THE NEED OF A NEW PATHOPHYSIOLOGICAL CLASSIFICATION OF CIRRHOSIS PINZANI M- 2012 THE NEED OF A NEW PATHOPHYSIOLOGICAL CLASSIFICATION OF CIRRHOSIS MASSIMO PINZANI, M.D., Ph.D., FRCP Sheila Sherlock Chair of Hepatology UCL Institute for Liver and Digestive Health Royal Free Hospital, London, UK m.pinzani@ucl.ac.uk

The Current Perception of Chronic Liver Disease PINZANI M- 2012 The Current Perception of Chronic Liver Disease Towards CIRRHOSIS F0 F1 F2 F3 F4 Beyond CIRRHOSIS CIRRHOSIS

>12 Decompensated Compensated Non-cirrhotic Clinical PINZANI M- 2012 Decompensated Compensated Non-cirrhotic Clinical Ascites, VH, Encephalopathy None (varices present) None (no varices) None Symptoms Stages 3,4,5* Stage 2 Stage 1 - Sub-stage Insoluble scar Thick (acellular) scar and nodules Scar and X-linking Fibrogenesis and Angiogenesis Biological Hemodynamic (HVPG, mmHg) Histological F1-F3 F4 (Cirrhosis) >6 >10 >12 *G. D’Amico, AASLD 2011 PGC

CIRRHOSIS: IN SEARCH OF A PATHOPHYSIOLOGICAL CLASSIFICATION, WHY? PINZANI M- 2012 CIRRHOSIS: IN SEARCH OF A PATHOPHYSIOLOGICAL CLASSIFICATION, WHY? 1.- Cirrhosis cannot be simply considered an “end-stage”. 2.- The evaluation of the cirrhotic patient is based on the observation of clinical and biochemical events often unpredictable and characterized by a rough and insufficient pathophysiological framing. 3.- The biology of hepatic fibrogenesis evolves in cirrhotic liver and it is tightly correlated with disease progression in “compensated” cirrhosis. 4.- Very limited diagnostic/prognostic resources are available to frame the stage of “Compensated” cirrhosis. 5.- “Decompensated” cirrhosis is based on the occurrence of clinical complications but not on other potentially relevant biological events (i.e. altered tissue regeneration, loss of specific liver functions, transition to a systemic disease, etc).

The Diversity of Chronic Liver Diseases PINZANI M- 2012 The Diversity of Chronic Liver Diseases Etiology has a relevant impact on disease progression (fibrogenesis) and regression (fibrolysis) Different etiologies result in different patterns of fibrosis development Etiology influences the prevailing pro-fibrogenic mechanism(s) ETIOLOGY !!

Hall A. et al., Histopathology 2012; 60:270-277 PINZANI M- 2012 Fibrosis Quantity and Distribution in Explanted Cirrhotic Liver Depending on Etiology Hall A. et al., Histopathology 2012; 60:270-277 Measurement of Collagen Proportionate Area (CPA)

The Progression of Chronic Hepatitis C and the METAVIR Score PINZANI M- 2012 The Progression of Chronic Hepatitis C and the METAVIR Score F1 PORTAL FIBROSIS Mild fibrous expansion of portal tracts F2 PERIPORTAL FIBROSIS Rare portal-portal septa F3 SEPTAL FIBROSIS Portal-portal linkage F4 CIRRHOSIS Bridging fibrosis and nodular regeneration F4 is WRONGLY considered an END-STAGE

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PINZANI M- 2012 Morphology and Collagen Proportionate Area Correlate with Portal Hypertension Nagula S et al., J. Hepatol. 2006; 44:111-117 Calvaruso V et al., Hepatology 2009; 49:1236-1244

Liver biopsy: 1 yr after OLT Staging: Ishak’s PINZANI M- 2012 Liver biopsy: 1 yr after OLT Staging: Ishak’s

Measuring Collagen Content: What Are We Missing? PINZANI M- 2012 Measuring Collagen Content: What Are We Missing? Hepatocyte necrosis/apoptosis,inflammatory infiltration All potential targets for bio-imaging and functional imaging Neoangiogenesis and microthrombosis Activation of the stem cell compartment Ductular reaction and “reactive” cholangiocytes Increasing tissue hypoxia and endothelial dysfunction Unbalanced vasoconstrictors and scar contraction

Biological Events in the Natural History of CLD PINZANI M- 2012 Biological Events in the Natural History of CLD Contribution of hepatic stem cell compartment R E G N A T I O HBV HCV GENETIC INSTABILITY AND MUTATIONS ABERRANT ACTIVATION OF SIGNALLING PATHWAYS HCC CHRONIC TISSUE DAMAGE CHRONIC WOUND HEALING FIBROGENESIS ANGIOGENESIS ALTERED MICRO- ENVIRONMENT ASH NASH IRON OXIDATIVE STRESS 13 13

Cytochrome C oxidase positive: regenerating hepatocytes PINZANI M- 2012 Cytochrome C oxidase positive: regenerating hepatocytes Cytochrome C oxidase negative (MtDNA mutation): progenitor cells Mixed population

>12 Decompensated Compensated Non-cirrhotic Clinical PINZANI M- 2012 Decompensated Compensated Non-cirrhotic Clinical Ascites, VH, Encephalopathy None (varices present) None (no varices) None Symptoms Stages 3.4,5* Stage 2 Stage 1 - Sub-stage Insoluble scar Thick (acellular) scar and nodules Scar and X-linking Fibrogenesis and Angiogenesis Biological Hemodynamic (HVPG, mmHg) Histological F1-F3 F4 (Cirrhosis) >6 >10 >12 REVERSIBLE PARTIALLY REVERSIBLE IRREVERSIBLE

Biochemical and Biological Evolution of Fibrillar Extracellular Matrix PINZANI M- 2012 Biochemical and Biological Evolution of Fibrillar Extracellular Matrix EARLY FIBROSIS Inter-fiber filaments (type VI) MMP-1 Fibrillar Collagen (type I,III, V) COLLAGEN CROSS-LINKING PRESENCE OF ELASTIN ACELLULAR FIBROSIS DOWNREGULATION OF MMP-1 AND UPREGULATION OF TIMP-1 INCREASE IN TISSUE RIGIDITY AND TENSION ESTABLISHED FIBROSIS

Hepatocellular Carcinoma PINZANI M- 2012 The Natural History of Cirrhosis: a Summary HVPG > 12 mm Hg Stage 3 Bleeding ? “Decompensating Event” SEPSIS Renal Failure HVPG: 5-12 mm Hg Stage 1 Stage 2 No Varices No Ascites Varices Stage 4 First non bleeding decompensation Death or OLT Stage 5 Second decompensation Hepatocellular Carcinoma Compensated Cirrhosis Decompensated Cirrhosis Modified from Arvaniti V. et al., Gastroenterology 2010; 139:1246-1256

Hepatocellular Carcinoma PINZANI M- 2012 Compensated Cirrhosis a Clinical Stage with Very Limited Diagnostic Resources Stage 3 Bleeding ? “Decompensating Event” SEPSIS Renal Failure Stage 1 Stage 2 No Varices No Ascites Varices Stage 4 First non bleeding decompensation Death or OLT Years Months Stage 5 Second decompensation Hepatocellular Carcinoma Compensated Cirrhosis ? Decompensated Cirrhosis Modified from Arvaniti V. et al., Gastroenterology 2010; 139:1246-1256

Measurement of portal pressure (HVPG) and liver tissue stiffness PINZANI M- 2012 Clinical observation, tissue morphology: an “expectant” algorithm that treats complications Measurement of portal pressure (HVPG) and liver tissue stiffness Bio-imaging, functional imaging?

Cinically Significant PINZANI M- 2012 Diagnostic performance of transient elastography for the detection of clinically significant portal hypertension (HVPG 10 mm Hg) Authors Carrion et al. (35) Vizzutti et al. (36) Sanchez-Condé et al. (39) Lemoine et al. (38) Bureau et al. (37) AUC 0.92 0.99 0.80 0.76 0.94 Se (%) 90 97 94 93 83 63 Sp 81 92 50 67 70 88 Etiologies HCV-LT HCV HIV-HCV Alcohol CLD * Hepatic Venous Pressure Gradient (HVPG) ≥6 mm Hg; ** severe portal hypertension HVPG ≥12 mm Hg Patients (n) 124 61 38 44 48 150 +LR 4.7 13.7 4.9 3.5 2.5 2.1 7.5 12.8 -LR 0.12 0.02 0.08 0.62 0.49 0.53 0.13 0.10 AUC: area under ROC curve; Se sensitivity; Sp specificity; +LR positive likelihood ratio; -LR negative likelihood ratio; HCV chronic hepatitis C; HCV-LT Liver transplant for hepatitis C; CLD chronic liver diseases; Study design Prospective monocentric Prospective monocentric Retrospective monocentric Cut-offs HVPG 10 mm Hg (kPa) 8.7* 13.6 17.6** 14.0 23.0** 20.5 34.9 21.0 Prevalence of Cinically Significant Portal hypertension 21% 77% 74% 83% 51% PPV 86 84 79 NPV 91 71 35 64 Castera L, Pinzani M, Bosch J, J Hepatology 2012

Hypertrophy and Hyperplasia PINZANI M- 2012 The Spleen in the Assessment of Advanced Chronic Liver Disease Congestion Hypertrophy and Hyperplasia Fibrosis

INCREASE IN SPLEEN STIFFNESS ?? Hypertrophy and Hyperplasia PINZANI M- 2012 The Spleen in the Assessment of Advanced Chronic Liver Disease INCREASE IN SPLEEN STIFFNESS ?? Congestion Hypertrophy and Hyperplasia Fibrosis

“Compensated” Cirrhosis PINZANI M- 2012 Spleen Stiffness (SS), a Promising Diagnostic Parameter in Cirrhosis Spleen Stiffness (SS), a Promising Diagnostic Parameter in Cirrhosis Colecchia A. et al., Gastroenterology 2012 ; 143(3):646-54 HVPG (mm Hg) HVPG (mm Hg) “Compensated” Cirrhosis Liver Stiffness (kPa) Spleen Stiffness (kPa) Esophageal Varices: NO Esophageal Varices: YES

Colecchia A. et al., Gastroenterology 2012 ; 143(3):646-54 PINZANI M- 2012 Liver and Spleen Stiffness for the Prediction of the Presence of Esophageal Varices Colecchia A. et al., Gastroenterology 2012 ; 143(3):646-54 EV: NO EV: YES EV: NO EV: YES

Hepatocellular Carcinoma PINZANI M- 2012 Compensated Cirrhosis a Clinical Stage with Very Limited Diagnostic Resources Stage 3 Bleeding ? “Decompensating Event” SEPSIS Renal Failure Stage 1 Stage 2 No Varices No Ascites Varices Stage 4 First non bleeding decompensation Death or OLT Years Months Stage 5 Second decompensation Hepatocellular Carcinoma Compensated Cirrhosis ? Decompensated Cirrhosis Modified from Arvaniti V. et al., Gastroenterology 2010; 139:1246-1256

>12 LS (kPa) 6-7 9-12 13.6 17.6 20-60 Decompensated Compensated PINZANI M- 2012 LS (kPa) 6-7 9-12 13.6 17.6 20-60 Decompensated Compensated Non-cirrhotic Clinical Ascites, VH, Encephalopathy None (varices present) None (no varices) None Symptoms Stage 2 Stage 1 - Sub-stage Insoluble scar Thick (acellular) scar and nodules Scar and X-linking Fibrogenesis and Angiogenesis Biological Hemodynamic (HVPG, mmHg) Histological F1-F3 F4 (Cirrhosis) >6 >10 >12 Stages 3.4,5* REVERSIBLE PARTIALLY REVERSIBLE IRREVERSIBLE

PINZANI M- 2012 FIBROSCAN FIBROTEST

Hepatocellular Carcinoma PINZANI M- 2012 Compensated Cirrhosis a Clinical Stage with Very Limited Diagnostic Resources Stage 3 Bleeding ? “Decompensating Event” SEPSIS Renal Failure Stage 1 Stage 2 No Varices No Ascites Varices Stage 4 First non bleeding decompensation Death or OLT Years Months Stage 5 Second decompensation Hepatocellular Carcinoma Compensated Cirrhosis ? Decompensated Cirrhosis Modified from Arvaniti V. et al., Gastroenterology 2010; 139:1246-1256

PINZANI M- 2012 Cirrhosis Causes Structural and Functional Changes in the Mucosa of the Small Intestine Changes in Microbiota Bacterial Overgrowth Decreased Bile Acids Immunosuppression Mesenteric Vein Congestion Mucosal Injury (ETOH) CIRRHOSIS Obesity/Overweight High Fat Diet Optical density at 540 nm Bacterial adherence to BBM Urinary excretion of DTPA (%) Intestinal permeability Control Cirrhosis Ramachandran A. et al. Hepatology 2002 Chiva M. et al. Eur J Gastroenterol Hepatol 2003 Perez-Páramo M et al. Hepatology 2003 Natarajan SK et al. Hepatology 2006 Functional abnormalities of the mucosa of the small intestine of rats with cirrhosis: • oxidative stress, ↑ xanthine oxidase activity • lipid peroxidation of brush border membrane • ↑ sugar content of brush border membrane • abnormal intestinal transport P<0.01 Increased Pathogen-Associated Molecular Patterns “PAMPs” (i.e. LPS) in the portal circulation 29 29

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Clinico-pathological PINZANI M- 2012 Beyond Cirrhosis………… Advanced CLD without clinically evident complications (compensated cirrhosis) Clinical Workup Pathology Clinico-pathological Correlation Assessment or re-assessment of ETIOLOGY, co-factors and co-morbidities ASSESSMENT OF SEVERITY: biochemistry, non invasive (Transient Elastography), HVPG, Upper GI endoscopy, imaging Morphological (distribution) and quantitative (CPA) assessment of tissue fibrosis Inflammatory activity, angiogenesis, histological correlates with co-factors (e.g. metabolic, alcohol, iron, etc) Features of REGRESSION Features predicting MALIGNANCY (HCC) Final Diagnosis Etiology + Stage: Advanced Stage with no complications Advanced Stage with complications (e.g. varices) Advanced Stage with features of regression End stage + Disease Activity + Risk for HCC

UCL Institute for Liver and Digestive Health Royal Free Hospital, London, United Kingdom