12th Club Symposium on Portal Hypertension April, 14th–15th 2023, Banská Štiavnica

The higher risk of liver cirrhosis in Pi*MZ SERPINA1 carriers is not caused by the presence of a different precipitating mutation

S. Fraňková, Z. Rábeková, D. Varyš, M. Neřoldová, O. Fabián, M. Květoň, M. Jirsa, J. Šperl

Institute for Clinical and Experimental Medicine, Prague

The homozygous carriage of the mutated Z allele at the rs28929474 locus in the SERPINA1 alpha-1-antitrypsin (AAT) gene leads to the development of pulmonary emphysema and liver cirrhosis. Recently, it has been shown that Pi*MZ heterozygotes have an increased risk of developing liver cirrhosis if they have liver disease of other etiologies. The underlying mechanism of this risk has not yet been elucidated. The aim of our study was to test whether AAT also precipitates in hepatocytes in Pi*MZ heterozygotes and whether other variants in the SERPINA1 gene localized in the trans position contribute to the higher risk of liver cirrhosis. The cohort consisted of 1,108 patients with advanced liver cirrhosis referred for liver transplantation between 1994 and 2020. The cohort consisted of 1,021 Pi*MM homozygotes, 55 Pi*MZ heterozygotes, and 32 carriers of the Pi*MS genotype of the SERPINA1 gene. Immunohistochemical examination with polyclonal anti-AAT antibody was performed in all available liver samples; in 46 of 55 Pi*MZ heterozygotes, in 10 of 18 Pi*MM homozygotes, and in 1 of 29 Pi*MS genotype carriers, i.e. in patients in whom the histological examination of the explanted liver revealed PAS-D (Periodic Acid-Schiff Diastase) positive granules in the cytoplasm of hepatocytes. Sanger sequencing of the coding regions and adjacent non-coding regions of the SERPINA1 gene was performed in all 55 Pi*MZ heterozygotes, in 7 Pi*MM homozygotes, and in one Pi*MS genotype carrier with immunohistochemical evidence of AAT granules in hepatocytes. Sequencing of the SERPINA1 gene identified eight different single nucleotide substitutions in the study cohort. Of these eight variants, seven have already been described in the NCBI SNP database. One single nucleotide substitution c. 832 C>T was not reported in the database, and it can be assumed that it is a rare, previously undescribed variant. Six variants had the predicted missense effect on the amino acid sequence, i.e. the nucleotide change resulted in an amino acid substitution in the protein. In two cases, rs20546 and c. 832 C>T, the nucleotide substitution did not result in an amino acid substitution. The missense variant rs111850950 was described in the NCBI SNP database as having no clear clinical significance, while the remaining missense variants rs709932, rs20546, rs6647, and rs1303 – PiM3 are considered benign. The mechanism of liver damage in Pi*MZ heterozygotes is the same as in Pi*ZZ homozygotes and consists of a proteinopathic effect caused by the precipitation of variant AAT in the endoplasmic reticulum of hepatocytes. The presence of other, previously unknown SERPINA1 gene variants is not the cause of AAT precipitation in hepatocytes and a higher risk of liver cirrhosis.

Supported by Ministry of Health of the Czech Republic, grant nr. NU22-06-00103. All rights reserved.

Autonomic nervous system activity in the prediction of liver diseases

B. Mravec1, M. Szántová2

1 Institute of Physiology, Faculty of Medicine, Comenius University Bratislava

2 3^rd Department of Internal Medicine Faculty of Medicine, Comenius University Bratislava and University Hospital Bratislava

Autonomic nerves participate in the maintenance of cellular and tissue homeostasis of the liver. These nerves also play an important role during pathological conditions. In general, sympathetic nerves potentiate the development and progression of liver diseases, on the contrary, parasympathetic nerves show protective effects. Determining the level of activity of sympathetic and parasympathetic nerves can therefore make it possible to better predict the prognosis of patients with liver diseases. The level of activity of autonomic nerves can be assessed non-invasively, by determining heart rate variability (HRV) from an ECG recording, or by measuring skin conductance. Currently, determining HRV appears to be an important parameter in several somatic diseases. If the HRV parameters indicate that sympathetic activity prevails over parasympathetic activity, it is possible to adjust the disturbed autonomic balance through several methods, which can also improve the course of the given disease and the overall functioning of the organism. The introduction of HRV determination in hepatology can therefore not only provide tool for more appropriate assessment of prognosis of liver diseases, but also accelerate the introduction of methods aimed at improving autonomic balance (e. g. biofeedback, autogenic training, breathing exercises) and thereby positively influence the prognosis of the patients and quality of their life.

Improvement of liver steatosis after bariatric surgery in obese patients

O. Snížková1, F. Doleček2, M. Hájek3, H. Gottfriedová3, E. Honsová1

1 AeskuLab Pathology, Prague

2 Surgery Department, Hořovice Hospital

3 Institute for Clinical and Experimental Medicine, Prague

The prevalence of overweight and obesity has been rapidly increasing over the past few decades. Obesity is associated with a lot of comorbidities, including mental illnesses which all result in low quality of life. Bariatric surgery is often the only method to help patients with severe obesity to significantly decline the body weight. In our study, 33 patients with BMI ≥40 kg/m² and almost 40 (39 and 39.9) undergone bariatric surgery. Liver biopsy samples were obtained during the surgery. Ultrasound and magnetic resonance of liver were performed and percentage of steatosis was evaluated. The histological evaluation of steatosis much better correlates with results of the MR than of the ultrasound. Among 33 patients, in the first liver biopsy, the median of steatosis was 70% (60–80%) and all of the patients had mild liver inflammation and mild fibrosis. After one year follow-up with clinical and laboratory check-ups, 6 patients underwent second liver biopsy. During the first year, these patients lost from 45.35 to 92.45% of their excess body weight. In all 6 patients, significant decrease of steatosis was detected with the median of steatosis of 8% (0–20%). There was also mild decrease of inflammation. Mild fibrosis persisted, however, the classification of fibrosis has several weaknesses. Fibrosis is classified according to the location of occurrence, not according to the extent of impairment, which will certainly change after reduction of steatosis. Bariatric surgery proves outstanding results with severe obese patients, not only reducing their body weight. There is a positive impact on many clinical conditions such as diabetes, hypertension, low back pain and numerous others, which all together dramatically improve quality of life.

Microbiome in severe alcoholic hepatitis

K. Šoltys1, P. Olejníková2, L. Messingerová3, Ľ. Skladaný3

1 Department of Microbiology and Virology, Faculty of Natural Sciences, Comenius University in Bratislava

2 Institute of Biochemistry and Microbiology, Faculty of Chemical and Food Technology STU in Bratislava

3 Dept. Internal Med II, Div. Hepatology, Gastroenterology and Liver Transplantation, Slovak Medical University and University Hospital F. D. Roosevelt, Banská Bystrica

Background and Aims: Gastrointestinal microbiota in patients with severe alcoholic hepatitis is significantly altered due to the increase of pH in the intestinal environment, which leads to dysbiosis associated with overgrowth of bacteria in the intestine. Fecal microbiota transplantation (FMT) is the application of live microorganisms from a healthy donor to patients with intestinal dysbiosis. The introduction of fecal microbiota transplantation into the therapy of severe alcoholic hepatitis is an approach that allows to influence the change in intestinal permeability, the state of the immune system as well as the patient‘s survival. The aim of the study was to determine the effect of FMT on gut microbiota composition and its outcome. Method: Using 16S rRNA amplicon sequencing and consequent bioinformatic and biostatistical analysis, we determined the composition of the intestinal bacteriome of 40 patients with severe alcoholic hepatitis before and after the application of fecal microbiota transplantation. Results: In gut microbiome of patients, we identified an increased number of bacterial genera Enterococcus, Streptococcus, Escherichia. There was no overall change in gut microbiome composition after FMT but we found that Faecalibacterium abundance was increased in patients who survived FMT. Conclusion: Fecal microbiota transplantation does not change the gut microbiota composition of patients with severe alcoholic hepatitis but is associated with better survival of some patients.

SIRIUS screening project of liver fibrosis in Slovakia

Ľ. Skladaný1,2, D. J. Havaj1, S. Adamcová Selčanová1, J. Vnenčáková1, N. Bystrianska1, D. Žilinčanová1, K. Šulejová1, B. Škvarková1, M. Rác3, S. Dražilová2, M. Janičko2, P. Jarčuška2, T. Koller4

1 F. D. Roosevelt University Hospital in Banská Bystrica

2 Louis Pasteur University Hospital in Košice

3 Faculty Hospital in Nitra 4 Faculty of Medicine, University of Comenius, Bratislava

Liver cirrhosis represents a major cause of morbidity and mortality worldwide and a significant economic burden for the healthcare system. Slovakia ranks at the top of the prevalence of liver cirrhosis in the world, moreover, liver diseases are the leading cause of death in the age group of 25–50 years old. Chronic liver disease is characterized by a slow and asymptomatic course before cirrhosis develops. This natural history is the reason why a diagnosis is made in an irreversible advanced stage, when patients have already developed complications of portal hypertension, or liver cancer. Potential change of the current approach to early diagnosis of chronic liver disease in an early stage of liver fibrosis provides the opportunity to change the natural history of the disease, allow the application of personalized therapeutic interventions to stop disease progression and thereby reduce the morbidity and mortality associated with cirrhosis and liver cancer. This new approach is a call for the development of a screening program, especially in Slovakia regarding epidemiological data. The ongoing project SIRIUS is a population-based screening study (NCT05486767) aimed at detecting subjects with asymptomatic chronic liver disease in the general population using transient elastography, uncovering the prevalence of liver fibrosis in the Slovakian population. The parallel aim is to identify the most common risk factors (such as alcohol consumption, obesity, diabetes, ultra-processed food…) and their association with liver fibrosis. The study is localized to the community of different sociomes (metropolis, city, village, hamlet), consisting of 2,491 subjects. A team of investigators composed of physicians, nurses, patient-organization members, and volunteers travels to pre-determined sociomes to perform screening examinations of applicants – adults of any ethnicity and gender in a stable health status without previous known liver disease except steatosis. The examination includes anthropometry, questioner related to medical history, alcohol consumption, ultra-processed food consumption, and satisfaction with life scale, capillary blood sampling for basic blood tests assessment, vibration-controlled transient elastography (VCTE) to obtain liver stiffness measurements (LSM), and controlled attenuation parameter (CAP), which estimate fibrosis severity and liver fat content. A hepatologist offers all subjects with pathological findings on-site consultation and all with liver stiffness >8 kPa or steatosis >250 dB/m and pathological aminotransferase activity obtain a “green card with personal identifier serving as a passport for the subsequent hepatology examination to assess the etiology and start the intervention. In the case of exceeding the capacity of screening day, the applicant obtains an “orange card” for examination at the screening center. The journey of SIRIUS started on August 2022 and until April 2023, 2,491 subjects from 2,654 registered in 26 locations have completed the whole screening protocol. Vibration-controlled transient elastography (Fibroscan) examination uncovered liver steatosis >250 dB/m in 50% of subjects and liver fibrosis over 8kPa in 13% of subjects. According to the preliminary data from SIRIUS project the prevalence of increased liver stiffness in the Slovakian population seems to be considerably higher than in other regions of Europe, thereby the need of early detection followed by intervention is high. As well, potential self-selection bias must be excluded by continuing enrollment, until the “tsunami” of interest to be screened levels off.