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Wang Y, Liu K. Therapeutic potential of oleanolic acid in liver diseases. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:4537-4554. [PMID: 38294504 DOI: 10.1007/s00210-024-02959-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/15/2024] [Indexed: 02/01/2024]
Abstract
Liver-associated diseases affect millions of individuals worldwide. In developed countries, the incidence of viral hepatitis is reducing due to advancements in disease prevention, diagnosis, and treatment. However, with improvements in living standards, the prevalence of metabolic liver diseases, such as non-alcoholic fatty liver disease and alcohol-related liver disease, is expected to increase; notably, this rise in the prevalence of metabolic liver disease can lead to the development of more severe liver diseases, including liver failure, cirrhosis, and liver cancer. The growing demand for natural alternative therapies for chronic diseases has highlighted the importance of studying the pharmacology of bioactive compounds in plants. One such compound is oleanolic acid (OA), a pentacyclic triterpenoid known for its antioxidant, anti-inflammatory, anti-ulcer, antibacterial, antiviral, antihypertensive, anti-obesity, anticancer, anti-diabetic, cardioprotective, hepatoprotective, and anti-neurodegenerative properties. Recent studies have demonstrated that OA treatment can reduce the risk of pathological liver damage, ultimately alleviating liver dysregulation and restoring overall liver function. This review aims to explore the latest research on the biological effects of OA and its derivatives. Notably, it explores the mechanisms of action of these compounds in both in vitro and in vivo research models and, ultimately, highlights OA as a promising candidate for alternative therapies in the treatment and management of chronic liver disease.
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Affiliation(s)
- Yongxin Wang
- Department of Hepatobiliary and Pancreatic Surgery II, General Surgery Center, The First Hospital of Jilin University, Changchun, 130021, China
| | - Kai Liu
- Department of Hepatobiliary and Pancreatic Surgery II, General Surgery Center, The First Hospital of Jilin University, Changchun, 130021, China.
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Hjorth M, Svanberg A, LoMartire R, Kaminsky E, Rorsman F. Patient perceived quality of cirrhosis care- adjunctive nurse-based care versus standard medical care: a pragmatic multicentre randomised controlled study. BMC Nurs 2024; 23:251. [PMID: 38637755 PMCID: PMC11027520 DOI: 10.1186/s12912-024-01934-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/12/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Cirrhosis treatment implies prevention and alleviation of serious disease events. Healthcare providers may, however, fail to meet patients' expectations of collaboration and specific needs of information and support. Individualised nursing care could meet patients' needs. The aim was thus to measure patient-perceived quality of care after adjunctive registered nurse-based intervention Quality Liver Nursing Care Model (QLiNCaM) compared with standard medical care. METHODS This pragmatic multicentre study consecutively randomised patients to either adjunctive registered nurse-based care, or standard medical care for 24 months (ClinicalTrials.gov NCT02957253). Patients were allocated to either group at an equal ratio, at six Swedish outpatient clinics during 2016-2022. Using the questionnaire 'Quality of care from the patient's perspective', patients rated their perceived lack of quality for the adjunctive registered nurse-based intervention compared with the control group at 12 and 24 months, respectively. RESULTS In total, 167 patients were recruited. Seven out of 22 items in the questionnaire supported the finding that 'lacking quality' decreased with adjunctive registered nurse-based care (p < 0.05) at 12 months follow-up; however, these differences could not be established at 24 months. CONCLUSION Additional structured registered nurse-based visits in the cirrhosis outpatient team provided support for improved patient-perceived quality of care during the first 12 months. Registered nurses increase patient involvement and present easy access to cirrhosis outpatient care. Patients express appreciation for personalised information. This study reinforces registered nurses' role in the outpatient cirrhosis team, optimising patient care in compensated and decompensated cirrhosis. TRIAL REGISTRATION Registered at Clinical Trials 18th of October 2016, [ https://www. CLINICALTRIALS gov ], registration number: NCT02957253.
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Affiliation(s)
- Maria Hjorth
- Centre for Clinical Research in Dalarna, Uppsala University, Falun, Sweden.
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
| | | | - Riccardo LoMartire
- Centre for Clinical Research in Dalarna, Uppsala University, Falun, Sweden
- School of Health and Wellfare, Dalarna University, Falun, Sweden
| | - Elenor Kaminsky
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Fredrik Rorsman
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Lisman T, Bernal W, Luyendyk JP. Anticoagulation to prevent disease progression in patients with cirrhosis. J Hepatol 2023; 79:e123-e124. [PMID: 36996940 DOI: 10.1016/j.jhep.2023.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 04/01/2023]
Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory, Section of Hepatobiliary Surgery and Liver Transplantation Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - James P Luyendyk
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
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Dezső K, Paku S, Kóbori L, Thorgeirsson SS, Nagy P. What Makes Cirrhosis Irreversible?-Consideration on Structural Changes. Front Med (Lausanne) 2022; 9:876293. [PMID: 35572980 PMCID: PMC9091510 DOI: 10.3389/fmed.2022.876293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/04/2022] [Indexed: 11/17/2022] Open
Abstract
Several studies have shown that liver fibrosis, and even cirrhosis can be reversed, disproving the old “dogma” that cirrhosis is irreversible. In addition to scaring, vascular alterations appear to be critically important in the progression of chronic liver diseases. To overcome the “tipping-point” of cirrhosis, we need to understand in depth what might make it irreversible in some cases. Morphologically, the initial, as well as the advanced stages of cirrhosis are characterized by specific structural changes. The hallmark of the initial stage is the division of the original liver parenchyma by centro-central or porto-portal septa. No significant vascular changes are observed in this stage. The advanced stage is characterized by several morphological alterations: (i) The main feature is the parenchymal extinction, with intact portal vein branches, hepatic artery branches, and biliary ductules; (ii) In the extinct areas we observed numerous loops in the ductular network, indicating the disruption of the hepato-biliary junctions; (iii) Although the ductular progenitor cells are able to generate hepatocytes via the budding process, the newly formed hepatocyte nodules cannot re-establish the original lobular architecture due to their disorganized growth. In conclusion, this regenerative process characteristic for the advanced stage, contributes to circulatory disorders, perpetuates parenchymal injury and may lead to the irreversibility of cirrhosis.
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Affiliation(s)
- Katalin Dezső
- Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Sándor Paku
- Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - László Kóbori
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Snorri S Thorgeirsson
- Laboratory of Human Carcinogenesis, Center for Cancer Research (CCR), National Cancer Institute, National Institute of Health (NIH), Bethesda, MD, United States
| | - Péter Nagy
- Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
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Intravenous Drip of Somatostatin Followed by Restricted Fluid Resuscitation to Treat Upper Gastrointestinal Bleeding in Patients with Liver Cirrhosis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:6548479. [PMID: 34721640 PMCID: PMC8550838 DOI: 10.1155/2021/6548479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/30/2021] [Indexed: 12/14/2022]
Abstract
Objective Liver cirrhosis is a common, often progressive, and usually fatal disorder. Upper gastrointestinal bleeding is a leading cause of death in patients with liver cirrhosis. The purpose of this study was to evaluate the effectiveness of somatostatin combined with restricted fluid resuscitation in the treatment of upper gastrointestinal bleeding in the patients with liver cirrhosis. Methods From January 2018 to December 2020, 84 patients with liver cirrhosis complicated by upper gastrointestinal bleeding admitted to the Department of Gastroenterology of Ningbo Yinzhou No. 2 Hospital were selected as study participants. They were randomly assigned into the study group (n = 42) and control group (n = 42). All patients were given intravenous drip of somatostatin. The study group was supplemented with restricted fluid resuscitation therapy. The hemoglobin (Hb), platelet, fibrinogen, hematocrit, transfusion volume of red blood cells, hemostatic time, hemostatic rates in 0 h–24 h, 24 h–48 h, and >48 h, rebleeding rates, resuscitation rate, and incidence rates of complications were compared between the two groups 48 h after treatment. Results It was found that the Hb, platelet, fibrinogen, and hematocrit were notably increased in the study group compared to the control group 48 h after treatment (P < 0.01). The proportion of patients with excellent response was notably higher in the study group than in the control group (P < 0.05). The overall response rate of the study group was 90.48%, which was significantly higher than 71.43% in the control group (P < 0.05). The study group had lower transfusion volume of red blood cells, shorter hemostatic time, and lower rebleeding rates than the control group (P < 0.01). The hemostatic rate of 0 h–24 h in the study group was remarkably higher than that in the control group (P < 0.05). The hemostatic rate of >48 h in the study group was lower than that in the control group (P < 0.05). The overall incidence rate of complications in the study group was 9.52%, which was significantly lower than 30.95% in the control group (P < 0.05). Conclusion These data suggest that intravenous drip of somatostatin followed by restricted fluid resuscitation leads to a better clinical efficacy in treating upper gastrointestinal bleeding in patients with liver cirrhosis considering higher resuscitation rate and hemostatic rate and reduced incidence of complications, which is conducive to the recovery of patients and worthy of further clinical promotion.
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Muñoz AE, Pollarsky F, Marino M, Cartier M, Míguez C, Vázquez H, Álvarez D, Salgado P, Romero G. Safety of Chronic Simvastatin Treatment in Patients with Decompensated Cirrhosis: Many Adverse Events but No Liver Injury. Dig Dis Sci 2021; 66:3199-3208. [PMID: 33033975 DOI: 10.1007/s10620-020-06630-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 09/20/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The high mortality rate of decompensated cirrhosis underlines the need for new treatments. Experimental models of cirrhosis and its reported relationship with atherosclerotic cardiovascular disease have provided data supporting the rational use of statins in these patients. However, little is known about the safety of statins in this setting. AIM We evaluate the safety of chronic simvastatin treatment in patients with decompensated cirrhosis. METHODS We conducted a prospective, open, uncontrolled, phase 2a trial in 30 patients with Child-Pugh class A (n = 6), B (n = 22), and C (n = 2) decompensated cirrhosis. The patients received standard treatment throughout the trial plus simvastatin 20 mg/day for 2 weeks and thereafter simvastatin 40 mg/day up to 1 year. RESULTS Sixteen out of 30 patients (53.3%) showed adverse events, including gastrointestinal toxicity (36.7%), muscle injury (MI) (36.7%), and headache (13.3%). No liver injury was registered. Due to MI alone, simvastatin dosage was reduced in 23.4% of cases and transiently interrupted in 13.3%. Once these adverse events were overcome, simvastatin was resumed until the end of the trial. MI was associated with baseline MELD score > 12 (p = 0.035) and with baseline Child-Pugh class C. No MI was associated with final Child-Pugh score ≤ 6 (p = 0.030) or final Child-Pugh class A (p = 0.020). CONCLUSIONS Chronic treatment with simvastatin 40 mg/day in patients with decompensated cirrhosis was associated with several adverse events, being MI the only clinically significant one, which appears to be related to the simvastatin dosage and the degree of cirrhosis severity. Noticeably, no liver injury was recorded.
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Affiliation(s)
- Alberto E Muñoz
- Sección de Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Facultad de Medicina, Universidad de Buenos Aires, Av. Caseros 2061 (1264), Ciudad Autónoma de Buenos Aires, Argentina.
- Instituto de Investigaciones en Salud Pública, Facultad de Odontología, Universidad de Buenos Aires, Marcelo T. Alvear 2142 (1122), Ciudad Autónoma de Buenos Aires, Argentina.
| | - Florencia Pollarsky
- Sección de Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Facultad de Medicina, Universidad de Buenos Aires, Av. Caseros 2061 (1264), Ciudad Autónoma de Buenos Aires, Argentina
| | - Mónica Marino
- Sección de Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Facultad de Medicina, Universidad de Buenos Aires, Av. Caseros 2061 (1264), Ciudad Autónoma de Buenos Aires, Argentina
| | - Mariano Cartier
- Sección de Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Facultad de Medicina, Universidad de Buenos Aires, Av. Caseros 2061 (1264), Ciudad Autónoma de Buenos Aires, Argentina
| | - Carlos Míguez
- Sección de Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Facultad de Medicina, Universidad de Buenos Aires, Av. Caseros 2061 (1264), Ciudad Autónoma de Buenos Aires, Argentina
| | - Horacio Vázquez
- Unidad Clínica, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Facultad de Medicina, Universidad de Buenos Aires, Av. Caseros 2061 (1264), Investigador Asociado del Gobierno de La Ciudad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Daniel Álvarez
- Servicio de Ecografía, Fundación Favaloro, Facultad de Medicina, Universidad Favaloro, Av. Belgrano 1782 (1093), Ciudad Autónoma de Buenos Aires, Argentina
| | - Pablo Salgado
- Instituto de Investigaciones en Salud Pública, Facultad de Odontología, Universidad de Buenos Aires, Marcelo T. Alvear 2142 (1122), Ciudad Autónoma de Buenos Aires, Argentina
| | - Gustavo Romero
- Sección de Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Facultad de Medicina, Universidad de Buenos Aires, Av. Caseros 2061 (1264), Ciudad Autónoma de Buenos Aires, Argentina
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Muciño-Bermejo MJ. Mechanisms of kidney dysfunction in the cirrhotic patient: Non-hepatorenal acute-on-chronic kidney damage considerations. Ann Hepatol 2021; 19:145-152. [PMID: 31594758 DOI: 10.1016/j.aohep.2019.06.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 06/22/2019] [Accepted: 06/25/2019] [Indexed: 02/04/2023]
Abstract
Renal dysfunction is a common finding in cirrhotic patients and has a great physiologic, and therefore, prognostic relevance. The combination of liver disease and renal dysfunction can occur as a result of systemic conditions that affect both the liver and the kidney, although primary disorders of the liver complicated by renal dysfunction are much more common. As most of the renal dysfunction scenarios in cirrhotic patients correspond to either prerenal azotemia or hepatorenal syndrome (HRS), physicians tend to conceive renal dysfunction in cirrhotic patients as mainly HRS. However, there are many systemic conditions that may cause both a "baseline" chronic kidney damage and a superimposed kidney dysfunction when this systemic condition worsens. The main aim of this article is to review some of the most important non prerenal non-HRS considerations regarding acute on chronic kidney dysfunction in cirrhotic patients, including renal manifestation of related to non-alcoholic steatohepatitis (NASH) viral hepatitis, the effect of cardiorenal syndrome in cirrhotics and corticosteroid-deficiency associated renal dysfunction.
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Affiliation(s)
- María-Jimena Muciño-Bermejo
- Medica Sur Clinical Foundation, Mexico City, Mexico; The American British Cowdray Medical Center, Mexico City, Mexico; International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy.
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Wu M, Wu L, Jin J, Wang J, Li S, Zeng J, Guo H, Zheng J, Chen S, Zheng R. Liver Stiffness Measured with Two-dimensional Shear-Wave Elastography Is Predictive of Liver-related Events in Patients with Chronic Liver Disease Due to Hepatis B Viral Infection. Radiology 2020; 295:353-360. [PMID: 32125254 DOI: 10.1148/radiol.2020191481] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Liver stiffness measurement has been proposed as a noninvasive marker for predicting liver-related complications of cirrhosis. Purpose To evaluate the predictive value of liver stiffness measurement by using two-dimensional (2D) shear-wave elastography (SWE) for liver-related events among patients with chronic hepatitis B. Materials and Methods This retrospective study recruited consecutive patients with chronic hepatitis B who were referred for liver biopsy between May 2011 and May 2015. All patients underwent 2D SWE before biopsy, and a subset of patients underwent transient elastography. Patients were followed up for 4 years through the electronic medical records or telephone interviews. Univariable and multivariable logistic regression analyses were used to determine prognostic factors. Accuracy of prognostic parameters was evaluated by using the area under the receiver operating characteristic curve (AUC). Results Among 430 patients (mean age, 38 years; range, 18-67 years) including 328 men and 102 women, 29 patients developed liver-related events. Multivariable analysis demonstrated that liver stiffness measured with 2D SWE, spleen longitudinal diameter at US, age, and albumin level were predictive factors of liver-related events. The AUC of the multivariable model was higher (0.89; 95% confidence interval [CI]: 0.86, 0.92) but not significantly different from that of 2D SWE (0.86; 95% CI: 0.82, 0.89; P = .23) and was significantly higher than that of the fibrosis stage (0.72; 95% CI: 0.68, 0.76; P < .001), the aspartate aminotransferase-to-platelet ratio index (0.80; 95% CI: 0.76, 0.84; P < .001), and the fibrosis-4 index (0.84; 95% CI: 0.80, 0.87; P = .02). In a subset of patients with available transient elastography (n = 188), the multivariable model, 2D SWE, and transient elastography showed comparable performance (AUC: 0.91 vs 0.86 vs 0.88, respectively). When inflammatory activity was considered, the multivariable model was highly accurate in patients with low-grade inflammation and normal levels of alanine aminotransferase (AUC: 0.97 and 0.94, respectively). Conclusion The multivariable model and two-dimensional shear-wave elastography are more accurate in predicting liver-related events than are the fibrosis stage and serum markers of liver fibrosis tests. © RSNA, 2020 Online supplemental material is available for this article.
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Affiliation(s)
- Manli Wu
- From the Department of Ultrasound, the Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou 510630, Guangdong, PR China (M.W., L.W., J.J., J.W., J.Zeng., H.G., R.Z.); Faculty of Engineering & Information Sciences, University of Wollongong, Wollongong, Australia (S.L.); Department of Ultrasound, the Third Hospital of Longgang, Shenzhen, China (J. Zheng); and Department of Radiology, College of Medicine, Mayo Clinic, Rochester, MN. (S.C.)
| | - Lili Wu
- From the Department of Ultrasound, the Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou 510630, Guangdong, PR China (M.W., L.W., J.J., J.W., J.Zeng., H.G., R.Z.); Faculty of Engineering & Information Sciences, University of Wollongong, Wollongong, Australia (S.L.); Department of Ultrasound, the Third Hospital of Longgang, Shenzhen, China (J. Zheng); and Department of Radiology, College of Medicine, Mayo Clinic, Rochester, MN. (S.C.)
| | - Jieyang Jin
- From the Department of Ultrasound, the Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou 510630, Guangdong, PR China (M.W., L.W., J.J., J.W., J.Zeng., H.G., R.Z.); Faculty of Engineering & Information Sciences, University of Wollongong, Wollongong, Australia (S.L.); Department of Ultrasound, the Third Hospital of Longgang, Shenzhen, China (J. Zheng); and Department of Radiology, College of Medicine, Mayo Clinic, Rochester, MN. (S.C.)
| | - Jinfen Wang
- From the Department of Ultrasound, the Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou 510630, Guangdong, PR China (M.W., L.W., J.J., J.W., J.Zeng., H.G., R.Z.); Faculty of Engineering & Information Sciences, University of Wollongong, Wollongong, Australia (S.L.); Department of Ultrasound, the Third Hospital of Longgang, Shenzhen, China (J. Zheng); and Department of Radiology, College of Medicine, Mayo Clinic, Rochester, MN. (S.C.)
| | - Shuoyang Li
- From the Department of Ultrasound, the Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou 510630, Guangdong, PR China (M.W., L.W., J.J., J.W., J.Zeng., H.G., R.Z.); Faculty of Engineering & Information Sciences, University of Wollongong, Wollongong, Australia (S.L.); Department of Ultrasound, the Third Hospital of Longgang, Shenzhen, China (J. Zheng); and Department of Radiology, College of Medicine, Mayo Clinic, Rochester, MN. (S.C.)
| | - Jie Zeng
- From the Department of Ultrasound, the Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou 510630, Guangdong, PR China (M.W., L.W., J.J., J.W., J.Zeng., H.G., R.Z.); Faculty of Engineering & Information Sciences, University of Wollongong, Wollongong, Australia (S.L.); Department of Ultrasound, the Third Hospital of Longgang, Shenzhen, China (J. Zheng); and Department of Radiology, College of Medicine, Mayo Clinic, Rochester, MN. (S.C.)
| | - Huanyi Guo
- From the Department of Ultrasound, the Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou 510630, Guangdong, PR China (M.W., L.W., J.J., J.W., J.Zeng., H.G., R.Z.); Faculty of Engineering & Information Sciences, University of Wollongong, Wollongong, Australia (S.L.); Department of Ultrasound, the Third Hospital of Longgang, Shenzhen, China (J. Zheng); and Department of Radiology, College of Medicine, Mayo Clinic, Rochester, MN. (S.C.)
| | - Jian Zheng
- From the Department of Ultrasound, the Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou 510630, Guangdong, PR China (M.W., L.W., J.J., J.W., J.Zeng., H.G., R.Z.); Faculty of Engineering & Information Sciences, University of Wollongong, Wollongong, Australia (S.L.); Department of Ultrasound, the Third Hospital of Longgang, Shenzhen, China (J. Zheng); and Department of Radiology, College of Medicine, Mayo Clinic, Rochester, MN. (S.C.)
| | - Shigao Chen
- From the Department of Ultrasound, the Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou 510630, Guangdong, PR China (M.W., L.W., J.J., J.W., J.Zeng., H.G., R.Z.); Faculty of Engineering & Information Sciences, University of Wollongong, Wollongong, Australia (S.L.); Department of Ultrasound, the Third Hospital of Longgang, Shenzhen, China (J. Zheng); and Department of Radiology, College of Medicine, Mayo Clinic, Rochester, MN. (S.C.)
| | - Rongqin Zheng
- From the Department of Ultrasound, the Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou 510630, Guangdong, PR China (M.W., L.W., J.J., J.W., J.Zeng., H.G., R.Z.); Faculty of Engineering & Information Sciences, University of Wollongong, Wollongong, Australia (S.L.); Department of Ultrasound, the Third Hospital of Longgang, Shenzhen, China (J. Zheng); and Department of Radiology, College of Medicine, Mayo Clinic, Rochester, MN. (S.C.)
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Zhang L, Huan H, Tong H, Wei B, Wang Z, Liu C, Wu H. Warfarin prevented de novo portal vein thrombosis after transjugular intrahepatic portosystemic shunt: A retrospective study. Medicine (Baltimore) 2020; 99:e18737. [PMID: 31914090 PMCID: PMC6959952 DOI: 10.1097/md.0000000000018737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Portal vein thrombosis (PVT) might impair the prognosis of cirrhotic patients. However, formation of de novo PVT after transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients without preexisting PVT was rarely reported. Moreover, it is not known whether warfarin is efficient in preventing de novo PVT after TIPS. The current study aimed to investigate retrospectively the incidence and location of de novo PVT, and preventive effects of warfarin on de novo PVT after TIPS for cirrhotic patients. Patients who received TIPS placement between March 1, 2015 and March 1, 2016 in our hospital were screened retrospectively. Patients without preexisting PVT before TIPS and those who were followed up for at least 12 months were included. There were 2 groups: 1 group received warfarin (warfarin group) post-TIPS, while another group (control group) did not receive prophylactic drug to prevent PVT. Their baseline characteristics and follow-up data were retrieved. The occurrence of PVT, adverse events due to warfarin, difference in stent patency and clinical complications such as stent dysfunction, hepatic encephalopathy, mortality, liver cancer, variceal bleeding, infection, and liver failure, and results of follow-up biochemical examination were compared. Eighty-three patients without preexisting PVT were included. There were 56 patients in the control group and 27 in the warfarin group. The incidence of PVT in the warfarin group was 14.8% (4/27), whereas the incidence in the control group was 42.9% (24/56, P = .013). The location of de novo PVT was mainly at left portal vein. Adverse events due to warfarin was mostly mild, such as hemorrhinia and gingival hemorrhage. No significant difference regarding to stent patency and clinical complications between the 2 groups was found. At 24-month after-TIPS, for the remaining patients in both groups, the total bilirubin was significantly increased while the red blood cell count was significantly decreased in control group compared with those in warfarin group (P < .05). PVT could commonly occur after TIPS in patients without preexisting PVT. Warfarin could prevent PVT in these patients, and might improve patient's liver function.
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Affiliation(s)
- Linhao Zhang
- Department of Gastroenterology
- Laboratory of Gastroenterology and Hepatology, West China Hospital, Sichuan University
| | - Hui Huan
- Department of Gastroenterology
- Department of Gastroenterology, Hospital of Chengdu Office of People's Government of Tibetan autonomous Region, Sichuan, China
| | | | - Bo Wei
- Department of Gastroenterology
| | | | - Chao Liu
- Department of Gastroenterology, Hospital of Chengdu Office of People's Government of Tibetan autonomous Region, Sichuan, China
| | - Hao Wu
- Department of Gastroenterology
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Kao W, Su C, Fang S, Tang J, Chang C, Liu J. Determination of the predictive factors for significant liver fibrosis assessed through transient elastography. ADVANCES IN DIGESTIVE MEDICINE 2019. [DOI: 10.1002/aid2.13102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Wei‐Yu Kao
- Division of Gastroenterology and Hepatology, Department of Internal MedicineTaipei Medical University Hospital Taipei Taiwan
- Department of Internal Medicine, School of Medicine, College of MedicineTaipei Medical University Taipei Taiwan
- Graduate Institute of Clinical Medicine, College of MedicineTaipei Medical University Taipei Taiwan
- Division of Gastroenterology and Hepatology, Department of MedicineTaipei Veterans General Hospital Taipei Taiwan
- Faculty of Medicine, School of MedicineNational Yang‐Ming University Taipei Taiwan
| | - Chien‐Wei Su
- Division of Gastroenterology and Hepatology, Department of MedicineTaipei Veterans General Hospital Taipei Taiwan
- Faculty of Medicine, School of MedicineNational Yang‐Ming University Taipei Taiwan
| | - Sheng‐Uei Fang
- Division of Gastroenterology and Hepatology, Department of Internal MedicineTaipei Medical University Hospital Taipei Taiwan
- Department of Internal Medicine, School of Medicine, College of MedicineTaipei Medical University Taipei Taiwan
| | - Jui‐Hsiang Tang
- Division of Gastroenterology and Hepatology, Department of Internal MedicineTaipei Medical University Hospital Taipei Taiwan
- Department of Internal Medicine, School of Medicine, College of MedicineTaipei Medical University Taipei Taiwan
| | - Chun‐Chao Chang
- Division of Gastroenterology and Hepatology, Department of Internal MedicineTaipei Medical University Hospital Taipei Taiwan
- Department of Internal Medicine, School of Medicine, College of MedicineTaipei Medical University Taipei Taiwan
| | - Jean‐Dean Liu
- Division of Gastroenterology and Hepatology, Department of Internal MedicineTaipei Medical University Hospital Taipei Taiwan
- Department of Internal Medicine, School of Medicine, College of MedicineTaipei Medical University Taipei Taiwan
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11
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Carvalho MVH, Kroll PC, Kroll RTM, Carvalho VN. Cirrhotic cardiomyopathy: the liver affects the heart. ACTA ACUST UNITED AC 2019; 52:e7809. [PMID: 30785477 PMCID: PMC6376321 DOI: 10.1590/1414-431x20187809] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 12/04/2018] [Indexed: 12/14/2022]
Abstract
Cirrhotic cardiomyopathy historically has been confused as alcoholic cardiomyopathy. The key points for diagnosis of cirrhotic cardiomyopathy have been well explained, however this entity was neglected for a long time. Nowadays the diagnosis of this entity has become important because it is a factor that contributes significantly to morbidity-mortality in cirrhotic patients. Characteristics of cirrhotic cardiomyopathy are a hyperdynamic circulatory state, altered diastolic relaxation, impaired contractility, and electrophysiological abnormalities, particularity QT interval prolongation. The pathogenesis includes impaired function of beta-receptors, altered transmembrane currents and overproduction of cardiodepressant factors, such as nitric oxide, cytokines and endogenous cannabinoids. In addition to physical signs of hyperdynamic state and heart failure under stress conditions, the diagnosis can be done with dosage of serum markers, electrocardiography, echocardiography and magnetic resonance. The treatment is mainly supportive, but orthotopic liver transplantation appears to improve this condition although the prognosis of liver transplantation in patients with cirrhotic cardiomyopathy is uncertain.
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Affiliation(s)
- M V H Carvalho
- Departamento de Cirurgia, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - P C Kroll
- Hospital de Transplante E.J. Zerbini, São Paulo, SP, Brasil
| | - R T M Kroll
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brasil
| | - V N Carvalho
- Hospital Municipal Dr. Mario Gatti, Campinas, SP, Brasil
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12
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Abstract
With the discovery of direct-acting antivirals and the prospective of viral hepatitis becoming curable, alcohol liver disease (ALD) is back to primetime. In the last 20 years, there have been many advances in the understanding of the biology, the psychology and the social and environmental factors associated with this long-known medical problem. Recent information about regional, ethnic, cultural and genetic factors seem to be relevant for the Latin American (LA) population. New approaches based on the new concepts and current information will render better results in the overall management of patients with this problem. Considering alcohol use disorder and ALD as part of the same entity managing it in a multidisciplinary approach seems to be best way to deal with this disease.
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Affiliation(s)
- Octavio Campollo
- Center of Studies on Alcohol and Addictions, Hospital Civil de Guadalajara FAA, Universidad de Guadalajara. Guadalajara, Jalisco, Mexico.
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13
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El-Gohary M, Moore M, Roderick P, Watkins E, Dash J, Reinson T, Newell C, Kim M, Stuart B, Becque T, Sheron N. Local care and treatment of liver disease (LOCATE) - A cluster-randomized feasibility study to discover, assess and manage early liver disease in primary care. PLoS One 2018; 13:e0208798. [PMID: 30576330 PMCID: PMC6303066 DOI: 10.1371/journal.pone.0208798] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 11/23/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Chronic liver disease is an escalating problem both in the United Kingdom and worldwide. In the UK mortality rates have risen sharply over the previous 50 years predominantly due to alcohol, however the increasing prevalence of non-alcohol related fatty liver disease both in the UK and elsewhere is also of concern. Liver disease develops silently hence early detection of fibrosis is essential to prevent progression. Primary care presents an opportunity to identify at risk populations, however assessment largely comprises of indirect markers of fibrosis which have little prognostic value. We hypothesised that setting up nurse-led primary care based liver clinics using additional non-invasive testing would increase the number of new diagnoses of liver disease compared to usual care. METHODS This was a prospective, cluster randomised feasibility trial based in urban primary care in Southampton, United Kingdom. 10 GP practices were randomised to either intervention (liver health nurse) or control (care as usual). Pre recruitment audits were carried out in each practice to ascertain baseline prevalence of liver disease. Participants were subsequently recruited in intervention practices from July 2014-March 2016 via one of 3 pathways: GP referral, nurse led case finding based on risk factors or random AUDIT questionnaire mailouts. Liver assessment included the Southampton Traffic Light test (serum fibrosis markers HA and P3NP) and transient elastography (FibroScan). Cases were ascribed as 'no fibrosis', 'liver warning', 'progressive fibrosis' or 'probable cirrhosis'. Post recruitment audits were repeated and incident liver diagnoses captured from July 2014-September 2016. Each new diagnosis was reviewed in a virtual clinic by a consultant hepatologist. FINDINGS 910 participants were seen in the nurse led clinic-44 (4.8%) probable cirrhosis, 141 (15.5%) progressive fibrosis, 220 (24.2%) liver warning and 505 (55.5%) no evidence of liver fibrosis. 450 (49.5%) cases were due to NAFLD with 356 (39.1%) from alcohol. In the 405 with a liver disease diagnosis, 136 (33.6%) were referred by GP, 218 (53.8%) from nurse led case finding and 51 (12.6%) from the AUDIT mailout. 544 incident cases were identified in the intervention arm compared to 221 in the control arm in the period July 2014-September 2016 (adjusted odds ratio 2.4, 95% CI 2.1 to 2.8). CONCLUSIONS The incorporation of a liver health nurse into GP practices was simple to arrange and yielded a much higher number of new diagnoses of liver disease compared to usual care. Nearly half of all participants recruited had a degree of liver disease. Nurse led case finding and GP referrals were most effective compared to AUDIT questionnaire mailouts in an urban population in identifying unknown disease. Utilising study and previous data allowed quick and effective virtual review by a hepatologist. Identifying those who are at risk of liver disease from harmful alcohol use remains a challenge and needs to be addressed in future work.
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Affiliation(s)
- Magdy El-Gohary
- Primary Care and Population Sciences, School of Medicine, University of Southampton, Southampton, Hampshire, United Kingdom
- * E-mail:
| | - Mike Moore
- Primary Care and Population Sciences, School of Medicine, University of Southampton, Southampton, Hampshire, United Kingdom
| | - Paul Roderick
- Primary Care and Population Sciences, School of Medicine, University of Southampton, Southampton, Hampshire, United Kingdom
| | - Emily Watkins
- National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, Hampshire, United Kingdom
| | - Joanne Dash
- National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, Hampshire, United Kingdom
| | - Tina Reinson
- National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, Hampshire, United Kingdom
| | - Colin Newell
- Primary Care and Population Sciences, School of Medicine, University of Southampton, Southampton, Hampshire, United Kingdom
| | - Miranda Kim
- National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, Hampshire, United Kingdom
| | - Beth Stuart
- Primary Care and Population Sciences, School of Medicine, University of Southampton, Southampton, Hampshire, United Kingdom
| | - Taeko Becque
- Primary Care and Population Sciences, School of Medicine, University of Southampton, Southampton, Hampshire, United Kingdom
| | - Nick Sheron
- National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, Hampshire, United Kingdom
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14
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Day JW, Rosenberg WM. The enhanced liver fibrosis (ELF) test in diagnosis and management of liver fibrosis. Br J Hosp Med (Lond) 2018; 79:694-699. [DOI: 10.12968/hmed.2018.79.12.694] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- James W Day
- Research Fellow, The Institute for Liver and Digestive Health, University College London Division of Medicine, University College London, London NW3 2PF
| | - William M Rosenberg
- Professor of Liver Medicine, The Institute for Liver and Digestive Health, University College London Division of Medicine, University College London, London
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15
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Transient elastography can stratify patients with Child-Pugh A cirrhosis according to risk of early decompensation. Eur J Gastroenterol Hepatol 2018; 30:1434-1440. [PMID: 30063481 DOI: 10.1097/meg.0000000000001224] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Compensated cirrhosis has a variable prognosis depending on stage. There are currently no straightforward and robust tools in clinical practice to predict decompensation in Child-Pugh A cirrhosis. We set out to determine whether transient elastography (TE) could be used across liver disease aetiologies to determine risk of decompensation. PATIENTS AND METHODS Participants were enrolled at two sites (Dublin and Nottingham) and followed up for a minimum of 2 years. The primary outcome of the study was liver decompensation, defined as the development of overt hepatic encephalopathy or ascites or presentation with bleeding varices. All patients received a TE examination to measure liver stiffness measurement (LSM) and had routine blood measurements taken at the baseline visit and on each subsequent visit. RESULTS In 259 participants, the overall rate of liver-related outcome was 31 per 1000 person-years (95% confidence interval: 19-47 per 1000 person-years). Of the total population, 6 and 11% developed a liver-related outcome within 2 and 4 years of follow-up, respectively. There were no events in the population with a LSM less than 21 kPa. A LSM of more than 35 kPa was associated with a decompensation risk of 39% at 4 years. For each unit increase in the LSM above 20 kPa, the risk of liver-related outcome increased by 6% (hazard ratio=1.06; 95% confidence interval: 1.04-1.82) after adjusting for age, sex Mayo End Liver Disease Score, cohort source and aetiology. CONCLUSION The risk of liver decompensation increased with increasing LSM in mixed aetiology compensated cirrhosis. LSM may be used to risk stratify patients, potentially reassure patients with low scores, and select patients with higher scores for experimental therapeutic studies with acceptable timelines.
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16
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Hjorth M, Sjöberg D, Svanberg A, Kaminsky E, Langenskiöld S, Rorsman F. Nurse-led clinic for patients with liver cirrhosis-effects on health-related quality of life: study protocol of a pragmatic multicentre randomised controlled trial. BMJ Open 2018; 8:e023064. [PMID: 30337316 PMCID: PMC6196856 DOI: 10.1136/bmjopen-2018-023064] [Citation(s) in RCA: 3] [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] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Liver cirrhosis affects health-related quality of life (HRQoL) even in its early stages. Morbidity is especially high when the disease decompensates and self-care actions become essential. Nurse involvement in secondary prevention in other chronic diseases has contributed to better symptom control, less need of inpatient care and improved HRQoL. In order to evaluate the impact of nurse involvement in the follow-up of patients with liver cirrhosis, we decided to compare structured nurse-led clinics, inspired by Dorothea Orem's nursing theory and motivational strategies, with a group of patients receiving standard care. The primary outcome is HRQoL and the secondary outcomes are quality of care, visits to outpatient clinics or hospitals, disease progress and health literacy. METHODS AND ANALYSIS This is a pragmatic, multicentre randomised controlled study conducted at six Swedish hepatology departments. Eligible patients are adults with diagnosed cirrhosis of the liver (n=500). Participants are randomised into either an intervention with nurse-led follow-up group or into a standard of care group. Recruitment started in November 2016 and is expected to proceed until 2020. Primary outcomes are physical and mental HRQoL measured by RAND-36 at enrolment, after 1 and 2 years. ETHICS AND DISSEMINATION The study is ethically approved by the Regional Ethical Review Board in Uppsala. The results shall be disseminated in international conferences and peer-reviewed articles. TRIAL REGISTRATION NUMBER NCT02957253; Pre-results.
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Affiliation(s)
- Maria Hjorth
- Center of Clinical Reaerch in Dalarna, Falun, Sweden
- Department of Medical Sciences, Uppsala Universitet Medicinska fakulteten, Uppsala, Sweden
| | | | - Anncarin Svanberg
- Department of Medical Sciences, Uppsala Universitet Medicinska fakulteten, Uppsala, Sweden
- Department of Public Health and Caring Sciences, Uppsala University, Falun, Sweden
- Dalarna University, Falun, Sweden
| | - Elenor Kaminsky
- Department of Public Health and Caring Sciences, Uppsala University, Falun, Sweden
| | - Sophie Langenskiöld
- Department of Public Health and Caring Sciences, Uppsala University, Falun, Sweden
| | - Fredrik Rorsman
- Department of Medical Sciences, Uppsala Universitet Medicinska fakulteten, Uppsala, Sweden
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17
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Day J, Patel P, Parkes J, Rosenberg W. Derivation and Performance of Standardized Enhanced Liver Fibrosis (ELF) Test Thresholds for the Detection and Prognosis of Liver Fibrosis. J Appl Lab Med 2018; 3:815-826. [PMID: 31639756 DOI: 10.1373/jalm.2018.027359] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 08/15/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Noninvasive tests are increasingly used to assess liver fibrosis and determine prognosis but suggested test thresholds vary. We describe the selection of standardized thresholds for the Enhanced Liver Fibrosis (ELF) test for the detection of liver fibrosis and for prognostication in chronic liver disease. METHODS A Delphi method was used to identify thresholds for the ELF test to predict histological liver fibrosis stages, including cirrhosis, using data derived from 921 patients in the EUROGOLF cohort. These thresholds were then used to determine the prognostic performance of ELF in a subset of 457 patients followed for a mean of 5 years. RESULTS The Delphi panel selected sensitivity of 85% for the detection of fibrosis and >95% specificity for cirrhosis. The corresponding thresholds were 7.7, 9.8, and 11.3. Eighty-five percent of patients with mild or worse fibrosis had an ELF score ≥7.7. The sensitivity for cirrhosis of ELF ≥9.8 was 76%. ELF ≥11.3 was 97% specific for cirrhosis. ELF scores show a near-linear relationship with Ishak fibrosis stages. Relative to the <7.7 group, the hazard ratios for a liver-related outcome at 5 years were 21.00 (95% CI, 2.68-164.65) and 71.04 (95% CI, 9.4-536.7) in the 9.8 to <11.3 and ≥11.3 subgroups, respectively. CONCLUSION The selection of standard thresholds for detection and prognosis of liver fibrosis is described and their performance reported. These thresholds should prove useful in both interpreting and explaining test results and when considering the relationship of ELF score to Ishak stage in the context of monitoring.
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Affiliation(s)
- James Day
- The Institute for Liver and Digestive Health, UCL Division of Medicine, UCL, London, UK
| | - Preya Patel
- The Institute for Liver and Digestive Health, UCL Division of Medicine, UCL, London, UK
| | - Julie Parkes
- The Institute for Liver and Digestive Health, UCL Division of Medicine, UCL, London, UK.,The Department of Public Health Sciences and Medical Statistics, University of Southampton, Southampton, UK
| | - William Rosenberg
- The Institute for Liver and Digestive Health, UCL Division of Medicine, UCL, London, UK;
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18
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Association Between Tumor Necrosis Factor-α and the Risk of Hepatic Events: A Median 3 Years Follow-Up Study. HEPATITIS MONTHLY 2018. [DOI: 10.5812/hepatmon.65537] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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19
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Shah AS, Amarapurkar DN. Natural History of Cirrhosis of Liver after First Decompensation: A Prospective Study in India. J Clin Exp Hepatol 2018; 8:50-57. [PMID: 29743797 PMCID: PMC5938527 DOI: 10.1016/j.jceh.2017.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 06/07/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIMS As liver cirrhosis is a dynamic condition, it is possible to improve survival in decompensated cirrhosis. Hence, we planned a prospective study to determine the natural history of cirrhosis after first decompensation. METHODS We enrolled all patients of liver cirrhosis who presented with first episode of decompensation defined by the presence of ascites, either overt or detected by Ultrasonography (UD), Gastroesophageal Variceal Bleeding (GEVB), and Hepatic Encephalopathy (HE). All patients were followed up to death/liver transplant or at least for the period of 1 year. Multivariable Cox proportional hazards regression was used to analyze the risk of failure (death or Orthotopic Liver Transplantation (OLT)). RESULTS In total of 110 cirrhotic patients (93 males, mean age 50 ± 11 years), the most frequent etiology was alcohol (48%), followed by nonalcoholic steatohepatitis/cryptogenic (26%), hepatitis B (10%), autoimmune hepatitis (7%), and hepatitis C (6%). The distribution of CTP classes was: 4%, 56%, and 41% in class A, B, and C, respectively. Ascites was the most common decompensation found in 88 patients (80%) followed by HE (14%) and GEVB (6%). At 1-year follow up, transplant free survival was 78%, 2 underwent OLT, 4 developed hepatocellular carcinoma, and 24 died. Cumulative incidence of failure (death or OLT) by type of decompensation after 1 year was: 22% overt ascites, 50% GEVB, 28% UD ascites, 20% HE, and 33% ascites and GEVB concomitant. CONCLUSIONS Patients with UD ascites do not have a negligible mortality rate as compared to overt ascites. Patients with cirrhosis after first decompensation have better transplant free survival with treatment of etiology and complications than previously mentioned in literature.
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Key Words
- ACLF, Acute-on-Chronic Liver Failure
- AIH, Autoimmune Hepatitis
- APASL, Asian Pacific Association for the Study of the Liver
- CI, Confidence Interval
- GEVB, Gastroesophageal Variceal Bleeding
- GI, Gastrointestinal
- HBV, Hepatitis B Virus
- HCC, Hepatocellular Carcinoma
- HCV, Hepatitis C Virus
- HE, Hepatic Encephalopathy
- HRS, Hepatorenal Syndrome
- MELD, Model for End-Stage Liver Disease
- NASH, Nonalcoholic Steatohepatitis
- OLT, Orthotopic Liver Transplantation
- PPI, Proton Pump Inhibitor
- SAAG, Serum-Ascites Albumin Gradient
- SBP, Spontaneous Bacterial Peritonitis
- UD, Ultrasonography
- ascites
- hepatic encephalopathy
- hepatocellular carcinoma
- liver transplant
- survival
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Affiliation(s)
- Apurva S. Shah
- Department of Gastroenterology, Apollo Hospital International Limited, Ahmedabad, India
- Address for correspondence: Apurva S. Shah, M.D., DNB Gastroenterologist, Department of Gastroenterology, Apollo Hospital International Limited, Ahmedabad 382428, India.
| | - Deepak N. Amarapurkar
- Department of Gastroenterology, Bombay Hospital & Medical Research Center, Mumbai, India
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20
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Antagonism of Interleukin-17A ameliorates experimental hepatic fibrosis by restoring the IL-10/STAT3-suppressed autophagy in hepatocytes. Oncotarget 2018; 8:9922-9934. [PMID: 28039485 PMCID: PMC5354781 DOI: 10.18632/oncotarget.14266] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/01/2016] [Indexed: 12/20/2022] Open
Abstract
Interleukin-17A has been identified as a driver of hepatic stellate cell activation and plays a critical role in the pathogenesis of hepatic fibrosis. However, the underlining fibrosis-promoting mechanism of IL-17A is far from understood. Here we aimed to define whether hepatocytes directly respond to IL-17A stimulation and are associated with the development of hepatic fibrosis. The functional significance of IL-17A was evaluated in bile duct ligation (BDL) or thioacetamide (TAA) injection-induced mouse models of hepatic fibrosis. Human cirrhosis and control tissues were obtained from the patients with cirrhosis who received an open surgical repair process. Neutralizing IL-17A promoted the resolution of BDL or TAA-induced acute or chronic inflammation and fibrosis, resulted in a shift of the suppressive immune response in fibrotic liver toward a Th1-type immune response, and restored autophagy activity in both cholestatic and hepatotoxic liver injury induced fibrotic liver tissues, which was accompanied by a significant inhibition of STAT3 phosphorylation. Moreover, we found that IL-17A stimulated the concentration-and time-dependent phosphorylation of STAT3 in AML-12 liver cells. Blocking STAT3 with a specific inhibitor STATTIC or STAT3 siRNA protected from the IL-17A-induced autophagy suppression in AML-12 cells, indicating that STAT3 mediates IL-17A-suppressed autophagy. Administration of IL-10, which activated STAT3 and inhibited autophagy, reversed the therapeutic effect of IL-17A antagonism in vivo. Our study suggests that the IL-17A/STAT3 signaling pathway plays a crucial role in the pathogenesis of hepatic fibrosis through suppressing hepatocellular autophagy and that blocking this pathway may provide therapeutic benefits for the treatment of hepatic fibrosis.
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21
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Roccarina D, Rosselli M, Genesca J, Tsochatzis EA. Elastography methods for the non-invasive assessment of portal hypertension. Expert Rev Gastroenterol Hepatol 2018; 12:155-164. [PMID: 28856972 DOI: 10.1080/17474124.2017.1374852] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The gold standard to assess the presence and severity of portal hypertension remains the hepatic vein pressure gradient, however the recent development of non-invasive assessment using elastography techniques offers valuable alternatives. In this review, we discuss the diagnostic accuracy and utility of such techniques in patients with portal hypertension due to cirrhosis. Areas covered: A literature search focused on liver and spleen stiffness measurement with different elastographic techniques for the assessment of the presence and severity of portal hypertension and oesophageal varices in people with chronic liver disease. The combination of elastography with parameters such as platelet count and spleen size is also discussed. Expert commentary: Non-invasive assessment of liver fibrosis and portal hypertension is a validated tool for the diagnosis and follow-up of patients. Baveno VI recommended the combination of transient elastography and platelet count for ruling out varices needing treatment in patients with compensated advanced chronic liver disease. Assessment of aetiology specific cut-offs for ruling in and ruling out clinically significant portal hypertension is an unmet clinical need. The incorporation of spleen stiffness measurements in non-invasive algorithms using validated software and improved measuring scales might enhance the non-invasive diagnosis of portal hypertension in the next 5 years.
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Affiliation(s)
- Davide Roccarina
- a UCL Institute for Liver and Digestive Health , Royal Free Hospital and UCL , London , UK
| | - Matteo Rosselli
- a UCL Institute for Liver and Digestive Health , Royal Free Hospital and UCL , London , UK
| | - Joan Genesca
- b Liver Unit, Department of Internal Medicine , Valld'Hebron University Hospital, VHIR, Universitat Autònoma de Barcelona, CIBERehd , Barcelona , Spain
| | - Emmanuel A Tsochatzis
- a UCL Institute for Liver and Digestive Health , Royal Free Hospital and UCL , London , UK
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22
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Fortea JI, Zipprich A, Fernandez-Mena C, Puerto M, Bosoi CR, Almagro J, Hollenbach M, Bañares J, Rodríguez-Sánchez B, Cercenado E, Clément MA, Rose CF, Bañares R, Vaquero J, Ripoll C. Enoxaparin does not ameliorate liver fibrosis or portal hypertension in rats with advanced cirrhosis. Liver Int 2018; 38:102-112. [PMID: 28665498 DOI: 10.1111/liv.13510] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 06/26/2017] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Recent studies suggest that heparins reduce liver fibrosis and the risk of decompensation of liver disease. Here, we evaluated the effects of enoxaparin in several experimental models of advanced cirrhosis. METHODS Cirrhosis was induced in male Sprague-Dawley (SD) rats by: (i) Oral gavage with carbon tetrachloride (CCl4ORAL ), (ii) Bile duct ligation (BDL) and (iii) CCl4 inhalation (CCl4INH ). Rats received saline or enoxaparin s.c. (40 IU/Kg/d or 180 IU/Kg/d) following various protocols. Blood biochemical parameters, liver fibrosis, endothelium- and fibrosis-related genes, portal pressure, splenomegaly, bacterial translocation, systemic inflammation and survival were evaluated. Endothelial dysfunction was assessed by in situ bivascular liver perfusions. RESULTS Enoxaparin did not ameliorate liver function, liver fibrosis, profibrogenic gene expression, portal hypertension, splenomegaly, ascites development and infection, serum IL-6 levels or survival in rats with CCl4ORAL or BDL-induced cirrhosis. Contrarily, enoxaparin worsened portal pressure in BDL rats and decreased survival in CCl4ORAL rats. In CCl4INH rats, enoxaparin had no effects on hepatic endothelial dysfunction, except for correcting the hepatic arterial dysfunction when enoxaparin was started with the CCl4 exposure. In these rats, however, enoxaparin increased liver fibrosis and the absolute values of portal venous and sinusoidal resistance. CONCLUSIONS Our results do not support a role of enoxaparin for improving liver fibrosis, portal hypertension or endothelial dysfunction in active disease at advanced stages of cirrhosis. These disease-related factors and the possibility of a limited therapeutic window should be considered in future studies evaluating the use of anticoagulants in cirrhosis.
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Affiliation(s)
- José I Fortea
- Laboratorio Investigación Hepatología y Gastroenterología, HGU Gregorio Marañón, Madrid, Spain.,Instituto Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Alexander Zipprich
- Innere Medizin I, Martin-Luther-Universität Halle-Wittenberg, Halle, Germany
| | - Carolina Fernandez-Mena
- Laboratorio Investigación Hepatología y Gastroenterología, HGU Gregorio Marañón, Madrid, Spain.,Instituto Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Marta Puerto
- Laboratorio Investigación Hepatología y Gastroenterología, HGU Gregorio Marañón, Madrid, Spain.,Instituto Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain.,CIBERehd, Madrid, Spain
| | - Cristina R Bosoi
- Hepato-neuro laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Jorge Almagro
- Laboratorio Investigación Hepatología y Gastroenterología, HGU Gregorio Marañón, Madrid, Spain.,Instituto Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Marcus Hollenbach
- Innere Medizin I, Martin-Luther-Universität Halle-Wittenberg, Halle, Germany
| | - Juan Bañares
- Laboratorio Investigación Hepatología y Gastroenterología, HGU Gregorio Marañón, Madrid, Spain.,Instituto Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Belén Rodríguez-Sánchez
- Instituto Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain.,Microbiología Clínica y Enfermedades Infecciosas, HGU Gregorio Marañón, Madrid, Spain.,CIBERES, Madrid, Spain
| | - Emilia Cercenado
- Instituto Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain.,Microbiología Clínica y Enfermedades Infecciosas, HGU Gregorio Marañón, Madrid, Spain
| | - Marc-André Clément
- Hepato-neuro laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Christopher F Rose
- Hepato-neuro laboratory, CRCHUM, Université de Montréal, Montréal, Canada
| | - Rafael Bañares
- Laboratorio Investigación Hepatología y Gastroenterología, HGU Gregorio Marañón, Madrid, Spain.,Instituto Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain.,CIBERehd, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Javier Vaquero
- Laboratorio Investigación Hepatología y Gastroenterología, HGU Gregorio Marañón, Madrid, Spain.,Instituto Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain.,CIBERehd, Madrid, Spain
| | - Cristina Ripoll
- Laboratorio Investigación Hepatología y Gastroenterología, HGU Gregorio Marañón, Madrid, Spain.,Instituto Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain.,Innere Medizin I, Martin-Luther-Universität Halle-Wittenberg, Halle, Germany.,CIBERehd, Madrid, Spain
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23
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Baiges A, Hernández-Gea V, Bosch J. Pharmacologic prevention of variceal bleeding and rebleeding. Hepatol Int 2017; 12:68-80. [PMID: 29210030 DOI: 10.1007/s12072-017-9833-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/31/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Variceal bleeding is a major complication of portal hypertension, which is associated with significant mortality. Moreover, patients surviving a variceal bleeding episode have very high risk of rebleeding, which is associated with mortality as high as that of the first bleed. Because of this, prevention of bleeding from gastroesophageal varices has been one of the main therapeutic goals since the advent of the first effective therapies for portal hypertension. AIM This review deals with the present day state-of-the-art pharmacological prevention of variceal bleeding in primary and secondary prophylaxis. RESULTS Pharmacological therapy aims to decrease portal pressure (PP) by acting on the pathophysiological mechanisms of portal hypertension such as increased hepatic vascular tone and splanchnic vasodilatation. Propranolol and nadolol block the beta-1 in the heart and the peripheral beta-2 adrenergic receptors. Beta-1 blockade of cardiac receptors reduces heart rate and cardiac output and subsequently decreases flow into splanchnic circulation. Beta-2 blockade leads to unopposed alpha-1 adrenergic activity that causes splanchnic vasoconstriction and reduction of portal inflow. Both effects contribute to reduction in PP. Carvedilol is more powerful in reducing hepatic venous pressure gradient (HVPG) than traditional nonselective beta-blockers (NSBBs) and achieves good hemodynamic response in nearly 75 % of cases. Simvastatin and atorvastatin improve endothelial dysfunction mainly by enhancing endothelial nitric oxide synthase (eNOS) expression and phosphorylation and NO production. In addition, statins deactivate hepatic stellate cells and ameliorate hepatic fibrogenesis. These effects cause a decrease in HVPG and improve liver microcirculation and hepatocyte perfusion in patients with cirrhosis. In addition, several promising drugs under development may change the management of portal hypertension in the coming years. CONCLUSION This review provides a background on the most important aspects of the treatment of portal hypertension in patients with compensated and decompensated liver cirrhosis. However, despite the great improvement in the prevention of variceal bleeding over the last years, further therapeutic options are needed.
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Affiliation(s)
- Anna Baiges
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, University of Barcelona, C.Villarroel 170, 08036, Barcelona, Spain
| | - Virginia Hernández-Gea
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, University of Barcelona, C.Villarroel 170, 08036, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Barcelona, España
| | - Jaime Bosch
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, University of Barcelona, C.Villarroel 170, 08036, Barcelona, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Barcelona, España. .,Swiss Liver Group, Inselspital, Bern University, Bern, Switzerland.
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24
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Chou CT, Chen RC, Wu WP, Lin PY, Chen YL. Prospective Comparison of the Diagnostic Performance of Magnetic Resonance Elastography with Acoustic Radiation Force Impulse Elastography for Pre-operative Staging of Hepatic Fibrosis in Patients with Hepatocellular Carcinoma. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:2783-2790. [PMID: 28965721 DOI: 10.1016/j.ultrasmedbio.2017.08.1879] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 08/14/2017] [Accepted: 08/20/2017] [Indexed: 06/07/2023]
Abstract
The purpose of this study was to compare the diagnostic accuracy of magnetic resonance (MR) elastography with that of acoustic radiation force impulse (ARFI) elastography for pre-operative staging of hepatic fibrosis in patients with hepatocellular carcinoma. We prospectively enrolled 77 patients who were scheduled to undergo hepatectomy for hepatocellular carcinoma. Pre-operative MRE and ARFI elastography examinations were performed on the same day, and liver stiffness/velocity values were determined. Fibrosis stage and necro-inflammatory activity of resected specimens were determined histopathologically using the METAVIR scoring system. Correlations between MRE and ARFI elastography findings and histologic findings were determined by receiver operating characteristic (ROC) analysis. Correlation of MRE was excellent and correlation of ARFI elastography was good with fibrosis stage. MRE had better diagnostic performance than ARFI elastography in estimating substantial fibrosis (F2), severe fibrosis (F3) and cirrhosis (F4). The optimal cutoff value and the area under the ROC curve (AUROC) were determined using ROC curve analysis. The highest Youden index was used as a criterion for selecting the optimal cutoff value. ROC analysis revealed that MRE discriminated advanced stages of fibrosis (F ≥ 2) well in patients with hepatocellular carcinoma at a cutoff value of 3.0 kPa with an AUROC value of 0.93, and ARFI elastography did so at a cutoff value of 1.77 m/s with an AUROC value of 0.81 for predicting advanced stages of fibrosis (F ≥ 2). In conclusion, MRE is a more accurate imaging modality than ARFI elastography in estimating advanced stages of fibrosis and cirrhosis.
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Affiliation(s)
- Chen-Te Chou
- Department of Radiology, Changhua Christian Hospital, Changhua, Taiwan; Department of Biomedical Imaging and Radiological Science, National Yang-Ming Medical University, Taipei, Taiwan; School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ran-Chou Chen
- Department of Biomedical Imaging and Radiological Science, National Yang-Ming Medical University, Taipei, Taiwan
| | - Wen-Pei Wu
- Department of Radiology, Changhua Christian Hospital, Changhua, Taiwan; Department of Biomedical Imaging and Radiological Science, National Yang-Ming Medical University, Taipei, Taiwan
| | - Ping-Yi Lin
- Transplant Medicine and Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Yao-Li Chen
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Transplant Medicine and Surgery Research Center, Changhua Christian Hospital, Changhua, Taiwan.
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25
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Hansi N, Williams MJ. Editorial: the role of statins in the treatment of alcohol-related cirrhosis. Aliment Pharmacol Ther 2017; 46:892-893. [PMID: 29023891 DOI: 10.1111/apt.14277] [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] [Indexed: 12/15/2022]
Affiliation(s)
- N Hansi
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - M J Williams
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, UK
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26
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Lisman T, Porte RJ. Pathogenesis, prevention, and management of bleeding and thrombosis in patients with liver diseases. Res Pract Thromb Haemost 2017; 1:150-161. [PMID: 30046685 PMCID: PMC6058283 DOI: 10.1002/rth2.12028] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 06/21/2017] [Indexed: 12/14/2022] Open
Abstract
Patients with liver diseases may develop alterations in all components of the hemostatic system. Thrombocytopenia, low levels of coagulation factors and inhibitors, low levels of fibrinolytic proteins, and increased levels of endothelial-derived proteins such as von Willebrand factor are all part of the coagulopathy of liver disease. Due to concomitant changes in pro- and antihemostatic drivers, the net effects of these complex hemostatic changes have long been unclear. According to current concepts, the hemostatic system of patients with liver disease is in an unstable balance, which explains the occurrence of both bleeding and thrombotic complications. This review will discuss etiology and management of bleeding and thrombosis in liver disease and will outline unsolved clinical questions. In addition, we will discuss the role of intrahepatic activation of coagulation for progression of liver disease, a novel paradigm with potential consequences for the general management of patients with liver disease.
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Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Robert J. Porte
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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27
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Onali S, Kalafateli M, Majumdar A, Westbrook R, O'Beirne J, Leandro G, Patch D, Tsochatzis EA. Non-selective beta-blockers are not associated with increased mortality in cirrhotic patients with ascites. Liver Int 2017; 37:1334-1344. [PMID: 28296047 DOI: 10.1111/liv.13409] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 03/02/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Controversy exists on the impact of non-selective beta-blockers (NSBBs) on survival in patients with ascites. We assessed whether NSBB treatment affects survival in a cohort of 316 consecutive patients with ascites undergoing evaluation for liver transplantation. METHODS Consecutive patients with cirrhosis and ascites assessed for liver transplantation between 2011 and 2014 were retrospectively evaluated. Competing risk Cox regression analysis in the whole population and in propensity score matched patients were performed to identify predictors of survival. RESULTS Three hundred and sixteen patients were evaluated: males 229 (73%), mean age 54 years, median follow-up: 7 months. Refractory ascites was diagnosed in 124 (39%) patients. Patients receiving NSBBs (n=128, 40.5%) had a higher frequency of previous spontaneous bacterial peritonitis (27% vs 17%, P=.025), lower frequency of refractory ascites (32% vs 44%, P=.03) but similar MELD and UKELD scores. Overall 80 (25%) patients died: 20 (16%) in the NSBB group vs. 60 (32%) in the non-NSBB group (P=.002). In multivariate competing risk Cox regression analysis, NSBB use was associated with reduced mortality (HR=0.55, 95% CI=0.33-0.94) along with prophylactic antibiotic use (HR=0.33, 95% CI=0.14-0.74), MELD score (HR=1.10, 95% CI=1.06-1.14) and sodium levels (HR=0.94, 95% CI: 0.89-0.98). No impact on survival was found when considering only patients with refractory ascites (NSBB use: HR=0.43, 95% CI=0.20-1.11). CONCLUSIONS Patients with ascites on NSBBs did not have impaired survival compared to those not receiving NSSBs and interestingly this observation was also confirmed in the subgroup with refractory ascites. Our results suggest that NSBBs are not detrimental, but instead seem safe even in more advanced stages of cirrhosis in patients on a transplant waiting list.
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Affiliation(s)
- Simona Onali
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Maria Kalafateli
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Avik Majumdar
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Rachel Westbrook
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - James O'Beirne
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Gioacchino Leandro
- Gastroenterology I Department, IRCCS De Bellis Hospital, Castellana Grotte, Italy
| | - David Patch
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
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28
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Tsochatzis EA, Bosch J. Statins in cirrhosis-Ready for prime time. Hepatology 2017; 66:697-699. [PMID: 28543643 DOI: 10.1002/hep.29277] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 05/15/2017] [Accepted: 05/17/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and University College London, London, UK
| | - Jaime Bosch
- Hepatic Hemodynamic Laboratory Hospital Clínic-IDIBAPS and CIBERehd, University of Barcelona, Barcelona, Spain.,Swiss Liver Center, Inselspital, Bern University, Bern, Switzerland
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29
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Fraser AR, Pass C, Burgoyne P, Atkinson A, Bailey L, Laurie A, W A McGowan N, Hamid A, Moore JK, Dwyer BJ, Turner ML, Forbes SJ, Campbell JDM. Development, functional characterization and validation of methodology for GMP-compliant manufacture of phagocytic macrophages: A novel cellular therapeutic for liver cirrhosis. Cytotherapy 2017; 19:1113-1124. [PMID: 28673774 PMCID: PMC5571439 DOI: 10.1016/j.jcyt.2017.05.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 05/02/2017] [Accepted: 05/20/2017] [Indexed: 12/12/2022]
Abstract
Background aims Autologous macrophage therapy represents a potentially significant therapeutic advance for the treatment of severe progressive liver cirrhosis. Administration of macrophages has been shown to reduce inflammation and drive fibrotic scar breakdown and tissue repair in relevant models. This therapeutic approach is being assessed for safety and feasibility in a first-in-human trial (MAcrophages Therapy for liver CirrHosis [MATCH] trial). Methods We outline the development and validation phases of GMP production. This includes use of the CliniMACS Prodigy cell sorting system to isolate CD14+ cells; optimizing macrophage culture conditions, assessing cellular identity, product purity, functional capability and determining the stability of the final cell product. Results The GMP-compliant macrophage products have a high level of purity and viability, and have a consistent phenotypic profile, expressing high levels of mature macrophage markers 25F9 and CD206 and low levels of CCR2. The macrophages demonstrate effective phagocytic capacity, are constitutively oriented to an anti-inflammatory profile and remain responsive to cytokine and TLR stimulation. The process validation shows that the cell product in excipient is remarkably robust, consistently passing the viability and phenotypic release criteria up to 48 hours after harvest. Conclusions This is the first report of validation of a large-scale, fully Good Manufacturing Practice–compliant, autologous macrophage cell therapy product for the potential treatment of cirrhosis. Phenotypic and functional assays confirm that these cells remain functionally viable for up to 48 h, allowing significant flexibility in administration to patients.
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Affiliation(s)
- Alasdair R Fraser
- Advanced Therapeutics, Scottish National Blood Transfusion Service, 21 Ellen's Glen Road, Edinburgh, United Kingdom
| | - Chloe Pass
- Scottish National Blood Transfusion Service Cellular Therapy Development Centre, MRC Centre for Regenerative Medicine, The University of Edinburgh bioQuarter, Edinburgh, United Kingdom
| | - Paul Burgoyne
- Advanced Therapeutics, Scottish National Blood Transfusion Service, 21 Ellen's Glen Road, Edinburgh, United Kingdom
| | - Anne Atkinson
- Scottish National Blood Transfusion Service Cellular Therapy Development Centre, MRC Centre for Regenerative Medicine, The University of Edinburgh bioQuarter, Edinburgh, United Kingdom
| | - Laura Bailey
- Scottish National Blood Transfusion Service Cellular Therapy Development Centre, MRC Centre for Regenerative Medicine, The University of Edinburgh bioQuarter, Edinburgh, United Kingdom
| | - Audrey Laurie
- Scottish National Blood Transfusion Service Cellular Therapy Development Centre, MRC Centre for Regenerative Medicine, The University of Edinburgh bioQuarter, Edinburgh, United Kingdom
| | - Neil W A McGowan
- Scottish National Blood Transfusion Service Cellular Therapy Development Centre, MRC Centre for Regenerative Medicine, The University of Edinburgh bioQuarter, Edinburgh, United Kingdom
| | - Akib Hamid
- Red Cell Integrated Laboratory, Scottish National Blood Transfusion Service, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Joanna K Moore
- MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Benjamin J Dwyer
- MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Marc L Turner
- Advanced Therapeutics, Scottish National Blood Transfusion Service, 21 Ellen's Glen Road, Edinburgh, United Kingdom; MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Stuart J Forbes
- MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - John D M Campbell
- Advanced Therapeutics, Scottish National Blood Transfusion Service, 21 Ellen's Glen Road, Edinburgh, United Kingdom; MRC Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, United Kingdom.
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30
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Perry MT, Savjani N, Bluth EI, Dornelles A, Therapondos G. Point Shear Wave Elastography in Assessment of Hepatic Fibrosis: Diagnostic Accuracy in Subjects With Native and Transplanted Livers Referred for Percutaneous Biopsy. Ultrasound Q 2017; 32:201-7. [PMID: 26808171 DOI: 10.1097/ruq.0000000000000219] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The objective of this study was to prospectively evaluate the use of point shear wave elastography for the assessment of liver fibrosis and to determine the usefulness and optimal location for obtaining elastography measurements in native and transplanted livers. Point shear wave elastography measurements were obtained from 100 consecutive patients presenting for percutaneous liver biopsy. Measurements were acquired within both the superior right hepatic lobe (segments VII/VIII) via an intercostal approach and the inferior right hepatic lobe (segments V/VI) via a subcostal approach. Analysis of variance was used to assess statistical differences between the degree of fibrosis on percutaneous liver biopsy and elastography measurements. No statistical difference was present when comparing elastography measurements in patients with hepatic steatosis compared with patients without steatosis (P = 0.2759). There was no difference in the accuracy of elastography measurements in native livers versus transplanted livers (P = 0.221). Point shear wave elastography can accurately differentiate between patients with no-to-mild hepatic fibrosis (F0-F1) and moderate-to-severe hepatic fibrosis (≥F2) with sensitivity of 72% and specificity of 69%. Point shear wave elastography can be used as a noninvasive method to assess fibrosis in patients with native or transplanted livers. In addition, measurements can be combined or taken separately from either the superior or inferior right hepatic lobe. The presence of hepatic steatosis does not affect the accuracy of point shear wave elastography. However, shear wave elastography values in patients with body mass index greater than 40 should be interpreted with caution.
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Affiliation(s)
- Michael T Perry
- *Department of Radiology, Ochsner Clinic Foundation; and †Department of Radiology, Ochsner Clinic Foundation, The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA; ‡Department of Economics, W.P. Carey School of Business, Tempe, AZ; and §Department of Gastroenterology & Hepatology, Ochsner Clinic Foundation, New Orleans, LA
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31
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Villanueva C, Graupera I, Aracil C, Alvarado E, Miñana J, Puente Á, Hernandez-Gea V, Ardevol A, Pavel O, Colomo A, Concepción M, Poca M, Torras X, Reñe JM, Guarner C. A randomized trial to assess whether portal pressure guided therapy to prevent variceal rebleeding improves survival in cirrhosis. Hepatology 2017; 65:1693-1707. [PMID: 28100019 DOI: 10.1002/hep.29056] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 12/07/2016] [Accepted: 01/12/2017] [Indexed: 12/17/2022]
Abstract
UNLABELLED Monitoring the hemodynamic response of portal pressure (PP) to drug therapy accurately stratifies the risk of variceal rebleeding (VRB). We assessed whether guiding therapy with hepatic venous pressure gradient (HVPG) monitoring may improve survival by preventing VRB. Patients with cirrhosis with controlled variceal bleeding were randomized to an HVPG-guided therapy group (N = 84) or to a control group (N = 86). In both groups, HVPG and acute β-blocker response were evaluated at baseline and HVPG measurements were repeated at 2-4 weeks to determine chronic response. In the HVPG-guided group, acute responders were treated with nadolol and acute nonresponders with nadolol+nitrates. Chronic nonresponders received nadolol+prazosin and had a third HVPG study. Ligation sessions were repeated until response was achieved. The control group was treated with nadolol+nitrates+ligation. Between-group baseline characteristics were similar. During long-term follow-up (median of 24 months), mortality was lower in the HVPG-guided therapy group than in the control group (29% vs. 43%; hazard ratio [HR] = 0.59; 95% confidence interval [CI] = 0.35-0.99). Rebleeding occurred in 19% versus 31% of patients, respectively (HR = 0.53; 95% CI = 0.29-0.98), and further decompensation of cirrhosis occurred in 52% versus 72% (HR = 0.68; 95% CI = 0.46-0.99). The survival probability was higher with HVPG-guided therapy than in controls, both in acute (HR = 0.59; 95% CI = 0.32-1.08) and chronic nonresponders (HR = 0.48; 95% CI = 0.23-0.99). HVPG-guided patients had a greater reduction of HVPG and a lower final value than controls (P < 0.05). CONCLUSION HVPG monitoring, by stratifying risk and targeting therapy, improves the survival achieved with currently recommended treatment to prevent VRB using β-blockers and ligation. HVPG-guided therapy achieved a greater reduction in PP, which may have contributed to reduce the risk of rebleeding and of further decompensation of cirrhosis, thus contributing to a better survival. (Hepatology 2017;65:1693-1707).
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Affiliation(s)
- Càndid Villanueva
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Autonomous University, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Lleida, Spain
| | - Isabel Graupera
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Autonomous University, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Lleida, Spain
| | - Carles Aracil
- Departmant of Gastroenterology, Hospital Arnau de Vilanova, Lleida, Spain
| | - Edilmar Alvarado
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Autonomous University, Barcelona, Spain
| | - Josep Miñana
- Departmant of Gastroenterology, Hospital Arnau de Vilanova, Lleida, Spain
| | - Ángela Puente
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Autonomous University, Barcelona, Spain
| | - Virginia Hernandez-Gea
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Autonomous University, Barcelona, Spain
| | - Alba Ardevol
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Autonomous University, Barcelona, Spain
| | - Oana Pavel
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Autonomous University, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Lleida, Spain
| | - Alan Colomo
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Autonomous University, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Lleida, Spain
| | - Mar Concepción
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Autonomous University, Barcelona, Spain
| | - María Poca
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Autonomous University, Barcelona, Spain
| | - Xavier Torras
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Autonomous University, Barcelona, Spain
| | - Josep M Reñe
- Departmant of Gastroenterology, Hospital Arnau de Vilanova, Lleida, Spain
| | - Carlos Guarner
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de Sant Pau, Barcelona, Autonomous University, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Lleida, Spain
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32
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Egan K, Dillon A, Dunne E, Kevane B, Galvin Z, Maguire P, Kenny D, Stewart S, Ainle FN. Increased soluble GPVI levels in cirrhosis: evidence for early in vivo platelet activation. J Thromb Thrombolysis 2017; 43:54-59. [PMID: 27416950 DOI: 10.1007/s11239-016-1401-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cirrhosis is a consequence of prolonged liver injury and is characterised by extensive tissue fibrosis: the deposition of collagen-rich extracellular matrix. The haemostatic balance is disordered in cirrhosis and coagulation activation appears to promote fibrosis. In spite of recent studies demonstrating a role for anticoagulant therapy in preventing cirrhosis progression, there has not been a change in clinical practice, suggesting that physicians are reluctant to anticoagulate patients with cirrhosis due to bleeding risks. Platelets play an important role in facilitating coagulation. Glycoprotein VI (GPVI) is a platelet-specific collagen receptor that is shed from the platelet surface in a metalloproteinase-dependent manner in response to GPVI ligation and coagulation activation. Our aim was to use soluble GPVI levels to determine whether there was evidence for collagen and coagulation-induced platelet activation in early, well-compensated cirrhosis. Plasma soluble GPVI levels were quantified in 46 patients with mixed aetiology cirrhosis and 55 healthy controls using an immunoassay. In the cirrhosis group, soluble GPVI levels were significantly increased (5.8 ± 4.4 ng/ml, n = 46) compared to healthy controls (3.3 ± 3.4 ng/ml, n = 55, p < 0.05). This increase in soluble GPVI levels was still evident when levels were adjusted for platelet count (Healthy controls; 0.015 ± 0.018 ng/106 platelets/ml vs. cirrhosis; 0.048 ± 0.04 ng/106 platelets/ml, p < 0.0001). This study provides evidence for early platelet activation in patients with well-compensated cirrhosis. This may have translational implications for prognosis, treatment, and risk stratification.
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Affiliation(s)
- Karl Egan
- School of Medicine and Medical Sciences, University College Dublin, Dublin 4, Ireland.,SPHERE Research Group, Conway Institute, University College Dublin, Dublin 4, Ireland
| | - Audrey Dillon
- Department of Hepatology, Mater Misericordiae University Hospital, Dublin 7, Ireland
| | - Eimear Dunne
- Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Barry Kevane
- School of Medicine and Medical Sciences, University College Dublin, Dublin 4, Ireland.,SPHERE Research Group, Conway Institute, University College Dublin, Dublin 4, Ireland.,Department of Haematology, Mater Misericordiae University Hospital, Dublin 7, Ireland
| | - Zita Galvin
- Department of Hepatology, Mater Misericordiae University Hospital, Dublin 7, Ireland
| | - Patricia Maguire
- SPHERE Research Group, Conway Institute, University College Dublin, Dublin 4, Ireland
| | - Dermot Kenny
- Department of Hepatology, Mater Misericordiae University Hospital, Dublin 7, Ireland
| | - Stephen Stewart
- Department of Hepatology, Mater Misericordiae University Hospital, Dublin 7, Ireland
| | - Fionnuala Ni Ainle
- School of Medicine and Medical Sciences, University College Dublin, Dublin 4, Ireland. .,SPHERE Research Group, Conway Institute, University College Dublin, Dublin 4, Ireland. .,Department of Haematology, Mater Misericordiae University Hospital, Dublin 7, Ireland.
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33
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Bacterial Infections Change Natural History of Cirrhosis Irrespective of Liver Disease Severity. Am J Gastroenterol 2017; 112:588-596. [PMID: 28220780 DOI: 10.1038/ajg.2017.19] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 01/18/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We assessed the prognostic significance of infections in relation to current prognostic scores and explored if infection could be considered per se a distinct clinical stage in the natural history of cirrhosis. METHODS We included consecutive patients with cirrhosis admitted to a tertiary referral liver unit for at least 48 h over a 2-year period. Diagnosis of infection was based on positive cultures or strict established criteria. We used competing risk analysis and propensity score matching for data analysis. RESULTS 501 patients (63% male, 48% alcoholic liver disease, median Model of End-stage Liver Disease (MELD)=17) underwent 781 admissions over the study period. Portal hypertensive bleeding and complicated ascites were the commonest reasons of admission. The incidence of proven bacterial infection was 25.6% (60% community acquired and 40% nosocomial). Survival rates at 3, 6, 12, and 30 months were 83%, 77%, 71%, and 62% in patients without diagnosis of infection, vs. 50%, 46%, 41%, and 34% in patients with diagnosis of infection. Overall survival was independently associated with MELD score (hazards ratio (HR) 1.099), intensive care (ITU) stay (HR 1.967) and bacterial infection (HR 2.226). Bacterial infection was an independent predictor of survival even when patients who died within the first 30 days were excluded from the analysis in Cox regression (HR 2.013) and competing risk Cox models in all patients (HR 1.46) and propensity risk score-matched infected and non-infected patients (HR 1.67). CONCLUSIONS Infection most likely represents a distinct prognostic stage of cirrhosis, which affects survival irrespective of disease severity, even after recovery from the infective episode.
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Sakai Y, Takamura M, Seki A, Sunagozaka H, Terashima T, Komura T, Yamato M, Miyazawa M, Kawaguchi K, Nasti A, Mochida H, Usui S, Otani N, Ochiya T, Wada T, Honda M, Kaneko S. Phase I clinical study of liver regenerative therapy for cirrhosis by intrahepatic arterial infusion of freshly isolated autologous adipose tissue-derived stromal/stem (regenerative) cell. Regen Ther 2017; 6:52-64. [PMID: 30271839 PMCID: PMC6134901 DOI: 10.1016/j.reth.2016.12.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 11/12/2016] [Accepted: 12/08/2016] [Indexed: 12/14/2022] Open
Abstract
Introduction Adipose tissue stromal cells contain a substantial number of mesenchymal stem cells. As such, their application to regeneration of miscellaneous impaired organs has attracted much attention. Methods We designed a clinical study to investigate freshly isolated autologous adipose tissue-derived stromal/stem (regenerative) cell (ADRC) therapy for liver cirrhosis and conducted treatment in four cirrhotic patients. ADRCs were isolated from autologous subcutaneous adipose tissue obtained by the liposuction method, followed with use of the Celution system adipose tissue dissociation device. The primary endpoint is assessment of safety one month after treatment. We also characterized the obtained ADRCs. Results Two patients had type C cirrhosis, one had nonalcoholic steatohepatitis-cirrhosis, and one had type B cirrhosis. No serious adverse events were observed during the 1-month study period after freshly isolated ADRC infusion. Serum albumin concentrations were maintained or improved during this period as well as during the succeeding follow-up of approximately 1 year in two patients and 6 months in another patient. Liver regeneration-related factors, namely hepatocyte growth factor and interleukin-6, were elevated 1 day after ADRC treatment in all patients. The obtained freshly isolated ADRCs were expanded in culture and found to express mesenchymal stem cell markers. Gene expression profile analysis of ADRCs was shown to involve inflammatory features, suggesting that characteristics of the obtained ADRCs were related to immunomodulatory biological effects. Conclusion This clinical study treatment for liver cirrhosis using ADRCs was proven to be safely conductible, and can be further investigated in future for regeneration/repair of liver cirrhosis. Clinical study of liver cirrhosis therapy using adipose tissue-derived stromal cells. Autologous adipose tissue-derived stromal/stem (regenerative) cells were administered via intrahepatic arterial transfusion into cirrhotic patients. The obtained adipose tissue-derived stromal cells were shown to contain mesenchymal stem cells.
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Affiliation(s)
- Yoshio Sakai
- Department of Gastroenterology, Kanazawa University Hospital, Japan.,Department of Laboratory Medicine, Kanazawa University, Japan
| | - Masayuki Takamura
- Department of Cardiology, Kanazawa University Hospital, Japan.,System Biology, Kanazawa University, Japan
| | | | - Hajime Sunagozaka
- Department of Gastroenterology, Kanazawa University Hospital, Japan.,System Biology, Kanazawa University, Japan
| | | | | | - Masatoshi Yamato
- Department of Gastroenterology, Kanazawa University Hospital, Japan.,System Biology, Kanazawa University, Japan
| | | | | | | | | | - Soichiro Usui
- Department of Cardiology, Kanazawa University Hospital, Japan.,System Biology, Kanazawa University, Japan
| | | | - Takahiro Ochiya
- Division of Molecular and Cellular Medicine, National Cancer Institute, Japan
| | - Takashi Wada
- Department of Laboratory Medicine, Kanazawa University, Japan
| | - Masao Honda
- Department of Gastroenterology, Kanazawa University Hospital, Japan
| | - Shuichi Kaneko
- Department of Gastroenterology, Kanazawa University Hospital, Japan.,System Biology, Kanazawa University, Japan
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A New Oleanolic Acid Derivative against CCl₄-Induced Hepatic Fibrosis in Rats. Int J Mol Sci 2017; 18:ijms18030553. [PMID: 28272302 PMCID: PMC5372569 DOI: 10.3390/ijms18030553] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 02/21/2017] [Accepted: 02/26/2017] [Indexed: 12/12/2022] Open
Abstract
A novel hepatoprotective oleanolic acid derivative, 3-oxours-oleana-9(11), 12-dien-28-oic acid (Oxy-Di-OA), has been reported. In previous studies, we found that Oxy-Di-OA presented the anti-HBV (Hepatitis B Virus) activity (IC50 = 3.13 µg/mL). Remarkably, it is superior to lamivudine in the inhibition of the rebound of the viral replication rate. Furthermore, Oxy-Di-OA showed good performance of anti-HBV activity in vivo. Some studies showed that liver fibrosis may affiliate with HBV gene mutations. In addition, the anti-hepatic fibrosis activity of Oxy-Di-OA has not been studied. Therefore, we evaluated the protective effect of Oxy-Di-OA against carbon tetrachloride (CCl4)-induced liver injury in rats. Daily intraperitoneally administration of Oxy-Di-OA prevented the development of CCl4-induced liver fibrosis, which was evidenced by histological study and immunohistochemical analysis. The entire experimental protocol lasted nine weeks. Oxy-Di-OA significantly suppressed the increases of plasma aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels (p < 0.05). Furthermore, Oxy-Di-OA could prevent expression of transforming growth factor β1 (TGF-β1). It is worth noting that the high-dose group Oxy-Di-OA is superior to bifendate in elevating hepatic function. Compared to the model group, Oxy-Di-OA in the high-dose group and low-dose group can significantly reduce the liver and spleen indices (p < 0.05). The acute toxicity test showed that LD50 and a 95% confidence interval (CIs) value of Oxy-Di-OA were 714.83 mg/kg and 639.73–798.73 mg/kg via intraperitoneal injection in mice, respectively. The LD50 value of Oxy-Di-OA exceeded 2000 mg/kg via gavage in mice. In addition, a simple and rapid high performance liquid chromatography-ultraviolet (HPLC-UV) method was developed and validated to study the pharmacokinetic characteristics of the compound. After single-dose oral administration, time to reach peak concentration of Oxy-Di-OA (Cmax = 8.18 ± 0.66 μg/mL) was 10 ± 2.19 h; the elimination half-life and area under the concentration-time curve from t = 0 to the last time of Oxy-Di-OA was 2.19 h and 90.21 μg·h/mL, respectively.
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Abstract
BACKGROUND Hepatic encephalopathy is a disorder of brain function as a result of liver failure or portosystemic shunt or both. Both hepatic encephalopathy (clinically overt) and minimal hepatic encephalopathy (not clinically overt) significantly impair patient's quality of life and daily functioning, and represent a significant burden on healthcare resources. Probiotics are live micro-organisms, which when administered in adequate amounts, may confer a health benefit on the host. OBJECTIVES To determine the beneficial and harmful effects of probiotics in any dosage, compared with placebo or no intervention, or with any other treatment for people with any grade of acute or chronic hepatic encephalopathy. This review did not consider the primary prophylaxis of hepatic encephalopathy. SEARCH METHODS We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, conference proceedings, reference lists of included trials, and the World Health Organization International Clinical Trials Registry Platform until June 2016. SELECTION CRITERIA We included randomised clinical trials that compared probiotics in any dosage with placebo or no intervention, or with any other treatment in people with hepatic encephalopathy. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. We conducted random-effects model meta-analysis due to obvious heterogeneity of participants and interventions. We defined a P value of 0.05 or less as significant. We expressed dichotomous outcomes as risk ratio (RR) and continuous outcomes as mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS We included 21 trials with 1420 participants, of these, 14 were new trials. Fourteen trials compared a probiotic with placebo or no treatment, and seven trials compared a probiotic with lactulose. The trials used a variety of probiotics; the most commonly used group of probiotic was VSL#3, a proprietary name for a group of eight probiotics. Duration of administration ranged from 10 days to 180 days. Eight trials declared their funding source, of which six were independently funded and two were industry funded. The remaining 13 trials did not disclose their funding source. We classified 19 of the 21 trials at high risk of bias.We found no effect on all-cause mortality when probiotics were compared with placebo or no treatment (7 trials; 404 participants; RR 0.58, 95% CI 0.23 to 1.44; low-quality evidence). No-recovery (as measured by incomplete resolution of symptoms) was lower for participants treated with probiotic (10 trials; 574 participants; RR 0.67, 95% CI 0.56 to 0.79; moderate-quality evidence). Adverse events were lower for participants treated with probiotic than with no intervention when considering the development of overt hepatic encephalopathy (10 trials; 585 participants; RR 0.29, 95% CI 0.16 to 0.51; low-quality evidence), but effects on hospitalisation and change of/or withdrawal from treatment were uncertain (hospitalisation: 3 trials, 163 participants; RR 0.67, 95% CI 0.11 to 4.00; very low-quality evidence; change of/or withdrawal from treatment: 9 trials, 551 participants; RR 0.70, 95% CI 0.46 to 1.07; very low-quality evidence). Probiotics may slightly improve quality of life compared with no intervention (3 trials; 115 participants; results not meta-analysed; low-quality evidence). Plasma ammonia concentration was lower for participants treated with probiotic (10 trials; 705 participants; MD -8.29 μmol/L, 95% CI -13.17 to -3.41; low-quality evidence). There were no reports of septicaemia attributable to probiotic in any trial.When probiotics were compared with lactulose, the effects on all-cause mortality were uncertain (2 trials; 200 participants; RR 5.00, 95% CI 0.25 to 102.00; very low-quality evidence); lack of recovery (7 trials; 430 participants; RR 1.01, 95% CI 0.85 to 1.21; very low-quality evidence); adverse events considering the development of overt hepatic encephalopathy (6 trials; 420 participants; RR 1.17, 95% CI 0.63 to 2.17; very low-quality evidence); hospitalisation (1 trial; 80 participants; RR 0.33, 95% CI 0.04 to 3.07; very low-quality evidence); intolerance leading to discontinuation (3 trials; 220 participants; RR 0.35, 95% CI 0.08 to 1.43; very low-quality evidence); change of/or withdrawal from treatment (7 trials; 490 participants; RR 1.27, 95% CI 0.88 to 1.82; very low-quality evidence); quality of life (results not meta-analysed; 1 trial; 69 participants); and plasma ammonia concentration overall (6 trials; 325 participants; MD -2.93 μmol/L, 95% CI -9.36 to 3.50; very low-quality evidence). There were no reports of septicaemia attributable to probiotic in any trial. AUTHORS' CONCLUSIONS The majority of included trials suffered from a high risk of systematic error ('bias') and a high risk of random error ('play of chance'). Accordingly, we consider the evidence to be of low quality. Compared with placebo or no intervention, probiotics probably improve recovery and may lead to improvements in the development of overt hepatic encephalopathy, quality of life, and plasma ammonia concentrations, but probiotics may lead to little or no difference in mortality. Whether probiotics are better than lactulose for hepatic encephalopathy is uncertain because the quality of the available evidence is very low. High-quality randomised clinical trials with standardised outcome collection and data reporting are needed to further clarify the true efficacy of probiotics.
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Affiliation(s)
- Rohan Dalal
- Sydney Medical School, Westmead Hospital, Sydney, Australia
| | - Richard G McGee
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia, 2145
| | - Stephen M Riordan
- Gastrointestinal and Liver Unit, The Prince of Wales, Barker St, Randwick, Australia, NSW 2031
| | - Angela C Webster
- Sydney School of Public Health, The University of Sydney, Edward Ford Building A27, Sydney, NSW, Australia, 2006
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Kalafateli M, Mantzoukis K, Choi Yau Y, Mohammad AO, Arora S, Rodrigues S, de Vos M, Papadimitriou K, Thorburn D, O'Beirne J, Patch D, Pinzani M, Morgan MY, Agarwal B, Yu D, Burroughs AK, Tsochatzis EA. Malnutrition and sarcopenia predict post-liver transplantation outcomes independently of the Model for End-stage Liver Disease score. J Cachexia Sarcopenia Muscle 2017; 8:113-121. [PMID: 27239424 PMCID: PMC4864202 DOI: 10.1002/jcsm.12095] [Citation(s) in RCA: 220] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 09/23/2015] [Accepted: 11/02/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Although malnutrition and sarcopenia are prevalent in cirrhosis, their impact on outcomes following liver transplantation is not well documented. METHODS The associations of nutritional status and sarcopenia with post-transplant infections, requirement for mechanical ventilation, intensive care (ICU) and hospital stay, and 1 year mortality were assessed in 232 consecutive transplant recipients. Nutritional status and sarcopenia were assessed using the Royal Free Hospital-Global Assessment (RFH-GA) tool and the L3-psoas muscle index (L3-PMI) on CT, respectively. RESULTS A wide range of RFH-SGA and L3-PMI were observed within similar Model for End-stage Liver Disease (MELD) sub-categories. Malnutrition and sarcopenia were independent predictors of all outcomes. Post-transplant infections were associated with MELD (OR = 1.055, 95%CI = 1.002-1.11) and severe malnutrition (OR = 6.55, 95%CI = 1.99-21.5); ventilation > 24 h with MELD (OR = 1.1, 95%CI = 1.036-1.168), severe malnutrition (OR = 8.5, 95%CI = 1.48-48.87) and suboptimal donor liver (OR = 2.326, 95%CI = 1.056-5.12); ICU stay > 5 days, with age (OR = 1.054, 95%CI = 1.004-1.106), MELD (OR = 1.137, 95%CI = 1.057-1.223) and severe malnutrition (OR = 7.46, 95%CI = 1.57-35.43); hospital stay > 20 days with male sex (OR = 2.107, 95%CI = 1.004-4.419) and L3-PMI (OR = 0.996, 95%CI = 0.994-0.999); 1 year mortality with L3-PMI (OR = 0.996, 95%CI = 0.992-0.999). Patients at the lowest L3-PMI receiving suboptimal grafts had longer ICU/hospital stay and higher incidence of infections. CONCLUSIONS Malnutrition and sarcopenia are associated with early post-liver transplant morbidity/mortality. Allocation indices do not include nutritional status and may jeopardize outcomes in nutritionally compromised individuals.
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Affiliation(s)
- Maria Kalafateli
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | | | - Yan Choi Yau
- Department of RadiologyRoyal Free Hospital London NHS Foundation TrustLondonUK
| | - Ali O. Mohammad
- Intensive Care UnitRoyal Free Hospital London NHS Foundation TrustLondonUK
- Department of Chest DiseasesMinia UniversityEgypt
| | - Simran Arora
- Nutrition and Dietetics DepartmentRoyal Free Hospital London NHS Foundation TrustLondonUK
| | - Susana Rodrigues
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - Marie de Vos
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | | | - Douglas Thorburn
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - James O'Beirne
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - David Patch
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - Massimo Pinzani
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - Marsha Y. Morgan
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - Banwari Agarwal
- Intensive Care UnitRoyal Free Hospital London NHS Foundation TrustLondonUK
| | - Dominic Yu
- Department of RadiologyRoyal Free Hospital London NHS Foundation TrustLondonUK
| | - Andrew K. Burroughs
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
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Lombardi R, Sambatakou H, Mariolis I, Cokkinos D, Papatheodoridis GV, Tsochatzis EA. Prevalence and predictors of liver steatosis and fibrosis in unselected patients with HIV mono-infection. Dig Liver Dis 2016; 48:1471-1477. [PMID: 27623186 DOI: 10.1016/j.dld.2016.08.117] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 08/07/2016] [Accepted: 08/15/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Significant liver disease may develop in HIV mono-infected patients, usually associated with fatty liver and/or cART exposure. We estimated the prevalence and predictors of hepatic steatosis and fibrosis as assessed by ultrasound and transient elastography (TE). METHODS We enrolled 125 consecutive HIV mono-infected patients who underwent ultrasound and TE. Clinical, biochemical, immunological, virological features and medication history were analysed. RESULTS Mean age was 39.5±10.3years and 91% were male. Metabolic syndrome (MS) was present in 9.8%, diabetes in 5.6%, hypertension in 9.7%, dyslipidemia in 32.8%. Increased AST and ALT were found in 5.6% and 16.8% respectively. Eighty-five (68%) patients were on cART (median length of treatment of 3 years, IQR 0-17). Hepatic steatosis was detected in 61 (55%) patients and was independently associated with male sex (OR 14.6, 95% CI 1.44-148.17), age (OR 1.082, 95% CI 1.01-1.16), HOMA (OR 2.56, 95% CI 1.101-5.96) and GGT (OR 1.037, 95% CI 1.007-1.075). Significant fibrosis (stiffness>7.4kPa) was present in 22 patients (17.6%) and was significantly associated with MS (OR 3.99, 95% CI 1.001-16.09). CONCLUSIONS Liver fibrosis can develop in asymptomatic HIV mono-infected patients. This is likely associated with NAFLD and usually manifests with normal transaminases. Non-invasive screening for the presence of NAFLD and fibrosis should be considered in the routine care of such patients.
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Affiliation(s)
- Rosa Lombardi
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
| | - Helen Sambatakou
- 2nd Department of Internal Medicine, Hippokration General Hospital, Athens, Greece
| | - Ilias Mariolis
- 2nd Department of Internal Medicine, Hippokration General Hospital, Athens, Greece
| | | | | | - Emmanuel A Tsochatzis
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK.
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Njei B, McCarty TR, Luk J, Ewelukwa O, Ditah I, Lim JK. Use of transient elastography in patients with HIV-HCV coinfection: A systematic review and meta-analysis. J Gastroenterol Hepatol 2016; 31:1684-1693. [PMID: 26952020 PMCID: PMC5014713 DOI: 10.1111/jgh.13337] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 02/23/2016] [Accepted: 02/28/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIM Patients with HIV-hepatitis C virus (HCV) coinfection progress towards liver fibrosis and cirrhosis more rapidly compared with HCV mono-infected individuals. This necessitates an accurate assessment of liver stiffness with transient elastography to guide treatment. METHODS Searches of PubMed, EMBASE, Web of Science, and the Cochrane Library databases were performed through January 2016 to assess the diagnostic accuracy of transient elastography for liver stiffness in the HIV-HCV population. Included studies were analyzed according to the Cochrane DTA Working Group methodology. Bivariate and hierarchical models were used to compute pooled sensitivity and specificity. Positive and negative likelihood ratios were also determined. A Fagan nomogram was constructed. Meta-regression analysis was performed with assessment of publication bias using Deeks' funnel plot asymmetry testing. RESULTS A total of six studies (n = 756) met the inclusion criteria. The diagnostic accuracy of elastography for the diagnosis of moderate (≥F2) fibrosis was 88% (95% confidence interval [CI], 0.85-0.90). The pooled sensitivity and specificity of moderate fibrosis was 97% (95% CI, 0.82-0.91) and 64% (95% CI, 0.45-0.79), respectively. The diagnostic accuracy of elastography for the assessment of cirrhosis was 94% (95% CI, 0.91-0.95). The pooled sensitivity and specificity for cirrhosis was 90% (95% CI, 0.74-0.97) and 87% (95% CI, 0.80-0.92), respectively. Meta-regression analysis demonstrated that CD4 cell count did not impact diagnostic accuracy of elastography. CONCLUSIONS Transient elastography is a noninvasive imaging modality with excellent ability to assess for cirrhosis in patients with HIV-HCV coinfection.
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Affiliation(s)
- Basile Njei
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Thomas R. McCarty
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA,Investigative Medicine Program, Yale Center of Clinical Investigation, New Haven, CT, USA
| | - Jeffrey Luk
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Oforbuike Ewelukwa
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Ivo Ditah
- Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - Joseph K. Lim
- Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
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Bertino G, Privitera G, Purrello F, Demma S, Crisafulli E, Spadaro L, Koukias N, Tsochatzis EA. Emerging hepatic syndromes: pathophysiology, diagnosis and treatment. Intern Emerg Med 2016; 11:905-16. [PMID: 27273018 DOI: 10.1007/s11739-016-1478-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 05/25/2016] [Indexed: 12/11/2022]
Abstract
Liver cirrhosis is a major cause of morbidity and mortality worldwide, mainly due to complications of portal hypertension. In this article, we review the current understanding on the pathophysiology, the diagnostic criteria and the available therapeutic options for patients with emerging hepatic syndromes in cirrhosis, namely the hepatorenal, hepato-adrenal and hepatopulmonary syndrome. The hepatorenal syndrome is a well-recognized complication of advanced cirrhosis and is usually associated with an accelerated course to death unless liver transplantation is performed. The hepatopulmonary syndrome is often missed in the evaluation of patients with cirrhosis; however, early recognition is essential for the efficient management of individual patients. The hepato-adrenal syndrome, although not fully characterized, offers an exciting field for research and potential therapeutic interventions.
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Affiliation(s)
- Gaetano Bertino
- Hepatology Unit, Department of Clinical and Experimental Medicine, University of Catania, Policlinico "G. Rodolico", Catania, Italy
| | - Graziella Privitera
- Internal Medicine, Department of Clinical and Experimental Medicine, University of Catania, Ospedale Garibaldi-Nesima, Catania, Italy
| | - Francesco Purrello
- Internal Medicine, Department of Clinical and Experimental Medicine, University of Catania, Ospedale Garibaldi-Nesima, Catania, Italy
| | - Shirin Demma
- Hepatology Unit, Department of Clinical and Experimental Medicine, University of Catania, Policlinico "G. Rodolico", Catania, Italy
| | - Emanuele Crisafulli
- Hepatology Unit, Department of Clinical and Experimental Medicine, University of Catania, Policlinico "G. Rodolico", Catania, Italy
| | - Luisa Spadaro
- Internal Medicine, Department of Clinical and Experimental Medicine, University of Catania, Ospedale Garibaldi-Nesima, Catania, Italy
| | - Nikolaos Koukias
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK
| | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK.
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Sclair SN, Carrasquillo O, Czul F, Trivella JP, Li H, Jeffers L, Martin P. Quality of Care Provided by Hepatologists to Patients with Cirrhosis at Three Parallel Health Systems. Dig Dis Sci 2016; 61:2857-2867. [PMID: 27289585 DOI: 10.1007/s10620-016-4221-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 05/29/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Evidence-based guidelines and quality indicators for cirrhosis care have been established. Whether there are variations in adherence to these cirrhosis standards at different specialty settings has not been investigated. AIMS To evaluate the quality of cirrhosis care delivered at diverse hepatology care sites. METHODS We conducted a retrospective study comparing the quality of care at three hepatology specialty clinics: a Faculty Practice, safety-net hospital, and Veterans Affairs (VA) Medical Center. Consecutive patients with cirrhosis (85 Faculty Practice, 81 safety-net, and 76 VA) between 2010 and 2011 were included. Median follow-up was 2.3 years. Outcome measures were the adherence to six cirrhosis-specific quality-of-care indicators. RESULTS Adherence to hepatitis A and B vaccinations was highest at the safety-net hospital, 81 and 74 %, compared to 46 and 30 % at the Faculty Practice (P < .001). Adherence to yearly hepatocellular carcinoma surveillance was highest at the safety-net site (79 %) versus the VA (50 %) and Faculty Practice (42 %), P = .001. In contrast, screening rates for esophageal varices were 75 % at the Faculty Practice and only 58 and 43 % at the VA and safety-net sites, respectively (P < .001). Liver transplant discussions were documented most consistently at the Faculty Practice (82 %) compared to the safety-net site (53 %) and VA (54 %), P < .001. CONCLUSIONS Disparities in cirrhosis quality measures existed by site. Strategies to overcome these disparities need to be developed to improve the delivery of quality cirrhosis care as we face a rise in cirrhosis-related complications over the next two decades.
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Affiliation(s)
- Seth N Sclair
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Olveen Carrasquillo
- Division of General Internal Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,Miami Clinical and Translational Sciences Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Frank Czul
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan P Trivella
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hua Li
- Miami Clinical and Translational Sciences Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Biostatistics Collaboration and Consulting Core, Department of Epidemiology and Public Health, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Lennox Jeffers
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,Hepatology Section, Medicine Service, Miami VA Medical Center, Miami, FL, USA
| | - Paul Martin
- Division of Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
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Abstract
Over the past decade, several advances have been made in the non-invasive assessment of liver fibrosis. Both serum markers and imaging-based tissue elastography predict the presence of advanced fibrosis compared with liver biopsy. Serum markers may be indirect or direct markers of liver structure and function. Imaging-based techniques measure liver stiffness as a surrogate for fibrosis and include ultrasound and MRI-based methods. Most non-invasive techniques work well at identifying subjects at the extremes of fibrosis but may not accurately discern intermediate stages. In addition to being a diagnostic tool, elastography may have an evolving role in prognosis. Increasing stiffness is associated with higher rates of liver decompensation, need for transplantation, hepatocellular carcinoma, and death. There are special populations of patients where elastography may serve as a non-invasive method to impart useful clinical information, such as patients after liver transplantation, those with congenital heart disease and those being treated for chronic viral hepatitis. The role of non-invasive markers in accurately predicting the presence of fibrosis in obese patients needs to be further refined.
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Affiliation(s)
- Michael Hagan
- a 1 Baylor University Medical Center, Dallas, TX, USA
| | | | - Jayant Talwalkar
- b 2 Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
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Transcriptional repression of SIRT1 by protein inhibitor of activated STAT 4 (PIAS4) in hepatic stellate cells contributes to liver fibrosis. Sci Rep 2016; 6:28432. [PMID: 27323886 PMCID: PMC4914937 DOI: 10.1038/srep28432] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 06/06/2016] [Indexed: 02/06/2023] Open
Abstract
Interstitial fibrosis represents a key pathological process in non-alcoholic steatohepatitis (NASH). In the liver, fibrogenesis is primarily mediated by activated hepatic stellate cells (HSCs) transitioning from a quiescent state in response to a host of stimuli. The molecular mechanism underlying HSC activation is not completely understood. Here we report that there was a simultaneous up-regulation of PIAS4 expression and down-regulation of SIRT1 expression accompanying increased hepatic fibrogenesis in an MCD-diet induced mouse model of NASH. In cultured primary mouse HSCs, stimulation with high glucose activated PIAS4 while at the same time repressed SIRT1. Over-expression of PIAS4 directly repressed SIRT1 promoter activity. In contrast, depletion of PIAS4 restored SIRT1 expression in HSCs treated with high glucose. Estrogen, a known NASH-protective hormone, antagonized HSC activation by targeting PIAS4. Lentivirus-mediated delivery of short hairpin RNA (shRNA) targeting PIAS4 in mice ameliorated MCD diet induced liver fibrosis by normalizing SIRT1 expression in vivo. PIAS4 promoted HSC activation in a SIRT1-dependent manner in vitro. Mechanistically, PIAS4 mediated SIRT1 repression led to SMAD3 hyperacetylation and enhanced SMAD3 binding to fibrogenic gene promoters. Taken together, our data suggest SIRT1 trans-repression by PIAS4 plays an important role in HSC activation and liver fibrosis.
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Zhou B, Zeng S, Li L, Fan Z, Tian W, Li M, Xu H, Wu X, Fang M, Xu Y. Angiogenic factor with G patch and FHA domains 1 (Aggf1) regulates liver fibrosis by modulating TGF-β signaling. Biochim Biophys Acta Mol Basis Dis 2016; 1862:1203-13. [DOI: 10.1016/j.bbadis.2016.02.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 01/26/2016] [Accepted: 02/01/2016] [Indexed: 11/26/2022]
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Kopec AK, Luyendyk JP. Role of Fibrin(ogen) in Progression of Liver Disease: Guilt by Association? Semin Thromb Hemost 2016; 42:397-407. [PMID: 27144445 DOI: 10.1055/s-0036-1579655] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Strong experimental evidence indicates that components of the hemostatic system, including thrombin, exacerbate diverse features of experimental liver disease. Clinical studies have also begun to address this connection and some studies have suggested that anticoagulants can improve outcome in patients with liver disease. Among the evidence of coagulation cascade activation in models of liver injury and disease is the frequent observation of thrombin-driven hepatic fibrin(ogen) deposition. Indeed, hepatic fibrin(ogen) deposition has long been recognized as a consequence of hepatic injury. Although commonly inferred as pathologic due to protective effects of anticoagulants in mouse models, the role of fibrin(ogen) in acute liver injury and chronic liver disease may not be universally detrimental. The localization of hepatic fibrin(ogen) deposits within the liver is connected to the disease stimulus and in animal models of liver toxicity and chronic disease, fibrin(ogen) deposition may not always be synonymous with large vessel thrombosis. Here, we provide a balanced review of the experimental evidence supporting a direct connection between fibrin(ogen) and liver injury/disease pathogenesis, and suggest a path forward bridging experimental and clinical research to improve our knowledge on the nature and function of fibrin(ogen) in liver disease.
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Affiliation(s)
- Anna K Kopec
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, Michigan
| | - James P Luyendyk
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, Michigan
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Chang W, Lee JM, Yoon JH, Han JK, Choi BI, Yoon JH, Lee KB, Lee KW, Yi NJ, Suh KS. Liver Fibrosis Staging with MR Elastography: Comparison of Diagnostic Performance between Patients with Chronic Hepatitis B and Those with Other Etiologic Causes. Radiology 2016; 280:88-97. [PMID: 26844364 DOI: 10.1148/radiol.2016150397] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Purpose To evaluate the diagnostic performance of magnetic resonance (MR) elastography in staging liver fibrosis in patients with chronic hepatitis B (CHB) and other etiologic causes. Materials and Methods This retrospective study was institutional review board-approved and the requirement for informed consent was waived. Before surgery, MR elastographic imaging was performed in 352 patients with chronic liver diseases (281 patients with CHB, 71 patients without CHB) and hepatocellular carcinomas and 64 living liver donor candidates. Liver stiffness (LS) values were measured on quantitative shear-stiffness maps of MR elastography, and the diagnostic performance of MR elastography in staging liver fibrosis was evaluated by using receiver operating characteristic curve analysis and the Obuchowski measure with the histopathologic analysis of liver fibrosis in the CHB group and in the group composed of other etiologic causes. In 120 patients (97 with CHB, 23 without CHB) and 51 donors, diagnostic performance of MR elastography was validated. Results Areas under the curve of LS values for the diagnosis of significant fibrosis (≥stage F2), severe fibrosis (≥stage F3), and cirrhosis (stage F4) in the CHB group were 0.972 (95% confidence interval: 0.948, 0.987), 0.946 (95% confidence interval: 0.916, 0.968), and 0.920 (95% confidence interval: 0.885, 0.947), respectively. Obuchowski measures were similarly high in the CHB group and in the group composed of other etiologic causes (0.970 vs 0.977). However, the estimated cutoff value for stage F4 in the group with CHB was substantially lower than in the participants with other etiologic causes: 3.67 kPa versus 4.65 kPa. In the validation study for stage F1 or greater, stage F2 or greater, stage F3 or greater, and stage F4, the Youden indexes were 0.807, 0.842, 0.806, and 0.639, respectively, in the group with CHB, and 0.783, 0.900, 1.000, and 0.917, respectively, in the group without CHB. Conclusion The diagnostic performance of MR elastography in liver fibrosis staging was similarly high in the groups with and without CHB, but the cutoff LS values for diagnosing liver cirrhosis differed between the groups with and without CHB. (©) RSNA, 2016 Online supplemental material is available for this article.
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Affiliation(s)
- Won Chang
- From the Departments of Radiology (W.C., J.M.L., Jeong Hee Yoon, J.K.H., B.I.C.), Internal Medicine (Jung Hwan Yoon), Pathology (K.B.L.), and Surgery (K.W.L., N.J.Y., K.S.S.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea; and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.K.H., B.I.C.)
| | - Jeong Min Lee
- From the Departments of Radiology (W.C., J.M.L., Jeong Hee Yoon, J.K.H., B.I.C.), Internal Medicine (Jung Hwan Yoon), Pathology (K.B.L.), and Surgery (K.W.L., N.J.Y., K.S.S.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea; and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.K.H., B.I.C.)
| | - Jeong Hee Yoon
- From the Departments of Radiology (W.C., J.M.L., Jeong Hee Yoon, J.K.H., B.I.C.), Internal Medicine (Jung Hwan Yoon), Pathology (K.B.L.), and Surgery (K.W.L., N.J.Y., K.S.S.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea; and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.K.H., B.I.C.)
| | - Joon Koo Han
- From the Departments of Radiology (W.C., J.M.L., Jeong Hee Yoon, J.K.H., B.I.C.), Internal Medicine (Jung Hwan Yoon), Pathology (K.B.L.), and Surgery (K.W.L., N.J.Y., K.S.S.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea; and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.K.H., B.I.C.)
| | - Byung Ihn Choi
- From the Departments of Radiology (W.C., J.M.L., Jeong Hee Yoon, J.K.H., B.I.C.), Internal Medicine (Jung Hwan Yoon), Pathology (K.B.L.), and Surgery (K.W.L., N.J.Y., K.S.S.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea; and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.K.H., B.I.C.)
| | - Jung Hwan Yoon
- From the Departments of Radiology (W.C., J.M.L., Jeong Hee Yoon, J.K.H., B.I.C.), Internal Medicine (Jung Hwan Yoon), Pathology (K.B.L.), and Surgery (K.W.L., N.J.Y., K.S.S.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea; and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.K.H., B.I.C.)
| | - Kyoung Bun Lee
- From the Departments of Radiology (W.C., J.M.L., Jeong Hee Yoon, J.K.H., B.I.C.), Internal Medicine (Jung Hwan Yoon), Pathology (K.B.L.), and Surgery (K.W.L., N.J.Y., K.S.S.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea; and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.K.H., B.I.C.)
| | - Kwang-Woong Lee
- From the Departments of Radiology (W.C., J.M.L., Jeong Hee Yoon, J.K.H., B.I.C.), Internal Medicine (Jung Hwan Yoon), Pathology (K.B.L.), and Surgery (K.W.L., N.J.Y., K.S.S.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea; and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.K.H., B.I.C.)
| | - Nam-Joon Yi
- From the Departments of Radiology (W.C., J.M.L., Jeong Hee Yoon, J.K.H., B.I.C.), Internal Medicine (Jung Hwan Yoon), Pathology (K.B.L.), and Surgery (K.W.L., N.J.Y., K.S.S.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea; and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.K.H., B.I.C.)
| | - Kyung-Suk Suh
- From the Departments of Radiology (W.C., J.M.L., Jeong Hee Yoon, J.K.H., B.I.C.), Internal Medicine (Jung Hwan Yoon), Pathology (K.B.L.), and Surgery (K.W.L., N.J.Y., K.S.S.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea; and Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.K.H., B.I.C.)
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Villanueva C, Albillos A, Genescà J, Abraldes JG, Calleja JL, Aracil C, Bañares R, Morillas R, Poca M, Peñas B, Augustin S, Garcia-Pagan JC, Pavel O, Bosch J. Development of hyperdynamic circulation and response to β-blockers in compensated cirrhosis with portal hypertension. Hepatology 2016; 63:197-206. [PMID: 26422126 DOI: 10.1002/hep.28264] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 09/28/2015] [Indexed: 12/25/2022]
Abstract
UNLABELLED Nonselective β-blockers are useful to prevent bleeding in patients with cirrhosis and large varices but not to prevent the development of varices in those with compensated cirrhosis and portal hypertension (PHT). This suggests that the evolutionary stage of PHT may influence the response to β-blockers. To characterize the hemodynamic profile of each stage of PHT in compensated cirrhosis and the response to β-blockers according to stage, we performed a prospective, multicenter (tertiary care setting), cross-sectional study. Hepatic venous pressure gradient (HVPG) and systemic hemodynamic were measured in 273 patients with compensated cirrhosis before and after intravenous propranolol (0.15 mg/kg): 194 patients had an HVPG ≥10 mm Hg (clinically significant PHT [CSPH]), with either no varices (n = 80) or small varices (n = 114), and 79 had an HVPG >5 and <10 mm Hg (subclinical PHT). Patients with CSPH had higher liver stiffness (P < 0.001), worse Model for End-Stage Liver Disease score (P < 0.001), more portosystemic collaterals (P = 0.01) and splenomegaly (P = 0.01) on ultrasound, and lower platelet count (P < 0.001) than those with subclinical PHT. Patients with CSPH had lower systemic vascular resistance (1336 ± 423 versus 1469 ± 335 dyne · s · cm(-5) , P < 0.05) and higher cardiac index (3.3 ± 0.9 versus 2.8 ± 0.4 L/min/m(2) , P < 0.01). After propranolol, the HVPG decreased significantly in both groups, although the reduction was greater in those with CSPH (-16 ± 12% versus -8 ± 9%, P < 0.01). The HVPG decreased ≥10% from baseline in 69% of patients with CSPH versus 35% with subclinical PHT (P < 0.001) and decreased ≥20% in 40% versus 13%, respectively (P = 0.001). CONCLUSION Patients with subclinical PHT have less hyperdynamic circulation and significantly lower portal pressure reduction after acute β-blockade than those with CSPH, suggesting that β-blockers are more suitable to prevent decompensation of cirrhosis in patients with CSPH than in earlier stages.
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Affiliation(s)
- Càndid Villanueva
- Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Agustín Albillos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Hospital Universitario Ramón y Cajal (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Joan Genescà
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan G Abraldes
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Institut Malalties Digestives i Metaboliques, IDIBAPS, Hospital Clínic, Barcelona, Spain
| | | | | | - Rafael Bañares
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Hospital General Universitario Gregorio Marañón (IISGM), Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Rosa Morillas
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Hospital Germans Trias, Badalona, Spain
| | - María Poca
- Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Beatriz Peñas
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Hospital Universitario Ramón y Cajal (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Salvador Augustin
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Carles Garcia-Pagan
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Institut Malalties Digestives i Metaboliques, IDIBAPS, Hospital Clínic, Barcelona, Spain
| | - Oana Pavel
- Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Jaume Bosch
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Institut Malalties Digestives i Metaboliques, IDIBAPS, Hospital Clínic, Barcelona, Spain
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Roh JW, Park EH, Song JC, Oh YS, Kim TY, Kim HS, Lim S. ST-Segment Elevation Myocardial Infarction as a Result of Coronary Artery Ectasia-Related Intracoronary Thrombus in a Patient with Liver Cirrhosis. Korean J Crit Care Med 2015. [DOI: 10.4266/kjccm.2015.30.4.358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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49
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Crossan C, Tsochatzis EA, Longworth L, Gurusamy K, Davidson B, Rodríguez-Perálvarez M, Mantzoukis K, O'Brien J, Thalassinos E, Papastergiou V, Burroughs A. Cost-effectiveness of non-invasive methods for assessment and monitoring of liver fibrosis and cirrhosis in patients with chronic liver disease: systematic review and economic evaluation. Health Technol Assess 2015; 19:1-409, v-vi. [PMID: 25633908 DOI: 10.3310/hta19090] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Liver biopsy is the reference standard for diagnosing the extent of fibrosis in chronic liver disease; however, it is invasive, with the potential for serious complications. Alternatives to biopsy include non-invasive liver tests (NILTs); however, the cost-effectiveness of these needs to be established. OBJECTIVE To assess the diagnostic accuracy and cost-effectiveness of NILTs in patients with chronic liver disease. DATA SOURCES We searched various databases from 1998 to April 2012, recent conference proceedings and reference lists. METHODS We included studies that assessed the diagnostic accuracy of NILTs using liver biopsy as the reference standard. Diagnostic studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Meta-analysis was conducted using the bivariate random-effects model with correlation between sensitivity and specificity (whenever possible). Decision models were used to evaluate the cost-effectiveness of the NILTs. Expected costs were estimated using a NHS perspective and health outcomes were measured as quality-adjusted life-years (QALYs). Markov models were developed to estimate long-term costs and QALYs following testing, and antiviral treatment where indicated, for chronic hepatitis B (HBV) and chronic hepatitis C (HCV). NILTs were compared with each other, sequential testing strategies, biopsy and strategies including no testing. For alcoholic liver disease (ALD), we assessed the cost-effectiveness of NILTs in the context of potentially increasing abstinence from alcohol. Owing to a lack of data and treatments specifically for fibrosis in patients with non-alcoholic fatty liver disease (NAFLD), the analysis was limited to an incremental cost per correct diagnosis. An analysis of NILTs to identify patients with cirrhosis for increased monitoring was also conducted. RESULTS Given a cost-effectiveness threshold of £20,000 per QALY, treating everyone with HCV without prior testing was cost-effective with an incremental cost-effectiveness ratio (ICER) of £9204. This was robust in most sensitivity analyses but sensitive to the extent of treatment benefit for patients with mild fibrosis. For HBV [hepatitis B e antigen (HBeAg)-negative)] this strategy had an ICER of £28,137, which was cost-effective only if the upper bound of the standard UK cost-effectiveness threshold range (£30,000) is acceptable. For HBeAg-positive disease, two NILTs applied sequentially (hyaluronic acid and magnetic resonance elastography) were cost-effective at a £20,000 threshold (ICER: £19,612); however, the results were highly uncertain, with several test strategies having similar expected outcomes and costs. For patients with ALD, liver biopsy was the cost-effective strategy, with an ICER of £822. LIMITATIONS A substantial number of tests had only one study from which diagnostic accuracy was derived; therefore, there is a high risk of bias. Most NILTs did not have validated cut-offs for diagnosis of specific fibrosis stages. The findings of the ALD model were dependent on assuptions about abstinence rates assumptions and the modelling approach for NAFLD was hindered by the lack of evidence on clinically effective treatments. CONCLUSIONS Treating everyone without NILTs is cost-effective for patients with HCV, but only for HBeAg-negative if the higher cost-effectiveness threshold is appropriate. For HBeAg-positive, two NILTs applied sequentially were cost-effective but highly uncertain. Further evidence for treatment effectiveness is required for ALD and NAFLD. STUDY REGISTRATION This study is registered as PROSPERO CRD42011001561. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Catriona Crossan
- Health Economics Research Group, Brunel University London, Uxbridge, UK
| | - Emmanuel A Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Louise Longworth
- Health Economics Research Group, Brunel University London, Uxbridge, UK
| | | | | | - Manuel Rodríguez-Perálvarez
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Konstantinos Mantzoukis
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Julia O'Brien
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Evangelos Thalassinos
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Vassilios Papastergiou
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Andrew Burroughs
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
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50
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Lombardi R, Buzzetti E, Roccarina D, Tsochatzis EA. Non-invasive assessment of liver fibrosis in patients with alcoholic liver disease. World J Gastroenterol 2015; 21:11044-11052. [PMID: 26494961 PMCID: PMC4607904 DOI: 10.3748/wjg.v21.i39.11044] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 07/30/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
Alcoholic liver disease (ALD) consists of a broad spectrum of disorders, ranging from simple steatosis to alcoholic steatohepatitis and cirrhosis. Fatty liver develops in more than 90% of heavy drinkers, however only 30%-35% of them develop more advanced forms of ALD. Therefore, even if the current “gold standard” for the assessment of the stage of alcohol-related liver injury is histology, liver biopsy is not reasonable in all patients who present with ALD. Currently, although several non-invasive fibrosis markers have been suggested as alternatives to liver biopsy in patients with ALD, none has been sufficiently validated. As described in other liver disease, the diagnostic accuracy of such tests in ALD is acceptable for the diagnosis of significant fibrosis or cirrhosis but not for lesser fibrosis stages. Existing data suggest that the use of non-invasive tests could be tailored to first tier screening of patients at risk, in order to diagnose early patients with progressive liver disease and offer targeted interventions for the prevention of decompensation. We review these tests and critically appraise the existing evidence.
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