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Murillo Perez CF, Ioannou S, Hassanally I, Trivedi PJ, Corpechot C, van der Meer AJ, Lammers WJ, Battezzati PM, Lindor KD, Nevens F, Kowdley KV, Bruns T, Cazzagon N, Floreani A, Mason AL, Gulamhusein A, Ponsioen CY, Carbone M, Lleo A, Mayo MJ, Dalekos GN, Gatselis NK, Thorburn D, Verhelst X, Parés A, Londoño MC, Janssen HLA, Invernizzi P, Vuppalanchi R, Hirschfield GM, Hansen BE, Levy C. Optimizing therapy in primary biliary cholangitis: Alkaline phosphatase at six months identifies one-year non-responders and predicts survival. Liver Int 2023; 43:1497-1506. [PMID: 37157905 DOI: 10.1111/liv.15592] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 02/07/2023] [Revised: 04/05/2023] [Accepted: 04/16/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND AND AIMS Patients with primary biliary cholangitis (PBC) and insufficient response to ursodeoxycholic acid (UDCA), currently assessed after 1 year, are candidates for second-line therapy. The aims of this study are to assess biochemical response pattern and determine the utility of alkaline phosphatase (ALP) at six months as a predictor of insufficient response. METHODS UDCA-treated patients in the GLOBAL PBC database with available liver biochemistries at one year were included. POISE criteria were used to assess response to treatment, defined as ALP <1.67 × upper limit of normal (ULN) and normal total bilirubin at one year. Various thresholds of ALP at six months were evaluated to predict insufficient response based on negative predictive value (NPV) and that with nearest to 90% NPV was selected. RESULTS For the study, 1362 patients were included, 1232 (90.5%) female, mean age of 54 years. The POISE criteria were met by 56.4% (n = 768) of patients at one year. The median ALP (IQR) of those who met POISE criteria compared to those who did not was 1.05 × ULN (0.82-1.33) vs. 2.37 × ULN (1.72-3.69) at six months (p < .001). Of 235 patients with serum ALP >1.9 × ULN at six months, 89% did not achieve POISE criteria (NPV) after one year of UDCA. Of those with insufficient response by POISE criteria at one year, 210 (67%) had an ALP >1.9 × ULN at six months and thus would have been identified early. CONCLUSIONS We can identify patients for second-line therapy at six months using an ALP threshold of 1.9 × ULN, given that approximately 90% of these patients are non-responders according to POISE criteria.
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Affiliation(s)
- C Fiorella Murillo Perez
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Stephanie Ioannou
- Schiff Center for Liver Diseases, Division of Digestive Health and Liver Diseases, University of Miami, Miami, Florida, USA
| | | | - Palak J Trivedi
- National Institute for Health Research Birmingham Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Christophe Corpechot
- Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, Paris, France
| | | | - Willem J Lammers
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | | | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | | | - Tony Bruns
- Department of Internal Medicine IV, Jena University Hospital, Friedrich Schiller University, Jena, Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Nora Cazzagon
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- IRCCS Negrar, Verona, Italy
| | - Andrew L Mason
- Divison of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Aliya Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Marco Carbone
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza, Italy
| | - Ana Lleo
- Division of Internal Medicine and Hepatology, IRCCS Humanitas Research Hospital, Department of Biomedical Sciences, Humanitas University, Rozzano (Milan), Italy
| | - Marlyn J Mayo
- Digestive and Liver diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, Full Member of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, Full Member of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre, The Royal Free Hospital, London, UK
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Albert Parés
- Liver Unit, Hospital Clínic de Barcelona, Health Care Provider of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER) CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Maria-Carlota Londoño
- Liver Unit, Hospital Clínic de Barcelona, Health Care Provider of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER) CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza, Italy
| | - Raj Vuppalanchi
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Cynthia Levy
- Schiff Center for Liver Diseases, Division of Digestive Health and Liver Diseases, University of Miami, Miami, Florida, USA
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Ali AH, Buness CW, Fischer R, Holtmann GJ, Shah A, Lewindon P, Shah S, Ragnekar AS, Taylor AE, Goel A, Cox KL, Alrabadi L, Wadsworth S, Kulkarni SS, Lindor KD. Letter to the Editor: Insurance should cover vancomycin for primary sclerosing cholangitis. Hepatology 2023; 77:E174-E175. [PMID: 36705026 DOI: 10.1097/hep.0000000000000304] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 01/28/2023]
Affiliation(s)
- Ahmad H Ali
- Division of Gastroenterology and Hepatology, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Cynthia W Buness
- Global Liver Institute Pediatric and Rare Liver Diseases Research Working Group; Stanford University, Autoimmune Liver Disease Network for Kids (A-LiNK); National Patient Advocate Foundation, Washington DC, USA
| | - Ryan Fischer
- Division of Hepatology and Transplant Medicine, Department of Gastroenterology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Gerald J Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Ayesha Shah
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Peter Lewindon
- Department of Gastroenterology, Queensland Children's Hospital, Brisbane, Queensland, Australia
- Children's Medical Research Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Shamita Shah
- Division of Gastroenterology, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
| | - Amol S Ragnekar
- MedStar Georgetown Transplant Institute, Department of Medicine, Georgetown University, Washington DC, USA
| | - Amy E Taylor
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Aparna Goel
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Palo Alto, California, USA
| | - Kenneth L Cox
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Emeritus, Stanford University School of Medicine Palo Alto, California, USA
| | - Leina Alrabadi
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Emeritus, Stanford University School of Medicine Palo Alto, California, USA
| | - Steve Wadsworth
- Children's PSC Foundation; Stanford University, Autoimmune Liver Disease Network for Kids (A-LiNK), Stanford, California, USA
| | - Sakil S Kulkarni
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona, USA
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Hochberg JT, Sohal A, Handa P, Maliken BD, Kim TK, Wang K, Gochanour E, Li Y, Rose JB, Nelson JE, Lindor KD, LaRusso NF, Kowdley KV. Serum miRNA profiles are altered in patients with primary sclerosing cholangitis receiving high-dose ursodeoxycholic acid. JHEP Rep 2023; 5:100729. [PMID: 37179785 PMCID: PMC10172698 DOI: 10.1016/j.jhepr.2023.100729] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 02/02/2023] [Accepted: 02/27/2023] [Indexed: 05/15/2023] Open
Abstract
Background & Aims Primary sclerosing cholangitis (PSC) is a chronic, progressive cholestatic liver disease that can lead to end-stage liver disease and cholangiocarcinoma. High-dose ursodeoxycholic acid (hd-UDCA, 28-30 mg/kg/day) was evaluated in a previous multicentre, randomised placebo-controlled trial; however, the study was discontinued early because of increased liver-related serious adverse events (SAEs), despite improvement in serum liver biochemical tests. We investigated longitudinal changes in serum miRNA and cytokine profiles over time among patients treated with either hd-UDCA or placebo in this trial as potential biomarkers for PSC and response to hd-UDCA, as well as to understand the toxicity associated with hd-UDCA treatment. Methods Thirty-eight patients with PSC were enrolled in a multicentred, randomised, double-blinded trial of hd-UDCA vs. placebo. Results Significant alterations in serum miRNA profiles were found over time in both patients treated with hd-UDCA or placebo. Additionally, there were striking differences between miRNA profiles in patients treated with hd-UDCA compared with placebo. In patients treated with placebo, the changes in concentration of serum miRNAs miR-26a, miR-199b-5p, miR-373, and miR-663 suggest alterations of inflammatory and cell proliferative processes consistent with disease progression. However, patients treated with hd-UDCA exhibited a more pronounced differential expression of serum miRNAs, suggesting that hd-UDCA induces significant cellular miRNA changes and tissue injury. Pathway enrichment analysis for UDCA-associated miRNAs suggested unique dysregulation of cell cycle and inflammatory response pathways. Conclusions Patients with PSC have distinct miRNAs in the serum and bile, although the implications of these unique patterns have not been studied longitudinally or in relation to adverse events related to hd-UDCA. Our study demonstrates marked changes in miRNA serum profiles with hd-UDCA treatment and suggests mechanisms for the increased liver toxicity with therapy. Impact and implications Using serum samples from patients with PSC enrolled in a clinical trial comparing hd-UDCA with placebo, our study found distinct miRNA changes in patients with PSC who are treated with hd-UDCA over a period of time. Our study also noted distinct miRNA patterns in patients who developed SAEs during the study period.
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Affiliation(s)
- Jessica T. Hochberg
- Liver Institute Northwest, Seattle, WA, USA
- Seattle Children’s Hospital/University of Washington, Seattle, WA, USA
- Miami Transplant Institute at University of Miami, Miami, FL, USA
| | | | - Priya Handa
- Benaroya Research Institute, Seattle, WA, USA
| | | | | | - Kai Wang
- Institute for Systems Biology, Seattle, WA, USA
| | | | - Yu Li
- Benaroya Research Institute, Seattle, WA, USA
| | | | | | - Keith D. Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, MN, USA
| | | | - Kris V. Kowdley
- Liver Institute Northwest, Seattle, WA, USA
- Corresponding author. Address: Liver Institute Northwest, 3216 NE 45th Pl Suite 212, Seattle, WA 98105, USA; Tel.: +1(206) 536-3030.
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Murillo Perez CF, Fisher H, Hiu S, Kareithi D, Adekunle F, Mayne T, Malecha E, Ness E, van der Meer AJ, Lammers WJ, Trivedi PJ, Battezzati PM, Nevens F, Kowdley KV, Bruns T, Cazzagon N, Floreani A, Mason AL, Parés A, Londoño MC, Invernizzi P, Carbone M, Lleo A, Mayo MJ, Dalekos GN, Gatselis NK, Thorburn D, Verhelst X, Gulamhusein A, Janssen HLA, Smith R, Flack S, Mulcahy V, Trauner M, Bowlus CL, Lindor KD, Corpechot C, Jones D, Mells G, Hirschfield GM, Wason J, Hansen BE. Greater Transplant-Free Survival in Patients Receiving Obeticholic Acid for Primary Biliary Cholangitis in a Clinical Trial Setting Compared to Real-World External Controls. Gastroenterology 2022; 163:1630-1642.e3. [PMID: 36150526 DOI: 10.1053/j.gastro.2022.08.054] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [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: 03/04/2022] [Revised: 07/19/2022] [Accepted: 08/30/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS The Primary Biliary Cholangitis (PBC) Obeticholic Acid (OCA) International Study of Efficacy (POISE) randomized, double-blind, placebo-controlled trial demonstrated that OCA reduced biomarkers associated with adverse clinical outcomes (ie, alkaline phosphatase, bilirubin, aspartate aminotransferase, and alanine aminotransferase) in patients with PBC. The objective of this study was to evaluate time to first occurrence of liver transplantation or death in patients with OCA in the POISE trial and open-label extension vs comparable non-OCA-treated external controls. METHODS Propensity scores were generated for external control patients meeting POISE eligibility criteria from 2 registry studies (Global PBC and UK-PBC) using an index date selected randomly between the first and last date (inclusive) on which eligibility criteria were met. Cox proportional hazards models weighted by inverse probability of treatment assessed time to death or liver transplantation. Additional analyses (Global PBC only) added hepatic decompensation to the composite end point and assessed efficacy in patients with or without cirrhosis. RESULTS During the 6-year follow-up, there were 5 deaths or liver transplantations in 209 subjects in the POISE cohort (2.4%), 135 of 1381 patients in the Global PBC control (10.0%), and 281 of 2135 patients in the UK-PBC control (13.2%). The hazard ratios (HRs) for the primary outcome were 0.29 (95% CI, 0.10-0.83) for POISE vs Global PBC and 0.30 (95% CI, 0.12-0.75) for POISE vs UK-PBC. In the Global PBC study, HR was 0.20 (95% CI, 0.03-1.22) for patients with cirrhosis and 0.31 (95% CI, 0.09-1.04) for those without cirrhosis; HR was 0.42 (95% CI, 0.21-0.85) including hepatic decompensation. CONCLUSIONS Patients treated with OCA in a trial setting had significantly greater transplant-free survival than comparable external control patients.
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Affiliation(s)
- C Fiorella Murillo Perez
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Holly Fisher
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Shaun Hiu
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | | | - Tracy Mayne
- Intercept Pharmaceuticals, Morristown, New Jersey
| | | | - Erik Ness
- Intercept Pharmaceuticals, Morristown, New Jersey
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | | | - Frederik Nevens
- University Hospital Katholieke Universiteit Leuven, Leuven, Belgium
| | | | - Tony Bruns
- Department of Gastroenterology and Hepatology, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen University, Aachen, Germany
| | | | | | - Andrew L Mason
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Albert Parés
- Department of Medicine, Liver Unit, Hospital Clínic, University of Barcelona, The August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Barcelona, Spain; European Reference Network on Hepatological Diseases, Barcelona, Spain
| | - Maria-Carlota Londoño
- Department of Medicine, Liver Unit, Hospital Clínic, University of Barcelona, The August Pi i Sunyer Biomedical Research Institute, Biomedical Research Networking Center in Hepatic and Digestive Diseases, Barcelona, Spain; European Reference Network on Hepatological Diseases, Barcelona, Spain
| | - Pietro Invernizzi
- European Reference Network on Hepatological Diseases, Barcelona, Spain; Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; San Gerardo Hospital, Monza, Italy
| | | | - Ana Lleo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marlyn J Mayo
- Department of Medicine, Division of Digestive and Liver Disease, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - George N Dalekos
- European Reference Network on Hepatological Diseases, Barcelona, Spain; Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Nikolaos K Gatselis
- European Reference Network on Hepatological Diseases, Barcelona, Spain; Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Douglas Thorburn
- Royal Free London National Health Service Foundation Trust, London, United Kingdom
| | - Xavier Verhelst
- Department of Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Aliya Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Rachel Smith
- Cambridge Liver Unit, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, United Kingdom
| | - Steve Flack
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, United Kingdom
| | - Victoria Mulcahy
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, United Kingdom
| | | | | | | | | | - David Jones
- Newcastle University, Newcastle upon Tyne, United Kingdom
| | - George Mells
- Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - James Wason
- Department of Biostatistics, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Epidemiology & Biostatistics, Erasmus MC, Rotterdam, the Netherlands, Toronto, Ontario, Canada; IHPME, University of Toronto, Toronto, Ontario, Canada.
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de Veer RC, Harms MH, Corpechot C, Thorburn D, Invernizzi P, Janssen HLA, Battezzati PM, Nevens F, Lindor KD, Floreani A, Ponsioen CY, Mayo MJ, Parés A, Mason AL, Kowdley KV, Trivedi PJ, Hirschfield GM, Bruns T, Dalekos GN, Gatselis NK, Verhelst X, Lammers WJ, Hansen BE, van Buuren HR, van der Meer AJ. Liver transplant-free survival according to alkaline phosphatase and GLOBE score in patients with primary biliary cholangitis treated with ursodeoxycholic acid. Aliment Pharmacol Ther 2022; 56:1408-1418. [PMID: 36138566 PMCID: PMC9826062 DOI: 10.1111/apt.17226] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 06/06/2022] [Revised: 06/23/2022] [Accepted: 09/05/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND After 1 year of ursodeoxycholic acid (UDCA), patients with primary biliary cholangitis (PBC) may have a normal GLOBE score despite high alkaline phosphatase (ALP) levels. AIM To assess the association between ALP and liver transplantation (LT)-free survival according to the GLOBE score METHODS: Among patients with a normal or elevated GLOBE score in the Global PBC cohort, the association between ALP after 1 year of UDCA and the risk of LT/death was assessed. The LT-free survival was compared with that of a matched general population. RESULTS After 1 year of UDCA, ALP was associated with the risk of LT/death (aHR 1.31, 95% CI 1.003-1.72, p = 0.048) among 2729 patients with a normal GLOBE score. The 10-year LT-free survival among these patients with an ALP >2.0 × ULN was 94.0% (95% CI 90.1-97.9) for those <50 years, and 82.6% (95% CI 76.5-88.7) for those ≥50 years, which was significantly lower (p = 0.040) and similar (p = 0.736) to that of the matched population, respectively. The 10-year LT-free survival in patients ≥50 years with normal GLOBE score and normal ALP (90.8%, 95% CI 87.7-93.9) was significantly higher (p = 0.022) than the matched population. Among 1045 patients with an elevated GLOBE score, ALP was associated with LT/death only in those <50 years (aHR 1.38, 95% CI 1.06-1.81, p = 0.016). CONCLUSION The LT-free survival of patients with PBC with a normal GLOBE score is optimal in case of normal ALP levels, also in relation to the general population. Despite their generally favourable prognosis, an elevated ALP level may still indicate a need for add-on therapy.
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Affiliation(s)
- Rozanne C. de Veer
- Department of Gastroenterology and HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Maren H. Harms
- Department of Gastroenterology and HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Christophe Corpechot
- Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, European Reference Network on Hepatological Diseases (ERN Rare‐Liver)Saint‐Antoine Hospital, Assistance Publique ‐ Hôpitaux de Paris; Inserm UMR_S938, Saint‐Antoine Research Center, Sorbonne UniversityParisFrance
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre, and UCL Institute of Liver and Digestive HealthThe Royal Free HospitalLondonUK
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | - Harry L. A. Janssen
- Toronto Centre for Liver disease, Toronto General HospitalUniversity Health NetworkTorontoCanada
| | | | - Frederik Nevens
- Department of HepatologyUniversity Hospitals LeuvenKU LeuvenLeuvenBelgium
| | - Keith D. Lindor
- Department of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA,Arizona State UniversityCollege of Health SolutionsPhoenixArizonaUSA
| | - Annarosa Floreani
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaPaduaItaly,Scientific Institute for ResearchHospitalization and HealthcareNegrarVeronaItaly
| | - Cyriel Y. Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centreslocation Academic Medical CenterAmsterdamThe Netherlands
| | - Marlyn J. Mayo
- Digestive and Liver diseases, UT Southwestern Medical CenterDallasTexasUSA
| | - Albert Parés
- Liver UnitHospital Clínic, CIBERehd, IDIBAPS, University of BarcelonaBarcelonaSpain
| | - Andrew L. Mason
- Division of Gastroenterology and HepatologyUniversity of AlbertaEdmontonAlbertaCanada
| | - Kris V. Kowdley
- Liver Care Network and Organ Care ResearchSwedish Medical CenterSeattleWAUSA
| | - Palak J. Trivedi
- Birmingham NIHR Biomedical Research Centre, and Centre for Liver ResearchUniversity of BirminghamBirminghamUK
| | - Gideon M. Hirschfield
- Toronto Centre for Liver disease, Toronto General HospitalUniversity Health NetworkTorontoCanada,Birmingham NIHR Biomedical Research Centre, and Centre for Liver ResearchUniversity of BirminghamBirminghamUK
| | - Tony Bruns
- Department of Internal Medicine IVJena University Hospital, Friedrich Schiller UniversityJenaGermany,Department of Internal Medicine IIIUniversity Hospital RWTH AachenAachenGermany
| | - George N. Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver DiseasesGeneral University Hospital of LarissaLarissaGreece,European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)General University Hospital of LarissaLarissaGreece
| | - Nikolaos K. Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver DiseasesGeneral University Hospital of LarissaLarissaGreece,European Reference Network on Hepatological Diseases (ERN RARE‐LIVER)General University Hospital of LarissaLarissaGreece
| | - Xavier Verhelst
- Department of Gastroenterology and HepatologyGhent University HospitalBelgium
| | - Willem J. Lammers
- Department of Gastroenterology and HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Bettina E. Hansen
- Toronto Centre for Liver disease, Toronto General HospitalUniversity Health NetworkTorontoCanada,Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoCanada
| | - Henk R. van Buuren
- Department of Gastroenterology and HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Adriaan J. van der Meer
- Department of Gastroenterology and HepatologyErasmus University Medical CenterRotterdamThe Netherlands
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Carey EJ, Eaton J, Clayton M, Gossard A, Iqbal S, Ullah H, Zhang N, Butterfield R, Lindor KD. A pilot study of vidofludimus calcium for treatment of primary sclerosing cholangitis. Hepatol Commun 2022; 6:1589-1597. [PMID: 35238498 PMCID: PMC9234677 DOI: 10.1002/hep4.1926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/22/2021] [Revised: 01/07/2022] [Accepted: 02/07/2022] [Indexed: 12/26/2022] Open
Abstract
The purpose of this pilot study was to explore the efficacy, safety, and tolerability of vidofludimus calcium (VC) in the treatment of primary sclerosing cholangitis (PSC). This was a single-arm open-label pilot study with a cohort of 18 patients with PSC. Study patients received VC for a period of 6 months. The study was undertaken at two sites, Mayo Clinic, Rochester, MN, and Mayo Clinic, Phoenix, AZ. The primary endpoint of the study was improvement of serum alkaline phosphatase (ALP) at the end of the study. Secondary endpoints included assessment of other liver biomarkers (bilirubin, alanine aminotransferase, and aspartate aminotransferase). Of 18 patients enrolled, 11 completed the 6 months of study treatment. Patients who completed treatment versus those who did not were similar other than a significantly higher direct bilirubin at baseline in the group that completed treatment (mean ± SD, 0.4 ± 0.3 versus 0.1 ± 0.1, p = 0.04). By intent to treat analysis, the primary outcome was met in 16.7% (3/18) of patients. By per-protocol analysis, including only patients who completed treatment, normalization of ALP occurred in 27.7% (3/11) at week 24 (95% confidence interval, 6.0% to 61.0%). VC was well tolerated with no drug-related serious adverse events. Conclusion: This proof of concept study provides support for further exploration of VC in patients with PSC.
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Affiliation(s)
- Elizabeth J Carey
- Division of Gastroenterology and HepatologyMayo ClinicPhoenixArizonaUSA
| | - John Eaton
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA
| | - Mitchell Clayton
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA
| | - Andrea Gossard
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMinnesotaUSA
| | - Sara Iqbal
- GastroenterologyWest Virginia UniversityMorgantownWest VirginiaUSA
| | - Hamid Ullah
- GastroenterologyWest Virginia UniversityMorgantownWest VirginiaUSA
| | - Nan Zhang
- Department of Quantitative Health ResearchMayo ClinicPhoenixArizonaUSA
| | | | - Keith D Lindor
- Division of Gastroenterology and HepatologyMayo ClinicPhoenixArizonaUSA
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7
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Lindor KD, Bowlus CL, Boyer J, Levy C, Mayo M. Primary biliary cholangitis: 2021 practice guidance update from the American Association for the Study of Liver Diseases. Hepatology 2022; 75:1012-1013. [PMID: 34431119 DOI: 10.1002/hep.32117] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [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: 08/16/2021] [Accepted: 08/16/2021] [Indexed: 12/08/2022]
Affiliation(s)
| | | | - James Boyer
- Yale School of MedicineNew HavenConnecticutUSA
| | | | - Marlyn Mayo
- University of Texas Southwestern Medical CenterDallasTexasUSA
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8
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Mehta TI, Weissman S, Fung BM, Sotiriadis J, Lindor KD, Tabibian JH. Global incidence, prevalence and features of primary sclerosing cholangitis: A systematic review and meta-analysis. Liver Int 2021; 41:2418-2426. [PMID: 34224208 DOI: 10.1111/liv.15007] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [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: 01/29/2021] [Revised: 06/03/2021] [Accepted: 06/08/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Primary sclerosing cholangitis (PSC) is an idiopathic, cholestatic liver disease with a diverse range of clinical manifestations. Inter-regional data on PSC are variable, but its global geoepidemiology has not been well-studied. We aimed to examine the worldwide incidence, prevalence and features of PSC and PSC-inflammatory bowel disease (PSC-IBD). METHODS A systematic search of multiple databases was conducted to identify all original, full-text studies until December 2020 with data regarding the incidence rate (IR) and/or prevalence of PSC. Outcomes were PSC IR, prevalence, features and IBD concurrence. Additionally, a meta-analysis of PSC IR was performed. The study was registered in PROSPERO (CRD42021224550). RESULTS Of the 1003 studies identified, 17 studies spanning three continents were included. PSC IR was 0.60 per 100 000 person-years (PY) (95% confidence interval: 0.37-0.88 per 100 000 PY). In pooled subgroup analysis for studies conducted in Europe and North America, PSC IR was 0.62 and 0.53 per 100 000 PY, respectively. PSC prevalence ranged 0-31.7 per 100 000 persons, with notable inter-regional differences. Mean age at PSC diagnosis was bimodally distributed, with relative peaks at 15 and 35 years. Mean concurrence of IBD with PSC was 50%, with 76% having ulcerative colitis, 17% Crohn's disease and 8% indeterminate/unspecified IBD. CONCLUSION While considerable heterogeneity exists in the geoepidemiology of PSC, overall, the classical dogmata of male predilection, bimodal distribution of mean age and high PSC-IBD concurrence appear to hold true. Despite a seemingly stable IR over time, further studies are needed to better understand the geoepidemiology of PSC.
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Affiliation(s)
- Tej I Mehta
- Department of Radiology, Johns Hopkins University Hospital, Baltimore, MD, USA
| | - Simcha Weissman
- Department of Medicine, Hackensack University-Palisades Medical Center, North Bergen, NJ, USA
| | - Brian M Fung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - John Sotiriadis
- Division of Gastroenterology and Hepatology, Hackensack University-Palisades Medical Center, North Bergen, NJ, USA
| | - Keith D Lindor
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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9
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Abstract
BACKGROUND AND AIM Off-label use of fibrates in patients with cholestatic liver diseases results in improved biochemical parameters and pruritus; however, their safety in this population has been a concern. This study summarizes safety data for fibrates when used for treatment of cholestatic liver diseases. METHODS A systematic review of published studies evaluating the use of fibrates for treatment of primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) was performed. Electronic databases were searched up to December 2019 for published studies evaluating treatment outcomes associated to fibrates for these 2 diseases. RESULTS A total of 37 studies were identified, including 31 for PBC and 6 for PSC, with a total of 1107 unique patients treated with fibrates ± ursodeoxycholic acid (UDCA). Most studies evaluated fenofibrate and bezafibrate, and only 1 study evaluated pemafibrate. There were no studies evaluating gemfibrozil or clofibrate. The most commonly reported adverse events (AEs) were gastrointestinal and musculoskeletal. Elevations of aminotransferases and serum creatinine were reported more commonly in patients treated with UDCA plus fibrates versus UDCA monotherapy. CONCLUSIONS Fibrates appear to be safe and well tolerated in patients with PBC, with a low frequency of AEs. There are scarce data about the safety of these agents for treatment of PSC.
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Affiliation(s)
- Andres F Carrion
- Division of Gastroenterology and Hepatology, University of Miami, Miami, FL, USA
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
- Office of University Provost, Arizona State University, Phoenix, AZ, USA
| | - Cynthia Levy
- Division of Gastroenterology and Hepatology, University of Miami, Miami, FL, USA
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10
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Eaton JE, Welle CL, Bakhshi Z, Sheedy SP, Idilman IS, Gores GJ, Rosen CB, Heimbach JK, Taner T, Harnois DM, Lindor KD, LaRusso NF, Gossard AA, Lazaridis KN, Venkatesh SK. Early Cholangiocarcinoma Detection With Magnetic Resonance Imaging Versus Ultrasound in Primary Sclerosing Cholangitis. Hepatology 2021; 73:1868-1881. [PMID: 32974892 PMCID: PMC8177077 DOI: 10.1002/hep.31575] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/19/2020] [Accepted: 09/06/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Early detection of perihilar cholangiocarcinoma (CCA) among patients with primary sclerosing cholangitis (PSC) is important to identify more people eligible for curative therapy. While many recommend CCA screening, there are divergent opinions and limited data regarding the use of ultrasound or magnetic resonance imaging (MRI) for early CCA detection, and it is unknown whether there is benefit in testing asymptomatic individuals. Our aims were to assess the diagnostic performances and prognostic implications of ultrasound and MRI-based CCA detection. APPROACH AND RESULTS This is a multicenter review of 266 adults with PSC (CCA, n = 120) who underwent both an ultrasound and MRI within 3 months. Images were re-examined by radiologists who were blinded to the clinical information. Respectively, MRI had a higher area under the curve compared with ultrasound for CCA detection: 0.87 versus 0.70 for the entire cohort; 0.81 versus 0.59 for asymptomatic individuals; and 0.88 versus 0.71 for those listed for CCA transplant protocol. The absence of symptoms at CCA diagnosis was associated with improved 5-year outcomes including overall survival (82% vs. 46%, log-rank P < 0.01) and recurrence-free survival following liver transplant (89% vs. 65%, log-rank P = 0.04). Among those with asymptomatic CCA, MRI detection (compared with ultrasound) was associated with reduction in both mortality (hazard ratio, 0.10; 95% confidence interval, 0.01-0.96) and CCA progression after transplant listing (hazard ratio, 0.10; 95% confidence interval, 0.01-0.90). These benefits continued among patients who had annual monitoring and PSC for more than 1 year before CCA was diagnosed. CONCLUSIONS MRI is superior to ultrasound for the detection of early-stage CCA in patients with PSC. Identification of CCA before the onset of symptoms with MRI is associated with improved outcomes.
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Affiliation(s)
- John E. Eaton
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | | | - Zeinab Bakhshi
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | | | | | - Gregory J. Gores
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | | | | | - Timucin Taner
- Division of Transplantation Surgery, Mayo Clinic, Rochester, MN
| | - Denise M. Harnois
- Division of Gastroenterology & Hepatology, Mayo Clinic, Jacksonville, FL
| | - Keith D. Lindor
- Division of Gastroenterology & Hepatology, Mayo Clinic, Scottsdale, AZ
| | | | - Andrea A. Gossard
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
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11
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Osman KT, Maselli DB, Idilman IS, Rowan DJ, Viehman JK, Harmsen WS, Harnois DM, Carey EJ, Gossard AA, LaRusso NF, Lindor KD, Venkatesh SK, Eaton JE. Liver Stiffness Measured by Either Magnetic Resonance or Transient Elastography Is Associated With Liver Fibrosis and Is an Independent Predictor of Outcomes Among Patients With Primary Biliary Cholangitis. J Clin Gastroenterol 2021; 55:449-457. [PMID: 32976197 PMCID: PMC8529876 DOI: 10.1097/mcg.0000000000001433] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/25/2020] [Indexed: 12/15/2022]
Abstract
GOALS We aimed to describe the diagnostic and prognostic performance of transient elastography (TE) and magnetic resonance elastography (MRE) in patients with primary biliary cholangitis (PBC). BACKGROUND The diagnostic performance of TE and MRE in detecting advanced fibrosis in PBC and in predicting outcomes independent of existing serologic prognostic markers is incompletely understood. MATERIALS AND METHODS Five hundred thirty-eight consecutive patients with PBC at 3 centers with liver stiffness (LS) measurements by TE (n=286) or MRE (n=332) were reviewed. LS cutoffs for predicting fibrosis stages were determined by receiver operating characteristic curves among those with a liver biopsy (TE, n=63; MRE, n=98). Cox proportional hazard regression modeling was used to identify associations between covariates and hepatic decompensation. RESULTS The optimal LS thresholds for predicting histologic stage F4 were 14.40 kPa (area under the curve=0.94) for TE and 4.60 kPa (area under the curve=0.82) for MRE. Both TE and MRE outperformed biochemical markers for the prediction of histologic advanced fibrosis. Optimal LS thresholds to predict hepatic decompensation were 10.20 kPa on TE and 4.30 kPa on MRE. LS by TE and MRE (respectively) remained predictors of hepatic decompensation after adjusting for ursodeoxycholic acid responsiveness [hazard ratio (HR), 1.14; 95% confidence interval (CI), 1.05-1.24 and HR, 1.68; 95% CI, 1.28-2.19] and the GLOBE score (HR, 1.13; 95% CI, 1.07-1.19 and HR, 2.09; 95% CI, 1.57-2.78). CONCLUSION LS measurement with either TE or MRE can accurately detect advanced fibrosis and offers additional prognostic value beyond existing serologic predictive tools.
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Affiliation(s)
- Karim T. Osman
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
| | - Daniel B. Maselli
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Daniel J. Rowan
- Department of Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Jason K. Viehman
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN 55905, USA
| | - William S. Harmsen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN 55905, USA
| | - Denise M. Harnois
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Elizabeth J. Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ 85259, USA
| | - Andrea A. Gossard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
| | - Nicholas F. LaRusso
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
| | - Keith D. Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ 85259, USA
| | | | - John E. Eaton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
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12
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McCain JD, Chascsa DM, Lindor KD. Assessing and managing symptom burden and quality of life in primary sclerosing cholangitis patients. Expert Opin Orphan Drugs 2021. [DOI: 10.1080/21678707.2021.1898370] [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: 12/24/2022]
Affiliation(s)
- Josiah D. McCain
- Department of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona, USA
| | - David M. Chascsa
- Department of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona, USA
- Department of Transplant Center, Mayo Clinic, Phoenix, Arizona, USA
| | - Keith D. Lindor
- Office of University Provost, Arizona State University, Arizona, USA
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13
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Ali AH, Bi Y, Machicado JD, Garg S, Lennon RJ, Zhang L, Takahashi N, Carey EJ, Lindor KD, Buness JG, Tabibian JH, Chari ST. The long-term outcomes of patients with immunoglobulin G4-related sclerosing cholangitis: the Mayo Clinic experience. J Gastroenterol 2020; 55:1087-1097. [PMID: 32770464 DOI: 10.1007/s00535-020-01714-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 03/24/2020] [Accepted: 07/27/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The long-term outcomes of immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) are not well known. METHODS The outcomes of patients with IgG4-SC at Mayo Clinic (1999-2018) were compared to an age- and gender-matched (1:1 ratio) group of patients with primary sclerosing cholangitis (PSC). RESULTS We identified 89 patients with IgG4-SC; median age at diagnosis was 67 years, 81% were males, and the median follow-up was 5.7 years. Seventy-eight patients received prednisone for induction of remission, and 53 received at least one other immunosuppressive agent for maintenance of remission. Of the IgG4-SC group, 10 died (median time from diagnosis until death was 6.5 years): 2 due to cirrhosis, 3 due to cholangiocarcinoma (CCA), and 5 due to non-hepatobiliary causes. Eleven patients in the PSC group underwent liver transplantation, while none did in the IgG4-SC group. The incidence of a hepatobiliary adverse event (cirrhosis or CCA) was 3.4 times greater in the PSC compared to the IgG4-SC group (events per 1000 person-years: 52.6; 95% CI 38-73; vs. 15.6; 95% CI 7-32). The probability of development of a hepatobiliary adverse event within 10 years was 11% in the IgG4-SC compared to 45% in the PSC group (P = 0.0001). The overall survival tended to be higher in the IgG4-SC compared to the PSC group (10-year: 79% vs. 68%, respectively; P = 0.11). CONCLUSIONS In a cohort of IgG4-SC patients, 88% of whom were treated with immunosuppressive drugs, the risk of cirrhosis and CCA was significantly lower compared to an age- and gender-matched group with PSC.
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Affiliation(s)
- Ahmad Hassan Ali
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA
| | - Yan Bi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Jorge D Machicado
- Division of Gastroenterology and Hepatology, Mayo Clinic Health System, Eau Claire, WI, USA
| | - Sushil Garg
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA
| | - Ryan J Lennon
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Lizhi Zhang
- Department of Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Elizabeth J Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA.,Arizona State University, Tempe, AZ, USA
| | - J Gage Buness
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ, USA
| | - James H Tabibian
- Division of Gastroenterology, Olive View-UCLA Medical Center, Sylmar, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 1st St SW, Rochester, MN, 55905, USA.
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14
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Ali AH, Damman J, Shah SB, Davies Y, Hurwitz M, Stephen M, Lemos LM, Carey EJ, Lindor KD, Buness CW, Alrabadi L, Berquist WE, Cox KL. Open-label prospective therapeutic clinical trials: oral vancomycin in children and adults with primary sclerosing cholangitis. Scand J Gastroenterol 2020; 55:941-950. [PMID: 32633158 DOI: 10.1080/00365521.2020.1787501] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [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: 02/06/2023]
Abstract
BACKGROUND Oral vancomycin (OV) in primary sclerosing cholangitis (PSC) has been evaluated as a potential therapeutic agent. We report the long-term biochemical course and outcomes of patients with PSC treated with OV. METHODS Patients were enrolled in 2 open-label clinical trials (ClinicalTrials.gov Identifier: NCT01802073 and NCT01322386) and offered OV at 50 mg/kg/day in 3 divided doses if weight <30kg, and 500 mg 3 times/day if weight ≥30kg. Patients with biliary strictures requiring stenting or awaiting liver transplant were excluded. Liver biochemistry, MRCP and histology were documented at baseline and while on OV. The primary outcome was a decrease in elevated gamma glutamyl transferase (GGT), alkaline phosphatase (ALP), and/or alanine aminotransferase (ALT) from baseline. RESULTS 30 subjects were enrolled, and 29 additional subjects who learned of the clinical trial requested OV (total n = 59; median age was 13.5 years [range, 1.5-44 years]; 64.4% were male; and 94.9% had inflammatory bowel disease [IBD]). The median treatment duration was 2.7 years (range, 0.2-14 years). Ninety-six percent (57/59), 81.3% (48/59), and 94.9% (56/59) experienced reduction of GGT, ALP, and ALT, respectively. Furthermore, 39% (23/59), 22% (13/59), and 55.9% (33/59) experienced normalization of GGT, ALP, and ALT, respectively, within the first 6 months of OV treatment. One patient underwent liver transplantation 8 years after beginning OV treatment, and one developed biliary strictures requiring endoscopic intervention. OV was well-tolerated by patients, and no patient developed treatment-related adverse events. CONCLUSION In PSC, OV was well-tolerated and was associated with improvement in liver chemistry. A randomized placebo-controlled clinical trial is warranted.
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Affiliation(s)
- Ahmad Hassan Ali
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA.,Division of Hepatology, University of Missouri-Columbia, Columbia, MO, USA.,Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - Jennifer Damman
- Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Shamita B Shah
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA, USA.,Division of Gastroenterology, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - Yinka Davies
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA, USA
| | - Melissa Hurwitz
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA, USA
| | - Mariam Stephen
- Lucile Packard Children's Hospital, Stanford University, Stanford, CA, USA
| | - Leta M Lemos
- Sacramento Pediatric Gastroenterology, Sacramento, CA, USA
| | - Elizabeth J Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA.,College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - Cynthia W Buness
- National Patient Advocate Foundation, Arizona State University, Phoenix, AZ, USA
| | - Leina Alrabadi
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA, USA
| | - William E Berquist
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA, USA
| | - Kenneth L Cox
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA, USA
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15
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Harms MH, de Veer RC, Lammers WJ, Corpechot C, Thorburn D, Janssen HLA, Lindor KD, Trivedi PJ, Hirschfield GM, Pares A, Floreani A, Mayo MJ, Invernizzi P, Battezzati PM, Nevens F, Ponsioen CY, Mason AL, Kowdley KV, Hansen BE, Buuren HRV, van der Meer AJ. Number needed to treat with ursodeoxycholic acid therapy to prevent liver transplantation or death in primary biliary cholangitis. Gut 2020; 69:1502-1509. [PMID: 31843787 PMCID: PMC7398464 DOI: 10.1136/gutjnl-2019-319057] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 10/31/2019] [Accepted: 11/16/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The clinical benefit of ursodeoxycholic acid (UDCA) in primary biliary cholangitis (PBC) has never been reported in absolute measures. The aim of this study was to assess the number needed to treat (NNT) with UDCA to prevent liver transplantation (LT) or death among patients with PBC. METHODS The NNT was calculated based on the untreated LT-free survival and HR of UDCA with respect to LT or death as derived from inverse probability of treatment weighting-adjusted Cox proportional hazard analyses within the Global PBC Study Group database. RESULTS We included 3902 patients with a median follow-up of 7.8 (4.1-12.1) years. The overall HR of UDCA was 0.46 (95% CI 0.40 to 0.52) and the 5-year LT-free survival without UDCA was 81% (95% CI 79 to 82). The NNT to prevent one LT or death within 5 years (NNT5y) was 11 (95% CI 9 to 13). Although the HR of UDCA was similar for patients with and without cirrhosis (0.33 vs 0.31), the NNT5y was 4 (95% CI 3 to 5) and 20 (95% CI 14 to 34), respectively. Among patients with low alkaline phosphatase (ALP) (≤2× the upper limit of normal (ULN)), intermediate ALP (2-4× ULN) and high ALP (>4× ULN), the NNT5y to prevent one LT or death was 26 (95% CI 15 to 70), 11 (95% CI 8 to 17) and 5 (95% CI 4 to 8), respectively. CONCLUSION The absolute clinical efficacy of UDCA with respect to LT or death varied with baseline prognostic characteristics, but was high throughout. These findings strongly emphasise the incentive to promptly initiate UDCA treatment in all patients with PBC and may improve patient compliance.
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Affiliation(s)
- Maren H Harms
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rozanne C de Veer
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Christophe Corpechot
- Service d'Hépatologie, Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada
| | - Keith D Lindor
- College of Health Solutions, Arizona State University, Phoenix, Arizona, USA
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Palak J Trivedi
- Birmingham NIHR Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada
- Birmingham NIHR Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Albert Pares
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, Universita degli Studi di Padova, Padova, Italy
| | - Marlyn J Mayo
- Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Pietro Invernizzi
- Division of Gastroenterology and Program for Autoimmune Liver Diseases, International Center for Digestive Health, Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | | | | | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology - location Academic Medical Center, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Andrew L Mason
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Kris V Kowdley
- Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, Washington, USA
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto Western Hospital Liver Centre, Toronto, Ontario, Canada
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Murillo Perez CF, Harms MH, Lindor KD, van Buuren HR, Hirschfield GM, Corpechot C, van der Meer AJ, Feld JJ, Gulamhusein A, Lammers WJ, Ponsioen CY, Carbone M, Mason AL, Mayo MJ, Invernizzi P, Battezzati PM, Floreani A, Lleo A, Nevens F, Kowdley KV, Bruns T, Dalekos GN, Gatselis NK, Thorburn D, Trivedi PJ, Verhelst X, Parés A, Janssen HLA, Hansen BE. Goals of Treatment for Improved Survival in Primary Biliary Cholangitis: Treatment Target Should Be Bilirubin Within the Normal Range and Normalization of Alkaline Phosphatase. Am J Gastroenterol 2020; 115:1066-1074. [PMID: 32618657 DOI: 10.14309/ajg.0000000000000557] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [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: 12/11/2022]
Abstract
INTRODUCTION In primary biliary cholangitis (PBC), bilirubin and alkaline phosphatase (ALP) are widely established as independent predictors of prognosis. Current treatment goals do not aim for normalization of surrogate markers because their association with survival has not been defined. METHODS The patient cohort from the GLOBAL PBC Study Group was used, comprising of long-term follow-up data from European and North American centers. Ursodeoxycholic acid-treated and untreated patients with bilirubin levels ≤1 × upper limit of normal (ULN) at baseline or 1 year were included. The association of normal ALP with transplant-free survival was assessed in a subgroup with ALP ≤1.67 × ULN at 1 year. Optimal thresholds of bilirubin and ALP to predict liver transplantation (LT) or death were evaluated. RESULTS There were 2,281 patients included in the time zero cohort and 2,555 patients in the 1-year cohort. The bilirubin threshold with the highest ability to predict LT or death at 1 year was 0.6 × ULN (hazard ratio 2.12, 95% CI 1.69-2.66, P < 0.001). The 10-year survival rates of patients with bilirubin ≤0.6 × ULN and >0.6 × ULN were 91.3% and 79.2%, respectively (P < 0.001). The risk for LT or death was stable below the bilirubin levels of 0.6 × ULN, yet increased beyond this threshold. Ursodeoxycholic acid-induced reduction in bilirubin below this threshold was associated with an 11% improvement in 10-year survival. Furthermore, ALP normalization was optimal, with 10-year survival rates of 93.2% in patients with ALP ≤ 1 × ULN and 86.1% in those with ALP 1.0-1.67 × ULN. DISCUSSION Attaining bilirubin levels ≤0.6 × ULN or normal ALP are associated with the lowest risk for LT or death in patients with PBC. This has important implications for treatment targets.
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Affiliation(s)
- Carla F Murillo Perez
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Maren H Harms
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Keith D Lindor
- College of Health Solutions, Arizona State University, Phoenix, Arizona
| | - Henk R van Buuren
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Christophe Corpechot
- Centre de Re[Combining Acute Accent]fe[Combining Acute Accent]rence des Maladies Inflammatoires des VoiesBiliaires, Ho[Combining Circumflex Accent]pital Saint-Antoine, Paris, France
| | - Adriaan J van der Meer
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Aliya Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Willem J Lammers
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - Marco Carbone
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Andrew L Mason
- Divison of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Marlyn J Mayo
- Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Pier Maria Battezzati
- Department of Health Sciences, Universita[Combining Grave Accent] degli Studi di Milano, Milan, Italy
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Ana Lleo
- Division of Internal Medicine and Hepatology, Humanitas Clinical Research Center IRCSS, Humanitas University, Rozzano (Milan), Italy
| | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Kris V Kowdley
- Liver Care Network, Swedish Medical Center, Seattle, Washington
| | - Tony Bruns
- Department of Internal Medicine IV, Jena University Hospital, Friedrich Schiller University, Jena, Germany
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre, The Royal Free Hospital, London, United Kingdom
| | - Palak J Trivedi
- National Institute for Health Research Birmingham Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, United Kingdom
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Albert Parés
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Murillo Perez CF, Hirschfield GM, Corpechot C, Floreani A, Mayo MJ, van der Meer A, Ponsioen CY, Lammers WJ, Parés A, Invernizzi P, Carbone M, Maria Battezzati P, Nevens F, Kowdley KV, Thorburn D, Mason AL, Trivedi PJ, Lindor KD, Bruns T, Dalekos GN, Gatselis NK, Verhelst X, Janssen HLA, Hansen BE, Gulamhusein A. Fibrosis stage is an independent predictor of outcome in primary biliary cholangitis despite biochemical treatment response. Aliment Pharmacol Ther 2019; 50:1127-1136. [PMID: 31621931 DOI: 10.1111/apt.15533] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [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: 06/20/2019] [Revised: 07/10/2019] [Accepted: 09/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Fibrosis stage predicts prognosis in patients with chronic liver disease independent of aetiology, although its precise role in risk stratification in patients with primary biliary cholangitis (PBC) remains undefined. AIM To assess the utility of baseline fibrosis stage in predicting long-term outcomes in the context of biochemical risk stratification METHODS: In a large and globally representative cohort of patients with PBC, liver biopsies performed from 1980 to 2014 were evaluated. The predictive ability of histologic fibrosis stage in addition to treatment response at 1 year (Toronto/Paris-II criteria), as well as non-invasive markers of fibrosis (AST/ALT ratio [AAR], AST to platelet ratio index [APRI], FIB-4), for transplant-free survival was assessed with Cox proportional-hazards models. RESULTS There were 1828 patients with baseline liver biopsy. Advanced histologic fibrosis (stage 3/4) was an independent predictor of survival in addition to non-invasive measures of fibrosis with the hazard ratios ranging from 1.59 to 2.73 (P < .001). Patients with advanced histologic fibrosis stage had worse survival despite biochemical treatment response, with a 10-year survival of 76.0%-86.6% compared to 94.5%-95.1% depending on the treatment response criteria used. Poor correlations were observed between non-invasive measures of fibrosis and histologic fibrosis stage. CONCLUSION Assessment of fibrosis stage grants prognostic value beyond biochemical treatment response at 1 year. This highlights the need to incorporate fibrosis stage in individual risk stratification in patients with PBC, partly to identify those that may derive benefit from novel therapies.
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Cheung AC, Lammers WJ, Murillo Perez CF, van Buuren HR, Gulamhusein A, Trivedi PJ, Lazaridis KN, Ponsioen CY, Floreani A, Hirschfield GM, Corpechot C, Mayo MJ, Invernizzi P, Battezzati PM, Parés A, Nevens F, Thorburn D, Mason AL, Carbone M, Kowdley KV, Bruns T, Dalekos GN, Gatselis NK, Verhelst X, Lindor KD, Lleo A, Poupon R, Janssen HLA, Hansen BE. Effects of Age and Sex of Response to Ursodeoxycholic Acid and Transplant-free Survival in Patients With Primary Biliary Cholangitis. Clin Gastroenterol Hepatol 2019; 17:2076-2084.e2. [PMID: 30616022 DOI: 10.1016/j.cgh.2018.12.028] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [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: 07/17/2018] [Revised: 12/07/2018] [Accepted: 12/23/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Primary biliary cholangitis (PBC) predominantly affects middle-aged women; there are few data on disease phenotypes and outcomes of PBC in men and younger patients. We investigated whether differences in sex and/or age at the start of ursodeoxycholic acid (UDCA) treatment are associated with response to therapy, based on biochemical markers, or differences in transplant-free survival. METHODS We performed a longitudinal retrospective study of 4355 adults in the Global PBC Study cohort, collected from 17 centers across Europe and North America. Patients received a diagnosis of PBC from 1961 through 2014. We evaluated the effects of sex and age on response to UDCA treatment (based on GLOBE score) and transplant-free survival using logistic regression and Cox regression analyses, respectively. RESULTS Male patients were older at the start of treatment (58.3±12.1 years vs 54.3±11.6 years for women; P<.0001) and had higher levels of bilirubin and lower circulating platelet counts (P<.0001). Younger patients (45 years or younger) had increased serum levels of transaminases than older patients (older than 45 years). Patients older than 45 years at time of treatment initiation had increased odds of a biochemical response to UDCA therapy, based on GLOBE score, compared to younger patients. The greatest odds of response to UDCA were observed in patients older than 65 years (odds ratio compared to younger patients 45 years or younger, 5.48; 95% CI, 3.92-7.67; P<.0001). Risk of liver transplant or death (compared to a general population matched for age, sex, and birth year) decreased significantly with advancing age: hazard ratio for patients 35 years or younger, 14.59 (95% CI, 9.66-22.02) vs hazard ratio for patients older than 65 years, 1.39 (95% CI, 1.23-1.57) (P<.0001). On multivariable analysis, sex was not independently associated with response or transplant-free survival. CONCLUSION In longitudinal analysis of 4355 adults in the Global PBC Study, we associated patient age, but not sex, with response to UDCA treatment and transplant-free survival. Younger age at time of treatment initiation is associated with increased risk of treatment failure, liver transplant, and death.
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Affiliation(s)
- Angela C Cheung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Carla F Murillo Perez
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Aliya Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Palak J Trivedi
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Centre for Liver Research, University of Birmingham, Birmingham, United Kingdom
| | | | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Christophe Corpechot
- Service d'Hépatologie, Centre national de référence des maladies inflammatoires du foie et des voies biliaires, Hôpital Saint-Antoine, Paris, France
| | - Marlyn J Mayo
- Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | | | - Albert Parés
- Liver Unit, Hospital Clínic, IDIBAPS, University of Barcelona, CIBERehd, Barcelona, Spain
| | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Douglas Thorburn
- Sheila Sherlock Liver Centre, Royal Free Hospital, London, United Kingdom
| | - Andrew L Mason
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Marco Carbone
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Kris V Kowdley
- Liver Care Network, Swedish Medical Center, Seattle, Washington
| | - Tony Bruns
- Department of Internal Medicine IV, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Keith D Lindor
- College of Health Solutions, Arizona State University, Phoenix, Arizona
| | - Ana Lleo
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Raoul Poupon
- Service d'Hépatologie, Centre national de référence des maladies inflammatoires du foie et des voies biliaires, Hôpital Saint-Antoine, Paris, France
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands; Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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Harms MH, van Buuren HR, Corpechot C, Thorburn D, Janssen HLA, Lindor KD, Hirschfield GM, Parés A, Floreani A, Mayo MJ, Invernizzi P, Battezzati PM, Nevens F, Ponsioen CY, Mason AL, Kowdley KV, Lammers WJ, Hansen BE, van der Meer AJ. Ursodeoxycholic acid therapy and liver transplant-free survival in patients with primary biliary cholangitis. J Hepatol 2019; 71:357-365. [PMID: 30980847 DOI: 10.1016/j.jhep.2019.04.001] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [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: 11/22/2018] [Revised: 03/12/2019] [Accepted: 04/01/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS The clinical efficacy of ursodeoxycholic acid (UDCA) in primary biliary cholangitis (PBC) remains subject to debate as definitive randomized controlled trials are lacking. We aimed to determine whether UDCA prolongs liver transplant (LT)-free survival in patients with PBC. METHODS This international cohort study included patients from the Global PBC Study Group database, originating from 8 countries in Europe and North America. Both UDCA-treated and untreated patients were included. LT and death were assessed as a combined endpoint through Cox regression analyses, with inverse probability treatment weighting (IPTW). RESULTS In the 3,902 patients included, the mean (SD) age was 54.3 (11.9) years, 3,552 patients (94.0%) were female, 3,529 patients (90.4%) were treated with UDCA and 373 patients (9.6%) were not treated. The median (interquartile range) follow-up was 7.8 (4.1-12.1) years. In total, 721 UDCA-treated patients and 145 untreated patients died or underwent LT. After IPTW, the 10-year cumulative LT-free survival was 79.7% (95% CI 78.1-81.2) among UDCA-treated patients and 60.7% (95% CI 58.2-63.4) among untreated patients (p <0.001). UDCA was associated with a statistically significant reduced risk of LT or death (hazard ratio 0.46, 95% CI 0.40-0.52; p <0.001). The hazard ratio remained statistically significant in all stages of disease. Patients classified as inadequate biochemical responders after 1 year of UDCA had a lower risk of LT or death than patients who were not treated (adjusted hazard ratio 0.56; 95% CI 0.45-0.69; p <0.001). CONCLUSION The use of UDCA improves LT-free survival among patients with PBC, regardless of the disease stage and the observed biochemical response. These findings support UDCA as the current universal standard of care in PBC. LAY SUMMARY In this international multicenter study of 3,902 patients with primary biliary cholangitis, we found that treatment with ursodeoxycholic acid is associated with prolonged liver transplant-free survival. This association was significant, irrespective of sex, age, or disease stage. The survival benefit remained statistically significant in patients with an incomplete biochemical response to ursodeoxycholic acid therapy.
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Affiliation(s)
- Maren H Harms
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Christophe Corpechot
- Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre, and UCL Institute of Liver and Digestive Health, The Royal Free Hospital, London, United Kingdom
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto General Hospital, Toronto, ON, Canada
| | - Keith D Lindor
- Arizona State University, College of Health Solutions, Phoenix, AZ, USA; Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto General Hospital, Toronto, ON, Canada; Birmingham NIHR Biomedical Research Centre, and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Albert Parés
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Marlyn J Mayo
- Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX, USA
| | - Pietro Invernizzi
- Division of Gastroenterology and Program for Autoimmune Liver Diseases, International Center for Digestive Health, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | | | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Andrew L Mason
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada
| | - Kris V Kowdley
- Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, WA, USA
| | - Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands; Toronto Centre for Liver Disease, Francis Family Liver Clinic, Toronto General Hospital, Toronto, ON, Canada
| | - Adriaan J van der Meer
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands.
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Kuo A, Gomel R, Safer R, Lindor KD, Everson GT, Bowlus CL. Characteristics and Outcomes Reported by Patients With Primary Sclerosing Cholangitis Through an Online Registry. Clin Gastroenterol Hepatol 2019; 17:1372-1378. [PMID: 29705262 DOI: 10.1016/j.cgh.2018.04.047] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 10/01/2017] [Revised: 04/03/2018] [Accepted: 04/20/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Primary sclerosing cholangitis (PSC) is a fibrostenosing disease of the bile ducts associated with inflammatory bowel disease (IBD), for which the only treatment is liver transplantation. PSC progression has been defined in cohorts from referral centers or single-nation population databases. However, observations made from these cohorts have limited applicability owing to referral bias and demographic confounders. We analyzed data from the worldwide PSC Partners Patient Registry, an international online database established in 2014 to obtain information from individuals with PSC or their caretakers and compare symptoms, disease progression, and treatments of PSC in the United States and other countries. METHODS We analyzed demographic and clinical characteristics, symptoms, and clinical outcomes of patients with PSC using the PSC Partners Patient Registry. Participants completed an online standardized questionnaire and electronic case report, providing information on age, age at symptom onset, age at PSC diagnosis, methods of diagnosis, concurrent diagnoses, family history, and medication use. RESULTS Of 873 registrants, 811 (92.9%) had completed questionnaires and 528 (65.1%) had their PSC diagnosis confirmed; we found no significant demographic or clinical differences between patients with vs without a confirmed diagnosis. In contrast to other studies, we found a higher proportion of individuals with PSC to be female (52.5%). However, the mean age at PSC diagnosis (32.4 ± 14.7 y) and the proportion of individuals with PSC and IBD (67.1%) were similar to those from prior reports. Most cases in the database were from the United States (74.9%). More than half of the participants reported having pruritus, abdominal pain, fatigue, or sleep disturbances; rates were not significantly different among participants within vs outside the United States. There was no significant difference in treatment with ursodeoxycholic acid between participants within vs outside the United States (50.0% and 57.8%; P = .07). The median time of transplant-free survival was 21 years; transplant-free survival was associated with female sex and Crohn's disease. CONCLUSIONS Our findings from an analysis of data from the PSC Partners Patient Registry confirm those from previous studies, although we found a higher proportion of individuals with PSC to be female. In addition to allowing efficient collection of patient-reported outcomes, the patient-driven registry allows for inclusion of previously under-represented cases of PSC.
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Affiliation(s)
- Alexander Kuo
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, California
| | - Rachel Gomel
- PSC Partners Seeking a Cure, Greenwood Village, Colorado
| | - Ricky Safer
- PSC Partners Seeking a Cure, Greenwood Village, Colorado
| | - Keith D Lindor
- College of Health Solutions, Arizona State University, Phoenix, AZ
| | - Gregory T Everson
- Division of Gastroenterology and Hepatology, University of Colorado, Denver, Colorado
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, California.
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Eaton JE, Nelson KM, Gossard AA, Carey EJ, Tabibian JH, Lindor KD, LaRusso NF. Efficacy and safety of curcumin in primary sclerosing cholangitis: an open label pilot study. Scand J Gastroenterol 2019; 54:633-639. [PMID: 31131678 PMCID: PMC7895452 DOI: 10.1080/00365521.2019.1611917] [Citation(s) in RCA: 20] [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] [Indexed: 02/04/2023]
Abstract
Goals: To assess if curcumin improves markers of cholestasis among subjects with primary sclerosing cholangitis (PSC). Background: PSC is a chronic cholestatic liver disorder for which there is no established medical therapy. Preclinical data suggest curcumin may have a beneficial effect in PSC. Study: Subjects with PSC and a serum alkaline phosphatase (SAP) greater than 1.5 times the upper limit of normal (ULN) received curcumin 750 mg orally twice daily for 12 weeks in an open-label pilot study. The primary composite endpoint was proportion of subjects who had a reduction of SAP to less than 1.5 times ULN or a 40% reduction in SAP between baseline and week 12. Secondary endpoints included changes in serum aspartate aminotransferase, total bilirubin, Mayo PSC risk score and self-reported health questionnaires. Results: Two-hundred and fifty-eight patients with PSC were screened and 15 subjects were enrolled and all completed 12 weeks of therapy. The most common reason for subject exclusion was SAP less than 1.5 times the ULN (n = 98). Curcumin did not result in a significant median (interquartile range) change in SAP times the ULN [3.43 (2.10-4.32) to 2.46 (1.89-4.41), p = .36], and only 20% (3/15) subjects achieved the primary endpoint. Similarly, there was no significant change in the secondary endpoints. There were no serious adverse events reported. Conclusion: While curcumin was well tolerated, it was not associated with significant improvements in cholestasis or symptoms. Moreover, this study also illustrates that a low SAP is common among those with PSC. Abbreviations PSC: Primary sclerosing cholangitis; IBD: inflammatory bowel disease; CCA: cholangiocarcinoma; SAP: serum alkaline phosphatase; ULN: upper limit of normal; UDCA: ursodeoxycholic acid; CRP: c-reactive protein; AST: aspartate aminotransferase; ALT: alanine aminotransferase; INR: international normalized ratio; FIS: fatigue impact scale; AE: adverse events; PREsTo: PSC risk estimate tool; IQR: interquartile range; ELF: enhanced liver fibrosis.
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Affiliation(s)
- John E. Eaton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Kevin M. Nelson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Andrea A. Gossard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth J. Carey
- Department of Gastroenterology and Hepatology, Arizona State University College of Health Solutions, Phoenix, AZ, USA
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - Keith D. Lindor
- Department of Gastroenterology and Hepatology, Arizona State University College of Health Solutions, Phoenix, AZ, USA
| | - Nicholas F. LaRusso
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Affiliation(s)
- Andrea A Gossard
- Mayo Clinic, Division of Gastroenterology and Hepatology, Rochester, MN, USA
| | - Keith D. Lindor
- Mayo Clinic, Division of Gastroenterology and Hepatology, Rochester, MN, USA
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Affiliation(s)
- James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - Keith D Lindor
- Professor of Medicine and Senior Advisor to the Provost, College of Health Solutions, Arizona State University, Phoenix, AZ, USA.
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25
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Fung BM, Lindor KD, Tabibian JH. Cancer risk in primary sclerosing cholangitis: Epidemiology, prevention, and surveillance strategies. World J Gastroenterol 2019; 25:659-671. [PMID: 30783370 PMCID: PMC6378537 DOI: 10.3748/wjg.v25.i6.659] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/10/2019] [Accepted: 01/15/2019] [Indexed: 02/06/2023] Open
Abstract
Primary sclerosing cholangitis (PSC) is a rare cholestatic liver disease characterized by progressive fibroinflammatory destruction of the intra- and/or extrahepatic biliary ducts. While its features and disease course can be variable, most patients with PSC have concurrent inflammatory bowel disease and will eventually develop liver cirrhosis and end-stage liver disease, with liver transplantation representing the only potentially curative option. Importantly, PSC is associated with a significantly increased risk of malignancy compared to the general population, mainly cholangiocarcinoma, gallbladder carcinoma, hepatocellular carcinoma, and colorectal cancer, with nearly 50% of deaths in patients with PSC being due to cancer. Therefore, robust surveillance strategies are needed, though uncertainty remains regarding how to best do so. In this review, we discuss the epidemiology, prevention, and surveillance of cancers in patients with PSC. Where evidence is limited, we present pragmatic approaches based on currently available data and expert opinion.
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Affiliation(s)
- Brian M Fung
- UCLA-Olive View Internal Medicine Residency Program, Olive View-UCLA Medical Center, Sylmar, CA 91342, United States
| | - Keith D Lindor
- Office of the University Provost, Arizona State University, Phoenix, AZ 85004, United States
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA 91342, United States
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26
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Lindor KD, Bowlus CL, Boyer J, Levy C, Mayo M. Primary Biliary Cholangitis: 2018 Practice Guidance from the American Association for the Study of Liver Diseases. Hepatology 2019; 69:394-419. [PMID: 30070375 DOI: 10.1002/hep.30145] [Citation(s) in RCA: 287] [Impact Index Per Article: 57.4] [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: 05/30/2018] [Accepted: 05/30/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Keith D Lindor
- Arizona State University, Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ
| | | | | | | | - Marlyn Mayo
- University of Texas Southwestern Medical Center, Dallas, TX
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27
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Abstract
Primary sclerosing cholangitis (PSC) is a rare cholestatic disorder that presents with multifocal biliary strictures. PSC has a variable course but often leads to progressive liver disease, and most patients will eventually require liver transplantation. PSC has a strong association with inflammatory bowel disease and autoimmune liver disease. Areas covered: The objective of this article is to compare and contrast the clinical features and natural history of PSC in children to adults. We performed a PubMed search of the English literature using keywords 'primary sclerosing cholangitis', 'PSC', 'children', and 'pediatric.' Expert commentary: While certain features of PSC are similar in the pediatric and adult population, there are unique features of pediatric PSC. More longitudinal studies are needed to better understand the natural history of pediatric PSC. It is conceivable that treatment for PSC that will alter the course of disease may become available in the future.
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Affiliation(s)
- Abimbola Adike
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Phoenix , AZ , USA
| | - Elizabeth J Carey
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Phoenix , AZ , USA
| | - Keith D Lindor
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Phoenix , AZ , USA
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Chascsa DM, Lindor KD. Managing PBC: Expanding the Provider Comfort Zone. Dig Dis Sci 2018; 63:2487-2488. [PMID: 29948561 DOI: 10.1007/s10620-018-5162-9] [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] [Indexed: 12/09/2022]
Affiliation(s)
| | - Keith D Lindor
- Mayo Clinic, Arizona, USA.,Office of University Provost, Arizona State University Arizona, Tempe, USA
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Ponsioen CY, Lindor KD, Mehta R, Dimick-Santos L. Design and Endpoints for Clinical Trials in Primary Sclerosing Cholangitis. Hepatology 2018; 68:1174-1188. [PMID: 29574971 DOI: 10.1002/hep.29882] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [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: 10/11/2017] [Revised: 02/11/2018] [Accepted: 03/13/2018] [Indexed: 12/15/2022]
Abstract
Primary sclerosing cholangitis (PSC) is a rare and chronic liver disease for which there is no effective therapy. Interest has grown in developing treatments for this condition, with several agents proposed as potential therapies. However, there is a lack of clarity about how to measure clinical benefit in trials involving patients with this complex and rare disease. This article reviews regulatory information, the available literature on natural history, as well as potential candidate clinical and surrogate endpoints for PSC. (Hepatology 2018; 00:000-000).
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Affiliation(s)
- Cyriel Y Ponsioen
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Keith D Lindor
- College of Health Solutions, Arizona State University, Phoenix, AZ
| | - Ruby Mehta
- Division of Gastroenterology and Inborn Errors Products, United States Food and Drug Administration, Silver Spring, MD
| | - Lara Dimick-Santos
- Division of Gastroenterology and Inborn Errors Products, United States Food and Drug Administration, Silver Spring, MD
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Abstract
Antimitochondrial antibody (AMA)-negative primary biliary cholangitis (PBC) is a term reserved for patients with clinical and histopathological findings consistent with PBC but without positive AMA. There does not seem to be a natural progression from AMA negativity to positivity. Antinuclear and antismooth muscle antibodies are frequently found in the absence of histologic autoimmune hepatitis features. The disease course may be more severe than AMA-positive. Response to standard therapy for PBC and autoimmune hepatitis varies. Nevertheless, there is insufficient evidence to suggest AMA-negative PBC is different enough to warrant classification as a separate disease from AMA-positive PBC.
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Affiliation(s)
- David M Chascsa
- Division of Gastroenterology and Hepatology, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA; Office of the Provost, Arizona State University, 550 North 3rd Street, Phoenix, AZ 85004, USA.
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31
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Tabibian JH, Ali AH, Lindor KD. Primary Sclerosing Cholangitis, Part 2: Cancer Risk, Prevention, and Surveillance. Gastroenterol Hepatol (N Y) 2018; 14:427-432. [PMID: 30166959 PMCID: PMC6111497] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a chronic, fibroinflammatory, progressive cholangiopathy. In a clinically significant proportion of patients, the disease course of PSC is punctuated by carcinogenesis, namely cholangiocarcinoma, gallbladder carcinoma, hepatocellular carcinoma, and/or colorectal carcinoma. Indeed, malignancy is arguably the most consequential sequela and the cause of nearly 50% of deaths in patients with PSC. This statistic is multifactorial, relating partly to the premalignant nature of PSC, challenges in diagnosis due to obscuration of cancer by the inflammation and fibrosis inherent to PSC, and the unpredictability of which type of cancer will develop in PSC and when. Here, in the second of a 2-part series, we review cancer risk, prevention, and surveillance in patients with PSC. We also discuss potential cancer surveillance strategies in PSC and, where evidence is limited, make pragmatic recommendations based on current data and expert opinion.
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Affiliation(s)
- James H Tabibian
- Dr Tabibian is an associate professor at the Geffen School of Medicine at UCLA in Los Angeles, California and director of endoscopy and resident research director in the Department of Medicine at Olive View-UCLA Medical Center in Sylmar, California
- Dr Ali is a research fellow in the Division of Gastroenterology and Hepatology at Mayo Clinic in Phoenix, Arizona
- Dr Lindor is a professor of medicine in the Division of Gastroenterology and Hepatology at Mayo Clinic and senior advisor to the provost at Arizona State University in Phoenix, Arizona
| | - Ahmad H Ali
- Dr Tabibian is an associate professor at the Geffen School of Medicine at UCLA in Los Angeles, California and director of endoscopy and resident research director in the Department of Medicine at Olive View-UCLA Medical Center in Sylmar, California
- Dr Ali is a research fellow in the Division of Gastroenterology and Hepatology at Mayo Clinic in Phoenix, Arizona
- Dr Lindor is a professor of medicine in the Division of Gastroenterology and Hepatology at Mayo Clinic and senior advisor to the provost at Arizona State University in Phoenix, Arizona
| | - Keith D Lindor
- Dr Tabibian is an associate professor at the Geffen School of Medicine at UCLA in Los Angeles, California and director of endoscopy and resident research director in the Department of Medicine at Olive View-UCLA Medical Center in Sylmar, California
- Dr Ali is a research fellow in the Division of Gastroenterology and Hepatology at Mayo Clinic in Phoenix, Arizona
- Dr Lindor is a professor of medicine in the Division of Gastroenterology and Hepatology at Mayo Clinic and senior advisor to the provost at Arizona State University in Phoenix, Arizona
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Kalani A, Tabibian JH, Lindor KD. Emerging therapeutic targets for primary sclerosing cholangitis. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1490643] [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: 10/28/2022]
Affiliation(s)
- Amir Kalani
- Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA Gastroenterology Fellowship Training Program, Los Angeles, CA, USA
| | - James H. Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - Keith D. Lindor
- Professor of Medicine and Senior Advisor to the Provost, College of Health Solutions, Arizona State University, USA
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Ali AH, Tabibian JH, Nasser-Ghodsi N, Lennon RJ, DeLeon T, Borad MJ, Hilscher M, Silveira MG, Carey EJ, Lindor KD. Surveillance for hepatobiliary cancers in patients with primary sclerosing cholangitis. Hepatology 2018; 67:2338-2351. [PMID: 29244227 DOI: 10.1002/hep.29730] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [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: 06/22/2017] [Revised: 10/25/2017] [Accepted: 12/08/2017] [Indexed: 12/19/2022]
Abstract
UNLABELLED Primary sclerosing cholangitis (PSC) is a risk factor for cholangiocarcinoma (CCA) and gallbladder carcinoma (GBCa). Surveillance for GBCa is recommended, but the clinical utility of surveillance for other hepatobiliary cancers (HBCa) in PSC, namely CCA and hepatocellular carcinoma (HCC), remains unclear. We aimed to determine whether surveillance is associated with better survival after diagnosis of HBCa in patients with PSC. Medical records of PSC patients seen at the Mayo Clinic Rochester from 1995 to 2015 were reviewed. Patients were included if they had ≥1 year of follow-up and developed HBCa. Patients were categorized according to their surveillance status (abdominal imaging, carbohydrate antigen 19-9, and alpha-fetoprotein). The primary endpoints were HBCa recurrence, HBCa-related death, and all-cause mortality. Overall survival was assessed by the Kaplan-Meier survival method; HBCa-related survival was assessed using competing risk regression. Tests of significance were two-tailed, and a P value <0.05 was considered statistically significant. From 1995 to 2015, a total of 79 of 830 PSC patients were diagnosed with HBCa. Cumulative follow-up was 712 and 283 person-years pre- and post-HBCa diagnosis, respectively. Seventy-eight percent of patients (54/79) developed CCA, 21% (17/79) HCC, 6% (5/79) GBCa, 3% (2/79) both CCA and HCC, and 1% (1/79) both HCC and GBCa. Fifty-one percent (40/79) were under HBCa surveillance, and 49% (39/79) were not. Patients in the surveillance group had significantly higher 5-year overall survival (68% versus 20%, respectively; P < 0.001) and significantly lower 5-year probability of experiencing an HBCa-related adverse event (32% versus 75%, respectively; P < 0.001) compared with the no-surveillance group. CONCLUSION This study demonstrates that HBCa surveillance significantly improves outcomes, including survival, in patients with PSC. (Hepatology 2018;67:2338-2351).
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Affiliation(s)
- Ahmad Hassan Ali
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ.,Texas Tech University Health Sciences Center, Amarillo, TX
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Ryan J Lennon
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | | | - Moira Hilscher
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Marina G Silveira
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT
| | - Elizabeth J Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ.,Arizona State University, Phoenix, AZ
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Hilscher MB, Tabibian JH, Carey EJ, Gostout CJ, Lindor KD. Dominant strictures in primary sclerosing cholangitis: A multicenter survey of clinical definitions and practices. Hepatol Commun 2018; 2:836-844. [PMID: 30027141 PMCID: PMC6049068 DOI: 10.1002/hep4.1194] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 02/28/2018] [Accepted: 04/01/2018] [Indexed: 12/12/2022] Open
Abstract
Dominant strictures (DSs) of the biliary tree occur in approximately 50% of patients with primary sclerosing cholangitis (PSC) and may cause significant morbidity. Nevertheless, the definition and management of DSs lacks consensus. We aimed to better understand current perceptions and practices regarding PSC‐associated DSs. We conducted an anonymous, 23‐question, survey‐based study wherein electronic surveys were distributed to 131 faculty in the Division of Gastroenterology and Hepatology at the three Mayo Clinic campuses (Rochester, Scottsdale, and Jacksonville) as well as the affiliated practice network. Responses were aggregated and compared, where applicable, to practice guidelines of the American Association for the Study of Liver Diseases and European Association for the Study of the Liver. A total of 54 faculty (41.2%) completed the survey, of whom 24 (44.4%) were hepatologists, 21 (38.9%) gastroenterologists, and 9 (16.7%) advanced endoscopists. One of the major study findings was that there was heterogeneity among participants' definition, evaluation, management, and follow‐up of DSs in PSC. The majority of participant responses were in accordance with societal practice guidelines, although considerable variation was noted. Conclusion: Despite the prevalence and morbidity of DSs in PSC, clinical perceptions and practices vary widely among hepatologists, gastroenterologists, and advanced endoscopists who manage these patients, even within a single health care system. Further studies are needed to address these variations, develop general and evidence‐based consensus, and increase adherence to societal guidelines. (Hepatology Communications 2018;2:836‐844)
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Affiliation(s)
- Moira B Hilscher
- Division of Gastroenterology and Hepatology Mayo Clinic Rochester MN
| | - James H Tabibian
- Division of Gastroenterology and Hepatology Mayo Clinic Rochester MN.,Division of Gastroenterology Olive View-University of California Los Angeles Medical Center Sylmar CA
| | - Elizabeth J Carey
- Division of Gastroenterology and Hepatology Mayo Clinic Scottsdale AZ
| | | | - Keith D Lindor
- Division of Gastroenterology and Hepatology Mayo Clinic Scottsdale AZ.,College of Health Solutions Arizona State University Phoenix AZ
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35
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Murillo Perez CF, Goet JC, Lammers WJ, Gulamhusein A, van Buuren HR, Ponsioen CY, Carbone M, Mason A, Corpechot C, Invernizzi P, Mayo MJ, Battezzati PM, Floreani A, Pares A, Nevens F, Kowdley KV, Bruns T, Dalekos GN, Thorburn D, Hirschfield G, LaRusso NF, Lindor KD, Zachou K, Poupon R, Trivedi PJ, Verhelst X, Janssen HLA, Hansen BE. Milder disease stage in patients with primary biliary cholangitis over a 44-year period: A changing natural history. Hepatology 2018; 67:1920-1930. [PMID: 29220537 DOI: 10.1002/hep.29717] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [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: 07/17/2017] [Revised: 11/21/2017] [Accepted: 12/02/2017] [Indexed: 01/03/2023]
Abstract
UNLABELLED Changes over time in the presenting features and clinical course of patients with primary biliary cholangitis are poorly described. We sought to describe temporal trends in patient and disease characteristics over a 44-year period across a large international primary biliary cholangitis cohort of 4,805 patients diagnosed between 1970 and 2014, from 17 centers across Europe and North America. Patients were divided into five cohorts according to their year of diagnosis: 1970-1979 (n = 143), 1980-1989 (n = 858), 1990-1999 (n = 1,754), 2000-2009 (n = 1,815), and ≥2010 (n = 235). Age at diagnosis, disease stage, response to ursodeoxycholic acid, and clinical outcomes were compared. Mean age at diagnosis increased incrementally by 2-3 years per decade from 46.9 ± 10.1 years in the 1970s to 57.0 ± 12.1 years from 2010 onward (P < 0.001). The female to male ratio (9:1) and antimitochondrial antibody positivity (90%) were not significantly variable. The proportion of patients presenting with mild biochemical disease (according to Rotterdam staging) increased from 41.3% in the 1970s to 72.2% in the 1990s (P < 0.001) and remained relatively stable thereafter. Patients with a mild histological stage at diagnosis increased from 60.4% (1970-1989) to 76.5% (1990-2014) (P < 0.001). Correspondingly, response to ursodeoxycholic acid according to Paris-I criteria increased; 51.7% in the 1970s and 70.5% in the 1990s (P < 0.001). Recent decades were also characterized by lower decompensation rates (18.5% in the 1970s to 5.8% in the 2000s, P < 0.001) and higher 10-year transplant-free survival (48.4%, 68.7%, 79.7%, and 80.1% for each respective cohort; P < 0.001). CONCLUSION In recent decades, a pattern of primary biliary cholangitis presentation consistent with an older age at diagnosis alongside reduced disease severity has been noted; the observed trends may be explained by an increase in routine testing of liver function and/or a changing environmental trigger. (Hepatology 2018;67:1920-1930).
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Affiliation(s)
- Carla F Murillo Perez
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Insitute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Jorn C Goet
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Willem J Lammers
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Aliya Gulamhusein
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Henk R van Buuren
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Marco Carbone
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Andrew Mason
- Divison of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada
| | - Christophe Corpechot
- Centre de Référence des Maladies Inflammatoires des VoiesBiliaires, Hôpital Saint-Antoine, Paris, France
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Marlyn J Mayo
- Digestive and Liver diseases, UT Southwestern Medical Center, Dallas, TX
| | | | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Albert Pares
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | | | - Tony Bruns
- Department of Internal Medicine IV, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre, The Royal Free Hospital, London, UK
| | - Gideon Hirschfield
- NIHR, Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | | | | | - Kalliopi Zachou
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly, Larissa, Greece
| | - Raoul Poupon
- Centre de Référence des Maladies Inflammatoires des VoiesBiliaires, Hôpital Saint-Antoine, Paris, France
| | - Palak J Trivedi
- NIHR, Biomedical Research Centre and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Harry L A Janssen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Bettina E Hansen
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, Toronto, ON, Canada.,Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Tabibian JH, Ali AH, Lindor KD. Primary Sclerosing Cholangitis, Part 1: Epidemiology, Etiopathogenesis, Clinical Features, and Treatment. Gastroenterol Hepatol (N Y) 2018; 14:293-304. [PMID: 29991937 PMCID: PMC6034608] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Primary sclerosing cholangitis (PSC) is a chronic, idiopathic cholangiopathy that can progress to cirrhosis, end-stage liver disease, hepatobiliary cancer, and/or colorectal cancer. The course of PSC is often complicated by portal hypertension, symptoms of cholestasis, and recurrent bacterial cholangitis, among other conditions, with a consequent decrease in survival (median, approximately 20 years) and quality of life. The etiopathogenesis of PSC remains poorly understood, and, as such, pharmacotherapy has yet to be definitively established. Despite its rarity, PSC is the fifth leading indication for liver transplantation (LT) in the United States. Although the only intervention known to extend survival of patients with PSC, LT is costly and invasive, and recurrent PSC affects approximately 30% of LT recipients. Over the past several years, owing in part to progress in the understanding of PSC, novel pharmacotherapeutics have been developed, some of which are currently in the PSC clinical trial pipeline. Here, in the first of a 2-part series, we provide a review and update of the epidemiology, etiopathogenesis, clinical features, and treatment of PSC. The second part of the series will focus on cancer risk, prevention, and surveillance of PSC.
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Affiliation(s)
- James H Tabibian
- Dr Tabibian is an associate professor in the Geffen School of Medicine at UCLA in Los Angeles, California and director of endoscopy in the Department of Medicine at Olive View-UCLA Medical Center in Sylmar, California. Dr Ali is a research fellow in the Division of Gastroenterology and Hepatology at Mayo Clinic in Phoenix, Arizona. Dr Lindor is a professor of medicine in the Division of Gastroenterology and Hepatology at Mayo Clinic and senior advisor to the provost at Arizona State University in Phoenix, Arizona
| | - Ahmad H Ali
- Dr Tabibian is an associate professor in the Geffen School of Medicine at UCLA in Los Angeles, California and director of endoscopy in the Department of Medicine at Olive View-UCLA Medical Center in Sylmar, California. Dr Ali is a research fellow in the Division of Gastroenterology and Hepatology at Mayo Clinic in Phoenix, Arizona. Dr Lindor is a professor of medicine in the Division of Gastroenterology and Hepatology at Mayo Clinic and senior advisor to the provost at Arizona State University in Phoenix, Arizona
| | - Keith D Lindor
- Dr Tabibian is an associate professor in the Geffen School of Medicine at UCLA in Los Angeles, California and director of endoscopy in the Department of Medicine at Olive View-UCLA Medical Center in Sylmar, California. Dr Ali is a research fellow in the Division of Gastroenterology and Hepatology at Mayo Clinic in Phoenix, Arizona. Dr Lindor is a professor of medicine in the Division of Gastroenterology and Hepatology at Mayo Clinic and senior advisor to the provost at Arizona State University in Phoenix, Arizona
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Tabibian JH, Lindor KD. Editorial: is proton pump inhibitor use associated with worse outcomes in patients with liver abscesses? Aliment Pharmacol Ther 2018; 47:1226-1227. [PMID: 29574873 DOI: 10.1111/apt.14568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 01/18/2023]
Affiliation(s)
- J H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
| | - K D Lindor
- Arizona State University, Phoenix, AZ, USA
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38
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Damman JL, Rodriguez EA, Ali AH, Buness CW, Cox KL, Carey EJ, Lindor KD. Review article: the evidence that vancomycin is a therapeutic option for primary sclerosing cholangitis. Aliment Pharmacol Ther 2018; 47:886-895. [PMID: 29411404 DOI: 10.1111/apt.14540] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [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: 10/15/2017] [Revised: 11/06/2017] [Accepted: 01/08/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS PSC is an autoimmune biliary inflammatory disorder that is often associated with inflammatory bowel disease (IBD), with 50%-75% of patients with PSC having coexisting IBD, most commonly ulcerative colitis. Currently, no medical therapies have been shown to improve the disease course or slow its progression. However, ongoing research has resulted in a growing interest in the use of antibiotics for treatment of PSC, of which vancomycin is the most studied. In this review, we summarise the current evidence on the use of vancomycin in PSC and comment on future research areas of interest. METHODS A comprehensive PUBMED and EMBASE literature search for articles on vancomycin, PSC, therapeutic options and microbiome was performed. RESULTS Two randomised clinical trials, three case series and two case reports were included in the study. These include uncontrolled data from at least 98 patients that include promising improvements in biochemistry and imaging. Optimal dosing regimens are unclear. CONCLUSION Vancomycin is one of the most studied antibiotics used in the treatment of PSC with promising results. There is not currently sufficient evidence to support treatment recommendations. Further research is needed to establish if vancomycin is a PSC treatment.
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Affiliation(s)
- J L Damman
- Pediatrics/Gastroenterology and Hepatology, Stanford University, Stanford, CA, USA
| | - E A Rodriguez
- Gastroenterology and Hepatology, Mayo Clinic, Arizona, USA
| | - A H Ali
- Hepatology, Mayo Clinic, Arizona, USA
| | - C W Buness
- National Patient Advocate Foundation, Paradise Valley, AZ, USA
| | - K L Cox
- Pediatric Gastroenterology and Hepatology, Stanford University, Stanford, CA, USA
| | - E J Carey
- Gastroenterology and Hepatology, Mayo Clinic, Arizona, USA
| | - K D Lindor
- Gastroenterology and Hepatology, Arizona State University and Mayo Clinic, Arizona, USA
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Zakharia K, Tabibian A, Lindor KD, Tabibian JH. Complications, symptoms, quality of life and pregnancy in cholestatic liver disease. Liver Int 2018; 38:399-411. [PMID: 28921801 DOI: 10.1111/liv.13591] [Citation(s) in RCA: 24] [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: 03/22/2017] [Accepted: 09/12/2017] [Indexed: 12/11/2022]
Abstract
Cholestatic liver diseases (CLDs) encompass a variety of disorders of bile formation and/or flow which generally result in progressive hepatobiliary injury and ultimately end-stage liver disease. Many patients with CLD are diagnosed between the ages of 20-50 years, a particularly productive period of life professionally, biologically and in other respects; it is not surprising, thus, that CLD is often associated with impaired health-related quality of life (HRQOL) and uncertainty regarding implications for and outcomes of pregnancy. Primary sclerosing cholangitis (PSC) and primary biliary cholangitis (PBC) are the most prominent CLDs, both having considerable morbidity and mortality and representing major indications for liver transplantation. These disorders, as a consequence of their complications (eg ascites, hepatic osteodystrophy), associated conditions (eg inflammatory bowel disease) and symptoms (eg pruritus and fatigue), can significantly impair an array of domains of HRQOL. Here we review these impactful clinical aspects of PSC and PBC as well as the topics of fertility and pregnancy.
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Affiliation(s)
- Kais Zakharia
- Internal Medicine Residency Program, Beaumont Health - Dearborn, Dearborn, MI, USA
| | - Anilga Tabibian
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Keith D Lindor
- Arizona State University, Phoenix, AZ, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
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Abstract
Curcumin, an aromatic phytoextract from the turmeric (Curcuma longa) rhizome, has been used for centuries for a variety of purposes, not the least of which is medicinal. A growing body of evidence suggests that curcumin has a broad range of potentially therapeutic pharmacological properties, including anti-inflammatory, anti-fibrotic, and anti-neoplastic effects, among others. Clinical applications of curcumin have been hampered by quality control concerns and limited oral bioavailability, although novel formulations appear to have largely overcome these issues. Recent in vitro and in vivo studies have found that curcumin's cytoprotective and other biological activities may play a role in an array of benign and malignant hepatobiliary conditions, including but not limited to non-alcoholic fatty liver disease, cholestatic liver disease (e.g. primary sclerosing cholangitis), and cholangiocarcinoma. Here we provide an overview of fundamental principles, recent discoveries, and potential clinical hepatobiliary applications of this pleiotropic phytocompound.
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Affiliation(s)
- Robert W Hu
- Department of Biology, College of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth J Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA Executive Vice Provost and Dean, College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
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Affiliation(s)
- Paul Martin
- Division of Gastroenterology and Hepatology, Miller School of Medicine, University of Miami, Miami, FL, USA.
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA.,Arizona State University, Phoenix, AZ, USA
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Affiliation(s)
- Marina G. Silveira
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Keith D. Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
- Office of the University Provost, Arizona State University, Phoenix, AZ, USA
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43
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Horsley-Silva JL, Rodriguez EA, Franco DL, Lindor KD. An update on cancer risk and surveillance in primary sclerosing cholangitis. Liver Int 2017; 37:1103-1109. [PMID: 28028930 DOI: 10.1111/liv.13354] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [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: 08/29/2016] [Accepted: 12/20/2016] [Indexed: 02/13/2023]
Abstract
Malignancy represents substantial morbidity and mortality in patients with primary sclerosing cholangitis (PSC). This subset of patients has been proven to be at increased risk for developing cholangiocarcinoma, gallbladder carcinoma and colorectal cancer in those with overlapping inflammatory bowel disease. Herein, we review the prevalence of these malignancies and recommend screening tools and current knowledge to reduce the disease burden in this population. Cholangiocarcinoma is the most dominant malignancy affecting PSC patients, with a lifetime risk ranging from 5% to 20%. We advocate for serial US or MRI/MRCP and CA 19-9 to screen for cholangiocarcinoma. Gallbladder cancer has a lifetime risk around 2% in this population and we agree with annual imaging for lesions as recommended by national guidelines. Patients with PSC and concomitant IBD are at increased risk of colorectal carcinoma from time of diagnosis and therefore should likely undergo annual surveillance. The low rates of hepatocellular cancer and pancreatic cancer indicate surveillance for these malignancies is less advantageous.
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Affiliation(s)
| | | | - Diana L Franco
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA.,College of Health Solutions, Arizona State University, Phoenix, AZ, USA
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Weismüller TJ, Trivedi PJ, Bergquist A, Imam M, Lenzen H, Ponsioen CY, Holm K, Gotthardt D, Färkkilä MA, Marschall HU, Thorburn D, Weersma RK, Fevery J, Mueller T, Chazouillères O, Schulze K, Lazaridis KN, Almer S, Pereira SP, Levy C, Mason A, Naess S, Bowlus CL, Floreani A, Halilbasic E, Yimam KK, Milkiewicz P, Beuers U, Huynh DK, Pares A, Manser CN, Dalekos GN, Eksteen B, Invernizzi P, Berg CP, Kirchner GI, Sarrazin C, Zimmer V, Fabris L, Braun F, Marzioni M, Juran BD, Said K, Rupp C, Jokelainen K, Benito de Valle M, Saffioti F, Cheung A, Trauner M, Schramm C, Chapman RW, Karlsen TH, Schrumpf E, Strassburg CP, Manns MP, Lindor KD, Hirschfield GM, Hansen BE, Boberg KM. Patient Age, Sex, and Inflammatory Bowel Disease Phenotype Associate With Course of Primary Sclerosing Cholangitis. Gastroenterology 2017; 152:1975-1984.e8. [PMID: 28274849 PMCID: PMC5546611 DOI: 10.1053/j.gastro.2017.02.038] [Citation(s) in RCA: 306] [Impact Index Per Article: 43.7] [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: 04/24/2016] [Revised: 01/09/2017] [Accepted: 02/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Primary sclerosing cholangitis (PSC) is an orphan hepatobiliary disorder associated with inflammatory bowel disease (IBD). We aimed to estimate the risk of disease progression based on distinct clinical phenotypes in a large international cohort of patients with PSC. METHODS We performed a retrospective outcome analysis of patients diagnosed with PSC from 1980 through 2010 at 37 centers in Europe, North America, and Australia. For each patient, we collected data on sex, clinician-reported age at and date of PSC and IBD diagnoses, phenotypes of IBD and PSC, and date and indication of IBD-related surgeries. The primary and secondary endpoints were liver transplantation or death (LTD) and hepatopancreatobiliary malignancy, respectively. Cox proportional hazards models were applied to determine the effects of individual covariates on rates of clinical events, with time-to-event analysis ascertained through Kaplan-Meier estimates. RESULTS Of the 7121 patients in the cohort, 2616 met the primary endpoint (median time to event of 14.5 years) and 721 developed hepatopancreatobiliary malignancy. The most common malignancy was cholangiocarcinoma (n = 594); patients of advanced age at diagnosis had an increased incidence compared with younger patients (incidence rate: 1.2 per 100 patient-years for patients younger than 20 years old, 6.0 per 100 patient-years for patients 21-30 years old, 9.0 per 100 patient-years for patients 31-40 years old, 14.0 per 100 patient-years for patients 41-50 years old, 15.2 per 100 patient-years for patients 51-60 years old, and 21.0 per 100 patient-years for patients older than 60 years). Of all patients with PSC studied, 65.5% were men, 89.8% had classical or large-duct disease, and 70.0% developed IBD at some point. Assessing the development of IBD as a time-dependent covariate, Crohn's disease and no IBD (both vs ulcerative colitis) were associated with a lower risk of LTD (unadjusted hazard ratio [HR], 0.62; P < .001 and HR, 0.90; P = .03, respectively) and malignancy (HR, 0.68; P = .008 and HR, 0.77; P = .004, respectively). Small-duct PSC was associated with a lower risk of LTD or malignancy compared with classic PSC (HR, 0.30 and HR, 0.15, respectively; both P < .001). Female sex was also associated with a lower risk of LTD or malignancy (HR, 0.88; P = .002 and HR, 0.68; P < .001, respectively). In multivariable analyses assessing the primary endpoint, small-duct PSC characterized a low-risk phenotype in both sexes (adjusted HR for men, 0.23; P < .001 and adjusted HR for women, 0.48; P = .003). Conversely, patients with ulcerative colitis had an increased risk of liver disease progression compared with patients with Crohn's disease (HR, 1.56; P < .001) or no IBD (HR, 1.15; P = .002). CONCLUSIONS In an analysis of data from individual patients with PSC worldwide, we found significant variation in clinical course associated with age at diagnosis, sex, and ductal and IBD subtypes. The survival estimates provided might be used to estimate risk levels for patients with PSC and select patients for clinical trials.
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Affiliation(s)
- Tobias J. Weismüller
- Department of Internal Medicine I, University of Bonn, Germany,Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Palak J. Trivedi
- National Institute for Health Research (NIHR) Birmingham, Liver Biomedical Research Centre (BRC), University of Birmingham, United Kingdom,Liver Unit, University Hospitals Birmingham Queen Elizabeth, United Kingdom
| | - Annika Bergquist
- Center for Digestive Diseases, Division of Hepatology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Mohamad Imam
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota,Department of Internal Medicine, University of North Dakota, Grand Forks, North Dakota
| | - Henrike Lenzen
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Cyriel Y. Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Kristian Holm
- Norwegian PSC Research Center and Section for Gastroenterology, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Daniel Gotthardt
- Department of Gastroenterology, Infectious Diseases and Intoxications, University Hospital Heidelberg, Heidelberg, Germany
| | - Martti A. Färkkilä
- Helsinki University, Clinic of Gastroenterology, Helsinki University Hospital, Helsinki, Finland
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Douglas Thorburn
- The Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | - Rinse K. Weersma
- Department of Gastroenterology and Hepatology, University of Groningen and University Medical Center, Groningen, The Netherlands
| | - Johan Fevery
- Department of Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Tobias Mueller
- Department of Internal Medicine, Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Olivier Chazouillères
- Service d’Hépatologie, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Pierre et Marie Curie, Paris, France
| | - Kornelius Schulze
- 1st Department of Medicine, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | | | - Sven Almer
- Division of Gastroenterology and Hepatology, Linköping University, Linköping; Sweden
| | - Stephen P. Pereira
- Institute for Liver and Digestive Health, University College London, London, United Kingdom
| | - Cynthia Levy
- Division of Hepatology, University of Miami, Miami, Florida
| | - Andrew Mason
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada
| | - Sigrid Naess
- Norwegian PSC Research Center and Section for Gastroenterology, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Christopher L. Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis, Davis, California
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Emina Halilbasic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Kidist K. Yimam
- Department of Hepatology and Liver Transplantation, California Pacific Medical Center, San Francisco, California
| | - Piotr Milkiewicz
- Department of Clinical and Molecular Biochemistry, Pomeranian Medical University, Szczecin, Poland,Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Poland
| | - Ulrich Beuers
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Dep K. Huynh
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Albert Pares
- Liver Unit, Hospital Clinic, IDIBAPS, CIBERehd, University of Barcelona, Spain
| | - Christine N. Manser
- Division for Gastroenterology and Hepatology, University Hospital Zurich (USZ), Zurich, Switzerland
| | - George N. Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, School of Medicine, University of Thessaly, Larissa, Greece
| | - Bertus Eksteen
- University of Calgary, Snyder Institute for Chronic Diseases, Alberta, AB, Canada
| | - Pietro Invernizzi
- Program for Autoimmune Liver Diseases, International Center for Digestive Health, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Christoph P. Berg
- Department of Gastroenterology, Hepatology, and Infectiology, Medical Clinic, University of Tübingen, Germany
| | - Gabi I. Kirchner
- Department of Internal Medicine 1, University Hospital of Regensburg, Regensburg, Germany
| | - Christoph Sarrazin
- Department of Internal Medicine 1, Johann Wolfgang Goethe-University Hospital, Frankfurt, Germany
| | - Vincent Zimmer
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Luca Fabris
- Department of Molecular Medicine, University of Padua School of Medicine, Padua, Italy
| | - Felix Braun
- Department of General, Visceral, Thoracic, Transplantation and Pediatric Surgery, Campus Kiel, UKSH, Kiel, Germany
| | - Marco Marzioni
- Clinic of Gastroenterology, Università Politecnica delle Marche, Ancona, Italy
| | - Brian D. Juran
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Karouk Said
- Center for Digestive Diseases, Division of Hepatology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Christian Rupp
- Department of Gastroenterology, Infectious Diseases and Intoxications, University Hospital Heidelberg, Heidelberg, Germany
| | - Kalle Jokelainen
- Helsinki University, Clinic of Gastroenterology, Helsinki University Hospital, Helsinki, Finland
| | - Maria Benito de Valle
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Francesca Saffioti
- The Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom
| | - Angela Cheung
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Christoph Schramm
- 1st Department of Medicine, University Medical Center Hamburg Eppendorf, Hamburg, Germany,Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Roger W. Chapman
- Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom,Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, United Kingdom
| | - Tom H. Karlsen
- Norwegian PSC Research Center and Section for Gastroenterology, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Erik Schrumpf
- Norwegian PSC Research Center and Section for Gastroenterology, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Michael P. Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Keith D. Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota,Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, Arizona,Arizona State University, College of Health Solutions, Phoenix, Arizona
| | - Gideon M. Hirschfield
- National Institute for Health Research (NIHR) Birmingham, Liver Biomedical Research Centre (BRC), University of Birmingham, United Kingdom
| | - Bettina E. Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada,Toronto Centre for Liver Disease, Toronto General Hospital, Toronto, Canada
| | - Kirsten M. Boberg
- Norwegian PSC Research Center and Section for Gastroenterology, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Abstract
Primary sclerosing cholangitis (PSC) is a chronic, cholestatic, idiopathic liver disease that can progress to end-stage liver disease, cirrhosis and cholangiocarcinoma. PSC is an uncommon and highly heterogeneous disease, associated with inflammatory bowel disease and a complex pathophysiology. To date, no medical therapies have proved effective. The only available treatment for end-stage PSC is liver transplant, but recurrence is a significant complication. Areas covered: This review will explore previously tested treatments, discuss current treatment strategies and present viewpoints about future emerging therapies in PSC. We searched PubMed using the noted keywords. We included data from full-text articles published in English. Further relevant articles were identified from the reference lists of review articles. Expert commentary: The development of new therapies in PSC has been challenging. However, with greater awareness of the disease nowadays, new insights into the disease may help in the design of future therapeutic agents in PSC and ultimately in effective therapies.
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Affiliation(s)
- Eduardo A Rodriguez
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Phoenix , AZ , USA
| | - Elizabeth J Carey
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Phoenix , AZ , USA
| | - Keith D Lindor
- a Division of Gastroenterology and Hepatology , Mayo Clinic , Phoenix , AZ , USA.,b College of Health Solutions , Arizona State University , Phoenix , AZ , USA
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46
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Quinn KP, Tabibian JH, Lindor KD. Clinical implications of serial versus isolated biliary fluorescence in situ hybridization (FISH) polysomy in primary sclerosing cholangitis. Scand J Gastroenterol 2017; 52:377-381. [PMID: 27908204 DOI: 10.1080/00365521.2016.1263681] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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] [Indexed: 02/04/2023]
Abstract
BACKGROUND Cholangiocarcinoma (CCA) is a leading cause of death in patients with primary sclerosing cholangitis (PSC). Biliary polysomy detected by fluorescence in situ hybridization (FISH) helps to identify patients with early CCA, but not all PSC patients with polysomy develop CCA. Here, we examined the features and clinical outcomes of PSC patients with serial versus isolated polysomy. METHODS All patients with PSC who underwent ≥1 endoscopic retrograde cholangiography (ERC) with FISH testing at Mayo Clinic, Rochester from 2008-2011 were identified. Patients diagnosed with CCA at the time of initial polysomy were excluded. Serial polysomy was defined as polysomy on ≥2 ERCs; isolated polysomy was defined as polysomy once followed by all nonpolysomy results. The primary outcome was the diagnosis of CCA. RESULTS Twenty-seven patients with polysomy and ≥1 subsequent ERC with FISH were identified. Of these, 11 (40.7%) had serial polysomy and 16 (59.3%) had isolated polysomy. CCA was more likely to be diagnosed in patients with serial versus isolated polysomy (36.4% vs. 6.3%; p = .046). Overall, four patients (36.4%) with serial polysomy and three (18.8%) with isolated polysomy underwent liver transplantation (LT), with time to LT being significantly shorter for the former (14.0 vs. 65.4 months; p = .0003). CONCLUSIONS Biliary polysomy reverted in ≥50% of patients with PSC; this group appears to be at decreased risk of CCA compared to those with serial polysomy. Nevertheless, both groups should be followed closely, and those with serial polysomy may benefit from early LT evaluation.
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Affiliation(s)
- Kevin P Quinn
- a Department of Internal Medicine , Mayo Clinic , Rochester , MN , USA
| | - James H Tabibian
- a Department of Internal Medicine , Mayo Clinic , Rochester , MN , USA.,b Division of Gastroenterology, Department of Medicine , University of Pennsylvania , PA , USA
| | - Keith D Lindor
- c College of Health Solutions , University of Arizona , Phoenix , AZ , USA
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47
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Abstract
Primary biliary cholangitis (formerly primary biliary cirrhosis) is a rare progressive cholestatic liver disease, whose hallmark features include a persistently elevated alkaline phosphatase level, presence of anti-mitochondrial antibodies and characteristic histology. Since 1998, ursodeoxycholic acid (UDCA), a bile acid, has been the only available therapeutic agent. Primary biliary cholangitis is associated with the development of end-stage liver disease, increased morbidity and mortality. UDCA has been shown to improve serum biochemistries, histology and delay the need for liver transplantation. The clinical issue is that approximately 25%-40% of patients do not respond to this standard therapy. In recent years, many trials have investigated alternative and adjunctive treatments, leading to the recent approval of obeticholic acid, an analogue of chenodeoxycholic acid, which has shown significant and sustained reductions in alkaline phosphatase levels in combination with UDCA. Obeticholic acid has rapidly been embraced as a new agent to improve the biochemical profile in refractory patients, in addition to being approved for use as monotherapy in patients who cannot tolerate UDCA. There are several other studies and targets which are being investigated. This review is intended to highlight the benefits of UDCA, educate the reader on the newly available obeticholic acid, and to summarize the many ongoing trials and therapeutic targets being investigated in attempts to control and cure primary biliary cholangitis.
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Affiliation(s)
- David Chascsa
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Elizabeth J Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA.,College of Health Solutions, Arizona State University, Phoenix, AZ, USA
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48
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Hilscher M, Enders FB, Carey EJ, Lindor KD, Tabibian JH. Alkaline phosphatase normalization is a biomarker of improved survival in primary sclerosing cholangitis. Ann Hepatol 2017; 15:246-53. [PMID: 26845602 DOI: 10.5604/16652681.1193721] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
UNLABELLED Introduction. Recent studies suggest that serum alkaline phosphatase may represent a prognostic biomarker in patients with primary sclerosing cholangitis. However, this association remains poorly understood. Therefore, the aim of this study was to investigate the prognostic significance and clinical correlates of alkaline phosphatase normalization in primary sclerosing cholangitis. MATERIAL AND METHODS This was a retrospective cohort study of patients with a new diagnosis of primary sclerosing cholangitis made at an academic medical center. The primary endpoint was time to hepatobiliaryneoplasia, liver transplantation, or liver-related death. Secondary endpoints included occurrence of and time to alkaline phosphatase normalization. Patients who did and did not achieve normalization were compared with respect to clinical characteristics and endpoint-free survival, and the association between normalization and the primary endpoint was assessed with univariate and multivariate Cox proportional-hazards analyses. RESULTS Eighty six patients were included in the study, with a total of 755 patient-years of follow-up. Thirty-eight patients (44%) experienced alkaline phosphatase normalization within 12 months of diagnosis. Alkaline phosphatase normalization was associated with longer primary endpoint-free survival (p = 0.0032) and decreased risk of requiring liver transplantation (p = 0.033). Persistent normalization was associated with even fewer adverse endpoints as well as longer survival. In multivariate analyses, alkaline phosphatase normalization (adjusted hazard ratio 0.21, p = 0.012) and baseline bilirubin (adjusted hazard ratio 4.87, p = 0.029) were the only significant predictors of primary endpoint-free survival. CONCLUSIONS Alkaline phosphatase normalization, particularly if persistent, represents a robust biomarker of improved long-term survival and decreased risk of requiring liver transplantation in patients with primary sclerosing cholangitis.
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Affiliation(s)
- Moira Hilscher
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Felicity B Enders
- Division of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth J Carey
- Division of Gastroenterology & Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - Keith D Lindor
- Executive Vice Provost & Dean, College of Health Solutions, Arizona State University, Phoenix, AZ, USA; Division of Gastroenterology & Hepatology. Mayo Clinic, Scottsdale, AZ
| | - James H Tabibian
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN, USA
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Tabibian JH, Gossard A, El-Youssef M, Eaton JE, Petz J, Jorgensen R, Enders FB, Lindor KD. Prospective Clinical Trial of Rifaximin Therapy for Patients With Primary Sclerosing Cholangitis. Am J Ther 2017; 24:e56-e63. [PMID: 24914504 PMCID: PMC4261045 DOI: 10.1097/mjt.0000000000000102] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [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] [Indexed: 12/15/2022]
Abstract
Primary sclerosing cholangitis (PSC) is a rare, chronic, cholestatic liver disease in which emerging data suggest that oral antibiotics may offer therapeutic effects. We enrolled patients with PSC in a 12-week, open-label pilot study to investigate the efficacy and safety of 550 mg of oral rifaximin twice daily. The primary end point was serum alkaline phosphatase (ALK) at 12 weeks. Secondary end points included (1) serum bilirubin, gamma-glutamyl transpeptidase, and Mayo PSC risk score; (2) fatigue impact scale, chronic liver disease questionnaire, and short form health survey (SF-36) scores; and (3) adverse effects (AEs). Analyses were performed with nonparametric tests. Sixteen patients were enrolled, among whom the median age was 40 years; 13 (81%) were male, 13 had inflammatory bowel disease, and baseline ALK was 342 IU/mL (interquartile range, 275-520 IU/mL). After 12 weeks of treatment, there were no significant changes in ALK (median increase of 0.9% to 345 IU/mL; P = 0.47) or any of the secondary biochemical end points (all P > 0.05). Similarly, there were no significant changes in fatigue impact scale, chronic liver disease questionnaire, or SF-36 scores (all P > 0.05). Three patients withdrew from the study due to AEs; 4 others reported mild AEs but completed the study. In conclusion, although some antibiotics may have promise in treating PSC, oral rifaximin, based on the results herein, seems inefficacious for this indication. Future studies are needed to understand how the antimicrobial spectra and other properties of antibiotics might determine their utility in treating PSC.
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Affiliation(s)
- James H. Tabibian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
- Center for Clinical and Translational Sciences, Mayo Graduate School, Rochester, MN
| | - Andrea Gossard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Mounif El-Youssef
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - John E. Eaton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Jan Petz
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Roberta Jorgensen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Felicity B. Enders
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Keith D. Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
- Executive Vice Provost & Dean, College of Health Solutions, Arizona State University, Phoenix, AZ
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Treeprasertsuk S, Romero-Corral A, Somers VK, Sierra-Johnson J, Lindor KD, Angulo P, Lopez-Jimenez F. Association of adiposity, measures of metabolic dysregulation, and elevated alanine aminotransferase in subjects with normal body mass index. ASIAN BIOMED 2017. [DOI: 10.5372/1905-7415.0805.331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background: Differences in body fat (BF) distribution in patients with normal body mass index (BMI) with elevated alanine aminotransferase (ALT) remains poorly described.
Objective: To determine the relationship between total BF, waist circumference (WC), insulin resistance (IR), and cardiometabolic risk profile in subjects with elevated ALT and normal BMI.
Methods: We analyzed cross-sectional data from 4,914 US participants in the third National Health and Nutrition Examination Survey database, who were ≥20 years of age, had normal BMI, and had body composition assessed by bioimpedance.
Results: Mean ± SD age was 41.4 ± 0.3 years, and 58% participants were women. BF was 20 ± 0.1% in men and 29.9 ± 0.1% in women. As total BF increased by tertiles, there was a tendency towards a higher prevalence of nonalcoholic fatty liver disease in men (6.1%, 6.5%, 9.5%, P = 0.13), but not in women (8.7%, 8.2%, 10.7%, P = 0.71). As WC increased by tertiles, there was a higher prevalence of elevated ALT in men (2.6%, 8.6%, 6.6%, P < 0.0001), but not in women. As ALT increased, men had significantly higher levels of nonhigh density lipoprotein cholesterol (HDL-C), increased apolipoprotein B, increased IR, and lower levels of C-reactive protein, whereas, women had higher levels of non-HDL-C and increased IR.
Conclusion: In subjects with normal BMI, increased WC is associated with a higher prevalence of elevated ALT in men, but not in women. Higher levels of ALT correlated with a poor cardiometabolic risk profile.
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Affiliation(s)
- Sombat Treeprasertsuk
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Mayo Foundation Rochester, Minnesota 55902, USA Thailand
- Correspondence: MD, PhD, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Abel Romero-Corral
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Mayo Foundation Rochester, MN, Minnesota 55902, USA United States of America
- Department of Internal Medicine, Albert Einstein Medical Center, Philadelphia 19141, United States of America
| | - Virend K. Somers
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Mayo Foundation Rochester, MN, Minnesota 55902, United States of America
| | - Justo Sierra-Johnson
- Department of Medicine, Atherosclerosis Research Unit, Karolinska Institute, SE-171 76 Stockholm, Sweden
| | - Keith D. Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Mayo Foundation Rochester, Minnesota 55902, United States of America
| | - Paul Angulo
- Division of Gastroenterology, University of Kentucky Chandler Medical Center, Lexington, Kentucky 40536-0509, United States of America
| | - Francisco Lopez-Jimenez
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Mayo Foundation Rochester, MN, Minnesota 55902, United States of America
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