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EASL Clinical Practice Guidelines: Management of alcohol-related liver disease. J Hepatol 2018; 69:154-181. [PMID: 29628280 DOI: 10.1016/j.jhep.2018.03.018] [Citation(s) in RCA: 477] [Impact Index Per Article: 79.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 03/20/2018] [Indexed: 12/12/2022]
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Singal AK, Kodali S, Vucovich LA, Darley-Usmar V, Schiano TD. Diagnosis and Treatment of Alcoholic Hepatitis: A Systematic Review. Alcohol Clin Exp Res 2016; 40:1390-402. [PMID: 27254289 PMCID: PMC4930399 DOI: 10.1111/acer.13108] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 04/24/2016] [Indexed: 12/16/2022]
Abstract
Alcoholic hepatitis (AH) occurs in about one-third of individuals reporting long-term heavy alcohol use. It is associated with high short-term mortality, economic burden, and hospital resources utilization. We performed this systematic review to (i) describe clinical characteristics and genomics associated with the risk of AH; (ii) discuss role and limitations of liver biopsy and prognostic scoring systems; (iii) summarize evidence regarding the currently available therapies including liver transplantation; and (iv) outline emerging therapies with areas of unmet need. Literature search was performed for studies published in English language (January 1971 through March 2016). The following search engines were used: PubMed, Elsevier Embase, PsycINFO, and Cochrane Library. For the treatment section, only randomized controlled studies were included for this review. A total of 138 studies (59 randomized, 22 systematic reviews or meta-analyses, 7 surveys or guidelines, 7 population-based, and 43 prospective cohorts) were cited. There are over 325,000 annual admissions with AH contributing to about 0.8% of all hospitalizations in the United States. Liver biopsy may be required in about 25 to 30% cases for uncertain clinical diagnosis. Corticosteroids with or without N-acetylcysteine remains the only available therapy for severe episodes. Data are emerging on the role of liver transplantation as salvage therapy for select patients. Abstinence remains the most important factor impacting long-term prognosis. Results from the ongoing clinical trials within the National Institute on Alcohol Abuse and Alcoholism-funded consortia are awaited for more effective and safer therapies. AH is a potentially lethal condition with a significant short-term mortality. A high index of suspicion is required. There remains an unmet need for noninvasive biomarkers for the diagnosis, and predicting prognosis and response to therapy.
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Affiliation(s)
- Ashwani K Singal
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sudha Kodali
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lee A Vucovich
- UAB Lister Hill Library of the Health Sciences, University of Alabama at Birmingham, Birmingham, Alabama
| | - Victor Darley-Usmar
- Department of Pathology and Center for Free Radical Biology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Thomas D Schiano
- Division of Liver Diseases, Mount Sinai School of Medicine, New York City, New York
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Mathurin P. Therapeutic management of alcoholic hepatitis. Clin Res Hepatol Gastroenterol 2015; 39 Suppl 1:S41-5. [PMID: 26189979 DOI: 10.1016/j.clinre.2015.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 05/18/2015] [Indexed: 02/04/2023]
Abstract
Several investigators have given priority to treatment of AH, as this entity is associated with significant early mortality. Patients at significant risk of early death are identified by the use of prognostic models. The Lille model highlights the benefits obtained from strategy integrating the impact of treatment upon the evaluated endpoint. Survival impact of corticosteroids is significant in complete and partial responders, whereas it appeared negligible in null-responders. Infection screening is warranted, but should not contraindicate steroids. In terms of mechanisms, non-response to steroids is the key factor in development of infection and prediction of survival. For patients with severe alcoholic hepatitis failing to medical therapy can be identified earlier and have a 6-month survival around 30%; early liver transplantation in those patients is attractive but highly controversial as it challenges the 6-month abstinence rule prior to LT.
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Affiliation(s)
- Philippe Mathurin
- Service d'hépato-gastroentérologie, hôpital Claude-Huriez, 1(er) étage est, avenue Michel-Polonovski, 59037 Lille, France.
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EASL clinical practical guidelines: management of alcoholic liver disease. J Hepatol 2012; 57:399-420. [PMID: 22633836 DOI: 10.1016/j.jhep.2012.04.004] [Citation(s) in RCA: 431] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 04/04/2012] [Indexed: 12/12/2022]
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Sidhu SS, Goyal O, Singla P, Gupta D, Sood A, Chhina RS, Soni RK. Corticosteroid plus pentoxifylline is not better than corticosteroid alone for improving survival in severe alcoholic hepatitis (COPE trial). Dig Dis Sci 2012; 57:1664-71. [PMID: 22388710 DOI: 10.1007/s10620-012-2097-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 02/10/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Corticosteroids and pentoxifylline reduce short-term mortality in severe alcoholic hepatitis (SAH), but not to the extent desired. Combining both drugs may lead to better survival, but has not yet been studied. AIM To compare the efficacy of corticosteroids plus pentoxifylline with that of corticosteroids alone in improving survival of SAH patients. METHODS Of the 111 patients screened, 70 patients with SAH (Maddrey discriminant function (MDF) ≥ 32) were enrolled. Patients with active infection, bleeding, renal failure, or pancreatitis were excluded. Treatment was given for four weeks to group A (n = 36; prednisolone 40 mg/day plus pentoxifylline 400 mg thrice/day) and group B (n = 34; prednisolone 40 mg/day). Patients were followed up for 6 months. Data are expressed as median (range) or percentage. RESULTS Baseline characteristics of the two groups were similar (MDF group A 78.5 (36.8-140.9), group B 74.9 (45.6-140.2)). Four-week and six-month survival in groups A and B were not significantly different (four-week 72.2 and 73.5%, respectively, p = 1.00; six-month 30.6 and 23.5%, respectively, p = 0.417). At seven days, 55.6% of patients in group A and 64.7% in group B had a Lille score <0.45 (p = 0.473). Six-month survival was significantly higher for patients with a Lille Score <0.45 than for those with a Lille score ≥0.45 (group A 55.5 vs. 0%, p = 0.0006; group B 36 vs. 0%, p = 0.0304). Biological improvement at 28 days was significant for both groups; however, the difference between the groups was not significant. CONCLUSIONS For patients with severe alcoholic hepatitis, a combination of corticosteroids and pentoxifylline has no additional survival advantage compared with corticosteroids alone.
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Affiliation(s)
- Sandeep Singh Sidhu
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India.
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Nguyen-Khac E, Thevenot T, Piquet MA, Benferhat S, Goria O, Chatelain D, Tramier B, Dewaele F, Ghrib S, Rudler M, Carbonell N, Tossou H, Bental A, Bernard-Chabert B, Dupas JL. Glucocorticoids plus N-acetylcysteine in severe alcoholic hepatitis. N Engl J Med 2011; 365:1781-9. [PMID: 22070475 DOI: 10.1056/nejmoa1101214] [Citation(s) in RCA: 257] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Mortality among patients with severe acute alcoholic hepatitis is high, even among those treated with glucocorticoids. We investigated whether combination therapy with glucocorticoids plus N-acetylcysteine would improve survival. METHODS We randomly assigned 174 patients to receive prednisolone plus N-acetylcysteine (85 patients) or only prednisolone (89 patients). All patients received 4 weeks of prednisolone. The prednisolone-N-acetylcysteine group received intravenous N-acetylcysteine on day 1 (at a dose of 150, 50, and 100 mg per kilogram of body weight in 250, 500, and 1000 ml of 5% glucose solution over a period of 30 minutes, 4 hours, and 16 hours, respectively) and on days 2 through 5 (100 mg per kilogram per day in 1000 ml of 5% glucose solution). The prednisolone-only group received an infusion in 1000 ml of 5% glucose solution per day on days 1 through 5. The primary outcome was 6-month survival. Secondary outcomes included survival at 1 and 3 months, hepatitis complications, adverse events related to N-acetylcysteine use, and changes in bilirubin levels on days 7 and 14. RESULTS Mortality was not significantly lower in the prednisolone-N-acetylcysteine group than in the prednisolone-only group at 6 months (27% vs. 38%, P = 0.07). Mortality was significantly lower at 1 month (8% vs. 24%, P = 0.006) but not at 3 months (22% vs. 34%, P = 0.06). Death due to the hepatorenal syndrome was less frequent in the prednisolone-N-acetylcysteine group than in the prednisolone-only group at 6 months (9% vs. 22%, P = 0.02). In a multivariate analysis, factors associated with 6-month survival were a younger age (P<0.001), a shorter prothrombin time (P<0.001), a lower level of bilirubin at baseline (P<0.001), and a decrease in bilirubin on day 14 (P<0.001). Infections were less frequent in the prednisolone-N-acetylcysteine group than in the prednisolone-only group (P = 0.001); other side effects were similar in the two groups. CONCLUSIONS Although combination therapy with prednisolone plus N-acetylcysteine increased 1-month survival among patients with severe acute alcoholic hepatitis, 6-month survival, the primary outcome, was not improved. (Funded by Programme Hospitalier de Recherche Clinique; AAH-NAC ClinicalTrials.gov number, NCT00863785 .).
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Affiliation(s)
- Eric Nguyen-Khac
- Service d'Hépato-Gastroentérologie, Amiens University Hospital, and Equipe Région INSERM 24, University of Picardy, Amiens, France.
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Gramenzi A, Gitto S, Caputo F, Biselli M, Lorenzini S, Bernardi M, Andreone P. Liver transplantation for patients with alcoholic liver disease: an open question. Dig Liver Dis 2011; 43:843-9. [PMID: 21550324 DOI: 10.1016/j.dld.2011.03.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 03/08/2011] [Accepted: 03/27/2011] [Indexed: 12/11/2022]
Abstract
End-stage alcoholic liver disease is a recognised indication for liver transplantation but some questions on the matter remain open. It is difficult to quantify alcohol consumption, and a single definition of post-transplant relapse is lacking. Moreover, there are no internationally accepted criteria for the selection of candidates for liver transplantation and the eligibility parameters for these patients are controversial. Additional clinical and psychological evaluations are necessary in this setting, especially to establish the risk of alcohol relapse. Nevertheless, patient and graft survival rates after liver transplantation in alcoholic liver disease are comparable to those after transplant for other aetiologies, alcohol consumption relapse being one of the most important problems in the post-transplant phase. In conclusion, alcohol-related liver disease is a good indication for liver transplantation. The main future goals are to formulate a well-defined pre-transplant approach and a single definition of alcohol relapse and to improve prevention strategies.
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Affiliation(s)
- Annagiulia Gramenzi
- Department of Clinical Medicine, University of Bologna, Semeiotica Medica, S.Orsola-Malpighi Hospital, Bologna, Italy
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Hépatite alcoolique aiguë : prise en charge en 2011. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-011-0276-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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9
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Li YM, Fan JG, Wang BY, Lu LG, Shi JP, Niu JQ, Shen W. Guidelines for the diagnosis and management of alcoholic liver disease: update 2010: (published in Chinese on Chinese Journal of Hepatology 2010; 18: 167-170). J Dig Dis 2011; 12:45-50. [PMID: 21276208 DOI: 10.1111/j.1751-2980.2010.00477.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- You Ming Li
- Department of Gastroenterology, 1st Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
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Abstract
The risk of developing alcohol-induced liver injury occurs above a risk threshold around 25-30g/day. A dose-dependent relationship between alcohol intake and the risk of developing alcohol-induced liver injury is observed in alcoholic subjects with a daily consumption above this threshold. Cirrhosis is the first cause of death related to alcohol. Cirrhosis occurs more frequently in heavy drinkers disclosing alcoholic hepatitis or steatosis. Excess weight is a risk factor for alcoholic liver disease. The role of alcohol in mouth, oropharynx and oesophageal cancers is clearly established. The evidence for the role of alcohol in breast cancer has become clear. Corticosteroids improved the short-term survival of patients with severe alcoholic hepatitis. The Lille model identifies patients who will not benefit from corticosteroids. The benefit of liver transplantation is restricted to alcoholic patients with severe cirrhosis. Only abstainers are considered as candidates for liver transplantation. The recent development of non invasive methods opens up new perspectives for the screening of cirrhosis in subjects with heavy drinking.
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Affiliation(s)
- P Mathurin
- Service des Maladies de l'Appareil Digestif, Hôpital Claude-Huriez, CHRU, 59000 Lille, France.
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Affiliation(s)
- Michael R Lucey
- Section of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA.
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Mathurin P, Louvet A, Dharancy S. [Acute alcoholic hepatitis. Management practices for 2007]. ACTA ACUST UNITED AC 2008; 32:S179-81. [PMID: 18467050 DOI: 10.1016/j.gcb.2008.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- P Mathurin
- Service d'hépato-gastroentérologie, hôpital Claude-Huriez, CHRU de Lille, avenue Michel-Polonovski, 59037 Lille cedex, France.
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Zeng MD, Li YM, Chen CW, Lu LG, Fan JG, Wang BY, Mao YM. Guidelines for the diagnosis and treatment of alcoholic liver disease. J Dig Dis 2008; 9:113-6. [PMID: 18419646 DOI: 10.1111/j.1751-2980.2008.00332.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Min De Zeng
- Shanghai Institute of Digestive Disease, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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Affiliation(s)
- Philippe Mathurin
- Service d'Hépato-Gastroentérologie Hôpital Claude Huriez 2(ème) étage Est, Avenue Michel Polonovski, CHRU Lille 59037, France.
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Mathurin P, Abdelnour M, Ramond MJ, Carbonell N, Fartoux L, Serfaty L, Valla D, Poupon R, Chaput JC, Naveau S. Early change in bilirubin levels is an important prognostic factor in severe alcoholic hepatitis treated with prednisolone. Hepatology 2003; 38:1363-9. [PMID: 14647046 DOI: 10.1016/j.hep.2003.09.038] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Early identification of patients with severe (discriminant function >or=32) biopsy-proven alcoholic hepatitis (AH) who are not responding to corticosteroids would be clinically relevant. Our goal was to develop simple criteria that will help physicians to promptly identify nonresponders to corticosteroids. A total of 238 patients were included. We used 6 months survival as an end point because of the rule requiring 6 months for listing alcoholic patients for transplantation. Overall survival at 1 and 6 months was 85% +/- 2.3% and 64.3% +/- 3.3%, respectively. An early change in bilirubin levels (ECBL) at 7 days (defined as bilirubin level at 7 days lower than bilirubin level on the first day of treatment) was observed in 73% of patients. At 7 days, in patients with ECBL, bilirubin decreased (84 +/- 75 micromol/L [4.94 +/- 4.40 mg/dL]), whereas it increased in patients without ECBL (76.5 +/- 77 micromol/L [4.50 +/- 4.54 mg/dL], P <.0001). Ninety-five percent of patients with ECBL continued to have improved liver function during treatment. At 6 months, survival of patients with ECBL was significantly higher than that of patients without ECBL, 82.8% +/- 3.3% versus 23% +/- 5.8%, P <.0001. On multivariate analysis, ECBL, discriminant function and creatinine were independent prognostic variables, and ECBL had the most important prognostic value. In conclusion, ECBL is a very simple predictive factor for identifying nonresponders. A recommendation to discontinue corticosteroids after 7 days in patients without ECBL, suggested by our results, awaits additional confirmation.
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Affiliation(s)
- Philippe Mathurin
- Sce d'Hépato-Gastroentérologie, Hôpital Claude Hurriez, and Inserm EPI 0114 Lille, Paris, France.
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Mathurin P, Mendenhall CL, Carithers RL, Ramond MJ, Maddrey WC, Garstide P, Rueff B, Naveau S, Chaput JC, Poynard T. Corticosteroids improve short-term survival in patients with severe alcoholic hepatitis (AH): individual data analysis of the last three randomized placebo controlled double blind trials of corticosteroids in severe AH. J Hepatol 2002; 36:480-7. [PMID: 11943418 DOI: 10.1016/s0168-8278(01)00289-6] [Citation(s) in RCA: 261] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND/AIMS Controversy surrounding the efficacy of corticosteroids in severe alcoholic hepatitis (AH) persists. THE AIMS OF OUR STUDY WERE (a) to analyze individual data of patients with severe AH discriminant function (DF)> or =32 from the last three randomized controlled trials; and (b) to identify the independent prognostic factors associated with short-term survival. METHODS Individual data were collected from the three principal investigators. Survival analysis was performed at 28 days using the Kaplan-Meier method and log-rank test. The independent prognostic values were assessed by the proportional hazards regression model. RESULTS About 102 placebo and 113 corticosteroid patients with DF > or =32 were analyzed. At 28 days, corticosteroid patients had significantly higher survival: 84.6+/-3.4% vs. 65.1+/-4.8%, P=0.001. In univariate analysis, corticosteroid treatment, age, DF, albumin, creatinine and encephalopathy were prognostic factors. In multivariate analysis, age (P=0.0001), serum creatinine (P<0.002) and corticosteroid treatment (P=0.002) were independent prognostic variables. A more dramatic decrease of median serum bilirubin values (micromol/l) was observed at 7 and 14 days in corticosteroid patients (P<0.05) : -76.5 vs. -35 and -105 vs. -45. CONCLUSIONS Corticosteroids improved short-term survival of patients with severe AH. Age and serum creatinine are independent prognostic factors. Corticosteroids are recommended for patients with severe AH.
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