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Liver Diseases in Latin America: Current Status, Unmet Needs, and Opportunities for Improvement. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2022; 20:261-278. [PMID: 35729970 PMCID: PMC9202671 DOI: 10.1007/s11938-022-00382-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 02/07/2023]
Abstract
Purpose of review
To assess the current challenges regarding liver diseases, including the burden of disease, access to care, screening, and treatment needs in Latin America. Recent findings Latin America is a region with a rich multicultural heritage and important socioeconomic differences. The burden of liver diseases is high and mainly determined by a high level of alcohol intake and the surge of risk factors associated with NAFLD (i.e., sedentary lifestyles, broader access to highly processed foods, obesity, and type 2 diabetes mellitus). Hepatotropic viruses also play a role in the development of chronic liver diseases, although their comparative frequency has been decreasing over the last decades. There are important disparities in access to screening and treatment for liver diseases in Latin America, which are reflected in low access to critical treatments such as direct-acting antiviral agents and drugs to treat hepatocellular carcinoma. Also, important barriers to liver transplantation are present in multiple countries, including a low deceased donors’ rate and a lack of availability in several countries (especially in Central America). Our region also has disadvantages in research and education in liver diseases, which limits regional academic development and improvement in quality of care of liver diseases. Summary In order to tackle an increasing health burden due to liver diseases, Latin America urgently needs tailored interventions aiming to control the main risk factors for these disorders through the establishment of effective public health policies. Also, development of liver transplantation programs and improvement of medical education and research capabilities as well as extensive collaboration between all stakeholders are keys to address the liver disease agenda in the region.
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Arab JP, Díaz LA, Dirchwolf M, Mark HE, Lazarus JV, Vaughan E, Méndez-Sánchez N, Oliveira CP, Gadano A, Arrese M. NAFLD: Challenges and opportunities to address the public health problem in Latin America. Ann Hepatol 2022; 24:100359. [PMID: 34004366 DOI: 10.1016/j.aohep.2021.100359] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 02/07/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is reaching epidemic proportions worldwide. Collectively, Latin American countries have some of the highest obesity rates in the world and the fastest-growing prevalence of type 2 diabetes mellitus (T2DM). Since obesity and T2DM are intrinsically linked with NAFLD, epidemiological projections are worrisome. In addition to this adverse epidemiological setting, the region of Latin America faces unique challenges and obstacles to addressing the growing burden of NAFLD. In this article, on the occasion of the International NASH Day on June 10, 2021, we describe the main challenges and opportunities to improve care of people living with NAFLD in Latin America. Among the major challenges to be tackled are: lack of disease awareness, limited educational opportunities for healthcare personnel and general public, health system fragmentation, and lack of effective strategies for the prevention and effective treatment of NAFLD and common comorbidities, namely obesity and T2DM. Wide dissemination of current concepts on NAFLD, and extensive collaboration between scientific societies, governments, non-governmental organizations, pharmaceutical industry, and other stakeholders is urgently needed to advance the NAFLD public health policies agenda that allows us to address this disease with a whole of society approach.
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Affiliation(s)
- Juan Pablo Arab
- Departamento de Gastroenterología, Escuela de Medicina, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Luis Antonio Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Melisa Dirchwolf
- Unidad de Trasplante Hepático, Servicio de Hepatología, Hospital Privado de Rosario, Rosario, Argentina
| | - Henry E Mark
- EASL International Liver Foundation, Geneva, Switzerland
| | - Jeffrey V Lazarus
- EASL International Liver Foundation, Geneva, Switzerland; Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Spain
| | - Elly Vaughan
- Health Policy and Clinical Evidence, The Economist Intelligence Unit, London, United Kingdom
| | - Nahum Méndez-Sánchez
- Liver Research Unit, Medica Sur Clinic & Foundation, Faculty of Medicine, National Autonomous University of Mexico, Mexico City, 14050, Mexico
| | - Claudia P Oliveira
- Division of Clinical Gastroenterology and Hepatology, Hospital das Clínicas HCFMUSP, Department of Gastroenterology, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Adrián Gadano
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Marco Arrese
- Departamento de Gastroenterología, Escuela de Medicina, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile.
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Piñero F, da Fonseca LG. Trial eligibility in advanced hepatocellular carcinoma: Does it support clinical practice in underrepresented subgroups? World J Gastroenterol 2021; 27:3429-3439. [PMID: 34239261 PMCID: PMC8240059 DOI: 10.3748/wjg.v27.i24.3429] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/06/2021] [Accepted: 05/20/2021] [Indexed: 02/06/2023] Open
Abstract
Although hepatocellular carcinoma is considered a highly lethal malignancy, recent therapeutic advances have been achieved during the last 10 years. This scenario resulted in an unprecedented improvement in survival for patients with advanced hepatocellular carcinoma, almost reaching 20-26 mo of overall survival after first-second line sequential treatment. The advent of the combination of atezolizumab with bevacizumab showed, for the first time, superiority over sorafenib with improvement in overall survival. However, first and second-line trials were correctly based on the premise that a strict selection of patients enhances the power to capture the positive effect of treatment by excluding competing risks for mortality such as liver failure, decompensated cirrhosis or other underlying medical conditions. As a result, the inclusion criteria used in clinical trials do not support the use of novel therapies in several real-world scenarios involving underrepresented subgroups, such as patients with unpreserved liver function, other comorbid conditions, a history of solid-organ transplantation, autoimmune disorders and those with a high risk of bleeding. The present text aims at discussing treatment strategies in these subgroups.
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Affiliation(s)
- Federico Piñero
- Hepatology and Liver Unit, Hospital Universitario Austral, School of Medicine, Austral University, Buenos Aires B1629HJ, Argentina
| | - Leonardo Gomes da Fonseca
- Clinical Oncology, Insituto do Cancer do Estado de São Paulo, University of São Paulo, São Paulo 05403-000, Brazil
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Mendizabal M, Ridruejo E, Ceballos S, Sixto M, Billordo A, Gadea C, Mengarelli S, Alonso C, Palazzo A, De María L, Bruno A, Perez D, Piñero F, Deltrozzo V, Mendoza C, Figueroa S, Manero E, Villa M, Barreyro F, Moreno V, Vilar J, Murga D, Fernandez M, O Flaherty M, Arora S, Silva M. The ECHO model proved to be a useful tool to increase clinicians' self-effectiveness for care of patients with Hepatitis C in Argentina. J Viral Hepat 2019; 26:1284-1292. [PMID: 31273860 DOI: 10.1111/jvh.13172] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/03/2019] [Accepted: 06/10/2019] [Indexed: 01/22/2023]
Abstract
The ECHO model was developed to expand access to medical care for populations with HCV infection in underserved areas. We aimed to compare HCV treatment outcomes in community-based clinics with the Austral University Hospital (AUH) and to assess improvement in physician knowledge and skills. In October 2015, we established an HCV ECHO clinic at the AUH in Buenos Aires. To evaluate the impact of this programme, we conducted a prospective cohort study comparing treatment for HCV infection at the AUH with healthcare providers from different Argentinean provinces. A survey evaluating skills and competence in HCV care was administered, and results were compared. The primary endpoint was sustained virologic response (SVR) and under direct-acting antivirals. Since the implementation of ECHO clinics, a total of 25 physicians participated in at least one session (median 10.0; IQR 3.0-18.0). SVR rates (n = 437 patients) were 94.2% (95% CI 90.4-96.8) in patients treated at AUH clinic (n = 227/242) and 96.4% (95% CI 92.7-98.5) in those treated at ECHO sites (n = 188/195), with a nonsignificant difference between sites, 2.2% SVR difference (95% CI -0.24-0.06; P = 0.4). We also found a significant improvement in all the evaluated skills and abilities. Replicating the ECHO model helped to improve participants' skills in the management of HCV achieving similar SVR rates. ECHO model was demonstrated to be an effective intervention able to multiply and expand HCV treatment, a critical barrier to access to care that needs to be solved if we are committed with WHO goals to eliminate HCV by 2030.
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Affiliation(s)
- Manuel Mendizabal
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina
| | - Ezequiel Ridruejo
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina.,Hepatology Section, Department of Medicine, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | | | | | | | - Claudia Gadea
- Sanatorio Pasquini, San Miguel de Tucumán, Argentina
| | | | - Cristina Alonso
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina
| | - Ana Palazzo
- Hospital Padilla, San Miguel de Tucumán, Argentina
| | | | | | | | - Federico Piñero
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina
| | | | | | | | - Estela Manero
- Hospital Pablo Soria, San Salvador de Jujuy, Argentina
| | | | | | | | - José Vilar
- Asociación Argentina para el Estudio de las Enfermedades del Hígado, Corrientes, Argentina
| | | | | | - Martin O Flaherty
- Department of Public Health and Policy, University of Liverpool, Liverpool, UK
| | - Sanjeev Arora
- Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Marcelo Silva
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina
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Piñero F, Poniachik J, Ridruejo E, Silva M. Hepatocellular carcinoma in Latin America: Diagnosis and treatment challenges. World J Gastroenterol 2018; 24:4224-4229. [PMID: 30310255 PMCID: PMC6175763 DOI: 10.3748/wjg.v24.i37.4224] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/06/2018] [Accepted: 08/24/2018] [Indexed: 02/06/2023] Open
Abstract
Latin America, a region with a population greater than 600000000 individuals, is well known due to its wide geographic, socio-cultural and economic heterogeneity. Access to health care remains as the main barrier that challenges routine screening, early diagnosis and proper treatment of hepatocellular carcinoma (HCC). Therefore, identification of population at risk, implementation of surveillance programs and access to curative treatments has been poorly obtained in the region. Different retrospective cohort studies from the region have shown flaws in the implementation process of routine surveillance and early HCC diagnosis. Furthermore, adherence to clinical practice guidelines recommendations assessed in two studies from Brazil and Argentina demonstrated that there is also room for improvement in this field, similarly than the one observed in Europe and the United States. In summary, Latin America shares difficulties in HCC decision-making processes similar to those from developed countries. However, a transversal limitation in the region is the poor access to health care with the consequent limitation to standard treatments for overall population. Specifically, universal health care access to the different World Health Organization levels is crucial, including improvement in research, education and continuous medical training in order to expand knowledge and generation of data promoting a continuous improvement in the care of HCC patients.
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Affiliation(s)
- Federico Piñero
- Liver Unit, Hospital Universitario Austral, Facultad de Ciencias Biomédicas, Universidad Austral, Pilar, Buenos Aires B1629HJ, Argentina
- Latin American Liver Research Educational and Awareness Network, Buenos Aires B1629HJ, Argentina
| | - Jaime Poniachik
- Department of Gastroenterology and Hepatology, Hospital Clínico Universidad de Chile, Santiago de Chile, Región Metropolitana Santiago 46010, Chile
- Gastroenterology and Hepatology, Clínica Santa María, Santiago de Chile, Región Metropolitana Santiago 834-0518, Chile
| | - Ezequiel Ridruejo
- Liver Unit, Hospital Universitario Austral, Facultad de Ciencias Biomédicas, Universidad Austral, Pilar, Buenos Aires B1629HJ, Argentina
- Latin American Liver Research Educational and Awareness Network, Buenos Aires B1629HJ, Argentina
- Hepatology Section, Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno, Ciudad de Buenos Aires C1425ASG, Argentina
| | - Marcelo Silva
- Liver Unit, Hospital Universitario Austral, Facultad de Ciencias Biomédicas, Universidad Austral, Pilar, Buenos Aires B1629HJ, Argentina
- Latin American Liver Research Educational and Awareness Network, Buenos Aires B1629HJ, Argentina
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