Chronic alcohol consumption causes increased intestinal permeability and changes in the intestinal microbiota composition, which contribute to the development and progression of alcohol‐related liver ...disease. In this setting, little is known about commensal fungi in the gut. We studied the intestinal mycobiota in a cohort of patients with alcoholic hepatitis, patients with alcohol use disorder, and nonalcoholic controls using fungal‐specific internal transcribed spacer amplicon sequencing of fecal samples. We further measured serum anti–Saccharomyces cerevisiae antibodies (ASCA) as a systemic immune response to fungal products or fungi. Candida was the most abundant genus in the fecal mycobiota of the two alcohol groups, whereas genus Penicillium dominated the mycobiome of nonalcoholic controls. We observed a lower diversity in the alcohol groups compared with controls. Antibiotic or steroid treatment was not associated with a lower diversity. Patients with alcoholic hepatitis had significantly higher ASCA levels compared to patients with alcohol use disorder and to nonalcoholic controls. Within the alcoholic hepatitis cohort, patients with levels of at least 34 IU/mL had a significantly lower 90‐day survival (59%) compared with those with ASCA levels less than 34 IU/mL (80%) with an adjusted hazard ratio of 3.13 (95% CI, 1.11‐8.82; P = 0.031). Conclusion: Patients with alcohol‐associated liver disease have a lower fungal diversity with an overgrowth of Candida compared with controls. Higher serum ASCA was associated with increased mortality in patients with alcoholic hepatitis. Intestinal fungi may serve as a therapeutic target to improve survival, and ASCA may be useful to predict the outcome in patients with alcoholic hepatitis.
Background and Aims
Alcoholic hepatitis (AH) is a severe manifestation of alcohol‐associated liver disease (ALD) with high mortality. Although gut bacteria and fungi modulate disease severity, little ...is known about the effects of the viral microbiome (virome) in patients with ALD.
Approach and Results
We extracted virus‐like particles from 89 patients with AH who were enrolled in a multicenter observational study, 36 with alcohol use disorder (AUD), and 17 persons without AUD (controls). Virus‐like particles from fecal samples were fractionated using differential filtration techniques, and metagenomic sequencing was performed to characterize intestinal viromes. We observed an increased viral diversity in fecal samples from patients with ALD, with the most significant changes in samples from patients with AH. Escherichia‐, Enterobacteria‐, and Enterococcus phages were over‐represented in fecal samples from patients with AH, along with significant increases in mammalian viruses such as Parvoviridae and Herpesviridae. Antibiotic treatment was associated with higher viral diversity. Specific viral taxa, such as Staphylococcus phages and Herpesviridae, were associated with increased disease severity, indicated by a higher median Model for End‐Stage Liver Disease score, and associated with increased 90‐day mortality.
Conclusions
In conclusion, intestinal viral taxa are altered in fecal samples from patients with AH and associated with disease severity and mortality. Our study describes an intestinal virome signature associated with AH.
Alcoholic hepatitis (AH) is associated with liver neutrophil infiltration through activated cytokine pathways leading to elevated chemokine expression. Super-enhancers are expansive regulatory ...elements driving augmented gene expression. Here, we explore the mechanistic role of super-enhancers linking cytokine TNFα with chemokine amplification in AH. RNA-seq and histone modification ChIP-seq of human liver explants show upregulation of multiple CXCL chemokines in AH. Liver sinusoidal endothelial cells (LSEC) are identified as an important source of CXCL expression in human liver, regulated by TNFα/NF-κB signaling. A super-enhancer is identified for multiple CXCL genes by multiple approaches. dCas9-KRAB-mediated epigenome editing or pharmacologic inhibition of Bromodomain and Extraterminal (BET) proteins, transcriptional regulators vital to super-enhancer function, decreases chemokine expression in vitro and decreases neutrophil infiltration in murine models of AH. Our findings highlight the role of super-enhancer in propagating inflammatory signaling by inducing chemokine expression and the therapeutic potential of BET inhibition in AH treatment.
Background and Aims
Alcoholic hepatitis (AH) is diagnosed by clinical criteria, although several objective scores facilitate risk stratification. Extracellular vesicles (EVs) have emerged as ...biomarkers for many diseases and are also implicated in the pathogenesis of AH. Therefore, we investigated whether plasma EV concentration and sphingolipid cargo could serve as diagnostic biomarkers for AH and inform prognosis to permit dynamic risk profiling of AH subjects.
Approach and Results
EVs were isolated and quantified from plasma samples from healthy controls, heavy drinkers, and subjects with end‐stage liver disease (ESLD) attributed to cholestatic liver diseases and nonalcoholic steatohepatitis, decompensated alcohol‐associated cirrhosis (AC), and AH. Sphingolipids were quantified by tandem mass spectroscopy. The median plasma EV concentration was significantly higher in AH subjects (5.38 × 1011/mL) compared to healthy controls (4.38 × 1010/mL; P < 0.0001), heavy drinkers (1.28 × 1011/mL; P < 0.0001), ESLD (5.35 × 1010/mL; P < 0.0001), and decompensated AC (9.2 × 1010/mL; P < 0.0001) disease controls. Among AH subjects, EV concentration correlated with Model for End‐Stage Liver Disease score. When EV counts were dichotomized at the median, survival probability for AH subjects at 90 days was 63.0% in the high‐EV group and 90.0% in the low‐EV group (log‐rank P value = 0.015). Interestingly, EV sphingolipid cargo was significantly enriched in AH when compared to healthy controls, heavy drinkers, ESLD, and decompensated AC (P = 0.0001). Multiple sphingolipids demonstrated good diagnostic and prognostic performance as biomarkers for AH.
Conclusions
Circulating EV concentration and sphingolipid cargo signature can be used in the diagnosis and differentiation of AH from heavy drinkers, decompensated AC, and other etiologies of ESLD and predict 90‐day survival permitting dynamic risk profiling.
Risk of alcoholic cirrhosis is determined by genetic and environmental factors. We aimed to investigate if climate has a causal effect on alcohol consumption and its weight on alcoholic cirrhosis. We ...collected extensive data from 193 sovereign countries as well as 50 states and 3,144 counties in the United States. Data sources included World Health Organization, World Meteorological Organization, and the Institute on Health Metrics and Evaluation. Climate parameters comprised Koppen‐Geiger classification, average annual sunshine hours, and average annual temperature. Alcohol consumption data, pattern of drinking, health indicators, and alcohol‐attributable fraction (AAF) of cirrhosis were obtained. The global cohort revealed an inverse correlation between mean average temperature and average annual sunshine hours with liters of annual alcohol consumption per capita (Spearman’s rho −0.5 and −0.57, respectively). Moreover, the percentage of heavy episodic drinking and total drinkers among population inversely correlated with temperature −0.45 and −0.49 (P < 0.001) and sunshine hours −0.39 and −0.57 (P < 0.001). Importantly, AAF was inversely correlated with temperature −0.45 (P < 0.001) and sunshine hours −0.6 (P < 0.001). At a global level, all included parameters in the univariable and multivariable analysis showed an association with liters of alcohol consumption and drinkers among population once adjusted by potential confounders. In the multivariate analysis, liters of alcohol consumption associated with AAF. In the United States, colder climates showed a positive correlation with the age‐standardized prevalence of heavy and binge drinkers. Conclusion: These results suggest that colder climates may play a causal role on AAF mediated by alcohol consumption.
The 10‐item Alcohol Use Disorders Identification Test (AUDIT‐10) and its shorter form, AUDIT‐Consumption (AUDIT‐C), are questionnaires used to characterize severity of drinking. We hypothesized that ...liver injury and short‐term outcomes of alcohol‐associated hepatitis (AH) would correlate with a patient’s recent alcohol consumption as determined by AUDIT‐10 and AUDIT‐C. We analyzed a prospective international database of patients with AH diagnosed based on the National Institute on Alcohol Abuse and Alcoholism (NIAAA) standard definitions. All patients were interviewed using AUDIT‐10. Primary outcomes included the discriminatory ability of the AUDIT‐10 and AUDIT‐C scores for predicting survival status at 28 and 90 days and severity of liver injury, as measured by Model for End‐Stage Liver Disease–sodium (MELD‐Na). The relationship between AUDIT scores and survival status was quantified by calculating the area under the curve of the receiver operating characteristic analysis. The relationship between AUDIT scores and MELD‐Na was examined using correlation coefficients. In 245 patients (age range 25‐75 years; 35% female), we found no correlation between AUDIT‐10 or AUDIT‐C scores and either 28‐ or 90‐day mortality. Similarly, there was no correlation between AUDIT‐10 and AUDIT‐C and MELD‐Na scores. There was a strong positive correlation between MELD‐Na and 28‐ and 90‐day mortality. Additional measures of severity of alcohol use (average grams of alcohol consumed per day, years of drinking, convictions for driving under the influence, and rehabilitation attempts) and psychosocial factors (marriage, paid employment, and level of social support) had no influence on MELD‐Na. In patients presenting with AH, AUDIT‐10 and AUDIT‐C were predictors of neither clinical severity of liver disease nor short‐term mortality, suggesting that level of alcohol consumption in the prior year is not key to the presenting features or outcome of AH.
Background and Aims
Lipoprotein Z (LP‐Z) is an abnormal free cholesterol (FC)–enriched LDL‐like particle discovered from patients with cholestatic liver disease. This study aims to define the ...diagnostic value of LP‐Z in alcohol‐associated hepatitis (AH) and interrogate the biology behind its formation.
Approach and Results
We measured serum levels of LP‐Z using nuclear magnetic resonance spectroscopy, a well‐established clinical assay. Serum levels of LP‐Z were significantly elevated in four AH cohorts compared with control groups, including heavy drinkers and patients with cirrhosis. We defined a Z‐index, calculated by the ratio of LP‐Z to total apolipoprotein B–containing lipoproteins, representing the degree of deviation from normal VLDL metabolism. A high Z‐index was associated with 90‐day mortality independent from the Model for End‐Stage Liver Disease (MELD) and provided added prognosticative value. Both a Z‐index ≤ 0.6 and a decline of Z‐index by ≥0.1 in 2 weeks predicted 90‐day survival. RNA‐sequencing analyses of liver tissues demonstrated an inverse association in the expression of enzymes responsible for the extrahepatic conversion of VLDL to LDL and AH disease severity, which was further confirmed by the measurement of serum enzyme activity. To evaluate whether the FC in LP‐Z could contribute to the pathogenesis of AH, we found significantly altered FC levels in liver explant of patients with AH. Furthermore, FC in reconstituted LP‐Z particles caused direct toxicity to human hepatocytes in a concentration‐dependent manner, supporting a pathogenic role of FC in LP‐Z.
Conclusions
Impaired lipoprotein metabolism in AH leads to the accumulation of LP‐Z in the circulation, which is hepatotoxic from excessive FC. A Z‐index ≤ 0.6 predicts 90‐day survival independent from conventional biomarkers for disease prognostication.
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