151
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Szabo G, Thursz M, Shah VH. Therapeutic advances in alcohol-associated hepatitis. J Hepatol 2022; 76:1279-1290. [PMID: 35589250 DOI: 10.1016/j.jhep.2022.03.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/03/2022] [Accepted: 03/24/2022] [Indexed: 02/07/2023]
Abstract
In recent years, there have been important advances in our understanding of alcohol-associated hepatitis (AH), which have occurred in parallel with a surge in clinical trial activity. Meanwhile, the broader medical field has seen a transformation in care paradigms based on emerging digital technologies. This review focuses on breakthroughs in our understanding of AH and how these breakthroughs are leading to new paradigms for biomarker discovery, clinical trial activity, and care models for patients. It portends a future in which multimodal data from genetic, radiomic, histologic, and environmental sources can be integrated and synthesised to generate personalised biomarkers and therapies for patients with AH.
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Affiliation(s)
- Gyongyi Szabo
- Carol M. Gatton Chairman of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mark Thursz
- Division of Digestive Diseases, Imperial College, London, UK.
| | - Vijay H Shah
- Mitchell T. Rabkin, M.D. Chair, Professor of Medicine, Harvard Medical School, Chief Academic Officer, Beth Israel Deaconess Medical Center and Beth Israel Lahey Health, Boston, MA, USA
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152
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Louvet A, Trabut JB, Moreno C, Moirand R, Aubin HJ, Ntandja Wandji LC, Nourredine M, Ningarhari M, Ganne-Carrié N, Pageaux GP, Bailly F, Boursier J, Daeppen JB, Luquiens A, Nguyen-Khac E, Anty R, Orban T, Donnadieu-Rigole H, Mallat A, Bureau C, Pariente EA, Paupard T, Benyamina A, Perney P, Mathurin P, Rolland B. Management of alcohol-related liver disease: the French Association for the Study of the Liver and the French Alcohol Society clinical guidelines. Liver Int 2022; 42:1330-1343. [PMID: 35488390 DOI: 10.1111/liv.15221] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 12/15/2022]
Abstract
Excessive alcohol consumption is the leading cause of liver diseases in Western countries, especially in France. Alcohol-related liver disease (ARLD) is an extremely broad context and there remains much to accomplish in terms of identifying patients, improving prognosis and treatment, and standardising practices. The French Association for the Study of the Liver wished to organise guidelines together with the French Alcohol Society in order to summarise the best evidence available about several key clinical points in ARLD. These guidelines have been elaborated based on the level of evidence available in the literature and each recommendation has been analysed, discussed and voted by the panel of experts. They describe how patients with ARLD should be managed nowadays and discuss the main unsettled issues in the field.
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Affiliation(s)
- Alexandre Louvet
- Service des Maladies de l'Appareil digestif, Hôpital Huriez, CHU, Lille, France
| | - Jean-Baptiste Trabut
- Groupe Hospitalier Cochin Saint-Vincent de Paul, Unité d'Hépatologie et d'Addictologie, Paris, France
| | | | - Romain Moirand
- Inserm, UMR 991, "Foie, Métabolismes et Cancer", Rennes, France.,Université de Rennes 1, Rennes, France
| | | | | | | | - Massih Ningarhari
- Service des Maladies de l'Appareil digestif, Hôpital Huriez, CHU, Lille, France
| | | | | | - François Bailly
- Service d'Hépato-Gastroentérologie, Hospices Civils de Lyon, Lyon, France
| | | | | | | | | | - Rodolphe Anty
- Service d'Hépato-Gastroentérologie, CHU de l'Archet 2, Nice, France
| | - Thomas Orban
- Société Scientifique de Médecine Générale, Brussels, Belgium
| | | | - Ariane Mallat
- Service d'Hépatologie, Hopital Henri-Mondor, Créteil, France
| | | | | | - Thierry Paupard
- Service d'Hépato-Gastroentérologie, Centre Hospitalier, Dunkerque, France
| | - Amine Benyamina
- Service d'Addictologie, Hôpital Paul-Brousse, Villejuif, France
| | | | - Philippe Mathurin
- Service des Maladies de l'Appareil digestif, Hôpital Huriez, CHU, Lille, France
| | - Benjamin Rolland
- Service Universitaire d'Addictologie de Lyon (SUAL), CH Le Vinatier, Université de Lyon, UCBL, Lyon, France
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153
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Yan YL, Xing X, Wang Y, Wang XZ, Wang Z, Yang L. Clinical utility of two-dimensional shear-wave elastography in monitoring disease course in autoimmune hepatitis-primary biliary cholangitis overlap syndrome. World J Gastroenterol 2022; 28:2021-2033. [PMID: 35664960 PMCID: PMC9150059 DOI: 10.3748/wjg.v28.i18.2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/16/2021] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Autoimmune hepatitis-primary biliary cholangitis (AIH-PBC) overlap syndrome has a worse prognosis than AIH or PBC alone. Therefore, accurately staging liver fibrosis and dynamically monitoring disease progression are essential.
AIM To investigate the performance of two-dimensional shear-wave elastography (2D-SWE) for noninvasively staging liver fibrosis and assessing the clinical utility of repeated 2D-SWE for monitoring treatment response in AIH-PBC overlap syndrome.
METHODS A total of 148 patients diagnosed with AIH-PBC overlap syndrome were retrospectively enrolled. Among them, 82 patients had a 2D-SWE follow-up time of more than 1 year. The Scheuer scoring system was used to evaluate stages of hepatic inflammation and liver fibrosis. The performance of 2D-SWE for staging liver fibrosis was evaluated with the liver biopsy. Changes in liver stiffness (LS) measured by 2D-SWE in patients with or without complete biochemical remission were evaluated.
RESULTS LS value was strongly correlated with liver fibrosis stage (Spearman r = 0.84, P < 0.0001). The areas under the receiver operating characteristic curves of LS for diagnosing significant fibrosis (≥ S2), severe fibrosis (≥ S3), and cirrhosis (S4) were 0.91, 0.97, and 0.96, respectively. Patients with complete biochemical remission had a considerable decrease in LS values (P < 0.0001). More importantly, the declined LS in patients with S0-S2 was significantly lower than that in patients with S3-S4 (P = 0.0002). In contrast, patients who failed to achieve biochemical remission had a slight but not significant decrease in LS (P = 0.37).
CONCLUSION LS measured by 2D-SWE is an accurate and reliable method in assessing liver fibrosis, especially for diagnosing severe fibrosis (≥ 3) and monitoring treatment response in patients with AIH-PBC overlap syndrome.
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Affiliation(s)
- Yu-Ling Yan
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Sichuan University, University of Oxford Huaxi Joint for Gastrointestinal Cancer Centre, Chengdu 610207, Sichuan Province, China
| | - Xian Xing
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Sichuan University, University of Oxford Huaxi Joint for Gastrointestinal Cancer Centre, Chengdu 610207, Sichuan Province, China
| | - Yi Wang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Sichuan University, University of Oxford Huaxi Joint for Gastrointestinal Cancer Centre, Chengdu 610207, Sichuan Province, China
| | - Xiao-Ze Wang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Sichuan University, University of Oxford Huaxi Joint for Gastrointestinal Cancer Centre, Chengdu 610207, Sichuan Province, China
| | - Zhi Wang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Sichuan University, University of Oxford Huaxi Joint for Gastrointestinal Cancer Centre, Chengdu 610207, Sichuan Province, China
| | - Li Yang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
- Sichuan University, University of Oxford Huaxi Joint for Gastrointestinal Cancer Centre, Chengdu 610207, Sichuan Province, China
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154
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Patidar KR, Peng JL, Kaur H, Worden A, Kettler CD, Pike F, Buckley CA, Orman ES, Desai AP, Nephew LD, Kubal CA, Gawrieh S, Chalasani N, Ghabril MS. Severe Alcohol-Associated Hepatitis Is Associated With Worse Survival in Critically Ill Patients With Acute on Chronic Liver Failure. Hepatol Commun 2022; 6:1090-1099. [PMID: 34860462 PMCID: PMC9035580 DOI: 10.1002/hep4.1874] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/08/2021] [Accepted: 11/08/2021] [Indexed: 11/11/2022] Open
Abstract
Differences in mortality between critically ill patients with severe alcohol-associated hepatitis (sAH) and acute-on-chronic liver failure (ACLF) and non-sAH ACLF (i.e., ACLF not precipitated by sAH) are unknown. Such differences are important, as they may inform on prognosis and optimal timing of liver transplantation (LT). Thus, we aimed to compare short-term and longer-term mortality between patients with sAH ACLF and patients with non-sAH ACLF who were admitted to the intensive care unit. Patients with ACLF admitted from 2016-2018 at two tertiary care intensive care units were analyzed. SAH was defined by the National Institute on Alcohol Abuse and Alcoholism's Alcoholic Hepatitis Consortium and Model for End-Stage Liver Disease score >20. Mortality without LT was compared between sAH ACLF and non-sAH ACLF using Fine and Gray's competing-risks regression. A total of 463 patients with ACLF (18% sAH and 82% non-sAH) were included. Compared to patients with non-sAH ACLF, patients with sAH ACLF were younger (49 vs. 56 years; P < 0.001) and had higher admission Model for End-Stage Liver Disease (MELD) (35 vs. 25; P < 0.001) and Chronic Liver Failure Consortium (CLIF-C) scores (61 vs. 57; P = 0.002). There were no significant differences between the two groups for vasopressor, mechanical ventilation, and hemodialysis use. The cumulative incidence of death was significantly higher in patients with sAH ACLF compared to patients with non-sAH ACLF: 30-day 74.7% versus 45.3%; 90-day 81.9% versus 57.4%; 180-day 83.2% versus 63.0% (unadjusted subdistribution hazard ratio [sHR] 1.88 [95% confidence interval (CI) 1.44-2.46]; P < 0.001). After adjusting for CLIF-C score and infection in a multivariable competing-risk model, patients with sAH ACLF had significantly higher risk of death (sHR 1.57 [95% CI 1.20-2.06]; P = 0.001) compared to patients with non-sAH ACLF. Conclusion: Critically ill patients with sAH ACLF have worse mortality compared to patients with non-sAH ACLF. These data may inform prognosis in patients with sAH and ACLF, and early LT referral in potentially eligible patients.
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Affiliation(s)
- Kavish R Patidar
- Division of Gastroenterology and HepatologyIndiana University School of MedicineIndianapolisINUSA
| | - Jennifer L Peng
- Division of Gastroenterology and HepatologyIndiana University School of MedicineIndianapolisINUSA
| | - Harleen Kaur
- Division of Internal MedicineIndiana University School of MedicineIndianapolisINUSA
| | - Astin Worden
- Division of Internal MedicineIndiana University School of MedicineIndianapolisINUSA
| | - Carla D Kettler
- Department of BiostatisticsIndiana University School of MedicineIndianapolisINUSA
| | - Francis Pike
- Department of BiostatisticsIndiana University School of MedicineIndianapolisINUSA
| | - Caitriona A Buckley
- Division of Pulmonology and Critical CareIndiana University School of MedicineIndianapolisINUSA
| | - Eric S Orman
- Division of Gastroenterology and HepatologyIndiana University School of MedicineIndianapolisINUSA
| | - Archita P Desai
- Division of Gastroenterology and HepatologyIndiana University School of MedicineIndianapolisINUSA
| | - Lauren D Nephew
- Division of Gastroenterology and HepatologyIndiana University School of MedicineIndianapolisINUSA
| | | | - Samer Gawrieh
- Division of Gastroenterology and HepatologyIndiana University School of MedicineIndianapolisINUSA
| | - Naga Chalasani
- Division of Gastroenterology and HepatologyIndiana University School of MedicineIndianapolisINUSA
| | - Marwan S Ghabril
- Division of Gastroenterology and HepatologyIndiana University School of MedicineIndianapolisINUSA
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155
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Jiménez C, Ventura-Cots M, Sala M, Calafat M, Garcia-Retortillo M, Cirera I, Cañete N, Soriano G, Poca M, Simón-Talero M, Altamirano J, Lucey M, Garcia-Tsao G, Brown RS, Schwabe RF, Verna EC, Schnabl B, Bosques-Padilla F, Mathurin P, Caballería J, Louvet A, Shawcross DL, Abraldes JG, Genescà J, Bataller R, Vargas V. Effect of rifaximin on infections, acute-on-chronic liver failure and mortality in alcoholic hepatitis: A pilot study (RIFA-AH). Liver Int 2022; 42:1109-1120. [PMID: 35220659 PMCID: PMC9311407 DOI: 10.1111/liv.15207] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 01/31/2022] [Accepted: 02/15/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND & AIMS Alcoholic hepatitis (AH) is associated with a high incidence of infection and mortality. Rifaximin reduces bacterial overgrowth and translocation. We aimed to study whether the administration of rifaximin as an adjuvant treatment to corticosteroids decreases the number of bacterial infections at 90 days in patients with severe AH compared to a control cohort. METHODS This was a multicentre, open, comparative pilot study of the addition of rifaximin (1200 mg/day/90 days) to the standard treatment for severe AH. The results were compared with a carefully matched historical cohort of patients treated with standard therapy and matching by age and model of end-stage liver disease (MELD). We evaluated bacterial infections, liver-related complications, mortality and liver function tests after 90 days. RESULTS Twenty-one and 42 patients were included in the rifaximin and control groups respectively. No significant baseline differences were found between groups. The mean number of infections per patient was 0.29 and 0.62 in the rifaximin and control groups, respectively (p = .049), with a lower incidence of acute-on-chronic liver failure (ACLF) linked to infections within the treatment group. Liver-related complications were lower within the rifaximin group (0.43 vs. 1.26 complications/patient respectively) (p = .01). Mortality was lower in the treated versus the control groups (14.2% vs. 30.9, p = .15) without significant differences. No serious adverse events were associated with rifaximin treatment. CONCLUSIONS Rifaximin is safe in severe AH with a significant reduction in clinical complications. A lower number of infections and a trend towards a lower ACLF and mortality favours its use in these patients.
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Affiliation(s)
- César Jiménez
- Vall d'Hebron Hospital Universitari, Liver Unit; Vall d'Hebron Institut de Recerca, Liver Unit, Universitat Autonoma de Barcelona, Department of Medicine, Barcelona, Spain
| | - Meritxell Ventura-Cots
- Vall d'Hebron Hospital Universitari, Liver Unit; Vall d'Hebron Institut de Recerca, Liver Unit, Universitat Autonoma de Barcelona, Department of Medicine, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Center for Liver Diseases, Pittsburgh Liver Research Center, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Margarita Sala
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Gastroenterology Department, Hospital Universitari Germans Trias I Pujol, Badalona, Spain
| | - Margalida Calafat
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Gastroenterology Department, Hospital Universitari Germans Trias I Pujol, Badalona, Spain
| | - Montserrat Garcia-Retortillo
- Liver Section, Gastroenterology Department, Hospital del Mar, IMIM (Hospital del Mar Medical Research Institute), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Isabel Cirera
- Liver Section, Gastroenterology Department, Hospital del Mar, IMIM (Hospital del Mar Medical Research Institute), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Nuria Cañete
- Liver Section, Gastroenterology Department, Hospital del Mar, IMIM (Hospital del Mar Medical Research Institute), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Germán Soriano
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Department of Gastroenterology Hospital de la Santa Creu i Sant Pau Barcelona Spain, Institut d'Investigació Biomèdica Sant Pau IIB Sant Pau, Gastroenterology, Barcelona, Catalunya, ES, Universitat Autonoma de Barcelona, Medicine, Barcelona, Catalunya, Spain
| | - María Poca
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Department of Gastroenterology Hospital de la Santa Creu i Sant Pau Barcelona Spain, Institut d'Investigació Biomèdica Sant Pau IIB Sant Pau, Gastroenterology, Barcelona, Catalunya, ES, Universitat Autonoma de Barcelona, Medicine, Barcelona, Catalunya, Spain
| | - Macarena Simón-Talero
- Vall d'Hebron Hospital Universitari, Liver Unit; Vall d'Hebron Institut de Recerca, Liver Unit, Universitat Autonoma de Barcelona, Department of Medicine, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - José Altamirano
- Department of Internal Medicine, Hospital Quironsalud, Barcelona, Spain
| | - Michael Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University, New Haven, Connecticut Section of Digestive Diseases, Department of Veterans Affairs Connecticut Healthcare, West Haven, Connecticut, USA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York City, New York, USA
| | - Robert F Schwabe
- Department of Medicine, Columbia University, New York City, New York, USA
| | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York City, New York, USA
| | - Bernd Schnabl
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | | | - Philippe Mathurin
- Service des Maladies de L'appareil Digestif et Unité INSERM U995, Lille, France
| | - Juan Caballería
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Liver Unit, Hospital Clinic, Barcelona, Spain
| | - Alexandre Louvet
- Service des Maladies de L'appareil Digestif et Unité INSERM U995, Lille, France
| | - Debbie L Shawcross
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Institute of Liver Sciences, King's College London, London, UK
| | - Juan G Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, Canada
| | - Joan Genescà
- Vall d'Hebron Hospital Universitari, Liver Unit; Vall d'Hebron Institut de Recerca, Liver Unit, Universitat Autonoma de Barcelona, Department of Medicine, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Ramon Bataller
- Center for Liver Diseases, Pittsburgh Liver Research Center, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Víctor Vargas
- Vall d'Hebron Hospital Universitari, Liver Unit; Vall d'Hebron Institut de Recerca, Liver Unit, Universitat Autonoma de Barcelona, Department of Medicine, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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156
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Lee BP, Cullaro G, Vosooghi A, Yao F, Panchal S, Goldberg DS, Terrault NA, Mahmud N. Discordance in categorization of acute-on-chronic liver failure in the United Network for Organ Sharing database. J Hepatol 2022; 76:1122-1126. [PMID: 35074470 PMCID: PMC9018597 DOI: 10.1016/j.jhep.2021.12.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/07/2021] [Accepted: 12/28/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Studies regarding acute-on-chronic liver failure (ACLF) among liver transplant (LT) candidates from the United Network for Organ Sharing (UNOS) database are being used to inform LT policy changes worldwide. We assessed the validity of identifying ACLF in UNOS. METHODS We performed stratified random sampling among 3 US LT centers between 2013-2019 to obtain a representative patient sample across ACLF grades. We compared the concordance of ACLF classification by UNOS vs. blinded manual chart review, according to EASL-CLIF. RESULTS Among 481 sampled LT registrants, 250 (52%) had no ACLF, 75 (16%) had ACLF grade 1, 79 (16%) had ACLF grade 2, and 77 (16%) had ACLF grade 3 per UNOS categorization. Concordance of ACLF grade by UNOS vs. chart review was: 72%, 64%, 56%, and 64% for no ACLF, grade 1, grade 2, and grade 3, respectively, with an overall Cohen's kappa coefficient of 0.48 (95% CI 0.42-0.54). Absence of acute decompensation was the most common reason for overestimation, and discordant brain and respiratory failure categorization were the most common reasons for underestimation of ACLF by UNOS. CONCLUSIONS In this retrospective multi-center study, ACLF categorization by UNOS showed weak agreement with manual chart review. These findings are informative for ongoing allocation policy discussions, highlight the importance of prospective studies regarding ACLF in LT, and should encourage UNOS reform. LAY SUMMARY Acute-on-chronic-liver-failure (ACLF) is a specific and common form of liver failure associated with high death rates. Studies have been published using the United States transplant registry (UNOS) to identify and describe outcomes of transplant candidates and recipients with ACLF, and these data are driving policy changes for transplant allocation around the world, but nobody has shown whether these data are reliable. We found that UNOS was not categorizing ACLF in concordance or accurately when compared to chart review, which shows the need for UNOS reform and non-UNOS studies to appropriately inform policies regarding the transplantation of patients with ACLF.
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Affiliation(s)
- Brian P Lee
- University of Southern California Keck School of Medicine, Los Angeles, CA, United States.
| | - Giuseppe Cullaro
- University of California San Francisco, San Francisco, CA, United States
| | - Aidan Vosooghi
- University of Southern California Keck School of Medicine, Los Angeles, CA, United States
| | - Frederick Yao
- University of California San Francisco, San Francisco, CA, United States
| | - Sarjukumar Panchal
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - David S Goldberg
- University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - Norah A Terrault
- University of Southern California Keck School of Medicine, Los Angeles, CA, United States
| | - Nadim Mahmud
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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157
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Israelsen M, Misas MG, Koutsoumourakis A, Hall A, Covelli C, Buzzetti E, Prat LI, Roccarina D, Luong TV, Quaglia A, Pinzani M, Tsochatzis EA. Collagen proportionate area predicts long-term mortality in patients with alcoholic hepatitis. Dig Liver Dis 2022; 54:663-668. [PMID: 34548258 DOI: 10.1016/j.dld.2021.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/12/2021] [Accepted: 08/26/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS There are several short-term prognostic scores for alcoholic hepatitis (AH) that combine demographical and biochemical parameters. The extent of liver fibrosis may also be relevant to the prognosis of AH with potential added value. We evaluated collagen proportionate area (CPA) as a predictor of short and long-term mortality in AH. METHODS We retrospectively included patients with biopsy-verified AH. Clinical, laboratory and outcome data were collected. CPA and five AH scores were calculated: Maddrey's DF, MELD, GAHS, ABIC, and the Lille Model. Predictors of short and long-term all-cause mortality were assessed using Cox regression analysis. RESULTS We included 140 patients with AH. In total, 67 (48%) patients died after a median follow-up of 66 (IQR 102) months, with 17 (12%) dying within the first 90-days. CPA was not a predictor of 90-days mortality and had no additional value to the prognostic AH scores on short-term mortality. However, CPA predicted long-term mortality independently of prognostic AH scores. Importantly, CPA and abstinence from alcohol were independent predictors of long-term mortality in patients alive 90 days after the biopsy. CONCLUSION CPA predicts long-term mortality in patients with AH independently of abstinence from alcohol but has no prognostic value on short-term mortality.
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Affiliation(s)
- Mads Israelsen
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK; Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.
| | - Marta Guerrero Misas
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
| | | | - Andrew Hall
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust and UCL Institute for Liver and Digestive Health, University College of London, London, UK.
| | - Claudia Covelli
- Pathology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
| | - Elena Buzzetti
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
| | - Laura Iogna Prat
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
| | - Davide Roccarina
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
| | - Tu Vinh Luong
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust and UCL Institute for Liver and Digestive Health, University College of London, London, UK.
| | - Alberto Quaglia
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust and UCL Institute for Liver and Digestive Health, University College of London, London, UK.
| | - Massimo Pinzani
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK.
| | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK.
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158
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Muthiah MD, Smirnova E, Puri P, Chalasani N, Shah VH, Kiani C, Taylor S, Mirshahi F, Sanyal AJ. Development of Alcohol-Associated Hepatitis Is Associated With Specific Changes in Gut-Modified Bile Acids. Hepatol Commun 2022; 6:1073-1089. [PMID: 34984859 PMCID: PMC9035568 DOI: 10.1002/hep4.1885] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/24/2021] [Accepted: 12/06/2021] [Indexed: 12/13/2022] Open
Abstract
The perturbations in bile acids (BAs) in alcohol-associated hepatitis (AH) and its relationship to disease severity is not well defined. The aims of this study were to define (1) the effects of heavy alcohol consumption on BAs and related microbiome, (2) the additional changes with AH, and (3) the relationship of these changes to disease severity. In this multicenter study, plasma and fecal BAs and related microbiome were interrogated in healthy individuals, heavy drinking controls (HDCs) without overt liver disease, and AH. Compared to healthy controls, HDCs had increased glycine-conjugated 7α and 27α primary BAs and increased secondary BA glycocholenic sulfate (multiple-comparison adjusted P < 0.05 for all). Plasma-conjugated cholic and chenodeoxycholic acid increased in AH along with the secondary BAs ursodeoxycholic and lithocholic acid (P < 0.001 for all), whereas deoxycholic acid decreased; however fecal concentrations of both deoxycholic acid and lithocholic acid were decreased. Glycocholenic acid further increased significantly from HDCs to AH. HDCs and AH had distinct plasma and fecal BA profiles (area under the curve, 0.99 and 0.93, respectively). Plasma taurochenodeoxycholic acid and tauroursodeoxycholic acid were directly related to disease severity, whereas fecal ursodeoxycholic acid was inversely related. The fecal abundance of multiple taxa involved in formation of secondary BAs, especially deoxycholic acid (Clostridium cluster XIVa) was decreased in AH. Multiple genera containing taxa expressing 3α, 3β, 7α, and 7β epimerases were decreased with concordant changes in fecal BAs that required these functions for formation. Conclusion: There are distinct changes in BA-transforming microbiota and corresponding BAs in AH that are related to disease severity.
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Affiliation(s)
- Mark D. Muthiah
- Department of MedicineYong Loo Lin School of MedicineNational University of SingaporeSingapore
- Division of Gastroenterology and HepatologyNational University HospitalSingapore
| | - Ekaterina Smirnova
- Department of BiostatisticsVirginia Commonwealth UniversityRichmondVAUSA
| | - Puneet Puri
- Division of Gastroenterology, Hepatology, and NutritionDepartment of Internal MedicineVirginia Commonwealth UniversityRichmondVAUSA
| | - Naga Chalasani
- Division of GastroenterologyDepartment of Internal MedicineIndiana UniversityIndianapolisINUSA
| | - Vijay H. Shah
- Division of GastroenterologyDepartment of Internal MedicineMayo ClinicRochesterMNUSA
| | - Calvin Kiani
- Division of Gastroenterology, Hepatology, and NutritionDepartment of Internal MedicineVirginia Commonwealth UniversityRichmondVAUSA
| | - Stephanie Taylor
- Division of Gastroenterology, Hepatology, and NutritionDepartment of Internal MedicineVirginia Commonwealth UniversityRichmondVAUSA
| | - Faridoddin Mirshahi
- Division of Gastroenterology, Hepatology, and NutritionDepartment of Internal MedicineVirginia Commonwealth UniversityRichmondVAUSA
| | - Arun J. Sanyal
- Division of Gastroenterology, Hepatology, and NutritionDepartment of Internal MedicineVirginia Commonwealth UniversityRichmondVAUSA
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159
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Shaheen AA, Kong K, Ma C, Doktorchik C, Coffin CS, Swain MG, Burak KW, Congly SE, Lee SS, Sadler M, Borman M, Abraldes JG. Impact of the COVID-19 Pandemic on Hospitalizations for Alcoholic Hepatitis or Cirrhosis in Alberta, Canada. Clin Gastroenterol Hepatol 2022; 20:e1170-e1179. [PMID: 34715379 PMCID: PMC8547973 DOI: 10.1016/j.cgh.2021.10.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/20/2021] [Accepted: 10/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Coronavirus disease 2019 (COVID-19) pandemic lockdown and restrictions had significant disruption to patient care. We aimed to evaluate the impact of COVID-19 restrictions on hospitalizations of patients with alcoholic and nonalcoholic cirrhosis as well as alcoholic hepatitis (AH) in Alberta, Canada. METHODS We used validated International Classification of Diseases (ICD-9 and ICD-10) coding algorithms to identify liver-related hospitalizations for nonalcoholic cirrhosis, alcoholic cirrhosis, and AH in the province of Alberta between March 2018 and September 2020. We used the provincial inpatient discharge and laboratory databases to identify our cohorts. We used elevated alanine aminotransferase or aspartate aminotransferase, elevated international normalized ratio, or bilirubin to identify AH patients. We compared COVID-19 restrictions (April-September 2020) with prior study periods. Joinpoint regression was used to evaluate the temporal trends among the 3 cohorts. RESULTS We identified 2916 hospitalizations for nonalcoholic cirrhosis, 2318 hospitalizations for alcoholic cirrhosis, and 1408 AH hospitalizations during our study time. The in-hospital mortality rate was stable in relation to the pandemic for alcoholic cirrhosis and AH. However, nonalcoholic cirrhosis patients had lower in-hospital mortality rate after March 2020 (8.5% vs 11.5%; P = .033). There was a significant increase in average monthly admissions in the AH cohort (22.1/10,000 admissions during the pandemic vs 11.6/10,000 admissions before March 2020; P < .001). CONCLUSIONS Before and during COVID-19 monthly admission rates were stable for nonalcoholic and alcoholic cirrhosis; however, there was a significant increase in AH admissions. Because alcohol sales surged during the pandemic, future impact on alcoholic liver disease could be detrimental.
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Affiliation(s)
- Abdel Aziz Shaheen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta; Center for Health Informatics, University of Calgary, Calgary, Alberta.
| | - Kristine Kong
- Center for Health Informatics, University of Calgary, Calgary, Alberta
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta,Center for Health Informatics, University of Calgary, Calgary, Alberta
| | | | - Carla S. Coffin
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Mark G. Swain
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Kelly W. Burak
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Stephen E. Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Samuel S. Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Matthew Sadler
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Meredith Borman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Juan G. Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, Alberta, Canada
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160
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Cabezas J. Management of Alcohol-Related Liver Disease and Its Complications. Clin Drug Investig 2022; 42:47-53. [PMID: 35467296 PMCID: PMC9205805 DOI: 10.1007/s40261-022-01143-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 12/19/2022]
Abstract
Alcohol-related liver disease (ALD) is a major healthcare/economic burden and one of the leading causes of liver transplantation. New epidemiological studies that detail the course of the disease are needed since, despite its high prevalence, it is still a stigmatised condition with underlying pathology. Alcoholic hepatitis, as the highest expression of ALD, has high morbidity. Current treatments have suboptimal results with the exception of liver transplantation. Epidemiological studies must also be developed to improve prevention and implement early diagnosis policies. It is essential to develop multidisciplinary health models that allow the liver transplantation candidate to be approached in a holistic way, both for indication and follow up. The implementation of alcohol consumption biomarkers (ethyl glucuronide, phosphatidylethanol) can assist in diagnosing and supporting recovery. There are several initiatives with new therapies that must be validated to establish their effectiveness and indication.
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Affiliation(s)
- Joaquín Cabezas
- Gastroenterology and Hepatology Department, Marqués de Valdecilla University Hospital, Clinical and Translational Research in Digestive Diseases Group-IDIVAL, Santander, Cantabria, Spain.
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161
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Goel A, Kwong A. CAQ Corner: Disease recurrence after liver transplantation. Liver Transpl 2022:1. [PMID: 37160054 DOI: 10.1002/lt.26492] [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: 02/23/2022] [Revised: 04/09/2022] [Accepted: 04/20/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Aparna Goel
- Division of Gastroenterology/Hepatology, Stanford University, Palo Alto, California, USA
| | - Allison Kwong
- Division of Gastroenterology/Hepatology, Stanford University, Palo Alto, California, USA
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162
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Singal AK, Kwo P, Kwong A, Liangpunsakul S, Louvet A, Mandrekar P, McClain C, Mellinger J, Szabo G, Terrault N, Thursz M, Winder GS, Kim WR, Shah VH. Research methodologies to address clinical unmet needs and challenges in alcohol-associated liver disease. Hepatology 2022; 75:1026-1037. [PMID: 34496071 PMCID: PMC9235468 DOI: 10.1002/hep.32143] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 08/13/2021] [Indexed: 12/12/2022]
Abstract
Alcohol-associated liver disease (ALD) is emerging worldwide as the leading cause of liver-related morbidity, mortality, and indication for liver transplantation. The ALD Special Interest Group and the Clinical Research Committee at the digital American Association for the Study of Liver Diseases meeting in November 2020 held the scientific sessions to identify clinical unmet needs in ALD, and addressing these needs using clinical research methodologies. Of several research methodologies, the sessions were focused on (a) studying disease burden of ALD using large administrative databases, (b) developing biomarkers for noninvasive diagnosis of alcohol-associated hepatitis (AH) and estimation of disease prognosis, (c) identifying therapeutic targets for ALD and AH, (d) deriving accurate models to predict prognosis or posttransplant alcohol relapse as a basis for developing treatment algorithm and a uniform protocol on patient-selection criteria for liver transplantation, and (e) examining qualitative research methodologies in studying the barriers to implementation of multidisciplinary integrated care model by hepatology and addiction teams for the management of dual pathology of liver disease and of alcohol use disorder. Prospective multicenter studies are required to address many of these clinical unmet needs. Further, multidisciplinary care models are needed to improve long-term outcomes in patients with ALD.
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Affiliation(s)
- Ashwani K Singal
- Department of Internal MedicineUniversity of South Dakota Sanford School of MedicineSioux FallsSouth DakotaUSA.,Division of Gastroenterology and HepatologyAvera Transplant InstituteSioux FallsSouth DakotaUSA
| | - Paul Kwo
- Division of Gastroenterology and HepatologyStanford University Medical CenterStanfordCaliforniaUSA
| | - Allison Kwong
- Division of Gastroenterology and HepatologyStanford University Medical CenterStanfordCaliforniaUSA
| | - Suthat Liangpunsakul
- Division of Gastroenterology and HepatologyIndiana UniversityIndianapolisIndianaUSA
| | | | - Pranoti Mandrekar
- Graduate School of Biomedical SciencesUMass Medical SchoolWorcesterMassachusettsUSA
| | - Craig McClain
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineUniversity of LouisvilleLouisvilleKentuckyUSA.,Department of Pharmacology and ToxicologyUniversity of Louisville School of MedicineLouisvilleKentuckyUSA.,Alcohol Research CenterUniversity of Louisville School of MedicineLouisvilleKentuckyUSA.,Robley Rex Veterans Affairs Medical CenterLouisvilleKentuckyUSA
| | - Jessica Mellinger
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA
| | - Gyongyi Szabo
- Division of Gastroenterology and HepatologyBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Norah Terrault
- Division of Gastroenterology and HepatologyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Mark Thursz
- Division of Digestive DiseasesImperial College LondonLondonUK
| | - Gerald S Winder
- Department of PsychiatryUniversity of MichiganAnn ArborMichiganUSA
| | - W Ray Kim
- Division of Gastroenterology and HepatologyStanford University Medical CenterStanfordCaliforniaUSA
| | - Vijay H Shah
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA
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163
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Hu K, Perez-Matos MC, Argemi J, Vilar-Gomez E, Shalaurova I, Bullitt E, Landeen L, Sugahara G, Deng H, Mathur K, Tran S, Cai H, He H, Yalcin Y, Vieira Barbosa J, Ventura-Cots M, Marx K, Gad AP, Niezen S, Izunza Barba S, Ang LH, Popov YV, Fricker Z, Lai M, Curry M, Afdhal N, Szabo G, Mukamal KJ, Sanyal AJ, Otvos JD, Malik R, Saito T, Connelly MA, Chalasani NP, Bataller R, Jiang ZG. Lipoprotein Z, a hepatotoxic lipoprotein, predicts outcome in alcohol-associated hepatitis. Hepatology 2022; 75:968-982. [PMID: 34662439 PMCID: PMC9299888 DOI: 10.1002/hep.32203] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/01/2021] [Accepted: 09/20/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Lipoprotein Z (LP-Z) is an abnormal free cholesterol (FC)-enriched LDL-like particle discovered from patients with cholestatic liver disease. This study aims to define the diagnostic value of LP-Z in alcohol-associated hepatitis (AH) and interrogate the biology behind its formation. APPROACH AND RESULTS We measured serum levels of LP-Z using nuclear magnetic resonance spectroscopy, a well-established clinical assay. Serum levels of LP-Z were significantly elevated in four AH cohorts compared with control groups, including heavy drinkers and patients with cirrhosis. We defined a Z-index, calculated by the ratio of LP-Z to total apolipoprotein B-containing lipoproteins, representing the degree of deviation from normal VLDL metabolism. A high Z-index was associated with 90-day mortality independent from the Model for End-Stage Liver Disease (MELD) and provided added prognosticative value. Both a Z-index ≤ 0.6 and a decline of Z-index by ≥0.1 in 2 weeks predicted 90-day survival. RNA-sequencing analyses of liver tissues demonstrated an inverse association in the expression of enzymes responsible for the extrahepatic conversion of VLDL to LDL and AH disease severity, which was further confirmed by the measurement of serum enzyme activity. To evaluate whether the FC in LP-Z could contribute to the pathogenesis of AH, we found significantly altered FC levels in liver explant of patients with AH. Furthermore, FC in reconstituted LP-Z particles caused direct toxicity to human hepatocytes in a concentration-dependent manner, supporting a pathogenic role of FC in LP-Z. CONCLUSIONS Impaired lipoprotein metabolism in AH leads to the accumulation of LP-Z in the circulation, which is hepatotoxic from excessive FC. A Z-index ≤ 0.6 predicts 90-day survival independent from conventional biomarkers for disease prognostication.
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Affiliation(s)
- Kunpeng Hu
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA.,Division of General SurgeryThe Third Affiliated Hospital of Sun Yat-Sen UniversityGuangzhouChina
| | - Maria C Perez-Matos
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Josepmaria Argemi
- Division of Gastroenterology, Hepatology, and NutritionUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA.,Hepatology ProgramCentro de Investigacion Medica Aplicada, Liver UnitClinica Universidad de NavarraInstituto de Investigacion de NavarraUniversity of NavarraPamplonaSpain
| | - Eduardo Vilar-Gomez
- Division of Gastroenterology and HepatologyIndiana University School of MedicineIndianapolisIndianaUSA
| | - Irina Shalaurova
- Laboratory Corporation of America HoldingsMorrisvilleNorth CarolinaUSA
| | - Esther Bullitt
- Department of Physiology and BiophysicsBoston University School of MedicineBostonMassachusettsUSA
| | | | - Go Sugahara
- Division of Gastrointestinal and Liver DiseasesKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA.,Research and Development DepartmentPhoenixBio, Co., LtdHigashi-Hiroshima, HiroshimaJapan
| | - Huiyan Deng
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Karan Mathur
- Division of Gastroenterology and HepatologyIndiana University School of MedicineIndianapolisIndianaUSA
| | - Stephanie Tran
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Huimei Cai
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Hanchang He
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Yusuf Yalcin
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Joana Vieira Barbosa
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA.,Division of Gastroenterology and HepatologyLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Meritxell Ventura-Cots
- Division of Gastroenterology, Hepatology, and NutritionUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Katherine Marx
- Transplant InstituteDepartment of SurgeryBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Aniket P Gad
- Confocal Imaging Core facilityBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Sebastian Niezen
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Sofia Izunza Barba
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Lay-Hong Ang
- Confocal Imaging Core facilityBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Yury V Popov
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Zachary Fricker
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Michelle Lai
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Michael Curry
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Nezam Afdhal
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Gyongyi Szabo
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Kenneth J Mukamal
- Division of General MedicineDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Arun J Sanyal
- Division of Gastroenterology, Hepatology and NutritionVirginia Commonwealth University School of MedicineRichmondVirginiaUSA
| | - James D Otvos
- Laboratory Corporation of America HoldingsMorrisvilleNorth CarolinaUSA
| | - Raza Malik
- Liver CenterDivision of GastroenterologyTufts Medical CenterBostonMassachusettsUSA
| | - Takeshi Saito
- Division of Gastrointestinal and Liver DiseasesKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | | | - Naga P Chalasani
- Division of Gastroenterology and HepatologyIndiana University School of MedicineIndianapolisIndianaUSA
| | - Ramon Bataller
- Division of Gastroenterology, Hepatology, and NutritionUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Z Gordon Jiang
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
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164
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Forrest E, Goldin R. Letter: the value of quality liver biopsy before initiation of corticosteroids for severe alcoholic hepatitis-authors' reply. Aliment Pharmacol Ther 2022; 55:1072. [PMID: 35362124 DOI: 10.1111/apt.16890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Ewan Forrest
- Glasgow Royal Infirmary and University of Glasgow, UK
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165
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Germani G, Angrisani D, Addolorato G, Merli M, Mazzarelli C, Tarli C, Lattanzi B, Panariello A, Prandoni P, Craxì L, Forza G, Feltrin A, Ronzan A, Feltracco P, Grieco A, Agnes S, Gasbarrini A, Rossi M, De Carlis L, Francesco D, Cillo U, Belli LS, Burra P. Liver transplantation for severe alcoholic hepatitis: A multicenter Italian study. Am J Transplant 2022; 22:1191-1200. [PMID: 34954874 DOI: 10.1111/ajt.16936] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 12/14/2021] [Accepted: 12/14/2021] [Indexed: 01/25/2023]
Abstract
There is increasing evidence that early liver transplantation (eLT), performed within standardized protocols can improve survival in severe alcoholic hepatitis (sAH). The aim of the study was to assess outcomes after eLT for sAH in four Italian LT centers and to compare them with non-responders to medical therapy excluded from eLT. Patients admitted for sAH (2013-2019), according to NIAAA criteria, were included. Patients not responding to medical therapy were placed on the waiting list for eLT after a strict selection. Histological features of explanted livers were evaluated. Posttransplant survival and alcohol relapse were evaluated. Ninety-three patients with severe AH were evaluated (65.6% male, median [IQR] age: 47 [42-56] years). Forty-five of 93 patients received corticosteroids, 52 of 93 were non-responders and among these, 20 patients were waitlisted. Sixteen patients underwent LT. Overall, 6-, 12-, and 24-month survival rates were 100% significantly higher compared with non-responders to medical therapy who were denied LT (45%, 45%, and 36%; p < .001). 2/16 patients resumed alcohol intake, one at 164 days and one at 184 days. Early LT significantly improves survival in sAH non-responding to medical therapy, when a strict selection process is applied. Further studies are needed to properly assess alcohol relapse rates.
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Affiliation(s)
- Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Debora Angrisani
- Department of Hepatology and Gastroenterology, ASST GOM Niguarda Hospital, Milan, Italy
| | - Giovanni Addolorato
- Alcohol Use Disorders Unit, Department of Internal Medicine, Institute of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy.,Internal Medicine, Gastroenterology and Hepatology Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Manuela Merli
- Gastroenterology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Chiara Mazzarelli
- Department of Hepatology and Gastroenterology, ASST GOM Niguarda Hospital, Milan, Italy
| | - Claudia Tarli
- Alcohol Use Disorders Unit, Department of Internal Medicine, Institute of Internal Medicine, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | - Barbara Lattanzi
- Gastroenterology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Adelaide Panariello
- Department of Mental Health and Addiction Services, Niguarda Hospital, Milan, Italy
| | - Paola Prandoni
- Department of Mental Health and Addiction Services, Niguarda Hospital, Milan, Italy
| | - Lucia Craxì
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, Palermo, Italy
| | - Giovanni Forza
- Department of Legal and Occupational Medicine, Toxicology and Public Health, Padua University Hospital, Padua, Italy
| | | | - Andrea Ronzan
- Psychiatry Unit, Padua University Hospital, Padua, Italy
| | - Paolo Feltracco
- Anesthesia and Intensive Care, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Antonio Grieco
- Liver Transplant Medicine Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Salvatore Agnes
- General Surgery and Liver Transplant Unit, Università Cattolica - Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Internal Medicine, Gastroenterology and Hepatology Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Massimo Rossi
- General Surgery and Organ Transplantation Unit, Department of General 3 Surgery and Organ Transplantation, Sapienza University of Rome, Rome, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy.,School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - D'Amico Francesco
- Hepatobiliary Surgery and Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit, Padua University Hospital, Padua, Italy
| | - Luca S Belli
- Department of Hepatology and Gastroenterology, ASST GOM Niguarda Hospital, Milan, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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166
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Fecal microbiota transplantation in alcohol-associated acute-on-chronic liver failure: an open-label clinical trial. Hepatol Int 2022; 16:433-446. [DOI: 10.1007/s12072-022-10312-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 02/08/2022] [Indexed: 02/07/2023]
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167
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Higuera‐de‐la‐Tijera F, Lira‐Vera J, Morales‐Gutiérrez O, Martínez‐Castillo M, Medina‐Ávila Z, Servín‐Caamaño A, Pérez‐Hernández J, Gutiérrez‐Reyes G. Alcoholic Liver Disease. Clin Liver Dis (Hoboken) 2022; 19:63-67. [PMID: 35308479 PMCID: PMC8912218 DOI: 10.1002/cld.1164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Content available: Author Interview and Audio Recording.
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Affiliation(s)
- Fátima Higuera‐de‐la‐Tijera
- Gastroenterology and Hepatology DepartmentHospital General de México “Dr. Eduardo Liceaga,”Mexico CityMexico,Internal Medicine DepartmentHospital General de México "Dr. Eduardo Liceaga"Mexico CityMexico
| | - Jorge Emilio Lira‐Vera
- Gastroenterology and Hepatology DepartmentHospital General de México “Dr. Eduardo Liceaga,”Mexico CityMexico
| | - Oscar Morales‐Gutiérrez
- Gastroenterology and Hepatology DepartmentHospital General de México “Dr. Eduardo Liceaga,”Mexico CityMexico
| | - Moisés Martínez‐Castillo
- Liver, Pancreas and Motility LaboratoryDepartment of Experimental MedicineFaculty of MedicineUNAMMexico CityMexico
| | - Zaira Medina‐Ávila
- Liver, Pancreas and Motility LaboratoryDepartment of Experimental MedicineFaculty of MedicineUNAMMexico CityMexico
| | - Alfredo Servín‐Caamaño
- Gastroenterology and Hepatology DepartmentHospital General de México “Dr. Eduardo Liceaga,”Mexico CityMexico,Internal Medicine DepartmentHospital General de México "Dr. Eduardo Liceaga"Mexico CityMexico
| | - José Luis Pérez‐Hernández
- Gastroenterology and Hepatology DepartmentHospital General de México “Dr. Eduardo Liceaga,”Mexico CityMexico
| | - Gabriela Gutiérrez‐Reyes
- Liver, Pancreas and Motility LaboratoryDepartment of Experimental MedicineFaculty of MedicineUNAMMexico CityMexico
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Kezer CA, Buryska SM, Ahn JC, Harmsen WS, Dunn W, Singal AK, Arab JP, Díaz LA, Arnold J, Kamath PS, Shah VH, Simonetto DA. The Mortality Index for Alcohol-Associated Hepatitis: A Novel Prognostic Score. Mayo Clin Proc 2022; 97:480-490. [PMID: 35181163 DOI: 10.1016/j.mayocp.2021.10.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/17/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To develop a new scoring system that more accurately predicts 30-day mortality in patients with alcohol-associated hepatitis (AH). METHODS A cohort of consecutive adults diagnosed with AH at a single academic center from January 1, 1998, to December 31, 2018, was identified for model derivation. Multivariate logistic regression was used to create a new scoring system to predict 30-day mortality. External validation of this score was performed on a multicenter retrospective cohort. RESULTS In the derivation cohort of 266 patients, the 30-day mortality rate was 19.2%. The following variables were found to be significantly associated with mortality on multivariate analysis: age (P=.002), blood urea nitrogen (P=.003), albumin (P=.01), bilirubin (P=.02), and international normalized ratio (P=.001). A model incorporating these variables, entitled the Mortality Index for Alcohol-Associated Hepatitis (MIAAH), achieved a C statistic of 0.86. Comparison of the accuracy of the MIAAH to existing prognostic models, including the Model for End-Stage Liver Disease and Maddrey Discriminant Function, showed that the highest concordance was achieved by the MIAAH and that this difference was significant. In the validation cohort of 249 patients, the MIAAH C statistic decreased to 0.73 and was found to be significantly superior to the Maddrey Discriminant Function but not to the Model for End-Stage Liver Disease. CONCLUSION The MIAAH competes with the current prognostication models and is at a minimum as accurate as these existing scores in identifying patients with AH at high risk of short-term mortality. Furthermore, the MIAAH demonstrates advantageous performance characteristics in its ability to increasingly accurately dichotomize patients into those at highest risk of death and those likely to survive.
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Affiliation(s)
| | - Seth M Buryska
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Joseph C Ahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Winston Dunn
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City
| | - Ashwani K Singal
- University of South Dakota Sanford School of Medicine and Transplant Hepatologist, Avera Transplant Institute, Sioux Falls
| | - Juan P Arab
- Department of Gastroenterology and Hepatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis A Díaz
- Department of Gastroenterology and Hepatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Arnold
- Department of Gastroenterology and Hepatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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169
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Kumar SE, Goel A, Zachariah U, Nair SC, David VG, Varughese S, Gandhi PB, Barpha A, Sharma A, Vijayalekshmi B, Balasubramanian KA, Elias E, Eapen CE. Low Volume Plasma Exchange and Low Dose Steroid Improve Survival in Patients With Alcohol-Related Acute on Chronic Liver Failure and Severe Alcoholic Hepatitis - Preliminary Experience. J Clin Exp Hepatol 2022; 12:372-378. [PMID: 35535077 PMCID: PMC9077153 DOI: 10.1016/j.jceh.2021.07.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 07/14/2021] [Indexed: 12/12/2022] Open
Abstract
Background Alcohol-related acute on chronic liver failure (A-ACLF) patients have high short-term mortality and are poor candidates for steroid therapy. Plasma exchange (PLEX) improves survival in ACLF patients. We analyzed our experience with low volume PLEX (50% of plasma volume exchanged per session) and low dose steroids to treat A-ACLF patients. Methods We retrospectively compared the efficacy of low volume PLEX and low-dose steroids with standard medical treatment (SMT) in A-ACLF patients treated at our center between November 2017 to June 2019. The primary study outcome was one-year survival. Results Twenty-one A-ACLF patients in PLEX group [age 40 (29-56) years, median (range); MELD score 31 (29-46)] and 29 A-ACLF patients in SMT group [age 41.5 (28-63) years, MELD score 37 (21-48)] were studied. All 50 study patients had severe alcoholic hepatitis [mDF 84.7 (50-389)]. PLEX group patients had 3 (1-7) PLEX sessions with 1.5 (1.4-1.6) liters of plasma exchanged per session and oral Prednisolone 20 mg daily, tapered over 1 month. Kaplan Meier analysis showed better survival over 1 year in the PLEX group compared to the SMT group (P = 0.03). There was renal dysfunction in 10 patients in the PLEX group, which normalized in six patients after PLEX. Conclusion In this preliminary report, compared to SMT, low volume PLEX and low dose steroid improved survival over one year in A-ACLF patients with severe alcoholic hepatitis. In patients with renal dysfunction, 60% showed improvement in renal function with PLEX. Studies with a larger number of patients are needed to validate these results.
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Key Words
- A-ACLF, Alcohol-related acute on chronic liver failure
- AARC score, APASL ACLF Research Consortium score
- ADAMTS13, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13
- APASL, Asia pacific association for the study of the liver
- INR, International normalized ratio
- MELD, Model for end-stage liver disease
- PLEX, Plasma exchange
- SMT, standard medical treatment
- VWF, von Willebrand factor
- acute on chronic liver failure
- alcohol
- mDF, modified discriminant function
- plasma exchange
- steroid
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Affiliation(s)
- Santhosh E. Kumar
- Departments of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ashish Goel
- Departments of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Uday Zachariah
- Departments of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sukesh C. Nair
- Transfusion Medicine and Immunohematology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vinoi G. David
- Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Prashanth B. Gandhi
- Departments of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Amit Barpha
- Departments of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anand Sharma
- Departments of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India
| | | | | | - Elwyn Elias
- Departments of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India
- Liver Unit, University Hospitals Birmingham, Birmingham, UK
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170
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Fujiwara N, Trépo E, Raman I, Li QZ, Degré D, Gustot T, Moreno C, Hoshida Y. Plasma-Signature-Model for End-Stage Liver Disease Score to Predict Survival in Severe Alcoholic Hepatitis. Clin Gastroenterol Hepatol 2022; 20:651-657. [PMID: 33667676 PMCID: PMC8410886 DOI: 10.1016/j.cgh.2021.02.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 02/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Severe alcoholic hepatitis (AH) is a highly lethal condition and it is still a challenge to predict the outcome. We previously identified and validated a composite score of hepatic 123-gene prognostic signature and the model for end-stage liver disease (MELD) score: gene signature-MELD. However, the need for liver biopsy limits its clinical application. Therefore, we aimed to identify a plasma protein-based surrogate of the gene signature and independently validate its prognostic capability. METHODS All patients were diagnosed with severe AH at Cliniques universitaires de Bruxelles Hôpital Erasme (Brussels, Belgium), and the plasma samples were collected at admission before any treatment. The primary outcome was death or liver transplantation within 90 days. Using our computational pipeline, named translation of tissue expression to secretome (TexSEC), a hepatic-transcriptome-based prognostic signature was converted to a plasma-based secretome signature, which was optimized in 50 patients by comparing their hepatic molecular dysregulation status and combining it with the MELD score. The composite score was validated independently in 57 patients. RESULTS The TexSEC and optimization process identified a 6-plasma-protein panel as a surrogate for the 123-gene signature. A composite score with the MELD score, the plasma-signature (ps)-MELD score, was created by using the coefficients of the gene signature-MELD equation. In the validation cohort, the high-risk ps-MELD (n = 23; 40%) was associated significantly with death or liver transplantation within 90 days (adjusted hazard ratio, 4.57; 95% CI, 2.15-9.30; P < .001). The ps-MELD score showed a stable, high prognostic association (time-dependent area under receiver operating characteristics curve, >0.80) and was well calibrated over time; it consistently outperformed existing clinical scores as indicated by various model performance indices. CONCLUSIONS The high-risk ps-MELD score was associated with short-term survival in patients with severe AH.
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Affiliation(s)
- Naoto Fujiwara
- Liver Tumor Translational Research Program, Simmons Comprehensive Cancer Center, Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, U.S.,Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Eric Trépo
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Indu Raman
- Microarray Core Facility, Department of Immunology, BioCenter, University of Texas Southwestern Medical Center, Dallas, TX, U.S
| | - Quan-Zhen Li
- Microarray Core Facility, Department of Immunology, BioCenter, University of Texas Southwestern Medical Center, Dallas, TX, U.S
| | - Delphine Degré
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Thierry Gustot
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Yujin Hoshida
- Liver Tumor Translational Research Program, Simmons Comprehensive Cancer Center, Division of Digestive and Liver Diseases, Department of Internal Medicine, Dallas, Texas.
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171
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Parker R, Cabezas J, Altamirano J, Arab JP, Ventura-Cots M, Sinha A, Dhanda A, Arrese M, McCune CA, Rowe IA, Schnabl B, Mathurin P, Shawcross D, Abraldes JG, Lucey MR, Garcia-Tsao G, Verna E, Brown RS, Bosques-Padilla F, Vargas V, Louvet A, Holt AP, Bataller R. Trajectory of Serum Bilirubin Predicts Spontaneous Recovery in a Real-World Cohort of Patients With Alcoholic Hepatitis. Clin Gastroenterol Hepatol 2022; 20:e289-e297. [PMID: 33516950 PMCID: PMC9188123 DOI: 10.1016/j.cgh.2021.01.042] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/20/2021] [Accepted: 01/24/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Alcoholic hepatitis (AH) is a severe condition with poor short-term prognosis. Specific treatment with corticosteroids slightly improves short-term survival but is associated with infection and is not used in many centers. A reliable method to identify patients who will recover spontaneously will minimise the numbers of patients who experience side effects of available treatments. METHODS We analysed the trajectory of serum bilirubin concentration over the course of hospital admissions in patients with AH to predict spontaneous survival and the need for treatment. RESULTS data from 426 patients were analysed. Based on bilirubin trajectory, patients were categorized into three groups: 'fast fallers' (bilirubin <0.8 x admission value at day 7), 'static' (bilirubin of >0.9 - <1.2 x admission value) and 'rapid risers' (bilirubin of ≥1.2 x admission bilirubin). Fast fallers had significantly better 90-day survival compared to other groups (log rank p < .001), and showed no benefit of corticosteroid therapy (OR for survival at 28 days of treatment, 0.94, 95% CI 0.06 - 8.41). These findings remained even amongst patients with severe disease based on initial DF, GAHS or MELD scores. CONCLUSIONS We present an intuitive method of classifying patients with AH based on the trajectory of bilirubin over the first week of admission. It is complimentary to existing scores that identify candidates for corticosteroid treatment or assess response to treatment. This method identifies a group of patients with AH who recover spontaneously and can avoid corticosteroid therapy.
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Affiliation(s)
- Richard Parker
- Leeds Liver Unit, St James's University Hospital, Leeds, United Kingdom.
| | - Joaquin Cabezas
- Department of Gastroenterology and Hepatology, University Hospital Marques de Valdecilla, Valdecilla Research Institute, Santander, Spain; Liver Center, Departments of Medicine and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jose Altamirano
- Internal Medicine Department, Hospital Quirónsalud, Barcelona, Spain
| | - Juan Pablo Arab
- Department of Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Meritxell Ventura-Cots
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ashish Sinha
- Department of Liver Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Ashwin Dhanda
- Institute of Translational and Stratified Medicine, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, United Kingdom
| | - Marco Arrese
- Department of Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Centro de Envejecimiento y Regeneración, Departamento de Biología Celular y Molecular, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - C Anne McCune
- Department of Liver Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Ian A Rowe
- Leeds Liver Unit, St James's University Hospital, Leeds, United Kingdom
| | - Bernd Schnabl
- Department of Medicine, VA San Diego Healthcare System, University of California, San Diego, La Jolla, California
| | - Phillipe Mathurin
- Service des Maladies de l'Appareil Digestif et Unité, French Institute of Health and Medical Research, Hôpital Huriez, Lille, France
| | - Debbie Shawcross
- Liver Sciences, Dept of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Juan G Abraldes
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Centre of Excellence Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Alberta, Canada
| | - Michael R Lucey
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University, New Haven, Connecticut; Section of Digestive Diseases, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Elizabeth Verna
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York
| | | | - Victor Vargas
- Liver Unit, Hospital Vall d'Hebron, Universitat Autònoma Barcelona, CIBEREHD, Barcelona, Spain
| | - Alexandre Louvet
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
| | - Andrew P Holt
- Liver and Hepatobiliary Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Ramon Bataller
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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172
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Voss JK, Li Z, Weinman SA. Elevated blood monocyte counts in alcohol-associated hepatitis. JGH Open 2022; 6:148-151. [PMID: 35155825 PMCID: PMC8829102 DOI: 10.1002/jgh3.12707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 02/02/2023]
Abstract
In this retrospective study of 164 patients with alcohol-associated hepatitis, we find that the mean absolute monocyte count is 0.95 thousand cells/L, which is significantly higher than the upper limit of normal (0.80 thousand cells/μL) (P < 0.0001). Monocyte count is correlated with disease severity as measured by MELD score (R = 0.400, P < 0.0001) and Maddrey discriminant function (R = 0.330, P < 0.0001).
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Affiliation(s)
- Jordan K. Voss
- School of Medicine, University of Kansas Medical CenterKansas CityKansasUSA
- Present address:
Department of Internal Medicine, Mayo ClinicRochesterMinnesotaUSA
| | - Zhuan Li
- Department of Internal MedicineUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Steven A. Weinman
- Department of Internal MedicineUniversity of Kansas Medical CenterKansas CityKansasUSA
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173
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Morales-Arráez D, Ventura-Cots M, Altamirano J, Abraldes JG, Cruz-Lemini M, Thursz MR, Atkinson SR, Sarin SK, Kim W, Chavez-Araujo R, Higuera-de la Tijera MF, Singal AK, Shah VH, Kamath PS, Duarte-Rojo A, Charles EA, Vargas V, Jager M, Rautou PE, Rincon D, Zamarripa F, Restrepo-Gutiérrez JC, Torre A, Lucey MR, Arab JP, Mathurin P, Louvet A, García-Tsao G, González JA, Verna EC, Brown RS, Argemi J, Fernández-Carrillo C, Clemente A, Alvarado-Tapias E, Forrest E, Allison M, Bataller R. The MELD Score Is Superior to the Maddrey Discriminant Function Score to Predict Short-Term Mortality in Alcohol-Associated Hepatitis: A Global Study. Am J Gastroenterol 2022; 117:301-310. [PMID: 34962498 PMCID: PMC8999152 DOI: 10.14309/ajg.0000000000001596] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 10/27/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Several scoring systems predict mortality in alcohol-associated hepatitis (AH), including the Maddrey discriminant function (mDF) and model for end-stage liver disease (MELD) score developed in the United States, Glasgow alcoholic hepatitis score in the United Kingdom, and age, bilirubin, international normalized ratio, and creatinine score in Spain. To date, no global studies have examined the utility of these scores, nor has the MELD-sodium been evaluated for outcome prediction in AH. In this study, we assessed the accuracy of different scores to predict short-term mortality in AH and investigated additional factors to improve mortality prediction. METHODS Patients admitted to hospital with a definite or probable AH were recruited by 85 tertiary centers in 11 countries and across 3 continents. Baseline demographic and laboratory variables were obtained. The primary outcome was all-cause mortality at 28 and 90 days. RESULTS In total, 3,101 patients were eligible for inclusion. After exclusions (n = 520), 2,581 patients were enrolled (74.4% male, median age 48 years, interquartile range 40.9-55.0 years). The median MELD score was 23.5 (interquartile range 20.5-27.8). Mortality at 28 and 90 days was 20% and 30.9%, respectively. The area under the receiver operating characteristic curve for 28-day mortality ranged from 0.776 for MELD-sodium to 0.701 for mDF, and for 90-day mortality, it ranged from 0.773 for MELD to 0.709 for mDF. The area under the receiver operating characteristic curve for mDF to predict death was significantly lower than all other scores. Age added to MELD obtained only a small improvement of AUC. DISCUSSION These results suggest that the mDF score should no longer be used to assess AH's prognosis. The MELD score has the best performance in predicting short-term mortality.
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Affiliation(s)
- D Morales-Arráez
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Department of Gastroenterology and Hepatology, Hospital Universitario de Canarias, Canarias, Spain
| | - M Ventura-Cots
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - J Altamirano
- Department of Internal Medicine, Hospital Quironsalud, Barcelona, Spain
| | - J G Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, Canada
| | - M Cruz-Lemini
- Women and Perinatal Research Group, Obstetrics and Gynecology Department, Sant Pau University Hospital, Barcelona, Spain, and Maternal and Child Health and Development Network (SAMID, RD16/0022/0015), Instituto de Salud Carlos III, Spanish Ministry of Health, Spain
| | - M R Thursz
- Department of Metabolism, Digestive disease and Reproduction, Imperial College London, UK
| | - S R Atkinson
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Department of Metabolism, Digestive disease and Reproduction, Imperial College London, UK
| | - S K Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - W Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - R Chavez-Araujo
- Hospital das Clinicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - A K Singal
- Division of Gastroenterology and Hepatology, the University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - V H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - P S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - A Duarte-Rojo
- Division of Gastroenterology and Hepatology, Department of Medicine, the University of Arkansas for Medical Science, Little Rock, Arkansas, USA
| | - E A Charles
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - V Vargas
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Universidad Autónoma, Barcelona, CIBERehd, Barcelona, Spain
| | - M Jager
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
| | - P E Rautou
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
- Inserm, UMR-970, Paris Cardiovascular Research Center, PARCC, Paris, France
| | - D Rincon
- Hepatology Department, Hospital General Universitario Gregorio Marañón, CIBERehd and Universidad Complutense, Madrid, Spain
| | - F Zamarripa
- Gastroenterology, Juarez Hospital, Mexico City, Mexico
| | - J C Restrepo-Gutiérrez
- Liver Transplant Program, Hospital Pablo Tobon Uribe, University of Antioquia, Medellin, Colombia
| | - A Torre
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - M R Lucey
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - J P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - P Mathurin
- Service des Maladies de l'Appareil Digestif et de la Nutrition, CHU Lille, Lille, France
- LIRIC-Lille Inflammation Research International Center-U995, Univ. Lille, Inserm, CHU Lille, Lille, France
| | - A Louvet
- Service des Maladies de l'Appareil Digestif et de la Nutrition, CHU Lille, Lille, France
| | - G García-Tsao
- Section of Digestive Diseases, Yale University School of Medicine/VA-CT Healthcare System, New Haven/West Haven, Connecticut¸ USA
| | - J A González
- Gastroenterology Department, Hospital Universitario "Dr. José E González" Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - E C Verna
- Division of Digestive and Liver Diseases, Department of Medicine and Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - R S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - J Argemi
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Liver Unit, Clinica Universidad de Navarra, IdisNA. Pamplona, Spain
| | - C Fernández-Carrillo
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - A Clemente
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Liver Unit and Digestive Department H.G.U. Gregorio Marañón, Madrid, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - E Alvarado-Tapias
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - E Forrest
- Glasgow Royal Infirmary, Glasgow, UK
| | - M Allison
- Liver Unit, Cambridge Biomedical Research Centre, Cambridge, UK
| | - R Bataller
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
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Lee BP, Im GY, Rice JP, Lazar A, Weinberg E, Han H, Maddur H, Ghobrial RM, Therapondos G, Hsu C, Fix OK, Eswaran S, Shetty K, Chhatwal J, Dalgic OO, Jakhete N, Mobley C, Victor DW, Mehta N, Dinges L, Rinella M, Schiano TD, Lucey MR, Terrault N. Patterns of Alcohol Use After Early Liver Transplantation for Alcoholic Hepatitis. Clin Gastroenterol Hepatol 2022; 20:409-418.e5. [PMID: 33279780 DOI: 10.1016/j.cgh.2020.11.024] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/06/2020] [Accepted: 11/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Early liver transplantation (LT) for alcoholic hepatitis (AH) is lifesaving but concerns regarding return to harmful alcohol use remain. We sought to identify distinct patterns of alcohol use post-LT to inform pre-LT candidate selection and post-LT addiction care. METHODS Detailed post-LT alcohol use data was gathered retrospectively from consecutive patients with severe AH at 11 ACCELERATE-AH sites from 2006-2018. Latent class analysis identified longitudinal patterns of alcohol use post-LT. Logistic and Cox regression evaluated associations between patterns of alcohol use with pre-LT variables and post-LT survival. A microsimulation model estimated the effect of selection criteria on overall outcomes. RESULTS Of 153 LT recipients, 1-, 3-, and 5-year survival were 95%, 88% and 82%. Of 146 LT recipients surviving to home discharge, 4 distinct longitudinal patterns of post-LT alcohol use were identified: Pattern 1 [abstinent](n = 103; 71%), pattern 2 [late/non-heavy](n = 9; 6.2%), pattern 3 [early/non-heavy](n = 22; 15%), pattern 4 [early/heavy](n = 12; 8.2%). One-year survival was similar among the 4 patterns (100%), but patients with early post-LT alcohol use had lower 5-year survival (62% and 53%) compared to abstinent and late/non-heavy patterns (95% and 100%). Early alcohol use patterns were associated with younger age, multiple prior rehabilitation attempts, and overt encephalopathy. In simulation models, the pattern of post-LT alcohol use changed the average life-expectancy after early LT for AH. CONCLUSIONS A significant majority of LT recipients for AH maintain longer-term abstinence, but there are distinct patterns of alcohol use associated with higher risk of 3- and 5-year mortality. Pre-LT characteristics are associated with post-LT alcohol use patterns and may inform candidate selection and post-LT addiction care.
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Affiliation(s)
- Brian P Lee
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Gene Y Im
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - John P Rice
- Department of Medicine, University of Wisconsin, Madison, Wisconsin.
| | - Ann Lazar
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Ethan Weinberg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hyosun Han
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Haripriya Maddur
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - R Mark Ghobrial
- Weil Cornell College of Medicine, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, Texas
| | - George Therapondos
- Ochsner Clinical School of Medicine, Ochsner Clinic, New Orleans, Louisiana
| | - Christine Hsu
- Georgetown University School of Medicine, Washington, DC
| | - Oren K Fix
- Swedish Organ Transplant and Liver Center, Swedish Medical Center, Seattle, Washington
| | - Sheila Eswaran
- Department of Medicine, Rush Medical Center, Chicago, Illinois
| | - Kirti Shetty
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jag Chhatwal
- Institute of Technology Assessment, Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Ozden O Dalgic
- Institute of Technology Assessment, Liver Center and Gastrointestinal Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Neha Jakhete
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Constance Mobley
- Weil Cornell College of Medicine, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, Texas
| | - David W Victor
- Weil Cornell College of Medicine, Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, Texas
| | - Neil Mehta
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Lisanne Dinges
- Swedish Organ Transplant and Liver Center, Swedish Medical Center, Seattle, Washington
| | - Mary Rinella
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Michael R Lucey
- Department of Medicine, University of Wisconsin, Madison, Wisconsin
| | - Norah Terrault
- Keck School of Medicine, University of Southern California, Los Angeles, California.
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Bala S, Babuta M, Catalano D, Saiju A, Szabo G. Alcohol Promotes Exosome Biogenesis and Release via Modulating Rabs and miR-192 Expression in Human Hepatocytes. Front Cell Dev Biol 2022; 9:787356. [PMID: 35096820 PMCID: PMC8795686 DOI: 10.3389/fcell.2021.787356] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/20/2021] [Indexed: 12/12/2022] Open
Abstract
Exosomes are membrane vesicles released by various cell types into the extracellular space under different conditions including alcohol exposure. Exosomes are involved in intercellular communication and as mediators of various diseases. Alcohol use causes oxidative stress that promotes exosome secretion. Here, we elucidated the effects of alcohol on exosome biogenesis and secretion using human hepatocytes. We found that alcohol treatment induces the expression of genes involved in various steps of exosome formation. Expression of Rab proteins such as Rab1a, Rab5c, Rab6, Rab10, Rab11, Rab27a and Rab35 were increased at the mRNA level in primary human hepatocytes after alcohol treatment. Rab5, Rab6 and Rab11 showed significant induction in the livers of patients with alcohol-associated liver disease. Further, alcohol treatment also led to the induction of syntenin, vesicle-associated membrane proteins (VAMPs), and syntaxin that all play various roles in exosome biogenesis and secretion. VAMP3, VAMP5, VAPb, and syntaxin16 mRNA transcripts were increased in alcohol treated cells and in the livers of alcohol-associated liver disease (ALD) patients. Induction in these genes was associated with increases in exosome secretion in alcohol treated hepatocytes. We found that hepatocyte enriched miR-192 and miR-122 levels were significantly decreased in alcohol treated hepatocytes whereas their levels were increased in the cell-free supernatant. The primary transcripts of miR-192 and miR-122 were reduced in alcohol treated hepatocytes, suggesting alcohol partially affects these miRNAs at the transcriptional level. We found that miR-192 has putative binding sites for genes involved in exosome secretion. Inhibition of miR-192 in human hepatoma cells caused a significant increase in Rab27a, Rab35, syntaxin7 and syntaxin16 and a concurrent increase in exosome secretion, suggesting miR-192 regulates exosomes release in hepatocytes. Collectively, our results reveal that alcohol modulates Rabs, VAMPs and syntaxins directly and partly via miR-192 to induce exosome machinery and release.
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Affiliation(s)
- Shashi Bala
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Mrigya Babuta
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Donna Catalano
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Aman Saiju
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Gyongyi Szabo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
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Abstract
In patients with cirrhosis and chronic liver disease, acute-on-chronic liver failure is emerging as a major cause of mortality. These guidelines indicate the preferred approach to the management of patients with acute-on-chronic liver failure and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation process. In instances where the evidence was not appropriate for Grading of Recommendations, Assessment, Development, and Evaluation, but there was consensus of significant clinical merit, key concept statements were developed using expert consensus. These guidelines are meant to be broadly applicable and should be viewed as the preferred, but not only, approach to clinical scenarios.
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177
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Jones BE, Allegretti AS, Pose E, Mara KC, Ufere NN, Avitabile E, Shah VH, Kamath PS, Ginès P, Simonetto DA. Renal Replacement Therapy for Acute Kidney Injury in Severe Alcohol-Associated Hepatitis as a Bridge to Transplant or Recovery. Dig Dis Sci 2022; 67:697-707. [PMID: 33604793 DOI: 10.1007/s10620-021-06864-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 01/20/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Acute kidney injury is seen in approximately 30% of patients with severe alcohol-associated hepatitis (AH) and is associated with increased mortality. Controversy exists surrounding initiation of renal replacement therapy (RRT) in these patients, as most are ineligible for early transplantation. AIMS The primary aim was to identify predictors of survival and identify patients who may benefit from RRT as a bridge to transplant or recovery. METHODS A retrospective multicenter cohort of adult patients with AH, who received RRT, was developed, including patients from two North American and one European liver transplant centers. RESULTS Fifty-five patients were included. Survival was 26/55 (47.3%) at 30 days, 17/55 (30.9%) at 3 months, and 15/55 (27.2%) at 6 months. Of those who survived 6 months, 2/15 (13.3%) received simultaneous liver and kidney transplantation, 11/15 (73.3%) had spontaneous recovery of kidney function, and 2/15 (13.3%) remained on RRT. Of patients who survived at least 3 months, 8/17 (47%) completed addiction treatment. Predictors of mortality were pre-RRT MELD (OR 1.10, 1.02-1.19) and pre-RRT MELD-Na (OR 1.14, 1.03-1.27). Pre-RRT MELD-Na < 35 was associated with lower 6-month mortality (OR 0.23, 0.06 - 0.81). Of patients with pre-RRT MELD-Na < 35, 50% survived 6 months compared to 18% of patients with pre-RRT MELD-Na ≥ 35. CONCLUSIONS Although RRT has a limited role in patients with decompensated cirrhosis, ineligible for transplant, it may be used in select patients with AH. This may allow for spontaneous recovery with alcohol abstinence or completion of addiction treatment prior to transplant.
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Affiliation(s)
- Brian E Jones
- Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Elisa Pose
- Liver Unit, Hospital Clínic, University of Barcelona, Villarroel, 170, 08036, Barcelona, Catalonia, Spain
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Nneka N Ufere
- Division of Gastroenterology and Hepatology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Emma Avitabile
- Liver Unit, Hospital Clínic, University of Barcelona, Villarroel, 170, 08036, Barcelona, Catalonia, Spain
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Pere Ginès
- Liver Unit, Hospital Clínic, University of Barcelona, Villarroel, 170, 08036, Barcelona, Catalonia, Spain
| | - Douglas A Simonetto
- Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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178
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Helsley RN, Miyata T, Kadam A, Varadharajan V, Sangwan N, Huang EC, Banerjee R, Brown AL, Fung KK, Massey WJ, Neumann C, Orabi D, Osborn LJ, Schugar RC, McMullen MR, Bellar A, Poulsen KL, Kim A, Pathak V, Mrdjen M, Anderson JT, Willard B, McClain CJ, Mitchell M, McCullough AJ, Radaeva S, Barton B, Szabo G, Dasarathy S, Garcia-Garcia JC, Rotroff DM, Allende DS, Wang Z, Hazen SL, Nagy LE, Brown JM. Gut microbial trimethylamine is elevated in alcohol-associated hepatitis and contributes to ethanol-induced liver injury in mice. eLife 2022; 11:e76554. [PMID: 35084335 PMCID: PMC8853661 DOI: 10.7554/elife.76554] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022] Open
Abstract
There is mounting evidence that microbes residing in the human intestine contribute to diverse alcohol-associated liver diseases (ALD) including the most deadly form known as alcohol-associated hepatitis (AH). However, mechanisms by which gut microbes synergize with excessive alcohol intake to promote liver injury are poorly understood. Furthermore, whether drugs that selectively target gut microbial metabolism can improve ALD has never been tested. We used liquid chromatography tandem mass spectrometry to quantify the levels of microbe and host choline co-metabolites in healthy controls and AH patients, finding elevated levels of the microbial metabolite trimethylamine (TMA) in AH. In subsequent studies, we treated mice with non-lethal bacterial choline TMA lyase (CutC/D) inhibitors to blunt gut microbe-dependent production of TMA in the context of chronic ethanol administration. Indices of liver injury were quantified by complementary RNA sequencing, biochemical, and histological approaches. In addition, we examined the impact of ethanol consumption and TMA lyase inhibition on gut microbiome structure via 16S rRNA sequencing. We show the gut microbial choline metabolite TMA is elevated in AH patients and correlates with reduced hepatic expression of the TMA oxygenase flavin-containing monooxygenase 3 (FMO3). Provocatively, we find that small molecule inhibition of gut microbial CutC/D activity protects mice from ethanol-induced liver injury. CutC/D inhibitor-driven improvement in ethanol-induced liver injury is associated with distinct reorganization of the gut microbiome and host liver transcriptome. The microbial metabolite TMA is elevated in patients with AH, and inhibition of TMA production from gut microbes can protect mice from ethanol-induced liver injury.
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Affiliation(s)
- Robert N Helsley
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, College of Medicine, University of KentuckyLexingtonUnited States
| | - Tatsunori Miyata
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Anagha Kadam
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Venkateshwari Varadharajan
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Naseer Sangwan
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Emily C Huang
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Rakhee Banerjee
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Amanda L Brown
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Kevin K Fung
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - William J Massey
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Chase Neumann
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Danny Orabi
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Lucas J Osborn
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Rebecca C Schugar
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Megan R McMullen
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Annette Bellar
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Kyle L Poulsen
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Adam Kim
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Vai Pathak
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Marko Mrdjen
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - James T Anderson
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Belinda Willard
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Craig J McClain
- Department of Medicine, University of LouisvilleLouisvilleUnited States
| | - Mack Mitchell
- Department of Internal Medicine, University of Texas Southwestern Medical CenterDallasUnited States
| | - Arthur J McCullough
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Svetlana Radaeva
- National Institute on Alcohol Abuse and AlcoholismBethesdaUnited States
| | - Bruce Barton
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical SchoolWorcesterUnited States
| | - Gyongyi Szabo
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical SchoolBostonUnited States
| | - Srinivasan Dasarathy
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | | | - Daniel M Rotroff
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Daniela S Allende
- Department of Anatomical Pathology, Cleveland ClinicClevelandUnited States
| | - Zeneng Wang
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Stanley L Hazen
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
- Department of Cardiovascular Medicine, Heart and Vascular and Thoracic Institute, Cleveland ClinicClevelandUnited States
| | - Laura E Nagy
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland ClinicClevelandUnited States
| | - Jonathan Mark Brown
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute of the Cleveland ClinicClevelandUnited States
- Center for Microbiome and Human Health, Lerner Research Institute, Cleveland ClinicClevelandUnited States
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Trebicka J, Louvet A, Arroyo V, Jalan R, Shah VH, Moreau R. Severe alcoholic hepatitis as precipitant for organ failure and ACLF. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:67-76. [PMID: 35042255 DOI: 10.1055/a-1713-3796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Alcoholic hepatitis is the acute deterioration of alcoholic liver disease with rapid onset or worsening of jaundice, which in severe cases, may transition to acute-on-chronic liver failure with extremely high short-term mortality, increasing with the number and severity of hepatic and extra-hepatic organ dysfunction. Diagnosis and treatment are insufficient and challenging, especially due to the complex, multi-factorial and as yet not fully understood pathogenesis. While current management is limited to steroids and best supportive care, debate is ongoing concerning liver transplantation for selected patients, and several novel approaches are under way with mixed results. These drawbacks in disease management together with increasing prevalence in Germany, and generally in Western countries, constitute an unmet need for the healthcare systems. This review tries to summarize the current status of these aspects and provides an overview for pathogenesis, management and potential future treatments.
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Affiliation(s)
- Jonel Trebicka
- Medizinische Klinik 1, University of Frankfurt, Frankfurt am Main, Germany
| | | | - Vicente Arroyo
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Rajiv Jalan
- University College London, London, United Kingdom of Great Britain and Northern Ireland
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180
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Choi JW, Son HJ, Lee SS, Jeon H, Cho JK, Kim HJ, Cha RR, Lee JM, Kim HJ, Jung WT, Lee OJ. Acute hepatitis E virus superinfection increases mortality in patients with cirrhosis. BMC Infect Dis 2022; 22:62. [PMID: 35042464 PMCID: PMC8767750 DOI: 10.1186/s12879-022-07050-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 01/12/2022] [Indexed: 12/20/2022] Open
Abstract
Background Although acute hepatitis E is not fatal in healthy individuals, it is unclear whether hepatitis E superinfection increases the mortality in patients with pre-existing liver disease. Thus, we investigated the prognosis of patients with acute hepatitis E according to their cirrhosis diagnosis, and the prognosis according to the development of acute-on-chronic liver failure (ACLF) in patients with cirrhosis and chronic liver disease (CLD).
Methods This study included 74 consecutive patients who were diagnosed with acute viral hepatitis E between January 2007 and December 2019. Of them, 39 patients without CLD, 13 patients with non-cirrhotic CLD, and 22 patients with cirrhotic CLD were analyzed.
Results Among the 74 patients with HEV infection, 7 (9.5%) died within 180 days: 5 with underlying cirrhosis (71.4%) and 2 without cirrhosis (28.6%). The 180-day mortality was significant higher for patients with cirrhosis than for patients without cirrhosis (22.7% vs. 3.8%, P = 0.013). The age- and sex-adjusted proportional-hazard model revealed an approximately eightfold increase in the 180-day mortality risk in patients with cirrhosis compared to patients without cirrhosis. In addition, development of hepatitis E virus-related ACLF due to acute liver function deterioration in patients with pre-existing CLD or cirrhosis worsened the 180-day mortality rate. Conclusions Our findings suggest that the acute hepatitis E mortality rate was low in healthy individuals but higher in patients with cirrhosis, and especially high in those with ACLF. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07050-w.
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181
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Musto J, Stanfield D, Ley D, Lucey MR, Eickhoff J, Rice JP. Recovery and outcomes of patients denied early liver transplantation for severe alcohol-associated hepatitis. Hepatology 2022; 75:104-114. [PMID: 34387875 DOI: 10.1002/hep.32110] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 07/06/2021] [Accepted: 07/18/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Liver transplantation (LT) in alcohol-associated hepatitis (AH) remains controversial, in part because spontaneous recovery (SR) can occur. There is a paucity of data on SR in patients with severe AH who undergo LT evaluation. The purpose of this study was to determine factors associated with SR and survival in patients with severe AH who undergo LT evaluation. APPROACH AND RESULTS This is a retrospective study of ALD patients with Model for End-Stage Liver Disease (MELD) >25 and <90 days abstinence who underwent LT evaluation at a single center between 2012 and 2018. One hundred forty-four patients (median age, 45.5 years; 68.1% male) were included. Forty-nine (34%) underwent LT and 95 (66%) patients did not undergo LT, and of those, 34 (23.6%) experienced SR. Factors associated with recovery were younger age (OR, 0.92; p = 0.004), lower index international normalized ratio (INR; 0.31; p = 0.03), and lower peak MELD (OR, 0.83; p = 0.02). Only 7 patients (20.6%) achieved a compensated state with a MELD <15 and absence of therapy for ascites or HE. Survival was improved in patients who underwent early LT when compared to SR. Survival was impaired in SR following relapse to alcohol use when compared to SR patients who abstained and LT recipients. Among all 6-month survivors of AH, alcohol use trended toward an association with mortality (HR, 2.05; p = 0.17), but only LT was associated with decreased mortality risk (HR, 0.20; p = 0.005). CONCLUSIONS SR from AH after LT evaluation is associated with age, index INR, and lower peak MELD. Most recovered patients continue to experience end-stage complications. LT is the only factor associated with lower mortality.
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Affiliation(s)
- Jessica Musto
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Dylan Stanfield
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Dana Ley
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Michael R Lucey
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Jens Eickhoff
- Department of Biostatistic and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - John P Rice
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
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Choudhary NS, Saraf N, Dhampalwar S, Saigal S, Gautam D, Rastogi A, Bhangui P, Srinivasan T, Rastogi V, Mehrotra S, Soin AS. Poor Outcomes after Recidivism in Living Donor Liver Transplantation for Alcohol-Related Liver Disease. J Clin Exp Hepatol 2022; 12:37-42. [PMID: 35068783 PMCID: PMC8766539 DOI: 10.1016/j.jceh.2021.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 04/04/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Recidivism in patients who underwent liver transplantation for alcohol-related liver disease (ALD) is shown to be associated with poor survival in some studies. METHODS Living donor liver transplantation (LDLT) recipients for ALD with at least 2 years of follow-up and history of significant alcohol relapse were included. The recipients underwent LDLT from June 2010 to December 2016, and data were analyzed until June 2019. The cohort had a median follow-up of 54 (33-78 IQR) months. Recidivism (significant alcohol intake) was defined as >21 units per week. RESULTS A total of 27 of 463 (5.8%) LDLT recipients (all men), aged 43.5 ± 9.6 years, had significant alcohol intake. A liver biopsy was performed on demand in 14 patients (in the presence of raised levels of liver enzymes or jaundice). The histological diagnoses in these patients were as follows: alcoholic hepatitis in 7 (50%), alcoholic hepatitis and acute cellular rejection or chronic rejection in 4 (28.5%), cirrhosis in 2 (14.2%), and acute cellular rejection and cirrhosis in 1 (7.1%) patient. Four of 5 patients with a biopsy diagnosis of acute or chronic rejection were noncompliant with immunosuppression. Six of these patients died. The mortality after 1 year of transplant was significantly more in patients with recidivism. CONCLUSION Recidivism was associated with significant morbidity and mortality after liver transplantation.
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Affiliation(s)
- Narendra S. Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India,Address for correspondence: Dr Neeraj Saraf, Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Medanta The Medicity Hospital, Sector 38, Gurugram, Delhi (NCR), India. Tel.: +919899077795.
| | - Swapnil Dhampalwar
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Sanjiv Saigal
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Dheeraj Gautam
- Department of Pathology, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Amit Rastogi
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Thiagrajan Srinivasan
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Vipul Rastogi
- Department of Mental Health, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Saurabh Mehrotra
- Department of Mental Health, Medanta the Medicity, Gurugram, Delhi (NCR), India
| | - Arvinder S. Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India
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183
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Jophlin L, Singal AK. Liver Biopsy in Patients With Alcohol-Associated Liver Disease With Acute-on-Chronic Liver Failure. J Clin Exp Hepatol 2022; 12:544-550. [PMID: 35535109 PMCID: PMC9077173 DOI: 10.1016/j.jceh.2021.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/09/2021] [Indexed: 01/11/2023] Open
Abstract
Patients with alcohol-associated liver disease may develop severe forms of presentation of acute-on-chronic liver failure, with a high risk for short-term mortality. Alcoholic hepatitis should be suspected among patients with alcohol-associated liver disease who present with acute-on-chronic liver failure. In this review, we discuss the need and feasibility of liver biopsy in the diagnosis of alcoholic hepatitis and predicting its prognosis among decompensated patients with alcohol-associated liver disease and acute-on-chronic liver failure.
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Key Words
- AARC, Asia-Pacific ACLF Research Consortium
- ACLF
- ACLF, acute-on-chronic liver failure
- AH
- AH, alcoholic hepatitis
- AHHS, alcoholic hepatitis histologic score
- ALD
- ALD, alcohol-associated liver disease
- AUD, alcohol use disorder
- DF, discriminant function
- EUS, endoscopic ultrasound
- EtG, ethyl glucuronide
- NIAAA, National Institute on Alcoholism and Alcohol Abuse
- PEth, phosphatidylethanol
- SALVE, Study of Alcohol-related LiVer disease in Europe
- histology
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Affiliation(s)
- Loretta Jophlin
- Department of Gastroenterology and Hepatology, University of Louisville, Louisville, KY, USA
| | - Ashwani K. Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of South Dakota Sanford School of Medicine, South Dakota, USA,Address for correspondence:. Ashwani K. Singal, Professor of Medicine, University of South Dakota Sanford School of Medicine, Transplant Hepatologist and Chief Clinical Research Affairs, Avera McKennan University Hospital Transplant Institute, Sioux Falls, SD, 57105, USA. Tel.: +605 322-8545; fax: +605 322 8536.
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184
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Management of alcohol use disorder in patients with cirrhosis in the setting of liver transplantation. Nat Rev Gastroenterol Hepatol 2022; 19:45-59. [PMID: 34725498 PMCID: PMC8559139 DOI: 10.1038/s41575-021-00527-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 02/07/2023]
Abstract
The prevalence of alcohol use disorder (AUD) has been steadily increasing over the past decade. In parallel, alcohol-associated liver disease (ALD) has been increasing at an alarming rate, especially among young patients. Data suggest that most patients with ALD do not receive AUD therapy. Although liver transplantation is the only curative therapy for end-stage ALD, transplant candidacy is often a matter of debate given concerns about patients being under-treated for AUD and fears of post-transplantation relapse affecting the allograft. In this Review, we discuss diagnosis, predictors and effects of relapse, behavioural therapies and pharmacotherapies, and we also propose an integrative, multidisciplinary and multimodality approach for treating AUD in patients with cirrhosis, especially in the setting of liver transplantation. Notably, this approach takes into account the utility of AUD pharmacotherapy in patients on immunosuppressive medications and those with renal impairment after liver transplantation. We also propose a comprehensive and objective definition of relapse utilizing contemporary biomarkers to guide future clinical trials. Future research using the proposed approach and definition is warranted with the goal of optimizing AUD treatment in patients with cirrhosis, the transplant selection process and post-transplantation care of patients with AUD.
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185
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Choi G, Benhammou JN, Yum JJ, Saab EG, Patel AP, Baird AJ, Aguirre S, Farmer DG, Saab S. Barriers for Liver Transplant in Patients with Alcohol-Related Hepatitis. J Clin Exp Hepatol 2022; 12:13-19. [PMID: 35068780 PMCID: PMC8766699 DOI: 10.1016/j.jceh.2021.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/13/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Liver transplantation (LT) for alcohol-related liver disease has historically been reserved for patients who have been six months abstinent. Given the increasing incidence of alcohol-related hepatitis (AH) and dismal survival in patients who fail medical therapy, transplant centers are extending their acceptance criteria for patients with less than 6 months of sobriety. We sought to determine the barriers for listing. METHODS We conducted a retrospective chart review of all inpatient LT referrals for a diagnosis of AH between September 2019 and December 2020. LT evaluations were performed by a multidisciplinary team. Descriptive statistics were reported using mean and standard deviation (SD) or percentage where appropriate. RESULTS During our study period, 82 patients were evaluated for LT. Of these 82 patients, 62 were declined for liver transplantation. The mean (SD) age of the 62-patient cohort was 44 years (10.7), and most patients were men. The mean (SD) number of reasons for denial was 2 (0.97). Four patients had medical contraindications for transplant. Twenty-seven (44%) and 35 (56%) patients lacked insight and were at risk of alcohol relapse, respectively. Forty-three (69%) and fourteen (22.5%) patients had insufficient social support and an inability to maintain a therapeutic relationship with the transplant team, respectively. CONCLUSION Patients are more likely denied for psychosocial factors than medical comorbidities. The majority were due to lack of insight, insufficient social support, and inability to maintain a therapeutic relationship with the transplant team. Resources should be allocated to address these issues.
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Affiliation(s)
- Gina Choi
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jihane N. Benhammou
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jung J. Yum
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Elena G. Saab
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ankur P. Patel
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Andrew J. Baird
- Department of Nursing, University of California, Los Angeles, Los Angeles, CA, USA
| | - Stephanie Aguirre
- Department of Social Work, University of California, Los Angeles, Los Angeles, CA, USA
| | - Douglas G. Farmer
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Nursing, University of California, Los Angeles, Los Angeles, CA, USA
- Address for correspondence. Sammy Saab, MD, MPH, AGAF, FAASLD, Pfleger Liver Institute, UCLA Medical Center, 200 Medical Plaza, Suite 214, Los Angeles, CA 90095, USA. Tel.: +1 310 206 6705; fax: +1 310 206 4197.
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186
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Im GY, Vogel AS, Florman S, Nahas J, Friedman SL, Aqui S, Ford L, Mirza O, Kim-Schluger L, Schiano TD. Extensive Health Care Utilization and Costs of an Early Liver Transplantation Program for Alcoholic Hepatitis. Liver Transpl 2022; 28:27-38. [PMID: 34133847 DOI: 10.1002/lt.26215] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 05/24/2021] [Accepted: 06/04/2021] [Indexed: 12/14/2022]
Abstract
Early liver transplantation (LT) for severe alcoholic hepatitis (AH) is a rescue therapy for highly selected patients with favorable psychosocial profiles not responding to medical therapy. Given the expected increase of AH candidate referrals requiring complex care and comprehensive evaluations, increased workload and cost might be expected from implementing an early LT program for AH but have not been determined. Some centers may also view AH as a strategy to expeditiously increase LT volume and economic viability. The aim of this study was to determine the health care use and costs of an early LT program for AH. Analyses of prospective databases of AH, interhospital transfers, and the hospital accounting system at a single center were performed from July 2011 to July 2016. For 5 years, 193 patients with severe AH were evaluated at our center: 143 newly referred transfers and 50 direct admissions. Annual increases of 13% led to 2 to 3 AH transfers/month and AH becoming the top reason for transfer. There were 169 (88%) nonresponders who underwent psychosocial evaluations; 15 (9%) underwent early LT. The median cost of early LT was $297,422, which was highly correlated with length of stay (r = 0.83; P < 0.001). Total net revenue of the program from LT admission to 90 days after LT was -$630,305 (-5.0% revenue), which was inversely correlated with MELD score (r = -0.70; P = 0.004) and yielded lower revenue than a contemporaneous LT program for acute-on-chronic liver failure (ACLF; $118,168; 1.4% revenue; P = 0.001). The health care use and costs of an early LT program for AH are extensive and lifesaving with marginally negative net revenue. Significantly increasing care of severe AH patients over 5 years resulted in increased LT volume, but at a lower rate than ACLF, and without improving economic outcomes due to high MELD and prolonged length of stay.
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Affiliation(s)
- Gene Y Im
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexander S Vogel
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sander Florman
- Recanati/Miller Transplantation Institute, Division of Abdominal Transplantation, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jonathan Nahas
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Scott L Friedman
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sarah Aqui
- Recanati/Miller Transplantation Institute, New York, NY
| | - Laura Ford
- Recanati/Miller Transplantation Institute, New York, NY
| | - Omar Mirza
- Department of Psychiatry, The Mount Sinai Medical Center, New York, NY
| | - Leona Kim-Schluger
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Thomas D Schiano
- Recanati/Miller Transplantation Institute, Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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187
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Cohen SM, Alexander RS, Holt SR. The Spectrum of Alcohol Use: Epidemiology, Diagnosis, and Treatment. Med Clin North Am 2022; 106:43-60. [PMID: 34823734 DOI: 10.1016/j.mcna.2021.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In the United States, alcohol is the most common substance used and the spectrum of unhealthy alcohol use is highly prevalent. Complications of unhealthy alcohol use affect nearly every organ system. One of the most frequent and potentially life-threatening of these complications is alcohol withdrawal syndrome for which benzodiazepines remain first-line therapy. Pharmacologic treatment of alcohol use disorder, the most severe form of unhealthy alcohol use, is underutilized despite the availability of multiple effective medications. Although behavioral therapies are an important component of treatment, they are overemphasized at the expense of pharmacotherapy.
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Affiliation(s)
- Shawn M Cohen
- Program in Addiction Medicine, Section of General Internal Medicine, Yale School of Medicine, 367 Cedar Street, Harkness Hal A, Suite 417A, New Haven, CT 06510, USA.
| | - Ryan S Alexander
- Program in Addiction Medicine, Section of General Internal Medicine, Yale School of Medicine, 367 Cedar Street, Harkness Hal A, Suite 417A, New Haven, CT 06510, USA; Department of Preventive Medicine, Griffin Hospital, Derby, CT 06418, USA; Department of Internal Medicine, Griffin Hospital, Derby, CT 06418, USA
| | - Stephen R Holt
- Program in Addiction Medicine, Section of General Internal Medicine, Yale School of Medicine, 367 Cedar Street, Harkness Hal A, Suite 417A, New Haven, CT 06510, USA
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188
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Reticuloendothelial activation correlates with disease severity and predicts mortality in severe alcoholic hepatitis. Eur J Gastroenterol Hepatol 2021; 33:e329-e334. [PMID: 33470708 DOI: 10.1097/meg.0000000000002056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Overactivation of reticuloendothelial cells lining liver sinusoids - Kupffer cells (macrophages) and sinusoidal endothelial cells - may narrow the sinusoidal lumen, impair perfusion in liver microcirculation and contribute to disease severity in alcoholic hepatitis. AIM The aim of the article was to assess reticuloendothelial activation in patients with severe alcoholic hepatitis (SAH). METHODS In SAH patients, we prospectively studied baseline reticuloendothelial activation markers [serum ferritin, sCD163 and plasma von Willebrand factor (VWF) antigen] and Macrophage Activation Syndrome (MAS) criteria, correlated them with disease severity scores [model for end-stage liver disease (MELD) and Sequential Organ Failure Assessment (SOFA) scores] and analyzed their ability to predict survival over a 90-day follow-up period. RESULTS A total of 50 SAH patients [45 (37-49) years, median (interquartile range), 49 males, discriminant function, 76.2 (54.5-106.6); MELD score, 30 (26.2-36)] were studied. 41 SAH patients (82%) had ferritin >500 ng/mL, and all (100%) had markedly raised sCD163 and VWF levels. The median sCD163 level was 10-fold higher than healthy controls and the median VWF level was 5-fold above the upper limit of normal. In total, 37 SAH patients (74%) met MAS criteria. Reticuloendothelial activation markers correlated with MELD and SOFA scores (P < 0.05). VWF was an independent marker to predict mortality in SAH [adjusted hazard ratio, 1.002 (1.000-1.004)]. CONCLUSIONS The reticuloendothelial system was markedly activated and correlated with disease severity scores in SAH patients.VWF predicted short-term mortality independent of MELD and sCD163. Further larger multicentric studies are needed to validate these findings.
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189
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Carrique L, Quance J, Tan A, Abbey S, Sales I, Lilly L, Bhat M, Galvin Z, Cattral M, Ghanekar A, McGilvray I, Reichman T, Sapisochin G, Sayed B, Selzner M, Lynch MJ, Selzner N. Results of Early Transplantation for Alcohol-Related Cirrhosis: Integrated Addiction Treatment With Low Rate of Relapse. Gastroenterology 2021; 161:1896-1906.e2. [PMID: 34370999 DOI: 10.1053/j.gastro.2021.08.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/28/2021] [Accepted: 08/02/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS In 2018, our team initiated a prospective pilot program to challenge the paradigm of the "6-month rule" of abstinence for patients with alcohol-related liver disease (ALD) requiring transplant. Our pilot involved an in-depth examination of patients' alcohol use, social support, and psychiatric comorbidity, as well as the provision of pre- and post-transplantation addiction treatment. METHODS Patients with ALD were assessed for inclusion in the pilot by a multidisciplinary team. Relapse prevention therapy was provided directly to all patients deemed to meet the program's inclusion criteria. Random biomarker testing for alcohol was used pre and post transplantation. RESULTS We received 703 referrals from May 1, 2018 to October 31, 2020. After fulfilling the program's criteria, 101 patients (14%) were listed for transplantation and 44 (6.2%) received transplants. There were no significant differences in survival rates between those receiving transplants through the pilot program compared with a control group with more than 6 months of abstinence (P = .07). Three patients returned to alcohol use during an average post-transplantation follow-up period of 339 days. In a multivariate analysis, younger age and lower Model for End-Stage Liver Disease scores at listing were associated with an increased likelihood of a return to alcohol use (P < .05); length of abstinence was not a predictor. CONCLUSIONS Our prospective program provided direct monitoring and relapse prevention treatment for patients with ALD and with less than 6 months of abstinence and resulted in a reduction of post-transplantation return to drinking. This pilot study provides a framework for the future of more equitable transplant care.
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Affiliation(s)
- Lauren Carrique
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Jill Quance
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Adrienne Tan
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada; Centre for Mental Health, University Health Network, Toronto, Canada
| | - Susan Abbey
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Isabel Sales
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Les Lilly
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Mamatha Bhat
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Zita Galvin
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Mark Cattral
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Anand Ghanekar
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Ian McGilvray
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Trevor Reichman
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | | | - Blayne Sayed
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Markus Selzner
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Marie-Josée Lynch
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Psychiatry, University of Toronto, Toronto, Canada; Centre for Mental Health, University Health Network, Toronto, Canada
| | - Nazia Selzner
- Ajmera Transplant Centre, University Health Network, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada.
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190
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Winters AC, May FP, Wang Y, Shao P, Yang L, Patel AA. Alcohol use disorder treatment and outcomes among hospitalized adults with alcoholic hepatitis. DRUG AND ALCOHOL DEPENDENCE REPORTS 2021; 1:100004. [PMID: 36843910 PMCID: PMC9948931 DOI: 10.1016/j.dadr.2021.100004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/04/2021] [Accepted: 11/04/2021] [Indexed: 11/25/2022]
Abstract
Purpose : The burden of alcohol-associated liver disease (ALD) in the United States (US) has continued to worsen in the background of rising rates of alcohol use disorder. Patients with ALD present to care at a late stage, often with the sequela of liver decompensation, such as gastrointestinal bleeding and infection. ALD is now the leading indication for liver transplantation. We aimed to measure the quality of care delivered to hospitalized patients with alcoholic hepatitis (AH) across 3 domains: 1) alcohol-use disorder (AUD) care, 2) inpatient cirrhosis care, and 3) alcohol-associated liver disease (ALD) care-and observe associations between quality of care and outcomes. Methods : We included hospital encounters between January 1, 2016 and January 1, 2019 to a large, diverse integrated health system for AH with active alcohol use within the prior 60 days. The diagnosis of AH was determined based on previously published clinical and laboratory criteria. Quality indicator (QI) pass rates were calculated as the proportion of patients eligible for each indicator who received the QI within the timeframe specified. We then evaluated the association between the receipt of all QIs and 6-month mortality, as well as AUD-specific QIs and 30-day readmission. Results : Of the 179 patients, the median age was 47 years-old, 59.2% were male and 49.2% were non-Hispanic White. The median Model for End-Stage Liver Disease-Sodium score was 25, while the median discriminant function was 33. Patients were followed for an average of 21 months. Overall, 14% of patients died during the index hospitalization while 17.3% died following discharge and 24.8% were re-admitted within 30-days. QI pass-rates were variable across the different domains. Few patients received AUD care-pass rates for receipt of pharmacotherapy and behavioral therapy at 6 months were only 19.1% and 35.1%, respectively. There was a significant association between receiving behavioral therapy and 6-month mortality-3% vs 18%, p = 0.05. Conclusion : The quality of care received during hospital encounters for AH is variable, and AUD-specific therapy is low. Future quality of care initiatives are warranted to link patients to AUD treatment to ensure optimal care and maximize patients survival in this at-risk population.
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Affiliation(s)
- Adam C. Winters
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Folasade P. May
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Yun Wang
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Paul Shao
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Liu Yang
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Arpan A. Patel
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA,Corresponding author.
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191
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Aloise DM, Izquierdo G. Uncertainty of Liver Cirrhosis Diagnosis and Use of Elastography. Cureus 2021; 13:e18411. [PMID: 34725628 PMCID: PMC8555918 DOI: 10.7759/cureus.18411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/30/2021] [Indexed: 11/30/2022] Open
Abstract
A case of severe jaundice in a patient with a long history of alcohol abuse led to a questionable diagnosis of liver cirrhosis. To determine its diagnostic utility in the setting of liver disease, elastography was utilized on our patient to confirm the clinically suspected diagnosis of cirrhosis. A 59-year-old male presented to our emergency department (ED) with two days of progressive jaundice and right upper quadrant (RUQ) pain. The patient admitted to drinking > 500 mL of vodka daily for the last seven years, with his last drink on the morning of admission. Physical exam revealed a man in mild acute distress with severe jaundice and an abdomen diffusely tender to palpation. Two spider angiomas were present on the torso along with caput medusae and mild asterixis. Labs revealed aspartate aminotransferase (AST) 408, alanine aminotransferase (ALT) 69, prothrombin time (PT) 16.3, partial thromboplastin time (PTT) 36, total bilirubin 22.6, and direct bilirubin 19.9 mg/dL. While admitted, total bilirubin rose as high as 31.5 mg/dL. Examination showed a Model for End-Stage Liver Disease (MELD) score of 22 and a Maddrey score of 37. Ultrasound revealed moderate hepatosplenomegaly with no signs of pancreatitis. Based on the patient’s history of alcohol abuse paired with physical exam findings and elevated laboratory markers, we were able to diagnose with a high level of suspicion that this patient was suffering from chronic alcoholic liver disease, exacerbated by an acute episode of alcoholic hepatitis, which led to hepatic encephalopathy. Based on these findings, a diagnosis of liver cirrhosis was suspected; however, this diagnosis required further confirmation. We utilized ultrasound elastography to measure the velocity of shear wave transmission in the liver of our patient. A literature review was conducted on the use of elastography for the diagnosis of liver disease, and a significant correlation between the velocity of shear wave transmission and hepatic histological findings was identified. Elastography revealed a mean velocity of shear wave transmission of 1.77 m/s in our patient. This finding is consistent with a Meta-analysis of Histological Data in Viral Hepatitis (METAVIR) score of F = 4, indicating significant fibrosis and confirming the suspected diagnosis of alcohol-induced liver cirrhosis. As a non-invasive and inexpensive diagnostic tool, elastography demonstrates significant potential for clinical utility in patients with liver disease. Clinicians may benefit from the use of elastography in diagnosis, while patients may receive both therapeutic and prognostic benefits secondary to its use. In similar cases with clinical uncertainty, elastography can reliably identify the presence of fibrous tissue in the liver without tissue biopsy, thus aiding in clinical diagnoses and enabling the use of optimal therapeutic regimens for future patients.
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Affiliation(s)
- Daniel M Aloise
- Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, USA
| | - Guillermo Izquierdo
- Internal Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, USA
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192
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Arab JP, Díaz LA, Baeza N, Idalsoaga F, Fuentes-López E, Arnold J, Ramírez CA, Morales-Arraez D, Ventura-Cots M, Alvarado-Tapias E, Zhang W, Clark V, Simonetto D, Ahn JC, Buryska S, Mehta TI, Stefanescu H, Horhat A, Bumbu A, Dunn W, Attar B, Agrawal R, Haque ZS, Majeed M, Cabezas J, García-Carrera I, Parker R, Cuyàs B, Poca M, Soriano G, Sarin SK, Maiwall R, Jalal PK, Abdulsada S, Higuera-de la Tijera MF, Kulkarni AV, Rao PN, Guerra Salazar P, Skladaný L, Bystrianska N, Prado V, Clemente-Sanchez A, Rincón D, Haider T, Chacko KR, Cairo F, de Sousa Coelho M, Romero GA, Pollarsky FD, Restrepo JC, Castro-Sanchez S, Toro LG, Yaquich P, Mendizabal M, Garrido ML, Narvaez A, Bessone F, Marcelo JS, Piombino D, Dirchwolf M, Arancibia JP, Altamirano J, Kim W, Araujo RC, Duarte-Rojo A, Vargas V, Rautou PE, Issoufaly T, Zamarripa F, Torre A, Lucey MR, Mathurin P, Louvet A, García-Tsao G, González JA, Verna E, Brown RS, Roblero JP, Abraldes JG, Arrese M, Shah VH, Kamath PS, Singal AK, Bataller R. Identification of optimal therapeutic window for steroid use in severe alcohol-associated hepatitis: A worldwide study. J Hepatol 2021; 75:1026-1033. [PMID: 34166722 PMCID: PMC11090180 DOI: 10.1016/j.jhep.2021.06.019] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/18/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Corticosteroids are the only effective therapy for severe alcohol-associated hepatitis (AH), defined by a model for end-stage liver disease (MELD) score >20. However, there are patients who may be too sick to benefit from therapy. Herein, we aimed to identify the range of MELD scores within which steroids are effective for AH. METHODS We performed a retrospective, international multicenter cohort study across 4 continents, including 3,380 adults with a clinical and/or histological diagnosis of AH. The main outcome was mortality at 30 days. We used a discrete-time survival analysis model, and MELD cut-offs were established using the transform-the-endpoints method. RESULTS In our cohort, median age was 49 (40-56) years, 76.5% were male, and 79% had underlying cirrhosis. Median MELD at admission was 24 (19-29). Survival was 88% (87-89) at 30 days, 77% (76-78) at 90 days, and 72% (72-74) at 180 days. A total of 1,225 patients received corticosteroids. In an adjusted-survival-model, corticosteroid use decreased 30-day mortality by 41% (hazard ratio [HR] 0.59; 0.47-0.74; p <0.001). Steroids only improved survival in patients with MELD scores between 21 (HR 0.61; 0.39-0.95; p = 0.027) and 51 (HR 0.72; 0.52-0.99; p = 0.041). The maximum effect of corticosteroid treatment (21-30% survival benefit) was observed with MELD scores between 25 (HR 0.58; 0.42-0.77; p <0.001) and 39 (HR 0.57; 0.41-0.79; p <0.001). No corticosteroid benefit was seen in patients with MELD >51. The type of corticosteroids used (prednisone, prednisolone, or methylprednisolone) was not associated with survival benefit (p = 0.247). CONCLUSION Corticosteroids improve 30-day survival only among patients with severe AH, especially with MELD scores between 25 and 39. LAY SUMMARY Alcohol-associated hepatitis is a condition where the liver is severely inflamed as a result of excess alcohol use. It is associated with high mortality and it is not clear whether the most commonly used treatments (corticosteroids) are effective, particularly in patients with very severe liver disease. In this worldwide study, the use of corticosteroids was associated with increased 30-day, but not 90- or 180-day, survival. The maximal benefit was observed in patients with an MELD score (a marker of severity of liver disease; higher scores signify worse disease) between 25-39. However, this benefit was lost in patients with the most severe liver disease (MELD score higher than 51).
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Affiliation(s)
- Juan Pablo Arab
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Luis Antonio Díaz
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Natalia Baeza
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Idalsoaga
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo Fuentes-López
- Department of Health Sciences, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Arnold
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Servicio Medicina Interna, Hospital El Pino, Santiago, Chile
| | | | - Dalia Morales-Arraez
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Meritxell Ventura-Cots
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Edilmar Alvarado-Tapias
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Wei Zhang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - Virginia Clark
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - Douglas Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Joseph C Ahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Seth Buryska
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Tej I Mehta
- Division of Gastroenterology and Hepatology, Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA; The Johns Hopkins Hospital, Department of Interventional Radiology, Baltimore, MD, USA
| | - Horia Stefanescu
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Adelina Horhat
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Andreea Bumbu
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | | | - Bashar Attar
- Division of Gastroenterology & Hepatology, Cook County Health and Hospital Systems, Chicago, Illinois, USA
| | - Rohit Agrawal
- Division of Gastroenterology and Hepatology, University of Illinois, Chicago, Illinois, USA
| | - Zohaib Syed Haque
- Division of Gastroenterology & Hepatology, Cook County Health and Hospital Systems, Chicago, Illinois, USA
| | - Muhammad Majeed
- Division of Gastroenterology & Hepatology, Cook County Health and Hospital Systems, Chicago, Illinois, USA
| | - Joaquín Cabezas
- Gastroenterology and Hepatology Department, University Hospital Marques de Valdecilla, Santander, Spain; Research Institute Valdecilla (IDIVAL), Santander, Spain
| | - Inés García-Carrera
- Gastroenterology and Hepatology Department, University Hospital Marques de Valdecilla, Santander, Spain; Research Institute Valdecilla (IDIVAL), Santander, Spain
| | - Richard Parker
- Leeds Liver Unit, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Berta Cuyàs
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, CIBERehd, Barcelona, Spain
| | - Maria Poca
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, CIBERehd, Barcelona, Spain
| | - German Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, CIBERehd, Barcelona, Spain
| | - Shiv K Sarin
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Prasun K Jalal
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Saba Abdulsada
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | | | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - P Nagaraja Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | | | - Lubomir Skladaný
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University, Slovak Republic; F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Natália Bystrianska
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University, Slovak Republic; F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | | | - Ana Clemente-Sanchez
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA; Liver Unit, Department of Digestive Diseases Hospital General Universitario Gregorio Marañón Madrid, Spain; CIBERehd Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas Madrid, Spain
| | - Diego Rincón
- Liver Unit, Department of Digestive Diseases Hospital General Universitario Gregorio Marañón Madrid, Spain; CIBERehd Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas Madrid, Spain
| | - Tehseen Haider
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, Bronx, NY, USA
| | - Kristina R Chacko
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, Bronx, NY, USA
| | - Fernando Cairo
- Liver Transplant Unit, Hospital El Cruce, Florencio Varela, Buenos Aires, Argentina
| | | | - Gustavo A Romero
- Sección Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Florencia D Pollarsky
- Sección Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Juan Carlos Restrepo
- Unidad de Hepatología del Hospital Pablo Tobon Uribe, Grupo de Gastrohepatología de la Universidad de Antioquia, Medellín, Colombia
| | - Susana Castro-Sanchez
- Unidad de Hepatología del Hospital Pablo Tobon Uribe, Grupo de Gastrohepatología de la Universidad de Antioquia, Medellín, Colombia
| | - Luis G Toro
- Hepatology and Liver Transplant Unit, Hospitales de San Vicente Fundación de Medellín y Rionegro, Colombia
| | - Pamela Yaquich
- Departamento de Gastroenterología, Hospital San Juan de Dios, Santiago, Chile
| | - Manuel Mendizabal
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Buenos Aires, Argentina
| | | | - Adrián Narvaez
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Fernando Bessone
- Hospital Provincial del Centenario, Universidad Nacional de Rosario, Rosario, Argentina
| | | | - Diego Piombino
- Servicio de Medicina Interna del Hospital de Emergencias Dr Clemente Alvarez de Rosario, Santa Fe, Argentina
| | - Melisa Dirchwolf
- Unidad de Hígado, Hospital Privado de Rosario, Rosario, Argentina
| | - Juan Pablo Arancibia
- Departamento de Gastroenterología y Hepatología, Clínica Santa María, Santiago, Chile
| | - José Altamirano
- Department of Internal Medicine, Hospital Quironsalud, Barcelona, Spain
| | - Won Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, South Korea
| | - Roberta C Araujo
- Gastroenterology Division, Ribeirão Preto Medical School, University of São Paulo, 14048-900 Ribeirão Preto, SP, Brazil
| | - Andrés Duarte-Rojo
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Victor Vargas
- Liver Unit, Hospital Vall d'Hebron, Universitat Autonoma Barcelona, CIBEREHD, Barcelona, Spain
| | - Pierre-Emmanuel Rautou
- Université de Paris, Centre de recherche sur l'inflammation, Inserm, U1149, CNRS, ERL8252, F-75018 Paris, France; Service d'Hépatologie, DHU Unity, DMU Digest, Hôpital Beaujon, AP-HP, Clichy, France; Centre de Référence des Maladies Vasculaires du Foie, French Network for Rare Liver Diseases (FILFOIE), European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Belgium
| | - Tazime Issoufaly
- Université de Paris, Centre de recherche sur l'inflammation, Inserm, U1149, CNRS, ERL8252, F-75018 Paris, France; Service d'Hépatologie, DHU Unity, DMU Digest, Hôpital Beaujon, AP-HP, Clichy, France; Centre de Référence des Maladies Vasculaires du Foie, French Network for Rare Liver Diseases (FILFOIE), European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Belgium
| | | | - Aldo Torre
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubiràn", Mexico City, Mexico
| | - Michael R Lucey
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Philippe Mathurin
- Hôpital Claude Huriez, Services des Maladies de l'Appareil Digestif, CHRU Lille, and Unité INSERM 995, Lille, France
| | - Alexandre Louvet
- Hôpital Claude Huriez, Services des Maladies de l'Appareil Digestif, CHRU Lille, and Unité INSERM 995, Lille, France
| | - Guadalupe García-Tsao
- Section of Digestive Diseases, Yale University School of Medicine/VA-CT Healthcare System, New Haven/West Haven, USA
| | - José Alberto González
- Gastroenterology Department, Hospital Universitario "Dr José E González" Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Elizabeth Verna
- Division of Digestive and Liver Diseases, Department of Medicine and Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY, USA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY
| | - Juan Pablo Roblero
- Sección Gastroenterología, Hospital Clínico Universidad de Chile, Escuela de Medicina Universidad de Chile, Santiago, Chile
| | - Juan G Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, Canada
| | - Marco Arrese
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA
| | - Ramon Bataller
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
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193
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Mathur K, Vilar-Gomez E, Connelly MA, He H, Sanyal AJ, Chalasani N, Jiang ZG. Circulating high density lipoprotein distinguishes alcoholic hepatitis from heavy drinkers and predicts 90-day outcome: lipoproteins in alcoholic hepatitis. J Clin Lipidol 2021; 15:805-813. [PMID: 34756674 PMCID: PMC8688310 DOI: 10.1016/j.jacl.2021.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 10/03/2021] [Accepted: 10/05/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Alcohol-associated liver disease (ALD) and alcoholic hepatitis (AH) significantly impact the liver, an organ central to the lipid and lipoprotein metabolism. OBJECTIVE To define changes in the lipid and lipoprotein profiles in subjects with alcoholic hepatitis (AH) versus heavy drinkers with normal liver function and to determine the association of the AH-mediated lipoprotein phenotype with AH severity and outcomes. METHODS AH cases (n=196) and a heavy drinker control group (n=169) were identified in a multicenter, prospective cohort. The relationships between lipid panels and lipoprotein profiles among AH and heavy drinkers were interrogated using three common measurements: the conventional lipid panel, extended lipid panel by NMR, and NMR-based direct lipoprotein profiling. Predictive values for AH severity and mortality were determined using Harrell's C-Index. RESULTS Lipid and lipoprotein profiles were significantly different in AH compared to heavy drinkers. Among them, high density lipoprotein (HDL) particle concentration exhibited the most significant reduction in AH compared to heavy drinkers (5.3 ± 3.4 vs 22.3 ± 5.4 μmol/L, p < 0.001). Within AH patients, HDL particle concentration was inversely associated with Maddrey's Discriminant Function (DF) (p < 0.001), and independently associated with mortality at both 90 and 365 days even after adjustment for DF (p = 0.02, p = 0.05 respectively). HDL particle concentration less than 3.5 μmol/L and total cholesterol ≤ 96 mg/dL identified AH patients with higher 90-day mortality. CONCLUSION Lipid and lipoprotein profiles are profoundly altered in AH and can help in prognosticating disease severity and mortality.
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Affiliation(s)
- Karan Mathur
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eduardo Vilar-Gomez
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Margery A Connelly
- Laboratory Corporation of America Holdings (Labcorp), Morrisville, NC, USA
| | - Hanchang He
- Divison of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Arun J Sanyal
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University, Richmond, Virginia
| | - Naga Chalasani
- Division of Gastroenterology & Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Z Gordon Jiang
- Divison of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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194
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Yang Z, Zhang T, Kusumanchi P, Tang Q, Sun Z, Radaeva S, Peiffer B, Shah VH, Kamath P, Gores GJ, Sanyal A, Chalasani N, Jiang Y, Huda N, Ma J, Liangpunsakul S. Transcriptomic Analysis Reveals the MicroRNAs Responsible for Liver Regeneration Associated With Mortality in Alcohol-Associated Hepatitis. Hepatology 2021; 74:2436-2451. [PMID: 34096637 PMCID: PMC8542623 DOI: 10.1002/hep.31994] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 05/03/2021] [Accepted: 05/13/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS We conducted a comprehensive serum transcriptomic analysis to explore the roles of microRNAs (miRNAs) in alcohol-associated hepatitis (AH) pathogenesis and their prognostic significance. APPROACH AND RESULTS Serum miRNA profiling was performed in 15 controls, 20 heavy drinkers without liver disease, and 65 patients with AH and compared to publicly available hepatic miRNA profiling in AH patients. Among the top 26 miRNAs, expression of miR-30b-5p, miR-20a-5p, miR-146a-5p, and miR-26b-5p were significantly reduced in both serum and liver of AH patients. Pathway analysis of the potential targets of these miRNAs uncovered the genes related to DNA synthesis and cell-cycle progression pathways, including ribonucleotide reductase regulatory subunit M2 (RRM2), cyclin D1 (CCND1), cyclin D2 (CCND2), MYC proto-oncogene (MYC), and phorbol-12-myristate-13-acetate-induced protein 1 (PMAIP1). We found a significant increase in the protein expression of RRM2, CCND1, and CCND2, but not MYC and PMAIP1, in AH patients who underwent liver transplantation; miR-26b-5p and miR-30b-5p inhibited the 3'-UTR (untranslated region) luciferase activity of RRM2 and CCND2, and miR-20a-5p reduced the 3'-UTR luciferase activity of CCND1 and CCND2. During a median follow-up of 346 days, 21% of AH patients died; these patients had higher body mass index (BMI), Model for End-Stage Liver Disease (MELD), and serum miR-30b-5p, miR-20a-5p, miR-146a-5p, and miR-26b-5p than those who survived. Cox regression analysis showed that BMI, MELD score, miR-20a-5p, miR-146a-5p, and miR-26b-5p predicted mortality. CONCLUSIONS Patients with AH attempt to deal with hepatocyte injury by down-regulating specific miRNAs and up-regulating genes responsible for DNA synthesis and cell-cycle progression. Higher expression of these miRNAs, suggestive of a diminished capacity in liver regeneration, predicts short-term mortality in AH patients.
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Affiliation(s)
- Zhihong Yang
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Ting Zhang
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Praveen Kusumanchi
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Qing Tang
- Department of Biostatistics, Indiana University, Indianapolis, IN
| | - Zhaoli Sun
- Department of Surgery, John Hopkins University, Rockville, MD
| | - Svetlana Radaeva
- National Institute on Alcohol Abuse and Alcoholism, Rockville, MD
| | - Brandon Peiffer
- Department of Surgery, John Hopkins University, Rockville, MD
| | - Vijay H. Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Patrick Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Greg J. Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Arun Sanyal
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University, Richmond, VA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Yanchao Jiang
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Nazmul Huda
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Jing Ma
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Suthat Liangpunsakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN,,Roudebush Veterans Administration Medical Center, Indianapolis, IN,,Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN
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195
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Pandey G, Singh H, Chaturvedi S, Hatti M, Kumar A, Mishra R, Mishra P, Krishna VP, Bhadauria A, Mohindra S, Misra DP, Saraswat VA, Agarwal V. Utility of neutrophil CD64 in distinguishing bacterial infection from inflammation in severe alcoholic hepatitis fulfilling SIRS criteria. Sci Rep 2021; 11:19726. [PMID: 34611256 PMCID: PMC8492738 DOI: 10.1038/s41598-021-99276-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/14/2021] [Indexed: 12/19/2022] Open
Abstract
To assess utility of neutrophilCD64 (nCD64) expression in differentiating bacterial infection from inflammation in patients with severe alcoholic hepatitis (SAH) fulfilling systemic inflammatory response syndrome criteria. Patients with SAH and infection (n = 58), SAH without infection (n = 70), and healthy controls (n = 20) were included. Neutrophil CD64 expression by flowcytometry, serum Procalcitonin (ELISA) and C-reactive protein (Nephelometry) and neutrophil–lymphocyte ratio (NLR) were studied. Percentage of neutrophils with CD64 expression (nCD64%) was significantly higher in patients with SAH and infection than in those without infection and controls [76.2% (56.9–86.5) vs. 16% (12.6–23.1) vs. 7.05% (1.4–9.5), p < 0.05], as was their mean fluorescence intensity [MFI; 1431 (229–1828) vs. 853 (20–968) vs. 99.5 (54.7–140.7), p < 0.05]. Using a cut-off of 27%, the sensitivity and specificity of nCD64% to diagnose bacterial infection was 94% and 81%, respectively, with area under curve (AUC) of 0.95. At a cut-off value of 0.261 ng/ml, the sensitivity and specificity of serum procalcitonin was 83% and 72%, respectively, with AUC of 0.86. Serum CRP, total leukocyte count, NLR had AUCs of 0.78, 0.63 and 0.64, respectively. Quantitative measurement of nCD64 can better distinguish systemic bacterial infection and inflammation in SAH as compared to traditional biomarkers.
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Affiliation(s)
- Gaurav Pandey
- Gastroenterology and Hepatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Harshit Singh
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - Saurabh Chaturvedi
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - Manjunath Hatti
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Alok Kumar
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Ravi Mishra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - Prabhakar Mishra
- Department of Statistics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - V P Krishna
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Arun Bhadauria
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Samir Mohindra
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India
| | - Vivek Anand Saraswat
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, 226014, India.
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196
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Musto JA, Eickhoff J, Ventura-Cots M, Abraldes JG, Bosques-Padilla F, Verna EC, Brown RS, Vargas V, Altamirano J, Caballería J, Shawcross D, Louvet A, Mathurin P, Garcia-Tsao G, Schnabl B, Bataller R, Lucey MR. The Level of Alcohol Consumption in the Prior Year Does Not Impact Clinical Outcomes in Patients With Alcohol-Associated Hepatitis. Liver Transpl 2021; 27:1382-1391. [PMID: 34109723 PMCID: PMC11075741 DOI: 10.1002/lt.26203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 04/19/2021] [Accepted: 05/03/2021] [Indexed: 12/13/2022]
Abstract
The 10-item Alcohol Use Disorders Identification Test (AUDIT-10) and its shorter form, AUDIT-Consumption (AUDIT-C), are questionnaires used to characterize severity of drinking. We hypothesized that liver injury and short-term outcomes of alcohol-associated hepatitis (AH) would correlate with a patient's recent alcohol consumption as determined by AUDIT-10 and AUDIT-C. We analyzed a prospective international database of patients with AH diagnosed based on the National Institute on Alcohol Abuse and Alcoholism (NIAAA) standard definitions. All patients were interviewed using AUDIT-10. Primary outcomes included the discriminatory ability of the AUDIT-10 and AUDIT-C scores for predicting survival status at 28 and 90 days and severity of liver injury, as measured by Model for End-Stage Liver Disease-sodium (MELD-Na). The relationship between AUDIT scores and survival status was quantified by calculating the area under the curve of the receiver operating characteristic analysis. The relationship between AUDIT scores and MELD-Na was examined using correlation coefficients. In 245 patients (age range 25-75 years; 35% female), we found no correlation between AUDIT-10 or AUDIT-C scores and either 28- or 90-day mortality. Similarly, there was no correlation between AUDIT-10 and AUDIT-C and MELD-Na scores. There was a strong positive correlation between MELD-Na and 28- and 90-day mortality. Additional measures of severity of alcohol use (average grams of alcohol consumed per day, years of drinking, convictions for driving under the influence, and rehabilitation attempts) and psychosocial factors (marriage, paid employment, and level of social support) had no influence on MELD-Na. In patients presenting with AH, AUDIT-10 and AUDIT-C were predictors of neither clinical severity of liver disease nor short-term mortality, suggesting that level of alcohol consumption in the prior year is not key to the presenting features or outcome of AH.
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Affiliation(s)
- Jessica A. Musto
- Division of Gastroenterology and Hepatology, University of
Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jens Eickhoff
- Division of Gastroenterology and Hepatology, University of
Wisconsin School of Medicine and Public Health, Madison, WI
| | - Meritxell Ventura-Cots
- University of Pittsburgh Medical Center, Pittsburgh,
PA
- Liver Unit, Hospital Universitari Vall d’Hebron,
Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación en Red de Enfermedades
Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Juan G. Abraldes
- Division of Gastroenterology, Liver Unit, University of
Alberta, Edmonton, AB, Canada
| | - Francisco Bosques-Padilla
- Hospital Universitario, Departamento de
Gastroenterología, Universidad Autonoma de Nuevo Leon, Monterrey,
Mexico
| | - Elizabeth C. Verna
- Division of Digestive and Liver Diseases, Department of
Medicine, Columbia College of Physicians and Surgeons, Columbia University Medical
Center, New York, NY
| | - Robert S. Brown
- Division of Gastroenterology and Hepatology, Weill Cornell
Medical College, New York, NY
| | - Victor Vargas
- Liver Unit, Hospital Universitari Vall d’Hebron,
Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación en Red de Enfermedades
Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Jose Altamirano
- Liver Unit, Hospital Universitari Vall d’Hebron,
Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Caballería
- Centro de Investigación en Red de Enfermedades
Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
- Liver Unit, Hospital Clinic, Institut
d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de
Investigación en Red de Enfermedades Hepáticas y Digestivas
(CIBERehd), Barcelona, Spain
| | - Debbie Shawcross
- Institute of Liver Studies, King’s College London
School of Medicine at King’s College Hospital, King’s College
Hospital, London, United Kingdom
| | - Alexandre Louvet
- Service des Maladies de L’appareil Digestif et
Unité INSERM, Hôpital Huriez, Lille, France
| | - Philippe Mathurin
- Service des Maladies de L’appareil Digestif et
Unité INSERM, Hôpital Huriez, Lille, France
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University School of
Medicine, New Haven, CT
- Section of Digestive Diseases, VA-CT Healthcare System,
West Haven, CT
| | | | | | - Michael R. Lucey
- Division of Gastroenterology and Hepatology, University of
Wisconsin School of Medicine and Public Health, Madison, WI
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197
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Vannier AGL, Wardwell B, Fomin V, PeBenito A, Wolczynski N, Piaker S, Kedrin D, Chung RT, Schaefer E, Goodman R, Patel SJ, Luther J. Serum HMGB1 associates with liver disease and predicts readmission and mortality in patients with alcohol use disorder. Alcohol 2021; 95:37-43. [PMID: 34118353 DOI: 10.1016/j.alcohol.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/05/2021] [Accepted: 05/17/2021] [Indexed: 12/18/2022]
Abstract
Identifying the minority of patients with alcohol use disorder (AUD) who develop the wide spectrum of alcohol-associated liver disease (ALD), and risk-stratifying these patients, is of critical importance. High-Mobility Group Box 1 protein (HMGB1) is an alarmin that has been implicated in the pathogenesis of multiple liver diseases. Its use as a biomarker for liver disease in those with AUD has not been studied. In this report, we investigated the association between serum HMGB1 and the presence, severity, and progression of ALD in two well-characterized cohorts of patients with AUD. In our discovery cohort of 80 patients, we found that patients with AUD and ALD exhibited higher serum HMGB1 levels compared to patients with AUD only (p = 0.0002). Additionally, serum HMGB1 levels were positively associated with liver disease severity (p < 0.0001). We found that index serum HMGB1 levels were associated with liver disease progression, defined by an increase in MELD score at 120 days (p = 0.0397). Serum HMGB1 was notable for its diagnostic and prognostic ability; it proved able to distinguish accurately between severe and non-severe forms of ALD in both our discovery cohort (AUC = 0.8199, p = 0.0003) and an independent validation cohort of 74 patients with AUD (AUC = 0.8818, p < 0.0001). Moreover, serum HMGB1 levels effectively predicted both liver-related readmission (AUC = 0.8849, p < 0.0001) and transplantation/death (AUC = 0.8614, p = 0.0002) at 90 days. The predictive potential of HMGB1 was also validated in an independent cohort of patients with AUD. Taken together, our results suggest that serum HMGB1 shows promise as a biologically relevant biomarker for ALD in patients with AUD.
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Affiliation(s)
- Augustin G L Vannier
- MGH Alcohol Liver Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States; Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States; Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States
| | - Ben Wardwell
- MGH Alcohol Liver Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States; Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States
| | - Vladislav Fomin
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States
| | - Amanda PeBenito
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States
| | - Nicholas Wolczynski
- MGH Alcohol Liver Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States
| | - Samuel Piaker
- Division of Endocrinology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02114, United States
| | - Dmitriy Kedrin
- MGH Alcohol Liver Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States
| | - Raymond T Chung
- MGH Alcohol Liver Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States; Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States; Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States
| | - Esperance Schaefer
- MGH Alcohol Liver Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States; Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States; Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States
| | - Russell Goodman
- MGH Alcohol Liver Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States; Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States; Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States
| | - Suraj J Patel
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States; Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States
| | - Jay Luther
- MGH Alcohol Liver Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States; Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States; Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States.
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198
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Forrest E, Goldin R. Letter: the diagnostic and prognostic significance of liver histology in alcoholic hepatitis-authors' reply. Aliment Pharmacol Ther 2021; 54:864. [PMID: 34425009 DOI: 10.1111/apt.16559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Ewan Forrest
- Glasgow Royal Infirmary and University of Glasgow, Glasgow, UK
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199
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Shamseddeen H, Madathanapalli A, Are VS, Shah VH, Sanyal AJ, Tang Q, Liang T, Gelow K, Zimmers TA, Chalasani N, Desai AP. Changes in Serum Myostatin Levels in Alcoholic Hepatitis Correlate with Improvement in MELD. Dig Dis Sci 2021; 66:3062-3073. [PMID: 33074470 PMCID: PMC8053725 DOI: 10.1007/s10620-020-06632-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Alcoholic hepatitis (AH) is a serious clinical syndrome often associated with muscle wasting. Myostatin, a member of the transforming growth factor-β superfamily, has been studied in diseases with muscle wasting; however, the role of myostatin in AH is unknown. AIMS To investigate the association between myostatin, clinical variables, and outcomes in AH. METHODS We analyzed data for cases of AH and controls of heavy drinkers (HD) in TREAT001 (NCT02172898) with serum myostatin levels (AH: n = 131, HD: n = 124). We compared characteristics between the two groups at baseline, 30, and 90 days and explored correlations between myostatin and clinical variables. We then modeled the relationship of myostatin to other variables, including mortality. RESULTS Baseline median myostatin was lower in AH compared to HD (males: 1.58 vs 3.06 ng/ml, p < 0.001; females: 0.84 vs 2.01 ng/ml, p < 0.001). In multivariable linear regression, bilirubin, WBC, and platelet count remained negatively correlated with myostatin in AH. AH females who died at 90 days had significantly lower myostatin, but in a multivariable logistic model with MELD and myostatin, only MELD remained significantly associated with 90-day mortality. During 1-year follow-up, AH cases (n = 30) demonstrated an increase in myostatin (mean, 1.73 ng/ml) which correlated with decreasing MELD scores (ρ = - 0.42, p = 0.01). CONCLUSIONS Myostatin levels are significantly lower in AH compared to HD and are negatively correlated with total bilirubin, WBC, and platelet count. Myostatin increased as patients experienced decreases in MELD. Overall, myostatin demonstrated a dynamic relationship with AH outcomes and future studies are needed to understand the prognostic role of myostatin in AH.
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Affiliation(s)
- Hani Shamseddeen
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA
| | | | - Vijay S Are
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Arun J Sanyal
- Division of Gastroenterology and Hepatology, VCU School of Medicine, Richmond, VA, USA
| | - Qing Tang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tiebing Liang
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA
| | - Kayla Gelow
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA
| | - Teresa A Zimmers
- Surgical Oncology, Surgery-Chairman's Office, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA
| | - Archita P Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA.
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200
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Vaz K, McLean C, Majeed A, Little R, Kemp W, Roberts S. Letter: the diagnostic and prognostic significance of liver histology in alcoholic hepatitis. Aliment Pharmacol Ther 2021; 54:862-863. [PMID: 34425014 DOI: 10.1111/apt.16539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Karl Vaz
- Department of Gastroenterology and Hepatology, Alfred Health, Melbourne, VIC, Australia.,Department of Gastroenterology and Hepatology, Austin Health, Melbourne, VIC, Australia
| | - Catriona McLean
- Department of Anatomical Pathology, Alfred Health, Melbourne, VIC, Australia
| | - Ammar Majeed
- Department of Gastroenterology and Hepatology, Alfred Health, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Robert Little
- Department of Gastroenterology and Hepatology, Alfred Health, Melbourne, VIC, Australia.,Department of Gastroenterology and Hepatology, St Vincent's Hospital, Melbourne, VIC, Australia
| | - William Kemp
- Department of Gastroenterology and Hepatology, Alfred Health, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Stuart Roberts
- Department of Gastroenterology and Hepatology, Alfred Health, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
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