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Jagdish RK, Kamaal A, Shasthry SM, Benjamin J, Maiwall R, Jindal A, Choudhary A, Rajan V, Arora V, Bhardwaj A, Kumar G, Kumar M, Sarin SK. Erectile Dysfunction in Cirrhosis: Its Prevalence and Risk Factors. J Clin Exp Hepatol 2022; 12:1264-1275. [PMID: 36157150 PMCID: PMC9499842 DOI: 10.1016/j.jceh.2022.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/03/2022] [Indexed: 12/12/2022] Open
Abstract
Background Erectile dysfunction (ED) is common in men with cirrhosis. The aim of this study was to assess the prevalence of ED and the factors associated with ED in men with cirrhosis. Methods 400 men with cirrhosis [Child-Turcotte-Pugh (CTP) class A, 44.0%; CTP class B, 41.0%; and CTP class C, 15.0%] having high Karnofsky performance score, and living in a stable monogamous relationship with a female partner were included in the study. International Index of Erectile Function (IIEF) questionnaire, and Short-Form (36) Health Survey (SF-36) were used to assess erectile function and the health-related quality of life (HRQOL), respectively. Results ED was found in 289 (72.3%) patients. Patients with ED reported significantly lower SF-36 scores across all the eight domains of SF-36 (i.e., physical functioning score, role physical score, bodily pain score, general health perception score, vitality score, social functioning score, role emotional score, and mental health score); physical component summary score, and mental physical component summary score, compared with those without ED. On multivariate analysis, factors associated with ED were older age, longer duration of cirrhosis, CTP-C (vs. CTP-A), higher hepatic venous pressure gradient (HVPG), presence of generalized anxiety disorder (GAD), presence of major depression, and lower appendicular skeletal muscle index measured by dual-energy X-ray absorptiometry (DEXA ASMI). Conclusion ED is common in men with cirrhosis, and men with ED have poor HRQOL compared with those without ED. Older age, longer duration of cirrhosis, CTP-C (vs. CTP-A), higher HVPG, presence of GAD, presence of major depression, and lower DEXA ASMI are associated with ED.
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Affiliation(s)
- Rakesh K. Jagdish
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ahmed Kamaal
- Department of Urology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Saggere M. Shasthry
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Jaya Benjamin
- Department of Clinical Nutrition, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankur Jindal
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ashok Choudhary
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vijayaraghavan Rajan
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vinod Arora
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankit Bhardwaj
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Biostatistics, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Manoj Kumar
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K. Sarin
- Department of Hepatology and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
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Mukund A, V Srinivasan S, Rana S, Vijayaraghavan R, Patidar Y, Arora V, Jindal A, Choudhury A, Shasthry SM, Sarin SK. Response evaluation of locoregional therapies in combined hepatocellular-cholangiocarcinoma and intrahepatic cholangiocarcinoma versus hepatocellular carcinoma: a propensity score matched study. Clin Radiol 2021; 77:121-129. [PMID: 34789395 DOI: 10.1016/j.crad.2021.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/14/2021] [Indexed: 11/16/2022]
Abstract
AIM To evaluate the response of locoregional therapy (LRT) on combined hepatocellular-cholangiocarcinoma (cHCC-CC) and intrahepatic cholangiocarcinoma (IHC) and compare their outcomes with propensity matched hepatocellular carcinoma (HCC) patients. MATERIALS AND METHODS From January 2011 to July 2020, 13 patients with cHCC-CC (11 men, two women, median age 56 years) and 15 IHC patients (10 men, five women, median age 60 years) were compared with 101 HCC patients (79 men, 22 women, median age 60 years) after LRT. All tumours were proven histologically. Among the 13 cHCC-CC patients, 11 received transarterial chemoembolisation (TACE), one received microwave ablation (MWA) and one received TACE with radiofrequency ablation (RFA). Of 15 IHC patients, eight received TACE, five received RFA, and one received MWA, and one received TACE with RFA. Propensity score matching (PSM) was done with conditional logistic regression adjusted for age, type of LRT, tumour specific features and Child-Pugh score. RESULTS After LRT, on univariate analysis an objective response was seen in 30% of cHCC-CC and 53% of IHC patients. PSM analysis demonstrated shorter progression-free survival (PFS; cHCC-CC versus HCC: 1.5 versus 7.5 months; IHC versus HCC: 6 versus 14 months, p<0.05), overall survival (OS; cHCC-CC versus HCC: 12 versus 28 months; IHC versus HCC: 18 versus 34 months, p<0.005), and poor objective response (cHCC-CC versus HCC: 25% versus 91%; IHC versus HCC: 58% versus 88%, p<0.05) in cHCC-CC and IHC patients versus HCC patients. Hypovascular tumour, macrovascular invasion, and infiltrative appearance were independent prognostic factors for OS in IHC patients. CONCLUSION cHCC-CC and IHC are aggressive tumours with a poor objective response, greater distant progression of the disease and shorter PFS and OS post LRT as compared to HCC.
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Affiliation(s)
- A Mukund
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - S V Srinivasan
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - S Rana
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - R Vijayaraghavan
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Y Patidar
- Department of Interventional Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - V Arora
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - A Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - A Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - S M Shasthry
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - S K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Sharma S, Baweja S, Maras JS, Shasthry SM, Moreau R, Sarin SK. Differential blood transcriptome modules predict response to corticosteroid therapy in alcoholic hepatitis. JHEP Rep 2021; 3:100283. [PMID: 34095796 PMCID: PMC8165449 DOI: 10.1016/j.jhepr.2021.100283] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 03/06/2021] [Accepted: 03/09/2021] [Indexed: 12/15/2022] Open
Abstract
Background & Aims In patients with severe alcoholic hepatitis (SAH), little is known about the profile of peripheral blood mononuclear cells (PBMCs) at baseline and during corticosteroid therapy, among those who can be treated successfully with steroids (steroid-responders [R] and those who cannot (steroid-non-responders [NR]); 2 groups with different outcomes. Methods We performed RNA-seq analysis in PBMCs from 32 patients with definite SAH, at baseline and after 7 days of corticosteroids. The data were sorted into R and NR (n = 16, each group) using the Lille model and 346 blood transcription modules (BTMs) were identified. BTMs are predefined modules of highly co-expressed PBMC genes, which can determine specific immune cell types and cellular functions. The activity of each BTM was taken as the mean value of its member genes. Results At baseline, 345 BTMs had higher activity (i.e. were upregulated) in NR relative to R. The 100 most upregulated BTMs in NR, included several modules related to lymphoid lineage (T, B, and natural killer [NK] cells), modules for cell division and mitochondrial respiratory electron transport chain (ETC, relating to energy production), but only a few modules of myeloid cells. Correlation studies of BTM activities found features of significantly greater activation/proliferation and differentiation for T and B cells in NR relative to R. After 7 days of corticosteroids, NR had no significant changes in BTM activities relative to baseline, whereas R had downregulation of BTMs related to innate and adaptive immunity. Conclusions At baseline and during corticosteroid therapy, increased activity in the PBMCs of gene modules related to activation/proliferation and differentiation of T and B cells, NK cells, and mitochondrial ETC, is a hallmark of SAH patients who are steroid-non-responders. Lay summary Patients with severe alcoholic hepatitis receive steroid therapy as the main line of treatment; however, this treatment is ineffective in some patients. This only becomes apparent after 7 days of steroid therapy. We have developed an approach where it can be estimated if a patient is going to respond or not to steroid therapy using the gene expression information of blood cells. This method will allow clinicians to assess the response of patients to steroids earlier, and will help them in adopting alternate strategies if the treatment is found to be ineffective in a particular patient. RNA-seq is an unprecedented tool for analysis of the bulk peripheral blood mononuclear cells (PBMCs) transcriptome. Co-expressed genes in the bulk PBMC transcriptome can be grouped as blood transcriptional modules (BTMs). Patients with severe alcoholic hepatitis, non-responsive to corticosteroids, have a distinct BTM profile at baseline. Deconvolution of RNA-seq data using CIBERSORTx showed increases in different populations of B cells, CD4 and CD8 T cells, and NK cells. Baseline FACS analysis of PBMCs can be reflective of immune cells identified by RNA-seq data analysis.
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Key Words
- Alcoholic liver disease
- BTM, blood transcription module
- CTP score, Child-Turcott-Pugh score
- DEGs, differentially expressed genes
- ETC, electron transport chain
- Glucocorticoid receptor
- MDF, Maddrey’s discriminant function
- MELD, model for end-stage liver disease
- NK cells, natural killer cells
- NR, non-responders
- NR3C1
- NR3C1, nuclear receptor subfamily 3 group c gene member 1
- OxPhos, oxidative phosphorylation
- PBMCs, peripheral blood mononuclear cells
- R, responders
- RNA-seq, RNA sequencing
- SAH, severe alcoholic hepatitis
- Steroid
- Transcriptome
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Affiliation(s)
- Shvetank Sharma
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sukriti Baweja
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Jaswinder S Maras
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Saggere M Shasthry
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Richard Moreau
- Centre de Recherche sur l'Inflammation (CRI), INSERM, Université de Paris, Paris, France.,Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Devarbhavi H, Aithal G, Treeprasertsuk S, Takikawa H, Mao Y, Shasthry SM, Hamid S, Tan SS, Philips CA, George J, Jafri W, Sarin SK. Drug-induced liver injury: Asia Pacific Association of Study of Liver consensus guidelines. Hepatol Int 2021; 15:258-282. [PMID: 33641080 DOI: 10.1007/s12072-021-10144-3] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/16/2021] [Indexed: 02/06/2023]
Abstract
Idiosyncratic drug-induced liver injury mimics acute and chronic liver disease. It is under recognized and underrecognised because of the lack of pathognomonic diagnostic serological markers. Its consequences may vary from being asymptomatic to self-limiting illness to severe liver injury leading to acute liver failure. Its incidence is likely to be more common in Asia than other parts of the world, mainly because of hepatotoxicity resulting from the treatment of tuberculosis disease and the ubiquitous use of traditional and complimentary medicines in Asian countries. This APASL consensus guidelines on DILI is a concise account of the various aspects including current evidence-based information on DILI with special emphasis on DILI due to antituberculosis agents and traditional and complementary medicine use in Asia.
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Affiliation(s)
- Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St John's Medical College Hospital, Bangalore, India.
| | - Guruprasad Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | | | - Hajime Takikawa
- Faculty of Medical Technology, Emeritus Professor, School of Medicine, Tokyo, Japan
| | - Yimin Mao
- Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, and Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Saggere M Shasthry
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Saeed Hamid
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Soek Siam Tan
- Department of Medicine, Hospital Selayang, Bata Caves, Selangor, Malaysia
| | - Cyriac Abby Philips
- The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Jacob George
- Department of Gastroenterology and Hepatology, Westmead Hospital and Sydney West Local Health District, Sydney, Australia
| | - Wasim Jafri
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
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Kumar M, Kainth S, Kumar S, Bhardwaj A, KumarAggarwal H, Maiwall R, Jamwal KD, Shasthry SM, Jindal A, Choudhary A, Anand L, Dhamija RM, Chibbar G, Chander Sharma B, Sarin SK. Prevalence of and Factors Associated with Sleep-Wake Abnormalities in Patients with Cirrhosis. J Clin Exp Hepatol 2021; 11:453-465. [PMID: 34276152 PMCID: PMC8267360 DOI: 10.1016/j.jceh.2020.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 10/17/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND & AIMS Sleep-wake abnormalities [poor nighttime sleep and excessive daytime sleepiness (EDS)] are common in patients with cirrhosis. The aim of this study was to assess the prevalence of sleep-wake abnormalities and clinical factors associated with these abnormalities in a group of patients with cirrhosis. METHODS 1098 patients with cirrhosis [Child Turcotte Pugh (CTP) class A, 22.2%; CTP class B, 29.2% and CTP class C, 48.6%], with either no ascites or mild ascites controlled on diuretics, and no history of or current overt hepatic encephalopathy were included in the study. RESULTS Poor nighttime sleep and EDS were found in 569 (51.8%) and 489 (44.5%) patients respectively. On multivariate analysis, factors associated with poor nighttime sleep were CTP class C (vs. class A), presence of minimal hepatic encephalopathy (MHE), intermediate or evening type of diurnal preference category (vs. morning type), high risk for obstructive sleep apnea (OSA), diuretic use, presence of major depression, and presence of generalized anxiety disorder (GAD). Factors associated with EDS on multivariate analysis were CTP class B and C (vs. class A), intermediate or evening type of diurnal preference category (vs. morning type), high risk for OSA, presence of major depression, and presence of GAD. CONCLUSIONS Sleep-wake abnormalities are common in patients with cirrhosis. CTP status, diurnal preference chronotype, risk of OSA, major depression and GAD are associated with both poor nighttime sleep and EDS. MHE and diuretic use are associated with poor nighttime sleep, but not with EDS.
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Key Words
- ACLF, Acute on chronic liver failure
- BQ, Berlin questionnaire
- CFF, Critical flicker frequency
- CLDQ, Chronic liver disease questionnaire
- CSM, Composite scale of morningness
- CTP, Child Turcotte Pugh
- EDS, Excessive daytime sleepiness
- ESS, Epworth sleepiness scale
- GAD, generalized anxiety disorder
- HE, Hepatic encephalopathy
- HRQOL, Health related quality of life
- MHE, Minimal hepatic encephalopathy
- NASH, Non-alcoholic steatohepatitis
- OSA, Obstructive sleep apnea
- PHQ, Patient health questionnaire
- PSQI, Pittsburgh sleep quality index
- cirrhosis
- insomnia
- sleep disturbances
- sleep-wake abnormalities
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Affiliation(s)
- Manoj Kumar
- Department of Hepatology and Liver Transplantation, New Delhi, India,Address for correspondence: Manoj Kumar, MD, DM, Department of Hepatology and Liver Transplantation, Institute of Liver & Biliary Sciences, D1 Vasant Kunj, New Delhi, 110070 India.
| | - Sumeet Kainth
- Department of Hepatology and Liver Transplantation, New Delhi, India
| | - Sachin Kumar
- Department of Pulmonary Medicine, New Delhi, India
| | | | - Hemant KumarAggarwal
- Department of Pulmonary Medicine, New Delhi, India,Department of Respiratory Medicine, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Rakhi Maiwall
- Department of Hepatology and Liver Transplantation, New Delhi, India
| | - Kapil D. Jamwal
- Department of Hepatology and Liver Transplantation, New Delhi, India
| | | | - Ankur Jindal
- Department of Hepatology and Liver Transplantation, New Delhi, India
| | - Ashok Choudhary
- Department of Hepatology and Liver Transplantation, New Delhi, India
| | - Lovkesh Anand
- Department of Hepatology and Liver Transplantation, New Delhi, India
| | | | - Guresh Chibbar
- Department of Biostatistics, Institute of Liver & Biliary Sciences, New Delhi, India
| | - Barjesh Chander Sharma
- Department of Hepatology and Liver Transplantation, New Delhi, India,Corresponding author.
| | - Shiv K. Sarin
- Department of Hepatology and Liver Transplantation, New Delhi, India
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Abstract
Pancreatic-pleural fistula (PPF) is a rare sequela of pancreatitis. High degree of clinical suspicion is required to diagnose a PPF. Confirmation is done by high amylase content in pleural fluid analysis. Here, we present two cases with varied presentation of PPF. A 43-year-old man presented with acute on chronic pancreatitis with bilateral (predominantly right) pleural effusion. Another 57-year-old man, previously diagnosed with chronic calcific pancreatitis, presented with left pleural effusion. Both cases were effectively managed with endoscopic pancreatic duct stenting.
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Affiliation(s)
- S V Sasturkar
- Department of HPB Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - S Gupta
- Department of HPB Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - S Thapar
- Department of Diagnostic Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - S M Shasthry
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Baghmar S, Shasthry SM, Singla R, Patidar Y, Bihari CB, Sarin SK. Solitary Duodenal Metastasis from Renal Cell Carcinoma with Metachronous Pancreatic Neuroendocrine Tumor: Review of Literature with a Case Discussion. Indian J Med Paediatr Oncol 2019. [DOI: 10.4103/ijmpo.ijmpo_214_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AbstractRenal cell cancinoma (RCC) is a unique malignancy with features of late recurrences, metastasis to any organ, and frequent association with second malignancy. It most commonly metastasizes to the lungs, bones, liver, renal fossa, and brain although metastases can occur anywhere. RCC metastatic to the duodenum is especially rare, with only few cases reported in the literature. Herein, we review literature of all the reported cases of solitary duodenal metastasis from RCC and cases of neuroendocrine tumor (NET) as synchronous/metachronous malignancy with RCC. Along with this, we have described a unique case of an 84-year-old man who had recurrence of RCC as solitary duodenal metastasis after 37 years of radical nephrectomy and metachronous pancreatic NET.
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Affiliation(s)
- Saphalta Baghmar
- Departments of Medical Oncology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - S M Shasthry
- Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rajesh Singla
- Departments of Medical Oncology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Yashwant Patidar
- Departments of Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chhagan B Bihari
- Departments of Pathology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - S K Sarin
- Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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8
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Das S, Maras JS, Maiwall R, Shasthry SM, Hussain S, Sharma S, Sukriti S, Singh TP, Sarin SK. Molecular Ellipticity of Circulating Albumin-Bilirubin Complex Associates With Mortality in Patients With Severe Alcoholic Hepatitis. Clin Gastroenterol Hepatol 2018; 16:1322-1332.e4. [PMID: 29155355 DOI: 10.1016/j.cgh.2017.11.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 10/06/2017] [Accepted: 11/08/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND & AIMS Hyperbilirubinemia and hypoalbuminemia are features of hepatic dysfunction that associate with disease severity. This is because hepatic insufficiency causes hypoalbuminemia, which indirectly increases the circulating levels of free bilirubin. Circular dichroism (CD) spectroscopy can be used to quantify the molecular ellipticity (ME) of the albumin-bilirubin complex, and might associate with the severity or outcome of severe alcoholic hepatitis (SAH). METHODS We performed a cross-sectional study of 265 patients with SAH admitted in the Department of Hepatology, Institute of Liver and Biliary Sciences in New Delhi, India from January 2014 through January 2016. Blood samples were collected and patients were followed for 12 months or death. The molar ratios of bilirubin: albumin and albumin-bilirubin complexes were determined for a discovery cohort (30 patients who survived the study period and 60 patients who did not survive) and compared with those of 60 patients with alcoholic cirrhosis and 30 healthy individuals (controls). Optical activities of albumin-bilirubin complexes in blood samples were determined by CD spectroscopy and compared among groups. Findings were validated in a separate cohort of 150 patients with SAH from the same institute. We studied the correlation between ME and albumin binding capacity (ABiC). RESULTS The molar ratio of bilirubin: albumin was higher in patients with SAH than with alcoholic cirrhosis or controls (P < .05). Patients with SAH had different CD spectra and higher ME than the other groups (P < .01); ME correlated with model for end-stage liver disease score (with and without Na) and discriminant function (r2 > .3; P < .01). ME values above a cut off of 1.84 mdeg predicted 3-month mortality in patients with SAH with an area under receiver operating characteristic curve of 0.87 (95% CI, 0.79-0.95), a 77% positive predictive value, and a 90% negative predictive value. The hazard ratio and concordance index of ME values for 3-month mortality in patients with SAH was 10% higher than the hazard ratio and concordance index of model for end-stage liver disease score. In patients with SAH, there was an inverse correlation between ME and ABiC (r2 > 0.7; P < .01). We observed a significant reduction in ABiC with increasing levels of bilirubin in vitro prepared albumin-bilirubin complex. CONCLUSION In a cross-sectional study of patients with SAH, we associated ME of the albumin-bilirubin complex, measured by CD spectroscopy, with outcomes of patients with SAH. Increased loading of bilirubin on albumin could explain reduced albumin function. Bilirubin removal by albumin dialysis might benefit patients with SAH.
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Affiliation(s)
- Sukanta Das
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Jaswinder Singh Maras
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Saggere M Shasthry
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shabir Hussain
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shvetank Sharma
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sukriti Sukriti
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Tej P Singh
- Department of Biophysics, All India Institute of Medical Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India; Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
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9
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Maras JS, Das S, Sharma S, Shasthry SM, Colsch B, Junot C, Moreau R, Sarin SK. Baseline urine metabolic phenotype in patients with severe alcoholic hepatitis and its association with outcome. Hepatol Commun 2018; 2:628-643. [PMID: 29881815 PMCID: PMC5983217 DOI: 10.1002/hep4.1176] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 11/17/2017] [Revised: 02/27/2018] [Accepted: 03/02/2018] [Indexed: 12/20/2022] Open
Abstract
Severe alcoholic hepatitis (SAH) has a high mortality rate, and corticosteroid therapy is effective in 60% patients. This study aimed to investigate a baseline metabolic phenotype that could help stratify patients not likely to respond to steroid therapy and to have an unfavorable outcome. Baseline urine metabolome was studied in patients with SAH using ultra‐high performance liquid chromatography and high‐resolution mass spectrometry. Patients were categorized as responders (Rs, n = 52) and nonresponders (NRs, n = 8) at day 7 according to the Lille score. Multivariate projection analysis identified metabolites in the discovery cohort (n = 60) and assessed these in a validation cohort of 80 patients (60 Rs, 20 NRs). A total of 212 features were annotated by using metabolomic/biochemical/spectral databases for metabolite identification. After a stringent selection procedure, a total of nine urinary metabolites linked to mitochondrial functions significantly discriminated nonresponders, most importantly by increased acetyl‐L‐carnitine (12‐fold), octanoylcarnitine (4‐fold), decanoylcarnitine (4‐fold), and alpha‐ketoglutaric acid (2‐fold) levels. Additionally, urinary acetyl‐L‐carnitine and 3‐hydroxysebasic acid discriminated nonsurvivors (P < 0.01). These urinary metabolites significantly correlated to severity indices and mortality (r > 0.3; P < 0.01) and were associated with nonresponse (odds ratio >3.0; P < 0.001). In the validation cohort, baseline urinary acetyl‐L‐carnitine documented an area under the receiver operating curve of 0.96 (0.85‐0.99) for nonresponse prediction and a hazard ratio of 3.5 (1.5‐8.3) for the prediction of mortality in patients with SAH. Acetyl‐L‐carnitine at a level of >2,500 ng/mL reliably segregated survivors from nonsurvivors (P < 0.01, log‐rank test) in our study cohort. Conclusion: Urinary metabolome signatures related to mitochondrial functions can predict pretherapy steroid response and disease outcome in patients with SAH. (Hepatology Communications 2018;2:628‐643)
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Affiliation(s)
- Jaswinder Singh Maras
- Department of Molecular and Cellular Medicine Institute of Liver and Biliary Sciences New Delhi India
| | - Sukanta Das
- Department of Molecular and Cellular Medicine Institute of Liver and Biliary Sciences New Delhi India
| | - Shvetank Sharma
- Department of Molecular and Cellular Medicine Institute of Liver and Biliary Sciences New Delhi India
| | - Saggere M Shasthry
- Department of Hepatology Institute of Liver and Biliary Sciences New Delhi India
| | - Benoit Colsch
- Service de Pharmacologie et Immunoanalyse, Laboratoire d'Etude du Métabolisme des Médicaments, DRF/Institut Joliot, CEA-Saclay, MetaboHUB Université Paris-Saclay Gif-sur-Yvette France
| | - Christophe Junot
- Service de Pharmacologie et Immunoanalyse, Laboratoire d'Etude du Métabolisme des Médicaments, DRF/Institut Joliot, CEA-Saclay, MetaboHUB Université Paris-Saclay Gif-sur-Yvette France
| | - Richard Moreau
- Department of Hepatology Institute of Liver and Biliary Sciences New Delhi India.,INSERM, Université Paris Diderot, Centre de Recherche sur l'Inflammation Paris France.,Département Hospitalo-Universitaire UNITY, Service d'Hépatologie, Hôpital Beaujon Assistance Publique-Hôpitaux de Paris Clichy France.,Laboratoire d'Excellence Inflamex COMUE Sorbonne Paris Cité Paris France
| | - Shiv Kumar Sarin
- Department of Hepatology Institute of Liver and Biliary Sciences New Delhi India
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Bhardwaj A, Kedarisetty CK, Vashishtha C, Bhadoria AS, Jindal A, Kumar G, Choudhary A, Shasthry SM, Maiwall R, Kumar M, Bhatia V, Sarin SK. Carvedilol delays the progression of small oesophageal varices in patients with cirrhosis: a randomised placebo-controlled trial. Gut 2017; 66:1838-1843. [PMID: 27298379 DOI: 10.1136/gutjnl-2016-311735] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [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: 02/26/2016] [Accepted: 05/20/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Carvedilol is effective in the primary prophylaxis for large oesophageal varices. We investigated its use in preventing progression of small to large oesophageal varices. METHODS Consecutive cirrhotics with small oesophageal varices were prospectively randomised to either carvedilol (n=70) or placebo (n=70) and followed up for a minimum of 24 months. Endoscopy was done at baseline and six monthly intervals. Hepatic vein pressure gradient (HVPG) was measured at baseline and at 12 months. The primary endpoint was development of large varices. RESULTS Baseline characteristics in two groups were comparable. The predominant aetiology of cirrhosis was non-alcoholic fatty liver disease in both the groups. The mean dose of carvedilol administered was 12±1.67 mg/day and the target heart rate achieved was 58±3 bpm. A higher proportion of patients in carvedilol group had non-progression to large varices than placebo (79.4% vs 61.4%; p=0.04); the mean time of non-progression to large varices was 20.8 months (95% CI 19.4 to 22.4) in carvedilol group and 18.7 months (95% CI 17.1 to 20.4) in placebo group (p=0.04). There was a modest reduction of HVPG at 1 year in carvedilol group (-8.64%) compared with placebo (+0.33%) (p=0.22). None of the patients in either group died of variceal bleeding or liver-related causes. No major adverse events were observed in either group. CONCLUSIONS Carvedilol is safe and effective in delaying the progression of small to large oesophageal varices in patients with cirrhosis. TRIAL REGISTRATION NUMBER NCT01196507; post-results.
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Affiliation(s)
- Ankit Bhardwaj
- Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Chandan Kumar Kedarisetty
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Chitranshu Vashishtha
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Ajeet Singh Bhadoria
- Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Ankur Jindal
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Guresh Kumar
- Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Ashok Choudhary
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - S M Shasthry
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Rakhi Maiwall
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Manoj Kumar
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Vikram Bhatia
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
| | - Shiv Kumar Sarin
- Hepatic Hemodynamic Laboratory, Departments of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
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Shasthry SM, Kumar M, Khumuckham JS, Sarin SK. Changes in cardiac output and incidence of volume overload in cirrhotics receiving 20% albumin infusion. Liver Int 2017; 37:1167-1176. [PMID: 28135785 DOI: 10.1111/liv.13375] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 01/17/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Patients with cirrhosis are prone to develop volume over load, have increased capillary permeability and latent or overt cardiomyopathy. Whether albumin infusion causes volume overload in cirrhotics has not been adequately studied. METHODS Ninety nine consecutive cirrhotic patients receiving 1gm per kg albumin infusion were evaluated for development of volume overload. Clinical, echocardiographic and haemodynamic changes were closely monitored during and after albumin infusion. RESULTS Thirty (30.30%) patients developed volume overload. Patients with higher BMI (P=.003), lower CTP (P=.01) and MELD (P=.034) were more often associated with the development of volume overload. Though baseline diastolic dysfunction was present in 82.8% of the patients, it did not influence the development of volume overload or changes in the cardiac output. The cardiac output increased significantly after albumin infusion (4.9±1.554 L/min to 5.86±1.85 L/min, P<.001) irrespective of the development of volume overload, or the presence of diastolic dysfunction or the Child's status. CONCLUSION Nearly, one-third of cirrhotics receiving standard albumin infusion develop volume overload, specially, those with higher BMI and lower severity of liver disease. Cardiac output increases after albumin infusion, and, baseline diastolic dysfunction has little effect on the development of volume overload or changes in cardiac output.
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Affiliation(s)
- Saggere M Shasthry
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Jelen S Khumuckham
- Department of Cardiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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