慢加急性肝衰竭前期患者血清M30和M65水平预测预后价值探讨*

目的 探讨慢加急性肝衰竭前期（pre-ACLF）患者血清M30和M65水平在早期诊断慢加急性肝衰竭（ACLF）患者的价值。方法 采用ELISA法检测35例pre-ACLF患者（痊愈20例、进展15例）、40 例 HBV 相关ACLF 患者（生存20 例,死亡20例）、20例慢性乙型肝炎患者（CHB）和20例健康对照者血清M30和M65水平,分析其对pre-ACLF及ACLF患者临床转归的预测价值。结果 ACLF组和pre-ACLF组血清M30和M65水平均显著高于健康对照组或CHB患者,ACLF组显著高于pre-ACLF组（P<0.05）;pre-ACLF进展组血清M30和M65[分别为（493.80±143.85）U/L和（712.47±305.67）U/L],与痊愈组[分别为（351.40±127.78）U/L和（448.15±165.14）U/L]比,差异具有统计学意义（P<0.05）;pre-ACLF进展组与ACLF患者比,血清M30和M65水平[分别为（503.29±184.43）U/L和（746.99±275.19）U/L],均无显著性差异（P>0.05）;以血清M30和M65水平鉴别诊断Pre-ACLF临床转归的ROC曲线下面积（AUC）分别为0.877和0.867;当M30≥453.70 U/L时,其预测预后的灵敏度和特异度分别为0.867和0.850;当M65≥626.71 U/L时,其早期预测ACLF的灵敏度和特异度分别为0.800 和 0.850。死亡的ACLF患者血清M30和M65水平虽高于ACLF好转组,但差异无统计学意义。结论 M30和M65是反应肝衰竭及肝衰竭前期患者肝细胞坏死或凋亡较敏感的指标,可用于早期诊断ACLF。     

CTP-MELD评分联合血清M30和M65预测乙型肝炎相关慢加急性肝衰竭短期预后的价值

目的探讨肝功能评分(CTP)-终末期肝病模型(MELD)联合血清M30和M65对乙型肝炎相关慢加急性肝衰竭(HBV-ACLF)患者短期预后的预测价值。方法选择2017年1月至2020年1月南京市第二医院接受治疗的HBV-ACLF患者106例,根据90 d预后分为生存组51例与死亡组55例。比较两组患者一般情况、实验室指标、血清M30和M65水平,受试者特征曲线分析下面积CTP-MELD评分联合血清M30和M65与HBV-ACLF短期预后的关系。结果死亡组患者的CTP、MELD评分分别为(23.02±5.18)分和(31.18±5.89)分,高于存活组的(10.49±1.05)分和(13.21±1.34)分(t=16.949、21.276,均P<0.01);死亡组的血清M30、M65水平分别为(1685.12±413.32)U/L和(2799.41±712.05)U/L,均高于存活组的(1001.40±316.49)U/L和(1808.85±669.43)U/L(t=9.507、8.608,均P<0.01)。CTP、MELD、M30、M65单独预测90 d病死的AUC分别为0.624(95%CI:0.525~0.716)、0.804(95%CI:0.716~0.875)、0.750(95%CI:0.656~0.829)、0.887(95%CI:0.810~0.940),4项联合的AUC为0.919(95%CI:0.850~0.963),明显优于CTP、MELD、M30单项评价(P<0.05),高于M65单项评价但差异无统计学意义(P>0.05)。结论CTP、MELD评分和血清M30、M65能够较好地预测HBV-ACLF患者短期预后,且4项联合检测具有更高的预测价值。     

HBV相关慢加急性肝衰竭患者血清角蛋白18水平及其与患者预后的关系探讨*

目的 探讨乙型肝炎病毒相关性慢加急性肝衰竭（HBV-ACLF）患者血清角蛋白18（K-18）水平变化及其对患者预后的预测价值。方法 2015年1月~2017年1月我院收治的HBV-ACLF患者100例,另选择性别和年龄相匹配的慢性乙型肝炎（CHB）患者30例和健康人30例。采用酶联免疫吸附试验法检测血清K18（M30和M65）水平。随访3 m。应用受试者工作特征曲线（ROC）分析M30/M65比值和终末期肝病模型（MELD）预测患者预后的效能。结果 ACLF患者血清M30、M65水平和M30/M65比值分别为（1.0±0.1） lg U/L、（3.4±0.3） lg U/L和（0.3±0.1）,与CHB患者【分别为（2.1±0.1） lg U/L、（3.3±0.2） lg U/L和（0.6±0.0）】或者健康人【分别为（2.1±0.1） lg U/L、（2.1±0.1） lg U/L和（1.0±0.2）】比,有显著性统计学差异（P<0.05）;68例生存患者MELD评分为（18.2±.0）,显著低于32例死亡患者的【（26.1±3.3）,P<0.05】,血清M65水平为（2.9±0.2） lg U/L,显著低于死亡患者的【（4.1±0.5） lg U/L,P<0.05】,M30/M65比值为（0.4±0.1）,显著高于死亡患者的【（0.2±0.1）,P<0.05】;MELD评分预测ACLF患者死亡的截断点为23.21,其AUC为0.650,预测的灵敏度、特异度和正确性分别为85.5%、65.0%和72.0%,而M30/M65比值预测ACLF患者死亡的截断点为0.30,其AUC为0.875,预测的灵敏度、特异度和正确性分别为94.5%、85.0%和85.0%,显著优于MELD评分（P<0.05）。结论 K18（M30和M65）与肝脏疾病的严重程度有关。早期检测血清M30和M65水平可能有助于对HBV-ACLF患者预后的判断。     

Serum thymosin ��4 levels in patients with hepatitis B virus-related liver failure

AIM: To investigate whether serum thymosin β4 can provide diagnostic or prognostic information in liver failure patients caused by chronic hepatitis B virus (HBV) infection.METHODS: Serum thymosin β4 levels were measured in 30 patients with acute-on-chronic liver failure (ACLF), 31 patients with chronic liver failure (CLF), 30 patients with compensated liver cirrhosis (CR) and 32 patients with chronic hepatitis B and 30 healthy controls. Serum thymosin β4 levels were measured by enzyme-linked immunosorbent assay and Child-Pugh and model for end-stage liver disease (MELD) scores were calculated for each patient on admission.RESULTS: Compared with healthy controls, serum thymosin β4 levels in ACLF, CLF, CR and chronic hepatitis B patients were significantly lower, 6.5047 (4.7879-10.5314) μg/mL vs 0.4632 (0.2759-0.8768) μg/mL, 0.6981 (0.5209-1.2008) μg/mL, 1.8053 (0.8110-2.3397) μg/mL, 3.7803 (1.8570-6.4722) μg/mL, respectively (P < 0.001). The levels of thymosin β4 in liver failure (ACLF or CLF) patients were markedly lower than that in CR (P < 0.001), and a difference was also found between CLF and ACLF patients (P = 0.038). In patients with chronic liver disease, there was a positive relationship between thymosin β4 levels and albumin, choline esterase, and platelet (P < 0.001), and negative relationship with alanine aminotransferase (P = 0.020), aspartate aminotransferase, total bilirubin, international normalized ratio of prothrombin time, and Child-Pugh and MELD scores (P < 0.001). Of the 61 liver failure patients, the thymosin β4 levels of non-survivors were significantly lower than that of survivors (P = 0.007). Receiver operating characteristics analysis identified a thymosin β4 cutoff level of 0.5708 μg/mL for predicting poor prognosis in all liver failure patients. The serial thymosin β4 values were observed in 13 liver failure inpatients. Lower initial values were observed in the death. While greater improvement in thymosin β4 value was found in those who recovered from the disease.CONCLUSION: Serum thymosin β4 can be used as an important potential predictor for liver failure caused by chronic HBV infection.     

HBsAg levels in HBeAg-positive chronic hepatitis B patients with different immune conditions

AIM:To investigate hepatitis B surface antigen(HBsAg)levels in patients with HBeAg-positive chronic hepatitis B(CHB)and different immune conditions.METHODS:HBeAg-positive CHB patients with different immune conditions were enrolled in this cross-sectional study.These patients were grouped according to the following criteria:immune-tolerant patients,IT group;patients with a mild immune response in the immune clearance phase,IC-Mild group;and patients with a dramatic immune response in the immune clearance phase and exhibiting acute on chronic liver failure(ACLF),ACLF group.All these patients had not previously received antiviral therapy and were enrolled at a pre-settled ratio of2:2:1.Serum HBsAg levels and the correlation between serum HBsAg level and serum hepatitis B virus(HBV)DNA level were evaluated in these groups.RESULTS:In total,180 HBeAg-positive CHB patients[IT group(n=72),IC-Mild group(n=72),and ACLF group(n=36)]were enrolled in this study.The median serum HBsAg levels varied among the groups(P<0.001):IT,4.86 log10IU/mL;IC-Mild,3.97 log10IU/mL;and ACLF,3.57 log10IU/mL.Serum HBsAg level showed a moderate positive correlation with serum HBV-DNA level in the IC-Mild group(r=0.60,P<0.001),but exhibited a weaker correlation in the IT(r=0.52,P<0.001)and ACLF groups(r=0.51,P=0.001).The ratio of HBsAg/HBV DNA did not differ significantly among the IT,IC-Mild,and ACLF groups(medians:0.56,0.55,and 0.56,respectively;P=0.179).CONCLUSION:Serum HBsAg levels varied significantly in HBeAg-positive patients with different immune conditions.These findings may have important implications for understanding the immune clearance of HBV in HBeAg-positive CHB patients.     

Chronic Liver Failure-Sequential Organ Failure Assessment is better than the Asia-Pacific Association for the Study of Liver criteria for defining acute-on-chronic liver failure and predicting outcome

AIM: To compare the utility of the Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) and Asia-Pacific Association for the Study of Liver (APASL) definitions of acute-on-chronic liver failure (ACLF) in predicting short-term prognosis of patients with ACLF.METHODS: Consecutive patients of cirrhosis with acute decompensation were prospectively included. They were grouped into ACLF and no ACLF groups as per CLIF-SOFA and APASL criteria. Patients were followed up for 3 mo from inclusion or mortality whichever was earlier. Mortality at 28-d and 90-d was compared between no ACLF and ACLF groups as per both criteria. Mortality was also compared between different grades of ACLF as per CLIF-SOFA criteria. Prognostic scores like CLIF-SOFA, Acute Physiology and Chronic Health Evaluation (APACHE)-II, Child-Pugh and Model for End-Stage Liver Disease (MELD) scores were evaluated for their ability to predict 28-d mortality using area under receiver operating curves (AUROC).RESULTS: Of 50 patients, 38 had ACLF as per CLIF-SOFA and 19 as per APASL criteria. Males (86%) were predominant, alcoholic liver disease (68%) was the most common etiology of cirrhosis, sepsis (66%) was the most common cause of acute decompensation while infection (66%) was the most common precipitant of acute decompensation. The 28-d mortality in no ACLF and ACLF groups was 8.3% and 47.4% (P = 0.018) as per CLIF-SOFA and 39% and 37% (P = 0.895) as per APASL criteria. The 28-d mortality in patients with no ACLF (n = 12), ACLF grade 1 (n = 11), ACLF grade 2 (n = 14) and ACLF grade 3 (n = 13) as per CLIF-SOFA criteria was 8.3%, 18.2%, 42.9% and 76.9% (χ² for trend, P = 0.002) and 90-d mortality was 16.7%, 27.3%, 78.6% and 100% (χ² for trend, P < 0.0001) respectively. Patients with prior decompensation had similar 28-d and 90-d mortality (39.3% and 53.6%) as patients without prior decompensation (36.4% and 63.6%) (P = NS). AUROCs for 28-d mortality were 0.795, 0.787, 0.739 and 0.710 for CLIF-SOFA, APACHE-II, Child-Pugh and MELD scores respectively. On multivariate analysis of these scores, CLIF-SOFA was the only significant independent predictor of mortality with an odds ratio 1.538 (95%CI: 1.078-2.194).CONCLUSION: CLIF-SOFA criteria is better than APASL criteria to classify patients into ACLF based on their prognosis. CLIF-SOFA score is the best predictor of short-term mortality.     

Compartmentalization and its implication for peripheral immunologically‐competent cells to the liver in patients with HBV‐related acute‐on‐chronic liver failure

Aims: This study attempts to characterize the feature of immunologically competent cells (ICCs) and evaluate its clinical implication in patients with acute‐on‐chronic liver failure (ACLF) in relation to chronic hepatitis B virus (HBV) infection. Methods: Circulating ICCs were examined in ACLF patients (n = 75), as well as in patients with hepatitis B (CHB, n = 31), CHB‐related liver cirrhosis (LC, n = 36), and normal controls (NC, n = 30). Intrahepatic ICCs in some patients were further analyzed via immunohistochemical and flow cytometric assays. Results: Total lymphocytes, CD4⁺ T cells, CD8⁺ T cells, and NK cells in circulation were numerically lower in the ACLF and LC groups compared to the CHB and NC groups. Importantly, the number of these cells was significantly lower in non‐surviving ACLF patients compared with surviving ACLF patients. In comparison to NC, ACLF patients displayed a significantly higher ratio of liver‐infiltrating CD4⁺ T‐cell frequency than its circulating counterpart, suggesting that the possiblility of the ICCs compartmentalization from the peripheral blood into the liver in ACLF. Immunohistochemical analysis showed that intrahepatic CD4⁺ cells, CD8⁺ cells, and CD56⁺ cells were significantly higher in the ACLF group compared with the other three groups, suggesting a stronger cellular immune response‐mediated inflammation in ACLF group than other patient groups. Conclusions: The abnormal prevalence of circulating and intrahepatic ICCs possibly acts as an important factor that may drive the progression of HBV‐related ACLF.     

HBV相关慢加急性肝衰竭患者血清M30、M65检测及其临床意义

目的检测HBV相关慢加急性肝衰竭（ACLF）患者血清M30、M65的水平,探讨其与疾病的关系。方法选取31例HBV相关ACLF患者（好转20例,无效11例）; 20例慢性乙型肝炎（CHB）患者,10例健康人为对照,采用ELISA方法检测外周血清中M30、M65水平,多组间数据比较采用方差分析,两两比较采用q检验。结果ACLF组血清M30 ［（508.65±340.16）U/L］、M65［（76875±290.02）U/L］高于CHB组［（212.27±91.33）U/L,P＜0.05;（384.40±134.46）U/L,P＜0.05］和健康对照组［（94.12±17.64）U/L,P＜0.05;（121.99±29.25）U/L,P＜0.05］。ACLF患者血清M30与M65水平呈正相关（r=0.78,P＜0.05）。好转组与无效组血清M30、M65水平差异无统计学意义［（572.38±349.45） vs （436.14±285.59）U/L,P=0.29;（817.25±307.66） vs （703.90±221.37）U/L,P=0.31］。结论M30、M65水平能够较为准确的反映肝脏的细胞凋亡及坏死程度,在HBV相关ACLF患者中显著升高。     

Entecavir vs lamivudine therapy for na?ve patients with spontaneous reactivation of hepatitis B presenting as acute-on-chronic liver failure

AIM:To investigate the short-term and long-term efficacy of entecavir versus lamivudine in patients with spontaneous reactivation of hepatitis B presenting as acute-on-chronic liver failure(ACLF).METHODS:This was a single center,prospective cohort study.Eligible,consecutive hospitalized patients received either entecavir 0.5 mg/d or lamivudine 100mg/d.All patients were given standard comprehensive internal medicine.The primary endpoint was survival rate at day 60,and secondary endpoints were reduction in hepatitis B virus(HBV)DNA and alanine aminotransferase(ALT)levels,and improvement in Child-Turcotte-Pugh(CTP)and model for end-stage liver disease(MELD)scores at day 60 and survival rate at week 52.RESULTS:One hundred and nineteen eligible subjects were recruited from 176 patients with severe acute exacerbation of chronic hepatitis B:65 were included in the entecavir group and 54 in the lamivudine group(full analysis set).No significant differences were found in patient baseline clinical parameters.At day 60,entecavir did not improve the probability of survival(P=0.066),despite resulting in faster virological suppression(P<0.001),higher rates of virological response(P<0.05)and greater reductions in the CTP and MELD scores(all P<0.05)than lamivudine.Intriguingly,at week 52,the probability of survival was higher in the entecavir group than in the lamivudine group[42/65(64.6%)vs 26/54(48.1%),respectively;P=0.038].The pretreatment MELD score(B,1.357;95%Cl:2.138-7.062;P=0.000)and virological response at day30(B,1.556;95%Cl:1.811-12.411;P=0.002),were found to be good predictors for 52-wk survival.CONCLUSION:Entecavir significantly reduced HBV DNA levels,decreased the CTP and MELD scores,and thereby improved the long-term survival rate in patients with spontaneous reactivation of hepatitis B presenting as ACLF.     

Outcomes of liver transplantation for end-stage biliary disease: A comparative study with end-stage liver disease

AIM: To evaluate the outcomes of patients with endstage biliary disease(ESBD) who underwent liver transplantation, to define the concept of ESBD, the criteria for patient selection and the optimal operation for decision-making.METHODS: Between June 2002 and June 2014, 43 patients with ESBD from two Chinese organ transplantation centres were evaluated for liver transplantation. The causes of liver disease were primary biliary cirrhosis(n = 8), cholelithiasis(n = 8), congenital biliary atresia(n = 2), graft-related cholangiopathy(n = 18), Caroli's disease(n = 2), iatrogenic bile duct injury(n = 2), primary sclerosing cholangitis(n = 1), intrahepatic bile duct paucity(n = 1) and Alagille's syndrome(n = 1). The patients with ESBD were compared with an end-stage liver disease(ESLD) case control group during the same period, and the potential prognostic values of multiple demographic and clinical variables were assessed. The examined variables included recipient age, sex, pre-transplant clinical status, pre-transplant laboratory values, operation condition and postoperative complications, as well as patient and allograft survival rates. Survival analysis was performed using Kaplan-Meier curves, and the rates were compared using log-rank tests. All variables identified by univariate analysis with P values 0.100 were subjected to multivariate analysis. A Cox proportional hazard regression model was used to determine the effect of the study variables on outcomes in the study group.RESULTS: Patients in the ESBD group had lower model for end-stage liver disease(MELD)/paediatric end-stage liver disease(PELD) scores and a higher frequency of previous abdominal surgery compared to patients in the ESLD group(19.2 ± 6.6 vs 22.0 ± 6.5, P = 0.023 and 1.8 ± 1.3 vs 0.1 ± 0.2, P = 0.000). Moreover, theoperation time and the time spent in intensive care were significantly higher in the ESBD group than in the ESLD group(527.4 ± 98.8 vs 443.0 ± 101.0, P = 0.000, and 12.74 ± 6.6 vs 10.0 ± 7.5, P = 0.000). The patient survival rate in the ESBD group was not significantly different from that of the ESBD group at 1, 3 and 5 years(ESBD: 90.7%, 88.4%, 79.4% vs ESLD: 84.9%, 80.92%, 79.0%, χ2 = 0.194, P = 0.660). The graftsurvival rates were also similar between the two groups at 1, 3 and 5 years(ESBD: 90.7%, 85.2%, 72.7% vs ESLD: 84.9%, 81.0%, 77.5%, χ2 = 0.003, P = 0.958). Univariate analysis identified MELD/PELD score(HR = 1.213, 95%CI: 1.081-1.362, P = 0.001) and bleeding volume(HR = 0.103, 95%CI: 0.020-0.538, P = 0.007) as significant factors affecting the outcomes of patients in the ESBD group. However, multivariate analysis revealed that MELD/PELD score(HR = 1.132, 95%CI: 1.005-1.275, P = 0.041) was the only negative factor that was associated with short survival time.CONCLUSION: MELD/PELD criteria do not adequately measure the clinical characteristics and staging of ESBD. The allocation system based on MELD/PELD criteria should be re-evaluated for patients with ESBD.     

Predictive factors for 28-day mortality in acute-on-chronic liver failure patients admitted to the intensive care unit

BackgroundAcute-on-chronic liver failure (ACLF) is an entity comprising an acute deterioration of liver function in cirrhotic patients, associated with organ failure(s) and high short-term mortality. We aimed to identify predictive factors for short-term mortality in patients admitted with ACLF that may benefit most from liver transplantation.MethodsRetrospective analysis of patients admitted in ACLF to a tertiary intensive care unit between 2013 and 2017 was performed. The EASL-CLIF acute-on-chronic liver failure in cirrhosis (CANONIC) criteria were used to define ACLF grade. Multivariable analysis using 28-day mortality as an end-point was performed, including severity-of-disease scores and clinical parameters.ResultsSeventy-seven patients were admitted in ACLF over the study period. The commonest aetiology of liver disease was alcohol related 52/77(68%) and the commonest precipitant of ACLF was variceal haemorrhage 38/77(49%). Overall 28-day mortality was 42/77(55%) [ACLF-(grade)1:3/42(7%); ACLF-2:10/42(24%); and, ACLF-3:29/42(69%);p = 0.002]. On multivariable analysis MELD ≥ 26 [odds ratio(OR) = 11.559; 95% confidence interval(CI):2.820–47.382;p = 0.001], ACLF-3 (OR = 3.287; 95%CI:1.047–10.325;p = 0.042) at admission and requirement for renal replacement therapy (OR = 5.348; 95%CI:1.385–20.645;p = 0.015) were independently associated with 28-day mortality.ConclusionPatients admitted with ACLF to intensive care have a high mortality rate. Defined early thresholds at admission can identify patients at the highest risk that may benefit most from liver transplantation.     

Serum thymosin β4 levels in patients with hepatitis B virus-related liver failure

AIM:To investigate whether serum thymosinβ4 can provide diagnostic or prognostic information in liver failure patients caused by chronic hepatitis B virus(HBV) infection. METHODS:Serum thymosinβ4 levels were measured in 30 patients with acute-on-chronic liver failure(ACLF), 31 patients with chronic liver failure(CLF),30 patients with compensated liver cirrhosis(CR)and 32 patients with chronic hepatitis B and 30 healthy controls.Serum thymosinβ4 levels were measured by enzyme-linked immunosorbent assay and C...     

Quantification of circulating miR-125b-5p predicts survival in chronic hepatitis B patients with acute-on-chronic liver failure

Aims

To analyze the role of serum miR-125b-5p in reflecting liver damage and predicting outcomes in chronic hepatitis B (CHB) patients with acute-on-chronic liver failure (ACLF).

Interleukin-21 is upregulated in hepatitis B-related acute-on-chronic liver failure and associated with severity of liver disease

Summary. The immune mechanism(s) that lead to hepatitis B‐related acute‐on‐chronic liver failure (HB‐ACLF) are poorly understood. Interleukin‐21 is a newly discovered cytokine that is involved in autoimmune and inflammatory diseases. Its potential role in HB‐ACLF remains unknown. The serum levels of 12 immune cytokines measured by cytometric bead arrays and the frequency of IL‐21‐secreting CD4⁺ T cells in peripheral blood mononuclear cells (PBMC) measured by intracellular cytokine staining were compared in moderate chronic hepatitis B (M‐CHB, n = 20), severe chronic hepatitis B (S‐CHB, n = 20), HB‐ACLF (n = 39) and healthy controls (n = 10). PBMC from M‐CHB patients or healthy subjects were stimulated with rhIL‐21 in vitro, and cytokines in supernatants were measured by FlowCytomix. The frequencies of IL‐21‐secreting CD4⁺ T cells were higher in HB‐ACLF (both P < 0.001) and S‐CHB (P = 0.002 and 0.001) as compared to M‐CHB patients and controls. Serum IL‐21 levels were highest (P < 0.001) in HB‐ACLF and positively associated with high MELD score (P = 0.001) and mortality (P = 0.038). Recovery from HB‐ACLF was associated with reduced serum IL‐21 levels (P = 0.003) and lower CD4⁺IL‐21⁺ T‐cell frequency (P = 0.006). The secretions of IL‐1β (P < 0.001), IL‐6 (P < 0.001), IL‐10 (P < 0.001), IFN‐γ (P = 0.001) and TNF‐α (P = 0.042) from PBMC were significantly increased with rhIL‐21 stimulation. In summary, IL‐21 has a causal role in the development of severe liver inflammation, which is upregulated in HB‐ACLF and associated with severity of liver disease.     

Prediction of the prognosis of patients with acute-on-chronic hepatitis B liver failure using the model for end-stage liver disease scoring system and a novel logistic regression model

Summary. The objective of this study was to determine the predictive value of the model for end‐stage liver disease (MELD) scoring system in patients with acute‐on‐chronic hepatitis B liver failure (ACLF‐HBV), and to establish a new model for predicting the prognosis of ACLF‐HBV. A total of 204 adult patients with ACLF‐HBV were retrospectively recruited between July 1, 2002 and December 31, 2004. The MELD scores were calculated according to the widely accepted formula. The 3‐month mortality was calculated. The validity of the MELD model was determined by means of the concordance (c) statistic. Clinical data and biochemical values were included in the multivariate logistic regression analysis based on which the regression model for predicting prognosis was established. The receiver‐operating characteristic curves were drawn for the MELD scoring system and the new regression model and the areas under the curves (AUC) were compared by the z‐test. The 3‐month mortality rate was 57.8%. The mean MELD score for the patients who died was significantly greater than those who survived beyond 3 months (28.7 vs 22.4, P = 0.003). The concordance (c) statistic (equivalent to the AUC) for the MELD scoring system predicting 3‐month mortality was 0.709 (SE = 0.036, P < 0.001, 95% confidence interval 0.638–0.780). The independent factors predicting prognosis were hepatorenal syndrome (P < 0.001), liver cirrhosis (P = 0.009), HBeAg (P = 0.013), albumin (P = 0.028) and prothrombin activity (P = 0.011) as identified in multivariate logistic regression analysis. The regression model that was constructed by the logistic regression analysis produced a greater prognostic value (c = 0.891) than the MELD scoring system (z = 4.333, P < 0.001). The MELD scoring system is a promising and useful predictor for 3‐month mortality of ACLF‐HBV patients. Hepatorenal syndrome, liver cirrhosis, HBeAg, albumin and prothrombin activity are independent factors affecting the 3‐month mortality. The newly established logistic regression model appears to be superior to the MELD scoring system in predicting 3‐month mortality in patients with ACLF‐HBV.     

Clinical significance of connective tissue growth factor in hepatitis B virus-induced hepatic fibrosis

AIM: To determine the utility of connective tissue growth factor (CCN2/CTGF) for assessing hepatic fibrosis in hepatitis B virus (HBV)-induced chronic liver diseases (CLD-B).METHODS: Enzyme-linked immunosorbent assay was used to measure CCN2 in sera from 107 patients with chronic hepatitis B (CHB) and 39 patients with HBV-induced active liver cirrhosis and 30 healthy individuals. Liver samples from 31 patients with CHB, 8 patients with HBV-induced liver cirrhosis and 8 HBV carriers with normal liver histology were examined for transforming growth factor β-1 (TGF-β1) or CCN2 mRNA levels by in situ hybridization, and computer image analysis was performed to measure integrated optimal density (IOD) of CCN2 mRNA-positive cells in liver tissues. Histological inflammation grading and fibrosis staging were evaluated by H and E staining and Van Gieson’s method.RESULTS: Serum CCN2 concentrations were, respectively, 4.0- or 4.9-fold higher in patients with CHB or active liver cirrhosis as compared to healthy individuals (P < 0.01). There was good consistency between the levels of CCN2 in sera and CCN2 mRNA expression in liver tissues (r = 0.87, P < 0.01). The levels of CCN2 in sera were increased with the enhancement of histological fibrosis staging in patients with CLD-B (r = 0.85, P < 0.01). Serum CCN2 was a reliable marker for the assessment of liver fibrosis, with areas under the receiver operating characteristic (ROC) curves (AUC) of 0.94 or 0.85 for, respectively, distinguishing normal liver controls from patients with F1 stage liver fibrosis or discriminating between mild and significant fibrosis.CONCLUSION: Detection of serum CCN2 in patients with CLD-B may have clinical significance for assessment of severity of hepatic fibrosis.     

乙型肝炎病毒相关慢加急性肝衰竭患者肝组织中环氧化酶-2和过氧化物酶体增殖物激活受体γ的表达

目的 研究HBV相关慢加急性肝衰竭(ACLF)患者肝组织的环氧化酶-2(COX-2)和过氧化物酶体增殖物激活受体γ(PPAR γ)的表达情况及其与临床指标的相关性.方法 选取ACLF患者35例,HBV相关慢性肝功能衰竭(CLF)患者35例,慢性乙型肝炎(CHB)患者27例及正常对照(NC)者15例,检测患者生物化学指标及HBV DNA水平;免疫组织化学法行肝组织COX-2和PPAR γ染色,检测并分析各组患者肝组织中COX-2和PPAR γ的表达水平及其与临床资料的相关性.多组间比较用Kruskal-Wallis检验,两组间比较用Mann Whitney非参数U检验,双变量的相关分析用Spearman相关分析.结果 ACLF组与CLF组、CHB组和NC组相比,AST、总胆红素、胆固醇、凝血酶原时间、国际标准化比率、纤维蛋白原、终末期肝病模型(MELD)评分差异有统计学意义(P值均<0.01).COX-2染色在肝细胞质呈阳性着色,PPAR γ染色以核阳性为主,亦可见细胞质阳性着色.ACLF、CLF、CHB和NC组肝组织COX-2表达水平评分分别为(4.77±0.95)分、(4.30±1.18)分、(4.65±0.70)分和(2.31±1.12)分,ACLF、CLF和CHB组表达水平高于NC组,差异有统计学意义(z值分别为-5.18、-4.50和-5.32,P值均<0.01);ACLF组高于CLF组,差异有统计学意义(z=-1.98,P<0.05).PPAR γ表达水平评分在ACLF、CLF、CHB和NC组分别为(6.23±1.78)分、(5.34±1.68)分、(5.90±1.06)分和(3.57±1.91)分,ACLF组高于其他各组,与CLF组及NC组相比,差异有统计学意义(z值分别为-2.62和-4.28,P值均<0.01).ACLF组的COX-2表达水平与MELD评分呈正相关(r=0.337,P<0.05),PPAR γ表达水平与HBV DNA水平的对数值呈正相关(r=0.348,P<0.05).结论 COX-2能反映肝脏炎症程度及肝脏损害程度,PPAR γ在慢性HBV感染时上调,并且炎症越明显,上调的幅度越大,可能是肝脏炎症时的保护机制.

Abstract：

Objective To study the expressions of cyclooxygenase-2 (COX-2) and Peroxisome proliferator-activated receptor gamma (PPAR γ) in liver of patients with hepatitis B virus (HBV) related acute-on-chronic liver failure (ACLF) and their correlation with clinical parameters. Methods 35 patients with ACLF, 35 patients with HBV related chronic liver failure (CLF), 27 patients with chronic hepatitis B (CHB) and 15 normal control were enrolled to study the expressions of COX-2 and PPAR γ in the liver tissues by immunohistochemical staining, and to analyze the correlation of the COX-2 and PPAR γ levels in liver tissues with clinical parameters. Results COX-2 was distinctly expressed in the cytoplasm of the hepatocytes, but PPAR γ was mostly expressed in the nuclei of the hepatocytes and also could be seen in the cytoplasm. The expressions of COX-2 in the liver of ACLF, CLF and CHB groups increased significantly as compared with NC group (z = -5.18, -4.50, -5.32, P < 0.01). The levels of COX-2 in ACLF livers also increased evidently as compared with CLF groups (z = -1.98, P < 0.05). The expression levels of PPAR γ in ACLF liver tissues were much higher than the other three groups, and statistical significances existed between ACLF group and the other two groups (CLF, NC groups) (z = -2.62, -4.28, P < 0.01). In ACLF group, the expression of COX-2 correlated with MELD score (r = 0.337, P < 0.05) and the expression of PPAR γ correlated with HBV DNA load (r = 0.348, P < 0.05). Clinical data showed that the levels of AST, TBil, CHOL, PT, INR, FIB and MELD score in ACLF group were significantly different from that in CLF, CHB and NC groups. Conclusions COX-2 expressed in liver may be a marker to reflect the degree of inflammation and injury of liver tissue. The PPAR γ expression of liver could be increased during chronic HBV infection and may be a protective mechanism against liver injury..     

Noninvasive assessment of liver damage in chronic hepatitis B

AIM:To evaluate the efficacy of the aspartate aminotransferase/platelet ratio index(APRI)and neutrophillymphocyte(N/L)ratio to predict liver damage in chronic hepatitis B(CHB).METHODS:We analyzed 89 patients diagnosed with CHB by percutaneous liver biopsy and 43 healthy subjects.Liver biopsy materials were stained with hematoxylin-eosin and Masson’s trichrome.Patients’fibrosis scores and histological activity index(HAI)were calculated according to the Ishak scoring system.Fibrosis score was recognized as follows:F0-1 No/early-stage fibrosis,F2-6 significant fibrosis,F0-4 non-cirrhotic and F5-6 cirrhotic.Significant liver fibrosis was defined as an Ishak score of≥2.APRI and N/L ratio calculation was made by blood test results.RESULTS:The hepatitis B and control group showed no difference in N/L ratios while there was a significant difference in terms of APRI scores(P<0.001).Multiple logistic regression analysis revealed that the only independent predictive factor for liver fibrosis in CHB was platelet count.APRI score was significantly higher in cirrhotic patients than in non-cirrhotic patients.However,this significance was not confirmed by multiple logistic regression analysis.The optimum APRI score cut-off point to identify patients with cirrhosis was 1.01with sensitivity,specificity,positive predictive value and negative predictive value of 62%(36%-86%),74%(62%-83%),29%(13%-49%)and 92%(82%-97%),respectively.In addition,correlation analyses revealed that N/L ratio has a negative and significant relationship with HAI(r=-0.218,P=0.041).CONCLUSION:N/L ratio was negatively correlated with HAI.APRI score may be useful to exclude cirrhosis in CHB patients.     

Cystatin C is a biomarker for predicting acute kidney injury in patients with acute-on-chronic liver failure

AIM:To investigate serum cystatin C level as an early biomarker for predicting acute kidney injury(AKI)in patients with acute-on-chronic liver failure(ACLF).METHODS:Fifty-six consecutive patients with hepatitis B virus-related ACLF who had normal serum creatinine(Cr)level(<1.2 mg/dL in men,or<1.1 mg/dL in women)were enrolled in the Liver Failure Treatment and Research Center of Beijing 302 Hospital between August 2011 and October 2012.Thirty patients with chronic hepatitis B(CHB)and 30 healthy controls in the same study period were also included.Measurement of serum cystatin C(CysC)was performed by a particle-enhanced immunonephelometry assay using the BN Prospec nephelometer system.The ACLF patients were followed during their hospitalization period.RESULTS:In the ACLF group,serum level of CysC was 1.1±0.4 mg/L,which was significantly higher(P<0.01)than those in the healthy controls(0.6±0.3mg/L)and CHB patients(0.7±0.2 mg/L).During the hospitalization period,eight ACLF patients developed AKI.Logistic regression analysis indicated that CysC level was an independent risk factor for AKI development(odds ratio=1.8;95%CI:1.4-2.3,P=0.021).The cutoff value of serum CysC for prediction of AKI in ACLF patients was 1.21 mg/L.The baseline CysC-based estimated glomerular filtration rate(eGFR CysC)was significantly lower than the creatinine-based eGFR(eGFR CG and eGFR MDRD)in ACLF patients with AKI,suggesting that baseline eGFR CysC represented early renal function in ACLF patients while the Cr levels were still within the normal ranges.CONCLUSION:Serum CysC provides early prediction of renal dysfunction in ACLF patients with a normal serum Cr level.     

Predictors and outcome of emergent Liver transplantation for patients with acute-on-chronic liver failure

Background and aimsControversy exists over whether emergent liver transplantation (LT) should be performed for patients with acute-on-chronic liver failure (ACLF), especially for patients with multiple organ failure.MethodsA total of 110 ACLF patients, defined by the European Association for the Study of the Liver (EASL) Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) criteria were analyzed. The primary outcome was overall survival after ACLF diagnosis.ResultsDuring follow-up, 76 patients received LT (59 received deceased-donor LT and 17 patients received living-donor LT). The overall survival was better for patients who received LT than patients who did not (82.9% vs. 17.6%, P < 0.001). Among the 76 patients who received LT, the overall survival was not different according to ACLF grade at diagnosis (70.0%, 85.3%, and 84.4% at one-year for ACLF grades 1, 2, and 3, respectively, P = 0.45). The baseline model for end-stage liver disease (MELD) score and progression of the ACLF grade during the pre-transplant period were independent factors for survival after LT. The one-year survival rate was 92.3% for patients with baseline MELD scores of ≤ 32 without ACLF grade progression, whereas it was 33.3% for those with baseline MELD scores of > 32 and ACLF grade progression.ConclusionsEmergent LT provided a significant survival benefit to ACLF patients, regardless of the baseline ACLF grade. Post-LT outcomes were associated with baseline MELD scores and ACLF progression during the pre-transplant period, which might be used in the emergent LT plan for patients presenting with ACLF.