Research Article Study of Effects of Probiotic Lactobacilli in Preventing Major Complications in Patients of Liver Cirrhosis RR. Pawar*, ML. Pardeshi and BB. Ghongane Department of Pharmacology, B.J. Medical College and Sassoon General Hospital, Station Road, Pune, Maharastra, India. ABSTRACT The aim was to evaluate the effects of probiotic lactobacilli on incidence of major complications, hospital admissions and mortality in patients of liver cirrhosis. In this randomized, double-blind, placebo-controlled study, 65 patients with liver cirrhosis received either lactobacilli (n = 34) or placebo (n =31) for 6 months. They were monitored for complications (hepatic encephalopathy, variceal bleeding, and spontaneous bacterial peritonitis), hospital admissions and deaths, if any. Serum bilirubin, SGPT, SGOT, serum proteins, blood urea, Sr.creatinine and plasma-ammonia were done at each visits. Probiotic lactobacilli significantly reduced the incidence of hepatic encephalopathy and hospital admissions. There was significant decrease in plasma-ammonia in lactobacilli treated group. Though the serum bilirubin levels worsened in both the groups, this worsening was significantly less in the lactobacilli treated group as against placebo. The present study suggests that the use of probiotic lactobacilli is beneficial in prevention of major complications in patients with liver cirrhosis. Key Words: Liver cirrhosis, Lactobacilli, Hepatic encephalopathy, Ammonia. INTRODUCTION Cirrhosis is a pathologically defined entity that is associated with a spectrum of characteristic clinical manifestations. The cardinal pathologic features reflect irreversible chronic injury of the hepatic parenchyma and include extensive fibrosis in association with the formation of regenerative nodules 1. Colonic bacteria clearly play a major role in the pathogenesis of major complications in patients with liver cirrhosis. By producing ammonia and endotoxins they can cause hepatic encephalopathy and their translocation from the gut to the peritoneal cavity is the major mechanism for spontaneous bacterial peritonitis 2. Probiotics are "live microorganisms which when administered in adequate amounts confer a health benefit on the host." They work a number of ways including competitive exclusion, production of bacteriocins and lowering of gut ph 3. Probiotics have been used successfully to alter the gut flora in many clinical conditions where growth and localization of non pathogenic bacteria replaces the pathogenic bacteria in the intestine. Silvia Wilson Gratz in her review article about role of probiotics in liver disease stated that, in the liver health, the main benefits of probiotics might occur through preventing the production and/or uptake of lipopolysaccharides in the gut, and therefore reducing levels of low-grade inflammation 4. Loguercio et al used the phrase gut liver axis and suggested that the microflora might affect the liver and be cofactor in etiology of chronic liver damage. This could happen via modulating chronic damage by ethanol or by contributing to complications such as encephalopathy (production of ammonia, ethanol, acetaldehyde, phenols, endotoxin, and benzodiazepines) 5. According to the results of a randomized trial published in the May issue of Hepatology, symbiotic modulation of gut flora or use of fermentable fiber is effective in the treatment of minimal hepatic encephalopathy (MHE) and may be an alternative to lactulose 6. However there is need of a study to determine whether the probiotics have any role in the prevention of major complications of liver cirrhosis. Hence the present study was undertaken for the same. MATERIALS AND METHODS This study was a prospective, randomised, doubleblind, placebo-controlled, single centre study. Vol. 3 (1) Jan Mar 2012 www.ijrpbsonline.com 206
The study was conducted on patients of liver cirrhosis attending Gastroenterology unit of a tertiary health care centre. The study protocol was approved by the Institutional Ethics Committee. Patients who were admitted for liver cirrhosis in the hospital or who developed any complication earlier but cured at the time of recruitment were included in the present study. Diagnosis of liver cirrhosis was confirmed on USG. Written informed consent (translated in Marathi) was obtained from each patient in the beginning of the study. Only those patients who fulfilled the eligibility criteria were included in the study. The patients were randomized into 2 groups by computer randomization The drugs were supplied by Unique Biotech, Chennai. All patients also received the routine treatment that was given to them in hospital, i.e. diuretics, antibiotics and lactulose etc. All the investigations were repeated at 3 months and six months. Patients were followed up for 6 months to see if they develop any complication like hepatic encephalopathy, spontaneous bacterial peritonitis, variceal bleeding etc. The detailed data was entered into the Microsoft excel sheet and subsequently analyzed by using appropriate statistical tests. RESULTS A total 65 patients were enrolled in the study. Out of these 51 (78.5%) completed the study. 14 patients could not complete the study. Of these, 2 patients in lactobacilli group and 2 patients in placebo group were excluded at visit 2, because they turned towards alcoholism. Also 2 patients in the placebo group were excluded from trial at V3 for the same reason. 5 patients died during the study period. 2 patients in lactobacilli group and 1 patient in placebo group did not come for follow up after V1. The data was analyzed by both intention to treat and per protocol approach. Both approaches showed comparable results. The data presented here is by the intention to treat method. The total data available for analysis was of 65 patients. Out of 65 patients, 62 were male and 3 were female. Sex distribution of patients in two groups was even (Table: 2). Average age of patients in lactobacilli group was 41.28 years + 5.97 SD with a range of 29 to 53 years while that of in placebo group 41.55 years ± 5.22 SD with range of 30 to 54 years. Average weight in lactobacilli group was 45.22 kg ± 4.96 SD with a range of 35 to 55 kg, whereas average weight in placebo group was 46.74 kg ± 4.64 SD with range of 36 to 67 kg (Table: 2). All the base-line investigations were comparable in both the groups (Table: 3). Incidence of Complications of Cirrhosis Primary efficacy variable was incidence of complications of cirrhosis in two groups during the period of six months. As seen in fig: 1; Out of 34 patients in lactobacilli group, 3 patients developed hepatic encephalopathy as complication in treatment period; which is significantly less than placebo group, in which out of 31 patients, 9 patients developed hepatic encephalopathy. Out of 34 patients in lactobacilli group, 4 patients suffered from variceal bleeding, 5 patients developed SBP and 4 patients developed other complications; which is not significantly different than placebo group, in which out of 31 patients 5 patients suffered from variceal bleeding, 3 patients developed SBP and 6 patients developed other complications. Number of Episodes of Hospital Admissions and Death In lactobacilli group significantly less number of episodes of hospital admissions were required (n = 18, i.e. 0.53 + 0.66 admissions/patient) as compared to the placebo group (n= 27, i.e. 0.87 + 0.67 admissions/patient) during the treatment period of 6 months (Table: 4). 3 patients died in lactobacilli group whereas 2 patients died in placebo group (Table: 4). There is no difference in two groups when number of deaths was compared. Plasma Ammonia Levels Plasma ammonia levels decreased (from 140.29 + 7.28 to 122.38 + 10.69) in the lactobacilli group during the study period (Fig. 3). The decrease was statistically significant at V2 and V3 as compared to V1. However plasma ammonia levels increased (from 142.13 + 7.75 to 154.19 + 13.18) in placebo group during the study period. The increase was statistically significant at V2 and V3 as compared to V1, this increase was significantly more at V3 than at V2. When the intergroup analysis was done, plasma ammonia level in lactobacilli group was significantly less than that of placebo group at V2 and V3. Serum bilirubin levels Serum bilirubin levels increased in both the groups during the study period. This increase in Sr. bilirubin levels was significant in both the groups at the last visit (V3) as compared to V1. The lactobacilli group showed increase from 1.76 + 1.11 to 2.08 + 1.14, during the period of 6 months whereas the placebo Vol. 3 (1) Jan Mar 2012 www.ijrpbsonline.com 207
group showed increase from 1.89 + 1.34 to 2.8 + 0.85 during the same period (Fig. 4). When the intergroup analysis was done, increase in Sr. Bilirubin level in lactobacilli group was significantly less than that of placebo group. When other liver function parameters like serum SGPT, SGOT, ALP, proteins, A/G ratio etc were compared in two groups, no significant difference was observed. All these parameters were significantly increased in both the treatment groups during the period of 6 months. DISCUSSION The distribution of intestinal microflora in healthy adults is relatively stable, unless disrupted by disease or medications. Both animal and clinical studies have shown that patients with liver cirrhosis have varying degrees of intestinal microflora imbalance, as shown by the changes in the counts of Bifidobacterium, Bacterioides, Enterobacter and yeasts 7, 8. In the present study, use of lactobacilli sporogenes in the patients of liver cirrhosis was studied. It was found that the treatment with lactobacilli significantly reduced the incidence of hepatic encephalopathy as compared to placebo over the period of six months. There was significant reduction in hospital admissions in patients taking lactobacilli as compared to placebo. However there was no significant reduction in the incidence of other complications like variceal bleeding, spontaneous bacterial peritonitis, hepatorenal syndrome etc. Also there was no significant difference in the number of deaths in two groups. It was also found that there was significant reduction in the plasma ammonia levels in lactobacilli group as compared to placebo group. Similarly, increase (worsening) in serum bilirubin levels was significantly less in lactobacilli group as compared to placebo group. However there was no significant improvement in other parameters like serum SGPT, SGOT, ALP, proteins, A/G ratio etc in both the groups. To our best knowledge, this was the first study with lactobacilli which studied effect of lactobacilli on all the major complications of liver cirrhosis without altering patients current medications. However, there were limitations like small sample size and shorter duration of follow up. Further studies should focus to evaluate the effect of different probiotics at different grades of cirrhosis using larger sample size. Also cost benefit analysis should be done to see whether probiotics are cheaper and effective alternative to current therapy. Table 1: Drugs used in the study Group No. of Patients Drugs Formulation, Dose, Frequency And Duration of Administeration Lactobacilli 34 Lactobacilli sporogenes Cap. Lactobacilli 2 billion CFU/ capsule, 2 cap. twice daily for 6 months. Placebo 31 Placebo Placebo capsules, 2 cap. twice daily for 6 months. Table 2: Demographic and Baseline Characteristics Criteria (n=34) (n=31) Average age in years [Mean ± SD] 41.26 ± 5.92 41.55 ± 5.22 Sex (M:F) 32/2 30/1 Average Weight (kg) [Mean ± SD] 45.18 ± 4.70 43.10 ± 9.26 No. of patients with h/o alcoholism (%) 27 (79.41) 26 (83.87) No. of patient taking Lactulose (%) 34 (100) 31 (100) No. of patients taking antibiotics (%) 23 (67.65) 27 (87.1) Vol. 3 (1) Jan Mar 2012 www.ijrpbsonline.com 208
Table 3: Comparison of Baseline (V1) Investigations in Two Groups Investigations Lactobacill Group (n=34) Placebo Group (n= 31) Sr. Bilirubin (mg/dl) 1.76 + 1.11 1.89 + 1.34 Sr. SGPT (IU/L) 30.17 + 15.27 33.06 + 15.39 Sr. SGOT (IU/L) 43.85 + 06.77 46.61 + 04.78 Sr. ALP (IU/L) 186.67 + 71.14 185.45 + 55.29 Sr. Albumin (gm/dl) 2.71 ± 0.54 2.53 ± 0.45 A/G Ratio 0.96 ± 0.19 0.90 ± 0.14 Blood Urea (mg/dl) 35.55 + 17.62 35.73 + 14.08 Sr. Creatinine (mg/dl) 1.19 + 0.73 1.32 + 0.54 Plasma Ammonia (µg/dl) 140.29 + 7.48 142.13 + 7.75 [Mean ± SD] Table 4: Hospital admissions and number of deaths Total Total Criteria admissions (Admissions/patient, admissions (Admissions/patient, p value Mean + SD) Mean + SD) Number of episodes of hospital admissions 18 (0.53 + 0.66) 27 (0.87 + 0.67) 0.043* Number of deaths 3 2 0.720 Day 0 (V1) Start of study: - History and examinations Investigation s:- LFT, RFT, Pl. Ammonia, Drugs 3 months (V2) All investigation s Drugs Inquiry about complication s Fig. 1: Study Design 6 months (V3) Number of complication s Hospital admissions PL. Ammonia, L FT, RFT,. Deaths if any Analysis Vol. 3 (1) Jan Mar 2012 www.ijrpbsonline.com 209
30 % 25 20 15 10 5 0 * *: p value < 0.05 Fig. 2: Incidences of Complications of Cirrhosis 200 Plasma Ammonia in µg/dl 170 140 110 80 V1 V2 V3 V1: Visit 1 V2: Visit 2 V3: Visit 3 *:p value < 0.05 **: p value < 0.001 Fig. 3: Plasma Ammonia Levels Vol. 3 (1) Jan Mar 2012 www.ijrpbsonline.com 210
3 Serum Bilirubin in mg/dl 2.6 2.2 1.8 1.4 1 V1 V2 V3 * V1: Visit 1 V2: Visit 2 V3: Visit 3 *:p value < 0.05 Fig. 4: Serum Bilirubin Levels CONCLUSION From the present study, it can be concluded that Probiotic lactobacilli showed significant reduction in the incidence of hepatic encephalopathy as compared to placebo during the treatment period of 6 months. Also there was significant reduction in the plasma ammonia levels in the lactobacilli treated patients as compared to placebo treated patients during the study period of 6 months. The increase was significantly less in the lactobacilli group as compared to placebo group. REFERENCES 1. Raymond D. Chung. Cirrhosis and its complications. In: Fauci, Braunwald et al editors. Harrison s principles of internal medicine. 16th ed. New York (USA): McGraw-Hill Publications; 2005:858-1869. 2. Suvarna VC and Boby VU. Probiotics in human health: A current assessment. Current science. 2005;88(11):1744 1748. 3. David Pereg. Probiotics for patients with compensated liver cirrhosis: A double-blind placebo-controlled study. Nutrition. Published online 2010. Available from: http://www.nutritionjrnl.com/article/s0899-9007(10)00032-8/ (Accessed 10 Oct 2010). 4. Silvia Wilson Gratz et al. Probiotics and gut health: A special focus on liver diseases. World J Gastroenterol. 2010;16(4):403-410. 5. Loguercio C, De Simone T, Federico A et al. Gutliver axis: a new point of attack to treat chronic liver damage? Am J Gastroenterol 2002;97:2144 2146. 6. Liu Q, Duan ZP, Hada K et al. Synbiotic modulation of gut flora: effect on minimal hepatic encephalopathy in patients with cirrhosis. Hepatology. 2004;39(5):1441 1449 7. Chen H, Chen GM, Yan H et al. A preliminary study on the change of intestinal microflora in patients with posthepatic cirrhosis. Chin J Dig. 1995; 15: 75 77. 8. Hua J, Li JQ, Zeng MD et al. A study of intestinal flora in patients with cirrhosis. Chin J Hepatol. 1998;6:79 81. Vol. 3 (1) Jan Mar 2012 www.ijrpbsonline.com 211