Supplemental Digital Content is available in the text The artificial liver support system (ALSS) offers the potential to improve the prognosis of patients with acute-on-chronic liver failure (ACLF). However, the literature has been inconsistent on its survival benefits. We aimed to conduct a time series-based meta-analysis of randomized clinical trials (RCTs) and observational studies which examined differences in mortality in ACLF patients treated with ALSS or not.MEDLINE, EMBASE, OVID, and COCHRANE library database were systemically searched up to December 2014. Quality of included studies was evaluated using the Jadad score. The outcome measure was mortality at different follow-up endpoints. Odds ratios (ORs) and survival curve data were pooled for analysis.Ten studies, 7 RCTs, and 3 controlled cohorts were enrolled, involving a total of 1682 ACLF patients, among whom 842 were treated with ALSS. ALSS was found to reduce the risk of short-term (1-month and 3-month) mortality for patients with ACLF by nearly 30%. Randomized trials and observational studies provided good internal and external validity respectively. The combined Kaplan–Meier curves showed a consistent pattern of findings. Meta-analysis also suggested that ALSS might reduce medium-term (6-month and 1-year) mortality risk by 30% and long-term (3-year) mortality risk by 50% in ACLF patients.ALSS therapy could reduce short-term mortality in patients with ACLF. Meanwhile, its impacts on medium- and long-term survival seem to be promising but remained inconclusive. Clinical utility of this system for survival benefit may be implied. Liver transplantation (LT) represents an adequate treatment, but remains limited due to organ scarcity. Hence, there is an unmet medical need for new therapeutic options.Acute-on-chronic failure (ACLF), defined as an acute deterioration of known or unknown chronic liver disease, is a serious medical ailment, and its incidence is increasing with the high prevalence of alcoholic liver disease (ALD), nonalcoholic fatty liver disease (NAFLD), hepatitis C virus (HCV) infection in developed countries, and hepatitis B virus (HBV) infection in China.4 and hepatorenal syndrome (HRS),5 studies on survival outcomes are controversial. Positive association of ALSS with short-term or long-term survival was suggested by several studies.7 In the meantime, inconclusive evidence, such as negative association, no association, or positive but not significant association, was suggested by other studies.8 Moreover, previous meta-analyses have revealed less consistent results.13 The seemingly conflicting findings may result from quite a few factors such as variable follow-up periods, variable ALSS methods, and variation across the populations. Thus, it is imperative to perform a more comprehensive and systematic meta-analysis to re-evaluate the effects of ALSS on the survival outcomes of patients with ACLF.The artificial liver support system (ALSS) was first applied to treat acute liver failure in 1970s with the attempt to replace the detoxification functions of the liver. Later, several methods have been added to the ALSS inventory. Plasma exchange (PE) represents a complete detoxification but is mainly limited by increased risk of allergies and infections due to exposure to exogenous plasma. Albumin dialysis allows the removal of albumin-bound toxins and soluble toxins, with external albumin in MARS (molecular adsorbent recirculating system) or the patient's own albumin in FPSA . Although some clinical trials have demonstrated the beneficial effects of ALSS on HEhttp://getdata-graph-digitizer.com/), the digitization and extraction of the data have become possible.14 Thus, using GetData software, we could extract data at specific time points and bring the observation periods into accord.Quantitative meta-analysis which combines information from the same endpoint results may be a rational approach to estimate an overall effect and to investigate sources of heterogeneity. However, some articles showed survival data indirectly with Kaplan–Meier curves and did not provide detailed data for each endpoint. With the development of software GetData Graph Digitizer 2.24  using the following terms:  and . All data of this study were from previous published studies; thus no ethical approval and patient consent are required.Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to conduct the present meta-analysis.Randomized clinical trials (RCTs) or observational studies involved patients with objective diagnosis of ACLF.Interventions (treatment groups) included ALSS, whereas the comparison interventions (control groups) adopted standard medical therapy (SMT).The survival outcome data provided in articles was sufficient and had a critical endpoint, follow-up period ≥ 28 days.Published in English.Two coauthors (X-LW and BW) screened the title and abstracts of retrieved citations. Full texts of those citations were assessed according to the following inclusion criteria:The data from the included articles were extracted independently by 2 coauthors (XLW and YS). Disagreements were resolved through discussion or consultation with a third author (GQ or LJW). The following characteristics were collected in each study: first author, year of publication, country of origin, study design, recruitment period, duration of follow-up, number of research centers, definition of ACLF, the sample size of each group, demographic and clinical information of the participants, the incidence of adverse events, characteristics of the ALSS used . Serious adverse events (SAEs) were defined by the level of intervention as registered in each study. If the articles showed survival data indirectly with Kaplan–Meier curves, the GetData Graph Digitizer was applied to digitize and extract the time-specific data.16 The outcome measure was mortality at different follow-up endpoints. Short-, medium-, and long-term mortality measurements were assessed from reported follow-up periods of 1 to 3 months, 6 months to 1 year, and 3 to 5 years, respectively.The quality of citation was assessed according to the Jadad score.I2 test. An I2 value of >50% was considered substantial heterogeneity and the random-effect model was conducted; otherwise, the fixed-effect model was used. Publication bias was evaluated with the rank correlation test (Begg's test), the regression asymmetry test (Egger's test), and the funnel plots visually.17 Meta-regression was performed to investigate the sources of heterogeneity in the included studies. Subgroup analysis was performed according to the study design (randomized or nonrandomized studies). Moreover, a sensitivity analysis was performed using a 1-study-removed analysis. Kaplan–Meier estimates of survival data (where estimable) comparing ALSS with control groups were analyzed using an unadjusted log-rank test. For categorical variables, data were analyzed using the χ2 and Fisher's exact tests as appropriate.The odds ratio (OR) with 95% confidence intervals (95% CI) were calculated for dichotomous outcomes. Heterogeneity across studies was assessed with the Cochrane Q statistics the P value ≤ 0.05.All analyses were performed with Stata version 13.0 . Statistically significant findings were defined as those with a Figure 18 2 were prospective controlled cohorts,20 and 1 was retrospective controlled cohort.21 Five studies were multicenter studies.18 These studies involved a total of 1682 ACLF patients, among whom 842 were treated with ALSS.Among the 10 included studies, 7 were RCTs,Countries involved in these studies were Germany, China, USA, Spain, UK, Belgium, Italy, Austria, Croatia, Denmark, France, Belgium, and Switzerland. The follow-up periods ranged from 28 days to 5 years. Table 20 which was defined as reappearance or increase of serum HBV DNA levels .22 Other studies recruited patients with varied etiology including HCV infection, alcoholic-related, drug-induced, or autoimmune liver diseases (Table s1).The definitions of ACLF differed among the studies and were mainly based on the relevant guidelines from Asian Pacific Association for the Study of the Liver (APASL), European Association for the Study of the Liver (EASL), American Association for the Study of Liver Diseases (AASLD), or Chinese Society of Hepatology. The disease etiology of most patients was alcohol ingestion or viral hepatitis. Two studies enrolled patients with ACLF caused solely by HBV reactivation,Table s2. showed the inclusion and exclusion criteria of each study. Many aspects of these criteria were in agreement with each other. Only adult  patients were recruited in these studies. Hepatobiliary obstruction, severe acute hemorrhages, malignancies (hepatic/extrahepatic), severe comorbid conditions such as cardiopulmonary diseases, chronic renal insufficiency or diabetes mellitus, and pregnancy were listed in the exclusion criteria in most of the studies.21 6 studies adopted MARS,19 1 study adopted FPSA.8 In some studies, none of the patients were eligible for liver transplant,5 or liver transplant was one of the exclusion criteria.19 In other studies, number of transplant patients were similar between study arms,18 except for 1 study.21 Two studies did not report the information on liver transplant.20Treatment characteristics in the included studies were shown in Table s3. All the studies used ALSS in their intervention arm with some variation. Concerning the therapeutic strategy in the treatment group, 3 studies adopted PE,21 There were 335 (42.35%) and 432 (50.70%) deaths during first 1 month in ALSS groups and control groups, respectively. The mortality was significant lower in ALSS groups  ; and the same result was obtained from 3 nonrandomized studies .Nine studies reported 1-month mortality of ACLF patients and involved 791 patients in ALSS groups and 852 in the control groups.19 The raw data were either obtained from texts18 or extracted by digitizing graphs using the GetData software.19 The pooled Kaplan–Meier curve showed that the overall survival rate in ALSS groups was higher than that in the control groups (Log-rank test P = 0.03)  Figure B.21 382 (52.54%) and 475 (60.51%) died during the first 3 months in ALSS groups and the control groups respectively. Patients in ALSS groups had significantly lower risk of 3-month mortality . In the subgroup analysis, the association of ALSS with 3-month mortality reduction remained significant both in randomized trials  and in nonrandomized studies   . However, in the subgroup analysis, the association of reduced 180-day mortality in the ALSS group remained significant in nonrandomized studies  whereas no significant in randomized trials  . With the subgroup analysis, 2 nonrandomized studies suggested that the association for reduction mortality in the ALSS group compared with the SMT group remained significant in , whereas only 1 randomized trial reported an insignificant association   Figure B.19 The meta-analysis showed significant reductions in the mortality following ALSS therapy  .Only 1 study reported 5-year survival rates, comparing ALSS with the control.7 Other adverse events were summarized in Table s4.Adverse events were reported inconsistently in the included studies. The incidence of 5 serious adverse events  were reported by at least 2 trials and thus pooled for analysis. The results showed little significant difference between ALSS groups and control groups . Meanwhile, the higher incidence of catheter-related events and skin rash in ALSS-treated patients was reported by Hassanein et al and Qin et al respectively.P > 0.05). According to our meta-regression analysis, difference concerning ALSS methods seems less important as previously acknowledged.23We used meta-regression analysis to investigate possible sources of heterogeneity among the included studies . The results indicated that none of the 6 factors  explained the heterogeneity .P < 0.05 in Begg's test and Egger's test, respectively (data not shown). Figure s4, showed the funnel plots.We evaluated publication bias for the pooled ORs and CIs with Begg's and Egger's tests. The publication bias was 2 Given the unique roles that the liver plays, the functions that artificial liver support devices should perform include: removal of toxins (such as ammonia and aromatic amino acids), replenishment of plasma proteins , and reversal of the massive inflammatory process initiated from the necrotic liver. Although the current liver support devices do not allow correction of all metabolic disturbances in liver failure, controversies have been focused on the role of ALSS whether as a bridge to liver transplantation (may be dead end street if LT not available) or a bridge to recovery (independent pathfinder). In the present study, we have tried to answer the crucial question about the real impact of these devices on patient survival.Acute-on-chronic liver failure is a serious medical ailment and associated with high mortality. Artificial liver support systems have been applied in patients with ACLF for nearly 2 decades. It has no justification to compare ALSS with the artificial renal support system (ARSS). Renal failure (RF) is resulted from intense reduction in the glomerular filtration rate (GFR) and the retaining water-soluble substances can be easily removed with current ARSS technology. In contrast, ACLF is a much more complex syndrome.24 However, data concerning the treatment variables were quite limited in the included studies. Although our results concerning the long-term effects of ALSS seem to be promising, the conclusion is inclusive. Our study highlights the need for more randomized trials for detailed analyses in the future before ALSS could be recommended as “a bridge to recovery” for routine practice.This review of 7 randomized trials and 3 nonrandomized studies compared the effect of artificial liver support system with standard medical therapy for acute-on-chronic liver failure. The meta-analysis found that ALSS reduced the risk of short-term (1-month and 3-month) mortality for patients with ACLF by nearly 30%. Randomized trials and observational studies provided good internal and external validity respectively. The combined Kaplan–Meier curves showed a consistent pattern of findings. In 2 randomized trials, ALSS was found to reduce medium-term (6-month and 1-year) mortality by 30% and long-term (3-year) mortality by 50% in ACLF patients. Actually, the prognosis of ACLF patients may be altered by treatment options other than ALSS. For instance, treatment with nonselective β blockers (NSBBs) may be another factor which might affect the outcome of patients with ACLF.It should be noted that the primary endpoints of most included studies were defined as liver transplant-free survival within certain periods. Although liver transplant was not one of the exclusion criteria, the number of transplant patients was comparable between study arms in most studies. Therefore, the effect of ALSS may not be counterbalanced by the treatment of transplant.13 but contrast with 2 other meta-analyses.12 It should be noted that our study differed from previous reviews in several aspects. First, due to the stringent selection criteria, some trials which had been included in other meta-analysis were excluded.26 Second, bio-artificial systems,29 due to their greater complexities, were not included here. Third, latest trial reports were replenished in this study. Two interim reports 31 in previous reviews were replaced by the final reports of these trials.18 The largest trial to date of ALSS use in ACLF were added for analysis.7 Last but not least, unlike the analysis with mortality rates from different time points in previous studies,13 we made point-to-point comparison of survival data with the help of Getdata software.Results from our meta-analysis are in consistence with 3 earlier meta-analyses,ALSS may be associated with a few serious and nonserious adverse events. However, in serious ailments such as ACLF, it may be difficult to establish the correlation between unwanted events and an intervention. Our analysis revealed no significant increase in risk of bleeding, hypotension, infection, coagulopathy, and respiratory failure. Adverse events were reported inconsistently, these results should be interpreted with caution. Additional studies addressing the safety issues in larger population are required before the definitive conclusions could be drawn.6 and may produce false negative or false-positive conclusions due to random error. Fortunately, the remaining 5 trials had adequate sample sizes and described their calculation methods.18 Second, due to the limited number of RCTs, a few nonrandomized studies were included for analysis. The selection bias and confounding were inevitable in these studies. However, it has been argued that observational studies may have better external validity as patients who are willing to enter a randomized trial differ from those who are not.32 Finally, analysis according to disease definition or etiology could not be conducted here. Instead, meta-regression analysis with countries, which may be associated with disease definition and etiology, did not show significant heterogeneity.Admittedly, our study has several limitations. First, the sample sizes of 2 individual trials were small In conclusion, this time series based meta-analysis demonstrated that ALSS therapy reduced short-term mortality in patients with ACLF. Meanwhile, its impacts on medium- and long-term survival seem to be promising but remained inconclusive. Besides, ALSS did not appear to increase the risks of main serious adverse events. Clinical utility of the device for survival benefit may be implied.


The extended spectrum ß-lactamases (ESBL) are enzymes that produce resistance to ß-lactam antibiotics, including penicillins, wide spectrum cephalosporins and aztreonam, by cleavage of ß-lactam ring . Since ESBL-producing bacteria are frequently associated with nosocomial infections, treatment options are becoming increasingly limited . In this context, the discovery of compounds which can inhibit the growth of micro-organisms which produce these enzymes becomes increasingly important.trans-cinnamaldehyde by microdilution technique and also determined its minimum bactericidal concentration (MBC) on nosocomial enteric bacilli ß-lactamases producers. We analyzed 45 bacterial species, 36 to the Enterobacteriaceae family and nine of the other species of Gram-negative bacteria. The most prevalent species ESBL-producing was Klebsiella pneumoniaessp. pneumoniae (70% of isolates of this specie). The detection of ESBL was performed by phenotypic testing .In this study were evaluated the antimicrobial activity of trans-cinnamaldehyde showed antibacterial activity and promote inhibition of growth for all planktonic microorganisms ESBL positive tested, with MIC ranging between 0.95 mM and 1.90 mM. Bactericidal activity was detected at a concentration of 1.90 mM, regardless of the species analyzed in this study. Our results suggest that trans-cinnamaldehyde is a compound with potential antimicrobial against ESBL-producing bacteria and can be employed both in preventing infection through their application in solutions used in the processes of disinfection of hospital instruments and equipment but also in drug development for topical action.The


Conflicting data have been reported on the clinical significance of contrast-induced nephropathy after CT scan (CT-CIN). In addition, the epidemiologic characteristics and clinical outcomes of CT-CIN following proper prophylactic intervention remain elusive.2 using an electronic health record-based pop-up alert system and provided an identical protocol of CIN prophylaxis to all patients.We examined the incidence, risk factors, and outcomes of CT-CIN in stable chronic kidney disease (CKD) patients using data collected from our outpatient CT-CIN prophylaxis program conducted between 2007 and 2014. The program recruited patients with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. To assess the outcomes of CT-CIN, patients with and without CT-CIN were compared after propensity score-based 1:2 matching. CT-CIN did not increase the mortality rate of patients. However, patients with CT-CIN were significantly more likely to start dialysis within 6 months of follow-up, but not after those initial 6 months.A total of 1666 subjects were included in this study, and 61 of the 1666 subjects (3.7%) developed CT-CIN. Multivariate analysis showed that baseline eGFR, diabetes mellitus, and low serum albumin were significant risk factors for CT-CIN. The generalized additive model analysis revealed a nonlinear relationship between the baseline eGFR and the risk of CT-CIN. In this analysis, the risk of CT-CIN began to increase below an eGFR threshold of 36.8 mL/min/1.73 mCT-CIN developed in only a small number of stable CKD patients who received proper prophylactic intervention, and the risk of CT-CIN was increased in patients with more advanced CKD. Despite the low incidence, CT-CIN conferred a non-negligible risk for the initiation of dialysis in the acute period, even after prophylaxis. First, the studies that understated the clinical significance of CT-CIN did not address CIN prophylaxis, which may have been performed in the contrast-enhanced CT group; 14 thus, the true incidence of CT-CIN after proper prophylaxis needs further study. Second, several previous studies were suspected to overestimate the outcome of CT-CIN because most of the enrolled patients were already hospitalized and had multiple confounding medical conditions.16 Third, there have been no data reported concerning patient-oriented outcomes following prophylactic management for CT-CIN. Indeed, most of the studies that examined patient-oriented outcomes did not consider whether or how the patients received prophylactic intervention, as stated above.16 In addition, the risk factors for CT-CIN after proper prophylactic intervention remain elusive. In particular, the threshold value for baseline renal function that is associated with an increased incidence of CT-CIN after CIN prophylaxis has not been well established. In this study, we analyzed data from our outpatient CIN prophylaxis program,4 which used a standardized protocol of 0.9% saline infusion and N-acetylcysteine, to assess the incidence, risk factors, threshold renal function, and patient-oriented outcomes of CT-CIN in stable patients with CKD.Because many previous studies examining the risk factors and prognosis of CIN involved contrast agents administered via an arterial route, there has been skepticism about whether those results can be extrapolated to the intravenous contrast agents used in computed tomography (CT). Owing to the lower volume of CT contrast agents and their dilution before reaching the kidneys, some researchers have assumed that CT scans are safer than procedures involving intra-arterial infusion.This study was approved by institutional review board by Seoul National University Hospital (1503–042–654). This study was conducted in accordance with the principles of the Declaration of Helsinki. As the study was retrospective study without medical intervention, informed consent was waived for electrical health record (EHR) review.4 Patients with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 who were scheduled for outpatient contrast-enhanced CT scans were enrolled in the program using an EHR-based alert system and received a standardized CIN prophylactic intervention. In the program, patients visited the daycare center and had a blood sample drawn if no baseline serum creatinine (sCr) level was available within the previous 2 weeks. Patients were referred to the emergency department if any other acute medical condition was identified by the attending physician. For CIN prophylaxis, 1 L of 0.9% saline was administered to the patient; the patient received 0.5 L for 3 hours before the CT scan and an additional 0.5 L for 3 hours after the examination. Additionally, oral N-acetylcysteine 300 mg was given 2 times a day for 2 days, starting on the day of CT. A follow-up blood sample that included sCr analysis was performed 48 to 96 hours after the CT scan.Seoul National University Hospital began an outpatient CIN prophylaxis program in January 2007.2. The following patients were excluded from the study: patients who had a history of renal replacement therapy (RRT) before the CT scan; patients who did not have a follow-up sCr analysis performed 48 to 96 hours after the CT scan; patients who were exposed to another contrast agent within 1 month; patients who were admitted to an emergency room or other ward because of a cause other than CIN before follow-up measurement of sCr. In cases with repeated CT scans in a single patient, we included only the most recent study.14The inclusion criteria were age 18 years or above, performance of an outpatient contrast-enhanced CT scans with prophylactic intervention, and an eGFR <60 mL/min/1.73 m17 hemoglobin level, serum albumin level, contrast agent type, volume and iodine dosage used, histories of diabetes mellitus, hypertension, congestive heart failure requiring hospitalization, cancer, and liver cirrhosis, and previous use of statins, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs).We collected the following demographic, laboratory, and clinical information from the EHR review: age, sex, weight, height, body mass index (BMI), baseline and follow-up sCr and eGFR values calculated using the Modification of Diet in Renal Disease (MDRD) equation,3 The secondary outcomes were the patient-oriented outcomes of death and the initiation of RRT. The follow-up period was measured beginning on the day of the CT scan and continued until the study ended, the patient died or the patient was lost to follow-up.The primary outcome was the development of CT-CIN. Laboratory results obtained within 2 weeks before the CT scan were used as the baseline. CIN was defined as an increase in the sCr level of ≥0.5 mg/dL or ≥25% from baseline within 48 to 96 hours after CT.www.ksn.or.kr). Additionally, the death registry maintained by the Statistics Korea (www.kostat.go.kr) tracks the date of death of all Korean people. These sources were reviewed, and relevant data concerning our study patients were included in our analysis after approval by the institutional review board and the Statistics Korea.In addition to the EHR review, national databases were reviewed to identify outcome events that occurred outside of our hospital. In South Korea, every patient who receives RRT is assigned a diagnosis code for national insurance support. These data are recorded in the RRT registry by the Korean Society of Nephrology (χ2 tests. Continuous variables were expressed as the mean (standard deviation) or median scores (interquartile ranges) depending on the results of Shapiro-Wilk normality test and were compared using an analysis of variance according to the levels of the baseline eGFR. To identify the risk factors for CT-CIN, logistic regression analysis was performed. We used generalized additive models (GAMs) to explore the relationship between the risk of CIN with a binomial distribution and the baseline eGFR with a smoothing function.18 To estimate the eGFR threshold, we first selected the eGFR range and then fitted the GAM to quantify the relationship between eGFR and the risk of CIN. We used Akaike's information criterion (AIC) as a primary measure of model fit. For the AIC, lower numbers within the data set indicate a better model fit. Secondary outcomes were compared between the CIN and the no CIN group. In addition, secondary outcomes in the early period were analyzed by assessing the outcomes during the initial 6 months of follow-up after the CT scan. The long-term effect of CIN was assessed by analyzing secondary outcomes in the late period by excluding cases with a follow-up duration of <6 months. For the subgroup analysis, a baseline eGFR of 30 mL/min/1.73 m2 was used as the criterion for dividing the subgroups.Data are presented as frequencies and percentages for categorical variables and were analyzed using t test for continuous variables according to the normality of the data or the χ2 test for categorical variables.Propensity score matching was performed to compare patients of similar demographic and clinical characteristics for CT-CIN using the MatchIt package in R. Subjects were matched using 1:2 nearest neighbor matching without replacement. Subjects with missing baseline characteristics were excluded from the matching. The following variables were used in propensity score matching: age, sex, total contrast volume used during CT, serum albumin level, baseline eGFR, history of hypertension, diabetes mellitus, cancer, or liver cirrhosis, and the use of statins, ACE inhibitors, or ARBs. Matched results were then compared using the Wilcoxon rank sum test or Student P values with a statistical significance level of 0.05 were used.Overall survival was assessed using a Kaplan-Meier survival curve. The Cox regression proportional hazard method was used to evaluate the secondary outcomes after adjustment for age, sex, contrast volume, and variables that were significant in the multivariate logistic regression risk factor analysis. All statistical analyses were performed using SAS version 9.4  or R package version 3.2.2 . Two-sided A total of 446,672 contrast-enhanced CT scans were performed in the outpatient setting from January 2007 to December 2014. Among those CT scans, 3487 CT examinations were performed on patients who received the CIN prophylaxis protocol. After the exclusion criteria were applied, 1666 patients with same number of contrast-enhanced CT scan were enrolled in this study , a history of diabetes mellitus , and the serum albumin level  were associated with an increased risk of CT-CIN.Univariate logistic regression analysis revealed that sex, diabetes mellitus, liver cirrhosis, baseline kidney function, total volume of radiocontrast agents, and serum albumin level were significantly different between the patients with and without CT-CIN. Multivariate logistic regression analysis was performed using the following variables as covariates Table : age, se2, we used a GAM to assess whether a nonlinear relationship existed between eGFR and the risk of CT-CIN and to explore the threshold baseline eGFR that conferred an increased risk of CT-CIN. The result of the GAM and calculated AIC values according to eGFR are shown in Figure 2, suggesting that the risk of CT-CIN began to increase as the baseline eGFR decreased below that threshold.Because the baseline eGFR was a significant risk factor for CT-CIN and the incidence of CT-CIN markedly increased in patients with a baseline eGFR <30 mL/min/1.73 mP = 0.86), but it significantly affected the initiation of RRT . After discovering the effect of CT-CIN on renal survival, we then assessed renal survival according to the follow-up period. We found that CT-CIN was a significant risk factor for the initiation of RRT within 6 months of the CT scan , but it did not affect the initiation of RRT after 6 months . In the subgroup analysis according to baseline eGFR, CT-CIN was a risk factor for RRT in both groups, which was determined using an eGFR threshold of 30 mL/min/1.73 m2. This result was nearly the same in the 1:2 propensity score-matched dataset. In our matched cohort, CT-CIN was not related to patient mortality , regardless of the follow-up period or baseline eGFR. CT-CIN did affect the initiation of RRT , and this trend was observed in both eGFR subgroups, although it was not statistically significant in the group with an eGFR ≥30 mL/min/1.73 m2. Similar to the results observed for the entire cohort, the effect on the initiation of RRT differed with regard to follow-up period. CT-CIN affected the initiation of RRT within the first 6 months of follow-up . However, a statistically significant relationship was not observed with the initiation of RRT after the initial 6 months after CT .To evaluate the clinical significance of CT-CIN, we analyzed mortality and renal survival before and after propensity score matching. The propensity scores of the baseline characteristics were calculated, followed by 1:2 matching. The matched dataset included 59 patients who developed CT-CIN and 118 patients who did not develop CT-CIN Table . No sign16 Moreover, mortality and RRT were assessed before and after propensity score matching to minimize any bias from confounding medical conditions.One strength of our study was that we analyzed outcomes of CT-CIN following a standardized prophylactic intervention. In addition, most of the CT examinations in our study were performed on patients in stable medical condition because patients with other acute medical conditions were excluded from the study. Consequently, the incidence of CT-CIN in our cohort was much lower than in previous studies, which primarily examined outcomes of hospitalized patients.14 However, careful interpretation of the results of these studies is necessary, and important limitations should be noted.19 Because most clinicians would not prescribe contrast agents to unstable patients, the patients who underwent non-enhanced CT scans may show exaggerated adverse outcomes. This selection bias could lead to the conclusion that acute kidney injury after non-contrast CT scans show comparable patient-oriented outcome with contrast-enhanced CT scans. In addition, as mentioned above, previous studies lacked information concerning CT-CIN prophylaxis measures, which could significantly affect the follow-up levels of sCr. Therefore, the patients who underwent contrast-enhanced CT scans in these previous studies could not have represented CKD patients with CIN prophylaxis intervention.Several recent studies have asserted that the effects of intravenously administered contrast agents used in CT scans are negligible and that the clinical impact of CT-CIN is insignificant.2 have a markedly increased incidence of CT-CIN.4 In our study, we demonstrated a nonlinear relationship between the baseline eGFR and the risk of CT-CIN. The threshold baseline renal function associated with an increased risk of CT-CIN was an eGFR of 36.8 mL/min/1.73 m2, which suggests that CT-CIN might occur predominantly among patients with more advanced kidney dysfunction. In recent clinical guidelines, an eGFR of 45 mL/min/1.73 m2, rather than the previously used eGFR of 60 mL/min/1.73 m2, has been suggested as the probable threshold value for CT-CIN risk; our results support this opinion.6Previous studies have shown that patients with an eGFR <45 mL/min/1.73 m20 Here, we tried to demonstrate the sole effect of CT-CIN by conducting our study in an outpatient setting and by using a matched analysis. Our results showed that CT-CIN was not related to patient mortality in stable CKD patients after proper prophylaxis, regardless of the baseline kidney function and the time since the CT scans. In contrast, CT-CIN was related to an increased risk of RRT initiation in the acute period, even after evidence-based prophylaxis protocol and close monitoring. Because our study participants had preexisting chronic kidney disease, this finding would be accepted and has been demonstrated in many previous studies. However, the long-term outcome of CIN has rarely been described. We showed that CT-CIN was not related with RRT initiation after 6 months, implying that the effect of the contrast agent is limited to the early post-procedure period with patients who recovered from the initial damage.The studies indicating that CT-CIN was related to increased mortality were questioned for possible confounding bias made by the patients’ coexisting medical conditions.Our study has several limitations because of its observational nature. First, we could not have included patients who underwent non-contrast CT scans as a control group owing to small number of patients who had their follow-up blood samples few days after non-contrast CT scans. This small number of eligible patients was probably because of their stable medical condition. Also, when considering a study with prospective design, it is nearly impossible to randomize patients or avoid selection bias because of clinical necessity and the potential harm caused by contrast agents. Additionally, the effect of the prophylaxis might contaminate the result. Second, every patient received prophylactic intervention to prevent CT-CIN; thus, the result of our study might not be applicable to patients who undergo contrast-enhanced CT scans without prophylaxis. Moreover, careful interpretation of the results is necessary when using different prophylaxis protocol. Third, we did not study the effect of CT-CIN on medically unstable or hospitalized patients, so the results of our study might not be identically applied to those patients. However, as previously mentioned, reducing the confounding bias would be challenging. To overcome this challenge, further study is necessary and should include hospitalized patients with exclusion of other causes for firm diagnosis of CIN, rather than defining CT-CIN merely by elevation of serum creatinine after contrast-enhanced CT scans.In conclusion, the incidence of CT-CIN was low among medically stable CKD patients who received proper prophylaxis; the risk of CT-CIN began to increase among patients with late stage 3 CKD. Despite the low incidence, CT-CIN was associated with renal failure requiring RRT in the acute post-procedure period. However, this adverse effect was not observed after 6 months. Mortality was not affected by CT-CIN following proper prophylaxis in stable CKD patients visiting outpatient clinics. Overall, careful prophylaxis and early follow-up visit should be scheduled for CKD patients who undergo CT scans. Also, frequent monitoring of possible renal function deterioration during the acute post-procedure period should be encouraged.


Exosomes are membranous nanovesicles of endocytic origin that carry host and pathogen derived genomic, proteomic, and lipid cargos. Exosomes are secreted by most cell types into the extracellular milieu and are subsequently internalized by recipient cells. Upon internalization, exosomes condition recipient cells by donating their cargos and/or activating various signal transduction pathways, consequently regulating physiological and pathophysiological processes. The role of exosomes in viral pathogenesis, especially human immunodeficiency virus type 1 [HIV-1] is beginning to unravel. Recent research reports suggest that exosomes from various sources play important but different roles in the pathogenesis of HIV-1. From these reports, it appears that the source of exosomes is the defining factor for the exosomal effect on HIV-1. In this review, we will describe how HIV-1 infection is modulated by exosomes and in turn how exosomes are targeted by HIV-1 factors. Finally, we will discuss potentially emerging therapeutic options based on exosomal cargos that may have promise in preventing HIV-1 transmission. Exosomes were discovered over 30 years ago when two different research groups led by Philip Stahl  and RoseThe multifunctional way that exosomes affect the host microenvironment is evident in the study of exosomes and HIV-1. Exosomes from a range of cells mediate micro-environmental changes in target cells by inducing pro- or anti- viral responses ,33,34,35Exosomes are a class of extracellular vesicles (EV) generated by living mammalian cells  and microorganisms, including protozoa , fungi , and bacAside from proteomics, various investigators have utilized different analytical techniques including unbiased deep sequencing and PCR assays to show that exosomes contain different RNA species, notably mRNA and miRNA. Also present in exosomes are small noncoding RNA species, including structural RNAs, tRNA fragments, vault RNA, Y RNA, repeat sequences, RNA transcripts overlapping with protein coding regions, and small interfering RNAs ,25,45,46While it is clear that exosomes contain proteinaceous and genetic cargos, the molecular mechanisms governing cargo recruitment into exosomes as well as cargo release by exosomes are yet to be defined. However, it is believed that Endosomal Sorting Complex Required for Transport (ESCRT) family members known to play a role in the formation of intraluminal vesicles (ILV) are involved in exosome biogenesis. Out of the four ESCRT complexes, ESCRT-0 plays a role in ubiquitin-dependent cargo clustering. An ESCRT-0 member HRS was shown to be required for exosome secretion from various cancer cells ,50,51. EExosomes can also be secreted independently of the ESCRT machinery. It has been demonstrated that some cells depleted of key subunits of all four ESCRT proteins secrete exosmoses using ESCRT-independent mechanisms . ExosomeAside from tetraspanins, proteomic studies identified the RAB family of small GTPase proteins as exosomal cargo . RAB proThe perceived involvement of the ESCRT machinery and the RAB proteins in exosome biogenesis has led to the use of ESCRT and RAB inhibition as an acceptable method for perturbing exosome secretion. However, given the role of ESCRT and ESCRT-associated proteins in plasma membrane-dependent budding of enveloped viruses ,60,61, c−1 [−1 [The biogenesis of exosomes and the cell types that released the exosomes determines exosomal content. The study of exosomes secreted from HIV-1 infected cells is complicated by the fact that exosomes have many features in common with HIV-1 including biophysical/molecular properties, biogenesis and uptake mechanisms. The density of exosomes range from 1.13 to 1.21 g·mL−1 , while H−1 [−1 . In size−1 [−1 . In addi−1 [−1 . Budding−1 [−1 . The con−1 [−1 ,66. The −1 [−1 , which ptrans infection of T cell by mDCs [trans HIV-1 infection. While the involvement of the exosomal pathway in HIV-1 entry and budding is thought provoking, the Trojan exosome hypothesis came to light during a time when terminology was limited with regard to extracellular vesicles and when the field of exosome research was just beginning to expand. Thus, the Trojan exosome hypothesis is a misnomer because HIV-1 is more aptly compared to ectosomes/microvesicles as evidence suggests that HIV-1 buds from the plasma membrane, the budding site of ectosomes and not from internal MVB membranes, which largely represents the exosome budding site.In support of the Trojan exosome hypothesis, HIV-1 recruits components of the host ESCRT machinery to the sight of viral budding and the virus shares some similarities with shedding microvesicles/ectosomes. In addition, the interaction between HIV-1 Gag protein and tetraspanins  suggest  by mDCs ,75. It iin vitro and within blood plasma-derived exosomes from HIV-1 seropositive individuals [Host-derived exosomal RNA and protein cargos are trafficked from one cell type to the other. Some of these cargos are common to all exosomes while others are specific to the producer cells from which they are secreted. Some cargos present in exosomes isolated from HIV-1 infected cells are viral components, suggesting a role for exosomes in facilitating viral evasion of host immunity. There is evidence that HIV-1 infection or transduction of cells with the HIV-1 accessory protein, Nef, increases the cellular release of exosomes ,76,77,78ividuals . AlthougOther viral proteins have also been shown to be targeted to exosomes. HIV-1 Gag is targeted to exosomes via Gag higher order oligomerization . Aside fThe function of exosomes in HIV-1 pathogenesis is beginning to emerge. Accumulating data reveal that exosomes released from HIV-1 infected cells have distinct functions from exosomes released from uninfected cells and biofluid. Exosomes released from infected cells have been shown to mostly enhance infection or function as immune decoys . In contAside from the role of exosomes in facilitating HIV-1 infection by transfer of the viral entry receptors, exosome-mediated transfer of viral proteins, such as HIV-1 Nef to host cells can modulate infection. Nef reprograms endocytosis, cytoskeletal rearrangement and organelle trafficking . These NContrary to evidence demonstrating that HIV-1 mediated hijacking of exosomal machinery enhances infection and thwarts host defense, there is evidence in support of the role of exosomes in inhibiting viral infections. It has been shown that exosomes and related EV have the capability to sample viral antigens and present these antigens to the relevant immune cells, with resultant stimulation of antiviral response in the host ,8,101. Ein vivo, cell culture exosomes originate from homogeneous and often times transformed cells that hardly recapitulate the in vivo microenvironment. Indeed, exosomes derived from tumor cells cultured in vitro differ from exosomes isolated from tumor cells grown in vivo [trans infection mediated by dendritic cells (DC) by binding DC-SIGN and blocking DC-mediated viral transfer to CD+ T cells [Unlike biofluid exosomes generated by a multitude of cell types  in vivo . The ant in vivo ,106, ill T cells . The bintrans HIV-1 infection from vaginal epithelial cells to monocytic and lymphocytic cell lineages, as well as peripheral blood leukocytes (PBLs) [in vivo. Semen-derived exosomes block intravaginal replication of murine AIDS (mAIDS) virus complex and restrict lymphatic mAIDS dissemination in mice [In sharp contrast to milk exosomes, blood-derived exosomes from plasma of HIV-1-seronegative donors do not inhibit HIV-1 infection . The inas (PBLs) . The ant in mice . While s in mice . These o in mice . While s in mice .HIV-1 reverse transcription is integral to synthesis of nascent viral copy DNA required for establishing productive infection and semen-derived exosomes impair this process. Therefore, it appears that semen-derived exosomes have early post entry effects on HIV-1. If the effect of semen-derived exosomes on HIV-1 is solely on the RT process, then semen-derived exosome-mediated deleterious effects on HIV-1 observed at later time points past reverse transcription may be downstream effects of a cascade of events initiated during reverse transcription. It is also possible that semen-derived exosomes may affect HIV-1 at different stages in the viral life cycle. Further studies are needed to investigate these propositions. Additionally, additional studies are required to understand the effect of breast milk and semen-derived exosomes purified from HIV-1-seropositive donors on virus replication.Not only do semen-derived exosomes have innate antiviral properties, these exosomes have natural anti-inflammatory functions. Various investigators implicated semen and its constituents in varied processes relating to spermatozoa function and protection from the female reproductive tract (FRT) immune responses ,122,123.Exosomes exert their biological functions by direct interactions with recipient cells, or through the transfer of their cargo following membrane fusion with or endocytosis into target cells. Because various molecules are recruited into exosomes, it is has been suggested that exosomes can simultaneously transfer multiple effector molecules to target cells. This unique ability makes exosomes superior vehicles for cargo shuttling compared to other classical secretion mechanisms such as those used by cytokines, chemokines and hormones. Various reports have shown that exosomes from different sources can transfer pro- and anti- viral factors to target cells with resultant modulation of host cell responses ,89,103. Additionally, the mRNA cargo of human semen-derived exosomes is transferable to mice. Apobec3G mRNA in exosomes isolated from human semen was transferred to mice following intravaginal inoculation of mice with these exosomes. In these mice, human Apobec3G mRNA was detected in vaginal cells . This fiin vitro [Aside from the exosomal HRF mRNA cargo, exosomes isolated from blood of HIV-1-seropositive donors are enriched with proinflammatory cytokines and chemokines compared to seronegative plasma controls. In addition, cell surface expression of CD38 activation marker is increased on naive and central memory CD4+ and CD8+ T-cells in the presence of HIV-1-seropositive blood-derived exosomes compared to HIV-1-seronegative exosomes . Therefoin vitro ,29. The Additionally present in exosomes are miRNAs that have been shown to be protective against HIV-1. These include miR-28 ,128, miRin vivo, host cells can tolerate exosomes and their contents; (ii) exosomes serve as a vehicle to shuttle RNA molecules, proteins and lipids between cells over short and long distances; and (iii) the host could use exosomes as a channel for elimination of antigens. For instance, cancer patients have high concentrations of exosomes loaded with tumor-specific molecules. In these patients, exosomes can be used and is being evaluated for their potential use as cancer biomarkers. As biofluid exosomes carry and transport specific proteins and various RNA species derived from multiple organs, biofluid exosomes may be associated with a given disease or carry protective molecules [As stated earlier, exosomes loaded with host or pathogen derived RNA molecules, proteins and lipids are released by cells into their surrounding environment. The presence of large numbers of exosomes containing various molecules in several biofluids indicate that (i) olecules ,29,135. The use of exosomes as biomarkers for therapeutic purposes for cancer has gathered momentum. However, the field of HIV-1 study is still in its infancy with regards to exosomes. Exosomes could potentially be used as biomarkers and as therapeutic tools for HIV-1. The detection of exosomes in blood of HIV-1-seropositive patients and the identification of HIV-1 proteins and RNAs in exosomes isolated from the blood of HIV-1-seropositive patients emphasizes the potential utility of exosomes and their contents as biomarkers for HIV-1. The demonstrations that HIV-1 RNA and protein are packaged into blood-derived exosomes suggest that in HIV-1-seropositive people, the body could clear viral factors by secreting them into exosomes. Blood-derived exosomes could therefore be harnessed as diagnostic and prognostic HIV-1 biomarkers by (i) stimulating the release of exosomes containing the HIV-1 genome to rid the body of viral factors; and (ii) efficiently targeting the HIV-1 genome to exosomes that have been engineered for efficient degradation. The presence of the HIV-1 genome in blood-derived exosomes could also be used as a tool to assess the efficacy of treatment. This could be done by evaluating the presence of specific viral molecules in exosomes as a means of assessing treatment efficacy with respect to suppression of viral load or disease progression.Based on recent observations that exosomes derived from human breast milk  and fromFurthermore, nanoparticle delivery systems mimicking semen-derived exosomes may have significant contribution in vaginal mucosal drug delivery based on the fact that semen-derived exosomes are more efficiently internalized than blood-derived exosomes and at least one cationic liposome formulation . It is ain vivo; (ii) what is the half-life of biofluid exosomes in vivo; and (iii) what is the mechanism of exosomal internalization in vivo, remain unanswered. Identifying the answers to these questions will fundamentally push the frontiers of our understanding of the roles exosomes play in HIV-1 pathogenesis. In order to achieve an HIV-1/AIDS-free world, we are in need of discovery and design of efficacious and affordable treatments. As this review outlines, discovering that exosomes mediate important cell-to-cell communication through the delivery of HIV-1 and host molecules has underlined particular interest for the use of exosomes from various sources as potential HIV-1 biomarkers and therapeutic tools. However, although significant advances have been made, many questions remain about the role of exosomes in general and biofluid exosomes in particular in intercellular communication, immune modulation, and immune surveillance. Additionally, little is known about the precise molecular mechanisms of biofluid exosome biogenesis, release, targeting, and interactions with target cells within the organs where they are released. Biofluid exosomes are heterogenous vesicles derived from different cell types and, as a result, they are likely to perform specific functions in their cognate environment. This issue remains to be clarified. For biofluid exosomes to be a reliable diagnostic and therapeutic tool, robust isolation systems that will purify exosomes of interest from total EV populations must emerge. Because exosomes encase HIV-1-derived or host-derived factors, these factors constitute a network of communication that may act in a specific context or in association with many other players. The consequence is eventual conditioning of host cells. Studies that will elucidate the physiological roles of biofluid exosomes in HIV-1 infection and transmission are imperative before exosomes themselves or biofluid-derived exosome-based synthetic nanoparticles can be used diagnostically and therapeutically. Currently, many questions such as (i) which cell types release and internalize biofluid exosomes


Persuasive data from many randomized controlled trials and large, long-term observational studies indicate a modestly increased risk for the emergence of new diabetes after statin initiation. Several meta-analyses of many statin trials as well as longitudinal population-based studies suggest that the risk factors for diabetes in statin-treated persons include underlying risk for diabetes at baseline , the intensity of statin therapy, certain genetic traits independent of diabetes risk, and adherence to lifestyle factors. Limited data suggest statins modestly worsen hyperglycemia and A1c levels in those with pre-existing diabetes or glucose intolerance. The precise mechanism(s) of diabetogenesis with statin therapy are unclear, but impaired insulin sensitivity and compromised β cell function via enhanced intracellular cholesterol uptake due to inhibition of intracellular cholesterol synthesis by statins, as well as other mechanisms, may be involved. Furthermore, while statins are known to have anti-inflammatory effects, it is hypothesized that, under dysmetabolic conditions, they might have pro-inflammatory effects via induction of certain inflammasomes. This concept requires further elucidation in the human. Finally, it is clear that the risk–benefit ratio for cardiovascular disease events is strongly in favor of statin therapy in those at risk, despite the emergence of new diabetes. Adherence to lifestyle regimen is critical in the prevention of new diabetes on statins. The practical significance of a modest absolute risk reduction in primary prevention of CVD is still debated4. However, the recent long-term, global, multi-ethnic, primary prevention trial Heart Outcomes and Prevention Evaluation (HOPE)-3 has confirmed the benefits of a moderate dose of statin (rosuvastatin 10 mg) in subjects at an intermediate CVD risk, with a 24% reduction in primary CVD outcomes  over a mean follow-up of 5.6 years5. These results were consistent with those reported in the meta-analysis of 27 primary prevention statin trials2. While the total mortality or the CVD mortality in the 12,705 subjects in HOPE-3 was not reduced, a significant 15% reduction in CVD mortality and a significant 9% reduction in overall mortality per 1 mmol/L reduction in low-density lipoprotein cholesterol (LDL-C) over ~5 years were reported in the previous meta-analysis of the primary prevention trials2. Based on the overall evidence from the randomized controlled trials (RCTs), various updated major guidelines8 have paved the way for greater attention to initiation and intensification of statin therapy in high-risk individuals (such as those with prior CVD) and in individuals without CVD (such as those with diabetes and multiple risk factors).The remarkable value of HMG-CoA reductase inhibitors (statins) in atherosclerotic cardiovascular disease (CVD) risk reduction is clearly established, based on landmark secondary intervention as well as primary prevention trials during the past two decades9. Since then, several meta-analyses have confirmed a smaller but significant increase with various statins 10. In a subsequent meta-analysis of five intensive-dose statin trials, Preisset al. reported a significant increase in diabetes incidence with more intensive- vs. moderate-dose statin  in 32,752 subjects over a mean follow-up of 4.9 years11. In general, there was no relationship between % LDL-C reduction and incident diabetes. Further analysis of baseline characteristics of the various trials reported a strong relationship between features of metabolic syndrome or pre-diabetes  at baseline and subsequent development of diabetes14.A clinically relevant concern with statin therapy is a significantly increased risk of new-onset diabetes in patients on statin therapy. The JUPITER trial reported a 25% increase with rosuvastatin 20 mg, over a median follow-up of 1.9 years, compared to those on placebostatins . The ana13, several secondary prevention studies14, and a meta-analysis of secondary prevention studies by Preisset al.11. Thus, regardless of whether or not diabetes was diagnosed during statin therapy, the CVD outcomes were reduced on statin therapy compared to those observed with placebo.Of note, the risk–benefit ratio for CVD still clearly favored statin therapy in various studies, including JUPITER, in primary preventionet al. is the largest so far: it includes 17 RCTs . It compared new-onset diabetes in patients receiving statin vs. placebo, or high-dose vs. moderate-dose statins15. The lowest risk was seen with pravastatin 40 mg compared to placebo , whereas rosuvastatin 20 mg was associated with the highest risk  and atorvastatin 80 mg was intermediate , even though none of these differences achieved statistical significance. Simvastatin also appears to be associated with higher risk compared to pravastatin. These differences among various statins persisted after adjustments for reduction in cholesterol. These findings suggest possible molecule-specific effects on diabetogenesis, although the data thus far are inconclusive.Another meta-analysis by Navarese16. If confirmed in a larger RCT, it will raise the possibility of differences in pharmacodynamics and drug-drug interactions on diabetogenecity.The effects of the newest statin, pitavastatin, are not available in a large enough cohort. In a recent meta-analysis of 15 short-term RCTs of pitavastatin, most of 12 weeks’ duration, total follow-up 1600 person-years, there was no significant difference in the risk for diabetes  compared to placebo21 comparing patients on statins with those not on statins in various populations. These analyses revealed considerable variability among studies and with various statins, with HRs ranging from 1.19–1.57 but statistically significant, after follow-up durations of 3–6 years. In the Women’s Health study, the women were older than several other populations and generally on moderate-dose therapy, yet the HR was 1.4817. In the largest study of over 2 million subjects in the UK, there was a significant time-dependent increase in diabetes risk , which increased further  in those who were followed for up to 15–20 years21. In one study in patients following myocardial infarction, there was no difference in intensive- vs. moderate-dose statin therapy22, although the CVD outcomes were reduced with the more intensive approach. One caveat with all of the observational studies is that, despite multifactorial adjustments, some differences in the cohort characteristics may not be fully accounted for. In particular, it should be noted that the risk for diabetes according to presence of pre-existing diabetes risk factors, as observed in the several analyses of RCTs14, was not adequately examined in the various observational studies, a major limitation in those studies, compared to RCTs.et al.19, the HR for progression to diabetes was similar in those with normoglycemia, or impaired fasting glucose at baseline, but both groups showed similar reduction in mortality after a 6-year follow-up. In a meta-analysis of nine RCTs in 9696 patients with type 2 diabetes, with a mean follow-up of 3.6 years, there was a modest but significant increase in mean A1c level of 0.12% (95% CI 0.04–0.20)23. In one cross-sectional study in patients with type 1 diabetes (n=1093), statin use was associated with a similar 0.2% increase in mean A1c after multivariate adjustments24.There are some observations of interest from a few studies in patients with pre-existing glucose intolerance or diabetes. In the study by Castro13. It has been controversial whether chemical differences and pharmacodynamic differences in statins or more intensive statin therapy are more likely to precipitate diabetes. In the analysis by Preisset al., intensive statin therapy led to a greater increase in diabetes11. This was also confirmed in other meta-analyses by Carteret al.25 and Dormuthet al.26. However, this was not confirmed in a propensity score-matched cohort of patients with myocardial infarction who were prescribed intensive- or moderate-dose statins and followed for 5 years (new diabetes in 13.6 vs. 13.0%)22. The reported lack of new diabetes in pitavastatin-treated subjects is intriguing in view of the relatively small and short-term studies with this newest statin so far (as discussed above)16. Another intriguing observation is that in the fairly large cohort of the HOPE-3 trial , there was no increase in the risk for new diabetes  compared to a 25% increase with rosuvastatin 20 mg in JUPITER9. Whether this relates to the differences in the intensity of statin therapy, risk factors for diabetes at baseline, or perhaps genetic differences in the multi-ethnic HOPE-3 cohort is worth exploring.The precise mechanism(s) for statin-induced diabetes remain unclear, although the majority of patients developing diabetes have pre-diabetes or features of metabolic syndrome indicating high risk for diabetes at baseline18. Similarly, in a small study in 28 patients with polycystic ovary syndrome (PCOS), treatment with atorvastatin 20 mg compared to placebo over 6 months led to a decrease in insulin sensitivity despite a decrease in the inflammatory marker C-reactive protein (CRP)27.Several mechanisms have been postulated underlying the derangements in glucose metabolism by statins. There is some evidence for the detrimental effects of statins on both insulin sensitivity and β cell secretion. In the large METSIM observational study of more than 8000 men, simvastatin and atorvastatin were related to a dose-dependent increase in post-glucose load, an increase in glycemia, a mean decrease in insulin sensitivity by 24%, and a decline in insulin secretion by 12%28. Statins are generally thought to have anti-inflammatory effects9. However, a recent novel hypothesis posits that under certain conditions, statins may activate inflammasome NLRP3 from macrophages or adipocytes in the presence of endotoxins, leading to interleukin-1β-mediated insulin resistance29. This hypothesis requires confirmation in human studies, as adipose tissue is not a major glucose-metabolizing tissue. A provocative possibility is that the altered gut microbiome, in the presence of obesity or other dysmetabolic states, might provide the endotoxin lipopolysaccharide (LPS) that may mediate the paradoxical pro-inflammatory effect of statins by activation of inflammasomes30. However, under physiological circumstances, a moderate decrease in insulin sensitivity should be compensated for by enhanced insulin secretion by β cells. Thus, ultimately, the direct or indirect effects of statins on β cell function may play an important role in diabetogenesis, particularly in those already at increased risk.A number of potential deleterious effects of statins on β cell function have been proposed, including the effects of increased influx of cholesterol due to inhibition of HMG-CoA-mediated intracellular cholesterol synthesis, inhibition of ubiquinone (CoQ 10) synthesis leading to mitochondrial oxidative stress, and β cell apoptosis31. This observation was validated in the randomized statin trials, and one particular allele was associated with a significant increase in the risk of new diabetes . Since statins inhibit HMG-CoA reductase as their mode of action, this may at least partly explain their diabetogenic effect.An exciting new observation is that a genetic polymorphism leading to a reduced activity of HMG-CoA reductase is associated with lower LDL-C, a significant increase in body weight, and features of insulin resistance32. Thus, the progression to diabetes could be explained by lifestyle-induced worsening in insulin sensitivity. It is possible that this and the other postulated mechanisms could co-exist.Finally, a mundane and more simplistic nutritional explanation has been reported by the long-term data in the NHANES study. In a cross-sectional follow-up of more than 27,000 adults followed over 10 years, it was shown that those on statins liberalized their fat and total caloric intake and gained weight over time compared to those not on statins14. Sattaret al. calculated, based on their meta-analysis of 13 RCTs, that treatment with statins compared to placebo in 255 subjects over 4 years will cause one new case of diabetes while preventing 5.4 major CVD events10. Similarly, Preisset al. estimated that intensive statin therapy, compared to moderate-dose statins, in those with prior CVD will prevent around three new events per year in ~500 subjects while resulting in one additional case of diabetes11. Finally, Ridkeret al. reported that in the JUPITER trial, despite a 25% increase in the relative risk for new diabetes with rosuvastatin 20 mg, the major CVD event rate reduction in those who developed diabetes  was consistent with event reductions in the trial as a whole 13. Moreover, the risk of developing diabetes in that trial was almost entirely confined to those with pre-existing features of metabolic syndrome or pre-diabetes13, with similar data from other trials12. Also, in JUPITER, in those with risk factors for diabetes, 134 vascular events or deaths were avoided for every 54 new cases of new diabetes. Finally, in recent data from a cohort of more than 15,000 propensity-matched subjects who initiated statin therapy and were followed for a median of 2.7 years, there was no increase; in fact, there was a significant decrease in the development of microvascular complications (retinopathy and neuropathy) in those developing diabetes compared to a matched non-diabetic cohort33.As summarized above, there appears to be a significant relationship between statin use and the development of new diabetes over the course of several years. This has resulted in an understandable concern about the need to be more vigilant in the use of statins in primary prevention, particularly in those at low absolute risk of CVD. However, the outcome data, particularly from the RCTs, remind us that the subsequent events are also significantly reduced in those with statin-induced diabetes32, that those on statin therapy generally increased their caloric intake and fat intake leading to progressive weight gain, i.e. factors known to be predictors of diabetes, further emphasize the need for lifestyle counseling as the integral component of both diabetes and CVD event reduction.Thus, it seems quite clear that statin treatment should not be withheld in those at high risk of CVD for the relatively minor concern of progression to diabetes. In fact, the data described above indicate that in the presence of multiple risk factors for diabetes or metabolic syndrome at baseline in the at-risk population, a modest diabetogenic effect of statin therapy may lead to progression from pre-diabetes to diabetes. This should therefore prompt advice for lifestyle intervention, already known to prevent or delay progression to diabetes, and should be implemented prior to statin initiation. Moreover, the observations from the NHANES survey stated above


Growth differentiation factor-15 (GDF-15) has been identified as a strong marker of cardiovascular disease; however, no data are available concerning the role of GDF-15 in the occurrence of organ dysfunction during coronary artery bypass grafting (CABG) associated with cardiopulmonary bypass (CPB).Five arterial blood samples were taken sequentially in 34 patients from anesthesia induction (IND) until 24 h after arrival at the intensive care unit (ICU). Plasma levels of GDF-15, follistatin-like 1 (FLST1), myeloperoxidases (MPO), hydroperoxides and plasma antioxidant status (PAS) were measured at each time-point. Markers of cardiac  and renal dysfunction  and other classical biological factors and clinical data were measured.Plasma GDF-15 levels increased gradually during and after surgery, reaching nearly three times the IND levels in the ICU . Plasma MPO levels increased dramatically during surgery, attaining their highest level after unclamping (UNCLAMP)  while PAS significantly decreased between IND and UNCLAMP (p<0.05), confirming the high oxidative status induced by this surgical procedure. ICU levels of GDF-15 correlated positively with cTnI and NGAL , and also with hemoglobin and estimated glomerular filtration rate (eGFR). Among all the post-operative biomarkers available, only eGFR, NGAL and GDF-15 measured at ICU arrival were significantly associated with the onset of acute kidney injury (AKI). Patients with a EuroSCORE >3 were shown to have higher GDF-15 levels.During cardiac surgery associated with CPB, GDF-15 levels increased substantially and were associated with markers of cardiac injury and renal dysfunction. During cardiopulmonary bypass (CPB), pro-inflammatory mediators activate leucocytes, vascular endothelial cells and platelets, thus producing a systemic inflammatory response that results in organ dysfunction, affecting the heart, brain, lungs and kidneys. Several factors, including operative trauma, the contact of blood components with the artificial surface of the circuit, cardioplegic techniques and allogenic blood transfusion account for this phenomenon. The cellular response is mediated by the main effectors of the inflammatory response, including neutrophils, which degranulate and release cytotoxic molecules such as elastase, myeloperoxidase (MPO) and free radicalsGDF-15  is a cytokine related to the superfamily of transforming growth factor-β (TGF-β), and is weakly expressed or not expressed at all under physiological conditionsThe present study was designed to evaluate the kinetics of plasma GDF-15 levels in patients with significant CAD undergoing cardiac surgery associated with CPB, and to relate GDF-15 to inflammatory/ oxidative stress status and to organ dysfunction.th 2012 and October 11th 2012. The study protocol complied with the Declaration of Helsinki and was approved by the regional ethics committee . Informed written consent was obtained from all of the patients. Patients with stable CAD were included. The following criteria led to the exclusion of patients: surgical emergencies, aortic valve replacement, ACS reported within 30 days before the surgery, LVEF <30%, chronic inflammatory pathologies, infectious or malignant diseases, chronic renal failure, transplant patients and patients treated with corticosteroids.Thirty-four consecutive patients operated on for CABG under CPB at Dijon University Hospital, Bocage Central, Dijon, France were included in this prospective study between April 26Clinical events were defined as hospital stay>10 days, intensive care unit (ICU) stay>5 days, the use of vasopressor therapy and clinical complications .The association between these events and biomarkers was also analyzed.−1), sufentanil (0.2 to 0.5 µg.kg−1.h−1), and propofol (1.5 to 2.5 mg.kg−1). After verifying that manual ventilation was satisfactory, cisatracurium dibesylate (0.06 mg.kg−1.h−1) was injected. Patients were orally intubated and ventilated with FiO2: 0.4. Anesthesia was maintained with sufentanil and cisatracurium as required and inhaled desflurane.Patients were pre-medicated with midazolam orally plus hydroxyzine 90 min before anesthesia. Routine cardiac medications were continued until the morning of the surgery, except for Clopidogrel, which was stopped at least 5 days earlier. Before the induction of anesthesia, a complete hemodynamic monitoring system was set up in the operating room. Anesthesia was induced with intravenous midazolam  was used. The time from removal of the aortic cross-clamp until the discontinuation of CPB was measured. After completion of the CABG (from 1 to 5 CABG in the patients studied), CPB was discontinued and protamine was given for heparin reversal. Patients were given a blood transfusion in the case of severe anemia . After closure of the sternum, the patients were transferred to the post-operative ICU, and finally to the surgery ward. Clinical and biological parameters were regularly recorded. Complications such as arrhythmia, blood loss, infection, and organ failure were recorded. ICU length of stay was noted.Blood samples were taken in heparinized tubes as shown in Plasma GDF-15 concentrations were measured by quantitative sandwich enzyme immunoassay  with a linear range from 200 to 50,000 ng/L. The color intensity, relative to GDF-15 concentration, was measured at 450 nm with a spectrophotometer . A GDF-15 value of 1,200 ng/L corresponds to the upper limit of normal in healthy elderly individuals, whereas GDF-15 levels of 1,200 and 1,800 ng/L allowed the identification of patients at low , intermediate , or high risk The plasma antioxidant status (PAS) was determined by measuring the Oxygen Radical Absorbance Capacity (ORAC), as detailed elsewhereet al.Plasma protein concentrations (expressed as grams per liter of plasma) were evaluated by the spectrophotometric method according to Lowry Neutrophil gelatinase-associated lipocalin (NGAL) is considered an early marker of acute kidney injury (AKI)Continuous variables are presented as mean ± SEM or median (IQR) as appropriate, and discrete variables as absolute number and percentages.th and 75th percentiles, or as means+SEM.Given time points were analyzed by Student’s un-paired t-test or the Mann-Whitney test for normally or not normally distributed data, respectively. Results are expressed as box plots in which the boxes represent the 25One Way Repeated Measures Analysis of Variance or Friedman Repeated Measures Analysis of Variance on Ranks was used to analyze differences within groups over time, and corrected for multiple comparisons by the Tukey test. A probability value of <0.05 was considered statistically significant.Associations between laboratory parameters and GDF-15 were tested using Spearman’s correlation rank test.To determine the incremental diagnostic value of post-operative GDF-15 in the early detection of AKI compared with conventional biomarkers, a stepwise analysis was performed given the limited number of events. We calculated the improvement in global χ2 after the addition of GDF-15 to a model that included post-operative eGFR and eGFR plus NGAL.A probability value <0.05 was considered statistically significant.Statistical analyses were performed using SigmaPlot version 12  and SPSS 20.0 0 .Perioperative clinical and laboratory information is shown in st October 2013.Intraoperative data and postoperative outcomes are shown in Compared with IND levels, plasma GDF-15 concentrations rose significantly (p<0.05) after removal of the cross-clamp and during the post-surgery period in the ICU, reaching nearly three times the induction level . Plasma Clinical and biological variables associated with IND plasma GDF-15 concentrations are shown in Although lower GFR values and higher plasma creatinine levels were associated with higher GDF-15 levels , neither urea nor NGAL concentrations were significantly associated with GDF-15 levels. Regarding the inflammatory and oxidative stress status, the highest GDF-15 levels were associated with CRP (p = 0.041), but not with higher hydroperoxide and MPO concentrations or PAS. Higher preoperative GDF-15 levels were significantly associated with higher EuroSCORE values .The association of clinical and biological variables with peak plasma GDF-15 concentrations, observed one day after surgery in ICU, was also investigated. Patients with moderate or high operative risk (EuroSCORE > 3) had higher plasma GDF-15 concentrations than did patients with low operative risk (EuroSCORE ≤3) (p = 0.007) . GDF-15 The PAS decreased significantly (p<0.05) during the CPB procedure  while plCardiac Troponin I (cTnI) was significantly higher (p = 0.008) on arrival at the ICU  and remaDuring CABG, ischemia-reperfusion injury may occur because of elevated intracellular levels of reactive oxygen species and calcium. CPB is associated with an inflammatory response that can generate systemic oxidative stress, which, in turn, causes further damage not only to the heart, but also to other organs. Therefore, it is necessary to identify new biomarkers of inflammation and oxidative stress during this surgical procedure, in order to predict the severity of damage to vital organs.et al. found that GDF-15 concentrations in apparently healthy elderly adults were higher than those in younger adults Our data showed that pre-operative GDF-15 levels in patients undergoing bypass surgery were positively associated with age, a history of diabetes, chronic renal failure, high NT-proBNP and plasma CRP levels. Clinical studies have shown that GDF-15 concentrations correlated strongly with age in both healthy and unhealthy adultsin vivo mouse model of cardiac IR injury, myocardial GDF-15 mRNA levels rapidly increased in the ischemic area after both permanent and transient coronary artery ligation. In our study, the median duration of ischemia (cross-clamp time) was 61.7±3.7 minutes, and we examined the levels of GDF-15 after unclamping and after 1 to 2 hours of reperfusion; showing that, in humans, plasma GDF-15 levels increased significantly after a period of myocardial IR.This is the first report of the time course of GDF-15 during cardiac surgery. Our study demonstrated that plasma GDF-15 levels in humans increased during cardiac surgery associated with CPB. Concerning myocardial IR injury during CABG, the increase in plasma GDF-15 levels that we report is in accordance with experimental findingsHeart surgery with CPB is associated with an acute inflammatory response, which has implications for postoperative recovery and myocardial functionTo summarize, our data emphasize the role of GDF-15 in inflammatory situations, and, as suggested by the rapid increase in levels of GDF-15, showed that this induction occurs quickly in cardiac surgery associated with CPB.et al.Increases in various markers of systemic oxidative stress and in inflammatory products have been shown to occur during CPBWe did find a close association between high GDF-15 levels and worse eGFR. As our population was small, few adverse events were recorded. There were only 9 AKI events, and the results of the multivariate analysis therefore need to be interpreted with caution. In particular, we were unable to show that the prognostic value of the early measurement of GDF-15 was better than a model that associated two powerful biomarkers of the AKIN. Nonetheless, this result supports our findings that GDF-15 is closely associated with renal function and, in combination with known biomarkers, such as NGAL and eGFR, could be of use for the early detection of AKI. This is in agreement with previous results showing that GDF-15 was a novel independent serum marker of mortality in chronic kidney diseaseWhile there was no correlation between preoperative GDF-15 and cTnI and CK, we found a significant positive association between GDF-15 and NT-proBNP during the post-operative reperfusion period, and there was a significant positive correlation between ICU GDF-15 and cTnI. In experimental conditionset al. demonstrated that GDF15 was significantly increased in chronic anemia in subjects with or without true iron deficiencyWe found a significant association between GDF-15 and hemoglobin levels during the post-operative period. GDF-15 is known to be implicated in dyserythropoietic syndromes such as thalassemia or sickle cell diseaseFinally, our results showed that higher pre-, per- and post-operative GDF-15 levels were significantly associated with higher EuroSCORE values. Our results are in agreement with a recent study showing that pre-operative plasma GDF-15 levels improved the predictive capacity of the additive EuroSCORE. Collectively, these results suggest that the addition of GDF-15 to conventional risk stratification tools could provide important prognostic informationIn conclusion, our prospective study demonstrated for the first time the kinetic increase in plasma GDF-15 levels during cardiac surgery in patients undergoing CABG associated with CPB. We confirm here the important role of GDF-15 as a marker of renal and cardiac injury in patients with CAD who underwent CABG associated with CPB. Given the value of GDF-15 as a marker of heart disease and cardiovascular risk and the prevalence of major adverse cardiovascular events associated with the post-CPB period, it seems important to measure GDF-15 levels in patients undergoing CABG with CPB so as to improve diagnosis and follow-up.


Supplemental Digital Content is available in the text Prognostic evaluation is important for the management of patients with autoimmune hepatitis (AIH). Although some autoantibodies have been associated with disease activity and outcomes, the implication of antibodies to soluble liver antigen (anti-SLA) remains controversial.To conduct a meta-analysis of observational studies which addressed differences in clinical characteristics by anti-SLA status in patients with AIH.Three databases PUBMED, EMBASE, and OVID were systemically searched up to January 2015 using the terms “soluble liver antigen” or “liver-pancreas antigen” and “autoimmune hepatitis” with restriction to English-language.Studies were included if at least 50 patients with objective diagnosis of AIH were enrolled, anti-SLA detection was performed for the patients, and prognostic outcomes and/or disease severity were reported.Two investigators independently reviewed retrieved literature and evaluated eligibility. Discrepancy was resolved by discussion and a third investigator. Quality of included studies was evaluated using Newcastle-Ottawa Quality Assessment Scale (NOS). Data were pooled using fixed-effect or random-effect models.Prognostic outcomes included death from hepatic failure or requirement for liver transplantation, and responses to immunosuppressive therapy regarding remission or relapse. Results were combined on the odds ratio (OR) or standardized mean difference (SMD) scales.Eight studies were enrolled in this study, involving a total of 1297 AIH patients among whom 195 with anti-SLA. Pooled serum AST levels tended to be lower in anti-SLA seropositive patients. The presence of anti-SLA conferred 3.1-fold increased risk of hepatic death in AIH patients. The remission rates were comparable between anti-SLA seropositive and seronegative AIH patients, while anti-SLA positivity was associated with nearly 2-fold increased risk of relapse after drug withdrawal. Human leukocyte antigen (HLA) allotype DR3 was positively associated with anti-SLA.Antibodies to SLA may be an indicator of increased risks of hepatic death and treatment relapse for AIH patients. Our findings suggest that the anti-SLA seropositive patients should be maintained indefinitely on individually adjusted medication to improve their prognosis. AIH has become a relatively common autoimmune liver disease.The epidemiological data on autoimmune hepatitis (AIH) in the United States as a whole are still lacking. According to data collected between 1984 and 2000, the prevalence of AIH in the Alaska native population is as high as 42.9 per 100,000 population.4 AIH is a “not-so-silent” disease. Histological findings, including the frequency of cirrhosis, are similar between asymptomatic patients and symptomatic patients.5 Before the widespread use of immunosuppressive agents for AIH, as many as 40% of patients with untreated severe disease died within 6 months of diagnosis.6The disease presentation of AIH ranges from asymptomatic to symptomatic onset, acute, chronic, or fulminant. The key consequences of AIH are cirrhosis, liver failure, and hepatocellular carcinoma (HCC), leading to death or requirement of liver transplantation (LT). Although asymptomatic patients account for nearly one third of total patients,7 Antibodies to SLA and liver-pancreas antigen were originally defined as different antibodies but subsequently have been identified as the same autoantibody given that they share the same antigenic target.8 Anti-SLA antibodies can be detected by radioimmunoassay, enzyme-linked immunosorbent assays, immunoblotting, or dotblotting assays, rather than by immunofluorescence. The native cytosolic antigen or recombinant 50 kDa protein identified as O-phosphoseryl-tRNA: selenocysteinyl-tRNA synthase used in detection assays was confirmed by mass spectrometry with human native antigen in 2010.10 It has been suggested that anti-SLA antibody might be a marker of disease severity in patients with AIH.11 Several studies demonstrated that anti-SLA was associated with relapse after corticosteroid therapy.13 However, a recent report indicated that anti-SLA may be not associated with treatment response and outcome.14Antibodies against soluble liver antigen (SLA) were first described in 1987 in a specific form of AIH.The prognostic value of anti-SLA has been addressed by a few studies but still remain controversial. We conduct this meta-analysis to determine whether the anti-SLA seropositivity could define a distinct subset of AIH patients, in terms of clinical characteristics, treatment responses, and prognostic outcomes.15 PUBMED, EMBASE, and OVID database were searched up to January 2015. The search strategy included in terms of “antibody to soluble liver antigen,” “anti-SLA,” “antibody to liver-pancreas” or “anti-liver-pancreas antigen,” and “autoimmune hepatitis.” No limits were appointed in country, race, or publication year. In order to identify more relevant studies, we scanned and hand-searched references of retrieved articles and conference proceedings.Preferred reporting items for systematic review and meta-analysis (PRISMA) protocols were followed for of the conduct of the current study.The initial study selection was performed by review of titles and abstracts. If the articles seemed possibly relevant, the full texts were downloaded and reviewed for data retrieval.To be included in this analysis, the studies should met the following criteria: types of studies—observational studies including cohort, cross-sectional, and case-control studies; types of participants—patients with objective diagnosis of AIH, and anti-SLA detection was performed for them; disease severity markers—laboratory tests such as aspartate aminotransferase (AST), total bilirubin (TBIL) immunoglobulin G (IgG) levels, evidence of cirrhosis, or histological examination; at least 1 of the following prognostic outcomes—death from liver failure or LT, responses to immunosuppressive therapy such as remission and relapse; a minimum sample size of 50; and published in English.Study eligibility was assessed by 2 investigators independently. Discrepancy was resolved by discussion and consultation with a third investigator.The collected information about study characteristics included: country, publication year, study design, number of patients, gender distribution, mean age, criteria for diagnosis of AIH, anti-SLA status, length of follow-up, laboratory and histological findings, prognosis such as hepatic death or LT, or responses to immunosuppressive therapy such as remission and relapse.16 Briefly, when a study had relevant information that could be related with NOS criteria, 1 point was added. A total of 8 items in cohort or case–control studies and 5 items in cross-sectional studies that could be associated with NOS were identified.Newcastle-Ottawa quality assessment scale (NOS) was used to evaluate the quality of the enrolled studies, as we described elsewhere.Two investigators independently extracted data and judged the quality of studies. Discrepancy was resolved by discussion and a third investigator.2 and inconsistency (I2) statistics, an I2 value greater than 50% represented heterogeneity.16 A fixed-effect model was applied for meta-analysis if there was no heterogeneity; otherwise, a random-effect model was adopted. Overall effects were evaluated using the Z test. Publication bias was assessed visually by funnel plots, and statistically by a rank correlation test (Begg test) and a regression asymmetry test (Egger test).Dichotomous variables were presented as odds ratios (ORs) with 95% confidence intervals (CIs), while continuous variables as standardized mean differences (SMDs) with 95% CIs. All measures of dispersion were described as standard deviations (SDs). Sometimes estimated SDs were derived from standard errors (SEs) from the studies. Statistical heterogeneity was determined by χP < 0.05.The meta-analysis was performed with Stata software version 12.0 , with significance set at The search procedures are summarized in Figure 20 3 were cross-sectional,21 and 1 was case–control study.14 Two studies were multi-center studies.18 A total of 1297 AIH patients, among whom 195 were anti-SLA seropositive, were involved.Among the 8 enrolled studies, 4 were retrospective cohorts,14 The length of follow-up ranged from 1 to 407 months. The main characteristics of the selected studies are reported in Tables Countries involved in these studies were USA, Germany, France, Italy, Turkey, Japan, and Greece. All of the 8 included studies used the similar diagnostic criteria of AIH proposed by International Autoimmune Hepatitis Group in 1993, 1999, or 2008. A total of 7 studies included corticosteroid monotherapy or combination therapy consisting of azathioprine and corticosteroid, only 1 study used mycophenolate mofetil as first line therapy.Serum biochemical parameters were assessed in all studies. However, AST and TBIL levels with mean and SD values for anti-SLA positive and negative subgroups were available in 4 studies, while IgG was available in only 3 studies. Liver biopsy was conducted in 3 studies. Histologic inflammation scores were reported in 2 studies, while fibrosis index only in 1 study.P = 0.012). Analysis about TBIL data which came from the same subjects showed that the summary mean bilirubin levels were comparable between the 2 groups of patients (P > 0.05). One study was excluded from the analysis of IgG because the authors did not disclose relevant data, the analysis showed that the standardized difference in mean values of IgG levels was not significantly different in anti-SLA positive AIH patients from negative ones.Data regarding AST extracted came from 583 AIH patients (anti-SLA positive in 91 cases and negative in 492 cases), and the analysis showed that the pooled mean AST levels were significantly lower in seropositive patients than in seronegative patients, according to the fixed-effect model  reported data about liver histological scores for inflammation. There was no significant association between anti-SLA and the inflammation scores in the fixed-effect model.One study with histological data of fibrosis index showed that anti-SLA was not associated with the degree of liver fibrosis Table .20 Among the 8 studies were 3 concerning the frequency of hepatic death,20 3 concerning the frequency of LT,21 and 4 concerning hepatic death or LT as another outcome measure.20Seven studies reported the evaluation of cirrhosis at the diagnosis of AIH.P > 0.05).Figure P = 0.011). However, the frequency of LT or the conjunction with hepatic death was comparable between the 2 groups.Anti-SLA were independently associated with the development of hepatic death   Figure B.20 The anti-SLA seropositive patients had HLA allotype DR3 more frequently than seronegative patients (64% vs 47%). Meanwhile, the seropositive patients had HLA DR4 less often than seronegative patients (20% vs 36%). The pooled results indicated that HLA DR3 was positively associated with anti-SLA   in the random-effect model . The funnel plots were shown in Figures S1–S3, http://links.lww.com/MD/A294.We assessed publication bias for all pooled ORs with CIs using Egger and Begg tests. The publication bias was 22 In the 4 studies included for analysis, serum AST levels tended to be lower in SLA seropositive patients and the difference was statistically significant. The bilirubin and IgG levels were comparable between the 2 groups. Thus, these traditional inflammatory markers might be insensitive to define disease severity here. Moreover, 2 studies with liver biopsy showed that patients with SLA positive or negative AIH had no significant difference in the degree of inflammation or fibrosis.There have been very few studies about the prognostic implications of antibodies to SLA, and the conclusions remains controversial.It was suggested that antibodies to conformational epitopes of SLA defined a severe form of AIH. However, the slightly higher frequency of cirrhosis at diagnosis in patients with anti-SLA did not distinguish them from those without anti-SLA. We also found that the frequency of hepatic death or application of LT, as 1 outcome-measure, was comparable in patients with or without anti-SLA. It is not surprizing because the organ sources are extremely limited and quite a few patients on the waitlist died of liver failure before LT was available. Interestingly, our analysis suggests that the presence of anti-SLA confers an over 3-fold increased risk of hepatic death in patients with AIH.17 indicated that patients with anti-SLA positive AIH had excellent responses to immunosuppressive therapy and reached complete remission within 1 to 7 months. In contrast, Montano-Loza et al19 suggested a less satisfying response. Based on the analysis of data from 8 studies, we found that the overall responses to immunosuppressive therapy did not differ significantly between seropositive and seronegative AIH patients. However, anti-SLA seropositivity was associated with nearly 2-fold increased risk of relapse after drug withdrawal. These finding suggests that the presence of anti-SLA may justify indefinite treatment after the induction of remission.With regard to the initial response in AIH patients with and without anti-SLA to immunosuppressive therapy, it remains controversial. Kanzler et al20 Therefore, anti-SLA antibody has a high degree of specificity for AIH and might reflect a pathogenic process more strongly than either antismooth muscle antibody (ASMA) or antinuclear antibody.Concerning the structure of protein, SLA has sequence homology with a short segment of human asialoglycoprotein receptor, which forms part of a hydrophobic membrane-spanning region. Thus, it may be possible that SLA can be inserted into the hepatocyte membrane and be targeted by immunocytes.23 A recent study revealed the association between the persistence of high titers of ASMA and/or antiactin antibodies and disease activity in patients with AIH.24 With respect to anti-SLA, previous studies indicated that it persisted during the disease and its treatment.20 However, it remains unknown whether the patients with untreated AIH have this auto-antibody in higher titers and how the titers change during disease progress and treatment course.Reactivity and titers of autoantibodies may vary during the course of AIH. For instance, ASMA and antinuclear antibody commonly disappear and reappear. Their disappearance was found associated with the improvement of laboratory and histological features of AIH.25 suggested that HLA DR3 was associated with early age onset and treatment failure, whereas HLA DR4 was associated with concurrent other immune diseases and remission during immunosuppressive therapy.26 Our analysis showed that patients with anti-SLA have HLA DR3 more frequently than patients without. The association of anti-SLA with relapse after drug withdrawal might reflect this allelic association.HLA DR3 and DR4 are known susceptibility factors in AIH. Czaja et al29 when surveillance in cirrhotic patients is considered to be cost-effective.30 Therefore, further studies are needed to determine the association of anti-SLA and the risk of HCC.Admittedly, our study has some limitations. Our restriction to studies published in English-language means some relevant studies might be missed in particular ethnic groups if they were published in non-English. Fortunately, only a small minority of studies was excluded specifically because they were not in English. Besides, 63% of the enrolled studies were conducted in countries where English is not the primary language. Another limitation of our study is that HCC, which is an important outcome of AIH, has not been covered. Actually, the risk for HCC for patients with liver cirrhosis caused by AIH has not been fully elucidated. Most studies have found that HCC in AIH was relatively uncommon, with the annual incidence of lower than 1.5%,In conclusion, our meta-analysis, for the first time, identified that patients with anti-SLA had over 3-fold increased risk of hepatic death and nearly 2-fold increased risk of treatment relapse, compared with seronegative patients. Anti-SLA may serve as a prognostic indicator for AIH. Our findings suggest that this subset of seropositive patients should be maintained indefinitely on individually adjusted medication in order to improve their prognosis.