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We read with interest the paper by Angeli et al 1 proposing the value of the acute-on-chronic liver failure (ACLF) stratification in the prediction of short-term mortality in patients with acute decompensation of cirrhosis. Other studies2 ,3 indicated that the dynamic changes in serological markers are associated with patients who have cirrhosis. We hypothesised that the pathological processes of HBV-related ACLF (HBV-ACLF) would result in specific changes in the levels of signalling proteins in the blood. Thus, we aimed to search detectable biomarkers to predict the outcome of HBV-ACLF.
We collected serum samples from 420 patients with HBV-ACLF, 121 patients with chronic hepatitis B (CHB) and 25 normal controls to identify novel serological biomarkers of HBV-ACLF (see online supplementary table S1). As an initial screening group, 15 subjects were included in the cytokine antibody array analyses (n=5 per group). The remaining 551 subjects were included in the ELISA measurement group. The enrolment criteria for the patients with HBV-ACLF corresponded to the previously published the chronic liver failure-sequential organ failure assessment (CLIF-SOFA) score.4
The bioinformatics analyses of the cytokine antibody array detection identified 15 predictive proteins that were significantly differentially expressed in patients with HBV-ACLF and CHB (table 1). Unsupervised clustering based on these predictive proteins led to a good separation of all HBV-ACLF samples from the CHB and normal samples. The ELISA-confirmed results in 279 patients with HBV-ACLF, 116 patients with CHB and 20 normal adults showed that six of these cytokines, including hepatocyte growth factor, macrophage inflammatory protein 3α (MIP-3α), carcinoembryonic antigen-related cell adhesion molecule 1, growth differentiation factor 15, E-selectin and osteopontin, were significantly increased in the HBV-ACLF subjects compared with the CHB and normal subjects (all, p<0.01).
Further analyses indicated that the MIP-3α level was significantly higher in the patients with HBV-ACLF in the deceased group compared with the survival group. Pearson's correlation coefficient analyses showed that the MIP-3α level had the most correlated relationship with the 3-month mortality rate of patients with HBV-ACLF. Logistic regression analyses showed that both the model for end-stage liver disease (MELD) score and the MIP-3α levels were significant factors in the model that combined both factors (ie, the MELD plus MIP-3α model). Analyses of area under the receiver operating characteristic curve (ROC-AUC) indicated that MIP-3α (0.73) may be useful for independently predicting mortality in patients with HBV-ACLF. Although the MELD score had the highest ROC-AUC when each indicator was assessed individually, the ROC-AUC of the MELD plus MIP-3α model increased to 0.08, indicating that the combined use of the MELD plus MIP-3α levels could improve the prediction of mortality in patients with HBV-ACLF (figure 1A, B). The ROC-AUCs of other clinical parameters (ie, HBV-DNA, total bilirubin, creatinine and international normalised ratio) showed limited contributions (all <0.7) to predicting the mortality of patients with HBV-ACLF (see online supplementary table S2).
To validate the predictive values of the MIP-3α, an additional 136 patients with HBV-ACLF were enrolled as an external validation group. An analysis of the ELISAs showed that the serum MIP-3α levels of the HBV-ACLF subjects in the external validation group were similar to those of the experimental group. The ROC-AUCs of the MIP-3α, MELD and MELD plus MIP-3α models in the validation group were 0.77, 0.76 and 0.84, respectively (figure 1C, D). These results demonstrated that the MIP-3α level was associated with the 3-month mortality rate of patients with HBV-ACLF. Immunohistochemical analyses further showed that MIP-3α was positively expressed in HBV-ACLF-derived liver tissues and absent in CHB-subject-derived and normal-subject-derived liver tissues (figure 1E).
In conclusion, this study is the first to show an association between MIP-3α and HBV-ACLF. Our results indicate that MIP-3α might be useful to predict the mortality of HBV-ACLF.
This work was supported by the Zhejiang Provincial and National Natural Science Foundation of China (LR13H030001 and 81271708), Chinese High-Tech Research and Development (863) Programme (2013AA020102), National S&T Major Project (2012ZX10004503-006 and 2012ZX10002004-001) and the Research Fund for the Doctoral Programme of Higher Education (20130101110008).
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- Data supplement 1 - Online supplement
Contributors JL and LL: conception and design of the study. JX, LJ, QZ, DS, LZ, CH and XX: acquisition of data. WD, SH and JL: analysis and interpretation of data. LL and WD: drafting of the manuscript. JL, LL, WD and SH: critical revision of the manuscript for important intellectual content. WD, SH, XC and JZ: statistical analysis. JX, LJ, QZ, DS, LZ and XX: technical or material support. JL and LL: study supervision.
Funding National S&T Major Project, Chinese High-Tech Research and Development (863) Programme, the Zhejiang Provincial and National Natural Science Foundation of China.
Competing interests None declared.
Patient consent Obtained.
Ethics approval The Clinical Research Ethics Committee of the First Affiliated Hospital, Zhejiang University School of Medicine.
Provenance and peer review Not commissioned; internally peer reviewed.
JX, WD and SH contributed equally.
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