Sandra Lemesch

Randomised clinical trial: the effects of a multispecies probiotic vs. placebo on innate immune function, bacterial translocation and gut permeability in patients with cirrhosis

Probiotics may correct intestinal dysbiosis and proinflammatory conditions in patients with liver cirrhosis.

Lactobacillus casei Shirota Supplementation Does Not Restore Gut Microbiota Composition and Gut Barrier in Metabolic Syndrome: A Randomized Pilot Study

Metabolic syndrome is associated with disturbances in gut microbiota composition. We aimed to investigate the effect of Lactobacillus casei Shirota (LcS) on gut microbiota composition, gut barrier integrity, intestinal inflammation and serum bile acid profile in metabolic syndrome. In a single-centre, prospective, randomised controlled pilot study, 28 subjects with metabolic syndrome received either LcS for 12 weeks (n = 13) or no LcS (n = 15). Data were compared to healthy controls (n = 16). Gut microbiota composition was characterised from stool using 454 pyrosequencing of 16S rRNA genes. Serum bile acids were quantified by tandem mass spectrometry. Zonulin and calprotectin were measured in serum and stool by ELISA. Bacteroidetes/Firmicutes ratio was significantly higher in healthy controls compared to metabolic syndrome but was not influenced by LcS. LcS supplementation led to enrichment of Parabacteroides. Zonulin and calprotectin were increased in metabolic syndrome stool samples but not influenced by LcS supplementation. Serum bile acids were similar to controls and not influenced by LcS supplementation. Metabolic syndrome is associated with a higher Bacteroidetes/Firmicutes ratio and gut barrier dysfunction but LcS was not able to change this. LcS administration was associated with subtle microbiota changes at genus level. Trial Registration ClinicalTrials.gov NCT01182844

MicroRNAs 223-3p and 93-5p in patients with chronic kidney disease before and after renal transplantation.

Chronic kidney disease (CKD) is associated with a multifactorial dysregulation of bone and vascular calcification and closely linked to increased cardiovascular mortality and concomitant bone disease. We aimed to investigate specific microRNA (miRNA) signatures in CKD patients to find indicators for vascular calcification and/or bone mineralization changes during CKD and after kidney transplantation (KT). A miRNA array was used to investigate serum miRNA profiles in CKD patients, then selected miRNAs were quantified in a validation cohort comprising 73 patients in CKD stages 3 to 5, 67 CKD patients after KT, and 36 healthy controls. A spectrum of biochemical parameters including markers for kidney function, inflammation, glucose, and mineral metabolism was determined. The relative expression of miR-223-3p and miR-93-5p was down-regulated in patients with CKD stage 4 and 5 compared to healthy controls. This down-regulation disappeared after kidney transplantation even when lower glomerular filtration rates (eGFR) persisted. MiR-223-3p and miR-93-5p were associated with interleukin-6 (IL-6) and eGFR levels, and by trend with interleukin-8 (IL-8), C-peptide, hematocrit, and parathyroid hormone (PTH). This study contributes new knowledge of serum miRNA expression profiles in CKD, potentially reflecting pathophysiological changes of bone and calcification pathways associated with inflammation, vascular calcification, mineral and glucose metabolism. Identified miRNA signatures can contribute to future risk markers or future therapeutic targets in bone and kidney disease.

Structural and functional differences in gut microbiome composition in patients undergoing haemodialysis or peritoneal dialysis

Complications of end-stage renal disease (ESRD) are critically related to inflammation. The gut microbiome is a key driver of inflammation. Since dialysis modalities may differently influence the gut microbiome, we aimed to compare the effects of haemodialysis (HD) and peritoneal dialysis (PD) on patients’ gut microbiome composition and function. We therefore studied faecal microbiome composition and function as well as inflammation and gut permeability in 30 patients with ESRD (15 HD, 15 PD) and compared to 21 healthy controls. We found an increase in potentially pathogenic species and a decrease in beneficial species in patients on HD and to a lesser extend in patients on PD when compared to controls. These changes in taxonomic composition also resulted in differences in predicted metagenome functions of the faecal microbiome. In HD but not in PD, changes in microbiome composition were associated with an increase in c-reactive protein (CRP) but not with intestinal inflammation or gut permeability. In conclusion microbiome composition in ESRD differs from healthy controls but also between modes of dialysis. These differences are associated with systemic inflammation and cannot completely be explained by dialysis vintage. The mode of renal replacement therapy seems to be an important driver of dysbiosis in ESRD.

Mode of renal replacement therapy determines endotoxemia and neutrophil dysfunction in chronic kidney disease

Bacterial infection and sepsis are common complications of chronic kidney disease (CKD). A vicious cycle of increased gut permeability, endotoxemia, inadequate activation of the innate immune system and resulting innate immune dysfunction is hypothesized. We assessed endotoxemia, neutrophil function and its relation to oxidative stress, inflammation and gut permeability in patients with CKD grade 3–5 without renal replacement therapy (CKD group, n = 57), patients with CKD stage 5 undergoing haemodialysis (HD, n = 32) or peritoneal dialysis (PD, n = 28) and patients after kidney transplantation (KT, n = 67) in a cross-sectional observational study. In HD patients, endotoxin serum levels were elevated and neutrophil phagocytic capacity was decreased compared to all other groups. Patients on HD had a significantly higher mortality, due to infections during follow up, compared to PD (p = 0.022). Oxidative stress, neutrophil energy charge, systemic inflammation and gut permeability could not completely explain these differences. Our findings suggest that dialysis modality and not renal function per se determine the development of neutrophil dysfunction and endotoxemia in CKD-patients. HD patients are particularly prone to neutrophil dysfunction and endotoxemia whereas neutrophil function seems to improve after KT. Multi-target approaches are therefore warranted to improve neutrophil function and potentially reduce the rate of infections with patients undergoing haemodialysis.

Oxidized plasma albumin promotes platelet-endothelial crosstalk and endothelial tissue factor expression

Plasma advanced oxidation protein products (AOPPs), a class of pro-inflammatory pathogenic mediators, accumulate in subjects with chronic kidney disease. Whether AOPPs contribute to coagulation abnormalities, which are frequently seen in uremic patients, is unknown. Here we report that AOPPs activate platelets via a CD36-mediated signaling pathway. Activation of signaling pathways by AOPP-platelet interaction resulted in the expression of several platelet activation markers and rapidly induced the expression of CD40 ligand, triggering platelet adhesion to endothelial cells and promoting endothelial tissue factor expression. AOPPs and serum tissue factor levels were considerably increased in end stage renal disease patients on hemodialysis and a significant correlation of AOPPs and serum tissue factor was found. Interestingly, serum levels of AOPPs and tissue factor were substantially lower in stable kidney transplant patients when compared with hemodialysis patients. Given that CD36 is known to transduce the effects of oxidized lipids into platelet hyperactivity, our findings reveal previously unknown pro-thrombotic activities of oxidized plasma albumin via a CD36 dependent pathway.

Triple Therapy with First Generation Protease Inhibitors for Hepatitis C Markedly Impairs Function of Neutrophil Granulocytes.

First-generation HCV protease inhibitors represent a milestone in antiviral therapy for chronic hepatitis C infection (CHC), but substantially increased rates of viral clearance are offset by increased rates of infection and infection-associated deaths, especially of patients with advanced liver disease. We aimed to assess whether first generation protease inhibitors interfere with neutrophil function. We included 108 consecutive, retrospective CHC patients and 44 consecutive, prospective CHC patients who were treated with peginterferon and ribavirin with or without protease inhibitors according to the guidelines in the period of November 2012 to June 2015. 33 healthy volunteers served as controls. Infection data were evaluated in all patients. Neutrophil phagocytosis, oxidative burst, elastase and diamine oxidase levels during 12 weeks of triple (n = 23) or dual therapy (n = 21) were studied in the prospective part. In the retro- and prospective cohorts patients experiencing clinically relevant infections were significantly more frequent during protease inhibitor therapy (31% and 26%) than during therapy with peginterferon and ribavirin (13% and 0%). Neutrophil phagocytosis decreased to 40% of baseline with addition of protease inhibitors to P/R but recovered 6 months after end of treatment. Protease inhibitors also seemed to reduce serum elastase levels but did not impact on gut permeability. Impaired neutrophil function during triple therapy with first generation HCV protease inhibitors may explain the high infection rate associated to these treatments and be of relevance for treatment success and patient survival. Trial Registration ClinicalTrials.gov NCT02545400 ClinicalTrials.gov NCT02545335

Hospital mortality of cirrhosis: better, but still room for improvement!

According to WHO projections, Cirrhosis will be the 9th most common cause of death in the western world by 2015 and the costs of hospital admission owing to complications in the US approximate

P0115 : Serum bile acids in cirrhosis depend on aetiology

13Bn. It is well known that patients with cirrhosis showing signs of decompensation have a higher mortality (1, 2). Several studies tried to define the impact of different clinical features of decompensation on survival (3). When patients are hospitalized, mortality ranges between 44 and 74% (4). This apparently heterogenous outcome can be explained by the fact that it is not the severity of liver disease, but the degree of end-organ failure that determines outcome. The article by Vergara et al. (5) has analysed hospital mortality in patients with cirrhosis in detail. They used registry data from the Administrative Inpatient Dataset of acute-care hospitals collected from 2003 to 2010 and searched for factors associated with mortality. Firstly, they showed that in-hospital mortality of patients with cirrhosis, who are acutely admitted to the hospital, is as high as 11.6%. The mortality, however, decreased remarkably over time during the observation period (27% decrease from 2003–2005 to 2009–2010). This is an encouraging information for hepatologists to further aim for improvement in the management of complications of cirrhosis. The authors conclude that the introduction of specific therapeutic options for complications of cirrhosis (e.g. terlipressin, albumin, cephalosporin) is the main reason for this improvement. It might also be possible that because of high level of awareness among physicians and because of the availability of new diagnostic tests (e.g. noninvasive fibrosis tests), cirrhosis is diagnosed earlier. This has been shown in several other conditions such as cancers, where earlier detection of a disease is associated with better survival rates. In cirrhosis, it is possible that not only the optimized medical care in case of decompensation but also the inclusion of patients into screening programs with optimized medical and supportive care and timely access to liver transplantation improves survival. Vergara et al. (5) identified factors associated with high mortality and found that hepatorenal syndrome carried the highest mortality rate, followed by spontaneous bacterial peritonitis, hepatic encephalopathy, pneumonia and malnutrition. Acute and chronic renal insufficiencies are also listed among the factors increasing mortality; however, it remains questionable how accurate the discrimination between these entities was made by the physicians who entered the data to this database. Another risk factor for mortality was ICU admission. These data are supported by a cohort study that showed a markedly increased 30-day mortality (58%) in cirrhotic inpatients who developed organ failure as compared with those who did not develop organ failure (8%) (6). This underpins again the notion that death in patients with cirrhosis is not related to the severity of underlying liver disease, but related to the development of organ failure (6). A closer look towards the factors associated with mortality leads to the hypothesis that infection and/or inflammation might play an important role in all these conditions. Two specific infections – spontaneous bacterial peritonitis and pneumonia – are among the top 5 factors. For hepatic encephalopathy, a synergistic role of inflammation in the development of brain failure has been well described (7). In hepatorenal syndrome, bacterial translocation and proinflammatory cytokines are important pathogenetic factors (8) and the systemic inflammatory response syndrome (SIRS) is frequently associated with hepatorenal syndrome (9, 10). Also in chronic kidney disease, the role of inflammation has been well established (11, 12). Malnutrition is known to be associated with an increased mortality in liver disease – in the present study by Vergara et al. (5), the odds ratio for death in patients with malnutrition was 6.2, which was the second highest odds ratio in this study. Therefore, patients with malnutrition in this study had a hospital mortality of 43.1%, which is terribly high. Malnutrition can lead to increased gut permeability (13), which consequently leads to an increased systemic endotoxaemia (14), which in turn can cause immune dysfunction and increases the risk of infection (15). As cirrhosis itself also increases gut permeability and endotoxaemia (16), this common pathway of inflammation, leading to immune dysfunction (17) and causing complications of cirrhosis seems to be a promising target for novel therapeutic strategies such as modulation of gut flora and/or permeability by probiotics. The role of inflammation and infection is also underpinned by recent data: the CANONIC study (18)

244 INCREASED GUT PERMEABILITY, ELEVATED ENDOTOXIN RELATED PROTEINS AND NEUTROPHIL DYSFUNCTION IN LIVER CIRRHOSIS

P0115 SERUM BILE ACIDS IN CIRRHOSIS DEPEND ON AETIOLOGY A. Horvath, B. Leber, E. Krones, G. Zollner, F. Durchschein, W. Spindelboeck, S. Lemesch, P. Douschan, G. Fauler, T. Stojakovic, P. Fickert, R. Stauber, P. Stiegler, V. Stadlbauer. Division for Gastroenterology and Hepatology, Department for Tranplantation Surgery, Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria E-mail: angela.horvath@medunigraz.at