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Premkumar M, Anand AC. Porto-sinusoidal Vascular Disease: Classification and Clinical Relevance. J Clin Exp Hepatol 2024; 14:101396. [PMID: 38601747 PMCID: PMC11001647 DOI: 10.1016/j.jceh.2024.101396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 03/05/2024] [Indexed: 04/12/2024] Open
Abstract
Non-cirrhotic portal hypertension (NCPH) is a well-recognized clinico-pathological entity, which is associated with clinical signs and symptoms, imaging, and endoscopic features of portal hypertension (PHT), in absence of cirrhosis. In patients with NCPH without known risk factors of PHT or extrahepatic portal vein thrombosis, the condition is called idiopathic non-cirrhotic portal hypertension (INCPH). There are multiple infectious, immune related causes, systemic diseases, drug and toxin exposures, haematological disorders, and metabolic risk factors that have been associated with this INCPH. However, the causal pathogenesis is still unclear. The Vascular liver disorders interest group group recently proposed porto-sinusoidal vascular disease (PSVD) as a syndromic entity, which provides definite histopathological criteria for diagnosis of NCPH (table 1). The three classical histo-morphological lesions specific for PSVD include obliterative portal venopathy, nodular regenerative hyperplasia, and incomplete septal fibrosis. The PSVD definition includes patients with portal vein thrombosis, PVT, and even those without PHT, thus broadening the scope of diagnosis to include patients who may have presented early, prior to haemodynamic changes consistent with PHT. However, this new diagnosis has pros and cons. The cons include mandating invasive liver biopsy to assess the PSVD histological triad in all patients with NCPH, an erstwhile clinical diagnosis in Asian patients. In addition, the natural history of the subclinical forms of PSVD without PHT and linear progression to develop PHT is unknown yet. In this review, we discuss the diagnosis and treatment of INCPH/PSVD, fallacies and strengths of the old and new schema, pathobiology of this disease, and clinical correlates in an Asian context. Although formulation of standardised diagnostic criteria is useful for comparison of clinical cohorts with INCPH/PSVD, prospective clinical validation in global cohorts is necessary to avoid misclassification of vascular disorders of the liver.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Anil C. Anand
- Department of Hepatology, Kalinga Institute of Medical Sciences, Bhubaneshwar, Odisha, India
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Sultanik P, Lherault G, Bouzbib C, Ratziu V, Pais R, Mouri S, Thabut D, Rudler M. Prevalence and prognosis of patients with MASLD-related cirrhosis after an ICU hospitalization in France: A single-centre prospective study. Aliment Pharmacol Ther 2024; 60:796-810. [PMID: 39034817 DOI: 10.1111/apt.18165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 04/29/2024] [Accepted: 07/04/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND AND AIMS The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD)-related cirrhosis has been increasing these last decades. There are no data regarding the prevalence of MASLD-related cirrhosis in intensive care unit (ICU). METHODS Prospective single-centre study in a cohort of patients hospitalized in the ICU of Hepatology La Pitié-Salpêtrière Hospital between January 2019 and September 2021. We analysed three groups of patients: MASLD-cirrhosis (alcohol ≤210 g for men and 140 g weekly for women), ALD (alcohol-related liver disease, alcohol>140 g weekly for women or >210 g for men)-cirrhosis alone and MetALD (metabolic and alcohol-related liver disease)-cirrhosis. Endpoints were 1-year transplant-free survival (TFS), further acute decompensation (AD) and re-admission. RESULTS A total of 410 patients were hospitalized, and 315 analysed: 39 in MASLD, 160 in ALD and 116 in MetALD groups. The global prevalence was 10% for MASLD, 41% ALD and 29.7% for MetALD. Patients in the MASLD group were significantly older (65 vs. 57 and 59 years, p < 0.001), and had lower Child-Pugh (8 vs. 11 vs. 10, p < 0.001) and MELD score (17 vs. 22 vs. 21, p < 0.001). The 1-year TFS was not different between groups (53% vs. 54% vs. 54%, p = 0.96). Cardiovascular mortality was <5% in all groups. The 1-year probability of developing hepatic encephalopathy was significantly higher in the MASLD group (73% vs. 27% and 21%, p < 0.001). There was no difference regarding the development of other complications between groups. CONCLUSION MASLD or MetALD was responsible for 1/3 of the causes of cirrhosis in the ICU. MASLD-related cirrhosis is as severe as ALD-related cirrhosis. Liver transplantation should be rapidly discussed.
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Affiliation(s)
- Philippe Sultanik
- AP-HP, Sorbonne Université, Liver Intensive Care Unit, Hepatogastroenterology Department, Pitié-Salpêtrière Hospital, Paris, France
| | - Guillaume Lherault
- AP-HP, Sorbonne Université, Liver Intensive Care Unit, Hepatogastroenterology Department, Pitié-Salpêtrière Hospital, Paris, France
| | - Charlotte Bouzbib
- AP-HP, Sorbonne Université, Liver Intensive Care Unit, Hepatogastroenterology Department, Pitié-Salpêtrière Hospital, Paris, France
| | - Vlad Ratziu
- AP-HP, Sorbonne Université, Liver Intensive Care Unit, Hepatogastroenterology Department, Pitié-Salpêtrière Hospital, Paris, France
- INSERM UMR_S 938, Centre de Recherche Saint-Antoine, Maladies métaboliques, Biliaires et Fibro-Inflammatoire du Foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
- Hôpital de la Pitié-Salpêtrière, Service d'hépato-Gastro-entérologie, unité de Soins Intensifs d'hépatologie, Sorbonne Université, AP-HP. Sorbonne Université, Paris, France
| | - Raluca Pais
- AP-HP, Sorbonne Université, Liver Intensive Care Unit, Hepatogastroenterology Department, Pitié-Salpêtrière Hospital, Paris, France
- INSERM UMR_S 938, Centre de Recherche Saint-Antoine, Maladies métaboliques, Biliaires et Fibro-Inflammatoire du Foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
- Hôpital de la Pitié-Salpêtrière, Service d'hépato-Gastro-entérologie, unité de Soins Intensifs d'hépatologie, Sorbonne Université, AP-HP. Sorbonne Université, Paris, France
| | - Sarah Mouri
- AP-HP, Sorbonne Université, Liver Intensive Care Unit, Hepatogastroenterology Department, Pitié-Salpêtrière Hospital, Paris, France
| | - Dominique Thabut
- AP-HP, Sorbonne Université, Liver Intensive Care Unit, Hepatogastroenterology Department, Pitié-Salpêtrière Hospital, Paris, France
- INSERM UMR_S 938, Centre de Recherche Saint-Antoine, Maladies métaboliques, Biliaires et Fibro-Inflammatoire du Foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
- Hôpital de la Pitié-Salpêtrière, Service d'hépato-Gastro-entérologie, unité de Soins Intensifs d'hépatologie, Sorbonne Université, AP-HP. Sorbonne Université, Paris, France
| | - Marika Rudler
- AP-HP, Sorbonne Université, Liver Intensive Care Unit, Hepatogastroenterology Department, Pitié-Salpêtrière Hospital, Paris, France
- INSERM UMR_S 938, Centre de Recherche Saint-Antoine, Maladies métaboliques, Biliaires et Fibro-Inflammatoire du Foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
- Hôpital de la Pitié-Salpêtrière, Service d'hépato-Gastro-entérologie, unité de Soins Intensifs d'hépatologie, Sorbonne Université, AP-HP. Sorbonne Université, Paris, France
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Roy A, Verma N, Jajodia S, Goenka U, Tiwari A, Sonthalia N, Goenka M. Magnetic resonance elastography (MRE) outperforms acoustic force radiation impulse (ARFI) in predicting oesophageal varices in obese NAFLD cirrhosis. Abdom Radiol (NY) 2024; 49:3088-3095. [PMID: 38652124 DOI: 10.1007/s00261-024-04309-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Liver stiffness measurement (LSM) by transient elastography has been shown to underperform in high-risk varices (HRVs) prediction in obese non-alcoholic fatty liver disease (NAFLD) compensated cirrhosis (CC). LSM by magnetic resonance elastography (MRE) and acoustic force radiation impulse (ARFI) has been shown to be useful in prediction of oesophageal varices (EVs), but has limited evidence in obese NAFLD-CC. METHODS Obese patients with NAFLD-CC who underwent MRE and ARFI for LSM and endoscopy for screening of varices were enrolled. Performance of MRE and ARFI for predicting EVs or HRVs was evaluated using area under receiver operating characteristics (AUROC) curves and regression analyses were performed for predictor variables. RESULTS One hundred eight patients [mean age 54.7 ± 9.6 years, median BMI, 28.5 (26.4-30.0) kg/m2. 72.2% diabetics, 45.4% hypertensive] were enrolled. Fifty-two (48.1%) had no varices, while 29 (26.8%) and 27 (25%) had low-risk varices (LRVs) and HRVs, respectively. MRE-LSM was higher in patients with LRVs (p = 0.01) or HRVs (p = 0.001) against those without varices. ARFI-LSM did not differ significantly between those without and with LRVs or HRVs (p > 0.05 for all). There was a low correlation between ARFI-LSM and MRE-LSM in the overall cohort (r = 0.19). Only platelet count (PC) [0.98 (0.97-0.99)] and MRE-LSM [1.8 (1.26-2.79)] were predictors of HRVs. At a cut-off of 4.75, MRE showed a sensitivity of 96.3%. Model combining MRE-LSM with PC had a diagnostic AUROC of 0.77 and 0.76 for EVs and HRVs. CONCLUSION In obese NAFLD-CC, MRE-LSM is significantly higher in patients with varices. MRE combined with PC predicts EVs and HRVs with better accuracy than ARFI.
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Affiliation(s)
- Akash Roy
- Department of Gastroenterology, Institute of Gastrosciences and Liver Transplantation, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
| | - Nipun Verma
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Surabhi Jajodia
- Department of Radiology and Imaging, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
| | - Usha Goenka
- Department of Radiology and Imaging, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
| | - Awanish Tiwari
- Department of Gastroenterology, Institute of Gastrosciences and Liver Transplantation, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
| | - Nikhil Sonthalia
- Department of Gastroenterology, Institute of Gastrosciences and Liver Transplantation, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
| | - Mahesh Goenka
- Department of Gastroenterology, Institute of Gastrosciences and Liver Transplantation, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India.
- Department of Gastroenterology, Institute of Gastrosciences and Liver Transplantation, Apollo Multispeciality Hospitals, Kolkata, 700054, India.
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Carlin S, Cuker A, Gatt A, Gendron N, Hernández-Gea V, Meijer K, Siegal DM, Stanworth S, Lisman T, Roberts LN. Anticoagulation for stroke prevention in atrial fibrillation and treatment of venous thromboembolism and portal vein thrombosis in cirrhosis: guidance from the SSC of the ISTH. J Thromb Haemost 2024; 22:2653-2669. [PMID: 38823454 DOI: 10.1016/j.jtha.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/14/2024] [Accepted: 05/20/2024] [Indexed: 06/03/2024]
Abstract
While advanced liver disease was previously considered to be an acquired bleeding disorder, there is increasing recognition of an associated prothrombotic state with patients being at higher risk of atrial fibrillation (AF) and stroke and venous thromboembolism (VTE) including portal vein thrombosis (PVT). We review the available literature on epidemiology, pathophysiology, and risk factors and provide guidance on anticoagulant management of these conditions in adults with cirrhosis. In patients with Child-Pugh A or B cirrhosis and AF, we recommend anticoagulation with standard-dose direct oral anticoagulants (DOACs) in accordance with cardiology guideline recommendations for patients without liver disease. In those with Child-Pugh C cirrhosis, there is inadequate evidence with respect to the benefit and risk of anticoagulation for stroke prevention in AF. In patients with cirrhosis and acute deep vein thrombosis or pulmonary embolism, we recommend anticoagulation and suggest use of either a DOAC or low-molecular-weight heparin (LMWH)/vitamin K antagonist (VKA) in Child-Pugh A or B cirrhosis and LMWH alone (or as a bridge to VKA in patients with a normal baseline international normalized ratio) in Child-Pugh C cirrhosis. We recommend anticoagulation for patients with cirrhosis and symptomatic PVT. We suggest anticoagulation for those with asymptomatic, progressing PVT and recommend continuing extended anticoagulation for liver transplant candidates with PVT.
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Affiliation(s)
- Stephanie Carlin
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alexander Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Nicolas Gendron
- University Paris Cité, Innovative Therapies in Haemostasis, National Institute for Health and Medical Research (INSERM), Paris, France; Hematology Department, Assistance Publique Hôpitaux de Paris, Centre-Université de Paris (APHP, CUP), Paris, France
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona, Barcelona, Spain; Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Karina Meijer
- Department of Haematology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Deborah M Siegal
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Simon Stanworth
- Transfusion Medicine, National Health Service Blood and Transplant, Oxford, United Kingdom; Department of Haematology, Oxford University Hospitals, National Health Service Foundation Trust, Oxford, United Kingdom; Radcliffe Department of Medicine, University of Oxford and National Institute for Health and Care Research Oxford Biomedical Research Centre (Haematology), Oxford, United Kingdom
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Lara N Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital, London, United Kingdom
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105
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Ballester MP, Abril C, Merino V, Alós M, Segarra G, Tosca J, Montón C, Casasus N, Lluch P. Atezolizumab Plus Bevacizumab Treatment for Unresectable Hepatocellular Carcinoma: Real-life Experience from a Single Tertiary Centre in Spain and ALBI Score as a Survival Prognostic Factor. CANCER DIAGNOSIS & PROGNOSIS 2024; 4:623-630. [PMID: 39238615 PMCID: PMC11372697 DOI: 10.21873/cdp.10373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 05/29/2024] [Accepted: 06/12/2024] [Indexed: 09/07/2024]
Abstract
Background/Aim Atezolizumab/bevacizumab (atez/bev) has been established as first-line systemic treatment for hepatocellular carcinoma (HCC). However, concerns regarding safety and efficacy have been raised, and no biomarkers to predict response have yet been identified. We aimed to evaluate the real-life experience of atez/bev in a Spanish tertiary hospital and identify factors associated with overall survival (OS). Patients and Methods A prospective study of consecutive patients with HCC treated with atez/bev was conducted from December 2020 to December 2022. Efficacy was assessed through OS and progression-free survival (PFS), whereas safety was evaluated based on adverse events (AE). Twenty-three patients were included; 91% were males with a mean of 70 years. Thirteen patients were classified as having BCLC-C. Results The median treatment duration was 126 days (range=567). Median OS was 381 days (95%CI=205-557) with a cumulative probability of death of 13%, 30%, and 49% at 3, 6 and 12-month follow-up, respectively. The only factor associated with OS was the ALBI score (HR=5.03; 95%CI=1.3-19.1), which showed an AUROC of 0.906 (95%CI=0.78-1.00) for the risk of death at 18 months follow up. Median PFS was 141 days (95%CI=110-172). Twenty (86.9%) patients experienced AE, which in nine (39.1%) cases led to the definitive discontinuation of the treatment, four of them (17.4%) due to an AE grade 5. Conclusion The initial experience with atez/bev at our center demonstrated poorer outcomes compared to the original trial (IMbrave150). A careful assessment of the ALBI score may serve as a crucial factor in the selection of systemic treatment for patients with HCC.
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Affiliation(s)
- María Pilar Ballester
- Servicio de Medicina Digestiva, Hospital Clínico Universitario, Valencia, Spain
- Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Carlos Abril
- Servicio de Medicina Digestiva, Hospital Clínico Universitario, Valencia, Spain
| | - Víctor Merino
- Servicio de Medicina Digestiva, Hospital Clínico Universitario, Valencia, Spain
| | - Manuel Alós
- Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
- Servicio de Farmacia, Hospital Clínico Universitario, Valencia, Spain
| | - Gloria Segarra
- Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
- Departamento de Fisiología, Universidad de Valencia, Valencia, Spain
| | - Joan Tosca
- Servicio de Medicina Digestiva, Hospital Clínico Universitario, Valencia, Spain
- Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Cristina Montón
- Servicio de Medicina Digestiva, Hospital Clínico Universitario, Valencia, Spain
- Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Nuria Casasus
- Servicio de Medicina Digestiva, Hospital Clínico Universitario, Valencia, Spain
| | - Paloma Lluch
- Servicio de Medicina Digestiva, Hospital Clínico Universitario, Valencia, Spain
- Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
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Drolz A. [Bleeding in liver diseases]. Med Klin Intensivmed Notfmed 2024; 119:458-464. [PMID: 39138654 DOI: 10.1007/s00063-024-01167-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 07/08/2024] [Indexed: 08/15/2024]
Abstract
Bleeding events are feared complications in patients with advanced liver diseases and are associated with morbidity and mortality. In this context, gastrointestinal bleeding, particularly upper gastrointestinal bleeding, has a special clinical importance. In addition to endoscopic measures for hemostasis, reducing portal pressure in particular is a key component of treatment. Although the standard coagulation parameters are often altered in patients with liver diseases, optimizing coagulation plays a secondary role. Typically, a bundle of measures are employed in patients with portal hypertensive bleeding, which nowadays in most cases can halt the bleeding and stabilize the situation. The measures include endoscopy, antibiotic treatment, vasopressor treatment and, if necessary, shunt placement (transjugular intrahepatic portosystemic shunt).
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Affiliation(s)
- Andreas Drolz
- I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
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107
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Rivera-Esteban J, Muñoz-Martínez S, Higuera M, Sena E, Bermúdez-Ramos M, Bañares J, Martínez-Gomez M, Cusidó MS, Jiménez-Masip A, Francque SM, Tacke F, Minguez B, Pericàs JM. Phenotypes of Metabolic Dysfunction-Associated Steatotic Liver Disease-Associated Hepatocellular Carcinoma. Clin Gastroenterol Hepatol 2024; 22:1774-1789.e8. [PMID: 38604295 DOI: 10.1016/j.cgh.2024.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 03/02/2024] [Accepted: 03/06/2024] [Indexed: 04/13/2024]
Abstract
Hepatocellular carcinoma (HCC) typically develops as a consequence of liver cirrhosis, but HCC epidemiology has evolved drastically in recent years. Metabolic dysfunction-associated steatotic liver disease (MASLD), including metabolic dysfunction-associated steatohepatitis, has emerged as the most common chronic liver disease worldwide and a leading cause of HCC. A substantial proportion of MASLD-associated HCC (MASLD-HCC) also can develop in patients without cirrhosis. The specific pathways that trigger carcinogenesis in this context are not elucidated completely, and recommendations for HCC surveillance in MASLD patients are challenging. In the era of precision medicine, it is critical to understand the processes that define the profiles of patients at increased risk of HCC in the MASLD setting, including cardiometabolic risk factors and the molecular targets that could be tackled effectively. Ideally, defining categories that encompass key pathophysiological features, associated with tailored diagnostic and treatment strategies, should facilitate the identification of specific MASLD-HCC phenotypes. In this review, we discuss MASLD-HCC, including its epidemiology and health care burden, the mechanistic data promoting MASLD, metabolic dysfunction-associated steatohepatitis, and MASLD-HCC. Its natural history, prognosis, and treatment are addressed specifically, as the role of metabolic phenotypes of MASLD-HCC as a potential strategy for risk stratification. The challenges in identifying high-risk patients and screening strategies also are discussed, as well as the potential approaches for MASLD-HCC prevention and treatment.
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Affiliation(s)
- Jesús Rivera-Esteban
- Liver Unit, Department of Internal Medicine, Vall d'Hebron University Hospital, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sergio Muñoz-Martínez
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain
| | - Mónica Higuera
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Elena Sena
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - María Bermúdez-Ramos
- Liver Unit, Department of Internal Medicine, Vall d'Hebron University Hospital, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain; Liver Unit, Department of Digestive Diseases, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Juan Bañares
- Liver Unit, Department of Internal Medicine, Vall d'Hebron University Hospital, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - María Martínez-Gomez
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - M Serra Cusidó
- Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Alba Jiménez-Masip
- Liver Unit, Department of Internal Medicine, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Sven M Francque
- Department of Gastroenterology Hepatology, Antwerp University Hospital, Edegem, Belgium; InflaMed Centre of Excellence, Laboratory for Experimental Medicine and Paediatrics, Translational Sciences in Inflammation and Immunology, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Beatriz Minguez
- Liver Unit, Department of Internal Medicine, Vall d'Hebron University Hospital, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Centros de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, Spain.
| | - Juan M Pericàs
- Liver Unit, Department of Internal Medicine, Vall d'Hebron University Hospital, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain; Centros de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Madrid, Spain.
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O'Rourke J, Todd A, Shekhar C, Forde C, Pallan A, Wadhwani S, Tripathi D, Mahon BS. EUS-guided thrombin injection and coil implantation for gastric varices: feasibility, safety, and outcomes. Gastrointest Endosc 2024; 100:549-556. [PMID: 38316226 DOI: 10.1016/j.gie.2024.01.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 01/07/2024] [Accepted: 01/28/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND AND AIMS Gastric varices (GVs) are reported in up to 20% of patients with portal hypertension, and bleeding is often more severe and challenging than esophageal variceal bleeding. Data are limited on prophylaxis of GV bleeding or management in the acute setting, and different techniques are used. This study evaluated outcomes after EUS-guided placement of coils in combination with thrombin to manage GVs. METHODS We retrospectively reviewed all patients treated with combination EUS-guided therapy with coils and thrombin between October 2015 and February 2020. RESULTS Twenty patients underwent 33 procedures for GV therapy; 16 of 20 (80%) had type 1 isolated GVs and 4 patients had type 2 gastroesophageal varices. The median follow-up was 842 days (interquartile range [IQR], 483-961). Seventeen patients (85%) had underlying cirrhosis, the most common etiologies being alcohol-related liver disease and nonalcoholic steatohepatitis. The median Child-Pugh score was 6 (IQR, 5-7). In 11 patients (55%), the indication was secondary prophylaxis to prevent recurrent bleeding; in 2 of 20 patients (10%), the bleeding was acute. Technical success was achieved in 19 patients (95%). During follow-up, the obliteration of flow within the varices was achieved in 17 patients (85%). The 6-week survival rate was 100%, and 2 adverse events, recurrent bleeding at day 5 and at day 37, were reported; both recurrent bleeding events were successfully managed endoscopically. CONCLUSIONS EUS-guided GV obliteration combining coil placement with thrombin, in our experience, was technically safe with good medium-term efficacy. A multicenter randomized controlled trial comparing different treatment strategies is desirable to understand options better.
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Affiliation(s)
- Joanne O'Rourke
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Andrew Todd
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Chander Shekhar
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Colm Forde
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Arvind Pallan
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Sharan Wadhwani
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Brinder Singh Mahon
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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Sultanik P, Kheloufi L, Leproux A, Bouzbib C, Mouri S, Santiago A, Galanaud D, Navarro V, Sakka M, Rudler M, Weiss N, Thabut D. Other causes of neurocognitive impairment than covert hepatic encephalopathy (CHE) are very frequent, either alone or associated with CHE, in cirrhotic patients with cognitive complaints. Aliment Pharmacol Ther 2024; 60:749-764. [PMID: 38973133 DOI: 10.1111/apt.18148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 05/27/2024] [Accepted: 06/22/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND/AIMS Although it is well admitted that cirrhotic patients display various causes of neurocognitive impairment (NI) hampering the diagnosis of covert hepatic encephalopathy (CHE), those are almost never investigated per se. The aims of this study were, in cirrhotic patients displaying cognitive complaints explored by a complete multimodal work-up, to assess: (1) the prevalence of CHE and/or that of other causes of NI and (2) their outcomes, according to the cause of NI. METHODS Prospective cohort of cirrhotic patients referred in a dedicated clinic because of cognitive complaints. Work-up included a complete neuropsychological assessment, electroencephalogram (EEG) and brain magnetic resonance imaging with spectroscopy. The diagnosis of CHE was made by an adjudication committee involving the physicians/neuropsychologist. RESULTS One hundred and twenty-three patients were included (alcohol/MASLD/virus in 63/53/14%, MELD = 11). Sixty-six per cent of them were diagnosed with CHE; among them, 73% exhibited also other causes of NI, mainly cerebrovascular diseases/psychiatric. Among patients without CHE, 48% and 59% displayed pathological Psychometric Hepatic Encephalopathy Score and animal naming test, respectively. Clinical improvement was observed in 77% of the patients re-evaluated after specific management. CHE, but not the other causes of NI, was independently associated with OHE occurrence. CONCLUSION Other causes of NI than CHE are frequent in patients with cirrhosis, and not ruled-out by the classical tests dedicated to CHE. Prognosis was influenced by the cause of NI. The management of patients even without CHE led to clinical improvement, underlining the need for a multifaceted approach of cirrhotic patients with cognitive complaints.
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Affiliation(s)
- Philippe Sultanik
- Liver Intensive Care Unit, Hepatogastroenterology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Lyes Kheloufi
- Liver Intensive Care Unit, Hepatogastroenterology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
- INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, biliaires et fibro-inflammatoire du foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Apolline Leproux
- Liver Intensive Care Unit, Hepatogastroenterology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Charlotte Bouzbib
- Liver Intensive Care Unit, Hepatogastroenterology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Sarah Mouri
- Liver Intensive Care Unit, Hepatogastroenterology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Antoine Santiago
- Liver Intensive Care Unit, Hepatogastroenterology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
| | - Damien Galanaud
- Neuroradiology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Vincent Navarro
- Neurology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Mehdi Sakka
- Biochemistry Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Marika Rudler
- Liver Intensive Care Unit, Hepatogastroenterology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
- INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, biliaires et fibro-inflammatoire du foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Nicolas Weiss
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
- INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, biliaires et fibro-inflammatoire du foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
- Neurology Intensive Care Unit, Neurology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
| | - Dominique Thabut
- Liver Intensive Care Unit, Hepatogastroenterology Department, La Pitié-Salpêtrière Hospital, AP-HP, Sorbonne Université, Paris, France
- Brain-Liver Pitié-Salpêtrière Study Group (BLIPS), Paris, France
- INSERM UMR_S 938, Centre de recherche Saint-Antoine, Maladies métaboliques, biliaires et fibro-inflammatoire du foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
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Li M, Lin Y, Yu H, Lin W, Chen J, Yang Y, Wu B. The steatosis-associated fibrosis estimator (SAFE) outperformed the FIB-4 score in screening the population for liver disease. Ann Hepatol 2024; 29:101516. [PMID: 38851395 DOI: 10.1016/j.aohep.2024.101516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 03/18/2024] [Accepted: 04/19/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION AND OBJECTIVES Assessing fibrosis risk noninvasively is essential. The steatosis-associated fibrosis estimator (SAFE) score shows promise but needs validation. PATIENTS AND METHODS This was a three-part study. In part 1, we compared the SAFE score with the Fibrosis-4 (FIB-4) and NAFLD fibrosis score (NFS) in the National Health and Nutrition Examination Survey (NHANES) cohort (2017-2020), using transient elastography (TE) as screening reference. In part 2, we examined patients who underwent liver biopsies at an Asian center between 2018 and 2020 to assess these models in various liver diseases. In part 3, the SAFE score was applied to adults in the NHANES cohort (1999-2016) to assess the correlation with mortality. RESULTS In part 1, we studied 6,677 patients, comprising 595 screening positive (TE ≥8 kPa). SAFE (cutoff 100) displayed a lower proportion of false positives (10.4 %) than FIB-4 (cutoff 1.3) and NFS (cutoff -1.455) (22.1 % and 43.6 %) while retaining a low proportion of false negatives (5.5 %). In part 2, SAFE outperformed FIB-4 (P = 0.04) and NFS (P = 0.04) in staging significant fibrosis (≥S2) in NAFLD and had similar accuracies in other etiologies. In part 3, the FIB-4, NFS, and SAFE score were associated with all-cause mortality in the general population, with c-statistics of 0.738, 0.736, and 0.759, respectively. CONCLUSIONS The SAFE score reduced futile referrals more effectively than FIB-4 without raising the missed TE ≥ 8 kPa rate. It correlated with all-cause mortality in the general population and excelled in staging significant fibrosis in NAFLD.
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Affiliation(s)
- Mingkai Li
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, People's Republic of China
| | - Ying Lin
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, People's Republic of China
| | - Hongsheng Yu
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, People's Republic of China
| | - Weichun Lin
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, People's Republic of China
| | - Jianning Chen
- Department of Pathology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, People's Republic of China
| | - Yidong Yang
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, People's Republic of China
| | - Bin Wu
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, People's Republic of China.
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Lee BP, Witkiewitz K, Mellinger J, Anania FA, Bataller R, Cotter TG, Curtis B, Dasarathy S, DeMartini KS, Diamond I, Diazgranados N, DiMartini AF, Falk DE, Fernandez AC, German MN, Kamath PS, Kidwell KM, Leggio L, Litten R, Louvet A, Lucey MR, McCaul ME, Sanyal AJ, Singal AK, Sussman NL, Terrault NA, Thursz MR, Verna EC, Radaeva S, Nagy LE, Mitchell MC. Designing clinical trials to address alcohol use and alcohol-associated liver disease: an expert panel Consensus Statement. Nat Rev Gastroenterol Hepatol 2024; 21:626-645. [PMID: 38849555 DOI: 10.1038/s41575-024-00936-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 06/09/2024]
Abstract
Most patients with alcohol-associated liver disease (ALD) engage in heavy drinking defined as 4 or more drinks per day (56 g) or 8 (112 g) or more drinks per week for women and 5 or more drinks per day (70 g) or 15 (210 g) or more drinks per week for men. Although abstinence from alcohol after diagnosis of ALD improves life expectancy and reduces the risk of decompensation of liver disease, few studies have evaluated whether treatment of alcohol use disorders will reduce progression of liver disease and improve liver-related outcomes. In November 2021, the National Institute of Alcohol Abuse and Alcoholism commissioned a task force that included hepatologists, addiction medicine specialists, statisticians, clinical trialists and members of regulatory agencies to develop recommendations for the design and conduct of clinical trials to evaluate the effect of alcohol use, particularly treatment to reduce or eliminate alcohol use in patients with ALD. The task force conducted extensive reviews of relevant literature on alcohol use disorders and ALD. Findings were presented at one in-person meeting and discussed over the next 16 months to develop the final recommendations. As few clinical trials directly address this topic, the 28 recommendations approved by all members of the task force represent a consensus of expert opinions.
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Affiliation(s)
- Brian P Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine and Institute for Addiction Science, University of Southern California, Los Angeles, CA, USA
| | - Katie Witkiewitz
- Center on Alcohol, Substance use and Addictions, University of New Mexico, Albuquerque, NM, USA
| | - Jessica Mellinger
- Department of Internal Medicine, Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, USA
| | - Frank A Anania
- Division of Hepatology and Nutrition, US Food and Drug Administration, Silver Spring, MD, USA
| | - Ramon Bataller
- Liver Unit, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Thomas G Cotter
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brenda Curtis
- Technology and Translational Research Unit, Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, USA
| | - Srinivasan Dasarathy
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Kelly S DeMartini
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | | | - Nancy Diazgranados
- Office of the Clinical Director, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Andrea F DiMartini
- Departments of Psychiatry and Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Daniel E Falk
- Medications Development Branch, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | | | - Margarita N German
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Kelley M Kidwell
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Lorenzo Leggio
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism Division of Intramural Clinical and Biological Research, National Institutes of Health, Baltimore, MD, USA
| | - Raye Litten
- Division of Treatment and Recovery, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Alexandre Louvet
- Service des maladies de l'appareil digestif, University Hospital of Lille, Lille, France
- Unité INSERM INFINITE, Lille, France
| | - Michael R Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Mary E McCaul
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Arun J Sanyal
- Stravitz-Sanyal Institute for Liver Disease and Metabolic Health, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Ashwani K Singal
- Department of Medicine, Division of Gastroenterology Hepatology and Nutrition, University of Louisville School of Medicine, Louisville, KY, USA
- Department of Medicine, Robley Rex VA Medical Center, Louisville, KY, USA
| | - Norman L Sussman
- DURECT Corporation, Cupertino, CA, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Norah A Terrault
- Division of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine and Institute for Addiction Science, University of Southern California, Los Angeles, CA, USA
| | - Mark R Thursz
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Elizabeth C Verna
- Division of Digestive and Liver Diseases, Columbia University, New York, NY, USA
| | - Svetlana Radaeva
- Svetlana Radaeva, Division of Metabolism and Health Effects, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Laura E Nagy
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Mack C Mitchell
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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112
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Tacke F, Horn P, Wai-Sun Wong V, Ratziu V, Bugianesi E, Francque S, Zelber-Sagi S, Valenti L, Roden M, Schick F, Yki-Järvinen H, Gastaldelli A, Vettor R, Frühbeck G, Dicker D. EASL-EASD-EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). J Hepatol 2024; 81:492-542. [PMID: 38851997 DOI: 10.1016/j.jhep.2024.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 04/30/2024] [Indexed: 06/10/2024]
Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed non-alcoholic fatty liver disease (NAFLD), is defined as steatotic liver disease (SLD) in the presence of one or more cardiometabolic risk factor(s) and the absence of harmful alcohol intake. The spectrum of MASLD includes steatosis, metabolic dysfunction-associated steatohepatitis (MASH, previously NASH), fibrosis, cirrhosis and MASH-related hepatocellular carcinoma (HCC). This joint EASL-EASD-EASO guideline provides an update on definitions, prevention, screening, diagnosis and treatment for MASLD. Case-finding strategies for MASLD with liver fibrosis, using non-invasive tests, should be applied in individuals with cardiometabolic risk factors, abnormal liver enzymes, and/or radiological signs of hepatic steatosis, particularly in the presence of type 2 diabetes (T2D) or obesity with additional metabolic risk factor(s). A stepwise approach using blood-based scores (such as FIB-4) and, sequentially, imaging techniques (such as transient elastography) is suitable to rule-out/in advanced fibrosis, which is predictive of liver-related outcomes. In adults with MASLD, lifestyle modification - including weight loss, dietary changes, physical exercise and discouraging alcohol consumption - as well as optimal management of comorbidities - including use of incretin-based therapies (e.g. semaglutide, tirzepatide) for T2D or obesity, if indicated - is advised. Bariatric surgery is also an option in individuals with MASLD and obesity. If locally approved and dependent on the label, adults with non-cirrhotic MASH and significant liver fibrosis (stage ≥2) should be considered for a MASH-targeted treatment with resmetirom, which demonstrated histological effectiveness on steatohepatitis and fibrosis with an acceptable safety and tolerability profile. No MASH-targeted pharmacotherapy can currently be recommended for the cirrhotic stage. Management of MASH-related cirrhosis includes adaptations of metabolic drugs, nutritional counselling, surveillance for portal hypertension and HCC, as well as liver transplantation in decompensated cirrhosis.
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Kwanten WJ, Hofer BS, Francque S. Reply to: "MetALD accounts for a large part of what we call MASLD!". J Hepatol 2024:S0168-8278(24)02498-X. [PMID: 39218227 DOI: 10.1016/j.jhep.2024.08.020] [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: 08/23/2024] [Accepted: 08/23/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Wilhelmus J Kwanten
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium; Laboratory of Experimental Medicine and Pediatrics (LEMP), Division of Gastroenterology-Hepatology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Benedikt Silvester Hofer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Sven Francque
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium; Laboratory of Experimental Medicine and Pediatrics (LEMP), Division of Gastroenterology-Hepatology, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
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114
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Roulot D, Brichler S, Layese R, D'alteroche L, Ganne-Carrie N, Stern C, Saviano A, Leroy V, Roudot-Thoraval F, De Ledinghen V. High Diagnostic Value of Transient Elastography for Advanced Fibrosis and Cirrhosis in Patients With Chronic Hepatitis Delta. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00776-6. [PMID: 39209196 DOI: 10.1016/j.cgh.2024.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 07/17/2024] [Accepted: 08/13/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND & AIMS Liver biopsy remains the gold standard for fibrosis staging in patients with chronic hepatitis delta (CHD). Here, we comparatively evaluated the performance of transient elastography (TE) and biomarkers for the diagnosis of liver fibrosis in patients with CHD. METHODS A total of 230 HDV-infected RNA-positive patients from various centers who underwent liver biopsy and liver stiffness measurements (LSMs) using Fibroscan, within a period of 6 months maximum, were investigated retrospectively. Area under the receiver operating characteristic curve and Youden index were used to establish cutoff values of LSM. TE was compared with other noninvasive tests: aspartate aminotransferase to platelet ratio index, Fibrosis-4, and Delta-4 fibrosis scores. RESULTS Histologic fibrosis stage distribution was: 20.4% for F0-F1; 27.0% for F2; 18.7% for F3; and 33.9% for F4. TE demonstrated good diagnostic performance for detecting cirrhosis and advanced fibrosis with an Area under the receiver operating characteristic curve of 0.88 and 0.86, which were significantly higher than those obtained with the other noninvasive tests (P = .004 and P < .001). With a cutoff value of >12 kPa for cirrhosis, the sensitivity was 70.5%, specificity was 86.2%, positive predictive value was 72.4%, negative predictive value was 85.1%, and accuracy was 80.9%. Using 10.4 kPa as the cutoff value for F3, the sensitivity was 70.2%, specificity was 83.5%, positive predictive value was 82.5%, negative predictive value was 71.7%, and accuracy was 76.5%. In 89% of patients with LSM ≤6.2 kPa, liver biopsy disclosed only absent or minimal fibrosis. CONCLUSION TE demonstrated good diagnostic performance for advanced fibrosis and cirrhosis in patients with CHD. Advanced fibrosis is highly probable for LSM values ≥10 kPa. LSM values <6 kPa almost totally exclude significant fibrosis. Between 6 and 10 kPa, liver biopsy should be discussed.
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Affiliation(s)
- Dominique Roulot
- AP-HP, Hôpital Avicenne, Unité d'Hépatologie, Bobigny; Université Sorbonne Paris Nord, Bobigny; Inserm U955, Equipe 18, Université Paris-Est, Créteil, France.
| | - Ségolène Brichler
- AP-HP, Hôpital Avicenne, Laboratoire de Microbiologie Clinique; Université Sorbonne Paris Nord, Centre National de Référence des Hépatites B, C et Delta, Bobigny, Inserm U955, Equipe 18, Université Paris-Est, Créteil, France
| | - Richard Layese
- Université Paris-Est Créteil, INSERM, IMRB, CEpiA (Clinical Epidemiology and Ageing Unit) Team, Créteil; AP-HP, Hôpital Henri-Mondor, Unité de Recherche Clinique (URC Mondor), Créteil, France
| | | | - Nathalie Ganne-Carrie
- AP-HP, Hôpital Avicenne, Service d'Hépatologie, Bobigny; Université Sorbonne Paris Nord, Bobigny; INSERM U1138, Université de Paris, France
| | | | - Antonio Saviano
- Pôle Hépato-digestif, University Hospital, Strasbourg; Inserm U110, Strasbourg, France
| | - Vincent Leroy
- AP-HP, Hôpital Henri-Mondor, Service d'Hépatologie, Créteil; Inserm U955, Equipe 18, Université Paris-Est, Créteil, France
| | - Françoise Roudot-Thoraval
- Université Paris-Est Créteil, INSERM, IMRB, CEpiA (Clinical Epidemiology and Ageing Unit) Team, Créteil; AP-HP, Hôpital Henri-Mondor, Unité de Recherche Clinique (URC Mondor), Créteil, France
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Tie J, Yuan X, Liu Z, Gou X, Zhu Y, Niu J, Xu J, Yue S, Shi Y. Transjugular mesenteric-caval shunt for portal vein cavernous transformation with recurrent variceal bleeding: preliminary results. Eur Radiol 2024:10.1007/s00330-024-11041-7. [PMID: 39214895 DOI: 10.1007/s00330-024-11041-7] [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: 04/09/2024] [Revised: 06/30/2024] [Accepted: 08/07/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVES This study aimed to evaluate the feasibility, safety, and efficacy of the transjugular mesenteric-caval shunt (TMCS) as a treatment for the cavernous transformation of the portal vein (CTPV) and recurrent variceal bleeding. METHODS This retrospective case series was conducted with approval from the institutional review board. It involved seven patients diagnosed with CTPV and recurrent variceal bleeding who underwent the TMCS procedure. We analyzed the rate of procedural complications, incidents of rebleeding, stent stenosis, hepatic encephalopathy, and overall survival to assess treatment outcomes. RESULTS The TMCS was successfully performed in all seven patients without any life-threatening complications. Postoperatively, one patient developed a lung infection and pleural effusion, which resolved with appropriate treatment. Additionally, two patients experienced an increase in total bilirubin levels, but there was no further deterioration in liver function. The median portal pressure gradient significantly decreased from a preoperative value of 27 mmHg (range 20-36 mmHg) to a postoperative value of 6 mmHg (range 4-11 mmHg). A notable improvement was observed in one cirrhotic patient, with liver function progressing from Child-Pugh class B (score 9) to class A (score 6). Over a median follow-up period of 14 months (range 7-18 months), none of the patients encountered rebleeding, stent stenosis, hepatic encephalopathy, or mortality. CONCLUSION The TMCS appears to be a viable and effective alternative for managing CTPV with recurrent variceal bleeding. Its long-term outcome requires further evaluation. CLINICAL RELEVANCE STATEMENT TMCS provides a promising treatment for patients with life-threatening CTPV complications when occluded portal vein cannot be recanalized and portal vein recanalization TIPS is not an option. KEY POINTS Performing TIPS in patients with portal vein cavernoma is complex due to the requirement for recanalization of the occluded portal vein. Creating a mesenteric-caval shunt through a transjugular approach is a feasible technique. Establishing a TMCS provides a means to manage life-threatening complications arising from portal vein cavernoma.
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Affiliation(s)
- Jun Tie
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Air Force Medical University, Xi'an, China.
| | - Xulong Yuan
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Air Force Medical University, Xi'an, China
| | - Zhengcai Liu
- Department of General Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Xiaoyuan Gou
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Air Force Medical University, Xi'an, China
| | - Ying Zhu
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Air Force Medical University, Xi'an, China
| | - Jing Niu
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Air Force Medical University, Xi'an, China
| | - Jiao Xu
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Air Force Medical University, Xi'an, China
| | - Shuqiang Yue
- Department of General Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Yongquan Shi
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Air Force Medical University, Xi'an, China.
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Anis MA, Majeed AA, Abid S. Road to recompensation: Baveno VII criteria and transjugular intrahepatic portosystemic shunt in liver cirrhosis. World J Gastroenterol 2024; 30:3743-3747. [PMID: 39221069 PMCID: PMC11362878 DOI: 10.3748/wjg.v30.i32.3743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 07/15/2024] [Accepted: 07/29/2024] [Indexed: 08/26/2024] Open
Abstract
Liver cirrhosis has long been considered a point of no return, with limited hope for recovery. However, recent advancements, particularly the Baveno VII criteria and the utilization of transjugular intrahepatic portosystemic shunt (TIPS), have illuminated the concept of hepatic recompensation. In this editorial we comment on the article by Gao et al published in the recent issue. This editorial provides a comprehensive overview of the evolution of understanding cirrhosis, the criteria for recompensation, and the efficacy of TIPS in achieving recompensation. We discuss key findings from recent studies, including the promising outcomes observed in patients who achieved recompensation post-TIPS insertion. While further research is needed to validate these findings and elucidate the mech-anisms underlying recompensation, the insights presented here offer renewed hope for patients with decompensated cirrhosis and highlight the potential of TIPS as a therapeutic option in their management.
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Affiliation(s)
- Muhammad Aarish Anis
- Department of Medicine, Section of Gastroenterology, Aga Khan University Hospital, Sindh, Karachi 74800, Pakistan
| | - Ammara Abdul Majeed
- Department of Medicine, Section of Gastroenterology, Aga Khan University Hospital, Sindh, Karachi 74800, Pakistan
| | - Shahab Abid
- Department of Medicine, Section of Gastroenterology, Aga Khan University Hospital, Sindh, Karachi 74800, Pakistan
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117
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Zhang JS. Hepatic recompensation according to the Baveno VII criteria via a transjugular intrahepatic portosystemic shunt: Is this true? World J Gastrointest Surg 2024; 16:2742-2744. [PMID: 39220088 PMCID: PMC11362940 DOI: 10.4240/wjgs.v16.i8.2742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 07/10/2024] [Accepted: 07/15/2024] [Indexed: 08/16/2024] Open
Abstract
Hepatic recompensation is firstly described in the Baveno VII criteria, which requires the fulfillment of strict criteria. First, a primary cause of cirrhosis must be addressed, suppressed, or cured. Second, complications of liver cirrhosis, including ascites, encephalopathy, and variceal hemorrhage, must disappear without any intervention. Finally, liver function indicators must be improved. Moreover, without addressing/suppressing/curing cirrhosis and improvement in liver synthetic function, complications, including ascites and variceal hemorrhage can be improved by a transjugular intrahepatic portosystemic shunt (TIPS), which is not evidence of hepatic recompensation. Therefore, on the basis of the definition of hepatic recompensation, TIPS does not achieve hepatic recompensation.
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Affiliation(s)
- Jin-Shan Zhang
- Department of General Surgery, Capital Institute of Pediatrics, Beijing 100020, China
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118
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Mak LY, Hui RWH, Chung MSH, Wong DKH, Fung J, Seto WK, Yuen MF. Regression of liver fibrosis after HBsAg loss: A prospective matched case-control evaluation using transient elastography and serum enhanced liver fibrosis test. J Gastroenterol Hepatol 2024. [PMID: 39188082 DOI: 10.1111/jgh.16728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 07/13/2024] [Accepted: 08/09/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND AND AIM We assessed the effect of hepatitis B surface antigen (HBsAg) seroclearance (HBsAg-loss) on liver fibrosis regression in patients with chronic hepatitis B (CHB) infection. METHOD CHB patients with recent documented HBsAg-loss were age- and gender-matched with treatment-naïve HBeAg-negative CHB infection. Paired assessment with transient elastography and enhanced liver fibrosis (ELF) measurements were performed and repeated at 3 years. Fibrosis regression was arbitrarily defined as decrease in ≥ 1 fibrosis stage by ELF, or combining with reduction > 30% in liver stiffness. RESULTS A total of 142 HBsAg-loss and 142 CHB subjects were recruited (median age 58.1 years, 51.4% male). A total of 1.8% (1.4% HBsAg-loss vs 2.1% CHB) achieved combined endpoint of fibrosis regression at 3 years. When ELF-only definition of fibrosis regression was used, 14.5% HBsAg-loss and 16.9% CHB subjects achieved this endpoint, which was significantly associated with baseline ELF (hazard ratio (HR) 1.827, 95% confidence interval (CI) 1.085-3.075) and time since HBsAg-loss (HR 2.688, 95% CI 1.257-5.748). While increasing time since HBsAg-loss increased the proportion of ELF-defined fibrosis regression, increasing age was also associated with significant fibrosis. Age of achieving HBsAg-loss (ageSC) was independently associated with high baseline ELF values. Up to 52.3% and 63.8% subjects with ageSC > 50 had advanced fibrosis/cirrhosis at baseline and 3 years, respectively, compared with 5.9% and 20.6% in subjects with ageSC < 50. CONCLUSION Fibrosis regression occurred in a minority of subjects achieving HBsAg-loss, which was not significantly different compared with subjects with persistent overt CHB. Subjects after achieving HBsAg-loss, especially among those with ageSC > 50, should receive ongoing surveillance for liver-related complications.
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Affiliation(s)
- Lung-Yi Mak
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Liver Research, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Rex Wan-Hin Hui
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Matthew S H Chung
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Danny Ka-Ho Wong
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Liver Research, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - James Fung
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Liver Research, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Liver Research, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Liver Research, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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119
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Roberts LN, Thachil J. Prevention and management of venous thrombosis in patients with cirrhosis. Br J Haematol 2024. [PMID: 39186931 DOI: 10.1111/bjh.19734] [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: 06/21/2024] [Accepted: 08/14/2024] [Indexed: 08/28/2024]
Abstract
Venous thromboembolism (VTE), particularly portal vein thrombosis, is common in patients with cirrhosis. Misconceptions around the increased bleeding risk in this patient group may lead to delayed and/or inadequate anticoagulation. This nutshell review focusses on the approach to management including the role of direct oral anticoagulants in the treatment of VTE in patients with cirrhosis.
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Affiliation(s)
- Lara N Roberts
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital NHS Foundation Hospital, London, UK
- Institute of Pharmaceutical Sciences, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
- MAHSC Professor, The University of Manchester, Manchester, UK
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120
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Gananandan K, Singh R, Mehta G. Systematic review and meta-analysis of biomarkers predicting decompensation in patients with compensated cirrhosis. BMJ Open Gastroenterol 2024; 11:e001430. [PMID: 39182920 PMCID: PMC11404266 DOI: 10.1136/bmjgast-2024-001430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 08/06/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND AND AIMS The transition from compensated to decompensated cirrhosis is crucial, drastically reducing prognosis from a median survival of over 10 years to 2 years. There is currently an unmet need to accurately predict decompensation. We systematically reviewed and meta-analysed data regarding biomarker use to predict decompensation in individuals with compensated cirrhosis. METHODS PubMed and EMBASE database searches were conducted for all studies from inception until February 2024. The study was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Quality of Prognosis Studies framework was used to assess the risk of bias. The meta-analysis was conducted with a random effects model using STATA software. RESULTS Of the 652 studies initially identified, 63 studies (n=31 438 patients) were included in the final review, examining 49 biomarkers. 25 studies (40%) were prospective with the majority of studies looking at all-cause decompensation (90%). The most well-studied biomarkers were platelets (n=17), Model for End-Stage Liver Disease (n=17) and albumin (n=16). A meta-analysis revealed elevated international normalised ratio was the strongest predictor of decompensation, followed by decreased albumin. However, high statistical heterogeneity was noted (l2 result of 96.3%). Furthermore, 21 studies were assessed as having a low risk of bias (34%), 26 (41%) moderate risk and 16 (25%) high risk. CONCLUSIONS This review highlights key biomarkers that should potentially be incorporated into future scoring systems to predict decompensation. However, future biomarker studies should be conducted with rigorous and standardised methodology to ensure robust and comparable data.
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Affiliation(s)
| | - Rabiah Singh
- UCL Institute for Liver & Digestive Health, London, UK
| | - Gautam Mehta
- UCL Institute for Liver & Digestive Health, London, UK
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121
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Premkumar M, Dhiman RK, Duseja A, Mehtani R, Taneja S, Gupta E, Gupta P, Sandhu A, Sharma P, Rathi S, Verma N, Kulkarni AV, Bhujade H, Chaluvashetty SB, Kalra N, Grover GS, Nain J, Reddy KR. Recompensation of Chronic Hepatitis C-Related Decompensated Cirrhosis Following Direct-Acting Antiviral Therapy: Prospective Cohort Study From a Hepatitis C Virus Elimination Program. Gastroenterology 2024:S0016-5085(24)05359-9. [PMID: 39181168 DOI: 10.1053/j.gastro.2024.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 07/04/2024] [Accepted: 08/14/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND & AIMS Chronic hepatitis C-related decompensated cirrhosis is associated with lower sustained virologic response (SVR)-12 rates and variable regression of disease severity after direct-acting antiviral agents. We assessed rates of SVR-12, recompensation (Baveno VII criteria), and survival in such patients. METHODS Between July 2018 and July 2023, patients with decompensated chronic hepatitis C-related cirrhosis after direct-acting antiviral agents treatment were evaluated for SVR-12 and then had 6-monthly follow-up. RESULTS Of 6516 patients with cirrhosis, 1152 with decompensated cirrhosis (age 53.2 ± 11.5 years; 63% men; Model for End-stage Liver Disease-Sodium [MELD-Na]: 16.5 ± 4.6; 87% genotype 3) were enrolled. SVR-12 was 81.8% after 1 course; ultimately SVR was 90.8% after additional treatment. Decompensation events included ascites (1098; 95.3%), hepatic encephalopathy (191; 16.6%), and variceal bleeding (284; 24.7%). Ascites resolved in 86% (diuretic withdrawal achieved in 24% patients). Recompensation occurred in 284 (24.7%) at a median time of 16.5 (interquartile range, 14.5-20.5) months. On multivariable Cox proportional hazards analysis, low bilirubin (aHR, 0.6; 95% confidence interval [CI], 0.5-0.8; P < 0.001), INR (aHR, 0.2; 95% CI, 0.1-0.3; P < 0.001), absence of large esophageal varices (aHR, 0.4; 95% CI, 0.2-0.9; P = 0.048), or gastric varices (aHR, 0.5; 95% CI, 0.3-0.7; P = 0.022) predicted recompensation. Portal hypertension progressed in 158 (13.7%) patients, with rebleed in 4%. Prior decompensation with variceal bleeding (aHR, 1.6; 95% CI, 1.2-2.8; P = 0.042), and presence of large varices (aHR, 2.9; 95% CI, 1.3-6.5; P < 0.001) were associated with portal hypertension progression. Further decompensation was seen in 221 (19%); 145 patients died and 6 underwent liver transplantation. A decrease in MELDNa of ≥3 was seen in 409 (35.5%) and a final MELDNa score of <10 was seen in 335 (29%), but 2.9% developed hepatocellular carcinoma despite SVR-12. CONCLUSIONS SVR-12 in hepatitis C virus-related decompensated cirrhosis in a predominant genotype 3 population led to recompensation in 24.7% of patients over a follow-up of 4 years in a public health setting. Despite SVR-12, new hepatic decompensation evolved in 19% and hepatocellular carcinoma developed in 2.9% of patients. (ClinicalTrials.gov, Number: NCT03488485).
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Radha K Dhiman
- Chairman, Technical Resource Group - National Viral Hepatitis Control Program, Government of India, India; Director, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rohit Mehtani
- Department of Hepatology, Amrita Institute of Medical Sciences and Research Centre, Faridabad, Haryana, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ekta Gupta
- Department of Virology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Pankaj Gupta
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anchal Sandhu
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Prerna Sharma
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahaj Rathi
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nipun Verma
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Harish Bhujade
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sreedhara B Chaluvashetty
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Naveen Kalra
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gagandeep S Grover
- Program Officer, Hepatitis C Virus Infection, Government of Punjab, Punjab, India
| | - Jasvinder Nain
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
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122
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Magaz M, Giudicelli-Lett H, Abraldes JG, Nicoară-Farcău O, Turon F, Rajoriya N, Goel A, Raymenants K, Hillaire S, Téllez L, Elkrief L, Procopet B, Orts L, Nery F, Shukla A, Larrue H, Degroote H, Aguilera V, Llop E, Turco L, Indulti F, Gioia S, Tosetti G, Bitto N, Becchetti C, Alvarado E, Roig C, Diaz R, Praktiknjo M, Konicek AL, Olivas P, Fortea JI, Masnou H, Puente Á, Ardèvol A, Navascués CA, Romero-Gutiérrez M, Scheiner B, Semmler G, Mandorfer M, Damião F, Baiges A, Ojeda A, Simón-Talero M, González-Alayón C, Díaz A, García-Criado Á, De Gottardi A, Hernández-Guerra M, Genescà J, Drilhon N, Noronha Ferreira C, Reiberger T, Rodríguez M, Morillas RM, Crespo J, Trebicka J, Bañares R, Villanueva C, Berzigotti A, Primignani M, La Mura V, Riggio O, Schepis F, Verhelst X, Calleja JL, Bureau C, Albillos A, Nevens F, Hernández-Gea V, Tripathi D, Rautou PE, García-Pagán JC. Porto-sinusoidal vascular liver disorder with portal hypertension: Natural history and long-term outcome. J Hepatol 2024:S0168-8278(24)02481-4. [PMID: 39181213 DOI: 10.1016/j.jhep.2024.07.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 07/24/2024] [Accepted: 07/30/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND & AIMS Current knowledge of the natural history of patients with porto-sinusoidal vascular disorder (PSVD) is derived from small studies. The aim of the present study was to determine the natural history of PSVD and prognostic factors in a large multicenter cohort of patients. METHODS We performed a retrospective study on patients with PSVD and signs of portal hypertension (PH) prospectively registered in 27 centers. RESULTS A total of 587 patients were included, median age of 47 years and 38% were women. Four-hundred and one patients had an associated condition, which was graded as severe in 157. Median follow-up was 68 months. At diagnosis, 64% of patients were asymptomatic while 36% had a PH-related complication: PH-related bleeding in 112 patients, ascites in 117, and hepatic encephalopathy in 11. In those not presenting with bleeding, the incidence of first bleeding was 15% at 5 years, with a 5-year rebleeding rate of 18%. The 5-year cumulative incidence of new or worsening ascites was 18% and of developing PVT was 16%. Fifty (8.5%) patients received a liver transplantation and 109 (19%) died, including 55 non-liver-related deaths. Transplant-free survival was 97% and 83% at 1 and 5 years, respectively. Variables independently associated with transplant-free survival were age, ascites, serum bilirubin, albumin and creatinine levels at diagnosis and severe associated conditions. This allowed for the creation of a nomogram that accurately predicted prognosis. CONCLUSIONS The prognosis of PSVD is strongly determined by the severity of the associated underlying conditions and parameters of liver and renal function. IMPACT AND IMPLICATIONS Porto-sinusoidal vascular liver disorder (PSVD) is a rare entity that usually affects young people, frequently causes severe complications of portal hypertension, and may reduce life expectancy. To date, there is scarce information regarding its clinical manifestations, natural history and prognostic factors. The present study, including the largest number of patients with PSVD reported so far, shows that overall, when managed at centers of expertise, the prognosis of patients with PSVD is good, with LT-free survival rates of 83% and 72% at 5 and 10 years, respectively. Presence and severity of an underlying associated condition, presence of ascites, age and bilirubin, albumin and creatinine levels were associated with poor prognosis. These results are important to know for hepatologists. A final model combining these parameters enabled development of a nomogram that predicts prognosis with good discrimination and calibration capacity and can be easily applied in clinical practice.
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Affiliation(s)
- Marta Magaz
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain
| | - Heloïse Giudicelli-Lett
- Université de Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France; AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Juan G Abraldes
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, AB, Canada
| | - Oana Nicoară-Farcău
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain
| | - Fanny Turon
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain
| | - Neil Rajoriya
- The Liver Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ashish Goel
- The Liver Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karlien Raymenants
- Department of Gastroenterology and Hepatology, University Hospital KU Leuven, Leuven, Belgium
| | - Sophie Hillaire
- Université de Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France; AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Luis Téllez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERehd, Universidad de Alcalá, Madrid, Spain
| | - Laure Elkrief
- Université de Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France; Service d'Hépato-Gastroentérologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland; Service d'Hépato-Gastroentérologie, CHU de Tours, France
| | - Bogdan Procopet
- Regional Institute of Gastroenterology and Hepatology "Octavian Fodor", Hepatology Department and "Iuliu Hatieganu" University of Medicine and Pharmacy, 3rd Medical Clinic, Cluj-Napoca, Romania
| | - Lara Orts
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain
| | - Filipe Nery
- Immuno-Physiology and Pharmacology Department, School of Medicine and Biomedical Sciences, University of Porto, Portugal
| | - Akash Shukla
- Seth GS Medical College and KEM Hospital, Sion, Mumbai, India
| | - Hélène Larrue
- Department of Hepatology, Rangueil Hospital, CHU Toulouse, University Paul Sabatier of Toulouse, France
| | - Helena Degroote
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Victoria Aguilera
- Liver Transplantation and Hepatology Unit, Hospital Universitari i Politécnic La Fe, Valencia, Spain. CIBERehd (Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Valencia Spain), Instituto de Salud Carlos III, Spain
| | - Elba Llop
- Liver Unit, Hospital U, Puerta de Hierro. Universidad Autònoma de Madrid, CIBEREHD, IDIPHISA, Madrid, Spain
| | - Laura Turco
- Department of Gastroenterology and Hepatology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy
| | - Federica Indulti
- Department of Gastroenterology and Hepatology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Giulia Tosetti
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine -Hemostasis and Thrombosis, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Niccolò Bitto
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine -Hemostasis and Thrombosis, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Chiara Becchetti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Edilmar Alvarado
- Liver Unit, Department of Gastroenterology Hospital Sant Pau, Barcelona, Autonomous University, Barcelona, Spain. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Cristina Roig
- Liver Unit, Department of Gastroenterology Hospital Sant Pau, Barcelona, Autonomous University, Barcelona, Spain. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Raquel Diaz
- Department of Gastroenterology and Hepatology, University Gregorio Marañón Hospital, liSGM, CIBERehd, Barcelona, Spain; Facultad de Medicina. Universidad Complutense de Madrid, Madrid, Spain
| | - Michael Praktiknjo
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Anna-Lena Konicek
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Pol Olivas
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain
| | - José Ignacio Fortea
- Liver Unit, Digestive Disease Department, Marqués de Valdecilla University Hospital, Santander, Cantabria University, Spain
| | - Helena Masnou
- Liver Unit, University Hospital Germans Trias i Pujol, Badalona, Spain. Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Spain
| | - Ángela Puente
- Liver Unit, Digestive Disease Department, Marqués de Valdecilla University Hospital, Santander, Cantabria University, Spain
| | - Alba Ardèvol
- Liver Unit, University Hospital Germans Trias i Pujol, Badalona, Spain. Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Spain
| | - Carmen A Navascués
- Liver Unit, Department of Gastroenterology and Hepatology, Hospital Universitario Central de Asturias, University of Oviedo, Oviedo, Spain
| | - Marta Romero-Gutiérrez
- Liver Unit, Department of Gastroenterology and Hepatology, Complejo Hospitalario Universitario de Toledo, Spain
| | - Bernhard Scheiner
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg Semmler
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Filipe Damião
- Department of Gastroenterology and Hepatology, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Anna Baiges
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain
| | - Asunción Ojeda
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain
| | - Macarena Simón-Talero
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBERehd, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos González-Alayón
- Liver Unit, Department of Gastroenterology and Hepatology, Hospital Universitario de Canarias. Tenerife, Spain
| | - Alba Díaz
- Department of Histopathology, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | | | - Andrea De Gottardi
- Dept. of Gastroenterology and Hepatology, Cantonal Hospital Lucerne, University of Lucerne, Switzerland
| | - Manuel Hernández-Guerra
- Liver Unit, Department of Gastroenterology and Hepatology, Hospital Universitario de Canarias. Tenerife, Spain
| | - Joan Genescà
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBERehd, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Nicolas Drilhon
- Université de Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France; AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Carlos Noronha Ferreira
- Department of Gastroenterology and Hepatology, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Thomas Reiberger
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Manuel Rodríguez
- Liver Unit, Department of Gastroenterology and Hepatology, Hospital Universitario Central de Asturias, University of Oviedo, Oviedo, Spain
| | - Rosa María Morillas
- Liver Unit, University Hospital Germans Trias i Pujol, Badalona, Spain. Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Spain
| | - Javier Crespo
- Liver Unit, Digestive Disease Department, Marqués de Valdecilla University Hospital, Santander, Cantabria University, Spain
| | - Jonel Trebicka
- Hepatology, Department of Internal Medicine I, Goethe University Frankfurt, Frankfurt, Germany; European Foundation for Study of Chronic Liver Failure, Barcelona, Spain
| | - Rafael Bañares
- Department of Gastroenterology and Hepatology, University Gregorio Marañón Hospital, liSGM, CIBERehd, Barcelona, Spain
| | - Càndid Villanueva
- Liver Unit, Department of Gastroenterology Hospital Sant Pau, Barcelona, Autonomous University, Barcelona, Spain. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Massimo Primignani
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine -Hemostasis and Thrombosis, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Vincenzo La Mura
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine -Hemostasis and Thrombosis, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Filippo Schepis
- Department of Gastroenterology and Hepatology, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Italy
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - José Luis Calleja
- Liver Unit, Hospital U, Puerta de Hierro. Universidad Autònoma de Madrid, CIBEREHD, IDIPHISA, Madrid, Spain
| | - Christophe Bureau
- Department of Hepatology, Rangueil Hospital, CHU Toulouse, University Paul Sabatier of Toulouse, France
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERehd, Universidad de Alcalá, Madrid, Spain
| | - Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospital KU Leuven, Leuven, Belgium
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain
| | - Dhiraj Tripathi
- The Liver Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Pierre-Emmanuel Rautou
- Université de Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France; AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Departament de Medicina i Ciències de la Salut. Universitat de Barcelona, Barcelona, Spain.
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Lv Y, Wang Q, Luo B, Bai W, Li M, Li K, Wang Z, Xia D, Guo W, Li X, Yuan J, Zhang N, Wang X, Xie H, Pan Y, Nie Y, Yin Z, Fan D, Han G. Identifying the optimal measurement timing and hemodynamic targets of portal pressure gradient after TIPS in patients with cirrhosis and variceal bleeding. J Hepatol 2024:S0168-8278(24)02485-1. [PMID: 39181214 DOI: 10.1016/j.jhep.2024.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 07/28/2024] [Accepted: 08/06/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND & AIMS The optimal timing of measurement and hemodynamic targets of portacaval pressure gradient (PPG) after transjugular intrahepatic portosystemic shunt (TIPS) placement remain unclear. This study aimed to identify the ideal moment for hemodynamic measurements and the optimal target of PPG in patients undergoing covered TIPS for variceal bleeding. METHODS Between May 2018 and December 2021, 466 consecutive patients with recurrent variceal bleeding treated with covered TIPS were prospectively included. Post-TIPS PPG was measured immediately (immediate PPG), 24-72 hours (early PPG), and again 1 month (late PPG) after TIPS placement. The agreement among PPGs measured at different time points was assessed by intra-class correlation coefficient (ICC) and Bland-Altman method. The unadjusted and confounder-adjusted effects of PPGs on clinical outcomes (portal hypertensive complications [PHCs], overt hepatic encephalopathy [OHE], further decompensation, and death) were assessed using Fine and Gray competing risk regression models. RESULTS The agreement between early PPG and late PPG (ICC: 0.34) was better than that between immediate PPG and late PPG (ICC: 0.23, p <0.001). Early PPG revealed an excellent predictive value for PHCs (early PPG≥ vs. <12 mmHg: adjusted hazard ratio 2.17, 95% CI 1.33-3.55, p = 0.002) and OHE (0.40, 95% CI 0.17-0.91, p = 0.030), while immediate PPG did not. Late PPG showed a predictive value for PHC risk but not OHE. By targeting the lowest risk of further decompensation, we identified an optimal hemodynamic target with early PPG ranging from 11 to 14 mmHg that was associated with a decreased risk of OHE and effective prevention of PHC. CONCLUSIONS PPG measured 24 to 72 hours after TIPS correlates with long-term PPG and clinical outcomes, and a hemodynamic target PPG of 11-14 mmHg is associated with reduced encephalopathy but not compromised clinical efficacy. IMPACT AND IMPLICATIONS The optimal timing of measurement and hemodynamic targets of portacaval pressure gradient (PPG) after transjugular intrahepatic portosystemic shunt (TIPS) remain unclear. Here we show that post-TIPS PPG measured at least 24 hours but not immediately after the procedure correlated with long-term PPG and clinical events. Thus, PPG measurements taken at least 24 hours after TIPS should be used to guide decision making in order to improve clinical outcomes. Targeting a post-TIPS PPG of 11-14 mmHg or a 20%-50% relative reduction from pre-TIPS baseline measured 24-72 hours after the procedure was associated with reduced encephalopathy but not compromised clinical efficacy. Thus, these criteria could be used to guide TIPS creation and revision in patients with cirrhosis and variceal bleeding undergoing covered TIPS. CLINICAL TRIAL REGISTRATION NUMBER ClinicalTrials.gov, ID: NCT03590288.
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Affiliation(s)
- Yong Lv
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Qiuhe Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Menghao Li
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Kai Li
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Dongdong Xia
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Jie Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Na Zhang
- Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Xing Wang
- Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Huahong Xie
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Yanglin Pan
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Yongzhan Nie
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China
| | - Daiming Fan
- National Clinical Research Center for Digestive Diseases and State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, China; Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an 710032, China.
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El-Azab G. Proton Pump Inhibitors in Patients with Cirrhosis: Pharmacokinetics, Benefits and Drawbacks. Curr Gastroenterol Rep 2024:10.1007/s11894-024-00943-7. [PMID: 39167119 DOI: 10.1007/s11894-024-00943-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2024] [Indexed: 08/23/2024]
Abstract
PURPOSE OF REVIEW This review explores the pharmacokinetics, benefits, and risks of proton pump inhibitors (PPIs) in cirrhotic patients, focusing on the appropriateness of their use and potential adverse effects. RECENT FINDINGS Recent studies highlight significant pharmacokinetic alterations in PPIs among cirrhotic patients, with marked increases in lansoprazole and pantoprazole exposure and relatively stable levels of esomeprazole. While effective for managing acid-related disorders and post-band ulcer rebleeding, evidence supporting PPI use for portal hypertension-related bleeding is lacking. Emerging research suggests potential adverse effects such as hepatic decompensation, spontaneous bacterial peritonitis, hepatic encephalopathy, and increased mortality, possibly linked to dysbiosis and bacterial translocation. PPI use in cirrhotic patients alters pharmacokinetics significantly, with esomeprazole potentially safer in advanced cirrhosis. The review advises caution in routine PPI use beyond acid-related conditions due to limited evidence and substantial risks. It underscores the need for careful risk-benefit assessments and exploration of alternative therapies. Future research should aim to identify safer management strategies for portal hypertension complications and to develop evidence-based guidelines for PPI use in patients with cirrhosis.
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Affiliation(s)
- Gasser El-Azab
- Hepatology and Gastroenterology Department, National Liver Institute, Menoufia University, Shebin El-Kom, Menoufia, Egypt.
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125
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Lee CL, Freeman M, Burak KW, Moffat GT, O’Donnell CDJ, Ding PQ, Lyubetska H, Meyers BM, Gordon V, Kosyachkova E, Bucur R, Cheung WY, Knox JJ, Tam VC. Real-World Outcomes of Atezolizumab with Bevacizumab Treatment in Hepatocellular Carcinoma Patients: Effectiveness, Esophagogastroduodenoscopy Utilization and Bleeding Complications. Cancers (Basel) 2024; 16:2878. [PMID: 39199649 PMCID: PMC11352899 DOI: 10.3390/cancers16162878] [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: 07/02/2024] [Revised: 08/15/2024] [Accepted: 08/17/2024] [Indexed: 09/01/2024] Open
Abstract
The IMbrave150 trial established atezolizumab with bevacizumab (A+B) as standard care for hepatocellular carcinoma (HCC), recommending an esophagogastroduodenoscopy (EGD) within 6 months of treatment initiation to prevent bleeding from esophagogastric varices. The necessity of mandatory EGD for all patients remains unclear. We retrospectively analyzed 112 HCC patients treated with A+B at five Canadian cancer centers from 1 July 2020 to 31 August 2022. A+B was the first-line therapy for 90% of patients, with median overall survival at 20.3 months and progression-free survival at 9.6 months. There was no survival difference between patients with bleeding and those without. Before A+B, 71% (n = 79) of patients underwent an EGD within 6 months, revealing varices in 41% (n = 32) and requiring intervention in 19% (n = 15). The overall bleeding rate was 15% (n = 17), with GI-specific bleeding occurring in 5% (n = 17). In the EGD group, GI-specific bleeding was 6% (n = 5) while in the non-EGD group, it was 3% (n = 1). Non-GI bleeding was observed in 10% (n = 11) of patients. Outcomes for HCC patients treated with A+B in Canada were comparable to IMbrave150. There was no increase in GI bleeding in patients without pre-treatment EGD, possibly supporting a selective EGD approach.
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Affiliation(s)
- Cha Len Lee
- Princess Margaret Cancer Center, University of Toronto, Toronto, ON M5G1Z5, Canada (J.J.K.)
| | - Mark Freeman
- Tom Baker Cancer Center, University of Calgary, Calgary, AB T2N4N2, Canada (V.C.T.)
| | - Kelly W. Burak
- Liver Unit, Divisions of Gastroenterology & Hepatology and Transplant Medicine, Departments of Medicine and Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N4N2, Canada;
| | - Gordon T. Moffat
- Princess Margaret Cancer Center, University of Toronto, Toronto, ON M5G1Z5, Canada (J.J.K.)
| | - Conor D. J. O’Donnell
- Juravinski Cancer Center, Escarpment Cancer Research Institute, McMaster University, Hamilton, ON L8S4L8, Canada
| | - Philip Q. Ding
- Tom Baker Cancer Center, University of Calgary, Calgary, AB T2N4N2, Canada (V.C.T.)
| | - Hanna Lyubetska
- CancerCare Manitoba, University of Manitoba, Winnipeg, MB R3A1R9, Canada
| | - Brandon M. Meyers
- Juravinski Cancer Center, Escarpment Cancer Research Institute, McMaster University, Hamilton, ON L8S4L8, Canada
| | - Vallerie Gordon
- CancerCare Manitoba, University of Manitoba, Winnipeg, MB R3A1R9, Canada
| | - Ekaterina Kosyachkova
- Princess Margaret Cancer Center, University of Toronto, Toronto, ON M5G1Z5, Canada (J.J.K.)
| | - Roxana Bucur
- Princess Margaret Cancer Center, University of Toronto, Toronto, ON M5G1Z5, Canada (J.J.K.)
| | - Winson Y. Cheung
- Tom Baker Cancer Center, University of Calgary, Calgary, AB T2N4N2, Canada (V.C.T.)
| | - Jennifer J. Knox
- Princess Margaret Cancer Center, University of Toronto, Toronto, ON M5G1Z5, Canada (J.J.K.)
| | - Vincent C. Tam
- Tom Baker Cancer Center, University of Calgary, Calgary, AB T2N4N2, Canada (V.C.T.)
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Chen Y, Ming W, Chen J, Wang X, He G. The impact of restrictive blood transfusion on the safety of patients with esophageal varices after endoscopic variceal ligation: A single-center retrospective study. Medicine (Baltimore) 2024; 103:e39407. [PMID: 39151488 PMCID: PMC11332775 DOI: 10.1097/md.0000000000039407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 07/31/2024] [Accepted: 08/01/2024] [Indexed: 08/19/2024] Open
Abstract
An investigation was conducted to examine the impact of restrictive blood transfusion on the safety of early rebleeding following endoscopic variceal ligation (EVL) in patients with liver cirrhosis. Data were collected from patients with cirrhosis and esophageal varices who underwent EVL at the Affiliated Hospital of North Sichuan Medical College between September 2021 and March 2023. Clinical information, including serum albumin levels, hemoglobin (Hb) levels, liver function classification, and the occurrence of early rebleeding, was recorded. Patients were divided into 2 groups based on their Hb levels: 60 g/L to 90 g/L (restrictive blood transfusion) or Hb ≥ 90 g/L after EVL. The impact of restrictive transfusion on the post-ligation safety of EVL was observed. A total of 246 cirrhotic patients were included in the analysis. Significant differences were found in Hb levels, liver function classification, early rebleeding rates, length of hospital stay, and hospitalization expenses between the restrictive transfusion and Hb ≥ 90 g/L groups. The early rebleeding rate was significantly varied between the groups with different Hb levels after EVL. Multivariate logistic analysis revealed that restrictive blood transfusion (OR = 4.61, 95% CI: 1.06-19.99; P = .041), Hb (OR = 0.96, 95% CI: 0.95-0.97; P < .001), and Child-Pugh class C (OR = 6.37, 95% CI: 1.28-31.67; P = .024) were identified as independent factors influencing early rebleeding. Our findings suggest that the risk of early rebleeding in cirrhotic patients after EVL may be increased by restrictive blood transfusion, and this should be further investigated in future research.
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Affiliation(s)
- Yufeng Chen
- Department of Gastroenterology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Wen Ming
- Department of Gastroenterology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Jingjing Chen
- Department of Gastroenterology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Xi Wang
- Department of Gastroenterology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Guobin He
- Department of Gastroenterology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
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Singh S, Chandan S, Inamdar S, Kadkhodayan KS, Dhar J, Samanta J, Facciorusso A. EUS-Guided Vascular Interventions: Recent Advances. J Clin Med 2024; 13:4835. [PMID: 39200976 PMCID: PMC11355666 DOI: 10.3390/jcm13164835] [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: 07/25/2024] [Revised: 08/09/2024] [Accepted: 08/15/2024] [Indexed: 09/02/2024] Open
Abstract
Endoscopic ultrasound (EUS)-guided vascular interventions were first reported in 2000 in a study that evaluated the utility of EUS in sclerotherapy of esophageal varices. Currently, gastric variceal therapy and portosystemic pressure gradient (PPG) measurements are the most widely utilized applications. Ectopic variceal obliteration, splenic artery embolization, aneurysm/pseudoaneurysm treatment, portal venous sampling, and portosystemic shunt creation using EUS are some of the other emerging interventions. Since the release of the American Gastroenterological Association (AGA)'s commentary in 2023, which primarily endorses EUS-guided gastric variceal therapy and EUS-PPG measurement, several new studies have been published supporting the use of EUS for various vascular conditions. In this review, we present the recent advances in this field, critically appraising new studies and trials.
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Affiliation(s)
- Sahib Singh
- Department of Internal Medicine, Sinai Hospital of Baltimore, Baltimore, MD 21215, USA;
| | - Saurabh Chandan
- Center for Interventional Endoscopy (CIE), Advent Health, Orlando, FL 32803, USA; (S.C.); (K.S.K.)
| | - Sumant Inamdar
- Gastroenterology & Hepatology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Kambiz S. Kadkhodayan
- Center for Interventional Endoscopy (CIE), Advent Health, Orlando, FL 32803, USA; (S.C.); (K.S.K.)
| | - Jahnvi Dhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India; (J.D.); (J.S.)
| | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India; (J.D.); (J.S.)
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy
- Clinical Effectiveness Research Group, Faculty of Medicine, Institute of Health and Society, University of Oslo, 0372 Oslo, Norway
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Mak LY, Liu K, Chirapongsathorn S, Yew KC, Tamaki N, Rajaram RB, Panlilio MT, Lui R, Lee HW, Lai JCT, Kulkarni AV, Premkumar M, Lesmana CRA, Hsu YC, Huang DQ. Liver diseases and hepatocellular carcinoma in the Asia-Pacific region: burden, trends, challenges and future directions. Nat Rev Gastroenterol Hepatol 2024:10.1038/s41575-024-00967-4. [PMID: 39147893 DOI: 10.1038/s41575-024-00967-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2024] [Indexed: 08/17/2024]
Abstract
Globally, nearly half of deaths from cirrhosis and chronic liver diseases (CLD) and three-quarters of deaths from hepatocellular carcinoma (HCC) occur in the Asia-Pacific region. Chronic hepatitis B is responsible for the vast majority of liver-related deaths in the region. Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common form of CLD, affecting an estimated 30% of the adult population. Compared with people of European descent, people from the Asia-Pacific region carry more genetic variants associated with MASLD and its progression. Alcohol is a fast-growing cause of CLD and HCC in Asia as a result of the rising per-capita consumption of alcohol. Drug-induced liver injury is under-recognized and probably has a high prevalence in this region. The epidemiological and outcome data of acute-on-chronic liver failure are heterogeneous, and non-unified definitions across regions contribute to this heterogeneity. CLDs are severely underdiagnosed, and effective treatments and vaccinations are underutilized. In this Review, we highlight trends in the burden of CLD and HCC in the Asia-Pacific region and discuss the rapidly changing aetiologies of liver disease. We examine the multiple gaps in the care cascade and propose mitigating strategies and future directions.
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Affiliation(s)
- Lung-Yi Mak
- The University of Hong Kong, Hong Kong, China
| | - Ken Liu
- The University of Sydney, Sydney, Australia
| | | | | | | | | | | | - Rashid Lui
- The Chinese University of Hong Kong, Hong Kong, China
| | - Hye Won Lee
- Yonsei University College of Medicine, Seoul, Korea
| | | | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Yao Chun Hsu
- Department of Medical Research, E-Da Hospital, Kaohsiung, Taiwan; School of Medicine and Graduate Institute of Medicine, I-Shou University, Kaohsiung, Taiwan
- School of Medicine and Graduate Institute of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Daniel Q Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore, Singapore.
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Giri S, Singh A, Das S, Strubchevska K, Tripathy T, Patel RK, Kozyk M, Roy A. Efficacy and safety of transjugular intrahepatic portosystemic shunt in patients with hepatocellular carcinoma-A systematic review and meta-analysis. Indian J Gastroenterol 2024:10.1007/s12664-024-01646-7. [PMID: 39126599 DOI: 10.1007/s12664-024-01646-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 06/28/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND Patients with hepatocellular carcinoma (HCC) and cirrhosis can present with features of severe portal hypertension, which can be worsened further by portal vein tumoral thrombosis (PVTT). Due to the technical difficulties and short survival of these patients, HCC was traditionally considered a relative contra-indication for transjugular intrahepatic portosystemic shunt (TIPS). However, there is an increasing body of evidence, mainly from China, supporting the use of TIPS in HCC. The present study aimed at analyzing the efficacy and safety of TIPS in patients with HCC. METHODS From 2000 through May 2023, MEDLINE, Embase and Scopus were searched for studies analyzing the outcome of TIPS in HCC. Technical and clinical success, adverse events (AE) and mortality were the main outcomes assessed. With the use of a random effects model, the event rates were combined. RESULTS Total 19 studies with 1498 patients were included in the final analysis. The pooled technical and clinical success rates with TIPS in HCC were 98.8% (98.0-99.7) and 94.1% (91.2-97.0), respectively. After TIPS, ascites was controlled in 89.2% (85.1-93.3) of the cases, while rebleeding was observed in 17.2% (9.4-25.0) of cases on follow-up. The pooled incidence of overall AE, serious AE and post-TIPS hepatic encephalopathy (HE) was 5.2% (2.5-7.9), 0.1% (0.0-0.4) and 25.1% (18.7-31.5), respectively. On follow-up, 11.9% (7.8-15.9) of the patients developed shunt dysfunction requiring re-intervention. CONCLUSION The present analysis supports the feasibility, safety and efficacy of TIPS in the management of portal hypertension in patients with HCC.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, 751 024, India
| | - Ankita Singh
- Department of Gastroenterology, King Edward Memorial Hospital and Seth G S Medical College, Mumbai, 400 012, India
| | - Swati Das
- Department of Radiology, Kalinga Institute of Medical Sciences, Bhubaneswar, 751 024, India
| | - Kateryna Strubchevska
- Department of Internal Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, USA
| | - Taraprasad Tripathy
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, 751 019, India
| | - Ranjan Kumar Patel
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, 751 019, India
| | - Marko Kozyk
- Department of Internal Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, USA
| | - Akash Roy
- Institute of Gastrosciences and Liver Transplantation, Apollo Multispecialty Hospital, Kolkata, 700 054, India.
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Bauer DJ, De Silvestri A, Maiocchi L, Raimondi A, Mare R, Mandorfer M, Sporea I, Müllner-Bucsics T, Ferraioli G, Reiberger T. Understanding confounding factors allows for accurate interpretation of liver stiffness measurements by ElastQ, a novel 2D shear wave elastography technique. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2024. [PMID: 39117313 DOI: 10.1055/a-2329-2801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
PURPOSE Liver stiffness measurement (LSM) using vibration-controlled transient elastography (VCTE) or two-dimensional shear wave elastography (2D-SWE) is recommended to assess the risk of liver fibrosis and advanced chronic liver disease. Even though both techniques measure liver stiffness, their numerical results often diverge. Confounders and reliability criteria for 2D-SWE have not been systematically investigated. MATERIALS AND METHODS We prospectively recruited participants with paired LSM by VCTE and the novel 2D-SWE technique ElastQ (Philips) in three European tertiary centers. The following parameters were recorded: sex, age, body mass index (BMI), etiology, laboratory markers of liver damage and function, as well as cholestasis, LSM by VCTE and controlled attenuation parameter (CAP), interquartile range (IQR)/median for VCTE-LSM and ElastQ-LSM, and the skin-to-liver capsule distance. RESULTS We included 840 participants: 447 (53.2%) males; median age 57.0 [IQR:19.0] years; median BMI 25.4 [6.0] kg/m2; median VCTE-LSM 7.25 [9.2] kPa; median ElastQ-LSM 6.7 [5.4] kPa. On uni- and multivariable modeling (adjusted for LSM), we found that the discrepancy increased with liver stiffness and markers of disease severity. Skin-to-liver capsule distance and BMI affected VCTE-LSM more compared to ElastQ-LSM and significantly increased the discordance between the two measurements. CONCLUSION The discrepancy of ElastQ-LSM to VCTE-LSM increases with liver stiffness and disease severity. BMI and skin-to-liver capsule distance increase the discrepancy between VCTE- and ElastQ-LSM but affect ElastQ-LSM less. The quality criterion IQR/median ≤ 30% indicates reliable ElastQ-LSM.
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Affiliation(s)
- David Jm Bauer
- Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Annalisa De Silvestri
- Clinical Epidemiology and Biometric Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Laura Maiocchi
- Clinical Sciences and Infectious Diseases Department, Fondazione IRCCS Policlinico San Matteo, Medical School University of Pavia, Pavia, Italy
| | - Ambra Raimondi
- Clinical Sciences and Infectious Diseases Department, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy, Pavia, Italy
| | - Ruxandra Mare
- Department of Internal Medicine II, Division of Gastroenterology & Hepatology, Center for Advanced Research in Gastroenterology and Hepatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Timisoara, Romania
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Ioan Sporea
- Department of Internal Medicine II, Division of Gastroenterology & Hepatology, Center for Advanced Research in Gastroenterology and Hepatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Timisoara, Romania
| | | | - Giovanna Ferraioli
- Infectious Diseases, Fondazione IRCCS Policlinico S. Matteo, Medical School, University of Pavia, Pavia, Italy
| | - Thomas Reiberger
- Internal Medicine III, Div. of Gastroenterology & Hepatology, Medical University of Vienna, Vienna, Austria
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131
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Singh J, Ebaid M, Saab S. Advances in the management of complications from cirrhosis. Gastroenterol Rep (Oxf) 2024; 12:goae072. [PMID: 39104730 PMCID: PMC11299547 DOI: 10.1093/gastro/goae072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/29/2024] [Accepted: 06/15/2024] [Indexed: 08/07/2024] Open
Abstract
Cirrhosis with complications of liver decompensation and hepatocellular carcinoma (HCC) constitute a leading cause of morbidity and mortality worldwide. Portal hypertension is central to the progression of liver disease and decompensation. The most recent Baveno VII guidance included revision of the nomenclature for chronic liver disease, termed compensated advanced chronic liver disease, and leveraged the use of liver stiffness measurement to categorize the degree of portal hypertension. Additionally, non-selective beta blockers, especially carvedilol, can improve portal hypertension and may even have a survival benefit. Procedural techniques with interventional radiology have become more advanced in the management of refractory ascites and variceal bleeding, leading to improved prognosis in patients with decompensated liver disease. While lactulose and rifaximin are the preferred treatments for hepatic encephalopathy, many alternative treatment options may be used in refractory cases and even procedural interventions such as shunt embolization may be of benefit. The approval of terlipressin for the treatment of hepatorenal syndrome (HRS) in the USA has improved the way in which HRS is managed and will be discussed in detail. Malnutrition, frailty, and sarcopenia lead to poorer outcomes in patients with decompensated liver disease and should be addressed in this patient population. Palliative care interventions can lead to improved quality of life and clinical outcomes. Lastly, the investigation of systemic therapies, in particular immunotherapy, has revolutionized the management of HCC. These topics will be discussed in detail in this review.
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Affiliation(s)
- Jasleen Singh
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Mark Ebaid
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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132
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Wester A, Jepsen P, Hagström H. Statin initiation after myocardial infarction in patients with alcohol-related liver disease: A nationwide population-based study. Liver Int 2024; 44:2002-2010. [PMID: 38651770 DOI: 10.1111/liv.15912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/06/2024] [Accepted: 03/14/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND AND AIMS Secondary prevention with statins improves clinical outcomes after myocardial infarction (MI). We aimed to compare odds of statin initiation after MI in patients with co-existing alcohol-related liver disease (ALD) to the general population, and the association between statin initiation and mortality in the patients with ALD. METHODS All statin-naïve patients with ALD and a first-time MI between 2006 and 2020 were identified from Swedish healthcare registers and matched for age, sex, and year of MI with up to ten ALD-free general population controls with a first-time MI. Logistic regression was used to estimate adjusted odds ratios (OR) for statin initiation within 30 days after MI for ALD patients versus controls. Cox regression was used in patients with ALD to compare mortality between statin initiators and non-initiators. RESULTS Of the 276 patients with a first-time MI and ALD, 206 (74.6%) were male, the median age was 67 (interquartile range 62-72), 151 (54.7%) had cirrhosis, and 62 (22.5%) had decompensated cirrhosis. 1769 matched controls were included. Initiation of statins was less common in ALD patients (50.0%) than controls (89.2%, adjusted OR = .15, 95% confidence interval [CI] = .10-.20). Among patients with ALD, statin initiators and non-initiators were followed for a median of 3.9 (interquartile range = 1.8-7.7) and 1.9 years (interquartile range = .5-4.4), respectively. Statin initiators had lower mortality than non-initiators (adjusted hazard ratio = .41, 95%CI = .28-.59). CONCLUSIONS Patients with ALD less often initiated statins after MI than the general population. Statin initiation was associated with improved survival, suggesting that patients with ALD might be undertreated following MI.
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Affiliation(s)
- Axel Wester
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Hannes Hagström
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
- Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden
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133
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Pons M, Rivera-Esteban J, Ma MM, Davyduke T, Delamarre A, Hermabessière P, Dupuy J, Wong GLH, Yip TCF, Pennisi G, Tulone A, Cammà C, Petta S, de Lédinghen V, Wong VWS, Augustin S, Pericàs JM, Abraldes JG, Genescà J. Point-of-Care Noninvasive Prediction of Liver-Related Events in Patients With Nonalcoholic Fatty Liver Disease. Clin Gastroenterol Hepatol 2024; 22:1637-1645.e9. [PMID: 37573987 DOI: 10.1016/j.cgh.2023.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/09/2023] [Accepted: 08/02/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND & AIMS Individual risk prediction of liver-related events (LRE) is needed for clinical assessment of nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH) patients. We aimed to provide point-of-care validated liver stiffness measurement (LSM)-based risk prediction models for the development of LRE in patients with NAFLD, focusing on selecting patients for clinical trials at risk of clinical events. METHODS Two large multicenter cohorts were evaluated, 2638 NAFLD patients covering all LSM values as the derivation cohort and 679 more advanced patients as the validation cohort. We used Cox regression to develop and validate risk prediction models based on LSM alone, and the ANTICIPATE and ANTICIPATE-NASH models for clinically significant portal hypertension. The main outcome of the study was the rate of LRE in the first 3 years after initial assessment. RESULTS The 3 predictive models had similar performance in the derivation cohort with a very high discriminative value (c-statistic, 0.87-0.91). In the validation cohort, the LSM-LRE alone model had a significant inferior discrimination (c-statistic, 0.75) compared with the other 2 models, whereas the ANTICIPATE-NASH-LRE model (0.81) was significantly better than the ANTICIPATE-LRE model (0.79). In addition, the ANTICIPATE-NASH-LRE model presented very good calibration in the validation cohort (integrated calibration index, 0.016), and was better than the ANTICIPATE-LRE model. CONCLUSIONS The ANTICIPATE-LRE models, and especially the ANTICIPATE-NASH-LRE model, could be valuable validated clinical tools to individually assess the risk of LRE at 3 years in patients with NAFLD/NASH.
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Affiliation(s)
- Mònica Pons
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Jesús Rivera-Esteban
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mang M Ma
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - Tracy Davyduke
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - Adèle Delamarre
- Service d'Hepatologie et de Transplantation Hepatique, Centre Hospitalier Universitaire Bordeaux et Bordeaux Institute of Oncology, Bordeaux, France; INSERM U1312, Université de Bordeaux, Bordeaux, France
| | - Paul Hermabessière
- Service d'Hepatologie et de Transplantation Hepatique, Centre Hospitalier Universitaire Bordeaux et Bordeaux Institute of Oncology, Bordeaux, France
| | - Julie Dupuy
- Service d'Hepatologie et de Transplantation Hepatique, Centre Hospitalier Universitaire Bordeaux et Bordeaux Institute of Oncology, Bordeaux, France
| | - Grace Lai-Hung Wong
- State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong; Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Terry Cheuk-Fung Yip
- State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong; Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Grazia Pennisi
- Section of Gastroenterology and Hepatology, Dipartimento Di Promozione Della Salute, Materno Infantile, Medicina Interna e Specialistica Di Eccellenza, University of Palermo, Palermo, Italy
| | - Adele Tulone
- Section of Gastroenterology and Hepatology, Dipartimento Di Promozione Della Salute, Materno Infantile, Medicina Interna e Specialistica Di Eccellenza, University of Palermo, Palermo, Italy
| | - Calogero Cammà
- Section of Gastroenterology and Hepatology, Dipartimento Di Promozione Della Salute, Materno Infantile, Medicina Interna e Specialistica Di Eccellenza, University of Palermo, Palermo, Italy
| | - Salvatore Petta
- Section of Gastroenterology and Hepatology, Dipartimento Di Promozione Della Salute, Materno Infantile, Medicina Interna e Specialistica Di Eccellenza, University of Palermo, Palermo, Italy
| | - Victor de Lédinghen
- Service d'Hepatologie et de Transplantation Hepatique, Centre Hospitalier Universitaire Bordeaux et Bordeaux Institute of Oncology, Bordeaux, France; INSERM U1312, Université de Bordeaux, Bordeaux, France
| | - Vincent Wai-Sun Wong
- State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong; Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Salvador Augustin
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Juan Manuel Pericàs
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain.
| | - Juan G Abraldes
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - Joan Genescà
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
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Bañares J, Aceituno L, Pons M, Genescà J. Noninvasive Assessment of Portal Hypertension. Clin Liver Dis 2024; 28:401-415. [PMID: 38945634 DOI: 10.1016/j.cld.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
The progressive use of noninvasive tests (NITs) has changed the way hepatologists diagnose and manage patients with chronic liver disease, mainly because of their easiness to use and the ability to be repeated during follow-up. Liver stiffness measurement is the NIT with more scientific evidence. NITs have demonstrated to be useful to detect not only liver fibrosis but also the presence of clinically significant portal hypertension. Moreover, current evidence supports they can also be useful to evaluate the prognosis of patients with chronic liver disease.
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Affiliation(s)
- Juan Bañares
- Liver Unit, Digestive Diseases Area, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Pg. Vall d'Hebron 119-129, Barcelona 08035, Spain
| | - Laia Aceituno
- Liver Unit, Digestive Diseases Area, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Pg. Vall d'Hebron 119-129, Barcelona 08035, Spain
| | - Mònica Pons
- Liver Unit, Digestive Diseases Area, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Pg. Vall d'Hebron 119-129, Barcelona 08035, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
| | - Joan Genescà
- Liver Unit, Digestive Diseases Area, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Pg. Vall d'Hebron 119-129, Barcelona 08035, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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Maida M, Vitello A, Shahini E, Vassallo R, Sinagra E, Pallio S, Melita G, Ramai D, Spadaccini M, Hassan C, Facciorusso A. Green endoscopy, one step toward a sustainable future: Literature review. Endosc Int Open 2024; 12:E968-E980. [PMID: 39184060 PMCID: PMC11343619 DOI: 10.1055/a-2303-8621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/30/2024] [Indexed: 08/27/2024] Open
Abstract
Rapid climate change or climate crisis is one of the most serious emergencies of the 21st century, accounting for highly impactful and irreversible changes worldwide. Climate crisis can also affect the epidemiology and disease burden of gastrointestinal diseases because they have a connection with environmental factors and nutrition. Gastrointestinal endoscopy is a highly intensive procedure with a significant contribution to greenhouse gas (GHG) emissions. Moreover, endoscopy is the third highest generator of waste in healthcare facilities with significant contributions to carbon footprint. The main sources of direct carbon emission in endoscopy are use of high-powered consumption devices (e.g. computers, anesthesia machines, wash machines for reprocessing, scope processors, and lighting) and waste production derived mainly from use of disposable devices. Indirect sources of emissions are those derived from heating and cooling of facilities, processing of histological samples, and transportation of patients and materials. Consequently, sustainable endoscopy and climate change have been the focus of discussions between endoscopy providers and professional societies with the aim of taking action to reduce environmental impact. The term "green endoscopy" refers to the practice of gastroenterology that aims to raise awareness, assess, and reduce endoscopy´s environmental impact. Nevertheless, while awareness has been growing, guidance about practical interventions to reduce the carbon footprint of gastrointestinal endoscopy are lacking. This review aims to summarize current data regarding the impact of endoscopy on GHG emissions and possible strategies to mitigate this phenomenon. Further, we aim to promote the evolution of a more sustainable "green endoscopy".
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Affiliation(s)
- Marcello Maida
- Department of Medicine and Surgery, University of Enna 'Kore', Enna, Italy
- Gastroenterology Unit, Umberto I Hospital, Enna, Italy
| | - Alessandro Vitello
- Gastroenterology and Endoscopy Unit, S. Elia Hospital, ASP di Caltanissetta, Caltanissetta, Italy
| | - Endrit Shahini
- Gastroenterology Unit, Istituto Nazionale di Ricovero e Cura a Carattere Scientifico Saverio de Bellis, Castellana Grotte, Italy
| | - Roberto Vassallo
- Gastroenterology Unit, Buccheri La Ferla Fatebenefratelli Hospital, Palermo, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto San Raffaele G Giglio di Cefalù, Cefalu, Italy
| | - Socrate Pallio
- Digestive Diseases Endoscopy Unit, Policlinico G. Martino Hospital, University of Messina, Messina, Italy
| | - Giuseppinella Melita
- Digestive Diseases Endoscopy Unit, Policlinico G. Martino Hospital, University of Messina, Messina, Italy
| | - Daryl Ramai
- Gastroenterology and Hepatology, The University of Utah School of Medicine, Salt Lake City, United States
| | - Marco Spadaccini
- Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Cesare Hassan
- Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
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Garcia-Guix M, Ardevol A, Sapena V, Alvarado-Tápias E, Huertas A, Brujats A, Fajardo J, Cuyas B, Poca M, Guarner C, Torras X, Escorsell À, Villanueva C. Influence of further decompensation on survival across clinical stages of decompensated cirrhosis: The role of portal hypertension and HVPG changes. Liver Int 2024; 44:1971-1989. [PMID: 38634685 DOI: 10.1111/liv.15937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/13/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND AND AIMS Decompensated-cirrhosis encompasses several stages with different prognosis, such as bleeding, ascites and bleeding-plus-ascites. Development of further-decompensation worsens survival, while non-selective β-blockers (NSBBs) can modify the risk. However, how this applies to each stage is uncertain. We aimed to investigate, in each stage of decompensated-cirrhosis, the influence of further-decompensation on mortality and whether changes in portal-pressure (HVPG) under NSBBs influence these outcomes. METHODS Patients with variceal bleeding were consecutively included differentiating those with bleeding-alone from those who also had ascites. Patients with ascites and high-risk varices referred for primary-prophylaxis were also investigated. A baseline haemodynamic study was performed and was repeated after 1-3-months under NSBBs. Outcomes were investigated by competing-risk. RESULTS Totally 103 patients had bleeding-alone, 186 bleeding-plus-ascites and 187 ascites-alone. Mean follow-up was 32-months (IQR, 12-60). Patients with bleeding-plus-ascites had higher HVPG and were more hyperdynamic than patients with ascites-alone and these than those with bleeding-alone. At each stage, the mortality risk was more than twice in patients developing further-decompensation vs. those without (p < .001). In each stage, HVPG-decrease under NSBBs showed better discrimination to predict further-decompensation than the baseline MELD, Child-Pugh or HVPG, by time-dependent ROC-curves (c-statistic >70%). At each stage, patients without HVPG-decreases, either ≥10% or ≥20% from the baseline, had higher risk of further-decompensation (sHR from 2.43 to 6.73, p < .01) and worse survival. CONCLUSIONS In each stage of decompensated cirrhosis, mortality risk significantly and very markedly increase with further-decompensation. HVPG-non-response to NSBBs may adequately stratify the risk of further decompensation and death, in each stage. This suggests potential benefit with pre-emptive therapies in HVPG-non-responders at each-stage.
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Affiliation(s)
- Marta Garcia-Guix
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Alba Ardevol
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Victor Sapena
- Biostatistics Unit, Medical School, Universitat Autònoma de Barcelona, Barcelona, Spain
- Medical Statistics Core Faculty, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Edilmar Alvarado-Tápias
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Anna Huertas
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anna Brujats
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Javier Fajardo
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Berta Cuyas
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - María Poca
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Carlos Guarner
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Xavier Torras
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Àngels Escorsell
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Càndid Villanueva
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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Zanetto A, Toffanin S, Campello E, Radu CM, Gavasso S, Burra P, Russo FP, Senzolo M, Simioni P. Reticulated platelets are increased and hyper-activated in patients with cirrhosis, especially those with poor outcome. Dig Liver Dis 2024; 56:1327-1334. [PMID: 38553338 DOI: 10.1016/j.dld.2024.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/26/2024] [Accepted: 03/11/2024] [Indexed: 07/29/2024]
Abstract
BACKGROUND Reticulated platelets (RePLT) are emergency circulating platelets released to contrast peripheral platelet destruction. AIM We conducted a prospective study to [a] characterize RePLT in cirrhosis; [b] evaluate the association between RePLT and hepatic decompensation/death. METHODS Cirrhosis patients without hepatocellular carcinoma were prospectively recruited and underwent assessment of RePLT and thrombopoietin (TPO). RePLT were evaluated by cytofluorimetry and immuno-fluorescence microscopy. Twenty healthy subjects were included as controls. Patients were followed for 6 months for hepatic decompensation and further decompensation/ACLF. RESULTS Forty-five patients were included (Child-Pugh [CP] A/B/C 18/11/16). Compared to controls, RePLT in cirrhosis were significantly increased (0.82% vs. 0.05%; p < 0.001) and hyperactivated (4.35% vs. 0.17%; p = 0.004). No correlation was observed between RePLT and CP, platelet count, TPO, MELD score, and C-reactive protein. TPO was lower in cirrhosis than controls (28 pg/mL vs. 52 pg/mL; p = 0.005), decreasing significantly with CP stage. In CP B/C patients (n = 27), RePLT were significantly higher in those who progressed towards further decompensation/ACLF (2.11 [0.56-2.95] vs. 0.69 [0.02-1.22]; p < 0.01). A proportion of RePLT >2% accurately identified high-risk patients (AUROC 0.818; 95%CI: 0.639-0.997; sensitivity 94%, specificity 73%). CONCLUSION RePLT in cirrhosis are increased and hyper-activated. In decompensated patients, higher RePLT appear to be associated with worse outcomes.
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Affiliation(s)
- Alberto Zanetto
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Serena Toffanin
- Thrombotic and Haemorrhagic Disease Unit and Haemophilia Center, Department of Medicine (DIMED), University of Padova, Italy
| | - Elena Campello
- Thrombotic and Haemorrhagic Disease Unit and Haemophilia Center, Department of Medicine (DIMED), University of Padova, Italy; General Internal Medicine Unit, Azienda Ospedale - Università Padova, Padova, Italy
| | - Claudia Maria Radu
- Thrombotic and Haemorrhagic Disease Unit and Haemophilia Center, Department of Medicine (DIMED), University of Padova, Italy
| | - Sabrina Gavasso
- Thrombotic and Haemorrhagic Disease Unit and Haemophilia Center, Department of Medicine (DIMED), University of Padova, Italy
| | - Patrizia Burra
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Francesco Paolo Russo
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy
| | - Paolo Simioni
- Thrombotic and Haemorrhagic Disease Unit and Haemophilia Center, Department of Medicine (DIMED), University of Padova, Italy; General Internal Medicine Unit, Azienda Ospedale - Università Padova, Padova, Italy.
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138
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Wong YJ, Abraldes JG. Pharmacologic Treatment of Portal Hypertension. Clin Liver Dis 2024; 28:417-435. [PMID: 38945635 DOI: 10.1016/j.cld.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Portal hypertension is the key mechanism driving the transition from compensated to decompensated cirrhosis. In this review, the authors described the pathophysiology of portal hypertension in cirrhosis and the rationale of pharmacologic treatment of portal hypertension. We discussed both etiologic and nonetiologic treatment of portal hypertension and the specific clinical scenarios how nonselective beta-blocker can be used in patients with cirrhosis. Finally, the authors summarized the evidence for emerging alternatives for portal hypertension in patients with cirrhosis.
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Affiliation(s)
- Yu Jun Wong
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Canada; Liver Unit, Division of Gastroenterology, University of Alberta, 1-38 Zeidler Ledcor Centre, 8540 112 Street Northwest, Edmonton, Alberta T6G 2X8, Canada
| | - Juan G Abraldes
- Liver Unit, Division of Gastroenterology, University of Alberta, 1-38 Zeidler Ledcor Centre, 8540 112 Street Northwest, Edmonton, Alberta T6G 2X8, Canada.
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Ferraioli G, Barr RG, Berzigotti A, Sporea I, Wong VWS, Reiberger T, Karlas T, Thiele M, Cardoso AC, Ayonrinde OT, Castera L, Dietrich CF, Iijima H, Lee DH, Kemp W, Oliveira CP, Sarin SK. WFUMB Guideline/Guidance on Liver Multiparametric Ultrasound: Part 1. Update to 2018 Guidelines on Liver Ultrasound Elastography. ULTRASOUND IN MEDICINE & BIOLOGY 2024; 50:1071-1087. [PMID: 38762390 DOI: 10.1016/j.ultrasmedbio.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 05/20/2024]
Abstract
The World Federation for Ultrasound in Medicine and Biology (WFUMB) endorsed the development of this document on multiparametric ultrasound. Part 1 is an update to the WFUMB Liver Elastography Guidelines Update released in 2018 and provides new evidence on the role of ultrasound elastography in chronic liver disease. The recommendations in this update were made and graded using the Oxford classification, including level of evidence (LoE), grade of recommendation (GoR) and proportion of agreement (Oxford Centre for Evidence-Based Medicine [OCEBM] 2009). The guidelines are clinically oriented, and the role of shear wave elastography in both fibrosis staging and prognostication in different etiologies of liver disease is discussed, highlighting advantages and limitations. A comprehensive section is devoted to the assessment of portal hypertension, with specific recommendations for the interpretation of liver and spleen stiffness measurements in this setting.
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Affiliation(s)
- Giovanna Ferraioli
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Richard Gary Barr
- Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio, USA; Southwoods Imaging, Youngstown, Ohio, USA
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ioan Sporea
- Division of Gastroenterology and Hepatology, Department of Internal Medicine II, Center for Advanced Research in Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, Timișoara, Romania
| | - Vincent Wai-Sun Wong
- Medical Data Analytics Centre, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China; State Key Laboratory of Digestive Disease, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong, China
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Thomas Karlas
- Division of Gastroenterology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Maja Thiele
- Center for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Department for Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ana Carolina Cardoso
- Hepatology Division, School of Medicine, Federal University of Rio de Janeiro, Clementino, Fraga Filho Hospital, Rua Prof. Rodolpho Paulo Rocco, Cidade Universitária da Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Oyekoya Taiwo Ayonrinde
- Department of Gastroenterology and Hepatology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia; Medical School, University of Western Australia, Crawley, Western Australia, Australia; Curtin Medical School, Curtin University, Kent Street, Bentley, Western Australia, Australia
| | - Laurent Castera
- Université Paris-Cité, Inserm UMR1149, Centre de Recherche sur l'Inflammation, Paris, France; Service d'Hépatologie, Hôpital Beaujon, Assistance-Publique Hôpitaux de Paris, Clichy, France
| | - Christoph Frank Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem and Permancence, Bern, Switzerland
| | - Hiroko Iijima
- Division of Hepatobiliary and Pancreatic Disease, Department of Gastroenterology, Hyogo Medical University, Nishinomiya, Hyogo, Japan; Ultrasound Imaging Center, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - William Kemp
- Department of Gastroenterology, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Claudia P Oliveira
- Gastroenterology Department, Laboratório de Investigação (LIM07), Hospital das Clínicas de São Paulo, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
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Huang CH, Tsai MH, Lin CY. Identifying the pivotal role of non-acute decompensation as a precursor to acute decompensation in cirrhosis. J Hepatol 2024; 81:e69-e70. [PMID: 38336345 DOI: 10.1016/j.jhep.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024]
Affiliation(s)
- Chien-Hao Huang
- Division of Hepatology, Department of Gastroenterology-Hepatology Linkou Medical Center, Chang Gung Memorial Hospital, Kweishan, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Kweishan, Taoyuan, Taiwan
| | - Ming-Hung Tsai
- Division of Hepatology, Department of Gastroenterology-Hepatology Linkou Medical Center, Chang Gung Memorial Hospital, Kweishan, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Kweishan, Taoyuan, Taiwan
| | - Chun-Yen Lin
- Division of Hepatology, Department of Gastroenterology-Hepatology Linkou Medical Center, Chang Gung Memorial Hospital, Kweishan, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Kweishan, Taoyuan, Taiwan.
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141
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Jachs M, Sandmann L, Hartl L, Tergast T, Schwarz M, Bauer DJM, Balcar L, Ehrenbauer A, Hofer BS, Cornberg M, Lenzen H, Deterding K, Trauner M, Mandorfer M, Wedemeyer H, Reiberger T, Maasoumy B. Validation of Baveno VII criteria and other non-invasive diagnostic algorithms for clinically significant portal hypertension in hepatitis delta. J Hepatol 2024; 81:248-257. [PMID: 38479612 DOI: 10.1016/j.jhep.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/15/2024] [Accepted: 03/07/2024] [Indexed: 07/26/2024]
Abstract
BACKGROUND & AIMS Non-invasive tests (NITs) for clinically significant portal hypertension (CSPH) require validation in patients with hepatitis D virus (HDV)-related compensated advanced chronic liver disease (cACLD). Therefore, we aimed to validate existing NIT algorithms for CSPH in this context. METHODS Patients with HDV-cACLD (LSM ≥10 kPa or histological METAVIR F3/F4 fibrosis) who underwent paired HVPG and NIT assessment at Medical University of Vienna or Hannover Medical School between 2013 and 2023 were retrospectively included. Liver stiffness measurement (LSM), von Willebrand factor to platelet count ratio (VITRO), and spleen stiffness measurement (SSM) were assessed. Individual CSPH risk was calculated according to previously published models (ANTICIPATE, 3P/5P). The diagnostic performance of Baveno VII criteria and refined algorithms (Baveno VII-VITRO, Baveno VII-SSM) was evaluated. The prognostic utility of NITs was investigated in the main cohort and an independent, multicenter, validation cohort. RESULTS Fifty-one patients (HVPG ≥10 mmHg/CSPH prevalence: 62.7%, varices: 42.2%) were included. Patients with CSPH had significantly higher LSM (25.8 [17.2-31.0] vs. 14.0 [10.5-19.8] kPa; p <0.001), VITRO (n = 31, 3.5 [2.7-4.5] vs. 1.3 [0.6-2.0] %/[G/L]; p <0.001), and SSM (n = 20, 53.8 [41.7-75.5] vs. 24.0 [17.0-33.9] kPa; p <0.001). Composite CSPH risk models yielded excellent AUROCs (ANTICIPATE: 0.885, 3P: 0.903, 5P: 0.912). Baveno VII criteria ruled out CSPH with 100% sensitivity and ruled in CSPH with 84.2% specificity. The Baveno VII 'grey zone' (41.1%) was significantly reduced by Baveno VII-VITRO or Baveno VII-SSM algorithms, which maintained diagnostic accuracy. Hepatic decompensation within 2 years only occurred in patients who had CSPH or met Baveno VII rule-in criteria. The prognostic value of NITs was confirmed in the validation cohort comprising 92 patients. CONCLUSIONS Standalone and composite NIT/diagnostic algorithms are useful for CSPH diagnosis in patients with HDV-cACLD. Thus, NITs may be applied to identify and prioritize patients with CSPH for novel antiviral treatments against chronic hepatitis D. IMPACT AND IMPLICATIONS Non-invasive tests (NITs) for clinically significant portal hypertension (CSPH) have been developed to identify patients with compensated advanced chronic liver disease (cACLD) at risk of decompensation, but conflicting data has been published regarding the accuracy of liver stiffness measurement (LSM) for the staging of fibrosis in patients infected with hepatitis D virus (HDV). In our study, including 51 patients with HDV-cACLD, LSM- and lab-based NITs yielded high AUROCs for CSPH. Moreover, only patients with CSPH or high non-invasively assessed CSPH risk were at risk of decompensation within 2 years, with the prognostic value of NITs confirmed in a validation cohort. Thus, NITs should be applied and updated in yearly intervals in clinical routine to identify patients with HDV-cACLD at short-term risk of clinical events; NITs may also guide prioritization for novel antiviral treatment options.
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Affiliation(s)
- Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Lisa Sandmann
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany; D-SOLVE Consortium, an EU Horizon Europe Funded Project (No 101057917), Germany; Excellence Cluster RESIST, Excellence Initiative Hannover Medical School, Germany
| | - Lukas Hartl
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Tammo Tergast
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Michael Schwarz
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - David Josef Maria Bauer
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Department of Medicine IV, Klinik Ottakring, Vienna, Austria
| | - Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alena Ehrenbauer
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Benedikt Silvester Hofer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany; D-SOLVE Consortium, an EU Horizon Europe Funded Project (No 101057917), Germany; Excellence Cluster RESIST, Excellence Initiative Hannover Medical School, Germany; German Center for Infection Research (DZIF), Hannover/Braunschweig, Germany; Centre for Individualised Infection Medicine, Helmholtz Centre for Infection Research/Hannover Medical School, Hannover, Germany
| | - Henrike Lenzen
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Katja Deterding
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany; D-SOLVE Consortium, an EU Horizon Europe Funded Project (No 101057917), Germany; Excellence Cluster RESIST, Excellence Initiative Hannover Medical School, Germany; German Center for Infection Research (DZIF), Hannover/Braunschweig, Germany
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany; German Center for Infection Research (DZIF), Hannover/Braunschweig, Germany.
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de Silva AP, Niriella MA, Nishad N, Jayasundara H, Jayasena H, Samarawickrama VT, Ranawaka C, Basnayake K, de Silva ST, de Silva HJ. Splenic Stiffness Measurement Combined With Liver Stiffness Measurement Compared With Baveno VII Criteria in Predicting the Presence of Oesophageal and Gastric Varices in Patients With Compensated Advanced Liver Cell Disease (cALCD). Cureus 2024; 16:e65954. [PMID: 39221371 PMCID: PMC11365573 DOI: 10.7759/cureus.65954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2024] [Indexed: 09/04/2024] Open
Abstract
INTRODUCTION Liver stiffness measurement (LSM) using vibration-controlled transient elastography (VCTE) is being increasingly used as a screening tool to predict varices. Our aim was to test the utility of Baveno VII criteria and other combinations of LSM, platelet count (PC), and splenic stiffness measurement (SSM) to predict the presence of varices in a cohort of Sri Lankan patients with compensated advanced liver cell disease (cALCD). METHODS Consecutive patients with newly diagnosed Child-Pugh class A cALCD (non-viral, BMI<30) were recruited prospectively. They underwent gastroscopy. LSM and SSM were taken using vibration-controlled transient elastography (VCTE) (Echosens FibroScan 502 Touch; Echosens SA, Paris, France) by a single operator who was unaware of endoscopy findings. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of different Baveno VII criteria to predict the varices and different combinations of LSM, SSM, and PC were also explored. RESULTS One hundred and seventy-four individuals were recruited. The mean age was 61.4 ((95% CI: 59.7-62.8) years. A total of 110 individuals were males, and 106 had varices. Our results indicated that the three Baveno VII criteria had sensitivities of 61%, 63%, and 42%, and specificities of 79%, 77%, and 87% to predict varices. SSM>30kPa alone and in combination with LSM>15kPa had sensitivities of 81 and 75%, specificities of 72 and 83%, PPVs of 82 and 87%, NPVs of 71% and 67%, and accuracies of 78 and 78%, respectively, to predict varices. CONCLUSION Baveno VII criteria had a low sensitivity but high specificity in predicting the presence of varices. However, SSM>30kPa alone or in combination with LSM>15kPa had better sensitivity, specificity, PPV, NPV, and accuracy in predicting varices.
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Affiliation(s)
- Arjuna P de Silva
- Department of Medicine, University Medical Unit, Colombo North Teaching Hospital, Faculty of Medicine, University of Kelaniya, Ragama, LKA
| | - Madunil A Niriella
- Department of Medicine, University Medical Unit, Colombo North Teaching Hospital, Faculty of Medicine, University of Kelaniya, Ragama, LKA
| | - Nilanga Nishad
- Gastroenterology and Hepatology, Addenbrooke's Hospital, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, GBR
| | - Hishali Jayasundara
- Department of Gastroenterology, University Medical Unit, Colombo North Teaching Hospital, Faculty of Medicine, University of Kelaniya, Ragama, LKA
| | - Hiruni Jayasena
- Department of Medicine, Faculty of Medicine, General Sir John Kotelawala Defence University, Colombo, LKA
| | - Vajira T Samarawickrama
- Department of Gastroenterology and Hepatology, University Medical Unit, Colombo North Teaching Hospital, Faculty of Medicine, University of Kelaniya, Ragama, LKA
| | - Chamila Ranawaka
- Department of Gastroenterology and Hepatology, University Medical Unit, Colombo North Teaching Hospital, Faculty of Medicine, University of Kelaniya, Ragama, LKA
| | - Kumarini Basnayake
- Gastroenterology, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, GBR
| | - Shamila T de Silva
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, LKA
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Gananandan K, Wiese S, Møller S, Mookerjee RP. Cardiac dysfunction in patients with cirrhosis and acute decompensation. Liver Int 2024; 44:1832-1841. [PMID: 38712826 DOI: 10.1111/liv.15896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/25/2024] [Accepted: 03/04/2024] [Indexed: 05/08/2024]
Abstract
The prevalence of cirrhotic cardiomyopathy (CCM) has been reported as high as 60%-70% in patients with liver cirrhosis and is associated with various negative outcomes. There has been a growing understanding of CCM over recent years. Indeed, the development of imaging techniques has enabled new diagnostic criteria to be proposed by the Cirrhotic Cardiomyopathy Consortium. However, important unanswered questions remain over pathophysiological mechanisms, optimal diagnostic modalities and potential treatment options. While there has been an increasing volume of literature evaluating CCM, there is a lack of clarity on its implications in acute decompensation, acute-on-chronic liver failure and following interventions such as transjugular intrahepatic portosystemic shunt insertion and liver transplantation. This review aims to summarise the literature in these challenging domains and suggest where future research should focus. We conclude that systemic inflammation and structural myocardial changes are likely to be crucial in the pathophysiology of the disease, but the relative contribution of different components remains elusive. Furthermore, future studies need to use standardised diagnostic criteria for CCM as well as incorporate newer imaging techniques assessing both myocardial structure and function. Finally, while specific treatments are currently lacking, therapeutics targeting systemic inflammation, microbial dysbiosis and bacterial translocation are promising targets and warrant further research.
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Affiliation(s)
- Kohilan Gananandan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, London, UK
| | - Signe Wiese
- Centre of Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, University of Copenhagen, Copenhagen, Denmark
- Gastroenterology Unit, Medical Division, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Søren Møller
- Centre of Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rajeshwar P Mookerjee
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, London, UK
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Ma L, Ma J, Zhang W, Yu J, Zhang Z, Yang M, Zhou Y, Ju S, Gu G, Luo J, Yan Z. Reduced risk of overt hepatic encephalopathy and death after transjugular intrahepatic portosystemic shunt in patients with hepatic venovenous communications. Eur J Radiol 2024; 177:111554. [PMID: 38850724 DOI: 10.1016/j.ejrad.2024.111554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/31/2024] [Accepted: 06/04/2024] [Indexed: 06/10/2024]
Abstract
PURPOSE Hepatic venovenous communications (HVVC) is detectable in more than one-third of cirrhotic patients, where portal hypertension (PHT) tends to present more severely. We aimed to explore the prognostic implications of HVVC in patients with sinusoidal PHT treated by transjugular intrahepatic portosystemic shunt (TIPS). METHOD The multicenter data of patients (2020-2022) undergoing balloon-occluded hepatic venography during TIPS were retrospectively analyzed. Pre-TIPS total bile acids (TBA) levels in portal, hepatic and peripheral veins were compared between groups. The primary endpoint was the development of overt hepatic encephalopathy (HE) within one year after TIPS. RESULTS 183 patients were eligible and classified by the presence (n = 69, 37.7 %) or absence (n = 114, 62.3 %) of HVVC. The agreement between wedged hepatic venous pressure and portal venous pressure was poor in HVVC group (intraclass correlation coefficients [ICC]: 0.141, difference: 13.4 mmHg, p < 0.001), but almost perfect in non-HVVC group (ICC: 0.877, difference: 0.4 mmHg, p = 0.152). At baseline, patients with HVVC had lower Model for end-stage liver disease scores (p < 0.001), blood ammonia levels (p < 0.001), TBA concentrations in the hepatic (p = 0.011) and peripheral veins (p = 0.049) rather than in the portal veins (p = 0.516), and a higher portosystemic pressure gradient (p = 0.035), suggesting more effective intrahepatic perfusion in this group. Within 1-year post-TIPS, HVVC group had a lower incidence of overt HE (11.7 % vs. 30.5 %, p = 0.004, HR: 0.34, 95 % CI: 0.16-0.74, absolute risk difference [ARD]: -17.4) and an improved liver transplantation-free survival rate (97.1 % vs. 86.8 %, p = 0.021, HR: 0.16, 95 % CI: 0.05-0.91, ARD: -10.3). CONCLUSIONS For patients with sinusoidal PHT treated by TIPS, the presence of HVVC was associated with a reduced risk of overt HE and a potential survival benefit.
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Affiliation(s)
- Li Ma
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jingqin Ma
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen Zhang
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiaze Yu
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zihan Zhang
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Minjie Yang
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yongjie Zhou
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shuai Ju
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China
| | - Guoqiang Gu
- Department of Radiology, Minhang Hospital, Fudan University, Shanghai, China
| | - Jianjun Luo
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China; Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.
| | - Zhiping Yan
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China; Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.
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Reiberger T, Lens S, Cabibbo G, Nahon P, Zignego AL, Deterding K, Elsharkawy AM, Forns X. EASL position paper on clinical follow-up after HCV cure. J Hepatol 2024; 81:326-344. [PMID: 38845253 DOI: 10.1016/j.jhep.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/05/2024] [Indexed: 07/26/2024]
Abstract
Following the advent of direct-acting antivirals (DAAs), hepatitis C virus (HCV) infection can be cured in almost all infected patients. This has led to a number of clinical questions regarding the optimal management of the millions of patients cured of HCV. This position statement provides specific guidance on the appropriate follow-up after a sustained virological response in patients without advanced fibrosis, those with compensated advanced chronic liver disease, and those with decompensated cirrhosis. Guidance on hepatocellular carcinoma risk assessment and the management of extrahepatic manifestations of HCV is also provided. Finally, guidance is provided on the monitoring and treatment of reinfection in at-risk patients. The recommendations are based on the best available evidence and are intended to help healthcare professionals involved in the management of patients after treatment for HCV.
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Affiliation(s)
- Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria. CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Sabela Lens
- Liver Unit, Hospital Clinic Barcelona. IDIBAPS. Liver and Digestive Diseases Networking Biomedical Research Centre (CIBERehd). University of Barcelona. Spain
| | - Giuseppe Cabibbo
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties PROMISE, University of Palermo, Italy
| | - Pierre Nahon
- AP-HP, Hôpitaux Universitaires Paris Seine Saint-Denis, Liver Unit, Bobigny; Université Sorbonne Paris Nord, F-93000 Bobigny; Inserm, UMR-1138 "Functional Genomics of Solid Tumors", Centre de Recherche des Cordeliers, Université de Paris, France
| | - Anna Linda Zignego
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Katja Deterding
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School. Germany
| | - Ahmed M Elsharkawy
- Liver Unit, Queen Elizabeth Hospital Birmingham. NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham, United Kingdom
| | - Xavier Forns
- Liver Unit, Hospital Clinic Barcelona. IDIBAPS. Liver and Digestive Diseases Networking Biomedical Research Centre (CIBERehd). University of Barcelona. Spain.
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Siddiqi H, Huang DQ, Mittal N, Nourredin N, Bettencourt R, Madamba E, Amangurbanova M, Hernandez C, Sirlin C, Yin M, Loomba R. Repeatability of vibration-controlled transient elastography versus magnetic resonance elastography in patients with cirrhosis: A prospective study. Aliment Pharmacol Ther 2024; 60:484-491. [PMID: 38863232 DOI: 10.1111/apt.18118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 05/09/2024] [Accepted: 06/03/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND AND AIMS Magnetic resonance elastography (MRE) and vibration-controlled transient elastography (VCTE) have the potential to assess disease progression; however, repeatability data in people with cirrhosis are lacking. We aimed to assess the effect of disease severity on measurement variability and contribute to the evidentiary basis for the qualification of repeating liver stiffness measurements (LSM) in practice and research. METHODS This prospective study included 49 adult participants (58.3% female) with cirrhosis who underwent same-day repeat LSM examinations. The primary outcome was the same-day, same-operator repeatability coefficient% (RC%) and the within-case coefficient of variation (wCV) for each modality. Secondary outcomes include the intra-class correlation coefficient (ICC). The relationship between measurement variability (interquartile for VCTE, standard deviation for MRE) and disease severity (mean liver stiffness) was evaluated by linear regression with the coefficient of determination R2 reported. RESULTS Same-day repeat MRE and VCTE exams were prospectively conducted in 33 and 45 participants, respectively. The RC% appeared 82% higher for VCTE versus MRE (38% vs. 21%), with consistent findings in head-to-head analyses. The wCV for VCTE and MRE was 14% and 8% respectively, indicating VCTE has 75% higher within-subject measurement variation than MRE. ICC was excellent for LSM by VCTE (0.92) and MRE (0.96). Measurement variability increased with mean liver stiffness for VCTE (R2 = 0.78) and MRE (R2 = 0.93). CONCLUSION Both VCTE and MRE demonstrated increased measurement variability with disease severity. However, MRE outperformed VCTE in terms of technical repeatability in patients with cirrhosis. These repeatability estimates may improve the qualification of NITs in practice.
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Affiliation(s)
- Harris Siddiqi
- MASLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, California, USA
| | - Daniel Q Huang
- MASLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, California, USA
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nikita Mittal
- MASLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, California, USA
| | - Nabil Nourredin
- MASLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, California, USA
| | - Ricki Bettencourt
- MASLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, California, USA
| | - Egbert Madamba
- MASLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, California, USA
| | - Maral Amangurbanova
- MASLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, California, USA
| | - Christie Hernandez
- MASLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, California, USA
| | - Claude Sirlin
- Liver Imaging Group, University of California at San Diego, La Jolla, California, USA
| | - Meng Yin
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Rohit Loomba
- MASLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, California, USA
- Division of Gastroenterology and Hepatology, University of California at San Diego, La Jolla, California, USA
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147
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Yang JO, Chittajallu P, Benhammou JN, Patel A, Pisegna JR, Tabibian J, Dong TS. Validation of a Machine Learning Algorithm, EVendo, for Predicting Esophageal Varices in Hepatocellular Carcinoma. Dig Dis Sci 2024; 69:3079-3084. [PMID: 38896359 PMCID: PMC11341647 DOI: 10.1007/s10620-024-08449-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 04/12/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Treatment with atezolizumab and bevacizumab has become standard of care for advanced unresectable hepatocellular carcinoma (HCC) but carries an increased gastrointestinal bleeding risk. Therefore, patients are often required to undergo esophagogastroduodenoscopy (EGD) to rule out esophageal varices (EV) prior to initiating therapy, which can delay care and lead to unnecessary procedural risks and health care costs. In 2019, the EVendo score was created and validated as a noninvasive tool to accurately screen out patients who were at low risk for having EV that required treatment. We sought to validate whether the EVendo score could be used to accurately predict the presence of EV and varices needing treatment (VNT) in patients with HCC. METHODS This was a retrospective multicenter cohort study of patients with HCC from 9/2004 to 12/2021. We included patients who underwent EGDs within 1 year after their HCC diagnosis. We collected clinical parameters needed to calculate an EVendo score at the time of EGD and compared the EVendo model prediction to the gold standard endoscopic report in predicting presence of VNT. RESULTS 112 with HCC were recruited to this study, with 117 qualifying EGDs. VNT occurred in 39 (33.3%) patients. The EVendo score had a sensitivity of 97.4% and a negative predictive value of 96.9%, supporting the validity in applying EVendo in predicting VNT in HCC. CONCLUSION In this study, we validated the use of the EVendo score in ruling out VNT in patients with HCC. The application of the EVendo score could safely defer about 30% of EGDs for EV screening in HCC patients. Although additional validation cohorts are needed, this suggests that EVendo score can potentially be applied in patients with HCC to avoid unnecessary EGDs, which can ultimately mitigate healthcare costs and delays in initiating HCC treatment with atezolizumab and bevacizumab.
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Affiliation(s)
- Jamie O Yang
- UCLA Department of Medicine, Los Angeles, CA, USA
| | - Punya Chittajallu
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA
- Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA David Geffen School of Medicine, Los Angeles, USA
| | - Jihane N Benhammou
- UCLA Department of Medicine, Los Angeles, CA, USA
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA
- Comprehensive Liver Research Center, UCLA, Los Angeles, USA
| | - Arpan Patel
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA
- Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA David Geffen School of Medicine, Los Angeles, USA
- Comprehensive Liver Research Center, UCLA, Los Angeles, USA
| | - Joseph R Pisegna
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA
- Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA David Geffen School of Medicine, Los Angeles, USA
- Comprehensive Liver Research Center, UCLA, Los Angeles, USA
| | - James Tabibian
- Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA David Geffen School of Medicine, Los Angeles, USA
- Olive View, UCLA Medical Center, Sylmar, USA
| | - Tien S Dong
- Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, USA.
- Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA David Geffen School of Medicine, Los Angeles, USA.
- Santa Monica Digestive Diseases, 1223 16th Street, Suite 3100, Santa Monica, CA, 90404, USA.
- Comprehensive Liver Research Center, UCLA, Los Angeles, USA.
- Goodman-Luskin Microbiome Center, UCLA, Los Angeles, USA.
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148
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Ranjan A, Jindal A, Maiwall R, Vashishtha C, Vijayaraghavan R, Arora V, Sarin SK. Midodrine plus propranolol versus propranolol alone in preventing first bleed in patients with cirrhosis and severe ascites: a randomized controlled trial. Hepatol Int 2024; 18:1261-1270. [PMID: 38727780 DOI: 10.1007/s12072-024-10687-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/21/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Propranolol, a non-selective beta-blocker, commonly used to prevent variceal bleed, but might precipitate circulatory dysfunction in severe ascites. Midodrine, an alpha-1 adrenergic agonist improves renal perfusion and systemic hemodynamics. Addition of midodrine might facilitate higher maximum tolerated dose (MTD) of propranolol, thereby less risk of variceal bleed in cirrhosis patients with severe ascites. METHODS 140 patients with cirrhosis and severe/refractory ascites were randomized- propranolol and midodrine (Gr.A,n = 70) or propranolol alone (Gr.B,n = 70). Primary outcome was incidence of bleed at 1 year. Secondary outcomes included ascites control, achievement of target heart rate (THR), HVPG response and adverse effects. RESULTS Baseline characteristics were comparable between two groups. Cumulative incidence of bleed at 1 year was lower in Gr.A than B (8.5%vs.27.1%,p-0.043). The MTD of propranolol was higher in Gr.A (96.67 ± 36.6 mg vs. 76.52 ± 24.4 mg; p-0.01) and more patients achieved THR (84.2%vs.55.7%,p-0.034). Significantly higher proportion of patients in Gr.A had complete resolution of ascites [17.1%vs.11.4%,p-0.014), diuretic tolerance (80%vs.60%,p-0.047) at higher doses(p-0.02) and lesser need for paracentesis. Patients in Gr.A also had greater reduction in variceal grade (75.7%vs.55.7%;p-0.01), plasma renin activity (54.4% from baseline) (p = 0.02). Mean HVPG reduction was greater in Gr.A than B [4.38 ± 2.81 mmHg(23.5%) vs. 2.61 ± 2.87 mmHg(14.5%),p-0.045]. Complications like post-paracentesis circulatory dysfunction and spontaneous bacterial peritonitis on follow-up were higher in Gr.B than A (22.8%vs.51.4%,p = 0.013 and 10%vs.15.7%, p = 0.03, respectively). CONCLUSION Addition of midodrine facilitates effective use of propranolol in higher doses and greater HVPG reduction, thereby preventing first variceal bleed, reduced paracentesis requirements with fewer ascites- related complications in patients with cirrhosis with severe/refractory ascites.
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Affiliation(s)
- Abhijeet Ranjan
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Chitranshu Vashishtha
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Rajan Vijayaraghavan
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Vinod Arora
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India.
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Hercun J, Asif B, Vittal A, Ahmed A, Gopalakrishna Pillai HK, Bergerson JRE, Holland S, Uzel G, Strober W, Fuss IJ, Koh C, Kleiner DE, Heller T. Development of hepatic fibrosis in common variable immunodeficiency-related porto-sinusoidal vascular disorder. Aliment Pharmacol Ther 2024. [PMID: 39090843 DOI: 10.1111/apt.18180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/03/2024] [Accepted: 07/13/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND AND AIMS Liver involvement is an increasingly recognised complication of common variable immunodeficiency (CVID). Nodular regenerative hyperplasia (NRH), a subgroup of porto-sinusoidal vascular disorder, and manifestations of portal hypertension (PH) unrelated to cirrhosis are the most common findings. Nonetheless, the evolution of liver disease over time remains unknown. METHODS Retrospective review of patients followed at the National Institutes of Health with CVID-related liver disease and liver biopsy from 1990 to 2020. Clinical, imaging and histological follow-up were recorded as part of clinical research protocols. RESULTS Forty patients were included, with a median age of 37.5 years at initial biopsy, 73% presenting with clear evidence of NRH, and a median fibrosis stage of 1. At biopsy, median platelet count was 100 × 109/L, spleen size 19.5 cm, hepatic venous pressure gradient 9.5 mmHg and 37.5% of patients had signs of PH. Cumulative incidence of PH was 65% at 5 years. In a subgroup of 16 patients, a follow-up liver biopsy, performed at a median time of 3 years after the index biopsy, revealed an increase in fibrosis by ≥2 stages in 31% of cases and an increase to an overall stage of 2.2 (p = 0.001). No clinical or histological factors were associated with progression of fibrosis. CONCLUSIONS In this CVID cohort, NRH is the most common initial histological finding; however, unexpectedly fibrosis progresses over time in a subgroup of patients. A better understanding of the underlying causal process of liver disease CVID might lead to improved outcomes.
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Affiliation(s)
- Julian Hercun
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Bilal Asif
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Anusha Vittal
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Abdel Ahmed
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Harish Kumar Gopalakrishna Pillai
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Jenna R E Bergerson
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Steven Holland
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Gulbu Uzel
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Warren Strober
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Ivan J Fuss
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland, USA
| | - Christopher Koh
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Theo Heller
- Translational Hepatology Section, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
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Garcia-Tsao G, Kaplan DE. Reply: On the use of nonselective beta blockers in cirrhosis. Hepatology 2024; 80:E35. [PMID: 38626347 DOI: 10.1097/hep.0000000000000889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/18/2024]
Affiliation(s)
- Guadalupe Garcia-Tsao
- Department of Medicine, Yale University, New Haven, Connecticut, USA
- Department of Medicine, VA-CT Healthcare System, West Haven, Connecticut, USA
| | - David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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