Objective To assess the severity of patients with acute-on-chronic liver failure ( ACLF) using Child-Turcotte-Pugh ( CTP) , Model for End-Stage Liver Disease ( MELD) , integrated MELD ( iMELD) , Chronic Liver Failure-Sequential Organ Failure Assessment ( CLIF-SOFA) , and Chronic Liver Failure-Consortium ACLF ( CLIF-C-ACLF) scores, and to investigate the value of these scoring systems in predicting 28-and 90-day mortality rates. Methods A total of 107 patients with ACLF who were hospitalized in Department of Gastroenterology in Xijing hospital from January 2013 to December 2017 were enrolled, and related laboratory markers on days1, 3-5, and 7-9 after diagnosis were collected. The CTP, MELD, iMELD, CLIF-SOFA, and CLIF-C-ACLF scores were calculated, and the receiver operator characteristic ( ROC) curve was used to compare the clinical value of these scoring systems. The t-test or the Satterthwaite t-test was used for comparison of normally distributed continuous data between groups, the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups. The chi-square test was used for comparison of categorical data between groups. Results Among the 107 patients, 44 ( 41. 1%) died within 28 days and 55 ( 51. 4%) died within 90 days. The scores of iMELD, CLIF-SOFA, and MELD at the time of diagnosis had an area under the ROC curve ( AUC) of 0. 81, 0. 73, and 0. 75, respectively, in predicting 28-day mortality, as well as an AUC of 0. 73, 0. 68, and 0. 70, respectively, in predicting 90-day mortality.On days 3-5 and 7-9 after diagnosis, there was no significant difference in the AUC for predicting 28-day mortality between MELD/CLIF-SOFA and iMELD ( Z = 0, 0. 15, 3. 08, and 3. 11, all P > 0. 05) , suggesting that the three scores had a similar predictive ability; on days 7-9 after diagnosis, there was no significant difference in the AUC for predicting 90-day mortality between MELD/CLIF-SOFA and iMELD ( Z = 2. 14 and 1. 98, both P > 0. 05) , suggesting that the three scores had a similar predictive ability. At the time of diagnosis and on days 3-5 and 7-9 after diagnosis, iMELD, CLIF-SOFA, and MELD scores had a significantly higher AUC than CLIF-C-ACLF and CTP scores. Conclusion The iMELD scoring system is proved to be an effective predictive system for short-term mortality in patients with ACLF, and dynamic evaluation of iMELD and CLIF-SOFA scores can effectively predict the prognosis of ACLF patients.

Objective To investigate the value of procalcitonin ( PCT) combined with Infection Probability Score ( IPS) in predicting the possibility of infection in patients with liver failure. Methods A retrospective analysis was performed for the clinical data of patients with liver failure who were admitted to The First Hospital Affiliated to Soochow University from January 2015 to June 2018. According to the clinical diagnosis, the patients were divided into infection group and non-infection group, and the two groups were compared in terms of clinical features, common laboratory markers, IPS score, and sequential organ failure assessment ( SOFA) score. The t-test and the Wilcoxon rank-sum test were used for comparison of continuous data between two groups, and the chi-square test was used for comparison of categorical data between two groups. A multivariate logistic regression analysis was performed to analyze the influencing factors for infection and establish a diagnostic model of PCT combined with IPS score. The receiver operating characteristic ( ROC) curve was used to assess the predictive efficiency of PCT combined with IPS score in infection. Results A total of 179 patients with liver failure were enrolled, among whom 123 ( 68. 72%) experienced infection. Among the 123 patients with infection, 99 ( 80. 49%) had pulmonary infection, 49 ( 39. 84%) had abdominal infection, and 40 ( 32. 52%) had infections at 2 or more sites. The multivariate logistic regression analysis showed that PCT ( odds ratio [OR]= 3. 822, 95% confidence interval [CI]: 1. 714-8. 523, P = 0. 001) and IPS score ( OR = 1. 125, 95% CI: 1. 030-1. 230, P = 0. 009) were independent predictive factors for liver failure with infection. The ROC curve analysis showed that PCT combined with IPS score had the strongest predictive efficiency in liver failure with infection with an area under the ROC curve ( AUC) of 0. 857 ( 95% CI:79. 7-90. 5) , with a significantly higher predictive efficiency than IPS alone and PCT alone ( 0. 857 vs 0. 803/0. 802, both P < 0. 05) , and PCT combined with IPS score had a positive likelihood ratio as high as 3. 40 and a negative likelihood ratio as low as 0. 28. Conclusion Both PCT and IPS score can predict infection in patients with liver failure with similar predictive efficiency, while a combination of PCT and IPS score has a better predictive value.

Objective To investigate whether response to the treatment of acute kidney injury ( AKI) is achieved at 48 hours and its effect on the 28-and 90-day prognosis of patients with hepatitis B virus-associated acute-on-chronic liver failure ( HBV-ACLF) and AKI.Methods A retrospective analysis was performed for the clinical data of 130 patients with HBV-ACLF and AKI who were hospitalized and treated in The Fifth Medical Center of Chinese PLA General Hospital from December 2012 to December 2014. According to the response to AKI treatment at 48 hours, the patients were divided into response group and non-response group, and the two groups were compared in terms of 28-and 90-day survival rates to screen out the independent influencing factors for 28-and 90-day prognosis. The t-test was used for comparison of normally distributed continuous data between two groups, and the Kolmogorov-Smirnov Z test was used for comparison of non-normally distributed continuous data between two groups. The chi-square test was used for comparison of categorical data between two groups. The Kaplan-Meier survival curve was used to analyze survival rate, and the log-rank test was used for comparison. The Cox regression model was used to perform the univariate and multivariate analyses of influencing factors for prognosis. Results There were38 patients ( 29. 2%) in the response group and 92 patients ( 70. 8%) in the non-response group. The non-response group had significantly lower 28-and 90-day survival rates than the response group ( χ2= 16. 91, 23. 28, both P < 0. 01) . The Cox regression analysis showed that response to AKI treatment at 48 hours, age, serum creatinine, serum sodium, international normalized ratio, and hepatic encephalopathy were independent risk factors for 28- ( HR ( 95% CI) = 0. 271 ( 0. 116-0. 631) , 1. 024 ( 1. 001-1. 047) , 1. 002 ( 1. 000-1. 005) , 0. 948 ( 0. 904-0. 993) , 1. 451 ( 1. 139-1. 849, 1. 987 ( 1. 076-3. 670) , all P < 0. 05) and 90-day ( HR ( 95% CI) = 0. 292 ( 0. 151-0. 563) , 1. 024 ( 1. 004-1. 044) , 1. 002 ( 1. 000-1. 004) , 0. 946 ( 0. 909-0. 984) , 1. 473 ( 1. 180-1. 839) , 2. 135 ( 1. 232-3. 700) , all P < 0. 05) mortality in patients with HBV-ACLF and AKI. Conclusion Response to AKI treatment at 48 hours can significantly improve the short-term prognosis of patients with HBV-ACLF and AKI. Early diagnosis and active treatment of AKI should be strengthened in clinical practice to improve patient prognosis.

Objective To investigate the expression of T-cell immunoglobulin and mucin domain-containing molecule 3 ( TIM-3) in natural killer T ( NKT) cells and its association with liver injury and prognosis in patients with hepatitis B virus-related acute-on-chronic liver failure ( HBV-ACLF) . Methods Peripheral blood mononuclear cells were isolated from 43 patients with HBV-ACLF and 28 patients with chronic hepatitis B ( CHB) who were treated in Beijing YouAn Hospital, Capital Medical University, from September 2016 to June 2018, and flow cytometry was used to measure the number of peripheral blood CD3+CD56+NKT cells and the expression of TIM-3.The t-test was used for comparison of normally distributed continuous data between two groups. The Kruskal-Wallis H test was used for comparision of non-normally distributed continuous data between multiple groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test was used for comparison of categorical data between groups, and the Pearson correlation coefficient was used to investigate correlation. Results Compared with the CHB group, the HBV-ACLF group had significantly higher alanine aminotransferase ( ALT) , aspartate aminotransferase ( AST) , total bilirubin ( TBil) , creatinine, international normalized ratio ( INR) , HBV DNA, TBil/ALT ratio, and Model for End-Stage Liver Disease ( MELD) score, as well as significantly lower albumin and prothrombin time activity ( PTA) ( all P < 0. 05) . Compared with the CHB group, the HBV-ACLF grouphad a significantly higher number of CD3+CD56+NKT cells ( 19. 13% ± 13. 82% vs 26. 75% ± 11. 84%, t = 2. 401, P = 0. 019) and significantly higher expression of TIM-3 in CD3+CD56+NKT cells [5. 53% ( 2. 95%-10. 2%) vs 1. 59% ( 0. 91%-2. 7%) , Z =-5. 260, P < 0. 001]. The expression of TIM-3 in CD3+CD56+NKT cells was positively correlated with ALT ( r = 0. 637, P < 0. 000 1) , AST ( r = 0. 414, P = 0. 006) , INR ( r = 0. 335, P = 0. 031) , and MELD score ( r = 0. 355, P = 0. 021) and was negatively correlated with PTA% ( r =-0. 313, P = 0. 043) . Among the 43 patients with HBV-ACLF, 12 had early-stage HBV-ACLF, 21 had middle-stage HBV-ACLF, and 10 had advanced HBV-ACLF, and there was no significant difference in the number of CD3+CD56+NKT cells between the three groups ( all P > 0. 05) , but with a tendency of increase; the patients with middle-stage or advanced HBV-ACLF had significantly higher expression of TIM-3 in CD3+CD56+NKT cells than those with early-stage HBV-ACLF [6. 5% ( 3. 16%-11. 45%) /8. 56% ( 4%-10. 93%) vs 2. 58% ( 1. 92%-6. 02%) , Z =-2. 284, -2. 641, both P < 0. 05]. Among the 43 patients with HBV-ACLF, the28-day survival group had significantly lower expression of TIM-3 in CD3+CD56+NKT cells than the 28-day liver transplantation/death group [2. 98% ( 1. 94%-6. 88%) vs 8. 56% ( 4. 27%-11. 43%) , Z =-2. 831, P = 0. 005]. Conclusion There is an increase in the expression of TIM-3 in peripheral blood CD3+CD56+NKT cells in patients with HBV-ACLF, which is associated with the degree of liver injury and prognosis.

Objective To investigate the serum level of interleukin-35 ( IL-35) and its influence on CD8+T cell function in patients with acute-on-chronic liver failure ( ACLF) . Methods A total of 28 patients with ACLF who attended Hainan Provincial People's Hospital from November 2018 to April 2019 and 14 healthy controls were enrolled in this study. ELISA was used to measure the serum level of IL-35. Peripheral CD8+T cells were separated and stimulated with recombinant human IL-35, and real-time quantitative PCR was used to measure the mRNA expression of perforin, granzyme B, and granulysin in CD8+T cells; flow cytometry was used to measure the expression of programmed death-1 ( PD-1) and cytotoxic T-lymphocyte-associated antigen 4 ( CTLA-4) in CD8+T cells. The direct-and indirect-contact co-culture systems were used for the co-culture of HLA-A2-restricted CD8+T cells and HepG2 cells, and after recombinant human IL-35 was added, the percentage of target cell death and the secretion of cytokines were measured to evaluate the changes in the cytolytic and noncytolytic activities of CD8+T cells. The two-independent-samples t test or the paired t-test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the Spearman correlation analysis was performed to investigate correlation. Results Compared with the health controls, the patients with ACLF had a significant increase in the serum level of IL-35 [72. 32 ( 54. 04-111. 30) pg/ml vs 46. 00 ( 27. 02-82. 29) pg/ml, Z = 2. 184, P = 0. 020]. CD8+T cell exhaustion was observed in ACLF patients, with the manifestations of reductions in the relative mRNA expression of perforin and granzyme B, increases in the percentages of PD-1+or CTLA-4+CD8+T cells, and reductions in the cytolytic ( induction of target cell death) and noncytolytic ( secretion of interferon-γ) functions of CD8+T cells ( all P < 0. 05) . After the stimulation with recombinant IL-35, both ACLF patients and healthy controls had significant reductions in the relative mRNA expression of perforin and granzyme B in CD8+T cells, significant increases in the percentages of PD-1+orCTLA-4+CD8+T cells, and significant reductions in the cytolytic and noncytolytic functions of CD8+T cells ( all P < 0. 05) . Conclusion Elevated IL-35 can suppress the cytolytic activity of CD8+T cells in ACLF patients, suggesting that IL-35 might induce the exhaustion of cellular immune function in ACLF patients.

Objective To investigate the expression of the leukocyte differentiation antigen CD38 and multiple myeloma oncogene 1 ( MUM-1) in liver biopsy tissue of patients with autoimmune hepatitis ( AIH) , as well as their roles in the development and progression of AIH. Methods Liver biopsy tissue samples from 46 AIH patients who were admitted to Department of Pathology in Wuxi Fifth People's Hospital from January 2017 to December 2018 were selected as experimental group, and normal liver tissue samples from 30 patients with gallbladder carcinoma who underwent radical treatment were selected as control group. Immunohistochemistry was used to measure the expression of CD38 and MUM-1, and an analysis was performed with reference to patients' clinical and pathological features. The Wilcoxon rank-sum test was used for comparison of non-normally distributed continuous data between two groups, the chi-square test was used for comparison of categorical data between groups, and a Spearman correlation analysis was also performed. Results The experimental group had significantly higher expression of CD38 and MUM-1 than the control group ( Z =-7. 181 and-7. 484, both P < 0. 001) . The AIH patients with inflammatory activity grade ≥3 and fibrosis stage 4 had significant increases in the expression of CD38 and MUM-1, with significantly higher expression than those with inflammatory activity grade < 3 and fibrosis stage < 4 ( χ2= 10. 085, 15. 769, 14. 988, and26. 966, all P < 0. 05) . The expression of CD38 and MUM-1 was positively correlated with chronic inflammatory activity grade and fibrosis stage ( r = 0. 552, 0. 876, 0. 603, and 0. 934, all P < 0. 001) , and CD38 was also positively correlated with MUM-1 ( r = 0. 932, P <0. 001) . Conclusion CD38 and MUM-1 are involved in the inflammatory activity of AIH and the process of fibrosis formation. There is a synergistic effect between them, which affects the process of liver cirrhosis. Therefore, they may become potential targets for diagnosis and treatment in future.

Objective To investigate the association of nonalcoholic fatty liver disease ( NAFLD) with vitamin D and bone mineral density.Methods A total of 180 patients with NAFLD who were hospitalized or visited the outpatient service of Zhongshan Hospital Affiliated to Dalian University from May 2018 to March 2019 were enrolled as NAFLD group, and 180 healthy individuals matched for age and sex who underwent physical examination were enrolled as control group. The two groups were compared in terms of vitamin D, bone mineral density, and biochemical markers for bone metabolism [β isomer of C-terminal telopeptide of type I collagen ( β-CTX) , type 1 procollagen amino terminal peptide ( P1 NP) , and osteocalcin ( OC) ]. The independent samples t-test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data. The chi-square test was used for comparison of categorical data between groups. A Spearman correlation analysis was performed, and a binary logistic regression analysis was used to investigate the risk factors for NAFLD. Results Compared with the control group, the NAFLD group had significantly lower levels of 25 ( OH) D [13. 06 ( 10. 73-19. 77) ng/ml vs 19. 88 ( 12. 56-22. 60) ng/ml, Z =-1. 37, P = 0. 041], L1-4 bone mineral density[0. 87 ( 0. 83-1. 05) g/cm2 vs 1. 05 ( 0. 92-1. 21) g/cm2, Z =-2. 17, P = 0. 034], bone mineral density of the femoral neck ( 0. 76 ±0. 21 g/cm2 vs 0. 84 ± 0. 51 g/cm2, t = 2. 02, P = 0. 015) , P1 NP [45. 40 ( 33. 35-58. 02) ng/ml vs 67. 39 ( 48. 09-87. 49) ng/ml, Z =-0. 83, P = 0. 044], and OC [14. 79 ( 11. 64-18. 87) ng/ml vs 17. 29 ( 15. 16-21. 04) ng/ml, Z =-2. 09, P = 0. 037], as wellas a significantly higher level of β-CTX [354. 75 ( 186. 32-526. 57) pg/ml vs 287. 67 ( 164. 10-497. 76) pg/ml, Z =-1. 04, P =0. 027]. Compared with those with alanine aminotransferase ( ALT) ≤2 × upper limit of normal ( ULN) , the NAFLD patients with ALT >2 × ULN had significantly lower levels of 25 ( OH) D ( 13. 51 ± 3. 20 ng/ml vs 18. 86 ± 3. 70 ng/ml, t = 3. 02, P = 0. 038) , L1-4 bone mineral density ( 0. 75 ± 0. 24 g/cm2 vs 1. 05 ± 0. 31 g/cm2, t = 2. 17, P = 0. 035) , and bone mineral density of the femoral neck ( 0. 71 ± 0. 18 g/cm2 vs 0. 82 ± 0. 21 g/cm2, t = 2. 25, P = 0. 042) . There were no significant differences in 25 ( OH) D, L1-4 bone mineral density, and bone mineral density of the femoral neck between the groups of patients with different degrees of fatty liver disease on CT ( all P > 0. 05) .Bone mineral density was positively correlated with high-density lipoprotein cholesterol ( r = 0. 232, P < 0. 05) and was negatively correlated with body mass index ( BMI) ( r =-0. 271, P < 0. 05) , blood glucose ( Glu) ( r =-0. 242, P < 0. 05) , ALT ( r =-0. 375, P < 0. 05) , aspartate aminotransferase ( r =-0. 312, P < 0. 05) , and low-density lipoprotein cholesterol ( r =-0. 247, P < 0. 05) . The logistic regression analysis showed that 25 ( OH) D ( odds ratio [OR] = 1. 113, 95% confidence interval [CI]: 1. 023-1. 210, P =0. 013) , BMI ( OR = 0. 676, 95% CI: 0. 522-0. 877, P = 0. 003) , and Glu ( OR = 0. 350, 95% CI: 0. 139-0. 882, P = 0. 026) were influencing factors for NAFLD. Conclusion Patients with NAFLD have significantly lower levels of vitamin D and bone mineral density than healthy individuals. An analysis of serum vitamin D and bone mineral density can further clarify the features of bone metabolism in NAFLD, and early screening of NAFLD with osteoporosis should be performed to improve the prognosis and quality of life of patients with NAFLD.

Objective To investigate the value of plasma levels of microparticles ( MPs) derived from CD14+cells and invariant natural killer T ( iNKT) cells in the diagnosis of nonalcoholic steatohepatitis ( NASH) . Methods A total of 36 patients with nonalcoholic fatty liver disease ( NAFLD) who underwent liver biopsy in Department of Gastroenterology and Department of Hepatobiliary Surgery, Sichuan Provincial People's Hospital, from March to November 2015, were enrolled, and according to the activity score of NAFLD and fibrosis stage, the patients were divided into NASH group with 22 patients and non-NASH group with 14 patients. A total of 15 individuals, matched for age and sex, who underwent physical examination were enrolled as control group. Flow cytometry was used to measure the plasma levels of MPs derived from CD14+cells and iNKT cells in all subjects. The t-test was used for comparison of normally distributed continuous data between groups; the t-test was used for comparison of non-normally distributed continuous data which became normally distributed after logarithmic transformation between groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between groups. The chi-square test was used for comparison of categorical data between two groups. An analysis of variance was used for comparison of normally distributed continuous data between multiple groups, and the least significant difference t-test was used for further comparison between two groups. The Pearson correlation analysis was used to investigate the correlation between two variables, and the receiver operating characteristic ( ROC) curve was used to evaluate the diagnostic value of MP. Results Compared with the control group, the NAFLD group had significantly higher plasma levels of MPs from CD14+cells ( 5. 92 ± 0. 62 cells/μl vs 4. 52 ± 0. 42 cells/μl, t =7. 160, P < 0. 001) and MPs from iNKT cells ( 4. 38 ± 0. 51 cells/μl vs 3. 79 ± 0. 28 cells/μl, t = 3. 966, P < 0. 001) . Compared with thenon-NASH group, the NASH group had significantly higher plasma levels of MPs from CD14+cells ( 6. 25 ± 0. 48 cells/μl vs 5. 44 ± 0. 49 cells/μl, t = 4. 773, P < 0. 001) and MPs from iNKT cells ( 4. 70 ± 0. 39 cells/μl vs 3. 96 ± 0. 26 cells/μl, t = 6. 544, P < 0. 001) . There were significant differences in the plasma levels of MPs from CD14+cells and iNKT cells between the three groups ( F = 61. 039 and42. 285, both P < 0. 05) ; the NASH group had significantly higher plasma levels of MPs than the non-NASH group and the control group, and the non-NASH group had significantly higher plasma levels of MPs than the control group ( all P < 0. 05) . The plasma levels of MPs from CD14+cells and iNKT cells were positively correlated with NAFLD activity score ( r = 0. 697 and 0. 793, both P < 0. 001) . MPs from CD14+cells had an area under the ROC curve ( AUC) of 0. 886 ( 95% confidence interval [CI]: 0. 750-1. 000, P < 0. 001) in the diagnosis of NASH, with a sensitivity of 90. 9% and a specificity of 85. 6%; MPs from iNKT cells had an AUC of 0. 935 ( 95% CI: 0. 822-1. 000, P < 0. 001) , with a sensitivity of 81. 8% and a specificity of 92. 9%. Conclusion There are increases in the plasma levels of MPs from CD14+cells and iNKT cells in patients with NASH, which are positively correlated with the degree of liver inflammation, and therefore, they can be used as potential noninvasive indices for liver inflammation.