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Bajaj JS, Kamath PS, Reddy KR, Asrani SK, Keaveny AP, Tandon P, Duarte-Rojo A, Kappus M, Verna E, Biggins SW, Vargas HE, Albhaisi S, Shaw J, Dahiya M, Filipek N, Fallahzadeh MA, Wegermann K, Cabello R, Bera C, Thuluvath P, Bush B, Thacker LR, Wong F. Predictors of Respiratory Failure Development in a Multicenter Cohort of Inpatients With Cirrhosis. Am J Gastroenterol 2024; 119:712-718. [PMID: 37938163 DOI: 10.14309/ajg.0000000000002574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/18/2023] [Indexed: 11/09/2023]
Abstract
INTRODUCTION Hospitalized patients with cirrhosis can develop respiratory failure (RF), which is associated with a poor prognosis, but predisposing factors are unclear. METHODS We prospectively enrolled a multicenter North American cirrhosis inpatient cohort and collected admission and in-hospital data (grading per European Association for the Study of Liver-Chronic Liver Failure scoring system, acute kidney injury [AKI], infections [admission/nosocomial], and albumin use) in an era when terlipressin was not available in North America. Multivariable regression to predict RF was performed using only admission day and in-hospital events occurring before RF. RESULTS A total of 511 patients from 14 sites (median age 57 years, admission model for end-stage liver disease [MELD]-Na 23) were enrolled: RF developed in 15%; AKI occurred in 24%; and 11% developed nosocomial infections (NI). At admission, patients who developed RF had higher MELD-Na, gastrointestinal (GI) bleeding/AKI-related admission, and prior infections/ascites. During hospitalization, RF developers had higher NI (especially respiratory), albumin use, and other organ failures. RF was higher in patients receiving albumin (83% vs 59%, P < 0.0001) with increasing doses (269.5 ± 210.5 vs 208.6 ± 186.1 g, P = 0.01) regardless of indication. Admission for AKI, GI bleeding, and high MELD-Na predicted RF. Using all variables, NI (odds ratio [OR] = 4.02, P = 0.0004), GI bleeding (OR = 3.1, P = 0.002), albumin use (OR = 2.93, P = 0.01), AKI (OR = 3.26, P = 0.008), and circulatory failure (OR = 3.73, P = 0.002) were associated with RF risk. DISCUSSION In a multicenter inpatient cirrhosis study of patients not exposed to terlipressin, 15% of patients developed RF. RF risk was highest in those admitted with AKI, those who had GI bleeding on admission, and those who developed NI and other organ failures or received albumin during their hospital course. Careful volume monitoring and preventing nosocomial respiratory infections and renal or circulatory failures could reduce this risk.
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Affiliation(s)
- Jasmohan S Bajaj
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - Patrick S Kamath
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | | | | | - Andrew P Keaveny
- Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
| | | | - Andres Duarte-Rojo
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Northwestern University, Chicago, Illinois, USA
| | | | | | | | - Hugo E Vargas
- Mayo Clinic College of Medicine and Science, Phoenix, Arizona, USA
| | - Somaya Albhaisi
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - Jawaid Shaw
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | | | | | | | | | | | | | - Paul Thuluvath
- Mercy Medical Center & University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Brian Bush
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - Leroy R Thacker
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
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Thaweethai T, Jolley SE, Karlson EW, Levitan EB, Levy B, McComsey GA, McCorkell L, Nadkarni GN, Parthasarathy S, Singh U, Walker TA, Selvaggi CA, Shinnick DJ, Schulte CCM, Atchley-Challenner R, Alba GA, Alicic R, Altman N, Anglin K, Argueta U, Ashktorab H, Baslet G, Bassett IV, Bateman L, Bedi B, Bhattacharyya S, Bind MA, Blomkalns AL, Bonilla H, Bush PA, Castro M, Chan J, Charney AW, Chen P, Chibnik LB, Chu HY, Clifton RG, Costantine MM, Cribbs SK, Davila Nieves SI, Deeks SG, Duven A, Emery IF, Erdmann N, Erlandson KM, Ernst KC, Farah-Abraham R, Farner CE, Feuerriegel EM, Fleurimont J, Fonseca V, Franko N, Gainer V, Gander JC, Gardner EM, Geng LN, Gibson KS, Go M, Goldman JD, Grebe H, Greenway FL, Habli M, Hafner J, Han JE, Hanson KA, Heath J, Hernandez C, Hess R, Hodder SL, Hoffman MK, Hoover SE, Huang B, Hughes BL, Jagannathan P, John J, Jordan MR, Katz SD, Kaufman ES, Kelly JD, Kelly SW, Kemp MM, Kirwan JP, Klein JD, Knox KS, Krishnan JA, Kumar A, Laiyemo AO, Lambert AA, Lanca M, Lee-Iannotti JK, Logarbo BP, Longo MT, Luciano CA, Lutrick K, Maley JH, Marathe JG, Marconi V, Marshall GD, Martin CF, Matusov Y, Mehari A, Mendez-Figueroa H, Mermelstein R, Metz TD, Morse R, Mosier J, Mouchati C, Mullington J, Murphy SN, Neuman RB, Nikolich JZ, Ofotokun I, Ojemakinde E, Palatnik A, Palomares K, Parimon T, Parry S, Patterson JE, Patterson TF, Patzer RE, Peluso MJ, Pemu P, Pettker CM, Plunkett BA, Pogreba-Brown K, Poppas A, Quigley JG, Reddy U, Reece R, Reeder H, Reeves WB, Reiman EM, Rischard F, Rosand J, Rouse DJ, Ruff A, Saade G, Sandoval GJ, Schlater SM, Shepherd F, Sherif ZA, Simhan H, Singer NG, Skupski DW, Sowles A, Sparks JA, Sukhera FI, Taylor BS, Teunis L, Thomas RJ, Thorp JM, Thuluvath P, Ticotsky A, Tita AT, Tuttle KR, Urdaneta AE, Valdivieso D, VanWagoner TM, Vasey A, Verduzco-Gutierrez M, Wallace ZS, Ward HD, Warren DE, Weiner SJ, Welch S, Whiteheart SW, Wiley Z, Wisnivesky JP, Yee LM, Zisis S, Horwitz LI, Foulkes AS. Development of a Definition of Postacute Sequelae of SARS-CoV-2 Infection. JAMA 2023; 329:1934-1946. [PMID: 37278994 PMCID: PMC10214179 DOI: 10.1001/jama.2023.8823] [Citation(s) in RCA: 152] [Impact Index Per Article: 152.0] [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: 03/09/2023] [Accepted: 05/01/2023] [Indexed: 06/07/2023]
Abstract
Importance SARS-CoV-2 infection is associated with persistent, relapsing, or new symptoms or other health effects occurring after acute infection, termed postacute sequelae of SARS-CoV-2 infection (PASC), also known as long COVID. Characterizing PASC requires analysis of prospectively and uniformly collected data from diverse uninfected and infected individuals. Objective To develop a definition of PASC using self-reported symptoms and describe PASC frequencies across cohorts, vaccination status, and number of infections. Design, Setting, and Participants Prospective observational cohort study of adults with and without SARS-CoV-2 infection at 85 enrolling sites (hospitals, health centers, community organizations) located in 33 states plus Washington, DC, and Puerto Rico. Participants who were enrolled in the RECOVER adult cohort before April 10, 2023, completed a symptom survey 6 months or more after acute symptom onset or test date. Selection included population-based, volunteer, and convenience sampling. Exposure SARS-CoV-2 infection. Main Outcomes and Measures PASC and 44 participant-reported symptoms (with severity thresholds). Results A total of 9764 participants (89% SARS-CoV-2 infected; 71% female; 16% Hispanic/Latino; 15% non-Hispanic Black; median age, 47 years [IQR, 35-60]) met selection criteria. Adjusted odds ratios were 1.5 or greater (infected vs uninfected participants) for 37 symptoms. Symptoms contributing to PASC score included postexertional malaise, fatigue, brain fog, dizziness, gastrointestinal symptoms, palpitations, changes in sexual desire or capacity, loss of or change in smell or taste, thirst, chronic cough, chest pain, and abnormal movements. Among 2231 participants first infected on or after December 1, 2021, and enrolled within 30 days of infection, 224 (10% [95% CI, 8.8%-11%]) were PASC positive at 6 months. Conclusions and Relevance A definition of PASC was developed based on symptoms in a prospective cohort study. As a first step to providing a framework for other investigations, iterative refinement that further incorporates other clinical features is needed to support actionable definitions of PASC.
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Affiliation(s)
- Tanayott Thaweethai
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Bruce Levy
- Harvard Medical School, Boston, Massachusetts
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Lisa McCorkell
- Patient-Led Research Collaborative, Calabasas, California
| | | | | | - Upinder Singh
- Stanford University School of Medicine, Stanford, California
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mario Castro
- University of Kansas Medical Center, Kansas City
| | | | | | - Peter Chen
- Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Helen Y Chu
- University of Washington School of Medicine, Seattle
| | | | | | | | | | | | | | | | | | | | | | | | - Cheryl E Farner
- The University of Texas Health Science Center at San Antonio
| | | | | | - Vivian Fonseca
- Tulane University Health Sciences Center, New Orleans, Louisiana
| | | | | | | | | | | | | | - Minjoung Go
- Stanford University School of Medicine, Stanford, California
| | | | | | | | | | - John Hafner
- University of Illinois Chicago College of Medicine
| | - Jenny E Han
- Emory University School of Medicine, Atlanta, Georgia
| | | | - James Heath
- Institute for Systems Biology, Seattle, Washington
| | | | - Rachel Hess
- University of Utah Schools of the Health Sciences, Salt Lake City
| | - Sally L Hodder
- West Virginia Clinical and Translational Science Institute, Morgantown
| | | | | | | | | | | | - Janice John
- Cambridge Health Alliance, Cambridge, Massachusetts
| | | | - Stuart D Katz
- New York University Grossman School of Medicine, New York
| | | | | | - Sara W Kelly
- University of Illinois College of Medicine at Peoria
| | | | - John P Kirwan
- Pennington Biomedical Research Center, Baton Rouge, Louisiana
| | | | | | - Jerry A Krishnan
- University of Illinois Hospital and Health Sciences System, Chicago
| | - Andre Kumar
- Stanford University School of Medicine, Stanford, California
| | | | | | | | | | | | | | | | | | - Jason H Maley
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Yuri Matusov
- Cedars-Sinai Medical Center, Los Angeles, California
| | - Alem Mehari
- Howard University College of Medicine, Washington, DC
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jan E Patterson
- The University of Texas Health Science Center at San Antonio
| | | | | | | | | | | | - Beth A Plunkett
- Harvard Medical School, Boston, Massachusetts
- NorthShore University HealthSystem, Evanston, Illinois
| | | | - Athena Poppas
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | | | - Uma Reddy
- Columbia University Irving Medical Center, New York, New York
| | - Rebecca Reece
- West Virginia University School of Medicine, Morgantown
| | | | - W B Reeves
- Department of Medicine, The University of Texas Health Science Center at San Antonio
| | | | | | | | | | - Adam Ruff
- The University of Kansas Medical Center, Kansas City
| | | | - Grecio J Sandoval
- Milken Institute of Public Health, The George Washington University, Washington, DC
| | | | | | - Zaki A Sherif
- Howard University College of Medicine, Washington, DC
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Steven J Weiner
- The George Washington University Biostatistics Center, Rockville, Maryland
| | | | | | | | | | - Lynn M Yee
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | | | - Andrea S Foulkes
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
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Bajaj JS, Tandon P, O'Leary JG, Reddy KR, Garcia-Tsao G, Thuluvath P, Lai JC, Subramanian RM, Vargas HE, Wong F, Fagan A, McGeorge S, Thacker LR, Kamath PS. Admission Serum Metabolites and Thyroxine Predict Advanced Hepatic Encephalopathy in a Multicenter Inpatient Cirrhosis Cohort. Clin Gastroenterol Hepatol 2023; 21:1031-1040.e3. [PMID: 35436625 PMCID: PMC11000256 DOI: 10.1016/j.cgh.2022.03.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/07/2022] [Accepted: 03/24/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Grades 3 to 4 hepatic encephalopathy (advanced HE), also termed brain failure, is an organ failure that defines acute-on-chronic liver failure. It is associated with poor outcomes in cirrhosis but cannot be predicted accurately. We aimed to determine the admission metabolomic biomarkers able to predict the development of advanced HE with subsequent validation. METHODS Prospective inpatient cirrhosis cohorts (multicenter and 2-center validation) without brain failure underwent admission serum collection and inpatient follow-up evaluation. Serum metabolomics were analyzed to predict brain failure on random forest analysis and logistic regression. A separate validation cohort also was recruited. RESULTS The multicenter cohort included 602 patients, of whom 144 developed brain failure (105 only brain failure) 3 days after admission. Unadjusted random forest analysis showed that higher admission microbially derived metabolites and lower isoleucine, thyroxine, and lysophospholipids were associated with brain failure development (area under the curve, 0.87 all; 0.90 brain failure only). Logistic regression area under the curve with only clinical variables significantly improved with metabolites (95% CI 0.65-0.75; P = .005). Four metabolites that significantly added to brain failure prediction were low thyroxine and maltose and high methyl-4-hydroxybenzoate sulfate and 3-4 dihydroxy butyrate. Thyroxine alone also significantly added to the model (P = .05). The validation cohort including 81 prospectively enrolled patients, of whom 11 developed brain failure. Admission hospital laboratory thyroxine levels predicted brain failure development despite controlling for clinical variables with high specificity. CONCLUSIONS In a multicenter inpatient cohort, admission serum metabolites, including thyroxine, predicted advanced HE development independent of clinical factors. Admission low local laboratory thyroxine levels were validated as a predictor of advanced HE development in a separate cohort.
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Affiliation(s)
- Jasmohan S Bajaj
- Department of Medicine, Virginia Commonwealth University, Richmond Veterans Affairs Medical Center, Richmond, Virginia.
| | - Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - K Rajender Reddy
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Paul Thuluvath
- Department of Medicine, Mercy Medical Center, Baltimore, Maryland
| | - Jennifer C Lai
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Ram M Subramanian
- Department of Medicine, Emory University Medical Center, Atlanta, Georgia
| | - Hugo E Vargas
- Department of Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Andrew Fagan
- Department of Medicine, Virginia Commonwealth University, Richmond Veterans Affairs Medical Center, Richmond, Virginia
| | - Sara McGeorge
- Department of Medicine, Virginia Commonwealth University, Richmond Veterans Affairs Medical Center, Richmond, Virginia
| | - Leroy R Thacker
- Department of Medicine, Virginia Commonwealth University, Richmond Veterans Affairs Medical Center, Richmond, Virginia
| | - Patrick S Kamath
- Department of Medicine, Mayo Clinic Rochester, Rochester, Minnesota
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4
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Jacobson IM, Bourgeois S, Mathurin P, Thuluvath P, Ryder SD, Gerken G, Hernandez C, Vanstraelen K, Scherbakovsky S, Osinusi A, Tedesco D, Foster GR. The tolerability of sofosbuvir/velpatasvir for 12 weeks in patients treated in the ASTRAL 1, 2 and 3 studies: A pooled safety analysis. J Viral Hepat 2023; 30:448-454. [PMID: 36740893 DOI: 10.1111/jvh.13814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 02/07/2023]
Abstract
To evaluate the safety and tolerability of the fixed-dose, single-tablet regimen sofosbuvir/velpatasvir (SOF/VEL) for the treatment of hepatitis C virus (HCV) infection in three Phase 3 studies in patients with and without compensated cirrhosis. Data from three registrational trials (ASTRAL-1, NCT02201940; ASTRAL-2, NCT02220998; ASTRAL-3, NCT02201953) were pooled by treatment regimen. Researchers assessed treatment-emergent adverse events (TEAEs) and laboratory abnormalities in patients randomized to SOF/VEL or placebo for 12 weeks in ASTRAL-1 and SOF/VEL for 12 weeks in ASTRAL-2 and ASTRAL-3. Overall, 1035 patients were treated with SOF/VEL, and 116 patients received placebo. Rates of any TEAE were generally similar between patients receiving SOF/VEL (79.4%) and those receiving placebo (76.7%). The majority of TEAEs were mild to moderate, with 23 (2.2%) treatment-emergent serious AEs in patients treated with SOF/VEL. Of these treatment-emergent serious AEs, none led to premature study discontinuation, nor were they considered related to treatment. Presence of compensated cirrhosis, greater age and mild renal impairment did not impact incidence or severity of TEAEs with SOF/VEL treatment. The most common TEAEs (incidence ≥10%) were headache, fatigue, nausea and nasopharyngitis in patients receiving SOF/VEL; similar rates were observed in placebo-treated patients. Three deaths (<1%) were reported in patients treated with SOF/VEL, all posttreatment and none assessed as related to study treatment. Similar to that of placebo, SOF/VEL treatment of HCV infection had a safety/tolerability profile that was not affected by baseline factors, such as the presence of compensated cirrhosis, mild renal impairment or advanced age.
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Affiliation(s)
| | | | - Phillipe Mathurin
- Centre Hospitalier Universitaire de Lille, Universite Nord de France, Lille, France
| | - Paul Thuluvath
- Institute for Digestive Health and Liver Disease, Baltimore, Maryland, USA
| | - Stephen D Ryder
- NIHR Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and The University of Nottingham, Queen's Medical Centre Campus, Nottingham, UK
| | | | | | | | | | - Anu Osinusi
- Gilead Sciences, Inc, Foster City, California, USA
| | - Dana Tedesco
- Gilead Sciences, Inc, Foster City, California, USA
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Khuc T, Agarwal A, Li F, Kantsevoy S, Curtin B, Hagan M, Harris M, Maheshwari A, Raina A, Zhou E, Thuluvath P. Accuracy and Inter-observer Agreement Among Endoscopists for Visual Identification of Colorectal Polyps Using Endoscopy Images. Dig Dis Sci 2023; 68:616-622. [PMID: 35947305 DOI: 10.1007/s10620-022-07643-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/06/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND It is essential to accurately distinguish small benign hyperplastic colon polyps (HP) from sessile serrated lesions (SSL) or adenomatous polyps (TA) based on endoscopic appearances. Our objective was to determine the accuracy and inter-observer agreements for the endoscopic diagnosis of small polyps. METHODS High-quality endoscopic images of 30 small HPs, SSLs, and TAs were used randomly to create two-timed PowerPoint slide sets-one with and another one without information on polyp size and location. Seven endoscopists viewed the slides on two separate occasions 90 days apart, identified the polyp type, and graded their confidence level. Overall and polyp-specific accuracies were assessed for the group and individual endoscopists. Chi-square tests and Kappa (κ) statistics were used to compare differences as appropriate. RESULTS When polyp size and location were provided, overall accuracy was 67.1% for TAs, 50.0% for SSLs, and 41.4% for HPs; the corresponding accuracies were 60%, 44.3%, and 34.3% when polyp size and location were withheld (p < .001). Inter-observer agreement was moderate for TAs (κ = 0.50) and fair for SSLs (κ = 0.26) and HPs (κ = 0.29); the corresponding inter-observer agreements were 0.44, 0.31, and 0.17 with polyp size and location withheld. Accuracy was not affected by knowledge of polyp size, location, or confidence level. Endoscopists with ≥ 10 years (vs. < 10 years) of colonoscopy experience had marginally higher (56% vs. 40%, p = 0.05) accuracy for SSL diagnosis. CONCLUSIONS The ability to distinguish between small TAs, SSLs, and HPs on their endoscopic appearance is poor regardless of the endoscopists' knowledge of polyp size and location.
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Affiliation(s)
- Thi Khuc
- Institute for Digestive Health and Liver Disease, Mercy Medical Center, Baltimore, MD, USA.
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Amol Agarwal
- Institute for Digestive Health and Liver Disease, Mercy Medical Center, Baltimore, MD, USA
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Feng Li
- Institute for Digestive Health and Liver Disease, Mercy Medical Center, Baltimore, MD, USA
| | - Sergey Kantsevoy
- Institute for Digestive Health and Liver Disease, Mercy Medical Center, Baltimore, MD, USA
| | - Bryan Curtin
- Institute for Digestive Health and Liver Disease, Mercy Medical Center, Baltimore, MD, USA
| | - Matilda Hagan
- Institute for Digestive Health and Liver Disease, Mercy Medical Center, Baltimore, MD, USA
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mary Harris
- Institute for Digestive Health and Liver Disease, Mercy Medical Center, Baltimore, MD, USA
| | - Anurag Maheshwari
- Institute for Digestive Health and Liver Disease, Mercy Medical Center, Baltimore, MD, USA
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Amit Raina
- Institute for Digestive Health and Liver Disease, Mercy Medical Center, Baltimore, MD, USA
| | - Elinor Zhou
- Institute for Digestive Health and Liver Disease, Mercy Medical Center, Baltimore, MD, USA
| | - Paul Thuluvath
- Institute for Digestive Health and Liver Disease, Mercy Medical Center, Baltimore, MD, USA
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
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Bajaj JS, Garcia-Tsao G, Reddy KR, O’Leary JG, Vargas HE, Lai JC, Kamath PS, Tandon P, Subramanian RM, Thuluvath P, Fagan A, Sehrawat T, de la Rosa Rodriguez R, Thacker LR, Wong F. Admission Urinary and Serum Metabolites Predict Renal Outcomes in Hospitalized Patients With Cirrhosis. Hepatology 2021; 74:2699-2713. [PMID: 34002868 PMCID: PMC9338693 DOI: 10.1002/hep.31907] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Acute kidney injury (AKI) has a poor prognosis in cirrhosis. Given the variability of creatinine, the prediction of AKI and dialysis by other markers is needed. The aim of this study is to determine the role of serum and urine metabolomics in the prediction of AKI and dialysis in an inpatient cirrhosis cohort. APPROACH AND RESULTS Inpatients with cirrhosis from 11 North American Consortium of End-stage Liver Disease centers who provided admission serum/urine when they were AKI and dialysis-free were included. Analysis of covariance adjusted for demographics, infection, and cirrhosis severity was performed to identify metabolites that differed among patients (1) who developed AKI or not; (2) required dialysis or not; and/pr (3) within AKI subgroups who needed dialysis or not. We performed random forest and AUC analyses to identify specific metabolite(s) associated with outcomes. Logistic regression with clinical variables with/without metabolites was performed. A total of 602 patients gave serum (218 developed AKI, 80 needed dialysis) and 435 gave urine (164 developed AKI, 61 needed dialysis). For AKI prediction, clinical factor-adjusted AUC was 0.91 for serum and 0.88 for urine. Major metabolites such as uremic toxins (2,3-dihydroxy-5-methylthio-4-pentenoic acid [DMTPA], N2N2dimethylguanosine, uridine/pseudouridine) and tryptophan/tyrosine metabolites (kynunerate, 8-methoxykyunerate, quinolinate) were higher in patients who developed AKI. For dialysis prediction, clinical factor-adjusted AUC was 0.93 for serum and 0.91 for urine. Similar metabolites as AKI were altered here. For dialysis prediction in those with AKI, the AUC was 0.81 and 0.79 for serum/urine. Lower branched-chain amino-acid (BCAA) metabolites but higher cysteine, tryptophan, glutamate, and DMTPA were seen in patients with AKI needing dialysis. Serum/urine metabolites were additive to clinical variables for all outcomes. CONCLUSIONS Specific admission urinary and serum metabolites were significantly additive to clinical variables to predict AKI development and dialysis initiation in inpatients with cirrhosis. These observations can potentially facilitate earlier initiation of renoprotective measures.
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Affiliation(s)
- Jasmohan S. Bajaj
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA
| | | | | | | | | | | | | | | | | | | | - Andrew Fagan
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA
| | | | | | - Leroy R. Thacker
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA
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7
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O'Leary JG, Rajender Reddy K, Tandon P, Biggins SW, Wong F, Kamath PS, Garcia-Tsao G, Maliakkal B, Lai JC, Fallon M, Vargas HE, Thuluvath P, Subramanian R, Thacker LR, Bajaj JS. Increased Risk of ACLF and Inpatient Mortality in Hospitalized Patients with Cirrhosis and Hepatic Hydrothorax. Dig Dis Sci 2021; 66:3612-3618. [PMID: 33185787 PMCID: PMC11034783 DOI: 10.1007/s10620-020-06677-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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: 06/11/2020] [Accepted: 10/13/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Hepatic hydrothorax (HH) remains a difficult-to-treat complication of cirrhosis. AIM To define the mortality, length of stay (LOS), and risk of ACLF in patients admitted with HH. METHODS We utilized the North American Consortium for the Study of End-stage Liver Disease, a prospective cohort of 2868 non-electively hospitalized patients with cirrhosis from 14 tertiary care hepatology centers in North America. A total of 121 patients who required an inpatient thoracentesis (HH group) were compared to 736 patients with refractory ascites without HH, and to 1639 patients without these complications (Other). Patients with a TIPS before or during admission were excluded. RESULTS There were no differences between the groups in age, gender, or liver disease etiology. Admission MELD (20.5, 21.6 vs. 18.7; p < 0.0001) was lower in HH than RA patients but lowest in other patients, respectively. In hospital, HH patients' rate of second infections and ICU transfer were the highest, and their LOS was the longest of all groups. Despite a similar mean discharge MELD compared to RA patients, the 90-day transplant rate was lower. Multivariable modeling showed patients with HH had an increased risk of ACLF (HR = 2.37 vs. RA, HR = 2.56 vs. Other; p = 0.01) even when controlling for MELD score, AKI, second infection, and history of prior 6-month hospitalization. Multivariable modeling also showed that HH increased the risk of inpatient mortality (HR = 2.22 vs. RA alone, HR = 2.31 vs. Other; p = 0.04). CONCLUSIONS HH that required a therapeutic thoracentesis more than doubled the risk of ACLF and inpatient mortality among hospitalized patients with cirrhosis.
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Affiliation(s)
- Jacqueline G O'Leary
- Department of Medicine, Dallas VA Medical Center, 4500 South Lancaster Road, Dallas, TX, 75216, USA.
| | - K Rajender Reddy
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Scott W Biggins
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | | | - Jennifer C Lai
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Michael Fallon
- Department of Medicine, University of Texas, Health Science Center, Houston, TX, USA
| | - Hugo E Vargas
- Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Paul Thuluvath
- Department of Medicine, Mercy Medical Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Leroy R Thacker
- Department of Biostatistics, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Jasmohan S Bajaj
- Department of Medicine, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
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8
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Wong F, Reddy KR, Tandon P, O'Leary JG, Garcia-Tsao G, Vargas HE, Lai JC, Biggins SW, Maliakkal B, Fallon M, Subramanian R, Thuluvath P, Kamath PS, Thacker L, Bajaj JS. Progression of Stage 2 and 3 Acute Kidney Injury in Patients With Decompensated Cirrhosis and Ascites. Clin Gastroenterol Hepatol 2021; 19:1661-1669.e2. [PMID: 32798707 DOI: 10.1016/j.cgh.2020.08.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Progression of stages 2 and 3 acute kidney injury (AKI) in cirrhosis has not been characterized adequately. Patients with higher stages of AKI are believed to have worse outcomes. We assessed outcomes and factors associated with stages 2 and 3 AKI in patients with cirrhosis in the North American Consortium for the Study of End-stage Liver Disease cohort. METHODS We collected data from 2297 hospitalized patients with cirrhosis and ascites from December 2011 through February 2017. Our final analysis included 760 patients who developed AKI per the International Ascites Club 2015 definition (419 with maximum stage 1 and 341 with maximum stage 2 or 3; 63% male; mean age, 58 y). We compared demographic features, laboratory values, AKI treatment response, and survival between patients with maximum stage 1 vs patients with stage 2 or 3 AKI. RESULTS Patients with stage 2 or 3 AKI had higher Model for End-Stage Liver Disease scores (25.9 ± 7.3) than patients with stage 1 AKI (21.9 ± 7.5) (P < .0001). More patients fulfilled systemic inflammatory response syndrome criteria on admission, and more developed a second nosocomial infection (P < .05 for both comparisons). More patients with stage 2 or 3 AKI also had progression of AKI and required dialysis and admission into intensive care units when compared to stage 1 AKI patients (P < .0001 for both). A lower proportion of patients with stage 2 or 3 AKI survived their hospital stay (80% vs 99% with stage 1 AKI; P < .0001), or survived for 30 days without a liver transplant (56% vs 81%; P < .0001). The development of stage 2 or 3 AKI was associated with a higher Model for End-Stage Liver Disease score at the time of admission (P < .0001), presence of systemic inflammatory response on admission (P = .039), and second infection (P < .0001). CONCLUSIONS Based on an analysis of data from the North American Consortium for the Study of End-stage Liver Disease cohort, we found that patients with cirrhosis and more advanced liver disease, as well as a second infection, are more likely to develop stages 2 or 3 AKI, with a progressive course associated with decreased 30-day transplant-free survival. Prevention of AKI progression in patients with cirrhosis and stage 2 or 3 AKI might improve their outcomes.
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Affiliation(s)
- Florence Wong
- University of Toronto, Department of Medicine, Division of Gastroenterology & Hepatology, Toronto, Ontario, Canada.
| | - K Rajender Reddy
- University of Pennsylvania, Department of Medicine, Division of Gastroenterology & Hepatology, Philadelphia, Pennsylvania
| | - Puneeta Tandon
- University of Alberta, Department of Medicine, Division of Gastroenterology, Edmonton, Alberta, Canada
| | - Jacqueline G O'Leary
- Dallas VA Medical Center, Department of Internal Medicine, Division of Gastroenterology, Dallas, Texas; Baylor University Medical Center, Dallas, Texas
| | - Guadalupe Garcia-Tsao
- Yale University, Section of Digestive Diseases, Departemtn of Medicine, New Haven, Connecticut
| | - Hugo E Vargas
- Mayo Clinic, Division of Gastroenterology and Hepatology and Transplantation Center, Scottsdale, Arizona
| | - Jennifer C Lai
- University of California San Francisco, Department of Medicine, Division of Gastroenterology/ Hepatology, San Francisco, California
| | - Scott W Biggins
- University of Washington Medical Center, Department of Medicine, Division of Gastroenterology, Seattle, Washington
| | - Benedict Maliakkal
- University of Tennessee, Department of Medicine, Division of Transplant Hepatology, Memphis, Tennessee
| | - Michael Fallon
- University of Arizona College of Medicine, Department of Medicine, Division of Transplant Hepatology, Phoenix, Arizona
| | - Ram Subramanian
- Emory University, Department of Medicine, Division of Digestive Diseases, Atlanta, Georgia
| | - Paul Thuluvath
- Mercy Medical Center, Division of Gastroenterology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Patrick S Kamath
- Mayo Clinic College of Medicine and Science, Division of Gastroenterology and Hepatology, Rochester, Minnesota
| | - Leroy Thacker
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Jasmohan S Bajaj
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Health Care System, Richmond, Virginia
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9
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Bajaj JS, Reddy KR, O’Leary JG, Vargas HE, Lai JC, Kamath PS, Tandon P, Wong F, Subramanian RM, Thuluvath P, Fagan A, White MB, Gavis EA, Sehrawat T, de la Rosa Rodriguez R, Thacker LR, Sikaroodi M, Garcia-Tsao G, Gillevet PM. Serum Levels of Metabolites Produced by Intestinal Microbes and Lipid Moieties Independently Associated With Acute-on-Chronic Liver Failure and Death in Patients With Cirrhosis. Gastroenterology 2020; 159:1715-1730.e12. [PMID: 32687928 PMCID: PMC7680282 DOI: 10.1053/j.gastro.2020.07.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [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: 02/27/2020] [Revised: 07/02/2020] [Accepted: 07/13/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Inpatients with cirrhosis have high rates of acute-on-chronic failure (ACLF) development and high mortality within 30 days of admission to the hospital. Better biomarkers are needed to predict these outcomes. We performed metabolomic analyses of serum samples from patients with cirrhosis at multiple centers to determine whether metabolite profiles might identify patients at high risk for ACLF and death. METHODS We performed metabolomic analyses, using liquid chromatography, of serum samples collected at time of admission to 12 North American tertiary hepatology centers from 602 patients in the North American Consortium for the Study of End-Stage Liver Disease sites from 2015 through 2017 (mean age, 56 years; 61% men; mean model for end-stage liver disease score, 19.5). We performed analysis of covariance, adjusted for model for end-stage liver disease at time of hospital admission, serum levels of albumin and sodium, and white blood cell count, to identify metabolites that differed between patients who did vs did not develop ACLF and patients who did vs did not die during hospitalization and within 30 days. We performed random forest analysis to identify specific metabolite(s) that were associated with outcomes and area under the curve (AUC) analyses to analyze them in context of clinical parameters. We analyzed microbiomes of stool samples collected from 133 patients collected at the same time and examined associations with serum metabolites. RESULTS Of the 602 patients analyzed, 88 developed ACLF (15%), 43 died in the hospital (7%), and 72 died within 30 days (12%). Increased levels of compounds of microbial origin (aromatic compounds, secondary or sulfated bile acids, and benzoate) and estrogen metabolites, as well as decreased levels of phospholipids, were associated with development of ACLF, inpatient, and 30-day mortality and were also associated with fecal microbiomes. Random forest analysis and logistic regression showed that levels of specific microbially produced metabolites identified patients who developed ACLF with an AUC of 0.84 (95% confidence interval [CI] 0.78-0.88; P = .001), patients who died while in the hospital with an AUC of 0.81 (95% CI 0.74-0.85; P = .002), and patients who died within 30 days with an AUC of 0.77 (95% CI 0.73-0.81; P = .02). The metabolites were significantly additive to clinical parameters for predicting these outcomes. Metabolites associated with outcomes were also correlated with microbiomes of stool samples. CONCLUSIONS In an analysis of serum metabolites and fecal microbiomes of patients hospitalized with cirrhosis at multiple centers, we associated metabolites of microbial origin and lipid moieties with development of ACLF and death as an inpatient or within 30 days, after controlling for clinical features.
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Affiliation(s)
- Jasmohan S Bajaj
- Department of Medicine, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia.
| | | | | | | | | | | | | | | | | | | | - Andrew Fagan
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, USA
| | - Melanie B White
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, USA
| | - Edith A Gavis
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, USA
| | | | | | - Leroy R Thacker
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, USA
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O'Leary JG, Tandon P, Reddy KR, Biggins SW, Wong F, Kamath PS, Garcia-Tsao G, Maliakkal B, Lai J, Fallon M, Vargas HE, Thuluvath P, Subramanian R, Thacker LR, Bajaj JS. Underutilization of Hospice in Inpatients with Cirrhosis: The NACSELD Experience. Dig Dis Sci 2020; 65:2571-2579. [PMID: 32146602 DOI: 10.1007/s10620-020-06168-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 02/20/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Little is known about patients discharged to hospice following hospitalization for complications of cirrhosis. AIM We sought to understand the current pattern of hospice utilization in patients with cirrhosis by evaluating the North American Consortium for the Study of End-stage Liver Disease (NACSELD) cohort. METHODS Patients with cirrhosis from 14 tertiary-care hepatology centers across North America non-electively hospitalized and prospectively enrolled were evaluated. Exclusion criteria included HIV infection, transplantation or non-hepatic malignancy. Random computer-based propensity score matching was undertaken in a 1:2 ratio based on admission MELD score ± 3 points. RESULTS Totally, 2718 patients were enrolled, 5% (N = 132) were discharged to hospice, 6% (N = 171) died, and the rest were discharged alive. Patients discharged to hospice were older (60 vs. 57 years, p = 0.04), less likely to have had SBP (13% vs. 28%, p = 0.002) and be listed for liver transplantation (11% vs. 26%, p = 0.0007). Features, on multivariable modeling, associated with increased probability of discharge to hospice as opposed to being discharged alive: grade-3-4 hepatic encephalopathy, a higher Child-Turcotte-Pugh (CTP) score, and a higher discharge serum creatinine; however, a higher serum sodium, being listed for transplant and being prescribed rifaximin or a statin were protective from hospice discharge. CONCLUSION Patients with more advanced liver disease, hepatic encephalopathy, renal dysfunction, and those not candidates for liver transplantation were more likely to be discharged to hospice. However, in this sick multinational cohort of cirrhotic inpatients, it seems that hospice is markedly underutilized (5%) since 25% of patients not discharged to hospice died within 6 months.
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Affiliation(s)
- Jacqueline G O'Leary
- Department of Medicine, Dallas VA Medical Center, Dallas, TX, USA. .,Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA.
| | - Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - K Rajender Reddy
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Scott W Biggins
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | | | - Jennifer Lai
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Michael Fallon
- Department of Medicine, University of Texas, Health Science Center, Houston, TX, USA
| | - Hugo E Vargas
- Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Paul Thuluvath
- Department of Medicine, Mercy Medical Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Leroy R Thacker
- Department of Biostatistics, McGuire VA Medical Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Jasmohan S Bajaj
- Department of Medicine, McGuire VA Medical Center, Virginia Commonwealth University, Richmond, VA, USA
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Chalasani N, Abdelmalek MF, Garcia-Tsao G, Vuppalanchi R, Alkhouri N, Rinella M, Noureddin M, Pyko M, Shiffman M, Sanyal A, Allgood A, Shlevin H, Horton R, Zomer E, Irish W, Goodman Z, Harrison SA, Traber PG, Balart L, Borg B, Chalasani N, Charlton M, Conjeevaram H, Fuchs M, Ghalib R, Gholam P, Halegoua-De Marzio D, Harrison S, Jue C, Kemmer N, Kowdley K, Lai M, Lawitz E, Loomba R, Noureddin M, Paredes A, Rinella M, Rockey D, Rodriguez M, Rubin R, Ryan M, Sanyal A, Scanga A, Sepe T, Shiffman M, Shiffman M, Tetri B, Thuluvath P, Torres D, Vierling J, Wattacheril J, Weiland A, Zogg D. Effects of Belapectin, an Inhibitor of Galectin-3, in Patients With Nonalcoholic Steatohepatitis With Cirrhosis and Portal Hypertension. Gastroenterology 2020; 158:1334-1345.e5. [PMID: 31812510 DOI: 10.1053/j.gastro.2019.11.296] [Citation(s) in RCA: 183] [Impact Index Per Article: 45.8] [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: 04/12/2019] [Revised: 11/25/2019] [Accepted: 11/27/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Increased levels of galectin 3 have been associated with nonalcoholic steatohepatitis (NASH) and contribute to toxin-induced liver fibrosis in mice. GR-MD-02 (belapectin) is an inhibitor of galectin 3 that reduces liver fibrosis and portal hypertension in rats and was safe and well tolerated in phase 1 studies. We performed a phase 2b, randomized trial of the safety and efficacy of GR-MD-02 in patients with NASH, cirrhosis, and portal hypertension. METHODS Patients with NASH, cirrhosis, and portal hypertension (hepatic venous pressure gradient [HVPG] ≥ 6 mm Hg) from 36 centers were randomly assigned, in a double-blind manner, to groups that received biweekly infusions of belapectin 2 mg/kg (n = 54), 8 mg/kg (n = 54), or placebo (n = 54) for 52 weeks. The primary endpoint was change in HVPG (Δ HVPG) at the end of the 52-week period compared with baseline. Secondary endpoints included changes in liver histology and development of liver-related outcomes. RESULTS We found no significant difference in ΔHVPG between the 2 mg/kg belapectin group and placebo group (-0.28 mm HG vs 0.10 mm HG, P = 1.0) or between the 8 mg/kg belapectin and placebo group (-0.25 mm HG vs 0.10 mm HG, P = 1.0). Belapectin had no significant effect on fibrosis or nonalcoholic fatty liver disease activity score, and liver-related outcomes did not differ significantly among groups. In an analysis of a subgroup of patients without esophageal varices at baseline (n = 81), 2 mg/kg belapectin was associated with a reduction in HVPG at 52 weeks compared with baseline (P = .02) and reduced development of new varices (P = .03). Belapectin (2 mg/kg) was well tolerated and produced no safety signals. CONCLUSIONS In a phase 2b study of 162 patients with NASH, cirrhosis, and portal hypertension, 1 year of biweekly infusion of belapectin was safe but not associated with significant reduction in HVPG or fibrosis compared with placebo. However, in a subgroup analysis of patients without esophageal varices, 2 mg/kg belapectin did reduce HVPG and development of varices. ClinicalTrials.gov number: NCT02462967.
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Affiliation(s)
- Naga Chalasani
- Indiana University School of Medicine, Indianapolis, Indiana.
| | | | | | - Raj Vuppalanchi
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | | | - Maxmillan Pyko
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Arun Sanyal
- Virginia Commonwealth University, Richmond, Virginia
| | | | | | - Rex Horton
- Galectin Therapeutics Alpharetta, Georgia
| | | | - William Irish
- East Carolina University, Greenville, South Carolina
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Yau T, Rimassa L, Cheng AL, Park JW, Braiteh F, Chaudhry A, Benzaghou F, Thuluvath P, Hazra S, Milwee S, Tan B, Sinha R, Kayali Z, Zhu A, Kelley R. Phase III (COSMIC-312) study of cabozantinib (C) in combination with atezolizumab (A) vs sorafenib (S) in patients (pts) with advanced hepatocellular carcinoma (aHCC) who have not received previous systemic anticancer therapy. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz422.075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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13
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Rimassa L, Cheng AL, Braiteh F, Chaudhry A, Benzaghou F, Thuluvath P, Hazra S, Borgman-Hagey A, Tan B, Kayali Z, Zhu A, Kelley R. Phase III (COSMIC-312) study of cabozantinib (C) in combination with atezolizumab (A) vs sorafenib (S) in patients (pts) with advanced hepatocellular carcinoma (aHCC) who have not received previous systemic anticancer therapy. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz247.159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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14
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O’Leary JG, Bajaj JS, Tandon P, Biggins SW, Wong F, Kamath PS, Garcia-Tsao G, Maliakkal B, Lai J, Fallon M, Vargas HE, Thuluvath P, Subramanian R, Thacker LR, Reddy KR. Outcomes After Listing for Liver Transplant in Patients With Acute-on-Chronic Liver Failure: The Multicenter North American Consortium for the Study of End-Stage Liver Disease Experience. Liver Transpl 2019; 25:571-579. [PMID: 30724010 PMCID: PMC11075742 DOI: 10.1002/lt.25426] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [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: 09/15/2018] [Accepted: 01/08/2019] [Indexed: 02/07/2023]
Abstract
Acute-on-chronic liver failure (ACLF) characterized with ≥2 extrahepatic organ failures in cirrhosis carries a high mortality. Outcomes of patients listed for liver transplantation (LT) after ACLF and after LT are largely unknown. The North American Consortium for the Study of End-Stage Liver Disease prospectively enrolled 2793 nonelectively hospitalized patients with cirrhosis; 768 were listed for LT. Within 3 months, 265 (35%) received a LT, 395 remained alive without LT, and 108 died/delisted. Compared with nonlisted patients, those listed were younger and more often had ACLF, acute kidney injury, and a higher admission Model for End-Stage Liver Disease (MELD) score. ACLF was most common in patients who died/delisted, followed by those alive with and without LT respectively, (30%, 22%, and 7%, respectively; P < 0.001). At LT, median MELD was 27.9% and 70% were inpatients; median time from hospitalization to LT was 26 days. Post-LT survival at 6 months was unchanged between those with and without ACLF (93% each at 6 months). There was no difference in 3- and 6-month mean post-LT creatinine in those with and without ACLF, despite those with ACLF having a higher mean pre-LT creatinine and a higher rate of perioperative dialysis (61%). In conclusion, patients with and without ACLF had similar survival after transplant with excellent renal recovery in both groups.
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Affiliation(s)
| | - Jasmohan S. Bajaj
- Medicine, Virginia Commonwealth University and McGuire VA
Medical Center, Richmond, VA
| | | | | | | | | | | | | | | | | | | | - Paul Thuluvath
- Mercy Medical Center, University of Maryland School of
Medicine, Baltimore, MD
| | | | - Leroy R. Thacker
- Biostatistics, Virginia Commonwealth University and McGuire
VA Medical Center, Richmond, VA
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Parikh N, Malahias L, Brown RS, Cabrera R, Jones PD, Landis C, Lee H, Mantry P, Mena E, Poddar N, Reddy KR, Shrestha R, Thuluvath P, Zink R, Singal AG. Regional, racial/ethnic, and socioeconomic disparities and treatment outcomes in patients with hepatocellular carcinoma (HCC) in the United States. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.4_suppl.424] [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: 11/20/2022] Open
Abstract
424 Background: Racial/ethnic (R/E) minorities and patients of low socioeconomic (SE) status are reported to have higher mortality related to HCC than their counterparts. However, prior studies are limited to administrative datasets without annotation for clinical covariates or represent single-center data with limited generalizability. The aim of this analysis was to characterize geographic, R/E, and SE disparities in HCC presentation, treatment, and survival among a representative sample of HCC patients in the US. Methods: TARGET-HCC is an observational, retrospective/prospective study of patients with HCC from academic and community sites. Complete medical records from consented patients are abstracted into a secure database. Multivariable logistic regression with random intercepts for site and Cox proportional hazard models with frailty adjustment were fit with adjustment for age, sex, BMI, liver disease etiology (LDE) and history of alcohol abuse to identify factors associated with early HCC detection, receipt of curative-intent therapy (CIT) and overall survival. Results: 925 patients with HCC (63% non-Hispanic white, 21% black, and 8% Hispanic) were consented from 42 sites in the US (22% Northeast, 27% Southeast, 21% Midwest, 14% South, and 16% West). Median age was 64 years and 76% were men. The most common LDE was hepatitis C (72%), and 72% had Child Pugh A cirrhosis. Most patients were diagnosed with early-stage HCC (72% Barcelona Clinic Liver Cancer 0/A). CIT was the initial therapy in 249 (32%), including 32% of BCLC 0/A. Although early tumor detection and CIT did not differ by region or R/E, there were SE disparities in CIT. Among those with early stage HCC, patients with private insurance [OR = 0.51, 95% CI (0.29, 0.91)] or Medicaid [OR = 0.50, 95% CI (0.25, 0.97)] were significantly less likely to undergo CIT. Overall survival was associated with BCLC stage and type of HCC treatment, with no significant association with region, R/E, or insurance. Conclusions: In this sample of HCC patients, there were no geographic or R/E disparities in early detection, treatment, and survival although SE disparities in administration of CIT were identified and warrant further study.
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Affiliation(s)
| | | | - Robert S Brown
- Center for Liver Disease and Transplantation, Columbia University, New York, NY
| | - Roniel Cabrera
- University of Florida College of Medicine, Gainesville, FL
| | | | | | - Hannah Lee
- Virginia Commonwealth University, Richmond, VA
| | - Parvez Mantry
- The Liver Institute at Methodist Dallas Medical Center, Dallas, TX
| | - Edward Mena
- California Liver Research Institute, Pasadena, CA
| | | | | | | | | | | | - Amit G. Singal
- University of Texas Southwestern Medical Center, Dallas, TX
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16
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O'Leary JG, Reddy KR, Garcia-Tsao G, Biggins SW, Wong F, Fallon MB, Subramanian RM, Kamath PS, Thuluvath P, Vargas HE, Maliakkal B, Tandon P, Lai J, Thacker LR, Bajaj JS. NACSELD acute-on-chronic liver failure (NACSELD-ACLF) score predicts 30-day survival in hospitalized patients with cirrhosis. Hepatology 2018; 67:2367-2374. [PMID: 29315693 DOI: 10.1002/hep.29773] [Citation(s) in RCA: 169] [Impact Index Per Article: 28.2] [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: 06/26/2017] [Revised: 12/02/2017] [Accepted: 12/13/2017] [Indexed: 12/11/2022]
Abstract
UNLABELLED The North American Consortium for the Study of End-Stage Liver Disease's definition of acute-on-chronic liver failure (NACSELD-ACLF) as two or more extrahepatic organ failures has been proposed as a simple bedside tool to assess the risk of mortality in hospitalized patients with cirrhosis. We validated the NACSELD-ACLF's ability to predict 30-day survival (defined as in-hospital death or hospice discharge) in a separate multicenter prospectively enrolled cohort of both infected and uninfected hospitalized patients with cirrhosis. We used the NACSELD database of 14 tertiary care hepatology centers that prospectively enrolled nonelective hospitalized patients with cirrhosis (n = 2,675). The cohort was randomly split 60%/40% into training (n = 1,605) and testing (n = 1,070) groups. Organ failures assessed were (1) shock, (2) hepatic encephalopathy (grade III/IV), (3) renal (need for dialysis), and (4) respiratory (mechanical ventilation). Patients were most commonly Caucasian (79%) men (62%) with a mean age of 57 years and a diagnosis of alcohol-induced cirrhosis (45%), and 1,079 patients had an infection during hospitalization. The mean Model for End-Stage Liver Disease score was 19, and the median Child score was 10. No demographic differences were present between the two split groups. Multivariable modeling revealed that the NACSELD-ACLF score, as determined by number of organ failures, was the strongest predictor of decreased survival after controlling for admission age, white blood cell count, serum albumin, Model for End-Stage Liver Disease score, and presence of infection. The c-statistics were 0.8073 for the training set and 0.8532 for the validation set. CONCLUSION Although infection status remains an important predictor of death, NACSELD-ACLF was independently validated in a separate large multinational prospective cohort as a simple, reliable bedside tool to predict 30-day survival in both infected and uninfected patients hospitalized with a diagnosis of cirrhosis. (Hepatology 2018;67:2367-2374).
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Affiliation(s)
- Jacqueline G O'Leary
- Dallas VA Medical Center, Dallas, TX.,Baylor University Medical Center, Dallas, TX
| | | | | | | | | | | | | | | | | | | | | | | | - Jennifer Lai
- University of California, San Francisco, San Francisco, CA
| | - Leroy R Thacker
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Jasmohan S Bajaj
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
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17
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Bajaj JS, Reddy RK, Tandon P, Wong F, Kamath PS, Biggins SW, Garcia-Tsao G, Fallon M, Maliakkal B, Lai J, Vargas HE, Subramanian RM, Thuluvath P, Thacker LR, OʼLeary JG. Prediction of Fungal Infection Development and Their Impact on Survival Using the NACSELD Cohort. Am J Gastroenterol 2018; 113:556-563. [PMID: 29257141 DOI: 10.1038/ajg.2017.471] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [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: 08/24/2017] [Accepted: 11/02/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Bacterial infections are associated with negative outcomes in cirrhosis but fungal infections are being increasingly recognized. The objective of this study is to define risk factors for fungal infection development and impact on 30-day survival. METHODS In a large, multi-center cirrhotic inpatient cohort, demographics, cirrhosis details, intensive care unit (ICU), organ failures/acute-on-chronic liver failure (ACLF), and 30-day survival were compared between patients without infections and with bacterial infections alone, with those with fungal infections. Variables associated with fungal infection development were determined using multi-variable regression. Ordinal variables (0=no infection, 1=community-acquired bacterial infection, 2=nosocomial bacterial, and 3=fungal infection) were input into a 30-day survival model. RESULTS A total of 2,743 patients (1,691 no infection, 918 bacterial, and 134 fungal infections) were included. Patients with fungal infection, all of which were nosocomial, were more likely to be admitted with bacterial infections, on spontaneous bacterial peritonitis prophylaxis, and have diabetes and advanced cirrhosis. Bacterial infection types did not predict risk for fungal infections. Multi-variable analysis showed male gender to be protective, whereas diabetes, longer stay, ICU admission, acute kidney injury (AKI), and admission bacterial infection were associated with fungal infection development (area under the curve (AUC)=0.82). Fungal infections were associated with significantly higher ACLF, inpatient stay, ICU admission, and worse 30-day survival. The case fatality rate was 30% with most fungal infections but >50% for fungemia and fungal peritonitis. On a multi-variable analysis, age, AKI, model for end-stage liver disease, ICU admission, and ordinal infection variables impaired survival (P<0.0001, AUC=0.83). CONCLUSIONS Fungal infections are associated with a poor 30-day survival in hospitalized cirrhotic patients compared with uninfected patients, and those with bacterial infections. Patients with diabetes, AKI, and those with an admission bacterial infection form a high-risk subgroup.
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Affiliation(s)
- Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | | | | | | | | | - Scott W Biggins
- University of Colorado, Denver, Colorado, USA.,University of Washington, Seattle, Washington, USA
| | | | - Michael Fallon
- University of Texas, Houston, Texas, USA.,University of Arizona, Phoenix, Arizona, USA
| | - Benedict Maliakkal
- University of Rochester, Rochester, New York, USA.,University of Tennessee, Memphis, Tennessee, USA
| | - Jennifer Lai
- University of California, San Francisco, California, USA
| | | | | | | | - Leroy R Thacker
- Department of Biostatistics, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - Jacqueline G OʼLeary
- Baylor University Medical Center, Dallas, Texas, USA.,Dallas VA Medical Center, Dallas, Texas, USA
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18
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Tandon P, Reddy KR, O'Leary JG, Garcia-Tsao G, Abraldes JG, Wong F, Biggins SW, Maliakkal B, Fallon MB, Subramanian RM, Thuluvath P, Kamath PS, Thacker LR, Bajaj JS. A Karnofsky performance status-based score predicts death after hospital discharge in patients with cirrhosis. Hepatology 2017; 65:217-224. [PMID: 27775842 DOI: 10.1002/hep.28900] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [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: 06/22/2016] [Revised: 09/05/2016] [Accepted: 10/12/2016] [Indexed: 02/06/2023]
Abstract
UNLABELLED Identification of patients with cirrhosis at risk for death within 3 months of discharge from the hospital is essential to individualize postdischarge plans. The objective of the study was to identify an easy-to-use prognostic model based on the Karnofsky Performance Status (KPS). The North American Consortium for the Study of End-Stage Liver Disease consists of 16 tertiary-care hepatology centers that prospectively enroll nonelectively admitted cirrhosis patients. Patients enrolled had KPS assessed 1 week postdischarge. KPS was categorized into low (score 10-40), intermediate (50-70), and high (80-100). Of 954 middle-aged patients (57 ± 10 years, 63% men) with a median Model for End-Stage Liver Disease (MELD) score of 17 (interquartile range 13-21), the mortality rates for the low, intermediate, and high performance status groups were 23% (36/159), 11% (55/489), and 5% (15/306), respectively. Low, intermediate, and high performance status was seen in 17%, 51%, and 32% of the cohort, respectively. Low performance status was associated with older age, dialysis, hepatic encephalopathy, longer length of stay, and higher white blood cell count or MELD score at discharge. A model was derived using the three independent predictors of 3-month mortality: KPS, age, and MELD score. This score had better discrimination (area under the receiver operating characteristic curve = 0.74) than a model using MELD (area under the receiver operating characteristic curve = 0.62) or MELD and age (area under the receiver operating characteristic curve = 0.67) to predict 3-month mortality. CONCLUSIONS Cirrhosis patients at risk for 3-month postdischarge mortality can be identified using a novel KPS-based score; this score may be adopted in practice to guide postdischarge early interventions, including the integrated provision of active and palliative management strategies. (Hepatology 2017;65:217-224).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Leroy R Thacker
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Jasmohan S Bajaj
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
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19
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Li L, Masica D, Ishida M, Tomuleasa C, Umegaki S, Kalloo AN, Georgiades C, Singh VK, Khashab M, Amateau S, Li Z, Okolo P, Lennon AM, Saxena P, Geschwind JF, Schlachter T, Hong K, Pawlik TM, Canto M, Law J, Sharaiha R, Weiss CR, Thuluvath P, Goggins M, Ji Shin E, Peng H, Kumbhari V, Hutfless S, Zhou L, Mezey E, Meltzer SJ, Karchin R, Selaru FM. Human bile contains microRNA-laden extracellular vesicles that can be used for cholangiocarcinoma diagnosis. Hepatology 2014; 60:896-907. [PMID: 24497320 PMCID: PMC4121391 DOI: 10.1002/hep.27050] [Citation(s) in RCA: 166] [Impact Index Per Article: 16.6] [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: 10/07/2013] [Accepted: 01/29/2014] [Indexed: 12/15/2022]
Abstract
UNLABELLED Cholangiocarcinoma (CCA) presents significant diagnostic challenges, resulting in late patient diagnosis and poor survival rates. Primary sclerosing cholangitis (PSC) patients pose a particularly difficult clinical dilemma because they harbor chronic biliary strictures that are difficult to distinguish from CCA. MicroRNAs (miRs) have recently emerged as a valuable class of diagnostic markers; however, thus far, neither extracellular vesicles (EVs) nor miRs within EVs have been investigated in human bile. We aimed to comprehensively characterize human biliary EVs, including their miR content. We have established the presence of extracellular vesicles in human bile. In addition, we have demonstrated that human biliary EVs contain abundant miR species, which are stable and therefore amenable to the development of disease marker panels. Furthermore, we have characterized the protein content, size, numbers, and size distribution of human biliary EVs. Utilizing multivariate organization of combinatorial alterations (MOCA), we defined a novel biliary vesicle miR-based panel for CCA diagnosis that demonstrated a sensitivity of 67% and specificity of 96%. Importantly, our control group contained 13 PSC patients, 16 with biliary obstruction of varying etiologies (including benign biliary stricture, papillary stenosis, choledocholithiasis, extrinsic compression from pancreatic cysts, and cholangitis), and 3 with bile leak syndromes. Clinically, these types of patients present with a biliary obstructive clinical picture that could be confused with CCA. CONCLUSION These findings establish the importance of using extracellular vesicles, rather than whole bile, for developing miR-based disease markers in bile. Finally, we report on the development of a novel bile-based CCA diagnostic panel that is stable, reproducible, and has potential clinical utility.
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Affiliation(s)
- Ling Li
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA,Division of Gastroenterology, Third hospital of Peking University Health Science Center, Beijing, China
| | - David Masica
- Department of Biomedical Engineering and Institute for Computational Medicine Johns Hopkins University, Baltimore, Maryland, USA
| | - Masaharu Ishida
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ciprian Tomuleasa
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA,Center for Genomics and Translational Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, and Department of Hematology, Ion Chiricuta Comprehensive Cancer Center, Cluj Napoca, Romania
| | - Sho Umegaki
- Tohoku University School of Medicine, Sendai, Miyagi, Japan
| | - Anthony N. Kalloo
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Christos Georgiades
- Division of Gastroenterology and Hepatology, Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland, USA,Vascular & Interventional Radiology, American Medical Center, Nicosia, Cyprus
| | - Vikesh K. Singh
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Stuart Amateau
- Division of Gastroenterology and Hepatology, University of Colorado, Denver, Colorado, USA
| | - Zhiping Li
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Patrick Okolo
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Anne-Marie Lennon
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Payal Saxena
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jean-Francois Geschwind
- Division of Gastroenterology and Hepatology, Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Todd Schlachter
- Division of Gastroenterology and Hepatology, Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kelvin Hong
- Division of Gastroenterology and Hepatology, Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Timothy M. Pawlik
- Division of Gastroenterology and Hepatology, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Marcia Canto
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joanna Law
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Reem Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, USA
| | - Clifford R. Weiss
- Division of Gastroenterology and Hepatology, Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Paul Thuluvath
- The Institute for Digestive Health & Liver Disease at Mercy, Baltimore, USA
| | - Michael Goggins
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Haoran Peng
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Susan Hutfless
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Liya Zhou
- Division of Gastroenterology, Third hospital of Peking University Health Science Center, Beijing, China
| | - Esteban Mezey
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Stephen J. Meltzer
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Rachel Karchin
- Department of Biomedical Engineering and Institute for Computational Medicine Johns Hopkins University, Baltimore, Maryland, USA
| | - Florin M. Selaru
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA,Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, Maryland, USA,Correspondence: Florin M. Selaru, MD, Johns Hopkins University, 720 Rutland Ave, Suite 950, Tel: (410) 614-3369, Fax: (410) 614-9612,
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20
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Verma S, Maheshwari A, Thuluvath P. Liver failure as initial presentation of autoimmune hepatitis: clinical characteristics, predictors of response to steroid therapy, and outcomes. Hepatology 2009; 49:1396-7. [PMID: 19330859 DOI: 10.1002/hep.22894] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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21
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Perumal V, Wang J, Thuluvath P, Choti M, Torbenson M. Hepatitis C and hepatitis B nucleic acids are present in intrahepatic cholangiocarcinomas from the United States. Hum Pathol 2006; 37:1211-6. [PMID: 16938527 DOI: 10.1016/j.humpath.2006.04.012] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2006] [Revised: 04/13/2006] [Accepted: 04/20/2006] [Indexed: 12/18/2022]
Abstract
Intrahepatic cholangiocarcinomas (IHCs) are rare in the United States, but the prevalence is steadily increasing and risk factors are poorly understood. Tissues were obtained at the time of surgical resection, and 11 cases of IHC were retrospectively studied for the presence of hepatitis B virus (HBV) DNA and hepatitis C virus (HCV) RNA. Hemi-nested and real-time polymerase chain reaction assays were used to detect HBV DNA, and nested reverse transcriptase-polymerase chain reaction was used to detect HCV RNA. Genotypes were determined for both HBV and HCV. The cases were predominantly from women (10/11), with an average age at surgery of 63 years and an average tumor size of 6 cm. Three cases (27%) were positive for either HBV or HCV nucleic acids: HBV alone (n = 1), HCV alone (1), coinfection with HBV and HCV (1). Both HBV-positive cases were genotype A, and both HCV cases were genotype 1a. Hepatitis B and C viral copy numbers were low in all cases. Evidence for active HBV replication was found in both HBV-positive cases, as they were positive for covalently closed circular DNA. In this study, 27% of ICC cases contained HBV and/or HCV nucleic acids, suggesting an etiologic role for these viruses in some cases of IHC.
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Affiliation(s)
- Vivekanandan Perumal
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
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22
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Weiss CR, Georgiades C, Hofmann LV, Schulick R, Choti M, Thuluvath P, Bluemke DA, Arepally A. Intrabiliary MR Imaging: Assessment of Biliary Obstruction with Use of an Intraluminal MR Receiver Coil. J Vasc Interv Radiol 2006; 17:845-53. [PMID: 16687751 DOI: 10.1016/s1051-0443(07)60823-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE The primary aim of this study was to determine whether intrabiliary magnetic resonance (MR) imaging is feasible in a clinical setting and to optimize MR imaging parameters for the technique. In addition, it was attempted to determine the accuracy of intrabiliary MR imaging in the setting of biliary obstruction of unknown cause. MATERIALS AND METHODS Intrabiliary MR was performed prospectively in 15 patients with biliary obstruction of unknown cause. A 0.030-inch MR intravascular receiver coil was placed in an existing biliary tube. Intrabiliary MR was performed on a 1.5-T system. T1-weighted, T2-weighted, and single-shot fast spin-echo images were acquired. T1-weighted images were also acquired after the administration of a gadolinium contrast agent. Signal intensity analysis was conducted in the region of the common bile duct. Accuracy of intrabiliary MR, computed tomography (CT), MR, and cholangiography were determined by correlation with surgical pathologic findings. RESULTS Intrabiliary MR was successfully performed in 14 of 15 patients. MR examinations were performed in less than 1 hour. The signal-to-noise ratio in the region of the common bile duct with the intrabiliary MR technique was increased by a factor of 9 compared with standard surface-coil MR imaging (P < .00001). The mean n-plane resolution achieved was 740 +/- 20 microm x 1,150 +/- 20 microm obtained with use of a field of view of 18 cm x 18 cm (range, 15-24 cm) and a matrix of 256 x 160. Of the pulse sequences tested, the gadolinium-enhanced T1-weighted image was the best for identifying tumor and delineating tumor margins. Intrabiliary MR had a higher sensitivity than CT (100% vs 50%), a higher specificity than cholangiography (80% vs 20%), and a better correlation (P = .015) with surgical pathologic findings than CT, MR imaging, or cholangiography. CONCLUSIONS Intrabiliary MR was well tolerated in a clinical setting and provided high spatial resolution and excellent contrast between the biliary lumen and adjacent structures. Intrabiliary MR demonstrated an advantage in detecting the presence or absence of biliary malignancies compared with currently available standard imaging techniques. The technique may be useful to evaluate biliary obstruction of unknown cause.
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Affiliation(s)
- Clifford R Weiss
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Cardiovascular and Interventional Radiology, Johns Hopkins Medical Institutes, Blalock 544, 600 North Wolfe Street, Baltimore, Maryland 21287, USA
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23
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Burger I, Hong K, Schulick R, Georgiades C, Thuluvath P, Choti M, Kamel I, Geschwind JFH. Transcatheter arterial chemoembolization in unresectable cholangiocarcinoma: initial experience in a single institution. J Vasc Interv Radiol 2005; 16:353-61. [PMID: 15758131 DOI: 10.1097/01.rvi.0000143768.60751.78] [Citation(s) in RCA: 151] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Unresectable cholangiocarcinoma carries a dismal prognosis, with median survival times ranging from 6 to 12 months from the time of diagnosis. Palliative therapies have been disappointing and have not been shown to significantly prolong survival. Conversely, transcatheter arterial chemoembolization (TACE) has been effective in prolonging the lives of patients with hepatocellular carcinoma but has not been used against cholangiocarcinoma. Therefore, the purpose of the present study was to assess the safety and efficacy (ie, survival) of TACE in patients with unresectable intrahepatic cholangiocarcinoma. MATERIALS AND METHODS Seventeen patients with unresectable cholangiocarcinoma were treated with one or more cycles of TACE between 1995 and 2004 at our institution. Follow-up imaging was performed on all patients 4-6 weeks after each TACE procedure to determine tumor response and need for further treatment. Survival was calculated with use of the Kaplan-Meier survival curve. RESULTS The median survival for 17 patients treated with TACE was 23 months. Two patients with previously unresectable disease underwent successful resection after TACE. The procedure was well tolerated by 82% of the patients, who experienced no side effects or mild side effects that quickly resolved with conservative therapy alone. Two patients had minor complications (12%), which were managed successfully, and one had a major complication that resulted in a fatal outcome. This patient had a rapidly declining course from the time of diagnosis and died shortly after TACE. CONCLUSIONS The results suggest that TACE was effective at prolonging survival of patients with unresectable cholangiocarcinoma. Therefore, for these patients, TACE may be an appropriate palliative therapy.
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Affiliation(s)
- Ingrid Burger
- Division of Vascular, The Johns Hopkins Hospital, 600 North Wolfe Street, Blalock 545, Baltimore, Maryland 21287, USA
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24
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Affiliation(s)
- Aravind Arepally
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutes, Blalock 544, 600 N Wolfe St., Baltimore, MD 21287, USA.
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25
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Abstract
The incidence of clinically significant pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) ranges from 1-13.5%. It is more common after therapeutic procedures such as sphincterotomy or balloon dilatation of the sphincter, and diagnostic procedures such as biliary or pancreatic manometry. The severity of post-ERCP pancreatitis may vary from very mild to extremely severe disease with multiple organ failure and fatal outcome. Several factors including papillary oedema, injection of hyperosmolar contrast-material, introduction of previously activated enzymes during repeated cannulation, bacterial contamination and thermal injury from endoscopic sphincterotomy have been implicated as triggering factors that initiate the sequential cascade of pancreatic autodigestion and release of proinflammatory cytokines leading to acute pancreatitis. Recovery from post-ERCP pancreatitis is usually rapid when the injury is confined to the pancreas. However, systemic production of inflammatory mediators may lead to the development of more serious manifestations including multiorgan failure.A wide range of pharmacological agents has been tested in experimental and clinical trials, but the results have been largely disappointing. Several drugs are discussed in this review, but only somatostatin and gabexate (gabexate mesilate) have consistently shown a moderate beneficial effect. In clinical trials, both gabexate and somatostatin appear equally effective in reducing the incidence of pancreatitis by two-thirds compared with controls. However, both drugs need to be given by continuous infusion for about 12 hours and this makes them less cost-effective than conventional treatment. One potential strategy is to reserve these drugs for high-risk patients undergoing ERCP. Preliminary studies have shown encouraging results with nitroglycerin, antibacterials and heparin. However, these observations need to be corroborated in a rigorous fashion in large, randomised, double-blind, controlled trials. If these drugs are found to be effective in further trials, it may become cost-effective to use them routinely for the prevention of post-ERCP pancreatitis. Despite the theoretical benefits, interleukin-10 has not shown a consistent benefit in clinical trials. It is probable that other cytokine inhibitors or modulators may become available for future trials to prevent pancreatitis or more probably, to reduce the severity of pancreatitis. Further research also should focus on developing newer molecules or the use of a combination of currently available drugs to prevent pancreatitis in high-risk patients undergoing therapeutic ERCP procedures.
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Affiliation(s)
- Hemant Pande
- Division of Gastroenterology & Hepatology, The Johns Hopkins University School of Medicine, 1830 E. Monument Street, Baltimore, MD 21205, USA
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26
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Darwin P, Mergner W, Thuluvath P. Torulopsis glabrata fungemia as a complication of a clotted transjugular intrahepatic portosystemic shunt. Liver Transpl Surg 1998; 4:89-90. [PMID: 9457972 DOI: 10.1002/lt.500040112] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Torulopsis glabrata fungemia developed in a patient with a clotted transjugular intrahepatic portosystemic shunt (TIPS) 11 months after placement. Fungemia persisted despite treatment with amphotericin B. On autopsy, T. glabrata was found in the thrombus occluding the TIPS and extending into the splenic and portal vein. TIPS infections may be considered in patients with fungemia.
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Affiliation(s)
- P Darwin
- Department of Pathology, University of Maryland Medical Center, Baltimore 21201, USA
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27
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Abstract
1. Studies of paracetamol metabolism were performed in a 58-year-old female with rheumatoid arthritis who had consumed 15-20 g paracetamol daily for 5 years without developing liver damage and data were compared with results in seven normal volunteers. 2. After a test dose of 2 g paracetamol, the formation of paracetamol sulphate and glucuronide conjugates detected in plasma from the patient was delayed by around 2 h relative to values in normal volunteers and the proportion of sulphate conjugates excreted in urine was 1.5 to 2 times those in normal volunteers (52% vs 26-35% of dose, respectively). The fractional metabolite clearance of paracetamol to glutathione-derived conjugates (0.28 ml min-1 kg-1) in our patient was > 30% lower than in normal females. 3. A combination of slow paracetamol absorption, enhanced detoxication of paracetamol (by sulphation) and reduced metabolism to potentially cytotoxic metabolites may have reduced the risk of liver damage in this patient. The latter may have reflected pharmacogenetic deficiencies in cytochrome P450 isoenzymes persisting despite chronic alcohol consumption (40-60 g per day) or resulted from inhibition of paracetamol activation by concomitant ingestion of aminophylline.
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Affiliation(s)
- J M Tredger
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK
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28
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Abstract
Sex and age differences in gastric alcohol dehydrogenase activity in relation to abnormalities of gastric histology and Helicobacter pylori infection were determined in 63 patients (32 men and 31 women) undergoing upper endoscopy for gastrointestinal symptoms. No sex difference was found in gastric alcohol dehydrogenase activity. Males older than 50 years had lower enzyme activity than younger males. Patients with H. pylori and/or moderate to severe chronic and acute inflammation and epithelial mucin depletion had lower alcohol dehydrogenase activity in the antrum, but not in the fundus. H. pylori was found more frequently in the older male patients. Antral alcohol dehydrogenase was most decreased in older patients of both sexes with H. pylori infection. In conclusion, H. pylori infection and/or chronic active gastritis are important causes of low gastric alcohol dehydrogenase activity.
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Affiliation(s)
- P Thuluvath
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205
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29
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McKendrick MW, Thuluvath P. Chloroquine-resistant malaria from Bombay. J Infect 1985; 11:79-80. [PMID: 3897389 DOI: 10.1016/s0163-4453(85)91150-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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