Metabolic interventions improve HBV envelope-specific T-cell responses in patients with chronic hepatitis B.

BACKGROUND: Restoration of HBV-specific T cell immunity is a promising approach for the functional cure of chronic Hepatitis B (CHB), necessitating the development of valid assays to boost and monitor HBV-specific T cell responses in patients with CHB. METHODS: We analyzed hepatitis B virus (HBV) core- and envelope (env)-specific T cell responses using in vitro expanded peripheral blood mononuclear cells (PBMCs) from patients with CHB exhibiting different immunological phases, including immune tolerance (IT), immune activation (IA), inactive carrier (IC), and HBeAg-negative hepatitis (ENEG). Additionally, we evaluated the effects of metabolic interventions, including mitochondria-targeted antioxidants (MTA), polyphenolic compounds, and ACAT inhibitors (iACAT), on HBV-specific T-cell functionality. RESULTS: We found that HBV core- and env-specific T cell responses were finely coordinated and more profound in IC and ENEG than in the IT and IA stages. HBV env-specific T cells were more dysfunctional but prone to respond to metabolic interventions using MTA, iACAT, and polyphenolic compounds than HBV core-specific T-cells. The responsiveness of HBV env-specific T cells to metabolic interventions can be predicted by the eosinophil (EO) count and the coefficient of variation of red blood cell distribution width (RDW-CV). CONCLUSION: These findings may provide valuable information for metabolically invigorating HBV-specific T-cells to treat CHB.

Serum cytokine change profile associated with HBsAg loss during combination therapy with PEG-IFN-α in NAs-suppressed chronic hepatitis B patients.

Objective: The aim of this study was to explore the profile of cytokine changes during the combination therapy with pegylated interferon alpha (PEG-IFN-α) and its relationship with HBsAg loss in nucleos(t)ide analogs (NAs)-suppressed chronic hepatitis B patients. Methods: Seventy-six patients with chronic hepatitis B with HBsAg less than 1,500 IU/ml and HBV DNA negative after receiving ≥ 1-year NAs therapy were enrolled. Eighteen patients continued to take NAs monotherapy (the NAs group), and 58 patients received combination therapy with NAs and PEG-IFN-α (the Add-on group). The levels of IFNG, IL1B, IL1RN, IL2, IL4, IL6, IL10, IL12A, IL17A, CCL2, CCL3, CCL5, CXCL8, CXCL10, TNF, and CSF2 in peripheral blood during treatment were detected. Results: At week 48, 0.00% (0/18) in the NAs group and 25.86% (15/58) in the Add-on group achieved HBsAg loss. During 48 weeks of combined treatment, there was a transitory increase in the levels of ALT, IL1RN, IL2, and CCL2. Compared to the NAs group, CXCL8 and CXCL10 in the Add-on group remain higher after rising, yet CCL3 showed a continuously increasing trend. Mild and early increases in IL1B, CCL3, IL17A, IL2, IL4, IL6, and CXCL8 were associated with HBsAg loss or decrease >1 log, while sustained high levels of CCL5 and CXCL10 were associated with poor responses to Add-on therapy at week 48. Conclusions: The serum cytokine change profile is closely related to the response to the combination therapy with PEG-IFN-α and NAs, and may help to reveal the mechanism of functional cure and discover new immunological predictors and new therapeutic targets.

Feasibility of machine learning-based modeling and prediction using multiple centers data to assess intrahepatic cholangiocarcinoma outcomes.

BACKGROUND AND AIMS: Currently, there are still no definitive consensus in the treatment of intrahepatic cholangiocarcinoma (iCCA). This study aimed to build a clinical decision support tool based on machine learning using the Surveillance, Epidemiology, and End Results (SEER) database and the data from the Fifth Medical Center of the PLA General Hospital in China. METHODS: 4,398 eligible patients from the SEER database and 504 eligible patients from the hospital data, who presented with histologically proven iCCA, were enrolled for modeling by cross-validation based on machine learning. All the models were trained using the open-source Python library scikit-survival version 0.16.0. Shapley additive explanations method was used to help clinicians better understand the obtained results. Permutation importance was calculated using library ELI5. RESULTS: All involved treatment modalities could contribute to a better prognosis. Three models were derived and tested using different data sources, with concordance indices of 0.67, 0.69, and 0.73, respectively. The prediction results were consistent with those under actual situations involving randomly selected patients. Model 2, trained using the hospital data, was selected to develop an online tool, due to its advantage in predicting short-term prognosis. CONCLUSION: The prediction model and tool established in this study can be applied to predict the prognosis of iCCA after treatment by inputting the patient's clinical parameters or TNM stages and treatment options, thus contributing to optimal clinical decisions.KEY MESSAGESA prognostic model related to disease staging and treatment mode was conducted using the method of machine learning, based on the big data of multi centers.The online calculator can predict the short-term survival prognosis of intrahepatic cholangiocarcinoma, thus, help to make the best clinical decision.The online calculator built to calculate the mortality risk and overall survival can be easily obtained and applied.

Immunogenicity of inactivated coronavirus disease 2019 vaccines in patients with chronic hepatitis B undergoing antiviral therapy.

Objectives: To investigate the effect and its mechanisms of different antiviral agents on the immunogenicity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines in patients with chronic hepatitis B (CHB). Methods: A total of 125 patients with CHB receiving nucleos(t)ide analogs (NAs) monotherapy or combined with Peg-interferon-alpha (Peg-IFNα) therapy and 29 healthy controls (HCs) were enrolled. Adverse reactions (ADRs) and levels of neutralizing antibody (NAb), immunoglobulin G (IgG), immunoglobulin M (IgM), and peripheral cytokines post-vaccination were analyzed. Results: All ADRs were tolerable in CHB patients. Overall, no significant difference was observed in the antibody levels between patients and HCs after two doses of vaccination. An inverse correlation between NAb, IgG titers and the days after two doses was found in non-IFN group but not in IFN group. Correspondingly, peripheral interferon-γ levels were significantly higher in IFN group than in non-IFN group. After a booster dose, NAb and IgG antibodies were maintained at high levels in NA-treated patients. Conclusion: Peg-interferon-alpha-based therapy may be beneficial for maintaining the immunogenicity of SARS-CoV-2 vaccines in CHB patients, which may be related to the high levels of IFN-γ induced by Peg-IFNα therapy. A booster dose can effectively recall the robust and long-lasting immunogenicity of SARS-CoV-2 vaccines.

A New Prognostic Model Covering All Stages of Intrahepatic Cholangiocarcinoma.

Background and Aims: Intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy that causes a poor survival. We aimed to identify its prognostic factors and to develop a nomogram that will predict survival of ICC patients among all stages. Methods: A total of 442 patients with pathology-proven ICC registered at the Fifth Medical Center of PLA General Hospital between July 2007 and December 2019 were enrolled. Subjects were followed for survival status until June 30, 2020. A prognostic model visualized as a nomogram was constructed in the training cohort using multivariate cox model, and was then validated in the validation cohort. Results: The median age was 55 years. With a median follow-up of 50.4 months, 337 patients died. The median survival was 11.6 months, with 1-, 3- and 5-year survival rates of 48.3%, 22.7% and 16.2%, respectively. Factors associated with overall survival were multiple tumors, lymph node involvement, vascular invasion, distant metastasis, decreased albumin, elevated lactate dehydrogenase (LDH), decreased iron, elevated fibrinogen, elevated CA125 and elevated CA19-9. A nomogram predicting survival of ICC patients at the time of diagnosis achieved a Harrel's c-statistic of 0.758, significantly higher than the 0.582 of the TNM stage alone. Predicted median survivals of those within the low, mid and high-risk subgroups were 35.6, 12.1 and 6.2 months, respectively. Conclusions: A nomogram based on imaging data and serum biomarkers at diagnosis showed good ability to predict survival in patients with all stages of ICC. Further studies are needed to validate the prognostic capability of our new model.

Remimazolam Protects Against LPS-Induced Endotoxicity Improving Survival of Endotoxemia Mice.

Remimazolam is a new benzodiazepine of sedative drugs with an ultra-short-acting anesthetic effect, commonly used for critically ill patients (especially septic patients) in intensive care units (ICUs). Although some anesthetics have been reported to show certain anti-inflammatory effects, the role of remimazolam in inflammation is still remained unknown. Here, we studied the effects of remimazolam on macrophage in response to LPS both in vivo and in vitro. Interestingly, compared with LPS treatment group, remimazolam remarkably improved survival rate of endotoxemia mice and decreased the release of LPS-induced inflammatory mediators (such as TNF-α, IL-6, and IL-1ß). We further found that remimazolam not only inhibited the activation of MAPK signal pathway at 15 min after LPS treatment but also disturbed Rab5a related TLR4 expression at cell surface in response to LPS at a later time. Such evidence suggests that remimazolam might be beneficial to septic patients who are suffering from uncontrolled inflammatory responses.

Erlotinib protests against LPS-induced parthanatos through inhibiting macrophage surface TLR4 expression.

Sepsis is a life-threatening cascading systemic inflammatory response syndrome on account of serve infection. In inflamed tissues, activated macrophages generate large amounts of inflammatory cytokines reactive species, and are exposed to the damaging effects of reactive species. However, comparing with necroptosis and pyroptosis, so far, there are few studies focusing on the overproduction-related cell death, such as parthanatos in macrophage during sepsis. In LPS-treated macrophage, we observed PARP-1 activation, PAR formation and AIF translocation. All these phenomena could be inhibited by both erlotinib and 3-AB, indicating the presence of parthanatos in endotoxemia. We further found that LPS induced the increase of cell surface TLR4 expression responsible for the production of ROS and subsequent parthanatos in endotoxemia. All these results shed a new light on how TLR4 regulating the activation of PARP-1 by LPS in macrophage.

Skewed CD39/CD73/adenosine pathway contributes to B-cell hyperactivation and disease progression in patients with chronic hepatitis B.

BACKGROUND: The mechanisms underlying B-cell hyperactivation in patients with chronic hepatitis B virus (HBV) infection remain largely undefined. The present study assessed the clinical characteristics of the CD39/CD73/adenosine pathway in patients with chronic hepatitis B (CHB). METHODS: We examined CD39 and CD73 expression and adenosine production by B-cells from 202 HBV-infected patients. B-cell-activation phenotypes were assessed by flow cytometry after CpG+CD40 ligand stimulation with or without blockade and activation of the adenosine pathway. RESULTS: CD39 and CD73 expression on circulating B-cells was decreased in CHB patients with high HBV DNA, HBeAg positivity, high HBsAg levels, and active liver inflammation, and was hierarchically restored in complete responders according to HBeAg seroconversion or HBsAg reduction. However, CD39 and CD73 expression on activated memory and tissue-like memory B-cell subsets in complete responders was not increased despite effective antiviral treatments. Furthermore, CD39 and CD73 expression on intra-hepatic B-cells was decreased in inflammatory livers. In vitro, B-cells from CHB patients showed a markedly reduced capacity to generate CD39/CD73-dependent extracellular adenosine and expressed increased levels of activation markers after adenosine-production blockade. Contrastingly, metformin significantly reduced activation-marker expression via regulating AMP-activated protein kinase. CONCLUSIONS: The skewed CD39 and CD73 expression on B-cells was associated with a high viral burden, liver inflammation, and antiviral efficacy in CHB patients, and the skewed CD39/CD73/adenosine pathway contributed to B-cell hyperactivation. Regulation of the CD39/CD73/adenosine pathway using metformin may represent a therapeutic option to reverse HBV-induced immune pathogenesis.

Interplay between RAGE and TLR4 Regulates HMGB1-Induced Inflammation by Promoting Cell Surface Expression of RAGE and TLR4.

Receptor for advanced glycation end-products (RAGE) and TLR4 play an important role in the inflammatory response against High-mobility group box 1 protein (HMGB1), a late proinflammatory cytokine and a damage-associated molecular pattern. As cell surface receptors, both RAGE and TLR4 are constantly trafficking between the cytoplasm and plasma membrane. However, whether TLR4 is related to the intracellular transport of RAGE in HMGB1-induced inflammation remains unknown. In this study, we demonstrated that HMGB1 not only increased RAGE expression in both the cytoplasm and plasma membrane but also upregulated the expression of TLR4 in the plasma membrane. Knocking out of RAGE led to decreased MAPK activation, TLR4 cellular membrane expression, and corresponding inflammatory cytokine generation. Meanwhile, inhibiting MAPK activation also decreased TLR4 surface expression. These results indicated that HMGB1 may bind to cell surface RAGE receptors on the cell surface, leading to MAPK activation, thus promoting TLR4 translocation on the cell surface, but does not regulate its transcription and translation. In contrast, TLR4 can increase the transcription and translation of RAGE, which translocates to the cell surface and is able to bind to more HMGB1. The cell surface receptors TLR4 and RAGE bind to HMGB1, leading to the transcription and secretion of inflammatory cytokines. Finally, we also observed these results in the mice pseudofracture model, which is closely related to HMGB1-induced inflammatory response. All these results demonstrated that the interplay between RAGE and TLR4 are critical for HMGB1-induced inflammatory response.

Management of COVID-19 in patients after liver transplantation: Beijing working party for liver transplantation.

Annually, around 850 liver transplantation is performed in Beijing, China. Recently, the new coronavirus pneumonia (COVID-19) caused by 2019 novel coronavirus (2019-nCoV) has affected nearly 200 countries worldwide. 2019-nCov can cause severe lung disease, multiple-organ damage, and significant mortalities. Liver transplant recipients, because of long-term oral immunosuppressant effects, may be more susceptible to 2019-nCoV infection and have a worse prognosis than the general population. It is urgent to set up guidelines for the prevention, diagnosis, and treatment of COVID-19 in liver transplant recipients. In this article, we reviewed the clinical aspects of 2019-nCoV infection, characteristics of liver transplant recipients, immunosuppressant usage, and potential drug interactions to provide recommendations to clinical staff managing liver transplant recipients during the COVID-19 epidemic.

Circulating CXCR3-CCR6-CXCR5+CD4+ T cells are associated with acute allograft rejection in liver transplantation.

Circulating T follicular helper (cTFH) cells have been demonstrated to be involved in B-cell-mediated alloreactive responses in kidney and liver transplantation; however, whether these cells are involved in acute liver allograft rejection after liver transplantation, and which subsets are involved, remains to be clarified. The present study aimed to investigate the profiles of cTFH cells in acute liver allograft rejection, including the CXC motif receptor 3 (CXCR3)+ chemokine receptor 6 (CCR6)- subset, the CXCR3-CCR6- subset, and the CXCR3-CCR6+ subset. Twelve liver transplant patients with acute rejection (AR) and 20 with no acute rejection (NAR) were enrolled in the study. The results showed that the proportion of CXCR3-CCR6-CXCR5+CD4+ T cells was significantly increased and the proportion of CXCR3-CCR6+CXCR5+CD4+ T cells was significantly decreased in patients with AR compared with patients with NAR. In addition, the proportion of CXCR3-CCR6-CXCR5+CD4+ T cells was positively correlated with the proportion of B cells in patients with AR. The level of serum interleukin (IL)-21 was higher in the AR group than in the NAR groups. Furthermore, the proportion of CXCR3-CCR6-CXCR5+CD4+ T cells was positively correlated with alanine amino transferase (ALT), whereas the proportion of CXCR3-CCR6+ CXCR5+CD4+ T cells was negatively correlated with ALT. B cells and TFH cells were detected in follicular-like structures in liver allograft tissues from patients with AR. These results suggest that CXCR3-CCR6-CXCR5+CD4+ T cells may be involved in acute allograft rejection after liver transplantation.

Hypothyroidism is associated with worse outcomes of hepatocellular carcinoma patients after liver transplantation.

BACKGROUND/AIMS: Hypothyroidism has been associated with hepatocellular carcinoma (HCC) incidence; however, the relationship between hypothyroidism and HCC patient outcomes is unclear. We investigated the impact of hypothyroidism on outcomes after liver transplantation for HCC. MATERIALS AND METHODS: We retrospectively studied HCC patients transplanted between January 2000 and December 2015. Hypothyroidism was defined as a thyroid-stimulating hormone (TSH) level continuously greater than 5 mIU/L, a documented history of hypothyroidism, or treatment with thyroid hormone replacement therapy. Multivariate Cox regression was used to assess the impact of hypothyroidism on overall survival (OS) and recurrence-free survival (RFS) adjusting for potential confounders. Subgroup analyses and interaction tests were conducted to compare the impact of hypothyroidism in different subgroups and assess for possible synergistic effects. Sensitivity analyses were performed among different cohorts to verify the stability of the results. RESULTS: A total of 343 HCC patients who underwent liver transplantation were included in the analysis. The primary analysis was conducted among 288 patients diagnosed with HCC prior to transplantation. Hypothyroidism was independently associated with worse OS and RFS, as was elevated TSH. The adjusted hazard ratio (AHR) of hypothyroidism was 2.45 (95% confidence interval [CI], 1.44-4.18) for OS and 5.54 (2.36, 13.01) for RFS. The AHR of TSH for OS was 1.05 (1.02, 1.09) and 1.08 (1.03, 1.13) for RFS. No interaction was found among different subgroups categorized by etiology and comorbidity. The results were stable to sensitivity analyses. CONCLUSION: Hypothyroidism is associated with poorer overall and recurrence-free survival of HCC patients receiving liver transplantation. These results require validation.

Rhubarb-based Chinese herbal formulae for hepatic encephalopathy: a systematic review and Meta-analysis.

OBJECTIVE: To evaluate the effectiveness and safety of rhubarb-based Chinese herbal formulae (RCHF), which are widely used to treat hepatic encephalopathy (HE) in China. METHODS: Nine online databases were searched from inception to November 22, 2016. Eligible studies were randomized controlled trials of Traditional Chinese Medicine (TCM) treatment for adult patients (≥ 18 years old) with HE. Outcomes such as mortality rate, clinical response rate, blood ammonia level, and alanine aminotransferase were evaluated between TCM group and control group. RESULTS: Thirty studies involving 2661 HE patients were analyzed. Most studies used RCHF treatment. Compared with conventional treatment as usual, lactulose, and vinegar, RCHF were associated with significant improvement in clinical response rate [risk ratio (RR) = 1.33, 95% confidence interval (CI) = 1.25, 1.43, I 2 = 0%; RR = 1.26, 95% CI = 1.14, 1.38, I 2 = 22%; and RR = 1.19, 95% CI = 1.06, 1.33, I 2 = 0%, respectively] and significant reductions in levels of blood ammonia and alanine aminotransferase. Only minor RCHF-associated adverse events, such as abdominal pain (0.3%), anal tenesmus (0.3%), and diarrhea (2.3%), were reported, and there were no significant differences in these events between the treatment group and the three types of control group. CONCLUSION: The findings suggest that RCHF may be an alternative treatment option for HE patients. More rigorous multicenter studies with larger samples and longer observational periods are needed to confirm these findings.

A case of de novo autoimmune hepatitis.

In this study, we reported a case of de novo autoimmune hepatitis. In this case, liver puncture biopsy was carried out and the result showed autoimmune hepatitis. In this report, we described the characteristics of this patient.

Efficacy and safety of low accelerating dose regimen of interferon/ribavirin antiviral therapy in patients with hepatitis C virus recurrence after liver transplantation.

BACKGROUND: Achievement of sustained virological response (SVR) is the main goal of interferon/ribavirin (IFN/RBV) antiviral therapy in patients with hepatitis C virus (HCV) recurrence after orthotopic liver transplantation (OLT). In this study, we have retrospectively evaluated the efficacy and safety of low accelerating dose regimen (LADR) of IFN/RBV in patients with HCV recurrence after OLT. MATERIAL AND METHODS: Thirty-one patients with HCV recurrent after OLT who were treated with LADR of antiviral therapy were analyzed in our study. Data of virological response (including rapid, early, end of treatment and sustained virological responses, designated as RVR, EVR, ETVR, and SVR, respectively) and liver histological change were collected. RESULTS: All patients received tacrolimus (TAC) and/or mycophenolate mofetil (MMF) for immunosuppression. Seven patients (23%), 6 patients (19%), and 18 patients (58%) finished complete treatment (CT), complete duration (CD), and incomplete treatment (IT), respectively. Twenty-four patients (77%) achieved ETVR. Among them, 8 patients (33%) achieved SVR, while 16 (67%) patients relapsed within 24 weeks after the end of the treatment. Univariate analysis showed that pretreatment viral load (p=0.002) as well as treatment dose and duration (p<0.001) were positively associated with SVR. Flu-like side effects were observed in all patients and 17 (54.8%) discontinued treatment due to adverse events. CONCLUSIONS: SVR achievement and tolerability to LADR of IFN/RBV therapy in our study are moderate in patients with HCV recurrence after liver transplantation. Pretreatment viral load and treatment dose and duration are positively related to SVR.

[Clinical analysis of liver transplantation for autoimmune hepatitis].

OBJECTIVE: To describe the outcomes and recurrence of autoimmune hepatitis (AIH) after liver transplantation. METHODS: Clinical data of 16 patients with AIH who underwent liver transplantation were analyzed retrospectively. The postoperative cumulative survival rate of the patients was calculated. The postoperative rejections and AIH recurrence were analyzed. The Kaplan-Meier method was used for statistical analysis of survival. RESULTS: All patients were female, with an average age of 52.6 years (range: 41-66 years), and an average MELD score of 21.4. According serological analysis, 15 patients were AIH type 1 and 1 patient was AIH type 2. Three patients died, including 2 of pulmonary infection and 1 of graft dysfunction.The 1-, 2-and 5-year cumulative survival rates were 93.8%, 87.1% and 79.1%, respectively. Five cases (31.3%) of recurrent AIH were diagnosed based on histological evidence. Acute rejection occurred in 6 (37.5%) patients, and de novo HBV infection occurred in 1 (6.3%) patient. CONCLUSION: Liver transplantation is an effective treatment for end-stage AIH. Recurrence and rejection were commonly associated with AIH, but did not negatively impact patient survival.

[The clinical analysis of orthotopic liver transplantation for primary biliary cirrhosis].

OBJECTIVE: To analyze the clinical outcome and complications of orthotopic liver transplantation (OLT) for patients with primary biliary cirrhosis(PBC). METHODS: Clinical data of 25 patients with PBC who underwent OLT were analyzed retrospectively. The postoperative cumulative survival rate of the patients was calculated. The postoperative recurrence of PBC, de novo diseases and other complications were analyzed. RESULTS: A total of 25 patients were recruited including 22 females and 3 males. The average age was 49.1 years (range from 40 to 64 years). The score of model for end-stage liver disease (MELD) was 21.80±5.49, and the Mayo score 8.01±1.38. Four patients died after liver transplantation. The 1-year, 2-year and 7-year patient cumulative survival rates were 92.0%, 87.8% and 75.3%, respectively. Eight cases (32.0%) developed recurrent PBC based on histological evidence. The median time to recurrence was 17.5 months. One of the eight patients with recurrent PBC was diagnosed with de novo auto-immune hepatitis (AIH) simultaneously, who eventually died. Acute rejection and de novo hepatitis B virus (HBV) infection developed in thirteen (52.0%) patients and five (20.0%) patients, respectively. Two cases (8.0%) of de novo AIH were diagnosed, one of which was fatal. CONCLUSIONS: OLT is an effective procedure for end-stage PBC. Much attention needs to be paid to the post-transplantation complications, including recurrence of primary disease, combined de novo HBV infection, de novo AIH, etc.