- Email: [email protected]
Aetiology, Outcome and Predictors of Mortality of Viral Related Acute Liver Failure: A Single Centre Prospective Cohort Study
POSTERS
Jalan has research collaborations with Ocera and Yaqrit and has received speaking fees from Norgine. Rajiv Jalan is the inventor.
CONFLICTS OF INTEREST The authors have none to declare. Corresponding author: Francesco De Chiara. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2017.01.099 Figure 1 Liver architecture and collagen staining in NC, IC and HFHCfed rats.
POSTER PRESENTATION
diet) and normal chow up to 16 weeks. Biochemical parameters and histological staining such as H&E and Sirius red were employed for detection of changes in hepatic architecture and collagen accumulation respectively. Levels of phenylacetylglycine (PAG) and phenylacetylglutamine (PAGN) in urine were assessed by HLPC. OTC enzyme activity was quantified to assess the functional capacity of ureagenesis. Results: All the groups treated with OCR002 showed high levels of PG and PAGN in the urine. Furthermore, HFHC fed rats showed increased blood level of cholesterol, triglycerides, ALT and AST and a significant increase in ammonia (P 0.05), when compared to normal chow fed rats, which was associated with decreased OTC activity at 4, 10 and 16 (50, 47, 43%) weeks. H&E staining showed massive lipid accumulation of HFHC-fed rats as well as collagen accumulation. On the other hand, IC-fed rats displayed massive lipid accumulation in absence of fibrosis. HFHC fed rats treated with OCR002 showed a substantial reduction in hepatic collagen accumulation, liver size and lipid content compared with HFHC fed rats (Figure 1). Conclusion: The data demonstrates for the first time that administration of the ammonia lowering drug OCR002 significantly reduces progression of fibrosis in a rodent model of NAFLD rats highlighting a novel strategy for the treatment of NAFLD/NASH patients. 1. The studies were funded through an unrestricted grant from Ocera Therapeutics. 2. Conflict of Interest for Dr Jalan: Rajiv Jalan has research collaborations with Ocera and Yaqrit and has received speaking fees from Norgine. Rajiv Jalan is the inventor of OCR-002, which was licensed by UCL to Ocera Therapeutics. He is also the Founder of Yaqrit Limited, which is a UCL spin out company. Disclosures/Financial Association: 1. The studies were funded through an unrestricted grant from Ocera Therapeutics. 2. Conflict of Interest for Dr Jalan: Rajiv S74
96 AETIOLOGY, OUTCOME AND PREDICTORS OF MORTALITY OF VIRAL RELATED ACUTE LIVER FAILURE: A SINGLE CENTRE PROSPECTIVE COHORT STUDY Chetan Kalal, Rakhi Maiwall, Shiv Sarin Department of Hepatology, Institute of Liver and Biliary Sciences, Delhi, India
Background: Acute liver failure (ALF)is a disease with high mortality. Intensive care and liver transplantation provide support and rescue. Cerebral edema forms the core of hepatic encephalopathy (HE) and poor outcome along with sepsis and multiorgan dysfunction. There is a paucity of studies on prognostic factors of viral-related ALF. Aim: To study prognostic factors and develop a dynamic prognostic model for prediction of 28-day mortality in viral-related ALF. Methods: 83 ALF were enrolled prospectively. Logistic regression models were used to identify score parameters and derived estimated coefficients were used as relative weights to compute the score which was also tested for sequential use with repeated measures. Results: Of 83 mean age 32.3 8 years,40% males with commonest etiology hepatitis E 33 (39.75%) f/b hepatitis A 22 (26.5%),median jaundice to HE time 8 (1–16) days. At admission 42 (50.6%) had hypercute presentation, 43 (51.8%) had grade III HE, 26 (31.32%) grade IV HE, 14 (16.8%) grade I and II HE. 69 (83.1%) were admitted in ICU. Total bilirubin 17.7 5.1 (mg%), INR 4.49 2.3 (IU), ALT 1486 (273 4173) IU/ml, AST 758 (255–1510) IU/ml, lactate 5.1 (2.5–11.6), ammonia 349.5 (179–704), creatinine 0.96 0.75 (mg%). Mean MELD, APACHEII and SOFA were 32.4 5.2, 13.48 2.4 and 13.24 2.5 respectively. 36 (43.3)% had KCH > 2 score. At 28-day 36 (43.3%) died, septic shock 30 (36.14%) and raised ICH in 6 (7.2%). Univariate analysis showed proportion of patients with advanced HE (grades III–IV), ammonia, serum lactate, © 2017, INASL
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
Figure 1 Receiver operating characteristic (ROC) curve of ammonia, lactate and INR and 28 days mortality. Lactate levels >3.5 were 72.3% sensitive and 70.8% specific for predicting 28 days mortality.
INR and creatinine was significantly higher among the non survivors than in survivors at 28 days. A multivariate analysis showed that ammonia (>303), INR (>4), and lactate (>3.5) at presentation were significant predictive factors for mortality at 28 days. Lactate >3.5 were 72.3% sensitive and 70.8% specific for predicting 28 days mortality. Conclusion: In ALF patients outcome remains poor with spontaneous 28 day transplant free survival is 55.8%. Factors associated with 28-day mortality are ammonia, PT INR, and lactate at presentation (Figure 1).
CONFLICTS OF INTEREST The authors have none to declare. Corresponding author: Chetan Kalal. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2017.01.100
97 THE NEURONAL TDP-43 AND TAU PROTEINOPATHIES IN CHRONIC LIVER FAILURE: ROLE OF ASTROCYTES AND MICROGLIA A.R. Jayakumar 1,2, Michael D. Norenberg 1,2
Chronic hepatic encephalopathy (CHE) due to chronic liver failure, is characterized by mental confusion, disorientation, behavioral changes, impaired cognition, and motor disturbances. The molecular basis for this neuropsychiatric disorder remains elusive. Transactivating DNA-binding protein-43 (TDP-43) inclusions and the accumulation of phosphorylated and ubiquitinated Tau protein (p-Tau) have been identified in various neurological disorders (e. g., amyotrophic lateral sclerosis, fronto-temporal lobar degeneration, ischemia, Alzheimer’s disease), and such changes have been strongly implicated in the development of the neurobehavioral deficits associated with these neurological disorders. We therefore examined whether the TDP-43 and Tau proteinopathies also occur in CHE, and whether such changes contribute to the neurobehavioral abnormities observed in CHE. We identified increased levels of TDP-43 and Tau phosphorylation in neurons in a rat model of CHE (treatment with the liver toxin thioacetamide). These neurochemical changes correlatedwell with the neurobehavioral abnormalities observed in these rats. Since astrocytes and microglia are known to play a critical role in the maintenance of neuronal integrity, and since astrocytes in HE are dysfunctional (Alzheimer type II astrocytes), while microglia are activated, we examined whether these glial cells contribute to the neuronal TDP-43 and Tau proteinopathies associated with CHE. To test this hypothesis, we used primary cultures of neural cells (neurons, astrocytes and microglia) and examined whether exposure of cultured neurons to ammonia had any effect on levels of neuronal TDP-43 and Tau phosphorylation, and whether exposure neurons to conditioned media (CM) from ammonia-treated cultured astrocytes and microglia had any effect on neuronal TDP-43 and Tau phosphorylation. While exposure of cultured neurons to ammonia (1 mM, for 7 d) had no effect on the phosphorylation of TDP-43 and Tau, the addition of conditioned media (CM) from cultured astrocytes that were chronically-treated with ammonia (for 10–15 d) significantly increased neuronal levels of phosphorylated TDP-43, but not phosphorylated Tau. However, exposure of cultured neurons to CM (for 7 d) from ammonia-treated microglia (5 d), increased both TDP-43 and Tau phosphorylation levels. The addition of the endotoxin lipopolysaccharide (LPS), a well-known inflammatory factor, potentiated the effect of ammonia on TDP-43 and tau phosphorylation in microglia. We also found increased cytokine (TNFa and IL-6) levels in the CM from ammonia and LPS-treated microglia, while exposure of neurons to these cytokines increased both TDP-43 and tau phosphorylation levels. Our findings indicate that ammonia and
Journal of Clinical and Experimental Hepatology | February 2017 | Vol. 7 | No. S1 | S22–S83
S75
POSTER PRESENTATION
1 Miami Veterans Affairs Medical Center, Miami, FL, USA, 2Departments of Pathology, Biochemistry & Molecular Biology, Neurology and Neurosurgery, University of Miami School of Medicine, Miami, FL 33125, USA
Jalan has research collaborations with Ocera and Yaqrit and has received speaking fees from Norgine. Rajiv Jalan is the inventor.
CONFLICTS OF INTEREST The authors have none to declare. Corresponding author: Francesco De Chiara. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2017.01.099 Figure 1 Liver architecture and collagen staining in NC, IC and HFHCfed rats.
POSTER PRESENTATION
diet) and normal chow up to 16 weeks. Biochemical parameters and histological staining such as H&E and Sirius red were employed for detection of changes in hepatic architecture and collagen accumulation respectively. Levels of phenylacetylglycine (PAG) and phenylacetylglutamine (PAGN) in urine were assessed by HLPC. OTC enzyme activity was quantified to assess the functional capacity of ureagenesis. Results: All the groups treated with OCR002 showed high levels of PG and PAGN in the urine. Furthermore, HFHC fed rats showed increased blood level of cholesterol, triglycerides, ALT and AST and a significant increase in ammonia (P 0.05), when compared to normal chow fed rats, which was associated with decreased OTC activity at 4, 10 and 16 (50, 47, 43%) weeks. H&E staining showed massive lipid accumulation of HFHC-fed rats as well as collagen accumulation. On the other hand, IC-fed rats displayed massive lipid accumulation in absence of fibrosis. HFHC fed rats treated with OCR002 showed a substantial reduction in hepatic collagen accumulation, liver size and lipid content compared with HFHC fed rats (Figure 1). Conclusion: The data demonstrates for the first time that administration of the ammonia lowering drug OCR002 significantly reduces progression of fibrosis in a rodent model of NAFLD rats highlighting a novel strategy for the treatment of NAFLD/NASH patients. 1. The studies were funded through an unrestricted grant from Ocera Therapeutics. 2. Conflict of Interest for Dr Jalan: Rajiv Jalan has research collaborations with Ocera and Yaqrit and has received speaking fees from Norgine. Rajiv Jalan is the inventor of OCR-002, which was licensed by UCL to Ocera Therapeutics. He is also the Founder of Yaqrit Limited, which is a UCL spin out company. Disclosures/Financial Association: 1. The studies were funded through an unrestricted grant from Ocera Therapeutics. 2. Conflict of Interest for Dr Jalan: Rajiv S74
96 AETIOLOGY, OUTCOME AND PREDICTORS OF MORTALITY OF VIRAL RELATED ACUTE LIVER FAILURE: A SINGLE CENTRE PROSPECTIVE COHORT STUDY Chetan Kalal, Rakhi Maiwall, Shiv Sarin Department of Hepatology, Institute of Liver and Biliary Sciences, Delhi, India
Background: Acute liver failure (ALF)is a disease with high mortality. Intensive care and liver transplantation provide support and rescue. Cerebral edema forms the core of hepatic encephalopathy (HE) and poor outcome along with sepsis and multiorgan dysfunction. There is a paucity of studies on prognostic factors of viral-related ALF. Aim: To study prognostic factors and develop a dynamic prognostic model for prediction of 28-day mortality in viral-related ALF. Methods: 83 ALF were enrolled prospectively. Logistic regression models were used to identify score parameters and derived estimated coefficients were used as relative weights to compute the score which was also tested for sequential use with repeated measures. Results: Of 83 mean age 32.3 8 years,40% males with commonest etiology hepatitis E 33 (39.75%) f/b hepatitis A 22 (26.5%),median jaundice to HE time 8 (1–16) days. At admission 42 (50.6%) had hypercute presentation, 43 (51.8%) had grade III HE, 26 (31.32%) grade IV HE, 14 (16.8%) grade I and II HE. 69 (83.1%) were admitted in ICU. Total bilirubin 17.7 5.1 (mg%), INR 4.49 2.3 (IU), ALT 1486 (273 4173) IU/ml, AST 758 (255–1510) IU/ml, lactate 5.1 (2.5–11.6), ammonia 349.5 (179–704), creatinine 0.96 0.75 (mg%). Mean MELD, APACHEII and SOFA were 32.4 5.2, 13.48 2.4 and 13.24 2.5 respectively. 36 (43.3)% had KCH > 2 score. At 28-day 36 (43.3%) died, septic shock 30 (36.14%) and raised ICH in 6 (7.2%). Univariate analysis showed proportion of patients with advanced HE (grades III–IV), ammonia, serum lactate, © 2017, INASL
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
Figure 1 Receiver operating characteristic (ROC) curve of ammonia, lactate and INR and 28 days mortality. Lactate levels >3.5 were 72.3% sensitive and 70.8% specific for predicting 28 days mortality.
INR and creatinine was significantly higher among the non survivors than in survivors at 28 days. A multivariate analysis showed that ammonia (>303), INR (>4), and lactate (>3.5) at presentation were significant predictive factors for mortality at 28 days. Lactate >3.5 were 72.3% sensitive and 70.8% specific for predicting 28 days mortality. Conclusion: In ALF patients outcome remains poor with spontaneous 28 day transplant free survival is 55.8%. Factors associated with 28-day mortality are ammonia, PT INR, and lactate at presentation (Figure 1).
CONFLICTS OF INTEREST The authors have none to declare. Corresponding author: Chetan Kalal. E-mail: [email protected] http://dx.doi.org/10.1016/j.jceh.2017.01.100
97 THE NEURONAL TDP-43 AND TAU PROTEINOPATHIES IN CHRONIC LIVER FAILURE: ROLE OF ASTROCYTES AND MICROGLIA A.R. Jayakumar 1,2, Michael D. Norenberg 1,2
Chronic hepatic encephalopathy (CHE) due to chronic liver failure, is characterized by mental confusion, disorientation, behavioral changes, impaired cognition, and motor disturbances. The molecular basis for this neuropsychiatric disorder remains elusive. Transactivating DNA-binding protein-43 (TDP-43) inclusions and the accumulation of phosphorylated and ubiquitinated Tau protein (p-Tau) have been identified in various neurological disorders (e. g., amyotrophic lateral sclerosis, fronto-temporal lobar degeneration, ischemia, Alzheimer’s disease), and such changes have been strongly implicated in the development of the neurobehavioral deficits associated with these neurological disorders. We therefore examined whether the TDP-43 and Tau proteinopathies also occur in CHE, and whether such changes contribute to the neurobehavioral abnormities observed in CHE. We identified increased levels of TDP-43 and Tau phosphorylation in neurons in a rat model of CHE (treatment with the liver toxin thioacetamide). These neurochemical changes correlatedwell with the neurobehavioral abnormalities observed in these rats. Since astrocytes and microglia are known to play a critical role in the maintenance of neuronal integrity, and since astrocytes in HE are dysfunctional (Alzheimer type II astrocytes), while microglia are activated, we examined whether these glial cells contribute to the neuronal TDP-43 and Tau proteinopathies associated with CHE. To test this hypothesis, we used primary cultures of neural cells (neurons, astrocytes and microglia) and examined whether exposure of cultured neurons to ammonia had any effect on levels of neuronal TDP-43 and Tau phosphorylation, and whether exposure neurons to conditioned media (CM) from ammonia-treated cultured astrocytes and microglia had any effect on neuronal TDP-43 and Tau phosphorylation. While exposure of cultured neurons to ammonia (1 mM, for 7 d) had no effect on the phosphorylation of TDP-43 and Tau, the addition of conditioned media (CM) from cultured astrocytes that were chronically-treated with ammonia (for 10–15 d) significantly increased neuronal levels of phosphorylated TDP-43, but not phosphorylated Tau. However, exposure of cultured neurons to CM (for 7 d) from ammonia-treated microglia (5 d), increased both TDP-43 and Tau phosphorylation levels. The addition of the endotoxin lipopolysaccharide (LPS), a well-known inflammatory factor, potentiated the effect of ammonia on TDP-43 and tau phosphorylation in microglia. We also found increased cytokine (TNFa and IL-6) levels in the CM from ammonia and LPS-treated microglia, while exposure of neurons to these cytokines increased both TDP-43 and tau phosphorylation levels. Our findings indicate that ammonia and
Journal of Clinical and Experimental Hepatology | February 2017 | Vol. 7 | No. S1 | S22–S83
S75
POSTER PRESENTATION
1 Miami Veterans Affairs Medical Center, Miami, FL, USA, 2Departments of Pathology, Biochemistry & Molecular Biology, Neurology and Neurosurgery, University of Miami School of Medicine, Miami, FL 33125, USA