Faecal cytokine profiling as a marker of intestinal inflammation in acutely decompensated cirrhosis

Antonio Riva; Elizabeth H Gray; Sarah Azarian; Ane Zamalloa; Mark J W McPhail; Royce P Vincent; Roger Williams; Shilpa Chokshi; Vishal C Patel; Lindsey A Edwards

doi:10.1016/j.jhepr.2020.100151

Faecal cytokine profiling as a marker of intestinal inflammation in acutely decompensated cirrhosis

JHEP Rep. 2020 Dec;2(6):100151. doi: 10.1016/j.jhepr.2020.100151. Epub 2020 Jul 30.

Authors

Antonio Riva^{1

2}, Elizabeth H Gray^{1

2}, Sarah Azarian^{1

2}, Ane Zamalloa³, Mark J W McPhail^{2

3}, Royce P Vincent^{4

5}, Roger Williams^{1

2}, Shilpa Chokshi^{1

2}, Vishal C Patel^{1

2

3}, Lindsey A Edwards^{1

2}

Affiliations

¹ Institute of Hepatology London, Foundation for Liver Research, London, UK.
² School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
³ Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK.
⁴ Department of Clinical Biochemistry, King's College Hospital NHS Foundation Trust, London, UK.
⁵ Department of Nutritional Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.

Abstract

Background & aims: Gut dysbiosis and inflammation perpetuate loss of gut barrier integrity (GBI) and pathological bacterial translocation (BT) in cirrhosis, contributing to infection risk. Little is known about gut inflammation in cirrhosis and how this differs in acute decompensation (AD). We developed a novel approach to characterise intestinal immunopathology by quantifying faecal cytokines (FCs) and GBI markers.

Methods: Faeces and plasma were obtained from patients with stable cirrhosis (SC; n = 16), AD (n = 47), and healthy controls (HCs; n = 31). A panel of 15 cytokines and GBI markers, including intestinal fatty-acid-binding protein-2 (FABP2), d-lactate, and faecal calprotectin (FCAL), were quantified by electrochemiluminescence/ELISA. Correlations between analytes and clinical metadata with univariate and multivariate analyses were performed.

Results: Faecal (F) IL-1β, interferon gamma, tumour necrosis factor alpha, IL-21, IL-17A/F, and IL-22 were significantly elevated in AD vs. SC (q <0.01). F-IL-23 was significantly elevated in AD vs. HC (p = 0.0007). FABP2/d-lactate were significantly increased in faeces in AD vs. SC and AD vs. HC (p <0.0001) and in plasma (p = 0.0004; p = 0.011). F-FABP2 correlated most strongly with disease severity (Spearman's rho: Child-Pugh 0.466; p <0.0001; model for end-stage liver disease 0.488; p <0.0001). FCAL correlated with plasma IL-21, IL-1β, and IL-17F only and none of the faecal analytes. F-cytokines and F-GBI markers were more accurate than plasma in discriminating AD from SC.

Conclusions: FC profiling represents an innovative approach to investigating the localised intestinal cytokine micro-environment in cirrhosis. These data reveal that AD is associated with a highly inflamed and permeable gut barrier. FC profiles are very different from the classical innate-like features of systemic inflammation. There is non-specific upregulation of T_H1/T_H17 effector cytokines and those known to mediate intestinal barrier damage. This prevents mucosal healing in AD and further propagates BT and systemic inflammation.

Lay summary: The gut barrier is crucial in cirrhosis in preventing infection-causing bacteria that normally live in the gut from accessing the liver and other organs via the bloodstream. Herein, we characterised gut inflammation by measuring different markers in stool samples from patients at different stages of cirrhosis and comparing this to healthy people. These markers, when compared with equivalent markers usually measured in blood, were found to be very different in pattern and absolute levels, suggesting that there is significant gut inflammation in cirrhosis related to different immune system pathways to that seen outside of the gut. This provides new insights into gut-specific immune disturbances that predispose to complications of cirrhosis, and emphasises that a better understanding of the gut-liver axis is necessary to develop better targeted therapies.

Keywords: ACLF, acute-on-chronic liver failure; AD, acute decompensation; AUROC, area under the receiver operating characteristic; BT, bacterial translocation; Bacterial translocation; CLIF-C AD, Chronic Liver Failure Consortium-acute decompensation; Chronic liver disease; Cytokines; DS, discriminant score; FABP2, fatty-acid-binding protein-2; FCAL, faecal calprotectin; FDR, false discovery rate; FL, faecal lysate; FWER, family-wise error rate; GVB, gut vascular barrier; Gut inflammation; HC, healthy control; IBD, inflammatory bowel disease; IEC, intestinal epithelial cell; Intestinal barrier function; MELD, model for end-stage liver disease; OPLS-DA, orthogonal projection to latent structures discriminant analysis; PAMP, pathogen-associated molecular pattern; PCA, principal component analysis; ROC, receiver operating characteristic; SC, stable cirrhosis; UKELD, United Kingdom model for end-stage liver disease.