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Cell Mediated Immunity and the Risk for Developing Spontaneous Bacterial Peritonitis in Patients With Cirrhosis
Mo1007
The Augmented Neutrophil Resting Burst in Patients With Liver Cirrhosis is Further Increased in Presence of a NOD2 Mutation Tony Bruns, Jack Peter, Andreas Stallmach
Cell Mediated Immunity and the Risk for Developing Spontaneous Bacterial Peritonitis in Patients With Cirrhosis Bradley Confer, Nizar N. Zein, Rocio Lopez
Background/Aims: Episodes of bacterial translocation are associated with increased concentrations of endotoxin, which is able to prime and activate neutrophils and monocytes. Since variants of the nucleotide-binding oligomerization domain containing 2 (NOD2) gene impair the innate immune response and contribute to bacterial translocation, we hypothesized that the phagocyte resting burst is increased in patients with liver cirrhosis that carry NOD2 variants. Methods: The common NOD2 gene variants G908R, R702W, and 1007fs were determined in 35 non-infected patients with liver cirrhosis. The formation of reactive oxygen species in neutrophils and monocytes from these patients was monitored through the oxidation of dihydrorhodamine 123 to rhodamine by flow cytometry in whole blood and compared with that of 25 healthy controls. Results: The resting burst was increased in patients with liver cirrhosis compared to control subjects (P≤0.001). 8 of 35 cirrhotic patients were carriers of NOD2 variants. The spontaneous production of ROS in neutrophils (P=0.012) and monocytes (P=0.018) was increased in presence of a NOD2 mutation. A higher resting burst in neutrophils was also associated with a higher MELD score (r[s]= 0.388; P=0.023) and with Child-Pugh-Stage C (P=0.040). However, in a multivariate regression model only the presence of a NOD2 variant (P=0.019) and of ascites (P=0.016) were independent predictors of spontaneous ROS production in neutrophils (adjusted R2=0.231). Conclusion: The augmented neutrophil resting burst in patients with liver cirrhosis is further increased in presence of a NOD2 mutation which is suggestive of an increased bacterial translocation in these patients.
Background: Immune dysfunction is common in patients with liver cirrhosis and is associated with a multitude of infections including spontaneous bacterial peritonitis (SBP). SBP is common and has high mortality mainly from the development of hepatorenal syndrome (HRS) or progressive liver failure. Antibiotic prophylaxis in selected patients has been shown to decrease the incidence of SBP. The aim of this study was to assess the relationship between cell mediated immunity (CMI) measured by peripheral blood CD4+ adenosine triphosphate (ATP) release (ImmuKnow assay) and the risk of developing SBP. Methods: We evaluated 606 patients with cirrhosis and ascites between August 2007 and March 2010. The ImmuKnow assay was prospectively performed on all patients. Seventy-nine patients were included in the study. Patients were excluded if they had autoimmune disorders including primary biliary cirrhosis and primary sclerosing cholangitis, were being treated with immune modulating therapy, had the human immunodeficiency virus (HIV), were on prophylactic antibiotics or had a prior episode of SBP or evidence of primary peritonitis. SBP was diagnosed with an ascitic fluid polymorphonuclear cell count of 250 cells/mL or greater with or without a positive culture. Results: ATP levels were lower in patients who developed SBP compared with patients who did not (122 versus 239 ng/mL, P<0.001). ATP levels of 201 or lower provides a sensitivity and specificity of 82% and 73%, respectively, for prediction of SBP. The mean time from ATP titer to SBP was 10.4 (SE=1.0) months. Patients with lower CMI (ATP<201 ng/mL) had a significantly greater hazard of developing SBP (P<0.001) (Figure 1) and increased mortality (P=0.038) compared to patients with increased CMI (ATP>201 ng/mL). ATP levels were also lower in patients who developed HRS compared to those without HRS (114 versus 172 ng/mL, P=0.002). Conclusion: Greater suppression of CMI as measured by the ImmuKnow assay is able to predict the patient population at highest risk to develop SBP and HRS. Monitoring of ATP titers may be a beneficial way to identify patients who would benefit from prophylactic antibiotics to decrease SBP, HRS and improve survival in cirrhotic patients with ascites.
AASLD Abstracts
Mo1005
Mo1006 Driving Simulation and Cognitive Testing Can Improve Insight Into Impaired Driving Skills in Cirrhotic Patients With MHE Jasmohan S. Bajaj, Arun J. Sanyal, Richard K. Sterling, Debulon E. Bell, Melanie B. White, Nicole Noble, R. Todd Stravitz, Michael Fuchs, Douglas M. Heuman Background:Cirrhotic patients with MHE have difficulty driving, but often lack insight into their impaired driving skills. Improved insight on the part of patients may reinforce physician recommendations against driving and reduce risk of harm from motor vehicle accidents. Aim: to define the impact of cognitive testing, including driving simulation, on personal insight into driving skills. Methods: Cirrhotic patients who were current drivers and were free of overt HE were asked to rate their driving skills on a Likert scale from 0-10 (selfassessment of driving skill [SADS]). Driving history was obtained, and they then underwent cognitive testing and driving simulation, after which SADS was again obtained. Cognitive testing included digit symbol, line tracing (errors, time), serial dotting, number connection A/B, block design, and inhibitory control test (ICT: lures and targets are outcomes). Driving simulation consisted of 3 parts: training, testing (outcomes=crashes, speeding); and navigation (outcomes=illegal turns and crashes). Results: 65 cirrhotic patients were included (55% male, 60% HCV; mean age=55, education=12 yrs, MELD=9, years of driving experience= 37). 31% reported an accident or a moving violation; however the pre-test SADS for pts with/without these offenses was statistically similar (8 vs 8,p=0.79). 51% met criteria for MHE using ICT and 45% using other tests. Simulator crashes were only significantly correlated with ICT performance (lures, r=0.3, p=0.03 and targets r=-0.3,p=0.008). Prior to testing and simulation, median SADS was 7; this decreased to 5 after these procedures. SADS decreased after testing in 16 (25%; SADS-D) with magnitude of the decrease averaging 18% (range 0-90%); SADS did not change in 49 (75%; SADS-N). Decrease in SADS after testing was found in 40% of patients whose ICT performance was abnormal, but only 15% of patients with normal ICT performance (p=0.045). There was a significantly higher rate of illegal turns in SADS-D compared to SADS-N (median 1 vs. 0,p=0.04). The percent reduction in SADS score correlated significantly with the number of illegal turns (r=0.4; p=0.01) and navigation crashes (r=0.38; p=0.03). Percent SADS reduction also significantly correlated with digital symbol errors (r=0.38) and line tracing errors (r=0.36). Conclusion: Cirrhotic patients gain insight into impairment of driving skills after experiencing navigation errors during driving simulation or perforing poorly on cognitive tests.
AASLD Abstracts
Figure 1 Kaplan Meier Plot: Shows the risk of developing spontaneous bacterial peritonitis based on cell mediated immune function. Mo1008 Overexpressions of Apelin -APJ on Hepatic Arterial Capillaries - Relevance to Arterial Sinusoidal Angiogenesis in Human Cirrhotic Liver Hiroaki Yokomori, Masaya Oda, Fumihiko Kaneko, Takako Komiyama, Akira Isomoto, Toshifumi Hibi Background and aims: Apelin is expressed primarily in the vascular endothelium. It acts both locally and via endocrine signaling to activate Apelin receptor (APJ). This study was designed to elucidate the localization and changes of Apelin and APJ in cirrhotic liver. Methods: Serum levels of apelin -36 were measured using EIA in control and cirrhotic patients (with Child's A cirrhosis undergoing surgical resection for hepatocellular carcinoma (HCC)(Child-A-LC) and (with decompensated Child's C cirrhosis) (Child-C-LC). All liver samples were subjected to immunohistochemical (IHC) studies for localization of Apelin and APJ. Fresh liver samples were examined using Western blot analysis, laser-capture microdissection (LCM) coupled with RT-PCR, and immunoelectron microscopic (IEM). Results: The serum levels of apelin were higher in Child's C cirrhotic patients than in control and Child's A cirrhotic patients. The IHC examination of liver samples in control liver tissue revealed only slight Apelin and APJ expressions in the vascular wall in the portal tract, but none in hepatic sinusoids. In cirrhotic liver (Child's A-LC and Child's C-LC), Apelin expression was evident in the portal venules, hepatic arterioles, and on the proliferated arterial capillaries extending into the sinusoid in the generating hepatic nodule. The APJ expressions were evident mainly along the sinusoids and on the fibroblasts in the fibrotic septa. Western
S-952
The Augmented Neutrophil Resting Burst in Patients With Liver Cirrhosis is Further Increased in Presence of a NOD2 Mutation Tony Bruns, Jack Peter, Andreas Stallmach
Cell Mediated Immunity and the Risk for Developing Spontaneous Bacterial Peritonitis in Patients With Cirrhosis Bradley Confer, Nizar N. Zein, Rocio Lopez
Background/Aims: Episodes of bacterial translocation are associated with increased concentrations of endotoxin, which is able to prime and activate neutrophils and monocytes. Since variants of the nucleotide-binding oligomerization domain containing 2 (NOD2) gene impair the innate immune response and contribute to bacterial translocation, we hypothesized that the phagocyte resting burst is increased in patients with liver cirrhosis that carry NOD2 variants. Methods: The common NOD2 gene variants G908R, R702W, and 1007fs were determined in 35 non-infected patients with liver cirrhosis. The formation of reactive oxygen species in neutrophils and monocytes from these patients was monitored through the oxidation of dihydrorhodamine 123 to rhodamine by flow cytometry in whole blood and compared with that of 25 healthy controls. Results: The resting burst was increased in patients with liver cirrhosis compared to control subjects (P≤0.001). 8 of 35 cirrhotic patients were carriers of NOD2 variants. The spontaneous production of ROS in neutrophils (P=0.012) and monocytes (P=0.018) was increased in presence of a NOD2 mutation. A higher resting burst in neutrophils was also associated with a higher MELD score (r[s]= 0.388; P=0.023) and with Child-Pugh-Stage C (P=0.040). However, in a multivariate regression model only the presence of a NOD2 variant (P=0.019) and of ascites (P=0.016) were independent predictors of spontaneous ROS production in neutrophils (adjusted R2=0.231). Conclusion: The augmented neutrophil resting burst in patients with liver cirrhosis is further increased in presence of a NOD2 mutation which is suggestive of an increased bacterial translocation in these patients.
Background: Immune dysfunction is common in patients with liver cirrhosis and is associated with a multitude of infections including spontaneous bacterial peritonitis (SBP). SBP is common and has high mortality mainly from the development of hepatorenal syndrome (HRS) or progressive liver failure. Antibiotic prophylaxis in selected patients has been shown to decrease the incidence of SBP. The aim of this study was to assess the relationship between cell mediated immunity (CMI) measured by peripheral blood CD4+ adenosine triphosphate (ATP) release (ImmuKnow assay) and the risk of developing SBP. Methods: We evaluated 606 patients with cirrhosis and ascites between August 2007 and March 2010. The ImmuKnow assay was prospectively performed on all patients. Seventy-nine patients were included in the study. Patients were excluded if they had autoimmune disorders including primary biliary cirrhosis and primary sclerosing cholangitis, were being treated with immune modulating therapy, had the human immunodeficiency virus (HIV), were on prophylactic antibiotics or had a prior episode of SBP or evidence of primary peritonitis. SBP was diagnosed with an ascitic fluid polymorphonuclear cell count of 250 cells/mL or greater with or without a positive culture. Results: ATP levels were lower in patients who developed SBP compared with patients who did not (122 versus 239 ng/mL, P<0.001). ATP levels of 201 or lower provides a sensitivity and specificity of 82% and 73%, respectively, for prediction of SBP. The mean time from ATP titer to SBP was 10.4 (SE=1.0) months. Patients with lower CMI (ATP<201 ng/mL) had a significantly greater hazard of developing SBP (P<0.001) (Figure 1) and increased mortality (P=0.038) compared to patients with increased CMI (ATP>201 ng/mL). ATP levels were also lower in patients who developed HRS compared to those without HRS (114 versus 172 ng/mL, P=0.002). Conclusion: Greater suppression of CMI as measured by the ImmuKnow assay is able to predict the patient population at highest risk to develop SBP and HRS. Monitoring of ATP titers may be a beneficial way to identify patients who would benefit from prophylactic antibiotics to decrease SBP, HRS and improve survival in cirrhotic patients with ascites.
AASLD Abstracts
Mo1005
Mo1006 Driving Simulation and Cognitive Testing Can Improve Insight Into Impaired Driving Skills in Cirrhotic Patients With MHE Jasmohan S. Bajaj, Arun J. Sanyal, Richard K. Sterling, Debulon E. Bell, Melanie B. White, Nicole Noble, R. Todd Stravitz, Michael Fuchs, Douglas M. Heuman Background:Cirrhotic patients with MHE have difficulty driving, but often lack insight into their impaired driving skills. Improved insight on the part of patients may reinforce physician recommendations against driving and reduce risk of harm from motor vehicle accidents. Aim: to define the impact of cognitive testing, including driving simulation, on personal insight into driving skills. Methods: Cirrhotic patients who were current drivers and were free of overt HE were asked to rate their driving skills on a Likert scale from 0-10 (selfassessment of driving skill [SADS]). Driving history was obtained, and they then underwent cognitive testing and driving simulation, after which SADS was again obtained. Cognitive testing included digit symbol, line tracing (errors, time), serial dotting, number connection A/B, block design, and inhibitory control test (ICT: lures and targets are outcomes). Driving simulation consisted of 3 parts: training, testing (outcomes=crashes, speeding); and navigation (outcomes=illegal turns and crashes). Results: 65 cirrhotic patients were included (55% male, 60% HCV; mean age=55, education=12 yrs, MELD=9, years of driving experience= 37). 31% reported an accident or a moving violation; however the pre-test SADS for pts with/without these offenses was statistically similar (8 vs 8,p=0.79). 51% met criteria for MHE using ICT and 45% using other tests. Simulator crashes were only significantly correlated with ICT performance (lures, r=0.3, p=0.03 and targets r=-0.3,p=0.008). Prior to testing and simulation, median SADS was 7; this decreased to 5 after these procedures. SADS decreased after testing in 16 (25%; SADS-D) with magnitude of the decrease averaging 18% (range 0-90%); SADS did not change in 49 (75%; SADS-N). Decrease in SADS after testing was found in 40% of patients whose ICT performance was abnormal, but only 15% of patients with normal ICT performance (p=0.045). There was a significantly higher rate of illegal turns in SADS-D compared to SADS-N (median 1 vs. 0,p=0.04). The percent reduction in SADS score correlated significantly with the number of illegal turns (r=0.4; p=0.01) and navigation crashes (r=0.38; p=0.03). Percent SADS reduction also significantly correlated with digital symbol errors (r=0.38) and line tracing errors (r=0.36). Conclusion: Cirrhotic patients gain insight into impairment of driving skills after experiencing navigation errors during driving simulation or perforing poorly on cognitive tests.
AASLD Abstracts
Figure 1 Kaplan Meier Plot: Shows the risk of developing spontaneous bacterial peritonitis based on cell mediated immune function. Mo1008 Overexpressions of Apelin -APJ on Hepatic Arterial Capillaries - Relevance to Arterial Sinusoidal Angiogenesis in Human Cirrhotic Liver Hiroaki Yokomori, Masaya Oda, Fumihiko Kaneko, Takako Komiyama, Akira Isomoto, Toshifumi Hibi Background and aims: Apelin is expressed primarily in the vascular endothelium. It acts both locally and via endocrine signaling to activate Apelin receptor (APJ). This study was designed to elucidate the localization and changes of Apelin and APJ in cirrhotic liver. Methods: Serum levels of apelin -36 were measured using EIA in control and cirrhotic patients (with Child's A cirrhosis undergoing surgical resection for hepatocellular carcinoma (HCC)(Child-A-LC) and (with decompensated Child's C cirrhosis) (Child-C-LC). All liver samples were subjected to immunohistochemical (IHC) studies for localization of Apelin and APJ. Fresh liver samples were examined using Western blot analysis, laser-capture microdissection (LCM) coupled with RT-PCR, and immunoelectron microscopic (IEM). Results: The serum levels of apelin were higher in Child's C cirrhotic patients than in control and Child's A cirrhotic patients. The IHC examination of liver samples in control liver tissue revealed only slight Apelin and APJ expressions in the vascular wall in the portal tract, but none in hepatic sinusoids. In cirrhotic liver (Child's A-LC and Child's C-LC), Apelin expression was evident in the portal venules, hepatic arterioles, and on the proliferated arterial capillaries extending into the sinusoid in the generating hepatic nodule. The APJ expressions were evident mainly along the sinusoids and on the fibroblasts in the fibrotic septa. Western
S-952