Human beta-defensin-1 is a highly predictive marker of 60 days mortality in patients with acute-on-chronic liver failure Ilianna Mani,Alexandra Alexopoulou, Larisa Vasilieva, Emilia Hadziyannis, Danai Agiasotelli, Theodoros Alexopoulos, Dimitrios Zampetas, Spyros P Dourakis 2nd Department of Internal Medicine and Research Laboratory, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
Conflict of interest No conflict of interest to declare
Introduction Acute on chronic liver failure Syndrome that occurs in cirrhotic patients and consists of A. Episode of acute decompensation B. Organ failure C. High rates of short term mortality (20-80 %) Moreau R et al. Gastroenterology 2013;144:1426 1437
THE CLIF-ORGAN FAILURE SCORE SYSTEM for diagnosing patients with ACLF CLIF-SOFA score Organ/System Liver Bilirubin (mg/dl) Kidney Creatinine (mg/dl) Brain West Haven scale for hepatic encephalopathy Coagulation INR Circulatory system Mean arterial pressure -MAP (mm/hg) Respiratory system PaO2/FIO2 (mmhg) or SaO2/FIO2 Sub-score 1 2 3 <6 6 and < 12 12 <2 2 and < 3.5 3.5 or renal replacement Grade 0 Grade 1-2 Grade 3-4 < 2.0 2.0&< 2.5 2.5 70 < 70 Vasopressors >300 or >357 300 and >200 or >214 and 357 200 or 214 Gastroenterology 2013;144:1426-37
Introduction Defensins are natural antimicrobial peptides, produced by epithelial cells and involved in the defense mechanisms of the mucous membranes, protecting against bacterial translocation Specifically, human beta-defensin-1 (hbd-1) is expressed in the epithelia of multiple tissues (pancreas, kidneys, respiratory tract, urogenital system, mammary glands) including the digestive tract. In a recent study, hbd-1 levels are high in cirrhotic patients, independently of the etiology of cirrhosis. Kaltsa et al, Annals of gastroenterology 29:63-70, 2016 Schneider et al, Journal of Molecular Medicine 83:587-595, 2005
Aim Estimation of As an indicator of severity of liver disease hbd-1 Correlation with laboratory characteristics Prediction of mortality in 30, 60 and 90 days in patients with decompesated cirrhosis with and without acute event.
Methods Observational study of 125 consecutive patients (89 ) with decompensated cirrhosis Median (interquartile range - IQR) ΜΕLD 17.0 (13.0-23.5) Median Child-Pugh 8.0 (8.0-9.5) Exclusion criteria: - Hepatocellular carcinoma - Extrahepatic cholestasis
Methods Serum hbd-1 Group 1 (ACLF) N = 39 Overall (n = 125) Group 2 (AD) N = 46 Group 3 (DC without acute event) N = 40 Control group (Healthy controls) N = 15 hbd-1in ascites (N = 57) Age, years (Median, IQR) Overall (n = 125) Controls (n=15) 60 (51-68) 63 (50-64) 0.649 Gender, 89 (71.2) 11 (73.3) 0.863 P ΑCLF = Acute-on-Chronic Liver Failure, AD = Acute Decompensation without ACLF, DC= Decompensated Cirrhosis without acute event
All patients were: Methods - examined at emergency department unit. Their clinical, epidemiological and laboratory data were collected. - hospitalized - underwent intensive investigation for possible infection. Cultures were received of blood, ascites and urine - received the appropriate treatment for hepatic encephalopathy, hepatorenal syndrome, variceal bleeding and / or infection, accordingly. - Followed up for three months. hbd-1 was evaluated in serum and ascites by enzymelinked-immunosorbent-assay (ELISA) Statistical analyses were performed with IBM SPSS, version 22.
Etiology of cirrhosis
Incidence of documented infection in ACLF Documented infection NO YES Documented infection Ν= 11
Clinical characteristics epidemiological data Comparisons of clinical characteristics between the 3 groups of study : ACLF, AD, DC (P1 ACLF vs AD non ACLF, P2 ACLF vs without acute event) Characteristics Total (125) ACLF (N=39) AD (N=46) DC (Ν=40) P1 P2 Age (years), Median (IQR) 60 (51-67) 53 (48-62) 57 (51-66) 65.5 (57.8-72) 0.268 0.009 Gender (males %) Diabetes mellitus (n, %) Coronary disease (n, %) 89 (71.2) 25(64.1) 33(71.7) 31 (77.5) 0.451 0.190 29 (23.4) 11 (28.9) 7(15.2) 11(27.5) 0.127 0.887 12 (9.6) 1 (2.6) 6(13) 5(12.5) 0.086 0.102
Comparisons of laboratory characteristics between the 3 groups of study : ACLF, AD, DC (P1 ACLF vs AD non ACLF, P2 ACLF vs without acute event) Median (IQR) Laboratory characteristic Total (N =125) ACLF (N=39) AD (N=46) DC (N=40) P1 P2 Hemoglobin (g/dl) 10 (8.7-11.7) 9.6(8.2-11.4) 10.2(8.9-11.8) 10.3(9-12.4) 0.053 0.060 White blood cells 10 6 /L 6650 (4305-10350) 8070(5750-14570) 7790(4797-10320) 4935(3482-6865) 0.334 <0.001 Polymorphonuclear leukocytes x10 6 /L 4637(2931-8246) 5618(3418-11160) 5576(3242-8494) 3190(2123-4912) 0.359 <0.001 Platelets 10 6 /L 115(76-184.5) 102(70-144) 130(88.5-192.5) 102.5(70.5-158.5) 0.209 0.996 CRP mg/dl 21.9 (8-46.1) 23.9 (6.9-48.7) 29.6(15.4-79) 11(4.6-28.8) 0.142 0.013 Total bilirubin (mg/dl) 4.2 (2.2-9.9) 14.5(4.3-22.8) 4.2(2.6-8.1) 2.3(1.5-3.7) <0.001 <0.001 AST (IU/L) 68(39.5-113) 93 (40-152) 91 (55-136) 44.5(30.3-67.8) 0.805 0.001 ALT (IU/L) 34 (20-53) 36(18-67) 38.5(27.5-58.25) 23(17.25-40.5) 0.781 0.021 INR 1.6 (1.3-2) 2(1.6-2.8) 1.5(1.3-1.8) 1.4(1.2-1.7) <0.001 <0.001 Albumin (g/dl) 2.6 (2.3-3.1) 2.6(2.2-3) 2.5(2.3-3) 2.8(2.4-3.8) 0.365 0.020 Creatinine (mg/l) 1 (0.8-1.5) 1.5(0.8-2.2) 0.8(0.7-1.2) 1 (0.8-1.1) <0.001 0.002 Na + (meq/l) 132(128-136) 131(125-135) 132(128.8-136) 133(131-137) 0.273 0.028 Child-Pugh score 11(9-12) 12(11-13) 10(9-11) 9 (8-11) <0.001 <0.001 CLIF-of score 10 (9-11) MELD score 17 (13-23.5) 27 (22-32) 16.5(12-20) 13 (11-18) <0.001 <0.001
hbd-1 (ng/ml) Comparison of levels of hbd-1 between the 3 groups of study : ACLF, AD, DC P < 0.001 P < 0.001 P < 0.001 38.30 (22.55 66.28) 20.74 (13.93 30.26) 13.07 (12.09 14.70) ACLF AD DC ΑCLF = Acute-on-Chronic Liver Failure, AD = Acute Decompensation without ACLF, DC= Decompensated Cirrhosis without acute event
hbd-1 (ng/ml) Comparison of levels of hbd-1 between patients with decompensated cirrhosis without acute event and healthy controls P = 0.902 12.68 (8.71-18.08) 13.07 (12.09-14.70) DC without acute event Healthy controls
Ascitic fluid hbd-1 (ng/ml) Serum hbd-1 (ng/ml) Comparison of levels of hbd-1 between serum and ascitic fluid P < 0.001 12.81 (9.23-17.24) 18.36 (12.33-29.72) 57 patients with ascites
hbd-1 (ng/ml) There was no correlation between levels of serum hbd- 1 and C reactive protein (CRP) in overall patients r = 0.224 CRP (mg/dl)
hbd-1 (ng/ml) There was a trend of serum hbd-1 to correlate with C- reactive protein (CRP) in ACLF r = 0.431 CRP (mg/l)
Sensitivity hbd-1 predicted mortality in 60 days more accurately than CRP in ACLF patients 1.0 36.625 ng/ml * 24.00 mg/dl * hbd-1 CRP hbd-1 c-statistic = 0.834 Sensitivity = 84.2% Specificity = 73.7% Negative predictive value (NPV) = 82.4% Positive predictive value (PPV) =76.2% CRP c-statistic = 0.635 Sensitivity= 61.1 % Specificity = 63.2 % 1 - Specificity
Sensitivity The accuracy of hbd-1 to predict mortality in 60 days improved substantially in ACLF group if alcoholic hepatitis was excluded 1.0 36.805 ng/ml * 24.00 mg/dl * hbd-1 c-statistic = 0.907 Sensitivity = 80% Specificity = 93.3% PPV=88.9% NPV=87.5% CRP c-statistic = 0.700 Sensitivity = 60.0 % Specificity = 80.0% hbd-1 CRP 1 - Specificity
Cumulative probability of survival Comparison of 60-day mortality between patients with high ( 36.625 ng/ml) and low (< 36.625 ng/ml) hbd-1 values in ACLF group hbd-1 < 36.625 ng/ml P (Log rank) = 0.001 hbd-1 36.625ng/ml Hazard ratio 6.114 (1.763 21.210), for hbd-1 36.625 vs. hbd-1 < 36.625 P = 0.004 Days
Factors predicting 60-days mortality in ACLF patients in multivariate analysis Age (years) (per year) Gender ( vs ) Univariate analysis Multivariate analysis HR (95% CI) P HR (95% CI) P 0.984 (0.952-1.017) 0.345 1.018 (0.978-1.059) 0.392 1.807 (0.731-4.466) 0.200 1.144 (0.435 0.785-3.007) MELD score 1.129 (1.054-1.209) < 0.001 1.110 (1.016-1.214) 0.021 Na 0.918 (0.863-0.976) 0.006 1.012 (0.912-1.124) 0.819 CLIF-C ACLF 1.093 (1.003-1.190) 0.042 1.015 (0.918-1.122) 0.772 CRP 1.010 (1.001-1.019) 0.027 1.003 (0.989-1.016) 0.694 Documented 1.310 (0.497-3.451) 0.585 Infection hbd-1 36.625 6.114 (1.763 21.210) 0.004 5.438 (1.038-28.506) 0.045
Conclusions Levels of hbd-1 were not higher in patients with decompensated cirrhosis without acute event compared to healthy controls Higher values of hbd-1 were assessed in serum compared to ascites hbd-1 values were higher in ACLF compared to AD and DC groups High serum hbd-1 was detected at presentation in patients with ACLF who died during the 60-day-follow-up period. Serum hbd-1 is an accurate predictor of short-term mortality in patients with ACLF and it may be superior to CLIF C ACLF score.
Introduction Prognostic markers of mortality in ACLF CLIF (Chronic Liver Failure) Consortium ACLF (CLIF-C ACLF) score sensitivity 64%, specifity 75%. Arroyo et al, J Hepatol 2015, 62:131-143 Markers and scores of liver function (INR, MELD score, Na-MELD) Markers of inflammation (CRP, λευκά, MERTK + tyrosine kinase receptor), Markers of oxidative stress πχ advanced glycation end - product specific receptor - RAGE), Markers of hepatocellular apoptosis (cyto - keratin 18) Hemodynamic parameters (change in the hepatic venous pressure gradient) Wlodzimirow et al, Liver Int 2013, 33:40-52
Incidence of documented infection in all patients NO YES Documented infection Ν= 28
Λοίμωξη N / % Αυτόματη βακτηριακή περιτονίτιδα / αυτόματη μικροβιαιμία 16 (57.1) Λοίμωξη αναπνευστικού 7 (25%) Λοίμωξη ουροποιητικού 3 (10.7%) Άλλο 2 (7.2%) ΣΥΝΟΛΟ 28
hbd-1 + OEΧΗΑ Μέλλον??????????????? Έγκαιρη μεταμόσχευση
ΟΡΙΣΜΟΣ ΟΞΕΙΑΣ ΕΠΙ ΧΡΟΝΙΑΣ ΗΠΑΤΙΚΗΣ ΑΝΕΠΑΡΚΕΙΑ (ΟΕΧΗΑ) Σύνδρομο που εμφανίζεται σε κιρρωτικούς ασθενείς και χαρακτηρίζεται από: A. Οξεία ρήξη της αντιρρόπησης B. Ανεπάρκεια οργάνων C. Υψηλή θνητότητα 28 ημερών > 15% Moreau R et al. Gastroenterology 2013;144:1426 1437
In AD-group neither serum hbd-1 nor CRP seemed to be associated with poor survival (cstatistics 0.500 and 0.596, respectively). In DC-group serum hbd-1 and CRP were equally accurate markers in predicting mortality (cstatistics 0.800 and 0.808, respectively).
Εισαγωγή Μειωμένη ανοσιακή απάντηση: Διαταραχή ακεραιότητας βλενογόννου Μειωμένη τοπική άμυνα Διαταραχή συστηματικής ανοσίας Εντερικός αυλός Βακτηριακά προιόντα Βακτήρια LPS Liver Enterocyte TNF-α NO Μακροφάγα Ηπατική βλάβη LPS NO TNF-α Πυλαία φλέβα Λεμφοκύτταρα Systemic involvement Μεσεντέριος λεμφαδένας Ηπατική εγκεφαλοπάθεια Alexopoulou A, Agiasotelli D, Vasilieva LE, Dourakis SP. Ann Gastroenterol. 2017;30:486-497
Υλικό με θετική καλλιέργεια στους ασθενείς με διαπιστωμένη λοίμωξη ΥΛΙΚΟ ΜΕ ΘΕΤΙΚΗ ΚΑΛΛΙΕΡΓΕΙΑ Αρνητική καλλιέργεια αίματος και ασκιτικού υγρού Θετική καλλιέργεια αίματος ή/και ασκιτικού υγρού
hbd-1 (ng/ml) Eπίπεδα hbd-1 μεταξύ ασθενών με μη-αντιρροπούμενη Κίρρωση χωρίς οξεία επιδείνωση (ΜΑΚ) υγιών μαρτύρων P = 0.005 13.07 (12.09-14.7) 12.67 (8.71-18.08)
hbd-1 (ng/ml) Correlation between levels of serum hbd-1 and procalcitonin in overall patients r = 0.633 P < 0.001 PCT (ng/dl)
hbd-1 (ng/ml) Correlation between levels of serum hbd-1 and procalcitonin in ACLF r = 0.399 P = 0.029 PCT (ng/dl)