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Niu X, Zhu L, Xu Y, Zhang M, Hao Y, Ma L, Li Y, Xing H. Global prevalence, incidence, and outcomes of alcohol related liver diseases: a systematic review and meta-analysis. BMC Public Health 2023; 23:859. [PMID: 37170239 PMCID: PMC10173666 DOI: 10.1186/s12889-023-15749-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/25/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Alcohol related liver disease (ARLD) is one of the major chronic liver diseases worldwide. This review aimed to describe the global prevalence, incidence, and outcomes of ARLD. METHODS Medline, Embase, The Cochrane Library, and China National Knowledge Infrastructure (CNKI) were searched from inception to May 31, 2022. The language was restricted to English or Chinese. According to the criteria, articles describing the basic characteristics of the population were selected. Two reviewers extracted the data independently. RESULTS A total of 372 studies were identified: 353 were used for prevalence analysis, 7 were used for incidence analysis, and 114 were used to for outcome analysis. The prevalence of ARLD worldwide was 4.8%. The prevalence in males was 2.9%, which was higher than female (0.5%). Among the ethnic groups, the percentage was highest in Caucasians (68.9%). Alcoholic liver cirrhosis comprised the highest proportion in the disease spectrum of ARLD at 32.9%. The prevalence of ascites in ARLD population was highest (25.1%). The ARLD population who drinking for > 20 years accounted for 54.8%, and the average daily alcohol intake was 146.6 g/d. About 59.5% of ARLD patients were current or former smokers, and 18.7% were complicated with hepatitis virus infection. The incidence was 0.208/1000 person-years. The overall mortality was 23.9%, and the liver-related mortality was 21.6%. CONCLUSION The global prevalence of ARLD was 4.8% and was affected by sex, region, drinking years, and other factors. Therefore, removing the factors causing a high disease prevalence is an urgent requisite. TRIAL REGISTRATION PROSPERO Nr: CRD42021286192.
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Affiliation(s)
- Xuanxuan Niu
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Lin Zhu
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Yifan Xu
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Menghan Zhang
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Yanxu Hao
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Lei Ma
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Yan Li
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China
| | - Huichun Xing
- Center of Liver Diseases Division 3, Beijing Ditan Hospital, Capital Medical University, 8 Jingshundong Street, Chaoyang District, Beijing, 100015, China.
- Peking University Ditan Teaching Hospital, Beijing, 100015, China.
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Sharma M, Gora BA, Kulkarni A, TR S, Shaik S, Jagtap N, Alla M, Gupta R, Archana C, Qadri S, Talukdar R, Rao PN, Reddy DN. The Pattern of Alcohol Use in Alcohol-Related Cirrhosis in Indian Patients: AUDIT Indian Liver Study. J Clin Exp Hepatol 2023; 13:437-446. [PMID: 37250882 PMCID: PMC10213840 DOI: 10.1016/j.jceh.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/19/2022] [Indexed: 05/31/2023] Open
Abstract
Background Alcohol is one of the most common causes of liver cirrhosis. Yet, the pattern of alcohol consumption in cirrhosis is rarely studied. This study aims to study the drinking patterns along with the educational, socioeconomic, and mental health in a cohort of patients with and without liver cirrhosis. Methods This prospective observational study was conducted at a tertiary-care hospital and included patients with harmful drinking. Demographic, alcohol intake history, assessment of socioeconomic and psychological status by modified Kuppuswamy scale and Beckwith Inventory, respectively, were recorded and analyzed. Results Cirrhosis was present in 38.31% of patients with heavy drinking (64%). Cirrhosis was more among illiterates (51.76%) with early onset (22.4. ± 7.30 yrs P = 0.0001) and longer duration of alcohol (12.5 ± 6.5 vs. 6.8 ± 3.4 P = 0.001). Higher education qualification was associated with lower cirrhosis (P < 0.0001). With the same employment and education qualifications, net income in cirrhosis was lower [USD 298 (175-435) vs. USD 386 (119-739) P = 0.0001]. Whiskey (86.8%) was the commonest drink consumed. Similar median alcoholic drinks per week were consumed by both groups [34 (22-41) vs. 30 (24-40), P = 0.625], while indigenous alcohol was more consumed in cirrhosis [105 (98.5-109.75) vs. 89.5.0 (69.25-110.0) P = 0.0001]. Loss of jobs (12.36%) and partner violence were more in cirrhotic (9.89% vs. 5.80%) with similar borderline depression. Conclusion Alcohol use disorder-related cirrhosis is present in a quarter of patients with harmful early onset and longer duration of drinking and is inversely related to the education status and affects the socioeconomic, physical, and family health of patients.
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Affiliation(s)
- Mithun Sharma
- Department of Hepatology and Liver Transplantation, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Baqar A. Gora
- Department of Hepatology and Liver Transplantation, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Anand Kulkarni
- Department of Hepatology and Liver Transplantation, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Soumya TR
- Department of Hepatology and Liver Transplantation, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Sameer Shaik
- Department of Hepatology and Liver Transplantation, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Nitin Jagtap
- Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Manasa Alla
- Department of Hepatology and Liver Transplantation, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Rajesh Gupta
- Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Chintam Archana
- Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Sabreena Qadri
- Department of Psychiatry, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Padaki N. Rao
- Department of Hepatology and Liver Transplantation, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
| | - Duvvur Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
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Raju B, Andani A, Kolhapure S, Agrawal A. Need for hepatitis A prevention in patients with chronic liver disease in the changing epidemiological setting of India. Hum Vaccin Immunother 2021; 17:1520-1529. [PMID: 33236963 PMCID: PMC8078677 DOI: 10.1080/21645515.2020.1832408] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The burden of chronic liver disease (CLD) in India is high, particularly among middle-aged men, with nearly 220,000 deaths due to cirrhosis in 2017. CLD increases the risk of infection, severe disease (e.g. hepatitis A virus or HAV superinfection, acute-on-chronic liver failure, fulminant hepatic failure), and mortality. Hence, various countries recommend HAV vaccination for CLD patients. While historic Indian studies showed high seroprevalences of protective HAV antibodies among Indian adults with CLD, the most recent ones found that nearly 7% of CLD patients were susceptible to HAV infection. Studies in healthy individuals have shown that HAV infection in childhood is decreasing in India, resulting in an increasing population of adults susceptible to HAV infection. As patients with CLD are at increased risk of severe HAV infection, now may be the time to recommend HAV vaccination among people with CLD in India.
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Mishra D, Dash KR, Khatua C, Panigrahi S, Parida PK, Behera SK, Barik RK, Pradhan S, Sahu SK, Thakur B, Singh SP. A Study on the Temporal Trends in the Etiology of Cirrhosis of Liver in Coastal Eastern Odisha. Euroasian J Hepatogastroenterol 2020; 10:1-6. [PMID: 32742964 PMCID: PMC7376596 DOI: 10.5005/jp-journals-10018-1312] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background The etiology of cirrhosis of liver is known to change with time due to various factors including awareness, preventive interventions, and lifestyle changes in society. However, there is scarce Indian data available about temporal trends in etiology of cirrhosis of liver. Hence, the aim of this study was to study the temporal trends in the etiology of cirrhosis of liver. Materials and methods This is a retrospective study conducted in the Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, from January 2005 to December 2017. Data were collected from hospital records of all patients admitted to the Gastroenterology unit. A Poisson regression model was used to compare the hospitalization rate for different etiologies of cirrhosis of liver. All data were analyzed using Stata version 5.1 software. Results A total of 4,331 hospitalized patients of cirrhosis of liver were included in the analysis, of whom 2,742 (63.3%) had alcohol-related cirrhosis, 858 (19.8%) had viral hepatitis-related cirrhosis, and 731 (16.9%) had cirrhosis of liver due to nonalcohol and nonviral causes. The proportion of alcohol-related cirrhosis was increased by 26% from 2005 to 2017 (RR 1.26, p for trend <0.001). Though there were minimal ups and downs observed in the admission rate of viral hepatitis-related liver cirrhosis during later years, this was remarkably reduced by 73% (RR 0.27, p for trend <0.001) in the year 2017 at the end of the study. Similarly, the proportion of cirrhosis due to nonalcohol and nonviral causes decreased by 26% (RR 0.74, p for trend <0.001) by 2017. Conclusion Alcohol is the most common cause of cirrhosis of liver and the burden of alcohol-related cirrhosis is significantly increasing in comparison to other causes including viral infection, nonalcoholic steatohepatitis (NASH), and autoimmune hepatitis. How to cite this article Mishra D, Dash KR, Khatua C, et al. A Study on the Temporal Trends in the Etiology of Cirrhosis of Liver in Coastal Eastern Odisha. Euroasian J Hepato-Gastroenterol 2020;10(1):1–6.
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Affiliation(s)
- Debakanta Mishra
- Department of Gastroenterology, Institute of Medical Sciences and Sum Hospital, Bhubaneswar, Odisha, India
| | - Kaibalya R Dash
- Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India
| | - Chittaranjan Khatua
- Department of General Medicine, MKCG Medical College, Berhampur, Odisha, India
| | - Subhendu Panigrahi
- Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India
| | - Prasanta K Parida
- Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India
| | - Sambit K Behera
- Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India
| | - Rakesh K Barik
- Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India
| | - Subhasis Pradhan
- Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India
| | - Saroj K Sahu
- Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India
| | - Bhaskar Thakur
- Division of Biostatistics, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, Odisha, India
| | - Shivaram P Singh
- Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India
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Ray G, Manjubhargav P. Clinical Presentation and Mortality Determinants of Alcohol-Related Liver Disease: A Single-Center Experience of the Rising Menace from Eastern India. Inflamm Intest Dis 2019; 4:104-114. [PMID: 31559262 DOI: 10.1159/000501274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 06/01/2019] [Indexed: 12/14/2022] Open
Abstract
Objectives Recently, the incidence of alcohol-related liver disease has been rising alarmingly in India with late presentation and short survival. Better delineation of factors affecting mortality is needed for optimal utilization of constrained resources like liver transplantation. Methods Baseline data of 395 patients with alcohol-related liver disease including age, clinical presentation, alcohol parameters (amount, duration, type), laboratory parameters for detecting organ failure, and prognostic scores were compared between survivor and deceased groups. Further subgroup analysis of deceased patients was done to identify factors associated with early mortality in acute-on-chronic liver failure (ACLF) and cirrhosis groups by multivariate analysis and receiver operating characteristic (ROC) curves. Only best supportive medical therapy was offered to all. Results 80 (20.3%) patients had alcoholic hepatitis (without cirrhosis) and recovered completely with abstinence. 315 (79.7%) had evidence of either cirrhosis (n = 182, 46.1%) or ACLF (n = 133, 33.6%) at presentation and all died within the next 2 years of follow-up, earlier in the ACLF cases. All deceased patients had been heavy drinkers for long periods (>85 g/day for >17 years). Higher age, amount of alcohol consumption, number of organ failures and discriminant function score predicted severe disease and early mortality, the latter being the best predictor. The European Foundation for the study of chronic liver failure consortium (CLIF-C) score has good applicability in Indian ACLF cohorts. Serum glutamic pyruvic transaminase was normal in 73.8% of deceased patients compared to only 12.5% of survivors. Abstinence did not result in complete normalization of deranged laboratory parameters in those who died. Conclusion Alcohol-related liver disease is serious with high short-term mortality, which has early identifiable but mostly irreversible factors. Urgent measures need to be taken to curb this rising menace.
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Affiliation(s)
- Gautam Ray
- Gastroenterology Unit, Department of Medicine, B.R. Singh Hospital, Kolkata, India
| | - P Manjubhargav
- Department of Medicine, B.R. Singh Hospital, Kolkata, India
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Singh SP, Panigrahi S, Mishra D, Khatua CR. Alcohol-associated liver disease, not hepatitis B, is the major cause of cirrhosis in Asia. J Hepatol 2019; 70:1031-1032. [PMID: 30782425 DOI: 10.1016/j.jhep.2019.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 12/31/2018] [Accepted: 01/03/2019] [Indexed: 02/06/2023]
Affiliation(s)
| | - Subhendu Panigrahi
- Sriram Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India.
| | - Debakanta Mishra
- Sriram Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India
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Epidemiology of Alcohol Consumption and Societal Burden of Alcoholism and Alcoholic Liver Disease. Clin Liver Dis 2019; 23:39-50. [PMID: 30454831 DOI: 10.1016/j.cld.2018.09.011] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Alcohol abuse is a major determinant of public health outcomes. Worldwide data from 2016 indicate that alcohol is the seventh leading risk factor in terms of disability-adjusted life years, an increase of more than 25% from 1990 to 2016. Understanding the epidemiology of alcoholic liver disease, including the regional variations in consumption and public policy, is an area of active research. In countries where the per capita consumption of alcohol decreases, there appears to be an associated decrease in disease burden. Given alcohol's health burden, an increased focus on alcohol control policies is needed.
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Bhadoria AS, Kedarisetty CK, Bihari C, Kumar G, Jindal A, Bhardwaj A, Shasthry V, Benjamin J, Sharma MK, Sarin SK. Positive familial history for metabolic traits predisposes to early and more severe alcoholic cirrhosis: A cross-sectional study. Liver Int 2019; 39:168-176. [PMID: 30188604 DOI: 10.1111/liv.13958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 08/24/2018] [Accepted: 08/25/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Familial aggregation of metabolic traits in NAFLD is well documented. However, relevance of these traits in alcoholic cirrhosis is not well studied. We aimed to explore the association of family history of metabolic traits with age at diagnosis, severity and complications of alcoholic cirrhosis. METHODS In a cross-sectional study, all consecutive patients with alcoholic cirrhosis presenting to our tertiary care centre were included. Family and personal history, demographic characteristics, medical history, anthropometric measurements and laboratory data were recorded. The amount and duration of alcohol consumption were also carefully recorded. RESULTS Out of 1084 alcoholic cirrhotics (age 48.5 ± 10.1 years, all males), family history for metabolic traits was documented in 688 (63.5%) patients. These patients had younger age at diagnosis, increased incidence of jaundice, ascites, variceal bleed and hepatic encephalopathy with consequently higher MELD and CTP score. These patients developed cirrhosis despite shorter median duration (13 years, IQR 7-20 vs 21, IQR 18-25) and lesser amount of alcohol consumption (74 g/d, IQR 24-96 vs 144, IQR 100-148). Patients with both family and personal history of metabolic traits had a higher risk by 3.3 times (95% CI 2.2-4.8) of an early age at diagnosis, 13.2 times (95% CI 8.7-20.1) of progression to cirrhosis with lesser amount of alcohol consumption and 4.6 times (95% CI 3.1-6.9) with lesser duration of alcohol consumption. CONCLUSIONS Positive family and personal history of metabolic traits predispose to alcoholic cirrhosis with an earlier age at onset and more severity despite lesser exposure to alcohol.
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Affiliation(s)
- Ajeet Singh Bhadoria
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Chhagan Bihari
- Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankit Bhardwaj
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Varsha Shasthry
- Department of Clinical Nutrition, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Jaya Benjamin
- Department of Clinical Nutrition, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Manoj Kumar Sharma
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Gu Y, Zhao J, Ao L, Ma J, Bao K, Liu M, Huang W. The influence of polymorphic GSTM1 gene on the increased susceptibility of non-viral hepatic cirrhosis: evidence from observational studies. Eur J Med Res 2018; 23:34. [PMID: 29921322 PMCID: PMC6011196 DOI: 10.1186/s40001-018-0331-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/13/2018] [Indexed: 12/19/2022] Open
Abstract
It is reported that glutathione S-transferase mu (GSTM1) polymorphism is associated with non-viral hepatic cirrhosis (HC). However, some studies showed different views. Therefore, in this paper, a meta-analysis was conducted to get a more comprehensive understanding of GSTM1 polymorphisms in non-viral HC susceptibility. The results showed that GSTM1 null was associated with the increased risk of non-viral HC (OR = 1.337, 95% CI 1.112–1.804, p = 0.005). Subgroup analysis of cirrhosis type revealed that GSTM1 null was a prominent risk factor for alcoholic HC (OR = 1.416, 95% CI 1.112–1.804, p = 0.005). Meanwhile, subgroup analysis of population indicated that the significant differences only existed in Asian population (OR = 1.719, 95% CI 1.212–2.438, p = 0.002). In hospital-based studies, patients with GSTM1 null were more likely in risk of HC (OR = 1.426, 95% CI 1.092–1.863, p = 0.009). Subgroup analysis using genotyping method showed a significant association between GSTM1 null genotype and HC occurrence in the studies employing the multiple PCR genotyping method (OR = 1.559, 95% CI 1.171–2.076, p = 0.002). Based on the results of this analysis, it was concluded that GSTM1 null genotype could increase the susceptibility of non-viral hepatic cirrhosis. In addition, alcohol intake, Asian ethnicity, sample source from hospital and multiple PCR genotyping method may also influence the susceptibility of hepatic cirrhosis.
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Affiliation(s)
- Ye Gu
- Department of Nursing, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, 1 Cheng Bei Road, Jiading District, Shanghai, 201800, China
| | - Jing Zhao
- Department of Nursing, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, 1 Cheng Bei Road, Jiading District, Shanghai, 201800, China
| | - Li Ao
- Department of Nursing, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, 1 Cheng Bei Road, Jiading District, Shanghai, 201800, China
| | - Jianning Ma
- Department of Nursing, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, 1 Cheng Bei Road, Jiading District, Shanghai, 201800, China
| | - Kena Bao
- Department of Nursing, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, 1 Cheng Bei Road, Jiading District, Shanghai, 201800, China
| | - Min Liu
- Department of Scientific Research, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, 1 Cheng Bei Road, Jiading District, Shanghai, 201800, China.
| | - Weiping Huang
- Department of Nursing, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, 1 Cheng Bei Road, Jiading District, Shanghai, 201800, China.
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