Further decompensation in cirrhosis: Results of a large multicenter cohort study supporting Baveno VII statements

BACKGROUND AND AIMS

The prognostic weight of further decompensation in cirrhosis is still unclear. We investigated the incidence of further decompensation and its effect on mortality in patients with cirrhosis.

APPROACH AND RESULTS

Multicenter cohort study. The cumulative incidence of further decompensation (development of a second event or complication of a decompensating event) was assessed using competing risks analysis in 2028 patients. A 4-state model was built: first decompensation, further decompensation, liver transplant, and death. A cause-specific Cox model was used to assess the adjusted effect of further decompensation on mortality. Sensitivity analyses were performed for patients included before or after 1999. In a mean follow-up of 43 months, 1192 patients developed further decompensation and 649 died. Corresponding 5-year cumulative incidences were 52% and 35%, respectively. The cumulative incidences of death and liver transplant after further decompensation were 55% and 9.7%, respectively. The most common further decompensating event was ascites/complications of ascites. Five-year probabilities of state occupation were 24% alive with first decompensation, 21% alive with further decompensation, 7% alive with a liver transplant, 16% dead after first decompensation without further decompensation, 31% dead after further decompensation, and <1% dead after liver transplant. The HR for death after further decompensation, adjusted for known prognostic indicators, was 1.46 (95% CI: 1.23-1.71) ( p <0.001). The significant impact of further decompensation on survival was confirmed in patients included before or after 1999.

CONCLUSIONS

In cirrhosis, further decompensation occurs in ~60% of patients, significantly increases mortality, and should be considered a more advanced stage of decompensated cirrhosis.

Analysis of The Left Atrial Function Using Two-Dimensional Strain in Patients with Recent Diagnosis of Hereditary Hemochromatosis

Hereditary Hemochromatosis (HH) is a genetic condition associated with a systemic iron overload. Heart failure is an important cause of mortality. It has been demonstrated early stages of systolic and diastolic left ventricular dysfunction in previous studies. The aim of the study is to compare the left atrial (LA) function between asymptomatic HH patients and a control group using 2D speckle tracking. Prospective study. LA strain, LA strain rate and LA volumetric parameters during the reservoir, conduit and contraction phases were studied. The LA Stiffness Index was calculated by the ratio between E/e and LA reservoir strain. 30 patients with HH (90% males, 47 ± 18 years old) and 30 healthy controls (85% males, 45 ± 13 years old) were included. LA volume was similar in both groups. No differences were observed in LA ejection fraction (EF), LA passive EF and LA active ejection fraction between both groups. On the contrary, the HH group had lower LA strain during the reservoir (31.5 ± 6.5% vs 38.3 ± 7.9%; P=0.002), and conduit phases (-18 ± 7% vs -23.3 ± 6.4%; P=0.01) and lower LA conduit strain rate (-1.7 ± 0.7 seg^-1 vs -2.1 ± 0.5 seg^-1; P=0.02) than controls. The LA stiffness index was significantly higher in the HH group (0.25 ± 0.9 vs 0.19 ± 0.6; P=0.01) Early abnormalities in the LA function could be detected by using 2D speckle tracking study despite no evidence of changes in atrial size or volumetric parameters.

Comparison of different prognostic scores for patients with cirrhosis hospitalized with SARS-CoV-2 infection

INTRODUCTION AND OBJECTIVES

Viral infections have been described to increase the risk of decompensation in patients with cirrhosis. We aimed to determine the effect of SARS-CoV-2 infection on outcome of hospitalized patients with cirrhosis and to compare the performance of different prognostic models for predicting mortality.

PATIENTS

We performed a prospective cohort study including 2211 hospitalized patients with confirmed SARS-CoV-2 infection from April 15, 2020 through October 1, 2020 in 38 Hospitals from 11 Latin American countries. We registered clinical and laboratory parameters of patients with and without cirrhosis. All patients were followed until discharge or death. We evaluated the prognostic performance of different scoring systems to predict mortality in patients with cirrhosis using ROC curves.

RESULTS

Overall, 4.6% (CI 3.7-5.6) subjects had cirrhosis (n = 96). Baseline Child-Turcotte-Pugh (CTP) class was assessed: CTP-A (23%), CTP-B (45%) and CTP-C (32%); median MELD-Na score was 19 (IQR 14-25). Mortality was 47% in patients with cirrhosis and 16% in patients without cirrhosis (P < .0001). Cirrhosis was independently associated with death [OR 3.1 (CI 1.9-4.8); P < .0001], adjusted by age, gender, and body mass index >30. The areas under the ROC curves for performance evaluation in predicting 28-days mortality for Chronic Liver Failure Consortium (CLIF-C), North American Consortium for the Study of End-Stage Liver Disease (NACSELD), CTP score and MELD-Na were 0.85, 0.75, 0.69, 0.67; respectively (P < .0001).

CONCLUSIONS

SARS-CoV-2 infection is associated with elevated mortality in patients with cirrhosis. CLIF-C had better performance in predicting mortality than NACSELD, CTP and MELD-Na in patients with cirrhosis and SARS-CoV-2 infection. Clinicaltrials.gov:NCT04358380.

Abstract P138: The Arterial Wall of the Central Vascular Compartment a Novel Target of Iron-Overload Disorders: A Preliminary Study With Experimental Correlation in Animals

In Hemochromatosis (H) iron is stored in tissues, causing organ injury and failure. Patients with H have a shorter life expectancy and an increase in CVR. Our group could prove that arterial stiffness was increased and they had added endothelial dysfunction. After that we also were able to demonstrate that both improve by reducing iron levels with phlebotomies. Due to these findings we ask how iron-overload made it (getting inside or more likely inducing inflammation). Anyway either directly or indirectly AW could be a target of iron-overload. To test this hypothesis we did an experimental correlation by using a known model of H in rats and we analize histologically the AW Twelve young rats (3 months old), an average weight of 300 gr, fed as usual, in individual cages with dark light cycles of 12 h and controlled temperature (22±3°C), were ramdonly divided in 2 groups: 1) Iron-overoload group (IOG). They were daily administrated intraperitoneally 10 mg of elemental iron (0,1 ml of dextran iron, Venofer®) 12 injections in total 2) Control group (CG) the same injections scheme but with placebo. The handlings of animals was under the norms of the bioterium and standards designed for that purpose. At the end of experimental period (8 weeks) animals were sacrificed and studied. The histoarchitecture of the proximal aortic wall (fixed in 4 % formalin, paraffin-embedded, sectioned into thin slices, H&E, Masson′s trichrome and VVG staining) showed no significant differences in the histology (H&E) between IOG and CG. No evidence of iron inside the AW. On the other hand inflammatory component was significantly increased in IOG compared to CG, perivascular lymphocyte count 5-12/0 IOG/CG, perivascular macrophages, 3-5/0 IOG/CG. Elastic fibers were not fragmented but become thin and lost their disposition in IOG. In conclusions we can affirm that AW could represent a novel target in H and could may the nexus to cardiovascular disease. The indirect mechanism (inflammation and elastic fibers) explains why previously improved after phlebotomies. Our findings supports future research including inflammatory mediators and their tissue expression, and extend them to others iron overload disorders.

Sublingual microcirculatory alterations in cirrhotic patients

OBJECTIVE

To assess sublingual microcirculation in cirrhotic patients and its relationship to spider angiomas, complications, and outcome.

METHODS

Thirty-one cirrhotic patients were prospectively compared to 31 matched controls. Sublingual microcirculation was evaluated by videomicroscopy. We specifically looked for capillaries with increased RBCV, which was defined as a velocity higher than the percentile 100th of controls.

RESULTS

Compared to controls, cirrhotic patients showed decreased total and PVD (14.4 ± 2.2 vs 16.0 ± 1.3 and 14.1 ± 2.3 vs 15.9 ± 1.6 mm/mm² , respectively, P < .001 for both) and increased HFI (0.64 ± 0.39 vs 0.36 ± 0.21, P = .001). They also exhibited high RBCV in 2% of the microvessels (P < .0001). Patients with MELD score ≥10 had higher RBCV than patients with score <10 (1414 ± 290 vs 1206 ± 239 μm/s, P < .05). Patients with spider angiomas showed lower vascular densities. Microcirculation did not differ between survivors and nonsurvivors.

CONCLUSIONS

Cirrhosis is associated with microcirculatory alterations that can be easily monitored in the sublingual mucosa. Alterations included decreased density and PPV and hyperdynamic microvessels. The most striking finding, however, was the microvascular heterogeneity. Patients with spider angiomas had more severe alterations. Larger studies should clarify the relationship between microcirculatory abnormalities and outcome.

Hepatocellular carcinoma in South America: Evaluation of risk factors, demographics and therapy

BACKGROUND & AIMS

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related death worldwide. Most studies addressing the epidemiology of HCC originate from developed countries. This study reports the preliminary findings of a multinational approach to characterize HCC in South America.

METHODS

We evaluated 1336 HCC patients seen at 14 centres in six South American countries using a retrospective study design with participating centres completing a template chart of patient characteristics. The diagnosis of HCC was made radiographically or histologically for all cases according to institutional standards. Methodology of surveillance for each centre was following AASLD or EASL recommendations.

RESULTS

Sixty-eight percent of individuals were male with a median age of 64 years at time of diagnosis. The most common risk factor for HCC was hepatitis C infection (HCV, 48%), followed by alcoholic cirrhosis (22%), Hepatitis B infection (HBV, 14%) and NAFLD (9%). We found that among individuals with HBV-related HCC, 38% were diagnosed before age 50. The most commonly provided therapy was transarterial chemoembolization (35% of HCCs) with few individuals being considered for liver transplant (<20%). Only 47% of HCCs were diagnosed during surveillance, and there was no difference in age of diagnosis between those diagnosed incidentally vs by surveillance. Nonetheless, being diagnosed during surveillance was associated with improved overall survival (P = .01).

CONCLUSIONS

Our study represents the largest cohort to date reporting characteristics and outcomes of HCC across South America. We found an important number of HCCs diagnosed outside of surveillance programmes, with associated increased mortality in those patients.

Abstract P252: Hemochromatosis Induce Arterial Stiffness and Endothelial Dysfunction and They Can Be Effectively Reversed by Phlebotomy

Hereditary Hemochromatosis (HH) is a genetically determined disease where iron is excessively stored in tissues, causing organ injury and failure. An increase of cardiovascular risk (CVR) has been reported in HH. Part of the iron overload induces vascular fibrosis and endothelial dysfunction (ED). Therefore, arterial wall emerge as a novel organ target organ in HH. Carotid-femoral pulse wave velocity (PWV-CF) assesses arterial stiffness (AS), and has predictive value for CV events. PWV variation pre- and post-induced transient ischemia of brachial artery (PWV-CB) has been validated to evaluate ED. We hypothetized that patients with HH have an increase in PWV-CF and PWV-CB due to iron overload, and that phlebotomy by reducing iron levels decreases arterial stiffness and restores endothelial function. To test this hypothesis we assessed PWV-CF and PWV-CB in 52 patients with HH before and after phlebotomy and compare against control. PWV-CF and PWV-CB variations were assessed using Complior System (Artech-Medical, Francia). PWV-CF was significantly increased in HH patients compared to control group (8.5±1.7 m/s vs. 6.4±0.8 m/s, P<0.001, n=52/30 patients/group), suggesting increased AS. Changes in PWV-CB after transient ischemia were reduced in HH patients (0.3%) compared to controls (8.2%) (P<0.001), suggesting ED. Phlebotomy significantly reduced PWV-CF in HH patients (Post-phlebotomy: 6.5±0.8 m/s vs. Pre-phlebotomy: 8.5±1.7 m/s, P<0.001) back to control values (6.4±0.8 m/s). Changes in PWV-CB variation were partially reduced post - phlebotomy. (PWV-CB variation was 0.3 % in HH pre-phlebotomy vs. - 5.7 % in HH post- phlebotomy). These results showed a significantly increased AS and ED in HH group suggesting that arterial wall represents a novel target in HH and could may the nexus to cardiovascular disease. Both parameters (AS and ED) were significantly improved after phlebotomy, Our findings supports future research including more patients with HH and others iron overload disorders.

New evidence for the therapeutic potential of curcumin to treat nonalcoholic fatty liver disease in humans

Introduction

The immune system acts on different metabolic tissues that are implicated in the pathogenesis of nonalcoholic fatty liver disease (NAFLD). Leptin and linoleic acid have the ability to potentially affect immune cells, whereas curcumin is a known natural polyphenol with antioxidant and anti-inflammatory properties.

Aims

This study was designed to evaluate the pro-inflammatory and pro-oxidant effects of leptin and linoleic acid on immune cells from patients with NAFLD and to corroborate the modulatory effects of curcumin and its preventive properties against the progression of NAFLD using a high-fat diet (HFD)-induced NAFLD/nonalcoholic steatohepatitis mouse model.

Results

The ex vivo experiments showed that linoleic acid increased the production of reactive oxygen species in monocytes and liver macrophages, whereas leptin enhanced tumor necrosis factor-α (TNF-α) production in monocytes and interferon-γ production in circulating CD4⁺ cells. Conversely, oral administration of curcumin prevented HFD-induced liver injury, metabolic alterations, intrahepatic CD4⁺ cell accumulation and the linoleic acid- and leptin- induced pro-inflammatory and pro-oxidant effects on mouse liver macrophages.

Conclusion

Our findings provide new evidence for the therapeutic potential of curcumin to treat human NAFLD. However, the development of a preventive treatment targeting human circulating monocytes and liver macrophages as well as peripheral and hepatic CD4⁺ cells requires additional research.