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Almishri W, Altonsy MO, Swain MG. Cholestatic liver disease leads to significant adaptative changes in neural circuits regulating social behavior in mice to enhance sociability. Biochim Biophys Acta Mol Basis Dis 2024; 1870:167100. [PMID: 38412926 DOI: 10.1016/j.bbadis.2024.167100] [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: 10/16/2023] [Revised: 02/16/2024] [Accepted: 02/19/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND & AIMS Cholestatic liver diseases (CLD) are commonly associated with behavioral changes, including social isolation, that negatively affects patient quality of life and remains unaltered by current therapies. It remains unclear whether CLD-associated social dysfunction stems from a direct effect on the brain, or from the psychological impact of CLD. The psychological component of disease is absent in animals, so we investigated the impact of CLD on social behavior and gene expression profiles in key social behavior-regulating brain regions in a mouse model. METHODS CLD due to bile duct ligation was used with the three-chamber sociability test for behavioral phenotyping. Differentially expressed gene (DEG) signatures were delineated in 3 key brain regions regulating social behavior using RNA-seq. Ingenuity Pathway Analysis (IPA®) was applied to streamline DEG data interpretation and integrate findings with social behavior-regulating pathways to identify important brain molecular networks and regulatory mechanisms disrupted in CLD. RESULTS CLD mice exhibited enhanced social interactive behavior and significantly altered gene expression in each of the three social behavior-regulating brain regions examined. DEG signatures in BDL mice were associated with key IPA®-identified social behavior-regulating pathways including Oxytocin in Brain Signaling, GABA Receptor Signaling, Dopamine Receptor Signaling, and Glutamate Receptor Signaling. CONCLUSIONS CLD causes complex alterations in gene expression profiles in key social behavior-regulating brain areas/pathways linked to enhanced social interactive behavior. These findings, if paralleled in CLD patients, suggest that CLD-associated reductions in social interactions predominantly relate to psychological impacts of disease and may inform new approaches to improve management.
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Affiliation(s)
- Wagdi Almishri
- Department of Medicine, Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
| | - Mohammed O Altonsy
- Department of Medicine, Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada; Department of Zoology, Faculty of Science, Sohag University, Sohag, Egypt
| | - Mark G Swain
- Department of Medicine, Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada; University of Calgary Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada.
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Yang J, Jiang S, Fan Q, Wen D, Liu Y, Wang K, Yang H, Guo C, Zhou X, Guo G, Shang Y, Han Y. Prevalence and effect on prognosis of sarcopenia in patients with primary biliary cholangitis. Front Med (Lausanne) 2024; 11:1346165. [PMID: 38487027 PMCID: PMC10937409 DOI: 10.3389/fmed.2024.1346165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/19/2024] [Indexed: 03/17/2024] Open
Abstract
Background Sarcopenia adversely affects the treatment outcomes in Cirrhosis and NAFLD. However, such research is limited in primary biliary cholangitis (PBC) patients. This study was performed to examine the prevalence of sarcopenia and its impact on PBC patients' prognoses. Methods This study enrolled confirmed PBC patients who had an abdominal CT scan. Sarcopenia was determined by the L3-skeletal muscle index with a Chinese population-based cut-off value. Laboratory test values and liver stiffness measurements values were obtained from the electronic medical records. Results In total, 174 PBC patients with a median age of 54 (IQR, 48, 62) years old, were enrolled. 45 (25.9%) patients among them were diagnosed with sarcopenia. Univariate and multivariate logistic regression results illustrated that male gender (OR = 9.152, 95%CI = 3.131-26.751, p < 0.001) and LSM ≥ 12.8 kPa (OR = 4.539, 95%CI = 1.651, 12.478, p = 0.003) were the independent risk factors of sarcopenia in PBC patients. In the prognosis analysis, sarcopenia was determined as a risk factor for indicating adverse events in PBC patients (HR = 4.058, 95%CI = 1.955-8.424, p < 0.001) by Cox proportional hazards regression. Conclusion The current findings illustrate that comprehensive evaluation and management of sarcopenia may contribute to the improvement of treatment outcomes and life quality of PBC patients.
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Affiliation(s)
- Jiaqi Yang
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Shuangshuang Jiang
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Qingling Fan
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Didi Wen
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Yansheng Liu
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Kemei Wang
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Hui Yang
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Changcun Guo
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xinmin Zhou
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Guanya Guo
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Yulong Shang
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Ying Han
- Department of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi’an, China
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Arenas YM, Izquierdo-Altarejos P, Martinez-García M, Giménez-Garzó C, Mincheva G, Doverskog M, Jones DEJ, Balzano T, Llansola M, Felipo V. Golexanolone improves fatigue, motor incoordination and gait and memory in rats with bile duct ligation. Liver Int 2024; 44:433-445. [PMID: 38010893 DOI: 10.1111/liv.15782] [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: 05/26/2023] [Revised: 09/11/2023] [Accepted: 10/23/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND AIMS Many patients with the chronic cholestatic liver disease primary biliary cholangitis (PBC) show fatigue and cognitive impairment that reduces their quality of life. Likewise, rats with bile duct ligation (BDL) are a model of cholestatic liver disease. Current PBC treatments do not improve symptomatic alterations such as fatigue or cognitive impairment and new, more effective treatments are therefore required. Golexanolone reduces the potentiation of GABAA receptors activation by neurosteroids. Golexanolone reduces peripheral inflammation and neuroinflammation and improves cognitive and motor function in rats with chronic hyperammonemia. The aims of the present study were to assess if golexanolone treatment improves fatigue and cognitive and motor function in cholestatic BDL rats and if this is associated with improvement of peripheral inflammation, neuroinflammation, and GABAergic neurotransmission in the cerebellum. METHODS Rats were subjected to bile duct ligation. One week after surgery, oral golexanolone was administered daily to BDL and sham-operated controls. Fatigue was analysed in the treadmill, motor coordination in the motorater, locomotor gait in the Catwalk, and short-term memory in the Y-maze. We also analysed peripheral inflammation, neuroinflammation, and GABAergic neurotransmission markers by immunohistochemistry and Western blot. RESULTS BDL induces fatigue, impairs memory and motor coordination, and alters locomotor gait in cholestatic rats. Golexanolone improves these alterations, and this was associated with improvement of peripheral inflammation, neuroinflammation, and GABAergic neurotransmission in the cerebellum. CONCLUSION Golexanolone may have beneficial effects to treat fatigue, and motor and cognitive impairment in patients with the chronic cholestatic liver disease PBC.
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Affiliation(s)
- Yaiza M Arenas
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | | | - Mar Martinez-García
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Carla Giménez-Garzó
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Gergana Mincheva
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | | | - David E J Jones
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
- Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Tiziano Balzano
- Centro Integral de Neurociencias, Hospital Universitario Puerta del Sur CINAC, Madrid, Spain
| | - Marta Llansola
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
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Ekerfors U, Simrén M, Marschall HU, Demir D, Josefsson A. The influence of muscle performance and fatigue on prognosis in patients with compensated liver disease. BMC Gastroenterol 2023; 23:302. [PMID: 37674115 PMCID: PMC10483859 DOI: 10.1186/s12876-023-02885-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 07/12/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Poor muscle function is associated with a negative prognosis in advanced liver disease but the impact in compensated chronic liver disease is unknown. Similar prognostic uncertainty applies to fatigue. We aimed to assess the prognostic value of muscle performance and fatigue in a cohort of patients with compensated chronic liver disease. METHODS We followed 241 patients with compensated chronic liver disease included in a study between 2010 and 2014. Subjects were 52 ± 15 years (mean ± SD; 134 females). All subjects performed four muscle function tests: "Timed Up and Go" test, walking speed, handgrip strength, and standing heel-rises. Fatigue was evaluated by fatigue impact scale. Follow up data was acquired through hospital records and registries. RESULTS During follow up of 6.75 ± 1.4 years, 13 patients died (5.5%) and 11 (4.5%) patients underwent liver transplantation. A timed up and go over 10 s was not significantly associated with a lower survival (Kaplan-Meier, log rank test p = 0.132), or with transplant free survival (p = 0.543), Fig. 3. It was also not specifically associated with liver related causes of death (p = 0.597). The other physical functioning tests and fatigue were not significantly associated with mortality or transplant-free survival (p > 0.05 for all) except for maximal walking speed (2.2 vs. 1.9 m/s, p = 0.007). CONCLUSIONS Our study suggests that muscle function and fatigue are not key prognostic factors in compensated chronic liver disease. However, further confirmation in future studies is needed.
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Affiliation(s)
- Ulrika Ekerfors
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.
- Institute of Internal Medicine Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Göteborg, 41345, Sweden.
| | - Magnus Simrén
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Daghan Demir
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Axel Josefsson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
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I. Rigopoulou E, Bakarozi M, Dimas I, Galanis K, Lygoura V, K. Gatselis N, Koulentaki M, N. Dalekos G. Total and individual PBC-40 scores are reliable for the assessment of health-related quality of life in Greek patients with primary biliary cholangitis. J Transl Int Med 2023; 11:246-254. [PMID: 37818155 PMCID: PMC10561069 DOI: 10.2478/jtim-2023-0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023] Open
Abstract
Background Primary biliary cholangitis (PBC) has been long associated with impairment of various aspects of health-related quality of life (HRQoL) with substantial differences among populations. This study evaluated for the first-time the HRQoL in Greek PBC patients in conjunction with clinical and laboratory parameters of patients. Methods We analyzed prospectively collected data regarding the HRQoL by using the PBC-40 and SF-36 questionnaires in 374 Greek PBC patients and 131 age- and sex-matched non-PBC controls. Results The PBC-40 questionnaire is a reliable tool for HRQoL assessment in Greek PBC patients (Cronbach's α > 0.7 for all domains). Implementation of PBC-40 and SF-36 demonstrated significant impairment of HRQoL in Greek PBC patients compared to controls (P < 0.001 for all comparisons). Emotional dysfunction, social impairment, and fatigue (100%, 80.5% and 78%, respectively) were amongst those with the highest, while cognitive dysfunction (32%) with the least impact on quality of life. Fatigue was associated with female sex (P = 0.02), longer disease duration (P = 0.01), presence of cirrhosis (P = 0.02) and positivity for PBC-specific ANA (P < 0.05), while social dysfunction with increased age (P < 0.001), longer disease duration (P < 0.001) and presence of cirrhosis (P = 0.004). Living in urban areas was linked to impaired social function (P = 0.04), cognition (P = 0.02), fatigue (P = 0.04) and increased total PBC-40 score (P = 0.01). Conclusions Implementation of PBC-40 and SF-36 revealed impaired HRQoL in Greek PBC patients with fatigue, social and emotional dysfunction exerting the highest impact. However, total, and individual PBC-40 scores were lower than that reported in studies from Northern/Central Europe and Canada. Deranged HRQoL was associated with severity of liver disease and presence of PBC-specific ANA.
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Affiliation(s)
- Eirini I. Rigopoulou
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa41110, Greece
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa41110, Greece
| | - Marianna Bakarozi
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa41110, Greece
| | - Ioannis Dimas
- Hepatology Outpatient Clinic, Gastroenterology Department, University Hospital Heraklion, Heraklion, Crete 70013, Greece
| | - Konstantinos Galanis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa41110, Greece
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa41110, Greece
| | - Vasiliki Lygoura
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa41110, Greece
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa41110, Greece
| | - Nikolaos K. Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa41110, Greece
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa41110, Greece
| | - Mairi Koulentaki
- Hepatology Outpatient Clinic, Gastroenterology Department, University Hospital Heraklion, Heraklion, Crete 70013, Greece
| | - George N. Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa41110, Greece
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa41110, Greece
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Liu J, Gong X, Lv H, Liu S, Jiang Y, Zhu G, Ma X, Wang J, Ye X, Gao Y, Li J, Chen G, Shi J. Is fatigue related to the severity of liver inflammation in patients with chronic liver disease? A cross-sectional study. BMJ Open 2023; 13:e069028. [PMID: 37080620 PMCID: PMC10124276 DOI: 10.1136/bmjopen-2022-069028] [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] [Indexed: 04/22/2023] Open
Abstract
OBJECTIVES Fatigue is common in patients with chronic liver disease; however, its pathogenesis is unclear. This study aimed to provide insights into the pathogenesis of chronic liver disease-related fatigue by assessing the relationship between fatigue and the degree of inflammation in chronic liver disease. DESIGN We performed a cross-sectional study of 1374 patients with pathologically proven chronic liver disease diagnosed at the Affiliated Hospital of Hangzhou Normal University in Hangzhou, China. SETTING Primary single-centre study. PARTICIPANTS One thousand three hundred and seventy-four patients with liver biopsy-proven chronic liver disease. INTERVENTIONS The patients were divided into fatigue and non-fatigue groups according to the Chronic Liver Disease Questionnaire. Propensity score matching was used to match the baseline features of the patients in the two groups. PRIMARY AND SECONDARY OUTCOME MEASURES Liver steatosis, ballooning, inflammation and fibrosis were measured according to the pathological results of liver biopsy. Fatigue was measured using the Chronic Liver Disease Questionnaire. RESULTS Of the 1374 patients, 262 (19.67%) experienced fatigue. There were 242 and 484 patients with and without fatigue, respectively, who were successfully matched for sex, age and classification of chronic liver disease by propensity score matching. After matching, the fatigue group showed higher liver enzyme levels, inflammation grades and fibrosis stages than the non-fatigue group (p<0.05). Multivariate analysis showed that age (OR: 2.026; p=0.003), autoimmune liver disease (OR: 2.749; p=0.002) and active inflammation (OR: 1.587; p=0.003) were independent risk factors for fatigue after adjusting for confounders. The OR of the risk for fatigue increased in a stepwise manner with increasing inflammation grade in young-aged and middle-aged patients (p<0.05). This tendency was not observed in elderly patients (p>0.05). CONCLUSION Patients with chronic liver disease were burdened by fatigue, which increased progressively with rising liver inflammation severity in young-aged and middle-aged rather than elderly patients.
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Affiliation(s)
- Jing Liu
- Department of Hepatology, Hangzhou Normal University Affiliated Hospital, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Xiying Gong
- Fourth Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, China
| | - Haifeng Lv
- Department of Intensive Care Unit, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Shiyi Liu
- Fourth Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, China
| | - Yanming Jiang
- Department of Hepatology, Hangzhou Normal University Affiliated Hospital, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Geli Zhu
- Department of Hepatology, Hangzhou Normal University Affiliated Hospital, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Xiaojie Ma
- Department of Hepatology, Hangzhou Normal University Affiliated Hospital, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Jie Wang
- Department of Hepatology, Hangzhou Normal University Affiliated Hospital, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Xiaoping Ye
- Department of Hepatology, Hangzhou Normal University Affiliated Hospital, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Yidan Gao
- Department of Hepatology, Hangzhou Normal University Affiliated Hospital, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Jie Li
- Department of Infectious Disease, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Gongying Chen
- Department of Hepatology, Hangzhou Normal University Affiliated Hospital, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Junping Shi
- Department of Hepatology, Hangzhou Normal University Affiliated Hospital, Hangzhou Normal University, Hangzhou, Zhejiang, China
- Department of Translational Medicine Platform, Zhejiang Key Laboratory for Research in Assessment of Cognitive Impairments, Hangzhou, China
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Toussaint A, Buck L, Hartl J, Löwe B, Schramm C. Factors associated with severity and persistence of fatigue in patients with primary biliary cholangitis: study protocol of a prospective cohort study with a mixed-methods approach (SOMA.LIV). BMJ Open 2022; 12:e061419. [PMID: 36600365 PMCID: PMC9730385 DOI: 10.1136/bmjopen-2022-061419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Fatigue is a common symptom and the major 'unmet need' in the management of patients with primary biliary cholangitis (PBC). To date, only few prospective studies have addressed the development of PBC-associated fatigue over time. At the same time, few biological and psychosocial risk factors and mechanisms have been identified that could explain the development and maintenance of fatigue in PBC. It is the overall aim of this study to identify factors that determine the course and severity of fatigue in PBC, and to target these factors within deliverable interventions in order to improve patients' quality of life. METHODS AND ANALYSIS To identify biological and psychosocial risk factors for severe fatigue, a prospective 12-month cohort study with one baseline and two follow-up measurements will be conducted. In a cross-sectional part, we will simultaneously examine clinically relevant biomedical and psychosocial factors and systematically assess and compare associations and interactions between these factors and fatigue in n=240 patients with PBC (a patient group severely affected by fatigue) and n=240 patients with primary sclerosing cholangitis, a control cholestatic liver disease group much less affected by fatigue. In a prospective part, we will longitudinally monitor these variables and assess their predictive value at 12-month follow-up. Within an embedded mixed-methods design, we will conduct an experimental study and qualitative interviews in patients with newly diagnosed PBC. ETHICS AND DISSEMINATION The study was approved by the Ethics Committee of the Hamburg Medical Association (2020-10196-BO-ff). The study will shed light onto the mechanisms underlying the evolvement and maintenance of fatigue in patients with PBC and enable the development of evidence-based intervention strategies. Findings will be disseminated through peer-reviewed publications, scientific conferences and the involvement of relevant stakeholders, patients and the lay public. TRIAL REGISTRATION NUMBER ISRCTN14379650.
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Affiliation(s)
- Anne Toussaint
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laura Buck
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Hartl
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Schramm
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- I. Department of Medicine and Martin Zeitz Centre for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Abstract
Fatigue is a common symptom in patients with liver disease and has a significant impact on the health-related quality of life (HR-QoL). Its pathogenesis is poorly understood and is considered multifactorial. The liver is central in the pathogenesis of fatigue because it uniquely regulates much of the production, storage, and release of substrate for energy generation. Also, the liver "cross-talks" with the key organs that are responsible for this symptom complex-gut, skeletal muscle, and brain. Fatigue can have both peripheral (i.e., neuromuscular) and central (i.e., resulting from changes in neurotransmission within the brain) components. The treatment strategies for the management of fatigue are behavioral changes and pharmacotherapy, along with dietetic intervention and exercise. However, there is no consensus on management strategies for fatigue in patients with liver disease. This article gives an overview of fatigue as a concept, its pathophysiology, measures to evaluate fatigue in patients with liver disease, the impact of fatigue on chronic liver disease, assessment of fatigue in an appropriate clinical setting, and various interventions to manage fatigue.
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Key Words
- 6MWD, 6 min walk distance
- ACG, anterior cingulate gyrus
- ADL, activities of daily living
- BBB, blood-brain barrier
- BNST, bed nucleus of stria terminalis
- CEC, cerebral endothelial cell
- CFS, chronic fatigue syndrome
- CPET, cardio-pulmonary exercise testing
- CRH, corticotropin release hormone
- DA, dopamine
- FAS, fatigue assessment scale
- FIS, fatigue impact scale
- FSS, fatigue severity scale
- HGS, hand-grip strength
- HPA, hypothalamus-pituitary-adrenal
- HR-QoL, health-related quality of life
- IADL, instrumental activities of daily living
- ME, meningo-encephalomyelitis
- ME, meningoencephalitis
- NAFLD, nonalcoholic fatty liver disease
- NM, neuromuscular
- NO, nitric oxide
- PGE2, prostaglandins
- PRO, patient-reported outcomes
- PROMIS-F, patient-reported outcome measure information system for fatigue
- PSC, primary sclerosing cholangitis
- SAMe, S-adenosyl-methionine
- SN, substantia nigra
- SPPB, short-physical performance battery
- VAS-F, visual analog scalefatigue
- VTA, ventral tegmental area
- central fatigue
- chronic liver disease
- health-related quality of life [HR-QoL]
- iNOS, inducible nitric oxide synthase
- patient-related outcomes [PRO]
- peripheral fatigue
- vmPFC, ventromedial prefrontal cortex
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Affiliation(s)
| | - Dharmesh Kapoor
- Address for correspondence: Dr. Dharmesh Kapoor, Department of Hepatology, Yashoda Hospitals, Alexander X road, Secunderabad, Telangana, 500026, India.
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Namisaki T, Fujinaga Y, Moriya K, Yoshiji H. The association of histological progression with biochemical response to ursodeoxycholic acid in primary biliary cholangitis. Hepatol Res 2021; 51:31-38. [PMID: 33210415 DOI: 10.1111/hepr.13593] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/01/2020] [Accepted: 11/03/2020] [Indexed: 02/08/2023]
Abstract
Primary biliary cholangitis (PBC) is currently diagnosed at an early stage; therefore, the number of patients with PBC without symptoms at the time of diagnosis is increasing. However, up to 30% of patients with PBC exhibit the suboptimal response to ursodeoxycholic acid (UDCA) and are at high risk of end-stage liver disease. Obeticholic acid is an approved second-line therapy for patients with PBC that are refractory to UDCA. Novel surrogate endpoints are required to identify individuals eligible for second-line therapies. An inadequate biochemical response to UDCA is a useful predictor of poor outcomes in patients with PBC. In addition to UDCA effects on biochemical parameters, histological outcomes could be considered as candidate surrogate endpoints. Alterations in liver histology are used as surrogate endpoints in clinical studies. However, current staging systems are insufficient to determine PBC disease severity and progression because of the pathological heterogeneity of the disease. Histological features at baseline and biochemical response to UDCA treatment can affect the disease course of PBC. Therefore, novel surrogate endpoints must be represented by parameters characterized by histological outcomes and treatment responses in PBC. In this review, we discuss the existing histological parameters and newly created factors to identify patients with PBC who are at a high risk of developing end-stage liver disease and, consequently, the potential need for additional treatments.
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Affiliation(s)
- Tadashi Namisaki
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Yukihisa Fujinaga
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Kei Moriya
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Hitoshi Yoshiji
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara, Japan
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Psychological, Cognitive, and Laboratory Characteristics of End-Stage Liver Disease Patients. HEPATITIS MONTHLY 2020. [DOI: 10.5812/hepatmon.96433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Background: End-Stage Liver Disease (ESLD) causes several clinical and psychological comorbidities. Some accompanying psychiatric disturbances have significant effects on the patients’ quality of life. Objectives: Thus, we aimed to evaluate some psychological characteristics of ESLD patients. Methods: A cross-sectional study was conducted on 91 ESLD patients aged 18 - 70 years. We assessed the patients using the California Verbal Learning Test (CVLT), Fatigue Severity Scale, Epworth Sleepiness Scale, and Hospital Anxiety and Depression Scale. Also, we measured the demographic and some laboratory data of the participants. The data were analyzed by SPSS version 21 software, and P values of less than 0.05 were considered significant. Results: The study included 68 men and 23 women with a mean age of 41.9 ± 13.72 years (range 19 - 68). The mean scores of fatigue (40.6 ± 14.8) and anxiety (12.98 ± 2.76) were more than the normal range. The most significant association was seen between age and CVLT items (attention (P = 0.01), immediate memory (P < 0.001), short delay free recall (0.01), and short delay cued recall (0.03). Conclusions: End-stage liver disease patients had anxiety, fatigue, and memory disorders in addition to their poor clinical conditions. Although the main treatment of ESLD is liver transplantation but the psychological and cognitive problems before transplantation in these patients are prognostic factors for post-operation compliance and follow up.
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11
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Aguilar MT, Chascsa DM. Update on Emerging Treatment Options for Primary Biliary Cholangitis. Hepat Med 2020; 12:69-77. [PMID: 32547264 PMCID: PMC7259454 DOI: 10.2147/hmer.s205431] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/29/2020] [Indexed: 12/12/2022] Open
Abstract
Primary biliary cholangitis (PBC) is a rare autoimmune cholestatic liver disease that may progress to fibrosis or cirrhosis. Treatment options are currently limited. Ursodeoxycholic acid (UDCA) remains first-line therapy and has been proven to normalize serum biochemistries, halt histologic disease progression, and lead to patient survival comparable to the general population. Obeticholic acid (OCA) was recently approved as adjunct therapy in PBC patients with inadequate response or intolerance to UDCA. However, OCA has been associated with worsening pruritus in clinical studies which may limit its use in this patient population. Several studies are currently underway to address the lack of treatment options for PBC. Of these, fibrates, which have been used in Japan for over a decade, have produced promising results. Furthermore, as currently approved therapies for PBC do not address the potentially debilitating clinical symptoms of PBC such as pruritus and fatigue, supplemental therapy is often required for symptom control.
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Affiliation(s)
- Maria T Aguilar
- Department of Gastroenterology & Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - David M Chascsa
- Department of Gastroenterology & Hepatology, Mayo Clinic, Phoenix, AZ, USA
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12
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Lee JY, Danford CJ, Trivedi HD, Tapper EB, Patwardhan VR, Bonder A. Treatment of Fatigue in Primary Biliary Cholangitis: A Systematic Review and Meta-Analysis. Dig Dis Sci 2019; 64:2338-2350. [PMID: 30632051 DOI: 10.1007/s10620-019-5457-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 01/03/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Fatigue is the most common complication of primary biliary cholangitis (PBC) and can be debilitating. Numerous interventions have been trialed targeting several proposed mechanisms of PBC-associated fatigue. We sought to summarize and perform a meta-analysis to determine the efficacy of these interventions. METHODS A comprehensive database search was conducted from inception through March 27, 2018. The primary outcome was proportion of fatigued patients or reduction in degree of fatigue. Adverse events were a secondary outcome. We assessed studies for risk of bias, graded quality of evidence, and used meta-analysis to obtain overall effect by pooling studies of the same class. RESULTS We identified 16 studies evaluating ursodeoxycholic acid (UDCA) (7), liver transplantation (2), serotonin reuptake inhibitors (2), colchicine (1), methotrexate (1), cyclosporine (1), modafinil (1), and obeticholic acid (1). On meta-analysis, UDCA was not associated with a reduction in risk of fatigue (RR = 0.86, 95% CI 0.69-1.08, p = 0.19, I2 = 56.2%). While liver transplantation did reduce degree of fatigue (SMD - 0.57, 95% CI - 0.89 to - 0.24, p = 0.001, I2 = 67.3%), fatigue did not return to baseline indicating the underlying cause may not be addressed. CONCLUSIONS While there is some improvement in fatigue with liver transplantation, there is a lack of high-quality evidence supporting the efficacy of any other intervention in the treatment of PBC-related fatigue. Further research into the underlying pathophysiology may help guide future trials.
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Affiliation(s)
- Jennifer Y Lee
- Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA, 02215, USA
| | - Christopher J Danford
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Dana 603, Boston, MA, 02215, USA
| | - Hirsh D Trivedi
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Dana 603, Boston, MA, 02215, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University Hospital, University of Michigan, Floor 2, Room 2B353, 1500 E. Medical Center Dr SPC 5051, Ann Arbor, MI, 48109-5051, USA
| | - Vilas R Patwardhan
- Liver Center, Autoimmune and Cholestatic Liver Disease Program, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Alan Bonder
- Liver Center, Autoimmune and Cholestatic Liver Disease Program, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA.
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13
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Ekerfors U, Sunnerhagen KS, Westin J, Jakobsson Ung E, Marschall HU, Josefsson A, Simrén M. Muscle performance and fatigue in compensated chronic liver disease. Scand J Gastroenterol 2019; 54:925-933. [PMID: 31287334 DOI: 10.1080/00365521.2019.1635638] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background: A common and debilitating symptom in patients with chronic liver disease is fatigue (CLD). Muscle dysfunction has been suggested to be a key mechanism of fatigue in CLD. Objective: We aimed to evaluate fatigue and the potential association with muscle performance and physical activity in outpatients with CLD. Methods: Two-hundred seventy outpatients with CLD were included, (52 ± 15 years, mean ± SD; 151 females) with autoimmune hepatitis (n = 49), primary biliary cholangitis (n = 45), primary sclerosing cholangitis (n = 46), chronic hepatitis B (n = 57) or C (n = 73). Patients with a Child-Pugh >6 were excluded. The questionnaire Fatigue Impact Scale (FIS) was used to evaluate fatigue, and physical activity was evaluated through a self-reported level of physical activity. Muscle function was assessed with four muscle tests, walking speed, handgrip strength, standing heel-rise test (SHT) and 'Timed Up and Go' test (TUG). Results: The median total FIS score was 30 (40% had FIS > 40, considered high-fatigue). Diminished muscle performance was observed in the SHT (% of predicted value: 53 ± 26%) and with maximum grip strength (85 ± 20%). The FIS score was significantly different between groups of CLDs (p = .004). In multivariate analysis the TUG (p = .001), SHT (p = .005), antidepressants (p < .001), and level of physical activity (p = .001) were associated with fatigue (R2 = 29%). Subjects with higher levels of physical activity had lower FIS (p < .001). Conclusions: In patients with CLD, fatigue was associated with low muscle performance and reduced level of physical activity, which could be a potential therapeutic target.
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Affiliation(s)
- Ulrika Ekerfors
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden.,University of Gothenburg Centre for Person-Centered Care (GPCC), Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Katharina Stibrant Sunnerhagen
- University of Gothenburg Centre for Person-Centered Care (GPCC), Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden.,Rehabilitation Medicine, Section for Clinical Neuroscience, Institute for Neuroscience and Physiology , Gothenburg , Sweden
| | - Johan Westin
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg , Gothenburg , Sweden
| | - Eva Jakobsson Ung
- University of Gothenburg Centre for Person-Centered Care (GPCC), Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden.,Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg , Gothenburg , Sweden
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Axel Josefsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Magnus Simrén
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden.,University of Gothenburg Centre for Person-Centered Care (GPCC), Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden.,Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
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14
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Mitchell E, Frith J, Newton J. Fatigue and cognitive impairment in immune thrombocytopenic purpura remain stable over time: short report from a longitudinal study. Br J Haematol 2019; 186:777-781. [PMID: 31119732 DOI: 10.1111/bjh.15993] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/11/2019] [Indexed: 11/28/2022]
Abstract
Immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterised by low platelet counts and increased bleeding risk. In 2009, two cross-sectional studies determined that fatigue and cognitive impairment (CI) were common in ITP. Here, we report the results from a longitudinal study of 34 people with ITP. Fatigue severity remained unchanged over 7 years, and CI significantly improved. Future fatigue and CI severity could be predicted using baseline severity scores. These findings may be reassuring for ITP patients, as symptoms remain stable over time. Furthermore, using baseline scores to predict future severity could aid the clinical management of ITP.
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Affiliation(s)
- Eleanor Mitchell
- Institute of Cellular Medicine, Medical School, Newcastle upon Tyne, UK
| | - James Frith
- Institute of Cellular Medicine, Medical School, Newcastle upon Tyne, UK
| | - Julia Newton
- Institute of Cellular Medicine, Medical School, Newcastle upon Tyne, UK
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15
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Gossard AA, Lindor KD. Current and promising therapy for primary biliary cholangitis. Expert Opin Pharmacother 2019; 20:1161-1167. [DOI: 10.1080/14656566.2019.1601701] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Andrea A Gossard
- Mayo Clinic, Division of Gastroenterology and Hepatology, Rochester, MN, USA
| | - Keith D. Lindor
- Mayo Clinic, Division of Gastroenterology and Hepatology, Rochester, MN, USA
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16
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Cazzagon N, Dal Lin C, Famoso G, Montisci R, Franceschet I, Floreani A, Tona F. Coronary flow reserve in patients with primary biliary cholangitis. Dig Liver Dis 2019; 51:542-548. [PMID: 30448459 DOI: 10.1016/j.dld.2018.10.016] [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: 07/03/2018] [Revised: 10/16/2018] [Accepted: 10/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND It is still not clear whether primary biliary cholangitis (PBC) is associated with abnormalities of the cardiovascular system. We aimed to assess the relationship between PBC and coronary flow reserve (CFR). METHODS Our inclusion criterion was a diagnosis of PBC with no clinical evidence of heart disease or metabolic syndrome. Coronary flow velocity in the left anterior descending coronary artery was measured using transthoracic Doppler echocardiography at rest (DFVr), and during adenosine infusion (DFVh). The corrected CFR (cCFR) was defined as the ratio of DFVh to DFVr corrected for cardiac workload (cDFVr). Microvascular resistance was also assessed in baseline (BMR) and hyperemic conditions (HMR). RESULTS 37 PBC patients and 37 sex- and age-matched controls were considered. The cCFR was significantly lower in PBC patients (2.8 ± 0.7 vs. 3.7 ± 0.7, p < 0.0001), and abnormal (≤2.5) in 13 (35%) of them, but in none of the controls (p < 0.0001). The cDFVr was higher in patients with abnormal cCFR (29.0 ± 6.0 vs. 20.4 ± 4.5 cm/sec, p < 0.0001). The CFR and cCFR did not correlate with any characteristics of PBC, comorbidities or Framingham risk scores. The BMR and HMR correlated with time since PBC diagnosis and duration of symptoms. CONCLUSION The CFR is reduced in PBC, apparently due to mechanisms correlating with the time since diagnosis. In particular, the higher cDFVr with a lower basal resistance in patients with cCFR ≤ 2.5 suggests a compensatory mechanism against any cardiomyocyte bioenergetics impairment.
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Affiliation(s)
- Nora Cazzagon
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy.
| | - Carlo Dal Lin
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Giulia Famoso
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Roberta Montisci
- Cardiology Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Irene Franceschet
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Annarosa Floreani
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Francesco Tona
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
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17
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Raikhelson KL, Kondrashina EA. Ademethionine in the treatment of fatigue in liver diseases: a systematic review. TERAPEVT ARKH 2019; 91:134-142. [DOI: 10.26442/00403660.2019.02.000130] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Fatigue has a significant effect on the condition of patients with liver disease. Ademethionine is considered one of the most promising drugs for its treatment. Aim. To systematize the published data on the treatment of hepatogenic fatigue with аdemethionine. Materials and methods. Search was performed using databases PubMed, EMBASE, Embase®, Medline®, eLIBRARY.ru, published in 1952-2018. Results and discussion. 16 articles were found on the use of ademethionine in liver diseases and the assessment of the dynamics of the symptom of fatigue, including 1 double-blind, randomized, placebo-controlled study, 3 open randomized studies; most of the works were multicenter open observation programs. The studies included 3238 patients (of which 2820 were included in the final data analysis) and a wide range of liver diseases: alcoholic liver disease, nonalcoholic fatty liver disease, primary biliary cholangitis, primary sclerosing cholangitis, cirrhosis of different causes, viral hepatitis, drug-induced liver injury. Different doses, routes of administration of аdemethionine and the duration of the course were used. Conclusions. Ademethionine, regardless of the route of administration, is effective in the treatment of fatigue due to different liver disease in the short and long term. The dose-dependent effect of the drug and the possibility of maintaining post-effect after end of the treatment course should be assumed, but this requires further study in randomized clinical trials.
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18
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Mosher V, Swain M, Pang J, Kaplan G, Sharkey K, MacQueen G, Goodyear BG. Primary biliary cholangitis patients exhibit MRI changes in structure and function of interoceptive brain regions. PLoS One 2019; 14:e0211906. [PMID: 30735529 PMCID: PMC6368379 DOI: 10.1371/journal.pone.0211906] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/22/2019] [Indexed: 12/12/2022] Open
Abstract
Background Many patients with primary biliary cholangitis (PBC) experience non-hepatic symptoms that are possibly linked to altered interoception, the sense of the body’s internal state. We used magnetic resonance imaging (MRI) to determine if PBC patients exhibit structural and functional changes of the thalamus and insula, brain regions that process signals related to interoception. Methods Fifteen PBC patients with mild disease and 17 controls underwent 3 Tesla T1-weighted MRI, resting-state functional MRI, and quantitative susceptibility mapping (QSM), to measure thalamic and insular volume, neuronal activity and iron deposition, respectively. Group differences were assessed using analysis of covariance, and stepwise linear regression was used to determine the predictive power of clinical indicators of disease. Results PBC patients exhibited reduced thalamic volume (p < 0.01), and ursodeoxycholic acid (UDCA) non-responders exhibited lower left thalamus activity (p = 0.05). PBC patients also exhibited reduced anterior insula activity (p = 0.012), and liver stiffness positively correlated with MRI indicators of anterior insula iron deposition (p < 0.02). Conclusions PBC affects structure and function of brain regions critically important to interoception. Moreover, these brain changes occur in patients with early, milder disease and thus may potentially be reversible.
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Affiliation(s)
- Victoria Mosher
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Seaman Family MR Research Centre, University of Calgary, Calgary, Alberta, Canada
| | - Mark Swain
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta, Canada
- Liver Unit – Calgary Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Jack Pang
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Keith Sharkey
- Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Physiology & Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - Glenda MacQueen
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
- Mathison Centre for Mental Health Research and Education, University of Calgary, Calgary, Alberta, Canada
| | - Bradley Gordon Goodyear
- Seaman Family MR Research Centre, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- * E-mail:
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19
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Swain MG, Jones DEJ. Fatigue in chronic liver disease: New insights and therapeutic approaches. Liver Int 2019; 39:6-19. [PMID: 29935104 DOI: 10.1111/liv.13919] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/20/2018] [Indexed: 02/07/2023]
Abstract
The management of fatigue associated with chronic liver disease is a complex and major clinical challenge. Although fatigue can complicate many chronic diseases, it is particularly common in diseases with an inflammatory component. Fatigue can have both peripheral (i.e., neuromuscular) and central (i.e., resulting from changes in neurotransmission within the brain) causes. However, fatigue in chronic liver disease has strong social/contextual components and is often associated with behavioural alterations including depression and anxiety. Given the increasing awareness of patient-reported outcomes as important components of treatment outcomes and clinical research, there is a growing need to better understand and manage this poorly understood yet debilitating symptom. Although several pathophysiological mechanisms for explaining the development of fatigue have been generated, our understanding of fatigue in patients with chronic liver disease remains incomplete. A better understanding of the pathways and neurotransmitter systems involved may provide specific directed therapies. Currently, the management of fatigue in chronic liver disease can involve a combined use of methods to beneficially alter behavioural components and pharmacological interventions, of which several treatments have potential for the improved management of fatigue in chronic liver disease. However, evidence and consensus are lacking on the best approach and the most appropriate biochemical target(s) whilst clinical trials to address this issue have been few and limited by small sample size. In this review, we outline current understanding of the impact of fatigue and related symptoms in chronic liver disease, discuss theories of pathogenesis, and examine current and emerging approaches to its treatment.
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Affiliation(s)
- Mark G Swain
- Calgary Liver Unit, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - David E J Jones
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, UK
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20
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Lindor KD, Bowlus CL, Boyer J, Levy C, Mayo M. Primary Biliary Cholangitis: 2018 Practice Guidance from the American Association for the Study of Liver Diseases. Hepatology 2019; 69:394-419. [PMID: 30070375 DOI: 10.1002/hep.30145] [Citation(s) in RCA: 288] [Impact Index Per Article: 57.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 05/30/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Keith D Lindor
- Arizona State University, Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ
| | | | | | | | - Marlyn Mayo
- University of Texas Southwestern Medical Center, Dallas, TX
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21
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Krawczyk M, Koźma M, Szymańska A, Leszko K, Przedniczek M, Mucha K, Foroncewicz B, Pączek L, Moszczuk B, Milkiewicz P, Raszeja-Wyszomirska J. Effects of liver transplantation on health-related quality of life in patients with primary biliary cholangitis. Clin Transplant 2018; 32:e13434. [PMID: 30362634 DOI: 10.1111/ctr.13434] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 10/15/2018] [Accepted: 10/19/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients with primary biliary cholangitis (PBC) have decreased health-related quality of life (HRQoL). Here, we investigate HRQoL in two cohorts of transplanted patients with PBC and compare their results to healthy subjects. PATIENTS AND METHODS We used generic SF-36 and disease-specific PBC-40 questionnaires to evaluate HRQoL in 26 patients with PBC (23 females, age 59.4 ± 5.7 years) before and after liver transplantation (LT), and in 107 patients with PBC (99 females, age 62.8 ± 6.7 years) who were previously transplanted. The control group was comprised of 60 healthy controls (55 females, age 54.6 ± 8.8 years). RESULTS Health-related quality of life improved after LT in 85% of PBC patients. The SF-36 measure showed significant (all P < 0.05) improvements in the majority of domains after LT, and in the summary scores both physical and mental. We also documented significant improvements in pruritus and fatigue after LT (all P < 0.01). However, liver graft recipients had significantly worse physical functioning, physical role, and emotional role domains, and physical component score (all P < 0.001), as compared to healthy subjects. No differences in HRQoL were detected between patients evaluated after short and prolonged post-LT periods (P > 0.05). CONCLUSION Liver transplantation substantially improves most aspects of life quality in PBC patients. Nevertheless, their HRQoL remains worse in comparison to healthy individuals, mainly in physical aspects.
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Affiliation(s)
- Marcin Krawczyk
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany.,Laboratory of Metabolic Liver Diseases, Center for Preclinical Research, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Małgorzata Koźma
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Agnieszka Szymańska
- Department of Immunology, Transplantology and Internal Medicine, Transplantation Institute, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Leszko
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Marta Przedniczek
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Mucha
- Department of Immunology, Transplantology and Internal Medicine, Transplantation Institute, Medical University of Warsaw, Warsaw, Poland.,Institute of Biochemistry and Biophysics, Polish Academy of Sciences, Warsaw, Poland
| | - Bartosz Foroncewicz
- Department of Immunology, Transplantology and Internal Medicine, Transplantation Institute, Medical University of Warsaw, Warsaw, Poland
| | - Leszek Pączek
- Department of Immunology, Transplantology and Internal Medicine, Transplantation Institute, Medical University of Warsaw, Warsaw, Poland.,Institute of Biochemistry and Biophysics, Polish Academy of Sciences, Warsaw, Poland
| | - Barbara Moszczuk
- Institute of Biochemistry and Biophysics, Polish Academy of Sciences, Warsaw, Poland
| | - Piotr Milkiewicz
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland.,Translational Medicine Group, Pomeranian Medical University, Szczecin, Poland
| | - Joanna Raszeja-Wyszomirska
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
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22
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Magnetic resonance imaging evidence of hippocampal structural changes in patients with primary biliary cholangitis. Clin Transl Gastroenterol 2018; 9:169. [PMID: 29977030 PMCID: PMC6033882 DOI: 10.1038/s41424-018-0038-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/11/2018] [Accepted: 06/07/2018] [Indexed: 12/13/2022] Open
Abstract
Introduction Behavioral symptoms are commonly reported by patients with primary biliary cholangitis (PBC). In other patient populations, symptoms are commonly associated with hippocampal volume reduction linked to neuroinflammation (inferred from regional iron deposition), as demonstrated by magnetic resonance imaging (MRI). We hypothesized that PBC patients would exhibit reduced volume and increased iron deposition of the hippocampus. Methods Seventeen female non-cirrhotic PBC patients and 17 age/gender-matched controls underwent 3-Tesla T1-weighted MRI and quantitative susceptibility mapping (QSM; an indicator of iron deposition). The hippocampus and its subfields were segmented from T1 images using Freesurfer, and susceptibility of the whole hippocampus was calculated from QSM images. Volume and susceptibility were compared between groups, and associations with PBC-40 score and disease indicators (years since diagnosis, Fibroscan value, alkaline phosphatase level, clinical response to ursodeoxycholic acid (UDCA)) were investigated. Results PBC patients exhibited significantly reduced hippocampal volume (p = 0.023) and increased susceptibility (p = 0.048). Subfield volumes were reduced for the subiculum, molecular layer, granule cell layer of the dentate gyrus and CA4 (p < 0.05). Fibroscan value was significantly correlated with PBC-40 (Spearman’s rho = 0.499; p = 0.041) and disease duration (Spearman’s rho = 0.568; p = 0.017). Discussion Our findings suggest hippocampal changes occur early in the disease course of PBC, similar in magnitude to those observed in major depressive disorder and neurodegenerative diseases. Translational impact Clinical management of PBC could include early interventional strategies that promote hippocampal neurogenesis that may beneficially impact behavioral symptoms and improve quality of life.
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23
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Parés A. Advances in treatment options for patients with primary biliary cholangitis. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1394840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Albert Parés
- Liver Unit, University of Barcelona, Hospital Clínic, Institut d’Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
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Mosher VAL, Swain MG, Pang JXQ, Kaplan GG, Sharkey KA, MacQueen GM, Goodyear BG. Primary Biliary Cholangitis Alters Functional Connections of the Brain's Deep Gray Matter. Clin Transl Gastroenterol 2017; 8:e107. [PMID: 28749455 PMCID: PMC5539342 DOI: 10.1038/ctg.2017.34] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 05/31/2017] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES Fatigue, itch, depressed mood, and cognitive impairment significantly impact the quality of life of many patients with primary biliary cholangitis (PBC). Previous neuroimaging studies of non-hepatic diseases suggest that these symptoms are often associated with dysfunction of deep gray matter brain regions. We used resting-state functional magnetic resonance imaging (rsfMRI) to determine whether PBC patients exhibit altered functional connections of deep gray matter. METHODS Twenty female non-cirrhotic PBC patients and 21 age/gender-matched controls underwent rsfMRI. Resting-state functional connectivity (rsFC) of deep gray matter brain structures (putamen, thalamus, amygdala, hippocampus) was compared between groups. Fatigue, itch, mood, cognitive performance, and clinical response to ursodeoxycholic acid (UDCA) were assessed, and their association with rsFC was determined. RESULTS Relative to controls, PBC patients exhibited significantly increased rsFC between the putamen, thalamus, amygdala, and hippocampus, as well as with frontal and parietal regions. Reduced rsFC of the putamen and hippocampus with motor and sensory regions of the brain were also observed. Fatigue, itch, complete response to UDCA, and verbal working memory performance were also associated with altered rsFC of deep gray matter. These rsFC changes were independent of biochemical disease severity. CONCLUSIONS PBC patients have objective evidence of altered rsFC of the brain's deep gray matter that is in part linked to fatigue severity, itch, response to UDCA therapy, and cognitive performance. These results may guide future approaches to define how PBC leads to altered brain connectivity and provide insight into novel targets for treating PBC-associated brain dysfunction and behavioral symptoms.
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Affiliation(s)
- Victoria A L Mosher
- Seaman Family MR Research Centre, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Mark G Swain
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta, Canada.,Liver Unit-Calgary Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Jack X Q Pang
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Keith A Sharkey
- Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Department of Physiology &Pharmacology, University of Calgary, Calgary, Alberta, Canada
| | - Glenda M MacQueen
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada.,Mathison Centre for Mental Health Research and Education, University of Calgary, Calgary, Alberta, Canada
| | - Bradley G Goodyear
- Seaman Family MR Research Centre, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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25
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EASL Clinical Practice Guidelines: The diagnosis and management of patients with primary biliary cholangitis. J Hepatol 2017; 67:145-172. [PMID: 28427765 DOI: 10.1016/j.jhep.2017.03.022] [Citation(s) in RCA: 729] [Impact Index Per Article: 104.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 03/23/2017] [Indexed: 02/07/2023]
Abstract
Primary biliary cholangitis (PBC) is a chronic inflammatory autoimmune cholestatic liver disease, which when untreated will culminate in end-stage biliary cirrhosis. Diagnosis is usually based on the presence of serum liver tests indicative of a cholestatic hepatitis in association with circulating antimitochondrial antibodies. Patient presentation and course can be diverse and risk stratification is important to ensure all patients receive a personalised approach to their care. The goals of treatment and management are the prevention of end-stage liver disease, and the amelioration of associated symptoms. Pharmacologic approaches in practice, to reduce the impact of the progressive nature of disease, currently include licensed therapies (ursodeoxycholic acid and obeticholic acid) and off-label therapies (fibric acid derivatives, budesonide). These clinical practice guidelines summarise the evidence for the importance of a structured, life-long and individualised, approach to the care of patients with PBC, providing a framework to help clinicians diagnose and effectively manage patients.
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Zec S, Popovic D, Matovic V, Nikolic V, Bojovic K, Jovic J, Markovic Denic L, Milosavljevic T, Alempijevic T. Translation and validation of the Serbian primary biliary cholangitis-40 questionnaire. PLoS One 2017; 12:e0175697. [PMID: 28406960 PMCID: PMC5391097 DOI: 10.1371/journal.pone.0175697] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 03/29/2017] [Indexed: 02/07/2023] Open
Abstract
Background and aims To translate into Serbian and validate the Primary Biliary Cholangitis–40 (PBC-40) and PBC-27 questionnaires. Materials and methods Ninety-four consecutive outpatients with the diagnosis of PBC from three departments across two tertiary care institutions in Belgrade were enrolled from February to October 2016. Standard methodology for cultural adaption of healthcare related quality of life questionnaires was used, and included: a forward translation, backward translation and a pilot test of the Serbian PBC-40 on five patients who gave suggestions and comments. For evaluation of the questionnaires, acceptance was shown by the proportion of missing items and the internal consistency was assessed using Cronbach’s α coefficient. The PBC-40 was self-administered under the supervision of an experienced hepatologist. The PBC-27 is a shorter version of the PBC-40. Results A total of 92 (97.9%) of the patients were females. The mean age was 59.26 ± 1.05 years and the average length of disease was 60.45 ± 48.314 months. The average PBC-40 score was 85.62 ± 30.46. The total time needed to complete the questionnaire ranged from 7 to 16 minutes. The proportion of missing items was 5.45% (205/3760). Cronbach’s α for the entire scale was 0.93. Reliability for all of the domains of the PBC-40 was above 0.70, except for the domain “Symptoms” (α = 0.52). Overall reliability of the PBC-27 was α = 0.90. Domains “Dryness”, “Symptoms” and “Fatigue” demonstrated reliability below α = 0.70. Conclusions The Serbian PBC-40 is a valid and reasonably adequate for use in Serbian PBC patients. The PBC-40 is preferred over the PBC-27.
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Affiliation(s)
- Simon Zec
- Department of Internal Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia
- * E-mail:
| | - Dusan Popovic
- Department of Internal Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
| | - Vera Matovic
- Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
| | - Vladimir Nikolic
- Department of Internal Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ksenija Bojovic
- Department of Internal Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Gastroenterology and Hepatology, Clinic for Tropical and Infectious Diseases, Clinical Center of Serbia, Belgrade, Serbia
| | - Jasna Jovic
- Department of Gastroenterology and Hepatology, Military Medical Academy, Belgrade, Serbia
| | - Ljiljana Markovic Denic
- Department of Internal Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia
- Institute of Epidemiology, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Tomica Milosavljevic
- Department of Internal Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
| | - Tamara Alempijevic
- Department of Internal Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Belgrade, Serbia
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A Randomized, Placebo-Controlled Clinical Trial of Efficacy and Safety: Modafinil in the Treatment of Fatigue in Patients With Primary Biliary Cirrhosis. Am J Ther 2017; 24:e167-e176. [PMID: 27148676 DOI: 10.1097/mjt.0000000000000387] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Fatigue is a common symptom of primary biliary cirrhosis (PBC), and is associated with an impaired quality of life. STUDY QUESTION No studies have assessed the use of modafinil in fatigue related to PBC in a controlled manner. STUDY DESIGN, MEASURES, AND OUTCOMES A randomized, double-blind, placebo-controlled study was conducted to determine the safety and efficacy of modafinil for the treatment of fatigue in PBC. Forty patients were randomized to modafinil (n = 20) or placebo (n = 20) for 12 weeks. A verbal report of fatigue for at least 6 months was required for enrollment. Modafinil was administered at 100 mg by mouth once daily; a change by 50 mg every 2 weeks (maximum: 200 mg once daily) was allowed, depending on the subject's response to treatment. The primary outcome was defined as a ≥50% improvement in fatigue severity [quantified by the Fisk Fatigue Impact Scale (FFIS)] after 12 weeks of treatment, compared with baseline values. RESULTS Thirty-three PBC patients completed the study. After 12 weeks of therapy, only 5 patients had a ≥50% reduction in FFIS scores: 3 patients (17.6%) in the modafinil arm and 2 (12.5%) in the placebo arm (P = 1.00). Change in median FFIS score was not statistically different between patients in the 2 treatment groups (P = 0.36). Modafinil was associated with minimal adverse events (headaches, diarrhea, and rash). CONCLUSIONS In patients with PBC who have fatigue, treatment with modafinil for 12 weeks was safe and fairly well tolerated; however, it did not result in beneficial effects on fatigue compared with patients treated with placebo (CONSORT Table 1). ClinicalTrials.gov identifier NCT00943176.
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Frändemark Å, Jakobsson Ung E, Törnblom H, Simrén M, Jakobsson S. Fatigue: a distressing symptom for patients with irritable bowel syndrome. Neurogastroenterol Motil 2017; 29. [PMID: 27401139 DOI: 10.1111/nmo.12898] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/07/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Fatigue is a frequent symptom in patients with irritable bowel syndrome (IBS), and is associated with poor quality of life. However, few studies have evaluated its impact on daily life or the perceived distress it can cause. Using a multi-methods approach, this study describes the impact and manifestations of fatigue in patients with IBS and investigates the relationship between fatigue severity and illness-related and health-promoting factors. METHODS A total of 160 patients with IBS completed self-reported questionnaires assessing fatigue, gastrointestinal symptoms, psychological distress, and sense of coherence. Fatigue was assessed with the Fatigue Impact Scale, which also includes structured and open-ended questions which were analyzed with a deductive qualitative analysis. Patients were classified as having severe, moderate, or mild fatigue based on frequency, distress and impact on daily life. KEY RESULTS The open-ended questions revealed a multidimensional impact on life. Fatigue mainly interfered with the ability to perform physical activities, work, and domestic work, and the ability to interact socially. Decreased stamina was evident, along with strategies to limit the bodily consequences of tiredness. Severe fatigue was accompanied by more severe IBS symptoms, anxiety and depression and lower sense of coherence. CONCLUSIONS & INFERENCES Fatigue is a distressing symptom which occurs in a sizeable proportion of patients with IBS. It affects life in a multidimensional way, with poor bodily stamina being the most prominent feature. Fatigue, along with sense of coherence, depression and anxiety, needs to be assessed, confirmed and targeted for interventions.
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Affiliation(s)
- Å Frändemark
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - E Jakobsson Ung
- Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,University of Gothenburg Centre for Person-Centered Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - H Törnblom
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,University of Gothenburg Centre for Person-Centered Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Simrén
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,University of Gothenburg Centre for Person-Centered Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S Jakobsson
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,University of Gothenburg Centre for Person-Centered Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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29
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Ali AH, Carey EJ, Lindor KD. The management of autoimmunity in patients with cholestatic liver diseases. Expert Rev Gastroenterol Hepatol 2016; 10:73-91. [PMID: 26523975 DOI: 10.1586/17474124.2016.1095088] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cholestatic liver diseases are rare diseases that often lead to cirrhosis and its consequent complications. In addition to liver-related morbidity, patients with cholestatic liver diseases often suffer from autoimmune diseases that affect several organs and tissues. The robust and efficient data collection and collaboration between hepatologists and rheumatologists have led to significant advancements in understanding the relationship between the cholestatic liver diseases and associated autoimmune diseases. In this paper, we discuss the cholestatic liver diseases (primary biliary cirrhosis, primary sclerosing cholangitis and immunoglobulin G4 associated cholangitis) and associated autoimmune diseases.
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Affiliation(s)
- Ahmad H Ali
- a 1 Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Elizabeth J Carey
- a 1 Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Keith D Lindor
- a 1 Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA.,b 2 Arizona State University, College of Health Solutions, Phoenix, AZ, USA
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30
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Han CJ, Yang GS. Fatigue in Irritable Bowel Syndrome: A Systematic Review and Meta-analysis of Pooled Frequency and Severity of Fatigue. Asian Nurs Res (Korean Soc Nurs Sci) 2016; 10:1-10. [PMID: 27021828 DOI: 10.1016/j.anr.2016.01.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 12/11/2015] [Accepted: 01/06/2016] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Fatigue is the third most common "extraintestinal" complaint of patients with irritable bowel syndrome (IBS), but it is still poorly understood. This study aimed to review characteristics of IBS-associated fatigue and to examine pooled frequency, severity of fatigue, and correlations of related factors with fatigue in IBS via meta-analyses. METHODS Publications were searched in eight databases from 1995 to 2014. Random effects meta-analyses were applied with standard error, weighted effect size, and correlation-based measure of effect size. RESULTS Twenty-four studies were included in systematic review. Seventeen studies were used for meta-analyses (2 studies were excluded in the frequency of fatigue analysis due to data unavailability). Using "tiredness" to define fatigue, and Fatigue Impact Scale to assess fatigue were the most frequently used across the studies. Gastrointestinal symptoms, psychological distress, and health-related quality of life were the most common correlates with fatigue. The pooled frequency of fatigue was 54.2% [95% confidence interval (38.5, 69.4)]. Metaregression on the frequency of fatigue showed positive and significant relations with tertiary care settings, female sex, and younger age. There was a negatively moderate relationship between the severity of fatigue and health-related quality of life score (correlation-based measure of effect size: -.378). CONCLUSIONS Fatigue is prevalent among patients with IBS and commonly co-occurs with other symptoms. This is the first study to fully examine fatigue in IBS, which shed light on the comprehensive management of fatigue in this patient group. Future research is warranted to further explore fatigue-related factors and underlying mechanisms of fatigue in IBS.
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Affiliation(s)
- Claire Jungyoun Han
- Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Seattle, USA.
| | - Gee Su Yang
- Department of Pain and Symptom Translational Science, School of Nursing, University of Maryland, College Park, USA
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31
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Zhao X, Wong P. Managing Sleep Disturbances in Cirrhosis. SCIENTIFICA 2016; 2016:6576812. [PMID: 27242950 PMCID: PMC4868900 DOI: 10.1155/2016/6576812] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 04/04/2016] [Indexed: 05/16/2023]
Abstract
Sleep disturbances, particularly daytime sleepiness and insomnia, are common problems reported by patients suffering from liver cirrhosis. Poor sleep negatively impacts patients' quality of life and cognitive functions and increases mortality. Although sleep disturbances can be an early sign of hepatic encephalopathy (HE), many patients without HE still complain of poor quality sleep. The pathophysiology of these disturbances is not fully understood but is believed to be linked to impaired hepatic melatonin metabolism. This paper provides an overview for the clinician of common comorbidities contributing to poor sleep in patients with liver disease, mainly restless leg syndrome and obstructive sleep apnea. It discusses nondrug and pharmacologic treatment options in these patients, such as the use of light therapy and histamine (H1) blockers.
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Affiliation(s)
- Xun Zhao
- Department of Gastroenterology and Hepatology, Royal Victoria Hospital, McGill University, 1001 Boulevard Decarie, Montreal, QC, Canada H4A 3J1
| | - Philip Wong
- Department of Gastroenterology and Hepatology, Royal Victoria Hospital, McGill University, 1001 Boulevard Decarie, Montreal, QC, Canada H4A 3J1
- *Philip Wong:
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32
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Tanaka A, Miura K, Yagi M, Kikuchi K, Ueno Y, Ohira H, Zeniya M, Takikawa H. The assessment of subjective symptoms and patient-reported outcomes in patients with primary biliary cholangitis using PBC-40. ACTA ACUST UNITED AC 2016. [DOI: 10.2957/kanzo.57.457] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine
| | - Kotaro Miura
- Department of Medicine, Teikyo University School of Medicine
| | - Minami Yagi
- Department of Medicine, Teikyo University School of Medicine
| | - Kentaro Kikuchi
- The Fourth Department of Internal Medicine, Teikyo University Mizonokuchi Hospital
| | - Yoshiyuki Ueno
- Department of Gastroenterology, Faculty of Medicine, Yamagata University
| | - Hiromasa Ohira
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | | | - Hajime Takikawa
- Department of Medicine, Teikyo University School of Medicine
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33
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Bittencourt PL, Cançado ELR, Couto CA, Levy C, Porta G, Silva AEB, Terrabuio DRB, Carvalho Filho RJD, Chaves DM, Miura IK, Codes L, Faria LC, Evangelista AS, Farias AQ, Gonçalves LL, Harriz M, Lopes Neto EPA, Luz GO, Oliveira P, Oliveira EMGD, Schiavon JLN, Seva-Pereira T, Parise ER, Parise ER. Brazilian society of hepatology recommendations for the diagnosis and management of autoimmune diseases of the liver. ARQUIVOS DE GASTROENTEROLOGIA 2015; 52 Suppl 1:15-46. [DOI: 10.1590/s0004-28032015000500002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ABSTRACT In order to draw evidence-based recommendations concerning the management of autoimmune diseases of the liver, the Brazilian Society of Hepatology has sponsored a single-topic meeting in October 18th, 2014 at São Paulo. An organizing committee comprised of seven investigators was previously elected by the Governing Board to organize the scientific agenda as well as to select twenty panelists to make a systematic review of the literature and to present topics related to the diagnosis and treatment of autoimmune hepatitis, primary sclerosing cholangitis, primary biliary cirrhosis and their overlap syndromes. After the meeting, all panelists gathered together for the discussion of the topics and the elaboration of those recommendations. The text was subsequently submitted for suggestions and approval of all members of the Brazilian Society of Hepatology through its homepage. The present paper is the final version of the reviewed manuscript organized in topics, followed by the recommendations of the Brazilian Society of Hepatology.
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Abstract
Primary biliary cirrhosis is a chronic cholestatic liver disease characterised by destruction of small intrahepatic bile ducts, leading to fibrosis and potential cirrhosis through resulting complications. The serological hallmark of primary biliary cirrhosis is the antimitochondrial antibody, a highly disease-specific antibody identified in about 95% of patients with primary biliary cirrhosis. These patients usually have fatigue and pruritus, both of which occur independently of disease severity. The typical course of primary biliary cirrhosis has changed substantially with the introduöction of ursodeoxycholic acid (UDCA). Several randomised placebo-controlled studies have shown that UDCA improves transplant-free survival in primary biliary cirrhosis. However, about 40% of patients do not have a biochemical response to UDCA and would benefit from new therapies. Liver transplantation is a life-saving surgery with excellent outcomes for those with decompensated cirrhosis. Meanwhile, research on nuclear receptor hormones has led to the development of exciting new potential treatments. This Seminar will review the current understanding of the epidemiology, pathogenesis, and natural history of primary biliary cirrhosis, discuss management of the disease and its sequelae, and introduce research on new therapeutic options.
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Affiliation(s)
- Elizabeth J Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Ahmad H Ali
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, USA; Arizona State University, College of Health Solutions, Phoenix, AZ, USA.
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An K, Jallo N, Menzies V, Kinser P, Robins JLW, Starkweather A. Integrative Review of Co-Occurring Symptoms Across Etiologies of Chronic Liver Disease and Implications for Symptom Management Research and Practice. J Nurs Scholarsh 2015; 47:310-7. [DOI: 10.1111/jnu.12146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Kyungeh An
- Gamma Omega , Associate Professor; Virginia Commonwealth University School of Nursing; Richmond VA USA
| | - Nancy Jallo
- Gamma Omega , Assistant Professor; Virginia Commonwealth University School of Nursing; Richmond VA USA
| | - Victoria Menzies
- Gamma Omega , Associate Professor; Virginia Commonwealth University School of Nursing; Richmond VA USA
| | - Patricia Kinser
- Gamma Omega , Assistant Professor; Virginia Commonwealth University School of Nursing; Richmond VA USA
| | - Jo Lynne W. Robins
- Gamma Omega , Assistant Professor; Virginia Commonwealth University School of Nursing; Richmond VA USA
| | - Angela Starkweather
- Gamma Omega , Associate Professor; Virginia Commonwealth University School of Nursing; Richmond VA USA
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Raszeja-Wyszomirska J, Wunsch E, Krawczyk M, Rigopoulou EI, Bogdanos D, Milkiewicz P. Prospective evaluation of PBC-specific health-related quality of life questionnaires in patients with primary sclerosing cholangitis. Liver Int 2015; 35:1764-71. [PMID: 25388280 DOI: 10.1111/liv.12730] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 11/03/2014] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Primary biliary cirrhosis and Primary sclerosing cholangitis are autoimmune cholestatic liver diseases sharing a lot in common, including a significant impairment of patients' health-related quality of life HRQoL HRQoL in PBC is assessed with disease-specific PBC-40 and PBC-27 questionnaires. A PSC-specific questionnaire has not been developed. Neither PBC-40 nor PBC-27s applicability for PSC has been evaluated. We applied these three questionnaires for HRQoL assessment in a large homogenous cohort of PSC patients. PATIENTS AND METHODS This cross-sectional study enrolled 102 Caucasian PSCs and 53 matched healthy controls and measured HRQoL using generic SF-36, and disease-specific (PBC-40/PBC-27) questionnaires. RESULTS (i) SF-36. Most SF-36 domains were significantly lower in PSCs than controls. Physical Functioning and Mental Component Summary scores were significantly lower in female patients and correlated negatively with age but not with concurrent inflammatory bowel disease. Cirrhosis was associated with lower Physical Functioning, Role Physical, General Health, Vitality and Physical Component Summary. (ii) PBC-40 and PBC-27. Both tools showed similar HRQoL impairment scoring. Fatigue and Cognitive were impaired in female patients. Several correlations existed between HRQoL and laboratory parameters, including cholestatic tests and Itch. Cirrhosis correlated with Other symptoms and Fatigue PBC-40. (iii) PBC-40 vs PBC-27. Strong correlations among most domains of both questionnaires were seen, as well as between (iv) SF-36 vs PBC-40 or SF-36 vs PBC-27. CONCLUSION This is the first study directly comparing PBC-40, PBC-27 and SF-36 in PSC. PSC patients, especially females, show HRQoL impairment. PBC-40 and PBC-27 questionnaires could be of potential use for HRQoL assessment in PSC.
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Affiliation(s)
- Joanna Raszeja-Wyszomirska
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery of the Medical University of Warsaw, Warsaw, Poland
| | - Ewa Wunsch
- Department of Clinical and Molecular Biochemistry, Pomeranian Medical University, Szczecin, Poland
| | - Marek Krawczyk
- Department of General, Transplant and Liver Surgery of the Medical University of Warsaw, Warsaw, Poland
| | - Eirini I Rigopoulou
- Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, London, UK
| | - Dimitrios Bogdanos
- Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, London, UK.,Department of Medicine, School of Health Sciences, Larissa, Greece
| | - Piotr Milkiewicz
- Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery of the Medical University of Warsaw, Warsaw, Poland.,Department of Clinical and Molecular Biochemistry, Pomeranian Medical University, Szczecin, Poland
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Ali AH, Carey EJ, Lindor KD, Chen Y, Lin Y, Zheng Q, Zhu K, Pan J. Recent advances in the development of farnesoid X receptor agonists. ANNALS OF TRANSLATIONAL MEDICINE 2015. [PMID: 25705637 DOI: 10.3978/j.issn.2305-5839] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Farnesoid X receptors (FXRs) are nuclear hormone receptors expressed in high amounts in body tissues that participate in bilirubin metabolism including the liver, intestines, and kidneys. Bile acids (BAs) are the natural ligands of the FXRs. FXRs regulate the expression of the gene encoding for cholesterol 7 alpha-hydroxylase, which is the rate-limiting enzyme in BA synthesis. In addition, FXRs play a critical role in carbohydrate and lipid metabolism and regulation of insulin sensitivity. FXRs also modulate live growth and regeneration during liver injury. Preclinical studies have shown that FXR activation protects against cholestasis-induced liver injury. Moreover, FXR activation protects against fatty liver injury in animal models of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH), and improved hyperlipidemia, glucose intolerance, and insulin sensitivity. Obeticholic acid (OCA), a 6α-ethyl derivative of the natural human BA chenodeoxycholic acid (CDCA) is the first-in-class selective FXR agonist that is ~100-fold more potent than CDCA. Preliminary human clinical trials have shown that OCA is safe and effective. In a phase II clinical trial, administration of OCA was well-tolerated, increased insulin sensitivity and reduced markers of liver inflammation and fibrosis in patients with type II diabetes mellitus and NAFLD. In two clinical trials of OCA in patients with primary biliary cirrhosis (PBC), a progressive cholestatic liver disease, OCA significantly reduced serum alkaline phosphatase (ALP) levels, an important disease marker that correlates well with clinical outcomes of patients with PBC. Together, these studies suggest that FXR agonists could potentially be used as therapeutic tools in patients suffering from nonalcoholic fatty and cholestatic liver diseases. Larger and Longer-term studies are currently ongoing.
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Affiliation(s)
- Ahmad H Ali
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
| | - Elizabeth J Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
| | - Yuanmei Chen
- 1 Department of Oncological Surgery, 2 Department of Radiation Oncology, 3 Department of Pathology, The Teaching Hospital of Fujian Medical University, Fujian Provincial Cancer Hospital, Fuzhou 350014, China
| | - Yu Lin
- 1 Department of Oncological Surgery, 2 Department of Radiation Oncology, 3 Department of Pathology, The Teaching Hospital of Fujian Medical University, Fujian Provincial Cancer Hospital, Fuzhou 350014, China
| | - Qingfeng Zheng
- 1 Department of Oncological Surgery, 2 Department of Radiation Oncology, 3 Department of Pathology, The Teaching Hospital of Fujian Medical University, Fujian Provincial Cancer Hospital, Fuzhou 350014, China
| | - Kunshou Zhu
- 1 Department of Oncological Surgery, 2 Department of Radiation Oncology, 3 Department of Pathology, The Teaching Hospital of Fujian Medical University, Fujian Provincial Cancer Hospital, Fuzhou 350014, China
| | - Jianji Pan
- 1 Department of Oncological Surgery, 2 Department of Radiation Oncology, 3 Department of Pathology, The Teaching Hospital of Fujian Medical University, Fujian Provincial Cancer Hospital, Fuzhou 350014, China
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Ali AH, Carey EJ, Lindor KD. Recent advances in the development of farnesoid X receptor agonists. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:5. [PMID: 25705637 DOI: 10.3978/j.issn.2305-5839.2014.12.06] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 11/21/2014] [Indexed: 12/13/2022]
Abstract
Farnesoid X receptors (FXRs) are nuclear hormone receptors expressed in high amounts in body tissues that participate in bilirubin metabolism including the liver, intestines, and kidneys. Bile acids (BAs) are the natural ligands of the FXRs. FXRs regulate the expression of the gene encoding for cholesterol 7 alpha-hydroxylase, which is the rate-limiting enzyme in BA synthesis. In addition, FXRs play a critical role in carbohydrate and lipid metabolism and regulation of insulin sensitivity. FXRs also modulate live growth and regeneration during liver injury. Preclinical studies have shown that FXR activation protects against cholestasis-induced liver injury. Moreover, FXR activation protects against fatty liver injury in animal models of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH), and improved hyperlipidemia, glucose intolerance, and insulin sensitivity. Obeticholic acid (OCA), a 6α-ethyl derivative of the natural human BA chenodeoxycholic acid (CDCA) is the first-in-class selective FXR agonist that is ~100-fold more potent than CDCA. Preliminary human clinical trials have shown that OCA is safe and effective. In a phase II clinical trial, administration of OCA was well-tolerated, increased insulin sensitivity and reduced markers of liver inflammation and fibrosis in patients with type II diabetes mellitus and NAFLD. In two clinical trials of OCA in patients with primary biliary cirrhosis (PBC), a progressive cholestatic liver disease, OCA significantly reduced serum alkaline phosphatase (ALP) levels, an important disease marker that correlates well with clinical outcomes of patients with PBC. Together, these studies suggest that FXR agonists could potentially be used as therapeutic tools in patients suffering from nonalcoholic fatty and cholestatic liver diseases. Larger and Longer-term studies are currently ongoing.
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Affiliation(s)
- Ahmad H Ali
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
| | - Elizabeth J Carey
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
| | - Keith D Lindor
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
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Ali AH, Carey EJ, Lindor KD. Diagnosis and management of primary biliary cirrhosis. Expert Rev Clin Immunol 2014; 10:1667-78. [DOI: 10.1586/1744666x.2014.979792] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
Primary biliary cirrhosis (PBC) is an autoimmune cholestatic liver disease characterised by a breakdown of immune tolerance to mitochondrial and nuclear antigens, causing injury to the biliary epithelial cells (BEC) lining the small intrahepatic bile ducts. This leads to bile duct injury and the retention of hydrophobic bile acids which cause further BEC injury leading to a self-sustaining cycle of bile duct injury. Initially the BEC respond to injury via a homeostatic response including through proliferation. Ultimately they become senescent; an active process with accompanying release of inflammatory cytokines ('the senescent secretome') which contributes to the process of interface hepatitis which is a feature of high-risk and treatment-unresponsive disease. This model for pathogenesis of PBC has implications for potential therapy approaches in targeting both the 'upstream' immune injury and 'downstream' BEC response to the immune injury. Fatigue is the commonest reported symptom in PBC and has a negative impact on patients' perceived quality of life, often through social isolation. It is unrelated to the severity of liver disease and appears unresponsive to current therapies, including ursodeoxycholic acid and transplantation. Fatigue in PBC is complex, with numerous associated peripheral and CNS features. Initially, cholestasis causes degenerative CNS change affecting areas of the brain regulating autonomic dysfunction and sleep, and these changes lead directly to some manifestations of fatigue and the associated cognitive impairment. In addition to this, the anti-mitochondrial antibody has direct muscle level metabolic effects leading to over-utilisation of anaerobic metabolism. Autonomic dysfunction contributes to the impact of this metabolic change by limiting the capacity of the muscle to respond through increased proton/lactate efflux from cells and outflow from tissues. The model has a number of implications for potential therapy approaches.
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Affiliation(s)
- Laura Griffiths
- Institute of Cellular Medicine, Newcastle University and Liver Unit, Freeman Hospital, Newcastle upon Tyne, UK
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McDonald C, Koshi S, Busner L, Kavi L, Newton JL. Postural tachycardia syndrome is associated with significant symptoms and functional impairment predominantly affecting young women: a UK perspective. BMJ Open 2014; 4:e004127. [PMID: 24934205 PMCID: PMC4067814 DOI: 10.1136/bmjopen-2013-004127] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 10/11/2013] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE To examine a large UK cohort of patients with postural tachycardia syndrome (PoTS), to compare demographic characteristics, symptoms and treatment of PoTS at one centre compared to the largest patient group PoTS UK and to verify if their functional limitation is similar to patients with chronic fatigue syndrome (CFS). DESIGN A cross-sectional study assessed the frequency of symptoms and their associated variables. PATIENTS AND SETTING Two PoTS cohorts were: (1) recruited via PoTS UK, (2) diagnosed at Newcastle Hospitals National Health Service (NHS) Foundation Trust 2009-2012. Patients with PoTS were then compared to a matched cohort with CFS. MAIN OUTCOME MEASURES Patients' detailed demographics, time to diagnosis, education, disability, medications, comorbidity and precipitants. Symptom assessment tools captured, Fatigue Impact Scale, Epworth Sleepiness Scale, Orthostatic Grading Scale (OGS), Hospital Anxiety and Depression Scale, Health Assessment Questionnaire, Cognitive Failures Questionnaire. RESULTS 136 patients with PoTS participated (84 members of PoTS UK (170 cohort; 50% return) and 52 (87 cohort; 60%) from Newcastle Clinics). The PoTS UK population was significantly younger than the clinic patients, with significantly fewer men (p=0.005). Over 60% had a university or postgraduate degree. Significantly more of the PoTS UK cohort were working, with hours worked being significantly higher (p=0.001). Time to diagnosis was significantly longer in the PoTS UK cohort (p=0.04). Symptom severity was comparable between cohorts. The PoTS total group was compared with a matched CFS cohort; despite comparable levels of fatigue and sleepiness, autonomic symptom burden (OGS) was statistically significantly higher. The most common treatment regime included β-blockers. Overall, 21 treatment combinations were described. Up to 1/3 were taking no treatment. CONCLUSIONS Patients with PoTS are predominantly women, young, well educated and have significant and debilitating symptoms that impact significantly on quality of life. Despite this, there is no consistent treatment.
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Affiliation(s)
- Claire McDonald
- Institute for Ageing & Health, Campus for Ageing & Vitality, Medical School, Newcastle University, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sharon Koshi
- Institute for Ageing & Health, Campus for Ageing & Vitality, Medical School, Newcastle University, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | - Julia L Newton
- Institute for Ageing & Health, Campus for Ageing & Vitality, Medical School, Newcastle University, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Abstract
PURPOSE OF REVIEW Primary biliary cirrhosis (PBC) was first described in the 1950s as a clinical syndrome of progressive cholestatic liver disease resulting from chronic inflammatory destruction of the intrahepatic bile ducts. In the 1980s, the autoimmune nature of the disease was appreciated with the discovery of disease-specific loss of immune tolerance to the pyruvate dehydrogenase complex and subsequent development of antimitochondrial antibodies and autoreactive T cells. Then, in the 1990s, multiple clinical trials demonstrating the efficacy of ursodiol as a treatment for PBC were published, although it has been clear that ursodiol is not a cure and only delays progression in some patients. RECENT FINDINGS The study of PBC in the 2000s has been buoyed by two basic science advances: rapid sequencing technologies that have led to genome wide association studies, and elucidation of the role of nuclear hormone receptors in the regulation of bile salt metabolism, which has led to novel therapies under study for cholestatic diseases. SUMMARY Today's clinician should be able to determine which patients with PBC are likely to progress despite treatment with ursodiol and understand the putative new bile acid and immunosuppressant treatment strategies under development, as well as be aware of the recently described genetic factors at play in the development of PBC.
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Abstract
Primary biliary cirrhosis (PBC) is a chronic, autoimmune, cholestatic liver disease. It is characterized by slow destruction of small intrahepatic bile ducts, impaired biliary secretion and stasis of toxic endogenous bile acids within the liver with progression to liver fibrosis and cirrhosis. It has an increasing prevalence worldwide. It occurs more commonly in women than men at a ratio of 10:1. In most cases, diagnosis relies on a positive antimitochondrial antibody in the context of chronic cholestasis, without the need for a liver biopsy. Ursodeoxycholic acid improves survival even in patients with advanced liver disease. Certain findings such as fatigue, anti-nuclear antibodies, anti-centromere antibodies and the GP210 antinuclear antibody predict a poor outcome. Up to 40% of patients do not respond satisfactorily to ursodeoxycholic acid therapy and should be considered for adjunctive therapies. Several adjunctive and newer therapies are being tested and some appear promising. We provide a review of PBC with a focus on advances in therapies that may impact the management of PBC in the near future.
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Liver-brain interactions in inflammatory liver diseases: implications for fatigue and mood disorders. Brain Behav Immun 2014; 35:9-20. [PMID: 24140301 DOI: 10.1016/j.bbi.2013.10.009] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 09/28/2013] [Accepted: 10/09/2013] [Indexed: 12/15/2022] Open
Abstract
Chronic inflammatory liver diseases are often accompanied by behavior alterations including fatigue, mood disorders, cognitive dysfunction and sleep disturbances. These altered behaviors can adversely affect patient quality of life. The communication pathways between the inflamed liver and the brain that mediate changes in central neural activity leading to behavior alterations during liver inflammation are poorly understood. Neural and humoral communication pathways have been most commonly implicated as driving peripheral inflammation to brain signaling. Classically, the cytokines TNFα, IL-1β and IL-6 have received the greatest scientific attention as potential mediators of this communication pathway. In mice with liver inflammation we have identified a novel immune-mediated liver-to-brain communication pathway whereby CCR2(+) monocytes found within the peripheral circulation transmigrate into the brain parenchyma in response to MCP-1/CCL2 expressing activated microglia. Inhibition of cerebral monocyte infiltration in these mice significantly improved liver inflammation associated sickness behaviors. Importantly, in recent work we have found that at an earlier time point, when cerebral monocyte infiltration is not evident in mice with liver inflammation, increased monocyte:cerebral endothelial cell adhesive interactions are observed using intravital microscopy of the brain. These monocyte:cerebral endothelial cell adhesive interactions are P-selectin mediated, and inhibition of these interactions attenuated microglial activation and sickness behavior development. Delineating the pathways that the periphery uses to communicate with the brain during inflammatory liver diseases, and the central neurotransmitter systems that are altered through these communication pathways (e.g., serotonin, corticotrophin releasing hormone) to give rise to liver inflammation-associated sickness behaviors, will allow for the identification of novel therapeutic targets to decrease the burden of debilitating symptoms in these patients.
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Akamatsu N, Sugawara Y. Primary biliary cirrhosis and liver transplantation. Intractable Rare Dis Res 2012; 1:66-80. [PMID: 25343075 PMCID: PMC4204562 DOI: 10.5582/irdr.2012.v1.2.66] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Revised: 04/28/2012] [Accepted: 05/11/2012] [Indexed: 12/13/2022] Open
Abstract
Primary biliary cirrhosis (PBC) is an immune-mediated chronic progressive inflammatory liver disease, predominantly affecting middle-aged women, characterized by the presence of antimitochondrial antibodies (AMAs), which can lead to liver failure. Genetic contributions, environmental factors including chemical and infectious xenobiotics, autoimmunity and loss of tolerance have been aggressively investigated in the pathogenesis of PBC, however, the actual impact of these factors is still controversial. Survival of PBC patients has been largely improved with the widespread use of ursodeoxycholic acid (UDCA), however, one third of patients still do not respond to the treatment and proceed to liver cirrhosis, requiring liver transplantation as a last resort for cure. The outcome of liver transplantation is excellent with 5- and 10-year survival rates around 80% and 70%, respectively, while along with long survival, the recurrence of the disease has become an important outcome after liver transplantation. Prevalence rates of recurrent PBC rage widely between 1% and 35%, and seem to increase with longer follow-up. Center-specific issues, especially the use of protocol biopsy, affect the variety of incidence, yet, recurrence itself does not affect patient and graft survival at present, and retransplantation due to recurrent disease is extremely rare. With a longer follow-up, recurrent disease could have an impact on patient and graft survival.
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Affiliation(s)
- Nobuhisa Akamatsu
- Department of Hepato-biliary-pancreatic Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Yasuhiko Sugawara
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
- Address correspondence to: Dr. Yasuhiko Sugawara, Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. E-mail:
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Hester KLM, Macfarlane JG, Tedd H, Jary H, McAlinden P, Rostron L, Small T, Newton JL, De Soyza A. Fatigue in bronchiectasis. QJM 2012; 105:235-40. [PMID: 22016379 DOI: 10.1093/qjmed/hcr184] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Fatigue is a complex, disabling symptom in non-CF bronchiectasis (nCF-Br). Fatigue can be formally measured using the validated fatigue impact scale (FIS). The relationship between fatigue and clinically important factors such as airflow obstruction, breathlessness or Pseudomonas aeruginosa infection in nCF-Br is unclear. AIM To measure the correlation between FIS scores and markers of disease severity in nCF-Br. DESIGN A prospective cohort study. METHODS Patients attending a specialist service were studied. Lung function (FEV(1)% predicted), Medical Research Council dyspnoea score (MRCD), sputum culture results and FIS were recorded. Patients were categorized according to sputum culture into three subgroups: Pseudomonas 'colonization', 'isolation' and neither. RESULTS One hundred and seventeen consecutive patients were included. Average FEV(1)% predicted was 64% (SD ±28%). Twelve (10%) patients had Pseudomonas aeruginosa isolation; 47 (40%) patients had P. aeruginosa colonization. Fatigue levels were similar in patients with and without colonization (median 38 versus 32, P = 0.155). Significant fatigue (FIS > 40) was similar in all three Pseudomonas subgroups (P = 0.31, chi-square). Fatigue correlated with MRCD score (r = 0.57, P < 0.001) and FEV(1)% predicted (r = -0.30, P = 0.001). FEV(1)% predicted was lower in patients who had ever isolated or been colonized with P. aeruginosa (P ≤ 0.001). CONCLUSION There are significant correlations between FIS score and MRCD score and FEV(1)% predicted in bronchiectasis. Pseudomonas aeruginosa infection appears to be associated with poorer lung function, and higher MRCD scores, yet there is no significant association between P. aeruginosa status and fatigue.
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Affiliation(s)
- K L M Hester
- Freeman Hospital, Freeman Road, High Heaton, Newcastle upon Tyne, NE7 7DN, UK
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Stinton L, Swain MG. Fatigue in cirrhosis: is transplant the answer? Clin Gastroenterol Hepatol 2012; 10:103-5. [PMID: 22062936 DOI: 10.1016/j.cgh.2011.10.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 10/25/2011] [Indexed: 02/07/2023]
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Abstract
Improved medical management and the changing disease demographic mean that the majority of patients with chronic liver disease are living with the disease rather than dying from it. Historically, the perception has been that the impact of chronic liver disease is related entirely to the consequences of endstage liver disease; however, more recently a number of systemic symptoms have been recognised that can occur at any point in the natural history of chronic liver disease and which can be associated with functional impairment and reduced quality of life. The most characteristic of these systemic symptoms is fatigue, which frequently associates with sleep disturbance and autonomic dysfunction, particularly manifest as abnormality of blood pressure regulation. Cognitive symptoms can occur even in non-cirrhotic patients. Falls can present in patients with autonomic dysfunction, complicated by the presence of peripheral muscle strength problems. Importantly for clinicians managing chronic liver disease, the severity of these systemic symptoms is typically not related to liver disease severity, and therefore despite optimal liver disease management, patients can often continue to experience debilitating symptoms. The similarity in systemic symptoms between different chronic liver diseases (and indeed chronic inflammatory conditions affecting other organs) suggests the possibility of shared pathogenetic processes and raises the possibility of common management strategies, although further research is urgently needed to confirm this. In primary biliary cirrhosis, where our understanding of systemic symptoms is arguably most developed, structured management strategies have been shown to improve the quality of life of patients. It is highly likely that similar approaches will have comparable benefits for other chronic liver disease groups. Here, we review the current understanding of systemic symptoms in chronic liver disease and offer recommendations regarding the successful management of these symptoms. Critical for successful treatment is use of a structured and systematic approach to management in which all contributing factors are addressed in an organised fashion. We believe that such a systematic approach, when applied to research as well as to clinical management, will allow us to reduce the overall burden of chronic liver disease, improve quality of life and enhance functional ability.
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Affiliation(s)
- Julia L Newton
- UK NIHR Biomedical Research Centre in Ageing and Age Related Diseases, Newcastle University, Newcastle, UK.
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Abstract
It is becoming increasingly evident that peripheral organ-centered inflammatory diseases, including chronic inflammatory liver diseases, are associated with changes in central neural transmission that result in alterations in behavior. These behavioral changes include sickness behaviors, such as fatigue, cognitive dysfunction, mood disorders, and sleep disturbances. While such behaviors have a significant impact on quality of life, the changes within the brain and the communication pathways between the liver and the brain that give rise to changes in central neural activity are not fully understood. Traditionally, neural and humoral communication pathways have been described, with the three cytokines TNFα, IL-1β, and IL-6 receiving the most attention in mediating communication between the periphery and the brain, in the setting of peripheral inflammation. However, more recently, we described an immune-mediated communication pathway in experimentally induced liver inflammation whereby, in response to activation of resident immune cells in the brain (i.e., the microglia), peripheral circulating monocytes transmigrate into the brain, leading to development of sickness behaviors. These signaling pathways drive changes in behavior by altering central neurotransmitter systems. Specifically, changes in serotonergic and corticotropin-releasing hormone neurotransmission have been demonstrated and implicated in liver inflammation-associated sickness behaviors. Understanding how the liver communicates with the brain in the setting of chronic inflammatory liver diseases will help delineate novel therapeutic targets that can reduce the burden of symptoms in patients with liver disease.
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Affiliation(s)
- Charlotte D'Mello
- Snyder Institute of Infection, Immunity, and Inflammation, Liver Unit, Department of Medicine, University of Calgary, Alberta, Canada
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Is fatigue related to suppression of hypothalamic–pituitary–adrenal axis activity by bile acids in chronic liver disease? Med Hypotheses 2011; 77:464-5. [DOI: 10.1016/j.mehy.2011.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 04/06/2011] [Accepted: 06/03/2011] [Indexed: 11/19/2022]
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