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Roberts SB, Choi WJ, Worobetz L, Vincent C, Flemming JA, Cheung A, Qumosani K, Swain M, Grbic D, Ko HH, Peltekian KM, Abrahamyan L, Saini M, Tirona K, Aziz B, Lytvyak E, Invernizzi P, Ponsioen CY, Bruns T, Cazzagon N, Lindor K, Dalekos GN, Gatselis NK, Verhelst X, Floreani A, Corpechot C, Mayo MJ, Levy C, Londoño MC, Battezzati PM, Pares A, Nevens F, van der Meer A, Kowdley KV, Trivedi PJ, Lleo A, Thorburn D, Carbone M, Selzner N, Gulamhusein AF, Janssen HLA, Montano-Loza AJ, Mason AL, Hirschfield GM, Hansen BE. Loss of biochemical response at any time worsens outcomes in UDCA-treated patients with primary biliary cholangitis. JHEP Rep 2024; 6:101168. [PMID: 39380718 PMCID: PMC11460452 DOI: 10.1016/j.jhepr.2024.101168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 06/28/2024] [Accepted: 07/04/2024] [Indexed: 10/10/2024] Open
Abstract
Background & Aims Biochemical response to ursodeoxycholic acid (UDCA) therapy is associated with good prognosis in people living with primary biliary cholangitis (PBC). Biochemical response is typically assessed early in disease and it is not known what proportion of patients lose previously attained biochemical response, nor whether this impacts long-term liver transplant (LT)-free survival. Methods We identified all UDCA-treated patients with PBC from the Canadian Network for Autoimmune Liver disease with biochemical measurements at 1 year, and evaluated their liver biochemistry over time. Inadequate biochemical response was defined as serum alkaline phosphatase ≥1.67x the upper limit of normal or abnormal serum total bilirubin at 1 year of UDCA therapy and all time points thereafter. Multistate Markov models were used to estimate transition rates between biochemical response states and from each state to LT or death. Results were validated in an external cohort (GLOBAL PBC registry). Results A total of 823 patients from eight centers were included. Mean age at diagnosis was 53 years, 91% were female, 33% had inadequate biochemical response to UDCA at 1 year (n = 269). Patients who retained initial adequate response had lower rates of LT or death compared to patients who subsequently lost response (relative rate 0.102, 95% CI 0.047-0.223). Patients who regained adequate response had lower rates than patients who did not (0.016, 95% CI 0.001-0.568), and patients who lost response once more (0.010, 95% CI 0.001-0.340). Patients who regained adequate response for a third time also had lower rates than patients who did not (0.151, 95% CI 0.040-0.566). Analyses in the GLOBAL PBC registry (n = 2,237) validated these results. Conclusion Loss of biochemical response at any time is associated with heightened risks of LT or death in people living with PBC. Achievement of biochemical response is an important goal throughout follow-up, regardless of biochemical response profile early in therapy. Impact and implications Early biochemical response to ursodeoxycholic acid is associated with good prognosis in patients with primary biliary cholangitis (PBC). Our work demonstrates that patients with PBC transition between biochemical response states over time, and that these transitions correspond with changes in risk of liver transplantation or death. Clinicians should re-evaluate risk and optimize treatment decisions for patients with PBC throughout follow-up, regardless of early biochemical response to therapy.
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Affiliation(s)
- Surain B. Roberts
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Woo Jin Choi
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Lawrence Worobetz
- Department of Medicine, University of Saskatchewan, Saskatoon, Canada
| | | | | | - Angela Cheung
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Karim Qumosani
- Department of Medicine, Western University, London, Canada
| | - Mark Swain
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Dusanka Grbic
- Départment de Médecine, Université de Sherbrooke, Sherbrooke, Canada
| | - Hin Hin Ko
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | | | - Lusine Abrahamyan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Royal Free London National Health Service Foundation Trust, London, United Kingdom
| | - Monika Saini
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Kattleya Tirona
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Bishoi Aziz
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Ellina Lytvyak
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Pietro Invernizzi
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Cyriel Y. Ponsioen
- Faculty of Medicine, University of Amsterdam, Amsterdam, the Netherlands
| | - Tony Bruns
- Department of Gastroenterology and Hepatology, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen University, Aachen, Germany
| | | | | | - George N. Dalekos
- European Reference Network on Hepatological Diseases, Barcelona, Spain
| | - Nikolaos K. Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Xavier Verhelst
- Department of Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Annarosa Floreani
- University of Padova, Padova, Italy
- Scientific Institute for Research, Hospitalization and Healthcare, Negrar, Verona, Italy
| | - Christophe Corpechot
- Reference center for inflammatory biliary diseases and autoimmune hepatitis, French network for rare liver diseases FILFOIE, European reference network RARE-LIVER, Saint-Antoine University Hospital, APHP & Sorbonne University, Paris, France
| | - Marlyn J. Mayo
- Department of Medicine, Division of Digestive and Liver Disease, University of Texas, Southwestern Medical Center, Dallas, Texas, USA
| | - Cynthia Levy
- Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Maria-Carlota Londoño
- Liver Unit, Hospital Clinic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d’Investigació Pi i Sunyer (FRCB-IDIBAPS), CIBEREHD, European Reference Network on Hepatological Rare Diseases (ERN-Liver), University of Barcelona, Barcelona, Spain
| | | | - Albert Pares
- Department of Medicine, Liver Unit, Hospital Clínic, University of Barcelona, The August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Barcelona, Spain; European Reference Network on Hepatological Diseases, Barcelona, Spain
| | - Frederik Nevens
- University Hospital Katholieke Universiteit Leuven, Leuven, Belgium
| | - Adriaan van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Palak J. Trivedi
- Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust Queen Elizabeth, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Birmingham Liver Biomedical Research Centre, University of Birmingham, College of Medical and Dental Sciences, Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ana Lleo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Douglas Thorburn
- Royal Free London National Health Service Foundation Trust, London, United Kingdom
| | - Marco Carbone
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Nazia Selzner
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
| | - Aliya F. Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Harry LA. Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Andrew L. Mason
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Gideon M. Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Bettina E. Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Epidemiology & Biostatistics, Erasmus MC, Rotterdam, the Netherlands
| | - the Canadian Network for Autoimmune Liver disease (CaNAL)
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Medicine, University of Saskatchewan, Saskatoon, Canada
- Département de Médecine, Université de Montréal, Montréal, Canada
- Department of Medicine, Queen’s University, Kingston, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Department of Medicine, Western University, London, Canada
- Department of Medicine, University of Calgary, Calgary, Canada
- Départment de Médecine, Université de Sherbrooke, Sherbrooke, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
- Department of Medicine, Dalhousie University, Halifax, Canada
- Department of Medicine, University of Alberta, Edmonton, Canada
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Faculty of Medicine, University of Amsterdam, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen University, Aachen, Germany
- University of Padova, Padova, Italy
- Mayo Clinic, Scottsdale, Arizona, USA
- European Reference Network on Hepatological Diseases, Barcelona, Spain
- Department of Hepatology, Ghent University Hospital, Ghent, Belgium
- Reference center for inflammatory biliary diseases and autoimmune hepatitis, French network for rare liver diseases FILFOIE, European reference network RARE-LIVER, Saint-Antoine University Hospital, APHP & Sorbonne University, Paris, France
- Department of Medicine, Division of Digestive and Liver Disease, University of Texas, Southwestern Medical Center, Dallas, Texas, USA
- Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
- Liver Unit, Hospital Clinic Barcelona, Fundació de Recerca Clínic Barcelona-Institut d’Investigació Pi i Sunyer (FRCB-IDIBAPS), CIBEREHD, European Reference Network on Hepatological Rare Diseases (ERN-Liver), University of Barcelona, Barcelona, Spain
- Università degli Studi di Milano, Milan, Italy
- Department of Medicine, Liver Unit, Hospital Clínic, University of Barcelona, The August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Barcelona, Spain; European Reference Network on Hepatological Diseases, Barcelona, Spain
- University Hospital Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
- Liver Institute Northwest, Seattle, Washington, USA
- Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust Queen Elizabeth, Birmingham, UK
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Royal Free London National Health Service Foundation Trust, London, United Kingdom
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Department of Epidemiology & Biostatistics, Erasmus MC, Rotterdam, the Netherlands
- National Institute for Health and Care Research (NIHR) Birmingham Liver Biomedical Research Centre, University of Birmingham, College of Medical and Dental Sciences, Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Scientific Institute for Research, Hospitalization and Healthcare, Negrar, Verona, Italy
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
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Gazda J, Drazilova S, Gazda M, Janicko M, Koky T, Macej M, Carbone M, Jarcuska P. Treatment response to ursodeoxycholic acid in primary biliary cholangitis: A systematic review and meta-analysis. Dig Liver Dis 2023; 55:1318-1327. [PMID: 36593158 DOI: 10.1016/j.dld.2022.12.010] [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: 08/26/2022] [Revised: 11/09/2022] [Accepted: 12/19/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Several ursodeoxycholic acid (UDCA) treatment response definitions have been introduced in primary biliary cholangitis (PBC). However, the lack of a gold standard results in heterogeneity in second-line treatment research and clinical practice. AIMS This study aimed to explore which UDCA treatment response endpoint serves as the most accurate predictive model of long-term outcome. METHODS A systematic review and meta-analysis of UDCA treatment response endpoints (and corresponding validations) were performed. RESULTS Sixteen individual UDCA treatment response endpoints and 96 external validations were found. Barcelona, Paris-1, Paris-2, Rotterdam, Toronto and GLOBE and UK-PBC Risk Scores are currently most robustly validated in external populations. The results show that the continuous models (GLOBE and UK-PBC Risk Scores) serve as the most accurate predictive models. Besides standard UDCA treatment response endpoints, the alkaline phosphatase and total bilirubin normalization has been suggested as a new therapeutic target. CONCLUSIONS The GLOBE and UK-PBC Risk Scores are the most suitable for the real-world allocation of second-line therapies (obeticholic acid and fibrates). However, in the wake of the recent findings, alkaline phosphatase and total bilirubin normalization should be the primary outcome in trial research in PBC.
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Affiliation(s)
- Jakub Gazda
- 2nd Department of Internal Medicine, Pavol Jozef Safarik University and Louis Pasteur University Hospital, Trieda SNP 1, 040 12, Kosice, Slovakia
| | - Sylvia Drazilova
- 2nd Department of Internal Medicine, Pavol Jozef Safarik University and Louis Pasteur University Hospital, Trieda SNP 1, 040 12, Kosice, Slovakia.
| | - Matej Gazda
- Intelligent Information Systems Laboratory, Technical University of Kosice, Bozeny Nemcovej 32, 04201 Kosice, Slovakia
| | - Martin Janicko
- 2nd Department of Internal Medicine, Pavol Jozef Safarik University and Louis Pasteur University Hospital, Trieda SNP 1, 040 12, Kosice, Slovakia
| | - Tomas Koky
- 2nd Department of Internal Medicine, Pavol Jozef Safarik University and Louis Pasteur University Hospital, Trieda SNP 1, 040 12, Kosice, Slovakia
| | - Marian Macej
- 2nd Department of Internal Medicine, Pavol Jozef Safarik University and Louis Pasteur University Hospital, Trieda SNP 1, 040 12, Kosice, Slovakia
| | - Marco Carbone
- Division of Gastroenterology and Centre for Autoimmune Liver Disease, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo, 1, 20126 Milano, Italy
| | - Peter Jarcuska
- 2nd Department of Internal Medicine, Pavol Jozef Safarik University and Louis Pasteur University Hospital, Trieda SNP 1, 040 12, Kosice, Slovakia
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Martini F, Balducci D, Mancinelli M, Buzzanca V, Fracchia E, Tarantino G, Benedetti A, Marzioni M, Maroni L. Risk Stratification in Primary Biliary Cholangitis. J Clin Med 2023; 12:5713. [PMID: 37685780 PMCID: PMC10488776 DOI: 10.3390/jcm12175713] [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: 07/10/2023] [Revised: 08/25/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
Primary Biliary Cholangitis (PBC) is a chronic cholestatic liver disease with a heterogeneous presentation, symptomatology, disease progression, and response to therapy. The current risk stratification assessment, aimed at identifying patients with a higher risk of disease progression, encompasses an in-depth analysis of demographic data, clinical and laboratory findings, antibody profiles, and the evaluation of liver fibrosis using both invasive and noninvasive techniques. Treatment response scores after one year of therapy remain to date a major factor influencing the prognosis of PBC patients. While the initial therapeutic approach with ursodeoxycholic acid (UDCA) is universally applied, new second-line treatment options have recently emerged, with many others under investigation. Consequently, the prevailing one-size-fits-all approach is poised to be supplanted by tailored strategies, ensuring high-risk patients receive the most appropriate treatment regimen from diagnosis. This will require the development of a risk prediction model to assess, at the time of diagnosis, the course, outcome, and response to first and additional treatments of PBC patients. This manuscript provides a comprehensive overview of the current and emerging tools used for risk stratification in PBC and speculates on how these developments might shape the disease landscape in the near future.
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Affiliation(s)
- Francesco Martini
- Clinic of Gastroenterology, Hepatology, and Emergency Digestive Endoscopy, Università Politecnica delle Marche, 60126 Ancona, Italy; (D.B.); (M.M.); (V.B.); (E.F.); (G.T.); (A.B.); (M.M.); (L.M.)
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AlWabel AH, Peedikayil M, AlNasser S, AlHusaini K, AlHekail O, Alqahtani SA, AlTraif IH, AlAshgar H. Efficacy of ursodeoxycholic acid for primary biliary cholangitis: Experience from a tertiary care centre in Saudi Arabia. Saudi J Gastroenterol 2023; 29:135-140. [PMID: 35229756 PMCID: PMC10270471 DOI: 10.4103/sjg.sjg_445_21] [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: 09/17/2021] [Revised: 09/21/2021] [Accepted: 10/23/2021] [Indexed: 11/04/2022] Open
Abstract
Background Primary biliary cholangitis (PBC) is a progressive autoimmune cholestatic liver disease that primarily affects females more than males and may lead to end-stage liver disease. We studied baseline characteristics, and the biochemical and clinical response to ursodeoxycholic acid (UDCA), a first-line treatment option for patients with PBC, in a cohort of patients diagnosed with PBC from Saudi Arabia. Methods A total of 30 patients meeting the diagnostic criteria of PBC who were being followed in the King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia, between January 1, 2008, and December 31, 2017, were enrolled in the study. The patients with autoimmune hepatitis, primary sclerosing cholangitis, and overlap syndromes were excluded. The baseline characteristics of the patients were recorded. The response to UDCA treatment was assessed according to the Barcelona, Paris I, Paris II, and Toronto criteria, and clinical outcomes, and biochemical changes were ascertained. Results The mean age was 46 years ± 11.7 with a female gender predominance of 93% (n = 28). Pruritus was the predominant symptom reported by 90% (n = 27) of the patients. A total of 23 (77.7%) patients underwent liver biopsy and all of them showed histological features suggestive of PBC. Cirrhosis was documented in 30% (n = 9) of the patients at baseline. Overall, 86.7% (n = 26) of the patients were positive for antimitochondrial antibodies. The biochemical response rates to UDCA based on Paris I, Paris II, Barcelona, and Toronto criteria were 73.3, 40, 56.7, and 53.3%, respectively. Conclusion Over 10 years, 30 patients with PBC were diagnosed at a large referral center in Saudi Arabia. The response to UDCA treatment was inadequate.
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Affiliation(s)
- Ahmed H AlWabel
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Musthafa Peedikayil
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Sulaiman AlNasser
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Khalid AlHusaini
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Othman AlHekail
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Saleh A Alqahtani
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Organ Transplant Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ibrahim H AlTraif
- Hepatology Division, Department of Hepatobiliary Sciences and Organ Transplant Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Hamad AlAshgar
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Cançado GGL, Couto CA, Terrabuio DRB, Cançado ELR, Villela-Nogueira CA, Ferraz MLG, Braga MH, Nardelli MJ, Faria LC, de Faria Gomes NM, Oliveira EMG, Rotman V, Oliveira MB, da Cunha SMCF, Cunha-Silva M, Mendes LSC, Ivantes CAP, Codes L, de Almeida E Borges VF, de Lima Pace FH, Pessoa MG, Guedes LV, Signorelli IV, Coral GP, Levy C, Bittencourt PL. Response to Ursodeoxycholic Acid May Be Assessed Earlier to Allow Second-Line Therapy in Patients with Unresponsive Primary Biliary Cholangitis. Dig Dis Sci 2023; 68:514-520. [PMID: 35989386 DOI: 10.1007/s10620-022-07654-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 07/31/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Response to ursodeoxycholic acid (UDCA) in primary biliary cholangitis (PBC) has been traditionally assessed 1 to 2 years after treatment initiation. With the development of new drugs, some patients may benefit from an earlier introduction of second-line therapies. AIMS This study aims to identify whether well-validated response criteria could correctly identify individuals likely to benefit from add-on second-line therapy at 6 months. METHODS Analysis of a multicenter retrospective cohort which included only patients with clear-cut PBC. RESULTS 206 patients with PBC (96.6% women; mean age 54 ± 12 years) were included. Kappa concordance was substantial for Toronto (0.67), Rotterdam (0.65), Paris 1 (0.63) and 2 (0.63) criteria at 6 and 12 months, whereas Barcelona (0.47) and POISE trial (0.59) criteria exhibited moderate agreement. Non-response rates to UDCA was not statistically different when assessed either at 6 or 12 months using Toronto, Rotterdam or Paris 2 criteria. Those differences were even smaller or absent in those subjects with advanced PBC. Mean baseline alkaline phosphatase was 2.73 ± 1.95 times the upper limit of normal (× ULN) among responders versus 5.05 ± 3.08 × ULN in non-responders (p < 0.001). CONCLUSIONS After 6 months of treatment with UDCA, the absence of response by different criteria could properly identify patients who could benefit from early addition of second-line therapies, especially in patients with advanced disease or high baseline liver enzymes levels.
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Affiliation(s)
- Guilherme Grossi Lopes Cançado
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, Belo Horizonte, Minas Gerais, 30130-100, Brazil.
- Hospital da Polícia Militar de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Cláudia Alves Couto
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | | | - Eduardo Luiz Rachid Cançado
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Cristiane Alves Villela-Nogueira
- Hospital Universitário Clementino Fraga Filho e Departamento de Clínica Médica da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria Lucia Gomes Ferraz
- Disciplina de Gastroenterologia, Universidade Federal de São Paulo, São Paulo, São Paulo, Brazil
| | - Michelle Harriz Braga
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Mateus Jorge Nardelli
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Luciana Costa Faria
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas da Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | | | | | - Vivian Rotman
- Hospital Universitário Clementino Fraga Filho e Departamento de Clínica Médica da Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria Beatriz Oliveira
- Ambulatório Municipal de Hepatites Virais de São José dos Campos, São José dos Campos, São Paulo, Brazil
| | | | - Marlone Cunha-Silva
- Divisão de Gastroenterologia (Gastrocentro), Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, São Paulo, Brazil
| | | | | | - Liana Codes
- Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, Bahia, Brazil
- Hospital Português, Salvador, Bahia, Brazil
| | - Valéria Ferreira de Almeida E Borges
- Instituto de Gastroenterologia, Endoscopia e Proctologia, Uberlândia, Minas Gerais, Brazil
- Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brazil
| | - Fabio Heleno de Lima Pace
- Serviço de Gastroenterologia e Hepatologia, Universidade Federal de Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - Mario Guimarães Pessoa
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Laura Vilar Guedes
- Departamento de Gastroenterologia, Faculdade de Medicina da Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Izabelle Venturini Signorelli
- Hospital Universitário Cassiano Antônio Moraes, Universidade Federal do Espírito Santo, Vitoria, Espírito Santo, Brazil
| | - Gabriela Perdomo Coral
- Irmandade da Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Paulo Lisboa Bittencourt
- Hospital Português, Salvador, Bahia, Brazil
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
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Scaravaglio M, Carbone M. Prognostic Scoring Systems in Primary Biliary Cholangitis: An Update. Clin Liver Dis 2022; 26:629-642. [PMID: 36270720 DOI: 10.1016/j.cld.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Primary biliary cholangitis (PBC) is a complex, chronic disease with a heterogeneous presentation, disease progression, and response to therapy. Several prognostic models based on disease stage and/or treatment response enhance risk stratification and therapeutic management. Recent work on disease modeling proposed early prediction of outcomes at PBC onset, yet this has not been implemented in clinical practice. Although early stratification of patients based on their individual risk of developing end-stage liver disease may prove cost-effective and actually become matter of medical deontology to timely offer the best therapeutic option, given the forthcoming availability of novel, disease-modifying drugs. This review outlines established and novel prognostic systems in PBC and provides some perspectives on the potential role of omics-derived biomarkers in developing reliable risk prediction models and promoting the implementation of personalized medicine in PBC.
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Affiliation(s)
- Miki Scaravaglio
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza (MB), Italy.
| | - Marco Carbone
- Division of Gastroenterology and Hepatology, Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore 48, 20900 Monza (MB), Italy.
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Gender and Autoimmune Liver Diseases: Relevant Aspects in Clinical Practice. J Pers Med 2022; 12:jpm12060925. [PMID: 35743710 PMCID: PMC9225254 DOI: 10.3390/jpm12060925] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 05/25/2022] [Accepted: 05/28/2022] [Indexed: 12/12/2022] Open
Abstract
Autoimmune liver diseases (AILDs) include autoimmune hepatitis, primary biliary cholangitis and primary sclerosing cholangitis. The etiologies of AILD are not well understood but appear to involve a combination of genetic and environmental factors. AILDs commonly affect young individuals and are characterized by a highly variable clinical course. These diseases significantly influence quality of life and can progress toward liver decompensation or the onset of hepatocellular or cholangiocarcinoma; a significant number of patients eventually progress to end-stage liver disease, requiring liver transplantation. In this review, we focus on the sex characteristics and peculiarities of AILD patients and highlight the relevance of a sex-specific analysis in future studies. Understanding the sex differences underlying AILD immune dysregulation may be critical for developing more effective treatments.
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Al Sulaiman K, Kharbosh A, Bin Salah K, Alsulaiman T, Al Andas N, Aljuhani O, Vishwakarma R. Impact of Ursodeoxycholic Acid in Critically Ill Patients With Sepsis: A Retrospective Study. J Pharm Pract 2022; 36:566-571. [PMID: 37189247 DOI: 10.1177/08971900211038363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Using ursodeoxycholic acid (UDCA) in critically ill patients as adjunctive therapy for sepsis/septic shock in neonates and children is controversial, while it has not been extensively investigated in adults. This study aims to assess the effect of UDCA use on the early resolution of sepsis/septic shock in critically ill adult patients. Method: A retrospective study of critically ill adult patients in the intensive care unit (ICU) admitted with sepsis/septic shock at King Abdulaziz Medical City. Based on their usage of UDCA, patients were categorized into two groups. A total of 88 patients were included for analysis after matching, based on severity of illness scores within 24-hours of ICU admission. The primary outcome was to assess the effect of UDCA on the severity and resolution of shock at day three of ICU admission. The secondary outcomes were 30-day in-hospital mortality, mechanical ventilation (MV) duration, and ICU length of stay (LOS). Results: Out of the 88 patients matched, 44 patients (50%) received UDCA during the study period. Using UDCA was neither associated with improvement in Sequential Organ Failure Assessment (SOFA) score ( p-value: 0.32), inotropes/vasopressors requirement ( p-value: 0.79), Glasgow Coma Scale (GCS) ( p-value: 0.59) nor total bilirubin levels ( p-value: 0.79) at day three compared with the control. There was a significant association between using UDCA and improvement in PaO2/FiO2 ratio ( p-value: 0.01) and early extubation at day three ( p-value: 0.04). Conclusion: Using UDCA in critically ill patients with sepsis/septic shock was not associated with improvement in shock severity and resolution. However, patients who received UDCA were more likely to be extubated and not require MV on day three of ICU admission.
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Affiliation(s)
- Khalid Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdullah Kharbosh
- Clinical Pharmacy Department, Pharmacy College, Taif University, Taif, Saudi Arabia
| | - Khalid Bin Salah
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Thamer Alsulaiman
- Family Medicine Department, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia
| | - Norah Al Andas
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Ohoud Aljuhani
- Faculty of Pharmacy, Department of Pharmacy Practice, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ramesh Vishwakarma
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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Wilde ACB, Lieb C, Leicht E, Greverath LM, Steinhagen LM, Wald de Chamorro N, Petersen J, Hofmann WP, Hinrichsen H, Heyne R, Berg T, Naumann U, Schwenzer J, Vermehren J, Geier A, Tacke F, Müller T. Real-World Clinical Management of Patients with Primary Biliary Cholangitis-A Retrospective Multicenter Study from Germany. J Clin Med 2021; 10:1061. [PMID: 33806503 PMCID: PMC7961881 DOI: 10.3390/jcm10051061] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 02/26/2021] [Accepted: 03/01/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Clinical practice guidelines for patients with primary biliary cholangitis (PBC) have been recently revised and implemented for well-established response criteria to standard first-line ursodeoxycholic acid (UDCA) therapy at 12 months after treatment initiation for the early identification of high-risk patients with inadequate treatment responses who may require treatment modification. However, there are only very limited data concerning the real-world clinical management of patients with PBC in Germany. OBJECTIVE The aim of this retrospective multicenter study was to evaluate response rates to standard first-line UDCA therapy and subsequent Second-line treatment regimens in a large cohort of well-characterized patients with PBC from 10 independent hepatological referral centers in Germany prior to the introduction of obeticholic acid as a licensed second-line treatment option. METHODS Diagnostic confirmation of PBC, standard first-line UDCA treatment regimens and response rates at 12 months according to Paris-I, Paris-II, and Barcelona criteria, the follow-up cut-off alkaline phosphatase (ALP) ≤ 1.67 × upper limit of normal (ULN) and the normalization of bilirubin (bilirubin ≤ 1 × ULN) were retrospectively examined between June 1986 and March 2017. The management and hitherto applied second-line treatment regimens in patients with an inadequate response to UDCA and subsequent response rates at 12 months were also evaluated. RESULTS Overall, 480 PBC patients were included in this study. The median UDCA dosage was 13.2 mg UDCA/kg bodyweight (BW)/d. Adequate UDCA treatment response rates according to Paris-I, Paris-II, and Barcelona criteria were observed in 91, 71.3, and 61.3% of patients, respectively. In 83.8% of patients, ALP ≤ 1.67 × ULN were achieved. A total of 116 patients (24.2%) showed an inadequate response to UDCA according to at least one criterion. The diverse second-line treatment regimens applied led to significantly higher response rates according to Paris-II (35 vs. 60%, p = 0.005), Barcelona (13 vs. 34%, p = 0.0005), ALP ≤ 1.67 × ULN and bilirubin ≤ 1 × ULN (52.1 vs. 75%, p = 0.002). The addition of bezafibrates appeared to induce the strongest beneficial effect in this cohort (Paris II: 24 vs. 74%, p = 0.004; Barcelona: 50 vs. 84%, p = 0.046; ALP < 1.67 × ULN and bilirubin ≤ 1 × ULN: 33 vs. 86%, p = 0.001). CONCLUSION Our large retrospective multicenter study confirms high response rates following UDCA first-line standard treatment in patients with PBC and highlights the need for close monitoring and early treatment modification in high-risk patients with an insufficient response to UDCA since early treatment modification significantly increases subsequent response rates of these patients.
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Affiliation(s)
- Anne-Christin Beatrice Wilde
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany; (C.L.); (E.L.); (L.M.G.); (L.M.S.); (N.W.d.C.); (F.T.); (T.M.)
| | - Charlotte Lieb
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany; (C.L.); (E.L.); (L.M.G.); (L.M.S.); (N.W.d.C.); (F.T.); (T.M.)
| | - Elise Leicht
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany; (C.L.); (E.L.); (L.M.G.); (L.M.S.); (N.W.d.C.); (F.T.); (T.M.)
| | - Lena Maria Greverath
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany; (C.L.); (E.L.); (L.M.G.); (L.M.S.); (N.W.d.C.); (F.T.); (T.M.)
| | - Lara Marleen Steinhagen
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany; (C.L.); (E.L.); (L.M.G.); (L.M.S.); (N.W.d.C.); (F.T.); (T.M.)
| | - Nina Wald de Chamorro
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany; (C.L.); (E.L.); (L.M.G.); (L.M.S.); (N.W.d.C.); (F.T.); (T.M.)
| | - Jörg Petersen
- IFI Institute for Interdisciplinary Medicine, Asklepios Klinik St. Georg, 20099 Hamburg, Germany;
| | | | | | | | - Thomas Berg
- Division of Hepatology, Department of Medicine II, Leipzig University, Medical Center, 04103 Leipzig, Germany;
| | | | | | - Johannes Vermehren
- Department of Hepatology and Gastroenterology, University Hospital Frankfurt Am Main, 60590 Frankfurt am Main, Germany;
| | - Andreas Geier
- Internal Medicine, University Hospital Wuerzburg, 97080 Wuerzburg, Germany;
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany; (C.L.); (E.L.); (L.M.G.); (L.M.S.); (N.W.d.C.); (F.T.); (T.M.)
| | - Tobias Müller
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany; (C.L.); (E.L.); (L.M.G.); (L.M.S.); (N.W.d.C.); (F.T.); (T.M.)
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Response Rate and Impact on Lipid Profiles of Obeticholic Acid Treatment for Patients with Primary Biliary Cholangitis: A Meta-Analysis. Can J Gastroenterol Hepatol 2021; 2021:8829510. [PMID: 33511089 PMCID: PMC7822683 DOI: 10.1155/2021/8829510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/16/2020] [Accepted: 12/30/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Up to 40% of patients with primary biliary cholangitis (PBC) have an inadequate response to ursodeoxycholic acid (UDCA). Obeticholic acid (OCA) is considered the addition of treatment, but the response rate based on commonly referenced biochemical response criteria and lipids' impact was unclear. Previous studies reported inconsistency results partially due to small sample size. Therefore, we performed a meta-analysis and aimed to explore OCA treatment's response rate and effect on lipids' profiles in PBC patients. METHODS We performed PubMed, Embase, and Cochrane controlled trials register (updated to JUN 2019) databases and manual bibliographical searches for randomized controlled trials reporting on OCA treatment in PBC patients. Two researchers independently extracted data and assessed the risk of bias of studies. We calculated risk ratio (RR) for the overall complete response rate, and the standardized mean difference (SMD) for the serum lipids changes after OCA treatment, all with 95% confidence intervals (CIs) using fixed-effects models. We registered this meta-analysis with PROSPERO (registration number: CRD42020148550). RESULTS Three trials, with 265 patients, were selected for the analysis. OCA was superior to placebo in PBC patients (RR, 1.48; 95% CI, 1.15-1.90). OCA's pooled treatment response rate was 65% (95% CI, 56%-74%), corresponding to Paris I criteria. Besides, OCA significantly decreased total cholesterol (P=0.02) with no heterogeneity (P=0.87, I 2 = 0%) and high-density lipoprotein levels (P < 0.05) with no heterogeneity (P=0.82, I 2 = 0%). CONCLUSIONS This meta-analysis demonstrated that OCA was a promising additional treatment for PBC patients and might reduce serum cholesterol levels. The longer follow-up studies are needed to give more evidence.
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Namisaki T, Fujinaga Y, Moriya K, Yoshiji H. The association of histological progression with biochemical response to ursodeoxycholic acid in primary biliary cholangitis. Hepatol Res 2021; 51:31-38. [PMID: 33210415 DOI: 10.1111/hepr.13593] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/01/2020] [Accepted: 11/03/2020] [Indexed: 02/08/2023]
Abstract
Primary biliary cholangitis (PBC) is currently diagnosed at an early stage; therefore, the number of patients with PBC without symptoms at the time of diagnosis is increasing. However, up to 30% of patients with PBC exhibit the suboptimal response to ursodeoxycholic acid (UDCA) and are at high risk of end-stage liver disease. Obeticholic acid is an approved second-line therapy for patients with PBC that are refractory to UDCA. Novel surrogate endpoints are required to identify individuals eligible for second-line therapies. An inadequate biochemical response to UDCA is a useful predictor of poor outcomes in patients with PBC. In addition to UDCA effects on biochemical parameters, histological outcomes could be considered as candidate surrogate endpoints. Alterations in liver histology are used as surrogate endpoints in clinical studies. However, current staging systems are insufficient to determine PBC disease severity and progression because of the pathological heterogeneity of the disease. Histological features at baseline and biochemical response to UDCA treatment can affect the disease course of PBC. Therefore, novel surrogate endpoints must be represented by parameters characterized by histological outcomes and treatment responses in PBC. In this review, we discuss the existing histological parameters and newly created factors to identify patients with PBC who are at a high risk of developing end-stage liver disease and, consequently, the potential need for additional treatments.
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Affiliation(s)
- Tadashi Namisaki
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Yukihisa Fujinaga
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Kei Moriya
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Hitoshi Yoshiji
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara, Japan
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Rabiee A, Polanco NAP, Vara AFDL, Levy C. Hispanic Patients with Primary Biliary Cholangitis Have Decreased Access to Care Compared to Non-Hispanics. J Clin Transl Hepatol 2020; 8:391-396. [PMID: 33447522 PMCID: PMC7782121 DOI: 10.14218/jcth.2020.00006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 07/21/2020] [Accepted: 09/18/2020] [Indexed: 12/30/2022] Open
Abstract
Background and Aims: Hispanic patients with primary biliary cholangitis (PBC) have reduced rates of biochemical response to ursodeoxycholic acid (UDCA) and increased risk of disease progression compared to non-Hispanic patients. In this study, we sought to identify differences in demographics, comorbidities, environmental risk factors and socioeconomic status between Hispanic and non-Hispanic patients with PBC. Methods: In a case control study, we analyzed data from Hispanic (n=37 females and 1 male) and non-Hispanic (n=54 females and 4 males) patients with PBC seen at the University of Miami/Jackson Memorial Hospital from January 1998 through January 2013. Data were obtained by filling out a questionnaire either via phone call, mail, or e-mail. Odds ratios were calculated to measure the association between exposure and outcomes. Results: Baseline demographics, environmental risk factors and comorbidities were similar between Hispanic and non-Hispanic patients with PBC. Hispanic patients were less likely to be married and fewer Hispanics had education beyond high school level compared to non-Hispanics. Sixty four percent of Hispanic patients had a household income of less than $50000, compared to 19.5% of non-Hispanics. Fewer Hispanic patients with PBC had health insurance coverage compared to non-Hispanics (86.5% vs. 98.1%; odds ratio: 0.1, 95% confidence interval: 0-0.9). Conclusions: Differences in disease severity and response to therapy observed in prior studies could not be explained by environmental exposures. In addition to genetic variation, socioeconomic discrepancies (access to care) may further explain these differences.
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Affiliation(s)
- Atoosa Rabiee
- Department of Gastroenterology and Hepatology, VA Medical Center, Washington DC, USA
- Correspondence to: Atoosa Rabiee, Department of Gastroenterology and Hepatology, VA Medical Center, 50 Irving St NW, Washington DC 20422, USA. Tel: +1-202-745-8456, E-mail:
| | - Nathalie A Pena Polanco
- Divison of Digestive Health and Liver Diseases Department of Medicine University of Miami Miller School of Medicine USA
| | | | - Cynthia Levy
- Divison of Digestive Health and Liver Diseases Department of Medicine University of Miami Miller School of Medicine USA
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Aguilar MT, Chascsa DM. Update on Emerging Treatment Options for Primary Biliary Cholangitis. Hepat Med 2020; 12:69-77. [PMID: 32547264 PMCID: PMC7259454 DOI: 10.2147/hmer.s205431] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/29/2020] [Indexed: 12/12/2022] Open
Abstract
Primary biliary cholangitis (PBC) is a rare autoimmune cholestatic liver disease that may progress to fibrosis or cirrhosis. Treatment options are currently limited. Ursodeoxycholic acid (UDCA) remains first-line therapy and has been proven to normalize serum biochemistries, halt histologic disease progression, and lead to patient survival comparable to the general population. Obeticholic acid (OCA) was recently approved as adjunct therapy in PBC patients with inadequate response or intolerance to UDCA. However, OCA has been associated with worsening pruritus in clinical studies which may limit its use in this patient population. Several studies are currently underway to address the lack of treatment options for PBC. Of these, fibrates, which have been used in Japan for over a decade, have produced promising results. Furthermore, as currently approved therapies for PBC do not address the potentially debilitating clinical symptoms of PBC such as pruritus and fatigue, supplemental therapy is often required for symptom control.
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Affiliation(s)
- Maria T Aguilar
- Department of Gastroenterology & Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - David M Chascsa
- Department of Gastroenterology & Hepatology, Mayo Clinic, Phoenix, AZ, USA
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Mané F, Cardoso H, Liberal R, Lopes S, Pereira P, Gonçalves R, Macedo G. Treatment response in primary biliary cholangitis: The role of autoimmune hepatitis features. Ann Hepatol 2020; 18:488-493. [PMID: 31036497 DOI: 10.1016/j.aohep.2018.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 11/14/2018] [Accepted: 11/23/2018] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM Primary biliary cholangitis is a rare disease with scarce epidemiological data in Southern Europe. The authors aimed to evaluate treatment response in a cohort of patients. MATERIALS AND METHODS This retrospective observational single-centre study included patients with diagnostic criteria of primary biliary cholangitis. Data on disease presentation, laboratory results, treatment and clinical endpoints were collected and analyzed. RESULTS Fifty-three patients were included, 89% women, with mean age of 62±15 years at diagnosis. The majority was asymptomatic (49%), tested positive for antimitochondrial antibodies (96%) and had increased alkaline phosphatase (median=214U/L). 75% of the patients had liver histology and the majority were in Ludwig's stage I (42%). Autoimmune hepatitis (AIH) features were found in seven patients (13%). All were treated with ursodeoxycholic acid (UDCA) and 56% achieved biochemical response at one year; patients with AIH features exhibited steeper decreases in alkaline phosphatase (p=0.007) and reached the endpoint of 40% decrease in alkaline phosphatase more frequently (p=0.017). CONCLUSION In conclusion a significant proportion of patients failed to achieve an adequate response to UDCA treatment. The response rate of patients with AIH features was better, which could be related to a different phenotype or to the potential impact of immunosuppressive agents.
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Affiliation(s)
- Fernando Mané
- Gastroenterology Department, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Hélder Cardoso
- Gastroenterology Department, Faculty of Medicine, University of Porto, Porto, Portugal; Gastroenterology Department, Hospitalar Center of São João, Porto, Portugal.
| | - Rodrigo Liberal
- Gastroenterology Department, Faculty of Medicine, University of Porto, Porto, Portugal; Gastroenterology Department, Hospitalar Center of São João, Porto, Portugal
| | - Susana Lopes
- Gastroenterology Department, Faculty of Medicine, University of Porto, Porto, Portugal; Gastroenterology Department, Hospitalar Center of São João, Porto, Portugal
| | - Pedro Pereira
- Gastroenterology Department, Faculty of Medicine, University of Porto, Porto, Portugal; Gastroenterology Department, Hospitalar Center of São João, Porto, Portugal
| | - Regina Gonçalves
- Gastroenterology Department, Faculty of Medicine, University of Porto, Porto, Portugal; Gastroenterology Department, Hospitalar Center of São João, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Faculty of Medicine, University of Porto, Porto, Portugal; Gastroenterology Department, Hospitalar Center of São João, Porto, Portugal
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Concomitant systemic lupus erythematosus might have a negative impact on the biochemical responses to treatment in patients with primary biliary cholangitis. Clin Rheumatol 2019; 39:795-803. [DOI: 10.1007/s10067-019-04853-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/15/2019] [Accepted: 11/11/2019] [Indexed: 12/15/2022]
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Murillo Perez CF, Hirschfield GM, Corpechot C, Floreani A, Mayo MJ, van der Meer A, Ponsioen CY, Lammers WJ, Parés A, Invernizzi P, Carbone M, Maria Battezzati P, Nevens F, Kowdley KV, Thorburn D, Mason AL, Trivedi PJ, Lindor KD, Bruns T, Dalekos GN, Gatselis NK, Verhelst X, Janssen HLA, Hansen BE, Gulamhusein A. Fibrosis stage is an independent predictor of outcome in primary biliary cholangitis despite biochemical treatment response. Aliment Pharmacol Ther 2019; 50:1127-1136. [PMID: 31621931 DOI: 10.1111/apt.15533] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 07/10/2019] [Accepted: 09/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Fibrosis stage predicts prognosis in patients with chronic liver disease independent of aetiology, although its precise role in risk stratification in patients with primary biliary cholangitis (PBC) remains undefined. AIM To assess the utility of baseline fibrosis stage in predicting long-term outcomes in the context of biochemical risk stratification METHODS: In a large and globally representative cohort of patients with PBC, liver biopsies performed from 1980 to 2014 were evaluated. The predictive ability of histologic fibrosis stage in addition to treatment response at 1 year (Toronto/Paris-II criteria), as well as non-invasive markers of fibrosis (AST/ALT ratio [AAR], AST to platelet ratio index [APRI], FIB-4), for transplant-free survival was assessed with Cox proportional-hazards models. RESULTS There were 1828 patients with baseline liver biopsy. Advanced histologic fibrosis (stage 3/4) was an independent predictor of survival in addition to non-invasive measures of fibrosis with the hazard ratios ranging from 1.59 to 2.73 (P < .001). Patients with advanced histologic fibrosis stage had worse survival despite biochemical treatment response, with a 10-year survival of 76.0%-86.6% compared to 94.5%-95.1% depending on the treatment response criteria used. Poor correlations were observed between non-invasive measures of fibrosis and histologic fibrosis stage. CONCLUSION Assessment of fibrosis stage grants prognostic value beyond biochemical treatment response at 1 year. This highlights the need to incorporate fibrosis stage in individual risk stratification in patients with PBC, partly to identify those that may derive benefit from novel therapies.
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Factors Associated With Potential Progressive Course of Primary Biliary Cholangitis: Data From Real-world US Database. J Clin Gastroenterol 2019; 53:693-698. [PMID: 30148766 DOI: 10.1097/mcg.0000000000001120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Although relatively, primary biliary cholangitis (PBC) is an important cause of nonalcoholic chronic liver disease which may lead to liver transplantation. PBC patients with alkaline phosphatase (ALP) ≥1.5× the upper limit of normal (ULN) tend to have a more aggressive course. The study was designed to identify factors associated with ALP≥1.5×ULN or cirrhosis in PBC and to evaluate concomitant health care resource utilization. METHODS We used a large real-world database that contained comprehensive and continuous electronic medical recored/claims data from over 500 health care practices or systems from the United States. RESULTS Of 195 million patients included in the database, 36,317 were adults with PBC. After applying exclusion criteria, 15,875 patients comprised the final PBC cohort (63.0±13.5 y, 78% female, 71% privately insured, 5% covered by Medicaid, 57% with other autoimmune diseases, 46% with cirrhosis); 6083 (38%) had ALP≥1.5×ULN. Patients with ALP≥1.5×ULN were more frequently female, less covered by Medicaid, had more pruritus, cirrhosis, and other autoimmune diseases (P<0.05). In multivariate analysis, older age, female gender, the presence of other autoimmune diseases, and having compensated or decompensated cirrhosis were independently associated with having ALP≥1.5×ULN in PBC (P<0.05). In contrast, being male was associated with higher risk of cirrhosis in PBC [odds ratio 2.3 (95% confidence interval, 2.1-2.5)]. Patients with ALP≥1.5×ULN and/or with cirrhosis also incurred substantially more health care resource utilization (P<0.05). CONCLUSIONS Many clinical, sociodemographic, and economic factors are associated with a potentially more aggressive profile of PBC with elevated ALP. These data may inform clinicians to implement management strategies to optimize care of these patients.
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Fujinaga Y, Namisaki T, Moriya K, Kitade M, Kawaratani H, Shimozato N, Kaji K, Takaya H, Sawada Y, Seki K, Akahane T, Okura Y, Sato S, Saikawa S, Nakanishi K, Kubo T, Furukawa M, Kitagawa K, Ozutsumi T, Tsuji Y, Kaya D, Mashitani T, Ishida K, Ogawa H, Takagi H, Noguchi R, Mitoro A, Yamao J, Yoshiji H. Identification of clinical risk factors for histological progression of primary biliary cholangitis. Hepatol Res 2019; 49:1015-1025. [PMID: 31021038 DOI: 10.1111/hepr.13355] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/11/2019] [Accepted: 04/12/2019] [Indexed: 02/08/2023]
Abstract
AIM To identify laboratory predictors of histological progression (HP) of primary biliary cholangitis (PBC). METHODS Sequential biopsies were carried out on 35 (11.4%) of 308 patients with PBC treated with ursodeoxycholic acid (UDCA). Patients were divided into high γ-glutamyl transpeptidase (GGT) (n = 18) and low GGT (n = 17) groups, based on the median value of GGT at baseline. Patients were then categorized as showing HP (progressive group, PG) or lacking HP (non-progressive group, NPG) according to the Scheuer and Nakanuma classifications, with the latter grading liver fibrosis (fibrosis score) and bile duct loss (BDL score). RESULTS According to the Scheuer definition, 12 patients had HP and 23 did not. According to the Nakanuma definition, 8 and 27 patients were in the PG and NPG groups, respectively. The fibrosis and BDL scores progressed in 13 and 8 patients, respectively, whereas 22 and 25 patients did not show HP, respectively. Fisher's exact probability test analysis revealed that the rate of HP using the Nakanuma fibrosis score was significantly higher in the high GGT group compared to the low GGT group (P < 0.05). However, no significant correlation was found between the HP of PBC and the biochemical response to UDCA therapy. Both univariate and multivariate logistic regression analyses indicated that the serum GGT level at baseline is an independent risk factor for an increased Nakanuma fibrosis score. CONCLUSIONS The level of serum GGT at baseline is significantly associated with liver fibrosis progression in PBC, and therefore could help to predict the HP of PBC.
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Affiliation(s)
- Yukihisa Fujinaga
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Tadashi Namisaki
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Kei Moriya
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Mitsuteru Kitade
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Hideto Kawaratani
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Naotaka Shimozato
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Kosuke Kaji
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Hiroaki Takaya
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Yasuhiko Sawada
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Kenichiro Seki
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Takemi Akahane
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Yasushi Okura
- Department of Endoscopy, Nara Medical University, Kashihara, Japan
| | - Shinya Sato
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Soichiro Saikawa
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Keisuke Nakanishi
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Takuya Kubo
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Masanori Furukawa
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Koh Kitagawa
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Takahiro Ozutsumi
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Yuki Tsuji
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Daisuke Kaya
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Tsuyoshi Mashitani
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Koji Ishida
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Hiroyuki Ogawa
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Hirotetsu Takagi
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Ryuichi Noguchi
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Akira Mitoro
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Junichi Yamao
- Department of Endoscopy, Nara Medical University, Kashihara, Japan
| | - Hitoshi Yoshiji
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
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Ronca V, Gerussi A, Cristoferi L, Carbone M, Invernizzi P. Precision medicine in primary biliary cholangitis. J Dig Dis 2019; 20:338-345. [PMID: 31099953 DOI: 10.1111/1751-2980.12787] [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] [Indexed: 12/11/2022]
Abstract
For many years the one-size-fits-all approach has been the only one available to manage patients affected by primary biliary cholangitis. The introduction of obeticholic acid in 2016 as a second-line treatment, together with the creation and validation of several biochemically based scores to stratify the risk of progressive disease, has opened up the need to redefine clinical practice by changing the actual paradigm. The precision medicine initiative is a model of patient-centered health care that aims to improve medicine based on genotypic and molecular characteristics that correlate to specific phenotypic, individual characteristics. In summary, the aim of the precision medicine is to define the right treatment for the right person at the right time. The availability of a second-line disease-modifying drug and new molecules in phase 2 or 3 trials makes this an exciting time for the precision medicine initiative in primary biliary cholangitis. In this review we describe the current risk stratification tools and we track a possible path towards the application of precision medicine in clinical daily life.
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Affiliation(s)
- Vincenzo Ronca
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, San Gerardo Hospital, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Alessio Gerussi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, San Gerardo Hospital, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Laura Cristoferi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, San Gerardo Hospital, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Marco Carbone
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, San Gerardo Hospital, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, San Gerardo Hospital, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
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20
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Örnolfsson KT, Lund SH, Olafsson S, Bergmann OM, Björnsson ES. Biochemical response to ursodeoxycholic acid among PBC patients: a nationwide population-based study. Scand J Gastroenterol 2019; 54:609-616. [PMID: 31074667 DOI: 10.1080/00365521.2019.1606931] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objective: To assess the proportion of PBC patients with a biochemical response to ursodeoxycholic acid (UDCA) in a population-based cohort and the association of biochemical response with outcomes. Methods: All patients diagnosed with PBC in Iceland from 1991-2015 were identified. Patients taking UDCA for an adequate period of time were analyzed for treatment response according to the Barcelona, Paris I, Paris II and Toronto criteria and outcomes. Results: Overall 182 females and 40 males were diagnosed with PBC and 135 patients were treated with UDCA. Overall 99 (73%) patients had adequate data on UDCA treatment and results of liver tests to assess biochemical response according to the Barcelona criteria, 95 (70%) according to the Toronto criterion and 85 (63%) according to the Paris I and II criteria. In all 74% (n = 63), 67% (n = 64), 54% (n = 53) and 46% (n = 39) responded to treatment according to the Paris I, Toronto, Barcelona and Paris II criteria. Among nonresponders according to the Paris I, Toronto, Paris II and Barcelona criteria, 50%, 39%, 33% and 30% developed cirrhosis versus 10%, 6%, 5% and 11% of responders, HR 5.36 (p = .002), 6.61 (p = .002), 10.94 (p = .003) and 2.21(p = .11), respectively. Age-adjusted mortality was significantly lower among responders according to the Paris I and Paris II criteria, HR 0.33 (p = .02) and 0.31 (p = .02), respectively. Conclusion: Development of cirrhosis and higher mortality was significantly associated with a lack of biochemical response to UDCA. Frequent development of cirrhosis and increased mortality in nonresponders underlines the need for a more effective therapy than UDCA for this sizeable subgroup of patients.
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Affiliation(s)
- Kristjan T Örnolfsson
- a Faculty of Medicine , University of Iceland, Reykjavík, Iceland.,b Division of Gastroenterology and Hepatology , Landspitali The National University Hospital of Iceland , Reykjavík , Iceland
| | - Sigrun H Lund
- a Faculty of Medicine , University of Iceland, Reykjavík, Iceland
| | - Sigurdur Olafsson
- b Division of Gastroenterology and Hepatology , Landspitali The National University Hospital of Iceland , Reykjavík , Iceland
| | - Ottar M Bergmann
- b Division of Gastroenterology and Hepatology , Landspitali The National University Hospital of Iceland , Reykjavík , Iceland
| | - Einar S Björnsson
- a Faculty of Medicine , University of Iceland, Reykjavík, Iceland.,b Division of Gastroenterology and Hepatology , Landspitali The National University Hospital of Iceland , Reykjavík , Iceland
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21
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Shahab O, Sayiner M, Paik J, Felix S, Golabi P, Younossi ZM. Burden of Primary Biliary Cholangitis Among Inpatient Population in the United States. Hepatol Commun 2019; 3:356-364. [PMID: 30859148 PMCID: PMC6396368 DOI: 10.1002/hep4.1314] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/21/2018] [Indexed: 12/14/2022] Open
Abstract
Primary biliary cholangitis (PBC) is an autoimmune liver disease that can lead to cirrhosis and liver failure. Our aim was to assess the recent trends in the mortality rates and health care utilization of patients with PBC seen in the inpatient setting in the United States. We used the National (Nationwide) Inpatient Sample data (2005‐2014). The study population included adults with PBC, using International Classification of Diseases, Ninth Revision codes. Trends in PBC‐related discharges, total charges, length of stay (LoS), and in‐hospital mortality were evaluated. Hierarchical generalized linear models were performed for determining predictors of mortality and total hospital charges. Between the study years of 2005 and 2014, a total of 22,665 hospitalized cases with PBC were identified (mean age 63 years; 84% female, 76% white). The number of PBC‐related discharges increased from 3.24 per 100,000 in 2005 to 3.68 per 100,000 in 2014, with an average annual increase of 1.4% (95% confidence interval [CI]: 0.4%‐2.4%). Fifty‐seven percent had Medicare as their primary payer, 37% had cirrhosis, and 1.3% had hepatocellular carcinoma. Between 2005 and 2014, the average total charges for PBC increased from $53,901 to $57,613 (annual percent change [APC], 1.7%; 95% CI: −0.2%‐3.5%), LoS decreased from 6.9 days to 5.4 days (APC, −2.2%; 95% CI: −3.2% to −1.1%), and mortality rate decreased from 3.8% to 2.8% (APC, −5.4%; 95% CI: −8.4% to −2.4%). Multivariable analysis revealed that ascites were independently associated with increased risk of in‐hospital mortality (odds ratio: 1.77; 95% CI: 1.50‐2.08), increased charge (percent change: 22.5%; 95% CI: 18.6%‐26.7%), and increased LoS (percent change: 29.7%; 95% CI: 25.7%‐33.9%). Conclusion: The number of PBC cases has increased in recent years. Mortality and LoS have decreased, and the total charges have remained the same.
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Affiliation(s)
- Omer Shahab
- Center for Liver Disease, Department of Medicine Inova Fairfax Hospital Falls Church VA
| | - Mehmet Sayiner
- Center for Liver Disease, Department of Medicine Inova Fairfax Hospital Falls Church VA
| | - James Paik
- Betty and Guy Beatty Center for Integrated Research Inova Health System Falls Church VA
| | - Sean Felix
- Betty and Guy Beatty Center for Integrated Research Inova Health System Falls Church VA
| | - Pegah Golabi
- Betty and Guy Beatty Center for Integrated Research Inova Health System Falls Church VA
| | - Zobair M Younossi
- Center for Liver Disease, Department of Medicine Inova Fairfax Hospital Falls Church VA.,Betty and Guy Beatty Center for Integrated Research Inova Health System Falls Church VA
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22
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Influence factors and a predictive scoring model for measuring the biochemical response of primary biliary cholangitis to ursodeoxycholic acid treatment. Eur J Gastroenterol Hepatol 2018; 30:1352-1360. [PMID: 29889683 DOI: 10.1097/meg.0000000000001186] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIMS The biochemical response after ursodeoxycholic acid (UDCA) treatment contributes toward predicting the prognosis for primary biliary cholangitis (PBC) patients. This study aimed to establish a score model that can be used for predicting the biochemical response. PATIENTS AND METHODS A total of 218 patients in the derivation group and 66 patients in the verification group were enrolled. Response endpoints were based on the Barcelona criteria combined with the Paris I criteria. We determined independent factors of the biochemical response by univariate and multivariate analyses. Then, we established a predictive score model on the basis of regression coefficients after adjusted multivariate analyses. RESULTS The median follow-up duration in the derivation and the verification group was 12.9 and 12.2 months, respectively. Multivariate logistic regression analysis after adjusting for sex and age indicated that First-UDCA treatment [odds ratio (OR)=2.543, 95% confidence interval (CI): 1.234-5.240, P=0.011], baseline alanine aminotransferase level (OR=1.265, 95% CI: 1.089-1.471, P=0.002), and baseline total bilirubin level (OR=0.571, 95% CI: 0.420-0.776, P<0.001) were independent factors that influenced the biochemical response in PBC patients after 1 year of UDCA treatment. Therefore, the resulting biochemical response prediction score model represented the sum of the points corresponding to these three variables. The area under the receiver operating characteristic curve of the score model in the derivation group and the verification group was 0.763 (95% CI: 0.701-0.817, P<0.001) and 0.798 (95% CI: 0.681-0.887, P<0.001), respectively. CONCLUSION We developed and verified an easy-to-use scoring model for the first time, which showed excellent predictive value for the biochemical response in PBC patients.
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Bossen L, Gerussi A, Lygoura V, Mells GF, Carbone M, Invernizzi P. Support of precision medicine through risk-stratification in autoimmune liver diseases – histology, scoring systems, and non-invasive markers. Autoimmun Rev 2018; 17:854-865. [DOI: 10.1016/j.autrev.2018.02.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 02/26/2018] [Indexed: 02/07/2023]
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24
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Bowlus CL. Scratching the surface of cholestatic itch treatments. Hepatology 2018; 67:2045-2048. [PMID: 29194716 DOI: 10.1002/hep.29698] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 11/27/2017] [Accepted: 11/27/2017] [Indexed: 12/07/2022]
Affiliation(s)
- Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, CA
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25
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Burman BE, Jhaveri MA, Kowdley KV. An Update on the Treatment and Follow-up of Patients with Primary Biliary Cholangitis. Clin Liver Dis 2017; 21:709-723. [PMID: 28987258 DOI: 10.1016/j.cld.2017.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Primary biliary cholangitis (PBC) is an autoimmune liver disease characterized by chronic granulomatous lymphocytic cholangitis of the small bile ducts. PBC was a leading indication for liver transplant in the United States; with early diagnosis and treatment, the majority of patients with PBC have a normal life expectancy. Pathogenesis involves inflammatory damage of bile duct epithelium secondary to innate and adaptive immune responses, and toxicity from accumulated bile acids. Cholestasis and disease progression can lead to cirrhosis. Extrahepatic complications include dyslipidemia, metabolic bone disease, and fat-soluble vitamin deficiency. Ursodeoxycholic acid is a well-established therapy. Novel targeted therapeutics are being developed.
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Affiliation(s)
- Blaire E Burman
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA 98101, USA
| | - Manan A Jhaveri
- Department of Organ Transplant & Liver Center, Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, 1124 Columbia Street, WA 98101, USA
| | - Kris V Kowdley
- Department of Organ Transplant & Liver Center, Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, 1124 Columbia Street, WA 98101, USA.
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26
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Namisaki T, Moriya K, Noguchi R, Kitade M, Kawaratani H, Yamao J, Mitoro A, Yoshida M, Sawai M, Uejima M, Mashitani T, Takeda K, Okura Y, Kaji K, Takaya H, Aihara Y, Douhara A, Nishimura N, Sawada Y, Sato S, Seki K, Yoshiji H. Liver fibrosis progression predicts survival in patients with primary biliary cirrhosis. Hepatol Res 2017; 47:E178-E186. [PMID: 27189879 DOI: 10.1111/hepr.12746] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 05/06/2016] [Accepted: 05/11/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Tadashi Namisaki
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Kei Moriya
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Ryuichi Noguchi
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Mitsuteru Kitade
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Hideto Kawaratani
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Junichi Yamao
- Department of Endoscopy and Ultrasound, Nara Medical University Hospital, Kashihara, Japan
| | - Akira Mitoro
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Motoyuki Yoshida
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Masayoshi Sawai
- Department of Endoscopy and Ultrasound, Nara Medical University Hospital, Kashihara, Japan
| | - Masakazu Uejima
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Tsuyoshi Mashitani
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Kosuke Takeda
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Yasushi Okura
- Department of Endoscopy and Ultrasound, Nara Medical University Hospital, Kashihara, Japan
| | - Kosuke Kaji
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Hiroaki Takaya
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Yosuke Aihara
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Akitoshi Douhara
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Norihisa Nishimura
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Yasuhiko Sawada
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Shinya Sato
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Kenichiro Seki
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
| | - Hitoshi Yoshiji
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Japan
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27
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Clinical significance of the Scheuer histological staging system for primary biliary cholangitis in Japanese patients. Eur J Gastroenterol Hepatol 2017; 29:23-30. [PMID: 27755231 DOI: 10.1097/meg.0000000000000765] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Inadequate response to ursodeoxycholic acid (UDCA) is associated with unfavorable outcomes in patients with primary biliary cholangitis (PBC). We aimed to identify surrogate markers for predicting long-term prognosis and biochemical response to UDCA in patients with PBC. PATIENTS AND METHODS In this single-center, retrospective study, 99 patients with PBC were classified into responders (n=53) and nonresponders (n=46) based on reductions in the γ-glutamyl transpeptidase levels at 1 year after initiating UDCA therapy (Nara criteria). We assessed whether the criteria for patentability by different countries are useful in predicting the prognosis of PBC. The accuracy of Scheuer and Nakanuma staging systems in predicting prognosis and treatment response was compared. RESULTS Nara definition had comparable utility to the Paris-II definition for selecting patients in whom UDCA monotherapy can be safely continued. Patients at Scheuer stage 1 had a significantly better prognosis than those at Scheuer stages 3 or 4 (P<0.05 and 0.0001, respectively). Patients at Nakanuma stage 4 had decreased survival compared with those at stage 1 (P<0.05). The proportion of responders to nonresponders was significantly higher in stages 1-3 PBC than in stage 4 PBC, according to both staging systems (P<0.05 for both). All patients with Scheuer stage 4 PBC were nonresponders, whereas only 28.6% (2/7) of those with Nakanuma stage 4 PBC were responders. CONCLUSION The Scheuer staging system had greater utility in predicting long-term prognosis and UDCA response than the Nakanuma staging system.
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Mayo MJ. Predicting Outcomes of Primary Biliary Cholangitis Using the GLOBE Score. Gastroenterol Hepatol (N Y) 2015; 11:842-844. [PMID: 27134602 PMCID: PMC4849514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Marlyn J Mayo
- Associate Professor Internal Medicine University of Texas Southwestern Medical Center Dallas, Texas
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29
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Abstract
Cholangiocytes (ie, the epithelial cells that line the bile ducts) are an important subset of liver cells. They are actively involved in the modification of bile volume and composition, are activated by interactions with endogenous and exogenous stimuli (eg, microorganisms, drugs), and participate in liver injury and repair. The term cholangiopathies refers to a category of chronic liver diseases that share a central target: the cholangiocyte. The cholangiopathies account for substantial morbidity and mortality given their progressive nature, the challenges associated with clinical management, and the lack of effective medical therapies. Thus, cholangiopathies usually result in end-stage liver disease requiring liver transplant to extend survival. Approximately 16% of all liver transplants performed in the United States between 1988 and 2014 were for cholangiopathies. For all these reasons, cholangiopathies are an economic burden on patients, their families, and society. This review offers a concise summary of the biology of cholangiocytes and describes a conceptual framework for development of the cholangiopathies. We also present the recent progress made in understanding the pathogenesis of and how this knowledge has influenced therapies for the 6 common cholangiopathies-primary biliary cirrhosis, primary sclerosing cholangitis, cystic fibrosis involving the liver, biliary atresia, polycystic liver disease, and cholangiocarcinoma-because the latest scientific progress in the field concerns these conditions. We performed a search of the literature in PubMed for published papers using the following terms: cholangiocytes, biliary epithelia, cholestasis, cholangiopathy, and biliary disease. Studies had to be published in the past 5 years (from June 1, 2009, through May 31, 2014), and non-English studies were excluded.
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Affiliation(s)
| | - Nicholas F LaRusso
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN.
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Zeniya M, Wada T. The therapeutic effect of UDCA is a factor in determining the prognosis of primary biliary cirrhosis. J Gastroenterol 2014; 49:1438-9. [PMID: 24898105 DOI: 10.1007/s00535-014-0969-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 05/14/2014] [Indexed: 02/04/2023]
Affiliation(s)
- Mikio Zeniya
- Health Care Center, Jikei University Hospital, Tokyo, Japan,
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Abstract
Primary biliary cirrhosis (PBC) is a chronic progressive cholestatic autoimmune liver disease characterized by the destruction of small intrahepatic bile ducts and the presence of highly specific serum antimitochondrial antibodies (AMAs). In this article, we will review the clinical, serological and histopathological features of PBC as well as the advances in the diagnosis and differential diagnosis of PBC. In addition, this article systematically describes the advances in the treatment of PBC, and the treatments include ursodeoxycholic acid (UDCA), budesonide, methotrexate (MTX), farnesoid X receptor (FXR) agonists, cyclosporine A, bezafibrate, rituximab, bone marrow-derived mesenchymal stem cell (BM-MSC) transplantation, and liver transplantation. At present, liver transplantation is the only option with known therapeutic benefit for end-stage PBC patients.
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