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Burton A, Wilburn J, Driver RJ, Wallace D, McPhail S, Cross TJS, Rowe IA, Marshall A. Routes to diagnosis for hepatocellular carcinoma patients: predictors and associations with treatment and mortality. Br J Cancer 2024:10.1038/s41416-024-02645-3. [PMID: 38499728 DOI: 10.1038/s41416-024-02645-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 02/22/2024] [Accepted: 02/26/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) incidence has increased rapidly, and prognosis remains poor. We aimed to explore predictors of routes to diagnosis (RtD), and outcomes, in HCC cases. METHODS HCC cases diagnosed 2006-2017 were identified from the National Cancer Registration Dataset and linked to Hospital Episode Statistics and the RtD metric. Multivariable logistic regression was used to explore associations between RtD, diagnosis year, 365-day mortality and receipt of potentially curative treatment. RESULTS 23,555 HCC cases were identified; 36.1% via emergency presentation (EP), 30.2% GP referral (GP), 17.1% outpatient referral, 11.0% two-week wait and 4.6% other/unknown routes. Odds of 365-day mortality was >70% lower via GP or OP routes than EP, and odds of curative treatment 3-4 times higher. Further adjustment for cancer/cirrhosis stage attenuated the associations with curative treatment. People who were older, female, had alcohol-related liver disease, or were more deprived, were at increased risk of an EP. Over time, diagnoses via EP decreased, and via GP increased. CONCLUSIONS HCC RtD is an important predictor of outcomes. Continuing to reduce EP and increase GP and OP presentations, for example by identifying and regularly monitoring patients at higher risk of HCC, may improve stage at diagnosis and survival.
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Affiliation(s)
- Anya Burton
- National Disease Registration Service, NHS England, Quarry House, Quarry Hill, Leeds, LS2 7UE, UK.
- Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Jennifer Wilburn
- National Disease Registration Service, NHS England, Quarry House, Quarry Hill, Leeds, LS2 7UE, UK
| | - Robert J Driver
- Leeds Institute for Medical Research at St. James's, University of Leeds, Leeds, LS9 7TF, UK
| | - David Wallace
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
- Institute of Liver Studies, Kings College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Sean McPhail
- National Disease Registration Service, NHS England, Quarry House, Quarry Hill, Leeds, LS2 7UE, UK
| | - Tim J S Cross
- Liverpool Experimental Cancer Medicine Centre, University of Liverpool, Liverpool, L7 8XP, UK
| | - Ian A Rowe
- Leeds Institute for Medical Research at St. James's, University of Leeds, Leeds, LS9 7TF, UK
| | - Aileen Marshall
- Sheila Sherlock Liver Centre, The Royal Free Hospital, London, NW3 2QG, UK
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2
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Hagström H, Adams LA, Allen AM, Byrne CD, Chang Y, Duseja A, Grønbæk H, Ismail MH, Jepsen P, Kanwal F, Kramer J, Loomba R, Mark HE, Newsome PN, Rinella ME, Rowe IA, Ryu S, Sanyal A, Schattenberg JM, Serper M, Sheron N, Simon TG, Spearman CW, Tapper EB, Villota-Rivas M, Wild SH, Wong VWS, Yilmaz Y, Zelber-Sagi S, Åberg F, Lazarus JV. The future of International Classification of Diseases coding in steatotic liver disease: An expert panel Delphi consensus statement. Hepatol Commun 2024; 8:e0386. [PMID: 38315102 PMCID: PMC10843430 DOI: 10.1097/hc9.0000000000000386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 12/01/2023] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Following the adoption of new nomenclature for steatotic liver disease, we aimed to build consensus on the use of International Classification of Diseases codes and recommendations for future research and advocacy. METHODS Through a two-stage Delphi process, a core group (n = 20) reviewed draft statements and recommendations (n = 6), indicating levels of agreement. Following revisions, this process was repeated with a large expert panel (n = 243) from 73 countries. RESULTS Consensus ranged from 88.8% to 96.9% (mean = 92.3%). CONCLUSIONS This global consensus statement provides guidance on harmonizing the International Classification of Diseases coding for steatotic liver disease and future directions to advance the field.
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Affiliation(s)
- Hannes Hagström
- Department of Upper GI, Division of Hepatology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Leon A. Adams
- Medical School, the University of Western Australia, Perth, Australia
| | - Alina M. Allen
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher D. Byrne
- Nutrition and Metabolism, Faculty of Medicine, University of Southampton, Southampton, UK
- Southampton National Institute for Health Research Biomedical Research Centre, University Hospital Southampton, Southampton General Hospital, Southampton, UK
| | - Yoosoo Chang
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Henning Grønbæk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Mona H. Ismail
- Department of Internal Medicine, Division of Gastroenterology, King Fahd Hospital of the University, Al-Khobar, Saudi Arabia
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Fasiha Kanwal
- Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Jennifer Kramer
- Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology and Epidemiology, University of California San Diego, La Jolla, California, USA
| | | | - Philip N. Newsome
- National Institute for Health Research Birmingham Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Mary E. Rinella
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Ian A. Rowe
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Seungho Ryu
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Arun Sanyal
- Department of Internal Medicine, Stravitz-Sanyal Institute of Liver Disease and Metabolic Health, VCU School of Medicine and Health System and Division of Gastroenterology, VCU School of Medicine, Richmond, Virginia, USA
| | - Jörn M. Schattenberg
- Department of Internal Medicine II, University Hospital of Saarland, Homburg, Germany
| | - Marina Serper
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nick Sheron
- The Roger Williams Institute of Hepatology, Foundation for Liver Research, Kings College London
| | - Tracey G. Simon
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - C. Wendy Spearman
- Department of Medicine, Division of Hepatology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Marcela Villota-Rivas
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Sarah H. Wild
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Yusuf Yilmaz
- Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Shira Zelber-Sagi
- School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
- Department of Gastroenterology, Tel Aviv Medical Centre, Tel Aviv, Israel
| | - Fredrik Åberg
- Transplantation and Liver Surgery, Helsinki University Hospital, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | - Jeffrey V. Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
- CUNY Graduate School of Public Health and Health Policy (CUNY SPH), New York, New York, USA
- Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
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3
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Rowe IA. Prediction of outcomes in patients with acute variceal bleeding. Hepatology 2024; 79:15-17. [PMID: 37607729 DOI: 10.1097/hep.0000000000000571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 07/28/2023] [Indexed: 08/24/2023]
Affiliation(s)
- Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds & Leeds Liver Unit, St James's University Hospital, Leeds, UK
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4
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Rowe IA, Villanueva C, Shearer JE, Torres F, Albillos A, Genescà J, Garcia-Pagan JC, Tripathi D, Hayes PC, Bosch J, Abraldes JG. Quantifying the benefit of nonselective beta-blockers in the prevention of hepatic decompensation: A Bayesian reanalysis of the PREDESCI trial. Hepatology 2023; 78:530-539. [PMID: 36897269 DOI: 10.1097/hep.0000000000000342] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/09/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND AND AIMS Beta-blockers have been studied for the prevention of variceal bleeding and, more recently, for the prevention of all-cause decompensation. Some uncertainties regarding the benefit of beta-blockers for the prevention of decompensation remain. Bayesian analyses enhance the interpretation of trials. The purpose of this study was to provide clinically meaningful estimates of both the probability and magnitude of the benefit of beta-blocker treatment across a range of patient types. APPROACH AND RESULTS We undertook a Bayesian reanalysis of PREDESCI incorporating 3 priors (moderate neutral, moderate optimistic, and weak pessimistic). The probability of clinical benefit was assessed considering the prevention of all-cause decompensation. Microsimulation analyses were done to determine the magnitude of the benefit. In the Bayesian analysis, the probability that beta-blockers reduce all-cause decompensation was >0.93 for all priors. The Bayesian posterior hazard ratios (HR) for decompensation ranged from 0.50 (optimistic prior, 95% credible interval 0.27-0.93) to 0.70 (neutral prior, 95% credible interval 0.44-1.12). Exploring the benefit of treatment using microsimulation highlights substantial treatment benefits. For the neutral prior derived posterior HR and a 5% annual incidence of decompensation, at 10 years, an average of 497 decompensation-free years per 1000 patients were gained with treatment. In contrast, at 10 years 1639 years per 1000 patients were gained from the optimistic prior derived posterior HR and a 10% incidence of decompensation. CONCLUSIONS Beta-blocker treatment is associated with a high probability of clinical benefit. This likely translates to a substantial gain in decompensation-free life years at the population level.
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Affiliation(s)
- Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Càndid Villanueva
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Salud Carlos III, Spain
| | - Jessica E Shearer
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ferran Torres
- Biostatistics Unit, Medical School, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Agustín Albillos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Salud Carlos III, Spain
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS). Madrid, Spain
| | - Joan Genescà
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Salud Carlos III, Spain
- Liver Unit, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Joan C Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Dhiraj Tripathi
- University Hospitals Birmingham NHS Foundation Trust. Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham. UK
- Department of Hepatology. Royal Infirmary of Edinburgh. Edinburgh, UK
| | - Peter C Hayes
- Department of Hepatology. Royal Infirmary of Edinburgh. Edinburgh, UK
| | - Jaume Bosch
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
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5
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Stutchfield BM, Attia A, Rowe IA, Harrison EM, Gordon-Walker T. UK liver transplantation allocation algorithm: transplant benefit score - Authors' reply. Lancet 2023; 402:371-372. [PMID: 37516542 DOI: 10.1016/s0140-6736(23)01307-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 06/21/2023] [Indexed: 07/31/2023]
Affiliation(s)
- Ben M Stutchfield
- Department of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh EH14 4SA, UK; Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK.
| | - Antony Attia
- School of Medicine, University of Edinburgh, Edinburgh EH14 4SA, UK
| | - Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Ewen M Harrison
- Department of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh EH14 4SA, UK; Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Tim Gordon-Walker
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
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6
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Rowe IA. Understanding the risks and benefits of policy action in NAFLD. J Hepatol 2023; 79:22-24. [PMID: 37023965 DOI: 10.1016/j.jhep.2023.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/21/2023] [Accepted: 03/26/2023] [Indexed: 04/08/2023]
Affiliation(s)
- Ian A Rowe
- Leeds Institute for Data Analytics, St. James's University Hospital, University of Leeds, Leeds, United Kingdom.
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7
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Rowe IA, Allen AM. Hepatic steatosis provides the terroir that promotes the development of cardiovascular risk factors and disease. Hepatology 2023; 77:1843-1845. [PMID: 36738088 DOI: 10.1097/hep.0000000000000327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 02/05/2023]
Affiliation(s)
- Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds, St. James's University Hospital, Leeds, UK
| | - Alina M Allen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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8
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Theodoreson MD, Aithal GP, Allison M, Brahmania M, Forrest E, Hagström H, Johansen S, Krag A, Likhitsup A, Masson S, McCune A, Rajoriya N, Thiele M, Rowe IA, Parker R. Extra-hepatic morbidity and mortality in alcohol-related liver disease: Systematic review and meta-analysis. Liver Int 2023; 43:763-772. [PMID: 36694995 DOI: 10.1111/liv.15526] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/05/2023] [Accepted: 01/18/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Alcohol use increases the risk of many conditions in addition to liver disease; patients with alcohol-related liver disease (ALD) are therefore at risk from both extra-hepatic and hepatic disease. AIMS This review synthesises information about non-liver-related mortality in persons with ALD. METHODS A systematic literature review was performed to identify studies describing non-liver outcomes in ALD. Information about overall non-liver mortality was extracted from included studies and sub-categorised into major causes: cardiovascular disease (CVD), non-liver cancer and infection. Single-proportion meta-analysis was done to calculate incidence rates (events/1000 patient-years) and relative risks (RR) compared with control populations. RESULTS Thirty-seven studies describing 50 302 individuals with 155 820 patient-years of follow-up were included. Diabetes, CVD and obesity were highly prevalent amongst included patients (5.4%, 10.4% and 20.8% respectively). Outcomes varied across the spectrum of ALD: in alcohol-related fatty liver the rate of non-liver mortality was 43.4/1000 patient-years, whereas in alcoholic hepatitis the rate of non-liver mortality was 22.5/1000 patient-years. The risk of all studied outcomes was higher in ALD compared with control populations: The RR of death from CVD was 2.4 (1.6-3.8), from non-hepatic cancer 2.2 (1.6-2.9) and from infection 8.2 (4.7-14.3). CONCLUSION Persons with ALD are at high risk of death from non-liver causes such as cardiovascular disease and non-hepatic cancer.
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Affiliation(s)
| | - Guruprasad P Aithal
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, Faculty of Health Sciences, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Michael Allison
- Liver Unit, Cambridge NIHR Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | | | - Stine Johansen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Fibrosis, Fatty Liver and Steatohepatitis Research Center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Aleksander Krag
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Fibrosis, Fatty Liver and Steatohepatitis Research Center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Alisa Likhitsup
- St Luke's Hospital, Kansas City, Missouri, USA
- University of Missouri School of Medicine, Kansas City, Missouri, USA
| | | | | | - Neil Rajoriya
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Maja Thiele
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Fibrosis, Fatty Liver and Steatohepatitis Research Center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Ian A Rowe
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Richard Parker
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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9
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Hinkson A, Lally H, Gibson H, Jones R, Rowe IA, Shinkins B, Parker R. Meta-analysis: Enhanced liver fibrosis test to identify hepatic fibrosis in chronic liver diseases. Aliment Pharmacol Ther 2023; 57:750-762. [PMID: 36650720 DOI: 10.1111/apt.17385] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/06/2022] [Accepted: 12/27/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND & AIMS Patients with liver disease can be stratified for risk of liver-related ill health by degree of hepatic fibrosis. The Enhanced liver fibrosis (ELF) test was developed to quantify hepatic fibrosis non-invasively and is widely used. The objective of this review was to identify and synthesise the evidence on the diagnostic accuracy of the ELF test for staging of hepatic fibrosis. APPROACH & RESULTS Searches of PubMed and EMBASE were conducted between October 2020 and November 2021 to identify studies reporting the diagnostic accuracy of the ELF test compared to histology in liver disease patients. QUADAS-2 was used to assess risk of bias in each study. Meta-analysis using the multiple thresholds model described by Steinhauser S, Schumacher M, Rücker G. Modelling multiple thresholds in meta-analysis of diagnostic test accuracy studies. BMC Med. Res. Methodol. 2016;16. 10.1186/s12874-016-0196-1 allowed synthesis of 2 × 2 data at different cut-offs. Sixty-three studies were included in this review. These studies included 19,285 patients with or at risk of liver disease from viral hepatitis, Non-Alcoholic Fatty Liver Disease, Alcohol-related Liver Disease and other mixed chronic liver diseases. The prevalence of significant fibrosis, advanced fibrosis and cirrhosis was 47.5%, 39.2% and 4.4%, respectively. Cut-offs with maximal Youden index were generated with AUROC = 0.811 (95% CI: 0.736-0.870), 0.812 (95% CI: 0.758-0.856) and 0.810 (95% CI: 0.694-0.888) to detect significant fibrosis, advanced fibrosis or cirrhosis, respectively. Diagnostic accuracy of the ELF test varied between different liver diseases and cut-offs to detect each stage with 95% sensitivity or specificity were also generated. CONCLUSIONS Meta-analysis revealed considerable variability in the ability of ELF to stage fibrosis across disease aetiologies. Research has mostly focused on viral hepatitis and NAFLD. There is currently a lack of data on the value of the ELF test in Alcohol-related liver disease and patients in primary care settings.
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Affiliation(s)
- Alexander Hinkson
- Leeds Liver Unit, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Liver Research Group, University of Leeds, Leeds, UK.,Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Hannah Lally
- School of Medicine, University of Leeds, Leeds, UK
| | | | - Rebecca Jones
- Leeds Liver Unit, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ian A Rowe
- Leeds Liver Unit, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Liver Research Group, University of Leeds, Leeds, UK.,Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Bethany Shinkins
- Test Evaluation Group, Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Richard Parker
- Leeds Liver Unit, St James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Liver Research Group, University of Leeds, Leeds, UK
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10
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Attia A, Rowe IA, Harrison EM, Gordon-Walker T, Stutchfield BM. Implausible algorithm output in UK liver transplantation allocation scheme: importance of transparency. Lancet 2023; 401:911-912. [PMID: 36870362 DOI: 10.1016/s0140-6736(23)00114-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 12/21/2022] [Accepted: 01/05/2023] [Indexed: 03/05/2023]
Affiliation(s)
- Antony Attia
- School of Medicine, University of Edinburgh, Edinburgh EH14 4SA, UK
| | - Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Ewen M Harrison
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh EH14 4SA, UK; Department of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh EH14 4SA, UK
| | - Tim Gordon-Walker
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ben M Stutchfield
- Department of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh EH14 4SA, UK; Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK.
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11
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Shearer JE, Jones R, Parker R, Ferguson J, Rowe IA. The Natural History of Advanced Chronic Liver Disease Defined by Transient Elastography. Clin Gastroenterol Hepatol 2023; 21:694-703.e8. [PMID: 35337981 DOI: 10.1016/j.cgh.2022.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 03/08/2022] [Accepted: 03/14/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The clinical course of cirrhosis does not follow a predictable trajectory. Transient elastography (TE) is commonly used in clinical practice to diagnose liver fibrosis and increasingly to risk stratify patients. The aim of this study was to assess the natural history of advanced chronic liver disease (ACLD) defined by TE using electronic health record (EHR) data in a multistate framework. METHODS TE data were collected between 2008 and 2019. Patients with a liver stiffness measurement (LSM) >10 kPa were included. Disease and procedure code information held in EHR was analyzed. Clinical events including decompensation, hepatocellular carcinoma (HCC), and death were identified. Outcomes were described in a multistate model using flexible parametric survival methods including LSM and the albumin bilirubin (ALBI) score. RESULTS Three thousand and twenty eight patients were included. Median follow up was 3.1 years. LSM and ALBI were associated with the development of varices and decompensation, and ALBI, age, sex, and viral liver disease were associated with the development of HCC from the compensated state. The cumulative incidence of HCC before decompensation was low for patients with alcohol-related liver disease (3.8%) and nonalcoholic fatty liver disease (1.3%) at 5 years after TE. Importantly, death was predicted to occur before decompensation or HCC in most cases. CONCLUSIONS Liver stiffness, ALBI score, and disease etiology are each associated with outcomes in a large contemporary cohort with ACLD. EHR data can be used to define clinical progression in these patients, facilitating large clinical effectiveness trials and cost-effectiveness analyses.
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Affiliation(s)
- Jessica E Shearer
- Leeds Institute for Medical Research, University of Leeds, Leeds, United Kingdom; Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Rebecca Jones
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Richard Parker
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - James Ferguson
- Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds, Leeds, United Kingdom; Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.
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12
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Cullen K, Jones M, Pockett RD, Burton A, Cross TJ, Rowe IA, Paley L, Tataru D, Alexander G, Marshall A, Fitzsimmons D. Cost of hepatocellular carcinoma to the national health service in England: a registry-based analysis. BMJ Open Gastroenterol 2023; 10:bmjgast-2022-000998. [PMID: 36810207 PMCID: PMC9945044 DOI: 10.1136/bmjgast-2022-000998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/28/2023] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVE Hepatocellular carcinoma (HCC) incidence in the UK trebled between 1997 and 2017. With increasing numbers requiring treatment, understanding the likely impact on healthcare budgets can inform service planning and commissioning. The aim of this analysis was to use existing registry data to describe the direct healthcare costs of current treatments for HCC and estimate the impact on National Health Service (NHS) budgets. DESIGN A retrospective data analysis based on the National Cancer Registration and Analysis Service cancer registry informed a decision-analytic model for England comparing patients by cirrhosis compensation status and those on palliative or curative treatment pathways. Potential cost drivers were investigated by undertaking a series of one-way sensitivity analyses. RESULTS Between 1 January 2010 and 31 December 2016, 15 684 patients were diagnosed with HCC. The median cost per patient over 2 years was £9065 (IQR: £1965 to £20 491), 66% did not receive active therapy. The cost of HCC treatment for England over 5 years was estimated to be £245 million. CONCLUSION The National Cancer Registration Dataset and linked data sets have enabled a comprehensive analysis of the resource use and costs of secondary and tertiary healthcare for HCC, providing an overview of the economic impact to the NHS England of treating HCC.
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Affiliation(s)
- Katherine Cullen
- Faculty of Medicine, Health and Life Sciences, Swansea University, Swansea, UK
| | - Mari Jones
- Faculty of Medicine, Health and Life Sciences, Swansea University, Swansea, UK
| | - Rhys D. Pockett
- Faculty of Medicine, Health and Life Sciences, Swansea University, Swansea, UK
| | - Anya Burton
- Bristol Medical School, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Timothy J.S. Cross
- Consultant in Liver Medicine, Department of Gastroenterology & Hepatology, The Royal Liverpool University Hospital, Liverpool, UK,Department of Molecular and Clinical Oncology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Ian A. Rowe
- Leeds Institute for Medical Research, School of Medicine, University of Leeds, Leeds, UK
| | - Lizz Paley
- National Cancer Registration and Analysis Service, National Disease Registration Service, NHS Digital, UK
| | - Daniela Tataru
- National Cancer Registration and Analysis Service, National Disease Registration Service, NHS Digital, UK
| | - Graeme Alexander
- Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK
| | - Aileen Marshall
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
| | - Deborah Fitzsimmons
- Faculty of Medicine, Health and Life Sciences, Swansea University, Swansea, UK
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13
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Abeysekera KW, Shearer J, Tavabie OD, Dillon JF, Rowe IA. #FGDebate: Should we focus on detecting patients at risk of liver disease in the community? Frontline Gastroenterol 2022; 14:343-345. [PMID: 37409342 DOI: 10.1136/flgastro-2022-102330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/20/2022] [Indexed: 12/03/2022] Open
Affiliation(s)
- Kushala Wm Abeysekera
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Oliver D Tavabie
- The Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
| | - John F Dillon
- Division of Clinical and Molecular Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds & Leeds Liver Unit, St James's University Hospital, Leeds, UK
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14
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Rowe IA, D'Amico G. Taking a risk-based approach to testing for liver disease in primary care, a step in the right direction. J Hepatol 2022; 77:293-295. [PMID: 35421424 DOI: 10.1016/j.jhep.2022.03.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK; Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - Gennaro D'Amico
- Gastroenterology Unit, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy; Gastroenterology Unit, Clinica La Maddalena, Palermo, Italy.
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15
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Abeysekera KWM, Macpherson I, Glyn-Owen K, McPherson S, Parker R, Harris R, Yeoman A, Rowe IA, Dillon JF. Community pathways for the early detection and risk stratification of chronic liver disease: a narrative systematic review. Lancet Gastroenterol Hepatol 2022; 7:770-780. [PMID: 35525248 DOI: 10.1016/s2468-1253(22)00020-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 02/07/2023]
Abstract
Patients with chronic liver disease are often diagnosed during an index presentation to hospital with decompensated cirrhosis or liver-related events, and these presentations are associated with high mortality. However, there is often a long asymptomatic phase, in which there is an opportunity for earlier diagnosis and interventions to prevent progression to advanced disease. Therefore, strategies for early diagnosis and interventions (including behavioural changes and pharmacological treatments) that prevent patients progressing to cirrhosis and its associated complications probably have substantial benefits for patients and health-care services. Many community pathways have been generated. Some pathways focus on abnormal liver function tests as a starting point to diagnose liver disease. Other pathways target groups at greater risk of chronic liver disease-particularly people with harmful alcohol consumption, type 2 diabetes, and obesity. This systematic review summarises the existing strategies available for the early detection or risk stratification of liver disease, focusing primarily on alcohol-related liver disease and non-alcoholic fatty liver disease. Conducting randomised clinical trials that compare different strategies will be essential to elucidate which pathways are acceptable to patients, feasible, provide high diagnostic accuracy for the detection of liver disease, improve liver-related outcomes, and are most cost-effective at the population level.
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Affiliation(s)
| | - Iain Macpherson
- Division of Clinical and Molecular Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Kate Glyn-Owen
- School of Primary Care, Population Science and Medical Education (PPM), Faculty of Medicine, University of Southampton, University Hospital Southampton, UK
| | - Stuart McPherson
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Liver Unit, Newcastle Upon Tyne Hospitals NHS Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - Richard Parker
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
| | - Rebecca Harris
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Andrew Yeoman
- Aneurin Bevan University Health Board, Hepatology, Newport, UK
| | - Ian A Rowe
- Leeds Liver Unit, St James's University Hospital, Leeds, UK; Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - John F Dillon
- Division of Clinical and Molecular Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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16
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McPherson S, Armstrong MJ, Cobbold JF, Corless L, Anstee QM, Aspinall RJ, Barclay ST, Brennan PN, Cacciottolo TM, Goldin RD, Hallsworth K, Hebditch V, Jack K, Jarvis H, Johnson J, Li W, Mansour D, McCallum M, Mukhopadhya A, Parker R, Ross V, Rowe IA, Srivastava A, Thiagarajan P, Thompson AI, Tomlinson J, Tsochatzis EA, Yeoman A, Alazawi W. Quality standards for the management of non-alcoholic fatty liver disease (NAFLD): consensus recommendations from the British Association for the Study of the Liver and British Society of Gastroenterology NAFLD Special Interest Group. Lancet Gastroenterol Hepatol 2022; 7:755-769. [PMID: 35490698 PMCID: PMC7614852 DOI: 10.1016/s2468-1253(22)00061-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 12/12/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is common, affecting approximately 25% of the general population. The evidence base for the investigation and management of NAFLD is large and growing, but there is currently little practical guidance to support development of services and delivery of care. To address this, we produced a series of evidence-based quality standard recommendations for the management of NAFLD, with the aim of improving patient care. A multidisciplinary group of experts from the British Association for the Study of the Liver and British Society of Gastroenterology NAFLD Special Interest Group produced the recommendations, which cover: management of people with, or at risk of, NAFLD before the gastroenterology or liver clinic; assessment and investigations in secondary care; and management in secondary care. The quality of evidence for each recommendation was evaluated by the Grading of Recommendation Assessment, Development and Evaluation tool. An anonymous modified Delphi voting process was conducted individually by each member of the group to assess the level of agreement with each statement. Statements were included when agreement was 80% or greater. From the final list of statements, a smaller number of auditable key performance indicators were selected to allow services to benchmark their practice. It is hoped that services will review their practice against our recommendations and key performance indicators and institute service development where needed to improve the care of patients with NAFLD.
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Affiliation(s)
- Stuart McPherson
- Liver Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.
| | - Matthew J Armstrong
- Liver Unit, Queen Elizabeth University Hospital Birmingham NHS Trust, Birmingham, UK; NIHR Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Jeremy F Cobbold
- Oxford Liver Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; UK NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Lynsey Corless
- Department of Gastroenterology, Hepatology and Endoscopy, Hull University Teaching Hospitals, Hull, UK
| | - Quentin M Anstee
- Liver Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Stephen T Barclay
- Walton Liver Clinic, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Paul N Brennan
- Centre for Regenerative Medicine, University of Edinburgh, Edinburgh BioQuarter, Edinburgh, UK
| | - Tessa M Cacciottolo
- Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Wellcome Trust/MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Cambridge, UK
| | - Robert D Goldin
- Division of Digestive Diseases, Imperial College, London, UK
| | - Kate Hallsworth
- Liver Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Kathryn Jack
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Helen Jarvis
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK; The Bellingham Practice, Northumberland, UK
| | - Jill Johnson
- Liver Unit, Queen Elizabeth University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Wenhao Li
- Barts Liver Centre, Queen Mary University London and Barts Health NHS Trust, London, UK
| | - Dina Mansour
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Queen Elizabeth Hospital, Gateshead NHS Foundation Trust, Gateshead, UK
| | - Mary McCallum
- Digestive Disorders Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Ashis Mukhopadhya
- Digestive Disorders Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Richard Parker
- Leeds Liver Unit, St James's University Hospital Leeds, Leeds, UK
| | - Valerie Ross
- Barts Liver Centre, Queen Mary University London and Barts Health NHS Trust, London, UK
| | - Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Ankur Srivastava
- North Bristol Liver Unit, Southmead Hospital, North Bristol Trust, Bristol, UK
| | | | - Alexandra I Thompson
- Centre for Liver and Digestive Disorders, The Royal Infirmary, Edinburgh, Edinburgh, UK
| | - Jeremy Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
| | - Andrew Yeoman
- Gwent Liver Unit, The Grange University Health Board, Anuerin Bevan Health Board, Wales, UK
| | - William Alazawi
- Barts Liver Centre, Queen Mary University London and Barts Health NHS Trust, London, UK
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17
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Rowe IA, Parker R. The Placebo Response in Randomized Trials in Nonalcoholic Steatohepatitis Simply Explained. Clin Gastroenterol Hepatol 2022; 20:e564-e572. [PMID: 34091047 DOI: 10.1016/j.cgh.2021.05.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/13/2021] [Accepted: 05/31/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Liver histology is the primary endpoint in phase III trials in nonalcoholic steatohepatitis (NASH). There is an appreciable response to placebo that confounds endpoint assessment. The aim of this study was to quantify contributors to the placebo response and its impact on liver fibrosis improvement. METHODS Estimates of fibrosis improvement in placebo-treated participants were made using probabilistic simulation. Each simulated trial included 120 participants. Parameters considered in the model included sampling and observer variability, regression to the mean, and net fibrosis progression calibrated to reported trial outcomes. RESULTS In large phase IIb and III trials, 22% of placebo-treated participants with fibrosis stage 2 or 3 NASH at baseline improved by at least 1 fibrosis stage with minimal net disease progression. Estimates of sampling and observer variability in simultaneous biopsy studies highlighted an imbalance where apparent fibrosis improvement was more likely than worsening. Using these estimates and known trial outcomes, net fibrosis progression was estimated at 0.05 stages per year. Simulations of the placebo response rate showed a rate of 22% with 80% of trials falling between 15 and 30%, in keeping with trials reported to date. Additional increases in observer variability further increased the placebo response. CONCLUSIONS The analyses presented simply define the placebo response in liver fibrosis in trials in NASH in terms of sampling and observer variability, regression to the mean, and fibrosis progression. Factors relating to liver biopsy are largely unmodifiable, and the variation in placebo response rates, both simulated and observed, challenges the role of biopsy in trial endpoint assessment.
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Affiliation(s)
- Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds, Leeds, United Kingdom; Leeds Liver Unit, St James's University Hospital, Leeds, United Kingdom.
| | - Richard Parker
- Leeds Liver Unit, St James's University Hospital, Leeds, United Kingdom
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18
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Shearer JE, Gonzalez JJ, Min T, Parker R, Jones R, Su GL, Tapper EB, Rowe IA. Systematic review: development of a consensus code set to identify cirrhosis in electronic health records. Aliment Pharmacol Ther 2022; 55:645-657. [PMID: 35166399 PMCID: PMC9302659 DOI: 10.1111/apt.16806] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/28/2021] [Accepted: 01/24/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Electronic health records (EHRs) collate longitudinal data that can be used to facilitate large-scale research in patients with cirrhosis. However, there is no consensus code set to define the presence of cirrhosis in EHR. This systematic review aims to evaluate the validity of diagnostic coding in cirrhosis and to synthesise a comprehensive set of ICD-10 codes for future EHR research. METHOD MEDLINE and EMBASE databases were searched for studies that used EHR to identify cirrhosis and cirrhosis-related complications. Validated code sets were summarised, and the performance characteristics were extracted. Citation analysis was done to inform development of a consensus code set. This was then validated in a cohort of patients. RESULTS One thousand six hundred twenty-six records were screened, and 18 studies were identified. The positive predictive value (PPV) was the most frequently reported statistical estimate and was ≥80% in 17/18 studies. Citation analyses showed continued variation in those used in contemporary research practice. Nine codes were identified as those most frequently used in the literature and these formed the consensus code set. This was validated in diverse patient populations from Europe and North America and showed high PPV (83%-89%) and greater sensitivity for the identification of cirrhosis than the most often used code set in the recent literature. CONCLUSION There is variation in code sets used to identify cirrhosis in contemporary research practice. A consensus set has been developed and validated, showing improved performance, and is proposed to align EHR study designs in cirrhosis to facilitate international collaboration and comparisons.
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Affiliation(s)
- Jessica E. Shearer
- Leeds Liver UnitLeeds Teaching Hospitals NHS TrustLeedsUK,Leeds Institute for Data AnalyticsUniversity of LeedsLeedsUK
| | - Juan J. Gonzalez
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA
| | - Thazin Min
- Leeds Liver UnitLeeds Teaching Hospitals NHS TrustLeedsUK
| | - Richard Parker
- Leeds Liver UnitLeeds Teaching Hospitals NHS TrustLeedsUK
| | - Rebecca Jones
- Leeds Liver UnitLeeds Teaching Hospitals NHS TrustLeedsUK
| | - Grace L. Su
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA
| | - Elliot B. Tapper
- Division of Gastroenterology and HepatologyUniversity of MichiganAnn ArborMichiganUSA
| | - Ian A. Rowe
- Leeds Liver UnitLeeds Teaching Hospitals NHS TrustLeedsUK,Leeds Institute for Data AnalyticsUniversity of LeedsLeedsUK
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19
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Parker R, Cabezas J, Altamirano J, Arab JP, Ventura-Cots M, Sinha A, Dhanda A, Arrese M, McCune CA, Rowe IA, Schnabl B, Mathurin P, Shawcross D, Abraldes JG, Lucey MR, Garcia-Tsao G, Verna E, Brown RS, Bosques-Padilla F, Vargas V, Louvet A, Holt AP, Bataller R. Trajectory of Serum Bilirubin Predicts Spontaneous Recovery in a Real-World Cohort of Patients With Alcoholic Hepatitis. Clin Gastroenterol Hepatol 2022; 20:e289-e297. [PMID: 33516950 PMCID: PMC9188123 DOI: 10.1016/j.cgh.2021.01.042] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/20/2021] [Accepted: 01/24/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Alcoholic hepatitis (AH) is a severe condition with poor short-term prognosis. Specific treatment with corticosteroids slightly improves short-term survival but is associated with infection and is not used in many centers. A reliable method to identify patients who will recover spontaneously will minimise the numbers of patients who experience side effects of available treatments. METHODS We analysed the trajectory of serum bilirubin concentration over the course of hospital admissions in patients with AH to predict spontaneous survival and the need for treatment. RESULTS data from 426 patients were analysed. Based on bilirubin trajectory, patients were categorized into three groups: 'fast fallers' (bilirubin <0.8 x admission value at day 7), 'static' (bilirubin of >0.9 - <1.2 x admission value) and 'rapid risers' (bilirubin of ≥1.2 x admission bilirubin). Fast fallers had significantly better 90-day survival compared to other groups (log rank p < .001), and showed no benefit of corticosteroid therapy (OR for survival at 28 days of treatment, 0.94, 95% CI 0.06 - 8.41). These findings remained even amongst patients with severe disease based on initial DF, GAHS or MELD scores. CONCLUSIONS We present an intuitive method of classifying patients with AH based on the trajectory of bilirubin over the first week of admission. It is complimentary to existing scores that identify candidates for corticosteroid treatment or assess response to treatment. This method identifies a group of patients with AH who recover spontaneously and can avoid corticosteroid therapy.
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Affiliation(s)
- Richard Parker
- Leeds Liver Unit, St James's University Hospital, Leeds, United Kingdom.
| | - Joaquin Cabezas
- Department of Gastroenterology and Hepatology, University Hospital Marques de Valdecilla, Valdecilla Research Institute, Santander, Spain; Liver Center, Departments of Medicine and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jose Altamirano
- Internal Medicine Department, Hospital Quirónsalud, Barcelona, Spain
| | - Juan Pablo Arab
- Department of Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Meritxell Ventura-Cots
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ashish Sinha
- Department of Liver Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Ashwin Dhanda
- Institute of Translational and Stratified Medicine, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, United Kingdom
| | - Marco Arrese
- Department of Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Centro de Envejecimiento y Regeneración, Departamento de Biología Celular y Molecular, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - C Anne McCune
- Department of Liver Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Ian A Rowe
- Leeds Liver Unit, St James's University Hospital, Leeds, United Kingdom
| | - Bernd Schnabl
- Department of Medicine, VA San Diego Healthcare System, University of California, San Diego, La Jolla, California
| | - Phillipe Mathurin
- Service des Maladies de l'Appareil Digestif et Unité, French Institute of Health and Medical Research, Hôpital Huriez, Lille, France
| | - Debbie Shawcross
- Liver Sciences, Dept of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Juan G Abraldes
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), Centre of Excellence Gastrointestinal Inflammation and Immunity Research, University of Alberta, Edmonton, Alberta, Canada
| | - Michael R Lucey
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University, New Haven, Connecticut; Section of Digestive Diseases, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Elizabeth Verna
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York
| | | | - Victor Vargas
- Liver Unit, Hospital Vall d'Hebron, Universitat Autònoma Barcelona, CIBEREHD, Barcelona, Spain
| | - Alexandre Louvet
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
| | - Andrew P Holt
- Liver and Hepatobiliary Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Ramon Bataller
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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20
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Burton A, Balachandrakumar VK, Driver RJ, Tataru D, Paley L, Marshall A, Alexander G, Rowe IA, Palmer DH, Cross TJS. Regional variations in hepatocellular carcinoma incidence, routes to diagnosis, treatment and survival in England. Br J Cancer 2021; 126:804-814. [PMID: 34837073 PMCID: PMC8888669 DOI: 10.1038/s41416-021-01509-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/14/2021] [Accepted: 07/21/2021] [Indexed: 12/16/2022] Open
Abstract
Background Hepatocellular carcinoma (HCC) incidence, management and survival across England were examined to determine if geographical inequalities exist. Method 15,468 HCC cases diagnosed 2010–2016 were included. Age-standardised incidence rates, net survival and proportions receiving potentially curative treatment and presenting through each route to diagnosis adjusted for age at diagnosis, sex and area-based deprivation quintile, were calculated overall and by Cancer Alliance. Results HCC incidence rates increased in men from 6.2 per 100,000 in 2010 to 8.8 in 2016, and in women from 1.5 to 2.2. The highest incidence rates, found in parts of the North of England and London, were nearly double the lowest. The adjusted proportion presenting as an emergency ranged 27–41% across Cancer Alliances. Odds increased with increasing deprivation quintile and age. Only one in five patients received potentially curative treatment (range 15–28%) and odds decreased with increasing deprivation and age. One-year survival in 2013–2016 ranged 38–53%. Conclusion This population-based, nationwide analysis demonstrates clear differences in HCC incidence, management and survival across England. It highlights socioeconomic-associated variation and the need for improvement in early diagnosis and curative treatment of HCC. This research should assist policymakers, service providers and clinicians to identify regions where additional training, services and resources would be best directed.
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Affiliation(s)
- Anya Burton
- HCC-UK/British Association for the Study of the Liver, Lichfield, UK.,National Cancer Registration and Analysis Service (NCRAS), Public Health England, London, UK
| | - Vinay K Balachandrakumar
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, London, UK.,Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Robert J Driver
- Leeds Institute for Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Daniela Tataru
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, London, UK
| | - Lizz Paley
- National Cancer Registration and Analysis Service (NCRAS), Public Health England, London, UK
| | - Aileen Marshall
- Sheila Sherlock Liver Centre, The Royal Free Hospital, London, UK
| | - Graeme Alexander
- Institute for Liver and Digestive Health, Royal Free Hospital Pond St, Hampstead, London, UK
| | - Ian A Rowe
- Leeds Institute for Medical Research at St. James's, University of Leeds, Leeds, UK
| | | | - Daniel H Palmer
- Liverpool Experimental Cancer Medicine Centre, University of Liverpool, Liverpool, UK
| | - Tim J S Cross
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.
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21
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Im YR, Hunter H, de Gracia Hahn D, Duret A, Cheah Q, Dong J, Fairey M, Hjalmarsson C, Li A, Lim HK, McKeown L, Mitrofan CG, Rao R, Utukuri M, Rowe IA, Mann JP. A Systematic Review of Animal Models of NAFLD Finds High-Fat, High-Fructose Diets Most Closely Resemble Human NAFLD. Hepatology 2021; 74:1884-1901. [PMID: 33973269 DOI: 10.1002/hep.31897] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [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: 03/23/2021] [Revised: 04/29/2021] [Accepted: 05/04/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Animal models of human disease are a key component of translational hepatology research, yet there is no consensus on which model is optimal for NAFLD. APPROACH AND RESULTS We generated a database of 3,920 rodent models of NAFLD. Study designs were highly heterogeneous, and therefore, few models had been cited more than once. Analysis of genetic models supported the current evidence for the role of adipose dysfunction and suggested a role for innate immunity in the progression of NAFLD. We identified that high-fat, high-fructose diets most closely recapitulate the human phenotype of NAFLD. There was substantial variability in the nomenclature of animal models: a consensus on terminology of specialist diets is needed. More broadly, this analysis demonstrates the variability in preclinical study design, which has wider implications for the reproducibility of in vivo experiments both in the field of hepatology and beyond. CONCLUSIONS This systematic analysis provides a framework for phenotypic assessment of NAFLD models and highlights the need for increased standardization and replication.
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Affiliation(s)
- Yu Ri Im
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Harriet Hunter
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Dana de Gracia Hahn
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Amedine Duret
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Qinrong Cheah
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Jiawen Dong
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Madison Fairey
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | | | - Alice Li
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Hong Kai Lim
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Lorcán McKeown
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | | | - Raunak Rao
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Mrudula Utukuri
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Ian A Rowe
- Leeds Institute for Medical Research and Leeds Institute for Data Analytics, University of Leeds, Leeds, United Kingdom
| | - Jake P Mann
- Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
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22
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Hagström H, Adams LA, Allen AM, Byrne CD, Chang Y, Grønbæk H, Ismail M, Jepsen P, Kanwal F, Kramer J, Lazarus JV, Long MT, Loomba R, Newsome PN, Rowe IA, Ryu S, Schattenberg JM, Serper M, Sheron N, Simon TG, Tapper EB, Wild S, Wai-Sun Wong V, Yilmaz Y, Zelber-Sagi S, Åberg F. Administrative Coding in Electronic Health Care Record-Based Research of NAFLD: An Expert Panel Consensus Statement. Hepatology 2021; 74:474-482. [PMID: 33486773 PMCID: PMC8515502 DOI: 10.1002/hep.31726] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [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: 11/13/2020] [Revised: 12/11/2020] [Accepted: 01/15/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Electronic health record (EHR)-based research allows the capture of large amounts of data, which is necessary in NAFLD, where the risk of clinical liver outcomes is generally low. The lack of consensus on which International Classification of Diseases (ICD) codes should be used as exposures and outcomes limits comparability and generalizability of results across studies. We aimed to establish consensus among a panel of experts on ICD codes that could become the reference standard and provide guidance around common methodological issues. APPROACH AND RESULTS Researchers with an interest in EHR-based NAFLD research were invited to collectively define which administrative codes are most appropriate for documenting exposures and outcomes. We used a modified Delphi approach to reach consensus on several commonly encountered methodological challenges in the field. After two rounds of revision, a high level of agreement (>67%) was reached on all items considered. Full consensus was achieved on a comprehensive list of administrative codes to be considered for inclusion and exclusion criteria in defining exposures and outcomes in EHR-based NAFLD research. We also provide suggestions on how to approach commonly encountered methodological issues and identify areas for future research. CONCLUSIONS This expert panel consensus statement can help harmonize and improve generalizability of EHR-based NAFLD research.
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Affiliation(s)
- Hannes Hagström
- Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Leon A Adams
- Medical School, University of Western Australia, Perth Australia
| | - Alina M. Allen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Christopher D. Byrne
- Nutrition and Metabolism, Faculty of Medicine, University of Southampton, UK
- Southampton National Institute for Health Research Biomedical Research Centre, University Hospital Southampton, Southampton General Hospital, Tremona Road, Southampton, UK
| | - Yoosoo Chang
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Henning Grønbæk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Mona Ismail
- Division of Gastroenterology, Department of Internal Medicine, King Fahad Hospital of the University, Al-Khobar, Saudi Arabia
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Fasiha Kanwal
- Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston TX, USA
| | - Jennifer Kramer
- Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston TX, USA
| | - Jeffrey V. Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Michelle T. Long
- Department of Medicine, Section of Gastroenterology, Boston University School of Medicine, Boston, MA, USA
| | - Rohit Loomba
- NAFLD Research Center, Division of Gastroenterology and Epidemiology, University of California at San Diego, La Jolla, California, USA
| | - Philip N. Newsome
- National Institute for Health Research Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, UK
| | - Ian A. Rowe
- Leeds Institute for Medical Research, University of Leeds, UK
| | - Seungho Ryu
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
| | - Jörn M. Schattenberg
- Metabolic Liver Research Program, I. Department of Medicine, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Tracey G. Simon
- Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, USA
| | - Sarah Wild
- Usher Institute, University of Edinburgh, UK
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Yusuf Yilmaz
- Liver Research Unit, Institute of Gastroenterology, Marmara University, Turkey
- Department of Gastroenterology, School of Medicine, Marmara University, Istanbul, Turkey
| | | | - Fredrik Åberg
- Transplantation and Liver Surgery Clinic, Helsinki University Hospital, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
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23
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Roskilly A, Hicks A, Taylor EJ, Jones R, Parker R, Rowe IA. Fibrosis progression rate in a systematic review of placebo-treated nonalcoholic steatohepatitis. Liver Int 2021; 41:982-995. [PMID: 33283415 DOI: 10.1111/liv.14749] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 10/06/2020] [Accepted: 10/28/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Liver fibrosis is the critical determinant of liver-related outcomes in persons with nonalcoholic fatty liver disease. The rate that fibrosis develops determines the time taken to reach cirrhosis and consequent clinical outcomes. Estimates of the fibrosis progression rate (FPR) are uncertain having been defined in small observational series that rely largely on nonstandardised repeat biopsy in selected patients. The aim of this study was to evaluate the FPR in placebo-treated participants with nonalcoholic steatohepatitis (NASH) in randomised controlled trials (RCTs). METHODS Systematic review and meta-analysis of RCTs in NASH with data on fibrosis change extracted. Calculated fibrosis progression rates were pooled in meta-analysis. The pooled estimate was then used to model the proportion of hypothetical cohorts starting with no fibrosis at the age of 30 who develop cirrhosis. RESULTS A total of 35 trials including 1419 placebo-treated participants who underwent repeat liver biopsy were evaluated. Considering all trials, the overall FPR was 0.00 stages per year, increasing to 0.03 stages per year in both trials at low risk of bias and trials including >50 placebo-treated participants. This estimate was markedly lower than the value derived from previously pooled analyses of observational data. Using a FPR of 0.03 resulted in a substantial reduction in the proportion of patients developing cirrhosis compared with the FPR derived from observational studies (13% vs 28%). CONCLUSIONS The FPR in placebo-treated participants in RCTs is lower than that described from observational data. Slower fibrosis progression predicts fewer persons with NASH will progress to cirrhosis than previously estimated.
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Affiliation(s)
- Anna Roskilly
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
| | - Amy Hicks
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
| | | | - Rebecca Jones
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
| | - Richard Parker
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
| | - Ian A Rowe
- Leeds Liver Unit, St James's University Hospital, Leeds, UK.,Leeds Institute for Medical Research and Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
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24
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Burton A, Tataru D, Driver RJ, Bird TG, Huws D, Wallace D, Cross TJ, Rowe IA, Alexander G, Marshall A. Primary liver cancer in the UK: Incidence, incidence-based mortality, and survival by subtype, sex, and nation. JHEP Rep 2021; 3:100232. [PMID: 33748727 PMCID: PMC7966867 DOI: 10.1016/j.jhepr.2021.100232] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/22/2020] [Accepted: 01/06/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND & AIMS The incidence of primary liver cancer (PLC) is increasing in Western Europe. To understand trends over time and the current burden in the UK, a detailed analysis of the epidemiology of PLC and its subtypes was conducted. METHODS Data on PLCs diagnosed during 1997-2017 were obtained from population-based, nationwide registries in the UK. European age-standardised incidence (ASR) and incidence-based mortality rates (ASMR) per 100,000 person-years were calculated overall and by sex and UK-nation. Annual percentage change in rates was estimated using Joinpoint regression. One-, 2-, and 5-year age-standardised net survival was estimated. RESULTS A total of 82,024 PLCs were diagnosed. Both hepatocellular carcinoma (HCC) incidence and mortality rates trebled (ASR 1.8-5.5 per 100,000, ASMR 1.3-4.0). The rate of increase appeared to plateau around 2014/2015. Scottish men consistently had the highest HCC incidence rates. PLC survival increased, driven by a substantial increase in the proportion that are HCC (as prognosis is better than other PLCs) and in HCC survival (change in 1-year survival 24-47%). Intrahepatic cholangiocarcinoma was the most common PLC in women and 1-year survival improved from 22.6% to 30.5%. CONCLUSIONS PLC incidence has been increasing rapidly but, as most risk factors are modifiable, it is largely a preventable cancer. This rate of increase has slowed in recent years, possibly attributable to effective treatment for hepatitis C. As other risk factors such as obesity and diabetes remain prevalent in the UK, it is unlikely the considerable burden of this disease will abate. While improvements in survival have been made, over half of patients are not alive after 1 year, therefore further progress in prevention, early detection, and treatment innovation are needed. LAY SUMMARY Many more people are getting liver cancer, particularly the subtype hepatocellular carcinoma, than 20 years ago. Men in Scotland are most likely to get liver cancer and to die from it. Survival after liver cancer diagnosis is getting longer but still less than half are alive after 1 year.
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Key Words
- AAPC, average annual percentage change
- APC, annual percentage change
- ASMR, age-standardised mortality rate
- ASR, age-standardised incidence rate
- BASL, British Association for the Study of the Liver
- DAA, direct-acting antivirals
- DCO, death certificate only
- HCC, hepatocellular carcinoma HCV, hepatitis C virus
- Hepatocellular carcinoma
- ICCA, intrahepatic cholangiocarcinoma
- ICD-10, International Classification of Diseases 10th Edition
- ICD-O, International Classification of Diseases for Oncology
- Incidence
- Intrahepatic cholangiocarcinoma
- Mortality
- NAFLD, non-alcoholic fatty liver disease
- NCRAS, National Cancer Registration and Analysis Service
- NI, Northern Ireland
- PLC, primary liver cancer
- Primary liver cancer
- Survival
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Affiliation(s)
- Anya Burton
- HCC-UK/British Association for the Study of the Liver (BASL), Lichfield, UK
- National Cancer Registration and Analysis Service, National Disease Registration Service, Public Health England, London, UK
- Corresponding author. Address: National Cancer Registration and Analysis Service, National Disease Registration Service, Public Health England, 2 Rivergate, Temple Quay, Bristol, BS1 6EH, UK. Tel.: +44 1179 689 124.
| | - Daniela Tataru
- National Cancer Registration and Analysis Service, National Disease Registration Service, Public Health England, London, UK
| | - Robert J. Driver
- Leeds Institute for Medical Research at St. James’s, University of Leeds, Leeds, UK
| | - Thomas G. Bird
- Cancer Research UK Beatson Institute, Glasgow, UK
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Dyfed Huws
- Welsh Cancer Intelligence and Surveillance Unit, Knowledge Directorate, Public Health Wales, Cardiff, UK
| | - David Wallace
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Timothy J.S. Cross
- Institute of Translational Medicine, The University of Liverpool, Liverpool, UK
| | - Ian A. Rowe
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
- Leeds Liver Unit, St. James's University Hospital, Leeds, UK
| | - Graeme Alexander
- UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Aileen Marshall
- Sheila Sherlock Liver Centre, The Royal Free Hospital, London, UK
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25
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Abstract
Nonalcoholic steatohepatitis (NASH) with liver fibrosis is an increasingly important cause of liver-related morbidity and mortality. A diagnosis of NASH can only be made using liver biopsy. Liver histology also forms the endpoint for the expedited licensing strategies that have been approved by regulators to allow patients with NASH access to treatment before the impact of these on clinical outcomes is known. Validation of these histological surrogate endpoints is critical for the ongoing development of new therapies for NASH. The use of liver biopsy to define both trial entry and endpoints raises questions about the use of treatments for NASH in practice when the effectiveness of treatment will likely depend, at least in part, on the use of histology for patient selection in the real world.
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Affiliation(s)
- Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds, United Kingdom.,Leeds Institute for Data Analytics, University of Leeds, United Kingdom.,Leeds Liver Unit, St James's University Hospital, Leeds, United Kingdom
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26
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Hunter H, de Gracia Hahn D, Duret A, Im YR, Cheah Q, Dong J, Fairey M, Hjalmarsson C, Li A, Lim HK, McKeown L, Mitrofan CG, Rao R, Utukuri M, Rowe IA, Mann JP. Weight loss, insulin resistance, and study design confound results in a meta-analysis of animal models of fatty liver. eLife 2020; 9:56573. [PMID: 33063664 PMCID: PMC7647398 DOI: 10.7554/elife.56573] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 10/15/2020] [Indexed: 12/30/2022] Open
Abstract
The classical drug development pipeline necessitates studies using animal models of human disease to gauge future efficacy in humans, however there is a low conversion rate from success in animals to humans. Non-alcoholic fatty liver disease (NAFLD) is a complex chronic disease without any established therapies and a major field of animal research. We performed a meta-analysis with meta-regression of 603 interventional rodent studies (10,364 animals) in NAFLD to assess which variables influenced treatment response. Weight loss and alleviation of insulin resistance were consistently associated with improvement in NAFLD. Multiple drug classes that do not affect weight in humans caused weight loss in animals. Other study design variables, such as age of animals and dietary composition, influenced the magnitude of treatment effect. Publication bias may have increased effect estimates by 37-79%. These findings help to explain the challenge of reproducibility and translation within the field of metabolism.
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Affiliation(s)
- Harriet Hunter
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Dana de Gracia Hahn
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Amedine Duret
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Yu Ri Im
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Qinrong Cheah
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Jiawen Dong
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Madison Fairey
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | | | - Alice Li
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Hong Kai Lim
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Lorcan McKeown
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | | | - Raunak Rao
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Mrudula Utukuri
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Ian A Rowe
- Leeds Institute for Medical Research & Leeds Institute for Data Analytics, University of Leeds, Leeds, United Kingdom
| | - Jake P Mann
- Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
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27
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Wallace D, Cowling T, McPhail MJ, Brown SE, Aluvihare V, Suddle A, Auzinger G, Heneghan MA, Rowe IA, Walker K, Heaton N, van der Meulen J, Bernal W. Assessing the Time-Dependent Impact of Performance Status on Outcomes After Liver Transplantation. Hepatology 2020; 72:1341-1352. [PMID: 31968130 DOI: 10.1002/hep.31124] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 06/15/2019] [Accepted: 12/23/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Identifying how the prognostic impact of performance status (PS) differs according to indication, era, and time period ("epoch") after liver transplantation (LT) could have implications for selection and treatment of patients on the waitlist. We used national data from the United Kingdom and Ireland to assess impact of PS on mortality separately for HCC and non-HCC recipients. APPROACH AND RESULTS We assessed pre-LT PS using the 5-point modified Eastern Cooperative Oncology Group scale and used Cox regression methods to estimate hazard ratios (HRs) that compared posttransplantation mortality in different epochs of follow-up (0-90 days and 90 days to 1 year) and in different eras of transplantation (1995-2005 and 2006-2016). 2107 HCC and 10,693 non-HCC patients were included. One-year survival decreased with worsening PS in non-HCC recipients where 1-year survival was 91.9% (95% confidence interval [CI], 88.3-94.4) in those able to carry out normal activity (PS1) compared to 78.7% (95% CI, 76.7-80.5) in those completely reliant on care (PS5). For HCC patients, these estimates were 89.9% (95% CI, 85.4-93.2) and 83.1% (95% CI, 61.0-93.3), respectively. Reduction in survival in non-HCC patients with poorer PS was in the first 90 days after transplant, with no major effect observed between 90 days and 1 year. Adjustment for donor and recipient characteristics did not change the findings. Comparing era, post-LT mortality improved for HCC (adjusted HR, 0.55; 95% CI, 0.40-0.74) and non-HCC recipients (0.48; 95% CI, 0.42-0.55), but this did not differ according to PS score (P = 0.39 and 0.61, respectively). CONCLUSIONS Impact on mortality of the recipient's pretransplant PS is principally limited to the first 3 months after LT. Over time, mortality has improved for both HCC and non-HCC recipients and across the full range of PS.
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Affiliation(s)
- David Wallace
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Thomas Cowling
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mark J McPhail
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Sarah E Brown
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Varuna Aluvihare
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Abid Suddle
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Georg Auzinger
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Ian A Rowe
- Liver Unit, St James' Hospital and University of Leeds, Leeds, United Kingdom.,Leeds Institute for Data Analytics, University of Leeds, Leeds, United Kingdom
| | - Kate Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - William Bernal
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
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28
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Tripathi D, Stanley AJ, Hayes PC, Travis S, Armstrong MJ, Tsochatzis EA, Rowe IA, Roslund N, Ireland H, Lomax M, Leithead JA, Mehrzad H, Aspinall RJ, McDonagh J, Patch D. Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension. Gut 2020; 69:1173-1192. [PMID: 32114503 PMCID: PMC7306985 DOI: 10.1136/gutjnl-2019-320221] [Citation(s) in RCA: 155] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 01/20/2020] [Accepted: 01/22/2020] [Indexed: 12/15/2022]
Abstract
These guidelines on transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of portal hypertension have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the Liver Section of the BSG. The guidelines are new and have been produced in collaboration with the British Society of Interventional Radiology (BSIR) and British Association of the Study of the Liver (BASL). The guidelines development group comprises elected members of the BSG Liver Section, representation from BASL, a nursing representative and two patient representatives. The quality of evidence and grading of recommendations was appraised using the GRADE system. These guidelines are aimed at healthcare professionals considering referring a patient for a TIPSS. They comprise the following subheadings: indications; patient selection; procedural details; complications; and research agenda. They are not designed to address: the management of the underlying liver disease; the role of TIPSS in children; or complex technical and procedural aspects of TIPSS.
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Affiliation(s)
- Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK .,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Adrian J Stanley
- Gastroenterology Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Peter C Hayes
- Hepatology Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Simon Travis
- Department if Radiology, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Matthew J Armstrong
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Emmanuel A Tsochatzis
- The Royal Free Sheila Sherlock Liver Centre, UCL Institute for Liver and Digestive Health, London, UK
| | | | | | - Hamish Ireland
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Joanne A Leithead
- Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Homoyon Mehrzad
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Aspinall
- Department of Hepatology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Joanne McDonagh
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, UCL Institute for Liver and Digestive Health, London, UK
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29
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Affiliation(s)
- Ian A Rowe
- Leeds Institute for Medical Research and Leeds Institute for Data Analytics, University of Leeds, UK.
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30
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Affiliation(s)
- Ian A Rowe
- Leeds Institute for Medical Research & Leeds Institute for Data Analytics, University of Leeds, Leeds, UK.,Leeds Liver Unit, St James's University Hospital, Leeds, UK
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31
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Driver RJ, Balachandrakumar V, Burton A, Shearer J, Downing A, Cross T, Morris E, Rowe IA. Validation of an algorithm using inpatient electronic health records to determine the presence and severity of cirrhosis in patients with hepatocellular carcinoma in England: an observational study. BMJ Open 2019; 9:e028571. [PMID: 31292182 PMCID: PMC6624046 DOI: 10.1136/bmjopen-2018-028571] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Outcomes in hepatocellular carcinoma (HCC) are determined by both cancer characteristics and liver disease severity. This study aims to validate the use of inpatient electronic health records to determine liver disease severity from treatment and procedure codes. DESIGN Retrospective observational study. SETTING Two National Health Service (NHS) cancer centres in England. PARTICIPANTS 339 patients with a new diagnosis of HCC between 2007 and 2016. MAIN OUTCOME Using inpatient electronic health records, we have developed an optimised algorithm to identify cirrhosis and determine liver disease severity in a population with HCC. The diagnostic accuracy of the algorithm was optimised using clinical records from one NHS Trust and it was externally validated using anonymised data from another centre. RESULTS The optimised algorithm has a positive predictive value (PPV) of 99% for identifying cirrhosis in the derivation cohort, with a sensitivity of 86% (95% CI 82% to 90%) and a specificity of 98% (95% CI 96% to 100%). The sensitivity for detecting advanced stage cirrhosis is 80% (95% CI 75% to 87%) and specificity is 98% (95% CI 96% to 100%), with a PPV of 89%. CONCLUSIONS Our optimised algorithm, based on inpatient electronic health records, reliably identifies and stages cirrhosis in patients with HCC. This highlights the potential of routine health data in population studies to stratify patients with HCC according to liver disease severity.
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Affiliation(s)
- Robert J Driver
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Department of Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | | | - Anya Burton
- National Cancer Registration and Analysis Service, Bristol, UK
| | - Jessica Shearer
- Department of Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Amy Downing
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Tim Cross
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Eva Morris
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Ian A Rowe
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Department of Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
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Affiliation(s)
- Ian A Rowe
- Leeds Institute for Data Analytics, University of Leeds, Leeds LS97TF, UK.
| | - Richard Parker
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Shearer J, Chizhande D, Jones R, Rowe IA. Non-invasive prediction of oesophageal varices in patients with cirrhosis secondary to non-alcoholic fatty liver disease. J Hepatol 2018; 69:1202-1203. [PMID: 30206018 DOI: 10.1016/j.jhep.2018.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/02/2018] [Accepted: 08/05/2018] [Indexed: 01/07/2023]
Affiliation(s)
- Jessica Shearer
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - David Chizhande
- Informatics Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rebecca Jones
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ian A Rowe
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Leeds Institute for Data Analytics, University of Leeds, Leeds, UK.
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Roskilly A, Rowe IA. Surveillance for hepatocellular cancer. Clin Med (Lond) 2018; 18. [PMID: 29700096 PMCID: PMC6334024 DOI: 10.7861/clinmedicine.18-2s-s66] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Hepatocellular carcinoma (HCC) is a common complication of cirrhosis. The incidence of HCC is rising and HCC-related mortality is rising in parallel such that there were more than 1,700 deaths in the UK in 2015. Since cirrhosis is a known risk factor for the development of HCC and early diagnosis is associated with improved outcomes, surveillance for the development of HCC using regular ultrasound scans is recommended by many expert bodies including the National Institute for Health and Care Excellence (NICE). This surveillance is not supported by high-quality evidence and there is an increasing appreciation of the associated harms. In this review the likely benefits of surveillance are discussed together with recommendations to increase the effectiveness of surveillance overall.
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Affiliation(s)
- Anna Roskilly
- ALiver Unit, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ian A Rowe
- BInstitute for Biomedical and Clinical Sciences, University of Leeds, UK,Address for correspondence: Dr Ian A Rowe, Room 6.1, Clinical Sciences Building, University of Leeds, St James’s University Hospital, Beckett Street, Leeds LS9 7TF, UK.
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Abstract
Hepatocellular carcinoma (HCC) is a common complication of cirrhosis. The incidence of HCC is rising and HCC-related mortality is rising in parallel such that there were more than 1,700 deaths in the UK in 2015. Since cirrhosis is a known risk factor for the development of HCC and early diagnosis is associated with improved outcomes, surveillance for the development of HCC using regular ultrasound scans is recommended by many expert bodies including the National Institute for Health and Care Excellence (NICE). This surveillance is not supported by high-quality evidence and there is an increasing appreciation of the associated harms. In this review the likely benefits of surveillance are discussed together with recommendations to increase the effectiveness of surveillance overall.
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Affiliation(s)
- Anna Roskilly
- Liver Unit, St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ian A Rowe
- Institute for Biomedical and Clinical Sciences, University of Leeds, UK
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36
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Wood CP, Rowe IA. What Are the Benefits of Anticoagulation for Portal Vein Thrombosis in Individuals With Cirrhosis? Gastroenterology 2018; 154:759-760. [PMID: 29352956 DOI: 10.1053/j.gastro.2017.08.075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 08/03/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Callum P Wood
- Leeds Liver Unit, St James University Hospital, Leeds, United Kingdom
| | - Ian A Rowe
- Leeds Liver Unit, St James University Hospital and Leeds Institute for Data Analytics, University of Leeds, Leeds, United Kingdom
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Taylor EJ, Jones RL, Guthrie JA, Rowe IA. Modeling the benefits and harms of surveillance for hepatocellular carcinoma: Information to support informed choices. Hepatology 2017; 66:1546-1555. [PMID: 28605060 DOI: 10.1002/hep.29315] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/31/2017] [Accepted: 06/07/2017] [Indexed: 12/20/2022]
Abstract
UNLABELLED Surveillance by ultrasonography for hepatocellular carcinoma (HCC) for individuals with cirrhosis is recommended. There is debate regarding the effectiveness of surveillance in reducing mortality, and there is little information on the harms available to patients considering surveillance. The aim of this study was to provide estimates of both the benefit and harms of surveillance. A Markov model was built to simulate outcomes of individuals aged 50 years with well-compensated cirrhosis entering surveillance. Following identification of a focal lesion by ultrasound surveillance, further investigations were defined by the European Association for the Study of the Liver/European Organization for Research and Treatment of Cancer recall policy. Benefit and harm outcomes are expressed per 1,000 patients over 5 years. For every 1,000 patients in surveillance over 5 years, there are 13 fewer deaths (95% confidence interval [CI], 12-14) compared with no surveillance, equating to a number needed to screen to prevent one death from HCC of 77. In comparison, many more individuals experienced harm through surveillance. For every 1,000 patients, 150 (95% CI, 146-154) had one or more false-positive tests equating to a number needed to harm from surveillance of 7. As a consequence of a false-positive test, 65 individuals required at least one additional unnecessary computed tomography scan or magnetic resonance imaging and 39 required an unnecessary liver biopsy according to the recall policy. Surveillance benefits were sensitive to the incidence of HCC and the mortality benefit achieved by treatment. Harms were sensitive to the rates of false-positive testing and the frequency of liver biopsy. CONCLUSION There is a balance between the small absolute mortality benefit to surveillance for HCC and the numerically more frequent harms resulting from false-positive testing. Implementation of the recently revised American Association for the Study of Liver Diseases recommendations is predicted to reduce harms from unnecessary liver biopsy. (Hepatology 2017;66:1546-1555).
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Affiliation(s)
- Eleanor J Taylor
- Liver Unit, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Rebecca L Jones
- Liver Unit, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - J Ashley Guthrie
- Department of Radiology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Ian A Rowe
- Liver Unit, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.,Institute for Biomedical and Clinical Sciences, University of Leeds, United Kingdom
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Schmidt-Martin D, Armstrong MJ, Rowe IA. Transplant-Free Survival Rates After Covered Transjugular Intrahepatic Portosystemic Shunt. Gastroenterology 2017; 153:869-870. [PMID: 28781224 DOI: 10.1053/j.gastro.2017.02.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 02/10/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Daniel Schmidt-Martin
- Liver Transplant Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Matthew J Armstrong
- Liver Transplant Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Ian A Rowe
- Liver Transplant Unit, St James University Hospital, Leeds, UK
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39
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Rowe IA. Understanding the benefits and risks in donor liver allocation. Clin Liver Dis (Hoboken) 2017; 10:21-24. [PMID: 30992753 PMCID: PMC6467108 DOI: 10.1002/cld.645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 05/31/2017] [Accepted: 06/05/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Ian A. Rowe
- Leeds Institute for Data AnalyticsUniversity of Leeds; and Leeds Liver Unit, St. James's University HospitalLeedsUnited Kingdom
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Affiliation(s)
| | - Nick Sheron
- Southampton General Hospital, University of Southampton, UK
| | - Ian A Rowe
- Leeds Institute for Data Analytics, University of Leeds, UK
| | - Gideon M Hirschfield
- Centre for Liver Research, NIHR Biomedical Research Centre, University of Birmingham, Birmingham, UK
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41
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Affiliation(s)
| | - Ian A Rowe
- Leeds Institute for Data Analytics, University of Leeds.,Leeds Liver Unit St. James's University Hospital, Leeds, UK
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Goldsworthy MA, Fateen W, Thygesen H, Aldersley MA, Rowe IA, Jones RL. Patient understanding of liver cirrhosis and improvement using multimedia education. Frontline Gastroenterol 2017; 8:214-219. [PMID: 28706622 PMCID: PMC5502237 DOI: 10.1136/flgastro-2016-100761] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 12/26/2016] [Accepted: 01/01/2017] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE For patients to engage with the long-term management of liver cirrhosis, sufficient understanding of their condition is essential. The aim of this study was to assess baseline patient knowledge and to test whether a condition-specific multimedia screencast could improve this. DESIGN Service quality improvement study. SETTING A UK tertiary liver centre. Patients were recruited during 12 general hepatology outpatient clinics. PATIENTS Fifty-two patients with liver cirrhosis were included. Sixty-two per cent were male; their median age was 56 years and their median clinic attendance period was 3 years. INTERVENTIONS Participants completed a baseline questionnaire assessing their knowledge of the management and complications of cirrhosis. They then watched a tailored screencast discussing this condition, which had been developed by expert hepatologists in collaboration with patient representatives. Knowledge was reassessed using a new copy of the original questionnaire after an interval of at least one month. MAIN OUTCOME MEASURES Patient scores on knowledge questionnaires at baseline and follow-up. RESULTS Fifty-two patients achieved a median score of 25.0% before viewing the screencast. Thirty-five patients then completed a follow-up questionnaire after an interval period. The median questionnaire score in this group improved from 25.0% to 66.7%; an increase of 41.7% compared with baseline (p<0.001). CONCLUSIONS Despite regular review at a specialist clinic, participants had poor baseline knowledge of liver cirrhosis. Delivering information by screencast led to a significant improvement. We therefore present an effective way to empower patients with accurate, up-to-date and retainable information that can easily be translated to many other conditions.
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Affiliation(s)
| | - Waleed Fateen
- School of Medicine, University of Leeds, Leeds, UK,NIHR Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and The University of Nottingham, Nottingham, UK
| | - Helene Thygesen
- College of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Mark A Aldersley
- Department of Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ian A Rowe
- School of Medicine, University of Leeds, Leeds, UK,Department of Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rebecca L Jones
- Department of Hepatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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43
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Young AL, Rowe IA, Absolom K, Jones RL, Downing A, Meader N, Glaser A, Toogood GJ. The effect of Liver Transplantation on the quality of life of the recipient's main caregiver - a systematic review. Liver Int 2017; 37:794-801. [PMID: 27917588 DOI: 10.1111/liv.13333] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 11/27/2016] [Indexed: 12/24/2022]
Abstract
Liver transplantation (LT) is a transformative, life-saving procedure with life-long sequale for patients and their caregivers. The impact of LT on the patient's main caregiver can be underestimated. We carried out a systematic review of the impact of LT on the Health-Related Quality of Life (HRQL) of LT patients' main caregivers. We searched 13 medical databases from 1996 to 2015. We included studies with HRQL data on caregivers of patients following LT then quality assessed and narratively synthesized the findings from these studies. Of 7076 initial hits, only five studies fell within the scope of this study. In general, they showed caregiver burden persisted in the early period following LT. One study showed improvements, however, the other four showed caregiver's levels of stress, anxiety and depression, remained similar or got worse post-LT and remained above that of the normal population. It was suggested that HRQL of the patient impacted on the caregiver and vice versa and may be linked to patient outcomes. No data were available investigating which groups were at particular risk of low HRQL following LT or if any interventions could improve this. The current information about LT caregivers' needs and factors that impact on their HRQL are not adequately defined. Large studies are needed to examine the effects of LT on the patients' family and caregivers to understand the importance of caregiver support to maximize outcomes of LT for the patient and their caregivers.
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Affiliation(s)
| | - Ian A Rowe
- Leeds liver unit, St James's University Hospital, Leeds, UK
| | - Kate Absolom
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | | | - Amy Downing
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Nick Meader
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Adam Glaser
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
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Abstract
Liver cirrhosis is responsible for more than 1 million deaths annually and the majority of these deaths are preventable. There is marked geographical variation in rates of mortality due to cirrhosis, and this variation in liver disease burden exemplifies the links between population risks for liver disease and mortality. The differing geographical distribution of the major risks factors for the development of liver disease including alcohol consumption, hepatitis C virus (HCV) infection, hepatitis B virus infection, and obesity and the metabolic syndrome has the potential to highlight opportunities for intervention, while the evolution of these risk factors provides insights into understanding the future burden of liver disease. This review focuses on the use of population data to identify high-risk areas and populations that would benefit from preventative interventions to reduce the mortality from liver disease. Specific strategies that are effective at the policy and public health levels are discussed to illustrate the impact these can have if widely implemented. The impact of therapies that have the potential to change the natural history of liver disease, including direct acting antivirals for HCV infection is also described. Finally, the challenges of describing the epidemiology of non-alcoholic fatty liver disease are highlighted to illustrate the need to understand the natural history of disease to inform and influence the development of novel therapies.
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Affiliation(s)
- Ian A Rowe
- University Academic Fellow, Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
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Armstrong MJ, Schmidt-Martin D, Rowe IA, Newsome PN. Caution in Using Non-Invasive Scoring Systems in NAFLD Beyond Highly Selected Study Populations. Am J Gastroenterol 2017; 112:653-654. [PMID: 28381853 DOI: 10.1038/ajg.2017.28] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- M J Armstrong
- Liver Transplant Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - D Schmidt-Martin
- Liver Transplant Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - I A Rowe
- Liver Transplant Unit, St James University Hospital, Leeds, UK
| | - P N Newsome
- Liver Transplant Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK
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46
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Driver R, Rowe IA. What is the benefit of early follow-up after hospitalization for patients with cirrhosis? Hepatology 2017; 65:1413. [PMID: 28100009 DOI: 10.1002/hep.29060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Robert Driver
- Liver Unit, St. James's University Hospital, Leeds, United Kingdom
| | - Ian A Rowe
- Liver Unit, St. James's University Hospital, Leeds, United Kingdom.,Leeds Institute for Data Analytics, University of Leeds, Leeds, United Kingdom
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Hedegaard DL, Tully DC, Rowe IA, Reynolds GM, Bean DJ, Hu K, Davis C, Wilhelm A, Ogilvie CB, Power KA, Tarr AW, Kelly D, Allen TM, Balfe P, McKeating JA. High resolution sequencing of hepatitis C virus reveals limited intra-hepatic compartmentalization in end-stage liver disease. J Hepatol 2017; 66:28-38. [PMID: 27531641 PMCID: PMC5558612 DOI: 10.1016/j.jhep.2016.07.048] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/22/2016] [Accepted: 07/29/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS The high replication and mutation rate of hepatitis C virus (HCV) results in a heterogeneous population of viral sequences in vivo. HCV replicates in the liver and infected hepatocytes occur as foci surrounded by uninfected cells that may promote compartmentalization of viral variants. Given recent reports showing interferon stimulated gene (ISG) expression in chronic hepatitis C, we hypothesized that local interferon responses may limit HCV replication and evolution. METHODS To investigate the spatial influence of liver architecture on viral replication we measured HCV RNA and ISG mRNA from each of the 8 Couinaud segments of the liver from 21 patients undergoing liver transplant. RESULTS HCV RNA and ISG mRNA levels were comparable across all sites from an individual liver but showed up to 500-fold difference between patients. Importantly, there was no association between ISG and HCV RNA expression across all sites in the liver or plasma. Deep sequencing of HCV RNA isolated from the 8 hepatic sites from two subjects showed a similar distribution of viral quasispecies across the liver and uniform sequence diversity. Single genome amplification of HCV E1E2-envelope clones from 6 selected patients at 2 hepatic sites supported these data and showed no evidence for HCV compartmentalization. CONCLUSIONS We found no differences between the hepatic and plasma viral quasispecies in all patients sampled. We conclude that in end-stage liver disease HCV RNA levels and the genetic pool of HCV envelope sequences are indistinguishable between distant sites in the liver and plasma, arguing against viral compartmentalization. LAY SUMMARY HCV is an RNA virus that exists as a quasispecies of closely related genomes that are under continuous selection by host innate and adaptive immune responses and antiviral drug therapy. The primary site of HCV replication is the liver and yet our understanding of the spatial distribution of viral variants within the liver is limited. High resolution sequencing of HCV and monitoring of innate immune responses at multiple sites across the liver identified a uniform pattern of diversity and argues against viral compartmentalization.
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Affiliation(s)
| | | | - Ian A. Rowe
- Centre for Human Virology, University of Birmingham, Birmingham, UK
| | - Gary M. Reynolds
- NIHR Birmingham Liver Biomedical Research Unit, University of Birmingham, UK
| | - David J. Bean
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA
| | - Ke Hu
- Centre for Human Virology, University of Birmingham, Birmingham, UK
| | | | - Annika Wilhelm
- NIHR Birmingham Liver Biomedical Research Unit, University of Birmingham, UK
| | | | - Karen A. Power
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA
| | - Alexander W. Tarr
- School of Life Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Deirdre Kelly
- Liver Unit, Birmingham Childrens’ Hospital, Birmingham, UK
| | - Todd M. Allen
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA
| | - Peter Balfe
- Centre for Human Virology, University of Birmingham, Birmingham, UK.
| | - Jane A. McKeating
- Centre for Human Virology, University of Birmingham, Birmingham, UK,NIHR Birmingham Liver Biomedical Research Unit, University of Birmingham, UK,Institute for Advanced Study, Technische Universität München, Lichtenbergstrasse 2a, D-85748 Garching, Germany
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Chimakurthi CR, Rowe IA. Establishing the independence and clinical importance of non-alcoholic fatty liver disease as a risk factor for cardiovascular disease. J Hepatol 2016; 65:1265-1266. [PMID: 27498134 DOI: 10.1016/j.jhep.2016.06.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 06/27/2016] [Indexed: 12/13/2022]
Affiliation(s)
| | - Ian A Rowe
- Liver Unit, St. James's University Hospital, Leeds, UK; Leeds Institute for Data Analytics, University of Leeds, Leeds, UK.
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Chaudhry T, Dillon A, Rowe IA. Uncertain Benefits of Simvastatin in the Treatment of Patients With Variceal Hemorrhage. Gastroenterology 2016; 151:1035. [PMID: 27713045 DOI: 10.1053/j.gastro.2016.06.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 06/06/2016] [Indexed: 12/02/2022]
Affiliation(s)
| | - Audrey Dillon
- Liver Unit, St. James's University Hospital, Leeds, UK
| | - Ian A Rowe
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
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