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Favre-Bulle T, Moradpour D, Marques-Vidal P, Vaucher J. Trends in the burden of hospitalised patients with cirrhosis in Switzerland: a cross-sectional study of cirrhosis-related hospitalisations between 1998 and 2020. BMJ Open 2024; 14:e081822. [PMID: 39181561 DOI: 10.1136/bmjopen-2023-081822] [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] [Indexed: 08/27/2024] Open
Abstract
OBJECTIVE Liver cirrhosis is an increasing cause of morbidity and mortality worldwide with a heavy load on healthcare systems. We analysed the trends in hospitalisations for cirrhosis in Switzerland. DESIGN Cross-sectional study. SETTING Large nationwide inpatient database, years between 1998 and 2020. PARTICIPANTS Hospitalisations for cirrhosis of adult patients were selected. MAIN OUTCOMES AND MEASURES Hospitalisations with either a primary diagnosis of cirrhosis or a cirrhosis-related primary diagnosis with a mandatory presence of cirrhosis as a secondary diagnosis were considered following the 10th revision of the International Statistical Classification of Diseases and Related Health Problems codes. Trends in demographic and clinical characteristics, in-hospital mortality and length of stay were analysed. Causes and costs of cirrhosis-related hospitalisations were available from 2012 onwards. RESULTS Cirrhosis-related hospitalisations increased from 1631 in 1998 to 4052 in 2020. Of the patients, 68.7% were men. Alcohol-related liver disease was the leading cause, increasing from 44.1% (95% CI, 42.4% to 45.9%) in 2012 to 47.9% (95% CI, 46.4% to 49.5%) in 2020. Assessed by exclusion of other coded causes, non-alcoholic fatty liver disease was the second cause at 42.7% (95% CI, 41.2% to 44.3%) in 2020. Hepatitis C virus-related cirrhosis decreased from 12.3% (95% CI, 11.2% to 13.5%) in 2012 to 3.2% (95% CI, 2.7% to 3.8%) in 2020. Median length of stay decreased from 11 to 8 days. Hospitalisations with an intensive care unit stay increased from 9.8% (95% CI, 8.4% to 11.4%) to 15.6% (95% CI, 14.5% to 16.8%). In-hospital mortality decreased from 12.1% (95% CI, 10.5% to 13.8%) to 9.7% (95% CI, 8.8% to 10.7%). Total costs increased from 54.4 million US$ (51.4 million €) in 2012 to 92.6 million US$ (87.5 million €) in 2020. CONCLUSIONS Cirrhosis-related hospitalisations and related costs increased in Switzerland from 1998 to 2020 but in-hospital mortality decreased. Alcohol-related liver disease and non-alcoholic fatty liver disease were the most prevalent and preventable aetiologies of cirrhosis-related hospitalisations.
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Affiliation(s)
- Timothee Favre-Bulle
- Service of Internal Medicine, Etablissements Hospitaliers du Nord Vaudois, Yverdon-les-Bains, Switzerland
- Department of Medicine, University of Lausanne Faculty of Biology and Medicine, Lausanne, Switzerland
| | - Darius Moradpour
- Department of Medicine, Service of Gastroenterology and Hepatology, University of Lausanne, Lausanne, Switzerland
| | | | - Julien Vaucher
- Department of Medicine, University of Lausanne, Lausanne, Switzerland
- Department of Medicine and Specialties, University of Fribourg, Fribourg, Switzerland
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2
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Tapper EB. Letter to the Editor: Modeling concerns. Hepatology 2023; 78:E39-E40. [PMID: 37162161 DOI: 10.1097/hep.0000000000000440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 04/10/2023] [Indexed: 05/11/2023]
Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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3
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Gingold-Belfer R, Shinhar N, Bachar GN, Issa N, Boltin D, Sharon E, Shohat T, Sapoznikov B, Swartz A, Peleg N, Konikoff T, Schmilovitz-Weiss H. Predictors of poor outcome following liver biopsy for the investigation of new hepatic space occupying lesion/s. Clin Imaging 2023; 99:19-24. [PMID: 37043869 DOI: 10.1016/j.clinimag.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/14/2023] [Accepted: 04/03/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Ultrasound-guided percutaneous liver biopsy (UPLB) is currently performed mainly to determine if new hepatic space occupying lesions (SOL) represent benign, primary malignant, or metastatic disease. This study sought to investigate the outcome of UPLB in this setting. METHODS In a retrospective study, patients with a new hepatic SOL who underwent UPLB during 1/2006-12/2016 were included and followed to 12/2018. Clinical data and pathology reports were reviewed. Mortality within 60 days and no change in patients' management following UPLB were defined as medically futile. RESULTS Included 140 patients, 50% male, mean age 68.8 ± 11.5 years; 112 patients died, all of malignant disease. 32 patients (23%) died within 60 days of UPLB. Median post-UPLB survival was 151 days. Survival was significantly shorter in patients with >1 hepatic lesion (n = 108) or an extrahepatic malignant lesion (n = 77) (p = 0.0082, p = 0.0301, respectively). On Cox Proportional Hazards analysis, significant predictors of mortality within 60 days of UPLB were: age as a continuous variable, (HR 1.070, 95% CI 1.011-1.131, p = 0.018), serum albumin <2.9 g/dL, (HR 4.822 95% CI 1.335-17.425, p = 0.016) and serum LDH >1500 U/L (HR 9.443, 95% CI 3.404-26.197, p < 0.0001). CONCLUSIONS In patients with these features or with disseminated disease, liver biopsy should be carefully reconsidered.
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Affiliation(s)
- Rachel Gingold-Belfer
- Gastroenterology Division, Rabin Medical Center - Beilinson Hospital, Petach Tikva 4941492, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Nadav Shinhar
- Gastroenterology Unit, Meir Hospital, Kfar Saba 4428164, Israel
| | - Gil N Bachar
- Radiology Department, Rabin Medical Center - Hasharon Hospital, Petach Tikva 4937211, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Nidal Issa
- Department of Surgery B, Rabin Medical Center - Hasharon Hospital, Petach Tikva 4937211, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Doron Boltin
- Gastroenterology Division, Rabin Medical Center - Beilinson Hospital, Petach Tikva 4941492, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Eran Sharon
- Department of Surgery B, Rabin Medical Center - Beilinson Hospital, Petach Tikva 4941492, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Tzippy Shohat
- Statistics Department, Rabin Medical Center - Beilinson Hospital, Petach Tikva 4941492, Israel
| | - Boris Sapoznikov
- Gastroenterology Division, Rabin Medical Center - Hasharon Hospital, Petach Tikva 4937211, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Ariel Swartz
- Pathology Department, Rabin Medical Center - Hasharon Hospital, Petach Tikva 4937211, Israel
| | - Noam Peleg
- Gastroenterology Division, Rabin Medical Center - Beilinson Hospital, Petach Tikva 4941492, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Tom Konikoff
- Gastroenterology Division, Rabin Medical Center - Beilinson Hospital, Petach Tikva 4941492, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Hemda Schmilovitz-Weiss
- Gastroenterology Division, Rabin Medical Center - Hasharon Hospital, Petach Tikva 4937211, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel.
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Romero-Gómez M, Aller R, Ampuero J, Fernández Rodríguez C, Augustín S, Latorre R, Rivera-Esteban J, Martínez Urroz B, Gutiérrez García ML, López SA, Albillos A, Hernández M, Graupera I, Benlloch S, Olveira A, Crespo J, Calleja JL. AEEH «Consensus about detection and referral of hidden prevalent liver diseases». GASTROENTEROLOGIA Y HEPATOLOGIA 2023; 46:236-247. [PMID: 35569541 DOI: 10.1016/j.gastrohep.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/02/2022] [Accepted: 04/05/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Manuel Romero-Gómez
- Servicio de Aparato Digestivo, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina (HUVR/CSIC/US), Universidad de Sevilla, Sevilla, España.
| | - Rocío Aller
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Valladolid, Universidad de Valladolid, Valladolid, España
| | - Javier Ampuero
- Servicio de Aparato Digestivo, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina (HUVR/CSIC/US), Universidad de Sevilla, Sevilla, España
| | | | - Salvador Augustín
- Servei de Hepatología, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Raquel Latorre
- Servicio de Aparato Digestivo, Hospital Universitario Son Llàtzer, Palma de Mallorca, Islas Baleares, España
| | | | | | | | - Sonia Alonso López
- Servicio de Aparato Digestivo, Hospital Universitario Gregorio Marañón, Madrid, España
| | - Agustín Albillos
- Servicio de Aparato Digestivo, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Marta Hernández
- Servicio de Aparato Digestivo, Hospital Universitario Puerta de Hierro-Majadahonda, IDIPHISA, Universidad Autónoma de Madrid, Majadahonda, Madrid, España
| | - Isabel Graupera
- Servicio de Hepatología, Hospital Clínic de Barcelona, IDIBAPS, Barcelona, España
| | - Salvador Benlloch
- Servicio de Aparato Digestivo, Hospital Arnau de Vilanova, Valencia, España; CIBERehd, Instituto de Salud Carlos III, Madrid, España
| | - Antonio Olveira
- Servicio de Aparato Digestivo, Hospital La Paz, Madrid, España
| | - Javier Crespo
- Servicio de Aparato Digestivo, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Valdecilla. IDIVAL, Santander, Cantabria, España
| | - José Luis Calleja
- Servicio de Aparato Digestivo, Hospital Universitario Puerta de Hierro-Majadahonda, IDIPHISA, Universidad Autónoma de Madrid, Majadahonda, Madrid, España
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5
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Gruneau L, Ekstedt M, Kechagias S, Henriksson M. Disease Progression Modeling for Economic Evaluation in Nonalcoholic Fatty Liver Disease-A Systematic Review. Clin Gastroenterol Hepatol 2023; 21:283-298. [PMID: 34757199 DOI: 10.1016/j.cgh.2021.10.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 09/10/2021] [Accepted: 10/24/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Globally, 25% of people have nonalcoholic fatty liver disease (NAFLD), and, currently, there are no approved pharmacologic treatments for NAFLD. With a slow disease progression, long-term impact of pharmacologic treatments can be assessed only by complementing emerging clinical trial evidence with data from other sources in disease progression modeling. Although this modeling is crucial for economic evaluation studies assessing the clinical and economic consequences of new treatments, the approach to modeling the natural history of NAFLD differs in contemporary research. This systematic literature review investigated modeling of the natural history of NAFLD. METHODS A systematic literature review was conducted searching PubMed, Scopus, Cochrane, and the National Health Service Economic Evaluation Database to identify articles focusing on modeling of the natural history of NAFLD. Model structure and transition probabilities were extracted from included studies. RESULTS Of the 28 articles identified, differences were seen in model structure and data input. Clear definitions of nonalcoholic steatohepatitis and NAFLD often were lacking; differences in the granularity of modeling fibrosis progression, the approach to disease regression, and modeling of advanced liver disease varied across studies. Observed transition probabilities for F0 to F1, F1 to F2, F2 to F3, and F3 to compensated cirrhosis varied between 0.059 to 0.095, 0.023 to 0.140, 0.018 to 0.070, and 0.040 to 0.118, respectively. CONCLUSIONS The difference in disease progression modeling for seemingly similar models warrants further inquiry regarding how to model the natural course of NAFLD. Such differences may have a large impact when assessing the value of emerging pharmacologic treatments.
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Affiliation(s)
- Lina Gruneau
- Center for Medical Technology Assessment, Linköping, Sweden.
| | - Mattias Ekstedt
- Division of Diagnostics and Specialist Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Stergios Kechagias
- Division of Diagnostics and Specialist Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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6
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Salehi H, Salehi AM, Ghamarchehreh ME, Khanlarzadeh E, Sohrabi MR. Diagnostic Accuracy of Vibration Controlled Transient Elastography as Non-invasive Assessment of Liver Fibrosis in Patients with Non-alcoholic Fatty Liver Disease. Middle East J Dig Dis 2023; 15:26-31. [PMID: 37547160 PMCID: PMC10404076 DOI: 10.34172/mejdd.2023.316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 09/25/2022] [Indexed: 08/08/2023] Open
Abstract
Background: Liver biopsy remain as the gold standard for diagnosing hepatic fibrosis; however, it has some limitations, such as life-threatening complications, low acceptance by the patients, and variations in the related sample. Therefore, there is a need for the development of non-invasive investigations for diagnosing hepatic fibrosis. Vibration-controlled transient elastography (VCTE) is one of these non-invasive methods. Methods: This study included 73 patients suffering from non-alcoholic fatty liver disease (NAFLD) who were older than 18 years. The patients underwent VCTE at the Baqiatallah and Firoozgar hospitals. Then, they underwent a liver biopsy by an experienced radiologist in the same hospital. A receiver operating characteristic (ROC) curve of different fibrosis stages was used to evaluate the VCTE verification. Results: VCTE could detect any fibrosis levels (stage 1 and higher) with an area under the ROC curve (AUROC) of 0.381. Moreover, it detected stage 2-4 fibrosis with an AUROC of 0.400, stage 3-4 fibrosis with an AUROC of 0.687, and stage 4 fibrosis with an AUROC of 0.984. Conclusion: The VCTE has high clinical validity in diagnosing the advanced stages of fibrosis (stages 3, 4) and can be a suitable alternative to the invasive method of liver biopsy with high reliability.
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Affiliation(s)
- Hossain Salehi
- Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Amir Mohammad Salehi
- Student Research Committee, Hamadan University of Medical Sciences School of Medicine, Hamadan, Iran
| | | | - Elham Khanlarzadeh
- Student Research Committee, Hamadan University of Medical Sciences School of Medicine, Hamadan, Iran
| | - Masoud Reza Sohrabi
- Department of Community Medicine, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
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7
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Chen ZX, Liu SY, Tong XM. Preoperative prediction of microvascular invasion: Is invasive biopsy of HCC necessary? J Hepatol 2022; 77:892-893. [PMID: 35483536 DOI: 10.1016/j.jhep.2022.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 02/03/2023]
Affiliation(s)
- Zi-Xiang Chen
- Key Laboratory of Tumor Molecular Diagnosis and Individualized Medicine of Zhejiang Province, Cancer Center, Affiliated People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Zhejiang, China; Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Si-Yu Liu
- The Key Laboratory of Imaging Diagnosis and Minimally Invasive Interventional Research of Zhejiang Province, Zhejiang University Lishui Hospital, Lishui, Zhejiang, China
| | - Xiang-Min Tong
- Key Laboratory of Tumor Molecular Diagnosis and Individualized Medicine of Zhejiang Province, Cancer Center, Affiliated People's Hospital of Hangzhou Medical College, Zhejiang Provincial People's Hospital, Zhejiang, China; The Key Laboratory of Imaging Diagnosis and Minimally Invasive Interventional Research of Zhejiang Province, Zhejiang University Lishui Hospital, Lishui, Zhejiang, China.
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8
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Liangpunsakul S. A Path Toward Improving Nonalcoholic Fatty Liver Disease Care Among Non-hepatologists. Endocr Pract 2022; 28:456-457. [PMID: 35569885 DOI: 10.1016/j.eprac.2022.03.014] [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: 01/04/2023]
Affiliation(s)
- Suthat Liangpunsakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, Indianapolis, IN 46202; Roudebush Veterans Administration Medical Center, Indianapolis, Indiana; Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, Indiana.
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9
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Canivet CM, Smati S, Lannes A, Brisseau J, Judon L, Roch ML, Cariou B, Bellanger W, Guerci B, Boursier J. Awareness of chronic liver diseases, a comparison between diabetologists and general practitioners. Clin Res Hepatol Gastroenterol 2022; 46:101848. [PMID: 34922062 DOI: 10.1016/j.clinre.2021.101848] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/10/2021] [Accepted: 11/27/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUNDS AND AIMS Because of the high prevalence of chronic liver disease (CLD), it is crucial that general practitioners (GPs, in contact with the general population) and diabetologists (in contact with the most at-risk non-alcoholic fatty liver disease population) identify patients with advanced CLD requiring specialized management. The aim of this study was to evaluate CLD and CLD management awareness among diabetologists and GPs. MATERIAL AND METHODS A questionnaire was sent to diabetologists within the Francophone Diabetes Society and to GPs in southern and western France. The questionnaire sounded participant characteristics and knowledge of CLD and its management. RESULTS 678 questionnaires were completed by 500 GPs and 178 diabetologists. CLD prevalence was underestimated by 90% of GPs and 59% of diabetologists (p<0.001). For biological CLD follow-up, liver injury explorations (transaminases) were systematically included whereas severity explorations (prothrombin time, bilirubin) were prescribed for less than 50% of blood samples; GPs were more likely to prescribe severity explorations than diabetologists were (p<0.001). 74% of GPs and 97% of diabetologists (p<0.001) were familiar with non-invasive tests, Fibroscan and Fibrotest being the two most-frequently mentioned of them. In contrast, the simple blood test Fibrosis-4 was cited by less than 15% of GPs and 30% of diabetologists (p<0.001). CONCLUSION GPs and diabetologists have limited knowledge of CLD, despite its high prevalence. Continuing medical education among GPs and diabetologists is therefore necessary to enable the discovery of patients with advanced fibrosis and early management for them so as to avoid liver-related complications.
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Affiliation(s)
- Clémence M Canivet
- Service d'Hépato-Gastroentérologie et Oncologie Digestive, Centre Hospitalier Universitaire d'Angers, Angers, France; Laboratoire HIFIH, UPRES EA3859, SFR 4208, Université d'Angers, Angers, France.
| | - Sarra Smati
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'Institut du Thorax, Nantes, France
| | - Adrien Lannes
- Service d'Hépato-Gastroentérologie et Oncologie Digestive, Centre Hospitalier Universitaire d'Angers, Angers, France; Laboratoire HIFIH, UPRES EA3859, SFR 4208, Université d'Angers, Angers, France
| | - Julie Brisseau
- Département de Médecine Générale, Université Côte d'Azur, Nice, France
| | - Louise Judon
- Département de Médecine Générale, Université d'Angers, Angers, France
| | - Marion Le Roch
- Département de Médecine Générale, Université d'Angers, Angers, France
| | - Bertrand Cariou
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'Institut du Thorax, Nantes, France
| | - William Bellanger
- Département de Médecine Générale, Université d'Angers, Angers, France
| | - Bruno Guerci
- Département d'Endocrinologie, Diabétologie et Nutrition, Hôpital Brabois et Université de Lorraine, Vandoeuvre Lès Nancy, France
| | - Jérôme Boursier
- Service d'Hépato-Gastroentérologie et Oncologie Digestive, Centre Hospitalier Universitaire d'Angers, Angers, France; Laboratoire HIFIH, UPRES EA3859, SFR 4208, Université d'Angers, Angers, France
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10
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The presence of diabetes impacts liver fibrosis and steatosis by transient elastography in a primary care population. Ann Hepatol 2022; 24:100336. [PMID: 33647502 DOI: 10.1016/j.aohep.2021.100336] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/11/2021] [Accepted: 02/18/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Noninvasive liver assessment in type 2 diabetes (T2DM) in a primary care population identifies higher risk non-alcoholic fatty liver disease (NAFLD). We aimed to evaluate the association of T2DM with liver fibrosis and steatosis by transient elastography (TE). MATERIALS AND METHODS This is a retrospective study of a TE referral program where primary care physicians were able to order TE. Patients with alcohol abuse were excluded. TE and Controlled Attenuation Parameter (CAP) scores were obtained. Multivariable linear and logistic regression models were used to adjust for confounders. RESULTS 28% had T2DM. The mean TE score in T2DM patients was 8.3 (±6) kilopascal (kPa) and 6.4 (±3.7) kPa in those without T2DM (p = 0.0001). Those with T2DM had a higher CAP (322 ± 51 dB/m vs. 296 ± 57 dB/m, p < 0.0001). In multivariable analysis, T2DM was associated with TE score (β: 1.9, 95% confidence interval [CI]: 0.74-3.1, p = 0.001) and CAP (β: 2.8, 95% CI: 9.3-36.2, p = 0.001). Patients with T2DM had higher-risk TE scores and more steatosis by CAP. CONCLUSION T2DM is associated with liver fibrosis and steatosis by TE within a primary care population. A TE referral pathway may be utilized for T2DM patients who are at higher risk of NAFLD and its complications.
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Khayyat YM. Determination of “indeterminate score” measurements in lean nonalcoholic fatty liver disease patients from western Saudi Arabia. World J Hepatol 2021; 13:2150-2160. [PMID: 35070015 PMCID: PMC8727213 DOI: 10.4254/wjh.v13.i12.2150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/24/2021] [Accepted: 10/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Noninvasive measures to estimate liver fibrosis in lieu of biopsy in nonalcoholic liver disease (NAFLD) can broadly differentiate high vs low degrees of condition extent. However, an “indeterminate score” necessitates further clinical investigation and biopsy becomes essential, highlighting the need for identification of other noninvasive factors with accuracy for this midlevel extent and its prognosis. Lean NAFLD cases are of particular interest regarding this issue, as they present as otherwise healthy, and will benefit greatly from the less invasive assessment.
AIM To estimate the agreement of two noninvasive assessment tools in lean NAFLD patients, and assess factors related to indeterminate scores.
METHODS Ultrasound-diagnosed NAFLD patients, without sign of other chronic liver disease (n = 1262), were enrolled from a tertiary private medical centre between 2016-2019. After grouping by body mass index (obese, overweight, and lean), each participant underwent FibroScan. NAFLD fibrosis score (NFS) was used for subclassification (lower, higher, and indeterminate). No patient underwent liver biopsy. The kappa statistic was used to assess inter-rater agreement between the three groups on liver fibrosis degree assessed via FibroScan and NFS. Indeterminate score among the three groups was assessed to identify factors that predict its determination.
RESULTS The NAFLD study cohort was composed of lean (159/1262, 12.6%), overweight (365/1262, 29%) and obese (737/1262, 58.4%) individuals. The lean patients were significantly younger (49.95 ± 15.3 years, P < 0.05), with higher serum high density lipoprotein (52.56 ± 16.27 mg/dL, P < 0.001) and lower prevalences of type 2 diabetes mellitus, hypertension and hyperlipidaemia. All groups showed a predominance of lower fibrosis degree. The lean NAFLD patients showed a significantly lower NFS (P < 0.001). Degree of agreement between FibroScan and NFS was fair between the lean and obese NAFLD categories, and moderate in the overweight category. NFS was predictive of indeterminate score. Age was a factor among all the body mass index (BMI) categories; other associated factors, but with less strength, were serum alanine aminotransferase in the overweight category and BMI in the obese category.
CONCLUSION Lean NAFLD patients showed lower degree and prevalence of liver fibrosis by NFS; however, follow-up biopsy is still needed.
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Affiliation(s)
- Yasir Mohammed Khayyat
- Department of Medicine, Umm Al Qura University, Makkah 13578, Saudi Arabia
- Department of Medicine, International Medical Centre, Jeddah 21451, Saudi Arabia
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Kosick HMK, Keyrouz A, Adeyi O, Sebastiani G, Patel K. A Stepwise Algorithmic Approach and External Validation Study for Noninvasive Prediction of Advanced Fibrosis in Nonalcoholic Fatty Liver Disease. Dig Dis Sci 2021; 66:4046-4057. [PMID: 33389416 DOI: 10.1007/s10620-020-06748-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 11/24/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Advanced F3-4 fibrosis predicts liver-related mortality in nonalcoholic fatty liver disease (NAFLD). Noninvasive tests, designed to rule in/out advanced fibrosis, are limited by indeterminates, necessitating biopsy. We aimed to determine whether stepwise combinations of noninvasive serum-based tests and elastography (VCTE) could predict F3-4, reduce indeterminates, and decrease liver biopsies. METHODS AND RESULTS Five hundred forty-one biopsy-proven NAFLD cases were identified between 2010 and 2018 from two Canadian centers. Characteristics of training (n = 407)/validation (n = 134) cohorts included: males 54%/59%; mean age 48.5/52.5 years; mean body mass index 32.3/33.6 kg/m2; diabetes mellitus 30%/34%; and F3-4 48%/43%. For training/validation cohorts, area under the receiver operating curve (AUROC) for FIB-4, AST-platelet ratio index (APRI), NAFLD fibrosis score (NFS), BARD score, and AST/ALT ratio ranged from 0.70 to 0.83/0.68 to 0.81, with indeterminates 25-39%/34-45%, for F3-4. In the training cohort, parallel FIB-4 + NFS had good accuracy (AUROC = 0.81) but was limited by 38% indeterminates and 16% misclassified. Sequential FIB-4 → NFS reduced indeterminates to 10%, and FIB-4 → VCTE to 0%, misclassified 20-22%, while maintaining high specificity (0.88-0.92) and accuracy (AUROC 0.75-0.78) for combined cohorts. Liver biopsy could have been avoided in 27-29% of patients using sequential algorithms. CONCLUSIONS Sequential FIB-4 ➔ NFS/VCTE predicts F3-4 with high specificity and good accuracy, while reducing indeterminates and need for biopsy. Parallel algorithms are limited by high indeterminates. Sequential FIB-4 ➔ NFS had similar accuracy to VCTE-containing algorithms. Validation in low-prevalence cohorts may allow for potential use in community or resource-limited areas for risk stratification.
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Affiliation(s)
- Heather Mary-Kathleen Kosick
- Division of Gastroenterology, University Health Network Toronto, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
| | - Aline Keyrouz
- Division of Gastroenterology and Hepatology, McGill University Health Center, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Oyedele Adeyi
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology, McGill University Health Center, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Keyur Patel
- Division of Gastroenterology, University Health Network Toronto, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
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Impact of metabolic surgery on cost and long-term health outcome: a cost-effectiveness approach. Surg Obes Relat Dis 2021; 18:260-270. [PMID: 34782294 DOI: 10.1016/j.soard.2021.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 09/20/2021] [Accepted: 10/13/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The increase in obesity has become a major public health concern. Morbid obesity is associated with co-morbidities, reduced quality-of-life, and death. Metabolic surgery (MS) is the most effective treatment for obesity. OBJECTIVES The aim of this study was to evaluate the costs and outcomes of MS compared with no surgery in patients with a body mass index ≥30 kg/m2. SETTING Health care system, Austria METHODS: A total of 177 patients who underwent MS were documented retrospectively, based on the hospital records of 2 specialized centers in Austria, over a 1-year period. At baseline 26.0% of patients exhibited type 2 diabetes (T2D), 52.5% cardiovascular disease (CVD), 23.2% hyperlipidemia, and 23.7% depression. Following the observation period, a Markov chain simulation model was developed to analyze the long-term consequences of T2D, including diabetic complications, CVD, hyperlipidemia, depression, non-alcoholic steatohepatitis (NASH), myocardial infarction, and stroke, over a total of 20 years. Direct medical costs were expressed in 2017 euros from the payer's perspective. Quality-adjusted life years (QALYs), life years (LYs), and costs were discounted. RESULTS MS led to costs of €40,427 and 9.58 QALYs (15.58 LYs) per patient over 20 years. No MS was associated with €64,819 and 6.33 QALYs (13.92 LYs). Total cost-savings amounted to €24,392, which offset the cost of the procedure including re-operations. Over 20 years MS saved -6.7 patient-years per patient with T2D, -5.8 patient-years with CVD, -1.5 patient-years with hyperlipidemia, -1.8 patient-years with depression, and -3.8 patient-years with NASH. CONCLUSION MS is associated with substantial savings in long-term costs, expected health benefits, and reduced onset of complications. MS significantly increases quality of life.
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Gonzalez JJ, DiBattista J, Gomez V, Gonzalez E, Zhang Q, Vaughn VM, Tapper EB. Impact of Inpatient Attending Specialty and Gastroenterology Consultation on Quality of Care of Patients Hospitalized with Decompensated Cirrhosis. Am J Med 2021; 134:1270-1277.e2. [PMID: 34144013 PMCID: PMC10838397 DOI: 10.1016/j.amjmed.2021.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Data suggest hospitalists are less adherent to quality indicators for decompensated cirrhosis, and gastroenterology consultation may improve adherence. We sought to evaluate the impact of inpatient attending specialty and gastroenterology consultation on quality of care for decompensated cirrhosis. METHODS This was a retrospective cohort study of patients with decompensated cirrhosis admitted to gastroenterology or hospitalist service at the University of Michigan between 2016-2020. The primary outcome was adherence to nationally recommended inpatient quality indicators for ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, and gastrointestinal bleeding. Performance was calculated per patient admission as the proportion of quality indicators met vs quality indicators for which the patient was eligible. Quality indicator scores were compared between services using t-tests. We also evaluated the effect of gastroenterology consultation on quality indicator scores for patients admitted to hospitalist service. Clinical outcomes were compared using multivariable models adjusted for patient characteristics. RESULTS Two hundred eighty-eight admissions were included (155 to gastroenterology service; 133 to hospitalist service). Quality indicator score for all admissions was 69.9% (standard deviation [SD] ± 24.2%). Quality indicator scores were similar between gastroenterology (69.9%, SD ± 23.6%) and hospitalist (69.8%, SD ± 25.1%) services (P = .913). There was no difference in quality indicator subscores for each complication between services. Hospitalists placed a gastroenterology consultation in 53.4% of admissions, and it was associated with higher albumin administration for patients with spontaneous bacterial peritonitis (57.1% vs 25%, P = .044). Patients admitted to gastroenterology service had higher readmissions within 30 days (adjusted odds ratio = 1.95) and shorter length of hospitalization (adjusted rate ratio = 0.85). CONCLUSIONS Hospitalists provided comparable quality of care to gastroenterologists for inpatients with decompensated cirrhosis.
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Affiliation(s)
- Juan J Gonzalez
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor.
| | - Jacob DiBattista
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | | | - Emelie Gonzalez
- Facultad de Medicina Dr. Jose Edmundo Vasquez, Universidad Dr. Jose Matias Delgado, La Libertad, El Salvador
| | - Qisu Zhang
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah Medical School, Salt Lake City
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
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Kang SH, Lee HW, Yoo JJ, Cho Y, Kim SU, Lee TH, Jang BK, Kim SG, Ahn SB, Kim H, Jun DW, Choi JI, Song DS, Kim W, Jeong SW, Kim MY, Koh H, Jeong S, Lee JW, Cho YK. KASL clinical practice guidelines: Management of nonalcoholic fatty liver disease. Clin Mol Hepatol 2021; 27:363-401. [PMID: 34154309 PMCID: PMC8273632 DOI: 10.3350/cmh.2021.0178] [Citation(s) in RCA: 139] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 06/22/2021] [Indexed: 02/06/2023] Open
Affiliation(s)
- Seong Hee Kang
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hye Won Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul Korea
| | - Jeong-Ju Yoo
- Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, Bucheon, Korea
| | - Yuri Cho
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul Korea
| | - Tae Hee Lee
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Byoung Kuk Jang
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, Bucheon, Korea
| | - Sang Bong Ahn
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Haeryoung Kim
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dae Won Jun
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Joon-Il Choi
- Department of Radiology, Seoul St.Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do Seon Song
- Department of Internal Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won Kim
- Department of Internal Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Soung Won Jeong
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hong Koh
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Yonsei University College of Medicine, Severance Children's Hospital, Seoul, Korea
| | - Sujin Jeong
- Division of Pediatric Gastroenterology Hepatology and Nutrition, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jin-Woo Lee
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Yong Kyun Cho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Congly SE, Shaheen AA, Swain MG. Modelling the cost effectiveness of non-alcoholic fatty liver disease risk stratification strategies in the community setting. PLoS One 2021; 16:e0251741. [PMID: 34019560 PMCID: PMC8139490 DOI: 10.1371/journal.pone.0251741] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 05/01/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is highly prevalent worldwide. Identifying high-risk patients is critical to best utilize limited health care resources. We established a community-based care pathway using 2D ultrasound shear wave elastography (SWE) to identify high risk patients with NAFLD. Our objective was to assess the cost-effectiveness of various non-invasive strategies to correctly identify high-risk patients. METHODS A decision-analytic model was created using a payer's perspective for a hypothetical patient with NAFLD. FIB-4 [≥1.3], NAFLD fibrosis score (NFS) [≥-1.455], SWE [≥8 kPa], transient elastography (TE) [≥8 kPa], and sequential strategies with FIB-4 or NFS followed by either SWE or TE were compared to identify patients with either significant (≥F2) or advanced fibrosis (≥F3). Model inputs were obtained from local data and published literature. The cost/correct diagnosis of advanced NAFLD was obtained and univariate sensitivity analysis was performed. RESULTS For ≥F2 fibrosis, FIB-4/SWE cost $148.75/correct diagnosis while SWE cost $276.42/correct diagnosis, identifying 84% of patients correctly. For ≥F3 fibrosis, using FIB-4/SWE correctly identified 92% of diagnoses and dominated all other strategies. The ranking of strategies was unchanged when stratified by normal or abnormal ALT. For ≥F3 fibrosis, the cost/correct diagnosis was less in the normal ALT group. CONCLUSIONS SWE based strategies were the most cost effective for diagnosing ≥F2 fibrosis. For ≥F3 fibrosis, FIB-4 followed by SWE was the most effective and least costly strategy. Further evaluation of the timing of repeating non-invasive strategies are required to enhance the cost-effective management of NAFLD.
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Affiliation(s)
- Stephen E. Congly
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary Alberta, Canada
- * E-mail:
| | - Abdel Aziz Shaheen
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary Alberta, Canada
| | - Mark G. Swain
- Division of Gastroenterology and Hepatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary Alberta, Canada
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Boursier J, Tsochatzis EA. Case-finding strategies in non-alcoholic fatty liver disease. JHEP Rep 2020; 3:100219. [PMID: 33659890 PMCID: PMC7896150 DOI: 10.1016/j.jhepr.2020.100219] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/18/2020] [Accepted: 11/23/2020] [Indexed: 12/18/2022] Open
Abstract
Among the large population of patients with non-alcoholic fatty liver disease (NAFLD), identifying those with advanced disease remains challenging. Many patients are diagnosed late, following the development of liver-related complications, leading to poor clinical outcomes. Accumulating evidence suggests that using non-invasive tests for liver fibrosis in patients with metabolic risk factors improves the detection of patients in need of specialised management and is cost-effective. Because of the vast number of patients requiring evaluation, the active participation of general practitioners and physicians who manage patients with metabolic disorders, such as diabetologists, is crucial; this calls for the increased awareness of NAFLD beyond liver clinics. Non-invasive case-finding strategies will need to be further validated and generalised for upcoming drug therapies to have the required impact on the worldwide burden of NAFLD.
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Key Words
- ALD, alcohol-related liver disease
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- Awareness
- Case-finding
- Cirrhosis
- Cost-effectiveness
- ELF, enhanced liver fibrosis
- Elastography
- FIB-4
- FIB-4, fibrosis-4
- GP, general practitioner
- Liver fibrosis
- NAFLD, non-alcoholic fatty liver disease
- NAS, NAFLD activity score
- NASH, non-alcoholic steatohepatitis
- NFS, NAFLD fibrosis score
- NICE, National Institute of Clinical Excellence
- NIT, non-invasive test
- Patient pathway
- Primary care
- QALY, quality-adjusted life year
- Screening
- T2DM, type 2 diabetes mellitus
- TE, transient elastography
- Type 2 diabetes mellitus
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Affiliation(s)
- Jerome Boursier
- Service d'Hépato-Gastroentérologie et Oncologie Digestive, Centre Hospitalier Universitaire d'Angers, Angers, France.,Laboratoire HIFIH, UPRES EA3859, SFR 4208, Université d'Angers, Angers, France
| | - Emmanuel A Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK.,UCL Institute for Liver and Digestive Health, Royal Free Campus, UCL, London, UK
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18
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Vilar-Gomez E, Lou Z, Kong N, Vuppalanchi R, Imperiale TF, Chalasani N. Cost Effectiveness of Different Strategies for Detecting Cirrhosis in Patients With Nonalcoholic Fatty Liver Disease Based on United States Health Care System. Clin Gastroenterol Hepatol 2020; 18:2305-2314.e12. [PMID: 32289535 DOI: 10.1016/j.cgh.2020.04.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/31/2020] [Accepted: 04/03/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Several strategies are available for detecting cirrhosis in patients with nonalcoholic fatty liver disease (NAFLD), but their cost effectiveness is not clear. We developed a decision model to quantify the accuracy and costs of 9 single or combination strategies, including 3 noninvasive tests (fibrosis-4 [FIB-4], vibration-controlled transient elastography [VCTE], and magnetic resonance elastography [MRE]) and liver biopsy, for the detection of cirrhosis in patients with NAFLD. METHODS Data on the diagnostic accuracy, costs, adverse events, and cirrhosis outcomes over a 5-year period were obtained from publications. The diagnostic accuracy, per-patient cost per correct diagnosis of cirrhosis, and incremental cost-effectiveness ratios (ICERs) were calculated for each strategy for base cirrhosis prevalence values of 0.27%, 2%, and 4%. RESULTS The combination of the FIB-4 and VCTE identified patients with cirrhosis in NAFLD populations with a 0.27%, 2%, and 4% prevalence of cirrhosis with the lowest cost per person ($401, $690, and $1024, respectively) and highest diagnostic accuracy (89.3%, 88.5%, and 87.5% respectively). The combination of FIB-4 and MRE ranked second in cost per person ($491, $781, and $1114, respectively) and diagnostic accuracy (92.4%, 91.6%, 90.6%, respectively). Compared with the combination of FIB-4 and VCTE (least costly), the ICERs were lower for the combination of FIB-4 and MRE ($2864, $2918, and $2921) than the combination of FIB-4 and liver biopsy ($4454, $5156, and $5956) at the cirrhosis prevalence values tested. When the goal was to avoid liver biopsy, FIB-4 + VCTE and FIB-4 + MRE had similar diagnostic accuracies, ranging from 87.5% to 89.3% and 90.6% to 92.4% for a cirrhosis diagnosis, respectively, although FIB-4 + MRE had a slightly higher cost. CONCLUSIONS In our cost-effectiveness analysis based on the US health care system, we found that results from FIB-4, followed by either VCTE, MRE, or liver biopsy, detect cirrhosis in patients with NAFLD with a high level of accuracy and low cost. Compared with FIB-4 + VCTE, which was the least costly strategy, FIB-4 + MRE had a lower ICER than FIB-4 + LB.
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Affiliation(s)
- Eduardo Vilar-Gomez
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Zhouyang Lou
- School of Industrial Engineering, Purdue University, West Lafayette, Indiana
| | - Nan Kong
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana
| | - Raj Vuppalanchi
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Thomas F Imperiale
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Center for Innovation, Health Services Research and Development, Roudebush Veterans Affairs Medical Center; Regenstrief Institute, Inc, Indianapolis, Indiana
| | - Naga Chalasani
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
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Schulz M, Tacke F. Identifying High-Risk NASH Patients: What We Know so Far. ACTA ACUST UNITED AC 2020; 12:125-138. [PMID: 32982495 PMCID: PMC7493213 DOI: 10.2147/hmer.s265473] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/24/2020] [Indexed: 12/12/2022]
Abstract
Steatosis is a condition of hepatic fat overload that is associated with overweight and the metabolic syndrome. Nonalcoholic fatty liver disease (NAFLD) has become the most common liver disease with a global impact on healthcare. A proportion of NAFLD patients develops nonalcoholic steatohepatitis (NASH), liver fibrosis, cirrhosis or hepatocellular carcinoma (HCC). Identifying patients at risk for potentially life-threatening complications is crucial in their prevention, surveillance and treatment. In addition to hepatic disease progression (cirrhosis, portal hypertension, HCC), NAFLD patients are also at risk of cardiovascular and metabolic diseases as well as extrahepatic malignancies. Liver fibrosis is related to morbidity and mortality in NASH patients, and biomarkers, imaging techniques (ultrasound, elastography, MRI) as well as liver biopsy help in diagnosing fibrosis. In this review, we discuss the tools for identifying patients at risk and their reasonable application in clinical routine in order to stratify prevention and treatment of this emerging disease.
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Affiliation(s)
- Marten Schulz
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum (CVK) Und Campus Charité Mitte (CCM), Berlin, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum (CVK) Und Campus Charité Mitte (CCM), Berlin, Germany
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20
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Han AL. Association between Non-Alcoholic Fatty Liver Disease and Dietary Habits, Stress, and Health-Related Quality of Life in Korean Adults. Nutrients 2020; 12:E1555. [PMID: 32471118 PMCID: PMC7352638 DOI: 10.3390/nu12061555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/22/2020] [Accepted: 05/24/2020] [Indexed: 02/06/2023] Open
Abstract
Considering the increasing prevalence of non-alcoholic fatty liver disease (NAFLD), this study aimed to evaluate the association between NAFLD and dietary habits, stress, and health-related quality of life (HRQoL) in Korean individuals by using data from the Korea National Health and Nutrition Examination Survey (KNHANES) VI 2013-2015. NAFLD was defined in individuals with a hepatic steatosis index (HSI) value ≥36. Eating habits were assessed based on the frequencies of eating and eating out; stress was assessed through the stress perception rate; and the EuroQol-5D (EQ-5D) questionnaire was used to assess the HRQoL. We performed a complex sample logistic regression analysis and estimated the odds ratios by adjusting for significant factors to evaluate associations between NAFLD and dietary habits, stress, and HRQoL. Occurrence of NAFLD was not significantly associated with meal frequencies over one week. With an increase in stress, based on the stress perception rate, the risk of NAFLD increased 1.316-fold (95% confidence interval (CI): 1.175-1.469, p < 0.05). Additionally, a decrease in the EQ-5D score by 1 increased the risk of NAFLD 3.38-fold (95% CI: 1.893-4.844, p < 0.05). Thus, NAFLD treatment should include stress management, and underlying HRQoL should be considered during treatment.
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Affiliation(s)
- A Lum Han
- Department of Family Medicine, Wonkwang University Hospital, Iksan 54538, Korea
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Hirode G, Saab S, Wong RJ. Trends in the Burden of Chronic Liver Disease Among Hospitalized US Adults. JAMA Netw Open 2020; 3:e201997. [PMID: 32239220 PMCID: PMC7118516 DOI: 10.1001/jamanetworkopen.2020.1997] [Citation(s) in RCA: 139] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 02/07/2020] [Indexed: 12/11/2022] Open
Abstract
Importance One factor associated with the rapidly increasing clinical and economic burden of chronic liver disease (CLD) is inpatient health care utilization. Objective To understand trends in the hospitalization burden of CLD in the US. Design, Setting, and Participants This cross-sectional study of hospitalized adults in the US used data from the National Inpatient Sample from 2012 to 2016 on adult CLD-related hospitalizations. Data were analyzed from June to October 2019. Main Outcomes and Measures Hospitalizations identified using a comprehensive review of CLD-specific International Classification of Diseases, Ninth Revision, Clinical Modification and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes. Survey-weighted annual trends in national estimates of CLD-related hospitalizations, in-hospital mortality, and hospitalization costs, stratified by demographic and clinical characteristics. Results This study included 1 016 743 CLD-related hospitalizations (mean [SD] patient age, 57.4 [14.4] years; 582 197 [57.3%] male; 633 082 [62.3%] white). From 2012 to 2016, the rate of CLD-related hospitalizations per 100 000 hospitalizations increased from 3056 (95% CI, 3042-3069) to 3757 (95% CI, 3742-3772), and total inpatient hospitalization costs increased from $14.9 billion (95% CI, $13.9 billion to $15.9 billion) to $18.8 billion (95% CI, $17.6 billion to $20.0 billion). Mean (SD) patient age increased (56.8 [14.2] years in 2012 to 57.8 [14.6] years in 2016) and, subsequently, the proportion with Medicare also increased (41.7% [95% CI, 41.1%-42.2%] to 43.6% [95% CI, 43.1%-44.1%]) (P for trend < .001 for both). The proportion of hospitalizations of patients with hepatitis C virus was similar throughout the period of study (31.6% [95% CI, 31.3%-31.9%]), and the proportion with alcoholic cirrhosis and nonalcoholic fatty liver disease showed increases. The mortality rate was higher among hospitalizations with alcoholic cirrhosis (11.9% [95% CI, 11.7%-12.0%]) compared with other etiologies. Presence of hepatocellular carcinoma was also associated with a high mortality rate (9.8% [95% CI, 9.5%-10.1%]). Cost burden increased across all etiologies, with a higher total cost burden among hospitalizations with alcoholic cirrhosis ($22.7 billion [95% CI, $22.1 billion to $23.2 billion]) or hepatitis C virus ($22.6 billion [95% CI, $22.1 billion to $23.2 billion]). Presence of cirrhosis, complications of cirrhosis, and comorbidities added to the CLD burden. Conclusions and Relevance Over the study period, the total estimated national hospitalization costs in patients with CLD reached $81.1 billion. The inpatient CLD burden in the US is likely increasing because of an aging CLD population with increases in concomitant comorbid conditions.
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Affiliation(s)
- Grishma Hirode
- Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland, California
| | - Sammy Saab
- David Geffen School of Medicine, Department of Medicine, University of California at Los Angeles
| | - Robert J. Wong
- Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland, California
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Viglino D, Martin M, Almeras N, Després JP, Coxson HO, Pépin JL, Vivodtzev I, Maltais F. Low Liver Density Is Linked to Cardiovascular Comorbidity in COPD: An ECLIPSE Cohort Analysis. Int J Chron Obstruct Pulmon Dis 2019; 14:3053-3061. [PMID: 32099343 PMCID: PMC6997198 DOI: 10.2147/copd.s233834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/17/2019] [Indexed: 12/13/2022] Open
Abstract
Purpose Fatty liver disease is associated with cardiometabolic disorders and represents a potential key comorbidity in Chronic Obstructive Pulmonary Disease (COPD). Some intermediary mechanisms of fatty liver disease (including its histological component steatosis) include tissue hypoxia, low-grade inflammation and oxidative stress that are key features of COPD. Despite these shared physiological pathways, the effect of COPD on the prevalence of hepatic steatosis, and the association between hepatic steatosis and comorbidities in this population remain unclear. Liver density measured by computed tomography (CT)-scan is a non-invasive surrogate of fat infiltration, with lower liver densities reflecting more fat infiltration and a liver density of 40 Hounsfield Units (HU) corresponding to a severe 30% fat infiltration. Patients and Methods We took advantage of the international cohort ECLIPSE in which non-enhanced chest CT-scans were obtained in 1554 patients with COPD and 387 healthy controls to analyse the liver density at T12-L1. Results The distribution of liver density was similar and the prevalence of severe steatosis (density<40 HU) was not different (4.7% vs 5.2%, p=0.7) between COPD and controls. In patients with COPD, the lowest liver density quartile was associated, after age and sex adjustment, with coronary artery disease (ORa=1.59, 95% CI 1.12 to 2.24) and stroke (ORa=2.20, 95% CI 1.07 to 4.50), in comparison with the highest liver density quartile. Conclusion The present data indicate that a low liver density emerged as a predictor of cardiovascular comorbidities in the COPD population. However, the distribution of liver density and the prevalence of severe steatosis were similar in patients with COPD and control subjects.
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Affiliation(s)
- Damien Viglino
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec, Canada.,Hypoxia Pathophysiology Laboratory INSERM U1042, Grenoble Alpes University Hospital, Grenoble, France
| | - Mickaël Martin
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec, Canada
| | - Natalie Almeras
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec, Canada
| | - Jean-Pierre Després
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec, Canada
| | - Harvey O Coxson
- Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jean-Louis Pépin
- Hypoxia Pathophysiology Laboratory INSERM U1042, Grenoble Alpes University Hospital, Grenoble, France
| | - Isabelle Vivodtzev
- Hypoxia Pathophysiology Laboratory INSERM U1042, Grenoble Alpes University Hospital, Grenoble, France
| | - François Maltais
- Centre de Recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec, Canada
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Libman H, Jiang ZG, Tapper EB, Reynolds EE. How Would You Manage This Patient With Nonalcoholic Fatty Liver Disease?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2019; 171:199-207. [PMID: 31382287 DOI: 10.7326/m19-1125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD), a common diagnosis in the United States and other developed countries, has been increasing in prevalence. The American Association for the Study of Liver Diseases recently published updated practice guidelines for diagnosing and managing NAFLD, including the following recommendations: Routine screening for NAFLD in high-risk groups is not advised because of uncertainties surrounding test and treatment options, along with a lack of knowledge about cost-effectiveness and long-term benefits. Noninvasive studies, including biomarkers from laboratory tests and liver stiffness measured through elastography, are clinically useful tools for identifying advanced fibrosis in patients with NAFLD. Liver biopsy should be considered in patients with NAFLD who are at increased risk for nonalcoholic steatohepatitis (NASH) or advanced fibrosis. Weight loss of at least 3% to 5% generally reduces NASH, but greater weight loss (7% to 10%) is needed to improve most histopathologic features, including fibrosis. Pharmacologic therapies (such as pioglitazone and vitamin E) should be considered only in patients with biopsy-proven NASH. Patients with NAFLD should not consume heavy amounts of alcohol, although insufficient data exist to provide advice about other levels of alcohol use. Here, 2 clinicians with expertise in this area debate whether to screen for NAFLD in primary care, how to monitor patients with NAFLD, and what interventions should be used to manage this condition.
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Affiliation(s)
- Howard Libman
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (H.L., Z.G.J., E.E.R.)
| | - Z Gordon Jiang
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (H.L., Z.G.J., E.E.R.)
| | | | - Eileen E Reynolds
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (H.L., Z.G.J., E.E.R.)
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24
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Armstrong MJ, Marchesini G. Referral pathways for NAFLD fibrosis in primary care - No longer a 'needle in a haystack'. J Hepatol 2019; 71:246-248. [PMID: 31229270 DOI: 10.1016/j.jhep.2019.05.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/20/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Matthew J Armstrong
- Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK; NIHR Biomedical Research Centre, Centre for Liver Research, University of Birmingham, Birmingham, UK.
| | - Giulio Marchesini
- Unit of Metabolic Diseases & Clinical Dietetics, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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25
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Heavener T, Memon A, Khan S, Davis S, Sager L, DeMorrow S, Jeffries M. Testing the ability of the nonalcoholic fatty liver disease fibrosis score to predict 1-year all-cause hospital admission. Proc (Bayl Univ Med Cent) 2019; 32:26-29. [PMID: 30956575 DOI: 10.1080/08998280.2018.1543227] [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: 08/03/2018] [Revised: 10/27/2018] [Accepted: 10/29/2018] [Indexed: 10/27/2022] Open
Abstract
The nonalcoholic fatty liver disease fibrosis score (NFS) has been shown to be a cost-effective screening strategy in the primary care setting to determine when gastroenterology referral is needed, but NFS as a predictor of hospitalization within 1 year is uncertain. This retrospective observational cohort study involved 1803 patients with a diagnosis of nonalcoholic fatty liver disease or nonalcoholic steatohepatitis. The NFS was categorized into the following: low (less than -1.455), moderate (between -1.455 and 0.676), and high (>0.676). The average NFS score by hospital admission was -0.760, the average number of admissions was 1.81, and the median number of days to hospital admission was 135.8 days (45.5-363, 25th to 75th percentile). A univariate logistic regression model showed that NFS significantly predicted hospital admission (P = 0.007); however, a multivariate logistic regression model, after adjusting for hypertension and tobacco use, indicated that NFS was not significantly associated with hospital admission. Using the logistic regression model, hypertension predicted admission at low (P < 0.0001) and moderate (P = 0.0005) NFS. Using this same model, tobacco use also predicted admission at low (P < 0.0001) and moderate (P = 0.0002) NFS. The NFS should not be used to determine which patients are at increased risk of hospitalization.
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Affiliation(s)
- Trace Heavener
- Department of Medicine, Division of Internal Medicine, Scott & White Medical Center-TempleTempleTexas
| | - Ahmed Memon
- College of Medicine, Texas A&M UniversityTempleTexas
| | - Shamyal Khan
- Department of Medicine, Division of Internal Medicine, Scott & White Medical Center-TempleTempleTexas
| | - Sam Davis
- Department of Medicine, Division of Internal Medicine, Scott & White Medical Center-TempleTempleTexas
| | - Lauren Sager
- Office of Biostatistics, Baylor Scott & White Research Institute-TempleTempleTexas
| | - Sharon DeMorrow
- Department of Medical Physiology, College of Medicine, Texas A&M University, and Research Biologist, Central Texas Veterans Healthcare SystemTempleTexas
| | - Mark Jeffries
- Department of Medicine, Division of Gastroenterology, Scott & White Medical Center-TempleTempleTexas
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26
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Kumar R, Teo EK, How CH, Wong TY, Ang TL. A practical clinical approach to liver fibrosis. Singapore Med J 2019; 59:628-633. [PMID: 30631885 DOI: 10.11622/smedj.2018145] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Liver fibrosis is a slow, insidious process involving accumulation of extracellular matrix protein in the liver. The stage of liver fibrosis in chronic liver disease (CLD) determines overall morbidity and mortality; the higher the stage, the worse the prognosis. Noninvasive composite scores can be used to determine whether patients with CLD have significant or advanced fibrosis. Patients with low composite scores can be safely followed up in primary care with periodic reassessment. Those with higher scores should be referred to a specialist. As the epidemic of diabetes mellitus, obesity and non-alcoholic fatty liver diseases is rising, CLD is becoming more prevalent. Easy-to-use fibrosis assessment composite scores can identify patients with minimal or advanced fibrosis, and should be an integral part of decision-making. Patients with cirrhosis, high composite scores, chronic hepatitis B with elevated alanine aminotransferase and aspartate aminotransferase, or deranged liver panel of uncertain aetiology should be referred to a specialist.
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Affiliation(s)
- Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Choon How How
- Care and Health Integration, Changi General Hospital, Singapore.,Family Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore
| | - Teck Yee Wong
- Department of Continuing and Community Care, Tan Tock Seng Hospital, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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27
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Tsochatzis EA, Newsome PN. Non-alcoholic fatty liver disease and the interface between primary and secondary care. Lancet Gastroenterol Hepatol 2019; 3:509-517. [PMID: 29893235 DOI: 10.1016/s2468-1253(18)30077-3] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 02/06/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) has a prevalence of 25-30% in unselected populations and has become the main reason for referrals to hepatology services. From the perspective of liver disease, NAFLD has a high prevalence but low severity. Screening studies in people at risk for NAFLD have shown a prevalence of advanced fibrosis of 5%, which underlines the need for robust pathways for risk stratification in primary care, with subsequent referrals as required. In this Review, we discuss the interface between primary and secondary care with regards to risk stratification and management of patients with NAFLD. We focus on selected issues of epidemiology and natural history and discuss the burden of disease in primary care, the evidence on screening for NAFLD, the rationale for testing for advanced fibrosis, and the optimal management of the disease in primary care.
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Affiliation(s)
- Emmanuel A Tsochatzis
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, UK.
| | - Philip N Newsome
- National Institute for Health Research, Liver Biomedical Research Unit and Liver Unit, University Hospitals Birmingham NHS Foundation Trust and Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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28
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Patel YA, Gifford EJ, Glass LM, Turner MJ, Han B, Moylan CA, Choi S, Suzuki A, Provenzale D, Hunt CM. Identifying Nonalcoholic Fatty Liver Disease Advanced Fibrosis in the Veterans Health Administration. Dig Dis Sci 2018; 63:2259-2266. [PMID: 29779083 DOI: 10.1007/s10620-018-5123-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 05/10/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease. Severe NAFLD with advanced fibrosis results in substantial morbidity and mortality. Associated with metabolic syndrome, NAFLD is often initially clinically silent, yet intensive lifestyle intervention with 7% or greater weight loss can improve or resolve NAFLD. Using a Veterans Health Administration (VHA) liver biopsy cohort, we evaluated simple noninvasive fibrosis scoring systems to identify NAFLD with advanced fibrosis (or severe disease) to assist providers. METHODS In our retrospective study of a national VHA sample of patients with biopsy-proven NAFLD or normal liver (2005-2015), we segregated patients by fibrosis stage (0-4). Non-NAFLD liver disease was excluded. We evaluated the diagnostic accuracy of the NAFLD fibrosis score (NFS), fibrosis-4 calculator (FIB-4), aspartate aminotransferase-to-alanine aminotransferase ratio (AST/ALT ratio), AST-to-platelet ratio index (APRI), and body mass index, AST/ALT ratio, and diabetes (BARD) score by age groups. RESULTS We included 329 patients with well-defined liver histology (296 NAFLD and 33 normal controls without fibrosis), in which 92 (28%) had advanced (stage 3-4) fibrosis. Across all age groups, NFS and FIB-4 best predicted advanced fibrosis (NFS with 0.676 threshold: AUROC 0.71-0.76, LR + 2.30-22.05, OR 6.00-39.58; FIB-4 with 2.67 threshold: AUROC of 0.62-0.80, LR + 4.70-27.45, OR 16.34-59.65). CONCLUSIONS While NFS and FIB-4 scores exhibit good diagnostic accuracy, FIB-4 is optimal in identifying NAFLD advanced fibrosis in the VHA. Easily implemented as a point-of-care clinical test, FIB-4 can be useful in directing patients that are most likely to have advanced fibrosis to GI/hepatology consultation and follow-up.
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Affiliation(s)
- Yuval A Patel
- Department of Medicine, Duke University Medical Center, Durham Veterans Administration Medical Center, Box 3913, Durham, NC, 27710, USA.
| | | | - Lisa M Glass
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA.,VA Ann Arbor Healthcare Systems, Ann Arbor, MI, USA
| | - Marsha J Turner
- Cooperative Studies Program Epidemiology Center, Durham Veterans Administration Medical Center, Durham, NC, USA
| | - Byungjoo Han
- Cooperative Studies Program Epidemiology Center, Durham Veterans Administration Medical Center, Durham, NC, USA
| | - Cynthia A Moylan
- Department of Medicine, Duke University Medical Center, Durham Veterans Administration Medical Center, Box 3913, Durham, NC, 27710, USA
| | - Steve Choi
- Department of Medicine, Duke University Medical Center, Durham Veterans Administration Medical Center, Box 3913, Durham, NC, 27710, USA
| | - Ayako Suzuki
- Department of Medicine, Duke University Medical Center, Durham Veterans Administration Medical Center, Box 3913, Durham, NC, 27710, USA
| | - Dawn Provenzale
- Department of Medicine, Duke University Medical Center, Durham Veterans Administration Medical Center, Box 3913, Durham, NC, 27710, USA.,Cooperative Studies Program Epidemiology Center, Durham Veterans Administration Medical Center, Durham, NC, USA
| | - Christine M Hunt
- Department of Medicine, Duke University Medical Center, Durham Veterans Administration Medical Center, Box 3913, Durham, NC, 27710, USA.,Cooperative Studies Program Epidemiology Center, Durham Veterans Administration Medical Center, Durham, NC, USA
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Abstract
Nonalcoholic fatty liver disease (NAFLD) affects 25% of the global adult population and is the most common chronic liver disease worldwide. Nonalcoholic steatohepatitis (NASH) is the active form of NAFLD, with hepatic necroinflammation and faster fibrosis progression. With an increasing number of patients developing NASH-related end-stage liver disease and pharmacological treatments on the horizon, there is a pressing need to develop NAFLD and NASH biomarkers for prognostication, selection of patients for treatment and monitoring. This requirement is particularly true as liver biopsy utility is limited by its invasive nature, poor patient acceptability and sampling variability. This article reviews current and potential biomarkers for different features of NAFLD, namely, steatosis, necroinflammation and fibrosis. For each biomarker, we evaluate its accuracy, reproducibility, responsiveness, feasibility and limitations. We cover biochemical, imaging and genetic biomarkers and discuss biomarker discovery in the omics era.
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30
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Abstract
OBJECTIVE To describe liver disease related mortality in the United States during 1999-2016 by age group, sex, race, cause of liver disease, and geographic region. DESIGN Observational cohort study. SETTING Death certificate data from the Vital Statistics Cooperative, and population data from the US Census Bureau compiled by the Center for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (1999-2016). PARTICIPANTS US residents. MAIN OUTCOME MEASURE Deaths from cirrhosis and hepatocellular carcinoma, with trends evaluated using joinpoint regression. RESULTS From 1999 to 2016 in the US annual deaths from cirrhosis increased by 65%, to 34 174, while annual deaths from hepatocellular carcinoma doubled to 11 073. Only one subgroup-Asians and Pacific Islanders-experienced an improvement in mortality from hepatocellular carcinoma: the death rate decreased by 2.7% (95% confidence interval 2.2% to 3.3%, P<0.001) per year. Annual increases in cirrhosis related mortality were most pronounced for Native Americans (designated as "American Indians" in the census database) (4.0%, 2.2% to 5.7%, P=0.002). The age adjusted death rate due to hepatocellular carcinoma increased annually by 2.1% (1.9% to 2.3%, P<0.001); deaths due to cirrhosis began increasing in 2009 through 2016 by 3.4% (3.1% to 3.8%, P<0.001). During 2009-16 people aged 25-34 years experienced the highest average annual increase in cirrhosis related mortality (10.5%, 8.9% to 12.2%, P<0.001), driven entirely by alcohol related liver disease. During this period, mortality due to peritonitis and sepsis in the setting of cirrhosis increased substantially, with respective annual increases of 6.1% (3.9% to 8.2%) and 7.1% (6.1% to 8.4%). Only one state, Maryland, showed improvements in mortality (-1.2%, -1.7% to -0.7% per year), while many, concentrated in the south and west, observed disproportionate annual increases: Kentucky 6.8% (5.1% to 8.5%), New Mexico 6.0% (4.1% to 7.9%), Arkansas 5.7% (3.9% to 7.6%), Indiana 5.0% (3.8% to 6.1%), and Alabama 5.0% (3.2% to 6.8%). No state showed improvements in hepatocellular carcinoma related mortality, while Arizona (5.1%, 3.7% to 6.5%) and Kansas (4.3%, 2.8% to 5.8%) experienced the most severe annual increases. CONCLUSIONS Mortality due to cirrhosis has been increasing in the US since 2009. Driven by deaths due to alcoholic cirrhosis, people aged 25-34 have experienced the greatest relative increase in mortality. White Americans, Native Americans, and Hispanic Americans experienced the greatest increase in deaths from cirrhosis. Mortality due to cirrhosis is improving in Maryland but worst in Kentucky, New Mexico, and Arkansas. The rapid increase in death rates among young people due to alcohol highlight new challenges for optimal care of patients with preventable liver disease.
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, MI, USA
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, MI, USA
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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31
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Abstract
NAFLD is a global epidemic. The prevalence of NAFLD is 20-30% in North America, northern Europe, Australia, Japan, India and China. It is crucial that patients with NAFLD receive an assessment for their risk of advanced fibrosis, which increases the risk of hepatocellular carcinoma and other complications of cirrhosis. Risk stratification that is efficient, cost-effective, patient-centred and evidence-based is one of the most important issues facing clinicians who care for those with liver disease. Given patients' preference to avoid liver biopsy, noninvasive alternatives to assess liver fibrosis are in high demand. The most accurate noninvasive methods are based on liver elastography. Research on these techniques - which include vibration-controlled transient elastography (VCTE), magnetic resonance elastography (MRE), shear-wave elastography and acoustic radiation force impulse - has proliferated. Unfortunately, the literature has not kept pace with clinical practice. There is limited guidance for how clinicians should anticipate and manage the pitfalls of these tests. Furthermore, guidance is unavailable for clinicians regarding the optimal incorporation of VCTE, MRE or the emerging elastographic techniques into their clinical strategy, particularly for patients with NAFLD. In this Review, we summarize the available evidence, highlight gaps to address in further research and explore optimization of these techniques in clinical practice.
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32
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Hassan A, Tapper EB. Editorial: the impact of steatosis on liver stiffness quantification is minimal. Aliment Pharmacol Ther 2018; 47:1416-1417. [PMID: 29676011 DOI: 10.1111/apt.14584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- A Hassan
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan Hospitals, Ann Arbor, MI, USA
| | - E B Tapper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan Hospitals, Ann Arbor, MI, USA
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33
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Abstract
Nonalcoholic fatty liver disease (NAFLD) is a common liver disorder that can be divided into benign steatosis or nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH). Elastography and scoring systems based on clinical features and routine biochemical testing can be used to assess fibrosis in patients with NAFLD. Patients with fibrosis are thought to have NASH. However, only a liver biopsy can reliably diagnose NAFLD and differentiate NAFL from NASH. Because medical therapy for NASH is not available, it is not necessary to perform a liver biopsy in all patients. Patients suspected of having NASH should undergo liver biopsy.
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34
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Patel YA, Gifford EJ, Glass LM, McNeil R, Turner MJ, Han B, Provenzale D, Choi SS, Moylan CA, Hunt CM. Risk factors for biopsy-proven advanced non-alcoholic fatty liver disease in the Veterans Health Administration. Aliment Pharmacol Ther 2018; 47:268-278. [PMID: 29115682 PMCID: PMC5861349 DOI: 10.1111/apt.14411] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 08/26/2017] [Accepted: 10/17/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND With its increasing incidence, nonalcoholic fatty liver disease (NAFLD) is of particular concern in the Veterans Health Administration (VHA). AIMS To evaluate risk factors for advanced fibrosis in biopsy-proven NAFLD in the VHA, to identify patients at risk for adverse outcomes. METHODS In randomly selected cases from VHA databases (2005-2015), we performed a retrospective case-control study in adults with biopsy-defined NAFLD or normal liver. RESULTS Of 2091 patients reviewed, 399 met inclusion criteria. Normal controls (n = 65) had normal liver function. The four NAFLD cohorts included: NAFL steatosis (n = 76), nonalcoholic steatohepatitis (NASH) without fibrosis (n = 68), NAFLD/NASH stage 1-3 fibrosis (n = 82), and NAFLD/NASH cirrhosis (n = 70). NAFLD with hepatocellular carcinoma (HCC) was separately identified (n = 38). Most patients were older White men. NAFLD patients with any fibrosis were on average severely obese (BMI>35 kg/m2 ). Diabetes (54.4%-79.6%) and hypertension (85.8%-100%) were more common in NAFLD with fibrosis or HCC. Across NAFLD, 12.3%-19.5% were enrolled in diet/exercise programs and 0%-2.6% had bariatric surgery. Hispanics exhibited higher rates of NASH (20.6%), while Blacks had low NAFLD rates (1.4%-11.8%), particularly NAFLD cirrhosis and HCC (1.4%-2.6%). Diabetes (OR 11.8, P < .001) and BMI (OR 1.4, P < .001) were the most significant predictors of advanced fibrosis. CONCLUSIONS In the VHA, diabetes and severe obesity increased risk for advanced fibrosis in NAFLD. Of these patients, only a small proportion (~20%) had enrolled in diet/exercise programs or had bariatric surgery (~2%). These results suggest that providers should focus/tailor interventions to improve outcomes, particularly in those with diabetes and severe obesity.
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35
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Xiao G, Zhu S, Xiao X, Yan L, Yang J, Wu G. Comparison of laboratory tests, ultrasound, or magnetic resonance elastography to detect fibrosis in patients with nonalcoholic fatty liver disease: A meta-analysis. Hepatology 2017; 66:1486-1501. [PMID: 28586172 DOI: 10.1002/hep.29302] [Citation(s) in RCA: 547] [Impact Index Per Article: 78.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 05/23/2017] [Accepted: 06/01/2017] [Indexed: 02/05/2023]
Abstract
UNLABELLED Many noninvasive methods for diagnosing liver fibrosis (LF) have been proposed. To determine the best method for diagnosing LF in nonalcoholic fatty liver disease (NAFLD), we conducted a systemic review and meta-analysis to compare the performance of aspartate aminotransferase to platelets ratio index (APRI), fibrosis-4 index (FIB-4), BARD score, NAFLD fibrosis score (NFS), FibroScan, shear wave elastography (SWE), and magnetic resonance elastography (MRE) for diagnosing LF in NAFLD. We compared the sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve (AUROC) of these noninvasive methods for detecting significant fibrosis (SF), advanced fibrosis (AF), and cirrhosis. Heterogeneity was explored using meta-regression. Sixty-four articles with a total of 13,046 NAFLD subjects were included. The overall mean prevalence of SF, AF, and cirrhosis was 45.0%, 24.0%, and 9.4% in NAFLD patients, respectively. With an APRI threshold of 1.0 and 1.5, the sensitivities and specificities were 50.0% and 84.0% and 18.3% and 96.1%, respectively, for AF. With a FIB-4 threshold of 2.67 and 3.25, the sensitivities and specificities were 26.6% and 96.5% and 31.8% and 96.0%, respectively, for AF. The summary sensitivities and specificities of BARD score (threshold of 2), NFS (threshold of -1.455), FibroScan M (threshold of 8.7-9), SWE, and MRE for detecting AF were 0.76 and 0.61, 0.72 and 0.70, 0.87 and 0.79, 0.90 and 0.93, and 0.84 and 0.90, respectively. The summary AUROC values using APRI, FIB-4, BARD score, NFS, FibroScan M probe, XL probe, SWE, and MRE for diagnosing AF were 0.77, 0.84, 0.76, 0.84, 0.88, 0.85, 0.95, and 0.96, respectively. CONCLUSION MRE and SWE may have the highest diagnostic accuracy for staging fibrosis in NAFLD patients. Among the four noninvasive simple indexes, NFS and FIB-4 probably offer the best diagnostic performance for detecting AF. (Hepatology 2017;66:1486-1501).
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Affiliation(s)
- Guangqin Xiao
- Cancer Center, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Sixian Zhu
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiao Xiao
- Department of Nursing, Xinxiang Medical University, Xinxiang, China
| | - Lunan Yan
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Jiayin Yang
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Gang Wu
- Cancer Center, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
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36
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Wong RJ, Liu B, Bhuket T. Significant burden of nonalcoholic fatty liver disease with advanced fibrosis in the US: a cross-sectional analysis of 2011-2014 National Health and Nutrition Examination Survey. Aliment Pharmacol Ther 2017; 46:974-980. [PMID: 28914448 DOI: 10.1111/apt.14327] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 07/20/2017] [Accepted: 08/26/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is a leading cause of chronic liver disease in the US. Understanding the epidemiology of NAFLD, with specific focus on individuals with hepatic fibrosis is important to guide healthcare resource planning. AIM To evaluate prevalence and predictors of hepatic fibrosis among US adults with NAFLD. METHODS We performed a cross-sectional study using data from the updated 2011-2014 National Health and Nutrition Examination Survey, a national, stratified, multistage sampling survey of non-institutionalised US adults age ≥ 20. METAVIR F2 or greater fibrosis among individuals with NAFLD was assessed using AST to Platelet Ratio Index (APRI) score > 0.7. METAVIR F3 or greater fibrosis was assessed using NAFLD fibrosis score (NFS) > 0.676 and FIB-4 score > 3.25. Multivariate logistic regression models evaluated for predictors of fibrosis among individuals with NAFLD. RESULTS Overall prevalence of NAFLD among US adults was 21.9% (95% CI 20.6-23.3), representing 51.6 million adults. Among individuals with NAFLD, we observed a 23.8% prevalence of ≥F2 fibrosis, representing 12.2 million individuals, and we observed a 2.3%-9.7% prevalence of ≥F3 fibrosis, representing as many as 5.0 million adults. On multivariate regression analyses, increasing age, obesity and concurrent diabetes mellitus were associated with increased risk of ≥F3 fibrosis. CONCLUSIONS NAFLD represents a major healthcare burden among US adults with as many as 5 million adults estimated to have NAFLD with ≥F3 fibrosis. Age and the components of the metabolic syndrome are independently associated with higher risk of fibrosis.
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Affiliation(s)
- R J Wong
- Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland, CA, USA
| | - B Liu
- Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland, CA, USA
| | - T Bhuket
- Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland, CA, USA
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Cheah MCC, McCullough AJ, Goh GBB. Current Modalities of Fibrosis Assessment in Non-alcoholic Fatty Liver Disease. J Clin Transl Hepatol 2017; 5:261-271. [PMID: 28936407 PMCID: PMC5606972 DOI: 10.14218/jcth.2017.00009] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 04/13/2017] [Accepted: 04/29/2017] [Indexed: 12/12/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a burgeoning global health concern. In the subset of NAFLD patients with non-alcoholic steatohepatitis (NASH), the presence of significant fibrosis at index assessment is associated with poor prognosis and increased mortality. Hence, there is a growing need to accurately assess and stage fibrosis. Liver biopsy, the current gold standard, has limitations with sampling error and is invasive, with associated inherent risk. This has led to a host of non-invasive means of assessing fibrosis, which has garnered relevance in a disease that requires serial assessment of fibrosis longitudinally over time. This review discusses, comprehensively, the various tools available to the clinician for the assessment of fibrosis, including the various scoring systems used in liver biopsy, the non-invasive means of serum biomarkers, such as the highly-validated NAFLD fibrosis score, and the imaging-based modalities, such as transient elastography and magnetic resonance elastography.
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Affiliation(s)
- Mark CC Cheah
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Arthur J McCullough
- Department of Gastroenterology, Cleveland Clinic, Ohio, USA
- Department of Pathobiology, Cleveland Clinic, Ohio, USA
| | - George Boon-Bee Goh
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
- *Correspondence to: Dr George Boon-Bee Goh, Department of Gastroenterology & Hepatology, Singapore General Hospital, 20 College Road, Singapore 169856, Singapore. Tel: +65-62223322, Fax: +65-62273623, E-mail:
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Affiliation(s)
- Elliot B Tapper
- From the Division of Gastroenterology and Hepatology and the Institute for Healthcare Policy and Innovation, University of Michigan (E.B.T., A.S.-F.L.), and the Veterans Affairs Hospital (E.B.T.) - both in Ann Arbor
| | - Anna S-F Lok
- From the Division of Gastroenterology and Hepatology and the Institute for Healthcare Policy and Innovation, University of Michigan (E.B.T., A.S.-F.L.), and the Veterans Affairs Hospital (E.B.T.) - both in Ann Arbor
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Before or After Transplantation? A Review of the Cost Effectiveness of Treating Waitlisted Patients With Hepatitis C. Transplantation 2017; 101:933-937. [PMID: 28437385 DOI: 10.1097/tp.0000000000001611] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
All patients with chronic hepatitis C virus (HCV) infections can and should be treated. Though highly effective direct-acting antiviral therapies are costly, the price of a cure is a 1-time investment that is outweighed by future benefits. For clinicians caring for patients requiring liver transplant, the key question relates to the timing of treatment: before or after liver transplantation? On 1 hand, treating HCV often improves our patients' model for end-stage liver disease (MELD) score, decreasing costs, and potentially improving longevity by reducing our patients' risk of death and transplantation. On the other hand, there is a concern that the cured patient with decompensated cirrhosis will find themselves in "MELD purgatory" with nonprogressive liver disease but a poor quality of life. At the same time, some patients, such as those with hepatocellular carcinoma, will require liver transplant irrespective of their MELD meaning that pretransplant therapy cannot reduce costs in such settings. These important tradeoffs are often difficult reconcile for clinicians who care for patients awaiting liver transplant. Fortunately, guidance for navigating these competing concerns can be obtained from cost-effectiveness analyses. Herein, we review the available data on this approach to HCV therapy before or after liver transplant.
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The Optimal Timing of Hepatitis C Therapy in Transplant Eligible Patients With Child B and C Cirrhosis: A Cost-Effectiveness Analysis. Transplantation 2017; 101:987-995. [PMID: 27495755 DOI: 10.1097/tp.0000000000001400] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Ledipasvir (LDV)/sofosbuvir (SOF) has demonstrated high efficacy, safety, and tolerability in hepatitis C virus (HCV)-infected patients. There is limited data, however, regarding the optimal timing of therapy in the context of possible liver transplantation (LT). METHODS We compared the cost-effectiveness of 12 weeks of HCV therapy before or after LT or nontreatment using a decision analytical microsimulation state-transition model for a simulated cohort of 10 000 patients with HCV Genotype 1 or 4 with Child B or C cirrhosis. All model parameters regarding the efficacy of therapy, adverse events and the effect of therapy on changes in model for end-stage liver disease (MELD) scores were derived from the SOLAR-1 and 2 trials. The simulations were repeated with 10 000 samples from the parameter distributions. The primary outcome was cost (2014 US dollars) per quality adjusted life year. RESULTS Treatment before LT yielded more quality-adjusted life year for less money than treatment after LT or nontreatment. Treatment before LT was cost-effective in 100% of samples at a willingness-to-pay threshold of US $100 000 in the base-case and when the analysis was restricted to Child B alone, Child C, or MELD > 15. Treatment before transplant was not cost-effective when MELD was 6-10. In sensitivity analyses, the MELD after which treatment before transplant was cost-effective was 13 and the maximum cost of LDV/SOF therapy at which treatment before LT is cost-effective is US $177 381. CONCLUSIONS From a societal perspective, HCV therapy using LDV/SOF with ribavirin before LT is the most cost-effective strategy for patients with decompensated cirrhosis and MELD score greater than 13.
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Tanajewski L, Harris R, Harman DJ, Aithal GP, Card TR, Gkountouras G, Berdunov V, Guha IN, Elliott RA. Economic evaluation of a community-based diagnostic pathway to stratify adults for non-alcoholic fatty liver disease: a Markov model informed by a feasibility study. BMJ Open 2017; 7:e015659. [PMID: 28679676 PMCID: PMC5734564 DOI: 10.1136/bmjopen-2016-015659] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To assess the long-term cost-effectiveness of a risk stratification pathway, compared with standard care, for detecting non-alcoholic fatty liver disease (NAFLD) in primary care. SETTING Primary care general practices in England. PARTICIPANTS Adults who have been identified in primary care to have a risk factor for developing NAFLD, that is, type 2 diabetes without a history of excessive alcohol use. INTERVENTION A community-based pathway, which uses transient elastography and hepatologists to stratify patients at risk of NAFLD, has been implemented and demonstrated to be feasible (NCT02037867). Earlier identification could mean earlier treatments, referral to specialist and enrolment into surveillance programmes. DESIGN The impact of earlier detection and treatment with the risk stratification pathway on progression to later stages of liver disease was examined using decision modelling with Markov chains to estimate lifetime health and economic effects of the two comparators. DATA SOURCES Data from a prospective cross-sectional feasibility study indicating risk stratification pathway and standard care diagnostic accuracies were combined with a Markov model that comprised the following states: no/mild liver disease, significant liver disease, compensated cirrhosis, decompensated cirrhosis, hepatocellular carcinoma, liver transplant and death. The model data were chosen from up-to-date UK sources, published literature and an expert panel. OUTCOME MEASURE An incremental cost-effectiveness ratio (ICER) indicating cost per quality-adjusted life year (QALY) of the risk stratification pathway compared with standard care was estimated. RESULTS The risk stratification pathway was more effective than standard care and costs £2138 per QALY gained. The ICER was most sensitive to estimates of the rate of fibrosis progression and the effect of treatment on reducing this, and ranged from -£1895 to £7032/QALY. The risk stratification pathway demonstrated an 85% probability of cost-effectiveness at the UK willingness-to-pay threshold of £20 000/QALY. CONCLUSIONS Implementation of a community-based risk stratification pathway is likely to be cost-effective. TRIAL REGISTRATION NUMBER NCT02037867, ClinicalTrials.gov.
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Affiliation(s)
- Lukasz Tanajewski
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Rebecca Harris
- Nottingham Digestive Diseases Centre, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham., Nottingham, United Kingdom
| | - David J Harman
- NIHR Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Guruprasad P Aithal
- NIHR Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Timothy R Card
- NIHR Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Georgios Gkountouras
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Vladislav Berdunov
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Indra N Guha
- NIHR Nottingham Digestive Diseases Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Rachel A Elliott
- Manchester Centre for Health Economics, School of Health Sciences, University of Manchester, Manchester, UK
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Cadier B, Bulsei J, Nahon P, Seror O, Laurent A, Rosa I, Layese R, Costentin C, Cagnot C, Durand-Zaleski I, Chevreul K. Early detection and curative treatment of hepatocellular carcinoma: A cost-effectiveness analysis in France and in the United States. Hepatology 2017; 65:1237-1248. [PMID: 28176349 DOI: 10.1002/hep.28961] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/20/2016] [Accepted: 11/17/2016] [Indexed: 12/17/2022]
Abstract
UNLABELLED Hepatocellular carcinoma (HCC) is the leading cause of death in patients with cirrhosis. Patients outside clinical trials seldom benefit from evidence-based monitoring. The objective of this study was to estimate the cost-effectiveness of complying with HCC screening guidelines. The economic evaluation compared surveillance of patients with cirrhosis as recommended by the guidelines ("gold-standard monitoring") to "real-life monitoring" from the health care system perspective. A Markov model described the history of the disease and treatment course including current first-line curative treatment: liver resection, radiofrequency ablation (RFA), and liver transplantation. Transition probabilities were derived mainly from two French cohorts, CIRVIR and CHANGH. Costs were computed using French and U.S. tariffs. Effectiveness was measured in life years gained (LYG). An incremental cost-effectiveness ratio (ICER) was calculated for a 10-year horizon and tested with one-way and probabilistic sensitivity analyses. The cost difference between the two groups was $648 ($87,476 in the gold-standard monitoring group vs. $86,829 in the real-life monitoring group) in France and $11,965 ($93,795 vs. $81,829) in the United States. Survival increased by 0.37 years (7.18 vs. 6.81 years). The ICER was $1,754 per LYG in France and $32,415 per LYG in the United States. The health gain resulted from earlier diagnosis and access to first-line curative treatments, among which RFA provided the best value for money. CONCLUSION Our results indicate that gold-standard monitoring for patients with cirrhosis is cost-effective, attributed to a higher probability of benefiting from a curative treatment and so a higher survival probability. (Hepatology 2017;65:1237-1248).
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Affiliation(s)
- Benjamin Cadier
- AP-HP, Health economics research unit, Paris, France.,ECEVE, UMRS 1123, French National Institute of Health and Medical Research, Paris, France
| | - Julie Bulsei
- AP-HP, Health economics research unit, Paris, France
| | - Pierre Nahon
- AP-HP, Department of Hepatology, Jean Verdier hospital, Bondy, France.,French League Against Cancer; Education and Research in Health Medicine and Human Biology, University Paris 13, Sorbonne Paris Cité, Paris, France.,Unité mixte de Recherche 1162, Génomique fonctionnelle des Tumeurs solides, Institut National de la Santé et de la Recherche médicale, Paris, France
| | - Olivier Seror
- Unité mixte de Recherche 1162, Génomique fonctionnelle des Tumeurs solides, Institut National de la Santé et de la Recherche médicale, Paris, France.,AP-HP, Department of Radiology, Jean Verdier hospital, Bondy, France
| | - Alexis Laurent
- AP-HP, Department of Hepatobiliary and Digestive Surgery, Henri Mondor hospital, Creteil l, France.,University Paris-Est, Creteil, France.,Inserm U955-Creteil, France
| | - Isabelle Rosa
- CHANGH study Group, Hepatology and Gastroenterology Department, Centre Hospitalier Intercommunal de Créteil, Creteil, France
| | - Richard Layese
- AP-HP, Department of Public Health, Henri Mondor hospital, Creteil, France.,University Paris-Est, A-TVB DHU, CEpiA (Clinical Epidemiology and Aging) Unit EA4393, University Paris-Est, Creteil, France
| | | | - Carole Cagnot
- Unit for Basic and Clinical research on Viral Hepatitis, ANRS (France REcherche Nord & sud Sida-HIV Hépatites-FRENSH), Paris, France
| | - Isabelle Durand-Zaleski
- AP-HP, Health economics research unit, Paris, France.,ECEVE, UMRS 1123, French National Institute of Health and Medical Research, Paris, France.,AP-HP, Department of Public Health, Henri Mondor hospital, Creteil, France
| | - Karine Chevreul
- AP-HP, Health economics research unit, Paris, France.,ECEVE, UMRS 1123, French National Institute of Health and Medical Research, Paris, France.,University Paris Diderot, Sorbonne Paris Cite, Paris, France
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Extensive testing or focused testing of patients with elevated liver enzymes. J Hepatol 2017; 66:313-319. [PMID: 27717864 DOI: 10.1016/j.jhep.2016.09.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/30/2016] [Accepted: 09/01/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Many patients have elevated serum aminotransferases reflecting many underlying conditions, both common and rare. Clinicians generally apply one of two evaluative strategies: testing for all diseases at once (extensive) or just common diseases first (focused). METHODS We simulated the evaluation of 10,000 adult outpatients with elevated with alanine aminotransferase to compare both testing strategies. Model inputs employed population-based data from the US (National Health and Nutrition Examination Survey) and Britain (Birmingham and Lambeth Liver Evaluation Testing Strategies). Patients were followed until a diagnosis was provided or a diagnostic liver biopsy was considered. The primary outcome was US dollars per diagnosis. Secondary outcomes included doctor visits per diagnosis, false-positives per diagnosis and confirmatory liver biopsies ordered. RESULTS The extensive testing strategy required the lowest monetary cost, yielding diagnoses for 54% of patients at $448/patient compared to 53% for $502 under the focused strategy. The extensive strategy also required fewer doctor visits (1.35 vs. 1.61 visits/patient). However, the focused strategy generated fewer false-positives (0.1 vs. 0.19/patient) and more biopsies (0.04 vs. 0.08/patient). Focused testing becomes the most cost-effective strategy when accounting for pre-test probabilities and prior evaluations performed. This includes when the respective prevalence of alcoholic, non-alcoholic and drug-induced liver disease exceeds 51.1%, 53.0% and 13.0%. Focused testing is also the most cost-effective strategy in the referral setting where assessments for viral hepatitis, alcoholic and non-alcoholic fatty liver disease have already been performed. CONCLUSIONS Testing for elevated liver enzymes should be deliberate and focused to account for pre-test probabilities if possible. LAY SUMMARY Many patients have elevated liver enzymes reflecting one of many possible liver diseases, some of which are very common and some of which are rare. Tests are widely available for most causes but it is unclear whether clinicians should order them all at once or direct testing based on how likely a given disease may be given the patient's history and physical exam. The tradeoffs of both approaches involve the money spent on testing, number of office visits needed, and false positive results generated. This study shows that if there are no clues available at the time of evaluation, testing all at once saves time and money while causing more false positives. However, if there are strong clues regarding the likelihood of a particular disease, limited testing saves time, money and prevents false positives.
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Prevalence of hepatic steatosis in apparently healthy medical students: a transient elastography study on the basis of a controlled attenuation parameter. Eur J Gastroenterol Hepatol 2016; 28:1264-7. [PMID: 27482784 DOI: 10.1097/meg.0000000000000681] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Despite the increasing burden of nonalcoholic fatty liver disease (NAFLD) in modern societies, the optimal screening method to detect hepatic steatosis in the general population remains to be established. Controlled attenuation parameter (CAP) measured with transient elastography (TE) has recently emerged as a reliable imaging tool for the screening and diagnosis of NAFLD. Here, we sought to investigate the prevalence of TE-defined hepatic steatosis in a sample of apparently healthy medical students. We also assessed the relationships between CAP and traditional NAFLD risk factors. MATERIALS AND METHODS A total of 112 Turkish medical students (48 women and 64 men, mean age 20.5±1.1 years) underwent TE. On the basis of previous studies, a cut-off value of 238 dB/m for CAP was used for the diagnosis of hepatic steatosis. RESULTS On the basis of the selected cut-off for CAP, we identified 26 students (23.2%) with TE-defined NAFLD. Univariate correlation analyses showed that CAP values were significantly associated with BMI (r=0.40, P<0.001), waist circumference (r=0.39, P<0.001), and hip circumference (r=0.34, P<0.001). In multivariable analysis, only BMI retained its independent association with CAP (β=0.36, t=3.4, P<0.001). CONCLUSION NAFLD is highly prevalent even in apparently healthy young individuals. CAP assessment with TE may be useful for an early, noninvasive identification of hepatic steatosis.
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Xu ZJ, Shi JP, Yu DR, Zhu LJ, Jia JD, Fan JG. Evaluating the Relationship Between Metabolic Syndrome and Liver Biopsy-Proven Non-Alcoholic Steatohepatitis in China: A Multicenter Cross-Sectional Study Design. Adv Ther 2016; 33:2069-2081. [PMID: 27743352 DOI: 10.1007/s12325-016-0416-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Non-alcoholic steatohepatitis (NASH) is a serious form of non-alcoholic fatty liver disease (NAFLD) that can progress to advanced fibrosis, cirrhosis, and hepatocellular carcinoma. Differentiating between non-alcoholic fatty liver (NAFL) and NASH/advanced fibrosis is an important step in the management of NAFLD. Metabolic syndrome (MS) and its components are important risk factors for NAFLD, and NASH is thought to be the hepatic injury of MS. The prevalence of NASH among NAFLD patients with MS is thought to be high. In China, NAFLD is a relatively new public health concern, and the current prevalence of NASH among Chinese liver biopsy-proven NAFLD patients with and without MS is not known. METHODS This multicenter, cross-sectional study will investigate the prevalence of NASH in approximately 480 Chinese NAFLD patients. Patients will be eligible for enrollment if they have biopsy-proven NAFLD and if their liver biopsies are available for rereading. For our analysis, patients will be stratified according to the presence/absence of MS, and the prevalence of NASH in the subgroups will be compared. Other possible tests that could indicate a risk of NASH, including transient elastography, ultrasonography, cytokeratin-18, liver function tests, and others, will be studied in an effort to derive a practical, noninvasive predictive model for NASH. DISCUSSION Patients with NAFL who have MS may also have a very high risk of developing NASH. The present study will inform about the risk of NASH in Chinese liver biopsy-proven NAFLD patients with and without MS. TRIAL REGISTRATION This study registered at http://www.chictr.org.cn (registration number: ChiCTR-OOC-16007902). FUNDING Sanofi (China) Investment Co., Ltd.
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46
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Pimentel CFMG, Lai M. Nutrition Interventions for Chronic Liver Diseases and Nonalcoholic Fatty Liver Disease. Med Clin North Am 2016; 100:1303-1327. [PMID: 27745596 DOI: 10.1016/j.mcna.2016.06.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The progressively increasing rates of obesity have led to a worldwide epidemic of nonalcoholic fatty liver disease (NAFLD), the hepatic manifestation of the metabolic syndrome. It is currently the most common cause of liver disease worldwide and projected to be the leading indication for liver transplantation in the United States by 2020. NAFLD is associated with both liver-related and overall mortality. Undoubtedly, nutrition interventions are key in the treatment of NAFLD, to reverse the disease, and prevent disease progression, complications, and associated comorbidities, including cardiovascular disease and diabetes.
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Affiliation(s)
| | - Michelle Lai
- Gastroenterology, Liver Center, Beth Israel Deaconess Medical Center, Harvard University, 110 Francis St, Boston, MA 02115, USA
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47
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Alkhouri N, Feldstein AE. Noninvasive diagnosis of nonalcoholic fatty liver disease: Are we there yet? Metabolism 2016; 65:1087-95. [PMID: 26972222 PMCID: PMC4931968 DOI: 10.1016/j.metabol.2016.01.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 12/22/2015] [Accepted: 01/07/2016] [Indexed: 12/15/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) has rapidly become the most common form of chronic liver disease in the United States affecting approximately 80-100 million Americans. NAFLD includes a spectrum of diseases ranging from nonalcoholic fatty liver (NAFL) to nonalcoholic steatohepatitis (NASH) to fibrosis and eventually cirrhosis. Patients with NASH and significant fibrosis on liver biopsy have an increased risk for liver-related morbidity and mortality compared to those with NAFL. Due to the high prevalence of NAFLD and its progressive nature, there has been an urgent need to develop reliable noninvasive tests that can accurately predict the presence of advanced disease without the need for liver biopsy. These tests can be divided into those that predict the presence of NASH and those that predict the presence of fibrosis. In this review, we provide a concise overview of different noninvasive methods for staging the severity of NAFLD.
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Affiliation(s)
- Naim Alkhouri
- Department of Pediatric Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA; Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ariel E Feldstein
- Department of Pediatrics, University of California San Diego (UCSD), CA, USA.
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Friedrich-Rust M, Poynard T, Castera L. Critical comparison of elastography methods to assess chronic liver disease. Nat Rev Gastroenterol Hepatol 2016; 13:402-11. [PMID: 27273167 DOI: 10.1038/nrgastro.2016.86] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Staging of liver fibrosis and diagnosis, or exclusion, of early compensated liver cirrhosis are important in the treatment decisions and surveillance of patients with chronic liver disease. Good diagnostic accuracy, increased availability and the possibility to perform follow-up examinations led to the implementation of noninvasive methods into clinical practice. Noninvasive tests are increasingly included in national and international guidelines, leaving liver biopsy reserved for patients with unexplained discordance or suspected additional aetiologies of liver disease. In addition to staging of liver fibrosis, data on the prognostic value of these methods have increased in the past few years and are of great importance for patient care. This Review focuses on elastography methods for noninvasive assessment of liver fibrosis, disease severity and prognosis. Although liver elastography started with transient elastography, at present all large ultrasonography companies offer an elastography technique integrated in their machines. The goal of this Review is to summarize the methodological problems of noninvasive tests in general, in addition to providing an overview on currently available techniques and latest developments in liver elastography.
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Affiliation(s)
- Mireen Friedrich-Rust
- Department of Internal Medicine, J.W. Goethe-University Hospital, Theodor-Stern-Kai 7, Frankfurt 60590, Germany
| | - Thierry Poynard
- Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Hepatology Department, 47-83 Boulevard de l'Hôpital, Paris 75013, France.,Université Pierre et Marie Curie, INSERM, UMR-S 938, 57 Boulevard de l'Hôpital, Paris 75013, France
| | - Laurent Castera
- Department of Hepatology, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, 100 Boulevard du General Leclerc, Clichy 92110, France.,Université Paris VII, INSERM UMR 1149, Centre de Recherche sur l'Inflammation, 16 Rue Huchard, Paris 75018, France
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49
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The Performance of Vibration Controlled Transient Elastography in a US Cohort of Patients With Nonalcoholic Fatty Liver Disease. Am J Gastroenterol 2016; 111:677-84. [PMID: 26977758 PMCID: PMC4860094 DOI: 10.1038/ajg.2016.49] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 01/24/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Identification of patients with nonalcoholic fatty liver disease (NAFLD) who have advanced fibrosis is crucial. Vibration controlled transient elastography (VCTE) is an alternative to biopsy, although published experience with VCTE in a US population is limited. METHODS We performed a prospective cohort of 164 biopsy-proven NAFLD patients evaluated with VCTE using an M probe and the NAFLD fibrosis score (NFS) at baseline and a repeat VCTE at 6 months. Reliable liver stiffness measurements (LSMs) were defined as 10 valid measurements and interquartile range ≤30% of the median. RESULTS A total of 120 (73.2%) patients had reliable LSM. The median LSMs for patients with and without F3-F4 (advanced) fibrosis were 6.6 kPA (5.3-8.9) and 14.4 kPA (12.1-24.3), respectively. The optimal LSM cutoff for advanced fibrosis was 9.9 kPA (sensitivity 95% and specificity 77%). In addition, 100% of patients with LSM<7.9 kPA did not have advanced fibrosis. A risk stratification strategy based on VCTE avoids the need for biopsy in at least the 74 (45.1%) patients correctly classified as low risk for advanced fibrosis. For the detection of F3-F4 fibrosis in patients with reliable VCTE, the area under the receiver operating curve (AUROC) is 0.93 (95% CI: 0.86-0.96). This is superior to the AUROC for the NFS (0.77), P=0.01. Patients who achieved a ≥5% weight loss at 6-month follow-up experienced improved LSM (P=0.009), independent of the changes in aminotransferase levels. CONCLUSIONS Reliable VCTE results can rule out advanced fibrosis and avoid the need for biopsy in at least 45% of US patients with NAFLD. However, 1 in 4 patients have uninterpretable studies using the M probe.
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Tapper EB, Lai M. Weight loss results in significant improvements in quality of life for patients with nonalcoholic fatty liver disease: A prospective cohort study. Hepatology 2016; 63:1184-9. [PMID: 26698379 PMCID: PMC4805484 DOI: 10.1002/hep.28416] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 11/28/2015] [Accepted: 12/19/2015] [Indexed: 01/08/2023]
Abstract
UNLABELLED Nonalcoholic fatty liver disease (NAFLD) is highly prevalent and associated with decreased quality of life (QOL). The currently available treatment is weight loss through lifestyle modification. However, longitudinal QOL data are lacking on whether weight loss improves QOL. We prospectively enrolled 151 patients with NAFLD from 2009 to 2014. All patients received a liver biopsy, lifestyle assessment, blood tests, and QOL tools, including the Chronic Liver Disease Questionnaire (CLDQ), a validated health-related quality of life measurement. All patients were followed with a repeat CLDQ at 6 months. The cohort included 91 (60%) men, ages 51.5 ± 12.6 years, 46 (30%) of whom were diabetic. Thirty (21%) had advanced fibrosis or cirrhosis and 67 (47%) had a NAFLD Activity Score >4. Overall, 47 (31%) patients achieved at least a 5% reduction in weight. The cohort's median baseline total CLDQ value was 5.6 (interquartile range: 4.8-6.2). Those who achieved at least a 5% reduction in weight had a 0.45 (95% confidence interval [CI]: 0.24-0.66; P < 0.0001) point improvement in the total CLDQ, compared to 0.003 (95% CI: -0.12-0.12; P = 0.95) in those who did not. Nondiabetic patients with nonalcoholic steatohepatitis and without advanced fibrosis are most likely to achieve QOL benefits from weight loss. For every decrement in body mass index (BMI), there was a corresponding increase of 0.09 (95% CI: 0.03-0.16) points in the CLDQ scale (P = 0.005), adjusting for histology, diabetes, sex, age, and change in alanine aminotransferase level and change in FIB-4 index. A decrease by 5 points in BMI leads to a 10% adjusted improvement in QOL. CONCLUSION Patients with NAFLD can experience significant improvements in QOL that appear specific to weight loss and not biochemical improvements.
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Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Michelle Lai
- Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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