Inflammatory activation of resident hepatic macrophages (Kupffer cells) by portal-derived lipopolysaccharide (LPS) has a primary role in animal models of alcoholic liver disease, but it has not been ...systematically or longitudinally studied in human alcoholic hepatitis (AH).
We followed 50 patients with AH for 30 days. 26 patients with stable alcoholic cirrhosis and 20 healthy individuals were controls. We measured the plasma (P) concentrations of soluble CD163 (sCD163; a specific marker of inflammatory macrophage activation) and the expression of CD163 in liver tissue by immunohistochemistry and stereology of liver biopsies. We also measured the key components of the LPS pathway, P-LPS, sCD14, and LPS-binding protein (LBP), by enzyme-linked immunosorbent assay (ELISA). The 84-day mortality was registered.
At study entry, the sCD163 concentration was 10-fold higher than in the healthy controls and 30% higher than in the stable cirrhotics (P<0.002), and it correlated with the Glasgow Alcoholic Hepatitis, Model for End-stage Liver Disease, and Child-Pugh scores (r>0.35, P<0.02, all). The liver biopsies confirmed markedly increased CD163 staining (P<0.01). P-LPS, P-CD14, and P-LBP were increased to the same degree as sCD163. During the follow-up, the sCD163 and LPS pathway components all decreased by ∼25% (P<0.05) but remained higher than in both control groups. sCD163 was an independent predictor of the 84-day mortality.
The hepatic inflammation of human AH involves marked activation of hepatic macrophages, likely via the LPS pathway. Hepatic macrophages may thus present a target for biological therapy of AH.
IntroductionHepatic macrophages (Kupffer cells) undergo inflammatory activation during the development of portal hypertension in experimental cirrhosis; this activation may play a pathogenic role or ...be an epiphenomenon. Our objective was to study serum soluble CD163 (sCD163), a sensitive marker of macrophage activation, before and after reduction of portal venous pressure gradient by insertion of a transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhosis.MethodssCD163 was measured in 11 controls and 36 patients before and 1, 4 and 26 weeks after TIPS. We used lipopolysaccharide binding protein (LBP) levels as a marker of endotoxinaemia. Liver function and clinical status of the patients were assessed by galactose elimination capacity and Model for End Stage Liver Disease score.ResultsThe sCD163 concentration was more than threefold higher in the patients than in the controls (median 5.22 mg/l vs 1.45 mg/l, p<0.001). The sCD163 was linearly related to the portal venous pressure gradient (r2=0.24, p<0.001), also after adjustment for cirrhosis status. The sCD163 concentration was 12% higher in the hepatic than in the portal vein (p<0.02). The LBP level was 70% higher in the patients (52.2 vs 30.4 μg/l, p<0.001). During follow-up after TIPS, the sCD163 concentration did not change while LBP almost normalised.ConclusionKupffer cells were activated in patients with liver cirrhosis in parallel with their portal hypertension. The activation was not alleviated by the mechanical reduction of portal hypertension and the decreasing signs of endotoxinaemia. The findings suggest that Kupffer cell activation is a constitutive event that may play a pathogenic role for portal hypertension.
Data on quantitative metabolic liver functions in the life-threatening disease alcoholic hepatitis are scarce. Urea synthesis is an essential metabolic liver function that plays a key regulatory role ...in nitrogen homeostasis. The urea synthesis capacity decreases in patients with compromised liver function, whereas it increases in patients with inflammation. Alcoholic hepatitis involves both mechanisms, but how these opposite effects are balanced remains unclear. Our aim was to investigate how alcoholic hepatitis affects the capacity for urea synthesis. We related these findings to another measure of metabolic liver function, the galactose elimination capacity (GEC), as well as to clinical disease severity.
We included 20 patients with alcoholic hepatitis and 7 healthy controls. The urea synthesis capacity was quantified by the functional hepatic nitrogen clearance (FHNC), i.e., the slope of the linear relationship between the blood α-amino nitrogen concentration and urea nitrogen synthesis rate during alanine infusion. The GEC was determined using blood concentration decay curves after intravenous bolus injection of galactose. Clinical disease severity was assessed by the Glasgow Alcoholic Hepatitis Score and Model for End-Stage Liver Disease (MELD) score.
The FHNC was markedly decreased in the alcoholic hepatitis patients compared with the healthy controls (7.2±4.9 L/h vs. 37.4±6.8 L/h, P<0.01), and the largest decrease was observed in those with severe alcoholic hepatitis (4.9±3.6 L/h vs. 9.9±4.9 L/h, P<0.05). The GEC was less markedly reduced than the FHNC. A negative correlation was detected between the FHNC and MELD score (rho = -0.49, P<0.05).
Alcoholic hepatitis markedly decreases the urea synthesis capacity. This decrease is associated with an increase in clinical disease severity. Thus, the metabolic failure in alcoholic hepatitis prevails such that the liver cannot adequately perform the metabolic up-regulation observed in other stressful states, including extrahepatic inflammation, which may contribute to the patients' poor prognosis.
The role of sterile inflammation caused by release of damage‐associated molecular patterns (DAMP) remains unclear in human alcoholic hepatitis (AH). The DAMP, high mobility group box‐1 protein ...(HMGB1) is released by tissue damage and inflammation. We aimed to investigate whether HMGB1 is a primary inflammatory driver in AH by determining HMGB1 serum levels and effects on inflammatory cells from AH patients. We measured serum HMGB1 in 34 AH patients and 10 healthy controls using ELISA. Toll‐like receptor 4 (TLR4) and CD14 expressions were assessed by flow cytometry on HMGB1‐stimulated peripheral blood mononuclear cells (PBMC) and ELISA was used to measure TNF‐α and IL‐1β in the supernatants. We observed 5‐fold higher serum levels of HMGB1 in AH patients at the day of diagnosis and day 30, but no associations to clinical outcome. HMGB1 stimulation increased the expression of TLR4 on CD14+‐monocytes compared with unstimulated cells in the AH patients. The TNF‐α and IL‐1β production in response to HMGB1 was diminished in AH patients. In conclusion, AH patients have increased levels of HMGB1 in their blood. This combined with an increased TLR4 expression, but an unaffected cytokine response to HMGB1 suggest that HMGB1 is not the primary driver of inflammation in AH.
Background
Long‐term excessive alcohol intake predisposes to infectious diseases. The hepatic acute‐phase response is a component of the innate immune system and is part of the first line of defense ...against invading pathogens, which may be compromised by alcohol. We aimed to investigate whether an induced acute‐phase response is impaired in long‐term ethanol (EtOH)‐fed rats.
Methods
For 6 weeks, rats were either fed a Lieber‐DeCarli EtOH‐containing (36% as calories) liquid diet ad libitum or calorically pair‐fed. Then, the rats were injected intraperitoneally with a low dose of lipopolysaccharide (LPS) (0.5 mg/kg) to induce an acute‐phase response. Two hours after LPS, we measured the plasma concentrations of an array of inflammatory cytokines. Twenty‐four hours after LPS, we measured the hepatic mRNA expression and serum concentrations of prominent rat acute‐phase proteins.
Results
EtOH‐fed rats showed either no liver histopathological changes or varying degrees of steatosis. EtOH feeding decreased the spontaneous liver mRNA expression of the prevailing acute‐phase protein alpha‐2‐macroglobulin (α2M) by 30% (p < 0.01). LPS immediately increased plasma tumor necrosis factor‐alpha and interleukin‐6 more than 100‐fold in both feeding groups (p < 0.001, all) and approximately twice as much in the EtOH‐fed rats (p < 0.05 and p = 0.08, respectively). LPS also induced a variable but marked amplification of (α2M), haptoglobin, alpha‐1‐acid glycoprotein, and lipocalin‐2 liver mRNA expression levels and serum concentrations in both feeding groups (p ≤ 0.01 to 0.001). However, the LPS‐induced increases in serum (α2M) and haptoglobin were less pronounced in the EtOH‐fed rats, averaging approximately 60% of the concentrations in the pair‐fed rats (p < 0.01 and p < 0.001, respectively).
Conclusions
Long‐term EtOH exposure in rats reduces the spontaneous hepatic mRNA expression of (α2M) and markedly impairs the hepatic acute‐phase response to endotoxin, despite higher pro‐inflammatory cytokine release. The same phenomenon may contribute to the increased susceptibility to infections observed in humans with long‐term excessive alcohol intake.
In this rat study, we found that long‐term ethanol exposure attenuated the effects of lipopolysaccharide (LPS) on the serum concentration of the prominent rat acute phase protein α‐2‐macroglobulin and of haptoglobin, in spite of an exaggerated pro‐inflammatory cytokine release. The results suggest that long‐term ethanol exposure makes the liver less responsive in terms of raising an acute phase response. The same phenomenon may contribute to the increased susceptibility to infections observed in humans with long‐term excessive alcohol intake.
Sixty-five patients had no previous decompensation; the remaining 51 (44%) had prior complications of cirrhosis including: ascites, bleeding varices, hepatic encephalopathy, spontaneous bacterial ...peritonitis; or were Child-Pugh C or model for end-stage liver disease (MELD) score >=15. Contributors: AR: study conception and design, acquisition of data, analysis and interpretation of data; drafting the article and revision; final approval; AN, HJM, PWA, IK, NA, AG, DL, KK, HV and HG: study conception and design, analysis and interpretation of data; drafting the article and revision; final approval; LL: study conception and design, data collection, analysis and interpretation of data; drafting the article and revision; final approval. 3 Gronbaek HST Mortensen C Vilstrup H . Soluble CD163, a marker of Kupffer cell activation, is related to portal hypertension in patients with liver cirrhosis.
Background
Recent studies have shown that the combination of radiofrequency ablation (RFA) and transarterial chemoembolization (TACE) for unresectable hepatocellular carcinoma (HCC) may offer a ...survival advantage compared to monotherapy.
Purpose
To study the effectiveness of combination therapy with RFA and TACE compared to that of TACE alone in a Scandinavian tertiary liver cancer center.
Material and Methods
A retrospective study of the patients treated with combination therapy vis-à-vis TACE alone from June 2007 to November 2012 was performed. Eighteen patients were treated with a combination of RFA and TACE with an interval of 1–4 days between the treatments. For comparison, a group of 18 patients treated with TACE as monotherapy in the same time period was matched with the combination group by demographic data, tumor characteristics, biochemical and clinical parameters, and performance status (PS).
Results
Each group consisted of 14 patients with cirrhosis and four without. There were no significant differences between the groups regarding age, gender, tumor characteristics, causes of cirrhosis, levels of bilirubin, creatinine, prothrombin time, Child Pugh score, or World Health Organization (WHO) performance status. The median survival of patients in the RFA + TACE combination group was 586 days compared to 296 days in the control group. The difference was not statistically significant (P = 0.26). However, when we stratified the data for cirrhosis and WHO performance status, patients in the combination group had significantly better survival (P = 0.024).
Conclusion
Combination therapy with RFA and TACE for unresectable HCC, compared to TACE alone, may offer a survival benefit for a selected group of patients with HCC.
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