Aforementioned randomized Title Loaded From File control trial. Although antiviral treatment may provide some short term survival benefits, many patients died despite the significant reduction of HBV DNA [29]. Thus, our data remained relevant for the understanding ofdisease mechanism and the future development of novel intervention. Previous studies have demonstrated that endotoxinemia and delayed clearance of LPS in the circulation resulted in the development of ACLF in alcoholic liver disease [18,30,31,32,33,34]. Although Han et al proposed that LPS played an important role in ACHBLF as a secondary liver injury on top of the CHB infection in animal models [10]. The changes of LPS levels and their roles on disease severity in patients with ACHBLF were not fully explored. Our study showed that Ivation of the MAPK signaling pathway plays a pivotal role in baseline LPS levels in ACHBLF patients did not differ from those in the healthy controls. However, significant elevation in LPS levels was observed in the peak phase of ACHBLF when compared to those in the progression or remission phase. The abnormal distributions of LPS levels among different phases were statistically significant in ACHBLF. In addition, the changes in LPS levels were correlated with MELD-Na scores in the progression and the peak phase. To our knowledge, this is by far the first study in which detailed the dynamic changes of LPSDynamic Changes of LPS in ACLF with HBVTable 1. Baseline assessments of ACHBLF patients and healthy subjects.Mean ?SD Male (M) Age (year)* HBeAg ( ) HBV-DNA (log10 IU/mL)* Serum bilirubin (umol/l)* ALT (IU/l)* AST (IU/l)* Creatinine(mmol/l)* Prothrobin time (Sec.)* MELD-Na score Serum LPS (EU/mL)Control group(n = 10) 8 32.3064.ACHBLF group(n = 5) 5 34.268.23 (80 ) 6.2762.case 1 M 28 + 3.44 237.1 423 293 57.8 23.3 15.13 0.case 2 M 37 + 6.22 321.7 921 1466 76.0 33.2 25.00 0.case 3 M 25 + 8.39 215.8 2579 2071 70.1 23.7 17.67 0.case 4 M 35 4.71 389.8 337 144 71.1 24.5 20.14 0.case 5 M 46 + 8.56 373.3 75 173 107.2 27.3 17.55 0.12.3362.06 20.7065.33 19.4063.37 47.6963.63 12.5460.307.54678.53 86761004.88 829.46885.32 76.44618.46 26.464.11 19.2263.0.020160.0.018360.Test of normality is done by Kolmogorov-Smirnov Test. *P.0.05. doi:10.1371/journal.pone.0049460.tlevels in different phases of ACHBLF, and provided the evidence of acute liver injury in ACHBLF associated 24272870 with increased LPS levels. Since MELD-Na scores were correlated with LPS levels in the progression and the peak phase, our data pointed to the direction of the secondary injury from LPS in chronic liver disease leading to liver failure, which was proposed by Han et al. in the study from animal model. Further studies with histology correlation to LPS are needed to confirm if the severity of liver injury actually is directly correlated with LPS levels in ACHBLF patients.The findings in this study also implied a possible therapeutic intervention for ACHBLF by removing LPS from the serum. Several studies done by Adachi et al observed that there was a positive correlation between the occurrence of bacterial translocation from the gut to portal system and liver dysfunction in alcoholic hepatitis [34,35]. Li et al demonstrated that elevation of endotoxin levels in the circulation from translocation of gut flora occurred during acute flares in patients with chronic hepatitis [27]. It is possible that the 1662274 elevation of LPS level in CHB patients was due to bacterial translocations from the gut to portal circulation resulting in endotoxemia in the early phase (or progressive phase ) of A.Aforementioned randomized control trial. Although antiviral treatment may provide some short term survival benefits, many patients died despite the significant reduction of HBV DNA [29]. Thus, our data remained relevant for the understanding ofdisease mechanism and the future development of novel intervention. Previous studies have demonstrated that endotoxinemia and delayed clearance of LPS in the circulation resulted in the development of ACLF in alcoholic liver disease [18,30,31,32,33,34]. Although Han et al proposed that LPS played an important role in ACHBLF as a secondary liver injury on top of the CHB infection in animal models [10]. The changes of LPS levels and their roles on disease severity in patients with ACHBLF were not fully explored. Our study showed that baseline LPS levels in ACHBLF patients did not differ from those in the healthy controls. However, significant elevation in LPS levels was observed in the peak phase of ACHBLF when compared to those in the progression or remission phase. The abnormal distributions of LPS levels among different phases were statistically significant in ACHBLF. In addition, the changes in LPS levels were correlated with MELD-Na scores in the progression and the peak phase. To our knowledge, this is by far the first study in which detailed the dynamic changes of LPSDynamic Changes of LPS in ACLF with HBVTable 1. Baseline assessments of ACHBLF patients and healthy subjects.Mean ?SD Male (M) Age (year)* HBeAg ( ) HBV-DNA (log10 IU/mL)* Serum bilirubin (umol/l)* ALT (IU/l)* AST (IU/l)* Creatinine(mmol/l)* Prothrobin time (Sec.)* MELD-Na score Serum LPS (EU/mL)Control group(n = 10) 8 32.3064.ACHBLF group(n = 5) 5 34.268.23 (80 ) 6.2762.case 1 M 28 + 3.44 237.1 423 293 57.8 23.3 15.13 0.case 2 M 37 + 6.22 321.7 921 1466 76.0 33.2 25.00 0.case 3 M 25 + 8.39 215.8 2579 2071 70.1 23.7 17.67 0.case 4 M 35 4.71 389.8 337 144 71.1 24.5 20.14 0.case 5 M 46 + 8.56 373.3 75 173 107.2 27.3 17.55 0.12.3362.06 20.7065.33 19.4063.37 47.6963.63 12.5460.307.54678.53 86761004.88 829.46885.32 76.44618.46 26.464.11 19.2263.0.020160.0.018360.Test of normality is done by Kolmogorov-Smirnov Test. *P.0.05. doi:10.1371/journal.pone.0049460.tlevels in different phases of ACHBLF, and provided the evidence of acute liver injury in ACHBLF associated 24272870 with increased LPS levels. Since MELD-Na scores were correlated with LPS levels in the progression and the peak phase, our data pointed to the direction of the secondary injury from LPS in chronic liver disease leading to liver failure, which was proposed by Han et al. in the study from animal model. Further studies with histology correlation to LPS are needed to confirm if the severity of liver injury actually is directly correlated with LPS levels in ACHBLF patients.The findings in this study also implied a possible therapeutic intervention for ACHBLF by removing LPS from the serum. Several studies done by Adachi et al observed that there was a positive correlation between the occurrence of bacterial translocation from the gut to portal system and liver dysfunction in alcoholic hepatitis [34,35]. Li et al demonstrated that elevation of endotoxin levels in the circulation from translocation of gut flora occurred during acute flares in patients with chronic hepatitis [27]. It is possible that the 1662274 elevation of LPS level in CHB patients was due to bacterial translocations from the gut to portal circulation resulting in endotoxemia in the early phase (or progressive phase ) of A.
