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Fuller SR, Schreiner AD. Hepatic Fibrosis Risk Assessment in Primary Care: Opportunities and Challenges. Dig Dis Sci 2024:10.1007/s10620-024-08498-3. [PMID: 38842740 DOI: 10.1007/s10620-024-08498-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Accepted: 05/11/2024] [Indexed: 06/07/2024]
Affiliation(s)
- Stephen R Fuller
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Andrew D Schreiner
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA.
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Schreiner AD, Zhang J, Moran WP, Koch DG, Marsden J, Livingston S, Bays C, Mauldin PD, Gebregziabher M. FIB-4 as a Time-varying Covariate and Its Association With Severe Liver Disease in Primary Care: A Time-dependent Cox Regression Analysis. J Clin Gastroenterol 2023:00004836-990000000-00229. [PMID: 37983873 PMCID: PMC11096263 DOI: 10.1097/mcg.0000000000001935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 10/02/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND AND GOALS The Fibrosis-4 Index (FIB-4) has demonstrated a strong association with severe liver disease (SLD) outcomes in primary care, but previous studies have only evaluated this relationship using 1 or 2 FIB-4 scores. In this study, we determined the association of FIB-4 as a time-varying covariate with SLD risk using time-dependent Cox regression models. STUDY This retrospective cohort study included primary care patients with at least 2 FIB-4 scores between 2012 and 2021. The outcome was the occurrence of an SLD event, a composite of cirrhosis, complications of cirrhosis, hepatocellular carcinoma, and liver transplantation. The primary predictor was FIB-4 advanced fibrosis risk, categorized as low-(<1.3), indeterminate-(1.3≤FIB to 4<2.67), and high-risk (≥2.67). FIB-4 scores were calculated and the index, last, and maximum FIB-4s were identified. Time-dependent Cox regression models were used to estimate hazard ratios (HR) and their corresponding 95% CI with adjustment for potentially confounding covariates. RESULTS In the cohort, 20,828 patients had a median of 5 (IQR: 3 to 11) FIB-4 scores each and 3% (n=667) suffered an SLD outcome during follow-up. Maximum FIB-4 scores were indeterminate-risk for 34% (7149) and high-risk for 24% (4971) of the sample, and 32% (6692) of patients had an increase in fibrosis risk category compared with their index value. The adjusted Cox regression model demonstrated an association between indeterminate- (hazard ratio 3.21; 95% CI 2.33-4.42) and high-risk (hazard ratio 20.36; 95% CI 15.03-27.57) FIB-4 scores with SLD outcomes. CONCLUSIONS Multiple FIB-4 values per patient are accessible in primary care, FIB-4 fibrosis risk assessments change over time, and high-risk FIB-4 scores (≥2.67) are strongly associated with severe liver disease outcomes when accounting for FIB-4 as a time-varying variable.
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Affiliation(s)
- Andrew D Schreiner
- Department of Medicine, Medical University of South Carolina, Charleston, SC
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Jingwen Zhang
- Department of Medicine, Medical University of South Carolina, Charleston, SC
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - William P Moran
- Department of Medicine, Medical University of South Carolina, Charleston, SC
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - David G Koch
- Department of Medicine, Medical University of South Carolina, Charleston, SC
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Justin Marsden
- Department of Medicine, Medical University of South Carolina, Charleston, SC
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Sherry Livingston
- Department of Medicine, Medical University of South Carolina, Charleston, SC
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Chloe Bays
- Department of Medicine, Medical University of South Carolina, Charleston, SC
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Patrick D Mauldin
- Department of Medicine, Medical University of South Carolina, Charleston, SC
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Mulugeta Gebregziabher
- Department of Medicine, Medical University of South Carolina, Charleston, SC
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
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Raya-Cano E, Molina-Luque R, Vaquero-Abellán M, Molina-Recio G, Jiménez-Mérida R, Romero-Saldaña M. Metabolic syndrome and transaminases: systematic review and meta-analysis. Diabetol Metab Syndr 2023; 15:220. [PMID: 37899468 PMCID: PMC10614379 DOI: 10.1186/s13098-023-01200-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/24/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND Metabolic syndrome (MetS) is a group of metabolic abnormalities characterised by hypertension, central obesity, dyslipidaemia and dysregulation of blood glucose, associated with the risk of diabetes, cardiovascular disease and overall mortality. The presence of elevated liver enzymes may precede the development of MetS, with alterations of the liver being observed that are directly related to metabolic problems. The study aims to provide the best evidence on the association between liver enzymes (ALT, AST, GGT) and MetS by determining the effect size of these biomarkers. METHODS A systematic review and meta-analysis of studies indexed in PubMed and Scopus databases were performed. Study quality was assessed using the STROBE tool. The Grade Pro tool was used to evaluate the evidence, and the quantitative synthesis was performed using RevMan (Cochrane Collaboration). RESULTS Seventeen articles comparing liver enzyme concentrations between 76,686 with MetS (MetS+) and 201,855 without MetS (MetS-) subjects were included. The concentration of ALT, AST and GGT in the MetS + subjects was significantly higher than in the control group 7.13 IU/L (CI95% 5.73-8.54; p < 0.00001; I2 = 96%), 2.68 IU/L (CI95% 1.82-3.54; p < 0.00001; I2 = 96%) and 11.20 IU/L (CI95% 7.11-15.29; p < 0.00001; I2 = 96%), respectively. CONCLUSIONS The evaluation of the relationship of liver enzymes in the pathophysiological process of MetS could lead to new insights into early diagnosis.
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Affiliation(s)
- Elena Raya-Cano
- Faculty of Medicine and Nursing, University of Córdoba, Avd. Menéndez Pidal N/N, Córdoba, 14004, Spain
| | - Rafael Molina-Luque
- Faculty of Medicine and Nursing, University of Córdoba, Avd. Menéndez Pidal N/N, Córdoba, 14004, Spain.
- Lifestyles, Innovation and Health (GA-16), Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain.
| | - Manuel Vaquero-Abellán
- Faculty of Medicine and Nursing, University of Córdoba, Avd. Menéndez Pidal N/N, Córdoba, 14004, Spain
| | - Guillermo Molina-Recio
- Faculty of Medicine and Nursing, University of Córdoba, Avd. Menéndez Pidal N/N, Córdoba, 14004, Spain
- Lifestyles, Innovation and Health (GA-16), Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain
| | - Rocío Jiménez-Mérida
- Faculty of Medicine and Nursing, University of Córdoba, Avd. Menéndez Pidal N/N, Córdoba, 14004, Spain
| | - Manuel Romero-Saldaña
- Faculty of Medicine and Nursing, University of Córdoba, Avd. Menéndez Pidal N/N, Córdoba, 14004, Spain
- Lifestyles, Innovation and Health (GA-16), Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain
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Eskridge W, Cryer DR, Schattenberg JM, Gastaldelli A, Malhi H, Allen AM, Noureddin M, Sanyal AJ. Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis: The Patient and Physician Perspective. J Clin Med 2023; 12:6216. [PMID: 37834859 PMCID: PMC10573476 DOI: 10.3390/jcm12196216] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/19/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
Diagnosing and managing metabolic dysfunction-associated steatotic liver disease (MASLD) remains a major challenge in primary care due to lack of agreement on diagnostic tools, difficulty in identifying symptoms and determining their cause, absence of approved pharmacological treatments, and limited awareness of the disease. However, prompt diagnosis and management are critical to preventing MASLD from progressing to more severe forms of liver disease. This highlights the need to raise awareness and improve understanding of MASLD among both patients and physicians. The patient perspective is invaluable to advancing our knowledge of this disease and how to manage it, as their perspectives have led to the growing recognition that patients experience subtle symptoms and that patient-reported outcomes should be incorporated into drug development. This review and expert opinion examine MASLD and metabolic dysfunction-associated steatohepatitis from the patient and physician perspective from pre-diagnosis to diagnosis and early care, through to progression to advanced liver damage. Specifically, the paper dives into the issues patients and physicians experience, and, in turn, what is required to improve diagnosis and management, including tips and tools to empower patients and physicians dealing with MASLD.
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Affiliation(s)
| | | | - Jörn M. Schattenberg
- Metabolic Liver Research Program, Department of Medicine, University Medical Center of the Johannes Gutenberg University, 155131 Mainz, Germany
| | - Amalia Gastaldelli
- Cardiometabolic Risk Laboratory, Institute of Clinical Physiology, Italian National Research Council CNR, 00133 Pisa, Italy
| | - Harmeet Malhi
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55901, USA
| | - Alina M. Allen
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN 55901, USA
| | - Mazen Noureddin
- Fatty Liver Program, Karsh Division of Gastroenterology and Hepatology, Cedar Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Arun J. Sanyal
- Stravitz-Sanyal Institute of Liver Disease and Metabolic Health, VCU School of Medicine and Health System and Division of Gastroenterology, Department of Internal Medicine, VCU School of Medicine, Richmond, VA 23298, USA
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Moore JA, Wheless WH, Zhang J, Marsden J, Mauldin PD, Moran WP, Schreiner AD. Gaps in Confirmatory Fibrosis Risk Assessment in Primary Care Patients with Nonalcoholic Fatty Liver Disease. Dig Dis Sci 2023; 68:2946-2953. [PMID: 37193930 PMCID: PMC10659111 DOI: 10.1007/s10620-023-07959-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/25/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND As recommendations for non-invasive fibrosis risk assessment in nonalcoholic fatty liver disease (NAFLD) emerge, it is not known how often they are performed in primary care. AIMS We investigated the completion of confirmatory fibrosis risk assessment in primary care patients with NAFLD and indeterminate-risk or greater Fibrosis-4 Index (FIB-4) and NAFLD Fibrosis Scores (NFS). METHODS This retrospective cohort study of electronic health record data from a primary care clinic identified patients with diagnoses of NAFLD from 2012 through 2021. Patients with a diagnosis of a severe liver disease outcome during the study period were excluded. The most recent FIB-4 and NFS scores were calculated and categorized by advanced fibrosis risk. Charts were reviewed to identify the outcome of a confirmatory fibrosis risk assessment by liver elastography or liver biopsy for all patients with indeterminate-risk or higher FIB-4 (≥ 1.3) and NFS (≥ - 1.455) scores. RESULTS The cohort included 604 patients diagnosed with NAFLD. Two-thirds of included patients (399) had a FIB-4 or NFS score greater than low-risk, 19% (113) had a high-risk FIB-4 (≥ 2.67) or NFS (≥ 0.676) score, and 7% (44) had high-risk FIB-4 and NFS values. Of these 399 patients with an indication for a confirmatory fibrosis test, 10% (41) underwent liver elastography (24) or liver biopsy (18) or both (1). CONCLUSIONS Advanced fibrosis is a key indicator of future poor health outcomes in patients with NAFLD and a critical signal for referral to hepatology. Significant opportunities exist to improve confirmatory fibrosis risk assessment in patients with NAFLD.
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Affiliation(s)
- Joseph A Moore
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - William H Wheless
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Jingwen Zhang
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Justin Marsden
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Patrick D Mauldin
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - William P Moran
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Andrew D Schreiner
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA.
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Khalifa A, Obeid JS, Gregoski MJ, Rockey DC. Accurate Identification of Patients with Cirrhosis and Its Complications in the Electronic Health Record. Dig Dis Sci 2023; 68:2360-2369. [PMID: 36899112 PMCID: PMC10847840 DOI: 10.1007/s10620-023-07876-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/11/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Cirrhosis represents a significant health burden; administrative data provide an important tool for research studies. AIMS We aimed to understand the validity of current ICD-10 codes compared to previously used ICD-9 codes to identify patients with cirrhosis and its complications. METHODS We identified 1981 patients presenting to MUSC between 2013 and 2019 with a diagnosis of cirrhosis. To validate the sensitivity of ICD codes, we reviewed the medical records of 200 patients for each associated ICD 9 and 10 codes. Sensitivity, specificity, and positive predictive value for each ICD code (individually or when combined) were calculated and univariate binary logistic models, for cirrhosis and its complications, predicted probabilities were used to calculate C-statistics. RESULTS Single ICD 9 and 10 codes were similarly insensitive for detection of cirrhosis, with sensitivity ranging from 5 to 94%. However, ICD-9 code combinations (when used as either/or) had high sensitivity and specificity for the detection of cirrhosis, with the combination of either 571.5 (or 456.21) or 571.2 codes having a C-statistic of 0.975. Combinations of ICD-10 codes were only slightly less sensitive and specific than ICD-9 codes for detection of cirrhosis (K76.6, or K70.31, plus K74.60 or K74.69, and K70.30 had a C-statistic of 0.927). CONCLUSIONS ICD-9 and ICD-10 codes when used alone were inaccurate for identifying cirrhosis. ICD-10 and ICD-9 codes had similar performance characteristics. Combinations of ICD codes exhibited the greatest sensitivity and specificity for detection of cirrhosis, and thus should be used to accurately identify cirrhosis.
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Affiliation(s)
- Ali Khalifa
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, SC, USA
| | - Jihad S Obeid
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Mathew J Gregoski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, SC, USA.
- Department of Internal Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 803, MSC 623, Charleston, SC, 29425, USA.
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Seo YG. Letter: Hepatic Fibrosis and Steatosis in Metabolic Syndrome (J Obes Metab Syndr 2022;31:61-9). J Obes Metab Syndr 2022; 31:350-351. [PMID: 36274243 PMCID: PMC9828699 DOI: 10.7570/jomes22049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/31/2022] [Accepted: 08/31/2022] [Indexed: 01/21/2023] Open
Affiliation(s)
- Young-Gyun Seo
- Department of Family Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea,Corresponding author Young-Gyun Seo https://orcid.org/0000-0001-8294-1741 Department of Family Medicine, Hallym University Sacred Heart Hospital, 22 Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang 14068, Korea Tel: +82-31-380-3805 Fax: +82-31-380-1782 E-mail:
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Liver Fibrosis and Hearing Loss in an Older Mediterranean Population: Results from the Salus in Apulia Study. J Clin Med 2022; 11:jcm11237213. [PMID: 36498787 PMCID: PMC9736605 DOI: 10.3390/jcm11237213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/23/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
Background: Aging is the main negative prognostic factor for various chronic diseases, such as liver fibrosis, and clinical disorders such as hearing loss. This study aimed to investigate the association between age-related hearing loss (ARHL) and age-related central auditory processing disorder (CAPD), and the risk for liver fibrosis in a cross-sectional study on an aging population. Methods: Liver fibrosis risk was judged on the fibrosis-4 (FIB-4) score. Peripheral ARHL was evaluated with pure tone audiometry using a calibrated audiometer. The pure tone average (PTA), calculated as a threshold ≤ 40 dB (HL) in the better ear, was measured at the frequencies 0.5−4 kHz. For age-related CAPD assessment, we employed the Synthetic Sentence Identification with an Ipsilateral Competitive Message test (SSI-ICM). General linear Logistic regression models were used to estimate the association. Results: The increase in the PTA 0.5−2 kHz (coefficient: 0.02, SE: 0.01, CI 95%: 0.01 to 0.03) was directly associated with a higher risk of liver fibrosis (FIB-4 ≥ 2.67). Moreover, the reduction in SSI (coefficient: −0.02, SE: 0.01, CI 95%: −0.03 to −0.01) was inversely associated with FIB-4 values < 2.67. Conclusion: Our results show an association between liver fibrosis and both ARHL and CAPD, linked by the typical consequence of aging. We also assume a role of inflammatory responses and oxidative stress.
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Yang X, Xia M, Chang X, Zhu X, Sun X, Yang Y, Wang L, Liu Q, Zhang Y, Xu Y, Lin H, Liu L, Yao X, Hu X, Gao J, Yan H, Gao X, Bian H. A novel model for detecting advanced fibrosis in patients with nonalcoholic fatty liver disease. Diabetes Metab Res Rev 2022; 38:e3570. [PMID: 35938229 PMCID: PMC9788169 DOI: 10.1002/dmrr.3570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 07/10/2022] [Accepted: 07/21/2022] [Indexed: 12/30/2022]
Abstract
AIMS The study aimed to develop a novel noninvasive model to detect advanced fibrosis based on routinely available clinical and laboratory tests. MATERIALS AND METHODS A total of 309 patients who underwent liver biopsy were randomly divided into the estimation group (n = 201) and validation group (n = 108). The model was developed using multiple regression analysis in the estimation group and further verified in the validation group. Diagnostic accuracy was evaluated using the receiver operating characteristic (ROC) curve. RESULTS The model was named NAFLD Fibrosis Index (NFI): -10.844 + 0.046 × age - 0.01 × platelet count + 0.19 × 2h postprandial plasma glucose (PG) + 0.294 × conjugated bilirubin - 0.015 × ALT + 0.039 × AST + 0.109 × total iron binding capacity -0.033 × parathyroid hormone (PTH). The area under the ROC curve (AUC) of NFI was 0.86 (95% CI: 0.79-0.93, p < 0.001) in the estimation group and 0.80 (95% CI: 0.69-0.91, p < 0.001) in the validation group, higher than NFS, FIB4, APRI, and BARD, and similar to FibroScan (NFI AUC = 0.77, 95% CI: 0.66-0.89, p = 0.001 vs. FibroScan AUC = 0.76, 95% CI: 0.62-0.90, p = 0.002). By applying the low cut-off value (-2.756), advanced fibrosis could be excluded among 49.3% and 48% of patients in the estimation group (sensitivity: 93.1%, NPV: 97.9%, specificity: 55.2%, and PPV: 26.0%) and validation group (sensitivity: 81.3%, NPV: 94.2%, specificity: 53.3%, and PPV: 23.2%), respectively, allowing them to avoid liver biopsy. CONCLUSIONS The study has established a novel model for advanced fibrosis, the diagnostic accuracy of which is superior to the current clinical scoring systems and is similar to FibroScan.
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Affiliation(s)
- Xinyu Yang
- Department of Endocrinology and MetabolismZhongshan HospitalFudan UniversityShanghaiChina
- Fudan Institute for Metabolic DiseaseFudan UniversityShanghaiChina
| | - Mingfeng Xia
- Department of Endocrinology and MetabolismZhongshan HospitalFudan UniversityShanghaiChina
- Fudan Institute for Metabolic DiseaseFudan UniversityShanghaiChina
| | - Xinxia Chang
- Department of Endocrinology and MetabolismZhongshan HospitalFudan UniversityShanghaiChina
- Fudan Institute for Metabolic DiseaseFudan UniversityShanghaiChina
| | - Xiaopeng Zhu
- Department of Endocrinology and MetabolismZhongshan HospitalFudan UniversityShanghaiChina
- Fudan Institute for Metabolic DiseaseFudan UniversityShanghaiChina
| | - Xiaoyang Sun
- Department of Endocrinology and MetabolismZhongshan HospitalFudan UniversityShanghaiChina
- Fudan Institute for Metabolic DiseaseFudan UniversityShanghaiChina
| | - Yinqiu Yang
- Department of Endocrinology and MetabolismZhongshan HospitalFudan UniversityShanghaiChina
- Fudan Institute for Metabolic DiseaseFudan UniversityShanghaiChina
| | - Liu Wang
- Department of Endocrinology and MetabolismZhongshan HospitalFudan UniversityShanghaiChina
- Fudan Institute for Metabolic DiseaseFudan UniversityShanghaiChina
- Second Affiliated Hospital of Army Military Medical UniversityChongqingChina
| | - Qiling Liu
- Department of Endocrinology and MetabolismZhongshan HospitalFudan UniversityShanghaiChina
- Fudan Institute for Metabolic DiseaseFudan UniversityShanghaiChina
| | - Yuying Zhang
- Department of Endocrinology and MetabolismZhongshan HospitalFudan UniversityShanghaiChina
- Fudan Institute for Metabolic DiseaseFudan UniversityShanghaiChina
| | - Yanlan Xu
- Department of Endocrinology and MetabolismZhongshan HospitalFudan UniversityShanghaiChina
- Fudan Institute for Metabolic DiseaseFudan UniversityShanghaiChina
- Department of GeriatricsQingpu Branch of Zhongshan HospitalFudan UniversityShanghaiChina
| | - Huandong Lin
- Department of Endocrinology and MetabolismZhongshan HospitalFudan UniversityShanghaiChina
- Fudan Institute for Metabolic DiseaseFudan UniversityShanghaiChina
| | - Lin Liu
- Department of Endocrinology and MetabolismZhongshan HospitalFudan UniversityShanghaiChina
- Fudan Institute for Metabolic DiseaseFudan UniversityShanghaiChina
| | - Xiuzhong Yao
- Department of RadiologyZhongshan HospitalFudan UniversityShanghaiChina
| | - Xiqi Hu
- Department of PathologyShanghai Medical CollegeFudan UniversityShanghaiChina
| | - Jian Gao
- Department of Clinical NutritionZhongshan HospitalCenter of Clinical EpidemiologyEBM of Fudan UniversityFudan UniversityShanghaiChina
| | - Hongmei Yan
- Department of Endocrinology and MetabolismZhongshan HospitalFudan UniversityShanghaiChina
- Fudan Institute for Metabolic DiseaseFudan UniversityShanghaiChina
| | - Xin Gao
- Department of Endocrinology and MetabolismZhongshan HospitalFudan UniversityShanghaiChina
- Fudan Institute for Metabolic DiseaseFudan UniversityShanghaiChina
| | - Hua Bian
- Department of Endocrinology and MetabolismZhongshan HospitalFudan UniversityShanghaiChina
- Fudan Institute for Metabolic DiseaseFudan UniversityShanghaiChina
- Department of Endocrinology and MetabolismWusong Branch of Zhongshan HospitalFudan UniversityShanghaiChina
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Schreiner AD, Moran WP, Zhang J, Livingston S, Marsden J, Mauldin PD, Koch D, Gebregziabher M. The Association of Fibrosis-4 Index Scores with Severe Liver Outcomes in Primary Care. J Gen Intern Med 2022; 37:3266-3274. [PMID: 35048297 PMCID: PMC9550951 DOI: 10.1007/s11606-021-07341-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 12/15/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The Fibrosis-4 Index (FIB-4)non-invasively assesses fibrosis risk in chronic liver disease (CLD), but underdiagnosis limits FIB-4's application in primary care. OBJECTIVE To evaluate the association of FIB-4 risk with hazard of severe liver outcomes in primary care patients with and without diagnosed CLD. DESIGN Retrospective cohort study of primary care data from 2007 to 2018. PARTICIPANTS Adult patients with qualifying aminotransferase and platelet count results were included and a single FIB-4 score was calculated for each patient using the first of these values. Patients with a CLD diagnosis or outcome prior to their FIB-4 score were excluded. MEASURES FIB-4 advanced fibrosis risk categorization (low, indeterminate, and high) was the primary predictor variable. Patients were followed from FIB-4 score to a severe liver outcome, a composite of cirrhosis, liver transplantation, and hepatocellular carcinoma. We analyzed the association of FIB-4 risk categories with hazard risk of a severe liver outcome using stratified Cox regression models, stratifying patients by known CLD. KEY RESULTS A total of 20,556 patients were followed for a mean 2,978 days (SD 1,201 days), and 4% of patients experienced a severe liver outcome. Of patients with low-, indeterminate-, and high-risk FIB-4 scores, 2%, 4%, and 20% suffered a severe liver outcome, respectively. In the overall adjusted model, high-risk FIB-4 scores were associated with hazard of severe liver disease (HR 6.64; 95% CI 5.58-7.90). High-risk FIB-4 scores were associated with severe liver outcomes for patients with known NAFLD (HR 7.32; 95% CI 3.44-15.58), other liver disease (HR 11.39; 95% CI 8.53-15.20), and no known CLD (HR 4.05; 95% CI 3.10-5.28). CONCLUSIONS High-risk FIB-4 scores were strongly associated with risk of severe liver outcomes in patients with and without known CLD. Comprehensive FIB-4 application in primary care may signal silently advancing liver fibrosis.
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Affiliation(s)
- Andrew D Schreiner
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA.
| | - William P Moran
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Jingwen Zhang
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Sherry Livingston
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Justin Marsden
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Patrick D Mauldin
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - David Koch
- Department of Medicine, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, 29425, USA
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Delgado GE, Kleber ME, Moissl AP, Yazdani B, Kusnik A, Ebert MP, März W, Krämer BK, Lammert A, Teufel A. Surrogate scores of advanced fibrosis in NAFLD/NASH do not predict mortality in patients with medium-to-high cardiovascular risk. Am J Physiol Gastrointest Liver Physiol 2021; 321:G252-G261. [PMID: 34132110 DOI: 10.1152/ajpgi.00058.2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Untreated non-alcoholic fatty liver disease (NAFLD) may have significant consequences including an increase in mortality and cardiovascular injury. Thus, early detection of NAFLD is currently believed not only to prevent liver-related but also cardiovascular mortality. However, almost nothing is known about coexisting NAFLD in patients with coronary artery disease (CAD). We investigated the impact of surrogate scores of fibrosis in NAFLD in a large cohort of patients referred to coronary angiography. Modeling the common NALFD and fibrosis scores, fibrosis-4 index (FIB-4) and NAFLD fibrosis score (NFS), as splines revealed significant associations with all-cause and cardiovascular mortality when Cox regression models were only adjusted for cardiovascular risk factors that were not already included in the calculation of the scores. Stratifying the scores into quartiles yielded hazard ratios [95% confidence interval (CI)] for all-cause and cardiovascular mortality for the 4th quartile versus the 1st quartile of 2.28 (1.90-2.75) and 2.11 (1.67-2.67) for FIB-4 and of 3.21 (2.61-3.94) and 3.12 (2.41-4.04) for NFS. However, we did not observe an independent association of FIB-4 or NFS with overall or cardiovascular mortality in our prospective CAD cohort after full adjustment for all cardiovascular risk factors [all-cause mortality: HR 1.13 (0.904-1.41) and 1.17 (0.903-1.52); cardiovascular mortality: HR 1.06 (0.8-1.41) and 1.02 (0.738-1.41)]. Thus, neither FIB-4 nor NFS, as surrogate markers for NAFLD/NASH, were independent risk factors for overall or cardiovascular mortality in patients with CAD. Our data show that surrogate risk scores for NAFLD-related fibrosis do not add information in assessing the CVD events in patients with CAD proven by angiography.NEW & NOTEWORTHY We investigated the impact of NAFLD surrogate markers in a large cohort of patients that had been referred to coronary angiography. In contrast to a repeatedly demonstrated increased link of cardiovascular events in patients with NALFD, we demonstrated that NAFLD surrogate markers were not independent risk factors for overall or cardiovascular mortality in patients with CAD. Thus, these markers may not be useful for primary prevention of cardiovascular events in patients with CAD.
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Affiliation(s)
- Graciela E Delgado
- Department of Medicine V, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Marcus E Kleber
- Department of Medicine V, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,SYNLAB MVZ Humangenetik Mannheim GmbH, Mannheim, Germany
| | - Angela P Moissl
- Department of Medicine V, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Institute of Nutritional Sciences, Friedrich Schiller University Jena, Jena, Germany.,Competence Cluster for Nutrition and Cardiovascular Health (nutriCARD), Halle-Jena-Leipzig, Germany
| | - Babak Yazdani
- Department of Medicine V, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Alexander Kusnik
- Department of Medicine II, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Clinical Cooperation Unit Healthy Metabolism, Center for Preventive Medicine and Digital Health Baden-Württemberg (CPDBW), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Matthias P Ebert
- Department of Medicine II, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Clinical Cooperation Unit Healthy Metabolism, Center for Preventive Medicine and Digital Health Baden-Württemberg (CPDBW), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Winfried März
- Department of Medicine V, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Synlab Academy, SYNLAB Holding Deutschland GmbH, Mannheim and Augsburg, Germany
| | - Bernhard K Krämer
- Department of Medicine V, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Clinical Cooperation Unit Healthy Metabolism, Center for Preventive Medicine and Digital Health Baden-Württemberg (CPDBW), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Alexander Lammert
- Department of Medicine V, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Praxis für Stoffwechsel- und Nierenerkrankungen, Zentrum für Dialyse und Apherese, Grünstadt, Germany
| | - Andreas Teufel
- Clinical Cooperation Unit Healthy Metabolism, Center for Preventive Medicine and Digital Health Baden-Württemberg (CPDBW), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Department of Medicine II, Section of Hepatology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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