Bacterial translocation in cirrhosis
P. AngeliUnit of Hepatic Emergencies and Liver Transplantation
Dept. of MedicineUniversityof Padova, Italy
AISF Monothematic Conference 2012The Gut-Liver axis: a bidiretional relation in health and disease
Bologna October 4-5th
Bacterial translocation (BT)
Definition
Bacterial translocation (BT), is defined as the migration of viable bacteria or bacterial products from the intestinal
lumen to mesenteric lymph nodes (MLNs) or other extraintestinal organs and sites.
R. Wiest et al. Hepatology 2005 ; 41 : 422-33
0
25
50
75
100
Controls Cirrhotic rats with GBT Cirrhotic rats witho utGBT
Non ascites Ascites
Bacterial DNA fragments in mesenteric lymph nodes (MLNs) in cirrhotic rats according to positive cultures from MLNs
Bacterial translocation (BT)
M. Ubeda et al. Hepatology 2010 ; 52 : 2086-2095
%
• Prevalence• Pathogenesis• Pathophysiological consequences• Clinical consequences• Prevention
Bacterial translocation (BT)
Headlines
0
25
50
75
100
Controls Cirrhotic ptsCTP A
Cirrhotic ptsCTP B
Cirrhotic ptsCTP C
Cirrhotic ptswith SID
Positive cultures from mesenteric lymph nodes in cirrhotic patients (pts) according to the Child-Turcotte-Pugh (CTP) class and selective intestinal
decontamination (SID)
Bacterial translocation (BT)
I. Cicera et al. J. Hepatol. 2001 ; 34 : 32-37
(%)
P <0.05
Markers of bacterial translocationMarkers of bacterial translocation
Bact-DNA Bacterial footprints� Endotoxins (LPS)
� LPS binding protein
Bacterial translocation (BT)
Plasma levels of lipopolysaccharide (LPS) binding protein (LBP) in patients with cirrhosis and ascites
A. Albillos et al . Hepatology 2003 ; 37: 208-217
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4
8
12
16
20
24
Cirrhotics withascites
Cirrhotic withoutascites
Normal subjects
LBP
(µg/
ml) 42 %
Bacterial translocation (BT)
Bact-DNA+vepatients
Bact-DNA-vepatients
63.4%36.6%
E. coli
E. fecium
K. pneumoniae
S. aureus
57.7%
7.7%
7.7%
26.9%
Prevalence of Bact-DNA in inpatients with cirrhosis and refcractory ascites
Bacterial tranlocation (BT)
P. Angeli et al . (AASLD Annual Meeting 2010)
• Prevalence• Pathogenesis• Pathophysiological consequences• Clinical consequences• Prevention
Bacterial translocation (BT)
Headlines
R. Wiest et al. Hepatology 2005 ; 41 : 422-433
Bacterial translocation (BT)
Mechanisms of bacterial translocation
0
25
50
75
100
SBP No SBP
Small intestine bacterial overgrowth in cirrhotic patients according with the occurrence of SBP
CS. Chang et al. Hepatology 1998 ; 28 : 1187-1190
(%) P <0.01
Bacterial translocation (BT)
0,0
0,5
1,0
1,5
2,0
Healthy controls Patients with cirrhosis
The Bifidobacteria/Enterobacteriaceae ratio in patients with decompensated cirrhosis
H. Lu et al. Micriobiol. Ecol. 2011 ; 61 : 693-703
P <0.01
Bacterial translocation (BT)
F. Bert et al. J. Clin. Microbiol. 2010 : 48 : 2709-2714
24
4
48
24
0
20
40
60
Group A Group B1 Group B2 Group D
Phylogenetic groups of E. coli. in patients with cirrhosis and spontaneous bacterial peritotinitis and/or bacteremia
%
Bacterial translocation (BT)
F. Bert et al. J. Clin. Microbiol. 2010 : 48 : 2709-2714
Bacterial translocation (BT)
• Reduced gastric acid secretion• Reduced intestinal peristalsis• Reduced bile ouput and/or abnormal bile
composition• Reduced intestinal mucosa secretion and/or
abnormal composition• Deficit of the mucosal immunity
Factors contributing to the bacterial overgrowth in cirrhotic patients
Bacterial translocation (BT)
Drugs used only for a liver-related condition in hospitalized patients with cirrhosis in Spain
0
20
40
60
80
100
Diuretics Antiulcerdrugs
Laxatives Vitamin K Beta-blockers
Nitrates
On admission At discharge
%
MI. Lucena et al. Eur. J. Clin. Pharmacol. 2002 ; 58 : 435-440
Bacterial translocation (BT)
0
20
40
60
80
100
SBP No SBP
Use of proton pump inhibitors (PPI) in patients with cirrhosis and spontaneous bacterial peritonitis
JS. Bajaj ,et al. Am. J. Gastroenterol. 2009 ; 104 :1130–1134
P <0.0001(%)
Bacterial translocation (BT)
Appropriate PPI use
Appropriate PPI use
R. Wiest et al. Hepatology 2005 ; 41 : 422-433
Bacterial translocation (BT)
Expression of Paneth cell antimicrobial peptides in control patients (C), patients with liver cirrhosis (LC) and patients with LC and bacterial translocation (LC + BT)
C LC LC+BT C LC LC+BT C LC LC+BT
R. Wiest et al. Hepatology 2005 ; 41 : 422-433
Bacterial translocation (BT)
Mechanisms of bacterial translocation
0
10
20
30
40
Control subjectcs Patients with cirrhosis
Percentage of urine excretion of a marker of integrity of mucosal barrier in cirrhotic patients
C. Ersoz et al. Eur. J. Gastroenterol. Hepatol. 1999 ; 11 : 409-412
(%) P <0.001
Bacterial translocation (BT)
R. Wiest et al. Hepatology 2005 ; 41 : 422-433
Bacterial translocation (BT)
Mechanisms of bacterial translocation
MLCK regulates ZO-1 exchange in vivo.
Yu D et al. PNAS 2010;107:8237-8241
©2010 by National Academy of Sciences
Schematic diagram of the molecular organization of epithelial tight junction
Bacterial translocation (BT)
Université de Genève 2011
MLCK regulates ZO-1 exchange in vivo.
Yu D et al. PNAS 2010;107:8237-8241
©2010 by National Academy of Sciences
Bacterial translocation (BT)
DE. Fouts et al. J. Hepatol. 2012 ; 56 : 1283–1292
0,0
0,5
1,0
1,5
2,0
2,5
Baseline 1 Day
P <0.05
Occludin expression 1 day after ligation of the common bile duct (BDL)
MLCK regulates ZO-1 exchange in vivo.
Yu D et al. PNAS 2010;107:8237-8241
©2010 by National Academy of Sciences
Schematic diagram of the molecular organization of epithelial tight junction
Bacterial translocation (BT)
Université de Genève 2011
R. Wiest et al. Hepatology 2005 ; 41 : 422-433
Bacterial translocation (BT)
Mechanisms of bacterial translocation
Model for a role of Nod1 and Nod2 as cytosolic surveillance proteins of mucosal surfaces
Bacterial translocation (BT)
M. Chamaillard et al. Cell. Microbiol. 2003 5 : 581–592
Bacterial translocation (BT)
B. Appenrodt et al. Hepatology 2010 ; 51 : 1327-1333
Nucleotide-binding oligomerization domain containing2 (NOD2) Variants as a risk factors for spontaneous bacterial peritonitis
in patients with cirrhosis
Acute (ALF), chronic (CLF) or acute on chronic liver failure (ACLF)
The expressions of TNFα- and IL-10 positive cells within the liver tissue
Zou ZH. et al. J. Clin. Gastroenterol. 2009 ; 43 : 182-190..
Model for a role of Nod1 and Nod2 as cytosolic surveillance proteins of mucosal surfaces
Bacterial translocation (BT)
M. Chamaillard et al. Cell. Microbiol. 2003 5 : 581–592
���� MLCK
0,0
0,5
1,0
1,5
2,0
2,5
3,0
Control IFN TNF IFN + TNF
Myosin II regulatory light chainkinase (MLCK) phosphorylation
Bacterial translocation (BT)
F. Wang et al. Am. J. Pathol. 2005 ; 166 : 409-419
γγγγ γγγγ γγγγ αααα
P < 0.05
0
50
100
150
200
250
Control IFN TNF IFN + TNF
Cultured intestinal epithelial cell permeability to 3kD fluorescein isothiocyanate-dextran exposed to IFN-γ followed by TNF-α
30 K
D D
extr
an fl
ux
Bacterial translocation (BT)
P < 0.001
F. Wang et al. Am. J. Pathol. 2005 ; 166 : 409-419
γγγγ γγγγ αααααααα
• Prevalence• Pathogenesis• Pathophysiological consequences• Clinical consequences• Prevention
Bacterial translocation (BT)
Headlines
Increasing rate of BT
Bacterial translocation (BT)
Endotoxins and proinflammatory citokines
• Bacterial infections
• Cardiovascular dysfunction• Renal failure• Hepatic encephalophaty
Bacterial translocation (BT)
Bacterial translocation in cirrhosis: clinical consequences
Bacterial translocation (BT)
↑↑↑↑ TNFα
SIRS
Bacterial infection
Viable Bacteria Translocation
↑↑↑↑ LPS
Bacterial translocation in cirrhosis: consequences
Actuarial probability of severe bacterial infetions in patients with cirrhosis and ascites according to the plasma level of lipopolysaccharide-binding protein
(LBP)
A. Albillos et al . Lancet 2004 ; 363 : 1608-1610
Bacterial translocation (BT)
↑↑↑↑ LPS
Bacterial translocation (BT)
↑↑↑↑ TNFα
SIRS
Bacterial infection
Bacterial fragments Translocation
↑↑↑↑ LPS
Bacterial translocation in cirrhosis: consequences
�
0
100
200
300
400
500
Serum TNF Serum IFN
Bact-DNA-ve Bact-DNA+ve SBP
R. Frances et al . Hepatology 2008 ; 47 : 978-985
Tumor necrosis factor α (TNFα) and Interferon γγγγ (INF γγγγlevels in cirrhotic patients with ascites
Bacterial translocation (BT)
(pg/
ml)
αααα γγγγ
N.S.N.S.
Molecular translocation persists during i.v. antibiotic tretament of SBP episodes
R. Frances et al . Hepatology 2008 ; 47 : 978-985
Bacterial translocation (BT)
• Bacterial infections
• Cardiovascular dysfunction• Renal failure• Hepatic encephalophaty
Bacterial translocation (BT)
Bacterial translocation in cirrhosis: clinical consequences
Event Bact-DNA+ve Bact-DNA-ve p value (n= 23) (n= 14)
All complications 96% 64% < 0.05HRS 1 26% 0 % < 0.05Death 46% 14% < 0.05
P. Angeli et al. (AASLD Annual Meeting 2010)
Six month follow up of patients with cirrhosis and refractory ascites according to the detection of Bact-DNA in ascites
Six month follow up of patients with cirrhosis and refractory ascites according to the detection of Bact-DNA in ascites
Bacterial translocation (BT)
Further derangement of
Systemic heamodynamicsFibrosis progression in the liver
dnd increase in portal pressure
Bacterial translocation (BT)
Endotoxins and proinflammatory citokines
Organ failure(s)
Bacterial translocation (BT)
N. Shah et al. Journal of Hepatology 2012 vol. 56 j 1047–1053
TLR4 expression in the Bile duct ligated and in the BDL + LPS group
Bacterial translocation (BT)
N. Shah et al. Journal of Hepatology 2012 vol. 56 j 1047–1053
Methamine silver staining of the kidney in the BDL group and in the BDL group administered LPS (BDL+LPS group)
• Bacterial infections
• Cardiovascular dysfunction• Renal failure• Hepatic encephalophaty
Bacterial translocation (BT)
Bacterial translocation in cirrhosis: clinical consequences
0
500
1000
1500
2000
2500
3000
Control rats Cirrhotic ratsBactDNA-ve and
GBT-ve
Cirrhotic ratsBactDNA+veand GBT-ve
Cirrhotic ratsGBT+ve
Bacterial translocation (BT)
L. Munoz et al. Hepatology 2012 (Epub ahead of print)
Activation state of CD103+ dendritic cells in mesenteric lymph nodes of control rats and cirrhotic rats according to the Bact-DNA state and gut
viable bacteria translocation (GBT)
Bcterial translocation (BT)
Schematic representation of the “in vitro” model of functional monocyte decativation
GA. Antoniades et al. J. Hepatol. 2008 ; 49 : 945-861
↑↑↑↑ LPS
Recurrent bacterial Translocation
↑↑↑↑ LPS
Monocyte deactivation
CARS
Bacterial translocation (BT)
↑↑↑↑ TNFα
SIRS
Bacterial infection
Bacterial Translocation
↑↑↑↑ LPS
Bacterial translocation (BT)
Parameter EstimateStandard
ErrorOR OR 95 % CI P Value
Intercept -4.9689 1.5511
MELD 0.1169 0.0281 1.124 (1.064-1.188) < 0.0001
Albumin -0.6863 0.3341 0.503 (0.262-0.069) 0.0399
Heart rate 0.0279 0.0120 1.028 (1.004-1.053) 0.0202
Second infection 1.4852 0.4022 4.4416 (2.007-9.713) 0.0002
JS. Bajaj et al. Hepatology 2012 (Epub ahead of print)
Prognostic model model in patients with cirrhosis who were admitted with or developed a bacterial infection during hospitalization
Actuarial probability of survival in patients with cirrhosis and ascites according to the Bact-DNA state and the MELD score
P. Zapater et al. Hepatology 2008 ; 48 : 1924-1931
Bacterial translocation (BT)
Bact-DNA+ve
Bact-DNA-ve
Bact-DNA+ve
Bact-DNA-ve
• Prevalence• Pathogenesis• Pathophysiological consequences• Clinical consequences• Prevention
Bacterial translocation (BT)
Headlines
• to decrease the bacterialovergrowth
• to change the microbiome• to reduce the intestinalpermeability• to manipulate the immune response
Bacterial translocation (BT)
Aims in the prevention of Bacterial translocation
• patients with cirrhosis and low protein asciticlevel (15 g/l)
Primary prevention of spontaneous bacterial peritonitis (SBP)
and one of the following conditions:
• advanced liver failure (CTP ≥ 9 with total serumbilirubin ≥ 3 mg/dl)
or
• impaired renal function (serum creatinine ≥ 1.2mg/dl, BUN ≥ 25 mg/dl)
or
• serumsodiumlevel ≤ 130 mmol/l
J. Fernandez et al. Gastroenterology 2007 ; 133 : 818-824
Bacterial translocation (BT)
0
20
40
60
80
100
(%)
Probability of development of spontaneous bacterial peritonitis
Norfloxacin
PlaceboP < 0.001
J. Fernandez et al. Gastroenterology 2007 ; 133 : 818-824
100 200 days300 400
Bacterial translocation (BT)
0
20
40
60
80
100(%)
Probability of one year survival
100
Norfloxacin
Placebo
P < 0.01
200 days
J. Fernandez et al. Gastroenterology 2007 ; 133 : 818-824
300 400
Bacterial translocation (BT)
0
20
40
60
80
100
(%)
Probability of hepatorenal syndrome
100
Norfloxacin
Placebo
P < 0.05
200 days
J. Fernandez et al. Gastroenterology 2007 ; 133 : 818-824
300 400
Bacterial translocation (BT)
Effects on norfloxacin on plasma endotoxins in patients with cirrhosis and ascites
0
4
8
12
16
Before After
(EU
/ml)
P < 0.05
B. Rasaratnam et al. Ann. Intern. Med. 2003 ; 139 : 186-193
Bacterial translocation (BT)
Bacterial translocation (BT)
P. Zapater et al. Gastroenterology 2009;137:1669–1679
Norfloxacin and TNF- concentrations in 2 patientswith multiple serum samples collected at inclusion (1) and at 15
days and 1, 2, 4, 7, 8, 9, and 10 months, respectively, after inclusion
Effects on norfloxacin on systemic vascular resistance in patients with cirrhosis and ascites
5
10
15
20
25
30
Before After
(uni
ts)
P < 0.05
B. Rasaratnam et al. Ann. Intern. Med. 2003 ; 139 : 186-193
Bacterial translocation (BT)
Bacterial translocation (BT)
P. Zapater et al. Gastroenterology 2009;137:1669–1679
Temporal relationship between intracellular levels of norfloxacin or trimethoprim/sulfamethoxazole and NF-B
Spontaneous bacterial peritonitis with septic shock sustained by Klebsiella pneumoniae in a patient with cirrhosis
S. Piano et al. Eur. J. Gastroenterol. Hepatol. 2012 ; 24 : 1234–1237
Bacterial translocation (BT)
0
25
50
75
100
Control rats LGG-Cirrhoticrats
MILK-Cirrhotic rats
NOR-LGGCirrhotic rats
NOR-MILKCirrhotic rats
Bacterial translocation (BT)
TM. Bauer et al. J. Hepatol. 2002 ; 36 : 501–506
Rate of bacterial translocation in cirrhotic rats receiving Lactobacillus GG (LGG) or Milk (MILK) or norfloxacin sigle dose f ollowed by LGG
(NOR-LGG) or milk (NOR-MILK)
Cecal colonization with Lactobacillus was achieved in 90% of treated rats
Bacterial translocation (BT)
C. Pande et al. Eur. J. Gastroenterol. Hepatol.. 2012 ; 24 : 831–839
Cumulative probability of developing spontaneous bacterial peritonitis (SBP) in patients with cirrhosis receiving norfloxacin and probiotics and
vs patients with cirrhosis receiving norfloxacin and placebo
Bacterial translocation (BT)
AM. Madrid et al. Am. J. Gastroenterol. 2001 ; 96 : 1251-1255
Effect of antibiotic, cisapride and placebo on small-intestinal bacterial overgrowth (SIBO) and oro-cecal transit time (OCTT)
• to decrease the bacterialovergrowth
• to change the microbiome• to restore the intestinalmucosal barrier• to manipulate the immune response
Bacterial translocation (BT)
Aims in the prevention of Bacterial translocation
Prevention of spontaneous bacterial peritonitis by proponolol in non randomized control trials (RCTs) and in non randomized comparative studies
M. Senzolo et al. Liver Int. 2009 ; 29 : 1189-19993
Bacterial translocation (BT)
0
10
20
30
40
Control rats Cintrol rats withSE
Cirrhotic rats Cirrhotic ratswith SE
Bacterial translocation (BT)
M. Worlicek et al. Gut 2010 ; 59 : 1127-1134
Effect of spanchnic sympathetcomy (SE) on in vitro phagocytosis index of peritoneal polymorhonuclear lecocytes
P < 0.01
P < 0.01
• to decrease the bacterialovergrowth
• to change the microbiome• to restore the intestinalmucosal barrier• to manipulate the immune response
Bacterial translocation (BT)
Aims in the prevention of Bacterial translocation
Rate of bacterial translocation in rats with cirrhosis receiving anti-TNFααααmonoclonal antibody (anti-TNFαααα), placebo, or an IgG isotype control(IgG2a),
R. Frances et al. J. Hepatol. 2007 ; 46 : 797–803
* = p < 0.05 vs Group I
Bacterial translocation (BT)
0
25
50
75
100
Anti-TNF Palcebo IgG2a
P < 0.05
αααα
0
25
50
75
100
IBO BT SBP
Control rats Pentoxifylline Norfloxacin Placebo
F. Corradi et al . Dig. Liver Dis. 2012 ; 44 : 239-244
Effects of pentoxifylline on intestinal bacterial overgrowth (IBO), bacterial translocation (BT) and spontaneous bacterial peritonitis
(SBP) in rats with cirrhosis
Bacterial translocation (BT)
P < 0.05 P < 0.05 P < 0.05
Pentoxifylline reduced the level of malonyldialdeide in the cecal mucosa