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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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Chongo G, Soldera J. Use of machine learning models for the prognostication of liver transplantation: A systematic review. World J Transplant 2024; 14:88891. [PMID: 38576762 PMCID: PMC10989468 DOI: 10.5500/wjt.v14.i1.88891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/08/2023] [Accepted: 12/11/2023] [Indexed: 03/15/2024] Open
Abstract
BACKGROUND Liver transplantation (LT) is a life-saving intervention for patients with end-stage liver disease. However, the equitable allocation of scarce donor organs remains a formidable challenge. Prognostic tools are pivotal in identifying the most suitable transplant candidates. Traditionally, scoring systems like the model for end-stage liver disease have been instrumental in this process. Nevertheless, the landscape of prognostication is undergoing a transformation with the integration of machine learning (ML) and artificial intelligence models. AIM To assess the utility of ML models in prognostication for LT, comparing their per formance and reliability to established traditional scoring systems. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we conducted a thorough and standardized literature search using the PubMed/MEDLINE database. Our search imposed no restrictions on publication year, age, or gender. Exclusion criteria encompassed non-English stu dies, review articles, case reports, conference papers, studies with missing data, or those exhibiting evident methodological flaws. RESULTS Our search yielded a total of 64 articles, with 23 meeting the inclusion criteria. Among the selected studies, 60.8% originated from the United States and China combined. Only one pediatric study met the criteria. Notably, 91% of the studies were published within the past five years. ML models consistently demonstrated satisfactory to excellent area under the receiver operating characteristic curve values (ranging from 0.6 to 1) across all studies, surpassing the performance of traditional scoring systems. Random forest exhibited superior predictive capa bilities for 90-d mortality following LT, sepsis, and acute kidney injury (AKI). In contrast, gradient boosting excelled in predicting the risk of graft-versus-host disease, pneumonia, and AKI. CONCLUSION This study underscores the potential of ML models in guiding decisions related to allograft allocation and LT, marking a significant evolution in the field of prognostication.
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Affiliation(s)
- Gidion Chongo
- Department of Gastroenterology, University of South Wales, Cardiff CF37 1DL, United Kingdom
| | - Jonathan Soldera
- Department of Gastroenterology, University of South Wales, Cardiff CF37 1DL, United Kingdom
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Jophlin LL, Singal AK, Bataller R, Wong RJ, Sauer BG, Terrault NA, Shah VH. ACG Clinical Guideline: Alcohol-Associated Liver Disease. Am J Gastroenterol 2024; 119:30-54. [PMID: 38174913 PMCID: PMC11040545 DOI: 10.14309/ajg.0000000000002572] [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: 04/19/2023] [Accepted: 10/04/2023] [Indexed: 01/05/2024]
Abstract
ABSTRACT Alcohol-associated liver disease (ALD) is the most common cause of advanced hepatic disease and frequent indication for liver transplantation worldwide. With harmful alcohol use as the primary risk factor, increasing alcohol use over the past decade has resulted in rapid growth of the ALD-related healthcare burden. The spectrum of ALD ranges from early asymptomatic liver injury to advanced disease with decompensation and portal hypertension. Compared with those with other etiologies of liver disease, patients with ALD progress faster and more often present at an advanced stage. A unique phenotype of advanced disease is alcohol-associated hepatitis (AH) presenting with rapid onset or worsening of jaundice, and acute on chronic liver failure in severe forms conveying a 1-month mortality risk of 20%-50%. The model for end stage disease score is the most accurate score to stratify AH severity (>20 defined as severe disease). Corticosteroids are currently the only available therapeutic with proven efficacy for patients with severe AH, providing survival benefit at 1 month in 50%-60% of patients. Abstinence of alcohol use, a crucial determinant of long-term outcomes, is challenging to achieve in ALD patients with concurrent alcohol use disorder (AUD). As patients with ALD are rarely treated for AUD, strategies are needed to overcome barriers to AUD treatment in patients with ALD and to promote a multidisciplinary integrated care model with hepatology, addiction medicine providers, and social workers to comprehensively manage the dual pathologies of liver disease and of AUD. Liver transplantation, a definitive treatment option in patients with advanced cirrhosis, should be considered in selected patients with AH, who are unresponsive to medical therapy and have a low risk of relapse to posttransplant alcohol use. Level of evidence and strength of recommendations were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations system. This guideline was developed under the American College of Gastroenterology Practice Parameters Committee.
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Affiliation(s)
- Loretta L Jophlin
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville Health, Louisville, Kentucky, USA
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, University of South Dakota, Sioux Falls, South Dakota, USA
| | - Ramon Bataller
- Liver Unit, Department of Digestive and Metabolic Diseases, Hospital Clinic, Barcelona, Spain
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | - Bryan G Sauer
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Norah A Terrault
- Division of Gastrointestinal and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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4
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Kazankov K, Nixon-Hill M, Kumar R, Amin A, Alabsawy E, Chikhlia A, Leung TS, Mookerjee RP. A novel smartphone scleral-image based tool for assessing jaundice in decompensated cirrhosis patients. J Gastroenterol Hepatol 2023; 38:330-336. [PMID: 36574965 PMCID: PMC10107452 DOI: 10.1111/jgh.16093] [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: 08/30/2022] [Revised: 12/12/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIM Serum bilirubin is an established marker of liver disease. Reliable tools for non-invasive assessment of jaundice in cirrhosis patients, at risk of clinical decompensation, are highly desirable. While smartphone-based imaging has been described in neonatal jaundice, it has not been investigated in advanced cirrhosis patients. METHODS We included 46 hospitalized patients with acute cirrhosis decompensation and jaundice. Scleral images using an Android smartphone were taken to derive "Scleral Color Values (SCV)," which were matched with same day serum bilirubin measurements. In 29 patients, repeat SCV and bilirubin measurements were performed over time. We analyzed the relationship of SCV and its dynamics with serum bilirubin, clinical scores, and patient outcomes. RESULTS Of 46 patients, 26 (57%) had alcoholic hepatitis as the decompensation precipitant. Seven patients died during admission; a further 12 following hospital discharge. SCV had an excellent linear correlation with serum bilirubin (rho = 0.90, P < 0.001); changes in SCV and serum bilirubin across different time points, were also closely associated (rho = 0.77, P < 0.001). SCV correlated significantly with CLIF Consortium Acute Decompensation score (rho = 0.38, P < 0.001) and grade of Acute-on-Chronic Liver Failure (rho = 0.42, P = 0.039). SCV was higher in patients who died, however, not significantly (86.1 [IQR 83.0-89.7] vs 82.3 [IQR 78.5-83.3], P = 0.22). The associations of SCV with clinical parameters mirrored those of serum bilirubin. CONCLUSION Smartphone-based assessment of jaundice shows excellent concordance with serum bilirubin and is associated with clinical parameters in acute cirrhosis decompensation. This approach offers promise for remote assessment of cirrhosis patients at-risk of decompensation, post hospital discharge.
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Affiliation(s)
- Konstantin Kazankov
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK.,Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Miranda Nixon-Hill
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Rahul Kumar
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Ahmed Amin
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Eman Alabsawy
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Anmol Chikhlia
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Terence S Leung
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Rajeshwar P Mookerjee
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK.,Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Israelsen M, Misas MG, Koutsoumourakis A, Hall A, Covelli C, Buzzetti E, Prat LI, Roccarina D, Luong TV, Quaglia A, Pinzani M, Tsochatzis EA. Collagen proportionate area predicts long-term mortality in patients with alcoholic hepatitis. Dig Liver Dis 2022; 54:663-668. [PMID: 34548258 DOI: 10.1016/j.dld.2021.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/12/2021] [Accepted: 08/26/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS There are several short-term prognostic scores for alcoholic hepatitis (AH) that combine demographical and biochemical parameters. The extent of liver fibrosis may also be relevant to the prognosis of AH with potential added value. We evaluated collagen proportionate area (CPA) as a predictor of short and long-term mortality in AH. METHODS We retrospectively included patients with biopsy-verified AH. Clinical, laboratory and outcome data were collected. CPA and five AH scores were calculated: Maddrey's DF, MELD, GAHS, ABIC, and the Lille Model. Predictors of short and long-term all-cause mortality were assessed using Cox regression analysis. RESULTS We included 140 patients with AH. In total, 67 (48%) patients died after a median follow-up of 66 (IQR 102) months, with 17 (12%) dying within the first 90-days. CPA was not a predictor of 90-days mortality and had no additional value to the prognostic AH scores on short-term mortality. However, CPA predicted long-term mortality independently of prognostic AH scores. Importantly, CPA and abstinence from alcohol were independent predictors of long-term mortality in patients alive 90 days after the biopsy. CONCLUSION CPA predicts long-term mortality in patients with AH independently of abstinence from alcohol but has no prognostic value on short-term mortality.
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Affiliation(s)
- Mads Israelsen
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK; Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.
| | - Marta Guerrero Misas
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
| | | | - Andrew Hall
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust and UCL Institute for Liver and Digestive Health, University College of London, London, UK.
| | - Claudia Covelli
- Pathology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
| | - Elena Buzzetti
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
| | - Laura Iogna Prat
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
| | - Davide Roccarina
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
| | - Tu Vinh Luong
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust and UCL Institute for Liver and Digestive Health, University College of London, London, UK.
| | - Alberto Quaglia
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust and UCL Institute for Liver and Digestive Health, University College of London, London, UK.
| | - Massimo Pinzani
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK.
| | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK.
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Kezer CA, Buryska SM, Ahn JC, Harmsen WS, Dunn W, Singal AK, Arab JP, Díaz LA, Arnold J, Kamath PS, Shah VH, Simonetto DA. The Mortality Index for Alcohol-Associated Hepatitis: A Novel Prognostic Score. Mayo Clin Proc 2022; 97:480-490. [PMID: 35181163 DOI: 10.1016/j.mayocp.2021.10.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/17/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To develop a new scoring system that more accurately predicts 30-day mortality in patients with alcohol-associated hepatitis (AH). METHODS A cohort of consecutive adults diagnosed with AH at a single academic center from January 1, 1998, to December 31, 2018, was identified for model derivation. Multivariate logistic regression was used to create a new scoring system to predict 30-day mortality. External validation of this score was performed on a multicenter retrospective cohort. RESULTS In the derivation cohort of 266 patients, the 30-day mortality rate was 19.2%. The following variables were found to be significantly associated with mortality on multivariate analysis: age (P=.002), blood urea nitrogen (P=.003), albumin (P=.01), bilirubin (P=.02), and international normalized ratio (P=.001). A model incorporating these variables, entitled the Mortality Index for Alcohol-Associated Hepatitis (MIAAH), achieved a C statistic of 0.86. Comparison of the accuracy of the MIAAH to existing prognostic models, including the Model for End-Stage Liver Disease and Maddrey Discriminant Function, showed that the highest concordance was achieved by the MIAAH and that this difference was significant. In the validation cohort of 249 patients, the MIAAH C statistic decreased to 0.73 and was found to be significantly superior to the Maddrey Discriminant Function but not to the Model for End-Stage Liver Disease. CONCLUSION The MIAAH competes with the current prognostication models and is at a minimum as accurate as these existing scores in identifying patients with AH at high risk of short-term mortality. Furthermore, the MIAAH demonstrates advantageous performance characteristics in its ability to increasingly accurately dichotomize patients into those at highest risk of death and those likely to survive.
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Affiliation(s)
| | - Seth M Buryska
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Joseph C Ahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Winston Dunn
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City
| | - Ashwani K Singal
- University of South Dakota Sanford School of Medicine and Transplant Hepatologist, Avera Transplant Institute, Sioux Falls
| | - Juan P Arab
- Department of Gastroenterology and Hepatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis A Díaz
- Department of Gastroenterology and Hepatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Arnold
- Department of Gastroenterology and Hepatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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Morales-Arráez D, Ventura-Cots M, Altamirano J, Abraldes JG, Cruz-Lemini M, Thursz MR, Atkinson SR, Sarin SK, Kim W, Chavez-Araujo R, Higuera-de la Tijera MF, Singal AK, Shah VH, Kamath PS, Duarte-Rojo A, Charles EA, Vargas V, Jager M, Rautou PE, Rincon D, Zamarripa F, Restrepo-Gutiérrez JC, Torre A, Lucey MR, Arab JP, Mathurin P, Louvet A, García-Tsao G, González JA, Verna EC, Brown RS, Argemi J, Fernández-Carrillo C, Clemente A, Alvarado-Tapias E, Forrest E, Allison M, Bataller R. The MELD Score Is Superior to the Maddrey Discriminant Function Score to Predict Short-Term Mortality in Alcohol-Associated Hepatitis: A Global Study. Am J Gastroenterol 2022; 117:301-310. [PMID: 34962498 PMCID: PMC8999152 DOI: 10.14309/ajg.0000000000001596] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 10/27/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Several scoring systems predict mortality in alcohol-associated hepatitis (AH), including the Maddrey discriminant function (mDF) and model for end-stage liver disease (MELD) score developed in the United States, Glasgow alcoholic hepatitis score in the United Kingdom, and age, bilirubin, international normalized ratio, and creatinine score in Spain. To date, no global studies have examined the utility of these scores, nor has the MELD-sodium been evaluated for outcome prediction in AH. In this study, we assessed the accuracy of different scores to predict short-term mortality in AH and investigated additional factors to improve mortality prediction. METHODS Patients admitted to hospital with a definite or probable AH were recruited by 85 tertiary centers in 11 countries and across 3 continents. Baseline demographic and laboratory variables were obtained. The primary outcome was all-cause mortality at 28 and 90 days. RESULTS In total, 3,101 patients were eligible for inclusion. After exclusions (n = 520), 2,581 patients were enrolled (74.4% male, median age 48 years, interquartile range 40.9-55.0 years). The median MELD score was 23.5 (interquartile range 20.5-27.8). Mortality at 28 and 90 days was 20% and 30.9%, respectively. The area under the receiver operating characteristic curve for 28-day mortality ranged from 0.776 for MELD-sodium to 0.701 for mDF, and for 90-day mortality, it ranged from 0.773 for MELD to 0.709 for mDF. The area under the receiver operating characteristic curve for mDF to predict death was significantly lower than all other scores. Age added to MELD obtained only a small improvement of AUC. DISCUSSION These results suggest that the mDF score should no longer be used to assess AH's prognosis. The MELD score has the best performance in predicting short-term mortality.
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Affiliation(s)
- D Morales-Arráez
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Department of Gastroenterology and Hepatology, Hospital Universitario de Canarias, Canarias, Spain
| | - M Ventura-Cots
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - J Altamirano
- Department of Internal Medicine, Hospital Quironsalud, Barcelona, Spain
| | - J G Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, Canada
| | - M Cruz-Lemini
- Women and Perinatal Research Group, Obstetrics and Gynecology Department, Sant Pau University Hospital, Barcelona, Spain, and Maternal and Child Health and Development Network (SAMID, RD16/0022/0015), Instituto de Salud Carlos III, Spanish Ministry of Health, Spain
| | - M R Thursz
- Department of Metabolism, Digestive disease and Reproduction, Imperial College London, UK
| | - S R Atkinson
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Department of Metabolism, Digestive disease and Reproduction, Imperial College London, UK
| | - S K Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - W Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - R Chavez-Araujo
- Hospital das Clinicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - A K Singal
- Division of Gastroenterology and Hepatology, the University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - V H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - P S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - A Duarte-Rojo
- Division of Gastroenterology and Hepatology, Department of Medicine, the University of Arkansas for Medical Science, Little Rock, Arkansas, USA
| | - E A Charles
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - V Vargas
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Universidad Autónoma, Barcelona, CIBERehd, Barcelona, Spain
| | - M Jager
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
| | - P E Rautou
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
- Inserm, UMR-970, Paris Cardiovascular Research Center, PARCC, Paris, France
| | - D Rincon
- Hepatology Department, Hospital General Universitario Gregorio Marañón, CIBERehd and Universidad Complutense, Madrid, Spain
| | - F Zamarripa
- Gastroenterology, Juarez Hospital, Mexico City, Mexico
| | - J C Restrepo-Gutiérrez
- Liver Transplant Program, Hospital Pablo Tobon Uribe, University of Antioquia, Medellin, Colombia
| | - A Torre
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - M R Lucey
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - J P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - P Mathurin
- Service des Maladies de l'Appareil Digestif et de la Nutrition, CHU Lille, Lille, France
- LIRIC-Lille Inflammation Research International Center-U995, Univ. Lille, Inserm, CHU Lille, Lille, France
| | - A Louvet
- Service des Maladies de l'Appareil Digestif et de la Nutrition, CHU Lille, Lille, France
| | - G García-Tsao
- Section of Digestive Diseases, Yale University School of Medicine/VA-CT Healthcare System, New Haven/West Haven, Connecticut¸ USA
| | - J A González
- Gastroenterology Department, Hospital Universitario "Dr. José E González" Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - E C Verna
- Division of Digestive and Liver Diseases, Department of Medicine and Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - R S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - J Argemi
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Liver Unit, Clinica Universidad de Navarra, IdisNA. Pamplona, Spain
| | - C Fernández-Carrillo
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - A Clemente
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Liver Unit and Digestive Department H.G.U. Gregorio Marañón, Madrid, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - E Alvarado-Tapias
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - E Forrest
- Glasgow Royal Infirmary, Glasgow, UK
| | - M Allison
- Liver Unit, Cambridge Biomedical Research Centre, Cambridge, UK
| | - R Bataller
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
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Mitra A, Myers L, Ahn J. Assessing the Severity and Prognosis of Alcoholic Hepatitis. Clin Liver Dis 2021; 25:585-593. [PMID: 34229841 DOI: 10.1016/j.cld.2021.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Acute alcoholic hepatitis is a clinical entity with significant consequences. Those with severe disease can have high short-term mortality, and considerations for liver transplant candidacy may be raised. Estimating prognosis and mortality is of the utmost importance, as it can guide decision making for corticosteroid therapy and help patients gain an understanding of their illness. Maddrey's discriminant function and MELD score are 2 commonly used static models validated to help estimate severity and prognosis in acute alcoholic hepatitis. This article reviews the 2 models and others used in this difficult setting to assess these patients and guide decision making.
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Affiliation(s)
- Arnab Mitra
- Division of Gastroenterology and Hepatology, Department of Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, L461, Portland, OR 97239-3098, USA.
| | - Lauren Myers
- Division of Gastroenterology and Hepatology, Department of Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, L461, Portland, OR 97239-3098, USA
| | - Joseph Ahn
- Division of Gastroenterology and Hepatology, Department of Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, L461, Portland, OR 97239-3098, USA
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Abstract
The natural history of moderate alcoholic hepatitis (AH) is not well known. It is a frequent disease with a probable underestimated incidence compared with its severe form. Among the different prognostic scores predicting short-term mortality in AH, MELD seems to be the most accurate. The mortality of moderate AH is 3% to 7% in the short to medium term and 13% to 20% at 1 year, mainly because of liver-related complications, including severe infections. Long-term abstinence is the main goal of the treatment. There is still need for the development of new therapies for AH, including the less severe forms.
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Affiliation(s)
- Ana Clemente-Sánchez
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center (UPMC), BST West 11th Floor, Suite 1116-17, 200 Lothrop Street, Pittsburgh, PA 15213, USA; CIBERehd, Instituto de Salud Carlos III, Avenida Monforte de Lemos, 3-5, Pavilion 11th, Floor 0, Madrid 28029, Spain
| | - Aline Oliveira-Mello
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center (UPMC), BST West 11th Floor, Suite 1116-17, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Ramón Bataller
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Kaufmann Medical Building, 3471 Fifth Avenue, Suite 201.19, Pittsburgh, PA 15213, USA.
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A Combination of N-Acetylcysteine and Prednisone Has No Benefit Over Prednisone Alone in Severe Alcoholic Hepatitis: A Retrospective Analysis. Dig Dis Sci 2020; 65:3726-3733. [PMID: 32072435 DOI: 10.1007/s10620-020-06142-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 02/10/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION In this study, we assessed whether there were any survival advantages with a combination treatment of intravenous N-acetylcysteine (NAC) and prednisone over prednisone alone in those with severe alcoholic hepatitis [discriminant function (DF) ≥ 32]. PATIENTS AND METHODS Between January 1, 2013, and February 28, 2019, we identified 68 patients (mean age 47.2 years ± 10.1, 57% women, 65% cirrhosis, MELD score 28.1 ± 6.6) with alcoholic hepatitis, and of those, 21 (31%) received prednisone and 47 (69%) received prednisone + NAC. Lille score ≥ 0.45 was considered a poor response. Renal insufficiency was defined as GFR < 60 ml/min/1.73m2 calculated on two separate occasions. RESULTS DF (74.2 ± 33.6 vs. 56.9 ± 15.9, p = 0.09) was similar, but MELD (29.2 ± 6.3 vs. 25.5 ± 6.4, p = 0.03) scores were higher in the combination group. The overall 30-day and 90-day mortality was 13.2% (9/68) and 20.6% (14/68), respectively. Women were more likely (OR 4.86, 95% CI 1.62-14.59) to respond to treatment based on Lille score compared to men, but the type of treatment regimen had no effect on Lille score (OR 0.84, 95% CI 0.25-2.78). Treatment regimen had no effect on both adjusted and unadjusted survivals. Multivariate analysis, after adjusting for confounding variables, confirmed these observations. DF + renal insufficiency had the highest AUROC (0.86) to predict mortality. CONCLUSION The combination treatment of NAC + prednisone is not better than prednisone alone in patients with severe alcoholic hepatitis.
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Iyer A, Devadas K, Varghese A, Sreesh S. Comparison of conventional scoring systems versus MAGIC score to predict short-term mortality in patients hospitalized for alcoholic hepatitis. Scand J Gastroenterol 2020; 55:1318-1323. [PMID: 33001708 DOI: 10.1080/00365521.2020.1822909] [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] [Indexed: 02/04/2023]
Abstract
BACKGROUND Multiple prognostic models are available to predict mortality in alcoholic hepatitis (AH) which are of modest benefit, but the best model remains unexplored. METHODS This is a retrospective analysis (2012-2015) of AH patients. Conventional prognostic scoring systems viz. Maddrey's Discriminant Function (mDF), Age Bilirubin International Normalized Ratio and Creatinine (ABIC), Glasgow Alcoholic Hepatitis Score (GAHS), and the Model for End-stage Liver Disease score (MELD), were compared with Model for AH to Grade the Severity in an Asian patient cohort (MAGIC) score, using area under the ROC curves for ascertaining 30/90-day mortality. RESULTS Eighty-eight patients (100% male); mean (SD) age of 45.6 (7.6) years with a follow-up of 80.7 (45.1) days were included. The 30 and 90-day mortality were 21 (23.9%) and 42 (47.7%), respectively; the commonest cause being sepsis in 22 (48.9%) patients. Survival probabilities for mDF < 32 and mDF > 32 were 100% and 42.25% ± 4.46%, respectively (p = .001). The mean (SD) scores of mDF, MELD and GAHS were significantly higher in deceased patients 70.8 (26.5), 23.4 (5.2), 8.1 (1.01), respectively, as compared to those who survived 40.8 (23.1), 18.9 (5.1), 7.3 (0.9), respectively; p = .001. ABIC and MAGIC scores were higher among the deceased, but were not significant. mDF had the best predictive AUROC value 0.872, followed by MELD 0.772, and MAGIC 0.626, respectively. mDF was significantly superior in comparison to MAGIC score (p < .001). CONCLUSION This study showed that mDF had a better predictive performance than other scoring systems in patients with AH.
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Affiliation(s)
- Arun Iyer
- Department of Gastroenterology and Hepatology, Government Medical College, Thiruvananthapuram, India
| | - Krishnadas Devadas
- Department of Gastroenterology and Hepatology, Government Medical College, Thiruvananthapuram, India
| | - Anoop Varghese
- Department of Gastroenterology and Hepatology, Government Medical College, Thiruvananthapuram, India
| | - Srijaya Sreesh
- Department of Gastroenterology and Hepatology, Government Medical College, Thiruvananthapuram, India
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12
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Vatsalya V, Cave MC, Kong M, Gobejishvili L, Falkner KC, Craycroft J, Mitchell M, Szabo G, McCullough A, Dasarathy S, Radaeva S, Barton B, McClain CJ. Keratin 18 Is a Diagnostic and Prognostic Factor for Acute Alcoholic Hepatitis. Clin Gastroenterol Hepatol 2020; 18:2046-2054. [PMID: 31811953 PMCID: PMC7269867 DOI: 10.1016/j.cgh.2019.11.050] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 11/19/2019] [Accepted: 11/24/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Acute alcoholic hepatitis (AAH) is a major cause of liver-related morbidity and mortality; there are no good blood biomarkers for diagnosis or determining magnitude of cell death. Keratin 18 (KRT18, also called K18), found in epithelial cells, is released from hepatocytes upon death. We investigated whether level of K18 is a better marker of hepatocyte death than standard biomarkers and might be used to identify patients with AAH at risk for death within 90 days. METHODS We analyzed data from 173 participants in a large trial performed at 4 medical centers. Participants with AAH were classified as severe (n = 57, model for end-stage liver disease [MELD] scores above 20) or moderate (n = 27, MELD scores from 12 to 19); 38 participants had alcohol use disorder with mild (n = 28) or no liver injury (n = 10); 34 participants had nonalcoholic steatohepatitis; and 17 participants were healthy (controls). We quantified serum levels of K18 using ELISAs and APOPTOSENSE kits. RESULTS Serum level of alanine aminotransferase (ALT), aspartate aminotransferase (AST), and the ratio of AST:ALT did not correlate with MELD scores. Patients with alcohol use disorder had higher serum levels of ALT than patients with severe AAH. Levels of K18M65 and K18M30 had statistically significant increases as liver disease worsened, as did the degree of necrosis (ratio of K18 M65:M30). The ratio of K18M65:ALT was increased in serum from patients with AAH compared with controls. Serum levels of K18 identified patients who died within 90 days with greater accuracy than commonly used static biomarkers. CONCLUSIONS There is a stronger association between serum level of keratin 18 and amount of hepatocyte death and liver disease severity than for other biomarkers (AST, ALT, and the AST:ALT ratio). The ratio of K18M65:M30 might be used as marker of mechanism of hepatocyte death, and the ratio of K18M65:ALT might be used to distinguish patients with AAH from patients with nonalcoholic steatohepatitis. Serum levels of K18 might be used to identify patients with severe AAH at risk for death. ClinicalTrials.gov identifier # NCT01922895 and NCT01809132.
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Affiliation(s)
- Vatsalya Vatsalya
- Division of Gastroenterology, Hepatology and Nutrition; Department of Medicine, University of Louisville, Louisville KY,Robley Rex VA Medical Center, Louisville KY,University of Louisville Alcohol Research Center,Hepatobiology & Toxicology Program, University of Louisville, Louisville KY
| | - Matthew C. Cave
- Division of Gastroenterology, Hepatology and Nutrition; Department of Medicine, University of Louisville, Louisville KY,Robley Rex VA Medical Center, Louisville KY,University of Louisville Alcohol Research Center,Hepatobiology & Toxicology Program, University of Louisville, Louisville KY,Department of Pharmacology & Toxicology, University of Louisville, Louisville KY,Department of Biochemistry and Molecular Biology, University of Louisville School of Medicine, Louisville KY
| | - Maiying Kong
- Department of Biostatistics and Bioinformatics, School of Public Health and Information Sciences, University of Louisville, Louisville KY
| | - Leila Gobejishvili
- Division of Gastroenterology, Hepatology and Nutrition; Department of Medicine, University of Louisville, Louisville KY,University of Louisville Alcohol Research Center,Hepatobiology & Toxicology Program, University of Louisville, Louisville KY,Department of Pharmacology & Toxicology, University of Louisville, Louisville KY
| | - K. Cameron Falkner
- Division of Gastroenterology, Hepatology and Nutrition; Department of Medicine, University of Louisville, Louisville KY
| | - John Craycroft
- Department of Biostatistics and Bioinformatics, School of Public Health and Information Sciences, University of Louisville, Louisville KY
| | - Mack Mitchell
- University of Texas Southwestern Medical Center, Dallas TX
| | - Gyongi Szabo
- University of Massachusetts Medical School, Worcester MA
| | | | | | | | - Bruce Barton
- University of Massachusetts Medical School, Worcester MA
| | - Craig J McClain
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville, Louisville, Kentucky; Robley Rex VA Medical Center, Louisville, Kentucky; University of Louisville Alcohol Research Center, Louisville, Kentucky; Hepatobiology and Toxicology Program, University of Louisville, Louisville Kentucky; Department of Pharmacology and Toxicology, University of Louisville, Louisville, Kentucky.
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Gitto S, Aspite S, Golfieri L, Caputo F, Vizzutti F, Grandi S, Patussi V, Marra F. Alcohol use disorder and liver transplant: new perspectives and critical issues. Korean J Intern Med 2020; 35:797-810. [PMID: 32241080 PMCID: PMC7373982 DOI: 10.3904/kjim.2019.409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 03/03/2020] [Indexed: 12/13/2022] Open
Abstract
Alcoholic liver disease is a consolidated indication for liver transplantation, but many unsolved issues can be highlighted. Patients with alcohol use disorder develop peculiar comorbidities that can become contraindications for transplantation. Moreover, a number of social and psychological patterns should be evaluated to select candidates with a low risk of alcohol relapse and adequate post-transplant adherence. In this context, the 6-month rule is too rigid to be widely applied. A short period of abstinence (1 to 3 months) is useful to estimate recovery of liver function and, possibly to avoid transplant. Cardiovascular disorders and extra-hepatic malignancies represent the main clinical issues after transplant. Patients transplanted due to alcoholic disease are a major risk for other liver diseases. Severe corticosteroid-resistant alcoholic acute hepatitis is a debated indication for transplant. However, available data indicate that well-selected patients have excellent post-transplant outcomes. Behavioral therapy, continued psychological support and a multidisciplinary team are essential to achieve and maintain complete alcohol abstinence during the transplant process. Alcoholic liver disease is an excellent indication for a liver transplant but patients with alcohol use disorder deserve a personalized approach and dedicated resources.
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Affiliation(s)
- Stefano Gitto
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Silvia Aspite
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Lucia Golfieri
- Department of Psychology, University of Bologna, Bologna, Italy
| | - Fabio Caputo
- Department of Internal Medicine, SS Annunziata Hospital, University of Ferrara, Cento, Italy
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Silvana Grandi
- Department of Psychology, University of Bologna, Bologna, Italy
| | | | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Research Center Denothe, University of Florence, Italy
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14
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Abstract
Although alcohol-associated liver disease has long been a major component of the liver disease landscape, it was overshadowed by chronic hepatitis C until recently. Nevertheless, with the declining incidence of hepatitis C in the wake of highly effective antiviral therapy, attention has shifted to the increasing burden of alcohol-associated liver disease. The incidence of advanced alcohol-associated liver disease, including acute alcoholic hepatitis and alcohol-associated cirrhosis, is rising in parallel with increasing rates of alcohol use disorders. As a result, alcohol-associated liver disease is now one of the most common indications for liver transplantation. Rates of liver transplantation for acute alcoholic hepatitis are rising as well in spite of the sparse guidance regarding candidate selection, counseling, postoperative care, long-term follow-up, and other best practices. To this day, liver transplant for acute alcoholic hepatitis remains a hotly debated clinical controversy.
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15
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Premkumar M, Bihari C, Saxena P, Devurgowda DR, Vyas T, Mirza R, Jain P, Kumar G, Bhatia P, Baweja S, Choudhury A, Sarin SK. Heparin-like Effect Associated With Risk of Bleeding, Sepsis, and Death in Patients With Severe Alcohol-Associated Hepatitis. Clin Gastroenterol Hepatol 2020; 18:486-495.e3. [PMID: 31077821 DOI: 10.1016/j.cgh.2019.04.057] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 03/04/2019] [Accepted: 04/26/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endogenous heparinoids or heparin-like effects (HLEs) can cause coagulation failure in patients with cirrhosis and sepsis. We performed a prospective study of the association between HLE and bleeding events, sepsis, and outcomes of patients with severe alcohol-associated hepatitis. METHODS Our final analysis comprised 78 patients with severe alcohol-associated hepatitis (44.3 ± 11.7 years; all male; discriminant function >32) who presented without sepsis at a single center in India from August 2015 through August 2016. Blood samples were collected at days 0, 3, and 7 after presentation and assessed by a global coagulation assay; by SONOCLOT (global and heparinase treated); and in assays for factor VIII, von Willebrand factor, protein C, and antithrombin. Patients were followed for sepsis, bleeding and outcome. The primary outcome was association of HLE with survival 28 days after presentation. RESULTS HLEs were observed in 32 patients (41%) at day 0, 27 patients (34.6%) at day 3, and 28 patients (35.9%) patients at day 7. Factors associated with mortality at day 0 were factor VIII activity >160% (hazard ratio [HR], 3.1; 95% CI, 1.4-9.5; P = .026), level of protein C <34% (HR, 0.7; 95% CI, 0.5-0.8; P = .037), antithrombin activity <28% (HR, 0.7; 95% CI, 0.3-1.1; P = .008) and international normalized ratio >2.6 (HR, 2.3; 95% CI, 1.8-9.7; P = .010). In multivariate analyses, only factor VIII activity (HR, 2.3; 95% CI, 1.6-7.8; P = .046), international normalized ratio (1.9; 95% CI, 1.2-4.3; P = .039), level of protein C (HR, 0.9; 95% CI, 0.7-1.1; P = .052) and model for end-stage liver disease score (HR, 3.2; 95% CI, 1.9-10.2; P = .042) were associated with mortality. Episodes of epistaxis, hemorrhoid bleeding, hemoperitoneum, and pulmonary hemorrhage occurred in 10.2%, 12.3%, 3.4%, and 4.5% of patients respectively. The presence of HLE at day 0 increased the risk of sepsis (HR, 2.5; 95% CI, 2.2-4.3; P = .002), bleeding (HR, 1.4; 95% CI, 1.2-5.3; P = .004) and death (HR, 1.2; 95% CI, 1.4-1.7; P = .044). CONCLUSIONS In a prospective study of patients with severe alcohol-associated hepatitis, we associated HLE with coagulation abnormalities, risk of sepsis, and mortality. Clinicaltrials.govNCT02307409.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chhagan Bihari
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Priyanka Saxena
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Tanmay Vyas
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Roshni Mirza
- Department of Hematology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Priyanka Jain
- Department of Epidemiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Epidemiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Puja Bhatia
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sukriti Baweja
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
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Asrani SK, Trotter J, Lake J, Ahmad A, Bonagura A, Cameron A, DiMartini A, Gonzalez S, Im G, Martin P, Mathurin P, Mellinger J, Rice JP, Shah V, Terrault N, Wall A, Winder S, Klintmalm G. Meeting Report: The Dallas Consensus Conference on Liver Transplantation for Alcohol Associated Hepatitis. Liver Transpl 2020; 26:127-140. [PMID: 31743578 PMCID: PMC8151800 DOI: 10.1002/lt.25681] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/29/2019] [Indexed: 12/13/2022]
Abstract
Liver transplantation (LT) for alcohol associated hepatitis (AH) remains controversial. We convened a consensus conference to examine various aspects of LT for AH. The goal was not to unequivocally endorse LT for AH; instead, it was to propose recommendations for programs that perform or plan to perform LT for AH. Criteria were established to determine candidacy for LT in the setting of AH and included the following: (1) AH patients presenting for the first time with decompensated liver disease that are nonresponders to medical therapy without severe medical or psychiatric comorbidities; (2) a fixed period of abstinence prior to transplantation is not required; and (3) assessment with a multidisciplinary psychosocial team, including a social worker and an addiction specialist/mental health professional with addiction and transplantation expertise. Supporting factors included lack of repeated unsuccessful attempts at addiction rehabilitation, lack of other substance use/dependency, acceptance of diagnosis/insight with a commitment of the patient/family to sobriety, and formalized agreement to adhere to total alcohol abstinence and counseling. LT should be avoided in AH patients who are likely to spontaneously recover. Short-term and longterm survival comparable to other indications for LT must be achieved. There should not be further disparity in LT either by indication, geography, or other sociodemographic factors. Treatment of alcohol-use disorders should be incorporated into pre- and post-LT care. The restrictive and focused evaluation process described in the initial LT experience for AH worldwide may not endure as this indication gains wider acceptance at more LT programs. Transparency in the selection process is crucial and requires the collection of objective data to assess outcomes and minimize center variation in listing. Oversight of program adherence is important to harmonize listing practices and outcomes.
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Affiliation(s)
- Sumeet K Asrani
- Baylor University Medical Center, Dallas, Texas,Corresponding author: Sumeet K Asrani MD MSc, Associate Professor of Medicine, Baylor University Medical Center, Dallas Texas, , Tele: 214 820 8500, Fax: 214 820 0993
| | | | - Jack Lake
- University of Minnesota, Minneapolis, Minnesota
| | | | | | | | | | | | | | - Paul Martin
- University of Miami health system, Miami, Florida
| | - Philippe Mathurin
- Service d’Hépato-gastroentérologie, Hôpital Claude Huriez, Lille, France
| | | | | | | | - Norah Terrault
- University of Southern California, Los Angeles, California
| | - Anji Wall
- Baylor University Medical Center, Dallas, Texas
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Bennett K, Enki DG, Thursz M, Cramp ME, Dhanda AD. Systematic review with meta-analysis: high mortality in patients with non-severe alcoholic hepatitis. Aliment Pharmacol Ther 2019; 50:249-257. [PMID: 31231848 DOI: 10.1111/apt.15376] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/07/2019] [Accepted: 05/26/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Alcoholic hepatitis is a serious complication of alcohol misuse. Severe alcoholic hepatitis with its high mortality, has been investigated in detail but 'nonsevere alcoholic hepatitis' is poorly characterised. Survival of this group of patients is unknown. AIM To conduct a systematic review and meta-analysis to determine 28-day, 90-day and 1-year mortality of patients with nonsevere alcoholic hepatitis. METHODS The protocol was registered on the PROSPERO database (CRD42018107451). Embase, Medline and Cochrane Central databases were searched until July 2018. All study designs reporting mortality rates in patients with nonsevere alcoholic hepatitis were eligible. Mortality data were extracted and meta-analysis performed using a random effects model. Risk of bias was assessed by Cochrane risk of bias or National Institutes of Health quality assessment tool for case series studies. RESULTS Twenty-five studies (n = 1372 patients; 12 prospective) met criteria. Nonsevere was variably defined based on bilirubin, prothrombin time, and creatinine. Twenty-eight day mortality (17 studies; n = 993) was 6% (95% CI 3%-9%; I2 = 67.3%; P < 0.001), 90-day mortality (15 studies; n = 755) was 7% (4%-11%, I2 = 64.2%; P < 0.001) and 1-year mortality (five studies; n = 234) was 13% (4%-24%; I2 = 72%; P = 0.006). Subgroup analyses by method of diagnosis (histological vs clinical) or study design (prospective vs retrospective) did not reveal differences in mortality. CONCLUSION Nonsevere alcoholic hepatitis is not benign with 6% and 13% 28-day and 1-year mortality, respectively. This systematic review demonstrates the paucity of high quality studies in patients with nonsevere alcoholic hepatitis. Our analysis suggests that patients who do not meet criteria for severe alcoholic hepatitis are an important and hitherto overlooked clinical group. Full characterisation of clinical outcome and development of treatment strategies to reduce mortality in this group is a priority.
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Affiliation(s)
- Kris Bennett
- Institute of Translational and Stratified Medicine, University of Plymouth, UK
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Doyo G Enki
- Medical Statistics Group, University of Plymouth, UK
| | - Mark Thursz
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Matthew E Cramp
- Institute of Translational and Stratified Medicine, University of Plymouth, UK
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Ashwin D Dhanda
- Institute of Translational and Stratified Medicine, University of Plymouth, UK
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
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18
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Early liver transplantation for severe alcoholic hepatitis: moving from controversy to consensus. Curr Opin Organ Transplant 2019; 23:229-236. [PMID: 29389821 DOI: 10.1097/mot.0000000000000507] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Alcohol-related liver disease is now the most common indication for liver transplant in the United States. Acute alcoholic hepatitis represents a subpopulation with short-term mortality approaching 70% in severe cases - these patients are not typically eligible for liver transplant, as most centers require a period of alcohol abstinence (typically 6 months) prior to transplant. Early liver transplant (prior to a requisite period of abstinence) is being increasingly offered in a minority of U.S. centers. The present review examines clinical and ethical considerations surrounding liver transplant for severe alcoholic hepatitis, key published studies and knowledge gaps, and future directions for clinical research to achieve optimal patient outcomes. RECENT FINDINGS Since a European pilot study published in 2011, published U.S. original studies in early liver transplantation for severe alcoholic hepatitis are limited to 1 UNOS review, and 2 retrospective single-center studies. A preliminary report from the ACCELERATE-AH consortium show short-term outcomes are acceptable and that use of alcohol posttransplant occurs in 25% of patients. These studies confirm the survival benefit of early liver transplant for alcoholic hepatitis and report rates of alcohol use posttransplant similar to historic cohorts in alcohol-related cirrhosis. SUMMARY Early liver transplantation for severe alcoholic hepatitis is lifesaving, with acceptable short to intermediate-term patient survival and rates of alcohol use posttransplant. Further study is needed to determine long-term outcomes, and how best to select and manage patients for this new indication for liver transplant.
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19
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Li YM, Fan JG. Guidelines of prevention and treatment for alcoholic liver disease (2018, China). J Dig Dis 2019; 20:174-180. [PMID: 30450822 DOI: 10.1111/1751-2980.12687] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 11/12/2018] [Accepted: 11/15/2018] [Indexed: 12/11/2022]
Affiliation(s)
- You Ming Li
- Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Jian Gao Fan
- Department of Gastroenterology, XinHua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Key Laboratory of Children's Digestion and Nutrition, Shanghai, China
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20
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Abstract
Alcoholic hepatitis is a unique type of alcohol-associated liver disease characterized by acute liver inflammation caused by prolonged heavy alcohol use. Treatment is mostly supportive. The short-term prognosis of acute alcoholic hepatitis depends on liver recovery, and ranges widely from rapid improvement to grim multiorgan failure despite treatment. Refinement of scoring systems have enhanced prognostication to guide clinical decision making in alcoholic hepatitis. Recent advances in the treatment of alcoholic hepatitis have solidified corticosteroids as the cornerstone of treatment to enhance short-term survival, but not intermediate or long-term survival.
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Affiliation(s)
- Gene Y Im
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, Recanati-Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029, USA.
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21
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Moreno C, Mueller S, Szabo G. Non-invasive diagnosis and biomarkers in alcohol-related liver disease. J Hepatol 2019; 70:273-283. [PMID: 30658728 DOI: 10.1016/j.jhep.2018.11.025] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 11/29/2018] [Accepted: 11/29/2018] [Indexed: 12/14/2022]
Abstract
Even though alcohol-related liver disease (ALD) is a major cause of severe liver disease worldwide, most patients with ALD are diagnosed at the decompensation stage. Liver biopsy is still considered the gold standard for establishing a definite diagnosis and assessing the fibrosis stage of ALD, but it is an invasive procedure, associated with significant morbidity. During the last decade, non-invasive tests have been developed to estimate the severity of liver fibrosis and steatosis. Measurement of liver stiffness by transient elastography has become the most commonly used non-invasive parameter to evaluate fibrosis. In ALD, transient elastography has been demonstrated to have an excellent performance to detect advanced fibrosis and cirrhosis. However, aspartate aminotransferase levels must be considered when interpreting liver stiffness cut-offs. Non-invasive biological tests have also been evaluated to assess liver fibrosis in ALD. The commercially available Enhanced Liver Fibrosis test and FibroTest have comparable performance for the diagnosis of advanced fibrosis in ALD, with studies suggesting that they are better than other biological tests (i.e. FIB-4 and APRI). Although ultrasound is still accepted as an initial screen for fatty liver diagnosis, new methods have recently been developed to detect steatosis. Magnetic resonance spectroscopy and magnetic resonance imaging techniques are highly accurate and reproducible, with superior sensitivities and specificities for detecting histological steatosis than ultrasound. However, low availability and high cost limit the use of magnetic resonance techniques in routine clinical practice. More recently, controlled attenuation parameter was developed as a novel tool to non-invasively assess liver steatosis; performed in combination with transient elastography, it was suggested to be superior to regular ultrasound for detecting steatosis and was shown to have acceptable diagnostic accuracy. New serum biomarkers are under investigation to non-invasively diagnose more severe forms of ALD and to predict prognosis of patients.
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Affiliation(s)
- Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.
| | - Sebastian Mueller
- Salem Medical Center and Center for Alcohol Research, University of Heidelberg, Zeppelinstraße 11-33, 69121 Heidelberg, Germany
| | - Gyongyi Szabo
- Department of Medicine, LRB-208, University of Massachusetts Medical School, 364 Plantation Street, Worcester, MA 01605, USA
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22
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Response to Forrest et al. Am J Gastroenterol 2019; 114:176. [PMID: 30633036 DOI: 10.14309/ajg.0000000000000073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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23
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Singal AK, Louvet A, Shah VH, Kamath PS. Grand Rounds: Alcoholic Hepatitis. J Hepatol 2018; 69:534-543. [PMID: 29753761 PMCID: PMC6258018 DOI: 10.1016/j.jhep.2018.05.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 04/20/2018] [Accepted: 05/01/2018] [Indexed: 12/17/2022]
Abstract
A 33-year-old Caucasian male was admitted to hospital with recent onset of jaundice of 2-3 weeks duration. He reported heavy use of alcohol for the last 10 years with the last drink a day prior to the onset of symptoms. At admission, he was alert and oriented to time, place, and person, and was deeply jaundiced. His laboratory profile can be summarised as follows: haemoglobin 12.1 g/dl, white blood cell count 18,700 with 81% neutrophils, serum bilirubin 33 (direct 22) mg/dl, aspartate aminotransferase 147 IU/L, alanine aminotransferase 62 IU/L, alkaline phosphatase 117 IU/L, serum albumin 2.8 gm/dl, serum creatinine 0.6 mg/dl, prothrombin time 18.3 (control 14.5) seconds, and international normalized ratio 1.48. He was diagnosed with severe alcoholic hepatitis (Maddrey discriminant function score of 50) and treated with prednisolone for 28 days with symptomatic and biochemical improvement. His Lille score at seven days was 0.4, and his serum bilirubin had decreased to 3.5 mg/dl at the end of treatment. He was also seen by the addiction team during hospitalisation; he agreed to follow through on recommendations. He was dismissed after completing a three-week inpatient rehabilitation programme but relapsed to alcohol use three months later, and was readmitted with alcohol withdrawal. He was readmitted two months later (about six months from the first episode) for a second episode of severe alcoholic hepatitis. At admission, his model for end-stage liver disease score was 32 and he was treated again with corticosteroids. His Lille score at seven days was 0.6 and steroids were discontinued. The hospital course was complicated by spontaneous bacterial peritonitis and pneumonia with development of acute kidney injury. He continued to worsen, developing multiorgan failure. After a course of one month, the family's preference was for him to receive comfort measures. This scenario raises several questions.
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Affiliation(s)
- Ashwani K. Singal
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL. USA,Corresponding author. Address 1808 7th Ave S, BDB 351, University of Alabama at Birmingham, Birmingham, AL, USA. Tel.: +1 205 934 5623; fax: +1 205 975 0961. (A.K. Singal)
| | - Alexandre Louvet
- Service des maladies de l’appareil digestif, Hôpital Huriez, Rue Polonowski, 59037 Lille cedex, France,Université Lille Nord de France, Lille, France
| | - Vijay H. Shah
- Division of gastroenterology and hepatology, Mayo Clinic, Rochester, MN, USA
| | - Patrick S. Kamath
- Division of gastroenterology and hepatology, Mayo Clinic, Rochester, MN, USA
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Calmet F, Martin P. A New Marker for Severity of Alcoholic Hepatitis. Clin Gastroenterol Hepatol 2018; 16:1207-1208. [PMID: 29427735 DOI: 10.1016/j.cgh.2018.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 02/02/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Fernando Calmet
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Paul Martin
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
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25
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Sandahl TD, Vilstrup H, Jepsen P. The long-term prognosis of alcoholic hepatitis is poor and independent of disease severity for patients surviving an acute episode. J Hepatol 2018. [PMID: 29524529 DOI: 10.1016/j.jhep.2018.02.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Denmark
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Predictors of 90-day mortality in patients with severe alcoholic hepatitis: Experience with 183 patients at a tertiary care center from India. Indian J Gastroenterol 2018; 37:141-152. [PMID: 29704174 DOI: 10.1007/s12664-018-0842-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 03/04/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Severe alcoholic hepatitis (AH) is not an uncommon indication for hospital admission in India. However, there is limited data from India on predictors of mortality in patients of severe AH. We analyzed the data on patients with severe AH admitted to our institute and compared various parameters and severity scores in predicting 90-day mortality. METHODS In this prospective study, we analyzed patients with severe AH (defined as discriminant function ≥ 32) admitted from January 2015 to February 2017 to our institute. All patients were administered standard treatment according to various guidelines, and their 90-day mortality was determined. Various hematologic, biochemical factors, and severity scores were compared between survivors and patients who died. RESULTS A total of 183 patients (98% males, median age 41 years [range 20-70 years]) were included in our study. The median model for end-stage liver disease (MELD) was 26 (15-40). Ascites were present in 83% and hepatic encephalopathy in 38%. Only 21 (12%) could be offered steroid therapy, due to contraindications in the remaining. By 90 days, only 103 (56%) patients survived while 80 (44%) died. All patients died due to progressive liver failure and its complications. On multivariate analysis, presence of ascites, hepatic encephalopathy, high bilirubin, low albumin, high creatinine, high INR, and low potassium independently predicted 90-day mortality. All the scores performed significantly in predicting 90-day mortality with no statistically significant difference between them. MELD score had a maximum area under the curve 0.76 for 90-day mortality. A combination of Child class and presence of acute kidney injury (creatinine ≥ 1.35) was good in predicting 90-day mortality. CONCLUSION Our patients had severe AH characterized by a median MELD score of 26 and had a 90-day mortality of 44%. Most patients were not eligible to receive corticosteroids. Presence of Child C status and high serum creatinine value (≥ 1.35 mg/dL) accurately predicted mortality. Newer treatment options need to be explored for these patients.
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Xi RR, Han T, Lv JY, Cai JJ. Comparison of five different scoring models for predicting short-term mortality in patients with alcohol-related acute-on-chronic liver failure. Shijie Huaren Xiaohua Zazhi 2018; 26:365-372. [DOI: 10.11569/wcjd.v26.i6.365] [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] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the performance of age, bilirubin, INR, and creatinine (ABIC), Maddrey's discriminant function (MDF), model for end-stage liver disease (MELD), chronic liver failure-sequential organ failure assessment (CLIF-SOFA), and Child-Turcotte-Pugh (CTP) in predicting short-term mortality in patients with alcohol-related acute-on-chronic liver failure (ACLF).
METHODS There were 462 consecutive patients with live failure treated from August 2005 to June 2017 at Tianjin Third Central Hospital, of whom 152 with alcohol-related ACLF were finally enrolled in this study according to the inclusion criteria and exclusion criteria. We divided patients into either group A or group B. Patients in group A met the criteria of Asian Pacific Association for the Study of the Liver but did not met the criteria of European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF), and patients in group B met the criteria of EASL-CLIF on admission. The performance of different scoring models in predicting short-term mortality was assessed using the area under the receiver operating characteristic curve (AUC-ROC).
RESULTS The 28-d mortality rate was 19% in group A and 50% in group B (P = 0.002). In group A, the AUC of CLIF-SOFA for predicting the 28-d mortality was highest (0.889), followed by MELD (0.761), MDF (0.738), ABIC (0.718), and CTP (0.671), and there was a significant difference between CTP and the others. In group B, the AUC of CLIF-SOFA was 0.916, followed by MELD (0.804), MDF (0.770), ABIC (0.729), and CTP (0.647), and there was a significant difference between CLIF-SOFA and the others and between CTP and the others.
CONCLUSION The five scoring systems could all predict the short-term prognosis of the two groups of patients. However, CLIF-SOFA performs well compared to the others, regardless of patients in group A or group B.
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28
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Daswani R, Kumar A, Sharma P, Singla V, Bansal N, Arora A. Role of liver transplantation in severe alcoholic hepatitis. Clin Mol Hepatol 2018; 24:43-50. [PMID: 29316778 PMCID: PMC5875200 DOI: 10.3350/cmh.2017.0027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 11/20/2017] [Indexed: 12/12/2022] Open
Abstract
Severe alcoholic hepatitis has very high short term mortality and corticosteroids have been the mainstay of treatment for decades. Patients with Lille score >0.45 are considered non-responders to steroids and have poor outcome. Recently Orthotopic Liver Transplantation (OLT) is being increasingly used as rescue treatment for these patients, without waiting for 6 months of abstinence. Liver transplant is the only rescue treatment which can potentially provide long term benefit for patients who are steroid non-responders. However, with scarcity of organs being a concern, all patients of severe alcoholic hepatitis cannot be chosen for transplantation in an arbitrary way. There is a need for development of predictive tools and objective protocols to select patients who can justify the use of precious liver grafts. With a stringent criteria for selection of patients receiving the graft, liver transplantation in severe alcoholic hepatitis can become a viable rescue therapeutic option conferring significant survival advantage of both short- and long-term basis. The optimal criteria for selection will also prevent misuse of the liver donor pool as well as to prevent mortality in salvageable patients. Further research needs to be done to identify subset of patients which are at low risk of recidivism and also cannot be managed with pharmacotherapy alone. We reviewed the current knowledge on role of OLT in patient with acute severe alcoholic hepatitis in the present review.
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Affiliation(s)
- Ravi Daswani
- Institute of Liver, Gastroenterology, & Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Ashish Kumar
- Institute of Liver, Gastroenterology, & Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Praveen Sharma
- Institute of Liver, Gastroenterology, & Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Vikas Singla
- Institute of Liver, Gastroenterology, & Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Naresh Bansal
- Institute of Liver, Gastroenterology, & Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Anil Arora
- Institute of Liver, Gastroenterology, & Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
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Predicting short-term and long-term mortality of hospitalized Portuguese patients with alcoholic hepatitis. Eur J Gastroenterol Hepatol 2017. [PMID: 28628497 DOI: 10.1097/meg.0000000000000926] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Alcohol abuse can result in a spectrum of liver injury that ranges from mild fatty infiltration to alcoholic hepatitis (AH), cirrhosis, and hepatocellular carcinoma. The present study aimed to evaluate current scoring systems in predicting short-term and long-term mortality because of AH. PATIENTS AND METHODS Records of 170 consecutive patients with AH admitted to a tertiary center between January 2005 and October 2015 were reviewed. Clinical and biochemical parameters were retrieved for the assessment of AH scores for the day of admission (D1) and for the seventh day of hospitalization (D7). Endpoints included admission to the ICU, and 30-day, 90-day, and 1-year mortality. RESULTS The Maddrey discriminant function and the Model of End-Stage Liver Disease (MELD) were modest predictors of the need for ICU admission. In-hospital, 30-day, 90-day, and 1-year mortality were 15.9, 18.2, 21.8, and 30.0%, respectively. There was a numerical, albeit nonsignificant, trend for higher accuracy using D7 scores, especially the MELD, in predicting 30-day and 1-year mortality. Overall, all scores showed high negative predictive values (30 day: 91.2-98.7% and 1 year: 78.8-93.7%), but modest positive predictive values (30 day: 30.6-70.8% and 1 year: 42.1-61.2%). Survival rates were the highest among patients showing a decrease in the MELD, Glasgow Alcoholic Hepatitis Score, and Age, serum Bilirubin, International normalized ratio, and serum Creatinine score over the first week of admission. DISCUSSION AH scores were comparable in identifying patients at low risk of mortality up to 1 year following admission. Reassessment of the MELD, Glasgow Alcoholic Hepatitis Score, and Age, serum Bilirubin, International normalized ratio, and serum Creatinine score scores after 1 week further improved mortality prediction.
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30
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Wu Q, Zhao X, You H. Characteristics of liver fibrosis with different etiologies using a fully quantitative fibrosis assessment tool. Braz J Med Biol Res 2017; 50:e5234. [PMID: 28538834 PMCID: PMC5479381 DOI: 10.1590/1414-431x20175234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 05/03/2017] [Indexed: 11/30/2022] Open
Abstract
This study aimed to test the diagnostic performance of a fully quantitative fibrosis assessment tool for liver fibrosis in patients with chronic hepatitis B (CHB), primary biliary cirrhosis (PBC) and non-alcoholic steatohepatitis (NASH). A total of 117 patients with liver fibrosis were included in this study, including 50 patients with CHB, 49 patients with PBC and 18 patients with NASH. All patients underwent liver biopsy (LB). Fibrosis stages were assessed by two experienced pathologists. Histopathological images of LB slices were processed by second harmonic generation (SHG)/two-photon excited fluorescence (TPEF) microscopy without staining, a system called qFibrosis (quantitative fibrosis) system. Altogether 101 quantitative features of the SHG/TPEF images were acquired. The parameters of aggregated collagen in portal, septal and fibrillar areas increased significantly with stages of liver fibrosis in PBC and CHB (P<0.05), but the same was not found for parameters of distributed collagen (P>0.05). There was a significant correlation between parameters of aggregated collagen in portal, septal and fibrillar areas and stages of liver fibrosis from CHB and PBC (P<0.05), but no correlation was found between the distributed collagen parameters and the stages of liver fibrosis from those patients (P>0.05). There was no significant correlation between NASH parameters and stages of fibrosis (P>0.05). For CHB and PBC patients, the highest correlation was between septal parameters and fibrosis stages, the second highest was between portal parameters and fibrosis stages and the lowest correlation was between fibrillar parameters and fibrosis stages. The correlation between the septal parameters of the PBC and stages is significantly higher than the parameters of the other two areas (P<0.05). The qFibrosis candidate parameters based on CHB were also applicable for quantitative analysis of liver fibrosis in PBC patients. Different parameters should be selected for liver fibrosis assessment in different stages of PBC compared with CHB.
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Affiliation(s)
- Q Wu
- Beijing Key Laboratory of Translational Medicine in Liver Cirrhosis, Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Digestive Diseases, Beijing, China
| | - X Zhao
- Beijing Key Laboratory of Translational Medicine in Liver Cirrhosis, Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Digestive Diseases, Beijing, China
| | - H You
- Beijing Key Laboratory of Translational Medicine in Liver Cirrhosis, Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Digestive Diseases, Beijing, China
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31
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Stickel F, Datz C, Hampe J, Bataller R. Pathophysiology and Management of Alcoholic Liver Disease: Update 2016. Gut Liver 2017; 11:173-188. [PMID: 28274107 PMCID: PMC5347641 DOI: 10.5009/gnl16477] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 10/14/2016] [Indexed: 12/13/2022] Open
Abstract
Alcoholic liver disease (ALD) is a leading cause of cirrhosis, liver cancer, and acute and chronic liver failure and as such causes significant morbidity and mortality. While alcohol consumption is slightly decreasing in several European countries, it is rising in others and remains high in many countries around the world. The pathophysiology of ALD is still incompletely understood but relates largely to the direct toxic effects of alcohol and its main intermediate, acetaldehyde. Recently, novel putative mechanisms have been identified in systematic scans covering the entire human genome and raise new hypotheses on previously unknown pathways. The latter also identify host genetic risk factors for significant liver injury, which may help design prognostic risk scores. The diagnosis of ALD is relatively easy with a panel of well-evaluated tests and only rarely requires a liver biopsy. Treatment of ALD is difficult and grounded in abstinence as the pivotal therapeutic goal; once cirrhosis is established, treatment largely resembles that of other etiologies of advanced liver damage. Liver transplantation is a sound option for carefully selected patients with cirrhosis and alcoholic hepatitis because relapse rates are low and prognosis is comparable to other etiologies. Still, many countries are restrictive in allocating donor livers for ALD patients. Overall, few therapeutic options exist for severe ALD. However, there is good evidence of benefit for only corticosteroids in severe alcoholic hepatitis, while most other efforts are of limited efficacy. Considering the immense burden of ALD worldwide, efforts of medical professionals and industry partners to develop targeted therapies in ALF has been disappointingly low.
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Affiliation(s)
- Felix Stickel
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich,
Switzerland
| | - Christian Datz
- Department of Internal Medicine, Hospital Oberndorf, Teaching Hospital of the Paracelsus Private University of Salzburg, Oberndorf,
Austria
| | - Jochen Hampe
- Medical Department 1, University Hospital Dresden, TU Dresden, Dresden,
Germany
| | - Ramon Bataller
- Division of Gastroenterology and Hepatology, Department of Medicine and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC,
USA
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A Day-4 Lille Model Predicts Response to Corticosteroids and Mortality in Severe Alcoholic Hepatitis. Am J Gastroenterol 2017; 112:306-315. [PMID: 27922027 DOI: 10.1038/ajg.2016.539] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 10/01/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Prednisolone therapy increases the risk of infections in patients with severe alcoholic hepatitis (SAH). We evaluated whether the use of the Lille Model at day 4 (LM4) is useful to predict response to prednisolone compared with the classic day 7 (LM7) in order to limit a futile exposure to corticosteroids. METHODS We performed a retrospective analysis of a large multinational cohort of patients with SAH with Maddrey's discriminant function (DF) ≥32. Response to corticosteroids was assessed with LM4 and LM7, according to the validated cutoff value (CUV>0.45). Receiver operating characteristics (ROC) curves were constructed to determine the optimal CUV for LM4 and to compare accuracy between LM4, LM7, MELD (Model for End-Stage Liver Disease), and ABIC (age, bilirubin, international normalized ratio, and creatinine). Logistic regression models were constructed to predict 28- and 90-day mortality. Cox regression analysis was performed to assess long-term survival. RESULTS A total of 163 (62.7%) out of 260 patients received corticosteroids. The median DF for the patients treated with corticosteroids was 64.1 (47.9-81.3). Overall 90-day mortality was 35.9%. The median LM4 and LM7 for the patients who received treatment was 0.39 (0.19-0.83) and 0.36 (0.13-0.77). LM4 was a strong independent predictor of 28-day mortality (OR 25.4, (95% confidence interval (CI) 5.1-126.8), P<0.001). By using LM4 with a CUV>0.45, 28- and 90-day survival was significantly higher for responders (90% and 76%) than non-responders (66% and 40%), P<0.001. Importantly, the area under the ROC curve for predicting mortality for LM4 was similar than the classic LM7 (0.77 vs. 0.75, respectively: P=0.558). CONCLUSIONS LM4 is as accurate as LM7 in predicting response to corticosteroids, as well as 28- and 90-day mortality. Assessing the efficacy of prednisolone at an earlier time point can avoid a more prolonged futile use of this therapy.
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Morabito V, Novelli S, Poli L, Ferretti G, Ruberto F, Pugliese F, Pretagostini R, Berloco PB, Rossi M. Adacolumn Granulocyte-Apheresis for Alcoholic Hepatitis: Preliminary Study. Transplant Proc 2017; 48:352-8. [PMID: 27109954 DOI: 10.1016/j.transproceed.2015.12.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 12/30/2015] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Alcoholic hepatitis (AH) is an acute-on-chronic inflammatory response affecting the liver. It has been recognized that white blood cells (WBCs) are involved in the pathogenesis and in the prognosis of AH. The aim of study was to use Adacolumn, which can selectively adsorb myeloid linage leucocytes (granulocytes and monocytes/macrophages) from the blood in the column and improve the clinical status of patients. MATERIALS Six patients with a diagnosis of AH were treated with Adacolumn granulocyte-apheresis therapy. INCLUSION CRITERIA patients not responders to corticosteroids therapy with Maddrey Discriminant Function (MDF) >32 and MELD score 20-26. The patients underwent five 1-hour sessions for 5 consecutive days with a follow-up at 28 days. The column was placed in an extracorporeal setting with a perfusion rate of 30 mL/min and a duration of 60 minutes. Liver parameters, WBC count, proinflammatory cytokines, coagulation, and predictive scores were valued before and after the cycle of apheresis treatment. RESULTS After 5 days, the findings showed a significant improvement of WBC count (P < .014) and cytokines such as interleukin (IL)-6 (P < .019), tumor necrosis factor α (TNFα) (P < .02), and IL-8 (P < .029). The results probably determined a reduction of aspartate transaminase (AST; P < .02) and alanine transaminase (ALT; P < .011), although we did not observe a significant improve in bilirubin, prothrombin time (PT), and Maddrey score. The improvement of MELD score, depending on an improvement of international normalized ratio for administration of plasma, was not considered. At day 28 of follow-up, PT, IL-6, TNFα, AST and ALT results significantly improved. CONCLUSIONS The Adacolumn apheresis was safe and was able to determine an improvement of clinical status of patients with reduction of inflammatory markers. More patients are needed to validate these results.
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Affiliation(s)
- V Morabito
- Italian National Transplant Center, Rome, Italy.
| | - S Novelli
- Department of Aerospace and Mechanical Engineering, Sapienza University of Rome, Rome, Italy
| | - L Poli
- Italian National Transplant Center, Rome, Italy
| | - G Ferretti
- Department of Infectious Disease, Sapienza University of Rome, Rome, Italy
| | - F Ruberto
- Department of Anesthesia and Intensive Care, Sapienza University of Rome, Rome, Italy
| | - F Pugliese
- Department of Anesthesia and Intensive Care, Sapienza University of Rome, Rome, Italy
| | | | - P B Berloco
- Italian National Transplant Center, Rome, Italy
| | - M Rossi
- Italian National Transplant Center, Rome, Italy
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Kim HY, Kim CW, Kim TY, Song DS, Sinn DH, Yoon EL, Jung YK, Suk KT, Lee SS, Lee CH, Kim TH, Kim JH, Yim HJ, Kim SE, Baik SK, Lee BS, Jang JY, Kim YS, Kim SG, Yang JM, Sohn JH, Lee HJ, Park SH, Choi EH, Kim DJ. Assessment of scoring systems for acute-on-chronic liver failure at predicting short-term mortality in patients with alcoholic hepatitis. World J Gastroenterol 2016; 22:9205-9213. [PMID: 27895407 PMCID: PMC5107601 DOI: 10.3748/wjg.v22.i41.9205] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 08/20/2016] [Accepted: 09/14/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the performance of proposed scores specific for acute-on-chronic liver failure in predicting short-term mortality among patients with alcoholic hepatitis.
METHODS We retrospectively collected data from 264 patients with clinically diagnosed alcoholic hepatitis from January to December 2013 at 21 academic hospitals in Korea. The performance for predicting short-term mortality was calculated for Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA), CLIF Consortium Organ Failure score (CLIF-C OFs), Maddrey’s discriminant function (DF), age, bilirubin, international normalized ratio and creatinine score (ABIC), Glasgow Alcoholic Hepatitis Score (GAHS), model for end-stage liver disease (MELD), and MELD-Na.
RESULTS Of 264 patients, 32 (12%) patients died within 28 d. The area under receiver operating characteristic curve of CLIF-SOFA, CLIF-C OFs, DF, ABIC, GAHS, MELD, and MELD-Na was 0.86 (0.81-0.90), 0.89 (0.84-0.92), 0.79 (0.74-0.84), 0.78 (0.72-0.83), 0.81 (0.76-0.86), 0.83 (0.78-0.88), and 0.83 (0.78-0.88), respectively, for 28-d mortality. The performance of CLIF-SOFA had no statistically significant differences for 28-d mortality. The performance of CLIF-C OFs was superior to that of DF, ABIC, and GAHS, while comparable to that of MELD and MELD-Na in predicting 28-d mortality. A CLIF-SOFA score of 8 had 78.1% sensitivity and 79.7% specificity, and CLIF-C OFs of 10 had 68.8% sensitivity and 91.4% specificity for predicting 28-d mortality.
CONCLUSION CLIF-SOFA and CLIF-C OF scores performed well, with comparable predictive ability for short-term mortality compared to the commonly used scoring systems in patients with alcoholic hepatitis.
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Mandrekar P, Bataller R, Tsukamoto H, Gao B. Alcoholic hepatitis: Translational approaches to develop targeted therapies. Hepatology 2016; 64:1343-55. [PMID: 26940353 PMCID: PMC5010788 DOI: 10.1002/hep.28530] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 02/10/2016] [Accepted: 02/21/2016] [Indexed: 12/12/2022]
Abstract
UNLABELLED Alcoholic liver disease is a leading cause of liver-related mortality worldwide. In contrast to recent advances in therapeutic strategies for patients with viral hepatitis, there is a significant lack of novel therapeutic options for patients with alcoholic liver disease. In particular, there is an urgent need to focus our efforts on effective therapeutic interventions for alcoholic hepatitis (AH), the most severe form of alcoholic liver disease. AH is characterized by an abrupt development of jaundice and complications related to liver insufficiency and portal hypertension in patients with heavy alcohol intake. The mortality of patients with AH is very high (20%-50% at 3 months). Available therapies are not effective in many patients, and targeted approaches are imminently needed. The development of such therapies requires translational studies in human samples and suitable animal models that reproduce the clinical and histological features of AH. In recent years, new animal models that simulate some of the features of human AH have been developed, and translational studies using human samples have identified potential pathogenic factors and histological parameters that predict survival. CONCLUSION This review summarizes the unmet needs for translational studies on the pathogenesis of AH, preclinical translational tools, and emerging drug targets to benefit the AH patient. (Hepatology 2016;64:1343-1355).
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Affiliation(s)
- Pranoti Mandrekar
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA.
| | - Ramon Bataller
- Division of Gastroenterology and Hepatology, Departments of Medicine and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Hidekazu Tsukamoto
- Southern California Research Center for ALPD and Cirrhosis and Department of Pathology, University of Southern California, Greater Los Angeles Department of Veterans Affairs Healthcare System, Los Angeles, CA.
| | - Bin Gao
- Laboratory of Liver Diseases, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD.
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36
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Im GY, Lucey MR. Practical Concerns and Controversies in the Management of Alcoholic Hepatitis. Gastroenterol Hepatol (N Y) 2016; 12:478-489. [PMID: 27917083 PMCID: PMC5114494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Recent advances in the treatment of alcoholic hepatitis (AH) have reinforced the utility of glucocorticoids, a treatment that has been in use for nearly 4 decades, to enhance short-term survival. As multi-institutional consortia research new therapeutic advances, this orphan disease, which afflicts younger patients and has poor outcomes, continues to be difficult to manage. AH has a protean clinical presentation and course, with various prediction models and treatment approaches that can challenge even experienced providers. This review addresses 4 key controversies and other practical issues associated with the diagnosis, prognosis, management, and treatment of patients with AH.
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Affiliation(s)
- Gene Y Im
- Dr Im is an assistant professor of medicine in the Division of Liver Diseases at the Icahn School of Medicine at Mount Sinai and the Recanati/Miller Transplantation Institute in New York, New York. Dr Lucey is a professor of medicine and chief of the Division of Gastroenterology and Hepatology at the University of Wisconsin School of Medicine and Public Health in Madison, Wisconsin
| | - Michael R Lucey
- Dr Im is an assistant professor of medicine in the Division of Liver Diseases at the Icahn School of Medicine at Mount Sinai and the Recanati/Miller Transplantation Institute in New York, New York. Dr Lucey is a professor of medicine and chief of the Division of Gastroenterology and Hepatology at the University of Wisconsin School of Medicine and Public Health in Madison, Wisconsin
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Gholam PM. Prognosis and Prognostic Scoring Models for Alcoholic Liver Disease and Acute Alcoholic Hepatitis. Clin Liver Dis 2016; 20:491-7. [PMID: 27373611 DOI: 10.1016/j.cld.2016.02.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Multiple prognostic scoring systems have been developed to predict mortality from acute alcoholic hepatitis. Some systems, such as the modified discriminant function, are specific to alcoholic hepatitis. Others, such as the model for end-stage liver disease, apply to a broad range of liver diseases. Prognostic factors are better at predicting patients who are likely to survive rather than die of this condition at 30 and 90 days. This important shortcoming may be improved by combining scores for better prediction accuracy.
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Affiliation(s)
- Pierre M Gholam
- Liver Center of Excellence, Digestive Health Institute, University Hospitals Case Medical Center, 11100 Euclid Avenue, WRN5066, Cleveland Heights, OH 44106, USA.
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Abstract
Alcoholic liver disease (ALD) is a leading cause of liver-related morbidity and mortality worldwide. ALD encompasses a spectrum of disorders including asymptomatic steatosis, steatohepatitis, fibrosis, cirrhosis and its related complications, and the acute-on-chronic state of alcoholic hepatitis. While multidisciplinary efforts continue to be aimed at curbing progression of this spectrum of disorders, there is an urgent need to focus our efforts on effective therapeutic interventions for alcoholic hepatitis (AH), the most severe form of ALD. AH is characterized by an abrupt development of jaundice and complications related to liver insufficiency and portal hypertension in patients with heavy alcohol intake. The mortality of patients with severe AH is very high (20-50 % at 3 months). The current therapeutic regimens are limited. The development of new therapies requires translational studies in human samples and suitable animal models that reproduce clinical and histological features of human AH. This review article summarizes the clinical syndrome, pre-clinical translational tools, and pathogenesis of AH at a molecular and cellular level, with the aim of identifying new targets of potential therapeutic intervention.
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Amieva-Balmori M, Mejia-Loza SMI, Ramos-González R, Zamarripa-Dorsey F, García-Ruiz E, Pérez y López N, Juárez-Valdés EI, López-Luria A, Remes-Troche JM. Model for end-stage liver disease-Na score or Maddrey discrimination function index, which score is best? World J Hepatol 2015; 7:2119-2126. [PMID: 26301054 PMCID: PMC4539405 DOI: 10.4254/wjh.v7.i17.2119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 01/16/2015] [Accepted: 07/17/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the ability of model for end-stage liver disease (MELD)-Na and Maddrey discrimination function index (DFI) to predict mortality at 30 and 90 d in patients with alcoholic hepatitis (AH).
METHODS: We prospectively assessed 52 patients with AH. Demographic, clinical and laboratory parameters were obtained. MELD-Na and Maddrey DFI were calculated on admission. Short-term mortality was assessed at 30 and 90 d. Receiver operating characteristic curve analysis was performed.
RESULTS: Thirty-day and 90-d mortality was 44% and 58%, respectively. In the univariate analysis, sodium levels was associated with mortality at 30 and 90 d (P = 0.001 and P = 0.03). Child stage, encephalopathy, ascites, or types of treatment were not associated with mortality. MELD-Na was the only predictive factor for mortality at 90 d. For 30-d mortality area under the curve (AUC) was 0.763 (95%CI: 0.63-0.89) for Maddrey DFI and 0.784 for MELD-Na (95%CI: 0.65-0.91, P = 0.82). For 90-d mortality AUC was 0.685 (95%CI: 0.54-0.83) for Maddrey DFI and 0.8710 for MELD-Na (95%CI: 0.76-0.97, P = 0.041).
CONCLUSION: AH is associated with high short-term mortality. Our results show that MELD-Na is a more valuable model than DFI to predict short-term mortality.
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Abstract
Alcoholic hepatitis (AH) is caused by acute inflammation of the liver in patients that consume excessive amounts of alcohol, usually in a background of cirrhosis. AH can range from mild to severe, life threatening disease with a high rate of short and long-term mortality. Prognostic models have been used to estimate mortality in order to identify those that may benefit from corticosteroids or pentoxifylline. This review focuses on the different prognostic models proposed. While limitations of the prognostic models exist, combining models may be beneficial in order to identify responders to therapy versus non-responders.
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Affiliation(s)
- Erik Rahimi
- Division of Gastroenterology, Hepatology and Nutrition, University of Texas Medical School at Houston, 6431 Fannin Street, MSB 4.234, Houston, TX 77030 USA
| | - Jen-Jung Pan
- Division of Gastroenterology, Hepatology and Nutrition, University of Texas Medical School at Houston, 6431 Fannin Street, MSB 4.234, Houston, TX 77030 USA
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Papastergiou V, Burroughs AK, Tsochatzis EA. Prognosis and treatment of patients with acute alcoholic hepatitis. Expert Rev Gastroenterol Hepatol 2014; 8:471-86. [PMID: 24716632 DOI: 10.1586/17474124.2014.903800] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Despite alcoholic hepatitis (AH) is the most acute manifestation of alcohol-related liver disease, its treatment remains controversial. Corticosteroids, given either as monotherapy or together with N-acetylecysteine, have been associated with a moderate short-term survival benefit in patients with severe disease. The Maddrey's discriminant function; Glasgow alcoholic hepatitis score; age, bilirubin, INR and creatinine score; and the Model for end-stage liver disease have been proposed for stratifying prognosis in AH enabling selection of the patients to treat. Definition of treatment non-responders using the Lille model after 7 days of therapy may prevent a detrimental impact of prolonged corticosteroids. Pentoxifylline is an effective alternative reducing the occurrence of hepatorenal syndrome. Emerging evidence supports use of liver transplantation in a strictly selected subset of corticosteroid non-responders.
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Affiliation(s)
- Vassilios Papastergiou
- The Royal Free Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
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42
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Parker R, Ferguson J. Commentary: scoring models for short-term mortality in alcoholic hepatitis. Aliment Pharmacol Ther 2014; 39:1235. [PMID: 24735136 DOI: 10.1111/apt.12710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 02/25/2014] [Indexed: 12/08/2022]
Affiliation(s)
- R Parker
- Center for Liver Research, University of Birmingham, Birmingham, UK.
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