Altérations des microARNs et des lymphocytes T circulants dans la décompensation aigüe de cirrhose

Introduction : La cirrhose est l’évolution terminale de la grande majorité des hépatopathies, et est caractérisée par la survenue de décompensations aiguës (DA) lors de sa progression. La survenue d’un sepsis est un évènement fréquent et grave lors de la DA, avec une mortalité de 20-30% à 1 mois. Ce risque est notamment sous-tendu par la dysfonction immunitaire associée à la cirrhose, induite par la stimulation antigénique chronique. Des données récentes suggèrent l’implication des réponses adaptatives dans cet état d’immunoparésie. Les outils diagnostiques actuels de l’infection bactérienne sont limités du fait de l’inflammation systémique liée à la cirrhose. Les microARNs (miRs) sont de petits ARNs non codant pouvant moduler la réponse immunitaire et l’interaction hôte-pathogène. Les miRs circulants ont montré un intérêt pour le diagnostic de sepsis dans la population générale mais aucune donnée n’a été rapportée chez les patients cirrhotiques. Notre objectif était de réaliser une description globale des miRs et lymphocytes T (LT) circulants chez des patients en DA de cirrhose, comparativement à des patients avec cirrhose compensée. Les enjeux cliniques sont d’identifier dans la DA de cirrhose des biomarqueurs diagnostiques du sepsis et de la dysfonction immunitaire, et pronostiques du risque d’infection secondaire et de décès. Méthodologie : Quatre-vingt-dix-sept patients ont été inclus prospectivement dans une étude monocentrique entre juillet 2019 et octobre 2021. Une cohorte externe de 13 patients a été intégrée à l’analyse des miRs circulants. Les données clinico-biologiques, les plasmas et les PBMCs ont été collectés lors de l’admission à l’hôpital et jusqu’à 6 mois après l’inclusion. Le diagnostic d’infection bactérienne a été posé selon les critères préalablement publiés. L’analyse des miRs a été réalisée par la technologie Nanostring®, permettant de détecter 800 miRs circulants. Le phénotypage des LT circulants a été réalisée par cytométrie spectrale (panel 26-couleurs). Les cytokines plasmatiques ont été dosées par l’automate ELLA (ProteinSimple®). Résultats : Au total, 67 patients en DA et 30 patients avec cirrhose stable ont été inclus. Une infection bactérienne était diagnostiquée à l’admission chez 34,3% des patients en DA. La mortalité à 6 mois était de 21,3% dans le groupe DA. Un grand nombre de miR étaient significativement dérégulés dans la DA, avec une diminution globale de leur niveau de détection. Les voies de signalisation associées à ces miRs étaient reliées notamment à la carcinogenèse, la fibrogenèse et le rythme circadien. Le phénotypage des LT a révélé une inversion du rapport entre réponses T de type 1 et 2 (rapports Th1/Th2 et Tc1/Tc2), ainsi que du rapport Th1/Treg dans la cirrhose et a fortiori dans la DA. Un score composite comprenant les polynucléaires neutrophiles (PNN), la CRP et le miR-362-3p permettait de diagnostiquer une infection bactérienne chez les patients en DA avec une AUC de 0,825 (IC 95% = 0,671-0,980; p < 0,001). Ses performances diagnostiques étaient supérieures à chacun de ses composants pris séparément. Les patients infectés présentaient également une diminution significative de leur proportion de LT Th17 circulants. La fraction de Th17 était inversement corrélée au miR-362-3p chez les patients en DA. Certaines altérations phénotypiques des LT et plusieurs miRs étaient également prédictifs du risque d’infection nosocomiale et de décès à 6 mois. Conclusion : Les miR et LT circulants sont dérégulés dans la DA de cirrhose et sont associés aux différentes évolutions cliniques. Un score composite incluant le miR-362-3p permet de diagnostiquer l’infection bactérienne avec une excellente performance et pourrait aider au diagnostic précoce d'infection bactérienne chez le patient cirrhotique en DA. Les LT et les miRs pourraient participer à l’état d’immunodéfaillance associé à la cirrhose, et nécessitent des études mécanistiques complémentaires afin de préciser leur rôle exact.Introduction: Cirrhosis is the end-stage of the vast majority of liver diseases, and is characterized by the occurrence of episodes of acute decompensation (AD) throughout its progression. Sepsis is a frequent and major event during AD, with a 1-month mortality rate of 20-30%. This risk is notably underpinned by cirrhosis-associated immune dysfunction, induced by chronic antigenic stimulation. Recent data suggest the involvement of adaptive responses in cirrhosis-related immunoparesis. Current diagnostic tools for bacterial infection are skewed by the systemic inflammation associated with cirrhosis. MicroRNAs (miRs) are small non-coding RNAs that can modulate immune responses and host-pathogen interaction. Circulating miRs have shown interest in the diagnosis of sepsis in general population but no data have been reported in cirrhotic patients. We aimed at providing a comprehensive picture of circulating miRs and T cells in AD patients, compared to patients with compensated cirrhosis. The unmet clinical needs are to identify diagnostic biomarkers of sepsis and immune dysfunction in AD of cirrhosis, and prognostic biomarkers of the risk of secondary infection and mortality. Methods: Ninety-seven patients were prospectively included in a monocenter study between July 2019 and October 2021. An outpatient cohort of 13 patients was retrospectively embedded in the analysis of circulating miRs. Clinical and biological data, plasma and PBMCs were collected at hospital admission and up to 6 months after inclusion. The diagnosis of bacterial infection was made according to previously published criteria. Analysis of miRs was performed using Nanostring® technology, allowing to detect up to 800 circulating miRs. Phenotyping of circulating T cells was conducted by spectral cytometry (26-color panel). Plasma cytokines were measured by ELLA instrument (ProteinSimple®). Results: A total of 67 patients with AD and 30 patients with compensated cirrhosis were included. Bacterial infection was diagnosed at hospital admission in 34.3% of AD patients. The 6-month mortality was 21.3% in the AD group. A large number of miRs were significantly down-regulated in AD. Signaling pathways associated with these miRs were notably related to carcinogenesis, fibrogenesis, and circadian rhythm. T cell phenotyping revealed imbalance between T cell type 1 and type 2 responses (Th1/Th2 and Tc1/Tc2 ratios) and reversal of the Th1/Treg ratio in cirrhosis and at a greater extent in AD. A composite score including neutrophil count, CRP and miR-362-3p could diagnose bacterial infection in AD with an AUC of 0.825 (95% CI = 0.671-0.980; p < 0.001). This score outperformed each of its components taken separately. In addition, proportion of Th17 population was significantly decreased in septic patients. Th17 fraction was negatively correlated with miR-362-3p in AD patients. Several phenotypic alterations of T cells and miRs were also predictive of nosocomial infection occurrence and 6-month mortality. Conclusion: Circulating miRs and T cells are deregulated in AD and are associated with different clinical outcomes. A composite score including miR-362-3p can diagnose bacterial infection with excellent performance and could improve early diagnosis of bacterial infection in AD patient. T cells and miRs may be involved in cirrhosis-associated immune dysfunction, and require further mechanistic studies to clarify their specific role

Case Report: Successful liver transplantation after achieving complete clinical remission of advanced HCC with Atezolizumab plus Bevacizumab combination therapy

Background Atezolizumab plus Bevacizumab combination therapy has recently emerged as the new standard of care for unresectable HCC. Significant tumor burden reduction can be observed under that treatment, raising the question of liver transplantation (LT). The safety of another immune checkpoint inhibitor (ICI), nivolumab, is unclear in the pre-transplant setting. Method We report the case of a 57-y old man, with initial unresectable multinodular HCC contraindicated to LT and locoregional therapies, who achieves complete tumor response after Atezolizumab/Bevacizumab, and subsequently underwent LT for liver failure. Results Explant analysis revealed complete pathological response with no tumor remnant. The patient suffered from several post-operative complications but no HCC recurrence or biopsy-proven acute rejection occurred 10 months after LT. Conclusions Atezolizumab/Bevacizumab therapy may enable complete pathological response of advanced HCC. Safety of prolonged treatment need to be assessed

Heparanase-1 is upregulated by hepatitis C virus and favors its replication

International audienceBackground & Aims: Over time, chronic HCV infection can lead to hepatocellular carcinoma (HCC), a process that involves changes to the liver extracellular matrix (ECM). However, the exact mechanisms by which HCV induces HCC remain unclear. Therefore, we sought to investigate the impact of HCV on the liver ECM, with a focus on heparanase-1 (HPSE).Methods: HPSE expression was assessed by quantitative reverse-transcription PCR, immunoblotting and immunofluorescence in liver biopsies infected or not with HCV, and in 10-day-infected hepatoma Huh7.5 cells. Cell lines deficient for or overexpressing HPSE were established to study its role during infection.Results: HCV propagation led to significant HPSE induction, in vivo and in vitro. HPSE enhanced infection when exogenously expressed or supplemented as a recombinant protein. Conversely, when HPSE expression was downregulated or its activity blocked, HCV infection dropped, suggesting a role of HPSE in the HCV life cycle. We further studied the underlying mechanisms of such observations and found that HPSE favored HCV release by enhancing CD63 synthesis and exosome secretion, but not by stimulating HCV entry or genome replication. We also showed that virus-induced oxidative stress was involved in HPSE induction, most likely through NF-κB activation.Conclusions: We report for the first time that HCV infection is favored by HPSE, and upregulates HPSE expression and secretion, which may result in pathogenic alterations of the ECM.Lay summary: Chronic hepatitis C virus (HCV) infection can lead to hepatocellular carcinoma development in a process that involves derangement of the extracellular matrix (ECM). Herein, we show that heparanase-1, a protein involved in ECM degradation and remodeling, favors HCV infection and is upregulated by HCV infection; this upregulation may result in pathogenic alterations of the ECM

Evaluation of the HBV liver reservoir with fine needle aspirates

Background &amp; Aims: Finite duration of treatment associated with HBsAg loss is the current goal for improved therapeutic approaches against chronic HBV infection, as it indicates elimination or durable inactivation of intrahepatic covalently closed circular DNA (cccDNA). To assist drug development, the definition of early predictive markers of HBsAg loss by assessing their value in reflecting intrahepatic cccDNA levels and transcriptional activity is essential. Fine needle aspirates (FNAs) have recently emerged as a less invasive alternative to core liver biopsy (CLB) and showed to be useful for investigating intrahepatic immune responses. The aim of this study was to optimise and validate the use of FNA vs. CLB to evaluate the intrahepatic viral reservoir. Methods: Paired FNA/CLB samples were obtained from patients with HBeAg+ chronic hepatitis (n = 4), HBeAg− chronic hepatitis (n = 4), and HBeAg− chronic infection (n = 1). One HBeAg+ patient was undergoing tenofovir treatment. HBV 3.5-kb RNA and cccDNA were quantified by droplet digital PCR. Results: cccDNA was quantifiable in all but one FNA/CLB pair, showing the highest levels in untreated HBeAg+ patients, except for the tenofovir-treated patient. Similarly, 3.5-kb RNA was detectable in all but one FNA sample and showed higher levels in HBeAg+ patients. When comparing cccDNA and 3.5-kb RNA quantification in FNA vs. CLB samples, no statistically significant differences were identified. Conclusions: These results demonstrate the possibility to quantify cccDNA and assess its transcriptional activity in patients with chronic hepatitis B by combining FNA and droplet digital PCR. This supports the use of FNA in clinical trials to evaluate the intrahepatic viral reservoir during the development of new antivirals and immunomodulatory agents. Impact and implications: Chronic hepatitis B infection is characterised by a complex interplay between immune responses and viral replication in the liver, which determines the long-term outcome of the disease. In this study, we show that fine needle aspiration of the liver, a less-invasive alternative to core biopsies, allows the assessment of the hepatic viral reservoir

Circulating microRNAs improve bacterial infection diagnosis and overall survival prediction in acute decompensation of liver cirrhosis

Summary: Bacterial infections are the most frequent precipitating event in patients with acute decompensation of cirrhosis (AD) and are associated with high mortality. Early diagnosis is challenging due to cirrhosis-related systemic inflammation. Here we investigated the potential of circulating microRNAs to diagnose bacterial infections and predict survival in cirrhotic patients with AD. High throughput profiling of circulating microRNAs was performed using the Nanostring technology in 57 AD patients and 24 patients with compensated cirrhosis (CC). Circulating miRs profiling showed that: (a) miRs differentially detected in AD vs. CC were mostly down-regulated; (b) a composite score including absolute neutrophil count, C reactive protein and miR-362-3p could diagnose bacterial infection with an excellent performance (AUC of 0.825 [95% CI = 0.671–0.980; p < 0.001]); (c) a composite score including miR-382-5p, miR-592 and MELD-Na improved 6-month survival prediction. Circulating miRs are strongly dysregulated in patients with AD and may help to improve bacterial infection diagnosis and survival prediction

Long term results of liver transplantation for alpha-1 antitrypsin deficiency

International audienceIntroduction: Liver transplantation (LT) is the therapeutic option for end-stage liver disease associated with alpha1 antitrypsin (A1AT) deficiency. The aim of the present retrospective study was to report on long-term outcomes following LT for A1AT deficiency.Methods: The medical records of 90 pediatric and adult patients transplanted between 1982 and 2017 in France and Geneva (Switzerland) were reviewed.Results: The study population consisted of 32 adults and 58 children; median age at transplant was 13.0 years (range: 0.2-65.1), and 65 were male (72.2%). Eighty-two patients (94.8% of children and 84.4% of adults) had the PI*ZZ genotype/phenotype and eight patients (8.9%) had the Pi*SZ genotype/phenotype. Eighty-four patients (93.3%) were transplanted for end-stage liver disease and six (all Pi*ZZ adults) for HCC. Median follow-up after LT was 13.6 years (0.1-31.7). The overall cumulative patient survival rates post-transplant were 97.8% at 1 year, and 95.5%, 95.5%, 92.0%, 89.1% at 5, 10, 15, 20 years respectively. The overall cumulative graft survival rates were 92.2% at 1 year, and 89.9%, 89.9%, 84.4%, 81.5% at 5, 10, 15 and 20 years, respectively.Conclusions: In a representative cohort of patients having presented with end-stage-liver disease or HCC secondary to A1AT, liver transplantation offered very good patient and graft survival rates

Liver transplantation for autoimmune hepatitis: Pre‐transplant does not predict the early post‐transplant outcome

Background and aims: Autoimmune hepatitis (AIH) is a rare indication (<5%) for liver transplantation (LT). The aim of this study was to describe the early outcome after LT for AIH.Methods: A multicenter retrospective nationwide study including all patients aged ≥16 transplanted for AIH in France was conducted. Occurrences of biliary and vascular complications, rejection, sepsis, retransplantation and death were collected during the first year after LT.Results: A total of 344 patients (78.8% of women, 17.0% of (sub)fulminant hepatitis and 19.2% of chronic liver diseases transplanted in the context of acute-on-chronic liver failure [ACLF]) were included, with a median age at LT of 43.6 years. Acute rejection, sepsis, biliary and vascular complications occurred in respectively 23.5%, 44.2%, 25.3% and 17.4% of patients during the first year after LT. One-year graft and patient survivals were 84.3% and 88.0% respectively. The main cause of early death was sepsis. Pre-LT immunosuppression was not associated with an increased risk for early infections or surgical complications. Significant risk factors for septic events were LT in the context of (sub)fulminant hepatitis or ACLF, acute kidney injury at the time of LT (AKI) and occurrence of biliary complications after LT. AKI was the only independent factor associated with graft (HR = 2.5; 95% CI: 1.1-5.4; p = .02) and patient survivals (HR = 2.6; 95% CI: 1.0-6.5; p = .04).Conclusion: Early prognosis is good after LT for AIH and is not impacted by pre-LT immunosuppression but by the presence of AKI at the time of LT

Long‐term outcome of liver transplantation for autoimmune hepatitis: A French nationwide study over 30 years

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