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Pereyra D, Mandorfer M, Santol J, Gregory L, Koeditz C, Ortmayr G, Schuetz C, Rumpf B, Ammon D, Laengle J, Schwarz C, Jonas JP, Pinter M, Lindenlaub F, Tamandl D, Thiels C, Warner S, Smoot R, Truty M, Kendrick M, Nagorney D, Cleary S, Gruenberger T, Reiberger T, Starlinger P. Von Willebrand Factor Antigen Improves Risk Stratification for Patients with a Diagnosis of Resectable Hepatocellular Carcinoma. Ann Surg Oncol 2024; 31:6526-6536. [PMID: 38896229 DOI: 10.1245/s10434-024-15618-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Posthepatectomy liver failure (PHLF), complications of portal hypertension, and disease recurrence determine the outcome for hepatocellular carcinoma (HCC) patients undergoing liver resection. This study aimed to evaluate the von Willebrand factor antigen (vWF-Ag) as a non-invasive test for clinically significant portal hypertension (CSPH) and a predictive biomarker for time to recurrence (TTR) and overall survival (OS). METHODS The study recruited 72 HCC patients with detailed preoperative workup from a prospective trial (NCT02118545) and followed for complications, TTR, and OS. Additionally, 163 compensated patients with resectable HCC were recruited to evaluate vWF-Ag cutoffs for ruling out or ruling in CSPH. Finally, vWF-Ag cutoffs were prospectively evaluated in an external validation cohort of 34 HCC patients undergoing liver resection. RESULTS In receiver operating characteristic (ROC) analyses, vWF-Ag (area under the curve [AUC], 0.828) was similarly predictive of PHLF as indocyanine green clearance (disappearance rate: AUC, 0.880; retention rate: AUC, 0.894), whereas computation of future liver remnant was inferior (AUC, 0.756). Cox-regression showed an association of vWF-Ag with TTR (per 10%: hazard ratio [HR], 1.056; 95% confidence interval [CI] 1.017-1.097) and OS (per 10%: HR, 1.067; 95% CI 1.022-1.113). In the analyses, VWF-Ag yielded an AUC of 0.824 for diagnosing CSPH, with a vWF-Ag of 182% or lower ruling out and higher than 291% ruling in CSPH. Therefore, a highest-risk group (> 291%, 9.7% of patients) with a 57.1% incidence of PHLF was identified, whereas no patient with a vWF-Ag of 182% or lower (52.7%) experienced PHLF. The predictive value of vWF-Ag for PHLF and OS was externally validated. CONCLUSION For patients with resectable HCC, VWF-Ag allows for simplified preoperative risk stratification. Patients with vWF-Ag levels higher than 291% might be considered for alternative treatments, whereas vWF-Ag levels of 182% or lower identify patients best suited for surgery.
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Affiliation(s)
- David Pereyra
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - Mattias Mandorfer
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, General Hospital, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, General Hospital, Vienna, Austria
| | - Jonas Santol
- Department of Surgery, HPB Center Vienna Health Network and Sigmund Freud Private University, Vienna, Austria
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Lindsey Gregory
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Christoph Koeditz
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - Gregor Ortmayr
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - Clara Schuetz
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - Benedikt Rumpf
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - Daphni Ammon
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - Johannes Laengle
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - Christoph Schwarz
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - Jan Philipp Jonas
- Department of Surgery, HPB Center Vienna Health Network and Sigmund Freud Private University, Vienna, Austria
| | - Matthias Pinter
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, General Hospital, Vienna, Austria
| | - Florian Lindenlaub
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, General Hospital, Vienna, Austria
| | - Dietmar Tamandl
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, General Hospital, Vienna, Austria
| | - Cornelius Thiels
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Susanne Warner
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rory Smoot
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mark Truty
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michael Kendrick
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - David Nagorney
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sean Cleary
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Thomas Gruenberger
- Department of Surgery, HPB Center Vienna Health Network and Sigmund Freud Private University, Vienna, Austria
| | - Thomas Reiberger
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, General Hospital, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, General Hospital, Vienna, Austria
- Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Patrick Starlinger
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, General Hospital, Vienna, Austria.
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN, USA.
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Yu JA, Yang SW, Wang Y, Li J, Su TH, Chang J, Chen G. The Balloon Catheter Method and the End-hole Catheter Method in the Measurement of Hepatic Venous Pressure Gradient: a Comparative Study. Cardiovasc Intervent Radiol 2024; 47:1356-1362. [PMID: 39060793 DOI: 10.1007/s00270-024-03814-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 07/13/2024] [Indexed: 07/28/2024]
Abstract
OBJECTIVE This study aims to evaluate the differences between The balloon catheter method and End-hole Catheter Method in measuring hepatic venous pressure gradient (HVPG) among cirrhosis patients. METHODS From October 2017 to January 2024, patients who underwent HVPG measurements using both methods were consecutively included. HVPGs obtained from both methods were compared with the portal vein pressure gradient (PPG) obtained via transjugular intrahepatic portosystemic shunt (TIPS) using paired comparisons. Additionally, the consistency and predictive ability for bleeding risk of the two methods, as well as the impact of intrahepatic veno-venous shunt (IHVS), were analyzed. RESULTS The study enrolled 145 patients, each of whom had HVPG measured by both methods. PPG was measured in 61 patients. There was a statistically significant difference between the PPGs and HVPGs measured by both the balloon catheter method and the end-hole catheter method (P < 0.001), with the HVPG mean values obtained by the end-hole catheter method being closer to the PPGs. In the non-IHVS group, no significant statistical difference was found between the two methods (P = 0.071). In contrast, the IHVS group showed a significant difference (P < 0.001), with a mean difference of 2.98 ± 4.03 mmHg. When IHVS was absent, the measurement results from the end-hole catheter method and the balloon catheter method were found to be highly correlated. The end-hole catheter method has a higher screening capability for patients at risk of bleeding compared to the balloon catheter method (75.90% vs. 72.86%). CONCLUSION HVPG measurements using either the balloon catheter method or end-hole catheter method showed significant difference with the PPG. The end-hole catheter method has a higher screening capability for patients at risk of bleeding, and IHVS could lead to lower HVPG measurements with The balloon catheter method.
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Affiliation(s)
- Jian-An Yu
- Department of Interventional Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Si-Wei Yang
- Department of Interventional Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Yu Wang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Jian Li
- Department of Interventional Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Tian-Hao Su
- Department of Interventional Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Jiang Chang
- Department of Interventional Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Guang Chen
- Department of Interventional Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China.
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Kang EJ, Cha MG, Kwon GH, Han SH, Yoon SJ, Lee SK, Ahn ME, Won SM, Ahn EH, Suk KT. Akkermansia muciniphila improve cognitive dysfunction by regulating BDNF and serotonin pathway in gut-liver-brain axis. MICROBIOME 2024; 12:181. [PMID: 39342324 PMCID: PMC11438137 DOI: 10.1186/s40168-024-01924-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 09/02/2024] [Indexed: 10/01/2024]
Abstract
BACKRGROUND Akkermansia muciniphila, a next-generation probiotic, is known as a cornerstone regulating the gut-organ axis in various diseases, but the underlying mechanism remains poorly understood. Here, we revealed the neuronal and antifibrotic effects of A. muciniphila on the gut-liver-brain axis in liver injury. RESULTS To investigate neurologic dysfunction and characteristic gut microbiotas, we performed a cirrhosis cohort (154 patients with or without hepatic encephalopathy) and a community cognition cohort (80 participants in one region for three years) and validated the existence of cognitive impairment in a 3,5-diethoxycarbonyl-1,4-dihydrocollidine-induced hepatic injury mouse model. The effects of the candidate strain on cognition were evaluated in animal models of liver injury. The expression of brain-derived neurotrophic factor (BDNF) and serotonin receptors was accessed in patients with fibrosis (100 patients) according to the fibrosis grade and hepatic venous pressure gradient. The proportion of A. muciniphila decreased in populations with hepatic encephalopathy and cognitive dysfunction. Tissue staining techniques confirmed gut-liver-brain damage in liver injury, with drastic expression of BDNF and serotonin in the gut and brain. The administration of A. muciniphila significantly reduced tissue damage and improved cognitive dysfunction and the expression of BDNF and serotonin. Isolated vagus nerve staining showed a recovery of serotonin expression without affecting the dopamine pathway. Conversely, in liver tissue, the inhibition of injury through the suppression of serotonin receptor (5-hydroxytryptamine 2A and 2B) expression was confirmed. The severity of liver injury was correlated with the abundance of serotonin, BDNF, and A. muciniphila. CONCLUSIONS A. muciniphila, a next-generation probiotic, is a therapeutic candidate for alleviating the symptoms of liver fibrosis and cognitive impairment.
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Affiliation(s)
- Eun Ji Kang
- Department of Physiology, College of Medicine, Hallym University, Hallymdaehak-Gil 1, Chuncheon-Si, Gangwon-Do, 24252, South Korea
| | - Min-Gi Cha
- Institute for Liver and Digestive Diseases, Hallym University College of Medicine, Chuncheon-Si, Gangwon-Do, 24253, South Korea
| | - Goo-Hyun Kwon
- Institute for Liver and Digestive Diseases, Hallym University College of Medicine, Chuncheon-Si, Gangwon-Do, 24253, South Korea
| | - Sang Hak Han
- Department of Pathology, College of Medicine, Hallym University, Hallymdaehak-Gil 1, Chuncheon-Si, Gangwon-Do, 24252, South Korea
| | - Sang Jun Yoon
- Institute for Liver and Digestive Diseases, Hallym University College of Medicine, Chuncheon-Si, Gangwon-Do, 24253, South Korea
| | - Sang Kyu Lee
- Department of Psychiatry, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon-si, Gangwon-Do, 24253, Chuncheon-Si, South Korea
| | - Moo Eob Ahn
- Department of Emergency Medicine, Hallym University, Chuncheon Sacred Heart Hospital, Chuncheon-Si, Gangwon-Do, 24253, South Korea
| | - Sung-Min Won
- Institute for Liver and Digestive Diseases, Hallym University College of Medicine, Chuncheon-Si, Gangwon-Do, 24253, South Korea.
| | - Eun Hee Ahn
- Department of Physiology, College of Medicine, Hallym University, Hallymdaehak-Gil 1, Chuncheon-Si, Gangwon-Do, 24252, South Korea.
- Department of Neurology, College of Medicine, Hallym University, Hallymdaehak-Gil 1, Chuncheon-Si, Gangwon-Do, 24252, South Korea.
| | - Ki Tae Suk
- Institute for Liver and Digestive Diseases, Hallym University College of Medicine, Chuncheon-Si, Gangwon-Do, 24253, South Korea.
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Dajti E, Villanueva C, Berzigotti A, Brujats A, Albillos A, Genescà J, Garcia-Pagán JC, Colecchia A, Bosch J. Exploring algorithms to select candidates for non-selective beta-blockers in cirrhosis: a post-hoc analysis of the PREDESCI trial. J Hepatol 2024:S0168-8278(24)02553-4. [PMID: 39303875 DOI: 10.1016/j.jhep.2024.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 09/03/2024] [Accepted: 09/04/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND & AIMS Whether non-invasive tests (NITs) can accurately select patients with cirrhosis requiring non-selective beta-blockers (NSBB) for clinically significant portal hypertension (CSPH) and prevention of decompensation is unclear. Our aim was to test the performance of NIT-based algorithms for CSPH diagnosis using the prospective PREDESCI cohort. We investigated a new algorithm combining NITs with endoscopy to improve performance. METHODS We included patients with compensated cirrhosis and available liver elastography who were screened during the trial. The performance of models based on liver stiffness measurement (LSM) and platelet count was evaluated. An algorithm considering endoscopy for patients with inconclusive results (the "grey zone") was then developed and validated in an independent cohort of 195 patients in whom also spleen stiffness was available. RESULTS We included 170 patients from the PREDESCI cohort. An LSM≥25 kPa alone (Baveno VII criteria) or an LSM>20 kPa plus thrombocytopenia (AASLD criteria) ruled-in CSPH with positive predictive value of 88 and 89%, respectively. However, 37%-47% patients fell into the grey zone while at high-risk of decompensation or death. Performing endoscopy in inconclusive cases identified patients with varices that, when re-classified as high-risk for CSPH, significantly reduced the grey zone to 22%. In this algorithm, 86% of CSPH patients were correctly classified as high-risk. The diagnostic performance was confirmed in the external validation cohort, where combining Baveno VII criteria with spleen stiffness showed similar accuracy to the model using endoscopy. CONCLUSIONS Algorithms based only on LSM and platelet count are suboptimal to identify NSBB treatment candidates. Performing endoscopy in patients with indeterminate findings from NITs improved diagnostic performance and risk stratification. Endoscopy may be substituted by spleen stiffness for stratifying the risk in the grey zone. IMPACT AND IMPLICATIONS The PREDESCI trial demonstrated that non-selective beta-blockers prevent decompensation in CSPH patients. Still it is unclear whether we can select treatment candidates using non-invasive tests to assess the presence of CSPH without measuring HVPG. In the prospective cohort of patients screened during the trial, we showed that algorithms based on liver stiffness and platelet count had suboptimal performance, mainly due to a high rate of indeterminate results. Performing endoscopy in the grey zone patients allowed to significantly increase the number of patients with CSPH and improved the risk stratification for decompensation or death on long-term follow-up. These findings were validated in an independent cohort. In addition, a model using spleen stiffness instead of endoscopy showed similar diagnostic performance in the external validation cohort, suggesting that adequate risk stratification to select treatment candidates can be achieved with a fully non-invasive algorithm.
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Affiliation(s)
- Elton Dajti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland; Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Bologna, Italy
| | - Càndid Villanueva
- Department of Digestive Diseases. Hospital de la Santa Creu i Sant Pau. Biomedical Research Institute Sant Pau (IIB Sant Pau). Barcelona. Medicine Department, Autonomous University of Barcelona; Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Madrid, Spain
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Anna Brujats
- Department of Digestive Diseases. Hospital de la Santa Creu i Sant Pau. Biomedical Research Institute Sant Pau (IIB Sant Pau). Barcelona. Medicine Department, Autonomous University of Barcelona
| | - Agustín Albillos
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Madrid, Spain; Department of Gastroenterology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Joan Genescà
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Madrid, Spain; Liver Unit, Digestive Diseases Division, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan C Garcia-Pagán
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Madrid, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Department de Medicina i Ciències de la Salut, University of Barcelona, Barcelona, Spain
| | - Antonio Colecchia
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Jaume Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland; Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Madrid, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Department de Medicina i Ciències de la Salut, University of Barcelona, Barcelona, Spain.
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Garcia-Guix M, Ardevol A, Sapena V, Alvarado-Tápias E, Huertas A, Brujats A, Fajardo J, Cuyas B, Poca M, Guarner C, Torras X, Escorsell À, Villanueva C. Influence of further decompensation on survival across clinical stages of decompensated cirrhosis: The role of portal hypertension and HVPG changes. Liver Int 2024; 44:1971-1989. [PMID: 38634685 DOI: 10.1111/liv.15937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/13/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND AND AIMS Decompensated-cirrhosis encompasses several stages with different prognosis, such as bleeding, ascites and bleeding-plus-ascites. Development of further-decompensation worsens survival, while non-selective β-blockers (NSBBs) can modify the risk. However, how this applies to each stage is uncertain. We aimed to investigate, in each stage of decompensated-cirrhosis, the influence of further-decompensation on mortality and whether changes in portal-pressure (HVPG) under NSBBs influence these outcomes. METHODS Patients with variceal bleeding were consecutively included differentiating those with bleeding-alone from those who also had ascites. Patients with ascites and high-risk varices referred for primary-prophylaxis were also investigated. A baseline haemodynamic study was performed and was repeated after 1-3-months under NSBBs. Outcomes were investigated by competing-risk. RESULTS Totally 103 patients had bleeding-alone, 186 bleeding-plus-ascites and 187 ascites-alone. Mean follow-up was 32-months (IQR, 12-60). Patients with bleeding-plus-ascites had higher HVPG and were more hyperdynamic than patients with ascites-alone and these than those with bleeding-alone. At each stage, the mortality risk was more than twice in patients developing further-decompensation vs. those without (p < .001). In each stage, HVPG-decrease under NSBBs showed better discrimination to predict further-decompensation than the baseline MELD, Child-Pugh or HVPG, by time-dependent ROC-curves (c-statistic >70%). At each stage, patients without HVPG-decreases, either ≥10% or ≥20% from the baseline, had higher risk of further-decompensation (sHR from 2.43 to 6.73, p < .01) and worse survival. CONCLUSIONS In each stage of decompensated cirrhosis, mortality risk significantly and very markedly increase with further-decompensation. HVPG-non-response to NSBBs may adequately stratify the risk of further decompensation and death, in each stage. This suggests potential benefit with pre-emptive therapies in HVPG-non-responders at each-stage.
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Affiliation(s)
- Marta Garcia-Guix
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Alba Ardevol
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Victor Sapena
- Biostatistics Unit, Medical School, Universitat Autònoma de Barcelona, Barcelona, Spain
- Medical Statistics Core Faculty, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Edilmar Alvarado-Tápias
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Anna Huertas
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anna Brujats
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Javier Fajardo
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Berta Cuyas
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - María Poca
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Carlos Guarner
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Xavier Torras
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Àngels Escorsell
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Càndid Villanueva
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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Tonutti A, Pugliese N, Ceribelli A, Isailovic N, De Santis M, Colapietro F, De Nicola S, Polverini D, Selmi C, Aghemo A. The autoimmune landscape of Porto-sinusoidal vascular disorder: What the rheumatologist needs to know. Semin Arthritis Rheum 2024; 67:152467. [PMID: 38805899 DOI: 10.1016/j.semarthrit.2024.152467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/23/2024] [Accepted: 04/29/2024] [Indexed: 05/30/2024]
Abstract
Porto-sinusoidal vascular disorder (PSVD) encompasses a group of vascular disorders characterized by lesions of the portal venules and sinusoids with clinical manifestations ranging from non-specific abnormalities in serum liver enzymes to clinically overt portal hypertension and related complications. Several reports have documented cases of PSVD in patients with systemic autoimmune conditions, such as systemic lupus erythematosus, systemic sclerosis, and rheumatoid arthritis. It is of note that these diseases share specific pathophysiological features with PSVD, including endothelial dysfunction, vascular inflammation, and molecular signatures. This narrative review aims to summarize the current knowledge on the association between PSVD and systemic autoimmune diseases, emphasizing the importance of promptly recognizing this condition in the rheumatological practice, and highlighting the key aspects where further research is necessary from both pathogenic and clinical perspectives.
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Affiliation(s)
- Antonio Tonutti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Nicola Pugliese
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Angela Ceribelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Natasa Isailovic
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Maria De Santis
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Francesca Colapietro
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Stella De Nicola
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Davide Polverini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Carlo Selmi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Rozzano, Italy.
| | - Alessio Aghemo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
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Ma L, Ma J, Zhang W, Yu J, Zhang Z, Yang M, Zhou Y, Ju S, Gu G, Luo J, Yan Z. Reduced risk of overt hepatic encephalopathy and death after transjugular intrahepatic portosystemic shunt in patients with hepatic venovenous communications. Eur J Radiol 2024; 177:111554. [PMID: 38850724 DOI: 10.1016/j.ejrad.2024.111554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/31/2024] [Accepted: 06/04/2024] [Indexed: 06/10/2024]
Abstract
PURPOSE Hepatic venovenous communications (HVVC) is detectable in more than one-third of cirrhotic patients, where portal hypertension (PHT) tends to present more severely. We aimed to explore the prognostic implications of HVVC in patients with sinusoidal PHT treated by transjugular intrahepatic portosystemic shunt (TIPS). METHOD The multicenter data of patients (2020-2022) undergoing balloon-occluded hepatic venography during TIPS were retrospectively analyzed. Pre-TIPS total bile acids (TBA) levels in portal, hepatic and peripheral veins were compared between groups. The primary endpoint was the development of overt hepatic encephalopathy (HE) within one year after TIPS. RESULTS 183 patients were eligible and classified by the presence (n = 69, 37.7 %) or absence (n = 114, 62.3 %) of HVVC. The agreement between wedged hepatic venous pressure and portal venous pressure was poor in HVVC group (intraclass correlation coefficients [ICC]: 0.141, difference: 13.4 mmHg, p < 0.001), but almost perfect in non-HVVC group (ICC: 0.877, difference: 0.4 mmHg, p = 0.152). At baseline, patients with HVVC had lower Model for end-stage liver disease scores (p < 0.001), blood ammonia levels (p < 0.001), TBA concentrations in the hepatic (p = 0.011) and peripheral veins (p = 0.049) rather than in the portal veins (p = 0.516), and a higher portosystemic pressure gradient (p = 0.035), suggesting more effective intrahepatic perfusion in this group. Within 1-year post-TIPS, HVVC group had a lower incidence of overt HE (11.7 % vs. 30.5 %, p = 0.004, HR: 0.34, 95 % CI: 0.16-0.74, absolute risk difference [ARD]: -17.4) and an improved liver transplantation-free survival rate (97.1 % vs. 86.8 %, p = 0.021, HR: 0.16, 95 % CI: 0.05-0.91, ARD: -10.3). CONCLUSIONS For patients with sinusoidal PHT treated by TIPS, the presence of HVVC was associated with a reduced risk of overt HE and a potential survival benefit.
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Affiliation(s)
- Li Ma
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jingqin Ma
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen Zhang
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiaze Yu
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zihan Zhang
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Minjie Yang
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yongjie Zhou
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shuai Ju
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China
| | - Guoqiang Gu
- Department of Radiology, Minhang Hospital, Fudan University, Shanghai, China
| | - Jianjun Luo
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China; Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.
| | - Zhiping Yan
- Shanghai Institution of Medical Imaging, Fudan University, Shanghai, China; Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China; National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, China; Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.
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Magyar CTJ, Gaviria F, Li Z, Choi WJ, Ma AT, Berzigotti A, Sapisochin G. Surgical Considerations in Portal Hypertension. Clin Liver Dis 2024; 28:555-576. [PMID: 38945643 DOI: 10.1016/j.cld.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
This review provides an in-depth exploration of portal hypertension (PH) and its implications in various surgical procedures. The prevalence of clinically significant PH is 50% to 60% in compensated cirrhosis and 100% in decompensated cirrhosis. The feasibility and safety of hepatic and nonhepatic surgical procedures in patients with PH has been shown. Adequate preoperative risk assessment and optimization of PH are integral parts of patient assessment. The occurrence of adverse outcomes after surgery has decreased over time in this specific population, due to the development of techniques and improved perioperative multidisciplinary care.
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Affiliation(s)
- Christian Tibor Josef Magyar
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada; Multi-Organ Transplant Program, University Health Network, Toronto, Canada; Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Felipe Gaviria
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada; Multi-Organ Transplant Program, University Health Network, Toronto, Canada
| | - Zhihao Li
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada; Multi-Organ Transplant Program, University Health Network, Toronto, Canada
| | - Woo Jin Choi
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada; Multi-Organ Transplant Program, University Health Network, Toronto, Canada
| | - Ann Thu Ma
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Gonzalo Sapisochin
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; University Health Network, HPB Surgical Oncology, Toronto, Ontario, Canada; Multi-Organ Transplant Program, University Health Network, Toronto, Canada.
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Vashishtha C, Sarin SK. Bleeding Complications of Portal Hypertension. Clin Liver Dis 2024; 28:483-501. [PMID: 38945639 DOI: 10.1016/j.cld.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
In portal hypertension, acute variceal bleed is the cause of 2/3rd of all upper gastrointestinal bleeding episodes. It is a life-threatening emergency in patients with cirrhosis. Nonselective beta-blockers by decreasing the hepatic venous pressure gradient are the mainstay of medical therapy for the prevention of variceal bleeding and rebleeding. Evaluation of the severity of bleed, hemodynamic resuscitation, prophylactic antibiotic, and intravenous splanchnic vasoconstrictors should precede the endoscopy procedure. Endoscopic band ligation is the recommended endotherapy. Rescue transjugular intrahepatic port-systemic shunt (TIPS) is recommended for variceal bleed refractory to endotherapy. In patients with a high risk of failure of combined pharmacologic and endoscopic therapy, pre-emptive TIPS may improve the outcome. For gastric varices, "Sarin classification" is universally applied as it is simple and has therapeutic implication. For IGV1 and GOV2, injection cyanoacrylate glue is considered the endotherapy of choice. Endoscopic ultrasound is a useful modality in the management of gastric varices.
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Affiliation(s)
- Chitranshu Vashishtha
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India.
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Rodrigues SG, Delgado MG, Stirnimann G, Berzigotti A, Bosch J. Hepatic Venous Pressure Gradient: Measurement and Pitfalls. Clin Liver Dis 2024; 28:383-400. [PMID: 38945633 DOI: 10.1016/j.cld.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Measurement of hepatic venous pressure gradient (HVPG) effectively mirrors the severity of portal hypertension (PH) and offers valuable insights into prognosis of liver disease, including the risk of decompensation and mortality. Additionally, HVPG offers crucial information about treatment response to nonselective beta-blockers and other medications, with its utility demonstrated in clinical trials in patients with PH. Despite the widespread dissemination and validation of noninvasive tests, HVPG still holds a significant role in hepatology. Physicians treating patients with liver diseases should comprehend the HVPG measurement procedure, its applications, and how to interpret the results and potential pitfalls.
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Affiliation(s)
- Susana G Rodrigues
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, MEM, Murtenstrasse 35 Office F807, Bern 3008, Switzerland
| | - Maria Gabriela Delgado
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, MEM, Murtenstrasse 35 Office F808, Bern 3008, Switzerland
| | - Guido Stirnimann
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, Bern 3010, Switzerland
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, BHH D115, Freiburgstrasse 10, Bern 3010, Switzerland
| | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, MEM, Murtenstrasse 35 Office F805, Bern 3008, Switzerland; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Barcelona, Spain.
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Liu C, Zhang L, Zhang S, Li X, Wong YJ, Liang X, Wang Y, Wu X, Gou W, Lv J, Hu S, Fu J, Huang J, Ge G, Huang M, Wang F, Zhang Q, Ren T, Meng Z, Ding D, Zhuoga B, Zhuoga C, Fan J, Dang D, Miao L, Song Z, Xiao X, Wu H, Jiang K, Liu T, Gao Y, Ma L, Fang T, Wang Y, Zhang Q, Zhu D, Ji D, Cao Z, Zeng QL, Li J, Chen P, Wei Y, Tong Z, Hong Z, Liang X, Li Y, Nan Y, Qi X. Carvedilol to prevent decompensation of cirrhosis in patients with clinically significant portal hypertension stratified by liver stiffness: study protocol for a randomied, double-blind, placebo-controlled, multicentre trial in China. BMJ Open 2024; 14:e081623. [PMID: 38991669 PMCID: PMC11243284 DOI: 10.1136/bmjopen-2023-081623] [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: 07/13/2024] Open
Abstract
INTRODUCTION Patients with clinically significant portal hypertension (CSPH) are recommended to be treated with non-selective beta-blockers (ie, carvedilol) to prevent the first hepatic decompensation event by the renewing Baveno VII consensus. CSPH is defined by hepatic venous pressure gradient (HVPG)≥10 mm Hg; however, the HVPG measurement is not widely adopted due to its invasiveness. Liver stiffness (LS)≥25 kPa can be used as a surrogate of HVPG≥10 mm Hg to rule in CSPH with 90% of the positive predicting value in majority aetiologies of patients. A compelling argument is existing for using LS≥25 kPa to diagnose CSPH and then to initiate carvedilol in patients with compensated cirrhosis, and about 5%-6% of patients under this diagnosis criteria may not be benefited from carvedilol and are at risk of lower heart rate and mean arterial pressure. Randomised controlled trial on the use of carvedilol to prevent liver decompensation in CSPH diagnosed by LS remains to elucidate. Therefore, we aimed to investigate if compensated cirrhosis patients with LS≥25 kPa may benefit from carvedilol therapy. METHODS AND ANALYSIS This study is a randomised, double-blind, placebo-controlled, multicentre trial. We will randomly assign 446 adult compensated cirrhosis patients with LS≥25 kPa and without any previous decompensated event and without high-risk gastro-oesophageal varices. Patients are randomly divided into two groups, with 223 subjects in group A and 223 subjects in group B. Group A is a carvedilol intervention group, while group B is a placebo group. All patients in both groups will receive aetiology therapies and are followed up at an interval of 6 months. The 3-year incidences of decompensated events of cirrhosis-related and liver-related death are the primary outcome. The secondary outcomes include development of each complication of portal hypertension individually (ascites, variceal bleeding or overt hepatic encephalopathy), development of spontaneous bacterial peritonitis and other bacterial infections, development of new varices, growth of small varices to large varices, delta changes in LS and spleen stiffness, change in hepatic dysfunction assessed by Child-Pugh and model for end-stage liver disease score, change in platelet count, development of hepatocellular carcinoma, development of portal vein thrombosis and adverse events with a 3-year follow-up. A predefined interim analysis will be performed to ensure that the calculation is reasonable. ETHICS AND DISSEMINATION The study protocol has been approved by the ethics committees of the Sixth People's Hospital of Shenyang (2023-05-003-01) and independent ethics committee for clinical research of Zhongda Hospital, affiliated to Southeast University (2023ZDSYLL433-P01). The results from this trial will be submitted for publication in peer-reviewed journals and will be presented at international conferences. TRIAL REGISTRATION NUMBER ChiCTR2300073864.
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Affiliation(s)
- Chuan Liu
- Center of Portal Hypertension, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nurturing Center of Jiangsu Province for State Laboratory of AI Imaging & Interventional Radiology (Southeast University), Nanjing, Jiangsu, China
- Basic Medicine Research and Innovation Center of Ministry of Education, Zhongda Hospital, Southeast University, State Key Laboratory of Digital Medical Engineering, Nanjing, Jiangsu, China
| | - Liting Zhang
- The Portal Hypertension Research Institute, Department of Hepatology, First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Shuairan Zhang
- Department of Gastroenterology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xiaoguo Li
- The Portal Hypertension Research Institute, Department of Hepatology, First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Yu-Jun Wong
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Xuan Liang
- Shenyang Sixth People's Hospital, Shenyang, Liaoning, China
| | - Yan Wang
- Shenyang Sixth People's Hospital, Shenyang, Liaoning, China
| | - Xiaofeng Wu
- Shenyang Sixth People's Hospital, Shenyang, Liaoning, China
| | - Wei Gou
- Qingdao Sixth People's Hospital, Qingdao, Shandong, China
| | - Jiaojian Lv
- Lishui People's Hospital, Lishui, Zhejiang, China
| | - Shengjuan Hu
- Department of Gastroenterology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia, China
| | - Junliang Fu
- Department of Infectious Disease Medicine, The Fifth center of PLA General Hospital, Beijing, China
| | - Ju Huang
- Zhenjiang Third People's Hospital, Zhenjiang, Jiangsu, China
| | - Guohong Ge
- Zhenjiang Third People's Hospital, Zhenjiang, Jiangsu, China
| | - Mingxing Huang
- Zhuhai Third People's Hospital, Zhuhai, Guangdong, China
| | - Fang Wang
- Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Qingge Zhang
- Department of Infectious Diseases, Xingtai People's Hospital, Xingtai, Hebei, China
| | - Tao Ren
- Sichuan University Huaxi Hospital Tibet Chengban Branch, Chengdu, Sichuan, China
| | - Zhongji Meng
- Department of Infectious Diseases, Institute of Biomedical Research, Regulatory Mechanism and Targeted Therapy for Liver Cancer Shiyan Key Laboratory, Hubei Provincial Clinical Research Center for Precise Diagnosis and Treatment of Liver Cancer, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
- Hubei Key Laboratory of Embryonic Stem Cell Research, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Deping Ding
- Department of Infectious Diseases, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Basang Zhuoga
- Third People's Hospital of Tibet Autonomous Region, Lhasa, Tibet, China
| | - Cidan Zhuoga
- Third People's Hospital of Tibet Autonomous Region, Lhasa, Tibet, China
| | - Jian Fan
- Handan Infectious Disease Hospital, Handan, Hebei, China
| | - Dianjie Dang
- Handan Infectious Disease Hospital, Handan, Hebei, China
| | - Liang Miao
- Qinhuangdao Third Hospital, Qinhuangdao, Hebei, China
| | - Zhaomin Song
- Qinhuangdao Third Hospital, Qinhuangdao, Hebei, China
| | - Xingguo Xiao
- Department of Gastroenterology, Zhengzhou Central Hospital, Zhengzhou, Henan, China
| | - Huili Wu
- Department of Gastroenterology, Zhengzhou Central Hospital, Zhengzhou, Henan, China
| | - Kai Jiang
- Fourth Department, Digestive Disease Center, Suining Central Hospital, Suining, Sichuan, China
| | - Tianyu Liu
- Fourth Department, Digestive Disease Center, Suining Central Hospital, Suining, Sichuan, China
| | - Youfang Gao
- Department of Infectious Disease, The People's Hospital of Bozhou, Bozhou, Anhui, China
| | - Lan Ma
- Department of Infectious Disease, The People's Hospital of Bozhou, Bozhou, Anhui, China
| | - Tao Fang
- Jinhua People's Hospital, Jinhua, Zhejiang, China
| | - Yuehua Wang
- Jinhua People's Hospital, Jinhua, Zhejiang, China
| | - Qianhua Zhang
- Department of Hepatology, Zhongshan Second People's Hospital, Zhongshan, Guangdong, China
| | - Da Zhu
- Department of Hepatology, Zhongshan Second People's Hospital, Zhongshan, Guangdong, China
| | - Dong Ji
- Senior Department of Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Zhujun Cao
- Department of Infectious Disease, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qing-Lei Zeng
- Department of Infectious Diseases and Hepatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jie Li
- Department of Infectious Diseases, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Ping Chen
- Shulan Hangzhou Hospital, Hangzhou, Zhejiang, China
| | - Yufang Wei
- The First People's Hospital of Lianyungang, Lianyungang, Jiangsu, China
| | - Zhaowei Tong
- Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, Huzhou, Zhejiang, China
| | - Zhongsi Hong
- Department of Infectious Diseases, Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong, China
| | - Xiao Liang
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yiling Li
- Department of Gastroenterology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yuemin Nan
- Department of Traditional and Western Medical Hepatology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xiaolong Qi
- Center of Portal Hypertension, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nurturing Center of Jiangsu Province for State Laboratory of AI Imaging & Interventional Radiology (Southeast University), Nanjing, Jiangsu, China
- Basic Medicine Research and Innovation Center of Ministry of Education, Zhongda Hospital, Southeast University, State Key Laboratory of Digital Medical Engineering, Nanjing, Jiangsu, China
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Biswas S, Vaishnav M, Gamanagatti S, Swaroop S, Arora U, Aggarwal A, Elhence A, Gunjan D, Kedia S, Mahapatra SJ, Mishra AK, Shalimar. Endoscopic Glue Injection vs Glue Plus BRTO or TIPSS for Preventing Gastric Variceal Bleeding: A Randomized Controlled Trial. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00593-7. [PMID: 38969074 DOI: 10.1016/j.cgh.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 06/18/2024] [Accepted: 06/18/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND AND AIMS The study sought to compare the efficacy of endoscopic injection sclerotherapy with cyanoacrylate glue (EIS-CYA) vs EIS-CYA plus a radiologic intervention (RI) (either transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde transvenous obliteration) for secondary prophylaxis in patients with liver cirrhosis who presented with acute variceal bleeding from cardiofundal varices. Primary outcome measure was gastric varix (GV) rebleed rates at 1 year. METHODS Consecutive cirrhosis patients with acute variceal bleeding from cardiofundal varices were randomized into 2 arms (45 in each) after primary hemostasis by EIS-CYA. In the endoscopic intervention (EI) arm, EIS-CYA was repeated at regular intervals (1, 3, 6, and 12 months), while in the RI arm, patients underwent transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde transvenous obliteration followed by endoscopic surveillance. RESULTS GV rebleed rates at 1 year were higher in the EI arm compared with the RI arm: 11 (24.4%; 95% confidence interval [CI], 12.9%-39.5%) vs 1 (2.2%; 95% CI, 0.1%-11.8%) (P = .004; absolute risk difference: 22.2%; 95% CI, 8.4%-36.6%). GV rebleed-related mortality in the EI arm (8 [17.8%; 95% CI, 8.0%-32.1%]) was significantly higher than in the RI arm (1 [2.2%; 0.1%-11.8%]) (P = .030; absolute risk difference: 15.6; 95% CI, 2.9%-29.2%); however, there was no difference in all-cause mortality between the 2 groups (12 [26.7%; 95% CI, 14.6%-41.9%] vs 7 [15.6%; 95% CI, 6.5%-29.5%]). The number needed to treat to prevent 1 GV-related rebleed at 1 year was 4.5. CONCLUSIONS RI for secondary prophylaxis reduces rebleeding from GV and GV rebleeding-related mortality in patients with GV hemorrhage. (CTRI/2021/02/031396).
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Affiliation(s)
- Sagnik Biswas
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Shivanand Gamanagatti
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Shekhar Swaroop
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Umang Arora
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Arnav Aggarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Soumya Jagannath Mahapatra
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Ashwani Kumar Mishra
- National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, Delhi, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India.
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Guixé-Muntet S, Quesada-Vázquez S, Gracia-Sancho J. Pathophysiology and therapeutic options for cirrhotic portal hypertension. Lancet Gastroenterol Hepatol 2024; 9:646-663. [PMID: 38642564 DOI: 10.1016/s2468-1253(23)00438-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/28/2023] [Accepted: 11/28/2023] [Indexed: 04/22/2024]
Abstract
Portal hypertension represents the primary non-neoplastic complication of liver cirrhosis and has life-threatening consequences, such as oesophageal variceal bleeding, ascites, and hepatic encephalopathy. Portal hypertension occurs due to increased resistance of the cirrhotic liver vasculature to portal blood flow and is further aggravated by the hyperdynamic circulatory syndrome. Existing knowledge indicates that the profibrogenic phenotype acquired by sinusoidal cells is the initial factor leading to increased hepatic vascular tone and fibrosis, which cause increased vascular resistance and portal hypertension. Data also suggest that the phenotype of hepatic cells could be further impaired due to the altered mechanical properties of the cirrhotic liver itself, creating a deleterious cycle that worsens portal hypertension in the advanced stages of liver disease. In this Review, we discuss recent discoveries in the pathophysiology and treatment of cirrhotic portal hypertension, a condition with few pharmacological treatment options.
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Affiliation(s)
- Sergi Guixé-Muntet
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Sergio Quesada-Vázquez
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Jordi Gracia-Sancho
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain; Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Aliseda D, Zozaya G, Martí-Cruchaga P, Herrero I, Iñarrairaegui M, Argemí J, Martínez De La Cuesta A, Blanco N, Sabatella L, Sangro B, Rotellar F. The Impact of Portal Hypertension Assessment Method on the Outcomes of Hepatocellular Carcinoma Resection: A Meta-Analysis of Matched Cohort and Prospective Studies. Ann Surg 2024; 280:46-55. [PMID: 38126757 DOI: 10.1097/sla.0000000000006185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Examine portal hypertension (PHT) impact on postoperative and survival outcomes in hepatocellular carcinoma (HCC) patients after liver resection (LR), specifically exploring distinctions between indirect signs and invasive measurements of PHT. BACKGROUND PHT has historically discouraged LR in individuals with HCC due to the elevated risk of morbidity, including liver decompensation (LD). METHODS A systematic review was conducted using 3 databases to identify prospective-controlled and matched cohort studies until December 28, 2022. Focus on comparing postoperative outcomes (mortality, morbidity, and liver-related complications) and overall survival in HCC patients with and without PHT undergoing LR. Three meta-analysis models were utilized: for aggregated data (fixed-effects inverse variance model), for patient-level survival data (one-stage frequentist meta-analysis with gamma-shared frailty Cox proportional hazards model), and for pooled data (Freeman-Tukey exact and double arcsine method). RESULTS Nine studies involving 1124 patients were analyzed. Indirect signs of PHT were not significantly associated with higher mortality, overall complications, PHLF or LD. However, LR in patients with hepatic venous pressure gradient (HVPG) ≥10 mm Hg significantly increased the risk of overall complications, PHLF, and LD. Despite elevated risks, the procedure resulted in a 5-year overall survival rate of 55.2%. Open LR significantly increased the risk of overall complications, PHLF, and LD. Conversely, PHT did not show a significant association with worse postoperative outcomes in minimally invasive LR. CONCLUSIONS LR in the presence of indirect signs of PHT poses no increased risk of complications. Yet, in HVPG ≥10 mm Hg patients, LR increases overall morbidity and liver-related complications risk. Transjugular HVPG assessment is crucial for LR decisions. Minimally invasive approach seems to be vital for favorable outcomes, especially in HVPG ≥10 mm Hg patients.
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Affiliation(s)
- Daniel Aliseda
- HPB and Liver Transplant Unit Department of General Surgery, Clinica Universidad de Navarra, University of Navarra, Pamplona, Spain
| | - Gabriel Zozaya
- HPB and Liver Transplant Unit Department of General Surgery, Clinica Universidad de Navarra, University of Navarra, Pamplona, Spain
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Pablo Martí-Cruchaga
- HPB and Liver Transplant Unit Department of General Surgery, Clinica Universidad de Navarra, University of Navarra, Pamplona, Spain
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Ignacio Herrero
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
- Liver Unit and HPB Oncology Area, Clinica Universidad de Navarra and CIBEREHD, Pamplona, Spain
| | - Mercedes Iñarrairaegui
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
- Liver Unit and HPB Oncology Area, Clinica Universidad de Navarra and CIBEREHD, Pamplona, Spain
| | - Josepmaría Argemí
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
- Liver Unit and HPB Oncology Area, Clinica Universidad de Navarra and CIBEREHD, Pamplona, Spain
| | - Antonio Martínez De La Cuesta
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
- Interventional Radiology, Department of Radiology, Clinica Universidad de Navarra, University of Navarra, Pamplona, Spain
| | - Nuria Blanco
- HPB and Liver Transplant Unit Department of General Surgery, Clinica Universidad de Navarra, University of Navarra, Pamplona, Spain
| | - Lucas Sabatella
- HPB and Liver Transplant Unit Department of General Surgery, Clinica Universidad de Navarra, University of Navarra, Pamplona, Spain
| | - Bruno Sangro
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
- Liver Unit and HPB Oncology Area, Clinica Universidad de Navarra and CIBEREHD, Pamplona, Spain
| | - Fernando Rotellar
- HPB and Liver Transplant Unit Department of General Surgery, Clinica Universidad de Navarra, University of Navarra, Pamplona, Spain
- Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
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15
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Li R, Li L, Cai Z, Chen J, Zhang H, Zhao S, Tu J, Sun C, Jin Y, Zhang M, Zhang F, Zhang W, Yin Q, Xu H, Han H, Li T, Zhuge Y, Xiao J. Histological evaluation of pyrrolizidine alkaloid-induced hepatic sinusoidal obstruction syndrome: Correlation with Drum Tower Severity Scoring. Dig Liver Dis 2024; 56:1220-1228. [PMID: 38151450 DOI: 10.1016/j.dld.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/11/2023] [Accepted: 12/16/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Hepatic sinusoidal obstruction syndrome induced by pyrrolizidine alkaloids (PA-HSOS) is a complication of drug-induced liver damage. Few studies have examined the relationship between pathological changes and clinical circumstances in PA-HSOS. The Drum Tower Severity Scoring System (DTSS) was developed using prognostic indicators from clinical treatment outcomes. We hypothesized that the severity of pathological damage is consistent with DTSS. AIMS We aimed to improve our understanding and assessment of vascular liver injury disease histopathology by studying larger sample sizes of human histopathological samples. We also wanted to confirm the link between histopathological findings and DTSS. METHODS The study included 62 patients with PA-HSOS who underwent transjugular liver biopsy. Their hepatic pathological tissues were evaluated. Analyses of linear regression and Spearman's correlation were employed to examine the relationship between DTSS and pathological characteristics. RESULTS Clinical performance and the DTSS score were used to determine histopathological severity. The sinusoidal congestion area (SCA), central venous endothelial injury (CVEI), and fibrinoid exudation in congestion foci (FECF) were significant indicators. SCA was linearly related to the DTSS score. CONCLUSION Our findings show that hepatic pathological characteristics correlate with DTSS scores in PA-HSOS. SCA, CVEI, and FECF may be helpful for determining PA-HSOS severity.
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Affiliation(s)
- Ruiqi Li
- Department of Gastroenterology, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China; School of Medicine, Southeast University, Nanjing, China
| | - Lin Li
- Department of Pathology, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China
| | - Zihao Cai
- Department of Gastroenterology, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China
| | - Jun Chen
- Department of Pathology, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China
| | - Han Zhang
- Department of Gastroenterology, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China
| | - Si Zhao
- Department of Gastroenterology, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China
| | - Jingjing Tu
- Department of Gastroenterology, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China
| | - Chang Sun
- Department of Gastroenterology, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China
| | - Yani Jin
- Department of Gastroenterology, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China
| | - Ming Zhang
- Department of Gastroenterology, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China
| | - Feng Zhang
- Department of Gastroenterology, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China
| | - Wei Zhang
- Department of Gastroenterology, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China
| | - Qin Yin
- Department of Gastroenterology, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China
| | - Hui Xu
- Department of Gastroenterology, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China
| | - Hao Han
- Department of Ultrasound, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China
| | - Taishun Li
- Medical Statistical Analysis Center, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China; School of Medicine, Southeast University, Nanjing, China.
| | - Jiangqiang Xiao
- Department of Gastroenterology, Drum Tower Hospital, Affiliated Medical College of Nanjing University, Nanjing, China.
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16
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Ye JZ, Lu HZ, Zeng C, Lei G, Wang XB, Chen J, Bai T, Wu FX, Mai RY, Guo WX, Li LQ. A novel surgical scheme for hepatectomy in hepatocellular carcinoma patients with clinically significant portal hypertension. BMC Cancer 2024; 24:764. [PMID: 38918786 PMCID: PMC11202348 DOI: 10.1186/s12885-024-12535-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 06/18/2024] [Indexed: 06/27/2024] Open
Abstract
OBJECTIVE Clinically significant portal hypertension (CSPH) seriously affects the feasibility and safety of surgical treatment for hepatocellular carcinoma (HCC) patients. The aim of this study was to establish a new surgical scheme defining risk classification of post-hepatectomy liver failure (PHLF) to facilitate the surgical decision-making and identify suitable candidates for individual hepatectomy among HCC patients with CSPH. BACKGROUNDS Hepatectomy is the preferred treatment for HCC. Surgeons must maintain a balance between the expected oncological outcomes of HCC removal and short-term risks of severe PHLF and morbidity. CSPH aggravates liver decompensation and increases the risk of severe PHLF thus complicating hepatectomy for HCC. METHODS Multivariate logistic regression and stochastic forest algorithm were performed, then the independent risk factors of severe PHLF were included in a nomogram to determine the risk of severe PHLF. Further, a conditional inference tree (CTREE) through recursive partitioning analysis validated supplement the misdiagnostic threshold of the nomogram. RESULTS This study included 924 patients, of whom 137 patients (14.8%) suffered from mild-CSPH and 66 patients suffered from (7.1%) with severe-CSPH confirmed preoperatively. Our data showed that preoperative prolonged prothrombin time, total bilirubin, indocyanine green retention rate at 15 min, CSPH grade, and standard future liver remnant volume were independent predictors of severe PHLF. By incorporating these factors, the nomogram achieved good prediction performance in assessing severe PHLF risk, and its concordance statistic was 0.891, 0.850 and 0.872 in the training cohort, internal validation cohort and external validation cohort, respectively, and good calibration curves were obtained. Moreover, the calculations of total points of diagnostic errors with 95% CI were concentrated in 110.5 (range 76.9-178.5). It showed a low risk of severe PHLF (2.3%), indicating hepatectomy is feasible when the points fall below 76.9, while the risk of severe PHLF is extremely high (93.8%) and hepatectomy should be rigorously restricted at scores over 178.5. Patients with points within the misdiagnosis threshold were further examined using CTREE according to a hierarchic order of factors represented by the presence of CSPH grade, ICG-R15, and sFLR. CONCLUSION This new surgical scheme established in our study is practical to stratify risk classification in assessing severe PHLF, thereby facilitating surgical decision-making and identifying suitable candidates for individual hepatectomy.
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Affiliation(s)
- Jia-Zhou Ye
- Department of Hepatobiliary Surgery, Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Hua-Ze Lu
- Department of Hepatobiliary Surgery, Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Can Zeng
- Department of Hepatobiliary Surgery, Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Guo Lei
- Department of Hepatic Suegery VI, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China
| | - Xiao-Bo Wang
- Department of Hepatobiliary Surgery, Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Jie Chen
- Department of Hepatobiliary Surgery, Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Tao Bai
- Department of Hepatobiliary Surgery, Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Fei-Xiang Wu
- Department of Hepatobiliary Surgery, Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Rong-Yun Mai
- Department of Hepatobiliary Surgery, Guangxi Medical University Cancer Hospital, Nanning, 530021, China.
| | - Wei-Xing Guo
- Department of Hepatic Suegery VI, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, 225 Changhai Road, Shanghai, 200438, China.
| | - Le-Qun Li
- Department of Hepatobiliary Surgery, Guangxi Medical University Cancer Hospital, Nanning, 530021, China.
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17
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Lim R, Hodge A, Warner S, Moore GT, Correia J, Krause M, McDonald H, Chan ST, Goonetilleke M, Lyon SM, Sievert W. Human Amniotic Epithelial Cell Transplantation is Safe and Well Tolerated in Patients with Compensated Cirrhosis: A First-in-Human Trial. Stem Cells Transl Med 2024; 13:522-531. [PMID: 38619045 PMCID: PMC11165158 DOI: 10.1093/stcltm/szae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 02/08/2024] [Indexed: 04/16/2024] Open
Abstract
Placenta-derived human amniotic epithelial cells (hAEC) exhibit anti-inflammatory and anti-fibrotic effects in cirrhosis models. We conducted a first-in-human phase I clinical trial to assess the safety and tolerability of hAEC in adults with compensated cirrhosis. We examined increasing and repeated doses of hAEC in 9 patients in 3 cohorts. Cohort 1 patients received 0.5 × 106/kg hAEC in one IV infusion. Cohort 2 patients received 1 × 106/kg hAEC in one IV infusion. The patients in cohort 3 received 1 × 106/kg hAEC on days 0 and 28. Here, we report follow-up to post-infusion day 56 (D56), during which no serious adverse events occurred. Six patients experienced no study-related adverse events, while 3 patients reported mild (grade 1) headaches that were possibly infusion-related. A transient decrease in serum platelet count occurred in all patients, which returned to baseline screening values by day 5. FIB-4 values to assess fibrosis were significantly lower at D56. Although not statistically significant, serum AST levels and liver stiffness measurements at D56 were lower than those at baseline. The hepatic venous pressure gradient, a measure of portal hypertension, declined in 4 patients, did not change in 3 patients, and increased in 2 patients. In conclusion, intravenous infusion of allogeneic hAEC in patients with compensated cirrhosis at the doses used in this study was safe and well tolerated, with no difference observed between 1 and 2 doses. Decreased hepatic inflammation, liver stiffness, and portal hypertension support larger studies aimed at identifying patients who may benefit from this therapy. Clinical Trial registration: The trial was prospectively entered on the Australian Clinical Trials Registry (ANZCTR12616000437460).
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Affiliation(s)
- Rebecca Lim
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne 3168, Australia
- Department of Obstetrics and Gynecology, Monash University, 246 Clayton Road, Clayton, Melbourne 3168, Australia
| | - Alexander Hodge
- Department of Gastroenterology, Eastern Health, 5 Arnold Street, Box Hill, Melbourne 3128, Australia
| | - Sherryne Warner
- School of Clinical Sciences, Monash University, 246 Clayton Road, Clayton, Melbourne 3168, Australia
- The John Goldman Centre for Cellular Therapy, Hammersmith Hospital, Ducane Road, London W12 OHS, United Kingdom
| | - Gregory T Moore
- School of Clinical Sciences, Monash University, 246 Clayton Road, Clayton, Melbourne 3168, Australia
- The John Goldman Centre for Cellular Therapy, Hammersmith Hospital, Ducane Road, London W12 OHS, United Kingdom
| | - Jeanne Correia
- The John Goldman Centre for Cellular Therapy, Hammersmith Hospital, Ducane Road, London W12 OHS, United Kingdom
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne 3168, Australia
| | - Mirja Krause
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne 3168, Australia
- Department of Obstetrics and Gynecology, Monash University, 246 Clayton Road, Clayton, Melbourne 3168, Australia
| | - Hannah McDonald
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne 3168, Australia
- Department of Gastroenterology, Monash Health, 246 Clayton Raod, Clayton, Melbourne 3168, Australia
| | - Siow T Chan
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne 3168, Australia
- Department of Obstetrics and Gynecology, Monash University, 246 Clayton Road, Clayton, Melbourne 3168, Australia
| | - Mihiri Goonetilleke
- The Ritchie Centre, Hudson Institute of Medical Research, 27-31 Wright Street, Clayton, Melbourne 3168, Australia
| | - Stuart M Lyon
- Diagnostic Imaging Department, Monash Health, 246 Clayton Road, Clayton, Melbourne 3168, Australia
| | - William Sievert
- School of Clinical Sciences, Monash University, 246 Clayton Road, Clayton, Melbourne 3168, Australia
- The John Goldman Centre for Cellular Therapy, Hammersmith Hospital, Ducane Road, London W12 OHS, United Kingdom
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18
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Giabicani M, Joly P, Sigaut S, Timsit C, Devauchelle P, Dondero F, Durand F, Froissant PA, Lamamri M, Payancé A, Restoux A, Roux O, Thibault-Sogorb T, Valainathan SR, Lesurtel M, Rautou PE, Weiss E. Predictive role of hepatic venous pressure gradient in bleeding events among patients with cirrhosis undergoing orthotopic liver transplantation. JHEP Rep 2024; 6:101051. [PMID: 38699073 PMCID: PMC11060951 DOI: 10.1016/j.jhepr.2024.101051] [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: 01/19/2024] [Revised: 01/31/2024] [Accepted: 02/14/2024] [Indexed: 05/05/2024] Open
Abstract
Background & Aims Major bleeding events during orthotopic liver transplantation (OLT) are associated with poor outcomes. The proportion of this risk related to portal hypertension is unclear. Hepatic venous pressure gradient (HVPG) is the gold standard for estimating portal hypertension. The aim of this study was to analyze the ability of HVPG to predict intraoperative major bleeding events during OLT in patients with cirrhosis. Methods We retrospectively analyzed a prospective database including all patients with cirrhosis who underwent OLT between 2010 and 2020 and had liver and right heart catheterizations as part of their pre-transplant assessment. The primary endpoint was the occurrence of an intraoperative major bleeding event. Results The 468 included patients had a median HVPG of 17 mmHg [interquartile range, 13-22] and a median MELD on the day of OLT of 16 [11-24]. Intraoperative red blood cell transfusion was required in 72% of the patients (median 2 units transfused), with a median blood loss of 1,000 ml [575-1,500]. Major intraoperative bleeding occurred in 156 patients (33%) and was associated with HVPG, preoperative hemoglobin level, severity of cirrhosis at the time of OLT (MELD score, ascites, encephalopathy), hemostasis impairment (thrombocytopenia, lower fibrinogen levels), and complications of cirrhosis (sepsis, acute-on-chronic liver failure). By multivariable regression analysis with backward elimination, HVPG, preoperative hemoglobin level, MELD score, and tranexamic acid infusion were associated with the primary endpoint. Three categories of patients were identified according to HVPG: low-risk (HVPG <16 mmHg), high-risk (HVGP ≥16 mmHg), and very high-risk (HVPG ≥20 mmHg). Conclusions HVPG predicted major bleeding events in patients with cirrhosis undergoing OLT. Including HVPG as part of pre-transplant assessment might enable better anticipation of the intraoperative course. Impact and implications Major bleeding events during orthotopic liver transplantation (OLT) are associated with poor outcomes but the proportion of this risk related to portal hypertension is unclear. Our work shows that hepatic venous pressure gradient (HVPG), the gold standard for estimating portal hypertension, is a strong predictor of major bleeding events and blood loss volume in patients with cirrhosis undergoing OLT. Three groups of patients can be identified according to their risk of major bleeding events: low-risk patients with HVPG <16 mmHg, high-risk patients with HVPG ≥16 mmHg, and very high-risk patients with HVPG ≥20 mmHg. HVPG could be systematically included in the pre-transplant assessment to anticipate intraoperative course and tailor patient management.
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Affiliation(s)
- Mikhael Giabicani
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
- Université Paris-Cité, Paris, France
| | - Pauline Joly
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Stéphanie Sigaut
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Clara Timsit
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Pauline Devauchelle
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Fédérica Dondero
- Departement of HPB Surgery & Liver Transplantation, AP-HP, Beaujon Hospital, DMU DIGEST, Université Paris-Cité, Clichy, France
| | - François Durand
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | | | - Myriam Lamamri
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Audrey Payancé
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Aymeric Restoux
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
| | - Olivier Roux
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | | | - Shantha Ram Valainathan
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Mickaël Lesurtel
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Departement of HPB Surgery & Liver Transplantation, AP-HP, Beaujon Hospital, DMU DIGEST, Université Paris-Cité, Clichy, France
| | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Emmanuel Weiss
- Département d’anesthésie réanimation, AP-HP, Hôpital Beaujon, DMU PARABOL, Clichy, France
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
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He R, Liu C, Grgurevic I, Guo Y, Xu H, Liu J, Liu Y, Wang X, Shi H, Madir A, Podrug K, Zhu Y, Hua Y, Wang K, Wen J, Su M, Zhang Q, Li J, Qi X. Validation of Baveno VII criteria for clinically significant portal hypertension by two-dimensional shear wave elastography. Hepatol Int 2024; 18:1020-1028. [PMID: 38740698 DOI: 10.1007/s12072-024-10657-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/02/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND The Baveno VII consensus proposed criteria for the non-invasively diagnosis of clinically significant portal hypertension (CSPH) in patients with compensated advanced chronic liver disease (cACLD). The performance of Baveno VII criteria for assessing CSPH by two-dimensional shear wave elastography (2D-SWE) had not been well validated. We aimed to validate the performance of Baveno VII criteria for rule-in and rule-out CSPH by 2D-SWE. METHOD This is an international multicenter study including cACLD patients from China and Croatia with paired liver stiffness measurement (LSM), spleen stiffness measurement (SSM) by 2D-SWE, and hepatic venous pressure gradient (HVPG) were included. CSPH was defined as HVPG ≥ 10 mmHg. RESULT A total of 146 patients with cACLD were enrolled, and finally 118 patients were included in the analysis. Among them, CSPH was documented in 79 (66.9%) patients. Applying the Baveno VII criteria for rule-out CSPH by 2D-SWE, [LSM ≤ 15 kPa and platelet count ≥ 150 × 109/L] OR SSM < 21 kPa, could exclude CSPH with sensitivity > 90% (93.5 or 98.7%) but negative predictive value < 90% (74.1 or 85.7%). Using the Baveno VII criteria for rule-in CSPH by 2D-SWE, LSM ≥ 25 kPa OR SSM ≥ 50 kPa, could diagnose CSPH with 100% specificity and 100% positive predictive values. CONCLUSION Baveno VII criteria by 2D-SWE showed a good diagnostic performance for ruling in but not for ruling out CSPH, which might become an emerging non-invasive elastography tool to select the patients who needed non-selective beta blocker therapy.
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Affiliation(s)
- Ruiling He
- Department of Ultrasound, Donggang Branch of the First Hospital of Lanzhou University, Lanzhou, China
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Chuan Liu
- Center of Portal Hypertension, Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nurturing Center of Jiangsu Province for State Laboratory of AI Imaging & Interventional Radiology (Southeast University), Nanjing, China
- Basic Medicine Research and Innovation Center of Ministry of Education, Zhongda Hospital, Southeast University; State Key Laboratory of Digital Medical Engineering, Nanjing, China
| | - Ivica Grgurevic
- Department of Gastroenterology, Hepatology and Clinical Nutrition, School of Medicine and Faculty of Pharmacy and Biochemistry, University Hospital Dubrava, University of Zagreb, Zagreb, Croatia
| | - Ying Guo
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Huixiong Xu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiacheng Liu
- Department of Infectious Diseases, Affiliated Hospital of Medical School, Nanjing Drum Tower Hospital, Nanjing University, Nanjing, China
| | - Yunfang Liu
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - XiaoYan Wang
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Hongmei Shi
- Department of Ultrasound, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Anita Madir
- 4-University Hospital Dubrava, Zagreb, Croatia
| | - Kristian Podrug
- Department of Gastroenterology and Hepatology, University Hospital Center Split, Split, Croatia
| | - Yuli Zhu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yongli Hua
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Kun Wang
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Jing Wen
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Meiqin Su
- Department of Ultrasound, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Qun Zhang
- Department of Infectious Disease, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Jie Li
- Department of Infectious Diseases, Affiliated Hospital of Medical School, Nanjing Drum Tower Hospital, Nanjing University, Nanjing, China.
| | - Xiaolong Qi
- The First Clinical Medical College of Lanzhou University, Lanzhou, China.
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Selvanderan SP, Lam E, Shahidi N. Endohepatology: Arrival at the frontier of interventional endosonography. World J Gastroenterol 2024; 30:2397-2401. [PMID: 38764768 PMCID: PMC11099394 DOI: 10.3748/wjg.v30.i18.2397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/16/2024] [Accepted: 04/19/2024] [Indexed: 05/11/2024] Open
Abstract
Endohepatology describes the emerging field where diagnostic and therapeutic endoscopic ultrasound (EUS) are used for the diagnosis and management of liver disease and its sequelae. In this editorial we comment on the article by Gadour et al. The spectrum of EUS-guided procedures includes liver parenchymal and lesional biopsy, abscess drainage, treatment of focal liver lesions, diagnosis of portal hypertension and management of gastric varices. The data suggest that the application of EUS to hepatology is technically feasible and safe, heralding the arrival at a new frontier for EUS. More data, specifically randomised trials comparing EUS to interventional radiology techniques, and continued partnership between endoscopy and hepatology are required to see this field establish itself outside expert tertiary centres.
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Affiliation(s)
- Shane P Selvanderan
- Department of Medicine, University of British Columbia, Vancouver V6Z 1Y6, BC, Canada
| | - Eric Lam
- Department of Medicine, University of British Columbia, Vancouver V6Z 1Y6, BC, Canada
| | - Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver V6Z 1Y6, BC, Canada
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21
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Glückert K, Decker A, Meier JA, Nowak S, Sanoubara F, Gödiker J, Reinartz Groba SN, Kimmann M, Luetkens JA, Chang J, Sprinkart AM, Praktiknjo M. 3D-Volumetric Shunt Measurement for Detection of High-Risk Esophageal Varices in Liver Cirrhosis. J Clin Med 2024; 13:2678. [PMID: 38731206 PMCID: PMC11084829 DOI: 10.3390/jcm13092678] [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: 03/18/2024] [Revised: 04/28/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
Background and Objectives: Esophageal varices (EV) and variceal hemorrhages are major causes of mortality in liver cirrhosis patients. Detecting EVs early is crucial for effective management. Computed tomography (CT) scans, commonly performed for various liver-related indications, provide an opportunity for non-invasive EV assessment. However, previous CT studies focused on variceal diameter, neglecting the three-dimensional (3D) nature of varices and shunt vessels. This study aims to evaluate the potential of 3D volumetric shunt-vessel measurements from routine CT scans for detecting high-risk esophageal varices in portal hypertension. Methods: 3D volumetric measurements of esophageal varices were conducted using routine CT scans and compared to endoscopic variceal grading. Receiver operating characteristic (ROC) analyses were performed to determine the optimal cutoff value for identifying high-risk varices based on shunt volume. The study included 142 patients who underwent both esophagogastroduodenoscopy (EGD) and contrast-enhanced CT within six months. Results: The study established a cutoff value for identifying high-risk varices. The CT measurements exhibited a significant correlation with endoscopic EV grading (correlation coefficient r = 0.417, p < 0.001). A CT cutoff value of 2060 mm3 for variceal volume showed a sensitivity of 72.1% and a specificity of 65.5% for detecting high-risk varices during endoscopy. Conclusions: This study demonstrates the feasibility of opportunistically measuring variceal volumes from routine CT scans. CT volumetry for assessing EVs may have prognostic value, especially in cirrhosis patients who are not suitable candidates for endoscopy.
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Affiliation(s)
- Kathleen Glückert
- Department of Internal Medicine I, University Hospital Bonn, 53127 Bonn, Germany
| | - Alexandra Decker
- Department of Internal Medicine I, University Hospital Bonn, 53127 Bonn, Germany
| | - Jörn Arne Meier
- Department of Internal Medicine B, University Hospital Münster, 48149 Münster, Germany
| | - Sebastian Nowak
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, 53127 Bonn, Germany
| | - Feras Sanoubara
- Department of Internal Medicine B, University Hospital Münster, 48149 Münster, Germany
| | - Juliana Gödiker
- Department of Internal Medicine B, University Hospital Münster, 48149 Münster, Germany
| | | | - Markus Kimmann
- Department of Internal Medicine B, University Hospital Münster, 48149 Münster, Germany
| | - Julian A. Luetkens
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, 53127 Bonn, Germany
| | - Johannes Chang
- Department of Internal Medicine I, University Hospital Bonn, 53127 Bonn, Germany
| | - Alois M. Sprinkart
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, 53127 Bonn, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine I, University Hospital Bonn, 53127 Bonn, Germany
- Department of Internal Medicine B, University Hospital Münster, 48149 Münster, Germany
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22
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Kaplan DE, Ripoll C, Thiele M, Fortune BE, Simonetto DA, Garcia-Tsao G, Bosch J. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024; 79:1180-1211. [PMID: 37870298 DOI: 10.1097/hep.0000000000000647] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/16/2023] [Indexed: 10/24/2023]
Affiliation(s)
- David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA USA
| | - Cristina Ripoll
- Internal Medicine IV, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Brett E Fortune
- Department of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS) and CIBERehd, University of Barcelona, Spain
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23
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Celsa C, Veneziano M, Di Giorgio FM, Cannova S, Lombardo A, Errigo E, Landro G, Simone F, Sinagra E, Calvaruso V. Non-Invasive Diagnostic Tests for Portal Hypertension in Patients with HBV- and HCV-Related Cirrhosis: A Comprehensive Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:690. [PMID: 38792873 PMCID: PMC11123262 DOI: 10.3390/medicina60050690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/10/2024] [Accepted: 04/17/2024] [Indexed: 05/26/2024]
Abstract
Clinically significant portal hypertension (CSPH) in patients with compensated advanced chronic liver disease indicates an increased risk of decompensation and death. While invasive methods like hepatic venous-portal gradient measurement is considered the gold standard, non-invasive tests (NITs) have emerged as valuable tools for diagnosing and monitoring CSPH. This review comprehensively explores non-invasive diagnostic modalities for portal hypertension, focusing on NITs in the setting of hepatitis B and hepatitis C virus-related cirrhosis. Biochemical-based NITs can be represented by single serum biomarkers (e.g., platelet count) or by composite scores that combine different serum biomarkers with each other or with demographic characteristics (e.g., FIB-4). On the other hand, liver stiffness measurement and spleen stiffness measurement can be assessed using a variety of elastography techniques, and they can be used alone, in combination with, or as a second step after biochemical-based NITs. The incorporation of liver and spleen stiffness measurements, alone or combined with platelet count, into established and validated criteria, such as Baveno VI or Baveno VII criteria, provides useful tools for the prediction of CSPH and for ruling out high-risk varices, potentially avoiding invasive tests like upper endoscopy. Moreover, they have also been shown to be able to predict liver-related events (e.g., the occurrence of hepatic decompensation). When transient elastography is not available or not feasible, biochemical-based NITs (e.g., RESIST criteria, that are based on the combination of platelet count and albumin levels) are valid alternatives for predicting high-risk varices both in patients with untreated viral aetiology and after sustained virological response. Ongoing research should explore novel biomarkers and novel elastography techniques, but current evidence supports the utility of routine blood tests, LSM, and SSM as effective surrogates in diagnosing and staging portal hypertension and predicting patient outcomes.
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Affiliation(s)
- Ciro Celsa
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London W12 0NN, UK
| | - Marzia Veneziano
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Francesca Maria Di Giorgio
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Simona Cannova
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Antonino Lombardo
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Emanuele Errigo
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Giuseppe Landro
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Fabio Simone
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto G. Giglio, 90015 Cefalù, Italy;
| | - Vincenza Calvaruso
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, 90127 Palermo, Italy; (M.V.); (F.M.D.G.); (S.C.); (A.L.); (E.E.); (G.L.); (F.S.); (V.C.)
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24
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Pastrovic F, Novak R, Grgurevic I, Hrkac S, Salai G, Zarak M, Grgurevic L. Serum proteomic profiling of patients with compensated advanced chronic liver disease with and without clinically significant portal hypertension. PLoS One 2024; 19:e0301416. [PMID: 38603681 PMCID: PMC11008873 DOI: 10.1371/journal.pone.0301416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 03/16/2024] [Indexed: 04/13/2024] Open
Abstract
INTRODUCTION Portal hypertension (PH) drives the progression of liver cirrhosis to decompensation and death. Hepatic venous pressure gradient (HVPG) measurement is the standard of PH quantification, and HVPG≥10 mmHg defines clinically significant PH (CSPH). We performed proteomics-based serum profiling to search for a proteomic signature of CSPH in patients with compensated advanced chronic liver disease (cACLD). MATERIALS AND METHODS Consecutive patients with histologically confirmed cACLD and results of HVPG measurements were prospectively included. Serum samples were pooled according to the presence/absence of CSPH and analysed by liquid chromatography-mass spectrometry. Gene set enrichment analysis was performed, followed by comprehensive literature review for proteins identified with the most striking difference between the groups. RESULTS We included 48 patients (30 with, and 18 without CSPH). Protein CD44, involved in the inflammatory response, vascular endothelial growth factor C (VEGF-C) and lymphatic vessel endothelial hyaluronan receptor-1 (LYVE-1), both involved in lymphangiogenesis were found solely in the CSPH group. Although identified in both groups, proteins involved in neutrophil extracellular traps (NET) formation, as well as tenascin C, autotaxin and nephronectin which mediate vascular contractility and lymphangiogenesis were more abundant in CSPH. DISCUSSION AND CONCLUSION We propose that altered inflammatory response, including NET formation, vascular contractility and formation of new lymph vessels are key steps in PH development. Proteins such as CD44, VEGF-C, LYVE-1, tenascin C, Plasminogen activator inhibitor 1, Nephronectin, Bactericidal permeability-increasing protein, Autotaxin, Myeloperoxidase and a disintegrin and metalloproteinase with thrombospondin motifs-like protein 4 might be considered for further validation as potential therapeutic targets and candidate biomarkers of CSPH in cACLD.
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Affiliation(s)
- Frane Pastrovic
- Department of Gastroenterology, Hepatology and Clinical Nutrition, Laboratory for Liver Diseases and Portal Hypertension, University Hospital Dubrava, Zagreb, Croatia
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Rudjer Novak
- Department of Proteomics, Center for Translational and Clinical Research, University of Zagreb School of Medicine, Zagreb, Croatia
- University of Zagreb, School of Medicine, Zagreb, Croatia
- Biomedical Research Center Salata, University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Ivica Grgurevic
- Department of Gastroenterology, Hepatology and Clinical Nutrition, Laboratory for Liver Diseases and Portal Hypertension, University Hospital Dubrava, Zagreb, Croatia
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
- University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Stela Hrkac
- Department of Clinical Immunology, Allergology and Rheumatology, University Hospital Dubrava, Zagreb, Croatia
| | - Grgur Salai
- Department of Pulmonology, University Hospital Dubrava, Zagreb, Croatia
| | - Marko Zarak
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
- Clinical Department of Laboratory Diagnostics, University Hospital Dubrava, Zagreb, Croatia
| | - Lovorka Grgurevic
- Department of Proteomics, Center for Translational and Clinical Research, University of Zagreb School of Medicine, Zagreb, Croatia
- Biomedical Research Center Salata, University of Zagreb, School of Medicine, Zagreb, Croatia
- Department of Anatomy, ˝Drago Perovic˝, School of Medicine, University of Zagreb, Zagreb, Croatia
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25
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Zeng X, Shi ZW, Yu JJ, Wang LF, Sun CY, Luo YY, Shi PM, Lin Y, Chen YX, Guo J, Zhang CQ, Xie WF. Skeletal muscle alterations indicate poor prognosis in cirrhotic patients: a multicenter cohort study in China. Hepatol Int 2024; 18:673-687. [PMID: 37332023 DOI: 10.1007/s12072-023-10497-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/04/2023] [Indexed: 06/20/2023]
Abstract
INTRODUCTION We aimed to determine the diagnostic criteria of myosteatosis in a Chinese population and investigate the effect of skeletal muscle abnormalities on the outcomes of cirrhotic patients. METHODS Totally 911 volunteers were recruited to determine the diagnostic criteria and impact factors of myosteatosis, and 480 cirrhotic patients were enrolled to verify the value of muscle alterations for prognosis prediction and establish new noninvasive prognostic strategies. RESULTS Multivariate analysis showed age, sex, weight, waist circumference, and biceps circumference had a remarkable influence on the L3 skeletal muscle density (L3-SMD). Based on the cut-off of a mean - 1.28 × SD among adults aged < 60 years, the diagnostic criteria for myosteatosis was L3-SMD < 38.93 Hu in males and L3-SMD < 32.82 Hu in females. Myosteatosis rather than sarcopenia has a close correlation with portal hypertension. The concurrence of sarcopenia and myosteatosis not only is associated with poor liver function but also evidently reduced the overall and liver transplantation-free survival of cirrhotic patients (p < 0.001). According to the stepwise Cox regression hazard model analysis, we established nomograms including TBil, albumin, history of HE, ascites grade, sarcopenia, and myosteatosis for easily determining survival probabilities in cirrhotic patients. The AUC is 0.874 (95% CI 0.800-0.949) for 6-month survival, 0.831 (95% CI 0.764-0.898) for 1-year survival, and 0.813 (95% CI 0.756-0.871) for 2-year survival prediction, respectively. CONCLUSIONS This study provides evidence of the significant correlation between skeletal muscle alterations and poor outcomes of cirrhosis, and establishes valid and convenient nomograms incorporating musculoskeletal disorders for the prognostic prediction of liver cirrhosis. Further large-scale prospective studies are necessary to verify the value of the nomograms.
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Affiliation(s)
- Xin Zeng
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China
| | - Zhi-Wen Shi
- Department of Gastroenterology, Changzheng Hospital, Navy Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Jia-Jun Yu
- Department of Gastroenterology, Changzheng Hospital, Navy Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Li-Fen Wang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Weiqi Road, Jinan, 250021, Shandong, China
| | - Chun-Yan Sun
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China
| | - Yuan-Yuan Luo
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China
| | - Pei-Mei Shi
- Department of Gastroenterology, Changzheng Hospital, Navy Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Yong Lin
- Department of Gastroenterology, Changzheng Hospital, Navy Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Yue-Xiang Chen
- Department of Gastroenterology, Changzheng Hospital, Navy Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Jia Guo
- Department of Ultrasound, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, 528 Zhangheng Road, Pudong New Area, Shanghai, 201203, China.
| | - Chun-Qing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324 Jingwu Weiqi Road, Jinan, 250021, Shandong, China.
| | - Wei-Fen Xie
- Department of Gastroenterology, Changzheng Hospital, Navy Military Medical University, 415 Fengyang Road, Shanghai, 200003, China.
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26
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Namisaki T. Noninvasive assessment of portal hypertension based on the Baveno VII criteria. Hepatol Res 2024; 54:323-325. [PMID: 38407529 DOI: 10.1111/hepr.14028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Affiliation(s)
- Tadashi Namisaki
- Department of Gastroenterology, Nara Medical University, Nara, Japan
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Madir A, Barisic Jaman M, Milosevic M, Dinjar Kujundžić P, Grgurevic I. Improved Applicability and Diagnostic Accuracy of the Novel Spleen-Dedicated Transient Elastography Device for High-Risk Esophageal Varices. Diagnostics (Basel) 2024; 14:743. [PMID: 38611656 PMCID: PMC11011917 DOI: 10.3390/diagnostics14070743] [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: 03/09/2024] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
Spleen stiffness measurement (SSM) by transient elastography (TE) has been repeatedly demonstrated as the reliable way to rule out the presence of high-risk esophageal varices (HRV). We aimed to evaluate and compare novel vs. standard TE-SSM module performance in diagnosing HRV in patients with compensated advanced chronic liver disease (cACLD). This retrospective study included patients with cACLD; blood data, upper digestive endoscopy performed within 3 months of TE, SSM@50Hz and SSM@100Hz were collected. Overall, 112 patients with cACLD were analyzed (75.9% males, average age of 66, 43.7% alcohol-related chronic liver disease, 22.3% metabolic-associated steatotic liver disease, 6.2% viral hepatitis). Reliable SSM was possible in 80.3% and 93.8% of patients by using SSM@50Hz and SSM@100Hz probe, respectively. At the cut-off 41.8 kPa and 40.9 kPa (Youden), SSM@50Hz and SSM@100Hz had AUROCs of 0.746 and 0.752, respectively, for diagnosing HRV (p = 0.71). At the respective cut-offs, sensitivities for HRV were 92.9% and 100%, resulting in misclassification rates of 7.1% and 0% by using SSM@50Hz and SSM@100Hz. SSM reliably excludes HRV in cACLD patients, with measurements below 41 kPa potentially avoiding EGD in around 50% of cases, with minimal risk of HRV omission. SSM@100Hz demonstrated less measurement failures and no HRV misclassification.
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Affiliation(s)
- Anita Madir
- Department of Gastroenterology, Hepatology and Clinical Nutrition, University Hospital Dubrava, 10000 Zagreb, Croatia; (A.M.); (M.B.J.); (P.D.K.)
| | - Mislav Barisic Jaman
- Department of Gastroenterology, Hepatology and Clinical Nutrition, University Hospital Dubrava, 10000 Zagreb, Croatia; (A.M.); (M.B.J.); (P.D.K.)
| | - Marko Milosevic
- Department of Gastroenterology, Hepatology and Clinical Nutrition, University Hospital Dubrava, 10000 Zagreb, Croatia; (A.M.); (M.B.J.); (P.D.K.)
| | - Petra Dinjar Kujundžić
- Department of Gastroenterology, Hepatology and Clinical Nutrition, University Hospital Dubrava, 10000 Zagreb, Croatia; (A.M.); (M.B.J.); (P.D.K.)
| | - Ivica Grgurevic
- Department of Gastroenterology, Hepatology and Clinical Nutrition, University Hospital Dubrava, 10000 Zagreb, Croatia; (A.M.); (M.B.J.); (P.D.K.)
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
- Faculty of Pharmacy and Biochemistry, University of Zagreb, 10000 Zagreb, Croatia
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28
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Busch F, De Paepe KN, Gibbs P, Allison M, Hoare M, See TC. The clinical value of the hepatic venous pressure gradient in patients undergoing hepatic resection for hepatocellular carcinoma with or without liver cirrhosis. Open Med (Wars) 2024; 19:20230851. [PMID: 38584825 PMCID: PMC10996929 DOI: 10.1515/med-2023-0851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/03/2023] [Accepted: 10/27/2023] [Indexed: 04/09/2024] Open
Abstract
The role of hepatic venous pressure gradient (HVPG) measurement in risk stratification before liver resection is an ongoing area of debate. This study examines the impact of preoperative HVPG levels on overall survival (OS)/time to recurrence (TTR) and postoperative complications after hepatic resection of hepatocellular carcinoma (HCC). Thirty-eight HCC patients undergoing HVPG measurement before liver resection at Cambridge University Hospitals NHS Foundation Trust between January 2014 and April 2022 were retrospectively analysed. Statistical analysis comprised univariable/multivariable Cox/logistic regression to identify risk factors of reduced OS/TTR or 90-day post-resection complications and Kaplan-Meier estimator, log-rank, chi-squared, Fisher's exact, and Mann-Whitney U test, or Student's t-test for survival/subgroup analysis. The median HPVG was 6 (range: 0-14) mmHg. The HVPG was an independent risk factor for poorer TTR in the overall cohort (cut-off: ≥7.5 mmHg (17.18/43.81 months; P = 0.009)). In the subgroup analysis of cirrhotic patients (N = 29 (76%)), HVPG was additionally an independent risk factor for lower OS (cut-off: ≥8.5 mmHg [44.39/76.84 months; P = 0.012]). The HVPG had no impact on OS/TTR in non-cirrhotic patients (N = 9 (24%)), nor was it associated with postoperative complications in any cohort. In conclusion, preoperative HVPG levels are useful predictors for TTR and OS in cirrhotic HCC patients undergoing hepatic resection.
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Affiliation(s)
- Felix Busch
- Department of Radiology, Charité – Universitätsmedizin Berlin, Hindenburgdamm 30, Berlin, 12203, Germany
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, CB2 0QQ, United Kingdom
| | - Katja N. De Paepe
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, CB2 0QQ, United Kingdom
| | - Paul Gibbs
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, CB2 0QQ, United Kingdom
| | - Michael Allison
- Department of Hepatology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, CB2 0QQ, United Kingdom
| | - Matthew Hoare
- Department of Hepatology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, CB2 0QQ, United Kingdom
- Early Cancer Institute, University of Cambridge, Hutchison Research Institute, Cambridge, CB2 0XZ, United Kingdom
| | - Teik Choon See
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, CB2 0QQ, United Kingdom
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29
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Vaishnav M, Biswas S, Shenoy A, Pathak P, Anand A, Swaroop S, Aggrawal A, Arora U, Elhence A, Jagannath S, Gunjan D, Kedia S, Mishra AK, Gamanagatti S, Nayak B, Garg P, Shalimar. Comparison of 1-day versus 3-day intravenous terlipressin in cirrhosis patients with variceal bleeding: A pilot randomised controlled trial. Aliment Pharmacol Ther 2024; 59:645-655. [PMID: 38186012 DOI: 10.1111/apt.17868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 10/18/2023] [Accepted: 12/24/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND In cirrhosis patients with acute variceal bleeding (AVB), the optimal duration of vasoconstrictor therapy after endoscopic haemostasis is unclear. AIMS We aimed to compare efficacy of 1-day versus 3-day terlipressin therapy in cirrhosis patients with AVB post-endoscopic intervention. The primary objective was to compare rebleeding at 5 days between the two arms. Secondary objectives included rebleeding and mortality rates at 6 weeks. METHODS In this open-label, randomised controlled trial, cirrhosis patients with AVB were randomised to either 1-day or 3-day terlipressin therapy. RESULTS A total of 150 cirrhosis patients with AVB were recruited to receive either 1 day (n = 75) or 3 days (n = 75) of terlipressin therapy. One patient from 1-day arm was excluded. Modified intention-to-treat analysis included 149 patients. Baseline characteristics were comparable between the two groups. Rebleeding at 5 days: 3 (4.1%; 95% confidence interval [CI]: 0.4-9.0) versus 4 (5.3%; 95% CI: 2.0-10.0), risk difference (RD) p = 0.726 and 5-day mortality rates: 1 (1.4%; 95% CI: 0-7.3) versus 1 (1.3%; 95% CI: 0.2-7.0), RD p = 0.960 were similar. Rebleeding at 42 days: 9 (12.2%; 95% CI: 7.0-20.0) versus 10 (13.3%; 95% CI: 7.0-20.0), RD p = 0.842 and mortality at 42 days: 5 (6.8%; 95% CI: 3.0-10.0) versus 4 (5.3%; 95% CI: 2.0-10.0), RD p = 0.704 were also similar. Patients in the 1-day terlipressin therapy arm experienced significantly fewer adverse effects compared with those receiving 3 days of terlipressin therapy: 28 (37.8%) versus 42 (56%), p = 0.026. CONCLUSIONS Our results suggest that 1 day of terlipressin therapy is associated with similar 5-day and 42-day rebleeding rates, 42-day mortality and an overall superior safety profile compared with 3-day of terlipressin therapy. These findings require to be validated in double-blinded, larger, multiethnic and multicentre studies across the various stages of cirrhosis (CTRI/2019/10/021771).
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Affiliation(s)
- Manas Vaishnav
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Sagnik Biswas
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Abhishek Shenoy
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Piyush Pathak
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Abhinav Anand
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Shekhar Swaroop
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Arnav Aggrawal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Umang Arora
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Soumya Jagannath
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Ashwani Kumar Mishra
- National Drug Dependence Treatment Centre (NDDTC), All India Institute of Medical Sciences, Delhi, India
| | | | - Baibaswata Nayak
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Pramod Garg
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
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Murillo Pineda MI, Siu Xiao T, Sanabria Herrera EJ, Ayala Aguilar A, Arriaga Escamilla D, Aleman Reyes AM, Rojas Marron AD, Fabila Lievano RR, de Jesús Correa Gomez JJ, Martinez Ramirez M. The Prediction and Treatment of Bleeding Esophageal Varices in the Artificial Intelligence Era: A Review. Cureus 2024; 16:e55786. [PMID: 38586705 PMCID: PMC10999134 DOI: 10.7759/cureus.55786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/09/2024] Open
Abstract
Esophageal varices (EVs), a significant complication of cirrhosis, present a considerable challenge in clinical practice due to their high risk of bleeding and associated morbidity and mortality. This manuscript explores the transformative role of artificial intelligence (AI) in the management of EV, particularly in enhancing diagnostic accuracy and predicting bleeding risks. It underscores the potential of AI in offering noninvasive, efficient alternatives to traditional diagnostic methods such as esophagogastroduodenoscopy (EGD). The complexity of EV management is highlighted, necessitating a multidisciplinary approach that includes pharmacological therapy, endoscopic interventions, and, in some cases, surgical options tailored to individual patient profiles. Additionally, the paper emphasizes the importance of integrating AI into medical education and practice, preparing healthcare professionals for the evolving landscape of medical technology. It projects a future where AI significantly influences the management of gastrointestinal bleeding, improving clinical decision-making, patient outcomes, and overall healthcare efficiency. The study advocates for a patient-centered approach in healthcare, balancing the incorporation of innovative technologies with ethical principles and the diverse needs of patients to optimize treatment efficacy and enhance healthcare accessibility.
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Affiliation(s)
| | - Tania Siu Xiao
- Radiology, Thomas Jefferson University Hospital, Philadelphia, USA
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Mukund A, Aravind A, Jindal A, Tevethia HV, Patidar Y, Sarin SK. Predictors and Outcomes of Post-transjugular Intrahepatic Portosystemic Shunt Liver Failure in Patients with Cirrhosis. Dig Dis Sci 2024; 69:1025-1034. [PMID: 38341393 DOI: 10.1007/s10620-023-08256-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/18/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND Post-transjugular intrahepatic portosystemic shunt (TIPS) liver failure (PTLF) is a serious complication of TIPS procedure with poor patient prognosis. This study tried to investigate the incidence of PTLF following elective TIPS procedure and evaluated possible predictive factors for the same. METHODS A retrospective analysis of patients who underwent elective TIPS placement between 2012 and 2022 and was conducted to determine development of PTLF (≥ 3-fold bilirubin and/or ≥ 2-fold INR elevation from the baseline) within 30 days following TIPS procedure. Medical record review was done and factors predicting development of PTLF and the 90-day transplant-free survival was determined. RESULTS Thirty of 352 (8.5%) patients developed PTLF within 30 days of TIPS (mean age 54.2 ± 9.8 years, 83% male). The etiology of cirrhosis was related to non-alcoholic steatohepatitis (NASH) in 50%, alcohol in 33.3%, and hepatitis B/C virus infection in 16.7% of the patients. The mean Child-Turcotte-Pugh (CTP) score was 9.5 ± 1.2 and mean model for end stage liver disease (MELD) score was 14.6 ± 4.5 at the time of admission in patients who developed PTLF. The indication for TIPS was recurrent variceal bleed in 50% (15 of 30) and refractory ascites in 46.7% (14 of 30) patients with PTLF. Multivariate analysis identified prior HE (OR 6.1; CI 2.57-14.5, p < 0.0001) and higher baseline CTP score (OR 1.47; CI 1.07-2.04; p = 0.018) as predictors of PTLF. PTLF was associated with significantly lower 90-day transplant-free survival, as compared to patients without PTLF (40% versus 96%, p < 0.001). CONCLUSION Almost 10% of patients with cirrhosis develop post-TIPS liver failure and is associated with significant early mortality and morbidity. Higher baseline CTP score and prior HE were identified as predictors for PTLF.
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Affiliation(s)
- Amar Mukund
- Department of Intervention Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ashish Aravind
- Department of Intervention Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India.
| | - Harsh Vardhan Tevethia
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India
| | - Yashwant Patidar
- Department of Intervention Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India
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Elhence H, Dodge JL, Lee BP. Association of Renin-Angiotensin System Inhibition With Liver-Related Events and Mortality in Compensated Cirrhosis. Clin Gastroenterol Hepatol 2024; 22:315-323.e17. [PMID: 37495200 PMCID: PMC11232660 DOI: 10.1016/j.cgh.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/26/2023] [Accepted: 07/13/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND & AIMS While renin-angiotensin system inhibition lowers the hepatic venous gradient, the effect on more clinically meaningful endpoints is less studied. We aimed to quantify the relationship between renin-angiotensin system inhibition and liver-related events (LREs) among adults with compensated cirrhosis. METHODS In this national cohort study using the Optum database, we quantified the association between angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) use and LREs (hepatocellular carcinoma, liver transplantation, ascites, hepatic encephalopathy, or variceal bleeding) among patients with cirrhosis between 2009 and 2019. Selective beta-blocker (SBB) users served as the comparator group. We used demographic and clinical features to calculate inverse-probability treatment weighting-weighted cumulative incidences, absolute risk differences, and Cox proportional hazard ratios. RESULTS Among 4214 adults with cirrhosis, 3155 were ACE inhibitor/ARB users and 1059 were SBB users. In inverse probability treatment weighting-weighted analyses, ACE inhibitor/ARB (vs SBB) users had lower 5-year cumulative incidence (30.6% [95% confidence interval (CI), 27.8% to 33.2%] vs 41.3% [95% CI, 34.0% to 47.7%]; absolute risk difference, -10.7% [95% CI, -18.1% to -3.6%]) and lower risk of LREs (adjusted hazard ratio [aHR], 0.69; 95% CI, 0.60 to 0.80). There was a dose-response relationship: compared with SBB use, ACE inhibitor/ARB prescriptions ≥1 defined daily dose (aHR, 0.65; 95% CI, 0.56 to 0.76) were associated with a greater risk reduction compared with <1 defined daily dose (aHR, 0.87; 95% CI, 0.71 to 1.07). Results were robust across sensitivity analyses such as comparing ACE inhibitor/ARB users with nonusers and as-treated analysis. CONCLUSIONS In this national cohort study, ACE inhibitor/ARB use was associated with significantly lower risk of LREs in patients with compensated cirrhosis. These results provide support for a randomized clinical trial to confirm clinical benefit.
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Affiliation(s)
- Hirsh Elhence
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jennifer L Dodge
- Department of Population Public Health Sciences, University of Southern California, Los Angeles, Los Angeles, California; Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California
| | - Brian P Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California.
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Ortega-Lobete O, Clemente-Sánchez A, Bañares R, Rincón D. Hepatic hemodynamic study: More than just HVPG measurement. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:199-205. [PMID: 37028758 DOI: 10.1016/j.gastrohep.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 03/08/2023] [Accepted: 03/26/2023] [Indexed: 04/09/2023]
Abstract
Evaluation and staging of liver disease is essential in the clinical decision-making process of liver tumors. The severity of portal hypertension (PH) is the main prognostic factor in advanced liver disease. Performing an accurate hepatic venous pressure gradient (HVPG) measurement is not always possible, especially when veno-venous communications are present. In those complex cases, a refinement in HVPG measurement with a thorough evaluation of each of the components of PH is mandatory. We aimed at describing how some technical modifications and complementary procedures may contribute to an accurate and complete clinical evaluation to improve therapeutic decisions.
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Affiliation(s)
- Olga Ortega-Lobete
- Hepatology Unit, Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ana Clemente-Sánchez
- Hepatology Unit, Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Rafael Bañares
- Hepatology Unit, Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.
| | - Diego Rincón
- Hepatology Unit, Department of Digestive Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain; Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Alsaeid M, Sung S, Bai W, Tam M, Wong YJ, Cortes J, Cobo E, Gonzalez JA, Abraldes JG. Heterogeneity of treatment response to beta-blockers in the treatment of portal hypertension: A systematic review. Hepatol Commun 2024; 8:e0321. [PMID: 38285880 PMCID: PMC10830085 DOI: 10.1097/hc9.0000000000000321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/28/2023] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND It has been suggested that a relevant proportion of patients do not respond to nonselective beta-blockers (NSBB)s, which raises questions regarding the need for individualized therapy. The existence of potential heterogeneity in the treatment response can be assessed using the variability ratio (VR) of the outcome measurement (in this case, HVPG) between the treated and placebo groups. We conducted a systematic review and meta-analysis of randomized controlled trials to assess the potential heterogeneity in the portal pressure response to NSBBs. METHODS After a systematic search, we quantified the heterogeneity of treatment response with the VR between the treatment and control groups, with VR > 1 indicating potential heterogeneity. We used a similar approach to compare carvedilol with propranolol and statins with placebo. RESULTS We identified 18 studies that included 965 patients. A comparison between beta-blockers and placebo showed a pooled VR of 0.99 (95% CI:0.87-1.14), which suggests a homogeneous HVPG response to NSBB at the individual patient level (ie, no evidence to support that some patients responded to beta-blockers and others did not). For the comparison between carvedilol and propranolol, pooled VR was 0.97 (95% CI 0.82-1.14), suggesting that carvedilol achieves a greater average response (rather than an increase in the proportion of responders). There was no evidence of a heterogeneous response to statins. CONCLUSION Our analysis did not support the existence of a heterogeneous patient-by-patient response to NSBBs in cirrhosis. These findings challenge the concept of personalized therapy based on portal pressure response and indicate that routine portal pressure measurement may not be necessary to guide NSBB therapy.
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Affiliation(s)
- Mohammad Alsaeid
- Liver Unit, Division of Gastroenterology, University of Alberta, Alberta, Canada
| | - Shuen Sung
- Liver Unit, Division of Gastroenterology, University of Alberta, Alberta, Canada
| | - Wayne Bai
- Waikato District Health Board, University of Auckland, Auckland, New Zealand
| | - Matthew Tam
- Liver Unit, Division of Gastroenterology, University of Alberta, Alberta, Canada
| | - Yu Jun Wong
- Liver Unit, Division of Gastroenterology, University of Alberta, Alberta, Canada
| | - Jordi Cortes
- Department of Statistics and Operations Research, Universitat Politècnica de Catalunya, Barcelona-Tech (UPC), Barcelona-Tech, Spain
| | - Erik Cobo
- Department of Statistics and Operations Research, Universitat Politècnica de Catalunya, Barcelona-Tech (UPC), Barcelona-Tech, Spain
| | - Jose Antonio Gonzalez
- Department of Statistics and Operations Research, Universitat Politècnica de Catalunya, Barcelona-Tech (UPC), Barcelona-Tech, Spain
| | - Juan G Abraldes
- Liver Unit, Division of Gastroenterology, University of Alberta, Alberta, Canada
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Madir A, Grgurevic I, Tsochatzis EA, Pinzani M. Portal hypertension in patients with nonalcoholic fatty liver disease: Current knowledge and challenges. World J Gastroenterol 2024; 30:290-307. [PMID: 38313235 PMCID: PMC10835535 DOI: 10.3748/wjg.v30.i4.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 12/19/2023] [Accepted: 01/08/2024] [Indexed: 01/26/2024] Open
Abstract
Portal hypertension (PH) has traditionally been observed as a consequence of significant fibrosis and cirrhosis in advanced non-alcoholic fatty liver disease (NAFLD). However, recent studies have provided evidence that PH may develop in earlier stages of NAFLD, suggesting that there are additional pathogenetic mechanisms at work in addition to liver fibrosis. The early development of PH in NAFLD is associated with hepatocellular lipid accumulation and ballooning, leading to the compression of liver sinusoids. External compression and intra-luminal obstacles cause mechanical forces such as strain, shear stress and elevated hydrostatic pressure that in turn activate mechanotransduction pathways, resulting in endothelial dysfunction and the development of fibrosis. The spatial distribution of histological and functional changes in the periportal and perisinusoidal areas of the liver lobule are considered responsible for the pre-sinusoidal component of PH in patients with NAFLD. Thus, current diagnostic methods such as hepatic venous pressure gradient (HVPG) measurement tend to underestimate portal pressure (PP) in NAFLD patients, who might decompensate below the HVPG threshold of 10 mmHg, which is traditionally considered the most relevant indicator of clinically significant portal hypertension (CSPH). This creates further challenges in finding a reliable diagnostic method to stratify the prognostic risk in this population of patients. In theory, the measurement of the portal pressure gradient guided by endoscopic ultrasound might overcome the limitations of HVPG measurement by avoiding the influence of the pre-sinusoidal component, but more investigations are needed to test its clinical utility for this indication. Liver and spleen stiffness measurement in combination with platelet count is currently the best-validated non-invasive approach for diagnosing CSPH and varices needing treatment. Lifestyle change remains the cornerstone of the treatment of PH in NAFLD, together with correcting the components of metabolic syndrome, using nonselective beta blockers, whereas emerging candidate drugs require more robust confirmation from clinical trials.
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Affiliation(s)
- Anita Madir
- Department of Gastroenterology, Hepatology and Clinical Nutrition, University Hospital Dubrava, Zagreb 10000, Croatia
| | - Ivica Grgurevic
- Department of Gastroenterology, Hepatology and Clinical Nutrition, University Hospital Dubrava, Zagreb 10000, Croatia
- School of Medicine, University of Zagreb, Zagreb 10000, Croatia
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb 10000, Croatia
| | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London NW3 2PF, United Kingdom
| | - Massimo Pinzani
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London NW3 2PF, United Kingdom
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Kotani K, Kawada N. Recent Advances in the Pathogenesis and Clinical Evaluation of Portal Hypertension in Chronic Liver Disease. Gut Liver 2024; 18:27-39. [PMID: 37842727 PMCID: PMC10791512 DOI: 10.5009/gnl230072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/16/2023] [Accepted: 06/25/2023] [Indexed: 10/17/2023] Open
Abstract
In chronic liver disease, hepatic stellate cell activation and degeneration of liver sinusoidal endothelial cells lead to structural changes, which are secondary to fibrosis and the presence of regenerative nodules in the sinusoids, and to functional changes, which are related to vasoconstriction. The combination of such changes increases intrahepatic vascular resistance and causes portal hypertension. The subsequent increase in splanchnic and systemic hyperdynamic circulation further increases the portal blood flow, thereby exacerbating portal hypertension. In clinical practice, the hepatic venous pressure gradient is the gold-standard measure of portal hypertension; a value of ≥10 mm Hg is defined as clinically significant portal hypertension, which is severe and is associated with the risk of liver-related events. Hepatic venous pressure gradient measurement is somewhat invasive, so evidence on the utility of risk stratification by elastography and serum biomarkers is needed. The various stages of cirrhosis are associated with different outcomes. In viral hepatitis-related cirrhosis, viral suppression or elimination by nucleos(t)ide analog or direct-acting antivirals results in recompensation of liver function and portal pressure. However, careful follow-up should be continued, because some cases have residual clinically significant portal hypertension even after achieving sustained virologic response. In this study, we reviewed the current and future prospects for portal hypertension.
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Affiliation(s)
- Kohei Kotani
- Department of Hepatology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Norifumi Kawada
- Department of Hepatology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
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Rabiee A, Rabiee A. Keep beta-blocking and carry on! Clin Liver Dis (Hoboken) 2024; 23:e0114. [PMID: 38304323 PMCID: PMC10833629 DOI: 10.1097/cld.0000000000000114] [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: 05/29/2023] [Accepted: 11/04/2023] [Indexed: 02/03/2024] Open
Affiliation(s)
| | - Atoosa Rabiee
- Veterans Affairs Medical Center, Division of Gastroenterology and HepatologyWashington, District of Columbia, USA
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Bruix J. A history of the treatment of primary liver cancer. Clin Liver Dis (Hoboken) 2024; 23:e0147. [PMID: 38707239 PMCID: PMC11068144 DOI: 10.1097/cld.0000000000000147] [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: 04/04/2023] [Accepted: 05/23/2023] [Indexed: 05/07/2024] Open
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Kumar MS. Paneth cell: The missing link between obesity, MASH and portal hypertension. Clin Res Hepatol Gastroenterol 2024; 48:102259. [PMID: 38070827 DOI: 10.1016/j.clinre.2023.102259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 11/26/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023]
Abstract
Obesity is a global health crisis, with its prevalence steadily rising over the past few decades. One concerning consequence of obesity is its association with metabolic associated steatohepatitis [MASH], portal hypertension and liver cirrhosis. Cirrhosis is irreversible, but stages of liver disease before the development of cirrhosis are reversible with appropriate interventions. Studies have brought into light new entities that influences the pathophysiology of portal hypertension. This review provides evidence supporting that, Paneth cells[PCs] in the intestinal epithelium, which remained enigmatic for a century, are the maneuverer of pathophysiology of portal hypertension and obesity. PC dysfunction can cause perturbation of the intestinal microbiota and changes in intestinal permeability, which are the potential triggers of systemic inflammation. Thus, it can offer unique opportunities to understand the pathophysiology of portal hypertension for intervention strategies.
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Affiliation(s)
- Minu Sajeev Kumar
- Department of Gastroenterology, Government Medical College, Thiruvanathapuram, India.
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Xiong Z, Wang X, Yan Y, Liu Z, Luo X, Zheng T. A streamlined controlled-expansion covered tapered stent for TIPS in the treatment of PHT. J Biomech 2024; 163:111937. [PMID: 38246010 DOI: 10.1016/j.jbiomech.2024.111937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/17/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) relieves cirrhotic complications by reducing portacaval pressure gradient (PCG), but it lacks precision in achieving a targeted post-TIPS PCG simply through diameter adjustment of equal diameter stents. This study aimed to present a controlled-expansion, streamlined, and covered tapered stent, and examined its effects on pressure reduction compared with equal- diameter stents. Twenty-four patients who underwent standardized 8-mm stent TIPS implantation at West China Hospital from December 2017 to February 2021 were included in the current study. Virtual equal-diameter stent graft with different diameter and streamlined tapered stents were created in the post-TIPS 3-dimentional models reconstructed based on computed tomography angiography data. The numerical simulation showed that only two patients achieved targeted post-TIPS PCG consistent with the clinical invasive measurement. When 6-mm and 10-mm equal-diameter stents were employed, simulated post-TIPS PCGs for most patients remained outside the safe range, and recirculating flow was observed at the stent-portal vein anastomosis. In contrast, the use of the new streamlined taper stent resulted in post-TIPS PCGs within the 10-12 mmHg range for 17 out of 24 patients, with no recirculating flow observed at the anastomotic sites. In conclusion, the streamlined tapered stent could pose an effective solution to the problem that the big jump depressurization between two different equal-diameter stents and it would improve the hemodynamics in the region near the PV-stent anchorage. Therefore, the streamlined tapered stent may present a superior alternative for TIPS procedure.
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Affiliation(s)
- Zhuxiang Xiong
- Department of Mechanics & Engineering, College of Architecture & Environment, Sichuan University, Chengdu 610065, China; Sichuan University Yibin Park/Yibin Institute of Industrial Technology, Yibin 644000, China
| | - Xiaoze Wang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu 610041, China
| | - Yuling Yan
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu 610041, China
| | - Zhan Liu
- Department of Mechanics & Engineering, College of Architecture & Environment, Sichuan University, Chengdu 610065, China; Sichuan University Yibin Park/Yibin Institute of Industrial Technology, Yibin 644000, China
| | - Xuefeng Luo
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu 610041, China
| | - Tinghui Zheng
- Department of Mechanics & Engineering, College of Architecture & Environment, Sichuan University, Chengdu 610065, China; West China Information Center, Sichuan University, Chengdu 610065, China.
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Liu S, Ma J, Chen P, Liu S, Guo Y, Tan M, Guo X, Feng Y, Wang Q, Li W, Yang C, Gao B, Hua Y, Liu N, Song H, He R, Wang R, Gao Q, Liu C, Qi X. Novel serum biomarker of Golgi protein 73 for the diagnosis of clinically significant portal hypertension in patients with compensated cirrhosis. J Med Virol 2024; 96:e29380. [PMID: 38235849 DOI: 10.1002/jmv.29380] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 12/17/2023] [Accepted: 12/28/2023] [Indexed: 01/19/2024]
Abstract
Hepatic venous pressure gradient (HVPG) is the gold standard for evaluating clinically significant portal hypertension (CSPH). However, reliable noninvasive methods are limited. Our study aims to investigate the diagnostic value of serum Golgi protein 73 (GP73) for CSPH in patients with compensated cirrhosis. The study enrolled 262 consecutive patients with compensated cirrhosis from three centers in China from February 2021 to September 2023, who underwent both serum GP73 tests and HVPG measurements. CSPH was defined as HVPG ≥ 10 mmHg. Diagnostic accuracy was evaluated using the areas under the receiver operating characteristic curve (AUC). The prevalence of CSPH was 56.9% (n = 149). There were significant differences between the CSPH and non-CSPH groups in the median serum GP73 level (126.8 vs. 73.1 ng/mL, p < 0.001). GP73 level showed a significant positive linear correlation with HVPG (r = 0.459, p < 0.001). The AUC for the diagnosis of CSPH using serum GP73 alone was 0.75 (95% confidence interval [CI] 0.68-0.81). Multivariate logistic regression analysis determined that the levels of GP73, platelets and international normalized ratio were independently associated with CSPH. The combination of these three markers was termed "IP73" score with an AUC value of 0.85 (95% CI 0.80-0.89) for CSPH. Using 0 as a cut-off value, the specificity and sensitivity of IP73 score were 77.9% and 81.9%, respectively. The IP73 score offers a novel, simple and noninvasive method of assessing CSPH in patients with compensated cirrhosis. A cut-off value of the IP73 score at 0 can distinguish patients with or without CSPH.
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Affiliation(s)
- Shanghao Liu
- Center of Portal Hypertension, Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
- Basic Medicine Research and Innovation Center of Ministry of Education, Zhongda Hospital, Southeast University, Nanjing, China
| | - Jianzhong Ma
- Department of General Surgery, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Ping Chen
- Department of infectious diseases, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, China
| | - Shirong Liu
- Department of Infectious Diseases, Qufu People's Hospital, Qufu, China
| | - Ying Guo
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Mingjie Tan
- Department of Gastrointestinal and Hepatology, Beijing You'An Hospital, Capital Medical University, Beijing, China
| | - Xiaoqing Guo
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Yinong Feng
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Qinghui Wang
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Wenhua Li
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Chengchen Yang
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Bo Gao
- Medical Laboratory, Qufu People's Hospital, Qufu, China
| | - Yongli Hua
- Department of Hepatology, The Third People's Hospital of Taiyuan, Taiyuan, China
| | - Ning Liu
- Department of Infectious Diseases, Qufu People's Hospital, Qufu, China
| | - Haolin Song
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Ruiling He
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Ruiying Wang
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Qi Gao
- Beijing Key Laboratory of POCT for Bioemergency and Clinic (No. BZ0329); Beijing Hotgen Biotechnology Inc., Beijing, China
| | - Chuan Liu
- Center of Portal Hypertension, Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
- Basic Medicine Research and Innovation Center of Ministry of Education, Zhongda Hospital, Southeast University, Nanjing, China
| | - Xiaolong Qi
- Center of Portal Hypertension, Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
- Basic Medicine Research and Innovation Center of Ministry of Education, Zhongda Hospital, Southeast University, Nanjing, China
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Martino A, Amitrano L, Guardascione M, Di Serafino M, Bennato R, Martino R, de Leone A, Orsini L, Romano L, Lombardi G. The role of computed tomography for the prediction of esophageal variceal bleeding: Current status and future perspectives. World J Gastrointest Endosc 2023; 15:681-689. [PMID: 38187916 PMCID: PMC10768040 DOI: 10.4253/wjge.v15.i12.681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/13/2023] [Accepted: 11/27/2023] [Indexed: 12/15/2023] Open
Abstract
Esophageal variceal bleeding (EVB) is one of the most common and severe complications related to portal hypertension (PH). Despite marked advances in its management during the last three decades, EVB is still associated with significant morbidity and mortality. The risk of first EVB is related to the severity of both PH and liver disease, and to the size and endoscopic appearance of esophageal varices. Indeed, hepatic venous pressure gradient (HVPG) and esophagogastroduodenoscopy (EGD) are currently recognized as the “gold standard” and the diagnostic reference standard for the prediction of EVB, respectively. However, HVPG is an invasive, expensive, and technically complex procedure, not widely available in clinical practice, whereas EGD is mainly limited by its invasive nature. In this scenario, computed tomography (CT) has been recently proposed as a promising modality for the non-invasive prediction of EVB. Although CT is only a diagnostic modality, thus being not capable of supplanting EGD or HVPG in providing therapeutic and physiological data, it could potentially assist liver disease scores, HVPG, and EGD in a more effective prediction of EVB. However, to date, evidence concerning the role of CT in this setting is still lacking. Our review aimed to summarize and discuss the current evidence concerning the role of CT in predicting the risk of EVB.
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Affiliation(s)
- Alberto Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Lucio Amitrano
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Marianna Guardascione
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Marco Di Serafino
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Raffaele Bennato
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Rossana Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Annalisa de Leone
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Luigi Orsini
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Luigia Romano
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Giovanni Lombardi
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
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Stankevic E, Israelsen M, Juel HB, Madsen AL, Ängquist L, Aldiss PSJ, Torp N, Johansen S, Hansen CD, Hansen JK, Thorhauge KH, Lindvig KP, Madsen BS, Sulek K, Legido-Quigley C, Thiele MS, Krag A, Hansen T. Binge drinking episode causes acute, specific alterations in systemic and hepatic inflammation-related markers. Liver Int 2023; 43:2680-2691. [PMID: 37592403 DOI: 10.1111/liv.15692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/07/2023] [Accepted: 07/31/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Frequent binge drinking is a known contributor to alcohol-related harm, but its impact on systemic and hepatic inflammation is not fully understood. We hypothesize that changes in immune markers play a central role in adverse effects of acute alcohol intake, especially in patients with early liver disease. AIM To investigate the effects of acute alcohol intoxication on inflammation-related markers in hepatic and systemic venous plasma in people with alcohol-related liver disease (ArLD), non-alcoholic fatty liver disease (NAFLD) and healthy controls. METHODS Thirty-eight participants (13 with ArLD, 15 with NAFLD and 10 healthy controls) received 2.5 mL of 40% ethanol per kg body weight via a nasogastric tube. Seventy-two inflammation-related markers were quantified in plasma from hepatic and systemic venous blood, at baseline, 60 and 180 min after intervention. RESULTS Alcohol intervention altered the levels of 31 of 72 and 14 of 72 markers in the systemic and hepatic circulation. All changes observed in the hepatic circulation were also identified in the systemic circulation after 180 min. Only FGF21 and IL6 were increased after alcohol intervention, while the remaining 29 markers decreased. Differences in response to acute alcohol between the groups were observed for 8 markers, and FGF21 response was blunted in individuals with steatosis. CONCLUSION Acute alcohol intoxication induced changes in multiple inflammation-related markers, implicated in alcohol metabolism and hepatocellular damage. Differences identified between marker response to binge drinking in ArLD, NAFLD and healthy controls may provide important clues to disease mechanisms and potential targets for treatment. CLINICAL TRIAL NUMBER NCT03018990.
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Affiliation(s)
- Evelina Stankevic
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Mads Israelsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Helene Baek Juel
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Anne Lundager Madsen
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Lars Ängquist
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Peter Stuart Jacob Aldiss
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Nikolaj Torp
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Stine Johansen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Camilla Dalby Hansen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Johanne Kragh Hansen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Katrine Holtz Thorhauge
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Katrine Prier Lindvig
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Bjørn Staehr Madsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | | | | | - Maja Sofie Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
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44
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Chooklin S, Chuklin S. Methods for assessing portal hypertension. EMERGENCY MEDICINE 2023; 19:393-401. [DOI: 10.22141/2224-0586.19.6.2023.1618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Many researchers and clinicians have taken the value of hepatic venous pressure gradient (HVPG) as an essential prognostic factor in subjects with chronic liver diseases. HVPG ≥ 10 mmHg indicates the presence of clinically significant portal hypertension, the main predictor of the risk of variceal bleeding, hepatic decompensation, and mortality. However, HVPG measurement is invasive and requires high expertise, so its routine use outside tertiary care centers or clinical trials is limited. Clinically significant portal hypertension also might be detected using non-invasive options such as ultrasonography, elastography, magnetic resonance imaging, and indices derived from laboratory parameters. Our review aims to present the feasibility and applicability of HVPG in modern clinical practice in patients with liver cirrhosis, including invasive and non-invasive methods, based on literary sources from the MEDLINE database.
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45
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Jain AK, Bundiwal AK, Jain S, Agrawal P, Jain D, Sircar S. Evaluation of liver and splenic stiffness by acoustic radiation force impulse for assessment of esophageal varices. Indian J Gastroenterol 2023:10.1007/s12664-023-01456-3. [PMID: 37930496 DOI: 10.1007/s12664-023-01456-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/02/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND In routine clinical practice, assessment of portal hypertension (PHT) among patients with liver cirrhosis is done by a upper gastrointestinal endoscopy (UGIE); however, its invasive nature limits its use. Recent advances in ultrasound imaging make it possible to evaluate the tissue stiffness of the liver and spleen reflecting the severity of underlying fibrosis. Liver stiffness and spleen stiffness can be used to predict the presence of esophageal varices/PHT among cirrhotic patients. AIM To predict the presence or absence of esophageal varices by measuring the stiffness of the liver and spleen by ultrasonography (USG)-based acoustic radiation force impulse (ARFI). METHODS This cross-sectional study included 90 subjects with liver cirrhosis. Liver and splenic stiffness were measured along with the USG abdomen, UGIE and aspartate aminotransferase to platelet ratio index (APRI). RESULTS Liver and spleen stiffness were significantly higher in cirrhotic patients compared to chronic hepatitis B. The best cut-off value of liver stiffness (LS) obtained by the receiver operating characteristic (ROC) curve was 2.16 m/s for predicting esophageal varices (AUROC 0.78, p 0.0002). The best cut-off value of splenic stiffness (SS) obtained by the ROC curve was 3.04 m/s for predicting esophageal varices (AUROC 0.698, p 0.0274). When both LS and SS were taken together, the accuracy in predicting esophageal varices increased to 92.22%. An equation to predict "esophageal varices = (0.225 LS + 0.377SS) - 0.555" was derived. CONCLUSION LS and SS values of ≥ 2.16 m/s and 3.04 m/s, respectively, predict esophageal varices independently; however, combined assessment is better with 92% accuracy.
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Affiliation(s)
- Ajay K Jain
- Department of Gastroenterology, Choithram Hospital and Research Centre, Indore, 452 014, India.
| | - Amit K Bundiwal
- Department of Gastroenterology, Choithram Hospital and Research Centre, Indore, 452 014, India
| | - Suchita Jain
- Department of Radiodiagnosis and Imaging, Choithram Hospital and Research Centre, Indore, 452 014, India
| | - Praveen Agrawal
- Department of Radiodiagnosis and Imaging, Choithram Hospital and Research Centre, Indore, 452 014, India
| | - Deepika Jain
- Department of Biostatistics, Choithram Hospital and Research Centre, Indore, 452 014, India
| | - Shohini Sircar
- Department of Gastroenterology, Choithram Hospital and Research Centre, Indore, 452 014, India
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Torres Rojas AM, Lorente S. Liver fibrosis emulation: Impact of the vascular fibrotic alterations on hemodynamics. Comput Biol Med 2023; 166:107563. [PMID: 37852110 DOI: 10.1016/j.compbiomed.2023.107563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/10/2023] [Accepted: 10/10/2023] [Indexed: 10/20/2023]
Abstract
The liver circulatory system comprises two blood supply vascular trees (the hepatic artery and portal venous networks), microcirculation through the hepatic capillaries (the sinusoids), and a blood drainage vascular tree (the hepatic vein network). Vasculature changes due to fibrosis -located predominantly at the microcirculation level- lead to a marked increase in resistance to flow causing an increase in portal pressure (portal hypertension). Here, we present a liver fibrosis/cirrhosis model. We build on our 1D model of the healthy hepatic circulation, which considers the elasticity of the vessels walls and the pulsatile character of blood flow and pressure, and recreate the deteriorated liver vasculature due to fibrosis. We emulate altered sinusoids by fibrous tissue (stiffened, compressed and splitting) and propose boundary conditions to investigate the impact of fibrosis on hemodynamic variables within the organ. We obtain that the sinusoids stiffness leads to changes in the amplitude and shape of the blood flow and pressure waveforms but not in their mean value. For the compressed and splitting sinusoids, we observe significant increases in the mean value and amplitude of the pressure waveform in the altered sinusoids and in the portal venous network. In other words, we obtain the portal hypertension clinically observed in fibrotic/cirrhotic patients. We also study the extent of the spreading fibrosis by performing the structural fibrotic changes in an increasingly number of sinusoids. Finally, we calculate the portal pressure gradient (PPG) in the model and obtain values in agreement with those reported in the literature for fibrotic/cirrhotic patients.
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Affiliation(s)
- Aimee M Torres Rojas
- Mechanical Engineering Department, Villanova University, 800 Lancaster Avenue, Villanova, PA, 19085, USA.
| | - Sylvie Lorente
- Mechanical Engineering Department, Villanova University, 800 Lancaster Avenue, Villanova, PA, 19085, USA
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Nishio T, Taura K, Koyama Y, Ishii T, Hatano E. Current status of preoperative risk assessment for posthepatectomy liver failure in patients with hepatocellular carcinoma. Ann Gastroenterol Surg 2023; 7:871-886. [PMID: 37927928 PMCID: PMC10623981 DOI: 10.1002/ags3.12692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/08/2023] [Accepted: 05/03/2023] [Indexed: 11/07/2023] Open
Abstract
Liver resection is an effective therapeutic option for patients with hepatocellular carcinoma. However, posthepatectomy liver failure (PHLF) remains a major cause of hepatectomy-related mortality, and the accurate prediction of PHLF based on preoperative assessment of liver functional reserve is a critical issue. The definition of PHLF proposed by the International Study Group for Liver Surgery has gained acceptance as a standard grading criterion. Liver function can be estimated using a variety of parameters, including routine blood biochemical examinations, clinical scoring systems, dynamic liver function tests, liver stiffness and fibrosis markers, and imaging studies. The Child-Pugh score and model for end-stage liver disease scores are conventionally used for estimating liver decompensation, although the alternatively developed albumin-bilirubin score shows superior performance for predicting hepatic dysfunction. Indocyanine green clearance, a dynamic liver function test mostly used in Japan and other Asian countries, serves as a quantitative estimation of liver function reserve and helps determine indications for surgical procedures according to the estimated risk of PHLF. In an attempt to improve predictive accuracy, specific evaluation of liver fibrosis and portal hypertension has gained popularity, including liver stiffness measurements using ultrasonography or magnetic resonance elastography, as well as noninvasive fibrosis markers. Imaging modalities, including Tc-99m-labeled galactosyl serum albumin scintigraphy and gadolinium-enhanced magnetic resonance imaging, are used for preoperative evaluation in combination with liver volume. This review aims to provide an overview of the usefulness of current options for the preoperative assessment of liver function in predicting PHLF.
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Affiliation(s)
- Takahiro Nishio
- Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Kojiro Taura
- Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
- Department of Gastroenterological Surgery and OncologyKitano HospitalOsakaJapan
| | - Yukinori Koyama
- Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Takamichi Ishii
- Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
| | - Etsuro Hatano
- Department of Surgery, Graduate School of MedicineKyoto UniversityKyotoJapan
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Mitten EK, Portincasa P, Baffy G. Portal Hypertension in Nonalcoholic Fatty Liver Disease: Challenges and Paradigms. J Clin Transl Hepatol 2023; 11:1201-1211. [PMID: 37577237 PMCID: PMC10412712 DOI: 10.14218/jcth.2023.00029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/04/2023] [Accepted: 05/17/2023] [Indexed: 07/03/2023] Open
Abstract
Portal hypertension in cirrhosis is defined as an increase in the portal pressure gradient (PPG) between the portal and hepatic veins and is traditionally estimated by the hepatic venous pressure gradient (HVPG), which is the difference in pressure between the free-floating and wedged positions of a balloon catheter in the hepatic vein. By convention, HVPG≥10 mmHg indicates clinically significant portal hypertension, which is associated with adverse clinical outcomes. Nonalcoholic fatty liver disease (NAFLD) is a common disorder with a heterogeneous clinical course, which includes the development of portal hypertension. There is increasing evidence that portal hypertension in NAFLD deserves special considerations. First, elevated PPG often precedes fibrosis in NAFLD, suggesting a bidirectional relationship between these pathological processes. Second, HVPG underestimates PPG in NAFLD, suggesting that portal hypertension is more prevalent in this condition than currently believed. Third, cellular mechanoresponses generated early in the pathogenesis of NAFLD provide a mechanistic explanation for the pressure-fibrosis paradigm. Finally, a better understanding of liver mechanobiology in NAFLD may aid in the development of novel pharmaceutical targets for prevention and management of this disease.
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Affiliation(s)
- Emilie K. Mitten
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Piero Portincasa
- Division of Internal Medicine and Department of Precision and Regenerative Medicine and Ionian Area, University ‘Aldo Moro’ Medical School, Bari, Italy
| | - György Baffy
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Section of Gastroenterology, Department of Medicine, VA Boston Healthcare System, Boston, MA, USA
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49
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Gaspar R, Silva M, Cardoso P, Goncalves R, Andrade P, Macedo G. Spleen stiffness: a new tool to predict high-risk varices in cirrhotic patients. J Gastroenterol Hepatol 2023; 38:1840-1846. [PMID: 37655720 DOI: 10.1111/jgh.16344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 07/23/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023]
Abstract
INTRODUCTION Cirrhosis is one of the major causes of morbidity and mortality worldwide. Portal hypertension is the major contributor of cirrhosis-related complications and is defined as a hepatic venous pressure gradient (HVPG) > 5 mmHg. Measurement of HVPG is an invasive, difficult, and costly procedure. Therefore, it is only performed in specialized centers. Liver stiffness measured with transient elastography is one of the most studied noninvasive markers of portal hypertension, and spleen elastography has recently emerged as an important adjuvant tool. The development of a new probe (100 Hz) that more reliably reflect the grade of portal hypertension evaluated by spleen stiffness measurement has improved the accuracy of this technique. The aim of this work was to evaluate the accuracy of spleen stiffness with the new dedicated probe to predict the presence of high-risk varices, as well as to determine the ideal cutoff to predict it. METHODS Prospective study of cirrhotic patients admitted to upper endoscopy that were also submitted to liver and spleen elastography with the 100-Hz probe by the same blinded operator in a tertiary center. RESULTS We included 209 cirrhotic patients, with mean age of 61.9 years (±9.9), 77.0% male. The most common etiology was alcoholic liver disease (72.7%). The median value of liver elastography was 25.3 [4.5-75] kPa, and the median value of spleen elastography was 42.4 [7.6-100] kPa. At the cutoff of 53.25 kPa, we obtained sensitivity of 100% and specificity of 72.6% to predict high-risk varices, and, according to this cutoff, 133/175 of esophagogastroduodenoscopy could have been spared (76.0%), while according to Baveno guidelines, only 51/175 would have been spared (29.1%). CONCLUSION In the era of noninvasive exams, spleen elastography with the 100-Hz probe emerges as an excellent tool for prediction of presence of high-risk varices. At the cutoff of 53.25 kPa, spleen elastography avoids upper endoscopy for screening for high-risk varices, promising to be become part of the hepatologists' daily routine.
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Affiliation(s)
- Rui Gaspar
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Marco Silva
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Pedro Cardoso
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Raquel Goncalves
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Patrícia Andrade
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar São João, Faculty of Medicine of the University of Porto, Porto, Portugal
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50
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Zhou J, Sun H, Wang Z, Cong W, Zeng M, Zhou W, Bie P, Liu L, Wen T, Kuang M, Han G, Yan Z, Wang M, Liu R, Lu L, Ren Z, Zeng Z, Liang P, Liang C, Chen M, Yan F, Wang W, Hou J, Ji Y, Yun J, Bai X, Cai D, Chen W, Chen Y, Cheng W, Cheng S, Dai C, Guo W, Guo Y, Hua B, Huang X, Jia W, Li Q, Li T, Li X, Li Y, Li Y, Liang J, Ling C, Liu T, Liu X, Lu S, Lv G, Mao Y, Meng Z, Peng T, Ren W, Shi H, Shi G, Shi M, Song T, Tao K, Wang J, Wang K, Wang L, Wang W, Wang X, Wang Z, Xiang B, Xing B, Xu J, Yang J, Yang J, Yang Y, Yang Y, Ye S, Yin Z, Zeng Y, Zhang B, Zhang B, Zhang L, Zhang S, Zhang T, Zhang Y, Zhao M, Zhao Y, Zheng H, Zhou L, Zhu J, Zhu K, Liu R, Shi Y, Xiao Y, Zhang L, Yang C, Wu Z, Dai Z, Chen M, Cai J, Wang W, Cai X, Li Q, Shen F, Qin S, Teng G, Dong J, Fan J. Guidelines for the Diagnosis and Treatment of Primary Liver Cancer (2022 Edition). Liver Cancer 2023; 12:405-444. [PMID: 37901768 PMCID: PMC10601883 DOI: 10.1159/000530495] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/24/2023] [Indexed: 10/31/2023] Open
Abstract
Background Primary liver cancer, of which around 75-85% is hepatocellular carcinoma in China, is the fourth most common malignancy and the second leading cause of tumor-related death, thereby posing a significant threat to the life and health of the Chinese people. Summary Since the publication of Guidelines for Diagnosis and Treatment of Primary Liver Cancer in China in June 2017, which were updated by the National Health Commission in December 2019, additional high-quality evidence has emerged from researchers worldwide regarding the diagnosis, staging, and treatment of liver cancer, that requires the guidelines to be updated again. The new edition (2022 Edition) was written by more than 100 experts in the field of liver cancer in China, which not only reflects the real-world situation in China but also may reshape the nationwide diagnosis and treatment of liver cancer. Key Messages The new guideline aims to encourage the implementation of evidence-based practice and improve the national average 5-year survival rate for patients with liver cancer, as proposed in the "Health China 2030 Blueprint."
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Affiliation(s)
- Jian Zhou
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Huichuan Sun
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zheng Wang
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenming Cong
- Department of Pathology, The Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Mengsu Zeng
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weiping Zhou
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Ping Bie
- Institute of Hepatobiliary Surgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Lianxin Liu
- Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Tianfu Wen
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Ming Kuang
- Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Zhiping Yan
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Maoqiang Wang
- Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, China
| | - Ruibao Liu
- Department of Interventional Radiology, The Tumor Hospital of Harbin Medical University, Harbin, China
| | - Ligong Lu
- Department of Interventional Oncology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhenggang Ren
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhaochong Zeng
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ping Liang
- Department of Interventional Ultrasound, Chinese PLA General Hospital, Beijing, China
| | - Changhong Liang
- Department of Radiology, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Min Chen
- Editorial Department of Chinese Journal of Digestive Surgery, Chongqing, China
| | - Fuhua Yan
- Department of Radiology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wenping Wang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jinlin Hou
- Department of Infectious Diseases, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuan Ji
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jingping Yun
- Department of Pathology, Tumor Prevention and Treatment Center, Sun Yat-sen University, Guangzhou, China
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Dingfang Cai
- Department of Integrative Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weixia Chen
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, China
| | - Yongjun Chen
- Department of Hematology, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenwu Cheng
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Shuqun Cheng
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Chaoliu Dai
- Department of Hepatobiliary and Spleenary Surgery, The Affiliated Shengjing Hospital, China Medical University, Shenyang, China
| | - Wengzhi Guo
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yabing Guo
- Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Baojin Hua
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaowu Huang
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weidong Jia
- Department of Hepatic Surgery, Affiliated Provincial Hospital, Anhui Medical University, Hefei, China
| | - Qiu Li
- Department of Oncology, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Li
- Department of General Surgery, Qilu Hospital, Shandong University, Jinan, China
| | - Xun Li
- The First Hospital of Lanzhou University, Lanzhou, China
| | - Yaming Li
- Department of Nuclear Medicine, The First Hospital of China Medical University, Shenyang, China
| | - Yexiong Li
- Department of Radiation Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Liang
- Department of Oncology, Peking University International Hospital, Beijing, China
| | - Changquan Ling
- Changhai Hospital of Traditional Chinese Medicine, Second Military Medical University, Shanghai, China
| | - Tianshu Liu
- Department of Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiufeng Liu
- Department of Medical Oncology, PLA Cancer Center, Nanjing Bayi Hospital, Nanjing, China
| | - Shichun Lu
- Institute and Hospital of Hepatobiliary Surgery of Chinese PLA, Chinese PLA Medical School, Chinese PLA General Hospital, Beijing, China
| | - Guoyue Lv
- Department of General Surgery, The First Hospital of Jilin University, Jilin, China
| | - Yilei Mao
- Department of Liver Surgery, Peking Union Medical College (PUMC) Hospital, PUMC and Chinese Academy of Medical Sciences, Beijing, China
| | - Zhiqiang Meng
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Tao Peng
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Weixin Ren
- Department of Interventional Radiology the First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Hongcheng Shi
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guoming Shi
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ming Shi
- Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Tianqiang Song
- Department of Hepatobiliary Surgery, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Kaishan Tao
- Department of Hepatobiliary Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Jianhua Wang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kui Wang
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Lu Wang
- Department of Hepatic Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Wentao Wang
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Xiaoying Wang
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhiming Wang
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, China
| | - Bangde Xiang
- Department of Hepatobiliary Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, China
| | - Baocai Xing
- Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital and Institute, Beijing, China
| | - Jianming Xu
- Department of Gastrointestinal Oncology, Affiliated Hospital Cancer Center, Academy of Military Medical Sciences, Beijing, China
| | - Jiamei Yang
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Jianyong Yang
- Department of Interventional Oncology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yefa Yang
- Department of Hepatic Surgery and Interventional Radiology, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Yunke Yang
- Department of Integrative Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shenglong Ye
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhenyu Yin
- Department of Hepatobiliary Surgery, Zhongshan Hospital of Xiamen University, Xiamen, China
| | - Yong Zeng
- Department of Liver Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Bixiang Zhang
- Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Boheng Zhang
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Leida Zhang
- Department of Hepatobiliary Surgery Institute, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Shuijun Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, ZhengZhou, China
| | - Ti Zhang
- Department of Hepatic Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai, China
| | - Yanqiao Zhang
- Department of Gastrointestinal Medical Oncology, The Affiliated Tumor Hospital of Harbin Medical University, Harbin, China
| | - Ming Zhao
- Minimally Invasive Interventional Division, Liver Cancer Group, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Yongfu Zhao
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, ZhengZhou, China
| | - Honggang Zheng
- Department of Oncology, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ledu Zhou
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Jiye Zhu
- Department of Hepatobiliary Surgery, Peking University People’s Hospital, Beijing, China
| | - Kangshun Zhu
- Department of Minimally Invasive Interventional Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Rong Liu
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yinghong Shi
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yongsheng Xiao
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lan Zhang
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chun Yang
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhifeng Wu
- Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhi Dai
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Minshan Chen
- Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jianqiang Cai
- Department of Abdominal Surgical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weilin Wang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiujun Cai
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qiang Li
- Department of Hepatobiliary Surgery, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Feng Shen
- The Third Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Shukui Qin
- Department of Medical Oncology, PLA Cancer Center, Nanjing Bayi Hospital, Nanjing, China
| | - Gaojun Teng
- Department of Radiology, Zhongda Hospital, Medical School, Southeast University, Nanjing, China
| | - Jiahong Dong
- Department of Hepatobiliary and Pancreas Surgery, Beijing Tsinghua Changgung Hospital (BTCH), School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jia Fan
- Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
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