Predicting short-term mortality and long-term survival for hospitalized US patients with alcoholic hepatitis

Dietary fiber alleviates alcoholic liver injury via Bacteroides acidifaciens and subsequent ammonia detoxification

The gut microbiota and diet-induced changes in microbiome composition have been linked to various liver diseases, although the specific microbes and mechanisms remain understudied. Alcohol-related liver disease (ALD) is one such disease with limited therapeutic options due to its complex pathogenesis. We demonstrate that a diet rich in soluble dietary fiber increases the abundance of Bacteroides acidifaciens (B. acidifaciens) and alleviates alcohol-induced liver injury in mice. B. acidifaciens treatment alone ameliorates liver injury through a bile salt hydrolase that generates unconjugated bile acids to activate intestinal farnesoid X receptor (FXR) and its downstream target, fibroblast growth factor-15 (FGF15). FGF15 promotes hepatocyte expression of ornithine aminotransferase (OAT), which facilitates the metabolism of accumulated ornithine in the liver into glutamate, thereby providing sufficient glutamate for ammonia detoxification via the glutamine synthesis pathway. Collectively, these findings uncover a potential therapeutic strategy for ALD involving dietary fiber supplementation and B. acidifaciens.

Global prevalence, incidence, and outcomes of alcohol related liver diseases: a systematic review and meta-analysis

BACKGROUND

Alcohol related liver disease (ARLD) is one of the major chronic liver diseases worldwide. This review aimed to describe the global prevalence, incidence, and outcomes of ARLD.

METHODS

Medline, Embase, The Cochrane Library, and China National Knowledge Infrastructure (CNKI) were searched from inception to May 31, 2022. The language was restricted to English or Chinese. According to the criteria, articles describing the basic characteristics of the population were selected. Two reviewers extracted the data independently.

RESULTS

A total of 372 studies were identified: 353 were used for prevalence analysis, 7 were used for incidence analysis, and 114 were used to for outcome analysis. The prevalence of ARLD worldwide was 4.8%. The prevalence in males was 2.9%, which was higher than female (0.5%). Among the ethnic groups, the percentage was highest in Caucasians (68.9%). Alcoholic liver cirrhosis comprised the highest proportion in the disease spectrum of ARLD at 32.9%. The prevalence of ascites in ARLD population was highest (25.1%). The ARLD population who drinking for > 20 years accounted for 54.8%, and the average daily alcohol intake was 146.6 g/d. About 59.5% of ARLD patients were current or former smokers, and 18.7% were complicated with hepatitis virus infection. The incidence was 0.208/1000 person-years. The overall mortality was 23.9%, and the liver-related mortality was 21.6%.

CONCLUSION

The global prevalence of ARLD was 4.8% and was affected by sex, region, drinking years, and other factors. Therefore, removing the factors causing a high disease prevalence is an urgent requisite.

TRIAL REGISTRATION

PROSPERO Nr: CRD42021286192.

Determining Prognosis of ALD and Alcohol-associated Hepatitis

Alcohol-associated hepatitis has a poor prognosis in terms of short-term mortality and often presents with symptoms, such as jaundice, acute renal failure, and ascites. There are many prognostic models that have been developed to predict short-term and long-term mortality in these patients. Current prognostic models can be divided into static scores, which are measured at admission, and dynamic models, which measure baseline and after a certain amount of time. The efficacy of these models in predicting short-term mortality is disputed. Numerous studies across the world have compared prognostic models, such as the Maddrey's discriminant function, the model for end-stage liver disease score, model for end-stage liver disease score-Na, Glasgow alcohol-associated hepatitis score, and the age-bilirubin-international normalized ratio-creatinine (ABIC) score, to each other to determine which score is more useful for a particular context. There are also prognostic markers such as liver biopsy, breath biomarkers, and acute kidney injury that are able to predict mortality. The accuracy of these scores is a key to determining when treatment with corticosteroids is futile since there is an increased risk of infection in those treated with it. Furthermore, although these scores are helpful in predicting short-term mortality, the only factor that is able to predict long-term mortality in patients with alcohol-related liver disease is abstinence. Numerous studies have proven that even though corticosteroids provide a treatment for alcohol-associated hepatitis, it is a temporary one, at best. The purpose of this paper is to compare the historical models to current ones in their ability to predict mortality in patients with alcohol-related liver disease by analyzing multiple studies that have examined these prognostic markers. This paper also isolates the knowledge gaps in the ability to delineate which patients would benefit from corticosteroids and patients who would not and provides potential models for the future that could narrow this gap.

Prospective clinical trials and novel therapies in the medical management of severe alcohol-associated hepatitis

Content available: Author Interview and Audio Recording.

Determinants of Short- and Long-Term Outcomes of an Australian Cohort of Patients Admitted with Alcoholic Hepatitis

BACKGROUND AND AIMS

Alcoholic hepatitis is a common condition with high mortality. This study aimed to firstly describe the presentation, treatment, and short- and long-term outcomes of an Australian cohort of patients admitted to hospital with alcoholic hepatitis and secondly to validate existing prognostic models.

METHODS

This is a retrospective study of consecutive patients admitted with alcoholic hepatitis to a major academic liver center in Melbourne, Australia, between January 1, 2010, and December 31, 2019. Cases were identified through appropriate International Classification of Diseases version 10 coding as well as review of non-coded patients with compatible biochemistry. Baseline demographic data, alcohol consumption, laboratory values, treatment, and outcomes at 30 days, 90 days, and 12 months post-diagnosis were collected from electronic medical records. Mortality data were extracted from an independent state government death registry.

RESULTS

In total, 126 patients (72 males [57%], median age 51 years) were included in the final analysis. Ninety-five (75%) were cirrhotic at diagnosis, 81 (64%) met criteria for severe alcoholic hepatitis, and 41 (33%) had an infection during their index admission. 54% of eligible patients were treated with corticosteroids. 30-day and 12-month mortality rates were 8.7% and 27.1%, respectively, with hepatic encephalopathy (hazard ratio 5.45) and neutrophil-to-lymphocyte ratio (hazard ratio 1.09) independent markers for 12-month mortality on Cox regression analysis. Glasgow alcoholic hepatitis score outperformed other major prognostic models for short-term mortality.

CONCLUSIONS

The 12-month mortality rate of 27% following alcoholic hepatitis is lower than previously reported studies, with hepatic encephalopathy and neutrophil-to-lymphocyte ratio predictive of long-term outcome.

Nomogram to Predict the Survival of Chinese Patients with Alcohol-Related Liver Disease

OBJECTIVES

Alcohol-related liver disease is an increasing public health burden in China, but there is a lack of models to predict its prognosis. This study established a nomogram for predicting the survival of Chinese patients with alcohol-related liver disease (ALD).

METHODS

Hospitalized alcohol-related liver disease patients were retrospectively enrolled from 2015 to 2018 and followed up for 24 months to evaluate survival profiles. A total of 379 patients were divided into a training cohort (n = 265) and validation cohort (n = 114). Cox proportional hazard survival analysis identified survival factors of the patients in the training cohort. A nomogram was built and internally validated.

RESULTS

The 3-month, 6-month, 12-month, and 24-month survival rates for the training cohort were 82.6%, 81.1%, 74.3%, and 64.5%, respectively. The Cox analysis showed relapse (P=0.001), cirrhosis (P=0.044), liver cancer (P < 0.001), and a model for end-stage liver diseases score of ≥21 (P=0.041) as independent prognostic factors. A nomogram was built, which predicted the survival of patients in the training cohort with a concordance index of 0.749 and in the internal validation cohort with a concordance index of 0.756.

CONCLUSION

The long-term survival of Chinese alcohol-related liver disease patients was poor with a 24-month survival rate of 64.5%. Relapse, cirrhosis, liver cancer, and a model for end-stage liver disease score of ≥21 were independent risk factors for those patients. A nomogram was developed and internally validated for predicting the probability of their survival at different time points.

Electronic Medical Record-Based Case Phenotyping for the Charlson Conditions: Scoping Review

Background

Electronic medical records (EMRs) contain large amounts of rich clinical information. Developing EMR-based case definitions, also known as EMR phenotyping, is an active area of research that has implications for epidemiology, clinical care, and health services research.

Objective

This review aims to describe and assess the present landscape of EMR-based case phenotyping for the Charlson conditions.

Methods

A scoping review of EMR-based algorithms for defining the Charlson comorbidity index conditions was completed. This study covered articles published between January 2000 and April 2020, both inclusive. Embase (Excerpta Medica database) and MEDLINE (Medical Literature Analysis and Retrieval System Online) were searched using keywords developed in the following 3 domains: terms related to EMR, terms related to case finding, and disease-specific terms. The manuscript follows the Preferred Reporting Items for Systematic reviews and Meta-analyses extension for Scoping Reviews (PRISMA) guidelines.

Results

A total of 274 articles representing 299 algorithms were assessed and summarized. Most studies were undertaken in the United States (181/299, 60.5%), followed by the United Kingdom (42/299, 14.0%) and Canada (15/299, 5.0%). These algorithms were mostly developed either in primary care (103/299, 34.4%) or inpatient (168/299, 56.2%) settings. Diabetes, congestive heart failure, myocardial infarction, and rheumatology had the highest number of developed algorithms. Data-driven and clinical rule–based approaches have been identified. EMR-based phenotype and algorithm development reflect the data access allowed by respective health systems, and algorithms vary in their performance.

Conclusions

Recognizing similarities and differences in health systems, data collection strategies, extraction, data release protocols, and existing clinical pathways is critical to algorithm development strategies. Several strategies to assist with phenotype-based case definitions have been proposed.

Current Management and Future Treatment of Alcoholic Hepatitis

Excessive alcohol consumption is responsible for approximately 50% of all deaths due to cirrhosis. Although the duration and amount of alcohol consumption are the primary factors responsible for the liver injury caused by consuming alcohol, the pathogenesis of the 3 stages of alcohol-associated liver disease (ALD)-fatty liver, alcoholic hepatitis (AH), and cirrhosis- is likely multifactorial. Preexisting obesity, dysbiosis of the gut microbiome, activation of proinflammatory cytokines, and genetic factors can all contribute to the risk of developing ALD. The cornerstone of therapy for all stages of ALD is abstinence from drinking alcoholic beverages. Severe AH, defined by a Maddrey discriminant function greater than 32, warrants additional therapy. The results of multiple studies evaluating the use of glucocorticoids in the treatment of severe AH led to guidelines from international societies that recommend glucocorticoid therapy in patients with severe AH without active infection. Liver transplantation provides an effective treatment option for patients who fail glucocorticoid therapy. Recent advances in understanding the pathogenesis of AH have led to the investigation of potential therapies directed at preventing the development of steatosis, inhibiting the innate immune response, modifying the gut microbiome, and stimulating liver regeneration.

Predicting short-term and long-term mortality of hospitalized Portuguese patients with alcoholic hepatitis

BACKGROUND

Alcohol abuse can result in a spectrum of liver injury that ranges from mild fatty infiltration to alcoholic hepatitis (AH), cirrhosis, and hepatocellular carcinoma. The present study aimed to evaluate current scoring systems in predicting short-term and long-term mortality because of AH.

PATIENTS AND METHODS

Records of 170 consecutive patients with AH admitted to a tertiary center between January 2005 and October 2015 were reviewed. Clinical and biochemical parameters were retrieved for the assessment of AH scores for the day of admission (D1) and for the seventh day of hospitalization (D7). Endpoints included admission to the ICU, and 30-day, 90-day, and 1-year mortality.

RESULTS

The Maddrey discriminant function and the Model of End-Stage Liver Disease (MELD) were modest predictors of the need for ICU admission. In-hospital, 30-day, 90-day, and 1-year mortality were 15.9, 18.2, 21.8, and 30.0%, respectively. There was a numerical, albeit nonsignificant, trend for higher accuracy using D7 scores, especially the MELD, in predicting 30-day and 1-year mortality. Overall, all scores showed high negative predictive values (30 day: 91.2-98.7% and 1 year: 78.8-93.7%), but modest positive predictive values (30 day: 30.6-70.8% and 1 year: 42.1-61.2%). Survival rates were the highest among patients showing a decrease in the MELD, Glasgow Alcoholic Hepatitis Score, and Age, serum Bilirubin, International normalized ratio, and serum Creatinine score over the first week of admission.

DISCUSSION

AH scores were comparable in identifying patients at low risk of mortality up to 1 year following admission. Reassessment of the MELD, Glasgow Alcoholic Hepatitis Score, and Age, serum Bilirubin, International normalized ratio, and serum Creatinine score scores after 1 week further improved mortality prediction.

Alcoholic hepatitis: current trends in management

PURPOSE OF REVIEW

Alcohol consumption is increasing globally, as are complications of alcohol-related liver disease, including the most severe manifestation, alcoholic hepatitis. Despite the increased prevalence, many patients hospitalized with alcoholic hepatitis are either not diagnosed or inadequately treated leading to significant morbidity and high mortality rates. The purpose of this review is to discuss current challenges in the diagnosis and management of this frequently fatal condition.

RECENT FINDINGS

Recent studies and meta-analyses have improved our understanding of both the evaluation and treatment of alcoholic hepatitis including the diagnostic criteria, appropriate use of glucocorticoids and other therapeutic modalities including novel disease-specific therapeutic agents and indications for considering liver transplantation.

SUMMARY

Glucocorticoid therapy and enteral nutrition represent the best options for reducing short-term mortality in patients with the severe form of acute alcoholic hepatitis. The efficacy of other medications such as pentoxifylline as currently used does not support a role for use outside clinical trials. While the current management options for alcoholic hepatitis remain insufficient, improvements in diagnosis, determining prognosis and severity and the potential role of novel treatments provides encouragement that outcomes from this devastating condition will improve.

Alcoholic Hepatitis: Risk Factors, Pathogenesis, and Approach to Treatment

BACKGROUND

Alcoholic hepatitis (AH) is an inflammatory disorder of the liver characterized clinically by jaundice, hepatomegaly, and abdominal pain, and histologically by macrovesicular steatosis and necroinflammation.

METHODS

This clinical review will cover what is known about the pathogenesis, clinical presentation, current treatments, and novel therapies for AH.

RESULTS

The pathogenesis and treatment of AH remain areas of active research. Although abstinence is the cornerstone of therapy for all stages of alcoholic liver disease, corticosteroids have shown modest short-term benefits in treatment of severe AH.

CONCLUSIONS

Improved understanding of the pathogenesis of AH has expanded the range of potential treatments for this devastating disease. Several novel therapies are also currently in various stages of testing through clinical trials.

Incidence, survival and cause-specific mortality in alcoholic liver disease: a population-based cohort study

OBJECTIVE

We studied the incidence of severe ALD requiring hospitalization in Finland, and survival and causes of death among the ALD patients.

METHODS

A cohort of 11,873 persons (8796 men and 3077 women) with diagnosis of ALD during the years 1996-2012 was identified from Finnish national Inpatient Register. The annual incidence of alcoholic hepatitis (AH) and alcoholic liver cirrhosis was calculated. The cohort was combined with the data from national Cause of Death Register of Statistics Finland.

RESULTS

The incidence of alcoholic liver cirrhosis increased from 8.8/100,000 in year 2001 to 14.6/100,000 in year 2012 among men and from 2.4 to 4.2/100,000 among women. The incidence of AH increased from 3.7 to 6.5/100,000 among men and from 1.3 to 2.7/100,000 among women. The relative 5-year survival ratios of patients with alcoholic liver cirrhosis and AH were 29 and 50% among men and 38 and 52% among women, respectively. Out of 8440 deaths, 65% were due to alcoholic-related causes. The risk of death among ALD patients was increased in malignancies (SMR 6.82; 95% CI: 6.35-7.29), cardiovascular diseases (6.13; 5.74-6.52), respiratory diseases (7.86; 6.70-9.10), dementia (3.31; 2.41-4.44) and accidents and violence (11.12; 10.13-12.15).

CONCLUSIONS

The incidence of AH and alcoholic liver cirrhosis is increasing. The survival is poor. Most deaths are alcohol-related and other common causes of excess deaths are cancers especially in the upper aerodigestive tract and cardiovascular, digestive and respiratory diseases as well as violence and accidents.

Ammonia level at admission predicts in-hospital mortality for patients with alcoholic hepatitis

OBJECTIVE

Alcoholic hepatitis (AH), a unique clinical syndrome among patients with chronic and active alcohol use, is associated with high short-term mortality. An elevated ammonia level is associated with mortality in patients with acute liver failure; however, its impact in AH has not been well-studied.

METHODS

A retrospective study was performed on patients admitted to a tertiary-care hospital with the discharge diagnosis of AH. Patients meeting criteria for AH were included in the final data analysis. Multivariate logistic regression models were built to examine the impact of serum ammonia in predicting in-hospital mortality (IHM) and 30-day mortality (TDM). Subgroup analysis was also performed, which was limited to patients who had hepatic encephalopathy.

RESULTS

Of the 105 AH patients included, 26 (25%) died during the initial hospitalization. Among the 79 patients who survived initial hospitalization, 30 (39%) died within 30 days. Information about ammonia levels at admission was available for 82 patients. Of these, 25 patients had IHM and significantly higher ammonia level (97 vs. 69 μmol/L, P < 0.01). Among the 57 who survived hospitalization, ammonia levels were not significantly different (71 vs. 67 μmol/L, P = 0.69) in patients with and without TDM. The addition of ammonia to the multivariate regression models including age, sex, cirrhosis, treatment and model for end-stage liver disease (MELD) score improved the C statistics for IHM from 0.708 to 0.801 and for TDM from 0.756 to 0.766, respectively. These results were identical, even when limited to patients with hepatic encephalopathy.

CONCLUSION

AH patients with elevated ammonia levels at admission have higher IHM; however, they do not seem to play a significant role in 30-day mortality for patients who survived hospitalization.