1
|
Dunn W, Li Y, Singal AK, Simonetto DA, Díaz LA, Idalsoaga F, Ayares G, Arnold J, Ayala-Valverde M, Perez D, Gomez J, Escarate R, Fuentes-López E, Ramirez-Cadiz C, Morales-Arraez D, Zhang W, Qian S, Ahn JC, Buryska S, Mehta H, Dunn N, Waleed M, Stefanescu H, Bumbu A, Horhat A, Attar B, Agrawal R, Cabezas J, Echavaría V, Cuyàs B, Poca M, Soriano G, Sarin SK, Maiwall R, Jalal PK, Higuera-de-la-Tijera F, Kulkarni AV, Rao PN, Guerra-Salazar P, Skladaný L, Kubánek N, Prado V, Clemente-Sanchez A, Rincon D, Haider T, Chacko KR, Romero GA, Pollarsky FD, Restrepo JC, Toro LG, Yaquich P, Mendizabal M, Garrido ML, Marciano S, Dirchwolf M, Vargas V, Jiménez C, Hudson D, García-Tsao G, Ortiz G, Abraldes JG, Kamath PS, Arrese M, Shah VH, Bataller R, Arab JP. An artificial intelligence-generated model predicts 90-day survival in alcohol-associated hepatitis: A global cohort study. Hepatology 2024:01515467-990000000-00843. [PMID: 38607809 DOI: 10.1097/hep.0000000000000883] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/14/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND AIMS Alcohol-associated hepatitis (AH) poses significant short-term mortality. Existing prognostic models lack precision for 90-day mortality. Utilizing artificial intelligence (AI) in a global cohort, we sought to derive and validate an enhanced prognostic model. APPROACH AND RESULTS The Global AlcHep initiative, a retrospective study across 23 centers in 12 countries, enrolled AH patients per NIAAA criteria. Centers were partitioned into derivation (11 centers, 860 patients) and validation cohorts (12 centers, 859 patients). Focusing on 30 and 90-day post-admission mortality, three AI algorithms (Random Forest, Gradient Boosting Machines, and eXtreme Gradient Boosting) informed an ensemble model, subsequently refined via Bayesian updating, integrating the derivation cohort's average 90-day mortality with each center's approximate mortality rate to produce post-test probabilities. The ALCoholic Hepatitis Artificial INtelligence (ALCHAIN) Ensemble score integrated age, gender, cirrhosis, and 9 laboratory values, with center-specific mortality rates. Mortality was 18.7% (30-day) and 27.9% (90-day) in the derivation cohort, versus 21.7% and 32.5% in the validation cohort. Validation cohort 30 and 90-day AUCs were 0.811 (0.779 - 0.844) and 0.799 (0.769 - 0.830), significantly surpassing legacy models like Maddrey's Discriminant Function, MELD variations, ABIC, Glasgow, and modified Glasgow Scores (p<0.001). ALCHAIN Ensemble score also showcased superior calibration against MELD and its variants. Steroid use improved 30-day survival for those with an ALCHAIN Ensemble score>0.20 in both derivation and validation cohorts. CONCLUSIONS Harnessing AI within a global consortium, we pioneered a scoring system excelling over traditional models for 30 and 90-day AH mortality predictions. Beneficial for clinical trials, steroid therapy, and transplant indications, it's accessible at: https://aihepatology.shinyapps.io/ALCHAIN/.
Collapse
Affiliation(s)
| | - Yanming Li
- University of Kansas Medical Center, KS, USA
| | - Ashwani K Singal
- Department of Gastroenterology and Hepatology, University of Louisville, Louisville, KY, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Luis A Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Idalsoaga
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gustavo Ayares
- Servicio Medicina Interna, Hospital El Pino, Santiago, Chile
| | - Jorge Arnold
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Diego Perez
- Servicio Medicina Interna, Hospital El Pino, Santiago, Chile
| | - Jaime Gomez
- Servicio Medicina Interna, Hospital El Pino, Santiago, Chile
| | | | - Eduardo Fuentes-López
- Department of Health Sciences, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carolina Ramirez-Cadiz
- Department of Anesthesiology and Perioperative Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
| | - Dalia Morales-Arraez
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Wei Zhang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
- Center for Liver Disease and Liver Transplantation, Columbia University, New York, NY, USA
| | - Steve Qian
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - Joseph C Ahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Seth Buryska
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Heer Mehta
- University of Kansas Medical Center, KS, USA
| | | | - Muhammad Waleed
- Department of Gastroenterology and Hepatology, University of Louisville, Louisville, KY, USA
| | - Horia Stefanescu
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Andreea Bumbu
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Adelina Horhat
- University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj-Napoca, Romania
| | - Bashar Attar
- Division of Gastroenterology & Hepatology, Cook County Health, and Hospital Systems, Chicago, Illinois, USA
| | - Rohit Agrawal
- Division of Gastroenterology and Hepatology, University of West Virginia, West Virginia, USA
| | - Joaquín Cabezas
- Gastroenterology and Hepatology Department. University Hospital Marqués de Valdecilla. Santander. Spain; Clinical and Translational Research in Digestive Diseases, Research Institute Valdecilla (IDIVAL). Santander, Spain
| | - Victor Echavaría
- Gastroenterology and Hepatology Department. University Hospital Marqués de Valdecilla. Santander. Spain; Clinical and Translational Research in Digestive Diseases, Research Institute Valdecilla (IDIVAL). Santander, Spain
| | - Berta Cuyàs
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Institut de Recerca Hospital de Sant Pau-IIB Sant Pau, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - Maria Poca
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Institut de Recerca Hospital de Sant Pau-IIB Sant Pau, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - German Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Institut de Recerca Hospital de Sant Pau-IIB Sant Pau, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Prasun K Jalal
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Fátima Higuera-de-la-Tijera
- Servicio de Gastroenterología y Hepatología, Hospital General de México "Dr. Eduardo Liceaga"; Facultad de Medicina, Universidad Nacional Autónoma de México, México
| | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - P Nagaraja Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | | | - Lubomir Skladaný
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University, F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Natália Kubánek
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University, F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | | | - Ana Clemente-Sanchez
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
- Liver Unit, Department of Digestive Diseases Hospital General Universitario Gregorio Marañón, Madrid, Spain
- CIBERehd Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Diego Rincon
- Liver Unit, Department of Digestive Diseases Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Tehseen Haider
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, Bronx, NY, USA
| | - Kristina R Chacko
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, Bronx, NY, USA
| | - Gustavo A Romero
- Sección Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Florencia D Pollarsky
- Sección Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Juan C Restrepo
- Unidad de Hepatología del Hospital Pablo Tobon Uribe, Grupo de Gastrohepatología de la Universidad de Antioquia, Medellín, Colombia
| | - Luis G Toro
- Hepatology and Liver Transplant Unit, Hospitales de San Vicente Fundación de Medellín y Rionegro, Colombia
| | - Pamela Yaquich
- Departamento de Gastroenterología, Hospital San Juan de Dios, Santiago, Chile
| | - Manuel Mendizabal
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Buenos Aires, Argentina
| | | | | | - Melisa Dirchwolf
- Unidad de Hígado, Hospital Privado de Rosario, Rosario, Argentina
| | - Victor Vargas
- Liver Unit, Hospital Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - César Jiménez
- Liver Unit, Hospital Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - David Hudson
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
| | - Guadalupe García-Tsao
- Section of Digestive Diseases, Yale University School of Medicine/VA-CT Healthcare System, New Haven, CT, USA
| | - Guillermo Ortiz
- Section of Digestive Diseases, Yale University School of Medicine/VA-CT Healthcare System, New Haven, CT, USA
| | - Juan G Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, Canada
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Marco Arrese
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Ramon Bataller
- Liver Unit, Hospital Clinic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Juan P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada
| |
Collapse
|
2
|
Arab JP, Dunn W, Im G, Singal AK. Changing landscape of alcohol-associated liver disease in younger individuals, women, and ethnic minorities. Liver Int 2024. [PMID: 38578107 DOI: 10.1111/liv.15933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 03/06/2024] [Accepted: 03/28/2024] [Indexed: 04/06/2024]
Abstract
Alcohol use is the most important determinant of the development of alcohol-associated liver disease (ALD) and of predicting long-term outcomes in those with established liver disease. Worldwide, the amount, type, and pattern of use of alcohol vary. Alcohol use and consequent liver disease have been increasing in certain ethnic groups especially Hispanics and Native Americans, likely due to variations in genetics, cultural background, socio-economic status, and access to health care. Furthermore, the magnitude and burden of ALD have been increasing especially in the last few years among females and young adults who are at the prime of their productivity. It is critical to recognize the problem and care for these patients integrating cultural aspects in liver clinics. At the federal level, a societal approach is needed with the implementation of public health policies aiming to reduce alcohol consumption in the community. By addressing these challenges and promoting awareness, we can strive to reduce the burden of ALD, especially in high-risk demographic groups to improve their long-term health outcomes. Finally, we need studies and quality research examining these changing landscapes of demographics in ALD as a basis for developing therapeutic targets and interventions to reduce harmful drinking behaviours in these high-risk demographic groups.
Collapse
Affiliation(s)
- Juan P Arab
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Winston Dunn
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Gene Im
- Division of Gastroenterology and Hepatology, Department of Medicine, Mount Sinai Medical School, New York, New York, USA
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Louisville, Louisville, Kentucky, USA
- Health Research, VA Medical Center, Sioux Falls, South Dakota, USA
| |
Collapse
|
3
|
Omran M, Omr M, Mohamed AA, Abdelghafour RA, Muharram NM, Hassan MB, Fangry A, Emran T, Arab JP, Arnold J, Diaz LA, Zheng MH, El-Kassas M. Development and validation of nonalcoholic fatty liver disease test: a simple sensitive and specific marker for early diagnosis of nonalcoholic fatty liver disease. Eur J Gastroenterol Hepatol 2023; 35:874-880. [PMID: 37395240 DOI: 10.1097/meg.0000000000002575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
AIM This study aimed to develop a noninvasive test for identifying patients with nonalcoholic fatty liver disease (NAFLD) based on clinical and routine laboratory data. METHODS The developed model 'NAFLD test' was compared to the most commonly used NAFLD scores and then validated in three groups of NAFLD patients from five centers in Egypt, China, and Chile. Patients were divided into the discovery cohort (n = 212) and the validation study (n = 859). The ROC curve and stepwise multivariate discriminant analysis were used to develop and validate the NAFLD test and evaluate its diagnostic performance, which was then compared to other NAFLD scores. RESULTS Elevated C-reactive protein (CRP), cholesterol, BMI, and alanine aminotransferase (ALT) levels were significantly associated with NAFLD (P < 0.0001). NAFLD test is depicted as (-0.695 + 0.031 × BMI + 0.003 × cholesterol + 0.014 × ALT + 0.025 × CRP) to discriminate patients with NAFLD from healthy individuals. The area under the ROC curve (AUC) of the NAFLD test was 0.92 [95% confidence interval (CI): 0.88-0.96]. The NAFLD test was the most accurate diagnostic indicator of NAFLD when compared to widely used NAFLD indices. Upon validating the NAFLD test, its AUC (95% CI) for distinguishing patients with NAFLD from healthy individuals was 0.95 (0.94-0.97), 0.90 (0.87-0.93), and 0.94 (0.91-0.97) in Egyptian, Chinese, and Chilean patients with NAFLD respectively. CONCLUSION The NAFLD test is a new validated diagnostic biomarker that can be utilized for the early diagnosis of NAFLD with high diagnostic performance.
Collapse
Affiliation(s)
- Mohamed Omran
- Chemistry Department, Faculty of Science, Helwan University, Cairo
| | - Mona Omr
- Chemistry Department, Faculty of Science, Damietta University, Damietta
| | - Amal A Mohamed
- Biochemistry Department, National Hepatology Tropical Medicine Research Institute, Cairo
| | | | - Nashwa M Muharram
- Medical Biochemistry and Molecular Biology, Faculty of Medicine, Menoufia University, Shebin ElKom
| | - Mohamed B Hassan
- Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo
| | | | - Tarek Emran
- Clinical Pathology Department, Faculty of Medicine, Al-Azhar University, Damietta, Egypt
| | - Juan P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
| | - Jorge Arnold
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis Antonio Diaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ming-Hua Zheng
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
- Key Laboratory of Diagnosis and Treatment for the Development of Chronic Liver Disease in Zhejiang Province, Wenzhou, China
| | - Mohamed El-Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo
| |
Collapse
|
4
|
Arab JP, Addolorato G, Mathurin P, Thursz MR. Alcohol-Associated Liver Disease: Integrated Management With Alcohol Use Disorder. Clin Gastroenterol Hepatol 2023; 21:2124-2134. [PMID: 36858144 DOI: 10.1016/j.cgh.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/21/2023] [Accepted: 02/03/2023] [Indexed: 03/03/2023]
Abstract
Alcohol-associated liver disease (ALD) is the most common cause of cirrhosis and liver-related mortality in many regions worldwide. Around 75% of patients with cirrhosis are unaware of their disease until they are referred to the emergency department. An innovative, noninvasive screening approach is required for an earlier diagnosis of liver fibrosis. In patients with ALD the physician is inevitably dealing with 2 major disorders: the liver disease itself and the alcohol use disorder (AUD). Focus only on the liver disease will inevitably lead to failure because transient improvements in liver function are rapidly overturned if the patient returns to alcohol consumption. For this reason, integrated models of care provided by hepatologists and addiction specialists are an effective approach, which are, however, not widely available. There are multiple pharmacologic and non-pharmacologic therapies for AUD. Progress has recently been made in the management of patients with severe AH who have improved survival through better understanding of the concept of response to medical treatment, improved survival prediction, and the advent of early liver transplantation. The emerging concept is that listing for transplantation a patient with severe ALD could lead to adjusting the duration of abstinence according to the severity and evolution of liver dysfunction and the patient's addictive profile.
Collapse
Affiliation(s)
- Juan P Arab
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Giovanni Addolorato
- Department of Medical and Surgical Sciences, Internal Medicine and Hepatology Unit, Catholic University of Rome, Rome, Italy
| | - Philippe Mathurin
- Service des maladies de l'appareil digestif, Hôpital Huriez, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Mark R Thursz
- Division of Digestive Diseases, Imperial College, London, United Kingdom
| |
Collapse
|
5
|
Howarth NC, Arab JP. Acute Kidney Injury in Alcohol-Associated Hepatitis: More than a Bystander. J Clin Exp Hepatol 2023; 13:193-195. [PMID: 36950482 PMCID: PMC10025756 DOI: 10.1016/j.jceh.2023.01.018] [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: 03/24/2023] Open
Affiliation(s)
- Nisha C Howarth
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
| | - Juan P Arab
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| |
Collapse
|
6
|
Ayares G, Idalsoaga F, Arnold J, Fuentes-López E, Arab JP, Díaz LA. Public Health Measures and Prevention of Alcohol-Associated Liver Disease. J Clin Exp Hepatol 2022; 12:1480-1491. [PMID: 36340308 PMCID: PMC9630023 DOI: 10.1016/j.jceh.2022.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/25/2022] [Indexed: 12/12/2022] Open
Abstract
Hazardous alcohol consumption causes approximately 4% of deaths globally, constituting one of the leading risk factors for the burden of the disease worldwide. Alcohol has several health consequences, such as alcohol-associated liver disease, hepatocellular carcinoma, nonliver neoplasms, physical injury, cardiac disease, and psychiatric disorders. Alcohol misuse significantly affects workforce productivity, with elevated direct and indirect economic costs. Due to the high impact of alcohol consumption on the population, public health has led to the development of a range of strategies to reduce its harmful effects. Regulatory public health policies (PHP) for alcohol can exist at the global, regional, international, national, or subnational levels. Effective strategies incorporate a multilevel, multicomponent approach, targeting multiple determinants of drinking and alcohol-related harms. The World Health Organization categorizes the PHP into eight categories: national plan to fight the harmful consequences of alcohol, national license and production and selling control, taxes control and pricing policies, limiting drinking age, restrictions on alcohol access, driving-related alcohol policies, control over advertising and promotion, and government monitoring systems. These policies are supported by evidence from different populations, demonstrating that determinants of alcohol use depend on several factors such as socioeconomic level, age, sex, ethnicity, production, availability, marketing, and others. Although most policies have a significant individual effect, a higher number of PHP are associated with a lower burden of disease due to alcohol. The excessive consequences of alcohol constitute a call for action, and clinicians should advocate for developing and implementing a new PHP on alcohol consumption.
Collapse
Key Words
- ACLF, Acute-on-Chronic Liver Failure
- ALD, Alcohol-associated Liver Disease
- AUC, Area Under the Curve
- AUD, Alcohol Use Disorder
- AUDIT, Alcohol Use Disorders Identification Test
- AUDIT-C, Alcohol Use Disorders Identification Test Concise
- AVT, Alcohol Volumetric Tax
- BAC, Blood Alcohol Concentration
- DALYs, Disability-adjusted life years
- GDP, Gross domestic product
- PHP, Public Health Policies
- PNPLA3, Patatin-like Phospholipase Domain-containing 3
- USA, United States
- USD, United States Dollars
- WHO, World Health Organization
- alcohol use disorders
- alcohol-associated hepatitis
- cirrhosis
- fatty liver disease
- steatosis
Collapse
Affiliation(s)
- Gustavo Ayares
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Idalsoaga
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Arnold
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo Fuentes-López
- Departamento de Ciencias de La Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan P. Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis A. Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| |
Collapse
|
7
|
Ayares G, Idalsoaga F, Díaz LA, Arnold J, Arab JP. Current Medical Treatment for Alcohol-Associated Liver Disease. J Clin Exp Hepatol 2022; 12:1333-1348. [PMID: 36157148 PMCID: PMC9499849 DOI: 10.1016/j.jceh.2022.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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: 11/23/2021] [Accepted: 02/06/2022] [Indexed: 12/12/2022] Open
Abstract
Alcohol-associated liver disease is one of the main causes of chronic liver disease. It comprises a clinical-histologic spectrum of presentations, from steatosis, steatohepatitis, to different degrees of fibrosis, including cirrhosis and severe necroinflammatory disease, called alcohol-associated hepatitis. In this focused update, we aim to present specific therapeutic interventions and strategies for the management of alcohol-associated liver disease. Current evidence for management in all spectra of manifestations is derived from general chronic liver disease recommendations, but with a higher emphasis on abstinence and nutritional support. Abstinence should comprise the treatment of alcohol use disorder as well as withdrawal syndrome. Nutritional assessment should also consider the presence of sarcopenia and its clinical manifestation, frailty. The degree of compensation of the disease should be evaluated, and complications, actively sought. The most severe acute form of this disease is alcohol-associated hepatitis, which has high mortality and morbidity. Current treatment is based on corticosteroids that act by reducing immune activation and blocking cytotoxicity and inflammation pathways. Other aspects of treatment include preventing and treating hepatorenal syndrome as well as preventing infections although there is no clear evidence as to the benefit of probiotics and antibiotics in prophylaxis. Novel therapies for alcohol-associated hepatitis include metadoxine, interleukin-22 analogs, and interleukin-1-beta antagonists. Finally, granulocyte colony-stimulating factor, microbiota transplantation, and gut-liver axis modulation have shown promising results. We also discuss palliative care in advanced alcohol-associated liver disease.
Collapse
Key Words
- AC, Amoxicillin/clavulanate
- ACLF, Acute-on-Chronic Liver Failure
- ADLs, Activities of Daily Living
- AH, Alcohol-Associated Hepatitis
- AKI-HRS, Acute Kidney Injury - Hepatorenal Syndrome
- ALD
- ALD, Alcohol-Associated Liver Disease
- ASH, Alcoholic Steatohepatitis
- AUD, Alcohol Use Disorder
- AWS, Alcohol Withdrawal Syndrome
- BCAAs, Branched-Chain Amino Acids
- CDC, Center for Disease Control
- CI, Confidence Interval
- COVID-19, Coronavirus Disease 2019
- CT, Computerized Tomography
- GABA, gamma-aminobutyric acid agonist
- HBV, Hepatitis B Virus
- HCC, Hepatocellular Carcinoma
- HCV, Hepatitis C Virus
- HE, Hepatic Encephalopathy
- HIV, Human Immunodeficiency Virus
- HR, Hazard Ratio
- IBW, Ideal Body Weight
- ICA, International Club of Ascites
- IL-1β, Interleukin-1β
- IL-22, Interleukin-22
- KPS, Karnofsky Performance Status
- LB, Liver Biopsy
- LPS, Lipopolysaccharide
- LSM, Liver Stiffness Measurement
- LT, Liver Transplantation
- MDF, Maddrey’s Discriminant Function
- MELD, Model of End-Stage Liver Disease
- MRI, Magnetic Resonance Imaging
- MUST, Malnutrition Universal Screening Tool
- NIAAA, National Institute on Alcohol Abuse and Alcoholism
- NRS-2002, Nutritional Risk Screening-2002
- OR, Odds Ratio
- PAMPs, Pathogen-Activated Molecular Patterns
- PMI, Psoas Muscle Index
- PTX, Pentoxifylline
- RAI, Relative Adrenal Insufficiency
- RCT, Randomized Clinical Trials
- RFH-NPT, Royal Free Hospital-Nutritional Prioritizing Tool
- ROS, Reactive Oxygen Species
- RR, Relative Risk
- SIRS, Systemic Inflammatory Response Syndrome
- TNF, Tumor Necrosis Factor
- WKS, Wernicke-Korsakoff Syndrome
- alcohol
- alcohol use disorders
- alcohol-associated hepatitis
- cirrhosis
- fatty liver disease
- steatosis
Collapse
Affiliation(s)
- Gustavo Ayares
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Idalsoaga
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis A. Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Arnold
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan P. Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| |
Collapse
|
8
|
Abstract
Strategies to prevent infection and improve outcomes in patients with cirrhosis. HAV, hepatitis A virus; HBV, hepatitis B virus; COVID-19, novel coronavirus disease 2019; NSBB, nonselective β-blocker; PPI, proton pump inhibitors.Cirrhosis is a risk factor for infections. Majority of hospital admissions in patients with cirrhosis are due to infections. Sepsis is an immunological response to an infectious process that leads to end-organ dysfunction and death. Preventing infections may avoid the downstream complications, and early diagnosis of infections may improve the outcomes. In this review, we discuss the pathogenesis, diagnosis, and biomarkers of infection; the incremental preventive strategies for infections and sepsi; and the consequent organ failures in cirrhosis. Strategies for primary prevention include reducing gut translocation by selective intestinal decontamination, avoiding unnecessary proton pump inhibitors' use, appropriate use of β-blockers, and vaccinations for viral diseases including novel coronavirus disease 2019. Secondary prevention includes early diagnosis and a timely and judicious use of antibiotics to prevent organ dysfunction. Organ failure support constitutes tertiary intervention in cirrhosis. In conclusion, infections in cirrhosis are potentially preventable with appropriate care strategies to then enable improved outcomes.
Collapse
Affiliation(s)
- Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Juan P Arab
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Karan Kumar
- Department of Hepatology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Mithun Sharma
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Nageshwar D Reddy
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Nagaraja R Padaki
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Rajender K Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
9
|
Singal AK, Kuo YF, Arab JP, Bataller R. Racial and Health Disparities among Cirrhosis-related Hospitalizations in the USA. J Clin Transl Hepatol 2022; 10:398-404. [PMID: 35836764 PMCID: PMC9240250 DOI: 10.14218/jcth.2021.00227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/15/2021] [Accepted: 10/10/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND AND AIMS Alcohol-associated liver disease (ALD) is the most common cause of advanced liver disease worldwide, including in the USA. Alcohol use and cirrhosis mortality is higher in American Indian/Alaska Native (AI/AN) compared to Whites. Data are scanty on ALD as a liver disease etiology in AI/AN compared to other races and ethnicities. METHODS The National Inpatient Sample on 199,748 cirrhosis-related hospitalizations, 14,241 (2,893 AI/AN, 2,893 Whites, 2,882 Blacks, 2,879 Hispanics, and 2,694 Asians or other races) matched 1:1 for race/ethnicity on demographics, insurance, and income quartile of the residence zip code analyzed. RESULTS After controlling for geographic location and hospital type, odds ratio (OR) and 95% confidence interval (CI) for ALD as cirrhosis etiology was higher among admissions in AI/AN vs. Whites [1.55 (1.37-1.75)], vs. Blacks [1.87 (1.65-2.11)], vs. Hispanic [1.89 (1.68-2.13)] and Asians/other races [2.24 (1.98-2.53)]. OR was also higher for AI/AN vs. all other races for alcohol-associated hepatitis (AH) as one of the discharge diagnoses. The findings were similar in a subgroup of 4,649 admissions with decompensated cirrhosis and in a cohort of 350 admissions with acute-on-chronic liver failure as defined by EASL-CLIF criteria. Alcohol use disorder diagnosis was present in 38% of admissions in AI/AN vs. 24-30% in other races, p<0.001. A total of 838 (5.9%) admissions were associated with in-hospital mortality. OR (95% CI) for in-hospital mortality in AI/AN individuals was 34% reduced vs. Blacks [0.66 (0.51-0.84)], but no difference was observed on comparison with other races. CONCLUSIONS ALD, including AH, is the most common etiology among cirrhosis-related hospitalizations in the USA among AI/AN individuals. In-hospital mortality was observed in about 6% of admissions, which was higher for Blacks and similar in other races compared to admissions for AI/AN. Public health policies should be implemented to reduce the burden of advanced ALD among AI/AN individuals.
Collapse
Affiliation(s)
- Ashwani K. Singal
- Department of Medicine, University of SD Sanford School of Medicine, Sioux Falls, SD, USA
- Division of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, SD, USA
- Correspondence to: Ashwani K. Singal, University of South Dakota, Sanford School of Medicine, Avera McKennan University Hospital Transplant Institute, Sioux Falls, SD 57105, USA. ORCID: https://orcid.org/0000-0003-1207-3998. Tel: +1-605-322-8545, Fax: +1-605-322-8536, E-mail:
| | - Yong-Fang Kuo
- Department of Biostatistics, University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Juan P. Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ramon Bataller
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
10
|
Singal AK, DiMartini A, Leggio L, Arab JP, Kuo YF, Shah VH. Identifying Alcohol Use Disorder in Patients With Cirrhosis Reduces 30-Days Readmission Rate. Alcohol Alcohol 2022; 57:576-580. [PMID: 35544033 PMCID: PMC9465529 DOI: 10.1093/alcalc/agac015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/01/2022] [Accepted: 03/04/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS Readmission is frequent among patients with cirrhosis and is a complex multifactorial process. To examine the association of alcohol use disorder (AUD) and risk of readmission in patients with alcohol-associated cirrhosis. METHODS AND RESULTS National Readmission Dataset (2016-2017) was used to extract a retrospective cohort of 53,348 patients with primary or secondary discharge diagnosis code of alcohol-associated cirrhosis with their first admission (26,674 patients with vs. propensity matched 26,674 without a primary or secondary discharge diagnosis code of AUD). Readmission within 30-day was lower (43.9 vs. 48%, P < 0.001) among patients identified to have AUD at the time of discharge. In a conditional logistic regression model, a diagnosis of AUD was associated with 15% reduced odds of 30-day readmission, 0.85 (0.83-0.88). Furthermore, the reason for readmission among patients identified vs. not identified to have AUD was less likely to be liver disease complication. The findings remained similar in a matched cohort of patients where the AUD diagnosis at discharge was listed as one of the secondary diagnoses only. CONCLUSION Although, our study findings suggest that identification of AUD at the time of discharge among patients hospitalized for alcohol-associated cirrhosis reduces the risk of 30-day readmission, unavailable information on patient counseling, referral for mental health specialist and treatment received for AUD limit the causality assessment. Future studies are needed overcoming the inherent limitations of the database to establish the role of identification and treatment of AUD in reducing readmission and liver decompensation in patients with alcohol-associated cirrhosis.
Collapse
Affiliation(s)
- Ashwani K Singal
- Department of Medicine, University of South Dakota, Vermillion, SD, USA.,Avera Transplant Institute and McKennan University Hospital, Sioux Falls, SD, USA
| | - Andrea DiMartini
- Departments of Psychiatry and Transplant Surgery, and the Clinical and Translational Science Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Lorenzo Leggio
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism Division of Intramural Clinical and Biological Research, National Institutes of Health, Bethesda, MD, USA.,Medication Development Program, National Institute on Drug Abuse Intramural Research Program, National Institutes of Health, Baltimore, MD, USA.,Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, Brown University, Providence, RI, USA.,Division of Addiction Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.,Department of Neuroscience, Georgetown University Medical Center, Washington, DC, USA
| | - Juan P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
11
|
Morales-Arráez D, Ventura-Cots M, Altamirano J, Abraldes JG, Cruz-Lemini M, Thursz MR, Atkinson SR, Sarin SK, Kim W, Chavez-Araujo R, Higuera-de la Tijera MF, Singal AK, Shah VH, Kamath PS, Duarte-Rojo A, Charles EA, Vargas V, Jager M, Rautou PE, Rincon D, Zamarripa F, Restrepo-Gutiérrez JC, Torre A, Lucey MR, Arab JP, Mathurin P, Louvet A, García-Tsao G, González JA, Verna EC, Brown RS, Argemi J, Fernández-Carrillo C, Clemente A, Alvarado-Tapias E, Forrest E, Allison M, Bataller R. Correction to: The MELD Score Is Superior to the Maddrey Discriminant Function Score to Predict Short-Term Mortality in Alcohol-Associated Hepatitis: A Global Study. Am J Gastroenterol 2022; 117:818. [PMID: 35501978 DOI: 10.14309/ajg.0000000000001704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- D Morales-Arráez
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Department of Gastroenterology and Hepatology, Hospital Universitario de Canarias, Canarias, Spain
| | - M Ventura-Cots
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - J Altamirano
- Department of Internal Medicine, Hospital Quironsalud, Barcelona, Spain
| | - J G Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, Canada
| | - M Cruz-Lemini
- Women and Perinatal Research Group, Obstetrics and Gynecology Department, Sant Pau University Hospital, Barcelona, Spain, and Maternal and Child Health and Development Network (SAMID, RD16/0022/0015), Instituto de Salud Carlos III, Spanish Ministry of Health, Spain
| | - M R Thursz
- Department of Metabolism, Digestive Disease and Reproduction, Imperial College London, London, UK
| | - S R Atkinson
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Department of Metabolism, Digestive Disease and Reproduction, Imperial College London, London, UK
| | - S K Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - W Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - R Chavez-Araujo
- Hospital das Clinicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - A K Singal
- Division of Gastroenterology and Hepatology, the University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - V H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - P S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - A Duarte-Rojo
- Division of Gastroenterology and Hepatology, Department of Medicine, the University of Arkansas for Medical Science, Little Rock, Arkansas, USA
| | - E A Charles
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - V Vargas
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Universidad Autónoma, Barcelona, CIBERehd, Barcelona, Spain
| | - M Jager
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
| | - P E Rautou
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
- Inserm, UMR-970, Paris Cardiovascular Research Center, PARCC, Paris, France
| | - D Rincon
- Hepatology Department, Hospital General Universitario Gregorio Marañón, CIBERehd and Universidad Complutense, Madrid, Spain
| | - F Zamarripa
- Gastroenterology, Juarez Hospital, Mexico City, Mexico
| | - J C Restrepo-Gutiérrez
- Liver Transplant Program, Hospital Pablo Tobon Uribe, University of Antioquia, Medellin, Colombia
| | - A Torre
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - M R Lucey
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - J P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - P Mathurin
- Service des Maladies de l'Appareil Digestif et de la Nutrition, CHU Lille, Lille, France
- LIRIC-Lille Inflammation Research International Center-U995, Univ. Lille, Inserm, CHU Lille, Lille, France
| | - A Louvet
- Service des Maladies de l'Appareil Digestif et de la Nutrition, CHU Lille, Lille, France
| | - G García-Tsao
- Section of Digestive Diseases, Yale University School of Medicine/VA-CT Healthcare System, New Haven/West Haven, Connecticut¸ USA
| | - J A González
- Gastroenterology Department, Hospital Universitario "Dr. José E González" Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - E C Verna
- Division of Digestive and Liver Diseases, Department of Medicine and Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - R S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - J Argemi
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Liver Unit, Clinica Universidad de Navarra, IdisNA, Pamplona, Spain
| | - C Fernández-Carrillo
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - A Clemente
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Liver Unit and Digestive Department H.G.U. Gregorio Marañón, Madrid, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - E Alvarado-Tapias
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - E Forrest
- Glasgow Royal Infirmary, Glasgow, UK
| | - M Allison
- Liver Unit, Cambridge Biomedical Research Centre, Cambridge, UK
| | - R Bataller
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| |
Collapse
|
12
|
Kezer CA, Buryska SM, Ahn JC, Harmsen WS, Dunn W, Singal AK, Arab JP, Díaz LA, Arnold J, Kamath PS, Shah VH, Simonetto DA. The Mortality Index for Alcohol-Associated Hepatitis: A Novel Prognostic Score. Mayo Clin Proc 2022; 97:480-490. [PMID: 35181163 DOI: 10.1016/j.mayocp.2021.10.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 04/15/2021] [Revised: 09/17/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To develop a new scoring system that more accurately predicts 30-day mortality in patients with alcohol-associated hepatitis (AH). METHODS A cohort of consecutive adults diagnosed with AH at a single academic center from January 1, 1998, to December 31, 2018, was identified for model derivation. Multivariate logistic regression was used to create a new scoring system to predict 30-day mortality. External validation of this score was performed on a multicenter retrospective cohort. RESULTS In the derivation cohort of 266 patients, the 30-day mortality rate was 19.2%. The following variables were found to be significantly associated with mortality on multivariate analysis: age (P=.002), blood urea nitrogen (P=.003), albumin (P=.01), bilirubin (P=.02), and international normalized ratio (P=.001). A model incorporating these variables, entitled the Mortality Index for Alcohol-Associated Hepatitis (MIAAH), achieved a C statistic of 0.86. Comparison of the accuracy of the MIAAH to existing prognostic models, including the Model for End-Stage Liver Disease and Maddrey Discriminant Function, showed that the highest concordance was achieved by the MIAAH and that this difference was significant. In the validation cohort of 249 patients, the MIAAH C statistic decreased to 0.73 and was found to be significantly superior to the Maddrey Discriminant Function but not to the Model for End-Stage Liver Disease. CONCLUSION The MIAAH competes with the current prognostication models and is at a minimum as accurate as these existing scores in identifying patients with AH at high risk of short-term mortality. Furthermore, the MIAAH demonstrates advantageous performance characteristics in its ability to increasingly accurately dichotomize patients into those at highest risk of death and those likely to survive.
Collapse
Affiliation(s)
| | - Seth M Buryska
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Joseph C Ahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Winston Dunn
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City
| | - Ashwani K Singal
- University of South Dakota Sanford School of Medicine and Transplant Hepatologist, Avera Transplant Institute, Sioux Falls
| | - Juan P Arab
- Department of Gastroenterology and Hepatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis A Díaz
- Department of Gastroenterology and Hepatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Arnold
- Department of Gastroenterology and Hepatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | |
Collapse
|
13
|
Cabrera D, Rao I, Raasch F, Solis N, Pizarro M, Freire M, Sáenz De Urturi D, Ramírez CA, Triantafilo N, León J, Riquelme A, Barrera F, Baudrand R, Aspichueta P, Arrese M, Arab JP. Mineralocorticoid receptor modulation by dietary sodium influences NAFLD development in mice. Ann Hepatol 2022; 24:100357. [PMID: 33940220 DOI: 10.1016/j.aohep.2021.100357] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/02/2021] [Accepted: 03/02/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Nonalcoholic-fatty-liver disease (NAFLD) is considered the hepatic manifestation of metabolic syndrome (MetS). Mineralocorticoid receptor (MR) activation is associated with increased risk of MetS but few studies have assessed the role of liver MR on NAFLD. We aimed to evaluate the effect of MR modulation by sodium intake in liver injury in experimental models of NAFLD. MATERIALS AND METHODS C57BL/6J mice were fed either a high-fat-diet (HFD) or a choline/methionine deficient (MCD) diet with different sodium concentrations. Hepatic concentration of lipid species, serum aldosterone levels, expression of MR, proinflammatory and profibrotic markers and liver histology were assessed. RESULTS Mice fed with High-Na+/HFD showed a lower MR expression in liver (p = 0.01) and less steatosis on histology (p = 0.04). Consistently, animals from this group exhibited lower levels of serum aldosterone (p = 0.028) and lower hepatic triglyceride content (p = 0.008). This associated to a reduced expression of lipogenic genes, significant changes in lipid subspecies, lower HOMA-IR (p < 0.05), and lower expression of pro-inflammatory and profibrotic markers compared to those mice fed a Low-Na+/HFD. Additionally, mice fed a High-Na+/HFD showed higher expression of salt-inducible kinase (SIK)-1 and lower expression of serum-and-glucocorticoid-inducible kinase (SGK)-1. Similar results were observed with the MCD diet model. CONCLUSION We identified in two experimental models of NAFLD that High-Na+ diet content is associated to lower serum aldosterone levels and hepatic MR downregulation, associated to decreased steatosis and reduced de novo hepatic lipogenesis, proinflammatory and profibrotic markers. Decreased activation of hepatic MR seems to generate beneficial downstream inhibition of lipogenesis in experimental NAFLD.
Collapse
Affiliation(s)
- Daniel Cabrera
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile; Facultad de Ciencias Médicas, Universidad Bernardo O Higgins, Santiago, Chile
| | - Isabel Rao
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Fabiola Raasch
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Nancy Solis
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Margarita Pizarro
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Mariela Freire
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | | | | | - Nicolás Triantafilo
- Departamento de Hematologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Jonathan León
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Arnoldo Riquelme
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile; Departamento de Ciencias de la Salud, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Francisco Barrera
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Rene Baudrand
- Departamento de Endocrinologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Patricia Aspichueta
- Department of Physiology, University of the Basque Country UPV/EHU, Leioa, Spain; Biocruces Health Research Institute, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Marco Arrese
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile; Centro de Envejecimiento y Regeneracion (CARE), Departamento de Biologia Celular y Molecular, Facultad de Ciencias Biologicas Pontificia Universidad Catolica de Chile, Santiago, Chile.
| | - Juan P Arab
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile; Centro de Envejecimiento y Regeneracion (CARE), Departamento de Biologia Celular y Molecular, Facultad de Ciencias Biologicas Pontificia Universidad Catolica de Chile, Santiago, Chile.
| |
Collapse
|
14
|
Morales-Arráez D, Ventura-Cots M, Altamirano J, Abraldes JG, Cruz-Lemini M, Thursz MR, Atkinson SR, Sarin SK, Kim W, Chavez-Araujo R, Higuera-de la Tijera MF, Singal AK, Shah VH, Kamath PS, Duarte-Rojo A, Charles EA, Vargas V, Jager M, Rautou PE, Rincon D, Zamarripa F, Restrepo-Gutiérrez JC, Torre A, Lucey MR, Arab JP, Mathurin P, Louvet A, García-Tsao G, González JA, Verna EC, Brown RS, Argemi J, Fernández-Carrillo C, Clemente A, Alvarado-Tapias E, Forrest E, Allison M, Bataller R. The MELD Score Is Superior to the Maddrey Discriminant Function Score to Predict Short-Term Mortality in Alcohol-Associated Hepatitis: A Global Study. Am J Gastroenterol 2022; 117:301-310. [PMID: 34962498 PMCID: PMC8999152 DOI: 10.14309/ajg.0000000000001596] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [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: 02/06/2021] [Accepted: 10/27/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Several scoring systems predict mortality in alcohol-associated hepatitis (AH), including the Maddrey discriminant function (mDF) and model for end-stage liver disease (MELD) score developed in the United States, Glasgow alcoholic hepatitis score in the United Kingdom, and age, bilirubin, international normalized ratio, and creatinine score in Spain. To date, no global studies have examined the utility of these scores, nor has the MELD-sodium been evaluated for outcome prediction in AH. In this study, we assessed the accuracy of different scores to predict short-term mortality in AH and investigated additional factors to improve mortality prediction. METHODS Patients admitted to hospital with a definite or probable AH were recruited by 85 tertiary centers in 11 countries and across 3 continents. Baseline demographic and laboratory variables were obtained. The primary outcome was all-cause mortality at 28 and 90 days. RESULTS In total, 3,101 patients were eligible for inclusion. After exclusions (n = 520), 2,581 patients were enrolled (74.4% male, median age 48 years, interquartile range 40.9-55.0 years). The median MELD score was 23.5 (interquartile range 20.5-27.8). Mortality at 28 and 90 days was 20% and 30.9%, respectively. The area under the receiver operating characteristic curve for 28-day mortality ranged from 0.776 for MELD-sodium to 0.701 for mDF, and for 90-day mortality, it ranged from 0.773 for MELD to 0.709 for mDF. The area under the receiver operating characteristic curve for mDF to predict death was significantly lower than all other scores. Age added to MELD obtained only a small improvement of AUC. DISCUSSION These results suggest that the mDF score should no longer be used to assess AH's prognosis. The MELD score has the best performance in predicting short-term mortality.
Collapse
Affiliation(s)
- D Morales-Arráez
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Department of Gastroenterology and Hepatology, Hospital Universitario de Canarias, Canarias, Spain
| | - M Ventura-Cots
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - J Altamirano
- Department of Internal Medicine, Hospital Quironsalud, Barcelona, Spain
| | - J G Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, Canada
| | - M Cruz-Lemini
- Women and Perinatal Research Group, Obstetrics and Gynecology Department, Sant Pau University Hospital, Barcelona, Spain, and Maternal and Child Health and Development Network (SAMID, RD16/0022/0015), Instituto de Salud Carlos III, Spanish Ministry of Health, Spain
| | - M R Thursz
- Department of Metabolism, Digestive disease and Reproduction, Imperial College London, UK
| | - S R Atkinson
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Department of Metabolism, Digestive disease and Reproduction, Imperial College London, UK
| | - S K Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
| | - W Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - R Chavez-Araujo
- Hospital das Clinicas, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - A K Singal
- Division of Gastroenterology and Hepatology, the University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - V H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - P S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - A Duarte-Rojo
- Division of Gastroenterology and Hepatology, Department of Medicine, the University of Arkansas for Medical Science, Little Rock, Arkansas, USA
| | - E A Charles
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - V Vargas
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Universidad Autónoma, Barcelona, CIBERehd, Barcelona, Spain
| | - M Jager
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
| | - P E Rautou
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
- Inserm, UMR-970, Paris Cardiovascular Research Center, PARCC, Paris, France
| | - D Rincon
- Hepatology Department, Hospital General Universitario Gregorio Marañón, CIBERehd and Universidad Complutense, Madrid, Spain
| | - F Zamarripa
- Gastroenterology, Juarez Hospital, Mexico City, Mexico
| | - J C Restrepo-Gutiérrez
- Liver Transplant Program, Hospital Pablo Tobon Uribe, University of Antioquia, Medellin, Colombia
| | - A Torre
- Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - M R Lucey
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - J P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - P Mathurin
- Service des Maladies de l'Appareil Digestif et de la Nutrition, CHU Lille, Lille, France
- LIRIC-Lille Inflammation Research International Center-U995, Univ. Lille, Inserm, CHU Lille, Lille, France
| | - A Louvet
- Service des Maladies de l'Appareil Digestif et de la Nutrition, CHU Lille, Lille, France
| | - G García-Tsao
- Section of Digestive Diseases, Yale University School of Medicine/VA-CT Healthcare System, New Haven/West Haven, Connecticut¸ USA
| | - J A González
- Gastroenterology Department, Hospital Universitario "Dr. José E González" Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - E C Verna
- Division of Digestive and Liver Diseases, Department of Medicine and Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - R S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - J Argemi
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Liver Unit, Clinica Universidad de Navarra, IdisNA. Pamplona, Spain
| | - C Fernández-Carrillo
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - A Clemente
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
- Liver Unit and Digestive Department H.G.U. Gregorio Marañón, Madrid, Spain
- CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - E Alvarado-Tapias
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - E Forrest
- Glasgow Royal Infirmary, Glasgow, UK
| | - M Allison
- Liver Unit, Cambridge Biomedical Research Centre, Cambridge, UK
| | - R Bataller
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| |
Collapse
|
15
|
Kulkarni AV, Kumar K, Candia R, Arab JP, Tevethia HV, Premkumar M, Sharma M, Menon B, Rao GV, Reddy ND, Rao NP. Prophylactic Perioperative Terlipressin Therapy for Preventing Acute Kidney Injury in Living Donor Liver Transplant Recipients: A Systematic Review and Meta-Analysis. J Clin Exp Hepatol 2022; 12:417-427. [PMID: 35535072 PMCID: PMC9077193 DOI: 10.1016/j.jceh.2021.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/18/2021] [Indexed: 12/12/2022] Open
Abstract
Background Acute kidney injury (AKI) is common in the perioperative transplant period and is associated with poor outcomes. Few studies reported a reduction in AKI incidence with terlipressin therapy by counteracting the hemodynamic alterations occurring during liver transplantation. However, the effect of terlipressin on posttransplant outcomes has not been systematically reviewed. Methods A comprehensive search of electronic databases was performed. Studies reporting the use of terlipressin in the perioperative period of living donor liver transplantation were included. We expressed the dichotomous outcomes as risk ratio (RR, 95% confidence interval [CI]) using the random effects model. The primary aim was to assess the posttransplant risk of AKI. The secondary aims were to assess the need for renal replacement therapy (RRT), vasopressors, effect on hemodynamics, blood loss during surgery, hospital and intensive care unit (ICU) stay, and in-hospital mortality. Results A total of nine studies reporting 711 patients (309 patients in the terlipressin group and 402 in the control group) were included for analysis. Terlipressin was administered for a mean duration of 53.44 ± 28.61 h postsurgery. The risk of AKI was lower with terlipressin (0.6 [95% CI, 0.44-0.8]; P = 0.001). However, on sensitivity analysis including only four randomized controlled trials (I2 = 0; P = 0.54), the risk of AKI was similar in both the groups (0.7 [0.43-1.09]; P = 0.11). The need for RRT was similar in both the groups (0.75 [0.35-1.56]; P = 0.44). Terlipressin therapy reduced the need for another vasopressor (0.34 [0.25-0.47]; P < 0.001) with a concomitant rise in mean arterial pressure and systemic vascular resistance by 3.2 mm Hg (1.64-4.7; P < 0.001) and 77.64 dyne cm-1.sec-5 (21.27-134; P = 0.007), respectively. Blood loss, duration of hospital/ICU stay, and mortality were similar in both groups. Conclusions Perioperative terlipressin therapy has no clinically relevant benefit.
Collapse
Key Words
- AKI, acute kidney injury
- BMI, body mass index
- BUN, blood urea nitrogen
- C, control
- CI, confidence interval
- CNI, calcineurin inhibitors
- CTP, Child-Turcotte-Pugh score
- DDLT, deceased donor liver transplantation
- GRWR, graft-torecipient weight ratio
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- HRS, hepatorenal syndrome
- ICU, intensive care unit
- LDLT, living donor liver transplantation
- MAP, mean arterial pressure
- MELD, model for end-stage liver disease
- NR, not reported
- PRBC, packed red blood cells
- RCT, randomized controlled trial
- RRT, renal replacement therapy
- SD, standard deviation
- SVR, systemic vascular resistance
- Tp, Terlipressin
- acute kidney injury
- hemodynamics
- mTORi, mammalian target of rapamycin inhibitors
- portal hypertension
- renal replacement therapy
- sCr, serum creatinine
- vasoconstrictors
Collapse
Affiliation(s)
- Anand V. Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India,Address for correspondence. Dr. Anand V.Kulkarni, Department of Hepatology and Liver Transplantation, Asian Institute of Gastroenterology, Hyderabad, India.
| | - Karan Kumar
- Department of Hepatology, Pacific Institute of Medical Sciences, Udaipur, India
| | - Roberto Candia
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Juan P. Arab
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Harsh V. Tevethia
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | | | - Mithun Sharma
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Balachandandran Menon
- Department of Hepatobiliary Surgery and Liver Transplantation, Asian Institute of Gastroenterology, Hyderabad, India
| | - Guduru V. Rao
- Department of Hepatobiliary Surgery and Liver Transplantation, Asian Institute of Gastroenterology, Hyderabad, India
| | - Nageshwar D Reddy
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Nagaraja P. Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| |
Collapse
|
16
|
Schneekloth TD, Arab JP, Simonetto DA, Petterson TM, Niazi SK, Hall-Flavin DK, Karpyak VM, Kolla BP, Roth JE, Kremers WK, Rosen CB. Factors Having an Impact on Relapse and Survival in Transplant Recipients With Alcohol-Induced Liver Disease. Mayo Clin Proc Innov Qual Outcomes 2021; 5:1153-1164. [PMID: 34938953 PMCID: PMC8666351 DOI: 10.1016/j.mayocpiqo.2021.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Objective To assess the impact of standardized pretransplant alcohol abstinence and treatment guidelines on liver transplant outcomes. Methods This study assessed the posttransplant relapse and survival associated with a pretransplant guideline mandating alcohol abstinence, addiction treatment, and Alcoholics Anonymous (AA) attendance. This retrospective cohort study included liver recipients with alcohol-induced liver disease transplanted between January 1, 2000, and December 31, 2012, at a Midwest transplant center. Cox regression models tested for associations between pretransplant treatment, demographic and clinical characteristics, and outcome measures. Results Of 236 liver recipients (188 [79.7%] male; 210 [89%] white; mean follow-up, 88.6±55.0 months), 212 (90.2%) completed pretransplant treatment and 135 (57.2%) attended AA weekly. At 5 years, 16.3% and 8.2% had relapsed to any alcohol use and to high-dose drinking, respectively. Smoking during the 6 months before transplant was associated with any relapse (P=.0002) and high-dose relapse (P<.0001), and smoking at transplant was associated with death (P=.001). High-dose relapse was associated with death (hazard ratio, 3.5; P<.0001). Conclusion A transplant center with a guideline requiring abstinence, treatment, and AA participation experienced lower posttransplant relapse rates from those previously reported in comparable large US transplant programs. Smoking cessation may further improve posttransplant outcomes.
Collapse
Affiliation(s)
| | - Juan P Arab
- Department of Gastroenterology and Hepatology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.,William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
| | - Tanya M Petterson
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Shehzad K Niazi
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL
| | | | - Victor M Karpyak
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
| | - Bhanu P Kolla
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
| | | | - Walter K Kremers
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN.,Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Charles B Rosen
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN.,Department of Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
17
|
Im GY, Mellinger JL, Winters A, Aby ES, Lominadze Z, Rice J, Lucey MR, Arab JP, Goel A, Jophlin LL, Sherman CB, Parker R, Chen PH, Devuni D, Sidhu S, Dunn W, Szabo G, Singal AK, Shah VH. Provider Attitudes and Practices for Alcohol Screening, Treatment, and Education in Patients With Liver Disease: A Survey From the American Association for the Study of Liver Diseases Alcohol-Associated Liver Disease Special Interest Group. Clin Gastroenterol Hepatol 2021; 19:2407-2416.e8. [PMID: 33069880 PMCID: PMC8291372 DOI: 10.1016/j.cgh.2020.10.026] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/28/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS While abstinence-promoting behavioral and pharmacotherapies are part of the therapeutic foundation for alcohol use disorder (AUD) and alcohol-associated liver disease (ALD), these therapies, along with alcohol screening and education, are often underutilized. Our aim was to examine provider attitudes and practices for alcohol screening, treatment and education in patients with liver disease. METHODS We conducted a survey of primarily (89%) hepatology and gastroenterology providers within (80%) and outside the United States (20%). Surveys were sent to 921 providers with 408 complete responses (44%), of whom 343 (80%) work in a tertiary liver transplant center. RESULTS While alcohol screening rates in liver disease patients was nearly universal, less than half of providers reported practicing with integrated addiction providers, using alcohol biomarkers and screening tools. Safe alcohol use by liver disease patients was felt to exist by 40% of providers. While 60% of providers reported referring AUD patients for behavioral therapy, 71% never prescribed AUD pharmacotherapy due to low comfort (84%). Most providers (77%) reported low addiction education and 90% desired more during GI/hepatology fellowship training. Amongst prescribers, baclofen was preferred, but with gaps in pharmacotherapy knowledge. Overall, there was low adherence to the 2019 AASLD practice guidance for ALD, although higher in hepatologists and experienced providers. CONCLUSIONS While our survey of hepatology and gastroenterology providers demonstrated higher rates of alcohol screening and referrals for behavioral therapy, we found low rates of prescribing AUD pharmacotherapy due to knowledge gaps from insufficient education. Further studies are needed to assess interventions to improve provider alignment with best practices for treating patients with AUD and ALD.
Collapse
Affiliation(s)
- Gene Y Im
- Division of Liver Diseases, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Jessica L Mellinger
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Adam Winters
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Elizabeth S Aby
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Zurabi Lominadze
- Division of Gastroenterology, Department of Medicine, University of Maryland, Baltimore, Maryland
| | - John Rice
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Michael R Lucey
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Juan P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Aparna Goel
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Loretta L Jophlin
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Courtney B Sherman
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, California
| | - Richard Parker
- Leeds Liver Unit, St James's University Hospital, Leeds, United Kingdom
| | - Po-Hung Chen
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Deepika Devuni
- Division of Gastroenterology, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sandeep Sidhu
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Winston Dunn
- Department of Internal Medicine, The University of Kansas Medical Center, Kansas City, Kansas
| | - Gyongyi Szabo
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, Avera McKennan University Hospital Transplant Institute, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
18
|
Abstract
The acronym nonalcoholic fatty-liver disease (NAFLD) groups a heterogeneous patient population. Although in many patients the primary driver is metabolic dysfunction, a complex and dynamic interaction of different factors (i.e., sex, presence of one or more genetic variants, coexistence of different comorbidities, diverse microbiota composition, and various degrees of alcohol consumption among others) takes place to determine disease subphenotypes with distinct natural history and prognosis and, eventually, different response to therapy. This review aims to address this topic through the analysis of existing data on the differential contribution of known factors to the pathogenesis and clinical expression of NAFLD, thus determining the different clinical subphenotypes observed in practice. To improve our understanding of NAFLD heterogeneity and the dominant drivers of disease in patient subgroups would predictably impact on the development of more precision-targeted therapies for NAFLD.
Collapse
Affiliation(s)
- Marco Arrese
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile,Centro de Envejecimiento y Regeneración (CARE), Departamento de Biología Celular y Molecular, Facultad de Ciencias Biologicas, Pontificia Universidad Catolica de Chile, Santiago, Chile,Address for correspondence Marco Arrese, MD Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de ChileDiagonal Paraguay #362, 8330077 SantiagoChile
| | - Juan P. Arab
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile,Centro de Envejecimiento y Regeneración (CARE), Departamento de Biología Celular y Molecular, Facultad de Ciencias Biologicas, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Francisco Barrera
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile,Centro de Envejecimiento y Regeneración (CARE), Departamento de Biología Celular y Molecular, Facultad de Ciencias Biologicas, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Benedikt Kaufmann
- Department of Pediatric Gastroenterology, Rady Children's Hospital, University of California San Diego, California
| | - Luca Valenti
- Department of Pathophysiology and Transplantation, Universita degli Studi di Milano, Translational Medicine, Department of Transfusion, Medicine and Hematology, Fondazione IRCCS Ca' Granda, Pad Marangoni, Milan, Italy
| | - Ariel E. Feldstein
- Department of Pediatric Gastroenterology, Rady Children's Hospital, University of California San Diego, California,Ariel E. Feldstein, MD Division of Pediatric Gastroenterology Hepatology and NutritionUCSD 3020 Children’s Way, MC 5030, San Diego, CA 92103-8450
| |
Collapse
|
19
|
Singal AK, Arsalan A, Dunn W, Arab JP, Wong RJ, Kuo YF, Kamath PS, Shah VH. Editorial: trends in alcohol use and alcohol-associated liver disease in the US population-authors' reply. Aliment Pharmacol Ther 2021; 54:513-514. [PMID: 34331802 DOI: 10.1111/apt.16520] [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: 12/09/2022]
Affiliation(s)
- Ashwani K Singal
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA.,Division of Gastroenterology and Hepatology, Avera Transplant Institute, Sioux Falls, SD, USA
| | - Arshad Arsalan
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA
| | - Winston Dunn
- Division of Gastroenterology and Hepatology, Kansas University Medical Center, Kansas City, KS, USA
| | - Juan P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Palo Alto VA Medical Center, Stanford University, Stanford, CA, USA
| | - Yong-Fang Kuo
- Department of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
20
|
Singal AK, Arsalan A, Dunn W, Arab JP, Wong RJ, Kuo YF, Kamath PS, Shah VH. Alcohol-associated liver disease in the United States is associated with severe forms of disease among young, females and Hispanics. Aliment Pharmacol Ther 2021; 54:451-461. [PMID: 34247424 DOI: 10.1111/apt.16461] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [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: 02/07/2021] [Revised: 03/12/2021] [Accepted: 05/18/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Alcohol use and alcohol-associated liver disease (ALD) burden are increasing in young individuals. AIM To assess host factors associated with this burden. METHODS National Health and Nutrition Examination Survey (NHANES), National Inpatient Sample (NIS), and United Network for Organ Sharing (UNOS) databases (2006-2016) were used to identify individuals with harmful alcohol use, ALD-related admissions, and ALD-related LT listings respectively. RESULTS Of 15 981 subjects in NHANES database, weighted prevalence of harmful alcohol use was 17.7%, 29.3% in <35 years (G1) versus 16.9% in 35-64 years (G2) versus 5.1% in ≥65 years (G3). Alcohol use was about 11 and 4.7 folds higher in G1 and G2 versus G3, respectively. Male gender and Hispanic race associated with harmful alcohol use. Of 593 600 ALD admissions (5%, 77%, and 18% in G1-G3 respectively), acute on chronic liver failure (ACLF) occurred in 7.2%, (7.2 in G2 vs 6.7% in G1 and G3, P < 0.001). After controlling for other variables, ACLF development among ALD hospitalizations was higher by 14% and 10% in G1 and G2 versus G3, respectively. Female gender and Hispanic race were associated with increased ACLF risk by 8% and 17% respectively. Of 20,245 ALD LT listings (3.4%, 84.4%, and 12.2% in G1-G3 respectively), ACLF occurred in 28% candidates. Risk of severe (grade 2 or 3) ACLF was higher by about 1.7 fold in G1, 1.5 fold in females and 20% in Hispanics. CONCLUSION Young age, female gender, and Hispanic race are independently associated with ALD-related burden and ACLF in the United States. If these findings are validated in prospective studies, strategies will be needed to reduce alcohol use in high risk individuals to reduce burden from ALD.
Collapse
Affiliation(s)
- Ashwani K Singal
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA.,Division of Gastroenterology and Hepatology, Avera Transplant Institute, Sioux Falls, SD, USA
| | - Arshad Arsalan
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA
| | - Winston Dunn
- Division of Gastroenterology and Hepatology, Kansas University Medical Center, Kansas City, KS, USA
| | - Juan P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Palo Alto VA Medical Center, Stanford University, Stanford, CA, USA
| | - Yong-Fang Kuo
- Department of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
21
|
Liu M, Cao S, He L, Gao J, Arab JP, Cui H, Xuan W, Gao Y, Sehrawat TS, Hamdan FH, Ventura-Cots M, Argemi J, Pomerantz WCK, Johnsen SA, Lee JH, Gao F, Ordog T, Mathurin P, Revzin A, Bataller R, Yan H, Shah VH. Super enhancer regulation of cytokine-induced chemokine production in alcoholic hepatitis. Nat Commun 2021; 12:4560. [PMID: 34315876 PMCID: PMC8316465 DOI: 10.1038/s41467-021-24843-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/01/2021] [Indexed: 02/08/2023] Open
Abstract
Alcoholic hepatitis (AH) is associated with liver neutrophil infiltration through activated cytokine pathways leading to elevated chemokine expression. Super-enhancers are expansive regulatory elements driving augmented gene expression. Here, we explore the mechanistic role of super-enhancers linking cytokine TNFα with chemokine amplification in AH. RNA-seq and histone modification ChIP-seq of human liver explants show upregulation of multiple CXCL chemokines in AH. Liver sinusoidal endothelial cells (LSEC) are identified as an important source of CXCL expression in human liver, regulated by TNFα/NF-κB signaling. A super-enhancer is identified for multiple CXCL genes by multiple approaches. dCas9-KRAB-mediated epigenome editing or pharmacologic inhibition of Bromodomain and Extraterminal (BET) proteins, transcriptional regulators vital to super-enhancer function, decreases chemokine expression in vitro and decreases neutrophil infiltration in murine models of AH. Our findings highlight the role of super-enhancer in propagating inflammatory signaling by inducing chemokine expression and the therapeutic potential of BET inhibition in AH treatment.
Collapse
Affiliation(s)
- Mengfei Liu
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Sheng Cao
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Li He
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jinhang Gao
- Lab of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
| | - Juan P Arab
- Department of Gastroenterology and Hepatology, School of Medicine of the Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Huarui Cui
- Department of Chemistry, University of Minnesota, Minneapolis, MN, USA
| | - Weixia Xuan
- Department of Respiratory and Critical Care Medicine, Henan Provincial People's Hospital, Zhengzhou, China
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yandong Gao
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | - Tejasav S Sehrawat
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Feda H Hamdan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Meritxell Ventura-Cots
- Department of Gastroenterology Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA
| | - Josepmaria Argemi
- Department of Gastroenterology Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Steven A Johnsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jeong-Heon Lee
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | - Fei Gao
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tamas Ordog
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Alexander Revzin
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | - Ramon Bataller
- Department of Gastroenterology Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA, USA
| | - Huihuang Yan
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
22
|
Asrani SK, Mellinger J, Arab JP, Shah VS. Reducing the Global Burden of Alcohol-Associated Liver Disease: A Blueprint for Action. Hepatology 2021; 73:2039-2050. [PMID: 32986883 PMCID: PMC9361217 DOI: 10.1002/hep.31583] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [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: 06/10/2020] [Revised: 08/18/2020] [Accepted: 09/08/2020] [Indexed: 12/12/2022]
Abstract
Alcohol-associated liver disease (ALD) is a major driver of global liver related morbidity and mortality. There are 2.4 billion drinkers (950 million heavy drinkers) and the lifetime prevalence of any alcohol use disorder (AUD) is 5.1%-8.6%. In 2017, global prevalence of alcohol-associated compensated and decompensated cirrhosis was 23.6 million and 2.5 million, respectively. Combined, alcohol-associated cirrhosis and liver cancer account for 1% of all deaths worldwide with this burden expected to increase. Solutions for this growing epidemic must be multi-faceted and focused on both population and patient-level interventions. Reductions in ALD-related morbidity and mortality require solutions that focus on early identification and intervention, reducing alcohol consumption at the population level (taxation, reduced availability and restricted promotion), and solutions tailored to local socioeconomic realities (unrecorded alcohol consumption, focused youth education). Simple screening tools and algorithms can be applied at the population level to identify alcohol misuse, diagnose ALD using non-invasive serum and imaging markers, and risk-stratify higher-risk ALD/AUD patients. Novel methods of healthcare delivery and platforms are needed (telehealth, outreach, use of non-healthcare providers, partnerships between primary and specialty care/tertiary hospitals) to proactively mitigate the global burden of ALD. An integrated approach that combines medical and AUD treatment is needed at the individual level to have the highest impact. Future needs include (1) improving quality of ALD data and standardizing care, (2) supporting innovative healthcare delivery platforms that can treat both ALD and AUD, (3) stronger and concerted advocacy by professional hepatology organizations, and (4) advancing implementation of digital interventions.
Collapse
Affiliation(s)
- Sumeet K Asrani
- Baylor University Medical Center, Dallas, TX, United States,Corresponding Author and reprint requests Sumeet K Asrani MD MSc, Baylor University Medical Center, Dallas Texas, 2148208500
| | - Jessica Mellinger
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Juan P Arab
- Depto. Gastroenterología y Hepatología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Vijay S Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| |
Collapse
|
23
|
Singal AK, Ahmed Z, Axley P, Arora S, Arab JP, Haas A, Kuo YF, Kamath PS. Hospitalizations for Acute on Chronic Liver Failure at Academic Compared to Non-academic Centers Have Higher Mortality. Dig Dis Sci 2021; 66:1306-1314. [PMID: 32318884 DOI: 10.1007/s10620-020-06263-w] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/08/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIM Acute on chronic liver failure (ACLF) in patients with cirrhosis has high short-term mortality. Data comparing ACLF admissions to academic centers (AC) and non-academic centers (NAC) are scanty. METHODS National Inpatient Sample (2006-2014) was queried for admissions with cirrhosis and ACLF using the ICD-09 codes, and was stratified to AC or NAC. RESULTS Of 1,928,764 admissions with cirrhosis (2006-2014), 112,174 (5. 9%) had ACLF. 6.7% of 1,018,568 cirrhosis admissions to AC had ACLF versus 5% of 910,196 admissions to NAC, P < 0.0001. Proportion of ACLF admissions to AC increased from 49% during 2006-2008 to 59% during 2012-2014. In a cohort of 73,630 ACLF admissions (36,615 each to AC and NAC) matched for patient demographics, cirrhosis etiology, number of comorbidities, elective versus emergent admission, ACLF grade, and type of organ failure. In-hospital mortality declined by 7% over the study period, but remained higher in AC (46% vs. 42%, P < 0.001), with 11% increased odds for in-hospital mortality compared to admission to NAC. Further admissions to AC versus NAC had higher median (IQR) length of stay at 13 (6-25) versus 11 (5-20) days, with higher median (IQR) hospital charges: 138,239 (66,772-275,603) versus 116,209 (55,767-232,699) USD, P < 0.001 for both. CONCLUSION Patients with ACLF have high in-hospital mortality. Further, this is higher among admissions to AC. Although the in-hospital mortality is improving, strategies are needed on early identification of patients with futility of care for early discussion on goals of care, and optimal utilization of hospital resources among admissions with ACLF.
Collapse
Affiliation(s)
- Ashwani K Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, Transplant Hepatologist and Chief Clinical Research Affairs, Avera McKennan University Hospital Transplant Institute, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, 57105, USA.
| | - Zunirah Ahmed
- Department of Internal Medicine, University of Alabama at Birmingham, Montgomery, AL, USA
| | - Page Axley
- Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sumant Arora
- Division of Gastroenterology, Department of Medicine, University of Iowa Hospital & Clinics, Iowa, USA
| | - Juan P Arab
- Department of Gastroenterology and Hepatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Allen Haas
- Department of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
| | - Yong-Fang Kuo
- Department of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| |
Collapse
|
24
|
Sehrawat TS, Arab JP, Liu M, Amrollahi P, Wan M, Fan J, Nakao Y, Pose E, Navarro-Corcuera A, Dasgupta D, Liao CY, He L, Mauer AS, Avitabile E, Ventura-Cots M, Bataller RA, Sanyal AJ, Chalasani NP, Heimbach JK, Watt KD, Gores GJ, Gines P, Kamath PS, Simonetto DA, Hu TY, Shah VH, Malhi H. Circulating Extracellular Vesicles Carrying Sphingolipid Cargo for the Diagnosis and Dynamic Risk Profiling of Alcoholic Hepatitis. Hepatology 2021; 73:571-585. [PMID: 32246544 PMCID: PMC7541595 DOI: 10.1002/hep.31256] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 02/27/2020] [Accepted: 03/16/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Alcoholic hepatitis (AH) is diagnosed by clinical criteria, although several objective scores facilitate risk stratification. Extracellular vesicles (EVs) have emerged as biomarkers for many diseases and are also implicated in the pathogenesis of AH. Therefore, we investigated whether plasma EV concentration and sphingolipid cargo could serve as diagnostic biomarkers for AH and inform prognosis to permit dynamic risk profiling of AH subjects. APPROACH AND RESULTS EVs were isolated and quantified from plasma samples from healthy controls, heavy drinkers, and subjects with end-stage liver disease (ESLD) attributed to cholestatic liver diseases and nonalcoholic steatohepatitis, decompensated alcohol-associated cirrhosis (AC), and AH. Sphingolipids were quantified by tandem mass spectroscopy. The median plasma EV concentration was significantly higher in AH subjects (5.38 × 1011 /mL) compared to healthy controls (4.38 × 1010 /mL; P < 0.0001), heavy drinkers (1.28 × 1011 /mL; P < 0.0001), ESLD (5.35 × 1010 /mL; P < 0.0001), and decompensated AC (9.2 × 1010 /mL; P < 0.0001) disease controls. Among AH subjects, EV concentration correlated with Model for End-Stage Liver Disease score. When EV counts were dichotomized at the median, survival probability for AH subjects at 90 days was 63.0% in the high-EV group and 90.0% in the low-EV group (log-rank P value = 0.015). Interestingly, EV sphingolipid cargo was significantly enriched in AH when compared to healthy controls, heavy drinkers, ESLD, and decompensated AC (P = 0.0001). Multiple sphingolipids demonstrated good diagnostic and prognostic performance as biomarkers for AH. CONCLUSIONS Circulating EV concentration and sphingolipid cargo signature can be used in the diagnosis and differentiation of AH from heavy drinkers, decompensated AC, and other etiologies of ESLD and predict 90-day survival permitting dynamic risk profiling.
Collapse
Affiliation(s)
| | - Juan P Arab
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMN.,Departamento de GastroenterologiaEscuela de MedicinaPontificia Universidad Catolica de ChileSantiagoChile
| | - Mengfei Liu
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMN
| | - Pouya Amrollahi
- Virginia G. Piper Biodesign Center for Personalized DiagnosticsThe Biodesign InstituteArizona State UniversityTempeAZ.,School of Biological and Health Systems EngineeringArizona State UniversityTempeAZ
| | - Meihua Wan
- Virginia G. Piper Biodesign Center for Personalized DiagnosticsThe Biodesign InstituteArizona State UniversityTempeAZ.,School of Biological and Health Systems EngineeringArizona State UniversityTempeAZ.,Department of Integrated Traditional Chinese and Western MedicineWest China Hospital of Sichuan UniversityChengduChina
| | - Jia Fan
- Virginia G. Piper Biodesign Center for Personalized DiagnosticsThe Biodesign InstituteArizona State UniversityTempeAZ.,School of Biological and Health Systems EngineeringArizona State UniversityTempeAZ
| | - Yasuhiko Nakao
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMN.,Nagasaki University HospitalNagasakiJapan
| | - Elisa Pose
- Liver UnitHospital Clínic de BarcelonaSchool of Medicine and Health SciencesUniversity of BarcelonaBarcelonaSpain.,Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS)BarcelonaSpain.,Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBEReHD)BarcelonaSpain
| | | | | | - Chieh-Yu Liao
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMN
| | - Li He
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMN.,Division of GastroenterologyTongji HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Amy S Mauer
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMN
| | - Emma Avitabile
- Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS)BarcelonaSpain
| | - Meritxell Ventura-Cots
- Division of Gastroenterology, Hepatology and NutritionUniversity of Pittsburgh Medical CenterPittsburghPA
| | - Ramon A Bataller
- Division of Gastroenterology, Hepatology and NutritionUniversity of Pittsburgh Medical CenterPittsburghPA
| | - Arun J Sanyal
- Division of Gastroenterology, Hepatology and NutritionVirginia Commonwealth UniversityRichmondVA
| | - Naga P Chalasani
- Division of Gastroenterology and HepatologyIndiana UniversityIndianapolisIN
| | | | - Kymberly D Watt
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMN
| | - Gregory J Gores
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMN
| | - Pere Gines
- Liver UnitHospital Clínic de BarcelonaSchool of Medicine and Health SciencesUniversity of BarcelonaBarcelonaSpain.,Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS)BarcelonaSpain.,Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBEReHD)BarcelonaSpain
| | - Patrick S Kamath
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMN
| | | | - Tony Y Hu
- Virginia G. Piper Biodesign Center for Personalized DiagnosticsThe Biodesign InstituteArizona State UniversityTempeAZ.,School of Biological and Health Systems EngineeringArizona State UniversityTempeAZ
| | - Vijay H Shah
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMN
| | - Harmeet Malhi
- Division of Gastroenterology and HepatologyMayo ClinicRochesterMN
| |
Collapse
|
25
|
Waleed M, Abdallah MA, Kuo YF, Arab JP, Wong R, Singal AK. Higher Frequency of Hospital-Acquired Infections but Similar In-Hospital Mortality Among Admissions With Alcoholic Hepatitis at Academic vs. Non-academic Centers. Front Physiol 2020; 11:594138. [PMID: 33343391 PMCID: PMC7744884 DOI: 10.3389/fphys.2020.594138] [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: 08/12/2020] [Accepted: 10/26/2020] [Indexed: 12/20/2022] Open
Abstract
Background Alcoholic hepatitis (AH) is a unique syndrome characterized by high short-term mortality. The impact of the academic status of a hospital (urban and teaching) on outcomes in AH is unknown. Methods National Inpatient Sample dataset (2006–2014) on AH admissions stratified to academic center (AC) or non-academic center (NAC) and analyzed for in-hospital mortality (IHM), hospital resource use, length of stay in days (d), and total charges (TC) in United States dollars (USD). Admission year was stratified to 2006–2008 (TMI), 2009–2011 (TM2), and 2012–2014 (TM3). Results Of 62,136 AH admissions, the proportion at AC increased from 46% in TM1 to 57% in TM3, Armitage trend, p < 0.001. On logistic regression, TM3, younger age, black race, Medicaid and private insurance, and development of acute on chronic liver failure (ACLF) were associated with admission to an AC. Of 53,264 admissions propensity score matched for demographics, pay status, and disease severity, admissions to AC vs. NAC (26,622 each) were more likely to have liver disease complications (esophageal varices, ascites, and hepatic encephalopathy) and hospital-acquired infections (HAI), especially Clostridioides difficile and ventilator-associated pneumonia. Admissions to AC were more likely transfers from outside hospital (1.6% vs. 1.3%) and seen by palliative care (4.8% vs. 3.3%), p < 0.001. Use of endoscopy, dialysis, and mechanical ventilation were similar. With similar IHM comparing AC vs. NAC (7.7% vs. 7.8%, p = 0.93), average LOS and number of procedures were higher at AC (7.7 vs. 7.1 d and 2.3 vs. 1.9, respectively, p < 0.001) without difference on total charges ($52,821 vs. $52,067 USD, p = 0.28). On multivariable logistic regression model after controlling for demographics, ACLF grade, and calendar year, IHM was similar irrespective of academic status of the hospital, HR (95% CI): 1.01 (0.93–1.08, p = 0.70). IHM decreased over time, with ACLF as strongest predictor. A total of 63 and 22% were discharged to home and skilled nursing facility, respectively, without differences on academic status of the hospital. Conclusion Admissions with AH to AC compared to NAC have higher frequency of liver disease complications and HAI, with longer duration of hospitalization. Prospective studies are needed to reduce HAI among hospitalized patients with AH.
Collapse
Affiliation(s)
- Muhammad Waleed
- Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, United States
| | - Mohamed A Abdallah
- Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, United States
| | - Yong-Fang Kuo
- Department of Biostatistics, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Juan P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Robert Wong
- Division of Gastroenterology and Hepatology, Alameda Health System Highland Hospital, Oakland, CA, United States
| | - Ashwani K Singal
- Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, United States.,Division of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, SD, United States
| |
Collapse
|
26
|
Li J, Sehrawat TS, Chen J, Hilscher MB, Glaser KJ, Arab JP, De Assuncao TM, Simonetto DA, Mounajjed T, Manduca A, Ehman RL, Shah VH, Yin M. Quantitative assessment of portal hypertension with bi-parametric dual-frequency hepatic MR elastography in mouse models. Eur Radiol 2020; 31:2303-2311. [PMID: 33026502 DOI: 10.1007/s00330-020-07341-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/28/2020] [Accepted: 09/22/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To determine the potential of bi-parametric dual-frequency hepatic MR elastography (MRE) for predicting portal pressure (PP) in mouse models of portal hypertension (PHTN) with the presence of varying hepatic fibrosis. METHODS We studied 73 wild-type male mice, including 22 mice with hepatic congestion, 20 mice with cholestatic liver injury, and 31 age-matched sham mice. Hepatic shear stiffness (SS) and volumetric strain (VS) were calculated by 3D MRE acquired at 80 and 200 Hz. We measured PP immediately after MRE. Liver fibrosis was verified by hydroxyproline assay. We predicted PP by fitting generalized linear models with single- and dual-frequency SS and VS, respectively. The relationship between predicted and actual PP was evaluated by Spearman's correlation. We compared the prediction accuracy of portal hypertension for all models with DeLong tests at a significance level of 0.05. RESULTS Animals with congestive or cholestatic liver disease developed significant PHTN and hepatic fibrosis to varying degrees. In both models, SS increased, while VS decreased significantly compared with shams. All bi-parametric models had high diagnostic accuracy for PHTN. The dual-frequency models (AUCs: 0.90 [81-95%], 0.91 [81-95%]) had substantially or significantly higher accuracy than single-frequency ones (AUCs: 0.83 [71-91%], and 0.78 [66-87%]). The predicted PP of dual-frequency models also showed stronger correlations with actual PP than single-frequency predictions. CONCLUSIONS The bi-parametric dual-frequency model improved the diagnostic accuracy of liver MRE in diagnosing PHTN in preclinical models. This technical advance has the potential to monitor PHTN progression and treatment efficacy in the presence of varying fibrosis. KEY POINTS • Bi-parametric hepatic MR elastography can predict portal pressure. • The prediction models of shear stiffness and volumetric strain with dual-frequency measurements demonstrate high diagnostic accuracy (AUCs > 0.9) in two different portal hypertension mouse models with varying fibrosis.
Collapse
Affiliation(s)
- Jiahui Li
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Tejasav S Sehrawat
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jingbiao Chen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Moira B Hilscher
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Kevin J Glaser
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Juan P Arab
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Armando Manduca
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
| | | | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Meng Yin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
27
|
Arab JP, Sehrawat TS, Simonetto DA, Verma VK, Feng D, Tang T, Dreyer K, Yan X, Daley WL, Sanyal A, Chalasani N, Radaeva S, Yang L, Vargas H, Ibacache M, Gao B, Gores GJ, Malhi H, Kamath PS, Shah VH. An Open-Label, Dose-Escalation Study to Assess the Safety and Efficacy of IL-22 Agonist F-652 in Patients With Alcohol-associated Hepatitis. Hepatology 2020; 72:441-453. [PMID: 31774566 PMCID: PMC7250715 DOI: 10.1002/hep.31046] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [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: 07/02/2019] [Accepted: 11/07/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Interleukin-22 has beneficial effects on inflammation and impaired hepatic regeneration that characterize alcohol-associated hepatitis (AH). F-652 is a recombinant fusion protein of human interleukin-22 and immunoglobulin G2 fragment crystallizable. This study aims to assess the safety and efficacy signals of F-652 in patients with moderate and severe AH. APPROACH AND RESULTS A phase-2 dose-escalating study was carried out. F-652 (10 μg/kg, 30 μg/kg, or 45 μg/kg) administered on days 1 and 7 was tested in 3 patients each with moderate (Model for End-Stage Liver Disease [MELD] scores: 11-20) and severe AH (MELD scores: 21-28). Safety was defined by absence of serious adverse events and efficacy was assessed by Lille score, changes in MELD score, and serum bilirubin and aminotransferases at days 28 and 42. Three independent propensity-matched comparator patient cohorts were used. Plasma extracellular vesicles and multiplex serum cytokines were measured to assess inflammation and hepatic regeneration. Eighteen patients (9 moderate and 9 severe AH) were enrolled, 66% were male, and the mean age was 48 years. The half-life of F-652 following the first dose was 61-85 hours. There were no serious adverse events leading to discontinuation. The MELD score and serum aminotransferases decreased significantly at days 28 and 42 from baseline (P < 0.05). Day-7 Lille score was 0.45 or less in 83% patients as compared with 6%, 12%, and 56% among the comparator cohorts. Extracellular vesicle counts decreased significantly at day 28 (P < 0.013). Cytokine inflammatory markers were down-regulated, and regeneration markers were up-regulated at days 28 and 42. CONCLUSIONS F-652 is safe in doses up to 45 μg/kg and associated with a high rate of improvement as determined by Lille and MELD scores, reductions in markers of inflammation and increases in markers of hepatic regeneration. This study supports the need for randomized placebo-controlled trials to test the efficacy of F-652 in AH.
Collapse
Affiliation(s)
- Juan P. Arab
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, CHILE
| | - Tejasav S. Sehrawat
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Vikas K. Verma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Dechun Feng
- Laboratory of Liver Diseases, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA
| | - Tom Tang
- Generon Corporation Ltd. Shanghai, China
| | | | | | | | - Arun Sanyal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Naga Chalasani
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Svetlana Radaeva
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Liu Yang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Hugo Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - Mauricio Ibacache
- División Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, CHILE
| | - Bin Gao
- Laboratory of Liver Diseases, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA
| | - Gregory J. Gores
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Harmeet Malhi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Patrick S. Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Vijay H. Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
28
|
Benítez C, Inzunza M, Riveros S, Rivas V, Garrido M, Dib M, Barrera F, Arab JP, Torres J, Cortinez LI, Briceño E, Guerra JF, Fernandes E, Martínez JA. Living Donor Liver Transplantation for Imatinib-Resistant Gastrointestinal Stromal Tumor Liver Metastases: A New Therapeutic Option in Transplant Oncology. Liver Transpl 2020; 26:945-948. [PMID: 32246733 DOI: 10.1002/lt.25769] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 12/27/2019] [Revised: 02/27/2020] [Accepted: 03/13/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Carlos Benítez
- Liver Transplant Program, UC-CHRISTUS Health Hospital, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile.,Department of Gastroenterology, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - Martin Inzunza
- Department of Digestive Surgery, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - Sergio Riveros
- Department of Digestive Surgery, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - Violeta Rivas
- Liver Transplant Program, UC-CHRISTUS Health Hospital, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - Marcelo Garrido
- Department of Oncology, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - Martin Dib
- Liver Transplant Program, UC-CHRISTUS Health Hospital, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile.,Department of Digestive Surgery, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - Francisco Barrera
- Liver Transplant Program, UC-CHRISTUS Health Hospital, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile.,Department of Gastroenterology, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - Juan P Arab
- Liver Transplant Program, UC-CHRISTUS Health Hospital, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile.,Department of Gastroenterology, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - Javiera Torres
- Department of Pathology, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - Luis I Cortinez
- Department of Anesthesiology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo Briceño
- Liver Transplant Program, UC-CHRISTUS Health Hospital, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile.,Department of Digestive Surgery, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - Juan F Guerra
- Liver Transplant Program, UC-CHRISTUS Health Hospital, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile.,Department of Digestive Surgery, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile.,MedStar Georgetown Transplant Institute, Washington, DC
| | - Eduardo Fernandes
- Transplant Unit, School of Medicine, Adventista Silvestre Cosme Velho Hospital, Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | - Jorge A Martínez
- Liver Transplant Program, UC-CHRISTUS Health Hospital, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile.,Department of Digestive Surgery, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| |
Collapse
|
29
|
Arab JP, Cabrera D, Sehrawat TS, Jalan-Sakrikar N, Verma VK, Simonetto D, Cao S, Yaqoob U, Leon J, Freire M, Vargas JI, De Assuncao TM, Kwon JH, Guo Y, Kostallari E, Cai Q, Kisseleva T, Oh Y, Arrese M, Huebert RC, Shah VH. Hepatic stellate cell activation promotes alcohol-induced steatohepatitis through Igfbp3 and SerpinA12. J Hepatol 2020; 73:149-160. [PMID: 32087348 PMCID: PMC7305991 DOI: 10.1016/j.jhep.2020.02.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 01/23/2020] [Accepted: 02/01/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Steatohepatitis drives fibrogenesis in alcohol-related liver disease. Recent studies have suggested that hepatic stellate cells (HSCs) may regulate the parenchymal cell injury and inflammation that precedes liver fibrosis, although the mechanism remains incompletely defined. Neuropilin-1 (NRP-1) and synectin are membrane proteins implicated in HSC activation. In this study, we disrupted NRP-1 and synectin as models to evaluate the role of HSC activation on the development of steatohepatitis in response to alcohol feeding in mice. METHODS Mice with HSC-selective deletion of NRP (ColCre/Nrp1loxP) or synectin (ColCre/synectinloxP) vs. paired Nrp1loxP or synectinloxP mice were fed a control diet or the chronic/binge alcohol feeding model. Several markers of steatosis and inflammation were evaluated. RESULTS ColCre/Nrp1loxP mice showed less fibrosis, as expected, but also less inflammation and steatosis, with lower hepatic triglyceride content. Similar results were observed in the synectin model. Hepatocytes treated with supernatant of HSCs from ColCre/Nrp1loxP mice compared to supernatant from Nrp1loxP mice were protected against ethanol-induced lipid droplet formation. An adipokine and inflammatory protein array from the supernatant of HSCs with NRP-1 knockdown showed a significant reduction in Igfbp3 (a major insulin-like growth factor-binding protein with multiple metabolic functions) and an increase in SerpinA12 (a serine-protease inhibitor) secretion compared to wild-type HSCs. Recombinant Igfbp3 induced lipid droplets, triglyceride accumulation, and lipogenic genes in hepatocytes in vitro, while SerpinA12 was protective against ethanol-induced steatosis. Finally, Igfbp3 was increased, and SerpinA12 was decreased in serum and liver tissue from patients with alcoholic hepatitis. CONCLUSION Selective deletion of NRP-1 from HSCs attenuates alcohol-induced steatohepatitis through regulation of Igfbp3 and SerpinA12 signaling. LAY SUMMARY Hepatic stellate cells are known for their role in fibrosis (scarring of the liver). In this study, we describe their role in the modulation of fat deposition and inflammation in the liver, which occurs secondary to alcohol damage.
Collapse
Affiliation(s)
- Juan P. Arab
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.,Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Daniel Cabrera
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Departamento de Ciencias Químicas y Biológicas, Universidad Bernardo O Higgins, Santiago, Chile
| | - Tejasav S. Sehrawat
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Vikas K. Verma
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Douglas Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Sheng Cao
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Usman Yaqoob
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jonathan Leon
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Mariela Freire
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Jose I. Vargas
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | | | - Jung H. Kwon
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Yi Guo
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Enis Kostallari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Qing Cai
- Department of Pathology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA, USA
| | - Tatiana Kisseleva
- Department of Surgery, University of California-San Diego, San Diego, CA, USA
| | - Youngman Oh
- Department of Pathology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA, USA
| | - Marco Arrese
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Robert C. Huebert
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Vijay H. Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
30
|
Gaete MI, Díaz LA, Arenas A, González K, Cattaneo M, Fuster F, Henríquez R, Soza A, Arrese M, Barrera F, Arab JP, Benítez C. Baveno VI and Expanded Baveno VI criteria successfully predicts the absence of high-risk gastro-oesophageal varices in a Chilean cohort. Liver Int 2020; 40:1427-1434. [PMID: 31916360 DOI: 10.1111/liv.14373] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/02/2019] [Accepted: 01/02/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Baveno VI and expanded Baveno VI criteria have been recommended to circumvent the need for endoscopy screening in patients with a very low probability of varices needing treatment (VNT). AIM To validate these criteria in a Latin American population. METHODS The ability of Baveno VI criteria (liver stiffness measurement (LSM) <20 kPa and platelet count >150 × 103/μL) and expanded Baveno VI criteria (LSM < 25kPa and platelet count >110 × 103/μL) to exclude the presence of VNT was tested in a prospectively recruited cohort of patients with Child-Pugh A liver cirrhosis and with no previous variceal haemorrhage who attended the liver clinics of three major hospitals in Chile. RESULTS Three hundred patients were included. The median (IQR) age was 61 [18-86] years, median MELD was 8.0 (6-17), median LSM was 17.2 (10.2-77) kPa and median platelet count was 137 (23-464) × 103 /μL. The main aetiology was non-alcoholic fatty liver disease (67.3%). VNT were present in 18% of patients. The Baveno VI criteria had a sensitivity of 98.1% and a specificity of 38.2%, potentially sparing 31.3% of upper endoscopies with a very low risk of missing VNT (1.1%). The expanded Baveno VI criteria had a sensitivity of 90.7% and a specificity of 61%, potentially sparing 51.3% of upper endoscopies with a risk of missing VNT of 3.6%. Both criteria were independently associated with the absence of VNT. CONCLUSION We validated the Baveno VI and expanded Baveno VI criteria in Chilean population, potentially sparing 31.3% and 51.3% of endoscopies, respectively, with a very low risk of missing VNT. Fondecyt 1191183.
Collapse
Affiliation(s)
- María I Gaete
- School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis A Díaz
- Department of Gastroenterology, Faculty of medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alex Arenas
- Department of Gastroenterology, Faculty of medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.,Digestive Diseases Unit, Hospital Sótero del Río, Santiago, Chile
| | - Katherine González
- Department of Gastroenterology, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Máximo Cattaneo
- Department of Gastroenterology, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Francisco Fuster
- Digestive diseases unit, Hospital Dr. Gustavo Fricke, Viña del Mar, Chile
| | - Romina Henríquez
- Department of Gastroenterology, Faculty of medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alejandro Soza
- Department of Gastroenterology, Faculty of medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marco Arrese
- Department of Gastroenterology, Faculty of medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Barrera
- Department of Gastroenterology, Faculty of medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan P Arab
- Department of Gastroenterology, Faculty of medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carlos Benítez
- Department of Gastroenterology, Faculty of medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| |
Collapse
|
31
|
Arab JP, Arrese M, Shah VH. Gut microbiota in non-alcoholic fatty liver disease and alcohol-related liver disease: Current concepts and perspectives. Hepatol Res 2020; 50:407-418. [PMID: 31840358 PMCID: PMC7187400 DOI: 10.1111/hepr.13473] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/05/2020] [Accepted: 12/10/2020] [Indexed: 12/17/2022]
Abstract
The term, gut-liver axis, is used to highlight the close anatomical and functional relationship between the intestine and the liver. It has been increasingly recognized that the gut-liver axis plays an essential role in the development and progression of liver disease. In particular, in non-alcoholic fatty liver disease and alcohol-related liver disease, the two most common causes of chronic liver disease, a dysbiotic gut microbiota can influence intestinal permeability, allowing some pathogens or bacteria-derived factors from the gut reaching the liver through the enterohepatic circulation contributing to liver injury, steatohepatitis, and fibrosis progression. Pathways involved are multiple, including changes in bile acid metabolism, intestinal ethanol production, generation of short-chain fatty acids, and other by-products. Bile acids act through dedicated bile acid receptors, farnesoid X receptor and TGR5, in both the ileum and the liver, influencing lipid metabolism, inflammation, and fibrogenesis. Currently, both non-alcoholic fatty liver disease and alcohol-related liver disease lack effective therapies, and therapeutic targeting of gut microbiota and bile acids enterohepatic circulation holds promise. In this review, we summarize current knowledge about the role of gut microbiota in the pathogenesis of non-alcoholic fatty liver disease and alcohol-related liver disease, as well as the relevance of microbiota or bile acid-based approaches in the management of those liver diseases.
Collapse
Affiliation(s)
- Juan P. Arab
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.,Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marco Arrese
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile,Centro de Envejecimiento y Regeneración (CARE), Departamento de Biología Celular y Molecular, Facultad de Ciencias Biológicas Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Vijay H. Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
32
|
Estrada LD, Ahumada P, Cabrera D, Arab JP. Liver Dysfunction as a Novel Player in Alzheimer's Progression: Looking Outside the Brain. Front Aging Neurosci 2019; 11:174. [PMID: 31379558 PMCID: PMC6650779 DOI: 10.3389/fnagi.2019.00174] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [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: 03/31/2019] [Accepted: 06/25/2019] [Indexed: 12/03/2022] Open
Abstract
Alzheimer's disease (AD) afflicts an estimated 20 million people worldwide and is the fourth-leading cause of death in the developed world. The most common cause of dementia in older individuals, AD is characterized by neuropathologies including synaptic and neuronal degeneration, amyloid plaques, and neurofibrillary tangles (NTFs). Amyloid plaques are primarily composed of amyloid-beta peptide (Aβ), which accumulates in the brains of patients with AD. Further, small aggregates termed Aβ oligomers are implicated in the synaptic loss and neuronal degeneration underlying early cognitive impairments. Whether Aβ accumulates in part because of dysregulated clearance from the brain remains unclear. The flow of substances (e.g., nutrients, drugs, toxins) in and out of the brain is mediated by the blood-brain-barrier (BBB). The BBB exhibits impairment in AD patients and animal models. The effect of BBB impairment on Aβ, and whether BBB function is affected by non-neurological pathologies that impair peripheral clearance requires further investigation. In particular, impaired peripheral clearance is a feature of nonalcoholic fatty liver disease (NAFLD), a spectrum of liver disorders characterized by accumulation of fat in the liver accompanied by varying degrees of inflammation and hepatocyte injury. NAFLD has reached epidemic proportions, with an estimated prevalence between 20% and 30% of the general population. This chronic condition may influence AD pathogenesis. This review article summarizes the current state of the literature linking NAFLD and AD, highlighting the role of the major Aβ efflux and clearance protein, the LRP-1 receptor, which is abundantly expressed in liver, brain, and vasculature.
Collapse
Affiliation(s)
- Lisbell D. Estrada
- Bionanotechnology Laboratory, Integrative Center for Applied Biology and Chemistry (CIBQA), Department of Chemical & Biological Sciences, Universidad Bernardo O’Higgins, Santiago, Chile
| | - Pablo Ahumada
- Bionanotechnology Laboratory, Integrative Center for Applied Biology and Chemistry (CIBQA), Department of Chemical & Biological Sciences, Universidad Bernardo O’Higgins, Santiago, Chile
| | - Daniel Cabrera
- Bionanotechnology Laboratory, Integrative Center for Applied Biology and Chemistry (CIBQA), Department of Chemical & Biological Sciences, Universidad Bernardo O’Higgins, Santiago, Chile
- Laboratório de Hepatologia Experimental, Gastroenterology Department, Facultad de Medicina, Centro de Envejecimiento y Regeneración (CARE Chile-UC), P. Universidad Catolica de Chile, Santiago, Chile
| | - Juan P. Arab
- Laboratório de Hepatologia Experimental, Gastroenterology Department, Facultad de Medicina, Centro de Envejecimiento y Regeneración (CARE Chile-UC), P. Universidad Catolica de Chile, Santiago, Chile
| |
Collapse
|
33
|
Argemi J, Latasa MU, Atkinson SR, Blokhin IO, Massey V, Gue JP, Cabezas J, Lozano JJ, Van Booven D, Bell A, Cao S, Vernetti LA, Arab JP, Ventura-Cots M, Edmunds LR, Fondevila C, Stärkel P, Dubuquoy L, Louvet A, Odena G, Gomez JL, Aragon T, Altamirano J, Caballeria J, Jurczak MJ, Taylor DL, Berasain C, Wahlestedt C, Monga SP, Morgan MY, Sancho-Bru P, Mathurin P, Furuya S, Lackner C, Rusyn I, Shah VH, Thursz MR, Mann J, Avila MA, Bataller R. Defective HNF4alpha-dependent gene expression as a driver of hepatocellular failure in alcoholic hepatitis. Nat Commun 2019; 10:3126. [PMID: 31311938 PMCID: PMC6635373 DOI: 10.1038/s41467-019-11004-3] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [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: 07/09/2018] [Accepted: 06/10/2019] [Indexed: 02/07/2023] Open
Abstract
Alcoholic hepatitis (AH) is a life-threatening condition characterized by profound hepatocellular dysfunction for which targeted treatments are urgently needed. Identification of molecular drivers is hampered by the lack of suitable animal models. By performing RNA sequencing in livers from patients with different phenotypes of alcohol-related liver disease (ALD), we show that development of AH is characterized by defective activity of liver-enriched transcription factors (LETFs). TGFβ1 is a key upstream transcriptome regulator in AH and induces the use of HNF4α P2 promoter in hepatocytes, which results in defective metabolic and synthetic functions. Gene polymorphisms in LETFs including HNF4α are not associated with the development of AH. In contrast, epigenetic studies show that AH livers have profound changes in DNA methylation state and chromatin remodeling, affecting HNF4α-dependent gene expression. We conclude that targeting TGFβ1 and epigenetic drivers that modulate HNF4α-dependent gene expression could be beneficial to improve hepatocellular function in patients with AH.
Collapse
Affiliation(s)
- Josepmaria Argemi
- 0000 0001 0650 7433grid.412689.0Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA 15261 USA ,0000000419370271grid.5924.aLiver Unit, Clínica Universidad de Navarra, University of Navarra, Pamplona, 31008 Spain
| | - Maria U. Latasa
- 0000000419370271grid.5924.aHepatology Program, Center for Applied Medical Research (CIMA), University of Navarra, Pamplona, 31008 Spain
| | - Stephen R. Atkinson
- 0000 0001 2113 8111grid.7445.2Division of Digestive Diseases, Department of Surgery and Cancer, Imperial College London, London, SW7 2AZ UK
| | - Ilya O. Blokhin
- 0000 0004 1936 8606grid.26790.3aCenter for Therapeutic Innovation and Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - Veronica Massey
- 0000000122483208grid.10698.36Division of Gastroenterology and Hepatology, Departments of Medicine and Nutrition and Bowles Center for Alcohol Studies, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516 USA
| | - Joel P. Gue
- 0000 0001 0650 7433grid.412689.0Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA 15261 USA
| | - Joaquin Cabezas
- 0000000122483208grid.10698.36Division of Gastroenterology and Hepatology, Departments of Medicine and Nutrition and Bowles Center for Alcohol Studies, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516 USA ,0000 0001 0627 4262grid.411325.0Departament of Hepatology, Marqués de Valdecilla University Hospital, Santander, 39008 Spain
| | - Juan J. Lozano
- grid.452371.60000 0004 5930 4607Centro de Investigacion Biomedica en Red, Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, 28029 Spain ,grid.10403.360000000091771775Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, 08036 Spain
| | - Derek Van Booven
- 0000 0004 1936 8606grid.26790.3aJohn P. Hussman Institute of Human Genomics. Miller School of Medicine, University of Miami, Miami, FL 33136 USA
| | - Aaron Bell
- 0000 0004 1936 9000grid.21925.3dDepartments of Pathology and Medicine, Pittsburgh Liver Research Center, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261 USA
| | - Sheng Cao
- 0000 0004 0459 167Xgrid.66875.3aDivision of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905 USA
| | - Lawrence A. Vernetti
- 0000 0004 1936 9000grid.21925.3dUniversity of Pittsburgh Drug Discovery Institute, Department of Computational & Systems Biology, University of Pittsburgh, Pittsburgh, PA 15261 USA
| | - Juan P. Arab
- 0000 0004 0459 167Xgrid.66875.3aDivision of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905 USA ,0000 0001 2157 0406grid.7870.8Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Meritxell Ventura-Cots
- 0000 0001 0650 7433grid.412689.0Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA 15261 USA
| | - Lia R. Edmunds
- 0000 0004 1936 9000grid.21925.3dDepartment of Medicine, Division of Endocrinology and Metabolism, Center for Metabolic and Mitochondrial Medicine, University of Pittsburgh, Pittsburgh, PA 15261 USA
| | - Constantino Fondevila
- 0000 0004 1937 0247grid.5841.8Liver Transplant Unit, Department of Surgery, Hospital Clinic, University of Barcelona, Barcelona, 08036 Spain
| | - Peter Stärkel
- 0000 0001 2294 713Xgrid.7942.8Service d’Hépato-gastroentérologie, Cliniques Universitaires Saint-Luc and Laboratory of Hepatogastroenterology, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, 1200 Belgium
| | - Laurent Dubuquoy
- 0000 0001 2242 6780grid.503422.2Service des Maladies de l’appareil digestif, CHU Lille. Inserm LIRIC - UMR995, University of Lille, Lille, 59000 France
| | - Alexandre Louvet
- 0000 0001 2242 6780grid.503422.2Service des Maladies de l’appareil digestif, CHU Lille. Inserm LIRIC - UMR995, University of Lille, Lille, 59000 France
| | - Gemma Odena
- 0000000122483208grid.10698.36Division of Gastroenterology and Hepatology, Departments of Medicine and Nutrition and Bowles Center for Alcohol Studies, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516 USA
| | - Juan L. Gomez
- 0000 0004 1936 9000grid.21925.3dDepartments of Pathology and Medicine, Pittsburgh Liver Research Center, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261 USA
| | - Tomas Aragon
- 0000000419370271grid.5924.aDepartment of Gene Therapy and Regulation, Center for Applied Medical Research, University of Navarra, Pamplona, 31008 Spain
| | - Jose Altamirano
- grid.440085.d0000 0004 0615 254XLiver Unit, Department of Internal Medicine, Vall d’Hebron Institut de Recerca. Internal Medicine Department, Hospital Quiron Salud, Barcelona, 08035 Spain
| | - Juan Caballeria
- grid.452371.60000 0004 5930 4607Centro de Investigacion Biomedica en Red, Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, 28029 Spain ,grid.10403.360000000091771775Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, 08036 Spain
| | - Michael J. Jurczak
- 0000 0004 1936 9000grid.21925.3dDepartment of Medicine, Division of Endocrinology and Metabolism, Center for Metabolic and Mitochondrial Medicine, University of Pittsburgh, Pittsburgh, PA 15261 USA
| | - D. Lansing Taylor
- 0000 0004 1936 9000grid.21925.3dUniversity of Pittsburgh Drug Discovery Institute, Department of Computational & Systems Biology, University of Pittsburgh, Pittsburgh, PA 15261 USA
| | - Carmen Berasain
- 0000000419370271grid.5924.aHepatology Program, Center for Applied Medical Research (CIMA), University of Navarra, Pamplona, 31008 Spain ,grid.452371.60000 0004 5930 4607Centro de Investigacion Biomedica en Red, Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, 28029 Spain
| | - Claes Wahlestedt
- 0000 0004 1936 8606grid.26790.3aCenter for Therapeutic Innovation and Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - Satdarshan P. Monga
- 0000 0004 1936 9000grid.21925.3dDepartments of Pathology and Medicine, Pittsburgh Liver Research Center, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261 USA
| | - Marsha Y. Morgan
- 0000000121901201grid.83440.3bUCL Institute for Liver and Digestive Health, Division of Medicine, Royal Free Campus, University College London, London, WC1E 6BT UK
| | - Pau Sancho-Bru
- grid.452371.60000 0004 5930 4607Centro de Investigacion Biomedica en Red, Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, 28029 Spain ,grid.10403.360000000091771775Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, 08036 Spain
| | - Philippe Mathurin
- 0000 0001 2242 6780grid.503422.2Service des Maladies de l’appareil digestif, CHU Lille. Inserm LIRIC - UMR995, University of Lille, Lille, 59000 France
| | - Shinji Furuya
- 0000 0004 4687 2082grid.264756.4Department of Veterinary Integrative Biosciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77845 USA
| | - Carolin Lackner
- grid.11598.340000 0000 8988 2476Medical University of Graz, Institute of Pathology, Graz, 8036 Austria
| | - Ivan Rusyn
- 0000 0004 4687 2082grid.264756.4Department of Veterinary Integrative Biosciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77845 USA
| | - Vijay H. Shah
- 0000 0004 0459 167Xgrid.66875.3aDivision of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905 USA
| | - Mark R. Thursz
- 0000 0001 2113 8111grid.7445.2Division of Digestive Diseases, Department of Surgery and Cancer, Imperial College London, London, SW7 2AZ UK
| | - Jelena Mann
- 0000 0001 0462 7212grid.1006.7Newcastle Fibrosis Research Group, Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH UK
| | - Matias A. Avila
- 0000000419370271grid.5924.aHepatology Program, Center for Applied Medical Research (CIMA), University of Navarra, Pamplona, 31008 Spain ,grid.452371.60000 0004 5930 4607Centro de Investigacion Biomedica en Red, Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, 28029 Spain
| | - Ramon Bataller
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, 15261, USA. .,Division of Gastroenterology and Hepatology, Departments of Medicine and Nutrition and Bowles Center for Alcohol Studies, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27516, USA.
| |
Collapse
|
34
|
Arab JP, Arrese M. Old Remedies to Heal the Liver: Novel Effects of Digoxin in Hepatic Sterile Inflammation. Hepatology 2019; 69:904-906. [PMID: 30033594 DOI: 10.1002/hep.30188] [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: 05/30/2018] [Accepted: 07/17/2018] [Indexed: 01/17/2023]
Affiliation(s)
- Juan P Arab
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.,Department of Gastroenterology, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - Marco Arrese
- Department of Gastroenterology, School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile.,Center of Aging and Regeneration (CARE), Faculty of the Biological Sciences, Pontifical Catholic University of Chile, Santiago, Chile
| |
Collapse
|
35
|
Drinane MC, Yaqoob U, Yu H, Luo F, Greuter T, Arab JP, Kostallari E, Verma VK, Maiers J, De Assuncao TM, Simons M, Mukhopadhyay D, Kisseleva T, Brenner DA, Urrutia R, Lomberk G, Gao Y, Ligresti G, Tschumperlin DJ, Revzin A, Cao S, Shah VH. Synectin promotes fibrogenesis by regulating PDGFR isoforms through distinct mechanisms. JCI Insight 2017; 2:92821. [PMID: 29263300 DOI: 10.1172/jci.insight.92821] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 11/22/2017] [Indexed: 12/30/2022] Open
Abstract
The scaffold protein synectin plays a critical role in the trafficking and regulation of membrane receptor pathways. As platelet-derived growth factor receptor (PDGFR) is essential for hepatic stellate cell (HSC) activation and liver fibrosis, we sought to determine the role of synectin on the PDGFR pathway and development of liver fibrosis. Mice with deletion of synectin from HSC were found to be protected from liver fibrosis. mRNA sequencing revealed that knockdown of synectin in HSC demonstrated reductions in the fibrosis pathway of genes, including PDGFR-β. Chromatin IP assay of the PDGFR-β promoter upon synectin knockdown revealed a pattern of histone marks associated with decreased transcription, dependent on p300 histone acetyltransferase. Synectin knockdown was found to downregulate PDGFR-α protein levels, as well, but through an alternative mechanism: protection from autophagic degradation. Site-directed mutagenesis revealed that ubiquitination of specific PDGFR-α lysine residues was responsible for its autophagic degradation. Furthermore, functional studies showed decreased PDGF-dependent migration and proliferation of HSC after synectin knockdown. Finally, human cirrhotic livers demonstrated increased synectin protein levels. This work provides insight into differential transcriptional and posttranslational mechanisms of synectin regulation of PDGFRs, which are critical to fibrogenesis.
Collapse
Affiliation(s)
- Mary C Drinane
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Usman Yaqoob
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Haibin Yu
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.,Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Fanghong Luo
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.,Medical College, Xiamen University, Xiamen, Fujian, China
| | - Thomas Greuter
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Juan P Arab
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Enis Kostallari
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vikas K Verma
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jessica Maiers
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Thiago Milech De Assuncao
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Simons
- Section of Cardiovascular Medicine, Yale University, New Haven, Connecticut, USA
| | - Debabrata Mukhopadhyay
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Jacksonville, Florida, USA
| | | | | | - Raul Urrutia
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gwen Lomberk
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yandong Gao
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Giovanni Ligresti
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel J Tschumperlin
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander Revzin
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Sheng Cao
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vijay H Shah
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
36
|
Abstract
The term gut-liver axis is used to highlight the close anatomical and functional relationship between the intestine and the liver. The intestine has a highly specialized epithelial membrane which regulates transport across the mucosa. Due to dysbiosis, impairment of the intestinal barrier and altered immunity status, bacterial products can reach the liver through the portal vein, where they are recognized by specific receptors, activate the immune system and lead to a proinflammatory response. Gut microbiota and bacterial translocation play an important role in the pathogenesis of chronic liver diseases, including alcoholic and non-alcoholic fatty liver disease, cirrhosis, and its complications, such as portal hypertension, spontaneous bacterial peritonitis and hepatic encephalopaty. The gut microbiota also plays a critical role as a modulator of bile acid metabolism which can also influence intestinal permeability and portal hypertension through the farnesoid-X receptor. On the other hand, cirrhosis and portal hypertension affect the microbiota and increase translocation, leading to a "chicken and egg" situation, where translocation increases portal pressure, and vice versa. A myriad of therapies targeting gut microbiota have been evaluated specifically in patients with chronic liver disease. Further studies targeting intestinal microbiota and its possible hemodynamic and metabolic effects are needed. This review summarizes the current knowledge about the role of gut microbiota in the pathogenesis of chronic liver diseases and portal hypertension.
Collapse
Affiliation(s)
- Juan P Arab
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First ST SW, Rochester, MN, USA.,Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Rosa M Martin-Mateos
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First ST SW, Rochester, MN, USA
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First ST SW, Rochester, MN, USA.
| |
Collapse
|
37
|
Arab JP, Barrera F, Gallego C, Valderas JP, Uribe S, Tejos C, Serrano C, Serrano C, Huete Á, Liberona J, Labbé P, Quiroga T, Benítez C, Irarrázaval P, Riquelme A, Arrese M. High prevalence of undiagnosed liver cirrhosis and advanced fibrosis in type 2 diabetic patients. Ann Hepatol 2017; 15:721-8. [PMID: 27493111 DOI: 10.5604/16652681.1212434] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
UNLABELLED Background. Patients with type 2 diabetes mellitus (T2DM) are at risk for developing end-stage liver disease due to nonalcoholic steatohepatitis (NASH), the aggressive form of non-alcoholic fatty liver disease (NAFLD). Data on prevalence of advanced fibrosis among T2DM patients is scarce. AIM To evaluate prevalence of steatosis, advanced fibrosis and cirrhosis using non-invasive methods in T2DM patients. MATERIAL AND METHODS 145 consecutive T2DM patients (> 55 years-old) were prospectively recruited. Presence of cirrhosis and advanced fibrosis was evaluated by magnetic resonance imaging (MRI) and NAFLD fibrosis score (NFS) respectively. Exclusion criteria included significant alcohol consumption, markers of viral hepatitis infection or other liver diseases. Results are expressed in percentage or median (interquartile range). RESULTS 52.6% of patients were women, the median age was 60 years old (57-64), mean BMI was 29.6 ± 4.7 kg/m2 and diabetes duration was 7.6 ± 6.9 years. A high prevalence of liver steatosis (63.9%), advanced fibrosis assessed by NFS (12.8%) and evidence of liver cirrhosis in MRI (6.0%) was observed. In a multivariate analysis GGT > 82 IU/L (P = 0.004) and no alcohol intake (P = 0.032) were independently associated to advanced fibrosis. CONCLUSION A high frequency of undiagnosed advanced fibrosis and cirrhosis was observed in non-selected T2DM patients. Screening of these conditions may be warranted in this patient population.
Collapse
Affiliation(s)
- Juan P Arab
- Departamento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Barrera
- Departamento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Consuelo Gallego
- Departamento de Nutrición, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan P Valderas
- Departamento de Nutrición, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sergio Uribe
- Departamento de Radiología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Cristian Tejos
- Escuela de Medicina and Departamento de Ingeniería Eléctrica, Escuela de Ingeniería, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Cristóbal Serrano
- Departamento de Radiología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Cristóbal Serrano
- Departamento de Radiología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Álvaro Huete
- Departamento de Radiología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jessica Liberona
- Departamento de Nutrición, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pilar Labbé
- Departamento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Teresa Quiroga
- Departamento de Laboratorio Clínico, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carlos Benítez
- Departamento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo Irarrázaval
- Escuela de Medicina and Departamento de Ingeniería Eléctrica, Escuela de Ingeniería, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Arnoldo Riquelme
- Departamento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marco Arrese
- Departamento de Gastroenterología, Pontificia Universidad Católica de Chile, Santiago, Chile
| |
Collapse
|
38
|
Arab JP, Karpen SJ, Dawson PA, Arrese M, Trauner M. Bile acids and nonalcoholic fatty liver disease: Molecular insights and therapeutic perspectives. Hepatology 2017; 65:350-362. [PMID: 27358174 PMCID: PMC5191969 DOI: 10.1002/hep.28709] [Citation(s) in RCA: 383] [Impact Index Per Article: 54.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/09/2016] [Accepted: 06/23/2016] [Indexed: 12/11/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a burgeoning health problem worldwide and an important risk factor for both hepatic and cardiometabolic mortality. The rapidly increasing prevalence of this disease and of its aggressive form nonalcoholic steatohepatitis (NASH) will require novel therapeutic approaches to prevent disease progression to advanced fibrosis or cirrhosis and cancer. In recent years, bile acids have emerged as relevant signaling molecules that act at both hepatic and extrahepatic tissues to regulate lipid and carbohydrate metabolic pathways as well as energy homeostasis. Activation or modulation of bile acid receptors, such as the farnesoid X receptor and TGR5, and transporters, such as the ileal apical sodium-dependent bile acid transporter, appear to affect both insulin sensitivity and NAFLD/NASH pathogenesis at multiple levels, and these approaches hold promise as novel therapies. In the present review, we summarize current available data on the relationships of bile acids to NAFLD and the potential for therapeutically targeting bile-acid-related pathways to address this growing world-wide disease. (Hepatology 2017;65:350-362).
Collapse
Affiliation(s)
- Juan P. Arab
- Department of Gastroenterology, School of MedicinePontificia Universidad Católica de ChileSantiagoChile
| | - Saul J. Karpen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of PediatricsEmory University School of MedicineAtlantaGAUSA
| | - Paul A. Dawson
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of PediatricsEmory University School of MedicineAtlantaGAUSA
| | - Marco Arrese
- Department of Gastroenterology, School of MedicinePontificia Universidad Católica de ChileSantiagoChile
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
| |
Collapse
|
39
|
Arab JP, Claro JC, Arancibia JP, Contreras J, Gómez F, Muñoz C, Nazal L, Roessler E, Wolff R, Arrese M, Benítez C. Therapeutic alternatives for the treatment of type 1 hepatorenal syndrome: A Delphi technique-based consensus. World J Hepatol 2016; 8:1075-1086. [PMID: 27660674 PMCID: PMC5026999 DOI: 10.4254/wjh.v8.i25.1075] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 07/07/2016] [Accepted: 08/01/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To propose several alternatives treatment of type 1 hepatorenal syndrome (HRS-1) what is the most severe expression of circulatory dysfunction on patients with portal hypertension.
METHODS A group of eleven gastroenterologists and nephrologists performed a structured analysis of available literature. Each expert was designated to review and answer a question. They generated draft statements for evaluation by all the experts. Additional input was obtained from medical community. In order to reach consensus, a modified three-round Delphi technique method was used. According to United States Preventive Services Task Force criteria, the quality of the evidence and level of recommendation supporting each statement was graded.
RESULTS Nine questions were formulated. The available evidence was evaluated considering its quality, number of patients included in the studies and the consistency of its results. The generated questions were answered by the expert panel with a high level of agreement. Thus, a therapeutic algorithm was generated. The role of terlipressin and norepinephrine was confirmed as the pharmacologic treatment of choice. On the other hand the use of the combination of octreotide, midodrine and albumin without vasoconstrictors was discouraged. The role of several other options was also evaluated and the available evidence was explored and discussed. Liver transplantation is considered the definitive treatment for HRS-1. The present consensus is an important effort that intends to organize the available strategies based on the available evidence in the literature, the quality of the evidence and the benefits, adverse effects and availability of the therapeutic tools described.
CONCLUSION Based on the available evidence the expert panel was able to discriminate the most appropriate therapeutic alternatives for the treatment of HRS-1.
Collapse
|
40
|
Hernández-Rocha C, Pidal P, Ajenjo MC, Quera R, Quintanilla M, Lubascher J, Jemenao MI, Ibáñez P, Álvarez-Lobos M, Diomedi A, Marcotti A, Acuña M, Arab JP, Riquelme A, Candía R, Carvajal S. [Chilean consensus of prevention, diagnosis and treatment of Clostridium difficile-associated diarrhea]. Rev Chilena Infectol 2016; 33:98-118. [PMID: 26965890 DOI: 10.4067/s0716-10182016000100020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Clostridium dijfficile-associated diarrhea (CDAD) has become very important due to the increase in its incidence, severity, recurrence and the associated economic burden. Having a national consensus guideline is essential to improve its management. OBJECTIVE To build a multidisciplinary and evidence-based consensus in prevention, diagnosis and treatment of CDAD. METHODS We convened a panel of experts in the field of infectious diseases, gastroenterology, evidence-based medicine and consensus methodology. The panel conducted a structured review of published literature in CDAD evaluating evidence levels and recommendation degree according to the methodology proposed by the GRADE working-group. A modified three-round Delphi technique was used to reach a consensus among the experts. RESULTS A group of 16 experts was established, 12 of them answered 18 clinically relevant questions. The levels of agreement achieved by the panel of 16 experts were 79% in the first round and 100% in the second and third round. The main consensus recommendations in prevention are: restricting the use of proton-pump inhibitors, primary prophylaxis with probiotics in antibiotics users, education of health personnel, isolation for patients hospitalized with CDAD, and cleaning the rooms exposed to C. difficile with products based in chlorine or hydrogen peroxide. In the diagnosis: use of biology molecular-based techniques is preferred and if not available, glutamate dehydrogenase-based algorithms may be recommended. With regard to treatment: the use of oral metronidazole in mild-moderate CDAD and oral vancomycin in severe CDAD are recommended. Treat the first recurrence with the same antibiotics according to severity. In the case of second and subsequent recurrences consider prolonged therapy with vancomycin, rifaximin or fecal microbiota transplant. CONCLUSION The first Chilean consensus on prevention, diagnosis and treatment of CDAD is presented, which is a major step in improving national standards in the management of this disease.
Collapse
|
41
|
Affiliation(s)
- Juan P Arab
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.,Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| |
Collapse
|
42
|
Martínez J, Besa S, Arab JP, Quintana JC, Regonesi C, Huete A, Jarufe N, Guerra JF, Benítez C, Arrese M. Gastrointestinal neuroendocrine tumor with unresectable liver metastases: an example of multimodal therapeutic approach. Ann Hepatol 2016; 14:752-5. [PMID: 26256906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastrointestinal neuroendocrine tumors (NET) frequently present with unresectable hepatic metastases, which poses a barrier for curative treatment. Resection of the primary tumor and subsequent orthotopic liver transplantation (OLT) has been proposed as a treatment approach but available data in this regard is limited. We present a clinical case of an otherwise asymptomatic 44-yo man complaining of abdominal pain and dyspepsia that was diagnosed of a 10 cm duodenal tumor with multiple hepatic metastases. A CT-guided biopsy confirmed a NET. He underwent first a Whipple's procedure, and then was listed for liver transplantation. During the waiting time a multimodal therapeutic approach was used including the use of radioactive 177lutetium-labeled somatostatin analogues, long-acting somastostatin analogues and antiangiogenic antibodies (bevacizumab) in order to keep neoplastic disease under control. Two years after Whipple's procedure and given disease stability he underwent OLT with an uneventful postoperative evolution. Patient condition and graft function are optimal after a 4-year follow-up period with no evidence of recurrence. This case report underscores how a multimodal approach involving careful patient selection, resective surgery as well as use of somatostatin analogues and antiangiogenic biological therapy followed by liver transplantation can achieve excellent long-term results in this difficult patient population.
Collapse
Affiliation(s)
- Jorge Martínez
- Departments of School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Santiago Besa
- Departments of School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan P Arab
- Gastrointestinal Surgery School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan C Quintana
- Radiology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Alvaro Huete
- Radiology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Nicolás Jarufe
- Departments of School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan F Guerra
- Departments of School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carlos Benítez
- Gastrointestinal Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marco Arrese
- Gastrointestinal Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| |
Collapse
|
43
|
Aguirre-Reyes DF, Sotelo JA, Arab JP, Arrese M, Tejos R, Irarrazaval P, Tejos C, Uribe SA, Andia ME. Intrahepatic portal vein blood volume estimated by non-contrast magnetic resonance imaging for the assessment of portal hypertension. Magn Reson Imaging 2015; 33:970-7. [PMID: 26117696 DOI: 10.1016/j.mri.2015.06.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 06/21/2015] [Indexed: 12/31/2022]
Abstract
PURPOSE To investigate the feasibility of estimating the portal vein blood volume that flows into the intrahepatic volume (IHPVBV) in each cardiac cycle using non-contrast MR venography technique as a surrogate marker of portal hypertension (PH). MATERIALS AND METHODS Ten patients with chronic liver disease and clinical symptoms of PH (40% males, median age: 54.0, range: 44-73 years old) and ten healthy volunteers (80% males, median age: 54.0, range: 44-66 years old) were included in this study. A non-contrast Triple-Inversion-Recovery Arterial-Spin-Labeling (TIR-ASL) technique was used to quantify the IHPVBV in one and two cardiac cycles. Liver (LV) and spleen volumes (SV) were measured by manual segmentation from anatomical MR images as morphological markers of PH. All images were acquired in a 1.5T Philips Achieva MR scanner. RESULTS PH patients had larger SV (P=0.02) and lower liver-to-spleen ratio (P=0.02) compared with healthy volunteers. The median IHPVBV in healthy volunteers was 13.5cm(3) and 26.5cm(3) for one and two cardiac cycles respectively, whereas in PH patients a median volume of 3.1cm(3) and 9.0cm(3) was observed. When correcting by LV, the IHPVBV was significantly higher in healthy volunteers than PH patients for one and two cardiac cycles. The combination of morphological information (liver-to-spleen ratio) and functional information (IHPVBV/LV) can accurately identify the PH patients with a sensitivity of 90% and specificity of 100%. CONCLUSION Results show that the portal vein blood volume that flows into the intrahepatic volume in one and two cardiac cycles is significantly lower in PH patients than in healthy volunteers and can be quantified with non-contrast MRI techniques.
Collapse
Affiliation(s)
- Daniel F Aguirre-Reyes
- Biomedical Imaging Center, Pontificia Universidad Catolica de Chile, Santiago, 7820436, Chile; Electrical Engineering Department, School of Engineering, Pontificia Universidad Catolica de Chile, Santiago, 7820436, Chile; Computation Sciences and Electronic Department, Universidad Tecnica Particular de Loja, Ecuador, Loja 1101608, Ecuador.
| | - Julio A Sotelo
- Biomedical Imaging Center, Pontificia Universidad Catolica de Chile, Santiago, 7820436, Chile; Electrical Engineering Department, School of Engineering, Pontificia Universidad Catolica de Chile, Santiago, 7820436, Chile.
| | - Juan P Arab
- Gastroenterology Department, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, 8331150, Chile.
| | - Marco Arrese
- Gastroenterology Department, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, 8331150, Chile.
| | - Rodrigo Tejos
- Gastroenterology Department, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, 8331150, Chile.
| | - Pablo Irarrazaval
- Biomedical Imaging Center, Pontificia Universidad Catolica de Chile, Santiago, 7820436, Chile; Electrical Engineering Department, School of Engineering, Pontificia Universidad Catolica de Chile, Santiago, 7820436, Chile.
| | - Cristian Tejos
- Biomedical Imaging Center, Pontificia Universidad Catolica de Chile, Santiago, 7820436, Chile; Electrical Engineering Department, School of Engineering, Pontificia Universidad Catolica de Chile, Santiago, 7820436, Chile.
| | - Sergio A Uribe
- Biomedical Imaging Center, Pontificia Universidad Catolica de Chile, Santiago, 7820436, Chile; Radiology Department, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, 8331150, Chile.
| | - Marcelo E Andia
- Biomedical Imaging Center, Pontificia Universidad Catolica de Chile, Santiago, 7820436, Chile; Radiology Department, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, 8331150, Chile.
| |
Collapse
|
44
|
Arab JP, Candia R, Zapata R, Muñoz C, Arancibia JP, Poniachik J, Soza A, Fuster F, Brahm J, Sanhueza E, Contreras J, Cuellar MC, Arrese M, Riquelme A. Management of nonalcoholic fatty liver disease: an evidence-based clinical practice review. World J Gastroenterol 2014; 20:12182-201. [PMID: 25232252 PMCID: PMC4161803 DOI: 10.3748/wjg.v20.i34.12182] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 03/27/2014] [Accepted: 04/27/2014] [Indexed: 02/06/2023] Open
Abstract
AIM To build a consensus among Chilean specialists on the appropriate management of patients with nonalcoholic fatty liver disease (NAFLD) in clinical practice. METHODS NAFLD has now reached epidemic proportions worldwide. The optimal treatment for NAFLD has not been established due to a lack of evidence-based recommendations. An expert panel of members of the Chilean Gastroenterological Society and the Chilean Hepatology Association conducted a structured analysis of the current literature on NAFLD therapy. The quality of the evidence and the level of recommendations supporting each statement were assessed according to the recommendations of the United States Preventive Services Task Force. A modified three-round Delphi technique was used to reach a consensus among the experts. RESULTS A group of thirteen experts was established. The survey included 17 open-ended questions that were distributed among the experts, who assessed the articles associated with each question. The levels of agreement achieved by the panel were 93.8% in the first round and 100% in the second and third rounds. The final recommendations support the indication of lifestyle changes, including diet and exercise, for all patients with NAFLD. Proven pharmacological therapies include only vitamin E and pioglitazone, which can be used in nondiabetic patients with biopsy-proven nonalcoholic steatohepatitis (the progressive form of NAFLD), although the long-term safety and efficacy of these therapies have not yet been established. CONCLUSION Current NAFLD management is rapidly evolving, and new pathophysiology-based therapies are expected to be introduced in the near future. All NAFLD patients should be evaluated using a three-focused approach that considers the risks of liver disease, diabetes and cardiovascular events.
Collapse
|
45
|
Huebert RC, Jagavelu K, Hendrickson HI, Vasdev MM, Arab JP, Splinter PL, Trussoni CE, Larusso NF, Shah VH. Aquaporin-1 promotes angiogenesis, fibrosis, and portal hypertension through mechanisms dependent on osmotically sensitive microRNAs. Am J Pathol 2011; 179:1851-60. [PMID: 21854740 DOI: 10.1016/j.ajpath.2011.06.045] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Revised: 06/20/2011] [Accepted: 06/28/2011] [Indexed: 12/21/2022]
Abstract
Changes in hepatic vasculature accompany fibrogenesis, and targeting angiogenic molecules often attenuates fibrosis in animals. Aquaporin-1 (AQP1) is a water channel, overexpressed in cirrhosis, that promotes angiogenesis by enhancing endothelial invasion. The effect of AQP1 on fibrogenesis in vivo and the mechanisms driving AQP1 expression during cirrhosis remain unclear. The purpose of this study was to test the effect of AQP1 deletion in cirrhosis and explore mechanisms regulating AQP1. After bile duct ligation, wild-type mice overexpress AQP1 that colocalizes with vascular markers and sites of robust angiogenesis. AQP1 knockout mice demonstrated reduced angiogenesis compared with wild-type mice, as evidenced by immunostaining and endothelial invasion/proliferation in vitro. Fibrosis and portal hypertension were attenuated based on immunostaining, portal pressure, and spleen/body weight ratio. AQP1 protein, but not mRNA, was induced by hyperosmolality in vitro, suggesting post-transcriptional regulation. Endothelial cells from normal or cirrhotic mice were screened for microRNA (miR) expression using an array and a quantitative PCR. miR-666 and miR-708 targeted AQP1 mRNA and were decreased in cirrhosis and in cells exposed to hyperosmolality, suggesting that these miRs mediate osmolar changes via AQP1. Binding of the miRs to the untranslated region of AQP1 was assessed using luciferase assays. In conclusion, AQP1 promotes angiogenesis, fibrosis, and portal hypertension after bile duct ligation and is regulated by osmotically sensitive miRs.
Collapse
Affiliation(s)
- Robert C Huebert
- Gastroenterology Research Unit, Mayo Clinic and Foundation, 200 First St. SW, Rochester, MN 55905, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|