Hypermethylation of thymosinβ4 predicts a poor prognosis for patients with acute-on-chronic hepatitis B liver failure

Background:It has been demonstrated that thymosinβ4(Tβ4)could inflect the severity of acute-on-chronic hepatitis B liver failure(ACHBLF),but the relationship between its methylation status and the prognosis of liver failure is not clear.This study aimed to determine Tβ4 promoter methylation status in patients with ACHBLF and to evaluate its prognostic value.Methods:The study recruited 115 patients with ACHBLF,80 with acute-on-chronic hepatitis B pre-liver failure(pre-ACHBLF),and 86 with chronic hepatitis B(CHB).In addition,there were 36 healthy controls(HCs)from the Department of Hepatology,Qilu Hospital of Shandong University.The 115 patients with ACHBLF were divided into three subgroups:33 with early stage ACHBLF(E-ACHBLF),42 with mid-stage ACHBLF(M-ACHBLF),and 40 with advanced stage ACHBLF(A-ACHBLF).Tβ4 promoter methylation status in peripheral blood mononuclear cells(PBMCs)was measured by methylation-specific polymerase chain reaction,and mRNA was detected by quantitative real-time polymerase chain reaction.Results:Methylation frequency of Tβ4 was significantly higher in patients with ACHBLF than in those with pre-ACHBLF,CHB or HCs.However,expression of Tβ4 mRNA showed the opposite trend.In patients with ACHBLF,Tβ4 promoter methylation status correlated negatively with mRNA levels.The 3-month mortality of ACHBLF in the methylated group was significantly higher than that in the unmethylated group.Also,Tβ4 promoter methylation frequency was lower in survivors than in non-survivors.When used to predict the 1-,2-,and 3-month incidence of ACHBLF,Tβ4 methylation status was better than the model for end-stage liver disease(MELD)score.The predictive value of Tβ4 methylation was higher than that of MELD score for the mortality of patients with E-ACHBLF and M-ACHBLF,but not for A-ACHBLF.Conclusions:Tβ4 methylation might be an important early marker for predicting disease incidence and prognosis in patients with ACHBLF.

The Pathogenesis of Acute on Chronic Hepatitis B liver Failure

Acute-on-chronic liver failure is a characteristic clinical liver syndrome, which should be differentiated from acute liver failure, acute decompensated liver cirrhosis and chronic liver failure. The pathogenesis of ACLF is not fully understood yet. Viral factors and immune injury have been reported to be the two major pathogenesis. This paper reviewed the researches on the pathogenesis of acute on chronic hepatitis B liver failure in recent years, to provide theoretical basis for prompt and accurate diagnosis and treatment of this syndrome. This would benefit for the prognosis and raise the survival rate of patients.

Prognoses of patients with acute-on-chronic hepatitis B liver failure are closely associated with altered SOCS1 mRNA expression and cytokine production following glucocorticoid treatment

Suppressor of cytokine signaling （SOCS） 1 plays a crucial role in the immune response and might contribute to the prognoses of liver failure treated with glucocorticoid. We recruited 47 acute-on-chronic hepatitis B liver failure （ACHBLF） patients receiving glucocorticoid treatment and 30 healthy controls to determine the potential effects of glucocorticoid on the transcriptional level of SOCS1 in peripheral blood mononuclear cells. On the third and twenty-eighth days of glucocorticoid treatment, SOCS1 expression was negatively correlated with model for end-stage liver disease （MELD） score. Interleukin-6 （IL-6） and tumor-necrosis factor-a （＇I＇NF-a） levels were statistically lower, while the SOCS1 transcription level was higher in survivors than non-survivors both in pre- and post-treatment ACHBLF patients. The methylation rate of the SOCS1 promoter in ACHBLF patients was higher than in healthy control patients as determined by methylation-specific polymerase chain reaction. The mRNA level of SOCS1 in methylated promoters was significantly lower than from patients with unmethylated SOCS1 promoters, interferon （IFN）-y-responsive and STATl-dependent gene expression was higher in survivors and was dramatically decreased with rising expression of SOCS1 after glucocorticoid treatment. Mortality rates were significantly higher in methylated patients than for those without methylation at the end of a 90-day follow-up. Furthermore, we found that five in six surviving patients displayed demethylated SOCS1 on the twenty-eighth day after treatment, while that number was 3 in 10 in the non-survivors. These findings suggested that ACHBLF patients without SOCS1 methylation may have a favorable response to corticosteroid treatment.

Epidemiological and clinical features of hepatitis B virus related liver failure in China

AIM： To examine the epidemiologic and clinical characteristics of hepatitis B virus （HBV） related liver failure in patients in China. METHODS： This study was conducted with a retro- spective design to examine 1066 patients with HBV- related liver failure in the southwest of China. RESULTS： There were more male than female patients. Young and middle-aged people comprised most of the patients. Farmers and laborers comprised the larg- est proportion （63.09%）. Han Chinese accounted for 98.12%, while minority ethnic groups only accounted for 0.88% of patients. A total of 43.47% patients had a family history of HBV-related liver failure and 56.66% patients had a history of drinking alcohol. A total of 42.59% patients with HBV-related liver failure had defi- nite causes. With regard to the clinical manifestation of HBV-related liver failure, the symptoms were： hypodynamia, anorexia and abdominal distension. Total bilirubin （TBIL） and alanine aminotransferase （ALT） levels were altered in 46.23% of patients with evident damage of the liver. Univariate logistic regression analysis showed that the patients＇ prognoses were correlated with ALT, aspartate aminotransferase, albumin, TBIL, prothrombin activity （PTA）, and alpha-fetoprotein levels, and drinking alcohol, ascites, hepatorenal syndrome, infection and 〉i 2 complications. Multifactor logistic regression analysis showed that the activity of thrombinogen and the number of complications were related to the prognosis. CONCLUSION： Alcohol influences the patients＇ prognosis and condition. PTA and complications are independent factors that can be used for estimating the prognosis of HBV-related liver failure.

Progress in hepatitis B virus-related acute-on-chronic liver failure treatment in China:A large,multicenter,retrospective cohort study using a propensity score matching analysis

Background:Hepatitis B virus-related acute-on-chronic liver failure(HBV-ACLF)has a high short-term mortality.However,the treatment progression for HBV-ACLF in China in the past decade has not been well characterized.The present study aimed to determine whether the HBV-ACLF treatment has significantly improved during the past decade.Methods:This study retrospectively compared short-term(28/56 days)survival rates of two different nationwide cohorts(cohort I:2008-2011 and cohort II:2012-2015).Eligible HBV-ACLF patients were enrolled retrospectively.Patients in the cohorts I and II were assigned either to the standard medical therapy(SMT)group(cohort I-SMT,cohort II-SMT)or artificial liver support system(ALSS)group(cohort IALSS,cohort II-ALSS).Propensity score matching analysis was conducted to eliminate baseline differences,and multivariate logistic regression analysis was used to explore the independent factors for 28-day survival.Results:Short-term(28/56 days)survival rates were significantly higher in the ALSS group than those in the SMT group(P<0.05)and were higher in the cohort II than those in the cohort I(P<0.001).After propensity score matching,short-term(28/56 days)survival rates were higher in the cohort II than those in the cohort I for both SMT(60.7%vs.53.0%,50.0%vs.39.8%,P<0.05)and ALSS(66.1%vs.56.5%,53.0%vs.44.4%,P<0.05)treatments.The 28-day survival rate was higher in patients treated with nucleos(t)ide analogs than in patients without such treatments(P=0.046).Multivariate logistic regression analysis revealed that ALSS(OR=0.962,95%CI:0.951-0.973,P=0.038),nucleos(t)ide analogs(OR=0.927,95%CI:0.871-0.983,P=0.046),old age(OR=1.028,95%CI:1.015-1.041,P<0.001),total bilirubin(OR=1.002,95%CI:1.001-1.003,P=0.004),INR(OR=1.569,95%CI:1.044-2.358,P<0.001),COSSH-ACLF grade(OR=2.683,95%CI:1.792-4.017,P<0.001),and albumin(OR=0.952,95%CI:0.924-0.982,P=0.002)were independent factors for 28-day mortality.Conclusions:The treatment for patients with HBV-ACLF has improved in the past decade.

Metabonomic analysis of hepatitis B virus-induced liver failure:identification of potential diagnostic biomarkers by fuzzy support vector machine

Hepatitis B virus （HBV）-induced liver failure is an emergent liver disease leading to high mortality. The severity of liver failure may be reflected by the profile of some metabolites. This study assessed the potential of using metabolites as biomarkers for liver failure by identifying metabolites with good discriminative performance for its phenotype. The serum samples from 24 HBV-indueed liver failure patients and 23 healthy volunteers were collected and analyzed by gas chromatography-mass spectrometry （GC-MS） to generate metabolite profiles. The 24 patients were further grouped into two classes according to the severity of liver failure. Twenty-five eommensal peaks in all metabolite profiles were extracted, and the relative area values of these peaks were used as features for each sample. Three algorithms, F-test, k-nearest neighbor （KNN） and fuzzy support vector machine （FSVM） combined with exhaustive search （ES）, were employed to identify a subset of metabolites （biomarkers） that best predict liver failure. Based on the achieved experimental dataset, 93.62% predictive accuracy by 6 features was selected with FSVM-ES and three key metabolites, glyeerie acid, cis-aeonitie acid and citric acid, are identified as potential diagnostic biomarkers.

Changes in circulating Foxp3^+ regulatory T cells and interleukin-17-producing T helper cells during HBV-related acute-on-chronic liver failure

AIM: To longitudinally investigate cytokine gene expression and protein levels in Th17 and Treg cells, to observe T-cell phenotypes during hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACHBLF) and to analyze changes in Th17 and Treg phenotypes during disease progression.

Novel Prognostic Models for Predicting the 180-day Outcome for Patients with Hepatitis-B Virus-related Acute-on-chronic Liver Failure

Background and Aims:It remains difficult to forecast the 180-day prognosis of patients with hepatitis B virus-acuteon-chronic liver failure(HBV-ACLF)using existing prognostic models.The present study aimed to derive novel-innovative models to enhance the predictive effectiveness of the 180-day mortality in HBV-ACLF.Methods:The present cohort study examined 171 HBV-ACLF patients(non-survivors,n=62;survivors,n=109).The 27 retrospectively collected parameters included the basic demographic characteristics,clinical comorbidities,and laboratory values.Backward stepwise logistic regression(LR)and the classification and regression tree(CART)analysis were used to derive two predictive models.Meanwhile,a nomogram was created based on the LR analysis.The accuracy of the LR and CART model was detected through the area under the receiver operating characteristic curve(AUROC),compared with model of end-stage liver disease(MELD)scores.Results:Among 171 HBV-ACLF patients,the mean age was 45.17 years-old,and 11.7%of the patients were female.The LR model was constructed with six independent factors,which included age,total bilirubin,prothrombin activity,lymphocytes,monocytes and hepatic encephalopathy.The following seven variables were the prognostic factors for HBV-ACLF in the CART model:age,total bilirubin,prothrombin time,lymphocytes,neutrophils,monocytes,and blood urea nitrogen.The AUROC for the CART model(0.878)was similar to that for the LR model(0.878,p=0.898),and this exceeded that for the MELD scores(0.728,p<0.0001).Conclusions:The LR and CART model are both superior to the MELD scores in predicting the 180-day mortality of patients with HBV-ACLF.Both the LR and CART model can be used as medical decision-making tools by clinicians.

What MELD score mandates use of entecavir for ACLF-HBV HBeAg-negative patients?

AIM: To investigate optimal timing for therapeutic efficacy of entecavir for acute-on-chronic hepatitis B liver failure (ACLF-HBV) in hepatitis B e antigen (HBeAg)negative patients. METHODS: A total of 109 inpatients with ACLF-HBV were recruited from the Department of Infectious Diseases of the Third Affiliated Hospital, Sun Yat-sen University from October 2007 to October 2010. Entecavir 0.5 mg/d was added to each patient's comprehensive therapeutic regimen. Patients were divided into threegroups according to model for end-stage liver disease (MELD) score: high (≥ 30, 20 males and 4 females, mean age 47.8 ± 13.5 years); intermediate (22-30, 49 males and 5 females, 45.9 ± 12.4 years); and low (≤ 22, 28 males and 3 females, 43.4 ± 9.4 years). Statistical analysis were performed using SPSS 11.0 software. Data with normal distribution were expressed as mean ± SD and comparisons were made with Student's t tests. A value of P < 0.05 was considered statistically significant. Viral loads were related exponentially and logarithmic data were used for analysis. RESULTS: For 24 patients with MELD score ≥ 30, treatment lasted 17.2 ± 16.5 d. Scores before and after treatment were significantly different (35.97 ± 4.87 and 40.48 ± 8.17, respectively, t = -2.762, P = 0.011); HBV DNA load was reduced (4.882 ± 1.847 copies log10/mL to 3.685 ± 1.436 copies log10/mL); and mortality rate was 95.83% (23/24). Of 54 patients with scores of 22-30, treatment lasted for 54.0 ± 43.2 d; scores before and after treatment were 25.87 ± 2.33 and 25.82 ± 13.92, respectively (t = -0.030, P = 0.976); HBV DNA load decreased from 6.308 ± 1.607 to 3.473 ± 2.097 copies log10/mL; and mortality was 51.85% (28/54). Of 31 patients with scores ≤ 22, treatment lasted for 66.1 ± 41.9 d; scores before and after treatment were 18.88 ± 2.44 and 12.39 ± 7.80, respectively, (t = 4.860, P = 0.000); HBV DNA load decreased from 5.841 ± 1.734 to 2.657 ± 1.154 copies log10/mL; and mortality was 3.23% (1/31). CONCLUSION: For HBeAg-negative patients with ACLF-HBV, when entecavir was added to comprehensive therapy, a MELD score ≥ 30 predicted very poor prognosis due to fatal liver failure.

Development and Validation of a Nomogram for 90-day Outcome in Patients with Hepatitis B Virus-related Acute-on-chronic Liver Failure

Background and Aims:It is challenging to predict the 90-day outcomes of patients infected with hepatitis B virus-related acute-on-chronic liver failure(HBV-ACLF)via prevailing predictive models.This study aimed to develop an innovative model to enhance the analytical efficacy of 90-day mortality in HBV-ACLF.Methods:In this study,149 HBV-ACLF patients were evaluated by constructing a death risk prediction nomogram.Bootstrap resampling and an independent validation cohort comprising 31 patients from June 2019 to February 2020 were assessed for model confirmation.Results:The nomogram was constructed by entering and identifying five factors age,total bilirubin,prothrombin activity(PTA),lymphocyte(L)%,and monocyte(M)%.Healthy refinement was achieved from the nomogram analysis,where the area under the receiver operating characteristic curve was 0.864 for the training cohort and 0.874 was achieved for the validation cohort.There was admirable concordance between the predicted and true results in the equilibrium curve.The decision curve assessment revealed the useful clinical application of the nomogram.Conclusions:We constructed an innovative nomogram and validated it for the prediction of 90-day HBV-ACLF patient outcomes.This model might help develop optimized treatment protocol recommendations for HBV-ACLF patients。

The “Traditional Chinese medicine regulating liver regeneration” treatment plan for reducing mortality of patients with hepatitis B-related liver failure based on real-world clinical data

On the basis of real-world clinical data,the study aimed to explore the effect and mechanisms of the treatment plan of“traditional Chinese medicine(TCM)regulating liver regeneration.”A total of 457 patients with HBV-related liver failure were retrospectively collected.The patients were divided into three groups:the modern medicine control group(MMC group),patients treated with routine medical treatment;the control group combining traditional Chinese and Western medicine(CTW),patients treated with routine medical treatment plus the common TCM formula;and the treatment group of“TCM regulating liver regeneration”(RLR),patients treated with both routine medical treatment and the special TCM formula of RLR.After 8 weeks of treatment,the mortality of patients in the RLR group(12.31%)was significantly lower than those in the MMC(50%)and CTW(29.11%)groups.Total bilirubin level significantly decreased and albumin increased in the RLR group when compared with the MMC and CTW groups(P<0.05).In addition,there were significant differences in the expression of several cytokines related to liver regeneration in the RLR group compared with the MMC group.RLR treatment can decrease jaundice,improve liver function,and significantly reduce the mortality in patients with HBV-related liver failure.The mechanism may be related to the role of RLR treatment in influencing cytokines related to liver regeneration.

Short-Term Efficacy of Treating Hepatitis B Virus-Related Acute-on-Chronic Liver Failure Based on Cold Pattern Differentiation with Hot Herbs: A Randomized Controlled Trial

Objective： To evaluate the clinical efficacy and safety of Yinchen Zhufu Decoction（茵陈术附汤, YCZFD） in the treatment of acute-on-chronic liver failure caused by hepatitis B virus（HBV-ACLF） with cold pattern in Chinese medicine（CM）. Methods： This is a multi-center randomized controlled trial of integrative treatment of CM and Western medicine（WM） for the management of HBV-ACLF patients. A total of 200 HBV-ACLF patients with cold pattern were equally randomly assigned to receive YCZFD and WM（integrative treatment） or WM conventional therapy alone respectively for 4 weeks. The primary end point was the mortality for HBV-ACLF patients. Secondary outcome measures included Model for End-Stage Liver disease（MELD） score, liver biochemical function, coagulation function and complications. Adverse events during treatment were reported. Results： The mortality was decreased 14.28% in the integrative treatment group compared with WM group（χ^2=6.156, P=0.013）. The integrative treatment was found to significantly improve the MELD score（t=2.353, P=0.020）. There were statistically significant differences in aspartate transaminase, total bilirubin, indirect bilirubin, direct bilirubin and prothrombin time between the two groups（P〈0.05 or P〈0.01）. The complications of ascites（χ^2=9.033, P=0.003） and spontaneous bacteria peritonitis（χ^2=4.194, P=0.041） were improved significantly in the integrative treatment group. No serious adverse event was reported. Conclusions： The integrative treatment of CM and WM was effective and safe for HBV-ACLF patients with cold pattern in CM. The Chinese therapeutic principle ＂treating cold pattern with hot herbs＂ remains valuable to the clinical therapy.（Trial registration No. Chi CTR-TRC-10000766）

Prognostic value of keratin 18 for the patients with hepatitis B virus-related acute-on-chronic liver failure

Objective To analyze the serum keratin 18(K18)level of patients with hepatitis B virus(HBV)-related acute-on-chronic liver failure(HBV-ACLF)and its correlation with prognosis.Methods From December 2012 to October 2014,120 patients who visited Fuzhou Infectious Diseases Hospital and were diagnosed with HBV-ACLF were enrolled,and 20 chronic hepatitis B(CHB)pa-

The possible role and clinical implication of myeloid-derived suppressor cells in the peripheral blood of patients with hepatitis B virus-related acute-on-chronic liver failure

Objective To explore the possible role and clinical implications of myeloid-derived suppressor cells(MDSC)in the peripheral blood of patients with hepatitis B virus(HBV)-related acute-on-chronic liver failure(HBVACLF).Methods A total of 25 HBV-ACLF patients