careers.
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Affiliation(s)
- Michael McFarlane
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Neeraj Bhala
- Department of Gastroenterology, University Hospital Birmingham, Birmingham, UK
| | - Louise China
- Division of Medicine, University College London, London, UK
| | | | - Fergus Chedgy
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | - Benjamin R Disney
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Adam D Farmer
- Department of Gastroenterology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Edward Fogden
- Department of Gastroenterology, Sandwell and West Birmingham Hospitals, Birmingham, UK
| | - Gareth Sadler
- Department of Gastroenterology, St George’s University Hospitals NHS Trust, London, UK
| | - Mark A Hull
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - John McLaughlin
- School of Medical Sciences, The University of Manchester, Manchester, UK
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China L, Skene SS, Bennett K, Shabir Z, Hamilton R, Bevan S, Chandler T, Maini AA, Becares N, Gilroy D, Forrest EH, O’Brien A. ATTIRE: Albumin To prevenT Infection in chronic liveR failurE: study protocol for an interventional randomised controlled trial. BMJ Open 2018; 8:e023754. [PMID: 30344180 PMCID: PMC6196858 DOI: 10.1136/bmjopen-2018-023754] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Circulating prostaglandin E2 levels are elevated in acutely decompensated cirrhosis and have been shown to contribute to immune suppression. Albumin binds to and inactivates this immune-suppressive lipid mediator. Human albumin solution (HAS) could thus be repurposed as an immune-restorative drug in these patients.This is a phase III randomised controlled trial (RCT) to verify whether targeting a serum albumin level of ≥35 g/L in hospitalised patients with decompensated cirrhosis using repeated intravenous infusions of 20% HAS will reduce incidence of infection, renal dysfunction and mortality for the treatment period (maximum 14 days or discharge if <14 days) compared with standard medical care. METHODS AND ANALYSIS Albumin To prevenT Infection in chronic liveR failurE stage 2 is a multicentre, open-label, interventional RCT. Patients with decompensated cirrhosis admitted to the hospital with a serum albumin of <30 g/L are eligible, subject to exclusion criteria. Patients randomised to intravenous HAS will have this administered, according to serum albumin levels, for up to 14 days or discharge. The infusion protocol aims to increase serum albumin to near-normal levels.The composite primary endpoint is: new infection, renal dysfunction or mortality within the trial treatment period. Secondary endpoints include mortality at up to 6 months, incidence of other organ failures, cost-effectiveness and quality of life outcomes and time to liver transplant. The trial will recruit 866 patients at more than 30 sites across the UK. ETHICSANDDISSEMINATION Research ethics approval was given by the London-Brent research ethics committee (ref: 15/LO/0104). The clinical trials authorisation was issued by the medicines and healthcare products regulatory agency (ref: 20363/0350/001-0001). The trial is registered with the European Medicines Agency (EudraCT 2014-002300-24) and has been adopted by the National Institute for Health Research (ISRCTN 14174793). This manuscript refers to version 6.0 of the protocol. Results will be disseminated through peer-reviewed journals and international conferences. Recruitment of the first participant occurred on 25 January 2016.
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Affiliation(s)
- Louise China
- Division of Medicine, University College London, London, UK
| | - Simon S Skene
- School of Biosciences and Medicine, University of Surrey, Guildford, UK
| | - Kate Bennett
- Comprehensive Clinical Trials Unit, UCL, London, UK
| | | | | | - Scott Bevan
- Comprehensive Clinical Trials Unit, UCL, London, UK
| | | | | | | | - Derek Gilroy
- Division of Medicine, University College London, London, UK
| | - Ewan H Forrest
- Department of Gastroenterology, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
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Biswas S, Alrubaiy L, China L, Lockett M, Ellis A, Hawkes N. Trends in UK endoscopy training in the BSG trainees' national survey and strategic planning for the future. Frontline Gastroenterol 2018; 9:200-207. [PMID: 30046424 PMCID: PMC6056087 DOI: 10.1136/flgastro-2017-100848] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 07/26/2017] [Accepted: 08/19/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Improvements in the structure of endoscopy training programmes resulting in certification from the Joint Advisory Group in Gastrointestinal Endoscopy have been acknowledged to improve training experience and contribute to enhanced colonoscopy performance. OBJECTIVES The 2016 British Society of Gastroenterology trainees' survey of endoscopy training explored the delivery of endoscopy training - access to lists; level of supervision and trainee's progression through diagnostic, core therapy and subspecialty training. In addition, the barriers to endoscopy training progress and utility of training tools were examined. METHODS A web-based survey (Survey Monkey) was sent to all higher specialty gastroenterology trainees. RESULTS There were some improvements in relation to earlier surveys; 85% of trainees were satisfied with the level of supervision of their training. But there were ongoing problems; 12.5% of trainees had no access to a regular training list, and 53% of final year trainees had yet to achieve full certification in colonoscopy. 9% of final year trainees did not feel confident in endoscopic management of upper GI bleeds. CONCLUSIONS The survey findings provide a challenge to those agencies tasked with supporting endoscopy training in the UK. Acknowledging the findings of the survey, the paper provides a strategic response with reference to increased service pressures, reduced overall training time in specialty training programmes and the requirement to support general medical and surgical on-call commitments. It describes the steps required to improve training on the ground: delivering additional training tools and learning resources, and introducing certification standards for therapeutic modalities in parallel with goals for improving the quality of endoscopy in the UK.
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Affiliation(s)
- Sujata Biswas
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Laith Alrubaiy
- Department of Gastroenterology, Swansea University Medical School, Swansea, UK
| | - Louise China
- Division of Medicine, University College London, London, UK
| | | | - Melanie Lockett
- Department of Gastroenterology, North Bristol NHS Trust, Bristol, UK
| | - Antony Ellis
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Neil Hawkes
- Department of Gastroenterology, Royal Glamorgan Hospital, Llantrisant, UK
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China L, Skene SS, Shabir Z, Maini A, Sylvestre Y, Bennett K, Bevan S, O'Beirne J, Forrest E, Portal J, Ryder S, Wright G, Gilroy DW, O'Brien A. Administration of Albumin Solution Increases Serum Levels of Albumin in Patients With Chronic Liver Failure in a Single-Arm Feasibility Trial. Clin Gastroenterol Hepatol 2018; 16:748-755.e6. [PMID: 28911947 PMCID: PMC6168936 DOI: 10.1016/j.cgh.2017.09.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/21/2017] [Accepted: 09/06/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Infections are life-threatening to patients with acute decompensation and acute-on-chronic liver failure (AD/ACLF). Patients with AD/ACLF have prostaglandin E2-mediated immune suppression, which can be reversed by administration of albumin; infusion of 20% human albumin solution (HAS) might improve outcomes of infections. We performed a feasibility study to determine optimal trial design, assess safety, and validate laboratory assessments of immune function to inform design of a phase 3 trial. METHODS We performed a prospective multicenter, single-arm, open-label trial of 79 patients with AD/ACLF and levels of albumin lower than 30 g/L, seen at 10 hospitals in the United Kingdom from May through December 2015. Patients were given daily infusions of 20% HAS, based on serum levels, for 14 days or until discharge from the hospital. Rates of infection, organ dysfunction, and in-hospital mortality were recorded. The primary end point was daily serum albumin level during the treatment period. Success would be demonstrated if 60% achieved and maintained serum albumin levels at or above 30 g/L on at least one third of days with recorded levels. RESULTS The patients' mean model for end-stage disease score was 20.9 ± 6.6. The primary end point (albumin ≥30 g/L on at least one third of days recorded) was achieved by 68 of the 79 patients; 75% of administrations were in accordance with suggested dosing regimen. Mean treatment duration was 10.3 days (104 ± 678 mL administered). There were 8 deaths and 13 serious adverse events, considered by the independent data-monitoring committee to be consistent with those expected. Twelve of 13 patients that developed either respiratory or cardiovascular dysfunction (based on ward-based clinical definitions) as their only organ dysfunction were alive at 30 days compared with 1 of 3 that developed renal dysfunction. Only 1 case of brain dysfunction was recorded. CONCLUSIONS In a feasibility trial, we found that administration of HAS increased serum levels of albumin in patients with AD/ACLF. The dosing regimen was acceptable at multiple sites and deemed safe by an independent data-monitoring committee. We also developed a robust system to record infections. The poor prognosis for patients with renal dysfunction was confirmed. However, patients with cardiovascular or respiratory dysfunction had good outcomes, which is counterintuitive. Severe encephalopathy appeared substantially under-reported, indicating that ward-based assessment of these parameters cannot be recorded with sufficient accuracy for use as a primary outcome in phase 3 trials. Trial registration no: EudraCT 2014-002300-24 and ISRCTN14174793.
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Affiliation(s)
- Louise China
- Division of Medicine, University College London, United Kingdom.
| | - Simon S Skene
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
| | - Zainib Shabir
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
| | - Alexander Maini
- Division of Medicine, University College London, United Kingdom
| | - Yvonne Sylvestre
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
| | - Kate Bennett
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
| | - Scott Bevan
- Comprehensive Clinical Trials Unit, University College London, United Kingdom
| | - James O'Beirne
- Royal Free National Health Service Trust, London, United Kingdom
| | - Ewan Forrest
- Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Jim Portal
- Bristol Royal Infirmary, Bristol, United Kingdom
| | - Steve Ryder
- Nottingham University Hospital, Nottingham, United Kingdom
| | - Gavin Wright
- Basildon University Hospital, Essex, United Kingdom
| | - Derek W Gilroy
- Division of Medicine, University College London, United Kingdom
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China L, Maini A, Skene SS, Shabir Z, Sylvestre Y, Colas RA, Ly L, Becares Salles N, Belloti V, Dalli J, Gilroy DW, O’Brien A. Albumin Counteracts Immune-Suppressive Effects of Lipid Mediators in Patients With Advanced Liver Disease. Clin Gastroenterol Hepatol 2018; 16:738-747.e7. [PMID: 28859868 PMCID: PMC6168974 DOI: 10.1016/j.cgh.2017.08.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/28/2017] [Accepted: 08/08/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with acute decompensation and acute-on-chronic liver failure (AD/ACLF) have immune dysfunction, which increases their risk for infections; however, there are no effective treatments to restore their immune function. We investigated whether the potentially immune-restorative effects of albumin are mediated by its effects on prostaglandin E2 (PGE2) and other lipids. METHODS We analyzed bloods samples from 45 of 79 patients with AD/ACLF and serum levels of albumin less than 30 g/L for whom infusion of 20% human albumin solution (HAS) increased serum levels of albumin 30 g/L or more in a feasibility study of effects of 20% HAS. Immune function was determined by comparison of macrophage function following addition of plasma samples. We also used samples from 12 healthy individuals. We measured binding of plasma proteins to PGE2 and serum levels of endotoxin (lipopolysaccharide) and cytokines; using 10 patients' samples, we investigated the effects of PGE2 inhibitors. We performed a comprehensive lipid metabolomic analysis using samples from 10 different patients, before and after HAS administration. RESULTS At baseline, AD/ACLF patient plasma induced significantly lower production of tumor necrosis factor by healthy macrophages than plasma from healthy individuals (P < .0001). Plasma from patients after HAS infusion induced significantly higher levels of tumor necrosis factor production by macrophages (19.5 ± 4.8 ng/mL) compared with plasma collected before treatment (17.7 ± 4.5 ng/mL; P = .0013). There was a significantly lower proportion of plasma protein (albumin) binding to PGE2 from patients with AD/ACLF plasma (mean, 61.9%) compared with plasma from control subjects (77.1%; P = .0012). AD/ACLF plasma protein binding to PGE2 increased following HAS treatment compared with baseline (mean increase, 8.7%; P < .0001). Circulating levels of PGE2, lipopolysaccharide, and inflammatory or anti-inflammatory cytokines were higher in patients with AD/ACLF than healthy volunteers. Unexpectedly, HAS infusion had no effect on mediator levels. Principal component analysis of baseline levels of lipids that induce or resolve inflammation identified 2 distinct groups of patients that differed according to baseline plasma level of lipopolysaccharide. Sample analyses after HAS treatment indicated that albumin regulates circulating levels of lipid mediators, but this effect was distinct in each group. CONCLUSIONS Analysis of blood samples from patients with AD/ACLF participating in a feasibility study of 20% HAS infusions has shown that infusions to raise serum albumin above 30 g/L reversed plasma-mediated immune dysfunction by binding and inactivating PGE2. We also describe a method to classify the inflammatory response in AD/ACLF, based on lipid profile, which could improve identification of patients most likely to respond to HAS treatment. A randomized controlled trial is needed to determine whether these effects of HAS reduce infections in AD/ACLF. Trial registered with European Medicines Agency (EudraCT 2014-002300-24) and adopted by NIHR (ISRCTN14174793).
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Affiliation(s)
- Louise China
- Division of Medicine, University College London, London, United Kingdom.
| | - Alexander Maini
- Division of Medicine, University College London, London, United Kingdom
| | - Simon S. Skene
- University of London Comprehensive Clinical Trials Unit, London, United Kingdom
| | - Zainib Shabir
- University of London Comprehensive Clinical Trials Unit, London, United Kingdom
| | - Yvonne Sylvestre
- University of London Comprehensive Clinical Trials Unit, London, United Kingdom
| | - Romain A. Colas
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Lucy Ly
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | | | - Vittorio Belloti
- Division of Medicine, University College London, London, United Kingdom
| | - Jesmond Dalli
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Derek W. Gilroy
- Division of Medicine, University College London, London, United Kingdom
| | - Alastair O’Brien
- Division of Medicine, University College London, London, United Kingdom
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O'Brien A, China L, Gant V. The potential danger of empiric antimicrobial therapy for nosocomial SBP. Hepatology 2016; 64:2267-2268. [PMID: 27453062 DOI: 10.1002/hep.28733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 05/18/2016] [Indexed: 01/27/2023]
Affiliation(s)
- Alastair O'Brien
- Institute of Liver and Digestive Health, University College London, London, United Kingdom
| | - Louise China
- Institute of Liver and Digestive Health, University College London, London, United Kingdom
| | - Vanya Gant
- Institute of Liver and Digestive Health, University College London, London, United Kingdom
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O'Brien A, China L. Is human albumin solution really the best resuscitation fluid for patients with advanced cirrhosis? Gut 2016; 65:1392-3. [PMID: 27196578 DOI: 10.1136/gutjnl-2016-311999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 04/12/2016] [Indexed: 01/27/2023]
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O'Brien A, China L, Massey KA, Nicolaou A, Winstanley A, Newson J, Hobbs A, Audzevich T, Gilroy DW. Bile duct-ligated mice exhibit multiple phenotypic similarities to acute decompensation patients despite histological differences. Liver Int 2016; 36:837-46. [PMID: 26012885 PMCID: PMC4869675 DOI: 10.1111/liv.12876] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 05/13/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Patients with decompensated cirrhosis are susceptible to infection. Innate immune dysfunction and development of organ failure are considered to underlie this. A rodent model of liver disease sharing these phenotypic features would assist in vivo study of underlying mechanisms and testing of therapeutics. We evaluated three models to identify which demonstrated the greatest clinical and immunological phenotypic similarity to patients with acutely decompensated (AD) cirrhosis. METHODS We selected Bile Duct Ligation (BDL) rats at 4 weeks, BDL mice at 14 days and Carbon tetrachloride (CCl4 ) mice at 10 weeks (with studies performed 7 days after final CCl4 infection). We examined organ dysfunction, inflammatory response to carrageenan-in-paw, plasma eicosanoid concentrations, macrophage cytokine production and responses to peritoneal infection. RESULTS Bile duct ligation caused sarcopenia, liver, cardiovascular and renal dysfunction whereas CCl4 mice demonstrated no clinical abnormalities. BDL rodents exhibited depressed response to carrageenan-in-paw unlike CCl4 mice. BDL rats have slightly elevated plasma eicosanoid levels and plasma showed partial PGE2 -mediated immune suppression whereas CCl4 mice did not. Plasma NOx was elevated in patients with acute or chronic liver failure (AoCLF) compared to healthy volunteers and BDL rodents but not CCl4 mice. Elevated nitric oxide (NO) via inducible nitric oxide synthase (iNOS) mediates defective leucocyte trafficking in BDL rodent models. CONCLUSIONS We conclude that BDL mice and rats are not simply models of cholestatic liver injury but may be used to study mechanisms underlying poor outcome from infection in AD and have identified elevated NO as a potential mediator of depressed leucocyte trafficking.
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Affiliation(s)
- Alastair O'Brien
- Centre for Clinical Pharmacology and TherapeuticsDivision of MedicineUniversity College LondonLondonUK
| | - Louise China
- Centre for Clinical Pharmacology and TherapeuticsDivision of MedicineUniversity College LondonLondonUK
| | - Karen A. Massey
- Manchester Pharmacy SchoolFaculty of Medical and Human Sciencesthe University of ManchesterManchesterUK
| | - Anna Nicolaou
- Manchester Pharmacy SchoolFaculty of Medical and Human Sciencesthe University of ManchesterManchesterUK
| | - Alison Winstanley
- Department of HistopathologyUniversity College London HospitalsLondonUK
| | - Justine Newson
- Centre for Clinical Pharmacology and TherapeuticsDivision of MedicineUniversity College LondonLondonUK
| | | | - Tatsiana Audzevich
- Centre for Clinical Pharmacology and TherapeuticsDivision of MedicineUniversity College LondonLondonUK
| | - Derek W. Gilroy
- Manchester Pharmacy SchoolFaculty of Medical and Human Sciencesthe University of ManchesterManchesterUK
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Affiliation(s)
| | - Laith Alrubaiy
- British Society of Gastroenterology Trainees Section, London, UK; Swansea University, Swansea, UK
| | - Louise China
- British Society of Gastroenterology Trainees Section, London, UK; University College London, London, UK
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China L, Muirhead N, Skene SS, Shabir Z, PH De Maeyer R, Maini AAN, W Gilroy D, J O'Brien A. ATTIRE: Albumin To prevenT Infection in chronic liveR failurE: study protocol for a single-arm feasibility trial. BMJ Open 2016; 6:e010132. [PMID: 26810999 PMCID: PMC4735307 DOI: 10.1136/bmjopen-2015-010132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Circulating prostaglandin E2 levels are elevated in acutely decompensated cirrhosis and have been shown to contribute to immune suppression. Albumin binds and inactivates this hormone. Human albumin solution could thus be repurposed as an immune restorative drug in these patients.This feasibility study aims to determine whether it is possible and safe to restore serum albumin to >30 g/L and maintain it at this level in patients admitted with acute decompensated cirrhosis using repeated 20% human albumin infusions according to daily serum albumin levels. METHODS AND ANALYSIS Albumin To prevenT Infection in chronic liveR failurE (ATTIRE) stage 1 is a multicentre, open label dose feasibility trial. Patients with acutely decompensated cirrhosis admitted to hospital with a serum albumin of <30 g/L are eligible, subject to exclusion criteria. Daily intravenous human albumin solution will be infused, according to serum albumin levels, for up to 14 days or discharge in all patients. The primary end point is daily serum albumin levels for the duration of the treatment period and the secondary end point is plasma-induced macrophage dysfunction. The trial will recruit 80 patients. Outcomes will be used to assist with study design for an 866 patient randomised controlled trial at more than 30 sites across the UK. ETHICS AND DISSEMINATION Research ethics approval was given by the London-Brent research ethics committee (ref: 15/LO/0104). The clinical trials authorisation was issued by the medicines and healthcare products regulatory agency (ref: 20363/0350/001-0001). RESULTS Will be disseminated through peer reviewed journals and international conferences. Recruitment of the first participant occurred on 26/05/2015. TRIAL REGISTRATION NUMBER The trial is registered with the European Medicines Agency (EudraCT 2014-002300-24) and has been adopted by the NIHR (ISRCTN 14174793). This manuscript refers to V.4.0 of the protocol; Pre-results.
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Affiliation(s)
- Louise China
- Division of Medicine, University College London (UCL), London, UK
| | - Nicola Muirhead
- Comprehensive Clinical Trials Unit, University College London (UCL), London, UK
| | - Simon S Skene
- Comprehensive Clinical Trials Unit, University College London (UCL), London, UK
| | - Zainib Shabir
- Comprehensive Clinical Trials Unit, University College London (UCL), London, UK
| | | | | | - Derek W Gilroy
- Division of Medicine, University College London (UCL), London, UK
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