Alexandre Louvet

A 6-month abstinence from alcohol is usually required before patients with severe alcoholic hepatitis are considered for liver transplantation. Patients whose hepatitis is not responding to medical therapy have a 6-month survival rate of approximately 30%. Since most alcoholic hepatitis deaths occur within 2 months, early liver transplantation is attractive but controversial.

<h3>Background & Aims</h3> The effects of bariatric surgery in patients with nonalcoholic fatty liver disease (NASH) are not well established. We performed a prospective study to determine the biological and clinical effects of bariatric surgery in patients with NASH. <h3>Methods</h3> From May 1994 through May 2013, one hundred and nine morbidly obese patients with biopsy-proven NASH underwent bariatric surgery at the University Hospital of Lille, France (the Lille Bariatric Cohort). Clinical, biological, and histologic data were collected before and 1 year after surgery. <h3>Results</h3> One year after surgery, NASH had disappeared from 85% of the patients (95% confidence interval [CI]: 75.8%−92.2%). Compared with before surgery, patients had significant reductions in mean ± SD body mass index (BMI, from 49.3 ± 8.2 to 37.4 ± 7) and level of alanine aminotransferase (from 52.1 ± 25.7 IU/L to 25.1 ± 20 IU/L); mean levels of γ-glutamyltransferases were reduced from 51 IU/L before surgery (interquartile range [IQR], 34−87 IU/L) to 23 IU/L afterward (IQR, 14−33 IU/L) and mean insulin resistance index values were reduced from 3.6 ± 0.5 to 2.9 ± 0.5 (<i>P</i> < .01 for each comparison). NASH disappeared from a higher proportion of patients with mild NASH before surgery (94%) than severe NASH (70%) (<i>P</i> < .05) according to Brunt score. In histologic analysis, steatosis was detected in 60% of the tissue before surgery (IQR, 40%−80%) but only 10% 1 year after surgery (IQR, 2.5%−21.3%); the mean nonalcoholic fatty liver disease score was reduced from 5 (IQR, 4−5) to 1 (IQR, 1−2) (each <i>P</i> < .001). Hepatocellular ballooning was reduced in 84.2% of samples (n = 69; 95% CI: 74.4−91.3) and lobular inflammation in 67.1% (n = 55; 95% CI: 55.8−77.1). According to Metavir scores, fibrosis was reduced in 33.8% of patients (95% CI: 23.6%−45.2%). Patients whose NASH persisted 1 year after surgery (n = 12) had lost significantly less weight (change in BMI, 9.1 ± 1.5) than those without NASH (change in BMI, 12.3 ± 0.6) (<i>P</i> = .005). Patients who underwent laparoscopic gastric banding lost less weight (change in BMI, 6.4 ± 0.7) than those who underwent gastric bypass (change in BMI, 14.0 ± 0.5) (<i>P</i> < .0001), and a higher proportion had persistent NASH (30.4% vs 7.6% of those with gastric bypass; <i>P</i> = .015). <h3>Conclusions</h3> Bariatric surgery induced the disappearance of NASH from nearly 85% of patients and reduced the pathologic features of the disease after 1 year of follow-up. It could be a therapeutic option for appropriate morbidly obese patients with NASH who do not respond to lifestyle modifications. More studies are needed to determine the long-term effects of bariatric surgery in morbidly obese patients with NASH.

Early identification of patients with severe (discriminant function > or = 32) alcoholic hepatitis (AH) not responding to corticosteroids is crucial. We generated a specific prognostic model (Lille model) to identify candidates early on for alternative therapies. Three hundred twenty patients with AH prospectively treated by corticosteroids were included in the development cohort and 118 in its validation. Baseline data and a change in bilirubin at day 7 were tested. The model was generated by logistic regression. The model combining six reproducible variables (age, renal insufficiency, albumin, prothrombin time, bilirubin, and evolution of bilirubin at day 7) was highly predictive of death at 6 months (P < 0.000001). The area under the receiver operating characteristic (AUROC) curve of the Lille model was 0.89 +/- 0.02, higher than the Child-Pugh (0.62 +/- 0.04, P < 0.00001) or Maddrey scores (0.66 +/- 0.04, P < 0.00001). In the validation cohort, its AUROC was 0.85 +/- 0.04, still higher than the other models, including MELD (0.72 +/- 0.05, P = 0.01) and Glasgow scores (0.67 +/- 0.05, P = 0.0008). Patients above the ideal cutoff of 0.45 showed a marked decrease in 6-month survival as compared with others: 25% +/- 3.8% versus 85% +/- 2.5%, P < 0.0001. This cutoff was able to identify approximately 75% of the observed deaths.In the largest cohort to date of patients with severe AH, we demonstrate that the term "nonresponder" can now be extended to patients with a Lille score above 0.45, which corresponds to 40% of cases. Early identification of subjects with substantial risk of death according to the Lille model will improve management of patients suffering from severe AH and will aid in the design of future studies for alternative therapies.

Chronic liver disease due to alcohol-use disorder contributes markedly to the global burden of disease and mortality1-3. Alcoholic hepatitis is a severe and life-threatening form of alcohol-associated liver disease. The gut microbiota promotes ethanol-induced liver disease in mice4, but little is known about the microbial factors that are responsible for this process. Here we identify cytolysin-a two-subunit exotoxin that is secreted by Enterococcus faecalis5,6-as a cause of hepatocyte death and liver injury. Compared with non-alcoholic individuals or patients with alcohol-use disorder, patients with alcoholic hepatitis have increased faecal numbers of E. faecalis. The presence of cytolysin-positive (cytolytic) E. faecalis correlated with the severity of liver disease and with mortality in patients with alcoholic hepatitis. Using humanized mice that were colonized with bacteria from the faeces of patients with alcoholic hepatitis, we investigated the therapeutic effects of bacteriophages that target cytolytic E. faecalis. We found that these bacteriophages decrease cytolysin in the liver and abolish ethanol-induced liver disease in humanized mice. Our findings link cytolytic E. faecalis with more severe clinical outcomes and increased mortality in patients with alcoholic hepatitis. We show that bacteriophages can specifically target cytolytic E. faecalis, which provides a method for precisely editing the intestinal microbiota. A clinical trial with a larger cohort is required to validate the relevance of our findings in humans, and to test whether this therapeutic approach is effective for patients with alcoholic hepatitis.

Alcoholic and nonalcoholic fatty liver disease (ALD and NAFLD) are the predominant causes of liver-related mortality in Western countries. We have shown that limiting classical (M1) Kupffer cell (KC) polarization reduces alcohol-induced liver injury. Herein, we investigated whether favoring alternatively activated M2 KCs may protect against ALD and NAFLD. Ongoing alcohol drinkers and morbidly obese patients, with minimal hepatic injury and steatosis, displayed higher hepatic expression of M2 genes, as compared to patients with more severe liver lesions; individuals with limited liver lesions showed negligible hepatocyte apoptosis but significant macrophage apoptosis. Experiments in mouse models of ALD or NAFLD further showed that BALB/c or resveratrol-treated mice fed alcohol or a high-fat diet displayed preponderant M2 KC polarization, M1 KC apoptosis, and resistance to hepatocyte steatosis and apoptosis, as compared to control C57BL6/J mice. In vitro experiments in isolated KC, peritoneal, and Raw264.7 macrophages demonstrated that M1 macrophage apoptosis was promoted by conditioned medium from macrophages polarized into an M2 phenotype by either interleukin (IL)4, resveratrol, or adiponectin. Mechanistically, IL10 released from M2 cells promoted M1 death, and anti-IL10 antibodies blunted the proapoptic effects of M2-conditioned media. IL10 secreted by M2 KCs promoted selective M1 death by a mechanism involving activation of arginase in high inducible nitric oxide synthase-expressing M1 KCs. In alcohol-exposed mice, neutralization of IL10 impaired M1 apoptosis.These data uncover a novel mechanism regulating the M1/M2 balance that relies on apoptotic effects of M2 KCs towards their M1 counterparts. They suggest that promoting M2-induced M1 KC apoptosis might prove a relevant strategy to limit alcohol- and high fat-induced inflammation and hepatocyte injury.

Severe obesity is implicated in development of nonalcoholic fatty liver disease (NAFLD). Bariatric surgery induces weight loss and increases survival time of obese patients, but little is known about its effects on liver damage. We performed a 5-year prospective study to evaluate fibrosis and nonalcoholic steatosis (NASH) in severely obese patients after bariatric surgery.Bariatric surgery was performed on 381 patients. Clinical and biological data, along with liver biopsies, were collected before and at 1 and 5 years after surgery.Five years after surgery, levels of fibrosis increased significantly, but 95.7% of patients maintained a fibrosis score <or= F1. The percentage of patients with steatosis decreased from 37.4% before surgery to 16%, the NAFLD score from 1.97 to 1, ballooning from 0.2 to 0.1. Inflammation remained unchanged. The percentage of patients with probable or definite NASH decreased significantly over 5 years, from 27.4% to 14.2%. The kinetics of insulin resistance (IR) paralleled that of steatosis and ballooning; the greatest improvements occurred within the first year and were sustained 5 years later. Steatosis and ballooning occurred more frequently in patients with a refractory IR profile. In multivariate analysis, the refractory IR profile independently predicted the persistence of steatosis and ballooning 5 years later.Five years after bariatric surgery for severe obesity, almost all patients had low levels of NAFLD, whereas fibrosis slightly increased. Steatosis and ballooning were closely linked to IR; long-term effects could be predicted by early improvement in IR.

A meta-analysis was performed using individual patient data from the five most recent randomised controlled trials (RCTs) which evaluated corticosteroids in severe alcoholic hepatitis (Maddrey discriminant function (DF) ≥ 32 or encephalopathy). This approach overcomes limitations associated with the use of literature data and improves the relevance of the study and estimates of effect size.To compare 28-day survival between corticosteroid- and non-corticosteroid-treated patients and to analyse the response to treatment using the Lille model.Individual patient data were obtained from five RCTs comparing corticosteroid treatment with placebo (n=3), enteral nutrition (n=1) or an antioxidant cocktail (n=1).221 patients allocated to corticosteroid treatment and 197 allocated to non-corticosteroid treatment were analysed. The two groups were similar at baseline. 28-day survival was higher in corticosteroid-treated patients than in non-corticosteroid-treated patients (79.97±2.8% vs 65.7±3.4%, p=0.0005). In multivariate analysis, corticosteroids (p=0.005), DF (p=0.006), leucocytes (p=0.004), Lille score (p<0.00001) and encephalopathy (p=0.003) were independently predictive of 28-day survival. A subgroup analysis was performed according to the percentile distribution of the Lille score. Patients were classified as complete responders (Lille score ≤ 0.16; ≤ 35th percentile), partial responders (Lille score 0.16-0.56; 35th-70th percentile) and null responders (Lille ≥ 0.56; ≥ 70th percentile). 28-day survival was strongly associated with these groupings (91.1±2.7% vs 79.4±3.8% vs 53.3±5.1%, p<0.0001). Corticosteroids had a significant effect on 28-day survival in complete responders (HR 0.18, p=0.006) and in partial responders (HR 0.38, p=0.04) but not in null responders.Analysis of individual data from five RCTs showed that corticosteroids significantly improve 28-day survival in patients with severe alcoholic hepatitis. The survival benefit is mainly observed in patients classified as responders by the Lille model.

There is no histologic classification system to determine prognoses of patients with alcoholic hepatitis (AH). We identified histologic features associated with disease severity and created a histologic scoring system to predict short-term (90-day) mortality.We analyzed data from 121 patients admitted to the Liver Unit (Hospital Clinic, Barcelona, Spain) from January 2000 to January 2008 with features of AH and developed a histologic scoring system to determine the risk of death using logistic regression. The system was tested and updated in a test set of 96 patients from 5 academic centers in the United States and Europe, and a semiquantitative scoring system called the Alcoholic Hepatitis Histologic Score (AHHS) was developed. The system was validated in an independent set of 109 patients. Interobserver agreement was evaluated by weighted κ statistical analysis.The degree of fibrosis, degree of neutrophil infiltration, type of bilirubinostasis, and presence of megamitochondria were independently associated with 90-day mortality. We used these 4 parameters to develop the AHHS to identify patients with a low (0-3 points), moderate (4-5 points), or high (6-9 points) risk of death within 90 days (3%, 19%, and 51%, respectively; P < .0001). The AHHS estimated 90-day mortality in the training and test sets with an area under the receiver operating characteristic value of 0.77 (95% confidence interval, 0.71-0.83). Interrater agreement values were 0.65 for fibrosis, 0.86 for bilirubinostasis, 0.60 for neutrophil infiltration, and 0.46 for megamitochondria. Interestingly, the type of bilirubinostasis predicted the development of bacterial infections.We identified histologic features associated with the severity of AH and developed a patient classification system that might be used in clinical decision making.

Background and Aims Studies are needed to determine the long-term effects of bariatric surgery for patients with nonalcoholic steatohepatitis (NASH). We evaluated sequential liver samples, collected the time of bariatric surgery and 1 and 5 years later, to assess the long-term effects of bariatric surgery in patients with NASH. Methods We performed a prospective study of 180 severely obese patients with biopsy-proven NASH, defined by the NASH clinical research network histologic scores. The patients underwent bariatric surgery at a single center in France and were followed for 5 years. We obtained liver samples from 125 of 169 patients (76%) having reached 1 year and 64 of 94 patients (68%) having reached 5 years after surgery. The primary endpoint was the resolution of NASH without worsening of fibrosis at 5 years. Secondary end points were improvement in fibrosis (reduction of ≥1 stage) at 5 years and regression of fibrosis and NASH at 1 and 5 years. Results At 5 years after bariatric surgery, NASH was resolved, without worsening fibrosis, in samples from 84% of patients (n = 64; 95% confidence interval, 73.1%-92.2%). Fibrosis decreased, compared with baseline, in samples from 70.2% of patients (95% CI, 56.6%-81.6%). Fibrosis disappeared from samples from 56% of all patients (95% CI, 42.4%-69.3%) and from samples from 45.5% of patients with baseline bridging fibrosis. Persistence of NASH was associated with no decrease in fibrosis and less weight loss (reduction in body mass index of 6.3 ± 4.1 kg/m2 in patients with persistent NASH vs reduction of 13.4 ± 7.4 kg/m2; P = .017 with resolution of NASH). Resolution of NASH was observed at 1 year after bariatric surgery in biopsies from 84% of patients, with no significant recurrence between 1 and 5 years (P = .17). Fibrosis began to decrease by 1 year after surgery and continued to decrease until 5 years (P < .001). Conclusions In a long-term follow-up of patients with NASH who underwent bariatric surgery, we observed resolution of NASH in liver samples from 84% of patients 5 years later. The reduction of fibrosis is progressive, beginning during the first year and continuing through 5 years. Studies are needed to determine the long-term effects of bariatric surgery for patients with nonalcoholic steatohepatitis (NASH). We evaluated sequential liver samples, collected the time of bariatric surgery and 1 and 5 years later, to assess the long-term effects of bariatric surgery in patients with NASH. We performed a prospective study of 180 severely obese patients with biopsy-proven NASH, defined by the NASH clinical research network histologic scores. The patients underwent bariatric surgery at a single center in France and were followed for 5 years. We obtained liver samples from 125 of 169 patients (76%) having reached 1 year and 64 of 94 patients (68%) having reached 5 years after surgery. The primary endpoint was the resolution of NASH without worsening of fibrosis at 5 years. Secondary end points were improvement in fibrosis (reduction of ≥1 stage) at 5 years and regression of fibrosis and NASH at 1 and 5 years. At 5 years after bariatric surgery, NASH was resolved, without worsening fibrosis, in samples from 84% of patients (n = 64; 95% confidence interval, 73.1%-92.2%). Fibrosis decreased, compared with baseline, in samples from 70.2% of patients (95% CI, 56.6%-81.6%). Fibrosis disappeared from samples from 56% of all patients (95% CI, 42.4%-69.3%) and from samples from 45.5% of patients with baseline bridging fibrosis. Persistence of NASH was associated with no decrease in fibrosis and less weight loss (reduction in body mass index of 6.3 ± 4.1 kg/m2 in patients with persistent NASH vs reduction of 13.4 ± 7.4 kg/m2; P = .017 with resolution of NASH). Resolution of NASH was observed at 1 year after bariatric surgery in biopsies from 84% of patients, with no significant recurrence between 1 and 5 years (P = .17). Fibrosis began to decrease by 1 year after surgery and continued to decrease until 5 years (P < .001). In a long-term follow-up of patients with NASH who underwent bariatric surgery, we observed resolution of NASH in liver samples from 84% of patients 5 years later. The reduction of fibrosis is progressive, beginning during the first year and continuing through 5 years.

Background & AimsIn severe (Maddrey score ≥32) alcoholic hepatitis (AH), infection is classically viewed as a contraindication for corticosteroids, although specific data are lacking. This study's aims were (1) to evaluate the incidence of infection in patients with severe AH before and after corticosteroid treatment; (2) to determine whether infection contraindicates corticosteroids; and (3) to focus on predictive factors of development of infection.MethodsAt admission, systematic screening of infection consisted of chest x-ray and blood, ascites, and urinary cultures. All patients were treated with prednisolone. Response to steroids was defined using the Lille model.ResultsTwo hundred forty-six patients with severe AH were prospectively included. Infections at admission were as follows: 63 infections (25.6%) were diagnosed: 28 (44.4%) spontaneous bacterial peritonitis or bacteremia, 8 (12.7%) pulmonary infections, 20 (31.7%) urinary tract infections, and 7 (11.2%) other infections. Patients infected before using corticosteroids had 2-month survival similar to that of others: 70.9% ± 6.1% vs 71.6% ± 3.4%, respectively, P = .99. Development of infection after steroids: 57 patients (23.7%) developed infection: 16 (28.1%) spontaneous bacterial peritonitis or bacteremia, 23 (40.3%) pulmonary, 10 (17.5%) urinary tract, and 8 (14.1%) other infections. Infection occurred more frequently in nonresponders than in responders: 42.5% vs 11.1%, respectively, P < .000001. In multivariate analysis, only the Lille model (P = .0002) independently predicted infection upon steroids use. The Lille model (P = .000001) and Model for End-Stage Liver Disease score (P = .006) were independently associated with survival, whereas infection was not (P = .52).ConclusionsSevere AH is associated with high risk of infection. Infection screening is warranted but should not contraindicate steroids. In terms of mechanisms, nonresponse to steroids is the key factor in development of infection and prediction of survival. In severe (Maddrey score ≥32) alcoholic hepatitis (AH), infection is classically viewed as a contraindication for corticosteroids, although specific data are lacking. This study's aims were (1) to evaluate the incidence of infection in patients with severe AH before and after corticosteroid treatment; (2) to determine whether infection contraindicates corticosteroids; and (3) to focus on predictive factors of development of infection. At admission, systematic screening of infection consisted of chest x-ray and blood, ascites, and urinary cultures. All patients were treated with prednisolone. Response to steroids was defined using the Lille model. Two hundred forty-six patients with severe AH were prospectively included. Infections at admission were as follows: 63 infections (25.6%) were diagnosed: 28 (44.4%) spontaneous bacterial peritonitis or bacteremia, 8 (12.7%) pulmonary infections, 20 (31.7%) urinary tract infections, and 7 (11.2%) other infections. Patients infected before using corticosteroids had 2-month survival similar to that of others: 70.9% ± 6.1% vs 71.6% ± 3.4%, respectively, P = .99. Development of infection after steroids: 57 patients (23.7%) developed infection: 16 (28.1%) spontaneous bacterial peritonitis or bacteremia, 23 (40.3%) pulmonary, 10 (17.5%) urinary tract, and 8 (14.1%) other infections. Infection occurred more frequently in nonresponders than in responders: 42.5% vs 11.1%, respectively, P < .000001. In multivariate analysis, only the Lille model (P = .0002) independently predicted infection upon steroids use. The Lille model (P = .000001) and Model for End-Stage Liver Disease score (P = .006) were independently associated with survival, whereas infection was not (P = .52). Severe AH is associated with high risk of infection. Infection screening is warranted but should not contraindicate steroids. In terms of mechanisms, nonresponse to steroids is the key factor in development of infection and prediction of survival.

Liver transplantation (LT) for the most severely ill patients with cirrhosis, with multiple organ dysfunction (accurately assessed by the acute-on-chronic liver failure [ACLF] classification) remains controversial. We aimed to report the results of LT in patients with ACLF grade 3 and to compare these patients to non-transplanted patients with cirrhosis and multiple organ dysfunction as well as to patients transplanted with lower ACLF grade.All patients with ACLF-3 transplanted in three liver intensive care units (ICUs) were retrospectively included. Each patient with ACLF-3 was matched to a) non-transplanted patients hospitalized in the ICU with multiple organ dysfunction, or b) control patients transplanted with each of the lower ACLF grades (three groups).Seventy-three patients were included. These severely ill patients were transplanted following management to stabilize their condition with a median of nine days after admission (progression of mean organ failure from 4.03 to 3.67, p=0.009). One-year survival of transplanted patients with ACLF-3 was higher than that of non-transplanted controls: 83.9 vs. 7.9%, p<0.0001. This high survival rate was not different from that of matched control patients with no ACLF (90%), ACLF-1 (82.3%) or ACLF-2 (86.2%). However, a higher rate of complications was observed (100 vs. 51.2 vs. 76.5 vs. 74.3%, respectively), with a longer hospital stay. The notion of a "transplantation window" is discussed.LT strongly influences the survival of patients with cirrhosis and ACLF-3 with a 1-year survival similar to that of patients with a lower grade of ACLF. A rapid decision-making process is needed because of the short "transplantation window" suggesting that patients with ACLF-3 should be rapidly referred to a specific liver ICU. Lay summary: Liver transplantation improves survival of patients with very severe cirrhosis. These patients must be carefully monitored and managed in a specialized unit. The decision to transplant a patient must be quick to avoid a high risk of mortality.

Alcoholic hepatitis (AH) frequently progresses to multiple organ failure (MOF) and death. However, the driving factors are largely unknown. At admission, patients with AH often show criteria of systemic inflammatory response syndrome (SIRS) even in the absence of an infection. We hypothesize that the presence of SIRS may predispose to MOF and death. To test this hypothesis, we studied a cohort including 162 patients with biopsy‐proven AH. The presence of SIRS and infections was assessed in all patients, and multivariate analyses identified variables independently associated with MOF and 90‐day mortality. At admission, 32 (19.8%) patients were diagnosed with a bacterial infection, while 75 (46.3%) fulfilled SIRS criteria; 58 patients (35.8%) developed MOF during hospitalization. Short‐term mortality was significantly higher among patients who developed MOF (62.1% versus 3.8%, P &lt; 0.001). The presence of SIRS was a major predictor of MOF (odds ratio = 2.69, P = 0.025) and strongly correlated with mortality. Importantly, the course of patients with SIRS with and without infection was similar in terms of MOF development and short‐term mortality. Finally, we sought to identify serum markers that differentiate SIRS with and without infection. We studied serum levels of high‐sensitivity C‐reactive protein, procalcitonin, and lipopolysaccharide at admission. All of them predicted mortality. Procalcitonin, but not high‐sensitivity C‐reactive protein, serum levels identified those patients with SIRS and infection. Lipopolysaccharide serum levels predicted MOF and the response to prednisolone. Conclusion : In the presence or absence of infections, SIRS is a major determinant of MOF and mortality in AH, and the mechanisms involved in the development of SIRS should be investigated; procalcitonin serum levels can help to identify patients with infection, and lipopolysaccharide levels may help to predict mortality and the response to steroids. (H epatology 2015;62:762–772)

HepatologyVolume 54, Issue 4 p. 1217-1226 Steatohepatitis/Metabolic Liver DiseaseFree Access Cannabinoid CB2 receptors protect against alcoholic liver disease by regulating Kupffer cell polarization in mice†‡ Alexandre Louvet, Alexandre Louvet INSERM, U955, Créteil, France Université Paris-Est, Faculté de Médecine, UMR-S955, Créteil, France These authors contributed equally to this work.Search for more papers by this authorFatima Teixeira-Clerc, Fatima Teixeira-Clerc INSERM, U955, Créteil, France Université Paris-Est, Faculté de Médecine, UMR-S955, Créteil, France These authors contributed equally to this work.Search for more papers by this authorMarie-Noële Chobert, Marie-Noële Chobert INSERM, U955, Créteil, France Université Paris-Est, Faculté de Médecine, UMR-S955, Créteil, FranceSearch for more papers by this authorVanessa Deveaux, Vanessa Deveaux INSERM, U955, Créteil, France Université Paris-Est, Faculté de Médecine, UMR-S955, Créteil, FranceSearch for more papers by this authorCatherine Pavoine, Catherine Pavoine INSERM, U955, Créteil, France Université Paris-Est, Faculté de Médecine, UMR-S955, Créteil, FranceSearch for more papers by this authorAndreas Zimmer, Andreas Zimmer Department of Molecular Psychiatry, University of Bonn, Bonn, GermanySearch for more papers by this authorFrançoise Pecker, Françoise Pecker INSERM, U955, Créteil, France Université Paris-Est, Faculté de Médecine, UMR-S955, Créteil, FranceSearch for more papers by this authorAriane Mallat, Ariane Mallat INSERM, U955, Créteil, France Université Paris-Est, Faculté de Médecine, UMR-S955, Créteil, France AP-HP, Groupe Henri Mondor-Albert Chenevier, Départment d'Hépatologie et de Gastroentérologie, Créteil, FranceSearch for more papers by this authorSophie Lotersztajn, Corresponding Author Sophie Lotersztajn [email protected] INSERM, U955, Créteil, France Université Paris-Est, Faculté de Médecine, UMR-S955, Créteil, France AP-HP, Groupe Henri Mondor-Albert Chenevier, Départment d'Hépatologie et de Gastroentérologie, Créteil, France fax: +33 (0)1 48 98 09 08INSERM U955, Institut Mondor de Recherche Biomédicale, Hôpital Henri Mondor, 51 avenue du Marechal de Lattre de Tassigny, 94000 Créteil, France===Search for more papers by this author Alexandre Louvet, Alexandre Louvet INSERM, U955, Créteil, France Université Paris-Est, Faculté de Médecine, UMR-S955, Créteil, France These authors contributed equally to this work.Search for more papers by this authorFatima Teixeira-Clerc, Fatima Teixeira-Clerc INSERM, U955, Créteil, France Université Paris-Est, Faculté de Médecine, UMR-S955, Créteil, France These authors contributed equally to this work.Search for more papers by this authorMarie-Noële Chobert, Marie-Noële Chobert INSERM, U955, Créteil, France Université Paris-Est, Faculté de Médecine, UMR-S955, Créteil, FranceSearch for more papers by this authorVanessa Deveaux, Vanessa Deveaux INSERM, U955, Créteil, France Université Paris-Est, Faculté de Médecine, UMR-S955, Créteil, FranceSearch for more papers by this authorCatherine Pavoine, Catherine Pavoine INSERM, U955, Créteil, France Université Paris-Est, Faculté de Médecine, UMR-S955, Créteil, FranceSearch for more papers by this authorAndreas Zimmer, Andreas Zimmer Department of Molecular Psychiatry, University of Bonn, Bonn, GermanySearch for more papers by this authorFrançoise Pecker, Françoise Pecker INSERM, U955, Créteil, France Université Paris-Est, Faculté de Médecine, UMR-S955, Créteil, FranceSearch for more papers by this authorAriane Mallat, Ariane Mallat INSERM, U955, Créteil, France Université Paris-Est, Faculté de Médecine, UMR-S955, Créteil, France AP-HP, Groupe Henri Mondor-Albert Chenevier, Départment d'Hépatologie et de Gastroentérologie, Créteil, FranceSearch for more papers by this authorSophie Lotersztajn, Corresponding Author Sophie Lotersztajn [email protected] INSERM, U955, Créteil, France Université Paris-Est, Faculté de Médecine, UMR-S955, Créteil, France AP-HP, Groupe Henri Mondor-Albert Chenevier, Départment d'Hépatologie et de Gastroentérologie, Créteil, France fax: +33 (0)1 48 98 09 08INSERM U955, Institut Mondor de Recherche Biomédicale, Hôpital Henri Mondor, 51 avenue du Marechal de Lattre de Tassigny, 94000 Créteil, France===Search for more papers by this author First published: 06 July 2011 https://doi.org/10.1002/hep.24524Citations: 187 † Potential conflict of interest: Nothing to report. ‡ This work was supported by the INSERM, the Université Paris-Est, and by grants (to S.L.) of the Agence Nationale de la Recherche and Fondation pour la Recherche Médicale. AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Abstract Activation of Kupffer cells plays a central role in the pathogenesis of alcoholic liver disease. Because cannabinoid CB2 receptors (CB2) display potent anti-inflammatory properties, we investigated their role in the pathogenesis of alcoholic liver disease, focusing on the impact of CB2 on Kupffer cell polarization and the consequences on liver steatosis. Wild-type (WT) mice fed an alcohol diet showed an induction of hepatic classical (M1) and alternative (M2) markers. Cotreatment of alcohol-fed mice with the CB2 agonist, JWH-133, decreased hepatic M1 gene expression without affecting the M2 profile. In keeping with this, genetic ablation of CB2 enhanced hepatic induction of M1 gene signature and blunted the induction of M2 markers. CB2 also modulated alcohol-induced fatty liver, as shown by the reduction of hepatocyte steatosis in JWH-133-treated mice and its enhancement in CB2−/− animals. Studies in isolated Kupffer cells and cultured macrophages further demonstrated that CB2 inhibits M1 polarization and favors the transition to an M2 phenotype. In addition, conditioned-medium experiments showed that preventing M1 polarization in CB2-activated macrophages protects from lipid accumulation in hepatocytes. Heme oxygenase-1 (HO-1) mediated the anti-inflammatory effects of CB2 receptors. Indeed, alcohol-fed mice treated with JWH-133 showed increased hepatic expression of macrophage HO-1, as compared to vehicle-treated counterparts. In keeping with this, JWH-133 induced HO-1 expression in cultured macrophages, and the HO-1 inhibitor, zinc protoporphyrin, blunted the inhibitory effect of JWH-133 on lipopolysaccharide-induced nuclear factor-kappa B activation and M1 polarization. Altogether, these findings demonstrate that CB2 receptors display beneficial effects on alcohol-induced inflammation by regulating M1/M2 balance in Kupffer cells, thereby reducing hepatocyte steatosis via paracrine interactions between Kupffer cells and hepatocytes. These data identify CB2 agonists as potential therapeutic agents for the management of alcoholic liver disease. (HEPATOLOGY 2011;) Macrophages are a highly heterogeneous, plastic population that undergo pleiotropic coordinated responses to tissue damage through distinct programs of activation, known as classical (M1) or alternative (M2).1, 2 The classical M1 activation process is mainly driven by bacterial molecular patterns, including endotoxin/lipopolysaccharide (LPS), or by Th1 cytokines, such as interferon gamma, and results in high proinflammatory and bactericidal potential.1, 2 Thus, the macrophage switch to an M1 phenotype plays a key role in the pathogenesis of a variety of chronic inflammatory diseases, including atherosclerosis,2 inflammatory bowel disease,3 or insulin resistance associated with obesity.4 In contrast, Th2 cytokines, such as interleukin (IL)-4 and IL-13, promote macrophage polarization into an alternative M2 phenotype.2 M2-polarized macrophages promote the resolution of inflammation and are involved in tissue repair and remodeling.1, 2 Indeed, recent reports indicate that alternative M2 macrophages show antidiabetic properties5, 6 and beneficial effects on atherosclerosis,2 muscle repair,7 and infectious colitis.3 Chronic alcohol abuse, a leading cause of liver-related morbimortality in Western countries, is associated with several patterns of liver injury, ranging from isolated fatty liver to alcoholic hepatitis, cirrhosis, and hepatocellular carcinoma.8 Compelling evidence indicates that Kupffer cells play a key role in the early events of alcoholic liver disease. Thus, gadolinium-induced depletion of Kupffer cells prevents steatosis and liver inflammation in rodent models of chronic alcohol feeding.9 The currently accepted model stipulates that alcohol-induced enhancement of gut permeability to bacterial LPS/endotoxin increases the translocation of endotoxin to the liver that activates Kupffer cells after binding to Toll-like receptor 4 (TLR4).8, 10 Alcohol also sensitizes Kupffer cells to LPS by increasing oxidative stress and primes Kupffer cells to respond to LPS by up-regulating a number of proinflammatory mediators, including cytokines and chemokines, as well as their cognate receptors.11, 12 Among the panel of secreted cytokines, tumor necrosis factor-alpha (TNF-α) is considered as a major mediator of alcohol-induced liver injury, as shown in a number of clinical studies,8, 13 and on the basis of experimental data demonstrating the substantial reduction of hepatic steatosis, as well as liver inflammation and injury, in TNF-R1 deficient mice and in rats treated with TNF-α antibodies.14, 15 These findings have prompted an evaluation of the effect of TNF-α antibody treatment in patients with severe alcoholic hepatitis, an entity associated with elevated short-term mortality. Unfortunately, direct blockade of TNF-α has proved deleterious, owing to a high rate of infectious events in these patients.16 Therefore, other strategies need to be envisioned, and interventional tools able to favor the anti-inflammatory M2 phenotype in the liver warrant consideration as potential protective agents for the management of alcohol-induced liver injury. Cannabinoid CB2 receptors are G-protein-coupled receptors predominantly expressed by cells of the immune system, including macrophages. These receptors are constituent elements of an endocannabinoid system with pleiotropic effects that also comprise CB1 receptors, highly lipophilic ligands known as endocannabinoids, and mediators responsible for their synthesis, metabolism, and catabolism.17, 18 A number of studies have demonstrated that CB2 receptors display potent anti-inflammatory properties, although proinflammatory effects have occasionally been described.17, 19, 20 Thus, CB2 receptors reduce inflammation in models of atherosclerosis21 and in a variety of neuroinflammatory disorders, including multiple sclerosis, Alzheimer's disease, or amyotrophic lateral sclerosis.22 In addition, in vitro studies have shown that CB2-receptor activation impairs several macrophage functions, such as oxidized low-density lipoprotein (oxLDL)-induced inflammatory response, oxidative stress, migration, and antigen processing.22 In the liver, recent data indicate that CB2 receptors are induced after acute or chronic injury, both in Kupffer cells and in liver fibrogenic cells.23-25 Remarkably, endogenous activation of these receptors has been shown to limit liver injury in several instances. Thus, CB2 receptors reduce hepatocyte apoptosis and promote liver regeneration in response to an acute insult,24 inhibit the inflammatory process associated with acute ischemia/reperfusion,26 and prevent the progression of hepatic fibrosis in response to chronic liver injury.23 In addition, endogenous production of the nonselective CB1/CB2 ligand, 2-arachidonoylglycerol, is increased in the liver in response to chronic alcohol feeding.27 However, though recent studies have reported the steatogenic and fibrogenic properties of CB1 receptors,27, 28 there are no data as to the functional relevance of CB2 receptors during chronic exposure to ethanol. We show here that during alcohol-induced liver injury, activation of Kupffer-cell CB2 receptors inhibits classical M1 polarization and favors a transition to an M2 alternative phenotype by a mechanism involving heme oxygenase-1 (HO-1) induction, thereby protecting from the deleterious inflammatory response to chronic ethanol feeding. In addition, our data indicate that activation of macrophage CB2 receptors reduces the development of alcohol-induced fatty liver by paracrine effects on hepatocytes. These findings identify CB2 agonism as a potential therapeutic approach for the management of alcohol-induced liver injury. Abbreviations Arg1, arginase 1; ALT, alanine aminotransferase; AST, aspartate aminotransferase; Ca2+, calcium; CB2, cannabinoid CB2 receptors; CCL, chemokine (C-C motif) ligand; CD, control diet; CD163, cluster of differentiation 163; CM, conditioned medium; DMEM, Dulbecco's modified Eagle's medium; FBS, fetal bovine serum; HO-1, heme oxygenase-1; IL, interleukin; ITS, insulin, transferrin, selenium; LPS, lipopolysaccharide; Mg2+, magnesium; Mgl1, macrophage galactose-type C-type lectin 1; Mrc2, mannose receptor C type 2; mRNA, messenger RNA; NF-κB, nuclear factor-kappa B; NOS2, nitric oxide synthase 2; oxLDL, oxidized low-density lipoprotein; TLR4, Toll-like receptor 4; TNF-α, tumor necrosis factor alpha; WT: wild type; ZnPP, zinc protoporphyrin. Materials and Methods Additional methods are available in the Supporting Information. Animals. Female, (8-10 weeks old) mice were used. Experiments included wild-type (WT) C57Bl/6J mice (Janvier, Le Genest, France) and mice with a targeted mutation of the Cnr2 gene.29 Homozygous CB2−/− animals were obtained from heterozygous CB2+/− mice that were back-crossed with WT C57Bl/6J animals over 10 generations, and further intercrossed to obtain homozygous animals. Animals were housed in temperature- and humidity-controlled rooms, kept on a 12-hour light-dark cycle, and provided unrestricted amounts of food and water. Animal procedures were conducted in accord with French government policies (Comité d'éthique COMETH authorization no.: 10-0048). Chronic Exposure to Ethanol. WT and CB2−/− mice were fed for 17 days with a liquid diet adapted from Lieber-De Carli, as described by Gustot et al.30 Briefly, the ethanol diet was obtained by adding absolute ethanol to a solution of caseine, oils (e.g., safflower, corn, and olive oils), and powders (e.g., maltodextrin, vitamins, xanthan gum, choline bitartrate, mineral mix, methionine, and cellulose) in distillated water. The final concentration of ethanol in this liquid diet is 6.3% (vol/vol), and ethanol accounts for 28% of total caloric intake. The control diet (CD) was obtained by replacing the ethanol by an equivalent quantity of maltodextrin. WT and CB2−/− mice were randomized into ethanol- (n = 15 for WT and CB2−/−) and CD-fed (n = 6 for WT and CB2−/−) groups, then adapted to control liquid diet ad libitum for 7 days. Ethanol-fed groups were allowed free access to a 6.3% (vol/vol) ethanol diet for 10 days. Control mice were pair-fed with isocaloric control diet over the entire feeding period. Three independent experiments were performed with the same number of animals and treatments. The impact of the CB2 agonist, JWH-133, was evaluated in WT mice administered a daily intraperitoneal injection of JWH-133 (3 mg/kg; n = 15) or its vehicle (n = 15) during the 10-day feeding with ethanol. JWH-133 was freshly dissolved in a vehicle solution containing 1 drop of Tween 80 in 0.1 mL of dimethyl sulfoxide, sonicated, and further diluted 50 times in NaCl 9‰. Body weight and food intake were measured daily for all experiments. The liver was removed, weighed, and either fixed in buffered formalin or snap-frozen in liquid nitrogen. All samples were stored at −80°C until use. Mouse Kupffer Cells. A Kupffer cell–enriched fraction was obtained from WT and CB2−/− mice after perfusion with liberase and differential centrifugation in Percoll. Briefly, the livers were perfused in situ with an isotonic calcium (Ca2+)- and magnesium (Mg2+)-free saline solution containing 10 mM of Ca2+ and 15.4 μg/mL of liberase for 10 minutes. After digestion in 10 mM of Ca2+, 15.4 μg/mL of liberase, 10 μg/mL of DNAse I, and 200 μg/mL of pronase, hepatocytes were pelleted, and the supernatant containing nonparenchymal cells was further centrifuged at 400g, resuspended in RPMI with 2% fetal bovine serum (FBS), and separated by centrifugation on a 25%-50% Percoll gradient. The Kupffer-cell fraction located at the interface of the 25%-50% Percoll layer was seeded in RPMI containing 10% FBS and 10 mM of HEPES. This procedure routinely yielded 2 × 106 cells/liver with a purity higher than 65%, as determined by F4/80 immunostaining. Adherent Kupffer cells were treated with 1 ng/mL of LPS or 5 ng/mL of IL-4 for 6 hours. RAW264.7 Macrophages. Cells were seeded in Dulbecco's modified Eagle's medium (DMEM), supplemented with 10% FBS. After 24 hours, cells were serum-starved and treated with 5 μM of JWH-133 or vehicle for an additional 24-hour period. When indicated, cells were treated with 1 ng/mL of LPS or 5 ng/mL of IL-4 during the last 6 hours. Culture and Treatment of Hepatocyte Cell Line AML-12. Cells were cultured in DMEM/F12 supplemented with 10% FBS, ITS (insulin, transferring, selenium) (5 μg/mL of insulin, 5 μg/mL of transferrin, and 5 ng/mL of selenium) and 40 ng/mL of dexamethasone. Cells were incubated for 24 hours with a conditioned medium (CM) obtained from RAW264.7 cells treated with 5 μM of JWH-133 or vehicle for 24 hours and 1 ng/mL of LPS for the last 6 hours. Statistical Analysis. Results are expressed as mean ± standard error of the mean and were analyzed by Mann-Whitney or Kruskal-Wallis, as appropriate, using Prism 4.0 software (GraphPad Software, Inc., San Diego, CA). P < 0.05 was taken as the minimum level of significance. Results CB2 Receptors Regulate Kupffer Cell Polarization in Alcohol-Fed Mice. Kupffer cell polarization was evaluated in parallel groups of female WT and CB2−/− mice and in WT mice concurrently treated with the CB2 agonist, JWH-133. Animals were fed either a Lieber-De Carli alcohol diet, modified according to Gustot et al.30 or a paired isocaloric diet. General characteristics of experimental groups are depicted in Table 1. Body weights were similar between groups at the end of the experiment (Table 1), and ethanol-fed groups showed no differences in daily alcohol intakes, serum ethanol levels, and serum transaminases at time of sacrifice (Table 1). Table 1. General Characteristics of Mice Fed Alcohol and Control Diet WT CD CB2−/−CD WT Alcohol CB2−/−Alcohol WT CD WT Alcohol JWH-133-Treated WT Alcohol Body weight before alcohol (g) 21.6±0.3 21.8 ± 0.1 21.4 ± 0.2 21.7 ± 0.3 19.6 ± 0.4 19.3 ± 0.2 20.1 ± 0.2 Body weight 10 days after alcohol (g) 21±0.4 21.5 ± 0.1 20.8 ± 0.3* 20.8 ± 0.4* 19.6 ± 0.4 19.4 ± 0.2 19.4 ± 0.2 Alcohol consumption (g/kg/day) — — 18.1 ± 0.4 17 ± 0.3 — 21.0 ± 1.0 19.9 ± 0.6 Serum ethanol level (g/L) — — 1.3 ± 0.1 1.2 ± 0.2 — ND ND AST (IU/L) 92 ± 12 94 ± 17 209 ± 16* 218 ± 35* 96 ± 6 244 ± 22* 214 ± 28* ALT (IU/L) 26 ± 4 25 ± 3 84 ± 13* 88 ± 20* 21 ± 3 38 ± 6* 38 ± 6* * P < 0.05, as compared to control-diet–fed mice. Abbreviations: WT, wild type; CD, control diet; ALT, alanine aminotransferase; AST, aspartate aminotransferase; ND, not determined. As anticipated, alcohol-fed WT mice displayed significant hepatic induction of M1 markers, including TNF-α and the chemokines, chemokine (C-C motif) ligand 3 (CCL3), CCL4, and IL-6 (Fig. 1). In addition, there was also a parallel induction of genes characteristic of an M2 gene signature, such as arginase 1 (Arg1), mannose receptor C type 2 (Mrc2), and cluster of differentiation 163 (CD163) (Fig. 1). Chronic alcohol feeding did not increase F4/80 and CCR2 messenger RNA (mRNA) expression in either group of animals (Fig. 1), therefore ruling out the possibility that alterations in hepatic M1/M2 marker expression might be related to infiltrating by blood monocytes. These findings show that chronic alcohol feeding promotes polarization of Kupffer cells toward a mixed M1/M2 phenotype. Figure 1Open in figure viewerPowerPoint Endogenous or exogenous activation of CB2 receptors prevents alcohol-induced classical M1 polarization of Kupffer cells and favors alternative M2 polarization in vivo. mRNA expression of M1 and M2 genes was characterized in (A) ethanol- or CD WT mice treated with JWH-133 (n = 20) or vehicle (n = 20). #P < 0.05 for ethanol versus control diet; †P < 0.05 for JWH-133 versus vehicle. (B) Ethanol- or CD-fed WT (n = 63) and CB2−/− (n = 58) mice. #P < 0.05 for ethanol versus control diet; †P < 0.05 for CB2−/− versus WT. Treatment of alcohol-fed WT mice with the CB2 receptor agonist, JWH-133, inhibited the induction of M1 genes, as shown by the decrease in IL-6, TNF-α, nitric oxide synthase 2 (NOS2), CCL3, and CCL4 expressions, compared to vehicle-treated animals (Fig. 1A), whereas the M2 response was unaffected (Fig. 1A). CB2−/− mice displayed opposite alterations in the M1 response to alcohol, characterized by enhanced hepatic induction of several M1 markers, including IL-1β, IL-6, TNF-α, and NOS2, compared to WT counterparts (Fig. 1B). In addition, CB2 receptor invalidation also blunted M2 response to alcohol feeding, as reflected by unchanged expressions of Arg1, Mrc2, macrophage galactose-type C-type lectin 1 (Mgl1), and CD163 mRNAs, as compared to control diet-fed mice (Fig. 1B). Altogether, these data indicate that endogenous or exogenous activation of CB2 receptors prevents alcohol-induced M1 polarization of Kupffer cells. In addition, findings in CB2-deficient animals also suggest that CB2 receptors promote a switch of Kupffer cells toward an alternative M2 phenotype. Beneficial Impact of CB2 Receptors on Alcohol-Induced Fatty Liver. We next investigated the impact of CB2 receptor modulation on alcohol-induced fatty liver, a characteristic feature of alcoholic liver disease. CB2-deficient, alcohol-fed mice displayed more severe steatosis, higher levels of liver triglycerides, and a more pronounced hepatomegaly, compared to alcohol-fed WT counterparts (Fig. 2A). Consistent with these data, alcohol-fed WT mice exposed to JWH-133 showed a lesser increase in liver/body weight ratio and in hepatic triglyceride accumulation (Fig. 2B). These findings demonstrate that endogenous and exogenous activation of CB2 receptors reduces the development of alcohol-induced fatty liver. Figure 2Open in figure viewerPowerPoint Endogenous or exogenous activation of CB2 receptors prevents alcohol-induced hepatic steatosis. Liver to body weight ratio, hepatic triglyceride content, and hematoxylin-eosin staining (original magnification, ×200) (A) in CD-fed or alcohol-fed WT (n = 63) and CB2−/− mice (n = 58). #P < 0.05 for ethanol versus control diet; †P < 0.05 for CB2−/− versus WT. (B) CD-fed or alcohol-fed WT mice treated with JWH-133 (n = 20) or vehicle (n = 20). #P < 0.05 for ethanol versus control diet; †P < 0.05 for JWH-133 versus vehicle. Antisteatogenic Effects of CB2 Receptors Result From Paracrine Effects of Macrophage CB2 Receptors on Hepatocytes. Considering the predominant expression of CB2 receptors in immune cells, culture experiments were designed to evaluate the role of macrophage CB2 receptors in the regulation of macrophage polarization and hepatocyte steatogenesis. In a first series of experiments, we characterized the impact of CB2 Kupffer cells isolated from WT or CB2−/− mice and in the macrophage cell line, RAW264.7. M1 and M2 polarization was induced by incubation with LPS and IL-4, respectively. In keeping with in vivo findings, CB2−/− Kupffer cells exhibited an enhanced M1 response to LPS, compared to WT Kupffer cells, as shown by a greater induction of TNF-α, IL-1β, and CCL4 induction and a tendency to increase IL-6 expression (Fig. 3A). In addition, the alternative response of CB2−/− Kupffer cells to IL-4 was reduced, as demonstrated by the lower induction of Mrc2, C-type lectin domain family 7 member A (Clec7A) and a tendency to decrease Mgl1 (Fig. 3B). In contrast, JWH-133 reduced M1 gene expression (Fig. 4A) and corresponding cytokine secretion (Fig. 4B) in RAW264.7 cells, without affecting the alternative M2 response elicited by IL-4 (Fig. 4C). There was no effect of JWH-133 on TLR4 mRNA expression (data not shown), suggesting that CB2 receptor activation does reduce the sensitivity of macrophages to LPS. Overall, these data indicate that activation of macrophage CB2 receptors reduces the proinflammatory M1 response to LPS and contributes to the alternative M2 response to IL-4, in keeping with results obtained from in vivo experiments. Figure 3Open in figure viewerPowerPoint CB2 receptor invalidation favors M1 polarization and reduces alternative M2 polarization of Kupffer cells in vitro. Characterization of M1 and M2 gene-expression profile in Kupffer cells isolated from WT and CB2−/− mice after incubation for 6 hours with 1 ng/mL of LPS (A) with 5 ng/mL of IL-4 (B) (n = 3). †P < 0.05 for CB2−/− versus WT. Figure 4Open in figure viewerPowerPoint In vitro activation of macrophage CB2 receptor inhibits the proinflammatory M1 phenotype and the steatogenic responses via paracrine effects on hepatocytes. RAW264.7 cells were treated with vehicle or 5 μM of JWH-133 for 18 hours and further incubated with 1 ng/mL of LPS for (A) 6 hours or (B) 24 hours or (C) with 5 ng/mL of IL-4 for 6 hours. (A) M1 gene expression, (B) quantification of secreted cytokine levels, and (C) M2 gene expression (n = 3) †P < 0.05 for JWH-133 versus vehicle. (D) Oil Red O staining and quantification from AML-12 hepatocytes exposed to a) the CM from RAW264.7 cells treated with the indicated effectors, b) 1 ng/mL of LPS added directly to the CM from vehicle-treated RAW264.7 cells, c) 5 μM of JWH-133 directly added to the CM from LPS-stimulated RAW264.7 cells. #P < 0.05 for LPS versus H2O; †P < 0.05 for JWH-133 versus vehicle. We next evaluated the impact of CB2 receptor activation in macrophages on fat accumulation in hepatocytes. To that aim, CM was collected from LPS-exposed RAW264.7 cells incubated in the absence or presence of JWH-133. Hepatocytes cultured in the presence of the CM obtained from LPS-exposed RAW264.7 cells displayed enhanced lipid accumulation, as compared to control, as illustrated by Oil Red O staining quantification (Fig. 4D). Fat accumulation was reduced by 74% in hepatocytes exposed to CM prepared from JWH-133-treated, LPS-exposed RAW264.7 macrophages (Fig. 4D). LPS added directly to AML-12 cells had no effect on fat accumulation (Fig. 4D). Moreover, the addition of JWH-133 to AML-12 cells had no protective effects against steatosis elicited by the CM of LPS-treated RAW264.7 cells, therefore ruling out direct effects of the compounds on hepatocytes (Fig. 4D). Altogether, these data demonstrate that macrophage CB2 receptors reduce fat accumulation in hepatocytes via paracrine effects. HO-1 Mediates Anti-inflammatory Properties of CB2 Receptors. HO-1 is a stress-inducible protein highly expressed in Kupffer cells that displays potent protective anti-inflammatory and cytoprotective effects in the liver against alcohol-induced liver injury,31 endotoxemia,32 or ischemia-reperfusion injury.33 We, therefore, investigated whether HO-1 might mediate CB2-induced anti-inflammatory effects in alcohol-fed mice and, first, characterized the impact of JWH-133 treatment on Kupffer-cell HO-1 protein expression by double immunohistochemistry combining antibodies to HO-1 and F4/80. Alcohol-fed mice treated with JWH-133 displayed a strong HO-1 protein increase in Kupffer cells, compared to alcohol-fed control animals (82% ± 2% versus 57% ± 3%, P < 0.05; Fig. 5A). In keeping with in vivo findings, JWH-133 induced HO-1 mRNA and protein expression in isolated Kupffer cells and in RAW264.7 macrophages, either alone or in combination with LPS (Fig. 5B,C). Figure 5Open in figure viewerPowerPoint CB2 receptor activation induces HO-1 expression in macrophages both in vivo and in vitro. (A) Representative images of HO-1 (red) and F4/80 (white) immunochemical labeling, and percentage of HO-1-positive macrophages in liver tissue sections from ethanol-fed WT mice treated with JWH-133 or vehicle (confocal microscopy; original magnification, ×400); double-positive cells are indicated by the arrows (†P < 0.05 for JWH-133 versus vehicle). (B and C) Kupper cells (B) or RAW264.7 cells (C) were treated with 5 μM of JWH-133 or vehicle for 18 hours and further stimulated with 1 ng/mL of LPS or vehicle for 6 hours; HO-1 mRNA expression was quantified by reverse-transcriptase polymerase chain reaction analysis and HO-1 protein expression by immunocytochemistry and western blotting analysis. †P < 0.05 for JWH-133 versus vehicle; #P < 0.05 for LPS versus H2O. We next investigated the impact of zinc protoporphyrin (ZnPP), a specific competitive inhibitor of HO-1 activity, on LPS-treated RAW264.7 macrophages exposed to JWH-133. Strikingly, ZnPP blunted the inhibitory effect of JWH-133 on LPS-induced nuclear factor-kappa B (NF-κB) translocation into the nucleus (Fig. 6A). In addition, ZnPP also prevented the inhibitory effect of JWH-133 on IL-6 and IL-1β expressions, whereas its effect on TNF-α did not reach statistical significance (Fig. 6B). These data demonstrate that CB2 activation induces HO-1 in macrophages, thereby limiting

Prednisolone or pentoxifylline is recommended for severe alcoholic hepatitis, a life-threatening disease. The benefit of their combination is unknown.To determine whether the addition of pentoxifylline to prednisolone is more effective than prednisolone alone.Multicenter, randomized, double-blind clinical trial conducted between December 2007 and March 2010 in 1 Belgian and 23 French hospitals of 270 patients aged 18 to 70 years who were heavy drinkers with severe biopsy-proven alcoholic hepatitis, as indicated by recent onset of jaundice in the prior 3 months and a Maddrey score of at least 32. Duration of follow-up was 6 months. The last included patient completed the study in October 2010. None of the patients were lost to follow-up for the main outcome.Patients were randomly assigned to receive either a combination of 40 mg of prednisolone once a day and 400 mg of pentoxifylline 3 times a day (n=133) for 28 days, or 40 mg of prednisolone and matching placebo (n=137) for 28 days.Six-month survival, with secondary end points of development of hepatorenal syndrome and response to therapy based on the Lille model, which defines treatment nonresponders after 7 days of initiation of treatment.In intention-to-treat analysis, 6-month survival was not different in the pentoxifylline-prednisolone and placebo-prednisolone groups (69.9% [95% CI, 62.1%-77.7%] vs 69.2% [95% CI; 61.4%-76.9%], P = .91), corresponding to 40 vs 42 deaths, respectively. In multivariable analysis, only the Lille model and the Model for End-Stage Liver Disease score were independently associated with 6-month survival. At 7 days, response to therapy assessed by the Lille model was not significantly different between the 2 groups (Lille model score, 0.41 [95% CI, 0.36-0.46] vs 0.40 [95% CI, 0.35-0.45], P = .80). The probability of being a responder was not different in both groups (62.6% [95% CI, 53.9%-71.3%] vs 61.9% [95% CI, 53.7%-70.3%], P = .91). The cumulative incidence of hepatorenal syndrome at 6 months was not significantly different in the pentoxifylline-prednisolone and the placebo-prednisolone groups (8.4% [95% CI, 4.8%-14.8%] vs 15.3% [95% CI, 10.3%-22.7%], P = .07).In patients with alcoholic hepatitis, 4-week treatment with pentoxifylline and prednisolone, compared with prednisolone alone, did not result in improved 6-month survival. The study may have been underpowered to detect a significant difference in incidence of hepatorenal syndrome, which was less frequent in the group receiving pentoxifylline.clinicaltrials.gov Identifier: NCT01214226.

Albumin infusion improves renal function and survival in cirrhotic patients with spontaneous bacterial peritonitis (SBP) but its efficacy in other types of infections remains unknown. We investigated this issue through a multicenter randomized controlled trial.A total of 193 cirrhotic patients with a Child-Pugh score greater than 8 and sepsis unrelated to SBP were randomly assigned to receive antibiotics plus albumin (1.5 g/kg on day 1 and 1g/kg on day 3; albumin group [ALB]: n=96) or antibiotics alone (control group [CG]: n=97). The primary endpoint was the 3-month renal failure rate (increase in creatinine ⩾50% to reach a final value ⩾133 μmol/L). The secondary endpoint was 3-month survival rate.Forty-seven (24.6%) patients died (ALB: n=27 vs. CG: n=20; 3-month survival: 70.2% vs. 78.3%; p=0.16). Albumin infusion delayed the occurrence of renal failure (mean time to onset, ALB: 29.0 ± 21.8 vs. 11.7 ± 9.1 days, p=0.018) but the 3-month renal failure rate was similar (ALB: 14.3% vs. CG: 13.5%; p=0.88). By multivariate analysis, MELD score (p<0.0001), pneumonia (p=0.0041), hyponatremia (p=0.031) and occurrence of renal failure (p<0.0001) were predictors of death. Of note, pulmonary edema developed in 8/96 (8.3%) patients in the albumin group of whom two died, one on the day and the other on day 33 following albumin infusion.In cirrhotic patients with infections other than SBP, albumin infusion delayed onset of renal failure but did not improve renal function or survival at 3 months. Infusion of large amounts of albumin should be cautiously administered in the sickest cirrhotic patients.

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 & AimsWe performed a meta-analysis of individual patient data from 11 randomized controlled trials comparing corticosteroids, pentoxifylline, or their combination in patients with severe alcoholic hepatitis. We compared the effects of the treatments on survival for 28 days or 6 months, and response to treatment based on the Lille model.MethodsWe searched PubMed for randomized controlled trials of pharmacologic therapy for severe alcoholic hepatitis. Our final analysis comprised 11 studies, of 2111 patients. We performed 4 meta-analyses of the effects of corticosteroids vs placebo or control, corticosteroids vs pentoxifylline, corticosteroids and pentoxifylline vs corticosteroids and placebo or control, and pentoxifylline vs placebo. In each meta-analysis, the effect of treatment on the primary outcome (overall survival at 28 days, defined as the period from the first day of assigned treatment to 28 days) was estimated using a Cox proportional hazards regression model, including trials as random effect.ResultsCorticosteroid treatment significantly decreased risk of death within 28 days compared with controls (hazard ratio [HR] 0.64; 95% confidence interval [CI] 0.48–0.86) or to pentoxifylline (HR 0.64; 95% CI 0.43–0.95). In multiple-imputation and complete case analyses, the effect of corticosteroids compared with controls remained significant. When we compared corticosteroids vs pentoxifylline, the corticosteroid effect remained significant in the complete case analysis (HR 0.66; P = .04) but not in multiple-imputation analysis (HR 0.71; P = .08). There was no difference in 28-day mortality when patients were given a combination of corticosteroids and pentoxifylline vs corticosteroids alone or between patients given pentoxifylline vs control. In our analysis of secondary outcomes, we found no significant differences in 6-month mortality when any treatments or controls were compared. Corticosteroids were significantly associated with increased response to therapy compared with controls (relative risk 1.24; 95% CI 1.10–1.41) or pentoxifylline (relative risk 1.43; 95% CI 1.20–1.68). We found no difference in response to therapy between patients given a combination of corticosteroids and pentoxifylline vs corticosteroids alone or pentoxifylline vs controls.ConclusionsIn a meta-analysis of 4 controlled trials, we found corticosteroid use to reduce risk of death within 28 days of treatment, but not in the following 6 months. This loss of efficacy over time indicates a need for new therapeutic strategies to improve medium-term outcomes. We performed a meta-analysis of individual patient data from 11 randomized controlled trials comparing corticosteroids, pentoxifylline, or their combination in patients with severe alcoholic hepatitis. We compared the effects of the treatments on survival for 28 days or 6 months, and response to treatment based on the Lille model. We searched PubMed for randomized controlled trials of pharmacologic therapy for severe alcoholic hepatitis. Our final analysis comprised 11 studies, of 2111 patients. We performed 4 meta-analyses of the effects of corticosteroids vs placebo or control, corticosteroids vs pentoxifylline, corticosteroids and pentoxifylline vs corticosteroids and placebo or control, and pentoxifylline vs placebo. In each meta-analysis, the effect of treatment on the primary outcome (overall survival at 28 days, defined as the period from the first day of assigned treatment to 28 days) was estimated using a Cox proportional hazards regression model, including trials as random effect. Corticosteroid treatment significantly decreased risk of death within 28 days compared with controls (hazard ratio [HR] 0.64; 95% confidence interval [CI] 0.48–0.86) or to pentoxifylline (HR 0.64; 95% CI 0.43–0.95). In multiple-imputation and complete case analyses, the effect of corticosteroids compared with controls remained significant. When we compared corticosteroids vs pentoxifylline, the corticosteroid effect remained significant in the complete case analysis (HR 0.66; P = .04) but not in multiple-imputation analysis (HR 0.71; P = .08). There was no difference in 28-day mortality when patients were given a combination of corticosteroids and pentoxifylline vs corticosteroids alone or between patients given pentoxifylline vs control. In our analysis of secondary outcomes, we found no significant differences in 6-month mortality when any treatments or controls were compared. Corticosteroids were significantly associated with increased response to therapy compared with controls (relative risk 1.24; 95% CI 1.10–1.41) or pentoxifylline (relative risk 1.43; 95% CI 1.20–1.68). We found no difference in response to therapy between patients given a combination of corticosteroids and pentoxifylline vs corticosteroids alone or pentoxifylline vs controls. In a meta-analysis of 4 controlled trials, we found corticosteroid use to reduce risk of death within 28 days of treatment, but not in the following 6 months. This loss of efficacy over time indicates a need for new therapeutic strategies to improve medium-term outcomes.

Understanding the mechanisms of outcome according to the time frame can help optimize the therapeutic development in severe alcoholic hepatitis. We assessed short-term and long-term survival in severe alcoholic hepatitis based on baseline disease severity, extent of therapeutic improvement, long-term influence of alcohol relapse, and their interaction. Data and alcohol consumption were prospectively recorded in 398 patients treated with corticosteroids in the short term (from corticosteroid initiation to 6 months) and long term (from 6 months to maximum follow-up time). Cumulative incidence rate of first alcohol relapse was 25.2%, 33.7%, and 35.2% at 1, 3, and 5 years, respectively. Alcohol relapse (≥30 g/day) was not associated with mortality (P = 0.24) during the short-term period (1,606 patient-months at risk), but the Lille (P < 0.0001) and Model for End-Stage Liver Disease (P < 0.0001) scores were independent prognostic factors. In patients who were alive at 6 months (median follow-up, 42 months; interquartile range 11-88), corresponding to 10,413 patient-months at risk, alcohol consumption (≥30 g/day) was associated with mortality (hazard ratio, 3.9; P < 0.0001). Additional analysis with abstinent patients as a reference showed a dose effect of alcohol on the hazard ratio of death: 2.36 (P = 0.052) for 1-29 g/day, 3.2 (P = 0.003) for 30-49 g/day, 3.51 (P < 0.0001) for 50-99 g/day, and 5.61 (P < 0.0001) for ≥ 100 g/day. The baseline Model for End-Stage Liver Disease score was not predictive of long-term outcome, while Lille score (P = 0.02) and alcohol relapse (P < 0.0001) were independent prognostic factors.This study shows that new therapeutic development for severe alcoholic hepatitis must target liver injury in the short term and alcohol consumption in the long term; thus, health agencies can endorse future study designs adapted to the time frame of factors influencing mortality; with this in mind, drug-targeting mechanisms involved in liver injury should only be tested for the short-term period. (Hepatology 2017;66:1464-1473).

The degree of cholestasis is an important disease driver in alcoholic hepatitis, a severe clinical condition that needs new biomarkers and targeted therapies. We aimed to identify the largely unknown mechanisms and biomarkers linked to cholestasis in alcoholic hepatitis.Herein, we analyzed a well characterized cohort of patients with alcoholic hepatitis and correlated clinical and histological parameters and outcomes with serum bile acids and fibroblast growth factor 19 (FGF19), a major regulator of bile acid synthesis.We found that total and conjugated bile acids were significantly increased in patients with alcoholic hepatitis compared with controls. Serum FGF19 levels were strongly increased and gene expression of FGF19 was induced in biliary epithelial cells and ductular cells of patients with alcoholic hepatitis. De novo bile acid synthesis (CYP7A1 gene expression and C4 serum levels) was significantly decreased in patients with alcoholic hepatitis. Importantly, total and conjugated bile acids correlated positively with FGF19 and with disease severity (model for end-stage liver disease score). FGF19 correlated best with conjugated cholic acid, and model for end-stage liver disease score best with taurine-conjugated chenodeoxycholic acid. Univariate analysis demonstrated significant associations between FGF19 and bilirubin as well as gamma glutamyl transferase, and negative correlations between FGF19 and fibrosis stage as well as polymorphonuclear leukocyte infiltration, in all patients with alcoholic hepatitis.Serum FGF19 and bile acids are significantly increased in patients with alcoholic hepatitis, while de novo bile acid synthesis is suppressed. Modulation of bile acid metabolism or signaling could represent a promising target for treatment of alcoholic hepatitis in humans.Understanding the underlying mechanisms that drive alcoholic hepatitis is important for the development of new biomarkers and targeted therapies. Herein, we describe a molecule that is increased in patients with alcoholic hepatitis. Modulating the molecular pathway of this molecule might lead to promising targets for the treatment of alcoholic hepatitis.

Alcoholic hepatitis (AH) is a life-threatening condition characterized by profound hepatocellular dysfunction for which targeted treatments are urgently needed. Identification of molecular drivers is hampered by the lack of suitable animal models. By performing RNA sequencing in livers from patients with different phenotypes of alcohol-related liver disease (ALD), we show that development of AH is characterized by defective activity of liver-enriched transcription factors (LETFs). TGFβ1 is a key upstream transcriptome regulator in AH and induces the use of HNF4α P2 promoter in hepatocytes, which results in defective metabolic and synthetic functions. Gene polymorphisms in LETFs including HNF4α are not associated with the development of AH. In contrast, epigenetic studies show that AH livers have profound changes in DNA methylation state and chromatin remodeling, affecting HNF4α-dependent gene expression. We conclude that targeting TGFβ1 and epigenetic drivers that modulate HNF4α-dependent gene expression could be beneficial to improve hepatocellular function in patients with AH.

Early liver transplantation for severe alcohol-related hepatitis is an emerging treatment option. We aimed to assess the risk of alcohol relapse 2 years after early liver transplantation for alcohol-related hepatitis compared with liver transplantation for alcohol-related cirrhosis after at least 6 months of abstinence.We conducted a multicentre, non-randomised, non-inferiority, controlled study in 19 French and Belgian hospitals. All participants were aged 18 years or older. There were three groups of patients recruited prospectively: patients with severe alcohol-related hepatitis who did not respond to medical treatment and were eligible for early liver transplantation according to a new selection scoring system based on social and addiction items that can be quantified in points (early transplantation group); patients with alcohol-related cirrhosis listed for liver transplantation after at least 6 months of abstinence (standard transplantation group); patients with severe alcohol-related hepatitis not responding to medical treatment not eligible for early liver transplantation according to the selection score (not eligible for early transplantation group), this group did not enter any further liver transplantation processes. We also defined a historical control group of patients with severe alcohol-related hepatitis unresponsive to medical therapy and non-transplanted. The primary outcome was the non-inferiority of 2-year rate of alcohol relapse after transplantation in the early transplantation group compared with the standard transplantation group using the alcohol timeline follow back (TLFB) method and a prespecified non-inferiority margin of 10%. Secondary outcomes were the pattern of alcohol relapse, 2-year survival rate post-transplant in the early transplantation group compared with the standard transplantation group, and 2-year overall survival in the early transplantation group compared with patients in the not eligible for early transplantation group and historical controls. This trial is registered with ClinicalTrials.gov, NCT01756794.Between Dec 5, 2012, and June 30, 2016, we included 149 patients with severe alcohol-related hepatitis: 102 in the early transplantation group and 47 in the not eligible for early transplantation group. 129 patients were included in the standard transplantation group. 68 patients in the early transplantation group and 93 patients in the standard transplantation group received a liver transplant. 23 (34%) patients relapsed in the early transplantation group, and 23 (25%) patients relapsed in the standard transplantation group; therefore, the non-inferiority of early transplantation versus standard transplantation was not demonstrated (absolute difference 9·1% [95% CI -∞ to 21·1]; p=0·45). The 2-year rate of high alcohol intake was greater in the early transplantation group than the standard transplantation group (absolute difference 16·7% [95% CI 5·8-27·6]) The time spent drinking alcohol was not different between the two groups (standardised difference 0·24 [95% CI -0·07 to 0·55]), but the time spent drinking a large quantity of alcohol was higher in the early transplantation group than the standard transplantation group (standardised difference 0·50 [95% CI 0·17-0·82]). 2-year post-transplant survival was similar between the early transplantation group and the standard transplantation group (hazard ratio [HR] 0·87 [95% CI 0·33-2·26]); 2-year overall survival was higher in the early transplantation group than the not eligible for early transplantation group and historical controls (HR 0·27 [95% CI 0·16-0·47] and 0·21 [0·13-0·32]).We cannot conclude non-inferiority in terms of rate of alcohol relapse post-transplant between early liver transplantation and standard transplantation. High alcohol intake is more frequent after early liver transplantation. This prospective controlled study confirms the important survival benefit related to early liver transplantation for severe alcohol-related hepatitis; and this study provides objective data on survival and alcohol relapse to tailor the management of patients with severe alcohol-related hepatitis.The present study has been granted by the French Ministry of Health-Programme Hospitalier de Recherche Clinique 2010.

The harmful impact of heavy alcohol consumption and recurrence in patients with alcohol-related cirrhosis is long-established, although this is based on old studies. However, the drivers of long-term outcome still need to be clearly investigated.All patients with biopsy-proven compensated alcohol-related cirrhosis included in the CIRRAL cohort (22 centers) were prospectively studied. Prognostic variables of survival and liver event-free survival were assessed using multivariable Cox models with stepwise selection. The prognostic impact of alcohol recurrence during follow-up (computed in glass-years in the same way as pack-years for tobacco) was assessed using a time-dependent covariable.From 2010 to 2016, 650 patients were included. The median age at baseline was 58.4 years, 67.4% were men and the median BMI was 27.8 kg/m2, 63.8% had a history of liver decompensation, and 70.2% had discontinued alcohol. At 5 years, recurrence occurred in 30.9% of abstinent patients and this risk was higher in patients with a history of drug abuse and in those with shorter alcohol discontinuation times. Median survival was 97 months. Age, alcohol consumption at baseline, platelet count and Child-Pugh score >5 were associated with overall and liver event-free survival on multivariate analysis. Alcohol consumption of more than 25 glass-years during follow-up was independently associated with lower survival and with a trend toward lower liver event-free survival, with the risk increasing from 1 glass-year, though not significantly. Simon & Makuch plots confirm the benefit of no alcohol consumption (<1 glass/week) on both outcomes and the dose-dependent impact of alcohol over time.This prospective study in patients with compensated alcohol-related cirrhosis identifies factors predictive of alcohol recurrence during follow-up and shows that moderate alcohol consumption during follow-up negatively impacts outcomes. Patients with alcohol-related cirrhosis should be advised to completely stop drinking alcohol.CIRRAL (NCT01213927) cohort was registered at ClinicalTrials.gov and the full protocol is available at the following link: https://clinicaltrials.gov/ct2/show/NCT01213927.In patients with alcohol-related cirrhosis, data are lacking about the impact of the amount of alcohol consumed on both survival and liver-related events. The present study based on the CIRRAL cohort demonstrates that alcohol recurrence occurs in more than 30% of patients with compensated cirrhosis and that even a moderate recurrence strongly influences outcomes. Patients with compensated alcohol-related cirrhosis should be advised to completely discontinue alcohol consumption, even in small amounts, as the present study shows that no alcohol consumption can be regarded as safe when cirrhosis has developed.

•HCC risk stratification will ultimately enable refinement of surveillance strategies in patients with cirrhosis. •Universal scoring systems based on routine parameters may currently be applied regardless of the cause of liver disease. •Seven genetic variants can be combined into a genetic risk score for HCC in patients in surveillance programs. •The addition of this genetic information to clinical scoring systems modestly improves their performance for risk stratification. Background & Aims Identifying individuals at higher risk of developing hepatocellular carcinoma (HCC) is pivotal to improve the performance of surveillance strategies. Herein, we aimed to evaluate the ability of single nucleotide polymorphisms (SNPs) to refine HCC risk stratification. Methods Six SNPs in PNPLA3, TM6SF2, HSD17B13, APOE, and MBOAT7 affecting lipid turnover and one variant involved in the Wnt–β-catenin pathway (WNT3A-WNT9A rs708113) were assessed in patients with alcohol-related and/or HCV-cured cirrhosis included in HCC surveillance programmes (prospective CirVir and CIRRAL cohorts). Their prognostic value for HCC occurrence was assessed using Fine-Gray models combined into a 7-SNP genetic risk score (GRS). The predictive ability of two clinical scores (a routine non-genetic model determined by multivariate analysis and the external aMAP score) with/without the GRS was evaluated by C-indices. The standardised net benefit was derived from decision curves. Results Among 1,145 patients, 86 (7.5%) developed HCC after 43.7 months. PNPLA3 and WNT3A-WNT9A variants were independently associated with HCC occurrence. The GRS stratified the population into three groups with progressively increased 5-year HCC incidence (Group 1 [n = 627, 5.4%], Group 2 [n = 276, 10.7%], and Group 3 [n = 242, 15.3%]; p <0.001). The multivariate model identified age, male sex, diabetes, platelet count, gamma-glutamyltransferase levels, albuminemia and the GRS as independent risk factors. The clinical model performance for 5-year HCC prediction was similar to that of the aMAP score (C-Index 0.769). The addition of the GRS to both scores modestly improved their performance (C-Indices of 0.786 and 0.783, respectively). This finding was confirmed by decision curve analyses showing only fair clinical net benefit. Conclusions Patients with cirrhosis can be stratified into HCC risk classes by variants affecting lipid turnover and the Wnt–β-catenin pathway. The incorporation of this genetic information modestly improves the performance of clinical scores. Impact and implications The identification of patients at higher risk of developing liver cancer is pivotal to improve the performance of surveillance. Risk assessment can be achieved by combining several clinical and biological parameters used in routine practice. The addition of patients’ genetic characteristics can modestly improve this prediction and will ultimately pave the way for precision medicine in patients eligible for HCC surveillance, allowing physicians to trigger personalised screening strategies. Identifying individuals at higher risk of developing hepatocellular carcinoma (HCC) is pivotal to improve the performance of surveillance strategies. Herein, we aimed to evaluate the ability of single nucleotide polymorphisms (SNPs) to refine HCC risk stratification. Six SNPs in PNPLA3, TM6SF2, HSD17B13, APOE, and MBOAT7 affecting lipid turnover and one variant involved in the Wnt–β-catenin pathway (WNT3A-WNT9A rs708113) were assessed in patients with alcohol-related and/or HCV-cured cirrhosis included in HCC surveillance programmes (prospective CirVir and CIRRAL cohorts). Their prognostic value for HCC occurrence was assessed using Fine-Gray models combined into a 7-SNP genetic risk score (GRS). The predictive ability of two clinical scores (a routine non-genetic model determined by multivariate analysis and the external aMAP score) with/without the GRS was evaluated by C-indices. The standardised net benefit was derived from decision curves. Among 1,145 patients, 86 (7.5%) developed HCC after 43.7 months. PNPLA3 and WNT3A-WNT9A variants were independently associated with HCC occurrence. The GRS stratified the population into three groups with progressively increased 5-year HCC incidence (Group 1 [n = 627, 5.4%], Group 2 [n = 276, 10.7%], and Group 3 [n = 242, 15.3%]; p <0.001). The multivariate model identified age, male sex, diabetes, platelet count, gamma-glutamyltransferase levels, albuminemia and the GRS as independent risk factors. The clinical model performance for 5-year HCC prediction was similar to that of the aMAP score (C-Index 0.769). The addition of the GRS to both scores modestly improved their performance (C-Indices of 0.786 and 0.783, respectively). This finding was confirmed by decision curve analyses showing only fair clinical net benefit. Patients with cirrhosis can be stratified into HCC risk classes by variants affecting lipid turnover and the Wnt–β-catenin pathway. The incorporation of this genetic information modestly improves the performance of clinical scores.

Importance The benefits of prophylactic antibiotics for hospitalized patients with severe alcohol-related hepatitis are unclear. Objective To determine the efficacy of amoxicillin-clavulanate, compared with placebo, on mortality in patients hospitalized with severe alcohol-related hepatitis and treated with prednisolone. Design, Setting, and Participants Multicenter, randomized, double-blind clinical trial among patients with biopsy-proven severe alcohol-related hepatitis (Maddrey function score ≥32 and Model for End-stage Liver Disease [MELD] score ≥21) from June 13, 2015, to May 24, 2019, in 25 centers in France and Belgium. All patients were followed up for 180 days. Final follow-up occurred on November 19, 2019. Intervention Patients were randomly assigned (1:1 allocation) to receive prednisolone combined with amoxicillin-clavulanate (n = 145) or prednisolone combined with placebo (n = 147). Main Outcome and Measures The primary outcome was all-cause mortality at 60 days. Secondary outcomes were all-cause mortality at 90 and 180 days; incidence of infection, incidence of hepatorenal syndrome, and proportion of participants with a MELD score less than 17 at 60 days; and proportion of patients with a Lille score less than 0.45 at 7 days. Results Among 292 randomized patients (mean age, 52.8 [SD, 9.2] years; 80 [27.4%] women) 284 (97%) were analyzed. There was no significant difference in 60-day mortality between participants randomized to amoxicillin-clavulanate and those randomized to placebo (17.3% in the amoxicillin-clavulanate group and 21.3% in the placebo group [ P = .33]; between-group difference, −4.7% [95% CI, −14.0% to 4.7%]; hazard ratio, 0.77 [95% CI, 0.45-1.31]). Infection rates at 60 days were significantly lower in the amoxicillin-clavulanate group (29.7% vs 41.5%; mean difference, −11.8% [95% CI, −23.0% to −0.7%]; subhazard ratio, 0.62; [95% CI, 0.41-0.91]; P = .02). There were no significant differences in any of the remaining 3 secondary outcomes. The most common serious adverse events were related to liver failure (25 in the amoxicillin-clavulanate group and 20 in the placebo group), infections (23 in the amoxicillin-clavulanate group and 46 in the placebo group), and gastrointestinal disorders (15 in the amoxicillin-clavulanate group and 21 in the placebo group). Conclusion and Relevance In patients hospitalized with severe alcohol-related hepatitis, amoxicillin-clavulanate combined with prednisolone did not improve 2-month survival compared with prednisolone alone. These results do not support prophylactic antibiotics to improve survival in patients hospitalized with severe alcohol-related hepatitis. Trial Registration ClinicalTrials.gov Identifier: NCT02281929

The long-term impact of alcohol-related public health policies (PHPs) on disease burden is unclear. We aimed to assess the association between alcohol-related PHPs and alcohol-related health consequences.We conducted an ecological multi-national study including 169 countries. We collected data on alcohol-related PHPs from the WHO Global Information System of Alcohol and Health 2010. Data on alcohol-related health consequences between 2010-2019 were obtained from the Global Burden of Disease database. We classified PHPs into five items, including criteria for low, moderate, and strong PHP establishment. We estimated an alcohol preparedness index (API) using multiple correspondence analysis (0 lowest and 100 highest establishment). We estimated an incidence rate ratio (IRR) for outcomes according to API using adjusted multilevel generalized linear models with a Poisson family distribution.The median API in the 169 countries was 54 [IQR 34.9-76.8]. The API was inversely associated with alcohol use disorder (AUD) prevalence (IRR 0.13; 95% CI 0.03-0.60; p = 0.010), alcohol-associated liver disease (ALD) mortality (IRR 0.14; 95% CI 0.03-0.79; p = 0.025), mortality due to neoplasms (IRR 0.09; 95% CI 0.02-0.40; p = 0.002), alcohol-attributable hepatocellular carcinoma (HCC) (IRR 0.13; 95% CI 0.02-0.65; p = 0.014), and cardiovascular diseases (IRR 0.09; 95% CI 0.02-0.41; p = 0.002). The highest associations were observed in the Americas, Africa, and Europe. These associations became stronger over time, and AUD prevalence was significantly lower after 2 years, while ALD mortality and alcohol-attributable HCC incidence decreased after 4 and 8 years from baseline API assessment, respectively (p <0.05).The API is a valuable instrument to quantify the robustness of alcohol-related PHP establishment. Lower AUD prevalence and lower mortality related to ALD, neoplasms, alcohol-attributable HCC, and cardiovascular diseases were observed in countries with a higher API. Our results encourage the development and strengthening of alcohol-related policies worldwide.We first developed an alcohol preparedness index, an instrument to assess the existence of alcohol-related public policies for each country. We then evaluated the long-term association of the country's alcohol preparedness index in 2010 with the burden of chronic liver disease, hepatocellular carcinoma, other neoplasms, and cardiovascular disease. The strengthening of alcohol-related public health policies could impact long-term mortality rates from cardiovascular disease, neoplasms, and liver disease. These conditions are the main contributors to the global burden of disease related to alcohol use. Over time, this association has not only persisted but also grown stronger. Our results expand the preliminary evidence regarding the importance of public health policies in controlling alcohol-related health consequences.

Myxomatous mitral valve disease (MMVD) continues to be an important cause of morbidity and mortality in geriatric dogs despite conventional therapy.Pimobendan in addition to conventional therapy will extend time to sudden cardiac death, euthanasia for cardiac reasons, or treatment failure when compared with conventional therapy plus benazepril in dogs with congestive heart failure (CHF) attributable to MMVD.Two hundred and sixty client-owned dogs in CHF caused by MMVD were recruited from 28 centers in Europe, Canada, and Australia.A prospective single-blinded study with dogs randomized to PO receive pimobendan (0.4-0.6 mg/kg/d) or benazepril hydrochloride (0.25-1.0 mg/kg/d). The primary endpoint was a composite of cardiac death, euthanized for heart failure, or treatment failure.Eight dogs were excluded from analysis. One hundred and twenty-four dogs were randomized to pimobendan and 128 to benazepril. One hundred and ninety dogs reached the primary endpoint; the median time was 188 days (267 days for pimobendan, 140 days for benazepril hazard ratio = 0.688, 95% confidence limits [CL]=0.516-0.916, P= .0099). The benefit of pimobendan persisted after adjusting for all baseline variables. A longer time to reach the endpoint was also associated with being a Cavalier King Charles Spaniel, requiring a lower furosemide dose, and having a higher creatinine concentration. Increases in several indicators of cardiac enlargement (left atrial to aortic root ratio, vertebral heart scale, and percentage increase in left ventricular internal diameter in systole) were associated with a shorter time to endpoint, as was a worse tolerance for exercise.Pimobendan plus conventional therapy prolongs time to sudden death, euthanasia for cardiac reasons, or treatment failure in dogs with CHF caused by MMVD compared with benazepril plus conventional therapy.

Obesity-associated inflammation is of critical importance in the development of insulin resistance and non-alcoholic fatty liver disease. Since the cannabinoid receptor CB2 regulates innate immunity, the aim of the present study was to investigate its role in obesity-induced inflammation, insulin resistance and fatty liver.Murine obesity models included genetically leptin-deficient ob/ob mice and wild type (WT) mice fed a high fat diet (HFD), that were compared to their lean counterparts. Animals were treated with pharmacological modulators of CB2 receptors. Experiments were also performed in mice knock-out for CB2 receptors (Cnr2 -/-).In both HFD-fed WT mice and ob/ob mice, Cnr2 expression underwent a marked induction in the stromal vascular fraction of epididymal adipose tissue that correlated with increased fat inflammation. Treatment with the CB2 agonist JWH-133 potentiated adipose tissue inflammation in HFD-fed WT mice. Moreover, cultured fat pads isolated from ob/ob mice displayed increased Tnf and Ccl2 expression upon exposure to JWH-133. In keeping, genetic or pharmacological inactivation of CB2 receptors decreased adipose tissue macrophage infiltration associated with obesity, and reduced inductions of Tnf and Ccl2 expressions. In the liver of obese mice, Cnr2 mRNA was only weakly induced, and CB2 receptors moderately contributed to liver inflammation. HFD-induced insulin resistance increased in response to JWH-133 and reduced in Cnr2 -/- mice. Finally, HFD-induced hepatic steatosis was enhanced in WT mice treated with JWH-133 and blunted in Cnr2 -/- mice.These data unravel a previously unrecognized contribution of CB2 receptors to obesity-associated inflammation, insulin resistance and non-alcoholic fatty liver disease, and suggest that CB2 receptor antagonists may open a new therapeutic approach for the management of obesity-associated metabolic disorders.

In severe alcoholic hepatitis (AH), 40% of patients will obtain no benefit from corticosteroids. Improvement in management of non-responders is warranted and only pentoxifylline can be considered an alternative. A two-step strategy was evaluated consisting of early withdrawal of corticosteroids and a switch to pentoxifylline for 28 additional days in non-responders identified using early change in bilirubin level.One hundred and twenty-one patients with AH were treated prospectively with corticosteroids, and the two-step strategy was proposed to 29 non-responders treated according to a two-step strategy who were compared to 58 matched non-responders treated with corticosteroids only.Clinical and biological features of the two groups were similar. There was no survival improvement at 2 months in patients treated with the two-step strategy compared to controls: 35.5+/-6.3% vs 31+/-8.6%. After 21 days, biological evolution was similar for prothrombin time (-0.25s vs +0.2s), bilirubin (0.8 mg/dl vs 2.03 mg/dl) and creatinine (+0.16 mg/dl vs -0.7 mg/dl). In multivariate analysis, only age, evolution of bilirubin during the first week, creatinine and DF were associated with 2-month survival.Non-responders to corticosteroids do not obtain any benefit from an early switch to pentoxifylline. Thus, the issue of management of non-responders remains unresolved.

Several models have been used to determine prognoses of patients with alcoholic hepatitis. These include static systems (the Maddrey discriminant function; age, bilirubin, international normalized ratio, creatinine [ABIC] score; and model for end-stage liver disease [MELD] score) and dynamic models (the Lille model). We aimed to combine features of all of these models to develop a better method to predict outcomes of patients with alcoholic hepatitis.We collected data from several databases of patients with severe alcoholic hepatitis treated with corticosteroids in France and the United Kingdom to create a model to predict patient survival (derivation cohort, n = 538 patients). We compared the performances of 3 joint-effect models (Maddrey+Lille, MELD+Lille, and ABIC+Lille) to determine which combination had the best prognostic value, based on known patient outcomes. The model was validated using data from trials of the effects of corticosteroids in patients in the United States, France, Korea, and Belgium (n = 604 patients).We created a joint-effect model to predict patient survival after 2 and 6 months; in the derivation and validation cohorts it predicted outcome significantly better than either static or dynamic models alone (P < .01 for all comparisons). The joint model accurately predicted patient survival regardless of patient risk level. The MELD+Lille combination was better than the Maddrey+Lille or ABIC+Lille combination in predicting patient survival, with Akaike information criterion values of 1305, 1313, and 1312, respectively. For example, based on the MELD+Lille combination model, the predicted 6-month mortality of complete responders with MELD scores of 15-45 (Lille score, 0.16) was 8.5% to 49.7%, compared with 16.4%-75.2% for nonresponders (Lille score, 0.45). According to the joint-effect model, for 2 patients with the same baseline MELD score of 21, the patient with a Lille score of 0.45 had a 1.9-fold higher risk of death than the patient with a Lille score of 0.16 (23.7% vs 12.5%).By combining results from static and dynamic scoring systems for liver disease, we can better predict outcomes of patients with alcoholic hepatitis, compared with either model alone. This may help patient management and design of clinical trials.

Background & Aims: In severely obese patients, factors implicated in the evolution of severe steatosis after bariatric surgery remain unresolved. Our aim was to determine whether insulin resistance (IR) influences the histologic effects induced by bariatric surgery. Methods: We prospectively included 185 severely obese patients (body mass index ≥35 kg/m2) referred for bariatric surgery. The evolution of IR (IR index = 1/quantitative insulin sensitivity check index) and liver injury with consecutive biopsy was concomitantly assessed before and 1 year after surgery. Results: At preoperative biopsy, 27% of severely obese patients disclosed severe steatosis (≥60%). The alanine aminotransferase (P = .01) and IR indexes (P = .04) were independent predictive factors of severe steatosis at baseline. One year after surgery, surgical treatment induced a decrease in body mass index (9.5 kg/m2; P < .0001), steatosis score (8.5%; P < .0001), and IR index (0.29; P < .0001). The preoperative IR index (P = .01) and preoperative steatosis (P = .006) were independent predictive factors in the persistence of severe steatosis after surgery. Moderate or severe steatosis was more frequently observed in patients who had conserved a higher IR index after surgery than in patients who had improved their IR index (44% vs 20.2%; P = .04). Conclusions:: IR was independently associated with severe steatosis and predicted its persistence after surgery. The amelioration of IR after surgery is associated with a decrease in the amount of fat. Taken together, the results of this prospective study in severely obese patients demonstrate that severe steatosis and its evolution after surgery are intimately connected with IR. Background & Aims: In severely obese patients, factors implicated in the evolution of severe steatosis after bariatric surgery remain unresolved. Our aim was to determine whether insulin resistance (IR) influences the histologic effects induced by bariatric surgery. Methods: We prospectively included 185 severely obese patients (body mass index ≥35 kg/m2) referred for bariatric surgery. The evolution of IR (IR index = 1/quantitative insulin sensitivity check index) and liver injury with consecutive biopsy was concomitantly assessed before and 1 year after surgery. Results: At preoperative biopsy, 27% of severely obese patients disclosed severe steatosis (≥60%). The alanine aminotransferase (P = .01) and IR indexes (P = .04) were independent predictive factors of severe steatosis at baseline. One year after surgery, surgical treatment induced a decrease in body mass index (9.5 kg/m2; P < .0001), steatosis score (8.5%; P < .0001), and IR index (0.29; P < .0001). The preoperative IR index (P = .01) and preoperative steatosis (P = .006) were independent predictive factors in the persistence of severe steatosis after surgery. Moderate or severe steatosis was more frequently observed in patients who had conserved a higher IR index after surgery than in patients who had improved their IR index (44% vs 20.2%; P = .04). Conclusions:: IR was independently associated with severe steatosis and predicted its persistence after surgery. The amelioration of IR after surgery is associated with a decrease in the amount of fat. Taken together, the results of this prospective study in severely obese patients demonstrate that severe steatosis and its evolution after surgery are intimately connected with IR. Obesity is associated with severe complications such as arterial hypertension, diabetes, coronary heart disease, stroke, sleep apnea, and peripheral vascular disease.1Keller K.B. Lemberg L. Obesity and the metabolic syndrome.J Crit Care. 2003; 12: 167-170Google Scholar Obesity is also the most frequently reported epidemiologic condition associated with nonalcoholic fatty liver disease (NAFLD).2Neuschwander-Tetri B.A. Caldwell S.H. Nonalcoholic steatohepatitis summary of an AASLD single topic conference.Hepatology. 2003; 37: 1202-1219Crossref PubMed Scopus (1796) Google Scholar, 3Wanless I. Lentz J. Fatty liver hepatitis (steatohepatitis) and obesity an autopsy study with analysis of risk factors.Hepatology. 1990; 12: 1106-1110Crossref PubMed Scopus (1066) Google Scholar In patients with NAFLD, it has been shown that nonalcoholic steatohepatitis (NASH) constitutes the main lesion associated with a high risk of occurrence of cirrhosis.4Lee R.G. Nonalcoholic steatohepatitis a study of 49 patients.Hum Pathol. 1989; 20: 594-598Abstract Full Text PDF PubMed Scopus (505) Google Scholar, 5Teli M.R. James O.F. Burt A.D. Bennett M.K. Day C.P. 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In this subgroup, surgical treatment of obesity improves quality of life and decreases short-term morbidity,20Kral J.G. Sjostrom L.V. Sullivan M.B. Assessment of quality of life before and after surgery for severe obesity.Am J Clin Nutr. 1992; 55: 611S-614SPubMed Scopus (142) Google Scholar, 21O’Brien P.E. Dixon J.B. Brown W. Schachter L.M. Chapman L. Burn A.J. Dixon M.E. Scheinkestel C. Halket C. Sutherland L.J. Korin A. Baquie P. The laparoscopic adjustable gastric band (Lap-Band) a prospective study of medium-term effects on weight, health and quality of life.Obes Surg. 2002; 12: 652-660Crossref PubMed Scopus (332) Google Scholar, 22Sjostrom C.D. Lissner L. Wedel H. Sjostrom L. Reduction in incidence of diabetes, hypertension and lipid disturbances after intentional weight loss induced by bariatric surgery the SOS Intervention Study.Obes Res. 1999; 7: 477-484Crossref PubMed Scopus (548) Google Scholar, 23Torgerson J.S. 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Sanjuan J.C. Herrera L. Hernanz F. Martino E. Casafont F. Gomez Fleitas M. Liver transplantation in a case of steatohepatitis and subacute hepatic failure after biliopancreatic diversion for morbid obesity.Obes Surg. 2001; 11: 640-642Crossref PubMed Scopus (59) Google Scholar, 36Grimm I.S. Schindler W. Haluszka O. Steatohepatitis and fatal hepatic failure after biliopancreatic diversion.Am J Gastroenterol. 1992; 87: 775-779PubMed Google Scholar, 37Hamilton D.L. Vest T.K. Brown B.S. Shah A.N. Menguy R.B. Chey W.Y. Liver injury with alcoholic like hyalin after gastroplasty for morbid obesity.Gastroenterology. 1983; 85: 722-726PubMed Google Scholar Studies focusing on the prospective evaluation of obese patients treated by bariatric surgery constitute an important information source in NAFLD. Indeed, this approach avoids the usual bias of selection observed in studies from cohorts of patients referred to a hepatology unit for liver biopsy. A previous study of severely obese patients treated by bariatric surgery showed that IR is a key factor in the development of liver injury before surgery.38Dixon J.B. Bhathal P.S. O’Brien P.E. Nonalcoholic fatty liver disease predictors of nonalcoholic steatohepatitis and liver fibrosis in the severely obese.Gastroenterology. 2001; 121: 91-100Abstract Full Text PDF PubMed Scopus (1160) Google Scholar That study did not concurrently evaluate the evolution of IR and liver injury with consecutive biopsy. Therefore, the effect of IR on improvement of severe steatosis after weight loss induced by bariatric surgery remains unsettled. A recent study observed that bariatric surgery seems to have a beneficial effect on histologic features of NASH.39Dixon J.B. Bhathal P.S. Hughes N.R. O’Brien P.E. Nonalcoholic fatty liver disease improvement in liver histological analysis with weight loss.Hepatology. 2004; 39: 1647-1654Crossref PubMed Scopus (653) Google Scholar That study had the classic bias of selection, because consecutive biopsies were performed in only 36 of the 197 patients treated by bariatric surgery. Therefore, studies with a prospective design of a histologic survey are needed. We focused on the role of IR in obesity-induced liver injury after bariatric surgery to gain additional insight into the pathogenesis of NAFLD. Thus, this is the first prospective study on a large cohort of unselected severely obese patients that concurrently evaluated both the evolution of liver injury using sequential biopsies and IR before and 1 year after surgery. Between 1994 and 2003, 185 severely to morbidly obese patients were referred to our unit for surgical treatment of obesity. To be eligible for the study, all patients had to have fulfilled the following criteria: (1) severe obesity (BMI ≥35 kg/m2) with comorbidity/comorbidities or morbid obesity alone (BMI ≥40 kg/m2) for at least 5 years and resistance to medical treatment; (2) the absence of medical or psychological contraindications for bariatric surgery; (3) the absence of current excessive drinking, as defined by an average daily consumption of alcohol of <20 g/day for women and <30 g/day for men, and no history of past excessive drinking for a period longer than 2 years at any time in the past 20 years; (4) the absence of long-term consumption of hepatotoxic drugs; and (5) negative screening for chronic liver diseases, including negative testing for hepatitis B surface antigen and hepatitis C virus antibodies; negative testing for antinuclear, anti–smooth muscle actin, anti–liver-kidney microsomes, and antimitochondrial antibodies; no evidence of genetic hemochromatosis; and normal ceruloplasmin and α1-antitrypsin serum levels. The surgeon examined all patients and explained in detail the biliointestinal bypass and gastric band surgical procedures (standardized information). Body weight and height were measured. BMI was calculated as weight (kilograms) divided by height (meters) squared. BMI was calculated before and 1 year after surgery. When surgery was planned, patients were free to choose the surgical procedure. Informed written consent was obtained from all patients, and the study was conducted in conformity with the Helsinki Declaration. The biliointestinal bypass described by Eriksson consisted of jejunoileostomy coupled with cholecystojejunal anastomosis.40Eriksson F. Biliointestinal bypass.Int J Obes. 1981; 5: 437-447PubMed Google Scholar The second bariatric procedure consisted of an adjustable gastric band inserted by laparoscopy (Lap-Band System; INAMED Health, Santa Barbara, CA). All patients who underwent a biliointestinal bypass were submitted to treatment consisting of calcium, vitamins, and metronidazole 15 days per month after surgery. The following biologic features were assessed prospectively before and 1 year after surgery: alanine aminotransferase (ALT) level, γ-glutamyltransferase (GGT) level, serum triglyceride level, cholesterolemia, blood glucose level, and fasting insulin level. Diabetes, hypercholesterolemia, and hypertriglyceridemia were defined as follows: fasting blood glucose level >1.2 g/L, cholesterol level >2.4 g/L, and serum triglyceride level >1.5 g/L, respectively. In the present study, we assessed IR using the quantitative insulin sensitivity check index (QUICKI). This method is significantly correlated with the hyperinsulinemic euglycemic glucose clamp and is considered a valid method for evaluating IR in obese patients.41Katz A. Nambi S.S. Mather K. Baron A.D. Follmann D.A. Sullivan G. Quon M.J. Quantitative insulin sensitivity check index a simple, accurate method for assessing insulin sensitivity in humans.J Clin Endocrinol Metab. 2000; 85: 2402-2410Crossref PubMed Scopus (2365) Google Scholar The QUICKI was calculated with the following equation: QUICKI = 1/(Log Fasting Insulin) + (Log Fasting Plasma Glucose). The IR index is equal to 1/QUICKI. Liver biopsies were performed during the operative procedure and, on average, 1 year after surgery. Liver biopsy specimens were evaluated by 2 independent pathologists who were unaware of patients’ clinical and laboratory data. Biopsy specimens were routinely stained with H&E and Masson’s trichrome. All biopsy specimens were a minimum of 15 mm in length and had an appropriate number of portal tracts to enable a confident evaluation of histologic features and diagnosis.42Bravo A.A. Sheth S.G. Chopra S. Liver biopsy.N Engl J Med. 2001; 344: 495-500Crossref PubMed Scopus (1861) Google Scholar Steatosis was quantified in the percentage of hepatocytes containing fat droplets (steatosis amount) and graded using the following scale: 0, absent (<5% of hepatocytes affected); 1, mild (<30% of hepatocytes affected); 2, moderate (30%–60% of hepatocytes affected); and 3, severe (>60% of hepatocytes affected).43Brunt E.M. Janney C.G. Di Bisceglie A.M. Neuschwander-Tetri B.A. Bacon B.R. Nonalcoholic steatohepatitis a proposal for grading and staging the histological lesions.Am J Gastroenterol. 1999; 94: 2467-2474Crossref PubMed Scopus (3152) Google Scholar, 44Silverman J.F. O’Brien K.F. Long S. Leggett N. Khazanie P.G. Pories W.J. Norris H.T. Caro J.F. Liver pathology in morbidly obese patients with and without diabetes.Am J Gastroenterol. 1990; 85: 1349-1355PubMed Google Scholar NASH was defined as the presence of steatosis plus mixed lobular inflammation plus hepatocellular ballooning2Neuschwander-Tetri B.A. Caldwell S.H. Nonalcoholic steatohepatitis summary of an AASLD single topic conference.Hepatology. 2003; 37: 1202-1219Crossref PubMed Scopus (1796) Google Scholar and was graded according to Brunt’s score as follows: 0, absent; 1, mild; 2, moderate; and 3, severe.43Brunt E.M. Janney C.G. Di Bisceglie A.M. Neuschwander-Tetri B.A. Bacon B.R. Nonalcoholic steatohepatitis a proposal for grading and staging the histological lesions.Am J Gastroenterol. 1999; 94: 2467-2474Crossref PubMed Scopus (3152) Google Scholar Liver fibrosis was assessed semiquantitatively using a 5-grade scale: F0, normal; F1, focal pericellular fibrosis in zone 3; F2, perivenular and pericellular fibrosis confined to zones 2 and 3 with or without portal/periportal fibrosis; F3, bridging or extensive fibrosis with architectural distortion and no obvious cirrhosis; and F4, cirrhosis.43Brunt E.M. Janney C.G. Di Bisceglie A.M. Neuschwander-Tetri B.A. Bacon B.R. Nonalcoholic steatohepatitis a proposal for grading and staging the histological lesions.Am J Gastroenterol. 1999; 94: 2467-2474Crossref PubMed Scopus (3152) Google Scholar Histologic analysis classified the liver as normal when the amount of steatosis was <5% and necroinflammatory features and fibrosis were absent. For each patient, the following variables were assessed at baseline and 1 year after surgery: BMI, ALT level, GGT level, serum triglyceride level, cholesterolemia, blood glucose level, fasting insulin level, 1/QUICKI value, steatosis amount, fibrosis score, and grade of NASH. Continuous variables were expressed as median with its 95% confidence interval (CI). Parametric tests (Student t test and Fisher exact test) and nonparametric tests (Mann–Whitney test) were used to compare quantitative variables. Differences were considered as significant for a P value ≤.05. Severe steatosis was defined as a steatosis amount >60%. The relationship between severe steatosis and various risk factors was studied using a univariate comparison followed by multivariate analysis using logistic regression. In univariate analysis, 2 groups were compared according to the presence or absence of severe steatosis. Baseline variables that reached a univariate P value ≤.05 were included in multivariate analysis. In multivariate analysis, severe steatosis was the dependent variable. Regression coefficients were expressed with their standard error. Statistical analysis was performed using NCSS 2001 software (NCSS, Kaysville, UT). A total of 185 consecutive obese patients (148 women and 37 men; mean age, 41 ± 9 years) with a mean BMI at 49 ± 8 kg/m2 were prospectively included. They were referred for undergoing bariatric surgery for morbid obesity in 176 cases (95%) or severe obesity with comorbidity (arterial hypertension and/or diabetes mellitus) in 9 cases (5%). Biliointestinal bypass and gastric band procedures were performed in 71 patients (42%) and 100 patients (58%), respectively. Bariatric surgery was contraindicated for suspicion of cirrhosis in 14 patients with the following patterns: (1) biologic abnormalities (low platelet count, low prothrombin time, or abnormal bilirubin levels) suggestive of cirrhosis and observed at inclusion in 8 patients and (2) macroscopic appearance of cirrhosis preoperatively diagnosed in 6 cases, leading to postponement of bariatric surgery. Among these 14 patients, cirrhosis was biopsy proven in 10 cases. The main clinical, biologic, and histologic characteristics of the patients are given in Table 1. ALT levels were normal in 53 patients (28%), with a common threshold of 45 IU/L used as the upper normal range. Liver biopsy was performed during the surgical procedure. Histologic analysis was not available in 21 patients; the size of the liver biopsy specimen was insufficient to permit histologic analysis in 17 cases and biopsy was postponed because of macroscopic diagnosis of cirrhosis by the surgeon in 4 cases.Table 1Clinical, Biologic, and Histologic Characteristics of the 185 Patients Before Bariatric SurgeryFemale sex, no. (%)148 (80)Age (y), median (95% CI)40.6 (39–42.8)BMI (kg/m2), median (95% CI)47.1 (46.1–48.2)Diabetes mellitus, no. (%)31 (16.8)aTwelve percent of patients below the median IR index were diabetic as compared with 35.4% of patients above this cutoff (P = .002). Seventy-four percent of diabetic patients had an IR index above the median. None of the diabetic patients were treated with insulin.Arterial hypertension, no. (%)69 (37.3)Cholesterol level (g/L), median (95% CI)2.06 (1.97–2.14)Hypercholesterolemia, no. (%)71 (44.7)Serum triglyceride level (g/L), median (95% CI)1.34 (1.25–1.43)Hypertriglyceridemia, no. (%)84 (53.9)Hypothyroidism, no. (%)18 (9.7)ALT level (IU/L), median (95% CI)21 (19–25)GGT level (IU/L), median (95% CI)29 (26–36)Fasting blood glucose level (g/L), median (95% CI)1 (0.97–1.04)Fasting serum insulin level (IU/L), median (95% CI)12.9 (11.3–14.7)IR index (1/QUICKI), median (95% CI)3.13 (3.07–3.19)Amount of steatosis (%), median (95% CI)bLiver histology was classified as normal (for more details, see Methods) in 50 patients (30%).20 (15–30)Severe steatosis, no. (%)44 (26.8)NASH, no. (%)24 (14.4)Fibrosis F0/F1/F2/F3/F4, no. (%)136 (81)/17 (10)/4 (2)/1 (1)/10 (6)cTen patients had cirrhosis and were contraindicated for surgery.a Twelve percent of patients below the median IR index were diabetic as compared with 35.4% of patients above this cutoff (P = .002). Seventy-four percent of diabetic patients had an IR index above the median. None of the diabetic patients were treated with insulin.b Liver histology was classified as normal (for more details, see Methods) in 50 patients (30%).c Ten patients had cirrhosis and were contraindicated for surgery. Open table in a new tab BMI was similar in patients with NASH and patients without NASH (47.4 kg/m2 [95% CI, 41.3–51.1] vs 47.3 kg/m2 [95% CI, 46.2–48.5]; not significant). Conversely, the insulin resistance index was significantly higher in patients with NASH than in those without NASH (3.4 [95% CI, 3.08–3.71] vs 3.1 [95% CI, 3.06–3.17]; P = .004). Patients treated by biliointestinal bypass and those treated by gastric banding were similar in terms of clinical and biologic characteristics (Table 2). Although there was no difference between the 2 groups in terms of steatosis and fibrosis, a higher frequency of NASH was observed in the gastric band group (15% vs 3%; P = .03).Table 2Comparison of Bypass and Gastric Band Groups Before SurgeryVariablesBiliointestinal bypass group(n = 71)Gastric band group(n = 100)Significant P valueFemale sex, no. (%)58 (81.7)85 (85)NSAge (y), median (95% CI)40.5 (37.6–45.2)39.3 (36.7–41.6)NSBMI (kg/m2), median (95% CI)48.5 (46.3–52.2)46.6 (45.2–47.8)NSDiabetes mellitus, no. (%)10 (14)15 (15)NSArterial hypertension, no. (%)29 (41)34 (34)NSHypercholesterolemia, no. (%)22 (42)43 (43)NSHypertriglyceridemia, no. (%)24 (46)54 (57)NSHypothyroidism, no. (%)4 (6)13 (13)NSALT level (IU/L), median (95% CI)19 (17–26)20 (18–23)NSGGT level (IU/L), median (95% CI)28 (23–36)27 (23–35)NSIR index, median (95% CI)3.08 (3.01–3.13)3.15 (3.08–3.25)NSAmount of steatosis (%), median (95% CI)25 (15–50)20 (15–30)NSSevere steatosis, no. (%)19 (29)22 (24)NSNASH, no. (%)2 (3)12 (13).03Fibrosis F0/F1/F2/F3/F4, no. (%)57 (88)/8 (12)/0/0/078 (87)/8 (9)/3 (3)/1 (1)/0NSNormal liver, no. (%)17 (26)33 (37)NSNS, not significant. Open table in a new tab NS, not significant. One year after bariatric surgery, the median weight loss was 27 kg (95% CI, 23–29), corresponding to a median decrease in BMI of 9.5 kg/m2, and all important biologic parameters of the metabolic syndrome were improved (Table 3). In addition, bariatric surgery induced a marked improvement in liver injury. ALT and GGT levels decreased significantly, and the amount of steatosis was significantly reduced with a median decrease of 8.5% (Table 3). The percentage of patients disclosing features of NASH decreased (10% vs 6.8%; P = .37), although not significantly, and NASH disappeared in 75% of patients showing histologic features of NASH before surgery. Although the fibrosis score increased significantly 1 year after surgery, the mean magnitude of the increase (0.24) and the mean score of fibrosis on the second biopsy (0.38) were not clinically relevant.Table 3One-Year Effects of Bariatric Surgery on Clinical, Biologic, and Histologic ParametersVariablesBefore surgery1 year after surgeryDifferenceSignificant P valueBMI (kg/m2), median (95% CI)47.1 (46–48.4)38.1 (36.6–39.9)9.5 (8.3–10.4)<.0001Arterial hypertension, no. (%)70 (37.6)46 (30.3)7.3%NSCholesterol level (g/L), median (95% CI)2.1 (1.99–2.16)1.8 (1.65–1.93)0.21 (0.15–0.27)<.0001Serum triglyceride level (g/L), median (95% CI)1.35 (1.25–1.46)1.1 (0.98–1.2)03 (0.18–0.39)<.0001IR index, median (95% CI)3.

Background & AimsSevere alcoholic hepatitis (AH) is a life-threatening disease for which adequate oral nutritional support is recommended. We performed a randomized controlled trial to determine whether the combination of corticosteroid and intensive enteral nutrition therapy is more effective than corticosteroid therapy alone in patients with severe AH.MethodsWe enrolled 136 heavy consumers of alcohol (age, 18–75 y) with recent onset of jaundice and biopsy-proven severe AH in our study, performed at 18 hospitals in Belgium and 2 in France, from February 2010 through February 2013. Subjects were assigned randomly (1:1) to groups that received either intensive enteral nutrition plus methylprednisolone or conventional nutrition plus methylprednisolone (controls). In the intensive enteral nutrition group, enteral nutrition was given via feeding tube for 14 days. The primary end point was patient survival for 6 months.ResultsIn an intention-to-treat analysis, we found no significant difference between groups in 6-month cumulative mortality: 44.4% of patients died in the intensive enteral nutrition group (95% confidence interval [CI], 32.2%–55.9%) and 52.1% of controls died (95% CI, 39.4%–63.4%) (P = .406). The enteral feeding tube was withdrawn prematurely from 48.5% of patients, and serious adverse events considered to be related to enteral nutrition occurred in 5 patients. Regardless of group, a greater proportion of patients with a daily calorie intake less than 21.5 kcal/kg/day died (65.8%; 95% CI, 48.8–78.4) than patients with a higher intake of calories (33.1%; 95% CI, 23.1%–43.4%) (P < .001).ConclusionsIn a randomized trial of patients with severe AH treated with corticosteroids, we found that intensive enteral nutrition was difficult to implement and did not increase survival. However, low daily energy intake was associated with greater mortality, so adequate nutritional intake should be a main goal for treatment. ClinicalTrials.gov number: NCT01801332. Severe alcoholic hepatitis (AH) is a life-threatening disease for which adequate oral nutritional support is recommended. We performed a randomized controlled trial to determine whether the combination of corticosteroid and intensive enteral nutrition therapy is more effective than corticosteroid therapy alone in patients with severe AH. We enrolled 136 heavy consumers of alcohol (age, 18–75 y) with recent onset of jaundice and biopsy-proven severe AH in our study, performed at 18 hospitals in Belgium and 2 in France, from February 2010 through February 2013. Subjects were assigned randomly (1:1) to groups that received either intensive enteral nutrition plus methylprednisolone or conventional nutrition plus methylprednisolone (controls). In the intensive enteral nutrition group, enteral nutrition was given via feeding tube for 14 days. The primary end point was patient survival for 6 months. In an intention-to-treat analysis, we found no significant difference between groups in 6-month cumulative mortality: 44.4% of patients died in the intensive enteral nutrition group (95% confidence interval [CI], 32.2%–55.9%) and 52.1% of controls died (95% CI, 39.4%–63.4%) (P = .406). The enteral feeding tube was withdrawn prematurely from 48.5% of patients, and serious adverse events considered to be related to enteral nutrition occurred in 5 patients. Regardless of group, a greater proportion of patients with a daily calorie intake less than 21.5 kcal/kg/day died (65.8%; 95% CI, 48.8–78.4) than patients with a higher intake of calories (33.1%; 95% CI, 23.1%–43.4%) (P < .001). In a randomized trial of patients with severe AH treated with corticosteroids, we found that intensive enteral nutrition was difficult to implement and did not increase survival. However, low daily energy intake was associated with greater mortality, so adequate nutritional intake should be a main goal for treatment. ClinicalTrials.gov number: NCT01801332.

In alcoholic hepatitis (AH), development of targeted therapies is crucial and requires improved knowledge of cellular and molecular drivers in liver dysfunction. The unique opportunity of using explanted livers from patients with AH having undergone salvage liver transplantation allowed to perform more in-depth molecular translational studies.We studied liver explants from patients with AH submitted to salvage transplantation (n=16), from patients with alcoholic cirrhosis without AH (n=12) and fragments of normal livers (n=16). Hepatic cytokine content was quantified. Hepatocyte function and proliferation and the presence of hepatic progenitor cells (HPCs) were evaluated by immunohistochemistry, western blot or quantitative PCR. Mitochondrial morphology was evaluated by electron microscopy.Livers from patients with AH showed decreased cytokine levels involved in liver regeneration (tumour necrosis factor α and interleukin-6), as well as a virtual absence of markers of hepatocyte proliferation compared with alcoholic cirrhosis and normal livers. Electron microscopy revealed obvious mitochondrial abnormalities in AH hepatocytes. Importantly, livers from patients with AH showed substantial accumulation of HPCs that, unexpectedly, differentiate only into biliary cells. AH livers predominantly express laminin (extracellular matrix protein favouring cholangiocyte differentiation); consequently, HPC expansion is inefficient at yielding mature hepatocytes.AH not responding to medical therapy is associated with lack of expression of cytokines involved in liver regeneration and profound mitochondrial damage along with lack of proliferative hepatocytes. Expansion of HPCs is inefficient to yield mature hepatocytes. Manoeuvres aimed at promoting differentiation of HPCs into mature hepatocytes should be tested in AH.

Background & AimsThere is debate over the effects of long-term oral fluoroquinolone therapy in patients with advanced cirrhosis. We performed a randomized controlled trial to evaluate the effects of long-term treatment with the fluoroquinolone norfloxacin on survival of patients with cirrhosis.MethodsWe performed a double-blind trial of 291 patients with Child-Pugh class C cirrhosis who had not received recent fluoroquinolone therapy. The study was performed at 18 clinical sites in France from April 2010 through November 2014. Patients were randomly assigned to groups given 400 mg norfloxacin (n = 144) or placebo (n = 147) once daily for 6 months. Patients were evaluated monthly for the first 6 months and at 9 months and 12 months thereafter. The primary outcome was 6-month mortality, estimated by the Kaplan–Meier method, censoring spontaneous bacterial peritonitis, liver transplantation, or loss during follow-up.ResultsThe Kaplan–Meier estimate for 6-month mortality was 14.8% for patients receiving norfloxacin and 19.7% for patients receiving placebo (P = .21). In competing risk analysis that took liver transplantation into account, the cumulative incidence of death at 6 months was significantly lower in the norfloxacin group than in the placebo group (subdistribution hazard ratio, 0.59; 95% confidence interval, 0.35–0.99). The subdistribution hazard ratio for death at 6 months with norfloxacin vs placebo was 0.35 (95% confidence interval, 0.13–0.93) in patients with ascites fluid protein concentrations <15 g/L and 1.39 (95% confidence interval, 0.42–4.57) in patients with ascites fluid protein concentrations ≥15 g/L. Norfloxacin significantly decreased the incidence of any and Gram-negative bacterial infections without increasing infections caused by Clostridium difficile or multiresistant bacteria.ConclusionsIn a randomized controlled trial of patients with advanced cirrhosis without recent fluoroquinolone therapy, norfloxacin did not reduce 6-month mortality, estimated by the Kaplan–Meier method. Norfloxacin, however, appears to increase survival of patients with low ascites fluid protein concentrations. ClinicalTrials.gov ID: NCT01037959. There is debate over the effects of long-term oral fluoroquinolone therapy in patients with advanced cirrhosis. We performed a randomized controlled trial to evaluate the effects of long-term treatment with the fluoroquinolone norfloxacin on survival of patients with cirrhosis. We performed a double-blind trial of 291 patients with Child-Pugh class C cirrhosis who had not received recent fluoroquinolone therapy. The study was performed at 18 clinical sites in France from April 2010 through November 2014. Patients were randomly assigned to groups given 400 mg norfloxacin (n = 144) or placebo (n = 147) once daily for 6 months. Patients were evaluated monthly for the first 6 months and at 9 months and 12 months thereafter. The primary outcome was 6-month mortality, estimated by the Kaplan–Meier method, censoring spontaneous bacterial peritonitis, liver transplantation, or loss during follow-up. The Kaplan–Meier estimate for 6-month mortality was 14.8% for patients receiving norfloxacin and 19.7% for patients receiving placebo (P = .21). In competing risk analysis that took liver transplantation into account, the cumulative incidence of death at 6 months was significantly lower in the norfloxacin group than in the placebo group (subdistribution hazard ratio, 0.59; 95% confidence interval, 0.35–0.99). The subdistribution hazard ratio for death at 6 months with norfloxacin vs placebo was 0.35 (95% confidence interval, 0.13–0.93) in patients with ascites fluid protein concentrations <15 g/L and 1.39 (95% confidence interval, 0.42–4.57) in patients with ascites fluid protein concentrations ≥15 g/L. Norfloxacin significantly decreased the incidence of any and Gram-negative bacterial infections without increasing infections caused by Clostridium difficile or multiresistant bacteria. In a randomized controlled trial of patients with advanced cirrhosis without recent fluoroquinolone therapy, norfloxacin did not reduce 6-month mortality, estimated by the Kaplan–Meier method. Norfloxacin, however, appears to increase survival of patients with low ascites fluid protein concentrations. ClinicalTrials.gov ID: NCT01037959.

Aliment Pharmacol Ther 2011; 34: 1193–1201 Summary Background Sorafenib increases median survival and time to radiological progression in patients with advanced hepatocellular carcinoma, but its benefit for Child-Pugh B patients remains uncertain. Aim To evaluate the safety and efficacy of sorafenib in real-life clinical practice conditions and to assess the influence of Child-Pugh class B on safety and efficacy. Methods All patients treated with sorafenib for advanced hepatocellular carcinoma in our institution were included prospectively. Adverse events, overall survival and time to progression were recorded. A case control study was performed to compare outcome of patients with comparable stages of hepatocellular carcinoma, but a different Child-Pugh class. Results From March 2007 to May 2009, 120 patients were included. Overall survival was 11.1 months, Child-Pugh A patients (n = 100) had significantly higher median survival than Child-Pugh B patients (n = 20) (13 vs. 4.5 months, P = 0.0008). In multivariate analysis, Child-Pugh class B, α-fetoprotein level and total size of lesions were independent predictive factors of death. Patients with radiological progression in the first 3 months had shorter median survival (5.4 vs. 17.4 months). In a case control study, time to symptomatic progression (2.5 vs. 3.6 months), frequency of adverse events and discontinuation of sorafenib were not correlated with Child-Pugh class. Conclusions Patients with advanced hepatocellular carcinoma treated with sorafenib had a median survival of 11 months. Sorafenib therapy must be considered with caution in Child-Pugh B patients due to their poor survival. Radiological assessment of tumour progression at an early stage may be advantageous when tailoring sorafenib therapy.

•One-third of the patients with cirrhosis and variceal bleeding are eligible for early-TIPS. •TIPS is restricted to 7% of patients displaying less severe cirrhosis. •Other studies are needed to confirm the benefit of early-TIPS on survival. Background & Aims The Baveno VI consensus meeting concluded that an early transjugular intra-hepatic porto-systemic shunt (TIPS) must be considered in high-risk patients with cirrhosis, presenting with variceal bleeding (VB) (Child B + active bleeding at endoscopy or Child C10-13 patients). Whether this therapeutic approach is feasible in a real-life setting remains unclear. The aim of this study was to determine (i) the proportion of patients eligible for early-TIPS among patients with cirrhosis and VB, (ii) the proportion of these patients who underwent early-TIPS placement and the main reasons for discarding TIPS, and (iii) the outcomes of patients who experienced early-TIPS placement. Methods A large, national, prospective, multicentre audit of academic and non-academic centres, in which all French centres recruiting patients with gastrointestinal bleeding were invited to participate. All consecutive patients with cirrhosis and portal hypertension-related bleeding were included. Results A total of 964 patients were included (58 centres: 26 academic, 32 non-academic; patient characteristics: male sex 77%; age 59.6 ± 12.1 years; aetiologies of cirrhosis (alcoholic 67%, viral 15%, other 18%); source of bleeding (oesophageal varices 80%, gastric varices 11%, other 9%); active bleeding at endoscopy 34%; Child A 21%, B 44%, C 35%. Overall, 35% of the patients were eligible for early-TIPS, but only 6.8%, displaying less severe cirrhosis underwent early-TIPS placement. The main reason for discarding TIPS was a lack of availability. The actuarial probability of survival at one year was significantly increased in early-TIPS patients (85.7 ± 0.07% vs. 58.9 ± 0.03%, p = 0.04). The severity of liver disease was the only parameter independently associated with improved one-year survival. Conclusion In this real-life study, one-third of the patients with cirrhosis, admitted for VB fulfilled the criteria for early-TIPS placement, whereas only 7% had access to TIPS. TIPS was restricted to patients displaying less severe cirrhosis. The severity of liver disease was the only parameter that influenced survival. Lay summary Bleeding from oesophageal or gastric varices is a severe complication of cirrhosis, related to an increased pressure in the portal vein perfusing the liver. Some patients are described as “severe”, either because their liver disease is already severe, or because the bleeding is very important. Those patients could benefit from a prothesis, placed inside the liver by an interventional radiologist, aiming to decrease the pressure in the portal vein, just after the control of bleeding by medications and endoscopic treatment. New studies are warranted to demonstrate a real beneficial effect of this therapeutic attitude, which is not adopted in real-life practice, as shown by this national French audit of practice. The Baveno VI consensus meeting concluded that an early transjugular intra-hepatic porto-systemic shunt (TIPS) must be considered in high-risk patients with cirrhosis, presenting with variceal bleeding (VB) (Child B + active bleeding at endoscopy or Child C10-13 patients). Whether this therapeutic approach is feasible in a real-life setting remains unclear. The aim of this study was to determine (i) the proportion of patients eligible for early-TIPS among patients with cirrhosis and VB, (ii) the proportion of these patients who underwent early-TIPS placement and the main reasons for discarding TIPS, and (iii) the outcomes of patients who experienced early-TIPS placement. A large, national, prospective, multicentre audit of academic and non-academic centres, in which all French centres recruiting patients with gastrointestinal bleeding were invited to participate. All consecutive patients with cirrhosis and portal hypertension-related bleeding were included. A total of 964 patients were included (58 centres: 26 academic, 32 non-academic; patient characteristics: male sex 77%; age 59.6 ± 12.1 years; aetiologies of cirrhosis (alcoholic 67%, viral 15%, other 18%); source of bleeding (oesophageal varices 80%, gastric varices 11%, other 9%); active bleeding at endoscopy 34%; Child A 21%, B 44%, C 35%. Overall, 35% of the patients were eligible for early-TIPS, but only 6.8%, displaying less severe cirrhosis underwent early-TIPS placement. The main reason for discarding TIPS was a lack of availability. The actuarial probability of survival at one year was significantly increased in early-TIPS patients (85.7 ± 0.07% vs. 58.9 ± 0.03%, p = 0.04). The severity of liver disease was the only parameter independently associated with improved one-year survival. In this real-life study, one-third of the patients with cirrhosis, admitted for VB fulfilled the criteria for early-TIPS placement, whereas only 7% had access to TIPS. TIPS was restricted to patients displaying less severe cirrhosis. The severity of liver disease was the only parameter that influenced survival.

<h3>Background & Aims</h3> More than 90% of cases of hepatocellular carcinoma (HCC) occur in patients with cirrhosis, of which alcohol is a major cause. The CIRRAL cohort aimed to assess the burden of complications in patients with alcoholic cirrhosis, particularly the occurrence of HCC. <h3>Methods</h3> Patients with biopsy-proven compensated alcoholic cirrhosis were included then prospectively followed. The main endpoint was the incidence of HCC. Secondary outcomes were incidence of hepatic focal lesions, overall survival (OS), liver-related mortality and event-free survival (EFS). <h3>Results</h3> From October 2010 to April 2016, 652 patients were included in 22 French and Belgian centers. During follow-up (median 29 months), HCC was diagnosed in 43 patients. With the limitation derived from the uncertainty of consecutive patients' inclusion and from a sizable proportion of dropouts (153/652), the incidence of HCC was 2.9 per 100 patient-years, and one- and two-year cumulative incidences of 1.8% and 5.2%, respectively. Although HCC fulfilled the Milan criteria in 33 cases (77%), only 24 patients (56%) underwent curative treatment. An explorative prognostic analysis showed that age, male gender, baseline alpha-fetoprotein, bilirubin and prothrombin were significantly associated with the risk of HCC occurrence. Among 73 deaths, 61 had a recorded cause and 27 were directly attributable to liver disease. At two years, OS, EFS and cumulative incidences of liver-related deaths were 93% (95% CI 90.5–95.4), 80.3% (95% CI 76.9–83.9), and 3.2% (95% CI 1.6–4.8) respectively. <h3>Conclusion</h3> This large prospective cohort incompletely representative of the whole population with alcoholic cirrhosis showed: a) an annual incidence of HCC of up to 2.9 per 100 patient-years, suggesting that surveillance might be cost effective in these patients; b) a high proportion of HCC detected within the Milan criteria, but only one-half of detected HCC cases were referred for curative treatments; c) a two-year mortality rate of up to 7%. <h3>Lay summary</h3> Cirrhosis is a risk factor for primary liver cancer, leading to recommendations for periodic screening. However, for alcohol-related liver disease the rational of periodic screening for hepatocellular carcinoma (HCC) is controversial, as registry and databased studies have suggested a low incidence of HCC in these patients and highly competitive mortality rates. In this study, a large cohort of patients with biopsy-proven alcoholic cirrhosis prospectively screened for HCC demonstrated a high annual incidence of HCC (2.9%) and a high percentage of small cancers theoretically eligible for curative treatment. This suggests that patients with liver disease related to alcohol should not be ruled out of screening.

Alcohol-related liver disease (ALD) remains the most important cause of death due to alcohol. Infections, particularly bacterial infections, are one of the most frequent and severe complications of advanced ALDs, such as alcoholic cirrhosis and severe alcoholic hepatitis (sAH). The specific mechanisms responsible for this altered host defence are yet to be deciphered. The aim of the present study is to review the current knowledge of infectious complications in ALD and its pathophysiological mechanisms, distinguishing the role of alcohol consumption and the contribution of different forms of ALD. To date, corticosteroids are the only treatment with proven efficacy in sAH, but their impact on the occurrence of infections remains controversial. The combination of an altered host defence and corticosteroid treatment in sAH has been suggested as a cause of opportunistic fungal and viral infections. A high level of suspicion with systematic screening and prompt, adequate treatment are warranted to improve outcomes in these patients. Prophylactic or preemptive strategies in this high-risk population might be a preferable option, because of the high short-term mortality rate despite adequate therapies. However, these strategies should be assessed in well-designed trials before clinical implementation.

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.

Corticosteroids are the only effective therapy for severe alcohol-associated hepatitis (AH), defined by a model for end-stage liver disease (MELD) score >20. However, there are patients who may be too sick to benefit from therapy. Herein, we aimed to identify the range of MELD scores within which steroids are effective for AH.We performed a retrospective, international multicenter cohort study across 4 continents, including 3,380 adults with a clinical and/or histological diagnosis of AH. The main outcome was mortality at 30 days. We used a discrete-time survival analysis model, and MELD cut-offs were established using the transform-the-endpoints method.In our cohort, median age was 49 (40-56) years, 76.5% were male, and 79% had underlying cirrhosis. Median MELD at admission was 24 (19-29). Survival was 88% (87-89) at 30 days, 77% (76-78) at 90 days, and 72% (72-74) at 180 days. A total of 1,225 patients received corticosteroids. In an adjusted-survival-model, corticosteroid use decreased 30-day mortality by 41% (hazard ratio [HR] 0.59; 0.47-0.74; p <0.001). Steroids only improved survival in patients with MELD scores between 21 (HR 0.61; 0.39-0.95; p = 0.027) and 51 (HR 0.72; 0.52-0.99; p = 0.041). The maximum effect of corticosteroid treatment (21-30% survival benefit) was observed with MELD scores between 25 (HR 0.58; 0.42-0.77; p <0.001) and 39 (HR 0.57; 0.41-0.79; p <0.001). No corticosteroid benefit was seen in patients with MELD >51. The type of corticosteroids used (prednisone, prednisolone, or methylprednisolone) was not associated with survival benefit (p = 0.247).Corticosteroids improve 30-day survival only among patients with severe AH, especially with MELD scores between 25 and 39.Alcohol-associated hepatitis is a condition where the liver is severely inflamed as a result of excess alcohol use. It is associated with high mortality and it is not clear whether the most commonly used treatments (corticosteroids) are effective, particularly in patients with very severe liver disease. In this worldwide study, the use of corticosteroids was associated with increased 30-day, but not 90- or 180-day, survival. The maximal benefit was observed in patients with an MELD score (a marker of severity of liver disease; higher scores signify worse disease) between 25-39. However, this benefit was lost in patients with the most severe liver disease (MELD score higher than 51).

INTRODUCTION: Several scoring systems predict mortality in alcohol-associated hepatitis (AH), including the Maddrey discriminant function (mDF) and model for end-stage liver disease (MELD) score developed in the United States, Glasgow alcoholic hepatitis score in the United Kingdom, and age, bilirubin, international normalized ratio, and creatinine score in Spain. To date, no global studies have examined the utility of these scores, nor has the MELD-sodium been evaluated for outcome prediction in AH. In this study, we assessed the accuracy of different scores to predict short-term mortality in AH and investigated additional factors to improve mortality prediction. METHODS: Patients admitted to hospital with a definite or probable AH were recruited by 85 tertiary centers in 11 countries and across 3 continents. Baseline demographic and laboratory variables were obtained. The primary outcome was all-cause mortality at 28 and 90 days. RESULTS: In total, 3,101 patients were eligible for inclusion. After exclusions (n = 520), 2,581 patients were enrolled (74.4% male, median age 48 years, interquartile range 40.9–55.0 years). The median MELD score was 23.5 (interquartile range 20.5–27.8). Mortality at 28 and 90 days was 20% and 30.9%, respectively. The area under the receiver operating characteristic curve for 28-day mortality ranged from 0.776 for MELD-sodium to 0.701 for mDF, and for 90-day mortality, it ranged from 0.773 for MELD to 0.709 for mDF. The area under the receiver operating characteristic curve for mDF to predict death was significantly lower than all other scores. Age added to MELD obtained only a small improvement of AUC. DISCUSSION: These results suggest that the mDF score should no longer be used to assess AH's prognosis. The MELD score has the best performance in predicting short-term mortality.

Studies using consecutive liver biopsies constitute an attractive approach to gaining insight into the pathogenesis of alcoholic liver disease.To analyse histological factors at baseline, which are predictive of fibrosis progression and recurrence of alcoholic hepatitis.A total of 193 drinkers underwent consecutive biopsies at an interval of 4 years. At baseline, 20 had normal livers, 135 steatosis, five fibrosis and 33 alcoholic hepatitis. The fibrosis score increased from 1.07 +/- 0.07 to 1.7 +/- 0.94 (P < 0.001). In multivariate analysis, only steatosis (P = 0.04), alcoholic hepatitis (P = 0.0004) and stage of fibrosis (P < 0.0001) were independent predictive factors of the fibrosis score at the second biopsy. Cirrhosis developed more frequently in patients with steatosis (11%) and alcoholic hepatitis (39%) than in others (0%, P < 0.0001). Alcoholic hepatitis recurred more frequently in patients with alcoholic hepatitis at baseline: 58% vs. 15%, P < 0.0001. In multivariate analysis, alcoholic hepatitis at the first biopsy was the only predictive factor of its recurrence (P < 0.0001).In a large cohort of drinkers with consecutive biopsies, steatosis, fibrosis stage and alcoholic hepatitis at baseline were independent predictive factors of fibrosis progression. In terms of mechanisms, we propose a novel concept of multiple hits of alcoholic hepatitis occurring in the same patient.

The cannabinoid receptor 2 (CB2) plays a pleiotropic role in innate immunity and is a crucial mediator of liver disease. In this study, we investigated the impact of CB2 receptors on the regenerative process associated with liver injury. Following acute hepatitis induced by carbon tetrachloride (CCl4), CB2 was induced in the nonparenchymal cell fraction and remained undetectable in hepatocytes. Administration of CCl4 to CB2−/− mice accelerated liver injury, as shown by increased alanine/aspartate aminotransferase levels and hepatocyte apoptosis, and delayed liver regeneration, as reflected by a retarded induction of hepatocyte proliferating cell nuclear antigen expression; proliferating cell nuclear antigen induction was also delayed in CB2−/− mice undergoing partial hepatectomy. Conversely, following treatment with the CB2 agonist JWH-133, CCl4-treated WT mice displayed reduced liver injury and accelerated liver regeneration. The CCl4-treated CB2−/− mice showed a decrease in inducible nitric oxide synthase and tumor necrosis factor-α expression, and administration of the nitric oxide donor moldomine (SIN-1) to these animals reduced hepatocyte apoptosis, without affecting liver regeneration. Impaired liver regeneration was consecutive to an interleukin-6 (IL-6)-mediated decrease in matrix metalloproteinase 2 (MMP-2) activity. Indeed, CCl4-treated CB2−/− mice displayed lower levels of hepatic IL-6 messenger RNA and increased MMP-2 activity. Administration of IL-6 to these mice decreased MMP-2 activity and improved liver regeneration, without affecting hepatocyte apoptosis. Accordingly, administration of the MMP inhibitor CTTHWGFTLC to CCl4-treated CB2−/− mice improved liver regeneration. Finally, in vitro studies demonstrated that incubation of hepatic myofibroblasts with JWH-133 increased tumor necrosis factor-α and IL-6 and decreased MMP-2 expressions. Conclusion: CB2 receptors reduce liver injury and promote liver regeneration following acute insult, via distinct paracrine mechanisms involving hepatic myofibroblasts. These results suggest that CB2 agonists display potent hepatoprotective properties, in addition to their antifibrogenic effects. (HEPATOLOGY 2010)

Background Liver biopsy is considered as the gold standard for assessing nonalcoholic fatty liver disease (NAFLD) histologic lesions in patients with morbid obesity. The aim of this study was to determine the diagnostic utility of noninvasive markers of fibrosis (FibroTest), steatosis (SteatoTest), and steatohepatitis (NashTest, ActiTest) in these patients. Materials and methods Two hundred and eighty-eight patients presenting with interpretable baseline operative biopsy and biomarkers, in an ongoing prospective cohort of patients treated with bariatric surgery, were included. Histology (NAFLD activity score, or NAFLD scoring system) and biochemical measurements were centralized and blinded to other characteristics. The area under the receiver operating characteristic curves (AUROC), sensitivity, specificity, positive and negative predictive values were assessed. Weighted AUROC (Obuchowski method) was used to prevent multiple testings and a spectrum effect. Results The prevalence of advanced fibrosis (bridging) was 6.9%, advanced steatosis (>33%) was 48%, and steatohepatitis was 6.9% (NAFLD scoring system>4). Weighted AUROCs of the tests were as follows (mean, 95% confidence interval, significance): FibroTest for advanced fibrosis: 0.85, 0.83–0.87, P<0.0001; SteatoTest for advanced steatosis: 0.81, 0.79–0.83, P<0.0001; and ActiTest for steatohepatitis: 0.77, 0.73–0.81, P<0.0001. Conclusion In patients with morbid obesity, the diagnostic performances of the FibroTest, SteatoTest, and ActiTest were statistically significant, thereby possibly reducing the need for biopsy in this population.

Background & Aims Recent studies suggested that SVR rates might be lower in HCV patients with insulin resistance (IR) than in patients without IR, but the extent of the impact of IR on treatment response has not been established. We aimed to confirm the role of IR assessed by the homoeostasis model assessment (HOMA-IR) on SVR and to determine its magnitude. Methods We performed meta-analysis of studies evaluating the impact of IR in HCV patients treated with pegylated interferon and ribavirin. Results Fourteen studies involving 2732 patients were included. SVR was less frequent in patients with IR than in patients without IR (mean difference: −19.6%, 95% CI: −29.9% to −9.4%, p<0.001). In sensitivity analyses according to HCV-1 patients, patients with IR also less frequently attained a SVR than patients without IR (mean difference: −13.0%, 95% CI: −22.6% to −3.4%, p = 0.008). In addition, the baseline HOMA-IR index was lower in responders than in non-responders (mean difference: −0.92, 95% CI: −1.53 to −0.32, p<0.001). In sensitivity analyses restricted to HCV-1 patients, the baseline HOMA-IR index remained lower in responders than in non-responders (mean difference: −0.63, 95% CI: −1.13 to −0.14, p<0.001). Conclusions HCV patients with IR have a 20% lower SVR than patients without IR. The baseline HOMA-IR index is a major determinant of SVR. Recent studies suggested that SVR rates might be lower in HCV patients with insulin resistance (IR) than in patients without IR, but the extent of the impact of IR on treatment response has not been established. We aimed to confirm the role of IR assessed by the homoeostasis model assessment (HOMA-IR) on SVR and to determine its magnitude. We performed meta-analysis of studies evaluating the impact of IR in HCV patients treated with pegylated interferon and ribavirin. Fourteen studies involving 2732 patients were included. SVR was less frequent in patients with IR than in patients without IR (mean difference: −19.6%, 95% CI: −29.9% to −9.4%, p<0.001). In sensitivity analyses according to HCV-1 patients, patients with IR also less frequently attained a SVR than patients without IR (mean difference: −13.0%, 95% CI: −22.6% to −3.4%, p = 0.008). In addition, the baseline HOMA-IR index was lower in responders than in non-responders (mean difference: −0.92, 95% CI: −1.53 to −0.32, p<0.001). In sensitivity analyses restricted to HCV-1 patients, the baseline HOMA-IR index remained lower in responders than in non-responders (mean difference: −0.63, 95% CI: −1.13 to −0.14, p<0.001). HCV patients with IR have a 20% lower SVR than patients without IR. The baseline HOMA-IR index is a major determinant of SVR.

A 33-year-old Caucasian male was admitted to hospital with recent onset of jaundice of 2-3 weeks duration. He reported heavy use of alcohol for the last 10 years with the last drink a day prior to the onset of symptoms. At admission, he was alert and oriented to time, place, and person, and was deeply jaundiced. His laboratory profile can be summarised as follows: haemoglobin 12.1 g/dl, white blood cell count 18,700 with 81% neutrophils, serum bilirubin 33 (direct 22) mg/dl, aspartate aminotransferase 147 IU/L, alanine aminotransferase 62 IU/L, alkaline phosphatase 117 IU/L, serum albumin 2.8 gm/dl, serum creatinine 0.6 mg/dl, prothrombin time 18.3 (control 14.5) seconds, and international normalized ratio 1.48. He was diagnosed with severe alcoholic hepatitis (Maddrey discriminant function score of 50) and treated with prednisolone for 28 days with symptomatic and biochemical improvement. His Lille score at seven days was 0.4, and his serum bilirubin had decreased to 3.5 mg/dl at the end of treatment. He was also seen by the addiction team during hospitalisation; he agreed to follow through on recommendations. He was dismissed after completing a three-week inpatient rehabilitation programme but relapsed to alcohol use three months later, and was readmitted with alcohol withdrawal. He was readmitted two months later (about six months from the first episode) for a second episode of severe alcoholic hepatitis. At admission, his model for end-stage liver disease score was 32 and he was treated again with corticosteroids. His Lille score at seven days was 0.6 and steroids were discontinued. The hospital course was complicated by spontaneous bacterial peritonitis and pneumonia with development of acute kidney injury. He continued to worsen, developing multiorgan failure. After a course of one month, the family's preference was for him to receive comfort measures. This scenario raises several questions.

•Liver BHB concentration is low in human AH, and reducing BHB in mice worsens liver injury after alcohol. •BHB supplementation reduced alcohol induced liver injury in wild-type but not Hcar2 deficient mice. •BHB supplementation increased IL-10 levels and increased the M2 macrophage phenotype. •Development of the M2 phenotype is dependent on reduction of mitochondrial membrane potential by BHB. Background & Aims Sterile inflammation resulting in alcoholic hepatitis (AH) occurs unpredictably after many years of excess alcohol intake. The factors responsible for the development of AH are not known but mitochondrial damage with loss of mitochondrial function are common features. Hcar2 is a G-protein coupled receptor which is activated by β-hydroxybutyrate (BHB). We aimed to determine the relevance of the BHB-Hcar2 pathway in alcoholic liver disease. Methods We tested if loss of BHB production can result in increased liver inflammation. We further tested if BHB supplementation is protective in AH through interaction with Hcar2, and analyzed the immune and cellular basis for protection. Results Humans with AH have reduced hepatic BHB, and inhibition of BHB production in mice aggravated ethanol-induced AH, with higher plasma alanine aminotransferase levels, increased steatosis and greater neutrophil influx. Conversely supplementation of BHB had the opposite effects with reduced alanine aminotransferase levels, reduced steatosis and neutrophil influx. This therapeutic effect of BHB is dependent on the receptor Hcar2. BHB treatment increased liver Il10 transcripts, and promoted the M2 phenotype of intrahepatic macrophages. BHB also increased the transcriptional level of M2 related genes in vitro bone marrow derived macrophages. This skewing towards M2 related genes is dependent on lower mitochondrial membrane potential (Δψ) induced by BHB. Conclusions Collectively, our data shows that BHB production during excess alcohol consumption has an anti-inflammatory and hepatoprotective role through an Hcar2 dependent pathway. This introduces the concept of metabolite-based therapy for AH. Lay summary Alcoholic hepatitis is a life-threatening condition with no approved therapy that occurs unexpectedly in people who consume excess alcohol. The liver makes many metabolites, and we demonstrate that loss of one such metabolite β-hydroxybutyrate occurs in patients with alcoholic hepatitis. This loss can increase alcohol-induced liver injury, and β-hydroxybutyrate can protect from alcohol-induced liver injury via a receptor on liver macrophages. This opens the possibility of metabolite-based therapy for alcoholic hepatitis. Sterile inflammation resulting in alcoholic hepatitis (AH) occurs unpredictably after many years of excess alcohol intake. The factors responsible for the development of AH are not known but mitochondrial damage with loss of mitochondrial function are common features. Hcar2 is a G-protein coupled receptor which is activated by β-hydroxybutyrate (BHB). We aimed to determine the relevance of the BHB-Hcar2 pathway in alcoholic liver disease. We tested if loss of BHB production can result in increased liver inflammation. We further tested if BHB supplementation is protective in AH through interaction with Hcar2, and analyzed the immune and cellular basis for protection. Humans with AH have reduced hepatic BHB, and inhibition of BHB production in mice aggravated ethanol-induced AH, with higher plasma alanine aminotransferase levels, increased steatosis and greater neutrophil influx. Conversely supplementation of BHB had the opposite effects with reduced alanine aminotransferase levels, reduced steatosis and neutrophil influx. This therapeutic effect of BHB is dependent on the receptor Hcar2. BHB treatment increased liver Il10 transcripts, and promoted the M2 phenotype of intrahepatic macrophages. BHB also increased the transcriptional level of M2 related genes in vitro bone marrow derived macrophages. This skewing towards M2 related genes is dependent on lower mitochondrial membrane potential (Δψ) induced by BHB. Collectively, our data shows that BHB production during excess alcohol consumption has an anti-inflammatory and hepatoprotective role through an Hcar2 dependent pathway. This introduces the concept of metabolite-based therapy for AH.

While metabolic syndrome and alcohol consumption are the two main causes of chronic liver disease, one of the two conditions is often predominant, with the other acting as a cofactor of morbimortality. It has been shown that obesity and alcohol act synergistically to increase the risk of fibrosis progression, hepatic carcinogenesis and mortality, while genetic polymorphisms can strongly influence disease progression. Based on common pathogenic pathways, there are several potential targets that could be used to treat both diseases; based on the prevalence and incidence of these diseases, new therapies and clinical trials are needed urgently.

Body composition may be modified after improvement of portal hypertension (PHT) by transjugular intrahepatic portosystemic shunt (TIPSS) insertion.To evaluate changes in body composition following TIPSS placement, their relationship with radiological TIPSS patency and function, and the predictive value of these parameters METHODS: We retrospectively included 179 patients with cirrhosis who underwent TIPSS placement in our centre for severe PHT from 2011 to 2017. CT scan-based surveillance was performed at baseline, 1-3 (M1-M3) and 6 months (M6).The median model for end-stage liver disease (MELD) score was 11.4 (8.8-15.1) and Child-Pugh score 8 (7-9). Only the MELD score (HR 1.14, 95% CI 1.08-1.20) and sarcopenia assessed by transversal right psoas muscle thickness at the umbilical level/height (TPMPT/height) (HR 0.86, 95% CI 0.79-0.96) were independently associated with 6-month mortality on multivariate analysis. After TIPSS insertion, TPMT/height increased from 19 mm/m (baseline) to 19.6 mm/m (M1-M3, P = 0.004) and 21.1 mm/m (M6, P < 0.0001). The improvement and its extent were dependent on the radiological patency and dysfunction of TIPSS. Subcutaneous fat surface (SCFS) increased from 183.4 to 193 cm2 (P < 0.0001) and 229.8 cm2 (P < 0.0001), respectively. We observed a decrease in visceral fat surface (VFS) between baseline and M1-M3 (163.5-140.5 cm2 [P < 0.0001]), but not between M1-M3 and M6 (140.5-141.2 cm2 [P = 0.9]). SCFS and VFS did not seem to be modified by radiological TIPSS patency and dysfunction.Sarcopenia is independently associated with 6-month outcome and improves after TIPSS placement, together with an inverse evolution of subcutaneous and visceral fat. TIPSS not only treats PHT but also improves body composition.

Alcoholic hepatitis (AH) is a life-threatening disease with limited therapeutic options, as the molecular mechanisms leading to death are not well understood. This study evaluates the Hippo/Yes-associated protein (YAP) pathway which has been shown to play a role in liver regeneration.The Hippo/YAP pathway was dissected in explants of patients transplanted for AH or alcohol-related cirrhosis and in control livers, using RNA-seq, real-time PCR, western blot, immunohistochemistry and transcriptome analysis after laser microdissection. We transfected primary human hepatocytes with constitutively active YAP (YAPS127A) and treated HepaRG cells and primary hepatocytes isolated from AH livers with a YAP inhibitor. We also used mouse models of ethanol exposure (Lieber de Carli) and liver regeneration (carbon tetrachloride) after hepatocyte transduction of YAPS127A.In AH samples, RNA-seq analysis and immunohistochemistry of total liver and microdissected hepatocytes revealed marked downregulation of the Hippo pathway, demonstrated by lower levels of active MST1 kinase and abnormal activation of YAP in hepatocytes. Overactivation of YAP in hepatocytes in vitro and in vivo led to biliary differentiation and loss of key biological functions such as regeneration capacity. Conversely, a YAP inhibitor restored the mature hepatocyte phenotype in abnormal hepatocytes taken from patients with AH. In ethanol-fed mice, YAP activation using YAPS127A resulted in a loss of hepatocyte differentiation. Hepatocyte proliferation was hampered by YAPS127A after carbon tetrachloride intoxication.Aberrant activation of YAP plays an important role in hepatocyte transdifferentiation in AH, through a loss of hepatocyte identity and impaired regeneration. Thus, targeting YAP is a promising strategy for the treatment of patients with AH.Alcoholic hepatitis is characterized by inflammation and a life-threatening alteration of liver regeneration, although the mechanisms behind this have not been identified. Herein, we show that liver samples from patients with alcoholic hepatitis are characterized by profound deregulation of the Hippo/YAP pathway with uncontrolled activation of YAP in hepatocytes. We used human cell and mouse models to show that inhibition of YAP reverts this hepatocyte defect and could be a novel therapeutic strategy for alcoholic hepatitis.

Background & AimsWe recently showed that alcoholic hepatitis (AH) is characterized by dedifferentiation of hepatocytes and loss of mature functions. Glucose metabolism is tightly regulated in healthy hepatocytes. We hypothesize that AH may lead to metabolic reprogramming of the liver, including dysregulation of glucose metabolism.MethodsWe performed integrated metabolomic and transcriptomic analyses of liver tissue from patients with AH or alcoholic cirrhosis or normal liver tissue from hepatic resection. Focused analyses of chromatin immunoprecipitation coupled to DNA sequencing was performed. Functional in vitro studies were performed in primary rat and human hepatocytes and HepG2 cells.ResultsPatients with AH exhibited specific changes in the levels of intermediates of glycolysis/gluconeogenesis, the tricarboxylic acid cycle, and monosaccharide and disaccharide metabolism. Integrated analysis of the transcriptome and metabolome showed the used of alternate energetic pathways, metabolite sinks and bottlenecks, and dysregulated glucose storage in patients with AH. Among genes involved in glucose metabolism, hexokinase domain containing 1 (HKDC1) was identified as the most up-regulated kinase in patients with AH. Histone active promoter and enhancer markers were increased in the HKDC1 genomic region. High HKDC1 levels were associated with the development of acute kidney injury and decreased survival. Increased HKDC1 activity contributed to the accumulation of glucose-6-P and glycogen in primary rat hepatocytes.ConclusionsAltered metabolite levels and messenger RNA expression of metabolic enzymes suggest the existence of extensive reprogramming of glucose metabolism in AH. Increased HKDC1 expression may contribute to dysregulated glucose metabolism and represents a novel biomarker and therapeutic target for AH. We recently showed that alcoholic hepatitis (AH) is characterized by dedifferentiation of hepatocytes and loss of mature functions. Glucose metabolism is tightly regulated in healthy hepatocytes. We hypothesize that AH may lead to metabolic reprogramming of the liver, including dysregulation of glucose metabolism. We performed integrated metabolomic and transcriptomic analyses of liver tissue from patients with AH or alcoholic cirrhosis or normal liver tissue from hepatic resection. Focused analyses of chromatin immunoprecipitation coupled to DNA sequencing was performed. Functional in vitro studies were performed in primary rat and human hepatocytes and HepG2 cells. Patients with AH exhibited specific changes in the levels of intermediates of glycolysis/gluconeogenesis, the tricarboxylic acid cycle, and monosaccharide and disaccharide metabolism. Integrated analysis of the transcriptome and metabolome showed the used of alternate energetic pathways, metabolite sinks and bottlenecks, and dysregulated glucose storage in patients with AH. Among genes involved in glucose metabolism, hexokinase domain containing 1 (HKDC1) was identified as the most up-regulated kinase in patients with AH. Histone active promoter and enhancer markers were increased in the HKDC1 genomic region. High HKDC1 levels were associated with the development of acute kidney injury and decreased survival. Increased HKDC1 activity contributed to the accumulation of glucose-6-P and glycogen in primary rat hepatocytes. Altered metabolite levels and messenger RNA expression of metabolic enzymes suggest the existence of extensive reprogramming of glucose metabolism in AH. Increased HKDC1 expression may contribute to dysregulated glucose metabolism and represents a novel biomarker and therapeutic target for AH.

Because of the extensive use of this drug, further evaluation of acute liver injury (ALI) with therapeutic doses of acetaminophen (APAP; ≤6 g/d) is required. We characterize ALI with therapeutic doses of APAP and determine the host factors associated with disease severity and the predictors of outcome.All patients admitted with severe APAP-related ALI in our center were included from 2002 to 2019, either attributable to therapeutic doses or overdose. ALI with therapeutic doses (ALITD) was defined as APAP intake <6 g/d. Overall, 311 of 400 patients with APAP-related ALI had overdose and 89 had taken therapeutic doses. The host factors associated with ALITD were fasting ≥1 day (47.5% of ALITD patients vs. 26% in overdose; P = 0.001), excess drinking (93.3% vs. 48.5%; P < 0.0001), and repeated APAP use (4 vs. 1 day; P < 0.0001). Patients with ALITD were older (44 vs. 30.7 years; P < 0.0001) and had more severe liver injury. In the overall population, the independent predictors of disease severity were older age, longer duration of APAP, and excess drinking. Thirty-day survival was lower in ALITD than in overdose (87.2 ± 3.6% vs. 94.6 ± 1.3%; P = 0.02). Age and the presence of at least one of the King's College Hospital criteria were independent predictors of 30-day survival whereas the pattern of drug intoxication, excess drinking, and bilirubin were not.ALI with therapeutic doses of APAP is associated with more severe liver injury than overdose. It only occurs in patients with excess drinking and/or fasting. A warning should be issued about the repeated use of nontoxic doses of APAP in patients with those risk factors.

Abstract Background &amp; Aims Alcoholic hepatitis (AH) is associated with a high incidence of infection and mortality. Rifaximin reduces bacterial overgrowth and translocation. We aimed to study whether the administration of rifaximin as an adjuvant treatment to corticosteroids decreases the number of bacterial infections at 90 days in patients with severe AH compared to a control cohort. Methods This was a multicentre, open, comparative pilot study of the addition of rifaximin (1200 mg/day/90 days) to the standard treatment for severe AH. The results were compared with a carefully matched historical cohort of patients treated with standard therapy and matching by age and model of end‐stage liver disease (MELD). We evaluated bacterial infections, liver‐related complications, mortality and liver function tests after 90 days. Results Twenty‐one and 42 patients were included in the rifaximin and control groups respectively. No significant baseline differences were found between groups. The mean number of infections per patient was 0.29 and 0.62 in the rifaximin and control groups, respectively ( p = .049), with a lower incidence of acute‐on‐chronic liver failure (ACLF) linked to infections within the treatment group. Liver‐related complications were lower within the rifaximin group (0.43 vs. 1.26 complications/patient respectively) ( p = .01). Mortality was lower in the treated versus the control groups (14.2% vs. 30.9, p = .15) without significant differences. No serious adverse events were associated with rifaximin treatment. Conclusions Rifaximin is safe in severe AH with a significant reduction in clinical complications. A lower number of infections and a trend towards a lower ACLF and mortality favours its use in these patients.

Alcoholic hepatitis (AH) is a severe condition with poor short-term prognosis. Specific treatment with corticosteroids slightly improves short-term survival but is associated with infection and is not used in many centers. A reliable method to identify patients who will recover spontaneously will minimise the numbers of patients who experience side effects of available treatments.We analysed the trajectory of serum bilirubin concentration over the course of hospital admissions in patients with AH to predict spontaneous survival and the need for treatment.data from 426 patients were analysed. Based on bilirubin trajectory, patients were categorized into three groups: 'fast fallers' (bilirubin <0.8 x admission value at day 7), 'static' (bilirubin of >0.9 - <1.2 x admission value) and 'rapid risers' (bilirubin of ≥1.2 x admission bilirubin). Fast fallers had significantly better 90-day survival compared to other groups (log rank p < .001), and showed no benefit of corticosteroid therapy (OR for survival at 28 days of treatment, 0.94, 95% CI 0.06 - 8.41). These findings remained even amongst patients with severe disease based on initial DF, GAHS or MELD scores.We present an intuitive method of classifying patients with AH based on the trajectory of bilirubin over the first week of admission. It is complimentary to existing scores that identify candidates for corticosteroid treatment or assess response to treatment. This method identifies a group of patients with AH who recover spontaneously and can avoid corticosteroid therapy.

Objective Alcohol-related liver disease (ALD) ranges from never-decompensated ALD (ndALD) to the life-threatening decompensated phenotype, known as alcohol-related hepatitis (AH). A multidimensional study of the clinical, histological and molecular features of these subtypes is lacking. Design Two large cohorts of patients were recruited in an international, observational multicentre study: a retrospective cohort of patients with ndALD (n=110) and a prospective cohort of patients with AH (n=225). Clinical, analytical, immunohistochemistry and hepatic RNA microarray analysis of both disease phenotypes were performed. Results Age and mean alcohol intake were similar in both groups. AH patients had greater aspartate amino transferase/alanine amino transferase ratio and lower gamma-glutamyl transferase levels than in ndALD patients. Patients with AH demonstrated profound liver failure and increased mortality. One-year mortality was 10% in ndALD and 50% in AH. Histologically, steatosis grade, ballooning and pericellular fibrosis were similar in both groups, while advanced fibrosis, Mallory-Denk bodies, bilirubinostasis, severe neutrophil infiltration and ductular reaction were more frequent among AH patients. Transcriptome analysis revealed a profound gene dysregulation within both phenotypes when compare to controls. While ndALD was characterised by deregulated expression of genes involved in matrisome and immune response, the development of AH resulted in a marked deregulation of genes involved in hepatocyte reprogramming and bile acid metabolism. Conclusions Despite comparable alcohol intake, AH patients presented with worse liver function compared with ndALD patients. Bilirubinostasis, severe fibrosis and ductular reaction were prominent features of AH. AH patients exhibited a more profound deregulation of gene expression compared with ndALD patients.

Hepatic encephalopathy (HE) is a frequent and severe complication of liver disease with poor patient outcomes. However, it is a poorly understood complication, with no consensus for diagnosis. Therefore, HE is often underdiagnosed. Differential diagnosis may be cumbersome because of non-specific symptoms, such as confusion, cognitive disorders, the aetiological factors of cirrhosis and comorbidities, which are often observed in cirrhotic patients. Therefore, an overt or covert form of HE should be systematically investigated. Advice is provided to drive patient work-up. Effective treatments are available to prevent or treat HE bouts, but the issue of single or combination therapy has not been resolved. Transjugular intrahepatic portosystemic shunt (TIPS) placement largely improved the prognosis of cirrhotic patients, but HE occurrence of HE is often a fear, even when post-TIPS HE can be avoided by a careful selection of patients and preventive treatment. HE is an indication of liver transplantation. However, its reversibility post-transplantation and the consequences of transplantation in patients with other causes of neurological disorders remain controversial, which supports the performance of an extensive work-up in expert centres for this subset of patients. The present guidelines assist clinicians in the diagnosis of the overt or covert form of HE to implement curative and preventive treatments and clarify which patients require referral to expert centres for consideration for liver transplantation. These guidelines are very clinically oriented and address different frequent clinical issues to help physicians make bedside decisions.

Abstract Background Crohn’s disease (CD) is a progressive, destructive, and disabling disorder. Our study aimed to assess changes over time in the Lémann index (LI) and the Inflammatory Bowel Disease Disability Index (IBD-DI) in a cohort of CD patients. Methods This was a single-center prospective cohort study of 130 consecutive CD patients with a follow-up of at least 4 years. The LI 1 and the IBD-DI 1 questionnaires were assessed in 2016 and again between September 2020 and October 2021 (LI 2 and IBD-DI 2). Results Of the 130 patients with assessment of both LI 1 and IBD-DI 1, 61 had calculation of the LI 2 and 98 patients answered the IBD-DI 2 questionnaire, with a median time between the 2 evaluations of 4.2 years. The LI increased for 16 (26%), decreased for 26 (43%), and remained unchanged for 19 (31%) patients. The median LI did not change over time (9.6 vs 9.3; P = .14). Clinical disease activity was significantly associated with bowel damage progression. A high initial LI (&amp;gt;7.9) was not associated with CD progression (surgery, drug dose escalation, or change of biologic). The IBD-DI decreased for 59 (60.2%), increased for 37 (37.8%), and remained unchanged for 2 (2%) patients. The median IBD-DI decreased significantly over time (23.2 vs 21.4; P = .006). There was no correlation between the 2 indexes. Conclusions This is the first prospective cohort study assessing changes over time in both the LI and the IBD-DI in CD patients. After 4 years, the LI appeared to be stable and the IBD-DI decreased, with no correlation between the 2 indexes.

Because of the ongoing debate on the benefit of ultrasound (US) screening for hepatocellular carcinoma (HCC), we assessed the impact of screening on hepatitis C virus (HCV)-related compensated cirrhosis patients aware of their HCV status. A Markov model simulated progression from HCC diagnosis to death in 700 patients with HCV-related compensated cirrhosis aware of their HCV status to estimate life expectancy (LE) and cumulative death at 5 years. Five scenarios were compared: S1, no screening; S2, screening by currently existing practices (57% access and effectiveness leading to the diagnosis of 42% at Barcelona Clinic Liver Cancer stage [BCLC-0/A]); S3, S2 with increased access (97%); S4, S2 with an efficacy of screening close to that achieved in a randomized controlled trial leading to the diagnosis of 87% of patients at stage BCLC-0/A; S5, S3+S4. The analysis was corrected for lead-time bias. Currently existing practices of HCC screening increased LE by 11 months and reduced HCC mortality at 5 years by 6% compared to no screening (P = 0.0013). Compared to current screening practices, we found that: 1) increasing the rate of access to screening would increase LE by 7 months and reduce HCC mortality at 5 years by 5% (P = 0.045); 2) optimal screening would increase LE by 14 months and reduce HCC mortality at 5 years by 9% (P = 0.0002); 3) the combination of an increased rate of access and optimal effectiveness of HCC screening would increase LE by 31 months and decrease HCC mortality at 5 years by 20% (P < 0.0001).The present study shows that US screening for HCC in patients with compensated HCV-related cirrhosis aware of their HCV status improves survival and emphasizes the crucial role of screening effectiveness.

The reliability of transient elastography (TE) to assess liver fibrosis is insufficiently validated in alcoholic liver disease (ALD). We aimed to validate the diagnostic utility of TE for liver fibrosis in patients with excessive alcohol consumption and evaluate whether Fibrotest® adds diagnostic value relative to or in combination with TE.We conducted a multicentre prospective study on a total of 217 heavy drinkers with high serum aminotransferase levels. Patients underwent liver biopsy, TE, Fibrotest® , PGAA, APRI, FIB-4 and FORNS. The overall diagnostic performance was evaluated by the area under the receiver operating characteristic (AUROC) curves and Obuchowski measures.TE values correlated with fibrosis stage (r=.73; P<.0001) and steatosis stage (r=.19; P<.01). Patients with alcoholic hepatitis had higher TE values than those without alcoholic hepatitis (P<.0001). In an multivariate analysis, fibrosis stage and the presence of alcoholic hepatitis were the only parameters that correlated with liver stiffness. For the diagnosis of advanced fibrosis (F≥3), the AUROC curves were 0.90, 0.85, 0.83, 0.91 and 0.90 for TE, Fibrotest® , PGAA and associations TE-Fibrotest® , TE-PGAA respectively. For the diagnosis of cirrhosis, the AUROC curves were 0.93, 0.88, 0.89, 0.94 and 0.95 respectively. The Obuchowski measures for the diagnosis of fibrosis were 0.94, 0.92, 0.91, 0.95 and 0.94 respectively. The performance of TE was not significantly different than those of Fibrotest® , PGAA and combinations TE-Fibrotest® , TE-PGAA.TE has excellent diagnostic value for liver fibrosis in alcoholic liver disease. The combined use of TE-Fibrotest® or TE-PGAA does not improve the performance of TE.

Background: Cannabidiol (CBD) is a natural component of cannabis that possesses a widespread and complex immunomodulatory, antioxidant, anxiolytic, and antiepileptic properties. Much experimental data suggest that CBD could be used for various purposes in alcohol use disorder (AUD) and alcohol-related damage on the brain and the liver. Aim: To provide a rationale for using CBD to treat human subjects with AUD, based on the findings of experimental studies. Methods: Narrative review of studies pertaining to the assessment of CBD efficiency on drinking reduction, or on the improvement of any aspect of alcohol-related toxicity in AUD. Results: Experimental studies find that CBD reduces the overall level of alcohol drinking in animal models of AUD by reducing ethanol intake, motivation for ethanol, relapse, anxiety, and impulsivity. Moreover, CBD reduces alcohol-related steatosis and fibrosis in the liver by reducing lipid accumulation, stimulating autophagy, modulating inflammation, reducing oxidative stress, and by inducing death of activated hepatic stellate cells. Finally, CBD reduces alcohol-related brain damage, preventing neuronal loss by its antioxidant and immunomodulatory properties. Conclusions: CBD could directly reduce alcohol drinking in subjects with AUD. Any other applications warrant human trials in this population. By reducing alcohol-related steatosis processes in the liver, and alcohol-related brain damage, CBD could improve both hepatic and neurocognitive outcomes in subjects with AUD, regardless of the individual's drinking trajectory. This might pave the way for testing new harm reduction approaches in AUD, in order to protect the organs of subjects with an ongoing AUD.

<h3>Background & Aims</h3> Severe alcoholic hepatitis (SAH) is associated with a high risk of infection. The IL-33/ST2 pathway is involved in sepsis control but data regarding its role in alcohol-related liver disease (ALD) are lacking. We aimed to characterize the role of IL-33/ST2 in the polymorphonuclear neutrophils (PMNs) of patients with ALD and SAH. <h3>Methods</h3> Serum and circulating neutrophils were collected from patients with SAH, alcoholic cirrhosis and healthy controls. We quantified IL-33/ST2 pathway activity and CXCR2 at baseline and after exposure to IL-33. We also determined the migration capacity of PMNs. <h3>Results</h3> The decoy receptor of IL-33 (soluble ST2 [sST2]) was increased in SAH <i>vs.</i> cirrhosis and controls, demonstrating the defect in this pathway during ALD. The sST2 level was associated with response to treatment, 2-month survival, infection-free survival and probability of infection in SAH. Endotoxemia was weakly correlated with sST2. GRK2, a negative regulator of CXCR2, was overexpressed in PMNs of patients with SAH and cirrhosis and was decreased by IL-33. CXCR2 levels on PMNs were lower in SAH <i>vs.</i> cirrhosis and controls. Treatment with IL-33 partially restored CXCR2 expression in SAH and cirrhosis. PMN migration upon IL-8 was lower in patients with SAH and cirrhosis <i>vs.</i> controls. Treatment with IL-33 partially restored migration in those with SAH and cirrhosis. Interestingly, the migration capacity of PMNs and the response to IL-33 were enhanced in responders to corticosteroids (Lille <0.45) compared to non-responders. <h3>Conclusion</h3> The IL33/ST2 pathway is defective in SAH and predicts outcome. This defect is associated with decreased CXCR2 expression on the surface of PMNs and lower migration capacity, which can be corrected by IL-33, especially in patients responding to steroids. These results suggest that IL-33 has therapeutic potential for SAH and its infectious complications. <h3>Lay summary</h3> The neutrophils of patients with severe alcoholic hepatitis are associated with a defect in the IL-33/ST2 pathway. This defect is associated with lower migration capacities in neutrophils and a higher probability of getting infected. Administration of IL-33 to the neutrophils at least partly restores this defect and may be effective at reducing the risk of infection in patients with severe alcoholic hepatitis.

To produce French guidelines on Management of Liver failure in general Intensive Care Unit (ICU). A consensus committee of 23 experts from the French Society of Anesthesiology and Critical Care Medicine (Société française d’anesthésie et de réanimation, SFAR) and the French Association for the Study of the Liver (Association française pour l’étude du foie, AFEF) was convened. A formal conflict-of-interest (COI) policy was developed at the start of the process and enforced throughout. The entire guideline process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Some recommendations were ungraded. Two fields were defined: acute liver failure (ALF) and cirrhotic patients in general ICU. The panel focused on three questions with respect to ALF: (1) Which etiological examinations should be performed to reduce morbidity and mortality? (2) Which specific treatments should be initiated rapidly to reduce morbidity and mortality? (3) Which symptomatic treatment should be initiated rapidly to reduce morbidity and mortality? Seven questions concerning cirrhotic patients were addressed: (1) Which criteria should be used to guide ICU admission of cirrhotic patients in order to improve their prognosis? (2) Which specific management of kidney injury should be implemented to reduce morbidity and mortality in cirrhotic ICU patients? (3) Which specific measures to manage sepsis in order to reduce morbidity and mortality in cirrhotic ICU patients? (4) In which circumstances, human serum albumin should be administered to reduce morbidity and mortality in cirrhotic ICU patients? (5) How should digestive haemorrhage be treated in order to reduce morbidity and mortality in cirrhotic ICU patients? (6) How should haemostasis be managed in order to reduce morbidity and mortality in cirrhotic ICU patients? And (7) When should advice be obtained from an expert centre in order to reduce morbidity and mortality in cirrhotic ICU patients? Population, intervention, comparison and outcome (PICO) issues were reviewed and updated as required, and evidence profiles were generated. An analysis of the literature and recommendations was then performed in accordance with the GRADE® methodology. The SFAR/AFEF Guidelines panel produced 18 statements on liver failure in general ICU. After two rounds of debate and various amendments, a strong agreement was reached on 100% of the recommendations: six had a high level of evidence (Grade 1 ±), seven had a low level of evidence (Grade 2 ±) and six were expert judgments. Finally, no recommendation was provided with respect to one question. Substantial agreement exists among experts regarding numerous strong recommendations on the optimum care of patients with liver failure in general ICU.

Abstract Alcohol‐associated liver disease (ALD) is emerging worldwide as the leading cause of liver‐related morbidity, mortality, and indication for liver transplantation. The ALD Special Interest Group and the Clinical Research Committee at the digital American Association for the Study of Liver Diseases meeting in November 2020 held the scientific sessions to identify clinical unmet needs in ALD, and addressing these needs using clinical research methodologies. Of several research methodologies, the sessions were focused on (a) studying disease burden of ALD using large administrative databases, (b) developing biomarkers for noninvasive diagnosis of alcohol‐associated hepatitis (AH) and estimation of disease prognosis, (c) identifying therapeutic targets for ALD and AH, (d) deriving accurate models to predict prognosis or posttransplant alcohol relapse as a basis for developing treatment algorithm and a uniform protocol on patient‐selection criteria for liver transplantation, and (e) examining qualitative research methodologies in studying the barriers to implementation of multidisciplinary integrated care model by hepatology and addiction teams for the management of dual pathology of liver disease and of alcohol use disorder. Prospective multicenter studies are required to address many of these clinical unmet needs. Further, multidisciplinary care models are needed to improve long‐term outcomes in patients with ALD.

•AH hepatitis is associated with multi-organ failure and high short-term mortality.•MELD 3.0 predicted 30- and 90-day mortality better compared with the MELD-Na score and mDF.•MELD 3.0 was not superior to MELD and ABIC scores in predicting mortality, but its classification accuracy was similar between countries.•MELD 3.0 was the best predictor of renal replacement therapy requirements compared with other models. Background & AimsModel for End-Stage Liver Disease (MELD) score better predicts mortality in alcohol-associated hepatitis (AH) but could underestimate severity in women and malnourished patients. Using a global cohort, we assessed the ability of the MELD 3.0 score to predict short-term mortality in AH.MethodsThis was a retrospective cohort study of patients admitted to hospital with AH from 2009 to 2019. The main outcome was all-cause 30-day mortality. We compared the AUC using DeLong's method and also performed a time-dependent AUC with competing risks analysis.ResultsA total of 2,124 patients were included from 28 centres from 10 countries on three continents (median age 47.2 ± 11.2 years, 29.9% women, 71.3% with underlying cirrhosis). The median MELD 3.0 score at admission was 25 (20–33), with an estimated survival of 73.7% at 30 days. The MELD 3.0 score had a better performance in predicting 30-day mortality (AUC:0.761, 95%CI:0.732–0.791) compared with MELD sodium (MELD-Na; AUC: 0.744, 95% CI: 0.713–0.775; p = 0.042) and Maddrey’s discriminant function (mDF) (AUC: 0.724, 95% CI: 0.691–0.757; p = 0.013). However, MELD 3.0 did not perform better than traditional MELD (AUC: 0.753, 95% CI: 0.723–0.783; p = 0.300) and Age-Bilirubin-International Normalised Ratio-Creatinine (ABIC) (AUC:0.757, 95% CI: 0.727–0.788; p = 0.765). These results were consistent in competing-risk analysis, where MELD 3.0 (AUC: 0.757, 95% CI: 0.724–0.790) predicted better 30-day mortality compared with MELD-Na (AUC: 0.739, 95% CI: 0.708–0.770; p = 0.028) and mDF (AUC:0.717, 95% CI: 0.687–0.748; p = 0.042). The MELD 3.0 score was significantly better in predicting renal replacement therapy requirements during admission compared with the other scores (AUC: 0.844, 95% CI: 0.805–0.883).ConclusionsMELD 3.0 demonstrated better performance compared with MELD-Na and mDF in predicting 30-day and 90-day mortality, and was the best predictor of renal replacement therapy requirements during admission for AH. However, further prospective studies are needed to validate its extensive use in AH.Impact and implicationsSevere AH has high short-term mortality. The establishment of treatments and liver transplantation depends on mortality prediction. We evaluated the performance of the new MELD 3.0 score to predict short-term mortality in AH in a large global cohort. MELD 3.0 performed better in predicting 30- and 90-day mortality compared with MELD-Na and mDF, but was similar to MELD and ABIC scores. MELD 3.0 was the best predictor of renal replacement therapy requirements. Thus, further prospective studies are needed to support the wide use of MELD 3.0 in AH. Model for End-Stage Liver Disease (MELD) score better predicts mortality in alcohol-associated hepatitis (AH) but could underestimate severity in women and malnourished patients. Using a global cohort, we assessed the ability of the MELD 3.0 score to predict short-term mortality in AH. This was a retrospective cohort study of patients admitted to hospital with AH from 2009 to 2019. The main outcome was all-cause 30-day mortality. We compared the AUC using DeLong's method and also performed a time-dependent AUC with competing risks analysis. A total of 2,124 patients were included from 28 centres from 10 countries on three continents (median age 47.2 ± 11.2 years, 29.9% women, 71.3% with underlying cirrhosis). The median MELD 3.0 score at admission was 25 (20–33), with an estimated survival of 73.7% at 30 days. The MELD 3.0 score had a better performance in predicting 30-day mortality (AUC:0.761, 95%CI:0.732–0.791) compared with MELD sodium (MELD-Na; AUC: 0.744, 95% CI: 0.713–0.775; p = 0.042) and Maddrey’s discriminant function (mDF) (AUC: 0.724, 95% CI: 0.691–0.757; p = 0.013). However, MELD 3.0 did not perform better than traditional MELD (AUC: 0.753, 95% CI: 0.723–0.783; p = 0.300) and Age-Bilirubin-International Normalised Ratio-Creatinine (ABIC) (AUC:0.757, 95% CI: 0.727–0.788; p = 0.765). These results were consistent in competing-risk analysis, where MELD 3.0 (AUC: 0.757, 95% CI: 0.724–0.790) predicted better 30-day mortality compared with MELD-Na (AUC: 0.739, 95% CI: 0.708–0.770; p = 0.028) and mDF (AUC:0.717, 95% CI: 0.687–0.748; p = 0.042). The MELD 3.0 score was significantly better in predicting renal replacement therapy requirements during admission compared with the other scores (AUC: 0.844, 95% CI: 0.805–0.883). MELD 3.0 demonstrated better performance compared with MELD-Na and mDF in predicting 30-day and 90-day mortality, and was the best predictor of renal replacement therapy requirements during admission for AH. However, further prospective studies are needed to validate its extensive use in AH.

Background/Aims The benefit of amantadine combination therapy, either with interferon (IFN) alone (double therapy) or with ribavirin and IFN (triple therapy) is unknown. Methods We analyzed the effect of amantadine on the end-of-treatment virological response and the sustained response using meta-analysis of 31 randomized controlled trials. Results Overall analysis revealed a significant effect of amantadine. Triple therapy was the best regimen for improving the sustained response (mean difference: 8.4%, 95% CI: 2.4–13.8%, P=0.002). In subgroup analysis, amantadine did not have a significant effect upon naive patients or relapsers. In non-responders, combination therapy with amantadine was associated with a significant effect on the sustained response (mean difference: 8.3%, 95% CI: 1.9–14.6%, P=0.01). In sensitivity analysis, double therapy did not improve virological responses. Conversely, triple therapy tended to improve the end-of-treatment virological response and was associated with a significant effect upon the sustained response (mean difference: 12.7%, 95% CI: 3.8–21.6%, P=0.005). Conclusions Combination therapy with amantadine is of no effect upon naive patients or relapsers. In non-responders, triple therapy with amantadine improved the sustained response. New randomized controlled trials are required to confirm this meta-analysis. The benefit of amantadine combination therapy, either with interferon (IFN) alone (double therapy) or with ribavirin and IFN (triple therapy) is unknown. We analyzed the effect of amantadine on the end-of-treatment virological response and the sustained response using meta-analysis of 31 randomized controlled trials. Overall analysis revealed a significant effect of amantadine. Triple therapy was the best regimen for improving the sustained response (mean difference: 8.4%, 95% CI: 2.4–13.8%, P=0.002). In subgroup analysis, amantadine did not have a significant effect upon naive patients or relapsers. In non-responders, combination therapy with amantadine was associated with a significant effect on the sustained response (mean difference: 8.3%, 95% CI: 1.9–14.6%, P=0.01). In sensitivity analysis, double therapy did not improve virological responses. Conversely, triple therapy tended to improve the end-of-treatment virological response and was associated with a significant effect upon the sustained response (mean difference: 12.7%, 95% CI: 3.8–21.6%, P=0.005). Combination therapy with amantadine is of no effect upon naive patients or relapsers. In non-responders, triple therapy with amantadine improved the sustained response. New randomized controlled trials are required to confirm this meta-analysis.

Tumor necrosis factor is an adipocytokine possessing a well-established lipolytic effect. In Crohn's disease (CD) patients, infliximab therapy may thus result in visceral fat accumulation, which is associated with an increased risk of metabolic syndrome. A total of 132 CD patients were investigated. In a first prospective study, magnetic resonance imaging (MRI) quantification of subcutaneous and visceral abdominal fat was performed before and 8 weeks after initiation of infliximab induction therapy (5 mg/kg at weeks 0, 2, and 6) in 21 responding patients treated for perianal disease. In a second prospective study, fasting glycemia, glycated hemoglobin (HbA1c), HDL, LDL, and total cholesterol and triglyceride levels were assessed in 111 responding patients receiving infliximab infusions every 8 weeks, with a mean follow-up of 41 weeks. A significant homogeneous 18% increase in total abdominal fat was observed in the 21 CD patients after infliximab induction therapy (P = 0.027), independently of body mass index evolution. Infliximab maintenance therapy was associated with a decrease in glycemia (P < 0.0001) and HbA1c (P = 0.0005) concentrations, together with an increase in both total cholesterol (P = 0.02) and HDL cholesterol (P = 0.008) concentrations. All glycemic and lipid parameters remained within the normal range throughout the study. Infliximab induction therapy is associated with a significant increase in abdominal fat tissue in CD patients. Infliximab maintenance therapy has no deleterious effects on lipid profile and is accompanied by a decrease in glycemia and HbA1c concentrations, probably by reversing the impairment of tumor necrosis factor-induced insulin-mediated glucose uptake.

Hepatocellular carcinoma in noncirrhotic liver (NC-HCC) presents usually with large size, which is seen as a contraindication to liver transplantation (LT) or even resection. The objective of our single-center study was to identify prognostic factors following resection of large NC-HCCs and to subsequently devise a treatment strategy (including LT) in selected patients.From 2000 to 2010, 89 patients who had hepatic resection for NC-HCC (large ≥ 8 cm in 52) were analyzed with regard to pathological findings, postoperative and long-term outcome.Five patients died postoperatively. After a mean follow-up of 35 ± 30 months, NC-HCC recurred in 36 patients (26/47 survivors in group 8 cm+, 10/37 in group 8 cm-; p = 0.007). Five-year overall (OS) and disease-free survival (DFS) rates were significantly worse for group 8 cm+ (43.4% vs. 89.2% and 39.3% vs. 60.7% for group 8 cm-, p < 0.05). Seven patients underwent re-hepatectomy and/or LT for isolated intrahepatic recurrence, with 5-year DFS of 57.1%. In a multivariate analysis, the factors associated with poor OS and DFS were vascular invasion and tumor size ≥ 8 cm in the overall population and vascular invasion, fibrosis and satellite nodules in group 8 cm+. Adjuvant transarterial chemotherapy was a protective factor in group 8 cm+. In 22 isolated NC-HCC cases with no vascular invasion or fibrosis, tumor size had no impact on five-year DFS (85%).Although patients with NC-HCC ≥ 8 cm had a poorer prognosis, the absence of vascular invasion or fibrosis was associated with excellent survival, regardless of the tumor size. In recurrent patients, aggressive treatment (including LT) can be considered.

Background Myxomatous mitral valve disease (MMVD) is an important cause of morbidity and mortality in dogs. Objectives To compare, throughout the period of follow‐up of dogs that had not yet reached the primary endpoint, the longitudinal effects of pimobendan versus benazepril hydrochloride treatment on quality‐of‐life (QoL) variables, concomitant congestive heart failure (CHF) treatment, and other outcome variables in dogs suffering from CHF secondary to MMVD. Animals A total of 260 dogs in CHF because of MMVD. Methods A prospective single‐blinded study with dogs randomized to receive pimobendan (0.4–0.6 mg/kg/day) or benazepril hydrochloride (0.25–1.0 mg/kg/day). Differences in outcome variables and time to intensification of CHF treatment were compared. Results A total of 124 dogs were randomized to pimobendan and 128 to benazepril. No difference was found between groups in QoL variables during the trial. Time from inclusion to 1st intensification of CHF treatment was longer in the pimobendan group (pimobendan 98 days, IQR 30–276 days versus benazepril 59 days, IQR 11–121 days; P = .0005). Postinclusion, dogs in the pimobendan group had smaller heart size based on VHS score ( P = .013) and left ventricular diastolic ( P = .035) and systolic ( P = .0044) dimensions, higher body temperature ( P = .030), serum sodium ( P = .0027), and total protein ( P = .0003) concentrations, and packed cell volume ( P = .030). Incidence of arrhythmias was similar in treatment groups. Conclusions and Clinical Importance Pimobendan versus benazepril resulted in similar QoL during the study, but conferred increased time before intensification of CHF treatment. Pimobendan treatment resulted in smaller heart size, higher body temperature, and less retention of free water.

Alcohol-related liver disease is one of the most prevalent chronic liver diseases worldwide. Mechanisms involved in the pathogenesis of alcohol-related liver disease are not well understood. Oxylipins play a crucial role in numerous biological processes and pathological conditions. Nevertheless, oxylipins are not well studied in alcohol-related liver disease.(1) To characterize the patterns of bioactive ω-3 and ω-6 polyunsaturated fatty acid metabolites in alcohol use disorder and alcoholic hepatitis patients and (2) to identify associations of serum oxylipins with clinical parameters in patients with alcohol-related liver disease.We performed a comprehensive liquid chromatography with tandem mass spectrometry (LC-MS/MS) analysis of serum and fecal oxylipins derived from ω-6 arachidonic acid, ω-3 eicosapentaenoic acid, and docosahexaenoic acid in a patient cohort with alcohol-related liver disease.Our results show profound alterations in the serum oxylipin profile of patients with alcohol use disorder and alcoholic hepatitis compared to nonalcoholic controls. Spearman correlation of the oxylipins with clinical parameters shows a link between different serum oxylipins and intestinal permeability, aspartate aminotransferase, bilirubin, albumin, international normalized ratio, platelet count, steatosis, fibrosis and model for end-stage liver disease score. Especially, higher level of serum 20-HETE was significantly associated with decreased albumin, increased hepatic steatosis, polymorphonuclear infiltration, and 90-day mortality.Patients with alcohol-related liver disease have different oxylipin profiles. Future studies are required to confirm oxylipins as disease biomarker or to connect oxylipins to disease pathogenesis.

Liver transplantation for patients with acute-on-chronic liver failure (ACLF) in Europe: Results of the ELITA/EF-CLIF collaborative study (ECLIS)Journal of HepatologyVol. 75Issue 3PreviewLiver transplantation (LT) has been proposed as an effective salvage therapy even for the sickest patients with acute-on-chronic liver failure (ACLF). This large collaborative study was designed to assess the current clinical practice and outcomes of patients with ACLF who are wait-listed for LT in Europe. Full-Text PDF Reply to: “Sarcopenia should be evaluated in patients with acute-on-chronic liver failure and candidates to liver transplantation”Journal of HepatologyVol. 76Issue 4PreviewWe thank Artru and colleagues1 for their interest in our study and for commenting specifically on the importance of sarcopenia on post-LT outcomes. Given the retrospective nature of our study, the severity of sarcopenia was not routinely measured.2 Therefore, we welcome the important data provided by Artru et al. in this issue of the Journal. They studied 314 patients who underwent liver transplantation for ACLF and had detailed evaluation of sarcopenia using transversal right psoas muscle thickness at the level of the umbilicus (TPMT/height) and psoas muscle index (PMI) at the L3-L4 level. Full-Text PDF We have read with great interest the manuscript of Belli et al.[1]Belli L.S. Duvoux C. Artzner T. Bernal W. Conti S. Cortesi P.A. et al.Liver transplantation for patients with acute-on-chronic liver failure (ACLF) in Europe: results of the ELITA/EF-CLIF collaborative study (ECLIS).J Hepatol. 2021; 75: 610-622https://doi.org/10.1016/j.jhep.2021.03.030Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar reporting a wide variation in listing for patients with acute-on-chronic liver failure (ACLF) in Europe despite favorable outcome after liver transplantation (LT). The authors have particularly observed, after multivariate analyses, the negative impact of pre-LT multi drug resistant organism (MDRO) infection, arterial lactate levels at LT >4 mmol/L and the need for renal replacement therapy (RRT) at LT.[1]Belli L.S. Duvoux C. Artzner T. Bernal W. Conti S. Cortesi P.A. et al.Liver transplantation for patients with acute-on-chronic liver failure (ACLF) in Europe: results of the ELITA/EF-CLIF collaborative study (ECLIS).J Hepatol. 2021; 75: 610-622https://doi.org/10.1016/j.jhep.2021.03.030Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar Identifying risk factors associated with poorer post-LT outcomes in this population is crucial and the authors must be congratulated for their efforts in this regard. However, the retrospective design of this study and others in the field might bias the analyses, as several variables, considered as important, have not been studied yet. Indeed, as highlighted by the authors in the discussion section, the impact of sarcopenia on post-LT outcome was not assessed in this study nor in others in the field. As only few retrospective studies are available on this topic, it is unclear if clinicians considered the nutritional status of patients with ACLF at time of deciding on transplantability. In a new analysis of our cohort previously published in Journal of Hepatology[2]Artru F. Louvet A. Ruiz I. Levesque E. Labreuche J. Ursic-Bedoya J. et al.Liver transplantation in the most severely ill cirrhotic patients: a multicenter study in acute-on-chronic liver failure grade 3.J Hepatol. 2017; 67: 708-715https://doi.org/10.1016/j.jhep.2017.06.009Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar reporting favorable and non-different 1-year survival in patients transplanted with ACLF grade 3 compared to matched control patients transplanted with ACLF grade <3 or no ACLF, we aimed to assess if radiological parameters of sarcopenia were associated with outcome. All patients included in our first publication were considered in the present study. Radiological parameters of sarcopenia were retrospectively assessed on CT scans performed at time of LT (±15 days) when available using transversal right psoas muscle thickness at the umbilical level/height (TPMT/height in mm/m)[3]Durand F. Buyse S. Francoz C. Laouénan C. Bruno O. Belghiti J. et al.Prognostic value of muscle atrophy in cirrhosis using psoas muscle thickness on computed tomography.J Hepatol. 2014; 60: 1151-1157https://doi.org/10.1016/j.jhep.2014.02.026Abstract Full Text Full Text PDF PubMed Scopus (242) Google Scholar and psoas muscle index (PMI in cm2/m2) at the L3-L4 level.[4]Ebadi M. Wang C.W. Lai J.C. Dasarathy S. Kappus M.R. Dunn M.A. et al.Poor performance of psoas muscle index for identification of patients with higher waitlist mortality risk in cirrhosis.J Cachexia Sarcopenia Muscle. 2018; 9: 1053-1062https://doi.org/10.1002/jcsm.12349Crossref PubMed Scopus (70) Google Scholar Age, hospitalization status (home, general ward, intensive care unit [ICU]), model for end-stage liver disease score and grade of ACLF were available for patients at time of LT. We studied the main patient characteristics in the ACLF cohort that were associated with 1-year survival on univariate and multivariate analysis using the Cox proportional hazards regression models. The overall survival curves at 1 year were estimated using the Kaplan-Meier method and were compared using the log-rank test. Statistical testing was done at the 2-tailed α level of 0.05. CT scans allowing for the assessment of TPMT/height and PMI were available in 584 out of 629 patients (93%) initially included in our previous study: 270/292 patients without ACLF, 105/119 patients with ACLF grade 1, 139/145 ACLF grade 2 and 70/73 ACLF grade 3. For these patients, 1-year survival was respectively 91% (95% CI 87-94) vs. 83% (76-90) vs. 88% (83-94) vs. 83% (74-92), p = 0.1. TPMT/height was 18.4 mm/m (15.4-21.1) vs. 17.5 mm/m (15.4 - 20.0) vs. 16.9 mm/m (14.6-20.2) vs. 16.1 mm/m (14.1-18.6), respectively, p <0.0001. PMI was 6.9 cm2/m2 (5.6-8.3) vs. 6.3 cm2/m2 (5.1-7.3) vs. 6.1 cm2/m2 (5.2-7.4) vs. 5.4 cm2/m2 (4.6-6.5), respectively, p <0.0001. Uni and multivariate analyses associated with 1-year survival in the ACLF cohort are provided in Table 1 and suggest an independent association between 1-year mortality and radiological parameters of sarcopenia. In a second step, we aimed to assess the ability of the already published thresholds of TPMT/height (16.6 mm/m)[3]Durand F. Buyse S. Francoz C. Laouénan C. Bruno O. Belghiti J. et al.Prognostic value of muscle atrophy in cirrhosis using psoas muscle thickness on computed tomography.J Hepatol. 2014; 60: 1151-1157https://doi.org/10.1016/j.jhep.2014.02.026Abstract Full Text Full Text PDF PubMed Scopus (242) Google Scholar and PMI (5.1 cm2/m2 in men and 4.3 cm2/m2) in women[4]Ebadi M. Wang C.W. Lai J.C. Dasarathy S. Kappus M.R. Dunn M.A. et al.Poor performance of psoas muscle index for identification of patients with higher waitlist mortality risk in cirrhosis.J Cachexia Sarcopenia Muscle. 2018; 9: 1053-1062https://doi.org/10.1002/jcsm.12349Crossref PubMed Scopus (70) Google Scholar to identify patients with ACLF with poorer outcome following LT. These thresholds respectively identified 2 populations with different 1-year survival: 91% (86-96) vs. 79% (73-86), p = 0.004 (Fig. 1A) and 88% (84-92) vs. 75% (65-85), p = 0.007 (Fig. 1B).Table 1Multivariate analysis of factors associated with 1-year mortality in patients with ACLF at time of liver transplantation.CovariantUnivariate analysisMultivariate analysisHR95% CIp valueHR95% CIp valueMale sex1.110.56 -1.980.86Age (per 10-year increase)0.920.72-1.340.92MELD score1.010.96-1.060.83Hospitalization status1.510.98-2.350.061.430.91-2.220.11Grade ACLF0.910.64-1.430.84TPMT/height0.920.86-0.990.050.930.86-1.000.07∗Analyses performed separately to avoid collinearity.PMI0.890.66-0.970.020.820.68-0.990.03∗Analyses performed separately to avoid collinearity.Male (n = 222)Age (per 10-year increase)1.310.89-1.930.24MELD score1.030.97-1.100.33Hospitalization status1.470.88-2.460.13Grade ACLF1.020.64-1.640.91TPMT/height0.950.88-1.010.090.950.88-1.010.09∗Analyses performed separately to avoid collinearity.PMI0.830.67-1.000.080.830.67-1.000.08∗Analyses performed separately to avoid collinearity.Female (n = 92)Age (per 10-year increase)0.470.28-0.830.0080.520.29-0.940.03MELD score0.960.89-1.030.29Hospitalization status1.640.71-3.800.25Grade ACLF0.820.40-1.700.60TPMT/height0.820.71-0.950.010.850.73-0.970.03∗Analyses performed separately to avoid collinearity.PMI0.720.61-0.980.040.880.79.-0.990.05∗Analyses performed separately to avoid collinearity.ACLF, acute on chronic liver failure; MELD, model for end-stage liver disease; PMI psoas muscle index; TPMT/height transversal right psoas muscle thickness at the umbilical level/height. Uni and multivariate analysis using the Cox proportional hazards regression models.∗ Analyses performed separately to avoid collinearity. Open table in a new tab In sensitivity analyses according to sex, there was only a trend towards an association of these parameters with 1-year survival in men while the association was independent in women, in cox regression analyses (Table 1). In the same line, women with low TPMT/height and PMI according to established thresholds experienced lower survival 77% (67-88) vs. 97% (91-100), p = 0.01, and 74% (56-90) vs. 88% (81-96), p = 0.04, respectively. Men with low PMI had significant lower 1-year survival (76% (63-88) vs. 88% (83-93), p = 0.05). Male patients with low TPMT/height experienced a trend towards lower survival (80% (73-85) vs. 89% (84-95), p = 0.07).The present analyses on our previously published cohort suggest three important considerations. First, even if non-different 1-year survivals after LT were observed, patients transplanted with ACLF showed significantly decreased muscle mass compared to patients without ACLF, with the most severe sarcopenia observed in ACLF grade 3 patients. This suggests that despite a stringent selection process, only about 3% of patients with cirrhosis in the ICU were selected for LT,[2]Artru F. Louvet A. Ruiz I. Levesque E. Labreuche J. Ursic-Bedoya J. et al.Liver transplantation in the most severely ill cirrhotic patients: a multicenter study in acute-on-chronic liver failure grade 3.J Hepatol. 2017; 67: 708-715https://doi.org/10.1016/j.jhep.2017.06.009Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar some patients with severe sarcopenia were still carefully chosen for LT. Second, and despite the first observation, patients with the most severe sarcopenia have the lowest 1-year survival independently of other cofounding factors. Third, the evaluation of sarcopenia by psoas measurements seems less sensitive in men than in women, for transplanted patients with ACLF. However, due to the intrinsic retrospective design of our analyses, patients with the most severe sarcopenia still had acceptable outcomes.Nonetheless, our study has several limitations mainly related to the use of psoas-related sarcopenia parameters (variation of umbilicus level, psoas accounting for less than 15% of the total skeletal muscle area etc…). It has recently been confirmed that L3-skeletal muscle index (L3SMI) is more strongly correlated with total body protein[5]Wells C.I. McCall J.L. Plank L.D. Relationship between total body protein and cross-sectional skeletal muscle area in liver cirrhosis is influenced by overhydration.Liver Transplant Off Publ Am Assoc Study Liver Dis Int Liver Transplant Soc. 2019; 25: 45-55https://doi.org/10.1002/lt.25314Crossref PubMed Scopus (19) Google Scholar with less misclassification of mortality risk in patients with cirrhosis.[4]Ebadi M. Wang C.W. Lai J.C. Dasarathy S. Kappus M.R. Dunn M.A. et al.Poor performance of psoas muscle index for identification of patients with higher waitlist mortality risk in cirrhosis.J Cachexia Sarcopenia Muscle. 2018; 9: 1053-1062https://doi.org/10.1002/jcsm.12349Crossref PubMed Scopus (70) Google Scholar Moreover, patients with higher mortality risk are underestimated using psoas cut-offs. The psoas cut-offs in the present study were mainly used to illustrate the association between TPMT/height and PMI with 1-year mortality.[4]Ebadi M. Wang C.W. Lai J.C. Dasarathy S. Kappus M.R. Dunn M.A. et al.Poor performance of psoas muscle index for identification of patients with higher waitlist mortality risk in cirrhosis.J Cachexia Sarcopenia Muscle. 2018; 9: 1053-1062https://doi.org/10.1002/jcsm.12349Crossref PubMed Scopus (70) Google Scholar However, even if not ideal, the present study strongly suggests that psoas sarcopenia evaluation is an independent predictor of 1-year mortality in patients with ACLF.Therefore, we feel that a prospective evaluation of sarcopenia, particularly using L3SMI, should be integrated into the pre-transplant work up of patients with ACLF who are candidates for LT. This would allow us to assess the impact of sarcopenia on outcomes after LT. Finally, sarcopenia parameters could be implemented into a multivariate model to identify patients undergoing potentially inappropriate LT.Financial supportThe authors received no financial support to produce this manuscript.Authors’ contributionsDesign of the study: FA, CLG, GPG, FS, AL. Acquisition of data: FA, CLG. Statistical analysis: FA, AL. Drafting of the manuscript: FA, CLG, GPG, FS, AL. We have read with great interest the manuscript of Belli et al.[1]Belli L.S. Duvoux C. Artzner T. Bernal W. Conti S. Cortesi P.A. et al.Liver transplantation for patients with acute-on-chronic liver failure (ACLF) in Europe: results of the ELITA/EF-CLIF collaborative study (ECLIS).J Hepatol. 2021; 75: 610-622https://doi.org/10.1016/j.jhep.2021.03.030Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar reporting a wide variation in listing for patients with acute-on-chronic liver failure (ACLF) in Europe despite favorable outcome after liver transplantation (LT). The authors have particularly observed, after multivariate analyses, the negative impact of pre-LT multi drug resistant organism (MDRO) infection, arterial lactate levels at LT >4 mmol/L and the need for renal replacement therapy (RRT) at LT.[1]Belli L.S. Duvoux C. Artzner T. Bernal W. Conti S. Cortesi P.A. et al.Liver transplantation for patients with acute-on-chronic liver failure (ACLF) in Europe: results of the ELITA/EF-CLIF collaborative study (ECLIS).J Hepatol. 2021; 75: 610-622https://doi.org/10.1016/j.jhep.2021.03.030Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar Identifying risk factors associated with poorer post-LT outcomes in this population is crucial and the authors must be congratulated for their efforts in this regard. However, the retrospective design of this study and others in the field might bias the analyses, as several variables, considered as important, have not been studied yet. Indeed, as highlighted by the authors in the discussion section, the impact of sarcopenia on post-LT outcome was not assessed in this study nor in others in the field. As only few retrospective studies are available on this topic, it is unclear if clinicians considered the nutritional status of patients with ACLF at time of deciding on transplantability. In a new analysis of our cohort previously published in Journal of Hepatology[2]Artru F. Louvet A. Ruiz I. Levesque E. Labreuche J. Ursic-Bedoya J. et al.Liver transplantation in the most severely ill cirrhotic patients: a multicenter study in acute-on-chronic liver failure grade 3.J Hepatol. 2017; 67: 708-715https://doi.org/10.1016/j.jhep.2017.06.009Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar reporting favorable and non-different 1-year survival in patients transplanted with ACLF grade 3 compared to matched control patients transplanted with ACLF grade <3 or no ACLF, we aimed to assess if radiological parameters of sarcopenia were associated with outcome. All patients included in our first publication were considered in the present study. Radiological parameters of sarcopenia were retrospectively assessed on CT scans performed at time of LT (±15 days) when available using transversal right psoas muscle thickness at the umbilical level/height (TPMT/height in mm/m)[3]Durand F. Buyse S. Francoz C. Laouénan C. Bruno O. Belghiti J. et al.Prognostic value of muscle atrophy in cirrhosis using psoas muscle thickness on computed tomography.J Hepatol. 2014; 60: 1151-1157https://doi.org/10.1016/j.jhep.2014.02.026Abstract Full Text Full Text PDF PubMed Scopus (242) Google Scholar and psoas muscle index (PMI in cm2/m2) at the L3-L4 level.[4]Ebadi M. Wang C.W. Lai J.C. Dasarathy S. Kappus M.R. Dunn M.A. et al.Poor performance of psoas muscle index for identification of patients with higher waitlist mortality risk in cirrhosis.J Cachexia Sarcopenia Muscle. 2018; 9: 1053-1062https://doi.org/10.1002/jcsm.12349Crossref PubMed Scopus (70) Google Scholar Age, hospitalization status (home, general ward, intensive care unit [ICU]), model for end-stage liver disease score and grade of ACLF were available for patients at time of LT. We studied the main patient characteristics in the ACLF cohort that were associated with 1-year survival on univariate and multivariate analysis using the Cox proportional hazards regression models. The overall survival curves at 1 year were estimated using the Kaplan-Meier method and were compared using the log-rank test. Statistical testing was done at the 2-tailed α level of 0.05. CT scans allowing for the assessment of TPMT/height and PMI were available in 584 out of 629 patients (93%) initially included in our previous study: 270/292 patients without ACLF, 105/119 patients with ACLF grade 1, 139/145 ACLF grade 2 and 70/73 ACLF grade 3. For these patients, 1-year survival was respectively 91% (95% CI 87-94) vs. 83% (76-90) vs. 88% (83-94) vs. 83% (74-92), p = 0.1. TPMT/height was 18.4 mm/m (15.4-21.1) vs. 17.5 mm/m (15.4 - 20.0) vs. 16.9 mm/m (14.6-20.2) vs. 16.1 mm/m (14.1-18.6), respectively, p <0.0001. PMI was 6.9 cm2/m2 (5.6-8.3) vs. 6.3 cm2/m2 (5.1-7.3) vs. 6.1 cm2/m2 (5.2-7.4) vs. 5.4 cm2/m2 (4.6-6.5), respectively, p <0.0001. Uni and multivariate analyses associated with 1-year survival in the ACLF cohort are provided in Table 1 and suggest an independent association between 1-year mortality and radiological parameters of sarcopenia. In a second step, we aimed to assess the ability of the already published thresholds of TPMT/height (16.6 mm/m)[3]Durand F. Buyse S. Francoz C. Laouénan C. Bruno O. Belghiti J. et al.Prognostic value of muscle atrophy in cirrhosis using psoas muscle thickness on computed tomography.J Hepatol. 2014; 60: 1151-1157https://doi.org/10.1016/j.jhep.2014.02.026Abstract Full Text Full Text PDF PubMed Scopus (242) Google Scholar and PMI (5.1 cm2/m2 in men and 4.3 cm2/m2) in women[4]Ebadi M. Wang C.W. Lai J.C. Dasarathy S. Kappus M.R. Dunn M.A. et al.Poor performance of psoas muscle index for identification of patients with higher waitlist mortality risk in cirrhosis.J Cachexia Sarcopenia Muscle. 2018; 9: 1053-1062https://doi.org/10.1002/jcsm.12349Crossref PubMed Scopus (70) Google Scholar to identify patients with ACLF with poorer outcome following LT. These thresholds respectively identified 2 populations with different 1-year survival: 91% (86-96) vs. 79% (73-86), p = 0.004 (Fig. 1A) and 88% (84-92) vs. 75% (65-85), p = 0.007 (Fig. 1B). ACLF, acute on chronic liver failure; MELD, model for end-stage liver disease; PMI psoas muscle index; TPMT/height transversal right psoas muscle thickness at the umbilical level/height. Uni and multivariate analysis using the Cox proportional hazards regression models. In sensitivity analyses according to sex, there was only a trend towards an association of these parameters with 1-year survival in men while the association was independent in women, in cox regression analyses (Table 1). In the same line, women with low TPMT/height and PMI according to established thresholds experienced lower survival 77% (67-88) vs. 97% (91-100), p = 0.01, and 74% (56-90) vs. 88% (81-96), p = 0.04, respectively. Men with low PMI had significant lower 1-year survival (76% (63-88) vs. 88% (83-93), p = 0.05). Male patients with low TPMT/height experienced a trend towards lower survival (80% (73-85) vs. 89% (84-95), p = 0.07). The present analyses on our previously published cohort suggest three important considerations. First, even if non-different 1-year survivals after LT were observed, patients transplanted with ACLF showed significantly decreased muscle mass compared to patients without ACLF, with the most severe sarcopenia observed in ACLF grade 3 patients. This suggests that despite a stringent selection process, only about 3% of patients with cirrhosis in the ICU were selected for LT,[2]Artru F. Louvet A. Ruiz I. Levesque E. Labreuche J. Ursic-Bedoya J. et al.Liver transplantation in the most severely ill cirrhotic patients: a multicenter study in acute-on-chronic liver failure grade 3.J Hepatol. 2017; 67: 708-715https://doi.org/10.1016/j.jhep.2017.06.009Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar some patients with severe sarcopenia were still carefully chosen for LT. Second, and despite the first observation, patients with the most severe sarcopenia have the lowest 1-year survival independently of other cofounding factors. Third, the evaluation of sarcopenia by psoas measurements seems less sensitive in men than in women, for transplanted patients with ACLF. However, due to the intrinsic retrospective design of our analyses, patients with the most severe sarcopenia still had acceptable outcomes. Nonetheless, our study has several limitations mainly related to the use of psoas-related sarcopenia parameters (variation of umbilicus level, psoas accounting for less than 15% of the total skeletal muscle area etc…). It has recently been confirmed that L3-skeletal muscle index (L3SMI) is more strongly correlated with total body protein[5]Wells C.I. McCall J.L. Plank L.D. Relationship between total body protein and cross-sectional skeletal muscle area in liver cirrhosis is influenced by overhydration.Liver Transplant Off Publ Am Assoc Study Liver Dis Int Liver Transplant Soc. 2019; 25: 45-55https://doi.org/10.1002/lt.25314Crossref PubMed Scopus (19) Google Scholar with less misclassification of mortality risk in patients with cirrhosis.[4]Ebadi M. Wang C.W. Lai J.C. Dasarathy S. Kappus M.R. Dunn M.A. et al.Poor performance of psoas muscle index for identification of patients with higher waitlist mortality risk in cirrhosis.J Cachexia Sarcopenia Muscle. 2018; 9: 1053-1062https://doi.org/10.1002/jcsm.12349Crossref PubMed Scopus (70) Google Scholar Moreover, patients with higher mortality risk are underestimated using psoas cut-offs. The psoas cut-offs in the present study were mainly used to illustrate the association between TPMT/height and PMI with 1-year mortality.[4]Ebadi M. Wang C.W. Lai J.C. Dasarathy S. Kappus M.R. Dunn M.A. et al.Poor performance of psoas muscle index for identification of patients with higher waitlist mortality risk in cirrhosis.J Cachexia Sarcopenia Muscle. 2018; 9: 1053-1062https://doi.org/10.1002/jcsm.12349Crossref PubMed Scopus (70) Google Scholar However, even if not ideal, the present study strongly suggests that psoas sarcopenia evaluation is an independent predictor of 1-year mortality in patients with ACLF. Therefore, we feel that a prospective evaluation of sarcopenia, particularly using L3SMI, should be integrated into the pre-transplant work up of patients with ACLF who are candidates for LT. This would allow us to assess the impact of sarcopenia on outcomes after LT. Finally, sarcopenia parameters could be implemented into a multivariate model to identify patients undergoing potentially inappropriate LT. Financial supportThe authors received no financial support to produce this manuscript. The authors received no financial support to produce this manuscript. Authors’ contributionsDesign of the study: FA, CLG, GPG, FS, AL. Acquisition of data: FA, CLG. Statistical analysis: FA, AL. Drafting of the manuscript: FA, CLG, GPG, FS, AL. Design of the study: FA, CLG, GPG, FS, AL. Acquisition of data: FA, CLG. Statistical analysis: FA, AL. Drafting of the manuscript: FA, CLG, GPG, FS, AL. The authors declare no conflicts of interest that pertain to this work. Please refer to the accompanying ICMJE disclosure forms for further details. Supplementary dataThe following are the supplementary data to this article: Download .pdf (.23 MB) Help with pdf files Multimedia component 1 The following are the supplementary data to this article: Download .pdf (.23 MB) Help with pdf files Multimedia component 1

Abstract Excessive alcohol consumption is the leading cause of liver diseases in Western countries, especially in France. Alcohol‐related liver disease (ARLD) is an extremely broad context and there remains much to accomplish in terms of identifying patients, improving prognosis and treatment, and standardising practices. The French Association for the Study of the Liver wished to organise guidelines together with the French Alcohol Society in order to summarise the best evidence available about several key clinical points in ARLD. These guidelines have been elaborated based on the level of evidence available in the literature and each recommendation has been analysed, discussed and voted by the panel of experts. They describe how patients with ARLD should be managed nowadays and discuss the main unsettled issues in the field.

Alcohol-related liver disease (ARLD) remains one of the leading causes of chronic liver disease and the prevalence of alcohol-related cirrhosis is still increasing worldwide. Thus, ARLD is one of the leading indications for liver transplantation (LT) worldwide especially after the arrival of direct-acting antivirals for chronic hepatitis C infection. Despite the risk of alcohol relapse, the outcomes of LT for ARLD are as good as for other indications such as hepatocellular carcinoma (HCC), with 1-, 5-, and 10- year survival rates of 85%, 74%, and 59%, respectively. Despite these good results, certain questions concerning LT for ARLD remain unanswered, in particular because of persistent organ shortages. As a result, too many transplantation centers continue to require 6 months of abstinence from alcohol for patients with ARLD before LT to reduce the risk of alcohol relapse even though compelling data show the poor prognostic value of this criterion. A recent pilot study even observed a lower alcohol relapse rate in patients receiving LT after less than 6 months of abstinence as long as addictological follow-up is reinforced. Thus, the question should not be whether LT should be offered to patients with ARLD but how to select patients who will benefit from this treatment.

Congenital and acquired modifications of glycosylation in diseases are a rapidly growing field that demonstrates the importance of glycosylation in human biology.Unfortunately, in clinical biochemistry, very few tests are available to explore oligosaccharide metabolism on a large scale.Such an assay needs to be of high throughput, rapid, and preferentially noninvasive.In the present study, we describe a method to analyze qualitative variations of N-glycosylation of human serum proteins.The method is based on direct release of N-linked oligosaccharides from patient serum samples, a single-step purification, and a matrix-assisted laser desorption ionization time of flight mass spectrometric analysis.A complementary structural study of the released oligosaccharides was achieved by enzymatic digestions, linkage analysis, and electrospray ionization ion trap mass spectrometry (ESI-IT-MS) of the permethylated N-glycome.A total of 26 oligosaccharide structures were individualized, their presence in human serum being the result of the combination of the biosynthesis and catabolic pathways.Application of the protocol to the serum of patients with cirrhosis demonstrates the ability of this assay to identify acquired modifications of glycosylation.Furthermore, we have analyzed the N-glycans and showed the increase in bisecting N-acetylglucosamine residue, core fucosylation, and the presence of an important population of neutral oligosaccharides.The study of total serum N-glycome modifications is a preliminary for the discovery of new noninvasive diagnostic or prognostic biomarkers resulting from the variations of the N-glycan metabolism during diseases.

Background/Aims In France, two recent studies enabled modeling of the impact of viral eradication on HCV mortality. Methods The French HCV population was simulated from infection to death using a computer-based model. We took into account the impact of alcohol, present screening and antiviral therapy to predict 2006–2025 HCV mortality and to assess the impact of viral eradication. Results In 2006, the model estimated that among HCV-RNA+, 55% were F0–F1, 18% F2, 22% F3–F4 and 6% had liver complications. The mortality ratio was 11-fold higher in alcoholic patients 40–65 years old. Current therapy will save 14,400 (95% CI, 13,900–15,000) lives compared to absence of therapy. Sensitivity analyses did not change the main results. Contrary to guidelines, if patients F < 2 were treated in the same proportions as those with F ⩾ 2, 700 (95% CI, 700–750) lives would be saved. If screening were to reach 75% in 2010, 4 years earlier than model expectation, 950 (95% CI, 900–1000) lives would be saved. If a new molecule improving eradication for genotype 1/4 by 40% were to become available in 2010, 1500 (95% CI, 1400–1600) lives would be saved. Conclusions Current therapy is reducing HCV mortality. Therapeutic guidelines must take into account their impact on HCV mortality. In France, two recent studies enabled modeling of the impact of viral eradication on HCV mortality. The French HCV population was simulated from infection to death using a computer-based model. We took into account the impact of alcohol, present screening and antiviral therapy to predict 2006–2025 HCV mortality and to assess the impact of viral eradication. In 2006, the model estimated that among HCV-RNA+, 55% were F0–F1, 18% F2, 22% F3–F4 and 6% had liver complications. The mortality ratio was 11-fold higher in alcoholic patients 40–65 years old. Current therapy will save 14,400 (95% CI, 13,900–15,000) lives compared to absence of therapy. Sensitivity analyses did not change the main results. Contrary to guidelines, if patients F < 2 were treated in the same proportions as those with F ⩾ 2, 700 (95% CI, 700–750) lives would be saved. If screening were to reach 75% in 2010, 4 years earlier than model expectation, 950 (95% CI, 900–1000) lives would be saved. If a new molecule improving eradication for genotype 1/4 by 40% were to become available in 2010, 1500 (95% CI, 1400–1600) lives would be saved. Current therapy is reducing HCV mortality. Therapeutic guidelines must take into account their impact on HCV mortality.

Recent studies suggested that IL28B polymorphisms may affect rapid and sustained virological response rates in HCV patients infected with genotype 2 or 3.To assess the role of IL28B polymorphisms on the virological response in HCV-2 and -3 patients.We performed meta-analysis of studies evaluating the impact of rs12979860 and rs8099917 polymorphisms on rapid and sustained virological response in HCV-2 or -3 patients.Twenty-three studies involving 3042 patients were included. The first meta-analysis evaluated the impact of rs12979860 polymorphism and included 1963 patients. When compared with rs12979860 CT/TT patients, CC patients had a higher rapid virological response rate (mean difference: 12.9%, 95% CI: 6.5-19.4%, P < 0.001) and a higher sustained virological response rate (mean difference: 4.9%, 95% CI: 0.1-9.8%, P = 0.046). The second meta-analysis evaluated the impact of rs8099917 polymorphism and included 2246 patients. When compared with rs8099917 TG/GG patients, TT patients had a higher rapid virological response rate (mean difference: 14.8%, 95% CI: 7.2-22.4%, P < 0.001) and a higher sustained virological response rate (mean difference: 5.5%, 95% CI: 0.4-10.6%, P = 0.033). When considering only patients treated for 24 weeks, results were unchanged. No potential sources of between-study heterogeneity were identified.Favourable IL28B polymorphisms are associated with higher rapid and sustained virological response rates in HCV-2 and -3 patients. However, as the impact on a sustained response is very limited, it is unlikely that IL28B polymorphisms provide additional predictive value when considering other predictors of a sustained response.

Abstract Alcoholic liver disease, considered as a self‐inflected disease, is an example of how moral judgment may affect ethical exercise of medicine which requires equity and fair utilization of a scarce resource in a context of organ shortage. Some consider that selection process should prioritize access to liver transplantation (LT) for patients who develop liver failure “through no fault of their own” even if limiting care because of a patient's perceived responsibility has been considered unethical. The absence of improvement after alcohol withdrawal, the high short‐term mortality risk and the poor predictability of the 6‐month rule in post‐LT relapse in alcohol consumption in AH patients not responding to medical therapy led to recommend an evaluation of LT. In the French‐Belgian pilot study, 26 patients with severe AH not responding to medical therapy underwent early LT (eLT). Stringent selection criteria were applied. Six‐month and 2‐year survivals of eLT patients were better than that of non‐transplanted matched controls: 77% vs 23% and 71% vs 23% respectively. Alcohol relapse occurred in 12% of patients after eLT. Three studies confirmed these results. The impact organ donation should be limited as showed by a recent survey and the efforts that should be made in public information campaigns based on scientific data and medical ethics. In conclusion, the ongoing accumulation of scientific evidence and requirement of ethical exercise of medicine lead to continue evaluating eLT as a therapeutic option in patients with severe AH not responding to medical therapy.

The recent discovery of bacterial receptors such as NOD2 that contribute to crosstalk between innate and adaptive immune systems in the digestive tract constitutes an important challenge in our understanding of liver injury mechanisms. The present study focuses on NOD2 functions during liver injury. NOD2, TNF-alpha and IFN-gamma mRNA were quantified using real-time PCR in liver samples from patients and mice with liver injury. We evaluated the susceptibility of concanavalin A (ConA) challenge in NOD2-deficient mice (Nod2-/-) compared to wild-type littermates. We tested the effect of muramyl dipeptide (MDP), the specific activator of NOD2, on ConA-induced liver injury in C57BL/6 mice. We studied the cellular distribution and the role of NOD2 in immune cells and hepatocytes. We demonstrated that NOD2, TNF-alpha and IFN-gamma were upregulated during liver injury in mice and humans. Nod2-/- mice were resistant to ConA-induced hepatitis compared to their wild-type littermates, through reduced IFN-gamma production by immune cells. Conversely, administration of MDP exacerbated ConA-induced liver injury. MDP was a strong inducer of IFN-gamma in freshly isolated human PBMC, splenocytes and hepatocytes. Our study supports the hypothesis that NOD2 contributes to liver injury via a regulatory mechanism affecting immune cells infiltrating the liver and hepatocytes. Taken together, our results indicate that NOD2 may represent a new therapeutic target in liver diseases.

Aliment Pharmacol Ther 2011; 34: 454–461 Summary Background In end-stage renal disease (ESRD) patients, hepatitis C virus (HCV) eradication improves patient and graft survival. Aim To determine optimal use of erythropoietin (EPO) and ribavirin, to compare ribavirin concentrations with those of HCV patients having normal renal function and to evaluate sustained virological response (SVR) in a prospective observatory of ESRD candidates for renal transplantation. Methods Thirty-two naïve patients were treated with Peg-IFN-α2a and ribavirin. Two different schedules of ribavirin and EPO administration were used: starting ribavirin at 600 mg per week and adapting EPO when haemoglobin (Hb) fell below 10 g/dL (adaptive strategy) or starting ribavirin at 1000 mg per week while increasing EPO from the start of treatment (preventive strategy). Results Patients treated with the adaptive strategy had lower median Hb levels (9.6 vs. 10.9 g/dL, P = 0.02) and more frequent median Hb levels below 10 g/dL (58 vs. 5%, P = 0.0007) despite lower median ribavirin doses (105 vs. 142 mg/day, P < 0.0001) than patients treated with the preventive strategy. There was a trend for more frequent transfusion in patients treated with the adaptive strategy than in patients treated with preventive strategy (50 vs. 20%, P = 0.08). Compared to patients with normal renal function, ESRD patients had lower ribavirin concentrations during the first month (0.81 vs. 1.7 mg/L, P = 0.007) and similar concentrations thereafter. SVR was reached in 50%. Conclusions Pegylated interferon (Peg-IFN) and an adapted schedule of ribavirin are effective in ESRD patients. Increasing EPO from the start of treatment provides better haematological tolerance. The optimal dosage of ribavirin remains unresolved, in light of frequent side effects.

A more complete understanding of the mechanisms involved in pathogen-associated molecular pattern signaling is crucial in the setting of liver injury. In intestinal diseases, nucleotide-binding oligomerization domain 1 (NOD1), a receptor for bacteria, appears to regulate cross-talk between innate and adaptive immunity, involving polymorphonuclear neutrophils (PMNs). Our aim was to explore the role of NOD1 in PMN-induced liver injury.Nod1(+/+) and Nod1(-/-) mice were challenged with carbon tetrachloride (CCl(4)). Migration and phagocytosis of Nod1(+/+) and Nod1(-/-) PMN were studied in vivo and ex vivo. We evaluated main inflammatory pathways in PMNs by Western blot and CD11b expression using fluorescence-activated cell sorting. Mice were submitted to liver ischemia/reperfusion.After CCl(4) exposure, livers of Nod1(-/-) mice had more than 50% less PMN infiltration within necrotic areas than those of Nod1(+/+). PMNs isolated from Nod1(-/-) mice displayed a 90% decrease in migration capacity compared with Nod1(+/+) PMNs, whereas FK 565, a potent NOD1 ligand, increased PMN migration. Upon FK 565 stimulation, mitogen-activated protein kinase and nuclear factor kappaB were activated in Nod1(+/+) PMNs, but less so in Nod1(-/-) PMNs. Expression of CD11b on the Nod1(-/-) PMN was decreased compared with Nod1(+/+). The phagocytic capacity of Nod1(-/-) PMNs was decreased by more than 50% compared with Nod1(+/+). In an ischemia/reperfusion model of PMN-induced liver injury, FK 565 increased lesions, whereas Nod1(-/-) mice were protected.The identification of NOD1 as a modulator of PMN function and migration in the liver suggests that this receptor may represent a new therapeutic target in PMN-dependent liver diseases.

Introduction: The use of human albumin for the management of cirrhosis has increased. Recommendations have been published for therapeutic paracentesis (TP), spontaneous bacterial peritonitis (SBP), and type 1 hepatorenal syndrome (HRS). The goal of this survey was to assess the prescription practices of French hepatogastroenterologists. Methods: All hepatogastroenterologists were contacted. The questionnaire evaluated (1) the use of albumin in validated indications and (2) the prescription of albumin for nonvalidated clinical situations. Results: Responses were analyzed from 451 (50.1%) practitioners. The mean age was 40 years (range, 24 to 67 y). Physicians practiced in a university hospital (47.7%) or a general hospital (45.8%). There were 56.7% senior practitioners. Overall 99.6% of the practitioners compensated for TP. Albumin was used by 87.8% of the physicians, with a fixed dose being used by 84.6%. For SBP, 94% of the physicians used albumin concomitantly with antibiotics. The recommended protocol was followed by 56.2% of the practitioners: more often by senior university hospital practitioners than by senior general hospital practitioners ( P =0.015). About 66.5% used albumin infusion for the diagnosis of HRS: used more often by senior university hospital practitioners ( P =0.0006). Albumin was used concomitantly with vasopressor treatment by 84%; the dose and the duration varied considerably. About 23.5% used albumin for severe bacterial infection, 47.9% for severe hyponatremia, 43.9% for severe hypoalbuminemia, and 65.9% for hydrothorax. Conclusions: In this large French survey, albumin is only prescribed in accordance with recommendations for TP. The schedule for SBP is followed by only 56% of the practitioners. The use of albumin for HRS is not adapted to recommendations, which are not well known, suggesting that they should be more diffused.

Supraselective transarterial chemoembolization (STACE) more efficiently targets chemotherapy delivered via the feeding arterial branches of the tumor than does conventional transarterial chemoembolization (TACE). However, the hypothesis of its greater efficacy compared with the latter is subject to controversy. The aim of the present study was to compare STACE to conventional TACE in a controlled study of candidates for liver transplantation (LT) for hepatocellular carcinoma (HCC). Patients were matched for factors associated with HCC recurrence and survival. Sixty patients were included: 30 who were treated with STACE and 30 treated with conventional TACE. The 2 groups were similar in terms of matched criteria. In the overall population (uni- and multinodular HCC), there was no marked difference between the 2 groups in 5-year disease-free survival: 76.8% vs. 74.8%. In sensitivity analysis of patients considered to be the best candidates for TACE (uninodular HCC < or =5 cm), there was a trend toward significance between STACE and TACE in 5-year disease-free survival: 87% vs. 64% (P = 0.09). The only factor associated with complete tumor necrosis was STACE in the overall population (30.8% vs. 6.9%, P = 0.02), with a similar trend in the subgroup of patients with a single nodule (33.3% vs. 6.7%, P = 0.06), whereas the mean number of procedures was similar in the 2 groups (mean, 1.3 procedures; range 1-5 procedures; P = NS). STACE is more efficient at inducing complete tumor necrosis in the liver. This study observed trends toward improvement in the disease-free survival of patients with uninodular HCC < or =5 cm. Future studies focusing on such patients are warranted.

N-glycosylation modifications in human serum glycoproteins have been described in hepatic cirrhosis. To identify the glycoproteins carrying these modifications and to determine their influences in the modification of the total serum N-glycome (TSNG) in cirrhotic patients, we have performed the glycosylation analysis of immunoglobulins, transferrin, 1 antitrypsin and haptoglobin of patients who have developed cirrhosis.The glycosylation analysis of immunoglobulins G, transferrin, 1 antitrypsin and haptoglobin of 14 patients who have developed cirrhosis and 11 healthy controls was performed using strategies based on MS, 2-DE and affinity chromatography.We demonstrated that the N-glycosylation of both hepatic and plasma cell secreted glycoproteins is modified, and that the major modifications of TSNG are carried by immunoglobulins A and G.The search for glycomic biomarkers used as an alternative to liver biopsy for the assessment of fibrosis in chronic liver disease is extremely important. Variations in the glycosylation of immunoglobulins are responsible for the main modifications affecting the TSNG and effector properties of the Fc of these molecules, and certainly contribute to the pathophysiology of fibrosis.

Clinicians continue to raise questions concerning the necessity of treating chronic hepatitis C virus (HCV)-infected patients with normal alanine aminotransferase (N-ALT), in light of their slower progression to cirrhosis than patients with elevated alanine aminotraferase (E-ALT). This study was undertaken to predict the impact of pegylated interferon (IFN) and ribavirin on HCV-related morbidity and mortality in patients with N-ALT. A previous Markov model was adapted to separately simulate patients with N-ALT (30%) and those with E-ALT (70%). The model estimates fibrosis progression rates according to age, sex, and whether ALT levels are normal or elevated, assuming that patients with E-ALT have a 2.6 times higher progression than those with N-ALT. It takes into account improvement in HCV screening and treatment and competitive mortality. We assumed that N-ALT patients were treated 80% less frequently between 2002 and 2004 and 70% less frequently from 2005 on, as obtained in real life from three multicentric cohorts (Hepatys, Adequation, Persee). Antiviral treatment of HCV-infected populations might reduce 2008-2025 HCV-related morbidity and mortality by 34,200 cases of cirrhosis (36%, 33,000-35,000), 22,400 complications (28%, 21,000-23,000) and 17,500 deaths (25%, 17,000-18,000), including 3000 cases of cirrhosis (22%, 2000-5000), 1200 complications (15%, 1000-1700), and 1000 deaths (14%, 900-1300) in the N-ALT population, despite a probability of receiving treatment that is three to five times less in this population. If N-ALT patients are treated at the same proportions as those with E-ALT, morbidity and mortality could be further reduced by 1400 cases of cirrhosis (13%, 1200-2200), 600 complications (9%, 600-1000), and 500 deaths (9%, 500-800).Treatment of N-ALT patients would decrease HCV morbidity and mortality. These patients should be considered candidates for treatment just as others are.

•NOD1 agonists induced expression of adhesion molecules in the normal and IR-injured livers. •NOD1 mediates interactions between hepatocytes and polymorphonuclear neutrophils during liver IR. •Insoluble NOD1 inhibitors were efficiently integrated into PLGA nanoparticles for use in vivo. •NOD1 antagonist nanoparticles reduced ICAM-1 expression and IR-induced liver injury. •The NOD1 pathway modulates liver IR injury by targeting polymorphonuclear neutrophil function and adhesion molecules. Background & Aims In liver transplantation, organ shortage leads to the use of marginal grafts that are more susceptible to ischemia–reperfusion (IR) injury. We identified nucleotide-binding oligomerization domain 1 (NOD1) as an important modulator of polymorphonuclear neutrophil (PMN)-induced liver injury, which occurs in IR. Herein, we aimed to elucidate the role of NOD1 in IR injury, particularly focusing on its effects on the endothelium and hepatocytes. Method Nod1 WT and KO mice were treated with NOD1 agonists and subjected to liver IR. Expression of adhesion molecules was analyzed in total liver, isolated hepatocytes and endothelial cells. Interactions between PMNs and hepatocytes were studied in an ex vivo co-culture model using electron microscopy and lactate dehydrogenase levels. We generated NOD1 antagonist-loaded nanoparticles (np ALINO). Results NOD1 agonist treatment increased liver injury, PMN tissue infiltration and upregulated ICAM-1 and VCAM-1 expression 20 hours after reperfusion. NOD1 agonist treatment without IR increased expression of adhesion molecules (ICAM-1, VCAM-1) in total liver and more particularly in WT hepatocytes, but not in Nod1 KO hepatocytes. This induction is dependent of p38 and ERK signaling pathways. Compared to untreated hepatocytes, a NOD1 agonist markedly increased hepatocyte lysis in co-culture with PMNs as shown by the increase of lactate dehydrogenase in supernatants. Interaction between hepatocytes and PMNs was confirmed by electron microscopy. In a mouse model of liver IR, treatment with np ALINO significantly reduced the area of necrosis, aminotransferase levels and ICAM-1 expression. Conclusion NOD1 regulates liver IR injury through induction of adhesion molecules and modulation of hepatocyte-PMN interactions. NOD1 antagonist-loaded nanoparticles reduced liver IR injury and provide a potential approach to prevent IR, especially in the context of liver transplantation. Lay summary Nucleotide-binding oligomerization domain 1 (NOD1) is as an important modulator of polymorphonuclear neutrophil (PMN)-induced liver injury, which occurs in ischemia-reperfusion. Here, we show that the NOD1 pathway targets liver adhesion molecule expression on the endothelium and on hepatocytes through p38 and ERK signaling pathways. The early increase of adhesion molecule expression after reperfusion emphasizes the importance of adhesion molecules in liver injury. In this study we generated nanoparticles loaded with NOD1 antagonist. These nanoparticles reduced liver necrosis by reducing PMN liver infiltration and adhesion molecule expression. In liver transplantation, organ shortage leads to the use of marginal grafts that are more susceptible to ischemia–reperfusion (IR) injury. We identified nucleotide-binding oligomerization domain 1 (NOD1) as an important modulator of polymorphonuclear neutrophil (PMN)-induced liver injury, which occurs in IR. Herein, we aimed to elucidate the role of NOD1 in IR injury, particularly focusing on its effects on the endothelium and hepatocytes. Nod1 WT and KO mice were treated with NOD1 agonists and subjected to liver IR. Expression of adhesion molecules was analyzed in total liver, isolated hepatocytes and endothelial cells. Interactions between PMNs and hepatocytes were studied in an ex vivo co-culture model using electron microscopy and lactate dehydrogenase levels. We generated NOD1 antagonist-loaded nanoparticles (np ALINO). NOD1 agonist treatment increased liver injury, PMN tissue infiltration and upregulated ICAM-1 and VCAM-1 expression 20 hours after reperfusion. NOD1 agonist treatment without IR increased expression of adhesion molecules (ICAM-1, VCAM-1) in total liver and more particularly in WT hepatocytes, but not in Nod1 KO hepatocytes. This induction is dependent of p38 and ERK signaling pathways. Compared to untreated hepatocytes, a NOD1 agonist markedly increased hepatocyte lysis in co-culture with PMNs as shown by the increase of lactate dehydrogenase in supernatants. Interaction between hepatocytes and PMNs was confirmed by electron microscopy. In a mouse model of liver IR, treatment with np ALINO significantly reduced the area of necrosis, aminotransferase levels and ICAM-1 expression. NOD1 regulates liver IR injury through induction of adhesion molecules and modulation of hepatocyte-PMN interactions. NOD1 antagonist-loaded nanoparticles reduced liver IR injury and provide a potential approach to prevent IR, especially in the context of liver transplantation.

Before antiviral therapy, kidney transplant recipients infected with hepatitis B virus (HBV) or hepatitis C virus (HCV) had poor outcomes. Since the 90s, nucleos(t)ide analogues have been widely used in HBV-infected patients, while interferon-based therapy was rarely used in HCV-infected patients. The aim of this study was to assess the impact of HBV and HCV on patient and graft survival, according to viral replication status.Data from January 1993 to December 2010 were extracted from the French national database CRISTAL. A total of 31,433 kidney transplant recipients were included, of whom 575, 1,060 and 29,798 had chronic hepatitis B, C, or were not infected, respectively.Ten-year survival was lower in HCV-infected (71.3%) than in HBV-infected (81.2%, p = 0.0004) or non-infected kidney transplant recipients (82.7%, p <0.0001). Ten-year kidney graft survival was lower in HCV-infected (50.6%) than in HBV-infected (62.3%, p <0.0001) or non-infected kidney transplant recipients (64.7%, p <0.0001). A random analysis of the medical records of 184 patients with HBV and 504 patients with HCV showed a control of viral replication in 94% and 35% of cases, respectively. Ten-year patient and graft survival in patients with detectable HCV RNA was lower than in their matching controls. Conversely, patients with HCV and undetectable HCV RNA had higher 10-year survival than their matched controls without significant differences in graft survival.Chronic HBV infection does not impact 10-year patient and kidney graft survival thanks to control of viral replication with nucleos(t)ide analogues. In kidney transplant recipients infected with HCV, patients with detectable RNA had worse outcomes, whereas the outcomes of those with undetectable RNA were at least as good as non-infected patients. Thus, direct-acting antivirals should be systematically offered to HCV-infected patients.Previously, infections with hepatitis B or hepatitis C virus led to poor outcomes in kidney transplant recipients. However, the outcomes of kidney transplants in patients with viral suppression are as good as those for kidney transplants in non-infected patients. Antiviral therapy should be systematically proposed to hepatitis B and/or hepatitis C-infected kidney transplant recipients or candidates to prevent the deleterious hepatic and extrahepatic impact of chronic viral replication. Recent access to direct-acting antivirals in patients with hepatitis C virus and renal dysfunction provides exciting new opportunities.

<h3>Background & Aims</h3> Alcohol-related liver disease (ALD) causes chronic liver disease. We investigated how information on patients' drinking history and amount, stage of liver disease, and demographic feature can be used to determine risk of disease progression. <h3>Methods</h3> We collected data from 2334 heavy drinkers (50 g/day or more) with persistently abnormal results from liver tests who had been admitted to a hepato-gastroenterology unit in France from January 1982 through December 1997; patients with a recorded duration of alcohol abuse were assigned to the development cohort (n=1599; 75% men) or the validation cohort (n=735; 75% men), based on presence of a liver biopsy. We collected data from both cohorts on patient history and disease stage at the time of hospitalization. For the development cohort, severity of the disease was scored by the METAVIR (due to the availability of liver histology reports); in the validation cohort only the presence of liver complications was assessed. We developed a model of ALD progression and occurrence of liver complications (hepatocellular carcinoma and/or liver decompensation) in association with exposure to alcohol, age at the onset of heavy drinking, amount of alcohol intake, sex and body mass index. The model was fitted to the development cohort and then evaluated in the validation cohort. We then tested the ability of the model to predict disease progression for any patient profile (baseline evaluation). Patients with a 5-y weighted risk of liver complications greater than 5% were considered at high risk for disease progression. <h3>Results</h3> Model results are given for the following patient profiles: men and women, 40 y old, who started drinking at an age of 25 y, drank 150 g/day, and had a body mass index of 22 kg/m² according to the disease severity at baseline evaluation. For men with baseline F0–F2 fibrosis, the model estimated the probabilities of normal liver, steatosis, or steatohepatitis at baseline to be 31.8%, 61.5% and 6.7%, respectively. The 5-y weighted risk of liver complications was 1.9%, ranging from 0.2% for men with normal liver at baseline evaluation to 10.3% for patients with steatohepatitis at baseline. For women with baseline F0–F2 fibrosis, probabilities of normal liver, steatosis, or steatohepatitis at baseline were 25.1%, 66.5% and 8.4%, respectively; the 5-y weighted risk of liver complications was 3.2%, ranging from 0.5% for women with normal liver at baseline to 14.7% for patients with steatohepatitis at baseline. Based on the model, men with F3–F4 fibrosis at baseline have a 24.5% 5-y weighted risk of complications (ranging from 20.2% to 34.5%) and women have a 30.1% 5-y weighted risk of complications (ranging from 24.7% to 41.0%). <h3>Conclusions</h3> We developed a Markov model that integrates data on level and duration of alcohol use to identify patients at high risk of liver disease progression. This model might be used to adapt patient care pathways.

Liver transplant (LT) candidates with a body mass index (BMI) over 40 kg/m2 have lower access to a liver graft without clear explanation. Thus, we studied the impact of obesity on the waiting list (WL) and aimed to explore graft proposals and refusal.Data between January 2007 and December 2017 were extracted from the French prospective national database: CRISTAL. Competing risk analyses were performed to evaluate predictors of receiving LT. Competitive events were (1) death/WL removal for disease aggravation or (2) improvement. The link between grade obesity, grafts propositions, and reason for refusal was studied.15,184 patients were analysed: 10,813 transplant, 2847 death/dropout for aggravation, 748 redirected for improvement, and 776 censored. Mortality/dropout were higher in BMI over 35 (18% vs. 14% 1 year after listing) than in other candidates. In multivariate analysis, BMI>35, age, hepatic encephalopathy, and ascites were independent predictors of death/dropout. Candidates with a BMI ≥ 35 kg/m2 had reduced access to LT, without differences in graft proposals. However, grafts refusal was more frequent especially for 'morphological incompatibility' (14.9% vs. 12.7% p < 0.01).BMI over 35 kg/m2 reduces access to LT with increased risk of dropout and mortality. Increased mortality and dropout could be due to a lower access to liver graft secondary to increased graft refusal for morphological incompatibility.

Artru, Florent; Sacleux, Sophie-Caroline; Ursic-Bedoya, Jose; Pageaux, Georges-Philippe; Louvet, Alexandre; Saliba, Faouzi Author Information

In patients with compensated alcohol-related cirrhosis, reliable prognostic biomarkers are lacking. Keratin-18 and hepatocyte-derived large extracellular vesicles (lEVs) concentrations reflect disease activity, but their ability to predict liver-related events is unknown. Methods We measured plasma keratin-18 and hepatocyte lEVs concentrations in 500 patients with Child-Pugh class A alcohol-related cirrhosis. Ability of these hepatocyte-derived biomarkers, alone or combined with MELD and FibroTest, to predict liver-related events at 2 years was analyzed, taking into account the alcohol consumption at inclusion and during the follow-up. Results Keratin-18 and hepatocyte lEVs concentrations increased with alcohol consumption. In patients without active alcohol consumption at enrollment (n=419), keratin-18 concentration predicted liver-related events at 2 years, independently of FibroTest and MELD. Patients with both keratin-18 concentration >285 U/L and FibroTest >0.74 had a 24% cumulative incidence of liver-related events at 2 years, versus 5% to 14% in other groups of patients. Similar results were obtained when combining keratin-18 concentration >285 U/L with MELD >10. In patients with active alcohol consumption at enrollment (n=81), hepatocyte lEVs predicted liver-related events at 2 years, independently of FibroTest and MELD. Patients with both hepatocyte lEVs concentration >50 U/L and FibroTest>0.74 had a 62% cumulative incidence of liver-related events at 2 years, versus 8% to 13% in other groups of patients. Combining hepatocyte lEVs concentration >50 U/L with MELD >10 had a lower discrimination ability. Similar results were obtained using as endpoint decompensation of cirrhosis defined according Baveno VII criteria. Conclusion In patients with Child-Pugh class A alcohol-related cirrhosis, combining hepatocyte-derived biomarkers with FibroTest or MELD score identifies patients at high-risk of liver-related events, and could be used for risk stratification and patient selection in clinical trials.

The presence of a pre-existing or recent extra-hepatic solid tumor was considered for a long time as an absolute contraindication to liver transplantation, by fear of futility with an unacceptable increase in non-liver-related mortality. However, cancer-related mortality in solid malignancies is heterogeneous, and experts suggest that case-by-case multidisciplinary decisions should be made. Here, we report the cases of 3 patients with favorable oncological and liver outcome in patients with renal cell carcinoma detected during pre-transplant evaluation that nonetheless underwent liver transplantation.

Background and Aims: Patients with alcohol-associated hepatitis (AH) have an altered fecal metabolome, including reduced microbiota-derived tryptophan metabolites, which function as ligands for aryl hydrocarbon receptor (AhR). The aim of this study was to assess serum AhR ligand activity in patients with AH. Approach and Results: The study included 74 controls without AUD, 97 patients with AUD, and 330 patients with AH from 2 different multicenter cohorts (InTeam: 134, AlcHepNet: 196). Serum AhR activity was evaluated using an AhR reporter assay with HepG2-Lucia cells incubated with serum for 24 hours. Serum AhR activity was significantly higher in patients with AH compared with both controls (1.59 vs. 0.96-fold change, p &lt; 0.001) and patients with AUD (1.59 vs. 0.93, p &lt; 0.001). In both AH cohorts, patients with AhR activity ≥ 2.09 had significantly lower cumulative survival rates at 30, 60, 90, and 180 days compared to those with AhR activity &lt; 2.09. When serum AhR activity was used to further stratify patients with severe AH, the cumulative 30, 60, 90, and 180-day survival rates for patients with severe AH and the AhR activity ≥ 2.09 group were all significantly lower than those with an AhR activity &lt; 2.09 group. Conclusions: Serum AhR activity was significantly higher in patients with AH compared with controls and individuals with AUD, and this increased activity was associated with higher mortality. Consequently, serum AhR activity holds potential as a prognostic marker.

Sarcopenia is a morbi-mortality risk factor in digestive surgery, though its impact after major hepatectomy (MH) remains unknown. This prospective pilot study investigated whether volume and function of a regenerating liver is influenced by body composition. From 2011 to 2016, 125 consecutive patients had computed tomography and 99mTc-labelled-mebrofenin SPECT-scintigraphy before and after MH at day 7 and 1 month for measurements of liver volumes and functions. L3 vertebra muscle mass identified sarcopenia. Primary endpoint was the impact of sarcopenia on regeneration capacities (i.e. volume/function changes and post-hepatectomy liver failure (PHLF) rate). Secondary endpoint was 3-month morbi-mortality. Sarcopenic patients (SP; N=69) were significantly older than non-sarcopenic (NSP), with lower BMI and more malignancies, but with comparable liver function/volume at baseline. Postoperatively, SP showed higher rates of ISGLS_PHLF (24.6% vs 10.9%; p=0.05) but with comparable rates of severe morbidity (23.2% vs 16.4%; p=0.35), overall (8.7% vs 3.6%; p=0.3) and PHLF-related mortality (8,7% vs 1.8%; p=0.075). After matching on the extent of resection or using propensity score, regeneration and PHLF rates were similar. This prospective study using first sequential SPECT-scintigraphy showed that sarcopenia by itself does not affect liver regeneration capacities and short-term postoperative course after MH.

We study spanners in planar domains, including polygonal domains, polyhedral terrain, and planar metrics. Previous work showed that for any constant $\epsilon\in (0,1)$, one could construct a $(2+\epsilon)$-spanner with $O(n\log(n))$ edges (SICOMP 2019), and there is a lower bound of $\Omega(n^2)$ edges for any $(2-\epsilon)$-spanner (SoCG 2015). The main open question is whether a linear number of edges suffices and the stretch can be reduced to $2$. We resolve this problem by showing that for stretch $2$, one needs $\Omega(n\log n)$ edges, and for stretch $2+\epsilon$ for any fixed $\epsilon \in (0,1)$, $O(n)$ edges are sufficient. Our lower bound is the first super-linear lower bound for stretch $2$. En route to achieve our result, we introduce the problem of constructing non-Steiner tree covers for metrics, which is a natural variant of the well-known Steiner point removal problem for trees (SODA 2001). Given a tree and a set of terminals in the tree, our goal is to construct a collection of a small number of dominating trees such that for every two points, at least one tree in the collection preserves their distance within a small stretch factor. Here, we identify an unexpected threshold phenomenon around $2$ where a sharp transition from $n$ trees to $\Theta(\log n)$ trees and then to $O(1)$ trees happens. Specifically, (i) for stretch $ 2-\epsilon$, one needs $\Omega(n)$ trees; (ii) for stretch $2$, $\Theta(\log n)$ tree is necessary and sufficient; and (iii) for stretch $2+\epsilon$, a constant number of trees suffice. Furthermore, our lower bound technique for the non-Steiner tree covers of stretch $2$ has further applications in proving lower bounds for two related constructions in tree metrics: reliable spanners and locality-sensitive orderings. Our lower bound for locality-sensitive orderings matches the best upper bound (STOC 2022).

In light of the impact of emerging hepatitis C virus treatments on morbidity and mortality, we sought to determine whether candidates for liver transplantation for hepatocellular carcinoma and decompensated cirrhosis will decrease sufficiently to match liver grafts for hepatitis C virus-infected patients.Using a Markov model, we quantified future liver graft needs for hepatitis C virus-induced diseases and estimated the impact of current and emerging treatments.We simulated progression of yearly-hepatitis-C-virus-infected cohorts from the beginning of the epidemic and calculated 2013-2022 candidates for liver transplantation up until 2022 without and with therapies. We compared these estimated numbers to projected trends in liver grafts for hepatitis C virus.Overall, current treatment would avoid transplantation of 4425 (4183-4684) potential candidates during the period 2013-2022. It would enable an 88% and 42% reduction in the gap between liver transplantation activity and candidates for hepatocellular carcinoma and decompensated cirrhosis, respectively. Emerging hepatitis C virus treatments would allow adequacy in transplant activities for hepatocellular carcinoma. However, they would not lead to adequacy in decompensated cirrhosis from 2013 to 2022. Results were robust to sensitivity analysis.Our study indicates that patients will benefit from public health policies regarding hepatitis C virus screening and therapeutic access to new emerging treatments.

We aimed to assess the performance of a new strip (Periscreen) for the rapid diagnosis of spontaneous bacterial peritonitis (SBP).Ascitic fluid (AF) of cirrhotic patients hospitalized between March 2014 and August 2015 was independently tested by two readers using the new strip, which has four colorimetric graduations (negative, trace, small, and large). SBP was diagnosed on neutrophils in ascites>250/mm3. Ascites not related to portal hypertension were excluded.Overall, 649 patients from 21 French centers were included and 1,402 AF (803 AF samples from 315 outpatients and 599 samples from 334 inpatients) were assessed. Eighty-four AF samples (17 AF in 9 outpatients and 67 AF in 31 inpatients) were diagnosed as SBP. The prevalence of SBP was 6% (2.1% in outpatients vs. 11.2% in inpatients; P<0.001) and 7.2% in patients with symptoms suggestive of SBP (3% in outpatients vs. 11.3% in inpatients; P<0.001). The κ value for inter-reader agreement was 0.81 (95% confidence interval: 0.77-0.84) when using the "trace" threshold. Considering discordant results (n=131) as positive to interpret the diagnostic performance of the strip at the "trace" threshold, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 91.7, 57.1, 12.0, and 99.1%, respectively. At this "trace" threshold, sensitivity and NPV were both 100% in outpatients, and 89.5 and 97.9% in inpatients, respectively. At the "small" threshold, sensitivity, specificity, PPV and NPV were 81.0, 85.9, 25.9 and 98.7%, respectively.The Periscreen strip is a rapid and highly efficient tool for excluding SBP in the outpatient setting.

Severe alcohol-related hepatitis (AH) is associated with an increased risk of infection, but the impact of pneumonia has not been specifically analyzed in a specific cohort.All patients admitted for severe AH between 2002 and 2020 were prospectively included. Systematic screening for infection was performed at admission and renewed in the case of clinical suspicion.We included 614 patients (60.4% men, mean age 49.9 years, median model for end-stage liver disease [MELD] 25.2, bilirubin 18.1 mg/dL), 202 (32.9%) with infections at admission (73 lung infections). Encephalopathy ( P = 0.006), MELD score ( P = 0.0002), and tobacco exposure (past vs never smokers: P = 0.002 or active vs past smokers: P = 0.005) were associated with lung infection at admission on multivariate analysis. Factors independently associated with death before steroid initiation were encephalopathy ( P = 0.003), MELD score ( P = 0.05), and especially lung infection ( P < 0.0001). Thus, patients with a lung infection had a lower probability of receiving steroids than those with other infections and noninfected patients: 54.8 vs 88.4 vs 98.1% ( P < 0.0001). One hundred forty-six of the 558 patients who received corticosteroids developed infection, including 57 (39.04%) pneumonias. The risk of respiratory and nonrespiratory infection was higher in nonresponders to steroids (Lille score ≥0.45) than in responders: 13% vs 7.6%, P = 0.03 and 27.9% vs 10.6%, P < 0.001, respectively. The variables independently associated with 3-month mortality after steroid initiation were lung infection ( P = 0.004), nonresponse to steroids ( P < 0.0001), MELD score ( P = 0.0003), ascites ( P = 0.003), and encephalopathy ( P = 0.018), whereas nonrespiratory infections were not ( P = 0.91).Lung infection is frequent during severe AH and influences mortality at admission and after steroid initiation. These results emphasize the need for specific management of lung infection during the course of AH.