Overt Hepatic encephalopathy is associated with increased CD4+ T-lymphocyte- mediated inflammation in alcohol-associated ACLF

Background and Aim: Acute-on-chronic liver failure (ACLF) is associated with systemic inflammation response syndrome and may have multifactorial neurological impairment due to hepatic encephalopathy (HE), neuro-inflammation, hyperammonaemia or secondary sepsis. Alcohol use may also cause withdrawal symptoms and delirium tremens. We aimed to study the inflammatory milieu in patients with alcohol-associated-ACLF with overt HE by immunophenotyping of T-lymphocytes and subsets and correlated with clinical outcomes. Methods: Patients (aged 18-60 years) of either gender with EASL-CLIF-defined alcohol-associated ACLF for the presence of HE, and other organ failures were screened. Patients with non-alcohol etiology, dialysis, extrahepatic organ failures, structural brain lesion/disorder and hepatocellular carcinoma were excluded. Patients with alcohol-associated-ALCF without HE & alcohol-related cirrhosis [Decompensated Cirrhosis (DC) & Compensated Cirrhosis (CC)] served as controls. Baseline blood samples were incubated with monoclonal antibodies (CD45, CD3, CD4, CD28, CD69) for surface and intranuclear (T-Bet, GATA-3 &RoryT) as per manufactures protocol. Immunophenotyping was performed on flow-cytometer, and FACS DIVA software was used for data analysis. Ammonia estimated with Pocket-chem point-of-care NH3Analyzer. Results: Hundred and fifty patients with ACLF were screened between December 2022 to April 2023 at the emergency/liver-intensive care unit of PGIMER, Chandigarh. Finally, 26 Alcohol-associated-ALCF (18 with HE and 8 without HE), mean age 41±8.76 years; mean CLIF-C-ACLF score (45±18.3) were prospectively enrolled. Eight controls (5 -DC and 3 -CC) were also recruited. The expression of CD69 in CD4+T-lymphocytes increased in Alcohol-associated-ALCF with HE (4.14%, p=0.019), compared to Alcohol-associated-ALCF without-HE (2.75%), DC (1.7%) & CC (0.93%). The expression of CD4+Th1Th17++T-lymphocytes was increased in Alcohol-associated-ALCF with HE (48.08%, p=0.006) compared to Alcohol-associated-ALCF without-HE (1.34%), DC (3.76%) & CC (3.1%, p=0.002). Conclusion: Ammonia increased in Alcohol-associated-ALCF with HE (248.9±86.1μg/dL,p=0.001) compared to Alcohol-associated-ALCF without-HE(172.0±96.2μg/dL), DC(139±65.9μg/dL) and CC(40±1.2μg/dL).