PREDICT identifies precipitating events associated with the clinical course of acutely decompensated cirrhosis

BACKGROUND & AIMS

Acute decompensation (AD) of cirrhosis may present without acute-on-chronic liver failure (ACLF) (AD-No ACLF), or with ACLF (AD-ACLF), defined by organ failure(s). Herein, we aimed to analyze and characterize the precipitants leading to both of these AD phenotypes.

METHODS

The multicenter, prospective, observational PREDICT study (NCT03056612) included 1,273 non-electively hospitalized patients with AD (No ACLF = 1,071; ACLF = 202). Medical history, clinical data and laboratory data were collected at enrolment and during 90-day follow-up, with particular attention given to the following characteristics of precipitants: induction of organ dysfunction or failure, systemic inflammation, chronology, intensity, and relationship to outcome.

RESULTS

Among various clinical events, 4 distinct events were precipitants consistently related to AD: proven bacterial infections, severe alcoholic hepatitis, gastrointestinal bleeding with shock and toxic encephalopathy. Among patients with precipitants in the AD-No ACLF cohort and the AD-ACLF cohort (38% and 71%, respectively), almost all (96% and 97%, respectively) showed proven bacterial infection and severe alcoholic hepatitis, either alone or in combination with other events. Survival was similar in patients with proven bacterial infections or severe alcoholic hepatitis in both AD phenotypes. The number of precipitants was associated with significantly increased 90-day mortality and was paralleled by increasing levels of surrogates for systemic inflammation. Importantly, adequate first-line antibiotic treatment of proven bacterial infections was associated with a lower ACLF development rate and lower 90-day mortality.

CONCLUSIONS

This study identified precipitants that are significantly associated with a distinct clinical course and prognosis in patients with AD. Specific preventive and therapeutic strategies targeting these events may improve outcomes in patients with decompensated cirrhosis.

LAY SUMMARY

Acute decompensation (AD) of cirrhosis is characterized by a rapid deterioration in patient health. Herein, we aimed to analyze the precipitating events that cause AD in patients with cirrhosis. Proven bacterial infections and severe alcoholic hepatitis, either alone or in combination, accounted for almost all (96-97%) cases of AD and acute-on-chronic liver failure. Whilst the type of precipitant was not associated with mortality, the number of precipitant(s) was. This study identified precipitants that are significantly associated with a distinct clinical course and prognosis of patients with AD. Specific preventive and therapeutic strategies targeting these events may improve patient outcomes.

Including Relative Adrenal Insufficiency in Definition and Classification of Acute-on-Chronic Liver Failure

BACKGROUND & AIMS

Relative adrenal insufficiency (RAI) is defined by insufficient production of cortisol relative to organ demand. RAI is observed frequently in hospitalized patients with cirrhosis, but there is disagreement over the clinical effects of RAI in these patients. We evaluated the prevalence and the clinical effects of RAI in hospitalized patients with cirrhosis.

METHODS

We performed a prospective study of 160 patients admitted to a hospital in Italy for acute decompensation of cirrhosis from May 2011 through September 2016. Patients were followed up until death, liver transplantation, or a maximum of 90 days. Serum and salivary levels of cortisol were measured before and after a 1-hour Short Synacthen Test. A diagnosis of RAI was given to patients with an increase in serum cortisol of less than 9 μg/dL, after Synacthen administration, in patients with baseline serum levels of cortisol less than 35 μg/dL. We collected blood samples before the Synacthen test and analyzed them for blood cell counts, liver and renal function, levels of C-reactive protein, and lipid profiles (total cholesterol, high-density lipoprotein cholesterol, apolipoprotein-A1).

RESULTS

A diagnosis of RAI was made for 78 patients (49%). Age (odds ratio [OR], 0.95; P = .030), number of leukocytes (OR, 3.10; P = .006), and levels of high-density lipoprotein cholesterol (OR, 0.30; P = .039) were associated independently with RAI. Patients with RAI had a significantly higher risk of developing bacterial infections (hazard ratio [HR], 1.60; P = .038), sepsis (HR, 2.95; P = .001), septic shock (HR, 4.94; P = .038), new organ failures (HR, 2.45; P = .014), and acute-on-chronic liver failure (HR, 2.27; P = .037) than patients without RAI. RAI was associated independently with death within 90 days of diagnosis (subdistribution HR, 4.83; P = .001). Patients with RAI and mild renal dysfunction or hepatic encephalopathy had no significant difference in cumulative incidence of 28-day mortality vs patients with acute-on-chronic liver failure grade 1 (25% vs 22%).

CONCLUSIONS

We found RAI to occur in almost half of patients admitted to a hospital for acute decompensation of cirrhosis. RAI was associated with a deficit of substrates for steroidogenesis and an increase in markers of inflammation. Patients with RAI have a high risk of developing sepsis, septic shock, organ failure, and death within 90 days. RAI has similar prognostic value to nonrenal organ failures.

Infections complicating cirrhosis

Patients with cirrhosis have a high risk of bacterial infections. Bacterial infections induce systemic inflammation that may lead to organ failure and acute-on-chronic liver failure (ACLF) resulting in a high risk of short term mortality. The early diagnosis and treatment of bacterial infections is essential to improve the patient's prognosis. However, in recent years, the spread of multidrug resistant (MDR) bacterial infections has reduced the efficacy of commonly used antibiotics such as third generation cephalosporins. In patients at high risk of MDR bacteria, such as those with nosocomial infections, the early administration of broad spectrum antibiotics has been shown to improve the prognosis. However, early de-escalation of antibiotics is recommended to reduce a further increase in antibiotic resistance. Strategies to prevent acute kidney injury and other organ failures should be implemented. Although prophylaxis of bacterial infections with antibiotics improves the prognosis in selected patients, their use should be limited to patients at high risk of developing infections. In this article, we review the pathogenesis and management of bacterial infections in patients with cirrhosis.

Incidence, predictors and outcomes of acute-on-chronic liver failure in outpatients with cirrhosis

BACKGROUND & AIMS

Acute-on-chronic liver failure (ACLF) is the most life-threatening complication of cirrhosis. Prevalence and outcomes of ACLF have recently been described in hospitalized patients with cirrhosis. However, no data is currently available on the prevalence and the risk factors of ACLF in outpatients with cirrhosis. The aim of this study was to evaluate incidence, predictors and outcomes of ACLF in a large cohort of outpatients with cirrhosis.

METHODS

A total of 466 patients with cirrhosis consecutively evaluated in the outpatient clinic of a tertiary hospital were included and followed up until death and/or liver transplantation for a mean of 45±44months. Data on development of hepatic and extrahepatic organ failures were collected during this period. ACLF was defined and graded according to the EASL-CLIF Consortium definition.

RESULTS

During the follow-up, 118 patients (25%) developed ACLF: 57 grade-1, 33 grade-2 and 28 grade-3. The probability of developing ACLF was 14%, 29%, and 41% at 1year, 5years, and 10years, respectively. In the multivariate analysis, baseline mean arterial pressure (hazard ratio [HR] 0.96; p=0.012), ascites (HR 2.53; p=0.019), model of end-stage liver disease score (HR 1.26; p<0.001) and baseline hemoglobin (HR 0.07; p=0.012) were found to be independent predictors of the development of ACLF at one year. As expected, ACLF was associated with a poor prognosis, with a 3-month probability of transplant-free survival of 56%.

CONCLUSIONS

Outpatients with cirrhosis have a high risk of developing ACLF. The degree of liver failure and circulatory dysfunction are associated with the development of ACLF, as well as low values of hemoglobin. These simple variables may help to identify patients at a high risk of developing ACLF and to plan a program of close surveillance and prevention in these patients.

LAY SUMMARY

There is a need to identify predictors of acute-on-chronic liver failure (ACLF) in patients with cirrhosis in order to identify patients at high risk of developing ACLF and to plan strategies of prevention. In this study, we identified four simple predictors of ACLF: model of end-stage liver disease (MELD) score, ascites, mean arterial pressure and hemoglobin. These variables may help to identify patients with cirrhosis, at a high risk of developing ACLF, that are candidates for new strategies of surveillance and prevention. Anemia is a potential new target for treating these patients.

Assessment of the Quantitative Value Usefulness of the Aldosterone-Renin Ratio (ARR) for Primary Aldosteronism (AQUARR) Study

Current guidelines recommend use of the aldosterone-renin ratio (ARR) for the case detection of primary aldosteronism (PA), the most common cause of secondary hypertension, in selected hypertensive patients. "Confirmatory" tests are then recommended in patients who tested positive at the ARR to exclude from further diagnostic work-up false positive results. Based on our experience we hypothesized that the ARR carries quantitative information, which can avoid the need of confirmatory tests. We herein describe a study protocol to identify the ARR cut-off value with a high specificity for the exclusion of aldosterone-producing adenoma (APA) based on analysis of two large prospectively collected datasets of patients in which a conclusive diagnosis of APA was made by the four corners criteria. This will also serve to investigate the diagnostic gain provided over this ARR cut-off value by one confirmatory test, the captopril challenge test. Hence, with this protocol we expect to identify an ARR cut-off value that might prevent further testing in patients with either a low or a high probability of APA. This could translate in a higher diagnostic accuracy and, by preventing unnecessary invasive testing, into a substantial saving of money, time, and resources.

GPER-1 and estrogen receptor-β ligands modulate aldosterone synthesis

Fertile women have lower blood pressure and cardiovascular risk than age-matched men, which suggests that estrogens exert cardiovascular protective effects. However, whether 17 β-estradiol (E2) blunts aldosterone secretion, and thereby affects the gender dimorphism of blood pressure, is unknown. We therefore sought for the estrogen receptor (ER) subtypes in human adrenocortical tissues ex vivo by performing gene and protein expression studies. We also investigated the effect of E2 on aldosterone synthesis and the involved receptors through in vitro functional experiments in the adrenocortical cells HAC15. We found that in the human adrenal cortex and aldosterone-producing adenoma cells, the most expressed ERs were the ERβ and the G protein-coupled receptor-1 (GPER-1), respectively. After selective ERβ blockade, E2 (10 nmol/L) markedly increased both the expression of aldosterone synthase and the production of aldosterone (+5- to 7-fold vs baseline, P < .001). Under the same condition, the GPER-1 receptor agonist 1-[4-(6-bromo-benzo (1, 3)dioxol-5-yl)-3a,4,5,9b-tetrahydro-3H-cyclopenta[c] quinolin-8-yl]-ethanone (G-1) (10 nmol/L) mimicked this effect, which was abrogated by cotreatment with either the GPER-1 receptor antagonist (3aS*,4R*,9bR*)-4-(6-Bro-mo-1,3-benzodioxol-5-yl)-3a,4,5,9b-3H-cyclopenta[c]quinoline (G-15), or a selective protein kinase A inhibitor 8-Bromo-2-monobutyryladenosine-3,5-cyclic mono-phosphorothioate, Rp-isomer. Silencing of the ERβ significantly raised aldosterone synthase expression and aldosterone production. Conversely, silencing of the GPER-1 lowered aldosterone synthase gene and protein expression. Moreover, it blunted the stimulatory effect of E2 on aldosterone synthase that was seen during ERβ blockade. These results support the conclusion that in humans, E2 inhibits aldosterone synthesis by acting via ERβ. Pharmacologic disinhibition of ERβ unmasks a potent secretagogue effect of E2 that involves GPER-1 and protein kinase A signaling.

Abstract 359: Modulation of Aldosterone Synthase by Estrogens: Evidence for an Interaction of Gper-1 and Estrogen B Receptors and Relevance for the Gender Dimorphism of Blood Pressure

Background. Fertile women have lower blood pressure and are held to be at lower risk for cardiovascular events than age-matched man. However, whether this gender dimorphism involves a modulation of aldosterone synthesis by 17 beta-estradiol (E2) is unknown.

Aims. i) To investigate estrogen receptor subtypes gene expression in the normal human adrenal cortex (NAC), in aldosterone producing adenoma (APA) and in a human adrenocortical carcinoma cell line (HAC15); ii) To assess the effect of E2 on aldosterone synthase (CYP11B2) gene expression and to identify the receptor subtypes involved in this effect.

Methods. We measured the expression of alpha (ERa), beta (ERb) and of G protein-coupled receptor (GPER-1)-1 in NAC and in APA tissue, and in HAC15 cells by real time RT-PCR. After demonstration that HAC15 cells express ERa, ERb, and GPER-1 we stimulated cells with 10-7M E2 alone, or after ERb selective blockade with 10-5M tetrahydrochrysenediol (THC), ERa selective blockade with 10-5M MPP dihydrochloride (MPP), non selective ERa and ERb blockade with 10-5M ICI 182.780, or after selective GPER-1 receptor blockade with 10-5M G-15. The cells were also exposed to the GPER-1 agonist G-1, alone or in the presence of MPP, THC, or Fulvestrant, and/or G-15. Changes of expression of CYP11B2 mRNA, measured with RT RT-PCR, was the experimental endpoint.

Results. The quantitative expression of estrogen receptor subtypes was ERb > GPER-1 >> ERα in NAC, GPER-1 > ERb> ERa in APA, and ERb>ERa=GPER-1 in HAC15 cells. E2 alone or on top of selective ERa antagonism did not alter CYP11B2 expression. By contrast, E2 significantly increased CYP11B2 expression (+500 to + 700% from baseline, p <0.001) after selective ERb antagonism, or combined ERa and ERb blockade. Likewise, G-1 markedly increased CYP11B2 gene after combined ERb blockade, an effect that was abolished by G15 co-treatment.

Conclusion. E2 potently stimulates aldosterone synthase expression via GPER-1 subtype receptor activation when the ERb is blocked. The ERb-mediated tonic inhibition of aldosterone synthase could contribute to explaining both the lower BP and CV risk of fertile women and the increase of BP after when this tonic ERb-mediated inhibition wanes during menopause or estrogen-modulation treatment.

Abstract 280: Modulation of Aldosterone Synthesis in Human Adrenocortical Cells by Estrogens via an Interaction on Beta Estrogen and Gpr30 Receptor Subtypes

Background and aim. The gender dimorphism in the pressor effect of hyperaldosteronism suggests that estrogens may modulate aldosterone synthesis. Estrogens were suggested to affect adrenocortical cell proliferation via beta estrogen receptor (ERβ), but it remains unknown if they also influence aldosterone synthesis.

Methods. We therefore investigated the expression of alpha (ERα), ERβ and of G protein-coupled receptor (GPR)30 in HAC15 cells, a human adrenocortical carcinoma cell line. HAC15 cells were stimulated with 10 -7 M 17β-estradiol (E2) alone, or with a selective ERβ antagonist (10 -5 M; Tetrahydrochrysenediol THC), a selective ERα antagonist (10 -5 M; MPP dihydrochloride), a non selective ERα and ERβ antagonist (10 -5 M; ICI 182.780 fulvestrant), a selective GPR30 receptor antagonist (10 -5 M; G-15). The cells were also exposed to the highly selective GPR30 agonist G-1, alone or in the presence of MPP, or THC, or Fulvestrant and G-15. CYP11B2 mRNA expression was measured with quantitative real time RT-PCR (Universal Probe Library Roche).

Results. The three estrogen receptor subtypes were found to be expressed at different levels (ERβ>>ERα=GPR30) in HAC15 cells. E2 alone or on top of selective ERα antagonism did not alter CYP11B2 expression. At variance, E2 on top of selective ERβ antagonism, or of combined ERβ and ERα antagonism, caused a 5- to 7- fold upregulation of CYP11B2 mRNA, a finding that was replicated by the exposure of cells to G-1 on top of combined ERβ and ERα blockade.

Conclusions . 1) GPR30 is expressed in human adrenocortical cells at levels that are comparable to ERα, but less abundatly than ERβ subtype receptor. 2) 17β-estradiol activates CYP11B2 synthesis via an interaction between ERβ blockade and GPR30 activation. Hence, by showing a role for estrogens in the regulation of aldosterone synthesis via GPR30 subtype receptor, these results could account for the diverse pressor effects of excess aldosterone in men and in fertile vs post-menopausal women.