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Ramirez-Cadiz C, Blaney H, Kubanek N, Díaz LA, Loomba R, Skladany L, Arab JP. Review article: Current indications and selection criteria for early liver transplantation in severe alcohol-associated hepatitis. Aliment Pharmacol Ther 2024; 59:1049-1061. [PMID: 38475893 DOI: 10.1111/apt.17948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 10/17/2023] [Accepted: 03/03/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Alcohol-associated hepatitis (AH) is a severe inflammatory form of alcohol-associated liver disease (ALD) that carries a high mortality rate. Early liver transplantation for severe AH is increasingly available. However, specific criteria for referral and selection remain a subject of debate. AIMS To provide a narrative review of the natural history, diagnostic criteria and indications for referral for early liver transplantation for severe AH. METHODS We searched PubMed for articles published through August 2023. Key search terms were 'alcoholic hepatitis,' 'alcohol-associated hepatitis,' 'abstinence,' 'alcohol relapse,' and 'liver transplantation.' RESULTS Previously, a six-month period of alcohol abstinence was required before patients with ALD were considered for liver transplantation. However, studies in recent years have demonstrated that, among carefully selected patients, patients who received early transplants have much higher survival rates than patients with similarly severe disease who did not undergo transplants (77% vs. 23%). Despite these successes, early liver transplantation remains controversial, as these patients have typically not undergone treatment for alcohol use disorder, with the ensuing risk of returning to alcohol use. CONCLUSIONS While early liver transplantation for AH has survival benefits, many patients would not have received treatment for alcohol use disorder. An integrated approach to evaluating candidacy for early liver transplantation is needed.
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Affiliation(s)
- Carolina Ramirez-Cadiz
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
| | - Hanna Blaney
- Division of Gastroenterology and Hepatology, University of Maryland, College Park, Maryland, USA
| | - Natalia Kubanek
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University Faculty of Medicine, F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Luis Antonio Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rohit Loomba
- Division of Gastroenterology, University of California at San Diego, San Diego, California, USA
| | - Lubomir Skladany
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University Faculty of Medicine, F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Juan Pablo Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada
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Broekhoven AGC, Ostyn T, van Melkebeke L, Verspaget HW, van der Merwe S, Verbeek J, Coenraad MJ, Roskams TA, Nevens F. Histological characteristics in patients admitted to the hospital with alcoholic hepatitis complicated by acute-on-chronic liver failure. Scand J Gastroenterol 2024; 59:577-583. [PMID: 38306114 DOI: 10.1080/00365521.2024.2309527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 01/20/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVES Alcoholic hepatitis (AH) is a frequent precipitating event for the development of acute-on-chronic liver failure (ACLF), a syndrome characterised by organ failures due to immune dysfunction. The histological features of this complication are not well characterized. We investigated whether ACLF has specific histological characteristics. METHODS Prospective cohort study in consecutive adult patients admitted between 03-2008 and 04-2021 to a tertiary referral centre with suspected AH. Diagnosis of AH was based on clinical presentation and confirmed by transjugular liver biopsy. All biopsies were assessed by a dedicated liver pathologist, blinded for clinical data and outcome. Diagnosis of ACLF was based on EASL-CLIF criteria. Histological and clinical characteristics of patients with and without ACLF at baseline were compared. RESULTS 184 patients with biopsy-proven AH were enrolled. Median time from hospital admission to transjugular biopsy was 4.5 days (IQR 2-8). At baseline, ACLF was present in 73 patients (39.7%). Out of the 110 patients without ACLF at baseline, 30 (27.3%) developed ACLF within 28 days (median 7.5 days (IQR 2-20)). At baseline, ductular bilirubinostasis (DB) was the only histological feature significantly more frequently present in patients with ACLF compared to patients without ACLF (50.7% vs. 30.6%, p = 0.003). No clear association between histological features and the development of ACLF later on could be demonstrated. CONCLUSIONS In this well-defined cohort of patients with biopsy-proven AH, DB was associated with the presence of ACLF. This finding fits with the pathophysiology of this syndrome, which is characterized by systemic inflammation and an increased risk of infections.
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Affiliation(s)
- Annelotte G C Broekhoven
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Tessa Ostyn
- Department of Imaging and Pathology, Translational Cell and Tissue Research, KU Leuven, Leuven, Belgium
| | - Lukas van Melkebeke
- Department of Gastroenterology and Hepatology, University Hospitals, Leuven, Belgium
- Laboratory of Hepatology, KU Leuven, Leuven, Belgium
| | - Hein W Verspaget
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Schalk van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals, Leuven, Belgium
- Laboratory of Hepatology, KU Leuven, Leuven, Belgium
| | - Jef Verbeek
- Department of Gastroenterology and Hepatology, University Hospitals, Leuven, Belgium
- Laboratory of Hepatology, KU Leuven, Leuven, Belgium
| | - Minneke J Coenraad
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Tania A Roskams
- Department of Imaging and Pathology, Translational Cell and Tissue Research, KU Leuven, Leuven, Belgium
| | - Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospitals, Leuven, Belgium
- Laboratory of Hepatology, KU Leuven, Leuven, Belgium
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Kim TH, Yim HJ, Jung YK, Song DS, Yoon EL, Kim HY, Kang SH, Chang Y, Yoo JJ, Jun BG, Lee SW, Park JG, Park JW, Kim SE, Kim TY, Jeong SW, Suk KT, Kim MY, Kim SG, Kim W, Jang JY, Yang JM, Kim DJ. New prognostic model for hospitalized patients with alcoholic cirrhosis and Maddrey's discriminant function <32. Hepatol Int 2024; 18:500-508. [PMID: 37831433 DOI: 10.1007/s12072-023-10582-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/09/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND & AIMS Few studies have investigated the prognosis of patients with non-severe alcoholic hepatitis (Non-SAH). The study aimed to develop a new prognostic model for patients with especially Non-SAH. METHODS We extracted 316 hospitalized patients with alcoholic cirrhosis without severe alcoholic hepatitis, defined as Maddrey's discriminant function score lower than 32, from the retrospective Korean Acute-on-Chronic Liver Failure (KACLiF) cohort to develop a new prognostic model (training set), and validated it in 419 patients from the prospective KACLiF cohort (validation set). Prognostic factors for death and liver transplantation were analyzed to construct a prognostic model. RESULTS Twenty-one and 24 patients died within 6 months in both sets, respectively. In the training set, the highest area under the curve (AUC) of conventional prognostic models was 0.765, 0.732, and 0.684 for 1-, 3-, and 6-month mortality, respectively. Refractory ascites, vasopressor use, and hyponatremia were independently associated with mortality of cirrhotic patients with Non-SAH. The new model consisted of four variables: past deterioration, neutrophil proportion > 70%, Na < 128 mmol/L, and vasopressor use. It showed the highest accuracy for short-term mortality in the training and validation sets (0.803 and 0.786; 0.797 and 0.776; and 0.789 and 0.721 for 1-, 3-, and 6-month mortality, respectively). CONCLUSION There is a group of patients with high risk among those classified as Non-SAH. The new model will help stratifying cirrhotic patients with Non-SAH more accurately in terms of prognosis. The patients with high Non-SAH score need to monitor closely and might be considered for preemptive liver transplantation. TRIAL REGESTRATION ClinicalTrials.gov identifier: NCT02650011.
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Affiliation(s)
- Tae Hyung Kim
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Korea University Ansan Hospital, Korea University Ansan Hospital, 123 Jeokgeum-ro, Danwon-gu, Ansan-si, 15355, Gyeonggi-do, Korea
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Hyung Joon Yim
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Korea University Ansan Hospital, Korea University Ansan Hospital, 123 Jeokgeum-ro, Danwon-gu, Ansan-si, 15355, Gyeonggi-do, Korea.
| | - Young Kul Jung
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Korea University Ansan Hospital, Korea University Ansan Hospital, 123 Jeokgeum-ro, Danwon-gu, Ansan-si, 15355, Gyeonggi-do, Korea
| | - Do Seon Song
- Department of Internal medicine, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Eileen L Yoon
- Department of Internal Medicine, Hanyang University Seoul Hospital, Seoul, Korea
| | - Hee Yeon Kim
- Department of Internal medicine, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu, Korea
- Department of Internal medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, Bucheon, Korea
| | - Seong Hee Kang
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Korea University Ansan Hospital, Korea University Ansan Hospital, 123 Jeokgeum-ro, Danwon-gu, Ansan-si, 15355, Gyeonggi-do, Korea
- Department of Internal Medicine, Yonsei University Wonju Severance Christian Hospital, Wonju, Korea
| | - Young Chang
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Jeong-Ju Yoo
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Baek Gyu Jun
- Department of Internal Medicine, Ulsan University Gangneung Asan Hospital, Gangneung, Korea
- Department of Internal Medicine, Asan Seoul Internal Medicine Clinic, Seoul, Korea
| | - Sung Won Lee
- Department of Internal medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, Bucheon, Korea
| | - Jung Gil Park
- Department of Internal Medicine, Yeungnam University Hospital, Daegu, Korea
| | - Ji Won Park
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sung-Eun Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Tae Yeob Kim
- Department of Internal Medicine, New Hope Internal Medicine Clinic Seoul, Seoul, Korea
| | - Soung Won Jeong
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Ki Tae Suk
- Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon-si, 24253, Gangwon-do, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju Severance Christian Hospital, Wonju, Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Won Kim
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jae Young Jang
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Jin Mo Yang
- Department of Internal medicine, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Korea
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon-si, 24253, Gangwon-do, Korea.
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Aryan M, Qian S, Chen Z, Louissaint J, Qian X, Rosenblatt R, Verna E, Brown R, Wong R, Clark V, Zhang W. Patients with early-stage alcohol-associated liver disease are at increased risk of hospital readmission and death. Eur J Gastroenterol Hepatol 2024; 36:318-325. [PMID: 38179871 DOI: 10.1097/meg.0000000000002701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
BACKGROUND AND AIMS Patients with alcohol use disorder (AUD) can develop alcohol-associated fatty liver disease (AFLD). However, the impact of AFLD on outcomes remains unclear. We studied the impact of AFLD on readmission, 30-day mortality, and overall mortality in patients admitted with AUD. METHODS Hospitalized patients with AUD between 2011 and 2019 at a tertiary medical center were retrospectively evaluated. Our population included patients with AUD with AFLD: AST and ALT elevation and serum bilirubin <3 mg/dl. Patients with AUD without evidence of liver disease served as control and were labeled as no ALD. Patients with alcohol-associated cirrhosis (AC) and alcohol-associated hepatitis (AH) were included for comparison. Kaplan-Meier survival analysis and multivariable regression for predictors of mortality and survival were performed. RESULTS There were 7522 patients of which 32.44% were female with mean age of 51.86 ± 14.41 years. Patient distribution included no ALD (n = 3775), AFLD (n = 2192), AC (n = 1017) and AH (n = 538) groups. Compared to no ALD group, AFLD group was associated with significantly higher 30-day mortality [4.43% vs. 1.56%, hazard ratio (HR): 2.84; P < 0.001], overall mortality [15.97% vs. 12.69%, HR 1.40, P < 0.001], and 30-day readmission [21.85% vs. 18.49%, odds ratio: 1.21; P < 0.01]. CONCLUSION We demonstrated that AFLD is not a benign entity and poses significant mortality risk. Our results suggest that AFLD may be under-recognized and highlight the need for focused management and close follow-up after discharge.
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Affiliation(s)
- Mahmoud Aryan
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama
| | - Steve Qian
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine
| | - Zhiguo Chen
- Department of Biostatistics, University of Florida, Gainesville, Florida
| | - Jeremy Louissaint
- Center for Liver Disease and Liver Transplantation, Columbia University Vagelos College of Physicians and Surgeons
| | - Xia Qian
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine
| | - Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - Elizabeth Verna
- Center for Liver Disease and Liver Transplantation, Columbia University Vagelos College of Physicians and Surgeons
| | - Robert Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
| | - Robert Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine and Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Virginia Clark
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine
| | - Wei Zhang
- Division of Gastroenterology and Hepatology, University of Florida College of Medicine
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Tarli C, Mannucci S, Vecchione M, Antonelli M, Sestito L, Mancarella FA, Tosoni A, Dionisi T, Maccauro V, Sario GD, Burra P, Germani G, Gasbarrini A, Addolorato G. Prothrombin time predicts steroid response in severe alcohol-related hepatitis. Liver Int 2024; 44:823-830. [PMID: 38238897 DOI: 10.1111/liv.15835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 12/19/2023] [Accepted: 12/25/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND AND AIMS Alcohol-related hepatitis (AH) is the most severe form of acute alcohol-related liver disease. Maddrey's discriminant function ≥32 defines the severe form of AH, which is associated with a high mortality. Steroid therapy represents the main medical treatment that may reduce short-term mortality. Lille score at day 7 assesses the therapeutic response to steroid therapy. At present, no parameters able to predict the response to steroid therapy have been highlighted. The aim of the present study was to evaluate if baseline prothrombin time (BPT) could predict the response to steroid in severe AH (sAH). METHODS Patients consecutively admitted in two Italian Liver Units, from 2017 to 2022, suffering from sAH were included. Data were collected prospectively. In order to evaluate if BPT could predict steroid response, we assessed the correlation between BPT using the Lille score at day 7. RESULTS A total of 52 patients received steroid treatment were enrolled in the study. The response to therapy was assessed by Lille score at day 7. Responders were 34 patients (65%), non-responders 18 patients (34%). BPT significantly predicted the steroid response (p < .001). The likelihood of not responding to the steroid therapy was significantly higher in patients with higher BPT (OR = 2.954). CONCLUSIONS BPT value predicted steroid response in patients with sAH. BPT could quickly identify non-responder patients to steroid therapy, reducing the risk of infections and it could allow the early evaluation for liver transplantation.
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Affiliation(s)
- Claudia Tarli
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Sergio Mannucci
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Michele Vecchione
- Department of Social and Developmental Psychology Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Mariangela Antonelli
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luisa Sestito
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Antonio Mancarella
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alberto Tosoni
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Dionisi
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valeria Maccauro
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanna Di Sario
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Antonio Gasbarrini
- Internal Medicine Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- CEMAD Digestive Disease Center, Department of Medical and Surgical Sciences, Hepatology and Gastroenterology Unit, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Addolorato
- Internal Medicine and Alcohol Related Disease Unit, Department of Medical and Surgical Sciences, Columbus-Gemelli Hospital, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- CEMAD Digestive Disease Center, Department of Medical and Surgical Sciences, Hepatology and Gastroenterology Unit, Università Cattolica del Sacro Cuore, Rome, Italy
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Singeap AM, Minea H, Petrea O, Robea MA, Balmuș IM, Duta R, Ilie OD, Cimpoesu CD, Stanciu C, Trifan A. Real-World Utilization of Corticosteroids in Severe Alcoholic Hepatitis: Eligibility, Response, and Outcomes. Medicina (Kaunas) 2024; 60:311. [PMID: 38399598 PMCID: PMC10890054 DOI: 10.3390/medicina60020311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: Alcoholic hepatitis (AH) poses a medical challenge, causing moderately severe to life-threatening episodes with high short- and long-term mortality. This study aimed to explore real-world corticosteroid utilization in severe AH, response predictors, and patient outcomes. Materials and Methods: We conducted a retrospective study on patients admitted for severe AH, defined as a Maddrey Discriminant Function score equal to or above 32, at a tertiary care center. We reviewed patients' medical observation charts to identify corticosteroid prescriptions, reasons for ineligibility, and response rates. Responders were defined based on the Lille score, and predictors of non-response were identified. Short-term (one-month) and long-term (one-year) mortality rates were calculated according to treatment and response. Results: Out of 310 patients enrolled with severe AH, 59% received corticosteroids, achieving a response rate of 75.4%. The reasons for not administering corticosteroids were as follows: uncontrolled infections (27.6%), renal dysfunction (20.4%), gastrointestinal bleeding (18.9%), acute pancreatitis (7.1%), uncontrolled diabetes (3.1%), and other or unknown causes (22.8%). The overall 1-month mortality rate was 12.2%, higher in non-responders (35.3%) and patients who did not receive corticosteroids (13.4%) compared to responders (3.6%). The overall 1-year mortality rate was 62.5%, similar between patients who did not receive corticosteroids (78.7%) and non-responders (77.7%) and higher compared to responders (42.8%). Predictive factors for non-response included older age (OR = 1.05, 95%CI: 1.01-1.08), concomitant cirrhosis (OR= 2.11, 95% CI: 1.064-4.20), MELD scores exceeding 30 (OR = 2.42, 95% CI: 1.21-4.80), severe hypoalbuminemia (OR = 2.46, 95%CI: 1.12-5.37), and increased serum creatinine (OR = 1.5, 95% CI: 1.1-2.03). Among the prognostic scores, MELD 3.0 score exhibited superior efficacy for short-term (AUC = 0.734, 95% CI 0.656-0.811) and long-term mortality (AUC = 0.777, 95% CI: 0.724-0.830) compared to alternative scoring systems. Conclusions: Low eligibility rate and poor prognosis underscore the need for effective therapies. Our findings contribute to refining risk stratification and early prediction of non-response, aiding clinicians in identifying more beneficial therapies.
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Affiliation(s)
- Ana-Maria Singeap
- Department of Gastroenterology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (A.-M.S.); (C.S.); (A.T.)
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700111 Iasi, Romania
- CENEMED Platform for Interdisciplinary Research, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (M.-A.R.); (I.-M.B.); (R.D.); (O.-D.I.); (C.D.C.)
| | - Horia Minea
- Department of Gastroenterology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (A.-M.S.); (C.S.); (A.T.)
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700111 Iasi, Romania
| | - Oana Petrea
- Department of Gastroenterology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (A.-M.S.); (C.S.); (A.T.)
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700111 Iasi, Romania
| | - Madalina-Andreea Robea
- CENEMED Platform for Interdisciplinary Research, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (M.-A.R.); (I.-M.B.); (R.D.); (O.-D.I.); (C.D.C.)
- Department of Exact Sciences and Natural Sciences, Institute of Interdisciplinary Research, “Alexandru Ioan Cuza” University of Iasi, 700057 Iasi, Romania
| | - Ioana-Miruna Balmuș
- CENEMED Platform for Interdisciplinary Research, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (M.-A.R.); (I.-M.B.); (R.D.); (O.-D.I.); (C.D.C.)
- Department of Exact Sciences and Natural Sciences, Institute of Interdisciplinary Research, “Alexandru Ioan Cuza” University of Iasi, 700057 Iasi, Romania
| | - Raluca Duta
- CENEMED Platform for Interdisciplinary Research, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (M.-A.R.); (I.-M.B.); (R.D.); (O.-D.I.); (C.D.C.)
- Department of Exact Sciences and Natural Sciences, Institute of Interdisciplinary Research, “Alexandru Ioan Cuza” University of Iasi, 700057 Iasi, Romania
| | - Ovidiu-Dumitru Ilie
- CENEMED Platform for Interdisciplinary Research, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (M.-A.R.); (I.-M.B.); (R.D.); (O.-D.I.); (C.D.C.)
- Department of Mother and Child, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No. 16, 700115 Iasi, Romania
| | - Carmen Diana Cimpoesu
- CENEMED Platform for Interdisciplinary Research, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (M.-A.R.); (I.-M.B.); (R.D.); (O.-D.I.); (C.D.C.)
- Department of Emergency Medicine, “St. Spiridon” University Hospital, 700111 Iasi, Romania
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, Iasi, Blvd. Independentei 1, 700111 Iasi, Romania
| | - Carol Stanciu
- Department of Gastroenterology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (A.-M.S.); (C.S.); (A.T.)
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700111 Iasi, Romania
- Centre of Biomedical Research, Romanian Academy, Carol I Avenue, No. 8, 700506 Iasi, Romania
| | - Anca Trifan
- Department of Gastroenterology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (A.-M.S.); (C.S.); (A.T.)
- Institute of Gastroenterology and Hepatology, “St. Spiridon” University Hospital, 700111 Iasi, Romania
- CENEMED Platform for Interdisciplinary Research, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (M.-A.R.); (I.-M.B.); (R.D.); (O.-D.I.); (C.D.C.)
- Centre of Biomedical Research, Romanian Academy, Carol I Avenue, No. 8, 700506 Iasi, Romania
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Singal AK, Leggio L, DiMartini A. Alcohol use disorder in alcohol-associated liver disease: Two sides of the same coin. Liver Transpl 2024; 30:200-212. [PMID: 37934047 DOI: 10.1097/lvt.0000000000000296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/16/2023] [Indexed: 11/08/2023]
Abstract
Alcohol-associated liver disease (ALD) has emerged as the leading indication for liver transplantation (LT) worldwide, with 40% of LTs in the United States performed for ALD in 2019. The ALD-related health care burden accelerated during the COVID-19 pandemic, especially in young individuals. Alcohol use disorder (AUD), which focuses on the negative effects of alcohol on psychosocial, physical, and mental health, is present in the majority of patients with ALD, with moderate to severe AUD in 75%-80%. During the last decade, early liver transplantation (eLT) has emerged as a lifesaving treatment for selected patients with alcohol-associated hepatitis; these patients may have a higher risk of using alcohol after LT. The risk of alcohol use recurrence may be reduced during the pretransplant or post-transplant period with AUD treatment using behavioral and/or pharmacological therapies and with regular monitoring for alcohol use (self-reported and complemented with biomarkers like phosphatidylethanol). However, AUD treatment in patients with ALD is challenging due to patient, clinician, and system barriers. An integrated model to provide AUD and ALD care by hepatologists and addiction experts in a colocated clinic starting from LT evaluation and selection to monitoring listed candidates and then to following up on recipients of LT should be promoted. However, the integration of addiction and hepatology teams in an LT program in the real world is often present only during evaluation and candidate selection for LT. Data are emerging to show that a multidisciplinary integrated AUD treatment within an LT program reduces recurrent alcohol use after LT. If we want to continue using early liver transplantation for patients with severe alcohol-associated hepatitis, LT programs should focus on building integrated multidisciplinary care teams for the integrated treatment of both AUD and ALD.
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Affiliation(s)
- Ashwani K Singal
- Department of Medicine, University of South Dakota, Vermillion, South Dakota, USA
- Department of Gastroenterology and Hepatology, Avera McKennan University Hospital, Sioux Falls, South Dakota, USA
- Department of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, South Dakota, USA
- Department of Medicine, VA Medical Center, Sioux Falls, South Dakota, USA
| | - Lorenzo Leggio
- Department of Neuropsychopharmacology Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, Division of Intramural Clinical and Biological Research, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
- Department of Behavioral and Social Sciences, Center for Alcohol and Addiction Studies, Brown University, Providence, Rhode Island, USA
- Department of Medicine, Division of Addiction Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Neuroscience, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Andrea DiMartini
- Departments of Psychiatry and Transplant Surgery, and the Clinical and Translational Science Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Pérez-Hernández O, González-Reimers E, García-Rodríguez A, Fernández-Rodríguez C, Abreu-González P, González-Pérez JM, Sánchez-Pérez MJ, Ferraz-Amaro I, Martín-González C. Value of inflammatory response and oxidative damage in the diagnosis of infections in severe alcoholic hepatitis. Eur J Intern Med 2024; 119:64-70. [PMID: 37586986 DOI: 10.1016/j.ejim.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/26/2023] [Accepted: 08/03/2023] [Indexed: 08/18/2023]
Abstract
Severe alcoholic hepatitis is the most lethal complication in alcohol dependent patients. The concurrence of infections in these patients is very frequent. Both produce a systemic inflammatory response syndrome (SIRS), secondary to intense release of inflammatory cytokines, which can complicate the diagnosis. In our study, Interleukin (IL)-6 and IL-10 levels are higher in patients with SIRS (p<0.001 and p = 0.033, respectively). IL-4, IL-6, Interferon-gamma (IFNγ), Tumor necrosis factor alpha (TNFα) and IL-17 levels correlate with liver function, as estimated by MELD-Na (p = 0.018, p = 0.008, p = 0.009, p = 0.016 and p = 0.006, respectively). Malondialdehyde (MDA), a product of lipid peroxidation and marker of cell damage, also correlates with liver function (p = 0.002), but not with SIRS or infections. Only elevated IL-6 correlates independently with the presence of infections (RR=1.023 IC 95% 1.000-1.047), so it may be useful for the correct diagnosis in these patients. Values greater than 30 pg/mL have a sensitivity: 86.7% and specificity: 94.7% for the diagnosis of infections.
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Affiliation(s)
- Onán Pérez-Hernández
- Servicio de Medicina Interna, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Canary Islands, Spain
| | - Emilio González-Reimers
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de La Laguna, San Cristóbal de La Laguna, Canary Islands, Spain
| | - Alen García-Rodríguez
- Servicio de Medicina Interna, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Canary Islands, Spain
| | - Camino Fernández-Rodríguez
- Servicio de Medicina Interna, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Canary Islands, Spain
| | - Pedro Abreu-González
- Departamento de Ciencias Médicas Básicas, Unidad de Fisiología, Universidad de la Laguna, San Cristóbal de La Laguna, Canary Islands, Spain
| | - José María González-Pérez
- Servicio de Medicina Interna, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Canary Islands, Spain
| | - María José Sánchez-Pérez
- Servicio de Medicina Interna, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Canary Islands, Spain
| | - Iván Ferraz-Amaro
- Servicio de Reumatología, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Canary Islands, Spain
| | - Candelaria Martín-González
- Servicio de Medicina Interna, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Canary Islands, Spain; Departamento de Medicina Interna, Facultad de Medicina, Universidad de La Laguna, San Cristóbal de La Laguna, Canary Islands, Spain.
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9
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Gaurnizo-Ortiz M, Nephew LD, Vilar-Gomez E, Kettler CD, Slaven JE, Ghabril MS, Desai AP, Orman ES, Chalasani N, Gawrieh S, Patidar KR. Clinical characteristics and prognosis of hospitalized patients with moderate alcohol-associated hepatitis. Liver Int 2024; 44:241-249. [PMID: 37904305 DOI: 10.1111/liv.15771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/14/2023] [Accepted: 10/15/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND AND AIMS Little is known about the clinical characteristics and prognosis of hospitalized patients with moderate alcohol-associated hepatitis (mAH) as compared to severe alcohol-associated hepatitis (sAH). Therefore, we aimed to describe the clinical characteristics and risk factors associated with mortality in hospitalized mAH patients. METHODS Patients hospitalized with alcohol-associated hepatitis (AH) from 1 January 2010 to 31 December 2020 at a large US healthcare system [11 hospitals, one liver transplant centre] were retrospectively analysed for outcomes. Primary outcome was 90-day mortality. AH and mAH were defined according to NIAAA Alcoholic Hepatitis Consortia and Model for End-stage Liver Disease Score ≤ 20 respectively. Multivariable Cox regression analysis was performed to identify independent risk factors associated with 90-day mortality. RESULTS 1504 AH patients were hospitalized during the study period, of whom 39% (n = 590) had mAH. Compared to sAH patients, mAH patients were older (50 vs. 48 years, p < 0.001) and less likely to have underlying cirrhosis (74% vs. 83%, p < 0.001). There were no differences between the two groups for median alcohol intake g/day (mAH 140.0 vs. sAH 112.0, p = 0.071). The cumulative proportion surviving at 90 days was 88% in mAH versus 62% in sAH (p < 0.001). On multivariable analysis, older age [HR 1.03 (95% CI 1.00-1.06), p = 0.020], corticosteroid use [HR 1.80 (95% CI 1.06-3.06), p = 0.030] and acute kidney injury (AKI) [HR 2.43 (95% CI 1.33-4.47), p = 0.004] were independently associated with 90-day mortality. CONCLUSIONS mAH carries a 12% mortality rate at 90 days. Age, AKI and corticosteroid use were associated with an increased risk for 90-day mortality. Avoidance of corticosteroids and strategies to reduce the risk of AKI could improve outcomes in mAH patients.
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Affiliation(s)
- Maria Gaurnizo-Ortiz
- Division of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lauren D Nephew
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eduardo Vilar-Gomez
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Carla D Kettler
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - James E Slaven
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Archita P Desai
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eric S Orman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Samer Gawrieh
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kavish R Patidar
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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10
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Jindal A, Sharma MK, Vijayaraghavan R, Sm S, Kumar G, Sarin SK. Severity of Acute Portal Hypertension Determines the Clinical Outcomes in Severe Alcoholic Hepatitis. Dig Dis Sci 2024; 69:298-307. [PMID: 37907805 DOI: 10.1007/s10620-023-08144-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 10/02/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Severe alcohol-associated hepatitis (SAH) presenting as acute-on-chronic liver failure (ACLF) has high mortality. Severe hepatic inflammation and ongoing hepatocellular cell death lead to rapid rise in portal pressure, a hyperdynamic circulation that might precipitate infections and organ failures. METHODS Consecutive SAH patients were classified based on baseline HVPG measurement as 6to < 12 mmHg, 12to < 20 mmHg, and ≥ 20 mmHg. We analyzed portal hypertension severity in relation to fibrosis stage, ACLF at presentation, response to prednisolone, severity scores(MELD and Maddrey's Discriminant Function, mDF), and 90-day mortality. RESULTS Of 819 SAH patients (94.6% ACLF, 85.4% histological cirrhosis, median MELD and mDF scores 25 and 66, respectively), 250(30.5%) had HVPG ≥ 20 mmHg. Patients with HVPG ≥ 20 mmHg more often had large esophageal varices (25.2%vs.13.2%; p-0.001), higher baseline MELD (27.1 ± 5.6vs.25.3 ± 5.2; p-0.001), and mDF(76.1 ± 16vs.68.4 ± 15.1; p-0.01) scores. No patient without ACLF had HVPG ≥ 20 mmHg. Moreover, during hospital course these patients had higher incidence of variceal bleed (17.2%vs.8.8%; p-0.001), acute kidney injury (36.4%vs.25.3%; p-0.001), and spontaneous bacterial peritonitis (6.4%vs.3.5%; p-0.05). Of 412(50.3%) eligible patients treated with prednisolone, 69.2% showed response at day 7(Lille's score < 0.45). 90-day mortality was 27.6%; and baseline MELD > 25.5[HR 1.78], HVPG ≥ 20 mmHg [HR 1.86], the presence of HE[HR 1.63], and prednisolone ineligibility due to sepsis[HR 1.27] were independent predictors. Mortality was unrelated to varices grade, variceal bleed, and histological cirrhosis. Repeat HVPG performed in 114(19.2%) patients after a median of 5.2 months showed significant decrease (3.6 mmHg; p-0.001) which correlated with improvement in MELD score(13points; p-0.05). CONCLUSION Development of ACLF and complications in SAH are likely a result of acute rise in HVPG. "High-risk" SAH are SAH patients with HVPG ≥ 20 mmHg in the presence of ascites. Understanding the drivers for acute rise in portal pressure in SAH ACLF might help introduction of newer therapies.
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Affiliation(s)
- Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Manoj K Sharma
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Rajan Vijayaraghavan
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Shasthry Sm
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Guresh Kumar
- Department of Biostatistics, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India.
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Sigal SH, Sanyal AJ, Frederick RT, Weinberg EM, Pappas SC, Jamil K. Terlipressin Treatment Is Associated With Reversal of Hepatorenal Syndrome in Patients With Alcoholic Hepatitis. Clin Gastroenterol Hepatol 2023; 21:3455-3457.e3. [PMID: 36848979 DOI: 10.1016/j.cgh.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 02/03/2023] [Accepted: 02/11/2023] [Indexed: 03/01/2023]
Affiliation(s)
- Samuel H Sigal
- Division of Hepatology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
| | - Arun J Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - R Todd Frederick
- Department of Transplant, California Pacific Medical Center, San Francisco, California
| | - Ethan M Weinberg
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - S Chris Pappas
- Department of Clinical Development and Scientific Affairs, Orphan Therapeutics, LLC, Longboat Key, Florida
| | - Khurram Jamil
- Department of Scientific Affairs, VP of Hepatology, Mallinckrodt Pharmaceuticals, Hampton, New Jersey
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12
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Di Martino V, Questiaux J, Lemagoarou T, Weil D, Vendeville S, Engelmann C, Hu J, Singh V, Newsome PN, Lal SB, Sarin SK, Berg T, Thevenot T. Granulocyte colony stimulating factor in decompensated cirrhosis, acute alcoholic hepatitis, and acute-on-chronic liver failure: A comprehensive meta-analysis of randomized controlled trials. Clin Res Hepatol Gastroenterol 2023; 47:102207. [PMID: 37716522 DOI: 10.1016/j.clinre.2023.102207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/08/2023] [Accepted: 09/08/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND GCSF may improve the prognosis of severe liver disease by promoting liver regeneration and immune restoration. Our Aim was to investigate its controversial efficacy in decompensated cirrhosis, acute alcoholic hepatitis (AAH), or acute-on-chronic liver failure (ACLF) through meta-analysis. METHODS Meta-analysis of proportions (random effect model) including 19 RCTs (1287 patients from 16 Asian and 3 European studies including 487 ACLF, 231 AAH and 569 cirrhotic patients) evaluating survival at day-28, day-90, 6 months, one year, and/or occurrence of sepsis as major outcomes. RESULTS In patients with decompensated cirrhosis, G-CSF administration was associated with a reduction in the weight-adjusted risk of mortality of 9% at day-90 (OR=0.33; 95%CI: 0.18-0.58; p = 0.0002), 16% at 6 months (OR=0.31; 95%CI: 0.15-0.62; p = 0.0009), 26% at one year (OR=0.21; 95%CI:0.12-0.38, p<0.0001) and a weight-adjusted 28% risk reduction for sepsis (OR=0.28; 95%CI: 0.16-0.49; p<0.0001). Only Asian studies were positive. In AAH, G-CSF was associated with an 18% reduction in weight-adjusted mortality risk at day-28 (OR=0.31; 95%CI:0.11-0.83, p = 0.021), 32% at day-90 (OR=0.20; 95%CI:0.09-0.46, p<0.0001) and a weight-adjusted 42% risk reduction for sepsis (OR=0.17; 95%CI: 0.08-0.38; p<0.0001). Only Asian studies, in which corticosteroids were not given systematically in case of severe AAH, were positive. In patients with ACLF, the results on mortality at day-28 were heterogeneous, and GCSF had no beneficial effect on sepsis or survival at day-90. CONCLUSION G-CSF may be effective in patients with decompensated cirrhosis or AAH by reducing the occurrence of sepsis and mortality. Further meta-analyses of individual data, or new, powerful and methodologically flawless therapeutic trials, are warranted to confirm these results, which harbor wide divergences between Asian and European RCTs.
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Affiliation(s)
- Vincent Di Martino
- Service d'Hépatologie, CHU Jean Minjoz, Besançon, France; Laboratoire EPILAB EA4266, Université de Franche Comté, Besançon, France.
| | | | - Tristan Lemagoarou
- Département d'information Médicale et de Santé Publique, GHPSO CREIL, Creil, France
| | - Delphine Weil
- Service d'Hépatologie, CHU Jean Minjoz, Besançon, France; Laboratoire EPILAB EA4266, Université de Franche Comté, Besançon, France
| | | | - Cornelius Engelmann
- Department of Hepatology and Gastroenterology, Universitätsmedizin Berlin, Berlin, Germany; Berlin Institute of Health, Berlin, Germany; Institute for Liver and Digestive Health, University College London, London, United Kingdom
| | - Jinhua Hu
- Department of Hepatology, the Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Virendra Singh
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Philip N Newsome
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Sadhna B Lal
- Division of Paediatric Gastroenterology and Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shiv K Sarin
- Institute of Liver and Biliary Sciences (ILBS), New Delhi, India
| | - Thomas Berg
- Division of Hepatology Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Thierry Thevenot
- Service d'Hépatologie, CHU Jean Minjoz, Besançon, France; Laboratoire EPILAB EA4266, Université de Franche Comté, Besançon, France
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van Velsen EFS, Zervou Z, Zillikens MC. Serum alkaline phosphatase can be elevated in patients with hypophosphatasia due to liver disease. Eur J Med Genet 2023; 66:104866. [PMID: 37839783 DOI: 10.1016/j.ejmg.2023.104866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/16/2023] [Accepted: 10/01/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Hypophosphatasia (HPP) is a rare inherited disorder caused by pathogenic loss-of-function variants in the ALPL gene, encoding the tissue-nonspecific isoenzym of alkaline phosphatase (ALP; TNSALP). Low serum ALP is the biochemical hallmark of HPP, but it is unknown whether ALP levels can increase due to concurring liver disease, which may lead to a missed diagnose of HPP. We present a patient with genetically confirmed HPP, who showed a transient increase of serum ALP levels due to alcohol-induced hepatitis. CLINICAL REPORT A 71-year old man was seen at our Bone Center for surveillance of HPP. Serum ALP was always low (23 U/L; reference value: <115 U/L). During follow-up, his serum ALP increased (156 U/L, further rising to 204 U/L), with concomitantly elevated serum gamma-glutamyl transferase and transaminases, and a rise in bone specific ALP (18.7 μg/L; reference value: 5.7-32.9 μg/L). This was attributed to alcohol-induced hepatitis. After refraining from alcohol intake, both serum ALP and bone specific ALP levels returned to initial low levels (30 U/L and 4.3 μg/L respectively). CONCLUSIONS We demonstrated the history of a 71-year old patient with HPP, presenting during routine follow-up with an elevated serum ALP level up to 204 U/L due to alcohol-induced hepatitis. This case illustrates that the diagnosis of HPP can potentially be missed when ALP levels are normal or elevated due to a concomitant liver disease.
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Affiliation(s)
- Evert F S van Velsen
- Department of Internal Medicine, Erasmus Medical Center, University Medical Center, Dr. Molewaterplein 40, 3015 CE, Rotterdam, the Netherlands; Erasmus MC Bone Center, Erasmus Medical Center, University Medical Center, Dr. Molewaterplein 40, 3015 CE, Rotterdam, the Netherlands.
| | - Zografia Zervou
- Department of Internal Medicine, Erasmus Medical Center, University Medical Center, Dr. Molewaterplein 40, 3015 CE, Rotterdam, the Netherlands; Erasmus MC Bone Center, Erasmus Medical Center, University Medical Center, Dr. Molewaterplein 40, 3015 CE, Rotterdam, the Netherlands.
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus Medical Center, University Medical Center, Dr. Molewaterplein 40, 3015 CE, Rotterdam, the Netherlands; Erasmus MC Bone Center, Erasmus Medical Center, University Medical Center, Dr. Molewaterplein 40, 3015 CE, Rotterdam, the Netherlands.
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Ariga KK, Verma G, Agrawal D. Higher Respiratory Complications in Alcoholic Hepatitis Patients With Hepatorenal Syndrome When Treated With Terlipressin: Is it Safe? Clin Gastroenterol Hepatol 2023; 21:3197-3198. [PMID: 37031717 DOI: 10.1016/j.cgh.2023.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 04/11/2023]
Affiliation(s)
| | - Govind Verma
- Department of Gastroenterology, PACE Hospitals, Hitec City, Hyderabad, India
| | - Dhiraj Agrawal
- Department of Gastroenterology and Hepatology, PACE Hospitals, Hitec City, Hyderabad, India
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15
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Moreau R, Tonon M, Krag A, Angeli P, Berenguer M, Berzigotti A, Fernandez J, Francoz C, Gustot T, Jalan R, Papp M, Trebicka J. EASL Clinical Practice Guidelines on acute-on-chronic liver failure. J Hepatol 2023; 79:461-491. [PMID: 37364789 DOI: 10.1016/j.jhep.2023.04.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/19/2023] [Indexed: 06/28/2023]
Abstract
Acute-on-chronic liver failure (ACLF), which was described relatively recently (2013), is a severe form of acutely decompensated cirrhosis characterised by the existence of organ system failure(s) and a high risk of short-term mortality. ACLF is caused by an excessive systemic inflammatory response triggered by precipitants that are clinically apparent (e.g., proven microbial infection with sepsis, severe alcohol-related hepatitis) or not. Since the description of ACLF, some important studies have suggested that patients with ACLF may benefit from liver transplantation and because of this, should be urgently stabilised for transplantation by receiving appropriate treatment of identified precipitants, and full general management, including support of organ systems in the intensive care unit (ICU). The objective of the present Clinical Practice Guidelines is to provide recommendations to help clinicians recognise ACLF, make triage decisions (ICU vs. no ICU), identify and manage acute precipitants, identify organ systems that require support or replacement, define potential criteria for futility of intensive care, and identify potential indications for liver transplantation. Based on an in-depth review of the relevant literature, we provide recommendations to navigate clinical dilemmas followed by supporting text. The recommendations are graded according to the Oxford Centre for Evidence-Based Medicine system and categorised as 'weak' or 'strong'. We aim to provide the best available evidence to aid the clinical decision-making process in the management of patients with ACLF.
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16
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Agrawal D, Ravula PK, Verma G. An unusual opportunistic infection causing lower gastrointestinal tract bleeding in a patient with severe alcoholic hepatitis, post-liver transplantation. Transpl Infect Dis 2023; 25:e14062. [PMID: 37073834 DOI: 10.1111/tid.14062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 04/20/2023]
Affiliation(s)
- Dhiraj Agrawal
- Department of Gastroenterology and Hepatology, PACE Hospitals, Hyderabad, Telangana, India
| | - Phani Krishna Ravula
- Department of Surgical Gastroenterology, PACE Hospitals, Hyderabad, Telangana, India
| | - Govind Verma
- Department of Gastroenterology and Hepatology, PACE Hospitals, Hyderabad, Telangana, India
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17
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Hsu CL, Wang Y, Duan Y, Chu H, Hartmann P, Llorente C, Zhou R, Schnabl B. Differences in Bacterial Translocation and Liver Injury in Ethanol Versus Diet-Induced Liver Disease. Dig Dis Sci 2023; 68:3059-3069. [PMID: 36807831 PMCID: PMC10313731 DOI: 10.1007/s10620-023-07860-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 01/30/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Alcohol-associated liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH) are two of the most common etiologies of chronic liver disease worldwide. Changes in intestinal permeability and increased gut microbial translocation have been posited as important contributors to inflammation in both ALD and NAFLD. However, gut microbial translocation has not been compared between the two etiologies and can lead to better understanding of the differences in their pathogenesis to liver disease. METHODS We compared serum and liver markers in the following five models of liver disease to understand the differences in the role of gut microbial translocation on liver disease progression caused by ethanol versus Western diet: (1) 8-week chronic ethanol feeding model. (2) 2-week chronic-plus-binge (National Institute on Alcohol Abuse and Alcoholism (NIAAA)) ethanol feeding model. (3) 2-week chronic-plus-binge (NIAAA) ethanol feeding model in microbiota-humanized gnotobiotic mice colonized with stool from patients with alcohol-associated hepatitis. (4) 20-week Western-diet-feeding model of NASH. (5) 20-week Western-diet-feeding model in microbiota-humanized gnotobiotic mice colonized with stool from NASH patients. RESULTS Translocation of bacterial lipopolysaccharide to the peripheral circulation was seen in both ethanol-induced and diet-induced liver disease, but translocation of bacteria itself was restricted to only ethanol-induced liver disease. Moreover, the diet-induced steatohepatitis models developed more significant liver injury, inflammation, and fibrosis compared with ethanol-induced liver disease models, and this positively correlated with the level of lipopolysaccharide translocation. CONCLUSIONS More significant liver injury, inflammation, and fibrosis are seen in diet-induced steatohepatitis, which positively correlates with translocation of bacterial components, but not intact bacteria.
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Affiliation(s)
- Cynthia L Hsu
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, MC0063, USA
| | - Yanhan Wang
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, MC0063, USA
- Department of Medicine, VA San Diego Healthcare System, San Diego, CA, USA
| | - Yi Duan
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, MC0063, USA
- Department of Medicine, VA San Diego Healthcare System, San Diego, CA, USA
| | - Huikuan Chu
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, MC0063, USA
- Department of Medicine, VA San Diego Healthcare System, San Diego, CA, USA
| | - Phillipp Hartmann
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA
- Division of Gastroenterology, Hepatology & Nutrition, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Cristina Llorente
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, MC0063, USA
| | - Rongrong Zhou
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, MC0063, USA
- Department of Medicine, VA San Diego Healthcare System, San Diego, CA, USA
| | - Bernd Schnabl
- Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, MC0063, USA.
- Department of Medicine, VA San Diego Healthcare System, San Diego, CA, USA.
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18
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Perabattula S, Quraishi S, Kichloo A, Dahiya DS. Portal Venous Thrombosis in Alcoholic Hepatitis: A Relatively Unknown Association. J Investig Med High Impact Case Rep 2023; 11:23247096231202625. [PMID: 37811780 PMCID: PMC10563462 DOI: 10.1177/23247096231202625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 08/26/2023] [Accepted: 09/02/2023] [Indexed: 10/10/2023] Open
Abstract
Portal venous thrombosis (PVT) is a rare diagnosis in the general population. However, it is seen in patients with liver cirrhosis with an estimated prevalence ranging from 0.6% to 26%. Literature reports that about one-third of PVT cases have an unknown etiology. Identifying the precipitating factors implicated in the development of PVT is imperative as it may help guide therapy. Although the association between liver cirrhosis and PVT has been well established in current literature, there continues to be a relative lack of awareness of alcoholic hepatitis (AH) as a risk factor for PVT. Identifying AH as a trigger for thrombosis can help avoid extended anticoagulation and its complications. In the following case report and brief review, we discuss an uncommon case of a 33-year-old male who came to the hospital emergency department with complaints of nauseousness, abdominal discomfort, and yellow discoloration. Lab investigations showed transaminitis. The diagnosis of AH was established, and an abdominal duplex ultrasound revealed PVT. Heparin drip was started as a part of treatment, which improved his abdominal discomfort. He was eventually discharged on apixaban 5 mg twice daily for 3 months and a repeat abdominal duplex ultrasound in 3 months to check for the resolution of the PVT.
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Affiliation(s)
| | | | - Asim Kichloo
- Samaritan Medical Center, Watertown, NY, USA
- Central Michigan University, Saginaw, USA
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19
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Wakil A, Mohamed M, Tafesh Z, Niazi M, Olivo R, Xia W, Greenberg P, Pyrsopoulos N. Trends in hospitalization for alcoholic hepatitis from 2011 to 2017: A USA nationwide study. World J Gastroenterol 2022; 28:5036-5046. [PMID: 36160652 PMCID: PMC9494933 DOI: 10.3748/wjg.v28.i34.5036] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/01/2022] [Accepted: 07/25/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Severe alcoholic hepatitis (AH) is one of the most lethal manifestations of alcohol-associated liver disease. In light of the increase in alcohol consumption worldwide, the incidence of AH is on the rise, and data examining the trends of AH admission is needed.
AIM To examine inpatient admission trends secondary to AH, along with their clinical outcomes and epidemiological characteristics.
METHODS The National Inpatient Sample (NIS) database was utilized, and data from 2011 to 2017 were reviewed. We included individuals aged ≥ 21 years who were admitted with a primary or secondary diagnosis of AH using the International Classification of Diseases (ICD)-9 and its correspondent ICD-10 codes. Hepatitis not related to alcohol was excluded. The national estimates of inpatient admissions were obtained using sample weights provided by the NIS.
RESULTS AH-related hospitalization demonstrated a significant increase in the USA from 281506 (0.7% of the total admission in 2011) to 324050 (0.9% of the total admission in 2017). The median age was 54 years. The most common age group was 45–65 years (range 57.8%–60.7%). The most common race was white (63.2%–66.4%), and patients were predominantly male (69.7%–71.2%). The primary healthcare payers were Medicare (29.4%–30.7%) and Medicaid (21.5%–32.5%). The most common geographical location was the Southern USA (33.6%–34.4%). Most patients were admitted to a tertiary care center (50.2%–62.3%) located in urban areas. Mortality of AH in this inpatient sample was 5.3% in 2011 and 5.5% in 2017. The most common mortality-associated risk factors were acute renal failure (59.6%–72.1%) and gastrointestinal hemorrhage (17.2%–20.3%). The total charges were noted to range between $25242.62 and $34874.50.
CONCLUSION The number of AH inpatient hospitalizations significantly increased from 2011 to 2017. This could have a substantial financial impact with increasing healthcare costs and utilization. AH-mortality remained the same.
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Affiliation(s)
- Ali Wakil
- Department of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Mujtaba Mohamed
- Department of Gastroenterology and Hepatology, Marshall University Hospital, Huntington, WV 25701, USA
| | - Zaid Tafesh
- Department of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Mumtaz Niazi
- Department of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Raquel Olivo
- Department of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Weiyi Xia
- Department of Biostatistics & Epidemiology, Rutgers School of Public Health, Piscataway, NJ 08854, USA
| | - Patricia Greenberg
- Department of Biostatistics & Epidemiology, Rutgers School of Public Health, Piscataway, NJ 08854, USA
| | - Nikolaos Pyrsopoulos
- Department of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
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20
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Keating M, Lardo O, Hansell M. Alcoholic Hepatitis: Diagnosis and Management. Am Fam Physician 2022; 105:412-420. [PMID: 35426628] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Alcoholic hepatitis is a clinical syndrome characterized by acute-onset jaundice and liver enzyme abnormalities in the setting of long-term heavy alcohol use. High rates of concomitant infections, systemic inflammation, and multiorgan failure lead to significant morbidity and mortality. Diagnosis of alcoholic hepatitis is primarily clinical, based on a consensus definition from the National Institute on Alcohol Abuse and Alcoholism. Initial workup should include chest radiography and cultures of peritoneal fluid, blood, and urine. Close monitoring for inflammation and organ failure is crucial throughout hospitalization. Laboratory-based prognostic scores, including Maddrey Discriminant Function and the Model for End-Stage Liver Disease, help determine disease severity and treatment options. Treatment for moderate disease primarily consists of supportive care, including alcohol cessation and nutritional support. Corticosteroids are recommended for severe alcoholic hepatitis. Responsiveness to corticosteroid therapy should be evaluated using the Lille score on day 7 of treatment. Hospital physicians should involve a multidisciplinary team, including substance abuse specialists, gastroenterologists or hepatologists, nephrologists, dietitians, and intensivists, as appropriate. Long-term follow-up should focus on abstinence from alcohol, management of underlying cirrhosis, and evaluation for liver transplantation if indicated. Pharmacologic treatment of alcohol use disorder can aid patients in maintaining abstinence from alcohol. The presence of underlying cirrhosis and continued alcohol use negatively impact long-term prognosis.
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Affiliation(s)
| | - Olivia Lardo
- Wake Forest School of Medicine, Winston-Salem, NC, USA
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21
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Lee DU, Fan GH, Hastie DJ, Addonizio EA, Prakasam VN, Ahern RR, Seog KJ, Karagozian R. The Impact of Malnutrition on the Hospital and Infectious Outcomes of Patients Admitted With Alcoholic Hepatitis: 2011 to 2017 Analysis of US Hospitals. J Clin Gastroenterol 2022; 56:349-359. [PMID: 33769393 DOI: 10.1097/mcg.0000000000001528] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/06/2021] [Indexed: 01/13/2023]
Abstract
GOALS We specifically evaluate the effect of malnutrition on the infection risks of patients admitted with alcoholic hepatitis using a national registry of hospitalized patients in the United States. BACKGROUND Malnutrition is a common manifestation of alcoholic hepatitis that affects patient outcomes. STUDY 2011 to 2017 National Inpatient Sample was used to isolated patients with alcoholic hepatitis, stratified using malnutrition (protein-calorie malnutrition, sarcopenia, and weight loss/cachexia) and matched using age, gender, and race with 1:1 nearest neighbor matching method. Endpoints included mortality and infectious endpoints. RESULTS After matching, there were 10,520 with malnutrition and 10,520 malnutrition-absent controls. Mortality was higher in the malnutrition cohort [5.02 vs. 2.29%, P<0.001, odds ratio (OR): 2.25, 95% confidence interval (CI): 1.93-2.63], as were sepsis (14.2 vs. 5.46, P<0.001, OR: 2.87, 95% CI: 2.60-3.18), pneumonia (10.9 vs. 4.63%, P<0.001, OR: 2.51, 95% CI: 2.25-2.81), urinary tract infection (14.8 vs. 9.01%, P<0.001, OR: 1.76, 95% CI: 1.61-1.91), cellulitis (3.17 vs. 2.18%, P<0.001, OR: 1.47, 95% CI: 1.24-1.74), cholangitis (0.52 vs. 0.20%, P<0.001, OR: 2.63, 95% CI: 1.59-4.35), and Clostridium difficile infection (1.67 vs. 0.91%, P<0.001, OR: 1.85, 95% CI: 1.44-2.37). In multivariate models, malnutrition was associated with mortality [P<0.001, adjusted odds ratio (aOR): 1.61, 95% CI: 1.37-1.90] and infectious endpoints: sepsis (P<0.001, aOR: 2.42, 95% CI: 2.18-2.69), pneumonia (P<0.001, aOR: 2.19, 95% CI: 1.96-2.46), urinary tract infection (P<0.001, aOR: 1.68, 95% CI: 1.53-1.84), cellulitis (P<0.001, aOR: 1.46, 95% CI: 1.22-1.74), cholangitis (P=0.002, aOR: 2.27, 95% CI: 1.36-3.80), and C. difficile infection (P<0.001, aOR: 1.89, 95% CI: 1.46-2.44). CONCLUSION This study shows the presence of malnutrition is an independent risk factor of mortality and local/systemic infections in patients admitted with alcoholic hepatitis.
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Affiliation(s)
- David U Lee
- Liver Center, Division of Gastroenterology, Tufts Medical Center, Washington Street, Boston, MA
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22
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Morales-Arráez D, Ventura-Cots M, Altamirano J, Abraldes JG, Cruz-Lemini M, Thursz MR, Atkinson SR, Sarin SK, Kim W, Chavez-Araujo R, Higuera-de la Tijera MF, Singal AK, Shah VH, Kamath PS, Duarte-Rojo A, Charles EA, Vargas V, Jager M, Rautou PE, Rincon D, Zamarripa F, Restrepo-Gutiérrez JC, Torre A, Lucey MR, Arab JP, Mathurin P, Louvet A, García-Tsao G, González JA, Verna EC, Brown RS, Argemi J, Fernández-Carrillo C, Clemente A, Alvarado-Tapias E, Forrest E, Allison M, Bataller R. The MELD Score Is Superior to the Maddrey Discriminant Function Score to Predict Short-Term Mortality in Alcohol-Associated Hepatitis: A Global Study. Am J Gastroenterol 2022; 117:301-310. [PMID: 34962498 PMCID: PMC8999152 DOI: 10.14309/ajg.0000000000001596] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [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: 02/06/2021] [Accepted: 10/27/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Several scoring systems predict mortality in alcohol-associated hepatitis (AH), including the Maddrey discriminant function (mDF) and model for end-stage liver disease (MELD) score developed in the United States, Glasgow alcoholic hepatitis score in the United Kingdom, and age, bilirubin, international normalized ratio, and creatinine score in Spain. To date, no global studies have examined the utility of these scores, nor has the MELD-sodium been evaluated for outcome prediction in AH. In this study, we assessed the accuracy of different scores to predict short-term mortality in AH and investigated additional factors to improve mortality prediction. METHODS Patients admitted to hospital with a definite or probable AH were recruited by 85 tertiary centers in 11 countries and across 3 continents. Baseline demographic and laboratory variables were obtained. The primary outcome was all-cause mortality at 28 and 90 days. RESULTS In total, 3,101 patients were eligible for inclusion. After exclusions (n = 520), 2,581 patients were enrolled (74.4% male, median age 48 years, interquartile range 40.9-55.0 years). The median MELD score was 23.5 (interquartile range 20.5-27.8). Mortality at 28 and 90 days was 20% and 30.9%, respectively. The area under the receiver operating characteristic curve for 28-day mortality ranged from 0.776 for MELD-sodium to 0.701 for mDF, and for 90-day mortality, it ranged from 0.773 for MELD to 0.709 for mDF. The area under the receiver operating characteristic curve for mDF to predict death was significantly lower than all other scores. Age added to MELD obtained only a small improvement of AUC. DISCUSSION These results suggest that the mDF score should no longer be used to assess AH's prognosis. The MELD score has the best performance in predicting short-term mortality.
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Affiliation(s)
- D Morales-Arráez
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Department of Gastroenterology and Hepatology, Hospital Universitario de Canarias, Canarias, Spain
| | - M Ventura-Cots
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - J Altamirano
- Department of Internal Medicine, Hospital Quironsalud, Barcelona, Spain
| | - J G Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, Canada
| | - M Cruz-Lemini
- Women and Perinatal Research Group, Obstetrics and Gynecology Department, Sant Pau University Hospital, Barcelona, Spain, and Maternal and Child Health and Development Network (SAMID, RD16/0022/0015), Instituto de Salud Carlos III, Spanish Ministry of Health, Spain
| | - M R Thursz
- Department of Metabolism, Digestive disease and Reproduction, Imperial College London, UK
| | - S R Atkinson
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Department of Metabolism, Digestive disease and Reproduction, Imperial College London, UK
| | - S K Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - W Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - R Chavez-Araujo
- Hospital das Clinicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - A K Singal
- Division of Gastroenterology and Hepatology, the University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - V H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - P S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - A Duarte-Rojo
- Division of Gastroenterology and Hepatology, Department of Medicine, the University of Arkansas for Medical Science, Little Rock, Arkansas, USA
| | - E A Charles
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - V Vargas
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Universidad Autónoma, Barcelona, CIBERehd, Barcelona, Spain
| | - M Jager
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
| | - P E Rautou
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
- Inserm, UMR-970, Paris Cardiovascular Research Center, PARCC, Paris, France
| | - D Rincon
- Hepatology Department, Hospital General Universitario Gregorio Marañón, CIBERehd and Universidad Complutense, Madrid, Spain
| | - F Zamarripa
- Gastroenterology, Juarez Hospital, Mexico City, Mexico
| | - J C Restrepo-Gutiérrez
- Liver Transplant Program, Hospital Pablo Tobon Uribe, University of Antioquia, Medellin, Colombia
| | - A Torre
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - M R Lucey
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - J P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - P Mathurin
- Service des Maladies de l'Appareil Digestif et de la Nutrition, CHU Lille, Lille, France
- LIRIC-Lille Inflammation Research International Center-U995, Univ. Lille, Inserm, CHU Lille, Lille, France
| | - A Louvet
- Service des Maladies de l'Appareil Digestif et de la Nutrition, CHU Lille, Lille, France
| | - G García-Tsao
- Section of Digestive Diseases, Yale University School of Medicine/VA-CT Healthcare System, New Haven/West Haven, Connecticut¸ USA
| | - J A González
- Gastroenterology Department, Hospital Universitario "Dr. José E González" Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - E C Verna
- Division of Digestive and Liver Diseases, Department of Medicine and Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - R S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - J Argemi
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Liver Unit, Clinica Universidad de Navarra, IdisNA. Pamplona, Spain
| | - C Fernández-Carrillo
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - A Clemente
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Liver Unit and Digestive Department H.G.U. Gregorio Marañón, Madrid, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - E Alvarado-Tapias
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - E Forrest
- Glasgow Royal Infirmary, Glasgow, UK
| | - M Allison
- Liver Unit, Cambridge Biomedical Research Centre, Cambridge, UK
| | - R Bataller
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
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Otero Sanchez L, Karakike E, Njimi H, Putignano A, Degré D, Hites M, Jacobs F, Moreno C, Trepo E, Gustot T. Clinical Course and Risk Factors for Infection in Severe Forms of Alcohol-Associated Liver Disease. Hepatology 2021; 74:2714-2724. [PMID: 34046927 DOI: 10.1002/hep.31984] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Infection is a major driver of mortality in patients with advanced alcohol-associated liver disease (ALD). The epidemiology and clinical course of patients infected with life-threatening forms of ALD, including severe alcohol-associated hepatitis (sAH) and decompensated alcohol-associated cirrhosis (DAC), and specific risk factors for infection remain mostly unknown. APPROACH AND RESULTS In this observational study, we assessed all infectious episodes occurring within a 90-day period from diagnosis in all consecutive patients with biopsy-proven sAH (modified Maddrey's discriminant function ≥ 32, Model for End-Stage Liver Disease [MELD] ≥ 18) and DAC (MELD ≥ 18) without alcohol-associated hepatitis in our tertiary hospital between 2003 and 2016. A total of 207 patients were included: 139 with sAH and 68 with DAC. One hundred seventeen (84%) patients with sAH and 41 (60%) patients with DAC experienced at least one infection episode at 90 days (P < 0.001). In multivariable analysis, factors associated with the development of infection were the presence of sAH and baseline MELD score. Bacterial infections represented the most common infection in the two groups, and only the MELD score was independently associated with the occurrence of bacterial infection. In both groups, pneumonia was the most prevalent bacterial infection, and gram-negative bacilli were the main pathogens. Invasive fungal infections (IFI) occurred in 20 (14.5%) patients with sAH and 3 (4.5%) with patients with DAC (P < 0.05). Multivariable regression showed that younger age, higher MELD, and corticosteroid therapy were independently associated with IFI. The 90-day cumulative incidence of death in patients infected with sAH and patients infected with DAC was 46% and 41.5%, respectively (P = 0.43). CONCLUSIONS Patients with sAH are more susceptible to develop infection than those with DAC. In life-threatening forms of ALD, patients who were infected share a similar mortality rate. Corticosteroid treatment, not sAH, seems to be the main risk factor triggering IFI.
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Affiliation(s)
- Lukas Otero Sanchez
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Eleni Karakike
- Clinic of Infectious Diseases, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Hassane Njimi
- Biomedical Statistics, Université Libre de Bruxelles, Brussels, Belgium
| | - Antonella Putignano
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Delphine Degré
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Maya Hites
- Clinic of Infectious Diseases, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Frédérique Jacobs
- Clinic of Infectious Diseases, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Eric Trepo
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Thierry Gustot
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
- Inserm Unité 1149, Centre de Recherche sur l'inflammation (CRI), Paris, France
- UMR S_1149, Université Paris Diderot, Paris, France
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Sheriff L, Khan RS, Saborano R, Wilkin R, Luu NT, Gunther UL, Hubscher SG, Newsome PN, Lalor PF. Alcoholic hepatitis and metabolic disturbance in female mice: a more tractable model than Nrf2-/- animals. Dis Model Mech 2020; 13:dmm046383. [PMID: 33067186 PMCID: PMC7790192 DOI: 10.1242/dmm.046383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/07/2020] [Indexed: 12/20/2022] Open
Abstract
Alcoholic hepatitis (AH) is the dramatic acute presentation of alcoholic liver disease, with a 15% mortality rate within 28 days in severe cases. Research into AH has been hampered by the lack of effective and reproducible murine models that can be operated under different regulatory frameworks internationally. The liquid Lieber-deCarli (LdC) diet has been used as a means of ad libitum delivery of alcohol but without any additional insult, and is associated with relatively mild liver injury. The transcription factor nuclear factor-erythroid 2-related factor 2 (Nrf2) protects against oxidative stress, and mice deficient in this molecule are suggested to be more sensitive to alcohol-induced injury. We have established a novel model of AH in mice and compared the nature of liver injury in C57/BL6 wild-type (WT) versus Nrf2-/- mice. Our data showed that both WT and Nrf2-/- mice demonstrate robust weight loss, and an increase in serum transaminase, steatosis and hepatic inflammation when exposed to diet and ethanol. This is accompanied by an increase in peripheral blood and hepatic myeloid cell populations, fibrogenic response and compensatory hepatocyte regeneration. We also noted characteristic disturbances in hepatic carbohydrate and lipid metabolism. Importantly, use of Nrf2-/- mice did not increase hepatic injury responses in our hands, and female WT mice exhibited a more-reproducible response. Thus, we have demonstrated that this simple murine model of AH can be used to induce an injury that recreates many of the key human features of AH - without the need for challenging surgical procedures to administer ethanol. This will be valuable for understanding of the pathogenesis of AH, for testing new therapeutic treatments or devising metabolic approaches to manage patients whilst in medical care.This article has an associated First Person interview with the joint first authors of the paper.
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Affiliation(s)
- Lozan Sheriff
- Centre for Liver and Gastroenterology Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Birmingham National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Reenam S Khan
- Centre for Liver and Gastroenterology Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Birmingham National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Raquel Saborano
- Centre for Liver and Gastroenterology Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Birmingham National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Richard Wilkin
- Centre for Liver and Gastroenterology Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Birmingham National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Nguyet-Thin Luu
- Centre for Liver and Gastroenterology Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Birmingham National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Ulrich L Gunther
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Institute of Chemistry and Metabolomics, University of Lübeck, 23562 Lübeck, Germany
| | - Stefan G Hubscher
- Centre for Liver and Gastroenterology Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Birmingham National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Liver Unit, University Hospitals Birmingham, Birmingham B15 2TH, UK
- Department of Cellular Pathology, University Hospitals Birmingham, Birmingham B15 2TH, UK
| | - Philip N Newsome
- Centre for Liver and Gastroenterology Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Birmingham National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Patricia F Lalor
- Centre for Liver and Gastroenterology Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Birmingham National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
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Lang S, Duan Y, Liu J, Torralba MG, Kuelbs C, Ventura-Cots M, Abraldes JG, Bosques-Padilla F, Verna EC, Brown RS, Vargas V, Altamirano J, Caballería J, Shawcross D, Lucey MR, Louvet A, Mathurin P, Garcia-Tsao G, Ho SB, Tu XM, Bataller R, Stärkel P, Fouts DE, Schnabl B. Intestinal Fungal Dysbiosis and Systemic Immune Response to Fungi in Patients With Alcoholic Hepatitis. Hepatology 2020; 71:522-538. [PMID: 31228214 PMCID: PMC6925657 DOI: 10.1002/hep.30832] [Citation(s) in RCA: 140] [Impact Index Per Article: 35.0] [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: 02/04/2019] [Accepted: 06/06/2019] [Indexed: 02/06/2023]
Abstract
Chronic alcohol consumption causes increased intestinal permeability and changes in the intestinal microbiota composition, which contribute to the development and progression of alcohol-related liver disease. In this setting, little is known about commensal fungi in the gut. We studied the intestinal mycobiota in a cohort of patients with alcoholic hepatitis, patients with alcohol use disorder, and nonalcoholic controls using fungal-specific internal transcribed spacer amplicon sequencing of fecal samples. We further measured serum anti-Saccharomyces cerevisiae antibodies (ASCA) as a systemic immune response to fungal products or fungi. Candida was the most abundant genus in the fecal mycobiota of the two alcohol groups, whereas genus Penicillium dominated the mycobiome of nonalcoholic controls. We observed a lower diversity in the alcohol groups compared with controls. Antibiotic or steroid treatment was not associated with a lower diversity. Patients with alcoholic hepatitis had significantly higher ASCA levels compared to patients with alcohol use disorder and to nonalcoholic controls. Within the alcoholic hepatitis cohort, patients with levels of at least 34 IU/mL had a significantly lower 90-day survival (59%) compared with those with ASCA levels less than 34 IU/mL (80%) with an adjusted hazard ratio of 3.13 (95% CI, 1.11-8.82; P = 0.031). Conclusion: Patients with alcohol-associated liver disease have a lower fungal diversity with an overgrowth of Candida compared with controls. Higher serum ASCA was associated with increased mortality in patients with alcoholic hepatitis. Intestinal fungi may serve as a therapeutic target to improve survival, and ASCA may be useful to predict the outcome in patients with alcoholic hepatitis.
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Affiliation(s)
- Sonja Lang
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Yi Duan
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
- Department of Medicine, VA San Diego Healthcare System, San Diego, CA, USA
| | - Jinyuan Liu
- Division of Biostatistics and Bioinformatics, Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, USA
| | | | - Claire Kuelbs
- J. Craig Venter Institute, La Jolla, California, USA
| | - Meritxell Ventura-Cots
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh Liver Research Center, Pittsburgh, Pennsylvania, USA
| | - Juan G. Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Francisco Bosques-Padilla
- Hospital Universitario, Departamento de Gastroenterología, Universidad Autonoma de Nuevo Leon, Monterrey, México
| | - Elizabeth C. Verna
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia College of Physicians and Surgeons, Columbia University Medical Center, New York, NY, USA
| | - Robert S. Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Victor Vargas
- Liver Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Jose Altamirano
- Liver Unit, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Caballería
- Centro de Investigación en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
- Liver Unit, Hospital Clinic, Barcelona, Spain
| | - Debbie Shawcross
- Institute of Liver Studies, King's College London School of Medicine at King's College Hospital, King's College Hospital, London, UK
| | - Michael R. Lucey
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, WI, USA
| | - Alexandre Louvet
- Service des Maladies de L'appareil Digestif et Unité INSERM, Hôpital Huriez, Lille, France
| | - Philippe Mathurin
- Service des Maladies de L'appareil Digestif et Unité INSERM, Hôpital Huriez, Lille, France
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA, and Section of Digestive Diseases, VA-CT Healthcare System, West Haven, CT, USA
| | - Samuel B. Ho
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
- Department of Medicine, VA San Diego Healthcare System, San Diego, CA, USA
| | - Xin M. Tu
- Division of Biostatistics and Bioinformatics, Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, USA
| | - Ramon Bataller
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh Liver Research Center, Pittsburgh, Pennsylvania, USA
| | - Peter Stärkel
- St. Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | | | - Bernd Schnabl
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
- Department of Medicine, VA San Diego Healthcare System, San Diego, CA, USA
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Chung MW, Kim UJ, Jun CH, Cho SB, Park SY, Park CH, Kim HS, Choi SK, Rew JS. Pneumocystis pneumonia after use of corticosteroids in a man with severe alcoholic hepatitis: A case report. Medicine (Baltimore) 2020; 99:e18696. [PMID: 31914071 PMCID: PMC6959895 DOI: 10.1097/md.0000000000018696] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Indexed: 12/19/2022] Open
Abstract
RATIONALE Severe alcoholic hepatitis (AH) has a very high mortality rate. Current guidelines recommend oral corticosteroids as first-line agents in individuals with severe AH to reduce short-term mortality. However, systemic corticosteroids have serious adverse effects. In individuals with AH, infection, which is one of the complications of steroid use, can result in serious outcomes, such as acute-on-chronic liver failure. Pneumocystis pneumonia (PCP) is a life-threatening opportunistic infection which may occur when high-dose corticosteroids are prescribed for more than 1 month. Therefore, when high-dose corticosteroids are used, providing PCP prophylaxis is warranted. Although trimethoprim-sulfamethoxazole (TMP-SMX) is the drug of choice for the prophylaxis of PCP, its hepatotoxicity limits its use in patients with severe AH who are on high-dose corticosteroids. Moreover, there is a lack of consensus on which drugs should be used for PCP prophylaxis in individuals with severe AH who are on glucocorticoid treatment. Herein, we report a case of a 43-year-old male with fatal PCP that occurred after the use of corticosteroids for severe AH. PATIENT CONCERNS A 43-year-old alcoholic man presented with a hematoma on his right leg. His liver function was poor, and he was he was diagnosed with severe AH and treated with oral corticosteroids for 26 days. After glucocorticoid treatment, he developed a productive cough. DIAGNOSES A sputum PCR test was positive for Pneumocystis jirovecii. INTERVENTIONS He was initially treated with TMP-SMX and required artificial ventilation. OUTCOMES He developed disseminated intravascular coagulation and multi-organ failure, and died 10 days after starting TMP-SMX. LESSONS To date, prevention of PCP in individuals with severe AH who are on corticosteroids has been overlooked. This case illustrates the need for prophylaxis of PCP in individuals with severe AH taking corticosteroids.
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Affiliation(s)
| | - Uh Jin Kim
- Department of Infectious diseases, Chonnam National University Hospital and College of Medicine, Gwangju, South Korea
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27
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Sujan R, Cruz-Lemini M, Altamirano J, Simonetto DA, Maiwall R, Axley P, Richardson T, Desai V, Cabezas J, Vargas V, Kamath PS, Shah VH, Sarin SK, Bataller R, Singal AK. A Validated Score Predicts Acute Kidney Injury and Survival in Patients With Alcoholic Hepatitis. Liver Transpl 2018; 24:1655-1664. [PMID: 30153377 DOI: 10.1002/lt.25328] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [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: 03/05/2018] [Accepted: 08/07/2018] [Indexed: 02/07/2023]
Abstract
Identifying patients at high risk for acute kidney injury (AKI) during hospitalization among patients admitted with severe alcoholic hepatitis (AH) is an unmet clinical need. We performed a multicentric prospective cohort study using data from 4 different cohorts on well-characterized patients hospitalized with severe AH. Data collected on 773 AH patients from 4 cohorts across the globe were randomly split into test (n = 390) and validation (n = 383) cohorts. We found that 32% of the patients developed inpatient AKI in the test cohort. Approximately 60% of patients met criteria for systemic inflammatory response syndrome (SIRS) at admission. Hepatic encephalopathy, SIRS, and Model for End-Stage Liver Disease score at admission predicted inpatient AKI with odds ratios of 3.86, 2.24, and 1.14, respectively. The AKI risk score developed using these predictors stratified risk of inpatient AKI to low (score <3), moderate (3-4), and high (>4). These findings were replicated in the validation cohort. In the whole study cohort, patients with AKI had a lower 90-day survival (53% versus 77%; P < 0.001). Those with AKI risk score of >4 had significantly lower 90-day survival as compared with those with risk scores between 3 and 4 and <3 (47% versus 68% versus 88%; P < 0.001). In conclusion, AKI occurs frequently in AH patients and negatively impacts short-term mortality. The AKI risk score is useful in identifying patients at high risk for inpatient AKI and may be useful for developing new therapeutic strategies to prevent AKI in patients with AH.
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Affiliation(s)
- Ravi Sujan
- University of Alabama at Birmingham, Birmingham, AL
| | - Monica Cruz-Lemini
- Unidad de Investigación en Neurodesarrollo, Instituto de Neurobiología, Universidad Nacional Autónoma de México, Campus Juriquilla, Queretaro, Mexico
| | - Jose Altamirano
- Liver Unit, Internal Medicine Department, Vall d'Hebrón University Hospital, Vall d'Hebrón Institut de Recerca, Barcelona, Spain
| | | | - Rakhi Maiwall
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Page Axley
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | - Joaquin Cabezas
- Pittsburgh Liver Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Victor Vargas
- Liver Unit, Internal Medicine Department, Vall d'Hebrón University Hospital, Vall d'Hebrón Institut de Recerca, Barcelona, Spain
| | | | | | - Shiv K Sarin
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ramon Bataller
- Pittsburgh Liver Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA
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28
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Wu N, McDaniel K, Zhou T, Ramos-Lorenzo S, Wu C, Huang L, Chen D, Annable T, Francis H, Glaser S, Alpini G, Meng F. Knockout of microRNA-21 attenuates alcoholic hepatitis through the VHL/NF-κB signaling pathway in hepatic stellate cells. Am J Physiol Gastrointest Liver Physiol 2018; 315:G385-G398. [PMID: 29848019 PMCID: PMC6415712 DOI: 10.1152/ajpgi.00111.2018] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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: 04/02/2018] [Revised: 05/21/2018] [Accepted: 05/27/2018] [Indexed: 01/31/2023]
Abstract
microRNA-21 (miRNA) is one of the most abundant miRNAs in chronic liver injuries including alcoholic liver injury. Previous studies have demonstrated that miR-21 plays a role in inflammation in the liver and functions in hepatic stellate cells (HSCs), which reside in the perisinusoidal space between sinusoidal endothelial cells and hepatocytes and regulate sinusoidal circulation. HSCs integrate cytokine-mediated inflammatory responses in the sinusoids and relay them to the liver parenchyma. Here, we showed that the activation of Von Hippel-Lindau (VHL) expression, by miR-21 knockout in vivo and anti-miR-21 or VHL overexpression in vitro, suppressed the production of proinflammatory cytokines, such as interleukin (IL)-6, monocyte chemoattractant protein-1, and IL-1β, in human HSCs during alcoholic liver injury. Sequence and functional analyses confirmed that miR-21 directly targeted the 3'-untranslated region of VHL. Immunofluorescence and real-time PCR analysis revealed that miR-21 depletion blocked NF-κB activation in human HSCs both in cultured HSCs as well as HSCs isolated from alcohol-related liver disease mice liver by laser capture microdissection. We also showed that conditioned medium from anti-miR-21-transfected HSCs suppressed human monocyte-derived THP-1 cell migration. Taken together, our study indicates that depletion of miR-21 may downregulate cytokine production in HSCs and macrophage chemotaxis during alcoholic liver injury and that the targeting of miR-21 may have therapeutic potential for preventing the progression of alcoholic liver diseases. NEW & NOTEWORTHY This study demonstrates that silencing microRNA-21 can inhibit cytokine production and inflammatory responses in human hepatic stellate cells during alcoholic liver injury and that the targeting of microR-21 in hepatic stellate cells may have therapeutic potential for prevention and treatment of alcoholic liver diseases.
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Affiliation(s)
- Nan Wu
- Research, Central Texas Veterans Health Care System, Temple, Texas
- Department of Medicine and Baylor Scott & White Digestive Disease Research Center, Texas A&M Health Sciences Center and Scott & White Hospital, Temple, Texas
| | - Kelly McDaniel
- Research, Central Texas Veterans Health Care System, Temple, Texas
- Department of Medicine and Baylor Scott & White Digestive Disease Research Center, Texas A&M Health Sciences Center and Scott & White Hospital, Temple, Texas
- Research Institute, Baylor Scott & White Health, Temple, Texas
| | - Tianhao Zhou
- Research, Central Texas Veterans Health Care System, Temple, Texas
- Department of Medicine and Baylor Scott & White Digestive Disease Research Center, Texas A&M Health Sciences Center and Scott & White Hospital, Temple, Texas
| | - Sugeily Ramos-Lorenzo
- Research, Central Texas Veterans Health Care System, Temple, Texas
- Department of Medicine and Baylor Scott & White Digestive Disease Research Center, Texas A&M Health Sciences Center and Scott & White Hospital, Temple, Texas
- Research Institute, Baylor Scott & White Health, Temple, Texas
| | - Chaodong Wu
- Department of Nutrition and Food Science, Texas A&M University , College Station, Texas
| | - Li Huang
- Department of Hepatobiliary Surgery and Center for Translational Medicine, The First Affiliated Hospital of Sun Yat-sen University , Guangdong , China
| | - Demeng Chen
- Department of Hepatobiliary Surgery and Center for Translational Medicine, The First Affiliated Hospital of Sun Yat-sen University , Guangdong , China
| | - Tami Annable
- Research Institute, Baylor Scott & White Health, Temple, Texas
- Texas Bioscience District, Temple, Texas
| | - Heather Francis
- Research, Central Texas Veterans Health Care System, Temple, Texas
- Department of Medicine and Baylor Scott & White Digestive Disease Research Center, Texas A&M Health Sciences Center and Scott & White Hospital, Temple, Texas
- Research Institute, Baylor Scott & White Health, Temple, Texas
| | - Shannon Glaser
- Research, Central Texas Veterans Health Care System, Temple, Texas
- Department of Medicine and Baylor Scott & White Digestive Disease Research Center, Texas A&M Health Sciences Center and Scott & White Hospital, Temple, Texas
| | - Gianfranco Alpini
- Research, Central Texas Veterans Health Care System, Temple, Texas
- Department of Medicine and Baylor Scott & White Digestive Disease Research Center, Texas A&M Health Sciences Center and Scott & White Hospital, Temple, Texas
| | - Fanyin Meng
- Research, Central Texas Veterans Health Care System, Temple, Texas
- Department of Medicine and Baylor Scott & White Digestive Disease Research Center, Texas A&M Health Sciences Center and Scott & White Hospital, Temple, Texas
- Research Institute, Baylor Scott & White Health, Temple, Texas
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29
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Evans J. Wound on a patient with alcoholic hepatitis recovering from sepsis. Br J Nurs 2017; 26:S19-S20. [PMID: 29144780 DOI: 10.12968/bjon.2017.26.sup20a.s19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Julie Evans
- Tissue Viability Nurse, Abertawe Bro Morgannwg University Health Board, Swansea
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30
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Philips CA, Pande A, Shasthry SM, Jamwal KD, Khillan V, Chandel SS, Kumar G, Sharma MK, Maiwall R, Jindal A, Choudhary A, Hussain MS, Sharma S, Sarin SK. Healthy Donor Fecal Microbiota Transplantation in Steroid-Ineligible Severe Alcoholic Hepatitis: A Pilot Study. Clin Gastroenterol Hepatol 2017; 15:600-602. [PMID: 27816755 DOI: 10.1016/j.cgh.2016.10.029] [Citation(s) in RCA: 218] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 10/27/2016] [Accepted: 10/27/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Cyriac Abby Philips
- Department of Hepatology and Transplant Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Apurva Pande
- Department of Hepatology and Transplant Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - S Murali Shasthry
- Department of Hepatology and Transplant Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Kapil Dev Jamwal
- Department of Hepatology and Transplant Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vikas Khillan
- Department of Microbiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shivendra Singh Chandel
- Department of Hepatology and Transplant Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Biostatistics, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Manoj K Sharma
- Department of Hepatology and Transplant Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology and Transplant Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankur Jindal
- Department of Hepatology and Transplant Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ashok Choudhary
- Department of Hepatology and Transplant Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Md Shabbir Hussain
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shvetank Sharma
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology and Transplant Medicine, Institute of Liver and Biliary Sciences, New Delhi, India; Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India.
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31
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Dhanda AD, Sinha A, Hunt V, Saleem S, Cramp ME, Collins PL. Infection does not increase long-term mortality in patients with acute severe alcoholic hepatitis treated with corticosteroids. World J Gastroenterol 2017; 23:2052-2059. [PMID: 28373772 PMCID: PMC5360647 DOI: 10.3748/wjg.v23.i11.2052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 01/06/2017] [Accepted: 02/17/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine whether infection in patients with acute severe alcoholic hepatitis (AAH) treated with corticosteroids is associated with increased mortality.
METHODS Consecutive patients with AAH were treated with steroids and recruited to the study. Clinically relevant infections (body temperature > 38 °C or < 36 °C for more than 4 h, ascitic neutrophil count > 0.25 ×109/L, consolidation on chest radiograph or clinically relevant positive microbiological culture of bodily fluid) were recorded prospectively. Clinical and laboratory parameters were recorded and survival at 90 d and 6 mo was determined. Univariate analysis of factors associated with 90-d mortality was performed and significant variables included in a multivariate analysis.
RESULTS Seventy-two patients were included in the final analysis (mean age 47.9 years, 26% female, mean discriminant function 53.0). Overall mortality in the group occurred in 15 (21%), 23 (32%) and 31 (43%) at day 28, day 90 and 1 year respectively. 36 (50%) had a clinically relevant infection during their hospitalisation (23 after initiation of steroids). The median time to development of incident infection after commencement of steroids was 10 d. The commonest site of infection was ascites (31%) and bacteraemia (31%) followed by urinary tract (19%) and respiratory tract (8%). Forty-one separate organisms were isolated in 33 patients; the most frequent genus was Escherichia (22%) and Enterococcus (20%). Infection was not associated with 90-d or 1 year mortality but was associated with higher creatinine, model for end-stage liver disease and Lille score. Baseline urea was the only independent predictor of 90-d mortality.
CONCLUSION Clinically relevant infections are common in patients with AAH but are not associated with increased 90-d or 1 year mortality.
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32
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John ES, Sedhom R, Dalal I, Sharma R. Posterior reversible encephalopathy syndrome in alcoholic hepatitis: Hepatic encephalopathy a common theme. World J Gastroenterol 2017; 23:373-376. [PMID: 28127211 PMCID: PMC5236517 DOI: 10.3748/wjg.v23.i2.373] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 09/06/2016] [Accepted: 10/10/2016] [Indexed: 02/06/2023] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neuro-radiologic diagnosis that has become more widely recognized and reported over the past few decades. As such, there are a number of known risk factors that contribute to the development of this syndrome, including volatile blood pressures, renal failure, cytotoxic drugs, autoimmune disorders, pre-eclampsia, and eclampsia. This report documents the first reported case of PRES in a patient with severe alcoholic hepatitis with hepatic encephalopathy and delves into a molecular pathophysiology of the syndrome.
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33
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Neuman MG, French SW, Zakhari S, Malnick S, Seitz HK, Cohen LB, Salaspuro M, Voinea-Griffin A, Barasch A, Kirpich IA, Thomes PG, Schrum LW, Donohue TM, Kharbanda KK, Cruz M, Opris M. Alcohol, microbiome, life style influence alcohol and non-alcoholic organ damage. Exp Mol Pathol 2017; 102:162-180. [PMID: 28077318 DOI: 10.1016/j.yexmp.2017.01.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 01/04/2017] [Indexed: 02/06/2023]
Abstract
This paper is based upon the "8th Charles Lieber's Satellite Symposium" organized by Manuela G. Neuman at the Research Society on Alcoholism Annual Meeting, on June 25, 2016 at New Orleans, Louisiana, USA. The integrative symposium investigated different aspects of alcohol-induced liver disease (ALD) as well as non-alcohol-induced liver disease (NAFLD) and possible repair. We revealed the basic aspects of alcohol metabolism that may be responsible for the development of liver disease as well as the factors that determine the amount, frequency and which type of alcohol misuse leads to liver and gastrointestinal diseases. We aimed to (1) describe the immuno-pathology of ALD, (2) examine the role of genetics in the development of alcoholic hepatitis (ASH) and NAFLD, (3) propose diagnostic markers of ASH and non-alcoholic steatohepatitis (NASH), (4) examine age and ethnic differences as well as analyze the validity of some models, (5) develop common research tools and biomarkers to study alcohol-induced effects, 6) examine the role of alcohol in oral health and colon and gastrointestinal cancer and (7) focus on factors that aggravate the severity of organ-damage. The present review includes pre-clinical, translational and clinical research that characterizes ALD and NAFLD. Strong clinical and experimental evidence lead to recognition of the key toxic role of alcohol in the pathogenesis of ALD with simple fatty infiltrations and chronic alcoholic hepatitis with hepatic fibrosis or cirrhosis. These latter stages may also be associated with a number of cellular and histological changes, including the presence of Mallory's hyaline, megamitochondria, or perivenular and perisinusoidal fibrosis. Genetic polymorphisms of ethanol metabolizing enzymes and cytochrome p450 (CYP) 2E1 activation may change the severity of ASH and NASH. Other risk factors such as its co-morbidities with chronic viral hepatitis in the presence or absence of human deficiency virus were discussed. Dysregulation of metabolism, as a result of ethanol exposure, in the intestine leads to colon carcinogenesis. The hepatotoxic effects of ethanol undermine the contribution of malnutrition to the liver injury. Dietary interventions such as micro and macronutrients, as well as changes to the microbiota have been suggested. The clinical aspects of NASH, as part of the metabolic syndrome in the aging population, have been presented. The symposium addressed mechanisms and biomarkers of alcohol induced damage to different organs, as well as the role of the microbiome in this dialog. The microbiota regulates and acts as a key element in harmonizing immune responses at intestinal mucosal surfaces. It is known that microbiota is an inducer of proinflammatory T helper 17 cells and regulatory T cells in the intestine. The signals at the sites of inflammation mediate recruitment and differentiation in order to remove inflammatory inducers and promote tissue homeostasis restoration. The change in the intestinal microbiota also influences the change in obesity and regresses the liver steatosis. Evidence on the positive role of moderate alcohol consumption on heart and metabolic diseases as well on reducing steatosis have been looked up. Moreover nutrition as a therapeutic intervention in alcoholic liver disease has been discussed. In addition to the original data, we searched the literature (2008-2016) for the latest publication on the described subjects. In order to obtain the updated data we used the usual engines (Pub Med and Google Scholar). The intention of the eighth symposia was to advance the international profile of the biological research on alcoholism. We also wish to further our mission of leading the forum to progress the science and practice of translational research in alcoholism.
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Affiliation(s)
- Manuela G Neuman
- In Vitro Drug Safety and Biotechnology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | | | | | - Stephen Malnick
- Department Internal Medicine, Kaplan Medical Centre and Hebrew University of Jerusalem, Rehovot, Israel
| | - Helmut K Seitz
- Centre of Alcohol Research, University of Heidelberg, Heidelberg, Germany
| | - Lawrence B Cohen
- Division of Gastroenterology, Sunnybrook Health Sciences Centre, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mikko Salaspuro
- Research Unit on Acetaldehyde and Cancer, University of Helsinki, Helsinki, Finland
| | - Andreea Voinea-Griffin
- Public Health Science Texas A&M University, College of Dentistry, Dallas University, TX, USA
| | - Andrei Barasch
- Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Irina A Kirpich
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA; Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY, USA
| | - Paul G Thomes
- Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC, USA; Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Laura W Schrum
- Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Terrence M Donohue
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kusum K Kharbanda
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA; Research Service, Veterans Affairs Nebraska-Western Iowa Health Care System, University of Nebraska Medical Center, Omaha, NE, USA; Department of Biochemistry & Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Marcus Cruz
- In Vitro Drug Safety and Biotechnology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mihai Opris
- Department of Pharmacology and Toxicology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Family Medicine Clinic CAR, Bucharest, Romania
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Kim HY, Kim CW, Kim TY, Song DS, Sinn DH, Yoon EL, Jung YK, Suk KT, Lee SS, Lee CH, Kim TH, Kim JH, Yim HJ, Kim SE, Baik SK, Lee BS, Jang JY, Kim YS, Kim SG, Yang JM, Sohn JH, Lee HJ, Park SH, Choi EH, Kim DJ. Assessment of scoring systems for acute-on-chronic liver failure at predicting short-term mortality in patients with alcoholic hepatitis. World J Gastroenterol 2016; 22:9205-9213. [PMID: 27895407 PMCID: PMC5107601 DOI: 10.3748/wjg.v22.i41.9205] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 08/20/2016] [Accepted: 09/14/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the performance of proposed scores specific for acute-on-chronic liver failure in predicting short-term mortality among patients with alcoholic hepatitis.
METHODS We retrospectively collected data from 264 patients with clinically diagnosed alcoholic hepatitis from January to December 2013 at 21 academic hospitals in Korea. The performance for predicting short-term mortality was calculated for Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA), CLIF Consortium Organ Failure score (CLIF-C OFs), Maddrey’s discriminant function (DF), age, bilirubin, international normalized ratio and creatinine score (ABIC), Glasgow Alcoholic Hepatitis Score (GAHS), model for end-stage liver disease (MELD), and MELD-Na.
RESULTS Of 264 patients, 32 (12%) patients died within 28 d. The area under receiver operating characteristic curve of CLIF-SOFA, CLIF-C OFs, DF, ABIC, GAHS, MELD, and MELD-Na was 0.86 (0.81-0.90), 0.89 (0.84-0.92), 0.79 (0.74-0.84), 0.78 (0.72-0.83), 0.81 (0.76-0.86), 0.83 (0.78-0.88), and 0.83 (0.78-0.88), respectively, for 28-d mortality. The performance of CLIF-SOFA had no statistically significant differences for 28-d mortality. The performance of CLIF-C OFs was superior to that of DF, ABIC, and GAHS, while comparable to that of MELD and MELD-Na in predicting 28-d mortality. A CLIF-SOFA score of 8 had 78.1% sensitivity and 79.7% specificity, and CLIF-C OFs of 10 had 68.8% sensitivity and 91.4% specificity for predicting 28-d mortality.
CONCLUSION CLIF-SOFA and CLIF-C OF scores performed well, with comparable predictive ability for short-term mortality compared to the commonly used scoring systems in patients with alcoholic hepatitis.
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Affiliation(s)
- Aniket N Tavare
- Royal Free London NHS Foundation Trust, London, United Kingdom
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Abstract
Alcoholic hepatitis (AH) is a severe form of alcoholic liver disease with high mortality. The pathogenesis of AH is not fully understood, but it is generally believed that inflammation is a key factor leading to liver failure in AH. Steroids, which have broad immunosuppressive effects, have been used for the treatment of AH over the last forty years. Steroids elicit modest improvement in short-term survival rate in patients with severe AH, but also cause severe side effects. Several specific inflammatory targets (e.g., IL-1, LPS, and gut microbiota) are currently under investigation for the treatment of AH with the goal to obviate or reduce steroid administration. In addition to inflammation, impaired liver regeneration is another major cause of liver failure in AH, which deteriorates further after steroid treatment because inflammation plays a key role in promoting liver repair. Interleukin-22 (IL-22) is a promising drug for the treatment of AH because of its hepatoprotective and anti-fibrotic functions and relatively few known side effects. In addition, IL-22 treatment also ameliorates bacterial infection and kidney injury, two major complications associated with severe AH. IL-22 is currently under investigation in preclinical and clinical studies and may hold great promise for AH by providing more beneficial effects and fewer side effects than current therapies.
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Affiliation(s)
- Bin Gao
- Laboratory of Liver Diseases, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA.
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Michelena J, Altamirano J, Abraldes JG, Affò S, Morales-Ibanez O, Sancho-Bru P, Dominguez M, García-Pagán JC, Fernández J, Arroyo V, Ginès P, Louvet A, Mathurin P, Mehal WZ, Caballería J, Bataller R. Systemic inflammatory response and serum lipopolysaccharide levels predict multiple organ failure and death in alcoholic hepatitis. Hepatology 2015; 62:762-72. [PMID: 25761863 PMCID: PMC4549175 DOI: 10.1002/hep.27779] [Citation(s) in RCA: 198] [Impact Index Per Article: 22.0] [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: 10/20/2014] [Accepted: 03/09/2015] [Indexed: 12/12/2022]
Abstract
UNLABELLED Alcoholic hepatitis (AH) frequently progresses to multiple organ failure (MOF) and death. However, the driving factors are largely unknown. At admission, patients with AH often show criteria of systemic inflammatory response syndrome (SIRS) even in the absence of an infection. We hypothesize that the presence of SIRS may predispose to MOF and death. To test this hypothesis, we studied a cohort including 162 patients with biopsy-proven AH. The presence of SIRS and infections was assessed in all patients, and multivariate analyses identified variables independently associated with MOF and 90-day mortality. At admission, 32 (19.8%) patients were diagnosed with a bacterial infection, while 75 (46.3%) fulfilled SIRS criteria; 58 patients (35.8%) developed MOF during hospitalization. Short-term mortality was significantly higher among patients who developed MOF (62.1% versus 3.8%, P < 0.001). The presence of SIRS was a major predictor of MOF (odds ratio = 2.69, P = 0.025) and strongly correlated with mortality. Importantly, the course of patients with SIRS with and without infection was similar in terms of MOF development and short-term mortality. Finally, we sought to identify serum markers that differentiate SIRS with and without infection. We studied serum levels of high-sensitivity C-reactive protein, procalcitonin, and lipopolysaccharide at admission. All of them predicted mortality. Procalcitonin, but not high-sensitivity C-reactive protein, serum levels identified those patients with SIRS and infection. Lipopolysaccharide serum levels predicted MOF and the response to prednisolone. CONCLUSION In the presence or absence of infections, SIRS is a major determinant of MOF and mortality in AH, and the mechanisms involved in the development of SIRS should be investigated; procalcitonin serum levels can help to identify patients with infection, and lipopolysaccharide levels may help to predict mortality and the response to steroids.
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Affiliation(s)
- Javier Michelena
- Liver Unit, Hospital Cliníc, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August-Pi-Sunyer, University of Barcelona, Centro de Investigacion Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - José Altamirano
- Liver Unit, Hospital Cliníc, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August-Pi-Sunyer, University of Barcelona, Centro de Investigacion Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
- Liver Unit, Department of Internal Medicine, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - Juan G. Abraldes
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Silvia Affò
- Liver Unit, Hospital Cliníc, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August-Pi-Sunyer, University of Barcelona, Centro de Investigacion Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Oriol Morales-Ibanez
- Liver Unit, Hospital Cliníc, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August-Pi-Sunyer, University of Barcelona, Centro de Investigacion Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Pau Sancho-Bru
- Liver Unit, Hospital Cliníc, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August-Pi-Sunyer, University of Barcelona, Centro de Investigacion Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Marlene Dominguez
- Servicio de Gastroenterología, Hospital Domingo Luciani, Caracas, Venezuela
| | - Juan Carlos García-Pagán
- Liver Unit, Hospital Cliníc, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August-Pi-Sunyer, University of Barcelona, Centro de Investigacion Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
- Hepatic Hemodynamic Laboratory, Hospital Clinic, Barcelona, Spain
| | - Javier Fernández
- Liver Unit, Hospital Cliníc, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August-Pi-Sunyer, University of Barcelona, Centro de Investigacion Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Vicente Arroyo
- Liver Unit, Hospital Cliníc, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August-Pi-Sunyer, University of Barcelona, Centro de Investigacion Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Pere Ginès
- Liver Unit, Hospital Cliníc, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August-Pi-Sunyer, University of Barcelona, Centro de Investigacion Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Alexandre Louvet
- INSERM U995, Universitè Lille Nord de France, Lille, France
- Service de Maladies de l’Apareil Digestif et de la Nutrition, Hôpital Claude Huriez, Lille, France
| | - Philippe Mathurin
- INSERM U995, Universitè Lille Nord de France, Lille, France
- Service de Maladies de l’Apareil Digestif et de la Nutrition, Hôpital Claude Huriez, Lille, France
| | | | - Juan Caballería
- Liver Unit, Hospital Cliníc, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August-Pi-Sunyer, University of Barcelona, Centro de Investigacion Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Ramón Bataller
- Institut d’Investigacions Biomèdiques August-Pi-Sunyer, University of Barcelona, Centro de Investigacion Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
- Division of Gastroenterology and Hepatology, Departments of Medicine and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Abstract
For many years, hepatorenal syndrome was considered a uniformly and rapidly fatal complication of end-stage liver disease. Although the syndrome still carries a poor long-term prognosis, increased understanding of its hemodynamic derangements has led to new pharmacologic treatments that significantly improve short-term outcomes. In this article, Drs Tong, Hurley, and Hayashi discuss a case of remarkable reversal of hepatorenal syndrome with use of oral midodrine hydrochloride, subcutaneous octreotide acetate, and intravenous albumin. The authors highlight the great progress that has been made in this field and review new therapeutic options that are on the market or under study. It is important for physicians who are caring for patients with hepatorenal syndrome to know about and consider the available treatments before an approach of "supportive care only" is taken.
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Affiliation(s)
- Wendy Tong
- US Air Force Medical Corps, Kadena Air Base, Okinawa, Japan
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Abstract
Cryptogenic cirrhosis is a clinical entity which has the potential for better diagnosis of actual underlying maladies with future advancements in medicine. Current understanding of CC is rapidly undergoing transformation (Figures 1 & 2). In the light of available evidence of frequent disappearance of fat in NASH-associated cirrhosis, CC explants showing steatosis, allografts demonstrating the full blown recurrence of NASH in CC, and the association of CC with diabetes and obesity, suggests CC to be more proximately linked with NAS than believed until now (Figure 2). However, there are subsets of patients within CC that appear to emerge from other etiologies. With increasing clarity of NASH pathogenesis, a useful biomarker might soon be available. Advancements in diagnostics and our understanding of NASH are likely to elucidate NASH-associated cirrhosis as the predominant cause of cryptogenic cirrhosis.
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Berry PA, Thomson SJ. The patient presenting with decompensated cirrhosis. Acute Med 2013; 12:232-238. [PMID: 24364057] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The rates of liver disease in the UK are rising and hence more patients than ever are presenting to acute medical units with potentially life threatening sequelae. Early recognition and treatment of sepsis, kidney injury, bleeding and alcoholic hepatitis can significantly improve outcomes, but requires a comprehensive approach to assessment. This patient cohort often suffers from a perceived uniform poor prognosis, especially in alcohol related disease, but evidence for this is changing and reassessment of prognosis after 48 hours of organ support may be more accurate than that made 'at the front door'. This article summarises the most important complications of decompensated cirrhosis, their early management, and presents a targeted system of care: 'RING Liver'--Renal failure, Infection, Nutrition, Gastrointestinal bleeding and transit, Liver dysfunction/transplantation. Factors favouring transfer to tertiary units are also explored.
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Affiliation(s)
- P A Berry
- Consultant Gastroenterologist and Hepatologist, Frimley Park Hospital NHS Foundation Trust
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Altamirano J, Fagundes C, Dominguez M, García E, Michelena J, Cárdenas A, Guevara M, Pereira G, Torres-Vigil K, Arroyo V, Caballería J, Ginès P, Bataller R. Acute kidney injury is an early predictor of mortality for patients with alcoholic hepatitis. Clin Gastroenterol Hepatol 2012; 10:65-71.e3. [PMID: 21946124 DOI: 10.1016/j.cgh.2011.09.011] [Citation(s) in RCA: 122] [Impact Index Per Article: 10.2] [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: 07/16/2011] [Revised: 08/25/2011] [Accepted: 09/04/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Alcoholic hepatitis (AH) is a severe condition with high mortality. To improve therapeutic strategies, it is important to identify factors that affect survival times. The age, bilirubin, international normalized ratio, and creatinine scoring system (also known as the ABIC scoring system) was developed previously to determine the prognosis of patients with AH. We studied effects of acute kidney injury (AKI) on survival of patients with AH. METHODS We retrospectively analyzed data from 103 patients with biopsy-proven AH. AKI was defined as an abrupt reduction (within 48 h) in kidney function that resulted in an absolute increase of at least 0.3 mg/dL (or a 50% increase) in serum levels of creatinine from baseline (the AKI network [AKIN] criteria). RESULTS Twenty-nine patients (28%) developed AKI during hospitalization, with a median time to diagnosis of 3 days. Overall 90-day mortality was 23%, which was significantly higher among patients with AKI than those without (65% vs 7%; P < .0001). The age, bilirubin, international normalized ratio, and creatinine score (P < .0001) and development of AKI (P < .0001) were the most accurate independent predictors of 90-day mortality. The presence of systemic inflammatory response syndrome (P < .0001), serum bilirubin (P = .01), and international normalized ratio at admission (P = .03) were the most accurate predictors of AKI. Importantly, the AKIN criteria were more accurate than traditional criteria for renal failure (serum creatinine >1.5 mg/dL) in predicting 90-day mortality (area under the receiver operating characteristic, 0.83 vs 0.70, respectively; P = .02). CONCLUSIONS Development of AKI reduces survival of patients with AH, in the short term. The AKIN criteria are useful and more accurate than traditional criteria in predicting mortality. Strategies to prevent AKI therefore should be considered in the management of patients with AH.
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Affiliation(s)
- José Altamirano
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain
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Jain D, Nayak NC, Saigal S. Hepatocellular carcinoma arising in association with von-Meyenburg's complexes: an incidental finding or precursor lesions? A clinicopatholigic study of 4 cases. Ann Diagn Pathol 2010; 14:317-20. [PMID: 20850692 DOI: 10.1016/j.anndiagpath.2010.04.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2010] [Accepted: 04/06/2010] [Indexed: 12/22/2022]
Abstract
Biliary hamartomas or von-Meyenburg complexes form part of a spectrum of ductal plate malformation that includes polycystic liver disease, congenital hepatic fibrosis, and Caroli disease. These lesions are known to have neoplastic transformation. Development of intrahepatic cholangiocarcinoma is well described in these complexes. Rarely, hepatocellular carcinomas (HCCs) have been seen in association with bile duct hamartomas, however; it is not clear whether development of HCC is an epiphenomenon unrelated to the precursor lesion or biliary hamartomas may progress to liver cancers. We herein report 4 interesting cases of hepatitis C virus-, alcohol-, and nonalcoholic fatty liver disease-associated end-stage liver disease with coexisting HCC and multiple large von-Meyenburg complexes.
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Affiliation(s)
- Deepali Jain
- Department of Pathology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India.
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Higuera-de la Tijera MF, Pérez-Hernández JL, Servín-Caamaño AL, Serralde-Zúñiga AE, Cruz-Palacios A. [The amount of alcohol intake, upper gastrointestinal bleeding, acute renal failure and hepatic encephalopathy as the risk factors implied in the increase of patients with alcoholic hepatitis]. Rev Gastroenterol Mex 2009; 74:306-313. [PMID: 20423759] [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] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND Acute renal failure (ARF) worsens the prognosis of patients with alcoholic hepatitis (HA). Other factors like the amount of alcohol intake, upper gastrointestinal bleeding (UGB) or hepatic encephalopathy (HE) are not considered at present in any prognostic index. OBJECTIVE To evaluate if the amount of alcohol intake, development of UGB, ARF and/or HE are associated with high mortality in patients with AH. METHODS Consecutive patients with diagnosis of AH were included. Demographic, laboratory data, complications and mortality were registered. A comparison was performed between survivors and non-survivors. RESULTS Seventy-one patients were included. Median amount of alcohol consumption was 187.7 g/day, and was superior in men (190.8 vs. 169 g/day, p = 0.02) and in patients who developed ARF (219.6 vs. 144.1 g/day, p = 0.001). Maddrey s index was higher in patients who died than those who survive (111.4 vs. 52.9, p = 0.02). No differences between groups were recorded regarding Glasgow and MELD scales. ARF was the only one complication related with higher risk of death (RR = 6.7, p = 0.02). Isolated UGB and HE were non-significantly associated with mortality, but combination of two or three complications was highly significantly associated with mortality risk: ARF and HE (OR = 8.9, p = 0.001), HE and UGB (OR = 6.7, p = 0.01) and ARF + UGB + HE (OR = 10, p = 0.001). CONCLUSION The amount of alcohol intake is associated with development of ARF. ARF was the most significant risk factor associated with mortality. The presence of two or three complications increases the mortality risk significantly. Key words: acute renal failure, hepatic encephalopathy, risk factors, mortality, alcoholic hepatitis, Mexico.
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Mathurin SA, Agüero AP, Dascani NA, Prestera JA, Gianserra C, Londero E, Chiorra C. [Anemia in hospitalized patients with cirrhosis: prevalence, clinical relevance and predictive factors]. Acta Gastroenterol Latinoam 2009; 39:103-111. [PMID: 19663083] [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] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND few studies have examined the anemia in hospitalized cirrhotic patients. OBJECTIVE to assess the prevalence, predictive factors and prognosis for mortality of anemia in admitted cirrhotic patients. PATIENTS AND METHODS descriptive study of cases and controls; 178 hospitalization of 114 patients were reviewed (mean age 52.4 years; 106 alcoholics) between May/2004 and June/2007. Those with acute losses of blood were excluded. The anemia was classified as slight, moderate, and severe, since a hemoglobin < 12 g/dl. There were considered as cases the admissions in which the hemoglobin had < 10 g/dl (moderate and severe anemia). RESULTS a diagnosis of anemia was made in 155 admissions, 47% were moderate and 19% severe. Hospital mortality rate in cases was 19.6%, and in controls 5.3%, [OR 4.39 (p = 0.004)]. The independent predictive factors for mortality were: score of Child-Pügh [OR 1.99 (p = 0.0005)], creatinine > 1.5 mg/dl [OR 11.34 (p = 0.0006)] and infections [OR 5.78 (p = 0.018)]. The cases had a greater risk of renal insufficiency [27.5% vs. 3.9%, OR 9.2 (p = 0.0001)]. Classification of Child-Pügh, total bilirubin > 10 mg/dl, albumin < 2.5 g/dl, infections, hepatic encephalopathy and alcoholic hepatitis also were predictive factors of moderate-severe anemia. The independent predictive factors for moderate-severe anemia were score ofChild-Piigh and renal insufficiency. CONCLUSION the anemia had a high prevalence with an increase of hospital mortality rate, although it was not an independent risk factor for death. The renal insufficiency and the severity of the hepatic disease were associated in independent form with moderate-severe anemia in patients admitted with cirrhosis.
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