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Campos-Varela I, Castells L, Quiroga S, Vargas V, Simon-Talero M. Frailty and sarcopenia in patients with acute-on-chronic liver failure: Assessment and risk in the liver transplant setting. Ann Hepatol 2024; 29:101515. [PMID: 38851394 DOI: 10.1016/j.aohep.2024.101515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/17/2023] [Accepted: 05/31/2024] [Indexed: 06/10/2024]
Abstract
Frailty and sarcopenia are well-recognized factors related to worse outcomes in patients with cirrhosis, including liver transplant (LT) candidates. Implications of pre-LT functional and muscle deterioration also affect post-LT outcomes. Patients with cirrhosis and acute-on-chronic liver failure (ACLF) have a lower survival rate, both before and after LT. There is a need to better identify those patients with ACLF who would benefit from LT. This review aims to present the available data about frailty and sarcopenia in patients with ACLF in the LT setting. An exhaustive review of the published literature was conducted. Data regarding frailty and sarcopenia in LT candidates with ACLF are scarce and heterogeneous. Studies evaluating frailty and sarcopenia in critically ill patients outside the liver literature are also presented in this review to enrich the knowledge of this field in expansion. Frailty and sarcopenia seem to contribute to worse outcomes in LT candidates with ACLF, both before and after LT. Sarcopenia evaluation may be the most prudent approach for those very sick patients. Skeletal muscle index assessed by computed tomography is recommended to evaluate sarcopenia. The role of muscle ultrasound and bioelectrical impedance analysis is to be determined. Frailty and sarcopenia are crucial factors to consider on a case-by-case basis in LT candidates with ACLF to improve patient outcomes.
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Affiliation(s)
- Isabel Campos-Varela
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
| | - Lluis Castells
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Sergi Quiroga
- Radiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Victor Vargas
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Macarena Simon-Talero
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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2
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Thuluvath AJ, Verna EC. Deciphering an expanding array of clinical and research frailty measures. Clin Liver Dis (Hoboken) 2024; 23:e0180. [PMID: 38872786 PMCID: PMC11168841 DOI: 10.1097/cld.0000000000000180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/01/2024] [Indexed: 06/15/2024] Open
Affiliation(s)
- Avesh J. Thuluvath
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Surgery, Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - Elizabeth C. Verna
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Surgery, Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
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3
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Desai AP, Parvataneni S, Knapp SM, Nephew LD, Chalasani N, Ghabril MS, Orman ES. Hospital frailty risk score is superior to legacy comorbidity indices for risk adjustment of in-hospital cirrhosis cases. JHEP Rep 2024; 6:100955. [PMID: 38192536 PMCID: PMC10772247 DOI: 10.1016/j.jhepr.2023.100955] [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: 09/20/2023] [Accepted: 10/17/2023] [Indexed: 01/10/2024] Open
Abstract
Background & Aims The hospital frailty risk score (HFRS) identifies older patients at risk of poor outcomes and may have value in cirrhosis. We compared the Charlson (CCI), Elixhauser (ECI), and cirrhosis (CirCom) comorbidity indices with the HFRS in predicting outcomes for cirrhosis hospitalisations. Methods Using the National Inpatient Sample (quarter 4 of 2015-2019), we analysed cirrhosis hospitalisations. For each index, we described the prevalence of comorbid conditions and inpatient mortality. We compared the ability of CCI, ECI, CirCom, and HFRS to predict inpatient mortality. Raw and adjusted models predicting inpatient mortality were compared using the area under the receiver operating characteristic curve and the Akaike information criterion. Results The cohort's (N = 626,553) median age was 61 years (IQR 52-68 years), 60% were male, cirrhosis was caused by alcohol in 43%, and 38% had ascites. The median comorbidity scores are as follows: ECI 4 (IQR 3-6), CCI 5 (IQR 4-8), and HFRS 5.6 (IQR 3.0-8.6). The most common CirCom score was 0 + 0 (44%). Across the range of values of each index, we observed different mortality ranges: CCI 1.9-13.1%, ECI 3.2-8.7%, CirCom 4.9-13.8%, and HFRS 1.0-15.2%. An adjusted model with HFRS had the highest area under the receiver operating characteristic curve in predicting mortality (HFRS 0.782 vs. ECI 0.689, CCI 0.695, and CirCom 0.692). We observed substantial variation in mortality with HFRS within each level of CCI, ECI, and CirCom. For example, for ECI 4, mortality increased from 0.6 to 16.4%, as HFRS increased from 0 to 15. Conclusions Comorbidity indices predict inpatient cirrhosis mortality, but HFRS performs better than CCI, ECI, and CirCom. HFRS is an ideal tool for measuring comorbidity burden and disease severity risk adjustment in cirrhosis-related administrative database studies. Impact and Implications We compared commonly used comorbidity indices to a more recently described risk score (hospital frailty risk score [HFRS]) in patients with cirrhosis using a national sample of hospital records. Comorbid conditions are common in hospitalised patients with cirrhosis. There is significant variability in mortality across the range of each index. HFRS outperforms the Charlson comorbidity index, Elixhauser comorbidity index, and CirCom (cirrhosis-specific comorbidity scoring system) in predicting inpatient mortality. HFRS is a valuable index for risk adjustment in inpatient administrative database studies.
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Affiliation(s)
- Archita P. Desai
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Swetha Parvataneni
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Shannon M. Knapp
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana University Simon Comprehensive Cancer Center, Indianapolis, IN, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana University Health, Indianapolis, IN, USA
| | - Marwan S. Ghabril
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eric S. Orman
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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Deng Y, Hui Y, Cui B, Xie W, Sun C. Accumulating awareness on the clinical significance and relevance of frailty in cirrhosis: Time to dig deeper into mechanistic basis! Liver Int 2023; 43:1629-1643. [PMID: 37288711 DOI: 10.1111/liv.15639] [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: 12/10/2022] [Revised: 04/03/2023] [Accepted: 05/25/2023] [Indexed: 06/09/2023]
Abstract
Frailty corresponds to an emerging construct in the hepatology which is originally introduced as a validated geriatric syndrome regarding increased vulnerability to pathophysiological stressors. As for patients with cirrhosis, the presence of frailty is indicative of debilitating conditions that subjects are prone to deleterious acute insults and have difficulties to restore even if the underlying liver function partially returned to normal levels. Since this conceptual development, a variety of tools assessing frailty have been proposed and evaluated in the context of cirrhosis. A recent performance-based metric for frailty, designated as Liver Frailty Index, has broadly been applied in patients with cirrhosis and exhibited acceptable predictive ability in relation to disease progression, mortality and hospitalization. However, those functional tests measuring frailty may be impossible to perform in circumstance that patients are critically ill or undergoing detrimental events. An interesting modality indicates the use of alternative tests to evaluate frailty, which may be more adaptable and of choice for specific subgroups. The interrelation between frailty and various cirrhosis-associated pathological entities is of clinical importance and implication. Noticeably, it is imperative to clarify these complex linkages to highlight novel therapeutic targets or interventional endpoints. The efficient and effective management of frailty is still challenging, but many attempts have been made to overcome barriers of affordability and availability. Some clinical trials on small scale revealed that home-based exercise and individualized nutrition therapy show benefits in patients with cirrhosis, and high adherence to the treatment regimen may direct better efficacy and performance.
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Affiliation(s)
- You Deng
- Center of Liver Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yangyang Hui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
| | - Binxin Cui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
| | - Wen Xie
- Center of Liver Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
- Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, Tianjin, China
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Moosavi SA, Mashhadiagha A, Taherifard E, Fallahzadeh MA, Motazedian N, Sayadi M, Azarpira N, Rahimi RS. Frailty as a predictor of poor outcomes among patients awaiting liver transplant: a systematic review and meta-analysis. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2023; 16:364-377. [PMID: 38313349 PMCID: PMC10835093 DOI: 10.22037/ghfbb.v16i4.2795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 02/07/2023] [Indexed: 02/06/2024]
Abstract
Aim This review sought to evaluate the significance of a functional assessment for liver transplant candidates, i.e., frailty, in the pre-transplant setting and its association with mortality and morbidities. Background Liver transplantation (LT) remains the treatment of choice for patients with end-stage liver disease. Due to the shortage of organs for LT, a careful selection of suitable recipients is essential. Frailty, a measure of physiologic reserve and increased vulnerability to stressors, was initially used in geriatrics and then introduced to the field of transplantation for better patient selection. Methods PubMed, Scopus, and Web of Science databases were reviewed up until January 2023. The search terms included: "frail*", "liver", and "transplant*". A Meta-analysis was conducted for the hazard ratios (HRs) obtained from the COX regression models. Fifty-five studies were included in this review; ten were included in the meta-analysis. Results The prevalence of frailty varied from 2.82% to 70.09% in the studies. Meta-analysis showed that overall frailty had a significant association with mortality (pooled adjusted HR [95%CI]: 2.66 [1.96-3.63]). Subgroup analyses revealed that both the Liver Frailty Index and Fried Frailty Index were significantly associated with mortality. Furthermore, these studies have demonstrated that this population's frailty is associated with ascites, hepatic encephalopathy, and esophageal varices. Conclusion According to emerging evidence, frailty is associated with increased morbidity and mortality of the patients on the LT waiting list. Further randomized trials are required to determine the efficacy and safety of variable interventions in the frail population.
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Affiliation(s)
- Seyed Ali Moosavi
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
- These authors contributed equally
| | - Amirali Mashhadiagha
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
- These authors contributed equally
| | - Erfan Taherifard
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Nasrin Motazedian
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehrab Sayadi
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Negar Azarpira
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Robert S Rahimi
- Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas, United States
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Li C, Zhao C, Yu Z, Yang W, Sun M, Li Y, Guo G, Hui Y, Wang X, Fan X, Wang B, Zhang J, Sun C. Low free triiodothyronine levels are associated with frail phenotype in hospitalized inpatients with cirrhosis. Postgrad Med 2022; 134:516-523. [PMID: 35382681 DOI: 10.1080/00325481.2022.2063487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Frailty is a prevalent complication predicting morbidity and mortality in cirrhosis. However, the association between thyroid hormone levels and frailty in cirrhotics remains elusive. Therefore we aimed to evaluate the relationship between thyroid hormone and frail phenotype in euthyroid patients with cirrhosis. METHODS A total of 214 adult cirrhotic inpatients were divided into two groups according to Frailty Index. Concentrations of free triiodothyronine (FT3), free thyroxine (FT4) and thyroid stimulating hormone (TSH) were compared. An analysis of the receiver operating characteristic (ROC) curve was implemented to determine the best cut-off for frailty. Multiple logistic regression was used to assess the association between FT3 and frailty. RESULTS ROC analysis indicated that the optimal cut-off to stratify frailty was FT3 <3.03 pmol/L with an area under the curve of 0.673 (95% CI: 0.582-0.764, p = 0.002), sensitivity of 81.8% and specificity of 51.9%. Patients with FT3 <3.03 pmol/L exhibited higher incidence of Child-Pugh class B/C, elevated model for end-stage liver disease score, higher creatinine, lower sodium as well as higher incidence of frailty (23.7 vs 6.0%, p < 0.001). A negative correlation was observed between FT3 values and Frailty Index (r = -0.220, p = 0.001). FT3 remained an independent risk factor for frailty after adjusting for age, Child-Pugh class, creatinine, sodium and alanine aminotransferase. CONCLUSION In our current study, FT3 <3.03 pmol/L were significantly associated with increased risk for frailty. Measuring FT3, a readily available biomarker, may be useful for identifying frail phenotype in euthyroid patients with cirrhosis.
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Affiliation(s)
- Chaoqun Li
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Department of Internal Medicine, Tianjin Hexi Hospital, Qiongzhou Road 43, Tianjin, Hexi District 300202, China
| | - Chunshan Zhao
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Zihan Yu
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Wanting Yang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Mingyu Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Yifan Li
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Gaoyue Guo
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Yangyang Hui
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Xiaoyu Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Xiaofei Fan
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Bangmao Wang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Jie Zhang
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China
| | - Chao Sun
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Tianjin Institute of Digestive Disease, Tianjin Medical University General Hospital, Anshan Road 154, Tianjin, Heping District 300052, China.,Department of Gastroenterology, Tianjin Medical University General Hospital Airport Hospital, East Street 6, Tianjin Airport Economic Area, Tianjin 300308, China
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Mahmud N, Goldberg DS, Bittermann T. Best Practices in Large Database Clinical Epidemiology Research in Hepatology: Barriers and Opportunities. Liver Transpl 2022; 28:113-122. [PMID: 34265178 PMCID: PMC8688188 DOI: 10.1002/lt.26231] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 06/10/2021] [Accepted: 06/27/2021] [Indexed: 01/03/2023]
Abstract
With advances in computing and information technology, large health care research databases are becoming increasingly accessible to investigators across the world. These rich, population-level data sources can serve many purposes, such as to generate "real-world evidence," to enhance disease phenotyping, or to identify unmet clinical needs, among others. This is of particular relevance to the study of patients with end-stage liver disease (ESLD), a socioeconomically and clinically heterogeneous population that is frequently under-represented in clinical trials. This review describes the recommended "best practices" in the execution, reporting, and interpretation of large database clinical epidemiology research in hepatology. The advantages and limitations of selected data sources are reviewed, as well as important concepts on data linkages. The appropriate classification of exposures and outcomes is addressed, and the strategies needed to overcome limitations of the data and minimize bias are explained as they pertain to patients with ESLD and/or liver transplantation (LT) recipients. Lastly, selected statistical concepts are reviewed, from model building to analytic decision making and hypothesis testing. The purpose of this review is to provide the practical insights and knowledge needed to ensure successful and impactful research using large clinical databases in the modern era and advance the study of ESLD and LT.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL
| | - Therese Bittermann
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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