Reply to: "Cirrhotic controls in a pooled analysis of hepatitis D and hepatocellular carcinoma"

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Reply to: "Cirrhotic controls in a pooled analysis of hepatitis D and hepatocellular carcinoma"

ALFAIATE, Dulce, et al.

ALFAIATE, Dulce, et al . Reply to: "Cirrhotic controls in a pooled analysis of hepatitis D and hepatocellular carcinoma". Journal of Hepatology , 2020, vol. 73, no. 6, p. 1585-1586

DOI : 10.1016/j.jhep.2020.08.012 PMID : 32933779

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http://archive-ouverte.unige.ch/unige:148296

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Reply to: “ Cirrhotic controls in a pooled analysis of hepatitis D and hepatocellular carcinoma ”

To the Editor:

We appreciate Argirionet al.'s interest on our paper. We agree that the overall odds ratio of 1.28 underestimates the real impact of HDV superinfection on oncogenesis. We would like to point out, however, that thisfigure is the consequence of including a great deal of studies of weak quality. When the data quality is assured by a robust study design–such as in prospective cohort studies–the OR is significantly increased, suggesting that HDV may indeed be a potent carcinogen.

Liver oncogenesis associated with chronic viral hepatitis is clearly a multistep process, as suggested by the fact that most hepatocellular carcinomas (HCCs) occur preferentially at late stages of infection, i.e. when advanced fibrosis/cirrhosis has set in. Indeed, cirrhosis is the most important risk factor for HCC, and this is not questioned even in the case of chronic hepatitis B, where some direct mechanisms of oncogenesis have been postulated.¹The exact molecular pathways leading to HCC in HDV infection are unknown. However, long-term follow-up studies show that most HDV-associated HCCs arise in cirrhotic livers, suggesting that cirrhosis may also be the main carcinogenic driver in these patients.^2,3 That said, the fact that HDV does not integrate into the host cell genome does not exclude its direct oncogenic potential and experimental data indeed support a potential hepatoca- rcinogenic role of HDV antigens and a specific molecular signature of HDV-associated HCC.^4,5

The demonstration of a potential specific oncogenic role of HDV in human infection is only possible using robust cohort study designs where cirrhosis is no longer a confounder. In our analysis, only 1 cohort study accounted for cirrhosis as a confounder and found a significant hazard ratio of 2.1 for HCC in HDV-infected patients, independently of cirrhosis (which, non-surprisingly, was itself found to be associated with HCC development).⁶Considering only cohort studies that enrolled patients with histologically proven cirrhosis is an alternative strategy that, although not ideal, removes this confounder.

In our meta-analysis, 3 such studies were identified (all pro- spective) with a pooled odds ratio of 2.36 (95% CI 1.34–4.14;

p= 0.04) and limited heterogeneity (I²= 21.7%),^7–9suggesting that HDV-associated oncogenesis is indeed not simply associated with cirrhosis.

In summary, while we recognize, and have discussed, that our broad inclusion criteria, considering low-quality studies, with significant heterogeneity, may underestimate the potentially higher risk of HCC in HDV-infected patients, we respectfully disagree with Argirionet al.'s suggestion that a comparison with non-cirrhotic controls would have been more informative.

A conclusive exclusion of cirrhosis as a bias will only be possible

in well-designed cohort studies that we hope will be conducted in the years to come.

Financial support

DA was funded by a grant from the Nuovo Soldati Foundation.

Conflict of interest

The authors declare no conflicts of interest that pertain to this work.

Please refer to the accompanyingICMJE disclosureforms for further details.

Authors' contributions

DA drafted the manuscript; all authors participated in the conceptualization and revision of the manuscript.

Supplementary data

Supplementary data to this article can be found online athttps://

doi.org/10.1016/j.jhep.2020.08.012.

References

[1] Levrero M, Zucman-Rossi J. Mechanisms of HBV-induced hepatocellular carcinoma. J Hepatol 2016;64:S84–S101.

[2] Buti M, Homs M, Rodriguez-Frias F, Funalleras G, Jardí R, Sauleda S, et al. Clinical outcome of acute and chronic hepatitis delta over time: a long-term follow-up study. J Viral Hepat 2011;18(6):434– 442.

[3] Romeo R, Del Ninno E, Rumi M, Russo A, Sangiovanni A, de Franchis R, et al.

A 28-year study of the course of hepatitis Delta infection: a risk factor for cirrhosis and hepatocellular carcinoma. Gastroenterology 2009;136:1629– 1638.

[4] Puigvehí M, Moctezuma-Velázquez C, Villanueva A, Llovet JM. The onco- genic role of hepatitis delta virus in hepatocellular carcinoma. JHEP Rep 2019;1:120–130.

[5] Diaz G, Engle RE, Tice A, Melis M, Montenegro S, Rodriguez-Canales J, et al. Molecular signature and mechanisms of hepatitis D virus- associated hepatocellular carcinoma. Mol Cancer Res MCR 2018;16:

1406–1419.

[6] Kushner T, Serper M, Kaplan DE. Delta hepatitis within the Veterans Affairs medical system in the United States: prevalence, risk factors, and out- comes. J Hepatol 2015;63:586–592.

[7] Brichler S, Layese R, Bourcier V, Cagnot C, Marcellin P, Guyader D, et al.

Epidemiological, clinical, biological and virological factors influencing the occurrence of hepatocellular carcinoma and validation of predictive scores in 317 HBV-related cirrhotic patients. Prospective study Cir-B nested in the ANRS CO12 CirVir cohort. Hepatology 2016;63:898A– 899A.

[8] Fattovich G, Giustina G, Christensen E, Pantalena M, Zagni I, Realdi G, et al.

Influence of hepatitis delta virus infection on morbidity and mortality in compensated cirrhosis type B. Gut 2000;46:420–426.

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Received 7 August 2020; accepted 11 August 2020; available online 12 September 2020 https://doi.org/10.1016/j.jhep.2020.08.012

Journal of Hepatology2020vol. 73^j1566–1593 1585

Dulce Alfaiate¹ Sophie Clément² Nicolas Goossens³ Francesco Negro^2,3,*

1Department of Infectious Diseases, Lyon University Hospitals, Lyon, France

2Division of Clinical Pathology, Geneva University Hospitals, Geneva, Switzerland

3Division of Gastroenterology and Hepatology, Geneva University Hospitals, Geneva, Switzerland

*Corresponding author. Address: Divisions of Gastroenterology and Hepatology and Clinical Pathology, Geneva University Hospitals, 4 Rue Gabrielle-Perret-Gentil, 1211 Geneva 14, Switzerland.

Tel.: +41 22 3729355; fax: +41 22 3729366.

E-mail address:Francesco.Negro@hcuge.ch(F. Negro)

Macrophage markers and innate immunity in cirrhosis

To the Editor:

We read with great interest the review article“Innate immune cells in cirrhosis”by Bernsmeieret al.¹We strongly agree on the important role of innate immune cells, especially monocytes and macrophages viz. Kupffer cells, in the development and progression of liver cirrhosis and complications such as acute decompensation (AD) and acute-on-chronic liver failure (ACLF).

Even though the review is very comprehensive, we think it is missing a section on macrophage biomarkers to further support the role of macrophages in cirrhosis development and progres- sion including complications.²

The most thoroughly studied biomarker is soluble (s)CD163, which originates exclusively from monocytes and macrophages;

during macrophage activation, it is shed from the cell surface by the TACE/ADAM enzyme, which also cleaves pro-TNFa^{.2 The} macrophage activation marker soluble mannose receptor (sMR), also detected on dendritic and endothelial cells, is most likely shed by proteolytic activity.²The soluble urokinase plasminogen activator receptor (suPAR) is ubiquitously expressed on immune cells, including neutrophils, lymphocytes, monocytes and macrophages, and is cleaved by proteases upon inflammation.

Other biomarkers may include cytokines and microRNAs; the latter possess diagnostic and prognostic relevance in NAFLD- relatedfibrosis.³

In recent years, sCD163, sMR and suPAR have been investi- gated in acute and chronic inflammatory liver diseases. As shown inFig. 1Aand1C, there is a stepwise increase in sCD163 and sMR levels in parallel with worsening inflammation and fibrosis in NAFLD, chronic HBV and HCV,⁴ alcohol-related liver disease, primary biliary cholangitis and Wilson Disease; the lowest levels are seen in patients with NAFLD withoutfibrosis, and the highest in cirrhosis of different etiologies. Both markers show a concentration-gradient across the liver suggesting intrahepatic excretion.⁵A few studies demonstrated increasing suPAR levels with incrementing degrees of inflammation and fibrosis in patients with NAFLD, HBV and HCV.

In patients with established cirrhosis, sCD163, sMR and suPAR significantly associate with liver disease severity,e.g. MELD and

Child-Pugh scores, as well as the degree of portal hyperten- sion^5–7(Fig. 1B–D). Importantly, sCD163, sMR and suPAR also add prognostic information in cirrhosis in terms of decompensating events and mortality.⁶

Remarkably, sCD163 and sMR levels decrease during in- terventions ameliorating liver inflammation and fibrosis as demonstrated after antiviral treatment for patients with HBV and HCV, following life-style intervention or bariatric surgery in childhood and adult patients with NAFLD, and after steroid treat- ment in patients with autoimmune hepatitis. Interestingly, sCD163 and sMR levels are unaffected by lowering portal hypertension with a transjugular intrahepatic portosystemic shunt,⁵suggesting constitutive activation of liver macrophages in cirrhosis.

The highest overall sCD163, sMR and suPAR levels are found in patients with the most severe forms of liver diseases such as acute liver failure, alcoholic hepatitis, acute autoimmune hepatitis and ACLF.^2,8In ACLF, sCD163 and sMR are independently associated with severity and prognosis; the addition of sCD163 and sMR to standard clinical scores (CLIF-C ACLF and CLIF-C AD scores) im- proves the prognostic capability.⁸ Further, in ACLF, the combination of sCD163 and urinary neutrophil gelatinase- associated lipocalin further improved mortality prediction.

Recently, sCD163 and sMR were linked to changes in metabolic pathways of mitochondrial energy production, contributing to the development of organ failure in ACLF.⁹Further, a broad panel of cytokines and chemokines, some excreted by macrophages, others potent stimulators of macrophage activation and monocyte migration, were evaluated in AD and ACLF. The highest numbers of elevated markers were found in ACLF, where the baseline cytokine and chemokine profiles among AD patients who developed ACLF were significantly elevated compared with AD patients who did not progress to ACLF.

We suggest that constitutive upregulation of liver macro- phage activation by cirrhosis and the underlying liver disease per se, as demonstrated by increased sCD163, sMR and suPAR levels, represent a vulnerable condition with a resulting exag- gerated immune response caused by any precipitating event in AD/ACLF. This may offset a chain of severe hepatic and systemic inflammation accompanied by immune exhaustion, organ hypoperfusion, further liver dysfunction and subsequently multiorgan failure as suggested by Bernsmeieret al.¹

Thus, the accumulating evidence from macrophage-specific biomarkers emphasizes the important role of the Kupffer cells

Keywords: Cirrhosis; Macrophages; Acute-on-chronic liver failure; CD163; Mannose receptor; Innate immune system.

Received 29 June 2020; received in revised form 20 July 2020; accepted 20 July 2020;

available online 29 September 2020 https://doi.org/10.1016/j.jhep.2020.07.033

1586 Journal of Hepatology2020vol. 73^j1566–1593

Letters to the Editor