The quest for the elusive factors that underpin neutrophil dysfunction in cirrhosis goes on
Authors: Godhev K. Manakkat Vijay, Nicholas J. Taylor, Debbie Lindsay Shawcross
Journal: Journal of Hepatology (2011)

We congratulate Tritto and colleagues on their recently published study [[1]Tritto G. Bechlis Z. Stadlbauer V. Davies N. Frances R. Shah N. et al.Evidence of neutrophil functional defect despite inflammation in stable cirrhosis.J Hepatol. 2011; 55: 574-581Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar], which aimed at extending our understanding of why patients with cirrhosis paradoxically exhibit features of impaired bacteriocidal capacity despite maintaining the ability to generate inflammation and bystander tissue damage. The neutrophil is a key component of the innate immune system and has been shown to play a vital role in the development of systemic inflammation and organ failure in sepsis [[2]Brown K.A. Brain S.D. Pearson J.D. Edgeworth J.D. Lewis S.M. Treacher D.F. Neutrophils in development of multiple organ failure in sepsis.Lancet. 2006; 368: 157-169Abstract Full Text Full Text PDF PubMed Scopus (458) Google Scholar]. The evidence base supporting neutrophil malfunction in acute and chronic liver disease continues to grow although factors that underpin this dysfunction are less clear and are likely to be related to a number of different factors [3Altin M. Rajkovic I.A. Hughes R.D. Williams R. Neutrophil adherence in chronic liver disease and fulminant hepatic failure.Gut. 1983; 24: 746-750Crossref PubMed Scopus (33) Google Scholar, 4Rajkovic I.A. Williams R. Abnormalities of neutrophil phagocytosis, intracellular killing and metabolic activity in alcoholic cirrhosis and hepatitis.Hepatology. 1986; 6: 252-262Crossref PubMed Scopus (233) Google Scholar, 5Wyke R.J. Yousif-Kadaru A.G. Rajkovic I.A. Eddleston A.L. Williams R. Serum stimulatory activity and polymorphonuclear leucocyte movement in patients with fulminant hepatic failure.Clin Exp Immunol. 1982; 50: 442-449PubMed Google Scholar, 6Mookerjee R. Stadlbauer V. Lidder S. Wright G. Hodges S. Davies N. et al.Neutrophil dysfunction in alcoholic hepatitis superimposed on cirrhosis is reversible and predicts outcome.Hepatology. 2007; 46: 831-840Crossref PubMed Scopus (230) Google Scholar]. In their study, Tritto and colleagues explore how the exposure of normal neutrophils to plasma from patients with varying severity and aetiology of liver disease in vitro may impact on their function. Furthermore, they aimed at investigating what role the presence of bacterial DNA, endotoxin and circulating cytokines within that plasma might play on neutrophil function and Toll-like receptor (TLR) expression. Lastly, they used a novel aseptic inflammation technique (blister study) to assess how neutrophils behave in vivo in 8 patients with Child Pugh A/B alcohol-related cirrhosis. The resulting data are both important and insightful but we would urge that these data need to be interpreted with caution at this stage due to several inherent flaws that exist in the study methodology. Firstly, further clarification on the control data is warranted. In the in vitro part of the study, the authors state that age- and sex-matched healthy volunteers were used as normal controls. No further details are given as to the control demographics or number of controls used, which appear to vary significantly in number between several figures in the manuscript. This is critical as the range of phagocytic capacity found in the healthy controls is vast (50,000–225,000 geometric mean of fluorescence intensity [GMFI]), suggesting the neutrophil function within the control group was highly variable and making valid statistical comparisons hard to achieve. A number of factors can influence neutrophil function in 'healthy' individuals including ethnicity, alcohol, tobacco habits and exercise within the previous 24 h which need to be controlled for. This is also fundamental when interpreting the blister studies, as 3 out of the 5 healthy controls had reduced phagocytic capacity of a similar magnitude to the cirrhotic patients and 2 patients stayed the same. This is somewhat at odds with the conclusion that the cirrhotic patients have impaired neutrophil phagocytic capacity in the blister fluid compared to controls. Moreover, there was a huge variation in GMFI in the cirrhotic patients (range 25,000–225,000). Four of the eight patients with cirrhosis also had evidence of impaired phagocytic capacity in peripheral blood at baseline, clouding the argument that stable cirrhotic patients did not have impairment of phagocytic capacity in peripheral blood but did in the inflammatory environment. Secondly, with regard to the TLR data, the baseline expression of TLR-2, 4 and 9 is not stated prior to exposure to cirrhotic plasma. This makes it difficult to interpret the impact of the cirrhotic plasma on the normal neutrophils. It might also have been better to have used healthy control plasma rather than phosphate-buffered saline which might have significantly influenced the neutrophil viability and the rate of apoptosis. It would also be interesting to determine whether the presence or absence of ascites had any relationship with baseline TLR-4 expression, which might be expected if this cohort has an increased rate of gut bacterial translocation. Lastly, we would be keen to learn more about the cohort (n = 34) with high oxidative burst. Did a large proportion of these patients have alcohol-related disease, ascites or encephalopathy? It is also fascinating to see that these patients had increased levels of IL-12, IFN-gamma and TNF-alpha. IL-12 and IFN-gamma are not cytokines that are typically associated with neutrophil activation and may have been released by other immune cell subtypes such as dendritic cells, macrophages and natural killer cells, which will undoubtedly have a role to play. In an ongoing prospective longitudinal cohort study of neutrophil morphology, phenotype and function at King's College Hospital in over 125 patients with cirrhosis, we have shown that phagocytic dysfunction is universal in patients with cirrhosis (including those with Child Pugh A disease), which is reversible following liver transplantation [[7]Taylor N. Ma Y. Abeles R. Hussein M. Auzinger G. Vergani D. et al.Cirrhosis leads to impaired neutrophil phagocytosis and spontaneous oxidative burst which correlates with increasing IL-10 concentration and is reversed following liver transplantation.Hepatology. 2009; 50 ([Abstract]): 121AGoogle Scholar]. Neutrophil dysfunction is likely to be determined by a large number of variables including plasma complement, immunoglobulin, sodium and ammonia concentrations [[8]Shawcross D. Wright G. Stadlbauer V. Hodges S. Wheeler-Jones C. Pitsillides A. et al.Ammonia impairs neutrophil phagocytic function in liver disease.Hepatology. 2008; 48: 1202-1212Crossref PubMed Scopus (119) Google Scholar], the presence of hepatic encephalopathy [[9]Shawcross D.L. Shabbir S.S. Taylor N.J. Hughes R.D. Ammonia and the neutrophil in the pathogenesis of hepatic encephalopathy in cirrhosis.Hepatology. 2010; 51: 1062-1069Crossref PubMed Scopus (135) Google Scholar], the presence of ascites and the pro- and anti-inflammatory cytokine milieu [[10]Taylor N. Abeles R. Ma Y. Wendon J. Shawcross D. A compensatory anti-inflammatory response syndrome (CARS) triggered by neutrophil-induced oxidative stress is associated with chronic low grade hepatic encephalopathy in patients with advanced cirrhosis.J Hepatol. 2010; 52 ([Abstract]): S216Google Scholar] which warrant further investigation. The quest for the elusive factor(s) that underpin neutrophil function therefore continues. The authors declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript. Dr. Shawcross is funded by a 5 year Department of Health HEFCE Clinical Senior Lectureship. Evidence of neutrophil functional defect despite inflammation in stable cirrhosisJournal of HepatologyVol. 55Issue 3PreviewDeranged neutrophil function in alcoholic hepatitis has been shown to be transmissible to normal neutrophils by patient plasma. The aims of this study were (i) to evaluate whether patients with stable cirrhosis have a similar transmissible neutrophil defect and (ii) to explore the possible mechanisms. Full-Text PDF Reply to: "The quest for the elusive factors that underpin neutrophil dysfunction in cirrhosis goes on"Journal of HepatologyVol. 56Issue 5PreviewWe thank Vijay and colleagues for their appreciation and interest in our paper evaluating some features of neutrophil dysfunction in cirrhosis of different severity [1]. 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