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Singh J, Ebaid M, Saab S. Advances in the management of complications from cirrhosis. Gastroenterol Rep (Oxf) 2024; 12:goae072. [PMID: 39104730 PMCID: PMC11299547 DOI: 10.1093/gastro/goae072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/29/2024] [Accepted: 06/15/2024] [Indexed: 08/07/2024] Open
Abstract
Cirrhosis with complications of liver decompensation and hepatocellular carcinoma (HCC) constitute a leading cause of morbidity and mortality worldwide. Portal hypertension is central to the progression of liver disease and decompensation. The most recent Baveno VII guidance included revision of the nomenclature for chronic liver disease, termed compensated advanced chronic liver disease, and leveraged the use of liver stiffness measurement to categorize the degree of portal hypertension. Additionally, non-selective beta blockers, especially carvedilol, can improve portal hypertension and may even have a survival benefit. Procedural techniques with interventional radiology have become more advanced in the management of refractory ascites and variceal bleeding, leading to improved prognosis in patients with decompensated liver disease. While lactulose and rifaximin are the preferred treatments for hepatic encephalopathy, many alternative treatment options may be used in refractory cases and even procedural interventions such as shunt embolization may be of benefit. The approval of terlipressin for the treatment of hepatorenal syndrome (HRS) in the USA has improved the way in which HRS is managed and will be discussed in detail. Malnutrition, frailty, and sarcopenia lead to poorer outcomes in patients with decompensated liver disease and should be addressed in this patient population. Palliative care interventions can lead to improved quality of life and clinical outcomes. Lastly, the investigation of systemic therapies, in particular immunotherapy, has revolutionized the management of HCC. These topics will be discussed in detail in this review.
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Affiliation(s)
- Jasleen Singh
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Mark Ebaid
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Flamm SL. Key Insights and Clinical Pearls in the Identification and Management of Cirrhosis and Its Complications. Am J Med 2024:S0002-9343(24)00326-7. [PMID: 38788826 DOI: 10.1016/j.amjmed.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 04/02/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024]
Abstract
Cirrhosis is a prevalent, chronic condition with an asymptomatic compensated phase, in which patients may feel well, and a decompensated phase that begins with the onset of complications (eg hepatic encephalopathy, ascites, and/or variceal bleeding). Because patients with cirrhosis may appear healthy with normal liver enzymes, alkaline phosphatase, and serum bilirubin levels, awareness of clinical signals is important. For example, patients with thrombocytopenia should be evaluated for chronic liver disease and cirrhosis. Early recognition and management of cirrhosis-related complications (eg hepatic encephalopathy, ascites, and/or variceal bleeding) are important, given their association with hospitalization and poor prognosis (eg increased odds of short-term mortality). Hepatic encephalopathy can be the most subtle cirrhosis-related complication and associated cognitive impairment may be misdiagnosed. Because hepatic encephalopathy can be associated with hospital readmissions, reducing readmission rates after hepatic encephalopathy-related hospitalizations is critical. This includes incorporating ongoing therapy (eg rifaximin plus lactulose) in postdischarge management plans to reduce the risk of hepatic encephalopathy recurrence. Strategies that mitigate cirrhosis progression and prevent the development of cirrhosis-related complications are key to improving patient outcomes.
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Affiliation(s)
- Steven L Flamm
- Section of Gastroenterology and Hepatology, Rush University Medical School, Chicago, Ill.
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3
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Adebayo D, Wong F. Review article: Recent advances in ascites and acute kidney injury management in cirrhosis. Aliment Pharmacol Ther 2024; 59:1196-1211. [PMID: 38526023 DOI: 10.1111/apt.17972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/08/2024] [Accepted: 03/14/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Better understanding of disease pathophysiology has led to advances in managing ascites and its associated complications including hepatorenal syndrome-acute kidney Injury (HRS-AKI), especially medicinal and interventional advances. AIM To review the latest changes in the management of ascites and HRS-AKI. METHODS A literature search was conducted in Pubmed, using the keywords cirrhosis, ascites, renal dysfunction, acute kidney injury, hepatorenal syndrome, beta-blockers, albumin, TIPS and vasoconstrictors, including only publications in English. RESULTS The medicinal advances include earlier treatment of clinically significant portal hypertension to delay the onset of ascites and the use of human albumin solution to attenuate systemic inflammation thus improving the haemodynamic changes associated with cirrhosis. Furthermore, new classes of drugs such as sodium glucose co-transporter 2 are being investigated for use in patients with cirrhosis and ascites. For HRS-AKI management, newer pharmacological agents such as vasopressin partial agonists and relaxin are being studied. Interventional advances include the refinement of TIPS technique and patient selection to improve outcomes in patients with refractory ascites. The development of the alfa pump system and the study of outcomes associated with the use of long-term palliative abdominal drain will also serve to improve the quality of life in patients with refractory ascites. CONCLUSIONS New treatment strategies emerged from better understanding of the pathophysiology of ascites and HRS-AKI have shown improved prognosis in these patients. The future will see many of these approaches confirmed in large multi-centre clinical trials with the aim to benefit the patients with ascites and HRS-AKI.
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Affiliation(s)
- Danielle Adebayo
- Department of Gastroenterology, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Florence Wong
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Kaplan DE, Ripoll C, Thiele M, Fortune BE, Simonetto DA, Garcia-Tsao G, Bosch J. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024; 79:1180-1211. [PMID: 37870298 DOI: 10.1097/hep.0000000000000647] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/16/2023] [Indexed: 10/24/2023]
Affiliation(s)
- David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA USA
| | - Cristina Ripoll
- Internal Medicine IV, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Brett E Fortune
- Department of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS) and CIBERehd, University of Barcelona, Spain
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Tapper EB, Serper M, Goldberg D. Implementing pragmatic clinical trials in hepatology. Hepatology 2024; 79:704-712. [PMID: 36825597 PMCID: PMC10460456 DOI: 10.1097/hep.0000000000000345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 02/10/2023] [Indexed: 02/25/2023]
Abstract
Patients with chronic liver disease would benefit from pragmatic trial designs. A pragmatic trial seeks to inform clinical decision-making by providing evidence for the adoption of an intervention into real-world clinical practice. A trial's pragmatism is based on the efficiency by which it identifies, recruits, and follows patients, the degree to which the interventions and design mirror the usual clinical care, and the importance of the outcomes to the patients. We review the promise, trade-offs, and purpose of pragmatic trials in hepatology.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan
| | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine
| | - David Goldberg
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine
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Elhence H, Dodge JL, Lee BP. Association of Renin-Angiotensin System Inhibition With Liver-Related Events and Mortality in Compensated Cirrhosis. Clin Gastroenterol Hepatol 2024; 22:315-323.e17. [PMID: 37495200 PMCID: PMC11232660 DOI: 10.1016/j.cgh.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/26/2023] [Accepted: 07/13/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND & AIMS While renin-angiotensin system inhibition lowers the hepatic venous gradient, the effect on more clinically meaningful endpoints is less studied. We aimed to quantify the relationship between renin-angiotensin system inhibition and liver-related events (LREs) among adults with compensated cirrhosis. METHODS In this national cohort study using the Optum database, we quantified the association between angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) use and LREs (hepatocellular carcinoma, liver transplantation, ascites, hepatic encephalopathy, or variceal bleeding) among patients with cirrhosis between 2009 and 2019. Selective beta-blocker (SBB) users served as the comparator group. We used demographic and clinical features to calculate inverse-probability treatment weighting-weighted cumulative incidences, absolute risk differences, and Cox proportional hazard ratios. RESULTS Among 4214 adults with cirrhosis, 3155 were ACE inhibitor/ARB users and 1059 were SBB users. In inverse probability treatment weighting-weighted analyses, ACE inhibitor/ARB (vs SBB) users had lower 5-year cumulative incidence (30.6% [95% confidence interval (CI), 27.8% to 33.2%] vs 41.3% [95% CI, 34.0% to 47.7%]; absolute risk difference, -10.7% [95% CI, -18.1% to -3.6%]) and lower risk of LREs (adjusted hazard ratio [aHR], 0.69; 95% CI, 0.60 to 0.80). There was a dose-response relationship: compared with SBB use, ACE inhibitor/ARB prescriptions ≥1 defined daily dose (aHR, 0.65; 95% CI, 0.56 to 0.76) were associated with a greater risk reduction compared with <1 defined daily dose (aHR, 0.87; 95% CI, 0.71 to 1.07). Results were robust across sensitivity analyses such as comparing ACE inhibitor/ARB users with nonusers and as-treated analysis. CONCLUSIONS In this national cohort study, ACE inhibitor/ARB use was associated with significantly lower risk of LREs in patients with compensated cirrhosis. These results provide support for a randomized clinical trial to confirm clinical benefit.
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Affiliation(s)
- Hirsh Elhence
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jennifer L Dodge
- Department of Population Public Health Sciences, University of Southern California, Los Angeles, Los Angeles, California; Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California
| | - Brian P Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California.
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Villanueva C, Sapena V, Lo GH, Seo YS, Shah HA, Singh V, Tripathi D, Schepke M, Gheorghe C, Bonilha DQ, Jutabha R, Wang HM, Rodrigues SG, Brujats A, Lee HA, Azam Z, Kumar P, Hayes PC, Sauerbruch T, Chen WC, Iacob S, Libera ED, Jensen DM, Alvarado E, Torres F, Bosch J. Improving primary prophylaxis of variceal bleeding by adapting therapy to the clinical stage of cirrhosis. A competing-risk meta-analysis of individual participant data. Aliment Pharmacol Ther 2024; 59:306-321. [PMID: 38108646 DOI: 10.1111/apt.17824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/24/2023] [Accepted: 11/21/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND & AIMS Non-selective β-blockers (NSBBs) and endoscopic variceal-ligation (EVL) have similar efficacy preventing first variceal bleeding. Compensated and decompensated cirrhosis are markedly different stages, which may impact treatment outcomes. We aimed to assess the efficacy of NSBBs vs EVL on survival in patients with high-risk varices without previous bleeding, stratifying risk according to compensated/decompensated stage of cirrhosis. METHODS By systematic review, we identified RCTs comparing NSBBs vs EVL, in monotherapy or combined, for primary bleeding prevention. We performed a competing-risk, time-to-event meta-analysis, using individual patient data (IPD) obtained from principal investigators of RCTs. Analyses were stratified according to previous decompensation of cirrhosis. RESULTS Of 25 RCTs eligible, 14 failed to provide IPD and 11 were included, comprising 1400 patients (656 compensated, 744 decompensated), treated with NSBBs (N = 625), EVL (N = 546) or NSBB+EVL (N = 229). Baseline characteristics were similar between groups. Overall, mortality risk was similar with EVL vs. NSBBs (subdistribution hazard-ratio (sHR) = 1.05, 95% CI = 0.75-1.49) and with EVL + NSBBs vs either monotherapy, with low heterogeneity (I2 = 28.7%). In compensated patients, mortality risk was higher with EVL vs NSBBs (sHR = 1.76, 95% CI = 1.11-2.77) and not significantly lower with NSBBs+EVL vs NSBBs, without heterogeneity (I2 = 0%). In decompensated patients, mortality risk was similar with EVL vs. NSBBs and with NSBBs+EVL vs. either monotherapy. CONCLUSIONS In patients with compensated cirrhosis and high-risk varices on primary prophylaxis, NSBBs significantly improved survival vs EVL, with no additional benefit noted adding EVL to NSBBs. In decompensated patients, survival was similar with both therapies. The study suggests that NSBBs are preferable when advising preventive therapy in compensated patients.
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Affiliation(s)
- Càndid Villanueva
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Victor Sapena
- Biostatistics Unit, Medical School, Universitat Autònoma de Barcelona, Barcelona, Spain
- Medical Statistics Core Facility, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Gin-Ho Lo
- Division of Gastroenterology, Department of Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yeon Seok Seo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hasnain Ali Shah
- Section of Gastroenterology, Aga Khan University, Karachi, Pakistan
| | - Virendra Singh
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Dhiraj Tripathi
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Department of Hepatology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Michael Schepke
- Helios Clinic Siegburg, Department Gastroenterology and Hepatology, Siegburg, Germany
| | - Cristian Gheorghe
- Center of Gastroenterology & Hepatology, Fundeni Clinical Institute, "Carol Davila" University of Medicine, Bucharest, Romania
| | - Daniell Q Bonilha
- Department of Gastroenterology, Federal University of São Paulo, State University of Campinas, Campinas, Brazil
| | - Rome Jutabha
- University of Southern California (USC) School of Medicine, Los Angeles, USA
- Keck School of Medicine of University of Southern California and Clinical Outreach and Development, Los Angeles, USA
| | - Huay-Min Wang
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Veterans, General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Susana G Rodrigues
- University Clinic for Visceral Surgery and Medicine, Inselspital Bern University Hospital, Bern, Switzerland
| | - Anna Brujats
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Han Ah Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Zahid Azam
- National Institute of Liver & GI Diseases, Dow University of Health Sciences, Karachi, Pakistan
| | - Pramod Kumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Peter C Hayes
- Department of Hepatology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Tilman Sauerbruch
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Wen-Chi Chen
- Division of Gastroenterology, Department of Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Speranta Iacob
- Center of Gastroenterology & Hepatology, Fundeni Clinical Institute, "Carol Davila" University of Medicine, Bucharest, Romania
| | - Ermelindo D Libera
- Department of Gastroenterology, Federal University of São Paulo, State University of Campinas, Campinas, Brazil
| | - Dennis M Jensen
- Department of Medicine, Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Center for the Health Sciences, Los Angeles, Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Center for Ulcer Research and Education: Digestive Diseases Research Center
| | - Edilmar Alvarado
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Ferran Torres
- Biostatistics Unit, Medical School, Universitat Autònoma de Barcelona, Barcelona, Spain
- Medical Statistics Core Facility, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Jaume Bosch
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
- University Clinic for Visceral Surgery and Medicine, Inselspital Bern University Hospital, Bern, Switzerland
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Patel M, Hunt C, VanWagner L. Recent Approaches in Portal Hypertension Involving Risk Stratification and Medical Management. Gastroenterol Hepatol (N Y) 2023; 19:662-669. [PMID: 38405225 PMCID: PMC10882863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Portal hypertension leads to the formation of portosystemic collaterals that divert portal blood to the systemic circulation and bypass the liver, resulting in multiple severe complications. Portal hypertension has classically been diagnosed using invasive methods to calculate the hepatic venous pressure gradient. There has been a recent evolution in portal hypertension pathology emphasizing dynamic changes and integrated pathophysiology, as well as concurrent changes in medical management. There is now a focus on using less-invasive approaches to diagnose portal hypertension and novel treatments that target the various components of evolving portal hypertension pathophysiology. This article details the latest techniques in diagnosing and treating portal hypertension that are becoming cornerstones of portal hypertension management.
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Affiliation(s)
- Mausam Patel
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Charlotte Hunt
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lisa VanWagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
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Mattos AAD, Mattos AZD, Sartori GDP, Both GT, Tovo CV. THE ROLE OF ELASTOGRAPHY IN CLINICALLY SIGNIFICANT PORTAL HYPERTENSION. ARQUIVOS DE GASTROENTEROLOGIA 2023; 60:525-535. [PMID: 38018555 DOI: 10.1590/s0004-2803.230402023-64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/08/2023] [Indexed: 11/30/2023]
Abstract
• In compensated cirrhosis, using non-invasive methods would exempt the patient from the need of an endoscopy. • The Baveno VII presented the "rule of 5" for Vibration-Controlled Transient Elastography; liver stiffness measurement ≤15 kPa and platelets >150.000/mm3 exclude clinically significant portal hypertension (CSPH), while when ≥25 kPa is highly suggestive of CSPH. • Spleen stiffness measurement has been proposed as a more specific technique to predict the presence of CSPH. • Elastography has gained prestige in the non-invasive evaluation of patients with advanced chronic liver disease by allowing prophylactic measures to be taken when suggesting the presence of CSPH. This is a narrative review that aims to discuss the importance of elastographic methods in the evaluation of clinically significant portal hypertension (CSPH) in cirrhotic patients, where the authors propose an algorithm for evaluating these patients. In compensated advanced chronic liver disease, the goal is to prevent the development of CSPH and, in those already with CSPH, prevent the appearance of gastroesophageal varices (GEV) and other complications of portal hypertension. In compensated cirrhosis, the prevalence of GEV is 30-40%, of which 10-20% are at risk of bleeding. Therefore, using non-invasive methods would exempt the patient from the need of an endoscopy. Hepatic Elastography is a non-invasive, safe, reproducible method, available through many techniques: Vibration-Controlled Transient Elastography (VCTE), Shear Wave Elastography (SWE) and Magnetic Resonance Elastography (MRE). The Baveno VII presented the "rule of 5" for VCTE: liver stiffness measurement (LSM) ≤15 kPa and platelets >150.000/mm3 exclude CSPH, while an LSM ≥25 kPa is highly suggestive of CSPH. Also, the "rule of 4" for SWE has been proposed: patients with ≥17 kPa could be considered as having CSPH. At last, spleen stiffness measurement (SSM) has been proposed as a more specific technique to predict the presence of CSPH. In conclusion, elastography has gained prestige in the non-invasive evaluation of patients with advanced chronic liver disease by allowing prophylactic measures to be taken when suggesting the presence of CSPH.
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Affiliation(s)
- Angelo Alves de Mattos
- Universidade Federal de Ciências da Saúde de Porto Alegre, Departamento de Clínica Médica, Porto Alegre, RS, Brasil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Curso de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
| | - Angelo Zambam de Mattos
- Universidade Federal de Ciências da Saúde de Porto Alegre, Departamento de Clínica Médica, Porto Alegre, RS, Brasil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Curso de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
| | - Giovana Dal Pozzo Sartori
- Universidade Federal de Ciências da Saúde de Porto Alegre, Curso de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
| | - Gustavo Tovo Both
- Universidade Luterana do Brasil, Departamento de Clínica Médica, Canoas, RS, Brasil
| | - Cristiane Valle Tovo
- Universidade Federal de Ciências da Saúde de Porto Alegre, Departamento de Clínica Médica, Porto Alegre, RS, Brasil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Curso de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
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Rowe IA, Villanueva C, Shearer JE, Torres F, Albillos A, Genescà J, Garcia-Pagan JC, Tripathi D, Hayes PC, Bosch J, Abraldes JG. Quantifying the benefit of nonselective beta-blockers in the prevention of hepatic decompensation: A Bayesian reanalysis of the PREDESCI trial. Hepatology 2023; 78:530-539. [PMID: 36897269 DOI: 10.1097/hep.0000000000000342] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/09/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND AND AIMS Beta-blockers have been studied for the prevention of variceal bleeding and, more recently, for the prevention of all-cause decompensation. Some uncertainties regarding the benefit of beta-blockers for the prevention of decompensation remain. Bayesian analyses enhance the interpretation of trials. The purpose of this study was to provide clinically meaningful estimates of both the probability and magnitude of the benefit of beta-blocker treatment across a range of patient types. APPROACH AND RESULTS We undertook a Bayesian reanalysis of PREDESCI incorporating 3 priors (moderate neutral, moderate optimistic, and weak pessimistic). The probability of clinical benefit was assessed considering the prevention of all-cause decompensation. Microsimulation analyses were done to determine the magnitude of the benefit. In the Bayesian analysis, the probability that beta-blockers reduce all-cause decompensation was >0.93 for all priors. The Bayesian posterior hazard ratios (HR) for decompensation ranged from 0.50 (optimistic prior, 95% credible interval 0.27-0.93) to 0.70 (neutral prior, 95% credible interval 0.44-1.12). Exploring the benefit of treatment using microsimulation highlights substantial treatment benefits. For the neutral prior derived posterior HR and a 5% annual incidence of decompensation, at 10 years, an average of 497 decompensation-free years per 1000 patients were gained with treatment. In contrast, at 10 years 1639 years per 1000 patients were gained from the optimistic prior derived posterior HR and a 10% incidence of decompensation. CONCLUSIONS Beta-blocker treatment is associated with a high probability of clinical benefit. This likely translates to a substantial gain in decompensation-free life years at the population level.
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Affiliation(s)
- Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Càndid Villanueva
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Salud Carlos III, Spain
| | - Jessica E Shearer
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ferran Torres
- Biostatistics Unit, Medical School, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Agustín Albillos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Salud Carlos III, Spain
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS). Madrid, Spain
| | - Joan Genescà
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Salud Carlos III, Spain
- Liver Unit, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Joan C Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Dhiraj Tripathi
- University Hospitals Birmingham NHS Foundation Trust. Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham. UK
- Department of Hepatology. Royal Infirmary of Edinburgh. Edinburgh, UK
| | - Peter C Hayes
- Department of Hepatology. Royal Infirmary of Edinburgh. Edinburgh, UK
| | - Jaume Bosch
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
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Villanueva C, Torres F, Tripathi D, Bosch J. Reply to: "Carvedilol in patients with compensated cirrhosis: The ongoing benefits of definitive randomised trials over meta-analysis in patients with small varices". J Hepatol 2023; 79:e23-e24. [PMID: 36848975 DOI: 10.1016/j.jhep.2023.02.025] [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: 02/14/2023] [Accepted: 02/14/2023] [Indexed: 03/01/2023]
Affiliation(s)
- Càndid Villanueva
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, 08025 Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain.
| | - Ferran Torres
- Medical Statistics Core Facility, IDIBAPS, Hospital Clinic, Barcelona, Spain; Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Dhiraj Tripathi
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jaume Bosch
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain; Department of Visceral Surgery and Medicine, Inselspital, University of Bern, Switzerland; Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
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Shanahan W, Clarke M, Carolan E, Ryan JD. Letter: practical considerations for nonselective beta-blocker therapy in portal hypertension. Aliment Pharmacol Ther 2023; 57:1475-1476. [PMID: 37243473 DOI: 10.1111/apt.17482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 03/11/2023] [Indexed: 05/28/2023]
Affiliation(s)
- William Shanahan
- Hepatology Unit, Beaumont Hospital, Beaumont Road, Dublin, Ireland
| | - Maeve Clarke
- Hepatology Unit, Beaumont Hospital, Beaumont Road, Dublin, Ireland
| | - Eimear Carolan
- Hepatology Unit, Beaumont Hospital, Beaumont Road, Dublin, Ireland
- Pharmacy, Beaumont Hospital, Beaumont Road, Dublin, Ireland
| | - John D Ryan
- Hepatology Unit, Beaumont Hospital, Beaumont Road, Dublin, Ireland
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Chapin S, Kaplan DE, Taddei T, Mahmud N. Association between statin exposure and short-term mortality in patients with high-grade acute-on-chronic liver failure. JHEP Rep 2023; 5:100740. [PMID: 37215188 PMCID: PMC10193237 DOI: 10.1016/j.jhepr.2023.100740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 05/24/2023] Open
Abstract
Background & Aims Acute-on-chronic liver failure (ACLF) carries a high short-term mortality for patients with cirrhosis. Prior literature suggests that statin exposure may reduce the likelihood of ACLF events. However, it is unclear if statin exposure is associated with ACLF-related mortality. This study sought to determine the association between statin use and short-term mortality among patients hospitalised with ACLF. Methods This was a retrospective cohort study of Veterans Health Administration (VHA) patients diagnosed with cirrhosis between 2008 and 2021 and hospitalised with high-grade (2 or 3) ACLF. Patients were stratified into those with and without continuous statin exposure for at least 90 days prior to hospitalisation. Multivariable logistic regression models were created to determine the adjusted association between statin exposure and 28-day and 90-day mortality. Categorical statin dose exposure, converted to simvastatin equivalents, was also explored. Results A total of 11,731 patients with cirrhosis hospitalised with Grade 2 or 3 ACLF were included in the analytic cohort, 26% of whom had statin exposure. In adjusted logistic regression models, statin use was associated with 18% lower odds of ACLF-related 28-day mortality (odds ratio [OR] 0.82, 95% CI 0.73-0.93, p = 0.001) and 24% lower odds of 90-day mortality (OR 0.76, 95% CI 0.68-0.86, p <0.001). Increasing statin dose exposure was also associated with further reductions in 90-day mortality (e.g. OR 0.81, 95% CI 0.70-0.93 for 10-40 mg vs. 0 mg and OR 0.72, 95% CI 0.60-0.87 for 80 mg vs. 0 mg, p <0.001). Conclusions In this large, retrospective cohort study, statin exposure before high-grade ACLF hospitalisation was associated with reduced odds of 28-day and 90-day mortality in patients with cirrhosis. A statin dose-dependent reduction in 90-day ACLF-related mortality was also observed. Impact and Implications Statins have been identified as a class of medications with potential beneficial effects for patients with cirrhosis. In this large, retrospective cohort study of patients with cirrhosis who seek care at the Veterans Health Administration, statin use was associated with a decrease in short term (28-day and 90-day) mortality as a result of acute-on-chronic liver failure. Future prospective studies are needed to further clarify the relative safety and efficacy of statin therapy in reducing morbidity and mortality associated with acute-on-chronic liver failure in patients with cirrhosis.
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Affiliation(s)
- Sara Chapin
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Tamar Taddei
- VA Connecticut-Healthcare System, West Haven, CT, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard David Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
Importance Cirrhosis affects approximately 2.2 million adults in the US. From 2010 to 2021, the annual age-adjusted mortality of cirrhosis increased from 14.9 per 100 000 to 21.9 per 100 000 people. Observations The most common causes of cirrhosis in the US, which can overlap, include alcohol use disorder (approximately 45% of all cases of cirrhosis), nonalcoholic fatty liver disease (26%), and hepatitis C (41%). Patients with cirrhosis experience symptoms including muscle cramps (approximately 64% prevalence), pruritus (39%), poor-quality sleep (63%), and sexual dysfunction (53%). Cirrhosis can be diagnosed by liver biopsy but may also be diagnosed noninvasively. Elastography, a noninvasive assessment of liver stiffness measured in kilopascals, can typically confirm cirrhosis at levels of 15 kPa or greater. Approximately 40% of people with cirrhosis are diagnosed when they present with complications such as hepatic encephalopathy or ascites. The median survival time following onset of hepatic encephalopathy and ascites is 0.92 and 1.1 years, respectively. Among people with ascites, the annual incidence of spontaneous bacterial peritonitis is 11% and of hepatorenal syndrome is 8%; the latter is associated with a median survival of less than 2 weeks. Approximately 1% to 4% of patients with cirrhosis develop hepatocellular carcinoma each year, which is associated with a 5-year survival of approximately 20%. In a 3-year randomized clinical trial of 201 patients with portal hypertension, nonselective β-blockers (carvedilol or propranolol) reduced the risk of decompensation or death compared with placebo (16% vs 27%). Compared with sequential initiation, combination aldosterone antagonist and loop diuretics were more likely to resolve ascites (76% vs 56%) with lower rates of hyperkalemia (4% vs 18%). In meta-analyses of randomized trials, lactulose was associated with reduced mortality relative to placebo (8.5% vs 14%) in randomized trials involving 705 patients and reduced risk of recurrent overt hepatic encephalopathy (25.5% vs 46.8%) in randomized trials involving 1415 patients. In a randomized clinical trial of 300 patients, terlipressin improved the rate of reversal of hepatorenal syndrome from 39% to 18%. Trials addressing symptoms of cirrhosis have demonstrated efficacy for hydroxyzine in improving sleep dysfunction, pickle brine and taurine for reducing muscle cramps, and tadalafil for improving sexual dysfunction in men. Conclusions and Relevance Approximately 2.2 million US adults have cirrhosis. Many symptoms, such as muscle cramps, poor-quality sleep, pruritus, and sexual dysfunction, are common and treatable. First-line therapies include carvedilol or propranolol to prevent variceal bleeding, lactulose for hepatic encephalopathy, combination aldosterone antagonists and loop diuretics for ascites, and terlipressin for hepatorenal syndrome.
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
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Gillespie SL, Hanrahan TP, Rockey DC, Majumdar A, Hayes PC. Review article: controversies surrounding the use of carvedilol and other beta blockers in the management of portal hypertension and cirrhosis. Aliment Pharmacol Ther 2023; 57:454-463. [PMID: 36691947 DOI: 10.1111/apt.17380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/03/2022] [Accepted: 12/18/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Advanced chronic liver disease is an increasing cause of premature morbidity and mortality in the UK. Portal hypertension is the primary driver of decompensation, including the development of ascites, hepatic encephalopathy and variceal haemorrhage. Non-selective beta blockers (NSBB) reduce portal pressure and are well established in the prevention of variceal haemorrhage. Carvedilol, a newer NSBB, is more effective at reducing portal pressure due to additional α-adrenergic blockade and has additional anti-oxidant, anti-inflammatory and anti-fibrotic effects. AIM To summarise the available evidence on the use of beta blockers, specifically carvedilol, in cirrhosis, focussing on when and why to start METHODS: We performed a comprehensive literature search of PubMed for relevant publications. RESULTS International guidelines advise the use of NSBB in primary prophylaxis against variceal haemorrhage in those with high-risk varices, with substantial evidence of efficacy comparable with endoscopic band ligation (EBL). NSBB are also well established in secondary prophylaxis, in combination with EBL. More controversial is their use in patients without large varices, but with clinically significant portal hypertension. However, there is gathering evidence that NSBB, particularly carvedilol, reduce the risk of decompensation and improve survival. While caution is advised in patients with advanced cirrhosis and refractory ascites, recent evidence suggests that NSBB can continue to be used safely, and that premature discontinuation may be detrimental. CONCLUSIONS With increasing evidence of benefit independent of variceal bleeding, namely retardation of decompensation and improvement in survival, it is time to consider whether carvedilol should be offered to all patients with advanced chronic liver disease.
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Affiliation(s)
| | - Timothy P Hanrahan
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Gastroenterology and Hepatology, Austin Health, Melbourne, Australia
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Avik Majumdar
- Department of Gastroenterology and Hepatology, Austin Health, Melbourne, Australia.,The University of Melbourne, Melbourne, Australia
| | - Peter C Hayes
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, UK.,College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
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