N. Vergis

Prednisolone or Pentoxifylline for Alcoholic Hepatitis

BACKGROUND Alcoholic hepatitis is a clinical syndrome characterized by jaundice and liver impairment that occurs in patients with a history of heavy and prolonged alcohol use. The short-term mortality among patients with severe disease exceeds 30%. Prednisolone and pentoxifylline are both recommended for the treatment of severe alcoholic hepatitis, but uncertainty about their benefit persists. METHODS We conducted a multicenter, double-blind, randomized trial with a 2-by-2 factorial design to evaluate the effect of treatment with prednisolone or pentoxifylline. The primary end point was mortality at 28 days. Secondary end points included death or liver transplantation at 90 days and at 1 year. Patients with a clinical diagnosis of alcoholic hepatitis and severe disease were randomly assigned to one of four groups: a group that received a pentoxifylline-matched placebo and a prednisolone-matched placebo, a group that received prednisolone and a pentoxifylline-matched placebo, a group that received pentoxifylline and a prednisolone-matched placebo, or a group that received both prednisolone and pentoxifylline. RESULTS A total of 1103 patients underwent randomization, and data from 1053 were available for the primary end-point analysis. Mortality at 28 days was 17% (45 of 269 patients) in the placebo-placebo group, 14% (38 of 266 patients) in the prednisolone-placebo group, 19% (50 of 258 patients) in the pentoxifylline-placebo group, and 13% (35 of 260 patients) in the prednisolone-pentoxifylline group. The odds ratio for 28-day mortality with pentoxifylline was 1.07 (95% confidence interval [CI], 0.77 to 1.49; P=0.69), and that with prednisolone was 0.72 (95% CI, 0.52 to 1.01; P=0.06). At 90 days and at 1 year, there were no significant between-group differences. Serious infections occurred in 13% of the patients treated with prednisolone versus 7% of those who did not receive prednisolone (P=0.002). CONCLUSIONS Pentoxifylline did not improve survival in patients with alcoholic hepatitis. Prednisolone was associated with a reduction in 28-day mortality that did not reach significance and with no improvement in outcomes at 90 days or 1 year. (Funded by the National Institute for Health Research Health Technology Assessment program; STOPAH EudraCT number, 2009-013897-42 , and Current Controlled Trials number, ISRCTN88782125 ).

CD14, CD16 and HLA-DR reliably identifies human monocytes and their subsets in the context of pathologically reduced HLA-DR expression by CD14(hi) /CD16(neg) monocytes: Expansion of CD14(hi) /CD16(pos) and contraction of CD14(lo) /CD16(pos) monocytes in acute liver failure

Changes in monocytes and their subsets (CD14hi/CD16neg, CD14hi/CD16pos and CD14lo/CD16pos) have been described in several diseases. The combination of CD14, CD16 and HLA‐DR has been suggested to discriminate monocytes from the CD16pos/HLA‐DRneg NK‐cells and neutrophils but no data exist whether this strategy can be used in situations when monocyte HLA‐DR expression is pathologically reduced. Monocytes and their subsets were concurrently identified through negative (exclusion of CD66bpos neutrophils, CD56pos NKcells, CD19pos B‐cells, and CD3pos T‐cells) and positive gating (inclusion of monocytes by expression of CD14, CD16, and HLA‐DR) strategies on 30 occasions [9 healthy controls (HC) and 21 patients with conditions associated with low monocyte HLA‐DR expression]. Bland‐Altman and Passing and Bablok regression statistics did not demonstrate any significant measurement bias between the two strategies of monocyte identification. Monocyte subset phenotype was then compared in 18 HC and 41 patients with acute liver failure (ALF). Compared with HC, in ALF, the percentage of CD14hi/CD16pos monocytes was higher (7% vs 4%) whilst the percentage of CD14lo/CD16pos was lower (1.9% vs. 7%) (P ≤ 0.001); HLA‐DR and CD86 MFIs on all monocyte subsets were lower, whilst CCR5, CD64, and CD11b MFIs were higher (P < 0.05). The relative expression by monocyte subsets of HLA‐DR, CCR2, CCR5, CX3CR1, and CD11a was similar in ALF patients and HCs. Repeat analysis of an identical antibody‐fluorochrome “backbone” targeting HLA‐DR, CD14, and CD16 was assessed in 189 samples across 5 different experiments. There was excellent agreement in the results obtained using the positive gating strategy (interclass correlation coefficients > 0.8). Monocytes and their subsets can be reliably identified using an antibody‐fluorochrome “backbone” of HLA‐DR, CD14, and CD16. CD16pos monocytes continue to constitutively express HLA‐DR even in conditions where HLA‐DR is pathologically reduced on CD14hi/CD16neg monocytes. Understanding the changes in monocyte pheontype in ALF and similar clinico‐pathological diseases may allow the development of novel biomarkers or therapeutic strategies.

Blockade of PD1 and TIM3 Restores Innate and Adaptive Immunity in Patients with Acute Alcoholic Hepatitis

BACKGROUND & AIMS Susceptibility to bacterial infection is a feature of alcohol-related liver disease. Programmed cell death 1 (PD1), the T-cell immunoglobulin and mucin domain-containing protein 3 (TIM3, also known as hepatitis A virus cellular receptor 2), and their respective ligands-CD274 (also known as PD ligand 1 [PDL1]) and galectin-9-are inhibitory receptors that regulate the balance between protective immunity and host immune-mediated damage. However, their sustained hyperexpression promotes immune exhaustion and paralysis. We investigated the role of these immune inhibitory receptors in driving immune impairments in patients with alcoholic liver disease. METHODS In a prospective study, we collected blood samples from 20 patients with acute alcoholic hepatitis (AAH), 16 patients with stable advanced alcohol-related cirrhosis, and 12 healthy individuals (controls). Whole blood or peripheral blood mononuclear cells were assessed for expression of PD1, PDL1, TIM3, galectin-9, and Toll-like receptors on subsets of innate and adaptive immune effector cells. We measured antibacterial immune responses to lipopolysaccharide (endotoxin) using ELISpot assays, and used flow cytometry to quantify cytokine production, phagocytosis, and oxidative burst in the presence or absence of blocking antibodies against PD1 or TIM3. RESULTS Antibacterial innate and adaptive immune responses were greatly reduced in patients with AAH, compared with controls, and patients with alcohol-related cirrhosis had less severe dysfunctions in innate immune effector cells and preserved functional T-cell responses. Fewer T cells from patients with AAH produced interferon gamma in response to lipopolysaccharide, compared with controls. In addition, patients with AAH had greater numbers of interleukin 10-producing T cells, and reduced levels of neutrophil phagocytosis and oxidative burst in response to Escherichia coli stimulation, compared with controls. T cells from patients with AAH, but not alcohol-related cirrhosis, expressed higher levels of PD1 and PDL1, or TIM3 and galectin-9, than T cells from controls. Antibodies against PD1 and TIM3 restored T-cell production of interferon gamma, reduced the numbers of interleukin 10-producing T cells, and increased neutrophil antimicrobial activities. Circulating levels of endotoxin in plasma from patients with AAH caused over expression of immune inhibitory receptors on T cells via Toll-like receptor 4 binding to CD14(+) monocytes. CONCLUSIONS Antibacterial immune responses are impaired in patients with AAH. Lymphocytes from these patients express high levels of immune inhibitory receptors, produce lower levels of interferon gamma, and have increased IL10 production due to chronic endotoxin exposure. These effects can be reversed by blocking PD1 and TIM3, which increase the antimicrobial activities of T cells and neutrophils.

In Patients With Severe Alcoholic Hepatitis, Prednisolone Increases Susceptibility to Infection and Infection-Related Mortality, and Is Associated With High Circulating Levels of Bacterial DNA

Background & Aims Infections are common in patients with severe alcoholic hepatitis (SAH), but little information is available on how to predict their development or their effects on patients. Prednisolone is advocated for treatment of SAH, but can increase susceptibility to infection. We compared the effects of infection on clinical outcomes of patients treated with and without prednisolone, and identified risk factors for development of infection in SAH. Methods We analyzed data from 1092 patients enrolled in a double-blind placebo-controlled trial to evaluate the efficacy of treatment with prednisolone (40 mg daily) or pentoxifylline (400 mg 3 times each day) in patients with SAH. The 2 × 2 factorial design led to 547 patients receiving prednisolone; 546 were treated with pentoxifylline. The trial was conducted in the United Kingdom from January 2011 through February 2014. Data on development of infection were collected at evaluations performed at screening, baseline, weekly during admission, on discharge, and after 90 days. Patients were diagnosed with infection based on published clinical and microbiologic criteria. Risk factors for development of infection and effects on 90-day mortality were evaluated separately in patients treated with prednisolone (n = 547) and patients not treated with prednisolone (n = 545) using logistic regression. Pretreatment blood levels of bacterial DNA (bDNA) were measured in 731 patients. Results Of the 1092 patients in the study, 135 had an infection at baseline, 251 developed infections during treatment, and 89 patients developed an infection after treatment. There was no association between pentoxifylline therapy and the risk of serious infection (P = .084), infection during treatment (P = .20), or infection after treatment (P = .27). Infections classified as serious were more frequent in patients treated with prednisolone (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.27−2.92; P = .002). There was no association between prednisolone therapy and infection during treatment (OR, 1.04; 95% CI, 0.78−1.37; P = .80). However, a higher proportion (10%) of patients receiving prednisolone developed an infection after treatment than of patients not given prednisolone (6%) (OR, 1.70; 95% CI, 1.07−2.69; P = .024). Development of infection was associated with increased 90-day mortality in patients with SAH treated with prednisolone, independent of model for end-stage liver disease or Lille score (OR, 2.46; 95% CI, 1.41−4.30; P = .002). High circulating bDNA predicted infection that developed within 7 days of prednisolone therapy, independent of Model for End-Stage Liver Disease and white blood cell count (OR, 4.68; 95% CI, 1.80−12.17; P = .001). In patients who did not receive prednisolone, infection was not independently associated with 90-day mortality (OR, 0.94; 95% CI, 0.54−1.62; P = .82) or levels of bDNA (OR, 0.83; 95% CI, 0.39−1.75; P = .62). Conclusions Patients with SAH given prednisolone are at greater risk for developing serious infections and infections after treatment than patients not given prednisolone, which may offset its therapeutic benefit. Level of circulating bDNA before treatment could identify patients at high risk of infection if given prednisolone; these data could be used to select therapies for patients with SAH. EudraCT no: 2009-013897-42; Current Controlled Trials no: ISRCTN88782125.

Defective monocyte oxidative burst predicts infection in alcoholic hepatitis and is associated with reduced expression of NADPH oxidase

Objective In order to explain the increased susceptibility to serious infection in alcoholic hepatitis, we evaluated monocyte phagocytosis, aberrations of associated signalling pathways and their reversibility, and whether phagocytic defects could predict subsequent infection. Design Monocytes were identified from blood samples of 42 patients with severe alcoholic hepatitis using monoclonal antibody to CD14. Phagocytosis and monocyte oxidative burst (MOB) were measured ex vivo using flow cytometry, luminometry and bacterial killing assays. Defects were related to the subsequent development of infection. Intracellular signalling pathways were investigated using western blotting and PCR. Interferon-γ (IFN-γ) was evaluated for its therapeutic potential in reversing phagocytic defects. Paired longitudinal samples were used to evaluate the effect of in vivo prednisolone therapy. Results MOB, production of superoxide and bacterial killing in response to Escherichia coli were markedly impaired in patients with alcoholic hepatitis. Pretreatment MOB predicted development of infection within two weeks with sensitivity and specificity that were superior to available clinical markers. Accordingly, defective MOB was associated with death at 28 and 90 days. Expression of the gp91phox subunit of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase was reduced in patients with alcoholic hepatitis demonstrating defective MOB. Monocytes were refractory to IFN-γ stimulation and showed high levels of a negative regulator of cytokine signalling, suppressor of cytokine signalling-1. MOB was unaffected by 7 days in vivo prednisolone therapy. Conclusions Monocyte oxidative burst and bacterial killing is impaired in alcoholic hepatitis while bacterial uptake by phagocytosis is preserved. Defective MOB is associated with reduced expression of NADPH oxidase in these patients and predicts the development of infection and death.

Right Or Left in COLonoscopy (ROLCOL)? A Randomized Controlled Trial of Right- versus Left-Sided Starting Position in Colonoscopy.

OBJECTIVES:Colonoscopy is technically challenging and can cause discomfort for patients. We aimed to test whether right-sided starting position for colonoscopy would result in shorter procedure time and greater patient comfort when compared with conventional left-sided starting position.METHODS:We conducted a randomized controlled trial in which patients were randomized to begin in either the right- (RL) or conventional left-lateral (LL) position. One hundred and sixty-three adult patients undergoing scheduled colonoscopy were stratified by age, gender, body mass index, and experience of the endoscopist. Patients were then randomized 1:1 in permuted blocks. The primary outcome measure was time to cecal intubation and secondary outcome measures included patient comfort that was evaluated by visual analog comfort scale.RESULTS:Median time to reach the cecum was quicker when colonoscopy began with patients positioned RL rather than LL (P=0.0078). Moreover, patients found RL more comfortable than LL (P=0.02). Multiple linear regression confirmed starting position in colonoscopy as an independent determinant of time to reach the cecum (P=0.007). Women and those who had previously undergone abdominal surgery gained the greatest benefit from right-sided positioning (RL vs. LL: 498 vs. 824 s; P=0.03 and 498 vs. 797 s; P=0.006, respectively).CONCLUSIONS:Our study reveals that right-sided positioning at the start of colonoscopy results in more comfortable and quicker procedures. Of the factors identified by multiple linear regression to independently have an impact on time to reach the cecum, only starting position is modifiable. Right-sided starting position may therefore be of benefit in colonoscopy, in particular for women and patients who have previously undergone abdominal surgery.

Acute alcoholic hepatitis and cellular Th1 immune responses to alcohol dehydrogenase

BACKGROUND Alcoholic hepatitis is characterised by florid hepatic inflammation, liver failure, and death within 28 days in 35% of patients. We recently showed proliferative peripheral blood mononuclear cell (PBMC) responses to alcohol dehydrogenase (ADH) in patients with alcohol-related cirrhosis, associated with T-helper-type 1 (Th1) immunity and disease severity. We aimed to define whether ADH-specific cellular immunity is present in alcoholic hepatitis. METHODS PBMCs were collected from 15 patients with alcoholic hepatitis (modified Maddreys discriminant function >32), nine with alcohol-related cirrhosis (long-term alcohol abstinence), and three healthy controls. 25 overlapping peptides, spanning the human ADH β1 subunit, were constructed. Proliferation to ADH peptides (1 × 10(5) cells per well, cultured with 10 mM peptides for 7 days) was assessed by (3)H-thymidine incorporation. A stimulation index (SI) of 2·5 or more was regarded as positive. ELISA measured concentrations of interferon γ (IFNγ), interleukin (IL) 17, and IL4 from supernatant. FINDINGS PBMCs from seven of 15 patients with alcoholic hepatitis recognised one to three ADH peptides (SI ≤5·7). IFNγ (mean 390·9 pg/mL [SE 31·4]) was detected in 48% of wells, IL17 (20·1 [3 ·4]) in 15%, and IL4 (90·5 [9·3]) in 14%. PBMCs from six of the nine patients with alcohol-related cirrhosis recognised one to five peptides (SI ≤5·2). IFNγ (360·7 [58·9], p>0·05) was detected in 31% of wells, IL17 (57·7 [10·9], p=0·0006) in 19%, and IL4 (219·7 [11·2], p=0·0012) in 28%. PBMCs from two healthy controls recognised one to two peptides (SI ≤3·1); all cytokine levels were below baseline. INTERPRETATION Proliferative anti-ADH immune responses in alcoholic hepatitis focused on individual epitopic regions. Predominance of proinflammatory Th1 responses was more pronounced in alcoholic hepatitis than in alcoholic-related cirrhosis. This finding requires investigation of targeted therapies to inhibit Th1 immunity in alcoholic hepatitis. FUNDING Wellcome Trust.

PWE-113 The liver biopsy in alcoholic hepatitis: data from the steroids or pentoxifylline in alcoholic hepatitis (stopah) clinical trial

Introduction The European Association for the Study of the Liver guidelines recommend the use of liver biopsy to confirm alcoholic steatohepatitis (ASH) in patients suspected to be suffering from alcoholic hepatitis and who are classified as high risk after prognostic assessment. Despite this it was only in 2014 that Altamirano et alpublished the first prognostic liver biopsy based scoring system for the evaluation of ASH (the Alcoholic Hepatitis Histological Score or AHHS). This work sought to validate their scoring system and further explore the utility of the liver biopsy in ASH. Method Two independent histopathologists, blinded to treatment and outcome, centrally reviewed liver biopsies of patients with clinically high-risk alcoholic hepatitis who had been recruited to the STOPAH trial. Results 93 (47%) of the 208 biopsies received were both adequate in quality and taken between admission and day 5 of trial treatment. 88% (82/93) had histological features diagnostic of ASH. 89% (32/36) of cases obtained as routine clinical practice were diagnostic of ASH compared to 79% (15/19) biopsied for diagnostic uncertainty. Clinically more severe liver disease was associated a higher rate of ASH diagnosis (82% of GAHS ≤8 vs. 97% of GAHS >8). 65% (53/82) of biopsy proven cases of ASH were classified as severe by AHHS. This group had a significantly higher 28 day mortality rate than those classified as mild/moderate (18% vs. 0%, Fisher’s exact p = 0.02). AHHS severity positively correlated with baseline Maddrey’s Discriminant Function and Glasgow Alcoholic Hepatitis Score (r = 0.2, p = 0.045 and r = 0.3, p = 0.01 respectively). Clinical markers of severe disease positively correlated with biopsy features of severe disease including: - serum bilirubin with bilirubinostasis (r = 0.5, p= <0.0001) - serum white cell and neutrophil count with lobular inflammation (r = 0.4, p = <0.001) Elevation of serum alkaline phosphatase (ALP) and bilirubin are usually associated with more severe liver disease, however in this study they were seen to negatively correlate with certain biopsy features of more severe disease: - serum ALP negatively correlated with ductular changes (r = -0.2, p = 0.04) - serum bilirubin negatively correlated with Laennec fibrosis grading (r = -0.3, p = 0.01) Conclusion This work goes some way towards validating the AHHS classification. The work also highlights the parallels between clinical and histological parameters and documents negative correlations seen in other liver diseases but not previously noted in ASH. Disclosure of interest None Declared.

OC-021 Monocyte oxidative burst defect is associated with susceptibility to infection in severe alcoholic hepatitis

Introduction Infection is a common cause of mortality in severe alcoholic hepatitis (SAH). Monocytes are innate immune cells that play a key role in fighting infection. We sought to characterise monocyte phenotype and function in SAH and relate defects to the development of infection. Method We analysed pre-treatment blood samples from 73 patients admitted to hospital suffering from SAH (DF >32), 34 healthy controls (HC) and 17 abstinent compensated cirrhotic patients (CLD). Flow cytometry was used to measure monocyte phenotype, cytokine production, phagocytosis and oxidative burst ex vivo . Production of superoxide (O2 -) was measured by luminometry and bacterial killing was assessed by counting viable E. coli colonies growing on agar plates after incubation with monocytes. Additionally, we evaluated the impact of in vivosteroid therapy on monocyte function via the Steroids or Pentoxyfilline for Alcoholic Hepatitis (STOPAH) clinical trial. Results The proportion of CD14+ +CD16+ + monocytes was increased in SAH and CLD vs HC (P < 0.003). These cells expressed elevated levels of activation marker HLA-DR (P < 0.01) and chemokine receptor CCR-5 (.01). In addition, they produced greater TNF-α in response to lipopolysaccharide vs CD14+ +CD16- cells (.03). Conversely, patrolling CD14+CD16+ + monocytes were reduced in SAH vs CLD and HC (.01). Phagocytosis was preserved in SAH for all subsets but monocyte oxidative burst (mOB) (P < 0.001), O2 -production (.02) and bacterial killing (.01) were markedly impaired vs CLD and HC. Importantly, pre-treatment mOB defect predicted the development of infection within the subsequent two weeks of sampling with area under receiver-operator curve of 0.86 (P < 0.02) (Figure 1). Accordingly, defective mOB was associated with death at 28 and 90 days (one-tailed .04 for both). Ex vivomOB was unchanged in patients who had received 7 days steroid therapy.Abstract OC-021 Figure 1 Conclusion Defective mOB is prevalent in patients with SAH and is strongly associated with the development of infection within the subsequent two weeks. In addition, CD14+ +CD16+ +monocytes are expanded in SAH and bear features suggestive of an inflammatory role in disease pathogenesis. Further work should seek the molecular mechanisms of these defects and components that might be amenable to therapeutic intervention. Disclosure of interest None Declared.

Universal screening of acute medical admissions for excess alcohol consumption: What’s the misuse?

Alcohol misuse is frequently identified amongst patients presenting to Emergency Departments. Additionally, ‘‘covert” alcohol excess may be identified in cases where admission is not obviously related to alcohol or its sequelae. In this issue, Westwood and colleagues examine the feasibility of screening acute medical admissions for alcohol use disorders with a retrospective, observational cohort study encompassing more than 50,000 admissions over a 3-year period. Screening was completed in[90% of hospital admissions. Patients at ‘‘high” and ‘‘increasing” risk of alcohol related harm, the minority, were identified using a modification of the Paddington Alcohol Test and further assessed by an Alcohol Specialist Nurse Service (ASNS) using the Alcohol Use Disorders Identification Test (AUDIT). In their 1968 paper, ‘Principles and Practice of Screening for Disease’, Wilson and Jungner described principles central to the effective detection of early disease; the study by Westwood and colleagues can be considered with respect to these criteria (Table 1). Certainly, alcohol misuse is an important health problem. Around 200 different diseases, including a significant proportion of cancers, are wholly or partly attributable to alcohol. Globally nearly 6% of all deaths may be attributed to alcohol, rising to almost half for cirrhosis-related deaths. ALD is the most common aetiology in emergency presentations with decompensated cirrhosis. The healthcare and economic costs associated with alcohol misuse are estimated at £3.5bn and £21bn per annum, respectively, in England alone. Alcohol related liver, pancreas or brain damage all have an early phase that can be latent or symptomatic, satisfying Wilson and Jungner’s second criterion. Consequently, treatment of alcohol misuse could both reduce costs and arrest the development of end-organ damage, avoiding future hospital admissions, morbidity and mortality.