Phenotypical and Pathophysiological Characterization of Patients with Alcohol-related Liver Disease.

Alcohol related disease is an important cause of morbidity and mortality in the
world, 5.9% deaths are accountable to alcohol use. Alcohol is the most frequent
cause of cirrhosis in Europe and a major indication for liver transplantation.

There is a high need for accurate biomarkers to asses alcohol abstinence or use
in patients with alcoholic liver disease (ALD). Firstly to identify alcohol
abuse in patiens to prevent progression of liver disease and secondly to
provide accurate and objective tools to assess alcohol use in the screening
process for liver transplantation. Physicians currently rely on the information
provided by patient and family and on psychomatric tests, which may be
unreliable. Direct measurement of alcohol in blood or exhaled air is considered
as the gold standard to detect alcohol use. However their diagnostic purpose is
undermined by the short half-life of alcohol of only a few hours. Carbohydrate
deficient transferrin analysis in blood can detect heavy drinking in patients
during the last two weeks, unfortunately in the target population with liver
cirrhosis false positive test results can occur because of transferrin
bridging. So non of the commonly used tests has a diagnostic range or accuracy
to diagnose alcohol use. There is a high need to identify non-invasive
biomarker in patients with alcoholic liver disease.

Ethylglucuronide (EtG) is secondary metabolite of the alcohol metabolism and a
direct marker for alcohol intake. EtG can be detected in urine, hair and nails.
Measuring EtG can give an indication of the alcohol ingestion of patients in
these tissues. However hEtG levels should be interpreted with caution in
patients with severe renal impairment and cosmetic hair treatment. A recent
study also showed that people with livercirrhosis and alcohol abstinence had a
significantly higher concentration of hEtG, this above the currently withheld
cut-off for sobriety by the society of hair testing. hEtG diagnosis in mass
spectrum imaging may also provide extra information about the timeline of
alcohol ingestion. EtG in nail matrix has been tested with a higher dose of EtG
present, so lower levels of alcohol intake could be detected in nails. Urinay
EtG is a highly sensitive marker for alcohol intake in the last 72 hours,
however it should be noted tests can be altered and be false positive because
of alcohol ingested with food.

Our hypothesis is that is we combine ethylglucuronide in hair, nail and urine
we could give an objective image of the alcohol intake in patients with ALD in
the last 3 months.

Little is known about the etiology of alcoholic liver disease. Translational
research is necessary to provide new insights and to develop therapeutic
options in the future.

The primary objective of the study is to identify, develop and validate
non-invasive biomarkers for the assessment of alcohol use in patients with ALD.
This by determining ethylglucuronide in hair, nail and urine in this
population. By validating the test it will be possible to help detect
alcoholabusus earlier and provide support in abstaining and also make an
objective analysis in the pretransplant traject.
Secondary objective is to obtain body samples for translational research in the
pathophiology of alcohol liver disease en identify possible targets for the
treatment of ALD, this with an explicit focus on the gut-liver axis.

Patients with alcoholic liver disease will be included from in- outpatient
clinic of the Maastricht University Medical Center. Patients will be asked to
undergo several questionnaires about their characteritics, medical history and
alcoholabuse including the validated Timeline Followback methode, where
alcoholintake during the last three months will be assessed.

Patients will be divided in three groups: abstinent patients (0 units
alcohol/day), patient witch moderate ( >0 - <6 units alcohol/day) and excessive
intake (6 or more units of alcohol a day) over the last three months (counting
back from study visit). Patients will provide hair, urine and nail samples on
study visit.
An application cohort will also be included, the cohort will consist of
patients with alcoholic liver disease denying alcoholintake over the last 3
months.

Patients can also participate in more extensive testing: multiple sugar
testing, donating stool en exhaled air. If patients participates in the
permeability testing, it is required to complete a three day food
questionnaire. If endoscopy is performed in the context of standard care;
biopsies of the stomach, duodenum and colon will be acquired.

Result will be analyzed. Follow-up will not be performed in the context of this
study.

Patient must come to the hospital for the study visit, study visite will take,
by estimate, 2 hours. A blood sample will be obtained this in the context of
standard care. Risk of hematoma is present. If patients participates in
permeability testing he has to collect 24 hour urine sample and a 3 day food
questionnaire.