Immune Profile, Neuronal Dysfunction, Metabolomics and Ammonia in Therapeutic Response of HE in ACLF

Dynamic Changes in Immune Profile, Neuronal Dysfunction, Metabolomics and Ammonia in Pathogenesis and Therapeutic Response of Hepatic Encephalopathy in Acute-on-Chronic Liver Failure: a Prospective Cohort Study

There is very little data related to the natural history of disease from covert HE (MHE and grade 1 HE) to overt HE (grades II, III and IV) in ACLF, with implications on long-term neurological recovery after an episode of overt HE. The evolution and pathogenesis of HE is well described in ALF and cirrhosis, but the dynamic changes in HE in ACLF in response to therapy such as ammonia reduction measures, antibiotics to target sepsis and inflammation, measures to alter dysbiosis such as probiotics or fecal microbiota transplant, and measures to target immune dysfunction such as steroids in alcohol-associated hepatitis. The central role of ammonia in the pathogenesis of HE in ACLF has been challenged by recent data. The approach to HE in ACLF has now refocused on systemic and neuro-inflammation, gut dysbiosis, immune dysregulation, and multi-omics approach. Most importantly, the modulation of the metabolome in response to therapy and interventions, and the use of sedatives, paralytic agents, antibiotics etc. in ACLF with HE in a real-world setting has not been reported.

Study Overview

• Status: Recruiting
• Conditions: Decompensated Cirrhosis; Acute-On-Chronic Liver Failure; Hepatic Encephalopathy

Detailed Description

Hepatic Encephalopathy (HE) is a neuropsychiatric disorder characterized by cerebral dysregulation due to hepatic metabolic dysfunction and/or porto-systemic shunting (PSS) resulting in bypass of portal blood flow to the systemic circulation without hepatic detoxification. Hepatic Encephalopathy manifests as a broad spectrum of neurological, cognitive or psychiatric abnormalities ranging from subclinical alterations of cerebral function to coma"(1). Subtle alterations in cerebral function are only detectable by neuropsychological or neurophysiological assessment in minimal hepatic encephalopathy. Weissenborn et al., define HE as a 'significant condition of severe chronic or acute liver insufficiency that is characterized mainly by modifications of motor function, cognition, consciousness, personality. HE was traditionally differentiated into 3 categories as Type A, Type B and Type C. Acute-on-chronic liver (ACLF) has emerged as an independent clinical entity in the field of chronic liver disease which is related to high short-term mortality. The pathogenesis of HE involves blood-derived precipitating factors that cause a neurological deficit in patients with cirrhosis. A major presumption of pathogenesis of HE was assumed to be the central role of ammonia. However, there is now a paradigm shift in our understanding of the etiology, pathogenesis, evolution, and clinical correlation of HE in critically ill patients with cirrhosis and ACLF, wherein systemic inflammation, neuronal dysfunction, cerebral edema, oxidative stress and immune dysregulation are key factors in the multifactorial pathogenesis of HE.

In liver failure, changes in gut microbiota and their by-products like amino acid metabolites, ammonia, endotoxin, oxidative stress, result in neurological transmission alterations like changes in glutamine (Glx), GABA transmission and oxidative stress. Systemic inflammation causes the release of pro inflammatory cytokines such as tumor necrosis factor (TNF)-α, interleukin (IL)-1β and IL-6. They act synergistically with ammonia in developing cognitive dysfunction in patients with HE in and cirrhosis. Currently, there is evidence of the role of neuroinflammation in liver failure. Neuroinflammation is characterized by microglial activation and increased synthesis of the in situ pro-inflammatory cytokines IL-6, IL-1β and TNF-α. Additionally, there is increased gut-liver-brain axis signaling that includes effects of chemokines and cytokines, increased monocytes demand after microglial activation, and changed permeability of the blood-brain barrier(BBB).

However, the exact mechanism by which cerebral edema and HE in ACLF is caused by inflammation is not well known. Thus, identification of novel biomarkers using markers of inflammation, metabolomics, and cerebral imaging techniques to assess the severity of HE in ACLF is essential. The presence of HE is a significant negative predictor of survival in patients with ACLF; hence, studies are needed to fill the gap that is present in the monitoring and prognostication of HE in critically ill patients.

Lactulose is mainstay treatment for HE currently and acts beyond mere ammonia reduction. Lactulose therapy over three months causes a reduction in levels of serum endotoxin, arterial ammonia, inflammatory cytokines and magnetic resonance spectroscopy (MRS) abnormalities(decreased Glx and increased choline and Myo-inositol) (10). Increased cerebral ammonia causes astrocyte swelling and leads to brain edema (11) Hence, most of the drugs used in the HE treatment primarily target ammonia level reduction in the blood. The therapeutic response and progression of HE in ACLF is yet unclear.

• Study Type: Observational
• Enrollment (Anticipated): 135

Contacts and Locations

• Study Contact: Name: Dr Madhumita Premkumar, DM; Phone Number: 7087003409; Email: drmadhumitap@gmail.com

Study Locations

• India
  • Chandigarh, India, 160012
    • Recruiting
    • Postgraduate Institute of Medical Education and Research

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 65 years (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes

• Sampling Method: Probability Sample

Study Population

Experimental group (A1) n=75 Disease Control Group (A2) [ACLF without HE (n=20)], [Decompensated Cirrhosis without HE (n=20)] Healthy Control group-20

Description

Inclusion Criteria:

1 . Age 18-65 years 2. Either gender 3. Patients with ACLF (CANONIC definition) of any etiology with HE ≥grade 2 as per West-Haven Criteria

Exclusion Criteria:

1. Patients with structural brain lesions, stroke, diagnosed neurological disease or history of seizures and are on neuropsychiatric medications, like sedatives, antidepressants, or antiepileptic drugs.
2. Severe preexisting cardiopulmonary disease.
3. Patients with hepatocellular carcinoma or systemic malignancy.
4. Post liver transplant patients.
5. HIV/AIDS infection.
6. Patients who are having active COVID-19 infection.
7. Those who do not consent to participate in the study.
8. Those who have TIPS or Porto systemic surgical shunt in situ.

Study Plan

How is the study designed?

Design Details

• Observational Models: Cohort
• Time Perspectives: Prospective

Number of groups / cohorts

3

Cohorts and Interventions

Group / Cohort
Experimental; All patients with overt HE in ACLF of any etiology.
Disease Control Group; Diseased Control patients with Acute-on-Chronic Liver Failure with no Hepatic Encephalopathy; Diseased Control patients with Decompensated Cirrhosis with no Hepatic Encephalopathy
Control Group 2; Healthy Control without any liver disease

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Baseline Assessment of dynamic markers of systemic inflammation (IL-1, IL-6, TNF alpha, CD163, CD10, etc) following HE specific management strategies in ACLF.	Systemic inflammation and Immune profiling will be accessed by Flow Cytometry	Day 0
Changes in markers of systemic inflammation (IL-1, IL-6, TNF alpha, CD163, CD10, etc) following HE specific management strategies in ACLF.	Systemic inflammation and Immune profiling will be accessed by Flow Cytometry	Day 7
MR Imaging of HE in ACLF	MRI-MRS	MRI-MRS (At time of Discharge from Hospital)
Assessment of markers of neuronal dysfunction in HE in ACLF	Neuronal dysfunction markers will be assessed by ELISA for GFAP, S110B, etc	Day 0
Change in markers of neuronal dysfunction in HE in ACLF	Neuronal dysfunction markers will be assessed by ELISA for GFAP, S110B, etc	Day 7
Assessment of conventional markers of HE and clinical outcomes using standard tests like arterial ammonia, WHC and CHESS scores and severity scores of ACLF like (CLIF-C-ACLF/MELD Na).	Ammonia will be assessed by PocketChem BA Blood Ammonia meter. WHC, CHESS will be assessed for encephalopathy and severity score will be calculated using blood investigation.	Day 0
Assessment of conventional markers of HE and clinical outcomes using standard tests like arterial ammonia, WHC and CHESS scores and severity scores of ACLF like (CLIF-C-ACLF/MELD Na).	Ammonia will be assessed by PocketChem BA Blood Ammonia meter. WHC, CHESS will be assessed for encephalopathy and severity score will be calculated using blood investigation.	Day 4
Assessment of conventional markers of HE and clinical outcomes using standard tests like arterial ammonia, WHC and CHESS scores and severity scores of ACLF like (CLIF-C-ACLF/MELD Na).	Ammonia will be assessed by PocketChem BA Blood Ammonia meter. WHC, CHESS will be assessed for encephalopathy and severity score will be calculated using blood investigation.	Day 7
Baseline Metabolomics in patients with HE in ACLF	Metabolomics will be performed by LC/GC-MS to find putative metabolites associated with HE	Day 0
Change in Metabolomics following specific management strategies for HE in ACLF and standard medical management of ACLF.	Metabolomics will be performed by LC/GC-MS to find putative metabolites associated with HE	Day 7

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Predictors of HE resolution in ACLF	Predictability for outcomes of HE resolution and survival will be compared between novel biomarker and conventional tests	Day 90
New hospitalization till 90 days after enrolment.	Patient will be followed for 90 days to assess re-hospitalization and recurrence of HE	Day 90

Collaborators and Investigators

• Sponsor: Postgraduate Institute of Medical Education and Research
• Investigators: Principal Investigator: Dr Madhumita Premkumar, DM, Postgraduate Institute of Medical Education and Research

Study record dates

Study Major Dates

• Study Start (Actual): October 2, 2022
• Primary Completion (Anticipated): May 1, 2024
• Study Completion (Anticipated): May 1, 2025

Study Registration Dates

• First Submitted: May 23, 2022
• First Submitted That Met QC Criteria: June 13, 2022
• First Posted (Actual): June 16, 2022

Study Record Updates

• Last Update Posted (Actual): May 3, 2023
• Last Update Submitted That Met QC Criteria: April 28, 2023
• Last Verified: April 1, 2023

More Information

Terms related to this study

• Keywords: Acute-On-Chronic Liver Failure; Metabolomics; Hepatic Encephalopathy; Neurological Dysfunction; Immune Profiling
• Additional Relevant MeSH Terms: Digestive System Diseases; Metabolic Diseases; Central Nervous System Diseases; Nervous System Diseases; Liver Diseases; Liver Failure, Acute; Brain Diseases, Metabolic; End Stage Liver Disease; Liver Failure; Hepatic Insufficiency; Acute-On-Chronic Liver Failure; Hepatic Encephalopathy; Brain Diseases
• Other Study ID Numbers: IEC/04/2022-2356

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No