Survival benefit of l-carnitine supplementation in patients with cirrhosis.

BACKGROUND: l-Carnitine supplementation is effective in improving muscle cramps, hyperammonemia, and hepatic encephalopathy in patients with cirrhosis. However, limited evidence is available on the effect of l-carnitine supplementation on the survival of patients with cirrhosis. METHODS: In this retrospective study, 674 patients with cirrhosis admitted to Gifu University Hospital or Chuno Kosei Hospital between October 2011 and December 2018 were enrolled. l-carnitine supplementation was defined as the use of l-carnitine for >30 consecutive days during the follow-up period. Propensity score matching was applied to create comparable groups between l-carnitine-treated and untreated patients. Mortality was evaluated using the Cox proportional hazards model. RESULTS: Among the patients, 93 were excluded. Of the remaining 581 patients, 71 (12%) received l-carnitine supplementation. Propensity matching identified 189 patients (63 l-carnitine-treated and 126 untreated patients) with comparable baseline characteristics in both groups. Of the matched patients, 33 (52%) l-carnitine-treated and 74 (59%) untreated patients died during the median follow-up period of 36.3 months. Overall survival was significantly higher in l-carnitine-treated patients than in untreated patients (hazard ratio [HR], 0.66; 95% CI, 0.43-0.99). A subgroup analysis showed that the survival benefit of l-carnitine supplementation was prominent in patients with Child-Pugh Class B or C (HR, 0.39; 95% CI, 0.23-0.68), serum albumin levels ≤3.5 g/dl (HR, 0.59; 95% CI, 0.37-0.95), and ammonia levels ≥90 mcg/dl (HR, 0.50; 95% CI, 0.26-0.97), and in those without sarcopenia (HR, 0.56; 95% CI, 0.35-0.90). CONCLUSION: l-Carnitine supplementation may improve survival in patients with cirrhosis.

Usefulness of the Trabecular Bone Score in Assessing the Risk of Vertebral Fractures in Patients with Cirrhosis.

The trabecular bone score (TBS), a surrogate measure of bone microarchitecture, provides complementary information to bone mineral density (BMD) in the assessment of osteoporotic fracture risk. This cross-sectional study aimed to determine whether TBS can identify patients with liver cirrhosis that are at risk of vertebral fractures. We enrolled 275 patients who completed evaluations for lumbar BMD, TBS, and vertebral fractures between November 2018 and April 2021. BMD was measured using dual-energy X-ray absorptiometry (DXA), TBS was calculated by analyzing DXA images using TBS iNsight software, and vertebral fractures were evaluated using Genant's semi-quantitative method with lateral X-ray images. Factors associated with vertebral fractures and their correlation with the TBS were identified using regression models. Of the enrolled patients, 128 (47%) were female, the mean age was 72 years, and 62 (23%) were diagnosed with vertebral fractures. The prevalence of vertebral fractures was higher in women than in men (33% vs. 14%; p < 0.001). The unadjusted odds ratio (OR) of the vertebral fractures for one standard deviation decrease in TBS and BMD was 2.14 (95% confidence interval [CI], 1.69−2.73) and 1.55 (95% CI, 1.26−1.90), respectively. After adjusting for age, sex, and BMD, the adjusted OR of the vertebral fractures in TBS was 2.26 (95% CI, 1.52−3.35). Multivariate linear regression analysis showed that TBS was independently correlated with age (ß = −0.211), body mass index (ß = −0.251), and BMD (ß = 0.583). TBS can help identify patients with cirrhosis at risk of vertebral fractures.

Usefulness of nutritional therapy recommended in the Japanese Society of Gastroenterology/Japan Society of Hepatology evidence-based clinical practice guidelines for liver cirrhosis 2020.

BACKGROUND: The JSGE/JSH guidelines for the management of patients with liver cirrhosis revised in 2020 recommends new strategies for nutritional assessment and intervention, although their usefulness in daily clinical practice is unclear. METHODS: A total of 769 patients with cirrhosis were classified into low-, intermediate-, and high-risk groups according to hypoalbuminemia and sarcopenia, the criteria established for initiating the nutritional therapy algorithm in the guidelines. The association between these groups and mortality was analyzed using a Cox proportional hazards model. The effect of branched-chain amino acids (BCAAs) on survival was evaluated using propensity score matching. RESULTS: Of the enrolled patients, 495 (64%) were men with a median age of 73 years, 428 (56%) had hypoalbuminemia, 156 (20%) had sarcopenia, and 288 (37%) were receiving BCAAs. During a median follow-up period of 1.5 years, 276 (36%) patients died. The intermediate-risk [hazard ratio (HR), 1.60; 95% confidence interval (CI), 1.18-2.18] and high-risk (HR, 2.85; 95% CI, 1.92-4.23) groups independently predicted mortality. Among the propensity score-matched 250 patients, 49 (39%) BCAA-treated and 58 (46%) untreated died. Overall survival was higher in BCAA-treated patients than in untreated patients (HR, 0.67; 95% CI, 0.46-0.98). The survival benefit of BCAAs was pronounced in the intermediate-risk (HR, 0.50; 95% CI, 0.31-0.80) and high-risk (HR, 0.38; 95% CI, 0.16-0.91) groups. CONCLUSIONS: The 2020 JSGE/JSH guidelines for liver cirrhosis are useful in stratifying the mortality risk and providing effective nutritional interventions for malnourished patients with cirrhosis.

Late Evening Snack with Branched-Chain Amino Acids Supplementation Improves Survival in Patients with Cirrhosis.

The clinical efficacy of a late evening snack (LES) is well documented in patients with cirrhosis, but its effect on survival remains unclear. This cohort study aimed to compare the overall survival between LES-treated patients and untreated patients. We conducted a retrospective cohort study to determine the effect of LES, which is defined as an oral intake of a branched-chain amino acids (BCAA)-enriched nutrient before bedtime, on survival in 523 patients with cirrhosis seen at a tertiary referral center in Japan from March 2004 to April 2019. The association between LES and all-cause mortality was evaluated using propensity score matching and inverse probability of treatment weighting analyses. The median age of the 523 participants was 66 years; 286 (55%) patients were men and 87 (17%) received LES therapy. Of the 231 propensity-matched patients, 20 (26%) LES-treated patients and 72 (47%) untreated patients died during a median follow-up of 2.0 years (interquartile range, 0.5-4.8). Propensity score matching analysis showed that the overall survival was significantly higher in LES-treated patients than in untreated patients (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.34-0.93). The survival benefit of LES therapy was most prominent in patients with Child-Pugh C cirrhosis (HR, 0.40; 95% CI, 0.20-0.81). Inverse probability of treatment weighting analysis also revealed that LES significantly improved the prognosis of patients with cirrhosis (HR, 0.57; 95% CI, 0.33-0.99). In this retrospective study of patients with cirrhosis, we found that nocturnal BCAA supplementation was associated with a significant reduction in the risk of death in patients with liver cirrhosis.

Imaging the Different Mechanisms of Prostate Cancer Cell-killing by Tumor-targeting Salmonella typhimurium A1-R.

BACKGROUND/AIMS: We previously developed a genetically-modified bacterial strain of Salmonella typhimurium, auxotrophic for leucine and arginine, which also expresses green fluorescent protein (GFP), termed S. typhimurium A1-R. S. typhimurium A1-R was found to be effective against metastatic human prostate, breast, pancreatic, cervical and ovarian cancer, as well as osteosarcoma, fibrosarcoma and glioma, in clinically relevant nude mouse models. MATERIALS AND METHODS: To understand the tumor cell-killing mechanism of S. typhimurium A1-R-GFP, we studied the interaction of S. typhimurium A1-R-GFP with three different prostate cancer cell lines in vitro. S. typhimurium-GFP invasion, proliferation, and means of killing in three different human prostate cancer cell lines were visualized by confocal fluorescence microscopy with the Olympus FV1000. RESULTS: We found that S. typhimurium A1-R-induced cancer-cell death had different mechanisms in different prostate cancer cell lines, occurring through apoptosis and necrosis in the PC-3 prostate cancer cell line, and by cell bursting in the LNCaP and DU-145 prostate cancer cell lines. The time required for S. typhimurium A1-R-GFP to kill the majority of cancer cells varied from line to line, ranging from 2 hours to 48 hours. CONCLUSION: Understanding the various mechanisms of cancer-cell killing by S. typhimurium A1-R will be important for its use as a general therapeutic for cancer.

Skeletal muscle depletion predicts the prognosis of patients with hepatocellular carcinoma treated with sorafenib.

The aim of this study was to determine whether skeletal muscle depletion predicts the prognosis of patients with hepatocellular carcinoma (HCC) that is being treated with sorafenib. We evaluated 40 consecutive HCC patients who received sorafenib treatment. The skeletal muscle cross-sectional area was measured by computed tomography at the third lumbar vertebra (L3), from which the L3 skeletal muscle index (L3 SMI) was obtained. The factors contributing to overall survival, sorafenib dose reduction, and discontinuation of sorafenib were analyzed using the Cox proportional hazards model. L3 SMI (p = 0.020) and log (α-fetoprotein (AFP)) (p = 0.010) were identified as independent prognostic factors in HCC patients treated with sorafenib. The initial dose of sorafenib (p = 0.008) was an independent risk factor for sorafenib dose reduction, and log (AFP) (p = 0.008) was the only significant risk factor for the discontinuation of this drug. L3 SMI was not a risk factor for either dose reduction (p = 0.423) or the discontinuation (p = 0.132) of sorafenib. A multiple linear regression analysis determined the following relationship between skeletal muscle mass (assessed as L3 SMI) and the explanatory factors: L3 SMI = -0.1896 × (Age) - 10.3441 × (Child-Pugh score) - 9.3922 × (log (AFP)) + 1.6139 × (log (AFP)) × (Child-Pugh score) + 112.9166. Skeletal muscle depletion is inversely associated with age, Child-Pugh score, and log (AFP). Moreover, it is an independent prognostic factor for HCC patients treated with sorafenib.

Sarcopenia impairs prognosis of patients with liver cirrhosis.

OBJECTIVE: Sarcopenia is characterized by the loss of skeletal muscle mass, and is reported to appear in patients with liver cirrhosis (LC). The aim of this study was to investigate the prevalence of sarcopenia in patients with LC, and to test the association between sarcopenia and patient outcomes. We also analyzed the effect of branched-chain amino acid (BCAA) supplementation on sarcopenic LC. METHODS: Clinical and blood biochemical data of 130 patients with LC who underwent abdominal computed tomography scan were analyzed in this retrospective study. The cross-sectional area of skeletal muscles was measured at the level of the third lumbar vertebra on the scan. The skeletal muscle index was calculated to identify sarcopenia. Cirrhotic patients who were treated with BCAA supplementation of 12 g/d for ≥ 1 y were defined as the BCAA group, and the effect of BCAA on sarcopenic LC was evaluated. RESULTS: Sixty-eight percent of all patients (82% of men and 50% of women) were diagnosed with sarcopenia. Male sex (P = 0.01) and body mass index (P < 0.0001) were predictors of sarcopenia. The multivariate Cox proportional hazards model found BCAA supplementation (hazard ratio [HR], 0.38; P = 0.01), sarcopenia (HR, 3.03; P < 0.01), and Child-Pugh classes B (HR, 2.39; P = 0.03) and C (HR, 5.49; P < 0.001) to be independently associated with mortality. The mortality of sarcopenic LC was significantly higher than that of non-sarcopenic LC (P = 0.01). Moreover, BCAA supplementation improved the survival of sarcopenic patients in subgroup analysis (P < 0.01). CONCLUSIONS: Sarcopenia is significantly associated with mortality in patients with LC. BCAA supplementation might be associated with improved survival of such patients.

Pharmaceutical and nutraceutical approaches for preventing liver carcinogenesis: chemoprevention of hepatocellular carcinoma using acyclic retinoid and branched-chain amino acids.

The poor prognosis for patients with hepatocellular carcinoma (HCC) is associated with its high rate of recurrence in the cirrhotic liver. Therefore, more effective strategies need to be urgently developed for the chemoprevention of this malignancy. The malfunction of retinoid X receptor α, a retinoid receptor, due to phosphorylation by Ras/mitogen-activated protein kinase is closely associated with liver carcinogenesis and may be a promising target for HCC chemoprevention. Acyclic retinoid (ACR), a synthetic retinoid, can prevent HCC development by inhibiting retinoid X receptor α phosphorylation and improve the prognosis for this malignancy. Supplementation with branched-chain amino acids (BCAA), which are used to improve protein malnutrition in patients with liver cirrhosis, can also reduce the risk of HCC in obese cirrhotic patients. In experimental studies, both ACR and BCAA exert suppressive effects on HCC development and the growth of HCC cells. In particular, combined treatment with ACR and BCAA cooperatively inhibits the growth of HCC cells. Furthermore, ACR and BCAA inhibit liver tumorigenesis associated with obesity and diabetes, both of which are critical risk factors for HCC development. These findings suggest that pharmaceutical and nutraceutical approaches using ACR and BCAA may be promising strategies for preventing HCC and improving the prognosis of this malignancy.

Real-time imaging of apoptosis induction of human breast cancer cells by the traditional Chinese medicinal herb tubeimu.

Traditional Chinese Medicine (TCM) has been used for thousands of years, including treatment for cancer. Use of modern technology and the scientific method to evaluate the efficacy of TCM for cancer should enable its more widespread use. In the present study, the efficacy of the TCM tubeimu, extracted from the tuber of the plant Bolbostemma paniculatum, on the MDA-MB-231 human breast cancer cell line was evaluated. The MDA-MB-231 cell line was engineered to express red fluorescent protein (RFP) in the cytoplasm and green fluorescent protein (GFP) linked to histone H2B in the nucleus, which allows real-time imaging of nuclear-cytoplasmic dynamics. Apoptosis was readily visualized in these cells by nuclear shape changes and fragmentation. The MDA-MB-231 RFP-GFP cells were cultured either in two-dimensions on plastic or in three-dimensions on Gelfoam®. Cells were treated with a dichloromethane extract of fresh tubeimu. Apoptosis was further monitored by DNA fragmentation determined by gel electrophoresis. Tubeimu induced apoptosis of MDA-MB-231 cells, as observed by fluorescence microscopy, as early as 24 hours of treatment in vitro in two-dimensional culture. By 48 hours' treatment, DNA fragmentation could be observed. The frequency of apoptosis increased through at least 72 hours' treatment, with most of the cells being killed. Tubeimu also induced apoptosis of MDA-MB-231 cells in three-dimensional culture on Gelfoam®, but to a lesser extent than in 2D culture. The results of the present study indicate the potential of tubeimu in breast cancer therapy.

Efficacy against lung metastasis with a tumor-targeting mutant of Salmonella typhimurium in immunocompetent mice.

Salmonella typhimurium double leu-arg auxotrophs have been shown to be highly effective as antitumor agents in nude mouse models of human metastatic cancer. In order to proceed to clinical development of the S. typhimurium double auxotroph, termed A1-R, it is necessary to evaluate antitumor efficacy in immunocompetent mice. In the present study, we have observed the efficacy of A1-R on the Lewis lung (LLC) carcinoma in vitro as well as in C57BL/6 (C57) immunocompetent mice. In vitro, A1-R treatment of LLC began to induce cell death within one hour. Various doses and schedules of A1-R were administered to C57 mice implanted with LLC, including bolus single intravenous injection; medium dose with weekly intravenous administration and metronomic treatment with small intravenous doses twice a week. Bolus treatment was toxic to the immunocompetent host, in contrast to nude mice. Lower-dose weekly doses and metronomic doses were well tolerated by the immunocompetent host. Weekly intravenous injection with 2 × 10(7) bacteria and twice a week intravenous injection with 10(7) bacteria significantly inhibited metastasis formation, while bolus injection was toxic. Intra-thoracic administration was carried out with 10(8) bacteria A1-R injected into Lewis lung-bearing C57 mice weekly for three weeks. Lung metastasis was significantly inhibited by intrathoracic bacterial administration, without toxicity. The results in this report, demonstrating the anti-metastatic efficacy of S. typhimurium A1-R in immunocompetent mice, indicate the clinical potential of bacterial therapy of cancer.