Roles of inflammatory factors in the pathogenesis of hepatitis B virus-related acute-on-chronic liver failure and CAR-T therapy

Roles of inflammatory factors in the pathogenesis of hepatitis B virus-related acute-on-chronic liver failure and CAR-T therapy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Roles of inflammatory factors in the pathogenesis of hepatitis B virus-related acute-on-chronic liver failure and CAR-T therapy Yan Wang, Jing Gu, Guanghua Chen, Yanfeng Jiang, Ying Xu, Xiaoping Huang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4579363/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) pathogenesis remains unclear. Cytokine release syndrome (CRS) is a serious concomitant disease caused by pathogen infection and immunotherapies, such as HBV infection and chimeric antigen receptor T (CAR-T) therapy respectively while the role of inflammatory factors (IFs) in such patients still remains to be elucidated. This study aims to explore HBV-ACLF pathogenesis according to analyze IFs changes in patients with HBV-ACLF, prophase of HBV-ACLF(pro-HBV-ACLF) and CAR-T therapy, and the relationship between IFs and liver function indexes (LFIs) in patients receiving CAR-T therapy. The clinical records of 68 patients with HBV-ACLF, 30 patients with pro-HBV-ACLF, and 372 patients with hematologic tumors but without abnormal liver function who received CAR-T therapy at the First Affiliated Hospital of Soochow University were retrospectively examined in this investigation. Serum interleukin-10 (IL-10) levels was significantly increased from healthy controls to pro-HBV-ACLF and to HBV-ACLF. IL-10 was decreased in patients who experienced improvement compared to those whose condition deteriorated. Consistently, alanine transaminase (ALT), aspartate aminotransferase (AST), total bilirubin (TBil) and international normalized ratio (INR) also increased with the development of HBV-ACLF. However, IL-6 did not significantly change from pro-HBV-ACLF to HBV-ACLF and to HBV-ACLF without infection, while IL-6 was even lower in patients with HBV-ACLF without secondary infection than in patients with pro-HBV-ACLF. In addition, Serum levels of IL-2, IL-10, tumor necrosis factor α (TNF-α), and interferon γ (IFN-γ), especially IL-6, increased significantly after CAR-T treatment in tumor patients, while TBIL and ALT levels did not markedly increase. These results elucidate the role of inflammatory factors in the pathogenesis of HBV-ACLF and the side effects of CRS induced by CAR-T therapy. Hepatitis B virus-related acute-on-chronic liver failure Inflammatory factors Cytokine release syndrome Liver function Chimeric antigen receptor T therapy Figures Figure 1 Figure 2 Background CRS or uncontrollable systemic inflammatory response syndrome (SIRS), is an acute systemic inflammatory syndrome[ 1 – 4 ]. CRS is thought to be caused by the release of IFs, such as IL-2, IL-6, IL-10, TNF-α, IFN-γ, which can lead to a series of clinical symptoms, including fever, low blood pressure, severe inflammation syndrome, or even dysfunction of a wide range of organs [ 5 – 7 ]. Hepatitis B virus infection is a major public health problem worldwide, and approximately 30% of the global population has current or past serological infection [ 8 , 9 ]. At present, data on the epidemiology of HBV-ACLF among hepatitis HBV-infected patients are lacking. However, some studies have reported an approximately 35% incidence of ACLF among patients with underlying HBV-related cirrhosis suffering from acute decompensation [ 10 , 11 ]. The pathological changes caused by various basic liver diseases and acute inducements differ among patient groups [ 12 ]. Therefore, ACLF still lacks a global unified definition and diagnostic criteria. China is a region with a high incidence of HBV infection, and HBV-ACLF is the most common form [ 13 – 15 ]. HBV-ACLF is a common type of end-stage liver disease among patients with chronic HBV infection that is characterized by rapid deterioration of underlying chronic liver diseases with multiorgan failure and high short-term mortality. The pathogenesis of liver failure is very complex, and there are different etiologies. At present, in-depth studies are being carried out in China and internationally to identify the mechanism of progressive liver failure and develop therapeutic strategies to suppress ongoing injury and supplement hepatic regeneration. There has been much debate about whether sepsis is the cause or the result of ACLF. Previous studies have emphasized the important role of cytokine storm in the pathogenesis of liver failure 16 . Additionally, it has been reported that systemic inflammation (SI), which can be attributed to the overactivation of innate immunity, is a major driver of HBV-associated ACLF [ 16 ]. According to the Asian Pacific Association for the Study of Liver (APASL) guidelines updated in 2019, sepsis is a consequence rather than the cause of the ACLF [ 17 ]. The APASL definition does not include sepsis as a primary cause for liver failure, but in the Western definition, sepsis is considered the most common precipitant; the APASL has proposed an SI hypothesis stating that ACLF is the expression of an acute exacerbation of the SI already present in decompensated cirrhosis [ 18 ]. CAR-T cell therapy is an effective new cellular immunotherapy for hematologic malignancies where the patient's immune cells are collected and then transfected back into the patient after being modified in vitro . However, some patients tend to develop CRS. In fact, CAR-T cells can cause toxicity in multiple end organs, and transient elevations in the levels of hepatic enzymes and bilirubin have been reported [ 5 , 19 , 20 ]. To explore the role of IFs in the occurrence and development of HBV-ACLF and evaluate CRS of tumor patients who received CAR-T therapy, we measured the levels of a series of serum IFs and LFIs from HBV-ACLF patients in different stages, as well as from tumor patients who received CAR-T therapy. We also analyzed the relationship between IFs release and LFIs change during CAR-T therapy in tumor patients. Methods Patients We retrospectively analyzed 68 patients with HBV-ACLF, 30 patients with pro-HBV-ACLF, and 372 patients with hematologic tumors but without abnormal liver function treated with CAR-T therapy from January 2017 to December 2020 in the First Affiliated Hospital of Soochow University. The concentrations of HBV-DNA in 16 patients with hematologic tumors complicated with HBV received anti-HBV drugs before receiving CAR-T therapy were lower than the limit of detection (LOD) before and after treatment. Twenty outpatients with normal liver function served as the control group. Before CAR-T therapy was administered, serum levels of the IFs IL-2, IL-4, IL-6, IL-10, TNF-α, IFN-γ, and IL-17A were quantified using ELISA, and none were significantly increased. A comprehensive assessment including temperature, abdominal signs, ascites routine, ascites biochemical indexes, procalcitonin (PCT), blood routine, G test, GM test, chest CT, and other comprehensive evaluations were performed for the pro-HBV-ACLF and HBV-ACLF patients. Diagnoses and data collection ACLF was diagnosed based on the Chinese Medical Association (CMA) guidelines [ 21 ]. The CMA guidelines use higher cutoff levels of serum TBIL (171 µmol/L) than the APASL guidelines (85 µmol/L)[ 17 ]. HBV-ACLF was diagnosed based on the COSSH-ACLF criteria (2018): whether cirrhosis is present or not, patients with chronic hepatitis B were diagnosed with ACLF if their TBIL level was ≥ 12 mg/dL (1 mg/dl = 17.1 µmol/L) and the INR was ≥ 1.5 [ 22 ]. The diagnosis of prophase of liver failure (pro-LF) was made according to the LF criteria from the CMA (2018), suggesting that patients should be diagnosed with pro-LF when ALT and/or AST levels are significantly elevated, 85.5 ≤ TBIL < 171 µmol/L or increasing by 17.1 µmol/L per day, and 40%<Prothrombin activity(PTA) ≤ 50% (INR < 1.5) [ 17 ]. Infection was diagnosed based on clinical symptoms and signs (e.g., fever, cough, expectoration, abdominal pain, and frequency, urgency of and pain with urination), laboratory tests (e.g., blood, sputum, ascites, and urine), and imaging findings (e.g., CT). The exclusion criteria were as follows: liver failure due to causes other than HBV, such as autoimmunity, alcohol, drugs, genetics, metabolism, and unknown causes; acute or subacute liver failure or chronic liver failure; patients with malignant tumors of the liver or other organs; pregnancy or breastfeeding; patients receiving immunosuppressant treatment 6 months before admission; and human immunodeficiency virus (HIV) infection. Clinical data collection The relevant clinical data were recorded when participants were enrolled. The baseline clinical data and biochemical parameters were evaluated. Serum liver function parameters, such as ALT, AST, TBIL, and INR, were assessed using standard clinical methods available at the First Affiliated Hospital of Soochow University. The liver function was tested by a continuous method, and the blood coagulation INR was assessed using a coagulation method. IF concentrations were measured using a commercial ELISA kit at the First Affiliated Hospital of Soochow University. The changes in IF levels in patients who received CAR-T cell treatment were monitored, and LFIs (TBIL, ALT, AST, and INR) at the highest level of IL-6 release were measured. If there was no significant increase in IF levels, LFIs were assessed one week after treatment. Measurement of serum IFs A total of 1 ml of peripheral blood for each IF was obtained using an EDTA anticoagulated vacuum blood collection tube (BD, USA), and the plasma specimens were separated in a centrifugation condition of 2500 rpm for 10 min. The concentrations of IL-2, IL-4, IL-6, IL-10, TNF-α, IFN-γ, and IL-17A were measured using an FC500 flow cytometer (Coulter, USA) using the Human Th1 Th2 Th17 7 cytokine assay kit (Biolegend, USA), according to the instructions provided by the manufacturer. The results were analyzed using the FCAP microarray software (Softflow, USA). Inc.). Data analysis The variables for each group did not follow a normal distribution, so they were analyzed by nonparametric correlation analysis. Quantitative data are expressed as medians with interquartile ranges (IQRs). Categorical variables are shown as frequencies and percentages. Differences in characteristics among the three groups were compared by Kruskal–Wallis rank sum tests, and the Bonferroni method was used for multiple comparisons. The differences between two independent samples were compared using the Wilcoxon rank sum test, and the differences between two related samples were compared using the Wilcoxon signed ranks test. Spearman correlation analysis was used to calculate correlation coefficients among individual IFs and LFIs (i.e., T-BIL, ALT, AST, and INR). A scatter plot with a fitted regression line was implemented using R to show the association of individual IFs and LFIs. For better visualization, the concentrations of the measured index were log-transformed before plotting. The concentrations of the measured index lower than the LOD (i.e., 0) were imputed with half of the minimum of the measured index. For all tests, 0.05 level represented statistically significant deviations from the respective null hypothesis. Data were analyzed using IBM SPSS Statistics Version 23.0 (Armonk, NY: IBM Corp.) and R Version 3.4.2 (R Core Team, 2017, R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria). Results Clinical baseline features The final analysis included 372 patients who received CAR-T cell therapy, 30 with pro-HBV-ACLF, 68 with HBV-ACLF, and 20 healthy control subjects. The baseline clinical characteristics of the study participants are summarized in Table 1 . LFIs and IFs changes in HBV-ACLF and pro-HBV-ACLF patients To evaluate whether LFIs and IFs participate in HBV-ACLF pathogenesis, we compared the serum concentration of a series of LFIs and IFs in HBV-ACLF and pro-HBV-ACLF patients. Our results showed that patients with HBV-ACLF had markedly higher TBil levels and longer INR than patients with pro-HBV-ACLF [TBil: 269.85 (175.65; 377.25) µmol/L, n = 68 vs. 158.60 (69.80; 241.55) µmol/L, n = 30; P < 0.05; INR: 2.43 (1.94; 2.75), n = 68 vs. 1.27 (1.20; 1.43), n = 30; P < 0.05]. In addition, the patients with pro-HBV-ACLF had markedly higher ALT, AST, and TBil levels and longer INR than patients with healthy controls [ALT: 172.1 (40.9; 462.5)U/L, n = 30 vs. 11.95 (6.18;15.80)U/L, n = 20; P < 0.05; AST: 108.50 (61.70; 217.20)U/L, n = 30 vs. 10.80 (5.60;15.3028)U/L, n = 20; P < 0.05; TBil: 158.60 (69.80;241.55) µmol/L, n = 30 vs. 9.20 (6.90;12.93) µmol/L, n = 20; P < 0.05; INR: 1.27 (1.20; 1.43), n = 30 vs 1.02 (0.99; 1.06), n = 20; P < 0.05]. Moreover, the serum level of IL-10 at enrollment was significantly higher in patients with HBV-ACLF than in those with pro-HBV-ACLF [5.95 (3.90;14.75) pg/mL, n = 68 vs. 3.80 (2.38;11.83) pg/mL, n = 30; P < 0.05]. In contrast, the serum level of IL-17A was significantly lower in patients with HBV-ACLF than in patients with pro-HBV-ACLF [1.35 (0.59;11.81) pg/mL, n = 68 vs. 2.90 (2.80;22.53) pg/mL, n = 30; P < 0.05]. In addition, the serum IL-6 level did not significantly change in patients with HBV-ACLF and with pro-HBV-ACLF [12.95 (6.60; 41.93) pg/mL, n = 68 vs. 14.15 (3.68; 24.13) pg/mL, n = 30; P = 0.353]. IFs changes in pro-HBV-ACLF and HBV-ACLF patients with or without secondary infection Infection is known to induce CRS; however, whether secondary infection induces IFs changes in pro-HBV-ACLF and HBV-ACLF patients remains needs further study. In order to address this issue, we compared serum concentrations of IFs in pro-HBV-ACLF and HBV-ACLF patients with or without secondary infection. The serum IL-6 level was significantly higher in patients with HBV-ACLF with secondary infection than in patients with HBV-ACLF without secondary infection or pro-HBV-ACLF (40.60 (20.18; 133.75) pg/mL vs. 7.40 (4.23;11.15) pg/mL or 14.15 (3.68; 24.1) pg/mL; P < 0.05). In contrast, the serum IL-6 level was lower in patients with HBV-ACLF without secondary infection than in patients with pro-HBV-ACLF [7.40 (4.23;11.15) pg/mL vs. 14.15 (3.68;24.1) pg/mL; P < 0.05]. However, there was no significant difference between patients with pro-HBV-ACLF and patients with HBV-ACLF without infection in the serum IL-6 level [14.15 (3.68; 24.1) pg/mL vs. 7.40 (4.23; 11.15) pg/mL; P > 0.05] ( Table 1 ) . Table 1 Baseline characteristics and parameters of the study participants Parameters Healthy controls (n = 20) before-CAR-T (n = 372) pro-HBV-ACLF (n = 30) HBV-ACLF (n = 68) HBV-ACLF without infection(n = 36) HBV-ACLF with infection(n = 32) Male, n (%) # 15(75.0) 258(69.4) 26(86.7) 50(73.5) $ 28(77.8) $ 22(66.8) $ Age, y (IQR) # 38(28;55) 44(26;55) 39(34;51) 48(34;58) $ 46(33;49) 54(43;61) WBC, /nL (IQR) - 2.10(0.83;3.59) - 8.91(6.36;12.60) 7.85(6.22;10.26) 10.87(7.36;13.46) PCT, ng/mL (IQR) - 0.09(0.05;0.20) - 1.0(0.54;2.29) 0.59(0.30;0.86) 2.33(1.34;3.22) T-BIL, µmol/L (IQR)* 9.20(6.90;12.93) 10.10(7.63;13.80) 158.60(69.80;241.55) 269.85(175.65;377.25) & 293.35(238.85;325.50) 241.15(157.85;447.0) ALT, U/L (IQR)* 11.95(6.18;15.80) 11.90(18.40;27.50) 172.1(40.9;462.5) 414.5(60.5;747.4) $ 552.0(385.10;788.10) 70.30(30.95;499.70) AST, U/L (IQR)* 10.80(5.60;15.3028) 18.80(14.05;25.40) 108.50(61.70;217.20) 183.35(89.45;396.95) $ 268.95(128.45;410.65) 115.80(60.43;267.48) INR, (IQR)* 1.02(0.99;1.06) 1.01(0.95;1.07) 1.27(1.20;1.43) 2.43(1.94;2.75) & 2.35(1.94;2.52) 2.49(1.96;3.13) IL-2, pg/mL (IQR)* 0.25(0.25;0.25) 0.50(0.50;3.50) 1.15(0.58;3.33) 2.50(0.60;8.48) $ 2.30(0.60;8.65) $ 2.80(0.60;8.40) $@ IL-4, pg/mL (IQR)* 0.10(0.10;0.35) 1.80(0.20;4.30) 6.45(1.30;19.73) 6.20(3.43;8.85) $ 4.70(3.05;8.85) $ 6.40(4.85;8.83) $@ IL-6, pg/mL (IQR)* 0.90(0.25;1.85) 5.10(3.03;10.10) 14.15(3.68;24.13) 12.95(6.60;41.93) $ 7.40(4.23;11.15) $ 40.60(20.18;133.75) &¥ IL-10, pg/mL (IQR)* 0.15(0.10;2.18) 3.15(1.80;5.88) 3.80(2.38;11.83) 5.95(3.90;14.75) & 4.45(2.95;12.50) $ 11.25(4.30;16.25) &@ TNF-α, pg/mL (IQR)* 1.40(0.25;2.63) 1.75(0.40;4.21) 4.75(1.58;11.03) 5.40(3.55;12.05) $ 5.40(3.73;13.65) $ 5.65(1.93;9.35) $@ IFN-γ, pg/mL (IQR)* 0.40(0.40;0.70) 2.10(0.50;4.70) 1.95(0.98;7.53) 4.85(0.70;7.98) $ 3.70(0.70;6.58) $ 6.75(1.05;8.25) $@ IL-17A, pg/mL (IQR)* 0.01(0.01;0.01) 0.50(0.50;5.35) 2.90(2.80;22.53) 1.35(0.59;11.81) & 4.13(0.70;24.01) $ 0.70(0.55;11.46) &@ * P 0.05; & vs. pro-HBV-ACLF, P 0.05; ¥ vs. HBV-ACLF without infection, P 0.05. The Kruskal compared differences in characteristics among three groups–Wallis rank sum test, and differences between two groups were compared by Wilcoxon rank sum test comparisons or Wilcoxon signed-rank tests. IFs changes in HBV-ACLF patients with improved or deteriorated outcomes To further explore if IFs affect the outcomes of HBV-ACLF patients, we compared the IFs parameters in HBV-ACLF patients with improved or deteriorated outcomes, finding that the serum levels of IL-2 [7.60 (0.60; 10.45) pg/mL vs. 1.85 (0.60; 3.85) pg/mL; P < 0.05], IL-6 [26.20 (8.98; 126.53) pg/mL vs. 10.40 (5.28; 15.75) pg/mL; P < 0.05], IL-10 [12.30 (5.60; 17.20) pg/mL vs. 3.90 (2.38; 5.95) pg/mL; P < 0.05], and IFN-γ [7.50 (0.70;8.38) pg/mL vs. 2.50 (0.70;5.75) pg/mL; P < 0.05] at enrollment were markedly higher in patients with HBV-ACLF whose condition deteriorated than in patients with HBV-ACLF whose condition subsequently improved (Table 2 ). Table 2 Comparison of serum IF levels at enrollment between patients with HBV-ACLF who improved and patients with HBV-ACLF who deteriorated Parameter HBV-ACLF with improvement(n = 32) HBV-ACLF with deterioration(n = 36) IL-2, pg/mL (IQR)* 1.85(0.60;3.85) 7.60(0.60;10.45) IL-4, pg/mL (IQR) # 4.90(3.53;7.95) 6.55(3.25;9.25) IL-6, pg/mL (IQR)* 10.40(5.28;15.75) 26.20(8.98;126.53) IL-10, pg/mL (IQR)* 3.90(2.38;5.95) 12.30(5.60;17.20) TNF-α, pg/mL (IQR) # 4.15(2.65;12.33) 7.80(3.70;10.45) IFN-γ, pg/mL (IQR)* 2.50(0.70;5.75) 7.50(0.70;8.38) IL-17A, pg/mL (IQR) # 8.48(0.70;20.61) 0.70(0.55;11.81) * P 0.05. Differences in characteristics between the two groups were compared using the Wilcoxon rank sum test. Abbreviation: Acute-on-chronic liver failure (HBV-ACLF). IFs and LFIs changes in cancer patients before and after CAR-T treatment In addition to virus infection, immunotherapy can also induce CRS. In recent years, CAR-T has become a promising cancer therapy. We further measured and compared serum IFs and LFIs in cancer patients before and after CAR-T treatment to determine whether CAR-T treatment would induce CRS or liver function injury. Our results showed that serum levels of IL-2, IL-6, IL-10, TNF-α, and IFN-γ [IL-2: 3.45 (0.10; 11.50) pg/mL vs. 0.50 (0.50; 3.50) pg/mL; IL-6; 86.35 (5.38; 683.35) pg/mL vs. 5.10 (3.03;10.10) pg/mL; IL-10: 12.40 (4.80; 35.68) pg/mL vs. 3.15 (1.80; 5.88) pg/mL; TNF-α: 3.05 (0.50; 5.28) pg/mL vs. 1.75 (0.40; 4.21) pg/mL; IFN-γ: 11.65 (3.20; 71.85) pg/mL vs. 2.10 (0.50; 4.70) pg/mL; P < 0.05; Table 3 ], especially IL-6 [86.35 (5.38; 683.35) pg/mL vs. 5.10 (3.03;10.10) pg/mL; P < 0.05], increased significantly after treatment. Conversely, TBIL and ALT levels did not markedly increase. Moreover, patients after CAR-T treatment had markedly higher IL-6, IL-10, and IFN-γ levels than patients with HBV-ACLF [IL-6: 86.35 (5.38; 683.35) pg/mL vs. 12.95 (6.60; 41.93) pg/mL; IL-10: 12.40 (4.80; 35.68) pg/mL vs. 5.95 (3.90; 14.75) pg/mL; IFN-γ: 11.65 (3.20; 71.85) pg/mL vs. 4.85 (0.70; 7.98) pg/mL, respectively; Tables 1 and 3 ]. Table 3 Comparison of serum IF levels and LFI at enrollment between patients with before-CAR-T and after-CAR-T Parameter Before receiving CAR-T cell therapy (n = 372) After receiving CAR-T cell therapy (n = 372) T-BIL, µmol/L (IQR) # 10.10(7.63;13.80) 10.20(7.40;15.08) ALT, U/L (IQR) # 11.90(18.40;27.50) 19.75(11.80;33.68) AST, U/L (IQR)* 18.80(14.05;25.40) 19.65(13.90;34.08) INR (IQR)* 1.01(0.95;1.07) 1.11(1.01;1.25) IL-2, pg/mL (IQR)* 0.50(0.50;3.50) 3.45(0.10;11.50) IL-4, pg/mL (IQR) # 1.80(0.20;4.30) 2.00(0.20;4.68) $ IL-6, pg/mL (IQR)* 5.10(3.03;10.10) 86.35(5.38;683.35) $ IL-10, pg/mL (IQR)* 3.15(1.80;5.88) 12.40(4.80;35.68) $ TNF-α, pg/mL (IQR)* 1.75(0.40;4.21) 3.05(0.50;5.28) $ IFN-γ, pg/mL (IQR)* 2.10(0.50;4.70) 11.65(3.20;71.85) $ IL-17A, pg/mL (IQR) # 0.50(0.50;5.35) 0.50(0.50;7.55) $ * P 0.05; $ vs. HBV-ACLF group, P < 0.05. Differences between two related samples were compared by the Wilcoxon signed ranks test. Correlation between IFs and LFIs levels in patients receiving CAR-T cell therapy To determine if changed IFs caused liver failure in cancer patients after CAR-T treatment, we compared the relationship between IFs and LFIs, finding that treatment with CAR-T cells (including 16 patients with CHB), IFs (i.e., IL-2, IL-6, IL-10, TNF-α, and IFN-γ) was weakly or not at all correlated with TBIL (rho = 0.245, 0.420, 0.268, 0.119, 0.288 respectively; P > 0.05), ALT (rho = 0.148, 0.192, 0.164, 0.140, 0.272 respectively; P ≥ 0.05), and AST ((rho = 0.165, 0.314, 0.318, 0.138, 0.384 respectively; P < 0.05) (Fig. 1 ). IFs and LFIs changes in cancer patients with CHB before and after CAR-T treatment Furthermore, patients with CHB from a group of patients receiving CAR-T cell therapy were selected for further analysis. Serum IFs and LFIs levels were tested before and after receiving therapy. The results also showed that serum IL-6 [23.80 (3.75; 1198.48) pg/mL vs. 9.0 (4.38;20.45) pg/mL, P < 0.05], IL-10 [10.70 (3.0; 34.75) pg/mL vs. 2.75 (2.30; 9.33) pg/mL, P < 0.05], and IFN-γ [13.95 (1.78; 148.18) pg/mL vs. 2.25 (1.10;4.38) pg/mL, P 0.05], ALT [16.15 (11.38; 22.43) U/L vs. 10.75 (7.93; 26.23) U/L, P > 0.05], and AST [20.85(187.80; 25.68) U/L vs. 18.55 (12.58; 31.90) U/L, P > 0.05] levels between the two groups (Table 4 ). Table 4 Comparison of serum IF levels and LFI levels at enrollment between patients complicated with CHB with before-CAR-T and after-CAR-T Parameter Before receiving CAR-T cell therapy(n = 16) After receiving CAR-T cell therapy(n = 16) T-BIL, µmol/L (IQR) # 9.65 (7.03;12.73) 10.05 (7.55;13.05) ALT, U/L (IQR) # 16.15 (11.38;22.43) 10.75 (7.93;26.23) AST, U/L (IQR) # 20.85 (187.80;25.68) 18.55 (12.58;31.90) INR (IQR)* 0.98 (0.95;1.12) 1.11 (1.02;1.21) IL-2, pg/mL (IQR) * 0.50 (0.50;3.30) 4.05 (1.05;12.83) IL-4, pg/mL (IQR) # 1.80 (0.50;5.48) 1.65 (1.70;3.85) IL-6, pg/mL (IQR) * 9.0 (4.38;20.45) 23.80 (3.75;1198.48) IL-10, pg/mL (IQR) * 2.75 (2.30;9.33) 10.70 (3.0;34.75) TNF-α, pg/mL (IQR) # 1.90 (1.90;6.35) 2.20 (0.50;6.80) IFN-γ, pg/mL (IQR) * 2.25 (1.10;4.38) 13.95 (1.78;148.18) IL-17A, pg/mL (IQR) # 1.30 (1.30;3.80) 3.0 (1.40;9.70) * vs.before-CAR-T group, P < 0.05; # vs. before-CAR-T group, P < 0.05. Differences between two related samples were compared using the Wilcoxon signed ranks test. Association between IFs and LFIs in tumor patients with HBV receiving CAR-T therapy Specifically, for the tumor patients with HBV, we compared the association between IFs and LFIs after CAR-T treatment, finding that TBIL, ALT, and AST levels were not significantly correlated with levels of various IFs (i.e., IL-2, IL-4, IL-6, IL-10, TNF-α, IFN-γ and IL-17A) (rho = 0.215, -0.372, 0.366, 0.402, 0.385, 0.427, 0.053, P > 0.05; rho=-0.012, 0.442, -0.171, -0.009, 0.161, -0.091, 0.051, P > 0.05; rho = 0.054, 0.361, -0.118, 0.194, 0.203, 0.029, 0.204, P > 0.05; respectively) (Fig. 2 ). Only the INR was correlated with IL-2 and TNF-α levels (rho = 0.536, P = 0.032; 0.669, P = 0.005; respectively) (Fig. 2 ). Discussion In the present study, we compared healthy people, pro-HBV-ACLF patients, and HBV-ACLF patients, finding that serum levels of IL-10 were significantly increased, which was correlated with the development of HBV-ACLF. These results indicate that IL-10 may have an important role in the pathogenesis of HBV-ACLF. Consistent with this conclusion, we further found that serum IL-10 was much higher in HBV-ACLF patients with deteriorated outcomes than those with improved outcomes. In parallel, liver function, indicated by serum levels of ALT, AST, TBil, and INR, was impaired in pro-HBV-ACLF patients and deteriorated in HBV-ACLF patients. IL-10 is well known as an immunosuppressive cytokine [ 23 ] that has been recently reported to be secreted in response to hepatitis B core antigen (HBcAg) by peripheral blood mononuclear cells (PBMCs) in patients with chronic HBV infection [ 24 ]. Our observations are consistent with previous studies, implying that IL-10 has a functional role in the pathogenesis of HBV-ACLF and can be used as a diagnostic marker, prognostic marker, and therapy target of HBV-ACLF. Furthermore, we found the serum IL-6 level did not significantly change in HBV-ACLF patients compared to pro-HBV-ACLF patients, which is not consistent with a previous study, which reported high plasma IL-6 levels in CHB patients [ 25 ]. Interestingly, the serum IL-6 was significantly higher in HBV-ACLF patients with secondary infection than in HBV-ACLF patients without secondary infection, considering that IL-6 has a crucial role in HBV infection (PMID: 26807383). These results suggest a specific role of IL-6 in response to HBV secondary infection. Immunotherapy induces CRS and causes side effects in patients [ 26 ]. In this study, we found increased serum levels of IL-2, IL-6, IL-10, TNF-α, and IFN-γ, especially IL-6, in tumor patients after CAR-T treatment, a feature of CRS. A preclinical study found that CAR-T cell-mediated cancer clearance triggers elevated IL-6 levels, not produced by infused CAR-T cells but by recipient macrophages/monocytes. More importantly, the CRS was prevented by blocking the IL-6 receptor with tocilizumab [ 27 , 28 ]. Our observation, as well as previous reports, shed insights into improvements in CAR-T therapy. However, TBIL and ALT levels were not markedly increased, indicating liver function remained normal during CAR-T therapy, although marked changes in a series of cytokines were observed. This uncoupling suggests that the liver is not the target of elevated cytokines after CAR-T therapy in tumor patients. Considering the uncoupling between IFs and LFIs levels in patients receiving CAR-T cell therapy, we further analyzed the relationship between IFs and LFIs in subsets of patients, including tumor patients with CHB and HBV. Results showed changed cytokines; however, there was no significant relationship between IFs and LFIs, confirming the uncoupling between IFs and LFIs levels in HBV or CHB subsets. The preset study has some limitations. Our sample of CHB patients who received CAR-T cell therapy was relatively small, so our analysis may be underpowered to detect a real correlation between inflammatory factors and liver function. In addition, the mechanisms underlying the association between inflammatory factor levels and liver function in HBV-ACLF patients were not directly investigated. Additional studies are needed to confirm our results and validate serum IL-10 level as a diagnostic marker. Conclusions In summary, we found that serum IL6 and IL-10 levels were strongly correlated with the pathogenesis, development, and outcome of HBV-ACLF, which is consistent with the impaired liver function of HBV-ACLF patients, especially those with secondary infections. In addition, CAR-T therapy induced CRS in tumor patients, while no significant liver function impairment was observed. Abbreviations HBV-ACLF : Hepatitis B virus-related acute-on-chronic liver failure; CRS : Cytokine release syndrome; CAR-T : chimeric antigen receptor T; IFs : inflammatory factors; pro-HBV-ACLF : prophase of HBV-ACLF; LFIs : liver function indexes; IL-10 : Serum interleukin-10; ALT : alanine transaminase; AST : aspartate aminotransferase; TBil : total bilirubin; INR : international normalized ratio; TNF- α : tumor necrosis factor α; IFN- γ : interferon γ; SIRS : systemic inflammatory response syndrome; SI : systemic inflammation; APASL : Asian Pacific Association for the Study of Liver; LOD : limit of detection; PCT : procalcitonin; CMA : Chinese Medical Association; pro-LF : prophase of liver failure; IQRs : interquartile ranges Declarations Funding This work was supported by grants from the National Science and Technology“13th Five-Year Plan” Major Special Project (2017ZX110203201) and Suzhou Science and Education Xingwei Youth Science and Technology Project (KJXW2020003). Author information Y.W. and J.G. contributed equally to this study. Acknowledgements We thank the other doctors on the medical team (Wenting Li, Wei Sun, Li Chen, Yan Huang) for their work in treating patients. Author contributions Y.W., X.-p.H. and J.-h.G. designed the study; Y.W., Y.X. and G.-h.C. collected patient samples and the data; Y.W. and J.G. analyzed the data; Y.W. and Y.-f.J. prepared figures 1-2; Y.W., J.G., X.-p.H. and J.-h.G. drafted the manuscript; All authors read and approved the final manuscript. Data availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate This single-center retrospective study was approved by the medical ethics committee of the First Affiliated Hospital of Soochow University (Ethical Approval No.: (2022) LEN Research Approval No. 089). All procedures performed in studies were in accordance with the ethical standards of the institutional and/or national research committee. The study was based on existing data collected in the course of routine clinical practice,and no additional risks were posed to the patients. Therefore, the need for individual informed consent was waived by the ethics committee of the First Affiliated Hospital of Soochow University. Competing interests The authors declare no competing interests. References Lee DW, Barrett DM, Mackall C, Orentas R, Grupp SA. The future is now: chimeric antigen receptors as new targeted therapies for childhood cancer. Clin Cancer Res. 2012;18(10):2780–90. Johnson LA, June CH. Driving gene-engineered T cell immunotherapy of cancer. Cell Res. 2017;27(1):38–58. Rouce RH, Sharma S, Huynh M, Heslop HE. Recent advances in T-cell immunotherapy for haematological malignancies. Br J Haematol. 2017;176(5):688–704. June CH, Sadelain M. Chimeric Antigen Receptor Therapy. N Engl J Med. 2018;379(1):64–73. Kochenderfer JN, Dudley ME, Feldman SA, et al. B-cell depletion and remissions of malignancy along with cytokine-associated toxicity in a clinical trial of anti-CD19 chimeric-antigen-receptor-transduced T cells. Blood. 2012;119(12):2709–20. Lee DW, Gardner R, Porter DL, et al. Current concepts in the diagnosis and management of cytokine release syndrome. Blood. 2014;124(2):188–95. Teachey DT, Lacey SF, Shaw PA, et al. Identification of Predictive Biomarkers for Cytokine Release Syndrome after Chimeric Antigen Receptor T-cell Therapy for Acute Lymphoblastic Leukemia. Cancer Discov. 2016;6(6):664–79. Trepo C, Chan HL, Lok A. Hepatitis B virus infection. Lancet. 2014;384(9959):2053–63. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2095–128. Shi Y, Yang Y, Hu Y, et al. Acute-on-chronic liver failure precipitated by hepatic injury is distinct from that precipitated by extrahepatic insults. Hepatology. 2015;62(1):232–42. Li H, Chen LY, Zhang NN, et al. Characteristics, Diagnosis and Prognosis of Acute-on-Chronic Liver Failure in Cirrhosis Associated to Hepatitis B. Sci Rep. 2016;6:25487. Zhang YY, Meng ZJ. Definition and classification of acute-on-chronic liver diseases. World J Clin Cases. 2022;10(15):4717–25. Seto WK, Lai CL, Yuen MF. Acute-on-chronic liver failure in chronic hepatitis B. J Gastroenterol Hepatol. 2012;27(4):662–9. Zhao RH, Shi Y, Zhao H, Wu W, Sheng JF. Acute-on-chronic liver failure in chronic hepatitis B: an update. Expert Rev Gastroenterol Hepatol. 2018;12(4):341–50. Wang FS, Fan JG, Zhang Z, Gao B, Wang HY. The global burden of liver disease: the major impact of China. Hepatology. 2014;60(6):2099–108. Wu W, Yan H, Zhao H, et al. Characteristics of systemic inflammation in hepatitis B-precipitated ACLF: Differentiate it from No-ACLF. Liver Int. 2018;38(2):248–57. Sarin SK, Choudhury A, Sharma MK, et al. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update. Hepatol Int. 2019;13(4):353–90. Claria J, Stauber RE, Coenraad MJ, et al. Systemic inflammation in decompensated cirrhosis: Characterization and role in acute-on-chronic liver failure. Hepatology. 2016;64(4):1249–64. Brudno JN, Maric I, Hartman SD, et al. T Cells Genetically Modified to Express an Anti-B-Cell Maturation Antigen Chimeric Antigen Receptor Cause Remissions of Poor-Prognosis Relapsed Multiple Myeloma. J Clin Oncol. 2018;36(22):2267–80. Fitzgerald JC, Weiss SL, Maude SL, et al. Cytokine Release Syndrome After Chimeric Antigen Receptor T Cell Therapy for Acute Lymphoblastic Leukemia. Crit Care Med. 2017;45(2):e124–31. Liver F, Artificial Liver Group CS, o. I. DCMA, Severe Liver D, Artificial Liver Group CS. o. H. C. M. A.Guideline for diagnosis and treatment of liver failure. Zhonghua Gan Zang Bing Za Zhi. 2019;27(1):18–26. Wu TZ, Li J, Shao L, et al. Development of diagnostic criteria and a prognostic score for hepatitis B virus -related acute -on - chronic liver failure. Gut. 2018;67(12):2181–91. Fabri A, Kandara K, Coudereau R, et al. Characterization of Circulating IL-10-Producing Cells in Septic Shock Patients: A Proof of Concept Study. Front Immunol. 2020;11:615009. Hyodo N, Nakamura I, Imawari M. Hepatitis B core antigen stimulates interleukin-10 secretion by both T cells and monocytes from peripheral blood of patients with chronic hepatitis B virus infection. Clin Exp Immunol. 2004;135(3):462–6. Wu ZB, Zheng YB, Wang K, et al. Plasma Interleukin-6 Level: A Potential Prognostic Indicator of Emergent HBV-Associated ACLF. Can J Gastroenterol Hepatol. 2021;2021:5545181. Shah D, Soper B, Shopland L. Cytokine release syndrome and cancer immunotherapies - historical challenges and promising futures. Front Immunol. 2023;14:1190379. Norelli M, Camisa B, Barbiera G, et al. Monocyte-derived IL-1 and IL-6 are differentially required for cytokine-release syndrome and neurotoxicity due to CAR T cells. Nat Med. 2018;24(6):739–48. Giavridis T, van der Stegen SJC, Eyquem J, Hamieh M, Piersigilli A, Sadelain M. CAR T cell-induced cytokine release syndrome is mediated by macrophages and abated by IL-1 blockade. Nat Med. 2018;24(6):731–8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4579363","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":317806324,"identity":"9844c902-d4d5-4945-83b0-9cb87a5ac30d","order_by":0,"name":"Yan Wang","email":"","orcid":"","institution":"Department of Infectious Diseases, The First Afliated Hospital of Soochow University, Suzhou","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Wang","suffix":""},{"id":317806325,"identity":"74cad6dc-0966-4fea-88a9-5c0f3bb50b3b","order_by":1,"name":"Jing Gu","email":"","orcid":"","institution":"Department of Infectious Diseases, The First Afliated Hospital of Soochow University, Suzhou","correspondingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Gu","suffix":""},{"id":317806326,"identity":"519a27cb-dfaf-4b6c-b9f9-ac26cd885dca","order_by":2,"name":"Guanghua Chen","email":"","orcid":"","institution":"National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou","correspondingAuthor":false,"prefix":"","firstName":"Guanghua","middleName":"","lastName":"Chen","suffix":""},{"id":317806328,"identity":"9c709a06-0128-4c77-9e01-052bbcfdddf3","order_by":3,"name":"Yanfeng Jiang","email":"","orcid":"","institution":"State Key Laboratory of Genetic Engineering, Human Phenome Institute, Fudan University, Shanghai","correspondingAuthor":false,"prefix":"","firstName":"Yanfeng","middleName":"","lastName":"Jiang","suffix":""},{"id":317806330,"identity":"85e00cfb-a2ee-4d78-9c9e-5bdd80b48548","order_by":4,"name":"Ying Xu","email":"","orcid":"","institution":"Department of Infectious Diseases, The First Afliated Hospital of Soochow University, Suzhou","correspondingAuthor":false,"prefix":"","firstName":"Ying","middleName":"","lastName":"Xu","suffix":""},{"id":317806333,"identity":"46394e91-ee56-44fd-bfe5-9a6fe4307ee3","order_by":5,"name":"Xiaoping Huang","email":"","orcid":"","institution":"Department of Infectious Diseases, The First Afliated Hospital of Soochow University, Suzhou","correspondingAuthor":false,"prefix":"","firstName":"Xiaoping","middleName":"","lastName":"Huang","suffix":""},{"id":317806335,"identity":"0e1be5f9-6a5a-44ab-aef4-857b7af0d330","order_by":6,"name":"Jianhe Gan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIie2PoQrCUBSGzxC2MrDepb3CtVh8AF/jnDLLGIJgMizN5qrgS8wn8MJFLdOsaJgIJoNJDCJuC9quswnerx34Pz4OgEbzo3AEQLBCQ+B3ii2gulKAwBBEpanbXoluNtgHdeeYiUMkA7DkPFEpjTRAjotTz5l4XFAke2B73kaphD7naEpKdlgqFDK7qVbic648JM22y0s1xWV5pVgmzK5Y4Syv0EjSOPW7Atcdij794sZ+s3G7SoqHy+nh1m9RbMmFuiLA5K/LMAFM1byshFDL3uf9016j0Wj+kSd091f4xbh2VQAAAABJRU5ErkJggg==","orcid":"","institution":"Department of Infectious Diseases, The First Afliated Hospital of Soochow University, Suzhou","correspondingAuthor":true,"prefix":"","firstName":"Jianhe","middleName":"","lastName":"Gan","suffix":""}],"badges":[],"createdAt":"2024-06-14 04:29:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4579363/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4579363/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59600061,"identity":"a153bc2b-316b-4c36-96c0-803cf81ad441","added_by":"auto","created_at":"2024-07-03 16:37:39","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":298316,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe correlation between LFIs (e.g., TBIL, ALT, AST, and INR) and levels of IFs in 372 patients treated with CAR-T cells.\u003c/strong\u003eALT and AST levels had weak linear correlations with IL-2, IL-6, IL-10, TNF-α, and IFN-γ levels; the TBIL level had a significant linear correlation with IL-6 level but a weak linear correlation with IL-2, IL-10, TNF-αand IFN-γ levels; the INR had a significant linear correlation with IL-2, IL-6, IL-10, and IFN-γ levels.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4579363/v1/dac792f44f549a21626dba78.jpg"},{"id":59600062,"identity":"91feb38d-f824-4f2e-a9d8-3796e117ac03","added_by":"auto","created_at":"2024-07-03 16:37:40","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":180597,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe correlation between LFIs (e.g., TBIL, ALT, AST, INR) and levels of IFs in 16 patients treated with CAR-T therapy.\u003c/strong\u003e TBIL, ALT, and AST levels were not correlated with IL-2, IL-4, IL-6, IL-10, TNF-α, IFN-γ, or IL-17A levels. The INR was significantly linearly correlated with IL-2 and TNF-α levels.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4579363/v1/6f00392999af68b0d540178d.jpg"},{"id":63530109,"identity":"944cfda7-fd2c-40c2-811b-2e52eec5602d","added_by":"auto","created_at":"2024-08-29 07:47:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1224704,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4579363/v1/ed2cedd0-b397-4494-b27d-dc964234447b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Roles of inflammatory factors in the pathogenesis of hepatitis B virus-related acute-on-chronic liver failure and CAR-T therapy","fulltext":[{"header":"Background","content":"\u003cp\u003eCRS or uncontrollable systemic inflammatory response syndrome (SIRS), is an acute systemic inflammatory syndrome[\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. CRS is thought to be caused by the release of IFs, such as IL-2, IL-6, IL-10, TNF-α, IFN-γ, which can lead to a series of clinical symptoms, including fever, low blood pressure, severe inflammation syndrome, or even dysfunction of a wide range of organs [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHepatitis B virus infection is a major public health problem worldwide, and approximately 30% of the global population has current or past serological infection [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. At present, data on the epidemiology of HBV-ACLF among hepatitis HBV-infected patients are lacking. However, some studies have reported an approximately 35% incidence of ACLF among patients with underlying HBV-related cirrhosis suffering from acute decompensation [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The pathological changes caused by various basic liver diseases and acute inducements differ among patient groups [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Therefore, ACLF still lacks a global unified definition and diagnostic criteria. China is a region with a high incidence of HBV infection, and HBV-ACLF is the most common form [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. HBV-ACLF is a common type of end-stage liver disease among patients with chronic HBV infection that is characterized by rapid deterioration of underlying chronic liver diseases with multiorgan failure and high short-term mortality.\u003c/p\u003e \u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eThe pathogenesis of liver failure is very complex, and there are different etiologies. At present, in-depth studies are being carried out in China and internationally to identify the mechanism of progressive liver failure and develop therapeutic strategies to suppress ongoing injury and supplement hepatic regeneration. There has been much debate about whether sepsis is the cause or the result of ACLF. Previous studies have emphasized the important role of cytokine storm in the pathogenesis of liver failure \u003csup\u003e16\u003c/sup\u003e. Additionally, it has been reported that systemic inflammation (SI), which can be attributed to the overactivation of innate immunity, is a major driver of HBV-associated ACLF [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. According to the Asian Pacific Association for the Study of Liver (APASL) guidelines updated in 2019, sepsis is a consequence rather than the cause of the ACLF [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The APASL definition does not include sepsis as a primary cause for liver failure, but in the Western definition, sepsis is considered the most common precipitant; the APASL has proposed an SI hypothesis stating that ACLF is the expression of an acute exacerbation of the SI already present in decompensated cirrhosis [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e \u003cp\u003eCAR-T cell therapy is an effective new cellular immunotherapy for hematologic malignancies where the patient's immune cells are collected and then transfected back into the patient after being modified \u003cem\u003ein vitro\u003c/em\u003e. However, some patients tend to develop CRS. In fact, CAR-T cells can cause toxicity in multiple end organs, and transient elevations in the levels of hepatic enzymes and bilirubin have been reported [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo explore the role of IFs in the occurrence and development of HBV-ACLF and evaluate CRS of tumor patients who received CAR-T therapy, we measured the levels of a series of serum IFs and LFIs from HBV-ACLF patients in different stages, as well as from tumor patients who received CAR-T therapy. We also analyzed the relationship between IFs release and LFIs change during CAR-T therapy in tumor patients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eWe retrospectively analyzed 68 patients with HBV-ACLF, 30 patients with pro-HBV-ACLF, and 372 patients with hematologic tumors but without abnormal liver function treated with CAR-T therapy from January 2017 to December 2020 in the First Affiliated Hospital of Soochow University. The concentrations of HBV-DNA in 16 patients with hematologic tumors complicated with HBV received anti-HBV drugs before receiving CAR-T therapy were lower than the limit of detection (LOD) before and after treatment. Twenty outpatients with normal liver function served as the control group. Before CAR-T therapy was administered, serum levels of the IFs IL-2, IL-4, IL-6, IL-10, TNF-α, IFN-γ, and IL-17A were quantified using ELISA, and none were significantly increased. A comprehensive assessment including temperature, abdominal signs, ascites routine, ascites biochemical indexes, procalcitonin (PCT), blood routine, G test, GM test, chest CT, and other comprehensive evaluations were performed for the pro-HBV-ACLF and HBV-ACLF patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDiagnoses and data collection\u003c/h2\u003e \u003cp\u003eACLF was diagnosed based on the Chinese Medical Association (CMA) guidelines [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The CMA guidelines use higher cutoff levels of serum TBIL (171 \u0026micro;mol/L) than the APASL guidelines (85 \u0026micro;mol/L)[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. HBV-ACLF was diagnosed based on the COSSH-ACLF criteria (2018): whether cirrhosis is present or not, patients with chronic hepatitis B were diagnosed with ACLF if their TBIL level was \u0026ge;\u0026thinsp;12 mg/dL (1 mg/dl\u0026thinsp;=\u0026thinsp;17.1 \u0026micro;mol/L) and the INR was \u0026ge;\u0026thinsp;1.5 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The diagnosis of prophase of liver failure (pro-LF) was made according to the LF criteria from the CMA (2018), suggesting that patients should be diagnosed with pro-LF when ALT and/or AST levels are significantly elevated, 85.5\u0026thinsp;\u0026le;\u0026thinsp;TBIL\u0026thinsp;\u0026lt;\u0026thinsp;171 \u0026micro;mol/L or increasing by 17.1 \u0026micro;mol/L per day, and 40%\u0026lt;Prothrombin activity(PTA)\u0026thinsp;\u0026le;\u0026thinsp;50% (INR\u0026thinsp;\u0026lt;\u0026thinsp;1.5) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Infection was diagnosed based on clinical symptoms and signs (e.g., fever, cough, expectoration, abdominal pain, and frequency, urgency of and pain with urination), laboratory tests (e.g., blood, sputum, ascites, and urine), and imaging findings (e.g., CT).\u003c/p\u003e \u003cp\u003eThe exclusion criteria were as follows: liver failure due to causes other than HBV, such as autoimmunity, alcohol, drugs, genetics, metabolism, and unknown causes; acute or subacute liver failure or chronic liver failure; patients with malignant tumors of the liver or other organs; pregnancy or breastfeeding; patients receiving immunosuppressant treatment 6 months before admission; and human immunodeficiency virus (HIV) infection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eClinical data collection\u003c/h2\u003e \u003cp\u003eThe relevant clinical data were recorded when participants were enrolled. The baseline clinical data and biochemical parameters were evaluated. Serum liver function parameters, such as ALT, AST, TBIL, and INR, were assessed using standard clinical methods available at the First Affiliated Hospital of Soochow University. The liver function was tested by a continuous method, and the blood coagulation INR was assessed using a coagulation method. IF concentrations were measured using a commercial ELISA kit at the First Affiliated Hospital of Soochow University. The changes in IF levels in patients who received CAR-T cell treatment were monitored, and LFIs (TBIL, ALT, AST, and INR) at the highest level of IL-6 release were measured. If there was no significant increase in IF levels, LFIs were assessed one week after treatment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eMeasurement of serum IFs\u003c/h2\u003e \u003cp\u003eA total of 1 ml of peripheral blood for each IF was obtained using an EDTA anticoagulated vacuum blood collection tube (BD, USA), and the plasma specimens were separated in a centrifugation condition of 2500 rpm for 10 min. The concentrations of IL-2, IL-4, IL-6, IL-10, TNF-α, IFN-γ, and IL-17A were measured using an FC500 flow cytometer (Coulter, USA) using the Human Th1 Th2 Th17 7 cytokine assay kit (Biolegend, USA), according to the instructions provided by the manufacturer. The results were analyzed using the FCAP microarray software (Softflow, USA). Inc.).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe variables for each group did not follow a normal distribution, so they were analyzed by nonparametric correlation analysis. Quantitative data are expressed as medians with interquartile ranges (IQRs). Categorical variables are shown as frequencies and percentages. Differences in characteristics among the three groups were compared by Kruskal\u0026ndash;Wallis rank sum tests, and the Bonferroni method was used for multiple comparisons. The differences between two independent samples were compared using the Wilcoxon rank sum test, and the differences between two related samples were compared using the Wilcoxon signed ranks test. Spearman correlation analysis was used to calculate correlation coefficients among individual IFs and LFIs (i.e., T-BIL, ALT, AST, and INR). A scatter plot with a fitted regression line was implemented using R to show the association of individual IFs and LFIs. For better visualization, the concentrations of the measured index were log-transformed before plotting. The concentrations of the measured index lower than the LOD (i.e., 0) were imputed with half of the minimum of the measured index. For all tests, 0.05 level represented statistically significant deviations from the respective null hypothesis. Data were analyzed using IBM SPSS Statistics Version 23.0 (Armonk, NY: IBM Corp.) and R Version 3.4.2 (R Core Team, 2017, R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eClinical baseline features\u003c/h2\u003e \u003cp\u003eThe final analysis included 372 patients who received CAR-T cell therapy, 30 with pro-HBV-ACLF, 68 with HBV-ACLF, and 20 healthy control subjects. The baseline clinical characteristics of the study participants are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eLFIs and IFs changes in HBV-ACLF and pro-HBV-ACLF patients\u003c/h2\u003e \u003cp\u003eTo evaluate whether LFIs and IFs participate in HBV-ACLF pathogenesis, we compared the serum concentration of a series of LFIs and IFs in HBV-ACLF and pro-HBV-ACLF patients. Our results showed that patients with HBV-ACLF had markedly higher TBil levels and longer INR than patients with pro-HBV-ACLF [TBil: 269.85 (175.65; 377.25) \u0026micro;mol/L, n\u0026thinsp;=\u0026thinsp;68 vs. 158.60 (69.80; 241.55) \u0026micro;mol/L, n\u0026thinsp;=\u0026thinsp;30; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; INR: 2.43 (1.94; 2.75), n\u0026thinsp;=\u0026thinsp;68 vs. 1.27 (1.20; 1.43), n\u0026thinsp;=\u0026thinsp;30; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05]. In addition, the patients with pro-HBV-ACLF had markedly higher ALT, AST, and TBil levels and longer INR than patients with healthy controls [ALT: 172.1 (40.9; 462.5)U/L, n\u0026thinsp;=\u0026thinsp;30 vs. 11.95 (6.18;15.80)U/L, n\u0026thinsp;=\u0026thinsp;20; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; AST: 108.50 (61.70; 217.20)U/L, n\u0026thinsp;=\u0026thinsp;30 vs. 10.80 (5.60;15.3028)U/L, n\u0026thinsp;=\u0026thinsp;20; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; TBil: 158.60 (69.80;241.55) \u0026micro;mol/L, n\u0026thinsp;=\u0026thinsp;30 vs. 9.20 (6.90;12.93) \u0026micro;mol/L, n\u0026thinsp;=\u0026thinsp;20; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; INR: 1.27 (1.20; 1.43), n\u0026thinsp;=\u0026thinsp;30 vs 1.02 (0.99; 1.06), n\u0026thinsp;=\u0026thinsp;20; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05].\u003c/p\u003e \u003cp\u003eMoreover, the serum level of IL-10 at enrollment was significantly higher in patients with HBV-ACLF than in those with pro-HBV-ACLF [5.95 (3.90;14.75) pg/mL, n\u0026thinsp;=\u0026thinsp;68 vs. 3.80 (2.38;11.83) pg/mL, n\u0026thinsp;=\u0026thinsp;30; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05]. In contrast, the serum level of IL-17A was significantly lower in patients with HBV-ACLF than in patients with pro-HBV-ACLF [1.35 (0.59;11.81) pg/mL, n\u0026thinsp;=\u0026thinsp;68 vs. 2.90 (2.80;22.53) pg/mL, n\u0026thinsp;=\u0026thinsp;30; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05]. In addition, the serum IL-6 level did not significantly change in patients with HBV-ACLF and with pro-HBV-ACLF [12.95 (6.60; 41.93) pg/mL, n\u0026thinsp;=\u0026thinsp;68 vs. 14.15 (3.68; 24.13) pg/mL, n\u0026thinsp;=\u0026thinsp;30; P\u0026thinsp;=\u0026thinsp;0.353].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIFs changes in pro-HBV-ACLF and HBV-ACLF patients with or without secondary infection\u003c/h2\u003e \u003cp\u003eInfection is known to induce CRS; however, whether secondary infection induces IFs changes in pro-HBV-ACLF and HBV-ACLF patients remains needs further study. In order to address this issue, we compared serum concentrations of IFs in pro-HBV-ACLF and HBV-ACLF patients with or without secondary infection. The serum IL-6 level was significantly higher in patients with HBV-ACLF with secondary infection than in patients with HBV-ACLF without secondary infection or pro-HBV-ACLF (40.60 (20.18; 133.75) pg/mL vs. 7.40 (4.23;11.15) pg/mL or 14.15 (3.68; 24.1) pg/mL; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In contrast, the serum IL-6 level was lower in patients with HBV-ACLF without secondary infection than in patients with pro-HBV-ACLF [7.40 (4.23;11.15) pg/mL vs. 14.15 (3.68;24.1) pg/mL; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05]. However, there was no significant difference between patients with pro-HBV-ACLF and patients with HBV-ACLF without infection in the serum IL-6 level [14.15 (3.68; 24.1) pg/mL vs. 7.40 (4.23; 11.15) pg/mL; P\u0026thinsp;\u0026gt;\u0026thinsp;0.05]\u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics and parameters of the study participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealthy controls\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ebefore-CAR-T\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;372)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003epro-HBV-ACLF\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHBV-ACLF\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHBV-ACLF without infection(n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHBV-ACLF with infection(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, n (%)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15(75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e258(69.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26(86.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50(73.5)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28(77.8)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e22(66.8)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, y (IQR)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38(28;55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44(26;55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39(34;51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48(34;58)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e46(33;49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e54(43;61)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC, /nL (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.10(0.83;3.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.91(6.36;12.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.85(6.22;10.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.87(7.36;13.46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCT, ng/mL (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.09(0.05;0.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.0(0.54;2.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.59(0.30;0.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.33(1.34;3.22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT-BIL, \u0026micro;mol/L (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.20(6.90;12.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.10(7.63;13.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e158.60(69.80;241.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e269.85(175.65;377.25)\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e293.35(238.85;325.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e241.15(157.85;447.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALT, U/L (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.95(6.18;15.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.90(18.40;27.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e172.1(40.9;462.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e414.5(60.5;747.4)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e552.0(385.10;788.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e70.30(30.95;499.70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAST, U/L (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.80(5.60;15.3028)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.80(14.05;25.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e108.50(61.70;217.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e183.35(89.45;396.95)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e268.95(128.45;410.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e115.80(60.43;267.48)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINR, (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.02(0.99;1.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.01(0.95;1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.27(1.20;1.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.43(1.94;2.75)\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.35(1.94;2.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.49(1.96;3.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-2, pg/mL (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.25(0.25;0.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.50(0.50;3.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.15(0.58;3.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.50(0.60;8.48)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.30(0.60;8.65)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.80(0.60;8.40)\u003csup\u003e$@\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-4, pg/mL (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.10(0.10;0.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.80(0.20;4.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.45(1.30;19.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.20(3.43;8.85)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.70(3.05;8.85)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.40(4.85;8.83)\u003csup\u003e$@\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-6, pg/mL (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.90(0.25;1.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.10(3.03;10.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.15(3.68;24.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.95(6.60;41.93)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.40(4.23;11.15)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e40.60(20.18;133.75)\u003csup\u003e\u0026amp;\u0026yen;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-10, pg/mL (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.15(0.10;2.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.15(1.80;5.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.80(2.38;11.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.95(3.90;14.75)\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.45(2.95;12.50)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11.25(4.30;16.25)\u003csup\u003e\u0026amp;@\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTNF-α, pg/mL (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.40(0.25;2.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.75(0.40;4.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.75(1.58;11.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.40(3.55;12.05)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.40(3.73;13.65)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.65(1.93;9.35)\u003csup\u003e$@\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIFN-γ, pg/mL (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.40(0.40;0.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.10(0.50;4.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.95(0.98;7.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.85(0.70;7.98)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.70(0.70;6.58)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.75(1.05;8.25)\u003csup\u003e$@\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-17A, pg/mL (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.01(0.01;0.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.50(0.50;5.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.90(2.80;22.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.35(0.59;11.81)\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.13(0.70;24.01)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.70(0.55;11.46)\u003csup\u003e\u0026amp;@\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; \u003csup\u003e#\u003c/sup\u003e P\u0026thinsp;\u0026gt;\u0026thinsp;0.05;\u003csup\u003e\u0026amp;\u003c/sup\u003e vs. pro-HBV-ACLF, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; \u003csup\u003e$\u003c/sup\u003e vs. pro-HBV-ACLF, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05; \u003csup\u003e\u0026yen;\u003c/sup\u003e vs. HBV-ACLF without infection, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05;\u003csup\u003e@\u003c/sup\u003e vs. HBV-ACLF without infection, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05. The Kruskal compared differences in characteristics among three groups\u0026ndash;Wallis rank sum test, and differences between two groups were compared by Wilcoxon rank sum test comparisons or Wilcoxon signed-rank tests.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eIFs changes in HBV-ACLF patients with improved or deteriorated outcomes\u003c/h2\u003e \u003cp\u003eTo further explore if IFs affect the outcomes of HBV-ACLF patients, we compared the IFs parameters in HBV-ACLF patients with improved or deteriorated outcomes, finding that the serum levels of IL-2 [7.60 (0.60; 10.45) pg/mL vs. 1.85 (0.60; 3.85) pg/mL; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05], IL-6 [26.20 (8.98; 126.53) pg/mL vs. 10.40 (5.28; 15.75) pg/mL; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05], IL-10 [12.30 (5.60; 17.20) pg/mL vs. 3.90 (2.38; 5.95) pg/mL; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05], and IFN-γ [7.50 (0.70;8.38) pg/mL vs. 2.50 (0.70;5.75) pg/mL; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05] at enrollment were markedly higher in patients with HBV-ACLF whose condition deteriorated than in patients with HBV-ACLF whose condition subsequently improved (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of serum IF levels at enrollment between patients with HBV-ACLF who improved and patients with HBV-ACLF who deteriorated\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHBV-ACLF with improvement(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHBV-ACLF with deterioration(n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-2, pg/mL (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.85(0.60;3.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.60(0.60;10.45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-4, pg/mL (IQR)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.90(3.53;7.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.55(3.25;9.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-6, pg/mL (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.40(5.28;15.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.20(8.98;126.53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-10, pg/mL (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.90(2.38;5.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.30(5.60;17.20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTNF-α, pg/mL (IQR)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.15(2.65;12.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.80(3.70;10.45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIFN-γ, pg/mL (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.50(0.70;5.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.50(0.70;8.38)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-17A, pg/mL (IQR)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.48(0.70;20.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.70(0.55;11.81)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; \u003csup\u003e#\u003c/sup\u003e P\u0026thinsp;\u0026gt;\u0026thinsp;0.05. Differences in characteristics between the two groups were compared using the Wilcoxon rank sum test. Abbreviation: Acute-on-chronic liver failure (HBV-ACLF).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eIFs and LFIs changes in cancer patients before and after CAR-T treatment\u003c/h2\u003e \u003cp\u003eIn addition to virus infection, immunotherapy can also induce CRS. In recent years, CAR-T has become a promising cancer therapy. We further measured and compared serum IFs and LFIs in cancer patients before and after CAR-T treatment to determine whether CAR-T treatment would induce CRS or liver function injury. Our results showed that serum levels of IL-2, IL-6, IL-10, TNF-α, and IFN-γ [IL-2: 3.45 (0.10; 11.50) pg/mL vs. 0.50 (0.50; 3.50) pg/mL; IL-6; 86.35 (5.38; 683.35) pg/mL vs. 5.10 (3.03;10.10) pg/mL; IL-10: 12.40 (4.80; 35.68) pg/mL vs. 3.15 (1.80; 5.88) pg/mL; TNF-α: 3.05 (0.50; 5.28) pg/mL vs. 1.75 (0.40; 4.21) pg/mL; IFN-γ: 11.65 (3.20; 71.85) pg/mL vs. 2.10 (0.50; 4.70) pg/mL; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e], especially IL-6 [86.35 (5.38; 683.35) pg/mL vs. 5.10 (3.03;10.10) pg/mL; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05], increased significantly after treatment. Conversely, TBIL and ALT levels did not markedly increase.\u003c/p\u003e \u003cp\u003eMoreover, patients after CAR-T treatment had markedly higher IL-6, IL-10, and IFN-γ levels than patients with HBV-ACLF [IL-6: 86.35 (5.38; 683.35) pg/mL vs. 12.95 (6.60; 41.93) pg/mL; IL-10: 12.40 (4.80; 35.68) pg/mL vs. 5.95 (3.90; 14.75) pg/mL; IFN-γ: 11.65 (3.20; 71.85) pg/mL vs. 4.85 (0.70; 7.98) pg/mL, respectively; Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of serum IF levels and LFI at enrollment between patients with before-CAR-T and after-CAR-T\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore receiving CAR-T cell therapy (n\u0026thinsp;=\u0026thinsp;372)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter receiving CAR-T cell therapy (n\u0026thinsp;=\u0026thinsp;372)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT-BIL, \u0026micro;mol/L (IQR)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.10(7.63;13.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.20(7.40;15.08)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALT, U/L (IQR)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11.90(18.40;27.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.75(11.80;33.68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAST, U/L (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18.80(14.05;25.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.65(13.90;34.08)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINR (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.01(0.95;1.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.11(1.01;1.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-2, pg/mL (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.50(0.50;3.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.45(0.10;11.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-4, pg/mL (IQR)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.80(0.20;4.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.00(0.20;4.68) \u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-6, pg/mL (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.10(3.03;10.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86.35(5.38;683.35)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-10, pg/mL (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.15(1.80;5.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.40(4.80;35.68) \u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTNF-α, pg/mL (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.75(0.40;4.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.05(0.50;5.28)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIFN-γ, pg/mL (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.10(0.50;4.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.65(3.20;71.85)\u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-17A, pg/mL (IQR)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.50(0.50;5.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.50(0.50;7.55) \u003csup\u003e$\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; \u003csup\u003e#\u003c/sup\u003e P\u0026thinsp;\u0026gt;\u0026thinsp;0.05;\u003csup\u003e$\u003c/sup\u003e vs. HBV-ACLF group, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Differences between two related samples were compared by the Wilcoxon signed ranks test.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eCorrelation between IFs and LFIs levels in patients receiving CAR-T cell therapy\u003c/h2\u003e \u003cp\u003eTo determine if changed IFs caused liver failure in cancer patients after CAR-T treatment, we compared the relationship between IFs and LFIs, finding that treatment with CAR-T cells (including 16 patients with CHB), IFs (i.e., IL-2, IL-6, IL-10, TNF-α, and IFN-γ) was weakly or not at all correlated with TBIL (rho\u0026thinsp;=\u0026thinsp;0.245, 0.420, 0.268, 0.119, 0.288 respectively; P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), ALT (rho\u0026thinsp;=\u0026thinsp;0.148, 0.192, 0.164, 0.140, 0.272 respectively; P\u0026thinsp;\u0026ge;\u0026thinsp;0.05), and AST ((rho\u0026thinsp;=\u0026thinsp;0.165, 0.314, 0.318, 0.138, 0.384 respectively; P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eIFs and LFIs changes in cancer patients with CHB before and after CAR-T treatment\u003c/h2\u003e \u003cp\u003eFurthermore, patients with CHB from a group of patients receiving CAR-T cell therapy were selected for further analysis. Serum IFs and LFIs levels were tested before and after receiving therapy. The results also showed that serum IL-6 [23.80 (3.75; 1198.48) pg/mL vs. 9.0 (4.38;20.45) pg/mL, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05], IL-10 [10.70 (3.0; 34.75) pg/mL vs. 2.75 (2.30; 9.33) pg/mL, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05], and IFN-γ [13.95 (1.78; 148.18) pg/mL vs. 2.25 (1.10;4.38) pg/mL, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05] were significantly higher in patients after CAR-T treatment (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). However, there was no difference in TBIL [9.65 (7.03; 12.73) \u0026micro;mol/L vs. 10.05 (7.55; 13.05) \u0026micro;mol/L, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05], ALT [16.15 (11.38; 22.43) U/L vs. 10.75 (7.93; 26.23) U/L, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05], and AST [20.85(187.80; 25.68) U/L vs. 18.55 (12.58; 31.90) U/L, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05] levels between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of serum IF levels and LFI levels at enrollment between patients complicated with CHB with before-CAR-T and after-CAR-T\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore receiving CAR-T cell therapy(n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter receiving CAR-T cell therapy(n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT-BIL, \u0026micro;mol/L (IQR)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.65 (7.03;12.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.05 (7.55;13.05)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALT, U/L (IQR)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.15 (11.38;22.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.75 (7.93;26.23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAST, U/L (IQR)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20.85 (187.80;25.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.55 (12.58;31.90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINR (IQR)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.98 (0.95;1.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.11 (1.02;1.21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-2, pg/mL (IQR) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.50 (0.50;3.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.05 (1.05;12.83)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-4, pg/mL (IQR)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.80 (0.50;5.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.65 (1.70;3.85)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-6, pg/mL (IQR) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.0 (4.38;20.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.80 (3.75;1198.48)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-10, pg/mL (IQR) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.75 (2.30;9.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.70 (3.0;34.75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTNF-α, pg/mL (IQR)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.90 (1.90;6.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.20 (0.50;6.80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIFN-γ, pg/mL (IQR) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.25 (1.10;4.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.95 (1.78;148.18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIL-17A, pg/mL (IQR)\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.30 (1.30;3.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.0 (1.40;9.70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* vs.before-CAR-T group, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05;\u003csup\u003e#\u003c/sup\u003e vs. before-CAR-T group, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Differences between two related samples were compared using the Wilcoxon signed ranks test.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eAssociation between IFs and LFIs in tumor patients with HBV receiving CAR-T therapy\u003c/h2\u003e \u003cp\u003eSpecifically, for the tumor patients with HBV, we compared the association between IFs and LFIs after CAR-T treatment, finding that TBIL, ALT, and AST levels were not significantly correlated with levels of various IFs (i.e., IL-2, IL-4, IL-6, IL-10, TNF-α, IFN-γ and IL-17A) (rho\u0026thinsp;=\u0026thinsp;0.215, -0.372, 0.366, 0.402, 0.385, 0.427, 0.053, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05; rho=-0.012, 0.442, -0.171, -0.009, 0.161, -0.091, 0.051, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05; rho\u0026thinsp;=\u0026thinsp;0.054, 0.361, -0.118, 0.194, 0.203, 0.029, 0.204, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05; respectively) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Only the INR was correlated with IL-2 and TNF-α levels (rho\u0026thinsp;=\u0026thinsp;0.536, P\u0026thinsp;=\u0026thinsp;0.032; 0.669, P\u0026thinsp;=\u0026thinsp;0.005; respectively) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present study, we compared healthy people, pro-HBV-ACLF patients, and HBV-ACLF patients, finding that serum levels of IL-10 were significantly increased, which was correlated with the development of HBV-ACLF. These results indicate that IL-10 may have an important role in the pathogenesis of HBV-ACLF. Consistent with this conclusion, we further found that serum IL-10 was much higher in HBV-ACLF patients with deteriorated outcomes than those with improved outcomes. In parallel, liver function, indicated by serum levels of ALT, AST, TBil, and INR, was impaired in pro-HBV-ACLF patients and deteriorated in HBV-ACLF patients. IL-10 is well known as an immunosuppressive cytokine [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] that has been recently reported to be secreted in response to hepatitis B core antigen (HBcAg) by peripheral blood mononuclear cells (PBMCs) in patients with chronic HBV infection [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Our observations are consistent with previous studies, implying that IL-10 has a functional role in the pathogenesis of HBV-ACLF and can be used as a diagnostic marker, prognostic marker, and therapy target of HBV-ACLF.\u003c/p\u003e \u003cp\u003eFurthermore, we found the serum IL-6 level did not significantly change in HBV-ACLF patients compared to pro-HBV-ACLF patients, which is not consistent with a previous study, which reported high plasma IL-6 levels in CHB patients [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Interestingly, the serum IL-6 was significantly higher in HBV-ACLF patients with secondary infection than in HBV-ACLF patients without secondary infection, considering that IL-6 has a crucial role in HBV infection (PMID: 26807383). These results suggest a specific role of IL-6 in response to HBV secondary infection.\u003c/p\u003e \u003cp\u003eImmunotherapy induces CRS and causes side effects in patients [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In this study, we found increased serum levels of IL-2, IL-6, IL-10, TNF-α, and IFN-γ, especially IL-6, in tumor patients after CAR-T treatment, a feature of CRS. A preclinical study found that CAR-T cell-mediated cancer clearance triggers elevated IL-6 levels, not produced by infused CAR-T cells but by recipient macrophages/monocytes. More importantly, the CRS was prevented by blocking the IL-6 receptor with tocilizumab [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Our observation, as well as previous reports, shed insights into improvements in CAR-T therapy.\u003c/p\u003e \u003cp\u003eHowever, TBIL and ALT levels were not markedly increased, indicating liver function remained normal during CAR-T therapy, although marked changes in a series of cytokines were observed. This uncoupling suggests that the liver is not the target of elevated cytokines after CAR-T therapy in tumor patients. Considering the uncoupling between IFs and LFIs levels in patients receiving CAR-T cell therapy, we further analyzed the relationship between IFs and LFIs in subsets of patients, including tumor patients with CHB and HBV. Results showed changed cytokines; however, there was no significant relationship between IFs and LFIs, confirming the uncoupling between IFs and LFIs levels in HBV or CHB subsets.\u003c/p\u003e \u003cp\u003eThe preset study has some limitations. Our sample of CHB patients who received CAR-T cell therapy was relatively small, so our analysis may be underpowered to detect a real correlation between inflammatory factors and liver function. In addition, the mechanisms underlying the association between inflammatory factor levels and liver function in HBV-ACLF patients were not directly investigated. Additional studies are needed to confirm our results and validate serum IL-10 level as a diagnostic marker.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn summary, we found that serum IL6 and IL-10 levels were strongly correlated with the pathogenesis, development, and outcome of HBV-ACLF, which is consistent with the impaired liver function of HBV-ACLF patients, especially those with secondary infections. In addition, CAR-T therapy induced CRS in tumor patients, while no significant liver function impairment was observed.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cem\u003eHBV-ACLF\u003c/em\u003e: Hepatitis B virus-related acute-on-chronic liver failure; \u003cem\u003eCRS\u003c/em\u003e: Cytokine release syndrome; \u003cem\u003eCAR-T\u003c/em\u003e: chimeric antigen receptor T; \u003cem\u003eIFs\u003c/em\u003e: inflammatory factors; \u003cem\u003epro-HBV-ACLF\u003c/em\u003e:\u0026nbsp;prophase of HBV-ACLF; \u003cem\u003eLFIs\u003c/em\u003e: liver function indexes; \u003cem\u003eIL-10\u003c/em\u003e: Serum interleukin-10;\u0026nbsp;\u003cem\u003eALT\u003c/em\u003e: alanine transaminase;\u0026nbsp;\u003cem\u003eAST\u003c/em\u003e: aspartate aminotransferase;\u0026nbsp;\u003cem\u003eTBil\u003c/em\u003e: total bilirubin;\u0026nbsp;\u003cem\u003eINR\u003c/em\u003e: international normalized ratio;\u0026nbsp;\u003cem\u003eTNF-\u003c/em\u003e\u003cem\u003e\u0026alpha;\u003c/em\u003e: tumor necrosis factor\u0026nbsp;\u0026alpha;;\u0026nbsp;\u003cem\u003eIFN-\u003c/em\u003e\u003cem\u003e\u0026gamma;\u003c/em\u003e: interferon \u0026gamma;;\u0026nbsp;\u003cem\u003eSIRS\u003c/em\u003e: systemic inflammatory response syndrome;\u0026nbsp;\u003cem\u003eSI\u003c/em\u003e: systemic inflammation; \u003cem\u003eAPASL\u003c/em\u003e: Asian Pacific Association for the Study of Liver; \u003cem\u003eLOD\u003c/em\u003e: limit of detection;\u0026nbsp;\u003cem\u003ePCT\u003c/em\u003e: procalcitonin; \u003cem\u003eCMA\u003c/em\u003e: Chinese Medical Association; \u003cem\u003epro-LF\u003c/em\u003e: prophase of liver failure; \u003cem\u003eIQRs\u003c/em\u003e: interquartile ranges\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003eThis work was supported by grants from the National Science and Technology\u0026ldquo;13th Five-Year Plan\u0026rdquo;\u0026nbsp;Major Special Project (2017ZX110203201) and Suzhou Science and Education Xingwei Youth Science and Technology Project (KJXW2020003).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u0026nbsp;\u003c/strong\u003eY.W. and J.G. contributed equally to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003eWe thank the other doctors on the medical team (Wenting Li, Wei Sun, Li Chen, Yan Huang) for their work in treating patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003eY.W., X.-p.H. and J.-h.G. designed the study; Y.W., Y.X. and G.-h.C. collected patient samples and the data; Y.W. and J.G. analyzed the data; Y.W. and Y.-f.J. prepared figures 1-2; Y.W., J.G., X.-p.H. and J.-h.G. drafted the manuscript; All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003eThis single-center retrospective study was approved by the medical ethics committee of the First Affiliated Hospital of Soochow University (Ethical Approval No.: (2022) LEN Research Approval No. 089). All procedures performed in studies were in accordance with the ethical standards of the institutional and/or national research committee. The study was based on existing data collected in the course of routine clinical practice,and no additional risks were posed to the patients. Therefore, the need for individual informed consent was waived by the ethics committee of the First Affiliated Hospital of Soochow University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLee DW, Barrett DM, Mackall C, Orentas R, Grupp SA. The future is now: chimeric antigen receptors as new targeted therapies for childhood cancer. Clin Cancer Res. 2012;18(10):2780\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson LA, June CH. Driving gene-engineered T cell immunotherapy of cancer. 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Plasma Interleukin-6 Level: A Potential Prognostic Indicator of Emergent HBV-Associated ACLF. Can J Gastroenterol Hepatol. 2021;2021:5545181.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShah D, Soper B, Shopland L. Cytokine release syndrome and cancer immunotherapies - historical challenges and promising futures. Front Immunol. 2023;14:1190379.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorelli M, Camisa B, Barbiera G, et al. Monocyte-derived IL-1 and IL-6 are differentially required for cytokine-release syndrome and neurotoxicity due to CAR T cells. Nat Med. 2018;24(6):739\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGiavridis T, van der Stegen SJC, Eyquem J, Hamieh M, Piersigilli A, Sadelain M. CAR T cell-induced cytokine release syndrome is mediated by macrophages and abated by IL-1 blockade. Nat Med. 2018;24(6):731\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hepatitis B virus-related acute-on-chronic liver failure, Inflammatory factors, Cytokine release syndrome, Liver function, Chimeric antigen receptor T therapy","lastPublishedDoi":"10.21203/rs.3.rs-4579363/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4579363/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eHepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) pathogenesis remains unclear. Cytokine release syndrome (CRS) is a serious concomitant disease caused by pathogen infection and immunotherapies, such as HBV infection and chimeric antigen receptor T (CAR-T) therapy respectively while the role of inflammatory factors (IFs) in such patients still remains to be elucidated. This study aims to explore HBV-ACLF pathogenesis according to analyze IFs changes in patients with HBV-ACLF, prophase of HBV-ACLF(pro-HBV-ACLF) and CAR-T therapy, and the relationship between IFs and liver function indexes (LFIs) in patients receiving CAR-T therapy. The clinical records of 68 patients with HBV-ACLF, 30 patients with pro-HBV-ACLF, and 372 patients with hematologic tumors but without abnormal liver function who received CAR-T therapy at the First Affiliated Hospital of Soochow University were retrospectively examined in this investigation. Serum interleukin-10 (IL-10) levels was significantly increased from healthy controls to pro-HBV-ACLF and to HBV-ACLF. IL-10 was decreased in patients who experienced improvement compared to those whose condition deteriorated. Consistently, alanine transaminase (ALT), aspartate aminotransferase (AST), total bilirubin (TBil) and international normalized ratio (INR) also increased with the development of HBV-ACLF. However, IL-6 did not significantly change from pro-HBV-ACLF to HBV-ACLF and to HBV-ACLF without infection, while IL-6 was even lower in patients with HBV-ACLF without secondary infection than in patients with pro-HBV-ACLF. In addition, Serum levels of IL-2, IL-10, tumor necrosis factor α (TNF-α), and interferon γ (IFN-γ), especially IL-6, increased significantly after CAR-T treatment in tumor patients, while TBIL and ALT levels did not markedly increase. These results elucidate the role of inflammatory factors in the pathogenesis of HBV-ACLF and the side effects of CRS induced by CAR-T therapy.\u003c/p\u003e","manuscriptTitle":"Roles of inflammatory factors in the pathogenesis of hepatitis B virus-related acute-on-chronic liver failure and CAR-T therapy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-03 16:37:35","doi":"10.21203/rs.3.rs-4579363/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0725581d-8f77-4ca7-82f1-9e1041436d57","owner":[],"postedDate":"July 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-29T07:39:24+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-03 16:37:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4579363","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4579363","identity":"rs-4579363","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}