Prognosis Prediction In Choledocholithiasis After ERCP Based On Metabolomics

Part OneRoles of Ursodeoxycholic Acid in the Bile Biochemistry and Metabolomics in Patients with CholedocholithiasisIntroduction Mounting evidence supported an association between cholelithiasis and changes in the composition of the metabolomics.Still,the role of the metabolomics in the biliary metabolic profile of choledocholithiasis(CDC)remains largely undefined.Recurrences after endoscopic treatment of common bile duct stones(CBDS)is related to bile metabolism and bile compositions.Ursodeoxycholic acid(UDCA)has been proved effective in reducing the recurrence of CBDS.However,the in-depth effects of UDCA on bile metabolism were still understudied.Objectives Our cross-sectional analysis assessed the association of the biliary metabolic profile would provide a novel insight in both prevention and therapeutics for CDC.The RCT study aimed to analyze the role of UDCA in the patients with CDC from the perspective of biochemistry and metabolomics.Methods A total of 112 patients(23 controls,89 choledocholithiasis)were recruited in this cross-sectional study and a 1:1 propensity score matching(PSM)analysis was conducted controlling for confounders.Serum and bile biochemical parameters from patients with choledocholithiasis were compared with controls.Nontargeted metabolomics analysis based on liquid chromatography/mass spectrometry was performed on the bile to characterize the metabolite profiles.A total of 89 patients with CDC who underwent endoscopic retrograde cholangiopancreatography(ERCP)were prospectively studied and randomly assigned to control group and UDCA group.The biochemical detections(cholesterol,bilirubin,and so on)were performed on the collected bile.Moreover,metabolomics analysis based on bile from 20 patients in UDCA group was performed.Results After PSM,serum parameters including liver function and lipids concentrations did not differ substantially between groups.However,there was an elevation in bile concentrations of total bile acids(941.18 nmol/m L vs 531.59 nmol/m L;P=0.033),Ca2+(4.23mmol/L vs 2.67 mmol/L;P=0.012),and endotoxin(3.5 EU/m L vs 0.99 EU/m L;P=0.003)in CDC,whereas the bile concentrations of total bilirubin,direct bilirubin,cholesterol,and immunoglobulin G had no significant change in choledocholithiasis.As to bile metabolomics,16 metabolites,including fatty acids,nucleotides,pyridines and bile acids,were significantly altered in CDC group(P<0.05).Pathway enrichment analysis showed that the formation of common bile duct stones evoked a common response related to bile acid biosynthesis and pyrimidine metabolism.As to the RCT study,the bile concentrations of cholesterol and endotoxin were significantly decreased after UDCA treatment.As to bile metabolomics,25 metabolites changed significantly after the treatment of UDCA.Pathway enrichment analysis showed that the UDCA addition evoked a common response related to phenylalanine,tyrosine and tryptophan biosynthesis,phenylalanine metabolism,arachidonic acid metabolism,and terpenoid backbone biosynthesis.Conclusions This cross-sectional study establishes preliminary metabolic profiling of human bile from CDC patients via using LC/MS metabolite profiles,and provided a novel method for recognizing and observing the CBDS.In CDC patients with prior endoscopy surgery,UDCA treatment within a short time interval(7 days)did not improve circulating laboratory values;there were however relevant decreases in bile concentrations of cholesterol and endotoxin.Furthermore,UDCA evoked a common response related to lipid metabolism and amino acid metabolism,which would probably reduce the bile level of cholesterol,protect hepatocytes,and correct the abnormity of lipid metabolism caused by CDC.Part TwoPrognosis Prediction in Choledocholithiasis after ERCP Based on Bile Acid ProfilesBackground and Aims The underlying pathogenesis of common bile duct stones(CBDS)recurrence after endoscopic treatment has not been fully elucidated.It has been proved that bile acids play a critical role in pathophysiology of cholelithiasis.However,the in-depth associations of bile acids and choledocholithiasis(CDC)were still understudied.This study aimed to explore the alteration of plasma BA profiles in CDC patients and construct an effective clinical prediction model for evaluating the risk of CBDS recurrence after endoscopic treatment.Methods A total of 320 subjects(218 CDC and 102 non-neoplastic polyps)were recruited and serum BA profiles including 15 metabolites were compared between groups.The time to CBDS recurrence after ERCP was collected.Based on the serum bile acid profile,both diagnostic score of CDC and prognostic risk score of CBDS recurrence were established by lasso regression.Combining risk score and the prognostic factors selected by univariate and multivariate Cox regression analysis,nomogram model was developed to predict the 1,2 and 3-year stone recurrence probability after ERCP.Results The bile acid profiles of patients with CDC were significantly different with controls,mainly exhibiting in the increase of conjugated bile acid,the decrease of G: T ratio in conjugated bile acid,the decrease of hydrophobic bile acid ratio,and the increase ratio of primary bile acid to secondary bile acid.The diagnostic model can effectively distinguish the patients with CDC from control,with an area under the curve of 0.763.Until the last follow-up,40(18.35%)patients in CDC group occurred recurrence of CBDS.The prognosis risk score was constructed based on bile acid profiles in training group.CDC patients with low-risk score exhibited high stone recurrence free survival(RFS)possibility(training group: P=0.00018;validation group: P=0.01).Through univariate Cox regression analysis and multivariate Cox regression,the history of cholecystectomy and multiple stones(n≥2),bile duct angulation≥132.7° and low BA risk score were independent related factors of stone recurrence(P<0.05),and the hazard ratios were 2.43,4.18,0.42 and 0.31,respectively.The nomogram model established based on these four factors was robust and had a better effect on predicting the prognosis of stone recurrence.Conclusion Serum bile acid profiles altered in patients with CDC and can be used to distinguish CDC from controls.The nomogram model developed based on the history of LC,multiple stones(n≥2),BDA and bile acid risk score for predicting the risk of CBDS recurrence in patients with CDC after ERCP treatment has a highly accuracy and clinical usability.