1
|
Yüksekyayla O, Kina N, Ulaba A, Emin Ergün M, Batibay E, Şimşek C, Yildiz Zeyrek F, Wahlin S, Efe C. The frequency and clinical significance of antibodies to soluble liver antigen/liver pancreas in autoimmune hepatitis: a prospective single-center study. Eur J Gastroenterol Hepatol 2024; 36:652-656. [PMID: 38477840 DOI: 10.1097/meg.0000000000002747] [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: 03/14/2024]
Abstract
BACKGROUND AND AIMS Soluble liver antigen/liver pancreas antibodies (anti-SLA/LP) are specific markers for autoimmune hepatitis (AIH) that have been associated with a distinct clinical phenotype and a more aggressive form of AIH. We prospectively evaluated the frequency and clinical significance of anti-SLA/LP in Turkish patients with AIH. MATERIAL AND METHODS We prospectively included patients diagnosed with AIH between January 2018 and May 2023. Autoantibodies were detected using by immunofluorescence and immunoblot. RESULTS We included 61 (80%, female) AIH patients with a median age of 31 years (15-78) at the time of diagnosis. Anti-SLA/LP was detected in 20% ( n = 12) of the patients. Baseline characteristics, treatment responses and outcomes were similar among anti-SLA/LP-positive and anti-SLA/LP-negative AIH patients. Anti-SLA/LP-positive patients had significantly higher biochemical response rates after 4 weeks (100 vs. 67%, P = 0.027), 3 months (100 vs. 39%, P < 0.001), 6 months (100 vs. 69%, P = 0.041) of therapy but not after 12 months (100 vs. 76%, P = 0.103) and at the end of follow-up (100 vs. 91%, P = 0.328). Relapse rates following treatment response were similar in patients with and without anti-SLA/LP (22 vs. 23%, P = 0.956). Second-line therapies (tacrolimus and mycophenolate mofetil) were given to seven (11%) patients, all were anti-SLA/LP-negative. Two of these progressed into end-stage liver disease and both underwent liver transplantation. CONCLUSION Our study results suggest that anti-SLA/LP positivity does not entail clinically distinct or severe features in AIH. In our cohort, anti-SLA/LP-positive patients showed a quicker response to immunosuppressive therapy.
Collapse
Affiliation(s)
| | | | - Arjen Ulaba
- Department of Microbiology, Harran University, Şanliurfa
| | | | | | - Cem Şimşek
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | | | - Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | | |
Collapse
|
2
|
Lissing M, Wang B, Wahlin S. Liver transplantation and primary liver cancer in porphyria. Liver Int 2024. [PMID: 38456621 DOI: 10.1111/liv.15894] [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: 01/26/2024] [Revised: 02/22/2024] [Accepted: 02/28/2024] [Indexed: 03/09/2024]
Abstract
The porphyrias are a heterogeneous group of metabolic disorders that result from defects in heme synthesis. The metabolic defects are present in all cells, but symptoms are mainly cutaneous or related to neuropathy. The porphyrias are highly relevant to hepatologists since patients can present with symptoms and complications that require liver transplantation (LT), and some porphyrias are associated with a high risk for primary liver cancer (PLC). Among the cutaneous porphyrias, erythropoietic protoporphyria (EPP) can lead to cholestatic liver failure where LT cures the liver disease but not the porphyria. In acute porphyria (AP), neurotoxic porphyrin precursors are produced in the liver and LT is a curative treatment option in patients with recurrent severe neuropathic attacks. Patients with AP, mainly acute intermittent porphyria, have a significantly increased risk for PLC that warrants surveillance and adequate follow-up of high-risk groups. LT is well established in both EPP with liver failure and AP with recurrent attacks, but most transplant centres have little porphyria experience and cooperation between transplant hepatologists, and porphyria experts is important in the often-difficult decisions on timing and management of comorbid conditions.
Collapse
Affiliation(s)
- Mattias Lissing
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Bruce Wang
- Department of Medicine and Division of Gastroenterology, University of California San Francisco, San Francisco, California, USA
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
3
|
Şimşek C, Wahlin S, Efe C. Autoimmune Hepatitis: Mycophenolate mofetil versus azathioprine as first line therapy. J Hepatol 2024:S0168-8278(24)00142-9. [PMID: 38458322 DOI: 10.1016/j.jhep.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 02/21/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Cem Şimşek
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Cumali Efe
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey; Department of Gastroenterology, Harran University, Şanlıurfa, Turkey.
| |
Collapse
|
4
|
Storjord E, Wahlin S, Karlsen BO, Hardersen RI, Dickey AK, Ludviksen JK, Brekke OL. Potential Biomarkers for the Earlier Diagnosis of Kidney and Liver Damage in Acute Intermittent Porphyria. Life (Basel) 2023; 14:19. [PMID: 38276268 DOI: 10.3390/life14010019] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/14/2023] [Accepted: 12/19/2023] [Indexed: 01/27/2024] Open
Abstract
Acute intermittent porphyria (AIP) is an inherited metabolic disorder associated with complications including kidney failure and hepatocellular carcinoma, probably caused by elevations in the porphyrin precursors porphobilinogen (PBG) and delta-aminolevulinic acid (ALA). This study explored differences in modern biomarkers for renal and hepatic damage between AIP patients and controls. Urine PBG testing, kidney injury panels, and liver injury panels, including both routine and modern biomarkers, were performed on plasma and urine samples from AIP cases and matched controls (50 and 48 matched pairs, respectively). Regarding the participants' plasma, the AIP cases had elevated kidney injury marker-1 (KIM-1, p = 0.0002), fatty acid-binding protein-1 (FABP-1, p = 0.04), and α-glutathione S-transferase (α-GST, p = 0.001) compared to the matched controls. The AIP cases with high PBG had increased FABP-1 levels in their plasma and urine compared to those with low PBG. In the AIP cases, KIM-1 correlated positively with PBG, CXCL10, CCL2, and TCC, and the liver marker α-GST correlated positively with IL-13, CCL2, and CCL4 (all p < 0.05). In conclusion, KIM-1, FABP-1, and α-GST could represent potential early indicators of renal and hepatic damage in AIP, demonstrating associations with porphyrin precursors and inflammatory markers.
Collapse
Affiliation(s)
- Elin Storjord
- Department of Laboratory Medicine, Nordland Hospital Trust, 8092 Bodø, Norway
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Porphyria Centre Sweden, Karolinska Institute and Karolinska University Hospital, 14186 Stockholm, Sweden
| | - Bård Ove Karlsen
- Department of Laboratory Medicine, Nordland Hospital Trust, 8092 Bodø, Norway
- Research Laboratory, Nordland Hospital Trust, 8092 Bodø, Norway
| | - Randolf I Hardersen
- Department of Nephrology, Nordland Hospital Trust, 8092 Bodø, Norway
- Department of Clinical Medicine, UiT-The Arctic University of Norway, 9019 Tromsø, Norway
| | - Amy K Dickey
- Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
| | | | - Ole-Lars Brekke
- Department of Laboratory Medicine, Nordland Hospital Trust, 8092 Bodø, Norway
- Department of Clinical Medicine, UiT-The Arctic University of Norway, 9019 Tromsø, Norway
| |
Collapse
|
5
|
Lissing M, Wester A, Vassiliou D, Floderus Y, Harper P, Sardh E, Wahlin S. Porphyrin precursors and risk of primary liver cancer in acute intermittent porphyria: A case-control study of 188 patients. J Inherit Metab Dis 2023; 46:1186-1194. [PMID: 37650859 DOI: 10.1002/jimd.12676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/24/2023] [Accepted: 08/29/2023] [Indexed: 09/01/2023]
Abstract
Acute intermittent porphyria (AIP) is a rare hereditary metabolic disease characterized by acute attacks and accumulation of the porphyrin precursors 5-aminolevulinic acid (ALA) and porphobilinogen (PBG). Patients with AIP have a high risk of primary liver cancer (PLC). We aimed to assess the association between porphyrin precursor excretion and the risk for PLC in patients with AIP. We studied 48 patients with AIP who developed PLC between 1987 and 2015 and 140 age and sex matched controls with AIP but no PLC. Data on all available urinary PBG and ALA samples collected from 1975 until 1 year before PLC diagnosis were analyzed and compared between cases and controls using logistic regression. Porphyrin precursor excretion was higher in patients with PLC (PBG median 7.9 [IQR 4.4-21.9] mmol/mol creatinine) than in controls (3.8 [1.2-9.8]) (adjusted odds ratio 1.07, 95% confidence interval: 1.02-1.12). None of the 28 patients with all registered samples below the upper limit of normal (ULN) developed PLC, and only one of the 45 patients with all samples <2× ULN developed PLC. Among non-PLC controls, ALA and PBG levels decreased after age 50-60 while an increasing trend was observed after age 65 among those who developed PLC. Increased urinary porphyrin precursors are associated with a high risk of developing PLC. Patients with normal levels appear to have a low risk while high or increasing ALA and PBG after age 65 indicates high risk, which should be considered in surveillance decisions.
Collapse
Affiliation(s)
- Mattias Lissing
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Axel Wester
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Daphne Vassiliou
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Ylva Floderus
- Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden
- Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Pauline Harper
- Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden
- Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Eliane Sardh
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
6
|
Amouzandeh M, Sundström A, Wahlin S, Wernerman J, Rooyackers O, Norberg Å. Albumin and fibrinogen synthesis rates in advanced chronic liver disease. Am J Physiol Gastrointest Liver Physiol 2023; 325:G391-G397. [PMID: 37605837 DOI: 10.1152/ajpgi.00072.2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 04/14/2023] [Revised: 07/30/2023] [Accepted: 08/21/2023] [Indexed: 08/23/2023]
Abstract
Synthesis of plasma proteins is an important function of the liver that has sparsely been investigated by modern techniques in patients with advanced chronic liver disease (CLD). Twenty-eight well-characterized patients with CLD under evaluation for liver transplantation were included. Albumin and fibrinogen synthesis rates were measured by the flooding dose technique using stable isotope-labeled phenylalanine. Transcapillary escape rate of albumin and plasma volume were assessed by radioiodinated human serum albumin. The absolute albumin synthesis rates were low (65 mg/kg/day, range: 32-203) and were associated with impaired liver function, as reflected by the risk-scores Child-Pugh (P = 0.025) and model for end-stage liver disease (rs = -0.62, P = 0.0005). The fibrinogen synthesis rate (12.8 mg/kg/day, range: 2.4-52.9) was also negatively associated with liver function. The synthesis rates of albumin and fibrinogen were positively correlated. Plasma volume was high (51 ± 9 mL/kg body wt), which contributed to an almost normal intravascular albumin mass despite low plasma concentration. Autoimmune inflammatory etiologies to CLD were associated with higher fibrinogen synthesis. De novo synthesis rates of albumin and fibrinogen in advanced chronic liver failure were negatively correlated to prognostic scores of liver disease. Albumin synthesis rate was low and associated with both liver failure and autoimmune inflammation, whereas fibrinogen synthesis was often normal and positively associated with chronic inflammation. This is different from acute inflammatory states in which both albumin and fibrinogen synthesis rates are high.NEW & NOTEWORTHY Albumin and fibrinogen synthesis were positively correlated, but the high variation indicates that these are probably influenced by different mechanisms. There might be a limited metabolic reserve for the liver to increase both albumin and fibrinogen synthesis in response to longstanding inflammation in CLD and fibrinogen seems to be prioritized.
Collapse
Affiliation(s)
- Mariam Amouzandeh
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Division of Anaesthesiology and Intensive Care, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Anna Sundström
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Staffan Wahlin
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jan Wernerman
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Division of Anaesthesiology and Intensive Care, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Olav Rooyackers
- Division of Anaesthesiology and Intensive Care, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Åke Norberg
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Division of Anaesthesiology and Intensive Care, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
7
|
Mantel Ä, Vassiliou D, Lissing M, Stephansson O, Wahlin S, Sardh E. Maternal and fetal outcomes in acute hepatic porphyria: A Swedish National Cohort Study. J Inherit Metab Dis 2023; 46:675-686. [PMID: 37078226 DOI: 10.1002/jimd.12616] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 01/18/2023] [Revised: 03/22/2023] [Accepted: 04/19/2023] [Indexed: 04/21/2023]
Abstract
Current knowledge of pregnancy and perinatal outcomes in women with acute hepatic porphyria (AHP) is largely based on biochemical disease models, case reports, and case series. We performed a nationwide, registered-based cohort study to investigate the association between maternal AHP and the risk of adverse pregnancy and perinatal outcomes. All women in the Swedish Porphyria Register with confirmed AHP aged 18 years or older between 1987 and 2015 and matched general population comparators, with at least one registered delivery in the Swedish Medical Birth Register were included. Risk ratios (RRs) of pregnancy complications, delivery mode and perinatal outcomes were estimated and adjusted for maternal age at delivery, area of residency, birth year and parity. Women with acute intermittent porphyria (AIP), the most common form of AHP, were further categorized according to maximal lifetime urinary porphobilinogen (U-PBG) levels. The study included 214 women with AHP and 2174 matched comparators. Women with AHP presented with a higher risk for pregnancy-induced hypertensive disorder (aRR 1.73, 95% CI 1.12-2.68), gestational diabetes (aRR 3.41, 95% CI 1.69-6.89), and small-for-gestational-age birth (aRR 2.08, 95% CI 1.26-3.45). In general, RRs were higher among women with AIP who had high lifetime U-PBG levels. Our study shows an increased risk for pregnancy induced hypertensive disease, gestational diabetes, and small for gestational age births for AHP women, with higher relative risks for women with biochemically active AIP. No increased risk for perinatal death or malformations was observed.
Collapse
Affiliation(s)
- Ängla Mantel
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
- Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
- Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Daphne Vassiliou
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Centre for Inherited Metabolic Diseases, Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Lissing
- Hepatology Division, Karolinska University Hospital, Stockholm, Sweden
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Olof Stephansson
- Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
- Division of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
- Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Staffan Wahlin
- Hepatology Division, Karolinska University Hospital, Stockholm, Sweden
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Eliane Sardh
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Centre for Inherited Metabolic Diseases, Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
8
|
Lissing M, Vassiliou D, Floderus Y, Harper P, Yan J, Hagström H, Sardh E, Wahlin S. Risk for incident comorbidities, nonhepatic cancer and mortality in acute hepatic porphyria: A matched cohort study in 1244 individuals. J Inherit Metab Dis 2023; 46:286-299. [PMID: 36546345 DOI: 10.1002/jimd.12583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
The acute hepatic porphyrias (AHP) are associated with long-term complications such as primary liver cancer, hypertension, and chronic kidney disease. Data on other related comorbidities are scarce. In this register-based, matched cohort study, we assessed the risks of nonhepatic cancers, cardiovascular diseases, renal diseases, psychiatric disorders, and mortality in relation to porphyria type, sex, and biochemical disease activity. All patients in the Swedish porphyria register with a verified AHP diagnosis during 1987-2015 were included. The biochemical activity of acute intermittent porphyria was assessed using recorded maximal urinary porphobilinogen (U-PBG). Data on incident comorbidities and mortality were collected from national health registries. Cumulative incidences, rates, and hazards were compared to reference individuals from the general population, matched 1:10 by age, sex, and county. We identified 1244 patients with AHP with a median follow-up of 19 years. Health registries identified 149 AHP-subjects (12.0%) with nonhepatic cancer, similar to 1601 (13.0%) in the matched reference population (n = 12 362). Patients with AHP had a higher risk of kidney cancer (0.8% vs. 0.2%, p < 0.001), hypertension, and chronic kidney disease but no increase in risk for cardiovascular disease, except for cerebrovascular disease in patients with elevated U-PBG, (aHR = 1.40 [95% CI:1.06-1.85]). Mortality risk during follow-up was higher among patients with AHP (21% vs. 18%, p = 0.001), and associated with primary liver cancer, female sex, and biochemical activity. In conclusion, AHP is associated with an increased risk of kidney cancer, hypertension, chronic kidney disease, and mortality but not with cardiovascular disease or other nonhepatic cancers.
Collapse
Affiliation(s)
- Mattias Lissing
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Daphne Vassiliou
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Ylva Floderus
- Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden
- Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Pauline Harper
- Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden
- Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Jacinth Yan
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hannes Hagström
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Eliane Sardh
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
9
|
Lissing M, Vassiliou D, Harper P, Sardh E, Wahlin S. Comment on Ramai et al. Risk of Hepatocellular Carcinoma in Patients with Porphyria: A Systematic Review. Cancers 2022, 14, 2947. Cancers (Basel) 2023; 15:cancers15030795. [PMID: 36765753 PMCID: PMC9913564 DOI: 10.3390/cancers15030795] [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: 08/23/2022] [Accepted: 01/17/2023] [Indexed: 01/31/2023] Open
Abstract
We read with interest this review by Ramai et al. [...].
Collapse
Affiliation(s)
- Mattias Lissing
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, 17164 Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, 14186 Stockholm, Sweden
- Correspondence:
| | - Daphne Vassiliou
- Department of Endocrinology, Karolinska University Hospital, 17164 Stockholm, Sweden
- Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, 17164 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 14186 Stockholm, Sweden
| | - Pauline Harper
- Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, 17164 Stockholm, Sweden
- Department of Medical Biochemistry and Biophysics, Karolinska Institutet, 14186 Stockholm, Sweden
| | - Eliane Sardh
- Department of Endocrinology, Karolinska University Hospital, 17164 Stockholm, Sweden
- Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, 17164 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 14186 Stockholm, Sweden
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, 17164 Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, 14186 Stockholm, Sweden
| |
Collapse
|
10
|
Henriksson I, Udumyan R, Nilsson E, Önnerhag K, Rorsman F, Werner M, Marschall HU, Wahlin S, Nyhlin N. Clinical outcomes and sick leave in relation to UDCA treatment in Swedish patients with primary biliary cholangitis. Scand J Gastroenterol 2023; 58:70-75. [PMID: 35993428 DOI: 10.1080/00365521.2022.2103729] [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] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Primary biliary cholangitis (PBC) is an autoimmune liver disease that may progress into liver cirrhosis. Ursodeoxycholic acid (UDCA) is known to prevent or delay the disease progression, but little is known about work incapacity in PBC patients. We aimed to compare clinical outcomes (transplantation-free survival; cirrhosis development) and sick leave in patients with PBC with and without UDCA therapy. METHODS The medical records of 526 patients with PBC diagnosed from 2004 to 2016 were reviewed retrospectively. Sick leave data retrieved from the Swedish Social Insurance Agency were analysed for a sub-cohort of patients and matched controls. Cox regression was used for analysis of clinical outcomes. Logistic and conditional logistic regressions were used for sick leave analysis. RESULTS A total of 10.6% of patients died and 3.4% received liver transplantation over a median follow-up time of 5.7 years. UDCA-untreated patients (HR 3.62 (95%CI 2.02-6.49)) and UDCA non-responders (HR 3.78 (95% CI 1.87-7.66)) had higher mortality or transplantation rates than UDCA responders. Patients with PBC had higher odds of sick leave (OR 2.50; 95% CI 1.69-3.70) than matched controls. Untreated patients were more likely to be on sick leave (OR 3.22; 95% CI 1.12-9.25) two years after diagnosis than UDCA responders. CONCLUSION Both untreated patients and UDCA non-responders had lower liver transplantation-free survival rates than UDCA responders. Patients with PBC were more likely to be on sick leave compared to matched controls from the general population.
Collapse
Affiliation(s)
- Ida Henriksson
- Department of Internal Medicine, Division of Gastroenterology, Örebro University Hospital, Örebro, Sweden
| | - Ruzan Udumyan
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Emma Nilsson
- Department of Clinical Sciences, Gastroenterology Division, Skåne University Hospital, Lund, Sweden
| | - Kristina Önnerhag
- Department of Gastroenterology and Hepatology, Skåne University Hospital, Malmö, Sweden
| | - Fredrik Rorsman
- Department of Gastroenterology and Hepatology, Uppsala University Hospital, Uppsala, Sweden
| | - Mårten Werner
- Department of Public Health and Clinical Medicine, Umeå University Hospital, Umeå, Sweden
| | - Hanns-Ulrich Marschall
- Sahlgrenska Academy, Institute of Medicine, Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Staffan Wahlin
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Nils Nyhlin
- Department of Internal Medicine, Division of Gastroenterology, Örebro University Hospital, Örebro, Sweden
| | | |
Collapse
|
11
|
Efe C, Kulkarni AV, Terziroli Beretta-Piccoli B, Magro B, Stättermayer A, Cengiz M, Clayton-Chubb D, Lammert C, Bernsmeier C, Gül Ö, la Tijera FHD, Anders M, Lytvyak E, Akın M, Purnak T, Liberal R, Peralta M, Ebik B, Duman S, Demir N, Balaban Y, Urzua Á, Contreras F, Venturelli MG, Bilgiç Y, Medina A, Girala M, Günşar F, Londoño MC, Androutsakos T, Kisch A, Yurci A, Güzelbulut F, Çağın YF, Avcı E, Akyıldız M, Dindar-Demiray EK, Harputluoğlu M, Kumar R, Satapathy SK, Mendizabal M, Silva M, Fagiuoli S, Roberts SK, Soylu NK, Idilman R, Yoshida EM, Montano-Loza AJ, Dalekos GN, Ridruejo E, Schiano TD, Wahlin S. Liver injury after SARS-CoV-2 vaccination: Features of immune-mediated hepatitis, role of corticosteroid therapy and outcome. Hepatology 2022; 76:1576-1586. [PMID: 35567545 PMCID: PMC9348326 DOI: 10.1002/hep.32572] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [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: 02/28/2022] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS A few case reports of autoimmune hepatitis-like liver injury have been reported after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. We evaluated clinical features, treatment response and outcomes of liver injury following SARS-CoV-2 vaccination in a large case series. APPROACH AND RESULTS We collected data from cases in 18 countries. The type of liver injury was assessed with the R-value. The study population was categorized according to features of immune-mediated hepatitis (positive autoantibodies and elevated immunoglobulin G levels) and corticosteroid therapy for the liver injury. We identified 87 patients (63%, female), median age 48 (range: 18-79) years at presentation. Liver injury was diagnosed a median 15 (range: 3-65) days after vaccination. Fifty-one cases (59%) were attributed to the Pfizer-BioNTech (BNT162b2) vaccine, 20 (23%) cases to the Oxford-AstraZeneca (ChAdOX1 nCoV-19) vaccine and 16 (18%) cases to the Moderna (mRNA-1273) vaccine. The liver injury was predominantly hepatocellular (84%) and 57% of patients showed features of immune-mediated hepatitis. Corticosteroids were given to 46 (53%) patients, more often for grade 3-4 liver injury than for grade 1-2 liver injury (88.9% vs. 43.5%, p = 0.001) and more often for patients with than without immune-mediated hepatitis (71.1% vs. 38.2%, p = 0.003). All patients showed resolution of liver injury except for one man (1.1%) who developed liver failure and underwent liver transplantation. Steroid therapy was withdrawn during the observation period in 12 (26%) patients after complete biochemical resolution. None had a relapse during follow-up. CONCLUSIONS SARS-CoV-2 vaccination can be associated with liver injury. Corticosteroid therapy may be beneficial in those with immune-mediated features or severe hepatitis. Outcome was generally favorable, but vaccine-associated liver injury led to fulminant liver failure in one patient.
Collapse
Affiliation(s)
- Cumali Efe
- Department of GastroenterologyHarran University HospitalŞanlıurfaTurkey
| | - Anand V Kulkarni
- Department of Hepatology and Liver TransplantationAsian Institute of Gastroenterology HospitalsHyderabadIndia
| | | | - Bianca Magro
- Gastroenterology Hepatology and TransplantationASST Papa Giovanni XXIII-BergamoBergamoItaly
| | - Albert Stättermayer
- Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Mustafa Cengiz
- Department of GastroenterologyGülhane Training and Research HospitalAnkaraTurkey
| | | | - Craig Lammert
- Department of Medicine IndianaUniversity School of MedicineIndianapolisIndianaUSA
| | - Christine Bernsmeier
- Department of BiomedicineUniversity of BaselBaselSwitzerland.,University Centre for Gastrointestinal and Liver DiseasesBaselSwitzerland
| | - Özlem Gül
- Department of GastroenterologyKırıkkale UniversityKırıkkaleTurkey
| | | | - Margarita Anders
- Hepatology and Liver Transplant UnitHospital AlemánCiudad Autónoma de Buenos AiresArgentina
| | - Ellina Lytvyak
- Division of Gastroenterology and Liver UnitUniversity of AlbertaEdmontonAlbertaCanada
| | - Mete Akın
- Department of GastroenterologyAkdeniz University Faculty of MedicineAntalyaTurkey
| | - Tugrul Purnak
- Division of GastroenterologyHepatology and NutritionMcGovern Medical SchoolHoustonTexasUSA
| | - Rodrigo Liberal
- Gastroenterology and Hepatology DepartmentCentro Hospitalar e Universitário de São JoãoPortoPortugal.,World Gastroenterology Organization (WGO) Porto Training CenterPortoPortugal
| | - Mirta Peralta
- Hepatology SectionHospital Francisco J MuñizCiudad Autónoma de Buenos AiresArgentina.,Latin American Liver Research Educational and Awareness Network (LALREAN)PilarArgentina
| | - Berat Ebik
- Department of GastroenterologyGazi Yaşargil Education and Research HospitalDiyarbakirTurkey
| | - Serkan Duman
- Department of GastroenterologyAnkara University Medical FacultyAnkaraTurkey
| | - Nurhan Demir
- Department of GastroenterologyHaseki Training and Research HospitalIstanbulTurkey
| | - Yasemin Balaban
- Department of GastroenterologyFaculty of MedicineHacettepe UniversityAnkaraTurkey
| | - Álvaro Urzua
- Gastroenterology and Hepatology UnitHospital Clínico Universidad de ChileSantiago de ChileChile
| | | | | | - Yılmaz Bilgiç
- Department of GastroenterologyInönü University School of MedicineMalatyaTurkey
| | - Adriana Medina
- Gastroenterology and Hepatology UnitHospital de Clínicas, Universidad Nacional de AsunciónSan LorenzoParaguay
| | - Marcos Girala
- Gastroenterology and Hepatology UnitHospital de Clínicas, Universidad Nacional de AsunciónSan LorenzoParaguay
| | - Fulya Günşar
- Department of GastroenterologyEge University School of MedicineİzmirTurkey
| | | | - Theodoros Androutsakos
- Department of PathophysiologyNational and Kapodistrian University of AthensMedical SchoolAthensGreece
| | - Ayelen Kisch
- Hepatology SectionHospital Bonorino UdaondoCiudad Autónoma de Buenos AiresArgentina
| | - Alper Yurci
- Department of GastroenterologyErciyes University School of MedicineKayseriTurkey
| | - Fatih Güzelbulut
- Department of GastroenterologyHaydarpaşa Numune Education and Research HospitalİstanbulTurkey
| | - Yasir Furkan Çağın
- Department of GastroenterologyInönü University School of MedicineMalatyaTurkey
| | - Enver Avcı
- Department of GastroenterologyKTO Karatay University Medical School Affiliated Konya Medicana HospitalKonyaTurkey
| | - Murat Akyıldız
- Department of GastroenterologyKoc University School of MedicineIstanbulTurkey
| | | | - Murat Harputluoğlu
- Department of GastroenterologyInönü University School of MedicineMalatyaTurkey
| | - Rahul Kumar
- Department of Gastroenterology and HepatologyChangi General HospitalMedicine Academic Clinical ProgrammeSing Health Duke-NUS Academic Medical CentreSingapore
| | - Sanjaya K Satapathy
- Department of Internal MedicineDonald and Barbara Zucker School of MedicineNorthwell HealthManhassetNew YorkUSA
| | - Manuel Mendizabal
- Latin American Liver Research Educational and Awareness Network (LALREAN)PilarArgentina.,Hepatology and Liver Transplant UnitHospital Universitario AustralPilarArgentina
| | - Marcelo Silva
- Latin American Liver Research Educational and Awareness Network (LALREAN)PilarArgentina.,Hepatology and Liver Transplant UnitHospital Universitario AustralPilarArgentina
| | - Stefano Fagiuoli
- Gastroenterology Hepatology and TransplantationASST Papa Giovanni XXIII-BergamoBergamoItaly
| | - Stuart K Roberts
- Department of GastroenterologyAlfred HealthMelbourneVictoriaAustralia.,Central Clinical SchoolDepartment of MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Neşe Karadağ Soylu
- Department of PathologyInönü University Faculty of MedicineMalatyaTurkey
| | - Ramazan Idilman
- Department of GastroenterologyAnkara University Medical FacultyAnkaraTurkey
| | - Eric M Yoshida
- Division of GastroenterologyUniversity of British Columbia and Vancouver General HospitalVancouverBritish ColumbiaCanada
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver UnitUniversity of AlbertaEdmontonAlbertaCanada
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal MedicineNational Expertise Center of Greece in Autoimmune Liver DiseasesGeneral University Hospital of LarissaLarissaGreece.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER)General University Hospital of LarissaLarissaGreece
| | - Ezequiel Ridruejo
- Latin American Liver Research Educational and Awareness Network (LALREAN)PilarArgentina.,Hepatology and Liver Transplant UnitHospital Universitario AustralPilarArgentina.,Hepatology SectionDepartment of MedicineCentro de Educación Médica e Investigaciones Clínicas, CEMICCiudad Autónoma de Buenos AiresArgentina
| | - Thomas D Schiano
- Division of Liver Diseasesthe Mount Sinai Medical CenterNew YorkNew YorkUSA
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI DiseasesKarolinska Institutet and Karolinska University HospitalStockholmSweden
| |
Collapse
|
12
|
Efe C, Taşçılar K, Gerussi A, Bolis F, Lammert C, Ebik B, Stättermayer AF, Cengiz M, Gökçe DT, Cristoferi L, Peralta M, Massoumi H, Montes P, Cerda E, Rigamonti C, Yapalı S, Adali G, Çalışkan AR, Balaban Y, Eren F, Eşkazan T, Barutçu S, Lytvyak E, Zazueta GM, Kayhan MA, Heurgue-Berlot A, De Martin E, Yavuz A, Bıyık M, Narro GC, Duman S, Hernandez N, Gatselis NK, Aguirre J, Idilman R, Silva M, Mendizabal M, Atay K, Güzelbulut F, Dhanasekaran R, Montano-Loza AJ, Dalekos GN, Ridruejo E, Invernizzi P, Wahlin S. SARS-CoV-2 vaccination and risk of severe COVID-19 outcomes in patients with autoimmune hepatitis. J Autoimmun 2022; 132:102906. [PMID: 36088883 PMCID: PMC9448709 DOI: 10.1016/j.jaut.2022.102906] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/24/2022] [Accepted: 08/26/2022] [Indexed: 02/06/2023]
Abstract
Background Data regarding outcome of Coronavirus disease 2019 (COVID-19) in vaccinated patients with autoimmune hepatitis (AIH) are lacking. We evaluated the outcome of COVID-19 in AIH patients who received at least one dose of Pfizer- BioNTech (BNT162b2), Moderna (mRNA-1273) or AstraZeneca (ChAdOx1-S) vaccine. Patients and methods We performed a retrospective study on AIH patients with COVID-19. The outcomes of AIH patients who had acute respiratory syndrome coronavirus 2 (SARS-CoV-2) breakthrough infection after at least one dose of COVID-19 vaccine were compared to unvaccinated patients with AIH. COVID-19 outcome was classified according to clinical state during the disease course as: (i) no hospitalization, (ii) hospitalization without oxygen supplementation, (iii) hospitalization with oxygen supplementation by nasal cannula or mask, (iv) intensive care unit (ICU) admission with non-invasive mechanical ventilation, (v) ICU admission with invasive mechanical ventilation or (vi) death, and data was analyzed using ordinal logistic regression. Results We included 413 (258 unvaccinated and 155 vaccinated) patients (81%, female) with a median age of 52 (range: 17–85) years at COVID-19 diagnosis. The rates of hospitalization were (36.4% vs. 14.2%), need for any supplemental oxygen (29.5% vs. 9%) and mortality (7% vs. 0.6%) in unvaccinated and vaccinated AIH patients with COVID-19. Having received at least one dose of SARS-CoV-2 vaccine was associated with a significantly lower risk of worse COVID-19 severity, after adjusting for age, sex, comorbidities and presence of cirrhosis (adjusted odds ratio [aOR] 0.18, 95% confidence interval [CI], 0.10–0.31). Overall, vaccination against SARS-CoV-2 was associated with a significantly lower risk of mortality from COVID-19 (aOR 0.20, 95% CI 0.11–0.35). Conclusions SARS-CoV-2 vaccination significantly reduced the risk of COVID-19 severity and mortality in patients with AIH.
Collapse
Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Harran University Hospital, Şanlıurfa, Turkey.
| | - Koray Taşçılar
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Alessio Gerussi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Francesca Bolis
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Craig Lammert
- Department of Medicine Indiana, University School of Medicine, Indianapolis, IN, USA
| | - Berat Ebik
- Department of Gastroenterology, Gazi Yaşargil Education and Research Hospital, Diyarbakir, Turkey
| | - Albert Friedrich Stättermayer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mustafa Cengiz
- Department of Gastroenterology, Gülhane Training and Research Hospital, Ankara, Turkey
| | | | - Laura Cristoferi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Mirta Peralta
- Hepatology Section, Hospital Francisco J Muñiz, Ciudad Autónoma de Buenos Aires, Argentina; Latin American Liver Research Educational and Awareness Network (LALREAN), Pilar, Argentina
| | - Hatef Massoumi
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Pedro Montes
- Gastroenterology and Hepatology Unit, Hospital Nacional Daniel A. Carrión, Callao, Peru
| | - Eira Cerda
- Hepatology Unit, Hospital Militar Central de México, Ciudad de México, Mexico
| | - Cristina Rigamonti
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy; Division of Internal Medicine, "AOU Maggiore della Carità", Novara, Italy
| | - Suna Yapalı
- Department of Gastroenterology, Acıbadem University School of Medicine, İstanbul, Turkey
| | - Gupse Adali
- Department of Gastroenterology, Umraniye Education and Research Hospital, Istanbul, Turkey
| | - Ali Rıza Çalışkan
- Department of Gastroenterology, Adıyaman University, Adıyaman, Turkey
| | - Yasemin Balaban
- Department of Gastroenterology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Fatih Eren
- Department of Gastroenterology, Medical Faculty, Uludag University, Bursa, Turkey
| | - Tuğçe Eşkazan
- Department of Gastroenterology, Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Sezgin Barutçu
- Department of Gastroenterology, University of Gaziantep Medical Faculty, Gaziantep, Turkey
| | - Ellina Lytvyak
- University of Alberta Division of Gastroenterology and Liver Unit, Edmonton, AB, Canada
| | - Godolfino Miranda Zazueta
- Gastroenterology Unit, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - Meral Akdogan Kayhan
- Department of Gastroenterology, Gülhane Training and Research Hospital, Ankara, Turkey
| | | | - Eleonora De Martin
- Centre Hepato-Biliaire, Hôpital Paul-Brousse, FHU Hepatinov, INSERM Unit UMR 1193, Univ Paris-Saclay, France
| | - Ahmet Yavuz
- Division of Gastroenterology, Necmettin Erbakan University, Meram School of Medicine, Konya, Turkey
| | - Murat Bıyık
- Division of Gastroenterology, Necmettin Erbakan University, Meram School of Medicine, Konya, Turkey
| | - Graciela Castro Narro
- Gastroenterology Unit, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, Mexico
| | - Serkan Duman
- Department of Gastroenterology, Ankara University Medical Faculty, Ankara, Turkey
| | - Nelia Hernandez
- Gastroenterology and Hepatology Unit, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Greece; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Jonathan Aguirre
- Hepatology Unit, Hospital Ángeles Pedregal, Ciudad de México, Mexico
| | - Ramazan Idilman
- Department of Gastroenterology, Ankara University Medical Faculty, Ankara, Turkey
| | - Marcelo Silva
- Latin American Liver Research Educational and Awareness Network (LALREAN), Pilar, Argentina; Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina
| | - Manuel Mendizabal
- Latin American Liver Research Educational and Awareness Network (LALREAN), Pilar, Argentina; Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina
| | - Kadri Atay
- Department of Gastroenterology, Mardin State Hospital, Mardin, Turkey
| | - Fatih Güzelbulut
- Department of Gastroenterology, Haydarpaşa Numune Education and Research Hospital, İstanbul, Turkey
| | | | - Aldo J Montano-Loza
- University of Alberta Division of Gastroenterology and Liver Unit, Edmonton, AB, Canada
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Greece; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), General University Hospital of Larissa, Larissa, Greece
| | - Ezequiel Ridruejo
- Latin American Liver Research Educational and Awareness Network (LALREAN), Pilar, Argentina; Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina; Hepatology Section, Department of Medicine, Centro de Educación Médica e Investigaciones Clínicas, CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
13
|
Norén S, Bengtsson B, Hagström H, Ljunggren G, Wahlin S. Hepatocellular carcinoma in Stockholm, Sweden 2003-2018: a population-based cohort study. Scand J Gastroenterol 2022; 57:1080-1088. [PMID: 35605144 DOI: 10.1080/00365521.2022.2062257] [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] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Available epidemiological data on hepatocellular carcinoma (HCC) originate mainly from centre-based or disease-specific cohorts and may not reflect the general population. This population-based register study presents the incidence, aetiologies, treatments, survival, and differences related to sex or socioeconomic status in patients with HCC from Stockholm, which constitutes more than a fifth of the Swedish population. METHODS ICD-10 codes identified incident HCC cases in the regional administrative health care database 2003-2018. Administrative coding on diseases, socioeconomic status, and dispensed drugs were used to identify risk factors and therapies. Two validation analyses 2014-2015 studied the correctness of register-based aetiologies and reasons for providing only best supportive care (BSC). RESULTS We identified 2,245 incident cases of HCC. The incidence increased from 6 to 7.5 per 100,000 inhabitants over the time-period. The most common aetiologies were hepatitis C (26%), non-alcoholic fatty liver disease (22%), and alcohol-related liver disease (19%). Five-year survival probability was 79% after liver transplantation, 60% after resection, and 35% after ablation but <10% for chemoembolization, Sorafenib, and BSC. The proportion receiving any treatment increased but half of the patients only received BSC. At least 14% of potentially treatable HCC (surveillance indicated but not performed) received only BSC 2014-2015. We found no significant differences in treatments or outcomes between socioeconomic groups. CONCLUSIONS The incidence of HCC is rising in Stockholm, Sweden but is still low by global comparison. Near half of all patients still receive only BSC and study data suggest that surveillance practices are incomplete.
Collapse
Affiliation(s)
- Sanna Norén
- Division of Hepatology, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Bonnie Bengtsson
- Division of Hepatology, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.,Unit of Gastroenterology and Rheumatology, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Hannes Hagström
- Division of Hepatology, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.,Unit of Gastroenterology and Rheumatology, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Division of Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Gunnar Ljunggren
- Division of Family Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.,Academic Primary Health Care Centre, Region Stockholm Region, Stockholm, Sweden
| | - Staffan Wahlin
- Division of Hepatology, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.,Unit of Gastroenterology and Rheumatology, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
14
|
Bayhan I, Wahlin S, Efe C. Editorial: acute severe autoimmune hepatitis-a diagnostic and therapeutic dilemma. Aliment Pharmacol Ther 2022; 56:170-171. [PMID: 35689316 DOI: 10.1111/apt.16981] [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)
- Ibrahim Bayhan
- Department of Gastroenterology, Harran University, Şanlıurfa, Turkey
| | - Staffan Wahlin
- Hepatology Division, Department of Upper Gastrointestinal Tract, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Cumali Efe
- Department of Gastroenterology, Harran University, Şanlıurfa, Turkey
| |
Collapse
|
15
|
Lissing M, Vassiliou D, Floderus Y, Harper P, Bottai M, Kotopouli M, Hagström H, Sardh E, Wahlin S. Risk of primary liver cancer in acute hepatic porphyria patients: A matched cohort study of 1244 individuals. J Intern Med 2022; 291:824-836. [PMID: 35112415 PMCID: PMC9311710 DOI: 10.1111/joim.13463] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The acute hepatic porphyrias (AHP) are associated with a risk of primary liver cancer (PLC), but risk estimates are unclear, and what AHP characteristics that predict PLC risk are unknown. In this register-based, matched cohort study, we assessed the PLC risk in relation to biochemical and clinical porphyria severity, genotype, age, and sex. METHODS All patients in the Swedish porphyria register with acute intermittent porphyria (AIP), variegate porphyria (VP), or hereditary coproporphyria (HCP) during 1987-2015 were included. This AHP cohort was compared with age-, sex-, and county-matched reference individuals from the general population. National register-based hospital admissions for AHP were used to indicate the clinical severity. For AIP, the most common AHP type, patients were stratified by genotype and urinary porphobilinogen (U-PBG). Incident PLC data were collected from national health registers. RESULTS We identified 1244 individuals with AHP (1063 [85%] AIP). During a median follow-up of 19.5 years, we identified 108 incident PLC cases, including 83 AHP patients (6.7%) and 25 of 12,333 reference individuals (0.2%). The adjusted hazard ratio for AHP-PLC was 38.0 (95% confidence interval: 24.3-59.3). Previously elevated U-PBG and hospitalizations for porphyria, but not AIP genotype or sex, were associated with increased PLC risk. Patients aged >50 years with previously elevated U-PBG (n = 157) had an annual PLC incidence of 1.8%. CONCLUSION This study confirmed a high PLC risk and identified a strong association with clinical and biochemical AIP activity. Regular PLC surveillance is motivated in patients older than 50 years with a history of active AIP.
Collapse
Affiliation(s)
- Mattias Lissing
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Daphne Vassiliou
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden.,Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Ylva Floderus
- Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Pauline Harper
- Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Matteo Bottai
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Marianna Kotopouli
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hannes Hagström
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Unit for Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Eliane Sardh
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden.,Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
16
|
Bengtsson B, Widman L, Wahlin S, Stål P, Björkström NK, Hagström H. The risk of hepatocellular carcinoma in cirrhosis differs by etiology, age and sex: A Swedish nationwide population‐based cohort study. United European Gastroenterol J 2022; 10:465-476. [PMID: 35491484 PMCID: PMC9189467 DOI: 10.1002/ueg2.12238] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 04/14/2022] [Indexed: 02/06/2023] Open
Affiliation(s)
- Bonnie Bengtsson
- Division of Hepatology Department of Upper GI Diseases Karolinska University Hospital Stockholm Sweden
- Unit of Gastroenterology and Rheumatology Department of Medicine, Huddinge Karolinska Institutet Stockholm Sweden
| | - Linnea Widman
- Division of Biostatistics Institute of Environmental Medicine Karolinska Institutet Stockholm Sweden
| | - Staffan Wahlin
- Division of Hepatology Department of Upper GI Diseases Karolinska University Hospital Stockholm Sweden
- Unit of Gastroenterology and Rheumatology Department of Medicine, Huddinge Karolinska Institutet Stockholm Sweden
| | - Per Stål
- Division of Hepatology Department of Upper GI Diseases Karolinska University Hospital Stockholm Sweden
- Unit of Gastroenterology and Rheumatology Department of Medicine, Huddinge Karolinska Institutet Stockholm Sweden
| | - Niklas K. Björkström
- Center for Infectious Medicine Department of Medicine Huddinge Karolinska Institutet Karolinska University Hospital Stockholm Sweden
| | - Hannes Hagström
- Division of Hepatology Department of Upper GI Diseases Karolinska University Hospital Stockholm Sweden
- Unit of Gastroenterology and Rheumatology Department of Medicine, Huddinge Karolinska Institutet Stockholm Sweden
- Clinical Epidemiology Unit Department of Medicine, Solna Karolinska Institutet Stockholm Sweden
| |
Collapse
|
17
|
Pape S, Snijders RJALM, Gevers TJG, Chazouilleres O, Dalekos GN, Hirschfield GM, Lenzi M, Trauner M, Manns MP, Vierling JM, Montano-Loza AJ, Lohse AW, Schramm C, Drenth JPH, Heneghan MA, Alvarez F, Andrade R, Arikan C, Assis D, Bardou-Jacquet E, Biewenga M, Cancado E, Cazzagon N, Chazouillères O, Colloredo G, Cuarterolo M, Dalekos G, Debray D, Robles-Díaz M, Drenth J, Dyson J, Efe C, Engel B, Ferri S, Fontana R, Gatselis N, Gerussi A, Halilbasic E, Halliday N, Heneghan M, Hirschfield G, van Hoek B, Hørby Jørgensen M, Indolfini G, Iorio R, Jeong S, Jones D, Kelly D, Kerkar N, Lacaille F, Lammert C, Leggett B, Lenzi M, Levy C, Liberal R, Lleo A, Lohse A, Ines Lopez S, de Martin E, McLin V, Mieli-Vergani G, Milkiewicz P, Mohan N, Muratori L, Nebbia G, van Nieuwkerk C, Oo Y, Ortega A, Páres A, Pop T, Pratt D, Purnak T, Ranucci G, Rushbrook S, Schramm C, Stättermayer A, Swain M, Tanaka A, Taubert R, Terrabuio D, Terziroli B, Trauner M, Valentino P, van den Brand F, Villamil A, Wahlin S, Ytting H, Zachou K, Zeniya M. Systematic review of response criteria and endpoints in autoimmune hepatitis by the International Autoimmune Hepatitis Group. J Hepatol 2022; 76:841-849. [PMID: 35066089 DOI: 10.1016/j.jhep.2021.12.041] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [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: 04/09/2021] [Revised: 11/18/2021] [Accepted: 12/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Autoimmune hepatitis (AIH) has been well characterised and codified through the development of diagnostic criteria. These criteria have been adapted and simplified and are widely used in clinical practice. However, there is a need to update and precisely define the criteria for both treatment response and treatment. METHODS A systematic review was performed and a modified Delphi consensus process was used to identify and redefine the response criteria in autoimmune hepatitis. RESULTS The consensus process initiated by the International Autoimmune Hepatitis Group proposes that the term 'complete biochemical response' defined as 'normalization of serum transaminases and IgG below the upper limit of normal' be adopted to include a time point at 6 months after initiation of treatment. An insufficient response by 6 months was a failure to meet the above definition. Non-response was defined as '<50% decrease of serum transaminases within 4 weeks after initiation of treatment'. Remission is defined as liver histology with a Hepatitis Activity Index <4/18. Intolerance to treatment was agreed to stand for 'any adverse event possibly related to treatment leading to potential drug discontinuation'. CONCLUSIONS These definitions provide a simple and reproducible framework to define treatment response and non-response, irrespective of the therapeutic intervention. A consensus on endpoints is urgently required to set a global standard for the reporting of study results and to enable inter-study comparisons. Future prospective database studies are needed to validate these endpoints. LAY SUMMARY Consensus among international experts on response criteria and endpoints in autoimmune hepatitis is lacking. A consensus on endpoints is urgently required to set a global standard for the reporting of study results and to enable the comparison of results between clinical trials. Therefore, the International Autoimmune Hepatitis Group (IAIHG) herein presents a statement on 5 agreed response criteria and endpoints: complete biochemical response, insufficient response, non-response, remission, and intolerance to treatment, which can be used to guide future reporting.
Collapse
Affiliation(s)
- Simon Pape
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Romée J A L M Snijders
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Tom J G Gevers
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht 6229HX, The Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Oliver Chazouilleres
- Hepatology Department, Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, Saint-Antoine Hospital Assistance Publique-Hôpitaux de Paris, Paris, France; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, University of Thessaly Medical School, Larissa, Greece
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada
| | - Marco Lenzi
- Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - John M Vierling
- Departments of Medicine and Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Hepatology, University of Alberta Hospital, Edmonton, Canada
| | - Ansgar W Lohse
- 1(st) Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Christoph Schramm
- 1(st) Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands; European Reference Network on Hepatological Diseases (ERN RARE-LIVER)
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom; European Reference Network on Hepatological Diseases (ERN RARE-LIVER).
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Efe C, Lammert C, Taşçılar K, Dhanasekaran R, Ebik B, Higuera-de la Tijera F, Calışkan AR, Peralta M, Gerussi A, Massoumi H, Catana AM, Purnak T, Rigamonti C, Aldana AJG, Khakoo N, Nazal L, Frager S, Demir N, Irak K, Melekoğlu-Ellik Z, Kacmaz H, Balaban Y, Atay K, Eren F, Alvares-da-Silva MR, Cristoferi L, Urzua Á, Eşkazan T, Magro B, Snijders R, Barutçu S, Lytvyak E, Zazueta GM, Demirezer-Bolat A, Aydın M, Heurgue-Berlot A, De Martin E, Ekin N, Yıldırım S, Yavuz A, Bıyık M, Narro GC, Kıyıcı M, Akyıldız M, Kahramanoğlu-Aksoy E, Vincent M, Carr RM, Günşar F, Reyes EC, Harputluoğlu M, Aloman C, Gatselis NK, Üstündağ Y, Brahm J, Vargas NCE, Güzelbulut F, Garcia SR, Aguirre J, Anders M, Ratusnu N, Hatemi I, Mendizabal M, Floreani A, Fagiuoli S, Silva M, Idilman R, Satapathy SK, Silveira M, Drenth JPH, Dalekos GN, N Assis D, Björnsson E, Boyer JL, Yoshida EM, Invernizzi P, Levy C, Montano-Loza AJ, Schiano TD, Ridruejo E, Wahlin S. Effects of immunosuppressive drugs on COVID-19 severity in patients with autoimmune hepatitis. Liver Int 2022; 42:607-614. [PMID: 34846800 DOI: 10.1111/liv.15121] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [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: 09/02/2021] [Revised: 11/25/2021] [Accepted: 11/28/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND We investigated associations between baseline use of immunosuppressive drugs and severity of Coronavirus Disease 2019 (COVID-19) in autoimmune hepatitis (AIH). PATIENTS AND METHODS Data of AIH patients with laboratory confirmed COVID-19 were retrospectively collected from 15 countries. The outcomes of AIH patients who were on immunosuppression at the time of COVID-19 were compared to patients who were not on AIH medication. The clinical courses of COVID-19 were classified as (i)-no hospitalization, (ii)-hospitalization without oxygen supplementation, (iii)-hospitalization with oxygen supplementation by nasal cannula or mask, (iv)-intensive care unit (ICU) admission with non-invasive mechanical ventilation, (v)-ICU admission with invasive mechanical ventilation or (vi)-death and analysed using ordinal logistic regression. RESULTS We included 254 AIH patients (79.5%, female) with a median age of 50 (range, 17-85) years. At the onset of COVID-19, 234 patients (92.1%) were on treatment with glucocorticoids (n = 156), thiopurines (n = 151), mycophenolate mofetil (n = 22) or tacrolimus (n = 16), alone or in combinations. Overall, 94 (37%) patients were hospitalized and 18 (7.1%) patients died. Use of systemic glucocorticoids (adjusted odds ratio [aOR] 4.73, 95% CI 1.12-25.89) and thiopurines (aOR 4.78, 95% CI 1.33-23.50) for AIH was associated with worse COVID-19 severity, after adjusting for age-sex, comorbidities and presence of cirrhosis. Baseline treatment with mycophenolate mofetil (aOR 3.56, 95% CI 0.76-20.56) and tacrolimus (aOR 4.09, 95% CI 0.69-27.00) were also associated with more severe COVID-19 courses in a smaller subset of treated patients. CONCLUSION Baseline treatment with systemic glucocorticoids or thiopurines prior to the onset of COVID-19 was significantly associated with COVID-19 severity in patients with AIH.
Collapse
Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Harran University Hospital, Şanlıurfa, Turkey
| | - Craig Lammert
- Department of Medicine Indiana, University School of Medicine Indianapolis, Indianapolis, Indiana, USA
| | - Koray Taşçılar
- Department of Medicine 3-Rheumatology and Immunology, Friedrich-Alexander University (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Renumathy Dhanasekaran
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, California, USA
| | - Berat Ebik
- Department of Gastroenterology, Gazi Yaşargil Education and Research Hospital, Diyarbakir, Turkey
| | | | - Ali R Calışkan
- Department of Gastroenterology, Adıyaman University, Adıyaman, Turkey
| | - Mirta Peralta
- Hepatology Section, Hospital Francisco J Muñiz, Ciudad Autónoma de Buenos Aires, Argentina.,Latin American Liver Research Educational and Awareness Network (LALREAN), Pilar, Argentina
| | - Alessio Gerussi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Hatef Massoumi
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Andreea M Catana
- Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Tugrul Purnak
- Division of Gastroenterology, Hepatology and Nutrition, McGovern Medical School, Houston, Texas, USA
| | - Cristina Rigamonti
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy.,Division of Internal Medicine, "AOU Maggiore della Carità", Novara, Italy
| | - Andres J G Aldana
- Gastroenterology and Hepatology Unit, Fundación Santa Fe de Bogotá y universidad de Los Andes, Bogotá, Colombia
| | - Nidah Khakoo
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Leyla Nazal
- Gastroenterology and Hepatology Unit, Clínica Las Condes, Santiago de Chile, Chile
| | - Shalom Frager
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Nurhan Demir
- Department of Gastroenterology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Kader Irak
- Department of Gastroenterology, SBU Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | | | - Hüseyin Kacmaz
- Department of Gastroenterology, Adıyaman University, Adıyaman, Turkey
| | - Yasemin Balaban
- Department of Gastroenterology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kadri Atay
- Departmant of Gastroenterology, Mardin State Hospital, Mardin, Turkey
| | - Fatih Eren
- Departmant of Gastroenterology, Ordu State Hospital, Ordu, Turkey
| | - Mario R Alvares-da-Silva
- Gastroenterology and Hepatology Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Laura Cristoferi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Álvaro Urzua
- Gastroenterology and Hepatology Unit. Hospital Clínico, Universidad de Chile, Santiago de Chile, Chile
| | - Tuğçe Eşkazan
- Department of Gastroenterology, Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Bianca Magro
- Gastroenterology Hepatology and Transplantation, ASST Papa Giovanni XXIII-Bergamo, Bergamo, Italy
| | - Romee Snijders
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Nijmegen, The Netherlands
| | - Sezgin Barutçu
- Department of Gastroenterology, University of Gaziantep Medical Faculty, Gaziantep, Turkey
| | - Ellina Lytvyak
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Godolfino M Zazueta
- Gastroenterology Unit, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, México
| | | | - Mesut Aydın
- School of Medicine, Department of Gastroenterology, Van Yuzuncu Yil University, Van, Turkey
| | | | - Eleonora De Martin
- Centre Hepato-Biliaire, Hôpital Paul-Brousse, FHU Hepatinov, INSERM Unit UMR 1193, Univ Paris-Saclay, Gif-sur-Yvette, France
| | - Nazım Ekin
- Department of Gastroenterology, Gazi Yaşargil Education and Research Hospital, Diyarbakir, Turkey
| | - Sümeyra Yıldırım
- Department of Gastroenterology, Erciyes Hospital, Kayseri, Turkey
| | - Ahmet Yavuz
- Division of Gastroenterology, Meram School of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Murat Bıyık
- Division of Gastroenterology, Meram School of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Graciela C Narro
- Gastroenterology Unit, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Ciudad de México, México
| | - Murat Kıyıcı
- Department of Gastroenterology, Medical Faculty, Uludag University, Bursa, Turkey
| | - Murat Akyıldız
- Department of Gastroenterology, Koc University School of Medicine, Istanbul, Turkey
| | | | - Maria Vincent
- Department of Internal Medicine, Donald and Barbara Zucker School of Medicine, Northwell Health, Manhasset, NY, USA
| | - Rotonya M Carr
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fulya Günşar
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Eira C Reyes
- Hepatology Unit. Hospital Militar Central de México, Ciudad de México, México
| | - Murat Harputluoğlu
- Department of Gastroenterology, Inönü University School of Medicine, Malatya, Turkey
| | - Costica Aloman
- Section of Hepatology, Rush University Medical Center, Chicago, Illinois, USA
| | - Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Yücel Üstündağ
- Department of Gastroenterology, Bulent Ecevit University of Medicine, Zonguldak, Turkey
| | - Javier Brahm
- Gastroenterology Unit, Clínica Las Condes, Santiago, Chile
| | - Nataly C E Vargas
- Hepatology Unit Hospital Nacional Almanzor Aguinaga Asenjo, Chiclayo, Perú
| | - Fatih Güzelbulut
- Department of Gastroenterology, Haydarpaşa Numune Education and Research Hospital, İstanbul, Turkey
| | - Sandro R Garcia
- Gastroenterology Unit, Hospital Víctor Lazarte Echegaray, Trujillo, Perú
| | - Jonathan Aguirre
- Hepatology Unit, Hospital Ángeles Pedregal, Ciudad de México, México
| | - Margarita Anders
- Hepatology and Liver Transplant Unit, Hospital Alemán, Buenos Aires, Argentina
| | - Natalia Ratusnu
- Hepatology Unit, Hospital Regional de Ushuaia, Ushuaia, Argentina
| | - Ibrahim Hatemi
- Department of Gastroenterology, Cerrahpaşa School of Medicine, İstanbul, Turkey
| | - Manuel Mendizabal
- Latin American Liver Research Educational and Awareness Network (LALREAN), Pilar, Argentina.,Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina
| | - Annarosa Floreani
- Scientific Consultant IRCCS Negrar, Verona, Italy.,Senior Scholar, University of Padova, Padova, Italy
| | - Stefano Fagiuoli
- Gastroenterology Hepatology and Transplantation, ASST Papa Giovanni XXIII-Bergamo, Bergamo, Italy
| | - Marcelo Silva
- Latin American Liver Research Educational and Awareness Network (LALREAN), Pilar, Argentina.,Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina
| | - Ramazan Idilman
- Department of Gastroenterology, Ankara University Medical Faculty, Ankara, Turkey
| | - Sanjaya K Satapathy
- Department of Internal Medicine, Donald and Barbara Zucker School of Medicine, Northwell Health, Manhasset, NY, USA
| | - Marina Silveira
- Department of Medicine, Section of Digestive Diseases Yale School of Medicine, New Haven, Connecticut, USA
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Nijmegen, The Netherlands
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - David N Assis
- Department of Medicine, Section of Digestive Diseases Yale School of Medicine, New Haven, Connecticut, USA
| | - Einar Björnsson
- Department of Internal Medicine, Section of Gastroenterology, Landspitali University Hospital, Reykjavik, Iceland
| | - James L Boyer
- Department of Medicine, Section of Digestive Diseases Yale School of Medicine, New Haven, Connecticut, USA
| | - Eric M Yoshida
- Division of Gastroenterology, University of British Columbia and Vancouver General Hospital, Vancouver, Canada
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), San Gerardo Hospital, Monza, Italy
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Thomas D Schiano
- Division of Liver Diseases, The Mount Sinai Medical Center, New York, New York, USA
| | - Ezequiel Ridruejo
- Latin American Liver Research Educational and Awareness Network (LALREAN), Pilar, Argentina.,Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina.,Hepatology Section, Department of Medicine, Centro de Educación Médica e Investigaciones Clínicas, CEMIC, Ciudad Autónoma de Buenos Aires, Argentina
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
19
|
Abstract
BACKGROUND/AIMS Autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC) are the 3 main autoimmune liver diseases (AILDs). The epidemiology of AILD in Turkey is not known. To determine the scientific status, we performed a scientometric analysis of AILD-related original articles that originated from Turkey. MATERIALS AND METHODS We searched the Web of Science database, the Science Citation Index Expanded (SCI-E), and the Social Sciences Citation Index (SSCI) by using the keywords "autoimmune hepatitis," "primary biliary cholangitis/primary biliary cirrhosis," and "primary sclerosing cholangitis" in conjunction with "Turkey." A scientometric analysis was done on the search results. RESULTS We identified 117 AILD-related papers that were published in Turkey from 1997 to 2019. Among these, 70 case reports, letters, and reviews and 2 original articles that were not cited in SCI-E/SSCI were excluded. The remaining 45 original articles were further analyzed. These studies were related to AIH (n=22), PBC (n=7), PSC (n=9), PBC-AIH overlap (n=5), and others (n=2). Four of the publications originated in pediatric settings; 9 of 45 papers were published from 1997 to 2008 and 36 papers were published from 2009 to 2019. Most papers (75%) were reported from 5 centers; 9 papers (20%) were published in journals with an impact factor of 3 or higher. CONCLUSION The overall number and quality of AILD-related papers in Turkey are unexpectedly low, although a number of papers have received considerable international recognition. More epidemiologic, prospective, and multicenter research projects are warranted to advance AILD knowledge and to produce high-quality research from Turkey.
Collapse
Affiliation(s)
- Nurhan Demir
- Department of Gastroenterology, Diyarbakır Health Science University EAH, Diyarbakır
| | - Nazım Ekin
- Department of Gastroenterology, Diyarbakır Health Science University EAH, Diyarbakır
| | - Murat Torgutalp
- Department of rheumatology, Ankara University and Ibni-Sina Hospital, Ankara, Turkey
| | - Staffan Wahlin
- Hepatology Division, Centre for Digestive Diseases, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Cumali Efe
- Department of Gastroenterology, Harran University, Şanlıurfa, Turkey
| |
Collapse
|
20
|
Affiliation(s)
| | - Staffan Wahlin
- Hepatology DivisionDepartment of Upper GIKarolinska Institutet and Karolinska University HospitalStockholmSweden
| | - Cumali Efe
- Department of GastroenterologyHarran University HospitalŞanlıurfaTurkey
| |
Collapse
|
21
|
Wahlin S, Andersson J. Liver health literacy and social stigma of liver disease: A general population e-survey. Clin Res Hepatol Gastroenterol 2021; 45:101750. [PMID: 34175458 DOI: 10.1016/j.clinre.2021.101750] [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: 04/30/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Health literacy is increasingly recognized as an essential determinant for the health of the population. Liver patients report perceived stigma to be a considerable problem. Little is however known about liver health literacy in the general population and to what extent liver disease is considered stigmatizing in comparison with other chronic diseases. We aimed to explore these knowledge gaps. METHODS We performed an exploratory e-survey in a statistically representative sample of 500 Swedes from the general population. A questionnaire developed for this purpose investigated awareness, attention, knowledge and attitudes towards liver health and compared some aspects with other common health problems. FINDINGS Few worry (23%), think (28%), discuss with their doctor (31%) or hear about liver health in the news (19%). Few (18%) had a liver test in the last year and knew (23%) what is considered a normal liver test. More knew what is considered normal blood pressure (89%), blood sugar (74%) and BMI (73%). Few (22%) talk about liver health, mainly (50%) because abuse is presumed. Many (36%) believe that cirrhosis is only caused by alcohol, 31% that the liver produces urine and 21% that you can survive without a liver. Only mental illness (78%) and obesity (74%) were considered more stigmatizing than liver cirrhosis (61%). INTERPRETATION The study confirms often held views that liver health receives less attention than many other health areas. Knowledge about liver health is generally poor, and liver cirrhosis carries significant social stigma. Improving public awareness and knowledge about liver health, and thereby ameliorating stigma, should be essential parts of policy objectives and action plans to improve liver health in Europe. FUNDING This research was supported by a general grant from the Bengt Ihre Foundation.
Collapse
Affiliation(s)
- Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - Johanna Andersson
- Department of Medicine, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
22
|
Efe C, Wahlin S. Letter to the Editor: Reply to Autoimmune Hepatitis and Coronavirus Disease 2019: Disease Outcomes and Tacrolimus Use. Hepatol Commun 2021; 6:3272. [PMID: 34558846 PMCID: PMC8653226 DOI: 10.1002/hep4.1798] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Cumali Efe
- Department of GastroenterologyHarran University HospitalŞanlıurfaTurkey
| | - Staffan Wahlin
- Hepatology DivisionDepartment of Upper Gastrointestinal TractKarolinska Institutet and Karolinska University HospitalStockholmSweden
| |
Collapse
|
23
|
Efe C, Dhanasekaran R, Lammert C, Ebik B, Higuera‐de la Tijera F, Aloman C, Rıza Calışkan A, Peralta M, Gerussi A, Massoumi H, Catana AM, Torgutalp M, Purnak T, Rigamonti C, Gomez Aldana AJ, Khakoo N, Kacmaz H, Nazal L, Frager S, Demir N, Irak K, Ellik ZM, Balaban Y, Atay K, Eren F, Cristoferi L, Batıbay E, Urzua Á, Snijders R, Kıyıcı M, Akyıldız M, Ekin N, Carr RM, Harputluoğlu M, Hatemi I, Mendizabal M, Silva M, Idilman R, Silveira M, Drenth JP, Assis DN, Björnsson E, Boyer JL, Invernizzi P, Levy C, Schiano TD, Ridruejo E, Wahlin S. Outcome of COVID-19 in Patients With Autoimmune Hepatitis: An International Multicenter Study. Hepatology 2021; 73:2099-2109. [PMID: 33713486 PMCID: PMC8250536 DOI: 10.1002/hep.31797] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/01/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Data regarding outcome of COVID-19 in patients with autoimmune hepatitis (AIH) are lacking. APPROACH AND RESULTS We performed a retrospective study on patients with AIH and COVID-19 from 34 centers in Europe and the Americas. We analyzed factors associated with severe COVID-19 outcomes, defined as the need for mechanical ventilation, intensive care admission, and/or death. The outcomes of patients with AIH were compared to a propensity score-matched cohort of patients without AIH but with chronic liver diseases (CLD) and COVID-19. The frequency and clinical significance of new-onset liver injury (alanine aminotransferase > 2 × the upper limit of normal) during COVID-19 was also evaluated. We included 110 patients with AIH (80% female) with a median age of 49 (range, 18-85) years at COVID-19 diagnosis. New-onset liver injury was observed in 37.1% (33/89) of the patients. Use of antivirals was associated with liver injury (P = 0.041; OR, 3.36; 95% CI, 1.05-10.78), while continued immunosuppression during COVID-19 was associated with a lower rate of liver injury (P = 0.009; OR, 0.26; 95% CI, 0.09-0.71). The rates of severe COVID-19 (15.5% versus 20.2%, P = 0.231) and all-cause mortality (10% versus 11.5%, P = 0.852) were not different between AIH and non-AIH CLD. Cirrhosis was an independent predictor of severe COVID-19 in patients with AIH (P < 0.001; OR, 17.46; 95% CI, 4.22-72.13). Continuation of immunosuppression or presence of liver injury during COVID-19 was not associated with severe COVID-19. CONCLUSIONS This international, multicenter study reveals that patients with AIH were not at risk for worse outcomes with COVID-19 than other causes of CLD. Cirrhosis was the strongest predictor for severe COVID-19 in patients with AIH. Maintenance of immunosuppression during COVID-19 was not associated with increased risk for severe COVID-19 but did lower the risk for new-onset liver injury during COVID-19.
Collapse
|
24
|
Efe C, Torgutalp M, Henriksson I, Alalkim F, Lytvyak E, Trivedi H, Eren F, Fischer J, Chayanupatkul M, Coppo C, Purnak T, Muratori L, Werner M, Muratori P, Rorsman F, Onnerhag K, Nilsson E, Heurgué-Berlot A, Demir N, Semela D, Kıyıcı M, Schiano TD, Montano-Loza AJ, Berg T, Ozaslan E, Yoshida EM, Bonder A, Marschall HU, Beretta-Piccoli BT, Wahlin S. Extrahepatic autoimmune diseases in primary biliary cholangitis: Prevalence and significance for clinical presentation and disease outcome. J Gastroenterol Hepatol 2021; 36:936-942. [PMID: 32790935 DOI: 10.1111/jgh.15214] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [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: 05/26/2020] [Revised: 07/28/2020] [Accepted: 08/09/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM The prevalence and clinical significance of extrahepatic autoimmune diseases (EHAIDs) have not been evaluated in a large cohort of primary biliary cholangitis (PBC). METHODS The medical records of 1554 patients with PBC from 20 international centers were retrospectively reviewed. Development of decompensated cirrhosis (ascites, variceal bleeding, and/or hepatic encephalopathy) and hepatocellular carcinoma were considered clinical endpoints. RESULTS A total of 35 different EHAIDs were diagnosed in 440 (28.3%) patients with PBC. Patients with EHAIDs were more often female (92.5% vs 86.1%, P < 0.001) and seropositive for anti-mitochondrial antibodies (88% vs 84%, P = 0.05) and antinuclear antibodies and/or smooth muscle antibodies (53.8% vs 43.6%, P = 0.005). At presentation, patients with EHAIDs had significantly lower levels of alkaline phosphatase (1.76 vs 1.98 × upper limit of normal [ULN], P = 0.006), aspartate aminotransferase (1.29 vs 1.50 × ULN, P < 0.001), and total bilirubin (0.53 vs 0.58 × ULN, P = 0.002). Patients with EHAIDs and without EHAIDs had similar rates of GLOBE high-risk status (12.3% vs 16.1%, P = 0.07) and Paris II response (71.4% vs 69.4%, P = 0.59). Overall, event-free survival was not different in patients with and without EHAIDs (90.8% vs 90.7%, P = 0.53, log rank). Coexistence of each autoimmune thyroid diseases (10.6%), Sjögren disease (8.3%), systemic sclerosis (2.9%), rheumatoid arthritis (2.7%), systemic lupus erythematosus (1.7%), celiac disease (1.7%), psoriasis (1.5%), and inflammatory bowel diseases (1.3%) did not influence the outcome. CONCLUSIONS Our study confirms that EHAIDs are frequently diagnosed in patients with PBC. The presence of EHAIDs may influence the clinical phenotype of PBC at presentation but has no impact on PBC outcome.
Collapse
Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Gazi Yaşargil Education and Research Hospital, Diyarbakir, Turkey
| | - Murat Torgutalp
- Department of Rheumatology, Ankara University Hospital, Ankara, Turkey
| | - Ida Henriksson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Fatema Alalkim
- Division of Gastroenterology, University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Ellina Lytvyak
- University of Alberta Division of Gastroenterology and Liver Unit, Edmonton, Alberta, Canada
| | - Hirsh Trivedi
- Division of GI and Hepatology, Beth Israel Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Fatih Eren
- Department of Gastroenterology, Medical Faculty, Uludag University, Bursa, Turkey
| | - Janett Fischer
- Division of Gastroenterology, Clinic and Polyclinic for Oncology, Hepatology, Infectious Diseases and Pneumology, University Clinic Leipzig, Leipzig, Germany
| | - Maneerat Chayanupatkul
- Division of Liver Diseases, The Mount Sinai Medical Center, New York, New York, USA.,Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Claudia Coppo
- Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System, University of Bologna, Bologna, Italy
| | - Tugrul Purnak
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Luigi Muratori
- Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System, University of Bologna, Bologna, Italy
| | - Mårten Werner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Paolo Muratori
- Center for the Study and Treatment of Autoimmune Diseases of the Liver and Biliary System, University of Bologna, Bologna, Italy
| | - Fredrik Rorsman
- Department of Gastroenterology and Hepatology, Uppsala University Hospital, Uppsala, Sweden
| | - Kristina Onnerhag
- Department of Gastroenterology and Hepatology, Skåne University Hospital, Malmö, Sweden
| | - Emma Nilsson
- Department of Clinical Sciences, Gastroenterology Division, Skåne University Hospital, Lund, Sweden
| | | | - Nurhan Demir
- Department of Gastroenterology, Gazi Yaşargil Education and Research Hospital, Diyarbakir, Turkey
| | - David Semela
- Division of Gastroenterology and Hepatology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Murat Kıyıcı
- Department of Gastroenterology, Medical Faculty, Uludag University, Bursa, Turkey
| | - Thomas D Schiano
- Division of Liver Diseases, The Mount Sinai Medical Center, New York, New York, USA
| | - Aldo J Montano-Loza
- University of Alberta Division of Gastroenterology and Liver Unit, Edmonton, Alberta, Canada
| | - Thomas Berg
- Division of Gastroenterology, Clinic and Polyclinic for Oncology, Hepatology, Infectious Diseases and Pneumology, University Clinic Leipzig, Leipzig, Germany
| | - Ersan Ozaslan
- Department of Gastroenterology, Ankara City Hospital, Ankara, Turkey
| | - Eric M Yoshida
- Division of Gastroenterology, University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Alan Bonder
- Division of GI and Hepatology, Beth Israel Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Staffan Wahlin
- Hepatology Division, Centre for Digestive Diseases, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
25
|
Lissing M, Nowak G, Adam R, Karam V, Boyd A, Gouya L, Meersseman W, Melum E, Ołdakowska‐Jedynak U, Reiter FP, Colmenero J, Sanchez R, Herden U, Langendonk J, Ventura P, Isoniemi H, Boillot O, Braun F, Perrodin S, Mowlem E, Wahlin S. Liver Transplantation for Acute Intermittent Porphyria. Liver Transpl 2021; 27:491-501. [PMID: 37160035 PMCID: PMC8248103 DOI: 10.1002/lt.25959] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 10/19/2020] [Accepted: 11/03/2020] [Indexed: 12/14/2022]
Abstract
Recurrent attacks of acute intermittent porphyria (AIP) result in poor quality of life and significant risks of morbidity and mortality. Liver transplantation (LT) offers a cure, but published data on outcomes after LT are limited. We assessed the pretransplant characteristics, complications, and outcomes for patients with AIP who received a transplant. Data were collected retrospectively from the European Liver Transplant Registry and from questionnaires sent to identified transplant and porphyria centers. We studied 38 patients who received transplants in 12 countries from 2002 to 2019. Median age at LT was 37 years (range, 18-58), and 34 (89%) of the patients were women. A total of 9 patients died during follow-up, and 2 patients were retransplanted. The 1-year and 5-year overall survival rates were 92% and 82%, which are comparable with other metabolic diseases transplanted during the same period. Advanced pretransplant neurological impairment was associated with increased mortality. The 5-year survival rate was 94% among 19 patients with moderate or no neuropathy at LT and 83% among 10 patients with severe neuropathy (P = 0.04). Pretransplant renal impairment was common. A total of 19 (51%) patients had a GFR < 60 mL/minute. Although few patients improved their renal function after LT, neurological impairments improved, and no worsening of neurological symptoms was recorded. No patient had AIP attacks after LT, except for a patient who received an auxiliary graft. LT is a curative treatment option for patients with recurrent attacks of AIP. Severe neuropathy and impaired renal function are common and increase the risk for poor outcomes. If other treatment options fail, an evaluation for LT should be performed early.
Collapse
Affiliation(s)
- Mattias Lissing
- Hepatology DivisionDepartment of Upper GI DiseasesPorphyria Centre SwedenKarolinska Institutet and Karolinska University HospitalStockholmSweden
| | - Greg Nowak
- Department of Clinical Science, Intervention and Technology (CLINTEC)Karolinska Institutet and Karolinska University HospitalStockholmSweden
| | - René Adam
- Paul Brousse HospitalUniversity Paris‐SudInserm U935VillejuifFrance
| | - Vincent Karam
- Paul Brousse HospitalUniversity Paris‐SudInserm U935VillejuifFrance
| | | | - Laurent Gouya
- Centre Francais des PorphyriesHôpital Louis MourierAssistance Publique‐Hôpitaux de ParisParisFrance
| | - Wouter Meersseman
- Department of General Internal MedicineUniversitair Ziekenhuis (UZ) LeuvenLeuvenBelgium
| | - Espen Melum
- Section for GastroenterologyNorwegian Primary Sclerosing Cholangitis (PSC) Research CenterDepartment of Transplantation MedicineResearch Institute of Internal MedicineDivision of SurgeryInflammatory Diseases and TransplantationOslo University Hospital RikshospitaletHybrid Technology Hub‐Centre of ExcellenceInstitute of Basic Medical SciencesInstitute of Clinical MedicineFaculty of MedicineUniversity of OsloOsloNorway
| | | | - Florian P. Reiter
- Liver Center MunichDepartment of Medicine IIUniversity HospitalLudwig Maximilian University (LMU) MunichMunichGermany
| | - Jordi Colmenero
- Liver Transplant UnitHospital Clínic de BarcelonaInstitut d'Investigacions Biomèdiques August Pi i SunyerCentro de Investigación Biomédica en Red en Enfermedades Hepáticas y DigestivasUniversitat de BarcelonaBarcelonaSpain
| | - Rosario Sanchez
- Institute of Sanitary and Biomedical Investigation of AlicanteAlicanteSpain
| | - Uta Herden
- Department of Visceral Transplant SurgeryUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Janneke Langendonk
- Erasmus MCUniversity Medical Center RotterdamPorphyria Center RotterdamRotterdamThe Netherlands
| | - Paolo Ventura
- Department of Medical and Surgical Sciences for Children and AdultsUniversity of Modena and Reggio EmiliaUnit of Internal MedicinePoliclinico Hospital of ModenaModenaItaly
| | - Helena Isoniemi
- Department of Transplantation and Liver SurgeryHelsinki University HospitalHelsinkiFinland
| | | | - Felix Braun
- Department of General, Visceral, Thoracic, Transplantation and Pediatric SurgeryUniversitätsklinikum Schleswig‐Holstein (UKSH)Campus KielKielGermany
| | - Stéphanie Perrodin
- Department of Visceral Surgery and MedicineInselspital University Hospital of BernBernSwitzerland
| | - Elizabeth Mowlem
- The Liver UnitAddenbrooke's HospitalCambridge University HospitalsCambridgeUK
| | - Staffan Wahlin
- Hepatology DivisionDepartment of Upper GI DiseasesPorphyria Centre SwedenKarolinska Institutet and Karolinska University HospitalStockholmSweden
| | | |
Collapse
|
26
|
Wahlin S, Efe C. Both tacrolimus and mycophenylate mophetil should be considered second-line therapy for autoimmune hepatitis. J Hepatol 2021; 74:753-755. [PMID: 33309114 DOI: 10.1016/j.jhep.2020.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
| | - Cumali Efe
- Department of Gastroenterology, Harran University, Şanlıurfa, Turkey
| |
Collapse
|
27
|
Efe C, Simşek C, Batıbay E, Calışkan AR, Wahlin S. Feasibility of telehealth in the management of autoimmune hepatitis before and during the COVID-19 pandemic. Expert Rev Gastroenterol Hepatol 2020; 14:1215-1219. [PMID: 32909852 DOI: 10.1080/17474124.2020.1822734] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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] [Indexed: 12/14/2022]
Abstract
OBJECTIVES We aimed to evaluate the feasibility of telehealth in the management of patients with autoimmune hepatitis (AIH). The COVID-19 outbreak during the study period provided an opportunity to evaluate any pandemic influence on how telehealth was perceived by patients and physicians. METHODS We included patients with AIH who were followed in the Harran University hospital, Turkey. Patients were managed by either remote telehealth or standard care. RESULTS A total of 46 (telehealth, n=19 and standard care, n= 27) patients (40 female) with a median age of 32 (range 17-74) years at diagnosis were included in the study. Until the start of the COVID-19 pandemic, the rates of biochemical remission and relapse after remission were similar in the telehealth and standard care groups (89.5% vs. 89.1% and 15.8% vs. 25.9%, p=ns, for both). The telehealth group maintained remission significantly better than the standard care group (100% vs. 77.3%, p=0.035) during the COVID-19 period. All relapses were due to non-adherence to therapy. Psychiatric problems, pregnancy-related issues and drug side-effects could all be managed remotely by telehealth. CONCLUSIONS In this study, we show for the first time that telehealth is a feasible alternative for managing AIH, both under normal circumstances and during the COVID-19 pandemic. EXPERT OPINION Autoimmune hepatitis (AIH) requires long-life lifelong immunosuppression and follow-up for most patients. The use of telehealth may be an alternative way to evaluate these patients remotely. We show for the first time that telehealth is effective and useful in the management of AIH in regular time as well during COVID-19. We hope that our study can extend use of telehealth in the evaluation of patients with other causes of chronic liver disease.
Collapse
Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Harran University , Şanlıurfa, Turkey
| | - Cem Simşek
- Department of Gastroenterology, Hacettepe University , Ankara, Turkey
| | - Ersin Batıbay
- Department of Gastroenterology, Harran University , Şanlıurfa, Turkey
| | - Ali Rıza Calışkan
- Department of Gastroenterology, Adıyaman University , Adıyaman, Turkey
| | - Staffan Wahlin
- Hepatology Division, Centre for Digestive Diseases, Karolinska Institutet and Karolinska University Hospital , Stockholm, Sweden
| |
Collapse
|
28
|
Lindqvist C, Nordstedt P, Nowak G, Slinde F, Majeed A, Bottai M, Wahlin S. Energy expenditure early after liver transplantation: Better measured than predicted. Nutrition 2020; 79-80:110817. [DOI: 10.1016/j.nut.2020.110817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 12/13/2022]
|
29
|
Lindqvist C, Slinde F, Majeed A, Bottai M, Wahlin S. Nutrition impact symptoms are related to malnutrition and quality of life – A cross-sectional study of patients with chronic liver disease. Clin Nutr 2020; 39:1840-1848. [DOI: 10.1016/j.clnu.2019.07.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/19/2019] [Accepted: 07/31/2019] [Indexed: 02/08/2023]
|
30
|
Peoc'h K, Manceau H, Karim Z, Wahlin S, Gouya L, Puy H, Deybach JC. Hepatocellular carcinoma in acute hepatic porphyrias: A Damocles Sword. Mol Genet Metab 2019; 128:236-241. [PMID: 30413387 DOI: 10.1016/j.ymgme.2018.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/05/2018] [Accepted: 10/05/2018] [Indexed: 02/08/2023]
Abstract
Porphyrias are inherited diseases with low penetrance affecting the heme biosynthesis pathway. Acute intermittent porphyria (AIP), variegate porphyria (VP) and hereditary coproporphyria (HCP) together constitute the acute hepatic porphyrias (AHP). These diseases have been identified as risk factors for primary liver cancers (PLC), mainly hepatocellular carcinoma (HCC: range 87-100%) but also cholangiocarcinoma, alone or combination with HCC. In AHP, HCC annual incidence rates range from 0.16 to 0.35% according to the populations studied. Annual incidence rates are higher in Swedish and Norwegian patients, due to a founder effect. It increases above age 50. The pathophysiology could include both direct toxic effects of heme precursors, particularly δ-aminolevulinic acid (ALA), compound heterozygosity for genes implied in heme biosynthesis pathway or the loss of oxidative stress homeostasis due to a relative lack of heme. The high HCC incidence justifies radiological surveillance in AHP patients above age 50. Efforts are made to find new biological non-invasive markers. In this respect, we describe here the first report of PIVKA-II clinical utility in the follow-up of an AIP patient that develop an HCC. In this manuscript we reviewed the epidemiology, the physiopathology, and the screening strategy of HCC in AHP.
Collapse
Affiliation(s)
- Katell Peoc'h
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, HUPNVS, Biochimie Clinique, Hôpital Beaujon, F-92110 Clichy, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France
| | - Hana Manceau
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, HUPNVS, Biochimie Clinique, Hôpital Beaujon, F-92110 Clichy, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France
| | - Zoubida Karim
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France
| | - Staffan Wahlin
- Department of Gastroenterology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden; Department of Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Laurent Gouya
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, HUPNVS Centre Français des Porphyries, Hôpital Louis Mourier, 178 Rue des Renouillers, F-92701 Colombes, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France
| | - Hervé Puy
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, HUPNVS Centre Français des Porphyries, Hôpital Louis Mourier, 178 Rue des Renouillers, F-92701 Colombes, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France.
| | - Jean-Charles Deybach
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, HUPNVS Centre Français des Porphyries, Hôpital Louis Mourier, 178 Rue des Renouillers, F-92701 Colombes, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France
| |
Collapse
|
31
|
Karalli A, Teiler J, Haji M, Seth E, Brismar TB, Wahlin S, Axelsson R, Stål P. Comparison of lipiodol infusion and drug-eluting beads transarterial chemoembolization of hepatocellular carcinoma in a real-life setting. Scand J Gastroenterol 2019; 54:905-912. [PMID: 31287338 DOI: 10.1080/00365521.2019.1632925] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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] [Indexed: 02/04/2023]
Abstract
Aim: Doxorubicin-eluting beads transarterial chemoembolization (DEB-TACE) is reported to improve survival and tolerability when compared with conventional lipiodol-TACE (cTACE) for the treatment of hepatocellular carcinoma (HCC). The aim of this study was to evaluate tolerability and long-term survival in patients treated with cTACE or DEB-TACE in a real-life setting. Methods: Incidence of adverse events and overall survival in HCC patients treated with either cTACE or DEB-TACE at Karolinska University Hospital 2004-2012 were analyzed retrospectively. Median follow-up was 7.1 years. Patients were censored when transplanted or at the end of follow-up. Patients receiving both cTACE and DEB-TACE, or treated with resection or ablation post-TACE were excluded from the survival analysis. Results: A total of 202 patients (76 cTACE and 126 DEB-TACE) were eligible for analysis of adverse events, and 179 patients (69 cTACE and 110 DEB-TACE) were included in the survival analysis. cTACE patients were younger and had fewer tumors but higher BCLC stage than DEB-TACE. Child-Pugh and ECOG performance status were similar between groups. Adverse events (abdominal pain, nausea and vomiting, fever, fatigue) were significantly less common in the DEB-TACE group. Median survival was 17.1 months in the cTACE group and 19.1 months in the DEB-TACE (NS). In multivariate Cox regression analysis, portal vein thrombosis and tumor size were associated with increased, and sorafenib treatment post-TACE with decreased mortality. Conclusion: In this retrospective real-life analysis, DEB-TACE had better tolerability compared to cTACE, but overall survival did not differ between the two treatments. Portal vein thrombosis, tumor size and sorafenib treatment after TACE influence survival.
Collapse
Affiliation(s)
- Amar Karalli
- Division of Medical Imaging and Technology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet , Stockholm , Sweden
| | - Johan Teiler
- Division of Medical Imaging and Technology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet , Stockholm , Sweden
| | - Mojgan Haji
- Division of Medical Imaging and Technology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet , Stockholm , Sweden
| | - Elin Seth
- Department of Clinical Science and Education, Karolinska Institutet South Hospital , Stockholm , Sweden
| | - Torkel B Brismar
- Division of Medical Imaging and Technology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet , Stockholm , Sweden
| | - Staffan Wahlin
- Unit of Gastroenterology and Rheumatology, Department of Medicine Huddinge, Karolinska Institutet , Stockholm , Sweden.,Unit of Liver Diseases, Department of Upper Gastrointestinal Diseases, Karolinska University Hospital , Stockholm , Sweden
| | - Rimma Axelsson
- Division of Medical Imaging and Technology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet , Stockholm , Sweden.,Medical Radiation Physics and Nuclear Medicine, Functional Unit of Nuclear Medicine, Karolinska University Hospital , Huddinge , Sweden
| | - Per Stål
- Unit of Gastroenterology and Rheumatology, Department of Medicine Huddinge, Karolinska Institutet , Stockholm , Sweden.,Unit of Liver Diseases, Department of Upper Gastrointestinal Diseases, Karolinska University Hospital , Stockholm , Sweden
| |
Collapse
|
32
|
Bengtsson B, Stål P, Wahlin S, Björkström NK, Hagström H. Characteristics and outcome of hepatocellular carcinoma in patients with NAFLD without cirrhosis. Liver Int 2019; 39:1098-1108. [PMID: 30829446 DOI: 10.1111/liv.14087] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [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: 11/13/2018] [Revised: 01/27/2019] [Accepted: 02/25/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Non-alcoholic fatty liver disease (NAFLD) is a growing cause of hepatocellular carcinoma (HCC). In NAFLD, HCC occurs more commonly in the absence of cirrhosis compared with other liver diseases; yet, patients with non-cirrhotic NAFLD-HCC are poorly characterized. Here, we characterized a large cohort of HCC cases and assessed the outcomes of patients with non-cirrhotic NAFLD-HCC. METHODS We identified all cases of HCC treated at the Karolinska University Hospital, Stockholm, Sweden from 2004 to 2017. Patient charts were manually reviewed for variable extraction. Cases were followed passively for all-cause and HCC-related mortality until the end of April 2018. Cox regression was performed to estimate mortality rates and identify mortality risk factors in patients with non-cirrhotic NAFLD-HCC. RESULTS Totally, 1562 cases with HCC were identified. Of these, 225 (14.4%) had NAFLD-HCC, of which 83 (37%) did not have cirrhosis. Compared with patients with cirrhotic NAFLD-HCC, patients with non-cirrhotic NAFLD-HCC were older (74 vs 70 years, P < 0.001), had a lower prevalence of type 2 diabetes (T2DM) (66% vs 80%, P = 0.02), larger tumours, less frequently underwent liver transplantation (0% vs 11%, P = 0.002), but more frequently underwent resection (35% vs 8%, P < 0.001). Mortality was similar (aHR for non-cirrhotic NAFLD-HCC vs cirrhotic NAFLD-HCC 0.93, 95% CI 0.58-1.51, P = 0.78). Parameters independently associated with increased mortality included the Barcelona Clinic Liver Cancer stage, number of tumours, lower albumin and presence of T2DM. CONCLUSIONS Patients with non-cirrhotic NAFLD-HCC differ from those with cirrhosis in age, tumour size and allocated treatments. Despite these differences, survival is similar.
Collapse
Affiliation(s)
- Bonnie Bengtsson
- Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Huddinge, Unit of Gastroenterology and Rheumatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Per Stål
- Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Huddinge, Unit of Gastroenterology and Rheumatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Staffan Wahlin
- Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Huddinge, Unit of Gastroenterology and Rheumatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Niklas K Björkström
- Department of Medicine Huddinge, Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Hannes Hagström
- Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Solna, Clinical Epidemiology Unit, Stockholm, Sweden
| |
Collapse
|
33
|
Lindqvist C, Brismar TB, Majeed A, Wahlin S. Assessment of muscle mass depletion in chronic liver disease: Dual-energy x-ray absorptiometry compared with computed tomography. Nutrition 2019; 61:93-98. [DOI: 10.1016/j.nut.2018.10.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 09/18/2018] [Accepted: 10/24/2018] [Indexed: 12/12/2022]
|
34
|
Lindqvist C, Slinde F, Majeed A, Wahlin S. Nutrition impact symptoms affects quality of life and nutritional status in patients with chronic liver disease. Clin Nutr 2018. [DOI: 10.1016/j.clnu.2018.06.1270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
35
|
Schmitt C, Lenglet H, Yu A, Delaby C, Benecke A, Lefebvre T, Letteron P, Paradis V, Wahlin S, Sandberg S, Harper P, Sardh E, Sandvik AK, Hov JR, Aarsand AK, Chiche L, Bazille C, Scoazec JY, To-Figueras J, Carrascal M, Abian J, Mirmiran A, Karim Z, Deybach JC, Puy H, Peoc'h K, Manceau H, Gouya L. Recurrent attacks of acute hepatic porphyria: major role of the chronic inflammatory response in the liver. J Intern Med 2018; 284:78-91. [PMID: 29498764 DOI: 10.1111/joim.12750] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [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] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute intermittent porphyria (AIP) is an inherited disorder of haem metabolism characterized by life-threatening acute neurovisceral attacks due to the induction of hepatic δ-aminolevulinic acid synthase 1 (ALAS1) associated with hydroxymethylbilane synthase (HMBS) deficiency. So far, the treatment of choice is hemin which represses ALAS1. The main issue in the medical care of AIP patients is the occurrence of debilitating recurrent attacks. OBJECTIVE The aim of this study was to determine whether chronic hemin administration contributes to the recurrence of acute attacks. METHODS A follow-up study was conducted between 1974 and 2015 and included 602 French AIP patients, of whom 46 had recurrent AIP. Moreover, we studied the hepatic transcriptome, serum proteome, liver macrophage polarization and oxidative and inflammatory profiles of Hmbs-/- mice chronically treated by hemin and extended the investigations to five explanted livers from recurrent AIP patients. RESULTS The introduction of hemin into the pharmacopeia has coincided with a 4.4-fold increase in the prevalence of chronic patients. Moreover, we showed that both in animal model and in human liver, frequent hemin infusions generate a chronic inflammatory hepatic disease which induces HO1 remotely to hemin treatment and maintains a high ALAS1 level responsible for recurrence. CONCLUSION Altogether, this study has important impacts on AIP care underlying that hemin needs to be restricted to severe neurovisceral crisis and suggests that alternative treatment targeting the liver such as ALAS1 and HO1 inhibitors, and anti-inflammatory therapies should be considered in patients with recurrent AIP.
Collapse
Affiliation(s)
- C Schmitt
- Centre Français des Porphyries, Hôpital Louis Mourier, Assistance publique-Hôpitaux de Paris (AP-HP), Colombes, France.,Centre de Recherche sur l'Inflammation (CRI), UMR1149 INSERM, Université Paris Diderot, site Bichat, Paris, France.,Laboratoire d'excellence, GR-Ex, Paris, France
| | - H Lenglet
- Centre de Recherche sur l'Inflammation (CRI), UMR1149 INSERM, Université Paris Diderot, site Bichat, Paris, France.,Laboratoire d'excellence, GR-Ex, Paris, France
| | - A Yu
- STIM CNRS ERL 7368, Physiologie des Cellules Cardiaques et Vasculaires, Tours, France
| | - C Delaby
- Laboratory for Clinical Biochemistry and Proteomics, Institute for Regenerative Medicine and Biotherapy (IRMB), CHU de Montpellier and Université Montpellier, Montpellier, France
| | - A Benecke
- Centre National de la Recherche Scientifique, Institut des Hautes Études Scientifiques, Bures-sur-Yvette, France.,Center for Innate Immunity and Immune Disease (CIIID), University of Washington School of Medicine, Seattle, WA, USA
| | - T Lefebvre
- Centre Français des Porphyries, Hôpital Louis Mourier, Assistance publique-Hôpitaux de Paris (AP-HP), Colombes, France.,Centre de Recherche sur l'Inflammation (CRI), UMR1149 INSERM, Université Paris Diderot, site Bichat, Paris, France.,Laboratoire d'excellence, GR-Ex, Paris, France
| | - P Letteron
- Centre de Recherche sur l'Inflammation (CRI), UMR1149 INSERM, Université Paris Diderot, site Bichat, Paris, France
| | - V Paradis
- Centre de Recherche sur l'Inflammation (CRI), UMR1149 INSERM, Université Paris Diderot, site Bichat, Paris, France.,DHU Unity, Pathology Department, Hôpital Beaujon, AP-HP, Clichy, France
| | - S Wahlin
- Department of Gastroenterology and Hepatology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - S Sandberg
- Laboratory for Clinical Biochemistry, Norwegian Porphyria Centre (NAPOS), Haukeland University Hospital, Bergen, Norway.,Department of Global Health and Primary Health Care, University of Bergen, Bergen, Norway
| | - P Harper
- Porphyria Centre Sweden, Centre for Inherited Metabolic Diseases, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - E Sardh
- Porphyria Centre Sweden, Centre for Inherited Metabolic Diseases, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - A K Sandvik
- Department of Gastroenterology and Hepatology, St. Olav's University Hospital, Trondheim, Norway
| | - J R Hov
- Department of Transplantation Medicine, Norwegian PSC Research Center and Section of Gastroenterology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - A K Aarsand
- Laboratory for Clinical Biochemistry, Norwegian Porphyria Centre (NAPOS), Haukeland University Hospital, Bergen, Norway.,Department of Global Health and Primary Health Care, University of Bergen, Bergen, Norway
| | - L Chiche
- Centre Hospitalier Universitaire Bordeaux, Chirurgie Hépatobiliaire et Pancréatique, Maison du Haut Lévèque, Bordeaux, France
| | - C Bazille
- Service d'Anatomie Pathologique, Centre Hospitalo-Universitaire de Caen, Caen, France
| | - J-Y Scoazec
- Service d'anatomopathologie, Institut Gustave Roussy, Villejuif, France
| | - J To-Figueras
- Biochemistry and Molecular Genetics Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - M Carrascal
- CSIC/UAB Proteomics Laboratory, IIBB-CSIC, IDIBAPS, Barcelona, Spain
| | - J Abian
- CSIC/UAB Proteomics Laboratory, IIBB-CSIC, IDIBAPS, Barcelona, Spain
| | - A Mirmiran
- Centre de Recherche sur l'Inflammation (CRI), UMR1149 INSERM, Université Paris Diderot, site Bichat, Paris, France.,Laboratoire d'excellence, GR-Ex, Paris, France
| | - Z Karim
- Centre de Recherche sur l'Inflammation (CRI), UMR1149 INSERM, Université Paris Diderot, site Bichat, Paris, France.,Laboratoire d'excellence, GR-Ex, Paris, France
| | - J-C Deybach
- Centre Français des Porphyries, Hôpital Louis Mourier, Assistance publique-Hôpitaux de Paris (AP-HP), Colombes, France.,Centre de Recherche sur l'Inflammation (CRI), UMR1149 INSERM, Université Paris Diderot, site Bichat, Paris, France.,Laboratoire d'excellence, GR-Ex, Paris, France
| | - H Puy
- Centre Français des Porphyries, Hôpital Louis Mourier, Assistance publique-Hôpitaux de Paris (AP-HP), Colombes, France.,Centre de Recherche sur l'Inflammation (CRI), UMR1149 INSERM, Université Paris Diderot, site Bichat, Paris, France.,Laboratoire d'excellence, GR-Ex, Paris, France
| | - K Peoc'h
- Centre de Recherche sur l'Inflammation (CRI), UMR1149 INSERM, Université Paris Diderot, site Bichat, Paris, France.,Laboratoire d'excellence, GR-Ex, Paris, France.,Laboratory for Clinical Biochemistry, Hôpital Beaujon, AP-HP, Clichy, France
| | - H Manceau
- Centre de Recherche sur l'Inflammation (CRI), UMR1149 INSERM, Université Paris Diderot, site Bichat, Paris, France.,Laboratoire d'excellence, GR-Ex, Paris, France.,Laboratory for Clinical Biochemistry, Hôpital Beaujon, AP-HP, Clichy, France
| | - L Gouya
- Centre Français des Porphyries, Hôpital Louis Mourier, Assistance publique-Hôpitaux de Paris (AP-HP), Colombes, France.,Centre de Recherche sur l'Inflammation (CRI), UMR1149 INSERM, Université Paris Diderot, site Bichat, Paris, France.,Laboratoire d'excellence, GR-Ex, Paris, France
| |
Collapse
|
36
|
Al-Dury S, Wahlström A, Wahlin S, Langedijk J, Elferink RO, Ståhlman M, Marschall HU. Pilot study with IBAT inhibitor A4250 for the treatment of cholestatic pruritus in primary biliary cholangitis. Sci Rep 2018; 8:6658. [PMID: 29704003 PMCID: PMC5923243 DOI: 10.1038/s41598-018-25214-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 04/17/2018] [Indexed: 12/31/2022] Open
Abstract
Pruritus is a common complication of cholestatic liver diseases. Inhibition of the ileal bile acid transporter (IBAT/ASBT) may emerge as treatment option. Our aim was to assess tolerability and effect on pruritus of the selective IBAT inhibitor A4250 in patients with primary biliary cholangitis (PBC). Ten patients with PBC and bile acid sequestrant treatment of cholestatic pruritus were after a two-week wash out of the bile acid sequestrant treated with either 0.75 mg (n = 4) or 1.5 mg (n = 5) of A4250 for four weeks. Patients' pruritus was assessed by Visual Analogue Scale (VAS), 5-D itch scale and the pruritus module of the PBC40 questionnaire. Plasma bile acids and 7α-hydroxy-4-cholesten-3-one were measured by UPLC-MS/MS, plasma fibroblast growth factor 19 by ELISA, and serum autotaxin activity by homemade assay. All nine patients exposed to A4250 reported a remarkable improvement in pruritus, until none or mild according to 5-D itch, VAS and PBC40 pruritus. Five patients finished the study prematurely due to abdominal pain (5/5) and diarrhoea (4/5). The high incidence of probably bile acid malabsorption-related diarrhoea and abdominal pain in the bile acid sequestrant pre-treated population indicates that the start dose of A4250 may have been too high for adult patients.
Collapse
Affiliation(s)
- Samer Al-Dury
- Sahlgrenska Academy, Institute of Medicine, Department of Molecular and Clinical Medicine and Wallenberg Laboratory, University of Gothenburg, Gothenburg, Sweden
| | - Annika Wahlström
- Sahlgrenska Academy, Institute of Medicine, Department of Molecular and Clinical Medicine and Wallenberg Laboratory, University of Gothenburg, Gothenburg, Sweden
| | - Staffan Wahlin
- Karolinska University Hospital Huddinge, Department of Gastroenterology and Hepatology, Stockholm, Sweden
| | - Jacqueline Langedijk
- Tytgat Institute for Liver and Intestinal Research, Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Ronald Oude Elferink
- Tytgat Institute for Liver and Intestinal Research, Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus Ståhlman
- Sahlgrenska Academy, Institute of Medicine, Department of Molecular and Clinical Medicine and Wallenberg Laboratory, University of Gothenburg, Gothenburg, Sweden
| | - Hanns-Ulrich Marschall
- Sahlgrenska Academy, Institute of Medicine, Department of Molecular and Clinical Medicine and Wallenberg Laboratory, University of Gothenburg, Gothenburg, Sweden.
| |
Collapse
|
37
|
Gilg S, Sparrelid E, Saraste L, Nowak G, Wahlin S, Strömberg C, Lundell L, Isaksson B. The molecular adsorbent recirculating system in posthepatectomy liver failure: Results from a prospective phase I study. Hepatol Commun 2018; 2:445-454. [PMID: 29619422 PMCID: PMC5880195 DOI: 10.1002/hep4.1167] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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: 12/11/2017] [Revised: 02/06/2018] [Accepted: 02/10/2018] [Indexed: 12/11/2022] Open
Abstract
Posthepatectomy liver failure (PHLF) represents the single most important cause of postoperative mortality after major liver resection, yet no effective treatment option is available. Extracorporeal liver support devices might be helpful, but systematic studies are lacking. Accordingly, we aimed to assess the safety and feasibility of the Molecular Adsorbent Recirculating System (MARS) in patients with PHLF. Between December 2012 and May 2015, a total of 206 patients underwent major or extended hepatectomy, and 10 consecutive patients with PHLF (according to the Balzan 50:50 criteria) were enrolled into the study. MARS treatment was initiated on postoperative day 5-7, and five to seven consecutive treatment sessions were completed for each patient. In total, 59 MARS cycles were implemented, and MARS was initiated and completed without major complications in any patient. However, 1 patient developed an immense asymptomatic hyperbilirubinemia (without encephalopathy), 1 had repeated clotting problems in the MARS filter, and 2 patients experienced access problems with the central venous line. Otherwise, no adverse events were observed. In 9 patients, the bilirubin level and international normalized ratio decreased significantly (P < 0.05) during MARS treatment. The 60- and 90-day mortality was 0% and 10%, respectively. Among the 9 survivors, 4 still had liver dysfunction at 90 days postoperatively. Five patients were alive 1 year postoperatively without any signs of liver dysfunction or disease recurrence. Conclusion: The use of MARS in PHLF is feasible and safe and improves liver function in patients with PHLF. In the present study, 60- and 90-day mortality rates were unexpectedly low compared to a historical control group. The impact of MARS treatment on mortality in PHLF should be further evaluated in a randomized controlled clinical trial. (Hepatology Communications 2018;2:445-454).
Collapse
Affiliation(s)
- Stefan Gilg
- Department for Clinical Science, Intervention and Technology Karolinska InstituteStockholmSweden.,Department of Surgery at the Center for Digestive Diseases Karolinska University Hospital Stockholm Sweden
| | - Ernesto Sparrelid
- Department for Clinical Science, Intervention and Technology Karolinska InstituteStockholmSweden.,Department of Surgery at the Center for Digestive Diseases Karolinska University Hospital Stockholm Sweden
| | - Lars Saraste
- Department of Anesthesiology and Intensive Care Karolinska University Hospital Stockholm Sweden
| | - Greg Nowak
- Department for Clinical Science, Intervention and Technology Karolinska InstituteStockholmSweden.,Department of Transplantation Surgery Karolinska University Hospital Stockholm Sweden
| | - Staffan Wahlin
- Department for Clinical Science, Intervention and Technology Karolinska InstituteStockholmSweden.,Department of Hepatology Karolinska University Hospital Stockholm Sweden
| | - Cecilia Strömberg
- Department for Clinical Science, Intervention and Technology Karolinska InstituteStockholmSweden.,Department of Surgery at the Center for Digestive Diseases Karolinska University Hospital Stockholm Sweden
| | - Lars Lundell
- Department for Clinical Science, Intervention and Technology Karolinska InstituteStockholmSweden.,Department of Surgery at the Center for Digestive Diseases Karolinska University Hospital Stockholm Sweden
| | - Bengt Isaksson
- Department for Clinical Science, Intervention and Technology Karolinska InstituteStockholmSweden.,Department of Surgical Sciences Uppsala University Hospital Uppsala Sweden
| |
Collapse
|
38
|
Efe C, Hagström H, Ytting H, Bhanji RA, Müller NF, Wang Q, Purnak T, Muratori L, Werner M, Marschall HU, Muratori P, Gunşar F, Klintman D, Parés A, Heurgué-Berlot A, Schiano TD, Cengiz M, May-Sien Tana M, Ma X, Montano-Loza AJ, Berg T, Verma S, Larsen FS, Ozaslan E, Heneghan MA, Yoshida EM, Wahlin S. Efficacy and Safety of Mycophenolate Mofetil and Tacrolimus as Second-line Therapy for Patients With Autoimmune Hepatitis. Clin Gastroenterol Hepatol 2017; 15:1950-1956.e1. [PMID: 28603052 DOI: 10.1016/j.cgh.2017.06.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 05/24/2017] [Accepted: 06/02/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Predniso(lo)ne, alone or in combination with azathioprine, is the standard-of-care (SOC) therapy for autoimmune hepatitis (AIH). However, the SOC therapy is poorly tolerated or does not control disease activity in up to 20% of patients. We assessed the efficacy of mycophenolate mofetil (MMF) and tacrolimus as second-line therapy for patients with AIH. METHODS We performed a retrospective study of data (from 19 centers in Europe, the United States, Canada, and China) from 201 patients with AIH who received second-line therapy (121 received MMF and 80 received tacrolimus), for a median of 62 months (range, 6-190 mo). Patients were categorized according to their response to SOC. Patients in group 1 (n = 108) had a complete response to the SOC, but were switched to second-line therapy as a result of side effects of predniso(lo)ne or azathioprine, whereas patients in group 2 (n = 93) had not responded to SOC. RESULTS There was no significant difference in the proportion of patients with a complete response to MMF (69.4%) vs tacrolimus (72.5%) (P = .639). In group 1, MMF and tacrolimus maintained a biochemical remission in 91.9% and 94.1% of patients, respectively (P = .682). Significantly more group 2 patients given tacrolimus compared with MMF had a complete response (56.5% vs 34%, respectively; P = .029) There were similar proportions of liver-related deaths or liver transplantation among patients given MMF (13.2%) vs tacrolimus (10.3%) (log-rank, P = .472). Ten patients receiving MMF (8.3%) and 10 patients receiving tacrolimus (12.5%) developed side effects that required therapy withdrawal. CONCLUSIONS Long-term therapy with MMF or tacrolimus generally was well tolerated by patients with AIH. The agents were equally effective in previous complete responders who did not tolerate SOC therapy. Tacrolimus led to a complete response in a greater proportion of previous nonresponder patients compared with MMF.
Collapse
Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey.
| | - Hannes Hagström
- Hepatology Division, Centre for Digestive Diseases, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Henriette Ytting
- Department of Hepatology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Rahima A Bhanji
- Division of Gastroenterology and Liver Unit, University of Alberta, Alberta, Canada
| | - Niklas F Müller
- Sektion Hepatologie, Klinik für Gastroenterologie und Rheumatologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Qixia Wang
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Cancer Institute, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Tugrul Purnak
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Luigi Muratori
- Centro per lo Studio e la Cura delle Malattie Autoimmuni del Fegato e delle Vie Biliari, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, Università di Bologna, Bologna, Italy
| | - Mårten Werner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Paolo Muratori
- Centro per lo Studio e la Cura delle Malattie Autoimmuni del Fegato e delle Vie Biliari, Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, Università di Bologna, Bologna, Italy
| | - Fulya Gunşar
- Department of Gastroenterology, Ege University, Bornova, Izmir, Turkey
| | - Daniel Klintman
- Department of Molecular and Clinical Medicine, Skåne University Hospital, Lund, Sweden; Division of Gastroenterology University of British Columbia, Vancouver General Hospital, Vancouver, Canada
| | - Albert Parés
- Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | - Thomas D Schiano
- Division of Liver Diseases, The Mount Sinai Medical Center, New York, New York
| | - Mustafa Cengiz
- Department of Gastroenterology, Dr A.Y. Oncology Training and Research Hospital, Ankara, Turkey
| | - Michele May-Sien Tana
- The Liver Center at University of California, San Francisco, Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Xiong Ma
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Cancer Institute, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Aldo J Montano-Loza
- Division of Gastroenterology and Liver Unit, University of Alberta, Alberta, Canada
| | - Thomas Berg
- Sektion Hepatologie, Klinik für Gastroenterologie und Rheumatologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Sumita Verma
- Department of Medicine, Brighton and Sussex Medical School, Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospital, Brighton, United Kingdom
| | - Fin Stolze Larsen
- Department of Hepatology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ersan Ozaslan
- Department of Gastroenterology, Numune Research and Education Hospital, Ankara, Turkey
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Eric M Yoshida
- Division of Gastroenterology University of British Columbia, Vancouver General Hospital, Vancouver, Canada
| | - Staffan Wahlin
- Hepatology Division, Centre for Digestive Diseases, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
39
|
Purnak T, Efe C, Kav T, Wahlin S, Ozaslan E. Treatment Response and Outcome with Two Different Prednisolone Regimens in Autoimmune Hepatitis. Dig Dis Sci 2017; 62:2900-2907. [PMID: 28871464 DOI: 10.1007/s10620-017-4728-2] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 08/18/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Beyond available guidelines, therapy of autoimmune hepatitis (AIH) shows wide variation among physicians. We compared two regimens for treatment naive AIH: one recommended protocol with an initial prednisolone dose of 30 mg/day and our own 40 mg/day prednisolone with a slow dose tapering protocol. We analyzed the safety, response rates, and outcomes for two groups of treated patients. PATIENTS AND METHODS We retrospectively evaluated data of 71 AIH patients including, group I (n = 32, prednisone 30 mg/day) and group II (n = 39, prednisone 40 mg/day). All patients also received azathioprine. RESULTS The frequency of complete biochemical response was significantly higher in group II than in group I (69.2 vs. 43.8%, p = 0.031) after 3 months of therapy, but not after 6 and 12 months (79.5 vs. 59.4%, p = 0.065 and 89.5 vs. 80.6%, p = 0.30). In patients with severe interface hepatitis, the complete response rates were significantly higher in group II than in group I after 3 (63.6 vs. 23.1%, p = 0.02) and 6 months (72.7 vs. 38.5%, p = 0.046), but not after 12 months of therapy (86.4 vs. 69.2%, p = 0.221). Relapses were observed in 50% of group I and in 35.9% of group II during maintenance therapy (p = 0.23). Overall survival was significantly better in group II than in group I (100 vs. 87.5%, log-rank, p = 0.048). No severe steroid-related side effects were observed in either group. CONCLUSIONS Our real-world experience suggests that an initial prednisolone dose of 40 mg/day with a slower tapering protocol induces earlier biochemical response, tends to result in less relapses during maintenance, and is associated with a better disease outcome.
Collapse
Affiliation(s)
- Tugrul Purnak
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Cumali Efe
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey.
| | - Taylan Kav
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Staffan Wahlin
- Hepatology Division, Centre for Digestive Disease, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Ersan Ozaslan
- Department of Gastroenterology, Numune Research and Education Hospital, Ankara, Turkey
| |
Collapse
|
40
|
Dumitrescu G, Januszkiewicz A, Ågren A, Magnusson M, Wahlin S, Wernerman J. Thromboelastometry: Relation to the severity of liver cirrhosis in patients considered for liver transplantation. Medicine (Baltimore) 2017; 96:e7101. [PMID: 28591054 PMCID: PMC5466232 DOI: 10.1097/md.0000000000007101] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The severity of liver disease is assessed by scoring systems, which include the conventional coagulation test prothrombin time-the international normalized ratio (PT-INR). However, PT-INR is not predictive of bleeding in liver disease and thromboelastometry (ROTEM) has been suggested to give a better overview of the coagulation system in these patients. It has now been suggested that coagulation as reflected by tromboelastomety may also be used for prognostic purposes. The objective of our study was to investigate whether thrombelastometry may discriminate the degree of liver insufficiency according to the scoring systems Child Pugh and Model for End-stage Liver Disease (MELD).Forty patients with chronic liver disease of different etiologies and stages were included in this observational cross-sectional study. The severity of liver disease was evaluated using the Child-Pugh score and the MELD score, and blood samples for biochemistry, conventional coagulation tests, and ROTEM were collected at the time of the final assessment for liver transplantation. Statistical comparisons for the studied parameters with scores of severity were made using Spearman correlation test and receiver-operating characteristic (ROC) curves.Spearman correlation coefficients indicated that the thromboelastometric parameters did not correlate with Child-Pugh or MELD scores. The ROC curves of the thromboelastometric parameters could not differentiate advanced stages from early stages of liver cirrhosis.Standard ROTEM cannot discriminate the stage of chronic liver disease in patients with severe chronic liver disease.
Collapse
Affiliation(s)
- Gabriel Dumitrescu
- Department of Anesthesia and Intensive Care Medicine, Karolinska University Hospital
| | - Anna Januszkiewicz
- Department of Anesthesia and Intensive Care Medicine, Karolinska University Hospital
| | - Anna Ågren
- Department of Medicine, Division of Hematology, Coagulation Unit, Karolinska University Hospital
| | - Maria Magnusson
- CLINTEC, Division of Pediatrics, Astrid Lindgren Children's Hospital
- MMK, Clinical Chemistry and Blood Coagulation Research, Karolinska Institute
| | - Staffan Wahlin
- Division of Hepatology, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Wernerman
- Department of Anesthesia and Intensive Care Medicine, Karolinska University Hospital
| |
Collapse
|
41
|
Lindqvist C, Majeed A, Wahlin S. Body composition assessed by dual-energy X-ray absorptiometry predicts early infectious complications after liver transplantation. J Hum Nutr Diet 2016; 30:284-291. [PMID: 27709718 DOI: 10.1111/jhn.12417] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND It is challenging to identify malnutrition, which is a risk factor for poor outcome in patients with liver cirrhosis. In the present study, we aimed to investigate the prevalence of malnutrition among patients listed for liver transplantation, as assessed by different methods, and also to relate dual-energy X-ray absorptiometry (DXA) to short-term post-transplant outcomes. METHODS In this retrospective cohort study, we reviewed the medical records of 106 patients who underwent liver transplantation in 2009-2012. Body composition was assessed by the fat-free mass index (FFMI) and fat mass index (FMI) obtained using DXA. Severe infections within 1 month, length of stay in intensive care unit and length of hospital stay were endpoints of primary interest. RESULTS The prevalence of malnutrition was 2-20% depending on sex and the assessment method. Thirty-nine (37%) patients developed severe infections within 1 month after liver transplantation. In multivariate analysis with logistic regression, body composition was significantly associated with post-operative infection when measured with FFMI (P = 0.043) but not with FMI (P = 0.087). Post-operative dialysis (P = 0.004) and post-operative infections (P < 0.001) were significantly associated with length of stay in hospital. Post-operative bleeding (P = 0.015), duration of mechanical ventilation (P < 0.001) and the need for dialysis (P < 0.001), but not body composition, were significant predictors of the length of stay in the intensive care unit. CONCLUSIONS The prevalence of malnutrition depends on assessment method. FFMI is an independent predictor for early post-transplant infections. Body composition measured by DXA during the pretransplant evaluation provides valuable information about nutritional status in patients with liver cirrhosis.
Collapse
Affiliation(s)
- C Lindqvist
- Department of Clinical Nutrition and Dietetics, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - A Majeed
- Department of Gastroenterology and Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - S Wahlin
- Department of Gastroenterology and Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
42
|
Lindqvist C, Brismar T, Majeed A, Wahlin S. OR04: Muscle Mass Depletion Measured with CT Compared with DXA in Predicting Outcome after Liver Transplantation. Clin Nutr 2016. [DOI: 10.1016/s0261-5614(16)30243-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
43
|
Wahlin S. [Hepatic encephalopathy – the acute management]. Lakartidningen 2016; 113:DPCI. [PMID: 26978809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Hepatic encephalopathy causes significant impairment and morbidity. Hepatic encephalopathy is just one of many causes for altered mental status in patients with cirrhosis of the liver. The initial management at admission to hospital includes a search for differential diagnoses and precipitating factors. A structured description of the type, cause, time course and clinical severity is essential for achieving medically safe communication and care of the HE patient. Lactulose and correction of any precipitating factors is the basis for initial therapy. A post-discharge management which includes frequent monitoring, preventive measures as well as education of patient and caregivers may ameliorate the often very high readmission rate.
Collapse
Affiliation(s)
- Staffan Wahlin
- Karolinska Universitetssjukhuset - Gastrocentrum, Leversektionen Stockholm, Sweden Karolinska Universitetssjukhuset - Gastrocentrum, Leversektionen Stockholm, Sweden
| |
Collapse
|
44
|
Helling G, Wahlin S, Smedberg M, Pettersson L, Tjäder I, Norberg Å, Rooyackers O, Wernerman J. Plasma Glutamine Concentrations in Liver Failure. PLoS One 2016; 11:e0150440. [PMID: 26938452 PMCID: PMC4777432 DOI: 10.1371/journal.pone.0150440] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 02/12/2016] [Indexed: 12/12/2022] Open
Abstract
Background Higher than normal plasma glutamine concentration at admission to an intensive care unit is associated with an unfavorable outcome. Very high plasma glutamine levels are sometimes seen in both acute and chronic liver failure. We aimed to systematically explore the relation between different types of liver failure and plasma glutamine concentrations. Methods Four different groups of patients were studies; chronic liver failure (n = 40), acute on chronic liver failure (n = 20), acute fulminant liver failure (n = 20), and post-hepatectomy liver failure (n = 20). Child-Pugh and Model for End-stage Liver Disease (MELD) scores were assessed as indices of liver function. All groups except the chronic liver failure group were followed longitudinally during hospitalisation. Outcomes were recorded up to 48 months after study inclusion. Results All groups had individuals with very high plasma glutamine concentrations. In the total group of patients (n = 100), severity of liver failure correlated significantly with plasma glutamine concentration, but the correlation was not strong. Conclusion Liver failure, regardless of severity and course of illness, may be associated with a high plasma glutamine concentration. Further studies are needed to understand whether high glutamine levels should be regarded as a biomarker or as a contributor to symptomatology in liver failure.
Collapse
Affiliation(s)
- Gunnel Helling
- Department of Anesthesia & Intensive Care, Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden
| | - Staffan Wahlin
- Department of gastroenterology and hepatology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Marie Smedberg
- Department of Anesthesia & Intensive Care, Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden
| | - Linn Pettersson
- Department of Anesthesia & Intensive Care, Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden
| | - Inga Tjäder
- Department of Anesthesia & Intensive Care, Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden
| | - Åke Norberg
- Department of Anesthesia & Intensive Care, Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden
| | - Olav Rooyackers
- Department of Anesthesia & Intensive Care, Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden
| | - Jan Wernerman
- Department of Anesthesia & Intensive Care, Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| |
Collapse
|
45
|
Lindqvist C, Majeed A, Wahlin S. MON-PP044: Nutrition Impact Symptoms in Patients Listed for Liver Transplantation. Clin Nutr 2015. [DOI: 10.1016/s0261-5614(15)30476-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
46
|
Beyazit Y, Efe C, Tanoglu A, Purnak T, Sayilir A, Taskıran I, Kekilli M, Turhan T, Ozaslan E, Wahlin S. Nitric oxide is a potential mediator of hepatic inflammation and fibrogenesis in autoimmune hepatitis. Scand J Gastroenterol 2015; 50:204-10. [PMID: 25495215 DOI: 10.3109/00365521.2014.974203] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite advances in the understanding of the pathophysiological basis of autoimmune hepatitis (AIH), it is still difficult to delineate the mechanisms involved in progression from hepatic inflammation toward fibrosis. Our aim was to study serum concentrations of NO in AIH of different histological severity and possible effects of immunosuppressive therapy on NO production. MATERIALS AND METHODS We studied serum NO metabolites (NOx) in 47 consecutive patients with AIH and in 28 age- and sex-matched controls. RESULTS Serum NOx concentrations were higher in AIH patients than in controls (10.3 (4.5-27.3 µmol/L) vs. 4.3 (1.6-14.3 µmol/L), p < 0.001). According to liver histology, median NOx concentrations were significantly higher in patients with severe interface hepatitis compared to patients with mild-moderate interface hepatitis (12.3 (4.5-27.3 µmol/L) vs. 9.3 (4.6-20.3 µmol/L), p = 0.029). Similarly, serum NOx concentrations were significantly higher in patients with advanced fibrosis than in those with early fibrosis (12.2 (4.6-27.3 µmol/L) vs. 9.3 (6.6-12.8 µmol/L), p = 0.018). NOx concentrations decreased in 16 AIH patients who were tested also after biochemical remission was achieved (12.6 (4.5-22.8 µmol/L) at baseline and 5.9 (2.8-10.5 µmol/L) after remission, p = 0.001). CONCLUSION This study shows that serum NOx levels are associated with the histological severity of AIH. Hepatocyte inflammation and injury may activate hepatic stellate cells and kupffer cells, and the consequences may include release of NO, which ultimately promotes hepatic fibrosis. Immunosuppressive therapy inhibits this process and the production of NO.
Collapse
Affiliation(s)
- Yavuz Beyazit
- Department of Gastroenterology, Canakkale State Hospital , Canakkale , Turkey
| | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Yin Z, Wahlin S, Ellis ECS, Harper P, Ericzon BG, Nowak G. Hepatocyte Transplantation Ameliorates the Metabolic Abnormality in a Mouse Model of Acute Intermittent Porphyria. Cell Transplant 2014; 23:1153-62. [DOI: 10.3727/096368913x666980] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Acute intermittent porphyria (AIP) is an autosomal dominant disorder characterized by insufficient porphobilinogen deaminase (PBGD) activity. When hepatic heme synthesis is induced, porphobilinogen (PBG) and 5-aminolevulinic acid (ALA) accumulate, which causes clinical symptoms such as abdominal pain, neuropathy, and psychiatric disturbances. Our aim was to investigate if hepatocyte transplantation can prevent or minimize the metabolic alterations in an AIP mouse model. We transplanted wild-type hepatocytes into PBGD-deficient mice and induced heme synthesis with phenobarbital. ALA and PBG concentrations in plasma were monitored, and the gene transcriptions of hepatic enzymes ALAS1, PBGD, and CYP2A5 were analyzed. Results were compared with controls and correlated to the percentage of engrafted hepatocytes. The accumulation of ALA and PBG was reduced by approximately 50% after the second hepatocyte transplantation. We detected no difference in mRNA levels of PBGD, ALAS1, or CYP2A5. Engraftment corresponding to 2.7% of the total hepatocyte mass was achieved following two hepatocyte transplantations. A lack of precursor production in less than 3% of the hepatocytes resulted in a 50% reduction in plasma precursor concentrations. This disproportional finding suggests that ALA and PBG produced in PBGD-deficient hepatocytes crossed cellular membranes and was metabolized by transplanted cells. The lack of effect on enzyme mRNA levels suggests that no significant efflux of heme from normal to PBGD-deficient hepatocytes takes place. Further studies are needed to establish the minimal number of engrafted hepatocytes needed to completely correct the metabolic abnormality in AIP and whether amelioration of the metabolic defect by partial restoration of PBGD enzyme activity translates into a clinical effect in human AIP.
Collapse
Affiliation(s)
- Zhaohui Yin
- Division of Transplantation Surgery, Department for Clinical Science, Intervention and Technology CLINTEC, Karolinska University Hospital, Stockholm, Sweden
- Department of General Surgery, First Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
| | - Staffan Wahlin
- Department of Gastroenterology and Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ewa C. S. Ellis
- Division of Transplantation Surgery, Department for Clinical Science, Intervention and Technology CLINTEC, Karolinska University Hospital, Stockholm, Sweden
| | - Pauline Harper
- Porphyria Centre Sweden, Division of Metabolic Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Bo-Göran Ericzon
- Division of Transplantation Surgery, Department for Clinical Science, Intervention and Technology CLINTEC, Karolinska University Hospital, Stockholm, Sweden
| | - Greg Nowak
- Division of Transplantation Surgery, Department for Clinical Science, Intervention and Technology CLINTEC, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
48
|
Efe C, Kahramanoğlu-Aksoy E, Yilmaz B, Ozseker B, Takci S, Roach EC, Purnak T, Kav T, Ozaslan E, Wahlin S. Pregnancy in women with primary biliary cirrhosis. Autoimmun Rev 2014; 13:931-5. [PMID: 24879082 DOI: 10.1016/j.autrev.2014.05.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 05/20/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Primary biliary cirrhosis (PBC) may present in all decades of life, also in childbearing age. Data on maternal and fetal outcome is limited. We aimed to investigate the impact of pregnancy and childbirth on the disease course and possible effects of PBC on fetal outcome. METHODS Retrospective study of local cases and a compact review of published reports between 1950 and 2014. RESULTS Our cases along with literature review provided 98 pregnancies in 72 PBC patients. PBC was diagnosed during pregnancy in 26 (36%) patients and 46 (64%) had the diagnosis before conception. Twenty-four (30%) of the pregnancies were associated with biochemical flares and 55 (70%) with clinical improvement or stabilization. De novo onset or worsening of pruritus was seen in 49% (45/92). No maternal deaths were reported. Post-partum disease activation was observed in 60% (53/88). One patient was referred for liver transplantation after delivery. A miscarriage rate of 24% and three stillbirths were reported. Most patients were treated with ursodeoxycholic acid (UDCA) during breastfeeding and 12 patients also received UDCA during the first trimester without any identified side effects. CONCLUSION Most women with PBC maintain a stable disease during pregnancy, but post-partum biochemical flares are common. Symptomatic pruritus may be challenging in pregnant PBC patients. UDCA appears to be safe during pregnancy and breastfeeding. A successful pregnancy outcome is a realistic expectation for women with PBC.
Collapse
Affiliation(s)
- Cumali Efe
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey.
| | | | - Bülent Yilmaz
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Burak Ozseker
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Sahin Takci
- Department of Neonatology, Gaziosmanpaşa University, Tokat, Turkey
| | | | - Tugrul Purnak
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Taylan Kav
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Ersan Ozaslan
- Department of Gastroenterology, Numune Research and Education Hospital, Ankara, Turkey
| | - Staffan Wahlin
- Department of Gastroenterology and Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
49
|
Sardh E, Wahlin S, Björnstedt M, Harper P, Andersson DEH. High risk of primary liver cancer in a cohort of 179 patients with Acute Hepatic Porphyria. J Inherit Metab Dis 2013; 36:1063-71. [PMID: 23344888 DOI: 10.1007/s10545-012-9576-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 11/21/2012] [Accepted: 12/12/2012] [Indexed: 12/29/2022]
Abstract
BACKGROUND/AIMS Previous studies have indicated a high risk of hepatocellular carcinoma in acute hepatic porphyrias. In this retrospective study we present the incidence of primary liver cancer and clinical characteristics in a cohort of 179 acute porphyria patients above the age of 50 years. METHODS Twenty-three cases with primary liver cancer were found either by a surveillance program or due to clinical suspicion. Standardized rate ratio was used to estimate the relative risk of primary liver cancer after indirect standardization. Survival data were calculated using the Kaplan-Meier method. RESULTS The mean age at diagnosis was 69 years. Hepatocellular carcinoma was found in 19 patients while four patients had cholangiocarcinoma or a combination of the two. Four patients had underlying cirrhosis. Mean tumour size was 4.3 cm in the surveillance group and 10.3 cm in the non-surveillance group (p = 0.01). The overall relative risk of primary liver cancer was 86 above the age of 50: 150 for women and 37 for men. Mean survival time was 5.7 years. CONCLUSION Acute hepatic porphyria carries a high risk of primary liver cancer above the age of 50 which warrants ultrasound surveillance. Sex distribution and frequency of cirrhosis differs from more common aetiologies of primary liver cancer.
Collapse
Affiliation(s)
- Eliane Sardh
- Department of Internal Medicine, Karolinska Institutet, Stockholm South Hospital, 11883, Stockholm, Sweden,
| | | | | | | | | |
Collapse
|
50
|
Wahlin S, Marschall HU, Fischler B. Maternal and fetal outcome in Swedish women with erythropoietic protoporphyria. Br J Dermatol 2013; 168:1311-5. [PMID: 23738640 DOI: 10.1111/bjd.12242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Painful photosensitivity is characteristic of erythropoietic protoporphyria (EPP). In women, symptoms may be affected by menstrual cycle and pregnancy but very little is known about maternal and fetal outcome. OBJECTIVES To investigate the impact of menstruation, pregnancy and breast-feeding on photosensitivity and possible effects of EPP on maternal, fetal and neonatal outcome. METHODS Retrospective study screening all 20 Swedish women alive and older than 18 years diagnosed with EPP with a total of 33 deliveries. Data were retrieved for 19 women and 32 deliveries in medical records and completed by a questionnaire sent to the patients. RESULTS Photosensitivity worsened in five of 19 (26%) women around menstruation whereas amelioration was reported in 17 of 32 (53%) pregnancies and during 11 of 32 (34%) breast-feeding periods. Fertility rate was normal and there were no maternal or fetal complications apart from minor arterial hypertension in one woman. CONCLUSIONS The study confirms changes in photosensitivity during menstruation and pregnancy. Amelioration during breast-feeding is a new finding. Pregnancy appears safe without increased risks of pregnancy complications or adverse effects on fetal or neonatal health.
Collapse
Affiliation(s)
- S Wahlin
- Department of Gastroenterology and Hepatology, K63, Karolinska Institutet, Karolinska University Hospital, Huddinge, SE-141 86, Stockholm, Sweden.
| | | | | |
Collapse
|