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Leung RHM, Hui RWH, Mak LY, Mao X, Liu KSH, Wong DKH, Fung J, Seto WK, Yuen MF. ALT to qHBsAg ratio predicts long-term HBsAg seroclearance after entecavir cessation in Chinese patients with chronic hepatitis B. J Hepatol 2024:S0168-8278(24)00204-6. [PMID: 38527527 DOI: 10.1016/j.jhep.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 01/30/2024] [Accepted: 03/13/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND & AIMS Factors predicting HBsAg seroclearance after treatment cessation, irrespective of nucleos(t)ide analogue (NA) resumption, have important clinical implications. We evaluated predictors of long-term HBsAg seroclearance after entecavir cessation. METHODS This study followed-up Chinese patients with chronic hepatitis B from two previous studies of entecavir cessation. All patients were non-cirrhotic, HBeAg-negative, with undetectable HBV DNA (<20 IU/ml) at end-of-treatment (EOT). They were monitored closely for 48 weeks with regular HBV DNA, quantitative HBsAg (qHBsAg) and alanine aminotransferase (ALT) measurements. Entecavir was resumed at HBV DNA >2,000 IU/ml, irrespective of ALT levels. After the initial 48 weeks, patients were assessed every 6 months, regardless of entecavir resumption, to monitor for HBsAg seroclearance. RESULTS A total of 194 patients (63.4% male, mean age 49.9 years, on entecavir for a median of 47.2 months) were recruited; 94 (48.5%) and 158 (81.4%) patients had EOT qHBsAg <100 IU/ml and <1,000 IU/ml, respectively; 151 (77.8%) patients were eventually resumed on entecavir. After follow-up for a median of 70.7 (51.0-118.2) months, 28 (14.4%) patients had HBsAg seroclearance. qHBsAg levels at weeks 36 and 48 after EOT independently predicted HBsAg seroclearance (both p <0.01), whereas qHBsAg from EOT to week 24 only trended towards statistical significance. The ratio of ALT/qHBsAg at all time points from EOT to week 48 independently predicted HBsAg seroclearance (hazard ratios ranging from 1.003-1.028, all p <0.01) with excellent diagnostic performance (area under the receiver-operating characteristic curve 0.799-0.933, negative predictive value >90% at different time points), regardless of whether entecavir was resumed. CONCLUSIONS The ALT/qHBsAg ratio after entecavir cessation predicts HBsAg seroclearance, even in patients who were resumed on treatment. Its use may mitigate the risk of severe hepatitis flares in patients managed by observation without treatment resumption. IMPACT AND IMPLICATIONS Current predictors of HBsAg seroclearance after finite nucleos(t)ide analogue (NA) therapy have suboptimal predictive value. We demonstrated that the ALT/qHBsAg ratio may be able to reflect the balance between host control and virological activity. The ALT/qHBsAg ratio at different time points from end-of-treatment till week 48 independently and accurately predicted HBsAg seroclearance in patients who have stopped entecavir. The ALT/qHBsAg ratio may be utilized by clinicians for patient selection and retreatment decisions in finite NA therapy.
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Affiliation(s)
- Ryan Hin-Man Leung
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR
| | - Rex Wan-Hin Hui
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR
| | - Lung-Yi Mak
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR
| | - Xianhua Mao
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR
| | - Kevin Sze-Hang Liu
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR
| | - Danny Ka-Ho Wong
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR
| | - James Fung
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR; Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR.
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Nguyen-Hoang L, Chaemsaithong P, Cheng YKY, Feng Q, Fung J, Duan H, Chong MKC, Leung TY, Poon LC. Longitudinal evaluation of cervical length and shear wave elastography in women with spontaneous preterm birth. Ultrasound Obstet Gynecol 2024. [PMID: 38354177 DOI: 10.1002/uog.27614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 02/07/2024] [Accepted: 02/07/2024] [Indexed: 02/16/2024]
Abstract
OBJECTIVES To compare longitudinal changes in cervical length (CL) and mean cervical shear wave elastography (CSWE) scores between women with singleton and twin pregnancies who experience spontaneous preterm birth (sPTB) and those who have term births (TB). METHODS This was a prospective longitudinal study of 1264 unselected women with singleton (n=1143) and twin (n=121) pregnancy attending a dedicated research clinic for screening of sPTB at 4 timepoints during pregnancy including 11-15+6 (visit 1), 16-20+6 (visit 2), 21-24+6 (visit 3) and 28-32+6 (visit 4) weeks of gestation. At each visit, a transvaginal ultrasound scan was conducted to measure the CL and the CSWE scores from six regions of interest (ROI) (inner, middle, and external parts of anterior and posterior lips) in the cervix. The mean of CSWE scores from the six ROIs were calculated for data analysis. Log10 transformation was applied to make the data Gaussian prior to statistical analysis. A multilevel mixed-effects analysis was performed to compare CL and CSWE longitudinally between sPTB and TB groups. RESULTS A total of 57 (4.99%) singleton pregnancies and 33 (27.27%) twin pregnancies were complicated with sPTB. Women with sPTB had shorter CL across gestation when controlling for history of cervical surgery, number of fetuses, gestational age at cervical assessment (GA), and the interaction between GA and sPTB. CL in the sPTB group was significantly lower than that of the TB group at 21-24+6 weeks (p=0.039) and 28-32+6 weeks (p<0.001). Twin pregnancies had significantly longer CL throughout pregnancy, compared to singleton pregnancies (coefficient=0.01864, p<0.001). Furthermore, after adjusting for maternal age, weight, height, body mass index (BMI), and GA, CSWE scores in sPTB group were significantly lower in the sPTB group across gestation, compared to the TB group (1.28265 vs 1.32832; p=0.013). However, in the individual visit analysis, CSWE scores in the sPTB group were significantly lower than that of the TB group only at 11-15+6 weeks (p=0.013). There was no difference in CSWE scores between singleton and twin pregnancies throughout pregnancy (coefficient=-0.00128, p=0.937). CONCLUSION Women with sPTB have shorter CL and softer cervix across gestation when compared to those with TB. In the individual visit analysis, the reduction in CL in the sPTB group occurs from late second trimester onwards, while the reduction in cervical stiffness in the sPTB group is observed primarily in the first trimester. Additionally, our study has found that CL is significantly shorter in singleton pregnancies compared to twin pregnancies, while cervical stiffness does not differ between the two types of pregnancy. Our findings indicate that the cervix tends to undergo a softening process prior to shortening in the sPTB cases This article is protected by copyright. All rights reserved.
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Affiliation(s)
- L Nguyen-Hoang
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - P Chaemsaithong
- Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
| | - Y K Y Cheng
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Q Feng
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, China
| | - J Fung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - H Duan
- Department of Obstetrics and Gynecology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - M K C Chong
- The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR
| | - T Y Leung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - L C Poon
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
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Lim WH, Ng CH, Tan DJH, Xiao J, Fu CE, Ong C, Koh B, Chung C, Tan SN, Wong ZY, Mitchell K, Joseph AA, Tseng M, Syn N, Mak LY, Fung J, Huang DQ, Muthiah M, Tan EXX, Siddiqui MS. Donor Diabetes and Steatosis Affects Recipient Survival Following Liver Transplantation Based on Etiology of Liver Cirrhosis. Transplantation 2024; 108:473-482. [PMID: 37439778 DOI: 10.1097/tp.0000000000004718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
BACKGROUND Liver transplantation (LT) offers patients with decompensated cirrhosis the best chance at long-term survival. With the rising prevalence of diabetes, further clarity is needed on the impact of receiving a liver allograft from a donor with diabetes on post-LT outcomes. This study aims to evaluate the impact of donor diabetes on clinical outcomes after LT. METHODS This is a retrospective analysis of the United Network for Organ Sharing registry data of LT recipients from January 1, 2000, to December 31, 2021. Outcomes analysis was performed using Cox proportional model for all-cause mortality and graft failure. Confounding was reduced by coarsened exact matching causal inference analysis. RESULTS Of 66 960 donors identified, 7178 (10.7%) had diabetes. Trend analysis revealed a longitudinal increase in the prevalence of donor diabetes ( P < 0.001). Importantly, donor diabetes was associated with increased all-cause mortality (hazard ratio [HR]: 1.13; 95% confidence interval [CI], 1.07-1.19; P < 0.001) and graft failure (HR: 1.16; 95% CI, 1.11-1.22; P < 0.001). Receiving donor organ with diabetes reduced graft survival in patients who received LT for nonalcoholic steatohepatitis cirrhosis (HR: 1.26; 95% CI, 1.13-1.41; P < 0.001) but not other etiologies of cirrhosis. CONCLUSIONS Donor diabetes was associated with worse outcomes post-LT, particularly in patients receiving LT for nonalcoholic steatohepatitis cirrhosis. Future studies are needed to better understand the mechanism underlying this association to develop better risk stratification and clinical practice to improve the outcomes of the transplanted patients.
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Affiliation(s)
- Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Cheng Han Ng
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jieling Xiao
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Clarissa Elysia Fu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Christen Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Benjamin Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Charlotte Chung
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Shi Ni Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Zhen Yu Wong
- School of Medicine, International Medical University, Kuala Lumpur, Malaysia
| | - Kimberly Mitchell
- Division of Transplant Surgery, Virginia Commonwealth University, Richmond, VA
| | | | - Michael Tseng
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lung Yi Mak
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - James Fung
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Daniel Q Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Mark Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Eunice X X Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Mohammad Shadab Siddiqui
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
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Razavi-Shearer D, Child H, Razavi-Shearer K, Voeller A, Razavi H, Buti M, Tacke F, Terrault N, Zeuzem S, Abbas Z, Aghemo A, Akarca U, Al Masri N, Alalwan A, Blomé MA, Jerkeman A, Aleman S, Kamal H, Alghamdi A, Alghamdi M, Alghamdi S, Al-Hamoudi W, Ali E, Aljumah A, Altraif I, Amarsanaa J, Asselah T, Baatarkhuu O, Babameto A, Ben-Ari Z, Berg T, Biondi M, Braga W, Brandão-Mello C, Brown R, Brunetto M, Cabezas J, Cardoso M, Martins A, Chan H, Cheinquer H, Chen CJ, Yang HI, Chen PJ, Chien CH, Chuang WL, Garza LC, Coco B, Coffin C, Coppola N, Cornberg M, Craxi A, Crespo J, Cuko L, De Ledinghen V, Duberg AS, Etzion O, Ferraz M, Ferreira P, Forns X, Foster G, Fung J, Gaeta G, García-Samaniego J, Genov J, Gheorghe L, Gholam P, Gish R, Glenn J, Hamid S, Hercun J, Hsu YC, Hu CC, Huang JF, Idilman R, Jafri W, Janjua N, Jelev D, Jia J, Kåberg M, Kaita K, Kao JH, Khan A, Kim D, Kondili L, Lagging M, Lampertico P, Lázaro P, Lazarus J, Lee MH, Yang HI, Lim YS, Lobato C, Macedo G, Marinho R, Marotta P, Mendes-Correa M, Méndez-Sánchez N, Navas MC, Ning Q, Örmeci N, Orrego M, Osiowy C, Pan C, Pessoa M, Piracha Z, Pop C, Qureshi H, Raimondo G, Ramji A, Ribeiro S, Ríos-Hincapié C, Rodríguez M, Rosenberg W, Roulot D, Ryder S, Saeed U, Safadi R, Shouval D, Sanai F, Sanchez-Avila J, Santantonio T, Sarrazin C, Seto WK, Seto WK, Simonova M, Tanaka J, Tergast T, Tsendsuren O, Valente C, Villalobos-Salcedo J, Waheed Y, Wong G, Wong V, Yip T, Wong V, Wu JC, Yang HI, Yu ML, Yuen MF, Yurdaydin C, Zuckerman E. Adjusted estimate of the prevalence of hepatitis delta virus in 25 countries and territories. J Hepatol 2024; 80:232-242. [PMID: 38030035 DOI: 10.1016/j.jhep.2023.10.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/13/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND & AIMS Hepatitis delta virus (HDV) is a satellite RNA virus that requires the hepatitis B virus (HBV) for assembly and propagation. Individuals infected with HDV progress to advanced liver disease faster than HBV-monoinfected individuals. Recent studies have estimated the global prevalence of anti-HDV antibodies among the HBV-infected population to be 5-15%. This study aimed to better understand HDV prevalence at the population level in 25 countries/territories. METHODS We conducted a literature review to determine the prevalence of anti-HDV and HDV RNA in hepatitis B surface antigen (HBsAg)-positive individuals in 25 countries/territories. Virtual meetings were held with experts from each setting to discuss the findings and collect unpublished data. Data were weighted for patient segments and regional heterogeneity to estimate the prevalence in the HBV-infected population. The findings were then combined with The Polaris Observatory HBV data to estimate the anti-HDV and HDV RNA prevalence in each country/territory at the population level. RESULTS After adjusting for geographical distribution, disease stage and special populations, the anti-HDV prevalence among the HBsAg+ population changed from the literature estimate in 19 countries. The highest anti-HDV prevalence was 60.1% in Mongolia. Once adjusted for the size of the HBsAg+ population and HDV RNA positivity rate, China had the highest absolute number of HDV RNA+ cases. CONCLUSIONS We found substantially lower HDV prevalence than previously reported, as prior meta-analyses primarily focused on studies conducted in groups/regions that have a higher probability of HBV infection: tertiary care centers, specific risk groups or geographical regions. There is large uncertainty in HDV prevalence estimates. The implementation of reflex testing would improve estimates, while also allowing earlier linkage to care for HDV RNA+ individuals. The logistical and economic burden of reflex testing on the health system would be limited, as only HBsAg+ cases would be screened. IMPACT AND IMPLICATIONS There is a great deal of uncertainty surrounding the prevalence of hepatitis delta virus among people living with hepatitis B virus at the population level. In this study, we aimed to better understand the burden in 25 countries and territories, to refine techniques that can be used in future analyses. We found a lower prevalence in the majority of places studied than had been previously reported. These data can help inform policy makers on the need to screen people living with hepatitis B virus to find those coinfected with hepatitis delta virus and at high risk of progression, while also highlighting the pitfalls that other researchers have often fallen into.
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Xu W, Liu G, Varghese C, Wells C, Smith N, Windsor J, Gaborit L, Goh S, Basam A, Elhadi M, Soh RT, Saeed U, Abdulwahed E, Farrell M, Wright D, Martin J, Pockney P, Xu W, Basam A, Goh S, Li J, Shah J, Waraich A, Gaborit L, Pathak U, Hilder A, Elhadi M, Jabur A, Kalyanasundaram K, Ohis C, Ong CF, Park M, Siribaddana V, Raubenheimer K, Vu J, Wells C, Liu G, Ferguson L, Xu W, Varghese C, Pockney P, Atherton K, Dawson A, Martin J, Banerjee A, Dudi-Venkata N, Lightfoot N, Ludbrook I, Peters L, Sara R, Watson D, Wright D, Adeyeye A, Alvarez-Lozada LA, Atici SD, Buhavac M, Calini G, Elhadi M, Ioannidis O, Tepe MD, Nath U, Uzair A, Yang W, Zaidi F, Singh S, Abdullah B, Palacios DSG, Ragab A, Ahmed A, Raubenheimer K, Daudu D, Goh S, Benyani SV, Karthikeyan N, Mansour LT, Seow W, Tasi Z, Jabur A, Pathak U, Park M, Abdelmelek DE, Boussahel IFZ, Kaabache O, Lemdaoui N, Nebbar O, Rais M, Abdoun M, Kouicem AT, Bouaoud S, Bouchenak K, Saada H, Ouyahia A, Messai W, Choong ZS, Ting C, Larkin M, Fong PJ, Soh I, Grandi AD, Iftikhar H, Sinha A, Kapoor D, Chlebicka T, Singer D, Goddard K, Matthews L, Lin R, Chambers J, Chan J, Macnab B, Barker J, Mckenzie M, Ferguson N, Juwaheer G, Muralidharan V, Gill S, Sung N, Patel R, Walters C, Nguyen K, Liu D, Cabalag C, Lee J, Leow SHA, Ng SL, Ashraf H, Mulder F, Loo J, Proud D, Wong S, Zhou Y, Soh QR, Chye D, Stevens S, Tang P, Kritharides S, Dong J, Morice O, Huang D, Hardidge A, Amarasekara M, Kink A, Bolton D, Rawal A, Singh J, Heard M, Hassan Y, Naqeeb A, Cobden A, Prinsloo D, Quadros D, Gunn E, Kim HJ, Ekwebelam J, Shanahan J, Alkazali M, Hoosenally M, Nara N, Nguyen P, Barker S, Hilder A, Hui A, Karmakar A, Wang B, Goonawardena J, Cheung KT, Chan N, Natarajan R, Cade R, Jin R, Sengupta S, Snider R, Morisetty H, Weeda L, Sun P, Chilaka L, Cover J, Gunasekara ADSA, Senthilrajan R, Alwahaib A, Limmer A, Zamanbandhon B, Jaffry K, Shen Y, Chua A, Syed S, Saha S, Glynatsis J, Aitchison L, Lagana B, Crossman M, Watson D, Dawson A, Fong B, Harrison E, Horsburgh E, Glynatsis J, Khoo M, Mishra K, Hewton L, Mesecke A, Tu H, Tun T, Wong J, Ong E, Law TN, Landy A, Leano A, Li A, Soni A, Dowdle B, Pilgrim C, Abeysirigunawardana D, Jeyarajan DR, Patel D, Mckinnon K, Gould M, Gilmore P, Geng R, Loughnan R, Norton-Smith S, Nyame S, Tan S, Yoon SW, Wang Y, Zhang Y, Wang Z, Mare H, Withanage I, Khattar M, Toft A, Sivasuthan G, Zhao H, Addley J, O'brien L, Raza M, Bindra R, Sharma S, Cornwell C, Patil A, Cheung A, Lown A, Dawson A, Blassey A, Ochigbo B, Cheng F, Fatima A, Zhang E, Kocatekin H, Roth C, Brewster D, Kwok K, Chen P, Laura S, Tynan D, Latif E, Lun E, Honore E, Ziergiebel F, Blake J, Chandiok K, Bird K, Ngothanh L, Lee M, El-Masry M, Hamer P, Palaniappan RR, Mcgee R, Huang S, Zhang S, Hariharan S, Silva YD, Lee C, Fotheringham P, Incoll I, Cordingley T, Cheng F, Brown M, Kang L, Wijayaratne R, Moore P, Qian G, Elgindy Y, Carnuccio E, Rae H, Shehata M, Liu M, Lockwood B, Bockxmeer JV, Alsoudani A, Swan D, Hsieh J, Orchard-Hall F, Tay KYJ, Mehra R, Gebeh A, Bailey A, Brown G, Colaco A, Gopal H, Boyley J, Changati V, Fletcher J, Khandelwal T, House C, O'neil C, Jaarsma E, Ly V, Balogh Z, Shui A, Sathasivam V, Legge-Wilkinson H, Wong KH, Chen A, Tran A, Rehfisch P, Wang G, Nguyen J, Peker J, Gallert K, Komesaroff M, Namburi M, Goldfinch E, Muchabaiwa R, Jangam A, Taylor I, Nusem I, Park JH(D, Gundara J, Heigan R, Tran T, Mackay T, Butterworth Y, Sadauskas T, Tung M, Ellepola H, Gan C, Fong H, Das A, Naicker L, Hauptman S, Kamath A, Yew A, Parange A, Kim K, Kharwadkar S, Gamage T, Vance L, Seldon A, Ghaly M, Phan V, Chauhan K, Bassam A, Vollenhoven B, Jaffry K, Mandhan K, Sritharan M, Sakthivel M, Evans N, Robinson S, Sivakumar S, Marrison L, Jollow D, Joshi K, Tao S, Shrestha P, Nukala SK, Hodgson R, Crotty A, Esho A, Harris A, Surkitt A, Bland L, Mcleod B, Yin C, Keng C, Greenwood E, Yuan G, Haege E, Wu H, Xiao H, Pozzi I, Fu J, Ross JS, Gentle J, Gan K, Chang K, Sun K, Singh M, Xie M, Mccabe N, Slavec M, Clarnette N, Niknami B, Zou P, Flintoft S, Jayatilleke S, Sok R, Tan S, Wadhwa S, Swansson W, Abulafia D, Blundell J, Sweetapple A, Solar CD, Martin C, Bell D, Fernando I, Chang J, Vanzuylekom K, Zuylekom KV, Zuylekom KV, Hobbs K, Liang R, Jabur A, Tarmidi J, Ugool M, Beatson N, Bowman S, Moin S, Tan WPJ, Chidambaram S, Gan SW, Wang P, Naicker L, Kim K, Wang NQ, Kwan YX, Patil C, Joshi D, Kamath A, Hanan A, Sheriff A, Duffield J, Naiker L, Smitham P, Neo EL, Chua M, Prasad S, Nagaratnam A, Sammour T, Lin Y, Lee C, Hopping E, Jangra M, Das A, Lin K, Bunjo Z, Raubenheimer K, Yunos MHM, Yeung KL, Phu R, Betts A, Just B, Gera S, Leeson H, Jamieson J, Wang K, Luu E, Innes M, Vu J, Hong J, Dzator S, Flame A, Jiang V, Kwok J, Lawrence A, Meads K, Pearce L, Sarangadasa P, Shaw H, Yu V, Crostella ;E, Wong J, Bobba S, Muller M, Hau YCH, Wilson T, Markovic A, Green J, Forbes C, Burrows E, Hou L, O'sullivan C, Foo J, Greig H, Collins AJ, Chandler C, Heaney E, Gross H, Morgan M, Loder R, Rajesh K, Ananthapadmanabhan S, Razmi A, Vong C, Pothukuchi P, Theophilus M, Sriranjan R, Kaur S, Kanczuk M, Groot JD, Corrigan A, Li D, Badri D, Ciranni D, Needi ET, Clanfield M, Copertino N, Rumble W, Vanguardia MK, Lew C, Dennaoui R, Shah J, Kong J, Koh I, Zeng R, Baziotis-Kalfas K, Denby H, Li A, Tran W, Singh A, Lin O, Chau M, Donaldson O, Min C(S, Ballah S, Tsui SCT, Yong N, Standish L, Tan S, Fujihara A, Davies L, Odisho R, Ravi A, Collins J, Chandra P, Abdelmeguid R, Singh G, Feierdaiweisi X, Seneviratne D, Srivastava S, Yao M, Teng C, Chowdhury N, Vidanagama S, Lin C, Sampatha-Waduge T, Wang E, Yodkitydomying C, Koh I, Silverii J, Lam A, Zeng R, Solanki K, Franks A, Edwards L, Atilhan R, Nandurkar R, Wells O, Vanguardia K, King D, Edwards E, Edwards L, Tran Q, Chau M, Min S, Rauf A, Fu Y, Haximolla H, Shang M, Segaran S, Wang S, Sivakumar G, Sandhu JK, Mishra N, Hauptman S, Chua A, Chene D, Maddern G, Shaw H, Wang Q, Pang S, Lu C, Fung J, Cyr K, Lu K, How MZ, Hu N, Anderson P, Jakanovski P, Youssef A, Tang H, Keenan R, Chan A, Canny M, Tahir F, Egerton J, Yeung J, Chan J, Tiffany L, Bei M, Raj M, Williams P, Nagpal S, Outhred T, Krawitz R, Choi CCM, Younus K, Giurgius M, Kirk R, Pegorer AG, Tang-Ieam P, Ward J, Wijetunga A, Zhang C, Nahm C, Wang C, Golja D, Jenkins G, Qian H, Luong J, Nguyen K, Suttor S, Lai S, Ma V, Chen Y, Yu HH, Lee A, Barbaro A, Mcguinness C, Maddern G, Young S, Lim YF, Trotta G, Chao P, Ding G, Fang C, Lu A, Wagaarachchi P, Cornwell C, Gojnich A, Stewart P, Dong I, Wong K, Burruso L, Hogan L, Mcorist N, Singh R, Jeyamohan R, Hou Z, Lai W, Taylor E, Palacios DSG, Pantoja MAN, Nanez DMB, Hernandez GOP, Jimenez Ramirez LJ, Mohamed M, El-Taher AK, Elewa A, Soliman MA, Diab M, Ali R, Ahmed A, Galal A, Elkhodary A, Alaa A, Faisal A, Badawy A, Eldomiaty D, Sayed MA, Rasslan E, Ramadan M, Fares GE, Altabbaa H, Emad H, Alboridy M, Mongy M, Albarhomy O, Selim O, Rafaei R, Atta R, Altaweel A, Sherif Y, Elghoul Y, Tarek Y, Sabry AA, Moustafa A, AbouHiekal O, Shaqran OA, Haggag Z, Abbas AM, Temerik AR, Atef D, Mahmoud A, Saad MM, Ragab M, Mahmoud AO, Hussien A, Abdelbaky M, Muhammad I, Morad A, Ali A, Hussien A, Shipa A, Aboulfotouh A, Abdelaal AM, Hashem AM, Youssef AA, Morsi A, Ebrahim A, Sayed AM, Kamel AM, Elmaghrabey A, Elgharib AM, Abdelrahman A, Ali A, Abdelnaeam S, Emam A, el-mola AG, Shaban A, Shaltout AS, Nabil B, Barsoum F, Mostafa E, Abdelbaset D, Salah D, Othman D, Othman S, Khairallah NS, Hassan SA, Morsi S, Azer A, Abdelsamed EA, Ahmed R, Ibrahim I, AbdElbaset E, Hamoda E, Monib F, Harb F, Maher H, Ahmed H, Mohammed H, Hana K, Ayoub K, Henes K, Shamshoon K, Soliman K, Hassanein M, Abdelhamid MM, Mahdy M, Khalil M, Ali M, Khalifa M, Amary M, Suliman ME, Abdallah MM, Nasr MSA, Elia M, Adly M, Roshdy M, Ramadan MF, Shahat MA, Abdelnasser MK, Zaed M, Al-Quossi M, Zarzour MA, Hares MM, Abdelfatah MA, Abughanima M, Abdeljaber M, Saber M, Amin MK, Abbas M, Haroon O, Khalil O, Talaat O, Elnagar R, Soliman R, Aboelela R, Salah S, Abdelgawad S, Mohammed T, Hussien TA, Sobhy G, Sayed Y, Silem YOR, Dawood A, Hemaida T, Ahmed R, Kamaleldin A, Zakaria A, Salah M, Salem E, Rashed OFAA, Halawa M, Elfeki H, Mosaad A, Shaaban A, Abdelsalam H, Sakr A, Sanad A, Elsawy A, Maged BM, Hegazy D, Abdelmaksoud M, Laymon M, Taman M, Moawad ER, AboElfarh HE, Elkenawi K, Osama M, Sadek M, Elghazy MA, Attia M, Nader M, Shalaby M, Attiya O, Gaarour OS, Zaghloul A, Mikhail P, Badr K, Soltan H, Donia M, Gaafar M, Abdelwahab K, Sallam A, Eid A, Yousri M, Hamdy O, Al-Touny A, Alshawadfy A, Hamdy A, Ellilly A, Mahdy A, El-Sakka A, Hendawy H, Salah A, Raslan B, Teema E, Albayadi E, Nasser E, Mohamed H, Mahmoud M, Elsaied M, Taha O, Dahshan S, Al-Touny S, Karrar A, Khairy A, Farag A, Deafallah A, Ads AM, Alomar R, AbuShawareb I, Saeed A, Mashaal A, Ads AM, Ghanem S, Elghamry A, Nada EA, Noureldin YA, Fouda MF, Shaheen N, Allam S, Mazrou I, Shehab AF, Kussaili W, Korkolis D, Fradelos E, Sarafi A, Machairas N, Giannakopoulos KS, Stavratis F, Korovesis G, Tsourouflis G, Keramida MD, Kydonakis N, Kykalos S, Syllaios A, Dorovinis P, Schizas D, Ioannidis O, Malliora A, Anestiadou E, Zapsalis K, Kontidis F, Loutzidou L, Ouzounidis N, Bitsianis S, Symeonidis S, Skalidou S, Ioannidis O, Valaroutsou OM, Dagklis T, Arvanitaki A, Mamopoulos A, Athanasiadis A, Kopatsaris S, Kalogiannidis I, Tsakiridis I, Kapetanios G, Papanikolaou E, Tsakiridis N, Zachomitros F, Larentzakis A, Gyftopoulos A, Albanopoulos K, Champipis A, Yiannakopoulos C, Vrakopoulou GZ, Saliaris K, Lathouras K, Skoufias S, Doulami G, Bareka M, Arnaoutoglou E, Angelis F, Angeslis F, Hantes M, Ntalouka M, Al-Juaifari MA, Alwash M, Maala R, Zwain YA, Saleh SA, Khorsheed M, Pesce A, Feo CV, Bernabei M, Petrarulo F, Fabbri N, Labriola R, Barbara SJ, Bosi S, Romano A, Canavese A, Catalioto C, Isopi C, Larotonda C, Dajti G, Rottoli M, Russo IS, Cardelli S, Castagnini F, Traina F, Guizzardi G, Giuzzardi G, Gorgone M, Maestri M, Cianci P, Conversano I, Restini E, Gattulli D, Grillea G, Varesano M, Calini G, Andriani A, Gattesco D, Terrosu G, Zambon M, Cerinic PM, Moretti L, Muschitiello D, Polo S, Bresadola V, Wardeh SA, Al-Baw M, Alhaleeq S, Al-Issawi S, Alsaify E, Banihani F, Massadeh N, Massadeh N, Al-issawi D, Elyan B, Al-Shami Q, Alomari Y, Khamees A, Al-Tahayneh SA, Alsheik A, Sawaftah K, Sarhan O, Alkhatib AA, Alzghoul B, Saleh A, Yaghmour J, Shahin M, Maali M, Alatefi D, Al-Smirat H, Hezam A, Alathameen N, Kaddah AA, Al Hammoud A, Ayasrah S, Abuuqteish H, Al-Mwajeh T, Makableh R, Bataineh S, Shabaneh A, Alnatsheh W, Aldeges M, Hamad H, Shehahda S, Khassawneh D, Alzyoud O, Alrosan R, Awad H, Khaldoon T, Shannaq R, hamoud MA, fadalah BA, Al-Hazaimeh M, Khraise W, Alnajjar L, Alnajjar M, Al-Omary S, Ababneh A, Albashaireh A, Khadrawi M, Aljamal M, Athamneh T, Muqbel RA, Al-jammal M, Masarrat A, Al-zawaydeh A, Taha I, Qattawi T, Smadi R, Alhaleem A, Alboon M, Hazaymeh O, Karasneh L, Al-Haek S, Almahroush M, Alfrijat T, Elporgay A, Shanag H, Agilla H, Alameen H, Bensalem M, Altair M, Ghemmied M, Alarabi R, Alhudhairy S, Gweder R, Alzarroug A, Alabed E, Elreaid F, Elkharaz OA, Elreaid FF, Albatni SS, Elmehdawi H, Gahwagi M, Mohamed A, Alfrjani T, Khafifi K, Rasheed A, Akwaisah A, Bushaala H, Elfadli M, Moftah M, Algabbasi S, Esaiti S, Elfallah S, Alharam A, Alariby F, Isweesi M, Eldarat TA, Dabas AA, Alkaseek A, Abodina AM, Alqaarh A, Bakeer HB, Alhaddad HS, Aboudlal H, Alsaih S, Abubaker N, Abdelrahim N, Alzarga A, Omar B, Faris F, Alhadad Q, Abufanas A, Badi H, Benismai I, Obeid H, Abdalei A, Abdulrahman A, Swalem A, Alzarouq E, Safar A, Shagroun E, Hashem B, Elrishi F, Abdulali F, Ahmed H, Eltaib I, Elzoubia J, Albarki A, Mugassabi HE, Abushaala F, Abuzaho A, Juha N, Egzait R, Shetwan S, Lemhaishi A, Matoug F, Abdulwahed E, Askar A, Ashur AB, Bezweek A, Altughar B, Emhimmed D, Elferis D, Elgherwi L, Soula E, Gidiem D, Grada M, Derwish K, Alameen M, Algatanesh N, Elkheshebi A, Ghmagh R, Barka S, Ahmeed S, Aljamal S, Alragig Z, Addalla M, Atia A, Kharim A, Mahmoud F, Binnawara M, Alshareea E, Alsori M, Alshawesh A, Alrifae GMH, Ashour A, Abozid A, Alflite AOS, Mohamed A, Arebi J, Alagelli F, Gineeb HY, Ghmagh R, Omar RMB, Alaqoubi R, Mohammed S, Bensalem SH, Elgadi T, Sami W, Bariun Y, Alhashimi AMA, Abdulla DA, Rhuma H, Enaami H, Alboueishi AA, Alkchr HBHMAA, Albakosh BA, Hasan NB, Alsari N, Aldreawi M, Abushanab K, Yahya R, Samalavicius N, Eismontas V, Jurgaitis J, Aliosin O, Nutautiene V, Zakaria AD, Pillai AKSK, Vadioaloo DK, Daud MAM, Soh JY, Zakaria MZ, Rusli SM, Ashar NAK, Ahmad ZA, Ramlee AA, Alsagoff SNASAL, Sofian AA, Jamil MBHM, Abdullah B, Noorman MF, Abidin MFZ, Isahak MI, Adnan SNN, Noor ZHM, Alvarez-Lozada LA, Garza AQ, Leal AA, Reyes BAF, Guerra EVO, Garza FJA, Mey HEA, Isais JAR, Zertuche JTG, García PLG, Sánchez LAH, Mercado MPF, Sierra OAV, Morales PER, Fuentes SO, Martínez VMP, Guerra-Juárez YA, Flores-González AK, Singh S, Hadi A, Woodbridge C, Thornton-Hume D, Forsythe J, Dharmaratne I, Pai V, Windsor J, Zargar K, Waldin L, Winthrop L, Alvarez M, Huang M, Kumove M, Simonetti M, Chand N, Goldsmith O, Guo O, Monk P, Zhou K, Penneru SH, Prasad S, Ren S, Hill T, Mistry V, Sun S, Pereira A, Mclaughlin S, Stokes A, Sathiyaseelan A, Rossaak J, Lim J, Brooke K, Quinlan L, Pottier M, Podder N, Jinu P, Ramphal S, Vermeulen W, Jeffery F, Busaidi ISA, Divinagracia J, Ju W, Liu Y, Glyn T, Thompson N, Graziadei V, Canton J, Furey J, Choi H, Coomber G, Divekar T, English T, Gernhoefer E, Healy T, Chou J, Parajuli D, Reed C, Studd R, Lin A, Wells C, Xu C, Hadi A, Maccormick A, Park H, Rathnayake A, Williams B, Chan A, Smith C, Casciola F, Bhikha J, Luo J, Yi K, Singhal M, George R, Luo R, Frost T, Hakak F, George A, Carlos A, Ho A, Mcrae C, Lescheid J, Soek J, Pham A, Clair SS, Yee SA, Lim J, Wu CY, Kim T, Chua AQ, Harmston C, Boyes H, Cook H, Struthers J, Radovanovich J, Quek N, Fearnley-Fitzgerald C, Wright D, Ghandi K, Matheson N, McGuinness MJ, Chen B, Douglas RI, Richter K, Soliman NB, Bolam SM, Vimalan V, Currie W, Cuthbert M, Ross P, Nicholson A, Garton B, Agnew E, Conlon N, Waaka N, Kejriwal R, Nguyen S, Leung E, Ratnayake M, Smith Q, Joseph N, Yue B, Fraser C, Lam C, Figgitt E, Liu G, Tan K, You HS, Zheng H, Luo J, Sharp J, Khanna K, Simiona L, Luo M, Ratnayake M, Wong P, Luu R, Paul R, Nair S, Asadyari-Lupo S, Hung W, Ying G, Ho J, Wu A, Walsh E, Lee J, Liu J, Yao S, Nosseir O, Dang J, Young S, Zyul'korneeva S, Boyd T, Ho J, Wu A, Yao S, Kirfi AM, Ningi AB, Garba MA, Salihu MB, Ukwuoma OE, Ibrahim A, Sajo IM, Aminu MB, Usman LH, Lanre ON, Shuaibu IS, Yusuf S, Ismail T, Umar GI, Adeyeye A, Afeikhena E, Nnaji FC, Agu JO, Maxwell TP, Motajo OO, Ifoto O, Okon SAI, Makama JG, Mohammed-Durosinlorun AA, Aminu B, Onwuhafua PI, Mohammed C, Abdulrasheed L, Adze JA, Suleiman KR, Airede LR, Taingson MC, Bature SB, Kache SA, Ogbonna UO, Fufore MB, Iya A, Ajulo AA, Mahmud A, Yahya BS, Onimisi-Yusuf F, Isaac H, Jawa T, Joseph F, Kala B, Bakari MA, Ngwan DW, umar A, Filikus AL, Wycliff D, Okunlola A, Abiola O, Adeniyi A, Adeyemo O, Awoyinka B, Babalola O, Bakare A, Buari T, Okunlola C, Adeleye G, Salawu A, Abiyere H, Ogidi A, Orewole T, Abdullahi HI, Akaba G, Achem A, Bassey AO, Ayogu E, Sulaiman B, Isah DA, Akpamgbo CN, Asudo F, Adewole N, Oguche O, Ejembi P, Sani SA, Andrew PC, Isah A, Eniola B, Songden Z, Agida T, Atim T, Mohammed TO, Raji HO, Ibiyemi F, Salawu H, Fasiku O, Solagbade RS, Shiru MM, Ibraheem GH, Oruade J, Ezeoke G, Chawla T, Aziz AB, Marium A, Waheed AA, Aamir FB, Qureshi F, Ather MH, Ali IFM, Tahir I, Akbar MG, Ukrani RD, Raja S, Virani SS, Noordin S, Rehman SU, Golani S, Aamir SR, Mufarrih SM, Waqar U, Taufiq M, Ammar AS, Ejaz A, Sarwar A, Khalid AU, Khattak S, Imran A, Khalid OB, Kaleem U, Muneer U, Kashaf Y, Zafar F, Zaheer A, Ali M, Shafaat A, Qazi A, Tariq AI, Aslam MN, Ali S, Atiq T, Wasim T, Babar D, Zain A, Ibtisam M, Ahmed U, Aqeel STB, Muhib M, Abbal MA, Khan NA, Javed I, Alkaraja L, Amro D, Manasrah G, Hammouri I, Hilail IA, Zalloum J, Alamlih L, Nasereddin M, Rajabi M, Shalalfeh S, Natsheh Z, Elessi K, Jayyab MA, Astal M, Al-Dahdouh M, Salameh AE, Ayyad A, Dawod N, Alsaid H, Matar I, Hassan M, Bakeer M, Malasah M, Abuhashem S, Salem M, Lunca S, Dimofte MG, Morarasu S, Musina AM, Roata CE, Velenciuc N, Butyrskii A, Bozhko M, Ametov A, Chowdhury S, Bagazi D, Domenech J, Rosello-Añon A, Monis A, Chiappe C, Cuneo B, Clemente-Navarro P, Febre J, Sanz-Romera J, Lopez-Vega M, Miranda I, Valverde-Vazquez R, Garcia S, Sanguesa MJ, Balciscueta Z, Ruiz E, Marco E, Talavera E, Farre J, Bacariza L, Duart M, Ureña V, Carre X, Hamid HKS, Abd-Albain MA, Galal-Eldin S, Sarih M, Adam E, Ismail S, Azhari M, Hassan T, Salaheldein M, Abdalla Z, Ahmed W, Alhassan M, Mohamed A, Suliman HMA, Eltayeb MOM, Ahmed RAA, Babekir EMA, Khairy MAT, Mukhtar MMA, Ali RAH, Al-Shambaty YBA, Yousif FI, Mohammed HMH, Osher L, Osher L, Abdelbast M, Yassin M, Moawia N, Abdalsadeg R, Husein A, Elhassan B, Abdelbagi AY, Adam MA, Ali EM, Mohammed IAB, Mohamed M, Abdulaziz M, Akasha M, Hassan M, Hilal N, Mohamed NAA, Abubaker N, Mohammed O, Mohamed S, Osman W, Mustafa F, Salih AA, Ali D, Almakki DMA, Mohamed HE, Elmubark A, Hassan M, Alnour A, Elaagib A, Abdelrahman A, Abdelkhalig M, Eldaim KN, Babiker A, Ahmed E, Ali M, Hussain E, Wedatalla M, Ahmed A, Hamza AA, Mohammed M, Osman O, Ibrahim R, Ahmed R, Ahmed R, Yasir R, Awadallah S, Mohmmed S, Hassan S, Shaban W, Hussein A, Rafea R, Abdalla A, Ahmed A, Mohamed K, Mohammed M, Altahir M, Adam M, Mohamed O, Abdullah W, Fadlalmola H, Abdalla AY, Omer AA, Mustafa AA, Elhadi REH, Banaga EEA, Osman F, Abdalla MGA, Taha HAM, Abdalmahmoud NE, Nafie RH, Jamal S, Ahmed S, Ali RA, Aladna A, Aljoumaa A, Nawfal H, Jamali S, Khouja F, Niazi A, Al Rawashdeh T, Kechiche N, Gara M, Nasr M, Baccar M, Benamor O, Chakroun S, Sanli AN, Yildiz A, Demirkiran MA, Atadag YB, Tandogan YI, Ozkan E, Ozer Y, Ozkan E, Oncel MM, Kalkan S, Gover T, Manoglu B, Oksak I, Kurt I, Rifaioglu K, Sokmen S, Bisgin T, Yildirim Y, Keskin AY, Dogan T, Sahin Bİ, Aydin C, Benek DE, Tiras HN, Arslangilay M, Aslangilay M, Yaytokgil M, Capar MA, Yazgan Y, Bektas S, Alagoz AC, Dagsali AE, Izgis A, Uzel K, Soytas M, Cakir N, Askin AE, Azboy I, Sabuncu K, Aslan M, Sahin M, Oncel M, Okkabaz N, Sivrikaya RK, Saylar A, Saylar A, Yasar M, Erginoz E, Bozkir HO, Zengin K, Ozcelik MF, Uludag SS, Ozdemir Z, Sibic O, Telci H, Bozkurt MA, Kara Y, Tepe MD, Gündoğdu A, Akın B, Pehlivan D, Guner A, Baysallar D, Yıldız B, Cepe H, Reis ME, Yuzgec AN, Kıralı N, Kodalak TA, Ulusahin M, Selim K, Kale A, Gecici ME, Ozbilen M, Düzyol Z, Gemici A, Korkmaz E, Şen E, Taşcı ME, Camkıran E, Elieyioğlu G, Kayabaş İ, Uprak TK, Aral C, Saraçoğlu A, Uğurlu MÜ, Baltacı ZH, Akkaya EN, Fergar C, Tabak EZ, Kocyigit GZ, Kayilioglu I, Polat S, Çolak E, Kara ME, Candan M, Uyanık MS, Sarı AC, Ulkucu A, Certel AT, Dindar A, Durdu B, Bayram C, Kaya E, Akdere H, Cakcak IE, Yavuz I, Omur M, Ajredini M, Aydoğdu EO, Şenödeyici E, Koksoy UC, Kazbek BK, Korkmaz DS, Yavuz D, Yilmaz H, Cetınkaya ZS, Durmus E, Tuzuner F, Hokelekli F, Mutlu M, Akbuz SO, Kus ZC, Kus ZC, Farrell M, Craig-Lucas A, Painter M, Titan A, Narayan A, Fariyike B, Knowlton L, Yue T, Benham E, Nimeri A, Werenski H, Kaiser N, Reinke C. Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries. Br J Surg 2024; 111:znad421. [PMID: 38207169 PMCID: PMC10783642 DOI: 10.1093/bjs/znad421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/29/2023] [Accepted: 12/05/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures. METHODS This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge. RESULTS The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (β coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not. CONCLUSION Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely.
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Razavi-Shearer D, Gamkrelidze I, Pan C, Jia J, Berg T, Gray R, Lim YS, Chen CJ, Ocama P, Desalegn H, Abbas Z, Abdallah A, Aghemo A, Ahmadbekova S, Ahn SH, Aho I, Akarca U, Al Masri N, Alalwan A, Alavian S, Al-Busafi S, Aleman S, Alfaleh F, Alghamdi A, Al-Hamoudi W, Aljumah A, Al-Naamani K, Al-Rifai A, Alserkal Y, Altraif I, Amarsanaa J, Anderson M, Andersson M, Armstrong P, Asselah T, Athanasakis K, Baatarkhuu O, Ben-Ari Z, Bensalem A, Bessone F, Biondi M, Bizri AR, Blach S, Braga W, Brandão-Mello C, Brosgart C, Brown K, Brown, Jr R, Bruggmann P, Brunetto M, Buti M, Cabezas J, Casanovas T, Chae C, Chan HLY, Cheinquer H, Chen PJ, Cheng KJ, Cheon ME, Chien CH, Choudhuri G, Christensen PB, Chuang WL, Chulanov V, Cisneros L, Coffin C, Contreras F, Coppola N, Cornberg M, Cowie B, Cramp M, Craxi A, Crespo J, Cui F, Cunningham C, Dalgard O, De Knegt R, De Ledinghen V, Dore G, Drazilova S, Duberg AS, Egeonu S, Elbadri M, El-Kassas M, El-Sayed M, Estes C, Etzion O, Farag E, Ferradini L, Ferreira P, Flisiak R, Forns X, Frankova S, Fung J, Gane E, Garcia V, García-Samaniego J, Gemilyan M, Genov J, Gheorghe L, Gholam P, Gish R, Goleij P, Gottfredsson M, Grebely J, Gschwantler M, Guingane NA, Hajarizadeh B, Hamid S, Hamoudi W, Harris A, Hasan I, Hatzakis A, Hellard M, Hercun J, Hernandez J, Hockicková I, Hsu YC, Hu CC, Husa P, Janicko M, Janjua N, Jarcuska P, Jaroszewicz J, Jelev D, Jeruma A, Johannessen A, Kåberg M, Kaita K, Kaliaskarova K, Kao JH, Kelly-Hanku A, Khamis F, Khan A, Kheir O, Khoudri I, Kondili L, Konysbekova A, Kristian P, Kwon J, Lagging M, Laleman W, Lampertico P, Lavanchy D, Lázaro P, Lazarus JV, Lee A, Lee MH, Liakina V, Lukšić B, Malekzadeh R, Malu A, Marinho R, Mendes-Correa MC, Merat S, Meshesha BR, Midgard H, Mohamed R, Mokhbat J, Mooneyhan E, Moreno C, Mortgat L, Müllhaupt B, Musabaev E, Muyldermans G, Naveira M, Negro F, Nersesov A, Nguyen VTT, Ning Q, Njouom R, Ntagirabiri R, Nurmatov Z, Oguche S, Omuemu C, Ong J, Opare-Sem O, Örmeci N, Orrego M, Osiowy C, Papatheodoridis G, Peck-Radosavljevic M, Pessoa M, Pham T, Phillips R, Pimenov N, Pincay-Rodríguez L, Plaseska-Karanfilska D, Pop C, Poustchi H, Prabdial-Sing N, Qureshi H, Ramji A, Rautiainen H, Razavi-Shearer K, Remak W, Ribeiro S, Ridruejo E, Ríos-Hincapié C, Robalino M, Roberts L, Roberts S, Rodríguez M, Roulot D, Rwegasha J, Ryder S, Sadirova S, Saeed U, Safadi R, Sagalova O, Said S, Salupere R, Sanai F, Sanchez-Avila JF, Saraswat V, Sargsyants N, Sarrazin C, Sarybayeva G, Schréter I, Seguin-Devaux C, Seto WK, Shah S, Sharara A, Sheikh M, Shouval D, Sievert W, Simojoki K, Simonova M, Sinn DH, Sonderup M, Sonneveld M, Spearman CW, Sperl J, Stauber R, Stedman C, Sypsa V, Tacke F, Tan SS, Tanaka J, Tergast T, Terrault N, Thompson A, Thompson P, Tolmane I, Tomasiewicz K, Tsang TY, Uzochukwu B, Van Welzen B, Vanwolleghem T, Vince A, Voeller A, Waheed Y, Waked I, Wallace J, Wang C, Weis N, Wong G, Wong V, Wu JC, Yaghi C, Yesmembetov K, Yip T, Yosry A, Yu ML, Yuen MF, Yurdaydin C, Zeuzem S, Zuckerman E, Razavi H. Global prevalence, cascade of care, and prophylaxis coverage of hepatitis B in 2022: a modelling study. Lancet Gastroenterol Hepatol 2023; 8:879-907. [PMID: 37517414 DOI: 10.1016/s2468-1253(23)00197-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND The 2016 World Health Assembly endorsed the elimination of hepatitis B virus (HBV) infection as a public health threat by 2030; existing therapies and prophylaxis measures make such elimination feasible, even in the absence of a virological cure. We aimed to estimate the national, regional, and global prevalence of HBV in the general population and among children aged 5 years and younger, as well as the rates of diagnosis, treatment, prophylaxis, and the future burden globally. METHODS In this modelling study, we used a Delphi process with data from literature reviews and interviews with country experts to quantify the prevalence, diagnosis, treatment, and prevention measures for HBV infection. The PRoGReSs Model, a dynamic Markov model, was used to estimate the country, regional, and global prevalence of HBV infection in 2022, and the effects of treatment and prevention on disease burden. The future incidence of morbidity and mortality in the absence of additional interventions was also estimated at the global level. FINDINGS We developed models for 170 countries which resulted in an estimated global prevalence of HBV infection in 2022 of 3·2% (95% uncertainty interval 2·7-4·0), corresponding to 257·5 million (216·6-316·4) individuals positive for HBsAg. Of these individuals, 36·0 million were diagnosed, and only 6·8 million of the estimated 83·3 million eligible for treatment were on treatment. The prevalence among children aged 5 years or younger was estimated to be 0·7% (0·6-1·0), corresponding to 5·6 million (4·5-7·8) children with HBV infection. Based on the most recent data, 85% of infants received three-dose HBV vaccination before 1 year of age, 46% had received a timely birth dose of vaccine, and 14% received hepatitis B immunoglobulin along with the full vaccination regimen. 3% of mothers with a high HBV viral load received antiviral treatment to reduce mother-to-child transmission. INTERPRETATION As 2030 approaches, the elimination targets remain out of reach for many countries under the current frameworks. Although prevention measures have had the most success, there is a need to increase these efforts and to increase diagnosis and treatment to work towards the elimination goals. FUNDING John C Martin Foundation, Gilead Sciences, and EndHep2030.
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Mak LY, Chan AC, Wong TC, Dai WC, She WH, Ma KW, Sin SL, Chu KW, Seto WK, Yuen MF, Lo CM, Fung J. High prevalence of de novo metabolic dysfunction-associated fatty liver disease after liver transplantation and the role of controlled attenuation parameter. BMC Gastroenterol 2023; 23:307. [PMID: 37700227 PMCID: PMC10498589 DOI: 10.1186/s12876-023-02940-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 08/30/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND & AIMS Although non-alcoholic fatty liver disease (NAFLD) remains an uncommon indication for liver transplantation (LT) in the Chinese, the prevalence of NAFLD is increasing. We aimed to determine the prevalence of de novo steatosis and metabolic dysfunction-associated fatty liver disease (MAFLD) after LT. METHODS Transient elastography assessment for liver stiffness and controlled attenuation parameter (CAP) were performed after LT in 549 patients at median time of 77 months from LT. CAP was compared with implant liver biopsy, and also validated in 42 patients with post-LT liver biopsy. Longitudinal history including diabetes mellitus (DM), dyslipidemia, hypertension, and immunosuppressive regimen were recorded. RESULTS The optimal cut-off level of CAP for diagnosing at least mild (≥ S1) and moderate-to-severe steatosis (≥ S2/3) was 266 and 293 dB/m respectively, with AUROC of 0.740 and 0.954 respectively. Using this newly derived cut-off, 28.9% patients have de novo NAFLD, of which 95.6% fulfilled the criteria for MAFLD. After multivariate analysis, BMI (HR 1.34), DM (HR 2.01), hypertension (HR 2.03), HDL-cholesterol (HR 0.25), LDL-cholesterol (HR 1.5) and cryptogenic cirrhosis (HR 4.85) were associated with the development of S2/3 graft steatosis. de novo NAFLD was associated with higher incidence of new-onset hypertension (p < 0.001), graft dysfunction (defined as ALT > 40 U/L; p = 0.008), but not associated with graft fibrosis (defined as liver stiffness > 12 kPa; p = 0.761). CONCLUSION Although NAFLD remains an uncommon primary liver disease indication for LT in Chinese patients, post-transplant de novo graft steatosis is common and the majority is classified as MAFLD. Development of graft steatosis is not associated with an increase in graft fibrosis but was associated with worse metabolic control and graft dysfunction. Routine CAP measurement to detect de novo graft steatosis should be considered after LT regardless of the primary indication of LT.
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Affiliation(s)
- Lung-Yi Mak
- Department of Medicine, The University of Hong Kong Queen Mary Hospital, 102 Pokfulam Road, Pok Fu Lam, Hong Kong
- State Key Laboratory Research of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Albert Cy Chan
- Department of Medicine, The University of Hong Kong Queen Mary Hospital, 102 Pokfulam Road, Pok Fu Lam, Hong Kong
- State Key Laboratory Research of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Tiffany Cl Wong
- Department of Medicine, The University of Hong Kong Queen Mary Hospital, 102 Pokfulam Road, Pok Fu Lam, Hong Kong
- State Key Laboratory Research of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Wing-Chiu Dai
- Department of Medicine, The University of Hong Kong Queen Mary Hospital, 102 Pokfulam Road, Pok Fu Lam, Hong Kong
- State Key Laboratory Research of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Wong-Hoi She
- Department of Medicine, The University of Hong Kong Queen Mary Hospital, 102 Pokfulam Road, Pok Fu Lam, Hong Kong
- State Key Laboratory Research of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Ka-Wing Ma
- Department of Medicine, The University of Hong Kong Queen Mary Hospital, 102 Pokfulam Road, Pok Fu Lam, Hong Kong
- State Key Laboratory Research of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Sui-Ling Sin
- Department of Medicine, The University of Hong Kong Queen Mary Hospital, 102 Pokfulam Road, Pok Fu Lam, Hong Kong
- State Key Laboratory Research of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Ka-Wan Chu
- Department of Medicine, The University of Hong Kong Queen Mary Hospital, 102 Pokfulam Road, Pok Fu Lam, Hong Kong
- State Key Laboratory Research of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Wai-Kay Seto
- Department of Medicine, The University of Hong Kong Queen Mary Hospital, 102 Pokfulam Road, Pok Fu Lam, Hong Kong
- State Key Laboratory Research of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Man-Fung Yuen
- Department of Medicine, The University of Hong Kong Queen Mary Hospital, 102 Pokfulam Road, Pok Fu Lam, Hong Kong
- State Key Laboratory Research of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Chung-Mau Lo
- Department of Medicine, The University of Hong Kong Queen Mary Hospital, 102 Pokfulam Road, Pok Fu Lam, Hong Kong
- State Key Laboratory Research of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - James Fung
- Department of Medicine, The University of Hong Kong Queen Mary Hospital, 102 Pokfulam Road, Pok Fu Lam, Hong Kong.
- State Key Laboratory Research of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong.
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Mak LY, Fung J. Editorial: Mitigating the risk of severe hepatitis flare following nucleoside analogue discontinuation-Insights from a real-world study. Aliment Pharmacol Ther 2023; 58:548-549. [PMID: 37559515 DOI: 10.1111/apt.17630] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
LINKED CONTENTThis article is linked to Hsu et al papers. To view these articles, visit https://doi.org/10.1111/apt.17614 and https://doi.org/10.1111/apt.17644
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Affiliation(s)
- Lung-Yi Mak
- Department of Medicine, School of Clinical Medicine, The Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, Hong Kong
| | - James Fung
- Department of Medicine, School of Clinical Medicine, The Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, Hong Kong
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Mak LY, Hui RWH, Fung J, Seto WK, Yuen MF. Bepirovirsen (GSK3228836) in chronic hepatitis B infection: an evaluation of phase II progress. Expert Opin Investig Drugs 2023; 32:971-983. [PMID: 37902953 DOI: 10.1080/13543784.2023.2277389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 10/26/2023] [Indexed: 11/01/2023]
Abstract
INTRODUCTION Chronic hepatitis B infection is a major global health issue associated with significant liver-related morbidity and mortality. While existing treatments can suppress the virus effectively, they are incapable of inducing functional cure, as defined by hepatitis B surface antigen (HBsAg) seroclearance. Currently, numerous novel compounds are being developed, including bepirovirsen, an antisense oligonucleotide (ASO). AREAS COVERED This review summarizes the mechanism of action, pharmacokinetics, clinical efficacy and safety data collected from phase I and II studies of bepirovirsen. The data were extracted from publications relevant to the pivotal trials of bepirovirsen, in either full manuscript or conference abstracts. EXPERTOPINION Bepirovirsen, a 20-mer ASO, has already entered phase III clinical evaluation using the optimal dosing regimen of 300 mg subcutaneous injection weekly for 24 weeks in nucleoside analogue-treated HBeAg-negative non-cirrhotic patients with low (<3000 IU/mL) baseline HBsAg. The durability and long-term clinical outcomes among Bepirovirsen responders will need to be evaluated. The stop-to-cure approach in those reaching HBsAg < 100 IU/mL should also be explored. In the long run, Bepirovirsen has the potential to facilitate viral hepatitis elimination.
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Affiliation(s)
- Lung-Yi Mak
- Department of Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Rex Wan-Hin Hui
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - James Fung
- Department of Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Wai-Kay Seto
- Department of Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Man-Fung Yuen
- Department of Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
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Lim WH, Tan C, Xiao J, Tan DJH, Ng CH, Yong JN, Fu C, Chan KE, Zeng RW, Ren YP, Goh XL, Chew N, Tseng M, Syn N, Mak LY, Fung J, Muthiah M, Siddiqui MS, Tan EXX. De novo metabolic syndrome after liver transplantation: a meta-analysis on cumulative incidence, risk factors, and outcomes. Liver Transpl 2023; 29:413-421. [PMID: 36724882 DOI: 10.1097/lvt.0000000000000004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/14/2022] [Indexed: 02/03/2023]
Abstract
Post-transplant metabolic syndrome (PTMS) has been associated with increased cardiovascular risk which significantly impacts the morbidity and mortality rates of liver transplant (LT) recipients. This study sought to conduct a meta-analysis and systematic review on the cumulative incidence, risk factors, and cardiovascular outcomes associated with de novo PTMS.Medline and Embase were searched for articles describing the incidence, risk factors, and cardiovascular outcomes of de novo PTMS. Meta-analysis of proportions was conducted to calculate incidence. Conventional pairwise analysis using random effects model was used to tabulate OR and hazard ratio for risk factors and cardiovascular outcomes, respectively. Fifteen studies involving 2683 LT recipients were included. Overall rate of de novo PTMS was 24.7% (CI: 18.0%-32.9%) over a mean follow-up period of 15.3 months and was highest in patients with NAFLD (60.0%, CI: 52.0%-67.5%) compared with other liver diseases. Older age (OR: 1.05, CI: 1.01-1.09, p = 0.02) and pre-LT type II diabetes mellitus (OR: 5.00, CI: 4.17-5.99, p < 0.01) were predictive factors of de novo PTMS. Patients with de novo PTMS had significantly higher likelihood of cardiovascular disease events compared with those who did not (hazard ratio: 2.42, CI: 1.54-3.81, p < 0.01). De novo PTMS is a common complication and is significantly associated with increased cardiovascular disease morbidity. High-risk patients such as elderly recipients, those with pre-LT type II diabetes mellitus, or NASH-related cirrhosis should undergo routine screening to allow timely intervention.
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Affiliation(s)
- Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Caitlyn Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jieling Xiao
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jie Ning Yong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Clarissa Fu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kai En Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Yi Ping Ren
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Xin Lei Goh
- Department of Internal Medicine, Tan Tock Seng Hospital, Singapore
| | - Nicholas Chew
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore
| | - Michael Tseng
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Biostatistics & Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Lung Yi Mak
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - James Fung
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Mark Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
- Department of Medicine, Division of Gastroenterology and Hepatology, National University Hospital, Singapore
| | - Mohammad Shadab Siddiqui
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Eunice X X Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
- Department of Medicine, Division of Gastroenterology and Hepatology, National University Hospital, Singapore
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Hui RWH, Mak LY, Seto WK, Yuen MF, Fung J. Chronic hepatitis B - A scoping review on the guidelines for stopping nucleos(t)ide analogue therapy. Expert Rev Gastroenterol Hepatol 2023; 17:443-450. [PMID: 36972516 DOI: 10.1080/17474124.2023.2196405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Nucleos(t)ide analogues (NAs) are effective in suppressing the replication of the hepatitis B virus. However, NAs cannot effectively induce hepatitis B surface antigen (HBsAg) seroclearance, which represents the optimal treatment endpoint in chronic hepatitis B (CHB). Hence, most CHB patients are advised for indefinite NA therapy, but recent data has supported the concept of finite NA therapy before HBsAg seroclearance. AREAS COVERED This article covered the latest evidence on stopping NAs in CHB, with focused analysis on international guidelines. Articles were retrieved by a literature search on PubMed with the keywords "chronic hepatitis B", "antiviral therapy", "nucleos(t)ide analogue", "cessation", "stopping" and "finite". Studies up till 1 December 2022 were included. EXPERT OPINION Finite NA therapy in CHB has potential in enhancing HBsAg seroclearance, however it also carries rare but potentially severe risks. NA cessation before HBsAg seroclearance is only suitable for a highly-selected group of patients, whereas the majority of CHB patients should be treated indefinitely or until HBsAg seroclearance. Current guidelines have provided recommendations on stopping NAs, but further research is required to optimize the monitoring and retreatment protocol after stopping NAs.
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Affiliation(s)
- Rex Wan-Hin Hui
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Lung-Yi Mak
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - James Fung
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
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Mak LY, Hui RWH, Cheung KS, Fung J, Seto WK, Yuen MF. Advances in determining new treatments for hepatitis B infection by utilizing existing and novel biomarkers. Expert Opin Drug Discov 2023; 18:401-416. [PMID: 36943183 DOI: 10.1080/17460441.2023.2192920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Chronic hepatitis B (CHB) infection is a major global health threat and accounts for significant liver-related morbidity and mortality. An improved understanding of how hepatitis B virus (HBV) interacts with the host immune system allows the discovery of novel biomarkers and new treatment options. Viral biomarkers including hepatitis B surface antigen (HBsAg) and newer ones like HBV RNA and hepatitis B core-related antigen appear to be useful to select patients who are likely to benefit from cessation of long-term antiviral therapy. These markers can also help to confirm target engagement for novel compounds, and efficacy in HBsAg reduction and seroclearance is deemed essential as this is how the current treatment endpoint of functional cure is defined. AREAS COVERED In this review, the authors discuss the current standard of care and the gaps between such standard and the ideal goals for treatment in CHB. The authors highlight novel viral and immunological biomarkers that are potentially useful to evaluate treatment response. Novel treatment approaches in relation to these novel biomarkers are also evaluated. EXPERT OPINION Novel serum viral biomarkers and immunological markers are indispensable in the HBV functional cure program. These will likely become part of standard monitoring soon.
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Affiliation(s)
- Lung-Yi Mak
- Department of Medicine, School of Clinical Medicine, Pokfulam, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Rex Wan-Hin Hui
- Department of Medicine, School of Clinical Medicine, Pokfulam, Hong Kong
| | - Ka-Shing Cheung
- Department of Medicine, School of Clinical Medicine, Pokfulam, Hong Kong
| | - James Fung
- Department of Medicine, School of Clinical Medicine, Pokfulam, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, Pokfulam, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, Pokfulam, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
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Hui KY, Fung J, Cheung KS, Mak LY, Seto WK, Yuen MF. Long-term Hepatitis B Surface Antigen Profile and Seroclearance after Severe Acute Flares of Chronic Hepatitis B. Gut Liver 2023; 17:280-287. [PMID: 36317514 PMCID: PMC10018308 DOI: 10.5009/gnl220122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/02/2022] [Accepted: 06/21/2022] [Indexed: 11/07/2022] Open
Abstract
Background/Aims Hepatitis B surface antigen (HBsAg) seroclearance remains uncommon in chronic hepatitis B (CHB) infection. During acute flares of CHB (AFOCHB), alanine aminotransferase elevation reflects a mounting immune response toward viral clearance. We hypothesized that severe AFOCHB is associated with a greater quantitative HBsAg (qHBsAg) decline and HBsAg seroclearance rate. Methods A total of 75 patients with severe AFOCHB with alanine aminotransferase 10× the upper limit of normal were matched to a control group by age and sex in a 1:2 ratio. qHBsAg levels were measured at the time of flare and annually (for both cases and controls) until the last follow-up. Results The median follow-up times for patients with severe AFOCHB and controls were 8.8 and 10.5 years, respectively. The cumulative rate of HBsAg seroclearance was higher in the severe AFOCHB group than in the control group (11.8% vs 5.0%, p=0.04) despite the former group having a trend of a higher baseline median qHBsAg (3,127 IU/mL vs 1,178 IU/mL, p=0.076). Compared with the control group, the severe AFOCHB group had a greater annual qHBsAg reduction (-242.4 IU/mL/yr vs -47.3 IU/mL/yr, p=0.002). Increasing age (p=0.049), lower baseline qHBsAg (p=0.002), and severe AFOCHB (p=0.014) were independently associated with HBsAg seroclearance. However, the cumulative rate of hepatocellular carcinoma was significantly higher in the severe AFOCHB group than in the control group (15.8% vs 1.9%, p<0.001). Conclusions Severe AFOCHB was associated with a greater incidence of HBsAg seroclearance and qHBsAg decline. However, it was associated with a higher incidence of hepatocellular carcinoma.
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Affiliation(s)
- Ka-Yin Hui
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
| | - James Fung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
| | - Ka-Shing Cheung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China.,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Lung-Yi Mak
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR, China
| | - Wai-Kay Seto
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China.,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR, China
| | - Man-Fung Yuen
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR, China
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Wong DKH, Inoue T, Mak LY, Hui RWH, Fung J, Cheung KS, Seto WK, Tanaka Y, Yuen MF. A longitudinal study to detect hepatitis B surface and core-related antigens in chronic hepatitis B patients with hepatitis B surface antigen seroclearance using highly sensitive assays. J Clin Virol 2023; 160:105375. [PMID: 36623378 DOI: 10.1016/j.jcv.2022.105375] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/29/2022] [Accepted: 12/22/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND This study aimed to evaluate the usefulness of two novel assays, namely the iTACT-hepatitis B surface antigen (iTACT-HBsAg) and iTACT-hepatitis B core-related antigen (iTACT-HBcrAg) assays, in chronic hepatitis B (CHB) patients with HBsAg seroclearance (SC) documented by standard assays. METHODS HBsAg and HBcrAg were measured by the two iTACT-assays in 556 serial sera collected from 96 CHB patients at 7 different time points spanning from 5 years before to 10 years after SC and 120 HBsAg-negative, anti-HBc-positive individuals. As controls, 60 seronegative individuals, who were negative for HBsAg, anti-HBc and anti-HBs, were tested. RESULTS Using the iTACT-assays, HBsAg was detectable in 154/418 (36.8%) samples collected after SC. HBcrAg was detectable in 78.3% and 65.9% of samples collected before and after SC, respectively. The detectability rates of both HBsAg and HBcrAg progressively decreased over time after SC. At 10 years after SC, 20.4% and 64.5% of the patients still had detectable HBsAg and HBcrAg, respectively. 66 (71%) patients had detectable HBsAg and/or HBcrAg. Among the 120 HBsAg-negative, anti-HBc-positive individuals, 11 (9.2%) and 4 (3.3%) had detectable HBsAg and HBcrAg respectively. Both HBsAg and HBcrAg were undetectable in the controls. CONCLUSION The iTACT assays detected a low level of HBsAg and/or HBcrAg in >70% of patients even at 10 years after SC, suggesting that CHB patients with SC still harbour a low level of HBV protein expression. The clinical significance of detectable viral proteins after SC with regard to disease progression and HBV reactivation deserves further investigations.
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Affiliation(s)
- Danny Ka-Ho Wong
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Takako Inoue
- Department of Clinical Laboratory Medicine, Nagoya City University Hospital, Nagoya, Japan
| | - Lung-Yi Mak
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Rex Wan-Hin Hui
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - James Fung
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Ka-Shing Cheung
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Yasuhito Tanaka
- Department of Gastroenterology and Hepatology, Kumamoto University, Kumamoto, Japan
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong.
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15
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Yu Q, Pillai A, Liao A, Baker T, Fung J, DiSabato D, Van Ha T, Ungchusri E, Hwang G, Ahmed O. Abstract No. 125 Selective Internal Radiation Therapy using Yttrium-90 Microspheres for Treatment of Localized and Locally Advanced Intrahepatic Cholangiocarcinoma. J Vasc Interv Radiol 2023. [DOI: 10.1016/j.jvir.2022.12.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023] Open
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16
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Chow N, Wong D, Lai CL, Mak LY, Fung J, Ma HT, Lei MW, Seto WK, Yuen MF. Effect of Antiviral Treatment on Hepatitis B Virus Integration and Hepatocyte Clonal Expansion. Clin Infect Dis 2023; 76:e801-e809. [PMID: 35594553 DOI: 10.1093/cid/ciac383] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 04/29/2022] [Accepted: 05/13/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND This study investigated the effect of nucleos(t)ide analogue (NUC) treatment on hepatitis B virus (HBV) DNA integration and hepatocyte clonal expansion, both of which are implicated in hepatocellular carcinoma (HCC) in chronic hepatitis B. METHODS Twenty-eight patients receiving NUCs (11 lamivudine, 7 telbivudine, 10 entecavir) were included. All had liver biopsies at baseline and year 1, and 7 had a third biopsy at year 10. HBV DNA integration and hepatocyte clone size were assessed by inverse polymerase chain reaction. RESULTS All patients had detectable HBV integration at baseline, with a median integration frequency of 1.01 × 109 per liver and hepatocyte clone size of 2.41 × 105. Neither integration frequency nor hepatocyte clone size correlated with age and HBV virologic parameters. After 1 year of treatment, HBV integration was still detectable in all patients, with a median of 5.74 × 108 integration per liver (0.22 log reduction; P = .008) and hepatocyte clone size of 1.22 × 105 (0.40 log reduction; P = .002). HBV integration remained detectable at year 10 of treatment, with a median integration frequency of 4.84 × 107 integration per liver (0.93 log reduction from baseline) and hepatocyte clone size of 2.55 × 104 (1.02 log reduction from baseline). From baseline through year 1 to year 10, there was a decreasing trend in both integration frequency and hepatocyte clone size (P = .066 and.018, respectively). CONCLUSIONS NUCs reduced both HBV DNA integration and hepatocyte clonal expansion, suggesting another alternative pathway besides direct viral suppression to reduce HCC risk. Our findings supported the notion for a long-term NUC treatment to prevent HCC.
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Affiliation(s)
- Ning Chow
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - Danny Wong
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - Ching-Lung Lai
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - Lung-Yi Mak
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - James Fung
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - Hoi-Tang Ma
- State Key Laboratory of Liver Research, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China.,Department of Pathology, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - Meng-Wai Lei
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - Wai-Kay Seto
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - Man-Fung Yuen
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
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17
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Affiliation(s)
- James Fung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, 102 Pokfulam Road, Hong Kong, China.
- The Liver Transplant Centre, Queen Mary Hospital, Hong Kong, China.
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China.
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18
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Mak LY, Hui RWH, Lee CH, Mao X, Cheung KS, Wong DKH, Lui DTW, Fung J, Yuen MF, Seto WK. Glycemic burden and the risk of adverse hepatic outcomes in patients with chronic hepatitis B with type 2 diabetes. Hepatology 2023; 77:606-618. [PMID: 36130882 DOI: 10.1002/hep.32716] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/27/2022] [Accepted: 08/08/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Type 2 diabetes (T2D) is common among patients with chronic hepatitis B infection (CHB) and has been associated with increased risk of carcinogenesis, including HCC. We investigated factors associated with HCC and fibrosis progression among patients with CHB with T2D (CHB+T2D). APPROACH AND RESULTS Chinese patients with CHB were prospectively recruited for the incidence of HCC and fibrosis progression defined by transient elastography. Among patients with CHB+T2D, glycemic control was assessed by mean glycated hemoglobin (HbA1c) and HbA1c variability determined using HbA1c measurements in the 5 years preceding recruitment. A total of 2330 patients with CHB were recruited (mean age 54.6 ±11.8 years old, 55.5% male, 57.9% antiviral-treated), with 671 (28.8%) having CHB+T2D (mean T2D duration 7.2 ± 4.6 years, mean HbA1c 7.2 ± 0.9%). T2D was independently associated with HCC (HR 2.080, 95% CI 1.343-3.222) and fibrosis progression (OR 4.305, 95% CI 3.416-5.424) in the overall cohort. In patients with CHB+T2D, factors reflecting glycemic burden (T2D duration [HR 1.107, 95% CI 1.023-1.198]), mean HbA1c (HR 1.851, 95% CI 1.026-3.339), time reaching target HbA1c (HbA1c-TRT; HR 0.978, 95% CI 0.957-0.999), liver stiffness (HR 1.041-1.043), and smoking (HR 2.726-3.344) were independently associated with HCC (all p < 0.05), but not HbA1c variability or controlled attenuation parameter. The same glycemic burden-related factors (T2D duration, mean HbA1c, and HbA1c-TRT), in addition to baseline fasting glucose, baseline HbA1c, AST and antiviral therapy, were independently associated with fibrosis progression at 3 years. CONCLUSIONS High glycemic burden was associated with HCC development and fibrosis progression among patients with CHB+T2D, highlighting the importance of glycemic control in reducing liver-related complications.
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Affiliation(s)
- Lung-Yi Mak
- Department of Medicine , Queen Mary Hospital, The University of Hong Kong , Hong Kong.,State Key Laboratory of Liver Research , The University of Hong Kong , Hong Kong
| | - Rex Wan-Hin Hui
- Department of Medicine , Queen Mary Hospital, The University of Hong Kong , Hong Kong
| | - Chi-Ho Lee
- Department of Medicine , Queen Mary Hospital, The University of Hong Kong , Hong Kong
| | - XianHua Mao
- Department of Medicine , Queen Mary Hospital, The University of Hong Kong , Hong Kong
| | - Ka-Shing Cheung
- Department of Medicine , Queen Mary Hospital, The University of Hong Kong , Hong Kong.,Department of Medicine , The University of Hong Kong-Shenzhen Hospital , Shenzhen , China
| | - Danny Ka-Ho Wong
- Department of Medicine , Queen Mary Hospital, The University of Hong Kong , Hong Kong.,State Key Laboratory of Liver Research , The University of Hong Kong , Hong Kong
| | - David Tak-Wai Lui
- Department of Medicine , Queen Mary Hospital, The University of Hong Kong , Hong Kong
| | - James Fung
- Department of Medicine , Queen Mary Hospital, The University of Hong Kong , Hong Kong.,State Key Laboratory of Liver Research , The University of Hong Kong , Hong Kong
| | - Man-Fung Yuen
- Department of Medicine , Queen Mary Hospital, The University of Hong Kong , Hong Kong.,State Key Laboratory of Liver Research , The University of Hong Kong , Hong Kong
| | - Wai-Kay Seto
- Department of Medicine , Queen Mary Hospital, The University of Hong Kong , Hong Kong.,State Key Laboratory of Liver Research , The University of Hong Kong , Hong Kong.,Department of Medicine , The University of Hong Kong-Shenzhen Hospital , Shenzhen , China
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19
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Cortesi PA, Viganò R, Conti S, Lenci I, Volpes R, Martini S, Angelico M, Fung J, Buti M, Coilly A, Durand F, Fondevila C, Lebray P, Nevens F, Polak WG, Rizzetto M, Zoulim F, Perricone G, Berenguer M, Mantovani LG, Duvoux C, Belli LS. Economic Impact of European Liver and Intestine Transplantation Association (ELITA) Recommendations for Hepatitis B Prophylaxis After Liver Transplantation. Transpl Int 2023; 36:10954. [PMID: 36793896 PMCID: PMC9922709 DOI: 10.3389/ti.2023.10954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/12/2023] [Indexed: 01/31/2023]
Abstract
The European Liver and Intestine Transplant Association, ELITA, promoted a Consensus Conference involving 20 experts across the world which generated updated guidelines on HBV prophylaxis in liver transplant candidates and recipients. This study explores the economic impact associated with the implementation of the new ELITA guidelines. To this aim, a condition-specific cohort simulation model has been developed to compare new and historical prophylaxis, including only pharmaceutical cost and using the European perspective. The target population simulated in the model included both prevalent and incident cases, and consisted of 6,133 patients after the first year, that increased to 7,442 and 8,743 patents after 5 and 10 years from its implementation. The ELITA protocols allowed a cost saving of around € 235.65 million after 5 years and € 540.73 million after 10 years; which was mainly due to early HIBG withdrawal either after the first 4 weeks or after the first year post Liver Transplantation (LT) depending on the virological risk at transplantation. Results were confirmed by sensitivity analyses. The money saved by the implementation of the ELITA guidelines would allow healthcare decision makers and budget holders to understand where costs could be reduced and resources re-allocated to different needs.
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Affiliation(s)
- Paolo Angelo Cortesi
- Research Centre on Public Health (CESP), University of Milano-Bicocca, Monza, Italy,*Correspondence: Paolo Angelo Cortesi,
| | - Raffaella Viganò
- Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy
| | - Sara Conti
- Research Centre on Public Health (CESP), University of Milano-Bicocca, Monza, Italy
| | - Ilaria Lenci
- Unit of Hepatology and Liver Transplant Unit, Tor Vergata University, Rome, Italy
| | - Riccardo Volpes
- Hepatology Unit, Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapia ad Alta Specializzazione), Palermo, Italy
| | - Silvia Martini
- Gastro-hepatology Unit, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Mario Angelico
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - James Fung
- Department of Medicine, School of Clinical Medicine, Queen Mary Hospital, State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Maria Buti
- Liver Unit, Hospital Universitario Valld’Hebron, Barcelona, Spain,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Audrey Coilly
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Villejuif, France,Unité INSERM 1193, Université Paris-Saclay, Paris, France
| | - Francois Durand
- Hepatology and Liver Intensive care, Hospital Beaujon, Clichy, France,Service d’Hépatologie et Transplantation Hépatique, APHP, Hôpital Beaujon, Université Paris Diderot, INSERM U1149, Clichy, France
| | - Constantino Fondevila
- HPB Surgery and Transplantation, Hospital Universitario La Paz, Instituto de Investigación Hospital Universitario La Paz (IdiPAZ), CIBERehd, Madrid, Spain
| | - Pascal Lebray
- Médecine Sorbonne Université, Service d’Hépato-gastroentérologie, Hôpitaux Universitaires Pitié Salpêtrière—Charles Foix, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Frederik Nevens
- Division of Hepatology and Liver Transplantation, European Reference Network on Hepatological Diseases (ERN Rare-Liver), University Hospitals KU, Leuven, Belgium
| | - Wojciech G. Polak
- Erasmus MC, Transplant Institute, University Medical Center Rotterdam, Department of Surgery, Division of HPB and Transplant Surgery, Rotterdam, Netherlands
| | - Mario Rizzetto
- Department of Medical Sciences, School of Medicine, University of Turin, Turin, Italy
| | - Fabien Zoulim
- INSERM U1052—Cancer Research Center of Lyon (CRCL), Lyon University, Hospices Civils de Lyon, Lyon, France
| | | | - Marina Berenguer
- Hepatology and Liver Transplantation Unit, Ciberehd; Faculty of Medicine, La Fe University Hospital, Valencia, Spain
| | | | - Christophe Duvoux
- Service d'Hépatologie, Hôpitaux Universitaires Henri Mondor, Créteil, France
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20
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Afzal B, Cirocchi R, Dawani A, Desiderio J, Di Cintio A, Di Nardo D, Farinacci F, Fung J, Gemini A, Guerci L, Kam SYM, Lakunina S, Madi L, Mazzetti S, Nadyrshine B, Shams O, Ranucci MC, Ricci F, Sharmin A, Trastulli S, Yasin T, Bond-Smith G, Tebala GD. Is it possible to predict the severity of acute appendicitis? Reliability of predictive models based on easily available blood variables. World J Emerg Surg 2023; 18:10. [PMID: 36707812 PMCID: PMC9882741 DOI: 10.1186/s13017-023-00478-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 01/16/2023] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Recent evidence confirms that the treatment of acute appendicitis is not necessarily surgical, and selected patients with uncomplicated appendicitis can benefit from a non-operative management. Unfortunately, no cost-effective test has been proven to be able to effectively predict the degree of appendicular inflammation as yet, therefore, patient selection is too often left to the personal choice of the emergency surgeon. Our paper aims to clarify if basic and readily available blood tests can give reliable prognostic information to build up predictive models to help the decision-making process. METHODS Clinical notes of 2275 patients who underwent an appendicectomy with a presumptive diagnosis of acute appendicitis were reviewed, taking into consideration basic preoperative blood tests and histology reports on the surgical specimens. Variables were compared with univariate and multivariate analysis, and predictive models were created. RESULTS 18.2% of patients had a negative appendicectomy, 9.6% had mucosal only inflammation, 53% had transmural inflammation and 19.2% had gangrenous appendicitis. A strong correlation was found between degree of inflammation and lymphocytes count and CRP/Albumin ratio, both at univariate and multivariate analysis. A predictive model to identify cases of gangrenous appendicitis was developed. CONCLUSION Low lymphocyte count and high CRP/Albumin ratio combined into a predictive model may have a role in the selection of patients who deserve appendicectomy instead of non-operative management of acute appendicitis.
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Affiliation(s)
- Barza Afzal
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Roberto Cirocchi
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Aruna Dawani
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Jacopo Desiderio
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Antonio Di Cintio
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Domenico Di Nardo
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Federico Farinacci
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - James Fung
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Alessandro Gemini
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Lorenzo Guerci
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Sen Yin Melina Kam
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Svetlana Lakunina
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Lee Madi
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Stefano Mazzetti
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Bakhtiar Nadyrshine
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Ola Shams
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Maria Chiara Ranucci
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Francesco Ricci
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Afroza Sharmin
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Stefano Trastulli
- grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
| | - Tanzela Yasin
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Giles Bond-Smith
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Giovanni D. Tebala
- grid.4991.50000 0004 1936 8948Surgical Emergency Unit, Oxford University Hospital NHS Foundation Trust, Oxford, UK ,grid.416377.00000 0004 1760 672XDigestive and Emergency Surgery Unit, S.Maria Hospital Trust, Terni, Italy
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Mak LY, Hui RWH, Fung J, Seto WK, Yuen MF. The role of different viral biomarkers on the management of chronic hepatitis B For special issue 'Challenging issues in the treatment of viral hepatitis'. Clin Mol Hepatol 2023; 29:263-276. [PMID: 36655304 PMCID: PMC10121282 DOI: 10.3350/cmh.2022.0448] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/15/2023] [Indexed: 01/20/2023] Open
Abstract
Chronic hepatitis B infection is a major public health challenge. With the advancement in technology, various components of the viral cycle can now be measured in the blood to assess viral activity. In this review article, we summarize the relevant data of how antiviral therapies impact viral biomarkers, and discuss their potential implications. Viral nucleic acids including HBV DNA and to a lesser extent, pre-genomic RNA (pgRNA), are readily suppressed by nucleos(t)ide analogues (NUCs). The primary role of these markers include risk prediction for hepatocellular carcinoma (HCC) and risk stratification for partial cure, defined as off-therapy virological control, or functional cure, defined as hepatitis B surface antigen (HBsAg) seroclearance plus undetectable serum HBV DNA for ≥6 months. Viral translational products including hepatitis e antigen, quantitative HBsAg and hepatitis B core-related antigen can be reduced by NUCs and pegylated interferon α. They are important in defining disease phase, delineating treatment endpoints, and predicting clinical outcomes including HCC risk and partial/ functional cure. As the primary outcome of phase III trials in CHB is set as HBsAg seroclearance, appropriate viral biomarkers can potentially inform the efficacy of novel compounds. Early viral biomarker response can help with prioritization of subjects into clinical trials. However, standardization and validation studies would be crucial before viral biomarkers can be broadly implemented in clinical use.
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Affiliation(s)
- Lung-Yi Mak
- Department of Medicine, School of Clinical Medicine, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Rex Wan-Hin Hui
- Department of Medicine, School of Clinical Medicine, Hong Kong
| | - James Fung
- Department of Medicine, School of Clinical Medicine, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Wai Kay Seto
- Department of Medicine, School of Clinical Medicine, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
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22
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Hui RWH, Fung J. World Hepatitis Day 2023: Are we close to the target? Indian J Med Res 2023; 158:1-4. [PMID: 37602579 PMCID: PMC10550067 DOI: 10.4103/ijmr.ijmr_1250_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Indexed: 08/03/2023] Open
Affiliation(s)
- Rex Wan-Hin Hui
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - James Fung
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
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23
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Lim WH, Chan KE, Ng CH, Tan DJH, Tay PWL, Chin YH, Yong JN, Xiao J, Fu CE, Nah B, Tiong HY, Syn N, Devi K, Griva K, Mak LLY, Huang DQ, Fung J, Siddiqui MS, Muthiah M, Tan EXX. A qualitative systematic review of anonymous/unspecified living kidney and liver donors' perspectives. PLoS One 2022; 17:e0277792. [PMID: 36584032 PMCID: PMC9803135 DOI: 10.1371/journal.pone.0277792] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/03/2022] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES & BACKGROUND Anonymous live organ donors or unspecified donors are individuals willing to be organ donors for any transplant recipient with whom they have no biological or antecedent emotional relationship. Despite excellent recipient outcomes and the potential to help address organ scarcity, controversy surrounds the unconditional act of gifting one's organs to an unrelated recipient. This qualitative systematic review provides insights into the first-hand experiences, motivations, and challenges that unspecified donors face. METHODS A systematic search was conducted on Medline, Embase, CINAHL, PsycINFO, and Web of Science database for qualitative literature regarding unspecified living donors' motivations and experiences in liver and kidney transplantation. An inductive thematic analysis was conducted to generate themes and supportive subthemes. RESULTS 12 studies were included. The four major themes were (i) motivations, (ii) perception of risks, (iii) donor support, and (iv) benefits of donation. Unspecified donors demonstrated a deep sense of social responsibility but tended to underestimate health risks in favour of benefits for recipients. Despite the lack of emotional support from family and friends, the decision to donate was a resolute personal decision for donors. Majority benefitted emotionally and did not express regret. CONCLUSION This qualitative review bridges the gap in literature on unspecified living donor psychology and provides a comprehensive understanding of the decision-making matrix and experiences of donors.
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Affiliation(s)
- Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- * E-mail: (WHL); (EXXT)
| | - Kai En Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Phoebe Wen Lin Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yip Han Chin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jie Ning Yong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jieling Xiao
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Clarissa Elysia Fu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Benjamin Nah
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Ho Yee Tiong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
- Department of Urology, University Surgical Cluster, National University Hospital, Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kamala Devi
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Konstadina Griva
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Loey Lung Yi Mak
- Division of Gastroenterology and Hepatology, Department of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Daniel Q. Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - James Fung
- Division of Liver Transplantation, Department of Surgery at Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | - Mohammad Shadab Siddiqui
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, United States of America
| | - Mark Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Eunice X. X. Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
- * E-mail: (WHL); (EXXT)
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Mak LY, Cheung KS, Hui RWH, Wong DKH, Fung J, Yuen MF, Seto WK. Enhanced Liver Fibrosis Score Stratifies Hepatocellular Carcinoma Risk in Patients With Hepatitis B Surface Antigen Seroclearance. Clin Infect Dis 2022; 75:2257-2259. [PMID: 35594565 DOI: 10.1093/cid/ciac387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/27/2022] [Accepted: 05/13/2022] [Indexed: 01/19/2023] Open
Abstract
In this prospective study involving 337 chronic hepatitis B patients who achieved spontaneous hepatitis B surface antigen (HBsAg) seroclearance (SC), serum enhanced liver fibrosis (ELF) before SC was associated with hepatocellular carcinoma (HCC) (hazard ratio 2.588), and ELF <10.8 was associated with >97% reduction in risk of HCC development in patients with age SC ≥ 50 (n = 190).
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Affiliation(s)
- Lung-Yi Mak
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, Hong Kong
| | - Ka-Shing Cheung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong.,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Rex Wan-Hin Hui
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - Danny Ka-Ho Wong
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, Hong Kong
| | - James Fung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, Hong Kong
| | - Man-Fung Yuen
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, Hong Kong
| | - Wai-Kay Seto
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, Hong Kong.,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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Kam LY, Huang DQ, Teng ML, Takahashi H, Tanaka K, Yasuda S, Fung J, Lee TY, Hyogo H, Ono M, Saruwatari J, Oniki K, Yeo YH, Barnett S, Henry L, Li J, Zou B, Cheung RC, Kumada T, Yuen MF, Eguchi Y, Toyoda H, Nguyen MH. Clinical Profiles of Asians with NAFLD: A Systematic Review and Meta-Analysis. Dig Dis 2022; 40:734-744. [PMID: 34942625 PMCID: PMC9808705 DOI: 10.1159/000521662] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/08/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION NAFLD is increasingly prevalent in Asia, where people suffer more metabolic comorbidities at a lower body mass index (BMI), suggesting potential differences in their clinical profile. Therefore, we attempted to characterize the clinical profile of Asians with NAFLD via a meta-analytic approach. METHODS We searched PubMed, EMBASE, and Cochrane databases from January 1, 2000, to January 17, 2019. Two authors independently reviewed and selected 104 articles (2,247,754 persons) that identified NAFLD in Asians and reported relevant data, especially BMI and ALT, and excluded individuals with other liver disease and excessive alcohol consumption. Individual patient-level data were obtained from seven cohorts in Asia to complement meta-analyzed data. RESULTS Overall, the mean age was 52.07 (95% CI: 51.28-52.85) years, with those from Southeast Asia (42.66, 95% CI: 32.23-53.11) being significantly younger. The mean BMI was 26.2 kg/m2, higher in moderate-severe versus mild hepatic steatosis (28.3 vs. 25.7) patients and NFS ≥ -1.455 versus <-1.455 (27.09 vs. 26.02), with 34% having nonobese NAFLD. The mean ALT was 31.74 U/L, higher in NFS < -1.455 versus ≥-1.455 (33.74 vs. 27.83), though no differences were found by obesity or steatosis severity. The majority of males (85.7%) and females (60.7%) had normal to minimally elevated ALT (1-1.5 × 95% ULN). Individual patient-level data analysis (N = 7,668) demonstrated similar results. CONCLUSION About one-third of Asians with NAFLD were nonobese, and the majority did not have markedly elevated ALT. Therefore, abnormal ALT or BMI is not recommended as a criterion for NAFLD screening in this population. Additionally, there were significant differences in the clinical profiles of NAFLD among the different regions of Asia.
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Affiliation(s)
- Leslie Y. Kam
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Daniel Q. Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Margaret L.P. Teng
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | | | - Kenichi Tanaka
- Division of Metabolism and Endocrinology, Facility of Medicine, Saga University, Saga, Japan
| | - Satoshi Yasuda
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | - James Fung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong, China
| | - Teng-Yu Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan,Department of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Hideyuki Hyogo
- Department of Gastroenterology and Hepatology, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Masafumi Ono
- Department of Internal Medicine, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Junji Saruwatari
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kentaro Oniki
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yee Hui Yeo
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Scott Barnett
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Linda Henry
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Jie Li
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA,Department of Infectious Disease, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Biyao Zou
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA
| | - Ramsey C. Cheung
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA,Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Takashi Kumada
- Department of Nursing, Faculty of Nursing, Gifu Kyoritsu University, Ogaki, Japan
| | - Man-Fung Yuen
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong, China
| | - Yuichiro Eguchi
- Liver Center, Saga University Hospital, Saga, Japan,Loco Medical General Institute, Loco Medical Eguchi Hospital, Saga, Japan
| | - Hidenori Toyoda
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Mindie H. Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California, USA,*Mindie H. Nguyen,
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Liu Y, Kim S, Roselaar N, Ramos K, Fung J, Burke W. 8884 Assessment of Patient-Initiated Communications Following Benign Hysterectomy. J Minim Invasive Gynecol 2022. [DOI: 10.1016/j.jmig.2022.09.504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mak LY, Wong DKH, Cheung KS, Hui RWH, Liu F, Fung J, Seto WK, Yuen MF. Role of Serum M2BPGi Levels in Predicting Persistence of Advanced Fibrosis in Chronic Hepatitis B Virus Infection. Dig Dis Sci 2022; 67:5127-5136. [PMID: 35258755 DOI: 10.1007/s10620-022-07429-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/30/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Serum mac-2-binding protein glycosylation isomer (M2BPGi) is a novel marker for liver fibrosis assessment in patients with different liver diseases. For chronic hepatitis B infection (CHB), advanced fibrosis or cirrhosis is a risk factor for liver cancer and hepatic decompensation. We aimed to assess the role of serum M2BPGi in prediction of persistence of advanced fibrosis in CHB patients despite potent antiviral therapy. METHODS CHB patients with advanced fibrosis or cirrhosis who were put on nucleos(t)ide analogs for ≥ 3 years with normal alanine aminotransferase and undetectable serum HBV DNA were prospectively recruited. Assessment of liver fibrosis with transient elastography (TE) and M2BPGi measurements were performed at baseline and repeated at 3 years. Advanced fibrosis and cirrhosis were defined by liver stiffness (LS) ≥ 9.0 kPa and ≥ 12.0 kPa, respectively. RESULTS A total of 143 patients (M:F = 101:42; median age 58.7 years; 53.8% cirrhotic) were recruited and completed paired assessment. The median value of baseline LS and M2BPGi were 12.0 (IQR: 10.5-18.2) kPa and 0.99 cut-off-index (IQR: 0.75-1.74) (COI), respectively, with 96% concordance for diagnosing F3/F4. Ninety-six (67.1%) patients had persistent advanced fibrosis or cirrhosis at 3 years despite continuation of long-term antiviral treatment. Upon multivariate analysis, baseline M2BPGi (OR 2.128, 95% CI 1.037-4.366) and presence of central obesity (OR 4.648, 95% CI 1.742-12.402) were significantly associated with persistent advanced fibrosis or cirrhosis at 3 years. Baseline M2BPGi ≥ 1.265 COI has 50.6% sensitivity and 79.4% specificity for predicting persistent advanced fibrosis or cirrhosis at 3 years (area under the receiver-operating characteristic curve: 0.695). The presence of central obesity in combination with baseline M2BPGi ≥ 1.265 COI was associated with 95.7% patients having persistent advanced fibrosis or cirrhosis at 3 years. HCC development was observed in five patients during follow-up and was associated with bigger median increase in the level of serum M2BPGi compared to patients without HCC (46% vs 6.2%, P = 0.038). CONCLUSION Persistent advanced fibrosis or cirrhosis was observed in two-thirds of CHB patients despite potent antiviral therapy. High serum M2BPGi and central obesity were associated with more than twofold and fourfold increase in risk of persistent advanced fibrosis or cirrhosis, respectively.
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Affiliation(s)
- Lung-Yi Mak
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road 102, Hong Kong, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Danny Ka-Ho Wong
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road 102, Hong Kong, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Ka-Shing Cheung
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road 102, Hong Kong, China.,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Rex Wan-Hin Hui
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road 102, Hong Kong, China
| | - Fen Liu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - James Fung
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road 102, Hong Kong, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Wai-Kay Seto
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road 102, Hong Kong, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China.,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Man-Fung Yuen
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road 102, Hong Kong, China. .,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China.
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Mao X, Cheung KS, Peng C, Mak LY, Cheng HM, Fung J, Peleg N, Leung HHW, Kumar R, Lee JH, Shlomai A, Yuen MF, Seto WK. Steatosis, HBV-related HCC, cirrhosis, and HBsAg seroclearance: A systematic review and meta-analysis. Hepatology 2022; 77:1735-1745. [PMID: 36111362 DOI: 10.1002/hep.32792] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/22/2022] [Accepted: 09/13/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND AIMS NAFLD and chronic hepatitis B (CHB) infection are common etiologies of HCC. The impact of hepatic steatosis on HCC in CHB, as well as its relationship with the development of cirrhosis, fibrosis, and HBsAg seroclearance, remains controversial. APPROACH AND RESULTS Data from observational studies were collected through PubMed, EMBASE, and the Cochrane Library from inception to February 1, 2022. Outcomes of interest included the association of hepatic steatosis with HCC, cirrhosis, advanced fibrosis, and HBsAg seroclearance, expressed in terms of pooled ORs. Additional subgroup and sensitivity analyses were performed to validate the robustness of findings. A total of 34 studies with 68,268 patients with CHB were included. Hepatic steatosis was associated with higher odds of HCC (OR, 1.59; 95% CI, 1.12-2.26; I2 = 72.5%), with the association remaining consistent in Asia (OR, 1.56; 95% CI, 1.08-2.25), studies with a median follow-up duration of ≥5 years (OR, 2.82; 95% CI, 1.57-5.08), exclusion of alcohol use (OR, 1.71; 95% CI, 1.01-2.91), and biopsy-proven steatosis (OR, 2.86; 95% CI, 1.61-5.06), although no significant association was noted among nucleos(t)ide analogue-treated patients (OR, 1.05; 95% CI, 0.62-1.77). Steatosis was associated with the development of cirrhosis (OR, 1.52; 95% CI, 1.07-2.16; I2 = 0%) and HBsAg seroclearance (OR, 2.22; 95% CI, 1.58-3.10; I2 = 49.0%). CONCLUSIONS Hepatic steatosis was associated with an increased risk of HCC and cirrhosis among patients with CHB but with a higher chance of achieving a functional cure, highlighting the importance of identifying concomitant steatosis in CHB.
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Affiliation(s)
- Xianhua Mao
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Ka Shing Cheung
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong.,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Chengzhi Peng
- Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Lung-Yi Mak
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Ho Ming Cheng
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - James Fung
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Noam Peleg
- Division of Gastroenterology, Rabin Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Howard H-W Leung
- Department of Anatomical and Cellular Pathology, The Chinese University of Hong Kong, Hong Kong
| | - Rajneesh Kumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-NUS Graduate Medical School, Singapore
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Amir Shlomai
- Department of Medicine D and The Liver Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong.,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
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Mak LY, Cheung KS, Fung J, Seto WK, Yuen MF. New strategies for the treatment of chronic hepatitis B. Trends Mol Med 2022; 28:742-757. [PMID: 35780008 DOI: 10.1016/j.molmed.2022.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/03/2022] [Accepted: 06/06/2022] [Indexed: 10/17/2022]
Abstract
Functional cure, as defined by seroclearance of hepatitis B surface antigen (HBsAg), is the desired treatment endpoint for chronic hepatitis B (CHB) infection, yet is rarely achieved with the currently approved therapy. Novel treatments currently in the clinical phase of development act by inhibiting viral replication/antigen reduction and/or by restoring host immune control. Although some agents are effective in reducing the viral antigen load, a greater magnitude of suppression is required to achieve functional cure. Compounds that target the covalently closed circular DNA (cccDNA) pool, hepatitis B X (HBx) protein inhibition, and mRNA destabilization are also in the preclinical phase of development. Challenges which remain include the clinical implications, immunological perturbations, and safety of these novel compounds to be used in the real-life setting.
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Affiliation(s)
- Lung-Yi Mak
- Department of Medicine, School of Clinical Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Ka-Shing Cheung
- Department of Medicine, School of Clinical Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong; Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - James Fung
- Department of Medicine, School of Clinical Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong; Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Man-Fung Yuen
- Department of Medicine, School of Clinical Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong; State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong.
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Hui RWH, Chiu KWH, Mak LY, Chang HC, Cheung KS, Fung J, Yuen MF, Seto WK. Magnetic resonance imaging metrics and the predictability of adverse outcomes in on-treatment Asian chronic hepatitis B. J Gastroenterol Hepatol 2022; 37:1139-1147. [PMID: 35368120 DOI: 10.1111/jgh.15846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/21/2022] [Accepted: 03/20/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Liver fibrosis and steatosis are important factors affecting chronic hepatitis B (CHB) disease outcome. Multiparametric magnetic resonance (MR) imaging of the liver measures fibroinflammation, fat, and iron through iron-corrected T1 relaxation time (cT1), proton density fat fraction (PDFF), and T2*-weighted imaging, respectively. We assessed the utility of MR metrics for prognostication in CHB. METHODS Chronic hepatitis B patients receiving nucleos(t)ide analogs with advanced fibrosis documented by vibration-controlled transient elastography were recruited. Paired multiparametric MR liver and transient elastography were performed at baseline and after at least 2 years. Adverse outcomes including death, hepatocellular carcinoma (HCC), and liver decompensation were monitored. RESULTS One hundred and ninety-two patients (mean age 60.3 ± 8.5 years; 76.0% male) were recruited. Eight patients (4.2%) developed HCC after 11.6 (8.8-22.8) months, and increased baseline liver iron independently predicted HCC (hazard ratio 2.329 [1.030-5.266]; P = 0.042). Liver MR metrics were not predictive of death or hepatic decompensation. Among 150 patients with follow-up liver MR at 30.3 (25.2-35.6) months, longitudinal liver PDFF increase was associated with liver cT1 increase (odds ratio 1.571 [1.217-2.029]; P = 0.001). Ninety patients received simultaneous multiparametric MR pancreas during the follow-up MR. Pancreatic PDFF correlated with liver PDFF (r = 0.501, P < 0.001), while pancreatic T1 had no correlation with liver cT1 (r = -0.092, P = 0.479). Pancreatic T1 and PDFF were not associated with adverse outcomes. CONCLUSION Among CHB patients with advanced disease, liver iron level on MR predicts HCC. Multiparametric MR can also simultaneously assess the pancreas and the liver. Multiparametric MR should be further studied as a one-stop option for monitoring and prognosticating CHB.
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Affiliation(s)
- Rex Wan-Hin Hui
- Department of Medicine, The University of Hong Kong, Hong Kong
| | | | - Lung Yi Mak
- Department of Medicine, The University of Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Hing-Chiu Chang
- Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong
| | - Ka-Shing Cheung
- Department of Medicine, The University of Hong Kong, Hong Kong.,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - James Fung
- Department of Medicine, The University of Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Man-Fung Yuen
- Department of Medicine, The University of Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong
| | - Wai-Kay Seto
- Department of Medicine, The University of Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong.,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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Tan DJH, Ng CH, Tay PWL, Syn N, Muthiah MD, Lim WH, Tang ASP, Lim KE, Lim GEH, Tamaki N, Kim BK, Teng MLP, Fung J, Loomba R, Nguyen MH, Huang DQ. Risk of Hepatocellular Carcinoma With Tenofovir vs Entecavir Treatment for Chronic Hepatitis B Virus: A Reconstructed Individual Patient Data Meta-analysis. JAMA Netw Open 2022; 5:e2219407. [PMID: 35767258 PMCID: PMC9244612 DOI: 10.1001/jamanetworkopen.2022.19407] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Conventional meta-analyses with aggregated study-level data have yielded conflicting results for the comparative effectiveness of tenofovir disoproxil fumarate vs entecavir in reducing hepatocellular carcinoma (HCC) risk among patients with chronic hepatitis B virus. Within-study heterogeneity, between-study heterogeneity, and the inability of conventional meta-analyses to capture time-to-event data were associated with these results. OBJECTIVE To perform a reconstructed individual patient data meta-analysis of high-quality propensity score-matched studies to provide robust estimates for comparative HCC risk between groups receiving tenofovir or entecavir. DATA SOURCES Medline and Embase databases were searched from inception to October 6, 2021. STUDY SELECTION The initial search yielded 3435 articles. Fourteen studies that used propensity score matching to balance baseline characteristics were included in the final analysis. DATA EXTRACTION AND SYNTHESIS The Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was followed. Individual patient data were reconstructed from Kaplan-Meier curves. Risk of HCC was evaluated using random-effects hazard ratios (HRs) via a shared-frailty model and a Cox proportional hazards model stratified by study group. Restricted mean survival time (RMST) analysis was conducted to account for varying estimated treatment effect across time. MAIN OUTCOMES AND MEASURES The comparative risk of HCC with tenofovir vs entecavir treatment. RESULTS From analysis of 14 studes with 24 269 patients (10 534 receiving tenofovir and 13 735 receiving entecavir; mean age, 49.86 [95% CI, 48.35-51.36] years; 65.05% [95% CI, 58.60%-71.00%] men), tenofovir was associated with decreased HCC incidence compared with entecavir (stratified Cox HR, 0.85 [95% CI, 0.76-0.94] at 5 years; P = .002). However, there was no significant difference in subanalysis of clinical cohort studies (stratified Cox HR, 0.92 [95% CI, 0.80-1.06] at 5 years; P = .24). Among administrative database studies, proportionality was violated, and HRs could not be obtained via Cox proporational hazards-based models. The mean time to HCC development in RMST analysis was 2.8 (95% CI, 1.8-3.7) weeks longer (P < .001) for tenofovir vs entecavir at 5 years. The RMST analyses for other subgroups revealed either insignificant or minimal differences (<3 weeks) in the mean time to HCC at 5 years. CONCLUSIONS AND RELEVANCE In this meta-analysis, there was no clinically meaningful difference in the risk of HCC between patients who received entecavir and patients who received tenofovir. There was no difference between tenofovir and entecavir among clinical cohort studies, whereas the mean time to HCC development was less than 3 weeks longer for patients who received tenofovir vs those who received entecavir at year 5 among administrative database studies. The choice between tenofovir or entecavir should be decided based on patient convenience and tolerability.
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Affiliation(s)
- Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Phoebe Wen Lin Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mark D. Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ansel Shao Pin Tang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kai En Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Grace En Hui Lim
- Lee Kong Chian School of Medicine, Nanyang Technological University, Sinagpore
| | - Nobuharu Tamaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo, Japan
| | - Beom Kyung Kim
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo, Japan
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Yonsei Liver Center, Severance Hospital, Yonsei University Health System, Seoul, South Korea
| | - Margaret Li Peng Teng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - James Fung
- Division of Liver Transplantation, Department of Surgery, Queen Mary Hospital, Hong Kong
| | - Rohit Loomba
- NAFLD (Nonalcoholic Fatty Liver Disease) Research Center, Division of Medicine, University of California, San Diego, La Jolla
| | - Mindie H. Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California
| | - Daniel Q. Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
- NAFLD (Nonalcoholic Fatty Liver Disease) Research Center, Division of Medicine, University of California, San Diego, La Jolla
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Fung J. SARS-COV-2 positive donors for liver transplantation - the way forward. J Liver Transpl 2022; 6:100079. [PMID: 38620961 PMCID: PMC8898346 DOI: 10.1016/j.liver.2022.100079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- James Fung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR
- The Liver Transplant Center, Queen Mary Hospital, Hong Kong SAR
- State Key Laboratory of Liver Research The University of Hong Kong, Hong Kong SAR
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33
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Mak LY, Fung J. Non-alcoholic fatty liver disease in cerebrovascular disease: a bystander or a real risk factor? Hepatol Int 2022; 16:24-26. [PMID: 35088389 DOI: 10.1007/s12072-021-10273-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/07/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Lung-Yi Mak
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - James Fung
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China. .,Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Room 305, New Clinical Building, Pokfulam Road 102, Hong Kong, China.
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34
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Tan EXX, Quek WL, Suryadi, Chahed H, Iyer SG, Jeyaraj PR, Lee GH, Chan A, Cheng S, Hoe J, Tan EK, Chew LY, Fung J, Chen M, Muthiah MD, Huang DQ. Impact of COVID-19 on Liver Transplantation in Hong Kong and Singapore: A Modelling Study. Lancet Reg Health West Pac 2021; 16:100262. [PMID: 34514452 PMCID: PMC8421812 DOI: 10.1016/j.lanwpc.2021.100262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Liver transplantation (LT) activities during the COVID-19 pandemic have been curtailed in many countries. The impact of various policies restricting LT on outcomes of potential LT candidates is unclear. METHODS We studied all patients on the nationwide LT waitlists in Hong Kong and Singapore between January 2016 and May 2020. We used continuous time Markov chains to model the effects of different scenarios and varying durations of disruption on LT candidates. FINDINGS With complete cessation of LT, the projected 1-year overall survival (OS) decreased by 3•6%, 10•51% and 19•21% for a 1-, 3- and 6-month disruption respectively versus no limitation to LT, while 2-year OS decreased by 4•1%, 12•55%, and 23•43% respectively. When only urgent (acute-on-chronic liver failure [ACLF] or acute liver failure) LT was allowed, the projected 1-year OS decreased by a similar proportion: 3•1%, 8•41% and 15•20% respectively. When deceased donor LT (DDLT) and urgent living donor LT (LDLT) were allowed, 1-year projected OS decreased by 1•2%, 5•1% and 8•85% for a 1-, 3- and 6-month disruption respectively. OS was similar when only DDLT was allowed. Complete cessation of LT activities for 3-months resulted in an increased projected incidence of ACLF and hepatocellular carcinoma (HCC) dropout at 1-year by 49•1% and 107•96% respectively. When only urgent LT was allowed, HCC dropout and ACLF incidence were comparable to the rates seen in the scenario of complete LT cessation. INTERPRETATION A short and wide-ranging disruption to LT results in better outcomes compared with a longer duration of partial restrictions. FUNDING None to disclose.
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Affiliation(s)
- Eunice Xiang-Xuan Tan
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Wei Liang Quek
- School of Humanities, Nanyang Technological University, Singapore
| | - Suryadi
- School of Physical and Mathematical Sciences, Nanyang Technological University, Singapore
| | - Haroun Chahed
- School of Humanities, Nanyang Technological University, Singapore
| | - Shridhar Ganpathi Iyer
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
- Department of Surgery, National University Health System, Singapore
| | - Prema Raj Jeyaraj
- SingHealth Duke-NUS Transplant Centre, Singapore
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Guan-Huei Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Albert Chan
- Division of Hepatobiliary and Pancreatic Surgery, and Liver Transplantation, Department of Surgery, The University of Hong Kong, China
| | - Stephanie Cheng
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Jan Hoe
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Ek Khoon Tan
- SingHealth Duke-NUS Transplant Centre, Singapore
- Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Lock Yue Chew
- School of Physical and Mathematical Sciences, Nanyang Technological University, Singapore
| | - James Fung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Melvin Chen
- School of Humanities, Nanyang Technological University, Singapore
| | - Mark D. Muthiah
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Daniel Q. Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
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35
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Lim SY, Wang R, Tan DJH, Ng CH, Lim WH, Quek J, Syn N, Nah BKY, Wong ETY, Huang DQ, Vathsala A, Siddiqui MS, Fung J, Muthiah MD, Tan EXX. A meta-analysis of the cumulative incidence, risk factors, and clinical outcomes associated with chronic kidney disease after liver transplantation. Transpl Int 2021; 34:2524-2533. [PMID: 34714569 DOI: 10.1111/tri.14149] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/19/2021] [Accepted: 09/29/2021] [Indexed: 12/15/2022]
Abstract
Chronic kidney disease (CKD) remains a relatively common complication after liver transplantation (LT), and significantly impacts overall survival. We sought to assess the cumulative incidence, risk factors and mortality associated with post-LT CKD. CKD was defined as eGFR <60 ml/min/1.73 m2 as estimated by the Modified Diet in Renal Disease (MDRD) formula. Single-arm meta-analysis was done to evaluate the cumulative incidence of CKD at 1-, 3-, and 5-year timepoints post-LT. Risk factors for CKD were evaluated using hazard ratios (HR). Twenty-one studies involving 44 383 patients were included. Cumulative incidence of stage 3-5 CKD was 31.44% (CI 0.182-0.447), 36.71% (CI 0.188-0.546), and 43.52% (CI 0.296-0.574) at 1, 3, and 5 years after LT, respectively. Stage 5 CKD cumulative incidence increased from 0.274% (CI 0.001-0.005) at 1 year to 2.06% (CI 0.009-0.045) at 5 years post-LT. Age, female sex, diabetes, and peri-operative acute kidney injury (AKI) were significant risk factors for CKD. Stage 4-5 CKD was associated with a decrease in overall survival (HR 3.23, 95% CI 1.74-5.98, P < 0.01). CKD after LT is relatively common, and is associated with significantly reduced overall survival. Identification of patients at high risk of developing CKD allows physicians to prophylactically use renal-sparing immunosuppression which may be crucial in achieving desirable clinical outcomes.
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Affiliation(s)
- Sze Yinn Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Renaeta Wang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jingxuan Quek
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Biostatistics & Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Benjamin Kai Yi Nah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Emmett Tsz-Yeung Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,National University Center for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Daniel Q Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,National University Center for Organ Transplantation, National University Health System, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Anantharaman Vathsala
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,National University Center for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Mohammad Shadab Siddiqui
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University, Richmond, VA, USA
| | - James Fung
- Division of Gastroenterology and Hepatology, Department of Medicine, Queen Mary Hospital, Hong Kong, Hong Kong
| | - Mark D Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,National University Center for Organ Transplantation, National University Health System, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Eunice Xiang-Xuan Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,National University Center for Organ Transplantation, National University Health System, Singapore, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
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36
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Mak LY, Ko KL, To WP, Wong DKH, Seto WK, Fung J, Yuen MF. Entecavir Reduced Serum Hepatitis B Core-Related Antigen in Chronic Hepatitis B Patients with Hepatocellular Carcinoma. Gut Liver 2021; 14:665-668. [PMID: 32457279 PMCID: PMC7492492 DOI: 10.5009/gnl19434] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/12/2020] [Accepted: 03/01/2020] [Indexed: 12/21/2022] Open
Abstract
Serum hepatitis B core-related antigen (HBcrAg) was shown to predict the risk of hepatocellular carcinoma (HCC) in chronic hepatitis B (CHB) patients undergoing treatment. We investigated the longitudinal profile of HBcrAg in entecavir (ETV)-treated CHB patients with subsequent HCC development. We identified HCC cases diagnosed at ≥1 year after ETV initiation. CHB patients without HCC (matched for age, sex, cirrhosis status, baseline hepatitis B virus [HBV] DNA level, and ETV treatment duration) were identified as controls at an HCC:non-HCC ratio of 1:2. Serum samples were retrieved at baseline (ETV initiation) and at 3 and 5 years of ETV therapy for HBcrAg measurement (log IU/mL). In total, 180 patients (60 HCC patients matched with 120 CHB patients without HCC; median age, 56.5 years; 80.6% male; baseline HBV DNA, 5.9 log IU/mL; median follow-up, 6.8 years) were recruited. The median time from ETV initiation to HCC development was 3.2 years. HBcrAg levels were higher in HCC cases than in controls at all three time points: 5.69 log IU/mL versus 5.02 log IU/mL (p=0.025), 4.23 log IU/mL versus 3.36 log IU/mL (p=0.007), and 3.86 log IU/mL versus 3.36 log IU/mL (p=0.009), respectively. ETV led to similar rates of decline in HBcrAg from baseline to 3 years in both groups (0.34 log IU/mL/year vs 0.39 log IU/mL/year, p=0.774), although the decline from 3 to 5 years was slower in the non-HCC group (0.05 log IU/mL/year) than in the HCC group (0.09 log IU/mL/year, p=0.055). ETV time-dependently reduced HBcrAg in HCC and non-HCC patients. HBcrAg interpretation should consider the antiviral treatment duration.
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Affiliation(s)
- Lung-Yi Mak
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, China
| | - Kwan-Lung Ko
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, China
| | - Wai-Pan To
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, China
| | - Danny Ka-Ho Wong
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Wai-Kay Seto
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China.,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - James Fung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Man-Fung Yuen
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
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37
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Duvoux C, Belli LS, Fung J, Angelico M, Buti M, Coilly A, Cortesi P, Durand F, Féray C, Fondevila C, Lebray P, Martini S, Nevens F, Polak WG, Rizzetto M, Volpes R, Zoulim F, Samuel D, Berenguer M. 2020 position statement and recommendations of the European Liver and Intestine Transplantation Association (ELITA): management of hepatitis B virus-related infection before and after liver transplantation. Aliment Pharmacol Ther 2021; 54:583-605. [PMID: 34287994 DOI: 10.1111/apt.16374] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 11/25/2020] [Accepted: 04/01/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prophylaxis of HBV recurrence is critical after liver transplantation in HBV patients. Despite new prophylactic schemes, most European LT centres persist on a conservative approach combining hepatitis B immunoglobulin (HBIG) and nucleos(t)ides analogues (NA). AIM This setting prompted the European Liver Intestine Transplantation Association (ELITA) to look for a consensus on the prevention of HBV recurrence. METHODS Based on a 4-round Delphi process, ELITA investigated 16 research questions and established 50 recommendations. RESULTS Prophylaxis should be driven according to 3 simplified risk groups: Low and high virological risk patients, with undetectable and detectable HBV DNA pre-LT, respectively, and special populations (HDV, HCC, poorly adherent patients). In low-risk patients, short-term (4 weeks) combination of third-generation NA+ HBIG, or third generation NA monotherapy can be considered as prophylactic options. In high-risk patients, HBIG can be discontinued once HBV DNA undetectable. Combined therapy for 1 year is advised. HBV-HCC patients should be treated according to their virological risk. In HDV/HBV patients, indefinite dual prophylaxis remains the gold standard. Full withdrawal of HBV prophylaxis following or not HBV vaccination should only be attempted in the setting of clinical trials. Organs from HBsAg+ve donors may be considered after assessment of risks, benefits, and patient consent. They should not be used if HDV is present. In poorly adherent patients, dual long-term prophylaxis is recommended. Budget impact analysis should be taken into account to drive prophylactic regimen. CONCLUSIONS These ELITA recommendations should stimulate a more rational and homogeneous approach to HBV prophylaxis across LT programs.
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38
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Ng CH, Lim WH, Lim XC, Xiao J, Tan DJH, Syn N, Ho CS, Kow AWC, Tan EXX, Fung J, Muthiah MD. A Meta-Analysis on the Incidence of Donor Related Depression after Liver Transplant. Transpl Int 2021; 34:2061-2070. [PMID: 34273136 DOI: 10.1111/tri.13975] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/28/2021] [Accepted: 07/02/2021] [Indexed: 11/26/2022]
Abstract
AIM Living donor liver transplantation (LDLT) is increasing, yet gaps exist in the understanding of psychological wellbeing of donors after liver transplant. This meta-analysis seeks to evaluate the incidence and risk factors for donor-related depression after liver transplantation. METHODS A search was conducted on Medline and Embase database. Articles assessing incidence of depression in LDLT donors were included. Incidence was pooled after Freeman-Tukey double-arcsine transformation. For risk factors, dichotomous variables were analyzed with generalized linear model while a conventional meta regression with logit transformation was conducted for continuous variables. RESULTS Of 1,069 abstracts, 40 articles underwent full-text review. 17 articles were included. The pooled incidence of depression among 1,888 LT donors was 7.66% (CI: 4.47% - 12.80%). Depression rates were significantly higher in Asian compared to Western studies (RR: 1.73, CI: 1.19 - 2.52, p=0.0039). Female gender (p<0.001), Caucasian ethnicity (p=0.047), employment status (p<0.001) and lower education levels (p=0.044) were significantly associated with depression. Donor relationship with recipients was not a significant risk factor. CONCLUSIONS LDLT remains a core aspect of the treatment of end-stage liver disease. However, the high depression rates after LT suggest that there remains room for improvement in the care of donors' mental health post-transplant.
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Affiliation(s)
- Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Xiong Chang Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jieling Xiao
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Biostatistics & Modelling Domain, Saw Swee Hock School of Public Health, National University of Singapore
| | - Cyrus Sh Ho
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Alfred Wei Chieh Kow
- National University Centre for Organ Transplantation, National University Health System, Singapore.,Division of Hepatobiliary & Pancreatic Surgery, Department of Surgery, National University Hospital.,Division of Surgical Oncology, National University Cancer Institute, Singapore
| | - Eunice Xiang Xuan Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - James Fung
- Division of Liver Transplantation, Department of Surgery at Queen Mary Hospital, Hong Kong
| | - Mark Dhinesh Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,National University Centre for Organ Transplantation, National University Health System, Singapore.,Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
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39
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Mak LY, Hui RWH, Fung J, Liu F, Wong DKH, Li B, Cheung KS, Yuen MF, Seto WK. Reduced hepatic steatosis is associated with higher risk of hepatocellular carcinoma in chronic hepatitis B infection. Hepatol Int 2021; 15:901-911. [PMID: 34152534 DOI: 10.1007/s12072-021-10218-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/31/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Concomitant chronic hepatitis B infection (CHB) and non-alcoholic fatty liver disease (NAFLD) is common, but the implications of NAFLD on clinical outcomes of CHB, including hepatocellular carcinoma (HCC), are not well-investigated. METHODS CHB patients were recruited for transient elastography assessment for liver stiffness (LS), and controlled attenuation parameter (CAP), a non-invasive quantification of hepatic steatosis, and were prospectively followed up for development of HCC. Steatosis and severe steatosis were diagnosed by CAP ≥ 248 dB/m and ≥ 280 dB/m respectively, and advanced fibrosis/cirrhosis was diagnosed by LS ≥ 9 kPa. The independent effect of hepatic steatosis on HCC was examined via propensity score matching (PSM) of LS and other significant clinical variables. RESULTS Forty-eight patients developed HCC among 2403 CHB patients (55.6% male, median age 55.6 years, 57.1% antiviral-treated, median ALT 26 U/L) during a median follow-up of 46.4 months. Multivariate Cox regression analysis showed age (HR 1.063), male (HR 2.032), Albumin-Bilirubin score (HR 2.393) and CAP (HR 0.993) were associated with HCC development. The cumulative probability of HCC was 2.88%, 1.56% and 0.71%, respectively for patients with no steatosis, mild-to-moderate steatosis, and severe steatosis, respectively (p = 0.01). The risk of HCC increased from 1.56 to 8.89% in patients without severe steatosis if advanced fibrosis/cirrhosis was present (p < 0.001). PSM yielded 957 pairs of CHB patients and hepatic steatosis was independently associated with HCC (HR 0.41). CONCLUSION Reduced hepatic steatosis was significantly associated with a higher risk of incident HCC in CHB infection. Routine CAP and LS measurements are important for risk stratification.
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Affiliation(s)
- Lung-Yi Mak
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road 102, Hong Kong, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Rex Wan-Hin Hui
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road 102, Hong Kong, China
| | - James Fung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road 102, Hong Kong, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Fen Liu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Danny Ka-Ho Wong
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road 102, Hong Kong, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Bofei Li
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Ka-Shing Cheung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road 102, Hong Kong, China.,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Man-Fung Yuen
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road 102, Hong Kong, China. .,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China.
| | - Wai-Kay Seto
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road 102, Hong Kong, China. .,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China. .,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
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Mak LY, Cloherty G, Wong DKH, Gersch J, Seto WK, Fung J, Yuen MF. HBV RNA Profiles in Patients With Chronic Hepatitis B Under Different Disease Phases and Antiviral Therapy. Hepatology 2021; 73:2167-2179. [PMID: 33159329 DOI: 10.1002/hep.31616] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Large-scale comprehensive studies on HBV RNA in chronic hepatitis B are lacking. We aimed to study the HBV RNA profile and its correlation with other viral markers in patients with chronic hepatitis B who are treatment-naïve and patients receiving nucleos(t)ide analogues (NA). APPROACH AND RESULTS Biomarkers, including HBV RNA and hepatitis B core-related antigen (HBcrAg), were measured in 388 patients. Of these, 246 were treatment-naïve and were categorized into HBeAg-positive chronic infection (n = 41), HBeAg-positive chronic hepatitis (n = 81), HBeAg-negative chronic infection (n = 39), HBeAg-negative chronic hepatitis (n = 66), and HBsAg seroclearance (n = 19). These biomarkers were also measured in 142 patients who were NA-treated receiving tenofovir or entecavir at baseline, week 48, and week 96. The pattern of serum HBV RNA levels mirrored HBV DNA (1-2 logs higher than HBV RNA) and HBcrAg in patients who were treatment-naïve. HBV RNA correlated best with HBcrAg (r = 0.84) and to a lesser extent with HBV DNA (r = 0.737) (both P < 0.001). In patients with HBsAg seroclearance, 15.8% and 15.8% had detectable serum HBV RNA and HBcrAg, respectively. NA treatment reduced serum HBV RNA by 1.46 logs and 1.77 logs at weeks 48 and 96, respectively. At week 96 of NA therapy, only 19.1% patients who were tenofovir-treated and 25.7% patients who were entecavir-treated had unquantifiable HBV RNA (P > 0.05). In patients who were treated and had undetectable HBV DNA, 77.5% and 30% had quantifiable HBV RNA and HBcrAg, respectively. CONCLUSIONS HBV RNA showed distinct and corresponding profiles in patients with HBV in different disease phases. HBV RNA and HBcrAg could be used to monitor residual transcriptional activities in patients with HBsAg seroclearance. NA led to reduction of serum HBV RNA. Monitoring of viral activities can still be achieved in patients with undetectable HBV DNA by serum HBV RNA.
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Affiliation(s)
- Lung-Yi Mak
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, Hong Kong
| | - Gavin Cloherty
- Department of Infectious Diseases, Abbott Laboratories, Chicago, IL
| | - Danny Ka-Ho Wong
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, Hong Kong
| | - Jeffrey Gersch
- Department of Infectious Diseases, Abbott Laboratories, Chicago, IL
| | - Wai-Kay Seto
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, Hong Kong
| | - James Fung
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, Hong Kong
| | - Man-Fung Yuen
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, Hong Kong
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Cheung KS, Mak LY, Lam LK, Fung J, Liu F, Seto WK, Yuen MF. Statins associate with better clinical outcomes in chronic hepatitis B patients with HBsAg seroclearance. Hepatol Int 2021; 15:881-891. [PMID: 33988834 DOI: 10.1007/s12072-021-10197-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION We aimed to describe long-term clinical outcomes in chronic hepatitis B (CHB) patients after HBsAg seroclearance, and identify factors that modify disease outcomes. METHODS CHB patients with HBsAg seroclearance occurring between 1986 and 2017 were recruited. Primary outcome was cirrhosis/hepatocellular carcinoma (HCC), and secondary outcomes were hepatic decompensation, liver-related death/transplantation, and all-cause mortality. Multivariable Cox model included demographics, prior antivirals, comorbidities, drugs (statins, metformin, proton-pump inhibitors, non-selective beta-blockers), and laboratory parameters (platelet, liver function test, prothrombin time, alpha-fetoprotein [AFP], anti-HBs). Statin users were propensity score matched (PSM) with non-users (1:2 ratio) for survival analysis of all outcomes. RESULTS Of 913 patients with HBsAg seroclearance (male: 613 [67.1%]; median age: 53.4 years [18.5-87.0]), 129 (14.1%) were statin users. During median follow-up of 7.7 years (up to 29.1 years), 64/833 (7.7%) developed cirrhosis, 25/905 (2.8%) developed HCC, 3/913 (0.3%) underwent transplantation, and 76/913 (8.3%) died. Statins were associated with lower cirrhosis/HCC risk (adjusted hazard ratio [aHR]: 0.44; 95% CI 0.20-0.96; aHR for every 1-year increase in use: 0.85; 95% CI 0.75-0.97). Statin users had no hepatic decompensation or liver-related death/transplantation (vs 18/778 [2.3%] and 18/784 [2.3%] cases in statin non-users, respectively). Statins were also associated with lower all-cause mortality risk (aHR: 0.21; 95% CI 0.08-0.53). PSM yields consistent results for beneficial effects of statins (log-rank p < 0.05 for all outcomes). Other factors for cirrhosis/HCC included increasing age (aHR: 1.06), diabetes (aHR: 2.03), higher creatinine (aHR: 1.008), GGT > 50U/L (aHR: 3.25), and AFP > 9 ng/mL (aHR: 10.14). CONCLUSION Patients with HBsAg seroclearance have favorable long-term survival. However, liver-related adverse outcomes still develop, necessitating further investigations on beneficial effects of statins.
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Affiliation(s)
- Ka Shing Cheung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China.,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Lung Yi Mak
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Lok Ka Lam
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - James Fung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Fen Liu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Wai Kay Seto
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China. .,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China. .,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China.
| | - Man Fung Yuen
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China. .,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China.
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Seto WK, Liu KS, Mak LY, Cloherty G, Wong DKH, Gersch J, Lam YF, Cheung KS, Chow N, Ko KL, To WP, Fung J, Yuen MF. Role of serum HBV RNA and hepatitis B surface antigen levels in identifying Asian patients with chronic hepatitis B suitable for entecavir cessation. Gut 2021; 70:775-783. [PMID: 32759300 DOI: 10.1136/gutjnl-2020-321116] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/16/2020] [Accepted: 06/27/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Treatment cessation in chronic HBV infection may be durable in certain patient subgroups before hepatitis B surface antigen (HBsAg) seroclearance. The role of serum HBV RNA in determining treatment cessation suitability has not been well-investigated. METHODS Nucleos(t)ide analogue (NUC) treatment was discontinued in non-cirrhotic patients with chronic HBV with serum HBsAg <200 IU/mL and fulfilling internationally recommended criteria for treatment cessation. Patients were monitored till 48 weeks with baseline and serial measurements of serum HBsAg, HBV RNA and hepatitis B core-related antigen. NUCs were resumed when HBV DNA reaches >2000 IU/mL regardless of alanine aminotransferase (ALT) levels. RESULTS 114 entecavir-treated patients (median age 58.4 years, median serum HBsAg 54.4 IU/mL) with median treatment duration of 6.7 years were recruited. The 48-week cumulative rate of HBV DNA >2000 IU/mL was 58.1%. End-of-treatment serum HBV RNA and off-treatment serial HBV RNA were both independently associated with HBV DNA >2000 IU/mL (HR 2.959, 95% CI 1.776 to 4.926, p<0.001; HR 2.278, 95% CI 1.151 to 4.525, p=0.018, respectively). Patients with HBV RNA ≥44.6 U/mL had a cumulative 48-week rate of 93.2%, while combining HBV RNA undetectability and HBsAg <10 IU/mL had a cumulative 48-week rate of 9.1%. 24 patients (38.7%) developed off-treatment ALT elevation, highest peak ALT was 1515 U/L. 8 patients (median serum HBsAg 2.6 IU/mL) developed HBsAg seroclearance. CONCLUSION Serum HBV RNA measurement is essential for deciding on entecavir cessation in patients with chronic HBV, especially with low HBsAg levels. Patients can be stratified on their risk of off-treatment relapse based on both viral determinants. TRIAL REGISTRATION NUMBER NCT02738554.
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Affiliation(s)
- Wai-Kay Seto
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China .,State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, China.,Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Kevin Sh Liu
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Lung-Yi Mak
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China.,State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, China
| | - Gavin Cloherty
- Infectious Disease Research, Abbott Laboratories, Abbott Park, Illinois, USA
| | - Danny Ka-Ho Wong
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China.,State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, China
| | - Jeffrey Gersch
- Infectious Disease Research, Abbott Laboratories, Abbott Park, Illinois, USA
| | - Yuk-Fai Lam
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Ka-Shing Cheung
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China.,Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Ning Chow
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Kwan-Lung Ko
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Wai-Pan To
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - James Fung
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China.,State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, China
| | - Man-Fung Yuen
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China .,State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong, China
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Mak LY, Wong DKH, Cheung KS, Seto WK, Fung J, Yuen MF. First-line oral antiviral therapies showed similar efficacies in suppression of serum HBcrAg in chronic hepatitis B patients. BMC Gastroenterol 2021; 21:123. [PMID: 33731023 PMCID: PMC7968194 DOI: 10.1186/s12876-021-01711-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 03/07/2021] [Indexed: 12/11/2022] Open
Abstract
Background Serum hepatitis B core-related antigen (HBcrAg) is a potential surrogate marker for intra-hepatic covalently-closed circular DNA in chronic hepatitis B (CHB). We aimed to study the profiles of serum HBcrAg in CHB patients treated with first-line nucleos(t)ide analogues (NA): entecavir (ETV), tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide (TAF). Method Serum HBcrAg was measured in 120 treatment-naïve CHB patients receiving one of the 3 NAs (ETV: TDF: TAF = 60: 26: 34) using the Lumipulse G HBcrAg assay in a Lumipulse G1200 analyzer (Fujirebio Inc, Toyko, Japan). Serum HBcrAg levels were measured at week 0, week 48 and week 96 of NA therapy. Results Among the 120 patients, 67 (55.8%) were hepatitis B e antigen (HBeAg) positive. Both tenofovir and ETV led to significantly lower serum HBcrAg at week 48 and week 96 compared to week 0. There were no significant differences for the magnitude of median HBcrAg decline at week 96 between tenofovir and ETV in HBeAg-positive (2.28 vs. 1.65 log U/mL, p > 0.05) and HBeAg-negative (0.83 vs. 0.54 log U/mL, p > 0.05) patients. TDF and TAF produced no significant differences in the magnitude of median HBcrAg decline at week 96 (HBeAg-positive: 2.63 vs. 1.83, respectively; HBeAg-negative: 1.04 vs. 0.40, respectively; both p > 0.05). Conclusion Magnitude of reduction of HBcrAg levels after 2-year first-line treatment did not differ statistically among the current first-line NAs, although HBcrAg reduction was numerically greater in tenofovir-treated group. More long-term studies are essential to determine whether tenofovir exerts a more pronounced effect on HBcrAg. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-021-01711-x.
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Affiliation(s)
- Lung-Yi Mak
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road 102,, Pok Fu Lam, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Danny Ka-Ho Wong
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road 102,, Pok Fu Lam, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Ka-Shing Cheung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road 102,, Pok Fu Lam, Hong Kong.,Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Wai-Kay Seto
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road 102,, Pok Fu Lam, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - James Fung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road 102,, Pok Fu Lam, Hong Kong.,State Key Laboratory of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Man-Fung Yuen
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road 102,, Pok Fu Lam, Hong Kong. .,State Key Laboratory of Liver Research, The University of Hong Kong, Pok Fu Lam, Hong Kong.
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Marla S, Mortlock S, Houshdaran S, Fung J, McKinnon B, Holdsworth-Carson SJ, Girling JE, Rogers PAW, Giudice LC, Montgomery GW. Genetic risk factors for endometriosis near estrogen receptor 1 and coexpression of genes in this region in endometrium. Mol Hum Reprod 2021; 27:gaaa082. [PMID: 33394050 PMCID: PMC8453628 DOI: 10.1093/molehr/gaaa082] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/29/2020] [Indexed: 01/14/2023] Open
Abstract
The etiology and pathogenesis of endometriosis are complex with both genetic and environmental factors contributing to disease risk. Genome-wide association studies (GWAS) have identified multiple signals in the estrogen receptor 1 (ESR1) region associated with endometriosis and other reproductive traits and diseases. In addition, candidate gene association studies identified signals in the ESR1 region associated with endometriosis risk suggesting genetic regulation of genes in this region may be important for reproductive health. This study aimed to investigate hormonal and genetic regulation of genes in the ESR1 region in human endometrium. Changes in serum oestradiol and progesterone concentrations and expression of hormone receptors ESR1 and progesterone receptor (PGR) were assessed in endometrial samples from 135 women collected at various stages of the menstrual cycle. Correlation between hormone concentrations, receptor expression and expression of genes in the ESR1 locus was investigated. The effect of endometriosis risk variants on expression of genes in the region was analyzed to identify gene targets. Hormone concentrations and receptor expression varied significantly across the menstrual cycle. Expression of genes in the ESR1 region correlated with progesterone concentration; however, they were more strongly correlated with expression of ESR1 and PGR suggesting coregulation of genes. There was no evidence that endometriosis risk variants directly regulated expression of genes in the region. Limited sample size and cellular heterogeneity in endometrial tissue may impact the ability to detect significant genetic effects on gene expression. Effects of these variants should be validated in a larger dataset and in relevant individual cell types.
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Affiliation(s)
- S Marla
- Institute for Molecular Bioscience, The University of Queensland, St Lucia, Brisbane, QLD 4072, Australia
| | - S Mortlock
- Institute for Molecular Bioscience, The University of Queensland, St Lucia, Brisbane, QLD 4072, Australia
| | - S Houshdaran
- Department of Obstetrics, Gynecology and Reproductive Sciences, Center for Reproductive Sciences, University of California, San Francisco, CA 94143, USA
| | - J Fung
- Institute for Molecular Bioscience, The University of Queensland, St Lucia, Brisbane, QLD 4072, Australia
- School of Biomedical Sciences, The University of Queensland, St Lucia, Brisbane, QLD 4072, Australia
| | - B McKinnon
- Institute for Molecular Bioscience, The University of Queensland, St Lucia, Brisbane, QLD 4072, Australia
- Department of Gynaecology, Inselspital, Bern, Switzerland
| | - S J Holdsworth-Carson
- Department of Obstetrics and Gynaecology, Gynaecology Research Centre, Royal Women’s Hospital, University of Melbourne, Parkville, VIC 3052, Australia
| | - J E Girling
- Department of Obstetrics and Gynaecology, Gynaecology Research Centre, Royal Women’s Hospital, University of Melbourne, Parkville, VIC 3052, Australia
- Department of Anatomy, University of Otago, Dunedin 9016, New Zealand
| | - P A W Rogers
- Department of Obstetrics and Gynaecology, Gynaecology Research Centre, Royal Women’s Hospital, University of Melbourne, Parkville, VIC 3052, Australia
| | - L C Giudice
- Department of Obstetrics, Gynecology and Reproductive Sciences, Center for Reproductive Sciences, University of California, San Francisco, CA 94143, USA
| | - G W Montgomery
- Institute for Molecular Bioscience, The University of Queensland, St Lucia, Brisbane, QLD 4072, Australia
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Fung J, Mak LY, Chan A, Wong T, Dai WC, Sin SL, She WH, Chu KW, Ma KW, Cheung TT, Seto WK, Yuen MF, Lo CM. Trends in Liver Transplantation for Chronic Hepatitis B in an Era of Highly Potent Antiviral Therapies. Liver Transpl 2021; 27:134-139. [PMID: 32652770 DOI: 10.1002/lt.25846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/04/2020] [Accepted: 06/16/2020] [Indexed: 12/14/2022]
Affiliation(s)
- James Fung
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
- The Liver Transplant Center, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Pokfulam, Hong Kong
| | - Lung-Yi Mak
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Albert Chan
- The Liver Transplant Center, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Pokfulam, Hong Kong
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Tiffany Wong
- The Liver Transplant Center, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Wing-Chiu Dai
- The Liver Transplant Center, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Sui-Ling Sin
- The Liver Transplant Center, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Wong-Hoi She
- The Liver Transplant Center, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Ka-Wan Chu
- The Liver Transplant Center, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Ka-Wing Ma
- The Liver Transplant Center, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Tan-To Cheung
- The Liver Transplant Center, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Pokfulam, Hong Kong
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Wai-Kay Seto
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Pokfulam, Hong Kong
| | - Man-Fung Yuen
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Pokfulam, Hong Kong
| | - Chung-Mau Lo
- The Liver Transplant Center, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
- State Key Laboratory of Liver Research, The University of Hong Kong, Pokfulam, Hong Kong
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
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Juloori A, Liao C, Lemons J, Singh A, Iyer R, Robbins J, George B, Fung J, Pillai A, Arif F, Sharma M, Liauw S. Phase I Study of Stereotactic Body Radiotherapy followed by Ipilimumab with Nivolumab vs. Nivolumab alone in Unresectable Hepatocellular Carcinoma. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Huang DQ, Yeo YH, Tan E, Takahashi H, Yasuda S, Saruwatari J, Tanaka K, Oniki K, Kam LY, Muthiah MD, Hyogo H, Ono M, Barnett SD, Li J, Zou B, Fung J, Lee TY, Wong VWS, Yuen MF, Dan YY, Lim SG, Cheung R, Toyoda H, Eguchi Y, Nguyen MH. ALT Levels for Asians With Metabolic Diseases: A Meta-analysis of 86 Studies With Individual Patient Data Validation. Hepatol Commun 2020; 4:1624-1636. [PMID: 33163833 PMCID: PMC7603525 DOI: 10.1002/hep4.1593] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/06/2020] [Accepted: 07/27/2020] [Indexed: 12/14/2022] Open
Abstract
The current alanine aminotransferase (ALT) upper limit of normal was defined using selected healthy Caucasian blood donors. Given the global rise in obesity and different body habitus in Asians, we aimed to perform a systematic review and meta-analysis combined with bootstrap modeling and individual patient data validation to estimate the ALT upper threshold for Asians, including the overweight and diabetics. We included studies from PubMed, Embase, and Cochrane database searches that identified individuals without known liver diseases (i.e., viral hepatitis, alcohol, and ultrasound-detected nonalcoholic fatty liver disease). The mean ALT (U/L) was estimated using a random-effects mixed model and upper threshold (95th-percentile value, U/L) via a bootstrap model with 10,000 resamples. We screened 4,995 studies and identified 86 studies that reported ALT values for 526,641 individuals without excessive alcohol intake or known liver diseases, yielding a mean ALT of 19 and ALT upper threshold of 32. The ALT upper threshold was 37 in males versus 31 in females, 39 in overweight versus 28 in normal-weight individuals, and 36 for diabetics versus 33 for nondiabetics. We validated our study level data with individual patient level data in 6,058 individuals from five study centers in Japan. Consistent with our study-level data, we found that the ALT upper threshold in our individual patient data analysis was indeed higher in overweight versus normal-weight individuals (39 vs. 32) and in diabetics versus nondiabetics (42 vs. 33). Conclusion: We provide validated reference ranges for ALT upper threshold derived from Asians without known liver disease, including individuals with ultrasound-detected nonalcoholic fatty liver disease who are normal weight, overweight, nondiabetic, and diabetic, to inform practice.
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Affiliation(s)
- Daniel Q Huang
- Division of Gastroenterology and Hepatology Department of Medicine National University Hospital Singapore Singapore.,Department of Medicine Yong Loo Lin School of Medicine National University of Singapore Singapore Singapore
| | - Yee Hui Yeo
- Division of Gastroenterology and Hepatology Stanford University Medical Center Palo Alto CA USA
| | - Eunice Tan
- Division of Gastroenterology and Hepatology Department of Medicine National University Hospital Singapore Singapore
| | | | - Satoshi Yasuda
- Department of Gastroenterology Ogaki Municipal Hospital Ogaki Japan
| | - Junji Saruwatari
- Division of Pharmacology and Therapeutics Graduate School of Pharmaceutical Sciences Kumamoto University Kumamoto Japan
| | | | - Kentaro Oniki
- Division of Pharmacology and Therapeutics Graduate School of Pharmaceutical Sciences Kumamoto University Kumamoto Japan
| | - Leslie Y Kam
- Division of Gastroenterology and Hepatology Stanford University Medical Center Palo Alto CA USA
| | - Mark D Muthiah
- Division of Gastroenterology and Hepatology Department of Medicine National University Hospital Singapore Singapore.,Department of Medicine Yong Loo Lin School of Medicine National University of Singapore Singapore Singapore
| | - Hideyuki Hyogo
- Department of Gastroenterology and Hepatology JA Hiroshima General Hospital Hiroshima Japan
| | - Masafumi Ono
- Department of Internal Medicine Tokyo Women's Medical University Medical Center East Tokyo Japan
| | - Scott D Barnett
- Division of Gastroenterology and Hepatology Stanford University Medical Center Palo Alto CA USA
| | - Jie Li
- Department of Infectious Disease Shandong Provincial Hospital Affiliated to Shandong University Shandong China
| | - Biyao Zou
- Division of Gastroenterology and Hepatology Stanford University Medical Center Palo Alto CA USA
| | - James Fung
- Department of Medicine Queen Mary Hospital The University of Hong Kong Hong Kong Hong Kong
| | - Teng-Yu Lee
- Division of Gastroenterology Department of Internal Medicine Taichung Veterans General Hospital Taichung Taiwan.,Department of Medicine Chung Shan Medical University Taichung Taiwan
| | - Vincent Wai-Sun Wong
- Institute of Digestive Disease Faculty of Medicine Chinese University of Hong Kong Hong Kong Hong Kong
| | - Man-Fung Yuen
- Department of Medicine Queen Mary Hospital The University of Hong Kong Hong Kong Hong Kong
| | - Yock Young Dan
- Division of Gastroenterology and Hepatology Department of Medicine National University Hospital Singapore Singapore.,Department of Medicine Yong Loo Lin School of Medicine National University of Singapore Singapore Singapore
| | - Seng Gee Lim
- Division of Gastroenterology and Hepatology Department of Medicine National University Hospital Singapore Singapore.,Department of Medicine Yong Loo Lin School of Medicine National University of Singapore Singapore Singapore
| | - Ramsey Cheung
- Division of Gastroenterology and Hepatology Stanford University Medical Center Palo Alto CA USA
| | - Hidenori Toyoda
- Department of Gastroenterology Ogaki Municipal Hospital Ogaki Japan
| | | | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology Stanford University Medical Center Palo Alto CA USA
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48
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Fung J, Mak LY, Chan ACY, Chok KSH, Wong TCL, Cheung TT, Dai WC, Sin SL, She WH, Ma KW, Seto WK, Lai CL, Lo CM, Yuen MF. Model for End-Stage Liver Disease With Additional Criteria to Predict Short-Term Mortality in Severe Flares of Chronic Hepatitis B. Hepatology 2020; 72:818-828. [PMID: 31872444 DOI: 10.1002/hep.31086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 12/12/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The prognosis in severe acute flares of chronic hepatitis B (AFOCHB) is often unclear. The current study aimed to establish the predictive value using the Model for End-Stage Liver Disease (MELD) score for short-term mortality for severe AFOCHB. APPROACH AND RESULTS Patients with severe AFOCHB with bilirubin > 50 µmol/L, alanine aminotransferase > 10× upper limit of normal, and international normalized ratio > 1.5 were included. All patients were commenced on entecavir and/or tenofovir. Laboratory results and MELD scores were pooled to calculate mortality at four time points (days 7, 14, 21, and 28). A total of 240 patients were included. Median hepatitis B virus DNA was 7.77 log IU/mL (range, 4.11-10.06), and 49 (20.4%) were hepatitis B e antigen-positive. The 7, 14, 21, and 28-day survival was 96.7%, 88.5%, 79.5%, and 72.8%, respectively. Using pooled results derived from 4,201 blood samples, the area under the receiver operating curve for the MELD score to predict day 7, 14, 21, and 28 mortality was 0.909, 0.892, 0.883, and 0.871, respectively. For MELD ≤ 28, mortality at day 28 was low (<25%) compared with > 50% mortality for MELD ≥ 32. For MELD = 28-32, higher day-28 mortality was observed for four criteria: age ≥52 years, alanine aminotransferase > 217 U/L, platelets < 127, and abnormal baseline imaging (all P < 0.001). In this MELD bracket, the 28-day mortality was 0%, 12.1%, 23.8%, 59.4%, and 78.8% for the presence of zero, one, two, three, and four criteria, respectively. CONCLUSIONS MELD score at any time points can accurately predict the short-term mortality. Patients with MELD ≥ 28 should be worked up for liver transplantation, and those with MELD = 28-32 with three to four at-risk criteria, or MELD ≥ 32 should be listed.
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Affiliation(s)
- James Fung
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China.,The Liver Transplant Center, Queen Mary Hospital, Hong Kong SAR, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR, China
| | - Lung-Yi Mak
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Albert Chi-Yan Chan
- The Liver Transplant Center, Queen Mary Hospital, Hong Kong SAR, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR, China.,Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - Kenneth Siu-Ho Chok
- The Liver Transplant Center, Queen Mary Hospital, Hong Kong SAR, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR, China.,Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - Tiffany Cho-Lam Wong
- The Liver Transplant Center, Queen Mary Hospital, Hong Kong SAR, China.,Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - Tan-To Cheung
- The Liver Transplant Center, Queen Mary Hospital, Hong Kong SAR, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR, China.,Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - Wing-Chiu Dai
- The Liver Transplant Center, Queen Mary Hospital, Hong Kong SAR, China.,Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - Sui-Ling Sin
- The Liver Transplant Center, Queen Mary Hospital, Hong Kong SAR, China.,Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - Wong-Hoi She
- The Liver Transplant Center, Queen Mary Hospital, Hong Kong SAR, China.,Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - Ka-Wing Ma
- The Liver Transplant Center, Queen Mary Hospital, Hong Kong SAR, China.,Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - Wai-Kay Seto
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR, China
| | - Ching-Lung Lai
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR, China
| | - Chung-Mau Lo
- The Liver Transplant Center, Queen Mary Hospital, Hong Kong SAR, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR, China.,Department of Surgery, The University of Hong Kong, Hong Kong SAR, China
| | - Man-Fung Yuen
- Department of Medicine, The University of Hong Kong, Hong Kong SAR, China.,State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong SAR, China
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49
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Tampi RP, Wong VWS, Wong GLH, Shu SST, Chan HLY, Fung J, Stepanova M, Younossi ZM. Modelling the economic and clinical burden of non-alcoholic steatohepatitis in East Asia: Data from Hong Kong. Hepatol Res 2020; 50:1024-1031. [PMID: 32537840 DOI: 10.1111/hepr.13535] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/27/2020] [Accepted: 06/09/2020] [Indexed: 02/08/2023]
Abstract
AIM Non-alcoholic steatohepatitis (NASH) is the progressive form of non-alcoholic fatty liver disease (NAFLD) and prevalence is rising in Asia due to increasing rates of urbanization, sedentary lifestyles, and poor nutrition. METHODS We built a Markov model with 20-year horizon to estimate the burden of NASH in Hong Kong. Cohort size was determined by population size, prevalence of NAFLD, and incidence of NASH in 2017. Health states include hepatic steatosis, fibrosis stages 0-3, compensated and decompensated cirrhosis, hepatocellular carcinoma, post-liver transplant, and liver-related, cardiovascular, and background mortality. Transition probabilities were estimated from published reports and we converted 2017 Gazette price from the Hospital Authority of Hong Kong to US dollars. We discounted costs by 3% annually. Health utilities were assumed to be the same as in the USA. RESULTS Non-alcoholic steatohepatitis will cost $1.32 billion and 124 liver transplants over 20 years, with average cost per person-year of $257. Sensitivity analyses show our model is robust in predicting costs for the prevalent population but likely overestimates costs for the incident population. CONCLUSIONS Non-alcoholic steatohepatitis will contribute to a significant clinical and economic burden in Hong Kong over the next two decades. Due to the limited number of donors and small number of liver transplants undertaken annually, patients with advanced liver disease due to NASH in Hong Kong are more likely to die from NASH than their counterparts in North America and Europe. Thus, rising prevalence of metabolic syndrome in elderly adults in Hong Kong make NASH an important consideration for clinicians and policy makers.
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Affiliation(s)
- Radhika P Tampi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.,State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Grace Lai-Hung Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.,State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Sally She-Ting Shu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.,State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Henry Lik-Yuen Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.,State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - James Fung
- Department of Medicine, The University of Hong Kong, Hong Kong.,State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong
| | - Maria Stepanova
- Center for Outcomes Research in Liver Diseases, Washington, DC, USA
| | - Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA.,Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, USA
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50
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Estes C, Chan HLY, Chien RN, Chuang WL, Fung J, Goh GBB, Hu TH, Huang JF, Jang BK, Jun DW, Kao JH, Lee JW, Lin HC, Razavi-Shearer K, Seto WK, Wong GLH, Wong VWS, Razavi H. Editorial: increasing burden of nonalcoholic fatty liver disease-a call to action. Authors' reply. Aliment Pharmacol Ther 2020; 51:1430-1432. [PMID: 32445526 DOI: 10.1111/apt.15718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Chris Estes
- Center for Disease Analysis Foundation, Lafayette, Colorado, US
| | - Henry L Y Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.,State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Rong N Chien
- Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital and University at Keelung, Keelung, Taiwan.,Community Medicine Research Center, Chang-Gung Memorial Hospital, Keelung, Taiwan
| | - Wan-Long Chuang
- Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - James Fung
- State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong.,Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - George Boon-Bee Goh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.,Duke-National University of Singapore Medical School, Singapore
| | - Tsung H Hu
- Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Jee-Fu Huang
- Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Internal Medicine and Hepatitis Research Center, School of Medicine, College of Medicine, and Center for Cancer Research and Liquid Biopsy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Byoung K Jang
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Dae W Jun
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jia H Kao
- National Taiwan University College of Medicine, and National Taiwan University Hospital, Taipei, Taiwan
| | - Jin-Woo Lee
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Han-Chieh Lin
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, School of Medicine, ational Yang-Ming University, Taipei, Taiwan
| | | | - Wai-Kay Seto
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Grace L-H Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.,State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Vincent W-S Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong.,State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Homie Razavi
- Center for Disease Analysis Foundation, Lafayette, Colorado, US
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