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Senanayake S, Barnett A, Brain D, Allen M, Powell EE, O'Beirne J, Valery P, Hickman IJ, Kularatna S. A discrete choice experiment to elicit preferences for a chronic disease screening programme in Queensland, Australia. Public Health 2024; 228:105-111. [PMID: 38354579 DOI: 10.1016/j.puhe.2024.01.007] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 12/25/2023] [Accepted: 01/09/2024] [Indexed: 02/16/2024]
Abstract
OBJECTIVE Patient-centred care, increasingly highlighted in healthcare strategies, necessitates understanding public preferences for healthcare service attributes. We aimed to understand the preferences of the Australian population regarding the attributes of chronic disease screening programmes. STUDY DESIGN The preferences were elicited using the discrete choice experiment (DCE) methodology. METHODS A DCE was administered to a sample of the Australian general population. Respondents were asked to make choices, each offering two hypothetical screening scenarios defined by screening conduct, quality and accuracy of the test results, cost to the patient, wait time and source of information. Data were analysed using a panel mixed multinomial logit model. RESULTS A strong preference for highly accurate screening tests and nurse-led screenings at local health clinics was evident. They expressed disutility for waiting time and out-of-pocket costs but were indifferent about the source of information. Their preference for a nurse-led programme was highlighted by the fact that they were willing to pay $81 and $88 to get a nurse-led programme when they were offered a general practitioner-led and a specialist-led programme, respectively. Furthermore, they were willing to pay $32 to reduce a week of waiting time and $205 for a 95% accurate test compared to a 75% accurate test. Preferences remained consistent irrespective of the respondent's place of residence. CONCLUSIONS Our findings highlight the importance of diagnostic test accuracy and nurse-led service delivery in chronic disease screening programmes. These insights could guide the development of patient-centric services by enhancing test accuracy, reducing waiting times and promoting nurse-led care models.
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Affiliation(s)
- S Senanayake
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD 4001, Australia; Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - A Barnett
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD 4001, Australia
| | - D Brain
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD 4001, Australia.
| | - M Allen
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD 4001, Australia
| | - E E Powell
- The University of Queensland, St Lucia, QLD 4072, Australia; Centre for Liver Disease Research, Translational Research Institute, Faculty of Medicine, The University of Queensland, Brisbane, Australia; Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - J O'Beirne
- University of the Sunshine Coast, Locked Bag 4, Maroochydore DC, QLD 4558, Australia
| | - P Valery
- QIMR Berghofer Medical Research Institute, Royal Brisbane Hospital, Herston, QLD 4029, Australia
| | - I J Hickman
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, QLD 4102, Australia; The University of Queensland, St Lucia, QLD 4072, Australia
| | - S Kularatna
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, QLD 4001, Australia; Health Services and Systems Research, Duke-NUS Medical School, Singapore
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2
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Rinella ME, Lazarus JV, Ratziu V, Francque SM, Sanyal AJ, Kanwal F, Romero D, Abdelmalek MF, Anstee QM, Arab JP, Arrese M, Bataller R, Beuers U, Boursier J, Bugianesi E, Byrne CD, Narro GEC, Chowdhury A, Cortez-Pinto H, Cryer DR, Cusi K, El-Kassas M, Klein S, Eskridge W, Fan J, Gawrieh S, Guy CD, Harrison SA, Kim SU, Koot BG, Korenjak M, Kowdley KV, Lacaille F, Loomba R, Mitchell-Thain R, Morgan TR, Powell EE, Roden M, Romero-Gómez M, Silva M, Singh SP, Sookoian SC, Spearman CW, Tiniakos D, Valenti L, Vos MB, Wong VWS, Xanthakos S, Yilmaz Y, Younossi Z, Hobbs A, Villota-Rivas M, Newsome PN. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. Ann Hepatol 2024; 29:101133. [PMID: 37364816 DOI: 10.1016/j.aohep.2023.101133] [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] [Indexed: 06/28/2023]
Abstract
The principal limitations of the terms NAFLD and NASH are the reliance on exclusionary confounder terms and the use of potentially stigmatising language. This study set out to determine if content experts and patient advocates were in favor of a change in nomenclature and/or definition. A modified Delphi process was led by three large pan-national liver associations. The consensus was defined a priori as a supermajority (67%) vote. An independent committee of experts external to the nomenclature process made the final recommendation on the acronym and its diagnostic criteria. A total of 236 panelists from 56 countries participated in 4 online surveys and 2 hybrid meetings. Response rates across the 4 survey rounds were 87%, 83%, 83%, and 78%, respectively. Seventy-four percent of respondents felt that the current nomenclature was sufficiently flawed to consider a name change. The terms "nonalcoholic" and "fatty" were felt to be stigmatising by 61% and 66% of respondents, respectively. Steatotic liver disease was chosen as an overarching term to encompass the various aetiologies of steatosis. The term steatohepatitis was felt to be an important pathophysiological concept that should be retained. The name chosen to replace NAFLD was metabolic dysfunction-associated steatotic liver disease. There was consensus to change the definition to include the presence of at least 1 of 5 cardiometabolic risk factors. Those with no metabolic parameters and no known cause were deemed to have cryptogenic steatotic liver disease. A new category, outside pure metabolic dysfunction-associated steatotic liver disease, termed metabolic and alcohol related/associated liver disease (MetALD), was selected to describe those with metabolic dysfunction-associated steatotic liver disease, who consume greater amounts of alcohol per week (140-350 g/wk and 210-420 g/wk for females and males, respectively). The new nomenclature and diagnostic criteria are widely supported and nonstigmatising, and can improve awareness and patient identification.
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Affiliation(s)
- Mary E Rinella
- University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA.
| | - Jeffrey V Lazarus
- City University of New York Graduate School of Public Health and Health Policy (CUNY SPH), New York, New York, USA; Barcelona Institute for Global Health (ISGlobal), Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Vlad Ratziu
- Sorbonne Université, ICAN Institute for Metabolism and Nutrition, Hospital Pitié-Salpêtrière, Paris, France
| | - Sven M Francque
- Department of Gastroenterology Hepatology, Antwerp University Hospital, Edegem, Belgium; InflaMed Centre of Excellence, Laboratory for Experimental Medicine and Paediatrics, Translational Sciences in Inflammation and Immunology, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Arun J Sanyal
- Virginia Commonwealth University, Richmond, Virginia, USA
| | - Fasiha Kanwal
- Sections of Gastroenterology and Hepatology and Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA; VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Diana Romero
- City University of New York Graduate School of Public Health and Health Policy (CUNY SPH), New York, New York, USA
| | | | - Quentin M Anstee
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Newcastle NIHR Biomedical Research Center, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Juan Pablo Arab
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada; Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Marco Arrese
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile; Latin American Association for the Study of the Liver (ALEH) Santiago, Chile
| | - Ramon Bataller
- Liver Unit, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ulrich Beuers
- Department of Gastroenterology & Hepatology, Tytgat Institute for Liver and Intestinal Research, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Jerome Boursier
- Hepato-Gastroenterology and Digestive Oncology Department, Angers University Hospital, Angers, France & HIFIH Laboratory UPRES EA3859, SFR 4208, Angers University, Angers, France
| | | | - Christopher D Byrne
- Nutrition and Metabolism, Faculty of Medicine, University of Southampton, Southampton, UK; National Institute for Health and Care Research Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Graciela E Castro Narro
- Latin American Association for the Study of the Liver (ALEH) Santiago, Chile; Hepatology and Transplant Unit, Hospital Médica Sur, Mexico City, Mexico; Department of Gastroenterology, National Institute of Medical Sciences and Nutrition "Salvador Zubirán" Mexico City, Mexico
| | - Abhijit Chowdhury
- Indian Institute of Liver and Digestive Sciences, Sonarpur, Kolkata, India; John C. Martin Centre for Liver Research and Innovations, Sonarpur, Kolkata, India
| | - Helena Cortez-Pinto
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Donna R Cryer
- Global Liver Institute, Washington, District of Columbia, USA
| | - Kenneth Cusi
- Division of Endocrinology, Diabetes and Metabolism, The University of Florida, Gainesville, Florida, USA
| | - Mohamed El-Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Samuel Klein
- Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Jiangao Fan
- Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Samer Gawrieh
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Cynthia D Guy
- Department of Pathology, Duke Health Systems, Durham, North Carolina, USA
| | | | - Seung Up Kim
- Yonsei University College of Medicine, Seoul, Korea
| | - Bart G Koot
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Kris V Kowdley
- Liver Institute Northwest Elson S. Floyd College of Medicine Washington State University Seattle, Washington, USA
| | | | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California at San Diego, La Jolla, California, USA
| | | | - Timothy R Morgan
- Medical Service, VA Long Beach Healthcare System, Long Beach, California, USA; Department of Medicine, University of California, Irvine, California, USA
| | - Elisabeth E Powell
- Centre for Liver Disease Research, Faculty of Medicine, The University of Queensland, Translational Research Institute, Brisbane, Queensland, Australia; QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia; Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Michael Roden
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany; German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
| | - Manuel Romero-Gómez
- Digestive Diseases and Ciberehd, Virgen del Rocio University Hospital, Institute of Biomedicine of Seville (CSIC/HUVR/US), University of Seville, Seville, Spain
| | - Marcelo Silva
- Austral University Hospital, Buenos Aires, Argentina
| | | | - Silvia C Sookoian
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile; Clinical and Molecular Hepatology, Centro de Altos Estudios en Ciencias Humanas y de la Salud (CAECIHS), Universidad Abierta Interamericana, Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina; Universidad Maimónides, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
| | - C Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Dina Tiniakos
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Department of Pathology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Luca Valenti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy; Biological Resource Center Unit, Precision Medicine lab, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Milan, Italy
| | - Miriam B Vos
- Division of Gastroenterology, Department of Paediatrics, Hepatology and Nutrition, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Stavra Xanthakos
- Department of paediatrics, Division of Gastroenterology Hepatology and Nutrition, Cincinnati Children's, Nonalcoholic Steatohepatitis Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Yusuf Yilmaz
- Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Zobair Younossi
- Inova Medicine, Inova Health System, Falls Church, Virginia, USA; Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, United States; Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Ansley Hobbs
- City University of New York Graduate School of Public Health and Health Policy (CUNY SPH), New York, New York, USA
| | - Marcela Villota-Rivas
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Philip N Newsome
- National Institute for Health Research, Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK; Centre for Liver & Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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3
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Rinella ME, Lazarus JV, Ratziu V, Francque SM, Sanyal AJ, Kanwal F, Romero D, Abdelmalek MF, Anstee QM, Arab JP, Arrese M, Bataller R, Beuers U, Boursier J, Bugianesi E, Byrne CD, Castro Narro GE, Chowdhury A, Cortez-Pinto H, Cryer DR, Cusi K, El-Kassas M, Klein S, Eskridge W, Fan J, Gawrieh S, Guy CD, Harrison SA, Kim SU, Koot BG, Korenjak M, Kowdley KV, Lacaille F, Loomba R, Mitchell-Thain R, Morgan TR, Powell EE, Roden M, Romero-Gómez M, Silva M, Singh SP, Sookoian SC, Spearman CW, Tiniakos D, Valenti L, Vos MB, Wong VWS, Xanthakos S, Yilmaz Y, Younossi Z, Hobbs A, Villota-Rivas M, Newsome PN. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. J Hepatol 2023; 79:1542-1556. [PMID: 37364790 DOI: 10.1016/j.jhep.2023.06.003] [Citation(s) in RCA: 231] [Impact Index Per Article: 231.0] [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: 06/15/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
The principal limitations of the terms NAFLD and NASH are the reliance on exclusionary confounder terms and the use of potentially stigmatising language. This study set out to determine if content experts and patient advocates were in favour of a change in nomenclature and/or definition. A modified Delphi process was led by three large pan-national liver associations. The consensus was defined a priori as a supermajority (67%) vote. An independent committee of experts external to the nomenclature process made the final recommendation on the acronym and its diagnostic criteria. A total of 236 panellists from 56 countries participated in 4 online surveys and 2 hybrid meetings. Response rates across the 4 survey rounds were 87%, 83%, 83%, and 78%, respectively. Seventy-four percent of respondents felt that the current nomenclature was sufficiently flawed to consider a name change. The terms "nonalcoholic" and "fatty" were felt to be stigmatising by 61% and 66% of respondents, respectively. Steatotic liver disease was chosen as an overarching term to encompass the various aetiologies of steatosis. The term steatohepatitis was felt to be an important pathophysiological concept that should be retained. The name chosen to replace NAFLD was metabolic dysfunction-associated steatotic liver disease (MASLD). There was consensus to change the definition to include the presence of at least 1 of 5 cardiometabolic risk factors. Those with no metabolic parameters and no known cause were deemed to have cryptogenic steatotic liver disease. A new category, outside pure metabolic dysfunction-associated steatotic liver disease, termed metabolic and alcohol related/associated liver disease (MetALD), was selected to describe those with metabolic dysfunction-associated steatotic liver disease, who consume greater amounts of alcohol per week (140-350 g/wk and 210-420 g/wk for females and males, respectively). The new nomenclature and diagnostic criteria are widely supported and non-stigmatising, and can improve awareness and patient identification.
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Affiliation(s)
- Mary E Rinella
- University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA.
| | - Jeffrey V Lazarus
- City University of New York Graduate School of Public Health and Health Policy (CUNY SPH), New York, New York, USA; Barcelona Institute for Global Health (ISGlobal), Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Vlad Ratziu
- Sorbonne Université, ICAN Institute for Metabolism and Nutrition, Hospital Pitié-Salpêtrière, Paris, France
| | - Sven M Francque
- Department of Gastroenterology Hepatology, Antwerp University Hospital, Edegem, Belgium; InflaMed Centre of Excellence, Laboratory for Experimental Medicine and Paediatrics, Translational Sciences in Inflammation and Immunology, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Arun J Sanyal
- Virginia Commonwealth University, Richmond, Virginia, USA
| | - Fasiha Kanwal
- Sections of Gastroenterology and Hepatology and Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA; VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Diana Romero
- City University of New York Graduate School of Public Health and Health Policy (CUNY SPH), New York, New York, USA
| | | | - Quentin M Anstee
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Newcastle NIHR Biomedical Research Center, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Juan Pablo Arab
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada; Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Marco Arrese
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile; Latin American Association for the Study of the Liver (ALEH) Santiago, Chile
| | - Ramon Bataller
- Liver Unit, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ulrich Beuers
- Department of Gastroenterology & Hepatology, Tytgat Institute for Liver and Intestinal Research, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Jerome Boursier
- Hepato-Gastroenterology and Digestive Oncology Department, Angers University Hospital, Angers, France & HIFIH Laboratory UPRES EA3859, SFR 4208, Angers University, Angers, France
| | | | - Christopher D Byrne
- Nutrition and Metabolism, Faculty of Medicine, University of Southampton, Southampton, UK; National Institute for Health and Care Research Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Graciela E Castro Narro
- Latin American Association for the Study of the Liver (ALEH) Santiago, Chile; Hepatology and Transplant Unit, Hospital Médica Sur, Mexico City, Mexico; Department of Gastroenterology, National Institute of Medical Sciences and Nutrition "Salvador Zubirán" Mexico City, Mexico
| | - Abhijit Chowdhury
- Indian Institute of Liver and Digestive Sciences, Sonarpur, Kolkata, India; John C. Martin Centre for Liver Research and Innovations, Sonarpur, Kolkata, India
| | - Helena Cortez-Pinto
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Donna R Cryer
- Global Liver Institute, Washington, District of Columbia, USA
| | - Kenneth Cusi
- Division of Endocrinology, Diabetes and Metabolism, The University of Florida, Gainesville, Florida, USA
| | - Mohamed El-Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Samuel Klein
- Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Jiangao Fan
- Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Samer Gawrieh
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Cynthia D Guy
- Department of Pathology, Duke Health Systems, Durham, North Carolina, USA
| | | | - Seung Up Kim
- Yonsei University College of Medicine, Seoul, Korea
| | - Bart G Koot
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Kris V Kowdley
- Liver Institute Northwest Elson S. Floyd College of Medicine Washington State University Seattle, Washington, USA
| | | | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California at San Diego, La Jolla, California, USA
| | | | - Timothy R Morgan
- Medical Service, VA Long Beach Healthcare System, Long Beach, California, USA; Department of Medicine, University of California, Irvine, California, USA
| | - Elisabeth E Powell
- Centre for Liver Disease Research, Faculty of Medicine, The University of Queensland, Translational Research Institute, Brisbane, Queensland, Australia; QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia; Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Michael Roden
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany; German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
| | - Manuel Romero-Gómez
- Digestive Diseases and Ciberehd, Virgen del Rocio University Hospital, Institute of Biomedicine of Seville (CSIC/HUVR/US), University of Seville, Seville, Spain
| | - Marcelo Silva
- Austral University Hospital, Buenos Aires, Argentina
| | | | - Silvia C Sookoian
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile; Clinical and Molecular Hepatology, Centro de Altos Estudios en Ciencias Humanas y de la Salud (CAECIHS), Universidad Abierta Interamericana, Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina; Universidad Maimónides, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
| | - C Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Dina Tiniakos
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Department of Pathology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Luca Valenti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy; Biological Resource Center Unit, Precision Medicine lab, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Milan, Italy
| | - Miriam B Vos
- Division of Gastroenterology, Department of Paediatrics, Hepatology and Nutrition, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Stavra Xanthakos
- Department of paediatrics, Division of Gastroenterology Hepatology and Nutrition, Cincinnati Children's, Nonalcoholic Steatohepatitis Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Yusuf Yilmaz
- Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Zobair Younossi
- Inova Medicine, Inova Health System, Falls Church, Virginia, USA; Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, United States; Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Ansley Hobbs
- City University of New York Graduate School of Public Health and Health Policy (CUNY SPH), New York, New York, USA
| | - Marcela Villota-Rivas
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Philip N Newsome
- National Institute for Health Research, Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK; Centre for Liver & Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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Rinella ME, Lazarus JV, Ratziu V, Francque SM, Sanyal AJ, Kanwal F, Romero D, Abdelmalek MF, Anstee QM, Arab JP, Arrese M, Bataller R, Beuers U, Boursier J, Bugianesi E, Byrne CD, Castro Narro GE, Chowdhury A, Cortez-Pinto H, Cryer DR, Cusi K, El-Kassas M, Klein S, Eskridge W, Fan J, Gawrieh S, Guy CD, Harrison SA, Kim SU, Koot BG, Korenjak M, Kowdley KV, Lacaille F, Loomba R, Mitchell-Thain R, Morgan TR, Powell EE, Roden M, Romero-Gómez M, Silva M, Singh SP, Sookoian SC, Spearman CW, Tiniakos D, Valenti L, Vos MB, Wong VWS, Xanthakos S, Yilmaz Y, Younossi Z, Hobbs A, Villota-Rivas M, Newsome PN. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. Hepatology 2023; 78:1966-1986. [PMID: 37363821 PMCID: PMC10653297 DOI: 10.1097/hep.0000000000000520] [Citation(s) in RCA: 280] [Impact Index Per Article: 280.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
The principal limitations of the terms NAFLD and NASH are the reliance on exclusionary confounder terms and the use of potentially stigmatising language. This study set out to determine if content experts and patient advocates were in favor of a change in nomenclature and/or definition. A modified Delphi process was led by three large pan-national liver associations. The consensus was defined a priori as a supermajority (67%) vote. An independent committee of experts external to the nomenclature process made the final recommendation on the acronym and its diagnostic criteria. A total of 236 panelists from 56 countries participated in 4 online surveys and 2 hybrid meetings. Response rates across the 4 survey rounds were 87%, 83%, 83%, and 78%, respectively. Seventy-four percent of respondents felt that the current nomenclature was sufficiently flawed to consider a name change. The terms "nonalcoholic" and "fatty" were felt to be stigmatising by 61% and 66% of respondents, respectively. Steatotic liver disease was chosen as an overarching term to encompass the various aetiologies of steatosis. The term steatohepatitis was felt to be an important pathophysiological concept that should be retained. The name chosen to replace NAFLD was metabolic dysfunction-associated steatotic liver disease. There was consensus to change the definition to include the presence of at least 1 of 5 cardiometabolic risk factors. Those with no metabolic parameters and no known cause were deemed to have cryptogenic steatotic liver disease. A new category, outside pure metabolic dysfunction-associated steatotic liver disease, termed metabolic and alcohol related/associated liver disease (MetALD), was selected to describe those with metabolic dysfunction-associated steatotic liver disease, who consume greater amounts of alcohol per week (140-350 g/wk and 210-420 g/wk for females and males, respectively). The new nomenclature and diagnostic criteria are widely supported and nonstigmatising, and can improve awareness and patient identification.
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Affiliation(s)
- Mary E. Rinella
- University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - Jeffrey V. Lazarus
- City University of New York Graduate School of Public Health and Health Policy (CUNY SPH), New York, New York, USA
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Vlad Ratziu
- Sorbonne Université, ICAN Institute for Metabolism and Nutrition, Hospital Pitié-Salpêtrière, Paris, France
| | - Sven M. Francque
- Department of Gastroenterology Hepatology, Antwerp University Hospital, Edegem, Belgium
- InflaMed Centre of Excellence, Laboratory for Experimental Medicine and Paediatrics, Translational Sciences in Inflammation and Immunology, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Arun J. Sanyal
- Virginia Commonwealth University, Richmond, Virginia, USA
| | - Fasiha Kanwal
- Sections of Gastroenterology and Hepatology and Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Diana Romero
- City University of New York Graduate School of Public Health and Health Policy (CUNY SPH), New York, New York, USA
| | | | - Quentin M. Anstee
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Newcastle NIHR Biomedical Research Center, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Juan Pablo Arab
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Marco Arrese
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
- Latin American Association for the Study of the Liver (ALEH) Santiago, Chile
| | - Ramon Bataller
- Liver Unit, Hospital Clinic, Institut d’Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ulrich Beuers
- Department of Gastroenterology & Hepatology, Tytgat Institute for Liver and Intestinal Research, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Jerome Boursier
- Hepato-Gastroenterology and Digestive Oncology Department, Angers University Hospital, Angers, France & HIFIH Laboratory UPRES EA3859, SFR 4208, Angers University, Angers, France
| | | | - Christopher D. Byrne
- Nutrition and Metabolism, Faculty of Medicine, University of Southampton, Southampton, UK
- National Institute for Health and Care Research Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Graciela E. Castro Narro
- Latin American Association for the Study of the Liver (ALEH) Santiago, Chile
- Hepatology and Transplant Unit, Hospital Médica Sur, Mexico City, Mexico
- Department of Gastroenterology, National Institute of Medical Sciences and Nutrition “Salvador Zubirán” Mexico City, Mexico
| | - Abhijit Chowdhury
- Indian Institute of Liver and Digestive Sciences, Sonarpur, Kolkata, India
- John C. Martin Centre for Liver Research and Innovations, Sonarpur, Kolkata, India
| | - Helena Cortez-Pinto
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Donna R. Cryer
- Global Liver Institute, Washington, District of Columbia, USA
| | - Kenneth Cusi
- Division of Endocrinology, Diabetes and Metabolism, The University of Florida, Gainesville, Florida, USA
| | - Mohamed El-Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Samuel Klein
- Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Jiangao Fan
- Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Samer Gawrieh
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Cynthia D. Guy
- Department of Pathology, Duke Health Systems, Durham, North Carolina, USA
| | | | - Seung Up Kim
- Yonsei University College of Medicine, Seoul, Korea
| | - Bart G. Koot
- Department of Pediatric Gastroenterology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Kris V. Kowdley
- Liver Institute Northwest Elson S. Floyd College of Medicine Washington State University Seattle, Washington, USA
| | | | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California at San Diego, La Jolla, California, USA
| | | | - Timothy R. Morgan
- Medical Service, VA Long Beach Healthcare System, Long Beach, California, USA
- Department of Medicine, University of California, Irvine, California, USA
| | - Elisabeth E. Powell
- Centre for Liver Disease Research, Faculty of Medicine, The University of Queensland, Translational Research Institute, Brisbane, Queensland, Australia
- QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Michael Roden
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
| | - Manuel Romero-Gómez
- Digestive Diseases and Ciberehd, Virgen del Rocio University Hospital, Institute of Biomedicine of Seville (CSIC/HUVR/US), University of Seville, Seville, Spain
| | - Marcelo Silva
- Austral University Hospital, Buenos Aires, Argentina
| | | | - Silvia C. Sookoian
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
- Clinical and Molecular Hepatology, Centro de Altos Estudios en Ciencias Humanas y de la Salud (CAECIHS), Universidad Abierta Interamericana, Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
- Universidad Maimónides, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
| | - C. Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Dina Tiniakos
- Translational & Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Pathology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Luca Valenti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Biological Resource Center Unit, Precision Medicine lab, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milano, Milan, Italy
| | - Miriam B. Vos
- Division of Gastroenterology, Department of Paediatrics, Hepatology and Nutrition, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Stavra Xanthakos
- Department of paediatrics, Division of Gastroenterology Hepatology and Nutrition, Cincinnati Children’s, Nonalcoholic Steatohepatitis Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Yusuf Yilmaz
- Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Zobair Younossi
- Inova Medicine, Inova Health System, Falls Church, Virginia, USA
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, United States
- Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Ansley Hobbs
- City University of New York Graduate School of Public Health and Health Policy (CUNY SPH), New York, New York, USA
| | - Marcela Villota-Rivas
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Philip N. Newsome
- National Institute for Health Research, Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK
- Centre for Liver & Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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El-Atem NA, Wojcik K, Horsfall L, Irvine KM, Johnson T, McPhail SM, Powell EE. Patterns of service utilisation within Australian hepatology clinics: high prevalence of advanced liver disease. Intern Med J 2017; 46:420-6. [PMID: 26762655 DOI: 10.1111/imj.13008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 12/20/2015] [Indexed: 01/18/2023]
Abstract
BACKGROUND Liver diseases in Australia are estimated to affect 6 million people with a societal cost of $51 billion annually. Information about utilisation of specialist hepatology care is critical in informing policy makers about the requirements for delivery of hepatology-related healthcare. AIMS This study examined the aetiology and severity of liver disease seen in a tertiary hospital hepatology clinic, as well as the resource utilisation patterns. METHODS A longitudinal cohort study included consecutive patients booked in hepatology outpatient clinics during a 3-month period. Subsequent outpatient appointments for these patients over the following 12 months were then recorded. RESULTS During the initial 3-month period, 1471 appointments were scheduled with a hepatologist, 1136 of which were attended. Twenty-one per cent of patients were 'new cases'. Hepatitis B virus (HBV) was the most common disease aetiology for new cases (37%). Advanced disease at presentation varied between aetiology; only 5% of HBV cases had advanced liver disease at presentation, in contrast with HCV, NAFLD and ALD, in which advanced disease was identified at presentation in 31%, 46% and 72% of cases, respectively. Most patients (83%) attended multiple hepatology appointments, and a range of referral patterns for procedures, investigations and other specialty assessments were observed. CONCLUSIONS There is a high prevalence of HBV in new case referrals. Patients with HCV infection, NAFLD and ALD have a high prevalence of advanced liver disease at referral, requiring ongoing surveillance for development of decompensated liver disease and liver cancer. These findings that describe the patterns of health service utilisation among patients with liver disease provide useful information for planning sustainable health service provision for this clinical population.
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Affiliation(s)
- N A El-Atem
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.,School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia.,Centre for Functioning and Health Research, Metro South Health, Brisbane, Queensland, Australia
| | - K Wojcik
- Centre for Liver Disease Research, The University of Queensland, Brisbane, Queensland, Australia
| | - L Horsfall
- Centre for Liver Disease Research, The University of Queensland, Brisbane, Queensland, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - K M Irvine
- Centre for Liver Disease Research, The University of Queensland, Brisbane, Queensland, Australia
| | - T Johnson
- Inala Primary Care, Brisbane, Queensland, Australia
| | - S M McPhail
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.,School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia.,Centre for Functioning and Health Research, Metro South Health, Brisbane, Queensland, Australia
| | - E E Powell
- Centre for Liver Disease Research, The University of Queensland, Brisbane, Queensland, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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6
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von Wulffen M, Clark PJ, Macdonald GA, Raj AS, Kendall BJ, Powell EE, Jones MP, Holtmann G. Liver-related mortality in countries of the developed world: an ecological study approach to explain the variability. Aliment Pharmacol Ther 2016; 44:68-77. [PMID: 27189900 DOI: 10.1111/apt.13657] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 02/24/2016] [Accepted: 04/08/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Liver-related mortality varies across developed nations. AIM To assess the relative role of various risk factors in relation to liver-related mortality in an ecological study approach. METHODS Data for liver-related mortality, prevalence data for hepatitis B and C, human immunodeficiency virus (HIV), alcohol consumption per capita, Type 2 Diabetes mellitus (T2DM), overweight and obesity were extracted from peer-reviewed publications or WHO databases for different developed countries. As potential other risk-modifying factors, purchase power parity (PPP)-adjusted gross domestic product (GDP) per capita and health expenditure per capita were assessed. As an environmental 'hygiene factor', we also assessed the effect of the prevalence of Helicobacter pylori. Only countries with a PPP-adjusted GDP greater than $20 000 and valid information for at least 8 risk modifiers were included. Univariate and multivariate analyses were utilised to quantify the contribution to the variability in liver-related mortality. RESULTS The proportion of chronic liver diseases (CLD)-related mortality ranged from 0.73-2.40% [mean 1.56%, 95% CI (1.43-1.69)] of all deaths. Univariately, CLD-related mortality was significantly associated with Hepatitis B prevalence, alcohol consumption, PPP-adjusted GDP (all P < 0.05) and potentially H. pylori prevalence (P = 0.055). Other investigated factors, including hepatitis C, did not yield significance. Backward elimination suggested hepatitis B, alcohol consumption and PPP-adjusted GDP as risk factors (explaining 66.3% of the variability). CONCLUSION Hepatitis B infection, alcohol consumption and GDP, but not hepatitis C or other factors, explain most of the variance of liver-related mortality.
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Affiliation(s)
- M von Wulffen
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Qld, Australia.,Translational Research Institute, Brisbane, Qld, Australia
| | - P J Clark
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Qld, Australia.,Cancer Control Unit, Berghofer-QIMR Medical Research Institute, Brisbane, Qld, Australia
| | - G A Macdonald
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Qld, Australia.,Translational Research Institute, Brisbane, Qld, Australia
| | - A S Raj
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Qld, Australia
| | - B J Kendall
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Qld, Australia
| | - E E Powell
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Qld, Australia.,Translational Research Institute, Brisbane, Qld, Australia
| | - M P Jones
- Faculty of Human Sciences, Macquire University, Sydney, NSW, Australia
| | - G Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Qld, Australia.,Translational Research Institute, Brisbane, Qld, Australia.,Faculty of Health and Behavioral Sciences, University of Queensland, Brisbane, Qld, Australia
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7
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Fagan KJ, Zhao EY, Horsfall LU, Ruffin BJ, Kruger MS, McPhail SM, O'Rourke P, Ballard E, Irvine KM, Powell EE. Burden of decompensated cirrhosis and ascites on hospital services in a tertiary care facility: time for change? Intern Med J 2015; 44:865-72. [PMID: 24893971 DOI: 10.1111/imj.12491] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 05/25/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ascites, the most frequent complication of cirrhosis, is associated with poor prognosis and reduced quality of life. Recurrent hospital admissions are common and often unplanned, resulting in increased use of hospital services. AIMS To examine use of hospital services by patients with cirrhosis and ascites requiring paracentesis, and to investigate factors associated with early unplanned readmission. METHODS A retrospective review of the medical chart and clinical databases was performed for patients who underwent paracentesis between October 2011 and October 2012. Clinical parameters at index admission were compared between patients with and without early unplanned hospital readmissions. RESULTS The 41 patients requiring paracentesis had 127 hospital admissions, 1164 occupied bed days and 733 medical imaging services. Most admissions (80.3%) were for management of ascites, of which 41.2% were unplanned. Of those eligible, 69.7% were readmitted and 42.4% had an early unplanned readmission. Twelve patients died and nine developed spontaneous bacterial peritonitis. Of those eligible for readmission, more patients died (P = 0.008) and/or developed spontaneous bacterial peritonitis (P = 0.027) if they had an early unplanned readmission during the study period. Markers of liver disease, as well as haemoglobin (P = 0.029), haematocrit (P = 0.024) and previous heavy alcohol use (P = 0.021) at index admission, were associated with early unplanned readmission. CONCLUSION Patients with cirrhosis and ascites comprise a small population who account for substantial use of hospital services. Markers of disease severity may identify patients at increased risk of early readmission. Alternative models of care should be considered to reduce unplanned hospital admissions, healthcare costs and pressure on emergency services.
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Affiliation(s)
- K J Fagan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; Centre for Liver Disease Research, School of Medicine, The University of Queensland, Translational Research Institute, Brisbane, Queensland, Australia
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8
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Bergqvist CJ, Skoien R, Horsfall L, Clouston AD, Jonsson JR, Powell EE. Awareness and opinions of non-alcoholic fatty liver disease by hospital specialists. Intern Med J 2013; 43:247-53. [PMID: 22646061 DOI: 10.1111/j.1445-5994.2012.02848.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2012] [Accepted: 04/05/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIM Subjects with metabolic risk factors for non-alcoholic fatty liver disease (NAFLD) are commonly seen by hospital specialists other than gastroenterologists/hepatologists. The aim of this study was to assess the awareness of NAFLD and opinions regarding management among non-hepatologists at two major tertiary hospitals in Brisbane. METHODS A face-to-face questionnaire assessing current beliefs and practices regarding NAFLD was administered to specialists and specialists-in-training across six specialties (internal medicine, cardiology/cardiac surgery, endocrinology, thoracic medicine, rheumatology and nephrology). RESULTS One hundred clinicians were surveyed with 99% returning completed questionnaires (>89% questions answered). The majority of respondents (75%) believe the prevalence of NAFLD in the general population to be ≤ 10%, although two-thirds feel that its incidence will rise markedly. The vast majority (>90%) appreciate that traditional cardiovascular risk factors (obesity, hypertriglyceridaemia and diabetes) are risk factors for NAFLD and acknowledge that these are common in non-hepatology patients. Despite this, most believe that NAFLD is uncommon in their own patients (89% indicated a prevalence ≤ 30%). The vast majority (93%) agree that non-alcoholic steatohepatitis (NASH) is associated with increased overall mortality, but 60% also believe that simple steatosis confers increased liver-related mortality. Most (74%) agree that a diagnosis of NASH cannot be made using liver enzymes, but 67% support 6-monthly liver function tests as the most effective way to monitor progression of NAFLD. Most respondents (71%) make no referrals to hepatology for suspected NAFLD. CONCLUSIONS Non-hepatologists appreciate the seriousness of NAFLD but appear to underestimate its prevalence, especially among their own patients despite known risk factors. Attitudes regarding simple steatosis versus NASH and appropriate monitoring of suspected NAFLD suggest that more can be done to improve the understanding of this disease among non-hepatologists. This has implications for targeting 'at-risk' populations and appropriate referral of patients to hepatology clinics.
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Affiliation(s)
- C-J Bergqvist
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital; School of Medicine, Southern Clinical Division, The University of Queensland, Brisbane, Queensland, Australia
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9
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Richardson MM, Powell EE, Barrie HD, Clouston AD, Purdie DM, Jonsson JR. A combination of genetic polymorphisms increases the risk of progressive disease in chronic hepatitis C. J Med Genet 2006; 42:e45. [PMID: 15994870 PMCID: PMC1736103 DOI: 10.1136/jmg.2005.032557] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND There is increasing interest in the influence of host genetic factors on hepatic fibrosis, and whether genetic markers can reliably identify subjects at risk of developing severe disease. We hypothesised that hepatitis C virus (HCV) infected subjects with progressive fibrosis, classified using strict criteria based on histology at biopsy in addition to disease duration would be more likely to inherit several genetic polymorphisms associated with disease progression compared with subjects with a low rate of disease progression. METHODS We examined polymorphisms in eight genes that have been reported to have an association with hepatic fibrosis. RESULTS Associations between polymorphisms in six genes and more rapidly progressing fibrosis were observed, with individual adjusted odds ratios ranging from 2.1 to 4.5. The relationship between rapidly progressing fibrosis and possession of > or =3, > or =4, or > or =5 progression associated alleles was determined and the adjusted odds ratios increased with increasing number of progression associated alleles (9.1, 15.5, and 24.1, respectively). Using logistic regression analysis, a predictive equation was developed and tested using a second cohort of patients with rapidly progressing fibrosis. The predictive equation correctly classified 80% of patients in this second cohort. CONCLUSIONS This approach may allow determination of a genetic profile predictive of rapid disease progression in HCV and identify patients warranting more aggressive therapeutic management.
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10
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Walsh MJ, Jonsson JR, Richardson MM, Lipka GM, Purdie DM, Clouston AD, Powell EE. Non-response to antiviral therapy is associated with obesity and increased hepatic expression of suppressor of cytokine signalling 3 (SOCS-3) in patients with chronic hepatitis C, viral genotype 1. Gut 2006; 55:529-35. [PMID: 16299039 PMCID: PMC1856185 DOI: 10.1136/gut.2005.069674] [Citation(s) in RCA: 218] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Interferon alpha (IFN-alpha) activated cellular signalling is negatively regulated by inhibitory factors, including the suppressor of cytokine signalling (SOCS) family. The effects of host factors such as obesity on hepatic expression of these inhibitory factors in subjects with chronic hepatitis C virus (HCV) are unknown. OBJECTIVES To assess the independent effects of obesity, insulin resistance, and steatosis on response to IFN-alpha therapy and to determine hepatic expression of factors inhibiting IFN-alpha signalling in obese and non-obese subjects with chronic HCV. METHODS A total of 145 subjects were analysed to determine host factors associated with non-response to antiviral therapy. Treatment comprised IFN-alpha or peginterferon alpha, either alone or in combination with ribavirin. In a separate cohort of 73 patients, real time-polymerase chain reaction was performed to analyse hepatic mRNA expression. Immunohistochemistry for SOCS-3 was performed on liver biopsy samples from 38 patients with viral genotype 1 who had received antiviral treatment. RESULTS Non-response (NR) to treatment occurred in 55% of patients with HCV genotypes 1 or 4 and 22% with genotypes 2 or 3. Factors independently associated with NR were viral genotype 1/4 (p < 0.001), cirrhosis on pretreatment biopsy (p = 0.025), and body mass index > or = 30 kg/m2 (p = 0.010). Obese subjects with viral genotype 1 had increased hepatic mRNA expression of phosphoenolpyruvate carboxy kinase (p = 0.01) and SOCS-3 (p = 0.047), in comparison with lean subjects. Following multivariate analysis, SOCS-3 mRNA expression remained independently associated with obesity (p = 0.023). SOCS-3 immunoreactivity was significantly increased in obesity (p = 0.013) and in non-responders compared with responders (p = 0.014). CONCLUSIONS In patients with chronic HCV viral genotype 1, increased expression of factors that inhibit interferon signalling may be one mechanism by which obesity reduces the biological response to IFN-alpha.
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Affiliation(s)
- M J Walsh
- School of Medicine, Southern Division, University of Queensland, Queensland, Australia
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11
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Eri R, Jonsson JR, Pandeya N, Purdie DM, Clouston AD, Martin N, Duffy D, Powell EE, Fawcett J, Florin THJ, Radford-Smith GL. CCR5-Delta32 mutation is strongly associated with primary sclerosing cholangitis. Genes Immun 2005; 5:444-50. [PMID: 15215889 DOI: 10.1038/sj.gene.6364113] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
CCR5 plays a key role in the distribution of CD45RO+ T cells and contributes to generation of a T helper 1 immune response. CCR5-Delta32 is a 32-bp deletion associated with significant reduction in cell surface expression of the receptor. We investigated the role of CCR5-Delta32 on susceptibility to ulcerative colitis (UC), Crohn's disease (CD) and primary sclerosing cholangitis (PSC). Genotype and allelic association analyses were performed in 162 patients with UC, 131 with CD, 71 with PSC and 419 matched controls. There was a significant difference in CCR5 genotype (OR 2.27, P=0.003) between patients with sclerosing cholangitis and controls. Similarly, CCR5-Delta32 allele frequency was significantly higher in sclerosing cholangitis (17.6%) compared to controls (9.9%, OR 2.47, P=0.007) and inflammatory bowel disease patients without sclerosing cholangitis (11.3%, OR 1.9, P=0.027). There were no significant differences in CCR5 genotype or allele frequency between those with either UC or CD and controls. Genotypes with the CCR5-Delta32 variant were increased in patients with severe liver disease defined by portal hypertension and/or transplantation (45%) compared to those with mild liver disease (21%, OR 3.17, P=0.03). The CCR5-Delta32 mutation may influence disease susceptibility and severity in patients with PSC.
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Affiliation(s)
- R Eri
- Brisbane IBD Research Group, Clinical Research Centre, Royal Brisbane Hospital Research Foundation, Brisbane, Australia
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12
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Abstract
Nonalcoholic fatty liver disease is now a major cause of liver disease in developed countries, largely as a result of an epidemic of obesity, diabetes and sedentary lifestyles. This has resulted in raised clinical awareness and diagnostic refinement. The entity encompasses several histologic patterns from benign steatosis to nonalcoholic steatohepatitis, the latter having a significant risk of progressive fibrosis and the development of cirrhosis. Laboratory tests and imaging are not able to distinguish steatosis from steatohepatitis, which requires liver biopsy. However following an assessment of several risk factors, patients can be stratified for the potential risk of fibrosis, allowing the rational use of liver biopsy. This review will describe the various patterns of nonalcoholic fatty liver disease and relate this to disease pathogenesis and progression. Strategies for management, including experimental interventions, will be discussed.
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Affiliation(s)
- A D Clouston
- Sullivan Nicolaides Pathology, University of Queensland, Brisbane, Queensland, Australia.
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13
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Hickman IJ, Jonsson JR, Prins JB, Ash S, Purdie DM, Clouston AD, Powell EE. Modest weight loss and physical activity in overweight patients with chronic liver disease results in sustained improvements in alanine aminotransferase, fasting insulin, and quality of life. Gut 2004; 53:413-9. [PMID: 14960526 PMCID: PMC1773957 DOI: 10.1136/gut.2003.027581] [Citation(s) in RCA: 279] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Obesity is a risk factor for progression of fibrosis in chronic liver diseases such as non-alcoholic fatty liver disease and hepatitis C. The aim of this study was to investigate the longer term effect of weight loss on liver biochemistry, serum insulin levels, and quality of life in overweight patients with liver disease and the effect of subsequent weight maintenance or regain. PATIENTS Thirty one patients completed a 15 month diet and exercise intervention. RESULTS On completion of the intervention, 21 patients (68%) had achieved and maintained weight loss with a mean reduction of 9.4 (4.0)% body weight. Improvements in serum alanine aminotransferase (ALT) levels were correlated with the amount of weight loss (r = 0.35, p = 0.04). In patients who maintained weight loss, mean ALT levels at 15 months remained significantly lower than values at enrollment (p = 0.004), while in regainers (n = 10), mean ALT levels at 15 months were no different to values at enrollment (p = 0.79). Improvements in fasting serum insulin levels were also correlated with weight loss (r = 0.46, p = 0.04), and subsequent weight maintenance sustained this improvement. Quality of life was significantly improved after weight loss. Weight maintainers sustained recommended levels of physical activity and had higher fasting insulin levels (p = 0.03) at enrollment than weight regainers. CONCLUSION In summary, these findings demonstrate that maintenance of weight loss and exercise in overweight patients with liver disease results in a sustained improvement in liver enzymes, serum insulin levels, and quality of life. Treatment of overweight patients should form an important component of the management of those with chronic liver disease.
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Affiliation(s)
- I J Hickman
- School of Medicine, University of Queensland, and Department of Nutrition and Dietetic Services, Princess Alexandra Hospital, Brisbane, Australia
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14
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Hickman IJ, Clouston AD, Macdonald GA, Purdie DM, Prins JB, Ash S, Jonsson JR, Powell EE. Effect of weight reduction on liver histology and biochemistry in patients with chronic hepatitis C. Gut 2002; 51:89-94. [PMID: 12077098 PMCID: PMC1773265 DOI: 10.1136/gut.51.1.89] [Citation(s) in RCA: 215] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Steatosis occurs in more than 50% of patients with chronic hepatitis C and is associated with increased hepatic fibrosis. In many of these patients the pathogenesis of steatosis appears to be the same as for patients with non-alcoholic fatty liver disease-that is, related to visceral adiposity and obesity. METHODS The effect of a three month weight reduction programme on liver biochemistry and metabolic parameters was examined in 19 subjects with steatosis and chronic hepatitis C. Paired liver biopsies were performed in 10 subjects, prior to and 3-6 months following the intervention, to determine the effect of weight loss on liver histology. RESULTS There was a mean weight loss of 5.9 (3.2) kg and a mean reduction in waist circumference of 9.0 (5.0) cm. In 16 of the 19 patients, serum alanine aminotransferase levels fell progressively with weight loss. Mean fasting insulin fell from 16 (7) to 11 (4) mmol/l (p<0.002). Nine of 10 patients with paired liver biopsies had a reduction in steatosis irrespective of viral genotype. In these subjects the median modified Knodell fibrosis score decreased from 3 to 1 (p=0.04) and activated stellate cells significantly decreased (p<0.004). CONCLUSIONS Weight loss in patients with chronic hepatitis C may be associated with a reduction in steatosis and abnormal liver enzymes and an improvement in fibrosis, despite the persistence of the virus. Weight reduction may provide an important adjunct treatment strategy for patients with chronic hepatitis C.
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Affiliation(s)
- I J Hickman
- Department of Nutrition and Operational Support Services, Princess Alexandra Hospital, Brisbane, Australia
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15
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Jonsson JR, Clouston AD, Ando Y, Kelemen LI, Horn MJ, Adamson MD, Purdie DM, Powell EE. Angiotensin-converting enzyme inhibition attenuates the progression of rat hepatic fibrosis. Gastroenterology 2001; 121:148-55. [PMID: 11438504 DOI: 10.1053/gast.2001.25480] [Citation(s) in RCA: 234] [Impact Index Per Article: 10.2] [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] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS There is a significant relationship between inheritance of high transforming growth factor (TGF)-beta1 and angiotensinogen-producing genotypes and the development of progressive hepatic fibrosis in patients with chronic hepatitis C. In cardiac and renal fibrosis, TGF-beta1 production may be enhanced by angiotensin II, the principal effector molecule of the renin-angiotensin system. The aim of the present study was to determine the effects of the angiotensin-converting enzyme inhibitor, captopril, on the progression of hepatic fibrosis in the rat bile duct ligation model. METHODS Rats were treated with captopril (100 mg. kg(-1). day(-1)) commencing 1 or 2 weeks after bile duct ligation. Animals with bile duct ligation only and sham-operated animals served as controls. Four weeks after bile duct ligation, indices of fibrosis were assessed. RESULTS Captopril treatment significantly reduced hepatic hydroxyproline levels, mean fibrosis score, steady state messenger RNA levels of TGF-beta1 and procollagen alpha1(I), and matrix metalloproteinase 2 and 9 activity. CONCLUSIONS Captopril significantly attenuates the progression of hepatic fibrosis in the rat bile duct ligation model, and its effectiveness should be studied in human chronic liver diseases associated with progressive fibrosis.
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Affiliation(s)
- J R Jonsson
- Department of Surgery, The University of Queensland, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Queensland, Australia.
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16
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Jonsson JR, Hong C, Purdie DM, Hawley C, Isbel N, Butler M, Balderson GA, Clouston AD, Pandeya N, Stuart K, Edwards-Smith C, Crawford DH, Fawcett J, Powell EE. Role of cytokine gene polymorphisms in acute rejection and renal impairment after liver transplantation. Liver Transpl 2001; 7:255-63. [PMID: 11244168 DOI: 10.1053/jlts.2001.22450] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [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] [Indexed: 02/07/2023]
Abstract
Although immunosuppressive regimens are effective, rejection occurs in up to 50% of patients after orthotopic liver transplantation (OLT), and there is concern about side effects from long-term therapy. Knowledge of clinical and immunogenetic variables may allow tailoring of immunosuppressive therapy to patients according to their potential risks. We studied the association between transforming growth factor-beta, interleukin-10, and tumor necrosis factor alpha (TNF-alpha) gene polymorphisms and graft rejection and renal impairment in 121 white liver transplant recipients. Clinical variables were collected retrospectively, and creatinine clearance was estimated using the formula of Cockcroft and Gault. Biallelic polymorphisms were detected using polymerase chain reaction-based methods. Thirty-seven of 121 patients (30.6%) developed at least 1 episode of rejection. Multivariate analysis showed that Child-Pugh score (P =.001), immune-mediated liver disease (P =.018), normal pre-OLT creatinine clearance (P =.037), and fewer HLA class 1 mismatches (P =.038) were independently associated with rejection. Renal impairment occurred in 80% of patients and was moderate or severe in 39%. Clinical variables independently associated with renal impairment were female sex (P =.001), pre-OLT renal dysfunction (P =.0001), and a diagnosis of viral hepatitis (P =.0008). There was a significant difference in the frequency of TNF-alpha-308 alleles among the primary liver diseases. After adjustment for potential confounders and a Bonferroni correction, the association between the TNF-alpha-308 polymorphism and graft rejection approached significance (P =.06). Recipient cytokine genotypes do not have a major independent role in graft rejection or renal impairment after OLT. Additional studies of immunogenetic factors require analysis of large numbers of patients with appropriate phenotypic information to avoid population stratification, which may lead to inappropriate conclusions.
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Affiliation(s)
- J R Jonsson
- Department of Surgery, The University of Queensland, The Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, Queensland 4102, Australia
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17
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Abstract
BACKGROUND/AIMS Steatosis is a frequent histological finding in chronic hepatitis C and is associated with increased hepatic fibrosis. METHODS We studied 80 patients with untreated chronic hepatitis C to determine whether steatosis contributes to fibrosis through a steatohepatitis-like pathway. RESULTS Fine sinusoidal and/or central vein fibrosis was present in 52 patients (65%). This was typically located in acinar zone 3 and had a chicken-wire appearance similar to that seen in steatohepatitis. A statistically significant relationship was found between subsinusoidal fibrosis and age (r(s) = 0.33, P = 0.003) and grade of steatosis (r(s) = 0.35, P = 0.001). Mean body mass index was higher in patients with focal (28.4 +/- 4.7 kg/m2) or extensive (29.6 +/- 5.9 kg/m2) subsinusoidal fibrosis than in those patients with no subsinusoidal fibrosis (25.5 +/- 3.7 kg/m2). The extent of alpha-smooth muscle actin staining (as a marker of stellate cell activation) correlated with the degree of portal inflammation and the stage of portal fibrosis, but not with the grade of hepatic steatosis. CONCLUSIONS These findings suggest that in hepatitis C infection, host factors, particularly adiposity, contribute to both steatosis and acinar fibrosis. The implication of these observations is that weight reduction may provide an important therapeutic strategy for patients with chronic hepatitis C.
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Affiliation(s)
- A D Clouston
- Department of Pathology, University of Queensland Mayne Medical School, Brisbane, Australia.
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18
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Gerhardt RR, Gottfried KL, Apperson CS, Davis BS, Erwin PC, Smith AB, Panella NA, Powell EE, Nasci RS. First isolation of La Crosse virus from naturally infected Aedes albopictus. Emerg Infect Dis 2001; 7:807-11. [PMID: 11747692 PMCID: PMC2631884 DOI: 10.3201/eid0705.017506] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
La Crosse (LAC) virus, a California serogroup bunyavirus, is the leading cause of pediatric arboviral encephalitis in the United States and an emerging disease in Tennessee, West Virginia, and North Carolina. Human cases of LAC encephalitis in Tennessee and North Carolina have increased above endemic levels during 1997 to 1999 and may represent an expansion of a new southeastern endemic focus. This report describes the isolation of LAC virus from the exotic mosquito Aedes albopictus. The discovery of LAC virus in wild populations of Ae. albopictus coupled with its expanding distribution in the southeastern United States, suggests that this mosquito may become an important accessory vector, potentially increasing the number of human cases in endemic foci or expanding the range of the disease.
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19
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Fanning PA, Jonsson JR, Clouston AD, Edwards-Smith C, Balderson GA, Macdonald GA, Crawford DH, Kerlin P, Powell LW, Powell EE. Detection of male DNA in the liver of female patients with primary biliary cirrhosis. J Hepatol 2000; 33:690-5. [PMID: 11097474 DOI: 10.1016/s0168-8278(00)80297-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.8] [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] [Indexed: 12/04/2022]
Abstract
BACKGROUND/AIMS Primary biliary cirrhosis is a chronic cholestatic liver disease characterized by progressive inflammatory destruction of bile ducts, with eventual hepatic fibrosis and cirrhosis. Since primary biliary cirrhosis affects predominantly middle-aged women and has pathological similarities to hepatic graft-versus-host-disease, we investigated whether fetal cell microchimerism might be involved in the development of this disease. METHODS The presence of Y-chromosome-specific sequences was analyzed by polymerase chain reaction using peripheral blood mononuclear cells from women with primary biliary cirrhosis (n=18) and healthy (control) women (n=18), and by in situ hybridization of liver biopsy sections from women with primary biliary cirrhosis (n=19) and women with chronic hepatitis C or alcoholic liver disease (n=20). RESULTS Male cells were detected in liver biopsy specimens of 8 of 19 patients (42%) with primary biliary cirrhosis. Y-chromosome-containing cells were not seen in any of the liver biopsy specimens from women with chronic hepatitis C or alcoholic liver disease. Male cells were detected in peripheral blood mononuclear cells from one healthy control at a level of 1 male cell per 10(6) female cells, but were not detected in peripheral blood mononuclear cells of women with primary biliary cirrhosis. CONCLUSIONS The presence of male cells in the liver of women with primary biliary cirrhosis raises the possibility that fetal cell microchimerism may be involved in the pathogenesis of this chronic liver disease.
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Affiliation(s)
- P A Fanning
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Queensland, Brisbane, Australia
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20
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Herzig KA, Falk MC, Jonsson JR, Axelsen RA, Griffin AD, Hawley CM, Rigby RJ, Cobcroft R, Nicol DL, Powell EE, Johnson DW. Novel surveillance and cure of a donor-transmitted lymphoma in a renal allograft recipient. Transplantation 2000; 70:149-52. [PMID: 10919592] [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: 02/17/2023]
Abstract
BACKGROUND In this report we describe a malignant lymphoma of donor origin inadvertently transplanted into two renal allograft recipients, despite standard comprehensive donor screening. The successful clearance of the tumor from both patients and a novel method of surveillance are detailed. METHODS Initial management consisted of withdrawal of immunosuppression to promote rejection of the allograft and the transplanted tumor in both patients, followed by graft removal. Peripheral blood microchimerism was assessed in both recipients using nested polymerase chain reaction to detect the DYZ3 gene on the Y chromosome (donor male, recipients female). RESULTS Although microchimerism was detected on day 6 after transplantation and day 1 after explantation, repeat peripheral blood examination at 1, 3, and 6 months after explantation demonstrated no microchimerism. Both patients remain well at 12 months and have been relisted for transplantation. CONCLUSION Despite inadvertent transplantation of a previously undiagnosed malignancy of donor origin, the recipients' immune response was able to eliminate donor tumor cells after the withdrawal of immunosuppression. Repeated surveillance of peripheral blood from both recipients, using a novel application of the technique of nested polymerase chain reaction to amplify donor DNA, demonstrated no persistence of donor cells, supporting effective eradication of the donor malignancy.
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Affiliation(s)
- K A Herzig
- University of Queensland Department of Surgery, Princess Alexandra Hospital, Woolloongabba, Australia
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21
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Powell EE, Edwards-Smith CJ, Hay JL, Clouston AD, Crawford DH, Shorthouse C, Purdie DM, Jonsson JR. Host genetic factors influence disease progression in chronic hepatitis C. Hepatology 2000; 31:828-33. [PMID: 10733535 DOI: 10.1053/he.2000.6253] [Citation(s) in RCA: 316] [Impact Index Per Article: 13.2] [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] [Indexed: 02/06/2023]
Abstract
Progressive hepatic fibrosis and cirrhosis develops in 20% to 30% of patients with chronic hepatitis C virus (HCV). We propose that host genetic factors influencing fibrogenesis may account for some of the variability in progression of this disease. In progressive fibrosis of other organs, particularly heart and kidney, production of the profibrogenic cytokine, transforming growth factor beta1 (TGF-beta1), may be enhanced by angiotensin II, the principal effector molecule of the renin-angiotensin system. The inheritance of polymorphisms in TGF-beta1, interleukin 10 (IL-10), tumor necrosis factor alpha (TNF-alpha), and genes of the renin-angiotensin system was examined in 128 patients with chronic HCV. The influence of genotypes on the stage of hepatic fibrosis was tested after adjustment for potential confounders (age, gender, alcohol consumption, portal inflammation, and steatosis), which may have independent effects on histological severity. The stage of fibrosis was 0 in 30 (23.4%), 1 in 44 (34.4%), 2 in 27 (21.1%), and 3 or 4 in 27 (21.1%). A statistically significant relationship was seen between inheritance of high TGF-beta1- and angiotensinogen (AT)-producing genotypes and the development of progressive hepatic fibrosis. This association persisted after correcting for potential confounders. Patients who inherited neither of the profibrogenic genotypes had no or only minimal fibrosis. Knowledge of these polymorphisms may have prognostic significance in patients with chronic HCV and may direct more aggressive therapy towards those patients with an increased risk of disease progression. The documentation of a significant relationship between AT genotype and fibrosis raises the novel suggestion that angiotensin II may be another mediator of extracellular matrix production in the liver.
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Affiliation(s)
- E E Powell
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
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22
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Jonsson JR, Edwards-Smith CJ, Catania SC, Morotomi Y, Hogan PG, Clouston AD, Bansal AS, Lynch SV, Strong RW, Powell EE. Expression of cytokines and factors modulating apoptosis by human sinusoidal leucocytes. J Hepatol 2000; 32:392-8. [PMID: 10735607 DOI: 10.1016/s0168-8278(00)80388-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [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] [Indexed: 12/04/2022]
Abstract
BACKGROUND/AIMS Liver sinusoids contain a large population of spontaneously cytotoxic cells (NK cells), CD8+ T cells and macrophages. The physiological role of these leucocytes remains unclear. They may participate in immune surveillance and peripheral tolerance by deleting tumour cells, virus-infected cells and activated T cells as they traffic through the liver. In order to gain further information about the function of these leucocytes within the hepatic sinusoids, we examined their production of immunomodulatory cytokines and apoptosis-related molecules. METHODS Semi-quantitative polymerase chain reaction and immunohistochemistry were used to determine the spontaneous production of cytokines and apoptosis-related molecules by sinusoidal leucocytes isolated from donor liver preservation solution. RESULTS In comparison with matched peripheral blood mononuclear cells, sinusoidal leucocytes produced more mRNA for IL-10, IL-15, TNF-alpha, IL-18, IFN-gamma, FasL, perforin and granzyme. IL-4 and IL-12 were not detected and IL-2 was only faintly detected in the liver-derived CD4+ population. Less bcl-2 was expressed in liver-derived CD4+ and CD8+ cells in comparison with matched peripheral blood cell populations. CONCLUSIONS The cytokines produced spontaneously by sinusoidal leucocytes are consistent with their high level of activation and spontaneous cytotoxicity. Their strong expression of apoptosis-mediating molecules (FasL, perforin, granzyme and TNF-alpha) support a role for these cells in immune surveillance and peripheral tolerance induction.
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Affiliation(s)
- J R Jonsson
- University of Queensland Department of Surgery, Princess Alexandra Hospital, Australia
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23
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Edwards-Smith CJ, Jonsson JR, Purdie DM, Bansal A, Shorthouse C, Powell EE. Interleukin-10 promoter polymorphism predicts initial response of chronic hepatitis C to interferon alfa. Hepatology 1999; 30:526-30. [PMID: 10421663 DOI: 10.1002/hep.510300207] [Citation(s) in RCA: 329] [Impact Index Per Article: 13.2] [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] [Indexed: 12/18/2022]
Abstract
Serum levels of interleukin-10 (IL-10) are elevated in a proportion of patients with untreated chronic hepatitis C, and this may compromise the host immune response to the virus. The capacity for IL-10 production varies according to the genetic composition of the IL-10 locus. We examined the inheritance of 3 biallelic polymorphisms in the IL-10 gene promoter in patients with chronic hepatitis C and their association with response to treatment with interferon alfa (IFN-alpha). After adjusting for potential confounding variables, a highly significant relationship was found between inheritance of the IL-10 promoter -592*A and -819*T alleles or the ATA haplotype and response to IFN-alpha therapy (P =.016). Response to treatment was also associated with viral genotype 3a, a low viral load, and less fibrosis on liver biopsy. Following in vitro stimulation of peripheral blood mononuclear cells, the IL-10 promoter haplotypes, GCC, ACC, and ATA, were associated with high, intermediate, and low IL-10 production, respectively. These findings indicate that heterogeneity in the promoter region of the IL-10 gene has a role in determining the initial response of chronic hepatitis C to IFN-alpha therapy. Patients who are genetically predisposed to high IL-10 production have a poor response to IFN-alpha and may benefit from additional treatment strategies designed to enhance a T-helper type 1 (Th1) response.
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Affiliation(s)
- C J Edwards-Smith
- Department of Surgery,The University of Queensland, Brisbane, Australia
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24
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Maguire CM, Crawford DH, Hourigan LF, Clouston AD, Walpole ET, Powell EE. Case report: lamivudine therapy for submassive hepatic necrosis due to reactivation of hepatitis B following chemotherapy. J Gastroenterol Hepatol 1999; 14:801-3. [PMID: 10482432 DOI: 10.1046/j.1440-1746.1999.01961.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [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] [Indexed: 12/09/2022]
Abstract
This report describes the case of a 53-year-old woman who developed severe hepatitis following chemotherapy for breast carcinoma. The patient was hepatitis B surface antigen positive, e antigen negative and e antibody positive and had high levels of hepatitis B virus-DNA. Liver biopsy revealed submassive hepatic necrosis, consistent with reactivation of hepatitis B. Treatment with lamivudine resulted in rapid loss of hepatitis B virus-DNA, resolution of hepatitis and clinical recovery.
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Affiliation(s)
- C M Maguire
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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25
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Jonsson JR, Gill D, Hogan PG, Clouston AD, Edwards-Smith C, Griffin AD, Balderson GA, Lynch SV, Strong RW, Powell EE. Role of donor leukocyte chimerism in establishing the etiology of neutropenia after liver transplantation. Transplantation 1999; 67:1358-61. [PMID: 10360590 DOI: 10.1097/00007890-199905270-00011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The quantitation of donor leukocyte chimerism may aid in establishing the etiology of neutropenia after liver transplantation. METHODS The incidence and clinical and laboratory characteristics of severe neutropenia were studied in adults who have undergone liver transplantation at our institution over the last 4 years. RESULTS Severe neutropenia developed in 5 of 156 patients (3%). The clinical and pathological features were nonspecific. In two patients with a delayed diagnosis of graft-versus-host disease (GVHD), donor leukocytes comprised > or = 50% of the circulating peripheral blood mononuclear cells. In a third patient, an earlier diagnosis of GVHD was suspected on the basis of a donor leukocyte count of 3-10% in the peripheral blood. In contrast, donor leukocyte chimerism was < or = 0.01% in two patients with probable drug-induced neutropenia CONCLUSIONS The determination of donor leukocyte chimerism has an important role in the investigation of neutropenia after liver transplantation, allowing early diagnosis and treatment of GVHD.
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Affiliation(s)
- J R Jonsson
- Department of Surgery, The University of Queensland, Brisbane, Australia
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26
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Hourigan LF, Macdonald GA, Purdie D, Whitehall VH, Shorthouse C, Clouston A, Powell EE. Fibrosis in chronic hepatitis C correlates significantly with body mass index and steatosis. Hepatology 1999. [PMID: 10094967 DOI: 10.1002/hep.5102.90401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Steatosis is a frequent histological finding in chronic hepatitis C infection; however, the pathophysiology of steatosis and its role in disease progression have not been established. We studied 148 consecutive patients with untreated chronic hepatitis C to assess the effect of body mass index, diabetes mellitus, alcohol consumption, hepatic iron content, and viral load on steatosis and hepatic fibrosis. Ninety-one patients (61%) had steatosis: grade 1 (<30% hepatocytes involved) in 61 (41%), grade 2 (30%-70% hepatocytes involved) in 17 (11%), and grade 3 (>70% hepatocytes involved) in 13 (9%). After adjusting for potential confounding variables, a highly significant relationship was found primarily between steatosis and body mass index (P <.0001). The mean (+/-SD) body mass index of patients with no steatosis was 23.9 +/- 4.3 kg/m2, whereas for grade 1 steatosis it was 26.5 +/- 5.1 kg/m2, and for grade 2 and 3 steatosis combined the body mass index was 28.4 +/- 4. 9 kg/m2. Hepatic fibrosis was significantly associated with age (P =. 002). After adjusting for potential confounding variables, including age, hepatic fibrosis was also significantly associated with steatosis (P <.03). There was no significant association between hepatic iron content, alcohol intake, gender, and viral load and steatosis or fibrosis. These findings suggest that increasing body mass index has a role in the pathogenesis of steatosis in chronic hepatitis C and that steatosis may contribute to fibrosis. The association between body mass index and steatosis and fibrosis has important prognostic and therapeutic implications in the management of patients with chronic hepatitis C virus.
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Affiliation(s)
- L F Hourigan
- Department of Gastroenterology and Hepatology, The Princess Alexandra Hospital, The University of Queensland, Brisbane, Australia
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Bell TM, Bansal AS, Shorthouse C, Sandford N, Powell EE. Low-titre auto-antibodies predict autoimmune disease during interferon-alpha treatment of chronic hepatitis C. J Gastroenterol Hepatol 1999; 14:419-22. [PMID: 10355504 DOI: 10.1046/j.1440-1746.1999.01896.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [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] [Indexed: 12/12/2022]
Abstract
BACKGROUND In this study, we determined whether low-titre auto-antibodies are a risk factor for the development of autoimmune disease during interferon-alpha (IFNalpha) therapy for chronic hepatitis C (CHC) infection. METHODS Eighty-three patients with circulating hepatitis C virus RNA and chronic viral hepatitis on liver biopsy, who had not received IFNalpha, were assessed for serum auto-antibodies (anti-nuclear antibodies (ANA), anti-smooth muscle antibodies, thyroid microsomal antibodies, thyroglobulin antibodies) and thyroid function tests. RESULTS Thirty-five patients had one or more pre-existing auto-antibody. The majority were low titre ANA. Seven of the 35 patients had clinical autoimmune disease or immune-mediated disorders, predominantly thyroid disease. Twenty patients with low titre auto-antibodies received treatment with IFNalpha and of these 20 patients, six patients developed adverse effects with a possible auto-immune basis. In comparison, only five of the 48 patients without auto-antibodies had immune-mediated disorders and no patient developed autoimmune complications during therapy with IFNalpha. CONCLUSIONS These results suggest that the presence of low-titre auto-antibodies may be a risk factor for the development of autoimmune dysfunction during IFNalpha therapy for chronic hepatitis C. Patients with no detectable auto-antibodies have a low risk for developing autoimmune complications during treatment with IFNalpha.
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Affiliation(s)
- T M Bell
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Hourigan LF, Macdonald GA, Purdie D, Whitehall VH, Shorthouse C, Clouston A, Powell EE. Fibrosis in chronic hepatitis C correlates significantly with body mass index and steatosis. Hepatology 1999; 29:1215-9. [PMID: 10094967 DOI: 10.1002/hep.510290401] [Citation(s) in RCA: 466] [Impact Index Per Article: 18.6] [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] [Indexed: 12/12/2022]
Abstract
Steatosis is a frequent histological finding in chronic hepatitis C infection; however, the pathophysiology of steatosis and its role in disease progression have not been established. We studied 148 consecutive patients with untreated chronic hepatitis C to assess the effect of body mass index, diabetes mellitus, alcohol consumption, hepatic iron content, and viral load on steatosis and hepatic fibrosis. Ninety-one patients (61%) had steatosis: grade 1 (<30% hepatocytes involved) in 61 (41%), grade 2 (30%-70% hepatocytes involved) in 17 (11%), and grade 3 (>70% hepatocytes involved) in 13 (9%). After adjusting for potential confounding variables, a highly significant relationship was found primarily between steatosis and body mass index (P <.0001). The mean (+/-SD) body mass index of patients with no steatosis was 23.9 +/- 4.3 kg/m2, whereas for grade 1 steatosis it was 26.5 +/- 5.1 kg/m2, and for grade 2 and 3 steatosis combined the body mass index was 28.4 +/- 4. 9 kg/m2. Hepatic fibrosis was significantly associated with age (P =. 002). After adjusting for potential confounding variables, including age, hepatic fibrosis was also significantly associated with steatosis (P <.03). There was no significant association between hepatic iron content, alcohol intake, gender, and viral load and steatosis or fibrosis. These findings suggest that increasing body mass index has a role in the pathogenesis of steatosis in chronic hepatitis C and that steatosis may contribute to fibrosis. The association between body mass index and steatosis and fibrosis has important prognostic and therapeutic implications in the management of patients with chronic hepatitis C virus.
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Affiliation(s)
- L F Hourigan
- Department of Gastroenterology and Hepatology, The Princess Alexandra Hospital, The University of Queensland, Brisbane, Australia
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29
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Harrison BA, Whitt PB, Powell EE, Hickman EY. North Carolina mosquito records. I. Uncommon Aedes and Anopheles (Diptera: Culicidae). J Am Mosq Control Assoc 1998; 14:165-172. [PMID: 9673917] [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] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
New distribution records are provided for 10 mosquito species that are rare or uncommon in North Carolina: Aedes aegypti, Ae. cinereus, Ae. dupreei, Ae. fulvus pallens, Ae. hendersoni, Ae. mitchellae, Ae. thibaulti, Ae. tormentor, Ae. trivittatus, and Anopheles atropos. Biological notes are provided for habitats, behavior, and, in some cases, color patterns. Comments are also made about 6 additional species that are rare or uncommon in North Carolina.
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Affiliation(s)
- B A Harrison
- Department of Environment and Natural Resources, Winston-Salem, NC 27107, USA
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30
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Jonsson JR, Hogan PG, Balderson GA, Ooi LL, Lynch SV, Strong RW, Powell EE. Human liver transplant perfusate: an abundant source of donor liver-associated leukocytes. Hepatology 1997; 26:1111-4. [PMID: 9362349 DOI: 10.1002/hep.510260504] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [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] [Indexed: 02/05/2023]
Abstract
In vitro studies designed to examine the mechanisms of immune tolerance after liver transplantation in humans have been hampered by the difficulty in obtaining sufficient numbers of donor liver-associated leukocytes (LALs). We have investigated whether the ex vivo perfusion of donor livers releases a population of LALs that can be readily retrieved from the waste fluid. The mean number of cells recovered after Ficoll-Hypaque density-gradient separation was 2.6 +/- 0.5 x 10(8) cells, with a viability of 94% +/- 2%. The perfusate lymphocytes comprised mainly T cells (39% +/- 2%) with a very low CD4/CD8 ratio and natural killer (NK) cells (56% +/- 6%) with an increase in the proportion of the CD3-CD56+CD16- subset. The activation marker CD69 was present on the majority of the perfusate lymphocytes. These are the phenotypic characteristics that have been previously reported for lymphocytes isolated from hepatic sinusoids. In mixed lymphocyte reactions, the perfusate cells showed a marked increase in the ability to stimulate allogeneic responder cells, resulting in 353% +/- 78% (P = .003) greater incorporation of [3H]thymidine in responder cells when compared with stimulation by donor peripheral blood mononuclear cells. The results show that large numbers of viable donor lymphocytes can be readily isolated from the liver perfusate solution. These cells have the characteristics of liver-associated lymphocytes with a predominance of activated NK and CD8+ T cells. This population can now be used in in vitro assays to elucidate the influence of donor leukocytes on the development of graft acceptance.
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Affiliation(s)
- J R Jonsson
- Department of Surgery, University of Queensland, Brisbane, Australia
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31
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Bansal AS, Bruce J, Hogan PG, Prichard P, Powell EE. Serum soluble CD23 but not IL8, IL10, GM-CSF, or IFN-gamma is elevated in patients with hepatitis C infection. Clin Immunol Immunopathol 1997; 84:139-44. [PMID: 9245544 DOI: 10.1006/clin.1997.4371] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The increased frequency of autoantibodies and B cell non-Hodgkins lymphoma (B-NHL) in hepatitis C virus (HCV) infection suggests dysregulated humoral immunity. Soluble CD23 (sCD23) is involved in B cell activation and proliferation and the serum levels are raised in autoimmune diseases and B cell lymphoproliferative disease. We compared the serum levels of sCD23 in patients with HCV infection with those in patients with alcoholic cirrhosis (AC) and in healthy controls. Serum levels of interleukin (IL) 8, IL10, granulocyte macrophage-colony stimulating factor, and interferon-gamma were assessed simultaneously to check for generalized nonspecific immune stimulation. In contrast to the essentially normal serum levels of these latter cytokines, the levels of sCD23 were raised in the patients with HCV compared to those with AC and the normal controls (medians 34.0, 10.1, and 11.1 arbitrary units, respectively; HCV vs AC P < 0.0004, HCV vs controls P < 0.0001, AC vs controls P > 0.8). These results confirm HCV-induced humoral immune dysregulation and invite comparison with primary Sjögrens syndrome and Epstein-Barr virus infection, both of which are also associated with raised levels of serum sCD23, autoantibodies, and B-NHL.
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Affiliation(s)
- A S Bansal
- Department of Medicine, University of Queensland, Australia
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32
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Jonsson JR, Hogan PG, Thomas R, Steadman C, Clouston AD, Balderson GA, Lynch SV, Strong RW, Powell EE. Peripheral blood chimerism following human liver transplantation. Hepatology 1997; 25:1233-6. [PMID: 9141443 DOI: 10.1002/hep.510250528] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.8] [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] [Indexed: 02/04/2023]
Abstract
The aim of this study was to prospectively investigate the peak levels and kinetics of donor leucocyte chimerism in human recipients following liver transplantation. The peak levels of chimerism were observed within the first 48 hours following transplantation and ranged from 0.15% to 20% of total peripheral blood mononuclear cells. In all but one patient, who developed graft versus host disease, there was an early peak level of chimerism that declined over time such that donor leukocytes were only intermittently detectable after 3 to 4 weeks. In 8 patients who had no episodes of graft rejection, the peak level of donor leukocyte chimerism ranged from 1.3% to 20% (mean +/- SEM; 5.5% +/- 2.1%). In 3 patients who were treated for episodes of acute graft rejection during the first four postoperative weeks, the peak level of donor leukocyte chimerism ranged from 0.15% to 0.2% (0.18 +/- 0.02, P = .012). The results demonstrate a marked variation in the total number of donor leukocytes detectable in the peripheral blood early after liver transplantation and also, that lower levels of chimerism may be associated with lower rates of initial graft acceptance and a higher incidence of acute rejection.
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Affiliation(s)
- J R Jonsson
- University of Queensland Department of Surgery, Brisbane, Australia
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33
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Szumlas DE, Apperson CS, Powell EE, Hartig P, Francy DB, Karabotsos N. Relative abundance and species composition of mosquito populations (Diptera:Culicidae) in a La Crosse virus-endemic area in western North Carolina. J Med Entomol 1996; 33:598-607. [PMID: 8699454 DOI: 10.1093/jmedent/33.4.598] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Container surveys were conducted in 5 communities on the Cherokee Indian Reservation, an area of western North Carolina endemic for transmission of La Crosse (LAC) virus, to determine the potential for peridomestic mosquito breeding, the relative abundance of mosquito species, and the standing crop of mosquitoes per residence. Eleven species of mosquitoes were collected, but 80.9% of all mosquitoes reared from containers were Aedes triseriatus (Say). All communities averaged > 6 containers per residence, indicating that the potential for mosquito production was high. The Breteau index and mean standing crop of adults per residence in the 5 communities were highly concordant. LAC virus was isolated from 2 pools of 56 female and 36 male Ae. triseriatus adults that were reared from eggs collected by ovitraps. The minimum field infection rate was 0.26 per 1,000 adults tested. Aedes triseriatus, the most frequently collected blood-fed mosquito (98/112 blood-engorged specimens), fed predominantly on dogs (40.4%), rabbits (26.6%), and turtles (22.3%). Only 7.5% of the blood-fed mosquitoes had fed on eastern chipmunks. Peridomestic conditions on the Reservation appear to contribute to the maintenance of LAC virus transmission. Production of Ae. triseriatus occurs in artificial containers discarded around residences, and wooded areas immediately adjacent to residences provide resting cover for mosquitoes as well as suitable habitat for LAC virus reservoir hosts.
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Affiliation(s)
- D E Szumlas
- Department of Entomology, North Carolina State University, Raleigh 27695-7613, USA
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34
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Szumlas DE, Apperson CS, Powell EE. Seasonal occurrence and abundance of Aedes triseriatus and other mosquitoes in a La Crosse virus-endemic area in western North Carolina. J Am Mosq Control Assoc 1996; 12:184-193. [PMID: 8827591] [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] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The species composition and population abundance of mosquitoes were investigated from May to November in 1989 and 1990 on the Cherokee Indian Reservation, an area of western North Carolina endemic for transmission of La Crosse (LAC) virus. Mosquitoes representing 6 genera and 13 species were collected. Aedes triseriatus was the most abundant species collected, comprising over 98% of mosquitoes collected by ovitrapping and CO2-baited suction trapping, and 88% of resting adults collected by vacuuming vegetation and leaf litter. Culex restuans and Anopheles punctipennis were common but much less frequently collected. Host-seeking and resting Ae. triseriatus were most abundant in early to midsummer, whereas gravid Ae. triseriatus was most active in the fall. The previous occurrence of cases of LAC encephalitis was concordant with the seasonal activity of gravid but not host-seeking or resting Ae. triseriatus.
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Affiliation(s)
- D E Szumlas
- Department of Entomology, North Carolina State University, Raleigh 27695-7647, USA
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35
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McAleer MA, Reifsnyder P, Palmer SM, Prochazka M, Love JM, Copeman JB, Powell EE, Rodrigues NR, Prins JB, Serreze DV. Crosses of NOD mice with the related NON strain. A polygenic model for IDDM. Diabetes 1995; 44:1186-95. [PMID: 7556956 DOI: 10.2337/diab.44.10.1186] [Citation(s) in RCA: 99] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Chromosome locations of non-major histocompatibility complex (MHC) genes contributing to insulin-dependent diabetes mellitus (IDDM) in mice have been determined by outcrossing NOD mice to other inbred strains congenic for the NOD MHC haplotype (H2g7). At least nine non-MHC IDDM susceptibility genes (Idd) were previously identified at first backcross (BC1) after outcross of NOD to C57BL/10.H2g7 congenic mice (B10.H2g7). We investigated whether the same set of Idd loci segregated with IDDM susceptibility after outcross of NOD to NON.H2g7 congenic mice. Since the outcrosses to NON.H2g7 and B10.H2g7 were performed in the same vivarium, direct comparisons were made of the chromosomal locations and relative strengths of Idd alleles in diabetic progeny from the two different outcrosses. In comparison with the NOD x B10.H2g7 outcross, the NOD x NON.H2g7 outcross produced significantly higher IDDM frequencies in F1, F2, and BC1 generations. The high F2 diabetes frequency allowed evaluation of the effects of homozygous expression of both the susceptibility and the resistance allele at Idd loci. This analysis demonstrated that no single non-MHC Idd locus was essential for the onset of diabetes in this cross. After outcross to NON.H2g7, Idd4 (chromosome [Chr] 11), Idd5 (Chr 1), and Idd8 (Chr 14) did not segregate with IDDM in either the BC1 or the F2 generation. Diabetogenic NOD-derived alleles at Idd2 (Chr 9), Idd3 (Chr 3), and Idd10 (Chr 3) were segregating in the BC1. An NON-derived allele contributing to susceptibility on Chr 7 (Idd7) was also detected. Dominant traits, detectable only in the F2 cross, were encoded by Chr 4 (Idd9) and two newly mapped loci on Chr 13 (Idd14) and 5 (Idd15). A third dominant trait was encoded by Chr 6 (possibly Idd6), but here, in contrast to Idd9, Idd14, and Idd15, the NON allele was diabetogenic. Stepwise logistic regression analysis of the BC1 and F2 data confirmed that the ability to identify certainty of the non-MHC Idd loci was contingent on the extent of homozygosity for NOD background genes. This study shows that the diabetogenic phenotype can be achieved through the actions of variable combinations of MHC-unlinked genes and a diabetogenic MHC haplotype.
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Affiliation(s)
- M A McAleer
- Nuffield Department of Surgery, Wellcome Trust Centre for Human Genetics, University of Oxford, Headington, UK
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Bennett ST, Lucassen AM, Gough SC, Powell EE, Undlien DE, Pritchard LE, Merriman ME, Kawaguchi Y, Dronsfield MJ, Pociot F. Susceptibility to human type 1 diabetes at IDDM2 is determined by tandem repeat variation at the insulin gene minisatellite locus. Nat Genet 1995; 9:284-92. [PMID: 7773291 DOI: 10.1038/ng0395-284] [Citation(s) in RCA: 526] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The IDDM2 locus encoding susceptibility to type 1 diabetes was mapped previously to a 4.1-kb region spanning the insulin gene and a minisatellite or variable number of tandem repeats (VNTR) locus on human chromosome 11p15.5. By 'cross-match' haplotype analysis and linkage disequilibrium mapping, we have mapped the mutation IDDM2 to within the VNTR itself. Other polymorphisms were systematically excluded as primary disease determinants. Transmission of IDDM2 may be influenced by parent-of-origin phenomena. Although we show that the insulin gene is expressed biallelically in the adult pancreas, we present preliminary evidence that the level of transcription in vivo is correlated with allelic variation within the VNTR. Allelic variation at VNTRs may play an important general role in human disease.
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Affiliation(s)
- S T Bennett
- Nuffield Department of Surgery, Wellcome Trust Centre for Human Genetics, University of Oxford, UK
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37
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Abstract
Fertility is reduced in women with chronic active autoimmune hepatitis (AIH) and pregnancy is hazardous. This report describes a 33 year old woman with AIH and cirrhosis in whom a successful pregnancy was achieved following in vitro fertilization/embryo transfer. Disease exacerbation during pregnancy was controlled by azathioprine and an increased dose of prednisone, and a healthy child was delivered by Caesarean section at 36 weeks gestation. Since the perinatal care of preterm infants and the obstetric care available to women with complicated medical problems has improved markedly in recent years and since active disease can be controlled by adequate immunosuppressive therapy, we propose that it is justified to allow these patients access to in vitro fertilization programmes.
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Affiliation(s)
- E E Powell
- Clinical Research Centre, Royal Brisbane Hospital Foundation, University of Queensland, Australia
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38
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Affiliation(s)
- E E Powell
- Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, Headington, UK
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39
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Powell EE, Kroon PA. Low density lipoprotein receptor and 3-hydroxy-3-methylglutaryl coenzyme A reductase gene expression in human mononuclear leukocytes is regulated coordinately and parallels gene expression in human liver. J Clin Invest 1994; 93:2168-74. [PMID: 8182149 PMCID: PMC294355 DOI: 10.1172/jci117213] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The liver plays a key regulatory role in cholesterol metabolism. Two proteins are central in this role; the LDL receptor and 3-hydroxy-3-methylglutaryl CoA reductase (HMG CoA reductase), the rate-limiting enzyme in cholesterol biosynthesis. In the current investigation, we have used a sensitive nonradioactive method to study the regulation of LDL receptor and HMG CoA reductase mRNA levels in liver biopsy samples and freshly isolated mononuclear leukocytes from 13 patients who underwent cholecystectomy for gallstones. mRNA copy numbers were determined by PCR amplification of reverse-transcribed RNA using synthetic RNA as an internal standard. Incorporation of digoxigenin-11-dUTP during amplification allowed direct detection and quantitation of mRNA levels by chemiluminescence. These experiments showed that the average number of LDL receptor mRNA molecules in liver (21 +/- 3 x 10(4)/micrograms of RNA) and mononuclear leukocytes (24 +/- 3 x 10(4)/micrograms of RNA) are indistinguishable, whereas the number of HMG CoA reductase molecules in liver (107 +/- 15 x 10(4)/micrograms of RNA) is smaller than that in mononuclear leukocytes (158 +/- 21 x 10(4)/micrograms of RNA, P < 0.05). These numbers correspond to an average of 1-6 copies of LDL receptor mRNA and 5-42 copies of HMG CoA reductase mRNA per cell. There was a significant correlation between the numbers of LDL receptor (P = 0.0005) and HMG CoA reductase (P = 0.003) mRNA molecules in liver and mononuclear leukocytes. Furthermore, the numbers of copies of HMG CoA reductase and LDL receptor mRNA were correlated with each other in both liver (P = 0.02) and mononuclear leukocytes (P = 0.01), consistent with coordinate regulation. These data demonstrate that the mechanisms which regulate mRNA levels in liver and mononuclear cells are similar and suggest that freshly isolated mononuclear cells can be used to predict HMG CoA reductase and LDL receptor mRNA levels in liver.
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Affiliation(s)
- E E Powell
- Department of Biochemistry, University of Queensland, Brisbane, Australia
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40
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41
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Powell EE, Kroon PA. Measurement of mRNA by quantitative PCR with a nonradioactive label. J Lipid Res 1992; 33:609-14. [PMID: 1527484] [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: 12/27/2022] Open
Abstract
This report describes the development of a method to measure mRNA in small samples of human tissue by the polymerase chain reaction with a nonradioactive label. In this method RNA is reverse-transcribed in the presence of a control RNA, and subsequently amplified by the polymerase chain reaction during which a nonradioactive label (digoxigenin-11-dUTP) is incorporated. Gel blotting and immunological detection of digoxigenin followed by a chemiluminescent reaction provide an intense signal on film. This allows the detection and quantitation of 3-hydroxy-3-methylglutaryl (HMG) CoA reductase mRNA in 12 ng of RNA. We demonstrate that this is a sensitive and reproducible method, and that quantitation is linear with respect to the amount of mRNA present. The application of this method to the measurement of low density lipoprotein receptor and 3-hydroxy-3-methylglutaryl coenzyme A reductase mRNA levels in circulating peripheral blood mononuclear cells and human liver biopsy samples is discussed. The use of chemiluminescent reagents instead of radioactive labels allows this procedure to be performed safely in laboratories not equipped for radioactivity.
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Affiliation(s)
- E E Powell
- Department of Biochemistry, University of Queensland, Brisbane, Australia
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42
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Abstract
Cholesterol is a structural component of biological membranes and an immediate precursor for steroid hormones and bile acids. The liver is central to the production and removal of cholesterol-rich lipoproteins and bile acids. The basic biochemical aspects of hepatic lipoprotein and cholesterol metabolism and how abnormalities in liver function impair these metabolic pathways are reviewed.
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Affiliation(s)
- P A Kroon
- Department of Biochemistry, University of Queensland, Royal Brisbane Hospital, Australia
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43
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Abstract
The alterations in the concentration and composition of lipoproteins that occur in liver disease indicate the central role of the liver in lipoprotein metabolism. A number of studies have characterized plasma lipoproteins in patients with liver disease, although in most cases the underlying molecular defects responsible for the changes are still undetermined.
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Affiliation(s)
- E E Powell
- Department of Biochemistry, University of Queensland, Royal Brisbane Hospital, Australia
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44
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Fletcher LM, Kwoh-Gain I, Powell EE, Powell LW, Halliday JW. Markers of chronic alcohol ingestion in patients with nonalcoholic steatohepatitis: an aid to diagnosis. Hepatology 1991; 13:455-9. [PMID: 1999316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
We report here the use of the biochemical marker desialylated transferrin to aid in the diagnosis of nonalcoholic steatohepatitis. Conventional biochemical tests used for the detection of chronic alcohol consumption fail to differentiate nonalcoholic steatohepatitis patients from alcoholic subjects. In addition, even in those alcoholic subjects with alcoholic liver disease in whom biopsy has been performed, it is impossible to differentiate these two disease states on the basis of morphological examination alone. In this study we have examined two new markers of excessive alcohol intake, desialylated transferrin and mitochondrial AST in subjects with nonalcoholic steatohepatitis and in patients consuming excessive amounts of alcohol. All nonalcoholic steatohepatitis patients consumed minimal or no alcohol and were diagnosed by morphological criteria based on liver biopsy specimens. Alcoholic subjects were consuming in excess of 80 gm/day ethanol, often with clinical evidence of overt alcoholism. Control subjects included both healthy controls and patient controls with liver diseases unrelated to alcohol. The ratio of desialylated transferrin/total transferrin was elevated only in patients who consumed excessive amounts of alcohol, whereas the ratio of mitochondrial AST to total AST (mitochondrial AST/total AST) was not significantly different between alcoholic subjects and patients with nonalcoholic steatohepatitis. The sensitivity and specificity for the ratio desialylated transferrin/total transferrin was 81% and 98%, respectively, whereas the sensitivity for the mitochondrial AST/total AST ratio was 92%; the specificity was only 50%, indicating that there were a large number of false-positives. All the conventional markers were less sensitive and less specific than the ratio desialylated transferrin/total transferrin.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- L M Fletcher
- Department of Medicine, University of Queensland, Brisbane, Australia
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45
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Powell EE, Pender MP, Chalk JB, Parkin PJ, Strong R, Lynch S, Kerlin P, Cooksley WG, Cheng W, Powell LW. Improvement in chronic hepatocerebral degeneration following liver transplantation. Gastroenterology 1990; 98:1079-82. [PMID: 2311862 DOI: 10.1016/0016-5085(90)90036-z] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.2] [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] [Indexed: 12/31/2022]
Abstract
Chronic progressive hepatocerebral degeneration with spastic paraparesis, dementia, dysarthria, ataxia, tremor, and neuropsychiatric symptoms follows long-standing portal-systemic shunting, is associated with structural changes in the central nervous system, and does not respond to conventional therapy for hepatic encephalopathy. A case of advanced chronic liver disease with severe, progressive hepatocerebral degeneration after 23 yr of portal-systemic shunting is reported in whom there was significant objective improvement in intellectual function and in the chronic neurological signs 3 mo after orthotopic liver transplantation and further improvement 12 mo after transplantation.
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Affiliation(s)
- E E Powell
- Department of Medicine, University of Queensland, Australia
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Powell EE, Cooksley WG, Hanson R, Searle J, Halliday JW, Powell LW. The natural history of nonalcoholic steatohepatitis: a follow-up study of forty-two patients for up to 21 years. Hepatology 1990; 11:74-80. [PMID: 2295475 DOI: 10.1002/hep.1840110114] [Citation(s) in RCA: 1056] [Impact Index Per Article: 31.1] [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] [Indexed: 12/31/2022]
Abstract
Forty-two patients with nonalcoholic steatohepatitis were followed for a median of 4.5 yr (range = 1.5 to 21.5 yr). Except for two patients with lipodystrophy, all were obese; 35 of 42 were women, 26 of 32 were hyperlipidemic and 15 were hyperglycemic. Upper abdominal pain was the most common reason for presentation. Initial liver biopsy specimens showed the presence of macrovesicular fatty infiltration, lobular (acinar) inflammation, apoptosis, Mallory bodies (in four cases) and fibrosis (in 18 cases). Cirrhosis was present at initial diagnosis in one subject and in another two subjects liver biopsy showed marked fibrosis with disturbed architecture. Serial liver biopsy specimens revealed minimal or no apparent progression of the disorder in most of the patients, in keeping with their benign clinical course. However, one patient showed progression from fibrosis to cirrhosis during the 5-yr observation period, and in the patients with extensive fibrosis the liver disease evolved from one of active inflammation to one of inactive cirrhosis without fat or inflammation. The patient with cirrhosis later died of hepatocellular carcinoma. The severity or type of hepatic change did not correlate with the degree of obesity, hyperlipidemia or hyperglycemia. However, in individual patients, poorly controlled diabetes and rapid weight loss preceded the onset of steatohepatitis. We conclude that nonalcoholic steatohepatitis is a cause of hepatic inflammation histologically resembling that of alcohol-induced liver disease but usually slowly progressive and of low-grade severity. However, the disorder may ultimately result in cirrhosis. Nonalcoholic steatohepatitis should be distinguished from alcoholic steatohepatitis and recognized as a further cause of "cryptogenic cirrhosis."
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Affiliation(s)
- E E Powell
- Department of Medicine, University of Queensland, Australia
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Abstract
Two patients who presented with steatohepatitis had acquired partial lipodystrophy. This association has not previously been well documented. A common pathophysiological mechanism in lipodystrophy, obesity-associated nonalcoholic steatohepatitis, and alcoholic liver disease is possible.
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Affiliation(s)
- E E Powell
- Department of Medicine, University of Queensland, Brisbane, Australia
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Tierney TJ, Wythes JR, Powell EE, Crotty KJ, Shorthose WR, Rudder TH. Liveweight gains and carcass traits of high grade Simmental, Hereford, Africander x Hereford and Brahman x Hereford feedlot yearling steers. ACTA ACUST UNITED AC 1986. [DOI: 10.1071/ea9860651] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Sixty-three high grade Simmental (S), 40 Hereford (H), 96 Africander x Hereford (AH) and 33 Brahman x Hereford (BH) steers were fed high concentrate feedlot rations from about 8 months of age to slaughter at about 12 months to compare their suitability for producing feedlot beef. Selection for slaughter was made when estimated fat cover and liveweight were closest to market requirements (6-10 mm rib fat and 320-360 kg, respectively). The steers were slaughtered in 3 groups and their carcasses electrically stimulated. Mean slaughter liveweights and carcass weights were 398 and 212, 350 and 182, 349 and 189, 335 and 181 kg for S, H, AH and BH, respectively. Daily liveweight gains during the 4 months on feedlot rations were 1.53, 1.37, 1.24 and 1.25 kg/steer, respectively. Fat depths at rib 12-1 3 and sacral crest sites for S, H, AH and BH were 6.2 and 8.1, 7.3 and 10.3, 8.0 and 10.4,7.3 and 10.0 mm, respectively. In the same order, yield of saleable meat was 77.4, 75.7, 76.3 and 77.2%, and the S and BH had less fat trim than H and AH. Warner-Bratzler peak force shear values (kg) and cooking loss (%) were 3.4 and 33, 3.6 and 34, 3.9 and 34, 5.0 and 35 for S, H, AH and BH, respectively. There were no commercially important differences between H, AH and BH in terms of fat cover at preferred carcass weights and tenderness. However, feedlot liveweight gain favoured the H. Although S steers had highest liveweight gains, many steers did not have sufficient fat cover until liveweights were above the preferred range.
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