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Wong YJ, Abraldes JG. Pharmacologic Treatment of Portal Hypertension. Clin Liver Dis 2024; 28:417-435. [PMID: 38945635 DOI: 10.1016/j.cld.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Portal hypertension is the key mechanism driving the transition from compensated to decompensated cirrhosis. In this review, the authors described the pathophysiology of portal hypertension in cirrhosis and the rationale of pharmacologic treatment of portal hypertension. We discussed both etiologic and nonetiologic treatment of portal hypertension and the specific clinical scenarios how nonselective beta-blocker can be used in patients with cirrhosis. Finally, the authors summarized the evidence for emerging alternatives for portal hypertension in patients with cirrhosis.
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Affiliation(s)
- Yu Jun Wong
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Canada; Liver Unit, Division of Gastroenterology, University of Alberta, 1-38 Zeidler Ledcor Centre, 8540 112 Street Northwest, Edmonton, Alberta T6G 2X8, Canada
| | - Juan G Abraldes
- Liver Unit, Division of Gastroenterology, University of Alberta, 1-38 Zeidler Ledcor Centre, 8540 112 Street Northwest, Edmonton, Alberta T6G 2X8, Canada.
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2
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Lim J, Kim SE, Jo AJ, Kim JH, Han SK, Kim TH, Yim HJ, Jung YK, Song DS, Yoon EL, Kim HY, Kang SH, Chang Y, Yoo JJ, Lee SW, Park JG, Park JW, Jeong SW, Jin YJ, Kim HS, Suk KT, Kim MY, Kim SG, Kim W, Jang JY, Yang JM, Kim DJ. Effect of diabetes on mortality and liver transplantation in alcoholic liver cirrhotic patients with acute decompensation. Hepatol Int 2024:10.1007/s12072-024-10710-5. [PMID: 39020135 DOI: 10.1007/s12072-024-10710-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/14/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Previous studies have investigated the influence of diabetes on alcoholic liver cirrhosis patients, leaving its impact unclear. Thus, we conducted a study to reveal the association of diabetes and clinical outcomes of such patients. MATERIALS AND METHODS We prospectively collected data from multicenter pertaining to 965 patients diagnosed with alcoholic liver cirrhosis, all of whom were admitted due to acute decompensation between 2015 and 2019. Risk of major precipitating factors and incidences of death or liver transplantation in patients with and without diabetes was comparatively assessed. Propensity score (PS) matching was performed at a 1:2 ratio for accurate comparisons. RESULTS The mean age was 53.4 years, and 81.0% of the patients were male. Diabetes was prevalent in 23.6% of the cohort and was positively correlated with hepatic encephalopathy and upper gastrointestinal bleeding, although not statistically significant. During a median follow-up of 903.5 person-years (PYs), 64 patients with and 171 without diabetes died or underwent liver transplantation, with annual incidence of 33.6/100 PYs and 24.0/100 PYs, respectively. In the PS-matched cohort, the incidence of death or liver transplantation was 36.8/100 PYs and 18.6/100 PYs in the diabetes and matched control group, respectively. After adjusting for various factors, coexisting diabetes significantly heightened the risk of death or liver transplantation in the short and long term, in addition to prolonged prothrombin time, low serum albumin, elevated total bilirubin and creatinine, and decreased serum sodium levels. CONCLUSIONS Diabetes increases the risk of death or liver transplantation in patients with alcoholic liver cirrhosis.
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Affiliation(s)
- Jihye Lim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Eun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon, 24252, Republic of Korea.
| | - Ae Jeong Jo
- Department of Information Statistics, Andong National University, Andong-si, Republic of Korea
| | - Jung Hee Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon, 24252, Republic of Korea
| | - Seul Ki Han
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Ilsanro, Wonju, 26426, Republic of Korea
| | - Tae Hyung Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon, 24252, Republic of Korea
| | - Hyung Joon Yim
- Division of Gastroenterology, Department of Internal Medicine, Korea University Medical Center, Seoul, Republic of Korea
| | - Young Kul Jung
- Division of Gastroenterology, Department of Internal Medicine, Korea University Medical Center, Seoul, Republic of Korea
| | - Do Seon Song
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eileen L Yoon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, 04763, Republic of Korea
| | - Hee Yeon Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seong Hee Kang
- Division of Gastroenterology, Department of Internal Medicine, Korea University Medical Center, Seoul, Republic of Korea
| | - Young Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, 04401, Republic of Korea
| | - Jeong-Ju Yoo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, 14584, Republic of Korea
| | - Sung Won Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung Gil Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, 42415, Republic of Korea
| | - Ji Won Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon, 24252, Republic of Korea
| | - Soung Won Jeong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, 04401, Republic of Korea
| | - Young Joo Jin
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Republic of Korea
| | - Hyoung Su Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon, 24252, Republic of Korea
| | - Ki Tae Suk
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon, 24252, Republic of Korea
| | - Moon Young Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Ilsanro, Wonju, 26426, Republic of Korea
| | - Sang Gyune Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, 14584, Republic of Korea
| | - Won Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, 07061, Republic of Korea
| | - Jae Young Jang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, 04401, Republic of Korea
| | - Jin Mo Yang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong Joon Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon, 24252, Republic of Korea
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3
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Haque LY, Leggio L. Integrated and collaborative care across the spectrum of alcohol-associated liver disease and alcohol use disorder. Hepatology 2024:01515467-990000000-00939. [PMID: 38935926 DOI: 10.1097/hep.0000000000000996] [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: 04/06/2024] [Accepted: 06/08/2024] [Indexed: 06/29/2024]
Abstract
The public health impact of alcohol-associated liver disease (ALD), a serious consequence of problematic alcohol use, and alcohol use disorder (AUD) is growing, with ALD becoming a major cause of alcohol-associated death overall and the leading indication for liver transplantation in the United States. Comprehensive care for ALD often requires treatment of AUD. Although there is a growing body of evidence showing that AUD treatment is associated with reductions in liver-related morbidity and mortality, only a minority of patients with ALD and AUD receive this care. Integrated and collaborative models that streamline both ALD and AUD care for patients with ALD and AUD are promising approaches to bridge this treatment gap and rely on multidisciplinary and interprofessional teams and partnerships. Here, we review the role of AUD care in ALD treatment, the effects of AUD treatment on liver-related outcomes, the impact of comorbid conditions such as other substance use disorders, obesity, and metabolic syndrome, and the current landscape of integrated and collaborative care for ALD and AUD in various treatment settings. We further review knowledge gaps and unmet needs that remain, including the role of precision medicine, the application of harm reduction approaches, the impact of health disparities, and the need for additional AUD treatment options, as well as further efforts to support implementation and dissemination.
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Affiliation(s)
- Lamia Y Haque
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lorenzo Leggio
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Baltimore and Bethesda, Maryland, USA
- Department of Behavioral and Social Sciences, Center for Alcohol and Addiction Studies, School of Public Health, Brown University, Providence, Rhode Island, USA
- Division of Addiction Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Neuroscience, Georgetown University Medical Center, Washington, District of Columbia, USA
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4
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Taru V, Szabo G, Mehal W, Reiberger T. Inflammasomes in chronic liver disease: hepatic injury, fibrosis progression and systemic inflammation. J Hepatol 2024:S0168-8278(24)02322-5. [PMID: 38908436 DOI: 10.1016/j.jhep.2024.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 05/23/2024] [Accepted: 06/17/2024] [Indexed: 06/24/2024]
Abstract
Chronic liver disease (CLD) leads to hepatocellular injury that triggers a pro-inflammatory state in several parenchymal and non-parenchymal hepatic cell types ultimately resulting in liver fibrosis, cirrhosis, portal hypertension (PH) and liver failure. Thus, an improved understanding of the inflammasomes - as key molecular drivers of liver injury - supports the development of novel diagnostic or prognostic biomarkers and effective therapeutics. In liver disease, innate immune cells respond to hepatic noxes by activating cell-intrinsic inflammasomes via toll-like receptors (TLRs) and nuclear factor kappa-B (NF-κB) and release of pro-inflammatory cytokines (such as IL-1β, IL-18, TNF-α and IL-6). Subsequently, cells of the adaptive immune system are recruited to fuel hepatic inflammation, and liver parenchymal cells may undergo programmed cell-death mediated by gasdermin D, termed pyroptosis. With liver disease progression, there is a shift towards a type 2 inflammatory response, which promotes tissue repair but also fibrogenesis. Inflammasome activation may also occur at extrahepatic sites, such as the white adipose tissue in metabolic dysfunction-associated steatohepatitis (MASH). In end-stage liver disease, flares of inflammation (e.g., in severe alcohol-related hepatitis) that spark on a dysfunctional immune system, contribute to inflammasome-mediated liver injury and potentially result in organ dysfunctions/failures, as seen in acute-on-chronic liver failure (ACLF). This review provides an overview on current concepts regarding inflammasome activation in liver disease progression and related biomarkers and therapeutic approaches that are being developed for patients with liver disease.
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Affiliation(s)
- Vlad Taru
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria; Hepatology Department, 3rd Medical Clinic, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Gyongyi Szabo
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Wajahat Mehal
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA; West Haven Veterans Medical Center, West Haven, CT, USA.
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria; Center for Molecular Medicine (CeMM) of the Austrian Academy of Science, Vienna, Austria
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5
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Serrazina J, Cortez-Pinto H. Shaping new paths in clinical trial design to address alcohol use disorders and alcohol-associated liver disease. Nat Rev Gastroenterol Hepatol 2024:10.1038/s41575-024-00948-7. [PMID: 38849554 DOI: 10.1038/s41575-024-00948-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Affiliation(s)
- Juliana Serrazina
- Unidade Local de Saúde de Santa Maria, Lisbon, Portugal
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Helena Cortez-Pinto
- Unidade Local de Saúde de Santa Maria, Lisbon, Portugal.
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.
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6
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Lee BP, Witkiewitz K, Mellinger J, Anania FA, Bataller R, Cotter TG, Curtis B, Dasarathy S, DeMartini KS, Diamond I, Diazgranados N, DiMartini AF, Falk DE, Fernandez AC, German MN, Kamath PS, Kidwell KM, Leggio L, Litten R, Louvet A, Lucey MR, McCaul ME, Sanyal AJ, Singal AK, Sussman NL, Terrault NA, Thursz MR, Verna EC, Radaeva S, Nagy LE, Mitchell MC. Designing clinical trials to address alcohol use and alcohol-associated liver disease: an expert panel Consensus Statement. Nat Rev Gastroenterol Hepatol 2024:10.1038/s41575-024-00936-x. [PMID: 38849555 DOI: 10.1038/s41575-024-00936-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 06/09/2024]
Abstract
Most patients with alcohol-associated liver disease (ALD) engage in heavy drinking defined as 4 or more drinks per day (56 g) or 8 (112 g) or more drinks per week for women and 5 or more drinks per day (70 g) or 15 (210 g) or more drinks per week for men. Although abstinence from alcohol after diagnosis of ALD improves life expectancy and reduces the risk of decompensation of liver disease, few studies have evaluated whether treatment of alcohol use disorders will reduce progression of liver disease and improve liver-related outcomes. In November 2021, the National Institute of Alcohol Abuse and Alcoholism commissioned a task force that included hepatologists, addiction medicine specialists, statisticians, clinical trialists and members of regulatory agencies to develop recommendations for the design and conduct of clinical trials to evaluate the effect of alcohol use, particularly treatment to reduce or eliminate alcohol use in patients with ALD. The task force conducted extensive reviews of relevant literature on alcohol use disorders and ALD. Findings were presented at one in-person meeting and discussed over the next 16 months to develop the final recommendations. As few clinical trials directly address this topic, the 28 recommendations approved by all members of the task force represent a consensus of expert opinions.
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Affiliation(s)
- Brian P Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine and Institute for Addiction Science, University of Southern California, Los Angeles, CA, USA
| | - Katie Witkiewitz
- Center on Alcohol, Substance use and Addictions, University of New Mexico, Albuquerque, NM, USA
| | - Jessica Mellinger
- Department of Internal Medicine, Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, USA
| | - Frank A Anania
- Division of Hepatology and Nutrition, US Food and Drug Administration, Silver Spring, MD, USA
| | - Ramon Bataller
- Liver Unit, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Thomas G Cotter
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brenda Curtis
- Technology and Translational Research Unit, Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, USA
| | - Srinivasan Dasarathy
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Kelly S DeMartini
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | | | - Nancy Diazgranados
- Office of the Clinical Director, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Andrea F DiMartini
- Departments of Psychiatry and Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Daniel E Falk
- Medications Development Branch, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | | | - Margarita N German
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Kelley M Kidwell
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Lorenzo Leggio
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism Division of Intramural Clinical and Biological Research, National Institutes of Health, Baltimore, MD, USA
| | - Raye Litten
- Division of Treatment and Recovery, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Alexandre Louvet
- Service des maladies de l'appareil digestif, University Hospital of Lille, Lille, France
- Unité INSERM INFINITE, Lille, France
| | - Michael R Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Mary E McCaul
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Arun J Sanyal
- Stravitz-Sanyal Institute for Liver Disease and Metabolic Health, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Ashwani K Singal
- Department of Medicine, Division of Gastroenterology Hepatology and Nutrition, University of Louisville School of Medicine, Louisville, KY, USA
- Department of Medicine, Robley Rex VA Medical Center, Louisville, KY, USA
| | - Norman L Sussman
- DURECT Corporation, Cupertino, CA, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Norah A Terrault
- Division of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine and Institute for Addiction Science, University of Southern California, Los Angeles, CA, USA
| | - Mark R Thursz
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Elizabeth C Verna
- Division of Digestive and Liver Diseases, Columbia University, New York, NY, USA
| | - Svetlana Radaeva
- Svetlana Radaeva, Division of Metabolism and Health Effects, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Laura E Nagy
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Mack C Mitchell
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Tonon M, Gagliardi R, Zeni N, Piano S. Recompensation of cirrhosis in candidates of transplant: Tips and tricks for delisting. Liver Transpl 2024:01445473-990000000-00391. [PMID: 38926937 DOI: 10.1097/lvt.0000000000000409] [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: 12/27/2023] [Accepted: 05/16/2024] [Indexed: 06/28/2024]
Abstract
Liver transplantation (LT) is the most successful treatment for patients with decompensated cirrhosis. The availability of effective and safe etiological treatments has altered the natural history of decompensated cirrhosis. Recently, the concept of recompensation has been defined. Patients who achieve recompensation may be removed from the waiting list for LT. Therefore, achieving an etiological cure is the cornerstone in the treatment of patients with decompensated cirrhosis. However, most patients improve their liver function after an etiologic cure, and only a proportion of patients achieve true recompensation after an etiological cure. Some patients maintain a condition of "MELD purgatory," that is, an improvement in the Model for End-Stage Liver Disease score without relevant clinical improvement that prevents delisting and may be even detrimental because lower Model for End-Stage Liver Disease score delays LT. Herein, we review the available evidence regarding recompensation and the management of recompensated patients on the waiting list for LT.
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Affiliation(s)
- Marta Tonon
- Unit of Internal Medicine and Hepatology, Department of Medicine-DIMED, University and Hospital of Padova, Padova, Italy
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Narayanan P, Wu T, Shah VH, Curtis BL. Insights into ALD and AUD diagnosis and prognosis: Exploring AI and multimodal data streams. Hepatology 2024:01515467-990000000-00879. [PMID: 38743008 DOI: 10.1097/hep.0000000000000929] [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: 02/16/2024] [Accepted: 05/01/2024] [Indexed: 05/16/2024]
Abstract
The rapid evolution of artificial intelligence and the widespread embrace of digital technologies have ushered in a new era of clinical research and practice in hepatology. Although its potential is far from realization, these significant strides have generated new opportunities to address existing gaps in the delivery of care for patients with liver disease. In this review, we discuss how artificial intelligence and opportunities for multimodal data integration can improve the diagnosis, prognosis, and management of alcohol-associated liver disease. An emphasis is made on how these approaches will also benefit the detection and management of alcohol use disorder. Our discussion encompasses challenges and limitations, concluding with a glimpse into the promising future of these advancements.
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Affiliation(s)
- Praveena Narayanan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tiffany Wu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Brenda L Curtis
- Technology and Translational Research Unit, National Institute on Drug Abuse Intramural Research Program, National Institute of Health, Baltimore, Maryland, USA
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Blaney HL, Khalid MB, Yang AH, Asif BA, Vittal A, Kamal N, Wright EC, Abijo T, Koh C, George D, Goldman D, Horneffer Y, Diazgranados N, Heller T. Hepatology consultation is associated with decreased early return to alcohol use after discharge from an inpatient alcohol use disorder treatment program. Hepatol Commun 2024; 8:e0414. [PMID: 38619432 PMCID: PMC11019822 DOI: 10.1097/hc9.0000000000000414] [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: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Alcohol cessation is the only intervention that both prevents and halts the progressions of alcohol-associated liver disease. The aim of this study was to assess the relationship between a return to alcohol use and consultation with hepatology in treatment-seeking patients with alcohol use disorder (AUD). METHODS Two hundred forty-two patients with AUD were enrolled in an inpatient treatment program, with hepatology consultation provided for 143 (59%) patients at the request of the primary team. Patients not seen by hepatology served as controls. The primary outcome was any alcohol use after discharge assessed using AUDIT-C at 26 weeks after discharge. RESULTS For the primary endpoint, AUDIT at week 26, 61% of the hepatology group and 28% of the controls completed the questionnaire (p=0.07). For the secondary endpoint at week 52, these numbers were 22% and 11% (p = 0.6). At week 26, 39 (45%) patients in the hepatology group versus 31 (70%) controls (p = 0.006) returned to alcohol use. Patients evaluated by hepatology had decreased rates of hazardous alcohol use compared to controls, with 36 (41%) versus 29 (66%) (p = 0.008) of the patients, respectively, reporting hazardous use. There were no significant differences in baseline characteristics between groups and no difference in rates of prescribing AUD therapy. There was no difference in outcomes at 52 weeks. CONCLUSIONS Patients evaluated by hepatology had significantly lower rates of return to alcohol use and lower rates of hazardous drinking at 26 weeks but not at 52 weeks. These findings suggest that hepatology evaluation during inpatient treatment of AUD may lead to decreased rates of early return to alcohol use.
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Affiliation(s)
- Hanna L. Blaney
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Mian B. Khalid
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Alexander H. Yang
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Bilal A. Asif
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Anusha Vittal
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Natasha Kamal
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Elizabeth C. Wright
- Office of the Director, National Institutes of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Tomilowo Abijo
- Office of the Director, National Institutes of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Chris Koh
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - David George
- Office of the Clinical Director, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
| | - David Goldman
- Office of the Clinical Director, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
| | - Yvonne Horneffer
- Office of the Clinical Director, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
| | - Nancy Diazgranados
- Office of the Clinical Director, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
| | - Theo Heller
- Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
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10
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Israelsen M, Rungratanawanich W, Thiele M, Liangpunsakul S. Non-invasive tests for alcohol-associated liver disease. Hepatology 2024:01515467-990000000-00841. [PMID: 38607723 DOI: 10.1097/hep.0000000000000885] [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: 02/24/2024] [Accepted: 03/23/2024] [Indexed: 04/14/2024]
Abstract
Alcohol consumption is a global phenomenon and a major contributor to alcohol-associated liver disease (ALD). Detecting individuals at risk of ALD has been challenging, with only a small fraction of patients being identified at early stages compared to other chronic liver diseases. In response to this challenge, non-invasive tests (NITs) have become essential tools for the detection of ALD, offering opportunities for early identification and intervention to mitigate the disease burden. Noninvasive alcohol consumption biomarkers are crucial in estimating individuals' recent alcohol intake, providing valuable insights into their drinking patterns. Various NITs have been investigated for the initial screening of asymptomatic individuals at risk of ALD, as well as for identifying specific stages of the disease. These NITs are applied in 2 main clinical scenarios: population-based stratification for identifying and predicting liver-related symptoms and diagnosing and prognosticating compensated cirrhosis or advanced chronic liver disease in secondary or tertiary care settings. Moreover, NITs play a significant role in the prognostic assessment of patients with various manifestations of ALD, including alcohol-associated hepatitis (AH), decompensated cirrhosis, and metabolic-associated and ALD. These tests guide appropriate treatment decisions and predict outcomes. In this review, various NITs for the early detection and monitoring of alcohol consumption were discussed. Additionally, the evaluation of NITs for screening and predicting ALD and liver complications was addressed comprehensively. Future perspectives of NITs for ALD were explored, alongside a thorough discussion of the opportunities and challenges associated with NITs for ALD screening.
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Affiliation(s)
- Mads Israelsen
- Department of Gastroenterology and Hepatology, Fibrosis Fatty Liver and Steatohepatitis Research Centre, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Wiramon Rungratanawanich
- Section of Molecular Pharmacology and Toxicology, National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland, USA
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Fibrosis Fatty Liver and Steatohepatitis Research Centre, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Suthat Liangpunsakul
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Roudebush Veterans Administration Medical Center, Indianapolis, Indiana, USA
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11
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Hofer BS, Burghart L, Halilbasic E, Simbrunner B, Petrenko O, Mandorfer M, Stättermayer AF, Trauner M, Reiberger T. Evaluation of potential hepatic recompensation criteria in patients with PBC and decompensated cirrhosis. Aliment Pharmacol Ther 2024; 59:962-972. [PMID: 38409879 DOI: 10.1111/apt.17908] [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: 11/12/2023] [Revised: 11/25/2023] [Accepted: 02/06/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Aetiological therapy improves liver function and may enable hepatic recompensation in decompensated cirrhosis. AIMS We explored the potential for recompensation in patients with decompensated primary biliary cholangitis (PBC) - considering a biochemical response to ursodeoxycholic acid (UDCA) according to Paris-II criteria as a surrogate for successful aetiological treatment. METHODS Patients with PBC were retrospectively included at the time of first decompensation. Recompensation was defined as (i) resolution of ascites and hepatic encephalopathy (HE) despite discontinuation of diuretic/HE therapy, (ii) absence of variceal bleeding and (iii) sustained liver function improvement. RESULTS In total, 42 patients with PBC with decompensated cirrhosis (age: 63.5 [IQR: 51.9-69.2] years; 88.1% female; MELD-Na: 13.5 [IQR: 11.0-15.0]) were included and followed for 41.9 (IQR: 11.0-70.9) months after decompensation. Seven patients (16.7%) achieved recompensation. Lower MELD-Na (subdistribution hazard ratio [SHR]: 0.90; p = 0.047), bilirubin (SHR per mg/dL: 0.44; p = 0.005) and alkaline phosphatase (SHR per 10 U/L: 0.67; p = 0.001) at decompensation, as well as variceal bleeding as decompensating event (SHR: 4.37; p = 0.069), were linked to a higher probability of recompensation. Overall, 33 patients were treated with UDCA for ≥1 year and 12 (36%) achieved Paris-II response criteria. Recompensation occurred in 5/12 (41.7%) and in 2/21 (9.5%) patients with vs. without UDCA response at 1 year, respectively. Recompensation was linked to a numerically improved transplant-free survival (HR: 0.46; p = 0.335). Nonetheless, 4/7 recompensated patients presented with liver-related complications after developing hepatic malignancy and/or portal vein thrombosis and 2 eventually died. CONCLUSIONS Patients with PBC and decompensated cirrhosis may achieve hepatic recompensation under UDCA therapy. However, since liver-related complications still occur after recompensation, patients should remain under close follow-up.
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Affiliation(s)
- Benedikt Silvester Hofer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
| | - Lukas Burghart
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
- Klinik Ottakring, Wiener Gesundheitsverbund, Vienna, Austria
| | - Emina Halilbasic
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
| | - Oleksandr Petrenko
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
| | - Albert Friedrich Stättermayer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Rare Liver Diseases (RALID) Center of the ERN RARE-LIVER at the Vienna General Hospital, Vienna, Austria
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12
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Lim WH, Tay P, Ng CH, Tan DJH, Ong C, Koh JH, Teng M, Chee D, Wong ZY, Kawaguchi T, Takahashi H, Muthiah M, Tan EXX, Wijarnpreecha K, Lee GH, Noureddin M, Lee BP, Mathurin P, Loomba R, Huang DQ. Meta-analysis: Prevalence and impact of alcohol abstinence in alcohol-associated cirrhosis. Aliment Pharmacol Ther 2024; 59:730-741. [PMID: 38303565 DOI: 10.1111/apt.17888] [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: 10/18/2023] [Revised: 11/21/2023] [Accepted: 01/14/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Although alcohol abstinence may be an effective intervention for alcohol-associated cirrhosis, its association with prognosis has not been systematically assessed or quantified. AIMS To determine the prevalence of alcohol abstinence, factors associated with alcohol abstinence and the impact of abstinence on morbidity and overall survival in people with alcohol-associated cirrhosis. METHODS We searched Medline and Embase from inception to 15 April 2023 for prospective and retrospective cohort studies describing alcohol abstinence in people with known alcohol-associated cirrhosis. Meta-analysis of proportions for pooled estimates was performed. The method of inverse variance, employing a random-effects model, was used to pool the hazard ratio (HR) comparing outcomes of abstinent against non-abstinent individuals with alcohol-associated cirrhosis. RESULTS We included 19 studies involving 18,833 people with alcohol-associated cirrhosis. The prevalence of alcohol abstinence was 53.8% (CI: 44.6%-62.7%). Over a mean follow-up duration of 48.6 months, individuals who continued to consume alcohol had significantly lower overall survival compared to those who were abstinent (HR: 0.611, 95% CI: 0.506-0.738). These findings remained consistent in sensitivity/subgroup analysis for the presence of decompensation, study design and studies that assessed abstinence throughout follow-up. Alcohol abstinence was associated with a significantly lower risk of hepatic decompensation (HR: 0.612, 95% CI: 0.473-0.792). CONCLUSIONS Alcohol abstinence is associated with substantial improvement in overall survival in alcohol-associated cirrhosis. However, only half of the individuals with known alcohol-associated cirrhosis are abstinent.
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Affiliation(s)
- Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Phoebe Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Cheng Han Ng
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Christen Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jia Hong Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Margaret Teng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Douglas Chee
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Zhen Yu Wong
- School of Medicine, International Medical University, Kuala Lumpur, Malaysia
| | - Takumi Kawaguchi
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | | | - Mark Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Eunice X X Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Karn Wijarnpreecha
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, New York, USA
| | - Guan Huei Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | | | - Brian P Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Philippe Mathurin
- Service des Maladies de l'appareil Digestif, Hôpital Huriez, CHU, Lille, France
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, California, USA
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Daniel Q Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
- NAFLD Research Center, Division of Gastroenterology, University of California at San Diego, La Jolla, California, USA
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13
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Garbuzenko DV. Contemporary concepts of prevention and management of gastroesophageal variceal bleeding in liver cirrhosis patients. World J Hepatol 2024; 16:126-134. [PMID: 38495286 PMCID: PMC10941750 DOI: 10.4254/wjh.v16.i2.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/31/2023] [Accepted: 01/29/2024] [Indexed: 02/27/2024] Open
Abstract
This editorial describes the contemporary concepts of prevention and management of gastroesophageal variceal bleeding in liver cirrhosis (LC) patients according to the current guidelines. Gastroesophageal variceal bleeding is the most dangerous complication of portal hypertension in LC patients. Risk stratification and determination of an individual approach to the choice of therapeutic measures aimed at their prevention and management has emerged as one of the top concerns in modern hepatology. According to the current guidelines, in the absence of clinically significant portal hypertension, etiological and non-etiological therapies of LC is advisable for the primary preventing gastroesophageal variceal bleeding, whereas its presence serves as an indication for the administration of non-selective β-blockers, among which carvedilol is the drug of choice. Non-selective β-blockers, as well as endoscopic variceal ligation and transjugular intrahepatic portosystemic shunt can be used to prevent recurrence of gastroesophageal variceal bleeding. Pharmacotherapy with vasoactive drugs (terlipressin, somatostatin, octreotide), endoscopic variceal ligation, endovascular techniques and transjugular intrahepatic portosystemic shunt are recommended for the treatment of acute gastroesophageal variceal bleeding. Objective and accurate risk stratification of gastroesophageal variceal bleeding will allow developing individual strategies for their prevention and management, avoiding the first and further decompensation in LC, which will improve the prognosis and survival of patients suffering from it.
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Thiele M, Moreno C. Novel interventions against alcohol-related liver disease. Nat Rev Gastroenterol Hepatol 2024; 21:78-79. [PMID: 38081932 DOI: 10.1038/s41575-023-00877-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Affiliation(s)
- Maja Thiele
- FLASH Center for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.
- Department for Clinical Medicine, University of Southern Denmark, Odense, Denmark.
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
- Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
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15
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Sonderup MW, Kamath PS, Awuku YA, Desalegn H, Gogela N, Katsidzira L, Tzeuton C, Bobat B, Kassianides C, Spearman CW. Managing cirrhosis with limited resources: perspectives from sub-Saharan Africa. Lancet Gastroenterol Hepatol 2024; 9:170-184. [PMID: 38215781 DOI: 10.1016/s2468-1253(23)00279-0] [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: 05/18/2023] [Revised: 08/05/2023] [Accepted: 08/14/2023] [Indexed: 01/14/2024]
Abstract
Cirrhosis represents the end stage of chronic liver disease. Sub-Saharan Africa, a resource-constrained region, has a high burden of chronic liver disease, with causes including chronic viral hepatitis, excessive alcohol use, and metabolic dysfunction-associated steatotic liver disease (MASLD), the risk of which is burgeoning. The development of liver cirrhosis predicts for morbidity and mortality, driven by both liver dysfunction and the consequences of portal hypertension. Compensated cirrhosis portends a better prognosis than decompensated cirrhosis, highlighting the need for the early diagnosis of cirrhosis and its causes. With resource challenges, the diagnosis and management of cirrhosis is demanding, but less costly and less invasive interventions with substantial benefits, ranging from simple blood tests to transient elastography, are feasible in such settings. Simple interventions are also available to manage the complex manifestations of decompensation, such as β blockers in variceal bleeding prophylaxis, salt restriction and appropriate diuretic use in ascites, and lactulose and generic rifaximin in hepatic encephalopathy. Ultimately, managing the underlying causative factors of liver disease is key in improving prognosis. Management demands expanded policy interventions to increase screening and treatment for hepatitis B and C and reduce alcohol use and the metabolic factors driving MASLD. Furthermore, the skills needed for more specialised interventions, such as transjugular intrahepatic portosystemic shunt procedures and even liver transplantation, warrant planning, increased capacity, and support for regional centres of excellence. Such centres are already being developed in sub-Saharan Africa, demonstrating what can be achieved with dedicated initiatives and individuals.
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Affiliation(s)
- Mark W Sonderup
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
| | | | - Yaw A Awuku
- Department of Medicine, School of Medicine, University of Health and Allied Sciences, Ho, Ghana
| | - Hailemichael Desalegn
- Department of Internal Medicine, St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Neliswa Gogela
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Leolin Katsidzira
- Internal Medicine Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Christian Tzeuton
- Faculty of Medicine and Pharmaceutical Sciences of Douala, University of Douala, Douala, Cameroon
| | - Bilal Bobat
- Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand and Wits Donald Gordon Medical Centre, Johannesburg, South Africa
| | - Chris Kassianides
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - C Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
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16
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Gratacós-Ginès J, Bruguera P, Pérez-Guasch M, López-Lazcano A, Borràs R, Hernández-Évole H, Pons-Cabrera MT, Lligoña A, Bataller R, Ginès P, López-Pelayo H, Pose E. Medications for alcohol use disorder promote abstinence in alcohol-associated cirrhosis: Results from a systematic review and meta-analysis. Hepatology 2024; 79:368-379. [PMID: 37625154 DOI: 10.1097/hep.0000000000000570] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/28/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND AND AIMS The role of medications for alcohol use disorder (MAUD) in patients with cirrhosis is not well established. Evidence on the efficacy and safety of these drugs in these patients is scarce. APPROACH AND RESULTS We performed a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol guidelines on the efficacy of MAUD in patients with cirrhosis. A search was conducted in PubMed, Embase, and Scopus, including all studies until May 2022. The population was defined as patients with AUD and cirrhosis. The primary outcome was alcohol abstinence. Safety was a secondary outcome. We performed a random-effect analysis and expressed the results as relative risk of alcohol consumption. Heterogeneity was measured by I2 . Out of 4095 unique references, 8 studies on 4 different AUD treatments [baclofen (n = 6), metadoxine (n = 1), acamprosate (n = 1), and fecal microbiota transplant (n = 1)] in a total of 794 patients were included. Four were cohort studies, and 4 were RCTs. Only RCTs were included in the meta-analysis. MAUD was associated with a reduced rate of alcohol consumption [relative risk = 0.68 (CI: 0.48-0.97), P = 0.03], increasing alcohol abstinence by 32% compared to placebo or standard treatment, despite high heterogeneity ( I2 = 67%). Regarding safety, out of 165 serious adverse events in patients treated with MAUD, only 5 (3%) were possibly or probably related to study medications. CONCLUSION MAUD in patients with cirrhosis is effective in promoting alcohol abstinence and has a good safety profile. Larger studies on the effects of MAUD are needed, especially in patients with advanced liver disease.
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Affiliation(s)
- Jordi Gratacós-Ginès
- Liver Unit, Hospital Clínic de Barcelona, Catalunya, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Pol Bruguera
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain
- Addictions Unit, Department of Psychiatry, Hospital Clínic de Barcelona, Catalunya, Spain
| | - Martina Pérez-Guasch
- Liver Unit, Hospital Clínic de Barcelona, Catalunya, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Ana López-Lazcano
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain
- Clinical Health Psychology Section, Institute of Neuroscience (ICN), Hospital Clínic de Barcelona, Catalunya, Spain
| | - Roger Borràs
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
- Faculty of Medicine and Health Sciences, University of Barcelona, Catalunya, Spain
| | | | - Maria T Pons-Cabrera
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain
- Addictions Unit, Department of Psychiatry, Hospital Clínic de Barcelona, Catalunya, Spain
| | - Anna Lligoña
- Addictions Unit, Department of Psychiatry, Hospital Clínic de Barcelona, Catalunya, Spain
| | - Ramón Bataller
- Liver Unit, Hospital Clínic de Barcelona, Catalunya, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Faculty of Medicine and Health Sciences, University of Barcelona, Catalunya, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clínic de Barcelona, Catalunya, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Faculty of Medicine and Health Sciences, University of Barcelona, Catalunya, Spain
| | - Hugo López-Pelayo
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain
- Addictions Unit, Department of Psychiatry, Hospital Clínic de Barcelona, Catalunya, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
| | - Elisa Pose
- Liver Unit, Hospital Clínic de Barcelona, Catalunya, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalunya, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
- Faculty of Medicine and Health Sciences, University of Barcelona, Catalunya, Spain
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17
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Vidal-González J, Martínez J, Mulay A, López M, Baiges A, Elmahdy A, Lampichler K, Maleux G, Chang J, Poncela M, Low G, Ghigliazza G, Zipprich A, Picón C, Shah R, Llop E, Darnell A, Maurer MH, Bonne L, Ramón E, Quiroga S, Abraldes JG, Krag A, Trebicka J, Ripoll C, La Mura V, Tandon P, García-Martínez R, Praktiknjo M, Laleman W, Reiberger T, Berzigotti A, Hernández-Gea V, Calleja JL, Tsochatzis EA, Albillos A, Simón-Talero M, Genescà J. Evolution of spontaneous portosystemic shunts over time and following aetiological intervention in patients with cirrhosis. JHEP Rep 2024; 6:100977. [PMID: 38283756 PMCID: PMC10820312 DOI: 10.1016/j.jhepr.2023.100977] [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: 08/30/2023] [Revised: 10/27/2023] [Accepted: 11/10/2023] [Indexed: 01/30/2024] Open
Abstract
Background & Aims Spontaneous portosystemic shunts (SPSS) develop frequently in cirrhosis. Changes over time and the effect of aetiological interventions on SPSS are unknown, so we aimed to explore the effect of these variables on SPSS evolution. Methods Patients with cirrhosis from the Baveno VI-SPSS cohort were selected provided a follow-up abdominal CT or MRI scan was available. Clinical and laboratory data were collected at baseline and follow-up. Imaging tests were reviewed to evaluate changes in the presence and size of SPSS (large (L)-SPSS was ≥8 mm) over time. Regarding alcohol- or HCV-related cirrhosis, two populations were defined: cured patients (abstinent from alcohol or successful HCV therapy), and non-cured patients. Results A total of 617 patients were included. At baseline SPSS distribution was 22% L-SPSS, 30% small (S)-SPSS, and 48% without (W)-SPSS. During follow-up (median follow-up of 63 months), SPSS distribution worsened: L-SPSS 26%, S-SPSS 32%, and W-SPSS 42% (p <0.001). Patients with worse liver function during follow-up showed a simultaneous aggravation in SPSS distribution. Non-cured patients (n = 191) experienced a significant worsening in liver function, more episodes of liver decompensation and lower transplant-free survival compared to cured patients (n = 191). However, no differences were observed regarding SPSS distribution at inclusion and at follow-up, with both groups showing a trend to worsening. Total shunt diameter increased more in non-cured (52%) than in cured patients (28%). However, total shunt area (TSA) significantly increased only in non-cured patients (74 to 122 mm2, p <0.001). Conclusions The presence of SPSS in cirrhosis increases over time and parallels liver function deterioration. Aetiological intervention in these patients reduces liver-related complications, but SPSS persist although progression is decreased. Impact and implications There is no information regarding the evolution of spontaneous portosystemic shunts (SPSS) during the course of cirrhosis, and especially after disease regression with aetiological interventions, such as HCV treatment with direct-acting antivirals or alcohol abstinence. These results are relevant for clinicians dealing with patients with cirrhosis and portal hypertension because they have important implications for the management of cirrhosis with SPSS after disease regression. From a practical point of view, physicians should be aware that in advanced cirrhosis with portal hypertension, after aetiological intervention, SPSS mostly persist despite liver function improvement, and complications related to SPSS may still develop.
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Affiliation(s)
- Judit Vidal-González
- Liver Unit, Digestive Diseases Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Research (VHIR), Vall d’Hebron Barcelona Hospital Campus. Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Javier Martínez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Akhilesh Mulay
- Sheila Sherlock Liver Unit and University College London Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, UK
| | - Marta López
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Anna Baiges
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Ahmed Elmahdy
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Katharina Lampichler
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Geert Maleux
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Johannes Chang
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Marta Poncela
- Liver Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Gavin Low
- Department of Radiology, University of Alberta, Edmonton, Alberta, Canada
| | - Gabriele Ghigliazza
- Foundation I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi and Thrombosis center, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alexander Zipprich
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Internal Medicine IV. Jena University Hospital, Jena Germany
| | - Carmen Picón
- Department of Radiology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Spain
| | - Rushabh Shah
- Royal Free Hospital Radiology Department, Royal Free Hospital and University College London, London, UK
| | - Elba Llop
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Anna Darnell
- Department of Radiology, Hospital Clínic, Universitat de Barcelona, Barcelona Spain
| | - Martin H. Maurer
- Department of Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Lawrence Bonne
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Enrique Ramón
- Digestive Radiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Sergi Quiroga
- Radiology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan G. Abraldes
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Canada
| | - Aleksander Krag
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
- Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Cristina Ripoll
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Internal Medicine IV. Jena University Hospital, Jena Germany
| | - Vincenzo La Mura
- Foundation I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi and Thrombosis center, Milan, Italy
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Puneeta Tandon
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Canada
| | - Rita García-Martínez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Liver Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Michael Praktiknjo
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
- Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Virginia Hernández-Gea
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - José Luis Calleja
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Emmanuel A. Tsochatzis
- Sheila Sherlock Liver Unit and University College London Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, UK
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Macarena Simón-Talero
- Liver Unit, Digestive Diseases Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Research (VHIR), Vall d’Hebron Barcelona Hospital Campus. Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Joan Genescà
- Liver Unit, Digestive Diseases Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Research (VHIR), Vall d’Hebron Barcelona Hospital Campus. Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - for the Baveno VI-SPSS group from the Baveno Cooperation
- Liver Unit, Digestive Diseases Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Research (VHIR), Vall d’Hebron Barcelona Hospital Campus. Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
- Sheila Sherlock Liver Unit and University College London Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, UK
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
- Department of Radiology, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
- Liver Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
- Department of Radiology, University of Alberta, Edmonton, Alberta, Canada
- Foundation I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi and Thrombosis center, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Internal Medicine IV. Jena University Hospital, Jena Germany
- Department of Radiology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, Spain
- Royal Free Hospital Radiology Department, Royal Free Hospital and University College London, London, UK
- Department of Radiology, Hospital Clínic, Universitat de Barcelona, Barcelona Spain
- Department of Radiology, Inselspital, University of Bern, Bern, Switzerland
- Digestive Radiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
- Radiology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Centre of Excellence for Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Canada
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Internal Medicine B, University of Münster, Münster, Germany
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- Division of Gastroenterology and Hepatology, Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
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18
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Ratner JA, Blaney H, Rastegar DA. Management of alcohol withdrawal syndrome in patients with alcohol-associated liver disease. Hepatol Commun 2024; 8:e0372. [PMID: 38251886 PMCID: PMC10805424 DOI: 10.1097/hc9.0000000000000372] [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: 12/13/2023] [Accepted: 12/13/2023] [Indexed: 01/23/2024] Open
Abstract
Alcohol-associated liver disease is a common and severe sequela of excessive alcohol use; effective treatment requires attention to both liver disease and underlying alcohol use disorder (AUD). Alcohol withdrawal syndrome (AWS) can be dangerous, is a common barrier to AUD recovery, and may complicate inpatient admissions for liver-related complications. Hepatologists can address these comorbid conditions by learning to accurately stage alcohol-associated liver disease, identify AUD using standardized screening tools (eg, Alcohol Use Disorder Identification Test), and assess risk for and symptoms of AWS. Depending on the severity, alcohol withdrawal often merits admission to a monitored setting, where symptom-triggered administration of benzodiazepines based on standardized scoring protocols is often the most effective approach to management. For patients with severe liver disease, selection of benzodiazepines with less dependence on hepatic metabolism (eg, lorazepam) is advisable. Severe alcohol withdrawal often requires a "front-loaded" approach with higher dosing, as well as intensive monitoring. Distinguishing between alcohol withdrawal delirium and HE is important, though it can be difficult, and can be guided by differentiating clinical characteristics, including time to onset and activity level. There is little data on the use of adjuvant medications, including anticonvulsants, dexmedetomidine, or propofol, in this patient population. Beyond the treatment of AWS, inpatient admission and outpatient hepatology visits offer opportunities to engage in planning for ongoing management of AUD, including initiation of medications for AUD and referral to additional recovery supports. Hepatologists trained to identify AUD, alcohol-associated liver disease, and risk for AWS can proactively address these issues, ensuring that patients' AWS is managed safely and effectively and supporting planning for long-term recovery.
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Affiliation(s)
- Jessica A. Ratner
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Hanna Blaney
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Darius A. Rastegar
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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19
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Dhanda A, Andrade J, Allende H, Allgar V, Bailey M, Callaghan L, Cocking L, Goodwin E, Hawton A, Hayward C, Hudson B, Ingram W, Jeffery A, King A, Lavers V, Lomax J, McCune CA, Musicha C, Parker R, Rollinson C, Wilks J, Creanor ES. Mental Imagery to Reduce Alcohol-related harm in patients with alcohol use disorder and alcohol-related liver damaGE: the MIRAGE randomised pilot trial results. BMJ Open Gastroenterol 2024; 11:e001267. [PMID: 38286518 PMCID: PMC10870787 DOI: 10.1136/bmjgast-2023-001267] [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: 10/04/2023] [Accepted: 01/04/2024] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVE The healthcare burden of alcohol-related liver disease (ARLD) is increasing. ARLD and alcohol use disorder (AUD) is best managed by reduction or cessation of alcohol use, but effective treatments are lacking. We tested whether people with ARLD and AUD admitted to hospital could be recruited to and retained in a trial of Functional Imagery Training (FIT), a psychological therapy that uses mental imagery to reduce alcohol craving. We conducted a multicentre randomised pilot trial of treatment as usual (TAU) versus FIT+TAU in people admitted to hospital with ARLD and AUD. DESIGN Participants were randomised to TAU (a single session of brief intervention) or FIT+TAU (TAU with one hospital-based FIT session then eight telephone sessions over 6 months). Pilot outcomes included recruitment rate and retention at day 180. Secondary outcomes included fidelity of FIT delivery, alcohol use, and severity of alcohol dependence. RESULTS Fifty-four participants (mean age 49; 63% male) were recruited and randomised, 28 to TAU and 26 to FIT+TAU. The retention rate at day 180 was 43%. FIT was delivered adequately by most alcohol nurses. 50% of intervention participants completed FIT sessions 1 and 2. There were no differences in alcohol use or severity of alcohol dependence between treatment groups at day 180. CONCLUSION Participants with ARLD and AUD could be recruited to a trial of FIT versus FIT+TAU. However, retention at day 180 was suboptimal. Before conducting a definitive trial of FIT in this patient group, modifications in the intervention and recruitment/retention strategy must be tested. TRIAL REGISTRATION NUMBER ISRCTN41353774.
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Affiliation(s)
- Ashwin Dhanda
- Faculty of Health, University of Plymouth, Plymouth, UK
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - Hannah Allende
- Research, Development and Innovation, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | | | | | - Laura Cocking
- Faculty of Health, University of Plymouth, Plymouth, UK
| | | | - Annie Hawton
- Medical School, University of Exeter, Exeter, UK
| | | | - Ben Hudson
- Royal Devon University Hospital Foundation NHS Trust, Exeter, UK
| | - Wendy Ingram
- Faculty of Health, University of Plymouth, Plymouth, UK
| | | | - Angela King
- Faculty of Health, University of Plymouth, Plymouth, UK
| | | | - Joe Lomax
- Faculty of Health, University of Plymouth, Plymouth, UK
| | - C Anne McCune
- Department of Liver Medicine, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | - Richard Parker
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Christopher Rollinson
- Research, Development and Innovation, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jonny Wilks
- Faculty of Health, University of Plymouth, Plymouth, UK
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20
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Kalambokis GN, Chouliara N, Tsiakas I, Filippas-Ntekuan S, Christaki M, Despotis G, Milionis H. Impact of continued alcohol use on liver-related outcomes of alcohol-associated cirrhosis: a retrospective study of 440 patients. Eur J Gastroenterol Hepatol 2024; 36:89-96. [PMID: 37823451 DOI: 10.1097/meg.0000000000002648] [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] [Indexed: 10/13/2023]
Abstract
BACKGROUND AND AIM The prevalence of alcohol-associated cirrhosis is increasing. In this respect, we investigated the long-term impact of non-abstinence on the clinical course of alcohol-associated cirrhosis. METHODS We retrospectively evaluated 440 patients with alcohol-associated cirrhosis (compensated cirrhosis: n = 190; decompensated cirrhosis: n = 250) diagnosed between January 2000 and July 2017 who consumed alcohol until diagnosis of cirrhosis. We assessed liver-related outcomes including first and further decompensating events (ascites, variceal bleeding, and hepatic encephalopathy), and death in relation to continued alcohol use. RESULTS Overall, 53.6% of patients remained abstinent (compensated cirrhosis: 57.9%; decompensated cirrhosis: 50.4%). Non-abstinent versus abstinent patients with compensated cirrhosis and decompensated cirrhosis showed significantly higher 5-year probability of first decompensation (80.2% vs. 36.8%; P < 0.001) and further decompensation (87.9% vs. 20.6%; P < 0.001), respectively. Five-year survival was substantially lower among non-abstinent patients with compensated cirrhosis (45.9% vs. 90.7%; P < 0.001) and decompensated cirrhosis (22.9% vs. 73.8%; P < 0.001) compared to abstinent. Non-abstinent versus abstinent patients of the total cohort showed an exceedingly lower 5-year survival (32.2% vs. 82.4%; P < 0.001). Prolonged abstinence (≥2 years) was required to influence outcomes. Non-abstinence independently predicted mortality in the total cohort (hazard ratio [HR] 3.371; confidence interval [CI]: 2.388-4.882; P < 0.001) along with the Child-Pugh class (HR: 4.453; CI: 2.907-6.823; P < 0.001) and higher age (HR: 1.023; CI: 1.007-1.039; P = 0.005). CONCLUSION Liver-related outcomes are worse among non-abstinent patients with alcohol- associated cirrhosis prompting urgent interventions ensuring abstinence.
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Affiliation(s)
- Georgios N Kalambokis
- First Division of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
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21
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Avades T, Dhanda A. Minimum Unit Pricing in Scotland 32 months on: evidence demonstrates a significant reduction in alcohol related deaths. Evid Based Nurs 2023; 27:ebnurs-2023-103751. [PMID: 37500507 DOI: 10.1136/ebnurs-2023-103751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2023] [Indexed: 07/29/2023]
Affiliation(s)
- Tamar Avades
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Ashwin Dhanda
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Faculty of Health, University of Plymouth, Plymouth, UK
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22
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Abbas D, Ciricillo JA, Elom HA, Moon AM. Extrahepatic Health Effects of Alcohol Use and Alcohol-associated Liver Disease. Clin Ther 2023; 45:1201-1211. [PMID: 37806811 DOI: 10.1016/j.clinthera.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/08/2023] [Accepted: 08/24/2023] [Indexed: 10/10/2023]
Abstract
PURPOSE Alcohol use disorder (AUD) is a growing public health concern and an important contributor to global morbidity and mortality. While the hepatotoxic effects of alcohol are well known, the adverse effects of alcohol are manifested in almost every organ system. With the growing public health impact of AUD, the aim of this narrative review is to highlight the epidemiology and burden of AUD and its association with extrahepatic diseases including malignancy and disorders of the gastrointestinal (GI), cardiovascular, immunologic, neurologic, endocrine, and hematologic systems. METHODS A narrative review of the literature was performed to identify studies addressing the epidemiology, pathophysiology, clinical manifestations, and therapy of extrahepatic health manifestations of alcohol use. FINDINGS In the United States, an estimated 14.5 million people have AUD and approximately 88,000 adults die yearly due to alcohol-related causes. The consumption of alcohol and AUD is associated with injuries, violence, cancers, nonmalignant conditions of the GI system, infections, effects on the cardiovascular system, and neurodegenerative diseases. These conditions contribute to the increased mortality associated with AUD and are burdensome to patients and caregivers. IMPLICATIONS Increased awareness of the extrahepatic manifestations of AUD, screening for AUD using validated screening tools, such as the Alcohol Use Disorders Identification Test-Concise (AUDIT-C) score, and offering evidence-based interventions to patients with AUD is imperative to reduce the public health burden of AUD. Although historically controversial, recent evidence suggests that any level of alcohol consumption can have negative health consequences. Further research is warranted to determine if any amount of alcohol is safe for consumption. Public health efforts are warranted to help curtail the growing burden of AUD.
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Affiliation(s)
- Daniyal Abbas
- Department of Internal Medicine, East Carolina University, Greenville, North Carolina
| | - Jacob A Ciricillo
- Department of Internal Medicine, University of Cincinnati Medicine Center, Cincinnati, Ohio
| | - Hilary A Elom
- Department of Internal Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Andrew M Moon
- Department of Gastroenterology and Hepatology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina.
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23
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Prince DS, Nash E, Liu K. Alcohol-Associated Liver Disease: Evolving Concepts and Treatments. Drugs 2023; 83:1459-1474. [PMID: 37747685 PMCID: PMC10624727 DOI: 10.1007/s40265-023-01939-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2023] [Indexed: 09/26/2023]
Abstract
Alcohol is a prominent cause of liver disease worldwide with higher prevalence in developed nations. The spectrum of alcohol-associated liver disease (ALD) encompasses a diverse range of clinical entities, from asymptomatic isolated steatosis to decompensated cirrhosis, and in some cases, acute or chronic liver failure. Consequently, it is important for healthcare practitioners to maintain awareness and systematically screen for ALD. The optimal evaluation and management of ALD necessitates a collaborative approach, incorporating a multidisciplinary team and accounting for concurrent medical conditions. A repertoire of therapeutic interventions exists to support patients in achieving alcohol cessation and sustaining remission, with complete abstinence being the ultimate objective. This review explores the existing therapeutic options for ALD acknowledging geographical discrepancies in accessibility. Recent innovations, including the inclusion of alcohol consumption biomarkers into clinical protocols and the expansion of liver transplantation eligibility to encompass severe alcohol-associated hepatitis, are explored.
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Affiliation(s)
- David Stephen Prince
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
- Department of Gastroenterology and Liver, Liverpool Hospital, Sydney, NSW, Australia.
- Liver Injury and Cancer Program, Centenary Institute, Sydney, NSW, Australia.
- The Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.
- Faculty of Medicine and Health, The University of New South Wales, Sydney, NSW, Australia.
| | - Emily Nash
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Ken Liu
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Liver Injury and Cancer Program, Centenary Institute, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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24
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Parker R, Allison M, Anderson S, Aspinall R, Bardell S, Bains V, Buchanan R, Corless L, Davidson I, Dundas P, Fernandez J, Forrest E, Forster E, Freshwater D, Gailer R, Goldin R, Hebditch V, Hood S, Jones A, Lavers V, Lindsay D, Maurice J, McDonagh J, Morgan S, Nurun T, Oldroyd C, Oxley E, Pannifex S, Parsons G, Phillips T, Rainford N, Rajoriya N, Richardson P, Ryan J, Sayer J, Smith M, Srivastava A, Stennett E, Towey J, Vaziri R, Webzell I, Wellstead A, Dhanda A, Masson S. Quality standards for the management of alcohol-related liver disease: consensus recommendations from the British Association for the Study of the Liver and British Society of Gastroenterology ARLD special interest group. BMJ Open Gastroenterol 2023; 10:e001221. [PMID: 37797967 PMCID: PMC10551993 DOI: 10.1136/bmjgast-2023-001221] [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: 07/28/2023] [Accepted: 08/29/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVE Alcohol-related liver disease (ALD) is the most common cause of liver-related ill health and liver-related deaths in the UK, and deaths from ALD have doubled in the last decade. The management of ALD requires treatment of both liver disease and alcohol use; this necessitates effective and constructive multidisciplinary working. To support this, we have developed quality standard recommendations for the management of ALD, based on evidence and consensus expert opinion, with the aim of improving patient care. DESIGN A multidisciplinary group of experts from the British Association for the Study of the Liver and British Society of Gastroenterology ALD Special Interest Group developed the quality standards, with input from the British Liver Trust and patient representatives. RESULTS The standards cover three broad themes: the recognition and diagnosis of people with ALD in primary care and the liver outpatient clinic; the management of acutely decompensated ALD including acute alcohol-related hepatitis and the posthospital care of people with advanced liver disease due to ALD. Draft quality standards were initially developed by smaller working groups and then an anonymous modified Delphi voting process was conducted by the entire group to assess the level of agreement with each statement. Statements were included when agreement was 85% or greater. Twenty-four quality standards were produced from this process which support best practice. From the final list of statements, a smaller number of auditable key performance indicators were selected to allow services to benchmark their practice and an audit tool provided. CONCLUSION It is hoped that services will review their practice against these recommendations and key performance indicators and institute service development where needed to improve the care of patients with ALD.
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Affiliation(s)
- Richard Parker
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Medical Research at St James's University Hospital, University of Leeds, Leeds, UK
| | | | - Seonaid Anderson
- Angus Integrated Drug and Alcohol Recovery Service (AIDARS), Ninewells Hospital and Medical School, Dundee, UK
| | - Richard Aspinall
- Gastroenterology & Hepatology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Sara Bardell
- Birmingham Liver Services Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Vikram Bains
- Liver Transplant Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Ryan Buchanan
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Lynsey Corless
- Department of Gastroenterology, Hepatology and Endoscopy, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Ian Davidson
- NHS Fife Addiction Services, NHS Fife, Kirkcaldy, UK
| | - Pauline Dundas
- Peter Brunt Centre, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Jeff Fernandez
- Alcohol and Drug Liaison, Royal Free London NHS Foundation Trust, London, UK
| | - Ewan Forrest
- Dept of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Erica Forster
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Dennis Freshwater
- Birmingham Liver Services Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ruth Gailer
- Islington Primary Care Federation, London, UK
| | - Robert Goldin
- Department of Digestive Diseases, Department of Medicine, Imperial College London, London, UK
| | | | - Steve Hood
- Digestive Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Arron Jones
- Pharmacy, Barts and The London NHS Trust, London, UK
| | | | - Deborah Lindsay
- Alcohol Care Team, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - James Maurice
- Gastroenterology and hepatology, North Bristol NHS Trust, Westbury on Trym, UK
| | - Joanne McDonagh
- Birmingham Liver Services Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Tania Nurun
- Department of Gastroenterology, Hepatology and Endoscopy, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | | | | | - Sally Pannifex
- Hepatology, St George's Healthcare NHS Trust, London, UK
| | | | | | - Nicole Rainford
- Liver Transplant Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Neil Rajoriya
- Birmingham Liver Services Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paul Richardson
- Gastroenterology and Hepatology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - J Ryan
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
| | - Joanne Sayer
- Gastroenterology, Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Doncaster, UK
| | - Mandy Smith
- Alcohol care team, Southport and Ormskirk Hospital NHS Trust, Southport, UK
| | - Ankur Srivastava
- Gastroenterology and hepatology, North Bristol NHS Trust, Westbury on Trym, UK
| | - Emma Stennett
- Gastroenterology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Jennifer Towey
- Birmingham Liver Services Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Ian Webzell
- Liver Transplant Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Andrew Wellstead
- Gastroenterology, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Ashwin Dhanda
- Faculty of health, University of Plymouth, Plymouth, UK
| | - Steven Masson
- Liver unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
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25
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Semmler G, Yang Z, Fritz L, Köck F, Hofer BS, Balcar L, Hartl L, Jachs M, Stopfer K, Schedlbauer A, Neumayer D, Maurer J, Müllner-Bucsics T, Simbrunner B, Scheiner B, Trauner M, Mandorfer M, Reiberger T, Bauer DJM. Dynamics in Liver Stiffness Measurements Predict Outcomes in Advanced Chronic Liver Disease. Gastroenterology 2023; 165:1041-1052. [PMID: 37442301 DOI: 10.1053/j.gastro.2023.06.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 05/20/2023] [Accepted: 06/14/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND & AIMS Liver stiffness measurements (LSMs) provide an opportunity to monitor liver disease progression and regression noninvasively. We aimed to determine the prognostic relevance of LSM dynamics over time for liver-related events and death in patients with chronic liver disease. METHODS Patients with chronic liver disease undergoing 2 or more reliable LSMs at least 180 days apart were included in this retrospective cohort study and stratified at baseline (BL) as nonadvanced chronic liver disease (non-ACLD, BL-LSM < 10 kPa), compensated ACLD (cACLD; BL-LSM ≥ 10 kPa), and decompensated ACLD. Data on all consecutive LSMs and clinical outcomes were collected. RESULTS There were 2508 patients with 8561 reliable LSMs (3 per patient; interquartile range, 2-4) included: 1647 (65.7%) with non-ACLD, 757 (30.2%) with cACLD, and 104 (4.1%) with decompensated ACLD. Seven non-ACLD patients (0.4%) and 83 patients with cACLD (10.9%) developed hepatic decompensation (median follow-up, 71 months). A 20% increase in LSM at any time was associated with an approximately 50% increased risk of hepatic decompensation (hazard ratio, 1.58; 95% CI, 1.41-1.79; P < .001) and liver-related death (hazard ratio, 1.45; 95% CI, 1.28-1.68; P < .001) in patients with cACLD. LSM dynamics yielded a high accuracy to predict hepatic decompensation in the following 12 months (area under the receiver operating characteristics curve = 0.933). The performance of LSM dynamics was numerically better than dynamics in Fibrosis-4 score (0.873), Model for End-Stage Liver Disease (0.835), and single time-point LSM (BL-LSM: 0.846; second LSM: 0.880). Any LSM decrease to <20 kPa identified patients with cACLD with a substantially lower risk of hepatic decompensation (hazard ratio, 0.13; 95% CI, 0.07-0.24). If reliable, LSM also confers prognostic information in decompensated ACLD. CONCLUSIONS Repeating LSM enables an individual and updated risk assessment for decompensation and liver-related mortality in ACLD.
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Affiliation(s)
- Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Zhenwei Yang
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Laurenz Fritz
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Fiona Köck
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Benedikt Silvester Hofer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lukas Hartl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Katharina Stopfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Anna Schedlbauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Daniela Neumayer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Jurij Maurer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Theresa Müllner-Bucsics
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria.
| | - David Josef Maria Bauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Department of Internal Medicine IV, Klinik Ottakring, Vienna, Austria
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26
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Kumar R, Kumar S, Prakash SS. Compensated liver cirrhosis: Natural course and disease-modifying strategies. World J Methodol 2023; 13:179-193. [PMID: 37771878 PMCID: PMC10523240 DOI: 10.5662/wjm.v13.i4.179] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/05/2023] [Accepted: 06/27/2023] [Indexed: 09/20/2023] Open
Abstract
Compensated liver cirrhosis (CLC) is defined as cirrhosis with one or more decompensating events, such as ascites, variceal haemorrhage, or hepatic encephalopathy. Patients with CLC are largely asymptomatic with preserved hepatic function. The transition from CLC to decompensated cirrhosis occurs as a result of a complex interaction between multiple predisposing and precipitating factors. The first decompensation event in CLC patients is considered a significant turning point in the progression of cirrhosis, as it signals a drastic decline in median survival rates from 10-12 years to only 1-2 years. Furthermore, early cirrhosis has the potential to regress as liver fibrosis is a dynamic condition. With the advent of effective non-invasive tools for detecting hepatic fibrosis, more and more patients with CLC are currently being recognised. This offers clinicians a unique opportunity to properly manage such patients in order to achieve cirrhosis regression or, at the very least, prevent its progression. There are numerous emerging approaches for preventing or delaying decompensation in CLC patients. A growing body of evidence indicates that treating the underlying cause can lead to cirrhosis regression, and the use of non-selective beta-blockers can prevent decompensation by lowering portal hypertension. Additionally, addressing various cofactors (such as obesity, diabetes, dyslipidaemia, and alcoholism) and precipitating factors (such as infection, viral hepatitis, and hepatotoxic drugs) that have a detrimental impact on the natural course of cirrhosis may benefit patients with CLC. However, high-quality data must be generated through well-designed and adequately powered randomised clinical trials to validate these disease-modifying techniques for CLC patients. This article discussed the natural history of CLC, risk factors for its progression, and therapeutic approaches that could alter the trajectory of CLC evolution and improve outcomes.
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Affiliation(s)
- Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India
| | - Sudhir Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India
| | - Sabbu Surya Prakash
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India
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27
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Marot A, Henrion J, Knebel JF, Trépo E, Moreno C, Deltenre P. A model for individualized prediction of liver-related death in outpatients with alcohol-associated cirrhosis. Hepatol Commun 2023; 7:e0229. [PMID: 37655969 PMCID: PMC10476762 DOI: 10.1097/hc9.0000000000000229] [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: 10/17/2022] [Accepted: 06/15/2023] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION In alcohol-associated cirrhosis, an accurate estimate of the risk of death is essential for patient care. We developed individualized prediction charts for 5-year liver-related mortality among outpatients with alcohol-associated cirrhosis that take into account the impact of abstinence. METHODS We collected data on outpatients with alcohol-associated cirrhosis in a prospective registry. The model was derived, internally and externally validated, and compared with the Child-Pugh and the Model For End-Stage Liver Disease (MELD) scores. RESULTS A total of 527 and 127 patients were included in the derivation and validation data sets, respectively. A model was developed based on the 3 variables independently associated with liver-related mortality in multivariate analyses (age, Child-Pugh score, and abstinence). In the derivation data set, the model combining age, Child-Pugh score, and abstinence outperformed the Child-Pugh and the MELD scores. In the validation data set, the Brier score was lower for the model (0.166) compared with the Child-Pugh score (0.196, p = 0.008) and numerically lower compared with the MELD score (0.190) (p = 0.06). The model had the greatest AUC (0.77; 95% CI 0.68-0.85) compared with the Child-Pugh score (AUC = 0.66; 95% CI 0.56-0.76, p = 0.01) and was numerically higher than that of the MELD score (AUC = 0.66; 95% CI 0.56-0.78, p = 0.06). Also, the Akaike and Bayesian information criterion scores were lower for the model (2163; 2172) compared with the Child-Pugh (2213; 2216) or the MELD score (2205; 2208). CONCLUSION A model combining age, Child-Pugh score, and abstinence accurately predicts liver-related death at 5 years among outpatients with alcohol-associated cirrhosis. In this study, the model outperformed the Child-Pugh and the MELD scores, although the AUC and the Brier score of the model were not statically different from the MELD score in the validation data set.
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Affiliation(s)
- Astrid Marot
- Department of Gastroenterology and Hepatology, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Jean Henrion
- Department of Gastroenterology and Hepatology, Hôpital de Jolimont, Haine-Saint-Paul, Belgium
| | - Jean-François Knebel
- Division of Radiology, Centre d’Imagerie Biomédicale (CIBM), Hôpital Nestlé, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Eric Trépo
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre Deltenre
- Department of Gastroenterology and Hepatology, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Department of Gastroenterology and Hepatology, Clinique St Luc, Bouge, Belgium
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28
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Muiño-Domínguez D, Mínguez-Sabater A, Junquera-Alonso E, Piedra-Cerezal AM, Rodríguez M, Varela M. Prevalence and pattern of alcohol consumption in patients with hepatocellular carcinoma. Med Clin (Barc) 2023:S0025-7753(23)00142-2. [PMID: 37045669 DOI: 10.1016/j.medcli.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 04/14/2023]
Abstract
AIM Prospective cross-sectional study conducted to determine the prevalence and pattern of alcohol consumption (AC) in patients with hepatocellular carcinoma (HCC) and to assess the utility of the AUDIT in HCC patients. METHODS One hundred and two consecutive patients form our HCC monographic outpatient clinic visited between February and March 2022 were included. Patients with hepatic encephalopathy at the time of the interview, on the waiting list for liver transplantation and those undergoing post-transplant follow-up were excluded. RESULTS The prevalence of AC in patients diagnosed with HCC is 35%, although less than 10% consume more than 100g per week. AC was more frequent in males, in an urban environment, with a diagnosis of HCC more than a year ago, and in patients in early/very early stages of BCLC. AUDIT score greater than or equal to 3 (AUROC 0.849) predicts any AC with a sensitivity of 75% (95% CI: 59.47-90.53%) and a specificity of 84% (95% CI: 74.70-94.05%). CONCLUSIONS Despite the diagnosis of HCC, more than a third of the patients consume alcohol. An AUDIT score equal to or greater than 3 discriminates any AC with a sensitivity of 75% and a specificity of 84% in this population.
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Affiliation(s)
- Daniel Muiño-Domínguez
- Unidad de Hepatología, Servicio de Digestivo, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Alejandro Mínguez-Sabater
- Unidad de Hepatología, Servicio de Digestivo, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Eduardo Junquera-Alonso
- Sección de Digestivo, Servicio de Medicina Interna, Hospital Universitario San Agustín, Avilés, Asturias, España
| | - Ana María Piedra-Cerezal
- Unidad de Hepatología, Servicio de Digestivo, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - Manuel Rodríguez
- Unidad de Hepatología, Servicio de Digestivo, Hospital Universitario Central de Asturias, Oviedo, Asturias, España; Departamento de Medicina, Universidad de Oviedo, Oviedo, Asturias, España; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Asturias, España
| | - María Varela
- Unidad de Hepatología, Servicio de Digestivo, Hospital Universitario Central de Asturias, Oviedo, Asturias, España; Departamento de Medicina, Universidad de Oviedo, Oviedo, Asturias, España; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Asturias, España; Instituto Universitario de Oncología del Principado de Asturias (IUOPA), Oviedo, Asturias, España.
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