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Maimone S, Saffioti F, Filomia R, Alibrandi A, Isgrò G, Calvaruso V, Xirouchakis E, Guerrini GP, Burroughs AK, Tsochatzis E, Patch D. Predictors of Re-bleeding and Mortality Among Patients with Refractory Variceal Bleeding Undergoing Salvage Transjugular Intrahepatic Portosystemic Shunt (TIPS). Dig Dis Sci 2019; 64:1335-1345. [PMID: 30560334 DOI: 10.1007/s10620-018-5412-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 12/03/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) has proven clinical efficacy as rescue therapy for cirrhotic patients with acute portal hypertensive bleeding who fail endoscopic treatment. AIMS To investigate predictive factors of 6-week and 1-year mortality in patients undergoing salvage TIPS for refractory portal hypertensive bleeding. METHODS A total of 144 consecutive patients were retrospectively evaluated. Three logistic regression multivariate models were estimated to individualize prognostic factors for 6-week and 12-month mortality. Log-rank test was used to evaluate survival according to Child-Pugh classes and Bureau's criteria. RESULTS Mean age 51 ± 10 years, 66% male, mean MELD 18.5 ± 8.3, Child-Pugh A/B/C 8%/38%/54%. TIPS failure occurred in 23(16%) patients and was associated with pre-TIPS portal pressure gradient and pre-TIPS intensive care unit stay. Six-week and 12-month mortality was 36% and 42%, respectively. Pre-TIPS intensive care unit stay, MELD, and Child-Pugh score were independently associated with mortality at 6 weeks. Independent predictors of mortality at 12 months were pre-TIPS intensive care unit stay and Child-Pugh score. CONCLUSIONS In this large cohort of patients undergoing salvage TIPS, MELD and Child-Pugh scores were predictive of short- and long-term mortality, respectively. Pre-TIPS intensive care unit stay was independently associated with TIPS failure and mortality at 6 weeks and 12 months. Salvage TIPS is futile in patients with Child-Pugh score of 14-15.
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Affiliation(s)
- Sergio Maimone
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK.
- Division of Clinical and Molecular Hepatology, Department of Internal Medicine, University Hospital of Messina, Messina, Italy.
| | - Francesca Saffioti
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Roberto Filomia
- Division of Clinical and Molecular Hepatology, Department of Internal Medicine, University Hospital of Messina, Messina, Italy
| | - Angela Alibrandi
- Department of Economics, Unit of Statistical and Mathematical Sciences, University of Messina, Messina, Italy
| | - Grazia Isgrò
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
| | - Vincenza Calvaruso
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
- Gastroenterology and Hepatology Unit, Di.Bi.M.I.S., University of Palermo, Palermo, Italy
| | - Elias Xirouchakis
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
- Gastroenterology and Hepatology Department, Athens Medical P. Faliron Hospital, Athens, Greece
| | - Gian Piero Guerrini
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
- Department of Surgery, Ravenna Hospital, Ravenna, Italy
| | - Andrew K Burroughs
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
| | - Emmanuel Tsochatzis
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
| | - David Patch
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK
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Kalafateli M, Mantzoukis K, Choi Yau Y, Mohammad AO, Arora S, Rodrigues S, de Vos M, Papadimitriou K, Thorburn D, O'Beirne J, Patch D, Pinzani M, Morgan MY, Agarwal B, Yu D, Burroughs AK, Tsochatzis EA. Malnutrition and sarcopenia predict post-liver transplantation outcomes independently of the Model for End-stage Liver Disease score. J Cachexia Sarcopenia Muscle 2017; 8:113-121. [PMID: 27239424 PMCID: PMC4864202 DOI: 10.1002/jcsm.12095] [Citation(s) in RCA: 208] [Impact Index Per Article: 29.7] [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] [Received: 06/03/2015] [Revised: 09/23/2015] [Accepted: 11/02/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Although malnutrition and sarcopenia are prevalent in cirrhosis, their impact on outcomes following liver transplantation is not well documented. METHODS The associations of nutritional status and sarcopenia with post-transplant infections, requirement for mechanical ventilation, intensive care (ICU) and hospital stay, and 1 year mortality were assessed in 232 consecutive transplant recipients. Nutritional status and sarcopenia were assessed using the Royal Free Hospital-Global Assessment (RFH-GA) tool and the L3-psoas muscle index (L3-PMI) on CT, respectively. RESULTS A wide range of RFH-SGA and L3-PMI were observed within similar Model for End-stage Liver Disease (MELD) sub-categories. Malnutrition and sarcopenia were independent predictors of all outcomes. Post-transplant infections were associated with MELD (OR = 1.055, 95%CI = 1.002-1.11) and severe malnutrition (OR = 6.55, 95%CI = 1.99-21.5); ventilation > 24 h with MELD (OR = 1.1, 95%CI = 1.036-1.168), severe malnutrition (OR = 8.5, 95%CI = 1.48-48.87) and suboptimal donor liver (OR = 2.326, 95%CI = 1.056-5.12); ICU stay > 5 days, with age (OR = 1.054, 95%CI = 1.004-1.106), MELD (OR = 1.137, 95%CI = 1.057-1.223) and severe malnutrition (OR = 7.46, 95%CI = 1.57-35.43); hospital stay > 20 days with male sex (OR = 2.107, 95%CI = 1.004-4.419) and L3-PMI (OR = 0.996, 95%CI = 0.994-0.999); 1 year mortality with L3-PMI (OR = 0.996, 95%CI = 0.992-0.999). Patients at the lowest L3-PMI receiving suboptimal grafts had longer ICU/hospital stay and higher incidence of infections. CONCLUSIONS Malnutrition and sarcopenia are associated with early post-liver transplant morbidity/mortality. Allocation indices do not include nutritional status and may jeopardize outcomes in nutritionally compromised individuals.
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Affiliation(s)
- Maria Kalafateli
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | | | - Yan Choi Yau
- Department of RadiologyRoyal Free Hospital London NHS Foundation TrustLondonUK
| | - Ali O. Mohammad
- Intensive Care UnitRoyal Free Hospital London NHS Foundation TrustLondonUK
- Department of Chest DiseasesMinia UniversityEgypt
| | - Simran Arora
- Nutrition and Dietetics DepartmentRoyal Free Hospital London NHS Foundation TrustLondonUK
| | - Susana Rodrigues
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - Marie de Vos
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | | | - Douglas Thorburn
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - James O'Beirne
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - David Patch
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - Massimo Pinzani
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - Marsha Y. Morgan
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
| | - Banwari Agarwal
- Intensive Care UnitRoyal Free Hospital London NHS Foundation TrustLondonUK
| | - Dominic Yu
- Department of RadiologyRoyal Free Hospital London NHS Foundation TrustLondonUK
| | - Andrew K. Burroughs
- UCL Institute for Liver and Digestive HealthRoyal Free Hospital and UCLLondonUK
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3
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Kalafateli M, Wickham F, Burniston M, Cholongitas E, Theocharidou E, Garcovich M, O'Beirne J, Westbrook R, Leandro G, Burroughs AK, Tsochatzis EA. Development and validation of a mathematical equation to estimate glomerular filtration rate in cirrhosis: The royal free hospital cirrhosis glomerular filtration rate. Hepatology 2017; 65:582-591. [PMID: 27779785 DOI: 10.1002/hep.28891] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 09/17/2016] [Accepted: 09/25/2016] [Indexed: 01/02/2023]
Abstract
UNLABELLED Current expressions based on serum creatinine concentration overestimate kidney function in cirrhosis, leading to significant differences between "true" and calculated glomerular filtration rate (GFR). We compared the performance of the four-variable and six-variable Modification of Diet in Renal Disease and chronic kidney disease epidemiology with "true," or measured, GFR (mGFR) and the impact of this difference on Model for End-Stage Liver Disease (MELD) calculation. We subsequently developed and validated a GFR equation specifically for cirrhosis and compared the performance of the new derived formula with existing GFR formulae. We included 469 consecutive patients who had a transplant assessment between 2011 and 2014. mGFR was measured using plasma isotope clearance according to a technique validated in patients with ascites. A corrected creatinine was derived from the mGFR after application of the Modification of Diet in Renal Disease formula. Subsequently, a corrected MELD was calculated and compared with the conventionally calculated MELD. Stepwise multiple linear regression was used to derive a GFR equation. This was compared with the mGFR in independent external and internal validation sets of 82 and 174 patients with cirrhosis, respectively. A difference >20 mL/minute/1.73 m2 between existing formulae and mGFR was observed in 226 (48.2%) patients. The corrected MELD score was ≥3 points higher in 177 (37.7%) patients. The predicted equation (r2 = 74.6%) was GFR = 45.9 × (creatinine-0·836 ) × (urea-0·229 ) × (international normalized ratio-0·113 ) × (age-0.129 [Corrected November 29, 2016: originally written as "age-129."]) × (sodium0·972 ) × 0.809 (if female) × 0.92 (if moderate/severe ascites). An online calculator is available at http://rfh-cirrhosis-gfr.ucl.ac.uk. The model was a good fit and showed the greatest accuracy compared to that of existing formulae. CONCLUSION We developed and validated a new accurate model for GFR assessment in cirrhosis, the Royal Free Hospital cirrhosis GFR, using readily available variables; this remains to be tested and incorporated in prognostic scores in patients with cirrhosis. (Hepatology 2017;65:582-591).
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Affiliation(s)
- Maria Kalafateli
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and University College London, London, UK
| | - Fred Wickham
- Department of Nuclear Medicine, Royal Free Hospital, London, UK
| | - Maria Burniston
- Department of Nuclear Medicine, Royal Free Hospital, London, UK
| | - Evangelos Cholongitas
- 4th Department of Internal Medicine, Hippokration General Hospital of Thessaloniki, Medical School of Aristotle University, Thessaloniki, Greece
| | - Eleni Theocharidou
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and University College London, London, UK
| | - Matteo Garcovich
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and University College London, London, UK
| | - James O'Beirne
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and University College London, London, UK
| | - Rachel Westbrook
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and University College London, London, UK
| | - Gioacchino Leandro
- National Institute of Gastroenterology, "S. de Bellis" Research Hospital, Castellana Grotte, Italy
| | - Andrew K Burroughs
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and University College London, London, UK
| | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and University College London, London, UK
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Salerno F, Borzio M, Pedicino C, Simonetti R, Rossini A, Boccia S, Cacciola I, Burroughs AK, Manini MA, La Mura V, Angeli P, Bernardi M, Dalla Gasperina D, Dionigi E, Dibenedetto C, Arghittu M. The impact of infection by multidrug-resistant agents in patients with cirrhosis. A multicenter prospective study. Liver Int 2017; 37:71-79. [PMID: 27364035 DOI: 10.1111/liv.13195] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 06/17/2016] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Bacterial strains resistant to antibiotics are a serious clinical challenge. We assessed the antibiotic susceptibility of bacteria isolated from infections in patients with cirrhosis by a multicentre investigation. RESULTS Three hundred and thirteen culture-positive infections (173 community acquired [CA] and 140 hospital acquired [HA]) were identified in 308 patients. Urinary tract infections, spontaneous bacterial peritonitis and bacteremias were the most frequent. Quinolone-resistant Gram-negative isolates were 48%, 44% were extended-spectrum beta-lactamase producers and 9% carbapenem resistant. In 83/313 culture-positive infections (27%), multidrug-resistant agents (MDRA) were isolated. This prevalence did not differ between CA and HA infections. MDRA were identified in 17 of 37 patients on quinolone prophylaxis, and in 46 of 166 not on prophylaxis (45% vs 27%; P<.03). In 287 cases an empiric antibiotic therapy was undertaken, in 37 (12.9%) this therapy failed. The in-hospital mortality rate of this subset of patients was significantly higher compared to patients who received an effective broad(er)-spectrum therapy (P=.038). During a 3-month follow-up, 56/203 culture-positive patients (27.6%) died, 24/63 who have had MDRA-related infections (38%) and 32/140 who have had antibiotic-susceptible infections (22.8%) (P=.025). Multivariate analysis disclosed MDRA infection, age, hepatocellular carcinoma, bilirubin, international normalized ratio and the occurrence of portal hypertension-related complications independent predictors of death. CONCLUSIONS Infection by MDRA is frequent in patients with cirrhosis and the prognosis is severe, especially in patients unresponsive to empiric antibiotic therapy.
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Affiliation(s)
- Francesco Salerno
- Medicina Interna, IRCCS San Donato, Università degli studi di Milano, San Donato Milanese, Milano, Italy
| | - Mauro Borzio
- Unità di Gastroenterologia e Microbiologia, Ospedale Predabissi, Melegnano, Italy
| | - Claudia Pedicino
- Unità di Gastroenterologia e Microbiologia, Ospedale Predabissi, Melegnano, Italy
| | - Rosa Simonetti
- Unità di Medicina 2, Ospedali Riuniti, Villa Sofia Cervello, Palermo, Italy
| | - Angelo Rossini
- Unità di Epatologia, Dipartimento di Medicina, Azienda Ospedaliera Spedali Civili, Brescia, Italy
| | - Sergio Boccia
- Unità di Gastroenterologia, Azienda Universitaria Ospedaliera di Ferrara, Ferrara, Italy
| | - Irene Cacciola
- Unità di Epatologia Clinica e Biomolecolare, Policlinico Universitario, Messina, Italy
| | | | - Matteo A Manini
- Gastroenterologia-1, IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Vincenzo La Mura
- Medicina Interna, IRCCS San Donato, Università degli studi di Milano, San Donato Milanese, Milano, Italy
| | - Paolo Angeli
- Medicina Clinica e Sperimentale, Policlinico Universitario, Padova, Italy
| | - Mauro Bernardi
- Unità di Semeiotica Medica, Department of Clinical Medicine, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Daniela Dalla Gasperina
- Sezione di Malattie Infettive, Dipartimento di Medicina Clinica, Università dell'Insubria, Varese, Italy
| | - Elena Dionigi
- Unità di Gastroenterologia e Microbiologia, Ospedale Predabissi, Melegnano, Italy
| | - Clara Dibenedetto
- Unità di Gastroenterologia e Microbiologia, Ospedale Predabissi, Melegnano, Italy
| | - Milena Arghittu
- Unità di Gastroenterologia e Microbiologia, Ospedale Predabissi, Melegnano, Italy
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5
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Theocharidou E, Pieri G, Mohammad AO, Cheung M, Cholongitas E, Banwari A, Burroughs AK. Erratum: The Royal Free Hospital Score: A Calibrated Prognostic Model for Patients With Cirrhosis Admitted to Intensive Care Unit. Comparison With Current Models and CLIF-SOFA Score. Am J Gastroenterol 2017; 112:193. [PMID: 27958283 PMCID: PMC5817385 DOI: 10.1038/ajg.2016.562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Desborough MJR, Hockley B, Sekhar M, Burroughs AK, Stanworth SJ, Jairath V. Patterns of blood component use in cirrhosis: a nationwide study. Liver Int 2016; 36:522-9. [PMID: 26537012 DOI: 10.1111/liv.12999] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [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: 08/19/2015] [Accepted: 10/27/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Cirrhosis is a complex acquired disorder of coagulation and frequent indication for transfusion of blood components. We characterised blood component use in patients with cirrhosis and compared this to transfusion guidelines. METHODS All National Health Service trusts with representation on the British Society of Gastroenterology membership list were invited to take part. Data were collected prospectively on consecutive, unselected, hospitalised admissions with cirrhosis over 28 days. Detailed information was recorded for patients receiving blood components including indication (for bleeding or prophylaxis), type of component, laboratory indices triggering transfusion, complications, thromboembolic events and clinical outcome to day 28. RESULTS Data on 1313 consecutive patients with cirrhosis were collected from 85 hospitals. A total of 391/1313 (30%) were transfused a blood component; in 238/391 (61%), this was for treatment of bleeding and in 153/391 (39%) for prophylaxis of bleeding. In 48/185 (26%) cases with bleeding, the haemoglobin threshold was >80 g/L prior to red blood cell transfusion. In the prophylaxis group, 238/391 (61%) received transfusion in response to an abnormal haematological value in the absence of any planned procedure. In patients transfused for procedural prophylaxis, 10/34 (29%) received fresh frozen plasma at an International Normalised Ratio lower than the threshold where a benefit would be anticipated. An in-patient thromboembolic event was recorded in 3% (35/1313) and 10% (138/1313) died by day 28. CONCLUSIONS One-third of hospitalised patients with cirrhosis were transfused. Strategies for Patient Blood Management should include ensuring transfusion practice is consistent with guidelines and greater emphasis on alternatives to transfusion.
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Affiliation(s)
- Michael J R Desborough
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK.,Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Brian Hockley
- NHS Blood and Transplant, Sheffield Blood Centre, Sheffield, UK
| | - Mallika Sekhar
- Department of Haematology, Royal Free Hospital, London, UK
| | - Andrew K Burroughs
- Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK.,University College London Institute of Liver and Digestive Health, University College London, London, UK
| | | | - Vipul Jairath
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK.,Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
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7
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Carbone M, Sharp SJ, Flack S, Paximadas D, Spiess K, Adgey C, Griffiths L, Lim R, Trembling P, Williamson K, Wareham NJ, Aldersley M, Bathgate A, Burroughs AK, Heneghan MA, Neuberger JM, Thorburn D, Hirschfield GM, Cordell HJ, Alexander GJ, Jones DE, Sandford RN, Mells GF. The UK-PBC risk scores: Derivation and validation of a scoring system for long-term prediction of end-stage liver disease in primary biliary cholangitis. Hepatology 2016; 63. [PMID: 26223498 PMCID: PMC6984963 DOI: 10.1002/hep.28017] [Citation(s) in RCA: 228] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
UNLABELLED The biochemical response to ursodeoxycholic acid (UDCA)--so-called "treatment response"--strongly predicts long-term outcome in primary biliary cholangitis (PBC). Several long-term prognostic models based solely on the treatment response have been developed that are widely used to risk stratify PBC patients and guide their management. However, they do not take other prognostic variables into account, such as the stage of the liver disease. We sought to improve existing long-term prognostic models of PBC using data from the UK-PBC Research Cohort. We performed Cox's proportional hazards regression analysis of diverse explanatory variables in a derivation cohort of 1,916 UDCA-treated participants. We used nonautomatic backward selection to derive the best-fitting Cox model, from which we derived a multivariable fractional polynomial model. We combined linear predictors and baseline survivor functions in equations to score the risk of a liver transplant or liver-related death occurring within 5, 10, or 15 years. We validated these risk scores in an independent cohort of 1,249 UDCA-treated participants. The best-fitting model consisted of the baseline albumin and platelet count, as well as the bilirubin, transaminases, and alkaline phosphatase, after 12 months of UDCA. In the validation cohort, the 5-, 10-, and 15-year risk scores were highly accurate (areas under the curve: >0.90). CONCLUSIONS The prognosis of PBC patients can be accurately evaluated using the UK-PBC risk scores. They may be used to identify high-risk patients for closer monitoring and second-line therapies, as well as low-risk patients who could potentially be followed up in primary care.
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Affiliation(s)
- Marco Carbone
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, United Kingdom,Division of Gastroenterology and Hepatology, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Stephen J. Sharp
- MRC Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
| | - Steve Flack
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, United Kingdom
| | - Dimitrios Paximadas
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, United Kingdom
| | - Kelly Spiess
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, United Kingdom
| | - Carolyn Adgey
- Liver Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - Laura Griffiths
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Reyna Lim
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Paul Trembling
- Liver Unit, Barts and the London NHS Trust, London, United Kingdom
| | - Kate Williamson
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, United Kingdom
| | - Nick J. Wareham
- MRC Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
| | - Mark Aldersley
- Liver Unit, St James’s University Hospital, Leeds, United Kingdom
| | - Andrew Bathgate
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Andrew K. Burroughs
- Sheila Sherlock Liver Center, The Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Michael A. Heneghan
- Institute of Liver Studies, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | | | - Douglas Thorburn
- Sheila Sherlock Liver Center, The Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Gideon M. Hirschfield
- Center for Liver Research and NIHR Biomedical Research Unit, University of Birmingham, Birmingham, United Kingdom
| | - Heather J. Cordell
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Graeme J. Alexander
- Division of Gastroenterology and Hepatology, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - David E.J. Jones
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Richard N. Sandford
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, United Kingdom
| | - George F. Mells
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, United Kingdom,Division of Gastroenterology and Hepatology, Addenbrooke’s Hospital, Cambridge, United Kingdom
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8
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Trivedi PJ, Lammers WJ, van Buuren HR, Parés A, Floreani A, Janssen HLA, Invernizzi P, Battezzati PM, Ponsioen CY, Corpechot C, Poupon R, Mayo MJ, Burroughs AK, Nevens F, Mason AL, Kowdley KV, Lleo A, Caballeria L, Lindor KD, Hansen BE, Hirschfield GM. Stratification of hepatocellular carcinoma risk in primary biliary cirrhosis: a multicentre international study. Gut 2016; 65:321-9. [PMID: 25567117 DOI: 10.1136/gutjnl-2014-308351] [Citation(s) in RCA: 106] [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] [Received: 09/01/2014] [Accepted: 12/08/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Hepatocellular carcinoma (HCC) is an infrequent yet critical event in primary biliary cirrhosis (PBC); however, predictive tools remain ill-defined. Our objective was to identify candidate risk factors for HCC development in patients with PBC. DESIGN Risk factor analysis was performed in over 15 centres from North America and Europe spanning >40 years observation period using Cox proportional hazards assumptions, logistic regression, and Kaplan-Meier estimates. RESULTS Of 4565 patients with PBC 123 developed HCC, yielding an incidence rate (IR) of 3.4 cases/1000 patient-years. HCC was significantly more common in men (p<0.0001), and on univariate analysis factors at PBC diagnosis associated with future HCC development were male sex (unadjusted HR 2.91, p<0.0001), elevated serum aspartate transaminase (HR 1.24, p<0.0001), advanced disease (HR 2.72, p=0.022), thrombocytopenia (HR 1.65, p<0.0001), and hepatic decompensation (HR 9.89, p<0.0001). As such, non-treatment with ursodeoxycholic acid itself was not associated with cancer development; however, 12-month stratification by biochemical non-response (Paris-I criteria) associated significantly with future risk of HCC (HR 4.52, p<0.0001; IR 6.6 vs 1.4, p<0.0001). Non-response predicted future risk in patients with early stage disease (IR 4.7 vs 1.2, p=0.005), advanced disease (HR 2.79, p=0.02; IR 11.2 vs 4.4, p=0.033), and when restricting the analysis to only male patients (HR 4.44, p<0.001; IR 18.2 vs 5.4, p<0.001). On multivariable analysis biochemical non-response remained the most significant factor predictive of future HCC risk (adjusted HR 3.44, p<0.0001). CONCLUSIONS This uniquely powered, internationally representative cohort robustly demonstrates that 12-month biochemical non-response is associated with increased future risk of developing HCC in PBC. Such risk stratification is relevant to patient care and development of new therapies.
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Affiliation(s)
- Palak J Trivedi
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit (BRU) and Centre for Liver Research, University of Birmingham, Birmingham, UK Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Albert Parés
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Annarosa Floreani
- Department of Surgical, Oncological and Gastroenterological, University of Padua, Padua, Italy
| | - Harry L A Janssen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands Toronto Center for Liver Diseases, Toronto Western & General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Pietro Invernizzi
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center, Rozzano (MI), Italy
| | | | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, The Netherlands
| | - Christophe Corpechot
- Center de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Raoul Poupon
- Center de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Marlyn J Mayo
- Department of Digestive and Liver diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | | | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Andrew L Mason
- Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Kris V Kowdley
- Liver Center of Excellence, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA Liver Care Network, Swedish Medical Center, Seattle, Washington, USA
| | - Ana Lleo
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center, Rozzano (MI), Italy
| | - Llorenç Caballeria
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Keith D Lindor
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA Arizona State University, Phoenix, Arizona, USA
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gideon M Hirschfield
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit (BRU) and Centre for Liver Research, University of Birmingham, Birmingham, UK Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
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9
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Lammers WJ, Hirschfield GM, Corpechot C, Nevens F, Lindor KD, Janssen HLA, Floreani A, Ponsioen CY, Mayo MJ, Invernizzi P, Battezzati PM, Parés A, Burroughs AK, Mason AL, Kowdley KV, Kumagi T, Harms MH, Trivedi PJ, Poupon R, Cheung A, Lleo A, Caballeria L, Hansen BE, van Buuren HR. Development and Validation of a Scoring System to Predict Outcomes of Patients With Primary Biliary Cirrhosis Receiving Ursodeoxycholic Acid Therapy. Gastroenterology 2015; 149:1804-1812.e4. [PMID: 26261009 DOI: 10.1053/j.gastro.2015.07.061] [Citation(s) in RCA: 275] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 07/27/2015] [Accepted: 07/30/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Approaches to risk stratification for patients with primary biliary cirrhosis (PBC) are limited, single-center based, and often dichotomous. We aimed to develop and validate a better model for determining prognoses of patients with PBC. METHODS We performed an international, multicenter meta-analysis of 4119 patients with PBC treated with ursodeoxycholic acid at liver centers in 8 European and North American countries. Patients were randomly assigned to derivation (n = 2488 [60%]) and validation cohorts (n = 1631 [40%]). A risk score (GLOBE score) to predict transplantation-free survival was developed and validated with univariate and multivariable Cox regression analyses using clinical and biochemical variables obtained after 1 year of ursodeoxycholic acid therapy. Risk score outcomes were compared with the survival of age-, sex-, and calendar time-matched members of the general population. The prognostic ability of the GLOBE score was evaluated alongside those of the Barcelona, Paris-1, Rotterdam, Toronto, and Paris-2 criteria. RESULTS Age (hazard ratio = 1.05; 95% confidence interval [CI]: 1.04-1.06; P < .0001); levels of bilirubin (hazard ratio = 2.56; 95% CI: 2.22-2.95; P < .0001), albumin (hazard ratio = 0.10; 95% CI: 0.05-0.24; P < .0001), and alkaline phosphatase (hazard ratio = 1.40; 95% CI: 1.18-1.67; P = .0002); and platelet count (hazard ratio/10 units decrease = 0.97; 95% CI: 0.96-0.99; P < .0001) were all independently associated with death or liver transplantation (C-statistic derivation, 0.81; 95% CI: 0.79-0.83, and validation cohort, 0.82; 95% CI: 0.79-0.84). Patients with risk scores >0.30 had significantly shorter times of transplant-free survival than matched healthy individuals (P < .0001). The GLOBE score identified patients who would survive for 5 years and 10 years (responders) with positive predictive values of 98% and 88%, respectively. Up to 22% and 21% of events and nonevents, respectively, 10 years after initiation of treatment were correctly reclassified in comparison with earlier proposed criteria. In subgroups of patients aged <45, 45-52, 52-58, 58-66, and ≥66 years, age-specific GLOBE-score thresholds beyond which survival significantly deviated from matched healthy individuals were -0.52, 0.01, 0.60, 1.01 and 1.69, respectively. Transplant-free survival could still be accurately calculated by the GLOBE score with laboratory values collected at 2-5 years after treatment. CONCLUSIONS We developed and validated scoring system (the GLOBE score) to predict transplant-free survival of ursodeoxycholic acid-treated patients with PBC. This score might be used to select strategies for treatment and care.
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Affiliation(s)
- Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Gideon M Hirschfield
- NIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, United Kingdom
| | - Christophe Corpechot
- Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Keith D Lindor
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota; Arizona State University, College of Health Solutions, Phoenix, Arizona
| | - Harry L A Janssen
- Liver Clinic, Toronto Western and General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Marlyn J Mayo
- Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Pietro Invernizzi
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Pier M Battezzati
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Albert Parés
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Andrew K Burroughs
- The Sheila Sherlock Liver Centre, The Royal Free Hospital, London, United Kingdom
| | - Andrew L Mason
- Divison of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Kris V Kowdley
- Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, Washington
| | - Teru Kumagi
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Maren H Harms
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Palak J Trivedi
- NIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, United Kingdom
| | - Raoul Poupon
- Centre de Référence des Maladies Inflammatoires des Voies Biliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Angela Cheung
- Liver Clinic, Toronto Western and General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Ana Lleo
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Llorenç Caballeria
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands.
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Theocharidou E, Agarwal B, Jeffrey G, Jalan R, Harrison D, Burroughs AK, Kibbler CC. Early invasive fungal infections and colonization in patients with cirrhosis admitted to the intensive care unit. Clin Microbiol Infect 2015; 22:189.e1-189.e7. [PMID: 26551838 DOI: 10.1016/j.cmi.2015.10.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 10/15/2015] [Accepted: 10/21/2015] [Indexed: 12/15/2022]
Abstract
Bacterial infections in cirrhosis are common and associated with increased mortality, but little is known about fungal infections. The aim of this study, a sub-analysis of the Fungal Infection Risk Evaluation study, was to assess the incidence and implications of early invasive fungal disease (IFD) in patients with cirrhosis admitted to intensive care units (ICU). Clinical and laboratory parameters collected in the first 3 days of ICU stay for 782 patients with cirrhosis and/or portal hypertension were analysed and compared with those of 273 patients with very severe cardiovascular disease (CVD). The CVD patients had more co-morbidities and higher APACHE II scores. The overall incidence of IFD was similar in the two groups, but the incidence of IFD in ICU was higher in liver patients (1% versus 0.4%; p 0.025) as was fungal colonization (23.8% versus 13.9%; p 0.001). The ICU and in-hospital mortality, and length of stay were similar in the two groups. A higher proportion of liver patients received antifungal therapy (19.2% versus 7%; p <0.0005). There was no difference in mortality between colonized patients who received antifungal therapy and colonized patients who did not. The incidence of IFD in patients with cirrhosis in ICU is higher compared with another high-risk group, although it is still very low. This risk might be higher in patients with advanced liver disease admitted with acute-on-chronic liver failure, and this should be investigated further. Our data do not support prophylactic use of antifungal therapy in cirrhosis.
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Affiliation(s)
- E Theocharidou
- Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - B Agarwal
- Intensive Care Unit, Royal Free Hospital, London, UK
| | - G Jeffrey
- Western Australian Liver Transplantation Service, Sir Charles Gairdner Hospital, Perth, Australia
| | - R Jalan
- Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - D Harrison
- Intensive Care National Audit and Research Centre, London, UK
| | - A K Burroughs
- Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - C C Kibbler
- Centre for Medical Microbiology, University College London, UK.
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11
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Calvaruso V, Di Marco V, Bavetta MG, Cabibi D, Conte E, Bronte F, Simone F, Burroughs AK, Craxì A. Quantification of fibrosis by collagen proportionate area predicts hepatic decompensation in hepatitis C cirrhosis. Aliment Pharmacol Ther 2015; 41:477-86. [PMID: 25580867 DOI: 10.1111/apt.13051] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 04/17/2014] [Accepted: 11/24/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND It is unclear whether the course of cirrhosis and its prognosis are related to the amount of collagen in the liver. AIM To determine whether fibrosis, assessed by collagen proportionate area (CPA) in patients with compensated cirrhosis, is associated with the presence of oesophageal varices, and predict disease decompensation during the follow-up period. METHODS We prospectively evaluated 118 consecutive patients with compensated cirrhosis to correlate fibrosis, assessed by CPA in liver biopsies, with the presence of oesophageal varices (OV) and with the rate of liver decompensation (LD) development during a median follow-up of 72 months. RESULTS At baseline 38 (32.2%) patients had OV and during the follow-up (median 72 months, IQR 47-91), 17 patients (14.4%) developed LD. The mean CPA value was different in patients with and without OV (14.8 ± 5.9% vs. 21.6 ± 9.5%, P < 0.001). The best CPA cut-off for OV by area under the receiver operating characteristic (AUROC) was ≥14% and with multivariate logistic analysis CPA was the only variable associated with OV (OR: 28.32, 95% CI: 6.30-127.28; P < 0.001). By AUROC analysis the best CPA cut-off to predict LD was 18.0%. By Cox regression multivariate analysis CPA ≥18% (HR: 3.99, 95% CI: 1.04-11.45; P = 0.036), albumin (HR: 0.12, 95% CI: 0.04-0.43; P = 0.001) and presence of OV (HR: 8.15, 95% CI: 2.31-28.78; P = 0.001) were independently associated with LD. CONCLUSION Quantification of fibrosis by collagen proportionate area allows identification of patients with compensated HCV cirrhosis with a higher likelihood of clinically relevant portal hypertension and a higher risk of decompensation.
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Affiliation(s)
- V Calvaruso
- Sezione di Gastroenterologia e Epatologia, Dipartimento Biomedico di Medicina Interna e Specialistica (Di.Bi.M.I.S.), University of Palermo, Palermo, Italy
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12
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Pavlov CS, Casazza G, Nikolova D, Tsochatzis E, Burroughs AK, Ivashkin VT, Gluud C. Transient elastography for diagnosis of stages of hepatic fibrosis and cirrhosis in people with alcoholic liver disease. Cochrane Database Syst Rev 2015; 1:CD010542. [PMID: 25612182 PMCID: PMC7081746 DOI: 10.1002/14651858.cd010542.pub2] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The presence and progression of hepatic (liver) fibrosis into cirrhosis is a prognostic variable having impact on survival in people with alcoholic liver disease. Liver biopsy, although an invasive method, is the recommended 'reference standard' for diagnosis and staging of hepatic fibrosis in people with liver diseases. Transient elastography is a non-invasive method for assessing and staging hepatic fibrosis. OBJECTIVES To determine the diagnostic accuracy of transient elastography for diagnosis and staging hepatic fibrosis in people with alcoholic liver disease when compared with liver biopsy. To identify the optimal cut-off values for differentiating the five stages of hepatic fibrosis. SEARCH METHODS The Cochrane Hepato-Biliary Group Controlled and Diagnostic Test Accuracy Studies Registers, The Cochrane Library, MEDLINE (OvidSP), EMBASE (OvidSP), and the Science Citation Index Expanded (last search August 2014). SELECTION CRITERIA Diagnostic cohort and diagnostic case-control study designs that assessed hepatic fibrosis in participants with alcoholic liver disease with transient elastography and liver biopsy, irrespective of language or publication status. The study participants could be of any sex and ethnic origin, above 16 years old, hospitalised or managed as outpatients. We excluded participants with viral hepatitis, autoimmunity, metabolic diseases, and toxins. DATA COLLECTION AND ANALYSIS We followed the guidelines in the draft Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy. MAIN RESULTS Five retrospective and nine prospective cohort studies with 834 participants provided data for the review analyses. Authors of seven of those studies sent us individual participant data. The risk of bias in the included studies was high in all but three studies. We could identify no serious concerns regarding the applicability of the studies in answering the main study question of our review, namely to use transient elastography to diagnose hepatic fibrosis. We could not identify the optimal cut-off values for the fibrosis stages. The definition of the diagnosis of alcoholic liver disease was not provided in one study and was not clearly defined in two studies, but it was clear in the remaining 11 studies. The study authors used different liver stiffness cut-off values of transient elastography for the hepatic fibrosis stages.There was only one study (103 participants) with data on hepatic fibrosis stage F1 or worse, with a cut-off of 5.9 kPa, and reporting sensitivity of 0.83 (95% confidence interval (CI) 0.74 to 0.90) and specificity of 0.88 (95% CI 0.47 to 1.00). The summary sensitivity and specificity of transient elastography for F2 or worse (seven studies with 338 participants and with cut-offs around 7.5 kPa (range 7.00 to 7.8 kPa)) were 0.94 and 0.89 with LR+ 8.2 and LR- 0.07, which suggests that transient elastography could be useful to rule out the presence of significant hepatic fibrosis, thus avoiding liver biopsy.Due to the wide range of cut-off values (from 8.0 to 17.0 kPa) found in the 10 studies with 760 participants with hepatic fibrosis F3 or worse, we fitted a hierarchical summary receiver operating characteristic (HSROC) model and estimated a summary ROC (SROC) curve. The sensitivity of the 10 studies varied from 72% to 100% and the specificity from 59% to 89%. We performed an additional analysis by including the studies with a cut-off value of around and equal to 9.5 kPa (range 8.0 to 11.0 kPa). The summary sensitivity and specificity of transient elastography (eight studies with 564 participants) were 0.92 and 0.70 with LR+ 3.1 and LR- 0.11, which suggests that transient elastography could also be useful to rule out the presence of severe hepatic fibrosis (F3 or worse), avoiding liver biopsy. We carried out a sensitivity analysis by considering only the studies with a cut-off value equal to 9.5 kPa and the result did not differ.We performed an HSROC analysis and reported an SROC curve for hepatic fibrosis stage F4 (cirrhosis). The HSROC analysis suggested that when the cut-off value changes, there is a wide variation in specificity and a more limited variation in sensitivity. We performed an additional analysis with the studies with the most commonly used cut-off value of 12.5 kPa. The summary sensitivity and specificity of transient elastography (seven studies with 330 participants) were 0.95 and 0.71 with LR+ 3.3 and LR- 0.07, which again suggests that transient elastography could be useful to rule out the presence of cirrhosis, avoiding liver biopsy. AUTHORS' CONCLUSIONS We identified a small number of studies with a few participants and were unable to include several studies, which raises the risk of outcome reporting bias. With these caveats in mind, transient elastography may be used as a diagnostic method to rule out liver cirrhosis (F4) in people with alcoholic liver disease when the pre-test probability is about 51% (range 15% to 79%). Transient elastography may also help in ruling out severe fibrosis (F3 or worse). Liver biopsy investigation remains an option if the certainty to rule in or rule out the stage of hepatic fibrosis or cirrhosis remains insufficient after a clinical follow-up or any other non-invasive test considered useful by the clinician.The proposed cut-off values for the different stages of hepatic fibrosis may be used in clinical practice, but caution is needed, as those values reported in this review are only the most common cut-off values used by the study authors. The best cut-off values for hepatic fibrosis in people with alcoholic liver disease could not be established yet.In order to diagnose correctly the stage of hepatic fibrosis in people with alcoholic liver disease using transient elastography assessment, the studies should consider a single aetiology. Hepatic fibrosis should be diagnosed with both transient elastography and liver biopsy and in this sequence, and transient elastography cut-off values should be pre-specified and validated. The time interval between the two investigations should not exceed three months, which is the interval mainly valid for people without cirrhosis, and assessment of results should be properly blinded. Only studies with low risk of bias, fulfilling the Standards for Reporting of Diagnostic Accuracy may answer the review question.
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Affiliation(s)
- Chavdar S Pavlov
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
- I.M. Sechenov First Moscow State Medical UniversityClinic of Internal Diseases PropedeuticsPogodinskaja 1MoscowRussian Federation119991
| | - Giovanni Casazza
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Università degli Studi di MilanoDipartimento di Scienze Biomediche e Cliniche "L. Sacco"via GB Grassi 74MilanItaly20157
| | - Dimitrinka Nikolova
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Emmanuel Tsochatzis
- Royal Free Hampstead NHS Foundation Trust and UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentrePond StreetHampsteadLondonUKNW3 2QG
| | - Andrew K Burroughs
- Royal Free Hampstead NHS Foundation TrustSheila Sherlock Liver CentrePond StreetHampsteadLondonUKNW3 2QG
| | - Vladimir T Ivashkin
- I.M. Sechenov First Moscow State Medical UniversityClinic of Internal Diseases PropedeuticsPogodinskaja 1MoscowRussian Federation119991
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
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Rodríguez-Perálvarez M, García-Caparrós C, Tsochatzis E, Germani G, Hogan B, Poyato-González A, O'Beirne J, Senzolo M, Guerrero-Misas M, Montero-Álvarez JL, Patch D, Barrera P, Briceño J, Dhillon AP, Burra P, Burroughs AK, De la Mata M. Lack of agreement for defining 'clinical suspicion of rejection' in liver transplantation: a model to select candidates for liver biopsy. Transpl Int 2015; 28:455-64. [PMID: 25557691 DOI: 10.1111/tri.12514] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 10/17/2014] [Accepted: 12/30/2014] [Indexed: 12/14/2022]
Abstract
The gold standard to diagnose acute cellular rejection (ACR) after liver transplantation (LT) is histological evaluation, but there is no consensus to select patients for liver biopsy. We aimed to evaluate the agreement among clinicians to select candidates for liver biopsy early after LT. From a protocol biopsy population (n = 690), we randomly selected 100 LT patients in whom the biopsy was taken 7-10 days after LT. The clinical information between LT and protocol biopsy was given to nine clinicians from three transplant centres who decided whether a liver biopsy was needed. The agreement among clinicians to select candidates for liver biopsy was poor: κ = 0.06-0.62, being κ < 0.40 in 76% of comparisons. The concordance between indication for liver biopsy and moderate-severe ACR in the protocol biopsy was κ < 0.30 in all cases. A multivariate model based on the product age-by-MELD (OR = 0.81; P = 0.013), delta eosinophils (OR = 1.5; P = 0.002) and mean tacrolimus trough concentrations <6 ng/ml within the prior 4 days (OR = 11.4; P = 0.047) had an AUROC = 0.84 to diagnose moderate-severe histological ACR. In conclusion, the agreement among clinicians to select patients for liver biopsy is very poor. If further validated the proposed model would provide an objective method to select candidates for liver biopsy after LT.
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Affiliation(s)
- Manuel Rodríguez-Perálvarez
- Department of Hepatology and Liver Transplantation, Reina Sofía University Hospital, IMIBIC, CIBERehd, Córdoba, Spain
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14
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Aldridge RW, Mattes FM, Rolando N, Rolles K, Smith C, Shirling G, Atkinson C, Burroughs AK, Milne RSB, Emery VC, Griffiths PD. Effects of donor/recipient human leukocyte antigen mismatch on human cytomegalovirus replication following liver transplantation. Transpl Infect Dis 2015; 17:25-32. [PMID: 25572799 PMCID: PMC4345424 DOI: 10.1111/tid.12325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 07/24/2014] [Revised: 09/16/2014] [Accepted: 09/28/2014] [Indexed: 11/30/2022]
Abstract
Background Natural immunity against cytomegalovirus (CMV) can control virus replication after solid organ transplantation; however, it is not known which components of the adaptive immune system mediate this protection. We investigated whether this protection requires human leukocyte antigen (HLA) matching between donor and recipient by exploiting the fact that, unlike transplantation of other solid organs, liver transplantation does not require HLA matching, but some donor and recipient pairs may nevertheless be matched by chance. Methods To further investigate this immune control, we determined whether chance HLA matching between donor (D) and recipient (R) in liver transplants affected a range of viral replication parameters. Results In total, 274 liver transplant recipients were stratified according to matches at the HLA A, HLA B, and HLA DR loci. The incidence of CMV viremia, kinetics of replication, and peak viral load were similar between the HLA matched and mismatched patients in the D+/R+ and D−/R+ transplant groups. D+/R− transplants with 1 or 2 mismatches at the HLA DR locus had a higher incidence of CMV viremia >3000 genomes/mL blood compared to patients matched at this locus (78% vs. 17%; P = 0.01). Evidence was seen that matching at the HLA A locus had a small effect on peak viral loads in D+/R− patients, with median peak loads of 3540 and 14,706 genomes/mL in the 0 and combined (1 and 2) mismatch groups, respectively (P = 0.03). Conclusion Overall, our data indicate that, in the setting of liver transplantation, prevention of CMV infection and control of CMV replication by adaptive immunity is minimally influenced by HLA matching of the donor and recipient. Our data raise questions about immune control of CMV in the liver and also about the cells in which the virus is amplified to give rise to CMV viremia.
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Affiliation(s)
- R W Aldridge
- Department of Infection and Population Health, University College London (UCL), London, UK
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15
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Fan ST, Le Treut YP, Mazzaferro V, Burroughs AK, Olausson M, Breitenstein S, Frilling A. Liver transplantation for neuroendocrine tumour liver metastases. HPB (Oxford) 2015; 17:23-8. [PMID: 24992381 PMCID: PMC4266437 DOI: 10.1111/hpb.12308] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 06/02/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Search and review of available literature were made to define the indications for and timing of liver transplantation for neuroendocrine tumour (NET) liver metastases. METHODS Electronic bibliographical databases were searched. Prospective and retrospective cohort studies and case-controlled studies were used for qualitative and quantitative synthesis of the systematic review. Reports of patients with liver transplantation alone for NET liver metastases of any origin or combined with resection of extrahepatic tumour deposits were recruited. RESULTS The number of patients who have undergone liver transplantation for NET liver metastases is 706. The post-transplant 5-year survival rate from the time of diagnosis was approximately 70%. NET patients with metastases confined to the liver and not poorly differentiated are favourable candidates for liver transplantation. Selection of patients based on evolution of tumours over 6 months is not recommended. CONCLUSION Non-resectable NET liver metastasis resistant to medical treatment and confined to the liver is an accepted indication for liver transplantation.
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Affiliation(s)
- Sheung Tat Fan
- Department of Surgery, The University of Hong Kong, and Liver Surgery Centre, Hong Kong Sanatorium and HospitalHong Kong,Correspondence, Sheung Tat Fan, 102 Pok Fu Lam Road, Hong Kong. Tel: +852 22554703. Fax: +852 28551897. E-mail:
| | - Yves Patrice Le Treut
- Service de Chirurgie Générale et Transplantation Hépatique, Hôpital de la ConceptionMarseille, France
| | - Vincenzo Mazzaferro
- Gastrointestinal and Hepato-Pancreatic Surgery and Liver Transplantation Unit, Istituto Nazional dei TumoriMilan, Italy
| | | | | | - Stefan Breitenstein
- Department of Visceral and Transplant Surgery, Swiss Hepato-Pancreato-Biliary Center, University Hospital ZurichZurich, Switzerland
| | - Andrea Frilling
- Department of Surgery and Cancer, Imperial College LondonLondon, UK
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Lammers WJ, van Buuren HR, Hirschfield GM, Janssen HLA, Invernizzi P, Mason AL, Ponsioen CY, Floreani A, Corpechot C, Mayo MJ, Battezzati PM, Parés A, Nevens F, Burroughs AK, Kowdley KV, Trivedi PJ, Kumagi T, Cheung A, Lleo A, Imam MH, Boonstra K, Cazzagon N, Franceschet I, Poupon R, Caballeria L, Pieri G, Kanwar PS, Lindor KD, Hansen BE. Levels of alkaline phosphatase and bilirubin are surrogate end points of outcomes of patients with primary biliary cirrhosis: an international follow-up study. Gastroenterology 2014; 147:1338-49.e5; quiz e15. [PMID: 25160979 DOI: 10.1053/j.gastro.2014.08.029] [Citation(s) in RCA: 297] [Impact Index Per Article: 29.7] [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: 04/17/2014] [Revised: 07/31/2014] [Accepted: 08/20/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Noninvasive surrogate end points of long-term outcomes of patients with primary biliary cirrhosis (PBC) are needed to monitor disease progression and evaluate potential treatments. We performed a meta-analysis of individual patient data from cohort studies to evaluate whether patients' levels of alkaline phosphatase and bilirubin correlate with their outcomes and can be used as surrogate end points. METHODS We performed a meta-analysis of data from 4845 patients included in 15 North American and European long-term follow-up cohort studies. Levels of alkaline phosphatase and bilirubin were analyzed in different settings and subpopulations at different time points relative to the clinical end point (liver transplantation or death). RESULTS Of the 4845 patients, 1118 reached a clinical end point. The median follow-up period was 7.3 years; 77% survived for 10 years after study enrollment. Levels of alkaline phosphatase and bilirubin measured at study enrollment (baseline) and each year for 5 years were strongly associated with clinical outcomes (lower levels were associated with longer transplant-free survival). At 1 year after study enrollment, levels of alkaline phosphatase that were 2.0 times the upper limit of normal (ULN) best predicted patient outcome (C statistic, 0.71) but not significantly better than other thresholds. Of patients with alkaline phosphatase levels ≤ 2.0 times the ULN, 84% survived for 10 years compared with 62% of those with levels >2.0 times the ULN (P < .0001). Absolute levels of alkaline phosphatase 1 year after study enrollment predicted patient outcomes better than percentage change in level. One year after study enrollment, a bilirubin level 1.0 times the ULN best predicted patient transplant-free survival (C statistic, 0.79). Of patients with bilirubin levels ≤ 1.0 times the ULN, 86% survived for 10 years after study enrollment compared with 41% of those with levels >1.0 times the ULN (P < .0001). Combining levels of alkaline phosphatase and bilirubin increased the ability to predict patient survival times. We confirmed the predictive value of alkaline phosphatase and bilirubin levels in multiple subgroups, such as patients who had not received treatment with ursodeoxycholic acid, and at different time points after study enrollment. CONCLUSIONS Levels of alkaline phosphatase and bilirubin can predict outcomes (liver transplantation or death) of patients with PBC and might be used as surrogate end points in therapy trials.
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Affiliation(s)
- Willem J Lammers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Gideon M Hirschfield
- NIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, England
| | - Harry L A Janssen
- Liver Clinic, Toronto Western & General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Pietro Invernizzi
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Andrew L Mason
- Divison of Gastroenterology and Hepatology, University of Alberta, Edmonton, Alberta, Canada
| | - Cyriel Y Ponsioen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Annarosa Floreani
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Christophe Corpechot
- Centre de Référence des Maladies Inflammatoires des VoiesBiliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Marlyn J Mayo
- Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Pier M Battezzati
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Albert Parés
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Frederik Nevens
- Department of Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Andrew K Burroughs
- The Sheila Sherlock Liver Centre, The Royal Free Hospital, London, England
| | - Kris V Kowdley
- Liver Center of Excellence, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington
| | - Palak J Trivedi
- NIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, England
| | - Teru Kumagi
- Liver Clinic, Toronto Western & General Hospital, University Health Network, Toronto, Ontario, Canada; Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Angela Cheung
- Liver Clinic, Toronto Western & General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Ana Lleo
- Liver Unit and Center for Autoimmune Liver Diseases, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Mohamad H Imam
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kirsten Boonstra
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Nora Cazzagon
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Irene Franceschet
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Raoul Poupon
- Centre de Référence des Maladies Inflammatoires des VoiesBiliaires, Hôpital Saint-Antoine, APHP, Paris, France
| | - Llorenç Caballeria
- Liver Unit, Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Giulia Pieri
- The Sheila Sherlock Liver Centre, The Royal Free Hospital, London, England
| | - Pushpjeet S Kanwar
- Liver Center of Excellence, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington
| | - Keith D Lindor
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota; College of Health Solutions, Arizona State University, Phoenix, Arizona
| | - Bettina E Hansen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands.
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Parisi I, Tsochatzis E, Wijewantha H, Rodríguez-Perálvarez M, De Luca L, Manousou P, Fatourou E, Pieri G, Papastergiou V, Davies N, Yu D, Luong T, Dhillon AP, Thorburn D, Patch D, O'Beirne J, Meyer T, Burroughs AK. Inflammation-based scores do not predict post-transplant recurrence of hepatocellular carcinoma in patients within Milan criteria. Liver Transpl 2014; 20:1327-35. [PMID: 25088400 DOI: 10.1002/lt.23969] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 06/04/2014] [Accepted: 07/02/2014] [Indexed: 12/16/2022]
Abstract
Increased preoperative inflammation scores, such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and inflammation-based index (IBI) have been related to post-transplant HCC recurrence. We evaluated the association between inflammation-based scores (NLR, PLR, IBI) and post-LT HCC recurrence as well as tumor necrosis after transarterial embolization. 150 consecutive patients who underwent transplantation for HCC within the Milan criteria between 1996 and 2010 were included; data regarding inflammatory markers, patient and tumor characteristics were analyzed. NLR, PLR, and IBI were not significantly associated with post-LT HCC recurrence or worse overall survival. Increased NLR and PLR were associated with complete tumor necrosis in the subset of patients who received preoperative transarterial embolization (P < 0.05). Cox regression analysis revealed that absence of neoadjuvant transarterial therapy (OR = 4.33, 95% CI = 1.28-14.64; P = 0.02) and no fulfillment of the Milan criteria in the explanted liver (OR = 3.34, 95% CI = 1.08-10.35; P = 0.04) were independently associated with post-LT HCC recurrence inflammation-based scores did not predict HCC recurrence post-LT in our group of patients. NLR and PLR were associated with better response to TAE, as this was recorded histologically in the explanted liver. Histological fulfillment of the Milan criteria and absence of neoadjuvant transarterial treatment were significantly associated with post-LT HCC recurrence.
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Affiliation(s)
- Ioanna Parisi
- Royal Free Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, UCL and Royal Free Hospital, London, UK
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18
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Hall AR, Green AC, Luong TV, Burroughs AK, Wyatt J, Dhillon AP. The use of guideline images to improve histological estimation of hepatic steatosis. Liver Int 2014; 34:1414-27. [PMID: 24905412 DOI: 10.1111/liv.12614] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 05/22/2014] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Guideline images of specific fat proportionate area (FPA) percentages have recently been published to aid the histological assessment of liver steatosis as subjective estimates of FPA are usually overestimated. To assess, (i) the effect of guideline images on accuracy and concordance of estimated FPA (eFPA), (ii) experience of steatosis grading systems on eFPA, (iii) the effect of magnification on assessment of FPA (iv) and produce a range of guideline images at x4 objective magnification (OM). METHODS Two circulations of sample images (C1 and C2) were circulated to UK liver external quality assessment histopathology scheme members who were asked to independently evaluate steatosis. Each circulation consisted of 15 images taken at both x20 and x4OM representing the full range of steatosis. C1 was distributed first, then C2 with guideline images of FPA 6 weeks later. RESULTS Participants overestimated FPA in C1. In C2, there was significant improvement in accuracy (P < 0.001) of eFPA for sample images with mFPA >5%. Concordance of x4OM eFPA was substantial in both circulations (C1 K = 0.878, C2 K = 0.724). CONCLUSION The tendency to overestimate eFPA has been corroborated and can be largely corrected with the use of guideline images (without needing digital image analysis). There is a need to redefine steatosis grades that are clinically significant and validated using an accurate quantification of steatosis.
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Affiliation(s)
- Andrew R Hall
- The Department of Cellular Pathology, Royal Free London NHS Foundation Trust, London, UK
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19
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Tsochatzis EA, Crossan C, Longworth L, Gurusamy K, Rodriguez-Peralvarez M, Mantzoukis K, O'Brien J, Thalassinos E, Papastergiou V, Noel-Storr A, Davidson B, Burroughs AK. Cost-effectiveness of noninvasive liver fibrosis tests for treatment decisions in patients with chronic hepatitis C. Hepatology 2014; 60:832-43. [PMID: 25043847 PMCID: PMC4265295 DOI: 10.1002/hep.27296] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [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: 02/24/2014] [Accepted: 06/27/2014] [Indexed: 12/13/2022]
Abstract
UNLABELLED The cost-effectiveness of noninvasive tests (NITs) as alternatives to liver biopsy is unknown. We compared the cost-effectiveness of using NITs to inform treatment decisions in adult patients with chronic hepatitis C (CHC). We conducted a systematic review and meta-analysis to calculate the diagnostic accuracy of various NITs using a bivariate random-effects model. We constructed a probabilistic decision analytical model to estimate health care costs and outcomes (quality-adjusted life-years; QALYs) using data from the meta-analysis, literature, and national UK data. We compared the cost-effectiveness of four treatment strategies: testing with NITs and treating patients with fibrosis stage≥F2; testing with liver biopsy and treating patients with ≥F2; treat none; and treat all irrespective of fibrosis. We compared all NITs and tested the cost-effectiveness using current triple therapy with boceprevir or telaprevir, but also modeled new, more-potent antivirals. Treating all patients without any previous NIT was the most effective strategy and had an incremental cost-effectiveness ratio (ICER) of £9,204 per additional QALY gained. The exploratory analysis of currently licensed sofosbuvir treatment regimens found that treat all was cost-effective, compared to using an NIT to decide on treatment, with an ICER of £16,028 per QALY gained. The exploratory analysis to assess the possible effect on results of new treatments, found that if SVR rates increased to >90% for genotypes 1-4, the incremental treatment cost threshold for the "treat all" strategy to remain the most cost-effective strategy would be £37,500. Above this threshold, the most cost-effective option would be noninvasive testing with magnetic resonance elastography (ICER=£9,189). CONCLUSIONS Treating all adult patients with CHC, irrespective of fibrosis stage, is the most cost-effective strategy with currently available drugs in developed countries.
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Affiliation(s)
- Emmanuel A Tsochatzis
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free HospitalLondon, UK,* These two authors contributed equally to this work and are joint first auth
| | - Catriona Crossan
- Health Economics Research Group, Brunel UniversityUxbridge, UK,* These two authors contributed equally to this work and are joint first auth
| | | | | | | | - Konstantinos Mantzoukis
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free HospitalLondon, UK
| | - Julia O'Brien
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free HospitalLondon, UK
| | - Evangelos Thalassinos
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free HospitalLondon, UK
| | - Vassilios Papastergiou
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free HospitalLondon, UK
| | - Anna Noel-Storr
- Cochrane Dementia and Cognitive Improvement Group, Nuffield Department of Medicine, Oxford UniversityOxford, UK
| | | | - Andrew K Burroughs
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free HospitalLondon, UK
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20
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Affiliation(s)
- Ulrich Thalheimer
- The Exeter Liver Unit, Royal Devon & Exeter Foundation Trust, Exeter, UK.
| | - Jaime Bosch
- Hepatic Hemodynamic Laboratory, Hospital Clínic-IDIBAPS and Ciberehd, University of Barcelona, C.Villarroel 170, 08036 Barcelona, Spain
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Abstract
Despite alcoholic hepatitis (AH) is the most acute manifestation of alcohol-related liver disease, its treatment remains controversial. Corticosteroids, given either as monotherapy or together with N-acetylecysteine, have been associated with a moderate short-term survival benefit in patients with severe disease. The Maddrey's discriminant function; Glasgow alcoholic hepatitis score; age, bilirubin, INR and creatinine score; and the Model for end-stage liver disease have been proposed for stratifying prognosis in AH enabling selection of the patients to treat. Definition of treatment non-responders using the Lille model after 7 days of therapy may prevent a detrimental impact of prolonged corticosteroids. Pentoxifylline is an effective alternative reducing the occurrence of hepatorenal syndrome. Emerging evidence supports use of liver transplantation in a strictly selected subset of corticosteroid non-responders.
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Affiliation(s)
- Vassilios Papastergiou
- The Royal Free Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
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22
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Abstract
Cirrhosis can be sub-classified in clinical stages with distinct differences in prognosis and can even be reversed in some cases with successful etiological treatment. In this article, we review potential future therapies of cirrhosis, mainly focusing in the expansion of indications of currently licensed drugs. We strongly advocate that future therapies should focus on preventing the advent of complications and further progression of liver disease and should involve both primary and secondary care physicians. Such strategies could be based on the combination of currently licensed, relatively safe and inexpensive drugs and such randomized controlled trials should be prioritized in patients with advanced liver disease. The paradigm should be similar to that of prevention in cardiovascular diseases and long-term follow-up trials are needed.
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Affiliation(s)
- Emmanuel A Tsochatzis
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, London, UK
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23
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Triantos C, Louvros E, Kalafateli M, Riddell A, Thalheimer U, Michailidou M, Thomopoulos K, Lampropoulou-Karatza C, Gogos C, Nikolopoulou V, Burroughs AK. Endogenous heparinoids detected by anti-Xa activity are present in blood during acute variceal bleeding in cirrhosis. A prospective study. J Gastrointestin Liver Dis 2014; 23:187-94. [PMID: 24949611 DOI: 10.15403/jgld.2014.1121.232.cht1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND & AIMS Endogenous heparinoids have been detected by thromboelastography and quantified by clotting based anti-Xa activity assays in patients with cirrhosis, but their presence in variceal bleeding has not been established yet. METHODS Clotting based anti-Xa activity was measured in A) 30 cirrhotics with variceal bleeding, B) 15 non-cirrhotics with peptic ulcer bleeding, C) 10 cirrhotics without infection or bleeding, and D) 10 cirrhotics with hepatocellular carcinoma (HCC). RESULTS Anti-Xa activity was not detected in ulcer bleeders or in cirrhotics without infection or bleeding but was present in seven (23%) variceal bleeders (median levels: 0.03 u/mL (0.01-0.07)) and was quantifiable for 3 days in six of seven patients. Four of seven variceal bleeders with anti-Xa activity present had HCC (p=0.023). Age, creatinine, platelet count and total infections the second day from admission were significantly correlated with the presence of measureable anti-Xa levels (p=0.014, 0.032, 0.004 and 0.019, respectively). In the HCC group, anti-Xa activity was present in three patients (30%) [median levels: 0.05 u/mL (0.01-0.06)]. CONCLUSIONS In this study, variceal bleeders and 30% of the patients with HCC had endogenous heparinoids that were detected by a clotting based anti-Xa activity assay, whereas there was no anti Xa activity present in patients with cirrhosis without infection, or bleeding or HCC, nor in those with ulcer bleeding. Thus, the anti Xa activity is likely to be a response to bacterial infection and/or presence of HCC in cirrhosis.
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Affiliation(s)
- Christos Triantos
- Department of Gastroenterology, University Hospital of Patras, Patras, Greece.
| | - Emmanuel Louvros
- Department of Gastroenterology, University Hospital of Patras, Patras, Greece
| | - Maria Kalafateli
- Department of Gastroenterology, University Hospital of Patras, Patras, Greece
| | - Anne Riddell
- Katharine Dormandy Haemophilia Centre & Thrombosis Unit, Royal Free Hospital, London, UK
| | | | - Maria Michailidou
- Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | | | | | - Charalambos Gogos
- Department of Internal Medicine, University Hospital of Patras, Patras, Greece
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Thalheimer U, Burroughs AK. The importance of prognostic factors in cirrhosis. J Hepatol 2014; 60:1325. [PMID: 24583359 DOI: 10.1016/j.jhep.2013.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 12/26/2013] [Indexed: 12/04/2022]
Affiliation(s)
- Ulrich Thalheimer
- The Exeter Liver Unit, Royal Devon & Exeter Foundation Trust, Exeter, UK.
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Abstract
PURPOSE OF REVIEW Long-term survival of liver transplant recipients is threatened by increased rates of de-novo malignancy and recurrence of hepatocellular carcinoma (HCC), both events tightly related to immunosuppression. RECENT FINDINGS There is accumulating evidence linking increased exposure to immunosuppressants and carcinogenesis, particularly concerning calcineurin inhibitors (CNIs), azathioprine and antilymphocyte agents. A recent study including 219 HCC transplanted patients showed that HCC recurrence rates were halved if a minimization of CNIs was applied within the first month after liver transplant. With mammalian target of rapamycin (mTOR) inhibitors as approved immunosuppressants for liver transplant patients, pooled data from several retrospective studies have suggested their possible benefit for reducing HCC recurrence. SUMMARY Randomized controlled trials with sufficiently long follow-up are needed to evaluate the influence of different immunosuppression protocols in preventing malignancy after LT. Currently, early minimization of CNIs with or without mTOR inhibitors or mycophenolate seems a rational strategy for patients with risk factors for de-novo malignancy or recurrence of HCC after liver transplant. A deeper understanding of the immunological pathways of rejection and cancer would allow for designing more specific and safer drugs, and thus to prevent cancer after liver transplant.
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Affiliation(s)
- Manuel Rodríguez-Perálvarez
- Department of Hepatology and Liver Transplantation. Reina Sofía University Hospital, IMIBIC, CIBERehd, Córdoba, Spain
| | - Manuel De la Mata
- Department of Hepatology and Liver Transplantation. Reina Sofía University Hospital, IMIBIC, CIBERehd, Córdoba, Spain
| | - Andrew K. Burroughs
- The Royal Free Sheila Sherlock Liver Centre and Institute of Liver and Digestive Health, UCL, London, United Kingdom
- Deceased
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26
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Manousou P, Cholongitas E, Samonakis D, Tsochatzis E, Corbani A, Dhillon AP, Davidson J, Rodríguez-Perálvarez M, Patch D, O'Beirne J, Thorburn D, Luong T, Rolles K, Davidson B, McCormick PA, Hayes P, Burroughs AK. Reduced fibrosis in recurrent HCV with tacrolimus, azathioprine and steroids versus tacrolimus: randomised trial long term outcomes. Gut 2014; 63:1005-13. [PMID: 24131637 PMCID: PMC4033276 DOI: 10.1136/gutjnl-2013-305606] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Early results of a randomised trial showed reduced fibrosis due to recurrent HCV hepatitis with tacrolimus triple therapy (TT) versus monotherapy (MT) following transplantation for HCV cirrhosis. We evaluated the clinical outcomes after a median 8 years of follow-up, including differences in fibrosis assessed by collagen proportionate area (CPA). DESIGN 103 consecutive liver transplant recipients with HCV cirrhosis receiving cadaveric grafts were randomised to tacrolimus MT (n=54) or TT (n=49) with daily tacrolimus (0.1 mg/kg divided dose), azathioprine (1 mg/kg) and prednisolone (20 mg), the last tailing off to zero by 6 months. Both groups had serial transjugular biopsies with hepatic venous pressure gradient (HVPG) measurement. Time to reach Ishak stage 4 was the predetermined endpoint. CPA was measured in all biopsies. Factors associated with HCV recurrence were evaluated. Clinical decompensation was the first occurrence of ascites/hydrothorax, variceal bleeding or encephalopathy. RESULTS No significant preoperative, peri-operative or postoperative differences between groups were found. During 96 months median follow-up, stage 4 fibrosis was reached in 19 MT/11 TT with slower fibrosis progression in TT (p=0.009). CPA at last biopsy was 12% in MT and 8% in TT patients (p=0.004). 14 MT/ three TT patients reached HVPG≥10 mm Hg (p=0.002); 10 MT/three TT patients, decompensated. Multivariately, allocated MT (p=0.047, OR 3.23, 95% CI 1.01 to 10.3) was independently associated with decompensation: 14 MT/ seven TT died, and five MT/ four TT were retransplanted. CONCLUSIONS Long term immunosuppression with tacrolimus, azathioprine and short term prednisolone in HCV cirrhosis recipients resulted in slower progression to severe fibrosis assessed by Ishak stage and CPA, less portal hypertension and decompensation, compared with tacrolimus alone. ISRCTN94834276--Randomised study for immunosuppression regimen in liver transplantation.
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Affiliation(s)
- Pinelopi Manousou
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, London, UK
| | - Evangelos Cholongitas
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, London, UK
| | - Dimitrios Samonakis
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, London, UK
| | - Emmanuel Tsochatzis
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, London, UK
| | - Alice Corbani
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, London, UK
| | - A P Dhillon
- Department of Histopathology, Royal Free Hospital, London, UK
| | - Janice Davidson
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Manuel Rodríguez-Perálvarez
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, London, UK
| | - D Patch
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, London, UK
| | - J O'Beirne
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, London, UK
| | - D Thorburn
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, London, UK
| | - TuVinh Luong
- Department of Histopathology, Royal Free Hospital, London, UK
| | - K Rolles
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, London, UK
| | - Brian Davidson
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, London, UK
| | - P A McCormick
- Liver Unit, St Vincent's University Hospital, Dublin, Ireland
| | - Peter Hayes
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew K Burroughs
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, London, UK
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27
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Halliday N, Smith C, Atkinson C, O'Beirne J, Patch D, Burroughs AK, Thorburn D, Haque T. Characteristics of Epstein-Barr viraemia in adult liver transplant patients: A retrospective cohort study. Transpl Int 2014; 27:838-46. [DOI: 10.1111/tri.12342] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 11/25/2013] [Accepted: 04/14/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Neil Halliday
- Department of Virology; Royal Free London NHS Foundation Trust; London UK
| | - Colette Smith
- Research Department of Infection and Population Health; UCL; London UK
| | - Claire Atkinson
- Department of Virology; Royal Free London NHS Foundation Trust; London UK
| | - James O'Beirne
- Institute of Liver and Digestive Health; Royal Free London NHS Foundation Trust; London UK
| | - David Patch
- Institute of Liver and Digestive Health; Royal Free London NHS Foundation Trust; London UK
| | - Andrew K Burroughs
- Institute of Liver and Digestive Health; Royal Free London NHS Foundation Trust; London UK
| | - Douglas Thorburn
- Institute of Liver and Digestive Health; Royal Free London NHS Foundation Trust; London UK
| | - Tanzina Haque
- Department of Virology; Royal Free London NHS Foundation Trust; London UK
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28
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Abstract
Cirrhosis is an increasing cause of morbidity and mortality in more developed countries, being the 14th most common cause of death worldwide but fourth in central Europe. Increasingly, cirrhosis has been seen to be not a single disease entity, but one that can be subclassified into distinct clinical prognostic stages, with 1-year mortality ranging from 1% to 57% depending on the stage. We review the current understanding of cirrhosis as a dynamic process and outline current therapeutic options for prevention and treatment of complications of cirrhosis, on the basis of the subclassification in clinical stages. The new concept in management of patients with cirrhosis should be prevention and early intervention to stabilise disease progression and to avoid or delay clinical decompensation and the need for liver transplantation. The challenge in the 21st century is to prevent the need for liver transplantation in as many patients with cirrhosis as possible.
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Affiliation(s)
- Emmanuel A Tsochatzis
- Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, London, UK
| | - Jaime Bosch
- Hepatic Hemodynamic Laboratory, Hospital Clínic-IDIBAPS, University of Barcelona, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Andrew K Burroughs
- Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, London, UK.
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Tsochatzis E, Bruno S, Isgro G, Hall A, Theocharidou E, Manousou P, Dhillon AP, Burroughs AK, Luong TV. Collagen proportionate area is superior to other histological methods for sub-classifying cirrhosis and determining prognosis. J Hepatol 2014; 60:948-54. [PMID: 24412606 DOI: 10.1016/j.jhep.2013.12.023] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 11/26/2013] [Accepted: 12/26/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS One-year survival in cirrhosis ranges from 1 to 57% depending on the clinical stage. Accurate sub-classification has important prognostic implications but there is no stage beyond cirrhosis using current qualitative histological systems. We compared the performance of all histological semi-quantitative and quantitative methods specifically developed for sub-classifying cirrhosis that have been described to date, with collagen proportionate area (CPA), to evaluate how well they distinguish patients with and without hepatic clinical decompensation at presentation, and in predicting future decompensating events. METHODS We included consecutive patients with a histological diagnosis of cirrhosis that had a suitable liver biopsy between 2003 and 2007. We used semi-quantitative histological scoring systems proposed by Laennec, Kumar, and Nagula. We also measured quantitatively nodule size, septal width and fibrous tissue expressed in CPA. RESULTS Sixty-nine patients, mean age 52.3±11years, mean MELD 11.8±5.8, median follow-up 56months. Main aetiologies were alcohol (38%) and hepatitis C (27.5%). Twenty-four patients (34.8%) had had a previous episode of clinical decompensation. Amongst the 45 patients who were compensated, 11 (24%) decompensated on follow-up. In Cox regression, amongst all histological parameters, CPA was the only variable independently associated with clinical decompensation up to the time of biopsy, with an odds ratio that ranged from 1.245 to 1.292. Furthermore, only CPA was significantly associated with future decompensation (OR: 1.117, 95% CI 1.020-1.223; p=0.017). CONCLUSIONS Cirrhosis can be accurately sub-classified using quantification of fibrosis with CPA, and furthermore CPA is the only independent predictor of clinical decompensation amongst all other histological sub-classification systems described to date.
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Affiliation(s)
- Emmanuel Tsochatzis
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, London, UK
| | - Sara Bruno
- Department of Histopathology, UCL Medical School, Royal Free Campus, UK
| | - Graziella Isgro
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, London, UK
| | - Andrew Hall
- Department of Histopathology, UCL Medical School, Royal Free Campus, UK
| | - Eleni Theocharidou
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, London, UK
| | - Pinelopi Manousou
- Department of Histopathology, UCL Medical School, Royal Free Campus, UK
| | - Amar P Dhillon
- Department of Histopathology, UCL Medical School, Royal Free Campus, UK
| | - Andrew K Burroughs
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute for Liver and Digestive Health, London, UK.
| | - Tu Vinh Luong
- Department of Histopathology, UCL Medical School, Royal Free Campus, UK.
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Papastergiou V, Tsochatzis EA, Pieri G, Thalassinos E, Dhar A, Bruno S, Karatapanis S, Luong TV, O'Beirne J, Patch D, Thorburn D, Burroughs AK. Nine scoring models for short-term mortality in alcoholic hepatitis: cross-validation in a biopsy-proven cohort. Aliment Pharmacol Ther 2014; 39:721-32. [PMID: 24612165 PMCID: PMC4015369 DOI: 10.1111/apt.12654] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [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: 12/22/2013] [Revised: 01/08/2014] [Accepted: 01/20/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Several prognostic models have emerged in alcoholic hepatitis (AH), but lack of external validation precludes their universal use. AIM To validate the Maddrey Discriminant Function (DF); Glasgow Alcoholic Hepatitis Score (GAHS); Mayo End-stage Liver Disease (MELD); Age, Bilirubin, INR, Creatinine (ABIC); MELD-Na, UK End-stage Liver Disease (UKELD), and three scores of corticosteroid response at 1 week: an Early Change in Bilirubin Levels (ECBL), a 25% fall in bilirubin, and the Lille score. METHODS Seventy-one consecutive patients with biopsy-proven AH, admitted between November 2007-September 2011, were evaluated. The clinical and biochemical parameters were analysed to assess prognostic models with respect to 30- and 90-day mortality. RESULTS There were no significant differences in the areas under the receiver operating characteristics curve (AUROCs) relative to 30-day/90-day mortality: MELD 0.79/0.84, DF 0.71/0.74, GAHS 0.75/0.78, ABIC 0.71/0.78, MELD-Na 0.68/0.76, UKELD 0.56/0.68. One-week rescoring yielded a trend towards improved predictive accuracies (30-day/90-day AUROCs: 0.69–0.84/0.77–0.86). In patients with admission DF ≥ 32 (n = 31), response to corticosteroids according to ECBL, 25% fall in bilirubin and the Lille model yielded AUROCs of 0.73/0.73, 0.78/0.72 and 0.81/0.82 for a 30-day/90-day outcome respectively. All models showed excellent negative predictive values (NPVs; range: 86–100%), while the positive ones were low (range: 17–50%). CONCLUSIONS MELD, DF, GAHS, ABIC and scores of corticosteroid response proved to be valid in an independent cohort of biopsy-proven alcoholic hepatitis. MELD modifications incorporating sodium did not confer any prognostic advantage over classical MELD. Based on excellent NPVs, the models are best to identify patients at low risk of death.
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Affiliation(s)
- V Papastergiou
- The Royal Free Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free HospitalLondon, UK
| | - E A Tsochatzis
- The Royal Free Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free HospitalLondon, UK
| | - G Pieri
- The Royal Free Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free HospitalLondon, UK
| | - E Thalassinos
- The Royal Free Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free HospitalLondon, UK
| | - A Dhar
- The Royal Free Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free HospitalLondon, UK
| | - S Bruno
- The Royal Free Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free HospitalLondon, UK
| | - S Karatapanis
- The Royal Free Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free HospitalLondon, UK
| | - T V Luong
- The Royal Free Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free HospitalLondon, UK
| | - J O'Beirne
- The Royal Free Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free HospitalLondon, UK
| | - D Patch
- The Royal Free Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free HospitalLondon, UK
| | - D Thorburn
- The Royal Free Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free HospitalLondon, UK
| | - A K Burroughs
- The Royal Free Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free HospitalLondon, UK,Correspondence to:, Prof. A. K. Burroughs, The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital, NW3 2QG, London, UK., E-mail:
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Tsochatzis EA, Fatourou E, O’Beirne J, Meyer T, Burroughs AK. Transarterial chemoembolization and bland embolization for hepatocellular carcinoma. World J Gastroenterol 2014; 20:3069-3077. [PMID: 24695579 PMCID: PMC3964379 DOI: 10.3748/wjg.v20.i12.3069] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 01/08/2014] [Indexed: 02/06/2023] Open
Abstract
Transarterial chemoembolization (TACE) is the first line treatment for patients with intermediate stage hepatocellular carcinoma but is also increasingly being used for patients on the transplant waiting list to prevent further tumor growth. Despite its widespread use, TACE remains an unstandardized procedure, with variation in type and size of embolizing particles, type and dose of chemotherapy and interval between therapies. Existing evidence from randomized controlled trials suggest that bland transarterial embolization (TAE) has the same efficacy with TACE. In the current article, we review the use of TACE and TAE for hepatocellular carcinoma and we focus on the evidence for their use.
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Buck M, Garcia-Tsao G, Groszmann RJ, Stalling C, Grace ND, Burroughs AK, Patch D, Matloff DS, Clopton P, Chojkier M. Novel inflammatory biomarkers of portal pressure in compensated cirrhosis patients. Hepatology 2014; 59:1052-9. [PMID: 24115225 DOI: 10.1002/hep.26755] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 08/20/2013] [Accepted: 09/17/2013] [Indexed: 12/26/2022]
Abstract
UNLABELLED The rationale for screening inflammatory serum biomarkers of the hepatic vein pressure gradient (HVPG) is based on the fact that portal hypertension is pathogenically related to liver injury and fibrosis, and that in turn these are associated with the activation of inflammatory pathways. This was a nested cohort study in the setting of a randomized, clinical trial to assess the development of gastroesophageal varices (GEV) (N Engl J Med 2005;353:2254). Patients had cirrhosis and portal hypertension but did not have GEV. A total of 90 patients who had baseline day-1 sera available were enrolled in the present study. The objective of this study was to determine whether inflammatory biomarkers in conjunction with clinical parameters could be used to develop a predictive paradigm for HVPG. The correlations between HVPG and interleukin (IL)-1β (P=0.0052); IL-1R-α (P=0.0085); Fas-R (P=0.0354), and serum VCAM-1 (P=0.0007) were highly significant. By using multivariate logistic regression analysis and selected parameters (transforming growth factor beta [TGFβ]; heat shock protein [HSP]-70; at-risk alcohol use; and Child class B) we could exclude HVPG ≥ 12 mmHg with 86% accuracy (95% confidence interval [CI]: 67.78 to 96.16%) and the sensitivity was 87.01% (95% CI: 69.68 to 96.34%). Therefore, the composite test could identify 86% of compensated cirrhosis patients with HVPG below 12 mmHg and prevent unnecessary esophagogastroduodenoscopy with its associated morbidity and costs in these patients. Our diagnostic test was not efficient in predicting HVPG ≥ 12 mmHg. CONCLUSION A blood test for HVPG could be performed in cirrhosis patients to prevent unnecessary esophagogastroduodenoscopy.
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Affiliation(s)
- Martina Buck
- Veterans Affairs San Diego Healthcare System, San Diego, CA; Department of Medicine, University of California, San Diego, La Jolla, CA; Biomedical Sciences Program, University of California, San Diego, La Jolla, CA
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Affiliation(s)
- Ulrich Thalheimer
- The Exeter Liver Unit, Royal Devon & Exeter Foundation Trust, Exeter, UK.
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Abstract
Cirrhosis is an increasing cause of morbidity and mortality in more developed countries, being the 14th most common cause of death worldwide but fourth in central Europe. Increasingly, cirrhosis has been seen to be not a single disease entity, but one that can be subclassified into distinct clinical prognostic stages, with 1-year mortality ranging from 1% to 57% depending on the stage. We review the current understanding of cirrhosis as a dynamic process and outline current therapeutic options for prevention and treatment of complications of cirrhosis, on the basis of the subclassification in clinical stages. The new concept in management of patients with cirrhosis should be prevention and early intervention to stabilise disease progression and to avoid or delay clinical decompensation and the need for liver transplantation. The challenge in the 21st century is to prevent the need for liver transplantation in as many patients with cirrhosis as possible.
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Affiliation(s)
- Emmanuel A Tsochatzis
- Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, London, UK
| | - Jaime Bosch
- Hepatic Hemodynamic Laboratory, Hospital Clínic-IDIBAPS, University of Barcelona, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Andrew K Burroughs
- Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, London, UK.
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Pieri G, Agarwal B, Burroughs AK. C-reactive protein and bacterial infection in cirrhosis. Ann Gastroenterol 2014; 27:113-120. [PMID: 24733601 PMCID: PMC3982625] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 11/08/2013] [Indexed: 10/31/2022] Open
Abstract
In the general population, C-reactive protein (CRP) level increases in the presence of acute or chronic inflammation and infections. In patients with cirrhosis, the basal level is higher than in patients without cirrhosis, due to chronic hepatic and other inflammation, but when infection occurs the more severe the underlying liver dysfunction, the lower the increase in CRP. Therefore, the predictive power of CRP for infection and prognosis is weak in patients with decompensated/advanced cirrhosis and in the intensive care setting. However, higher CRP and also persistently elevated CRP levels can help identify patients with a higher short-term risk of mortality.
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Affiliation(s)
- Giulia Pieri
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital, Royal Free Hamsptead NHS Trust and Institute of Liver and Digestive Health, University College London (Giulia Pieri, Andrew K. Burroughs)
| | - Banwari Agarwal
- Critical Care Medicine, Royal Free London NHS Foundation Trust (Agarwal Banwari), London, United Kingdom
| | - Andrew K. Burroughs
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital, Royal Free Hamsptead NHS Trust and Institute of Liver and Digestive Health, University College London (Giulia Pieri, Andrew K. Burroughs),
Correspondence to: Andrew K. Burroughs, FRCP, FMedSci, Professor of Hepatology, Trust and Institute of Liver and Digestive Health, UCL, London, UK Pond Street, NW3 2QG, London, United Kingdom, Tel.: +44 2077 940500, Fax: +44 2074 726226 47, e-mail
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Gurusamy KS, Wilson E, Koretz RL, Allen VB, Davidson BR, Burroughs AK, Gluud C. Is sustained virological response a marker of treatment efficacy in patients with chronic hepatitis C viral infection with no response or relapse to previous antiviral intervention? PLoS One 2013; 8:e83313. [PMID: 24349487 PMCID: PMC3861485 DOI: 10.1371/journal.pone.0083313] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [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: 06/20/2013] [Accepted: 11/01/2013] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Randomised clinical trials (RCTs) of antiviral interventions in patients with chronic hepatitis C virus (HCV) infection use sustained virological response (SVR) as the main outcome. There is sparse information on long-term mortality from RCTs. METHODS We created a decision tree model based on a Cochrane systematic review on interferon retreatment for patients who did not respond to initial therapy or who relapsed following SVR. Extrapolating data to 20 years, we modelled the outcome from three scenarios: (1) observed medium-term (5 year) annual mortality rates continue to the long term (20 years); (2) long-term annual mortality in retreatment responders falls to that of the general population while retreatment non-responders continue at the medium-term mortality; (3) long-term annual mortality in retreatment non-responders is the same as control group non-responders (i.e., the increased treatment-related medium mortality "wears off"). RESULTS The mean differences in life expectancy over 20 years with interferon versus control in the first, second, and third scenarios were -0.34 years (95% confidence interval (CI) -0.71 to 0.03), -0.23 years (95% CI -0.69 to 0.24), and -0.01 (95% CI -0.3 to 0.27), respectively. The life expectancy was always lower in the interferon group than in the control group in scenario 1. In scenario 3, the interferon group had a longer life expectancy than the control group only when more than 7% in the interferon group achieved SVR. CONCLUSIONS SVR may be a good prognostic marker but does not seem to be a valid surrogate marker for assessing HCV treatment efficacy of interferon retreatment. The SVR threshold at which retreatment increases life expectancy may be different for different drugs depending upon the adverse event profile and treatment efficacy. This has to be determined for each drug by RCTs and appropriate modelling before SVR can be accepted as a surrogate marker.
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Affiliation(s)
- Kurinchi S. Gurusamy
- Department of Surgery, University College London, London, United Kingdom
- * E-mail:
| | - Edward Wilson
- Health Economics Group, University of East Anglia, Norwich, United Kingdom
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, United Kingdom
| | - Ronald L. Koretz
- Cochrane Hepato Biliary Group, Granada Hills, California, United States of America
| | - Victoria B. Allen
- Department of Surgery, University College London, London, United Kingdom
| | - Brian R. Davidson
- Department of Surgery, University College London, London, United Kingdom
| | - Andrew K. Burroughs
- Sheila Sherlock Liver Centre and Institute of Liver and Digestive Health, Royal Free Hospital, and UCL, London, United Kingdom
| | - Christian Gluud
- Cochrane Hepato-Biliary Group, The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet,Copenhagen University Hospital, Copenhagen, Denmark
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Gurusamy KS, Tsochatzis E, Toon CD, Xirouchakis E, Burroughs AK, Davidson BR. Antiviral interventions for liver transplant patients with recurrent graft infection due to hepatitis C virus. Cochrane Database Syst Rev 2013; 2013:CD006803. [PMID: 24307460 PMCID: PMC8930021 DOI: 10.1002/14651858.cd006803.pub4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Antiviral therapy for recurrent hepatitis C infection after liver transplantation is controversial due to unresolved balance between benefits and harms. OBJECTIVES To compare the therapeutic benefits and harms of different antiviral regimens in patients with hepatitis C re-infected grafts after liver transplantation. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1, 2013), MEDLINE, EMBASE, and Science Citation Index Expanded to February 2013. SELECTION CRITERIA We considered only randomised clinical trials (irrespective of language, blinding, or publication status) comparing various antiviral therapies (alone or in combination) in the treatment of hepatitis C virus recurrence in liver transplantation for the review. DATA COLLECTION AND ANALYSIS Two authors collected the data independently. We calculated the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) using the fixed-effect and the random-effects models based on available case-analysis. In the presence of only trials for a dichotomous outcome, we performed the Fisher's exact test. MAIN RESULTS Overall, 17 trials with 736 patients met the inclusion criteria for this review. All trials had high risk of bias. Five hundred and one patients randomised in 11 trials provided information for various comparisons in this systematic review after excluding post-randomisation drop-outs and patients from trials that did not report any of the outcomes of interest for this review. The comparisons for which outcomes were available included pegylated (peg) interferon versus control; peg interferon plus ribavirin versus control; ribavirin plus peg interferon versus peg interferon; peg interferon (1.5 μg/kg/week) plus ribavirin versus peg interferon (0.5 μg/kg/week) plus ribavirin; amantadine plus peg interferon plus ribavirin versus peg interferon plus ribavirin; interferon versus control; interferon plus ribavirin versus control; ribavirin versus interferon; and ribavirin versus placebo. Long-term follow-up was not available in these trials. There were no significant differences in mortality, retransplantation, graft rejections requiring retransplantation or medical treatment, or fibrosis worsening between the groups in any of the comparisons in which these outcomes were reported. Quality of life and liver decompensation were not reported in any of the trials. There was a significantly higher proportion of participants who developed serious adverse events in the ribavirin plus peg interferon combination therapy group than in the peg interferon monotherapy group (1 trial; 56 participants; 17/28 (60.7%) in the intervention group versus 5/28 (17.9%) in the control group; RR 3.40; 95% CI 1.46 to 7.94). There was no significant difference in proportion of participants who developed serious adverse events or in the number of serious adverse events between the intervention and control groups in the other comparisons that reported serious adverse events. AUTHORS' CONCLUSIONS Considering the lack of clinical benefit, there is currently no evidence to recommend or refute antiviral treatment for recurrent liver graft infection with hepatitis C virus. Further randomised clinical trials with low risk of bias and low risk of random errors with adequate duration of follow-up are necessary.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Emmanuel Tsochatzis
- Royal Free Hampstead NHS Foundation Trust and UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentrePond StreetHampsteadLondonUKNW3 2QG
| | - Clare D Toon
- University College LondonDivision of Surgery & Interventional Science9th Floor, Royal Free HospitalRowland Hill StreetLondonLondonUKNW3 2PF
| | - Elias Xirouchakis
- Athens Medical Group, Hospital P. FaliroGI and Hepatology36 Areos str.AthensGreece17562
| | - Andrew K Burroughs
- Royal Free Hampstead NHS Foundation TrustSheila Sherlock Liver CentrePond StreetHampsteadLondonUKNW3 2QG
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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Gurusamy KS, Tsochatzis E, Toon CD, Davidson BR, Burroughs AK. Antiviral prophylaxis for the prevention of chronic hepatitis C virus in patients undergoing liver transplantation. Cochrane Database Syst Rev 2013; 2013:CD006573. [PMID: 24297303 PMCID: PMC6599865 DOI: 10.1002/14651858.cd006573.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND It is not clear whether prophylactic antiviral therapy is indicated to improve patient and graft survival in patients undergoing liver transplantation for chronic decompensated hepatitis C virus (HCV) infection. OBJECTIVES To compare the benefits and harms of different prophylactic antiviral therapies for patients undergoing liver transplantation for chronic HCV infection. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1, 2013), MEDLINE, EMBASE, and Science Citation Index Expanded to February 2013. SELECTION CRITERIA Only randomised clinical trials irrespective of language, blinding, or publication status and comparing various prophylactic antiviral therapies (alone or in combination) in the prophylactic treatment of patients undergoing liver transplantation for chronic HCV infection. DATA COLLECTION AND ANALYSIS Two authors collected the data independently. We calculated the risk ratio (RR) or mean difference (MD) or hazard ratio (HR) with 95% confidence intervals (CI) using the fixed-effect and the random-effects models based on available case analysis. MAIN RESULTS A total of 501 liver transplant recipients undergoing liver transplantation for chronic HCV infection were randomised in 12 trials to various experimental interventions and control interventions. The proportion of genotype I varied between 49% and 100% in the seven trials that reported the genotype. Only one or two trials were included under each comparison. All the trials were of high risk of bias. Ten trials including 441 liver transplant recipients provided data for this review.There were no significant differences in the 90-day mortality (1 trial; 81 participants; 5/35 (adjusted proportion: 14.2%) in interferon group versus 5/46 (10.9%) in control group; RR 1.31; 95% CI 0.41 to 4.19); mortality at maximal follow-up (2 trials; 105 participants; 7/47 (adjusted proportion: 14.8%) in interferon group versus 10/58 (17.2%) in control group; RR 0.86; 95% CI 0.36 to 2.08); long-term mortality (1 trial; 81 participants; HR 0.45; 95% CI 0.13 to 1.56); mortality at maximal follow-up (1 trial; 54 participants; 1/26 (3.9%) in pegylated interferon group versus 2/28 (7.1%) in control group; RR 0.54; 95% CI 0.05 to 5.59); 90-day mortality (1 trial; 115 participants; 5/55 (9.1%) in pegylated interferon plus ribavirin group versus 3/60 (5.0%) in control group; RR 1.82; 95% 0.46 to 7.25); 90-day mortality (3 trials; 53 participants; 3/37 (adjusted proportion: 4.3%) in HCV antibody group versus 1/16 (6.3%) in placebo group; RR 0.69; 95% CI 0.15 to 3.11); or 90-day mortality (2 trials; 31 participants; 2/14 (adjusted proportion: 16.2%) in HCV antibody high-dose group versus 1/17 (5.9%) in HCV antibody low-dose group; RR 2.75; 95% CI; 0.30 to 25.35). There were no significant differences in the retransplantation at maximal follow-up (2 trials; 105 participants; 2/47 (adjusted proportion: 4.0%) in interferon group versus 2/58 (3.4%) in control group; RR 1.17; 95% CI 0.22 to 6.2); 90-day retransplantation (1 trial; 18 participants; 1/12 (8.3%) in HCV antibody group versus 0/6 (0%) in control group; RR 1.71; 95% CI 0.09 to 32.93); or 90-day retransplantation (1 trial; 12 participants; 1/6 (17.7%) in HCV antibody high-dose group versus 0/6 (0%) in HCV antibody low-dose group; RR 3.00; 95% CI 0.15 to 61.74). There were no significant differences in serious adverse events, graft rejection, worsening of fibrosis, or HCV recurrence between intervention and control groups in any of the comparisons that reported these outcomes. None of the trials reported quality of life, liver decompensation, intensive therapy unit stay, or hospital stay. Life-threatening adverse events were not reported in either group in any of the comparisons. AUTHORS' CONCLUSIONS There is currently no evidence to recommend prophylactic antiviral treatment to prevent recurrence of HCV infection either in primary liver transplantation or retransplantation. Further randomised clinical trials with adequate trial methodology and adequate duration of follow-up are necessary.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
| | - Emmanuel Tsochatzis
- Royal Free Hampstead NHS Foundation Trust and UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentrePond StreetHampsteadLondonUKNW3 2QG
| | - Clare D Toon
- West Sussex County CouncilPublic Health1st Floor, The GrangeTower StreetChichesterUKPO19 1QT
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free Hospital,Rowland Hill StreetLondonUKNW3 2PF
| | - Andrew K Burroughs
- Royal Free Hampstead NHS Foundation TrustSheila Sherlock Liver CentrePond StreetHampsteadLondonUKNW3 2QG
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Papastergiou V, Tsochatzis EA, Rodriquez-Peralvarez M, Thalassinos E, Pieri G, Manousou P, Germani G, Rigamonti C, Arvaniti V, Karatapanis S, Burroughs AK, Burroughs AK. Biochemical criteria at 1 year are not robust indicators of response to ursodeoxycholic acid in early primary biliary cirrhosis: results from a 29-year cohort study. Aliment Pharmacol Ther 2013; 38:1354-64. [PMID: 24117847 PMCID: PMC4028985 DOI: 10.1111/apt.12522] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [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: 08/08/2013] [Revised: 09/13/2013] [Accepted: 09/17/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND In primary biliary cirrhosis (PBC), biochemical criteria at 1 year are considered surrogates of response to ursodeoxycholic acid (UDCA). However, due to the slow natural history of PBC, evaluation at 1 year may be suboptimal to assess the therapeutic response, particularly in early disease. AIM To determine whether evaluation of biochemical criteria at 1 year is a reliable surrogate of UDCA response in early PBC. METHODS We analysed the prospectively collected data of 215 patients (untreated = 129; UDCA-treated = 86) with early PBC (normal baseline bilirubin/albumin) and a median follow-up of 8 years (range: 1-29.1). The 1-year attainment rates of the Barcelona, Paris-I, Paris-II and Toronto definitions, and their predictive relevance for a poor outcome (death, transplantation, complications of cirrhosis), were assessed either as a result of UDCA or no treatment. Independent associations with attaining each UDCA response definition were identified by multivariate analysis. RESULTS Untreated patients displayed 1-year biochemical features compatible with 'treatment response' at rates (Barcelona: 36.4%, Paris-I: 66.7%, Toronto: 59.7%, Paris-II: 40.3%) similar to those obtained under UDCA. Depending on the definition, baseline ALP≤3xULN (OR: 4.80-35.90), AST≤2xULN (OR: 5.63-9.34) and early histological stage (OR: 3.67-3.87) were the stronger predictors for attaining the criteria. UDCA treatment was associated with attaining Barcelona (OR = 2.16) and Paris-II (OR = 2.84), but not Paris-I, and not Toronto definition when excluding late histological cases. Paris-I criteria were significantly predictive of long-term outcomes (HR = 2.83) in untreated patients. CONCLUSIONS In early PBC, biochemical criteria at 1 year reflect severity of the disease rather than the therapeutic response to UDCA.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - A K Burroughs
- Correspondence to:, Prof. A. K. Burroughs, The Royal Free Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free Hospital and UCL, NW3 2QG, London, UK. E-mail:
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Tsochatzis EA, Burroughs AK. Liver stiffness measurements increase after meal ingestion--an important step towards standardization. Ann Hepatol 2013; 12:839-40. [PMID: 24018507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Emmanuel A Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and UCL Institute of Liver and Digestive Health, Pond Street, Hampstead, NW3 2QG, London, UK
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Davenport A, Agarwal B, Wright G, Mantzoukis K, Dimitrova R, Davar J, Vasianopoulou P, Burroughs AK. Can non-invasive measurements aid clinical assessment of volume in patients with cirrhosis? World J Hepatol 2013; 5:433-438. [PMID: 24023982 PMCID: PMC3767842 DOI: 10.4254/wjh.v5.i8.433] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the non-invasive assessments of volume status in patients with cirrhosis.
METHODS: Echocardiography and multifrequency bioimpedance analysis measurements and short synacthen tests were made in 20 stable and 25 acutely decompensated patients with cirrhosis.
RESULTS: Both groups had similar clinical assessments, cortisol response and total body water (TBW), however the ratio of extracellular water (ECW)/TBW was significantly greater in the trunk (0.420 ± 0.004 vs 0.404 ± 0.005), and limbs (R leg 0.41 ± 0.003 vs 0.398 ± 0.003, P < 0.05, and L leg 0.412 ± 0.003 vs 0.399 ± 0.003) with decompensated cirrhosis compared to stable cirrhotics, P < 0.05). Echocardiogram derived right atrial and ventricular filling and end diastolic pressures and presence of increased left ventricular end diastolic volume and diastolic dysfunction were similar in both groups. The decompensated group had lower systemic blood pressure, mean systolic 101.8 ± 4.3 vs 122.4 ± 5.3 and diastolic 58.4 ± 4.1 mmHg vs 68.8 ± 3.1 mmHg respectively, P < 0.01, and serum albumin 30 (27-33) vs 32 (31-40.5) g/L, P < 0.01.
CONCLUSION: Decompensated cirrhotics had greater leg and truncal ECW expansion with lower serum albumin levels consistent with intravascular volume depletion and increased vascular permeability.
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Silberhumer GR, Rahmel A, Karam V, Gonen M, Gyoeri G, Kern B, Adam R, Muehlbacher F, Rogiers X, Burroughs AK, Berlakovich GA. The difficulty in defining extended donor criteria for liver grafts: the Eurotransplant experience. Transpl Int 2013; 26:990-8. [PMID: 23931659 DOI: 10.1111/tri.12156] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 12/14/2012] [Accepted: 06/28/2013] [Indexed: 12/14/2022]
Abstract
Donor criteria for liver grafts have been expanded because of organ shortage. Currently, no exact definitions for extended donor grafts have been established. The aim of this study was to analyze the impact of donor-specific risk factors, independent of recipient characteristics. In collaboration with Eurotransplant and European Liver Transplant Register, solely donor-specific parameters were correlated with 1-year survival following liver transplantation. Analyses of 4701 donors between 2000 and 2005 resulted in the development of a nomogram to estimate graft survival for available grafts. Predictions by nomogram were compared to those by Donor Risk Index (DRI). In the multivariate analysis, cold ischemic time (CIT), highest sodium, cause of donor death, γ-glutamyl transferase (γ-GT), and donor sex (female) were statistically significant factors for 3 months; CIT, γ-GT, and cause of donor death for 12-month survival. The median DRI of this study population was 1.45 (Q1: 1.17; Q3: 1.67). The agreement between the nomogram and DRI was weak (kappa = 0.23). Several donor-specific risk factors were identified for early survival after liver transplantation. The provided nomogram will support quick organ quality assessment. Nevertheless, this study showed the difficulties of determining an exact definition of extended criteria donors.
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Affiliation(s)
- Gerd R Silberhumer
- Department of Transplant Surgery, Medical University Vienna, Vienna, Austria
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Mallett SV, Chowdary P, Burroughs AK. Clinical utility of viscoelastic tests of coagulation in patients with liver disease. Liver Int 2013; 33:961-74. [PMID: 23638693 DOI: 10.1111/liv.12158] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 02/28/2013] [Indexed: 12/18/2022]
Abstract
The prothrombin time (PT) and international normalised ratio (INR) are used in scoring systems (Child-Pugh, MELD, UKELD) in chronic liver disease and as a prognostic tool and for dynamic monitoring of hepatic function in acute liver disease. These tests are known to be poor predictors of bleeding risk in liver disease; however, they continue to influence clinical management decisions. Recent work on coagulation in liver disease, in particular thrombin generation studies, has led to a paradigm shift in our understanding and it is now recognised that haemostasis is relatively well preserved. Whole blood global viscoelastic tests (TEG(®) /ROTEM(®) ) produce a composite dynamic picture of the entire coagulation process and have the potential to provide more clinically relevant information in patients with liver disease. We performed a systematic review of all relevant studies that have used viscoelastic tests (VET) of coagulation in patients with liver disease. Although many studies are observational and small in size, it is clear that VET provide additional information that is in keeping with the new concepts of how coagulation is altered in these patients. This review provides the basis for large scale, prospective outcome studies to establish the clinical value of these tests.
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Affiliation(s)
- Susan V Mallett
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK
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Abstract
Prothrombotic haematological disorders, in particular myeloproliferative disorders, are identified in a significant proportion of patients with Budd-Chiari syndrome and portal vein thrombosis (PVT). Multiple prothrombotic disorders may coexist. PVT is diagnosed in one fourth of patients with cirrhosis and is more common with advanced liver disease and hepatocellular carcinoma. PVT in cirrhosis can precipitate decompensation. Intrahepatic microthrombosis may play a role in the pathogenesis of hepatic fibrosis. Sinusoidal obstruction syndrome is usually a complication of myeloablative treatment before haematopoietic stem cell transplantation. Post-transplant lymphoproliferative disorders can complicate liver transplantation and are related to Epstein-Barr virus infection. Hepatitis B reactivation in patients receiving chemotherapy for haematological malignancies is very common without pre-emptive treatment, and can lead to liver failure. Liver involvement is common in primary haematological diseases, such as haemolytic anaemias, lymphomas and leukaemia.
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Affiliation(s)
- Giulia Pieri
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital, Royal Free Hampstead NHS Trust and Institute of Liver and Digestive Health, University College London, Pond Street, NW3 2QG London, United Kingdom
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Abstract
Splanchnic vein thrombosis (SVT) is one of the most important complications of myeloproliferative neoplasms (MPN). Although MPN are common causes of SVT, the pathophysiological mechanisms underlying this predisposition, their epidemiology and natural history are not fully understood. Studies have concentrated on the generalized prothrombotic environment generated by MPN and their relationship with abnormal blood counts, thereby furthering our knowledge of arterial and venous thrombosis in this population. In contrast, there are few studies that have specifically addressed SVT in the context of MPN. Recent research has demonstrated in patients with MPN the existence of factors increasing the risk of SVT such as the presence of the JAK2 V617F mutation and its 46/1 haplotype. Features unique to the circulating blood cells, splanchnic vasculature and surrounding micro-environment in patients with MPN have been described. There are also abnormalities in local haemodynamics, haemostatic molecules, the spleen, and splanchnic endothelial and endothelial progenitor cells. This review considers these important advances and discusses the contribution of individual anomalies that lead to the development of SVT in both the pre-neoplastic and overt stage of MPN. Clinical issues relating to epidemiology, recurrence and survival in these patients have also been reviewed and their results discussed.
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Affiliation(s)
- Mallika Sekhar
- Department of Haematology, Royal Free Hospital, London, UK
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Kadalayil L, Benini R, Pallan L, O'Beirne J, Marelli L, Yu D, Hackshaw A, Fox R, Johnson P, Burroughs AK, Palmer DH, Meyer T. A simple prognostic scoring system for patients receiving transarterial embolisation for hepatocellular cancer. Ann Oncol 2013; 24:2565-2570. [PMID: 23857958 PMCID: PMC4023407 DOI: 10.1093/annonc/mdt247] [Citation(s) in RCA: 235] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background The prognosis for patients with hepatocellular cancer (HCC) undergoing transarterial therapy (TACE/TAE) is variable. Methods We carried out Cox regression analysis of prognostic factors using a training dataset of 114 patients treated with TACE/TAE. A simple prognostic score (PS) was developed, validated using an independent dataset of 167 patients and compared with Child–Pugh, CLIP, Okuda, Barcelona Clinic Liver Cancer (BCLC) and MELD. Results Low albumin, high bilirubin or α-fetoprotein (AFP) and large tumour size were associated with a two- to threefold increase in the risk of death. Patients were assigned one point if albumin <36 g/dl, bilirubin >17 μmol/l, AFP >400 ng/ml or size of dominant tumour >7 cm. The Hepatoma arterial-embolisation prognostic (HAP) score was calculated by summing these points. Patients were divided into four risk groups based on their HAP scores; HAP A, B, C and D (scores 0, 1, 2 and >2, respectively). The median survival for the groups A, B, C and D was 27.6, 18.5, 9.0 and 3.6 months, respectively. The HAP score validated well with the independent dataset and performed better than other scoring systems in differentiating high- and low-risk groups. Conclusions The HAP score predicts outcomes in patients with HCC undergoing TACE/TAE and may help guide treatment selection, allow stratification in clinical trials and facilitate meaningful comparisons across reported series.
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Affiliation(s)
- L Kadalayil
- Cancer Research UK & UCL Cancer Trials Centre, London
| | - R Benini
- Department of Oncology, UCL Medical School, Royal Free Campus, London
| | - L Pallan
- Cancer Research UK Institute for Cancer Studies, University of Birmingham
| | - J O'Beirne
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital, London
| | - L Marelli
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital, London
| | - D Yu
- Department of Radiology, Royal Free Hospital, London
| | - A Hackshaw
- Cancer Research UK & UCL Cancer Trials Centre, London
| | - R Fox
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham
| | - P Johnson
- Cancer Research UK Institute for Cancer Studies, University of Birmingham
| | - A K Burroughs
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital, London
| | - D H Palmer
- Cancer Research UK Institute for Cancer Studies, University of Birmingham
| | - T Meyer
- Department of Oncology, UCL Medical School, Royal Free Campus, London; UCL Cancer Institute, London, UK.
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Mells GF, Pells G, Newton JL, Bathgate AJ, Burroughs AK, Heneghan MA, Neuberger JM, Day DB, Ducker SJ, Sandford RN, Alexander GJ, Jones DEJ. Impact of primary biliary cirrhosis on perceived quality of life: the UK-PBC national study. Hepatology 2013; 58:273-83. [PMID: 23471852 DOI: 10.1002/hep.26365] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2012] [Revised: 01/31/2013] [Accepted: 02/26/2013] [Indexed: 12/14/2022]
Abstract
UNLABELLED Primary biliary cirrhosis (PBC) has a complex clinical phenotype, with debate about the extent and specificity of frequently described systemic symptoms such as fatigue. The aim of this study was to use a national patient cohort of 2,353 patients recruited from all clinical centers in the UK to explore the impact of disease on perceived life quality. Clinical data regarding diagnosis, therapy, and biochemical status were collected and have been reported previously. Detailed symptom phenotyping using recognized and validated symptom assessment tools including the PBC-40 was also undertaken and is reported here. Perception of poor quality of life and impaired health status was common in PBC patients (35% and 46%, respectively) and more common than in an age-matched and sex-matched community control group (6% and 15%, P < 0.0001 for both). Fatigue and symptoms of social dysfunction were associated with impaired perceived quality of life using multivariate analysis. Fatigue was the symptom with the greatest impact. Depression was a significant factor, but appeared to be a manifestation of complex symptom burden rather than a primary event. Fatigue had its greatest impact on perceived quality of life when accompanied by symptoms of social dysfunction, suggesting that maintenance of social networks is critical for minimizing the impact of fatigue. CONCLUSION The symptom burden in PBC, which is unrelated to disease severity or ursodeoxycholic acid response, is significant and complex and results in significant quality of life deficit. The complexity of symptom burden, and its lack of relation to disease severity and treatment response, suggest that specific approaches to symptom management are warranted that address both symptom biology and social impact.
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Affiliation(s)
- George F Mells
- Department of Hepatology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
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Tsochatzis E, Garcovich M, Marelli L, Papastergiou V, Fatourou E, Rodriguez-Peralvarez ML, Germani G, Davies N, Yu D, Luong TV, Dhillon AP, Thorburn D, Patch D, O'Beirne J, Meyer T, Burroughs AK. Transarterial embolization as neo-adjuvant therapy pretransplantation in patients with hepatocellular carcinoma. Liver Int 2013; 33:944-9. [PMID: 23530918 DOI: 10.1111/liv.12144] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Accepted: 02/14/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Neo-adjuvant transarterial therapies are commonly used for patients with HCC in the waiting list for liver transplantation (LT) to delay tumour progression, however, their effectiveness is not well-established. We studied the effect of pre-LT transarterial therapies on post-LT HCC recurrence, using the explanted liver histology to assess therapeutic efficacy and the predictors of response to these therapies. METHODS We included 150 consecutive patients from our prospectively compiled database, listed for liver transplantation using the Milan criteria. Transarterial embolization without chemotherapeutic agents was the transarterial therapy used as standard of care. PVA particles were the embolizing agent of choice. RESULTS Sixty-seven (45%) patients had TAE as bridging therapy to liver transplantation, of which 60 were transplanted after 2001. The majority of patients (36, 54%) had partial tumour necrosis after transarterial therapy, whereas 22 (33%) had complete tumour necrosis and 9 (13%) had no necrosis. HCC post-transplant recurrence was independently associated with no neo-adjuvant transarterial therapy (OR 5.395, 95% CI 1.289-22.577; P = 0.021) and the total radiological size of HCC nodules (OR 1.037, 95% CI 1.006-1.069; P = 0.020). CONCLUSIONS Pre-transplant TAE with the more permanently occluding PVA particles significantly reduces post-transplant HCC recurrence in patients within the Milan criteria.
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Affiliation(s)
- Emmanuel Tsochatzis
- The Royal Free Sheila Sherlock Liver Centre and UCL Institute of Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
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Laleman W, Simon-Talero M, Maleux G, Perez M, Ameloot K, Soriano G, Villalba J, Garcia-Pagan JC, Barrufet M, Jalan R, Brookes J, Thalassinos E, Burroughs AK, Cordoba J, Nevens F. Embolization of large spontaneous portosystemic shunts for refractory hepatic encephalopathy: a multicenter survey on safety and efficacy. Hepatology 2013; 57:2448-57. [PMID: 23401201 DOI: 10.1002/hep.26314] [Citation(s) in RCA: 175] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 02/01/2013] [Indexed: 02/06/2023]
Abstract
UNLABELLED Refractory hepatic encephalopathy (HE) remains a major cause of morbidity in cirrhosis patients. Large spontaneous portosystemic shunts (SPSSs) have been previously suggested to sustain HE in these patients. We aimed to retrospectively assess the efficacy and safety of patients treated with embolization of large SPSSs for the treatment of chronic therapy-refractory HE in a European multicentric working group and to identify patients who may benefit from this procedure. Between July 1998 and January 2012, 37 patients (Child A6-C13, MELD [Model of Endstage Liver Disease] 5-28) with refractory HE were diagnosed with single large SPSSs that were considered eligible for embolization. On a short-term basis (i.e., within 100 days after embolization), 22 out of 37 patients (59.4%) were free of HE (P < 0.001 versus before embolization) of which 18 (48.6% of patients overall) remained HE-free over a mean follow-up period of 697 ± 157 days (P < 0.001 versus before embolization). Overall, we noted improved autonomy, decreased number of hospitalizations, and severity of the worst HE episode after embolization in three-quarters of the patients. Logistic regression identified the MELD score as strongest positive predictive factor of HE recurrence with a cutoff of 11 for patient selection. As to safety, we noted one major nonlethal procedure-related complication. There was no significant increase in de novo development or aggravation of preexisting varices, portal hypertensive gastropathy, or ascites. CONCLUSION This multicenter European cohort study demonstrated a role for large SPSSs in chronic protracted or recurrent HE and substantiated the effectiveness and safety of embolization of these shunts, provided there is sufficient functional liver reserve.
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Affiliation(s)
- Wim Laleman
- Department of Liver and Biliopancreatic Disorders, University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium.
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Manousou P, Burroughs AK, Tsochatzis E, Isgro G, Hall A, Green A, Calvaruso V, Ma GL, Gale J, Burgess G, O'Beirne J, Patch D, Thorburn D, Leandro G, Dhillon AP, Dhillon AP. Digital image analysis of collagen assessment of progression of fibrosis in recurrent HCV after liver transplantation. J Hepatol 2013; 58:962-8. [PMID: 23262247 DOI: 10.1016/j.jhep.2012.12.016] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 11/11/2012] [Accepted: 12/07/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Histological assessment of fibrosis progression is currently performed by staging systems which are not continuous quantitative measurements. We aimed at assessing a quantitative measurement of fibrosis collagen proportionate area (CPA), to evaluate fibrosis progression and compare it to Ishak stage progression. METHODS We studied a consecutive cohort of 155 patients with recurrent HCV hepatitis after liver transplantation (LT), who had liver biopsies at one year and were subsequently evaluated for progression of fibrosis using CPA and Ishak staging, and correlated with clinical decompensation. The upper quartile of distribution of fibrosis rates (difference in CPA or Ishak stage between paired biopsies) defined fast fibrosers. RESULTS Patients had 610 biopsies and a median follow-up of 116 (18-252) months. Decompensation occurred in 29 (18%) patients. Median Ishak stage progression rate was 0.42 units/year: (24 (15%) fast fibrosers). Median CPA fibrosis progression rate was 0.71%/year (36 (23%) fast fibrosers). Clinical decompensation was independently associated by Cox regression only with CPA (p=0.007), with AUROCs of 0.81 (95% CI 0.71-0.91) compared to 0.68 (95% CI 0.56-0.81) for Ishak stage. Fast fibrosis defined by CPA progression was independently associated with histological de novo hepatitis (OR: 3.77), older donor age (OR: 1.03) and non-use/discontinuation of azathioprine before 1 year post-LT (OR: 3.85), whereas when defined by Ishak progression, fast fibrosers was only associated with histological de novo hepatitis. CONCLUSIONS CPA fibrosis progression rate is a better predictor of clinical outcome than progression by Ishak stage. Histological de novo hepatitis, older donor age and non-use/discontinuation of azathioprine are associated with rapid fibrosis progression in recurrent HCV chronic hepatitis after liver transplantation.
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Affiliation(s)
- Pinelopi Manousou
- The Royal Free Sheila Sherlock Liver Centre and Division of Surgery & Interventional Sciences, University College London, UK
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