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Verma N, Mehtani R, Haiar JM, Pradhan P, Duseja A, Im GY, Singal AK. Clinical criteria accurately diagnose severe but not moderate alcohol-associated hepatitis: A systematic review and meta-analysis. Hepatol Commun 2024; 8:e0404. [PMID: 38497934 PMCID: PMC10948131 DOI: 10.1097/hc9.0000000000000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 12/14/2023] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND The precision of clinical criteria and the utility of liver biopsy for diagnosis or prognosis remain unclear in patients with alcohol-associated hepatitis (AH). We systematically reviewed the literature to answer these questions. METHODS Four databases were searched for studies describing the precision of clinical criteria (National Institute on Alcohol Abuse and Alcoholism, European Association for Study of Liver, or classical) and the role of histology in AH. The precision(positive predictive value) of criteria was pooled through random-effects meta-analysis, and its variation was investigated through subgroups and meta-regression of study-level factors with their percent contribution to variation (R2). The risk of bias among studies was evaluated through the QUADAS2 tool (PROSPERO-ID-CRD4203457250). RESULTS Of 4320 studies, 18 in the systematic review and 15 (10/5: low/high risk of bias, N=1639) were included in the meta-analysis. The pooled precision of clinical criteria was 80.2% (95% CI: 69.7-89.7, I2:93%, p < 0.01), higher in studies with severe AH (mean-Model for End-Stage Liver Disease > 20) versus moderate AH (mean-Model for End-Stage Liver Disease < 20): 92% versus 67.1%, p < 0.01, and in studies with serum bilirubin cutoff 5 versus 3 mg/dL (88.5% vs.78.8%, p = 0.01). The factors contributing to variation in precision were Model for End-Stage Liver Disease (R2:72.7%), upper gastrointestinal bleed (R2:56.3%), aspartate aminotransferase:aspartate aminotransferase ratio (R2:100%), clinical criteria (R2:40.9%), bilirubin (R2:22.5%), and Mallory body on histology (R2:19.1%).The net inter-pathologist agreement for histologic findings of AH was variable (0.33-0.97), best among 2 studies describing AH through simple and uniform criteria, including steatosis, ballooning, and neutrophilic inflammation. Few studies reported the utility of histology in estimating steroid responsiveness (N = 1) and patient prognosis (N = 4); however, very broad septa, pericellular fibrosis, and cholestasis were associated with mortality. Bilirubinostasis was associated with infection in 1 study. CONCLUSIONS Clinical criteria are reasonably precise for diagnosing severe AH, while there is an unmet need for better criteria for diagnosing moderate AH. Histologic diagnosis of AH should be simple and uniform.
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Affiliation(s)
- Nipun Verma
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rohit Mehtani
- Department of Hepatology, Amrita Institute of Medical Sciences and Research, Faridabad, Haryana, India
| | - Jacob Martin Haiar
- Department of Internal Medicine, University of California, San Diego, California, USA
| | - Pranita Pradhan
- Department of Pediatrics, Indian Council of Medical Research Center for Evidence-Based Child Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gene Young Im
- Department of Medicine, Division of Liver Diseases, Recanati/Miller Transplantation Institute, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ashwani K. Singal
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Louisville School of Medicine, Louisville, Kentucky, USA
- Department of Medicine, Jewish Hospital and Trager Transplant Center, Louisville, Kentucky, USA
- Department of Medicine, VA Medical Center Sioux Falls, South Dakota, USA
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McLean Diaz P, Vannier A, Joshi AD, Mahle RE, Przybyszewski EM, Corey K, Chung RT, Luther J, Goodman RP, Schaefer EA. Serum Fibroblast Growth Factor-21 Discriminates Between Decompensated Alcohol-Associated Cirrhosis and Severe Alcohol-Associated Hepatitis. Clin Transl Gastroenterol 2023; 14:e00585. [PMID: 36972232 PMCID: PMC10299775 DOI: 10.14309/ctg.0000000000000585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/14/2023] [Indexed: 06/18/2023] Open
Abstract
INTRODUCTION We hypothesized that fibroblast growth factor-21 (FGF-21) would be highly expressed in patients with alcohol-associated hepatitis (AH) and could be a novel and biologically relevant predictive biomarker to reliably distinguish severe AH and decompensated alcohol-associated cirrhosis (AC). METHODS We identified a discovery cohort of 88 subjects with alcohol-associated liver disease (ALD) of varying disease severity from our ALD repository. Our validation cohort consisted of 37 patients with a biopsy-proven diagnosis of AH, AC, or absence of ALD with Model for End-Stage Liver Disease scores ≥10. Serum from both groups during index hospitalization was assayed for FGF-21 by ELISA. We performed receiver operating characteristic analysis and prediction modeling in both cohorts to discriminate between AH and AC in high Model for End-Stage Liver Disease (≥20) patients. RESULTS In both cohorts, FGF-21 concentrations were highest in subjects with moderate to severe AH compared with those having alcohol use disorder or AC (mean: 2,609 pg/mL, P < 0.0001). The discovery cohort area under the curve of FGF-21 between AH and AC was 0.81 (95% confidence interval: 0.65-0.98, P < 0.01). In the validation cohort, FGF-21 levels were higher in severe AH compared with AC (3,052 vs 1,235 pg/mL, P = 0.03), and the area under the curve was 0.76 (95% confidence interval: 0.56-0.96, P < 0.03). A survival analysis showed that patients with FGF-21 serum levels in the second interquartile had the highest survival compared with all other quartiles. DISCUSSION FGF-21 performs well as a predictive biomarker to distinguish severe AH from AC and may be helpful in the management and clinical investigation of patients with severe alcohol-associated liver diseases.
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Affiliation(s)
- Paige McLean Diaz
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Alcohol Liver Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Augustin Vannier
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Alcohol Liver Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amit D. Joshi
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Alcohol Liver Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rachael E. Mahle
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Alcohol Liver Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eric M. Przybyszewski
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Alcohol Liver Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kathleen Corey
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Raymond T. Chung
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Alcohol Liver Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jay Luther
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Alcohol Liver Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Russell P. Goodman
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Alcohol Liver Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Esperance A.K. Schaefer
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Alcohol Liver Center, Massachusetts General Hospital, Boston, Massachusetts, USA
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Jophlin L, Singal AK. Liver Biopsy in Patients With Alcohol-Associated Liver Disease With Acute-on-Chronic Liver Failure. J Clin Exp Hepatol 2022; 12:544-550. [PMID: 35535109 PMCID: PMC9077173 DOI: 10.1016/j.jceh.2021.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/09/2021] [Indexed: 01/11/2023] Open
Abstract
Patients with alcohol-associated liver disease may develop severe forms of presentation of acute-on-chronic liver failure, with a high risk for short-term mortality. Alcoholic hepatitis should be suspected among patients with alcohol-associated liver disease who present with acute-on-chronic liver failure. In this review, we discuss the need and feasibility of liver biopsy in the diagnosis of alcoholic hepatitis and predicting its prognosis among decompensated patients with alcohol-associated liver disease and acute-on-chronic liver failure.
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Key Words
- AARC, Asia-Pacific ACLF Research Consortium
- ACLF
- ACLF, acute-on-chronic liver failure
- AH
- AH, alcoholic hepatitis
- AHHS, alcoholic hepatitis histologic score
- ALD
- ALD, alcohol-associated liver disease
- AUD, alcohol use disorder
- DF, discriminant function
- EUS, endoscopic ultrasound
- EtG, ethyl glucuronide
- NIAAA, National Institute on Alcoholism and Alcohol Abuse
- PEth, phosphatidylethanol
- SALVE, Study of Alcohol-related LiVer disease in Europe
- histology
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Affiliation(s)
- Loretta Jophlin
- Department of Gastroenterology and Hepatology, University of Louisville, Louisville, KY, USA
| | - Ashwani K. Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of South Dakota Sanford School of Medicine, South Dakota, USA,Address for correspondence:. Ashwani K. Singal, Professor of Medicine, University of South Dakota Sanford School of Medicine, Transplant Hepatologist and Chief Clinical Research Affairs, Avera McKennan University Hospital Transplant Institute, Sioux Falls, SD, 57105, USA. Tel.: +605 322-8545; fax: +605 322 8536.
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Czekaj P, Król M, Limanówka Ł, Michalik M, Lorek K, Gramignoli R. Assessment of animal experimental models of toxic liver injury in the context of their potential application as preclinical models for cell therapy. Eur J Pharmacol 2019; 861:172597. [PMID: 31408648 DOI: 10.1016/j.ejphar.2019.172597] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 08/04/2019] [Accepted: 08/08/2019] [Indexed: 02/06/2023]
Abstract
Preclinical animal models allow to study development and progression of several diseases, including liver disorders. These studies, for ethical reasons and medical limits, are impossible to carry out in human patients. At the same time, such experimental models constitute an important source of knowledge on pathomechanisms for drug- and virus-induced hepatotoxicity, both acute and chronic. Carbon tetrachloride, D-Galactosamine, and retrorsine are xenobiotics that can be used in immunocompetent animal models of hepatotoxicity, where chemical-intoxicated livers present histological features representative of human viruses-related infection. A prolonged derangement into liver architecture and functions commonly lead to cirrhosis, eventually resulting in hepatocellular carcinoma. In human, orthotopic liver transplantation commonly resolve most the problems related to cirrhosis. However, the shortage of donors does not allow all the patients in the waiting list to receive an organ on time. A promising alternative treatment for acute and chronic liver disease has been advised in liver cell transplantation, but the limited availability of hepatocytes for clinical approaches, in addition to the immunosuppressant regiment required to sustain cellular long-term engraftment have been encouraging the use of alternative cell sources. A recent effective source of stem cells have been recently identified in the human amnion membrane. Human amnion epithelial cells (hAEC) have been preclinically tested and proven sufficient to rescue immunocompetent rodents lethally intoxicated with drugs. The adoption of therapeutic procedures based on hAEC transplant in immunocompetent recipients affected by liver diseases, as well as patients with immune-related disorders, may constitute a successful new alternative therapy in regenerative medicine.
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Affiliation(s)
- Piotr Czekaj
- Department of Cytophysiology, Chair of Histology and Embryology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland, Medyków 18 str., 40-752, Katowice, Poland.
| | - Mateusz Król
- Students Scientific Society, Department of Cytophysiology, Chair of Histology and Embryology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland, Medyków 18 str., 40-752, Katowice, Poland.
| | - Łukasz Limanówka
- Students Scientific Society, Department of Cytophysiology, Chair of Histology and Embryology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland, Medyków 18 str., 40-752, Katowice, Poland
| | - Marcin Michalik
- Students Scientific Society, Department of Cytophysiology, Chair of Histology and Embryology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland, Medyków 18 str., 40-752, Katowice, Poland
| | - Katarzyna Lorek
- Students Scientific Society, Department of Cytophysiology, Chair of Histology and Embryology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland, Medyków 18 str., 40-752, Katowice, Poland
| | - Roberto Gramignoli
- Department of Laboratory Medicine (LABMED), H5, Division of Pathology, Karolinska Institutet, Alfred Nobels Allé 8, 14152, Huddinge, Sweden.
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