Primary biliary cirrhosis is associated with falls and significant fall related injury

Home-based exercise in patients with refractory fatigue associated with primary biliary cholangitis: a protocol for the EXerCise Intervention in cholesTatic LivEr Disease (EXCITED) feasibility trial

INTRODUCTION

Fatigue is the most commonly reported symptom of the liver disease primary biliary cholangitis (PBC). It affects 40%-80% of patients, has no effective treatment and is associated with heightened mortality risk. The pathogenesis is unknown, but muscle bioenergetic abnormalities have been proposed to contribute. Directly observed exercise has been shown to attenuate symptoms in small groups; however, due to the rare nature of the disease, home-based interventions need to be evaluated for feasibility, safety and efficacy.

METHODS AND ANALYSIS

This is a phase 1/pilot, single-arm, open-label clinical trial evaluating a novel home-based exercise programme in patients with PBC with severe fatigue. Forty patients with moderate-severe fatigue (PBC40 fatigue domain score >33; other causes of fatigue excluded) will be selected using a convenience sampling method. A 12-week home-based exercise programme, consisting of individualised resistance, aerobic exercises and telephone health calls (first 6 weeks only), will be delivered. Measures of fatigue (PBC40 fatigue domain; fatigue impact scale), quality of life, sleep (Epworth Sleep Score), physical activity, anxiety and depression, aerobic exercise capacity (incremental shuttle walk test; Duke Activity Status Index) and functional capacity (short physical performance battery) will be assessed at baseline and at 6 and 12 weeks following the intervention.

ETHICS AND DISSEMINATION

The protocol is approved by the National Research Ethics Service Committee London (IRAS 253115). Recruitment commenced in April 2019 and ended in March 2020. Participant follow-up is due to finish by December 2020. Findings will be disseminated through peer-reviewed publication, conference presentation and social media.

TRIAL REGISTRATION NUMBER

NCT04265235.

Hepatic encephalopathy increases the risk of hip fracture: a nationwide cohort study

BACKGROUND

Osteoporotic hip fracture is a common general health problem with a significant impact on human life because it debilitates the patients and largely decreases their quality of life. Early prevention of fractures has become essential in recent decades. This can be achieved by evaluating the related risk factors, as a reference for further intervention. This is especially useful for the vulnerable patient group with comorbidities. Hepatic encephalopathy (HE), a major complication of liver cirrhosis, may increase the rate of falls and weaken the bone. This study evaluated the correlation between hepatic encephalopathy and osteoporotic hip fracture in the aged population using a national database.

METHODS

This retrospective cohort study used data from Taiwan's National Health Insurance Research Database between 2000 and 2012. We included people who were older than 50 years with hepatic encephalopathy or other common chronic illnesses. Patients with and without hepatic encephalopathy were matched at a ratio of 1:4 for age, sex, and index year. The incidence and hazard ratios of osteoporotic hip fracture between the both cohorts were calculated using Cox proportional hazard regression models.

RESULTS

The mean age of the enrolled patients was 66.5 years. The incidence ratio of osteoporotic hip fracture in the HE group was significantly higher than that in the non-HE group (68/2496 [2.7%] vs 98/9984 [0.98%]). Patients with HE were 2.15-times more likely to develop osteoporotic hip fractures than patients without HE in the whole group. The risk ratio was also significantly higher in female and older individuals. The results were also similar in the comorbidity subgroups of hypertension, diabetes mellitus, hyperlipidemia, senile cataract, gastric ulcer, and depression. Alcohol-related illnesses seemed to not confound the results of this study.

CONCLUSIONS

HE is significantly associated with an increased risk of osteoporotic hip fractures, and the significance is not affected by the comorbidities in people aged more than 50 years. The cumulative risk of fracture increases with age.

The British Society of Gastroenterology/UK-PBC primary biliary cholangitis treatment and management guidelines

Primary biliary cholangitis (formerly known as primary biliary cirrhosis, PBC) is an autoimmune liver disease in which a cycle of immune mediated biliary epithelial cell injury, cholestasis and progressive fibrosis can culminate over time in an end-stage biliary cirrhosis. Both genetic and environmental influences are presumed relevant to disease initiation. PBC is most prevalent in women and those over the age of 50, but a spectrum of disease is recognised in adult patients globally; male sex, younger age at onset (<45) and advanced disease at presentation are baseline predictors of poorer outcome. As the disease is increasingly diagnosed through the combination of cholestatic serum liver tests and the presence of antimitochondrial antibodies, most presenting patients are not cirrhotic and the term cholangitis is more accurate. Disease course is frequently accompanied by symptoms that can be burdensome for patients, and management of patients with PBC must address, in a life-long manner, both disease progression and symptom burden. Licensed therapies include ursodeoxycholic acid (UDCA) and obeticholic acid (OCA), alongside experimental new and re-purposed agents. Disease management focuses on initiation of UDCA for all patients and risk stratification based on baseline and on-treatment factors, including in particular the response to treatment. Those intolerant of treatment with UDCA or those with high-risk disease as evidenced by UDCA treatment failure (frequently reflected in trial and clinical practice as an alkaline phosphatase >1.67 × upper limit of normal and/or elevated bilirubin) should be considered for second-line therapy, of which OCA is the only currently licensed National Institute for Health and Care Excellence recommended agent. Follow-up of patients is life-long and must address treatment of the disease and management of associated symptoms.

Osteoporosis in chronic liver disease

Osteoporosis is a frequent complication in patients with chronic liver disease, especially in end-stages and in chronic cholestasis, in addition to non-alcoholic fatty liver disease, haemochromatosis and alcoholism. Mechanisms underlying osteoporosis are poorly understood, but osteoporosis mainly results from low bone formation. In this setting, sclerostin, a key regulator of the Wnt/β-catenin signalling pathway which regulates bone formation, in addition to the effects of the retained substances of cholestasis such as bilirubin and bile acids on osteoblastic cells, may influence the decreased bone formation in chronic cholestasis. Similarly, the damaging effects of iron and alcohol on osteoblastic cells may partially explain bone disease in haemochromatosis and alcoholism. A role for proinflammatory cytokines has been proposed in different conditions. Increased bone resorption may occur in cholestatic women with advanced disease. Low vitamin D, poor nutrition and hypogonadism, may be contributing factors to the full picture of bone disorders in chronic liver disease.

Risk and adverse outcomes of fractures in patients with liver cirrhosis: two nationwide retrospective cohort studies

OBJECTIVE

The aim of this study is to evaluate fracture risk and post-fracture outcomes in patients with and without liver cirrhosis (LC).

DESIGN

Retrospective cohort study and nested fracture cohort study.

SETTING

This study was based on Taiwan's National Health Insurance Research Database that included information on: (1) 3941 patients aged 20 years and older newly diagnosed with LC between 2000 and 2003; (2) 688290 hospitalised fracture patients aged 20 years and older between 2006 and 2013.

PRIMARY AND SECONDARY OUTCOME MEASURES

Followed-up events of fracture from 2000 to 2008 were noted from medical claims to evaluate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of fracture associated with LC. Adjusted odds ratios (ORs) and 95% CIs of adverse events after fracture were compared among patients with and without LC RESULTS: The incidences of fracture for people with and without LC were 29.1 and 17.2 per 1000 person-years, respectively. Compared with controls, the adjusted HR of fracture was 1.83 (95% CI 1.67 to 2.01) for patients with LC. Previous LC was associated with risks of septicaemia (OR 1.77, 95% CI 1.60 to 1.96), acute renal failure (OR 1.63, 95% CI 1.33 to 1.99), and 30-day in-hospital mortality (OR 1.61, 95 %CI 1.37 to 1.89) after fracture.

CONCLUSION

LC was associated with higher risk of fracture; patients with LC in particular had more complications and 30-day in-hospital mortality after fracture. Fracture prevention and attention to post-fracture adverse events are needed for these susceptible populations.

Falls in Patients With Liver Cirrhosis

Health-related quality of life (HRQOL) has become an important outcome for patients with liver cirrhosis as the number of transplantation candidates increases by the progression of treatment strategies. Falls and fall-related injuries are common in patients with liver cirrhosis and negatively affect HRQOL. Many factors increase the risk for falls such as minimal hepatic encephalopathy, psychoactive drugs, muscle strength, autonomic dysfunction, hyponatremia, and sleep problems. It is important to understand the underlying mechanisms for falls in cirrhotic patients to prevent severe injuries such as fractures, decrease healthcare costs, and improve HRQOL. Healthcare professionals, including physiotherapists and nurses, should be aware of the higher risk for falls in this population and therapeutic interventions must be designed for patients, especially those waiting on the transplant list.

Understanding and Treating Fatigue in Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis

Fatigue is a significant problem for patients with primary biliary cirrhosis and although experienced less by patients with primary sclerosing cholangitis, a minority still report significant fatigue. Fatigue is the symptom with the greatest impact on quality of life, particularly when associated with social dysfunction. The pathogenesis of fatigue in cholestatic liver disease is complex, poorly understood, and probably has central and peripheral components. Managing fatigue in cholestatic liver disease presents a challenge for clinicians given the complexity and its numerous associations. This article presents a structured approach to managing fatigue in cholestatic liver disease to improve fatigue severity and quality of life.

Promoting self-management and adherence with strength and balance training for older people with long-term conditions: a mixed-methods study

RATIONALE, AIMS AND OBJECTIVES

In the context of an ageing population, increasing numbers of older people with long-term conditions are presenting to secondary health care facilities in the United Kingdom having experienced a fall or fall-related injury. Despite such observations, falls and long-term conditions have traditionally been regarded as entirely separate entities. The purpose of this study was to explore the process of behaviour change in a small sample of older people with the fall-associated chronic liver disease primary biliary cirrhosis (PBC) receiving either a standard or an enhanced programme of strength and balance training (SBT).

METHODS

A qualitatively driven mixed-methods approach was employed that juxtaposed semi-structured interviews with graphical representations of patient-reported outcome measures collected during the course of an experimental case series in nine older people with the fall-associated chronic liver disease PBC.

RESULTS

Participants receiving both the standard and enhanced intervention completed the programme of SBT as instructed throughout the course of the case series. However, only the enhanced intervention, which focused on self-determination and self-management support, was associated with continued active participation on completion of the programme.

CONCLUSIONS

Longer, but not necessarily more intensive, periods of clinical intervention are necessary to support individuals at risk of falling to move through the incremental stages of behaviour change. Effective self-management support should focus on the development of a wide range of strategies and behaviours to empower older people with long-term conditions develop an ongoing active commitment to SBT.

Osteoporosis in primary biliary cirrhosis of the liver

Osteoporosis is a metabolic bone disease associated with a reduction in bone mass and deterioration of bone architecture, leading to increased fragility and subsequent low-trauma fractures in the vertebral column, hip, forearm and other bones. In literature, metabolic bone diseases such as osteoporosis and osteomalacia have been recognised as a complication of chronic liver disease, although the mechanisms of this association remain unclear. An increasing body of research data indicates a strong relationship between osteoporosis and primary biliary cirrhosis (PBC), which mainly results from early diagnosis of the disease, usually when it is still asymptomatic. The incidence of osteoporosis in PBC ranges from 20% to 44% and increases with the progression of the disease. Similarly, the incidence of bone fractures is high in this group of patients (10-20%). In this article, current knowledge on risk factors, pathogenesis, diagnosis and treatment of osteoporosis in PBC is reviewed.

Cognitive dysfunction in cirrhosis is associated with falls: a prospective study

Falls are frequent among patients with debilitating disorders and can have a serious effect on health status. Mild cognitive disturbances associated with cirrhosis may increase the risk for falls. Identifying subjects at risk may allow the implementation of preventive measures. Our aim was to assess the predictive value of the Psychometric Hepatic Encephalopathy Score (PHES) in identifying patients likely to sustain falls. One hundred and twenty-two outpatients with cirrhosis were assessed using the PHES and were followed at specified intervals. One third of them exhibited cognitive dysfunction (CD) according to the PHES (<-4). Seventeen of the forty-two patients (40.4%) with CD had at least one fall during follow-up. In comparison, only 5 of 80 (6.2%) without CD had falls (P < 0.001). Fractures occurred in 4 patients (9.5%) with CD, but in no patients without CD (P = 0.01). Patients with CD needed more healthcare (23.8% versus 2.5%; P < 0.001), more emergency room care (14.2% versus 2.5%; P = 0.02), and more hospitalization (9.5% versus 0%; P = 0.01) as a result of falls than patients without CD. Patients taking psychoactive treatment (n = 21) had a higher frequency of falls, and this was related to an abnormal PHES. In patients without psychoactive treatment (n = 101), the incidence of falls was 32.4% in patients with CD versus 7.5% in those without CD (P = 0.003). In the multivariate analysis, CD was the only independent predictive factor of falls (odds ratio, 10.2; 95% confidence interval, 3.4-30.4; P < 0.001). The 1-year probability of falling was 52.3% in patients with CD and 6.5% in those without (P < 0.001).

CONCLUSION

An abnormal PHES identifies patients with cirrhosis who are at risk for falls. This psychometric test may be useful to promote awareness of falls and identify patients who may benefit from preventive strategies.

Orthostatic Hypotension in Older Nursing Home Residents Who Fall

Orthostatic hypotension (OH) and dizziness have been linked to older adult falls. As a treatable condition, the detection of OH is of clinical importance to falls prevention. Gaps in the literature about symptoms associated with OH among older adult fallers, such as dizziness led to this secondary analysis of blood pressure data and reported symptoms. Of the 194 Registered Nurse (RN) documented falls, most ( n = 91; 46.9%) failed to meet the prevailing diagnostic criteria for OH; 18 (9.2%) met criteria; and 8 (4%) nearly met the OH criteria. OH determinations were incomplete or absent in 41% ( n = 77). Of the 18 residents with OH, none reported dizziness, instead half reported loss of balance. We conclude, older residents did not report symptoms of dizziness prior to OH drops in blood pressure and falls. Further study is warranted to identify other predictive symptoms of OH and to evaluate nursing staff’s understanding of OH.

Managing systemic symptoms in chronic liver disease

Improved medical management and the changing disease demographic mean that the majority of patients with chronic liver disease are living with the disease rather than dying from it. Historically, the perception has been that the impact of chronic liver disease is related entirely to the consequences of endstage liver disease; however, more recently a number of systemic symptoms have been recognised that can occur at any point in the natural history of chronic liver disease and which can be associated with functional impairment and reduced quality of life. The most characteristic of these systemic symptoms is fatigue, which frequently associates with sleep disturbance and autonomic dysfunction, particularly manifest as abnormality of blood pressure regulation. Cognitive symptoms can occur even in non-cirrhotic patients. Falls can present in patients with autonomic dysfunction, complicated by the presence of peripheral muscle strength problems. Importantly for clinicians managing chronic liver disease, the severity of these systemic symptoms is typically not related to liver disease severity, and therefore despite optimal liver disease management, patients can often continue to experience debilitating symptoms. The similarity in systemic symptoms between different chronic liver diseases (and indeed chronic inflammatory conditions affecting other organs) suggests the possibility of shared pathogenetic processes and raises the possibility of common management strategies, although further research is urgently needed to confirm this. In primary biliary cirrhosis, where our understanding of systemic symptoms is arguably most developed, structured management strategies have been shown to improve the quality of life of patients. It is highly likely that similar approaches will have comparable benefits for other chronic liver disease groups. Here, we review the current understanding of systemic symptoms in chronic liver disease and offer recommendations regarding the successful management of these symptoms. Critical for successful treatment is use of a structured and systematic approach to management in which all contributing factors are addressed in an organised fashion. We believe that such a systematic approach, when applied to research as well as to clinical management, will allow us to reduce the overall burden of chronic liver disease, improve quality of life and enhance functional ability.