Fatigue measurements in patients with primary biliary cirrhosis and the risk of mortality during follow-up

Cholestatic liver disease leads to significant adaptative changes in neural circuits regulating social behavior in mice to enhance sociability

BACKGROUND & AIMS

Cholestatic liver diseases (CLD) are commonly associated with behavioral changes, including social isolation, that negatively affects patient quality of life and remains unaltered by current therapies. It remains unclear whether CLD-associated social dysfunction stems from a direct effect on the brain, or from the psychological impact of CLD. The psychological component of disease is absent in animals, so we investigated the impact of CLD on social behavior and gene expression profiles in key social behavior-regulating brain regions in a mouse model.

METHODS

CLD due to bile duct ligation was used with the three-chamber sociability test for behavioral phenotyping. Differentially expressed gene (DEG) signatures were delineated in 3 key brain regions regulating social behavior using RNA-seq. Ingenuity Pathway Analysis (IPA®) was applied to streamline DEG data interpretation and integrate findings with social behavior-regulating pathways to identify important brain molecular networks and regulatory mechanisms disrupted in CLD.

RESULTS

CLD mice exhibited enhanced social interactive behavior and significantly altered gene expression in each of the three social behavior-regulating brain regions examined. DEG signatures in BDL mice were associated with key IPA®-identified social behavior-regulating pathways including Oxytocin in Brain Signaling, GABA Receptor Signaling, Dopamine Receptor Signaling, and Glutamate Receptor Signaling.

CONCLUSIONS

CLD causes complex alterations in gene expression profiles in key social behavior-regulating brain areas/pathways linked to enhanced social interactive behavior. These findings, if paralleled in CLD patients, suggest that CLD-associated reductions in social interactions predominantly relate to psychological impacts of disease and may inform new approaches to improve management.

Golexanolone improves fatigue, motor incoordination and gait and memory in rats with bile duct ligation

BACKGROUND AND AIMS

Many patients with the chronic cholestatic liver disease primary biliary cholangitis (PBC) show fatigue and cognitive impairment that reduces their quality of life. Likewise, rats with bile duct ligation (BDL) are a model of cholestatic liver disease. Current PBC treatments do not improve symptomatic alterations such as fatigue or cognitive impairment and new, more effective treatments are therefore required. Golexanolone reduces the potentiation of GABAA receptors activation by neurosteroids. Golexanolone reduces peripheral inflammation and neuroinflammation and improves cognitive and motor function in rats with chronic hyperammonemia. The aims of the present study were to assess if golexanolone treatment improves fatigue and cognitive and motor function in cholestatic BDL rats and if this is associated with improvement of peripheral inflammation, neuroinflammation, and GABAergic neurotransmission in the cerebellum.

METHODS

Rats were subjected to bile duct ligation. One week after surgery, oral golexanolone was administered daily to BDL and sham-operated controls. Fatigue was analysed in the treadmill, motor coordination in the motorater, locomotor gait in the Catwalk, and short-term memory in the Y-maze. We also analysed peripheral inflammation, neuroinflammation, and GABAergic neurotransmission markers by immunohistochemistry and Western blot.

RESULTS

BDL induces fatigue, impairs memory and motor coordination, and alters locomotor gait in cholestatic rats. Golexanolone improves these alterations, and this was associated with improvement of peripheral inflammation, neuroinflammation, and GABAergic neurotransmission in the cerebellum.

CONCLUSION

Golexanolone may have beneficial effects to treat fatigue, and motor and cognitive impairment in patients with the chronic cholestatic liver disease PBC.

An online mind-body program improves mental health and quality of life in primary biliary cholangitis: A randomized controlled trial

BACKGROUND AND AIMS

People with primary biliary cholangitis (PBC) experience high rates of mental distress and fatigue despite standard of care therapy. We aimed to assess the impact of an online mind-body intervention on these symptoms.

METHODS

This 12-week RCT used sequential mixed-methods evaluation. Alongside standard of care, participants with primary biliary cholangitis were randomized to receive weekly countdown emails, or the intervention consisting of (i) a weekly 20-30 minute-mind-body follow-along video, (ii) weekly 5-10-minute psychology-based "managing chronic disease skills videos," and (iii) 10-minute telephone check-ins. The primary outcome was a change in the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes evaluated changes in fatigue, perceived stress, resilience, and health-related quality of life. ANCOVA determined between-group differences.

RESULTS

Of the 87 randomized patients (control group: n = 44, intervention group: n = 43), the between-group HADS total score improved by 20.0% (95% CI 4.7, 35.2, p = 0.011). Significant improvements were seen in depression (25.8%), perceived stress (15.2%), and 2 primary biliary cholangitis-40 domains [emotional symptoms (16.3%) and social symptoms (11.8%)] with a mean satisfaction of 82/100. This corresponded with end-of-study qualitative findings. Although no improvements were observed in fatigue in the main analysis, a significant benefit was observed in the subgroup of intervention participants (20/36;56%) who completed the mind-body video routine at least 3 times per week.

CONCLUSION

This intervention improved measures of mental wellness and quality of life with high satisfaction and reasonable adherence. Future studies could explore strategies to optimize adherence and target fatigue.

Liver Transplantation for Primary Biliary Cholangitis

Despite a significant increase in the total number of liver transplants (LTs) performed over the last 3 decades, primary biliary cholangitis (PBC) has become an uncommon indication for LT, which likely reflects the benefits of earlier diagnosis and available treatment, such as ursodeoxycholic acid (UDCA). Nonetheless, LT remains the only cure for patients with progressive PBC despite medical therapy with survival rates that are among the highest of all indications for LT. Post-LT PBC patients, however, are at increased risk of rejection and disease recurrence.

Quality of life in patients with primary biliary cholangitis: A cross-geographical comparison

Background & aims

Several symptoms impair the quality of life (QoL) of patients with primary biliary cholangitis (PBC). They are reported to vary significantly in different countries. Aim of our study was to explore whether there is a geographical clustering that accounts for symptoms in PBC.

Methods

Data was analysed from four cohorts of PBC patients from the UK, Spain, Japan and Italy using the PBC-27 scale.

Results

Overall, 569 patients from four cohorts were identified, including 515 females (90.5%) with a mean age of 61 years. The analysis provided evidence for strict factorial invariance of the scale, a robust indicator of its validity for cross-cultural research. The mean of the fatigue domain of British patients was significantly greater than that of the Japanese (p ​< ​0.05), Italian (p ​< ​0.05), and Spanish patients (p ​< ​0.001). The mean of the cognitive domain after 54 years of age, was significantly greater in the British patients than in the Japanese (p ​< ​0.05) and Spanish patients (p ​< ​0.01). However, after 69 years of age, there were not significant differences between countries. The mean of the emotion domain after 54 years of age, was greater in the British that in the Spanish (p ​< ​0.01) and Italian patients (p ​< ​0.01).

Conclusions

Differences in the four countries concerning fatigue, cognitive and emotional dysfunction were found. The association of latitude and symptoms might provide new insights into the role of sun exposure, genetics and/or cultural component into disease phenotype in PBC.

Primary biliary cholangitis patients exhibit MRI changes in structure and function of interoceptive brain regions

Background

Many patients with primary biliary cholangitis (PBC) experience non-hepatic symptoms that are possibly linked to altered interoception, the sense of the body’s internal state. We used magnetic resonance imaging (MRI) to determine if PBC patients exhibit structural and functional changes of the thalamus and insula, brain regions that process signals related to interoception.

Methods

Fifteen PBC patients with mild disease and 17 controls underwent 3 Tesla T₁-weighted MRI, resting-state functional MRI, and quantitative susceptibility mapping (QSM), to measure thalamic and insular volume, neuronal activity and iron deposition, respectively. Group differences were assessed using analysis of covariance, and stepwise linear regression was used to determine the predictive power of clinical indicators of disease.

Results

PBC patients exhibited reduced thalamic volume (p < 0.01), and ursodeoxycholic acid (UDCA) non-responders exhibited lower left thalamus activity (p = 0.05). PBC patients also exhibited reduced anterior insula activity (p = 0.012), and liver stiffness positively correlated with MRI indicators of anterior insula iron deposition (p < 0.02).

Conclusions

PBC affects structure and function of brain regions critically important to interoception. Moreover, these brain changes occur in patients with early, milder disease and thus may potentially be reversible.

Effects of liver transplantation on health-related quality of life in patients with primary biliary cholangitis

BACKGROUND

Patients with primary biliary cholangitis (PBC) have decreased health-related quality of life (HRQoL). Here, we investigate HRQoL in two cohorts of transplanted patients with PBC and compare their results to healthy subjects.

PATIENTS AND METHODS

We used generic SF-36 and disease-specific PBC-40 questionnaires to evaluate HRQoL in 26 patients with PBC (23 females, age 59.4 ± 5.7 years) before and after liver transplantation (LT), and in 107 patients with PBC (99 females, age 62.8 ± 6.7 years) who were previously transplanted. The control group was comprised of 60 healthy controls (55 females, age 54.6 ± 8.8 years).

RESULTS

Health-related quality of life improved after LT in 85% of PBC patients. The SF-36 measure showed significant (all P < 0.05) improvements in the majority of domains after LT, and in the summary scores both physical and mental. We also documented significant improvements in pruritus and fatigue after LT (all P < 0.01). However, liver graft recipients had significantly worse physical functioning, physical role, and emotional role domains, and physical component score (all P < 0.001), as compared to healthy subjects. No differences in HRQoL were detected between patients evaluated after short and prolonged post-LT periods (P > 0.05).

CONCLUSION

Liver transplantation substantially improves most aspects of life quality in PBC patients. Nevertheless, their HRQoL remains worse in comparison to healthy individuals, mainly in physical aspects.

Patterns of disease progression and incidence of complications in primary biliary cholangitis (PBC)

Clinical outcome for patients with primary biliary cholangitis (PBC) is dictated by development of cirrhosis, portal hypertension and its associated complications; including for some, a predisposition toward hepatocellular carcinoma. However rates of clinical progression vary, and accurately identifying disease course is of critical importance to patients, clinicians, as well as industry, who are committed to developing new effective and life-prolonging therapy as well as treating symptoms that appear disproportionate to underlying disease severity. Patients seek reassurance and guidance as to their own prognosis, and clinicians wish to confidently recognise those at highest risk of poor outcomes as equally as they strive to reassure individuals with a more favourable disease trajectory. International registries have facilitated a much greater knowledge of disease incidence and heterogeneity of presenting phenotypes. In so doing they highlight the opportunity to provide a more individualized estimate of the clinical course that patients experience, and have led to a renewed approach to risk stratification; both in terms of 'hard outcomes' and also disease-associated complications in PBC specifically.

Primary Biliary Cholangitis Alters Functional Connections of the Brain's Deep Gray Matter

OBJECTIVES

Fatigue, itch, depressed mood, and cognitive impairment significantly impact the quality of life of many patients with primary biliary cholangitis (PBC). Previous neuroimaging studies of non-hepatic diseases suggest that these symptoms are often associated with dysfunction of deep gray matter brain regions. We used resting-state functional magnetic resonance imaging (rsfMRI) to determine whether PBC patients exhibit altered functional connections of deep gray matter.

METHODS

Twenty female non-cirrhotic PBC patients and 21 age/gender-matched controls underwent rsfMRI. Resting-state functional connectivity (rsFC) of deep gray matter brain structures (putamen, thalamus, amygdala, hippocampus) was compared between groups. Fatigue, itch, mood, cognitive performance, and clinical response to ursodeoxycholic acid (UDCA) were assessed, and their association with rsFC was determined.

RESULTS

Relative to controls, PBC patients exhibited significantly increased rsFC between the putamen, thalamus, amygdala, and hippocampus, as well as with frontal and parietal regions. Reduced rsFC of the putamen and hippocampus with motor and sensory regions of the brain were also observed. Fatigue, itch, complete response to UDCA, and verbal working memory performance were also associated with altered rsFC of deep gray matter. These rsFC changes were independent of biochemical disease severity.

CONCLUSIONS

PBC patients have objective evidence of altered rsFC of the brain's deep gray matter that is in part linked to fatigue severity, itch, response to UDCA therapy, and cognitive performance. These results may guide future approaches to define how PBC leads to altered brain connectivity and provide insight into novel targets for treating PBC-associated brain dysfunction and behavioral symptoms.

A Randomized, Placebo-Controlled Clinical Trial of Efficacy and Safety: Modafinil in the Treatment of Fatigue in Patients With Primary Biliary Cirrhosis

BACKGROUND AND AIMS

Fatigue is a common symptom of primary biliary cirrhosis (PBC), and is associated with an impaired quality of life.

STUDY QUESTION

No studies have assessed the use of modafinil in fatigue related to PBC in a controlled manner.

STUDY DESIGN, MEASURES, AND OUTCOMES

A randomized, double-blind, placebo-controlled study was conducted to determine the safety and efficacy of modafinil for the treatment of fatigue in PBC. Forty patients were randomized to modafinil (n = 20) or placebo (n = 20) for 12 weeks. A verbal report of fatigue for at least 6 months was required for enrollment. Modafinil was administered at 100 mg by mouth once daily; a change by 50 mg every 2 weeks (maximum: 200 mg once daily) was allowed, depending on the subject's response to treatment. The primary outcome was defined as a ≥50% improvement in fatigue severity [quantified by the Fisk Fatigue Impact Scale (FFIS)] after 12 weeks of treatment, compared with baseline values.

RESULTS

Thirty-three PBC patients completed the study. After 12 weeks of therapy, only 5 patients had a ≥50% reduction in FFIS scores: 3 patients (17.6%) in the modafinil arm and 2 (12.5%) in the placebo arm (P = 1.00). Change in median FFIS score was not statistically different between patients in the 2 treatment groups (P = 0.36). Modafinil was associated with minimal adverse events (headaches, diarrhea, and rash).

CONCLUSIONS

In patients with PBC who have fatigue, treatment with modafinil for 12 weeks was safe and fairly well tolerated; however, it did not result in beneficial effects on fatigue compared with patients treated with placebo (CONSORT Table 1). ClinicalTrials.gov identifier NCT00943176.

Assessment of health related quality of life in polish patients with primary biliary cirrhosis

BACKGROUND

Most patients with primary biliary cirrhosis (PBC) have impaired health related quality of life (HRQoL), as assessed by PBC-specific HRQoL (PBC-40) and generic (SF-36) questionnaires. Data on the applicability of PBC-27, a shorter version of PBC-40, have been limited.

AIMS

To assess HRQoL in Polish PBC patients, applying PBC-40, PBC-27 and SF-36 and to associate clinical or laboratory parameters with HRQoL factors.

METHODS

A total of 205 PBC patients (188 females) were analyzed using PBC-40, PBC-27 and SF-36; 85 disease-free demographically matched (in terms of age, gender, ethnicity) individuals were used as normal controls.

RESULTS

When compared to controls, PBC patients had significantly impaired HRQoL across all the domains of SF-36. HRQoL impairment by PBC-40 and PBC-27 was comparable between cirrhotics and non-cirrhotics, except for significantly worse Itch in cirrhotics (6.5±4.9 vs 5.1±4.3; P=0.03). In PBC-40/27, alkaline phosphatase (ALP) levels correlated with itch (P=0.0003). Female patients had marginally impaired cognitive function compared to males by PBC-40 (P=0.06). Other gender-related differences were not found. Anti-gp210 positive, as well as AMA negative PBC patients, had worse HRQoL features in itch and social/emotional domains of PBC-40/PBC-27 questionnaires. Very strong correlations (P<0.0001) between PBC-40/PBC-27 and SF-36 were seen for several domains.

CONCLUSIONS

HRQoL is significantly impaired in Polish patients with PBC, independently of gender and disease severity. PBC-40 and PBC-27 questionnaires are efficient in detecting HRQoL impairment in Polish PBC patients. The striking correlation between PBC-40/PBC-27 and SF-36 confirms the usefulness of the former HRQoL measures in PBC patients from Central-Eastern Europe.

Primary biliary cirrhosis

Primary biliary cirrhosis is a chronic cholestatic liver disease characterised by destruction of small intrahepatic bile ducts, leading to fibrosis and potential cirrhosis through resulting complications. The serological hallmark of primary biliary cirrhosis is the antimitochondrial antibody, a highly disease-specific antibody identified in about 95% of patients with primary biliary cirrhosis. These patients usually have fatigue and pruritus, both of which occur independently of disease severity. The typical course of primary biliary cirrhosis has changed substantially with the introduöction of ursodeoxycholic acid (UDCA). Several randomised placebo-controlled studies have shown that UDCA improves transplant-free survival in primary biliary cirrhosis. However, about 40% of patients do not have a biochemical response to UDCA and would benefit from new therapies. Liver transplantation is a life-saving surgery with excellent outcomes for those with decompensated cirrhosis. Meanwhile, research on nuclear receptor hormones has led to the development of exciting new potential treatments. This Seminar will review the current understanding of the epidemiology, pathogenesis, and natural history of primary biliary cirrhosis, discuss management of the disease and its sequelae, and introduce research on new therapeutic options.

Fatigue and physical activity levels in patients with liver cirrhosis

AIMS AND OBJECTIVES

This study aimed to explore the correlation between fatigue and physical activity in patients with liver cirrhosis.

BACKGROUND

Many patients with liver cirrhosis perceive lower physical functioning and more fatigue than non-cirrhotic individuals. To date, however, few studies have examined the relationship between fatigue and physical activity in this patient population.

DESIGN

This study used a correlation design. Participants were patients with liver cirrhosis recruited from the gastroenterology clinic of a teaching medical centre in Taiwan.

METHODS

Data were collected using a structured questionnaire, consisting of a fatigue scale and a seven-day Physical Activity Recall scale. spss version 13.0 software was used to analyse the data through statistical methods, including one-way analysis of variance, independent t-test and Pearson's correlations.

RESULTS

Patients participating in this study suffered from moderate-to-severe fatigue, and their engagement in physical activity of moderate or higher intensity was decreased. On average, fatigue had a moderate level of influence on physical activity. A significant negative correlation was found between the fatigue level and average seven-day physical activity level.

CONCLUSIONS

Patients with liver cirrhosis can experience severe fatigue, which may reduce their level of physical activity.

RELEVANCE TO CLINICAL PRACTICE

Early evaluation of the fatigue level and physical activity constraints in patients with liver cirrhosis should be conducted in the clinic or community. Individualised instructions for patient's physical activity should be provided.

Liver transplantation in PBC and PSC: indications and disease recurrence

Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) represent major indications for liver transplantation (LT). Despite the steady increase in the incidence and prevalence of PBC, the number of liver transplants for PBC has fallen in recent years, whereas the number of transplants for PSC has remained stable. Indications for LT for PBC and PSC are no different from those of other causes of chronic liver disease, apart from some disease-specific indications. PBC and PSC have more favourable outcomes after LT, compared to viral hepatitis and alcohol-associated liver disease. Numerous studies have clearly demonstrated that PBC and PSC recur after LT. The diagnosis of recurrent disease should be made on agreed criteria. The impact of recurrent disease on survival is unclear. Study of recurrent PBC and PSC may provide a better understanding of the mechanisms of these diseases in the native liver.

Asymptomatic primary biliary cirrhosis is not associated with increased frequency of cardiovascular disease

AIM

To estimate the prevalence of cardiovascular events in Primary biliary cirrhosis (PBC) and to determine whether this risk is higher within specific subgroups of patients with PBC.

METHODS

We included 180 patients with PBC (cases) and 151 patients seen for HCV infection (controls). Medical records were reviewed and statistical analyses were performed as appropriate.

RESULTS

When compared to controls, PBC patients were older, leaner and had higher serum levels of total cholesterol, high density lipoprotein and low density cholesterol. There were more females in the PBC group (91.7% vs 43%, P < 0.001). More control subjects had smoked than the PBC patients (63.6% vs 35%, P < 0.001). The prevalence of hypertension, diabetes, coronary artery disease and stroke was similar between the two groups. Seven percent of controls and 10% of cases developed any type of cardiovascular disease (P = 0.3). Only 36.7% were asymptomatic at diagnosis. Three cardiovascular events were documented among asymptomatic patients (4.5%) and fifteen among symptomatic patients (13.2%; P = 0.06). Among PBC patients with fatigue, 10 (13.5%) had a cardiovascular event compared to 7 (6.7%) among patients without fatigue (P = 0.1).

CONCLUSION

Asymptomatic PBC patients do not have a greater frequency of cardiovascular disease; nor do patients suffering with fatigue.

The specificity of fatigue in primary biliary cirrhosis: evaluation of a large clinic practice

Quality of life is an important concern for patients with chronic liver disease. We sought to describe the frequency, severity, and associations of fatigue, in patients with primary biliary cirrhosis (PBC). We performed association testing between PBC-40 multidomain disease-specific quality of life responses and clinical findings. Three hundred twenty-seven patients from a single clinic with PBC (94% female, 92% AMA-positive) were evaluated. The average age was 57 years and average disease duration 7.2 years. Verbally reported fatigue was noted in 48% but present in the overwhelming majority on PBC-40 completion, with 44% having moderate or severe symptoms. Of those not complaining of fatigue clinically, 25% documented moderate or severe fatigue by questionnaire. Age had an inverse relationship with fatigue (P < 0.01), whereas body mass index (BMI) was positively associated (P < 0.01), as was the presence of pruritus (P < 0.001), sicca symptoms (P < 0.001), depression (P < 0.001), fibromyalgia (P < 0.004), and scleroderma (P < 0.05). For those with varices (P < 0.05) or cirrhosis clinically (P < 0.05), higher fatigue scores were noted, although those who initially presented with noncirrhotic disease had higher scores at the time of testing (P < 0.005). Fatigue was associated with greater use of prescription medication (P < 0.01), in particular for antipruritics (cholestyramine: P < 0.001; rifampin: P < 0.001), proton pump inhibitors (P < 0.002), beta-blockers (P < 0.02), and antidepressants (P < 0.001), whereas those taking calcium and vitamin D appeared less fatigued (P < 0.05). In a multivariate model, calcium and vitamin D use, BMI, stage of disease at diagnosis, as well as symptomatic fatigue or pruritus, were significant. Biochemical response to UDCA was not associated with lower fatigue scores.

CONCLUSION

Attempts at defining the biological basis of fatigue in patients with PBC, and improving its treatment, must account for its multifactoral causes.

Fatigue in primary biliary cirrhosis

Primary biliary cirrhosis (PBC) is a chronic, autoimmune, cholestatic liver disease with a slowly progressive course. Without treatment, most patients eventually develop fibrosis of the liver and may need liver transplantation in the late stage of disease. Fatigue and pruritus are the most common symptoms of PBC, but the majority of patients are asymptomatic at first presentation. There is no specific treatment for fatigue in PBC, but modafinil has shown some potential beneficial effects, such as increased energy levels and decreased total sleep time. This Review article discusses the natural history and the measurement of fatigue in patients with PBC. The central and the peripheral mechanisms that have been suggested for the pathogenesis of fatigue in PBC are also discussed and treatment options are reviewed.