301
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Ioannou GN, Green PK, Berry K. HCV eradication induced by direct-acting antiviral agents reduces the risk of hepatocellular carcinoma. J Hepatol 2017; 68:S0168-8278(17)32273-0. [PMID: 28887168 PMCID: PMC5837901 DOI: 10.1016/j.jhep.2017.08.030] [Citation(s) in RCA: 342] [Impact Index Per Article: 48.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 08/16/2017] [Accepted: 08/27/2017] [Indexed: 12/04/2022]
Abstract
BACKGROUND & AIMS It is unclear whether direct-acting antiviral (DAA) treatment-induced sustained virologic response (SVR) reduces the risk of hepatocellular carcinoma (HCC) in patients with HCV infection. Therefore, in the current study, our aim was to determine the impact of DAA-induced SVR on HCC risk. METHODS We identified 62,354 patients who initiated antiviral treatment in the Veterans Affairs (VA) national healthcare system from 1 January 1999 to 31 December 2015, including 35,871 (58%) interferon (IFN)-only regimens, 4,535 (7.2%) DAA + IFN regimens, and 21,948 (35%) DAA-only regimens. We retrospectively followed patients until 15 June 2017 to identify incident cases of HCC. We used Cox proportional hazards regression to determine the association between SVR and HCC risk or between type of antiviral regimen (DAA-only vs. DAA + IFN vs. IFN-only) and HCC risk. RESULTS We identified 3,271 incident cases of HCC diagnosed at least 180 days after initiation of antiviral treatment during a mean follow-up of 6.1 years. The incidence of HCC was highest in patients with cirrhosis and treatment failure (3.25 per 100 patient-years), followed by cirrhosis and SVR (1.97), no cirrhosis and treatment failure (0.87), and no cirrhosis and SVR (0.24). SVR was associated with a significantly decreased risk of HCC in multivariable models irrespective of whether the antiviral treatment was DAA-only (adjusted hazard ratio [AHR] 0.29; 95% CI 0.23-0.37), DAA + IFN (AHR 0.48; 95% CI 0.32-0.73) or IFN-only (AHR 0.32; 95% CI 0.28-0.37). Receipt of a DAA-only or DAA + IFN regimen was not associated with increased HCC risk compared with receipt of an IFN-only regimen. CONCLUSIONS DAA-induced SVR is associated with a 71% reduction in HCC risk. Treatment with DAAs is not associated with increased HCC risk compared with treatment with IFN. LAY SUMMARY It was unclear whether direct-acting antiviral treatment-induced sustained virologic response reduces the risk of liver cancer in patients with HCV infection. We demonstrated that eradication of HCV infection with direct-acting antiviral agents reduces the risk of liver cancer by 71%.
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Affiliation(s)
- George N Ioannou
- Division of Gastroenterology, Department of Medicine Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA; Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA.
| | - Pamela K Green
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - Kristin Berry
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
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302
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Kanwal F, Tansel A, Kramer JR, Feng H, Asch SM, El-Serag HB. Trends in 30-Day and 1-Year Mortality Among Patients Hospitalized With Cirrhosis From 2004 to 2013. Am J Gastroenterol 2017; 112:1287-1297. [PMID: 28607480 DOI: 10.1038/ajg.2017.175] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 05/12/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Recent data suggest decreasing in-patient mortality in patients hospitalized with cirrhosis. We sought to determine if improvements in short-term outcomes for patients with cirrhosis are associated with changes in longer-term outcomes. METHODS We examined temporal trends in 30 days and 1-year postdischarge mortality among patients hospitalized with cirrhosis at any of the 126 Veterans Administration hospitals from 2004 and 2013. We adjusted for a range of demographic, liver disease severity, and comorbidity-related factors to account for differences in patient cohorts over time. RESULTS We identified 109,358 unique patients who were hospitalized with cirrhosis between 2004 and 2013. In-hospital mortality decreased from 11.4 to 7.6%, whereas 1-year mortality decreased from 34.5 to 33.2%. Over a third of out-of-hospital deaths occurred within the first 30 days after discharge; 30-day mortality increased from 9.3 to 10.1%. After adjusting for patient factors, the odds of in-hospital mortality in 2013 were 30% lower (adjusted odds ratio (OR)=0.70, 95% confidence interval (CI), 0.64-0.78), 1-year mortality were 13% lower (adjusted OR=0.87, 95% CI=0.82-0.93), whereas the 30-day mortality were 10% higher than 2004 (adjusted OR=1.10, 95% CI=0.99-1.21), although the latter did not reach statistical significance. CONCLUSIONS In patients admitted with cirrhosis, reduction in in-hospital mortality was associated with less marked reduction in 1-year mortality, and an unchanged, if not higher, 30-day mortality following discharge. Our data suggest that some of the burden of mortality in cirrhosis has shifted from in-hospital to the immediate postdischarge period.
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Affiliation(s)
- Fasiha Kanwal
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Aylin Tansel
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Jennifer R Kramer
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Hua Feng
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Steven M Asch
- Center for Innovation to Implementation (Ci2i), Palo Alto Veterans Affairs Medical Center, Palo Alto, California, USA.,Division of General Medical Disciplines, Stanford University, Palo Alto, California, USA
| | - Hashem B El-Serag
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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303
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Janjua NZ, Islam N, Wong J, Yoshida EM, Ramji A, Samji H, Butt ZA, Chong M, Cook D, Alvarez M, Darvishian M, Tyndall M, Krajden M. Shift in disparities in hepatitis C treatment from interferon to DAA era: A population-based cohort study. J Viral Hepat 2017; 24:624-630. [PMID: 28130810 DOI: 10.1111/jvh.12684] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 12/22/2016] [Indexed: 12/15/2022]
Abstract
We evaluated the shift in the characteristics of people who received interferon-based hepatitis C virus (HCV) treatments and those who received recently introduced direct-acting antivirals (DAAs) in British Columbia (BC), Canada. The BC Hepatitis Testers Cohort includes 1.5 million individuals tested for HCV or HIV, or reported cases of hepatitis B and active tuberculosis in BC from 1990 to 2013 linked to medical visits, hospitalization, cancer, prescription drugs and mortality data. This analysis included all patients who filled at least one prescription for HCV treatment until 31 July 2015. HCV treatments were classified as older interferon-based treatments including pegylated interferon/ribavirin (PegIFN/RBV) with/without boceprevir or telaprevir, DAAs with RBV or PegIFN/RBV, and newer interferon-free DAAs. Of 11 886 people treated for HCV between 2000 and 2015, 1164 (9.8%) received interferon-free DAAs (ledipasvir/sofosbuvir: n=1075; 92.4%), while 452 (3.8%) received a combination of DAAs and RBV or PegIFN/RBV. Compared to those receiving interferon-based treatment, people with HIV co-infection (adjusted odds ratio [aOR]: 2.96, 95% CI: 2.31-3.81), cirrhosis (aOR: 1.77, 95% CI: 1.45-2.15), decompensated cirrhosis (aOR: 1.72, 95% CI: 1.31-2.28), diabetes (aOR: 1.30, 95% CI: 1.10-1.54), a history of injection drug use (aOR: 1.34, 95% CI: 1.09-1.65) and opioid substitution therapy (aOR: 1.30, 95% CI: 1.01-1.67) were more likely to receive interferon-free DAAs. Socio-economically marginalized individuals were significantly less likely (most deprived vs most privileged: aOR: 0.71, 95% CI: 0.58-0.87) to receive DAAs. In conclusion, there is a shift in prescription of new HCV treatments to previously excluded groups (eg HIV-co-infected), although gaps remain for the socio-economically marginalized populations.
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Affiliation(s)
- N Z Janjua
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - N Islam
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - J Wong
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - E M Yoshida
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - A Ramji
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - H Samji
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Z A Butt
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - M Chong
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - D Cook
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - M Alvarez
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - M Darvishian
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - M Tyndall
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - M Krajden
- British Columbia Centre for Disease Control, Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
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304
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Hung TH, Liang CM, Hsu CN, Tai WC, Tsai KL, Ku MK, Wang JW, Tseng KL, Yuan LT, Nguang SH, Yang SC, Wu CK, Hsu PI, Wu DC, Chuah SK. Association between complicated liver cirrhosis and the risk of hepatocellular carcinoma in Taiwan. PLoS One 2017; 12:e0181858. [PMID: 28742130 PMCID: PMC5524412 DOI: 10.1371/journal.pone.0181858] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 07/07/2017] [Indexed: 02/07/2023] Open
Abstract
Hepatic encephalopathy, ascites, and variceal bleeding are the three major complications of cirrhosis. It is well known that cirrhosis is the most important risk factor of hepatocellular carcinoma (HCC). However, little is known about whether the severity of liver cirrhosis has an effect on the incidence of HCC. This population-based cohort study aimed to explore the association between complicated cirrhosis and HCC, and identify the risk factors of HCC in patients with complicated cirrhosis. Data of the years 1997–2011 were extracted from the National Health Insurance Research Database of Taiwan. A total of 2568 patients with complicated cirrhosis without HCC at baseline were enrolled. After propensity score matching, another 2568 patients with non-complicated cirrhosis were included. Hazards Cox regression analysis by using a competing risk regression model to control for possible confounding factors was utilized to estimate the association of the complications of liver cirrhosis with the risk of HCC. We observed by using competing risk analysis that the adjusted hazard ratio (HR) for developing HCC during the follow-up period after the initial hospitalization was higher among the patients with baseline complicated cirrhosis than in those with uncomplicated cirrhosis (HR, 1.23; 95% confidence interval, CI, 1.10–1.37, p<0.001). Additionally, older patients (HR, 1.01; 95% CI, 1.01–1.02, p<0.001), males (HR, 0.84; 95% CI, 0.74–0.96, p = 0.009), and patients with alcohol-related cirrhosis (HR, 1.93; 95% CI, 1.65–2.26, p<0.001) had a statistically significant difference in the incidence of HCC. In conclusion, complicated liver cirrhosis is associated with a higher risk of HCC in Taiwan compared with cirrhosis without complications.
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Affiliation(s)
- Tsung-Hsing Hung
- Division of Gastroenterology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Ming Liang
- Division of Hepato-gastroenterology; Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chien-Ning Hsu
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Chen Tai
- Division of Hepato-gastroenterology; Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,Chang Gung University, College of Medicine, Kaohsiung, Taiwan
| | - Kai-Lung Tsai
- Division of Colon and Rectal Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Ming-Kun Ku
- Division of Gastroenterology; FooYin University Hospital, Pin-Tung, Taiwan
| | - Jiunn-Wei Wang
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital and Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kuo-Lun Tseng
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital and Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Lan-Ting Yuan
- Divisions of Gastroenterology, Yuan General Hospital, Kaohsiung, Taiwan
| | - Seng-Howe Nguang
- Division of Gastroenterology; Pin-Tung Christian Hospital, Pin-Tung, Taiwan
| | - Shih-Cheng Yang
- Division of Hepato-gastroenterology; Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Cheng-Kun Wu
- Division of Hepato-gastroenterology; Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Pin-I Hsu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, National Yang-Ming University, Kaohsiung, Taiwan
| | - Deng-Chyang Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital and Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Seng-Kee Chuah
- Division of Hepato-gastroenterology; Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,Chang Gung University, College of Medicine, Kaohsiung, Taiwan
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305
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Beste LA, Green PK, Berry K, Kogut MJ, Allison SK, Ioannou GN. Effectiveness of hepatitis C antiviral treatment in a USA cohort of veteran patients with hepatocellular carcinoma. J Hepatol 2017; 67:32-39. [PMID: 28267622 PMCID: PMC6590903 DOI: 10.1016/j.jhep.2017.02.027] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 01/20/2017] [Accepted: 02/18/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Hepatitis C virus (HCV) treatment for patients with hepatocellular carcinoma (HCC) was uncommon before direct-acting antiviral (DAA) medications. Real-world effectiveness of DAAs for HCV in patients with HCC is unclear. We describe rates of sustained virologic response (SVR) with DAA regimens by HCV genotype in patients with a history of HCC. METHODS We identified patients who initiated antiviral treatment between January 1, 2014 and June 30, 2015 in the national Veterans Affairs health care system. Regimens included sofosobuvir, ledipasvir/sofosbuvir, and paritaprevir/ritonavir/ombitasvir and dasabuvir with or without ribavirin. HCC patients were divided into those who were treated with liver transplantation after HCC diagnosis ("HCC/LT" group) and those treated with other modalities prior to antiviral therapy ("HCC" group). RESULTS Of 17,487 HCV treatment recipients, 624 (3.6%) had prior HCC, including 142 with HCC/LT and 482 with HCC. Overall SVR was 91.1% in non-HCC, 74.4% in HCC, and 94.0% in HCC/LT. Among HCC patients, genotype 1 had the highest SVR overall (79.1% in HCC and 96.4% in HCC/LT), and genotype 3 the lowest (47.0% in HCC and 88.9% in HCC/LT). After adjustment for confounders, the presence of HCC was associated with lower likelihood of SVR overall (AOR 0.38 [95% CI 0.29, 0.48], p<0.001). CONCLUSION HCV can be cured with DAAs in the majority of patients with prior HCC, and in virtually all HCC patients post-liver transplant. Deferral of HCV treatment until the post-transplant setting may be considered among HCC patients listed for transplantation. LAY SUMMARY Over three-quarters of patients with hepatocellular carcinoma who have hepatitis C can achieve viral cure with direct-acting antiviral drugs. Among patients with hepatocellular carcinoma who subsequently received liver transplantation, over 90% of patients can achieve viral cure.
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Affiliation(s)
- Lauren A. Beste
- General Medicine Service, Veterans Affairs Puget Sound Health Care System, United States,Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, United States,Division of General internal Medicine, University of Washington, United States, Corresponding author. Address: Veterans Affairs Puget Sound Health Care System, 1660 S. Columbian Way (S-111-Gastro), Seattle, WA 98108, United States. Tel.: +1 206 277 4511; fax: +1 206 764 2232. , (L.A. Beste).
| | - Pamela K. Green
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, United States
| | - Kristin Berry
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, United States
| | - Matthew J. Kogut
- Diagnostic Imaging Service, Veterans Affairs Puget Sound Health Care System, United States,Division of interventional Radiology, University of Washington, United States
| | - Stephen K. Allison
- Diagnostic Imaging Service, Veterans Affairs Puget Sound Health Care System, United States,Division of interventional Radiology, University of Washington, United States
| | - George N. Ioannou
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, United States,Gastroenterology Service, Veterans Affairs Puget Sound Health Care System, United States,Division of Gastroenterology, University of Washington, United States
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306
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Direct-acting antivirals are effective for chronic hepatitis C treatment in elderly patients: a real-world study of 17 487 patients. Eur J Gastroenterol Hepatol 2017; 29:686-693. [PMID: 28195877 PMCID: PMC6534142 DOI: 10.1097/meg.0000000000000858] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The mean age of patients with chronic hepatitis C virus (HCV) infection in the USA has been increasing. Despite the increasing proportion of HCV-infected elderly patients, this group is under-represented in clinical trials of HCV treatment. AIM We aimed to describe the real-world effectiveness of direct-acting antivirals (DAAs) among elderly patients. PATIENTS AND METHODS We retrospectively identified 17 487 HCV-infected patients who were started on treatment with sofosbuvir, ledipasvir/sofosbuvir, or paritaprevir/ombitasvir/ritonavir/dasabuvir-based regimens in the Veterans Affairs Healthcare System between 1 January 2014 and 30 June 2015. We ascertained sustained virologic response (SVR) rates in patients aged below 55, 55-59, 60-64, 65-69, 70-74, and 75 years or older and performed multivariable logistic regression to determine whether age predicted SVR. RESULTS Overall unadjusted SVR rates were 91.2% [95% confidence interval (CI): 89.7-92.4], 89.8% (95% CI: 88.8-90.7), 90.8% (95% CI: 90.1-91.6), 91.1% (95% CI: 90.1-91.9), 90.0% (95% CI: 86.9-92.4), and 93.8% (95% CI: 88.8-96.7) in patients aged below 55, 55-59, 60-64, 65-69, 70-74, and 75 years or older. Unadjusted SVR rates were similar in all age groups after stratifying by genotype, treatment regimen, stage of liver disease, and treatment experience. In multivariate models, age was not predictive of SVR after adjusting for confounders. CONCLUSION DAAs produce high rates of SVR in all age groups, including patients in our oldest age category (≥75 years). Advanced age in and of itself should not be considered a barrier to initiating DAA treatment.
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307
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Ioannou GN. Transplant-related survival benefit should influence prioritization for liver transplantation especially in patients with hepatocellular carcinoma. Liver Transpl 2017; 23:652-662. [PMID: 28006870 DOI: 10.1002/lt.24690] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 11/26/2016] [Indexed: 02/07/2023]
Abstract
Transplant-related survival benefit is calculated as the difference between life expectancy with transplantation and life expectancy without transplantation. Determining eligibility and prioritization for liver transplantation based on the highest survival benefit is a superior strategy to prioritization based on the highest urgency (ie, the highest wait-list mortality) or the highest utility (ie, the highest posttransplant survival) because prioritization based on the highest survival benefit maximizes the overall life expectancy of all patients in need of liver transplantation. Although the Model for End-Stage Liver Disease (MELD)-based prioritization system was designed as an urgency-based system, in practice it functions to a large extent as a survival benefit-based system, when the natural MELD score is used without exceptions. Survival benefit considerations should be used to determine the consequences of deviating from prioritization based on the natural MELD score, such as when exception points are awarded to patients with hepatocellular carcinoma (HCC) that are independent of MELD score or tumor burden, or the appropriateness of expanding eligibility for transplantation. The most promising application of survival benefit-based prioritization would be to replace the current system of prioritization of patients with HCC by one that uses their natural MELD score and tumor characteristics such as HCC tumor burden, serum alpha fetoprotein level, and response to locoregional therapies to predict the impact on survival benefit caused by the presence of HCC and adjust the natural MELD score for prioritization accordingly. Liver Transplantation 23 652-662, 2017 AASLD.
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Affiliation(s)
- George N Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, WA
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308
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Moon AM, Green PK, Berry K, Ioannou GN. Transformation of hepatitis C antiviral treatment in a national healthcare system following the introduction of direct antiviral agents. Aliment Pharmacol Ther 2017; 45:1201-1212. [PMID: 28271521 PMCID: PMC5849458 DOI: 10.1111/apt.14021] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 02/07/2017] [Accepted: 02/09/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Highly effective direct antiviral agents (DAAs) for hepatitis C virus (HCV) were introduced recently. Their utilisation has been limited by high cost and low access to care. AIM To describe the effect of DAAs on HCV treatment and cure rates in the United States Veterans Affairs (VA) national healthcare system. METHODS We identified all HCV antiviral treatment regimens initiated from 1 January 1999 to 31 December 2015 (n = 105 369) in the VA national healthcare system, and determined if they resulted in sustained virological response (SVR). RESULTS HCV antiviral treatment rates were low (1981-6679 treatments/year) in the interferon era (1999-2010). The introduction of simeprevir and sofosbuvir in 2013 and ledipasvir/sofosbuvir and paritaprevir/ombitasvir/ritonavir/dasabuvir in 2014 were followed by increases in annual treatment rates to 9180 in 2014 and 31 028 in 2015. The number of patients achieving SVR was 1313 in 2010, the last year of the interferon era, and increased 5.6-fold to 7377 in 2014 and 21-fold to 28 084 in 2015. The proportion of treated patients who achieved SVR increased from 19.2% in 1999 and 36.0% in 2010 to 90.5% in 2015. Within 2015, monthly treatment rates ranged from 727 in July to 6868 in September correlating with the availability of funds for DAAs. CONCLUSIONS DAAs resulted in a 21-fold increase in the number of patients achieving HCV cure. Treatment rates in 2015 were limited primarily by the availability of funds. Further increases in funding and cost reductions of DAAs in 2016 suggest that the VA could cure the majority of HCV-infected Veterans in VA care within the next few years.
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Affiliation(s)
- A M Moon
- Divisions of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - P K Green
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - K Berry
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - G N Ioannou
- Divisions of General Internal Medicine, University of Washington, Seattle, WA, USA
- Health Services Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
- Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
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309
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Beste LA, Glorioso TJ, Ho PM, Au DH, Kirsh SR, Todd-Stenberg J, Chang MF, Dominitz JA, Barón AE, Ross D. Telemedicine Specialty Support Promotes Hepatitis C Treatment by Primary Care Providers in the Department of Veterans Affairs. Am J Med 2017; 130:432-438.e3. [PMID: 27998682 DOI: 10.1016/j.amjmed.2016.11.019] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 10/28/2016] [Accepted: 11/08/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND The Department of Veterans Affairs is the largest US provider of hepatitis C treatment. Although antiviral regimens are becoming simpler, hepatitis C antivirals are not typically prescribed by primary care providers. The Veterans Affairs Extension for Community Health Outcomes (VA-ECHO) program was launched to promote primary care-based hepatitis C treatment using videoconferencing-based specialist support. We aimed to assess whether primary care provider participation in VA-ECHO was associated with hepatitis C treatment and sustained virologic response. METHODS We identified 4173 primary care providers (n = 152 sites) responsible for 38,753 patients with chronic hepatitis C infection. A total of 6431 patients had a primary care provider participating in VA-ECHO; 32,322 patients had an unexposed primary care provider. Exposure was modeled as a patient-level time-varying covariate. Patients became exposed after primary care provider participation in ≥1 VA-ECHO session. Multivariable Cox proportional hazards frailty modeling assessed the association between VA-ECHO exposure and hepatitis C treatment. Among treated patients, modified Poisson regression assessed the relationship between exposure and sustained virologic response. RESULTS After adjustment, exposed patients received significantly higher rates of antiviral treatment compared with unexposed patients (adjusted hazard ratio, 1.20; 95% confidence interval, 1.10-1.32; P <.01). The rate of primary care provider-initiated antiviral medication was 21.4% among treated patients reviewed on VA-ECHO teleconferences compared with 2.5% among unexposed patients (P <.01). No difference in adjusted rates of sustained virologic response was observed for patients with exposed primary care providers (P = .32), with similar crude rates for primary care providers versus specialists. CONCLUSIONS National implementation of VA-ECHO was positively associated with hepatitis C treatment initiation by primary care providers, without differences in sustained virologic response.
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Affiliation(s)
- Lauren A Beste
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Wash; Department of Medicine, School of Medicine, University of Washington, Seattle; General Medicine Service, VA Puget Sound Health Care System, Seattle, Wash.
| | - Thomas J Glorioso
- VA Eastern Colorado Health Care System, Denver; Department of Biostatistics and Informatics, University of Colorado Denver, Aurora
| | - P Michael Ho
- VA Eastern Colorado Health Care System, Denver; Department of Medicine, University of Colorado School of Medicine, Aurora
| | - David H Au
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Wash; Department of Medicine, School of Medicine, University of Washington, Seattle; Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Wash
| | - Susan R Kirsh
- Louis Stokes Cleveland VA Medical Center, Ohio; Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio; Office of Specialty Care Services, Veterans Health Administration, Washington, DC
| | - Jeffrey Todd-Stenberg
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Wash
| | - Michael F Chang
- Portland VA Medical Center, Ore; Department of Medicine, Division of Gastroenterology, Oregon Health & Sciences University, Portland
| | - Jason A Dominitz
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Wash; Department of Medicine, School of Medicine, University of Washington, Seattle; Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Wash
| | - Anna E Barón
- Department of Medicine, School of Medicine, University of Washington, Seattle
| | - David Ross
- Department of Veterans Affairs, Washington, DC; Department of Medicine, George Washington University, DC
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310
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Goldberg D, Ditah IC, Saeian K, Lalehzari M, Aronsohn A, Gorospe EC, Charlton M. Changes in the Prevalence of Hepatitis C Virus Infection, Nonalcoholic Steatohepatitis, and Alcoholic Liver Disease Among Patients With Cirrhosis or Liver Failure on the Waitlist for Liver Transplantation. Gastroenterology 2017; 152:1090-1099.e1. [PMID: 28088461 PMCID: PMC5367965 DOI: 10.1053/j.gastro.2017.01.003] [Citation(s) in RCA: 439] [Impact Index Per Article: 62.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 12/30/2016] [Accepted: 01/04/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Concurrent to development of more effective drugs for treatment of hepatitis C virus (HCV) infection, there has been an increase in the incidence of nonalcoholic fatty liver disease. Data indicate that liver transplantation prolongs survival times of patient with acute hepatitis associated with alcoholic liver disease (ALD). We compared data on disease prevalence in the population with data from liver transplantation waitlists to evaluate changes in the burden of liver disease in the United States. METHODS We collected data on the prevalence of HCV from the 2010 and 2013-2014 cycles of the National Health and Nutrition Examination Survey. We also collected data from the HealthCore Integrated Research Database on patients with cirrhosis and chronic liver failure (CLF) from 2006 through 2014, and data on patients who received transplants from the United Network for Organ Sharing from 2003 through 2015. We determined percentages of new waitlist members and transplant recipients with HCV infection, stratified by indication for transplantation, modeling each calendar year as a continuous variable using the Spearman rank correlation, nonparametric test of trends, and linear regression models. RESULTS In an analysis of data from the National Health and Nutrition Examination Survey (2013-2014), we found that the proportion of patients with a positive HCV antibody who had a positive HCV RNA was 0.5 (95% confidence interval, 0.42-0.55); this value was significantly lower than in 2010 (0.64; 95% confidence interval, 0.59-0.73) (P = .03). Data from the HealthCore database revealed significant changes (P < .05 for all) over time in percentages of patients with compensated cirrhosis (decreases in percentages of patients with cirrhosis from HCV or ALD, but increase in percentages of patients with cirrhosis from nonalcoholic steatohepatitis [NASH]), CLF (decreases in percentages of patients with CLF from HCV or ALD, with an almost 3-fold increase in percentage of patients with CLF from NASH), and hepatocellular carcinoma (HCC) (decreases in percentages of patients with HCC from HCV or ALD and a small increase in HCC among persons with NASH). Data from the United Network for Organ Sharing revealed that among patients new to the liver transplant waitlist, or undergoing liver transplantation, for CLF, there was a significant decrease in the percentage with HCV infection and increases in percentages of patients with nonalcoholic fatty liver disease or ALD. Among patients new to the liver transplant waitlist or undergoing liver transplantation for HCC, proportions of those with HCV infection, nonalcoholic fatty liver disease, or ALD did not change between 2003 and 2015. CONCLUSIONS In an analysis of 3 different databases (National Health and Nutrition Examination Survey, HealthCore, and United Network for Organ Sharing), we found the proportion of patients on the liver transplant waitlist or undergoing liver transplantation for chronic HCV infection to be decreasing and fewer patients to have cirrhosis or CLF. However, the percentages of patients on the waitlist or receiving liver transplants for NASH or ALD are increasing, despite different relative burdens of disease among the entire population of patients with cirrhosis.
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Affiliation(s)
- David Goldberg
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania Philadelphia, Pennsylvania.
| | - Ivo C Ditah
- Division of Gastroenterology and Hepatology, Regions Hospital, St Paul, Minnesota
| | - Kia Saeian
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mona Lalehzari
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andrew Aronsohn
- Division of Gastroenterology and Hepatology, University of Chicago Medical Center, Center for Liver Diseases, Chicago, Illinois
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311
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Abstract
In chronic liver diseases, an ongoing hepatocellular injury together with inflammatory reaction results in activation of hepatic stellate cells (HSCs) and increased deposition of extracellular matrix (ECM) termed as liver fibrosis. It can progress to cirrhosis that is characterized by parenchymal and vascular architectural changes together with the presence of regenerative nodules. Even at late stage, liver fibrosis is reversible and the underlying mechanisms include a switch in the inflammatory environment, elimination or regression of activated HSCs and degradation of ECM. While animal models have been indispensable for our understanding of liver fibrosis, they possess several important limitations and need to be further refined. A better insight into the liver fibrogenesis resulted in a large number of clinical trials aiming at reversing liver fibrosis, particularly in patients with non-alcoholic steatohepatitis. Collectively, the current developments demonstrate that reversal of liver fibrosis is turning from fiction to reality.
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Affiliation(s)
- Miguel Eugenio Zoubek
- Department of Internal Medicine III, RWTH Aachen University Hospital, Aachen, Germany
| | - Christian Trautwein
- Department of Internal Medicine III, RWTH Aachen University Hospital, Aachen, Germany.
| | - Pavel Strnad
- Department of Internal Medicine III, RWTH Aachen University Hospital, Aachen, Germany
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312
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Baumert TF, Jühling F, Ono A, Hoshida Y. Hepatitis C-related hepatocellular carcinoma in the era of new generation antivirals. BMC Med 2017; 15:52. [PMID: 28288626 PMCID: PMC5348895 DOI: 10.1186/s12916-017-0815-7] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 02/10/2017] [Indexed: 02/08/2023] Open
Abstract
Hepatitis C virus infection is a major cause of hepatocellular carcinoma worldwide. Interferon has been the major antiviral treatment, yielding viral clearance in approximately half of patients. New direct-acting antivirals substantially improved the cure rate to above 90%. However, access to therapies remains limited due to the high costs and under-diagnosis of infection in specific subpopulations, e.g., baby boomers, inmates, and injection drug users, and therefore, hepatocellular carcinoma incidence is predicted to increase in the next decades even in high-resource countries. Moreover, cancer risk persists even after 10 years of viral cure, and thus a clinical strategy for its monitoring is urgently needed. Several risk-predictive host factors, e.g., advanced liver fibrosis, older age, accompanying metabolic diseases such as diabetes, persisting hepatic inflammation, and elevated alpha-fetoprotein, as well as viral factors, e.g., core protein variants and genotype 3, have been reported. Indeed, a molecular signature in the liver has been associated with cancer risk even after viral cure. Direct-acting antivirals may affect cancer development and recurrence, which needs to be determined in further investigation.
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Affiliation(s)
- Thomas F Baumert
- Inserm, U1110, Institut de Recherche sur les Maladies Virales et Hépatiques, Strasbourg, France.,Université de Strasbourg, Strasbourg, France.,Institut Hospitalo-Universitaire, Pôle Hépatodigestif, Nouvel Hôpital Civil, Strasbourg, France
| | - Frank Jühling
- Inserm, U1110, Institut de Recherche sur les Maladies Virales et Hépatiques, Strasbourg, France.,Université de Strasbourg, Strasbourg, France
| | - Atsushi Ono
- Division of Liver Diseases, Department of Medicine, Liver Cancer Program, Tisch Cancer Institute, Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, Box 1123, New York, NY, 10029, USA.,Department of Gastroenterology and Metabolism, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yujin Hoshida
- Division of Liver Diseases, Department of Medicine, Liver Cancer Program, Tisch Cancer Institute, Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, 1470 Madison Ave, Box 1123, New York, NY, 10029, USA.
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313
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Janjua NZ, Chong M, Kuo M, Woods R, Wong J, Yoshida EM, Sherman M, Butt ZA, Samji H, Cook D, Yu A, Alvarez M, Tyndall M, Krajden M. Long-term effect of sustained virological response on hepatocellular carcinoma in patients with hepatitis C in Canada. J Hepatol 2017; 66:504-513. [PMID: 27818234 DOI: 10.1016/j.jhep.2016.10.028] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 10/19/2016] [Accepted: 10/22/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND & AIMS Evidence is limited on hepatocellular carcinoma (HCC) risk after sustained virological response (SVR) to interferon-based treatment of hepatitis C virus (HCV) infection. We evaluated the effect of SVR on the risk of HCC and estimated its incidence in post-SVR HCV patients from a large population-based Canadian cohort. METHODS The British Columbia Hepatitis Testers Cohort includes individuals tested for HCV between 1990-2013 linked with data on their medical visits, hospitalizations, cancers, prescription drugs and mortality. Patients receiving interferon-based HCV treatments were followed from the end of treatment to HCC diagnosis, death or December 31, 2012. We examined HCC risk among those who did and did not achieve SVR using multivariable proportional hazard models with the Fine and Gray modification for competing risks. RESULTS Of 8147 individuals who received HCV treatment and were eligible for analysis, 4663 (57%) achieved SVR and 3484 (43%) did not. Each group was followed for a median of 5.6years (range: 0.5-12.9) for an HCC incidence rate of 1.1/1000 person-years (PY) among the SVR and 7.2/1000 PY among the no SVR group. The HCC incidence rate was higher among those with cirrhosis (SVR: 6.4, no SVR: 21.0/1000 PY). In the multivariable model, SVR was associated with a lower HCC risk (subdistribution hazard ratio [SHR]=0.20, 95% CI: 0.13-0.3), while cirrhosis (SHR=2.61, 95% CI: 1.68-4.04), age ⩾50years, being male and genotype 3 infection were associated with a higher HCC risk. Among those who achieved SVR, cirrhosis, age ⩾50years and being male were associated with a higher HCC risk. CONCLUSION SVR after interferon-based treatment substantially reduces but does not eliminate HCC risk, which is markedly higher among those with cirrhosis and age ⩾50years at treatment initiation. Treatment of patients at an advanced fibrosis stage with new highly effective drugs will warrant continued surveillance for HCC post-SVR. LAY SUMMARY We assessed the effect of successful hepatitis C treatment with older interferon-based treatment on the occurrence of liver cancer (hepatocellular carcinoma) and found that successful treatment prevents liver cancer. However, more people with cirrhosis and older age continued to develop liver cancer after successful treatment. Thus, treatment with new drugs among those with cirrhosis will require continued monitoring for liver cancer.
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Affiliation(s)
- Naveed Z Janjua
- British Columbia Centre for Disease Control, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
| | - Mei Chong
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Margot Kuo
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Ryan Woods
- British Columbia Cancer Agency, Vancouver, BC, Canada
| | - Jason Wong
- British Columbia Centre for Disease Control, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Eric M Yoshida
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Morris Sherman
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Zahid A Butt
- British Columbia Centre for Disease Control, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Hasina Samji
- British Columbia Centre for Disease Control, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Darrel Cook
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Amanda Yu
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Maria Alvarez
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Mark Tyndall
- British Columbia Centre for Disease Control, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Mel Krajden
- British Columbia Centre for Disease Control, Vancouver, BC, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
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314
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Younossi ZM, Stepanova M, Feld J, Zeuzem S, Sulkowski M, Foster GR, Mangia A, Charlton M, O'Leary JG, Curry MP, Nader F, Henry L, Hunt S. Sofosbuvir and Velpatasvir Combination Improves Patient-reported Outcomes for Patients With HCV Infection, Without or With Compensated or Decompensated Cirrhosis. Clin Gastroenterol Hepatol 2017; 15:421-430.e6. [PMID: 27847279 DOI: 10.1016/j.cgh.2016.10.037] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 10/14/2016] [Accepted: 10/31/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The combination of sofosbuvir and velpatasvir is used to treat patients with hepatitis C virus (HCV) infection of different genotypes. We compared the effects of this treatment regimen, with and without ribavirin, on outcomes reported by patients (patient-reported outcomes [PROs]) with HCV infection, with or without cirrhosis. METHODS We performed a post hoc analysis of data collected from phase 3 clinical trials (ASTRAL-1, -2, -3, and -4) of 1701 patients infected with HCV of different genotypes treated with sofosbuvir and velpatasvir with ribavirin for 12 weeks (n = 87), sofosbuvir with ribavirin for 12 or 24 weeks (n = 401), and ribavirin-free sofosbuvir and velpatasvir for 12 or 24 weeks (n = 1213). In all trials, participants completed 4 PRO questionnaires (while blinded to their HCV RNA levels): the Short Form-36, the Functional Assessment of Chronic Illness Therapy-Fatigue, the Chronic Liver Disease Questionnaire-HCV Version, and the Work Productivity and Activity Impairment: Specific Health Problem, at multiple time points. We compared baseline PROs and changes in PROs following treatment in patients without cirrhosis (n = 1112), with compensated cirrhosis (n = 338), and with decompensated cirrhosis (n = 251). RESULTS Baseline PRO scores were as much as 33.5% lower in patients with decompensated cirrhosis than in patients without cirrhosis (P < .05). Following treatment with ribavirin-containing regimens, changes in PRO scores were similar among patients with compensated and decompensated cirrhosis (all P > .01). Treatment with these regimens increased some PRO scores by as much as 11.8% from baseline (P < .05) and reduced others, by as much as 7.1% (P < .05). Despite this, by 12 weeks after cessation of treatment with ribavirin-containing regimens, all PRO decrements resolved; PRO scores increased by as much as 14.2%, and as much as 17.1% at 24 weeks after treatment, regardless of cirrhosis status (all P > .01 between cirrhosis groups). In contrast, treatment with ribavirin-free sofosbuvir and velpatasvir increased PRO scores for patients with compensated cirrhosis, and even more so in patients with decompensated cirrhosis starting at treatment Week 4; no statistically significant decrement was observed at any time point (all 1-sided P values > .05). In multivariate analysis, compensated cirrhosis was associated with a 2.3% to 5.0% greater increase in PRO scores following treatment with sofosbuvir and velpatasvir (P < .05); decompensated cirrhosis was associated with a 5.5%-9.1% greater increase (P < .002). Clinicaltrials.gov number, NCT02201940, NCT02220998, NCT02201953, NCT02201901. CONCLUSIONS In an analysis of data from 4 phase 3 clinical trials, we found that patients with HCV infection (especially those with decompensated cirrhosis) have significant increases in their PRO scores during treatment with sofosbuvir and velpatasvir and after achieving a sustained virologic response.
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Affiliation(s)
- Zobair M Younossi
- Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, Virginia.
| | - Maria Stepanova
- Center for Outcomes Research, Washington, District of Columbia
| | - Jordan Feld
- Toronto Center for Liver Disease, Toronto, Canada
| | - Stefan Zeuzem
- Johann Wolfgang Goethe University Medical Center, Frankfurt am Main, Germany
| | | | | | - Alessandra Mangia
- Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | | | | | | | - Fatema Nader
- Center for Outcomes Research, Washington, District of Columbia
| | - Linda Henry
- Center for Outcomes Research, Washington, District of Columbia
| | - Sharon Hunt
- Center for Outcomes Research, Washington, District of Columbia
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315
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Younossi ZM, Tanaka A, Eguchi Y, Lim YS, Yu ML, Kawada N, Dan YY, Brooks-Rooney C, Negro F, Mondelli MU. The impact of hepatitis C virus outside the liver: Evidence from Asia. Liver Int 2017; 37:159-172. [PMID: 27748564 DOI: 10.1111/liv.13272] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 09/30/2016] [Indexed: 12/11/2022]
Abstract
Between 80 and 115 million people worldwide are chronically infected with hepatitis C virus, with 60%-90% of these being undiagnosed. Untreated chronic hepatitis C (CHC) is associated with progressive liver disease, cirrhosis, hepatocellular carcinoma and liver-related mortality. A number of extrahepatic manifestations are also reported in CHC patients, further adding to the burden of the disease. CHC also impacts patients in terms of lower health-related quality of life, higher levels of fatigue and reduced productivity. Furthermore, the later stages of disease are costly for both healthcare systems and society. Pegylated-interferon (PEG-IFN)+ribavirin (RBV), for many years the mainstay of treatment, leads to sustained virological response (SVR) in 40%-70% of patients. However, a substantial number of patients are ineligible for treatment, and many patients fail to achieve SVR with this regimen. Furthermore, PEG-IFN+RBV leads to impairment of patient-reported outcomes during treatment, and most patients suffer from adverse events, associated with poor adherence, treatment discontinuation and treatment failure. The approval of second-generation direct-acting antivirals (DAAs) has revolutionized the treatment of CHC patients. All-oral, PEG-IFN and RBV-free regimens have higher efficacy rates, shorter treatment durations, fewer adverse events, higher adherence rates and improvement in PROs from as early as Week 4, compared to PEG-IFN+RBV regimens. The aim of this article is to review the evidence for HCV infection as a systemic disease, summarizing the impact of hepatitis C and its treatments on clinical, patient and economic outcomes, with a focus on data from Asia and Japan specifically.
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Affiliation(s)
- Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA.,Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yuichiro Eguchi
- Liver Center, Saga University Hospital, Saga University, Saga, Japan
| | - Young-Suk Lim
- Department of Gastroenterology, Liver Center, Asan Medical Center, Seoul, Korea
| | - Ming-Lung Yu
- Hepatobiliary Division, Department of Internal Medicine and Hepatitis Center, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Norifumi Kawada
- Department of Hepatology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Yock Young Dan
- Department of Medicine, National University of Singapore, Singapore
| | | | - Francesco Negro
- Division of Gastroenterology and Hepatology and Division of Clinical Pathology, University Hospital, Geneva, Switzerland
| | - Mario U Mondelli
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
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316
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Su F, Green PK, Berry K, Ioannou GN. The association between race/ethnicity and the effectiveness of direct antiviral agents for hepatitis C virus infection. Hepatology 2017; 65:426-438. [PMID: 27775854 PMCID: PMC6535089 DOI: 10.1002/hep.28901] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 09/28/2016] [Accepted: 10/12/2016] [Indexed: 12/14/2022]
Abstract
Black race and Hispanic ethnicity were associated with lower rates of sustained virologic response (SVR) to interferon-based treatments for chronic hepatitis C virus infection, whereas Asian race was associated with higher SVR rates compared to white patients. We aimed to describe the association between race/ethnicity and effectiveness of new direct-acting antiviral regimens in the Veterans Affairs health care system nationally. We identified 21,095 hepatitis C virus-infected patients (11,029 [52%] white, 6,171 [29%] black, 1,187 [6%] Hispanic, 348 [2%] Asian/Pacific Islander/American Indian/Alaska Native, and 2,360 [11%] declined/missing race or ethnicity) who initiated antiviral treatment with regimens containing sofosbuvir, simeprevir + sofosbuvir, ledipasvir/sofosbuvir, or paritaprevir/ombitasvir/ritonavir/dasabuvir during the 18-month period from January 1, 2014, to June 30, 2015. Overall SVR rates were 89.8% (95% confidence interval [CI] 89.2-90.4) in white, 89.8% (95% CI 89.0-90.6) in black, 86.0% (95% CI 83.7-88.0) in Hispanic, and 90.7% (95% CI 87.0-93.5) in Asian/Pacific Islander/American Indian/Alaska Native patients. However, after adjustment for baseline characteristics, black (adjusted odds ratio = 0.77, P < 0.001) and Hispanic (adjusted odds ratio = 0.76, P = 0.007) patients were less likely to achieve SVR than white patients, a difference that was not explained by early treatment discontinuations. Among genotype 1-infected patients treated with ledipasvir/sofosbuvir monotherapy, black patients had significantly lower SVR than white patients when treated for 8 weeks but not when treated for 12 weeks. CONCLUSION Direct-acting antivirals produce high SVR rates in white, black, Hispanic, and Asian/Pacific Islander/American Indian/Alaska Native patients; but after adjusting for baseline characteristics, black race and Hispanic ethnicity remain independent predictors of treatment failure. Short 8-week ledipasvir/sofosbuvir monotherapy regimens should perhaps be avoided in black patients with genotype 1 hepatitis C virus. (Hepatology 2017;65:426-438).
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Affiliation(s)
- Feng Su
- Division of Gastroenterology/Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, WA
| | - Pamela K Green
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - Kristin Berry
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - George N Ioannou
- Division of Gastroenterology/Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, WA
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA
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317
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Nasir A, Manivel JC, Yousaf H, Albrecht JH, Dykoski R, Mesa H. Markedly Increased Rate of Primary Liver Malignancies at Autopsy in Male US Veterans. Clin Gastroenterol Hepatol 2017; 15:316-318. [PMID: 27574757 DOI: 10.1016/j.cgh.2016.08.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 08/20/2016] [Accepted: 08/21/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Aqsa Nasir
- Department of Pathology and Laboratory Medicine, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Juan C Manivel
- Department of Pathology and Laboratory Medicine, University of Minnesota School of Medicine, Minneapolis, Minnesota; Department of Pathology and Laboratory Medicine, Veterans Administration Health Care System, Minneapolis, Minnesota
| | - Hira Yousaf
- Department of Pathology and Laboratory Medicine, Veterans Administration Health Care System, Minneapolis, Minnesota
| | - Jeffrey H Albrecht
- Division of Gastroenterology and Hepatology, Veterans Administration Health Care System, Minneapolis, Minnesota
| | - Richard Dykoski
- Department of Pathology and Laboratory Medicine, Veterans Administration Health Care System, Minneapolis, Minnesota
| | - Hector Mesa
- Department of Pathology and Laboratory Medicine, Veterans Administration Health Care System, Minneapolis, Minnesota.
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318
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Tsui JI, Williams EC, Green PK, Berry K, Su F, Ioannou GN. Alcohol use and hepatitis C virus treatment outcomes among patients receiving direct antiviral agents. Drug Alcohol Depend 2016; 169:101-109. [PMID: 27810652 PMCID: PMC6534140 DOI: 10.1016/j.drugalcdep.2016.10.021] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 09/30/2016] [Accepted: 10/01/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND It is unclear whether alcohol use negatively impacts HCV treatment outcomes in the era of direct antiviral agents (DAAs). We aimed to evaluate the associations between current levels of drinking and treatment response among persons treated for HCV with DAAs in the national Veterans Affairs (VA) healthcare system. METHODS We identified patients who initiated HCV DAAs over 18 months (1/1/14-6/30/15) and had documented alcohol screening with the Alcohol Use Disorders Identification Test Consumption (AUDIT-C) questionnaire within one year prior to initiating therapy. DAAs included: sofosbuvir (SOF), ledipasvir/sofosbuvir (LDV/SOF) or ombitasvir-paritaprevir-ritonavir, and dasabuvir (PrOD). AUDIT-C scores were categorized as 0 (abstinence), 1-3 (low-level drinking) and 4-12 (unhealthy drinking) in men or 0, 1-2 and 3-12 in women. RESULTS Among 17,487 patients who initiated DAAs, 15,151 (87%) completed AUDIT-C screening: 10,387 (68.5%) were categorized as abstinent, 3422 (22.6%) as low-level drinking and 1342 (8.9%) as unhealthy drinking. There were no significant differences in sustained virologic response (SVR) rates between abstinent (SVR 91%; 95% CI: 91-92%), low-level drinking (SVR 93%; 95% CI 92-94%) or unhealthy drinking (SVR 91%; 95% 89-92) categories in univariable analysis or in multivariable logistic regression models. However, after imputing missing SVR data, unhealthy drinkers were less likely to achieve SVR in multivariable analysis (AOR 0.75, 95% CI 0.60-0.92). CONCLUSION Absolute SVR rates were uniformly high among all persons regardless of alcohol use, with only minor differences in those who report unhealthy drinking, which supports clinical guidelines that do not recommend excluding persons with alcohol use.
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Affiliation(s)
| | - Emily C. Williams
- Department of Health Services, University of Washington, Seattle, WA, United States,Health Services Research and Development, Seattle, WA, United States,Center of Innovation for Veteran-Centered Value-Driven Care (COIN), Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States
| | - Pamela K. Green
- Health Services Research and Development, Seattle, WA, United States
| | - Kristin Berry
- Health Services Research and Development, Seattle, WA, United States
| | - Feng Su
- Division of Gastroenterology/Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, WA, United States
| | - George N. Ioannou
- Health Services Research and Development, Seattle, WA, United States,Division of Gastroenterology/Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, WA, United States,Corresponding author at: Veterans Affairs Puget Sound Health Care System,Gastroenterology, S-111-Gastro 1660 S. Columbian Way, Seattle, WA 98108, United States. (G.N. Ioannou)
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319
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Setiawan VW, Stram DO, Porcel J, Lu SC, Le Marchand L, Noureddin M. Prevalence of chronic liver disease and cirrhosis by underlying cause in understudied ethnic groups: The multiethnic cohort. Hepatology 2016; 64:1969-1977. [PMID: 27301913 PMCID: PMC5115980 DOI: 10.1002/hep.28677] [Citation(s) in RCA: 211] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 05/21/2016] [Indexed: 12/14/2022]
Abstract
UNLABELLED Chronic liver disease (CLD) and cirrhosis are major sources of morbidity and mortality in the United States. Little is known about the epidemiology of these two diseases in ethnic minority populations in the United States. We examined the prevalence of CLD and cirrhosis by underlying etiologies among African Americans, Native Hawaiians, Japanese Americans, Latinos, and whites in the Multiethnic Cohort. CLD and cirrhosis cases were identified using Medicare claims between 1999 and 2012 among the fee-for-service participants (n = 106,458). We used International Classification of Diseases Ninth Revision codes, body mass index, history of diabetes mellitus, and alcohol consumption from questionnaires to identify underlying etiologies. A total of 5,783 CLD (3,575 CLD without cirrhosis and 2,208 cirrhosis) cases were identified. The prevalence of CLD ranged from 3.9% in African Americans and Native Hawaiians to 4.1% in whites, 6.7% in Latinos, and 6.9% in Japanese. Nonalcoholic fatty liver disease (NAFLD) was the most common cause of CLD in all ethnic groups combined (52%), followed by alcoholic liver disease (21%). NAFLD was the most common cause of cirrhosis in the entire cohort. By ethnicity, NAFLD was the most common cause of cirrhosis in Japanese Americans, Native Hawaiians, and Latinos, accounting for 32% of cases. Alcoholic liver disease was the most common cause of cirrhosis in whites (38.2%), while hepatitis C virus was the most common cause in African Americans (29.8%). CONCLUSIONS We showed racial/ethnic variations in the prevalence of CLD and cirrhosis by underlying etiology; NAFLD was the most common cause of CLD and cirrhosis in the entire cohort, and the high prevalence of NAFLD among Japanese Americans and Native Hawaiians is a novel finding, warranting further studies to elucidate the causes. (Hepatology 2016;64:1969-1977).
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Affiliation(s)
- Veronica Wendy Setiawan
- Department of Preventive Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA,Norris Comprehensive Cancer Center, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Daniel O. Stram
- Department of Preventive Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Jacqueline Porcel
- Norris Comprehensive Cancer Center, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Shelly C. Lu
- Fatty Liver Program, Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Loїc Le Marchand
- Epidemiology Program, University of Hawaii Cancer Center, Honolulu, HI, USA
| | - Mazen Noureddin
- Fatty Liver Program, Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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320
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Trends in hepatocellular carcinoma among people with HBV or HCV notification in Australia (2000-2014). J Hepatol 2016; 65:1086-1093. [PMID: 27569777 DOI: 10.1016/j.jhep.2016.08.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/23/2016] [Accepted: 08/04/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS This study evaluates trends in hepatocellular carcinoma (HCC) among people with hepatitis B virus (HBV) or hepatitis C virus (HCV) infection in New South Wales (NSW), Australia between 2000 and 2014. METHODS Data on HBV and HCV notifications between January 1993 and December 2012 were linked to the NSW Admitted Patients Data Collection database between July 2000 and June 2014 and NSW Registry of Births Deaths and Marriages. The burden, crude and age-standardised incidence of HCC based on first hospitalization were calculated. RESULTS In NSW between 2000-2014, there were 54,399, 93,099 and 3,809 individuals notified with HBV, HCV and HBV/HCV coinfection respectively. There were 725 (1.3%) with HCC among those with HBV notification as compared to 1,309 with HCC (1.4%) in those with HCV notification. The population-level burden of new HCC cases per year has stabilised in the HBV cohort (53 in 2001 and 44 in 2013), but increased markedly in the HCV cohort (49 in 2001 to 151 in 2013). The age-standardised incidence rates of HCC (per 1,000 person-years) declined from 2.3 (95% confidence interval (CI) 1.4, 3.1) in 2001 to 0.9 (95% CI 0.6, 1.2) in 2012 among those with HBV and remained stable between 2001 (1.4; 95% CI 0.8, 1.9) and 2012 (1.5; 95% CI 1.2, 1.7) in those with HCV. Main factors associated with HCC in those with HBV included later study period (2005-2009; 2010-2014) (hazard ratio (HR)=0.54, 95% CI 0.42, 0.70), male gender (HR=4.50, 95% CI 3.6, 5.6), Asia-Pacific country of birth (HR=3.84, 95% CI 2.58, 5.71) and alcohol dependency (HR=2.84, 95% CI 1.95, 4.13). Main factors associated with HCC in those with HCV included male gender (HR=2.56, 95% CI 2.20, 2.98), rural place of residence (HR=0.73, 95% CI 0.62, 0.86), Asia-Pacific country of birth (HR=2.37, 95% CI 1.99, 2.82) and alcohol dependency (HR=3.90, 95% CI 3.39, 4.49). CONCLUSIONS Individual-level risk of HBV-related HCC has declined, suggesting an impact of more effective antiviral therapy from mid-2000s. In contrast, the interferon-containing HCV treatment era had no impact on individual-level HCV-related HCC risk and has seen escalating population-level HCC burden. LAY SUMMARY Individual-level risk of HBV-related HCC has declined, suggesting an impact of more effective antiviral therapy from mid-2000s. In contrast, the interferon-containing HCV treatment era had no impact on individual-level HCV-related HCC risk and has seen escalating population-level HCC burden.
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321
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D'Avola D, Labgaa I, Villanueva A. Natural history of nonalcoholic steatohepatitis/nonalcoholic fatty liver disease-hepatocellular carcinoma: Magnitude of the problem from a hepatology clinic perspective. Clin Liver Dis (Hoboken) 2016; 8:100-104. [PMID: 31041073 PMCID: PMC6490205 DOI: 10.1002/cld.579] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 08/02/2016] [Indexed: 02/04/2023] Open
Affiliation(s)
- Delia D'Avola
- Division of Liver Diseases, Liver Cancer Program, Department of MedicineTisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkNY,Liver Unit and Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas (Ciberehd)Clínica Universidad de NavarraPamplonaSpain
| | - Ismail Labgaa
- Division of Liver Diseases, Liver Cancer Program, Department of MedicineTisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkNY,Department of Visceral SurgeryUniversity Hospital of Lausanne (CHUV)LausanneSwitzerland
| | - Augusto Villanueva
- Division of Liver Diseases, Liver Cancer Program, Department of MedicineTisch Cancer Institute, Icahn School of Medicine at Mount SinaiNew YorkNY,Division of Hematology and Medical Oncology, Department of MedicineIcahn School of Medicine at Mount SinaiNew YorkNY
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322
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Gauthier TP, Moreira E, Chan C, Cabrera A, Toro M, Carrasquillo MZ, Corentin M, Sherman EM. Pharmacist engagement within a hepatitis C ambulatory care clinic in the era of a treatment revolution. J Am Pharm Assoc (2003) 2016; 56:670-676. [PMID: 27667501 DOI: 10.1016/j.japh.2016.06.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 06/17/2016] [Accepted: 06/20/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe an innovative hepatitis C virus (HCV) care program and treatment outcomes resulting from pharmacist services. SETTING Adult ambulatory care HCV clinic within the Miami Veteran Affairs Healthcare System. PRACTICE DESCRIPTION Pharmacists with limited prescriptive authority are integrated into a medical hepatology care team. PRACTICE INNOVATION Pharmacists screen patients with HCV infection for treatment eligibility, counsel patients upon treatment initiation, assess ongoing treatment success and toxicity through patient appointments, telephone calls, and the ordering of pertinent laboratory data, and provide oversight of all patients on HCV therapies. Treatment outcomes are reported to the institutional Antimicrobial Stewardship Program. EVALUATION Data produced from a continuous quality assurance initiative were utilized. Descriptive statistics were used to present data. RESULTS From January 2014 through September 2015 there were 1619 pharmacist encounters for 532 unique patients and 597 screenings (including 578 approvals) were completed by a pharmacist. During this time 555 patients were initiated on at least 1 HCV treatment course, with 565 total treatment courses initiated. As new agents became available for use, fluctuation in regimen selection was seen. The most commonly prescribed medications were sofosbuvir (46%), ledipasvir/sofosbuvir (37%), and simeprevir (33%). Of the 565 HCV treatment courses initiated, 360 were completed, 29 were stopped early during treatment, and 176 were ongoing. Of the 360 completed courses, 249 had sustained virologic response at week 12 results available, of which 225 (90%) achieved treatment success and 24 (10%) relapsed. Of the 29 courses stopped early, 11 were due to poor medication adherence and 8 were due to adverse drug reaction. CONCLUSION Through a structured process employing a scope of practice, pharmacists can extend the capacity of medical hepatology providers and provide pharmacotherapy services to enhance care. Information provided here may serve beneficial to others looking to initiate or expand existing HCV pharmacist services.
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323
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Brown CL, Hammill BG, Qualls LG, Curtis LH, Muir AJ. Significant Morbidity and Mortality Among Hospitalized End-Stage Liver Disease Patients in Medicare. J Pain Symptom Manage 2016; 52:412-419.e1. [PMID: 27265812 PMCID: PMC5144155 DOI: 10.1016/j.jpainsymman.2016.03.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 02/19/2016] [Accepted: 03/16/2016] [Indexed: 12/19/2022]
Abstract
CONTEXT For end-stage liver disease (ESLD) patients, care focuses on managing the life-threatening complications of portal hypertension, causing high resource utilization. OBJECTIVES To describe the end-of-life trajectory of hospitalized ESLD patients in Medicare. METHODS Using a 5% random sample of Medicare fee-for-service beneficiaries, we performed a retrospective cohort study, identifying hospitalized ESLD and heart failure (HF) patients (2007-2011). Index hospitalization end points included mortality, discharge to hospice, and length of stay. Postdischarge end points included all-cause mortality, rehospitalization, hospice enrollment, and days alive and out of hospital (DAOH). Follow-up was at one and three years after index hospitalization discharge. A reference cohort of decompensated HF patients was used for baseline comparison. RESULTS At one year, the ESLD cohort (n = 22,311) had 209 DAOH; decompensated HF (n = 85,397) had 252 DAOH. Among ESLD patients, inpatient mortality was 13.5%; all-cause mortality was 64.9%. For these outcomes, rates were higher in those with ESLD than HF. In the ESLD group, rehospitalization rate was 59.1% (slightly lower than the HF group), hospice enrollment rate was 36.1%, and there were higher than expected cancer rates. For hospice-enrolled patients, the median length of time spent in hospice was nine days. The HF cohort had lower hospice enrollment, but more days enrolled. CONCLUSION The results of this study show that morbidity and mortality rates associated with end of life in ESLD are substantial. There is an acute need for alternative approaches to manage the care of ESLD patients.
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Affiliation(s)
- Cristal L Brown
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Bradley G Hammill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Laura G Qualls
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lesley H Curtis
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Andrew J Muir
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
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324
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Ioannou GN, Beste LA, Chang MF, Green PK, Lowy E, Tsui JI, Su F, Berry K. Effectiveness of Sofosbuvir, Ledipasvir/Sofosbuvir, or Paritaprevir/Ritonavir/Ombitasvir and Dasabuvir Regimens for Treatment of Patients With Hepatitis C in the Veterans Affairs National Health Care System. Gastroenterology 2016; 151:457-471.e5. [PMID: 27267053 PMCID: PMC5341745 DOI: 10.1053/j.gastro.2016.05.049] [Citation(s) in RCA: 179] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND & AIMS We investigated the real-world effectiveness of sofosbuvir, ledipasvir/sofosbuvir, and paritaprevir/ritonavir/ombitasvir and dasabuvir (PrOD) in treatment of different subgroups of patients infected with hepatitis C virus (HCV) genotypes 1, 2, 3, or 4. METHODS We performed a retrospective analysis of data from 17,487 patients with HCV infection (13,974 with HCV genotype 1; 2131 with genotype 2; 1237 with genotype 3; and 135 with genotype 4) who began treatment with sofosbuvir (n = 2986), ledipasvir/sofosbuvir (n = 11,327), or PrOD (n = 3174), with or without ribavirin, from January 1, 2014 through June 20, 2015 in the Veterans Affairs health care system. Data through April 15, 2016 were analyzed to assess completion of treatments and sustained virologic response 12 weeks after treatment (SVR12). Mean age of patients was 61 ± 7 years, 97% were male, 52% were non-Hispanic white, 29% were non-Hispanic black, 32% had a diagnosis of cirrhosis (9.9% with decompensated cirrhosis), 36% had a Fibrosis-4 index score >3.25 (indicator of cirrhosis), and 29% had received prior antiviral treatment. RESULTS An SVR12 was achieved by 92.8% (95% confidence interval [CI], 92.3%-93.2%) of subjects with HCV genotype 1 infection (no significant difference between ledipasvir/sofosbuvir and PrOD regimens), 86.2% (95% CI, 84.6%-87.7%) of those with genotype 2 infection (treated with sofosbuvir and ribavirin), 74.8% (95% CI, 72.2%-77.3%) of those with genotype 3 infection (77.9% in patients given ledipasvir/sofosbuvir plus ribavirin, 87.0% in patients given sofosbuvir and pegylated-interferon plus ribavirin, and 70.6% of patients given sofosbuvir plus ribavirin), and 89.6% (95% CI 82.8%-93.9%) of those with genotype 4 infection. Among patients with cirrhosis, 90.6% of patients with HCV genotype 1, 77.3% with HCV genotype 2, 65.7% with HCV genotype 3, and 83.9% with HCV genotype 4 achieved an SVR12. Among previously treated patients, 92.6% with genotype 1; 80.2% with genotype 2; 69.2% with genotype 3; and 93.5% with genotype 4 achieved SVR12. Among treatment-naive patients, 92.8% with genotype 1; 88.0% with genotype 2; 77.5% with genotype 3; and 88.3% with genotype 4 achieved SVR12. Eight-week regimens of ledipasvir/sofosbuvir produced an SVR12 in 94.3% of eligible patients with HCV genotype 1 infection; this regimen was underused. CONCLUSIONS High proportions of patients with HCV infections genotypes 1-4 (ranging from 75% to 93%) in the Veterans Affairs national health care system achieved SVR12, approaching the results reported in clinical trials, especially in patients with genotype 1 infection. An 8-week regimen of ledipasvir/sofosbuvir is effective for eligible patients with HCV genotype 1 infection and could reduce costs. There is substantial room for improvement in SVRs among persons with cirrhosis and genotype 2 or 3 infections.
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Affiliation(s)
- George N. Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System, Seattle, Washington,Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington,Division of Gastroenterology, University of Washington, Seattle, Washington
| | - Lauren A. Beste
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington,Division of General Internal Medicine, Veterans Affairs Puget Sound Health Care System, Seattle, Washington,Division of General Internal Medicine, University of Washington, Seattle, Washington
| | - Michael F. Chang
- Division of Gastroenterology, Veterans Affairs Portland Health Care System, Portland, Oregon,Oregon Health Sciences University, Portland, Oregon
| | - Pamela K. Green
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Elliott Lowy
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Judith I. Tsui
- Division of General Internal Medicine, University of Washington, Seattle, Washington
| | - Feng Su
- Division of General Internal Medicine, University of Washington, Seattle, Washington
| | - Kristin Berry
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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325
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Velosa J. Why is viral eradication so important in patients with HCV-related cirrhosis? Antivir Ther 2016; 22:1-12. [PMID: 27553973 DOI: 10.3851/imp3077] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2016] [Indexed: 02/07/2023]
Abstract
Approximately one-third of patients infected with chronic HCV have cirrhosis, and this is likely to increase in the near future. The risk of complications, mainly the development of hepatocellular carcinoma, depends on the presence of cirrhosis, and a significant increase in the incidence of cirrhosis-related events, including mortality, is likely in the following years. All-oral therapy with direct-acting antivirals (DAAs) offers a safe and short treatment, with cure rates over 90% in compensated cirrhosis. Cirrhotic patients should be given high priority for treatment because viral clearance has a significant impact on the natural history of HCV infection, halting the progression of the disease and inducing the regression of fibrosis, as well as reducing the need for liver transplantation and improving survival. The benefit of DAAs is great in patients with decompensated cirrhosis, up until recently a population for whom no alternative therapy was available. The efficacy of all-oral therapy has been reported to improve liver function in about 50% of Child-Pugh class C patients. The regression of cirrhosis observed in more than half of patients achieving viral eradication on prior interferon-based regimens still has to be demonstrated in patients treated with DAAs, although there is reason to believe that this will happen. Advanced cirrhosis will eventually become the last boundary of antiviral therapy that will soon be conquered with new drugs currently pending approval.
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Affiliation(s)
- José Velosa
- Hospital de Santa Maria - Gastroenterology and Hepatology, Lisbon, Portugal
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326
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Abstract
The ∼90% probability of curing individual patients with hepatitis C virus (HCV)using direct-acting antivirals represents one of the most dramatic medical success stories of the modern era, and the journey from viral discovery to treatment occurred over just ∼25 years. The realities of the global burden of disease (2-3% of the world's population is infected), limited access to care and cost of treatment mean that HCV will continue to be a major problem for the next 25 years. But what if HCV (and hepatitis B) could be eradicated? Since liver transplantation and HCV management have been the mainstays of academic hepatology practice, where do we go from here? Unfortunately, we are in an era where the incidence and prevalence of liver diseases around the globe is increasing, and death from complications of cirrhosis is now among the top 10 causes in most countries; so hepatologists are expected to play a major role in the future. Despite remarkable progress, success at the population level is limited by the resource-intensive nature of caring for patients with end-stage disease. Accordingly, the major advances in the next decade are likely to focus on (i) the earlier identification of individuals and populations at higher risk for liver diseases, and (ii) initiation in high-risk populations of specific strategies for early detection and treatment of fibrosis, cancer and cirrhosis. The answers will lie in large part in the further exploration of the human genome in carefully phenotyped patients. Risk variants in the PNPLA3 gene represent the best example to date. The risk variants are common and are enriched in certain populations around the globe; and individuals that possess risk variants are more likely to have liver injury from fatty liver disease (even as children), alcohol and viral hepatitis. Further, those with liver injury are more likely to progress to cirrhosis and hepatoma. Similarly, in those with established liver disease, use of biomarkers and other strategies for early detection of fibrosis and hepatoma will pay dividends as the next generation of treatments focusing on (i) anti-fibrotic strategies and (ii) liver regeneration move to the forefront. There remains an important need to invest in hepatology as a growth industry even after the (unlikely) eradication of HCV.
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327
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Kolly P, Dufour JF. Surveillance for Hepatocellular Carcinoma in Patients with NASH. Diagnostics (Basel) 2016; 6:diagnostics6020022. [PMID: 27338480 PMCID: PMC4931417 DOI: 10.3390/diagnostics6020022] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/12/2016] [Accepted: 05/31/2016] [Indexed: 12/14/2022] Open
Abstract
European and American guidelines recommend surveillance for hepatocellular carcinoma (HCC) by performing ultrasonography on a six-month basis on an at risk population, defined by presence of cirrhosis. HCC, due to non-alcoholic steatohepatitis (NASH), is rising. Patients with NASH have a high risk of developing HCC and, therefore, have to be enrolled in a screening program. One of the challenges with NASH-induced HCC is that half of the cases arise in non-cirrhotic patients. There is a need to identify those patients in order to screen them for HCC. The obesity of these patients is another challenge, it makes ultrasound screening more difficult. Other radiological methods, such as computer tomography (CT) scans or magnetic resonance imaging (MRI), are available, but the surveillance program would no longer be cost-effective. There is a need to prospectively acquire information on cohorts of patients with NASH in order to improve the tools we have to diagnose early tumors in these patients.
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Affiliation(s)
- Philippe Kolly
- Hepatology, Department of Clinical Research, University of Bern, 3010 Bern, Switzerland.
- University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, 3010 Bern, Switzerland.
| | - Jean-François Dufour
- Hepatology, Department of Clinical Research, University of Bern, 3010 Bern, Switzerland.
- University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, 3010 Bern, Switzerland.
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328
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Cogliati B, Crespo Yanguas S, da Silva TC, Aloia TP, Nogueira MS, Real-Lima MA, Chaible LM, Sanches DS, Willebrords J, Maes M, Pereira IV, de Castro IA, Vinken M, Dagli ML. Connexin32 deficiency exacerbates carbon tetrachloride-induced hepatocellular injury and liver fibrosis in mice. Toxicol Mech Methods 2016; 26:362-370. [PMID: 27268753 PMCID: PMC5417356 DOI: 10.1080/15376516.2016.1190991] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Liver fibrosis results from the perpetuation of the normal wound healing response to several types of injury. Despite the wealth of knowledge regarding the involvement of intracellular and extracellular signaling pathways in liver fibrogenesis, information about the role of intercellular communication mediated by gap junctions is scarce. METHODS In this study, liver fibrosis was chemically induced by carbon tetrachloride in mice lacking connexin32, the major liver gap junction constituent. The manifestation of liver fibrosis was evaluated based on a series of read-outs, including collagen morphometric and mRNA analysis, oxidative stress, apoptotic, proliferative and inflammatory markers. RESULTS More pronounced liver damage and enhanced collagen deposition were observed in connexin32 knockout mice compared to wild-type animals in experimentally triggered induced liver fibrosis. No differences between both groups were noticed in apoptotic signaling nor in inflammation markers. However, connexin32 deficient mice displayed decreased catalase activity and increased malondialdehyde levels. CONCLUSION These findings could suggest that connexin32-based signaling mediates tissue resistance against liver damage by the modulation of the antioxidant capacity. In turn, this could point to a role for connexin32 signaling as a therapeutic target in the treatment of liver fibrosis.
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Affiliation(s)
- Bruno Cogliati
- Department of Pathology, School of Veterinary Medicine and Animal Science, University of Sao Paulo, Sao Paulo, Brazil
| | - Sara Crespo Yanguas
- Department of In Vitro Toxicology and Dermato-Cosmetology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Tereza C. da Silva
- Department of Pathology, School of Veterinary Medicine and Animal Science, University of Sao Paulo, Sao Paulo, Brazil
| | - Thiago P.A. Aloia
- Department of Pathology, School of Veterinary Medicine and Animal Science, University of Sao Paulo, Sao Paulo, Brazil
| | - Marina S. Nogueira
- Department of Food and Experimental Nutrition, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | - Mirela A. Real-Lima
- Department of Pathology, School of Veterinary Medicine and Animal Science, University of Sao Paulo, Sao Paulo, Brazil
| | - Lucas M. Chaible
- Department of Pathology, School of Veterinary Medicine and Animal Science, University of Sao Paulo, Sao Paulo, Brazil
| | - Daniel S. Sanches
- Department of Pathology, School of Veterinary Medicine and Animal Science, University of Sao Paulo, Sao Paulo, Brazil
| | - Joost Willebrords
- Department of In Vitro Toxicology and Dermato-Cosmetology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Michaël Maes
- Department of In Vitro Toxicology and Dermato-Cosmetology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Isabel V.A. Pereira
- Department of Pathology, School of Veterinary Medicine and Animal Science, University of Sao Paulo, Sao Paulo, Brazil
| | - Inar A. de Castro
- Department of Food and Experimental Nutrition, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | - Mathieu Vinken
- Department of In Vitro Toxicology and Dermato-Cosmetology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Maria L.Z. Dagli
- Department of Pathology, School of Veterinary Medicine and Animal Science, University of Sao Paulo, Sao Paulo, Brazil
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329
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Younossi Z, Henry L. Contribution of Alcoholic and Nonalcoholic Fatty Liver Disease to the Burden of Liver-Related Morbidity and Mortality. Gastroenterology 2016; 150:1778-85. [PMID: 26980624 DOI: 10.1053/j.gastro.2016.03.005] [Citation(s) in RCA: 213] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 02/15/2016] [Accepted: 03/02/2016] [Indexed: 12/15/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD) are common causes of chronic liver disease. NAFLD is associated with obesity and metabolic syndrome whereas ALD is associated with excessive alcohol consumption. Both diseases can progress to cirrhosis, hepatocellular carcinoma, and liver-related death. A higher proportion of patients with NAFLD die from cardiovascular disorders than patients with ALD, whereas a higher proportion of patients with ALD die from liver disease. NAFLD and ALD each are associated with significant morbidity, impairment to health-related quality of life, and economic costs to society.
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Affiliation(s)
- Zobair Younossi
- Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, Virginia; Beatty Liver and Obesity Program, Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia.
| | - Linda Henry
- Center for Outcomes Research in Liver Diseases, Washington, District of Columbia
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330
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Charrez B, Qiao L, Hebbard L. Hepatocellular carcinoma and non-alcoholic steatohepatitis: The state of play. World J Gastroenterol 2016; 22:2494-2502. [PMID: 26937137 PMCID: PMC4768195 DOI: 10.3748/wjg.v22.i8.2494] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 12/18/2015] [Accepted: 12/30/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is now the fifth cancer of greatest frequency and the second leading cause of cancer related deaths worldwide. Chief amongst the risks of HCC are hepatitis B and C infection, aflatoxin B1 ingestion, alcoholism and obesity. The latter can promote non-alcoholic fatty liver disease (NAFLD), that can lead to the inflammatory form non-alcoholic steatohepatitis (NASH), and can in turn promote HCC. The mechanisms by which NASH promotes HCC are only beginning to be characterized. Here in this review, we give a summary of the recent findings that describe and associate NAFLD and NASH with the subsequent HCC progression. We will focus our discussion on clinical and genomic associations that describe new risks for NAFLD and NASH promoted HCC. In addition, we will consider novel murine models that clarify some of the mechanisms that drive NASH HCC formation.
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MESH Headings
- Animals
- Biomarkers, Tumor/genetics
- Biomarkers, Tumor/metabolism
- Carcinoma, Hepatocellular/etiology
- Carcinoma, Hepatocellular/genetics
- Carcinoma, Hepatocellular/metabolism
- Carcinoma, Hepatocellular/pathology
- Cell Transformation, Neoplastic/genetics
- Cell Transformation, Neoplastic/metabolism
- Cell Transformation, Neoplastic/pathology
- Disease Models, Animal
- Humans
- Liver/metabolism
- Liver/pathology
- Liver Neoplasms/etiology
- Liver Neoplasms/genetics
- Liver Neoplasms/metabolism
- Liver Neoplasms/pathology
- Non-alcoholic Fatty Liver Disease/complications
- Non-alcoholic Fatty Liver Disease/genetics
- Non-alcoholic Fatty Liver Disease/metabolism
- Non-alcoholic Fatty Liver Disease/pathology
- Risk Factors
- Signal Transduction
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331
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Abstract
Advanced liver disease is becoming more prevalent in the United States. This increase has been attributed largely to the growing epidemic of nonalcoholic fatty liver disease and an aging population infected with hepatitis C. Complications of cirrhosis are a major cause of hospital admissions and readmissions. It is important to target efforts for preventing rehospitalization toward patients with cirrhosis who are at the highest risk for readmission, such as those who have high Model for End-Stage Liver Disease scores, are at risk for fluid/electrolyte abnormalities or overt hepatic encephalopathy recurrence, and those who have comorbid conditions (e.g. diabetes). The heart failure management paradigm may provide valuable insights for managing patients with cirrhosis, given the extensive research on preventing hospital readmission and improving health care utilization in this subpopulation. As quality measures related to hospital readmissions for cirrhosis and its complications are adopted by the Centers for Medicare & Medicaid Services and private payers in the future, understanding drivers of hospital readmissions and health care utilization in this vulnerable population are key to improving quality measure performance.
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Affiliation(s)
- Archita P Desai
- a Liver Research Institute, Department of Medicine , University of Arizona , Tucson , AZ , USA
| | - Nancy Reau
- b Section of Hepatology , Rush University , Chicago , IL , USA
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332
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Capitalising on improved rates of diagnosis of early hepatocellular carcinoma. J Hepatol 2016; 64:260-261. [PMID: 26551515 DOI: 10.1016/j.jhep.2015.10.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 10/31/2015] [Indexed: 12/04/2022]
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333
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Ioannou GN. The Role of Cholesterol in the Pathogenesis of NASH. Trends Endocrinol Metab 2016; 27:84-95. [PMID: 26703097 DOI: 10.1016/j.tem.2015.11.008] [Citation(s) in RCA: 325] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 11/12/2015] [Accepted: 11/16/2015] [Indexed: 01/01/2023]
Abstract
Lipotoxicity drives the development of progressive hepatic inflammation and fibrosis in a subgroup of patients with nonalcoholic fatty liver disease (NAFLD), causing nonalcoholic steatohepatitis (NASH) and even progression to cirrhosis and hepatocellular carcinoma (HCC). While the underlying molecular mechanisms responsible for the development of inflammation and fibrosis that characterize progressive NASH remain unclear, emerging evidence now suggests that hepatic free cholesterol (FC) is a major lipotoxic molecule critical in the development of experimental and human NASH. In this review, we examine the effects of excess FC in hepatocytes, Kupffer cells (KCs), and hepatic stellate cells (HSCs), and the subcellular mechanisms by which excess FC can induce cellular toxicity or proinflammatory and profibrotic effects in these cells.
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Affiliation(s)
- George N Ioannou
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA; University of Washington, Seattle, WA, USA.
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334
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O'Leary TJ, Dominitz JA, Chang KM. Veterans Affairs Office of Research and Development: Research Programs and Emerging Opportunities in Digestive Diseases Research. Gastroenterology 2015; 149:1652-61. [PMID: 26526712 PMCID: PMC4887273 DOI: 10.1053/j.gastro.2015.10.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Timothy J O'Leary
- Department of Veterans Affairs, Office of Research and Development, Washington, DC
| | - Jason A Dominitz
- Department of Veterans Affairs, VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington
| | - Kyong-Mi Chang
- Corporal Michael J. Crescenz VA Medical Center and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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335
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Stickel F, Hellerbrand C. Herbs to treat liver diseases: More than placebo? Clin Liver Dis (Hoboken) 2015; 6:136-138. [PMID: 31041010 PMCID: PMC6490665 DOI: 10.1002/cld.515] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 11/28/2015] [Indexed: 02/04/2023] Open
Affiliation(s)
- Felix Stickel
- Department of Gastroenterology and HepatologyUniversity Hospital of ZürichBerneSwitzerland
| | - Claus Hellerbrand
- Department of Internal Medicine 1University Hospital RegensburgRegensburgGermany
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336
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Leroy V, Asselah T. Universal hepatitis B vaccination: The only way to eliminate hepatocellular carcinoma? J Hepatol 2015; 63:1303-5. [PMID: 26450812 DOI: 10.1016/j.jhep.2015.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 10/01/2015] [Indexed: 01/27/2023]
Affiliation(s)
- Vincent Leroy
- Clinique Universitaire d'Hépato-Gastroentérologie, Pôle Digidune, CHU de Grenoble, France; Unité INSERM/Université Grenoble Alpes U823, IAPC Institut Albert Bonniot, Grenoble, France
| | - Tarik Asselah
- Department of Hepatology, Hôpital Beaujon, AP-HP, Université Paris-Diderot, Clichy, France; Centre de Recherche sur l'Inflammation (CRI), UMR 1149 Inserm, Université Paris-Diderot, France.
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