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Desai R, Alvi AT, Vasavada A, Pulakurthi YS, Patel B, Mohammed AS, Doshi S, Ogbu I. Sex and racial disparities in non-alcoholic fatty liver disease-related cardiovascular events: National inpatient sample analysis (2019). World J Cardiol 2024; 16:137-148. [PMID: 38576521 PMCID: PMC10989223 DOI: 10.4330/wjc.v16.i3.137] [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: 12/10/2023] [Revised: 01/15/2024] [Accepted: 02/18/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) increases cardiovascular disease (CVD) risk irrespective of other risk factors. However, large-scale cardiovascular sex and race differences are poorly understood. AIM To investigate the relationship between NAFLD and major cardiovascular and cerebrovascular events (MACCE) in subgroups using a nationally representative United States inpatient sample. METHODS We examined National Inpatient Sample (2019) to identify adult hospitalizations with NAFLD by age, sex, and race using ICD-10-CM codes. Clinical and demographic characteristics, comorbidities, and MACCE-related mortality, acute myocardial infarction (AMI), cardiac arrest, and stroke were compared in NAFLD cohorts by sex and race. Multivariable regression analyses were adjusted for sociodemographic characteristics, hospitalization features, and comorbidities. RESULTS We examined 409130 hospitalizations [median 55 (IQR 43-66) years] with NFALD. NAFLD was more common in females (1.2%), Hispanics (2%), and Native Americans (1.9%) than whites. Females often reported non-elective admissions, Medicare enrolment, the median age of 55 (IQR 42-67), and poor income. Females had higher obesity and uncomplicated diabetes but lower hypertension, hyperlipidemia, and complicated diabetes than males. Hispanics had a median age of 48 (IQR 37-60), were Medicaid enrollees, and had non-elective admissions. Hispanics had greater diabetes and obesity rates than whites but lower hypertension and hyperlipidemia. MACCE, all-cause mortality, AMI, cardiac arrest, and stroke were all greater in elderly individuals (P < 0.001). MACCE, AMI, and cardiac arrest were more common in men (P < 0.001). Native Americans (aOR 1.64) and Asian Pacific Islanders (aOR 1.18) had higher all-cause death risks than whites. CONCLUSION Increasing age and male sex link NAFLD with adverse MACCE outcomes; Native Americans and Asian Pacific Islanders face higher mortality, highlighting a need for tailored interventions and care.
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Affiliation(s)
- Rupak Desai
- Independent Researcher, Atlanta, GA 30079, United States
| | - Ali Tariq Alvi
- Department of Internal Medicine, HCA Florida Westside Hospital, Plantation, FL 33324, United States
| | - Advait Vasavada
- Department of Internal Medicine, M.P. Shah Medical Coll, Jamnagar 361008, India
| | | | - Bhavin Patel
- Department of Internal Medicine, Trinity Health Oakland Hospital, Pontiac, MI 48341, United States
| | - Adil Sarvar Mohammed
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI 48602, United States
| | - Shreyans Doshi
- Department of Internal Medicine, UCF College of Medicine HCA GME Consortium, Gainesville, FL 32605, United States
| | - Ikechukwu Ogbu
- Department of Internal Medicine, Mountainview Hospital, Las Vegas, NV 89108, United States.
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Sohail A, Ali H, Patel P, Subramanium S, Dahiya DS, Sohail AH, Gangwani MK, Satapathy SK. Impact of metabolic dysfunction-associated steatotic liver disease on COVID-19 hospitalizations: A propensity-matched analysis of the United States. World J Virol 2024; 13:91149. [PMID: 38616849 PMCID: PMC11008396 DOI: 10.5501/wjv.v13.i1.91149] [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: 12/24/2023] [Revised: 01/02/2024] [Accepted: 02/06/2024] [Indexed: 03/11/2024] Open
Abstract
BACKGROUND Metabolic dysfunction-associated steatotic liver disease (MASLD), formally known as nonalcoholic fatty liver disease, is the most common chronic liver disease in the United States. Patients with MASLD have been reported to be at a higher risk of developing severe coronavirus disease 2019 (COVID-19) and death. However, most studies are single-center studies, and nationwide data in the United States is lacking. AIM To study the influence of MASLD on COVID-19 hospitalizations during the initial phase of the pandemic. METHODS We retrospectively analyzed the 2020 National Inpatient Sample (NIS) database to identify primary COVID-19 hospitalizations based on an underlying diagnosis of MASLD. A matched comparison cohort of COVID-19 hospitalizations without MASLD was identified from NIS after 1: N propensity score matching based on gender, race, and comorbidities, including hypertension, heart failure, diabetes, and cirrhosis. The primary outcomes included inpatient mortality, length of stay, and hospitalization costs. Secondary outcomes included the prevalence of systemic complications. RESULTS A total of 2210 hospitalizations with MASLD were matched to 2210 hospitalizations without MASLD, with a good comorbidity balance. Overall, there was a higher prevalence of severe disease with more intensive care unit admissions (9.5% vs 7.2%, P = 0.007), mechanical ventilation (7.2% vs 5.7%, P = 0.03), and septic shock (5.2% vs 2.7%, P <0.001) in the MASLD cohort than in the non-MASLD cohort. However, there was no difference in mortality (8.6% vs 10%, P = 0.49), length of stay (5 d vs 5 d, P = 0.25), and hospitalization costs (42081.5 $ vs 38614$, P = 0.15) between the MASLD and non-MASLD cohorts. CONCLUSION The presence of MAFLD with or without liver cirrhosis was not associated with increased mortality in COVID-19 hospitalizations; however, there was an increased incidence of severe COVID-19 infection. This data (2020) predates the availability of COVID-19 vaccines, and many MASLD patients have since been vaccinated. It will be interesting to see if these trends are present in the subsequent years of the pandemic.
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Affiliation(s)
- Abdullah Sohail
- Department of Internal Medicine, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa, IA 52242, United States
| | - Hassam Ali
- Division of Gastroenterology and Hepatology, East Carolina University/Brody School of Medicine, Greenville, NC 27858, United States
| | - Pratik Patel
- Department of Gastroenterology, Mather Hospital/Hofstra University Zucker School of Medicine, NY, 11777, United States
| | - Subanandhini Subramanium
- Department of Internal Medicine, East Carolina University Brody School of Medicine, Greenville, NC 27834, United States
| | - Dushyant Singh Dahiya
- Division of Gastroenterology, Hepatology & Motility, The University of Kansas School of Medicine, Kansas City, KS 66160, United States
| | - Amir H Sohail
- Department of Surgery, University of New Mexico, Albuquerque, NM 87106, United States
| | - Manesh Kumar Gangwani
- Department of Internal Medicine, The University of Toledo, Toledo, OH 43606, United States
| | - Sanjaya K Satapathy
- Section on Gastroenterology and Hepatology, North Shore University Hospital and Long Island Jewish Medical Center, Manhasset, NY 11030, United States
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Zhu X, Qucuo N, Zhang N, Tang D, Hu Y, Xie X, Zhao X, Meng Q, Chen L, Jiang X, Zhuoma D, Zeng Q, Xiao X. Dietary patterns and metabolic dysfunction-associated fatty liver disease in China's multi-ethnic regions. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2023; 42:141. [PMID: 38093350 PMCID: PMC10717100 DOI: 10.1186/s41043-023-00485-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/02/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND The prevalence of metabolic dysfunction-associated fatty liver disease (MAFLD) has been rising rapidly in western China. Diet acts as an effective therapy for MAFLD. However, there has been scarce research on the association between a posteriori diet patterns (DPs) and MAFLD in this region. METHOD We identified three a posteriori DPs which were "Sichuan Basin pattern" characterized by a high intake of fish/seafood, poultry, fresh fruit and vegetables, indicating a balanced and modern DP; the "Yunnan-Guizhou Plateau dietary pattern" characterized mainly by a high intake of animal oil and salt, indicating an agricultural and poor DP; and the "Qinghai-Tibet Plateau dietary pattern" characterized by a high intake of coarse grains, wheat products, tubers and tea, respectively, indicating a high-altitude DP. Then, we performed marginal structural models that combined logistic regression and inverse probability exposure weighting (IPEW) to examine the associations between MAFLD and these a posteriori DPs. RESULT We found the "Yunnan-Guizhou Plateau dietary pattern" revealed stronger positive association (OR = 1.50, 95% CI 1.40-1.60) with MAFLD than that of the "Qinghai-Tibet Plateau dietary pattern" (OR = 1.21, 95% CI 1.14-1.30). In contrast, the "Sichuan Basin dietary pattern" showed no significant association with MAFLD. In the further stratified analysis, we found those above associations were stronger in ethnic minorities and rural residents than their counterparts. CONCLUSION Our study implied the unfavourable effects of "Yunnan-Guizhou Plateau dietary pattern" on MAFLD and provided evidence that reducing the intake of oil and sodium may be optimal for MAFLD control in the multi-ethnic region in western China.
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Affiliation(s)
| | - Nima Qucuo
- Tibet Center for Disease Control and Prevention, Lhasa, China
| | | | - Dan Tang
- Sichuan University, Chengdu, China
| | - Yifan Hu
- Sichuan University, Chengdu, China
| | | | | | - Qiong Meng
- School of Public Health, Kunming Medical University, Kunming, China
| | - Liling Chen
- Chongqing Municipal Center for Disease Control and Prevention, Chongqing, China
| | - Xiaoman Jiang
- Chengdu Center for Disease Control and Prevention, Chengdu, China
| | | | - Qibing Zeng
- School of Public Health, the key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, China.
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Ho B, Thompson A, Jorgensen AL, Pirmohamed M. Role of fatty liver index in risk-stratifying comorbid disease outcomes in non-alcoholic fatty liver disease. JHEP Rep 2023; 5:100896. [PMID: 37928746 PMCID: PMC10624587 DOI: 10.1016/j.jhepr.2023.100896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 07/03/2023] [Accepted: 08/03/2023] [Indexed: 11/07/2023] Open
Abstract
Background & Aims Population screening for non-alcoholic fatty liver disease (NAFLD) and associated comorbidities remains an unaddressed clinical need. We aimed to assess the utility of the fatty liver index (FLI) for risk stratification of NAFLD and related comorbidities using the UK Biobank. Methods Electronic health records and liver MRI-proton density fat fraction (PDFF) were used to define NAFLD cases. FLI was calculated and individuals with high alcohol intake and other liver diseases were excluded. Using listwise deletion analysis, the area under receiver-operating characteristic curve (AUROC) of FLI for NAFLD risk was determined. Thereafter, time-dependent covariate-adjusted Cox regression models were used to estimate FLI's risk stratification potential for comorbidities of interest. Results FLI was derived for 327,800 individuals with a median age of 58 (IQR 51.5-64.5), of whom 59.8% were females. Using Perspectum Diagnostics and AMRA protocols as references, FLI identified the risk of NAFLD with AUROCs (95% CI, n) of 0.858 (0.848-0.867, n = 7,566) and 0.851 (0.844-0.856, n = 10,777), respectively. Intermediate and high-risk FLI was associated with increased cardiometabolic and malignant disease. In the first 3 years, high-risk FLI conferred an increased risk (adjusted hazard ratio, 95% CI) of ischaemic heart disease (2.14, 1.94-2.36), hypertension (2.84, 2.70-2.98), type 2 diabetes mellitus (4.55, 4.04-5.12), dyslipidaemia (2.48, 2.32-2.64), ischaemic stroke (1.31, 1.20-1.42) and hepatic malignancy (1.69, 1.23-2.30). FLI was not associated with risk of extrahepatic malignancy but was associated with a higher risk of specific cancers (colon, upper gastrointestinal and breast). All-cause mortality was similarly stratified by FLI, independently of non-invasive fibrosis scores. Conclusions FLI identifies NAFLD and holds potential for the risk stratification of cardiometabolic and malignant disease outcomes (including some extrahepatic malignancies), as well as all-cause mortality. Its use in population screening for primary and secondary prevention of NAFLD should be considered. Impact and implications Our analysis using the UK Biobank study shows the potential of the fatty liver index as a risk stratification tool for identifying the risk of developing NAFLD, ischaemic heart disease, ischaemic stroke, type 2 diabetes mellitus, hypertension, hyperlipidaemia, hepatic malignancy, specific metabolism-related malignancies and all-cause mortality. These results suggest that the fatty liver index should be considered as a non-invasive steatosis score that may help guide primary prevention strategies for NAFLD and related outcomes.
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Affiliation(s)
- Brian Ho
- Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Pharmacology and Therapeutics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Andrew Thompson
- Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Pharmacology and Therapeutics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Health Analytics, Lane Clark & Peacock LLP, London, UK
| | - Andrea L Jorgensen
- Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Department of Pharmacology and Therapeutics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Dahiya DS, Jahagirdar V, Ali H, Gangwani MK, Aziz M, Chandan S, Singh A, Perisetti A, Soni A, Inamdar S, Sanaka MR, Al-Haddad M. Peptic ulcer disease in non-alcoholic fatty liver disease hospitalizations: A new challenge on the horizon in the United States. World J Hepatol 2023; 15:564-576. [PMID: 37206652 PMCID: PMC10190687 DOI: 10.4254/wjh.v15.i4.564] [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: 01/07/2023] [Revised: 02/24/2023] [Accepted: 03/27/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Peptic ulcer disease (PUD) is frequently seen in patients with liver cirrhosis. However, current literature lacks data on PUD in non-alcoholic fatty liver disease (NAFLD) hospitalizations.
AIM To identify trends and clinical outcomes of PUD in NAFLD hospitalizations in the United States.
METHODS The National Inpatient Sample was utilized to identify all adult (≥ 18 years old) NAFLD hospitalizations with PUD in the United States from 2009-2019. Hospitalization trends and outcomes were highlighted. Furthermore, a control group of adult PUD hospitalizations without NAFLD was also identified for a comparative analysis to assess the influence of NAFLD on PUD.
RESULTS The total number of NAFLD hospitalizations with PUD increased from 3745 in 2009 to 3805 in 2019. We noted an increase in the mean age for the study population from 56 years in 2009 to 63 years in 2019 (P < 0.001). Racial differences were also prevalent as NAFLD hospitalizations with PUD increased for Whites and Hispanics, while a decline was observed for Blacks and Asians. The all-cause inpatient mortality for NAFLD hospitalizations with PUD increased from 2% in 2009 to 5% in 2019 (P < 0.001). However, rates of Helicobacter pylori (H. pylori) infection and upper endoscopy decreased from 5% in 2009 to 1% in 2019 (P < 0.001) and from 60% in 2009 to 19% in 2019 (P < 0.001), respectively. Interestingly, despite a significantly higher comorbidity burden, we observed lower inpatient mortality (2% vs 3%, P = 0.0004), mean length of stay (LOS) (11.6 vs 12.1 d, P < 0.001), and mean total healthcare cost (THC) ($178598 vs $184727, P < 0.001) for NAFLD hospitalizations with PUD compared to non-NAFLD PUD hospitalizations. Perforation of the gastrointestinal tract, coagulopathy, alcohol abuse, malnutrition, and fluid and electrolyte disorders were identified to be independent predictors of inpatient mortality for NAFLD hospitalizations with PUD.
CONCLUSION Inpatient mortality for NAFLD hospitalizations with PUD increased for the study period. However, there was a significant decline in the rates of H. pylori infection and upper endoscopy for NAFLD hospitalizations with PUD. After a comparative analysis, NAFLD hospitalizations with PUD had lower inpatient mortality, mean LOS, and mean THC compared to the non-NAFLD cohort.
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Affiliation(s)
- Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI 48601, United States
| | - Vinay Jahagirdar
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO 64110, United States
| | - Hassam Ali
- Department of Internal Medicine, East Carolina University, Greenville, NC 27858, United States
| | - Manesh Kumar Gangwani
- Department of Internal Medicine, The University of Toledo, Toledo, OH 43606, United States
| | - Muhammad Aziz
- Department of Gastroenterology, The University of Toledo, Toledo, OH 43606, United States
| | - Saurabh Chandan
- Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE 68131, United States
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Abhilash Perisetti
- Division of Gastroenterology and Hepatology, Kansas City Veterans Affairs Medical Center, Kansas City, MO 64128, United States
| | - Aakriti Soni
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Sumant Inamdar
- Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Madhusudhan R Sanaka
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Mohammad Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN 46202, United States
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Soni A, Yekula A, Singh Y, Sood N, Dahiya DS, Bansal K, Abraham GM. Influence of non-alcoholic fatty liver disease on non-variceal upper gastrointestinal bleeding: A nationwide analysis. World J Hepatol 2023; 15:79-88. [PMID: 36744164 PMCID: PMC9896500 DOI: 10.4254/wjh.v15.i1.79] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/25/2022] [Accepted: 11/07/2022] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is the leading cause of liver disease globally with an estimated prevalence of 25%, with the clinical and economic burden expected to continue to increase. In the United States, non-variceal upper gastrointestinal bleeding (NVUGIB) has an estimated incidence of 61-78 cases per 100000 people with a mortality rate of 2%-15% based on co-morbidity burden.
AIM To identify the outcomes of NVUGIB in NAFLD hospitalizations in the United States.
METHODS We utilized the National Inpatient Sample from 2016-2019 to identify all NVUGIB hospitalizations in the United States. This population was divided based on the presence and absence of NAFLD. Hospitalization characteristics, outcomes and complications were compared.
RESULTS The total number of hospitalizations for NVUGIB was 799785, of which 6% were found to have NAFLD. NAFLD and GIB was, on average, more common in younger patients, females, and Hispanics than GIB without NAFLD. Interestingly, GIB was less common amongst blacks with NAFLD. Multivariate logistic regression analysis was conducted, controlling for the multiple covariates. The primary outcome of interest, mortality, was found to be significantly higher in patients with NAFLD and GIB [adjusted odds ratio (aOR) = 1.018 (1.013-1.022)]. Secondary outcomes of interest, shock [aOR = 1.015 (1.008-1.022)], acute respiratory failure [aOR = 1.01 (1.005-1.015)] and acute liver failure [aOR = 1.016 (1.013-1.019)] were all more likely to occur in this cohort. Patients with NAFLD were also more likely to incur higher total hospital charges (THC) [$2148 ($1677-$2618)]; however, were less likely to have a longer length of stay [0.27 d (0.17-0.38)]. Interestingly, in our study, the patients with NAFLD were less likely to suffer from acute myocardial infarction [aOR = 0.992 (0.989-0.995)]. Patients with NAFLD were not more likely to suffer acute kidney injury, sepsis, blood transfusion, intubation, or dialysis.
CONCLUSION NVUGIB in NAFLD hospitalizations had higher inpatient mortality, THC, and complications such as shock, acute respiratory failure, and acute liver failure compared to those without NAFLD.
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Affiliation(s)
- Aakriti Soni
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Anuroop Yekula
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Yuvaraj Singh
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - Nitish Sood
- Department of Internal Medicine, Medical College of Georgia, Augusta University, Augusta, GA 30912, United States
| | - Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University, Saginaw, MI 48602, United States
| | - Kannu Bansal
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
| | - GM Abraham
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
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VoPham T, Kim NJ, Berry K, Mendoza JA, Kaufman JD, Ioannou GN. PM 2.5 air pollution exposure and nonalcoholic fatty liver disease in the Nationwide Inpatient Sample. ENVIRONMENTAL RESEARCH 2022; 213:113611. [PMID: 35688225 PMCID: PMC9378584 DOI: 10.1016/j.envres.2022.113611] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/13/2022] [Accepted: 06/02/2022] [Indexed: 05/04/2023]
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease. Particulate matter air pollution <2.5 μm in diameter (PM2.5) is a ubiquitous exposure primarily produced from fossil fuel combustion. Previous epidemiologic studies have been mixed. The objective of this study was to examine the association between ambient PM2.5 exposure and NAFLD among hospitalized patients in the Nationwide Inpatient Sample (NIS). METHODS We conducted a cross-sectional analysis of hospitalizations from 2001 to 2011 using the NIS, the largest nationally representative all-payer inpatient care administrative database in the United States. Average annual PM2.5 exposure was estimated by linking census tracts (based on NIS-provided hospital ZIP Codes) with a spatiotemporal exposure model. Clinical conditions were identified using hospital discharge diagnosis codes. Multivariable logistic regression incorporating discharge weights was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between PM2.5 exposure and odds of NAFLD among hospitalized patients adjusting for age, sex, race/ethnicity, year, individual- and area-level socioeconomic status, urbanicity, region, obesity, diabetes, metabolic syndrome, impaired fasting glucose, dyslipidemia, hypertension, obstructive sleep apnea, and smoking. RESULTS There were 269,705 hospitalized patients with NAFLD from 2001 to 2011 (total unweighted n = 45,433,392 hospitalizations). Higher ambient PM2.5 exposure was associated with increased odds of NAFLD among hospitalized patients (adjusted OR: 1.24 per 10 μg/m3 increase, 95% CI 1.15-1.33, p < 0.01). There were statistically significant interactions between PM2.5 exposure and age, race/ethnicity, diabetes, smoking, and region, with stronger positive associations among patients who were aged ≥45 years, non-Hispanic White or Asian/Pacific Islander, non-diabetics, non-smokers, or in the Midwest and West regions, respectively. CONCLUSIONS In this nationwide cross-sectional analysis of the NIS database, there was a positive association between ambient PM2.5 exposure and odds of NAFLD among hospitalized patients. Future research should examine the effects of long-term historical PM2.5 exposure and incident NAFLD cases.
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Affiliation(s)
- Trang VoPham
- Epidemiology Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA.
| | - Nicole J Kim
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
| | - Jason A Mendoza
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics and Nutritional Sciences Program, University of Washington, Seattle, WA, USA; Cancer Prevention Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Joel D Kaufman
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA; Department of Environmental and Occupational Health Sciences, University of Washington School of Public Health, Seattle, WA, USA
| | - George N Ioannou
- Epidemiology Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA; Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, WA, USA
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Talens M, Tumas N, Lazarus JV, Benach J, Pericàs JM. What Do We Know about Inequalities in NAFLD Distribution and Outcomes? A Scoping Review. J Clin Med 2021; 10:jcm10215019. [PMID: 34768539 PMCID: PMC8584385 DOI: 10.3390/jcm10215019] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/17/2021] [Accepted: 10/25/2021] [Indexed: 02/06/2023] Open
Abstract
With prevalence high and rising given the close relationship with obesity and diabetes mellitus, non-alcoholic fatty liver disease (NAFLD) is progressively becoming the most common chronic liver condition worldwide. However, little is known about the health inequalities in NAFLD distribution and outcomes. This review aims to analyze health inequalities in NAFLD distribution globally and to assess the health disparities in NAFLD-related outcomes. We conducted a scoping review of global health inequalities in NAFLD distribution and outcomes according to gender/sex, ethnicity/race, and socioeconomic position from PubMed's inception to May 2021. Ultimately, 20 articles were included in the review, most (75%) of them carried out in the United States. Males were found to have a higher NAFLD prevalence (three articles), while available evidence suggests that women have an overall higher burden of advanced liver disease and complications (four articles), whereas they are less likely to be liver-transplanted once cirrhosis develops (one article). In the US, the Hispanic population had the highest NAFLD prevalence and poorer outcomes (seven articles), whereas Whites had fewer complications than other ethnicities (two articles). Patients with low socioeconomic status had higher NAFLD prevalence (four articles) and a higher likelihood of progression and complications (five articles). In conclusion, globally there is a lack of studies analyzing NAFLD prevalence and outcomes according to various axes of inequality through joint intersectional appraisals, and most studies included in our review were based on the US population. Available evidence suggests that NAFLD distribution and outcomes show large inequalities by social group. Further research on this issue is warranted.
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Affiliation(s)
- Mar Talens
- Research Group on Health Inequalities, Environment, and Employment Conditions, Department of Social and Political Science, Pompeu Fabra University, 08005 Barcelona, Spain; (M.T.); (N.T.); (J.B.)
| | - Natalia Tumas
- Research Group on Health Inequalities, Environment, and Employment Conditions, Department of Social and Political Science, Pompeu Fabra University, 08005 Barcelona, Spain; (M.T.); (N.T.); (J.B.)
- Public Policy Center (UPF-BSM), Johns Hopkins University-Pompeu Fabra University, 08005 Barcelona, Spain
- Centro de Investigaciones y Estudios sobre Cultura y Sociedad, Consejo Nacional de Investigaciones Científicas y Técnicas y Universidad Nacional de Córdoba, Córdoba 5016, Argentina
| | - Jeffrey V. Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain;
| | - Joan Benach
- Research Group on Health Inequalities, Environment, and Employment Conditions, Department of Social and Political Science, Pompeu Fabra University, 08005 Barcelona, Spain; (M.T.); (N.T.); (J.B.)
- Public Policy Center (UPF-BSM), Johns Hopkins University-Pompeu Fabra University, 08005 Barcelona, Spain
- Transdisciplinary Research Group on Socioecological Transitions (GinTrans2), Universidad Autónoma de Madrid, 28049 Madrid, Spain
| | - Juan M. Pericàs
- Research Group on Health Inequalities, Environment, and Employment Conditions, Department of Social and Political Science, Pompeu Fabra University, 08005 Barcelona, Spain; (M.T.); (N.T.); (J.B.)
- Public Policy Center (UPF-BSM), Johns Hopkins University-Pompeu Fabra University, 08005 Barcelona, Spain
- Liver Unit, Internal Medicine Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute for Research, 08035 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
- Correspondence:
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Oladunjoye O, Oladunjoye AO, Dhital R, Poudel D, Oladiran OD, Oke IO, Areoye G, Jehangir A, Shogbesan O. A Retrospective Study of Hospitalizations in the USA: Proportion of Hospitalizations With Non-Alcoholic Fatty Liver Disease in Non-Obese Population. Cureus 2021; 13:e17869. [PMID: 34660070 PMCID: PMC8502757 DOI: 10.7759/cureus.17869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2021] [Indexed: 11/05/2022] Open
Abstract
Background Non-alcoholic fatty liver disease (NAFLD), one of the leading causes of end-stage liver disease, is known to be associated with obesity. However, only a few studies in the United States (US) have described non-obese NAFLD, most of which were on the outpatient population. Aim We aimed to investigate the proportion of hospitalizations in the US with a diagnosis code that included NAFLD in the non-obese population. Methods We analyzed adult discharges from the Nationwide Inpatient Sample with a diagnosis of NAFLD from January 2010 to December 2014. We created two groups: obese (overweight or obese) and non-obese (normal or underweight) groups. Basic demographic and clinical characteristics were compared using the chi-square test and Student's t-test. Results A total of 194,787 hospitalizations with NAFLD were identified over the five-year period. It was observed that the prevalence of non-obese NAFLD hospitalizations increased yearly. Non-obese NAFLD hospitalizations had a higher mean age (57.5 vs 51.5 years, p < 0.0001) and a higher proportion of males (43.3% vs 36.1%, p < 0.0001) than obese NAFLD hospitalizations. With univariate analysis, non-obese NAFLD hospitalizations had lower odds of hypertension (OR 0.74, p < 0.0001), diabetes mellitus (OR 0.65, p < 0.0001). Non-obese hospitalizations had higher odds of cirrhosis (OR 1.30, p < 0.001) and decompensated cirrhosis (OR 1.30, p < 0.001) after adjusting for age, sex, race, diabetes mellitus, and dyslipidemia. Hospitalizations with non-obese NAFLD had higher odds of death (OR 1.49, p < 0.001) after adjusting for age, gender, race, co-morbidities, cirrhosis, and liver decompensation. Conclusion There is a continued rise in the proportion of non-obese NAFLD among hospitalizations in the US. Non-obese NAFLD hospitalizations were less likely to have hypertension and diabetes, but more likely to have decompensated liver disease. Further studies are needed to better characterize these patients to enable early detection, treatment, and reduction in complications of liver disease.
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Affiliation(s)
- Olubunmi Oladunjoye
- Internal Medicine, Reading Hospital - Tower Health System, West Reading, USA
| | - Adeolu O Oladunjoye
- Psychiatry, Baylor College of Medicine, Houston, USA.,Medical Critical Care, Boston Children's Hospital, Boston, USA
| | - Rashmi Dhital
- Internal Medicine, Reading Hospital - Tower Health System, West Reading, USA
| | | | | | - Ibiyemi O Oke
- Internal Medicine, Reading Hospital - Tower Health System, West Reading, USA
| | - Gabriel Areoye
- Internal Medicine, Reading Hospital - Tower Health System, West Reading, USA
| | - Asad Jehangir
- Gastroenterology and Hepatology, Medical College of Georgia at Augusta, Augusta, USA
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10
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Bonacini M, Kassamali F, Kari S, Lopez Barrera N, Kohla M. Racial differences in prevalence and severity of non-alcoholic fatty liver disease. World J Hepatol 2021; 13:763-773. [PMID: 34367497 PMCID: PMC8326166 DOI: 10.4254/wjh.v13.i7.763] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/08/2021] [Accepted: 07/07/2021] [Indexed: 02/06/2023] Open
Abstract
The aim of this review is to assess the evidence regarding racial differences in the prevalence and severity of nonalcoholic fatty liver disease (NAFLD). We reviewed the published literature that reported prevalence, severity, and genetic associations of NAFLD in different ethnic groups. The metabolic syndrome (MetS) has been associated with NAFLD, but each component of the MetS is present in various races in different percentages and their effect on NAFLD appears to be dissimilar. An elevated triglyceride (TG) level seems to have the strongest association with NAFLD. The latter is more prevalent in Hispanic patients; Blacks have lower TG levels and a lower NAFLD prevalence, compared to Caucasians or Hispanics. The severity of liver fibrosis is lower in some, but not all biopsy-based studies of Black patients. No study has evaluated the severity of liver disease controlling for the individual components of MetS, especially TG. Important racial differences in the prevalence of selected genetic polymorphisms, particularly PNPLA-3 and MBOAT7 have been documented, together with their effects on the prevalence of liver steatosis and fibrosis. Data on overall and liver mortality have found no significant differences according to race/ethnicity, with the possible exception of one paper reporting lower cirrhosis mortality in Black patients. We conclude that NAFLD is more prevalent in Hispanics and less in Blacks. This is supported by differences in key genetic polymorphisms associated with hepatic fat storage. However, there is presently insufficient evidence to firmly conclude that race, per se, plays a role in the development of liver fibrosis and its complications. Further studies, appropriately controlled for diet, exercise, and individual MetS parameters are needed.
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Affiliation(s)
- Maurizio Bonacini
- Department of Gastroenterology and Hepatology, California Pacific Medical Center, California Pacific Medical Center, San Francisco, CA 94115, United States
| | - Farah Kassamali
- Department of Gastroenterology and Hepatology, California Pacific Medical Center, San Francisco, CA 94115, United States
| | - Swathi Kari
- Department of Internal Medicine, St. Mary's medical Center, San Francisco, CA 94117, United States
| | | | - Mohamed Kohla
- Department of Hepatology, National Liver Institute, Menoufiya University, Shibin Al Kom 32511, Menoufiya, Egypt
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11
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Adejumo AC, Akhtar DH, Dennis BB, Cholankeril G, Alayo Q, Ogundipe OA, Kim D, Ahmed A. Gender and Racial Differences in Hospitalizations for Primary Biliary Cholangitis in the USA. Dig Dis Sci 2021; 66:1461-1476. [PMID: 32535779 DOI: 10.1007/s10620-020-06402-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 06/05/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND/AIM The prevalence, characteristics, burden and trends of primary biliary cholangitis (PBC) hospitalizations in the USA remain unclear. METHOD We identified primary PBC hospitalizations from the National Inpatient Sample (NIS) 2007 through 2014 using ICD-9-CM codes. We calculated the rates and trends of hospitalization for PBC per 100,000 US population among each gender (males and females) and racial categories (Whites, Blacks, Hispanics and other racial minorities), and measured the predictors of hospitalization, and of mortality, charges and length of stay (LOS) among PBC hospitalizations. RESULT There were 8460 (weighted: 41,191) PBC hospitalizations between 2007 and 2014. The mean national PBC hospitalization rate was 2.2 cases per 100,000 population (2.2/100,000), increasing from 1.7/100,000 (2007) to 2.5/100,000 (2014). From 2007 to 2014, the in-hospital mortality and LOS were unchanged while the charges increased from $65,993 to $73,093 ($225 million to $447 million overall expenses). Compared to Whites, the PBC hospitalization rate was 12% higher among Hispanics (RR: 1.12 [1.09-1.16]), 53% lower in Blacks (RR: 0.47 [0.45-0.49]) and 5% lower among other racial minorities (0.95 [0.91-0.99]). The rate was higher among females (RR:4.02 [3.93-4.12]) compared to males. On multivariate analysis, Blacks and other racial minorities, respectively, had higher odds of mortality (AOR: 1.47 [1.03-2.10] and 1.33 [0.96-1.84]), while other racial minorities had longer LOS (7.0 vs. 5.6 days) and higher hospital charges ($48,984 vs. $41,495) when compared to Whites. CONCLUSION The hospitalization rate and burden of PBC in the USA have increased disproportionately among females and Hispanics with higher mortality in Blacks.
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Affiliation(s)
- Adeyinka Charles Adejumo
- Department of Medicine, North Shore Medical Center, 81 Highland Ave., Salem, MA, 01970, USA. .,Department of Medicine, Tufts University School of Medicine, Boston, MA, USA.
| | - Daud H Akhtar
- Department of Medicine, University of British Columbia Faculty of Medicine, Vancouver General Hospital, Vancouver, Canada
| | - Brittany B Dennis
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | | | - Quazim Alayo
- Applied Clinical Research Program, St. Cloud State University, Plymouth, MN, USA
| | - Olumuyiwa A Ogundipe
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Donghee Kim
- Department of Medicine, St. Luke's Hospital, St. Louis, MO, USA
| | - Aijaz Ahmed
- Department of Medicine, St. Luke's Hospital, St. Louis, MO, USA
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12
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Han MAT, Yu Q, Tafesh Z, Pyrsopoulos N. Diversity in NAFLD: A Review of Manifestations of Nonalcoholic Fatty Liver Disease in Different Ethnicities Globally. J Clin Transl Hepatol 2021; 9:71-80. [PMID: 33604257 PMCID: PMC7868692 DOI: 10.14218/jcth.2020.00082] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/17/2020] [Accepted: 12/05/2020] [Indexed: 12/11/2022] Open
Abstract
Globally, the rise in prevalence of obesity and metabolic syndrome as a whole has been linked to increased access to processed foods, such as refined sugars and saturated fats. Consequently, nonalcoholic fatty liver disease (NAFLD) is on the rise in both developed and developing nations. However, much is still unknown on the NAFLD phenotype with regards to the effect of ethnic diversity. Despite similarities in dietary habits, it appears that certain ethnicities are more protected against NAFLD than others. However, manifestations of the same genetic polymorphisms in different groups of people increase those individuals' predisposition to NAFLD. Diets from different regions have been associated with a lower prevalence of NAFLD and have even been linked to regression of hepatic steatosis. Socioeconomic variations amongst different regions of the world also contribute to NAFLD prevalence and associated complications. Thus, a thorough understanding of ethnic variability in NAFLD is essential to tailoring treatment recommendations to patients of different backgrounds.
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Affiliation(s)
| | | | | | - Nikolaos Pyrsopoulos
- Correspondence to: Nikolaos Pyrsopoulos, Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, 185 South Orange Avenue, H-536, Newark, NJ 07103, USA. Tel: +1-973-972-5252, E-mail:
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13
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Swain MG, Ramji A, Patel K, Sebastiani G, Shaheen AA, Tam E, Marotta P, Elkhashab M, Bajaj HS, Estes C, Razavi H. Burden of nonalcoholic fatty liver disease in Canada, 2019-2030: a modelling study. CMAJ Open 2020; 8:E429-E436. [PMID: 32518095 PMCID: PMC7286622 DOI: 10.9778/cmajo.20190212] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) account for a growing proportion of liver disease cases, and there is a need to better understand future disease burden. We used a modelling framework to forecast the burden of disease of NAFLD and NASH for Canada. METHODS We used a Markov model to forecast fibrosis progression from stage F0 (no fibrosis) to stage F4 (compensated cirrhosis) and subsequent progression to decompensated cirrhosis, hepatocellular carcinoma, liver transplantation and liver-related death among Canadians with NAFLD from 2019 to 2030. We used historical trends for obesity prevalence among adults to estimate longitudinal changes in the number of incident NAFLD cases. RESULTS The model projected that the number of NAFLD cases would increase by 20% between 2019 and 2030, from an estimated 7 757 000 cases to 9 305 000 cases. Increases in advanced fibrosis cases were relatively greater, as the number of model-estimated prevalent stage F3 cases would increase by 65%, to 357 000, and that of prevalent stage F4 cases would increase by 95%, to 195 000. Estimated incident cases of hepatocellular carcinoma and decompensated cirrhosis would increase by up to 95%, and the number of annual NAFLD-related deaths would double, to 5600. INTERPRETATION Increasing rates of obesity translate into increasing NAFLD-related cases of cirrhosis and hepatocellular carcinoma and related mortality. Prevention efforts should be aimed at reducing the incidence of NAFLD and slowing fibrosis progression among those already affected.
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Affiliation(s)
- Mark G Swain
- Division of Gastroenterology and Hepatology (Swain, Shaheen), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji), University of British Columbia, Vancouver, BC; Toronto Centre for Liver Disease (Patel), University Hospital Network, Toronto, Ont.; Division of Gastroenterology and Hepatology (Sebastiani), McGill University Health Centre, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Division of Gastroenterology (Marotta), Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont.; Toronto Liver Centre (Elkhashab), Toronto, Ont.; LMC Diabetes and Endocrinology Brampton (Bajaj), Brampton, Ont.; Leadership Sinai Centre for Diabetes (Bajaj), Mount Sinai Hospital, Toronto, Ont.; Center for Disease Analysis Foundation (Estes, Razavi), Lafayette, Colo
| | - Alnoor Ramji
- Division of Gastroenterology and Hepatology (Swain, Shaheen), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji), University of British Columbia, Vancouver, BC; Toronto Centre for Liver Disease (Patel), University Hospital Network, Toronto, Ont.; Division of Gastroenterology and Hepatology (Sebastiani), McGill University Health Centre, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Division of Gastroenterology (Marotta), Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont.; Toronto Liver Centre (Elkhashab), Toronto, Ont.; LMC Diabetes and Endocrinology Brampton (Bajaj), Brampton, Ont.; Leadership Sinai Centre for Diabetes (Bajaj), Mount Sinai Hospital, Toronto, Ont.; Center for Disease Analysis Foundation (Estes, Razavi), Lafayette, Colo
| | - Keyur Patel
- Division of Gastroenterology and Hepatology (Swain, Shaheen), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji), University of British Columbia, Vancouver, BC; Toronto Centre for Liver Disease (Patel), University Hospital Network, Toronto, Ont.; Division of Gastroenterology and Hepatology (Sebastiani), McGill University Health Centre, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Division of Gastroenterology (Marotta), Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont.; Toronto Liver Centre (Elkhashab), Toronto, Ont.; LMC Diabetes and Endocrinology Brampton (Bajaj), Brampton, Ont.; Leadership Sinai Centre for Diabetes (Bajaj), Mount Sinai Hospital, Toronto, Ont.; Center for Disease Analysis Foundation (Estes, Razavi), Lafayette, Colo
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology (Swain, Shaheen), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji), University of British Columbia, Vancouver, BC; Toronto Centre for Liver Disease (Patel), University Hospital Network, Toronto, Ont.; Division of Gastroenterology and Hepatology (Sebastiani), McGill University Health Centre, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Division of Gastroenterology (Marotta), Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont.; Toronto Liver Centre (Elkhashab), Toronto, Ont.; LMC Diabetes and Endocrinology Brampton (Bajaj), Brampton, Ont.; Leadership Sinai Centre for Diabetes (Bajaj), Mount Sinai Hospital, Toronto, Ont.; Center for Disease Analysis Foundation (Estes, Razavi), Lafayette, Colo
| | - Abdel Aziz Shaheen
- Division of Gastroenterology and Hepatology (Swain, Shaheen), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji), University of British Columbia, Vancouver, BC; Toronto Centre for Liver Disease (Patel), University Hospital Network, Toronto, Ont.; Division of Gastroenterology and Hepatology (Sebastiani), McGill University Health Centre, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Division of Gastroenterology (Marotta), Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont.; Toronto Liver Centre (Elkhashab), Toronto, Ont.; LMC Diabetes and Endocrinology Brampton (Bajaj), Brampton, Ont.; Leadership Sinai Centre for Diabetes (Bajaj), Mount Sinai Hospital, Toronto, Ont.; Center for Disease Analysis Foundation (Estes, Razavi), Lafayette, Colo
| | - Edward Tam
- Division of Gastroenterology and Hepatology (Swain, Shaheen), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji), University of British Columbia, Vancouver, BC; Toronto Centre for Liver Disease (Patel), University Hospital Network, Toronto, Ont.; Division of Gastroenterology and Hepatology (Sebastiani), McGill University Health Centre, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Division of Gastroenterology (Marotta), Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont.; Toronto Liver Centre (Elkhashab), Toronto, Ont.; LMC Diabetes and Endocrinology Brampton (Bajaj), Brampton, Ont.; Leadership Sinai Centre for Diabetes (Bajaj), Mount Sinai Hospital, Toronto, Ont.; Center for Disease Analysis Foundation (Estes, Razavi), Lafayette, Colo
| | - Paul Marotta
- Division of Gastroenterology and Hepatology (Swain, Shaheen), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji), University of British Columbia, Vancouver, BC; Toronto Centre for Liver Disease (Patel), University Hospital Network, Toronto, Ont.; Division of Gastroenterology and Hepatology (Sebastiani), McGill University Health Centre, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Division of Gastroenterology (Marotta), Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont.; Toronto Liver Centre (Elkhashab), Toronto, Ont.; LMC Diabetes and Endocrinology Brampton (Bajaj), Brampton, Ont.; Leadership Sinai Centre for Diabetes (Bajaj), Mount Sinai Hospital, Toronto, Ont.; Center for Disease Analysis Foundation (Estes, Razavi), Lafayette, Colo
| | - Magdy Elkhashab
- Division of Gastroenterology and Hepatology (Swain, Shaheen), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji), University of British Columbia, Vancouver, BC; Toronto Centre for Liver Disease (Patel), University Hospital Network, Toronto, Ont.; Division of Gastroenterology and Hepatology (Sebastiani), McGill University Health Centre, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Division of Gastroenterology (Marotta), Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont.; Toronto Liver Centre (Elkhashab), Toronto, Ont.; LMC Diabetes and Endocrinology Brampton (Bajaj), Brampton, Ont.; Leadership Sinai Centre for Diabetes (Bajaj), Mount Sinai Hospital, Toronto, Ont.; Center for Disease Analysis Foundation (Estes, Razavi), Lafayette, Colo
| | - Harpreet S Bajaj
- Division of Gastroenterology and Hepatology (Swain, Shaheen), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji), University of British Columbia, Vancouver, BC; Toronto Centre for Liver Disease (Patel), University Hospital Network, Toronto, Ont.; Division of Gastroenterology and Hepatology (Sebastiani), McGill University Health Centre, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Division of Gastroenterology (Marotta), Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont.; Toronto Liver Centre (Elkhashab), Toronto, Ont.; LMC Diabetes and Endocrinology Brampton (Bajaj), Brampton, Ont.; Leadership Sinai Centre for Diabetes (Bajaj), Mount Sinai Hospital, Toronto, Ont.; Center for Disease Analysis Foundation (Estes, Razavi), Lafayette, Colo
| | - Chris Estes
- Division of Gastroenterology and Hepatology (Swain, Shaheen), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji), University of British Columbia, Vancouver, BC; Toronto Centre for Liver Disease (Patel), University Hospital Network, Toronto, Ont.; Division of Gastroenterology and Hepatology (Sebastiani), McGill University Health Centre, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Division of Gastroenterology (Marotta), Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont.; Toronto Liver Centre (Elkhashab), Toronto, Ont.; LMC Diabetes and Endocrinology Brampton (Bajaj), Brampton, Ont.; Leadership Sinai Centre for Diabetes (Bajaj), Mount Sinai Hospital, Toronto, Ont.; Center for Disease Analysis Foundation (Estes, Razavi), Lafayette, Colo.
| | - Homie Razavi
- Division of Gastroenterology and Hepatology (Swain, Shaheen), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Gastroenterology (Ramji), University of British Columbia, Vancouver, BC; Toronto Centre for Liver Disease (Patel), University Hospital Network, Toronto, Ont.; Division of Gastroenterology and Hepatology (Sebastiani), McGill University Health Centre, Montréal, Que.; LAIR Centre (Tam), Vancouver, BC; Division of Gastroenterology (Marotta), Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ont.; Toronto Liver Centre (Elkhashab), Toronto, Ont.; LMC Diabetes and Endocrinology Brampton (Bajaj), Brampton, Ont.; Leadership Sinai Centre for Diabetes (Bajaj), Mount Sinai Hospital, Toronto, Ont.; Center for Disease Analysis Foundation (Estes, Razavi), Lafayette, Colo
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