Decellularized human placenta supports hepatic tissue and allows rescue in acute liver failure

Trends in the Burden of Chronic Liver Disease Among Hospitalized US Adults

Importance

One factor associated with the rapidly increasing clinical and economic burden of chronic liver disease (CLD) is inpatient health care utilization.

Objective

To understand trends in the hospitalization burden of CLD in the US.

Design, Setting, and Participants

This cross-sectional study of hospitalized adults in the US used data from the National Inpatient Sample from 2012 to 2016 on adult CLD-related hospitalizations. Data were analyzed from June to October 2019.

Main Outcomes and Measures

Hospitalizations identified using a comprehensive review of CLD-specific International Classification of Diseases, Ninth Revision, Clinical Modification and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes. Survey-weighted annual trends in national estimates of CLD-related hospitalizations, in-hospital mortality, and hospitalization costs, stratified by demographic and clinical characteristics.

Results

This study included 1 016 743 CLD-related hospitalizations (mean [SD] patient age, 57.4 [14.4] years; 582 197 [57.3%] male; 633 082 [62.3%] white). From 2012 to 2016, the rate of CLD-related hospitalizations per 100 000 hospitalizations increased from 3056 (95% CI, 3042-3069) to 3757 (95% CI, 3742-3772), and total inpatient hospitalization costs increased from $14.9 billion (95% CI, $13.9 billion to $15.9 billion) to $18.8 billion (95% CI, $17.6 billion to $20.0 billion). Mean (SD) patient age increased (56.8 [14.2] years in 2012 to 57.8 [14.6] years in 2016) and, subsequently, the proportion with Medicare also increased (41.7% [95% CI, 41.1%-42.2%] to 43.6% [95% CI, 43.1%-44.1%]) (P for trend < .001 for both). The proportion of hospitalizations of patients with hepatitis C virus was similar throughout the period of study (31.6% [95% CI, 31.3%-31.9%]), and the proportion with alcoholic cirrhosis and nonalcoholic fatty liver disease showed increases. The mortality rate was higher among hospitalizations with alcoholic cirrhosis (11.9% [95% CI, 11.7%-12.0%]) compared with other etiologies. Presence of hepatocellular carcinoma was also associated with a high mortality rate (9.8% [95% CI, 9.5%-10.1%]). Cost burden increased across all etiologies, with a higher total cost burden among hospitalizations with alcoholic cirrhosis ($22.7 billion [95% CI, $22.1 billion to $23.2 billion]) or hepatitis C virus ($22.6 billion [95% CI, $22.1 billion to $23.2 billion]). Presence of cirrhosis, complications of cirrhosis, and comorbidities added to the CLD burden.

Conclusions and Relevance

Over the study period, the total estimated national hospitalization costs in patients with CLD reached $81.1 billion. The inpatient CLD burden in the US is likely increasing because of an aging CLD population with increases in concomitant comorbid conditions.

Association Between Aspirin Use and Risk of Hepatocellular Carcinoma

Importance

Prospective data on the risk of hepatocellular carcinoma (HCC) according to dose and duration of aspirin therapy are limited.

Objective

To examine the potential benefits of aspirin use for primary HCC prevention at a range of doses and durations of use within 2 prospective, nationwide populations.

Design, Setting, and Participants

Pooled analysis of 2 prospective US cohort studies: the Nurses' Health Study and the Health Professionals Follow-up Study. Data were accessed from November 1, 2017, through March 7, 2018. A total of 133 371 health care professionals who reported data on aspirin use, frequency, dosage, and duration of use biennially since 1980 in women and 1986 in men were included. Individuals with a cancer diagnosis at baseline (except nonmelanoma skin cancer) were excluded.

Main Outcomes and Measures

Cox proportional hazards regression models were used to calculate multivariable adjusted hazard ratios (HRs) and 95% CIs for HCC.

Results

Of the 133 371 participants, 87 507 were women and 45 864 were men; in 1996, the median time of follow-up, the mean (SD) age was 62 (8) years for women and 64 (8) years for men. Over more than 26 years of follow-up encompassing 4 232 188 person-years, 108 incident HCC cases (65 women, 43 men) were documented. Compared with nonregular use, regular aspirin use (≥2 standard-dose [325-mg] tablets per week) was associated with reduced HCC risk (adjusted HR, 0.51; 95% CI, 0.34-0.77). This benefit appeared to be dose related: compared with nonuse, the multivariable-adjusted HR for HCC was 0.87 (95% CI, 0.51-1.48) for up to 1.5 standard-dose tablets per week, 0.51 (95% CI, 0.30-0.86) for more than 1.5 to 5 tablets per week, and 0.49 (95% CI, 0.28-0.96) for more than 5 tablets per week (P for trend = .006). Significantly lower HCC risk was observed with increasing duration (P for trend = .03); this decrease was apparent with use of 1.5 or more standard-dose aspirin tablets per week for 5 or more years (adjusted HR, 0.41; 95% CI, 0.21-0.77). In contrast, use of nonaspirin nonsteroidal anti-inflammatory drugs was not significantly associated with HCC risk (adjusted HR, 1.09; 95% CI, 0.78-1.51).

Conclusions and Relevance

This study suggests that regular, long-term aspirin use is associated with a dose-dependent reduction in HCC risk, which is apparent after 5 or more years of use. Similar associations were not found with nonaspirin NSAIDs. Further research appears to be needed to clarify whether aspirin use represents a feasible strategy for primary prevention against HCC.

Association of Histologic Disease Activity With Progression of Nonalcoholic Fatty Liver Disease

IMPORTANCE

The histologic evolution of the full spectrum of nonalcoholic fatty liver disease (NAFLD) and factors associated with progression or regression remain to be definitively established.

OBJECTIVE

To evaluate the histologic evolution of NAFLD and the factors associated with changes in disease severity over time.

DESIGN, SETTING, AND PARTICIPANTS

A prospective cohort substudy from the Nonalcoholic Steatohepatitis Clinical Research Network (NASH CRN) NAFLD Database study, a noninterventional registry, was performed at 8 university medical research centers. Masked assessment of liver histologic specimens was performed, using a prespecified protocol to score individual biopsies. Participants included 446 adults with NAFLD enrolled in the NASH CRN Database studies between October 27, 2004, and September 13, 2013, who underwent 2 liver biopsies 1 or more year apart. Data analysis was performed from October 2016 to October 2018.

MAIN OUTCOMES AND MEASURES

Progression and regression of fibrosis stage, using clinical, laboratory, and histologic findings, including the NAFLD activity score (NAS) (sum of scores for steatosis, lobular inflammation, and ballooning; range, 0-8, with 8 indicating more severe disease).

RESULTS

A total of 446 adults (mean [SD] age, 47 [11] years; 294 [65.9%] women) with NAFLD (NAFL, 86 [19.3%]), borderline NASH (84 [18.8%]), and definite NASH (276 [61.9%]) were studied. Over a mean (SD) interval of 4.9 (2.8) years between biopsies, NAFL resolved in 11 patients (12.8%) and progressed to steatohepatitis in 36 patients (41.9%). Steatohepatitis resolved in 24 (28.6%) of the patients with borderline NASH and 61 (22.1%) of those with definite NASH. Fibrosis progression or regression by at least 1 stage occurred in 132 (30%) and 151 [34%] participants, respectively. Metabolic syndrome (20 [95%] vs 108 [72%]; P = .03), baseline NAS (mean [SD], 5.0 [1.4] vs 4.3 [1.6]; P = .005), and smaller reduction in NAS (-0.2 [2] vs -0.9 [2]; P < .001) were associated with progression to advanced (stage 3-4) fibrosis vs those without progression to stage 3 to 4 fibrosis. Fibrosis regression was associated with lower baseline insulin level (20 vs 33 μU/mL; P = .02) and decrease in all NAS components (steatosis grade -0.8 [0.1] vs -0.3 [0.9]; P < .001; lobular inflammation -0.5 [0.8] vs -0.2 [0.9]; P < .001; ballooning -0.7 [1.1] vs -0.1 [0.9]; P < .001). Only baseline aspartate aminotransferase (AST) levels were associated with fibrosis regression vs no change and progression vs no change on multivariable regression: baseline AST (regression: conditional odds ratio [cOR], 0.6 per 10 U/L AST; 95% CI, 0.4-0.7; P < .001; progression: cOR, 1.3; 95% CI, 1.1-1.5; P = .002). Changes in the AST level, alanine aminotransferase (ALT) level, and NAS were also associated with fibrosis regression and progression (ΔAST level: regression, cOR, 0.9; 95% CI, 0.6-1.2; P = .47; progression, cOR, 1.3; 95% CI, 1.0-1.6; P = .02; ΔALT level: regression, cOR, 0.7 per 10 U/L AST; 95% CI, 0.5-0.9; P = .002; progression, cOR, 1.0 per 10 U/L AST; 95% CI, 0.9-1.2; P = .93; ΔNAS: regression, cOR, 0.7; 95% CI, 0.6-0.9; P = .001; progression, cOR, 1.3; 95% CI, 1.1-1.5; P = .01).

CONCLUSIONS AND RELEVANCE

Improvement or worsening of disease activity may be associated with fibrosis regression or progression, respectively, in NAFLD.

How Would You Manage This Patient With Nonalcoholic Fatty Liver Disease?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Nonalcoholic fatty liver disease (NAFLD), a common diagnosis in the United States and other developed countries, has been increasing in prevalence. The American Association for the Study of Liver Diseases recently published updated practice guidelines for diagnosing and managing NAFLD, including the following recommendations: Routine screening for NAFLD in high-risk groups is not advised because of uncertainties surrounding test and treatment options, along with a lack of knowledge about cost-effectiveness and long-term benefits. Noninvasive studies, including biomarkers from laboratory tests and liver stiffness measured through elastography, are clinically useful tools for identifying advanced fibrosis in patients with NAFLD. Liver biopsy should be considered in patients with NAFLD who are at increased risk for nonalcoholic steatohepatitis (NASH) or advanced fibrosis. Weight loss of at least 3% to 5% generally reduces NASH, but greater weight loss (7% to 10%) is needed to improve most histopathologic features, including fibrosis. Pharmacologic therapies (such as pioglitazone and vitamin E) should be considered only in patients with biopsy-proven NASH. Patients with NAFLD should not consume heavy amounts of alcohol, although insufficient data exist to provide advice about other levels of alcohol use. Here, 2 clinicians with expertise in this area debate whether to screen for NAFLD in primary care, how to monitor patients with NAFLD, and what interventions should be used to manage this condition.

[Implantation strategy of tissue-engineered liver based on decellularized spleen matrix in rats]

OBJECTIVE

To explore the optimal implantation strategy of tissue-engineered liver (TEL) constructed based on decellularized spleen matrix (DSM) in rats.

METHODS

DSM was prepared by freeze-thawing and perfusion with sodium dodecyl sulfate (SDS) of the spleen of healthy SD rats. Primary rat hepatocytes isolated using modified Seglen 2-step perfusion method were implanted into the DSM to construct the TEL. The advantages and disadvantages were evaluated of 4 transplant strategies of the TEL, namely ectopic vascular anastomosis, liver cross-section suture transplantation, intrahepatic insertion and mesenteric transplantation.

RESULTS

The planting rate of hepatocytes in the DSM was (74.5∓7.7)%. HE staining and scanning electron microscopy showed satisfactory cell status, and immunofluorescence staining confirmed the normal expression of ALB and G6Pc in the cells. For TEL implantation, ectopic vascular anastomosis was difficult and resulted in a mortality rate of 33.3% perioperatively and massive thrombus formation in the matrix within 6 h. Hepatic cross-section suture failed to rapidly establish sufficient blood supply, and no viable graft was observed 3 days after the operation. With intrahepatic insertion method, the hepatocytes in the DSM could survive as long as 14 days. Mesenteric transplantation resulted in a hepatocyte survival rate of (38.3+7.1)% at 14 days after implantation.

CONCLUSION

TEL constructed based on DSM can perform liver-specific functions with a good cytological bioactivity. Mesenteric transplantation of the TEL, which is simple, safe and effective, is currently the optimal transplantation strategy.