Chronic Liver Disease-Associated Hospitalizations Among Adults with Diabetes, National Inpatient Sample, 2001-2012

The Impact of Supportive Housing on Liver-Related Outcomes Among Persons With Hepatitis C Virus Infection

BACKGROUND

Hepatitis C virus (HCV) infection disproportionately impacts people experiencing homelessness. Hepatitis C virus can lead to negative health outcomes, including mortality. We evaluated the impact of a permanent supportive housing (PSH) program (ie, "treatment") on liver-related morbidity and mortality among persons with chronic homelessness and HCV infection.

METHODS

We matched records for persons eligible for a New York City PSH program (2007-2014) with Heath Department HCV and Vital Statistics registries and Medicaid claims. Among persons diagnosed with HCV before or 2 years posteligibility, we added stabilized inverse probability of treatment weights to negative binomial regression models to compare rates for liver disease-related emergency department visits and hospitalizations, and hazard ratios for mortality, by program placement 2 and 5 years posteligibility.

RESULTS

We identified 1158 of 8783 placed and 1952 of 19 019 unplaced persons with laboratory-confirmed HCV infection. Permanent supportive housing placement was associated with significantly reduced liver-related emergency department visits (adjusted rate ratio [aRR] = 0.76, 95% confidence interval [CI] = .61-.95), hospitalizations (aRR = 0.62, 95% CI = .54-.71), and all-cause (adjusted hazard ratio [aHR] = 0.65, 95% CI = .46-.92) and liver-related mortality (aHR = 0.72, 95% CI = .09-.83) within 2 years. The reduction remained significant for hospitalizations after 5 years.

CONCLUSIONS

Placement into PSH was associated with reduced liver-related morbidity and mortality among persons with HCV infection and chronic homelessness.

Donor diabetes mellitus is a risk factor for diminished outcome after liver transplantation: a nationwide retrospective cohort study

With the growing incidence of diabetes mellitus (DM), an increasing number of organ donors with DM can be expected. We sought to investigate the association between donor DM with early post‐transplant outcomes. From a national cohort of adult liver transplant recipients (1996–2016), all recipients transplanted with a liver from a DM donor (n = 69) were matched 1:2 with recipients of livers from non‐DM donors (n = 138). The primary end‐point included early post‐transplant outcome, such as the incidence of primary nonfunction (PNF), hepatic artery thrombosis (HAT), and 90‐day graft survival. Cox regression analysis was used to analyze the impact of donor DM on graft failure. PNF was observed in 5.8% of grafts from DM donors versus 2.9% of non‐DM donor grafts (P = 0.31). Recipients of grafts derived from DM donors had a higher incidence of HAT (8.7% vs. 2.2%, P = 0.03) and decreased 90‐day graft survival (88.4% [70.9–91.1] vs. 96.4% [89.6–97.8], P = 0.03) compared to recipients of grafts from non‐DM donors. The adjusted hazard ratio for donor DM on graft survival was 2.21 (1.08–4.53, P = 0.03). In conclusion, donor DM is associated with diminished outcome early after liver transplantation. The increased incidence of HAT after transplantation of livers from DM donors requires further research.

Use of Elderly Donors in Liver Transplantation: A Paired-match Analysis at a Single Center

OBJECTIVE

To evaluate the use of elderly donors in liver transplantation (LT) and identify risk factors associated with a worse outcome.

SUMMARY BACKGROUND DATA

Use of livers from very old donors could expand the donor pool but is not universally implemented.

METHODS

This is a retrospective, single-center medical record review. From January 2001 to December 2014, 1354 LTs were performed. After exclusion of donors <18 years, ABO-incompatible LT, re-LT and UNOS 1 status patients, LT recipients were stratified into 2 groups based on donor age: 18-69 (n=692) vs. ≥70 years (n=515) then matched using a propensity score approach. Two groups were finally matched (young group = 448 cases; old group = 515 cases).

RESULTS

The median (interquartile range [IQR]) follow-up was 5.0 (2.0-8.4) years. Comparing the 2 identified groups, no differences were observed regarding early retransplants (1.8 vs. 2.9; P = 0.3), HCV-related death (7.6 vs. 8.7%; P = 0.6), vascular (5.8 vs. 5.0%; P = 0.7), and biliary complications (16.5 vs. 18.6%; P = 0.4). On multivariate analysis, independent risk factors for graft loss were: HCV-positive recipient (HR = 2.1; 95% CI = 1.6-2.7; P < 0.001), donor age (HR = 1.0; 95% CI = 1.0-1.0; P < 0.001), cold ischemia time (HR = 1.0; 95% CI = 1.0-1.0; P = 0.042), and donor history of diabetes mellitus (HR = 1.48; 95% CI = 1.03-2.13; P = 0.036).

CONCLUSIONS

Use of elderly donors is not associated per se with an increased risk of vascular and biliary complications. In the presence of cold ischemia time and diabetes mellitus, appropriate donor-to-recipient matching is warranted.

Acarbose Use and Liver Injury in Diabetic Patients With Severe Renal Insufficiency and Hepatic Diseases: A Propensity Score-Matched Cohort Study

Background: Acarbose has been deemed contraindicated in diabetic patients with chronic kidney disease (CKD) or end-stage renal disease (ESRD), but such use is not uncommon. We tested whether this concept hold true in this population with different background hepatic diseases.

Methods: All incident diabetic patients (n = 2,036,531) with stage 5 CKD/ESRD were enrolled from Taiwan between 2017 and 2013 and divided into those without chronic liver disease (CLD), with CLD but without cirrhosis, and those with cirrhosis. Among each group, acarbose users, defined as cumulative use >30 days within the preceding year, were propensity-score matched 1:2 to non-users. Our main outcome was the development of liver injury events during follow-up.

Results: Acarbose users did not exhibit an increased incidence of liver injury during follow-up compared to non-users (hazard ratio and 95% confidence interval, 1.04 [0.88–1.25], 0.97 [0.61–1.56], and 0.71 [0.33–1.54] among those without CLD, with CLD but without cirrhosis, and those with cirrhosis, respectively), after adjusting for demographic profiles, comorbidities, potentially hepatotoxic medication use, and diabetic severity.

Conclusions: The incidence of liver injury did not increase significantly among diabetic acarbose users with severe renal insufficiency than non-users, regardless of the presence or absence of chronic liver disease. Our findings support the renaissance of acarbose as a useful adjunct in diabetic patients with stage 5 and 5D chronic kidney disease.

Disparities in the Quality of Cardiovascular Care Between HIV-Infected Versus HIV-Uninfected Adults in the United States: A Cross-Sectional Study

BACKGROUND

Cardiovascular disease is emerging as a major cause of morbidity and mortality among patients with HIV. We compared use of national guideline-recommended cardiovascular care during office visits among HIV-infected versus HIV-uninfected adults.

METHODS AND RESULTS

We analyzed data from a nationally representative sample of HIV-infected and HIV-uninfected patients aged 40 to 79 years in the National Ambulatory Medical Care Survey/National Hospital Ambulatory Medical Care Survey, 2006 to 2013. The outcome was provision of guideline-recommended cardiovascular care. Logistic regressions with propensity score weighting adjusted for clinical and demographic factors. We identified 1631 visits by HIV-infected patients and 226 862 visits by HIV-uninfected patients with cardiovascular risk factors, representing ≈2.2 million and 602 million visits per year in the United States, respectively. The proportion of visits by HIV-infected versus HIV-uninfected adults with aspirin/antiplatelet therapy when patients met guideline-recommended criteria for primary prevention or had cardiovascular disease was 5.1% versus 13.8% (P=0.03); the proportion of visits with statin therapy when patients had diabetes mellitus, cardiovascular disease, or dyslipidemia was 23.6% versus 35.8% (P<0.01). There were no differences in antihypertensive medication therapy (53.4% versus 58.6%), diet/exercise counseling (14.9% versus 16.9%), or smoking cessation advice/pharmacotherapy (18.8% versus 22.4%) between HIV-infected versus HIV-uninfected patients, respectively.

CONCLUSIONS

Physicians generally underused guideline-recommended cardiovascular care and were less likely to prescribe aspirin and statins to HIV-infected patients at increased risk-findings that may partially explain higher rates of adverse cardiovascular events among patients with HIV. US policymakers and professional societies should focus on improving the quality of cardiovascular care that HIV-infected patients receive.

DIABETES MELLITUS IN PATIENTS WITH LIVER CIRRHOSIS: NEW TREATMENT OPTIONS

In economically developed countries, cirrhosis is one of the six leading causes of death at the age of 35–60 years and ranges from 14 to 30 cases per 100000 population. In the world 40 million people die of cirrhosis each year. At 6% of the population of the Russian Federation there is a diabetes mellitus. The combination of diabetes mellitus in patients with cirrhosis of the liver is a common comorbid pathology. Diabetes mellitusis a risk factor for the development of liver cirrhosis, and the incidence of combination of both diseases is quite high, although the frequency of occurrence varies. About 80% of patients with LC may have impaired glucose metabolism, and 30% have diabetes mellitus. Prospective studies have shown that diabetes is associated with an increased risk of developing hepatic complications and death in patients with cirrhosis of the liver. Diabetes mellitus increases the risk of complications of liver cirrhosis of any etiology (varicose veins of the esophagus, hepatic encephalopathy, hepatic-cell insufficiency) and subsequent survival. The incidence, frequency of hospitalizations and mortality from this combined pathology are very high. There are common mechanisms that provoke metabolic and autoimmune disorders in the development of chronic hepatitis and cirrhosis, leading to steatosis, insulin resistance, impaired glucose tolerance and the development of diabetes mellitus. There are certain features of the evaluation of the compensation of carbohydrate metabolism in patients with cirrhosis of the liver, anemia and impaired protein metabolism. Effective control of glycemia can have a beneficial effect on the treatment of these patients. However, few studies have evaluated the efficacy and safety of antidiabetic drugs and the effect of diabetes treatment on morbidity and mortality in patients with cirrhosis. Previously it was believed that in the presence of cirrhosis the only treatment remains insulin. At present, in connection with the emergence of modern groups of hypoglycemic drugs, as well as new approaches to the treatment of type 2 diabetes, this concept has radically changed. Unfortunately, the issues of correction of carbohydrate metabolism in patients with cirrhosis of the liver are practically not covered in the world literature. This article deals with the correction of carbohydrate metabolism in patients with cirrhosis and hepatocellular insufficiency of insulin analogs, biguanides, drugs with incretin effect — dipeptidyl peptidase‑4 inhibitors, agonists of glucagon-like peptide‑1, inhibitors of sodium-glucose cotransporter 2 diabetes. Particular attention is paid to the development of hepatocellular insufficiency and portal hypertension in patients with cirrhosis and type 2 diabetes, as well as processes for their prevention and insulin alternative correction methods.

The Burden of Rehospitalization for Patients With Liver Cirrhosis

Advanced liver disease is becoming more prevalent in the United States. This increase has been attributed largely to the growing epidemic of nonalcoholic fatty liver disease and an aging population infected with hepatitis C. Complications of cirrhosis are a major cause of hospital admissions and readmissions. It is important to target efforts for preventing rehospitalization toward patients with cirrhosis who are at the highest risk for readmission, such as those who have high Model for End-Stage Liver Disease scores, are at risk for fluid/electrolyte abnormalities or overt hepatic encephalopathy recurrence, and those who have comorbid conditions (e.g. diabetes). The heart failure management paradigm may provide valuable insights for managing patients with cirrhosis, given the extensive research on preventing hospital readmission and improving health care utilization in this subpopulation. As quality measures related to hospital readmissions for cirrhosis and its complications are adopted by the Centers for Medicare & Medicaid Services and private payers in the future, understanding drivers of hospital readmissions and health care utilization in this vulnerable population are key to improving quality measure performance.