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Tu W, Liangpunsakul S, Nguyen CM, Healey R, Li Y, Radaeva S, Gawrieh S, Bataller R, Su J. Risk of mortality among patients with alcohol-associated hepatitis in the US from 2007 to 2021. Alcohol 2024; 120:143-150. [PMID: 38908609 PMCID: PMC11405091 DOI: 10.1016/j.alcohol.2024.06.006] [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: 04/03/2024] [Revised: 05/23/2024] [Accepted: 06/16/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND/AIMS Alcohol-associated hepatitis (AH) mortality and risk factors have not been carefully studied in real-world settings. We examined the rate, temporal trend, and risk factors of mortality in AH. METHODS We conducted a cohort study of individuals with AH diagnoses using medical claims data from Optum's Clinformatics® Data Mart (CDM). Participants were individuals covered by Medicare Advantage and commercial insurance policies. Cases were identified using diagnostic codes. Cox regressions were used to estimate 90 and 180-day mortality rates by hospitalization status. RESULTS The cohort included 32,001 patients (72% men) who had at least one year of continuous insurance coverage prior to AH diagnoses. Of these, 20,912 were hospitalized within seven days of diagnosis. Ninety and 180-day mortality rates were 12.0% (95% CI [11.6%, 12.5%]) and 16.0% (95% CI [15.4%, 16.5%]), respectively, for the hospitalized patients and 3.1% (95% CI [2.8%, 3.4%]) and 5.1% (95% CI [4.6%, 5.5%]) for the non-hospitalized patients. Pre-existing liver disease, even in a mild form, was associated with an increased risk of death. In hospitalized patients, a history of mild liver disease was associated with a 24% increase in 180-day mortality risk (HR = 1.24, 95% CI: [1.14, 1.36]). Moderate-to-severe liver disease was associated with a more than doubled risk (HR = 2.33, 95% CI: [2.12, 2.56]). CONCLUSIONS History of liver disease was associated with significantly increased AH mortality. The finding highlights the chronic disease context of AH and suggests that prior diagnosis of liver disease should be considered for prognosis and targeted prevention.
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Affiliation(s)
- Wanzhu Tu
- Department of Biostatistics & Health Data, Indiana University School of Medicine, Indianapolis, IN 46202, USA; Regenstrief Institute, Inc., Indianapolis, IN 46202, USA
| | - Suthat Liangpunsakul
- Roudebush Veterans Administration Medical Center, Indianapolis, IN 46202, USA; Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
| | - Chi Mai Nguyen
- Department of Biostatistics & Health Data, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Ryan Healey
- Department of Biostatistics & Health Data, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Yang Li
- Department of Biostatistics & Health Data, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Svetlana Radaeva
- National Institute of Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Samer Gawrieh
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | | | - Jing Su
- Department of Biostatistics & Health Data, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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2
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Hardesty JE, McClain CJ. Current Pharmacotherapy and Nutrition Therapy of Alcohol-Associated Liver Disease. Clin Liver Dis 2024; 28:731-745. [PMID: 39362718 DOI: 10.1016/j.cld.2024.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2024]
Abstract
Patients with alcohol-associated liver disease (ALD) consume large amounts of empty calories and are at risk for malnutrition. Malnutrition can present with micro- or macro-nutrient deficiencies. The standard-of-care drug treatment for severe alcohol-associated hepatitis (AH) is corticosteroids. While still in the standard treatment there are limitations in efficacy and certain patients do not respond to treatment (Lille score ≥.45). This article will focus on important concepts related to nutrition and ALD and on recent findings on predicting corticosteroid response and prognosis for AH patients.
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Affiliation(s)
- Josiah E Hardesty
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY, USA; Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Craig J McClain
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY, USA; Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Louisville, Louisville, KY, USA; University of Louisville Alcohol Center, University of Louisville School of Medicine, Louisville, KY, USA; Robley Rex Veterans Medical Center, Louisville, KY, USA; University of Louisville Hepatobiology & Toxicology Center, University of Louisville School of Medicine, Louisville, KY, USA.
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3
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Witkiewitz K, Fernandez AC, Green EW, Mellinger JL. Diagnosis of Alcohol Use Disorder and Alcohol-Associated Liver Disease. Clin Liver Dis 2024; 28:699-713. [PMID: 39362716 DOI: 10.1016/j.cld.2024.06.009] [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: 10/05/2024]
Abstract
Harmful alcohol use and alcohol use disorder (AUD) are common worldwide, and rates of alcohol-associated liver disease (ALD) are also increasing. AUD is a disease that is treatable and can be diagnosed and managed, and recovery from AUD through abstinence or reductions in drinking is possible. Management of AUD among individuals with ALD is increasingly being addressed via integrated medical and psychosocial treatment teams that can support reductions in drinking and prevent progression of liver disease. Early diagnosis of AUD and ALD can improve lives and reduce mortality.
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Affiliation(s)
- Katie Witkiewitz
- Center on Alcohol, Substance Use, and Addictions, University of New Mexico, 2650 Yale Boulevard Southeast, Albuquerque, NM 87106, USA.
| | - Anne C Fernandez
- Department of Psychiatry, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Ellen W Green
- Division of Gastroenterology & Hepatology, University of North Carolina, 130 Mason Farm Road, Bioinformatics Building CB# 7080, Chapel Hill, NC 27599-7080, USA
| | - Jessica L Mellinger
- Department of Psychiatry, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA; Department of Medicine, University of Michigan
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4
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Kulkarni AV, Singal AK, Kamath PS. Research Priorities and Future Landscape of Clinical Trials in Alcohol-Associated Liver Disease. Clin Liver Dis 2024; 28:831-851. [PMID: 39362725 DOI: 10.1016/j.cld.2024.06.017] [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: 10/05/2024]
Abstract
Liver is the most common organ affected by alcohol misuse. The spectrum of alcohol-associated liver disease (ALD) ranges from simple steatosis to cirrhosis and its complications. The unique clinical phenotype of alcohol-associated hepatitis has a risk for high short-term mortality. Several gaps exist with respect to epidemiology, noninvasive testing, prognostication, and treatment of ALD. Most studies focus on short-term survival as the ideal endpoint and ignore other aspects of alcohol-use disorder and ALD. In this review, the authors discuss the existing knowledge gaps, enumerate ongoing clinical trials, and highlight the research priorities and future landscape of clinical trials.
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Affiliation(s)
| | - Ashwani K Singal
- Department of Medicine, Division of Gastroenterology Hepatology and Nutrition, University of Louisville, KY, USA; Department of Research, VA Medical Center, Sioux Falls, University of South Dakota, Sioux Falls, SD, USA; American Gastro Association Council (Liver Section); University of Louisville School of Medicine; Clinical Trials in Hepatology, UofL Clinical Trials Unit; University of Louisville Physics Group; University of Louisville Health and Jewish Hospital; Trager Transplant Center.
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5
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Shasthry SM, Sarin SK. Alcohol-Associated Liver Diseases: Spectrum, Nomenclature, and Definitions. Clin Liver Dis 2024; 28:621-631. [PMID: 39362711 DOI: 10.1016/j.cld.2024.06.003] [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: 10/05/2024]
Abstract
Alcohol-associated liver disease (AALD) is a global health problem with increasing incidence with associated high morbidity and mortality. Patients with AALD have varied clinical presentation encompassing a spectrum ranging from alcoholic steatosis, alcoholic steatohepatitis to alcohol-associated fibrosis/cirrhosis, which can be either compensated or decompensated. We need uniformity in defining each of the stages of AALD, which will help in both research and patient care. Algorithmic approach using noninvasive tests like enhanced liver fibrosis score, elastography, and fibrosis-4 scores can help in early diagnosis in addition to the presence of any red flags (low albumin, low platelet count, and raised transaminases).
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Affiliation(s)
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, Sector D1, Vasantkunj, New Delhi 110070, India.
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6
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Gautron MA, Clergue-Duval V, Chantre J, Lejoyeux M, Geoffroy PA. Predictive factors of cognitive impairment in alcohol use disorder inpatients. Addict Behav 2024; 158:108132. [PMID: 39146925 DOI: 10.1016/j.addbeh.2024.108132] [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: 04/29/2024] [Revised: 07/03/2024] [Accepted: 08/12/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND Cognitive impairments are common in patients with AUD and worsen the prognosis of addiction management. There are no clear guidelines for screening cognitive impairments in hospitalized patients with AUD. METHODS Fifty-seven patients with an AUD history who were admitted to an acute hospital and assessed by the addiction care team were included. Those patients were screened for cognitive impairments using the Montreal Cognitive Assessment (MoCA) test. We collected clinical information regarding addiction history, comorbidities, and current treatments. Chi-square tests, t-tests, and Mann-Whitney tests were performed to determine factors associated with a pathological MoCA score (<26). RESULTS A pathological MoCA score was positively associated with spatial-temporal disorientation, difficulty in recalling addiction history, patient underreporting of AUD and a date of last alcohol consumption lower than 11 days ago, and negatively associated with a reason for hospitalization due to alcohol-related health issues. No medication was associated with cognitive impairments. CONCLUSIONS Clinical elements from assessment by the addiction care team allow for relevant indication for screening cognitive impairments.
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Affiliation(s)
- Marie-Astrid Gautron
- Unité de Traitement Ambulatoire des Maladies Addictives, Département d'Addictologie et de Psychiatrie, Hôpital Beaujon, APHP GHU Nord, 100 bd du général Leclerc, 92110 Clichy, France; ResAlCog (Réseau pour la prise en charge des troubles cognitifs liés à l'alcool), 51 bis Rue des Epinettes, 75017 Paris, France.
| | - Virgile Clergue-Duval
- ResAlCog (Réseau pour la prise en charge des troubles cognitifs liés à l'alcool), 51 bis Rue des Epinettes, 75017 Paris, France; Département de Psychiatrie et de Médecine Addictologique, Site Lariboisière Fernand-Widal, APHP GHU Nord, 200 rue du faubourg Saint-Denis, 75010 Paris, France; UFR de Médecine, Université Paris Cité, 85 boulevard Saint-Germain, 75006 Paris, France; UMRS-1144 Optimisation thérapeutique en neuropsychopharmacologie, Inserm, Université Paris Cité, 4 avenue de l'Observatoire, 75006 Paris, France; FHU Network of Research in Substance Use Disorders (NOR-SUD), 4 avenue de l'Observatoire, 75006 Paris , France
| | - Janice Chantre
- Unité de Traitement Ambulatoire des Maladies Addictives, Département d'Addictologie et de Psychiatrie, Hôpital Beaujon, APHP GHU Nord, 100 bd du général Leclerc, 92110 Clichy, France; ResAlCog (Réseau pour la prise en charge des troubles cognitifs liés à l'alcool), 51 bis Rue des Epinettes, 75017 Paris, France; Département de psychiatrie et d'addictologie, AP-HP, DMU Neurosciences, Hôpital Bichat - Claude Bernard, APHP GHU Nord, 46 rue Henri Huchard, 75018 Paris, France
| | - Michel Lejoyeux
- UFR de Médecine, Université Paris Cité, 85 boulevard Saint-Germain, 75006 Paris, France; Département de psychiatrie et d'addictologie, AP-HP, DMU Neurosciences, Hôpital Bichat - Claude Bernard, APHP GHU Nord, 46 rue Henri Huchard, 75018 Paris, France; 22ème secteur de psychiatrie parisienne GHU Paris - Psychiatry & Neurosciences, 1 rue Cabanis, 75014 Paris, France
| | - Pierre A Geoffroy
- UFR de Médecine, Université Paris Cité, 85 boulevard Saint-Germain, 75006 Paris, France; Département de psychiatrie et d'addictologie, AP-HP, DMU Neurosciences, Hôpital Bichat - Claude Bernard, APHP GHU Nord, 46 rue Henri Huchard, 75018 Paris, France; Centre ChronoS, GHU Paris - Psychiatry & Neurosciences, 1 rue Cabanis, 75014 Paris, France; CNRS UPR 3212, Institute for Cellular and Integrative Neurosciences, Strasbourg, France
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7
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Kaur P, Verma N, Garg P, Ralmilay S, Wadhawan A, Nadda R, Prajapati J, Sharma G, Rathi S, De A, Premkumar M, Taneja S, Singal AK, Duseja A. Myokines are associated with progression, course and mortality in alcohol-associated liver disease. Aliment Pharmacol Ther 2024; 60:1005-1020. [PMID: 39135311 DOI: 10.1111/apt.18202] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 06/24/2024] [Accepted: 07/29/2024] [Indexed: 09/25/2024]
Abstract
BACKGROUND AND AIMS Myokines are the muscle-derived hormones orchestrating muscle and systemic health. Their role in the progression of alcohol-associated liver disease (ALD) remains elusive. METHODS Three-hundred-one patients across the spectrum of ALD including fatty liver (FL, N = 13), compensated cirrhosis (CC, N = 17), non-acute decompensation (NAD, N = 95), acute decompensation (AD, N = 51) and acute-on-chronic liver failure (ACLF, N = 125) were recruited between 2021 and 2023. Plasma myostatin, decorin levels, nutritional status, handgrip strength (HGS), systemic inflammation, infection, ammonia, disease course and 30-day mortality were recorded. RESULTS Patients aged 48 years (IQR: 38-52) and 97.7% of males were enrolled. Myostatin was elevated while decorin was reduced in cirrhosis compared to without cirrhosis, and further in DC compared to CC (p < 0.001). A step-wise increase in myostatin and reduction in decorin was observed transitioning from NAD to AD to ACLF (p < 0.001). Myostatin was further increased and decorin was reduced along with the grades and organ failures in AD and ACLF (p < 0.001, each). Baseline decorin (AUC: 0.797) and its combination with MELD (AUC: 0.814) predicted disease resolution in AD and ACLF. Although, both myostatin (aOR: 18.96) and decorin (aOR: 0.02) could predict mortality, decorin was independent (aOR: 0.04) and additive to MELD (AUC of MELD+logDecorin + logTLC + HE-grade:0.815); p < 0.05 each. Myostatin increased and decorin reduced with inflammation, hyperammonaemia, malnutrition and HGS in AD and ACLF (p < 0.05, each). CONCLUSION Myokines are linked with malnutrition, fibrosis, systemic inflammation, organ failures, disease course and mortality in ALD. Decorin enhances the risk estimation of mortality of MELD in AD and ACLF. Therapeutic modulation of myokines is a potentially disease-modifying target in ALD.
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Affiliation(s)
- Parminder Kaur
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nipun Verma
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pratibha Garg
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Samonee Ralmilay
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aishani Wadhawan
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rohit Nadda
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jiya Prajapati
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gaurav Sharma
- Department of Translational and Regenerative Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahaj Rathi
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arka De
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Taneja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashwani K Singal
- University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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8
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Yokoyama T, Iwadare T, Yamashita Y, Momose A, Ikeuchi H, Kondo S, Hashigami K, Iwaya M, Kimura T, Umemura T. Case of severe alcoholic hepatitis following acute pancreatitis. Clin J Gastroenterol 2024; 17:915-921. [PMID: 38809500 DOI: 10.1007/s12328-024-01988-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: 03/16/2024] [Accepted: 05/18/2024] [Indexed: 05/30/2024]
Abstract
This report describes the clinical course of a 41 year-old African woman who presented with an episode of acute alcoholic pancreatitis followed next by severe alcoholic hepatitis (SAH). Initially admitted for pancreatitis, the patient responded promptly to comprehensive treatment with strict abstinence from alcohol. However, remarkable elevations in white blood cell count to 44,000/µL and total bilirubin level to 12.4 mg/dL were observed 5-7 weeks later. Contrast-enhanced computed tomography revealed rapidly progressing hepatosplenomegaly. Histological analysis of a liver biopsy detected ballooned hepatocytes with Mallory-Denk bodies and significant neutrophilic infiltration in the hepatic parenchyma, which confirmed the diagnosis of SAH. The patient's hepatosplenomegaly and overall condition improved with supportive care alone. The reported case reveals the unexpected fact that SAH can develop after alcoholic acute pancreatitis.
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Affiliation(s)
- Takeru Yokoyama
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Takanobu Iwadare
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
| | - Yuki Yamashita
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
- Consultation Center for Liver Diseases, Shinshu University Hospital, Matsumoto, Japan
| | - Akari Momose
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Hiroshi Ikeuchi
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Shohei Kondo
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Kenta Hashigami
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Mai Iwaya
- Department of Laboratory Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takefumi Kimura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
- Consultation Center for Liver Diseases, Shinshu University Hospital, Matsumoto, Japan
| | - Takeji Umemura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
- Consultation Center for Liver Diseases, Shinshu University Hospital, Matsumoto, Japan
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9
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Huang PY, Lin YC, Wang CC, Chen CH. Clinical outcomes and predictors in patients with acute on chronic liver failure in Southern Taiwan. J Formos Med Assoc 2024:S0929-6646(24)00402-9. [PMID: 39261118 DOI: 10.1016/j.jfma.2024.08.034] [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: 07/07/2023] [Revised: 08/19/2024] [Accepted: 08/28/2024] [Indexed: 09/13/2024] Open
Abstract
BACKGROUND/AIMS The study is to analyze the clinical characteristics and identify prognostic factors as well as evaluate predictive models in patients with acute-on-chronic liver failure (ACLF) from Southern Taiwan. METHODS The cohort study was conducted using the Chang Gung Research Database. We included patients with ACLF based on the definition provided by the Asian-Pacific Association for the Study of the Liver ACLF Research Consortium (AARC). RESULTS A total of 231 patients diagnosed with ACLF were included in this study, out of which 26 patients underwent liver transplantation (LT). The primary cause of ACLF was acute exacerbation of hepatitis B virus (HBV) in 68.4% of cases and followed by severe alcoholic hepatitis (20.8%). Among LT-free patients, the 28-day mortality rate was observed to be 31%. Older age, higher INR and ammonia levels, and the presence of severe hepatic encephalopathy on 3-6 days of treatment were independent predictors of 28-day mortality. The CLIF-C ACLF and COSSH-ACLF scores, evaluated on 3-6 days, demonstrated the highest predictive performance for 28-day mortality. The optimal cut-off values for the CLIF-C ACLF and COSSH-ACLF scores were determined to be 47 and 6.3, respectively. Patients with CLIF-C ACLF score >63 or COSSH-ACLF score >8.1 experienced 100% mortality by day 28. CONCLUSIONS The CLIF-C ACLF and COSSH-ACLF scores, evaluated within one week after treatment, exhibit strong predictive capabilities for short-term mortality in ACLF patients. These models are valuable tools for guiding timely decision-making, including the consideration of liver transplantation or withdrawal from treatment.
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Affiliation(s)
- Pao-Yuan Huang
- Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan
| | - Yu-Cheng Lin
- Division of General Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan
| | - Chih-Chi Wang
- Division of General Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan
| | - Chien-Hung Chen
- Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taiwan.
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10
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Ma AT, Allegretti AS, Cullaro G, Ouyang T, Asrani SK, Chung RT, Przybyszewski EM, Wilechansky RM, Robinson JE, Sharma P, Simonetto DA, Jalal P, Orman ES, Wadei HM, St. Hillien SA, Saly D, Ufere NN, Dageforde LA, Regner KR, Belcher JM, Patidar KR. Outcomes of patients with alcohol-associated hepatitis and acute kidney injury - Results from the HRS Harmony Consortium. Aliment Pharmacol Ther 2024; 60:778-786. [PMID: 39010302 PMCID: PMC11349455 DOI: 10.1111/apt.18159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/23/2024] [Accepted: 06/29/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND & AIMS The development of acute kidney injury (AKI) in the setting of alcohol-associated hepatitis (AH) portends a poor prognosis. Whether the presence of AH itself drives worse outcomes in patients with cirrhosis and AKI is unknown. METHODS Retrospective cohort study of 11 hospital networks of consecutive adult patients admitted in 2019 with cirrhosis and AKI. AKI phenotypes, clinical course, and outcomes were compared between AH and non-AH groups. RESULTS A total of 2062 patients were included, of which 303 (15%) had AH, as defined by National Institute on Alcohol Abuse and Alcoholism (NIAAA) criteria. Patients with AH, compared to those without, were younger and had higher Model for End-stage Liver Disease-Sodium (MELD-Na) scores on admission. AKI phenotypes significantly differed between groups (p < 0.001) with acute tubular necrosis occurring more frequently in patients with AH. Patients with AH reached more severe peak AKI stage, required more renal replacement therapy, and had higher 90-day cumulative incidence of death (45% [95% CI: 39%-51%] vs. 38% [95% CI: 35%-40%], p = 0.026). Using no AH as reference, the unadjusted sHR for 90-day mortality was higher for AH (sHR: 1.24 [95% CI: 1.03-1.50], p = 0.024), but was not significant when adjusting for MELD-Na, age and sex. However, in patients with hepatorenal syndrome, AH was an independent predictor of 90-day mortality (sHR: 1.82 [95% CI: 1.16-2.86], p = 0.009). CONCLUSIONS Hospitalised patients with cirrhosis and AKI presenting with AH had higher 90-day mortality than those without AH, but this may have been driven by higher MELD-Na rather than AH itself. However, in patients with hepatorenal syndrome, AH was an independent predictor of mortality.
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Affiliation(s)
- Ann T. Ma
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Andrew S. Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Giuseppe Cullaro
- Division of Gastroenterology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Tianqui Ouyang
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Raymond T. Chung
- Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eric M. Przybyszewski
- Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert M. Wilechansky
- Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jevon E. Robinson
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pratima Sharma
- Department of Internal Medicine, University of Michigan Health, Ann Arbor, Michigan, USA
| | - Douglas A. Simonetto
- Division of Gastroenterology and Transplant Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasun Jalal
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Eric S. Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Hani M. Wadei
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - Shelsea A. St. Hillien
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Danielle Saly
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nneka N. Ufere
- Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Leigh Anne Dageforde
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kevin R. Regner
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Justin M. Belcher
- Section of Nephrology, Department of Internal Medicine, Yale University, New Haven, Connecticut, USA
- CT and VA Connecticut Healthcare, West Haven, Connecticut, USA
| | - Kavish R. Patidar
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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11
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Quek JWE, Loo JH, Jaroenlapnopparat A, Jimenez C, Al-Karaghouli M, Vargas V, Arab JP, Abraldes JG, Wong YJ. Prophylactic antibiotics in patients with alcohol-associated hepatitis receiving steroids: A systematic review and meta-analysis. Liver Int 2024; 44:2469-2476. [PMID: 39205440 DOI: 10.1111/liv.16014] [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: 03/27/2024] [Revised: 05/14/2024] [Accepted: 06/10/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND & AIMS The benefits of prophylactic antibiotics in patients with alcohol-associated hepatitis (AH) receiving steroids remain unclear. We aimed to assess the clinical impact of prophylactic antibiotics in AH patients receiving steroids. METHODS We systematically reviewed four electronic databases from inception to 30 November 2023. Pooled estimates were analysed using random-effects models. The primary outcome was 90-day survival. Secondary outcomes included infection at days 30 and 90 days, hepatorenal syndrome (HRS), acute kidney injury (AKI), hepatic encephalopathy (HE) and drug-related adverse events (AE). Trial sequential analyses were performed for the primary outcome of 90-day mortality. RESULTS We screened 419 articles and included six eligible studies (four RCTs and two matched cohort studies) with a total of 510 patients. Compared to standard medical treatment (SMT), prophylactic antibiotics were associated with a lower risk of infection at 30 days (OR: 0.35, 95%CI: 0.20-0.59, I 2 = 0%), infection at 90 days (OR: 0.26, 95%CI: 0.10-0.67, I 2 = 0%) and a lower rate of HE (OR: 0.32, 95%CI: 0.12-0.87, I 2 = 0%). However, prophylactic antibiotics did not improve 90-day survival, sepsis-related mortality, HRS, or AKI. The risks of drug-related AE and fungal infections were similar in patients with AH who received prophylactic antibiotics or SMT. Using trial sequential analysis, the minimum sample size required to detect a 15% relative risk reduction in 90 days mortality with prophylactic antibiotics was 1171. CONCLUSIONS In hospitalized AH patients receiving steroid therapy, prophylactic antibiotics reduced the risk of infection and HE, but did not improve survival or prevent AKI compared to SMT.
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Affiliation(s)
- Joo Wei E Quek
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jing Hong Loo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | | | - Cesar Jimenez
- Àrea de malalties digestives, Hospital Vall d'Hebron, Barcelona, Spain
- Department de Medicina, Facultat de Medicina, CIBERehD, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mustafa Al-Karaghouli
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Victor Vargas
- Àrea de malalties digestives, Hospital Vall d'Hebron, Barcelona, Spain
- Department de Medicina, Facultat de Medicina, CIBERehD, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Pablo Arab
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Juan G Abraldes
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Yu Jun Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
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12
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Rutledge SM, Nathani R, Wyatt BE, Eschbach E, Trivedi P, Kerznerman S, Chu L, Schiano TD, Kim-Schluger L, Florman S, Im GY. Age added to MELD or ACLF predicts survival in patients with alcohol-associated hepatitis declined for liver transplantation. Hepatol Commun 2024; 8:e0514. [PMID: 39167426 PMCID: PMC11340926 DOI: 10.1097/hc9.0000000000000514] [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: 10/18/2023] [Accepted: 02/14/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND Severe alcohol-associated hepatitis (AH) that is nonresponsive to corticosteroids is associated with high mortality, particularly with concomitant acute-on-chronic liver failure (ACLF). Most patients will not be candidates for liver transplantation (LT) and their outcomes are largely unknown. Our aim was to determine the outcomes of these declined candidates and to derive practical prediction models for transplant-free survival applicable at the time of the waitlist decision. METHODS We analyzed a database of patients with severe AH who were hospitalized at a LT center from January 2012 to July 2021, using the National Death Index for those lacking follow-up. Clinical variables were analyzed based on the endpoints of mortality at 30, 60, 90, and 180 days. Logistic and Cox regression analyses were used for model derivation. RESULTS Over 9.5 years, 206 patients with severe AH were declined for LT, mostly for unfavorable psychosocial profiles, with a mean MELD of 33 (±8), and 61% with ACLF. Over a median follow-up of 521 (17.5-1368) days, 58% (119/206) died at a median of 21 (9-124) days. Of 32 variables, only age added prognostic value to MELD and ACLF grade. CLIF-C ACLF score and 2 new models, MELD-Age and ACLF-Age, had similar predictability (AUROC: 0.73, 0.73, 0.72, respectively), outperforming Lille and Maddrey's (AUROC: 0.63, 0.62). In internal cross-validation, the average AUROC was 0.74. ACLF grade ≥2, MELD score >35, and age >45 years were useful cutoffs for predicting increased 90-day mortality from waitlist decision. Only two patients initially declined for LT for AH subsequently underwent LT (1%). CONCLUSIONS Patients with severe AH declined for LT have high short-term mortality and rare rates of subsequent LT. Age added to MELD or ACLF grade enhances survival prediction at the time of waitlist decision in patients with severe AH declined for LT.
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Affiliation(s)
- Stephanie M. Rutledge
- Department of Medicine, Division of Liver Diseases, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rohit Nathani
- Department of Medicine, Mount Sinai Morningside and West, New York, New York, USA
| | - Brooke E. Wyatt
- Department of Medicine, Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Erin Eschbach
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Parth Trivedi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stanley Kerznerman
- Department of Medicine, Division of Liver Diseases, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lily Chu
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Thomas D. Schiano
- Department of Medicine, Division of Liver Diseases, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Leona Kim-Schluger
- Department of Medicine, Division of Liver Diseases, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sander Florman
- Department of Surgery, Division of Abdominal Transplantation, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gene Y. Im
- Department of Medicine, Division of Liver Diseases, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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13
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Berg T, Aehling NF, Bruns T, Welker MW, Weismüller T, Trebicka J, Tacke F, Strnad P, Sterneck M, Settmacher U, Seehofer D, Schott E, Schnitzbauer AA, Schmidt HH, Schlitt HJ, Pratschke J, Pascher A, Neumann U, Manekeller S, Lammert F, Klein I, Kirchner G, Guba M, Glanemann M, Engelmann C, Canbay AE, Braun F, Berg CP, Bechstein WO, Becker T, Trautwein C. S2k-Leitlinie Lebertransplantation der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1397-1573. [PMID: 39250961 DOI: 10.1055/a-2255-7246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Affiliation(s)
- Thomas Berg
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Niklas F Aehling
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Tony Bruns
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martin-Walter Welker
- Medizinische Klinik I Gastroent., Hepat., Pneum., Endokrin. Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Tobias Weismüller
- Klinik für Innere Medizin - Gastroenterologie und Hepatologie, Vivantes Humboldt-Klinikum, Berlin, Deutschland
| | - Jonel Trebicka
- Medizinische Klinik B für Gastroenterologie und Hepatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Frank Tacke
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Pavel Strnad
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martina Sterneck
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Hamburg, Hamburg, Deutschland
| | - Utz Settmacher
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Daniel Seehofer
- Klinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Eckart Schott
- Klinik für Innere Medizin II - Gastroenterologie, Hepatologie und Diabetolgie, Helios Klinikum Emil von Behring, Berlin, Deutschland
| | | | - Hartmut H Schmidt
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Essen, Deutschland
| | - Hans J Schlitt
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Johann Pratschke
- Chirurgische Klinik, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Andreas Pascher
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - Ulf Neumann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Steffen Manekeller
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Frank Lammert
- Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
| | - Ingo Klein
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Gabriele Kirchner
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg und Innere Medizin I, Caritaskrankenhaus St. Josef Regensburg, Regensburg, Deutschland
| | - Markus Guba
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, München, Deutschland
| | - Matthias Glanemann
- Klinik für Allgemeine, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Cornelius Engelmann
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Ali E Canbay
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - Felix Braun
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
| | - Christoph P Berg
- Innere Medizin I Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Wolf O Bechstein
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Thomas Becker
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
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14
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Lee BP, Witkiewitz K, Mellinger J, Anania FA, Bataller R, Cotter TG, Curtis B, Dasarathy S, DeMartini KS, Diamond I, Diazgranados N, DiMartini AF, Falk DE, Fernandez AC, German MN, Kamath PS, Kidwell KM, Leggio L, Litten R, Louvet A, Lucey MR, McCaul ME, Sanyal AJ, Singal AK, Sussman NL, Terrault NA, Thursz MR, Verna EC, Radaeva S, Nagy LE, Mitchell MC. Designing clinical trials to address alcohol use and alcohol-associated liver disease: an expert panel Consensus Statement. Nat Rev Gastroenterol Hepatol 2024; 21:626-645. [PMID: 38849555 DOI: 10.1038/s41575-024-00936-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 06/09/2024]
Abstract
Most patients with alcohol-associated liver disease (ALD) engage in heavy drinking defined as 4 or more drinks per day (56 g) or 8 (112 g) or more drinks per week for women and 5 or more drinks per day (70 g) or 15 (210 g) or more drinks per week for men. Although abstinence from alcohol after diagnosis of ALD improves life expectancy and reduces the risk of decompensation of liver disease, few studies have evaluated whether treatment of alcohol use disorders will reduce progression of liver disease and improve liver-related outcomes. In November 2021, the National Institute of Alcohol Abuse and Alcoholism commissioned a task force that included hepatologists, addiction medicine specialists, statisticians, clinical trialists and members of regulatory agencies to develop recommendations for the design and conduct of clinical trials to evaluate the effect of alcohol use, particularly treatment to reduce or eliminate alcohol use in patients with ALD. The task force conducted extensive reviews of relevant literature on alcohol use disorders and ALD. Findings were presented at one in-person meeting and discussed over the next 16 months to develop the final recommendations. As few clinical trials directly address this topic, the 28 recommendations approved by all members of the task force represent a consensus of expert opinions.
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Affiliation(s)
- Brian P Lee
- Division of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine and Institute for Addiction Science, University of Southern California, Los Angeles, CA, USA
| | - Katie Witkiewitz
- Center on Alcohol, Substance use and Addictions, University of New Mexico, Albuquerque, NM, USA
| | - Jessica Mellinger
- Department of Internal Medicine, Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, USA
| | - Frank A Anania
- Division of Hepatology and Nutrition, US Food and Drug Administration, Silver Spring, MD, USA
| | - Ramon Bataller
- Liver Unit, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Thomas G Cotter
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brenda Curtis
- Technology and Translational Research Unit, Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program, Baltimore, MD, USA
| | - Srinivasan Dasarathy
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Kelly S DeMartini
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | | | - Nancy Diazgranados
- Office of the Clinical Director, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Andrea F DiMartini
- Departments of Psychiatry and Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Daniel E Falk
- Medications Development Branch, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | | | - Margarita N German
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Kelley M Kidwell
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Lorenzo Leggio
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism Division of Intramural Clinical and Biological Research, National Institutes of Health, Baltimore, MD, USA
| | - Raye Litten
- Division of Treatment and Recovery, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Alexandre Louvet
- Service des maladies de l'appareil digestif, University Hospital of Lille, Lille, France
- Unité INSERM INFINITE, Lille, France
| | - Michael R Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Mary E McCaul
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Arun J Sanyal
- Stravitz-Sanyal Institute for Liver Disease and Metabolic Health, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Ashwani K Singal
- Department of Medicine, Division of Gastroenterology Hepatology and Nutrition, University of Louisville School of Medicine, Louisville, KY, USA
- Department of Medicine, Robley Rex VA Medical Center, Louisville, KY, USA
| | - Norman L Sussman
- DURECT Corporation, Cupertino, CA, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Norah A Terrault
- Division of Gastroenterology and Liver Diseases, University of Southern California Keck School of Medicine and Institute for Addiction Science, University of Southern California, Los Angeles, CA, USA
| | - Mark R Thursz
- Division of Digestive Diseases, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Elizabeth C Verna
- Division of Digestive and Liver Diseases, Columbia University, New York, NY, USA
| | - Svetlana Radaeva
- Svetlana Radaeva, Division of Metabolism and Health Effects, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Laura E Nagy
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Mack C Mitchell
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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15
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Vergis N, Patel V, Bogdanowicz K, Czyzewska-Khan J, Keshinro R, Fiorentino F, Day E, Middleton P, Atkinson S, Tranah T, Cross M, Babalis D, Foster N, Lord E, Quaglia A, Lloyd J, Goldin R, Rosenberg W, Parker R, Richardson P, Masson S, Whitehouse G, Sieberhagan C, Patch D, Naoumov N, Dhanda A, Forrest E, Thursz M. IL-1 Signal Inhibition in Alcohol-Related Hepatitis: A Randomized, Double-Blind, Placebo-Controlled Trial of Canakinumab. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00759-6. [PMID: 39181422 DOI: 10.1016/j.cgh.2024.07.025] [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: 12/14/2023] [Revised: 06/18/2024] [Accepted: 07/05/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND AND AIMS Short-term mortality in alcohol-related hepatitis (AH) is high, and no current therapy results in durable benefit. A role for interleukin (IL)-1β has been demonstrated in the pathogenesis of alcohol-induced steatohepatitis. This study explored the safety and efficacy of canakinumab (CAN), a monoclonal antibody targeting IL-1β, in the treatment of patients with AH. METHODS Participants with biopsy-confirmed AH and discriminant function ≥32 but Model for End-Stage Liver Disease ≤27 were randomly allocated 1:1 to receive either CAN 3 mg/kg or placebo (PBO). Liver biopsies were taken before and 28 days after treatment. The primary endpoint was the overall histological improvement in inflammation analyzed by the modified intention-to-treat principle. RESULTS Fifty-seven participants were randomized: 29 to CAN and 28 to PBO. Two participants had histology that did not corroborate the clinical diagnosis. Of the remaining 55 participants, paired histology data were evaluable from 48 participants. In CAN-treated participants, 14 (58%) of 24 demonstrated histological improvement compared with 10 (42%) of 24 in the PBO group (P = .25). There was no improvement in prognostic scores of liver function. Four (7%) of the 55 participants died within 90 days, 2 in each group. The number of serious adverse events was similar between CAN vs PBO. In post hoc exploratory analyses after adjustment for baseline prognostic factors, CAN therapy was associated with overall histological improvement (P = .04). CONCLUSIONS CAN therapy in severe AH participants with Model for End-Stage Liver Disease ≤27 did not alter biochemical or clinical outcomes compared with PBO. Nonsignificant histological improvements did not translate into clinical benefit. EudraCT, Number: 2017-003724-79; ClinicalTrials.gov, Number: NCT03775109.
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Affiliation(s)
- Nikhil Vergis
- Division of Digestive Diseases, Imperial College London, London, United Kingdom
| | - Vishal Patel
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom; Roger Williams Institute of Hepatology London, Foundation for Liver Research, London, United Kingdom; School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Karolina Bogdanowicz
- Imperial College Clinical Trials Unit, Faculty of Medicine, Imperial College Lon London, United Kingdom
| | - Justyna Czyzewska-Khan
- Imperial College Clinical Trials Unit, Faculty of Medicine, Imperial College Lon London, United Kingdom
| | - Rosemary Keshinro
- Imperial College Clinical Trials Unit, Faculty of Medicine, Imperial College Lon London, United Kingdom
| | - Francesca Fiorentino
- Imperial College Clinical Trials Unit, Faculty of Medicine, Imperial College Lon London, United Kingdom; Nightingale-Saunders Clinical Trials and Epidemiology Unit, King's Clinical Trials Unit, King's College London, United Kingdom
| | - Emily Day
- Imperial College Clinical Trials Unit, Faculty of Medicine, Imperial College Lon London, United Kingdom
| | - Paul Middleton
- Division of Digestive Diseases, Imperial College London, London, United Kingdom
| | - Stephen Atkinson
- Division of Digestive Diseases, Imperial College London, London, United Kingdom
| | - Thomas Tranah
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Mary Cross
- Imperial College Clinical Trials Unit, Faculty of Medicine, Imperial College Lon London, United Kingdom
| | - Daphne Babalis
- Imperial College Clinical Trials Unit, Faculty of Medicine, Imperial College Lon London, United Kingdom
| | | | - Emma Lord
- Division of Digestive Diseases, Imperial College London, London, United Kingdom
| | - Alberto Quaglia
- Department of Cellular Pathology, UCL Cancer Institute, Royal Free Hospital, London, United Kingdom
| | - Josephine Lloyd
- North West London Pathology, Charing Cross Hospital, London, United Kingdom
| | - Robert Goldin
- Division of Digestive Diseases, Imperial College London, London, United Kingdom
| | - William Rosenberg
- Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | - Richard Parker
- Leeds Liver Unit, St James' Hospital, Leeds, United Kingdom
| | - Paul Richardson
- Liverpool University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Steven Masson
- Faculty of Medical Sciences, Newcastle University Medical School, Newcastle upon Tyne, United Kingdom
| | - Gavin Whitehouse
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | | | - David Patch
- Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | | | - Ashwin Dhanda
- Hepatology Research Group, Faculty of Health, University of Plymouth, Plymouth, United Kingdom
| | - Ewan Forrest
- Department of Gastroenterology, Glasgow Royal Infirmary, University of Glasgow, Glasgow, United Kingdom
| | - Mark Thursz
- Division of Digestive Diseases, Imperial College London, London, United Kingdom.
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16
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Mishra AK, Shasthry SM, Vijayaraghavan R, Kumar G, Sarin SK. Granulocyte Colony-Stimulating Factor Improves Prednisolone Responsiveness and 90-Day Survival in Steroid-Eligible Severe Alcohol-Associated Hepatitis: The GPreAH Study a Randomized Trial. Am J Gastroenterol 2024:00000434-990000000-01307. [PMID: 39162744 DOI: 10.14309/ajg.0000000000003038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 07/30/2024] [Indexed: 08/21/2024]
Abstract
INTRODUCTION Severe alcohol-associated hepatitis (SAH) carries high 1-month mortality. Corticosteroids provide a modest 28-day but not 90-day survival benefit, due to development of infections and organ failures. Granulocyte colony-stimulating factor (GCSF) has shown promise in patients with SAH by its immunomodulatory and regenerative capabilities. We studied the safety and efficacy of combination (GCSF + prednisolone, GPred) therapy in management of steroid-eligible patients with SAH. METHODS Steroid eligible patients with SAH (discriminant function scores 32-90) were randomized to receive prednisolone (GrA, n = 42), GPred (GrB, n = 42), or GCSF alone (GrC, n = 42). GCSF was given as 150-300 mcg/d for 7 days followed by every third day for a maximum of 12 doses in 1 month. Prednisolone 40 mg/d was given for 7 days and continued for 28 days in responders (Lille score <0.45). RESULTS Baseline characteristics of patient groups were comparable. On intention-to-treat analysis, the primary endpoint of 90-day survival was achieved in 64.3% (27/42) in prednisolone, 88.1% (37/42) in GPred, and 78.6%(33/42) in GCSF groups, respectively ( P = 0.03, prednisolone vs GPred). The 28-day survival was not different between the groups (85.7%, 95.2%, and 85.7%, respectively [ P = 0.27]). The GPred group had more responders by day 7 (71.4% vs 92.9% vs 76.2%, P = 0.037) and had greater reduction in discriminant function (-7.33 ± 4.78, -24.59 ± 3.7, -14.59 ± 3.41, P = 0.011) and MELDNa (-1.69 ± 1.26, -7.02 ± 1.24, -3.05 ± 0.83, P = 0.002) by day 90. The prednisolone-only group had higher incidence of new infections (35.7%, 19%, 7.1%, respectively, P < 0.002). Acute kidney injury (33.3%, 7.1%, 11.9%, P = 0.002), hepatic encephalopathy (35.7%, 9.5%, 26.2%, P = <0.001), and rehospitalizations (59.5%, 14.3%, 30.9%, P =<0.01) were lower in the GPred group. CONCLUSION Addition of GCSF to prednisolone improves steroid responsiveness and 90-day survival with fewer infections and new onset complications in patients with SAH.
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Affiliation(s)
| | | | | | - Guresh Kumar
- Department of Clinical Research, ILBS, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, ILBS, New Delhi, India
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17
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Al-Karaghouli M, Ventura-Cots M, Wong YJ, Genesca J, Bosques F, Brown RS, Mathurin P, Louvet A, Shawcross D, Vargas V, Verna EC, Schnabl B, Caballeria J, Shah VJ, Kamath PS, Lucey MR, Garcia-Tsao G, Bataller R, Abraldes JG. Relationship between updated MELD and prognosis in alcohol-associated hepatitis: Opportunities for more efficient trial design. Hepatol Commun 2024; 8:e0495. [PMID: 39082963 DOI: 10.1097/hc9.0000000000000495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/08/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND Alcohol-associated hepatitis (AH) is associated with significant mortality. Model for End-Stage Liver Disease (MELD) score is used to predict short-term mortality and aid in treatment decisions. MELD is frequently updated in the course of AH. However, once the most updated MELD is known, it is uncertain if previous ones still have prognostic value, which might be relevant for transplant allocation and trial design. We aimed to investigate the predictive performance of updated MELDs in a prospectively collected cohort of patients with AH by the InTeam consortium. METHODS Three hundred seven patients (with 859 MELD values within 60 d of admission) fulfilled the inclusion criteria. The main endpoint was time to death or transplant up to 90 days. We used a joint model approach to assess the predictive value of updated MELDs. RESULTS Updated MELD measurements had a strong prognostic value for death/transplant (HR: 1.20, 95% CI: 1.14-1.27) (p < 0.0001). Previous MELD values did not add predictive value to the most current MELD. We also showed that MELD at day 28 (MELD28) had a significant predictive value for subsequent mortality/transplant in a landmark analysis (HR: 1.18, 95% CI: 1.12-1.23). We show that the use of an ordinal scale including death, transplant, and MELD28 as a trial outcome could substantially reduce the sample size required to demonstrate short-term benefit of an intervention. CONCLUSION We show that updated MELDs during the trajectory of AH predict subsequent mortality or the need for transplant. MELD28 inclusion in an ordinal outcome (together with death or transplant) could increase the efficiency of randomized controlled trials.
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Affiliation(s)
- Mustafa Al-Karaghouli
- Division of Gastroenterology (Liver Unit). University of Alberta, Edmonton, Alberta, Canada
| | - Meritxell Ventura-Cots
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Yu Jun Wong
- Division of Gastroenterology (Liver Unit). University of Alberta, Edmonton, Alberta, Canada
| | - Joan Genesca
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Francisco Bosques
- Hospital Universitario Dr Jose E. Gonzalez, Servicio de Gastroenterologia, Universidad Autonoma de Nuevo Leon Monterrey, Mexico
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - Philippe Mathurin
- University of Lille, Inserm, CHU Lille, U1286-INFINITI-Institute for Translational Research in Inflammation, Lille, France
| | - Alexandre Louvet
- University of Lille, Inserm, CHU Lille, U1286-INFINITI-Institute for Translational Research in Inflammation, Lille, France
| | - Debbie Shawcross
- Department of Inflammation Biology, Institute of Liver Studies, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Victor Vargas
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Elizabeth C Verna
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia College of Physicians and Surgeons, Columbia University Medical Center, New York, New York, USA
| | - Bernd Schnabl
- Medicine, University of California San Diego, La Jolla, California, USA
| | - Joan Caballeria
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Vijay J Shah
- Mayo Clinic and Mayo Medical School, Rochester, Minnesota, USA
| | | | - Michael R Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University, New Haven, Connecticut, USA
- Division of Gastroenterology, Hepatology and Nutrition, Center for Liver Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ramon Bataller
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Liver Unit, Hospital Clínic, Barcelona, Spain
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit). University of Alberta, Edmonton, Alberta, Canada
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18
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Healey MA, Ramalingam G, Hang Y, Smirnova E, Asgharpour A, Patel V, Lee H, Luketic V, Matherly S, Siddiqui M, Wedd J, Sanyal A, Sterling RK. Utility of Lille Score in Predicting 30-Day Survival in Steroid-Treated Alcohol-Associated Hepatitis. Dig Dis Sci 2024; 69:3043-3050. [PMID: 38890230 PMCID: PMC11341594 DOI: 10.1007/s10620-024-08479-6] [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: 01/03/2024] [Accepted: 05/06/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND/AIMS In alcohol-associated hepatitis (AH), the Lille score is used to assess futility of steroids. However, the ability of the Lille score to predict 30-day survival in AH is not well-defined. Our aim is to compare the utility of the Lille score in predicting 30-day survival in those with AH treated with steroids. METHODS Retrospective chart review of 882 patients hospitalized with AH from January 1st, 2012 through December 30th, 2019 was performed. Of these, 201 patients with severe AH met the threshold to receive steroids. Those with data to calculate Lille score < 0.45 on day 4 (n = 29) or 7 (n = 89) who continued steroids were compared to 83 patients with Lille scores ≥ 0.45 on day 4 (n = 18) or 7 (n = 65) who stopped steroids. The primary outcome was 30-day survival. For comparison, a contemporaneous matched control group was also analyzed of 110 patients who were hospitalized with severe AH, but did not receive steroids. RESULTS In patients with Lille score < 0.45, survival was higher at 30-day when compared to those with Lille score ≥ 0.45 (94.9% vs. 80.72%; p = 0.002). The sensitivity, specificity, positive predictive value and negative predictive value of Lille score (< 0.45) to predict 30-day survival was 95%, 19%, 63%, and 73%, respectively. CONCLUSIONS In severe AH, those with Lille score < 0.45 at day 4 or 7 have improved 30-day survival compared to those with Lille score ≥ 0.45. In those receiving steroids, Lille score has excellent sensitivity to predict 30-day survival but poor specificity.
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Affiliation(s)
- Marcus A Healey
- Division of Gastroenterology, Hepatology, Nutrition at Virginia Commonwealth University (VCU) Health, Richmond, VA, USA.
- , 2505 Durhamshire Place, Midlothian, VA, 23113, USA.
| | - Geetha Ramalingam
- Clinical and Translational Research Master's Program at VCU, Richmond, VA, USA
| | - Yiwei Hang
- VCU Health School of Medicine, Richmond, VA, USA
| | | | - Amon Asgharpour
- Division of Gastroenterology, Hepatology, Nutrition at Virginia Commonwealth University (VCU) Health, Richmond, VA, USA
- VCU Health School of Medicine, Richmond, VA, USA
| | - Vaishali Patel
- Division of Gastroenterology, Hepatology, Nutrition at Virginia Commonwealth University (VCU) Health, Richmond, VA, USA
- VCU Health School of Medicine, Richmond, VA, USA
| | - Hannah Lee
- Division of Gastroenterology, Hepatology, Nutrition at Virginia Commonwealth University (VCU) Health, Richmond, VA, USA
- VCU Health School of Medicine, Richmond, VA, USA
| | - Velimir Luketic
- Division of Gastroenterology, Hepatology, Nutrition at Virginia Commonwealth University (VCU) Health, Richmond, VA, USA
- VCU Health School of Medicine, Richmond, VA, USA
| | - Scott Matherly
- Division of Gastroenterology, Hepatology, Nutrition at Virginia Commonwealth University (VCU) Health, Richmond, VA, USA
- VCU Health School of Medicine, Richmond, VA, USA
| | - Mohammad Siddiqui
- Division of Gastroenterology, Hepatology, Nutrition at Virginia Commonwealth University (VCU) Health, Richmond, VA, USA
- VCU Health School of Medicine, Richmond, VA, USA
| | - Joel Wedd
- Division of Gastroenterology, Hepatology, Nutrition at Virginia Commonwealth University (VCU) Health, Richmond, VA, USA
- VCU Health School of Medicine, Richmond, VA, USA
| | - Arun Sanyal
- Division of Gastroenterology, Hepatology, Nutrition at Virginia Commonwealth University (VCU) Health, Richmond, VA, USA
- VCU Health School of Medicine, Richmond, VA, USA
| | - Richard K Sterling
- Division of Gastroenterology, Hepatology, Nutrition at Virginia Commonwealth University (VCU) Health, Richmond, VA, USA
- VCU Health School of Medicine, Richmond, VA, USA
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19
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Sayed K, Dolin CE, Wilkey DW, Li J, Sato T, Beier JI, Argemi J, Vatsalya V, McClain CJ, Bataller R, Wahed AS, Merchant ML, Benos PV, Arteel GE. A plasma peptidomic signature reveals extracellular matrix remodeling and predicts prognosis in alcohol-associated hepatitis. Hepatol Commun 2024; 8:e0510. [PMID: 39082970 DOI: 10.1097/hc9.0000000000000510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/07/2024] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Alcohol-associated hepatitis (AH) is plagued with high mortality and difficulty in identifying at-risk patients. The extracellular matrix undergoes significant remodeling during inflammatory liver injury and could potentially be used for mortality prediction. METHODS EDTA plasma samples were collected from patients with AH (n = 62); Model for End-Stage Liver Disease score defined AH severity as moderate (12-20; n = 28) and severe (>20; n = 34). The peptidome data were collected by high resolution, high mass accuracy UPLC-MS. Univariate and multivariate analyses identified differentially abundant peptides, which were used for Gene Ontology, parent protein matrisomal composition, and protease involvement. Machine-learning methods were used to develop mortality predictors. RESULTS Analysis of plasma peptides from patients with AH and healthy controls identified over 1600 significant peptide features corresponding to 130 proteins. These were enriched for extracellular matrix fragments in AH samples, likely related to the turnover of hepatic-derived proteins. Analysis of moderate versus severe AH peptidomes was dominated by changes in peptides from collagen 1A1 and fibrinogen A proteins. The dominant proteases for the AH peptidome spectrum appear to be CAPN1 and MMP12. Causal graphical modeling identified 3 peptides directly linked to 90-day mortality in >90% of the learned graphs. These peptides improved the accuracy of mortality prediction over the Model for End-Stage Liver Disease score and were used to create a clinically applicable mortality prediction assay. CONCLUSIONS A signature based on plasma peptidome is a novel, noninvasive method for prognosis stratification in patients with AH. Our results could also lead to new mechanistic and/or surrogate biomarkers to identify new AH mechanisms.
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Affiliation(s)
- Khaled Sayed
- Department of Epidemiology, University of Florida, Gainesville, Florida, USA
- Department of Electrical & Computer Engineering and Computer Science, University of New Haven, West Haven, Connecticut, USA
| | - Christine E Dolin
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Daniel W Wilkey
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Jiang Li
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Toshifumi Sato
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Juliane I Beier
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Josepmaria Argemi
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Internal Medicine, Clinical University of Navarra, Navarra, Spain
| | - Vatsalya Vatsalya
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, Kentucky, USA
- University of Louisville Alcohol Research Center, University of Louisville, Louisville, Kentucky, USA
| | - Craig J McClain
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, Kentucky, USA
- University of Louisville Alcohol Research Center, University of Louisville, Louisville, Kentucky, USA
| | - Ramon Bataller
- Liver Unit, Hospital Clinic. Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Abdus S Wahed
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York, USA
| | - Michael L Merchant
- Department of Medicine, University of Louisville, Louisville, Kentucky, USA
- University of Louisville Alcohol Research Center, University of Louisville, Louisville, Kentucky, USA
| | - Panayiotis V Benos
- Department of Epidemiology, University of Florida, Gainesville, Florida, USA
| | - Gavin E Arteel
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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20
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Patidar KR, Tu W, Cotter TG, Simonetto DA, Asgharpour A, Jan MY, Tang Q, Yu Y, Li Y, Taiwo M, Thevkar Nagesh P, Dasarathy S, Kamath PS, McClain CJ, Chalasani N, Szabo G, Bataller R, Mitchell M, Mehal WZ, Nagy LE, Shah VH, Gawrieh S, Sanyal AJ. Acute kidney injury in severe alcohol-associated hepatitis treated with anakinra plus zinc or prednisone. Hepatology 2024:01515467-990000000-00965. [PMID: 39028887 DOI: 10.1097/hep.0000000000001019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 06/25/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND AND AIMS In a recent trial, patients with severe alcohol-associated hepatitis treated with anakinra plus zinc (A+Z) had lower survival and higher acute kidney injury (AKI) rates versus prednisone (PRED). We characterize the clinical factors and potential mechanisms associated with AKI development in that trial. APPROACH AND RESULTS Data from 147 participants in a multicenter randomized clinical trial (74 A+Z, 73 PRED) were analyzed. AKI, AKI phenotypes, and kidney injury biomarkers were compared between participants who did/did not develop AKI in the 2 treatment arms. Multivariable competing risk analyses were performed to identify baseline risk factors for incident AKI, with death treated as a competing event. Risk factors considered were age, sex, mean arterial pressure, white blood cell count, albumin, MELD, ascites, HE, and treatment arm. At baseline, no participants had AKI; 33% (n=49) developed AKI during follow-up. AKI incidence was higher in A+Z than in PRED (45% [n=33] versus 22% [n=16], p =0.001). AKI phenotypes were similar between the 2 treatment arms ( p =0.361), but peak AKI severity was greater in A+Z than PRED (stage 3 n=21 [63.6%] vs. n=8 [50.0%], p =0.035). At baseline, urine-neutrophil-gelatinase-associated lipocalin levels were similar between participants who developed AKI in both treatment arms ( p =0.319). However, day 7 and 14 urine-neutrophil-gelatinase-associated lipocalin levels were significantly elevated in participants treated with A+Z who developed AKI versus participants treated with PRED who developed AKI ( p =0.002 and 0.032, respectively). On multivariable competing risk analysis, only A+Z was independently associated with incident AKI (subdistribution hazard ratio 2.35, p =0.005). CONCLUSIONS AKI occurred more frequently and was more severe in participants treated with A+Z. A+Z-treated participants with AKI had higher urine-neutrophil-gelatinase-associated lipocalin, suggesting that A+Z maybe nephrotoxic in patients with severe alcohol-associated hepatitis.
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Affiliation(s)
- Kavish R Patidar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Indiana University, Indianapolis, Indiana, USA
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Wanzhu Tu
- Department of Biostatistics and Health Data Science, Indiana University, Indianapolis, Indiana, USA
| | - Thomas G Cotter
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Amon Asgharpour
- Division of Gastroenterology, Department of Internal Medicine, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Muhammad Y Jan
- Division of Nephrology, Department of Internal Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Qing Tang
- Department of Biostatistics and Health Data Science, Indiana University, Indianapolis, Indiana, USA
| | - Yunpeng Yu
- Department of Biostatistics and Health Data Science, Indiana University, Indianapolis, Indiana, USA
| | - Yang Li
- Department of Biostatistics and Health Data Science, Indiana University, Indianapolis, Indiana, USA
| | - Moyinoluwa Taiwo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Prashanth Thevkar Nagesh
- Division of Gastroenterology, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Craig J McClain
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Gyongyi Szabo
- Division of Gastroenterology, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ramon Bataller
- Division of Gastroenterology and Hepatology and Nutrition, Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- School of Medicine and Health Sciences, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Mack Mitchell
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Wajahat Z Mehal
- Department of Internal Medicine, Section of Digestive Diseases, Yale University, New Haven, Connecticut, USA
- Department of Internal Medicine, Veterans Affairs Medical Center, West Haven, Connecticut, USA
| | - Laura E Nagy
- Department of Inflammation and Immunity, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Samer Gawrieh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Arun J Sanyal
- Division of Gastroenterology, Department of Internal Medicine, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, Virginia, USA
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21
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Lim J, Kim SE, Jo AJ, Kim JH, Han SK, Kim TH, Yim HJ, Jung YK, Song DS, Yoon EL, Kim HY, Kang SH, Chang Y, Yoo JJ, Lee SW, Park JG, Park JW, Jeong SW, Jin YJ, Kim HS, Suk KT, Kim MY, Kim SG, Kim W, Jang JY, Yang JM, Kim DJ. Effect of diabetes on mortality and liver transplantation in alcoholic liver cirrhotic patients with acute decompensation. Hepatol Int 2024:10.1007/s12072-024-10710-5. [PMID: 39020135 DOI: 10.1007/s12072-024-10710-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/14/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Previous studies have investigated the influence of diabetes on alcoholic liver cirrhosis patients, leaving its impact unclear. Thus, we conducted a study to reveal the association of diabetes and clinical outcomes of such patients. MATERIALS AND METHODS We prospectively collected data from multicenter pertaining to 965 patients diagnosed with alcoholic liver cirrhosis, all of whom were admitted due to acute decompensation between 2015 and 2019. Risk of major precipitating factors and incidences of death or liver transplantation in patients with and without diabetes was comparatively assessed. Propensity score (PS) matching was performed at a 1:2 ratio for accurate comparisons. RESULTS The mean age was 53.4 years, and 81.0% of the patients were male. Diabetes was prevalent in 23.6% of the cohort and was positively correlated with hepatic encephalopathy and upper gastrointestinal bleeding, although not statistically significant. During a median follow-up of 903.5 person-years (PYs), 64 patients with and 171 without diabetes died or underwent liver transplantation, with annual incidence of 33.6/100 PYs and 24.0/100 PYs, respectively. In the PS-matched cohort, the incidence of death or liver transplantation was 36.8/100 PYs and 18.6/100 PYs in the diabetes and matched control group, respectively. After adjusting for various factors, coexisting diabetes significantly heightened the risk of death or liver transplantation in the short and long term, in addition to prolonged prothrombin time, low serum albumin, elevated total bilirubin and creatinine, and decreased serum sodium levels. CONCLUSIONS Diabetes increases the risk of death or liver transplantation in patients with alcoholic liver cirrhosis.
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Affiliation(s)
- Jihye Lim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Eun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon, 24252, Republic of Korea.
| | - Ae Jeong Jo
- Department of Information Statistics, Andong National University, Andong-si, Republic of Korea
| | - Jung Hee Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon, 24252, Republic of Korea
| | - Seul Ki Han
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Ilsanro, Wonju, 26426, Republic of Korea
| | - Tae Hyung Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon, 24252, Republic of Korea
| | - Hyung Joon Yim
- Division of Gastroenterology, Department of Internal Medicine, Korea University Medical Center, Seoul, Republic of Korea
| | - Young Kul Jung
- Division of Gastroenterology, Department of Internal Medicine, Korea University Medical Center, Seoul, Republic of Korea
| | - Do Seon Song
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eileen L Yoon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, 04763, Republic of Korea
| | - Hee Yeon Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seong Hee Kang
- Division of Gastroenterology, Department of Internal Medicine, Korea University Medical Center, Seoul, Republic of Korea
| | - Young Chang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, 04401, Republic of Korea
| | - Jeong-Ju Yoo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, 14584, Republic of Korea
| | - Sung Won Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung Gil Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, 42415, Republic of Korea
| | - Ji Won Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon, 24252, Republic of Korea
| | - Soung Won Jeong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, 04401, Republic of Korea
| | - Young Joo Jin
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Republic of Korea
| | - Hyoung Su Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon, 24252, Republic of Korea
| | - Ki Tae Suk
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon, 24252, Republic of Korea
| | - Moon Young Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Ilsanro, Wonju, 26426, Republic of Korea
| | - Sang Gyune Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, 14584, Republic of Korea
| | - Won Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, 07061, Republic of Korea
| | - Jae Young Jang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, 04401, Republic of Korea
| | - Jin Mo Yang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong Joon Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon, 24252, Republic of Korea
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22
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Bhalla S, Mcquillen B, Cay E, Reau N. Preoperative risk evaluation and optimization for patients with liver disease. Gastroenterol Rep (Oxf) 2024; 12:goae071. [PMID: 38966126 PMCID: PMC11222301 DOI: 10.1093/gastro/goae071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 05/24/2024] [Accepted: 06/14/2024] [Indexed: 07/06/2024] Open
Abstract
The prevalence of liver disease is rising and more patients with liver disease are considered for surgery each year. Liver disease poses many potential complications to surgery; therefore, assessing perioperative risk and optimizing a patient's liver health is necessary to decrease perioperative risk. Multiple scoring tools exist to help quantify perioperative risk and can be used in combination to best educate patients prior to surgery. In this review, we go over the various scoring tools and provide a guide for clinicians to best assess and optimize perioperative risk based on the etiology of liver disease.
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Affiliation(s)
- Sameer Bhalla
- Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | | | - Edward Cay
- Internal Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Nancy Reau
- Internal Medicine, Division of Digestive Diseases, Section of Hepatology, Rush University Medical Center, Chicago, IL, USA
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23
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Swain LA, Godley J, Brahmania M, Abraldes JG, Tang KL, Flemming J, Shaheen AA. Validating new coding algorithms to improve identification of alcohol-associated and nonalcohol-associated cirrhosis hospitalizations in administrative databases. Hepatol Commun 2024; 8:e0469. [PMID: 38896072 PMCID: PMC11186834 DOI: 10.1097/hc9.0000000000000469] [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: 02/01/2024] [Accepted: 04/23/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Alcohol (AC) and nonalcohol-associated cirrhosis (NAC) epidemiology studies are limited by available case definitions. We compared the diagnostic accuracy of previous and newly developed case definitions to identify AC and NAC hospitalizations. METHODS We randomly selected 700 hospitalizations from the 2008 to 2022 Canadian Discharge Abstract Database with alcohol-associated and cirrhosis-related International Classification of Diseases 10th revision codes. We compared standard approaches for AC (ie, AC code alone and alcohol use disorder and nonspecific cirrhosis codes together) and NAC (ie, NAC codes alone) case identification to newly developed approaches that combine standard approaches with new code combinations. Using electronic medical record review as the reference standard, we calculated case definition positive and negative predictive values, sensitivity, specificity, and AUROC. RESULTS Electronic medical records were available for 671 admissions; 252 had confirmed AC and 195 NAC. Compared to previous AC definitions, the newly developed algorithm selecting for the AC code, alcohol-associated hepatic failure code, or alcohol use disorder code with a decompensated cirrhosis-related condition or NAC code provided the best overall positive predictive value (91%, 95% CI: 87-95), negative predictive value (89%, CI: 86-92), sensitivity (81%, CI: 76-86), specificity (96%, CI: 93-97), and AUROC (0.88, CI: 0.85-0.91). Comparing all evaluated NAC definitions, high sensitivity (92%, CI: 87-95), specificity (82%, CI: 79-86), negative predictive value (96%, CI: 94-98), AUROC (0.87, CI: 0.84-0.90), but relatively low positive predictive value (68%, CI: 62-74) were obtained by excluding alcohol use disorder codes and using either a NAC code in any diagnostic position or a primary diagnostic code for HCC, unspecified/chronic hepatic failure, esophageal varices without bleeding, or hepatorenal syndrome. CONCLUSIONS New case definitions show enhanced accuracy for identifying hospitalizations for AC and NAC compared to previously used approaches.
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Affiliation(s)
- Liam A. Swain
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jenny Godley
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Sociology, University of Calgary, Calgary, Alberta, Canada
| | - Mayur Brahmania
- Department of Medicine, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Juan G. Abraldes
- Liver Unit, Department of Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Karen L. Tang
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jennifer Flemming
- Department of Medicine and Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Abdel Aziz Shaheen
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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24
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Mohy-Ud-Din N, Lin FP, Rachakonda V, Al-Khafaji A, Biggins SW, Ganesh S, Bataller R, DiMartini A, Hughes C, Humar A, Malik SM. Expedited liver transplantation as first-line therapy for severe alcohol hepatitis: ELFSAH; deferring corticosteroids in the sickest subset of patients. Clin Transplant 2024; 38:e15340. [PMID: 39049597 DOI: 10.1111/ctr.15340] [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: 04/02/2024] [Revised: 05/03/2024] [Accepted: 05/10/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND & AIMS Severe alcohol-associated hepatitis (SAH) represents a lethal subset of alcohol-associated liver disease. Although corticosteroids are recommended by guidelines, their efficacy and safety remain questionable and so liver transplantation (LT) has been increasingly utilized. The timing and indication of corticosteroid use, specifically in patients being considered for LT requires further clarification. METHODS A retrospective analysis was conducted on 256 patients with SAH between 2018 and 2022 at a single US center. RESULTS Twenty of these patients underwent LT. Of the 256 patients, 38% had what we termed "catastrophic" SAH, defined as a MELD-Na ≥35 and/or discriminant function (DF) ≥100, which carried a mortality of 90% without LT. Compared with 100 matched controls, patients undergoing LT exhibited a one-year survival rate of 100% versus 35% (p < .0005). LT provided an absolute risk reduction of 65%, with a number needed to treat of 1.5. Steroid utilization in the entire cohort was 19% with 60% developing severe complications. Patients administered steroids were younger with lower MELD and DF scores. Only 10% of those prescribed steroids derived a favorable response. Sustained alcohol use post-LT was 20%. CONCLUSIONS We propose ELFSAH: Expedited LT as First Line Therapy for SAH; challenging the current paradigm with recommendations to defer steroids in patients with "catastrophic" SAH (defined as: MELD-Na ≥35 and/or DF ≥100). Patients should be seen urgently by hepatology, transplant surgery, psychiatry and social work. Patients without an absolute contraindication should be referred for LT as first-line therapy during their index admission.
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Affiliation(s)
- Nabeeha Mohy-Ud-Din
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Fei-Pi Lin
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Vikrant Rachakonda
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine Veteran's Association Northern California Healthcare System, Sacramento, California, USA
| | - Ali Al-Khafaji
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Scott W Biggins
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Swaytha Ganesh
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Andrea DiMartini
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher Hughes
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Abhinav Humar
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Shahid M Malik
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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25
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Kumar H, Dhanjal DS, Guleria S, Nepovimova E, Sethi N, Dhalaria R, Kuca K. Hepatoprotective effects of fruits pulp, seed, and peel against chemical-induced toxicity: Insights from in vivo studies. Food Chem Toxicol 2024; 189:114742. [PMID: 38754807 DOI: 10.1016/j.fct.2024.114742] [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: 03/24/2024] [Revised: 05/11/2024] [Accepted: 05/13/2024] [Indexed: 05/18/2024]
Abstract
The liver is a vital organ in human physiology positioned in the upper right quadrant of the peritoneal cavity, which plats a critical role in metabolic processes, detoxification of various substances and overall homeostasis. Along with these critical functions, hepatic diseases impose as significant global health threat. Liver illness is the cause of two million fatalities every year, or 4% of all deaths. Traditionally, healthcare providers have prescribed antibacterial and antiviral medications to address liver illness. Nephrotoxicity is a frequently observed negative reaction to drugs, with the majority of such events happening in individuals who have advanced cirrhosis. Thus, recognizing this gap, there is a dire need of exploration of pharmaceutical alterative for hepatic diseases, with special focus on their efficacy and reduced toxicity. Fruits have long been known to therapeutic impact on human health, thus exploration of fruits components namely pulp, seeds and peels containing phytochemicals have emerged as a promising avenue for hepatoprotective interventions. Thus, review comprehends the information about worldwide burden of chemical induced toxicity and injuries as well as highlight the on-going challenges in hepatic disease management. It also shed light on the valuable contributions fruit parts and their phytocompounds obtained from different components of fruits. Fruit pulp, especially when rich in flavonoids, has demonstrated significant potential in animal model studies. It has been observed to enhance the activity of antioxidant enzymes and reduce the expression of pro-inflammatory markers. The methanolic and ethanolic extracts have demonstrated the most favorable outcomes. Further, this review also discusses about the safety assessments of fruits extracts for their utilization as hepatoprotective agents.
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Affiliation(s)
- Harsh Kumar
- Centre of Advanced Technologies, Faculty of Science, University of Hradec Kralove, Rokitanskeho 62, 50003, Hradec Kralove, Czech Republic
| | - Daljeet Singh Dhanjal
- School of Bioengineering and Biosciences, Lovely Professional University, Phagwara, Punjab, 144411, India
| | - Shivani Guleria
- Department of Biotechnology, TIFAC-Centre of Relevance and Excellence in Agro and Industrial Biotechnology (CORE), Thapar Institute of Engineering and Technology, Patiala, 147001, India.
| | - Eugenie Nepovimova
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, 50003, Hradec Kralove, Czech Republic
| | - Nidhi Sethi
- Department of Pharmaceutical Sciences, Guru Nanak Dev University, Amritsar, 143005, India
| | - Rajni Dhalaria
- School of Biological and Environmental Sciences, Shoolini University of Biotechnology and Management Sciences, Solan, 173229, India.
| | - Kamil Kuca
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, 50003, Hradec Kralove, Czech Republic.
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26
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Ignat M, Stefanescu H. Non-Invasive Biomarkers for Differentiating Alcohol Associated Hepatitis from Acute Decompensation in Patients with ALD. J Clin Med 2024; 13:3747. [PMID: 38999313 PMCID: PMC11242687 DOI: 10.3390/jcm13133747] [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: 05/19/2024] [Revised: 06/17/2024] [Accepted: 06/22/2024] [Indexed: 07/14/2024] Open
Abstract
Alcohol-associated hepatitis (AH) is the most severe form of alcohol-related liver disease. The natural course of alcohol-related liver disease is influenced by heavy alcohol consumption and abstinence periods. Differentiating between AH and decompensated cirrhosis (DC) could be extremely challenging in clinical practice due to clinical and bioclinical similarities. The severity of AH is made on bioclinical grounds, the severe form necessitating corticotherapy treatment. Liver biopsy is still the standard of care for establishing the diagnosis in atypical presentations. The pathogenesis of AH is an interplay between gene expression, cytokine dysregulation, the immune system and the gut microbiota. Non-invasive tests are increasingly and widely used for the purpose of early diagnosis and reliable prognostication. The non-invasive tests are emerging in concordance with disease pathogenesis. In this review, we describe the non-invasive tools that can distinguish AH from DC. We outline the available cut-offs and their performance in diagnosis and prognosis, as well as in assessing the treatment response to corticotherapy. Promising circulating biomarkers like keratin 18, microRNAs and sphingolipids will be in the review.
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Affiliation(s)
- Mina Ignat
- Regional Institute of Gastroenterology and Hepatology "Prof. Dr. O. Fodor", 400394 Cluj-Napoca, Romania
- Faculty of Medicine, University of Medicine and Pharmacy "Iuliu Hatieganu", 400347 Cluj-Napoca, Romania
| | - Horia Stefanescu
- Regional Institute of Gastroenterology and Hepatology "Prof. Dr. O. Fodor", 400394 Cluj-Napoca, Romania
- Faculty of Medicine, University of Medicine and Pharmacy "Iuliu Hatieganu", 400347 Cluj-Napoca, Romania
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27
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Houston K, Duong N, Sterling RK, Asgharpour A, Bullock S, Weinland S, Keller N, Smirnova E, Khan H, Matherly S, Wedd J, Lee H, Siddiqui M, Patel V, Arias A, Kumaran V, Lee S, Sharma A, Khan A, Imai D, Levy M, Bruno D. Utility of scores to predict alcohol use after liver transplant: Take them with a grain of salt. Liver Transpl 2024:01445473-990000000-00386. [PMID: 38775570 DOI: 10.1097/lvt.0000000000000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 04/23/2024] [Indexed: 09/19/2024]
Abstract
The Sustained Alcohol use post-Liver Transplant (SALT) and the High-Risk Alcohol Relapse (HRAR) scores were developed to predict a return to alcohol use after a liver transplant (LT) for alcohol-associated liver disease. A retrospective analysis of deceased donor LT from October 2018 to April 2022 was performed. All patients underwent careful pre-LT psychosocial evaluation. Data on alcohol use, substance abuse, prior rehabilitation, and legal issues were collected. After LT, all were encouraged to participate in rehabilitation programs and underwent interval phosphatidylethanol testing. Patients with alcohol-associated liver disease were stratified by < or > 6 months of sobriety before listing. Those with <6 months were further stratified as acute alcoholic hepatitis (AH) by NIAAA criteria and non-AH. The primary outcome was the utility of the SALT (<5 vs. ≥5) and HRAR (<3 vs. ≥3) scores to predict a return to alcohol use (+phosphatidylethanol) within 1 year after LT. Of the 365 LT, 86 had > 6 months of sobriety, and 85 had <6 months of sobriety; 41 with AH and 44 non-AH. In those with AH, the mean time of abstinence to LT was 58 days, and 71% failed prior rehabilitation. Following LT, the return to drinking was similar in the AH (24%) compared to <6-month non-AH (15%) and >6-month alcohol-associated liver disease (22%). Only 4% had returned to heavy drinking. The accuracy of both the SALT and HRAR scores to predict a return to alcohol was low (accuracy 61%-63%) with poor sensitivity (46% and 37%), specificity (67%-68%), positive predictive value (22%-26%) with moderate negative predictive value (81%-83%), respectively with higher negative predictive values (95%) in predicting a return to heavy drinking. Both SALT and HRAR scores had good negative predictive value in identifying patients at low risk for recidivism.
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Affiliation(s)
- Kevin Houston
- Department of Internal Medicine, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Nikki Duong
- Department of Internal Medicine, Virginia Commonwealth University Health System, Richmond, Virginia, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Health System, Richmond, Virginia, USA
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Richard K Sterling
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Health System, Richmond, Virginia, USA
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Amon Asgharpour
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Health System, Richmond, Virginia, USA
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Sheila Bullock
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Stephan Weinland
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Nicole Keller
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Ekaterina Smirnova
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Hiba Khan
- Department of Internal Medicine, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Scott Matherly
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Health System, Richmond, Virginia, USA
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Joel Wedd
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Health System, Richmond, Virginia, USA
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Hannah Lee
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Health System, Richmond, Virginia, USA
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Mohammad Siddiqui
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Health System, Richmond, Virginia, USA
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Vaishali Patel
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Health System, Richmond, Virginia, USA
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Albert Arias
- Department of Psychiatry, Virginia Commonwealth School of Medicine, and the VCU Institute for Drug and Alcohol Studies, Richmond, Virginia, USA
| | - Vinay Kumaran
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Seung Lee
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Amit Sharma
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Aamir Khan
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Daisuke Imai
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Marlon Levy
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - David Bruno
- Hume-Lee Transplant Center, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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28
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Ge X, Han H, Desert R, Das S, Song Z, Komakula SSB, Chen W, Athavale D, Lantvit D, Nieto N. A Protein Complex of Liver Origin Activates a Pro-inflammatory Program That Drives Hepatic and Intestinal Injury in Alcohol-Associated Liver Disease. Cell Mol Gastroenterol Hepatol 2024; 18:101362. [PMID: 38788899 PMCID: PMC11296289 DOI: 10.1016/j.jcmgh.2024.05.010] [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: 01/03/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND & AIMS There is limited information on how the liver-to-gut axis contributes to alcohol-associated liver disease (AALD). We previously identified that high-mobility group box-1 (HMGB1) undergoes oxidation in hepatocytes and demonstrated elevated serum levels of oxidized HMGB1 ([O] HMGB1) in alcoholic patients. Since interleukin-1 beta (IL-1B) increases in AALD, we hypothesized hepatocyte-derived [O] HMGB1 could interact with IL-1B to activate a pro-inflammatory program that, besides being detrimental to the liver, drives intestinal barrier dysfunction. RESULTS Alcohol-fed RageΔMye mice exhibited decreased nuclear factor kappa B signaling, a pro-inflammatory signature, and reduced total intestinal permeability, resulting in protection from AALD. In addition, [O] HMGB1 bound and signaled through the receptor for advanced-glycation end-products (RAGE) in myeloid cells, driving hepatic inflammation, intestinal permeability, and increased portal blood lipopolysaccharide in AALD. We identified that [O] HMGB1 formed a complex with IL-1B, which was found in the livers of patients with acute alcoholic hepatitis and mice with AALD. This complex originated from the liver, because it was absent in the intestine when hepatocytes did not produce [O] HMGB1. Mechanistically, the complex bound RAGE in Kupffer cells and macrophages induced a pro-inflammatory program. Moreover, it bound RAGE in intestinal macrophages and epithelial cells, leading to intestinal inflammation, altered intestinal epithelial cell tight junction protein expression, increased intestinal permeability, and elevated portal blood lipopolysaccharide, enhancing AALD pathogenesis. CONCLUSIONS We identified a protein complex of liver origin that amplifies the pro-inflammatory feedback loop in AALD; therefore, targeting this complex could have significant therapeutic potential.
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Affiliation(s)
- Xiaodong Ge
- Department of Pathology, University of Illinois Chicago, Chicago, Illinois
| | - Hui Han
- Department of Pathology, University of Illinois Chicago, Chicago, Illinois
| | - Romain Desert
- Department of Pathology, University of Illinois Chicago, Chicago, Illinois
| | - Sukanta Das
- Department of Pathology, University of Illinois Chicago, Chicago, Illinois
| | - Zhuolun Song
- Department of Pathology, University of Illinois Chicago, Chicago, Illinois
| | | | - Wei Chen
- Department of Pathology, University of Illinois Chicago, Chicago, Illinois
| | - Dipti Athavale
- Department of Pathology, University of Illinois Chicago, Chicago, Illinois
| | - Daniel Lantvit
- Department of Pathology, University of Illinois Chicago, Chicago, Illinois
| | - Natalia Nieto
- Department of Pathology, University of Illinois Chicago, Chicago, Illinois; Department of Medicine, Division of Gastroenterology and Hepatology, University of Illinois Chicago, Chicago, Illinois; Research & Development Service, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois.
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29
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Narayanan P, Wu T, Shah VH, Curtis BL. Insights into ALD and AUD diagnosis and prognosis: Exploring AI and multimodal data streams. Hepatology 2024:01515467-990000000-00879. [PMID: 38743008 DOI: 10.1097/hep.0000000000000929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 05/01/2024] [Indexed: 05/16/2024]
Abstract
The rapid evolution of artificial intelligence and the widespread embrace of digital technologies have ushered in a new era of clinical research and practice in hepatology. Although its potential is far from realization, these significant strides have generated new opportunities to address existing gaps in the delivery of care for patients with liver disease. In this review, we discuss how artificial intelligence and opportunities for multimodal data integration can improve the diagnosis, prognosis, and management of alcohol-associated liver disease. An emphasis is made on how these approaches will also benefit the detection and management of alcohol use disorder. Our discussion encompasses challenges and limitations, concluding with a glimpse into the promising future of these advancements.
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Affiliation(s)
- Praveena Narayanan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tiffany Wu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Brenda L Curtis
- Technology and Translational Research Unit, National Institute on Drug Abuse Intramural Research Program, National Institute of Health, Baltimore, Maryland, USA
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30
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Gawrieh S, Dasarathy S, Tu W, Kamath PS, Chalasani NP, McClain CJ, Bataller R, Szabo G, Tang Q, Radaeva S, Barton B, Nagy LE, Shah VH, Sanyal AJ, Mitchell MC. Randomized trial of anakinra plus zinc vs. prednisone for severe alcohol-associated hepatitis. J Hepatol 2024; 80:684-693. [PMID: 38342441 PMCID: PMC11214682 DOI: 10.1016/j.jhep.2024.01.031] [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: 07/07/2023] [Revised: 01/18/2024] [Accepted: 01/21/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND & AIMS Severe alcohol-associated hepatitis (SAH) is associated with high 90-day mortality. Glucocorticoid therapy for 28 days improves 30- but not 90-day survival. We assessed the efficacy and safety of a combination of anakinra, an IL-1 antagonist, plus zinc (A+Z) compared to prednisone using the Day-7 Lille score as a stopping rule in patients with SAH. METHODS In this phase IIb double-blind randomized trial in adults with SAH and MELD scores of 20-35, participants were randomized to receive either daily anakinra 100 mg subcutaneously for 14 days plus daily zinc sulfate 220 mg orally for 90 days, or daily prednisone 40 mg orally for 30 days. Prednisone or prednisone placebo was stopped if Day-7 Lille score was >0.45. All study drugs were stopped for uncontrolled infection or ≥5 point increase in MELD score. The primary endpoint was overall survival at 90 days. RESULTS Seventy-three participants were randomized to prednisone and 74 to A+Z. The trial was stopped early after a prespecified interim analysis showed prednisone was associated with higher 90-day overall survival (90% vs. 70%; hazard ratio for death = 0.34, 95% CI 0.14-0.83, p = 0.018) and transplant-free survival (88% vs. 64%; hazard ratio for transplant or death = 0.30, 95% CI 0.13-0.69, p = 0.004) than A+Z. Acute kidney injury was more frequent with A+Z (45%) than prednisone (22%) (p = 0.001), but rates of infection were similar (31% in A+Z vs. 27% in prednisone, p = 0.389). CONCLUSIONS Participants with SAH treated with prednisone using the Day-7 Lille score as a stopping rule had significantly higher overall and transplant-free 90-day survival and lower incidence of acute kidney injury than those treated with A+Z. IMPACT AND IMPLICATIONS There is no approved treatment for severe alcohol-associated hepatitis (SAH). In this double-blind randomized trial, patients with SAH treated with prednisone using the Lille stopping rule on Day 7 had higher 90-day overall and transplant-free survival and lower rates of acute kidney injury compared to patients treated with a combination of anakinra and zinc. The data support continued use of glucocorticoids for patients with SAH, with treatment discontinuation for those with a Lille score >0.45 on Day 7. TRIAL REGISTRATION NCT04072822.
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Affiliation(s)
- Samer Gawrieh
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, United States
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Wanzhu Tu
- Department of Biostatistics and Health Data Science, Indiana University, Indianapolis, IN, United States
| | - Patrick S Kamath
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Naga P Chalasani
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, United States
| | - Craig J McClain
- Division of Gastroenterology and Hepatology, University of Louisville, Louisville, KY, United States
| | - Ramon Bataller
- Division of Gastroenterology and Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, United States; Division of Hepatology, Hospital Clinic, Barcelona, Spain
| | - Gyongyi Szabo
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Qing Tang
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, United States
| | - Svetlana Radaeva
- National Institute on Alcohol Abuse and Alcoholism, Rockville, MD, United States
| | - Bruce Barton
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Laura E Nagy
- Division of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Vijay H Shah
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Arun J Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, VA, United States
| | - Mack C Mitchell
- Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, TX, United States.
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31
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Ramirez-Cadiz C, Blaney H, Kubanek N, Díaz LA, Loomba R, Skladany L, Arab JP. Review article: Current indications and selection criteria for early liver transplantation in severe alcohol-associated hepatitis. Aliment Pharmacol Ther 2024; 59:1049-1061. [PMID: 38475893 DOI: 10.1111/apt.17948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 10/17/2023] [Accepted: 03/03/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Alcohol-associated hepatitis (AH) is a severe inflammatory form of alcohol-associated liver disease (ALD) that carries a high mortality rate. Early liver transplantation for severe AH is increasingly available. However, specific criteria for referral and selection remain a subject of debate. AIMS To provide a narrative review of the natural history, diagnostic criteria and indications for referral for early liver transplantation for severe AH. METHODS We searched PubMed for articles published through August 2023. Key search terms were 'alcoholic hepatitis,' 'alcohol-associated hepatitis,' 'abstinence,' 'alcohol relapse,' and 'liver transplantation.' RESULTS Previously, a six-month period of alcohol abstinence was required before patients with ALD were considered for liver transplantation. However, studies in recent years have demonstrated that, among carefully selected patients, patients who received early transplants have much higher survival rates than patients with similarly severe disease who did not undergo transplants (77% vs. 23%). Despite these successes, early liver transplantation remains controversial, as these patients have typically not undergone treatment for alcohol use disorder, with the ensuing risk of returning to alcohol use. CONCLUSIONS While early liver transplantation for AH has survival benefits, many patients would not have received treatment for alcohol use disorder. An integrated approach to evaluating candidacy for early liver transplantation is needed.
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Affiliation(s)
- Carolina Ramirez-Cadiz
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
| | - Hanna Blaney
- Division of Gastroenterology and Hepatology, University of Maryland, College Park, Maryland, USA
| | - Natalia Kubanek
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University Faculty of Medicine, F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Luis Antonio Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rohit Loomba
- Division of Gastroenterology, University of California at San Diego, San Diego, California, USA
| | - Lubomir Skladany
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University Faculty of Medicine, F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Juan Pablo Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada
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Bajaj JS, Choudhury A, Kumaran V, Wong F, Seto WK, Alvares-Da-Silva MR, Desalgn H, Hayes PC, Idilman R, Topazian M, Torre A, Xie Q, George J, Kamath PS. Geographic disparities in access to liver transplant for advanced cirrhosis: Time to ring the alarm! Am J Transplant 2024; 24:733-742. [PMID: 38387623 DOI: 10.1016/j.ajt.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 02/03/2024] [Accepted: 02/06/2024] [Indexed: 02/24/2024]
Abstract
Decompensated cirrhosis and hepatocellular cancer are major risk factors for mortality worldwide. Liver transplantation (LT), both live-donor LT or deceased-donor LT, are lifesaving, but there are several barriers toward equitable access. These barriers are exacerbated in the setting of critical illness or acute-on-chronic liver failure. Rates of LT vary widely worldwide but are lowest in lower-income countries owing to lack of resources, infrastructure, late disease presentation, and limited donor awareness. A recent experience by the Chronic Liver Disease Evolution and Registry for Events and Decompensation consortium defined these barriers toward LT as critical in determining overall survival in hospitalized cirrhosis patients. A major focus should be on appropriate, affordable, and early cirrhosis and hepatocellular cancer care to prevent the need for LT. Live-donor LT is predominant across Asian countries, whereas deceased-donor LT is more common in Western countries; both approaches have unique challenges that add to the access disparities. There are many challenges toward equitable access but uniform definitions of acute-on-chronic liver failure, improving transplant expertise, enhancing availability of resources and encouraging knowledge between centers, and preventing disease progression are critical to reduce LT disparities.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, Virginia, USA.
| | - Ashok Choudhury
- Department of Hepatology, Institute for Liver and Biliary Sciences, New Delhi, India
| | - Vinay Kumaran
- Division of Transplant Surgery, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Florence Wong
- Division of Gastroenterology & Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Wai Kay Seto
- Department of Medicine, School of Clinical Medicine, the University of Hong Kong, Hong Kong, China
| | - Mario Reis Alvares-Da-Silva
- Department of Hepatology, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Hailemichael Desalgn
- Gastroenterology and Hepatology Unit, St Paul's Hospital, Millennium Medical College, Addis Ababa, Ethiopia
| | - Peter C Hayes
- Hepatology, Division of Health Sciences, Deanery of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - Ramazan Idilman
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Mark Topazian
- Gastroenterology and Hepatology Unit, St Paul's Hospital, Millennium Medical College, Addis Ababa, Ethiopia
| | - Aldo Torre
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Qing Xie
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jacob George
- Storr Liver Centre, Westmead Millennium Institute, Westmead Hospital and University of Sydney, New South Wales, Australia
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
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Thursz M, Mathurin P. Targeting IL-1 in severe alcohol-related hepatitis: How many frogs will we need to kiss to find an effective therapy? J Hepatol 2024; 80:678-680. [PMID: 38499249 DOI: 10.1016/j.jhep.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 03/10/2024] [Indexed: 03/20/2024]
Affiliation(s)
- Mark Thursz
- Department of Metabolism, Digestion & Reproduction, Imperial College, London W2 1NY, UK.
| | - Philippe Mathurin
- Service des maladies de l'appareil digestif, Hôpital Huriez, Rue Polonowski, 59037 Lille, France.
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Stauber RE, Rautou PE, Stefanescu H, Horhat A, Thiele M, Lackner C. Validation of NIAAAm-CRP criteria to predict alcohol-associated steatohepatitis on liver histology. JHEP Rep 2024; 6:101055. [PMID: 38601479 PMCID: PMC11002864 DOI: 10.1016/j.jhepr.2024.101055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/11/2024] [Accepted: 02/19/2024] [Indexed: 04/12/2024] Open
Abstract
Background & Aims In clinical practice, the diagnosis of alcohol-associated hepatitis (AH) is mostly based on non-invasive criteria, which were defined at a consensus conference by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). These criteria were recently modified by adding C-reactive protein (CRP) and termed NIAAAm-CRP criteria, which showed superior diagnostic accuracy for presence of alcohol-associated steatohepatitis (ASH) on liver histology. The aim of our study was to validate the diagnostic accuracy of both original NIAAA criteria and NIAAAm-CRP criteria for presence of ASH on liver histology in an independent cohort. Methods Data from a large multinational cohort of 445 patients with alcohol-associated liver disease (ALD) that served to establish a novel grading and staging system of alcohol-associated liver disease were analyzed retrospectively. Diagnosis of ASH was based on presence of hepatocyte ballooning plus lobular neutrophil infiltration and established in virtual consensus meetings of multiple expert liver pathologists. Results Complete data including CRP values were available in 346 patients. Overall diagnostic accuracy for prediction of ASH was 73% for NIAAA criteria and 77% for NIAAAm-CRP criteria. In a subgroup with suspected severe AH (MELD >20, n = 123), overall diagnostic accuracy for prediction of ASH was 69% for NIAAA criteria and 74% for NIAAAm-CRP criteria. Conclusion Our findings confirm recent data on suboptimal diagnostic accuracy of original NIAAA criteria and validate slightly better but still suboptimal performance of NIAAAm-CRP criteria for presence of ASH. Impact and Implications Alcohol-associated steatohepatitis (ASH) is diagnosed on liver histology but liver biopsy is not always feasible. Non-invasive diagnosis based on clinical findings has been proposed using the National Institute on Alcohol Abuse and Alcoholism (NIAAA) criteria and recently improved using NIAAAm-CRP criteria. Our findings validate slightly better but still suboptimal performance of NIAAAm-CRP criteria for the presence of histological ASH. Clinical trials of novel drugs should focus on histologically proven ASH.
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Affiliation(s)
- Rudolf E. Stauber
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Pierre-Emmanuel Rautou
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- Service d'Hépatologie, AP-HP, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
| | - Horia Stefanescu
- Liver Unit, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Adelina Horhat
- Service d’Hépato-Gastro-Entérologie, Hôpital La Pitié Salpêtrière, Paris, France
- “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Maja Thiele
- Center for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, and Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Carolin Lackner
- Institute of Pathology, Medical University of Graz, Graz, Austria
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Åberg F, Jiang ZG, Cortez-Pinto H, Männistö V. Alcohol-associated liver disease-Global epidemiology. Hepatology 2024:01515467-990000000-00852. [PMID: 38640041 DOI: 10.1097/hep.0000000000000899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 03/23/2024] [Indexed: 04/21/2024]
Abstract
Alcohol-associated liver disease (ALD), as highlighted in this narrative review, is a major public health concern, increasingly impacting global disease burden and premature mortality. In 2019, ALD accounted for the loss of 11 million life-years worldwide. The rising number of deaths and disability-adjusted life-years attributed to ALD, particularly pronounced in the United States, are alarming. Projections suggest that the economic impact of ALD, as seen in the United States, could potentially double by 2040. ALD is increasingly prevalent among younger adults (20-45 y) and has become the leading cause of liver transplantation in both United States and Europe. During the COVID-19 pandemic, the existing trend was further amplified as high-risk drinking patterns coincided with a rise in hospital admissions for alcohol-associated hepatitis and increased ALD-related mortality. The prevalence of ALD is estimated at 3.5% in the general population, 26.0% among hazardous drinkers, and 55.1% among those with alcohol use disorders. Alarmingly, 5-year mortality rates for patients with ALD exceed 50%, with even higher rates in more advanced disease stages. Methodological challenges, such as underreporting, diagnostic difficulties, and variability in registry data quality, complicate the accurate assessment of the impact of ALD. Additionally, the contribution of alcohol to the progression of other liver diseases is often under acknowledged in health care registries, leading to a significant underestimation of its broader implications for liver health. Addressing the growing ALD concern requires robust public health initiatives, heightened awareness, refined diagnostic techniques, and comprehensive epidemiological studies. These measures are vital to tackle the increasing prevalence of ALD and mitigate its extensive impact on individuals and health care systems.
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Affiliation(s)
- Fredrik Åberg
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Z Gordon Jiang
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Helena Cortez-Pinto
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - Ville Männistö
- Department of Medicine, University of Eastern Finland, Kuopio, Finland
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
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Dunn W, Li Y, Singal AK, Simonetto DA, Díaz LA, Idalsoaga F, Ayares G, Arnold J, Ayala-Valverde M, Perez D, Gomez J, Escarate R, Fuentes-López E, Ramirez-Cadiz C, Morales-Arraez D, Zhang W, Qian S, Ahn JC, Buryska S, Mehta H, Dunn N, Waleed M, Stefanescu H, Bumbu A, Horhat A, Attar B, Agrawal R, Cabezas J, Echavaría V, Cuyàs B, Poca M, Soriano G, Sarin SK, Maiwall R, Jalal PK, Higuera-de-la-Tijera F, Kulkarni AV, Rao PN, Guerra-Salazar P, Skladaný L, Kubánek N, Prado V, Clemente-Sanchez A, Rincon D, Haider T, Chacko KR, Romero GA, Pollarsky FD, Restrepo JC, Toro LG, Yaquich P, Mendizabal M, Garrido ML, Marciano S, Dirchwolf M, Vargas V, Jiménez C, Hudson D, García-Tsao G, Ortiz G, Abraldes JG, Kamath PS, Arrese M, Shah VH, Bataller R, Arab JP. An artificial intelligence-generated model predicts 90-day survival in alcohol-associated hepatitis: A global cohort study. Hepatology 2024:01515467-990000000-00843. [PMID: 38607809 DOI: 10.1097/hep.0000000000000883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/14/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND AND AIMS Alcohol-associated hepatitis (AH) poses significant short-term mortality. Existing prognostic models lack precision for 90-day mortality. Utilizing artificial intelligence in a global cohort, we sought to derive and validate an enhanced prognostic model. APPROACH AND RESULTS The Global AlcHep initiative, a retrospective study across 23 centers in 12 countries, enrolled patients with AH per National Institute for Alcohol Abuse and Alcoholism criteria. Centers were partitioned into derivation (11 centers, 860 patients) and validation cohorts (12 centers, 859 patients). Focusing on 30 and 90-day postadmission mortality, 3 artificial intelligence algorithms (Random Forest, Gradient Boosting Machines, and eXtreme Gradient Boosting) informed an ensemble model, subsequently refined through Bayesian updating, integrating the derivation cohort's average 90-day mortality with each center's approximate mortality rate to produce posttest probabilities. The ALCoholic Hepatitis Artificial INtelligence Ensemble score integrated age, gender, cirrhosis, and 9 laboratory values, with center-specific mortality rates. Mortality was 18.7% (30 d) and 27.9% (90 d) in the derivation cohort versus 21.7% and 32.5% in the validation cohort. Validation cohort 30 and 90-day AUCs were 0.811 (0.779-0.844) and 0.799 (0.769-0.830), significantly surpassing legacy models like Maddrey's Discriminant Function, Model for End-Stage Liver Disease variations, age-serum bilirubin-international normalized ratio-serum Creatinine score, Glasgow, and modified Glasgow Scores ( p < 0.001). ALCoholic Hepatitis Artificial INtelligence Ensemble score also showcased superior calibration against MELD and its variants. Steroid use improved 30-day survival for those with an ALCoholic Hepatitis Artificial INtelligence Ensemble score > 0.20 in both derivation and validation cohorts. CONCLUSIONS Harnessing artificial intelligence within a global consortium, we pioneered a scoring system excelling over traditional models for 30 and 90-day AH mortality predictions. Beneficial for clinical trials, steroid therapy, and transplant indications, it's accessible at: https://aihepatology.shinyapps.io/ALCHAIN/ .
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Affiliation(s)
- Winston Dunn
- Department of Gastroenterology, University of Kansas Medical Center, Kansas, USA
| | - Yanming Li
- Department of Gastroenterology, University of Kansas Medical Center, Kansas, USA
| | - Ashwani K Singal
- Department of Gastroenterology and Hepatology, University of Louisville, Louisville, Kentucky, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Luis A Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Idalsoaga
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gustavo Ayares
- Department of Medicine, Servicio Medicina Interna, Hospital El Pino, Santiago, Chile
| | - Jorge Arnold
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - María Ayala-Valverde
- Department of Medicine, Servicio Medicina Interna, Hospital El Pino, Santiago, Chile
| | - Diego Perez
- Department of Medicine, Servicio Medicina Interna, Hospital El Pino, Santiago, Chile
| | - Jaime Gomez
- Department of Medicine, Servicio Medicina Interna, Hospital El Pino, Santiago, Chile
| | - Rodrigo Escarate
- Department of Medicine, Servicio Medicina Interna, Hospital El Pino, Santiago, Chile
| | - Eduardo Fuentes-López
- Department of Health Sciences, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carolina Ramirez-Cadiz
- Department of Anesthesiology and Perioperative Medicine, Schulich School of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Dalia Morales-Arraez
- Department of Medicine, Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pennsylvania, USA
| | - Wei Zhang
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
- Department of Medicine, Center for Liver Disease and Liver Transplantation, Columbia University, New York, New York, USA
| | - Steve Qian
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Joseph C Ahn
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Seth Buryska
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Heer Mehta
- Department of Gastroenterology, University of Kansas Medical Center, Kansas, USA
| | - Nicholas Dunn
- Department of Gastroenterology, University of Kansas Medical Center, Kansas, USA
| | - Muhammad Waleed
- Department of Gastroenterology and Hepatology, University of Louisville, Louisville, Kentucky, USA
| | - Horia Stefanescu
- Department of Medicine, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Andreea Bumbu
- Department of Medicine, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Adelina Horhat
- University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj-Napoca, Romania
| | - Bashar Attar
- Division of Gastroenterology and Hepatology, Department of Medicine, Cook County Health, and Hospital Systems, Chicago, Illinois, USA
| | - Rohit Agrawal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of West Virginia, West Virginia, USA
| | - Joaquín Cabezas
- Department of Gastroenterology and Hepatology, University Hospital Marqués de Valdecilla, Santander, Spain
- Clinical and Translational Research in Digestive Diseases, Research Institute Valdecilla (IDIVAL). Santander, Spain
| | - Victor Echavaría
- Department of Gastroenterology and Hepatology, University Hospital Marqués de Valdecilla, Santander, Spain
- Clinical and Translational Research in Digestive Diseases, Research Institute Valdecilla (IDIVAL). Santander, Spain
| | - Berta Cuyàs
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Institut de Recerca Hospital de Sant Pau-IIB Sant Pau, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - Maria Poca
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Institut de Recerca Hospital de Sant Pau-IIB Sant Pau, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - German Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Institut de Recerca Hospital de Sant Pau-IIB Sant Pau, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Prasun K Jalal
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Fátima Higuera-de-la-Tijera
- Department of Medicine, Servicio de Gastroenterología y Hepatología, Hospital General de México "Dr. Eduardo Liceaga"; Facultad de Medicina, Universidad Nacional Autónoma de México, México
| | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - P Nagaraja Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | | | - Lubomir Skladaný
- Department of Internal Medicine II, Division of Hepatology, Gastroenterology and Liver Transplantation, Slovak Medical University, F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Natália Kubánek
- Department of Internal Medicine II, Division of Hepatology, Gastroenterology and Liver Transplantation, Slovak Medical University, F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Veronica Prado
- Department of Medicine, Centre Hospitalier de Luxembourg, Luxembourg
| | - Ana Clemente-Sanchez
- Department of Medicine, Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pennsylvania, USA
- Department of Digestive Diseases, Liver Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- CIBERehd Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Diego Rincon
- Department of Digestive Diseases, Liver Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Tehseen Haider
- Division of Gastroenterology and Hepatology, Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Kristina R Chacko
- Division of Gastroenterology and Hepatology, Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Gustavo A Romero
- Department of Medicine, Sección Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Florencia D Pollarsky
- Department of Medicine, Sección Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Juan C Restrepo
- Unidad de Hepatología del Hospital Pablo Tobon Uribe, Grupo de Gastrohepatología de la Universidad de Antioquia, Medellín, Colombia
| | - Luis G Toro
- Department of Medicine, Hepatology and Liver Transplant Unit, Hospitales de San Vicente Fundación de Medellín y Rionegro, Colombia
| | - Pamela Yaquich
- Departamento de Gastroenterología, Hospital San Juan de Dios, Santiago, Chile
| | - Manuel Mendizabal
- Department of Medicine, Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Buenos Aires, Argentina
| | | | - Sebastián Marciano
- Department of Medicine, Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Melisa Dirchwolf
- Department of Medicine, Unidad de Hígado, Hospital Privado de Rosario, Rosario, Argentina
| | - Victor Vargas
- Department of Medicine, Liver Unit, Hospital Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - César Jiménez
- Department of Medicine, Liver Unit, Hospital Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - David Hudson
- Department of Medicine, Division of Gastroenterology, Schulich School of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Guadalupe García-Tsao
- Department of Medicine, Section of Digestive Diseases, Yale University School of Medicine/VA-CT Healthcare System, New Haven, CT, USA
| | - Guillermo Ortiz
- Department of Medicine, Section of Digestive Diseases, Yale University School of Medicine/VA-CT Healthcare System, New Haven, CT, USA
| | - Juan G Abraldes
- Division of Gastroenterology, Department of Medicine, Liver Unit, University of Alberta, Edmonton, Canada
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Marco Arrese
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ramon Bataller
- Department of Medicine, Liver Unit, Hospital Clinic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Juan P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Medicine, Division of Gastroenterology, Schulich School of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada
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Israelsen M, Rungratanawanich W, Thiele M, Liangpunsakul S. Non-invasive tests for alcohol-associated liver disease. Hepatology 2024:01515467-990000000-00841. [PMID: 38607723 DOI: 10.1097/hep.0000000000000885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 03/23/2024] [Indexed: 04/14/2024]
Abstract
Alcohol consumption is a global phenomenon and a major contributor to alcohol-associated liver disease (ALD). Detecting individuals at risk of ALD has been challenging, with only a small fraction of patients being identified at early stages compared to other chronic liver diseases. In response to this challenge, non-invasive tests (NITs) have become essential tools for the detection of ALD, offering opportunities for early identification and intervention to mitigate the disease burden. Noninvasive alcohol consumption biomarkers are crucial in estimating individuals' recent alcohol intake, providing valuable insights into their drinking patterns. Various NITs have been investigated for the initial screening of asymptomatic individuals at risk of ALD, as well as for identifying specific stages of the disease. These NITs are applied in 2 main clinical scenarios: population-based stratification for identifying and predicting liver-related symptoms and diagnosing and prognosticating compensated cirrhosis or advanced chronic liver disease in secondary or tertiary care settings. Moreover, NITs play a significant role in the prognostic assessment of patients with various manifestations of ALD, including alcohol-associated hepatitis (AH), decompensated cirrhosis, and metabolic-associated and ALD. These tests guide appropriate treatment decisions and predict outcomes. In this review, various NITs for the early detection and monitoring of alcohol consumption were discussed. Additionally, the evaluation of NITs for screening and predicting ALD and liver complications was addressed comprehensively. Future perspectives of NITs for ALD were explored, alongside a thorough discussion of the opportunities and challenges associated with NITs for ALD screening.
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Affiliation(s)
- Mads Israelsen
- Department of Gastroenterology and Hepatology, Fibrosis Fatty Liver and Steatohepatitis Research Centre, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Wiramon Rungratanawanich
- Section of Molecular Pharmacology and Toxicology, National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland, USA
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Fibrosis Fatty Liver and Steatohepatitis Research Centre, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Suthat Liangpunsakul
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Roudebush Veterans Administration Medical Center, Indianapolis, Indiana, USA
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38
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Verma N, Mehtani R, Haiar JM, Pradhan P, Duseja A, Im GY, Singal AK. Clinical criteria accurately diagnose severe but not moderate alcohol-associated hepatitis: A systematic review and meta-analysis. Hepatol Commun 2024; 8:e0404. [PMID: 38497934 PMCID: PMC10948131 DOI: 10.1097/hc9.0000000000000404] [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: 11/28/2023] [Accepted: 12/14/2023] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND The precision of clinical criteria and the utility of liver biopsy for diagnosis or prognosis remain unclear in patients with alcohol-associated hepatitis (AH). We systematically reviewed the literature to answer these questions. METHODS Four databases were searched for studies describing the precision of clinical criteria (National Institute on Alcohol Abuse and Alcoholism, European Association for Study of Liver, or classical) and the role of histology in AH. The precision(positive predictive value) of criteria was pooled through random-effects meta-analysis, and its variation was investigated through subgroups and meta-regression of study-level factors with their percent contribution to variation (R2). The risk of bias among studies was evaluated through the QUADAS2 tool (PROSPERO-ID-CRD4203457250). RESULTS Of 4320 studies, 18 in the systematic review and 15 (10/5: low/high risk of bias, N=1639) were included in the meta-analysis. The pooled precision of clinical criteria was 80.2% (95% CI: 69.7-89.7, I2:93%, p < 0.01), higher in studies with severe AH (mean-Model for End-Stage Liver Disease > 20) versus moderate AH (mean-Model for End-Stage Liver Disease < 20): 92% versus 67.1%, p < 0.01, and in studies with serum bilirubin cutoff 5 versus 3 mg/dL (88.5% vs.78.8%, p = 0.01). The factors contributing to variation in precision were Model for End-Stage Liver Disease (R2:72.7%), upper gastrointestinal bleed (R2:56.3%), aspartate aminotransferase:aspartate aminotransferase ratio (R2:100%), clinical criteria (R2:40.9%), bilirubin (R2:22.5%), and Mallory body on histology (R2:19.1%).The net inter-pathologist agreement for histologic findings of AH was variable (0.33-0.97), best among 2 studies describing AH through simple and uniform criteria, including steatosis, ballooning, and neutrophilic inflammation. Few studies reported the utility of histology in estimating steroid responsiveness (N = 1) and patient prognosis (N = 4); however, very broad septa, pericellular fibrosis, and cholestasis were associated with mortality. Bilirubinostasis was associated with infection in 1 study. CONCLUSIONS Clinical criteria are reasonably precise for diagnosing severe AH, while there is an unmet need for better criteria for diagnosing moderate AH. Histologic diagnosis of AH should be simple and uniform.
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Affiliation(s)
- Nipun Verma
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rohit Mehtani
- Department of Hepatology, Amrita Institute of Medical Sciences and Research, Faridabad, Haryana, India
| | - Jacob Martin Haiar
- Department of Internal Medicine, University of California, San Diego, California, USA
| | - Pranita Pradhan
- Department of Pediatrics, Indian Council of Medical Research Center for Evidence-Based Child Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gene Young Im
- Department of Medicine, Division of Liver Diseases, Recanati/Miller Transplantation Institute, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ashwani K. Singal
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Louisville School of Medicine, Louisville, Kentucky, USA
- Department of Medicine, Jewish Hospital and Trager Transplant Center, Louisville, Kentucky, USA
- Department of Medicine, VA Medical Center Sioux Falls, South Dakota, USA
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Gratacós-Ginès J, Avitabile E, Montironi C, Guillamon-Thiery A, Hernández-Évole H, Moreta MJ, Blaya D, Ariño S, Rubio AB, Pérez-Guasch M, Cervera M, Carol M, Fabrellas N, Soria A, Juanola A, Graupera I, Sancho-Bru P, Díaz A, Coll M, Bataller R, Ginès P, Pose E. Alcoholic Foamy Degeneration, an Entity Resembling Alcohol-Associated Hepatitis: Diagnosis, Prognosis, and Molecular Profiling. Clin Gastroenterol Hepatol 2024; 22:768-777.e8. [PMID: 38065374 DOI: 10.1016/j.cgh.2023.11.031] [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: 08/16/2023] [Revised: 10/20/2023] [Accepted: 11/17/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND & AIMS Alcoholic foamy degeneration (AFD) is a condition with similar clinical presentation to alcohol-associated hepatitis (AH), but with a specific histologic pattern. Information regarding the prevalence and prognosis of AFD is scarce and there are no tools for a noninvasive diagnosis. METHODS A cohort of patients admitted to the Hospital Clinic of Barcelona for clinical suspicion of AH who underwent liver biopsy was included. Patients were classified as AFD, AH, or other findings, according to histology. Clinical features, histology, and genetic expression of liver biopsy specimens were analyzed. The accuracy of National Institute on Alcohol Abuse and Alcoholism criteria and laboratory parameters for differential diagnosis were investigated. RESULTS Of 230 patients with a suspicion of AH, 18 (8%) met histologic criteria for AFD, 184 (80%) had definite AH, and 28 (12%) had other findings. In patients with AFD, massive steatosis was more frequent and the fibrosis stage was lower. AFD was characterized by down-regulation of liver fibrosis and inflammation genes and up-regulation of lipid metabolism and mitochondrial function genes. Patients with AFD had markedly better long-term survival (100% vs 57% in AFD vs AH; P = .002) despite not receiving corticosteroid treatment, even in a model for end-stage liver disease-matched sensitivity analysis. Serum triglyceride levels had an area under the receiver operating characteristic of 0.886 (95% CI, 0.807-0.964) for the diagnosis of AFD, whereas the National Institute on Alcohol Abuse and Alcoholism criteria performed poorly. A 1-step algorithm using triglyceride levels of 225 mg/dL (sensitivity, 0.77; specificity, 0.90; and Youden index, 0.67) is proposed for differential diagnosis. CONCLUSIONS AFD in the setting of suspicion of AH is not uncommon. A differential diagnosis is important because prognosis and treatment differ largely. Triglyceride levels successfully identify most patients with AFD and may be helpful in decision making.
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Affiliation(s)
- Jordi Gratacós-Ginès
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Emma Avitabile
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain
| | - Carla Montironi
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain; Department of Pathology, Hospital Clínic de Barcelona, Barcelona, Catalunya, Spain
| | - Alex Guillamon-Thiery
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain
| | | | - María José Moreta
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Catalunya, Spain
| | - Delia Blaya
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain
| | - Silvia Ariño
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain
| | - Ana Belén Rubio
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain
| | - Martina Pérez-Guasch
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain
| | - Marta Cervera
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain
| | - Marta Carol
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain
| | - Núria Fabrellas
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain
| | - Anna Soria
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Adrià Juanola
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Isabel Graupera
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain
| | - Pau Sancho-Bru
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Alba Díaz
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Department of Pathology, Hospital Clínic de Barcelona, Barcelona, Catalunya, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain
| | - Mar Coll
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Ramón Bataller
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain
| | - Elisa Pose
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Catalunya, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Catalunya, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas, Madrid, Spain; Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain.
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40
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Wang D, Puglia M. Inpatient Screening, Brief Intervention, and Referral to Treatment for Alcohol Use Disorder in Patients Admitted with Alcohol-associated Liver Disease Is Not Universally Implemented in Practice, But Can Reduce Readmissions for Alcohol-associated Hepatitis. J Can Assoc Gastroenterol 2024; 7:169-176. [PMID: 38596805 PMCID: PMC10999764 DOI: 10.1093/jcag/gwad048] [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] [Indexed: 04/11/2024] Open
Abstract
Introduction The management of alcohol-related liver disease requires a multidisciplinary approach to treat alcohol use disorder. We aimed to determine the proportion of actively drinking patients admitted for alcohol-associated hepatitis (AAH) or decompensated alcohol-related cirrhosis (DARLC) who were offered or underwent screening, brief intervention, and referral to treatment (SBIRT) for alcohol use disorder during admission and if inpatient SBIRT is associated with reduced readmissions for alcohol-related liver disease. Methods We conducted a retrospective cohort study of actively drinking patients admitted to our institution from January 2017 to December 2021 with AAH or DARLC. Logistic regression was used to identify factors, such as conducting SBIRT, that were associated with 30-day and 90-day readmissions for recurrent AAH or DARLC. Results There were 120 AAH admissions (mean age 47.7 ± 13.6 years), and 177 DARLC admissions (mean age 58.2 ± 9.5 years). SBIRT was conducted in only 51.7% of AAH admissions, and 23.7% of DARLC admissions. For AAH, conducting SBIRT was associated with significantly reduced 30-day (OR 0.098, P = 0.001, 95% CI 0.024-0.408) and 90-day (OR 0.166, P = 0.003, 95% CI 0.052-0.534) readmissions. For DARLC, there was no association between conducting SBIRT and 30-day or 90-day readmissions. Conclusion SBIRT was conducted with actively drinking patients in only 51.7% of AAH admissions and 23.7% of DARLC admissions. Patients admitted for AAH who received inpatient SBIRT had decreased 30-day and 90-day readmission rates for AAH or DARLC.
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Affiliation(s)
- Dennis Wang
- McMaster University Adult Gastroenterology Residency Program, Hamilton, ON, Canada
| | - Marco Puglia
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, ON, Canada
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41
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Scarlata GGM, Colaci C, Scarcella M, Dallio M, Federico A, Boccuto L, Abenavoli L. The Role of Cytokines in the Pathogenesis and Treatment of Alcoholic Liver Disease. Diseases 2024; 12:69. [PMID: 38667527 PMCID: PMC11048950 DOI: 10.3390/diseases12040069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 03/27/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
Alcoholic liver disease (ALD) is a major cause of chronic liver disease. This term covers a broad spectrum of liver lesions, from simple steatosis to alcoholic hepatitis and cirrhosis. The pathogenesis of ALD is multifactorial and not fully elucidated due to complex mechanisms related to direct ethanol toxicity with subsequent hepatic and systemic inflammation. The accumulation of pro-inflammatory cytokines and the reduction of anti-inflammatory cytokines promote the development and progression of ALD. To date, there are no targeted therapies to counter the progression of chronic alcohol-related liver disease and prevent acute liver failure. Corticosteroids reduce mortality by acting on the hepatic-systemic inflammation. On the other hand, several studies analyzed the effect of inhibiting pro-inflammatory cytokines and stimulating anti-inflammatory cytokines as potential therapeutic targets in ALD. This narrative review aims to clarify the role of the main cytokines involved in the pathogenesis and treatment of ALD.
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Affiliation(s)
| | - Carmen Colaci
- Department of Health Sciences, University “Magna Græcia”, Viale Europa, 88100 Catanzaro, Italy; (G.G.M.S.); (C.C.)
| | - Marialaura Scarcella
- Anesthesia, Intensive Care and Nutritional Science, Azienda Ospedaliera “Santa Maria”, Via Tristano di Joannuccio, 05100 Terni, Italy;
| | - Marcello Dallio
- Hepatogastroenterology Division, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Piazza Miraglia 2, 80138 Naples, Italy; (M.D.); (A.F.)
| | - Alessandro Federico
- Hepatogastroenterology Division, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Piazza Miraglia 2, 80138 Naples, Italy; (M.D.); (A.F.)
| | - Luigi Boccuto
- Healthcare Genetics and Genomics Doctoral Program, School of Nursing, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC 29634, USA;
| | - Ludovico Abenavoli
- Department of Health Sciences, University “Magna Græcia”, Viale Europa, 88100 Catanzaro, Italy; (G.G.M.S.); (C.C.)
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42
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Khan R, Salman S, Harford L, Sheriff L, Hazeldine J, Rajoriya N, Newsome PN, Lalor PF. Circulating myeloid populations have prognostic utility in alcohol-related liver disease. Front Immunol 2024; 15:1330536. [PMID: 38545104 PMCID: PMC10965684 DOI: 10.3389/fimmu.2024.1330536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/23/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction Alcohol-related liver disease (ARLD) accounts for over one third of all deaths from liver conditions, and mortality from alcohol-related liver disease has increased nearly five-fold over the last 30 years. Severe alcohol-related hepatitis almost always occurs in patients with a background of chronic liver disease with extensive fibrosis or cirrhosis, can precipitate 'acute on chronic' liver failure and has a high short-term mortality. Patients with alcohol-related liver disease have impaired immune responses, and increased susceptibility to infections, thus prompt diagnosis of infection and careful patient management is required. The identification of early and non-invasive diagnostic and prognostic biomarkers in ARLD remains an unresolved challenge. Easily calculated predictors of infection and mortality are required for use in patients who often exhibit variable symptoms and disease severity and may not always present in a specialized gastroenterology unit. Methods We have used a simple haematological analyser to rapidly measure circulating myeloid cell parameters across the ARLD spectrum. Results and Discussion We demonstrate for the first time that immature granulocyte (IG) counts correlate with markers of disease severity, and our data suggests that elevated counts are associated with increased short-term mortality and risk of infection. Other myeloid populations such as eosinophils and basophils also show promise. Thus IG count has the potential to serve alongside established markers such as neutrophil: lymphocyte ratio as a simply calculated predictor of mortality and risk of infectious complications in patients with alcohol-related hepatitis. This would allow identification of patients who may require more intensive management.
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Affiliation(s)
- Reenam Khan
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, Birmingham, United Kingdom
| | - Shees Salman
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Laura Harford
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, Birmingham, United Kingdom
| | - Lozan Sheriff
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, Birmingham, United Kingdom
| | - Jon Hazeldine
- Institute of Inflammation and Ageing, University of Birmingham, and Birmingham National Institute for Health Research (NIHR), Biomedical Research Centre, Birmingham, United Kingdom
| | - Neil Rajoriya
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Philip N. Newsome
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, and Birmingham National Institute for Health Research (NIHR), Biomedical Research Centre, Birmingham, United Kingdom
| | - Patricia F. Lalor
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, Birmingham, United Kingdom
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Jophlin L, Liu TY, McClain CJ. Nutritional deficiencies in alcohol use disorder/alcohol-associated liver disease. Curr Opin Gastroenterol 2024; 40:112-117. [PMID: 38193343 DOI: 10.1097/mog.0000000000000999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW To delineate common and uncommon dietary and nutritional deficiencies in individuals with chronic heavy alcohol use and alcohol use disorder and to highlight important advances in the nutrition field in patients ranging from those with alcohol use disorder (AUD) and no liver disease to those with decompensated alcohol-associated liver disease (ALD). RECENT FINDINGS Patients with AUD may have nutritional deficiencies, especially isolated nutrient deficiencies, such as thiamine or zinc deficiencies. This should not be surprising, as alcohol is a major source of "empty calories." It is devoid of critical macronutrients, such as protein, and micronutrients including important vitamins and minerals. Patients with AUD frequently drink much more than often appreciated (10-20 drinks a day). Patients with AUD and early ALD often begin to develop more apparent nutritional deficiencies. Healthcare providers need to be aware of the presenting features of individual nutrient deficiencies, such as thiamine deficiency, and to provide prompt treatment. In patients with more advanced liver disease, malnutrition correlates with severity of liver disease. It is important to understand the value of nutritional support throughout the spectrum of AUD. SUMMARY We review nutritional deficiencies in the spectrum of patients with AUD and ALD and highlight new information and recommendations.
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Affiliation(s)
- Loretta Jophlin
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Tzu-Yu Liu
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Craig J McClain
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
- Robley Rex VAMC, Louisville KY, USA
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Dasarathy S, Tu W, Bellar A, Welch N, Kettler C, Tang Q, Liangpunsakul S, Gawrieh S, Radaeva S, Mitchell M. Development and evaluation of objective trial performance metrics for multisite clinical studies: Experience from the AlcHep Network. Contemp Clin Trials 2024; 138:107437. [PMID: 38215876 DOI: 10.1016/j.cct.2024.107437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 11/05/2023] [Accepted: 01/08/2024] [Indexed: 01/14/2024]
Abstract
BACKGROUND Recruitment and retention are critical in clinical studies but there are limited objective metrics of trial performance. We tested if development of trial performance metrics will allow for objective evaluation of study quality. Performance metrics were developed using data from the observational cohort (OBS) and randomized clinical trial (RCT) arms of the prospective Alcoholic Hepatitis Network. METHODS Yield-rate (%YR; eligible/screened), recruitment index (RI; mean recruitment time/patient), completion index (CI; average number of days to complete the follow-up/patient), and protocol adherence index (AI; average number of deviations/subject recruited) were determined. RESULTS 2250 patients (1168 for OBS; 1082 for RCT) were screened across 8 sites. Recruitment in the RCT (57% target) was similar to that in the OBS (59% target). Of those screened, 743 (63.6%) subjects in the OBS and 147 (13.6%) subjects in the RCT were enrolled in the study. In OBS study, 253 (34.1%) subjects, and in the RCT, 68 (46.3%) subjects, completed the study or reached a censoring event. Across all sites (range), YR for OBS was 63.6% (41.3-98.3%) and for RCT was 13.6% (5.5-92.6%); RI for OBS was 1.66 (8.79-19.85) and for RCT was 4.05 (19.76-36.43); CI for OBS was 4.87 (22.6-118.3) and for RCT was 8.75 (27.27-161.5); and AR for OBS was 0.56 (0.08-1.04) and for RCT was 1.55 (0.39-3.21. Factors related to participants, research design, study team, and research sponsors contributed to lower performance metrics. CONCLUSIONS Objective measures of clinical trial performance allow for strategies to enhance study quality and development of site-specific improvement plans. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT4072822 NCT03850899.
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Affiliation(s)
- Srinivasan Dasarathy
- Department of Gastroenterology & Hepatology and Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, United States of America.
| | - Wanzhu Tu
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Annette Bellar
- Department of Gastroenterology & Hepatology and Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, United States of America
| | - Nicole Welch
- Department of Gastroenterology & Hepatology and Inflammation and Immunity, Cleveland Clinic, Cleveland, OH, United States of America
| | - Carla Kettler
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Qing Tang
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Suthat Liangpunsakul
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Samer Gawrieh
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Svetlana Radaeva
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States of America
| | - Mack Mitchell
- Department of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
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Tarli C, Mannucci S, Vecchione M, Antonelli M, Sestito L, Mancarella FA, Tosoni A, Dionisi T, Maccauro V, Sario GD, Burra P, Germani G, Gasbarrini A, Addolorato G. Prothrombin time predicts steroid response in severe alcohol-related hepatitis. Liver Int 2024; 44:823-830. [PMID: 38238897 DOI: 10.1111/liv.15835] [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: 11/26/2023] [Revised: 12/19/2023] [Accepted: 12/25/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND AND AIMS Alcohol-related hepatitis (AH) is the most severe form of acute alcohol-related liver disease. Maddrey's discriminant function ≥32 defines the severe form of AH, which is associated with a high mortality. Steroid therapy represents the main medical treatment that may reduce short-term mortality. Lille score at day 7 assesses the therapeutic response to steroid therapy. At present, no parameters able to predict the response to steroid therapy have been highlighted. The aim of the present study was to evaluate if baseline prothrombin time (BPT) could predict the response to steroid in severe AH (sAH). METHODS Patients consecutively admitted in two Italian Liver Units, from 2017 to 2022, suffering from sAH were included. Data were collected prospectively. In order to evaluate if BPT could predict steroid response, we assessed the correlation between BPT using the Lille score at day 7. RESULTS A total of 52 patients received steroid treatment were enrolled in the study. The response to therapy was assessed by Lille score at day 7. Responders were 34 patients (65%), non-responders 18 patients (34%). BPT significantly predicted the steroid response (p < .001). The likelihood of not responding to the steroid therapy was significantly higher in patients with higher BPT (OR = 2.954). CONCLUSIONS BPT value predicted steroid response in patients with sAH. BPT could quickly identify non-responder patients to steroid therapy, reducing the risk of infections and it could allow the early evaluation for liver transplantation.
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Affiliation(s)
- Claudia Tarli
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Sergio Mannucci
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Michele Vecchione
- Department of Social and Developmental Psychology Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Mariangela Antonelli
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luisa Sestito
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Antonio Mancarella
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alberto Tosoni
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Dionisi
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valeria Maccauro
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanna Di Sario
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Antonio Gasbarrini
- Internal Medicine Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- CEMAD Digestive Disease Center, Department of Medical and Surgical Sciences, Hepatology and Gastroenterology Unit, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Addolorato
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- CEMAD Digestive Disease Center, Department of Medical and Surgical Sciences, Hepatology and Gastroenterology Unit, Università Cattolica del Sacro Cuore, Rome, Italy
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Hardesty J, Hawthorne M, Day L, Warner J, Warner D, Gritsenko M, Asghar A, Stolz A, Morgan T, McClain C, Jacobs J, Kirpich IA. Steroid responsiveness in alcohol-associated hepatitis is linked to glucocorticoid metabolism, mitochondrial repair, and heat shock proteins. Hepatol Commun 2024; 8:e0393. [PMID: 38437061 PMCID: PMC10914234 DOI: 10.1097/hc9.0000000000000393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 12/15/2023] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Alcohol-associated hepatitis (AH) is one of the clinical presentations of alcohol-associated liver disease. AH has poor prognosis, and corticosteroids remain the mainstay of drug therapy. However, ~40% of patients do not respond to this treatment, and the mechanisms underlying the altered response to corticosteroids are not understood. The current study aimed to identify changes in hepatic protein expression associated with responsiveness to corticosteroids and prognosis in patients with AH. METHODS Patients with AH were enrolled based on the National Institute on Alcohol Abuse and Alcoholism inclusion criteria for acute AH and further confirmed by a diagnostic liver biopsy. Proteomic analysis was conducted on liver samples acquired from patients with AH grouped as nonresponders (AH-NR, n = 7) and responders (AH-R, n = 14) to corticosteroids, and nonalcohol-associated liver disease controls (n = 10). The definition of responders was based on the clinical prognostic model, the Lille Score, where a score < 0.45 classified patients as AH-R and a score > 0.45 as AH-NR. Primary outcomes used to assess steroid response were Lille Score (eg, improved liver function) and survival at 24 weeks. RESULTS Reduced levels of the glucocorticoid receptor and its transcriptional co-activator, glucocorticoid modulatory element-binding protein 2, were observed in the hepatic proteome of AH-NR versus AH-R. The corticosteroid metabolizing enzyme, 11-beta-hydroxysteroid dehydrogenase 1, was increased in AH-NR versus AH-R along with elevated mitochondrial DNA repair enzymes, while several proteins of the heat shock pathway were reduced. Analysis of differentially expressed proteins in AH-NR who survived 24 weeks relative to AH-NR nonsurvivors revealed several protein expression changes, including increased levels of acute phase proteins, elevated coagulation factors, and reduced mast cell markers. CONCLUSIONS This study identified hepatic proteomic changes that may predict responsiveness to corticosteroids and mortality in patients with AH.
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Affiliation(s)
- Josiah Hardesty
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Meghan Hawthorne
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
| | - Le Day
- Department of Biological Sciences, Biological Sciences Division and Environmental Molecular Sciences Laboratory, Pacific Northwest National Laboratory, Richland, Washington, USA
| | - Jeffrey Warner
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Dennis Warner
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
| | - Marina Gritsenko
- Department of Biological Sciences, Biological Sciences Division and Environmental Molecular Sciences Laboratory, Pacific Northwest National Laboratory, Richland, Washington, USA
| | - Aliya Asghar
- Department of Medicine and Research Services, Medicine and Research Services, VA Long Beach Healthcare System, Long Beach, California, USA
| | - Andrew Stolz
- Department of Medicine, Division of Gastrointestinal and Liver Disease, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Timothy Morgan
- Department of Medicine and Research Services, Medicine and Research Services, VA Long Beach Healthcare System, Long Beach, California, USA
| | - Craig McClain
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, Kentucky, USA
- Robley Rex Veterans Medical Center, Louisville, Kentucky, USA
- Department of Medicine, University of Louisville Alcohol Center, University of Louisville School of Medicine, Louisville, Kentucky, USA
- Department of Medicine, University of Louisville Hepatobiology and Toxicology Center, University of Louisville School of Medicine, Louisville, Kentucky USA
| | - Jon Jacobs
- Department of Biological Sciences, Biological Sciences Division and Environmental Molecular Sciences Laboratory, Pacific Northwest National Laboratory, Richland, Washington, USA
| | - Irina A. Kirpich
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, Kentucky, USA
- Department of Medicine, University of Louisville Alcohol Center, University of Louisville School of Medicine, Louisville, Kentucky, USA
- Department of Medicine, University of Louisville Hepatobiology and Toxicology Center, University of Louisville School of Medicine, Louisville, Kentucky USA
- Department of Microbiology and Immunology, University of Louisville School of Medicine, Louisville, KY, USA
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Fahoum K, Ying X, Magahis PT, Ross J, Basu E, Shen NT, Baltich Nelson B, Brown RS, Jesudian AB. Non-invasive markers of inflammation in alcohol-associated liver disease: A scoping review. J Gastroenterol Hepatol 2024; 39:245-255. [PMID: 38054575 DOI: 10.1111/jgh.16432] [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: 08/25/2023] [Revised: 10/30/2023] [Accepted: 11/13/2023] [Indexed: 12/07/2023]
Abstract
Clinical manifestations of liver inflammation in alcohol-associated liver disease (ALD) can range from asymptomatic to severe alcoholic hepatitis. While biopsy is the gold standard for identifying liver inflammation, it is an invasive procedure with risks of bleeding, visceral damage, and infection. We aim to establish the state of the current literature on non-invasive markers of inflammation in ALD. We searched Ovid MEDLINE, Embase, and the Cochrane Library for original studies on the association between one or more non-invasive biomarker(s) and histological inflammation or hepatitis in ALD patients. Exclusion criteria were lack of histological data, abstract only, non-English-language articles, and animal studies. Two independent reviewers screened abstracts, reviewed full texts, and extracted data from included papers. Our search identified 8051 unique studies. Title and abstract screening resulted in 563 studies, and full-text screening resulted in 31 studies for final inclusion. The majority were single-center observational cohorts with an average sample size of 124. Review of these studies identified 44 unique biomarkers and 8 calculated scores associated with histological inflammation and/or hepatitis, in addition to a metabolomic panel of 468 metabolites. Six studies examined diagnostic accuracy for histological inflammation and/or hepatitis. The highest area under the receiver operating characteristic curve was 0.932 using a model based on four metabolites. This review highlights the available literature on non-invasive markers of inflammation in ALD. There is a dearth of studies that evaluate the diagnostic accuracy of these biomarkers, and larger studies are needed to confirm findings identified in small cohorts.
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Affiliation(s)
- Khalid Fahoum
- Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Xiaohan Ying
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | | | - Joshua Ross
- Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Elora Basu
- Department of Psychiatry, Weill Cornell Medicine, New York, New York, USA
| | - Nicole T Shen
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
- BJC HealthCare, St. Louis, Missouri, USA
| | | | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
| | - Arun B Jesudian
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York, USA
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48
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Mackowiak B, Fu Y, Maccioni L, Gao B. Alcohol-associated liver disease. J Clin Invest 2024; 134:e176345. [PMID: 38299591 PMCID: PMC10836812 DOI: 10.1172/jci176345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024] Open
Abstract
Alcohol-associated liver disease (ALD) is a major cause of chronic liver disease worldwide, and comprises a spectrum of several different disorders, including simple steatosis, steatohepatitis, cirrhosis, and superimposed hepatocellular carcinoma. Although tremendous progress has been made in the field of ALD over the last 20 years, the pathogenesis of ALD remains obscure, and there are currently no FDA-approved drugs for the treatment of ALD. In this Review, we discuss new insights into the pathogenesis and therapeutic targets of ALD, utilizing the study of multiomics and other cutting-edge approaches. The potential translation of these studies into clinical practice and therapy is deliberated. We also discuss preclinical models of ALD, interplay of ALD and metabolic dysfunction, alcohol-associated liver cancer, the heterogeneity of ALD, and some potential translational research prospects for ALD.
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Miller A, Carney B, Shah S, Chen HW, Gougol A, Borhani A, Bataller R, Malik S, Rachakonda V. Liver surface nodularity and ascites are associated with mortality risk in acute alcohol-associated hepatitis. ALCOHOL, CLINICAL & EXPERIMENTAL RESEARCH 2024; 48:273-282. [PMID: 38123167 DOI: 10.1111/acer.15248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 11/16/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Acute alcohol-associated hepatitis (AH) is associated with high mortality. CT-derived liver surface nodularity (LSN) is a robust prognostic biomarker in other chronic liver diseases. The aim of this study was to determine relationships between LSN, disease severity, and mortality in AH. METHODS Adults hospitalized with AH from January 2016 to March 2020 were included if an abdominal CT was performed between 8 weeks prior to 72 h after hospitalization. LSN was measured using quantitative methods (Liver Surface Nodularity Software version 0.88, Birmingham, AL, USA). Cox proportional hazards models, logistic regression and AUROC analysis were used to examine relationships between LSN and 180-day transplant-free survival. RESULTS Of 386 patients hospitalized with AH during the study period, 230 had CT scans performed, and 205 met inclusion criteria. Mean transplant-free survival was 127 days (95% CI 118-137). Within each cohort, patients were grouped into low [LSN-LOW, N = 109 (53.2%)] and high [LSN-HIGH, N = 96 (46.8%)] LSN strata based on an optimal cutoff of 2.86 derived from unadjusted ROC curves. Patients with high LSN had features of portal hypertension, which included encephalopathy [53 (55.2%) vs. 43 (39.4%), p = 0.017], ascites on CT [81 (84.4%) vs. 69 (63.3%), p = 0.001] and portosystemic shunts [78 (81.2%) vs. 69 (63.3%), p = 0.003]. High LSN, ascites and MELD were independently associated with lower likelihood of 180-day transplant-free survival, and inclusion of a score assigning 1 point each for high LSN or ascites on CT (AHRADS score) to MELD enhanced diagnostic accuracy of AUROC for 180-day survival compared to MELD alone [AUROC 0.782 (95% CI 0.719-0.845) vs. 0.735 (0.667-0.802), p = 0.023]. CONCLUSIONS CT-derived factors that include LSN and ascites are radiographic biomarkers associated with 180-day transplant-free survival in alcohol-associated hepatitis.
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Affiliation(s)
- Alex Miller
- Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, California, USA
| | - Benjamin Carney
- Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, California, USA
| | - Shivani Shah
- Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, California, USA
| | - Hui-Wei Chen
- Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Amir Gougol
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Amir Borhani
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Ramon Bataller
- Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Shahid Malik
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Vikrant Rachakonda
- Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, California, USA
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50
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Kasuga R, Chu PS, Taniki N, Yoshida A, Morikawa R, Tabuchi T, Noguchi F, Yamataka K, Nakadai Y, Kondo M, Ebinuma H, Kanai T, Nakamoto N. Granulocyte-monocyte/macrophage apheresis for steroid-nonresponsive or steroid-intolerant severe alcohol-associated hepatitis: A pilot study. Hepatol Commun 2024; 8:e0371. [PMID: 38285891 PMCID: PMC10830070 DOI: 10.1097/hc9.0000000000000371] [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: 10/18/2023] [Accepted: 11/22/2023] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Patients with severe alcohol-associated hepatitis (SAH) have a high short-term mortality rate. Unmet needs exist in patients who are refractory to corticosteroids (CS) or are ineligible for early liver transplantation. METHODS This was a prospective, open-label, nonrandomized pilot study conducted at a liver transplant center in Tokyo, Japan, starting in October 2015. Lille model and Model for End-stage Liver Disease (MELD) score-defined CS nonresponsive or CS-intolerant patients with SAH who fulfilled the inclusion criteria (leukocytosis over 10,000/μL, etc.) were considered for enrollment. The median duration from admission to enrollment was 23 days (IQR, 14-31 days), after standard of care. Granulocyte-monocyte/macrophage apheresis (GMA) performed with Adacolumn twice per week, up to 10 times per treatment course, was evaluated. RESULTS 13 GMA treatments were conducted through December 2021. Maddrey Discriminant Function was 53.217.7 at admission. The overall survival rate was 90.9% at 90 and 180 days. MELD scores significantly improved, from median (IQRs) of 23 (20-25) to 15 (13-21) after GMA (p<0.0001). Estimated mortality risks using the Lille model and MELD scores significantly improved from 20.9%±16.5% to 7.4%±7.3% at 2 months and from 30.4%±21.3% to 11.6%±10.8% at 6 months, respectively (both p<0.01), and were internally validated. The cumulative rate of alcohol relapse was 35.9% per year. No severe adverse events were observed. In exploratory analysis, granulocyte colony-stimulating factor levels were significantly correlated with prognostic systems such as MELD-Sodium scores after GMA (correlation coefficient= -0.9943, p<0.0001) but not before GMA (p=0.62). CONCLUSIONS Compared to published studies, GMA is associated with a lower-than-expected 90- and 180-day mortality in patients with CS-nonresponsive or CS-intolerant SAH. GMA may meet the needs as a salvage anti-inflammatory therapy for SAH. (Trial registration: UMIN000019351 and jRCTs No.032180221) (274 words).
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Affiliation(s)
- Ryosuke Kasuga
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Po-sung Chu
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Nobuhito Taniki
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Aya Yoshida
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Rei Morikawa
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Takaya Tabuchi
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Fumie Noguchi
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Karin Yamataka
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Yukie Nakadai
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Mayuko Kondo
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Hirotoshi Ebinuma
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Department of Gastroenterology, International University of Health and Welfare, School of Medicine, 4Narita City, Chiba, Japan
| | - Takanori Kanai
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Nobuhiro Nakamoto
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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