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Verma N, Mehtani R, Haiar JM, Pradhan P, Duseja A, Im GY, Singal AK. Clinical criteria accurately diagnose severe but not moderate alcohol-associated hepatitis: A systematic review and meta-analysis. Hepatol Commun 2024; 8:e0404. [PMID: 38497934 PMCID: PMC10948131 DOI: 10.1097/hc9.0000000000000404] [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: 11/28/2023] [Accepted: 12/14/2023] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND The precision of clinical criteria and the utility of liver biopsy for diagnosis or prognosis remain unclear in patients with alcohol-associated hepatitis (AH). We systematically reviewed the literature to answer these questions. METHODS Four databases were searched for studies describing the precision of clinical criteria (National Institute on Alcohol Abuse and Alcoholism, European Association for Study of Liver, or classical) and the role of histology in AH. The precision(positive predictive value) of criteria was pooled through random-effects meta-analysis, and its variation was investigated through subgroups and meta-regression of study-level factors with their percent contribution to variation (R2). The risk of bias among studies was evaluated through the QUADAS2 tool (PROSPERO-ID-CRD4203457250). RESULTS Of 4320 studies, 18 in the systematic review and 15 (10/5: low/high risk of bias, N=1639) were included in the meta-analysis. The pooled precision of clinical criteria was 80.2% (95% CI: 69.7-89.7, I2:93%, p < 0.01), higher in studies with severe AH (mean-Model for End-Stage Liver Disease > 20) versus moderate AH (mean-Model for End-Stage Liver Disease < 20): 92% versus 67.1%, p < 0.01, and in studies with serum bilirubin cutoff 5 versus 3 mg/dL (88.5% vs.78.8%, p = 0.01). The factors contributing to variation in precision were Model for End-Stage Liver Disease (R2:72.7%), upper gastrointestinal bleed (R2:56.3%), aspartate aminotransferase:aspartate aminotransferase ratio (R2:100%), clinical criteria (R2:40.9%), bilirubin (R2:22.5%), and Mallory body on histology (R2:19.1%).The net inter-pathologist agreement for histologic findings of AH was variable (0.33-0.97), best among 2 studies describing AH through simple and uniform criteria, including steatosis, ballooning, and neutrophilic inflammation. Few studies reported the utility of histology in estimating steroid responsiveness (N = 1) and patient prognosis (N = 4); however, very broad septa, pericellular fibrosis, and cholestasis were associated with mortality. Bilirubinostasis was associated with infection in 1 study. CONCLUSIONS Clinical criteria are reasonably precise for diagnosing severe AH, while there is an unmet need for better criteria for diagnosing moderate AH. Histologic diagnosis of AH should be simple and uniform.
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Affiliation(s)
- Nipun Verma
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rohit Mehtani
- Department of Hepatology, Amrita Institute of Medical Sciences and Research, Faridabad, Haryana, India
| | - Jacob Martin Haiar
- Department of Internal Medicine, University of California, San Diego, California, USA
| | - Pranita Pradhan
- Department of Pediatrics, Indian Council of Medical Research Center for Evidence-Based Child Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gene Young Im
- Department of Medicine, Division of Liver Diseases, Recanati/Miller Transplantation Institute, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ashwani K. Singal
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Louisville School of Medicine, Louisville, Kentucky, USA
- Department of Medicine, Jewish Hospital and Trager Transplant Center, Louisville, Kentucky, USA
- Department of Medicine, VA Medical Center Sioux Falls, South Dakota, USA
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Hardesty J, Hawthorne M, Day L, Warner J, Warner D, Gritsenko M, Asghar A, Stolz A, Morgan T, McClain C, Jacobs J, Kirpich IA. Steroid responsiveness in alcohol-associated hepatitis is linked to glucocorticoid metabolism, mitochondrial repair, and heat shock proteins. Hepatol Commun 2024; 8:e0393. [PMID: 38437061 PMCID: PMC10914234 DOI: 10.1097/hc9.0000000000000393] [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: 08/01/2023] [Accepted: 12/15/2023] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Alcohol-associated hepatitis (AH) is one of the clinical presentations of alcohol-associated liver disease. AH has poor prognosis, and corticosteroids remain the mainstay of drug therapy. However, ~40% of patients do not respond to this treatment, and the mechanisms underlying the altered response to corticosteroids are not understood. The current study aimed to identify changes in hepatic protein expression associated with responsiveness to corticosteroids and prognosis in patients with AH. METHODS Patients with AH were enrolled based on the National Institute on Alcohol Abuse and Alcoholism inclusion criteria for acute AH and further confirmed by a diagnostic liver biopsy. Proteomic analysis was conducted on liver samples acquired from patients with AH grouped as nonresponders (AH-NR, n = 7) and responders (AH-R, n = 14) to corticosteroids, and nonalcohol-associated liver disease controls (n = 10). The definition of responders was based on the clinical prognostic model, the Lille Score, where a score < 0.45 classified patients as AH-R and a score > 0.45 as AH-NR. Primary outcomes used to assess steroid response were Lille Score (eg, improved liver function) and survival at 24 weeks. RESULTS Reduced levels of the glucocorticoid receptor and its transcriptional co-activator, glucocorticoid modulatory element-binding protein 2, were observed in the hepatic proteome of AH-NR versus AH-R. The corticosteroid metabolizing enzyme, 11-beta-hydroxysteroid dehydrogenase 1, was increased in AH-NR versus AH-R along with elevated mitochondrial DNA repair enzymes, while several proteins of the heat shock pathway were reduced. Analysis of differentially expressed proteins in AH-NR who survived 24 weeks relative to AH-NR nonsurvivors revealed several protein expression changes, including increased levels of acute phase proteins, elevated coagulation factors, and reduced mast cell markers. CONCLUSIONS This study identified hepatic proteomic changes that may predict responsiveness to corticosteroids and mortality in patients with AH.
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Affiliation(s)
- Josiah Hardesty
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Meghan Hawthorne
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
| | - Le Day
- Department of Biological Sciences, Biological Sciences Division and Environmental Molecular Sciences Laboratory, Pacific Northwest National Laboratory, Richland, Washington, USA
| | - Jeffrey Warner
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Dennis Warner
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
| | - Marina Gritsenko
- Department of Biological Sciences, Biological Sciences Division and Environmental Molecular Sciences Laboratory, Pacific Northwest National Laboratory, Richland, Washington, USA
| | - Aliya Asghar
- Department of Medicine and Research Services, Medicine and Research Services, VA Long Beach Healthcare System, Long Beach, California, USA
| | - Andrew Stolz
- Department of Medicine, Division of Gastrointestinal and Liver Disease, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Timothy Morgan
- Department of Medicine and Research Services, Medicine and Research Services, VA Long Beach Healthcare System, Long Beach, California, USA
| | - Craig McClain
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, Kentucky, USA
- Robley Rex Veterans Medical Center, Louisville, Kentucky, USA
- Department of Medicine, University of Louisville Alcohol Center, University of Louisville School of Medicine, Louisville, Kentucky, USA
- Department of Medicine, University of Louisville Hepatobiology and Toxicology Center, University of Louisville School of Medicine, Louisville, Kentucky USA
| | - Jon Jacobs
- Department of Biological Sciences, Biological Sciences Division and Environmental Molecular Sciences Laboratory, Pacific Northwest National Laboratory, Richland, Washington, USA
| | - Irina A. Kirpich
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, Kentucky, USA
- Department of Medicine, University of Louisville Alcohol Center, University of Louisville School of Medicine, Louisville, Kentucky, USA
- Department of Medicine, University of Louisville Hepatobiology and Toxicology Center, University of Louisville School of Medicine, Louisville, Kentucky USA
- Department of Microbiology and Immunology, University of Louisville School of Medicine, Louisville, KY, USA
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Bedair AF, Wahid A, El-Mezayen NS, El-Yazbi AF, Khalil HA, Hassan NW, Afify EA. Nicorandil/ morphine crosstalk accounts for antinociception and hepatoprotection in hepatic fibrosis in rats: Distinct roles of opioid/cGMP and NO/KATP pathways. Biomed Pharmacother 2023; 165:115068. [PMID: 37392650 DOI: 10.1016/j.biopha.2023.115068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 07/03/2023] Open
Abstract
Previous report indicated that nicorandil potentiated morphine antinociception and attenuated hepatic injury in liver fibrotic rats. Herein, the underlying mechanisms of nicorandil/morphine interaction were investigated using pharmacological, biochemical, histopathological, and molecular docking studies. Male Wistar rats were injected intraperitoneally (i.p.) with carbon tetrachloride (CCl4, 40%, 2 ml/kg) twice weekly for 5 weeks to induce hepatic fibrosis. Nicorandil (15 mg/kg/day) was administered per os (p.o.) for 14 days in presence of the blockers; glibenclamide (KATP channel blocker, 5 mg/kg, p.o.), L-NG-nitro-arginine methyl ester (L-NAME, nitric oxide synthase inhibitor, 15 mg/kg, p.o.), methylene blue (MB, guanylyl cyclase inhibitor, 2 mg/kg, i.p.) and naltrexone (opioid antagonist, 20 mg/kg, i.p.). At the end of the 5th week, analgesia was evaluated using tail flick and formalin tests along with biochemical determinations of liver function tests, oxidative stress markers and histopathological examination of liver tissues. Naltrexone and MB inhibited the antinociceptive activity of the combination. Furthermore, combined nicorandil/morphine regimen attenuated the release of endogenous peptides. Docking studies revealed a possible interaction of nicorandil on µ, κ and δ opioid receptors. Nicorandil/morphine combination protected against liver damage as evident by decreased liver enzymes, liver index, hyaluronic acid, lipid peroxidation, fibrotic insults, and increased superoxide dismutase activity. Nicorandil/morphine hepatoprotection and antioxidant activity were inhibited by glibenclamide and L-NAME but not by naltrexone or MB. These findings implicate opioid activation/cGMP versus NO/KATP channels in the augmented antinociception, and hepatoprotection, respectively, of the combined therapy and implicate provoked cross talk by nicorandil and morphine on opioid receptors and cGMP signaling pathway. That said, nicorandil/morphine combination provides a potential multitargeted therapy to alleviate pain and preserve liver function.
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Affiliation(s)
- Asser F Bedair
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, University of Alexandria, Alexandria, Egypt
| | - Ahmed Wahid
- Department of Pharmaceutical Biochemistry, Faculty of Pharmacy, University of Alexandria, Alexandria, Egypt
| | - Nesrine S El-Mezayen
- Department of Pharmacology, Faculty of Pharmacy, Pharos University in Alexandria, Alexandria, Egypt
| | - Amira F El-Yazbi
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, University of Alexandria, Alexandria, Egypt
| | - Hadeel A Khalil
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, University of Alexandria, Alexandria, Egypt
| | - Nayera W Hassan
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, University of Alexandria, Alexandria, Egypt
| | - Elham A Afify
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, University of Alexandria, Alexandria, Egypt.
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Bedair AF, Wahid A, El-Mezayen NS, Afify EA. Nicorandil reduces morphine withdrawal symptoms, potentiates morphine antinociception, and ameliorates liver fibrosis in rats. Life Sci 2023; 319:121522. [PMID: 36822314 DOI: 10.1016/j.lfs.2023.121522] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 02/01/2023] [Accepted: 02/17/2023] [Indexed: 02/25/2023]
Abstract
AIMS Chronic liver disease (CLD) is a serious medical condition affecting patients globally and pain management poses a unique challenge. ATP-sensitive potassium channels (KATP) are expressed in nociceptive neurons and hepatic cells. We tested the hypothesis whether morphine and nicorandil, KATP channel opener, alone and in combination possess hepatoprotective, antinociceptive effect and alter morphine physical dependence. MAIN METHODS Intraperitoneal injection (i.p.) of carbon tetrachloride (CCl4) induced liver fibrosis in male Wistar rats. Nicorandil (15 mg/kg/day) was administered per os for two weeks. Morphine (3.8, 5, 10 mg/kg, i.p.) was administered prior to antinociception testing in tail flick and formalin tests. Morphine physical dependence following naloxone injection, fibrotic, oxidative stress markers, and liver histopathology were assessed. KEY FINDINGS Morphine alone, produced insignificant changes of serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), hyaluronic acid (HA), hepatic hydroxyproline (Hyp), malondialdehyde (MDA), and superoxide dismutase (SOD) levels and exerted significant antinociception in the pain models. Nicorandil alone protected against liver damage (decreased serum ALT, AST, HA, hepatic Hyp, MDA, increased SOD levels, improved fibrosis scores). Nicorandil/morphine combination produced remarkable hepatoprotection and persistent analgesia compared to morphine alone as evidenced by reduced (EC50) of morphine. Nicorandil augmented morphine analgesia and markedly decreased withdrawal signs in morphine-dependent rats. SIGNIFICANCE The data showed for the first time, the hepatoprotection and augmented antinociception mediated by nicorandil/morphine combination in liver fibrosis via antioxidant and antifibrotic mechanisms. Nicorandil ameliorated withdrawal signs in morphine dependence in CLD. Thus, combining nicorandil/morphine provides a novel treatment strategy to ameliorate hepatic injury, potentiate antinociception and overcome morphine-induced physical dependence in liver fibrosis.
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Affiliation(s)
- Asser F Bedair
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, University of Alexandria, Alexandria, Egypt.
| | - Ahmed Wahid
- Department of Pharmaceutical Biochemistry, Faculty of Pharmacy, University of Alexandria, Alexandria, Egypt.
| | - Nesrine S El-Mezayen
- Department of Pharmacology, Faculty of Pharmacy, Pharos University in Alexandria, Alexandria, Egypt.
| | - Elham A Afify
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, University of Alexandria, Alexandria, Egypt.
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Sharma M, Lakhtakia S, Jagtap N, Sekaran A, Kalapala R, Jahangeer B, Kulkarni A, Ramchandani M, Gupta R, Samudraala S, Khanna J, Nagaraja P, Iyengar S, Gora BA, Rao GV, Reddy N. EUS-guided left lobe liver biopsy: Safer modality with similar diagnostic yield as right lobe: a pilot study. Endosc Int Open 2023; 11:E172-E178. [PMID: 36845273 PMCID: PMC9949974 DOI: 10.1055/a-1978-6652] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/28/2022] [Indexed: 11/17/2022] Open
Abstract
Background and study aims Percutaneous liver biopsy is traditionally done on the right lobe of the liver. Endoscopic ultrasound-guided liver biopsy (EUS-LB) can be performed on either the left or right lobe or as a combined bi-lobar biopsy. Earlier studies did not compare the benefit of bi-lobar biopsies to single-lobe biopsy for reaching a tissue diagnosis. The current study compared the degree of agreement of pathological diagnosis between the left lobe of the liver compared to right-lobe and with bi-lobar biopsy. Patients and methods Fifty patients fulfilling the inclusion criteria were enrolled in the study. EUS-LB with a 22G core needle was performed separately on both the liver lobes. Three pathologists, who were blinded to the site of biopsy independently reviewed the liver biopsies. Sample adequacy, safety, and concordance of pathological diagnosis between left- and right-lobe biopsy of the liver were analyzed. Results The pathological diagnosis was made in 96 % of patients. Specimen lengths from the left lobe and the right lobe were 2.31 ± 0.57 cm and 2.28 ± 0.69 cm, respectively ( P = 0.476). The respective number of portal tracts were 11.84 ± 6.71 versus 9.58 ± 7.14; P = 0.106. Diagnosis between the two lobes showed substantial (κ = 0.830) concordance. Left-lobe (κ value 0.878) and right-lobe (κ = 0.903) biopsies showed no difference when compared with bi-lobar biopsies. Adverse events were observed in two patients, both of whom had biopsies of the right lobe. Conclusions EUS-guided left-lobe liver biopsy is safer than right-lobe biopsy with similar diagnostic yield.
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Affiliation(s)
- Mithun Sharma
- Asian Institute of Gastroenterology – Surgical Gastroenterology, Hyderabad, Telangana, India
| | - Sundeep Lakhtakia
- Asian Institute of Gastroenterology – Surgical Gastroenterology, Hyderabad, Telangana, India
| | - Nitin Jagtap
- Asian Institute of Gastroenterology – Surgical Gastroenterology, Hyderabad, Telangana, India
| | - Anuradha Sekaran
- Asian Institute of Gastroenterology – Surgical Gastroenterology, Hyderabad, Telangana, India
| | - Rakesh Kalapala
- Asian Institute of Gastroenterology – Surgical Gastroenterology, Hyderabad, Telangana, India
| | - Basha Jahangeer
- Asian Institute of Gastroenterology – Surgical Gastroenterology, Hyderabad, Telangana, India
| | - Anand Kulkarni
- Asian Institute of Gastroenterology – Surgical Gastroenterology, Hyderabad, Telangana, India
| | - Mohan Ramchandani
- Asian Institute of Gastroenterology – Surgical Gastroenterology, Hyderabad, Telangana, India
| | - Rajesh Gupta
- Asian Institute of Gastroenterology – Surgical Gastroenterology, Hyderabad, Telangana, India
| | - Swapna Samudraala
- Asian Institute of Gastroenterology – Surgical Gastroenterology, Hyderabad, Telangana, India
| | - Juhi Khanna
- Asian Institute of Gastroenterology – Surgical Gastroenterology, Hyderabad, Telangana, India
| | - Padaki Nagaraja
- Asian Institute of Gastroenterology – Surgical Gastroenterology, Hyderabad, Telangana, India
| | - Sowmya Iyengar
- Asian Institute of Gastroenterology – Surgical Gastroenterology, Hyderabad, Telangana, India
| | - Baker Ali Gora
- Asian Institute of Gastroenterology – Surgical Gastroenterology, Hyderabad, Telangana, India
| | - Guduru Venkat Rao
- Asian Institute of Gastroenterology – Surgical Gastroenterology, Hyderabad, Telangana, India
| | - Nageshwar Reddy
- Asian Institute of Gastroenterology – Surgical Gastroenterology, Hyderabad, Telangana, India
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Singh SP, Mishra AK, Jindal A. Letter to the editor: IL-1 receptor antagonist plus pentoxifylline and zinc for severe alcoholic hepatitis-More questions than answers! Hepatology 2022; 76:E112-E113. [PMID: 35776666 DOI: 10.1002/hep.32648] [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: 04/15/2022] [Accepted: 04/15/2022] [Indexed: 12/08/2022]
Affiliation(s)
- Satender Pal Singh
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ajay Kumar Mishra
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Jophlin L, Singal AK. Liver Biopsy in Patients With Alcohol-Associated Liver Disease With Acute-on-Chronic Liver Failure. J Clin Exp Hepatol 2022; 12:544-550. [PMID: 35535109 PMCID: PMC9077173 DOI: 10.1016/j.jceh.2021.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/09/2021] [Indexed: 01/11/2023] Open
Abstract
Patients with alcohol-associated liver disease may develop severe forms of presentation of acute-on-chronic liver failure, with a high risk for short-term mortality. Alcoholic hepatitis should be suspected among patients with alcohol-associated liver disease who present with acute-on-chronic liver failure. In this review, we discuss the need and feasibility of liver biopsy in the diagnosis of alcoholic hepatitis and predicting its prognosis among decompensated patients with alcohol-associated liver disease and acute-on-chronic liver failure.
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Key Words
- AARC, Asia-Pacific ACLF Research Consortium
- ACLF
- ACLF, acute-on-chronic liver failure
- AH
- AH, alcoholic hepatitis
- AHHS, alcoholic hepatitis histologic score
- ALD
- ALD, alcohol-associated liver disease
- AUD, alcohol use disorder
- DF, discriminant function
- EUS, endoscopic ultrasound
- EtG, ethyl glucuronide
- NIAAA, National Institute on Alcoholism and Alcohol Abuse
- PEth, phosphatidylethanol
- SALVE, Study of Alcohol-related LiVer disease in Europe
- histology
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Affiliation(s)
- Loretta Jophlin
- Department of Gastroenterology and Hepatology, University of Louisville, Louisville, KY, USA
| | - Ashwani K. Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of South Dakota Sanford School of Medicine, South Dakota, USA,Address for correspondence:. Ashwani K. Singal, Professor of Medicine, University of South Dakota Sanford School of Medicine, Transplant Hepatologist and Chief Clinical Research Affairs, Avera McKennan University Hospital Transplant Institute, Sioux Falls, SD, 57105, USA. Tel.: +605 322-8545; fax: +605 322 8536.
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Arab JP, Arrese M, Singal AK. Diagnosis of Alcohol-Associated Hepatitis: When Is Liver Biopsy Required? Clin Liver Dis 2021; 25:571-584. [PMID: 34229840 DOI: 10.1016/j.cld.2021.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Alcohol-associated hepatitis (AH) is a unique clinical syndrome in patients with excessive and prolonged alcohol consumption, and negatively impacts the patient outcomes. Among patients with asymptomatic alcohol-associated liver disease with elevated liver enzymes and/or steatosis, liver biopsy is required to diagnose AH. Noninvasive assessment should be performed in these patients to determine risk of advanced fibrosis. In symptomatic patients with jaundice, liver biopsy is required when the clinical diagnosis is uncertain. Liver biopsy is not recommended to determine prognosis of patients with AH. Noninvasive biomarkers are emerging for diagnosis of and determining prognosis of patients with AH.
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Affiliation(s)
- Juan Pablo Arab
- Department of Gastroenterology and Hepatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Av Libertador Bernardo O'Higgins 340, Santiago, Región Metropolitana, Chile; Departamento de Biología Celular y Molecular, Centro de Envejecimiento y Regeneración (CARE), Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marco Arrese
- Department of Gastroenterology and Hepatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Av Libertador Bernardo O'Higgins 340, Santiago, Región Metropolitana, Chile; Departamento de Biología Celular y Molecular, Centro de Envejecimiento y Regeneración (CARE), Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ashwani K Singal
- University of South Dakota Sanford School of Medicine, McKennan University Hospital Transplant Institute, Cliff Ave., Sioux Falls, SD 57105, USA.
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Rastogi A, Patil N, Maiwall R, Bihari C, Soshee A, Sarin SK. Second-harmonic generation (SHG) microscopy and hepatic venous pressure gradient-based validation of a novel histological staging system for alcoholic hepatitis. Virchows Arch 2021; 479:493-506. [PMID: 33797570 DOI: 10.1007/s00428-021-03089-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 03/06/2021] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Abstract
Alcoholic hepatitis (AH) lacks specific histological staging. A novel fibrosis staging that encompasses perisinusoidal fibrosis and cirrhosis sub-stages, substantiated by Hepatic venous pressure gradient (HVPG) and automated fibrosis quantification, is imperative. To correlate novel histological staging system of AH with second-harmonic generation microscopy (SHG)-based q-fibrosis, HVPG, and activated hepatic stellate cells (HSCs). Liver biopsies of AH (n = 175) were staged semi-quantitatively as F0, F1, F2, F3A and F3B and Laennec substages of cirrhosis 4A, 4B and 4C. Stages were correlated with SHG q-fibrosis parameters, HVPG and HSCs. Mean age 41.2 ± 9.4 years, 96.6% males, bilirubin 20.58 ± 8.0 mg/dl and Maddrey's discriminant function 78.9 ± 36.7 displayed advanced fibrosis in 98.6%. With increasing histological stages, an increase in q-fibrosis indices and mean HVPG (p < 0.0001) were recorded; stage 4C showed the most significant difference from other stages (p < 0.000). Stages 3A and 3B were comparable with the stages 4A and 4B, respectively, for q-fibrosis (p = 1) and HVPG (p = 1). HSCs (> 30%) were significantly higher in stage 3 (75%) compared with 4 (49%) and 2 (59%), p = 0.018. Overall agreement for histological staging was excellent for all stages (0.82). SHG quantified fibrosis and HVPG corroborates the novel histological staging of AH. Expansive PCF matches with collagen content and clinical severity to early sub-stages of cirrhosis. This highlights the need for an accurate quantification and inclusion of PCF as a separate stage. SHG-based quantification can be a useful adjunct to histological fibrosis staging systems.
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Affiliation(s)
- Archana Rastogi
- Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, Delhi, 110070, India.
| | - Nayana Patil
- Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, Delhi, 110070, India
| | - Rakhi Maiwall
- Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, Delhi, 110070, India
| | - Chhagan Bihari
- Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, Delhi, 110070, India
| | - Ananda Soshee
- Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, Delhi, 110070, India
| | - Shiv K Sarin
- Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, Delhi, 110070, India
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Sarin SK, Sharma S. Predictors of steroid non-response and new approaches in severe alcoholic hepatitis. Clin Mol Hepatol 2020; 26:639-651. [PMID: 33053936 PMCID: PMC7641572 DOI: 10.3350/cmh.2020.0196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/14/2020] [Accepted: 08/21/2020] [Indexed: 12/15/2022] Open
Abstract
Severe alcoholic hepatitis (SAH) remains a disease with high mortality. Steroid is the main stay and has been shown to give modest 28-day survival benefit in carefully selected patients, but no 90-day survival benefit. Since non-responders have high incidence of infections and increased mortality, it would be worthwhile to identify them before starting steroid therapy. A high and rising bilirubin, urinary acetyl carnitine >2,500 ng/mL, high asiloglycoprotein positive microparticles, and specific features in liver biopsy could predict steroid non-response at baseline. There is an ever-growing need to find new and effective therapies for SAH patients. Besides aggressive nutrition, granulocyte colony stimulating factor, fecal microbiota transplantation, and plasma exchange appear promising therapies and provide a hope for steroid ineligible or steroid non-responsive patients. Suppression of hepatic inflammation, preventing new bacterial or fungal infections, and enhancing liver regeneration will remain the key targets for next generation therapies.
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Affiliation(s)
- Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shvetank Sharma
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
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Premkumar M, Bihari C, Saxena P, Devurgowda DR, Vyas T, Mirza R, Jain P, Kumar G, Bhatia P, Baweja S, Choudhury A, Sarin SK. Heparin-like Effect Associated With Risk of Bleeding, Sepsis, and Death in Patients With Severe Alcohol-Associated Hepatitis. Clin Gastroenterol Hepatol 2020; 18:486-495.e3. [PMID: 31077821 DOI: 10.1016/j.cgh.2019.04.057] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 03/04/2019] [Accepted: 04/26/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endogenous heparinoids or heparin-like effects (HLEs) can cause coagulation failure in patients with cirrhosis and sepsis. We performed a prospective study of the association between HLE and bleeding events, sepsis, and outcomes of patients with severe alcohol-associated hepatitis. METHODS Our final analysis comprised 78 patients with severe alcohol-associated hepatitis (44.3 ± 11.7 years; all male; discriminant function >32) who presented without sepsis at a single center in India from August 2015 through August 2016. Blood samples were collected at days 0, 3, and 7 after presentation and assessed by a global coagulation assay; by SONOCLOT (global and heparinase treated); and in assays for factor VIII, von Willebrand factor, protein C, and antithrombin. Patients were followed for sepsis, bleeding and outcome. The primary outcome was association of HLE with survival 28 days after presentation. RESULTS HLEs were observed in 32 patients (41%) at day 0, 27 patients (34.6%) at day 3, and 28 patients (35.9%) patients at day 7. Factors associated with mortality at day 0 were factor VIII activity >160% (hazard ratio [HR], 3.1; 95% CI, 1.4-9.5; P = .026), level of protein C <34% (HR, 0.7; 95% CI, 0.5-0.8; P = .037), antithrombin activity <28% (HR, 0.7; 95% CI, 0.3-1.1; P = .008) and international normalized ratio >2.6 (HR, 2.3; 95% CI, 1.8-9.7; P = .010). In multivariate analyses, only factor VIII activity (HR, 2.3; 95% CI, 1.6-7.8; P = .046), international normalized ratio (1.9; 95% CI, 1.2-4.3; P = .039), level of protein C (HR, 0.9; 95% CI, 0.7-1.1; P = .052) and model for end-stage liver disease score (HR, 3.2; 95% CI, 1.9-10.2; P = .042) were associated with mortality. Episodes of epistaxis, hemorrhoid bleeding, hemoperitoneum, and pulmonary hemorrhage occurred in 10.2%, 12.3%, 3.4%, and 4.5% of patients respectively. The presence of HLE at day 0 increased the risk of sepsis (HR, 2.5; 95% CI, 2.2-4.3; P = .002), bleeding (HR, 1.4; 95% CI, 1.2-5.3; P = .004) and death (HR, 1.2; 95% CI, 1.4-1.7; P = .044). CONCLUSIONS In a prospective study of patients with severe alcohol-associated hepatitis, we associated HLE with coagulation abnormalities, risk of sepsis, and mortality. Clinicaltrials.govNCT02307409.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chhagan Bihari
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Priyanka Saxena
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Tanmay Vyas
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Roshni Mirza
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Priyanka Jain
- Department of Epidemiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Epidemiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Puja Bhatia
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sukriti Baweja
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
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12
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Identification of key genes, MicroRNAs and potentially regulated pathways in alcoholic hepatitis by integrative analysis. Gene 2019; 720:144035. [DOI: 10.1016/j.gene.2019.144035] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 07/29/2019] [Accepted: 07/31/2019] [Indexed: 12/25/2022]
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13
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Shasthry SM, Sharma MK, Shasthry V, Pande A, Sarin SK. Efficacy of Granulocyte Colony-stimulating Factor in the Management of Steroid-Nonresponsive Severe Alcoholic Hepatitis: A Double-Blind Randomized Controlled Trial. Hepatology 2019; 70:802-811. [PMID: 30664267 DOI: 10.1002/hep.30516] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 01/15/2019] [Indexed: 12/17/2022]
Abstract
Severe alcoholic hepatitis (SAH) is often a progressive disease with high mortality and limited steroid responsiveness. Management options of steroid nonresponsive SAH (day 7 Lille score > 0.45) are limited. We assessed the efficacy and safety of granulocyte colony-stimulating factor (G-CSF) in steroid nonresponders. A randomized, double-blind, single-center trial (NCT01820208) was conducted between March 2013 and June 2016 in patients with histologically proven SAH, nonresponsive to 40 mg/day of prednisolone were randomized to G-CSF (12 doses, 300 μg each in 28 days) or placebo. Responders were continued with prednisolone. Of the 430 patients with SAH, 132 received steroid therapy. Of these, 33 (25%) were nonresponders and were randomized to G-CSF or placebo (14 in each group after exclusions). The baseline characteristics of both groups were comparable. The 28-day mortality was comparable between the groups (21.4%, G-CSF; 28.6%, placebo; P = 0.69). At 90 days, in the G-CSF but not in the placebo group, the Model for End-Stage Liver Disease reduced from 24.6 ± 3.9 to 19.4 ± 3.7 (P = 0.002) and Maddrey's discriminant function from 74.8 ± 22.8 to 57.4 ± 31 (P = 0.26). Infections were less common (28% versus 71%; P < 0.001) with lower 90-day mortality (35.7% versus 71.4%; P = 0.04) in the G-CSF than in the placebo group. On Cox regression analysis, receiving G-CSF (hazard ratio, 0.37; SD, 0.14-0.98; P = 0.04), and high baseline serum creatinine (hazard ratio, 4.12; SD, 1.7-10.3; P = 0.002) predicted day-90 outcomes in steroid nonresponsive SAH. Patients tolerated G-CSF without any major adverse events. Conclusion: Approximately one-quarter of patients with SAH do not respond to corticosteroid therapy. Administration of G-CSF is safe and helps to reduce the disease severity and 90-day mortality in these patients.
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Affiliation(s)
| | - Manoj Kumar Sharma
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Varsha Shasthry
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Apurva Pande
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
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Forrest EH, Storey N, Sinha R, Atkinson SR, Vergis N, Richardson P, Masson S, Ryder S, Thursz MR, Allison M, Fraser A, Austin A, McCune A, Dhanda A, Katarey D, Potts J, Verma S, Parker R, Hayes PC. Baseline neutrophil-to-lymphocyte ratio predicts response to corticosteroids and is associated with infection and renal dysfunction in alcoholic hepatitis. Aliment Pharmacol Ther 2019; 50:442-453. [PMID: 31313853 DOI: 10.1111/apt.15335] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 03/13/2019] [Accepted: 05/14/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Treating severe alcoholic hepatitis involves the exposure of patients to corticosteroids for 7 days to assess "response". AIM To assess the prognostic and therapeutic implications of baseline neutrophil-to-lymphocyte ratio (NLR) in patients with severe alcoholic hepatitis. METHODS Patients recruited to the STOPAH trial and an independent validation group were analysed retrospectively. Area under the receiver operating curve (AUC) analysis was performed. Kaplan-Meier analysis was used to assess survival. Log-rank test and odds ratio (OR) were used for comparative analysis. RESULTS Baseline NLR was available for 789 STOPAH patients. The AUC for NLR was modest for 90-day outcome (0.660), but was associated with infection, acute kidney injury (AKI) and severity of alcoholic hepatitis. Ninety-day survival was not affected by prednisolone treatment if NLR < 5 or > 8 but mortality was reduced with prednisolone treatment when the NLR was 5-8 (21.0% cf. 34.5%; P = 0.012). Prednisolone treatment increased the chance of Lille response if the NLR was ≥ 5 (56.5% cf. 41.1%: P = 0.01; OR 1.86) but increased the risk of day 7 infection (17.3% cf. 7.4%: P = 0.006; OR 2.60) and AKI (20.8% cf. 7.0%: P = 0.008; OR 3.46) if the NLR was > 8. Incorporation of NLR into a modified Glasgow alcoholic hepatitis score (mGAHS) improved the AUC to 0.783 and 0.739 for 28-day and 90-day outcome, respectively. CONCLUSION The NLR is associated with AKI and infection in severe alcoholic hepatitis. The NLR identifies those most likely to benefit from corticosteroids at baseline (NLR 5-8). The mGAHS has a good predictive value for 28- and 90-day outcomes.
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Nunes Dos Santos K, Florentino RM, França A, Lima Filho ACM, Santos MLD, Missiaggia D, Fonseca MDC, Brasil Costa I, Vidigal PVT, Nathanson MH, Lemos FDO, Leite MF. Polymorphism in the Promoter Region of NFE2L2 Gene Is a Genetic Marker of Susceptibility to Cirrhosis Associated with Alcohol Abuse. Int J Mol Sci 2019; 20:E3589. [PMID: 31340446 PMCID: PMC6678089 DOI: 10.3390/ijms20143589] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/12/2019] [Accepted: 07/15/2019] [Indexed: 12/12/2022] Open
Abstract
Alcoholic liver disease (ALD) is a highly prevalent spectrum of pathologies caused by alcohol overconsumption. Morbidity and mortality related to ALD are increasing worldwide, thereby demanding strategies for early diagnosis and detection of ALD predisposition. A potential candidate as a marker for ALD susceptibility is the transcription factor nuclear factor erythroid-related factor 2 (Nrf2), codified by the nuclear factor erythroid 2-related factor 2 gene (NFE2L2). Nrf2 regulates expression of proteins that protect against oxidative stress and inflammation caused by alcohol overconsumption. Here, we assessed genetic variants of NFE2L2 for association with ALD. Specimens from patients diagnosed with cirrhosis caused by ALD were genotyped for three NFE2L2 single nucleotide polymorphisms (SNP) (SNPs: rs35652124, rs4893819, and rs6721961). Hematoxylin & eosin and immunohistochemistry were performed to determine the inflammatory score and Nrf2 expression, respectively. SNPs rs4893819 and rs6721961 were not specifically associated with ALD, but analysis of SNP rs35652124 suggested that this polymorphism predisposes to ALD. Furthermore, SNP rs35652124 was associated with a lower level of Nrf2 expression. Moreover, liver samples from ALD patients with this polymorphism displayed more severe inflammatory activity. Together, these findings provide evidence that the SNP rs35652124 variation in the Nrf2-encoding gene NFE2L2 is a potential genetic marker for susceptibility to ALD.
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Affiliation(s)
| | | | - Andressa França
- Universidade Federal de Minas Gerais, Belo Horizonte, MG 31270-901, Brazil
| | | | | | - Dabny Missiaggia
- Universidade Federal de Minas Gerais, Belo Horizonte, MG 31270-901, Brazil
| | - Matheus de Castro Fonseca
- Laboratório Nacional de Biociências (LNBio), Centro de Pesquisa em Energia e Materiais (CNPEM), Campinas, SP 13083-970, Brazil
| | - Igor Brasil Costa
- Instituto de Pesquisas Evandro Chagas - IEC, Ananindeua, PA 67030-000, Brazil
| | | | - Michael H Nathanson
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT 06510, USA
| | | | - M Fatima Leite
- Universidade Federal de Minas Gerais, Belo Horizonte, MG 31270-901, Brazil
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Veryan J, Forrest EH. Recent advances in alcoholic hepatitis. Frontline Gastroenterol 2019; 11:133-139. [PMID: 32133112 PMCID: PMC7043083 DOI: 10.1136/flgastro-2018-101104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/07/2019] [Accepted: 04/29/2019] [Indexed: 02/04/2023] Open
Abstract
Alcoholic hepatitis (AH) is an acute deterioration in liver function seen in the context of prolonged excessive alcohol consumption and is characterised by the rapid onset of jaundice. The diagnosis of AH has been controversial for many years: it is now accepted that there are clear clinical criteria which can be used to diagnose AH without the need for a liver biopsy. Corticosteroids remain the only treatment proven to be effective in reducing short-term mortality in severe AH; abstinence from alcohol is the most important factor in determining long-term survival. It is recommended a trial of corticosteroid therapy is considered only in those patients with high baseline 'static' scores (Glasgow Alcoholic Hepatitis score and model for end-stage liver disease). Response to corticosteroid therapy should be assessed using a 'dynamic' score such as the Lille score at day 7, with corticosteroids continuing only in patients with a favourable score. Infection and acute kidney injury are associated with poorer outcomes in AH. Early screening for and treatment of infection is recommended with antibiotic therapy overlapping with any subsequent corticosteroid treatment. A biomarker which predicts benefit from corticosteroids at baseline would avoid a trial of therapy to determine response. More efficacious therapeutic options for AH patients are required with N-acetylcysteine, granulocyte colony stimulating factor, faecal microbiota transplantation and routine antibiotics showing promise, but adequate controlled trials are needed to confirm efficacy. Liver transplant has an emerging role for some patients with severe AH not responding to corticosteroids and is likely to become more acceptable with improved methods of patient selection.
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Affiliation(s)
| | - EH Forrest
- Liver Unit, Glasgow Royal Infirmary, Glasgow, Glasgow, UK,College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, Glasgow, UK
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