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Gratacós-Ginès J, Ruz-Zafra P, Celada-Sendino M, Martí-Carretero A, Pujol C, Martín-Mateos R, Echavarría V, Frisancho LE, García S, Barreales M, Tejedor-Tejada J, Vázquez-Rodríguez S, Cañete N, Fernández-Carrillo C, Valenzuela M, Martí-Aguado D, Horta D, Quiñones M, Bernal-Monterde V, Acosta S, Artaza T, Pinazo J, Villar-Lucas C, Clemente-Sánchez A, Badia-Aranda E, Giráldez-Gallego Á, Rodríguez M, Sancho-Bru P, Cabezas J, Ventura-Cots M, Fernández-Rodríguez C, Aguilera V, Tomé S, Bataller R, Caballería J, Pose E. Recurrent alcohol-associated hepatitis is common and is associated with increased mortality. Hepatology 2024; 80:621-632. [PMID: 38441908 DOI: 10.1097/hep.0000000000000825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 02/06/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND AND AIMS Alcohol relapse after surviving an episode of alcohol-associated hepatitis (AH) is common. However, the clinical features, risk factors, and prognostic implications of recurrent alcohol-associated hepatitis (RAH) are not well described. APPROACH AND RESULTS A registry-based study was done of patients admitted to 28 Spanish hospitals for an episode of AH between 2014 and 2021. Baseline demographics and laboratory variables were collected. Risk factors for RAH were investigated using Cox regression analysis. We analyzed the severity of the index episodes of AH and compared it to that of RAH. Long-term survival was assessed by Kaplan-Meier curves and log-rank tests. A total of 1118 patients were included in the analysis, 125 (11%) of whom developed RAH during follow-up (median: 17 [7-36] months). The incidence of RAH in patients resuming alcohol use was 22%. The median time to recurrence was 14 (8-29) months. Patients with RAH had more psychiatric comorbidities. Risk factors for developing RAH included age <50 years, alcohol use >10 U/d, and history of liver decompensation. RAH was clinically more severe compared to the first AH (higher MELD, more frequent ACLF, and HE). Moreover, alcohol abstinence during follow-up was less common after RAH (18% vs. 45%, p <0.001). Most importantly, long-term mortality was higher in patients who developed RAH (39% vs. 21%, p = 0.026), and presenting with RAH independently predicted high mortality (HR: 1.55 [1.11-2.18]). CONCLUSIONS RAH is common and has a more aggressive clinical course, including increased mortality. Patients surviving an episode of AH should undergo intense alcohol use disorder therapy to prevent RAH.
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Affiliation(s)
- Jordi Gratacós-Ginès
- Department of Liver Diseases, Hospital Clínic de Barcelona, Barcelona, Spain
- Liver, Digestive System and Metabolism Department Institut d'Investigacions Biomèdiques August Pi i Sunyer, IDIBAPS, Barcelona, Spain
- Department of Liver Injury, Progression of Cirrhosis and Liver Transplantation, Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
| | - Pilar Ruz-Zafra
- Department of Digestive Diseases, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Miriam Celada-Sendino
- Department of Liver Diseases, Hospital Universitario Central de Asturias, ISPA, Oviedo, Spain
| | - Aina Martí-Carretero
- Department of Liver Diseases, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Clàudia Pujol
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Rosa Martín-Mateos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Víctor Echavarría
- Department of Gastroenterology and Hepatology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Luis E Frisancho
- Department of Liver Diseases, Hospital Parc Taulí, Sabadell, Spain
| | - Sonia García
- Department of Hepatology and Liver Transplant, Hospital Universitari i Politècnic La Fe, IISLa FE, Valencia, Spain
| | - Mónica Barreales
- Department of Liver Diseases, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Sergio Vázquez-Rodríguez
- Department of Gastroenterology. Xerencia Xestion Integrada de Vigo Research Group in Digestive Diseases, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, SERGAS, Vigo, Spain
| | - Nuria Cañete
- Liver Section, Department of Gastroenterology, Hospital del Mar, Barcelona, Spain
| | - Carlos Fernández-Carrillo
- Department of Gastroenterology and Hepatology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - María Valenzuela
- Department of Gastroenterology and Hepatology, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - David Martí-Aguado
- Digestive Disease Department, Clínic University Hospital, Biomedical Research Institute INCLIVA, Valencia, Spain
| | - Diana Horta
- Department of Digestive Diseases, Hospital Universitari Mútua Terrassa, Terrassa, Spain
| | - Marta Quiñones
- Gastroenterology Department, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | - Silvia Acosta
- Department of Digestive Diseases, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | - Tomás Artaza
- Department of Digestive Diseases, Hospital Universitario de Toledo, Toledo, Spain
| | - José Pinazo
- Department of Gastroenterology, Hospital Virgen de la Victoria, Málaga, Spain
| | - Carmen Villar-Lucas
- Department of Digestive Diseases, Hospital Universitario de Salamanca, Salamanca, Spain
| | - Ana Clemente-Sánchez
- Department of Liver Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ester Badia-Aranda
- Department of Digestive Diseases, Hospital Universitario de Burgos, Burgos, Spain
| | | | - Manuel Rodríguez
- Department of Liver Diseases, Hospital Universitario Central de Asturias, ISPA, Oviedo, Spain
| | - Pau Sancho-Bru
- Liver, Digestive System and Metabolism Department Institut d'Investigacions Biomèdiques August Pi i Sunyer, IDIBAPS, Barcelona, Spain
| | - Joaquín Cabezas
- Department of Gastroenterology and Hepatology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Meritxell Ventura-Cots
- Department of Liver Injury, Progression of Cirrhosis and Liver Transplantation, Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
- Department of Liver Diseases, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Conrado Fernández-Rodríguez
- Gastroenterology Department, Hospital Universitario Fundación Alcorcón, Madrid, Spain
- Department of Medicine, Universidad Rey Juan Carlos, Madrid, Spain
| | - Victoria Aguilera
- Department of Liver Injury, Progression of Cirrhosis and Liver Transplantation, Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
- Department of Hepatology and Liver Transplant, Hospital Universitari i Politècnic La Fe, IISLa FE, Valencia, Spain
| | - Santiago Tomé
- Department of Liver Diseases, Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Ramon Bataller
- Department of Liver Diseases, Hospital Clínic de Barcelona, Barcelona, Spain
- Department of Liver Injury, Progression of Cirrhosis and Liver Transplantation, Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
| | - Juan Caballería
- Department of Liver Diseases, Hospital Clínic de Barcelona, Barcelona, Spain
- Liver, Digestive System and Metabolism Department Institut d'Investigacions Biomèdiques August Pi i Sunyer, IDIBAPS, Barcelona, Spain
- Department of Liver Injury, Progression of Cirrhosis and Liver Transplantation, Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
| | - Elisa Pose
- Department of Liver Diseases, Hospital Clínic de Barcelona, Barcelona, Spain
- Liver, Digestive System and Metabolism Department Institut d'Investigacions Biomèdiques August Pi i Sunyer, IDIBAPS, Barcelona, Spain
- Department of Liver Injury, Progression of Cirrhosis and Liver Transplantation, Centro de Investigación Biomédica En Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
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Tu W, Liangpunsakul S, Nguyen CM, Healey R, Li Y, Radaeva S, Gawrieh S, Bataller R, Su J. Risk of mortality among patients with alcohol-associated hepatitis in the US from 2007 to 2021. Alcohol 2024; 120:143-150. [PMID: 38908609 DOI: 10.1016/j.alcohol.2024.06.006] [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: 04/03/2024] [Revised: 05/23/2024] [Accepted: 06/16/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND/AIMS Alcohol-associated hepatitis (AH) mortality and risk factors have not been carefully studied in real-world settings. We examined the rate, temporal trend, and risk factors of mortality in AH. METHODS We conducted a cohort study of individuals with AH diagnoses using medical claims data from Optum's Clinformatics® Data Mart (CDM). Participants were individuals covered by Medicare Advantage and commercial insurance policies. Cases were identified using diagnostic codes. Cox regressions were used to estimate 90 and 180-day mortality rates by hospitalization status. RESULTS The cohort included 32,001 patients (72% men) who had at least one year of continuous insurance coverage prior to AH diagnoses. Of these, 20,912 were hospitalized within seven days of diagnosis. Ninety and 180-day mortality rates were 12.0% (95% CI [11.6%, 12.5%]) and 16.0% (95% CI [15.4%, 16.5%]), respectively, for the hospitalized patients and 3.1% (95% CI [2.8%, 3.4%]) and 5.1% (95% CI [4.6%, 5.5%]) for the non-hospitalized patients. Pre-existing liver disease, even in a mild form, was associated with an increased risk of death. In hospitalized patients, a history of mild liver disease was associated with a 24% increase in 180-day mortality risk (HR = 1.24, 95% CI: [1.14, 1.36]). Moderate-to-severe liver disease was associated with a more than doubled risk (HR = 2.33, 95% CI: [2.12, 2.56]). CONCLUSIONS History of liver disease was associated with significantly increased AH mortality. The finding highlights the chronic disease context of AH and suggests that prior diagnosis of liver disease should be considered for prognosis and targeted prevention.
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Affiliation(s)
- Wanzhu Tu
- Department of Biostatistics & Health Data, Indiana University School of Medicine, Indianapolis, IN 46202, USA; Regenstrief Institute, Inc., Indianapolis, IN 46202, USA
| | - Suthat Liangpunsakul
- Roudebush Veterans Administration Medical Center, Indianapolis, IN 46202, USA; Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Chi Mai Nguyen
- Department of Biostatistics & Health Data, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Ryan Healey
- Department of Biostatistics & Health Data, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Yang Li
- Department of Biostatistics & Health Data, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Svetlana Radaeva
- National Institute of Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Samer Gawrieh
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | | | - Jing Su
- Department of Biostatistics & Health Data, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Åberg F, Jiang ZG, Cortez-Pinto H, Männistö V. Alcohol-associated liver disease-Global epidemiology. Hepatology 2024:01515467-990000000-00852. [PMID: 38640041 DOI: 10.1097/hep.0000000000000899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 03/23/2024] [Indexed: 04/21/2024]
Abstract
Alcohol-associated liver disease (ALD), as highlighted in this narrative review, is a major public health concern, increasingly impacting global disease burden and premature mortality. In 2019, ALD accounted for the loss of 11 million life-years worldwide. The rising number of deaths and disability-adjusted life-years attributed to ALD, particularly pronounced in the United States, are alarming. Projections suggest that the economic impact of ALD, as seen in the United States, could potentially double by 2040. ALD is increasingly prevalent among younger adults (20-45 y) and has become the leading cause of liver transplantation in both United States and Europe. During the COVID-19 pandemic, the existing trend was further amplified as high-risk drinking patterns coincided with a rise in hospital admissions for alcohol-associated hepatitis and increased ALD-related mortality. The prevalence of ALD is estimated at 3.5% in the general population, 26.0% among hazardous drinkers, and 55.1% among those with alcohol use disorders. Alarmingly, 5-year mortality rates for patients with ALD exceed 50%, with even higher rates in more advanced disease stages. Methodological challenges, such as underreporting, diagnostic difficulties, and variability in registry data quality, complicate the accurate assessment of the impact of ALD. Additionally, the contribution of alcohol to the progression of other liver diseases is often under acknowledged in health care registries, leading to a significant underestimation of its broader implications for liver health. Addressing the growing ALD concern requires robust public health initiatives, heightened awareness, refined diagnostic techniques, and comprehensive epidemiological studies. These measures are vital to tackle the increasing prevalence of ALD and mitigate its extensive impact on individuals and health care systems.
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Affiliation(s)
- Fredrik Åberg
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Z Gordon Jiang
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Helena Cortez-Pinto
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - Ville Männistö
- Department of Medicine, University of Eastern Finland, Kuopio, Finland
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
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Scarlata GGM, Colaci C, Scarcella M, Dallio M, Federico A, Boccuto L, Abenavoli L. The Role of Cytokines in the Pathogenesis and Treatment of Alcoholic Liver Disease. Diseases 2024; 12:69. [PMID: 38667527 PMCID: PMC11048950 DOI: 10.3390/diseases12040069] [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: 02/28/2024] [Revised: 03/27/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
Alcoholic liver disease (ALD) is a major cause of chronic liver disease. This term covers a broad spectrum of liver lesions, from simple steatosis to alcoholic hepatitis and cirrhosis. The pathogenesis of ALD is multifactorial and not fully elucidated due to complex mechanisms related to direct ethanol toxicity with subsequent hepatic and systemic inflammation. The accumulation of pro-inflammatory cytokines and the reduction of anti-inflammatory cytokines promote the development and progression of ALD. To date, there are no targeted therapies to counter the progression of chronic alcohol-related liver disease and prevent acute liver failure. Corticosteroids reduce mortality by acting on the hepatic-systemic inflammation. On the other hand, several studies analyzed the effect of inhibiting pro-inflammatory cytokines and stimulating anti-inflammatory cytokines as potential therapeutic targets in ALD. This narrative review aims to clarify the role of the main cytokines involved in the pathogenesis and treatment of ALD.
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Affiliation(s)
| | - Carmen Colaci
- Department of Health Sciences, University “Magna Græcia”, Viale Europa, 88100 Catanzaro, Italy; (G.G.M.S.); (C.C.)
| | - Marialaura Scarcella
- Anesthesia, Intensive Care and Nutritional Science, Azienda Ospedaliera “Santa Maria”, Via Tristano di Joannuccio, 05100 Terni, Italy;
| | - Marcello Dallio
- Hepatogastroenterology Division, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Piazza Miraglia 2, 80138 Naples, Italy; (M.D.); (A.F.)
| | - Alessandro Federico
- Hepatogastroenterology Division, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Piazza Miraglia 2, 80138 Naples, Italy; (M.D.); (A.F.)
| | - Luigi Boccuto
- Healthcare Genetics and Genomics Doctoral Program, School of Nursing, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC 29634, USA;
| | - Ludovico Abenavoli
- Department of Health Sciences, University “Magna Græcia”, Viale Europa, 88100 Catanzaro, Italy; (G.G.M.S.); (C.C.)
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5
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Prakash S, Tanaka T. The landscape of inpatient admissions for alcoholic hepatitis in the era of early liver transplantation. Ann Hepatol 2024; 29:101169. [PMID: 37816470 DOI: 10.1016/j.aohep.2023.101169] [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: 07/04/2023] [Revised: 08/28/2023] [Accepted: 09/11/2023] [Indexed: 10/12/2023]
Abstract
INTRODUCTION AND OBJECTIVES Liver transplant (LT) is a recent option available in the United States (US) to treat those with severe, refractory alcoholic hepatitis (AH). We examined changes in clinical characteristics of patients admitted with AH and tracked hospital outcomes as practice changes involving LT have shifted. MATERIALS AND METHODS Using the National Inpatient Sample, we performed a cross-sectional analysis of patients admitted with AH during the years 2016-2020 in the US. Differences in clinical characteristics over time were assessed. To compare outcomes between 2016-2017 (when LT was less common) and 2018-2020 (when LT was more common), we conducted linear and logistic regression. Propensity-score matching was used to compare outcomes between patients with and without LT. RESULTS From 2016-2017 to 2018-2020, patients admitted with AH tended to have a higher frequency of infection (p = 0.006), hepatorenal syndrome (<0.001), and ascites (<0.001). Hospital costs and length of stay (LOS) were highest in transplant hospitals, and costs rose over time in both non-transplant (NT) teaching and non-teaching hospitals (p < 0.001). Mortality decreased in NT teaching hospitals [aOR 0.7 (95% CI: 0.6-0.8)] and slightly decreased in NT non-teaching hospitals [aOR 0.7 (95% CI: 0.5-1.0)]. In the propensity-matched cohort involving LT versus non-LT patients, there was a 10% absolute reduction in-hospital mortality, but this came at a higher cost (p < 0.001) and length of stay (p < 0.001). CONCLUSIONS The severity of AH has been increasing over time, yet mortality has declined after adjusting for severity of disease. Patients who underwent LT survived; however, the healthcare burden of LT is substantial.
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Affiliation(s)
- Shahana Prakash
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States; Iowa City Veterans Administration Medical Center, Iowa City, IA, United States
| | - Tomohiro Tanaka
- Iowa City Veterans Administration Medical Center, Iowa City, IA, United States; Division of Gastroenterology-Hepatology, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States.
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Julien J, Ayer T, Tapper EB, Chhatwal J. The Rising Costs of Alcohol-Associated Liver Disease in the United States. Am J Gastroenterol 2024; 119:270-277. [PMID: 37463414 PMCID: PMC10872874 DOI: 10.14309/ajg.0000000000002405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/05/2023] [Indexed: 07/20/2023]
Abstract
INTRODUCTION Alcohol-associated liver disease (ALD) is rising in the United States because of an increase in high-risk drinking, but population-level ALD cost is unknown. Our aim was to project the direct and indirect costs associated with ALD in the US population through 2040. METHODS We used a previously validated microsimulation model of alcohol consumption and ALD with model parameters estimated from publicly available data sources, including the National Epidemiologic Survey Alcohol and Related Conditions-III, the Center for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research, the Bureau of Labor Statistics, and published studies informing the impact of alcohol consumption on ALD severity in the United States resident population. The simulated scenario included current and projected ALD-associated costs. RESULTS From 2022 to 2040, the ALD is projected to cost $880 billion, $355 billion in direct healthcare-related costs, and $525 billion in lost labor and economic consumption. The annual cost of ALD is projected to increase from $31 billion in 2022 to $66 billion (118% increase) in 2040. Although the female population makes up 29% of these costs in 2022, by 2040 on a per annum basis, female costs would be 43% of the total annual expenditure. DISCUSSION Increased consumption of alcohol in the US population, especially in females, will cause a steep rise in the economic burden of ALD in the United States. These findings highlight the need for planners and policymakers to plan for the increased impact of liver disease in the United States.
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Affiliation(s)
- Jovan Julien
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Turgay Ayer
- Department of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA
| | | | - Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA
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7
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Warner JB, Hardesty JE, Song YL, Floyd AT, Deng Z, Jebet A, He L, Zhang X, McClain CJ, Hammock BD, Warner DR, Kirpich IA. Hepatic Transcriptome and Its Regulation Following Soluble Epoxide Hydrolase Inhibition in Alcohol-Associated Liver Disease. THE AMERICAN JOURNAL OF PATHOLOGY 2024; 194:71-84. [PMID: 37925018 PMCID: PMC10768534 DOI: 10.1016/j.ajpath.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 09/02/2023] [Accepted: 09/27/2023] [Indexed: 11/06/2023]
Abstract
Alcohol-associated liver disease (ALD) is a serious public health problem with limited pharmacologic options. The goal of the current study was to investigate the efficacy of pharmacologic inhibition of soluble epoxide hydrolase (sEH), an enzyme involved in lipid metabolism, in experimental ALD, and to examine the underlying mechanisms. C57BL/6J male mice were subjected to acute-on-chronic ethanol (EtOH) feeding with or without the sEH inhibitor 4-[[trans-4-[[[[4-trifluoromethoxy phenyl]amino]carbonyl]-amino]cyclohexyl]oxy]-benzoic acid (TUCB). Liver injury was assessed by multiple end points. Liver epoxy fatty acids and dihydroxy fatty acids were measured by targeted metabolomics. Whole-liver RNA sequencing was performed, and free modified RNA bases were measured by mass spectrometry. EtOH-induced liver injury was ameliorated by TUCB treatment as evidenced by reduced plasma alanine aminotransferase levels and was associated with attenuated alcohol-induced endoplasmic reticulum stress, reduced neutrophil infiltration, and increased numbers of hepatic M2 macrophages. TUCB altered liver epoxy and dihydroxy fatty acids and led to a unique hepatic transcriptional profile characterized by decreased expression of genes involved in apoptosis, inflammation, fibrosis, and carcinogenesis. Several modified RNA bases were robustly changed by TUCB, including N6-methyladenosine and 2-methylthio-N6-threonylcarbamoyladenosine. These findings show the beneficial effects of sEH inhibition by TUCB in experimental EtOH-induced liver injury, warranting further mechanistic studies to explore the underlying mechanisms, and highlighting the translational potential of sEH as a drug target for this disease.
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Affiliation(s)
- Jeffrey B Warner
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky; Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, Kentucky
| | - Josiah E Hardesty
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky; Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, Kentucky
| | - Ying L Song
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Alison T Floyd
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Zhongbin Deng
- Division of Immunotherapy, Department of Surgery, University of Louisville, Louisville, Kentucky; Brown Cancer Center, University of Louisville, Louisville, Kentucky
| | - Audriy Jebet
- Department of Chemistry, University of Louisville, Louisville, Kentucky
| | - Liqing He
- Department of Chemistry, University of Louisville, Louisville, Kentucky
| | - Xiang Zhang
- Department of Chemistry, University of Louisville, Louisville, Kentucky
| | - Craig J McClain
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky; Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, Kentucky; University of Louisville Alcohol Center, University of Louisville School of Medicine, Louisville, Kentucky; University of Louisville Hepatobiology & Toxicology Center, University of Louisville School of Medicine, Louisville, Kentucky; Robley Rex Veterans Medical Center, Louisville, Kentucky
| | - Bruce D Hammock
- Department of Entomology and Nematology, Comprehensive Cancer Center, University of California, Davis, California
| | - Dennis R Warner
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Irina A Kirpich
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky; Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, Kentucky; University of Louisville Alcohol Center, University of Louisville School of Medicine, Louisville, Kentucky; University of Louisville Hepatobiology & Toxicology Center, University of Louisville School of Medicine, Louisville, Kentucky; Department of Microbiology and Immunology, University of Louisville School of Medicine, Louisville, Kentucky.
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8
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Pemmasani G, Tremaine WJ, Suresh Kumar VC, Aswath G, Sapkota B, Karagozian R, John S. Sex differences in clinical characteristics and outcomes associated with alcoholic hepatitis. Eur J Gastroenterol Hepatol 2023; 35:1192-1196. [PMID: 37577797 DOI: 10.1097/meg.0000000000002612] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
BACKGROUND Alcohol-associated liver disease is increasing among females with an earlier onset and more severe disease at lower levels of exposure. However, there is paucity of literature regarding sex differences related to alcoholic hepatitis. METHODS Hospitalized patients with alcoholic hepatitis were selected from the US Nationwide readmissions database 2019. In this cohort, we evaluated sex differences in baseline comorbidities, alcoholic hepatitis related complications and mortality. A subset of patients with alcoholic hepatitis who were hospitalized between January and June 2019 were identified to study sex differences in 6 month readmission rate, mortality during readmission, and composite of mortality during index hospitalization or readmission. RESULTS Among 112 790 patients with alcoholic hepatitis, 33.3% were female. Female patients were younger [48 (38-57) vs. 49 (39-58) years; both P < 0.001] but had higher rates of important medical and mental-health related comorbidities. Compared with males, females had higher rates of hepatic encephalopathy (11.5% vs. 10.1; P < 0.001), ascites (27.9% vs. 22.5%; P < 0.001), portal hypertension (18.5% vs. 16.4%; P < 0.001), cirrhosis (37.3% vs. 31.9%; P < 0.001), weight loss (19.0% vs. 14.5%; P < 0.001), hepatorenal syndrome (4.4% vs. 3.8%; P < 0.001), spontaneous bacterial peritonitis (1.9% vs. 1.7%; P = 0.026), sepsis (11.1% vs. 9.5%; P < 0.001), and blood transfusion (12.9% vs. 8.7%; P < 0.001). Females had a similar in-hospital mortality rate (4.3%) compared to males (4.1%; P = 0.202; adjusted odds ratio (OR) 1.02, 95% CI (cardiac index) 0.89-1.15; P = 0.994). In the subset of patients ( N = 58 688), females had a higher 6-month readmission rate (48.9% vs. 44.9%; adjusted OR 1.12 (1.06-1.18); P < 0.001), mortality during readmission (4.4% vs. 3.2%; OR 1.23 (1.08-1.40); P < 0.01), and composite of mortality during index hospitalization or readmission (8.7% vs. 7.2%; OR 1.15 (1.04-1.27); P < 0.01). CONCLUSION Compared to their male counterparts, females with alcoholic hepatitis were generally younger but had higher rates of comorbidities, alcoholic hepatitis related complications, rehospitalizations and associated mortality. The greater risks of alcohol-associated liver dysfunction in females indicate the need for more aggressive management.
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Affiliation(s)
- Gayatri Pemmasani
- Division of Gastroenterology and Hepatology, SUNY Upstate Medical University, Syracuse, New York
| | - William J Tremaine
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesto
| | | | - Ganesh Aswath
- Division of Gastroenterology and Hepatology, SUNY Upstate Medical University, Syracuse, New York
| | - Bishnu Sapkota
- Division of Gastroenterology and Hepatology, SUNY Upstate Medical University, Syracuse, New York
| | - Raffi Karagozian
- Division of Gastroenterology and Hepatology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Savio John
- Division of Gastroenterology and Hepatology, SUNY Upstate Medical University, Syracuse, New York
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9
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Niu X, Zhu L, Xu Y, Zhang M, Hao Y, Ma L, Li Y, Xing H. Global prevalence, incidence, and outcomes of alcohol related liver diseases: a systematic review and meta-analysis. BMC Public Health 2023; 23:859. [PMID: 37170239 PMCID: PMC10173666 DOI: 10.1186/s12889-023-15749-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/25/2023] [Indexed: 05/13/2023] Open
Abstract
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.
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Affiliation(s)
- Xuanxuan Niu
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Lin Zhu
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Yifan Xu
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Menghan Zhang
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Yanxu Hao
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Lei Ma
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Yan Li
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Huichun Xing
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China.
- Peking University Ditan Teaching Hospital, Beijing, 100015, China.
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10
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Chaudhry H, Sohal A, Iqbal H, Roytman M. Alcohol-related hepatitis: A review article. World J Gastroenterol 2023; 29:2551-2570. [PMID: 37213401 PMCID: PMC10198060 DOI: 10.3748/wjg.v29.i17.2551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 03/10/2023] [Accepted: 04/13/2023] [Indexed: 05/23/2023] Open
Abstract
Alcohol-related hepatitis (ARH) is a unique type of alcohol-associated liver disease characterized by acute liver inflammation caused by significant alcohol use. It ranges in severity from mild to severe and carries significant morbidity and mortality. The refinement of scoring systems has enhanced prognostication and guidance of clinical decision-making in the treatment of this complex disease. Although treatment focuses on supportive care, steroids have shown benefit in select circumstances. There has been a recent interest in this disease process, as coronavirus disease 2019 pandemic led to substantial rise in cases. Although much is known regarding the pathogenesis, prognosis remains grim due to limited treatment options. This article summarizes the epidemiology, genetics, pathogenesis, diagnosis and treatment of ARH.
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Affiliation(s)
- Hunza Chaudhry
- Department of Internal Medicine, University of California, San Francisco, Fresno, CA 93701, United States
| | - Aalam Sohal
- Department of Hepatology, Liver Institute Northwest, Seattle, WA 98105, United States
| | - Humzah Iqbal
- Department of Internal Medicine, University of California, San Francisco, Fresno, CA 93701, United States
| | - Marina Roytman
- Department of Gastroenterology and Hepatology, University of California, San Francisco, Fresno, CA 93701, United States
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11
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Durkin C, Bittermann T. Liver transplantation for alcohol-associated hepatitis. Curr Opin Organ Transplant 2023; 28:85-94. [PMID: 36512482 PMCID: PMC9992110 DOI: 10.1097/mot.0000000000001044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Early liver transplantation is emerging as a treatment option for severe alcohol-associated hepatitis refractory to pharmacotherapies. This review outlines the current status of transplantation for alcohol-associated hepatitis and the treatment of alcohol use disorder after liver transplantation. RECENT FINDINGS Rates of early liver transplantation for alcohol-associated hepatitis are increasing with significant heterogeneity in practices across the Unites States. Recent studies have demonstrated a substantial survival benefit in patients transplanted for alcohol-associated hepatitis with improved outcomes in early vs. late transplantation, first vs. prior hepatic decompensation, and posttransplant abstinence/delayed relapse vs. early return to alcohol use. Several prediction algorithms have been developed to ascertain patients' risk of alcohol relapse and aid in candidate selection, though data on treatment of alcohol use disorders in transplant recipients remains limited. SUMMARY Although controversial, early liver transplantation for severe alcohol-associated hepatitis has shown to be a lifesaving intervention. Additional research is needed to evaluate its long-term outcomes, optimize candidate selection, and understand treatment of alcohol use disorder posttransplant.
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Affiliation(s)
- Claire Durkin
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
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12
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Tu W, Gawrieh S, Dasarathy S, Mitchell MC, Simonetto DA, Patidar KR, McClain CJ, Bataller R, Szabo G, Tang Q, Barton BA, Radaeva S, Sanyal AJ, Shah V. Design of a multicenter randomized clinical trial for treatment of Alcohol-Associated Hepatitis. Contemp Clin Trials Commun 2023; 32:101074. [PMID: 36698742 PMCID: PMC9869411 DOI: 10.1016/j.conctc.2023.101074] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/04/2023] [Accepted: 01/14/2023] [Indexed: 01/19/2023] Open
Abstract
Background Mortality is high for severe alcohol-associated hepatitis (AH). Corticosteroids are the standard of care for patients without contraindications. Recent data showed that interleukin-1β receptor antagonist anakinra attenuated inflammation and liver damage. We designed a multicenter, double-blind, randomized controlled trial to assess the safety and efficacy of anakinra compared to prednisone. Methods Patients meeting the clinical and biochemical criteria for severe AH with MELD scores between 20 and 35 were recruited at eight clinical sites. Eligible patients enrolled in the study were randomized to anakinra, 100 mg subcutaneous injection for 14 days, plus zinc sulfate 220 mg for 90 days, vs. prednisone 40 mg PO daily for 30 days. Matching placebos for anakinra, zinc, and prednisone were provided to mask the treatment. Participants were followed for 180 days. The primary outcome was overall survival at 90 days. An unadjusted log-rank test was used to compare the survival of the two treatments in the first 90 days. Between July 10, 2020, and March 4, 2022, we screened 1082 patients with severe AH, and 147 eligible patients were enrolled and randomized. The average baseline MELD score was 25 [range 20-35], Maddrey discriminant function (MDF) was 59.4 [range 20.2-197.5]. The mean aspartate transaminase (AST)-to-alanine transaminase (ALT) ratio was 3.5. The baseline characteristics were not statistically different between the two treatment groups. Conclusions The study provided a direct comparison of the survival benefits and safety profiles of anakinra plus zinc vs. prednisone in patients with severe AH.
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Affiliation(s)
- Wanzhu Tu
- Indiana University School of Medicine, USA
| | | | | | | | | | | | | | | | | | - Qing Tang
- Indiana University School of Medicine, USA
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13
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Anugwom C, Thomson M, Freese RL, Lake JR, Lim N. Lower survival and higher rates of cirrhosis in patients with ROUX-EN-Y gastric bypass hospitalised with alcohol-associated hepatitis. BMJ Open Gastroenterol 2023; 10:bmjgast-2022-001083. [PMID: 36808070 PMCID: PMC9943920 DOI: 10.1136/bmjgast-2022-001083] [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: 11/28/2022] [Accepted: 01/31/2023] [Indexed: 02/23/2023] Open
Abstract
OBJECTIVE The incidence of alcohol-associated liver disease (ALD) is increasing, and weight loss surgery is more common due to the obesity epidemic. Roux-en-Y gastric bypass (RYGB) is associated with alcohol use disorder and ALD; however, its impact on outcomes in patients hospitalised for alcohol-associated hepatitis (AH) is unclear. DESIGN We performed a single-centre, retrospective study of patients with AH from June 2011 to December 2019. Primary exposure was the presence of RYGB. The primary outcome was inpatient mortality. Secondary outcomes included overall mortality, readmissions and cirrhosis progression. RESULTS 2634 patients with AH met the inclusion criteria; 153 patients had RYGB. Median age of the entire cohort was 47.3 years; median Model for End Stage Liver Disease - Sodium (MELD-Na) was 15.1 in the study group versus 10.9 in the control group. There was no difference in inpatient mortality between the two groups. On logistic regression, increased age, elevated body mass index, MELD-Na >20 and haemodialysis were all associated with higher inpatient mortality. RYGB status was associated with increased 30-day readmission (20.3% vs 11.7%, p<0.01), development of cirrhosis (37.5% vs 20.9%, p<0.01) and overall mortality (31.4% vs 24%, p=0.03). CONCLUSIONS Patients with RYGB have higher rates of readmissions, cirrhosis and overall mortality after discharge from hospital for AH. Allocation of additional resources on discharge may improve clinical outcomes and reduce healthcare expenditure in this unique patient population.
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Affiliation(s)
- Chimaobi Anugwom
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA .,Digestive Care, HealthPartners, Bloomington, Minnesota, USA
| | - Mary Thomson
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Rebecca L Freese
- Clinical and Translational Science Institute, Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - John R Lake
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Nicholas Lim
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
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14
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Aslam A, Kwo PY. Epidemiology and Disease Burden of Alcohol Associated Liver Disease. J Clin Exp Hepatol 2023; 13:88-102. [PMID: 36647400 PMCID: PMC9840073 DOI: 10.1016/j.jceh.2022.09.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 09/06/2022] [Indexed: 01/19/2023] Open
Abstract
Consumption of alcohol in excess leads to substantial medical, economic, and societal burdens. Approximately 5.3% of all global deaths may be attributed to alcohol consumption. Moreover, the burden of alcohol associated liver disease (ALD) accounts for 5.1% of all disease and injury worldwide. Alcohol use disorder (AUD) affects men more than women globally with significant years of life loss to disability in low, middle and well-developed countries. Precise data on global estimates of alcohol related steatosis, alcohol related hepatitis, and alcohol related cirrhosis have been challenging to obtain. In the United States (US), alcohol related steatosis has been estimated at 4.3% based on NHANES data which has remained stable over 14 years. However, alcohol-related fibrotic liver disease has increased over the same period. In those with AUD, the prevalence of alcohol related hepatitis has been estimated at 10-35%. Globally, the prevalence of alcohol-associated cirrhosis has been estimated at 23.6 million individuals for compensated cirrhosis and 2.46 million for those with decompensated cirrhosis. The contribution of ALD to global mortality and disease burden of liver related deaths is substantial. In 2016 liver disease related to AUD contributed to 50% of the estimated liver disease deaths for age groups 15 years and above. Data from the US report high cost burdens associated with those admitted with alcohol-related liver complications. Finally, the recent COVID-19 pandemic has been associated with marked increase in alcohol consumption worldwide and will likely increase the burden of ALD.
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Key Words
- AAPC, Average annual percentage change
- ABIC, Age, Serum bilirubin, INR and serum Creatinine
- ABV, Alcohol by volume
- ALD, Alcohol-associated liver disease
- AUD, Alcohol use disorder
- BAC, Blood alcohol concentration
- CDC, Centers for Disease Control and Prevention
- COVID-19, Coronavirus disease 2019
- GAHS, Glasgow alcoholic hepatitis score
- HE, Hepatic encephalopathy
- HRS, Hepatorenal syndrome
- ICD-10, International Classification of Diseases, 10th Edition
- MDF, Maddrey's Discriminant Function
- MELD, Model of end-stage liver disease
- MRI, Magnetic resonance imaging
- NHANES, National Health and Nutrition Examination Survey
- NIAAA, National Institute of Alcohol Abuse and Alcoholism
- NIS, National inpatient sample
- NSDUH, Annual National Survey on Drug Use and Health
- SAMHSA, Substance Abuse and Mental Health Services Administration
- US, United States
- USG, Ultrasonography
- WHO, World Health Organization
- YLD, Years of life lost to disability
- alcohol
- alcohol use disorder
- alcoholic cirrhosis
- alcoholic hepatitis
- alcoholic steatosis
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Affiliation(s)
- Aysha Aslam
- Stanford University School of Medicine, 430 Broadway, Pavilion C, 3rd Floor, Redwood City, CA 94063, USA
| | - Paul Y. Kwo
- Stanford University School of Medicine, 430 Broadway, Pavilion C, 3rd Floor, Redwood City, CA 94063, USA
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15
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Narrative Review: Glucocorticoids in Alcoholic Hepatitis—Benefits, Side Effects, and Mechanisms. J Xenobiot 2022; 12:266-288. [PMID: 36278756 PMCID: PMC9589945 DOI: 10.3390/jox12040019] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/03/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022] Open
Abstract
Alcoholic hepatitis is a major health and economic burden worldwide. Glucocorticoids (GCs) are the only first-line drugs recommended to treat severe alcoholic hepatitis (sAH), with limited short-term efficacy and significant side effects. In this review, I summarize the major benefits and side effects of GC therapy in sAH and the potential underlying mechanisms. The review of the literature and data mining clearly indicate that the hepatic signaling of glucocorticoid receptor (GR) is markedly impaired in sAH patients. The impaired GR signaling causes hepatic down-regulation of genes essential for gluconeogenesis, lipid catabolism, cytoprotection, and anti-inflammation in sAH patients. The efficacy of GCs in sAH may be compromised by GC resistance and/or GC’s extrahepatic side effects, particularly the side effects of intestinal epithelial GR on gut permeability and inflammation in AH. Prednisolone, a major GC used for sAH, activates both the GR and mineralocorticoid receptor (MR). When GC non-responsiveness occurs in sAH patients, the activation of MR by prednisolone might increase the risk of alcohol abuse, liver fibrosis, and acute kidney injury. To improve the GC therapy of sAH, the effort should be focused on developing the biomarker(s) for GC responsiveness, liver-targeting GR agonists, and strategies to overcome GC non-responsiveness and prevent alcohol relapse in sAH patients.
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16
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Birnbaum JA, Herman HS, Gao Q, Koenigsberg M, Sigal SH. The Prognostic Significance of the Platelet Count in Alcoholic Hepatitis. GASTRO HEP ADVANCES 2022; 2:8-15. [PMID: 39130158 PMCID: PMC11308416 DOI: 10.1016/j.gastha.2022.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/29/2022] [Indexed: 08/13/2024]
Abstract
Background and Aims Thrombocytopenia is present in up to 76% of patients with chronic liver disease, and lower platelet counts (PCs) are associated with greater severity of portal hypertension. In this study, we assess the relationship of PC in patients with a clinical diagnosis of severe alcoholic hepatitis (SAH) with clinical severity and response to corticosteroid (CS) therapy. Methods Clinical characteristics, treatment, and hospital outcomes for patients admitted with SAH were analyzed from an electronic health record system. Patients were categorized based on admission PC (k/uL) into 5 categories: <50, 50-99, 100-149, 150-199, and ≥200. Frequency of complications (acute kidney injury, ascites, and hepatic encephalopathy), length of stay, and admission to an intensive care unit were analyzed across PC categories. Characteristics of patients who did and did not receive at least 4 days of CS therapy were compared. Results Among 159 patients, 15 (9.4%) were in the PC < 50 category, 42 (26.4%) in PC 50-99, 51 (32%) in PC 100-149, 23 (14.5%) in PC 150-199, and 28 (17.6%) in PC ≥ 200. A higher admission PC was associated with greater white blood cell count, absolute neutrophil count, and total bilirubin (P < .05). Patients with higher PC on admission were more likely to receive steroids. PC was inversely associated with Lille score at treatment day 4 (P < .05). Conclusion A higher PC in SAH was associated with a greater inflammatory response and total bilirubin. Patients with a higher PC were more likely to receive CS and have a favorable treatment response.
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Affiliation(s)
| | | | - Qi Gao
- Albert Einstein College of Medicine, Bronx, New York
| | - Mordecai Koenigsberg
- Albert Einstein College of Medicine, Bronx, New York
- Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Samuel H. Sigal
- Albert Einstein College of Medicine, Bronx, New York
- Division of Hepatology, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
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17
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Marlowe N, Lam D, Krebs W, Lin W, Liangpunsakul S. Prevalence, co-morbidities, and in-hospital mortality of patients hospitalized with alcohol-associated hepatitis in the United States from 2015 to 2019. Alcohol Clin Exp Res 2022; 46:1472-1481. [PMID: 35778777 DOI: 10.1111/acer.14896] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/29/2022] [Accepted: 06/24/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The goals of our study are to determine the most recent trends in hospitalization, mortality, and healthcare utilization among hospitalized patients with alcohol-associated hepatitis (AH) in the United States. METHODS We examined the recent prevalence, co-morbidities, and mortality in hospitalized AH patients in the United States based on the available National Inpatient Sample (NIS) data (2015 to 2019) using appropriate International Classification of Diseases (ICD) codes. We reported our data as national estimates based on the discharge weighting variable (DISCWT). Logistic regression analyses were used to determine factors associated with mortality. RESULTS We observed an increase in the total number of hospitalized AH patients from 110,135 in 2015 to 136,620 in 2019, which represented 386 per 100,000 total hospitalizations or 42 per 100,000 US population, which in 2019 was 328 million. Patients were a mean of 48 years old and the majority were White and male. The average length of stay was around 6 days with an overall in-hospital mortality that decreased from 4.19% in 2015 to 3.86% in 2019 (p-value for trend = <0.0001). During the 5-year study period, a total of 24,795 hospitalized AH patients died and 592,885 survived the hospital stay. Those who died were older, had a longer length of stay, and higher hospital charges during the stay. Mortality was significantly greater in patients who presented with complications from portal hypertension, those with acute renal failure, underlying cirrhosis, and sepsis. CONCLUSIONS Our study documented the increasing prevalence of hospitalized AH patients and their significant associated healthcare costs and utilization. Our results underscore a continuing unmet and urgent need to identify effective therapies for hospitalized AH patients.
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Affiliation(s)
| | - David Lam
- Pharma Analytics, San Anselmo, California, USA
| | - William Krebs
- William B, Krebs Consulting Statistician, San Francisco, California, USA
| | - WeiQi Lin
- Durect Corporation, Cupertino, California, USA
| | - Suthat Liangpunsakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis, Indiana, USA
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18
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Proteomic analysis of alcohol-associated hepatitis reveals glycoprotein NMB (GPNMB) as a novel hepatic and serum biomarker. Alcohol 2022; 99:35-48. [PMID: 34923085 PMCID: PMC8919678 DOI: 10.1016/j.alcohol.2021.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 10/29/2021] [Accepted: 11/30/2021] [Indexed: 12/14/2022]
Abstract
Alcohol consumption remains a leading cause of liver disease worldwide, resulting in a complex array of hepatic pathologies, including steatosis, steatohepatitis, and cirrhosis. Individuals who progress to a rarer form of alcohol-associated liver disease (ALD), alcohol-associated hepatitis (AH), require immediate life-saving intervention in the form of liver transplantation. Rapid onset of AH is poorly understood and the metabolic mechanisms contributing to the progression to liver failure remain undetermined. While multiple mechanisms have been identified that contribute to ALD, no cures exist and mortality from AH remains high. To identify novel pathways associated with AH, our group utilized proteomics to investigate AH-specific biomarkers in liver explant tissues. The goal of the present study was to determine changes in the proteome as well as epigenetic changes occurring in AH. Protein abundance and acetylomic analyses were performed utilizing nHPLC-MS/MS, revealing significant changes to proteins associated with metabolic and inflammatory fibrosis pathways. Here, we describe a novel hepatic and serum biomarker of AH, glycoprotein NMB (GPNMB). The anti-inflammatory protein GPNMB was significantly increased in AH explant liver and serum compared to healthy donors by 50-fold and 6.5-fold, respectively. Further, bioinformatics analyses identified an AH-dependent decrease in protein abundance across fatty acid degradation, biosynthesis of amino acids, and carbon metabolism. The greatest increases in protein abundance were observed in pathways for focal adhesion, lysosome, phagosome, and actin cytoskeleton. In contrast with the hyperacetylation observed in murine models of ALD, protein acetylation was decreased in AH compared to normal liver across fatty acid degradation, biosynthesis of amino acids, and carbon metabolism. Interestingly, immunoblot analysis found epigenetic marks were significantly increased in AH explants, including Histone H3K9 and H2BK5 acetylation. The increased acetylation of histones likely plays a role in the altered proteomic profile observed, including increases in GPNMB. Indeed, our results reveal that the AH proteome is dramatically impacted through unanticipated and unknown mechanisms. Understanding the origin and consequences of these changes will yield new mechanistic insight for ALD as well as identify novel hepatic and serum biomarkers, such as GPNMB.
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19
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Aby ES, Lake JR. The Rush to Early Liver Transplantation for Alcoholic Hepatitis-Potential Financial Implications. Liver Transpl 2022; 28:9-10. [PMID: 34455686 DOI: 10.1002/lt.26282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 08/17/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Elizabeth S Aby
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN
| | - John R Lake
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN
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Rehman A, Mehta KJ. Betaine in ameliorating alcohol-induced hepatic steatosis. Eur J Nutr 2021; 61:1167-1176. [PMID: 34817678 PMCID: PMC8921017 DOI: 10.1007/s00394-021-02738-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/03/2021] [Indexed: 01/15/2023]
Abstract
Alcohol-associated liver disease (AALD) is one of most common chronic liver diseases. Hepatic steatosis is the earliest stage in AALD pathological spectrum, reversible by alcohol abstinence. Untreated steatosis can progress to steatohepatitis, fibrosis and/or cirrhosis. Considering the difficulties in achieving complete abstinence, challenges in disease reversal at advanced stages, high costs of AALD management and lack of standardised prescribed medications for treatment, it is essential to explore low-cost natural compounds that can target AALD at an early stage and halt or decelerate disease progression. Betaine is a non-hazardous naturally occurring nutrient. Here, we address the mechanisms of alcohol-induced hepatic steatosis, the role of betaine in reversing the effects i.e., its action against hepatic steatosis in animal models and humans, and the associated cellular and molecular processes. Accordingly, the review discusses how betaine restores the alcohol-induced reduction in methylation potential by elevating the levels of S-adenosylmethionine and methionine. It details how betaine reinstates alcohol-induced alterations in the expressions and/or activities of protein phosphtase-2A, FOXO1, PPAR-α, AMPK, SREBP-1c, fatty acid synthase, diacylglycerol transferase-2, adiponectin and nitric oxide. Interrelationships between these factors in preventing de novo lipogenesis, reducing hepatic uptake of adipose-tissue-derived free fatty acids, promoting VLDL synthesis and secretion, and restoring β-oxidation of fatty acids to attenuate hepatic triglyceride accumulation are elaborated. Despite its therapeutic potential, very few clinical trials have examined betaine’s effect on alcohol-induced hepatic lipid accumulation. This review will provide further confidence to conduct randomised control trials to enable maximum utilisation of betaine’s remedial properties to treat alcohol-induced hepatic steatosis.
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Affiliation(s)
- Aisha Rehman
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Kosha J Mehta
- Centre for Education, Faculty of Life Sciences and Medicine, King's College London, London, UK.
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21
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Winters AC, May FP, Wang Y, Shao P, Yang L, Patel AA. Alcohol use disorder treatment and outcomes among hospitalized adults with alcoholic hepatitis. DRUG AND ALCOHOL DEPENDENCE REPORTS 2021; 1:100004. [PMID: 36843910 PMCID: PMC9948931 DOI: 10.1016/j.dadr.2021.100004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/04/2021] [Accepted: 11/04/2021] [Indexed: 11/25/2022]
Abstract
Purpose : The burden of alcohol-associated liver disease (ALD) in the United States (US) has continued to worsen in the background of rising rates of alcohol use disorder. Patients with ALD present to care at a late stage, often with the sequela of liver decompensation, such as gastrointestinal bleeding and infection. ALD is now the leading indication for liver transplantation. We aimed to measure the quality of care delivered to hospitalized patients with alcoholic hepatitis (AH) across 3 domains: 1) alcohol-use disorder (AUD) care, 2) inpatient cirrhosis care, and 3) alcohol-associated liver disease (ALD) care-and observe associations between quality of care and outcomes. Methods : We included hospital encounters between January 1, 2016 and January 1, 2019 to a large, diverse integrated health system for AH with active alcohol use within the prior 60 days. The diagnosis of AH was determined based on previously published clinical and laboratory criteria. Quality indicator (QI) pass rates were calculated as the proportion of patients eligible for each indicator who received the QI within the timeframe specified. We then evaluated the association between the receipt of all QIs and 6-month mortality, as well as AUD-specific QIs and 30-day readmission. Results : Of the 179 patients, the median age was 47 years-old, 59.2% were male and 49.2% were non-Hispanic White. The median Model for End-Stage Liver Disease-Sodium score was 25, while the median discriminant function was 33. Patients were followed for an average of 21 months. Overall, 14% of patients died during the index hospitalization while 17.3% died following discharge and 24.8% were re-admitted within 30-days. QI pass-rates were variable across the different domains. Few patients received AUD care-pass rates for receipt of pharmacotherapy and behavioral therapy at 6 months were only 19.1% and 35.1%, respectively. There was a significant association between receiving behavioral therapy and 6-month mortality-3% vs 18%, p = 0.05. Conclusion : The quality of care received during hospital encounters for AH is variable, and AUD-specific therapy is low. Future quality of care initiatives are warranted to link patients to AUD treatment to ensure optimal care and maximize patients survival in this at-risk population.
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Affiliation(s)
- Adam C. Winters
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Folasade P. May
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Yun Wang
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Paul Shao
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Liu Yang
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Arpan A. Patel
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA,Corresponding author.
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22
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Han S, Yang Z, Zhang T, Ma J, Chandler K, Liangpunsakul S. Epidemiology of Alcohol-Associated Liver Disease. Clin Liver Dis 2021; 25:483-492. [PMID: 34229835 PMCID: PMC8996817 DOI: 10.1016/j.cld.2021.03.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Alcohol-associated liver disease (ALD) is a consequence of excessive alcohol use. It comprises a spectrum of histopathologic changes ranging from simple steatosis, steatohepatitis, and cirrhosis to hepatocellular carcinoma. The public health impact of ALD is growing because of an increase in the prevalence and incidence of ALD in parallel with liver transplant and mortalities. There are multiple factors involved in the pathogenesis and progression of ALD. Reducing alcohol consumption is the cornerstone of ALD management. The efforts to reduce excessive alcohol use at the individual and population levels are urgently needed to prevent adverse outcomes from ALD.
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Affiliation(s)
- Sen Han
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, Indianapolis, IN 46202, USA,Key Laboratory of Carcinogenesis and Translational Research, Peking University Cancer Hospital, Beijing, China
| | - Zhihong Yang
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, Indianapolis, IN 46202, USA
| | - Ting Zhang
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, Indianapolis, IN 46202, USA
| | - Jing Ma
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, Indianapolis, IN 46202, USA
| | - Kristina Chandler
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, Indianapolis, IN 46202, USA
| | - Suthat Liangpunsakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, Indianapolis, IN 46202, USA,Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, USA,Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA,Corresponding author. Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, Indianapolis, IN 46202.
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23
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Avanceña AL, Miller N, Uttal SE, Hutton DW, Mellinger JL. Cost-effectiveness of alcohol use treatments in patients with alcohol-related cirrhosis. J Hepatol 2021; 74:1286-1294. [PMID: 33326815 PMCID: PMC8177741 DOI: 10.1016/j.jhep.2020.12.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 11/24/2020] [Accepted: 12/03/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Alcohol use treatment such as medication-assisted therapies (MATs) and counseling are available and effective in promoting alcohol abstinence. We sought to explore the cost-effectiveness of different alcohol use treatments among patients with compensated alcohol-related cirrhosis (AC). METHODS We simulated a cohort of patients with compensated AC receiving care from a hepatology clinic over their lifetimes. We estimated costs (in 2017 US$) and benefits in terms of quality-adjusted life years (QALYs) gained from healthcare and societal perspectives. Transition probabilities, costs, and health utility weights were taken from the literature. Treatment effects of FDA-approved MATs (acamprosate and naltrexone) and non-FDA approved MATs (baclofen, gabapentin, and topiramate) and counseling were based on a study of employer-insured patients with AC. We calculated incremental cost-effectiveness ratios (ICERs) and performed one-way and probabilistic sensitivity analyses to understand the impact of parameter uncertainty. RESULTS Compared to a do-nothing scenario, MATs and counseling were found to be cost-saving from a healthcare perspective, which means that they provide more benefits with less costs than no intervention. Compared to other interventions, acamprosate and naltrexone cost the least and provide the most QALYs. If the effectiveness of MATs and counseling decreased, these interventions would still be cost-effective based on the commonly used $100,000 per QALY gained threshold. Several sensitivity and scenario analyses showed that our main findings are robust. CONCLUSIONS Among patients with compensated AC, MATs and counseling are extremely cost-effective, and in some cases cost-saving, interventions to prevent decompensation and improve health. Health policies (e.g. payer reimbursement) should emphasize and appropriately compensate for these interventions. LAY SUMMARY Alcohol use treatments, including physician counseling and medication-assisted therapies (MATs), improve the outcomes of patients with compensated alcohol-related cirrhosis, though use and access have remained suboptimal. In this study, we found that counseling and MATs are extremely cost-effective, and in some cases cost-saving, interventions to help patients with alcohol-related cirrhosis abstain from alcohol and improve their health. Wider use of these interventions should be encouraged.
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Affiliation(s)
- Anton L.V. Avanceña
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA,Corresponding author: Anton Avanceña, Department of Health Management and Policy, University of Michigan School of Public Health, 1415 Washington Heights, SPH II, Ann Arbor, MI 48109. . Phone: +1-734-0287. Fax: +1-734-764-4338
| | - Nicholas Miller
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Sarah E. Uttal
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - David W. Hutton
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA,Department of Industrial and Operations Engineering, College of Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Jessica L. Mellinger
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
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24
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Foncea CG, Sporea I, Lupușoru R, Moga TV, Bende F, Șirli R, Popescu A. Day-4 Lille Score Is a Good Prognostic Factor and Early Predictor in Assessing Therapy Response in Patients with Liver Cirrhosis and Severe Alcoholic Hepatitis. J Clin Med 2021; 10:jcm10112338. [PMID: 34071799 PMCID: PMC8198529 DOI: 10.3390/jcm10112338] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/16/2021] [Accepted: 05/25/2021] [Indexed: 12/12/2022] Open
Abstract
Lille score at Day 7 (LM7) helps to predict the outcome of patients with severe alcoholic hepatitis (sAH) undergoing corticotherapy. Several scores such as Maddrey’s discriminant function (MDF), MELD, ABIC, and GAHS are used for a 28-day mortality prognosis. Our study aimed to evaluate if the assessment of the Lille score at 4 days (LM4) is as useful as the Lille score at Day 7 (LM7) to predict response to corticosteroids and 28-day mortality and evaluate the utility of severity scores at admission for predicting the prognosis of patients with liver cirrhosis (LC) and severe alcoholic hepatitis (sAH). A retrospective study was performed, and all consecutive patients with AH and MDF > 32 without contraindications to corticosteroids were included. Prognostic scores were evaluated at admission, and 28-day mortality was assessed. Response to corticotherapy was assessed by LM4 and LM7. Results: A total of 55/103 patients with sAH (51.5%) had MDF > 32 and received corticosteroids. There was no difference between the proportion of patients with a responder LM4 versus LM7 (27% vs. 36%, p = 0.31). The mean value for LM4 was 0.64 ± 0.3 versus 0.60 ± 0.3 for LM7 (p = 0.48). Precisely 90.3% of patients were correctly identified as responders or not by LM4 compared with LM7. The best model for predicting 28-day mortality was composed of MELD and LM4/LM7, with an accuracy of 0.90 for both combinations. Conclusion: LM4 could be used instead of LM7 for predicting response to corticosteroid therapy in patients with sAH and LC, as well as 28-day mortality. Using LM4, we could avoid prolonged use of this therapy and its complications.
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Affiliation(s)
- Camelia Gianina Foncea
- Department of Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, Piața Eftimie Murgu 2, 300041 Timișoara, Romania; (C.G.F.); (I.S.); (R.L.); (T.V.M.); (F.B.); (R.Ș.)
- Center of Advanced Research in Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Ioan Sporea
- Department of Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, Piața Eftimie Murgu 2, 300041 Timișoara, Romania; (C.G.F.); (I.S.); (R.L.); (T.V.M.); (F.B.); (R.Ș.)
- Center of Advanced Research in Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Raluca Lupușoru
- Department of Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, Piața Eftimie Murgu 2, 300041 Timișoara, Romania; (C.G.F.); (I.S.); (R.L.); (T.V.M.); (F.B.); (R.Ș.)
- Center for Modeling Biological Systems and Data Analysis, Department of Functional Science, University of Medicine and Pharmacy “Victor Babeș”, 300041 Timișoara, Romania
| | - Tudor Voicu Moga
- Department of Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, Piața Eftimie Murgu 2, 300041 Timișoara, Romania; (C.G.F.); (I.S.); (R.L.); (T.V.M.); (F.B.); (R.Ș.)
- Center of Advanced Research in Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Felix Bende
- Department of Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, Piața Eftimie Murgu 2, 300041 Timișoara, Romania; (C.G.F.); (I.S.); (R.L.); (T.V.M.); (F.B.); (R.Ș.)
- Center of Advanced Research in Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Roxana Șirli
- Department of Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, Piața Eftimie Murgu 2, 300041 Timișoara, Romania; (C.G.F.); (I.S.); (R.L.); (T.V.M.); (F.B.); (R.Ș.)
- Center of Advanced Research in Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Alina Popescu
- Department of Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, Piața Eftimie Murgu 2, 300041 Timișoara, Romania; (C.G.F.); (I.S.); (R.L.); (T.V.M.); (F.B.); (R.Ș.)
- Center of Advanced Research in Gastroenterology and Hepatology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Correspondence: ; Tel.: +40-748-331233
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25
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Waleed M, Abdallah MA, Kuo YF, Arab JP, Wong R, Singal AK. Higher Frequency of Hospital-Acquired Infections but Similar In-Hospital Mortality Among Admissions With Alcoholic Hepatitis at Academic vs. Non-academic Centers. Front Physiol 2020; 11:594138. [PMID: 33343391 PMCID: PMC7744884 DOI: 10.3389/fphys.2020.594138] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/26/2020] [Indexed: 12/20/2022] Open
Abstract
Background Alcoholic hepatitis (AH) is a unique syndrome characterized by high short-term mortality. The impact of the academic status of a hospital (urban and teaching) on outcomes in AH is unknown. Methods National Inpatient Sample dataset (2006–2014) on AH admissions stratified to academic center (AC) or non-academic center (NAC) and analyzed for in-hospital mortality (IHM), hospital resource use, length of stay in days (d), and total charges (TC) in United States dollars (USD). Admission year was stratified to 2006–2008 (TMI), 2009–2011 (TM2), and 2012–2014 (TM3). Results Of 62,136 AH admissions, the proportion at AC increased from 46% in TM1 to 57% in TM3, Armitage trend, p < 0.001. On logistic regression, TM3, younger age, black race, Medicaid and private insurance, and development of acute on chronic liver failure (ACLF) were associated with admission to an AC. Of 53,264 admissions propensity score matched for demographics, pay status, and disease severity, admissions to AC vs. NAC (26,622 each) were more likely to have liver disease complications (esophageal varices, ascites, and hepatic encephalopathy) and hospital-acquired infections (HAI), especially Clostridioides difficile and ventilator-associated pneumonia. Admissions to AC were more likely transfers from outside hospital (1.6% vs. 1.3%) and seen by palliative care (4.8% vs. 3.3%), p < 0.001. Use of endoscopy, dialysis, and mechanical ventilation were similar. With similar IHM comparing AC vs. NAC (7.7% vs. 7.8%, p = 0.93), average LOS and number of procedures were higher at AC (7.7 vs. 7.1 d and 2.3 vs. 1.9, respectively, p < 0.001) without difference on total charges ($52,821 vs. $52,067 USD, p = 0.28). On multivariable logistic regression model after controlling for demographics, ACLF grade, and calendar year, IHM was similar irrespective of academic status of the hospital, HR (95% CI): 1.01 (0.93–1.08, p = 0.70). IHM decreased over time, with ACLF as strongest predictor. A total of 63 and 22% were discharged to home and skilled nursing facility, respectively, without differences on academic status of the hospital. Conclusion Admissions with AH to AC compared to NAC have higher frequency of liver disease complications and HAI, with longer duration of hospitalization. Prospective studies are needed to reduce HAI among hospitalized patients with AH.
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Affiliation(s)
- Muhammad Waleed
- Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, United States
| | - Mohamed A Abdallah
- Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, United States
| | - Yong-Fang Kuo
- Department of Biostatistics, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Juan P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Robert Wong
- Division of Gastroenterology and Hepatology, Alameda Health System Highland Hospital, Oakland, CA, United States
| | - Ashwani K Singal
- Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, United States.,Division of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, SD, United States
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26
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Dasarathy S, Mitchell MC, Barton B, McClain CJ, Szabo G, Nagy LE, Radaeva S, McCullough AJ. Design and rationale of a multicenter defeat alcoholic steatohepatitis trial: (DASH) randomized clinical trial to treat alcohol-associated hepatitis. Contemp Clin Trials 2020; 96:106094. [PMID: 32739495 DOI: 10.1016/j.cct.2020.106094] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/26/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND/AIMS Despite high mortality of alcohol-associated hepatitis, there has been limited advancement in treatment strategies. Defeat Alcoholic Steatohepatitis (DASH) is a multicenter, randomized, double-blind controlled trial whose primary objective was to evaluate the safety and efficacy of a novel combination of 3 drugs targeting different perturbations in AH. METHODS Severe AH was diagnosed by liver biopsy or clinical and biochemical criteria and model for end stage liver disease (MELD) score ≥ 20 stratified by MELD scores (20-25 and ≥ 26) and randomized to a combination of an interleukin receptor 1 antagonist, Anakinra(100 mg daily for 14 days) to suppress acute inflammation, pentoxifylline (400 mg three times a day for 28 days) to prevent hepatorenal syndrome, and zinc sulfate (220 mg orally once daily for 6 months) or the standard of care therapy including methylprednisolone 32 mg orally once daily for 28 days. The primary efficacy outcome was the unadjusted log-rank test of the Kaplan-Meier survival estimates for the two treatment groups at 180 days. RESULTS Between July 2012 to March 2018, 500 subjects with severe AH were screened of which 104 subjects were enrolled with MELD score of 25.6 ± 3.2 (20.0-35.0) in the investigational arm and 25.8 ± 4.5 (20.0-40.0) in the standard of care arm. Causes of screen failures included not meeting eligibility criteria (n = 347), declining to participate (n = 39), and other reasons (n = 10). CONCLUSIONS Data from the DASH consortium studies will determine if a combination of drugs targeting multiple mechanisms of injury in the severe AH will improve clinical outcomes.
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Affiliation(s)
| | | | | | | | - Gyongyi Szabo
- Harvard Medical School & Beth Israel Deaconess Medical Center, USA
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27
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Esmaeili A, Yu W, Cucciare MA, Combs AS, Joshi G, Humphreys K. Budget Impact Analysis of a Computer-Delivered Brief Alcohol Intervention in Veterans Affairs (VA) Liver Clinics: A Randomized Controlled Trial. ALCOHOLISM TREATMENT QUARTERLY 2020. [DOI: 10.1080/07347324.2020.1760755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Aryan Esmaeili
- U.S. Department of Veterans Affairs, Health Economics Resource Center, Menlo Park, California, USA
| | - Wei Yu
- U.S. Department of Veterans Affairs, Health Economics Resource Center, Menlo Park, California, USA
| | - Michael A. Cucciare
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System, North Little Rock, Arkansas, USA
- Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Ann S. Combs
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA
| | - Gauri Joshi
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA
| | - Keith Humphreys
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California, USA
- Department of Psychiatry, Stanford University, Stanford, California, USA
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28
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Increasing Burden of Acute-On-Chronic Liver Failure Among Alcohol-Associated Liver Disease in the Young Population in the United States. Am J Gastroenterol 2020; 115:88-95. [PMID: 31651447 DOI: 10.14309/ajg.0000000000000411] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Alcohol-associated liver disease is increasing, especially hospitalizations with acute on chronic liver failure and need for liver transplant. We examined trends in prevalence, inhospital mortality, and resource utilization associated with AALD and ACLF in the young. METHODS The National Inpatient Sample (2006-2014) was queried for hospitalizations with a discharge diagnosis of cirrhosis using the International Classification of Diseases, Ninth Edition, codes. ACLF hospitalization was defined as ≥2 organ failures and stratified by age: young (≤35 years) and older (>35 years). RESULTS Of 447,090 AALD admissions (16,126 in young) between 2006 and 2014, ACLF occurred in 29,599 (6.6%), of which 1,143 (7.1%) were in young. Compared with older, admissions in young had more women (35% vs 29%), were obese (11% vs 7.6%), were Hispanics (29% vs 18%), have alcoholic hepatitis (AH) (41% vs 17%), and have ACLF grades 2 or 3 (34% vs 25%), P < 0.001 for all. Between 2006 and 2014, ACLF in AALD among young increased from 2.8% to 5.2%, with an AH proportion from 24% to 42%, P < 0.0001 for both. Young had more complications requiring ventilation (79% vs 76%) and dialysis (32% vs 28%), P < 0.001 for both. Compared with older, ACLF admission in young had longer hospitalization (12 vs 10 days) with higher hospital charges ($127,915 vs $97,511), P < 0.0001 for both, with 20% reduced inhospital mortality (54%-45%), P < 0.001. DISCUSSION AALD-related hospitalizations are increasing in young in the United States, mainly because of the increasing frequency of AH. Furthermore, this disease burden in young is increasing with a higher frequency of admissions with more severe ACLF and consumption of hospital resources. Studies are needed to develop preventive strategies to reduce burden related to AALD and ACLF in young.
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29
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Epidemiology of Alcohol Consumption and Societal Burden of Alcoholism and Alcoholic Liver Disease. Clin Liver Dis 2019; 23:39-50. [PMID: 30454831 DOI: 10.1016/j.cld.2018.09.011] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Alcohol abuse is a major determinant of public health outcomes. Worldwide data from 2016 indicate that alcohol is the seventh leading risk factor in terms of disability-adjusted life years, an increase of more than 25% from 1990 to 2016. Understanding the epidemiology of alcoholic liver disease, including the regional variations in consumption and public policy, is an area of active research. In countries where the per capita consumption of alcohol decreases, there appears to be an associated decrease in disease burden. Given alcohol's health burden, an increased focus on alcohol control policies is needed.
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