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Yazdanfar M, Zepeda J, Dean R, Wu J, Levy C, Goldberg D, Lammert C, Prenner S, Reddy KR, Pratt D, Forman L, Assis DN, Lytvyak E, Montano-Loza AJ, Gordon SC, Carey EJ, Ahn J, Schlansky B, Korzenik J, Karagozian R, Hameed B, Chandna S, Yu L, Bowlus CL. African American race does not confer an increased risk of clinical events in patients with primary sclerosing cholangitis. Hepatol Commun 2024; 8:e0366. [PMID: 38285883 PMCID: PMC10830082 DOI: 10.1097/hc9.0000000000000366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 11/01/2023] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND The natural history of primary sclerosing cholangitis (PSC) among African Americans (AA) is not well understood. METHODS Transplant-free survival and hepatic decompensation-free survival were assessed using a retrospective research registry from 16 centers throughout North America. Patients with PSC alive without liver transplantation after 2008 were included. Diagnostic delay was defined from the first abnormal liver test to the first abnormal cholangiogram/liver biopsy. Socioeconomic status was imputed by the Zip code. RESULTS Among 850 patients, 661 (77.8%) were non-Hispanic Whites (NHWs), and 85 (10.0%) were AA. There were no significant differences by race in age at diagnosis, sex, or PSC type. Inflammatory bowel disease was more common in NHWs (75.8% vs. 51.8% p=0.0001). The baseline (median, IQR) Amsterdam-Oxford Model score was lower in NHWs (14.3, 13.4-15.2 vs. 15.1, 14.1-15.7, p=0.002), but Mayo risk score (0.03, -0.8 to 1.1 vs. 0.02, -0.7 to 1.0, p=0.83), Model for End-stage Liver Disease (5.9, 2.8-10.7 vs. 6.4, 2.6-10.4, p=0.95), and cirrhosis (27.4% vs. 27.1%, p=0.95) did not differ. Race was not associated with hepatic decompensation, and after adjusting for clinical variables, neither race nor socioeconomic status was associated with transplant-free survival. Variables independently associated with death/liver transplant (HR, 95% CI) included age at diagnosis (1.04, 1.02-1.06, p<0.0001), total bilirubin (1.06, 1.04-1.08, p<0.0001), and albumin (0.44, 0.33-0.61, p<0.0001). AA race did not affect the performance of prognostic models. CONCLUSIONS AA patients with PSC have a lower rate of inflammatory bowel disease but similar progression to hepatic decompensation and liver transplant/death compared to NHWs.
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Affiliation(s)
- Maryam Yazdanfar
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California, USA
| | - Joseph Zepeda
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California, USA
| | - Richard Dean
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California, USA
| | - Jialin Wu
- Division of Gastroenterology and Hepatology, Schiff Center for Liver Disease, University of Miami, Miami, Florida, USA
| | - Cynthia Levy
- Division of Gastroenterology and Hepatology, Schiff Center for Liver Disease, University of Miami, Miami, Florida, USA
| | - David Goldberg
- Division of Gastroenterology and Hepatology, Schiff Center for Liver Disease, University of Miami, Miami, Florida, USA
| | | | - Stacey Prenner
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - K. Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Lisa Forman
- University of Colorado, Denver, Colorado, USA
| | | | - Ellina Lytvyak
- Division of Preventive Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Aldo J. Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Stuart C. Gordon
- Henry Ford Health and Wayne State University School of Medicine, Detroit, Michigan, USA
| | | | - Joseph Ahn
- Oregon Health Sciences University, Portland, Oregon, USA
| | | | | | | | - Bilal Hameed
- UC San Francisco, San Francisco, California, USA
| | | | - Lei Yu
- University of Washington, Seattle, Washington, USA
| | - Christopher L. Bowlus
- Division of Gastroenterology and Hepatology, University of California Davis, Sacramento, California, USA
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Sanyal AJ, Williams SA, Lavine JE, Neuschwander-Tetri BA, Alexander L, Ostroff R, Biegel H, Kowdley KV, Chalasani N, Dasarathy S, Diehl AM, Loomba R, Hameed B, Behling C, Kleiner DE, Karpen SJ, Williams J, Jia Y, Yates KP, Tonascia J. Defining the serum proteomic signature of hepatic steatosis, inflammation, ballooning and fibrosis in non-alcoholic fatty liver disease. J Hepatol 2023; 78:693-703. [PMID: 36528237 PMCID: PMC10165617 DOI: 10.1016/j.jhep.2022.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 11/01/2022] [Accepted: 11/23/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Despite recent progress, non-invasive tests for the diagnostic assessment and monitoring of non-alcoholic fatty liver disease (NAFLD) remain an unmet need. Herein, we aimed to identify diagnostic signatures of the key histological features of NAFLD. METHODS Using modified-aptamer proteomics, we assayed 5,220 proteins in each of 2,852 single serum samples from 636 individuals with histologically confirmed NAFLD. We developed and validated dichotomized protein-phenotype models to identify clinically relevant severities of steatosis (grade 0 vs. 1-3), hepatocellular ballooning (0 vs. 1 or 2), lobular inflammation (0-1 vs. 2-3) and fibrosis (stages 0-1 vs. 2-4). RESULTS The AUCs of the four protein models, based on 37 analytes (18 not previously linked to NAFLD), for the diagnosis of their respective components (at a clinically relevant severity) in training/paired validation sets were: fibrosis (AUC 0.92/0.85); steatosis (AUC 0.95/0.79), inflammation (AUC 0.83/0.72), and ballooning (AUC 0.87/0.83). An additional outcome, at-risk NASH, defined as steatohepatitis with NAFLD activity score ≥4 (with a score of at least 1 for each of its components) and fibrosis stage ≥2, was predicted by multiplying the outputs of each individual component model (AUC 0.93/0.85). We further evaluated their ability to detect change in histology following treatment with placebo, pioglitazone, vitamin E or obeticholic acid. Component model scores significantly improved in the active therapies vs. placebo, and differential effects of vitamin E, pioglitazone, and obeticholic acid were identified. CONCLUSIONS Serum protein scanning identified signatures corresponding to the key components of liver biopsy in NAFLD. The models developed were sufficiently sensitive to characterize the longitudinal change for three different drug interventions. These data support continued validation of these proteomic models to enable a "liquid biopsy"-based assessment of NAFLD. CLINICAL TRIAL NUMBER Not applicable. IMPACT AND IMPLICATIONS An aptamer-based protein scan of serum proteins was performed to identify diagnostic signatures of the key histological features of non-alcoholic fatty liver disease (NAFLD), for which no approved non-invasive diagnostic tools are currently available. We also identified specific protein signatures related to the presence and severity of NAFLD and its histological components that were also sensitive to change over time. These are fundamental initial steps in establishing a serum proteome-based diagnostic signature of NASH and provide the rationale for using these signatures to test treatment response and to identify several novel targets for evaluation in the pathogenesis of NAFLD.
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Affiliation(s)
- Arun J Sanyal
- Stravitz-Sanyal Institute for Liver Disease and Metabolic Health, Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
| | | | - Joel E Lavine
- Dept. of Pediatrics, Columbia University, New York, NY, USA
| | | | | | | | | | | | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Anna Mae Diehl
- Division of Gastroenterology and Hepatology, Duke University School of Medicine, Durham, NC, USA
| | - Rohit Loomba
- NAFLD Research Center, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Bilal Hameed
- Division of Gastroenterology and Hepatology, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Cynthia Behling
- NAFLD Research Center, University of California San Diego School of Medicine, San Diego, CA, USA
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Saul J Karpen
- Dept. of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Yi Jia
- Clinical R&D, SomaLogic Inc., Boulder, CO, USA
| | - Katherine P Yates
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - James Tonascia
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Trauner M, Bowlus CL, Gulamhusein A, Hameed B, Caldwell SH, Shiffman ML, Landis C, Muir AJ, Billin A, Xu J, Liu X, Lu X, Chung C, Myers RP, Kowdley KV. Safety and sustained efficacy of the farnesoid X receptor (FXR) agonist cilofexor over a 96-week open-label extension in patients with PSC. Clin Gastroenterol Hepatol 2022; 21:1552-1560.e2. [PMID: 35934287 DOI: 10.1016/j.cgh.2022.07.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 06/09/2022] [Accepted: 07/18/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Primary sclerosing cholangitis (PSC) is a major unmet medical need in clinical hepatology. Cilofexor is a nonsteroidal farnesoid X receptor agonist being evaluated for the treatment of PSC. Here, we describe the safety and preliminary efficacy of cilofexor in a 96-week, open-label extension (OLE) of a phase II trial. METHODS Noncirrhotic subjects with large-duct PSC who completed the 12-week, blinded phase of a phase II study (NCT02943460) were eligible, after a 4-week washout period, for a 96-week OLE with cilofexor 100 mg daily. Safety, liver biochemistry, and serum markers of fibrosis, cellular injury, and pharmacodynamic effects of cilofexor (fibroblast growth factor 19, C4, and bile acids [BAs]) were evaluated. RESULTS Among 52 subjects enrolled in the phase II study, 47 (90%) continued in the OLE phase (median age, 44 years; 60% male patients, 60% with inflammatory bowel disease, and 45% on ursodeoxycholic acid [UDCA]). At OLE baseline (BL), the median serum alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) were 368 U/L (interquartile range [IQR], 277-468 U/L) and 417 U/L (IQR, 196-801 U/L), respectively. Of the 47 subjects enrolled, 15 (32%) discontinued treatment prematurely (pruritus [n = 5], other adverse events [n = 5], subject decision/investigator discretion [n = 5]). At week 96, reductions in liver biochemistry parameters occurred, including serum ALP (median, -8.3% [IQR, -25.9% to 11.0%]; P = .066), GGT (-29.8% [IQR, -42.3% to -13.9%]; P < .001), alanine aminotransaminase (ALT) (-29.8% [IQR, -43.7% to -6.6%]; P = .002), and aspartate aminotransaminase (AST) (-16.7% [IQR, -35.3% to 1.0%]; P = .010), and rebounded after 4 weeks of untreated follow-up. ALP response (≥20% reduction from BL to week 96) was similar in the presence or absence of UDCA therapy (29% vs 39%; P = .71). At week 96, cilofexor treatment was associated with a significant reduction in serum 7α-hydroxy-4-cholesten-3-one (C4) (-29.8% [IQR, -64.3% to -8.5%]; P = .001). In subjects with detectable serum BAs at BL (n = 40), BAs decreased -23.9% (IQR, -44.4% to -0.6%; P = .006) at week 48 (n = 28) and -25.7% (IQR, -35.9% to 53.7%; P = .91) at week 96 (n = 26). Serum cytokeratin 18 (CK18) M30 and M65 were reduced throughout the OLE; significant reductions were observed at week 72 (CK18 M30, -17.3% [IQR, -39.3% to 8.8%]; P = .018; CK18 M65, -43.5% [IQR, -54.9% to 15.3%]; P = .096). At week 96, a small, but statistically significant absolute increase of 0.15 units in Enhanced Liver Fibrosis score was observed compared with BL (median, 9.34 vs 9.53; P = .028). CONCLUSIONS In this 96-week OLE of a phase II study of PSC, cilofexor was safe and improved liver biochemistry and biomarkers of cholestasis and cellular injury. CLINICALTRIALS gov identifier: NCT02943460.
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Affiliation(s)
- Michael Trauner
- Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
| | - Christopher L Bowlus
- Division of Gastroenterology and Hepatology, University of California at Davis School of Medicine, Sacramento, California
| | | | - Bilal Hameed
- Division of Gastroenterology, University of California, San Francisco School of Medicine, San Francisco, California
| | - Stephen H Caldwell
- Division of Gastroenterology and Hepatology, University of Virginia School of Medicine, Charlottesville, Virginia
| | | | - Charles Landis
- Division of Gastroenterology & Hepatology, University of Washington School of Medicine, Seattle, Washington
| | - Andrew J Muir
- Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina
| | | | - Jun Xu
- Gilead Sciences, Inc, Foster City, California
| | - Xiangyu Liu
- Gilead Sciences, Inc, Foster City, California
| | - Xiaomin Lu
- Gilead Sciences, Inc, Foster City, California
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Russo MW, Kwok R, Serper M, Ufere N, Hameed B, Chu J, Goacher E, Lingerfelt J, Terrault N, Reddy KR. Impact of the Corona Virus Disease 2019 Pandemic on Hepatology Practice and Provider Burnout. Hepatol Commun 2022; 6:1236-1247. [PMID: 34783189 PMCID: PMC8652849 DOI: 10.1002/hep4.1870] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/29/2021] [Accepted: 10/25/2021] [Indexed: 01/16/2023] Open
Abstract
The corona virus disease 2019 (COVID-19) pandemic has had a wide-ranging impact on the clinical practice of medicine and emotional well-being of providers. Our aim was to determine the impact of the COVID-19 pandemic on practice and burnout among hepatology providers. From February to March 2021, we conducted an electronic survey of American Association for the Study of Liver Diseases (AASLD) members who were hepatologists, gastroenterologists, and advanced practice providers (APPs). The survey included 26 questions on clinical practice and emotional well-being derived from validated instruments. A total of 230 eligible members completed the survey as follows: 107 (47%) were adult transplant hepatologists, 43 (19%) were adult general hepatologists, 14 (6%) were adult gastroenterologists, 11 (5%) were pediatric hepatologists, 45 (19%) were APPs, and 9 (4%) were other providers. We found that 69 (30%) experienced a reduction in compensation, 92 (40%) experienced a reduction in staff, and 9 (4%) closed their practice; 100 (43%) respondents reported experiencing burnout. In univariate analysis, burnout was more frequently reported in those ≤55 years old (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.2-4.2), women (OR, 2.2; 95% CI, 1.3-3.7), nontransplant hepatology (OR, 2.0; 95% CI, 1.1-3.3), APPs (OR, 2.7; 95% CI, 1.4-5.1), and those less than 10 years in practice (OR, 1.9; 95% CI, 1.1-3.3). In multivariable analysis, only age ≤55 years was associated with burnout (OR, 2.3; 95% CI, 1.1-4.8). The most common ways the respondents suggested the AASLD could help was through virtual platforms for networking, mentoring, and coping with the changes in practice due to the COVID-19 pandemic. Conclusion: The COVID-19 pandemic has had a substantial impact on the clinical practice of hepatology as well as burnout and emotional well-being. Women, APPs, and early and mid-career clinicians more frequently reported burnout. Identified strategies to cope with burnout include virtual platforms to facilitate networking and mentoring.
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Affiliation(s)
- Mark W Russo
- Division of HepatologyAtrium Health Wake Forest School of MedicineCharlotteNCUSA
| | - Ryan Kwok
- Uniformed Services UniversityBethesdaMDUSA.,Madigan Army Medical CenterTacomaWAUSA
| | - Marina Serper
- Division of Gastroenterology and HepatologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
| | - Nneka Ufere
- Division of GastroenterologyDepartment of MedicineMassachusetts General Hospital BostonMAUSA
| | - Bilal Hameed
- Division of Gastroenterology and HepatologyUniversity of California San Francisco School of MedicineSan FranciscoCAUSA
| | - Jaime Chu
- Division of Pediatric HepatologyIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Elizabeth Goacher
- Division of GastroenterologyDuke University School of MedicineDurhamNCUSA
| | - John Lingerfelt
- American Association for the Study of Liver DiseasesAlexandriaVAUSA
| | - Norah Terrault
- Division of Gastroenterology and LiverKeck Medicine at University of Southern CaliforniaLos AngelesCAUSA
| | - K Rajender Reddy
- Division of Gastroenterology and HepatologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPAUSA
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Rao A, Rule JA, Hameed B, Ganger D, Fontana RJ, Lee WM. Secular Trends in Severe Idiosyncratic Drug-Induced Liver Injury in North America: An Update From the Acute Liver Failure Study Group Registry. Am J Gastroenterol 2022; 117:617-626. [PMID: 35081550 PMCID: PMC10668505 DOI: 10.14309/ajg.0000000000001655] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/03/2022] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Idiosyncratic drug-induced liver injury (DILI) is the second leading cause of acute liver failure (ALF) in the United States. Our study aims were to characterize secular trends in the implicated agents, clinical features, and outcomes of adults with DILI ALF over a 20-year period. METHODS Among 2,332 patients with ALF enrolled in the ALF Study Group registry, 277 (11.9%) were adjudicated as idiosyncratic DILI ALF (INR ≥ 1.5 and hepatic encephalopathy) through expert opinion. The 155 cases in era 1 (January 20, 1998-January 20, 2008) were compared with the 122 cases in era 2 (January 21, 2008-January 20, 2018). RESULTS Among 277 cases of DILI ALF, 97 different agents, alone or in combination, were implicated: antimicrobials, n = 118 (43%); herbal/dietary supplements (HDS), n = 42 (15%); central nervous system agents/illicit substances, n = 37 (13%); oncologic/biologic agents, n = 29 (10%); and other, n = 51 (18%). Significant trends over time included (i) an increase in HDS DILI ALF (9.7% vs 22%, P < 0.01) and decrease in antimicrobial-induced DILI ALF (45.8% vs. 38.5%, P = 0.03) and (ii) improved overall transplant-free survival (23.5%-38.7%, P < 0.01) while the number of patients transplanted declined (46.4% vs 33.6%, P < 0.03). DISCUSSION DILI ALF in North America is evolving, with HDS cases rising and other categories of suspect drugs declining. The reasons for a significant increase in transplant-free survival and reduced need for liver transplantation over time remain unclear but may be due to improvements in critical care, increased NAC utilization, and improved patient prognostication.
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Affiliation(s)
- Ashwin Rao
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jody A. Rule
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Bilal Hameed
- Division of Gastroenterology and Hepatology, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Daniel Ganger
- Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois, USA
| | - Robert J. Fontana
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - William M. Lee
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Abstract
Introduction: Non-Alcoholic Steatohepatitis is an increasing reason for liver transplantation in the western world. Knowledge of recipient life expectancy may assist in prudent allocation of a relatively scarce supply of donor livers. Research Questions: We calculated life expectancies for Non-alcoholic steatohepatitis (NASH) patients both at time of transplant and one year later, stratified by key risk factors, and examined whether survival has improved in recent years. Design: Data on 6635 NASH patients who underwent liver transplantation in the MELD era (2002-2018) from the United States OPTN database were analyzed using the Cox proportional hazards regression model and life table methods. Results: Factors related to survival were age, presence of diabetes or hepatic encephalopathy (HE), and whether the patient required dialysis in the week prior to transplant. Other important factors were whether the patient was working, hospitalization prior to transplant, ventilator support, and length of hospital stay (LOS). Survival improved over the study period at roughly 4.5% per calendar year during the first year posttransplant, though no improvement was observed in those who had survived one year. Conclusion: Life expectancy in NASH transplant patients was much reduced from normal, and varied according to age, medical factors, status at transplant, and post transplant course. Over the 17-year study period, patient survival improved markedly during the first year posttransplant, though not thereafter. The results given here may prove helpful in medical decision-making regarding treatment for both liver disease and other medical conditions, as they provide both clinicians and their patients with evidence-based information on prognosis.
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Affiliation(s)
| | | | - Ji Hun Kwak
- Life Expectancy Project, San Francisco, CA, USA
| | | | - Bilal Hameed
- Division of Gastroenterology, University of California, San Francisco, CA, USA
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Kwong A, Hameed B, Syed S, Ho R, Mard H, Arshad S, Ho I, Suleman T, Yao F, Mehta N. Machine learning to predict waitlist dropout among liver transplant candidates with hepatocellular carcinoma. Cancer Med 2022; 11:1535-1541. [PMID: 35029055 PMCID: PMC8921896 DOI: 10.1002/cam4.4538] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/30/2021] [Accepted: 12/04/2021] [Indexed: 12/18/2022] Open
Abstract
Background Accurate prediction of outcome among liver transplant candidates with hepatocellular carcinoma (HCC) remains challenging. We developed a prediction model for waitlist dropout among liver transplant candidates with HCC. Methods The study included 18,920 adult liver transplant candidates in the United States listed with a diagnosis of HCC, with data provided by the Organ Procurement and Transplantation Network. The primary outcomes were 3‐, 6‐, and 12‐month waitlist dropout, defined as removal from the liver transplant waitlist due to death or clinical deterioration. Results Using 1,181 unique variables, the random forest model and Spearman's correlation analyses converged on 12 predictive features involving 5 variables, including AFP (maximum and average), largest tumor size (minimum, average, and most recent), bilirubin (minimum and average), INR (minimum and average), and ascites (maximum, average, and most recent). The final Cox proportional hazards model had a concordance statistic of 0.74 in the validation set. An online calculator was created for clinical use and can be found at: http://hcclivercalc.cloudmedxhealth.com/. Conclusion In summary, a simple, interpretable 5‐variable model predicted 3‐, 6‐, and 12‐month waitlist dropout among patients with HCC. This prediction can be used to appropriately prioritize patients with HCC and their imminent need for transplant.
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Affiliation(s)
- Allison Kwong
- Division of Gastroenterology and Hepatology Stanford University Stanford USA
| | - Bilal Hameed
- Division of Gastroenterology University of California San Francisco California USA
| | - Shareef Syed
- Division of Transplant Surgery University of California San Francisco California USA
| | - Ryan Ho
- CloudMedx, Inc Palo Alto California USA
| | | | | | - Isaac Ho
- CloudMedx, Inc Palo Alto California USA
| | | | - Francis Yao
- Division of Gastroenterology University of California San Francisco California USA
| | - Neil Mehta
- Division of Gastroenterology University of California San Francisco California USA
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Shavelle RM, Saur RC, Kwak JH, Brooks JC, Hameed B. Life expectancy after liver transplantation for primary biliary cirrhosis, primary sclerosing cholangitis, or hepatitis B cirrhosis✰,✰✰. Journal of Liver Transplantation 2022. [DOI: 10.1016/j.liver.2021.100052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Mazzini GS, Augustin T, Noria S, Romero-Marrero C, Li N, Hameed B, Eisenberg D, Azagury DE, Ikramuddin S. ASMBS Position Statement on the Impact of Metabolic and Bariatric Surgery on Nonalcoholic Steatohepatitis. Surg Obes Relat Dis 2021; 18:314-325. [PMID: 34953742 DOI: 10.1016/j.soard.2021.11.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/07/2021] [Indexed: 10/25/2022]
Affiliation(s)
- Guilherme S Mazzini
- Division of Bariatric and Gastrointestinal Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Toms Augustin
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sabrena Noria
- Department of Surgery, Division of General and Gastrointestinal Surgery, The Ohio state University, Wexner Medical Center, Columbus, Ohio
| | - Carlos Romero-Marrero
- South Florida Transplant Center, Broward Health Medical Center, Fort Lauderdale, Florida
| | - Na Li
- Division of Gastroenterology, Hepatology, & Nutrition, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bilal Hameed
- Department of Medicine, University of California, San Francisco, California
| | - Dan Eisenberg
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Dan E Azagury
- Section of Minimally Invasive & Bariatric Surgery, Stanford University School of Medicine, Stanford, California
| | - Sayeed Ikramuddin
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota.
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Abstract
BACKGROUND Alcohol-associated liver disease is the leading cause of liver transplantation in the western world. For these patients we calculated life expectancies both at time of transplant and several years later, stratified by key risk factors, and determined if survival has improved in recent years. METHODS Data on 14 962 patients with alcohol-associated liver disease who underwent liver transplantation in the MELD era (2002-2018) from the United States Organ Procurement and Transplantation Network database were analyzed using the Cox proportional hazards regression model and life table methods. RESULTS Demographic and past medical history factors related to survival were patient age, presence of diabetes or severe hepatic encephalopathy, and length of hospital stay. Survival improved over the study period, at roughly 3% per calendar year during the first 5 years posttransplant and 1% per year thereafter. CONCLUSIONS Life expectancy in transplanted patients with alcohol-associated liver disease was much reduced from normal, and varied according to age, medical risk factors, and functional status. Survival improved modestly over the study period. Information on patient longevity can be helpful in making treatment decisions.
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Affiliation(s)
| | - Rachel C Saur
- Life Expectancy Project, San Francisco, California, USA
| | - Ji Hun Kwak
- Life Expectancy Project, San Francisco, California, USA
| | | | - Bilal Hameed
- Division of Gastroenterology, University of California, San Francisco, USA
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Sanyal AJ, Van Natta ML, Clark J, Neuschwander-Tetri BA, Diehl A, Dasarathy S, Loomba R, Chalasani N, Kowdley K, Hameed B, Wilson LA, Yates KP, Belt P, Lazo M, Kleiner DE, Behling C, Tonascia J. Prospective Study of Outcomes in Adults with Nonalcoholic Fatty Liver Disease. N Engl J Med 2021; 385:1559-1569. [PMID: 34670043 PMCID: PMC8881985 DOI: 10.1056/nejmoa2029349] [Citation(s) in RCA: 387] [Impact Index Per Article: 129.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The prognoses with respect to mortality and hepatic and nonhepatic outcomes across the histologic spectrum of nonalcoholic fatty liver disease (NAFLD) are not well defined. METHODS We prospectively followed a multicenter patient population that included the full histologic spectrum of NAFLD. The incidences of death and other outcomes were compared across baseline histologic characteristics. RESULTS A total of 1773 adults with NAFLD were followed for a median of 4 years. All-cause mortality increased with increasing fibrosis stages (0.32 deaths per 100 person-years for stage F0 to F2 [no, mild, or moderate fibrosis], 0.89 deaths per 100 persons-years for stage F3 [bridging fibrosis], and 1.76 deaths per 100 person-years for stage F4 [cirrhosis]). The incidence of liver-related complications per 100 person-years increased with fibrosis stage (F0 to F2 vs. F3 vs. F4) as follows: variceal hemorrhage (0.00 vs. 0.06 vs. 0.70), ascites (0.04 vs. 0.52 vs. 1.20), encephalopathy (0.02 vs. 0.75 vs. 2.39), and hepatocellular cancer (0.04 vs. 0.34 vs. 0.14). As compared with patients with stage F0 to F2 fibrosis, patients with stage F4 fibrosis also had a higher incidence of type 2 diabetes (7.53 vs. 4.45 events per 100 person-years) and a decrease of more than 40% in the estimated glomerular filtration rate (2.98 vs. 0.97 events per 100 person-years). The incidence of cardiac events and nonhepatic cancers were similar across fibrosis stages. After adjustment for age, sex, race, diabetes status, and baseline histologic severity, the incidence of any hepatic decompensation event (variceal hemorrhage, ascites, or encephalopathy) was associated with increased all-cause mortality (adjusted hazard ratio, 6.8; 95% confidence interval, 2.2 to 21.3). CONCLUSIONS In this prospective study involving patients with NAFLD, fibrosis stages F3 and F4 were associated with increased risks of liver-related complications and death. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; NAFLD DB2 ClinicalTrials.gov number, NCT01030484.).
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Affiliation(s)
- Arun J Sanyal
- From the Virginia Commonwealth University School of Medicine, Richmond (A.J.S.); the Bloomberg School of Public Health, Johns Hopkins University, Baltimore (M.L.V.N., J.C., L.A.W., K.P.Y., P.B., M.L., J.T.), and the Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda (D.E.K.) - both in Maryland; Saint Louis University, St. Louis (B.A.N.-T.); Duke University, Durham, NC (A.M.D.); Cleveland Clinic, Cleveland (S.D.); the University of California, San Diego, School of Medicine, La Jolla (R.L., C.B.), and the University of California, San Francisco, School of Medicine, San Francisco (B.H.); Indiana University School of Medicine, Indianapolis (N.C.); and the Liver Institute Northwest, Seattle (K.K.)
| | - Mark L Van Natta
- From the Virginia Commonwealth University School of Medicine, Richmond (A.J.S.); the Bloomberg School of Public Health, Johns Hopkins University, Baltimore (M.L.V.N., J.C., L.A.W., K.P.Y., P.B., M.L., J.T.), and the Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda (D.E.K.) - both in Maryland; Saint Louis University, St. Louis (B.A.N.-T.); Duke University, Durham, NC (A.M.D.); Cleveland Clinic, Cleveland (S.D.); the University of California, San Diego, School of Medicine, La Jolla (R.L., C.B.), and the University of California, San Francisco, School of Medicine, San Francisco (B.H.); Indiana University School of Medicine, Indianapolis (N.C.); and the Liver Institute Northwest, Seattle (K.K.)
| | - Jeanne Clark
- From the Virginia Commonwealth University School of Medicine, Richmond (A.J.S.); the Bloomberg School of Public Health, Johns Hopkins University, Baltimore (M.L.V.N., J.C., L.A.W., K.P.Y., P.B., M.L., J.T.), and the Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda (D.E.K.) - both in Maryland; Saint Louis University, St. Louis (B.A.N.-T.); Duke University, Durham, NC (A.M.D.); Cleveland Clinic, Cleveland (S.D.); the University of California, San Diego, School of Medicine, La Jolla (R.L., C.B.), and the University of California, San Francisco, School of Medicine, San Francisco (B.H.); Indiana University School of Medicine, Indianapolis (N.C.); and the Liver Institute Northwest, Seattle (K.K.)
| | - Brent A Neuschwander-Tetri
- From the Virginia Commonwealth University School of Medicine, Richmond (A.J.S.); the Bloomberg School of Public Health, Johns Hopkins University, Baltimore (M.L.V.N., J.C., L.A.W., K.P.Y., P.B., M.L., J.T.), and the Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda (D.E.K.) - both in Maryland; Saint Louis University, St. Louis (B.A.N.-T.); Duke University, Durham, NC (A.M.D.); Cleveland Clinic, Cleveland (S.D.); the University of California, San Diego, School of Medicine, La Jolla (R.L., C.B.), and the University of California, San Francisco, School of Medicine, San Francisco (B.H.); Indiana University School of Medicine, Indianapolis (N.C.); and the Liver Institute Northwest, Seattle (K.K.)
| | - AnnaMae Diehl
- From the Virginia Commonwealth University School of Medicine, Richmond (A.J.S.); the Bloomberg School of Public Health, Johns Hopkins University, Baltimore (M.L.V.N., J.C., L.A.W., K.P.Y., P.B., M.L., J.T.), and the Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda (D.E.K.) - both in Maryland; Saint Louis University, St. Louis (B.A.N.-T.); Duke University, Durham, NC (A.M.D.); Cleveland Clinic, Cleveland (S.D.); the University of California, San Diego, School of Medicine, La Jolla (R.L., C.B.), and the University of California, San Francisco, School of Medicine, San Francisco (B.H.); Indiana University School of Medicine, Indianapolis (N.C.); and the Liver Institute Northwest, Seattle (K.K.)
| | - Srinivasan Dasarathy
- From the Virginia Commonwealth University School of Medicine, Richmond (A.J.S.); the Bloomberg School of Public Health, Johns Hopkins University, Baltimore (M.L.V.N., J.C., L.A.W., K.P.Y., P.B., M.L., J.T.), and the Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda (D.E.K.) - both in Maryland; Saint Louis University, St. Louis (B.A.N.-T.); Duke University, Durham, NC (A.M.D.); Cleveland Clinic, Cleveland (S.D.); the University of California, San Diego, School of Medicine, La Jolla (R.L., C.B.), and the University of California, San Francisco, School of Medicine, San Francisco (B.H.); Indiana University School of Medicine, Indianapolis (N.C.); and the Liver Institute Northwest, Seattle (K.K.)
| | - Rohit Loomba
- From the Virginia Commonwealth University School of Medicine, Richmond (A.J.S.); the Bloomberg School of Public Health, Johns Hopkins University, Baltimore (M.L.V.N., J.C., L.A.W., K.P.Y., P.B., M.L., J.T.), and the Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda (D.E.K.) - both in Maryland; Saint Louis University, St. Louis (B.A.N.-T.); Duke University, Durham, NC (A.M.D.); Cleveland Clinic, Cleveland (S.D.); the University of California, San Diego, School of Medicine, La Jolla (R.L., C.B.), and the University of California, San Francisco, School of Medicine, San Francisco (B.H.); Indiana University School of Medicine, Indianapolis (N.C.); and the Liver Institute Northwest, Seattle (K.K.)
| | - Naga Chalasani
- From the Virginia Commonwealth University School of Medicine, Richmond (A.J.S.); the Bloomberg School of Public Health, Johns Hopkins University, Baltimore (M.L.V.N., J.C., L.A.W., K.P.Y., P.B., M.L., J.T.), and the Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda (D.E.K.) - both in Maryland; Saint Louis University, St. Louis (B.A.N.-T.); Duke University, Durham, NC (A.M.D.); Cleveland Clinic, Cleveland (S.D.); the University of California, San Diego, School of Medicine, La Jolla (R.L., C.B.), and the University of California, San Francisco, School of Medicine, San Francisco (B.H.); Indiana University School of Medicine, Indianapolis (N.C.); and the Liver Institute Northwest, Seattle (K.K.)
| | - Kris Kowdley
- From the Virginia Commonwealth University School of Medicine, Richmond (A.J.S.); the Bloomberg School of Public Health, Johns Hopkins University, Baltimore (M.L.V.N., J.C., L.A.W., K.P.Y., P.B., M.L., J.T.), and the Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda (D.E.K.) - both in Maryland; Saint Louis University, St. Louis (B.A.N.-T.); Duke University, Durham, NC (A.M.D.); Cleveland Clinic, Cleveland (S.D.); the University of California, San Diego, School of Medicine, La Jolla (R.L., C.B.), and the University of California, San Francisco, School of Medicine, San Francisco (B.H.); Indiana University School of Medicine, Indianapolis (N.C.); and the Liver Institute Northwest, Seattle (K.K.)
| | - Bilal Hameed
- From the Virginia Commonwealth University School of Medicine, Richmond (A.J.S.); the Bloomberg School of Public Health, Johns Hopkins University, Baltimore (M.L.V.N., J.C., L.A.W., K.P.Y., P.B., M.L., J.T.), and the Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda (D.E.K.) - both in Maryland; Saint Louis University, St. Louis (B.A.N.-T.); Duke University, Durham, NC (A.M.D.); Cleveland Clinic, Cleveland (S.D.); the University of California, San Diego, School of Medicine, La Jolla (R.L., C.B.), and the University of California, San Francisco, School of Medicine, San Francisco (B.H.); Indiana University School of Medicine, Indianapolis (N.C.); and the Liver Institute Northwest, Seattle (K.K.)
| | - Laura A Wilson
- From the Virginia Commonwealth University School of Medicine, Richmond (A.J.S.); the Bloomberg School of Public Health, Johns Hopkins University, Baltimore (M.L.V.N., J.C., L.A.W., K.P.Y., P.B., M.L., J.T.), and the Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda (D.E.K.) - both in Maryland; Saint Louis University, St. Louis (B.A.N.-T.); Duke University, Durham, NC (A.M.D.); Cleveland Clinic, Cleveland (S.D.); the University of California, San Diego, School of Medicine, La Jolla (R.L., C.B.), and the University of California, San Francisco, School of Medicine, San Francisco (B.H.); Indiana University School of Medicine, Indianapolis (N.C.); and the Liver Institute Northwest, Seattle (K.K.)
| | - Katherine P Yates
- From the Virginia Commonwealth University School of Medicine, Richmond (A.J.S.); the Bloomberg School of Public Health, Johns Hopkins University, Baltimore (M.L.V.N., J.C., L.A.W., K.P.Y., P.B., M.L., J.T.), and the Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda (D.E.K.) - both in Maryland; Saint Louis University, St. Louis (B.A.N.-T.); Duke University, Durham, NC (A.M.D.); Cleveland Clinic, Cleveland (S.D.); the University of California, San Diego, School of Medicine, La Jolla (R.L., C.B.), and the University of California, San Francisco, School of Medicine, San Francisco (B.H.); Indiana University School of Medicine, Indianapolis (N.C.); and the Liver Institute Northwest, Seattle (K.K.)
| | - Patricia Belt
- From the Virginia Commonwealth University School of Medicine, Richmond (A.J.S.); the Bloomberg School of Public Health, Johns Hopkins University, Baltimore (M.L.V.N., J.C., L.A.W., K.P.Y., P.B., M.L., J.T.), and the Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda (D.E.K.) - both in Maryland; Saint Louis University, St. Louis (B.A.N.-T.); Duke University, Durham, NC (A.M.D.); Cleveland Clinic, Cleveland (S.D.); the University of California, San Diego, School of Medicine, La Jolla (R.L., C.B.), and the University of California, San Francisco, School of Medicine, San Francisco (B.H.); Indiana University School of Medicine, Indianapolis (N.C.); and the Liver Institute Northwest, Seattle (K.K.)
| | - Mariana Lazo
- From the Virginia Commonwealth University School of Medicine, Richmond (A.J.S.); the Bloomberg School of Public Health, Johns Hopkins University, Baltimore (M.L.V.N., J.C., L.A.W., K.P.Y., P.B., M.L., J.T.), and the Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda (D.E.K.) - both in Maryland; Saint Louis University, St. Louis (B.A.N.-T.); Duke University, Durham, NC (A.M.D.); Cleveland Clinic, Cleveland (S.D.); the University of California, San Diego, School of Medicine, La Jolla (R.L., C.B.), and the University of California, San Francisco, School of Medicine, San Francisco (B.H.); Indiana University School of Medicine, Indianapolis (N.C.); and the Liver Institute Northwest, Seattle (K.K.)
| | - David E Kleiner
- From the Virginia Commonwealth University School of Medicine, Richmond (A.J.S.); the Bloomberg School of Public Health, Johns Hopkins University, Baltimore (M.L.V.N., J.C., L.A.W., K.P.Y., P.B., M.L., J.T.), and the Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda (D.E.K.) - both in Maryland; Saint Louis University, St. Louis (B.A.N.-T.); Duke University, Durham, NC (A.M.D.); Cleveland Clinic, Cleveland (S.D.); the University of California, San Diego, School of Medicine, La Jolla (R.L., C.B.), and the University of California, San Francisco, School of Medicine, San Francisco (B.H.); Indiana University School of Medicine, Indianapolis (N.C.); and the Liver Institute Northwest, Seattle (K.K.)
| | - Cynthia Behling
- From the Virginia Commonwealth University School of Medicine, Richmond (A.J.S.); the Bloomberg School of Public Health, Johns Hopkins University, Baltimore (M.L.V.N., J.C., L.A.W., K.P.Y., P.B., M.L., J.T.), and the Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda (D.E.K.) - both in Maryland; Saint Louis University, St. Louis (B.A.N.-T.); Duke University, Durham, NC (A.M.D.); Cleveland Clinic, Cleveland (S.D.); the University of California, San Diego, School of Medicine, La Jolla (R.L., C.B.), and the University of California, San Francisco, School of Medicine, San Francisco (B.H.); Indiana University School of Medicine, Indianapolis (N.C.); and the Liver Institute Northwest, Seattle (K.K.)
| | - James Tonascia
- From the Virginia Commonwealth University School of Medicine, Richmond (A.J.S.); the Bloomberg School of Public Health, Johns Hopkins University, Baltimore (M.L.V.N., J.C., L.A.W., K.P.Y., P.B., M.L., J.T.), and the Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda (D.E.K.) - both in Maryland; Saint Louis University, St. Louis (B.A.N.-T.); Duke University, Durham, NC (A.M.D.); Cleveland Clinic, Cleveland (S.D.); the University of California, San Diego, School of Medicine, La Jolla (R.L., C.B.), and the University of California, San Francisco, School of Medicine, San Francisco (B.H.); Indiana University School of Medicine, Indianapolis (N.C.); and the Liver Institute Northwest, Seattle (K.K.)
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Fontana RJ, Stravitz RT, Durkalski V, Hanje J, Hameed B, Koch D, Ganger D, Olson J, Liou I, McGuire BM, Clasen K, Lee WM. Prognostic Value of the 13 C-Methacetin Breath Test in Adults with Acute Liver Failure and Non-acetaminophen Acute Liver Injury. Hepatology 2021; 74:961-972. [PMID: 33660316 PMCID: PMC10683007 DOI: 10.1002/hep.31783] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 01/08/2021] [Accepted: 02/01/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND AIMS The 13 C-methacetin breath test (MBT) is a noninvasive, quantitative hepatic metabolic function test. The aim of this prospective, multicenter study was to determine the utility of initial and serial 13 C-MBT in predicting 21-day outcomes in adults with acute liver failure (ALF) and non-acetaminophen acute liver injury (ALI). APPROACH AND RESULTS The 13 C-MBT BreathID device (Exalenz Biosciences, Ltd.) provided the percent dose recovery (PDR) for a duration of 60 minutes after administration of 13 C-methacetin solution as the change in exhaled 13 CO2 /12 CO2 compared with pre-ingestion ratio on study days 1, 2, 3, 5, and 7. Results were correlated with 21-day transplant-free survival and other prognostic indices. A total of 280 subjects were screened for enrollment between May 2016 and August 2019. Median age of the 62 enrolled patients with adequate data was 43 years, 79% were Caucasian, 76% had ALF with the remaining 24% having ALI. The mean PDR peak on day 1 or day 2 was significantly lower in nonsurvivors compared with transplant-free survivors (2.3%/hour vs. 9.1%/hour; P < 0.0001). In addition, serial PDR peaks were consistently lower in nonsurvivors versus survivors (P < 0.0001). The area under the receiver operating characteristic curve (AUROC) of the 13 C-MBT in the combined cohort was 0.88 (95% CI: 0.79-0.97) and higher than that provided by King's College (AUROC = 0.70) and Model for End-Stage Liver Disease scores (AUROC = 0.83). The 13 C-MBT was well tolerated with only two gastrointestinal adverse events reported. CONCLUSIONS The 13 C-MBT is a promising tool to estimate the likelihood of hepatic recovery in patients with ALF and ALI. Use of the PDR peak data from the 13 C-MBT point-of-care test may assist with medical decision making and help avoid unnecessary transplantation in critically ill patients with ALF and ALI.
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Affiliation(s)
- Robert J. Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - R. Todd Stravitz
- Lee-Hume Transplant Center, Virginia Commonwealth University, Richmond, VA
| | - Valerie Durkalski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - James Hanje
- Department of Medicine, The Ohio State University, Columbus, OH
| | - Bilal Hameed
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - David Koch
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Daniel Ganger
- Division of Gastroenterology, Northwestern University, Chicago, IL
| | - Jody Olson
- Division of Gastroenterology, University of Kansas Medical Center, Kansas City, KS
| | - Iris Liou
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Kristen Clasen
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - William M. Lee
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX
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Mehta N, Parikh ND, Kelley RK, Hameed B, Singal AG. Surveillance and Monitoring of Hepatocellular Carcinoma During the COVID-19 Pandemic. Clin Gastroenterol Hepatol 2021; 19:1520-1530. [PMID: 32652308 PMCID: PMC7342037 DOI: 10.1016/j.cgh.2020.06.072] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 06/23/2020] [Accepted: 06/25/2020] [Indexed: 01/27/2023]
Abstract
The Coronavirus disease 2019 (COVID-19) pandemic is expected to have a long-lasting impact on the approach to care for patients at risk for and with hepatocellular carcinoma (HCC) due to the risks from potential exposure and resource reallocation. The goal of this document is to provide recommendations on HCC surveillance and monitoring, including strategies to limit unnecessary exposure while continuing to provide high-quality care for patients. Publications and guidelines pertaining to the management of HCC during COVID-19 were reviewed for recommendations related to surveillance and monitoring practices, and any available guidance was referenced to support the authors' recommendations when applicable. Existing HCC risk stratification models should be utilized to prioritize imaging resources to those patients at highest risk of incident HCC and recurrence following therapy though surveillance can likely continue as before in settings where COVID-19 prevalence is low and adequate protections are in place. Waitlisted patients who will benefit from urgent LT should be prioritized for surveillance whereas it would be reasonable to extend surveillance interval by a short period in HCC patients with lower risk tumor features and those more than 2 years since their last treatment. For patients eligible for systemic therapy, the treatment regimen should be dictated by the risk of COVID-19 associated with route of administration, monitoring and treatment of adverse events, within the context of relative treatment efficacy.
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Affiliation(s)
- Neil Mehta
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California.
| | - Neehar D. Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - R. Katie Kelley
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California
| | - Bilal Hameed
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California
| | - Amit G. Singal
- Division of Digestive and Liver Disease, UT Southwestern Medical Center, Dallas, Texas
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Fix OK, Blumberg EA, Chang KM, Chu J, Chung RT, Goacher EK, Hameed B, Kaul DR, Kulik LM, Kwok RM, McGuire BM, Mulligan DC, Price JC, Reau NS, Reddy KR, Reynolds A, Rosen HR, Russo MW, Schilsky ML, Verna EC, Ward JW, Fontana RJ. American Association for the Study of Liver Diseases Expert Panel Consensus Statement: Vaccines to Prevent Coronavirus Disease 2019 Infection in Patients With Liver Disease. Hepatology 2021; 74:1049-1064. [PMID: 33577086 PMCID: PMC8014184 DOI: 10.1002/hep.31751] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 02/06/2023]
Abstract
The aim of this document is to provide a concise scientific review of the currently available COVID-19 vaccines and those in development, including mRNA, adenoviral vectors, and recombinant protein approaches. The anticipated use of COVID-19 vaccines in patients with chronic liver disease (CLD) and liver transplant (LT) recipients is reviewed and practical guidance is provided for health care providers involved in the care of patients with liver disease and LT about vaccine prioritization and administration. The Pfizer and Moderna mRNA COVID-19 vaccines are associated with a 94%-95% vaccine efficacy compared to placebo against COVID-19. Local site reactions of pain and tenderness were reported in 70%-90% of clinical trial participants, and systemic reactions of fever and fatigue were reported in 40%-70% of participants, but these reactions were generally mild and self-limited and occurred more frequently in younger persons. Severe hypersensitivity reactions related to the mRNA COVID-19 vaccines are rare and more commonly observed in women and persons with a history of previous drug reactions for unclear reasons. Because patients with advanced liver disease and immunosuppressed patients were excluded from the vaccine licensing trials, additional data regarding the safety and efficacy of COVID-19 vaccines are eagerly awaited in these and other subgroups. Remarkably safe and highly effective mRNA COVID-19 vaccines are now available for widespread use and should be given to all adult patients with CLD and LT recipients. The online companion document located at https://www.aasld.org/about-aasld/covid-19-resources will be updated as additional data become available regarding the safety and efficacy of other COVID-19 vaccines in development.
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Affiliation(s)
- Oren K Fix
- Elson S. Floyd College of MedicineWashington State UniversitySpokaneWAUSA
| | | | - Kyong-Mi Chang
- University of PennsylvaniaPhiladelphiaPAUSA.,The Corporal Michael J. Crescenz VA Medical CenterPhiladelphiaPAUSA
| | - Jaime Chu
- Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mark W Russo
- Atrium HealthCarolinas Medical CenterCharlotteNCUSA
| | | | | | - John W Ward
- Coalition for Global Hepatitis EliminationDecaturGAUSA
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Veracruz N, Hameed B, Saab S, Wong RJ. The Association Between Nonalcoholic Fatty Liver Disease and Risk of Cardiovascular Disease, Stroke, and Extrahepatic Cancers. J Clin Exp Hepatol 2021; 11:45-81. [PMID: 33679048 PMCID: PMC7897860 DOI: 10.1016/j.jceh.2020.04.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 04/24/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND & AIMS Although primarily a disease with liver-specific complications, nonalcoholic fatty liver disease (NAFLD) is a systemic disease with extrahepatic complications. We aim to evaluate the association between NAFLD and cardiovascular disease (CVD), stroke and cerebrovascular disease, and extrahepatic cancers. METHODS We searched MEDLINE, EMBASE, and Cochrane Systematic Review Database from January 1, 2000 to July 1, 2019 to identify peer-reviewed English language literature using predefined keywords for NAFLD, CVD, stroke and cerebrovascular disease, and extrahepatic cancers among adults. Two reviewers independently selected studies for inclusion. Measures of association between NAFLD and CVD, stroke and cerebrovascular disease, and extrahepatic cancers were extracted. Quality assessed using Newcastle-Ottawa scale and Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS Thirty studies were included evaluating CVD, 16 studies evaluating stroke or cerebrovascular disease, and 13 studies evaluating extrahepatic cancers. On pooled meta-analysis assessment, NAFLD was associated with increased risk of CVD (risk ratio [RR]: 1.78; 95% confidence interval [CI]: 1.52-2.08) and stroke or cerebrovascular disease (RR: 2.08, 95% CI: 1.72-2.51). Significant heterogeneity in assessing extrahepatic cancers prevented applying meta-analysis methods, but NAFLD seemed to be associated with increased risk of breast and colorectal cancers. Overall level of quality of studies were very low by GRADE. CONCLUSIONS NAFLD is associated with increased risks of CVD and stroke or cerebrovascular disease among adults. There appears to be increased risk of breast and colorectal cancers. Given low quality of evidence, it is premature to make any strong conclusions to modify CVD, stroke, or cancer screening policies in patients with NAFLD.
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Affiliation(s)
- Nicolette Veracruz
- College of Medicine, Central Michigan University, Mount Pleasant, MI, USA
| | - Bilal Hameed
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, CA, USA
| | - Sammy Saab
- Division of Gastroenterology and Hepatology, Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Robert J. Wong
- Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland, CA, USA
- Address for correspondence:
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Loomba R, Neuschwander-Tetri BA, Sanyal A, Chalasani N, Diehl AM, Terrault N, Kowdley K, Dasarathy S, Kleiner D, Behling C, Lavine J, Van Natta M, Middleton M, Tonascia J, Sirlin C, Allende D, Dasarathy S, McCullough AJ, Penumatsa R, Dasarathy J, Lavine JE, Abdelmalek MF, Bashir M, Buie S, Diehl AM, Guy C, Kigongo C, Kopping M, Malik D, Piercy D, Chalasani N, Cummings OW, Gawrieh S, Ragozzino L, Sandrasegaran K, Vuppalanchi R, Brunt EM, Cattoor T, Carpenter D, Freebersyser J, King D, Lai J, Neuschwander‐Tetri BA, Siegner J, Stewart S, Torretta S, Wriston K, Gonzalez MC, Davila J, Jhaveri M, Kowdley KV, Mukhtar N, Ness E, Poitevin M, Quist B, Soo S, Ang B, Behling C, Bhatt A, Loomba R, Middleton MS, Sirlin C, Akhter MF, Bass NM, Brandman D, Gill R, Hameed B, Maher J, Terrault N, Ungermann A, Yeh M, Boyett S, Contos MJ, Kirwin S, Luketic VA, Puri P, Sanyal AJ, Schlosser J, Siddiqui MS, Yost‐Schomer L, Brunt EM, Fowler K, Kleiner DE, Doo EC, Hall S, Hoofnagle JH, Robuck PR, Sherker AH, Torrance R, Belt P, Clark JM, Dodge J, Donithan M, Isaacson M, Lazo M, Meinert J, Miriel L, Sharkey EP, Smith J, Smith M, Sternberg A, Tonascia J, Van Natta ML, Wagoner A, Wilson LA, Yamada G, Yates K, Covarrubias Y, Gamst A, Hamilton G, Henderson W, Hooker J, Lavine JE, Loomba R, Middleton MS, Schlein A, Schwimmer JB, Shen W, Sirlin C, Wolfson T. Multicenter Validation of Association Between Decline in MRI-PDFF and Histologic Response in NASH. Hepatology 2020; 72:1219-1229. [PMID: 31965579 PMCID: PMC8055244 DOI: 10.1002/hep.31121] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 12/23/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Emerging data from a single-center study suggests that a 30% relative reduction in liver fat content as assessed by magnetic resonance imaging-proton density fat fraction (MRI-PDFF) from baseline may be associated with histologic improvement in nonalcoholic steatohepatitis (NASH). There are limited multicenter data comparing an active drug versus placebo on the association between the quantity of liver fat reduction assessed by MRI-PDFF and histologic response in NASH. This study aims to examine the association between 30% relative reduction in MRI-PDFF and histologic response in obeticholic acid (OCA) versus placebo-treated patients in the FLINT (farnesoid X receptor ligand obeticholic acid in NASH trial). APPROACH AND RESULTS This is a secondary analysis of the FLINT trial including 78 patients with MRI-PDFF measured before and after treatment along with paired liver histology assessment. Histologic response was defined as a 2-point improvement in nonalcoholic fatty liver disease activity score without worsening of fibrosis. OCA (25 mg orally once daily) was better than placebo in improving MRI-PDFF by an absolute difference of -3.4% (95% confidence interval [CI], -6.5 to -0.2%, P value = 0.04) and relative difference of -17% (95% CI, -34 to 0%, P value = 0.05). The optimal cutoff point for relative decline in MRI-PDFF for histologic response was 30% (using Youden's index). The rate of histologic response in those who achieved less than 30% decline in MRI-PDFF versus those who achieved a 30% or greater decline in MRI-PDFF (MRI-PDFF responders) relative to baseline was 19% versus 50%, respectively. Compared with MRI-PDFF nonresponders, MRI-PDFF responders demonstrated both a statistically and clinically significant higher odds 4.86 (95% CI, 1.4-12.8, P value < 0.009) of histologic response, including significant improvements in both steatosis and ballooning. CONCLUSION OCA was better than placebo in reducing liver fat. This multicenter trial provides data regarding the association between 30% decline in MRI-PDFF relative to baseline and histologic response in NASH.
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Affiliation(s)
- Rohit Loomba
- University of California San Diego, La Jolla, CA, USA
| | | | - Arun Sanyal
- Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Norah Terrault
- University of California San Francisco, San Francisco, CA USA
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17
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Sheka AC, Hameed B, Ikramuddin S. Nonalcoholic Steatohepatitis-Reply. JAMA 2020; 324:899-900. [PMID: 32870294 DOI: 10.1001/jama.2020.10437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Adam C Sheka
- Department of Surgery, University of Minnesota, Minneapolis
| | - Bilal Hameed
- Division of Gastroenterology, University of California, San Francisco
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18
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Fix OK, Hameed B, Fontana RJ, Kwok RM, McGuire BM, Mulligan DC, Pratt DS, Russo MW, Schilsky ML, Verna EC, Loomba R, Cohen DE, Bezerra JA, Reddy KR, Chung RT. Clinical Best Practice Advice for Hepatology and Liver Transplant Providers During the COVID-19 Pandemic: AASLD Expert Panel Consensus Statement. Hepatology 2020; 72:287-304. [PMID: 32298473 PMCID: PMC7262242 DOI: 10.1002/hep.31281] [Citation(s) in RCA: 394] [Impact Index Per Article: 98.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/13/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS Coronavirus disease 2019 (COVID-19), the illness caused by the SARS-CoV-2 virus, is rapidly spreading throughout the world. Hospitals and healthcare providers are preparing for the anticipated surge in critically ill patients, but few are wholly equipped to manage this new disease. The goals of this document are to provide data on what is currently known about COVID-19, and how it may impact hepatologists and liver transplant providers and their patients. Our aim is to provide a template for the development of clinical recommendations and policies to mitigate the impact of the COVID-19 pandemic on liver patients and healthcare providers. APPROACH AND RESULTS This article discusses what is known about COVID-19 with a focus on its impact on hepatologists, liver transplant providers, patients with liver disease, and liver transplant recipients. We provide clinicians with guidance for how to minimize the impact of the COVID-19 pandemic on their patients' care. CONCLUSIONS The situation is evolving rapidly, and these recommendations will need to evolve as well. As we learn more about how the COVID-19 pandemic impacts the care of patients with liver disease, we will update the online document available at https://www.aasld.org/about-aasld/covid-19-and-liver.
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Affiliation(s)
| | - Bilal Hameed
- University of California San FranciscoSan FranciscoCA
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19
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Fels Elliott DR, Tavakol M, Lucas CH, Sheahon K, Kakar S, Hameed B, Ferrell LD, Gill RM. Clinicopathological features and outcomes of parenchymal rejection in liver transplant biopsies. Histopathology 2020; 76:822-831. [PMID: 31894595 DOI: 10.1111/his.14058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 11/26/2019] [Accepted: 12/30/2019] [Indexed: 11/27/2022]
Abstract
AIMS The aim of this study was to perform a comprehensive retrospective analysis of liver transplant biopsies with parenchymal rejection (PR) at our institution, including histological features, laboratory values and follow-up biopsies, and to compare PR with portal-based acute cellular rejection (ACR). METHODS AND RESULTS Biopsies from 173 patients were evaluated (retrospective database search 1990-2017), including 49 isolated PR, 35 PR with portal ACR (PR/ACR), 34 mild ACR and 52 moderate ACR cases. The rise and fall of serum liver enzymes was calculated as a measure of acute liver injury and response to immunotherapy, respectively. Isolated PR was associated with delayed-onset acute rejection (P < 0.001), as well as younger age (P = 0.004), and showed a similar rise in liver enzymes to mild ACR. PR/ACR and moderate ACR showed the highest elevations in transaminases (P < 0.05). Isolated PR on an initial biopsy was associated with recurrent episodes of PR (P = 0.01), chronic ductopaenic rejection (P = 0.002) and chronic vascular rejection (P = 0.017). Immunohistochemistry for C4d was performed, and strong C4d staining of venules was only detected in one severe isolated PR case (one of three, 33%) and one moderate ACR case (one of 20, 5%). CONCLUSIONS Isolated PR represents a form of late acute rejection with distinct clinical and histological features. There is value in reporting PR in liver transplant biopsies to identify patients at higher risk of developing recurrent PR and chronic rejection. Standardisation of terminology and histological criteria of PR can help in uniform reporting and ensure appropriate management.
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Affiliation(s)
| | - Mehdi Tavakol
- Division of Transplant Surgery, University of California, San Francisco, CA, USA
| | - Calixto-Hope Lucas
- Department of Pathology, University of California, San Francisco, CA, USA
| | - Kathleen Sheahon
- Department of Pathology, University of California, San Francisco, CA, USA
| | - Sanjay Kakar
- Department of Pathology, University of California, San Francisco, CA, USA
| | - Bilal Hameed
- Hepatology and Liver Transplantation, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Linda D Ferrell
- Department of Pathology, University of California, San Francisco, CA, USA
| | - Ryan M Gill
- Department of Pathology, University of California, San Francisco, CA, USA
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Abstract
IMPORTANCE Nonalcoholic steatohepatitis (NASH) is the inflammatory subtype of nonalcoholic fatty liver disease (NAFLD) and is associated with disease progression, development of cirrhosis, and need for liver transplant. Despite its importance, NASH is underrecognized in clinical practice. OBSERVATIONS NASH affects an estimated 3% to 6% of the US population and the prevalence is increasing. NASH is strongly associated with obesity, dyslipidemia, type 2 diabetes, and metabolic syndrome. Although a number of noninvasive tests and scoring systems exist to characterize NAFLD and NASH, liver biopsy is the only accepted method for diagnosis of NASH. Currently, no NASH-specific therapies are approved by the US Food and Drug Administration. Lifestyle modification is the mainstay of treatment, including dietary changes and exercise, with the primary goal being weight loss. Substantial improvement in histologic outcomes, including fibrosis, is directly correlated with increasing weight loss. In some cases, bariatric surgery may be indicated to achieve and maintain the necessary degree of weight loss required for therapeutic effect. An estimated 20% of patients with NASH will develop cirrhosis, and NASH is predicted to become the leading indication for liver transplants in the US. The mortality rate among patients with NASH is substantially higher than the general population or patients without this inflammatory subtype of NAFLD, with annual all-cause mortality rate of 25.56 per 1000 person-years and a liver-specific mortality rate of 11.77 per 1000 person-years. CONCLUSIONS AND RELEVANCE Nonalcoholic steatohepatitis affects 3% to 6% of the US population, is more prevalent in patients with metabolic disease and obesity, progresses to cirrhosis in approximately 20% of cases, and is associated with increased rates of liver-specific and overall mortality. Early identification and targeted treatment of patients with nonalcoholic steatohepatitis are needed to improve patient outcomes, including directing patients toward intensive lifestyle modification to promote weight loss and referral for bariatric surgery as indicated for management of obesity and metabolic disease.
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Affiliation(s)
- Adam C Sheka
- Department of Surgery, University of Minnesota, Minneapolis
| | - Oyedele Adeyi
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis
| | - Julie Thompson
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Minnesota, Minneapolis
| | - Bilal Hameed
- Division of Gastroenterology, Department of Medicine, University of California San Francisco
| | - Peter A Crawford
- Division of Molecular Medicine, Department of Medicine, University of Minnesota, Minneapolis
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21
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Butt AA, Yan P, Aslam S, Sherman KE, Siraj D, Safdar N, Hameed B. Hepatitis C virologic response in hepatitis B and C coinfected persons treated with directly acting antiviral agents: Results from ERCHIVES. Int J Infect Dis 2020; 92:184-188. [PMID: 31978574 DOI: 10.1016/j.ijid.2020.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 12/29/2019] [Accepted: 01/14/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND There are scant data regarding hepatitis C (HCV) virologic response to directly acting antiviral agents (DAAs) in chronic hepatitis B (HBV) and HCV coinfected persons. HCV treatment response in those with spontaneously cleared HBV infection is unknown. METHODS All HCV infected persons treated with a DAA regimen in ERCHIVES were identified and categorized into HBV/HCV-coinfected (HBsAg, HBV DNA or both positive), HCV-monoinfected, and resolved HBV (isolated HBcAb+). SVR rates were determined and compared for all groups. Logistic regression model was used to determine factors associated with SVR. RESULTS Among 115 HCV/HBV-coinfected, 38,570 HCV-monoinfected persons, and 13,096 persons with resolved HBV, 31.6% of HCV/HBV-coinfected, 24.6% of HCV-monoinfected and 26.4% with resolved HBV had cirrhosis at baseline. SVR was achieved in 90.4% of HCV/HBV-coinfected, 83.4% of HCV-monoinfected and 84.5% of those with resolved HBV infection (P = 0.04 HCV/HBV vs. HCV monoinfected). In a logistic regression model, those with HCV/HBV were more likely to achieve SVR compared with HCV monoinfected (OR 2.25, 95% CI 1.17, 4.31). For HCV/HBV coinfected, the SVR rates dropped numerically with increasing severity of liver fibrosis (P-value non-significant). Factors associated with a lower likelihood of attaining SVR included cirrhosis at baseline (OR 0.85, 95% CI 0.80, 0.92), diabetes (OR 0.93, 95% CI 0.87, 0.99) and higher pre-treatment HCV RNA (OR 0.86, 95% CI 0.84, 0.87). CONCLUSION HBV/HCV-coinfected persons have higher overall SVR rates with newer DAA regimens. Though not statistically significant, the virologic response is graded, with decreasing SVR rates with increasing degree of liver fibrosis as determined by the FIB-4 scores.
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Affiliation(s)
- Adeel A Butt
- VA Pittsburgh Healthcare System, Pittsburgh, PA, United States; Weill Cornell Medical College, New York, NY, United States; Weill Cornell Medical College, Doha, Qatar; Hamad Medical Corporation, Doha, Qatar.
| | - Peng Yan
- VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - Samia Aslam
- VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - Kenneth E Sherman
- University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Dawd Siraj
- University of Wisconsin School of Medicine, Madison, WI, United States
| | - Nasia Safdar
- University of Wisconsin School of Medicine, Madison, WI, United States
| | - Bilal Hameed
- University of California at San Francisco, San Francisco, CA, United States
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22
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Butt AA, Yan P, Aslam S, Sherman K, Siraj D, Safdar N, Hameed B. 285. Fibrosis Progression and Clinical Outcomes in HCV/HBV Coinfected Persons in the ERCHIVES Cohort. Open Forum Infect Dis 2019. [PMCID: PMC6809639 DOI: 10.1093/ofid/ofz360.360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Progression of liver disease and clinical outcomes in HCV/HBV coinfected persons and how they differ from HCV monoinfected persons and HCV infected persons with resolved HBV infection are not well characterized. We compared incidence of cirrhosis, hepatic decompensation and overall mortality in these three groups. Methods Using the Electronically Retrieved Cohort of HCV-infected Veterans (ERCHIVES), we identified those with HCV infection only, HCV/HBV coinfection (HbsAg or HBV DNA or both positive) or HCV with resolved HBV (HbcAb+ in absence of HbsAg or HBV DNA positivity). We excluded those with HIV coinfection or hepatocellular carcinoma at or before baseline, and those who received any HCV or HBV treatment. Incident rates (95% CI) were determined for cirrhosis, first hepatic decompensation event and overall mortality in the three groups. Results We identified 60,368 HCV monoinfected (Gp A), 151 HCV/HBV coinfected (Gp B) and 19,802 HCV infected with resolved HBV infection (Gp C). Mean age was 61.0, 60.9, and 63.0 years in the three groups and 96.5%, 96.0%, and 97.9% were males. Median baseline FIB-4 index was 2.0, 2.2, and 2.1, respectively. Incident cirrhosis (among those without cirrhosis at baseline) was increased 2- to 2.5-fold in HCV/HBV coinfected persons with baseline FIB-4 of 1.46–3.25. Hepatic decompensation and mortality were also increased several-fold in the HCV/HBV coinfected who had minimal or mild/moderate fibrosis at baseline. However, among those with cirrhosis at baseline, the difference was small among HCV/HBV coinfected and the other groups. Conclusion HCV/HBV coinfected persons with minimal or mild/moderate fibrosis at baseline have a much higher risk of developing cirrhosis, hepatic decompensation and mortality. However, once cirrhosis has is established, the difference is diminished. This underscores the need to intervene early when HCV/HBV coinfected persons still have minimal or mild/moderate fibrosis. ![]()
Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Adeel A Butt
- Weill Cornell Medical College, Doha, Ad Dawhah, Qatar
| | | | - Samia Aslam
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Kenneth Sherman
- The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Dawd Siraj
- University of Wisconsin, Madison, Wisconsin
| | - Nasia Safdar
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Bilal Hameed
- University of California at San Francisco, San Francisco, California
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23
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Butt AA, Yan P, Aslam S, Sherman K, Siraj D, Safdar N, Hameed B. 294. Hepatitis C Virologic Response in Hepatitis B and C Coinfected Persons Treated with Directly Acting Antiviral Agents: Results from ERCHIVES. Open Forum Infect Dis 2019. [PMCID: PMC6809903 DOI: 10.1093/ofid/ofz360.369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Methods Results Conclusion Disclosures
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Affiliation(s)
- Adeel A Butt
- Weill Cornell Medical College, Doha, Ad Dawhah, Qatar
| | | | - Samia Aslam
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Kenneth Sherman
- The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Dawd Siraj
- University of Wisconsin, Madison, Wisconsin
| | - Nasia Safdar
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Bilal Hameed
- University of California at San Francisco, San Francisco, California
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24
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Gawrieh S, Wilson LA, Cummings OW, Clark JM, Loomba R, Hameed B, Abdelmalek MF, Dasarathy S, Neuschwander-Tetri BA, Kowdley K, Kleiner D, Doo E, Tonascia J, Sanyal A, Chalasani N. Histologic Findings of Advanced Fibrosis and Cirrhosis in Patients With Nonalcoholic Fatty Liver Disease Who Have Normal Aminotransferase Levels. Am J Gastroenterol 2019; 114:1626-1635. [PMID: 31517638 PMCID: PMC6800246 DOI: 10.14309/ajg.0000000000000388] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Patients with nonalcoholic fatty liver disease (NAFLD) and normal aminotransferase levels may have advanced liver histology. We conducted a study to characterize the prevalence of and factors associated with advanced liver histology in patients with histologically characterized NAFLD and normal aminotransferase levels. METHODS We evaluated 534 adults with biopsy-proven NAFLD and alanine aminotransferase (ALT) and aspartate aminotransferase (AST) <40U/L within 3 months of their liver biopsy. Histological phenotypes of primary interest were nonalcoholic steatohepatitis (NASH) with stage 2-3 fibrosis (NASH F2-3) and cirrhosis. Using multiple logistic regression models with Akaike's Information Criteria (AIC), we identified variables associated with these histological phenotypes. We developed and internally validated their clinical prediction models. RESULTS The prevalence of NASH F2-F3 and cirrhosis was 19% and 7%, respectively. The best multiple regression AIC model for NASH F2-3 consisted of type 2 diabetes, white race, lower low-density lipoprotein, lower platelet count, higher AST/ALT ratio, higher serum triglycerides, and hypertension. The best AIC model for cirrhosis consisted of lower platelet count, lower AST/ALT ratio, higher body mass index, and female sex. The area under the receiver operator curves of the prediction models were 0.70 (95% confidence interval: 0.65-0.76) for detecting NASH-F2-3 and 0.85 (95% confidence interval: 0.77-0.92) for detecting cirrhosis. When models were fixed at maximum Youden's index, their positive and negative predictive values were 35% and 88% for NASH F2-F3 and 30% and 98% for cirrhosis, respectively. DISCUSSION Clinically significant histological phenotypes are observed in patients with NAFLD and normal aminotransferase levels. Our models can assist the clinicians in excluding advanced liver histology in NAFLD patients with normal aminotransferase levels.
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Affiliation(s)
| | | | | | | | | | - Bilal Hameed
- University of California, San Francisco, California
| | | | | | | | | | | | - Edward Doo
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | - Arun Sanyal
- Virginia Commonwealth University, Richmond, VA
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25
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Kim D, Yoo ER, Li AA, Fernandes CT, Tighe SP, Cholankeril G, Hameed B, Ahmed A. Low-Normal Thyroid Function Is Associated With Advanced Fibrosis Among Adults in the United States. Clin Gastroenterol Hepatol 2019; 17:2379-2381. [PMID: 30458247 PMCID: PMC6525074 DOI: 10.1016/j.cgh.2018.11.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 11/07/2018] [Indexed: 02/07/2023]
Abstract
The pathogenetic pathways leading to increasing prevalence of advanced fibrosis in the setting of nonalcoholic fatty liver disease (NAFLD) and resulting in higher rates of liver-related and cardiovascular morbidity and mortality in the United States are multifactorial.1 The negative health impact of "low-normal" thyroid function, which is defined as a higher level of thyroid-stimulating hormone (TSH) within the euthyroid reference range, may be comparable with overt and subclinical hypothyroidism.2-4 We reported a strong association between biopsy-proven advanced fibrosis in NAFLD with increasing TSH levels in a dose-dependent manner even within the euthyroid reference range.5 To generalize our findings across all ethnicities, we examined the association of both low-normal thyroid function and subclinical hypothyroidism with advanced fibrosis in the US general population.
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Affiliation(s)
- Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Eric R. Yoo
- Department of Medicine, Santa Clara Valley Medical Center, San Jose, California
| | - Andrew A. Li
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Christopher T. Fernandes
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Sean P. Tighe
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Bilal Hameed
- Division of Gastroenterology and Hepatology, University of California San Francisco–UCSF Health, San Francisco, California
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California.
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26
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Trauner M, Gulamhusein A, Hameed B, Caldwell S, Shiffman ML, Landis C, Eksteen B, Agarwal K, Muir A, Rushbrook S, Lu X, Xu J, Chuang J, Billin AN, Li G, Chung C, Subramanian GM, Myers RP, Bowlus CL, Kowdley KV. The Nonsteroidal Farnesoid X Receptor Agonist Cilofexor (GS-9674) Improves Markers of Cholestasis and Liver Injury in Patients With Primary Sclerosing Cholangitis. Hepatology 2019; 70:788-801. [PMID: 30661255 PMCID: PMC6767458 DOI: 10.1002/hep.30509] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 12/20/2018] [Indexed: 02/06/2023]
Abstract
Primary sclerosing cholangitis (PSC) represents a major unmet medical need. In a phase II double-blind, placebo-controlled study, we tested the safety and efficacy of cilofexor (formerly GS-9674), a nonsteroidal farnesoid X receptor agonist in patients without cirrhosis with large-duct PSC. Patients were randomized to receive cilofexor 100 mg (n = 22), 30 mg (n = 20), or placebo (n = 10) orally once daily for 12 weeks. All patients had serum alkaline phosphatase (ALP) > 1.67 × upper limit of normal and total bilirubin ≤ 2 mg/dL at baseline. Safety, tolerability, pharmacodynamic effects of cilofexor (serum C4 [7α-hydroxy-4-cholesten-3-one] and bile acids), and changes in liver biochemistry and serum fibrosis markers were evaluated. Overall, 52 patients were randomized (median age 43 years, 58% male, 60% with inflammatory bowel disease, 46% on ursodeoxycholic acid). Baseline median serum ALP and bilirubin were 348 U/L (interquartile range 288-439) and 0.7 mg/dL (0.5-1.0), respectively. Dose-dependent reductions in liver biochemistry were observed. At week 12, cilofexor 100 mg led to significant reductions in serum ALP (median reduction -21%; P = 0.029 versus placebo), gamma-glutamyl transferase (-30%; P < 0.001), alanine aminotransferase (ALT) (-49%; P = 0.009), and aspartate aminotransferase (-42%; P = 0.019). Cilofexor reduced serum C4 compared with placebo; reductions in bile acids were greatest with 100 mg. Relative reductions in ALP were similar between ursodeoxycholic acid-treated and untreated patients. At week 12, cilofexor-treated patients with a 25% or more relative reduction in ALP had greater reductions in serum alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, tissue inhibitor of metalloproteinase 1, C-reactive protein, and bile acids than nonresponders. Adverse events were similar between cilofexor and placebo-treated patients. Rates of grade 2 or 3 pruritus were 14% with 100 mg, 20% with 30 mg, and 40% with placebo. Conclusion: In this 12-week, randomized, placebo-controlled study, cilofexor was well tolerated and led to significant improvements in liver biochemistries and markers of cholestasis in patients with PSC.
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Affiliation(s)
| | | | - Bilal Hameed
- University of CaliforniaSan Francisco School of MedicineSan FranciscoCA
| | | | | | | | | | | | | | | | | | - Jun Xu
- Gilead Sciences, Inc.Foster CityCA
| | | | | | | | | | | | | | | | - Kris V. Kowdley
- Liver Care Network and Organ Care ResearchSwedish Medical CenterSeattleWA
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Leventhal TM, Gottfried M, Olson JC, Subramanian RM, Hameed B, Lee WM. Acetaminophen is Undetectable in Plasma From More Than Half of Patients Believed to Have Acute Liver Failure Due to Overdose. Clin Gastroenterol Hepatol 2019; 17:2110-2116. [PMID: 30731196 DOI: 10.1016/j.cgh.2019.01.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 01/08/2019] [Accepted: 01/12/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Evaluation of patients with acute liver injury (ALI) or acute liver failure (ALF) often includes measurement of plasma levels of acetaminophen, to determine exposure and/or toxicity. However, once liver injury has developed, acetaminophen might be undetectable in plasma. We investigated the association between level of acetaminophen measured and outcomes of patients designated as having ALF or ALI due to acetaminophen toxicity. METHODS We performed a retrospective analysis of data from 434 subjects in the Acute Liver Failure Study Group who met criteria for ALF (coagulopathy and hepatic encephalopathy within 26 weeks of the first symptoms, without pre-existing liver disease) or ALI (severe liver injury with coagulopathy but no encephalopathy) due to acetaminophen toxicity from January 1, 2010 through December 31, 2014. We collected data on patient demographics, biochemical features, reported acetaminophen use, N-acetylcysteine therapy, liver transplant, and outcomes. Descriptive statistics were used to assess patient demographics, clinical characteristics, and outcomes whereas differences in continuous variables between patients with vs without acetaminophen detection on admission were analyzed using the Wilcoxon rank-sum test. The primary aim was to determine the proportion of patients with detectable plasma levels of acetaminophen. RESULTS Acetaminophen was undetectable in serum samples from 227 patients (52%). There were no significant differences between groups of patients with detectable vs undetectable levels in demographic features, alcohol use, median levels of alanine aspartate, or use of N-acetylcysteine (given to 94.7% of patients with detectable acetaminophen vs 95.9% of those with undetectable acetaminophen; P=.63). We observed a significant difference in median dose taken between patients with detectable (29,500 mg; interquartile range, 15,000 mg-50,007 mg) vs no detectable parent compound (14,950 mg; interquartile range, 3960 mg-25,000) (P=.003). A lower proportion of patients with detectable plasma levels of acetaminophen (72.3%) survived without a liver transplant than of patients with undetectable levels (86.3%) in univariate analysis (P=.0006), although this was not significant in multivariable analysis (P=.12). Although most patients had unintentional overdoses, a higher proportion of patients with suicidal overdoses (43%) had detectable levels of acetaminophen than patients with accidental overdoses (29.3%; P=.01). CONCLUSION More than half of patients who present at the hospital with acetaminophen-induced ALI or ALF have undetectable levels of acetaminophen. Clinicians should not exclude acetaminophen toxicity because of undetectable levels or withhold N-acetylcysteine for patients with ALI or ALF when acetaminophen toxicity is suspected.
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Affiliation(s)
- Thomas M Leventhal
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas.
| | - Michelle Gottfried
- Public Health Sciences, Medical University of South Carolina, Charleston, South Caroline
| | - Jody C Olson
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas
| | - Ram M Subramanian
- Divisions of Hepatology and Critical Care, Emory University, Atlanta, Georgia
| | - Bilal Hameed
- Division of Gastroenterology, University of California San Francisco, San Francisco, California
| | - William M Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
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Kim D, Cholankeril G, Li AA, Kim W, Tighe SP, Hameed B, Kwo PY, Harrison SA, Younossi ZM, Ahmed A. Trends in hospitalizations for chronic liver disease-related liver failure in the United States, 2005-2014. Liver Int 2019; 39:1661-1671. [PMID: 31081997 DOI: 10.1111/liv.14135] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 03/11/2019] [Accepted: 05/08/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Current estimates of the population-based disease burden of liver failure or end-stage liver disease (ESLD) are lacking. We investigated recent trends in hospitalizations and in-hospital mortality among patients with ESLD in the United States (US). METHODS A retrospective analysis was performed utilizing the National Inpatient Sample from 2005 to 2014. We defined ESLD as either decompensated cirrhosis or hepatocellular carcinoma (HCC), criteria obtained from the International Classification of Diseases, Ninth Revision. Nationwide rates of hospitalization and in-hospital mortality were analysed from 2005 to 2014. RESULTS Hospitalization rates for decompensated cirrhosis during this period increased from 105.3/100 000 persons to 159.9/100 000 persons. In terms of HCC, hospitalization rates increased from 13.6/100 000 to 22.1/100 000. In patients with non-alcoholic fatty liver disease (NAFLD)-related decompensated cirrhosis, the hospitalization rate increased from 13.4/100 000 to 32.1/100 000 with an annual incremental increase of 10.6%, a magnitude twofold higher than other aetiologies. The proportion of NAFLD among hospitalizations with ESLD steadily increased from 12.7% to 20.1% for decompensated cirrhosis while the proportion of chronic hepatitis C (HCV) and alcoholic liver disease (ALD) declined (from 29.3% to 27.6% for HCV; from 39.0% to 37.4% for ALD). Although the overall in-hospital mortality rates for ESLD declined during the study, mortality rates for NAFLD-related decompensated cirrhosis showed no significant change. CONCLUSIONS Among aetiologies of chronic liver disease, NAFLD demonstrated the fastest growing rate of hospitalizations in non-HCC patients with ESLD in the US. Our study highlights the need for a focus on NAFLD-related hospitalizations and its impact on resource utilization.
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Affiliation(s)
- Donghee Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Andrew A Li
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Won Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul, Korea
| | - Sean P Tighe
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Bilal Hameed
- Division of Gastroenterology and Hepatology, University of California San Francisco - UCSF Health, San Francisco, California, USA
| | - Paul Y Kwo
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Stephen A Harrison
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Zobair M Younossi
- Department of Medicine, Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
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Rubin JB, Hameed B, Gottfried M, Lee WM, Sarkar M. Acetaminophen-induced Acute Liver Failure Is More Common and More Severe in Women. Clin Gastroenterol Hepatol 2018; 16:936-946. [PMID: 29199145 PMCID: PMC5962381 DOI: 10.1016/j.cgh.2017.11.042] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 11/19/2017] [Accepted: 11/21/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Acetaminophen overdose is the leading cause of acute liver injury (ALI) and acute liver failure (ALF) in the developed world. Sex differences in acetaminophen-induced hepatotoxicity have not been described. METHODS We collected data from the Acute Liver Failure Study Group cohort, a national registry of 32 academic medical centers in North America of adults with ALI or ALF, including 1162 patients with acetaminophen-induced ALI (n = 250) or acetaminophen-induced ALF (n = 912) from January 2000 through September 2016. We analyzed data on patient presentation, disease course, demographics, medical and psychiatric history, medication use, substance use, and details of acetaminophen ingestion. Sex differences in continuous and categorical variables were evaluated by Wilcoxon rank-sum and χ2 analysis or the Fisher exact test. Our primary aim was to evaluate sex differences in the presentation and clinical course of acetaminophen-induced acute liver injury or liver failure, and our secondary goal was to compare overall and transplant-free survival between sexes. RESULTS Most patients with acetaminophen-induced ALI (68%) or ALF (76%) were women. Higher proportions of women than men had psychiatric disease (60% of women vs 48% of men, P < .01) and had co-ingestion with sedating agents (70% of women vs 52% of men, P < .01)-more than half of which were opioids. Higher proportions of women had severe hepatic encephalopathy (HE) (68% of women vs 58% of men), and required intubation (67% of women vs 59% of men, P values <.03). Higher proportions of women used vasopressors (26% of women vs 19% of men, P = .04) or mannitol (13% of women vs 6% of men, P < .01); proportions of male vs female patients with transplant-free survival were similar (68%). On adjusted analysis, women had higher risk of severe HE (adjusted odds ratio [AOR], 1.66; 95% CI, 1.17-2.35). We found a significant interaction between sex and co-ingestion of sedating agents (P < .01); co-ingestion increased odds of severe HE in women 2-fold (AOR, 1.86; 95% CI, 1.28-2.69; P < .01) but not in men (AOR; 0.62; 95% CI, 0.34-1.13; P = .12). CONCLUSIONS In an analysis of the Acute Liver Failure Study Group cohort, we found acetaminophen-induced ALI and ALF to be more common among women. Women have greater critical care needs than men, and increased risk for severe HE, which could be due in part to increased use of sedatives. Future studies should investigate sex differences in acetaminophen metabolism and hepatotoxicity, particularly among users of opioids.
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Affiliation(s)
- Jessica B Rubin
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Bilal Hameed
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Michelle Gottfried
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - William M Lee
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Monika Sarkar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, California.
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Stravitz RT, Gottfried M, Durkalski V, Fontana RJ, Hanje AJ, Koch D, Hameed B, Ganger D, Subramanian RM, Bukofzer S, Ravis WR, Clasen K, Sherker A, Little L, Lee WM. Safety, tolerability, and pharmacokinetics of l-ornithine phenylacetate in patients with acute liver injury/failure and hyperammonemia. Hepatology 2018; 67:1003-1013. [PMID: 29080224 PMCID: PMC5826861 DOI: 10.1002/hep.29621] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 08/03/2017] [Accepted: 10/25/2017] [Indexed: 12/12/2022]
Abstract
Cerebral edema remains a significant cause of morbidity and mortality in patients with acute liver failure (ALF) and has been linked to elevated blood ammonia levels. l-ornithine phenylacetate (OPA) may decrease ammonia by promoting its renal excretion as phenylacetylglutamine (PAGN), decreasing the risk of cerebral edema. We evaluated the safety, tolerability, and pharmacokinetics of OPA in patients with ALF and acute liver injury (ALI), including those with renal failure. Forty-seven patients with ALI/ALF and ammonia ≥60 μM were enrolled. Patients received OPA in a dose escalation scheme from 3.3 g every 24 hours to 10 g every 24 hours; 15 patients received 20 g every 24 hours throughout the infusion for up to 120 hours. Plasma phenylacetate (PA) concentrations were uniformly below target (<75 μg/mL) in those receiving 3.3 g every 24 hours (median [interquartile range] 5.0 [5.0] μg/mL), and increased to target levels in all but one who received 20 g every 24 hours (150 [100] μg/mL). Plasma [PAGN] increased, and conversion of PA to PAGN became saturated, with increasing OPA dose. Urinary PAGN clearance and creatinine clearance were linearly related (r = 0.831, P < 0.0001). Mean ammonia concentrations based on the area under the curve decreased to a greater extent in patients who received 20 g of OPA every 24 hours compared with those who received the maximal dose of 3.3 or 6.7 g every 24 hours (P = 0.046 and 0.022, respectively). Of the reported serious adverse events (AEs), which included 11 deaths, none was attributable to study medication. The only nonserious AEs possibly related to study drug were headache and nausea/vomiting. CONCLUSION OPA was well-tolerated in patients with ALI/ALF, and no safety signals were identified. Target [PA] was achieved at infusion rates of 20 g every 24 hours, leading to ammonia excretion in urine as PAGN in proportion to renal function. Randomized, controlled studies of high-dose OPA are needed to determine its use as an ammonia-scavenging agent in patients with ALF. (Hepatology 2018;67:1003-1013).
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Affiliation(s)
| | | | | | | | | | - David Koch
- Medical University of South Carolina, Charleston, SC
| | - Bilal Hameed
- University of California at San Francisco, San Francisco, CA
| | | | | | | | | | | | - Averell Sherker
- National Institute of Diabetes, Digestive and Kidney Disease, Bethesda, MD
| | - Lanna Little
- University of Texas, Southwestern Medical Center, Dallas, TX
| | - William M. Lee
- University of Texas, Southwestern Medical Center, Dallas, TX
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Hameed B, Terrault NA, Gill RM, Loomba R, Chalasani N, Hoofnagle JH, Van Natta ML. Clinical and metabolic effects associated with weight changes and obeticholic acid in non-alcoholic steatohepatitis. Aliment Pharmacol Ther 2018; 47:645-656. [PMID: 29333665 PMCID: PMC5931362 DOI: 10.1111/apt.14492] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 08/17/2017] [Accepted: 12/07/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND In a 72-week, randomised controlled trial of obeticholic acid (OCA) in non-alcoholic steatohepatitis (NASH), OCA was superior to placebo in improving serum ALT levels and liver histology. OCA therapy also reduced weight. AIMS Because weight loss by itself can improve histology, to perform a post hoc analysis of the effects of weight loss and OCA treatment in improving clinical and metabolic features of NASH. METHODS The analysis was limited to the 200 patients with baseline and end-of-treatment liver biopsies. Weight loss was defined as a relative decline from baseline of 2% or more at treatment end. RESULTS Weight loss occurred in 44% (45/102) of OCA and 32% (31/98) of placebo-treated patients (P = 0.08). The NAFLD Activity score (NAS) improved more in those with than without weight loss in both the OCA- (-2.4 vs -1.2, P<0.001) and placebo-treated patients (-1.2 vs -0.5, P = 0.03). ALT levels also improved in those with vs without weight loss in OCA- (-43 vs -34 U/L, P = 0.12) and placebo-treated patients (-29 vs -10 U/L, P = 0.02). However, among those who lost weight, OCA was associated with opposite effects from placebo on changes in alkaline phosphatase (+21 vs -12 U/L, P<0.001), total (+13 vs -14 mg/dL, P = 0.02) and LDL cholesterol (+18 vs -12 mg/dL, P = 0.01), and HbA1c (+0.1 vs -0.4%, P = 0.01). CONCLUSIONS OCA leads to weight loss in up to 44% of patients with NASH, and OCA therapy and weight loss have additive benefits on serum aminotransferases and histology. However, favourable effects of weight loss on alkaline phosphatase, lipids and blood glucose seen in placebo-treated patients were absent or reversed on OCA treatment. These findings stress the importance of assessing concomitant metabolic effects of new therapies of NASH. Clinical trial number: NCT01265498.
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Affiliation(s)
- B. Hameed
- University of California San Francisco, San Francisco, CA, USA
| | - N. A. Terrault
- University of California San Francisco, San Francisco, CA, USA
| | - R. M. Gill
- University of California San Francisco, San Francisco, CA, USA
| | - R. Loomba
- University of California San Diego, San Diego, CA, USA
| | - N. Chalasani
- Indiana University School, Indianapolis, IN, USA
| | - J. H. Hoofnagle
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
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Azeem N, Ajmera V, Hameed B, Mehta N. Hilar cholangiocarcinoma associated with immunoglobulin G4-positive plasma cells and elevated serum immunoglobulin G4 levels. Hepatol Commun 2018; 2:349-353. [PMID: 29619414 PMCID: PMC5880190 DOI: 10.1002/hep4.1164] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 12/22/2017] [Accepted: 01/11/2018] [Indexed: 12/16/2022] Open
Abstract
Immunoglobulin G4 (IgG4)‐related disease is a fibroinflammatory systemic disorder with multiorgan involvement. Proximal bile duct involvement results in IgG4‐related sclerosing cholangitis, which is characterized by a lymphoplasmacytic infiltrate with abundant IgG4‐positive plasma cells and fibrosis. Differentiating between cholangiocarcinoma and IgG4‐sclerosing cholangitis can present a diagnostic dilemma. We describe an unusual presentation of a hepatic mass meeting multiple criteria for IgG4‐sclerosing cholangitis but was ultimately found to be cholangiocarcinoma. Several published case reports describe patients with suspected cholangiocarcinoma who are later found to have IgG4‐sclerosing cholangitis, but few reports have demonstrated the reverse. Distinguishing between cholangiocarcinoma and IgG4‐sclerosing cholangitis is challenging, and a high clinical suspicion for cholangiocarcinoma must always be maintained. (Hepatology Communications 2018;2:349‐353)
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Affiliation(s)
- Nabeel Azeem
- Division of Gastroenterology, Hepatology and Nutrition University of Minnesota Minneapolis MN
| | - Veeral Ajmera
- Division of Gastroenterology University of California San Diego San Diego CA
| | - Bilal Hameed
- Division of Gastroenterology and Hepatology University of California San Francisco San Francisco CA
| | - Neil Mehta
- Division of Gastroenterology and Hepatology University of California San Francisco San Francisco CA
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Karvellas CJ, Tillman H, Leung AA, Lee WM, Schilsky ML, Hameed B, Stravitz RT, McGuire BM, Fix OK. Acute liver injury and acute liver failure from mushroom poisoning in North America. Liver Int 2016; 36:1043-50. [PMID: 26837055 DOI: 10.1111/liv.13080] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 01/25/2016] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Published estimates of survival associated with mushroom (amatoxin)-induced acute liver failure (ALF) and injury (ALI) with and without liver transplant (LT) are highly variable. We aimed to determine the 21-day survival associated with amatoxin-induced ALI (A-ALI) and ALF (A-ALF) and review use of targeted therapies. METHODS Cohort study of all A-ALI/A-ALF patients enrolled in the US ALFSG registry between 01/1998 and 12/2014. RESULTS Of the 2224 subjects in the registry, 18 (0.8%) had A-ALF (n = 13) or A-ALI (n = 5). At admission, ALF patients had higher lactate levels (5.2 vs. 2.2 mm, P = 0.06) compared to ALI patients, but INR (2.8 vs. 2.2), bilirubin (87 vs. 26 μm) and MELD scores (28 vs. 24) were similar (P > 0.2 for all). Of the 13 patients with ALF, six survived without LT (46%), five survived with LT (39%) and two died without LT (15%). Of the five patients with ALI, four (80%) recovered and one (20%) survived post-LT. Comparing those who died/received LT (non-spontaneous survivors [NSS]) with spontaneous survivors (SS), N-acetylcysteine was used in nearly all patients (NSS 88% vs. SS 80%); whereas, silibinin (25% vs. 50%), penicillin (50% vs. 25%) and nasobiliary drainage (0 vs. 10%) were used less frequently (P > 0.15 for all therapies). CONCLUSION Patients with mushroom poisoning with ALI have favourable survival, while around half of those presenting with ALF may eventually require LT. Further study is needed to define optimal management (including the use of targeted therapies) to improve survival, particularly in the absence of LT.
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Affiliation(s)
- Constantine J Karvellas
- Divisions of Hepatology and Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Holly Tillman
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Alexander A Leung
- Division of Endocrinology and Metabolism, University of Calgary, Calgary, AB, Canada
| | - William M Lee
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Michael L Schilsky
- Division of Digestive Diseases and Transplant and Immunology, Yale University School of Medicine, New Haven, CT, USA
| | - Bilal Hameed
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, CA, USA
| | - R Todd Stravitz
- Division of Gastroenterology and Hepatology, Virginia Commonwealth University, Richmond, VA, USA
| | - Brendan M McGuire
- Division of Gastroenterology and Hepatology, University of Alabama, Birmingham, AL, USA
| | - Oren K Fix
- Organ Transplant Program, Swedish Medical Center, Seattle, WA, USA
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Reuben A, Tillman H, Fontana RJ, Davern T, McGuire B, Stravitz RT, Durkalski V, Larson AM, Liou I, Fix O, Schilsky M, McCashland T, Hay JE, Murray N, Shaikh OS, Ganger D, Zaman A, Han SB, Chung RT, Smith A, Brown R, Crippin J, Harrison ME, Koch D, Munoz S, Reddy KR, Rossaro L, Satyanarayana R, Hassanein T, Hanje AJ, Olson J, Subramanian R, Karvellas C, Hameed B, Sherker AH, Robuck P, Lee WM. Outcomes in Adults With Acute Liver Failure Between 1998 and 2013: An Observational Cohort Study. Ann Intern Med 2016; 164:724-32. [PMID: 27043883 PMCID: PMC5526039 DOI: 10.7326/m15-2211] [Citation(s) in RCA: 238] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute liver failure (ALF) is a rare syndrome of severe, rapid-onset hepatic dysfunction-without prior advanced liver disease-that is associated with high morbidity and mortality. Intensive care and liver transplantation provide support and rescue, respectively. OBJECTIVE To determine whether changes in causes, disease severity, treatment, or 21-day outcomes have occurred in recent years among adult patients with ALF referred to U.S. tertiary care centers. DESIGN Prospective observational cohort study. (ClinicalTrials .gov: NCT00518440). SETTING 31 liver disease and transplant centers in the United States. PATIENTS Consecutively enrolled patients-without prior advanced liver disease-with ALF (n = 2070). MEASUREMENTS Clinical features, treatment, and 21-day outcomes were compared over time annually for trends and were also stratified into two 8-year periods (1998 to 2005 and 2006 to 2013). RESULTS Overall clinical characteristics, disease severity, and distribution of causes remained similar throughout the study period. The 21-day survival rates increased between the two 8-year periods (overall, 67.1% vs. 75.3%; transplant-free survival [TFS], 45.1% vs. 56.2%; posttransplantation survival, 88.3% vs. 96.3% [P < 0.010 for each]). Reductions in red blood cell infusions (44.3% vs. 27.6%), plasma infusions (65.2% vs. 47.1%), mechanical ventilation (65.7% vs. 56.1%), and vasopressors (34.9% vs. 27.8%) were observed, as well as increased use of N-acetylcysteine (48.9% vs. 69.3% overall; 15.8% vs. 49.4% [P < 0.001] in patients with ALF not due to acetaminophen toxicity). When examined longitudinally, overall survival and TFS increased throughout the 16-year period. LIMITATIONS The duration of enrollment, the number of patients enrolled, and possibly the approaches to care varied among participating sites. The results may not be generalizable beyond such specialized centers. CONCLUSION Although characteristics and severity of ALF changed little over 16 years, overall survival and TFS improved significantly. The effects of specific changes in intensive care practice on survival warrant further study. PRIMARY FUNDING SOURCE National Institutes of Health.
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Abstract
Nonalcoholic fatty liver disease is the most common cause of liver disease in the United States. There are no drug therapies approved for the treatment of nonalcoholic steatohepatitis (NASH). Multiple different pathways are involved in the pathogenesis and each can be the target of the therapy. It is possible that more than 1 target is involved in disease development and progression. Multiple clinical trials with promising agents are underway. Because NASH is a slowly progressive disease and treatment likely to be of prolonged duration, acceptance and approval of any agent will require information on long-term clinical benefits and safety.
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Affiliation(s)
- Bilal Hameed
- Division of Gastroenterology, University of California San Francisco S357, 513 Parnassus Avenue, San Francisco, CA 94143-0538, USA.
| | - Norah Terrault
- Division of Gastroenterology, University of California San Francisco S357, 513 Parnassus Avenue, San Francisco, CA 94143-0538, USA
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Yao FY, Mehta N, Flemming J, Dodge J, Hameed B, Fix O, Hirose R, Fidelman N, Kerlan RK, Roberts JP. Downstaging of hepatocellular cancer before liver transplant: long-term outcome compared to tumors within Milan criteria. Hepatology 2015; 61:1968-77. [PMID: 25689978 PMCID: PMC4809192 DOI: 10.1002/hep.27752] [Citation(s) in RCA: 316] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Accepted: 02/13/2015] [Indexed: 12/07/2022]
Abstract
UNLABELLED We report on the long-term intention-to-treat (ITT) outcome of 118 patients with hepatocellular carcinoma (HCC) undergoing downstaging to within Milan/United Network for Organ Sharing T2 criteria before liver transplantation (LT) since 2002 and compare the results with 488 patients listed for LT with HCC meeting T2 criteria at listing in the same period. The downstaging subgroups include 1 lesion >5 and ≤8 cm (n = 43), 2 or 3 lesions at least one >3 and ≤5 cm with total tumor diameter ≤8 cm (n = 61), or 4-5 lesions each ≤3 cm with total tumor diameter ≤8 cm (n = 14). In the downstaging group, 64 patients (54.2%) had received LT and 5 (7.5%) developed HCC recurrence. Two of the five patients with HCC recurrence had 4-5 tumors at presentation. The 1- and 2-year cumulative probabilities for dropout (competing risk) were 24.1% and 34.2% in the downstaging group versus 20.3% and 25.6% in the T2 group (P = 0.04). Kaplan-Meier's 5-year post-transplant survival and recurrence-free probabilities were 77.8% and 90.8%, respectively, in the downstaging group versus 81% and 88%, respectively, in the T2 group (P = 0.69 and P = 0.66, respectively). The 5-year ITT survival was 56.1% in the downstaging group versus 63.3% in the T2 group (P = 0.29). Factors predicting dropout in the downstaging group included pretreatment alpha-fetoprotein ≥1,000 ng/mL (multivariate hazard ratio [HR]: 2.42; P = 0.02) and Child's B versus Child's A cirrhosis (multivariate HR: 2.19; P = 0.04). CONCLUSION Successful downstaging of HCC to within T2 criteria was associated with a low rate of HCC recurrence and excellent post-transplant survival, comparable to those meeting T2 criteria without downstaging. Owing to the small number of patients with 4-5 tumors, further investigations are needed to confirm the efficacy of downstaging in this subgroup.
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Azhar M, Sheikh ASF, Khan A, Mustafa S, Shah IA, Hameed B. HEPATOBILIARY ASCARIASIS COMPLICATED BY PANCREATITIS. J Ayub Med Coll Abbottabad 2015; 27:479-481. [PMID: 26411145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Ascaris lumbricoides is the commonest organism causing soil-transmitted helminth infection. It is particularly common in poor sanitary conditions. Nevertheless, involvement of the gallbladder by Ascaris is a rare entity. A lady presented to us with long-standing history of vague abdominal symptoms suggesting dyspepsia. Ultrasound showed a tube like structure invading the biliary channels. Serum amylase was elevated and the patient was managed conservatively, as for acute pancreatitis. She improved clinically, but subsequent imaging with magnetic resonance cholangiopancreatography revealed worm in the gallbladder. Laparoscopic cholecystectomy was done and Ascaris lumbricoides was removed. Ascaris infestation is an important differential diagnosis of patients with upper abdominal symptoms and screening with stool examination and ultrasound is warranted in high-risk population.
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Kelley RK, Magbanua MJM, Butler TM, Collisson EA, Hwang J, Sidiropoulos N, Evason K, McWhirter RM, Hameed B, Wayne EM, Yao FY, Venook AP, Park JW. Circulating tumor cells in hepatocellular carcinoma: a pilot study of detection, enumeration, and next-generation sequencing in cases and controls. BMC Cancer 2015; 15:206. [PMID: 25884197 PMCID: PMC4399150 DOI: 10.1186/s12885-015-1195-z] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 03/16/2015] [Indexed: 12/15/2022] Open
Abstract
Background Circulating biomarkers are urgently needed in hepatocellular carcinoma (HCC). The aims of this study were to determine the feasibility of detecting and isolating circulating tumor cells (CTCs) in HCC patients using enrichment for epithelial cell adhesion molecule (EpCAM) expression, to examine their prognostic value, and to explore CTC-based DNA sequencing in metastatic HCC patients compared to a control cohort with non-malignant liver diseases (NMLD). Methods Whole blood was obtained from patients with metastatic HCC or NMLD. CTCs were enumerated by CellSearch then purified by immunomagnetic EpCAM enrichment and fluorescence-activated cell sorting. Targeted ion semiconductor sequencing was performed on whole genome-amplified DNA from CTCs, tumor specimens, and peripheral blood mononuclear cells (PBMC) when available. Results Twenty HCC and 10 NMLD patients enrolled. CTCs ≥ 2/7.5 mL were detected in 7/20 (35%, 95% confidence interval: 12%, 60%) HCC and 0/9 eligible NMLD (p = 0.04). CTCs ≥ 1/7.5 mL was associated with alpha-fetoprotein ≥ 400 ng/mL (p = 0.008) and vascular invasion (p = 0.009). Sequencing of CTC DNA identified characteristic HCC mutations. The proportion with ≥ 100x coverage depth was lower in CTCs (43%) than tumor or PBMC (87%) (p < 0.025). Low frequency variants were higher in CTCs (p < 0.001). Conclusions CTCs are detectable by EpCAM enrichment in metastatic HCC, without confounding false positive background from NMLD. CTC detection was associated with poor prognostic factors. Sequencing of CTC DNA identified known HCC mutations but more low-frequency variants and lower coverage depth than FFPE or PBMC. Electronic supplementary material The online version of this article (doi:10.1186/s12885-015-1195-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Robin K Kelley
- Helen Diller Family Comprehensive Cancer Center and The Liver Center, University of California San Francisco (UCSF), 550 16th St., Box 3211, San Francisco, CA, 94143, USA.
| | - Mark Jesus M Magbanua
- Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, CA, 94143, USA.
| | - Timothy M Butler
- Department of Molecular and Medical Genetics, Oregon Health Sciences University, 3181 SW Sam Jackson Park Road, Mail Code #L103, Portland, OR, 97239, USA.
| | - Eric A Collisson
- Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, CA, 94143, USA.
| | - Jimmy Hwang
- Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, CA, 94143, USA.
| | | | - Kimberley Evason
- Department of Pathology, UCSF, 513 Parnassus Ave., San Francisco, CA, 94143, USA.
| | - Ryan M McWhirter
- Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, CA, 94143, USA.
| | - Bilal Hameed
- Division of Hepatology and Liver Transplant, UCSF, 513 Parnassus Ave., S-357, San Francisco, CA, 94143, USA.
| | - Elizabeth M Wayne
- Department of Transplantation-Abdominal, UCSF, 513 Parnassus Ave., S-357, San Francisco, CA, 94143, USA.
| | - Francis Y Yao
- Division of Hepatology and Liver Transplant and The Liver Center, UCSF, 513 Parnassus Ave., S-357, San Francisco, CA, 94143, USA.
| | - Alan P Venook
- Helen Diller Family Comprehensive Cancer Center and The Liver Center, University of California San Francisco (UCSF), 550 16th St., Box 3211, San Francisco, CA, 94143, USA.
| | - John W Park
- Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, CA, 94143, USA.
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Neuschwander-Tetri BA, Loomba R, Sanyal AJ, Lavine JE, Van Natta ML, Abdelmalek MF, Chalasani N, Dasarathy S, Diehl AM, Hameed B, Kowdley KV, McCullough A, Terrault N, Clark JM, Tonascia J, Brunt EM, Kleiner DE, Doo E. Farnesoid X nuclear receptor ligand obeticholic acid for non-cirrhotic, non-alcoholic steatohepatitis (FLINT): a multicentre, randomised, placebo-controlled trial. Lancet 2015; 385:956-65. [PMID: 25468160 PMCID: PMC4447192 DOI: 10.1016/s0140-6736(14)61933-4] [Citation(s) in RCA: 1606] [Impact Index Per Article: 178.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The bile acid derivative 6-ethylchenodeoxycholic acid (obeticholic acid) is a potent activator of the farnesoid X nuclear receptor that reduces liver fat and fibrosis in animal models of fatty liver disease. We assessed the efficacy of obeticholic acid in adult patients with non-alcoholic steatohepatitis. METHODS We did a multicentre, double-blind, placebo-controlled, parallel group, randomised clinical trial at medical centres in the USA in patients with non-cirrhotic, non-alcoholic steatohepatitis to assess treatment with obeticholic acid given orally (25 mg daily) or placebo for 72 weeks. Patients were randomly assigned 1:1 using a computer-generated, centrally administered procedure, stratified by clinical centre and diabetes status. The primary outcome measure was improvement in centrally scored liver histology defined as a decrease in non-alcoholic fatty liver disease activity score by at least 2 points without worsening of fibrosis from baseline to the end of treatment. A planned interim analysis of change in alanine aminotransferase at 24 weeks undertaken before end-of-treatment (72 weeks) biopsies supported the decision to continue the trial (relative change in alanine aminotransferase -24%, 95% CI -45 to -3). A planned interim analysis of the primary outcome showed improved efficacy of obeticholic acid (p=0·0024) and supported a decision not to do end-of-treatment biopsies and end treatment early in 64 patients, but to continue the trial to obtain the 24-week post-treatment measures. Analyses were done by intention-to-treat. This trial was registered with ClinicalTrials.gov, number NCT01265498. FINDINGS Between March 16, 2011, and Dec 3, 2012, 141 patients were randomly assigned to receive obeticholic acid and 142 to placebo. 50 (45%) of 110 patients in the obeticholic acid group who were meant to have biopsies at baseline and 72 weeks had improved liver histology compared with 23 (21%) of 109 such patients in the placebo group (relative risk 1·9, 95% CI 1·3 to 2·8; p=0·0002). 33 (23%) of 141 patients in the obeticholic acid developed pruritus compared with nine (6%) of 142 in the placebo group. INTERPRETATION Obeticholic acid improved the histological features of non-alcoholic steatohepatitis, but its long-term benefits and safety need further clarification. FUNDING National Institute of Diabetes and Digestive and Kidney Diseases, Intercept Pharmaceuticals.
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Affiliation(s)
| | - Rohit Loomba
- University of California San Diego, La Jolla, CA, USA
| | | | | | | | | | | | | | | | - Bilal Hameed
- University of California San Francisco, San Francisco, CA USA
| | | | | | - Norah Terrault
- University of California San Francisco, San Francisco, CA USA
| | | | | | | | | | - Edward Doo
- The National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
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Affiliation(s)
- Francis Y Yao
- Division of Gastroenterology, Department of Medicine; Division of Transplantation, Department of Surgery, University of California, San Francisco, San Francisco, CA
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Abstract
BACKGROUND The proportion of older patients awaiting liver transplantation (LT) is rising. Although increased age and LT-MELD are known to increase the risk of graft loss, no studies have explored whether there is a synergistic effect between LT-age and LT-MELD. METHODS All US adult, non-Status 1 recipients of primary deceased donor LT from 2/05 to 1/10 without MELD exceptions were included (n=15,677). Recipients were categorized by LT-age [18-59 yr (n=11,966), 60-64 yr (n=2181), 65-69 yr (n=1177), and ≥70 yr (n=343)] and LT-MELD [low (<20, n=5290), mid (20-27, n=5112), and high (≥28, n=5265)]. Adjusted Cox models evaluated the independent and combined effects of LT-age and LT-MELD on graft loss (death or re-LT). RESULTS LT-age ≥70 yr (HR=1.65, 95% CI 1.08-1.82) and LT-MELD ≥28 (HR=1.46, 95% CI 1.02-1.47) were independently associated with increased risk of graft loss (P<0.001). In a model allowing for the interaction between LT-age and LT-MELD, the risk of graft loss for recipients ≥70 years with MELD ≥28 was higher than predicted by the additive model (HR=2.38, 95% CI 1.73-3.27, P<0.001) resulting in 1-year graft survival of 56%. However, the increased risk of graft loss in recipients ≥70 years was attenuated at lower LT-MELD <28. Furthermore, the interaction term was not significant for any other LT-age and LT-MELD combination. CONCLUSION Our analyses suggest that recipients should not be excluded solely based on age; however, LT for recipients ≥70 years at high LT-MELD scores should be undertaken cautiously.
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Affiliation(s)
| | - Sandy Feng
- Department of Surgery, University of California, San Francisco
| | - Bilal Hameed
- Department of Medicine, University of California, San Francisco
| | - Francis Yao
- Department of Medicine, University of California, San Francisco
| | - Jennifer C. Lai
- Department of Medicine, University of California, San Francisco
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Hameed B, Mehta N, Sapisochin G, Roberts JP, Yao FY. Alpha-fetoprotein level > 1000 ng/mL as an exclusion criterion for liver transplantation in patients with hepatocellular carcinoma meeting the Milan criteria. Liver Transpl 2014; 20:945-51. [PMID: 24797281 PMCID: PMC4807739 DOI: 10.1002/lt.23904] [Citation(s) in RCA: 200] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 04/15/2014] [Accepted: 04/21/2014] [Indexed: 12/13/2022]
Abstract
Serum alpha-fetoprotein (AFP) has been increasingly recognized as a marker for a poor prognosis after liver transplantation (LT) for hepatocellular carcinoma (HCC). Many published reports, however, have included a large proportion of patients with HCC beyond the Milan criteria, and the effects of incorporating AFP as an exclusion criterion for LT remain unclear. We studied 211 consecutive patients undergoing LT for HCC within the Milan criteria according to imaging under the Model for End-Stage Liver Disease organ allocation system between June 2002 and January 2009. The majority (93.4%) had locoregional therapy before LT. The median follow-up was 4.5 years (minimum = 2 years). The Kaplan-Meier 1- and 5-year patient survival rates were 94.3% and 83.4%, respectively. In a univariate analysis, significant predictors of HCC recurrence included vascular invasion [hazard ratio (HR) = 10, 95% confidence interval (CI) = 3.9-26, P < 0.001], a pathological tumor stage beyond the University of California San Francisco criteria (HR = 4.1, 95% CI = 1.36-12.6, P = 0.01), an AFP level > 1000 ng/mL (HR = 4.5, 95% CI = 1.3-15.3, P = 0.02), and an AFP level > 500 ng/mL (HR = 3.1, 95% CI = 1.04-9.4, P = 0.04). In a multivariate analysis, vascular invasion was the only significant predictor of tumor recurrence (HR = 5.6, 95% CI = 1.9-19, P = 0.02). An AFP level > 1000 ng/mL was the strongest pretransplant variable predicting vascular invasion (odds ratio = 6.8, 95% CI = 1.6-19.1, P = 0.006). The 1- and 5-year rates of survival without recurrence were 90% and 52.7%, respectively, for patients with an AFP level > 1000 ng/mL and 95% and 80.3%, respectively, for patients with an AFP level ≤ 1000 ng/mL (P = 0.026). Applying an AFP level > 1000 ng/mL as a cutoff would have resulted in the exclusion of 4.7% of the patients fr m LT and a 20% reduction in HCC recurrence. In conclusion, an AFP level > 1000 ng/mL may be a surrogate for vascular invasion and may be used to predict posttransplant HCC recurrence. Incorporating an AFP level > 1000 ng/mL as an exclusion criterion for LT within the Milan criteria may further improve posttransplant outcomes.
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Kelley RK, Chang AN, Anguiano E, Hwang J, Stoppler HJ, McWhirter RM, Parks AL, Hameed B, Fix OK, Wayne EM, Nimeiri HS, Munster PN, Venook AP, Goga A. Next-generation sequencing of serum microRNA (miRNA) in hepatocellular carcinoma (HCC) patients on targeted therapy. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.4096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Robin Kate Kelley
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | | | | | - Jimmy Hwang
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | | | - Ryan M. McWhirter
- USCF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | - Anna L. Parks
- School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Bilal Hameed
- University of California, San Francisco, San Francisco, CA
| | - Oren K. Fix
- University of California, San Francisco, San Francisco, CA
| | | | | | - Pamela N. Munster
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | - Alan P. Venook
- University of California, San Francisco, San Francisco, CA
| | - Andrei Goga
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
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Kelley RK, Chang AN, Anguiano E, Hwang J, Stoppler HJ, McWhirter RM, Parks AL, Hameed B, Fix OK, Wayne EM, Nimeiri HS, Munster PN, Venook AP, Goga A. Next-generation sequencing (NGS) of serum microRNA in hepatocellular carcinoma (HCC) patients treated with sorafenib and an mTOR inhibitor. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.3_suppl.lba204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
LBA204 Background: Noninvasive biomarkers are urgently needed in HCC. MicroRNA (miRNA) are small, noncoding RNA that regulate mRNA expression and are detectable in tumor tissue and extracellular compartments. miRNA signatures in blood specimens show association with HCC diagnosis but have not been explored as pharmacodynamic or predictive biomarkers. We present a pilot study to identify differentially expressed miRNA using NGS on serum from HCC patients at baseline and on targeted therapy, compared to controls. Methods: Serum samples were obtained from HCC patients enrolled on a clinical trial of sorafenib plus temsirolimus. Control sera were obtained from patients with non-malignant liver diseases (NMLD) and healthy volunteers (HV). Total RNA was extracted using RNAzol followed by library construction for each sample. Small RNA were separated by gel purification and sequenced by Illumina HiSeq 2500 at 5M+ reads per sample. Raw sequencing reads were mapped using Novoalign and quantified. Counts were normalized using an exogenous spike-in miRNA. Comparisons between HCC vs. control and baseline vs. on treatment cohorts were performed by linear regression (one-way ANOVA) and multiple-test corrected using Benjamini-Hochberg statistics. Candidate signature miRNA were derived using fold change, p-value, and abundance cutoffs. Results: Cohorts: HCC baseline (n=23) and paired on treatment (n=20), NMLD (n=12), and HV (n=10). HCC cohort: HBV+/dual 40%, HCV+ 32%. NMLD cohort: HCV+ 83%. Median RNA yield/200 µL was 410 ng (range: 69-1066) for HCC, 406 ng (range: 224-1100) for NMLD. The mapping rate ranged from 10-70%. Elevated AFP was associated with up-regulated miRNA identified in TCGA HCC cases, including miR-10a/b. No significant differences were observed for HBV+ vs. HCV+. Multiple oncomiRs appeared downregulated on treatment including Let-7 and miR-17/92 family members. Some miRNA isoforms were differentially regulated in each cohort. Conclusions: Serum miRNA in HCC patients demonstrate changes on treatment and can be characterized by NGS. Certain miRNA implicated in HCC appeared related to clinical covariates and warrant further study as novel biomarkers.
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Affiliation(s)
- Robin Kate Kelley
- USCF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | | | | | - Jimmy Hwang
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | | | - Ryan M. McWhirter
- USCF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | - Anna L. Parks
- School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Bilal Hameed
- University of California, San Francisco, San Francisco, CA
| | - Oren K. Fix
- University of California, San Francisco, San Francisco, CA
| | | | | | - Pamela N. Munster
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | | | - Andrei Goga
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
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Mendelsohn BA, Mehta N, Hameed B, Pekmezci M, Packman S, Ralph J. Adult-Onset Fatal Neurohepatopathy in a Woman Caused by MPV17 Mutation. JIMD Rep 2013; 13:37-41. [PMID: 24190800 DOI: 10.1007/8904_2013_267] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 09/18/2013] [Accepted: 09/23/2013] [Indexed: 12/21/2022] Open
Abstract
Hepatocerebral mitochondrial DNA depletion syndromes are classically considered diseases of early childhood, typically affecting the liver, peripheral, and central nervous systems with a rapidly progressive course. Evidence is emerging that initial symptom onset can extend into adulthood, though few such cases have been reported. We describe a 25-year-old woman who presented initially with secondary amenorrhea, followed by a megaloblastic anemia, lactic acidosis, leukoencephalopathy, progressive peripheral neuropathy, and liver cirrhosis. An apparently homozygous P98L mutation was identified in MPV17, a gene associated with a lethal infantile neurohepatopathy. Homozygosity for the same allele was recently reported in a man with a similar hepatic and neurologic phenotype. This is the first clinical report of an adult female with this disorder, and the first to describe amenorrhea and megaloblastic anemia as likely associated symptoms.
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Affiliation(s)
- Bryce A Mendelsohn
- Division of Medical Genetics, Department of Pediatrics, UCSF Benioff Children's Hospital, San Francisco, CA, USA,
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Noureddin M, Yates KP, Vaughn IA, Neuschwander-Tetri BA, Sanyal AJ, McCullough A, Merriman R, Hameed B, Doo E, Kleiner DE, Behling C, Loomba R. Clinical and histological determinants of nonalcoholic steatohepatitis and advanced fibrosis in elderly patients. Hepatology 2013; 58:1644-54. [PMID: 23686698 PMCID: PMC3760979 DOI: 10.1002/hep.26465] [Citation(s) in RCA: 124] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 04/15/2013] [Indexed: 02/06/2023]
Abstract
UNLABELLED The characteristics of nonalcoholic fatty liver disease (NAFLD) in elderly patients are unknown. Therefore, we aimed to examine the differences between elderly and nonelderly patients with NAFLD and to identify determinants of nonalcoholic steatohepatitis (NASH) and advanced fibrosis (bridging fibrosis or cirrhosis) in elderly patients. This is a cross-sectional analysis of adult participants who were prospectively enrolled in the NASH Clinical Research Network studies. Participants were included based on availability of the centrally reviewed liver histology data within 1 year of enrollment, resulting in 61 elderly (age ≥65 years) and 735 nonelderly (18-64 years) participants. The main outcomes were the presence of NASH and advanced fibrosis. Compared to nonelderly patients with NAFLD, elderly patients had a higher prevalence of NASH (56% versus 72%, P = 0.02), and advanced fibrosis (25% versus 44%, P = 0.002). Compared to nonelderly patients with NASH, elderly patients with NASH had higher rates of advanced fibrosis (35% versus 52%, P = 0.03), as well as other features of severe liver disease including the presence of ballooning degeneration, acidophil bodies, megamitochondria, and Mallory-Denk bodies (P ≤ 0.05 for each). In multiple logistic regression analyses, independent determinants of NASH in elderly patients included higher aspartate aminotransferase (AST) (odds ratio [OR] = 1.12, P = 0.007) and lower platelets (OR = 0.98, P = 0.02); and independent determinants of advanced fibrosis included higher AST (OR = 1.08, P = 0.007), lower alanine aminotransferase value (OR = 0.91, P = 0.002), and an increased odds of having low high-density lipoprotein (OR = 8.35, P = 0.02). CONCLUSION Elderly patients are more likely to have NASH and advanced fibrosis than nonelderly patients with NAFLD. Liver biopsy may be considered in elderly patients and treatment should be initiated in those with NASH and advanced fibrosis.
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Affiliation(s)
- Mazen Noureddin
- Division of Gastroenterology and Epidemiology, University of California at San Diego School of Medicine, La Jolla, CA
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Hameed B, Mahto A. AB0207 Assessment of cardiovascular risk in patients with rheumatoid arthritis, where are we in 2012? Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2013-eular.2530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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48
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Kelley RK, Magbanua MJM, Butler TM, Sidiropoulos N, Hwang J, Evason K, Hameed B, Wayne EM, Yao FY, Siah I, Park JW, Venook AP, Collisson EA. Circulating tumor cells (CTC) in metastatic hepatocellular carcinoma (HCC): Comparison to control patients with nonmalignant liver diseases (NMLD) and exploratory characterization by next generation sequencing (NGS). J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.4_suppl.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
207 Background: Noninvasive biomarkers are urgently needed to improve diagnosis, prognosis, and molecular characterization in HCC. Detection of CTC by EpCAM-enrichment methods is associated with poor outcomes in other tumors. Approximately 35% of HCC are EpCAM+. We hypothesized that CTC are detectable in a subset of metastatic HCC but not in NMLD and that CTC DNA might serve as a source of tumor DNA for biomarker detection and discovery. Methods: Whole blood was obtained from (1) patients with metastatic HCC and (2) NMLD controls. CTC were enumerated using CellSearch by blinded investigators. If > 10 CTC/7.5 mL, immunomagnetic enrichment for EpCAM followed by fluorescence-activated cell sorting (FACS) was also performed to collect highly purified CTC for whole genome amplification (WGA) by GenomePlex WGA4 kit. NGS using 46-gene AmpliSeq Cancer Panel (Ion Torrent) was performed on DNA from CTC, formalin-fixed paraffin embedded tumor (FFPE), and peripheral blood mononuclear cells (PBMC) if available. Results: 20 HCC and 10 NMLD were enrolled. FFPE was available in 7 HCC. In HCC cohort, median alpha-fetoprotein (AFP) was 492 ng/mL (range: 3.8-587,134) and vascular invasion (VI) was present in 13/20 (65%). CTC ≥ 3/7.5 mL were detected in 6/20 (30%, 95% CI: 0.08, 0.52) HCC and 0/9 (95% CI: 0, 0) eligible NMLD (p=0.07). One NMLD had CTC > 3/7.5 mL but was found to have HCC on surveillance ultrasound and excluded. CTC ≥ 3/7.5 mL were associated with AFP ≥ 400 (p=0.01) and VI (p=0.05) by Fisher’s exact test. NGS identified mutations listed in COSMIC in the majority including TP53 and CTNNB1. Variants appeared more frequent in CTC than FFPE in this small sample. Coverage was significantly lower in CTC than FFPE (coverage 20x mean 50% vs 93%, p < 0.02 by unpaired t-test). Conclusions: CTC are a promising biomarker in metastatic HCC and merit further study, including non-EpCAM methods. CTC were associated with AFP and VI. NGS of CTC WGA DNA is feasible and identified characteristic mutations but was limited by coverage bias. Updated NGS findings including 5 cases with paired CTC, FFPE, and/or PBMC will be presented.
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Affiliation(s)
- Robin Katie Kelley
- University of California, San Francisco Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | | | | | | | - Jimmy Hwang
- University of California, San Francisco Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | | | - Bilal Hameed
- University of California, San Francisco, San Francisco, CA
| | | | - Francis Y Yao
- University of California, San Francisco, San Francisco, CA
| | - Iche Siah
- University of California, San Francisco, San Francisco, CA
| | - John W. Park
- University of California, San Francisco, San Francisco, CA
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Sebastian J, Derksen C, Khan K, Ibrahim M, Hameed B, Siddiqui M, Chow M, Findlay JM, Shuaib A, Saqqur M. Derivation of transcranial Doppler criteria for angiographically proven middle cerebral artery vasospasm after aneurysmal subarachnoid hemorrhage. J Neuroimaging 2012; 23:489-94. [PMID: 23163812 DOI: 10.1111/j.1552-6569.2012.00771.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 08/15/2012] [Accepted: 08/26/2012] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Transcranial Doppler (TCD) has been subjected to criticism for detecting vasospasm (VSP). Our study's aim is to derive criteria for middle cerebral artery (MCA) vasospasm (MCA-VSP) based on cerebral angiography (CA). METHODS A prospective data of patients with aneurysmal subarachnoid hemorrhage (aSAH) from January 2004 to August 2009. TCD was performed daily from day 2 to 14 from symptom's onset. Follow-up CA was done at day 7-9. TCD mean flow velocities (MFV) of all vessels at baseline (b), middle (m) and before CA (preangio) were recorded. Several MCA MFV ratios were computed. Moderate to severe VSP on CA was defined as >1/3 luminal narrowing. Univariate and stepwise logistic regression analysis were performed. RESULTS One hundred sixty-nine patients (338 MCA) with aSAH were included, mean age: 54.8 ± 13, women: 103 (62%). Twenty-nine patients (8.6%) had angiographic MCA-VSP. TCD scoring system of 3 points for MCA-VSP was computed based on (a) bMCA MFV ≥ 120 cm/s (sensitivity: 59.3%, specificity: 85%, PPV: 36.4%, NPV: 93.5%, P < .001) (1 point), Preangio MCA MFV ≥ 150 cm/s (79.3%, 89.9%, 39%, 97.3%, <.001) (1 point), and affected preangio MCA/bMCA MFV ratio ≥ 1.5 (84%, 63%, 25.6%, 96.3%, .001) (1 point). The score of 3 has 96% sensitivity and 96% specificity (OR: 300) whereas the score of 1 has 12% sensitivity and 58% specificity (OR: 4.3) for identifying MCA-VSP. CONCLUSION TCD stringent criteria for moderate to severe MCA-VSP are feasible and applicable in aSAH population.
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Affiliation(s)
- Joseph Sebastian
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Brandman D, Biggins SW, Hameed B, Roberts JP, Terrault NA. Pretransplant severe hepatic encephalopathy, peritransplant sodium and post-liver transplantation morbidity and mortality. Liver Int 2012; 32:158-64. [PMID: 22098119 DOI: 10.1111/j.1478-3231.2011.02618.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 07/10/2011] [Indexed: 02/13/2023]
Abstract
BACKGROUND Hepatic encephalopathy (HE) does not enhance the prediction of model of end-stage liver disease (MELD) wait-list mortality, but its influence on post-liver transplantation (LT) morbidity and mortality is largely unknown. AIMS To examine the association between severe pre-LT HE and peri-LT serum sodium levels as well as post-LT length of stay (LOS) and survival. METHODS A retrospective cohort of 393 adult patients undergoing first LT for end-stage liver disease and followed for a median of 4 years post-LT was performed to evaluate the association between severe HE within the 30 days prior to LT and selected in-hospital post-LT outcomes. RESULTS Thirty-nine (10%) of the cohort had severe HE pre-LT. Patients with severe HE more frequently had Na changes of ≥15 mmol/L in the peri-LT period (P = 0.002). LOS was significantly longer for severe HE than non-severe HE patients (16 vs. 8 days, P < 0.0001) and this association was independent of MELD, presence of hepatocellular carcinoma, pre-LT nadir serum sodium and pre- to post-LT change in serum sodium. The 1-year mortality was 15% in the severe HE vs. 7% in the non-severe HE groups (HR = 2.19, P = 0.08), and this difference was attenuated by adjusting for pre-LT severe hypernatremia, but increased by adjusting for donor risk index. CONCLUSION Severe HE mainly affects LOS, and this association is independent of MELD. Whether the large changes in peri-LT serum Na, more frequently seen in the severe HE group, contribute to post-LT morbidity requires further study.
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Affiliation(s)
- Danielle Brandman
- Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
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