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Siafarikas C, Kapelios CJ, Papatheodoridi M, Vlachogiannakos J, Tentolouris N, Papatheodoridis G. Sodium-glucose linked transporter 2 inhibitors in liver cirrhosis: Beyond their antidiabetic use. Liver Int 2024; 44:884-893. [PMID: 38293770 DOI: 10.1111/liv.15851] [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: 01/02/2024] [Accepted: 01/15/2024] [Indexed: 02/01/2024]
Abstract
Type 2 diabetes mellitus (T2DM) and liver cirrhosis are clinical entities that frequently coexist, but glucose-lowering medication options are limited in cirrhotic patients. Sodium-glucose linked transporter 2 (SGLT2) inhibitors are a class of glucose-lowering medication that act independently of insulin, by causing glycosuria in the proximal convoluted tubule. In this review, we aimed to briefly present the main data and to provide insight into the pathophysiology and potential usefulness of SGLT2 inhibitors in cirrhotic patients with or without T2DM. SGLT2 inhibitors have been proven useful as antidiabetic treatment in patients with metabolic liver disease, with most robust data from patients with metabolic dysfunction-associated steatotic liver disease (MASLD), where they also showed improvement in liver function parameters. Moreover, it has been suggested that SGLT2 inhibitors may have effects beyond their antidiabetic action. Accordingly, they have exhibited cardioprotective effects, expanding their indication in patients with heart failure without T2DM. Since decompensated liver cirrhosis and congestive heart failure share common pathophysiological features, namely renin-angiotensin-aldosterone axis and sympathetic nervous system activation as well as vasopressin secretion, SGLT2 inhibitors could also be beneficial in patients with decompensated cirrhosis, even in the absence of T2DM.
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Affiliation(s)
- Christos Siafarikas
- 1st Propaedeutic Department of Internal Medicine, Medical School of National and Kapodistrian University of Athens, General Hospital of Athens "Laiko", Athens, Greece
| | - Chris J Kapelios
- Heart Failure and Heart Transplantation Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Margarita Papatheodoridi
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, General Hospital of Athens "Laiko", Athens, Greece
| | - John Vlachogiannakos
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, General Hospital of Athens "Laiko", Athens, Greece
| | - Nikolaos Tentolouris
- 1st Propaedeutic Department of Internal Medicine, Medical School of National and Kapodistrian University of Athens, General Hospital of Athens "Laiko", Athens, Greece
| | - George Papatheodoridis
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, General Hospital of Athens "Laiko", Athens, Greece
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Asada S, Kaji K, Nishimura N, Koizumi A, Matsuda T, Tanaka M, Yorioka N, Sato S, Kitagawa K, Namisaki T, Akahane T, Yoshiji H. Tofogliflozin Delays Portal Hypertension and Hepatic Fibrosis by Inhibiting Sinusoidal Capillarization in Cirrhotic Rats. Cells 2024; 13:538. [PMID: 38534382 DOI: 10.3390/cells13060538] [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: 01/28/2024] [Revised: 03/14/2024] [Accepted: 03/14/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Liver cirrhosis leads to portal hypertension (PH) with capillarization of liver sinusoidal endothelial cells (LSECs), although drug treatment options for PH are currently limited. Sodium glucose transporter 2 inhibitors, which are antidiabetic agents, have been shown to improve endothelial dysfunction. We aimed to elucidate the effect of tofogliflozin on PH and liver fibrosis in a rat cirrhosis model. METHODS Male-F344/NSlc rats repeatedly received carbon tetrachloride (CCl4) intraperitoneally to induce PH and liver cirrhosis alongside tofogliflozin (10 or 20 mg/kg). Portal hemodynamics and hepatic phenotypes were assessed after 14 weeks. An in vitro study investigated the effects of tofogliflozin on the crosstalk between LSEC and activated hepatic stellate cells (Ac-HSC), which are relevant to PH development. RESULTS Tofogliflozin prevented PH with attenuated intrahepatic vasoconstriction, sinusoidal capillarization, and remodeling independent of glycemic status in CCl4-treated rats. Hepatic macrophage infiltration, proinflammatory response, and fibrogenesis were suppressed by treatment with tofogliflozin. In vitro assays showed that tofogliflozin suppressed Ac-HSC-stimulated capillarization and vasoconstriction in LSECs by enhancing the antioxidant capacity, as well as inhibited the capilliarized LSEC-stimulated contractive, profibrogenic, and proliferative activities of Ac-HSCs. CONCLUSIONS Our study provides strong support for tofogliflozin in the prevention of liver cirrhosis-related PH.
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Affiliation(s)
- Shohei Asada
- Department of Gastroenterology, Nara Medical University, Kashihara 634-8521, Nara, Japan
| | - Kosuke Kaji
- Department of Gastroenterology, Nara Medical University, Kashihara 634-8521, Nara, Japan
| | - Norihisa Nishimura
- Department of Gastroenterology, Nara Medical University, Kashihara 634-8521, Nara, Japan
| | - Aritoshi Koizumi
- Department of Gastroenterology, Nara Medical University, Kashihara 634-8521, Nara, Japan
| | - Takuya Matsuda
- Department of Gastroenterology, Nara Medical University, Kashihara 634-8521, Nara, Japan
| | - Misako Tanaka
- Department of Gastroenterology, Nara Medical University, Kashihara 634-8521, Nara, Japan
| | - Nobuyuki Yorioka
- Department of Gastroenterology, Nara Medical University, Kashihara 634-8521, Nara, Japan
| | - Shinya Sato
- Department of Gastroenterology, Nara Medical University, Kashihara 634-8521, Nara, Japan
| | - Koh Kitagawa
- Department of Gastroenterology, Nara Medical University, Kashihara 634-8521, Nara, Japan
| | - Tadashi Namisaki
- Department of Gastroenterology, Nara Medical University, Kashihara 634-8521, Nara, Japan
| | - Takemi Akahane
- Department of Gastroenterology, Nara Medical University, Kashihara 634-8521, Nara, Japan
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Kashihara 634-8521, Nara, Japan
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Castera L, Cusi K. Diabetes and cirrhosis: Current concepts on diagnosis and management. Hepatology 2023; 77:2128-2146. [PMID: 36631005 DOI: 10.1097/hep.0000000000000263] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/03/2022] [Indexed: 01/13/2023]
Abstract
Type 2 diabetes mellitus is often associated with cirrhosis as comorbidities, acute illness, medications, and other conditions profoundly alter glucose metabolism. Both conditions are closely related in NAFLD, the leading cause of chronic liver disease, and given its rising burden worldwide, management of type 2 diabetes mellitus in cirrhosis will be an increasingly common dilemma. Having diabetes increases cirrhosis-related complications, including HCC as well as overall mortality. In the absence of effective treatments for cirrhosis, patients with type 2 diabetes mellitus should be systematically screened as early as possible for NAFLD-related fibrosis/cirrhosis using noninvasive tools, starting with a FIB-4 index followed by transient elastography, if available. In people with cirrhosis, an early diagnosis of diabetes is critical for an optimal management strategy (ie, nutritional goals, and glycemic targets). Diagnosis of diabetes may be missed if based on A1C in patients with cirrhosis and impaired liver function (Child-Pugh B-C) as anemia may turn the test unreliable. Clinicians must also become aware of their high risk of hypoglycemia, especially in decompensated cirrhosis where insulin is the only therapy. Care should be within multidisciplinary teams (nutritionists, obesity management teams, endocrinologists, hepatologists, and others) and take advantage of novel glucose-monitoring devices. Clinicians should become familiar with the safety and efficacy of diabetes medications for patients with advanced fibrosis and compensated cirrhosis. Management is conditioned by whether the patient has either compensated or decompensated cirrhosis. This review gives an update on the complex relationship between cirrhosis and type 2 diabetes mellitus, with a focus on its diagnosis and treatment, and highlights knowledge gaps and future directions.
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Affiliation(s)
- Laurent Castera
- Departement of Hepatology, Hospital Beaujon, Assistance Publique-Hôpitaux de Paris, INSERM UMR 1149, Université Paris Cité, Clichy, France
| | - Kenneth Cusi
- Division of Endocrinology, Diabetes and Metabolism, The University of Florida, Gainesville, Florida, USA
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Lee S, Saffo S. Evolution of care in cirrhosis: Preventing hepatic decompensation through pharmacotherapy. World J Gastroenterol 2023; 29:61-74. [PMID: 36683719 PMCID: PMC9850948 DOI: 10.3748/wjg.v29.i1.61] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/22/2022] [Accepted: 12/14/2022] [Indexed: 01/04/2023] Open
Abstract
Cirrhosis is a leading cause of morbidity and mortality, impacting more than 120 million people worldwide. Although geographic differences exist, etiologic factors such as alcohol use disorder, chronic viral hepatitis infections, and non-alcoholic fatty liver disease are prevalent in nearly every region. Historically, significant effort has been devoted to modifying these risks to prevent disease progression. Nevertheless, more than 11% of patients with compensated cirrhosis experience hepatic decompensation each year. This transition signifies the most important prognostic factor in the natural history of the disease, corresponding to a decline in median survival to below 2 years. Over the past decade, the need for pharmacotherapies aimed at reducing the risk for hepatic decompensation has been emphasized, and non-selective beta-blockers have emerged as the most effective option to date. However, a critical therapeutic gap still exists, and additional therapies have been proposed, including statins, rifaximin, and sodium-glucose cotransporter-2 inhibitors. Based on the results of innovative retrospective analyses and small-scale prospective trials, these pharmacotherapies represent promising options, but further studies, including randomized controlled trials, are necessary before they can be incorporated into clinical use. This report highlights the potential impact of these agents and others in preventing hepatic decompensation and discusses how this paradigm shift may pave the way for guideline-directed medical therapy in cirrhosis.
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Affiliation(s)
- Seohyuk Lee
- Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, CT 06520-8019, United States
| | - Saad Saffo
- Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, CT 06520-8019, United States
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Nababan SHH, Lesmana CRA. Portal Hypertension in Nonalcoholic Fatty Liver Disease: From Pathogenesis to Clinical Practice. J Clin Transl Hepatol 2022; 10:979-985. [PMID: 36304507 PMCID: PMC9547264 DOI: 10.14218/jcth.2021.00593] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 04/05/2022] [Accepted: 06/06/2022] [Indexed: 12/04/2022] Open
Abstract
Portal hypertension in nonalcoholic fatty liver disease (NAFLD) mostly occur in cirrhotic stage. However, several experimental and clinical studies showed evidence of portal hypertension in NAFLD without significant or advance fibrosis. This early development of portal hypertension in NAFLD is associated with liver sinusoidal contraction by hepatocellular lipid accumulation and ballooning, which is also accompanied by capillarization and dysfunction of liver sinusoidal endothelial cells. Both of these impaired mechanical and molecular components can cause an increase in intrahepatic vascular resistance which lead to the increase of portal pressure in the absence of significant liver fibrosis. Extrahepatic factors such as insulin resistance and gut dysbiosis may also contribute to liver sinusoidal endothelial dysfunction and early portal hypertension in NAFLD. The clinical impact of early portal hypertension in NAFLD is still unclear. However, clinical tools for diagnosis and monitoring of portal hypertension in NAFLD are being investigated to predict high-risk patients and to guide therapy.
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Affiliation(s)
- Saut Horas H. Nababan
- Hepatobiliary Division, Department of Internal Medicine, Dr Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia
- Gastrointestinal Cancer Center, MRCCC Siloam Semanggi Hospital, Jakarta, Indonesia
| | - Cosmas Rinaldi Adithya Lesmana
- Hepatobiliary Division, Department of Internal Medicine, Dr Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia
- Gastrointestinal Cancer Center, MRCCC Siloam Semanggi Hospital, Jakarta, Indonesia
- Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta, Indonesia
- Correspondence to: Cosmas Rinaldi Adithya Lesmana, Hepatobiliary Division, Department of Internal Medicine, Dr Cipto Mangunkusomo National General Hospital Medical Faculty Universitas Indonesia, Jl. Diponegoro No.71 Jakarta 10430, Indonesia. ORCID: https://orcid.org/0000-0001-9992-9968. Tel: +62-21-31900924, Fax: +62-21-3918842, E-mail: mailto:
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Bañares J, Manzano-Nuñez R, Prió A, Rivera-Esteban J, Camps-Relats L, Villarejo A, Ruiz-Ortega L, Pons M, Ciudin A, Salcedo MT, Vargas V, Genescà J, Pericàs JM. Risk of infections in patients with NAFLD and Type 2 Diabetes under treatment with SGLT2 inhibitors and relationship with liver outcomes: A retrospective case-control study. Front Endocrinol (Lausanne) 2022; 13:945626. [PMID: 36093073 PMCID: PMC9449723 DOI: 10.3389/fendo.2022.945626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/04/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Non-alcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease in developed countries, with its incidence growing parallel to the epidemics of obesity and type 2 diabetes mellitus (T2DM). Sodium-glucose co-transporter-2 inhibitors (SGLT2i) are becoming a cornerstone in the management of cardiovascular health and some studies suggest the potential role in NAFLD. However, patients under treatment with SGLT2i are at risk of developing genitourinary fungal infections (GFIs). Moreover, both NAFLD and SGLT2i have a strong influence on the immune system, and therefore the risk of infections other than GFIs could be increased in NAFLD patients treated with SGLT2i. We aimed to examine the possible association of SGLT2i with infections and hepatic outcomes in NAFLD patients. Methods We conducted a case-control study including NAFLD patients with T2DM visited at the Liver Unit outpatient clinic from 2016 to 2021 with a minimum follow-up of 6 months by selecting 65 patients receiving SGLT2i and 130 matched patients with other types of antidiabetic treatment. Results During follow-up, GFIs were significantly higher in the SGLT2i group (15.4% vs. 3.8%; p=0.008), whereas there were no differences in the occurrence of overall infections (41.5% vs. 30%; p=0.1) nor in other types of specific infections. In the multivariable analysis, treatment with SGLT2i was not independently associated with higher odds of overall infection. On the other hand, SGLT2i patients showed a significantly lower incidence of hepatic events (1.5% vs. 10.7%; p=0.02). There were no significant different in all-cause mortality between cases and controls. Conclusions NAFLD patients with T2DM receiving SGLT2i more frequently presented GFIs, whereas the incidence of other types of infections was not found to be higher than in other patients with NAFLD and T2DM treated with other drugs. Moreover, SGLT2i-treated patients had a lower occurrence of hepatic events. Further studies are warranted to validate our data.
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Affiliation(s)
- Juan Bañares
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Ramiro Manzano-Nuñez
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Alba Prió
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Jesús Rivera-Esteban
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
- Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Camps-Relats
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Ana Villarejo
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Lourdes Ruiz-Ortega
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Mònica Pons
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
- Centro de Investigación Biomédica en Red de enfermedades digestivas y hepáticas (CIBERehd), Madrid, Instituto de Salud Carlos III, Madrid, Spain
| | - Andreea Ciudin
- Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain
- Endocrinology and Nutrition Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDem), Instituto de Salud Carlos III, Madrid, Spain
| | - María Teresa Salcedo
- Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain
- Pathology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
| | - Víctor Vargas
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
- Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de enfermedades digestivas y hepáticas (CIBERehd), Madrid, Instituto de Salud Carlos III, Madrid, Spain
| | - Joan Genescà
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
- Medicine Department, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de enfermedades digestivas y hepáticas (CIBERehd), Madrid, Instituto de Salud Carlos III, Madrid, Spain
| | - Juan M. Pericàs
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Campus Hospitalari, Barcelona, Spain
- Centro de Investigación Biomédica en Red de enfermedades digestivas y hepáticas (CIBERehd), Madrid, Instituto de Salud Carlos III, Madrid, Spain
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Saffo S, Kaplan DE, Mahmud N, Serper M, John BV, Ross JS, Taddei T. Impact of SGLT2 inhibitors in comparison with DPP4 inhibitors on ascites and death in veterans with cirrhosis on metformin. Diabetes Obes Metab 2021; 23:2402-2408. [PMID: 34227216 PMCID: PMC8429193 DOI: 10.1111/dom.14488] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 06/30/2021] [Accepted: 06/30/2021] [Indexed: 01/04/2023]
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) may have favourable neurohumoral and metabolic effects in patients with chronic liver disease. However, studies examining SGLT2i in this population have been limited to patients with non-alcoholic fatty liver disease and have focused on surrogate biomarkers. Our aim was to evaluate whether SGLT2i can reduce the incidence of ascites and death over a period of 36 months in patients with cirrhosis and diabetes mellitus. Using electronic health data from Veterans Affairs hospitals in the United States, we conducted a propensity score matched intention-to-treat analysis among veterans on metformin who subsequently received either SGLT2i or dipeptidyl peptidase-4 inhibitors. Among 423 matched pairs (in total, 846 patients), we found no significant difference in the risk for ascites (hazard ratio 0.68 for SGLT2i, 95% confidence interval 0.37-1.25; p = .22) but did find that SGLT2i users had a reduced risk for death (adjusted hazard ratio 0.33, 95% confidence interval 0.11-0.99; p < .05). In comparison with dipeptidyl peptidase-4 inhibitors, SGLT2i may improve survival for patients with cirrhosis who require additional pharmacotherapy for diabetes mellitus beyond metformin, but confirmatory studies are necessary.
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Affiliation(s)
- Saad Saffo
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut
| | - David E. Kaplan
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Nadim Mahmud
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marina Serper
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Binu V. John
- Section of Hepatology, Bruce W. Carter Veterans Affairs Medical Center, Miami, Florida
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Joseph S. Ross
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Tamar Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut
- Section of Digestive Diseases, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
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