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Johansen S, Langkjær S, Rasmussen DN, Israelsen M, Torp N, Lindvig K, Kjærgaard M, Hansen JK, Hansen CD, Thorhauge K, Andersen P, Detlefsen S, Juel HB, Justesen US, Hansen T, Krag A, Thiele M. Infections increase the risk of decompensation and death in patients with early alcohol-related liver disease. JHEP Rep 2024; 6:101016. [PMID: 38486819 PMCID: PMC10937840 DOI: 10.1016/j.jhepr.2024.101016] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/19/2023] [Accepted: 01/16/2024] [Indexed: 03/17/2024] Open
Abstract
Background & Aims Infections are frequent in patients with cirrhosis and worsen prognosis. We evaluated the incidence of infections and their impact on decompensation and death in patients with early alcohol-related liver disease (ALD) during long-term follow-up. Methods We performed a prospective cohort study of patients in secondary care with a history of excess alcohol intake, no prior decompensation, and with liver biopsies along with clinical investigations conducted at baseline. During follow-up, we reviewed the patients' electronic healthcare records for cases of infections, hospitalizations, transient elastography measurements, decompensations, all-cause mortality, and alcohol intake. Results We included 461 patients with a mean age of 56±10 years (76% males; fibrosis stage F0-1/F2/F3-4 = 259/107/93 [56%/23%/20%]). During a median follow-up of 4.5 years (IQR 2.9-6.3), 134 patients (29%) developed a total of 312 infections, most frequently pneumonia (106/312, 34%) and urinary tract infections (57/312, 18%). Excessive alcohol intake during follow-up, smoking ≥30 pack years, MELD score and elevated liver stiffness during follow-up were independent predictors of infections. Patients who developed at least one infection had a significantly increased risk of subsequent decompensation (hazard ratio 4.98, 95% CI 2.47-10.03) and death (hazard ratio 8.24, 95% CI 4.65-14.59). Infections increased the risk of decompensation and death independently of baseline fibrosis stage, age, gender, and MELD score. Conclusions Almost one-third of patients with early ALD develop an infection, which worsens their prognosis by increasing the risk of decompensation and death. The risk of infections increases with liver disease severity and ongoing harmful use of alcohol. Impact and implications This study reveals that infections significantly worsen the prognosis of patients with early alcohol-related liver disease (ALD), increasing the likelihood of decompensation and death by up to eight times. These findings, pertinent to healthcare providers, researchers, and policymakers, emphasize the importance of early prevention and management of infections in patients with ALD, even those in early stages who may be asymptomatic. It was observed that nearly one-third of patients with early-stage ALD developed infections over 4.5 years, with risk factors including alcohol overuse, smoking, and higher MELD scores. The research underscores the critical need to incorporate these insights into clinical practice and public health policies to improve patient outcomes and mitigate the impact of infections in patients with ALD.
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Affiliation(s)
- Stine Johansen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Simon Langkjær
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Ditlev Nytoft Rasmussen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Mads Israelsen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Nikolaj Torp
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Katrine Lindvig
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Maria Kjærgaard
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Johanne Kragh Hansen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Camilla Dalby Hansen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Katrine Thorhauge
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Peter Andersen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Sönke Detlefsen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Helene Bæk Juel
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Denmark
| | - Ulrik Stenz Justesen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Denmark
| | - Aleksander Krag
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Maja Thiele
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Israelsen M, Torp N, Johansen S, Hansen CD, Hansen ED, Thorhauge K, Hansen JK, Villesen I, Bech K, Wernberg C, Andersen P, Lindvig KP, Tsochatzis EA, Thiele M, Rinella ME, Krag A. Validation of the new nomenclature of steatotic liver disease in patients with a history of excessive alcohol intake: an analysis of data from a prospective cohort study. Lancet Gastroenterol Hepatol 2024; 9:218-228. [PMID: 38218202 DOI: 10.1016/s2468-1253(23)00443-0] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/05/2023] [Accepted: 12/05/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Steatotic liver disease is a new overarching term that includes metabolic dysfunction-associated steatotic liver disease (MASLD), metabolic dysfunction and alcohol-related steatotic liver disease (MetALD), and alcohol-related liver disease (ALD). We aimed to validate the prognostic importance of MASLD, MetALD, and ALD as steatotic liver disease subclasses. METHODS Between April 18, 2013, and Sept 17, 2018, we prospectively recruited patients aged 18-75 years with current or previous excessive alcohol intake (>24 g/day for women and >36 g/day for men) for at least a year and no previous hepatic decompensation from the Department of Gastroenterology and Hepatology at Odense University Hospital (Odense, Denmark). Participants were followed up until Sept 15, 2022. Here, we characterise these patients according to steatotic liver disease subclasses. We classified patients as having MASLD, MetALD, or ALD in accordance with the nomenclature definitions, on the basis of metabolic comorbidity and self-reported average alcohol intake in the 3 months leading up to inclusion. Histological scoring was done by a pathologist who was masked to the clinical data. We compared prognoses between classes using Cox regression analyses on hepatic decompensation and overall mortality as the two outcome measures. Patients not meeting the criteria for steatotic liver disease were classified as no steatotic liver disease and served as a reference group. FINDINGS We enrolled 446 patients with a history of excessive alcohol intake were included in this analysis (334 [75%] were male and 112 [25%] were female; median age 56 years [SD 10]). Cirrhosis was present in 58 (13%), and 435 (98%) had at least one cardiometabolic risk factor. 321 (72%) met steatotic liver disease criteria and 125 (28%) did not have steatotic liver disease, meaning no evident liver steatosis and no significant fibrosis (≥F2). Of the 321 patients with steatotic liver disease, six (2%) were identified as having ALD due to the absence of cardiometabolic risk factors. The remaining 315 (98%) patients presented with at least one cardiometabolic risk factor. Of these patients, 153 (49%) had MASLD, 76 (24%) had MetALD, and 86 (27%) had ALD. During follow-up, 67 (15%) of 446 patients decompensated and 97 (22%) died (median follow-up 70 months [IQR 53-94]). Patients with steatotic liver disease had a significantly higher risk of hepatic decompensation and overall mortality than those without steatotic liver disease, independent of age, sex, and liver stiffness. The risk of decompensation increased in a stepwise manner from MASLD (hazard ratio 4·73 [95% CI 1·03-21·6]), through MetALD (7·69 [1·66-35·6]), to ALD (10·2 [2·24-46·4]). Similarly, overall mortality increased from MASLD (HR 2·30 [95% CI 1·08-4·90]), through MetALD (2·94 [1·31-6·58]), to ALD (3·57 [1·64-7·80]), independent of age, sex, and liver stiffness. INTERPRETATION Steatotic liver disease and its subclasses portend distinct prognoses. There is a need to specify how historical alcohol intake should be integrated into the nomenclature and risk stratification of steatotic liver disease. FUNDING EU Horizon 2020 Research and Innovation Program.
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Affiliation(s)
- Mads Israelsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Nikolaj Torp
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Stine Johansen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Camilla Dalby Hansen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Emil Deleuran Hansen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Katrine Thorhauge
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Johanne Kragh Hansen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Ida Villesen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Katrine Bech
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
| | - Charlotte Wernberg
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
| | - Peter Andersen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
| | - Katrine Prier Lindvig
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Emmanuel A Tsochatzis
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark; UCL Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, UK
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Mary E Rinella
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark.
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Thorhauge KH, Semmler G, Johansen S, Lindvig KP, Kjærgaard M, Hansen JK, Torp N, Hansen CD, Andersen P, Hofer BS, Gu W, Israelsen M, Mandorfer M, Reiberger T, Trebicka J, Thiele M, Krag A. Using liver stiffness to predict and monitor the risk of decompensation and mortality in patients with alcohol-related liver disease. J Hepatol 2024:S0168-8278(24)00139-9. [PMID: 38428644 DOI: 10.1016/j.jhep.2024.02.019] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 02/07/2024] [Accepted: 02/16/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND & AIMS Liver stiffness measurement (LSM) is recommended for disease prognostication and monitoring. We evaluated if LSM, using transient elastography, and LSM changes predict decompensation and mortality in patients with alcohol-related liver disease (ALD). METHODS We performed an observational cohort study of compensated patients at risk of ALD from Denmark and Austria. We evaluated the risk of decompensation and all-cause mortality, stratified for compensated advanced chronic liver disease (cACLD: baseline LSM ≥10 kPa) and LSM changes after a median of 2 years. In patients with cACLD, we defined LSM changes as (A) LSM increase ≥20% ("cACLD increasers") and (B) follow-up LSM <10 kPa or <20 kPa with LSM decrease ≥20% ("cACLD decreasers"). In patients without cACLD, we defined follow-up LSM ≥10 kPa as an LSM increase ("No cACLD increasers"). The remaining patients were considered LSM stable. RESULTS We followed 536 patients for 3,008 patient-years, median age 57 years (IQR 49-63), baseline LSM 8.1 kPa (IQR 4.9-21.7). 371 patients (69%) had follow-up LSM after a median of 25 months (IQR 17-38), 41 subsequently decompensated and 55 died. Of 125 with cACLD at baseline, 14% were "cACLD increasers" and 43% "cACLD decreasers", while 13% of patients without cACLD were "No cACLD increasers" (n = 33/246). Baseline LSM, follow-up LSM and LSM changes accurately predicted decompensation (C-index: baseline LSM 0.85; follow-up LSM 0.89; LSM changes 0.85) and mortality (C-index: baseline LSM 0.74; follow-up LSM 0.74; LSM changes 0.70). When compared to "cACLD decreasers", "cACLD increasers" had significantly lower decompensation-free survival and higher risks of decompensation (subdistribution hazard ratio 4.39, p = 0.004) and mortality (hazard ratio 3.22, p = 0.01). CONCLUSION LSM by transient elastography predicts decompensation and all-cause mortality in patients with compensated ALD both at diagnosis and when used for monitoring. IMPACT AND IMPLICATIONS Patients at risk of alcohol-related liver disease (ALD) are at significant risk of progressive disease and adverse outcomes. Monitoring is essential for optimal disease surveillance and patient guidance, but non-invasive monitoring tools are lacking. In this study we demonstrate that liver stiffness measurement (LSM), using transient elastography, and LSM changes after a median of 2 years, can predict decompensation and all-cause mortality in patients at risk of ALD with and without compensated advanced chronic liver disease. These findings are in line with results from non-alcoholic fatty liver disease, hepatitis C and primary sclerosing cholangitis, and support the clinical utility of LSM, using transient elastography, for disease prognostication and monitoring in chronic liver diseases including ALD, as recommended by the Baveno VII.
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Affiliation(s)
- Katrine Holtz Thorhauge
- Fibrosis, Fatty Liver and Steatohepatitis Research Center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Spitalgasse 23 A-1090 Vienna, Austria
| | - Stine Johansen
- Fibrosis, Fatty Liver and Steatohepatitis Research Center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Katrine Prier Lindvig
- Fibrosis, Fatty Liver and Steatohepatitis Research Center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Maria Kjærgaard
- Fibrosis, Fatty Liver and Steatohepatitis Research Center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Johanne Kragh Hansen
- Fibrosis, Fatty Liver and Steatohepatitis Research Center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Nikolaj Torp
- Fibrosis, Fatty Liver and Steatohepatitis Research Center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Camilla Dalby Hansen
- Fibrosis, Fatty Liver and Steatohepatitis Research Center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Peter Andersen
- Fibrosis, Fatty Liver and Steatohepatitis Research Center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Benedikt Silvester Hofer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Spitalgasse 23 A-1090 Vienna, Austria
| | - Wenyi Gu
- Department of Internal Medicine B, Münster University Hospital, University of Münster, Münster, Germany
| | - Mads Israelsen
- Fibrosis, Fatty Liver and Steatohepatitis Research Center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Spitalgasse 23 A-1090 Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Spitalgasse 23 A-1090 Vienna, Austria
| | - Jonel Trebicka
- Department of Internal Medicine B, Münster University Hospital, University of Münster, Münster, Germany
| | - Maja Thiele
- Fibrosis, Fatty Liver and Steatohepatitis Research Center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.
| | - Aleksander Krag
- Fibrosis, Fatty Liver and Steatohepatitis Research Center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Kjaergaard M, Lindvig KP, Thorhauge KH, Johansen S, Hansen JK, Andersen P, Hansen CD, Schnefeld HL, Bech KT, Torp N, Israelsen M, Detlefsen S, Graupera I, Gines P, Krag A, Thiele M. Screening for Fibrosis Promotes Lifestyle Changes: A Prospective Cohort Study in 4796 Individuals. Clin Gastroenterol Hepatol 2023:S1542-3565(23)01053-4. [PMID: 38154729 DOI: 10.1016/j.cgh.2023.12.018] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/20/2023] [Accepted: 12/12/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND AND AIMS Early detection of liver fibrosis is believed to promote lifestyle changes. We evaluated self-reported changes in alcohol intake, diet, exercise, and weight after participating in a screening study for liver fibrosis. METHODS We conducted a prospective screening study of individuals at risk of alcohol-related liver disease (ALD) or metabolic dysfunction-associated steatotic liver disease (MASLD). We provided lifestyle advice to all participants and evaluated lifestyle changes by questionnaires after 1 week and 6 months, with re-examination of a subgroup after 2 years. RESULTS A total of 1850 at risk of ALD and 2946 at risk of MASLD were included, of whom 383 (8%) were screening positive (transient elastography ≥8 kPa). A total of 84% replied to the 6-month questionnaire. In ALD participants, excessive drinking decreased from 46% to 32% after 6 months. Only 15% reported increased drinking, without differences between screening positive and negative individuals (P = .698). In high-risk drinkers, a positive screening test predicted abstinence or decreased alcohol use after 6 months (odds ratio, 2.45; 95% confidence interval, 1.32-4.57; P = .005). After 2 years, excessive drinking decreased from 52% to 41% in a subgroup of 752 individuals and a positive screening test predicted abstinence or decreased alcohol use after 2 years (odds ratio, 1.84; 95% confidence interval, 1.09-3.11, P = .023). MASLD participants showed similar improvements: 35% improved their diet, 22% exercised more, and 13% reported a weight loss ≥5% after 6 months. CONCLUSIONS Screening for liver fibrosis is associated with sustained improvements in alcohol consumption, diet, weight, and exercise in at-risk ALD and MASLD. The changes are most pronounced in screening positive participants but not limited to this group.
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Affiliation(s)
- Maria Kjaergaard
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Katrine Prier Lindvig
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Katrine Holtz Thorhauge
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Stine Johansen
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Johanne Kragh Hansen
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Peter Andersen
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Camilla Dalby Hansen
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Helle Lindholm Schnefeld
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Katrine Tholstrup Bech
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Nikolaj Torp
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mads Israelsen
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sönke Detlefsen
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark; Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Isabel Graupera
- Liver Unit Hospital Clínic, Institut D'investigacions Biomédiques August Pi i Sunyer, Barcelona, Spain; Centro de Investigación En Red de Enfermedades Hepáticas y Digestivas, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Pere Gines
- Liver Unit Hospital Clínic, Institut D'investigacions Biomédiques August Pi i Sunyer, Barcelona, Spain; Centro de Investigación En Red de Enfermedades Hepáticas y Digestivas, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Aleksander Krag
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Maja Thiele
- Fibrosis Fatty Liver and Steatohepatitis Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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Stankevic E, Israelsen M, Juel HB, Madsen AL, Ängquist L, Aldiss PSJ, Torp N, Johansen S, Hansen CD, Hansen JK, Thorhauge KH, Lindvig KP, Madsen BS, Sulek K, Legido-Quigley C, Thiele MS, Krag A, Hansen T. Binge drinking episode causes acute, specific alterations in systemic and hepatic inflammation-related markers. Liver Int 2023; 43:2680-2691. [PMID: 37592403 DOI: 10.1111/liv.15692] [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: 05/23/2023] [Revised: 07/07/2023] [Accepted: 07/31/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Frequent binge drinking is a known contributor to alcohol-related harm, but its impact on systemic and hepatic inflammation is not fully understood. We hypothesize that changes in immune markers play a central role in adverse effects of acute alcohol intake, especially in patients with early liver disease. AIM To investigate the effects of acute alcohol intoxication on inflammation-related markers in hepatic and systemic venous plasma in people with alcohol-related liver disease (ArLD), non-alcoholic fatty liver disease (NAFLD) and healthy controls. METHODS Thirty-eight participants (13 with ArLD, 15 with NAFLD and 10 healthy controls) received 2.5 mL of 40% ethanol per kg body weight via a nasogastric tube. Seventy-two inflammation-related markers were quantified in plasma from hepatic and systemic venous blood, at baseline, 60 and 180 min after intervention. RESULTS Alcohol intervention altered the levels of 31 of 72 and 14 of 72 markers in the systemic and hepatic circulation. All changes observed in the hepatic circulation were also identified in the systemic circulation after 180 min. Only FGF21 and IL6 were increased after alcohol intervention, while the remaining 29 markers decreased. Differences in response to acute alcohol between the groups were observed for 8 markers, and FGF21 response was blunted in individuals with steatosis. CONCLUSION Acute alcohol intoxication induced changes in multiple inflammation-related markers, implicated in alcohol metabolism and hepatocellular damage. Differences identified between marker response to binge drinking in ArLD, NAFLD and healthy controls may provide important clues to disease mechanisms and potential targets for treatment. CLINICAL TRIAL NUMBER NCT03018990.
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Affiliation(s)
- Evelina Stankevic
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Mads Israelsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Helene Baek Juel
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Anne Lundager Madsen
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Lars Ängquist
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Peter Stuart Jacob Aldiss
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Nikolaj Torp
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Stine Johansen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Camilla Dalby Hansen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Johanne Kragh Hansen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Katrine Holtz Thorhauge
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Katrine Prier Lindvig
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Bjørn Staehr Madsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | | | | | - Maja Sofie Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
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Israelsen M, Alvarez-Silva C, Madsen BS, Hansen CD, Torp NC, Johansen S, Hansen JK, Prier Lindvig K, Insonere J, Riviere V, Juel HB, Brejnrod A, Jensen LJ, Thiele M, Lelouvier B, Hansen T, Arumugam M, Krag A. Impact of acute alcohol consumption on circulating microbiome in asymptomatic alcohol-related liver disease. Gut 2023:gutjnl-2023-330360. [PMID: 37344168 DOI: 10.1136/gutjnl-2023-330360] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/05/2023] [Indexed: 06/23/2023]
Affiliation(s)
- Mads Israelsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Camila Alvarez-Silva
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Bjørn Stæhr Madsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Camilla Dalby Hansen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Nikolaj Christian Torp
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Stine Johansen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Johanne Kragh Hansen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Katrine Prier Lindvig
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | | | | | - Helene Bæk Juel
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Asker Brejnrod
- Department of Health Technology, Technical University of Denmark, Lyngby, Hovedstaden, Denmark
| | - Lars Juhl Jensen
- Faculty of Health and Medical Sciences, University of Copenhagen, Kobenhavn, Denmark
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | | | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Manimozhiyan Arumugam
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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7
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Israelsen M, Madsen BS, Torp N, Johansen S, Hansen CD, Detlefsen S, Andersen P, Hansen JK, Lindvig KP, Rasmussen DN, Thorhauge KH, Kjærgaard M, Karsdal M, Hansen T, Arumugam M, Trebicka J, Thiele M, Krag A. Rifaximin-α for liver fibrosis in patients with alcohol-related liver disease (GALA-RIF): a randomised, double-blind, placebo-controlled, phase 2 trial. Lancet Gastroenterol Hepatol 2023; 8:523-532. [PMID: 36893774 PMCID: PMC10172147 DOI: 10.1016/s2468-1253(23)00010-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/18/2023] [Accepted: 01/18/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Alcohol is the leading cause of liver-related mortality worldwide. The gut-liver axis is considered a key driver in alcohol-related liver disease. Rifaximin-α improves gut-barrier function and reduces systemic inflammation in patients with cirrhosis. We aimed to compare the efficacy and safety of rifaximin-α with placebo in patients with alcohol-related liver disease. METHODS GALA-RIF was an investigator-initiated, randomised, double-blind, placebo-controlled, single-centre, phase 2 trial done at Odense University Hospital in Denmark. Eligible participants were adults (aged 18-75 years) who had current or previous alcohol overuse (at least 1 year with ≥24 g of alcohol per day for women and ≥36 g of alcohol per day for men), biopsy-proven alcohol-related liver disease, and no previous hepatic decompensation. Patients were randomly allocated (1:1) through a web-based randomisation system to receive oral rifaximin-α (550 mg) twice daily or matched placebo for 18 months. Randomisation was done in blocks of four and stratified according to fibrosis stage and alcohol abstinence. Participants, sponsor, investigators, and nurses involved in the study were masked to the randomisation outcome. The primary endpoint was a histological decrease from baseline to 18-month treatment of at least one fibrosis stage, according to the Kleiner fibrosis score. We also assessed the number of patients with progression by at least one fibrosis stage from baseline to 18 months. Primary analyses were done in the per-protocol and modified intention-to-treat populations; safety was assessed in the full intention-to-treat population. The per-protocol population was defined as all randomly assigned patients who did not present serious protocol violations, who ingested at least 75% of the treatment, and who were not withdrawn from the study due to non-adherence (interruption of treatment for 4 weeks or more). Participants receiving at least one dose of the intervention were included in the modified intention-to-treat analyses. This completed trial is registered with EudraCT, number 2014-001856-51. FINDINGS Between March 23, 2015, and Nov 10, 2021, we screened 1886 consecutive patients with a history of excessive alcohol consumption and no previous hepatic decompensation, of whom 136 were randomly assigned to either rifaximin-α (n=68) or placebo (n=68). All patients were White (100%), 114 (84%) were men, and 22 (16%) were women. 133 (98%) patients received at least one dose of the intervention and were included in the modified intention-to-treat analysis; 108 (79%) completed the trial per protocol. In the per-protocol analysis, 14 (26%) of 54 patients in the rifaximin-α group and 15 (28%) of 54 patients in the placebo group had a decrease in fibrosis stage after 18 months (odds ratio 1·10 [95% CI 0·45-2·68]; p=0·83). In the modified intention-to-treat analysis, 15 (22%) of 67 patients in the rifaximin-α group and 15 (23%) of 66 patients in the placebo group had a decrease in fibrosis stage at 18 months (1·05 [0·45-2·44]; p=0·91). In the per-protocol analysis, increase in fibrosis stage occurred in 13 (24%) patients in the rifaximin-α group and 23 (43%) patients in the placebo group (0·42 [0·18-0·98]; p=0·044). In the modified intention-to-treat analysis, increase in fibrosis stage occurred in 13 (19%) patients in the rifaximin-α group and 23 (35%) patients in the placebo group (0·45 [0·20-1·02]; p=0·055). The number of patients with adverse events (48 [71%] of 68 patients in the rifaximin-α group; 53 [78%] of 68 in the placebo group) and serious adverse events (14 [21%] in the rifaximin-α group; 12 [18%] in the placebo group) was similar between the groups. No serious adverse events were deemed related to treatment. Three patients died during the trial, but none of the deaths were considered treatment related. INTERPRETATION In patients with alcohol-related liver disease, rifaximin-α might reduce progression of liver fibrosis. These findings warrant confirmation in a multicentre phase 3 trial. FUNDING The EU Horizon 2020 Research and Innovation Program and The Novo Nordisk Foundation.
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Affiliation(s)
- Mads Israelsen
- Odense Liver Research Center, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.
| | - Bjørn Stæhr Madsen
- Odense Liver Research Center, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Nikolaj Torp
- Odense Liver Research Center, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Stine Johansen
- Odense Liver Research Center, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Camilla Dalby Hansen
- Odense Liver Research Center, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Sönke Detlefsen
- Department of Pathology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Peter Andersen
- Odense Liver Research Center, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Johanne Kragh Hansen
- Odense Liver Research Center, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Katrine Prier Lindvig
- Odense Liver Research Center, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Ditlev Nytoft Rasmussen
- Odense Liver Research Center, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Katrine Holtz Thorhauge
- Odense Liver Research Center, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Maria Kjærgaard
- Odense Liver Research Center, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Morten Karsdal
- Department of Molecular Medicine, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Nordic Bioscience Biomarkers and Research, Herlev, Denmark
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Manimozhiyan Arumugam
- Odense Liver Research Center, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Jonel Trebicka
- Odense Liver Research Center, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Department of Internal Medicine B, Münster University Hospital, WWU, Münster, Germany; European Foundation for Study of Chronic Liver Failure, Barcelona, Spain
| | - Maja Thiele
- Odense Liver Research Center, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Aleksander Krag
- Odense Liver Research Center, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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8
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Kjaergaard M, Lindvig KP, Thorhauge KH, Andersen P, Hansen JK, Kastrup N, Jensen JM, Hansen CD, Johansen S, Israelsen M, Torp N, Trelle MB, Shan S, Detlefsen S, Antonsen S, Andersen JE, Graupera I, Ginés P, Thiele M, Krag A. Using the ELF test, FIB-4 and NAFLD fibrosis score to screen the population for liver disease. J Hepatol 2023:S0168-8278(23)00225-8. [PMID: 37088311 DOI: 10.1016/j.jhep.2023.04.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [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: 08/25/2022] [Revised: 02/26/2023] [Accepted: 04/02/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND AND AIMS There is a need for accurate population screening biomarkers for alcohol-related and non-alcoholic fatty liver disease (ALD, NAFLD). We evaluated the Enhanced Liver Fibrosis (ELF) test compared to FIB-4 and NAFLD fibrosis score (NFS) using transient elastography (TE) as fibrosis screening reference. METHODS We prospectively included participants from the general population, and people at risk of ALD or NAFLD. Screening positive participants (TE ≥8 kPa) were offered a liver biopsy. We measured concomitant ELF, FIB-4, and NFS using validated cut-offs: ≥9.8, ≥1.3, ≥-1.45, respectively. RESULTS We included 3,378 participants (1,973 general population, 953 at risk of ALD, 452 at risk of NAFLD), with a median age of 57 years (IQR: 51-63). Two hundred-and-forty-two were screening positive (3.4% in general population, 12% in ALD, 14% in NAFLD). Most participants with TE <8 kPa also had ELF <9.8 (88%) despite a poor overall correlation between ELF and TE (Spearman´s rho=0.207). ELF had significantly fewer false positives (11%) than FIB-4 and NFS (35% and 45%), while retaining a low rate of false negatives (<8%). A screening strategy of FIB-4 followed by ELF in indeterminate cases resulted in 8% false positives, 4% false negatives and 88% correctly classified. We performed a liver biopsy in 155/242 (64%) screening positives, of those 54 (35%) had advanced fibrosis (≥F3). ELF diagnosed advanced fibrosis with significantly better diagnostic accuracy than FIB-4 and NFS: AUROC 0.85 (95% CI 0.79-0.92) versus 0.73 (0.64-0.81) and 0.66 (0.57-0.76). CONCLUSION The ELF test alone or combined with FIB-4 for liver fibrosis screening in the general population and at-risk groups reduces the number of futile referrals compared to FIB-4 and NFS, without overlooking true cases. IMPACT AND IMPLEMENTATIONS We need referral pathways that are efficient at detecting advanced fibrosis from alcohol-related and non-alcoholic fatty liver disease in the population, but without causing futile referrals or excessive use of resources. This study indicates that a sequential test strategy of FIB-4, followed by the ELF test in indeterminate cases leads to few patients referred for confirmatory liver stiffness measurement, while retaining a high rate of detected cases, and at low direct costs. This two-step referral pathway could be used by primary care for mass, targeted, or opportunistic screening for liver fibrosis in the population. CLINICAL TRIAL NUMBER Clinicaltrials.gov number NCT03308916.
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Affiliation(s)
- Maria Kjaergaard
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern Denmark, Denmark
| | - Katrine Prier Lindvig
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern Denmark, Denmark
| | - Katrine Holtz Thorhauge
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern Denmark, Denmark
| | - Peter Andersen
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark
| | - Johanne Kragh Hansen
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern Denmark, Denmark
| | - Nanna Kastrup
- Danish Center for Healthcare Improvements, Aalborg University
| | - Jane Møller Jensen
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark
| | - Camilla Dalby Hansen
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern Denmark, Denmark
| | - Stine Johansen
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern Denmark, Denmark
| | - Mads Israelsen
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark
| | - Nikolaj Torp
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern Denmark, Denmark
| | - Morten Beck Trelle
- Department of Clinical Research, University of Southern Denmark, Denmark; Department of Clinical Biochemistry, Odense University Hospital, Denmark
| | - Shan Shan
- Centre for Quantum Mathematics, Department of Mathematics and Computer Science, University of Southern Denmark
| | - Sönke Detlefsen
- Department of Clinical Research, University of Southern Denmark, Denmark; Department of Pathology, Odense University Hospital, Denmark
| | - Steen Antonsen
- Department of Clinical Biochemistry, Odense University Hospital, Denmark
| | - Jørgen Ellegaard Andersen
- Centre for Quantum Mathematics, Department of Mathematics and Computer Science, University of Southern Denmark; Danish Institute of Advanced Study (DIAS), University of Southern Denmark, Denmark
| | - Isabel Graupera
- Liver Unit Hospital Clínic, Institut D´investigacions Biomédiques August Pi I Sunyer (IDIBAPS), Spain; Centro de Investigación En Red de Enfermedades Hepáticas Y Digestivas (CIBEREHD) Barcelona; Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Pere Ginés
- Liver Unit Hospital Clínic, Institut D´investigacions Biomédiques August Pi I Sunyer (IDIBAPS), Spain; Centro de Investigación En Red de Enfermedades Hepáticas Y Digestivas (CIBEREHD) Barcelona; Faculty of Medicine and Health Sciences, University of Barcelona, Spain
| | - Maja Thiele
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern Denmark, Denmark.
| | - Aleksander Krag
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern Denmark, Denmark; Danish Institute of Advanced Study (DIAS), University of Southern Denmark, Denmark
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Indira Chandran V, Wernberg CW, Lauridsen MM, Skytthe MK, Bendixen SM, Larsen FT, Hansen CD, Grønkjær LL, Siersbæk MS, Caterino TD, Detlefsen S, Møller HJ, Grøntved L, Ravnskjaer K, Moestrup SK, Thiele MS, Krag A, Graversen JH. Circulating TREM2 as a noninvasive diagnostic biomarker for NASH in patients with elevated liver stiffness. Hepatology 2023; 77:558-572. [PMID: 35712786 PMCID: PMC9869959 DOI: 10.1002/hep.32620] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [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: 01/18/2022] [Revised: 05/24/2022] [Accepted: 06/12/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND AIMS Reliable noninvasive biomarkers are an unmet clinical need for the diagnosis of NASH. This study investigates the diagnostic accuracy of the circulating triggering receptor expressed on myeloid cells 2 (plasma TREM2) as a biomarker for NASH in patients with NAFLD and elevated liver stiffness. APPROACH AND RESULTS We collected cross-sectional, clinical data including liver biopsies from a derivation ( n = 48) and a validation cohort ( n = 170) of patients with elevated liver stiffness measurement (LSM ≥ 8.0 kPa). Patients with NAFLD activity scores (NAS) ≥4 were defined as having NASH. Plasma TREM2 levels were significantly elevated in patients with NASH of the derivation cohort, with an area under the receiver operating characteristics curve (AUROC) of 0.92 (95% confidence interval [CI], 0.84-0.99). In the validation cohort, plasma TREM2 level increased approximately two-fold in patients with NASH, and a strong diagnostic accuracy was confirmed (AUROC, 0.83; 95% CI, 0.77-0.89; p < 0.0001). Plasma TREM2 levels were associated with the individual histologic features of NAS: steatosis, lobular inflammation, and ballooning ( p < 0.0001), but only weakly with fibrosis stages. Dual cutoffs for rule-in and rule-out were explored: a plasma TREM2 level of ≤38 ng/ml was found to be an optimal NASH rule-out cutoff (sensitivity 90%; specificity 52%), whereas a plasma TREM2 level of ≥65 ng/ml was an optimal NASH rule-in cutoff (specificity 89%; sensitivity 54%). CONCLUSIONS Plasma TREM2 is a plausible individual biomarker that can rule-in or rule-out the presence of NASH with high accuracy and thus has the potential to reduce the need for liver biopsies and to identify patients who are eligible for clinical trials in NASH.
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Affiliation(s)
| | - Charlotte Wilhelmina Wernberg
- Liver Research Group, Department of Gastroenterology and Hepatology, University Hospital of South Denmark, Esbjerg, Denmark,Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Mette Munk Lauridsen
- Liver Research Group, Department of Gastroenterology and Hepatology, University Hospital of South Denmark, Esbjerg, Denmark
| | | | | | - Frederik Tibert Larsen
- Department of Biochemistry and Molecular Biology, University of Southern Denmark, Odense, Denmark
| | - Camilla Dalby Hansen
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Lea Ladegaard Grønkjær
- Liver Research Group, Department of Gastroenterology and Hepatology, University Hospital of South Denmark, Esbjerg, Denmark
| | - Majken Storm Siersbæk
- Department of Biochemistry and Molecular Biology, University of Southern Denmark, Odense, Denmark
| | - Tina Di Caterino
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Sönke Detlefsen
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Holger Jon Møller
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lars Grøntved
- Department of Biochemistry and Molecular Biology, University of Southern Denmark, Odense, Denmark
| | - Kim Ravnskjaer
- Department of Biochemistry and Molecular Biology, University of Southern Denmark, Odense, Denmark
| | - Søren Kragh Moestrup
- Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Maja Sofie Thiele
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Aleksander Krag
- Centre for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
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10
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Kjaergaard M, Lindvig KP, Hansen CD, Detlefsen S, Krag A, Thiele M. Hepatorenal Index by B-Mode Ratio Versus Imaging and Fatty Liver Index to Diagnose Steatosis in Alcohol-Related and Nonalcoholic Fatty Liver Disease. J Ultrasound Med 2023; 42:487-496. [PMID: 35475550 PMCID: PMC10084348 DOI: 10.1002/jum.15991] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 03/26/2022] [Accepted: 03/28/2022] [Indexed: 05/12/2023]
Abstract
OBJECTIVES We aimed to evaluate the accuracy of the hepatorenal index by B-mode ratio to diagnose hepatic steatosis, compared to ultrasound steatosis score, controlled attenuation parameter, and the fatty liver index using histology as the gold standard. METHODS We prospectively included participants with alcohol-related or nonalcoholic fatty liver disease for same-day noninvasive investigations and liver biopsy. RESULTS We included 137 participants, 72% male, median age 60 years (53-65) and body mass index 32 kg/m2 (28-38). Eighty percent had steatosis (S0/S1/S2/S3 = 20/37/24/19%). B-mode ratio had moderate diagnostic accuracy for any steatosis (≥S1, area under the receiver operating characteristics curve [AUROC] = 0.79; 95% confidence interval 0.70-0.88), significant steatosis (≥S2, AUROC = 0.76; 0.66-0.85), and severe steatosis (=S3, AUROC = 0.74; 0.62-0.86), independent of disease etiology. The cutoff values to rule-out and rule-in any steatosis were 1.09 and 1.45. While B-mode ratio and controlled attenuation parameter correlated poorly, their diagnostic accuracies were comparable to each other and to ultrasound steatosis scoring. Fatty liver index did not differ from B-mode ratio in detecting any steatosis but had poor accuracy to detect higher steatosis grades. B-mode ratio measurements failed in 12% of patients, compared to 1% for ultrasound steatosis scoring and 2% for controlled attenuation parameter. CONCLUSION The hepatorenal index by B-mode ratio diagnose steatosis with moderate accuracy in patients with alcohol-related or nonalcoholic fatty liver disease, comparable to B-mode ultrasound steatosis scoring and controlled attenuation parameter. However, its clinical use is limited by a high failure rate.
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Affiliation(s)
- Maria Kjaergaard
- Department of Gastroenterology and HepatologyOdense University HospitalOdenseDenmark
- Institute of Clinical Research, University of Southern DenmarkOdenseDenmark
| | - Katrine Prier Lindvig
- Department of Gastroenterology and HepatologyOdense University HospitalOdenseDenmark
- Institute of Clinical Research, University of Southern DenmarkOdenseDenmark
| | - Camilla Dalby Hansen
- Department of Gastroenterology and HepatologyOdense University HospitalOdenseDenmark
- Institute of Clinical Research, University of Southern DenmarkOdenseDenmark
| | - Sönke Detlefsen
- Institute of Clinical Research, University of Southern DenmarkOdenseDenmark
- Department of PathologyOdense University HospitalOdenseDenmark
| | - Aleksander Krag
- Department of Gastroenterology and HepatologyOdense University HospitalOdenseDenmark
- Institute of Clinical Research, University of Southern DenmarkOdenseDenmark
| | - Maja Thiele
- Department of Gastroenterology and HepatologyOdense University HospitalOdenseDenmark
- Institute of Clinical Research, University of Southern DenmarkOdenseDenmark
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Hansen CD, Gram-Kampmann EM, Hansen JK, Hugger MB, Madsen BS, Jensen JM, Olesen S, Torp N, Rasmussen DN, Kjærgaard M, Johansen S, Lindvig KP, Andersen P, Thorhauge KH, Brønd JC, Hermann P, Beck-Nielsen H, Detlefsen S, Hansen T, Højlund K, Thiele MS, Israelsen M, Krag A. Effect of Calorie-Unrestricted Low-Carbohydrate, High-Fat Diet Versus High-Carbohydrate, Low-Fat Diet on Type 2 Diabetes and Nonalcoholic Fatty Liver Disease : A Randomized Controlled Trial. Ann Intern Med 2023; 176:10-21. [PMID: 36508737 DOI: 10.7326/m22-1787] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [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] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND It remains unclear if a low-carbohydrate, high-fat (LCHF) diet is a possible treatment strategy for type 2 diabetes mellitus (T2DM), and the effect on nonalcoholic fatty liver disease (NAFLD) has not been investigated. OBJECTIVE To investigate the effect of a calorie-unrestricted LCHF diet, with no intention of weight loss, on T2DM and NAFLD compared with a high-carbohydrate, low-fat (HCLF) diet. DESIGN 6-month randomized controlled trial with a 3-month follow-up. (ClinicalTrials.gov: NCT03068078). SETTING Odense University Hospital in Denmark from November 2016 until June 2020. PARTICIPANTS 165 participants with T2DM. INTERVENTION Two calorie-unrestricted diets: LCHF diet with 50 to 60 energy percent (E%) fat, less than 20E% carbohydrates, and 25E% to 30E% proteins and HCLF diet with 50E% to 60E% carbohydrates, 20E% to 30E% fats, and 20E% to 25E% proteins. MEASUREMENTS Glycemic control, serum lipid levels, metabolic markers, and liver biopsies to assess NAFLD. RESULTS The mean age was 56 years (SD, 10), and 58% were women. Compared with the HCLF diet, participants on the LCHF diet had greater improvements in hemoglobin A1c (mean difference in change, -6.1 mmol/mol [95% CI, -9.2 to -3.0 mmol/mol] or -0.59% [CI, -0.87% to -0.30%]) and lost more weight (mean difference in change, -3.8 kg [CI, -6.2 to -1.4 kg]). Both groups had higher high-density lipoprotein cholesterol and lower triglycerides at 6 months. Changes in low-density lipoprotein cholesterol were less favorable in the LCHF diet group than in the HCLF diet group (mean difference in change, 0.37 mmol/L [CI, 0.17 to 0.58 mmol/L] or 14.3 mg/dL [CI, 6.6 to 22.4 mg/dL]). No statistically significant between-group changes were detected in the assessment of NAFLD. Changes were not sustained at the 9-month follow-up. LIMITATION Open-label trial, self-reported adherence, unintended weight loss, and lack of adjustment for multiple comparisons. CONCLUSION Persons with T2DM on a 6-month, calorie-unrestricted, LCHF diet had greater clinically meaningful improvements in glycemic control and weight compared with those on an HCLF diet, but the changes were not sustained 3 months after intervention. PRIMARY FUNDING SOURCE Novo Nordisk Foundation.
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Affiliation(s)
- Camilla Dalby Hansen
- Department of Gastroenterology and Hepatology, Odense University Hospital, and Institute of Clinical Research, University of Southern Denmark, Odense, Denmark (C.D.H., M.B.H., N.T., M.K., S.J., K.H.T., M.S.T.)
| | - Eva-Marie Gram-Kampmann
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark (E.M.G., H.B., K.H.)
| | - Johanne Kragh Hansen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark (J.K.H., B.S.M., J.M.J., S.O., D.N.R., P.A., M.I.)
| | - Mie Balle Hugger
- Department of Gastroenterology and Hepatology, Odense University Hospital, and Institute of Clinical Research, University of Southern Denmark, Odense, Denmark (C.D.H., M.B.H., N.T., M.K., S.J., K.H.T., M.S.T.)
| | - Bjørn Stæhr Madsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark (J.K.H., B.S.M., J.M.J., S.O., D.N.R., P.A., M.I.)
| | - Jane Møller Jensen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark (J.K.H., B.S.M., J.M.J., S.O., D.N.R., P.A., M.I.)
| | - Sara Olesen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark (J.K.H., B.S.M., J.M.J., S.O., D.N.R., P.A., M.I.)
| | - Nikolaj Torp
- Department of Gastroenterology and Hepatology, Odense University Hospital, and Institute of Clinical Research, University of Southern Denmark, Odense, Denmark (C.D.H., M.B.H., N.T., M.K., S.J., K.H.T., M.S.T.)
| | - Ditlev Nytoft Rasmussen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark (J.K.H., B.S.M., J.M.J., S.O., D.N.R., P.A., M.I.)
| | - Maria Kjærgaard
- Department of Gastroenterology and Hepatology, Odense University Hospital, and Institute of Clinical Research, University of Southern Denmark, Odense, Denmark (C.D.H., M.B.H., N.T., M.K., S.J., K.H.T., M.S.T.)
| | - Stine Johansen
- Department of Gastroenterology and Hepatology, Odense University Hospital, and Institute of Clinical Research, University of Southern Denmark, Odense, Denmark (C.D.H., M.B.H., N.T., M.K., S.J., K.H.T., M.S.T.)
| | - Katrine Prier Lindvig
- Department of Gastroenterology and Hepatology, Odense University Hospital, and Institute of Clinical Research, University of Southern Denmark, Odense SV, Denmark (K.P.L.)
| | - Peter Andersen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark (J.K.H., B.S.M., J.M.J., S.O., D.N.R., P.A., M.I.)
| | - Katrine Holtz Thorhauge
- Department of Gastroenterology and Hepatology, Odense University Hospital, and Institute of Clinical Research, University of Southern Denmark, Odense, Denmark (C.D.H., M.B.H., N.T., M.K., S.J., K.H.T., M.S.T.)
| | - Jan Christian Brønd
- Department of Sport Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark (J.C.B.)
| | - Pernille Hermann
- Department of Medical Endocrinology, Odense University Hospital, Odense, Denmark (P.H.)
| | - Henning Beck-Nielsen
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark (E.M.G., H.B., K.H.)
| | - Sönke Detlefsen
- Institute of Clinical Research, University of Southern Denmark, and Department of Pathology, Odense University Hospital, Odense, Denmark (S.D.)
| | - Torben Hansen
- Novo Nordisk Foundation, Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark (T.H.)
| | - Kurt Højlund
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark (E.M.G., H.B., K.H.)
| | - Maja Sofie Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, and Institute of Clinical Research, University of Southern Denmark, Odense, Denmark (C.D.H., M.B.H., N.T., M.K., S.J., K.H.T., M.S.T.)
| | - Mads Israelsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark (J.K.H., B.S.M., J.M.J., S.O., D.N.R., P.A., M.I.)
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, and Institute of Clinical Research, University of Southern Denmark, Odense C, Denmark (A.K.)
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12
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Hansen CD, Lindvig KP, Grønbæk H, Gluud LL, Thiele M, Krag A. [Not Available]. Ugeskr Laeger 2022; 184:V04220239. [PMID: 36305262] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is the most frequent liver disease in the world, affecting 25% of the population. Around 6% of people with NAFLD will be at risk of developing advanced fibrosis, but symptoms often first occur very late from a decompensated cirrhosis. We need better referral pathways to identify and treat patients with advanced fibrosis. Non-invasive tests such as FIB-4 and NFS can be used in primary care to identify patients who will benefit from a referral to secondary care.
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Affiliation(s)
- Camilla Dalby Hansen
- Center for Leverforskning, Afdeling for Medicinske Mavetarmsygdomme, Odense Universitetshospital
- Klinisk Institut, Det Sundhedsvidenskabelige Fakultet, Syddansk Universitet
| | - Katrine Prier Lindvig
- Center for Leverforskning, Afdeling for Medicinske Mavetarmsygdomme, Odense Universitetshospital
- Klinisk Institut, Det Sundhedsvidenskabelige Fakultet, Syddansk Universitet
| | - Henning Grønbæk
- Lever-, Mave- og Tarmsygdomme, Aarhus Universitetshospital
- Institut for Klinisk Medicin, Health, Aarhus Universitet
| | - Lise Lotte Gluud
- Gastroenheden, Københavns Universitetshospital - Hvidovre Hospital
- Institut for Klinisk Medicin, Det Sundhedsvidenskabelige Fakultet, Københavns Universitet
| | - Maja Thiele
- Center for Leverforskning, Afdeling for Medicinske Mavetarmsygdomme, Odense Universitetshospital
- Klinisk Institut, Det Sundhedsvidenskabelige Fakultet, Syddansk Universitet
| | - Aleksander Krag
- Center for Leverforskning, Afdeling for Medicinske Mavetarmsygdomme, Odense Universitetshospital
- Klinisk Institut, Det Sundhedsvidenskabelige Fakultet, Syddansk Universitet
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Israelsen M, Kim M, Suvitaival T, Madsen BS, Hansen CD, Torp N, Trost K, Thiele M, Hansen T, Legido-Quigley C, Krag A. Comprehensive lipidomics reveals phenotypic differences in hepatic lipid turnover in ALD and NAFLD during alcohol intoxication. JHEP Rep 2021; 3:100325. [PMID: 34401690 PMCID: PMC8350545 DOI: 10.1016/j.jhepr.2021.100325] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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: 03/12/2021] [Revised: 05/26/2021] [Accepted: 06/16/2021] [Indexed: 12/17/2022] Open
Abstract
Background & Aims In experimental models, alcohol induces acute changes in lipid metabolism that cause hepatocyte lipoapoptosis and inflammation. Here we study human hepatic lipid turnover during controlled alcohol intoxication. Methods We studied 39 participants with 3 distinct hepatic phenotypes: alcohol-related liver disease (ALD), non-alcoholic fatty liver disease (NAFLD), and healthy controls. Alcohol was administrated via nasogastric tube over 30 min. Hepatic and systemic venous blood was sampled simultaneously at 3 time points: baseline, 60, and 180 min after alcohol intervention. Liver biopsies were sampled 240 min after alcohol intervention. We used ultra-high performance liquid chromatography mass spectrometry to measure levels of more than 250 lipid species from the blood and liver samples. Results After alcohol intervention, the levels of blood free fatty acid (FFA) and lysophosphatidylcholine (LPC) decreased, while triglyceride (TG) increased. FFA was the only lipid class to decrease in NAFLD after alcohol intervention, whereas LPC and FFA decreased and TG increased after intervention in ALD and healthy controls. Fatty acid chain uptake preference in FFAs and LPCs were oleic acid, linoleic acid, arachidonic acid, and docosahexaenoic acid. Hepatic venous blood FFA and LPC levels were lower when compared with systemic venous blood levels throughout the intervention. After alcohol intoxication, liver lipidome in ALD was similar to that in NAFLD. Conclusions Alcohol intoxication induces rapid changes in circulating lipids including hepatic turnaround from FFA and LPC, potentially leading to lipoapoptosis and steatohepatitis. TG clearance was suppressed in NAFLD, possibly explaining why alcohol and NAFLD are synergistic risk factors for disease progression. These effects may be central to the pathogenesis of ALD. Clinical Trials Registration The study is registered at Clinicaltrials.gov (NCT03018990). Lay summary We report that alcohol induces hepatic extraction of free unsaturated fatty acids and lysophosphatidylcholines, hepatotoxic lipids which have not been previously associated with alcohol-induced liver injury. We also found that individuals with non-alcoholic fatty liver disease have reduced lipid turnover during alcohol intoxication when compared with people with alcohol-related fatty liver disease. This may explain why alcohol is particularly more harmful in people with non-alcoholic fatty liver and why elevated BMI and alcohol have a synergistic effect on the risk of liver-related death. Alcohol intoxication induces rapid changes in the profile of circulating lipids. Alcohol has a profound effect on monosaturated fatty acids. Triglyceride clearance is suppressed in NAFLD during alcohol intoxication. Hepatic lipid turnover differentiates ALD and NAFLD during alcohol intoxication. A suppressed metabolic response may explain why alcohol is particularly harmful in NAFLD.
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Key Words
- ALD, alcohol-related liver disease
- ALT, alanine aminotransferase
- AST, asparagine aminotransferase
- Alcohol
- CTL, healthy control
- Cer, ceramide
- DG, diglyceride
- Ethanol
- FFA, free fatty acid
- Fatty acids
- GGT, gamma-glutamyl transferase
- HOMA-IR, Homeostatic Model Assessment of Insulin Resistance
- Heavy drinking
- HexCer, hexosylceramide
- LPC, lysophosphatidylcholine
- LPE, lysophosphatidylethanolamine
- LacCer, lactosylceramides
- Lipidomics
- Liver disease
- Lysophosphatidylcholines
- NAFLD, non-alcoholic fatty liver disease
- P-glucose, plasma glucose
- PC, phosphatidylcholine
- PE, phosphatidylethanolamine
- PI, phosphatidylinositol
- PLA2, phospholipase A2
- QC, quality control
- SHexCer, sulfatides hexosylceramide
- SM, sphingomyelin
- TE, transient elastography
- TG, triglyceride
- Triglycerides
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Affiliation(s)
- Mads Israelsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
- OPEN Open Patient data Explorative Network, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Min Kim
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | | | - Bjørn Stæhr Madsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Camilla Dalby Hansen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Nikolaj Torp
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Kajetan Trost
- Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
| | - Torben Hansen
- Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | | | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense C, Denmark
- Corresponding author. Address: Odense Liver Research Centre, Department of Gastroenterology and Hepatology, Odense University Hospital, 5000 Odense C, Denmark
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14
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Samuelov L, Sarig O, Adir N, Pavlovsky M, Smith FJ, Schwartz J, Hansen CD, Sprecher E. Identification of clinically useful predictive genetic variants in pachyonychia congenita. Clin Exp Dermatol 2021; 46:867-873. [PMID: 33486795 DOI: 10.1111/ced.14569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/19/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Pachyonychia congenita (PC) refers to a group of autosomal dominant disorders caused by mutations in five keratin genes (KRT16,KRT6A,KRT17,KRT6B or KRT6C). Current disease classification is based on the gene harbouring disease-causing variants. AIMS We harnessed the International Pachyonychia Congenita Research Registry (IPCRR) containing both clinical and molecular data on patients with PC worldwide, to identify genetic variants predicting disease severity. METHODS We ascertained 815 individuals harbouring keratin mutations registered in the IPCRR. We looked for statistically significant associations between genetic variants and clinical manifestations in a subgroup of patients carrying mutations found in at least 10% of the cohort. Data were analysed using χ2 and Kruskal-Wallis tests. RESULTS We identified five mutations occurring in at least 10% of the patients registered in the IPCRR. The KRT16 p.L132P mutation was significantly associated with younger age of onset, presence of palmar keratoderma oral leucokeratosis and a higher number of involved nails. By contrast, the KRT16 p.N125S and p.R127C mutations resulted in a milder phenotype featuring a decreased number of involved nails and older age of onset. Patients carrying the p.N125S mutation were less likely to develop palmar keratoderma while p.R127C was associated with an older age of palmoplantar keratoderma onset. Moreover, the KRT17 p.L99P mutation resulted in an increased number of involved fingernails and patients demonstrating 20-nail dystrophy, while the opposite findings were observed with KRT17 p.N92S mutation. CONCLUSIONS We have identified novel and clinically useful genetic predictive variants in the largest cohort of patients with PC described to date.
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Affiliation(s)
- L Samuelov
- Division of Dermatology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - O Sarig
- Division of Dermatology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - N Adir
- Schulich Faculty of Chemistry, Technion-Israel Institute of Technology, Haifa, Israel
| | - M Pavlovsky
- Division of Dermatology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - F J Smith
- Pachyonychia Congenita Project, Holladay, UT, USA
| | - J Schwartz
- Pachyonychia Congenita Project, Holladay, UT, USA
| | - C D Hansen
- Pachyonychia Congenita Project, Holladay, UT, USA.,Department of Dermatology, University of Utah, Salt Lake City, UT, USA
| | - E Sprecher
- Division of Dermatology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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15
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Mathews J, Hansen CD, Chandrashekar L. Homozygous dominant missense mutation in Keratin 6b leading to severe pachyonychia congenita. Clin Exp Dermatol 2020; 46:410-412. [PMID: 33301203 DOI: 10.1111/ced.14494] [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] [Received: 01/21/2020] [Revised: 08/29/2020] [Accepted: 09/26/2020] [Indexed: 11/29/2022]
Affiliation(s)
- J Mathews
- Department of Dermatology, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Pondicherry, India
| | - C D Hansen
- Department of Dermatology, University of Utah College of Medicine, Salt Lake City, Utah, USA
| | - L Chandrashekar
- Department of Dermatology, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER), Pondicherry, India
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16
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Goldberg I, Mashiah J, Kutz A, Derowe A, Warshauer E, Schwartz ME, Smith F, Sprecher E, Hansen CD. Symptomatic mucosal involvement in pachyonychia congenita: challenges in infants and young children. Br J Dermatol 2019; 182:708-713. [PMID: 31777952 DOI: 10.1111/bjd.18742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pachyonychia congenita (PC) is a rare autosomal dominant genodermatosis caused by a mutation in any one of five keratin genes (KRT6A, KRT6B, KRT6C, KRT16 or KRT17). Characteristic features of PC are painful palmoplantar keratoderma, variable nail dystrophy, cysts, follicular hyperkeratosis and often oral leukokeratosis. Although oral leukokeratosis can go unnoticed, mucosal involvement of the oral cavity and upper airways can manifest with pain during feeding, hoarseness, stridor and, occasionally, life-threatening obstruction. OBJECTIVES To characterize patients with PC with symptomatic mucosal involvement. METHODS We present a case series of nine children with PC with symptomatic mucosal involvement, all with heterozygous mutations in KRT6A. Seven patients complained of painful feeding problems. Four patients were diagnosed with failure to thrive, three of whom required a feeding tube. Simple feeding solutions were beneficial in most cases. Seven patients had laryngeal involvement and one patient died at 4 years of age from acute laryngeal obstruction. CONCLUSIONS It is important for dermatologists and otolaryngologists to be aware that symptomatic mucosal involvement, and very rarely laryngeal obstruction, can occur in patients with PC. Usually simple feeding solutions may prevent complications and failure to thrive. What's already known about this topic? Pachyonychia congenita (PC) is a rare autosomal dominant genodermatosis due to a mutation in any one of five keratin genes. Symptomatic mucosal involvement is an important clinical feature of PC and appears to be more pronounced in KRT6A mutation carriers. Only leukokeratosis is frequently seen in PC and can be one of the earliest signs of disease. Laryngeal involvement is a less common feature. It might be symptomatic but usually presents as hoarseness, stridor and, occasionally, as a life-threatening respiratory distress. What does this study add? In most cases of laryngeal involvement, there is no need for any intervention. Although pain and feeding difficulties are usually attributed to the oral leukokeratosis, they can be related to a phenomenon called 'first bite syndrome' (FBS). Symptomatic mucosal involvement with feeding difficulty is important but can be managed in most cases with simple feeding solutions (e.g. softer nipple with a larger hole, thicker formula and feeding with a syringe). Linked Comment: Youssefian and Vahidnezhad. Br J Dermatol 2020; 182:536-537.
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Affiliation(s)
- I Goldberg
- Department ofDermatology, Tel Aviv University, Tel Aviv, Israel
| | - J Mashiah
- Department ofDermatology, Tel Aviv University, Tel Aviv, Israel
| | - A Kutz
- Department ofDermatology, Tel Aviv University, Tel Aviv, Israel
| | - A Derowe
- Department ofOtolaryngology, Head and Neck and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, affiliated to Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E Warshauer
- Pachyonychia Congenita Project, Holladay, UT, U.S.A
| | - M E Schwartz
- Pachyonychia Congenita Project, Holladay, UT, U.S.A
| | - F Smith
- Pachyonychia Congenita Project, Holladay, UT, U.S.A
| | - E Sprecher
- Department ofDermatology, Tel Aviv University, Tel Aviv, Israel
| | - C D Hansen
- Department of Dermatology, University of Utah, UT, U.S.A
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17
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Hugger MB, Israelsen M, Hansen CD, Krag A. [Statins are safe in patients with liver diseases and may have a beneficial effect]. Ugeskr Laeger 2019; 181:V11180794. [PMID: 31280763] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The Danish Medicines Agency recommends routine controls of liver enzymes in patients, who are treated with statins in order to prevent liver injury. In this review, much evidence showing that severe drug-induced hepatic injury is very rarely associated with statins is presented. No data support, that routine control of blood liver enzymes will improve prevention or detection of statin-induced liver injury. Furthermore, recent studies show, that statins are safe and may even have beneficial effects in chronic liver disease. In future revision of the Danish Medicines Agency recommendations, these new findings should be taken into consideration.
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18
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Abstract
Abstract
Background
Denmark and Sweden are in many respects two very similar countries with similar welfare state systems and work environment authorities. Nevertheless, marked differences in the incidence of fatal occupational accidents have been found in earlier comparisons of the two countries.
Aims
To investigate differences in the incidence of fatal occupational accidents in the period from 1993 to 2012 to establish to what extent characteristics of the deceased can explain some of the difference between the two countries.
Methods
Analyses of the accident registers of the two countries’ national work environment authorities with supplemental linkages to official registers on employment status are used to determine the incidence of fatal occupational accidents for different groups. The analysis is based on 2375 accidents (1068 in Denmark and 1307 in Sweden) over the period of 20 years. Poisson regression is used to derive incidence rates over time for specific groups.
Results
In the study period, the incidence of fatal occupational accidents decreased in both countries (incidence rate ratio [IRR]: 0.95), although the incidence was on average higher in Denmark (IRR: 1.20) and grew larger over time. This difference did not disappear after adjusting for age, sex and industry among the deceased (IRR: 1.12).
Conclusions
The incidence of fatal occupational accidents was slightly higher in Denmark in the entire period. The difference could not be explained completely by sociodemographic differences or differences related to the labour market structure in the two countries, i.e. other factors (e.g. cultural) may play a role in producing the difference.
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Affiliation(s)
- C D Hansen
- Department of Sociology and Social Work, Aalborg University, DK Aalborg Ø, Denmark
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19
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Kasparis C, Reid D, Wilson NJ, Okur V, Cole C, Hansen CD, Bosse K, Betz RC, Khan M, Smith FJD. Isolated recessive nail dysplasia caused by FZD6 mutations: report of three families and review of the literature. Clin Exp Dermatol 2016; 41:884-889. [PMID: 27786367 PMCID: PMC5132090 DOI: 10.1111/ced.12934] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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] [Accepted: 02/24/2016] [Indexed: 12/16/2022]
Abstract
Congenital abnormalities of the nail are rare conditions that are most frequently associated with congenital ectodermal syndromes involving several of the epidermal appendages including the skin, teeth, hair and nails. Isolated recessive nail dysplasia (IRND) is much rarer but has recently been recognized as a condition resulting in 20‐nail dystrophy in the absence of other cutaneous or extracutaneous findings. A few case reports have identified mutations in the Frizzled 6 (FZD6) gene in families presenting with abnormal nails consistent with IRND. These reports have highlighted the role of Wnt–FZD signalling in the process of nail formation. We report three families presenting with features of IRND, in whom we identified mutations in FZD6, including one previously unreported mutation.
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Affiliation(s)
- C Kasparis
- Dermatology Department, Walsall Healthcare NHS Trust, Walsall, UK
| | - D Reid
- Dermatology Department, Walsall Healthcare NHS Trust, Walsall, UK
| | - N J Wilson
- Centre for Dermatology and Genetic Medicine, Division of Biological Chemistry and Drug Discovery, School of Life Sciences, University of Dundee, Dundee, UK
| | - V Okur
- Department of Medical Genetics, Haydarpasa Numune Hospital, Istanbul, Turkey.,Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - C Cole
- Centre for Dermatology and Genetic Medicine, Division of Biological Chemistry and Drug Discovery, School of Life Sciences, University of Dundee, Dundee, UK.,Division of Computational Biology, School of Life Sciences, University of Dundee, Dundee, UK
| | - C D Hansen
- Department of Dermatology, University of Utah, Salt Lake City, UT, USA
| | - K Bosse
- Institute of Human Genetics, University of Bonn, Bonn, Germany.,Institute of Medical Genetics and Applied Genomics and Department of Obstetrics and Gynecology, University Hospital of Tübingen, Tübingen, Germany
| | - R C Betz
- Institute of Human Genetics, University of Bonn, Bonn, Germany
| | - M Khan
- Dermatology Department, Walsall Healthcare NHS Trust, Walsall, UK
| | - F J D Smith
- Centre for Dermatology and Genetic Medicine, Division of Biological Chemistry and Drug Discovery, School of Life Sciences, University of Dundee, Dundee, UK.,Pachyonychia Congenita Project, Salt Lake City, UT, USA
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Lund T, Hansen CD, Andersen JH, Labriola M. Mental health in childhood as risk indicator of labour market participation in young adulthood. Eur J Public Health 2015. [DOI: 10.1093/eurpub/ckv168.055] [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: 11/13/2022] Open
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Wilson NJ, O'Toole EA, Milstone LM, Hansen CD, Shepherd AA, Al-Asadi E, Schwartz ME, McLean WHI, Sprecher E, Smith FJD. The molecular genetic analysis of the expanding pachyonychia congenita case collection. Br J Dermatol 2014; 171:343-55. [PMID: 24611874 PMCID: PMC4282083 DOI: 10.1111/bjd.12958] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [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] [Accepted: 03/04/2014] [Indexed: 01/07/2023]
Abstract
BACKGROUND Pachyonychia congenita (PC) is a rare autosomal dominant keratinizing disorder characterized by severe, painful, palmoplantar keratoderma and nail dystrophy, often accompanied by oral leucokeratosis, cysts and follicular keratosis. It is caused by mutations in one of five keratin genes: KRT6A, KRT6B, KRT6C, KRT16 or KRT17. OBJECTIVES To identify mutations in 84 new families with a clinical diagnosis of PC, recruited by the International Pachyonychia Congenita Research Registry during the last few years. METHODS Genomic DNA isolated from saliva or peripheral blood leucocytes was amplified using primers specific for the PC-associated keratin genes and polymerase chain reaction products were directly sequenced. RESULTS Mutations were identified in 84 families in the PC-associated keratin genes, comprising 46 distinct keratin mutations. Fourteen were previously unreported mutations, bringing the total number of different keratin mutations associated with PC to 105. CONCLUSIONS By identifying mutations in KRT6A, KRT6B, KRT6C, KRT16 or KRT17, this study has confirmed, at the molecular level, the clinical diagnosis of PC in these families.
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Affiliation(s)
- N J Wilson
- Centre for Dermatology and Genetic Medicine, Colleges of Life Sciences and Medicine, Dentistry & Nursing, University of Dundee, Dundee, DD1 5EH, U.K
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Lund T, Hviid Andersen J, Hansen CD, Nøhr Winding T, Biering K, Labriola M. Childhood adversities as predictors of labour market participation in young adulthood. A prospective birth cohort study. Eur J Public Health 2013. [DOI: 10.1093/eurpub/ckt123.134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Hansen CD. Objectively measured work load, health status and sickness absence among Danish ambulance personnel. A longitudinal study. Eur J Public Health 2013. [DOI: 10.1093/eurpub/ckt126.329] [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: 11/13/2022] Open
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Harris K, Hull PR, Hansen CD, Smith FJD, McLean WHI, Arbiser JL, Leachman SA. Transgrediens pachyonychia congenita (PC): case series of a nonclassical PC presentation. Br J Dermatol 2012; 166:124-8. [PMID: 21790523 DOI: 10.1111/j.1365-2133.2011.10537.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Pachyonychia congenita (PC) is a rare keratin disorder that typically presents with nail dystrophy and focal plantar keratoderma. We present seven cases of PC with transgrediens involvement of the dorsal feet. OBJECTIVES To document the extension of their disease to the dorsum of the feet in patients with mutation-confirmed PC, to report the natural history of PC with such transgrediens involvement, to generate hypotheses regarding aetiology, and to suggest prevention and treatment modalities. METHODS Genetically confirmed cases of PC with transgrediens foot involvement were verified through the International Pachyonychia Congenita Research Registry (IPCRR) and characterized via telephone survey and photography. RESULTS Seven patients with PC in the IPCRR were confirmed to have transgrediens lesions on the dorsal feet (six KRT6A mutations; one KRT16 mutation). Six cases had pre-existing nontransgrediens keratoderma and all cases reported standing, wearing shoes, foot moisture, and/or infection as exacerbating or predisposing factors. Improvement, reported in six cases, was attributed to use of antibiotics or gentian violet, or improved footwear. CONCLUSIONS Transgrediens involvement of the dorsal feet is a rare manifestation of mutation-confirmed PC and may be more common in patients who carry a KRT6A mutation. Trauma, friction, infection and wound healing may exacerbate or predispose toward transgrediens lesions. It remains to be proven whether transgrediens-associated infection is causal or represents a primary or secondary process. Patients with PC who develop transgrediens lesions may benefit from fungal and bacterial cultures, followed by appropriate antimicrobial treatments. Efforts to decrease skin friction and moisture may also improve and/or prevent transgrediens spread.
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Affiliation(s)
- K Harris
- Department of Dermatology, University of Utah, Huntsman Cancer Institute, 2000 Circle of Hope, Rm 5242, Salt Lake City, UT 84112, USA
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Brownlee C, Pegoraro V, Shankar S, McCormick PS, Hansen CD. Physically-Based Interactive Flow Visualization Based on Schlieren and Interferometry Experimental Techniques. IEEE Trans Vis Comput Graph 2011; 17:1574-1586. [PMID: 21149891 DOI: 10.1109/tvcg.2010.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Understanding fluid flow is a difficult problem and of increasing importance as computational fluid dynamics (CFD) produces an abundance of simulation data. Experimental flow analysis has employed techniques such as shadowgraph, interferometry, and schlieren imaging for centuries, which allow empirical observation of inhomogeneous flows. Shadowgraphs provide an intuitive way of looking at small changes in flow dynamics through caustic effects while schlieren cutoffs introduce an intensity gradation for observing large scale directional changes in the flow. Interferometry tracks changes in phase-shift resulting in bands appearing. The combination of these shading effects provides an informative global analysis of overall fluid flow. Computational solutions for these methods have proven too complex until recently due to the fundamental physical interaction of light refracting through the flow field. In this paper, we introduce a novel method to simulate the refraction of light to generate synthetic shadowgraph, schlieren and interferometry images of time-varying scalar fields derived from computational fluid dynamics data. Our method computes physically accurate schlieren and shadowgraph images at interactive rates by utilizing a combination of GPGPU programming, acceleration methods, and data-dependent probabilistic schlieren cutoffs. Applications of our method to multifield data and custom application-dependent color filter creation are explored. Results comparing this method to previous schlieren approximations are finally presented.
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Abstract
BACKGROUND Little is known about the long-term consequences of sickness presence (ie, going to work despite ill-health), although one study suggests an association with coronary heart disease. This study examined the effect of sickness presence on future long-term sickness absence. METHODS Information from a random sample of 11 838 members of the Danish core workforce was collected from questionnaires, containing questions about work, family and attitudes towards sickness absence. Information on prospective sickness absence spells of at least 2 weeks was derived from an official register during a follow-up period of 1.5 years. RESULTS Sickness presence is associated with long-term sickness absence of at least 2 weeks' duration as well as with spells lasting at least 2 months. Participants who had gone to work ill more than six times in the year prior to baseline had a 74% higher risk of becoming sick-listed for more than 2 months, even when controlling for a wide range of potential confounders as well as baseline health status and previous long-term sickness absence. The association was consistent for most subgroups of employees reporting various symptoms, but either disappeared or became insignificant when analysing subgroups of employees with specific chronic diseases. CONCLUSIONS Going to work ill repeatedly is associated with long-term sickness absence at a later date. For this reason, researchers and policy-makers should consider this phenomenon more carefully when planning future studies of sickness absence or when laying out new policies.
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Affiliation(s)
- C D Hansen
- Department of Occupational Medicine, Herning Hospital, Herning, Denmark.
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Affiliation(s)
- J B Smith
- Emergency Department, USAF Hospital Hill, Hill AFB, Utah
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