Influence of Probiotics on Infections in Cirrhosis

Study Overview
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Brief Summary
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Liver cirrhosis is the 10th most common cause of death in the western world. Infection is the most common precipitant of deterioration of liver function in cirrhosis. Endotoxin, derived from gram-negative organisms in the gut, can enter the circulation due to increased gut permeability and contributes to neutrophil dysfunction, infection risk and mortality in alcoholic cirrhotics. As probiotics decrease gram-negative organisms in the gut and/or decrease gut permeability, the investigators hypothesize that probiotic treatment would restore neutrophil function and prevent infection in alcoholic cirrhosis. The investigators hypothesize that administration of a probiotic mixture in patients with liver cirrhosis will improve innate immune function through alteration of the gut bacterial flora and gut barrier integrity. The aim of this randomised, double-blinded placebo-controlled study is to assess whether food supplementation with probiotic mixture improves neutrophil phagocytic capacity in patients with cirrhosis and decreases the incidence of significant infections. 92 patients with alcoholic cirrhosis will be included according to a sample size calculation from preliminary data. Patients will be randomized in two groups: Group 1 receives a probiotic mixture Group 2 receives a similar looking and tasting placebo without bacteria. The recruited patients will be treated for 6 months. Besides routine clinical and laboratory assessments, neutrophil function, toll-like receptor expression, endotoxin levels, bacterial DNA, cytokine levels, albumin oxidation, gut permeability and analysis of gut microflora will be performed. Furthermore nutritional status and quality of life will be assessed. Primary endpoints will be neutrophil phagocytosis. Secondary endpoints will be significant infection, neutrophil oxidative burst, neutrophil toll-like receptor expression, endotoxin levels, bacterial DNA; cytokine levels, albumin oxidation, gut barrier function and bacterial flora, nutritional status and quality of life. If our hypothesis holds true, probiotics will provide an easily applicable and cost effective method to improve immune function and to prevent infection in liver cirrhosis. It is possible that this can improve survival of patients with liver cirrhosis.

Official Title
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Probiotic Modulation of Gut Microflora in Cirrhosis: Influence on Immune Function and Infections

Conditions
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Liver Cirrhosis

Intervention / Treatment
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* Dietary Supplement: Winclove-849
* Dietary Supplement: Placebo


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: • Patients aged between 18-80 years Clinical and radiological evidence of cirrhosis, and/or biopsy proven liver cirrhosis of any cause Informed consent Exclusion Criteria: Child-Pugh score > 11 Abstinence from alcohol for < 2 weeks at the time of screening for inclusion Clinical evidence of active infection Antibiotic treatment within 7 days prior to enrolment Gastrointestinal haemorrhage within previous 2 weeks Use of immunomodulating agents within previous month (steroids etc.) Use of proton pump inhibitors for preceding two weeks Concomitant use of supplements (pre-, pro-, or synbiotics) likely to influence the study Renal failure (such as hepatorenal syndrome), creatinine >1.7 mg/dL Hepatic encephalopathy II to IV Pancreatitis Other organ failure Hepatic or extra-hepatic malignancy Pregnancy Presumed non-compliance to the study medication

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Probiotic<br>6 g of Winclove-849 containing Bifidobacterium bifidum W23, Bifidobacterium lactis W52, Lactobacillus acidophilus W37, Lactobacillus brevis W63, Lactobacillus casei W56, Lactobacillus salivarius W24, Lactococcus lactis W19, Lactococcus lactis W58 at a concentration of 2.5 x 10E9 cfu/g per day | Dietary Supplement: Winclove-849<br>* 6 g of Winclove-849 containing Bifidobacterium bifidum W23, Bifidobacterium lactis W52, Lactobacillus acidophilus W37, Lactobacillus brevis W63, Lactobacillus casei W56, Lactobacillus salivarius W24, Lactococcus lactis W19, Lactococcus lactis W58 at a concentration of 2.5 x 109 cfu/g<br>|
| Placebo Comparator: Placebo<br>A similar looking and tasting powder | Dietary Supplement: Placebo<br>* A similar looking and tasting powder with no active substances<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in neutrophil phagocytic capacity | Percentage of neutrophil granulocytes showing phagocytosis of FITC (fluorescein isothiocyanate) -labelled E.coli bacteria | Change from baseline to 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of clinically significant infections | Occurence of infections that require specific treatment and/or hospitalisation during the study period of 12 months | during 12 months | 
| endotoxin levels | Endotoxin in serum (EU/ml) | 0, 6, 12 months | 
| neutrophil oxidative burst | percentage of neutrophil granulocytes showing oxidative burst with and without stimulation and mean fluorescence activity | 0, 6, 12 months | 
| neutrophil toll like receptor expression | percentage of neutrophil granulocytes showing TLR (Toll-like receptor) 2, TLR4 or TLR9 expression and mean fluorescence activity | 0, 6, 12 months | 
| albumin oxidation | oxidative status of albumin in the plasma (percentage of (human mercaptalbumin) HMA, (human non-mercaptalbumin) HNA1 and HNA2) | 0, 6, 12 months | 
| inflammatory response | elevation of one or more inflammatory markers: C reactive protein (mg/ml), lipopolysaccharide binding protein (ng/ml), soluble CD (cluster of differentiation) 14 (ng/ml) | 0, 6, 12 months | 
| bacterial flora | isolation of bacterial DNA and sequencing the gut microbiome from stool and duodenal aspirate | 0, 6, 12 months | 
| quality of life | (short form) SF-36 questionaire | 0, 6, 12 months | 
| nutritional status | subjective global assessment | 0,6, 12 months | 
| changes in gut permeability over time | elevated lactulose mannitol ratio, elevated zonulin | 0, 6, 12 months |