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Nabi O, Lapidus N, Boursier J, de Ledinghen V, Kab S, Renuy A, Zins M, Serfaty L, Lacombe K. The NAFLD burden on mortality and morbidities in general population: A community-based longitudinal study (NASH-CO study). Liver Int 2023; 43:2096-2106. [PMID: 37452492 DOI: 10.1111/liv.15674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 06/21/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The impact of non-alcoholic fatty liver disease (NAFLD) on morbidity and mortality has yet to be documented at the general population level. This study aimed to assess whether NAFLD was associated with morbidities and mortality and to estimate its impact on health status and mortality. METHODS The study population consisted of 137 206 participants from Constances cohort. Non-invasive diagnosis of NAFLD and advanced fibrosis was performed using the fatty liver index and Forns index, respectively. Constances data were linked to health care and hospitalization data to identify liver-related events, cardiovascular diseases (CVD), extrahepatic cancers (EHC), chronic kidney disease (CKD) and all-cause mortality. RESULTS The prevalence of NAFLD was 18.3% in subjects without other chronic liver diseases, among whom 2.7% had fibrosis. NAFLD after IPTW-weighted remained associated with an increased risk of death (HR 1.26, 95% CI 1.01-1.57), hepatic-related complications (HR 2.48, 95% CI 1.99-3.29), CVD (HR 1.42, 95% CI 1.30-1.55), EHC (HR 1.11, 95% CI 1.01-1.28) and CKD (HR 1.81, 95% CI 1.53-2.07) compared to those without chronic liver diseases risk factors (Non-NAFLD). In the trend analysis over the study period of inclusion and compared to Non-NAFLD, NAFLD has shown a fastest growing cause of hepatic events (HR 1.38, 95% CI 1.07-1.76 per year), CVD (HR 1.08, 95% CI 1.03-1.12), CKD (HR 1.16, 95% CI 1.07-1.25), and death (HR 1.39, 95% CI 1.39-1.50). CONCLUSION This large community-based cohort showed that NAFLD was associated with excess morbidity and mortality and demonstrated a fastest-growing trend.
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Affiliation(s)
- Oumarou Nabi
- Sorbonne University, Inserm, Pierre Louis Institute of Epidemiology and Public Health (IPLESP), AP-HP, Saint-Antoine Hospital, Paris, France
- Division of General Medical Sciences, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Nathanaël Lapidus
- Sorbonne University, Inserm, Pierre Louis Institute of Epidemiology and Public Health (IPLESP), AP-HP, Saint-Antoine Hospital, Paris, France
| | - Jerome Boursier
- HepatoGastroenterology Department, Anger University Hospital, Angers, France
- HIFIH Laboratory, UPRES EA3859, SFR 4208, Angers University, Angers, France
| | - Victor de Ledinghen
- Hepatology Unit, Haut-Lévêque Hospital, Bordeaux University Hospital Branch, Bordeaux, France
| | - Sofiane Kab
- Versailles-Saint Quentin University, UMS 11 Inserm, Versailles, France
| | - Adeline Renuy
- Versailles-Saint Quentin University, UMS 11 Inserm, Versailles, France
| | - Marie Zins
- Versailles-Saint Quentin University, UMS 11 Inserm, Versailles, France
- Paris-Saclay University, Paris, France
| | - Lawrence Serfaty
- Hepatogastroenterology Service, Hautepierre Hospital, Strasbourg University Hospital, Strasbourg, France
- Sorbonne University, Inserm UMR_S938, Paris, France
| | - Karine Lacombe
- Sorbonne University, Inserm, Pierre Louis Institute of Epidemiology and Public Health (IPLESP), AP-HP, Saint-Antoine Hospital, Paris, France
- Infectious Diseases Department, Saint-Antoine Hospital, APHP, Paris, France
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3
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Abaalkhail FA, Al Sebayel MI, Shagrani MA, O’Hali WA, Almasri NM, Alalwan AA, Alghamdi MY, Al-Bahili H, AlQahtani MS, Alabbad SI, Al-Hamoudi WK, Alqahtani SA. Clinical Practice Guidelines for Liver Transplantation in Saudi Arabia. Saudi Med J 2021; 42:927-968. [PMID: 34470833 PMCID: PMC9280503 DOI: 10.15537/smj.2021.42.9.20210126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/22/2021] [Indexed: 11/26/2022] Open
Abstract
The demand for liver transplantation in the Kingdom of Saudi Arabia (KSA) is associated with the country's high burden of liver disease. Trends in the epidemiology of liver transplantation indications among recipients in KSA have changed over 20 years. Non-alcoholic steatohepatitis has eclipsed the hepatitis C virus in the country due to the effective treatment strategies for HCV. Risk factors for NASH, like type 2 diabetes mellitus, obesity, and hyperlipidemia, are becoming a major concern and a leading indication for liver transplantation in the KSA. There is also a significantly increased prevalence and incidence of genetic adult familial liver diseases in KSA. New immunosuppressive agents and preservation solutions, improved surgical capabilities, and early disease recognition and management have increased the success rate of liver transplant outcome but concerns about the side effects of immunosuppressive therapy can jeopardise long-term survival outcomes. Despite this, indications for liver transplantation continue to increase, resulting in ongoing challenges to maximize the number of potential donors and reduce patient mortality rate while expecting to get transplanted. The Saudi Center of Organ Transplant is the recognized National Organ Donation Agency for transplantation, which renders important support for procurement and allocation of organs. This guidance document aims to help healthcare providers in managing patients in the liver transplant setting.
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Affiliation(s)
- Faisal A. Abaalkhail
- From the Department of Medicine (Abaalkhail), Gastroenterology Section, from the Organ Transplant Center (Shagrani, Alabbad, Al-hamoudi, Alqahtani S), King Faisal Specialist Hospital & Research Center; from the College of Medicine (Abaalkhail, Shagrani,) Alfaisal University; from the Department of Surgery (Al Sebayel), Almaarefah University; from the Hepatobiliary Sciences and Organ Transplant Center (O’Hali, Alalwan), King Abdulaziz Medical City; from the Department of Medicine (Almasri), Multiorgan Transplant Center (Al-Bahili), Prince Sultan Medical Military City; from the Liver Research Center (Al-hamoudi), King Saud University, Riyadh; from the Department of Medicine (Alghamdi), King Fahd Military Medical Complex, Dahran; from the Multi-Organ Transplant Center (Alqahtani M), King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia; and from the Johns Hopkins University (Alqahtani S), Baltimore, MD, United States of America.
| | - Mohammed I. Al Sebayel
- From the Department of Medicine (Abaalkhail), Gastroenterology Section, from the Organ Transplant Center (Shagrani, Alabbad, Al-hamoudi, Alqahtani S), King Faisal Specialist Hospital & Research Center; from the College of Medicine (Abaalkhail, Shagrani,) Alfaisal University; from the Department of Surgery (Al Sebayel), Almaarefah University; from the Hepatobiliary Sciences and Organ Transplant Center (O’Hali, Alalwan), King Abdulaziz Medical City; from the Department of Medicine (Almasri), Multiorgan Transplant Center (Al-Bahili), Prince Sultan Medical Military City; from the Liver Research Center (Al-hamoudi), King Saud University, Riyadh; from the Department of Medicine (Alghamdi), King Fahd Military Medical Complex, Dahran; from the Multi-Organ Transplant Center (Alqahtani M), King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia; and from the Johns Hopkins University (Alqahtani S), Baltimore, MD, United States of America.
| | - Mohammed A. Shagrani
- From the Department of Medicine (Abaalkhail), Gastroenterology Section, from the Organ Transplant Center (Shagrani, Alabbad, Al-hamoudi, Alqahtani S), King Faisal Specialist Hospital & Research Center; from the College of Medicine (Abaalkhail, Shagrani,) Alfaisal University; from the Department of Surgery (Al Sebayel), Almaarefah University; from the Hepatobiliary Sciences and Organ Transplant Center (O’Hali, Alalwan), King Abdulaziz Medical City; from the Department of Medicine (Almasri), Multiorgan Transplant Center (Al-Bahili), Prince Sultan Medical Military City; from the Liver Research Center (Al-hamoudi), King Saud University, Riyadh; from the Department of Medicine (Alghamdi), King Fahd Military Medical Complex, Dahran; from the Multi-Organ Transplant Center (Alqahtani M), King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia; and from the Johns Hopkins University (Alqahtani S), Baltimore, MD, United States of America.
| | - Wael A. O’Hali
- From the Department of Medicine (Abaalkhail), Gastroenterology Section, from the Organ Transplant Center (Shagrani, Alabbad, Al-hamoudi, Alqahtani S), King Faisal Specialist Hospital & Research Center; from the College of Medicine (Abaalkhail, Shagrani,) Alfaisal University; from the Department of Surgery (Al Sebayel), Almaarefah University; from the Hepatobiliary Sciences and Organ Transplant Center (O’Hali, Alalwan), King Abdulaziz Medical City; from the Department of Medicine (Almasri), Multiorgan Transplant Center (Al-Bahili), Prince Sultan Medical Military City; from the Liver Research Center (Al-hamoudi), King Saud University, Riyadh; from the Department of Medicine (Alghamdi), King Fahd Military Medical Complex, Dahran; from the Multi-Organ Transplant Center (Alqahtani M), King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia; and from the Johns Hopkins University (Alqahtani S), Baltimore, MD, United States of America.
| | - Nasser M. Almasri
- From the Department of Medicine (Abaalkhail), Gastroenterology Section, from the Organ Transplant Center (Shagrani, Alabbad, Al-hamoudi, Alqahtani S), King Faisal Specialist Hospital & Research Center; from the College of Medicine (Abaalkhail, Shagrani,) Alfaisal University; from the Department of Surgery (Al Sebayel), Almaarefah University; from the Hepatobiliary Sciences and Organ Transplant Center (O’Hali, Alalwan), King Abdulaziz Medical City; from the Department of Medicine (Almasri), Multiorgan Transplant Center (Al-Bahili), Prince Sultan Medical Military City; from the Liver Research Center (Al-hamoudi), King Saud University, Riyadh; from the Department of Medicine (Alghamdi), King Fahd Military Medical Complex, Dahran; from the Multi-Organ Transplant Center (Alqahtani M), King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia; and from the Johns Hopkins University (Alqahtani S), Baltimore, MD, United States of America.
| | - Abduljaleel A. Alalwan
- From the Department of Medicine (Abaalkhail), Gastroenterology Section, from the Organ Transplant Center (Shagrani, Alabbad, Al-hamoudi, Alqahtani S), King Faisal Specialist Hospital & Research Center; from the College of Medicine (Abaalkhail, Shagrani,) Alfaisal University; from the Department of Surgery (Al Sebayel), Almaarefah University; from the Hepatobiliary Sciences and Organ Transplant Center (O’Hali, Alalwan), King Abdulaziz Medical City; from the Department of Medicine (Almasri), Multiorgan Transplant Center (Al-Bahili), Prince Sultan Medical Military City; from the Liver Research Center (Al-hamoudi), King Saud University, Riyadh; from the Department of Medicine (Alghamdi), King Fahd Military Medical Complex, Dahran; from the Multi-Organ Transplant Center (Alqahtani M), King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia; and from the Johns Hopkins University (Alqahtani S), Baltimore, MD, United States of America.
| | - Mohammed Y. Alghamdi
- From the Department of Medicine (Abaalkhail), Gastroenterology Section, from the Organ Transplant Center (Shagrani, Alabbad, Al-hamoudi, Alqahtani S), King Faisal Specialist Hospital & Research Center; from the College of Medicine (Abaalkhail, Shagrani,) Alfaisal University; from the Department of Surgery (Al Sebayel), Almaarefah University; from the Hepatobiliary Sciences and Organ Transplant Center (O’Hali, Alalwan), King Abdulaziz Medical City; from the Department of Medicine (Almasri), Multiorgan Transplant Center (Al-Bahili), Prince Sultan Medical Military City; from the Liver Research Center (Al-hamoudi), King Saud University, Riyadh; from the Department of Medicine (Alghamdi), King Fahd Military Medical Complex, Dahran; from the Multi-Organ Transplant Center (Alqahtani M), King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia; and from the Johns Hopkins University (Alqahtani S), Baltimore, MD, United States of America.
| | - Hamad Al-Bahili
- From the Department of Medicine (Abaalkhail), Gastroenterology Section, from the Organ Transplant Center (Shagrani, Alabbad, Al-hamoudi, Alqahtani S), King Faisal Specialist Hospital & Research Center; from the College of Medicine (Abaalkhail, Shagrani,) Alfaisal University; from the Department of Surgery (Al Sebayel), Almaarefah University; from the Hepatobiliary Sciences and Organ Transplant Center (O’Hali, Alalwan), King Abdulaziz Medical City; from the Department of Medicine (Almasri), Multiorgan Transplant Center (Al-Bahili), Prince Sultan Medical Military City; from the Liver Research Center (Al-hamoudi), King Saud University, Riyadh; from the Department of Medicine (Alghamdi), King Fahd Military Medical Complex, Dahran; from the Multi-Organ Transplant Center (Alqahtani M), King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia; and from the Johns Hopkins University (Alqahtani S), Baltimore, MD, United States of America.
| | - Mohammed S. AlQahtani
- From the Department of Medicine (Abaalkhail), Gastroenterology Section, from the Organ Transplant Center (Shagrani, Alabbad, Al-hamoudi, Alqahtani S), King Faisal Specialist Hospital & Research Center; from the College of Medicine (Abaalkhail, Shagrani,) Alfaisal University; from the Department of Surgery (Al Sebayel), Almaarefah University; from the Hepatobiliary Sciences and Organ Transplant Center (O’Hali, Alalwan), King Abdulaziz Medical City; from the Department of Medicine (Almasri), Multiorgan Transplant Center (Al-Bahili), Prince Sultan Medical Military City; from the Liver Research Center (Al-hamoudi), King Saud University, Riyadh; from the Department of Medicine (Alghamdi), King Fahd Military Medical Complex, Dahran; from the Multi-Organ Transplant Center (Alqahtani M), King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia; and from the Johns Hopkins University (Alqahtani S), Baltimore, MD, United States of America.
| | - Saleh I. Alabbad
- From the Department of Medicine (Abaalkhail), Gastroenterology Section, from the Organ Transplant Center (Shagrani, Alabbad, Al-hamoudi, Alqahtani S), King Faisal Specialist Hospital & Research Center; from the College of Medicine (Abaalkhail, Shagrani,) Alfaisal University; from the Department of Surgery (Al Sebayel), Almaarefah University; from the Hepatobiliary Sciences and Organ Transplant Center (O’Hali, Alalwan), King Abdulaziz Medical City; from the Department of Medicine (Almasri), Multiorgan Transplant Center (Al-Bahili), Prince Sultan Medical Military City; from the Liver Research Center (Al-hamoudi), King Saud University, Riyadh; from the Department of Medicine (Alghamdi), King Fahd Military Medical Complex, Dahran; from the Multi-Organ Transplant Center (Alqahtani M), King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia; and from the Johns Hopkins University (Alqahtani S), Baltimore, MD, United States of America.
| | - Waleed K. Al-Hamoudi
- From the Department of Medicine (Abaalkhail), Gastroenterology Section, from the Organ Transplant Center (Shagrani, Alabbad, Al-hamoudi, Alqahtani S), King Faisal Specialist Hospital & Research Center; from the College of Medicine (Abaalkhail, Shagrani,) Alfaisal University; from the Department of Surgery (Al Sebayel), Almaarefah University; from the Hepatobiliary Sciences and Organ Transplant Center (O’Hali, Alalwan), King Abdulaziz Medical City; from the Department of Medicine (Almasri), Multiorgan Transplant Center (Al-Bahili), Prince Sultan Medical Military City; from the Liver Research Center (Al-hamoudi), King Saud University, Riyadh; from the Department of Medicine (Alghamdi), King Fahd Military Medical Complex, Dahran; from the Multi-Organ Transplant Center (Alqahtani M), King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia; and from the Johns Hopkins University (Alqahtani S), Baltimore, MD, United States of America.
| | - Saleh A. Alqahtani
- From the Department of Medicine (Abaalkhail), Gastroenterology Section, from the Organ Transplant Center (Shagrani, Alabbad, Al-hamoudi, Alqahtani S), King Faisal Specialist Hospital & Research Center; from the College of Medicine (Abaalkhail, Shagrani,) Alfaisal University; from the Department of Surgery (Al Sebayel), Almaarefah University; from the Hepatobiliary Sciences and Organ Transplant Center (O’Hali, Alalwan), King Abdulaziz Medical City; from the Department of Medicine (Almasri), Multiorgan Transplant Center (Al-Bahili), Prince Sultan Medical Military City; from the Liver Research Center (Al-hamoudi), King Saud University, Riyadh; from the Department of Medicine (Alghamdi), King Fahd Military Medical Complex, Dahran; from the Multi-Organ Transplant Center (Alqahtani M), King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia; and from the Johns Hopkins University (Alqahtani S), Baltimore, MD, United States of America.
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8
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Al Sebayel M, Abaalkhail F, Al Abbad S, AlBahili H, Elsiesy H, Aleid M, Al-Hamoudi W. Liver transplantation in the Kingdom of Saudi Arabia. Liver Transpl 2017. [PMID: 28650090 DOI: 10.1002/lt.24803] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The first liver transplantation (LT) in Saudi Arabia was performed in 1991; however, it was not until 1994 that the first structured LT program was launched. Until 1997, all LTs in the Kingdom of Saudi Arabia (KSA) were deceased donor liver transplantations. Programs performing LTs needed the authorization of the Saudi Center for Organ Transplantation (SCOT), which provides the essential support for organ procurement and allocation as well as regulatory support for organ transplantation in the country. Currently, there are 4 LT centers in the KSA. Three centers are in Riyadh, the capital city of KSA, and 1 is in the city of Dammam in the Eastern province. Pediatric living donor liver transplantation (LDLT) began in 1997, while the adult LDLT program started 4 years later in 2001. Currently, more than 2000 LTs have been performed by the 4 centers in the KSA. Over 50% of those were performed at King Faisal Specialist Hospital and Research Center in Riyadh. The outcomes of these transplants have been comparable with the international standards. The aim of this review is to provide an overview of LT in KSA. Liver Transplantation 23 1312-1317 2017 AASLD.
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Affiliation(s)
- Mohammed Al Sebayel
- Department of Liver Transplantation and Hepatobiliary-Pancreatic Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Faisal Abaalkhail
- Department of Liver Transplantation and Hepatobiliary-Pancreatic Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saleh Al Abbad
- Department of Liver Transplantation and Hepatobiliary-Pancreatic Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hamad AlBahili
- Department of Liver Transplantation and Hepatobiliary-Pancreatic Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hussien Elsiesy
- Department of Liver Transplantation and Hepatobiliary-Pancreatic Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Maha Aleid
- Department of Biostatistics, Epidemiology and Scientific Computing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Waleed Al-Hamoudi
- Department of Liver Transplantation and Hepatobiliary-Pancreatic Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.,Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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9
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Young K, Liu B, Bhuket T, Younossi Z, Saab S, Ahmed A, Wong RJ. Long-term trends in chronic hepatitis B virus infection associated liver transplantation outcomes in the United States. J Viral Hepat 2017; 24:789-796. [PMID: 28273387 DOI: 10.1111/jvh.12703] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 02/02/2017] [Indexed: 12/19/2022]
Abstract
With effective antiviral therapies, rates of hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) and decompensated liver disease requiring liver transplantation (LT) are expected to decrease. We aim to evaluate overall trends in LT waitlist registrations, waitlist survival and likelihood of receiving LT among chronic HBV patients in the United States. Using the United Network for Organ Sharing database, we retrospectively evaluated adults (age≥18) with chronic HBV (with and without HCC) listed for LT from 1992 to 1996 (Era 1) vs 1997 to 2004 (Era 2) vs 2005-2015 (Era 3). Multivariate Cox-regression models evaluated probability of waitlist survival and receiving LT. Overall, 6797 chronic HBV adults were listed for LT. While the total number of HBV patients listed for LT remained stable, the proportion of HBV patients with HCC increased from 5.4% in Era 1 to 39.0% in Era 3. Compared to Era 1, waitlist mortality was higher in Era 2 (HR: 4.55, P<.001) and Era 3 (HR: 3.63, P<.001). However, in the most recent era, waitlist mortality significantly improved (compared to 2005-2007: 2008-2011: HR: 0.74, P=.05, 95% CI: 0.55-0.99; 2012-2015: HR: 0.53, P<.001, 95% CI: 0.38-0.75). Probability of receiving LT was also lower with latter time periods (compared to 2005-2007: 2008-2011: HR: 0.77, P<.001 95% CI: 0.68-0.86; 2012-2015: HR: 0.61, P<.001, 95% CI: 0.54-0.69). Although the number of HBV patients requiring LT remained stable, the proportion of HBV patients with HCC continues to rise. The decrease in waitlist mortality and lower likelihood of LT among HBV patients may reflect the effectiveness of antiviral therapies in delaying disease progression in the current era.
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Affiliation(s)
- K Young
- Department of Medicine, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - B Liu
- Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA, USA
| | - T Bhuket
- Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA, USA
| | - Z Younossi
- Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA, USA.,Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - S Saab
- Departments of Medicine and Surgery, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, CA, USA
| | - A Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
| | - R J Wong
- Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA, USA
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