Stephen R. Atkinson

Comparative Effectiveness of Pharmacological Interventions for Severe Alcoholic Hepatitis: A Systematic Review and Network Meta-analysis

BACKGROUND & AIMS Severe alcoholic hepatitis (AH) has high mortality. We assessed the comparative effectiveness of pharmacological interventions for severe AH, through a network meta-analysis combining direct and indirect treatment comparisons. METHODS We conducted a systematic literature review, through February 2015, for randomized controlled trials of adults with severe AH (discriminant function ≥32 and/or hepatic encephalopathy) that compared the efficacy of active pharmacologic interventions (corticosteroids, pentoxifylline, and N-acetylcysteine [NAC], alone or in combination) with each other or placebo, in reducing short-term mortality (primary outcome) and medium-term mortality, acute kidney injury, and/or infections (secondary outcomes). We performed direct and Bayesian network meta-analysis for all treatments, and used Grading of Recommendations Assessment, Development and Evaluation criteria to appraise quality of evidence. RESULTS We included 22 randomized controlled trials (2621 patients) comparing 5 different interventions. In a direct meta-analysis, only corticosteroids decreased risk of short-term mortality. In a network meta-analysis, moderate quality evidence supported the use of corticosteroids alone (relative risk [RR], 0.54; 95% credible interval [CrI], 0.39-0.73) or in combination with pentoxifylline (RR, 0.53; 95% CrI, 0.36-0.78) or NAC (RR, 0.15; 95% CI, 0.05-0.39), to reduce short-term mortality; low quality evidence showed that pentoxifylline also decreased short-term mortality (RR, 0.70; 95% CrI, 0.50-0.97). The addition of NAC, but not pentoxifylline, to corticosteroids may be superior to corticosteroids alone for reducing short-term mortality. No treatment was effective in reducing medium-term mortality. Imprecise estimates and the small number of direct trials lowered the confidence in several comparisons. CONCLUSIONS In patients with severe AH, pentoxifylline and corticosteroids (alone and in combination with pentoxifylline or NAC) can reduce short-term mortality. No treatment decreases risk of medium-term mortality.

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.

Homozygosity for rs738409:G in PNPLA3 is associated with increased mortality following an episode of severe alcoholic hepatitis

BACKGROUND & AIMS Carriage of rs738409:G in PNPLA3 is associated with an increased risk of developing alcohol-related cirrhosis and has a significant negative effect on survival. Short-term mortality in patients with severe alcoholic hepatitis is high; drinking behaviour is a major determinant of outcome in survivors. The aim of this study was to determine whether carriage of rs738409:G has an additional detrimental effect on survival in this patient group. METHODS Genotyping was undertaken in 898 cases with severe alcoholic hepatitis, recruited through the UK Steroids or Pentoxifylline for Alcoholic Hepatitis (STOPAH) trial, and 1188 White British/Irish alcohol dependent controls with no liver injury, recruited via University College London. Subsequent drinking behaviour was classified, in cases surviving ≥90days, as abstinent or drinking. The relationship between rs738409 genotype, drinking behaviour and survival was explored. RESULTS The frequency of rs738409:G was significantly higher in cases than controls (29.5% vs. 18.9%; p=2.15×10-15; odds ratio 1.80 [95% confidence interval (CI) 1.55-2.08]). Case-mortality at days 28, 90 and 450 was 16%, 25% and 41% respectively. There was no association between rs738409:G and 28-day mortality. Mortality in the 90 to 450-day period was higher in survivors who subsequently resumed drinking (hazard ratio [HR] 2.77, 95% CI 1.79-4.29; p<0.0001) and in individuals homozygous for rs738409:G (HR 1.69, 95% CI 1.02-2.81, p=0.04). CONCLUSION Homozygosity for rs738409:G in PNPLA3 confers significant additional risk of medium-term mortality in patients with severe alcoholic hepatitis. Rs738409 genotype may be taken into account when considering treatment options for these patients. LAY SUMMARY Individuals misusing alcohol who carry a particular variant of the gene PNPLA3 are more at risk of developing severe alcoholic hepatitis, a condition with a poor chance of survival. The longer-term outcome in people with this condition who survive the initial illness is strongly influenced by their ability to remain abstinent from alcohol. However, carriers of this gene variant are less likely to survive even if they are able to stop drinking completely. Knowing if someone carries this gene variant could influence the way in which they are managed. Clinical trial numbers: EudraCT reference number: 2009-013897-42; ISRCTN reference number: ISRCTN88782125. CLINICAL TRIAL NUMBERS EudraCT reference number: 2009-013897-42; ISRCTN reference number: ISRCTN88782125.

Rifaximin in Non-Alcoholic Steatohepatitis: An Open-Label Pilot Study.

Gut microbial dysbiosis is implicated in the pathogenesis of non‐alcoholic steatohepatitis (NASH). We investigated downstream effects of gut microbiota modulation on markers of hepatic inflammation, steatosis, and hepatic and peripheral insulin sensitivity in patients with NASH using rifaximin therapy.

Prevalent acute-on-chronic liver failure and response to corticosteroids in alcoholic hepatitis

To the Editor: We read the paper by Sersté et al. regarding the significance of acute-on-chronic liver failure (ACLF) in alcoholic hepatitis (AH) with interest. They conclude that ACLF in AH is associated with a poor outcome and that the Lille response to corticosteroids was reduced in those with prevalent ACLF. In the light of this we have interrogated the STOPAH database to determine the role of ACLF in AH. The calculation of the CLIF-OF score in STOPAH patients was limited by the absence of data relating to respiratory function. However, in the Sersté study only 4.2% of patients in the Erasme cohort had pulmonary failure, which is assumed to have been infrequent in the STOPAH cohort. For the purposes of calculating the CLIF-C ACLF score, the respiratory sub-score was therefore assumed to be 1. Based on this assumption, the CLIF-OF score, the ACLF grade and the CLIF-C ACLF score were calculable in 1,019 of 1,069 patients who were previously described in the STOPAH trial. Comparisons between groups were analysed using chi-squared (v) tests and between survival curves using Kaplan-Meier logrank tests for trends. In addition to the absence of respiratory data, the STOPAH protocol excluded patients with severe renal impairment (creatinine >500 lmol/L) and those on inotropic support, thereby not including many patients with CLIF-OF sub-scores of 3 for renal and circulatory systems. Therefore, the proportion of those recruited with ACLF was less than that seen by Sersté et al. who noted that more than 20% of patients had circulatory and/or respiratory failure in the Erasme cohort. In the STOPAH cohort, the numbers of patients with ACLF were 737 (72.3%), 152 (14.9%), 115 (11.3%) and 15 (1.5%) for grades 0, 1, 2 and 3, respectively. The median CLIF-OF score was 8 (range 6–13) and mean CLIF-C ACLF score was 41.4 (standard deviation 6.8). For the purpose of analyses, ACLF Grade 2 and 3 patients were grouped together. Overall survival rates at 28 days were 90.2%, 75.7% and 56.9%, and at 90 days were 80.3%, 65.8% and 43.8% for ACLF 0, ACLF 1 and ACLF (2+3) respectively. The area under the curve for the CLIF-C ACLF score relating to prediction of 28-day outcome was 0.793 (95% CI 0.767–0.818) and of

A Prospective Multi-National Study of the Colorectal Cancer Mucosal Microbiome Reveals Specific Taxonomic Changes Indicative of Disease Stage and Prognosis

Introduction The colorectal cancer (CRC) microbiome is niche specific and individualised. Several putative driver organisms enriched on CRCs have been identified from human studies, but few data exist which properly account for important clinical variables in CRC. In this study, we used a meta-taxonomic approach to demonstrate how the CRC microbiome varies with disease stage, histological markers of prognosis and host molecular phenotypes. Method A prospective study was performed on patients undergoing colonoscopy and elective surgery for CRC at three hospitals in UK and Czech Republic. Tissue was sampled from tumours, adenomas, adjacent normal mucosa and mucosa from healthy colon controls. The V1-2 regions of the 16S rRNA gene were sequenced (Illumina MiSeq); data were processed in Mothur and analysed in Stamp and R. Species assignment was performed with NCBI BLAST for microbial genomes. False discovery rate p value correction accounted for multiple testing. Histological analysis and tumour molecular phenotyping were performed according to Royal College of Pathology guidelines. Results One hundred and ninety six patients were recruited: 158 CRC patients, 24 adenoma patients and 14 normal colon controls (median age 70; range 35–90). Tumours were staged as 6 T0, 4 T1, 23 T2, 97 T3, 27 T4; 99 N0, 40 N1, 27 N2; 6 M1. No significant differences were seen in diversity or taxonomy between the UK and Czech cohorts. Adenoma and healthy colon control samples were taxonomically indistinct. However, CRCs were characterised by reduced Shannon diversity (p Conclusion This large prospective analysis demonstrates that the CRC microbiome is stage-specific and appears to evolve with disease progression. We conclude that oral pathobionts which colonise advanced stage disease relate to markers of tumour prognosis, raising the possibility that they may be directly influencing tumour invasion. 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.

ACG Clinical Guideline for Alcoholic Liver Disease: The MELD Threshold for Corticosteroid Treatment has Yet to be Established

To the Editor: The recently published ACG clinical guidelines for alcoholic liver disease provide further useful advice for the clinician managing these patients with this illness, especially those with alcoholic hepatitis [1]. In the paper it is suggested that Prednisolone be considered only if the MELD score is greater than 20. However, the reference for this recommendation is a retrospective study of just 73 patients, 11 of whom had concomitant alternative liverrelevant diagnoses (Hepatitis C, Hepatitis B and acetominophen use) and 12 of whom received either corticosteroids or etanercept [2]. The study identified two optimal cut points for MELD: 22 for 30-day mortality and 21 for 90-day mortality. The paper did not assess whether there was any benefit from corticosteroid treatment for those either above or below these cut points. Other studies have assessed the MELD in Alcoholic Hepatitis with varying cutoffs suggested: 18 for in-hospital mortality; 30.5 for 30-day mortality and 19 for 90-day mortality; 27 for 180-day mortality; and 25 for both 30and 90-day mortality [3, 4]. The most recent AASLD Guidelines suggest Prednisolone should be considered if the MELD is greater than or equal to 18 [5]. This spread of possible thresholds for treatment is compounded by the potential inaccuracies in the measurement of INR and serum creatinine which may lead to substantial differences in calculated MELD values [6]. We have applied the MELD threshold of 21 to the STOPAH patient cohort as previously described [4, 7]. Of the 1022 patients with a calculable MELD score at baseline, 165 had a value less than 21. Eleven of these had a documented rise in MELD score in the first week, leaving 154 with consistently low MELD values, 86 of whom were treated with Prednisolone. The 28-day survival of Prednisolone-treated patients was 100% compared with 95.6% (3 deaths) for those untreated (p < 0.05; χ2 3.851). For the 857 patients with a MELD greater than 20, the 28-day survival was 83.5% compared with 79.4% for those untreated (p = 0.114; χ2 2.497). As per the main study, this survival difference for those with a low MELD was lost by Day 90: 91.9% compared with 94.1% (p = 0.613; χ2 0.256). Although this difference in 28-day survival for those with a MELD less than 21 may be artefactual due to the numbers studied and the low event rate, it does suggest that some of these patients may be disadvantaged by not being treated with corticosteroids. It also suggests that the benefit from Prednisolone for those with a MELD greater than 20 is marginal. When a threshold of 25 is applied, Prednisolone did not significantly improve the outcome of those with a low score [4]. These results indicate that whilst MELD may be a useful indicator of overall prognosis, a threshold of 21 is not a good predictor of benefit from Prednisolone treatment. Patients with values less than this have a relatively favourable outcome which may still be improved by such treatment even if only in the short-term. An effective threshold of MELD for determining treatment in alcoholic hepatitis has yet to be established.

People who survive an episode of severe alcoholic hepatitis should be advised to maintain total abstinence from alcohol

We read with interest the article published in HEPATOLOGY by Louvet et al. highlighting factors influencing outcomes in people with severe alcoholic hepatitis. They found that beyond 6 months, alcohol relapse, defined as consumption of 30 g/day, was an independent predictor of mortality with a dose-related effect on the hazard ratio (HR). The effect of drinking behavior on outcome has also been examined in data collected in the Steroids and Pentoxyfylline for Severe Alcoholic Hepatitis (STOPAH) trial. Patients were classified, in the original published analysis, as abstinent or drinking. A return to alcohol consumption at day 90 was associated with a significantly higher mortality at day 450 than abstinence (HR, 2.77; 95% confidence interval [CI], 1.79-4.29; P < 0.00001). We have reexamined these data in an attempt to replicate the dose-