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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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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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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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Watt M, Spence JC, Tandon P. Development of a Theoretically Informed Web-Based Mind-Body Wellness Intervention for Patients With Primary Biliary Cholangitis: Formative Study. JMIR Form Res 2021; 5:e29064. [PMID: 34623317 PMCID: PMC8538029 DOI: 10.2196/29064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/06/2021] [Accepted: 06/11/2021] [Indexed: 11/17/2022] Open
Abstract
Background Mind-body interventions have the potential to positively impact the symptom burden associated with primary biliary cholangitis (PBC). Interventions are more likely to be effective if they are informed by a theoretical framework. The Behaviour Change Wheel (BCW) and the behaviour change technique taxonomy version 1 (BCTv1) provide frameworks for intervention development. Objective This study describes how theory has guided the development of a 12-week multicomponent mind-body wellness intervention for PBC. Methods The steps involved in developing the BCW intervention included specifying the target behavior; explaining barriers and facilitators using the Capability, Opportunity, Motivation, and Behaviour and the theoretical domains framework; identifying intervention functions to target explanatory domains; and selecting relevant behavior change techniques to address intervention functions. Qualitative data from patients with inflammatory bowel disease using an earlier version of the program and feedback from a PBC patient advisory team were used to guide intervention development. Results Barriers and facilitators to intervention participation associated with capability, opportunity, and motivation were identified. Intervention functions and behavior change techniques were identified to target each barrier and facilitator. Conclusions The Peace Power Pack PBC intervention was developed to help individuals with PBC manage their symptom burden. The theoretical frameworks employed in this intervention provide direction on targeting antecedents of behavior and allow standardized reporting of intervention components. Trial Registration ClinicalTrials.gov NCT04791527; https://clinicaltrials.gov/ct2/show/NCT04791527
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Montali L, Gragnano A, Miglioretti M, Frigerio A, Vecchio L, Gerussi A, Cristoferi L, Ronca V, D’Amato D, O’Donnell SE, Mancuso C, Lucà M, Yagi M, Reig A, Jopson L, Pilar S, Jones D, Pares A, Mells G, Tanaka A, Carbone M, Invernizzi P. Quality of life in patients with primary biliary cholangitis: A cross-geographical comparison. J Transl Autoimmun 2021; 4:100081. [PMID: 33554101 PMCID: PMC7843515 DOI: 10.1016/j.jtauto.2021.100081] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 12/30/2020] [Indexed: 12/12/2022] Open
Abstract
Background & aims Several symptoms impair the quality of life (QoL) of patients with primary biliary cholangitis (PBC). They are reported to vary significantly in different countries. Aim of our study was to explore whether there is a geographical clustering that accounts for symptoms in PBC. Methods Data was analysed from four cohorts of PBC patients from the UK, Spain, Japan and Italy using the PBC-27 scale. Results Overall, 569 patients from four cohorts were identified, including 515 females (90.5%) with a mean age of 61 years. The analysis provided evidence for strict factorial invariance of the scale, a robust indicator of its validity for cross-cultural research. The mean of the fatigue domain of British patients was significantly greater than that of the Japanese (p < 0.05), Italian (p < 0.05), and Spanish patients (p < 0.001). The mean of the cognitive domain after 54 years of age, was significantly greater in the British patients than in the Japanese (p < 0.05) and Spanish patients (p < 0.01). However, after 69 years of age, there were not significant differences between countries. The mean of the emotion domain after 54 years of age, was greater in the British that in the Spanish (p < 0.01) and Italian patients (p < 0.01). Conclusions Differences in the four countries concerning fatigue, cognitive and emotional dysfunction were found. The association of latitude and symptoms might provide new insights into the role of sun exposure, genetics and/or cultural component into disease phenotype in PBC.
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Affiliation(s)
- Lorenzo Montali
- Department of Psychology, University of Milan Bicocca, Milan, Italy
| | - Andrea Gragnano
- Department of Psychology, University of Milan Bicocca, Milan, Italy
| | | | | | - Luca Vecchio
- Department of Psychology, University of Milan Bicocca, Milan, Italy
| | - Alessio Gerussi
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Laura Cristoferi
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Vincenzo Ronca
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Daphne D’Amato
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Sarah Elizabeth O’Donnell
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Clara Mancuso
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Martina Lucà
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Minami Yagi
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Anna Reig
- Liver Unit, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Laura Jopson
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Sesé Pilar
- Liver Unit, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Dave Jones
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Albert Pares
- Liver Unit, Hospital Clínic, University of Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - George Mells
- Department of Medical Genetics, University of Cambridge, Cambridge, UK
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Marco Carbone
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
- Corresponding author. Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano - Bicocca, Via Cadore 48, 20900, Monza, (MB), Italy.
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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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7
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Phaw NA, Jones DEJ. PBC: Better Solutions to Beat Feeling Beat. Dig Dis Sci 2019; 64:2075-2077. [PMID: 30830519 DOI: 10.1007/s10620-019-05552-3] [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: 12/09/2022]
Affiliation(s)
- Naw April Phaw
- Institute of Cellular Medicine, Newcastle University, 4th Floor William Leech Building , Medical School, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - David E J Jones
- Institute of Cellular Medicine, Newcastle University, 4th Floor William Leech Building , Medical School, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK.
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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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9
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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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10
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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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11
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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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12
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Hirschfield GM, Dyson JK, Alexander GJM, Chapman MH, Collier J, Hübscher S, Patanwala I, Pereira SP, Thain C, Thorburn D, Tiniakos D, Walmsley M, Webster G, Jones DEJ. The British Society of Gastroenterology/UK-PBC primary biliary cholangitis treatment and management guidelines. Gut 2018; 67:1568-1594. [PMID: 29593060 PMCID: PMC6109281 DOI: 10.1136/gutjnl-2017-315259] [Citation(s) in RCA: 180] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 01/22/2018] [Accepted: 01/23/2018] [Indexed: 12/12/2022]
Abstract
Primary biliary cholangitis (formerly known as primary biliary cirrhosis, PBC) is an autoimmune liver disease in which a cycle of immune mediated biliary epithelial cell injury, cholestasis and progressive fibrosis can culminate over time in an end-stage biliary cirrhosis. Both genetic and environmental influences are presumed relevant to disease initiation. PBC is most prevalent in women and those over the age of 50, but a spectrum of disease is recognised in adult patients globally; male sex, younger age at onset (<45) and advanced disease at presentation are baseline predictors of poorer outcome. As the disease is increasingly diagnosed through the combination of cholestatic serum liver tests and the presence of antimitochondrial antibodies, most presenting patients are not cirrhotic and the term cholangitis is more accurate. Disease course is frequently accompanied by symptoms that can be burdensome for patients, and management of patients with PBC must address, in a life-long manner, both disease progression and symptom burden. Licensed therapies include ursodeoxycholic acid (UDCA) and obeticholic acid (OCA), alongside experimental new and re-purposed agents. Disease management focuses on initiation of UDCA for all patients and risk stratification based on baseline and on-treatment factors, including in particular the response to treatment. Those intolerant of treatment with UDCA or those with high-risk disease as evidenced by UDCA treatment failure (frequently reflected in trial and clinical practice as an alkaline phosphatase >1.67 × upper limit of normal and/or elevated bilirubin) should be considered for second-line therapy, of which OCA is the only currently licensed National Institute for Health and Care Excellence recommended agent. Follow-up of patients is life-long and must address treatment of the disease and management of associated symptoms.
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Affiliation(s)
- Gideon M Hirschfield
- NIHR Birmingham Biomedical Research Centre, Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jessica K Dyson
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle, United Kingdom
| | - Graeme J M Alexander
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- UCL Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
| | - Michael H Chapman
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jane Collier
- Translational Gastroenterology Unit, Oxford University Hospitals, University of Oxford, Oxford, UK
| | - Stefan Hübscher
- Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Imran Patanwala
- Department of Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
- University of Liverpool, Liverpool, UK
| | - Stephen P Pereira
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- UCL Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Douglas Thorburn
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
- UCL Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
| | - Dina Tiniakos
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | | | - George Webster
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - David E J Jones
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle, United Kingdom
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13
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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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14
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Goñi M, Basu N, Murray AD, Waiter GD. Neural Indicators of Fatigue in Chronic Diseases: A Systematic Review of MRI Studies. Diagnostics (Basel) 2018; 8:diagnostics8030042. [PMID: 29933643 PMCID: PMC6163988 DOI: 10.3390/diagnostics8030042] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 06/11/2018] [Accepted: 06/20/2018] [Indexed: 02/08/2023] Open
Abstract
While fatigue is prevalent in chronic diseases, the neural mechanisms underlying this symptom remain unknown. Magnetic resonance imaging (MRI) has the potential to enable us to characterize this symptom. The aim of this review was to gather and appraise the current literature on MRI studies of fatigue in chronic diseases. We systematically searched the following databases: MedLine, PsycInfo, Embase and Scopus (inception to April 2016). We selected studies according to a predefined inclusion and exclusion criteria. We assessed the quality of the studies and conducted descriptive statistical analyses. We identified 26 studies of varying design and quality. Structural and functional MRI, alongside diffusion tensor imaging (DTI) and functional connectivity (FC) studies, identified significant brain indicators of fatigue. The most common regions were the frontal lobe, parietal lobe, limbic system and basal ganglia. Longitudinal studies offered more precise and reliable analysis. Brain structures found to be related to fatigue were highly heterogeneous, not only between diseases, but also for different studies of the same disease. Given the different designs, methodologies and variable results, we conclude that there are currently no well-defined brain indicators of fatigue in chronic diseases.
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Affiliation(s)
- María Goñi
- Aberdeen Biomedical Imaging Centre (ABIC), Lilian Sutton Building, Foresterhill, University of Aberdeen, Aberdeen AB25 2ZN, UK.
| | - Neil Basu
- Health Science Building, Foresterhill, University of Aberdeen, Aberdeen AB25 2ZN, UK.
| | - Alison D Murray
- Aberdeen Biomedical Imaging Centre (ABIC), Lilian Sutton Building, Foresterhill, University of Aberdeen, Aberdeen AB25 2ZN, UK.
| | - Gordon D Waiter
- Aberdeen Biomedical Imaging Centre (ABIC), Lilian Sutton Building, Foresterhill, University of Aberdeen, Aberdeen AB25 2ZN, UK.
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Khanna A, Leighton J, Lee Wong L, Jones DE. Symptoms of PBC - Pathophysiology and management. Best Pract Res Clin Gastroenterol 2018; 34-35:41-47. [PMID: 30343709 DOI: 10.1016/j.bpg.2018.06.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 06/08/2018] [Indexed: 01/31/2023]
Abstract
Primary biliary cholangitis is a chronic cholestatic liver disease characterised by progressive bile duct damage and, ultimately, biliary cirrhosis. Though up to fifty percent of the patients can be asymptomatic at presentation, symptoms when present are frequently debilitating with significant impact on quality of life and functional status. Characteristic symptoms include pruritus, fatigue and an increasingly recognised mild cognitive impairment. With the exception of pruritus, the "classic" cholestatic symptom, therapeutic options to treat PBC related symptoms are currently limited leaving patients with often significant residual problems. Symptoms can frequently contribute to depression and social isolation further compounding the quality of life impairment. There is need to better understand the current therapeutic options available in order to optimise their use, and to explore newer avenues to understand the pathophysiology of the symptom-generating processed in PBC in order to develop new therapies.
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Affiliation(s)
- Amardeep Khanna
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; NIHR Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK.
| | - Jess Leighton
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.
| | - Lin Lee Wong
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; NIHR Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK.
| | - David E Jones
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; NIHR Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK.
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16
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de Graaf KL, Lapeyre G, Guilhot F, Ferlin W, Curbishley SM, Carbone M, Richardson P, Moreea S, McCune CA, Ryder SD, Chapman RW, Floreani A, Jones DE, de Min C, Adams DH, Invernizzi P. NI-0801, an anti-chemokine (C-X-C motif) ligand 10 antibody, in patients with primary biliary cholangitis and an incomplete response to ursodeoxycholic acid. Hepatol Commun 2018; 2:492-503. [PMID: 29761166 PMCID: PMC5944576 DOI: 10.1002/hep4.1170] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 02/18/2018] [Accepted: 02/22/2018] [Indexed: 12/14/2022] Open
Abstract
NI-0801 is a fully human monoclonal antibody against chemokine (C-X-C motif) ligand 10 (CXCL10), which is involved in the recruitment of inflammatory T cells into the liver. The safety and efficacy of NI-0801 was assessed in patients with primary biliary cholangitis. In this open-label phase 2a study, patients with primary biliary cholangitis with an inadequate response to ursodeoxycholic acid received six consecutive intravenous administrations of NI-0801 (10 mg/kg) every 2 weeks. Patients were followed up for 3 months after the last infusion. Liver function tests, safety assessments, as well as pharmacokinetic and pharmacodynamic parameters were evaluated at different time points throughout the dosing period and the safety follow-up period. Twenty-nine patients were enrolled in the study and were treated with NI-0801. The most frequently reported adverse events included headaches (52%), pruritus (34%), fatigue (24%), and diarrhea (21%). No study drug-related serious adverse events were reported. NI-0801 administration did not lead to a significant reduction in any of the liver function tests assessed at the end of the treatment period (i.e., 2 weeks after final NI-0801 administration) compared to baseline. Conclusion: Despite clear pharmacologic responses in the blood, no therapeutic benefit of multiple administrations of NI-0801 could be demonstrated. The high production rate of CXCL10 makes it difficult to achieve drug levels that lead to sustained neutralization of the chemokine, thus limiting its targetability. (Hepatology Communications 2018;2:492-503).
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Affiliation(s)
| | | | | | | | - Stuart M. Curbishley
- Centre for Liver ResearchUniversity of BirminghamBirminghamUnited Kingdom
- National Institute for Health Research (NIHR) Biomedical Research CentreBirminghamUnited Kingdom
| | - Marco Carbone
- Division of Gastroenterology and Program for Autoimmune Liver Diseases, International Center for Digestive Health, Department of Medicine and SurgeryUniversity of Milan‐BicoccaMilanItaly
| | - Paul Richardson
- Royal Liverpool University National Health Service TrustLiverpoolUnited Kingdom
| | - Sulleman Moreea
- Department of GastroenterologyBradford Teaching Hospitals National Health Service Foundation TrustBradfordUnited Kingdom
| | - C. Anne McCune
- Department of HepatologyBristol Royal InfirmaryBristolUnited Kingdom
| | - Stephen D. Ryder
- NIHR Biomedical Research Unit in Gastrointestinal and Liver Diseases at Nottingham University Hospitals National Health Service Trust and The University of NottinghamNottinghamUnited Kingdom
| | - Roger W. Chapman
- Translational Gastroenterology UnitJohn Radcliffe HospitalOxfordUnited Kingdom
| | - Annarosa Floreani
- Department of Surgery, Oncology and GastroenterologyUniversity of PaduaPaduaItaly
| | - David E. Jones
- NIHR Newcastle Biomedical Research Centre and the Institute of Cellular MedicineNewcastle UniversityNewcastle upon TyneUnited Kingdom
| | | | - David H. Adams
- Centre for Liver ResearchUniversity of BirminghamBirminghamUnited Kingdom
- National Institute for Health Research (NIHR) Biomedical Research CentreBirminghamUnited Kingdom
| | - Pietro Invernizzi
- Division of Gastroenterology and Program for Autoimmune Liver Diseases, International Center for Digestive Health, Department of Medicine and SurgeryUniversity of Milan‐BicoccaMilanItaly
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17
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Shaheen AA, Kaplan GG, Almishri W, Vallerand I, Frolkis AD, Patten S, Swain MG. The impact of depression and antidepressant usage on primary biliary cholangitis clinical outcomes. PLoS One 2018; 13:e0194839. [PMID: 29617396 PMCID: PMC5884515 DOI: 10.1371/journal.pone.0194839] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 02/14/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Depression is prevalent in primary biliary cholangitis (PBC) patients. Our aims were to examine the effects of depression and antidepressants on hepatic outcomes of PBC patients. METHODS We used the UK Health Improvement Network database to identify PBC patients between 1974 and 2007. Our primary outcome was one of three clinical events: decompensated cirrhosis, liver transplantation and death. We assessed depression and each class of antidepressant medication in adjusted multivariate Cox proportional hazards models to identify independent predictors of outcomes. In a sensitivity analysis, the study population was restricted to PBC patients using ursodeoxycholic acid (UDCA). RESULTS We identified 1,177 PBC patients during our study period. In our cohort, 86 patients (7.3%) had a depression diagnosis prior to PBC diagnosis, while 79 patients (6.7%) had a depression diagnosis after PBC diagnosis. Ten-year incidence of mortality, decompensated cirrhosis, and liver transplantation were 13.4%, 6.6%, and 2.0%, respectively. In our adjusted models, depression status was not a predictor of poor outcomes. After studying all classes of antidepressants, using the atypical antidepressant mirtazapine after PBC diagnosis was significantly protective (Adjusted HR 0.23: 95% CI 0.07-0.72) against poor liver outcomes (decompensation, liver transplant, mortality), which remained statistically significant in patients using UCDA (HR 0.21: 95% CI 0.05-0.83). CONCLUSIONS In our study, depression was not associated with poor clinical outcomes. However, using the antidepressant mirtazapine was associated with decreased mortality, decompensated cirrhosis and liver transplantation in PBC patients. These findings support further assessment of mirtazapine as a potential treatment for PBC patients.
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Affiliation(s)
- Abdel-Aziz Shaheen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- * E-mail:
| | - Gilaad G. Kaplan
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Wagdi Almishri
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Isabelle Vallerand
- Departments of Community Health Sciences and Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Alexandra D. Frolkis
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Departments of Community Health Sciences and Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Scott Patten
- Departments of Community Health Sciences and Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Mark G. Swain
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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18
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Abstract
Purpose of Review This review presents an in-depth overview of the sleep–wake phenotype of patients with cirrhosis, together with available pharmacological and non-pharmacological treatment strategies. A set of simple, practical recommendations is also provided. Recent Findings The understanding of the pathophysiology of sleep disorders in this patient population has improved over the past decade, especially in relation to the interplay between homeostatic and circadian sleep regulation. In addition, new tools have been utilised for both screening and in-depth investigation of the sleep–wake profile of these patients. Finally, a number of studies have evaluated the efficacy of novel treatment strategies, often with encouraging results. Summary Since sleep disturbances are common in patients with cirrhosis, more so than in patients with other chronic diseases of similar severity, their assessment should become routine hepatological practice, along with the initiation of adequate treatment.
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Affiliation(s)
- Chiara Formentin
- 1Department of Medicine, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy
| | - Maria Garrido
- 1Department of Medicine, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy.,Department of Physiology, Neuroimmunophysiology and Chrononutrition Research Group, Faculty of Science, Avda. Elvas s/n, 06006 Badajoz, Spain
| | - Sara Montagnese
- 1Department of Medicine, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy
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Lundgren-Nilsson Å, Tennant A, Jakobsson S, Simrén M, Taft C, Dencker A. Validation of Fatigue Impact Scale with various item sets - a Rasch analysis. Disabil Rehabil 2017; 41:840-846. [PMID: 29228839 DOI: 10.1080/09638288.2017.1411983] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE Fatigue is a symptom in patients with chronic gastrointestinal (GI) and liver diseases. Different instruments have been developed to assess the severity of fatigue and the 40-item Fatigue Impact Scale (FIS) is among the most widely used. Shorter versions of FIS include the 21-item Modified Fatigue Impact Scale (MFIS), and an eight-item version for everyday use. The study aimed to assess construct validity, reliability, and sufficiency of the raw score of the original FIS with 40 items, and examine the sufficiency of the 21 items from the Modified scale and the eight items of the Daily Fatigue Impact Scale (D-FIS), all of which are embedded in the 40-item scale. METHODS Patients with chronic GI or liver disease (n = 354) completed the FIS with 40 items. The majority (57%) was under the age of 55 years and approximately half were females (48%). Various item sets of FIS were derived which showed fit to the Rasch model. RESULTS Local dependency and multidimensionality in FIS and the 21-item Modified scale were resolved with a testlet solution but the D-FIS showed local dependency and multidimensionality and differential item functioning (DIF) still remained. Two new item sets fulfilling unidimensionality and no DIF are suggested, one with 15 items and a six-item scale for daily use. The transformation table shows score-interval scale estimates for all these item sets. CONCLUSIONS Both the FIS and the Modified scale can be used to measure fatigue albeit requiring some adjustment for DIF. The eight-item D-FIS is more problematic, and its summed score is not valid. Alternative 15- and 6-item versions presented in this paper can offer valid summed scores, and the transformation table allows transformation of raw scores and comparisons across all versions. Implications for rehabilitation The Fatigue Impact Scale and the Modified Fatigue Impact Scale can be used to measure fatigue after adjustments for differential item functioning. Alternative 15- and 6-item versions of Fatigue Impact Scale offer valid summed scores. The summed score for the Daily Fatigue Impact Scale is not valid. A transformation table with raw scores and Rasch transformed interval scale metric makes it possible to compare scores derived from the Fatigue Impact Scale, the Modified Fatigue Impact Scale and the proposed 15- and 6-item versions of Fatigue Impact Scale for research and/or clinical use.
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Affiliation(s)
- Åsa Lundgren-Nilsson
- a Gothenburg Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden.,b Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Alan Tennant
- a Gothenburg Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden.,c Swiss Paraplegic Research , Nottwil , Switzerland
| | - Sofie Jakobsson
- a Gothenburg Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden.,d Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Magnus Simrén
- a Gothenburg Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden.,e Department of Internal Medicine and Clinical Nutrition , Institute of Medicine, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Charles Taft
- a Gothenburg Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden.,d Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Anna Dencker
- a Gothenburg Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden.,d Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
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20
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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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21
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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: 741] [Impact Index Per Article: 105.9] [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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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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Demonstration of two types of fatigue in subjects with chronic liver disease using factor analysis. Qual Life Res 2017; 26:1777-1784. [PMID: 28224256 DOI: 10.1007/s11136-017-1516-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE The purpose of this investigation was to determine if it was possible to separate fatigue self-reports into two distinct types of fatigue symptom clusters in research subjects with chronic liver disease (CLD). It was hypothesized that when items from the Medical Outcomes Study Short-Form (SF-36v2) are combined with items from the Fatigue Severity Scale (FSS), these distinct factors will emerge. METHODS Confirmatory and exploratory factor analyses from data collected in a prospective, natural history study of CLD patients were conducted. Items were selected from the SF-36v2 and the FSS for entry into the factor analyses. In order to establish convergent and discriminant validity, derived factor scores were correlated with subscale scores of the Human Activity Profile (HAP), Mental Component Score (MCS) from the SF-36v2, and the Emotional Functioning Subscale of the Chronic Liver Disease Questionnaire (CLDQ-EF). RESULTS 106 participants with CLD were included (50% female; age: 51 ± 10). Two factors were identified. The factors included one that clustered around questions addressing fatigue related to physical activity (peripheral fatigue) and the other to the questions addressing generalized fatigue that did not require physical tasks to produce the fatigue (central fatigue). The standardized factor loadings of all items were greater than 0.6 on their underlying constructs. Moreover, all factor loadings are significant at p < 0.01. Peripheral fatigue was related to HAP (r = 0.26, r = 0.24, p < 0.01), as was central fatigue (r = -0.34, r = -0.33, p < 0.01). Central fatigue was related to MCS and CLDQ-EF (r = -0.60; r = -0.63, p < 0.01), whereas peripheral fatigue was not (r = 0.07, p > 0.40). We then tested the original scales to determine if the newly created factors correlated better with the validity measures. The full FSS did not correlate as well as the newly created central fatigue scale, while the original peripheral fatigue scale (the SF-36v2 physical functioning) was more related to HAP than the newly created scale. CONCLUSIONS In individuals with CLD, two separate factors pertaining to fatigue were identified. This recognition of the multifaceted nature of fatigue may help increase the specificity of self-reports of fatigue and lead to treatments that can specifically address the underlying factors contributing to fatigue.
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Salama ZA, Darweesh SK, Shehab HM, Abd-Elhameed MA. Etiology and prevalence of fatigue in chronic liver disease: clinical view. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2016. [DOI: 10.4103/1110-7782.193892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Raszeja-Wyszomirska J, Wunsch E, Krawczyk M, Rigopoulou EI, Kostrzewa K, Norman GL, Bogdanos DP, Milkiewicz P. Assessment of health related quality of life in polish patients with primary biliary cirrhosis. Clin Res Hepatol Gastroenterol 2016; 40:471-9. [PMID: 26621536 DOI: 10.1016/j.clinre.2015.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 10/09/2015] [Accepted: 10/19/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Most patients with primary biliary cirrhosis (PBC) have impaired health related quality of life (HRQoL), as assessed by PBC-specific HRQoL (PBC-40) and generic (SF-36) questionnaires. Data on the applicability of PBC-27, a shorter version of PBC-40, have been limited. AIMS To assess HRQoL in Polish PBC patients, applying PBC-40, PBC-27 and SF-36 and to associate clinical or laboratory parameters with HRQoL factors. METHODS A total of 205 PBC patients (188 females) were analyzed using PBC-40, PBC-27 and SF-36; 85 disease-free demographically matched (in terms of age, gender, ethnicity) individuals were used as normal controls. RESULTS When compared to controls, PBC patients had significantly impaired HRQoL across all the domains of SF-36. HRQoL impairment by PBC-40 and PBC-27 was comparable between cirrhotics and non-cirrhotics, except for significantly worse Itch in cirrhotics (6.5±4.9 vs 5.1±4.3; P=0.03). In PBC-40/27, alkaline phosphatase (ALP) levels correlated with itch (P=0.0003). Female patients had marginally impaired cognitive function compared to males by PBC-40 (P=0.06). Other gender-related differences were not found. Anti-gp210 positive, as well as AMA negative PBC patients, had worse HRQoL features in itch and social/emotional domains of PBC-40/PBC-27 questionnaires. Very strong correlations (P<0.0001) between PBC-40/PBC-27 and SF-36 were seen for several domains. CONCLUSIONS HRQoL is significantly impaired in Polish patients with PBC, independently of gender and disease severity. PBC-40 and PBC-27 questionnaires are efficient in detecting HRQoL impairment in Polish PBC patients. The striking correlation between PBC-40/PBC-27 and SF-36 confirms the usefulness of the former HRQoL measures in PBC patients from Central-Eastern Europe.
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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
- Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | | | | | - Dimitrios P Bogdanos
- Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; Liver Sciences, Division of Transplantation Immunology and Mucosal Biology, King's College London School of Medicine, King's College Hospital, London, UK
| | - 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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Jopson L, Dyson JK, Jones DEJ. Understanding and Treating Fatigue in Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis. Clin Liver Dis 2016; 20:131-42. [PMID: 26593295 DOI: 10.1016/j.cld.2015.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Fatigue is a significant problem for patients with primary biliary cirrhosis and although experienced less by patients with primary sclerosing cholangitis, a minority still report significant fatigue. Fatigue is the symptom with the greatest impact on quality of life, particularly when associated with social dysfunction. The pathogenesis of fatigue in cholestatic liver disease is complex, poorly understood, and probably has central and peripheral components. Managing fatigue in cholestatic liver disease presents a challenge for clinicians given the complexity and its numerous associations. This article presents a structured approach to managing fatigue in cholestatic liver disease to improve fatigue severity and quality of life.
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Affiliation(s)
- Laura Jopson
- Institute of Cellular Medicine, Newcastle University, Level 3 William Leech Building, Medical School, Framlington Place, Newcastle upon Tyne NE24HH, UK
| | - Jessica K Dyson
- Institute of Cellular Medicine, Newcastle University, Level 3 William Leech Building, Medical School, Framlington Place, Newcastle upon Tyne NE24HH, UK
| | - David E J Jones
- Institute of Cellular Medicine, Newcastle University, Level 3 William Leech Building, Medical School, Framlington Place, Newcastle upon Tyne NE24HH, UK.
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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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James K, Al-Ali S, Tarn J, Cockell SJ, Gillespie CS, Hindmarsh V, Locke J, Mitchell S, Lendrem D, Bowman S, Price E, Pease CT, Emery P, Lanyon P, Hunter JA, Gupta M, Bombardieri M, Sutcliffe N, Pitzalis C, McLaren J, Cooper A, Regan M, Giles I, Isenberg D, Saravanan V, Coady D, Dasgupta B, McHugh N, Young-Min S, Moots R, Gendi N, Akil M, Griffiths B, Wipat A, Newton J, Jones DE, Isaacs J, Hallinan J, Ng WF. A Transcriptional Signature of Fatigue Derived from Patients with Primary Sjögren's Syndrome. PLoS One 2015; 10:e0143970. [PMID: 26694930 PMCID: PMC4687914 DOI: 10.1371/journal.pone.0143970] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 11/11/2015] [Indexed: 12/15/2022] Open
Abstract
Background Fatigue is a debilitating condition with a significant impact on patients’ quality of life. Fatigue is frequently reported by patients suffering from primary Sjögren’s Syndrome (pSS), a chronic autoimmune condition characterised by dryness of the eyes and the mouth. However, although fatigue is common in pSS, it does not manifest in all sufferers, providing an excellent model with which to explore the potential underpinning biological mechanisms. Methods Whole blood samples from 133 fully-phenotyped pSS patients stratified for the presence of fatigue, collected by the UK primary Sjögren’s Syndrome Registry, were used for whole genome microarray. The resulting data were analysed both on a gene by gene basis and using pre-defined groups of genes. Finally, gene set enrichment analysis (GSEA) was used as a feature selection technique for input into a support vector machine (SVM) classifier. Classification was assessed using area under curve (AUC) of receiver operator characteristic and standard error of Wilcoxon statistic, SE(W). Results Although no genes were individually found to be associated with fatigue, 19 metabolic pathways were enriched in the high fatigue patient group using GSEA. Analysis revealed that these enrichments arose from the presence of a subset of 55 genes. A radial kernel SVM classifier with this subset of genes as input displayed significantly improved performance over classifiers using all pathway genes as input. The classifiers had AUCs of 0.866 (SE(W) 0.002) and 0.525 (SE(W) 0.006), respectively. Conclusions Systematic analysis of gene expression data from pSS patients discordant for fatigue identified 55 genes which are predictive of fatigue level using SVM classification. This list represents the first step in understanding the underlying pathophysiological mechanisms of fatigue in patients with pSS.
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Affiliation(s)
- Katherine James
- Interdisciplinary Computing and Complex BioSystems Research Group, Newcastle University, Newcastle upon Tyne, United Kingdom
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Shereen Al-Ali
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Biology, College of Science, University of Basrah, Basrah, Iraq
| | - Jessica Tarn
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Simon J. Cockell
- Bioinformatics Support Unit, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Colin S. Gillespie
- School of Mathematics & Statistics, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Victoria Hindmarsh
- Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - James Locke
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Sheryl Mitchell
- Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Dennis Lendrem
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Simon Bowman
- Rheumatology Department, University Hospital Birmingham, Birmingham, United Kingdom
| | - Elizabeth Price
- Great Western Hospitals NHS Foundation Trust, Swindon, United Kingdom
| | - Colin T. Pease
- Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds & NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Paul Emery
- Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds & NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Peter Lanyon
- Nottingham University Hospital, Nottingham, United Kingdom
| | | | - Monica Gupta
- Gartnavel General Hospital, Glasgow, United Kingdom
| | - Michele Bombardieri
- Barts and the London NHS Trust & Barts and the London School of Medicine and Dentistry, London, United Kingdom
| | - Nurhan Sutcliffe
- Barts and the London NHS Trust & Barts and the London School of Medicine and Dentistry, London, United Kingdom
| | - Costantino Pitzalis
- Barts and the London NHS Trust & Barts and the London School of Medicine and Dentistry, London, United Kingdom
| | - John McLaren
- NHS Fife, Whyteman’s Brae Hospital, Kirkcaldy, United Kingdom
| | - Annie Cooper
- Royal Hampshire County Hospital, Winchester, United Kingdom
- Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom
| | | | - Ian Giles
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - David Isenberg
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | | | - David Coady
- Sunderland Royal Hospital, Sunderland, United Kingdom
| | | | - Neil McHugh
- Royal National Hospital for Rheumatic Diseases, Bath, United Kingdom
| | | | - Robert Moots
- Aintree University Hospitals, Liverpool, United Kingdom
| | | | - Mohammed Akil
- Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Bridget Griffiths
- Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - Anil Wipat
- Interdisciplinary Computing and Complex BioSystems Research Group, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Julia Newton
- Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - David E. Jones
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - John Isaacs
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
- National Institute for Health Research, Newcastle Biomedical Research Centre, Newcastle upon Tyne, United Kingdom
| | - Jennifer Hallinan
- Interdisciplinary Computing and Complex BioSystems Research Group, Newcastle University, Newcastle upon Tyne, United Kingdom
- BioThink Pty Ltd, Brisbane, Australia
| | - Wan-Fai Ng
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
- National Institute for Health Research, Newcastle Biomedical Research Centre, Newcastle upon Tyne, United Kingdom
- * E-mail:
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Abstract
Fatigue is an important aspect of health-related quality of life from the patient perspective and can have significant socio-economic consequences. It is a common feature of chronic illnesses and a significant number of both adults and children with immune thrombocytopenia (ITP) suffer from fatigue. Reliable, validated fatigue scales have been developed for use in ITP. These will facilitate future investigation of its pathogenesis and the effectiveness of intervention. Acute inflammation acts on neural and endocrine systems resulting in 'sickness behaviour', an adaptive response to infection and injury. Inflammation is also thought to cause fatigue in chronic disease and immune dysregulation in ITP appears to have a number of pro-inflammatory components. Clinicians should consider fatigue when assessing the burden of disease. Although effective ITP-directed therapy can improve fatigue, a number of fatigue-directed strategies may also need to be considered.
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Affiliation(s)
- Quentin A Hill
- Department of Haematology, St James's University Hospital, Leeds, UK
| | - Adrian C Newland
- Department of Haematology, The Royal London Hospital, London, UK
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Artom M, Moss-Morris R, Caskey F, Chilcot J. Fatigue in advanced kidney disease. Kidney Int 2014; 86:497-505. [DOI: 10.1038/ki.2014.86] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 12/10/2013] [Accepted: 01/09/2014] [Indexed: 01/14/2023]
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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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Karlsen TH, Vesterhus M, Boberg KM. Review article: controversies in the management of primary biliary cirrhosis and primary sclerosing cholangitis. Aliment Pharmacol Ther 2014; 39:282-301. [PMID: 24372568 DOI: 10.1111/apt.12581] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 10/09/2013] [Accepted: 11/18/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Despite considerable advances over the last two decades in the molecular understanding of cholestasis and cholestatic liver disease, little improvement has been made in diagnostic tools and therapeutic strategies. AIMS To critically review controversial aspects of the scientific basis for common clinical practice in primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) and to discuss key ongoing challenges to improve patient management. METHODS We performed a literature search using PubMed and by examining the reference lists of relevant review articles related to the clinical management of PBC and PSC. Articles were considered on the background of the European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD) practice guidelines and clinical experience of the authors. RESULTS Ongoing challenges in PBC mainly pertain to the improvement of medical therapy, particularly for patients with a suboptimal response to ursodeoxycholic acid. In PSC, development of medical therapies and sensitive screening protocols for cholangiocarcinoma represent areas of intense research. To rationally improve patient management, a better understanding of pathogenesis, including complications like pruritis and fatigue, is needed and there is a need to identify biomarker end-points for treatment effect and prognosis. Timing of liver transplantation and determining optimal regimens of immunosuppression post-liver transplantation will also benefit from better appreciation of pre-transplant disease mechanisms. CONCLUSION Controversies in the management of PBC and PSC relate to topics where evidence for current practice is weak and further research is needed.
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Affiliation(s)
- T H Karlsen
- Norwegian PSC Research Center, Division of Cancer Medicine, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Abstract
The care of the patient with cholestasis hinges on identifying the etiology, treating reversible causes, and managing chronic cholestatic processes. PBC and PSC are important causes of chronic cholestasis, and are the most common causes of cholestatic liver disease. Effective therapy is available for patients with PBC, whereas none exists for patients with PSC. Awareness of the complications that may be associated with cholestasis and implementing the appropriate management are essential.
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Affiliation(s)
- Andrea A Gossard
- Cholestatic Liver Disease Study Group, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
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Zenouzi R, Weiler-Normann C, Lohse AW. Is fatigue in primary biliary cirrhosis cured by transplantation? J Hepatol 2013; 59:418-9. [PMID: 23742911 DOI: 10.1016/j.jhep.2013.05.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 05/29/2013] [Indexed: 12/04/2022]
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Carbone M, Bufton S, Monaco A, Griffiths L, Jones DE, Neuberger JM. The effect of liver transplantation on fatigue in patients with primary biliary cirrhosis: a prospective study. J Hepatol 2013; 59:490-4. [PMID: 23628322 DOI: 10.1016/j.jhep.2013.04.017] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 04/03/2013] [Accepted: 04/12/2013] [Indexed: 01/14/2023]
Abstract
BACKGROUND & AIMS The role of liver transplantation (LT) for the relief of fatigue in patients with primary biliary cirrhosis (PBC) is unclear, and while many centers exclude fatigue as an indication for transplantation, there have been no studies to prospectively evaluate the impact of LT on fatigue. We aimed at assessing the severity of fatigue in LT candidates with PBC and the impact of LT on fatigue. METHODS In a prospective, longitudinal study, we used the PBC-40 questionnaire in 49 adult patients with PBC at listing and at 6, 12, and 24 months after LT and in two sex- and age-matched cohorts of community controls and non-transplanted PBC patients. Correlation analysis was used to assess the relationship between liver function and fatigue. ANOVA was used to compare the variation of fatigue score before and after LT. RESULTS There was no correlation between MELD and fatigue before LT (r(2)=0.01). Overall, the fatigue score after LT was substantially lower than before LT, falling from 40.7 ± 11.4 pre-transplant to 27.7 ± 9.5, 28.7 ± 10.1, 26.2 ± 10.1 (p<0.0001) at 6, 12, and 24 months after LT, respectively. The same improvement of fatigue was observed in both low-MELD (<17) and high-MELD (≥ 17) patients. Improvement in fatigue was also evident in the comparison with a "non-transplant PBC" control group (31.1 ± 11.6, p=0.03). However, 44% of the total cohort, and 47% of those with low-MELD, for whom the probability of dying of LT may be higher than that of dying without LT, had moderate to severe fatigue (defined as a fatigue score ≥ 29) at two years after LT. Moreover, fatigue scores at two years were higher in the transplant PBC cohort compared to a cohort of community controls (17.8 ± 5.9, p<0.0001). CONCLUSIONS Liver transplantation is associated with improvement in fatigue in patients with PBC. However, a substantial proportion of patients continue to suffer from significant fatigue after two years. Whether the improvement is enough to justify organ allocation in patients with fatigue alone, without liver failure, is still an open issue. Certainly, in the era of organ shortage, with many patients dying waiting for a graft, this may not represent the optimal use of donated deceased organs.
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Affiliation(s)
- Marco Carbone
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
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36
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Abstract
Cholestasis is defined as impairment of bile formation or bile flow. Care of the patient with cholestatic features is dependent on identifying the cause of the cholestasis, initiating appropriate treatment of reversible conditions, and the recognition and management of cholestasis-specific complications. Cholestasis may include extrahepatic ducts and intrahepatic bile ducts, or may be limited to one or the other. Jaundice and pruritus are the hallmarks of cholestasis clinically but biochemical evidence may, and often does, precede the clinical manifestations.
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Affiliation(s)
- Andrea A Gossard
- Cholestatic Liver Disease Study Group, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55901, USA.
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Montagnese S, Nsemi LM, Cazzagon N, Facchini S, Costa L, Bergasa NV, Amodio P, Floreani A. Sleep-Wake profiles in patients with primary biliary cirrhosis. Liver Int 2013; 33:203-9. [PMID: 23173839 DOI: 10.1111/liv.12026] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 10/04/2012] [Indexed: 02/13/2023]
Abstract
BACKGROUND Impaired sleep quality and daytime sleepiness have been described in patients with primary biliary cirrhosis (PBC). However, no information is available on their sleep timing/diurnal preference. AIMS To evaluate such variables and determine their relationship with sleep quality, fatigue, pruritus and quality of life. METHODS Seventy-four patients with PBC (58 ± 12 years), 79 healthy volunteers (56 ± 8 years) and 60 patients with cirrhosis (58 ± 12 years) underwent formal assessment of sleep quality/timing, diurnal preference and daytime sleepiness. Patients with PBC also underwent assessment of fatigue, quality of life and the daytime course of sleepiness/pruritus. RESULTS Sleep timing was significantly delayed in both patients with PBC and with cirrhosis, compared to healthy volunteers (sleep onset time: 23:18 ± 01:00 vs. 23:30 ± 01:00 vs. 22:54 ± 00:54 hours, respectively; P < 0.05). In patients with PBC, delayed sleep timing was associated with impaired sleep quality (P < 0.05). Sleepiness showed a physiological daily rhythm, with early afternoon/evening peaks. Pruritus was absent in the morning and increased over the afternoon/evening hours. Both the daytime course of pruritus and sleepiness changed in relation to diurnal preference. Patients with PBC and significant pruritus (upper quartile) had prolonged sleep latency (39 ± 37 vs. 21 ± 23 min, P = 0.05) and earlier wake-up times (5.9 ± 0.8 vs. 6.7 ± 0.9 min, P < 0.05). Significant correlations were observed between sleep timing and quality of life. CONCLUSIONS Patients with PBC exhibited a delay in sleep timing that was associated with impaired sleep quality/quality of life. In addition, an interplay was observed between diurnal preference and the daytime course of pruritus/sleepiness.
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Anderson K, Jones DEJ, Wilton K, Newton JL. Restless leg syndrome is a treatable cause of sleep disturbance and fatigue in primary biliary cirrhosis. Liver Int 2013; 33:239-43. [PMID: 23295055 DOI: 10.1111/liv.12035] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 10/11/2012] [Indexed: 02/13/2023]
Abstract
BACKGROUND Primary biliary cirrhosis (PBC) patients frequently describe sleep problems. The cause remains unclear and treatment is challenging. Restless leg syndrome (RLS) is a common sleep disorder. In this study, we systematically screened PBC patients for the presence of RLS. METHODS Participants were recruited from our specialist PBC clinical service. Subjects completed the International Restless Leg Syndrome Study Group rating scale (IRLSS) a validated measure of the presence of RLS and its severity. Those fulfilling diagnostic criteria for RLS underwent foot actigraphy (CamNtech Actiwatch) to objectively assess periodic limb movement index (PLMI) (normal <5/h). RESULTS Restless leg syndrome was assessed in 42 consecutive early stage PBC patients. Twelve (29%) fulfilled the IRLSS criteria for RLS. Scores were significantly higher in PBC compared to controls (P = 0.005). Twenty-four patients were further assessed with foot actigraphy for 3 nights (12 with subjective RLS symptoms and 12 with no RLS symptoms). Thirteen of twenty-four subjects had PLMI >5/h and four had moderate or severe PLMI >15/h. All moderate or severe PLMI subjects had subjective symptoms of moderate or severe RLS. No patients had PLMI >10 in the absence of RLS symptoms. Eleven PBC patients with symptomatic RLS went on to have treatment. Sixty-three per cent had clear benefit in restless leg symptoms and associated symptoms of fatigue. CONCLUSION Restless leg syndrome symptoms are common and underdiagnosed in PBC patients. RLS represents a potential therapy for PBC patients with daytime sleepiness, fatigue and unpleasant lower limb symptoms and this is worthy of further studies in larger cohorts.
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Affiliation(s)
- Kirstie Anderson
- Newcastle Hospitals NHS Foundation Trust, Newcastle University, Newcastle, UK
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Rudic JS, Poropat G, Krstic MN, Bjelakovic G, Gluud C. Ursodeoxycholic acid for primary biliary cirrhosis. Cochrane Database Syst Rev 2012; 12:CD000551. [PMID: 23235576 PMCID: PMC7045744 DOI: 10.1002/14651858.cd000551.pub3] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ursodeoxycholic acid is administered to patients with primary biliary cirrhosis, a chronic progressive inflammatory autoimmune-mediated liver disease with unknown aetiology. Despite its controversial effects, the U.S. Food and Drug Administration has approved its usage for primary biliary cirrhosis. OBJECTIVES To assess the beneficial and harmful effects of ursodeoxycholic acid in patients with primary biliary cirrhosis. SEARCH METHODS We searched for eligible randomised trials in The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, LILACS, Clinicaltrials.gov, and the WHO International Clinical Trials Registry Platform. The literature search was performed until January 2012. SELECTION CRITERIA Randomised clinical trials assessing the beneficial and harmful effects of ursodeoxycholic acid versus placebo or 'no intervention' in patients with primary biliary cirrhosis. DATA COLLECTION AND ANALYSIS Two authors independently extracted data. Continuous data were analysed using mean difference (MD) and standardised mean difference (SMD). Dichotomous data were analysed using risk ratio (RR). Meta-analyses were conducted using both a random-effects model and a fixed-effect model, with 95% confidence intervals (CI). Random-effects model meta-regression was used to assess the effects of covariates across the trials. Trial sequential analysis was used to assess risk of random errors (play of chance). Risks of bias (systematic error) in the included trials were assessed according to Cochrane methodology bias domains. MAIN RESULTS Sixteen randomised clinical trials with 1447 patients with primary biliary cirrhosis were included. One trial had low risk of bias, and the remaining fifteen had high risk of bias. Fourteen trials compared ursodeoxycholic acid with placebo and two trials compared ursodeoxycholic acid with 'no intervention'. The percentage of patients with advanced primary biliary cirrhosis at baseline varied from 15% to 83%, with a median of 51%. The duration of the trials varied from 3 to 92 months, with a median of 24 months. The results showed no significant difference in effect between ursodeoxycholic acid and placebo or 'no intervention' on all-cause mortality (45/699 (6.4%) versus 46/692 (6.6%); RR 0.97, 95% CI 0.67 to 1.42, I² = 0%; 14 trials); on all-cause mortality or liver transplantation (86/713 (12.1%) versus 89/706 (12.6%); RR 0.96, 95% CI 0.74 to 1.25, I² = 15%; 15 trials); on serious adverse events (94/695 (13.5%) versus 107/687 (15.6%); RR 0.87, 95% CI 0.68 to 1.12, I² = 23%; 14 trials); or on non-serious adverse events (27/643 (4.2%) versus 18/634 (2.8%); RR 1.46, 95% CI 0.83 to 2.56, I² = 0%; 12 trials). The random-effects model meta-regression showed that the risk of bias of the trials, disease severity of patients at entry, ursodeoxycholic acid dosage, and trial duration were not significantly associated with the intervention effects on all-cause mortality, or on all-cause mortality or liver transplantation. Ursodeoxycholic acid did not influence the number of patients with pruritus (168/321 (52.3%) versus 166/309 (53.7%); RR 0.96, 95% CI 0.84 to 1.09, I² = 0%; 6 trials) or with fatigue (170/252 (64.9%) versus 174/244 (71.3%); RR 0.90, 95% CI 0.81 to 1.00, I² = 62%; 4 trials). Two trials reported the number of patients with jaundice and showed a significant effect of ursodeoxycholic acid versus placebo or no intervention in a fixed-effect meta-analysis (5/99 (5.1%) versus 15/99 (15.2%); RR 0.35, 95% CI 0.14 to 0.90, I² = 51%; 2 trials). The result was not supported by the random-effects meta-analysis (RR 0.56, 95% CI 0.06 to 4.95). Portal pressure, varices, bleeding varices, ascites, and hepatic encephalopathy were not significantly affected by ursodeoxycholic acid. Ursodeoxycholic acid significantly decreased serum bilirubin concentration (MD -8.69 µmol/l, 95% CI -13.90 to -3.48, I² = 0%; 881 patients; 9 trials) and activity of serum alkaline phosphatases (MD -257.09 U/L, 95% CI -306.25 to -207.92, I² = 0%; 754 patients, 9 trials) compared with placebo or no intervention. These results were supported by trial sequential analysis. Ursodeoxycholic acid also seemed to improve serum levels of gamma-glutamyltransferase, aminotransferases, total cholesterol, and plasma immunoglobulin M concentration. Ursodeoxycholic acid seemed to have a beneficial effect on worsening of histological stage (random; 66/281 (23.5%) versus 103/270 (38.2%); RR 0.62, 95% CI 0.44 to 0.88, I² = 35%; 7 trials). AUTHORS' CONCLUSIONS This systematic review did not demonstrate any significant benefits of ursodeoxycholic acid on all-cause mortality, all-cause mortality or liver transplantation, pruritus, or fatigue in patients with primary biliary cirrhosis. Ursodeoxycholic acid seemed to have a beneficial effect on liver biochemistry measures and on histological progression compared with the control group. All but one of the included trials had high risk of bias, and there are risks of outcome reporting bias and risks of random errors as well. Randomised trials with low risk of bias and low risks of random errors examining the effects of ursodeoxycholic acid for primary biliary cirrhosis are needed.
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Affiliation(s)
- Jelena S Rudic
- Department of Hepatology, Clinic of Gastroenterology, Clinical Centre of Serbia, Belgrade, Serbia.
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Abstract
Primary biliary cirrhosis (PBC) is a chronic inflammatory autoimmune disease that mainly targets the cholangiocytes of the interlobular bile ducts in the liver. It is a rare disease with prevalence of less than one in 2000. Its prevalence in developing countries is increasing presumably because of growth in recognition and knowledge of the disease. PBC is thought to result from a combination of multiple genetic factors and superimposed environmental triggers. The contribution of the genetic predisposition is evidenced by familial clustering. Several risk factors, including exposure to infectious agents and chemical xenobiotics, have been suggested. Common symptoms of the disease are fatigue and pruritus, but most patients are asymptomatic at first presentation. The prognosis of PBC has improved because of early diagnosis and use of ursodeoxycholic acid, the only established medical treatment for this disorder. When administered at adequate doses of 13–15 mg/kg/day, up to two out of three patients with PBC may have a normal life expectancy without additional therapeutic measures. However, some patients do not respond adequately to ursodeoxycholic acid and might need alternative therapeutic approaches.
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Affiliation(s)
- Nadya Al-Harthy
- Gastroenterology and Hepatology, Royal Hospital, Muscat, Oman
| | - Teru Kumagi
- Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Japan
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Ng WF, Stangroom A, Davidson A, Wilton K, Mitchell S, Newton J. Primary Sjogrens syndrome is associated with impaired autonomic response to orthostasis and sympathetic failure. QJM 2012; 105:1191-9. [PMID: 22976617 PMCID: PMC3508582 DOI: 10.1093/qjmed/hcs172] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Symptoms in keeping with autonomic dysfunction are commonly described by primary Sjögrens syndrome patients (pSS); whether objective abnormalities of autonomic function occur is unclear. This study set out to explore dynamic cardiovascular autonomic responses in pSS and their relationship with symptoms and quality of life. METHODS Twenty-one people from the UK pSS registry, 21 community controls and 21 patients with the autoimmune liver disease primary biliary cirrhosis (PBC) (matched case-wise for age and sex) attended for assessment of autonomic responses to orthostasis and Valsalva manoeuvre (VM). pSS patients also completed EULAR Sjögrens Syndrome patient-reported index (ESSPRI), EULAR Sjögren's syndrome disease activity index (ESSDAI), fatigue impact scale and EURO-QOL 5-dimension (EQ-5D). RESULTS Compared with controls, pSS patients had significantly lower baseline systolic blood pressure (SBP) (114 ± 13 vs. 127 ± 20; P = 0.02), which dropped to a significantly lower value (98 ± 22 vs. 119 ± 24, P = 0.009). When area under the curve (AUC) was calculated for when the SBP was below baseline this was significantly greater in pSS compared to both control groups (pSS vs. control vs. PBC: 153 ± 236 vs. 92 ± 85 vs. 1.2 ± 0.3, P = 0.005). Peak phase IV SBP during the VM was significantly lower in pSS (P = 0.007) indicating early sympathetic failure. Increased heart rate associated with fatigue (P = 0.02; r(2) = 0.2) and EQ-5D. A shift in sympathetic-vagal balance associated with overall symptom burden (ESSPRI) (P = 0.04, r(2) = 0.3) and EULAR sicca score (P = 0.016; r(2) = 0.3), the latter also correlated with baroreceptor effectiveness (P = 0.03; r(2) = 0.2) and diastolic blood pressure variability (P = 0.003; r(2) = 0.4). CONCLUSION pSS patients have impaired blood pressure response to standing. Dysautonomia correlates with PSS-associated symptoms and quality of life.
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Affiliation(s)
- W.-F. Ng
- From the Institute of Cellular Medicine and Institute of Ageing and Health and NIHR Biomedical Research Centre for Ageing Health, Faculty of Medical Sciences, University of Newcastle upon Tyne, Newcastle Upon Tyne NE2 4HH, UK
| | - A.J. Stangroom
- From the Institute of Cellular Medicine and Institute of Ageing and Health and NIHR Biomedical Research Centre for Ageing Health, Faculty of Medical Sciences, University of Newcastle upon Tyne, Newcastle Upon Tyne NE2 4HH, UK
| | - A. Davidson
- From the Institute of Cellular Medicine and Institute of Ageing and Health and NIHR Biomedical Research Centre for Ageing Health, Faculty of Medical Sciences, University of Newcastle upon Tyne, Newcastle Upon Tyne NE2 4HH, UK
| | - K. Wilton
- From the Institute of Cellular Medicine and Institute of Ageing and Health and NIHR Biomedical Research Centre for Ageing Health, Faculty of Medical Sciences, University of Newcastle upon Tyne, Newcastle Upon Tyne NE2 4HH, UK
| | - S. Mitchell
- From the Institute of Cellular Medicine and Institute of Ageing and Health and NIHR Biomedical Research Centre for Ageing Health, Faculty of Medical Sciences, University of Newcastle upon Tyne, Newcastle Upon Tyne NE2 4HH, UK
| | - J.L. Newton
- From the Institute of Cellular Medicine and Institute of Ageing and Health and NIHR Biomedical Research Centre for Ageing Health, Faculty of Medical Sciences, University of Newcastle upon Tyne, Newcastle Upon Tyne NE2 4HH, UK
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Benito de Valle M, Rahman M, Lindkvist B, Björnsson E, Chapman R, Kalaitzakis E. Factors that reduce health-related quality of life in patients with primary sclerosing cholangitis. Clin Gastroenterol Hepatol 2012; 10:769-775.e2. [PMID: 22343690 DOI: 10.1016/j.cgh.2012.01.025] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 01/09/2012] [Accepted: 01/29/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Health-related quality of life (HRQL) is frequently reduced in patients with chronic liver disease, but there are limited data from patients with primary sclerosing cholangitis (PSC). We aimed to evaluate HRQL and its potential determinants in 2 population-based cohorts of patients with PSC and to study the prevalence of fatigue among these patients. METHODS Validated questionnaires were used to measure quality of life (the Short-Form 36 [SF-36] and the chronic liver disease questionnaire), fatigue (the fatigue impact scale), and psychological distress (the hospital anxiety and depression scale) in 182 PSC patients residing in Sweden or England. Results were compared with those from the general population (controls). Regression analysis was performed to identify factors independently associated with HRQL. RESULTS Patients with PSC had significantly lower scores from several areas of the SF-36, compared with controls (P < .05). Age (β = -0.62 to -0.21, P < .05) and systemic symptoms (β = 3.84-15.94, P < .05) such as pruritus were associated with lower scores from specific areas of the SF-36; serum level of alkaline phosphatase (β =-1.12 to -0.75, P < .05), and large-duct PSC (β = -15.35 to -10.05, P < .05) were associated with lower scores on mental health questionnaires. The proportion of patients with significant fatigue, depression, or anxiety did not differ between patients and controls (P > .05). CONCLUSIONS Quality of life is impaired in unselected patients with PSC. Fatigue does not seem to be a specific symptom of PSC. Older age, large-duct disease, and systemic symptoms seem to reduce HRQL in patients with PSC.
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Affiliation(s)
- Maria Benito de Valle
- Institute of Internal Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Regulatory T cells suppress sickness behaviour development without altering liver injury in cholestatic mice. J Hepatol 2012; 56:626-31. [PMID: 22027577 DOI: 10.1016/j.jhep.2011.09.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Revised: 09/06/2011] [Accepted: 09/15/2011] [Indexed: 01/04/2023]
Abstract
BACKGROUND & AIMS Cholestatic liver diseases are commonly accompanied by debilitating symptoms, collectively termed sickness behaviours. Regulatory T cells (T(regs)) can suppress inflammation; however, a role for T(regs) in modulating sickness behaviours has not been evaluated. METHODS A mouse model of cholestatic liver injury due to bile duct ligation (BDL) was used to study the role of T(regs) in sickness behaviour development. RESULTS BDL mice developed reproducible sickness behaviours, as assessed in a social investigation paradigm, characterized by decreased social investigative behaviour and increased immobility. Depletion of peripheral T(regs) in BDL mice worsened BDL-associated sickness behaviours, whereas infusion of T(regs) improved these behaviours; however, liver injury severity was not altered by T(reg) manipulation. Hepatic IL-6 mRNA and circulating IL-6 levels were elevated in BDL vs. control mice, and were elevated further in T(reg)-depleted BDL mice, but were decreased after infusion of T(regs) in BDL mice. IL-6 knock out (KO) BDL mice exhibited a marked reduction in sickness behaviours, compared to wildtype BDL mice. Furthermore, IL-6 KO BDL mice injected with rmIL-6 displayed sickness behaviours similar to wildtype BDL mice, whereas saline injection did not alter behaviour in IL-6 KO BDL mice. BDL was associated with increased hippocampal cerebral endothelial cell p-STAT3 expression, which was significantly reduced in IL-6 KO BDL mice. CONCLUSIONS T(regs) modulate sickness behaviour development in the setting of cholestatic liver injury, driven mainly through T(reg) inhibition of circulating monocyte and hepatic IL-6 production, and subsequent signalling via circulating IL-6 acting at the level of the cerebral endothelium.
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Primary biliary cirrhosis and Sjögren's syndrome: autoimmune epithelitis. J Autoimmun 2011; 39:34-42. [PMID: 22178199 DOI: 10.1016/j.jaut.2011.11.005] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 11/12/2011] [Indexed: 02/08/2023]
Abstract
Primary biliary cirrhosis (PBC) has been often coined a model autoimmune disease based on the homogeneity amongst patients, the frequency and similarity of antimitochondrial antibodies, including the highly directed immune response to pyruvate dehydrogenase (PDC-E2). A significant number of patients with PBC suffer from sicca and amongst these, there are patients who also have classic Sjögren's syndrome. Indeed, both PBC and Sjögren's syndrome are characterized by inflammation of target epithelial elements. Both diseases can be considered on the basis of a number of other related clinical aspects, including proposed unique apoptotic features of the target tissue, the role of secretory IgA, and the frequency with which both diseases overlap with each other. Indeed, PBC may be considered a Sjögren's syndrome of the liver, whereas Sjögren's syndrome can be equally discussed as PBC of the salivary glands. Dissection of the genetic predispositions for both diseases and especially the molecular basis of effector mechanisms, will become critical elements in developing new therapies.
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Huisman-de Waal G, Bazelmans E, van Achterberg T, Jansen J, Sauerwein H, Wanten G, Schoonhoven L. Predicting fatigue in patients using home parenteral nutrition: a longitudinal study. Int J Behav Med 2011; 18:268-76. [PMID: 20862618 PMCID: PMC3145911 DOI: 10.1007/s12529-010-9116-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Home parenteral nutrition (HPN) is a life-saving therapy for patients with diseases that preclude adequate oral or enteral food intake. HPN has a large impact on daily life. Many patients suffer from fatigue and depression, and they experience limits in social activities. This all contributes to a lower quality of life. Purpose Fatigue is the most frequently mentioned problem in Dutch HPN patients. Therefore, we studied the prevalence, course and predictors of fatigue in these patients. Methods Patients completed questionnaires at baseline and follow-up (12 months later). Measurements included fatigue, depression, functional impairment, social support, self-efficacy, coping, anxiety and acceptance. Laboratory measures, including total bilirubin, creatinine, albumin and haemoglobin levels, were obtained from the medical records. Descriptive statistics, correlations and linear regression analysis were performed. Results The response rate was 71% (n = 75). Sixty-five per cent of the patients were severely fatigued (n = 49). Eighty-nine per cent experienced persistent fatigue. Baseline fatigue predicted 57% of the variance of fatigue at follow-up, and avoidance was responsible for 3% of the variance. No significant correlations between fatigue and laboratory measures were found. A cross-sectional analysis showed that 46% of the variance of fatigue was explained by functional impairment, self-efficacy and depression. Conclusion Severe fatigue is a persistent problem for HPN patients. Baseline fatigue was the strongest predictor of fatigue at follow-up. Functional impairment, self-efficacy and depression are strongly related to fatigue. Early recognition and treatment of fatigue are important.
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Affiliation(s)
- Getty Huisman-de Waal
- IQ Healthcare, Nursing Science, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Wu LJ, Wu MS, Lien GS, Chen FC, Tsai JC. Fatigue and physical activity levels in patients with liver cirrhosis. J Clin Nurs 2011; 21:129-38. [PMID: 22023663 DOI: 10.1111/j.1365-2702.2011.03900.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES This study aimed to explore the correlation between fatigue and physical activity in patients with liver cirrhosis. BACKGROUND Many patients with liver cirrhosis perceive lower physical functioning and more fatigue than non-cirrhotic individuals. To date, however, few studies have examined the relationship between fatigue and physical activity in this patient population. DESIGN This study used a correlation design. Participants were patients with liver cirrhosis recruited from the gastroenterology clinic of a teaching medical centre in Taiwan. METHODS Data were collected using a structured questionnaire, consisting of a fatigue scale and a seven-day Physical Activity Recall scale. spss version 13.0 software was used to analyse the data through statistical methods, including one-way analysis of variance, independent t-test and Pearson's correlations. RESULTS Patients participating in this study suffered from moderate-to-severe fatigue, and their engagement in physical activity of moderate or higher intensity was decreased. On average, fatigue had a moderate level of influence on physical activity. A significant negative correlation was found between the fatigue level and average seven-day physical activity level. CONCLUSIONS Patients with liver cirrhosis can experience severe fatigue, which may reduce their level of physical activity. RELEVANCE TO CLINICAL PRACTICE Early evaluation of the fatigue level and physical activity constraints in patients with liver cirrhosis should be conducted in the clinic or community. Individualised instructions for patient's physical activity should be provided.
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Affiliation(s)
- Li-Jan Wu
- Department of Nursing, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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Abstract
It is becoming increasingly clear that quality of life (QOL) is impaired in those with chronic liver disease (CLD). One of the most important contributors to impaired QOL is the symptomatic burden which can range from slight to debilitating. Autonomic dysfunction accounts for a significant proportion of these symptoms, which can be common, non-specific and challenging to treat. Investigating the autonomic nervous system can be straight forward and can assist the clinician to diagnose and treat specific symptoms. Evidence-based treatment options for autonomic symptoms, specifically in CLD, can be lacking and must be extrapolated from other studies and expert opinion. For those with severely impaired quality of life, liver transplantation may offer an improvement; however, more research is needed to confirm this.
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Affiliation(s)
- James Frith
- NIHR Biomedical Research Centre in Ageing, Institute for Ageing and Health, Newcastle University, Newcastle UK
| | - Julia L Newton
- NIHR Biomedical Research Centre in Ageing, Institute for Ageing and Health, Newcastle University, Newcastle UK
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Functional capacity is significantly impaired in primary biliary cirrhosis and is related to orthostatic symptoms. Eur J Gastroenterol Hepatol 2011; 23:566-72. [PMID: 21593676 DOI: 10.1097/meg.0b013e3283470256] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess patient-reported functional ability and its relationship with symptoms in primary biliary cirrhosis (PBC). METHODS Functional status was assessed in a representative cohort of 75 patients with PBC using the Patient-Reported Outcome Measure Information System Health-Assessment Questionnaire (PROMIS-HAQ) functional assessment tool and was related to both symptom severity at the point of assessment (assessed using the PBC-40 and Orthostatic Grading Scale) and symptom severity change over the previous 4 years. Functional status in the PBC group was compared with primary sclerosing cholangitis (cholestatic liver disease) and community controls. RESULTS Functional impairment at follow-up (PROMIS-HAQ) was substantial in PBC significantly higher than that in both primary sclerosing cholangitis and community controls. PROMIS-HAQ domain scores confirmed that patients with PBC had significant impairment in arising, eating, walking, reach and grip and activity, but not dressing or hygiene. Functional impairment correlated positively with greater PBC-40 Fatigue, Cognitive and Social and Emotional domains and higher orthostatic symptoms. Over 4 years, total symptom burden increased significantly (P=0.03). The predominant factor was rise in Cognitive domain scores indicating worsening cognitive symptoms (P<0.0001). Change in PBC-40 Cognitive, Social and Emotional scores (2005-2009) strongly predicted functional ability in 2009. Multivariate analysis confirmed that PROMIS-HAQ scores were predicted independently by PBC-40 Social and Emotional scores (P=0.02; β=0.3) and orthostatic symptoms (P=0.04; β=0.3). CONCLUSION PBC associates with substantial functional impairment. PBC symptom distribution evolves over time, with cognitive symptoms making ever-greater contribution to overall symptom burden. The major potentially modifiable determinant responsible for the functional impairment appears to be orthostatic symptoms.
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Jelsness-Jørgensen LP, Bernklev T, Henriksen M, Torp R, Moum BA. Chronic fatigue is more prevalent in patients with inflammatory bowel disease than in healthy controls. Inflamm Bowel Dis 2011; 17:1564-72. [PMID: 21674713 DOI: 10.1002/ibd.21530] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Accepted: 09/21/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND Fatigue is a common symptom in chronic disease. Few studies, however, have focused on fatigue related to inflammatory bowel disease (IBD). The aim was to determine the prevalence of fatigue in IBD and to identify demographic and clinical factors that influence fatigue. METHODS Patients in remission and with mild and moderate IBD completed the Fatigue Questionnaire (FQ). Higher FQ scores indicate greater levels of fatigue. In addition, demographic and clinical variables were obtained. Corresponding FQ data from healthy controls (HC) are based on 2287 Norwegian citizens. RESULTS In total, 140 patients were included, mean age 43.9 years (SD 16.4), male/female = 61/79, ulcerative colitis (UC) / Crohn's disease (CD) = 92/48. Total fatigue (TF) was 14.4, 14.7, and 12.2 for UC, CD, and HC, respectively. Chronic fatigue (CF), defined as substantial fatigue with duration more than 6 months, was reported in 29% (14/48) of CD and 22% (20/92) of UC compared to 11% (260/2287) of HC (P < 0.001 for both diagnoses). Linear regression analysis confirmed hemoglobin values, present gastrointestinal symptoms, and altered sleep to be the most important predictors of CF. CONCLUSIONS Chronic fatigue is more common in patients with UC and CD compared with healthy controls. IBD symptoms, hemoglobin values, and altered sleep patterns are significant predictors of CF.
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Affiliation(s)
- Lars-Petter Jelsness-Jørgensen
- Østfold Hospital Trust, Fredrikstad, Norway, Oslo University Hospital Aker, Oslo, Norway, University of Oslo, Institute of Clinical Medicine, Oslo, Norway.
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50
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Liver transplantation in PBC and PSC: indications and disease recurrence. Clin Res Hepatol Gastroenterol 2011; 35:446-54. [PMID: 21459072 DOI: 10.1016/j.clinre.2011.02.007] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2011] [Accepted: 02/09/2011] [Indexed: 02/07/2023]
Abstract
Primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC) represent major indications for liver transplantation (LT). Despite the steady increase in the incidence and prevalence of PBC, the number of liver transplants for PBC has fallen in recent years, whereas the number of transplants for PSC has remained stable. Indications for LT for PBC and PSC are no different from those of other causes of chronic liver disease, apart from some disease-specific indications. PBC and PSC have more favourable outcomes after LT, compared to viral hepatitis and alcohol-associated liver disease. Numerous studies have clearly demonstrated that PBC and PSC recur after LT. The diagnosis of recurrent disease should be made on agreed criteria. The impact of recurrent disease on survival is unclear. Study of recurrent PBC and PSC may provide a better understanding of the mechanisms of these diseases in the native liver.
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