Introduction
Recent research endeavors in the field of cirrhosis have indicated that bacterial translocation (BT) from the intestines plays a decisive role in advanced chronic liver disease (ACLD) [
1]. Gut-derived bacteria and their products, i.e. pathogen-associated molecular patterns (PAMPs) may subsequently induce an immune response in the liver and other organs and promote systemic inflammation, portal hypertension, and circulatory dysfunction as key pathophysiological mechanisms in cirrhosis [
1,
2].
Considering that BT requires disruption of multiple defense mechanisms [
3], experimental animal studies suggested that BT in cirrhosis is related to dysbiosis, impaired antimicrobial peptide secretion, reduced mucus thickness, and downregulation of tight junction protein expression in the intestinal epithelium [
4‐
6]. Concordantly, detection of bacterial DNA in mesenteric lymph nodes, blood and ascitic fluid of rats with cirrhosis was linked to serum levels of inflammatory cytokines [
7]. Consequently, BT promotes a proinflammatory phenotype that is (at least partially) responsible for the association between systemic inflammation and liver-related complications in ACLD [
2].
The onset of BT in cirrhosis was traditionally considered to parallel with the development of ascites, as suggested in early experimental studies [
8,
9]. Accordingly, previous studies in humans investigating the link between circulating PAMPs and systemic inflammation and circulatory dysfunction have mostly focused on patients with ascites. For example, bacterial DNA in the blood of patients with ascites correlated with markers of systemic inflammatory response (e.g., tumor necrosis factor-alpha [TNF-α]) and endothelial or circulatory dysfunction [
10]. However, other experimental and clinical studies found that bacterial antigens were already detectable in non-cirrhotic liver disease and compensated cirrhosis [
11,
12]. Therefore, the presence and impact of BT across compensated and decompensated ACLD stages remain poorly characterized, particularly in stable patients without acute decompensation.
This study aimed to assess the link between circulating PAMPs and systemic inflammation, circulatory dysfunction, portal hypertension and clinical disease stages in a large cohort of consecutively recruited patients with stable ACLD undergoing liver vein catheterization. Furthermore, we analyzed the association between BT markers and disease progression and infections during follow-up.
Patients and methods
Study design, patient selection and clinical characterization.
Patients underwent hepatic venous pressure gradient (HVPG) measurement between 01/2017 and 08/2020 at the Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria, and were prospectively recruited in the Vienna Cirrhosis Study (VICIS). Portal hypertension (PH) and, thus, presence of ACLD was defined by an HVPG ≥ 6 mmHg. Patients with liver transplantation, pre/posthepatic/non-cirrhotic PH, transjugular intrahepatic portosystemic shunt, active extrahepatic malignant diseases, hepatocellular carcinoma out-of-Milan, non-selective betablockers, bacterial infection or non-elective hospitalization were excluded, resulting in a study cohort of 249 patients with stable ACLD (Supplementary fig. S1). Clinical disease stages were determined adapted to D’Amico et al. [
13] and guidelines by the European Association for the Study of the Liver (EASL) [
14]: stages (S) were defined as subclinical PH (S0; HVPG 6–9 mmHg), clinically significant PH (CSPH; S1-2; HVPG ≥ 10 mmHg without varices or presence of varices), previous variceal bleeding (S3), one non-bleeding decompensation event (S4), and ≥ 2 decompensation events (S5). Forty sex- and age-matched healthy individuals served as a control group for assessment of bacterial antigens in the systemic circulation.
Measurement of hepatic venous pressure gradient and systemic hemodynamics
HVPG was assessed by liver vein catheterization in accordance with a standard operating procedure, as published previously [
15]. Distinct steps of the procedure are outlined in the Supplementary material. Heart rate (HR) and non-invasive systolic, diastolic, and mean arterial pressure (MAP) were measured within the same session.
Biomarker measurements
Biomarkers of BT and systemic inflammation (all patients), as well as circulatory dysfunction (i.e. renin and copeptin; available in 218 patients) were measured in serum and plasma obtained through the catheter introducer sheath during HVPG measurement. Personnel performing biomarker measurements was blinded to patient characteristics. C-reactive protein (CRP), interleukin-6 (IL-6), procalcitonin (PCT), lipopolysaccharide-binding protein (LBP), renin and copeptin levels were measured by the ISO-certified Department of Laboratory Medicine, Medical University of Vienna, following the manufacturers’ instructions. TNF-α and IL-10 were measured with commercially available ELISA kits (Human TNF-alpha and IL-10 Quantikine ELISA Kits from R&D Systems, Minneapolis, MN) with a detection limit of 6.23 pg/mL and 3.9 pg/mL, respectively, according to the manufacturer’s instructions. Lipopolysaccharide (LPS) levels were quantified using a quantitative chromogenic limulus amebocyte lysate (LAL) test (BioWhittaker, Nottingham, UK). Lipoteichoic acid (LTA) levels were assessed by Human LTA ELISA kit (Abbexa Ltd., Cambridge, UK). Bacterial DNA (bactDNA) was determined by broad-range polymerase chain reaction (PCR) of the 16S rRNA gene according to the methodology described elsewhere [
16]. The presence of bactDNA was defined by a concentration of ≥ 5 pg/mL, while LPS and LTA detection limits were set at 0.25 UE/mL and 2.5 pg/mL, respectively [
12]. Further details are outlined in the Supplementary material.
Characterization of T-cell subsets in intestinal mucosa biopsies
Biopsies from the small intestine (duodenum) were obtained in seven patients with ACLD and four liver-healthy individuals undergoing endoscopy of the upper gastrointestinal tract with a standard biopsy forceps (Boston Scientific, MA, USA). T-cell subsets in the intestinal mucosa were characterized by multi-color flow cytometry analysis. Briefly, samples were digested, dissociated, and stained for multi-color flow cytometry to identify different T-cell subsets (αβT, γδT, CD8, CD4, TH1, TH2, TH17, Treg). More detailed information on sample processing and analysis is presented in the Supplementary material.
Statistical analysis
Statistical analyses were performed using IBM SPSS Statistics 27 (IBM, Armonk, NY, USA) or GraphPad Prism 9 (GraphPad Software, La Jolla, CA, USA). Standard statistical methods were applied for descriptive statistics and comparison of categorical and continuous variables, as depicted in the Supplementary material. Correlation between continuous variables was determined by Spearman correlation coefficients (95% confidence interval). Kaplan–Meier curves with log-rank test as well as Cox proportional hazard models were used to assess determinants for the composite endpoint of first/further decompensation (incidence/worsening of ascites or hepatic encephalopathy, or development of variceal bleeding) or liver-related death, as well as the incidence of infections, at 24 months of follow-up. Patients were censored at the end of follow-up or liver transplantation. A two-sided p value < 0.05 denoted statistical significance for all analyses. Further information on statistical analyses is provided in the Supplementary material.
Compliance with ethical standards
The study was conducted in accordance with the principles of the Declaration of Helsinki and its amendments, was approved by the local ethics committee of the Medical University of Vienna (EK1262/2017) and registered at clinicaltrials.org (NCT03267615). All patients provided written informed consent for liver vein catheterization and participation in the VICIS study. Patients and liver-healthy individuals undergoing endoscopy and duodenum biopsy gave written informed consent for endoscopic procedures and participation in the VICIS study and the VICIS control group, respectively. Healthy controls for measurement of bacterial antigens were recruited from the TraffEC study that was approved by the Ethics Committee of the Hospital General Universitario de Alicante, Spain.
Discussion
The present study investigated the link between bacterial antigens in the systemic circulation and disease severity, portal hypertension, hemodynamic dysfunction, and systemic inflammation in a well-characterized cohort of 249 patients with different clinical stages of compensated and decompensated ACLD undergoing HVPG measurement. Notably, patients with acute hepatic decompensation or bacterial infections were excluded to determine the significance of circulating bacterial antigens in patients with a rather stable steady state of ACLD. The underlying hypothesis for the present study is based on the significance attributed to BT in ACLD, as it is considered to occur due to impairment of multiple intestinal defense mechanisms, thus, enabling the crossing of pathogens and PAMPs across the intestinal barrier into the portal venous system [
1,
18]. Consequently, BT may promote systemic inflammation, portal hypertension, circulatory dysfunction, and thus, directly impact on disease progression [
2,
3].
We found that bacterial antigens in the systemic circulation were markedly higher in patients with ACLD, as compared to a sex-/age-matched control group, which confirms the concept that BT is an important feature of ACLD. LPS levels in patients with ACLD were higher in the presence of bactDNA, indicating that certain PAMPs tend to occur simultaneously in the systemic circulation. The concurrent presence of different bacterial antigens was also reported by Gómez-Hurtado et al. in patients with non-alcoholic fatty liver disease (NAFLD), particularly in patients with advanced fibrosis [
12]. The absence of a correlation between LTA (primarily a component of gram-positive bacteria) and LPS as well as bactDNA may also reflect the relatively more abundant colonization of gram-negative as compared to gram-positive bacteria in cirrhosis [
19]. Interestingly, our study found that the concentrations or presence of bacterial antigens were statistically similar between patients with cACLD and dACLD (and the respective subgroups), suggesting that BT may already occur in early (compensated) stages of ACLD and exhibits no apparent dynamics across the spectrum of (d)ACLD. At the first glance, these results seem in conflict with the widely propagated concept that BT primarily occurs in dACLD [
2], as suggested by animal studies that demonstrated the occurrence of BT in cirrhotic rats with ascites [
8,
9,
20], but also earlier studies in humans that suggested an elevation of LPS levels in patients with ascites [
21‐
23]. Of note, these and other previous studies had a considerably smaller sample size [
21‐
23], and in the study by Albillos et al., the reported increase of LPS was only restricted to a subgroup of patients with ascites [
22]. In our study, patients stratified by the presence or severity of ascites displayed similar bacterial antigen levels. Concordantly, a study by Genesca et al. also reported no association between LPS levels and presence of ascites or disease severity in patients with ACLD [
24]. Similar to aforementioned studies, our study is limited by not reporting bacterial antigen levels from portal venous blood, thus, not being able to quantify hepatic clearance of PAMPs originating from BT in the intestines — which might be quite functional even in the setting of chronic liver disease [
25]. Furthermore, we acknowledge that some subgroups of clinical disease stages had relatively small sample sizes, which may relate to limitations towards the robustness of the results in certain disease stages (e.g. in S3). Nevertheless, exploratory analyses on the comparison of cACLD and dACLD patients, and after exclusion of patients on prophylactic/poorly absorbable antibiotics, displayed the same results. Therefore, our results indicate that the concept of BT being an exclusive feature of dACLD (or patients with ascites) should be revisited.
Moreover, we investigated whether bacterial antigens were associated with systemic inflammation levels in patients with ACLD. BT is considered a major factor contributing to systemic inflammation [
2], which commonly increases in patients with dACLD and holds an important prognostic value in patients with both stable and acutely decompensated ACLD [
17,
26,
27]. The detrimental pathophysiological role of BT on the induction of hepatic and systemic inflammatory processes in the setting of liver cirrhosis has been documented by numerous experimental studies in animals [
28‐
31]. LPS and the presence of bactDNA correlated significantly with the inflammatory cytokine TNF-α, which is in line with a previous study focusing on patients with ascites [
32], and displayed a weak correlation with IL-10. Surprisingly, no meaningful correlation between bacterial antigens and other inflammation markers (e.g., CRP, IL-6, …) were observed in our study. The results suggest a selective systemic inflammatory response in the presence of PAMPs, but also indicate that commonly used systemic inflammation parameters such as CRP or IL-6, that have been linked to disease severity/progression and prognosis in multiple previous studies [
17,
27,
33‐
35], do not necessarily reflect the—at least momentary—presence of BT antigens in patients with (rather stable) ACLD.
Two contributing factors help explain this. First, CRP and IL-6 are acute-phase proteins that are secreted by the liver in response to hepatic damage, independently of other inflammatory triggers such as bacterial antigens (therefore independent of them). In second place, BT episodes have been described as recurrent events during advanced chronic liver disease. A sequential study following cirrhotic patients every eight hours for three days revealed a highly dynamic clearance of bacterial DNA in blood [
16] and suggested that transversal studies may be biased by the highly flexible rate and time interval of BT episodes. Furthermore, a compensatory tolerogenic response is also mounted to balance bacterial antigen-driven inflammation [
36]. Nevertheless, we acknowledge that that our study may not capture certain confounding factors promoting BT or influencing the presence of bacterial antigens in the systemic circulation (including the use of non-/poorly absorbable antibiotics).
On the background that BT may promote portal hypertension and circulatory dysfunction in ACLD [
3], our study addressed whether bacterial antigens were linked to hepatic and systemic hemodynamics. Experimental studies have demonstrated that BT is directly linked to the development of sinusoidal endothelial dysfunction and portal hypertension [
37,
38], and also studies in humans have linked the detection of bacterial antigens or LBP to portal hypertension and systemic hemodynamic dysfunction [
22,
39,
40]. Conversely, no clinically meaningful link between bacterial antigens and HVPG, MAP, HR/MAP ratio, or soluble markers of circulatory dysfunction were observed in our study. Considering the comparatively large sample size of the present study cohort, one may speculate that bacterial antigens are simply not well-suited to represent these measures in a relatively stable patient population. Concordantly, bacterial antigens were also not indicative of disease progression, in contrast to well-established measures such as HVPG, IL-6, or MAP. Furthermore, bacterial antigens did not predict the development of infections. In this context, a plausible hypothesis would establish that in patients with stable ACLD, BT challenges are better controlled, and antigen clearance mechanisms start a moderate systemic inflammatory response that in early stages do not correlate with the loss of hepatic function. During decompensation, the recurrent systemic inflammatory response further increases due to a significantly altered gut permeability, correlating with a deranged hepatic immune clearance and the general failure of liver functional activity [
36].
Finally, we characterized T-cells in small intestinal biopsies of patients with ACLD and liver-healthy controls and found a relative abundance of CD8 T-cells (in relation to CD4 T-cells) and increased T
H1 cells. Considering previous reports on changes in gut barrier integrity in the small intestine of patients with cirrhosis [
41] and the link between TNF-α and the stimulation of T-cells [
42], our results provide novel translational evidence on changes of the immune cell profile in the intestinal mucosa that may be related to BT. Therefore, further translational studies are needed to better understand immunological changes in the gut-liver axis and their link to the microbiota composition and BT in ACLD.
In summary, our study demonstrates that BT may already occur in compensated ACLD, and seems to trigger a selective inflammatory response, independent of hepatic damage progression. In fact, BT markers were not linked to disease stages and not suited to indicate portal hypertension, systemic inflammation, or circulatory dysfunction. Future studies need to investigate the longitudinal presence and dynamics of BT in patients with ACLD.
Declarations
Conflict of interest
BeSi has received travel support from AbbVie and Gilead. DB has received travel support from AbbVie and Gilead, as well as speaker fees from AbbVie. PS received speaking honoraria from Bristol-Myers Squibb and Boehringer-Ingelheim, consulting fees from PharmaIN, and travel support from Falk and Phenex Pharmaceuticals.MP is an investigator for Bayer, BMS, Lilly, and Roche; he received speaker honoraria from Bayer, BMS, Eisai, Lilly, and MSD; he is a consultant for Bayer, BMS, Ipsen, Eisai, Lilly, MSD, and Roche; he received travel support from Bayer and BMS. MT received grant support from Albireo, Alnylam, Cymabay, Falk, Gilead, Intercept, MSD, Takeda and Ultragenyx, honoraria for consulting from Abbvie, Albireo, BiomX, Boehringer Ingelheim, Falk, Genfit, Gilead, Hightide, Intercept, Janssen, MSD, Novartis, Phenex, Pliant, Regulus and Shire, speaker fees from BMS, Falk, Gilead, Intercept MSD and Roche, as well as travel support from Abbvie, Falk, Gilead, Intercept, Jannsen and Rochet. MM served as a speaker and/or consultant and/or advisory board member for AbbVie, Bristol-Myers Squibb, Gilead, Collective Acumen, and W. L. Gore & Associates and received travel support from AbbVie, Bristol-Myers Squibb, and Gilead. TR received grant support from Abbvie, Boehringer-Ingelheim, Gilead, MSD, Philips Healthcare, Gore; speaking honoraria from Abbvie, Gilead, Gore, Intercept, Roche, MSD; consulting/advisory board fee from Abbvie, Bayer, Boehringer-Ingelheim, Gilead, Intercept, MSD, Siemens; and travel support from Abbvie, Boehringer-Ingelheim, Gilead and Roche.RF received grant support from Abbvie and Janssen and served as a speaker and/or consultant and/or advisory board member for AbbVie, Janssen, Takeda, Novartis, Adacyte and GSK. EC, RM, TN, and GS declare no conflict of interest.
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