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Efe C, Lammert C, Taşçılar K, Dhanasekaran R, Ebik B, Higuera-de la Tijera F, Calışkan AR, Peralta M, Gerussi A, Massoumi H, Catana AM, Purnak T, Rigamonti C, Aldana AJG, Khakoo N, Nazal L, Frager S, Demir N, Irak K, Melekoğlu-Ellik Z, Kacmaz H, Balaban Y, Atay K, Eren F, Alvares-da-Silva MR, Cristoferi L, Urzua Á, Eşkazan T, Magro B, Snijders R, Barutçu S, Lytvyak E, Zazueta GM, Demirezer-Bolat A, Aydın M, Heurgue-Berlot A, De Martin E, Ekin N, Yıldırım S, Yavuz A, Bıyık M, Narro GC, Kıyıcı M, Akyıldız M, Kahramanoğlu-Aksoy E, Vincent M, Carr RM, Günşar F, Reyes EC, Harputluoğlu M, Aloman C, Gatselis NK, Üstündağ Y, Brahm J, Vargas NCE, Güzelbulut F, Garcia SR, Aguirre J, Anders M, Ratusnu N, Hatemi I, Mendizabal M, Floreani A, Fagiuoli S, Silva M, Idilman R, Satapathy SK, Silveira M, Drenth JPH, Dalekos GN, N Assis D, Björnsson E, Boyer JL, Yoshida EM, Invernizzi P, Levy C, Montano-Loza AJ, Schiano TD, Ridruejo E, Wahlin S. Effects of immunosuppressive drugs on COVID-19 severity in patients with autoimmune hepatitis. Liver Int 2022; 42:607-614. [PMID: 34846800 DOI: 10.1111/liv.15121] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [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: 09/02/2021] [Revised: 11/25/2021] [Accepted: 11/28/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND We investigated associations between baseline use of immunosuppressive drugs and severity of Coronavirus Disease 2019 (COVID-19) in autoimmune hepatitis (AIH). PATIENTS AND METHODS Data of AIH patients with laboratory confirmed COVID-19 were retrospectively collected from 15 countries. The outcomes of AIH patients who were on immunosuppression at the time of COVID-19 were compared to patients who were not on AIH medication. The clinical courses of COVID-19 were classified as (i)-no hospitalization, (ii)-hospitalization without oxygen supplementation, (iii)-hospitalization with oxygen supplementation by nasal cannula or mask, (iv)-intensive care unit (ICU) admission with non-invasive mechanical ventilation, (v)-ICU admission with invasive mechanical ventilation or (vi)-death and analysed using ordinal logistic regression. RESULTS We included 254 AIH patients (79.5%, female) with a median age of 50 (range, 17-85) years. At the onset of COVID-19, 234 patients (92.1%) were on treatment with glucocorticoids (n = 156), thiopurines (n = 151), mycophenolate mofetil (n = 22) or tacrolimus (n = 16), alone or in combinations. Overall, 94 (37%) patients were hospitalized and 18 (7.1%) patients died. Use of systemic glucocorticoids (adjusted odds ratio [aOR] 4.73, 95% CI 1.12-25.89) and thiopurines (aOR 4.78, 95% CI 1.33-23.50) for AIH was associated with worse COVID-19 severity, after adjusting for age-sex, comorbidities and presence of cirrhosis. Baseline treatment with mycophenolate mofetil (aOR 3.56, 95% CI 0.76-20.56) and tacrolimus (aOR 4.09, 95% CI 0.69-27.00) were also associated with more severe COVID-19 courses in a smaller subset of treated patients. CONCLUSION Baseline treatment with systemic glucocorticoids or thiopurines prior to the onset of COVID-19 was significantly associated with COVID-19 severity in patients with AIH.
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Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Harran University Hospital, Şanlıurfa, Turkey
| | - Craig Lammert
- Department of Medicine Indiana, University School of Medicine Indianapolis, Indianapolis, Indiana, USA
| | - Koray Taşçılar
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Renumathy Dhanasekaran
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, California, USA
| | - Berat Ebik
- Department of Gastroenterology, Gazi Yaşargil Education and Research Hospital, Diyarbakir, Turkey
| | | | - Ali R Calışkan
- Department of Gastroenterology, Adıyaman University, Adıyaman, Turkey
| | - Mirta Peralta
- Hepatology Section, Hospital Francisco J Muñiz, Ciudad Autónoma de Buenos Aires, Argentina.,Latin American Liver Research Educational and Awareness Network (LALREAN), Pilar, Argentina
| | - Alessio Gerussi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Hatef Massoumi
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Andreea M Catana
- Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Tugrul Purnak
- Division of Gastroenterology, Hepatology and Nutrition, McGovern Medical School, Houston, Texas, USA
| | - Cristina Rigamonti
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Division of Internal Medicine, "AOU Maggiore della Carità", Novara, Italy
| | - Andres J G Aldana
- Gastroenterology and Hepatology Unit, Fundación Santa Fe de Bogotá y universidad de Los Andes, Bogotá, Colombia
| | - Nidah Khakoo
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Leyla Nazal
- Gastroenterology and Hepatology Unit, Clínica Las Condes, Santiago de Chile, Chile
| | - Shalom Frager
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Nurhan Demir
- Department of Gastroenterology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Kader Irak
- Department of Gastroenterology, SBU Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | | | - Hüseyin Kacmaz
- Department of Gastroenterology, Adıyaman University, Adıyaman, Turkey
| | - Yasemin Balaban
- Department of Gastroenterology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kadri Atay
- Departmant of Gastroenterology, Mardin State Hospital, Mardin, Turkey
| | - Fatih Eren
- Departmant of Gastroenterology, Ordu State Hospital, Ordu, Turkey
| | - Mario R Alvares-da-Silva
- Gastroenterology and Hepatology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Laura Cristoferi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Álvaro Urzua
- Gastroenterology and Hepatology Unit. Hospital Clínico, Universidad de Chile, Santiago de Chile, Chile
| | - Tuğçe Eşkazan
- Department of Gastroenterology, Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Bianca Magro
- Gastroenterology Hepatology and Transplantation, ASST Papa Giovanni XXIII-Bergamo, Bergamo, Italy
| | - Romee Snijders
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Nijmegen, The Netherlands
| | - Sezgin Barutçu
- Department of Gastroenterology, University of Gaziantep Medical Faculty, Gaziantep, Turkey
| | - Ellina Lytvyak
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Godolfino M Zazueta
- Gastroenterology Unit, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, México
| | | | - Mesut Aydın
- School of Medicine, Department of Gastroenterology, Van Yuzuncu Yil University, Van, Turkey
| | | | - Eleonora De Martin
- Centre Hepato-Biliaire, Hôpital Paul-Brousse, FHU Hepatinov, INSERM Unit UMR 1193, Univ Paris-Saclay, Gif-sur-Yvette, France
| | - Nazım Ekin
- Department of Gastroenterology, Gazi Yaşargil Education and Research Hospital, Diyarbakir, Turkey
| | - Sümeyra Yıldırım
- Department of Gastroenterology, Erciyes Hospital, Kayseri, Turkey
| | - Ahmet Yavuz
- Division of Gastroenterology, Meram School of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Murat Bıyık
- Division of Gastroenterology, Meram School of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Graciela C Narro
- Gastroenterology Unit, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, México
| | - Murat Kıyıcı
- Department of Gastroenterology, Medical Faculty, Uludag University, Bursa, Turkey
| | - Murat Akyıldız
- Department of Gastroenterology, Koc University School of Medicine, Istanbul, Turkey
| | | | - Maria Vincent
- Department of Internal Medicine, Donald and Barbara Zucker School of Medicine, Northwell Health, Manhasset, NY, USA
| | - Rotonya M Carr
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fulya Günşar
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Eira C Reyes
- Hepatology Unit. Hospital Militar Central de México, Ciudad de México, México
| | - Murat Harputluoğlu
- Department of Gastroenterology, Inönü University School of Medicine, Malatya, Turkey
| | - Costica Aloman
- Section of Hepatology, Rush University Medical Center, Chicago, Illinois, USA
| | - Nikolaos K Gatselis
- 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
| | - Yücel Üstündağ
- Department of Gastroenterology, Bulent Ecevit University of Medicine, Zonguldak, Turkey
| | - Javier Brahm
- Gastroenterology Unit, Clínica Las Condes, Santiago, Chile
| | - Nataly C E Vargas
- Hepatology Unit Hospital Nacional Almanzor Aguinaga Asenjo, Chiclayo, Perú
| | - Fatih Güzelbulut
- Department of Gastroenterology, Haydarpaşa Numune Education and Research Hospital, İstanbul, Turkey
| | - Sandro R Garcia
- Gastroenterology Unit, Hospital Víctor Lazarte Echegaray, Trujillo, Perú
| | - Jonathan Aguirre
- Hepatology Unit, Hospital Ángeles Pedregal, Ciudad de México, México
| | - Margarita Anders
- Hepatology and Liver Transplant Unit, Hospital Alemán, Buenos Aires, Argentina
| | - Natalia Ratusnu
- Hepatology Unit, Hospital Regional de Ushuaia, Ushuaia, Argentina
| | - Ibrahim Hatemi
- Department of Gastroenterology, Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Manuel Mendizabal
- Latin American Liver Research Educational and Awareness Network (LALREAN), Pilar, Argentina.,Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina
| | - Annarosa Floreani
- Scientific Consultant IRCCS Negrar, Verona, Italy.,Senior Scholar, University of Padova, Padova, Italy
| | - Stefano Fagiuoli
- Gastroenterology Hepatology and Transplantation, ASST Papa Giovanni XXIII-Bergamo, Bergamo, Italy
| | - Marcelo Silva
- Latin American Liver Research Educational and Awareness Network (LALREAN), Pilar, Argentina.,Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina
| | - Ramazan Idilman
- Department of Gastroenterology, Ankara University Medical Faculty, Ankara, Turkey
| | - Sanjaya K Satapathy
- Department of Internal Medicine, Donald and Barbara Zucker School of Medicine, Northwell Health, Manhasset, NY, USA
| | - Marina Silveira
- Department of Medicine, Section of Digestive Diseases Yale School of Medicine, New Haven, Connecticut, USA
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Nijmegen, The Netherlands
| | - George N Dalekos
- 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
| | - David N Assis
- Department of Medicine, Section of Digestive Diseases Yale School of Medicine, New Haven, Connecticut, USA
| | - Einar Björnsson
- Department of Internal Medicine, Section of Gastroenterology, Landspitali University Hospital, Reykjavik, Iceland
| | - James L Boyer
- Department of Medicine, Section of Digestive Diseases Yale School of Medicine, New Haven, Connecticut, USA
| | - Eric M Yoshida
- Division of Gastroenterology, University of British Columbia and Vancouver General Hospital, Vancouver, Canada
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Thomas D Schiano
- Division of Liver Diseases, The Mount Sinai Medical Center, New York, New York, USA
| | - Ezequiel Ridruejo
- Latin American Liver Research Educational and Awareness Network (LALREAN), Pilar, Argentina.,Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina.,Hepatology Section, Department of Medicine, Centro de Educación Médica e Investigaciones Clínicas, CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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Efe C, Dhanasekaran R, Lammert C, Ebik B, Higuera‐de la Tijera F, Aloman C, Rıza Calışkan A, Peralta M, Gerussi A, Massoumi H, Catana AM, Torgutalp M, Purnak T, Rigamonti C, Gomez Aldana AJ, Khakoo N, Kacmaz H, Nazal L, Frager S, Demir N, Irak K, Ellik ZM, Balaban Y, Atay K, Eren F, Cristoferi L, Batıbay E, Urzua Á, Snijders R, Kıyıcı M, Akyıldız M, Ekin N, Carr RM, Harputluoğlu M, Hatemi I, Mendizabal M, Silva M, Idilman R, Silveira M, Drenth JP, Assis DN, Björnsson E, Boyer JL, Invernizzi P, Levy C, Schiano TD, Ridruejo E, Wahlin S. Outcome of COVID-19 in Patients With Autoimmune Hepatitis: An International Multicenter Study. Hepatology 2021; 73:2099-2109. [PMID: 33713486 PMCID: PMC8250536 DOI: 10.1002/hep.31797] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/01/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Data regarding outcome of COVID-19 in patients with autoimmune hepatitis (AIH) are lacking. APPROACH AND RESULTS We performed a retrospective study on patients with AIH and COVID-19 from 34 centers in Europe and the Americas. We analyzed factors associated with severe COVID-19 outcomes, defined as the need for mechanical ventilation, intensive care admission, and/or death. The outcomes of patients with AIH were compared to a propensity score-matched cohort of patients without AIH but with chronic liver diseases (CLD) and COVID-19. The frequency and clinical significance of new-onset liver injury (alanine aminotransferase > 2 × the upper limit of normal) during COVID-19 was also evaluated. We included 110 patients with AIH (80% female) with a median age of 49 (range, 18-85) years at COVID-19 diagnosis. New-onset liver injury was observed in 37.1% (33/89) of the patients. Use of antivirals was associated with liver injury (P = 0.041; OR, 3.36; 95% CI, 1.05-10.78), while continued immunosuppression during COVID-19 was associated with a lower rate of liver injury (P = 0.009; OR, 0.26; 95% CI, 0.09-0.71). The rates of severe COVID-19 (15.5% versus 20.2%, P = 0.231) and all-cause mortality (10% versus 11.5%, P = 0.852) were not different between AIH and non-AIH CLD. Cirrhosis was an independent predictor of severe COVID-19 in patients with AIH (P < 0.001; OR, 17.46; 95% CI, 4.22-72.13). Continuation of immunosuppression or presence of liver injury during COVID-19 was not associated with severe COVID-19. CONCLUSIONS This international, multicenter study reveals that patients with AIH were not at risk for worse outcomes with COVID-19 than other causes of CLD. Cirrhosis was the strongest predictor for severe COVID-19 in patients with AIH. Maintenance of immunosuppression during COVID-19 was not associated with increased risk for severe COVID-19 but did lower the risk for new-onset liver injury during COVID-19.
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4
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Mendizabal M, Ridruejo E, Piñero F, Anders M, Padilla M, Toro LG, Torre A, Montes P, Urzúa A, Gonzalez Ballerga E, Silveyra MD, Michelato D, Díaz J, Peralta M, Pages J, García SR, Gutierrez Lozano I, Macias Y, Cocozzella D, Chavez-Tapia N, Tagle M, Dominguez A, Varón A, Vera Pozo E, Higuera-de la Tijera F, Bustios C, Conte D, Escajadillo N, Gómez AJ, Tenorio L, Castillo Barradas M, Schinoni MI, Bessone F, Contreras F, Nazal L, Sanchez A, García M, Brutti J, Cabrera MC, Miranda-Zazueta G, Rojas G, Cattaneo M, Castro-Narro G, Rubinstein F, Silva MO. Comparison of different prognostic scores for patients with cirrhosis hospitalized with SARS-CoV-2 infection. Ann Hepatol 2021; 25:100350. [PMID: 33864948 PMCID: PMC8045426 DOI: 10.1016/j.aohep.2021.100350] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/01/2021] [Accepted: 03/05/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION AND OBJECTIVES Viral infections have been described to increase the risk of decompensation in patients with cirrhosis. We aimed to determine the effect of SARS-CoV-2 infection on outcome of hospitalized patients with cirrhosis and to compare the performance of different prognostic models for predicting mortality. PATIENTS We performed a prospective cohort study including 2211 hospitalized patients with confirmed SARS-CoV-2 infection from April 15, 2020 through October 1, 2020 in 38 Hospitals from 11 Latin American countries. We registered clinical and laboratory parameters of patients with and without cirrhosis. All patients were followed until discharge or death. We evaluated the prognostic performance of different scoring systems to predict mortality in patients with cirrhosis using ROC curves. RESULTS Overall, 4.6% (CI 3.7-5.6) subjects had cirrhosis (n = 96). Baseline Child-Turcotte-Pugh (CTP) class was assessed: CTP-A (23%), CTP-B (45%) and CTP-C (32%); median MELD-Na score was 19 (IQR 14-25). Mortality was 47% in patients with cirrhosis and 16% in patients without cirrhosis (P < .0001). Cirrhosis was independently associated with death [OR 3.1 (CI 1.9-4.8); P < .0001], adjusted by age, gender, and body mass index >30. The areas under the ROC curves for performance evaluation in predicting 28-days mortality for Chronic Liver Failure Consortium (CLIF-C), North American Consortium for the Study of End-Stage Liver Disease (NACSELD), CTP score and MELD-Na were 0.85, 0.75, 0.69, 0.67; respectively (P < .0001). CONCLUSIONS SARS-CoV-2 infection is associated with elevated mortality in patients with cirrhosis. CLIF-C had better performance in predicting mortality than NACSELD, CTP and MELD-Na in patients with cirrhosis and SARS-CoV-2 infection. Clinicaltrials.gov:NCT04358380.
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Affiliation(s)
- Manuel Mendizabal
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Universidad Austral, Pilar, Argentina; Latin American Liver Research Educational and Awareness Network (LALREAN).
| | - Ezequiel Ridruejo
- Latin American Liver Research Educational and Awareness Network (LALREAN); Liver Section, Centro de Educación Médica e Investigaciones Clínicas, Buenos Aires, Argentina
| | - Federico Piñero
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Universidad Austral, Pilar, Argentina; Latin American Liver Research Educational and Awareness Network (LALREAN)
| | - Margarita Anders
- Latin American Liver Research Educational and Awareness Network (LALREAN); Hepatology and Liver Transplant Unit, Hospital Alemán, Buenos Aires, Argentina
| | - Martín Padilla
- Gastroenterology Unit, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Perú
| | - Luis G Toro
- Hepatology and Liver Transplant Unit, Hospitales de San Vicente Fundación de Medellín y Rionegro, Medellín, Colombia
| | - Aldo Torre
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición, Ciudad de México, México
| | - Pedro Montes
- Gastroenterology Unit, Hospital Nacional Daniel A. Carrión, Callao, Perú
| | - Alvaro Urzúa
- Gastroenterology Section, Internal Medicine Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Esteban Gonzalez Ballerga
- Department of Gastroenterology, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Buenos Aires, Argentina
| | | | - Douglas Michelato
- Hospital Especializado en Enfermedades Infecciosas Instituto Couto Maia, Salvador de Bahía, Brazil
| | - Javier Díaz
- Hospital Nacional Edgardo Rebagliati Martins, Lima, Perú
| | - Mirta Peralta
- Latin American Liver Research Educational and Awareness Network (LALREAN); Intensive Care Unit, Hospital de Infecciosas Francisco J Muñiz, Buenos Aires, Argentina
| | - Josefina Pages
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Universidad Austral, Pilar, Argentina; Latin American Liver Research Educational and Awareness Network (LALREAN)
| | - Sandro Ruiz García
- Gastroenterology Unit, Hospital de Víctor Lazarte Echegaray, Trujillo, Perú
| | | | - Yuridia Macias
- Department of Medicine, IMSS Hospital General Regional No. 1 "Dr. Carlos Mc Gregor Sánchez", Ciudad de México, Mexico
| | - Daniel Cocozzella
- Latin American Liver Research Educational and Awareness Network (LALREAN); Department of Gastroenterology, Hospital Italiano de La Plata, La Plata, Argentina
| | | | - Martín Tagle
- Gastroenterology Unit, Clínica Anglo-Americana, Lima, Perú
| | | | - Adriana Varón
- Latin American Liver Research Educational and Awareness Network (LALREAN); Liver Unit, Fundación Cardio-Infantil, Bogotá, Colombia
| | - Emilia Vera Pozo
- Hospital Regional Dr. Teodoro Maldonado Carbo del IESS, Guayaquil, Ecuador
| | - Fátima Higuera-de la Tijera
- Department of Gastroenterology and Hepatology, Hospital General de México "Dr. Eduardo Liceaga", Ciudad de México, México
| | | | - Damián Conte
- Unidad de Hígado, Hospital Privado de Córdoba, Córdoba, Argentina
| | - Nataly Escajadillo
- Gastroenterology Unit, Hospital Nacional Almanzor Aguinaga Asenjo, Chiclayo, Perú
| | - Andrés J Gómez
- Endoscopy and Transplant Service, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Laura Tenorio
- Hospital Nacional Edgardo Rebagliati Martins, Lima, Perú
| | - Mauricio Castillo Barradas
- Gastroenterology Unit, Hospital de Especialidades del Centro Médico Nacional La Raza IMSS, Ciudad de México, México
| | - Maria Isabel Schinoni
- Latin American Liver Research Educational and Awareness Network (LALREAN); Department of Gastroenterology, Hospital Alianza, Bahía, Brazil
| | - Fernando Bessone
- Department of Gastroenterology, Hospital Provincial del Centenario, Rosario, Argentina
| | - Fernando Contreras
- Department of Gastroenterology, CEDIMAT, Santo Domingo, Dominican Republic
| | - Leyla Nazal
- Department of Gastroenterology, Clínica Las Condes, Santiago, Chile
| | - Abel Sanchez
- Department of Gastroenterology, Hospital Roosevelt, Ciudad de Guatemala, Guatemala
| | - Matías García
- Liver Section, Centro de Educación Médica e Investigaciones Clínicas, Buenos Aires, Argentina
| | - Julia Brutti
- Department of Internal Medicine, Sanatorio Anchorena, Buenos Aires, Argentina
| | | | - Godolfino Miranda-Zazueta
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición, Ciudad de México, México
| | - German Rojas
- Department of Gastroenterology, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Maximo Cattaneo
- Gastroenterology Section, Internal Medicine Department, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | | | | | - Marcelo O Silva
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Universidad Austral, Pilar, Argentina; Latin American Liver Research Educational and Awareness Network (LALREAN)
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