1
|
Cornman-Homonoff J, Fortune BE, Kolli KP, Kothary N, Nadolski G, Thornburg BG, Verma S, Madoff DC. Management of Ascites: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2025. [PMID: 40202355 DOI: 10.2214/ajr.23.30768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2025]
Abstract
Ascites can develop in the setting of a variety of pathologies. The approach to treatment depends on accurate determination of the underlying cause, for which fluid analysis plays a central role. In particular, the serum-ascites-albumin gradient serves as a primary diagnostic test for differentiating among causes, with certain additional fluid tests performed based on clinical suspicion. Treatment options range from nonspecific fluid removal, including large-volume paracentesis and tunneled peritoneal catheters, to targeted therapies (e.g., diuretics, transjugular intrahepatic portosystemic shunt, and lymphangiography). Societal guidelines exist for the approach to cirrhotic ascites, but the management of other less common causes remains less well defined. The goal of this AJR Expert Panel Narrative Review is to provide guidance for the diagnosis and management of ascites, based on available evidence and the authors' clinical experience.
Collapse
Affiliation(s)
| | | | - Kanti Pallav Kolli
- Univeristy of California San Francisco School of Medicine, San Francisco, CA, USA
| | | | - Gregory Nadolski
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Sumita Verma
- Brighton and Sussex Medical School and University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | | |
Collapse
|
2
|
Reddy KD, Chawla S. Wearable Technology in Gastroenterology: Current Applications and Future Directions. J Clin Med 2025; 14:2403. [PMID: 40217853 PMCID: PMC11989449 DOI: 10.3390/jcm14072403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2025] [Revised: 03/27/2025] [Accepted: 03/27/2025] [Indexed: 04/14/2025] Open
Abstract
Advances in wearable technology have revolutionized healthcare by enabling the continuous monitoring of patients and personalized healthcare delivery. In the field of gastroenterology, the integration of wearable devices and smartphone applications represents a promising frontier. As technology continues to expand, understanding the current landscape and future directions of wearable technology in gastroenterology is essential for improving patient outcomes and clinical practice. Background/Objectives: Most review articles, thus far, regarding wearable technology in healthcare have been directed towards cardiovascular health. The purpose of this review is to explore the evolving role of wearable technology in the management of gastrointestinal disorders, focusing on remote patient monitoring and the use of smartphone applications. Methods: We conducted a search for studies on wearable technology and included the following search terms: wearable technology, gastroenterology, wearable device, smartphone, application, heart rate variability, biosensor, watch, patch. We included randomized controlled trials, prospective studies, and feasibility studies published from 2018 onwards. We excluded studies in pediatrics or those unrelated to GI disorders. Results: We found that using wearable devices and digital health management may be an effective way to monitor symptoms, reduce hospitalizations, and improve healthcare delivery in several gastrointestinal diseases such as inflammatory bowel diseases, motility disorders, liver diseases, etc. Conclusions: This review proposes that remote patient monitoring through wearable devices and digital health management via smartphone applications could reduce hospitalizations and empower patients, though challenges related to data security, accuracy, and integration with the electronic medical record must be addressed.
Collapse
Affiliation(s)
- Keerthi D. Reddy
- Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA;
| | - Saurabh Chawla
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA
| |
Collapse
|
3
|
Hanson C, Goacher EK. Hepatic encephalopathy in patients with cirrhosis: Key clinical considerations for the nurse practitioner and physician assistant. J Am Assoc Nurse Pract 2025; 37:173-181. [PMID: 39932441 DOI: 10.1097/jxx.0000000000001105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 11/07/2024] [Indexed: 03/04/2025]
Abstract
BACKGROUND Hepatic encephalopathy (HE) is a common neurocognitive cirrhosis-related complication with a broad range of symptoms. Timely recognition and treatment of HE, including identifying precipitating factors, when possible, is critical for improving outcomes in patients with cirrhosis. Lactulose and rifaximin therapies, as appropriate, are recommended for patients with cirrhosis and a history of HE episode(s) to reduce risk of HE recurrence. OBJECTIVES To provide clinical considerations for nurse practitioners and physician assistants (PAs) on the diagnosis and management of patients with cirrhosis. DATA SOURCES A PubMed search of English-language articles published between January 1, 2008, and March 13, 2024, was performed to identify publications on the diagnosis and treatment of HE. RESULTS Important topics to address when discussing care with patients with cirrhosis and their caregivers include concomitant medication use, recent infection history, comorbid conditions (e.g., diabetes), fall and frailty risks, and sleep quality. In addition, ensuring treatment adherence is important for reducing the risk of future HE episodes and HE-related hospitalizations. Engaging and empowering caregivers helps reinforce the need for patient adherence to treatment and facilitates earlier identification of HE symptoms. CONCLUSIONS Early recognition of HE, treatment, and reduction in risk of recurrence are imperative to minimize patient morbidity and mortality. IMPLICATIONS FOR PRACTICE Nurse practitioners and PAs play an important role in supporting patients with cirrhosis who are at risk for developing HE, as well as their caregivers. Understanding and recognizing precipitating factors and clinical symptoms of HE and treating and preventing HE recurrence can improve patient outcomes.
Collapse
Affiliation(s)
| | - Elizabeth K Goacher
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
4
|
Wang S, Zhang L, Li J, Feng J, Gao J, Huang R. Hepatic encephalopathy and spontaneous bacterial peritonitis are associated with increased liver-related readmissions in cirrhosis. Front Med (Lausanne) 2025; 12:1417222. [PMID: 39958824 PMCID: PMC11825766 DOI: 10.3389/fmed.2025.1417222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 01/20/2025] [Indexed: 02/18/2025] Open
Abstract
Introduction Liver disease remains a significant global health concern. In China, the number of patients with liver cirrhosis is estimated to reach 7 million. In addition to the high risk of death, cirrhosis leads to several severe complications. Patients with cirrhosis have significantly longer hospital stays and higher total hospital costs than those without cirrhosis. We aimed to investigate the predictors of readmission among patients with cirrhosis in China. Materials and methods We conducted a retrospective study to evaluate adult patients with cirrhosis. Data on various sociodemographic, clinical, and hospitalization characteristics were collected. We defined the primary endpoint as the first liver-related readmission occurring within 30-90 days of initial hospitalization. Adult patients with cirrhosis admitted to our hospital between January 2009 and December 2022 were included. Differences between groups were analyzed using Student's t-test and chi-square test. Logistic and multiple linear regression analyses were performed to identify predictors associated with readmission and the length of the first hospitalization. Results In total, 1,285 patients were diagnosed with cirrhosis. Among these patients, 767 (59.7%) were males, and the mean age was 58.9 ± 12.3 years. Seventy-two (5.6%) and 154 (12.0%) patients were readmitted within 30 and 90 days, respectively. Compared with those who were not readmitted, patients readmitted at 30-day and 90-day had a higher proportion of males, ascites, spontaneous bacterial peritonitis, electrolyte abnormalities, higher Child-Pugh-Turcotte scores, longer initial hospital stays, and higher initial hospitalization costs. Logistic regression analysis indicated that hepatic encephalopathy, spontaneous bacterial peritonitis, diabetes, and ascites were predictors of 30- and 90-day readmission. Hypertension and spontaneous bacterial peritonitis were significant predictors of the length of the first hospitalization. Conclusion Patients with cirrhosis presenting with hepatic encephalopathy, ascites, and spontaneous bacterial peritonitis may have a higher risk of rehospitalization.
Collapse
Affiliation(s)
- Shan Wang
- Peking University Hepatology Institute, Peking University People’s Hospital, Beijing, China
- Department of Liver Diseases, The First Hospital of Lanzhou University, Lanzhou, China
| | - Lin Zhang
- Peking University Hepatology Institute, Peking University People’s Hospital, Beijing, China
| | - Jin Li
- The First Department of Neurology, The Third People’s Hospital of Liaoyang, Liaoyang, China
| | - Jiajun Feng
- Department of Marketing, School of Business, Renmin University of China, Beijing, China
| | - Jie Gao
- Department of Hepatobiliary Surgery, Peking University People’s Hospital, Beijing, China
| | - Rui Huang
- Peking University Hepatology Institute, Peking University People’s Hospital, Beijing, China
| |
Collapse
|
5
|
Gallego JJ, Ballester MP, Fiorillo A, Casanova-Ferrer F, López-Gramaje A, Urios A, Arenas YM, Ríos MP, Durbán L, Megías J, San-Miguel T, Benlloch S, Lluch P, Jalan R, Montoliu C. Ammonia and beyond - biomarkers of hepatic encephalopathy. Metab Brain Dis 2025; 40:100. [PMID: 39812958 PMCID: PMC11735499 DOI: 10.1007/s11011-024-01512-7] [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: 07/22/2024] [Accepted: 12/17/2024] [Indexed: 01/16/2025]
Abstract
Ammonia is a product of amino acid metabolism that accumulates in the blood of patients with liver cirrhosis, leading to neurotoxic effects and hepatic encephalopathy (HE). HE manifestations can range from mild, subclinical disturbances in cognition, or minimal HE (mHE) to gross disorientation and coma, a condition referred to as overt HE. Many blood-based biomarkers reflecting these neurotoxic effects of ammonia and liver disease can be measured in the blood allowing the development of new biomarkers to diagnose cirrhosis patients at risk of developing HE. The effect of ammonia on the brain is modulated by severity of systemic inflammation, and both hyperammonemia and inflammation can induce oxidative stress, which may mediate the neurological alterations associated to HE. This review aims to provide the latest evidence on biomarkers of HE beyond ammonia. We present different approaches to predict overt HE based on the combination of blood ammonia with some analytical and clinical parameters. Magnetic resonance analysis of brain images could also provide sensitive diagnostic biomarkers based on neuroimaging parameters. Some reports suggest that markers of systemic inflammation, oxidative stress, and central nervous system-derived components, may serve as additional biomarkers of HE. The involvement of extracellular vesicles and microbiota in the pathophysiology of mHE and HE has recently acquired importance and it would be interesting to explore their usefulness as early biomarkers of the disease. It is important to have a biomarker or a combination of them for early diagnosis of mHE to improve its treatment and prevent progression to overt HE.
Collapse
Affiliation(s)
- Juan-José Gallego
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, Valencia, 46010, Spain
- Departamento de Patología, Universidad de Valencia, Valencia, 46010, Spain
| | - María-Pilar Ballester
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, Valencia, 46010, Spain
- Servicio de Medicina Digestiva, Hospital Clínico Universitario de Valencia, Valencia, 46010, Spain
| | - Alessandra Fiorillo
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, Valencia, 46010, Spain
| | - Franc Casanova-Ferrer
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, Valencia, 46010, Spain
| | | | - Amparo Urios
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, Valencia, 46010, Spain
| | - Yaiza María Arenas
- Departamento de Patología, Universidad de Valencia, Valencia, 46010, Spain
| | - María-Pilar Ríos
- Servicio de Medicina Digestiva, Hospital Arnau de Vilanova, 46015, Valencia, Spain
| | - Lucía Durbán
- Servicio de Medicina Digestiva, Hospital Arnau de Vilanova, 46015, Valencia, Spain
| | - Javier Megías
- Departamento de Patología, Universidad de Valencia, Valencia, 46010, Spain
| | - Teresa San-Miguel
- Departamento de Patología, Universidad de Valencia, Valencia, 46010, Spain
| | - Salvador Benlloch
- Servicio de Medicina Digestiva, Hospital Arnau de Vilanova, 46015, Valencia, Spain
- CIBERehd. Instituto de Salud Carlos III, Madrid, 28029, Spain
- Universidad Cardenal Herrera-CEU Universities, Valencia, 46115, Spain
| | - Paloma Lluch
- Servicio de Medicina Digestiva, Hospital Clínico Universitario de Valencia, Valencia, 46010, Spain
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK.
- European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, 08021, Spain.
| | - Carmina Montoliu
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, Valencia, 46010, Spain.
- Departamento de Patología, Universidad de Valencia, Valencia, 46010, Spain.
| |
Collapse
|
6
|
Hurtado-Díaz-de-León I, Tapper EB. Systems of care that improve outcomes for people with hepatic encephalopathy. Metab Brain Dis 2024; 40:50. [PMID: 39621162 DOI: 10.1007/s11011-024-01430-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 10/31/2024] [Indexed: 12/11/2024]
Abstract
Hepatic encephalopathy (HE) is a critical neuropsychiatric complication of liver cirrhosis with a significant impact on patient quality of life and survival. The global prevalence of cirrhosis and associated HE necessitates a comprehensive understanding of the condition and effective systems of care to optimize outcomes. This review addresses the epidemiology, classification, diagnosis, and management of HE, with an emphasis on systems of care that improve outcomes for people with HE. Current diagnostic challenges include differentiating cognitive deficits attributable to HE from those caused by other etiologies, highlighting the need for accurate diagnostic methods. Traditional psychometric tests, while valuable for diagnosing covert HE (CHE), are limited in their ability to predict overt HE (OHE) due to various confounding factors. As a result, non-psychometric tools have been developed to provide outcome-based predictions aligned with the clinical course of HE. The management of HE includes addressing precipitating factors, pharmacologic interventions to reduce ammonia levels, and supportive care, with lactulose and rifaximin playing a central role. Preventive strategies with the use of remote monitoring in the outpatient management of HE, integrating technology for real-time tracking of therapy compliance and symptom evolution, could contribute to reducing hospital readmissions and improving patient care.
Collapse
Affiliation(s)
- Ivonne Hurtado-Díaz-de-León
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.
| |
Collapse
|
7
|
Zou P, Bi Y, Tong Z, Wu T, Li Q, Wang K, Fan Y, Zhao D, Wang X, Shao H, Huang H, Ma S, Qian Y, Zhang G, Liu X, Jin Q, Ru Q, Qian Z, Sun W, Chen Q, You L, Wang F, Zhang X, Qiu Z, Lin Q, Lv J, Zhang Y, Geng J, Mao R, Liu J, Zheng Y, Ding F, Wang H, Gao H. Comparisons of efficacy and safety of 400 or 800 ml bacterial count fecal microbiota transplantation in the treatment of recurrent hepatic encephalopathy: a multicenter prospective randomized controlled trial in China. Trials 2024; 25:799. [PMID: 39605077 PMCID: PMC11600821 DOI: 10.1186/s13063-024-08578-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Accepted: 10/24/2024] [Indexed: 11/29/2024] Open
Abstract
BACKGROUND Hepatic encephalopathy (HE) represents a critical complications of end-stage liver disease, serving as an independent predictor of mortality among patients with cirrhosis. Despite effective treatment with rifaximin, some patients with HE still progress to recurrent episodes, posing a significant therapeutic challenge. Recurrent HE is defined as experiencing two or more episodes within a 6-month period. Previous research has suggested that FMT may emerge as a promising treatment for recurrent HE. However, there remains a critical need to explore the optimal dosage. This trial aims to abscess the efficacy and safety of two FMT dosages: 800 ml or 400 ml total bacterial count, including mortality and quality of life. METHODS This multicenter, prospective, randomized controlled trial will enroll 100 eligible patients from 31 hospitals in China. Participants will be randomly assigned in a 1:1 ratio to either the high-dose group (800 ml total bacterial count) or the low-dose group (400 ml total bacterial count). The primary objective is to assess the efficacy and safety of both dosages on outcomes at 24 and 48 weeks, including mortality and quality of life. DISCUSSION If either or both dosages of FMT demonstrate safe and effective treatment of recurrent HE, leading to improve quality of life and survival at 24 and 48 weeks, this trial would address a significant gap in the management of recurrent HE, carrying innovative and clinically significant implications. TRIAL REGISTRATION NCT05669651 on ClinicalTrials.gov. Registered on 29 December 2022. CHiCTR2200067135 on China Registered Clinical Trial Registration Center. Registered on 27 December 2022.
Collapse
Affiliation(s)
- Pengfei Zou
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang, Shuren University Shulan International Medical College, Hangzhou, China
- Jinan Microecological Biomedicine Shandong Laboratory, Jinan, China
| | - Yunjiao Bi
- Zhejiang Chinese Medical University, Hangzhou, China
| | | | - Tao Wu
- Hainan General Hospital Branch - Ding'an Hospital, Ding'an, China
| | - Qiang Li
- Shandong Public Health Clinical Center, Jinan, China
| | - Kai Wang
- Department of Hepatology, Qilu Hospital of Shandong University, Jinan, China
| | - Yuchen Fan
- Department of Hepatology, Qilu Hospital of Shandong University, Jinan, China
| | - Dan Zhao
- Zhengzhou Third People's Hospital, Zhengzhou, China
| | - Xin Wang
- Shulan (Quzhou) Hospital, Quzhou, China
| | - Hui Shao
- Taizhou Hospital of Zhejiang, Taizhou, China
| | - Haijun Huang
- Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Suping Ma
- The First Affiliated Hospital of Henan University of CM, Zhengzhou, China
| | | | | | - Xiao Liu
- Ningbo Zhenhai District People's Hospital, Ningbo, China
| | - Qiaofei Jin
- Hangzhou Xixi HospitalAffiliated to, Zhejiang University School of Medicine , Hangzhou, China
| | - Qingjing Ru
- The Second Affiliated Hospital of Zhejiang, Chinese Medical University, Hangzhou, China
| | - Zhiping Qian
- Shanghai Public Health Clinical Center, Shanghai, China
| | - Wei Sun
- The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Qiang Chen
- Zouping People's Hospital, Binzhou, China
| | - Liying You
- ALMETTE Hospital &, The First Hospital of Kunming, Kunming, China
| | - Fang Wang
- Zoucheng People's Hospital, Jining, China
| | - Xiaoting Zhang
- Shenzhen Bao'an District Songgang People's Hospital, Shenzhen, China
| | | | - Qing Lin
- The People's Hospital of Jiulongpo District, Chongqing, China
| | | | - Yongping Zhang
- People's Hospital of Xinjiang Uygur Autonomous Region, Ürümqi, China
| | - Jiawei Geng
- Department of Infectious Disease and Hepatic Disease, First People's Hospital of Yunnan Province, Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China
| | - Richeng Mao
- Department Of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Jinfeng Liu
- The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yubao Zheng
- Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Feng Ding
- Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Hui Wang
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hainv Gao
- Shulan (Hangzhou) Hospital Affiliated to Zhejiang, Shuren University Shulan International Medical College, Hangzhou, China.
- Jinan Microecological Biomedicine Shandong Laboratory, Jinan, China.
| |
Collapse
|
8
|
Ravindranath A, Srivastava A, Yachha SK, Poddar U, Sarma MS, Mathias A. Prevalence and Precipitants of Hepatic Encephalopathy in Hospitalized Children With Chronic Liver Disease. J Clin Exp Hepatol 2024; 14:101452. [PMID: 39005950 PMCID: PMC11245966 DOI: 10.1016/j.jceh.2024.101452] [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: 01/10/2024] [Accepted: 05/25/2024] [Indexed: 07/16/2024] Open
Abstract
Objective Hepatic encephalopathy (HE) is a marker of poor prognosis in adults with chronic liver disease (CLD). We prospectively studied the prevalence and precipitants of HE in children with CLD as there is a paucity of literature on the same. Methods Children (1-18 years) admitted with CLD were examined daily for the presence and grading of HE (West Haven/Whittington grading). Precipitants were classified as infection, dyselectrolytemia, gastrointestinal bleeding, constipation and dehydration. Changes in grades of HE and outcome were noted. Results One hundred and sixty children (age 120 [84-168] months) were enrolled. HE was present in 50 (31.2%) patients with a total of 61 episodes. Maximum grade of HE was grade I (n = 16), II (n = 23), III (n = 11) and IV (n = 11). Forty-two cases had single and 8 had recurrent (2-5) episodes. Median duration of HE episodes was 96 (72-192) hours. Precipitants were identified in 55/61 (90.2%) episodes with infection (45/61, 73.7%) and dyselectrolytemia (33/61, 54%) being the most common. Lower albumin and sodium, higher INR and presence of infection were significantly associated with presence of HE. Overall, HE resolved in 33 (54%) episodes, while it progressed and persisted in 28 (45.9%) episodes. Patients with HE had a poorer outcome (25/50 vs 13/110; P < 0.01) with both higher in-hospital (11/50 vs 9/110; P = 0.02) and 1-month post discharge (14/39 vs 4/101; P < 0.01) mortality than those without HE. Conclusion One-third of admitted CLD children have HE, with identifiable precipitants in 90% of cases. Children with HE have poorer liver functions, higher rate of infections and worse outcome than those without HE.
Collapse
Affiliation(s)
- Aathira Ravindranath
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Surender K Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Moinak S Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amrita Mathias
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| |
Collapse
|
9
|
Wu S, Li L, Xi H, Wu X, He Y, Sun X, Wu L. Bibliometrics and knowledge mapping of the pathogenesis of hepatic encephalopathy in patients with liver cirrhosis. Heliyon 2024; 10:e34330. [PMID: 39145014 PMCID: PMC11320160 DOI: 10.1016/j.heliyon.2024.e34330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 07/06/2024] [Accepted: 07/08/2024] [Indexed: 08/16/2024] Open
Abstract
Background Hepatic encephalopathy is a common and serious complication of decompensated cirrhosis. It can considerably contribute to economic burden and impaired quality of life. However, its pathogenesis remains unclear. Method In this study, we aimed to visually analyse the research status and development trends in hepatic encephalopathy pathogenesis using bibliometrics and knowledge mapping. Information regarding publications between 1978 and 2022 were obtained from the Web of Science Core Collection. CiteSpace was used to analyse and present data by year, author, institution, country, journal, reference, and keyword. Results A total of 1578 publications on hepatic encephalopathy pathogenesis in patients with cirrhosis were retrieved from Web of Science Core Collection. A gradual increasing trend in annual publications has occurred. The collaborative network analysis results suggest the United States of America, the University of London, and Bajaj, Jasmohan S as the most influential country, institution, and author, respectively, in this research field. Notably, China appeariiuis to be the most promising country. Research on 'hepatology' garners the most significant papers in the field. Combined with reference co-citation and keyword co-occurrence analyses, we found that ammonia metabolism, gut microbiota, sarcopenia, and trace elements will become future research frontiers that are likely to be explored for a considerable length of time. Conclusion Future research directions in HE pathogenesis may target modulating the ammonia metabolism, the gut microbiota, sarcopenia, and trace elements.
Collapse
Affiliation(s)
- Shiyan Wu
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan Province, China
- Department of Gastroenterology, The Third People's Hospital of Chengdu, The Affiliated Hospital of Southwest Jiaotong University, Chengdu, 610031, Sichuan Province, China
| | - Lu Li
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan Province, China
- Department of Gastroenterology, The Third People's Hospital of Chengdu, The Affiliated Hospital of Southwest Jiaotong University, Chengdu, 610031, Sichuan Province, China
| | - Heng Xi
- Department of Pharmacy, The Third People's Hospital of Chengdu, The Affiliated Hospital of Southwest Jiaotong University, Chengdu, 610031, Sichuan Province, China
| | - Xiaoping Wu
- Department of Gastroenterology, The Third People's Hospital of Chengdu, The Affiliated Hospital of Southwest Jiaotong University, Chengdu, 610031, Sichuan Province, China
| | - Yumei He
- North Sichuan Medical College, Nanchong, 623300, Sichuan Province, China
| | - Xiaobin Sun
- Department of Gastroenterology, The Third People's Hospital of Chengdu, The Affiliated Hospital of Southwest Jiaotong University, Chengdu, 610031, Sichuan Province, China
| | - Liping Wu
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan Province, China
- Department of Gastroenterology, The Third People's Hospital of Chengdu, The Affiliated Hospital of Southwest Jiaotong University, Chengdu, 610031, Sichuan Province, China
| |
Collapse
|
10
|
Ballester MP, Durmazer EN, Qi T, Jalan R. The Value of Ammonia as a Biomarker in Patients with Cirrhosis. Semin Liver Dis 2024; 44:356-368. [PMID: 39095029 PMCID: PMC11449525 DOI: 10.1055/a-2378-8942] [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] [Indexed: 08/04/2024]
Abstract
Ammonia is a product of amino acid metabolism that accumulates in the blood of patients with cirrhosis and plays a pivotal role in the pathogenesis of hepatic encephalopathy (HE). Despite being one of the main drivers of brain dysfunction, for many years international societies stated that increased blood ammonia does not add any diagnostic, staging, or prognostic value for HE in patients with cirrhosis. Nonetheless, in the last decades, evidence is emerging that supports the utility of ammonia for risk stratification, but its role in guiding HE diagnosis, staging, and treatment is unclear and there is equipoise in its use in clinical practice. This review provides the latest evidence on the value of ammonia as a biomarker in patients with cirrhosis. Although correct measurement of ammonia requires disciplined sample collection, it provides extremely useful clinical guidance for the diagnosis of HE, offers prognostic information, and it defines a therapeutic target.
Collapse
Affiliation(s)
- Maria Pilar Ballester
- Hepatology Unit, Digestive Disease Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Department of Gastroenterology and Hepatology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Esra Nur Durmazer
- Department of Internal Medicine, Ege University Faculty of Medicine, Izmir, Turkey
| | - Tingting Qi
- Hepatology Unit, Department of Infectious Disease, Southern Medical University, Nanfang Hospital, Guangzhou, China
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, London, United Kingdom
- European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain
| |
Collapse
|
11
|
Lee DU, Adonizio EA, Hastie DJ, Ponder R, Lee KJ, Jung D, Fan GH, Malik R. The Trends in Health Care Utilization and Costs Associated With Primary Liver Cancer: An Analysis of United States Hospitals Between 2016 and 2019. J Clin Gastroenterol 2024; 58:726-736. [PMID: 37983843 PMCID: PMC10978554 DOI: 10.1097/mcg.0000000000001927] [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: 04/13/2023] [Accepted: 08/20/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Primary liver cancer (PLC) has placed an increasing economic and resource burden on the health care system of the United States. We attempted to quantify its epidemiology and associated costs using a national inpatient database. METHODS Hospital discharge and insurance claims data from the National Inpatient Sample were used to conduct this analysis. Patients diagnosed with PLC (hepatocellular carcinoma or cholangiocarcinoma) were included in the study population, which was then stratified using patient demographics, comorbidities, degree of cancer spread, liver disease complications, and other descriptors. Trends were analyzed via regression curves for each of these strata from the years 2016 to 2019, with special attention to patterns in hospitalization incidence, inpatient mortality rate, total costs, and average per-capita costs. The resulting curves were evaluated using goodness-of-fit statistics and P -values. RESULTS Aggregate hospitalization incidence, inpatient mortality rates, and total costs were found to significantly increase throughout the study period ( P =0.002, 0.002, and 0.02, respectively). Relative to their demographic counterparts, males, White Americans, and those older than 65 years of age contributed the largest proportions of total costs. These population segments also experienced significant increases in total expenditure ( P =0.04, 0.03, and 0.02, respectively). Admissions deemed to have multiple comorbidities were associated with progressively higher total costs throughout the study period ( P =0.01). Of the categorized underlying liver diseases, only admissions diagnosed with alcoholic liver disease or nonalcoholic fatty liver disease saw significantly increasing total costs ( P =0.006 and 0.01), although hepatitis C was found to be the largest contributor to total expenses. CONCLUSIONS From 2016 to 2019, total costs, admission incidence, and inpatient mortality rates associated with PLC hospitalization increased. Strata-specific findings may be reflective of demographic shifts in the PLC patient populations, as well as changes in underlying chronic liver disease etiologies.
Collapse
Affiliation(s)
- David Uihwan Lee
- Division of Gastroenterology and Hepatology, University of Maryland, 22 S. Greene St, Baltimore, MD 21201, USA
| | - Elyse Ann Adonizio
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA 02111, USA
| | - David Jeffrey Hastie
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA 02111, USA
| | - Reid Ponder
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA 02111, USA
| | - Ki Jung Lee
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA 02111, USA
| | - Daniel Jung
- Department of Medicine, University of Missouri–Kansas City School of Medicine, 2411 Holmes St, Kansas City, MO 64108
| | - Gregory Hongyuan Fan
- Department of Medicine, Tufts University School of Medicine, Washington St, Boston, MA 02111, USA
| | - Raza Malik
- Liver Center, Division of Gastroenterology, Albany Medical Center, 43 New Scotland Ave, Albany, NY 12208, USA
| |
Collapse
|
12
|
Ahmed Z, Badal J, Gangwani MK, Nawaz A, Badal B, Arif SF, Farooq U, Kamal F, Javaid T, Aziz M, Lee-Smith W, Mahmood A, Merza N, Kobeissy A, Nawras A, Hassan M. Sarcopenia is a risk factor for post-transjugular intrahepatic portosystemic shunt hepatic encephalopathy and mortality: A systematic review and meta-analysis. Indian J Gastroenterol 2024; 43:748-759. [PMID: 38085501 DOI: 10.1007/s12664-023-01465-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 09/24/2023] [Indexed: 08/14/2024]
Abstract
BACKGROUND/AIMS Transjugular intrahepatic portosystemic shunt (TIPS) is a commonly performed procedure in patients with liver cirrhosis to treat portal hypertension-related conditions, including variceal bleeding and refractory ascites. However, while the increased risk of hepatic encephalopathy (HE) after TIPS is important to consider when determining whether a patient is a good candidate for TIPS, currently there is no widely used method to predict the development of post-TIPS HE, although the model for end-stage liver disease (MELD) score is used to predict post-TIPS mortality. We conducted a systematic review and meta-analysis to evaluate sarcopenia as a risk factor for HE and mortality in patients undergoing TIPS. METHODS A comprehensive search strategy was used to identify reports of post-TIPS HE and mortality in sarcopenia vs. non-sarcopenia patients with liver cirrhosis who received TIPS in March 2023. Open Meta Analyst was used to compute the results. RESULTS Twelve studies with 2056 patients met inclusion criteria and were included in the final meta-analysis. Sarcopenia was associated with a significantly higher post-TIPS HE rate than non-sarcopenia (risk ratio [RR]: 1.68, 95% CI: 1.48-1.92, p < 0.00001, I2 = 65%), as well as a significantly higher post-TIPS mortality rate (RR: 1.73, 95% CI: 1.14-2.64, p < 0.00001, I2 = 87%). CONCLUSION Patients with sarcopenia have a significantly increased risk of post-TIPS HE and mortality. Presence of sarcopenia should be considered when weighing the risks and benefits of performing TIPS in patients with cirrhosis. Further studies are needed to determine the clinical utility of important risk factors such as sarcopenia on post-TIPS outcomes.
Collapse
Affiliation(s)
- Zohaib Ahmed
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Joyce Badal
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Ahmad Nawaz
- Department of Internal Medicine, Yale-New Haven Hospital, New Haven, CT, USA
| | - Bryan Badal
- Department of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, VA, USA
| | | | - Umer Farooq
- Department of Internal Medicine, Loyola Medicine/MacNeal Hospital, Chicago, IL, USA
| | - Faisal Kamal
- Department of Gastroenterology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Toseef Javaid
- Department of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| | - Muhammad Aziz
- Department of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| | - Wade Lee-Smith
- University of Toledo Libraries, University of Toledo, Toledo, OH, USA
| | - Asif Mahmood
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Nooraldin Merza
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Abdallah Kobeissy
- Department of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| | - Ali Nawras
- Department of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| | - Mona Hassan
- Department of Gastroenterology and Hepatology, University of Toledo, Toledo, OH, USA
| |
Collapse
|
13
|
Badal BD, Fagan A, Tate V, Mousel T, Gallagher ML, Puri P, Davis B, Miller J, Sikaroodi M, Gillevet P, Gedguadas R, Kupcinkas J, Thacker L, Bajaj JS. Substitution of One Meat-Based Meal With Vegetarian and Vegan Alternatives Generates Lower Ammonia and Alters Metabolites in Cirrhosis: A Randomized Clinical Trial. Clin Transl Gastroenterol 2024; 15:e1. [PMID: 38696431 PMCID: PMC11196077 DOI: 10.14309/ctg.0000000000000707] [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: 02/07/2024] [Accepted: 04/22/2024] [Indexed: 05/04/2024] Open
Abstract
INTRODUCTION Diet can affect ammoniagenesis in cirrhosis and hepatic encephalopathy (HE), but the impact of dietary preferences on metabolomics in cirrhosis is unclear. As most Western populations follow meat-based diets, we aimed to determine the impact of substituting a single meat-based meal with an equal protein-containing vegan/vegetarian alternative on ammonia and metabolomics in outpatients with cirrhosis on a meat-based diet. METHODS Outpatients with cirrhosis with and without prior HE on a stable Western meat-based diet were randomized 1:1:1 into 3 groups. Patients were given a burger with 20 g protein of meat, vegan, or vegetarian. Blood for metabolomics via liquid chromatography-mass spectrometry and ammonia was drawn at baseline and hourly for 3 hours after meal while patients under observation. Stool microbiome characteristics, changes in ammonia, and metabolomics were compared between/within groups. RESULTS Stool microbiome composition was similar at baseline. Serum ammonia increased from baseline in the meat group but not the vegetarian or vegan group. Metabolites of branched chain and acylcarnitines decreased in the meat group compared with the non-meat groups. Alterations in lipid profile (higher sphingomyelins and lower lysophospholipids) were noted in the meat group when compared with the vegan and vegetarian groups. DISCUSSION Substitution of a single meat-based meal with a non-meat alternatives results in lower ammoniagenesis and altered serum metabolomics centered on branched-chain amino acids, acylcarnitines, lysophospholipids, and sphingomyelins in patients with cirrhosis regardless of HE or stool microbiome. Intermittent meat substitution with vegan or vegetarian alternatives could be helpful in reducing ammonia generation in cirrhosis.
Collapse
Affiliation(s)
- Bryan D. Badal
- Division of Gastroenterology, Hepatology and Nutrition, Richmond VA Medical Center, Richmond, Virginia, USA
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Andrew Fagan
- Division of Gastroenterology, Hepatology and Nutrition, Richmond VA Medical Center, Richmond, Virginia, USA
| | - Victoria Tate
- Department of Dietetics, Richmond VA Medical Center, Richmond, Virginia, USA
| | - Travis Mousel
- Division of Gastroenterology, Hepatology and Nutrition, Richmond VA Medical Center, Richmond, Virginia, USA
| | - Mary Leslie Gallagher
- Division of Gastroenterology, Hepatology and Nutrition, Richmond VA Medical Center, Richmond, Virginia, USA
| | - Puneet Puri
- Division of Gastroenterology, Hepatology and Nutrition, Richmond VA Medical Center, Richmond, Virginia, USA
| | - Brian Davis
- Division of Gastroenterology, Hepatology and Nutrition, Richmond VA Medical Center, Richmond, Virginia, USA
| | - Jennifer Miller
- Division of Gastroenterology, Hepatology and Nutrition, Richmond VA Medical Center, Richmond, Virginia, USA
| | - Masoumeh Sikaroodi
- Microbiome Analysis Center, George Mason University, Fairfax, Virginia, USA
| | - Patrick Gillevet
- Microbiome Analysis Center, George Mason University, Fairfax, Virginia, USA
| | - Rolandas Gedguadas
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Juozas Kupcinkas
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Institute for Digestive Research, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Leroy Thacker
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Richmond VA Medical Center, Richmond, Virginia, USA
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University, Richmond, Virginia, USA
| |
Collapse
|
14
|
Makhani SS, Lee S, Bernstein D. Preventing Readmissions for Hepatic Encephalopathy. Clin Liver Dis 2024; 28:345-358. [PMID: 38548444 DOI: 10.1016/j.cld.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Hepatic encephalopathy is a strong predictor of hospital readmissions in patients with advanced liver disease. The frequent recurrence of hepatic encephalopathy and subsequent readmissions may lead to nonreversible organ dysfunction, resulting in a significant decrease of patient quality of life and increase of health care burden costs for patients and facilities. Many of these readmissions for hepatic encephalopathy are preventable. Multidisciplinary patient-centered care throughout the continuum is essential in the management of hepatic encephalopathy. Understanding the patient's daily functions and limitations in the outpatient setting is key to correctly identifying the cause of hospital admission.
Collapse
Affiliation(s)
- Salima S Makhani
- Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY 11030, USA
| | - Susan Lee
- Northwell Health Office of Access Strategy, 330 South Service Road, Melville, NY 11747, USA
| | - David Bernstein
- NYU Grossman School of Medicine, 240 East 38th Street, 23rd Floor, New York, NY 10016, USA.
| |
Collapse
|
15
|
He Q, Mao C, Chen Z, Zeng Y, Deng Y, Hu R. Efficacy of L-ornithine L-aspartate for minimal hepatic encephalopathy in patients with cirrhosis: A meta-analysis of randomized controlled trials. Arab J Gastroenterol 2024; 25:84-92. [PMID: 38403493 DOI: 10.1016/j.ajg.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/12/2023] [Accepted: 01/06/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND AND STUDY AIMS Minimal hepatic encephalopathy (MHE) is an early stage of hepatic encephalopathy (HE) and is highly prevalent. The efficacy of L-ornithine L-aspartate (LOLA) for the treatment of HE is well known but its role in MHE remains uncertain. The objectives of the current study were to evaluate the efficacy of LOLA for the treatment of MHE in patients with cirrhosis. METHODS The Cochrane Library, PubMed, EMBASE, Web of Science and Ovid databases were searched. Only randomized controlled trials (RCTs) that compared the efficacy of LOLA with placebo or no intervention for the treatment of MHE in patients with cirrhosis were included from inception to January 2023. The primary outcomes were reversal of MHE and development of overt hepatic encephalopathy (OHE). RESULTS Overall, six RCTs comprising 292 patients were included. Compared with placebo or no intervention, LOLA was more effective in reversing MHE (RR = 2.264, 95 % CI = 1.528, 3.352, P = 0.000, I2 = 0.0 %) and preventing progression of OHE (RR = 0.220, 95 % CI = 0.076, 0.637, P = 0.005, I2 = 0.0 %). Based on subgroup analyses, oral LOLA treatment appeared more likely to reverse MHE (RR = 2.648, 95 % CI = 1.593, 4.402, P = 0.000, I2 = 0.0 %), intravenous LOLA treatment yielded a similar probability of reversing MHE (RR = 1.669, 95 % CI = 0.904, 3.084, P = 0.102, I2 = 0.0 %). LOLA did not show a superior possibility in reducing mortality (RR = 0.422, 95 % CI = 0.064, 2.768, P = 0.368, I2 = 0.0 %) and ammonia levels (SMD = 0.044, 95 % CI = -0.290, 0.379, P = 0.795, I2 = 0.0 %) compared with placebo or no intervention. CONCLUSIONS LOLA has significant beneficial effects on reversal of MHE and prevention of OHE in patients with cirrhosis compared with placebo or no intervention.
Collapse
Affiliation(s)
- Qiufeng He
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Chuangjie Mao
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Zhili Chen
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Yilan Zeng
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Yang Deng
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China
| | - Rong Hu
- Department of Hepatology, Public Health Clinical Center of Chengdu, N0.377, Jing Ming Road, Jin Jiang District, Chengdu, Sichuan, China.
| |
Collapse
|
16
|
Lin E, Gandhi D, Volk M. Preventing Readmissions of Hepatic Encephalopathy: Strategies in the Acute Inpatient, Immediate Postdischarge, and Longitudinal Outpatient Setting. Clin Liver Dis 2024; 28:359-367. [PMID: 38548445 DOI: 10.1016/j.cld.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Hepatic encephalopathy (HE) is a strong predictor of early hospital readmission in patients with cirrhosis. Early hospital readmission increases health care costs and is associated with worse survival. Herein we provide an overview of strategies to prevent hospital readmissions in patients with HE, divided into 3 contexts: (a) acute inpatient, (b) immediate postdischarge, and (c) longitudinal outpatient setting.
Collapse
Affiliation(s)
- Emily Lin
- Department of Gastroenterology, Loma Linda University, Loma Linda, CA, USA
| | - Devika Gandhi
- Department of Gastroenterology, Loma Linda University, Loma Linda, CA, USA.
| | - Michael Volk
- Department of Medicine, Baylor Scott and White, Central Texas Region, Temple, TX, USA
| |
Collapse
|
17
|
Hasan I, Murti IS, Bayupurnama P, Kalista KF, Hill-Zabala C, Kananda D, Viayna E. Cost-effectiveness of albumin in the treatment of decompensated cirrhosis in resource-limited healthcare settings. Drugs Context 2024; 13:2024-1-1. [PMID: 38699066 PMCID: PMC11065133 DOI: 10.7573/dic.2024-1-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/18/2024] [Indexed: 05/05/2024] Open
Abstract
Background Human albumin (HA) is an effective adjuvant treatment for patients with cirrhosis developing spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS) and ascites requiring large-volume paracentesis (LVP). However, cost remains a barrier to use, particularly in resource-limited settings. This study aims to assess the cost-effectiveness of HA in patients with cirrhosis with SBP, HRS or ascites requiring LVP in the Indonesian healthcare system as a representative of a resource-limited setting. Methods Three decision-tree models were developed to assess the cost-effectiveness of (1) antibiotics and HA versus antibiotics alone in patients with SBP, (2) terlipressin and HA versus terlipressin alone in patients with HRS, and (3) LVP and HA versus LVP and gelatine for patients with ascites. Clinical utility and economic inputs were pooled from the available literature. Time horizon was 3 months. Outcomes were expressed as incremental cost-effectiveness ratios (ICER) reported as 2021 IDR per quality-adjusted life year (QALY) (exchange rate June 30, 2021: 1 EUR = 17,245 IDR). Willingness-to-pay thresholds considered were: three times the GDP per capita (199,355,561 IDR/QALY; 11,560 EUR/QALY) and one time the GDP per capita (66,451,854 IDR/QALY; 3853 EUR/QALY). Results The ICER for antibiotics and HA (versus antibiotics alone) for SBP was 80,562,652 IDR per QALY gained (4672 EUR/QALY). The ICER for terlipressin and HA (versus terlipressin) for HRS was 23,085,004 IDR per QALY gained (1339 EUR/QALY). The ICER for LVP and HA versus LVP and gelatine was 24,569,827 IDR per QALY gained (1425 EUR/QALY). Conclusion Adjunctive HA may be a cost-effective treatment for SBP, HRS and LVP in resource-limited settings.
Collapse
Affiliation(s)
- Irsan Hasan
- Hepatobiliary Division, Department of Internal Medicine, Faculty of Medicine, Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta, Indonesia
| | - Ignatia Sinta Murti
- Department of Internal Medicine, Abdul Wahab Sjahranie General Hospital Samarinda, East Kalimantan, Indonesia
| | - Putut Bayupurnama
- Gastroenterology & Hepatology Division, Department of Internal Medicine, Dr. Sardjito General Hospital/Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Kemal Fariz Kalista
- Hepatobiliary Division, Department of Internal Medicine, Faculty of Medicine, Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta, Indonesia
| | | | | | | |
Collapse
|
18
|
Haque LY, McDonough M, Deng Y, Ciarleglio MM, Liapakis A, Jakab S. Feasibility of an Interprofessional Inpatient Educational Intervention for Patients With Decompensated Cirrhosis. GASTRO HEP ADVANCES 2024; 3:615-617. [PMID: 39165423 PMCID: PMC11330928 DOI: 10.1016/j.gastha.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/20/2024] [Indexed: 08/22/2024]
Affiliation(s)
- Lamia Y. Haque
- Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Maryann McDonough
- Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Yanhong Deng
- Yale Center for Analytical Sciences, New Haven, Connecticut
| | - Maria M. Ciarleglio
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - AnnMarie Liapakis
- New York University Langone Transplant Institute, New York City, New York
| | - Simona Jakab
- Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| |
Collapse
|
19
|
Giles B, Fancey K, Gamble K, Riaz Z, Dowman JK, Fowell AJ, Aspinall RJ. Novel, nurse-led early postdischarge clinic is associated with fewer readmissions and lower mortality following hospitalisation with decompensated cirrhosis. Frontline Gastroenterol 2024; 15:124-129. [PMID: 38486673 PMCID: PMC10935524 DOI: 10.1136/flgastro-2023-102489] [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: 06/19/2023] [Accepted: 10/20/2023] [Indexed: 03/17/2024] Open
Abstract
Objective Patients hospitalised with decompensated cirrhosis have high rates of early unplanned readmission. Many readmissions are avoidable with secondary preventative strategies, but patients are often readmitted prior to outpatient review. To address this, we established a novel, nurse-led early postdischarge (EPD) clinic delivering goal-directed care for cirrhosis complications and evaluated the impact. Methods Retrospective cohort study comparing outcomes in 78 patients seen in the EPD clinic with 91 phenotypically matched controls receiving standard, consultant hepatologist care. Follow-up for 12 months from index admission with endpoints including survival, time to readmission, number of readmissions and healthcare burden. Results Median time to readmission was 51 days in controls and 98 days in the intervention group (p<0.01). The intervention cohort had significantly fewer readmissions at 30 days (12% vs 30%, p<0.01) and 90 days (27% vs 49%, p<0.01) but not significantly at 12 months (58% vs 68%, p=0.16) with an overall reduction in bed day usage of 29%. Mortality for the control group was 4% at 30 days with no deaths in the intervention group. There were significantly fewer deaths in the intervention group at 90 days (5% vs 15%, p<0.05) and 12 months (22% vs 41%, p<0.01). Conclusions Following an index hospitalisation with decompensated cirrhosis, goal-directed postdischarge care can be effectively delivered by specialist nurses, prior to outpatient review by hepatologists. This model was associated with significantly fewer readmissions, lower bed day usage and a reduced mortality. Our data suggest such models of care deserve wider implementation and further evaluation.
Collapse
Affiliation(s)
- Benjamin Giles
- Gastroenterology and Hepatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Kirsty Fancey
- Gastroenterology and Hepatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Karen Gamble
- Gastroenterology and Hepatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Zeshan Riaz
- Gastroenterology and Hepatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Joanna K Dowman
- Gastroenterology and Hepatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Andrew J Fowell
- Gastroenterology and Hepatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Richard J Aspinall
- Gastroenterology and Hepatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| |
Collapse
|
20
|
Li N, Xu M, Liu SY, Yu MQ, Ruan CF. Risk factors for hospital readmission among patients with cirrhosis and ascites in China: a retrospective observational study. J Int Med Res 2024; 52:3000605231223087. [PMID: 38258740 PMCID: PMC10807325 DOI: 10.1177/03000605231223087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/11/2023] [Indexed: 01/24/2024] Open
Abstract
OBJECTIVE In this investigation, we aimed to explore risk factors for 90-day hospital readmission among patients with cirrhosis and ascites in an Asian population. METHODS In this retrospective study, we included consecutive patients diagnosed with cirrhosis and ascites hospitalized in Renji Hospital between 2018 and 2022 to elucidate risk factors for 90-day readmission. We conducted multivariate logistic regression analysis to identify readmission risk factors. RESULTS We included 265 patients with cirrhosis and ascites. A 43% readmission rate was observed within 90 days. After adjustment for multiple covariates, we found that readmission within 90 days was independently linked to reduced levels of hemoglobin (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.94-0.97) and serum albumin (OR 0.88, 95% CI 0.83-0.93), and higher Model for End-Stage Liver Disease and sodium (MELD-Na) scores (OR 1.04, 95% CI 1.01-1.07) at discharge. CONCLUSIONS Patients with cirrhosis who have ascites are frequently rehospitalized within 90 days after discharge. Lower hemoglobin or albumin and higher MELD-Na scores at discharge may be the main risk factors for hospital readmission.
Collapse
Affiliation(s)
- Na Li
- Department of Nursing, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Mei Xu
- Department of Nursing, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shi-Ying Liu
- Department of Nursing, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ming-Qin Yu
- Department of Nursing, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chun-Feng Ruan
- Department of Nursing, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| |
Collapse
|
21
|
Louissaint J, Gibbs J, Shenoy A, Cohen-Mekelburg S, Lok A, Tapper E. Patient Portal Use and Risk of Readmissions in Decompensated Cirrhosis: Retrospective Study. JMIR Form Res 2023; 7:e47080. [PMID: 38113099 PMCID: PMC10762613 DOI: 10.2196/47080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 10/09/2023] [Accepted: 10/30/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Patient portals are a common electronic medical record tool that allow for the asynchronous exchange of health information between patients and their health care teams. Patients can leverage patient portals to perform tasks such as viewing test results, reviewing clinical notes, and messaging their health care team. The impact of patient portal use on clinical outcomes in cirrhosis is unknown. OBJECTIVE In this study, we evaluated the relationship between patient portal use patterns and readmissions in cirrhosis. METHODS We identified 131 patients with decompensated cirrhosis with an index cirrhosis-related admission between May 1, 2018, and May 1, 2019. We then examined patient portal enrollment and use data during the 6-month period preceding the study period. Portal functions evaluated included sending a message, reading a message, and reading a test result. Use was categorized as active (sending a message) and passive (reading a message or test result) and was further stratified as no, moderate, or frequent use based on the frequency of portal function use compared to the mean. The primary outcomes were 90-day and overall readmissions, adjusted for age, model for end-stage liver disease-sodium, alcohol-related cirrhosis etiology, ascites, and hepatic encephalopathy. Portal functions assessed included sending a message, reading a message, and reading a result; the total number of times a portal function was performed was divided by the number of months the patient was enrolled in the patient portal during the 6-month period. RESULTS The study population was 50.4% (66/131) female, with a mean age of 58 years. Enrollment in the patient portal was 63.4% (83/131), and there was no significant difference in enrollment based on clinical or demographic characteristics. For the entire cohort, 14.5% (19/131) and 22.1% (29/131) of patients were moderate and frequent active users, respectively. Of those enrolled in the patient portal, 97.6% (81/83) of patients were moderate or frequent passive users for both reading a message and reading a test result. Moderate active users had less 90-day readmissions (odds ratio 0.77, 95% CI 0.60-1.00) and overall readmissions (subdistribution hazard ratio 0.42, 95% CI 0.21-0.84), compared to nonactive users. There was no relationship between readmissions and passive use. CONCLUSIONS Passive use of the patient portal is very high but is not associated with the risk of readmissions in people with decompensated cirrhosis. However, moderately active use of the patient portal is associated with a reduced risk of readmissions. Further work is needed to identify possible confounders and refine key use behaviors that may be protective with regard to the risk of readmission in this population.
Collapse
Affiliation(s)
- Jeremy Louissaint
- Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, TX, United States
| | - Jeffrey Gibbs
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Abhishek Shenoy
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States
| | - Shirley Cohen-Mekelburg
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
- VA Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, MI, United States
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Anna Lok
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Elliot Tapper
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| |
Collapse
|
22
|
Vrbová P, Koller T. Rate of repeated hospitalization of patients with cirrhosis and its risk factors. VNITŘNÍ LÉKAŘSTVÍ 2023; 69:500-505. [DOI: 10.36290/vnl.2023.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
|
23
|
Agbalajobi O, Ebhohon E, Amuchi CB, Nzugang EC, Soladoye EO, Babajide O, Adejumo AC. National frequency, trends, and healthcare burden of care fragmentation in readmissions for end-stage liver disease in the USA. Minerva Gastroenterol (Torino) 2023; 69:470-478. [PMID: 38197846 DOI: 10.23736/s2724-5985.22.03232-6] [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] [Indexed: 01/11/2024]
Abstract
BACKGROUND End-stage liver disease (ESLD) patients have frequent readmissions to the same facility or a different hospital (care fragmentation). Care fragmentation results in care delivery from an unfamiliar clinical team or setting, a potential source of suboptimal clinical outcomes. We examined the occurrence, trends, and association between care fragmentation and outcomes during readmissions for ESLD. METHODS From the Nationwide Readmissions Database (January to September 2010-2014), we followed adult (age ≥18 years) hospitalizations for ESLD who were discharged alive for 90 days. During 30- and 90-day readmissions, we calculated the frequency, determinants, and clinical outcomes of care fragmentation (SAS 9.4). RESULTS Of the 67,480 ESLD hospitalizations surviving at discharge from 2010-2014, 35% (23,872) and 52% (35,549) were readmitted in 30- and 90-days respectively. During readmissions, the frequencies of care fragmentation were similar (30-day: 25.4% and 90-day: 25.8%) and remained stable from 2010 to 2014 (P trends>0.5). Similarly, factors associated with care fragmentation were consistent across 30- and 90-day readmissions. These included ages: 18-44 years, liver cancer, receipt of liver transplantation, hepatorenal syndrome, prolonged length of stay, and hospitalization in non-teaching facilities. During 30- and 90-day readmissions, care fragmentation was associated with higher risk of mortality (adjusted mean ratio: 1.13[1.03-1.24] and 1.14 [1.06-1.23]; P values<0.0001), prolonged length of stay (4.6-days vs. 4.1-days and 5.2-days vs. 4.6-days; P values<0.0001), and higher hospital charges ($36,884 vs. $28,932 and $37,354 vs. $30,851; P values<0.0001). CONCLUSIONS Care fragmentation is high among readmissions for ESLD and is associated with poorer outcomes.
Collapse
Affiliation(s)
| | - Ebehiwele Ebhohon
- Department of Internal Medicine, Lincoln Medical Center, New York, NY, USA
| | - Chineye B Amuchi
- School of Public Health, Boston University School of Public Health, Boston, MA, USA
| | - Edwige C Nzugang
- Department of Internal Medicine, Beth Israel Lahey Health, Burlington, VT, USA
| | | | - Oyedotun Babajide
- Department of Internal Medicine, Interfaith Medical Center, New York, NY, USA
| | - Adeyinka C Adejumo
- Department of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA -
- Individualized Genomics and Health Program, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
24
|
Muzammil TS, Gangu K, Nasrullah A, Majeed H, Chourasia P, Bobba A, Shekhar R, Bartlett C, Sheikh AB. Thirty-Day readmissions among COVID-19 patients hospitalized during the early pandemic in the United States: Insights from the Nationwide Readmissions Database. Heart Lung 2023; 62:16-21. [PMID: 37290138 PMCID: PMC10244017 DOI: 10.1016/j.hrtlng.2023.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Hospital readmissions are core indicators of the quality of health care provision. OBJECTIVE To understand factors associated with 30-day, all-cause hospital readmission rate for patients with COVID-19 in the United States during the early pandemic by utilizing the Nationwide Readmissions Database. METHODS This retrospective study characterized the 30-day, all-cause hospital readmission rate for patients with COVID-19 in the United States during the early pandemic by utilizing the Nationwide Readmissions Database. RESULTS The 30-day, all-cause hospital readmission rate in this population was 3.2%. We found the most common diagnoses at readmission to be sepsis, acute kidney injury, and pneumonia. Chronic alcoholic liver cirrhosis and congestive heart failure were prominent predictors of readmission among patients with COVID-19. Moreover, we found that younger patients and patients from economically disadvantaged backgrounds were at higher risk of 30-day readmission. Acute complications during index hospitalization, including acute coronary syndrome, congestive heart failure, acute kidney injury, mechanical ventilation, and renal replacement therapy, also increased the risk of 30-day readmission for patients with COVID-19. CONCLUSION Based on the results of our study, we advise clinicians to promptly recognize patients with COVID-19 who are at high risk of readmission, and to subsequently manage their underlying comorbidities, to institute timely discharge planning, and to allocate resources to underprivileged patients in order to decrease the risk of 30-day hospital readmissions.
Collapse
Affiliation(s)
| | - Karthik Gangu
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Adeel Nasrullah
- Division of Pulmonary and Critical Care, Allegheny Health Network, Pittsburg, PA, USA
| | - Harris Majeed
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Prabal Chourasia
- Department of Hospital Medicine, Mary Washington Hospital, Fredericksburg, VA, USA.
| | - Aneish Bobba
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA
| | - Rahul Shekhar
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Christopher Bartlett
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| |
Collapse
|
25
|
Kalo E, Baig A, Gregg E, George J, Read S, Ma WS, Ahlenstiel G. A novel, nurse-led 'one stop' clinic for patients with liver cirrhosis results in fewer liver-related unplanned readmissions and improved survival. BMC Gastroenterol 2023; 23:356. [PMID: 37845625 PMCID: PMC10578021 DOI: 10.1186/s12876-023-02986-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/02/2023] [Indexed: 10/18/2023] Open
Abstract
OBJECTIVE Delivering effective secondary preventive and integrated care has the potential to break the revolving-door phenomenon of frequent readmissions in patients with advanced chronic liver disease. To address this, we launched the Care Coordination of Liver Disease (CCoLD) pilot, a novel nurse-led cirrhosis clinic in Western Sydney. METHODS AND ANALYSIS Following an index presentation to Blacktown or Mount Druitt hospitals (BMDH), patients (n = 89, matched by age, sex, and MELD-NA) were consecutively either followed up by the CCoLD clinical nurse consultant (intervention cohort) or received standard care (control cohort). Controlled evaluation of the impact of the nurse-led clinic was carried out for a 3-month period including readmission rates, survival, and cost effectiveness. RESULTS The inaugural nurse-led clinic led to improvement in patient-level outcomes including a reduction in unplanned liver-related readmissions (2.08% for intervention cohort vs 12.2% for control cohort, p < 0.01), and mortality at 30 days (0% for intervention cohort vs 7.3% for control cohort, p = 0.03). Similar trends were observed at 90 days from index discharge. No deaths were observed in the intervention cohort as compared to the control cohort at 90 days (0% versus 7.3%, p = 0.03), while unplanned liver-related readmissions were 10.41% for the intervention cohort vs 19.5% for the control cohort (p = 0.115). Moreover, time to readmission was significantly longer in the intervention cohort, resulting in an overall cost-effective intervention. CONCLUSION These findings highlight the significant impact of optimised care-coordination. A nurse-led clinic can deliver patient-centred, goal-directed, and cost-effective secondary prevention and care. A multicentre randomised trial for wider evaluation of these findings is warranted.
Collapse
Affiliation(s)
- Eric Kalo
- Blacktown Clinical School and Research Centre, School of Medicine, Western Sydney University, 18 Blacktown Road, Blacktown, NSW, 2148, Australia
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia
| | - Asma Baig
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia
| | - Emily Gregg
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia
| | - Jacob George
- Storr Liver Centre, The Westmead Institute for Medical Research, University of Sydney, Westmead, NSW, 2145, Australia
- Westmead Hospital, Western Sydney Local Health District, Westmead, NSW, 2145, Australia
| | - Scott Read
- Blacktown Clinical School and Research Centre, School of Medicine, Western Sydney University, 18 Blacktown Road, Blacktown, NSW, 2148, Australia
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia
- Storr Liver Centre, The Westmead Institute for Medical Research, University of Sydney, Westmead, NSW, 2145, Australia
| | - Wai-See Ma
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia
| | - Golo Ahlenstiel
- Blacktown Clinical School and Research Centre, School of Medicine, Western Sydney University, 18 Blacktown Road, Blacktown, NSW, 2148, Australia.
- Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, 2148, Australia.
- Storr Liver Centre, The Westmead Institute for Medical Research, University of Sydney, Westmead, NSW, 2145, Australia.
| |
Collapse
|
26
|
Ballester MP, Tranah TH, Balcar L, Fiorillo A, Ampuero J, Kerbert AJC, Thomsen KL, Escudero MD, Mandorfer M, Reiberger T, Shawcross DL, Romero-Gómez M, Montoliu C, Carbonell-Asins JA, Jalan R. Development and validation of the AMMON-OHE model to predict risk of overt hepatic encephalopathy occurrence in outpatients with cirrhosis. J Hepatol 2023; 79:967-976. [PMID: 37277075 DOI: 10.1016/j.jhep.2023.05.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/05/2023] [Accepted: 05/08/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND & AIMS Neuropsychological and psychophysical tests are recommended to assess the risk of overt hepatic encephalopathy (OHE), but their accuracy is limited. Hyperammonaemia is central in the pathogenesis of OHE, but its predictive utility is unknown. In this study, we aimed to determine the role of neuropsychological or psychophysical tests and ammonia, and to develop a model (AMMON-OHE) to stratify the risk of subsequent OHE development in outpatients with cirrhosis. METHODS This observational, prospective study included 426 outpatients without previous OHE from three liver units followed for a median of 2.5 years. Psychometric hepatic encephalopathy score (PHES) <-4 or critical flicker frequency (CFF) <39 was considered abnormal. Ammonia was normalized to upper limit of normal (AMM-ULN) at the respective reference laboratory. Multivariable frailty competing risk and random survival forest analyses were performed to predict future OHE and to develop the AMMON-OHE model. External validation was carried out using 267 and 381 patients from two independent units. RESULTS Significant differences were found in time-to-OHE (log-rank p <0.001) according to PHES or CFF and ammonia, with the highest risk in patients with abnormal PHES plus high AMM-ULN (hazard ratio 4.4; 95% CI 2.4-8.1; p <0.001 compared with normal PHES and AMM-ULN). On multivariable analysis, AMM-ULN but not PHES or CFF was an independent predictor of the development of OHE (hazard ratio 1.4; 95% CI 1.1-1.9; p = 0.015). The AMMON-OHE model (sex, diabetes, albumin, creatinine and AMM-ULN) showed a C-index of 0.844 and 0.728 for the prediction of a first episode of OHE in two external validation cohorts. CONCLUSIONS In this study, we developed and validated the AMMON-OHE model, comprising readily available clinical and biochemical variables that can be used to identify outpatients at the highest risk of developing a first episode of OHE. IMPACT AND IMPLICATIONS In this study, we aimed to develop a model to predict which patients with cirrhosis are at risk of developing overt hepatic encephalopathy (OHE). Using data from three units and including 426 outpatients with cirrhosis, we developed the AMMON-OHE model - comprising sex, diabetes, albumin, creatinine and ammonia levels - which demonstrated good predictive ability. The AMMON-OHE model performs better than PHES and CFF to predict the first episode of OHE in outpatients with cirrhosis. This model was validated in 267 and 381 patients from two independent liver units. The AMMON-OHE model is available online for clinical use.
Collapse
Affiliation(s)
- Maria Pilar Ballester
- Digestive Disease Department, Hospital Clínico Universitario de Valencia, Spain; INCLIVA Biomedical Research Institute, Valencia, Spain.
| | - Thomas H Tranah
- Institute of Liver Studies, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King´s College London, London, United Kingdom
| | - Lorenz Balcar
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | | | - Javier Ampuero
- Digestive Diseases Department, Ciberehd, Virgen del Rocío University Hospital, Instituto de Biomedicina de Sevilla (HUVR/CSIC/US), University of Seville, Sevilla, Spain
| | - Annarein J C Kerbert
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom
| | - Karen L Thomsen
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom; Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - María Desamparados Escudero
- Digestive Disease Department, Hospital Clínico Universitario de Valencia, Spain; Department of Medicine, Faculty of Medicine, University of Valencia, Spain
| | - Mattias Mandorfer
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Thomas Reiberger
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Debbie L Shawcross
- Institute of Liver Studies, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King´s College London, London, United Kingdom
| | - Manuel Romero-Gómez
- Digestive Diseases Department, Ciberehd, Virgen del Rocío University Hospital, Instituto de Biomedicina de Sevilla (HUVR/CSIC/US), University of Seville, Sevilla, Spain
| | - Carmina Montoliu
- INCLIVA Biomedical Research Institute, Valencia, Spain; Department of Pathology, Faculty of Medicine, University of Valencia, Spain
| | | | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom; European Foundation for the Study of Chronic Liver Failure (EF Clif), Spain.
| |
Collapse
|
27
|
Tapper EB, Ospina E, Salim N, Chen X, Nikirk S. Lactulose therapy for patients with cirrhosis, portal hypertension, and poor patient-reported outcomes: The Mi-Kristal trial. Hepatology 2023; 78:1159-1167. [PMID: 37066820 PMCID: PMC10524505 DOI: 10.1097/hep.0000000000000408] [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: 02/19/2023] [Accepted: 04/08/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND AND AIMS Poor patient-reported outcomes (PROs) are common in cirrhosis, including poor sleep and health-related quality of life (HRQOL). HE is a major driver of poor PROs. Many clinicians initiate lactulose therapy to address poor PROs. PRO-triggered therapy, however, has not been studied till date. METHODS We conducted a 28-day randomized trial of crystalline lactulose therapy (20 g BID) compared with no HE-directed therapy in 52 patients with cirrhosis, portal hypertension, no prior HE, and high Work Productivity and Activity Impairment scores (0-10) attributed to cirrhosis. The primary outcome was change in global HRQOL measured with Short Form-8 Health Survey. Secondary outcomes included change in Animal Naming Test score, Work Productivity and Activity Impairment, and sleep quality (scored "very bad" to "very good"). APPROACH AND RESULTS Overall, 52 patients underwent randomization; 3 subjects withdrew from the crystalline lactulose arm (1 before medication initiation, 1 due to an unrelated condition, and 1 due to high baseline bowel movements). The average age was 60 years, the average Model for Endstage Liver Disease-Sodium score was 10.5, and 56% of the patients had ascites. Baseline bowel movements were 2.3/day, with 35% of the patients having Bristol Stool Scale >4. At 28 days, there was no improvement in HRQOL: patients receiving crystalline lactulose had an 8.1-point (95% CI: 3.7-12.4) increase compared with 6.6 (95% CI: 2.3-10.8) in the control group ( p = 0.6). Lactulose was associated with a significantly ( p = 0.002) increased Animal Naming Test score (3.7, 95% CI: 2.1-5.4) versus the control group (0.2, 95% CI: -1.7, 1.4). Lactulose users reported more good sleep (92% vs. 52%, p = 0.001) and lower activity impairment (3.0 vs. 4.8, p = 0.02). CONCLUSIONS Lactulose improves sleep and activity impairment in patients with poor PROs. We did not observe any improvement in global HRQOL after 28 days using the Short Form-8 Health Survey instrument.
Collapse
Affiliation(s)
- Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan
| | - Erin Ospina
- Division of Gastroenterology and Hepatology, University of Michigan
| | - Najat Salim
- Division of Gastroenterology and Hepatology, University of Michigan
| | - Xi Chen
- Division of Gastroenterology and Hepatology, University of Michigan
| | - Samantha Nikirk
- Division of Gastroenterology and Hepatology, University of Michigan
| |
Collapse
|
28
|
Lovett GC, Ha P, Roberts AT, Bell S, Liew D, Pianko S, Sievert W, Le STT. Healthcare utilisation and costing for decompensated chronic liver disease hospitalisations at a Victorian network. Intern Med J 2023; 53:1581-1587. [PMID: 36334267 DOI: 10.1111/imj.15962] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 10/02/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The economic burden of decompensated chronic liver disease (CLD) on Australian healthcare services is poorly characterised. AIMS To evaluate the in-patient healthcare utilisation costs associated with decompensated CLD at Monash Health, an Australian tertiary healthcare service. METHODS The current retrospective cost analysis examined patients with decompensated CLD admitted between 1 January 2012 and 31 December 2018. Hospitalisations were identified using CLD-specific International Classification of Diseases, Tenth Revision, codes. Cost measures were estimated using the Victorian Weighted Inlier Equivalent Separation funding data based on the Australian Refined Diagnosis Related Groups cost weights. RESULTS There were 707 hospitalisations in 435 adult patients. The mean age was 56.7 ± 11.7 years and the mean length of stay was 10.28 ± 11.2 days. Median survival was 31 months (interquartile range, 2-94 months) and 177 (40.8%) patients died within 1 year of admission. The cost of admission varied according to decompensation: hepatorenal syndrome ($20 162 AUD), variceal bleed ($16 630 AUD), spontaneous bacterial peritonitis ($12 664 AUD), hepatic encephalopathy ($9973 AUD) and ascites ($9001 AUD). There was no significant difference in the admissions or 30-day readmission rate from 2012 to 2018 financial year (FY). The total adjusted cost of cirrhotic admissions per year increased by 78% from FY2012 to FY2018. CONCLUSION Hospital admission and readmission for decompensated CLD is common and associated with 40.8% 1-year mortality and high costs. Clearer delineation of goals of care and alternative ambulatory care models for decompensated CLD are urgently required to reduce the high costs and burden on health services.
Collapse
Affiliation(s)
- Grace C Lovett
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
| | - Phil Ha
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
| | - Andrew T Roberts
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
| | - Sally Bell
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stephen Pianko
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
| | - William Sievert
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
| | - Suong T T Le
- Department of Gastroenterology and Hepatology, Monash Health, Melbourne, Victoria, Australia
- School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
29
|
Schwarz M, Schwarz C, Burghart L, Pfisterer N, Bauer D, Hübl W, Mandorfer M, Gschwantler M, Reiberger T. Late-stage presentation with decompensated cirrhosis is alarmingly common but successful etiologic therapy allows for favorable clinical outcomes. PLoS One 2023; 18:e0290352. [PMID: 37616205 PMCID: PMC10449133 DOI: 10.1371/journal.pone.0290352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 08/04/2023] [Indexed: 08/26/2023] Open
Abstract
INTRODUCTION Liver cirrhosis accounts for considerable morbidity and mortality worldwide and late presentation limits therapeutic options. We aimed to assess characteristics of patients with liver cirrhosis at the time of first presentation and during their clinical course. METHODS Patients with cirrhosis as evident by presence of varices at endoscopy, liver stiffness ≥15kPa at elastography, or ascites requiring paracentesis between Q1/2015-Q2/2020 were retrospectively included. Clinical, laboratory, and imaging data were collected from medical records at presentation and last follow-up. RESULTS 476 patients were included (alcohol-related liver disease, ALD: 211, 44.3%; viral hepatitis: 163, 34.2%). Of these, 106 patients (22.3%) and 160 patients (33.6%) presented already with Child-Pugh C and MELD >15, respectively, and decompensation events were registered in 50% (238 patients) at baseline, and even in 75.4% of ALD patients. During a median follow-up of 11.0 (IQR 4-24) months, 116 patients died. Two-year survival was worse for patients with ALD than for viral hepatitis (71.1% vs. 90.2%, log rank p<0.001). We observed the highest percentage of portal-vein thrombosis (30.0%), hepatocellular carcinoma (15.0%), and death (45.0%) in the MAFLD group (n = 20). Patients cured from hepatitis C showed significant improvements in platelet count (147 to 169 G/L, p<0.001) and liver stiffness (26.2 to 17.7 kPa, p<0.001), while ALD patients improved in Child-Pugh score (8.6 to 7.6, p<0.001) during follow-up. With increasing Child Pugh score and MELD, we found increasing serum concentrations of CRP (p<0.001) and an inverse correlation with serum HDL (Spearman's ρ = -0.573 and -0.529, respectively, p<0.001). CONCLUSION Half of the patients with cirrhosis had decompensated cirrhosis at presentation. This calls for increased awareness and strategies for earlier diagnosis of chronic liver disease and cirrhosis.
Collapse
Affiliation(s)
- Michael Schwarz
- Department of Internal Medicine IV, Department for Gastroenterology and Hepatology, Klinik Ottakring, Vienna, Austria
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Caroline Schwarz
- Department of Internal Medicine IV, Department for Gastroenterology and Hepatology, Klinik Ottakring, Vienna, Austria
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Lukas Burghart
- Department of Internal Medicine IV, Department for Gastroenterology and Hepatology, Klinik Ottakring, Vienna, Austria
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Nikolaus Pfisterer
- Department for Gastroenterology and Hepatology, Department of Internal Medicine IV, Klinik Landstraße, Vienna, Austria
| | - David Bauer
- Department of Internal Medicine IV, Department for Gastroenterology and Hepatology, Klinik Ottakring, Vienna, Austria
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Hübl
- Klinik Ottakring, Institute for Laboratory Medicine, Vienna, Austria
| | - Mattias Mandorfer
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Michael Gschwantler
- Department of Internal Medicine IV, Department for Gastroenterology and Hepatology, Klinik Ottakring, Vienna, Austria
- Sigmund Freud University, Vienna, Austria
| | - Thomas Reiberger
- Department of Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
30
|
Santos RPC, Toscano ECDB, Rachid MA. Anti-inflammatory strategies for hepatic encephalopathy: preclinical studies. ARQUIVOS DE NEURO-PSIQUIATRIA 2023. [PMID: 37487550 PMCID: PMC10371400 DOI: 10.1055/s-0043-1767819] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Hepatic encephalopathy (HE) is a potentially reversible neuropsychiatric syndrome. Often, HE causes cognitive and motor dysfunctions due to an acute or chronic insufficiency of the liver or a shunting between the hepatic portal vein and systemic vasculature. Liver damage induces peripheral changes, such as in the metabolism and peripheral inflammatory responses that trigger exacerbated neuroinflammation. In experimental models, anti-inflammatory strategies have demonstrated neuroprotective effects, leading to a reduction in HE-related cognitive and motor impairments. In this scenario, a growing body of evidence has shown that peripheral and central nervous system inflammation are promising preclinical targets. In this review, we performed an overview of FDA-approved drugs and natural compounds which are used in the treatment of other neurological and nonneurological diseases that have played a neuroprotective role in experimental HE, at least in part, through anti-inflammatory mechanisms. Despite the exciting results from animal models, the available data should be critically interpreted, highlighting the importance of translating the findings for clinical essays.
Collapse
Affiliation(s)
- Rafaela Pinto Coelho Santos
- Universidade Federal de Minas Gerais, Instituto de Ciências Biológicas, Departamento de Patologia Geral, Laboratório de Patologia Celular e Molecular, Belo Horizonte MG, Brazil
| | - Eliana Cristina de Brito Toscano
- Universidade Federal de Juiz de Fora, Faculdade de Medicina, Departamento de Patologia, Laboratório Integrado de Pesquisa em Patologia, Juiz de Fora MG, Brazil
- Universidade Federal de Juiz e Fora, Faculdade de Medicina, Programa de Pós-Graduação em Saúde, Juiz de Fora MG, Brazil
| | - Milene Alvarenga Rachid
- Universidade Federal de Minas Gerais, Instituto de Ciências Biológicas, Departamento de Patologia Geral, Laboratório de Patologia Celular e Molecular, Belo Horizonte MG, Brazil
| |
Collapse
|
31
|
Zhang L, Zhang W, Wang J, Jin Q, Ma D, Huang R. Neutrophil-to-lymphocyte ratio predicts 30-, 90-, and 180-day readmissions of patients with hepatic encephalopathy. Front Med (Lausanne) 2023; 10:1185182. [PMID: 37457569 PMCID: PMC10348710 DOI: 10.3389/fmed.2023.1185182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction Hepatic encephalopathy (HE) is a significant complication of cirrhosis, known to be associated with hospital readmission. However, few new serological indicators associated with readmission in HE patients have been identified and reported. The objective of our study was to identify simple and effective predictors reated to readmission in HE patients. Materials and methods We conducted a retrospective study at a single center on adult patients admitted with HE from January 2018 to December 2022. The primary endpoint was the first liver-related readmission within 30, 90, and 180 days, and we collected electronic medical records from our hospital for sociodemographic, clinical, and hospitalization characteristics. We utilized logistic regression analysis and multiple linear regression analysis to determine the predictors that were associated with the readmission rate and the length of the first hospitalization. Results A total of 424 patients were included in the study, among whom 24 (5.7%), 63 (14.8%), and 92 (21.7%) were readmitted within 30, 90, and 180 days, respectively. Logistic regression analysis showed that insurance status, alcoholic liver disease (ALD), ascites, the model for end-stage liver disease (MELD) score, and neutrophil-to-lymphocyte ratio (NLR) were significantly associated with 30-, 90-, and 180-day readmissions. Age and hepatocellular carcinoma (HCC) were predictors of 90- and 180-day readmissions. ALD was identified as a unique predictor of readmission in men, while hypertension was a predictor of 180-day readmission in women. Variceal bleeding, chronic kidney disease, and MELD score were associated with the length of the first hospitalization. Conclusions NLR at discharge was identified as a significant predictor of 30-, 90- and 180-day readmissions in patients with HE. Our findings suggest that incorporating NLR into routine clinical assessments could improve the evaluation of the prognosis of liver cirrhosis.
Collapse
|
32
|
Pusateri A, Litzenberg K, Griffiths C, Hayes C, Gnyawali B, Manious M, Kelly SG, Conteh LF, Jalil S, Nagaraja HN, Mumtaz K. Randomized intervention and outpatient follow-up lowers 30-d readmissions for patients with hepatic encephalopathy, decompensated cirrhosis. World J Hepatol 2023; 15:826-840. [PMID: 37397939 PMCID: PMC10308285 DOI: 10.4254/wjh.v15.i6.826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/23/2023] [Accepted: 04/14/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND We previously reported national 30-d readmission rates of 27% in patients with decompensated cirrhosis (DC).
AIM To study prospective interventions to reduce early readmissions in DC at our tertiary center.
METHODS Adults with DC admitted July 2019 to December 2020 were enrolled and randomized into the intervention (INT) or standard of care (SOC) arms. Weekly phone calls for a month were completed. In the INT arm, case managers ensured outpatient follow-up, paracentesis, and medication compliance. Thirty-day readmission rates and reasons were compared.
RESULTS Calculated sample size was not achieved due to coronavirus disease 2019; 240 patients were randomized into INT and SOC arms. 30-d readmission rate was 33.75%, 35.83% in the INT vs 31.67% in the SOC arm (P = 0.59). The top reason for 30-d readmission was hepatic encephalopathy (HE, 32.10%). There was a lower rate of 30-d readmissions for HE in the INT (21%) vs SOC arm (45%, P = 0.03). There were fewer 30-d readmissions in patients who attended early outpatient follow-up (n = 17, 23.61% vs n = 55, 76.39%, P = 0.04).
CONCLUSION Our 30-d readmission rate was higher than the national rate but reduced by interventions in patients with DC with HE and early outpatient follow-up. Development of interventions to reduce early readmission in patients with DC is needed.
Collapse
Affiliation(s)
- Antoinette Pusateri
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Kevin Litzenberg
- Division of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Claire Griffiths
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Caitlin Hayes
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Bipul Gnyawali
- The Ohio State University College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Michelle Manious
- Division of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Sean G Kelly
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Lanla F Conteh
- Division of Gastroenterology and Hepatology, The Ohio State Wexner Medical Center, Columbus, OH 43210, United States
| | - Sajid Jalil
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Haikady N Nagaraja
- Division of Biostatistics, The Ohio State University, Columbus, OH 43210, United States
| | - Khalid Mumtaz
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| |
Collapse
|
33
|
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: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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.
Collapse
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
| |
Collapse
|
34
|
Abstract
Importance Cirrhosis affects approximately 2.2 million adults in the US. From 2010 to 2021, the annual age-adjusted mortality of cirrhosis increased from 14.9 per 100 000 to 21.9 per 100 000 people. Observations The most common causes of cirrhosis in the US, which can overlap, include alcohol use disorder (approximately 45% of all cases of cirrhosis), nonalcoholic fatty liver disease (26%), and hepatitis C (41%). Patients with cirrhosis experience symptoms including muscle cramps (approximately 64% prevalence), pruritus (39%), poor-quality sleep (63%), and sexual dysfunction (53%). Cirrhosis can be diagnosed by liver biopsy but may also be diagnosed noninvasively. Elastography, a noninvasive assessment of liver stiffness measured in kilopascals, can typically confirm cirrhosis at levels of 15 kPa or greater. Approximately 40% of people with cirrhosis are diagnosed when they present with complications such as hepatic encephalopathy or ascites. The median survival time following onset of hepatic encephalopathy and ascites is 0.92 and 1.1 years, respectively. Among people with ascites, the annual incidence of spontaneous bacterial peritonitis is 11% and of hepatorenal syndrome is 8%; the latter is associated with a median survival of less than 2 weeks. Approximately 1% to 4% of patients with cirrhosis develop hepatocellular carcinoma each year, which is associated with a 5-year survival of approximately 20%. In a 3-year randomized clinical trial of 201 patients with portal hypertension, nonselective β-blockers (carvedilol or propranolol) reduced the risk of decompensation or death compared with placebo (16% vs 27%). Compared with sequential initiation, combination aldosterone antagonist and loop diuretics were more likely to resolve ascites (76% vs 56%) with lower rates of hyperkalemia (4% vs 18%). In meta-analyses of randomized trials, lactulose was associated with reduced mortality relative to placebo (8.5% vs 14%) in randomized trials involving 705 patients and reduced risk of recurrent overt hepatic encephalopathy (25.5% vs 46.8%) in randomized trials involving 1415 patients. In a randomized clinical trial of 300 patients, terlipressin improved the rate of reversal of hepatorenal syndrome from 39% to 18%. Trials addressing symptoms of cirrhosis have demonstrated efficacy for hydroxyzine in improving sleep dysfunction, pickle brine and taurine for reducing muscle cramps, and tadalafil for improving sexual dysfunction in men. Conclusions and Relevance Approximately 2.2 million US adults have cirrhosis. Many symptoms, such as muscle cramps, poor-quality sleep, pruritus, and sexual dysfunction, are common and treatable. First-line therapies include carvedilol or propranolol to prevent variceal bleeding, lactulose for hepatic encephalopathy, combination aldosterone antagonists and loop diuretics for ascites, and terlipressin for hepatorenal syndrome.
Collapse
Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
| |
Collapse
|
35
|
Chauhan M, Zhang T, Thuluvath PJ. Combined effects of hyponatremia and hepatic encephalopathy on inpatient mortality. Ann Hepatol 2023; 28:101084. [PMID: 36878465 DOI: 10.1016/j.aohep.2023.101084] [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: 11/26/2022] [Revised: 01/15/2023] [Accepted: 02/05/2023] [Indexed: 03/08/2023]
Abstract
INTRODUCTION AND OBJECTIVES Although hyponatremia and hepatic encephalopathy (HE) are known independent predictors of mortality, their combined effect is unknown. We investigated whether the inpatient mortality differed among patients with both hyponatremia and HE compared to those with either hyponatremia or HE alone. MATERIALS AND METHODS In this retrospective study, data were extracted from the National Inpatient Sample (NIS) to identify US adults (aged ≥18 years) with cirrhosis between January 1st, 2016, and December 31st, 2017. We analyzed the effects of hyponatremia, HE, or a combination of hyponatremia and HE on inpatient mortality using logistic regression. RESULTS Among 309,841 cirrhosis-related admissions, 22,870 (7%) patients died during hospitalization. Those with a combination of hyponatremia and HE had higher mortality (14%) than those with HE only (11%), hyponatremia only (9%), and neither hyponatremia nor HE (6%) (p<0.001). When compared to patients without hyponatremia or HE, patients with both hyponatremia and HE had the highest odds (adjusted odds ratio or aOR) of inpatient mortality (aOR 1.90, 95% CI: 1.79 - 2.01) followed by patients with HE only (aOR 1.75, 95% CI: 1.69 - 1.82) and patients with hyponatremia only (aOR 1.17, 95% CI: 1.12 - 1.22). Patients with HE only had 50% higher odds of inpatient mortality when compared to those with hyponatremia only (aOR: 1.50, 95% CI: 1.43 - 1.57). CONCLUSIONS In this nationwide study, the presence of both hyponatremia and HE was associated with higher inpatient mortality than either hyponatremia or HE alone.
Collapse
Affiliation(s)
- Mahak Chauhan
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, United States
| | - Talan Zhang
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, United States
| | - Paul J Thuluvath
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, United States; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD. United States.
| |
Collapse
|
36
|
Hund HC, Frantz SK, Wu H, Adeniran OR, Wong TY, Borgmann AJ, Matsuoka L, Geevarghese S, Alexopoulos S, Shingina A, Meranze SG, Baker JC, Garbett S, Brown DB. Six-Year Evaluation of Same-Day Discharge following Conventional Transarterial Chemoembolization of Hepatocellular Carcinoma. J Vasc Interv Radiol 2023; 34:378-385. [PMID: 36481322 DOI: 10.1016/j.jvir.2022.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/09/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To evaluate whether same-day discharge increased the incidence of 30-day readmission (30dR) after conventional transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) at a single institution. MATERIALS AND METHODS In this retrospective study, 253 patients with HCC underwent 521 transarterial chemoembolization procedures between 2013 and 2020. TACE was performed with 50-mg doxorubicin/10-mg mitomycin C/5-10-mL ethiodized oil/particles. Patients not requiring intravenous pain medications were discharged after a 3-hour observation, and 30dR was tracked. The primary objective was to determine the incidence of 30dR in same-day discharge patients versus patients admitted for observation using the chi-square test. Secondary objectives assessed factors associated with overnight admission and factors predictive of 30dR using generalized estimated equation calculations and logistic regression. RESULTS In the cohort, 24 readmissions occurred within 30 days (4.6%). Same-day discharge was completed after 331 TACE procedures with sixteen 30dRs (4.8%). Patients admitted overnight were readmitted 8 times after 190 TACE procedures (4.2%). This difference was not statistically significant (P = .4). Factors predicting overnight admission included female sex (58/190 [30.5%] vs 58/331 [17.5%], P < .001) and tumor size of ≥3.8 cm (104/190 [55%] vs 85/190 [45%]). Factors predicting 30dR included female sex (10/116 [8.6%] vs 14/405 [0.2%]) and younger age (median [interquartile range], 63 years [55-65 years] vs 65 years [59-71 years]). At regression, factors predictive of 30dR were Child-Pugh Class B/C (odds ratio [OR], 2.1; P = .04) and female sex (OR, 2.9; P = .004). CONCLUSIONS Same-day discharge after conventional TACE is a safe and effective strategy with 30dR rate of <5%, similar to overnight observation.
Collapse
Affiliation(s)
- Hannah C Hund
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Shelby K Frantz
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hui Wu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Oladapo R Adeniran
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Thomas Y Wong
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anthony J Borgmann
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lea Matsuoka
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Geevarghese
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sophoclis Alexopoulos
- Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexandra Shingina
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Steven G Meranze
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jennifer C Baker
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shawn Garbett
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel B Brown
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee.
| |
Collapse
|
37
|
Shaw J, Acharya C, Albhaisi S, Fagan A, McGeorge S, White MB, Lachar J, Olson J, Olofson A, Bergstrom L, Kamath PS, Bajaj JS. Subjective and objective burden on providers from a multicenter app-based study of patients with cirrhosis and caregivers. Hepatol Commun 2023; 7:e0030. [PMID: 36706194 PMCID: PMC9988316 DOI: 10.1097/hc9.0000000000000030] [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: 08/21/2022] [Accepted: 10/30/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND App-based technologies could enhance patient and caregiver communication and provide alerts that potentially reducing readmissions. However, the burden of App alerts needs to be optimized to reduce provider burnout. AIM The purpose of this study was to determine subjective and objective burden of using the Patient Buddy App, a health information technology (HIT) on providers in a randomized multicenter trial, who completed a semi-quantitative Likert scale survey regarding training procedures, data and privacy concerns, follow-up details, and technical support. This randomized multicenter trial recruits cirrhosis inpatients and their caregivers, and randomizes them into standard-of-care, HIT (communication only via App) and HIT+visits (App+phone calls/visits) for 30 days after discharge. The alerts are monitored by providers through a central iPad. The reason(s) and number of alerts were recorded as the objective burden. A total of 1442 messages were sent as alerts from the 103 dyads (patient + caregiver) (n=206) randomized to HIT arms. The most common messages related to Hepatic Encephalopathy (HE) (high or low bowel movement=50% or orientation tests=37%). Twelve providers completed the surveys reflecting the following themes-92% and 100%, felt adequately trained and confident about educating the patients and caregivers before roll out of App and had no concerns related to data and privacy; 70%, felt that appropriate time was spent on pursuing reason for data not being logged; 60% each, had issues with availability of adequate technical support and connectivity. CONCLUSION The Patient Buddy App randomized multicenter trial till date shows an overall favorable rating regarding training procedures/education, privacy concerns, and ease of message follow-up, from providers. However, it is important to gauge and address subjective and objective burdens of monitoring human resources in current and future HIT studies to avoid burnout and to ensure successful study completion.
Collapse
Affiliation(s)
- Jawaid Shaw
- Division of Hospital Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Chathur Acharya
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Somaya Albhaisi
- Division of Hospital Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Andrew Fagan
- GI Section, Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - Sara McGeorge
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Melanie B. White
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Jatinder Lachar
- Division of Hospital Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Jessica Olson
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Amy Olofson
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Lori Bergstrom
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Patrick S. Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
- GI Section, Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| |
Collapse
|
38
|
Stoll AM, Guido M, Pence A, Gentene AJ. Lack of Access to Rifaximin Upon Hospital Discharge Is Frequent and Results in Increased Hospitalizations for Hepatic Encephalopathy. Ann Pharmacother 2023; 57:133-140. [PMID: 35658580 DOI: 10.1177/10600280221100537] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Hepatic encephalopathy (HE) is a complication of cirrhosis. Rifaximin, added to lactulose, effectively maintains remission and reduces hospitalizations from HE compared with lactulose alone. Although the clinical evidence supports the use of rifaximin, concerns remain regarding the financial implications and subsequent impact on medication access and outcomes. OBJECTIVE The goal of this study was to determine whether medication access to rifaximin at hospital discharge reduces readmission and office visits related to HE. METHODS A retrospective study was conducted in compliance with local institutional review board including cirrhotic patients discharged with a rifaximin prescription for HE. Patients were stratified into 2 groups: those able to obtain rifaximin and those unable to obtain rifaximin upon discharge. The primary outcome was to evaluate the rate of HE recurrence in each group as defined as a composite of readmission or office visit for acute HE within 12 months of discharge. RESULTS Access to rifaximin significantly reduced the risk of hospital admission and office visit for acute HE over 12 months. A hospitalization or office visit occurred in 24.5% of patients in the medication access group compared with 50% in the group without medication access. Only 58% of patients had access to rifaximin at discharge. CONCLUSION AND RELEVANCE Rifaximin use was associated with significantly reduced risk of hospitalization and office visits for HE. At discharge, 42% of patients did not have access to rifaximin regardless of being prescribed the medication, identifying that copay is a significant barrier in allowing patients to have access to rifaximin.
Collapse
Affiliation(s)
- Ann Marie Stoll
- Internal Medicine, Department of Pharmacy Services, University of Cincinnati Medical Center, UC Health, Cincinnati, OH, USA
| | - Maria Guido
- Internal Medicine, Department of Pharmacy Services, University of Cincinnati Medical Center, UC Health, Cincinnati, OH, USA.,Division of Pharmacy Practice and Administration, University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
| | - Alicia Pence
- Specialty Pharmacy, Department of Pharmacy Services, University of Cincinnati Specialty Pharmacy, UC Health, Cincinnati, OH, USA
| | - Anthony J Gentene
- Internal Medicine, Department of Pharmacy Services, University of Cincinnati Medical Center, UC Health, Cincinnati, OH, USA.,Division of Pharmacy Practice and Administration, University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
| |
Collapse
|
39
|
Abstract
Hepatic encephalopathy (HE) is brain dysfunction secondary to liver insufficiency or portosystemic shunting. HE is a major burden on patients and caregivers, impairs quality of life and is associated with higher mortality. Overt HE is a clinical diagnosis while Covert HE, needs specialized diagnostic strategies. Mainstay of treatment of HE is nonabsorbable disaccharides such as lactulose as well as rifaximin; however, investigational therapies are discussed in this review. Better tools are needed to prognosticate which patients will go on to develop HE but microbiome and metabolomic-driven strategies are promising. Here we review methods to prevent the HE development and admissions.
Collapse
|
40
|
Jesudian AB, Gagnon-Sanschagrin P, Heimanson Z, Bungay R, Chen J, Guérin A, Bumpass B, Borroto D, Joseph G, Dashputre AA. Impact of rifaximin use following an initial overt hepatic encephalopathy hospitalization on rehospitalization and costs. J Med Econ 2023; 26:1169-1177. [PMID: 37664993 DOI: 10.1080/13696998.2023.2255074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 09/05/2023]
Abstract
AIM To assess the impact of rifaximin (± lactulose) use following discharge of an initial overt hepatic encephalopathy (OHE) hospitalization on OHE rehospitalizations and healthcare costs in a real-world setting. METHODS Adults (18-64 years) with an OHE hospitalization were identified from MarketScan® Commercial claims (Q4'15-Q2'20), classified into two mutually exclusive treatment cohorts (i.e. rifaximin and no rifaximin treatment), and further stratified into four subgroups based on decreasing quality of care (QoC; i.e. Type 1 - rifaximin without delay post-discharge; Type 2 - rifaximin with delay post-discharge; Type 3 - lactulose only post-discharge; Type 4 - no rifaximin/lactulose treatment post-discharge). The impact of rifaximin use on 30-day and annualized OHE hospitalizations and healthcare costs were assessed between cohorts and by the QoC subgroup. RESULTS Characteristics were similar between the rifaximin (N = 1,452; Type 1: 1,138, Type 2: 314) and no rifaximin (N = 560; Type 3:337, Type 4: 223) treatment cohorts. The 30-day risk of OHE rehospitalization was lower for the rifaximin vs. no rifaximin treatment cohort (odds ratio 0.56, p < .01) and increased with decreasing QoC. The annual rate of OHE hospitalizations was 59% lower for the rifaximin treatment cohort (incidence rate ratio 0.41, p < .01) and increased with decreasing QoC. Compared to the no rifaximin treatment cohort, the rifaximin treatment cohort had higher pharmacy costs, lower medical costs, and no difference in total healthcare costs. LIMITATIONS This was a claims-based study subject to common data limitations such as billing inaccuracies or omissions in coded claims. Total healthcare costs were reported from a payer's perspective, which do not capture indirect costs associated with patient burden. CONCLUSIONS Initiation of rifaximin after an OHE hospitalization was associated with reduced OHE hospitalizations both in the 30-days following and annually. Further, reduced medical costs offset increased pharmacy costs, and no annual cost differences were observed between cohorts.
Collapse
Affiliation(s)
- Arun B Jesudian
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY, USA
| | | | | | | | | | | | | | | | - George Joseph
- Bausch Health, Bridgewater, NJ, USA
- BioNTech US Inc, Cambridge, MA, USA
| | | |
Collapse
|
41
|
Vaz K, Tan K, Chew M, Crawford J, Ma R, Grace J, Gow P, Sinclair M, Testro A. Rate of early hospital readmission amongst cirrhotic patients is high in Australia: experience from a single liver transplant centre. Intern Med J 2022; 52:2086-2095. [PMID: 36114610 DOI: 10.1111/imj.15932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/01/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS The 30-day hospital readmission rate in cirrhotic patients has been demonstrated to be up to 40% in international studies, but is not well studied in Australia. The aim of the current study was to report on the rate and cause of 30-day hospital readmission from a single liver transplant referral centre, including a cost analysis of readmissions. METHODS This was a retrospective study of consecutive cirrhotic patients admitted to a liver transplant centre in Victoria, Australia, between 1 January 2019 and 31 December 2019. Cases were identified through International Classification of Diseases, Tenth Revision, 10 coding for cirrhosis and its complications. Baseline demographic data, liver-related complications and unrelated extra-hepatic comorbidities, laboratory values and prognostic scores were collected from the electronic medical record. RESULTS One hundred seventy-nine (63% men; median age at index admission, 59 years) patients who were admitted 427 times during the study period were included in the final analysis. The 30-day hospital readmission rate was 46%, with the majority of readmissions attributable to fluid overload (29%), miscellaneous reasons (27%) and infection (20%). One fifth of readmissions were considered preventable. History of variceal haemorrhage was found to be an independent predictor of 30-day hospital readmission. The annual cost of readmission is over AU$2.7 million and the median cost of hospital readmission was about AU$9000. CONCLUSIONS The 30-day hospital readmission rate of 46% is higher than previously reported and almost half of cases were caused by either fluid overload or infection.
Collapse
Affiliation(s)
- Karl Vaz
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Katrina Tan
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Melissa Chew
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Jordan Crawford
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Ronald Ma
- Clinical Costing, Austin Health, Melbourne, Victoria, Australia
| | - Josephine Grace
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Paul Gow
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marie Sinclair
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Adam Testro
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
42
|
Aspinall RJ, Hudson M, Ryder SD, Richardson P, Farrington E, Wright M, Przemioslo RT, Perez F, Kent M, Henrar R, Hickey J, Shawcross DL. Real-world evidence of long-term survival and healthcare resource use in patients with hepatic encephalopathy receiving rifaximin-α treatment: a retrospective observational extension study with long-term follow-up (IMPRESS II). Frontline Gastroenterol 2022; 14:228-235. [PMID: 37056320 PMCID: PMC10086718 DOI: 10.1136/flgastro-2022-102221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 10/02/2022] [Indexed: 11/12/2022] Open
Abstract
Objective To describe survival of patients with hepatic encephalopathy (HE), up to 5 years after initiation of rifaximin-α (RFX) treatment. Design/Method A retrospective, observational extension study within 9 National Health Service secondary/tertiary UK care centres. All patients had a clinical diagnosis of HE, were being treated with RFX and were included in the previous IMPRESS study which reported the 1-year experience. Demographics, clinical outcomes, selected cirrhosis-related complications, hospital admissions and attendances up to 5 years from RFX initiation were extracted from patient medical records and hospital electronic databases. The primary outcome measure was survival at 5 years post-initiation of RFX treatment. Results The study included 138 patients. The survival rate at 5 years post-initiation of RFX was 35% (95% CI 28.2% to 44.4%) overall and 36% (95% CI 26.1% to 45.4%) for patients with alcohol-related liver disease. Median survival from RFX initiation was 2.8 years (95% CI 2.0 to 3.8; n=136). Among 48 patients alive at 5 years, 69% remained on RFX treatment at the end of the observation period, 74% reported no cirrhosis-related complications and 24% (9/37) had received a liver transplant. Between 1 and 5 years post-initiation, total numbers of liver-related emergency department visits, inpatient admissions, intensive care unit admissions and outpatient visits were 84, 194, 3 and 709, respectively; the liver-related 30-day readmission rate was 37%. Conclusion Within UK clinical practice, RFX use in HE was associated with a 35% survival rate with high treatment adherence, 76% transplant-free survival rate, minimal healthcare resource and low rates of complications at 5 years post-initiation.
Collapse
Affiliation(s)
- Richard J Aspinall
- Department of Gastroenterology & Hepatology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Mark Hudson
- Formerly Liver Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Stephen D Ryder
- NIHR Biomedical Research Unit in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Paul Richardson
- Department of Gastroenterology and Hepatology, Royal Liverpool & Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Elizabeth Farrington
- Department of Gastroenterology & Hepatology, Royal Cornwall Hospital, Cornwall, UK
| | - Mark Wright
- Department of Hepatology, University Hospital Southampton, Southampton, UK
| | | | - Francisco Perez
- Department of Gastroenterology, University Hospital of North Durham, Durham, UK
| | - Melanie Kent
- Department of Gastroenterology, University Hospital of North Durham, Durham, UK
| | | | | | - Debbie L Shawcross
- Institute of Liver Studies, Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| |
Collapse
|
43
|
Liu YB, Chen MK. Epidemiology of liver cirrhosis and associated complications: Current knowledge and future directions. World J Gastroenterol 2022; 28:5910-5930. [PMID: 36405106 PMCID: PMC9669831 DOI: 10.3748/wjg.v28.i41.5910] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 09/30/2022] [Accepted: 10/19/2022] [Indexed: 02/06/2023] Open
Abstract
Cirrhosis causes a heavy global burden. In this review, we summarized up-to-date epidemiological features of cirrhosis and its complications. Recent epidemiological studies reported an increase in the prevalence of cirrhosis in 2017 compared to in 1990 in both men and women, with 5.2 million cases of cirrhosis and chronic liver disease occurring in 2017. Cirrhosis caused 1.48 million deaths in 2019, an increase of 8.1% compared to 2017. Disability-adjusted life-years due to cirrhosis ranked 16th among all diseases and 7th in people aged 50-74 years in 2019. The global burden of hepatitis B virus and hepatitis C virus-associated cirrhosis is decreasing, while the burden of cirrhosis due to alcohol and nonalcoholic fatty liver disease (NAFLD) is increasing rapidly. We described the current epidemiology of the major complications of cirrhosis, including ascites, variceal bleeding, hepatic encephalopathy, renal disorders, and infections. We also summarized the epidemiology of hepatocellular carcinoma in patients with cirrhosis. In the future, NAFLD-related cirrhosis will likely become more common due to the prevalence of metabolic diseases such as obesity and diabetes, and the prevalence of alcohol-induced cirrhosis is increasing. This altered epidemiology should be clinically noted, and relevant interventions should be undertaken.
Collapse
Affiliation(s)
- Yuan-Bin Liu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan 430000, Hubei Province, China
| | - Ming-Kai Chen
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan 430000, Hubei Province, China
| |
Collapse
|
44
|
Shaw J, Beyers L, Bajaj JS. Inadequate practices for hepatic encephalopathy management in the inpatient setting. J Hosp Med 2022; 17 Suppl 1:S8-S16. [PMID: 35972037 PMCID: PMC9542542 DOI: 10.1002/jhm.12897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/23/2022] [Accepted: 05/27/2022] [Indexed: 11/18/2022]
Abstract
Hepatic encephalopathy (HE) is an important complication of decompensated liver disease. Hospital admission for episodes of HE are very common, with these patients being managed by the hospitalists. These admissions are costly and burdensome to the health-care system. Diagnosis of HE at times is not straightforward, particularly in patients who are altered and unable to provide any history. Precipitants leading to episodes of HE, should be actively sought and effectively tackled along with the overall management. This mandates timely diagnostics, appropriate initiation of pharmacological treatment, and supportive care. Infections are the most important precipitants leading to HE and should be aggressively managed. Lactulose is the front-line medication for primary treatment of HE episodes and for prevention of subsequent recurrence. However, careful titration in the hospital setting along with the appropriate route of administration should be established and supervised by the hospitalist. Rifaximin has established its role as an add-on medication, in those cases where lactulose alone is not working. Overall effective management of HE calls for attention to guideline-directed nutritional requirements, functional assessment, medication reconciliation, patient education/counseling, and proper discharge planning. This will potentially help to reduce readmissions, which are all too common for HE patients. Early specialty consultation may be warranted in certain conditions. Numerous challenges exist to optimal care of hospitalized OHE patients. However, hospitalists if equipped with knowledge about a systematic approach to taking care of these frail patients are in an ideal position to ensure good inpatient and transition of care outcomes.
Collapse
Affiliation(s)
- Jawaid Shaw
- Department of Internal Medicine, Division of Hospital MedicineVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Lisa Beyers
- Department of Internal Medicine, Strong Memorial HospitalUniversity of RochesterRochesterNew YorkUSA
| | - Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology and NutritionVirginia Commonwealth University and Central Virginia Veterans Healthcare SystemRichmondVirginiaUSA
| |
Collapse
|
45
|
Amin AN, Nguyen PH, Tapper EB. Missed diagnosis of cirrhosis in the inpatient setting. J Hosp Med 2022; 17 Suppl 1:S1-S7. [PMID: 35972039 PMCID: PMC9387549 DOI: 10.1002/jhm.12918] [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: 02/28/2022] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 11/07/2022]
Abstract
Cirrhosis accounts for a large number of deaths in the United States and worldwide, leading to an increasing burden on the healthcare system. Cirrhosis is, however, a progressive disease with different potential complications related to liver dysfunction and portal hypertension. Often, patients may present with complications of cirrhosis without having been diagnosed previously. It is pertinent that clinicians recognize these signs to place patients on an appropriate course of management to help delay or avoid further disease progression while avoiding deleterious outcomes and unnecessary utilization. We will discuss the epidemiology of liver disease, cirrhosis, and its complications (hepatic encephalopathy, ascites, and varices). In this study, we will discuss the rationale and impact of missing these diagnoses on the healthcare system and patient.
Collapse
Affiliation(s)
- Alpesh N. Amin
- Department of Medicine, University of California, Irvine
| | | | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan
| |
Collapse
|
46
|
Tapper EB, Essien UR, Zhao Z, Ufere NN, Parikh ND. Racial and ethnic disparities in rifaximin use and subspecialty referrals for patients with hepatic encephalopathy in the United States. J Hepatol 2022; 77:377-382. [PMID: 35367057 DOI: 10.1016/j.jhep.2022.02.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/25/2022] [Accepted: 02/08/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND & AIMS Rifaximin use in combination with lactulose is associated with a decreased risk of overt hepatic encephalopathy (HE). We sought to determine whether race and ethnicity were associated with rifaximin prescriptions. METHODS We examined data for a 20% random sample of United States Medicare enrollees with cirrhosis and hepatic encephalopathy treated with outpatient lactulose and Part D prescription coverage from 2011-2019. Beginning at the time of first diagnosis, we evaluated time to first prescription of rifaximin accounting for competing risks (Fine-Gray, yielding subdistribution hazard ratios [sHRs]) and cumulative rifaximin exposure using a gamma hurdle model (yielding exposure length ratios). We aimed to determine the association of race and ethnicity with each outcome, adjusting for demographics, clinical factors, and other features of clinical management. RESULTS Overall, 29,095 patients were diagnosed with HE and treated with lactulose, of whom 13,272 were prescribed rifaximin. Compared to White patients, Black patients were least likely to receive any prescription for rifaximin (sHR 0.70; 95% CI 0.65-0.76). Asian and Hispanic patients were also less likely to receive rifaximin compared to White patients. Black patients also received fewer doses of rifaximin (exposure length ratio 0.90; 95% CI 0.82-0.98). Hispanic patients also received fewer doses (0.88; 95% CI 0.80-0.98). Out-of-pocket spending on rifaximin per person-year was higher for Black and Hispanic than White patients. Out-of-pocket medication spending was associated with reduced odds of filling a rifaximin prescription. Black and Hispanic patients were least likely to be referred to a gastroenterologist. CONCLUSION In a national cohort of patients with HE, we observed stark racial and ethnic disparities in the use of rifaximin, an approved therapy for the improvement of HE-specific outcomes. Access to gastroenterologists and cost controls may reduce disparities. LAY SUMMARY Hepatic encephalopathy is a serious problem that can affect people with cirrhosis. When someone develops hepatic encephalopathy, there are 2 main treatments. The first-line treatment is called lactulose. If episodes of hepatic encephalopathy happen on lactulose, another treatment called rifaximin is recommended. In this study, we found that compared to White patients, Black and Hispanic patients are less likely to be prescribed rifaximin, receive fewer rifaximin refills, spend more on rifaximin, and have less access to subspecialists who are familiar with rifaximin. We conclude that efforts to address the cost of rifaximin and access to gastroenterologists could help improve these disparities.
Collapse
Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, United States.
| | - Utibe R Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - Zhe Zhao
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, United States
| | - Nneka N Ufere
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, United States
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, United States
| |
Collapse
|
47
|
Changing Epidemiology of Cirrhosis and Hepatic Encephalopathy. Clin Gastroenterol Hepatol 2022; 20:S1-S8. [PMID: 35940729 PMCID: PMC9531320 DOI: 10.1016/j.cgh.2022.04.036] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 02/07/2023]
|
48
|
Association Between Kidney Dysfunction Types and Mortality Among Hospitalized Patients with Cirrhosis. Dig Dis Sci 2022; 67:3426-3435. [PMID: 34292470 PMCID: PMC9568372 DOI: 10.1007/s10620-021-07159-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 07/05/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND AIMS Kidney dysfunction is associated with increased mortality among patients with cirrhosis. We investigated whether kidney dysfunction types [e.g., acute kidney injury (AKI), chronic kidney disease (CKD), and AKI on CKD] were differentially associated with inpatient mortality. METHODS We utilized the nationwide inpatient sample, a nationally representative database, from 2007 to 2014. We included all hospitalizations with previously validated codes for cirrhosis or associated decompensated cirrhosis diagnoses. We defined kidney dysfunction types also from previously validated codes, and we grouped hospitalizations into the following diagnoses: normal, AKI, CKD, and AKI on CKD. Our primary outcome was inpatient mortality. RESULTS There were 1,293,779 hospitalizations with cirrhosis sampled in this study. Of these hospitalizations, 849,193 (66%) had normal kidney function, 176,418 (14%) had AKI, 157,600 (12%) had CKD, and 110,568 (9%) had AKI on CKD. We found that the proportion of hospitalizations with AKI, CKD, and AKI on CKD increased significantly throughout the study period (p < 0.001, test for trend for all). Kidney dysfunction type was differentially associated with inpatient mortality, even after adjustment: as compared to those with CKD, normal kidney function: OR 0.75 [95 CI 0.73-0.78], AKI: OR 2.40 [95 CI 2.32-2.48], and AKI on CKD: OR 1.66 [95 CI 1.60-1.72]. DISCUSSION Using a nationally representative cohort of all hospitalizations with cirrhosis, our study highlights that the burden of kidney dysfunction, especially AKI, among hospitalizations with cirrhosis is rising, and the inclusion of kidney dysfunction type may be an opportunity to improve prognostication.
Collapse
|
49
|
Tan J, Tang X, He Y, Xu X, Qiu D, Chen J, Zhang Q, Zhang L. In-patient Expenditure Between 2012 and 2020 Concerning Patients With Liver Cirrhosis in Chongqing: A Hospital-Based Multicenter Retrospective Study. Front Public Health 2022; 10:780704. [PMID: 35350474 PMCID: PMC8957842 DOI: 10.3389/fpubh.2022.780704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 02/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background Liver cirrhosis is a major global health and economic challenge, placing a heavy economic burden on patients, families, and society. This study aimed to investigate medical expenditure trends in patients with liver cirrhosis and assess the drivers for such medical expenditure among patients with liver cirrhosis. Methods Medical expenditure data concerning patients with liver cirrhosis was collected in six tertiary hospitals in Chongqing, China, from 2012 to 2020. Trends in medical expenses over time and trends according to subgroups were described, and medical expenditure compositions were analyzed. A multiple linear regression model was constructed to evaluate the factors influencing medical expenditure. All expenditure data were reported in Chinese Yuan (CNY), based on the 2020 value, and adjusted using the year-specific health care consumer price index for Chongqing. Results Medical expenditure for 7,095 patients was assessed. The average medical expenditure per patient was 16,177 CNY. An upward trend in medical expenditure was observed in almost all patient subgroups. Drug expenses were the largest contributor to medical expenditure in 2020. A multiple linear regression model showed that insurance type, sex, age at diagnosis, marital status, length of stay, smoking status, drinking status, number of complications, autoimmune liver disease, and the age-adjusted Charlson comorbidity index score were significantly related to medical expenditure. Conclusion Conservative estimates suggest that the medical expenditure of patients with liver cirrhosis increased significantly from 2012 to 2020. Therefore, it is necessary to formulate targeted measures to reduce the personal burden on patients with liver cirrhosis.
Collapse
Affiliation(s)
- Juntao Tan
- Medical Records and Statistics Room, People's Hospital of Chongqing Banan District, Chongqing, China
| | - Xuewen Tang
- Department of Cardiology, People's Hospital of Chongqing Banan District, Chongqing, China
| | - Yuxin He
- Department of Medical Administration, People's Hospital of Chongqing Banan District, Chongqing, China
| | - Xiaomei Xu
- Department of Gastroenterology, The Fifth People's Hospital of Chengdu, Chengdu, China.,Department of Infectious Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Daoping Qiu
- Medical Records and Statistics Room, People's Hospital of Chongqing Banan District, Chongqing, China
| | - Jianfei Chen
- Department of Cardiology, People's Hospital of Chongqing Banan District, Chongqing, China
| | - Qinghua Zhang
- Department of Science and Education, People's Hospital of Chongqing Banan District, Chongqing, China
| | - Lingqin Zhang
- Department of Biomedical Equipment, People's Hospital of Chongqing Bishan District, Chongqing, China
| |
Collapse
|
50
|
Kröner PT, Aby ES, Wijarnpreecha K, Palmer W. Wilson disease-related cirrhosis is associated with increased odds of hemolytic anemia. J Evid Based Med 2022; 15:15-18. [PMID: 35416435 DOI: 10.1111/jebm.12463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/10/2022] [Accepted: 03/10/2022] [Indexed: 01/11/2023]
Affiliation(s)
- Paul T Kröner
- Division of Gastroenterology and Herpetology, Mayo Clinic, Jacksonville, Florida
| | - Elizabeth S Aby
- Division of Gastroenterology and Herpetology, University of Minnesota, Minneapolis, Minnesota
| | - Karn Wijarnpreecha
- Division of Gastroenterology and Herpetology, Mayo Clinic, Jacksonville, Florida
| | - William Palmer
- Division of Gastroenterology and Herpetology, Mayo Clinic, Jacksonville, Florida
| |
Collapse
|