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Suraweera D, Fanous C, Jimenez M, Tong MJ, Saab S. Risk of Cardiovascular Events in Patients with Primary Biliary Cholangitis - Systematic Review. J Clin Transl Hepatol 2018; 6:119-126. [PMID: 29951355 PMCID: PMC6018312 DOI: 10.14218/jcth.2017.00064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 12/14/2017] [Accepted: 01/02/2018] [Indexed: 01/25/2023] Open
Abstract
Background and Aims: Hypercholesterolemia is a common finding in patients with primary biliary cholangitis (PBC) and is a well-defined risk factor for cardiovascular disease. However, studies have been mixed on whether PBC patients do, in fact, have higher cardiovascular risk. The aim of this study is to review the current literature and provide an evidence-based assessment of cardiovascular risk in PBC patients. Methods: We performed a systematic literature search on PubMed regarding patients with PBC and cardiovascular events from the database inception to July 1, 2017. A total of 33 articles fulfilling our inclusion criteria were found. Results: The majority of the studies evaluated yielded no statistically significant difference in cardiovascular disease in the PBC population compared to the general public. However, some reports found a statistically significantly increase in coronary artery disease. Several studies have looked at the specific lipid profile of patients with PBC with hypocholesteremia. While these lipid abnormalities differ by stage of disease, there is evidence to suggest that the specific lipid profile in PBC may have lower atherogenicity than in patients with hypercholesterolemia without PBC. Studies looking at patients with PBC with other risk factors for cardiovascular disease, such as hypertension and metabolic syndrome, have consistently found a higher risk for cardiovascular disease in these patients. Statin treatment is effective in reducing lipid levels and possibly improving endothelial inflammation in patients with PBC with hypercholesterolemia. Conclusions: There is not enough evidence to suggest an increased risk of cardiovascular disease in patients with PBC with hypercholesterolemia, except for those individuals with concomitant features of metabolic syndrome. In patients with PBC with no additional cardiovascular risk factors, individual risk/benefit discussion on lipid-lowering treatment should be considered.
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Affiliation(s)
| | - Christina Fanous
- Department of Surgery at the University of California at Los Angeles, Los Angeles, CA, USA
| | - Melissa Jimenez
- Department of Surgery at the University of California at Los Angeles, Los Angeles, CA, USA
| | | | - Sammy Saab
- Department of Surgery at the University of California at Los Angeles, Los Angeles, CA, USA
- Department of Medicine at the University of California at Los Angeles, Los Angeles, CA, USA
- *Correspondence to: Sammy Saab, Pfleger Liver Institute, UCLA Medical Center, 200 Medical Plaza, Suite 214, Los Angeles, CA 90095, USA. Tel: +1-310-206-6705, Fax: +1-310-206-4197, E-mail:
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Chalifoux SL, Konyn PG, Choi G, Saab S. Extrahepatic Manifestations of Primary Biliary Cholangitis. Gut Liver 2018; 11:771-780. [PMID: 28292174 PMCID: PMC5669592 DOI: 10.5009/gnl16365] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 08/16/2016] [Indexed: 12/11/2022] Open
Abstract
Primary biliary cholangitis (PBC) is an autoimmune liver disease characterized by progressive destruction of the intrahepatic bile ducts, leading to cholestasis. PBC is known to have both hepatic and extrahepatic manifestations. Extrahepatic manifestations are seen in up to 73% of patients with PBC, with the most common being Sjogren’s syndrome, thyroid dysfunction and systemic sclerosis. It is thought that patients with PBC are at increased risk of developing these extrahepatic manifestations, almost all of which are autoimmune, because patients with autoimmune disease are at higher risk of developing another autoimmune condition. Due to the high prevalence of extrahepatic diseases in patients with PBC, it is important to complete a thorough medical history at the time of diagnosis. Prompt recognition of extrahepatic disease can lead to improved patient outcomes and quality of life. The following review summarizes the most common extrahepatic conditions associated with PBC.
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Affiliation(s)
- Sara L Chalifoux
- Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - Peter G Konyn
- Department of Medicine, University of California, Los Angeles, CA, USA
| | - Gina Choi
- Department of Medicine, University of California, Los Angeles, CA, USA.,Department of Surgery, University of California, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Medicine, University of California, Los Angeles, CA, USA.,Department of Surgery, University of California, Los Angeles, CA, USA
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Kowdley KV, Luketic V, Chapman R, Hirschfield GM, Poupon R, Schramm C, Vincent C, Rust C, Parés A, Mason A, Marschall H, Shapiro D, Adorini L, Sciacca C, Beecher‐Jones T, Böhm O, Pencek R, Jones D. A randomized trial of obeticholic acid monotherapy in patients with primary biliary cholangitis. Hepatology 2018; 67:1890-1902. [PMID: 29023915 PMCID: PMC5947631 DOI: 10.1002/hep.29569] [Citation(s) in RCA: 190] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 08/24/2017] [Accepted: 09/27/2017] [Indexed: 12/11/2022]
Abstract
UNLABELLED Obeticholic acid (OCA), a potent farnesoid X receptor agonist, was studied as monotherapy in an international, randomized, double-blind, placebo-controlled phase 2 study in patients with primary biliary cholangitis who were then followed for up to 6 years. The goals of the study were to assess the benefit of OCA in the absence of ursodeoxycholic acid, which is relevant for patients who are intolerant of ursodeoxycholic acid and at higher risk of disease progression. Patients were randomized and dosed with placebo (n = 23), OCA 10 mg (n = 20), or OCA 50 mg (n = 16) given as monotherapy once daily for 3 months (1 randomized patient withdrew prior to dosing). The primary endpoint was the percent change in alkaline phosphatase from baseline to the end of the double-blind phase of the study. Secondary and exploratory endpoints included change from baseline to month 3/early termination in markers of cholestasis, hepatocellular injury, and farnesoid X receptor activation. Efficacy and safety continue to be monitored through an ongoing 6-year open-label extension (N = 28). Alkaline phosphatase was reduced in both OCA groups (median% [Q1, Q3], OCA 10 mg -53.9% [-62.5, -29.3], OCA 50 mg -37.2% [-54.8, -24.6]) compared to placebo (-0.8% [-6.4, 8.7]; P < 0.0001) at the end of the study, with similar reductions observed through 6 years of open-label extension treatment. OCA improved many secondary and exploratory endpoints (including γ-glutamyl transpeptidase, alanine aminotransferase, conjugated bilirubin, and immunoglobulin M). Pruritus was the most common adverse event; 15% (OCA 10 mg) and 38% (OCA 50 mg) discontinued due to pruritus. CONCLUSION OCA monotherapy significantly improved alkaline phosphatase and other biochemical markers predictive of improved long-term clinical outcomes. Pruritus increased dose-dependently with OCA treatment. Biochemical improvements were observed through 6 years of open-label extension treatment. (Hepatology 2018;67:1890-1902).
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Affiliation(s)
| | - Velimir Luketic
- Virginia Commonwealth University and McGuire Research InstituteMcGuire DVAMCRichmondVA
| | - Roger Chapman
- Department of Gastroenterology, John Radcliffe HospitalHeadingtonOxfordUK
| | - Gideon M. Hirschfield
- Centre for Liver Research and NIHR Biomedical Research CentreUniversity of BirminghamBirminghamUK
| | | | - Christoph Schramm
- 1st Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | | | - Christian Rust
- Department of Medicine 2, GrosshadernUniversity of MunichMunichGermany
| | - Albert Parés
- Liver Unit, Hospital Clinic, IDIBAPS, CIBERehdUniversity of BarcelonaBarcelonaSpain
| | - Andrew Mason
- Division of GastroenterologyUniversity of AlbertaEdmontonAlbertaCanada
| | - Hanns‐Ulrich Marschall
- Sahlgrenska AcademyDepartment of Molecular and Clinical Medicine, University of GothenburgGothenburgSweden
| | | | | | | | | | | | | | - David Jones
- Institute of Cellular MedicineNewcastle UniversityNewcastle‐upon‐TyneUK
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Moctezuma-Velázquez C, Abraldes JG, Montano-Loza AJ. The Use of Statins in Patients With Chronic Liver Disease and Cirrhosis. ACTA ACUST UNITED AC 2018; 16:226-240. [PMID: 29572618 DOI: 10.1007/s11938-018-0180-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Statins are drugs developed to treat hypercholesterolemia. Its use in patients with liver disease has been limited because one of its potential and most feared side effects is hepatotoxicity. However, there is robust evidence that supports the safety of statins in this population in the absence of severe liver dysfunction. In this review, we will summarize the efficacy and safety of statins in cirrhosis. RECENT FINDINGS Statins are effective in the treatment of dyslipidemia in patients with liver disease, because of their pleiotropic properties. These properties are independent of their effect on cholesterol levels, such as improving endothelial dysfunction or having antioxidant, antifibrotic, anti-inflammatory, antiproliferative, antiangiogenic, proapoptotic, or immunomodulation properties. Statins have been studied in other areas such as in treatment of portal hypertension, prevention of hepatocellular carcinoma, and/or protection against ischemia/reperfusion injury. Approved indications for statins in patients with cirrhosis are those of the general population, including dyslipidemia and increased cardiovascular risk. Compensated cirrhosis is not a contraindication. In patients with decompensated cirrhosis, statins should be prescribed with extreme caution at low doses, and with frequent monitoring of creatinine phosphokinase levels in order to detect adverse events in a timely fashion.
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Affiliation(s)
- Carlos Moctezuma-Velázquez
- Division of Gastroenterology and Liver Unit, University of Alberta, 8540 112 Street NW, Zeidler Ledcor Centre, Room 1-20B, Edmonton, Alberta, T6G 2X8, Canada
| | - Juan G Abraldes
- Division of Gastroenterology and Liver Unit, University of Alberta, 8540 112 Street NW, Zeidler Ledcor Centre, Room 1-20B, Edmonton, Alberta, T6G 2X8, Canada
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, 8540 112 Street NW, Zeidler Ledcor Centre, Room 1-20B, Edmonton, Alberta, T6G 2X8, Canada.
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Abnormalities of Lipoprotein Levels in Liver Cirrhosis: Clinical Relevance. Dig Dis Sci 2018; 63:16-26. [PMID: 29177578 DOI: 10.1007/s10620-017-4862-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 11/19/2017] [Indexed: 12/17/2022]
Abstract
Progressive lipoprotein impairment occurs in liver cirrhosis and is associated with increased morbidity and mortality. The present review aims to summarize the current evidence regarding the prognostic value of lipoprotein abnormalities in liver cirrhosis and to address the need of a better prognostic stratification of patients, including lipoprotein profile assessment. Low levels of lipoproteins are usual in cirrhosis. Much evidence supports the prognostic role of hypolipidemia in cirrhotic patients. In particular, hypocholesterolemia represents an independent predictor of survival in cirrhosis. In cirrhotic patients, lipoprotein impairment is associated with several complications: infections, malnutrition, adrenal function, and spur cell anemia. Alterations of liver function are associated with modifications of circulating lipids. Decreased levels of lipoproteins significantly impact the survival of cirrhotic patients and play an important role in the pathogenesis of some cirrhosis-related complications.
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Burman BE, Jhaveri MA, Kowdley KV. An Update on the Treatment and Follow-up of Patients with Primary Biliary Cholangitis. Clin Liver Dis 2017; 21:709-723. [PMID: 28987258 DOI: 10.1016/j.cld.2017.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Primary biliary cholangitis (PBC) is an autoimmune liver disease characterized by chronic granulomatous lymphocytic cholangitis of the small bile ducts. PBC was a leading indication for liver transplant in the United States; with early diagnosis and treatment, the majority of patients with PBC have a normal life expectancy. Pathogenesis involves inflammatory damage of bile duct epithelium secondary to innate and adaptive immune responses, and toxicity from accumulated bile acids. Cholestasis and disease progression can lead to cirrhosis. Extrahepatic complications include dyslipidemia, metabolic bone disease, and fat-soluble vitamin deficiency. Ursodeoxycholic acid is a well-established therapy. Novel targeted therapeutics are being developed.
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Affiliation(s)
- Blaire E Burman
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA 98101, USA
| | - Manan A Jhaveri
- Department of Organ Transplant & Liver Center, Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, 1124 Columbia Street, WA 98101, USA
| | - Kris V Kowdley
- Department of Organ Transplant & Liver Center, Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, 1124 Columbia Street, WA 98101, USA.
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Papakonstantinou PE, Theodoraki E, Koulentaki M, Papadakis JA. New-onset severe hypercholesterolemia in a patient with cholestatic liver disease. Should we treat the lipids? Hellenic J Cardiol 2017; 58:300-302. [DOI: 10.1016/j.hjc.2016.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/12/2016] [Accepted: 12/23/2016] [Indexed: 10/20/2022] Open
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Almasio PL, Licata A, Maida M, Macaluso FS, Costantino A, Alessi N, Grimaudo S, Accardi G, Caruso C, Craxi A. Clinical Course and Genetic Susceptibility of Primary Biliary Cirrhosis: Analysis of a Prospective Cohort. HEPATITIS MONTHLY 2016; 16:e31681. [PMID: 28070198 PMCID: PMC5203613 DOI: 10.5812/hepatmon.31681] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 11/28/2015] [Accepted: 12/19/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Natural history of primary biliary cirrhosis (PBC) is partially characterized in patients from the Mediterranean area whose genetic background differs from that of Northern Europeans. OBJECTIVES We aimed to describe genetic susceptibility and clinical course of PBC in patients from Southern Italy. METHODS Socio-demographic, clinical, biochemical and histological data at diagnosis as well as disease progression of 81 PBC consecutive patients were collected. All subjects were treated with Ursodeoxycholic acid at a dose of 15 mg/kg. HLA class II DRB1 alleles were compared with those of 237 healthy control subjects. IL28B genotyping for IL28B rs12979860 C/T and rs80899917 G/T was performed in a sub-group of patients. RESULTS HLA-DRB1*07 (RR 5.3, P = 0.0008) and HLA-DRB1*08 (RR n.c. P = 0.0005) were significantly associated with the risk of PBC development. Patients younger than 45 years had significantly higher alanine aminotransferase (P = 0.038) and alkaline phosphatase levels (P = 0.047) than older cases. In comparison to non-CC rs12979860, patients with CC rs12979860 genotype showed an early histological stage at onset (93.8% vs. 62.5%, P = 0.03). After a mean follow-up of 61 months, three patients died, one underwent liver transplantation and sixteen (21.9%) had progression of the disease. At multivariate analysis, extrahepatic autoimmune disease (P = 0.04), pruritus (P = 0.008) and advanced histological stage (P < 0.0001) were independent risk factors for disease progression. CONCLUSIONS HLA-DRB1*07 and HLA-DRB1*08 alleles increase susceptibility to disease development. At onset, higher biochemical activity was observed in younger patients, whereas rs12979860 CC genotype was associated with milder histological stage. Pruritus and coexistence of extrahepatic autoimmune diseases were significantly associated with poorer prognosis.
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Affiliation(s)
- Piero Luigi Almasio
- Sezione di Gastroenterologia ed Epatologia, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
- Corresponding Author: Piero Luigi Almasio, M.D., Section of Gastroenterology, Di.Bi.M.I.S., University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy. Tel: +39-916553131, Fax: +39-916552156, E-mail:
| | - Anna Licata
- Sezione di Gastroenterologia ed Epatologia, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
| | - Marcello Maida
- Sezione di Gastroenterologia ed Epatologia, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
| | - Fabio Salvatore Macaluso
- Sezione di Gastroenterologia ed Epatologia, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
| | - Andrea Costantino
- Sezione di Gastroenterologia ed Epatologia, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
| | - Nicola Alessi
- Sezione di Gastroenterologia ed Epatologia, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
| | - Stefania Grimaudo
- Sezione di Gastroenterologia ed Epatologia, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
| | - Giulia Accardi
- Dipartimento di Biopatologia e Biotecnologie Mediche, University of Palermo, Palermo, Italy
| | - Calogero Caruso
- Dipartimento di Biopatologia e Biotecnologie Mediche, University of Palermo, Palermo, Italy
| | - Antonio Craxi
- Sezione di Gastroenterologia ed Epatologia, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
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Heinl RE, Tennant HM, Ricketts JC, Rice CR, Robinson CB, Sandesara PB, Moriarty PM, Sperling L. Lipoprotein-X disease in the setting of severe cholestatic hepatobiliary autoimmune disease. J Clin Lipidol 2016; 11:282-286. [PMID: 28391896 DOI: 10.1016/j.jacl.2016.09.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 09/26/2016] [Accepted: 09/27/2016] [Indexed: 11/25/2022]
Abstract
Severe cholestatic disease and hyperlipidemia are both commonly encountered by medical professionals. This article reviews the current pathophysiological model of lipoprotein-X syndrome related to 3 cases from 2 academic medical centers in the United States.
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Affiliation(s)
- Robert E Heinl
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - Heather M Tennant
- Department of Clinical Pharmacology, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Claire R Rice
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Cordelia B Robinson
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Pratik B Sandesara
- Department of Medicine, Emory University, Atlanta, GA, USA; Division of Cardiology, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Patrick M Moriarty
- Department of Clinical Pharmacology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Laurence Sperling
- Department of Medicine, Emory University, Atlanta, GA, USA; Division of Cardiology, Department of Medicine, Emory University, Atlanta, GA, USA.
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Ali AH, Lindor KD. Obeticholic acid for the treatment of primary biliary cholangitis. Expert Opin Pharmacother 2016; 17:1809-15. [PMID: 27468093 DOI: 10.1080/14656566.2016.1218471] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Primary biliary cholangitis (PBC) is an autoimmune disease of the liver characterized by destruction and inflammation of the intrahepatic bile ducts. The disease affects mainly women. The disease is often discovered through abnormal alkaline phosphatase (ALP) activity, and is confirmed when anti-mitochondrial antibodies (AMA) are present. The etiology of PBC is poorly understood. Cigarette smoking, immune dysregulation, nail polish, urinary tract infections, and low socioeconomic status have been implicated but none have been confirmed. Genome wide association studies (GWAS) have disclosed strong associations between certain human leukocyte antigen (HLA) alleles and PBC. PBC can progress to cirrhosis and end-stage liver disease. Hepatocellular carcinoma (HCC) develops in up to 3.5% of PBC patients. Ursodeoxycholic acid (UDCA) is the only medication approved for the treatment of PBC. The use of UDCA in PBC delays histological progression and extends the transplant-free survival. 40% of PBC patients do not respond adequately to UDCA, and these patients are at high risk for serious complications. Therefore, there is a critical need for more effective therapies for this problematic disease. Multiple other agents have either been or are currently being studied as therapeutic options in UDCA non-responder PBC patients. Six-ethyl chenodeoxycholic acid (6-ECDCA), a potent farnesoid X receptor (FXR) agonist, has shown anti-cholestatic activity in rodent models of cholestasis. Obeticholic acid (OCA, 6-ECDCA, or INT-747), a first-in-class FXR agonist, has been examined in PBC patients with inadequate response to UDCA, and shown promising results. Particularly, initial clinical trials have demonstrated that the use of OCA (in addition to UDCA) in PBC patients with inadequate response to UDCA led to significant reduction of serum alkaline phosphatase (ALP, an important prognostic marker in PBC). More recently, the results of a randomized clinical trial of OCA monotherapy in PBC reported significant reduction of ALP in the treatment group compared to placebo. AREAS COVERED This review covers the preclinical and clinical studies of OCA in PBC. In addition, other alternative therapies that are currently being examined in PBC patients will also be discussed in this review. A literature search was carried out using the PubMed database. EXPERT OPINION If approved by the U.S. FDA, OCA will likely be an important alternative add-on therapy in PBC patients who have inadequate response to UDCA.
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Affiliation(s)
- Ahmad H Ali
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Phoenix , AZ , USA
| | - Keith D Lindor
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Phoenix , AZ , USA.,b College of Health Solutions , Arizona State University , Phoenix , AZ , USA
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Nemes K, Åberg F, Gylling H, Isoniemi H. Cholesterol metabolism in cholestatic liver disease and liver transplantation: From molecular mechanisms to clinical implications. World J Hepatol 2016; 8:924-932. [PMID: 27574546 PMCID: PMC4976211 DOI: 10.4254/wjh.v8.i22.924] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/07/2016] [Accepted: 07/13/2016] [Indexed: 02/06/2023] Open
Abstract
The aim of this review is to enlighten the critical roles that the liver plays in cholesterol metabolism. Liver transplantation can serve as gene therapy or a source of gene transmission in certain conditions that affect cholesterol metabolism, such as low-density-lipoprotein (LDL) receptor gene mutations that are associated with familial hypercholesterolemia. On the other hand, cholestatic liver disease often alters cholesterol metabolism. Cholestasis can lead to formation of lipoprotein X (Lp-X), which is frequently mistaken for LDL on routine clinical tests. In contrast to LDL, Lp-X is non-atherogenic, and failure to differentiate between the two can interfere with cardiovascular risk assessment, potentially leading to prescription of futile lipid-lowering therapy. Statins do not effectively lower Lp-X levels, and cholestasis may lead to accumulation of toxic levels of statins. Moreover, severe cholestasis results in poor micellar formation, which reduces cholesterol absorption, potentially impairing the cholesterol-lowering effect of ezetimibe. Apolipoprotein B-100 measurement can help distinguish between atherogenic and non-atherogenic hypercholesterolemia. Furthermore, routine serum cholesterol measurements alone cannot reflect cholesterol absorption and synthesis. Measurements of serum non-cholesterol sterol biomarkers - such as cholesterol precursor sterols, plant sterols, and cholestanol - may help with the comprehensive assessment of cholesterol metabolism. An adequate cholesterol supply is essential for liver-regenerative capacity. Low preoperative and perioperative serum cholesterol levels seem to predict mortality in liver cirrhosis and after liver transplantation. Thus, accurate lipid profile evaluation is highly important in liver disease and after liver transplantation.
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Patel AM, Brautbar A, Desai NK, Wilson DP. Severe hypercholesterolemia and liver disease in a 3-year old. J Clin Lipidol 2016; 10:650-3. [PMID: 27206954 DOI: 10.1016/j.jacl.2015.12.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/12/2015] [Accepted: 12/18/2015] [Indexed: 11/29/2022]
Abstract
Lipoprotein-X, which is composed of phospholipids and non-esterified cholesterol, is an abnormal lipoprotein with a density range similar to LDL-C. The two most common ways which lipoprotein-X accumulates is from reflux of bile salts into plasma or deficiency in lecithin cholesterol acyltransferase. This is a case of severe hypercholesterolemia and liver disease in a 3- year old male that presented with pruritus, pale stool, scleral ictus, and abdominal distention. He was diagnosed with primary sclerosing cholangitis which was confirmed by liver biopsy. Our patient was treated with steroids and immunomodulator therapy which was associated with significant reduction in cholestasis and LDL-C levels. Lipoprotein-X has several properties that make it anti-atherogenic, which raises the question if treatment for hypercholesterolemia should be initiated.
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Affiliation(s)
- Amol M Patel
- UNT Health Science Center, Texas College of Osteopathic Medicine, Fort Worth, TX
| | - Ariel Brautbar
- Pediatric Endocrinology and Diabetes, Cook Children's Medical Center, Fort Worth, TX; Department of Genetics, Cook Children's Medical Center, Fort Worth, TX.
| | - Nirav K Desai
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA
| | - Don P Wilson
- Pediatric Endocrinology and Diabetes, Cook Children's Medical Center, Fort Worth, TX
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Abstract
Lipid lowering, particularly with 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors ("statins"), reduces the risk of cardiovascular disease. Patients with chronic liver disease present challenges to the use of lipid medications. In the case of most liver disorders, the concern has been one of safety. There is evidence that most lipid-lowering medications can be used safely in many situations, although large outcomes trials are lacking. This review examines lipid physiology and cardiovascular risk in specific liver diseases and reviews the evidence for lipid lowering and the use of statins in chronic liver disease.
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Affiliation(s)
- Cynthia Herrick
- Division of Endocrinology, Metabolism and Lipid Research, Department of Medicine, Washington University School of Medicine, Campus Box 8127, 660 South Euclid, St Louis, MO 63110, USA.
| | - Samira Bahrainy
- VA Medical Center, Puget Sound, 1660 South Columbian Way, Seattle, WA 98104, USA
| | - Edward A Gill
- Harborview Medical Center, University of Washington School of Medicine, 325 Ninth Avenue, Box 359748, Seattle, WA 98104, USA
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Risk of cerebrovascular accident in patients with primary biliary cirrhosis: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2016; 28:90-4. [PMID: 26473301 DOI: 10.1097/meg.0000000000000493] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Dyslipidemia is common among patients with primary biliary cirrhosis (PBC) and might increase the risk of cerebrovascular accident (CVA). However, data from epidemiologic studies remain inconclusive. This study aims to further investigate this association. MATERIALS AND METHODS We carried out a systematic review and meta-analysis of observational studies that compared the risk of CVA in patients with PBC versus controls. Pooled risk ratios and 95% confidence intervals were combined using a random-effect, generic inverse variance method of DerSimonian and Laird. RESULTS Four studies with 2309 patients with PBC were identified and included in our data analysis. The pooled risk ratio of CVA in patients with PBC was 1.11 (95% confidence interval, 0.81-1.51). The statistical heterogeneity was insignificant, with an I of 14%. CONCLUSION A significantly increased risk of CVA among patients with PBC was not observed in this study.
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Chow A, Rifici VA, Schneider SH. Lipoprotein-X in a Patient with Lymphoplasmacytic Sclerosing Cholangitis: An Unusual Cause of Secondary Hypercholesterolemia. AACE Clin Case Rep 2016. [DOI: 10.4158/ep14249.cr] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Trivedi PJ, Hirschfield GM, Gershwin ME. Obeticholic acid for the treatment of primary biliary cirrhosis. Expert Rev Clin Pharmacol 2015; 9:13-26. [PMID: 26549695 DOI: 10.1586/17512433.2015.1092381] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Primary biliary cirrhosis (PBC) is characterized by progressive nonsuppurative destruction of small bile ducts, resulting in intrahepatic cholestasis, fibrosis and ultimately end-stage liver disease. Timely intervention with ursodeoxycholic acid is associated with excellent survival, although approximately one-third of all patients fail to achieve biochemical response, signifying a critical need for additional therapeutic strategies. Obeticholic acid (OCA) is a potent ligand of the nuclear hormone receptor farnesoid X receptor (FXR). Activation of FXR inhibits bile acid synthesis and protects against toxic accumulation in models of cholestasis and facilitates hepatic regeneration in preclinical studies. Data from recent Phase II and III controlled trials suggest a therapeutic impact of OCA in PBC biochemical nonresponders, as evidenced by change in proven laboratory surrogates of long-term outcome. Dose-dependent pruritus is a common adverse effect, but may be overcome through dose-titration. Longer term studies are needed with focus on safety and long-term clinical efficacy.
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Affiliation(s)
- Palak J Trivedi
- a National Institute of Health Research (NIHR) Birmingham Liver Biomedical Research Unit (BRU), Institute of Immunology and Immunotherapy, 5th Floor IBR Building , Wolfson Drive, University of Birmingham , UK
| | - Gideon M Hirschfield
- a National Institute of Health Research (NIHR) Birmingham Liver Biomedical Research Unit (BRU), Institute of Immunology and Immunotherapy, 5th Floor IBR Building , Wolfson Drive, University of Birmingham , UK
| | - M Eric Gershwin
- b Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis , California , Birmingham , USA
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Ungprasert P, Wijarnpreecha K, Ahuja W, Spanuchart I, Thongprayoon C. Coronary artery disease in primary biliary cirrhosis: A systematic review and meta-analysis of observational studies. Hepatol Res 2015; 45:1055-61. [PMID: 25689394 DOI: 10.1111/hepr.12452] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Revised: 11/05/2014] [Accepted: 11/16/2014] [Indexed: 02/08/2023]
Abstract
AIM To investigate the association between primary biliary cirrhosis (PBC) and risk of coronary artery disease (CAD). METHODS We conducted a systematic review and meta-analysis of published observational studies that reported relative risks, odd ratios, hazard ratios or standardized incidence ratios with 95% confidence intervals (CI) comparing CAD risk in patients with PBC versus non-PBC controls. Pooled risk ratios and 95% confidence intervals were combined using a random-effect model and generic inverse variance of DerSimonian and Laird methods. RESULT Four studies with 3362 patients with PBC were identified and included in our data analysis. The pooled risk ratio of CAD in patients with PBC was 1.57 (95% CI, 1.21-2.06). The statistical heterogeneity was low with an I(2) of 38%. CONCLUSION Our study demonstrated a statistically significant increased risk of CAD among patients with PBC.
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Affiliation(s)
- Patompong Ungprasert
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Karn Wijarnpreecha
- Cardiac Electrophysiology Unit, Department of Physiology, Chiang Mai University, Chiang Mai, Thailand
| | - Wasin Ahuja
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Ittikorn Spanuchart
- Department of Internal Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
Primary biliary cirrhosis is a chronic cholestatic liver disease characterised by destruction of small intrahepatic bile ducts, leading to fibrosis and potential cirrhosis through resulting complications. The serological hallmark of primary biliary cirrhosis is the antimitochondrial antibody, a highly disease-specific antibody identified in about 95% of patients with primary biliary cirrhosis. These patients usually have fatigue and pruritus, both of which occur independently of disease severity. The typical course of primary biliary cirrhosis has changed substantially with the introduöction of ursodeoxycholic acid (UDCA). Several randomised placebo-controlled studies have shown that UDCA improves transplant-free survival in primary biliary cirrhosis. However, about 40% of patients do not have a biochemical response to UDCA and would benefit from new therapies. Liver transplantation is a life-saving surgery with excellent outcomes for those with decompensated cirrhosis. Meanwhile, research on nuclear receptor hormones has led to the development of exciting new potential treatments. This Seminar will review the current understanding of the epidemiology, pathogenesis, and natural history of primary biliary cirrhosis, discuss management of the disease and its sequelae, and introduce research on new therapeutic options.
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Affiliation(s)
- Elizabeth J Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Ahmad H Ali
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA; Arizona State University, College of Health Solutions, Phoenix, AZ, USA.
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Affiliation(s)
- Midhat S Farooqi
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX
- Parkland Health & Hospital System, Dallas, TX
| | - Ibrahim A Hashim
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX
- Parkland Health & Hospital System, Dallas, TX
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Hirschfield GM, Mason A, Luketic V, Lindor K, Gordon SC, Mayo M, Kowdley KV, Vincent C, Bodhenheimer HC, Parés A, Trauner M, Marschall HU, Adorini L, Sciacca C, Beecher-Jones T, Castelloe E, Böhm O, Shapiro D. Efficacy of obeticholic acid in patients with primary biliary cirrhosis and inadequate response to ursodeoxycholic acid. Gastroenterology 2015; 148:751-61.e8. [PMID: 25500425 DOI: 10.1053/j.gastro.2014.12.005] [Citation(s) in RCA: 400] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 12/05/2014] [Accepted: 12/08/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS We evaluated the efficacy and safety of obeticholic acid (OCA, α-ethylchenodeoxycholic acid) in a randomized controlled trial of patients with primary biliary cirrhosis who had an inadequate response to ursodeoxycholic acid therapy. METHODS We performed a double-blind study of 165 patients with primary biliary cirrhosis (95% women) and levels of alkaline phosphatase (ALP) 1.5- to 10-fold the upper limit of normal. Patients were randomly assigned to groups given 10 mg, 25 mg, or 50 mg doses of OCA or placebo, once daily for 3 months. Patients maintained their existing dose of ursodeoxycholic acid throughout the study. The primary outcome was change in level of ALP from baseline (day 0) until the end of the study (day 85 or early termination). We also performed an open-label extension of the trial in which 78 patients were enrolled and 61 completed the first year. RESULTS OCA was superior to placebo in achieving the primary end point. Subjects given OCA had statistically significant relative reductions in mean ALP from baseline to the end of the study (P < .0001 all OCA groups vs placebo). Levels of ALP decreased 21%-25% on average from baseline in the OCA groups and 3% in the placebo group. Sixty-nine percent (68 of 99) of patients given OCA had at least a 20% reduction in ALP compared with 8% (3 of 37) of patients given placebo (P < .0003). Among secondary end points, levels of γ-glutamyl transpeptidase decreased 48%-63%, on average, among subjects given OCA, vs a 7% decrease in the group given placebo; levels of alanine aminotransferase decreased 21%-35% on average among subjects given OCA vs none of the patients given placebo. Pruritus was the principal adverse event; incidence values in the OCA 10 mg, 25 mg, and 50 mg groups were 47% (not significantly different), 87% (P < .0003), and 80% (P < .006), respectively, vs 50% in the placebo group. In the extension study, levels of ALP continued to decrease to a mean level of 202 ± 11 U/L after 12 months vs 285 ± 15 U/L at baseline. CONCLUSIONS Daily doses of OCA, ranging from 10 to 50 mg, significantly reduced levels of ALP, γ-glutamyl transpeptidase, and alanine aminotransferase, compared with placebo, in patients with primary biliary cirrhosis who had inadequate responses to ursodeoxycholic acid. The incidence and severity of pruritus were lowest among patients who received 10 mg/d OCA. Biochemical responses to OCA were maintained in a 12-month open-label extension trial. ClinicalTrials.gov ID: NCT00550862.
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Affiliation(s)
- Gideon M Hirschfield
- Centre for Liver Research, NIHR Birmingham Liver Biomedical Research Unit, University of Birmingham, Birmingham, UK.
| | - Andrew Mason
- Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Velimir Luketic
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University School of Medicine, Richmond, Virginia; McGuire Research Institute, McGuire VA Medical Center, Richmond, VA
| | - Keith Lindor
- Division of Gastroenterology and Hepatology, Mayo Medical School, Rochester, Minnesota; School for the Science of Health Care Delivery, Arizona State University, Phoenix, Arizona
| | - Stuart C Gordon
- Division of Hepatology, Henry Ford Health Systems, Detroit, Michigan
| | - Marlyn Mayo
- Division of Digestive and Liver Diseases, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - Kris V Kowdley
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington
| | | | - Henry C Bodhenheimer
- Department of Medicine, Mount Sinai School of Medicine, New York, New York; Division of Digestive Diseases, Beth Israel Medical Center, New York, New York
| | - Albert Parés
- Liver Unit, Hospital Clinic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Austria
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | | | | | | | - Olaf Böhm
- FGK Clinical Research, Munich, Germany
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Miyahara Y, Bessho K, Kondou H, Hasegawa Y, Yasuda K, Ida S, Ihara Y, Mizuta K, Miyoshi Y, Ozono K. Negative feedback loop of cholesterol regulation is impaired in the livers of patients with Alagille syndrome. Clin Chim Acta 2015; 440:49-54. [PMID: 25444747 DOI: 10.1016/j.cca.2014.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Revised: 10/06/2014] [Accepted: 10/24/2014] [Indexed: 10/24/2022]
Abstract
AIM To characterize cholesterol regulation in the liver of patients with Alagille syndrome (AGS). METHODS Serum total cholesterol (TC) and total bile acid (TBA) levels were measured in 23 AGS patients. The expressions of genes involved in cholesterol regulation, including low-density lipoprotein receptor (LDLR), scavenger receptor class B type I (SR-BI), 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR), cholesterol 7α-hydroxylase (CYP7A1), ATP-binding cassette transporter (ABC) A1, and ABCG1/5/8, were measured in liver tissues from five of these patients. Expression of regulators for these genes, including farnesoid X receptor/small heterodimer partner (SHP), liver X receptor α (LXRα) and mature Sterol regulatory element-binding protein 2 (SREBP2) was measured. The expression of mature SREBP2 protein was also examined. RESULTS Serum TC and TBA levels were correlated in the AGS patients. Liver cholesterol was also increased compared with controls, and correlated with bile acid contents. LDLR, SR-BI, HMGCR, and ABCGs mRNA expression were upregulated, while CYP7A1 mRNA expression was downregulated in AGS livers. SHP and LXRα mRNA expression was also increased, but maturation of SREBP2 was not suppressed in the patients. CONCLUSIONS The major upregulators of liver cholesterol might be increased in AGS patients, indicating an impaired negative feedback mechanism and accelerated liver cholesterol accumulation.
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Affiliation(s)
- Yuki Miyahara
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita City, Osaka, Japan
| | - Kazuhiko Bessho
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita City, Osaka, Japan
| | - Hiroki Kondou
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita City, Osaka, Japan.
| | - Yasuhiro Hasegawa
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita City, Osaka, Japan
| | - Kie Yasuda
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita City, Osaka, Japan
| | - Shinobu Ida
- Department of Pediatric Gastroenterology, Nutrition and Endocrinology, Osaka Medical Center and Research Institute for Maternal and Child Health, 840 Murodou, Izumi City, Osaka, Japan
| | - Yoshiyuki Ihara
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, Japan
| | - Koichi Mizuta
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi, Japan
| | - Yoko Miyoshi
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita City, Osaka, Japan
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita City, Osaka, Japan
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Matsushima K, Sugiuchi H, Anraku K, Nishimura H, Manabe M, Ikeda K, Ando Y, Kondo Y, Ishitsuka Y, Irikura M, Irie T. Differences in reaction specificity toward lipoprotein X and abnormal LDL among 6 homogeneous assays for LDL-cholesterol. Clin Chim Acta 2015; 439:29-37. [DOI: 10.1016/j.cca.2014.09.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 09/25/2014] [Accepted: 09/25/2014] [Indexed: 11/28/2022]
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Marchioni Beery RM, Vaziri H, Forouhar F. Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis: a Review Featuring a Women's Health Perspective. J Clin Transl Hepatol 2014; 2:266-84. [PMID: 26357630 PMCID: PMC4521232 DOI: 10.14218/jcth.2014.00024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 10/15/2014] [Accepted: 10/19/2014] [Indexed: 12/12/2022] Open
Abstract
Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) are two major types of chronic cholestatic liver disease. Each disorder has distinguishing features and variable progression, but both may ultimately result in cirrhosis and hepatic failure. The following offers a review of PBC and PSC, beginning with a general overview of disease etiology, pathogenesis, diagnosis, clinical features, natural course, and treatment. In addition to commonly associated manifestations of fatigue, pruritus, and fat-soluble vitamin deficiency, select disease-related topics pertaining to women's health are discussed including metabolic bone disease, hyperlipidemia and cardiovascular risk, and pregnancy-related issues influencing maternal disease course and birth outcomes. This comprehensive review of PBC and PSC highlights some unique clinical considerations in the care of female patients with cholestatic liver disease.
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Affiliation(s)
- Renée M. Marchioni Beery
- Division of Internal Medicine, Department of Gastroenterology and Hepatology, University of Connecticut Health Center, Farmington, CT, USA
- Correspondence to: Renée M. Marchioni Beery, DO, Division of Internal Medicine, Department of Gastroenterology and Hepatology, 263 Farmington Avenue, Farmington, CT 06030-1845, USA. Tel: +01-860-679-3158, Fax: +01-860-679-3159. E-mail:
| | - Haleh Vaziri
- Division of Internal Medicine, Department of Gastroenterology and Hepatology, University of Connecticut Health Center, Farmington, CT, USA
| | - Faripour Forouhar
- Department of Pathology and Lab Medicine, University of Connecticut Health Center, Farmington, CT, USA
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76
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Blom DJ. Secondary dyslipidaemia. S Afr Fam Pract (2004) 2014. [DOI: 10.1080/20786204.2011.10874107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- DJ Blom
- Division of Lipidology, Department of Medicine, University of Cape Town
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Abstract
Lipid lowering, particularly with HMG CoA reductase inhibitors ("statins"), reduces the risk of cardiovascular disease. Patients with chronic liver and kidney disease present challenges to the use of lipid medications. In the case of most liver disorders, the concern has been one of safety. There is evidence that most lipid-lowering medications can be used safely in many situations, although large outcomes trials are not available. In contrast, in chronic kidney disease, dosing of lipid medications may require substantial modification depending on creatinine clearance. There are significant alterations in lipid metabolism in chronic kidney disease with concomitant increases in cardiovascular risk. Some data are available on cardiovascular outcomes with dyslipidemia treatment in renal patients. This review will examine lipid physiology and cardiovascular risk in specific liver and kidney diseases and review the evidence for lipid lowering and the use of statin and non-statin therapies in chronic liver and kidney disease.
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Affiliation(s)
- Cynthia Herrick
- Division of Endocrinology, Metabolism and Lipid Research, Department of Medicine, Washington University School of Medicine, Campus Box 8127, 660 South Euclid, St. Louis, MO 63110, USA.
| | - Marina Litvin
- Division of Endocrinology, Metabolism and Lipid Research, Department of Medicine, Washington University School of Medicine, Campus Box 8127, 660 South Euclid, St. Louis, MO 63110, USA; Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, Campus Box 8127, 660 S. Euclid Ave, St. Louis, MO 63110, USA.
| | - Anne Carol Goldberg
- Division of Endocrinology, Metabolism and Lipid Research, Department of Medicine, Washington University School of Medicine, Campus Box 8127, 660 South Euclid, St. Louis, MO 63110, USA; Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, Campus Box 8127, 660 S. Euclid Ave, St. Louis, MO 63110, USA.
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Calmarza P, Bajador E, Lapresta C, García Castañón S, de Castro I, Civeira F. [Effect of biliary obstruction on lipoprotein(a) concentration]. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2014; 26:218-23. [PMID: 24629889 DOI: 10.1016/j.arteri.2014.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 01/29/2014] [Accepted: 01/30/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES This study was appointed to determine the correlation between the concentration of lipoprotein(a) [Lp(a)], apolipoproteins and lipids with biochemical parameters of liver function in a group of patients with reversible cholestasis. We have also determined the concentration of these parameters once solved the biliary obstruction process. MATERIAL AND METHODS Eighteen adults over 17 years with extrahepatic cholestasis were included in the study on a prospective basis, and we determined in them biochemical liver function parameters and lipoprotein metabolism parameters, particularly Lp(a) before and after unblocking. RESULTS The concentration of Lp(a) prior to desobstruction was inverse and statistically significantly correlated with the concentration of gamma glutamyl transpeptidase (correlation coefficient [r] = -0.757, P = .018). The concentration of Lp(a) (median = 2.66 mg/dL, interquartile range = 5,62) showed a statistically significant increase (median = 9.72 mg/dL, interquartile range = 28.76, P < .001), once the unblocking was performed. Concentrations of total cholesterol and triglycerides had a statistically significant decrease, and HDL cholesterol and apolipoprotein A-1 showed a statistically significant increase once the unblocking was carried out. CONCLUSIONS The concentration of Lp(a) is decreased during cholestasis, although there is a significant simultaneous hypercholesterolemia. Cholestasis has a causal role in lowering Lp(a), because the unblocking of bile duct recovers Lp(a) concentration. Our study supports the concept that bile acids exert a controlling effect on the synthesis of Lp(a) and open a mechanism for the treatment of hyper Lp(a).
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Affiliation(s)
- Pilar Calmarza
- Servicio de Bioquímica Clínica, Hospital Universitario Miguel Servet, Zaragoza, España.
| | - Eduardo Bajador
- Servicio de Digestivo, Hospital Universitario Miguel Servet, Zaragoza, España
| | - Carlos Lapresta
- Servicio de Medicina Preventiva, Hospital Universitario Miguel Servet, Zaragoza, España
| | | | - Isabel de Castro
- Unidad de Lípidos y Laboratorio de Investigación Molecular, Hospital Universitario Miguel Servet, Zaragoza, España
| | - Fernando Civeira
- Unidad de Lípidos y Laboratorio de Investigación Molecular, Hospital Universitario Miguel Servet, Zaragoza, España
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Stojakovic T, Claudel T, Trauner M. Editorial for 'randomized controlled trial assessing the effect of simvastatin in primary biliary cirrhosis'. Liver Int 2014; 34:328-9. [PMID: 24134772 DOI: 10.1111/liv.12359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 10/13/2013] [Indexed: 02/13/2023]
Affiliation(s)
- Tatjana Stojakovic
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
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Loria P, Marchesini G, Nascimbeni F, Ballestri S, Maurantonio M, Carubbi F, Ratziu V, Lonardo A. Cardiovascular risk, lipidemic phenotype and steatosis. A comparative analysis of cirrhotic and non-cirrhotic liver disease due to varying etiology. Atherosclerosis 2014; 232:99-109. [PMID: 24401223 DOI: 10.1016/j.atherosclerosis.2013.10.030] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 10/23/2013] [Accepted: 10/24/2013] [Indexed: 02/08/2023]
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Cash WJ, O'Neill S, O'Donnell ME, McCance DR, Young IS, McEneny J, McDougall NI, Callender ME. Randomized controlled trial assessing the effect of simvastatin in primary biliary cirrhosis. Liver Int 2013; 33:1166-74. [PMID: 23672463 DOI: 10.1111/liv.12191] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 04/14/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND This study evaluated the effect of statins in Primary biliary cirrhosis (PBC) on endothelial function, anti-oxidant status and vascular compliance. METHODS Primary biliary cirrhosis patients with hypercholesterolaemia were randomized to receive 20 mg simvastatin or placebo in a single blind, randomized controlled trial. Body mass index, blood pressure, glucose, liver function, lipid profile, immunoglobulin levels, serological markers of endothelial function and anti-oxidant status were measured as well as vascular compliance, calculated from pulse wave analysis and velocity, at recruitment and again at 3, 6, 9 and 12 months. RESULTS Twenty-one PBC patients (F = 20, mean age = 55) were randomized to simvastatin 20 mg (n = 11) or matched placebo (n = 10). At completion of the trial, serum cholesterol levels in the simvastatin group were significantly lower compared with the placebo group (4.91 mmol/L vs. 6.15 mmol/L, P = 0.01). Low-density lipoprotein (LDL) levels after 12 months were also significantly lower in the simvastatin group (2.33 mmol/L vs. 3.53 mmol/L, P = 0.01). After 12 months of treatment, lipid hydroperoxides were lower (0.49 μmol/L vs. 0.59 μmol/L, P = 0.10) while vitamin C levels were higher (80.54 μmol/L vs. 77.40 μmol/L, P = 0.95) in the simvastatin group. Pulse wave velocity remained similar between treatment groups at 12 months (8.45 m/s vs. 8.80 m/s, P = 0.66). Only one patient discontinued medication owing to side effects. No deterioration in liver transaminases was noted in the simvastatin group. CONCLUSIONS Statin therapy in patients with PBC appears safe and effective towards overall reductions in total cholesterol and LDL levels. Our initial study suggests that simvastatin may also confer advantageous effects on endothelial function and antioxidant status.
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Affiliation(s)
- William J Cash
- Department of Hepatology (Liver Unit), Royal Victoria Hospital, Belfast, UK.
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Liver disease and malnutrition. Best Pract Res Clin Gastroenterol 2013; 27:619-29. [PMID: 24090946 DOI: 10.1016/j.bpg.2013.06.018] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 06/01/2013] [Accepted: 06/12/2013] [Indexed: 01/31/2023]
Abstract
Patients with hepatic disorders are exceptionally vulnerable to developing malnutrition because of the key role played by the liver in regulating the nutritional state and the energy balance. Moreover, the presence of chronic liver disorders could reduce the appetite and thus influence the nutrient intake. Poor nutritional status has been shown in various patient groups with hepatic disorders, and particularly in patients with alcoholic cirrhosis who are at high nutritional risk. It is well established that malnourished patients with liver diseases generally have a higher risk of developing adverse clinical outcomes and increased healthcare costs. Nutrition screening with the Subjective Global Assessment and anthropometric measurements are an important first step in the early identification of malnutrition and initiates the whole nutrition care process. It is therefore important for appropriate nutrition policies and protocols to be implemented so that all patients with chronic liver diseases are monitored closely from a nutritional standpoint. Early and evidence-based nutritional interventions are eagerly needed to minimize the nutritional decline associated with chronic liver disorders and ultimately improve the prognosis of such patients. This review includes a comprehensive analysis of methods to identify malnutrition in patients with chronic liver diseases as well as the extent and impact of the malnutrition problem in selected patient populations.
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Honda A, Ikegami T, Nakamuta M, Miyazaki T, Iwamoto J, Hirayama T, Saito Y, Takikawa H, Imawari M, Matsuzaki Y. Anticholestatic effects of bezafibrate in patients with primary biliary cirrhosis treated with ursodeoxycholic acid. Hepatology 2013; 57:1931-41. [PMID: 22911624 DOI: 10.1002/hep.26018] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Accepted: 08/02/2012] [Indexed: 12/12/2022]
Abstract
UNLABELLED Bezafibrate is a widely used hypolipidemic agent and is known as a ligand of the peroxisome proliferator-activated receptors (PPARs). Recently this agent has come to be recognized as a potential anticholestatic medicine for the treatment of primary biliary cirrhosis (PBC) that does not respond sufficiently to ursodeoxycholic acid (UDCA) monotherapy. The aim of this study was to explore the anticholestatic mechanisms of bezafibrate by analyzing serum lipid biomarkers in PBC patients and by cell-based enzymatic and gene expression assays. Nineteen patients with early-stage PBC and an incomplete biochemical response to UDCA (600 mg/day) monotherapy were treated with the same dose of UDCA plus bezafibrate (400 mg/day) for 3 months. In addition to the significant improvement of serum biliary enzymes, immunoglobulin M (IgM), cholesterol, and triglyceride concentrations in patients treated with bezafibrate, reduction of 7α-hydroxy-4-cholesten-3-one (C4), a marker of bile acid synthesis, and increase of 4β-hydroxycholesterol, a marker of CYP3A4/5 activity, were observed. In vitro experiments using human hepatoma cell lines demonstrated that bezafibrate controlled the target genes of PPARα, as well as those of the pregnane X receptor (PXR); down-regulating CYP7A1, CYP27A1, and sinusoidal Na(+) /taurocholate cotransporting polypeptide (NTCP), and up-regulating CYP3A4, canalicular multidrug resistance protein 3 (MDR3), MDR1, and multidrug resistance-associated protein 2 (MRP2). CONCLUSION Bezafibrate is a dual PPARs/PXR agonist with potent anticholestatic efficacy in early-stage PBC patients with an incomplete biochemical response to UDCA monotherapy.
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Affiliation(s)
- Akira Honda
- Department of Gastroenterology, Tokyo Medical University Ibaraki Medical Center, Ami, Ibaraki, Japan
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84
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Gautier T, de Haan W, Grober J, Ye D, Bahr MJ, Claudel T, Nijstad N, Van Berkel TJC, Havekes LM, Manns MP, Willems SM, Hogendoorn PCW, Lagrost L, Kuipers F, Van Eck M, Rensen PCN, Tietge UJF. Farnesoid X receptor activation increases cholesteryl ester transfer protein expression in humans and transgenic mice. J Lipid Res 2013; 54:2195-2205. [PMID: 23620138 DOI: 10.1194/jlr.m038141] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cholesteryl ester transfer protein (CETP) activity results in a proatherogenic lipoprotein profile. In cholestatic conditions, farnesoid X receptor (FXR) signaling by bile acids (BA) is activated and plasma HDL cholesterol (HDL-C) levels are low. This study tested the hypothesis that FXR-mediated induction of CETP contributes to this phenotype. Patients with cholestasis and high plasma BA had lower HDL-C levels and higher plasma CETP activity and mass compared with matched controls with low plasma BA (each P < 0.01). BA feeding in APOE3*Leiden transgenic mice expressing the human CETP transgene controlled by its endogenous promoter increased cholesterol within apoB-containing lipoproteins and decreased HDL-C (each P < 0.01), while hepatic CETP mRNA expression and plasma CETP activity and mass increased (each P < 0.01). In vitro studies confirmed that FXR agonists substantially augmented CETP mRNA expression in hepatocytes and macrophages dependent on functional FXR expression (each P < 0.001). These transcriptional effects are likely mediated by an ER8 FXR response element (FXRE) in the first intron. In conclusion, using a translational approach, this study identifies CETP as novel FXR target gene. By increasing CETP expression, FXR activation leads to a proatherogenic lipoprotein profile. These results have clinical relevance, especially when considering FXR agonists as emerging treatment strategy for metabolic disease and atherosclerosis.
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Affiliation(s)
- Thomas Gautier
- Department of Pediatrics and University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Lipides, Nutrition, Cancer - Faculté de Médecine, Université de Bourgogne - INSERM UMR866, Dijon, France
| | - Willeke de Haan
- Department of Endocrinology, and Metabolic Diseases and Einthoven Laboratory for Experimental Vascular Medicine and Leiden University Medical Center, Leiden, The Netherlands
| | - Jacques Grober
- Lipides, Nutrition, Cancer - Faculté de Médecine, Université de Bourgogne - INSERM UMR866, Dijon, France
| | - Dan Ye
- Division of Biopharmaceutics, Leiden/Amsterdam Center for Drug Research, Leiden University, Leiden, The Netherlands
| | - Matthias J Bahr
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany; and
| | - Thierry Claudel
- Department of Pediatrics and University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Laboratory of Experimental and Molecular Hepatology, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Niels Nijstad
- Department of Pediatrics and University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Theo J C Van Berkel
- Division of Biopharmaceutics, Leiden/Amsterdam Center for Drug Research, Leiden University, Leiden, The Netherlands
| | - Louis M Havekes
- Department of Endocrinology, and Metabolic Diseases and Einthoven Laboratory for Experimental Vascular Medicine and Leiden University Medical Center, Leiden, The Netherlands
| | - Michael P Manns
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany; and
| | - Stefan M Willems
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Laurent Lagrost
- Lipides, Nutrition, Cancer - Faculté de Médecine, Université de Bourgogne - INSERM UMR866, Dijon, France
| | - Folkert Kuipers
- Department of Pediatrics and University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Miranda Van Eck
- Division of Biopharmaceutics, Leiden/Amsterdam Center for Drug Research, Leiden University, Leiden, The Netherlands
| | - Patrick C N Rensen
- Department of Endocrinology, and Metabolic Diseases and Einthoven Laboratory for Experimental Vascular Medicine and Leiden University Medical Center, Leiden, The Netherlands
| | - Uwe J F Tietge
- Department of Pediatrics and University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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85
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86
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Berkelhammer C, Lerma EV. Statin treatment in patients with elevated liver enzymes: pitch to proceed. J Clin Lipidol 2012; 6:310-1. [PMID: 22836066 DOI: 10.1016/j.jacl.2012.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Accepted: 05/16/2012] [Indexed: 12/18/2022]
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87
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Wong ML, Raghavan RP, Hedger NA, Ellis RD, Meeking DR, Albon L. The use of plasmapheresis in managing primary biliary cirrhosis presenting with profound hypercholesterolaemia. ACTA ACUST UNITED AC 2012. [DOI: 10.1177/1474651412442410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Mo Lee Wong
- Diabetes and Endocrinology, Royal Bournemouth Hospital, Bournemouth, UK
| | - Rajeev P Raghavan
- Diabetes & Endocrinology, Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | | | - Richard D Ellis
- Gastroenterology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Darryl R Meeking
- Academic Department of Diabetes and Endocrinology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Lorraine Albon
- Academic Department of Diabetes and Endocrinology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
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88
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Alempijevic T, Sokic-Milutinovic A, Pavlovic Markovic A, Jesic-Vukicevic R, Milicic B, Macut D, Popovic D, Tomic D. Assessment of metabolic syndrome in patients with primary biliary cirrhosis. Wien Klin Wochenschr 2012; 124:251-5. [PMID: 22531844 DOI: 10.1007/s00508-012-0162-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 01/16/2012] [Indexed: 12/30/2022]
Abstract
BACKGROUND Primary biliary cirrhosis (PBC) is a chronic, progressive liver disease with elevated serum lipids. It remains unclear if hyperlipidemia increases the risk for atherosclerosis in PBC patients. Metabolic syndrome (MS) promotes the development of atherosclerotic cardiovascular disease due to abdominal obesity and insulin resistance. AIMS The aim of this study was to assess incidence and parameters of MS, as well as subcutaneous and visceral fat using noninvasive ultrasonographic measurement in patients with PBC in our population. METHODS We included 55 patients with PBC and 44 age- and sex-matched healthy controls (CG-control group). Anthropometric measurements (weight, height, and waist circumference), age, sex, and body mass index were recorded for patients and controls. Laboratory tests for assessing MS and liver function tests were analyzed. We used ultrasonography to determine subcutaneous and visceral fat diameter and area (SF, VF and SA, VA, respectively), as well as perirenal fat diameter (PF). RESULTS Patients with PBC had significantly higher levels of cholesterol and liver function tests. There were no statistically significant difference in serum insulin and HOMA levels, as well as incidence of MS was diagnosed in 30.9 % (17/55) PBC patients and 43.2 % (19/44) controls. We registered lower amount of VF (PBC:10.92 ± 3.63 mm, CG:16.84 ± 5.51 mm,p < 0.001), VA (PBC:403.64 ± 166.97 mm(2), CG:720.57 ± 272.50 mm(2),p < 0.001), and PF (PBC:7.03 ± 1.82 mm, CG 10.49 ± 2.70 mm,p < 0.001) in patients with PBC. CONCLUSION MS is not more frequent in patients with PBC compared with healthy volunteers in our population. Lower amount of VF could be related to lower risk for cardiovascular events in PBC patients.
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Abstract
Primary biliary cirrhosis is a chronic autoimmune inflammatory disease of the liver with a striking female preponderance. It has an insidious onset and typically affects middle-aged women. The disease manifests gradually with symptoms of fatigue, pruritis, and increased alkaline phosphatase levels on laboratory evaluation. The hallmark of the disease is the circulating antimitochondrial antibody. Histology is characterized by inflammation of the bile ducts, destruction of cholangiocytes, and subsequent cholestasis, progressing to biliary cirrhosis. The standard treatment for primary biliary cirrhosis is ursodeoxycholic acid, which improves survival, but the disease can still lead to cirrhosis and liver failure over decades.
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Affiliation(s)
- Bhavik M Bhandari
- Division of Gastroenterology & Hepatology, Drexel University College of Medicine, 219 North Broad Street, Fifth Floor, Philadelphia, PA 19107, USA.
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90
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Ultrasound measurement of visceral fat in patients with primary biliary cirrhosis. VOJNOSANIT PREGL 2011; 68:739-43. [PMID: 22046877 DOI: 10.2298/vsp1109739a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background/Aim. Primary biliary cirrhosis (PBC) is a progressive, chronic
liver disease with elevated serum lipids, but it is unclear whether
hyperlipidemia in PBC patients is associated with atherosclerosis. Metabolic
syndrome promotes development of atherosclerotic cardiovascular disease
related to abdominal type obesity and insulin resistance. The aim of our
study was to assess abdominal adiposity in patients with PBC. Methods. The
study included 40 patients with PBC and 50 healthy controls. Age, sex and
anthropometric measurements (weight, height, body mass index and waist
circumference) were registered for all patients and controls. We used
ultrasonography to measure subcutaneous (SF) and visceral fat (VF) diameter,
subcutaneous area (SA) and visceral area (VA), as well as perirenal fat
diameter (PF). Results. Values of SF, VF and PF thicknesses in PBC patients
were 19.23 ? 5.85 mm, 10.92 ? 3.63 mm, and 7.03 ? 1.82 mm, respectively. In
controls these measurements were 22.73 ? 6.70 mm, 16.84 ? 5.51 mm and 10.50 ?
2.70 mm respectively. In PBC patients SA and VA were calculated to 983.64 ?
322.68 mm2 and 403.64 ? 166.97 mm2 and in controls 1124.89 ? 366.01 mm2 and
720.57 ? 272.50 mm2 respectrively. Significant difference was found for VF,
VA and RF values. Conclusions. Considering that the amount of visceral fat
plays an important role in development of metabolic syndrome and
cardiovascular diseases, we concluded that the lower amount of visceral fat
in PBC patients could be related to lower incidence of cardiovascular events,
despite hyperlipidemia.
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91
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Le HD, de Meijer VE, Zurakowski D, Meisel JA, Gura KM, Puder M. Parenteral Fish Oil as Monotherapy Improves Lipid Profiles in Children With Parenteral Nutrition–Associated Liver Disease. JPEN J Parenter Enteral Nutr 2010; 34:477-84. [DOI: 10.1177/0148607110371806] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hau D. Le
- Department of Surgery and The Vascular Biology Program, Children’s Hospital Boston, Boston, Massachusetts
| | - Vincent E. de Meijer
- Department of Surgery and The Vascular Biology Program, Children’s Hospital Boston, Boston, Massachusetts
| | - David Zurakowski
- Department of Surgery and The Vascular Biology Program, Children’s Hospital Boston, Boston, Massachusetts
| | - Jonathan A. Meisel
- Department of Surgery and The Vascular Biology Program, Children’s Hospital Boston, Boston, Massachusetts
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kathleen M. Gura
- Department of Pharmacy, Children’s Hospital Boston, Boston, Massachusetts
| | - Mark Puder
- Department of Surgery and The Vascular Biology Program, Children’s Hospital Boston, Boston, Massachusetts
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Calderon RM, Cubeddu LX, Goldberg RB, Schiff ER. Statins in the treatment of dyslipidemia in the presence of elevated liver aminotransferase levels: a therapeutic dilemma. Mayo Clin Proc 2010; 85:349-56. [PMID: 20360293 PMCID: PMC2848423 DOI: 10.4065/mcp.2009.0365] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The beneficial role of statins in primary and secondary prevention of coronary heart disease has resulted in their frequent use in clinical practice. However, safety concerns, especially regarding hepatotoxicity, have driven multiple trials, which have demonstrated the low incidence of statin-related hepatic adverse effects. The most commonly reported hepatic adverse effect is the phenomenon known as transaminitis, in which liver enzyme levels are elevated in the absence of proven hepatotoxicity. This class effect is usually asymptomatic, reversible, and dose-related. However, the increasing incidence of chronic liver diseases, including nonalcoholic fatty liver disease and hepatitis C, has created a new challenge when initiating statin treatment in patients with high cardiovascular risk. These diseases result in abnormally high liver biochemistry values, discouraging statin use by clinicians, fostering treatment discontinuation, and leaving a large number of at-risk patients untreated. A PubMed/MEDLINE search of the literature regarding statin safety (January 1, 1994-December 31, 2008) was performed, using the following search terms: statin safety, statin-related hepatotoxicity, and chronic liver disease and statin use, as well as the specific names of different statins and different liver diseases. Relevant clinical trials, review articles, panel discussions, and guideline recommendations were selected. This review supports the use of statin treatment in patients with high cardiovascular risk whose elevated aminotransferase levels have no clinical relevance or are attributable to known stable chronic liver conditions. For each patient, the decision should be based on an individual assessment of risks and benefits.
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Affiliation(s)
- Rossana M Calderon
- Department of Internal Medicine, Mount Sinai Medical Center, 4300 Alton Rd, Miami Beach, FL 33140, USA.
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93
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Awan Z, Bailey D, Hafiane A, Genest J. Acquired severe hypercholesterolemia and hypoalphalipoproteinemia. J Clin Lipidol 2009; 3:393-7. [PMID: 21291840 DOI: 10.1016/j.jacl.2009.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Revised: 09/20/2009] [Accepted: 10/01/2009] [Indexed: 11/27/2022]
Affiliation(s)
- Zuhier Awan
- Cardiovascular Research Laboratories, McGill University Health Center Research Institute, McGill University, Royal Victoria Hospital, 687 Pine Avenue West, Room M4.72, Montreal, Quebec, Canada H3A 1A1
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Tandra S, Vuppalanchi R. Use of statins in patients with liver disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2009; 11:272-8. [PMID: 19627660 DOI: 10.1007/s11936-009-0028-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cardiovascular disease is as common in individuals with chronic liver disease as in the general population. Moreover, recent data suggest that patients with nonalcoholic fatty liver disease (NAFLD) may have a cardiovascular risk greater than that conferred by the conventional risk factors. There is unequivocal evidence that cardiovascular disease is an important cause of morbidity and mortality in this patient population and thus requires consideration of aggressive therapy with lipid-lowering agents such as statins. Because all statins are hepatically cleared and can cause elevations in liver biochemistries, there is a concern that patients with underlying liver disease may be at increased risk for hepatotoxicity. However, recent data, along with an assessment of statin safety by the Liver Expert Panel, suggest that statins are generally well tolerated in patients with chronic liver disease such as NAFLD, primary biliary cirrhosis, and hepatitis C virus. These drugs also appear to be safe in patients with stable/compensated cirrhosis. However, decompensated cirrhosis and acute liver failure should be considered contraindications for lipid-lowering therapy as these patients are unlikely to benefit because of their generally grave prognosis. Although routine hepatic biochemical test monitoring is recommended, the cost-effectiveness of this approach has been questioned. The benefit of statins in patients with underlying liver disease who are otherwise important candidates for statin therapy far outweighs the risk of a very rare event of serious liver injury.
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Affiliation(s)
- Sweta Tandra
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
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95
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Stojakovic T, Claudel T, Putz-Bankuti C, Fauler G, Scharnagl H, Wagner M, Sourij H, Stauber RE, Winkler K, März W, Wascher TC, Trauner M. Low-dose atorvastatin improves dyslipidemia and vascular function in patients with primary biliary cirrhosis after one year of treatment. Atherosclerosis 2009; 209:178-83. [PMID: 19782361 DOI: 10.1016/j.atherosclerosis.2009.08.052] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2009] [Revised: 08/04/2009] [Accepted: 08/28/2009] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Primary biliary cirrhosis (PBC) is frequently associated with hypercholesterolemia and with an increased cardiovascular morbidity and mortality. Statins lower serum cholesterol levels and may thus improve the cardiovascular risk in PBC patients. The aim of our study was to prospectively examine the efficacy of low-dose atorvastatin on cholestasis as well as cardiovascular risk markers such as dyslipidemia and vascular function in patients with PBC. METHODS Nineteen patients with early-stage (biopsy proven and AMA positive) PBC and low-density lipoprotein cholesterol (LDL-C) above 130mg/dL were included in this single-center study and treated with atorvastatin 10mg per day for one year. RESULTS Concentrations of total cholesterol, LDL-C, LDL triglycerides, oxLDL, IgG and sVCAM-1 decreased significantly after 48 weeks of atorvastatin treatment. Flow-mediated dilation (FMD) of the brachial artery as an indicator of vascular function significantly increased, while carotid artery intima-media thickness and vascular wall stiffness did not progress under treatment. No statistical differences in liver enzymes were observed except a transient increase of alkaline phosphatase. CONCLUSION Treatment with low-dose atorvastatin is safe in early-stage PBC, effectively reduces total cholesterol, LDL-C, LDL triglycerides, oxLDL and sVCAM-1 and improves vascular function as reflected by FMD, without affecting cholestasis progression. Therefore, statin therapy should be considered in PBC patients with additional risk factors for cardiovascular disease.
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Affiliation(s)
- Tatjana Stojakovic
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
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Hohenester S, Oude-Elferink RPJ, Beuers U. Primary biliary cirrhosis. Semin Immunopathol 2009; 31:283-307. [PMID: 19603170 PMCID: PMC2758170 DOI: 10.1007/s00281-009-0164-5] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Accepted: 05/22/2009] [Indexed: 12/13/2022]
Abstract
Primary biliary cirrhosis (PBC) is an immune-mediated chronic cholestatic liver disease with a slowly progressive course. Without treatment, most patients eventually develop fibrosis and cirrhosis of the liver and may need liver transplantation in the late stage of disease. PBC primarily affects women (female preponderance 9–10:1) with a prevalence of up to 1 in 1,000 women over 40 years of age. Common symptoms of the disease are fatigue and pruritus, but most patients are asymptomatic at first presentation. The diagnosis is based on sustained elevation of serum markers of cholestasis, i.e., alkaline phosphatase and gamma-glutamyl transferase, and the presence of serum antimitochondrial antibodies directed against the E2 subunit of the pyruvate dehydrogenase complex. Histologically, PBC is characterized by florid bile duct lesions with damage to biliary epithelial cells, an often dense portal inflammatory infiltrate and progressive loss of small intrahepatic bile ducts. Although the insight into pathogenetic aspects of PBC has grown enormously during the recent decade and numerous genetic, environmental, and infectious factors have been disclosed which may contribute to the development of PBC, the precise pathogenesis remains enigmatic. Ursodeoxycholic acid (UDCA) is currently the only FDA-approved medical treatment for PBC. When administered at adequate doses of 13–15 mg/kg/day, up to two out of three patients with PBC may have a normal life expectancy without additional therapeutic measures. The mode of action of UDCA is still under discussion, but stimulation of impaired hepatocellular and cholangiocellular secretion, detoxification of bile, and antiapoptotic effects may represent key mechanisms. One out of three patients does not adequately respond to UDCA therapy and may need additional medical therapy and/or liver transplantation. This review summarizes current knowledge on the clinical, diagnostic, pathogenetic, and therapeutic aspects of PBC.
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Affiliation(s)
- Simon Hohenester
- Department of Gastroenterology & Hepatology/Liver Center, Academic Medical Center, G4-213, University of Amsterdam, P.O. Box 22700, 1100 DE, Amsterdam, The Netherlands
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97
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Lindor KD, Gershwin ME, Poupon R, Kaplan M, Bergasa NV, Heathcote EJ. Primary biliary cirrhosis. Hepatology 2009; 50:291-308. [PMID: 19554543 DOI: 10.1002/hep.22906] [Citation(s) in RCA: 870] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA.
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98
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Foley KF, Silveira MG, Hornseth JM, Lindor KD, McConnell JP. A Patient with Primary Biliary Cirrhosis and Elevated LDL Cholesterol. Clin Chem 2009; 55:187-91; disscusion 191-2. [DOI: 10.1373/clinchem.2008.108720] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Kevin F Foley
- Clinical Laboratory Science Department, Northern Michigan University, Marquette, MI
| | - Marina G Silveira
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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Shiomi M, Fan J. Unstable coronary plaques and cardiac events in myocardial infarction-prone Watanabe heritable hyperlipidemic rabbits: questions and quandaries. Curr Opin Lipidol 2008; 19:631-6. [PMID: 18957890 DOI: 10.1097/mol.0b013e3283189c18] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Use of suitable animal models is essential for investigation of the mechanisms underlying cardiac events and development of the therapeutic strategies; however, ideal animal models that can recapitulate human coronary atherosclerosis and subsequent acute myocardial infarction are still lacking. In this article, we review the insights learned from myocardial infarction-prone Watanabe heritable hyperlipidemic (designated as WHHLMI) rabbits and discuss the possibility of using this model for the study of human acute coronary syndromes. RECENT FINDINGS The vulnerable plaques of human coronary arteries are histologically characterized by a large lipid core and a thin fibrous cap with inflammatory cells. Recent studies have revealed that inflammatory cells and inflammatory mediators (such as cytokines and matrix metalloproteinases) play an important role in the plaque rupture. SUMMARY We developed the WHHLMI rabbit that shows spontaneous myocardial infarction caused by coronary atherosclerosis. The coronary lesions of WHHLMI rabbits have features of fatty streaks, fibrous plaques, and fibroatheromatous plaques. Some plaques contain a lipid core and a thin fibrous cap similar to human vulnerable plaques. In spite of this, the plaque rupture is not observed in WHHLMI rabbits, suggesting that other additional factors such as mechanical stress are required to trigger the rupture. WHHLMI rabbits may become an important means for elucidating the possible mechanisms of plaque rupture by exposing the plaques to additional risk factors beyond hyperlipidemia.
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Affiliation(s)
- Masashi Shiomi
- Institute for Experimental Animals, Kobe University School of Medicine, Kobe, Hyogo, Japan.
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100
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Solaymani-Dodaran M, Aithal GP, Card T, West J. Risk of cardiovascular and cerebrovascular events in primary biliary cirrhosis: a population-based cohort study. Am J Gastroenterol 2008; 103:2784-8. [PMID: 18759822 DOI: 10.1111/j.1572-0241.2008.02092.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hyperlipidemia is a common finding among patients with primary biliary cirrhosis (PBC). However, whether this results in higher rates of cardiovascular and cerebrovascular events in PBC patients compared with the general population is unclear. METHODS We compared the risk of developing myocardial infarction (MI), stroke, and transient ischemic attack (TIA) in a cohort of people with PBC with a general population control cohort matched on age, sex, and general practice (GP). Subjects were selected from the General Practice Research Database (GPRD). Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox regression. RESULTS Nine hundred thirty PBC patients (88% female) were compared with 9,202 controls. During a total of about 43,700 person-years of follow-up, 244 MIs, 591 strokes, and 221 TIAs were identified. Incidence rates per 1,000 person-years for MI, stroke, and TIA during the study period were 5.9 (3.9-9.0), 13.8 (10.5-18.2), and 3.5 (2.0-6.0) for PBC cohorts and 5.6 (4.9-6.4), 14.0 (12.9-15.2), and 5.3 (4.6-6.0) for control cohorts, respectively. HRs in PBC cohort compared with the control cohort were for any vascular event 0.99 (95% CI 0.77-1.27) MI 1.04 (95% CI 0.67-1.62), stroke 0.98 (95% CI 0.73-1.31), and TIA 0.66 (95% CI 0.38-1.16). Adjustment for confounders did not change the results substantially. CONCLUSIONS PBC was not associated with an increased risk of MI, stroke, or TIA in this cohort. Therefore, strategies for the prevention of vascular events in PBC patients should be similar to those in the general population.
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Affiliation(s)
- Masoud Solaymani-Dodaran
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, United Kingdom
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