University of Heidelberg Alcohol Research Center Alcoholic ... · PDF fileAlcoholic Hepatitis...

Alcoholic Hepatitis

and the Effect of Alcohol on other Types

of Hepatitis

Helmut K. Seitz

Centre for Alcohol Research, University of Heidelberg,

Germany

&

Department of Medicine, Salem Medical Centre,

Heidelberg, Germany

Seminar for laeger i alkohol- og stofmisbrugsbehandlingen

Vaerlose, Denmark, 12.-13.November 2014

Alcohol Research Center

University of Heidelberg

Alkoholforschungszentrum

Universität Heidelberg

Natural Course of Alcoholic Liver Disease

LTX

Decompensation

(20-40 %)

Hepatocellular Cancer

(3-10 %)

Alcoholic

Steatohepatitis

(10-35 %)

Alcoholic Fibrosis (20-40 %)

Alcoholic Cirrhosis (8-20 %)

Healthy Liver

Alcoholic Fatty Liver (90-100 %)

Alcoholic

Hepatitis

70

% 4

0 %



Definition

• One has to distinguish between a mild Alcoholic Steatohepatitis

(ASH) with elevation of serum transaminase activities and the

clinical feature of an Alcoholic Hepatitis (AH). The first has a good

prognosis with alcohol abstinence, while AH has a poor prognosis

with high mortality.

• Severe AH is a Clinical Syndrom with Jaundice, and Signs of

Hepatic Decompensation due to Alcohol.

• In approximately 30% AH is present in Alcoholic Cirrhosis.

• Alcoholic Steatohepatits (ASH) is a histologic Diagnosis with

Steatosis, Hepatocellular Balooning, and Infiltration of Neutrophils.



Alcoholic Hepatitis (AH)

AH is a clinical Syndrom characterized by

jaundice, anorexia, and hepatomegaly

with extensive hepatocellular necrosis,

inflammation and Fibrosis.

AH represents a spectrum of clinical Symptoms and is frequently present in

cirrhosis (acute on chronic disease).

Mortality depends on the severity of the disease.

MILD MODERATE SEVERE

30 day

Mortality

20% >40%

68%

PROGNOSIS

_

_ _ 8 year

Cirrhosis

Development

Morgan MY, 1994



Risk Factors

1. Non-genetic Risik factors of AH:

Massive Alcohol Abuse

Female Gender

Overweight and Obesety

2. Genetic Risk Factors have not been identified so far.



Alcoholic Steatohepatitis

PVF

Mallory-Denk-

Bodies



Diagnostics

Typical Clinical Feature

(Signs of Hepatic Decompensation: Jaundice, Fever, Ascites, HE,

Bleeding, Weight Loss, Malnutrition)

Alcohol History

Laboratory: DeRitis Ratio (AST>ALT; often >2, often not higher than 300U/l)

Histology: According to EASL Guidelines Liver Biopsy (konventional or

transjugular) is recommended but not mandatory.

Fibrosis: Transient Elastography



Differential Diagnosis

DILI

Sepsis

Ischemic Hepatit is



Prognosis

Discriminant function 1)

1) Maddrey et al. Gastroenterology 75,193:1978

2) Wiesner et al. Gastroenterology 124,91:2003

MELD 2)

4,6 x (PTT Patient – PTT Controls) + Bilirubin (mg %)

32= 1 month mortality 50 %

9,57 x loge (Krea mg %) + 3,78 x loge (Bili mg %) +

11,2 x loge (INR) + 6,43

21 = 3 month mortality 20 %



Glasgow Alcoholic Hepatitis Score

> 14.5 7.25-14.5 < 7.25 Bilirubin (mg%)

> 2.0 1.5-2.0 < 1.5 PT ratio

- > 5 < 5 Urea (mmol/l)

- > 15 < 15 WCC (109/l)

- > 50 < 50 AGE

3 2 1

SCORE

OVERALL ACCURACY

OUTCOME ON DAY 84

57 % vs. 78 % day 6-9

53 % vs. 75 % day 1 GAHS vs. DF

Forrest et al.GUT 2005;54:1174-79



Treatment of Severe AH



Nutritional Therapy – What is confirmed?

Established

– oral/enteral diet: improved malnutrition and

complications (A), mortality questionable

influenced in Alcohol Hepatitis (B)

– enteral diet through NG-tube: effectiv, no

increased complications, poor compliance

(B)

– parenteral diet: unsufficient data

Stickel et al, Aliment Pharm Ther 2003;18:357

No proven advantage on survival by:

o parenteral Nutrition

o branched-chain amino acids

o Anabole Steroids

o Vitamin Substitution



Steroids: meta analysis

• data of the last 3 RCTs

• 102 Placebos, 113 steroids

• All: DF >32, without

infections, without bleeding

• 28 days survival 85 % vs.

65 % (p<0.001)

• Only 1/5 has an advantage

• Age and creatinine have

also to be considered

Mathurin et al 2002



Who responds to steroids?

• 238 patients

• all DF > 32

• all treated with steroids

• ECBL = Early Change of Bilirubin Levels after 7 days of therapy

• highly significant for 6 months survival

Mathurin 2003

Louvet 2007



Steroid Therapy: Summary

• Steroids should be used in AH with DF>32 and GASH>9.

• Prerequisite: no GI bleeding, no infection (treatment of the

infection has priority).

• Problem: septic complications

• If ECBL appears within 7 days , therapy has to be continued,

otherwise stop therapy.



• AH no LTX

• Alcoholic Cirrhosis: 6 Month

Abstinence

Organ Availability!

Present Concept of Liver Transplantation in

ALD



Time of Abstinence before LTX Survival Died +

< 6 mo (n = 11) 7 4

6 to 24 mo (n = 29) 25 4

> 24 mo (n = 33) 20 13

Total 52 21

+ p NS

Kumar S, et al. Hepatology. Vol 11, No 2, 1990

Effect of Abstinence on Post-Transplant

Survival in Patients with Alcoholic Cirrhosis



Time of Abstinence before

LTX Total n (%) Drinking n (%) P Value

< 6 months 18 (6.6) 9 (50.0)

6 - < 12 months 64 (23.5) 15 (23.4) 0.001

12 months 190 (69.9) 30 (15.8)

Total 272 (100) 54 (19.9)

Pfitzmann R, et al. Liver Transpl. 13:197-205, 2007

Time of Abstinence before LTX and

Relapse after LTX



a. Frequency: 2nd frequent cause

b. Survival: Similar or better compared to other etiologies

c. Relapse: Yes

The Incidence depends on Definition.

In general no major problem. May, however,

have an influence on survival.

Therapy is available.

LTX in ALD: The Facts



Mathurin P. et al, N Engl J Med ;2011;365:1790-800

Survival of Patients with Severe AH and

LTX without Abstinence prior to LTX



Mathurin P. et al, N Engl J Med ;2011;365:1790-800

Survival of Patients with Severe AH and LTX

without Abstinence prior to LTX



Rapid onset of jaundice ,

poor liver function ,

active, most recent alcohol abuse

Exclusion of other causes of acute liver

failure

Prognosis-Scores (MDF, MELD,GAHS)

Low Risk:

MDF<32; MELD<18; GAHS<8

Increased Risk:

MDF≥32; MELD≥ 18; GAHS≥ 8

Hepatic Encephalopathy

Exclusion / Treatment of Infections

Malnutrition

•Nutrition Therapy (35kcal/kg; 1,5g/kg Proteine)

•Prednisolon 40mg/tgl. ± N-acetylcystein

Stop: No Response following 7 days of Treatment

•Possiblyl Pentoxifyllin (2 x 400mg/tgl. for 4 Weeks) Nutritional Therapy

(35kcal/kg; 1,5g/kg Protein)

Responder

(Lille Score<0,45)

Non- Responder

(Lille Score≥0,45)

Treatment for 28 days

Supportive Care, Treatment of Alcoholism, Follow up (HCC Screening)

LTX???

Adequate nutritional

status



Laboratory AFL/ASH

AFL: Frequently increased Serum -GT activity,

occasionally up to 4000 U/L.

ASH: Elevated Serum AST Activity (< 300 U/L) and

Serum -GT activity :often extremely high

AST/ALT-Ratio > 1



Ethylglucuronid as a highly sensitive Marker for

Alcohol Consumption



Ethylglucuronide:

Healthy individuals: 1 Glas of Wine/1 Bottle of Beer

EtG ca. 20h measurable in the urine,

ca. 0.1-0.5mg/l

Alcoholics: Begin of Detoxification : 2mg/l

after 24h Detoxification: 0.5 – 2mg/l

0.5mg/l

CDT: ca. 1week 60g ethanol /day (1 bottle of wine)

Albermann Int J Legal Med. 2012 Sep;126(5):757-64.

Amount of Ethanol?



Case Report II

Male, 59 years, LTx 2 years ago due to HCV Cirrhosis.

April 2013: jaundice, HCV-RNA 9 Mill IU/ml, Bili:10 mg%, GOT 412

U/l, GPT 470 U/L, GGT: 3039 U/L, AP:214 U/l

Histology: Steatosis, cholestatic HCV Relaps

Therapy: Sofosbuvir + RBV for 24 weeks, HCV RNA negativ

Laboratory: GOT: 89 U/L, GPT: 76 U/L, GGT: 800 U/L, Bili: 1.8mg%

Histology: no hepatitis, severe steatosis

EtG: > 2000 µg/g Creatinine



Natural Course of Alcoholic Liver Disease

• Amount of Alcohol

• Genetics

• Gender

• Other Liver Diseases (HepB/C,

Hemochromatosis, NASH)

• Obesity / Malnutrition

• Iron

• Drugs + Toxins (Cannabis)

• Vitamin A

• Smoking

LTX

Decompensation

(20-40 %)

Hepatocellular Cancer

(3-10 %)

Alcoholic

Steatohepatitis

(10-35 %)

Alcoholic Fibrosis (20-40 %)

Alcoholic Cirrhosis (8-20 %)

Healthy Liver

Alcoholic Fatty Liver (90-100 %)

Alcoholic

Hepatitis

70

% 4

0 %



Mallory Bodies, not only

peripherally (NASH), but also

centrally (ASH) found. Signs of

endogenous and exogenous

toxic damage

HE-stain

Round cell infiltrates by lymphocytes.

Typical for chronic Hepatitis C

Ballooning and fatty

hepatocytes

Casuistic Alcohol Research Center


Ladewig-stain

Pseudolobuli

chicken wire fibrosis.

septa

Casuistic Alcohol Research Center


Casuistic

Mallory Bodies

Mallory Bodies

Mallory Bodies



Etiology of chronic liver disease

Center of Disease Control and Prevention (Singal & Anand, 2007)

Hepatitis C +

Alcohol

14%

Hepatitis C

26%

Alcohol

24%Cryptogenic

17%

Others

5%

Hepatitis B +

Alcohol

3%

Hepatitis B

11%



Effect of Alcohol on Various Liver Diseases

• Hepatitis C

• Hepatitis B

• Non-Alcoholic Fatty Liver Disease

• Hereditary Hemochromatosis

• Drug Induced Liver Injury



1. INFLUENCE OF ALCOHOL ON THE PREVALENCE

OF HCV INFECTION

2. HEPATIC INTERACTIONS OF ALCOHOL AND HCV

VIRUSREDUPLICATION

FIBROSIS

HEPATOCELLULAR CARCINOMA

3. INFLUENCE OF ALCOHOL ON THE RESPONSE OF

HCV TREATMENT



Alcoholic liver disease and HCV prevalence

0

20

40

60

80

100

% Anit-HCV

positive

Alcoholic

fibrosis

Cirrhosis HCC

Takase et al., Alcohol Alcohol Suppl 1993;1A:77-84.




OF HCV INFECTION


VIRUSREDUPLICATION

FIBROSIS, CIRRHOSIS



HCV TREATMENT



Impact of alcohol consumption on serum

HCV-RNA level

Pessione et al. Hepatology 1998; 27: 1717-1722

Serum HCV-RNA (mEq x 105)

0

80

120

140

100

60

40

0 1-69 70-139 140-209 ≥ 210

SRAC g/Week

Serum HCV-RNA (mEq x 105)

0

80

120

140

100

60

40



Effect of alcohol reduction on serum HCV-RNA

Cromie et al. J Hepatol 1996; 25: 821-826

Copies/ml x 105

35

30

25

0

40

10

Start of Study

39-100 g daily

20

15

5

After 4 months

0-50 g daily

p = 0,018



Relative Risk (RR) for advanced fibrosis (FF) cirrhosis

(Ci), and decompensated cirrhosis (dCi) in Patients

with chronic HCV Infection and heavy Alcohol Abuse

(210-560 g/week)

Singal & Anand Clin Gastroenterol 2007; 41: 761-772

0

2,5

3

4

2

3,5

RR

FF

fortgeschrittene

Fibrose

Ci

Zirrhose

dCi

dekompensierte

Zirrhose

1,5

1

0,5



Alcohol and Liver Fibrosis

Patienten (%)

0

60

100

80

0 1-20 21-30 31-50

40

20

Alkohol (g/d)

Fibrosestadium

0-1

2-4

Hézode et al. Aliment Pharmacol Therap 2003;17:1031-37



Effect of Alcohol intake on the progression of hepatitis C

Patients Result

2.235 HCV 0; < 50; > 50 > 50 Progression of fibrosis

(p < 0,001) Poynard 1997

Roudot-Thoraval 1997

6.664 HCV

> 5 (f); >6 (m) drinks; > 1 J Higher prevalence of cirrhosis

(35 vs. 18 %; p < 0,001)

Serfaty 1997 168 HCV with &

without Ci < 30; 30-80; > 80; > 5 J

Higher prevalence of cirrhosis

(p < 0,05)

Ostapowicz 1998 234 HCV Calculation of total

alcohol intake p < 0,02

Pessione 1998 233 HCV Quantification of weekly alcohol

intake

Weekly alcohol correlates

with fibrosis score (p < 0,006)

176 HCV 40 (f); > 60 (m); > 5 J Faster progress of cirrhosis

(58 % vs. 10 %; p < 0,001) Wiley et al.

Carrao 1998 702 HCV 0; 25; 50; 75; 100; >125 RR for decompensated cirrhosis

= 9,2 (-50); 26,1 (-100); 133 (<125)

Thomas 2000 1.667 IDU + HCV Quantification Risk for ESLD 3,6 bei

>260 g/wkly comp. to < 90 g/wkly

Alcohol (g/d)

Harris 2001 636 HCV > 80 RR cirrhosis: HCV 7,8;

HCV + alcohol 31,1

Author



Fibrosis, alcohol and HCV

Wiley et al., Hepatology 28:805, 1998



0

1

2

3

4

0 5 10 15 20

Years of exposure

Fib

rosis

Gra

de

HCV + alcohol

HCV alone

Poynard et al. Lancet 1997; 349: 825-832

Fibrosis RR > 50 g Ethanol/day = 2,4 (p = 0,0001)

Alcohol and progression of hepatitis C

Patients: 78 with two liver biopsies at an mean

interval of 6.3 years.

Alcohol: < 40 g/d (median 5 g/d,1-12 g/d)

Result: Increase in progressive fibrosis:

1. Higher total alcohol

(15,4 kg vs. 3,9 kg; p = 0.007)

2. Higher daily alcohol consumption

(5,7 g vs. 2,6 g per day; p = 0,03)

3. Higher drinking frequency

(35 vs. 8 days per year; p = 0,006)

Westin et al. J Viral Hepat 2002; 9: 235-241



Odds ratio of HCC for patients with various amount of alcohol

intake with and without hepatitis C Alcohol Hepatitis C

Author / Country Case / Controls

(Quantity)

Odds ratio

(95 % Ci)

Case / Controls

(Quantity)

Odds ratio

(95 % Ci)

Tagger et al., Italy

Daily alcohol intake (g/d)

< 40

40-80

> 80

31 / 219

27 / 157

102 / 203

1.0 (reference)

1.5 (0.7-2.9)

7.3 (4.0-13.1)

47 / 18

32 / 7

42 / 5

26.1 (12.6-54)

62.6 (23.3-168)

126 (42.8-373)

Hassan et al., USA

Daily alcohol intake (g/d)

No

Yes

< 80 g/d

> 80 g/d

40 / 136

75 / 94

33 / 63

42 / 31

1.0 (reference)

2.4 (1.3-4.4)

1.7 (0.9-3.7)

4.5 (1.4-14.8)

19.1 (4.1-89.1)

53.9 (7.0-415.7)



Relative risk of HCC through alcohol consumption,

with and without hepatitis B/C-infection

Donato et al. Am J Epidemiol 2002; 155: 323-331

20

0

40 60 80 100 120

alcohol consumption

(g/day)

Log (Odds Ratio)

with HCV-infection 15

10

5

140

with HBV-Infection

without HCV-/HBV-

infection



Is there any dose of alcohol that causes no further

damage in hepatitis C? 1. Fibrogenesis is dose-dependent and starts already with small amounts of

alcohol (less than 30 g per day). There is no safe dose of alcohol for patients

with HCV infection, obese patients and diabetics are particularly at risk. (Monto

et al, Hepatology 39, 826-34:2004).

2. HCV patients with a history of excessive alcohol consumption have a 2-3-fold

increased risk to develop severe liver diseases compared to HCV patients

without alcohol consumption in the past (Delarocque-Astagneau et al, Ann

Epidemiol 15,551-557:2005).

3. It is still not clear how long a patient needs to restrain from alcohol to allow the

negative effects of alcohol to dissappear. (Tabone et al, J Viral Hepat 9,288-

294:2002).

4. The abstinence rate seems to be higher in alcoholics with HCV infection than in

alcoholics without HCV infection (Rifai et al, Psychosomatics 47,112:2006).




OF HCV INFECTION


VIRUSREDUPLICATION

FIBROSIS, CIRRHOSIS



HCV TREATMENT



Alcohol and Anti-HCV Treatment

Alcoholics have a lower response rate to

treatment with Interferon

(10 studies between 1994-2005).



Influence of alcohol on the Hepatitis – C - Therapy

Vir

olo

gic

al a

nd

bio

ch

em

ica

l tr

ea

tme

nt

res

po

ns

e (

%)

0

30

40

Alcoholics Non-alcoholics

20

10

ALT HCV RNA ALT HCV RNA

Mochida et al. Alcoholism Clin Exp Res 1996; 20: 371A-77A



Inhibiting effect of alcohol or bad compliance ?

In 726 patients, alcohol consumption during the past 12 months was

closely linked with a higher rate of discontinued therapy. (40% vs.

26%, p=0.002).

After correction the response rate was comparably similar (25% vs.

23%,NS) (Anand et al, Gastroenterology 130,1607:2006)

Bad compliance in alcoholics is probably the main reason

for a lower response rate compared to HCV treatment

Conclusion:



Alcohol and Anti-HCV Treatment

Summary

1. Alcoholics have an increased prevalence of HCV infection (life style,

immunosuppression?)

2. High alcohol consumption (> 50 g/day) stimulates 1) hepatic fibrogenesis

with an increased risk for cirrhosis and 2) hepatic carcinogenesis with an

increased risk for HCC.

3. A threshold level is difficult to state. Women reveal a deterioration of hepatic

histology already at a lower alcohol intake as compared to men. It is unclear

how long ethanol abstinence needs to be perfrormed to prevent the negative

effect of ethanol.

4. Alcoholics have a relatively low success rate of antiviral therapy, possibly

due to poor compliance.

5. Mechanisms explaining the negative effect of ethanol on hepatitis C include:

1) Stimulation of HCV replication and an increased generation of

quasispecies,

2) Immunomodulation,

3) increased oxidative stress due to various mechanisms,

4) increased fat accumulation.




• Hepatitis C

• Hepatitis B






Effect of alcohol on the development of a hepatocellular

carcinoma (cirrhosis) in HBSAG positive male patients



Ohnishi et al., Cancer 49,672 1982

Amount of alcohol HCC

(ml/day)

Number of

patients

Age (years)

Kein 7 (8) 61 ± 7 (49 ± 14)

< 24 20 (10) 49 ± 9 (39 ± 8)

25 – 75 5 (5) 43 ± 7 (35 ± 8)

75 – 125 12 (8) 50 ± 9 (43 ± 6)

> 125 3 52 ± 6

Patients Alcohol

RR

(compared to

no alcohol)

Reference

N = 400

chron. Hep B

≥ 3 days / week

> 15 years 3 – 5

Chen CJ, et al.

Hepatology

1991;13:398-406.

N = 341

HBSAg + 27 g / day 5

Oshima A, et al.

Int J Cancer

1984;34:775-9.

Risk of HCC in Patients with Hepatitis B and

Ethanol Consumption




• Hepatitis C

• Hepatitis B






Alcohol and nutrition

Moderate alcohol consumption

• Alcoholaddition

• 6-10 % of daily energie

• Metabolism by ADH

• Increase in weight



Steatosis at ultrasound

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

C HD O O+HD

16

46

76

94,5

Bellentani & Tribelli. J Hepatol 2001; 35:591

HD = Ethanol > 60g/d O = BMI > 25kg/m2



Obesity as a risk factor of ALD progression

Fibrosis ≤ 2

(n=151)

Fibrosis > 2

(n=117)

P

Age 50 ± 1 57 ± 1 <0.001

Female sex (%) 17 30 <0.01

BMI 23 ± 0.3 25 ± 0.4 <0.005

Alcohol (g/d) 110 ± 7 110 ± 6 NS

Alcohol (duration) 24 ± 1 30 ± 1 <0.005

Glucose 5.3 ± 0.1 7 ± 0.5 <0.01

Triglycerides 1.7 ± 0.3 1.5 ± 02 NS

Cholesterol 2.4 ± 0.1 2.3 ± 0.1 NS

Perl‘s grade 0.86 ± 0.06 1.18 ± 0.09 <0.005

Raynard et al. Hepatology 2002;35:635-8

0

20

40

60

80

100

120

140

Normal (BMI 21) Obese (BMI 29)

cirrhosis (%)

alcohol (g/d)

Naveau et al. Hepatology 1997;25:108-11

N=1,432

N=172



Factors associated with HCC in NASH

(n = 195)



Hazard Ratio

Characteristic (95% Confidence Interval) P Value

Age at time of cirrhosis diagnosis 1.07 (1.02-1.1) 0.012

Male sex 2.08 (0.94-4.6) 0.071

Non-Caucasian 0.92 (0.12-6.8) 0.93

BMI 0.94 (0.89-0.99) 0.025

Ever smoked 0.87 (0.39-1.9) 0.73

Any alcohol consumption 3.6 (1.5-8.3) 0.003

Diabetes mellitus 1.00 (0.40-2.5) 0.99

Ascha et al, Hepatology 2010; 1:1972-1978

Alcohol

Social Alcohol Intake compared with no Alcohol

Intake in the Development of HCC in HCV and

NASH



Ascha et al, Hepatology 2010; 1:1972-1978


• Hepatitis C

• Hepatitis B






Iron Deposition in ALD and Hepatitis C

HCV ALD

Alkoholforschungszentrum


no of subjects

death or hospitalisation related to cirrhosis or HCC

per 100.000 person-years hazard ratio

Transferrin saturation

15-30% 4658 76 1

30-35% 1355 100 1.3

35-40% 906 101 1.3

40-50% 815 175 2.3

>50% 326 311 4.1

<15% 707 101 1.3

Alcohol consumption

>2 drinks/day 5499 346 4.1

Alcohol consumption and Tf-S

>2 drink/day + Tf-S>40% 2483 480 6.9

Data from National Health and Nutrition Examination Survey (NHANES I), Ioannou et al. Clin Gastro and Hepatol. 2007

Iron overload is a prognostic factor for liver

disease





Gut 2000; 46:277-282


• Hepatitis C

• Hepatitis B








Mol.Med 17, 1285-94, 2011

Histology and Liver Collagen Accumulation in

Alcohol-Treated wild type and CB1-/- Mice



Patsenker et al. Mol Med. 2011 Aug 19;17(11-12):1285 - 94.

WT/no EtOH WT/EtOH

CB1-/-,EtOH CB1-/-,no EtOH

Alcohol and Cocaine

Cocaethylen

Cocaine + Ethanol

Cocaine alone

JPET 283,164-176, 1997

Kokaethylen

Kokain

+ Alcohol

100 mg Cocaine intranasal + Alcohol (0.8 g/kg)



Hepatotoxicity of Ethanol plus Cocaine in

Mice

Drug Alcohol Dep 31:253, 1993

0

2

4

6

8

10

12

14

Con

jug

ate

d D

ien

es

Ctrl/

NaCl

Ctrl/

ETOH

Coc/

NaCl

Coc/

ETOH

0

2000

4000

6000

8000

10000

12000

14000

SG

PT

U/L

Ctrl/

NaCl

Ctrl/

ETOH

Coc/

NaCl

Coc/

ETOH



Effect of Alcohol and

Cocaine on the

Cardiovascular System

placebo ( ), alcohol (), cocaine () and the

combination of alcohol and

cocaine ().



Methotrexate

Injury to

stellate cells

Hepatocellular

necrosis

Injury to

limiting plate

Perioportal

fibrosis

Portal-portal

fibrosis

Steatosis

Cirrhosis

Fibroblast

activation

Centrizonal

fibrosis

Central-portal

fibrosis

Alcohol



NADH+H+

NAD+

ADH

NAD+ NADH+H+

ALDH

Mitochondrium

Ethanol Acetaldehyde Acetate

Ethanol Metabolism

Cyp2E1

Microsomes

Cyp2E1

Drugs Metabolites

Procarcinogens Carcinogens

Vitamin A Metabolites

(toxic & apoptotic)



alcoholic fatty liver after 14 days of alcohol abstinence

Cytochrom P450 2E1 – Induction by Alcohol



Alcohol consumption and CYP2E1 activity

Oneta C, Lieber CS, Ji JJ, Rüttiman S, Rosman J, Seitz HK. J-Hepatol 2002;36:47-52



Inhibition of Meprobamate Metabolism by Ethanol

50

100

150

200

Ethanol 0 10 mM

p<0,01

50 mM

p<0,01

100 mM

p<0,01

ngM

B /

g L

eber

/Std

Rubin et al, Am J. Med., 49, 801-6, 1970



Chronic Ethanol Consumption enhances

Clearance

10

100

0 6 12 18 24

Stunden

Me

pro

ba

ma

t im

Blu

t %

Cm

ax

vor Alkohol nach Alkohol

Amer J Med 51:346-351, 1971

• Alcohol in a Dosis of 16% of total Calories during 1 month to 4 volunteers (ca. 50 g Alcohol/day)

• Meprobamat (Meprodil®) – Clear T1/2

• Pentobarbital

– Clear , T1/2

• Alcohol

– Elimination (13.8 → 23.8 mg/100ml/h)



Metabolism of Isoniacid



Isoniacid

Acetylisoniacid

Acetylhydrazin

Diacetylhydrazin

NAT2 (PM)

Hydrolyse

NAT2 (PM)

Hepatotoxins

CYP2E1 (PM)

Hepatotoxicity of Isoniacid

Risk factors

• Acetylator-Phenotype

• CYP4502E1

– Genotyp (Wildtype c1/c1 )

– Activity (Alcohol)

• Alcohol consumption

• Rifampicin (Enzyme induction)

• Age

Huang et al.,Hepatology 37:924, 2003

0%

5%

10%

15%

20%

25%

30%

fast slow

Incidence of transaminases >2x Norm

CYP4502E1 Genotype c2/c2 od c1/c2 c1/c1

Acetylators



Äthanol und Mikrosomen

S

Normal Leber Mikrosomen

Akuter Äthanol Leber Mikrosomen

Chronischer Äthanol Leber Mikrosomen

Nach Entzug Leber Mikrosomen

S

E

S

E

S

P

A

P

A

P

P



Interactions with Alcohol

Alcohol acute

• Frequently with oxidative

metabolized drugs:

Clearance decreases

Half life time increases

Bioavailability increases

• (Central acting drugs,

Antidiabetics, Nitrates)

• Acetylation increases

Alcohol chronic

Deterioration of Liver Function

Induction of CYP2E1

• Effects: partly moderate decrease

of half life time and increase of

clearance (approximately 10%) (ß-

blockers, anticoagulants )

Dosisadaptation

• However:

• Increased Toxicity of Isoniazide,

Paracetamol, Cocaine



CASE

40-year old patients suffers from depression and takes the following

drugs:

Amitryptilin (Saroten, Tryptizol), Ranitidin (Zantic), Ketoprofen

(Fastum), Paracetamol

Recently Fluoxetin (zB Fluctine) (40mg/day) was added..

On december 16th she visited a christmas party together with her

husband. Here she consumes a hot alcoholic beverage. She returns

home by 3 a.m. and takes one tablet of of amitryptiline before sleep. .

At 4.30 a.m. her husband wakes up due to her heavy breathing. He

realizes that she is unconscious.

In the Hospital her alcohol blood level is 1.3 g/l. EKG shows

supraventricular tachycardia and a prolongated QRS interval. The

patients is still unconscious and is transfered to the ICU.



At the present levels of Fluoxetin

plus Metabolite 95% of fast

metabolizers shift to phenotypic

slow CYP2D6 metabolizers.

A blood alcohol level of 1.3 g/L

interfers with the First-Pass

Metabolism of Amitryptilin and the

bioavailability is increased by a

factor of 2.

Bloood Levels of Amitryptilin Alcohol Research Center


Interaction between ethanol and xenobiotic metabolism at

the CYP2E1 site

Drugs Chemicals Carcinogens

Chemotherpeutics:

5 FU, Cyclophosphamid

Anesthetics:

Enfluoran,Isofluran,Methox

yfluran,Sevofluran

Central acting drugs:

Barbiturate, Meprobamat,

Tranquilizer

Acetaminophen

(Paracetamol)

Phenytoin

Propranolol

Isoniacid

Rifamipicin, Tolbutamide

Methadon

Warfarin

Aceton,

Butanol,

Pentanol

Anililn

Benzen,

Bromobenzen

CCI4

Solvents

Vinyle chloride

Acetyl Amino Fluorene,

2-Amino Fluorene

4-Amino Biphenyl

Aflatoxin

Amino Acid, Pyrrolyzates

Benzo (2) Pyrene

Dimethylhydrazine

Nitrosamine

Others

Vitamine A


AFZ



0

100

200

300

400

500

600

700

800

900

Normal Liver Fatty liver Alcoholic liver Cirrhosis

hepatic

vita

min

e A

(µ

g/g

wet w

eig

ht)

< 0.001 < 0.001 < 0.001

Liver autopsy

diabetes

Alcoholic liver disease and vitamine A

Concentration in the liver

Leo und Lieber, 1982



Retinoids, Ethanol and Cancer

RETINOL RETINAL RETINOIC ACID

RETINOIC ACID

ETHANOL

CYP2E1

ADH ALDH

METABOLITES

(apoptotic)

AP-1 GENE EXPRESSION

HYPERPROLIFERATION



Summary and Conclusion

• Chronic alcohol consumption is a risk factor for the deterioration of various types of liver disease such as hepatitis B and C, NAFLD, HH and DILI including cannabis and vitamin A associated liver fibrosis.

• Depending on the underlying liver disease this negative effect of alcohol is time and dose dependent, but may occur already at much lower alcohol intake as compared to an alcohol dose necessary to initiate alcoholic liver disease itself.

• As a consequence alcohol intake should be avoided or at least limited and certainly not consumed chronically under these conditions.



PRM-INDUCED DNA

FRAGMENTATION IN HEP G2 CELLS

Dan et al. FASEB J 19;1-4, 2005



Control (120h) PRM (24h) PRM (48h)

PRM (72h) PRM (96h) PRM (120h)

B

0

5

10

15

20

25

Control 24 48 72 96 120

Time (h)

% o

f S

ub-G

1

PRM – INDUCED TOXICITY




C AST C AST

A LDH

B LDH

0

10

20

30

40

50

60

70

80

90

100

0 3 6 12 24

Time (h)

LD

H le

akage (

%)

PRM

Control

C AST D AST

0

10

20

30

40

50

60

70

80

90

0,02 0,04 0,075 0,15 0,3

PRM Concentration ( m M)

AS

T le

akage (

%)

PRM

Control

0

3

6

9

12

15

0 3 6 12 24

Time (h)

AS

T le

akage (

x-f

old

to c

ontr

ol)

80

m

0

10

20

30

40

50

60

70

LD

H le

akage (

%)

PRM

Control

0.02 0.04 0.075 0.15 0.3

PRM concentration ( M)


A

Control (24 h) PRM (1 h) PRM (3 h)

PRM (6 h) PRM (12 h) PRM (24 h)

PRM (6h) PRM (12h) PRM (24h)

Control (120h) PRM (1h) PRM (3h)



EFFECT OF PRM ON MITOCHONDRIAL MEMBRANE

POTENTIAL

Alkohol als Risiko-Faktor für Paracetamol Hepatotoxizität

Ann Intern Med 104:399, 1986

toxic range

for non-

alcoholics

Experimentell:

• Akuter Alkohol schützt vor

Toxizität

• Chronischer Alkohol erhöht

Toxizität


AFZ

100

1000

10000

100000

0 10 20 30

Dose of Paracetamol g/24h

AS

T I

U/L

Paracetamol, GSH-Metabolite und Plasma GSH Plasma GSH wurde nach 2 g Paracetamol in 5 Alkoholikern und 5 Kontrollen gemessen

Velez und Lauterburg, Gut 29:1153, 1988

p<0.02 vs baseline

Mercaptur-

säure Addukt

Cystein

Addukt


AFZ

2g Paracetamol

0

100

200

300

µm

ol/

6h

Controls Alcoholics

0

2

4

6

8

10

0 2 4

Time after Paracetamol (h)

Pla

sma

GS

H n

mo

l/m

l

Controls Alcoholic Subjects

Pharmakodynamische Interaktion mit Antihistaminikum Hydroxyzin (Atarax) 50 mg + 0.3 g/kg Alkohol (ca. 0.5 Promille)

-5

0

5

10

15

20

25

30

35

0 2 4 6

Stunden

Mo

tor

Re

actio

n T

ime

(m

s)

Plazebo Plazebo+ETOH

Hydroxizin Hydroxizin+ETOH

Clin Ther 2003;25:1518-38


AFZ

% p

ositiv

e c

ells

for ed

A

Correlation between 4HNE, CYP2E1 and

etheno-DNA-adducts in liver biopsies

% p

ositiv

e c

ells

for ed

A

CYP2E1 staining intensity

1 2 3

0 2

0 4

0 6

0 8

0

1 2 3

0 2

0 4

0 6

0 8

0

4-HNE staining intensity

r = 0.846, p<0.01 r = 0.93, p<0.01



Wang et al. Hepatology 2009;50:453-61

H.K. Seitz & F. Stickel 2007



HCV, alcohol and oxidative stress

Inflammation / Liver Damage

NFκB

STAT-3

Products of

Lipid peroxidation

Fibrosis

HCV

Mitochondrial

Damage,

Steatosis

ROS

HCC

Ethanol

Iron



Mechanisms of Alchohol-HCV Interaction

• HCV Replication (intracellular signal transduction)

(Plumlee et al. 2005)

• HCV Genomes (quasi species) (Takahashi et al. 2001)

• Apoptosis (Szabo 2003)

• Immunomodulation (Geissler at al. 1997)

• Oxidative stress (cytochrome P-4502E1, Iron, glutathion)

(Seitz and Stickel 2007)

• Steatosis (Serfaty et al. 2002)



Liver histology in rats following the administration

of various diets

Wang Y, Seitz HK, Wang XD, ACER 34, 567-573, 2010



A

D

B

F E

C A B

D

Control diet

Control diet

High fat diet High fat diet

with alcohol

E F High fat diet High fat diet

with alcohol

Interactions with Alcohol

acute alcohol

• In most cases due to

oxidatively metabolized

drugs:

Decreasing clearance

Increasing half-life

Increasing bioavailability

• (antipsychotic drugs, anti

diabetic drugs, nitrates)

• Increasing acetylization

chronic alcohol consumption

Decreasing liver function

Induction of CYP2E1

• Result: partially low half-life and

increase in clearance (ca 10%)

(ß-blockers, anticoagulants)

• evt. dosis adaptation

• But:

Increase in toxicity of Isoniazid,

Paracetamol, Cocaine



Glassen K, Seitz HK 2010



Wölk und Wedemeyer, Hepatology 2008; 47: 343-5

Hepatitis C und Fettstoffwechsel

Alcohol as a risk factor for für

paracetamol hepatotoxicity

Ann Intern Med 104:399, 1986

toxic range

for non-

alcoholics

experimental:

• Acute alcohol protects against

toxicity

• Chronic alcohol increases

toxicity



100

1000

10000

100000

0 10 20 30

Dose of Paracetamol g/24h

AS

T I

U/L

0

2

4

6

8

10

0 2 4

Time after Paracetamol (h)

Pla

sm

a G

SH

nm

ol/

ml

Controls Alcoholic Subjects

Paracetamol, GSH-Metabolite and Plasma GSH Plasma GSH has been found in 5 alcoholics and 5 controls after administration of 2 g

paracetamol

Velez und Lauterburg, Gut 29:1153, 1988

p<0.02 vs baseline

Mercaptur-

acid adduct

Cysteine

adduct

2g Paracetamol

0

100

200

300

µm

ol/

6h

Controls Alcoholics



εdA and εdC correlate in liver biopsies

% positive cells for edC 0 20 40 60 80

% p

ositiv

e c

ells

for ed

A

0 2

0 4

0 6

0 8

0

r = 0.97, p<0.01



Wang et al. Hepatology 2009;50:453-61

Alkohol und HCV-Replikation

Plumlee et al. Virology Journal 2005; 2: 89

ETHANOL

- Membranproteine?

- Fluidität? Hemmung v. IFNAR?

Hemmung v. Jak?

SOCS Induktion?

↓ Stat1 Y701 ↑ Stat1 S727 ↑ p38 MAPK

↑ Antiviraler

Signalweg

IFN

↓ Antiviraler

Signalweg

↓ HCV Replikation ↑ HCV Replikation

Andere Signalproteine?

X

Mitogen-Aktivierte-Protein-Kinase (MAPK),

Signaltransduktoren und Aktivatoren der Transkription (STAT) Janus associated kinase (JaK)

Suppressors of cytokine signalling (SOCS) Interferon-Alpha Rezeptor (IFNAR)



• Design: patients with AH (DF > 32)

• Double-blind, Placebo-controlled (3 x 400 mg /d)

over 28 days

• primary end points:

• short term survival, HRS

Akriviadis et al., Gastroenterology2000;119:1637

0

10

20

30

40

50

60

70

80

90

100

PTX CTR

28 days mortality

p = 0,037

%

Result:

• improved survival, less HRS.

• decreased TNFα level

• higher effects through steroids

than expected

Pentoxifyllin in AH Alcohol Research Center


ethanol

ROS

(H2O2)

iron accumulation

Iron Accumulation by Ethanol

toxicity

hepcidin

iron absorption

iron release

TfR1

iron uptake



Isolated GGT-Elevation

1. Alcohol

2. NAFLD

3. Drugs

4. Myocardial Infarction, Insuff.

5. Acute Pankreatitis

6. Hypothyreodism

7. Anorexia nervosa

8. Myotonic Muscle Dystrophia

9. Guillain-Barre Syndrome

10. Porphyria Cutanea Tarda

11. Neurologic Diseases

12. Malignant Diseases / Radiotherapy



Comparison of CDT, GGT, MCV

in Alcoholic Liver Disease

Marker Sensitivity(%) Specifity (%)

CDT 61 92

GGT 85 18

MCV 70 66

Bell et al., Alc Clin Exp Res 17, 246:1993



Prevalence of Fractures

(Rips, vertebra, clavicle)

0

10

20

30

40

Alcohol.

Cirrhosis

Other

Cirrhosis

Controls Alcohol

Intoxication

p < 0.02 p < 0.001

Moreau et al., Alcoholism Clin Exp Res 16,141:1992



Patients

with

fractu

res

Specifity and Sensitivity of Various Markers in

ALD

Marker Specifity (%) Sensitivity (%)

Gamma-GT 17 85

MCV 36 66

Thorax Fractur 96 27

Moreau et al., Alcoholism Clin Exp Res 16,141:1992



Case Report I

Female, 62 years, LTx 3 years ago due to PSC with

elevated serum transaminase activities.

BMI: 17 kg/m2, no DM, normal lipids, graft intact.

Liver Biopsy: massive steatosis, no PSC

Ethylglucuronid: > 2000 µg/g Creatinine



Case Report III

Male, 42 years, LTx 3 years ago due to PSC, Recurrence of PSC in the

transplant.

Laboratory: GOT: 42U/L, GPT: 42U/L, GGT: 279 U/L, AP: 301 U/L

EtG: 475 µg/g Creatinine

The day before: Champion of Pistol shooting



Matrix Metalloproteinases mRNA in Alcohol-

Induced Liver Injury in wild type and CB1-/-

Mice



Patsenker et al. Cannabinoid Receptor Type I Modulates Alcohol-Induced

Liver Fibrosis. Mol Med. 2011 Aug 19;17(11-12):1285 - 94.

Fibrosis related mRNA Transcript in Alcohol-

Induced Liver Injury in wild type and CB1-/- Mice





CB1 and CB2 Expression in Human ALD





Hepatic Inflammation after Alcohol-Induced

Liver Injury in wild Type and CB1-/- Mice





Laboratory Pitfalls

Serum GGT Activity

Serum Transaminase Activity (AST/ALT)

Serum Ferritin



Histologic Prognostic Factors

Little or no Megamitochondria

Reduced Infiltration of PMNs

Increased Number of Progenitor Cells

Cholestasis



PARENTERAL NUTRITION

7 RCTs ; n = 244

21-30 days outcome:

Improvement in albumine and nitrogen balance.

No survival benefit.



LTX in Alcoholic Cirrhosis with and without

Alcoholic Hepatitis

Tome et al. J Hep 36,793,2002



Alcohol consumption and fibrosis


4.0

1.0

<10 11-20 21-30 31-40 >40

Duration of infection (years)

Grade of fibrosis

>50 g

Alcohol per

day

0-49 g

Alcohol per

day

n=1.039



Alcohol consumption and fibrosis


4.0

1.0

<30 31-40 41-50 51-60 >60

Age at biopsy (years)

Grade of fibrosis

>50 g

Alcohol per

day

0-49 g

Alcohol per

day

n=1.574



Alcohol, HCC & HCV infection

Study Result

HCV & HCC > 80 x 10 J HCC with alcohol earlier as

without (p < 0,05) Matsuda et al. 1995

Kuwana et al. 1997

HCV & HCC

> 80 Alcohol with RR =1,9

Tagger et al. 1999 CCRS 0-40; 41-80; >80 RR for HCV + 26, 63, 126

Kwon et al. 2000 RS (AC) > 80; > 5 J 34 % with AC + HCV vs. 6%

with AC without HCV

Khan u. Yatsuhashi 2000

RS (HCV) < 80; > 80 1,5x - 2,5x increased risk for HCC

HCV und HCC > 65; > 5 J Alcohol with RR = 3,04 Aizawa et al. 2000

Donato et al. 2002 CCRS > 60 2x increased risk for HCC

Hassan et al. 2002 HBCCS > 80 RR: Alcohol = 4, HCV =15,

Alcohol + HCV = 54

Alcohol (g/d) Author

75

343

915

162

120

153

1.150

345

N



Effect of Acetaldehyde, H2O2, Hypoxia and Endo- and

Exocannabinoids on CB1 and Fibrosis-related mRNA in

HSC





PREVALENCE

The Prevalence of AH is Population dependent.

A 20% Prevalence has been reported in a Biopsy Study with more than

1500 Alcoholic Patients.

Approximately 6% of all Patients with Hepatic Decompensation and

25% o an Acute on Chronic Liver Failure reveal AH (EASL

Guidelines 2012).



Cause of liver disease regarding 1.829 patients with

cirrhosis & 217 patients with HCC

De Bac et al. Hepatology 1994; 20: 1225-30. ; Morgan et al. Gastroenterology 2004; 127(Suppl 1): S87-S96

Cause of cirrhosis

HBV

HCV

Alcohol

Alcohol + HCV

HBV + HCV

75 ( 4.1)

873 (47.7)

159 ( 8.7)

387 (21.2)

58 ( 3.2)

12 ( 5.5)

90 (41.5)

16 ( 7.4)

62 (28.6)

5 ( 2.3)

12/75 (16.0)

90/873 (10.3)

16/159 (10.1)

62/387 (16.0)*

5/58 ( 8.6)

Cirrhosis

Quantity (%)

Quantity HCC (% of

217 patients with

HCC)

% cirrhotic

patients with

HCC

* p < 0,005 vs. Alkohol und vs. Hepatitis C



Occurence of Death according to the Presence or

Absence of stainable hepatic Iron in Patients with

Alcoholic Cirrhosis



Threshold of Hepatic Iron Score=1 Threshold of Hepatic Iron Score=5

Ganne-Carrie et al., Gut 2000; 46:277-282

Lille Score and Response to Steroid Therapy



Alcohol is a severe risk factor in the

progression of hepatitis C

1. Fibrogenesis is dose-dependent and starts already with small

amounts of alcohol (less than 30 g per day). There is no safe

dose of alcohol for patients with HCV infection, obese patients

and diabetics are particularly at risk. (Monto et al, Hepatology

39, 826-34:2004).

2. HCV patients with a history of excessive alcohol consumption

have a 2-3-fold increased risk to develop severe liver diseases

compared to HCV patients without alcohol consumption in the

past (Delarocque-Astagneau et al, Ann Epidemiol 15,551-

557:2005).





Lin et al, J Hep 2013; 58: 730-735

Effect of HBV DNA load in alcoholic

cirrotics on HCC incidence

Effect of antiviral therapy in alcoholic

cirrotics with HBV infection on HCC

incidents

GAHS, Steroids & 28 Days Mortality

• 188 patients with ASH

all DF >32

• GAHS > 9 at 64 %

• patients with GAHS < 9

have an excellent

prognosis without therapy

• GAHS > 9 = poor

prognosis without steroids

Forrest Gut 2007



Naveau S et al Hepatology 2004

Corticosteroid group 82 %

Infliximab group 61 %

100 %

80 %

60 %

40 %

20 %

0 % 0 10 20 30 40 50 60

Days

TNFα Antibodies: Reduced Survival in the French

Randomized Controlled Study

3 doses 10 mg / kg in 15 days!



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