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Lucena MI, Villanueva-Paz M, Alvarez-Alvarez I, Aithal GP, Björnsson ES, Cakan-Akdogan G, Cubero FJ, Esteves F, Falcon-Perez JM, Fromenty B, Garcia-Ruiz C, Grove JI, Konu O, Kranendonk M, Kullak-Ublick GA, Miranda JP, Remesal-Doblado A, Sancho-Bru P, Nelson L, Andrade RJ, Daly AK, Fernandez-Checa JC. Roadmap to DILI research in Europe. A proposal from COST action ProEuroDILINet. Pharmacol Res 2024; 200:107046. [PMID: 38159783 DOI: 10.1016/j.phrs.2023.107046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
In the current article the aims for a constructive way forward in Drug-Induced Liver Injury (DILI) are to highlight the most important priorities in research and clinical science, therefore supporting a more informed, focused, and better funded future for European DILI research. This Roadmap aims to identify key challenges, define a shared vision across all stakeholders for the opportunities to overcome these challenges and propose a high-quality research program to achieve progress on the prediction, prevention, diagnosis and management of this condition and impact on healthcare practice in the field of DILI. This will involve 1. Creation of a database encompassing optimised case report form for prospectively identified DILI cases with well-characterised controls with competing diagnoses, biological samples, and imaging data; 2. Establishing of preclinical models to improve the assessment and prediction of hepatotoxicity in humans to guide future drug safety testing; 3. Emphasis on implementation science and 4. Enhanced collaboration between drug-developers, clinicians and regulatory scientists. This proposed operational framework will advance DILI research and may bring together basic, applied, translational and clinical research in DILI.
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Affiliation(s)
- M I Lucena
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Plataforma de Investigación Clínica y Ensayos Clínicos UICEC-IBIMA, Plataforma ISCIII de Investigación Clínica, Madrid, Spain.
| | - M Villanueva-Paz
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - I Alvarez-Alvarez
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - G P Aithal
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom; NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom
| | - E S Björnsson
- Faculty of Medicine, University of Iceland, Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | - G Cakan-Akdogan
- Izmir Biomedicine and Genome Center, Izmir, Turkey. Department of Medical Biology, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - F J Cubero
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Department of Immunology, Ophthalmology and ORL, Complutense University School of Medicine, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - F Esteves
- Center for Toxicogenomics and Human Health (ToxOmics), NMS | FCM, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - J M Falcon-Perez
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Exosomes Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), Derio, Bizkaia, 48160, Spain. IKERBASQUE, Basque Foundation for Science, Bilbao, Bizkaia 48009, Spain
| | - B Fromenty
- INSERM, Univ Rennes, INRAE, Institut NUMECAN (Nutrition Metabolisms and Cancer) UMR_A 1341, UMR_S 1317, F-35000 Rennes, France
| | - C Garcia-Ruiz
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. University of Barcelona, Barcelona, Spain; Department of Cell Death and Proliferation, Institute of Biomedical Research of Barcelona (IIBB), CSIC, Barcelona, Spain
| | - J I Grove
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom; NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom
| | - O Konu
- Department of Molecular Biology and Genetics, Faculty of Science, Bilkent University, Ankara, Turkey; Interdisciplinary Neuroscience Program, Bilkent University, Ankara, Turkey; UNAM-Institute of Materials Science and Nanotechnology, Bilkent University, Ankara, Turkey
| | - M Kranendonk
- Center for Toxicogenomics and Human Health (ToxOmics), NMS | FCM, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - G A Kullak-Ublick
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; CMO & Patient Safety, Global Drug Development, Novartis Pharma, Basel, Switzerland
| | - J P Miranda
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - A Remesal-Doblado
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
| | - P Sancho-Bru
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. University of Barcelona, Barcelona, Spain
| | - L Nelson
- Institute for Bioengineering, School of Engineering, Faraday Building, The University of Edinburgh, Scotland, UK
| | - R J Andrade
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - A K Daly
- Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - J C Fernandez-Checa
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. University of Barcelona, Barcelona, Spain; Department of Cell Death and Proliferation, Institute of Biomedical Research of Barcelona (IIBB), CSIC, Barcelona, Spain; Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
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2
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Miller H, Harman D, Aithal GP, Manousou P, Cobbold JF, Parker R, Sheridan D, Newsome PN, Karpe F, Neville M, Arlt W, Sitch AJ, Korbonits M, Biehl M, Alazawi W, Tomlinson JW. Translating the potential of the urine steroid metabolome to stage NAFLD (TrUSt-NAFLD): study protocol for a multicentre, prospective validation study. BMJ Open 2024; 14:e074918. [PMID: 38238179 PMCID: PMC10806741 DOI: 10.1136/bmjopen-2023-074918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 01/09/2024] [Indexed: 01/23/2024] Open
Abstract
INTRODUCTION Non-alcoholic fatty liver disease (NAFLD) affects approximately one in four individuals and its prevalence continues to rise. The advanced stages of NAFLD with significant liver fibrosis are associated with adverse morbidity and mortality outcomes. Currently, liver biopsy remains the 'gold-standard' approach to stage NAFLD severity. Although generally well tolerated, liver biopsies are associated with significant complications, are resource intensive, costly, and sample only a very small area of the liver as well as requiring day case admission to a secondary care setting. As a result, there is a significant unmet need to develop non-invasive biomarkers that can accurately stage NAFLD and limit the need for liver biopsy. The aim of this study is to validate the use of the urine steroid metabolome as a strategy to stage NAFLD severity and to compare its performance against other non-invasive NAFLD biomarkers. METHODS AND ANALYSIS The TrUSt-NAFLD study is a multicentre prospective test validation study aiming to recruit 310 patients with biopsy-proven and staged NAFLD across eight centres within the UK. 150 appropriately matched control patients without liver disease will be recruited through the Oxford Biobank. Blood and urine samples, alongside clinical data, will be collected from all participants. Urine samples will be analysed by liquid chromatography-tandem mass spectroscopy to quantify a panel of predefined steroid metabolites. A machine learning-based classifier, for example, Generalized Matrix Relevance Learning Vector Quantization that was trained on retrospective samples, will be applied to the prospective steroid metabolite data to determine its ability to identify those patients with advanced, as opposed to mild-moderate, liver fibrosis as a consequence of NAFLD. ETHICS AND DISSEMINATION Research ethical approval was granted by West Midlands, Black Country Research Ethics Committee (REC reference: 21/WM/0177). A substantial amendment (TrUSt-NAFLD-SA1) was approved on 26 November 2021. TRIAL REGISTRATION NUMBER ISRCTN19370855.
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Affiliation(s)
- Hamish Miller
- Oxford Center for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
- Barts Liver Centre, Queen Mary University London and Barts Health NHS Trust, London, UK
| | - David Harman
- Royal Berkshire Hospital NHS Foundation Trust, Reading, UK
| | - Guruprasad Padur Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - Pinelopi Manousou
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Jeremy F Cobbold
- Oxford Liver Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University, Oxford, UK
| | - Richard Parker
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - David Sheridan
- Institute of Translational and Stratified Medicine, University of Plymouth, Plymouth, UK
| | - Philip N Newsome
- National Institute for Health Research Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK
| | - Fredrik Karpe
- Oxford Center for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Matthew Neville
- Oxford Center for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Medical Research Council London Institute of Medical Sciences, Imperial College London, Hammersmith Campus, London, UK
| | - Alice J Sitch
- National Institute for Health Research Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Marta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Michael Biehl
- Faculty of Science and Engineering, Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, Netherlands
- SMQB, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - William Alazawi
- Barts Liver Centre, Queen Mary University London and Barts Health NHS Trust, London, UK
| | - Jeremy W Tomlinson
- Oxford Center for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
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3
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Massen GM, Allen RJ, Leavy OC, Selby NM, Aithal GP, Oliver N, Parfrey H, Wain LV, Jenkins G, Stewart I, Quint JK. Classifying the unclassifiable-a Delphi study to reach consensus on the fibrotic nature of diseases. QJM 2023; 116:429-435. [PMID: 37004203 PMCID: PMC10250078 DOI: 10.1093/qjmed/hcad050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/25/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Traditionally, clinical research has focused on individual fibrotic diseases or fibrosis in a particular organ. However, it is possible for people to have multiple fibrotic diseases. While multi-organ fibrosis may suggest shared pathogenic mechanisms, yet there is no consensus on what constitutes a fibrotic disease and therefore fibrotic multimorbidity. AIM A Delphi study was performed to reach consensus on which diseases may be described as fibrotic. METHODS Participants were asked to rate a list of diseases, sub-grouped according to eight body regions, as 'fibrotic manifestation always present', 'can develop fibrotic manifestations', 'associated with fibrotic manifestations' or 'not fibrotic nor associated'. Classifications of 'fibrotic manifestation always present' and 'can develop fibrotic manifestations' were merged and termed 'fibrotic'. Clinical consensus was defined according to the interquartile range, having met a minimum number of responses. Clinical agreement was used for classification where diseases did not meet the minimum number of responses (required for consensus measure), were only classified if there was 100% consensus on disease classification. RESULTS After consulting experts, searching the literature and coding dictionaries, a total of 323 non-overlapping diseases which might be considered fibrotic were identified; 92 clinical specialists responded to the first round of the survey. Over three survey rounds, 240 diseases were categorized as fibrotic via clinical consensus and 25 additional diseases through clinical agreement. CONCLUSION Using a robust methodology, an extensive list of diseases was classified. The findings lay the foundations for studies estimating the burden of fibrotic multimorbidity, as well as investigating shared mechanisms and therapies.
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Affiliation(s)
- G M Massen
- National Heart and Lung Institute, Imperial College London, London, W12 0BZ, UK
| | - R J Allen
- Department of Population Health Sciences, University of Leicester, Leicester, LE1 7RH, UK
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, LE3 9QP, UK
| | - O C Leavy
- Department of Population Health Sciences, University of Leicester, Leicester, LE1 7RH, UK
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, LE3 9QP, UK
| | - N M Selby
- Department of Renal Medicine,, Derby Hospitals Foundation Trust, Derby, DE22 3NE,UK
| | - G P Aithal
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, University of Nottingham, Nottingham, NG7 2UH, UK
| | - N Oliver
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, SW7 2AZUK
| | - H Parfrey
- Cambridge Interstitial Lung Disease Unit, Royal Papworth Hospital, Cambridge, CB2 0AY, UK
| | - L V Wain
- Department of Population Health Sciences, University of Leicester, Leicester, LE1 7RH, UK
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, LE3 9QP, UK
| | - G Jenkins
- National Heart and Lung Institute, Imperial College London, London, W12 0BZ, UK
| | - I Stewart
- National Heart and Lung Institute, Imperial College London, London, W12 0BZ, UK
| | - J K Quint
- National Heart and Lung Institute, Imperial College London, London, W12 0BZ, UK
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4
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Mózes FE, Lee JA, Vali Y, Alzoubi O, Staufer K, Trauner M, Paternostro R, Stauber RE, Holleboom AG, van Dijk AM, Mak AL, Boursier J, de Saint Loup M, Shima T, Bugianesi E, Gaia S, Armandi A, Lupșor-Platon M, Wong VWS, Li G, Wong GLH, Cobbold J, Karlas T, Wiegand J, Sebastiani G, Tsochatzis E, Liguori A, Yoneda M, Nakajima A, Hagström H, Akbari C, Hirooka M, Chan WK, Mahadeva S, Rajaram R, Zheng MH, George J, Eslam M, Petta S, Pennisi G, Viganò M, Ridolfo S, Aithal GP, Palaniyappan N, Lee DH, Ekstedt M, Nasr P, Cassinotto C, de Lédinghen V, Berzigotti A, Mendoza YP, Noureddin M, Truong E, Fournier-Poizat C, Geier A, Martic M, Tuthill T, Anstee QM, Harrison SA, Bossuyt PM, Pavlides M. Performance of non-invasive tests and histology for the prediction of clinical outcomes in patients with non-alcoholic fatty liver disease: an individual participant data meta-analysis. Lancet Gastroenterol Hepatol 2023:S2468-1253(23)00141-3. [PMID: 37290471 DOI: 10.1016/s2468-1253(23)00141-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [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: 03/08/2023] [Revised: 04/20/2023] [Accepted: 04/27/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Histologically assessed liver fibrosis stage has prognostic significance in patients with non-alcoholic fatty liver disease (NAFLD) and is accepted as a surrogate endpoint in clinical trials for non-cirrhotic NAFLD. Our aim was to compare the prognostic performance of non-invasive tests with liver histology in patients with NAFLD. METHODS This was an individual participant data meta-analysis of the prognostic performance of histologically assessed fibrosis stage (F0-4), liver stiffness measured by vibration-controlled transient elastography (LSM-VCTE), fibrosis-4 index (FIB-4), and NAFLD fibrosis score (NFS) in patients with NAFLD. The literature was searched for a previously published systematic review on the diagnostic accuracy of imaging and simple non-invasive tests and updated to Jan 12, 2022 for this study. Studies were identified through PubMed/MEDLINE, EMBASE, and CENTRAL, and authors were contacted for individual participant data, including outcome data, with a minimum of 12 months of follow-up. The primary outcome was a composite endpoint of all-cause mortality, hepatocellular carcinoma, liver transplantation, or cirrhosis complications (ie, ascites, variceal bleeding, hepatic encephalopathy, or progression to a MELD score ≥15). We calculated aggregated survival curves for trichotomised groups and compared them using stratified log-rank tests (histology: F0-2 vs F3 vs F4; LSM: <10 vs 10 to <20 vs ≥20 kPa; FIB-4: <1·3 vs 1·3 to ≤2·67 vs >2·67; NFS: <-1·455 vs -1·455 to ≤0·676 vs >0·676), calculated areas under the time-dependent receiver operating characteristic curves (tAUC), and performed Cox proportional-hazards regression to adjust for confounding. This study was registered with PROSPERO, CRD42022312226. FINDINGS Of 65 eligible studies, we included data on 2518 patients with biopsy-proven NAFLD from 25 studies (1126 [44·7%] were female, median age was 54 years [IQR 44-63), and 1161 [46·1%] had type 2 diabetes). After a median follow-up of 57 months [IQR 33-91], the composite endpoint was observed in 145 (5·8%) patients. Stratified log-rank tests showed significant differences between the trichotomised patient groups (p<0·0001 for all comparisons). The tAUC at 5 years were 0·72 (95% CI 0·62-0·81) for histology, 0·76 (0·70-0·83) for LSM-VCTE, 0·74 (0·64-0·82) for FIB-4, and 0·70 (0·63-0·80) for NFS. All index tests were significant predictors of the primary outcome after adjustment for confounders in the Cox regression. INTERPRETATION Simple non-invasive tests performed as well as histologically assessed fibrosis in predicting clinical outcomes in patients with NAFLD and could be considered as alternatives to liver biopsy in some cases. FUNDING Innovative Medicines Initiative 2.
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Affiliation(s)
- Ferenc E Mózes
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Jenny A Lee
- Department of Epidemiology and Data Science, Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Yasaman Vali
- Department of Epidemiology and Data Science, Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Osama Alzoubi
- School of Medicine, The University of Jordan, Amman, Jordan
| | - Katharina Staufer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Division of Transplantation, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rudolf E Stauber
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Adriaan G Holleboom
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Anne-Marieke van Dijk
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Anne Linde Mak
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Jérôme Boursier
- Laboratoire HIFIH, UPRES EA 3859, SFR ICAT 4208, Université d'Angers, Angers, France; Service d'Hépato-Gastroentérologie et Oncologie Digestive, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Marc de Saint Loup
- Service d'Hépato-Gastroentérologie et Oncologie Digestive, Centre Hospitalier Universitaire d'Angers, Angers, France
| | | | | | - Silvia Gaia
- Department of Medical Sciences, University of Turin, Torino, Italy
| | - Angelo Armandi
- Department of Medical Sciences, University of Turin, Torino, Italy
| | - Monica Lupșor-Platon
- Department of Medical Imaging, Iuliu Hațieganu University of Medicine and Pharmacy, Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor", Cluj-Napoca, Romania
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Guanlin Li
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Grace Lai-Hung Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Jeremy Cobbold
- Translational Gastroenterology Unit, University of Oxford, Oxford, UK; Oxford National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Oxford University Hospitals National Health Service (NHS) Foundation Trust, University of Oxford, Oxford, UK
| | - Thomas Karlas
- Department of Oncology, Gastroenterology, Hepatology, Pulmonology and Infectious Diseases, University Hospital Leipzig, Leipzig, Germany
| | - Johannes Wiegand
- Department of Oncology, Gastroenterology, Hepatology, Pulmonology and Infectious Diseases, University Hospital Leipzig, Leipzig, Germany
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology and Division of Infectious Diseases, McGill University Health Centre, Montreal, QC, Canada
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust, London, UK; Institute for Liver and Digestive Health, University College London, London, UK
| | - Antonio Liguori
- Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust, London, UK; Institute for Liver and Digestive Health, University College London, London, UK; Department of Translational Medicine and Surgery, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Masato Yoneda
- Department of Gastroenterology and Hepatology, School of Medicine, Yokohama City University, Yokohama, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, School of Medicine, Yokohama City University, Yokohama, Japan
| | - Hannes Hagström
- Division of Liver and Pancreatic diseases, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Camilla Akbari
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Masashi Hirooka
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Touon, Japan
| | - Wah-Kheong Chan
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sanjiv Mahadeva
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ruveena Rajaram
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ming-Hua Zheng
- MAFLD Research Center, Department of Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China; Wenzhou Key Laboratory of Hepatology, Wenzhou, China; Institute of Hepatology, Wenzhou Medical University, Wenzhou, China; Key Laboratory of Diagnosis and Treatment for The Development of Chronic Liver Disease in Zhejiang Province, Wenzhou, China
| | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital, University of Sydney, Sydney, NSW, Australia
| | - Mohammed Eslam
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital, University of Sydney, Sydney, NSW, Australia
| | - Salvatore Petta
- Section of Gastroenterology and Hepatology, PROMISE, Palermo, Italy
| | - Grazia Pennisi
- Section of Gastroenterology and Hepatology, PROMISE, Palermo, Italy
| | - Mauro Viganò
- Gastroenterology Hepatology and Transplantation Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Sofia Ridolfo
- Hepatology Unit, Ospedale San Giuseppe, University of Milan, Milan, Italy
| | - Guruprasad Padur Aithal
- NIHR Nottingham Biomedical Research Centre and Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Naaventhan Palaniyappan
- NIHR Nottingham Biomedical Research Centre and Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Dae Ho Lee
- Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Mattias Ekstedt
- Department of Health, Medical and Caring Sciences, Linköping University, Linköping, Sweden
| | - Patrik Nasr
- Department of Health, Medical and Caring Sciences, Linköping University, Linköping, Sweden
| | - Christophe Cassinotto
- Department of Diagnostic and Interventional Radiology, Saint-Eloi Hospital and Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, University Hospital of Montpellier, Montpellier, France
| | - Victor de Lédinghen
- Centre d'Investigation de la Fibrose Hépatique, Hôpital Haut-Lévêque, Bordeaux University Hospital, Pessac, France; INSERM1312, Bordeaux University, Bordeaux, France
| | - Annalisa Berzigotti
- Department for Visceral Medicine and Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Yuly P Mendoza
- Department of Biomedical Research, University of Bern, Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Mazen Noureddin
- Houston Research Institute, Houston Methodist Hospital, Houston, TX, USA
| | - Emily Truong
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Andreas Geier
- Division of Hepatology, University Hospital Würzburg, Würzburg, Germany
| | - Miljen Martic
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Theresa Tuthill
- Digital Sciences and Translational Imaging, Pfizer, Cambridge, MA, USA
| | - Quentin M Anstee
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Stephen A Harrison
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Patrick M Bossuyt
- Department of Epidemiology and Data Science, Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Michael Pavlides
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Translational Gastroenterology Unit, University of Oxford, Oxford, UK; Oxford National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Oxford University Hospitals National Health Service (NHS) Foundation Trust, University of Oxford, Oxford, UK.
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Graupera I, Thiele M, Serra-Burriel M, Caballeria L, Roulot D, Wong GLH, Fabrellas N, Guha IN, Arslanow A, Expósito C, Hernández R, Aithal GP, Galle PR, Pera G, Wong VWS, Lammert F, Ginès P, Castera L, Krag A. Low Accuracy of FIB-4 and NAFLD Fibrosis Scores for Screening for Liver Fibrosis in the Population. Clin Gastroenterol Hepatol 2022; 20:2567-2576.e6. [PMID: 34971806 DOI: 10.1016/j.cgh.2021.12.034] [Citation(s) in RCA: 66] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 11/29/2021] [Accepted: 12/22/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Fibrosis-4 (FIB-4) and the nonalcoholic fatty liver disease fibrosis score (NFS) are the 2 most popular noninvasive blood-based serum tests proposed for widespread fibrosis screening. We therefore aimed to describe the accuracy of FIB-4 and NFS to detect elevated liver stiffness as an indicator of hepatic fibrosis in low-prevalence populations. METHODS This study included a total of 5129 patients with concomitant measurement of FIB-4, NFS, and liver stiffness measurement (LSM) by Fibroscan (Echosens, France) from 5 independent population-based cohorts from Spain, Hong Kong, Denmark, England, and France; 3979 participants from the general population and 1150 from at-risk cohorts due to alcohol, diabetes, or obesity. We correlated LSM with FIB-4 and NFS, and calculated pre- and post-test predictive values of FIB-4 and NFS to detect elevated LSM at 8 kPa and 12 kPa cutoffs. The mean age was 53 ± 12 years, the mean body mass index was 27 ± 5 kg/m2, and 2439 (57%) were women. One in 10 patients (552; 11%) had liver stiffness ≥8 kPa, but 239 of those (43%) had a normal FIB-4, and 171 (31%) had normal NFS. The proportion of false-negatives was higher in at-risk patients than the general population. FIB-4 was false-negative in 11% of diabetic subjects, compared with 2.5% false-negatives with NFS. Waist circumference outperformed FIB-4 and NFS for detecting LSM ≥8 kPa in the general population. Almost one-third (28%-29%) of elevated FIB-4/NFS were false-positive in both the general population and at-risk cohorts. CONCLUSIONS FIB-4 and NFS are suboptimal for screening purposes due to a high risk of overdiagnosis and a non-negligible percentage of false-negatives, especially in patients with risk factors for chronic liver disease. Waist circumference emerged as a potential first step to identify patients at risk for liver fibrosis in the general population.
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Affiliation(s)
- Isabel Graupera
- Liver Unit Hospital Clínic. Institut D'investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Centro de Investigación En Red de Enfermedades Hepáticas Y Digestivas (Ciberehd), Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Maja Thiele
- Center for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, and Department for Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Miquel Serra-Burriel
- Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Llorenç Caballeria
- USR Metropolitana Nord, IDIAP Jordi Gol, ICS Institut Català de la Salut, Barcelona, Spain
| | - Dominique Roulot
- Department of Hepatology, AP-HP, Hopital Avicenne, Bobigny, France; Université Paris 13, Sorbonne Paris Cité, Villetaneuse, France
| | - Grace Lai-Hung Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Núria Fabrellas
- Faculty of Medicine and Health Sciences, School of Nursing, University of Barcelona; Institut D'investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Centro de Investigación En Red de Enfermedades Hepáticas Y Digestivas (Ciberehd), Barcelona, Spain
| | - Indra Neil Guha
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom
| | - Anita Arslanow
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany; Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Carmen Expósito
- USR Metropolitana Nord, IDIAP Jordi Gol, ICS Institut Català de la Salut, Barcelona, Spain
| | - Rosario Hernández
- CAP La Marina, Institut Català de la Salut de Barcelona, Barcelona, Spain
| | - Guruprasad Padur Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom
| | - Peter R Galle
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Guillem Pera
- USR Metropolitana Nord, IDIAP Jordi Gol, ICS Institut Català de la Salut, Barcelona, Spain
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Pere Ginès
- Liver Unit Hospital Clínic. Institut D'investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Centro de Investigación En Red de Enfermedades Hepáticas Y Digestivas (Ciberehd), Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Laurent Castera
- Hôpital Beaujon; Department of Hepatology, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France; Université Paris VII, Inserm Umr 1149, Centre de Recherche Sur L'inflammation, Paris, France
| | - Aleksander Krag
- Center for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, and Department for Clinical Research, University of Southern Denmark, Odense, Denmark
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6
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Mózes FE, Lee JA, Selvaraj EA, Jayaswal ANA, Trauner M, Boursier J, Fournier C, Staufer K, Stauber RE, Bugianesi E, Younes R, Gaia S, Lupșor-Platon M, Petta S, Shima T, Okanoue T, Mahadeva S, Chan WK, Eddowes PJ, Hirschfield GM, Newsome PN, Wong VWS, de Ledinghen V, Fan J, Shen F, Cobbold JF, Sumida Y, Okajima A, Schattenberg JM, Labenz C, Kim W, Lee MS, Wiegand J, Karlas T, Yılmaz Y, Aithal GP, Palaniyappan N, Cassinotto C, Aggarwal S, Garg H, Ooi GJ, Nakajima A, Yoneda M, Ziol M, Barget N, Geier A, Tuthill T, Brosnan MJ, Anstee QM, Neubauer S, Harrison SA, Bossuyt PM, Pavlides M. Diagnostic accuracy of non-invasive tests for advanced fibrosis in patients with NAFLD: an individual patient data meta-analysis. Gut 2022; 71:1006-1019. [PMID: 34001645 PMCID: PMC8995830 DOI: 10.1136/gutjnl-2021-324243] [Citation(s) in RCA: 172] [Impact Index Per Article: 86.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/23/2021] [Accepted: 04/29/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Liver biopsy is still needed for fibrosis staging in many patients with non-alcoholic fatty liver disease. The aims of this study were to evaluate the individual diagnostic performance of liver stiffness measurement by vibration controlled transient elastography (LSM-VCTE), Fibrosis-4 Index (FIB-4) and NAFLD (non-alcoholic fatty liver disease) Fibrosis Score (NFS) and to derive diagnostic strategies that could reduce the need for liver biopsies. DESIGN Individual patient data meta-analysis of studies evaluating LSM-VCTE against liver histology was conducted. FIB-4 and NFS were computed where possible. Sensitivity, specificity and area under the receiver operating curve (AUROC) were calculated. Biomarkers were assessed individually and in sequential combinations. RESULTS Data were included from 37 primary studies (n=5735; 45% women; median age: 54 years; median body mass index: 30 kg/m2; 33% had type 2 diabetes; 30% had advanced fibrosis). AUROCs of individual LSM-VCTE, FIB-4 and NFS for advanced fibrosis were 0.85, 0.76 and 0.73. Sequential combination of FIB-4 cut-offs (<1.3; ≥2.67) followed by LSM-VCTE cut-offs (<8.0; ≥10.0 kPa) to rule-in or rule-out advanced fibrosis had sensitivity and specificity (95% CI) of 66% (63-68) and 86% (84-87) with 33% needing a biopsy to establish a final diagnosis. FIB-4 cut-offs (<1.3; ≥3.48) followed by LSM cut-offs (<8.0; ≥20.0 kPa) to rule out advanced fibrosis or rule in cirrhosis had a sensitivity of 38% (37-39) and specificity of 90% (89-91) with 19% needing biopsy. CONCLUSION Sequential combinations of markers with a lower cut-off to rule-out advanced fibrosis and a higher cut-off to rule-in cirrhosis can reduce the need for liver biopsies.
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Affiliation(s)
- Ferenc Emil Mózes
- Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Jenny A Lee
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Emmanuel Anandraj Selvaraj
- Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK,Translational Gastroenterology Unit, University of Oxford, Oxford, Oxfordshire, UK,NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust and the University of Oxford, Oxford, UK
| | | | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Jerome Boursier
- Laboratoire HIFIH, UPRES EA 3859, SFR ICAT 4208, Universite d'Angers, Angers, Pays de la Loire, France,Service d'Hepato-Gastroenterologie et Oncologie Digestive, Centre Hospitalier Universitaire d'Angers, Angers, Pays de la Loire, France
| | | | - Katharina Staufer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria,Department of Visceral Surgery and Medicine, Inselspital University Hospital Bern, Bern, Switzerland,Department of Surgery, Division of Transplantation, Medical University of Vienna, Vienna, Austria
| | - Rudolf E Stauber
- Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Ramy Younes
- Boehringer Ingelheim International GmbH, Ingelheim, Rheinland-Pfalz, Germany
| | - Silvia Gaia
- Medical Sciences, University of Turin, Torino, Italy
| | - Monica Lupșor-Platon
- Department of Ultrasonography, University of Medicine and Pharmacy, Regional Institute of Gastroenterology and Hepatology “Prof. Dr. Octavian Fodor”, Cluj Napoca, Romania
| | - Salvatore Petta
- Section of Gastroenterology and Hepatology, PROMISE, Palermo, Italy
| | - Toshihide Shima
- Hepatology Center, Saiseikai Suita Hospital, Suita, Osaka, Japan
| | - Takeshi Okanoue
- Hepatology Center, Saiseikai Suita Hospital, Suita, Osaka, Japan
| | - Sanjiv Mahadeva
- Faculty of Medicine, Department of Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Wah-Kheong Chan
- Faculty of Medicine, Department of Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Peter J Eddowes
- NIHR Biomedical Research Centre, University of Birmingham, Birmingham, UK,NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, University Health Network, Toronto, Ontario, Canada
| | - Philip Noel Newsome
- NIHR Biomedical Research Centre, University of Birmingham, Birmingham, UK,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Victor de Ledinghen
- Centre d'Investigation de la Fibrose Hépatique, Hopital Haut-Leveque, Pessac, France,INSERM1053, Universite de Bordeaux, Talence, Aquitaine, France
| | - Jiangao Fan
- Department of Gastroenterology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Shen
- Department of Gastroenterology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jeremy F Cobbold
- Translational Gastroenterology Unit, University of Oxford, Oxford, Oxfordshire, UK,NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust and the University of Oxford, Oxford, UK
| | - Yoshio Sumida
- Department of Internal Medicine, Aichi Medical University, Nagakute, Aichi, Japan
| | - Akira Okajima
- Department of Gastroenterology, Koseikai Takeda Hospital, Kyoto, Japan
| | - Jörn M Schattenberg
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Rhineland-Palatinate, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Rhineland-Palatinate, Germany
| | - Won Kim
- Department of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Myoung Seok Lee
- Department of Radiology, Seoul National University Seoul Metropolitan Government Boramae Medical Center, Dongjak-gu, Seoul, The Republic of Korea
| | - Johannes Wiegand
- Department of Medicine II, Leipzig University Medical Center, Leipzig, Sachsen, Germany
| | - Thomas Karlas
- Department of Medicine II, Leipzig University Medical Center, Leipzig, Sachsen, Germany
| | - Yusuf Yılmaz
- Department of Gastroenterology, Marmara University School of Medicine, Istanbul, Turkey,Institute of Gastroenterology, Marmara University, Istanbul, Turkey
| | - Guruprasad Padur Aithal
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, Nottinghamshire, UK,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Naaventhan Palaniyappan
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, Nottinghamshire, UK,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Christophe Cassinotto
- Diagnostic and Interventional Radiology, University Hospital Centre Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Sandeep Aggarwal
- Department of Surgical Disciplines, AIIMS, New Delhi, Delhi, India
| | - Harshit Garg
- Department of Surgical Disciplines, AIIMS, New Delhi, Delhi, India
| | - Geraldine J Ooi
- Department of Surgery, Monash University, Prahran, Victoria, Australia
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Masato Yoneda
- Department of Gastroenterology and Hepatology, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Marianne Ziol
- Service d'Anatomie Pathologique et Centre de Ressources Biologiques, Hopital Jean Verdier, Paris, France
| | - Nathalie Barget
- Centre de Ressources Biologiques, Hopitaux Universitaires Paris-Seine-Saint-Denis, Bondy, Île-de-France, France
| | - Andreas Geier
- Division of Hepatology, University Hospital Wurzburg, Wurzburg, Bayern, Germany
| | - Theresa Tuthill
- Internal Medicine Research Unit, Pfizer Inc, Cambridge, Massachusetts, USA
| | - M. Julia Brosnan
- Internal Medicine Research Unit, Pfizer Inc, Cambridge, Massachusetts, USA
| | - Quentin Mark Anstee
- Translational and Clinical Research Institute, Faculty of Medicine, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Stefan Neubauer
- Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Stephen A. Harrison
- Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Patrick M Bossuyt
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Michael Pavlides
- Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK .,Translational Gastroenterology Unit, University of Oxford, Oxford, Oxfordshire, UK.,NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust and the University of Oxford, Oxford, UK
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7
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Selvaraj EA, Mózes FE, Jayaswal ANA, Zafarmand MH, Vali Y, Lee JA, Levick CK, Young LAJ, Palaniyappan N, Liu CH, Aithal GP, Romero-Gómez M, Brosnan MJ, Tuthill TA, Anstee QM, Neubauer S, Harrison SA, Bossuyt PM, Pavlides M. Diagnostic accuracy of elastography and magnetic resonance imaging in patients with NAFLD: A systematic review and meta-analysis. J Hepatol 2021; 75:770-785. [PMID: 33991635 DOI: 10.1016/j.jhep.2021.04.044] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/15/2021] [Accepted: 04/25/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Vibration-controlled transient elastography (VCTE), point shear wave elastography (pSWE), 2-dimensional shear wave elastography (2DSWE), magnetic resonance elastography (MRE), and magnetic resonance imaging (MRI) have been proposed as non-invasive tests for patients with non-alcoholic fatty liver disease (NAFLD). This study evaluated their diagnostic accuracy for liver fibrosis and non-alcoholic steatohepatitis (NASH). METHODS PubMED/MEDLINE, EMBASE and the Cochrane Library were searched for studies examining the diagnostic accuracy of these index tests, against histology as the reference standard, in adult patients with NAFLD. Two authors independently screened and assessed methodological quality of studies and extracted data. Summary estimates of sensitivity, specificity and area under the curve (sAUC) were calculated for fibrosis stages and NASH, using a random effects bivariate logit-normal model. RESULTS We included 82 studies (14,609 patients). Meta-analysis for diagnosing fibrosis stages was possible in 53 VCTE, 11 MRE, 12 pSWE and 4 2DSWE studies, and for diagnosing NASH in 4 MRE studies. sAUC for diagnosis of significant fibrosis were: 0.83 for VCTE, 0.91 for MRE, 0.86 for pSWE and 0.75 for 2DSWE. sAUC for diagnosis of advanced fibrosis were: 0.85 for VCTE, 0.92 for MRE, 0.89 for pSWE and 0.72 for 2DSWE. sAUC for diagnosis of cirrhosis were: 0.89 for VCTE, 0.90 for MRE, 0.90 for pSWE and 0.88 for 2DSWE. MRE had sAUC of 0.83 for diagnosis of NASH. Three (4%) studies reported intention-to-diagnose analyses and 15 (18%) studies reported diagnostic accuracy against pre-specified cut-offs. CONCLUSIONS When elastography index tests are acquired successfully, they have acceptable diagnostic accuracy for advanced fibrosis and cirrhosis. The potential clinical impact of these index tests cannot be assessed fully as intention-to-diagnose analyses and validation of pre-specified thresholds are lacking. LAY SUMMARY Non-invasive tests that measure liver stiffness or use magnetic resonance imaging (MRI) have been suggested as alternatives to liver biopsy for assessing the severity of liver scarring (fibrosis) and fatty inflammation (steatohepatitis) in patients with non-alcoholic fatty liver disease (NAFLD). In this study, we summarise the results of previously published studies on how accurately these non-invasive tests can diagnose liver fibrosis and inflammation, using liver biopsy as the reference. We found that some techniques that measure liver stiffness had a good performance for the diagnosis of severe liver scarring.
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Affiliation(s)
- Emmanuel Anandraj Selvaraj
- Oxford Centre for Clinical Magnetic Resonance Research, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust and the University of Oxford, Oxford, UK
| | - Ferenc Emil Mózes
- Oxford Centre for Clinical Magnetic Resonance Research, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Arjun Narayan Ajmer Jayaswal
- Oxford Centre for Clinical Magnetic Resonance Research, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Mohammad Hadi Zafarmand
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Yasaman Vali
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Jenny A Lee
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Christina Kim Levick
- Oxford Centre for Clinical Magnetic Resonance Research, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Liam Arnold Joseph Young
- Oxford Centre for Clinical Magnetic Resonance Research, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Naaventhan Palaniyappan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Chang-Hai Liu
- UCM Digestive Diseases. Virgen del Rocio University Hospital. Institute of Biomedicine of Seville, University of Seville, Sevilla, Spain; Center for Infectious Diseases, West China Hospital of Sichuan University; Division of Infectious Diseases, State Key Laboratory of Biotherapy and Center of Infectious Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Guruprasad Padur Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Manuel Romero-Gómez
- UCM Digestive Diseases. Virgen del Rocio University Hospital. Institute of Biomedicine of Seville, University of Seville, Sevilla, Spain
| | - M Julia Brosnan
- Internal Medicine Research Unit, Pfizer Inc, Cambridge, MA, USA
| | | | - Quentin M Anstee
- Liver Research Group, Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals, NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Stefan Neubauer
- Oxford Centre for Clinical Magnetic Resonance Research, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Stephen A Harrison
- Oxford Centre for Clinical Magnetic Resonance Research, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Patrick M Bossuyt
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Michael Pavlides
- Oxford Centre for Clinical Magnetic Resonance Research, Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust and the University of Oxford, Oxford, UK.
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8
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Affiliation(s)
- Naaventhan Palaniyappan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Guruprasad Padur Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
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9
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Parker R, Kim SJ, Im GY, Nahas J, Dhesi B, Vergis N, Sinha A, Ghezzi A, Rink MR, McCune A, Aithal GP, Newsome PN, Weston CJ, Holt A, Gao B. Obesity in acute alcoholic hepatitis increases morbidity and mortality. EBioMedicine 2019; 45:511-518. [PMID: 31278069 PMCID: PMC6642069 DOI: 10.1016/j.ebiom.2019.03.046] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/15/2019] [Accepted: 03/18/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Alcohol and obesity synergise to increase the risk of liver-related mortality. We examined the influence of adiposity on clinical outcomes in alcoholic hepatitis (AH) and the underlying inflammatory crosstalk between adipose tissue (AT) and the liver. METHODS A cohort of 233 patients with AH from the UK and USA provided data to analyse the effects of obesity in AH. Body mass index was corrected for the severity of ascites, termed cBMI. Inflammatory and metabolic profiling was undertaken by proteome analysis of human serum samples. The effect of alcohol on adipose tissue and CXCL11 expression was studied in 3 T3-derived adipocytes and in mice using the high-fat diet-plus-binge ethanol model. FINDINGS Obesity was common amongst patients with AH, seen in 19% of individuals. Obesity (HR 2.22, 95%CI 1.1-4.3, p = .022) and underweight (HR 2.38, 1.00-5.6, p = .049) were independently associated with mortality at 3 months. Proteome analysis demonstrated multiple metabolic and inflammatory factors differentially expressed in obese AH verse lean AH, with CXCL11 being the most elevated factor in obese AH. In vitro analysis of cultured adipocytes and in vivo analysis of mouse models showed that alcohol induced CXCL11 expression in AT, but not in liver. INTERPRETATION Obesity is common in AH and associated with a greater than two-fold increase in short-term mortality. Obese AH is associated with a different inflammatory phenotype, with the greatest elevation in CXCL11. These data confirm that adiposity is clinically important in acute alcohol-related liver disease and illustrate the adipose-liver inflammatory axis in AH. FUND: This work was supported in part by an EASL Sheila Sherlock Physician Scientist Fellowship. The funder played no role in gathering or analysing data or writing the manuscript. This paper presents independent research supported by the NIHR Birmingham Biomedical Research Centre at the University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.
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Affiliation(s)
- Richard Parker
- Liver and Hepatobiliary Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Centre for Liver Research, University of Birmingham, Birmingham, UK; National Institute for Alcoholism and Alcohol Abuse, National Institutes of Health, Rockville, MD, USA.
| | - S J Kim
- National Institute for Alcoholism and Alcohol Abuse, National Institutes of Health, Rockville, MD, USA
| | - G Y Im
- Mount Sinai Medical Centre, New York, NY, USA
| | - J Nahas
- Mount Sinai Medical Centre, New York, NY, USA
| | - B Dhesi
- Liver and Hepatobiliary Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - N Vergis
- Imperial College Healthcare NHS Foundation Trust, UK
| | - A Sinha
- Department of Liver Medicine, University Hospitals Bristol NHS Foundation Trust, UK
| | - A Ghezzi
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University Of Nottingham, Nottingham, UK
| | - M R Rink
- Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - A McCune
- Department of Liver Medicine, University Hospitals Bristol NHS Foundation Trust, UK
| | - G P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University Of Nottingham, Nottingham, UK
| | - P N Newsome
- Liver and Hepatobiliary Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - C J Weston
- Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - A Holt
- Liver and Hepatobiliary Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - B Gao
- National Institute for Alcoholism and Alcohol Abuse, National Institutes of Health, Rockville, MD, USA
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10
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Molnar MZ, Joglekar K, Jiang Y, Cholankeril G, Abdul MKM, Kedia S, Gonzalez HC, Ahmed A, Singal A, Bhamidimarri KR, Aithal GP, Duseja A, Wong VWS, Gulnare A, Puri P, Nair S, Eason JD, Satapathy SK. Association of Pretransplant Renal Function With Liver Graft and Patient Survival After Liver Transplantation in Patients With Nonalcoholic Steatohepatitis. Liver Transpl 2019; 25:399-410. [PMID: 30369023 PMCID: PMC6709989 DOI: 10.1002/lt.25367] [Citation(s) in RCA: 23] [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: 07/13/2018] [Accepted: 09/28/2018] [Indexed: 12/13/2022]
Abstract
Nonalcoholic steatohepatitis (NASH) is one of the top 3 indications for liver transplantation (LT) in Western countries. It is unknown whether renal dysfunction at the time of LT has any effect on post-LT outcomes in recipients with NASH. From the United Network for Organ Sharing-Standard Transplant Analysis and Research data set, we identified 4088 NASH recipients who received deceased donor LT. We divided our recipients a priori into 3 categories: group 1 with estimated glomerular filtration rate (eGFR) <30 mL/minute/1.73 m2 at the time of LT and/or received dialysis within 2 weeks preceding LT (n = 937); group 2 with recipients who had eGFR ≥30 mL/minute/1.73 m2 and who did not receive renal replacement therapy prior to LT (n = 2812); and group 3 with recipients who underwent simultaneous liver-kidney transplantation (n = 339). We examined the association of pretransplant renal dysfunction with death with a functioning graft, all-cause mortality, and graft loss using competing risk regression and Cox proportional hazards models. The mean ± standard deviation age of the cohort at baseline was 58 ± 8 years, 55% were male, 80% were Caucasian, and average exception Model for End-Stage Liver Disease score was 24 ± 9. The median follow-up period was 5 years (median, 1816 days; interquartile range, 1090-2723 days). Compared with group 1 recipients, group 2 recipients had 19% reduced trend for risk for death with a functioning graft (subhazard ratio [SHR], 0.81; 95% confidence interval [CI], 0.64-1.02) and similar risk for graft loss (SHR, 1.25; 95% CI, 0.59-2.62), whereas group 3 recipients had similar risk for death with a functioning graft (SHR, 1.23; 95% CI, 0.96-1.57) and graft loss (SHR, 0.18; 95% CI, 0.02-1.37) using an adjusted competing risk regression model. In conclusion, recipients with preserved renal function before LT showed a trend toward lower risk of death with a functioning graft compared with SLKT recipients and those with pretransplant severe renal dysfunction in patients with NASH.
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Affiliation(s)
- Miklos Z Molnar
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN.,Department of Medicine, University of Tennessee Health Science Center, Memphis, TN.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Kiran Joglekar
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Yu Jiang
- School of Public Health, University of Memphis, Memphis, TN
| | - George Cholankeril
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA
| | | | - Satish Kedia
- School of Public Health, University of Memphis, Memphis, TN
| | - Humberto C Gonzalez
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA
| | - Ashwani Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | | | - Guruprasad Padur Aithal
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals National Health Service Trust and University of Nottingham, Nottingham, United Kingdom
| | - Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Agayeva Gulnare
- Department of Internal Medicine, Grand Hospital, Baku, Azerbaijan
| | - Puneet Puri
- Division of Gastroenterology, Hepatology and Nutrition, McGuire Veterans Affairs Medical Center, Virginia Commonwealth University, Richmond, VA
| | - Satheesh Nair
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - James D Eason
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Sanjaya K Satapathy
- Division of Transplant Surgery, Methodist University Hospital Transplant Institute, Memphis, TN.,Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
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11
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Sheel ARG, Harrison S, Sarantitis I, Nicholson JA, Hanna T, Grocock C, Raraty M, Ramesh J, Farooq A, Costello E, Jackson R, Chapman M, Smith A, Carter R, Mckay C, Hamady Z, Aithal GP, Mountford R, Ghaneh P, Hammel P, Lerch MM, Halloran C, Pereira SP, Greenhalf W. Identification of Cystic Lesions by Secondary Screening of Familial Pancreatic Cancer (FPC) Kindreds Is Not Associated with the Stratified Risk of Cancer. Am J Gastroenterol 2019; 114:155-164. [PMID: 30353057 DOI: 10.1038/s41395-018-0395-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 12/11/2022]
Abstract
OBJECTIVES Intraductal papillary mucinous neoplasms (IPMNs) are associated with risk of pancreatic ductal adenocarcinoma (PDAC). It is unclear if an IPMN in individuals at high risk of PDAC should be considered as a positive screening result or as an incidental finding. Stratified familial pancreatic cancer (FPC) populations were used to determine if IPMN risk is linked to familial risk of PDAC. METHODS This is a cohort study of 321 individuals from 258 kindreds suspected of being FPC and undergoing secondary screening for PDAC through the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer (EUROPAC). Computerised tomography, endoscopic ultrasound of the pancreas and magnetic resonance imaging were used. The risk of being a carrier of a dominant mutation predisposing to pancreatic cancer was stratified into three even categories (low, medium and high) based on: Mendelian probability, the number of PDAC cases and the number of people at risk in a kindred. RESULTS There was a median (interquartile range (IQR)) follow-up of 2 (0-5) years and a median (IQR) number of investigations per participant of 4 (2-6). One PDAC, two low-grade neuroendocrine tumours and 41 cystic lesions were identified, including 23 IPMN (22 branch-duct (BD)). The PDAC case occurred in the top 10% of risk, and the BD-IPMN cases were evenly distributed amongst risk categories: low (6/107), medium (10/107) and high (6/107) (P = 0.63). CONCLUSIONS The risk of finding BD-IPMN was independent of genetic predisposition and so they should be managed according to guidelines for incidental finding of IPMN.
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Affiliation(s)
- A R G Sheel
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GA, UK
| | - S Harrison
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GA, UK
| | - I Sarantitis
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GA, UK
| | - J A Nicholson
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GA, UK
| | - T Hanna
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GA, UK
| | - C Grocock
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GA, UK
| | - M Raraty
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GA, UK
| | - J Ramesh
- Department of Gastroenterology, The Royal Liverpool University Hospital, London, UK
| | - A Farooq
- Department of Radiology, The Royal Liverpool University Hospital, London, UK
| | - E Costello
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GA, UK
| | - R Jackson
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GA, UK
| | - M Chapman
- Institute for Liver & Digestive Health, University College London, London, UK
| | - A Smith
- Department of Pancreatico-Biliary Surgery, Leeds Teaching Hospital Trust, Leeds, UK
| | - R Carter
- West of Scotland Pancreatic unit, Glasgow Royal Infirmary, Glasgow, UK
| | - C Mckay
- West of Scotland Pancreatic unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Z Hamady
- Department of Hepatobiliary and Pancreatic Diseases, University Hospital Southampton, Southampton, UK
| | - G P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, NG7 2UH, UK
| | - R Mountford
- Mersey Regional Molecular Genetics Laboratory, Liverpool Women's Hospital, Liverpool, UK
| | - P Ghaneh
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GA, UK
| | - P Hammel
- Service de Gastroentérologie-Pancréatologie, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, 92118, Clichy Cedex, France
| | - M M Lerch
- Department of Medicine A, University Medicine Greifswald, Sauerbruch-Strasse, 17475, Greifswald, Germany
| | - C Halloran
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GA, UK
| | - S P Pereira
- Institute for Liver & Digestive Health, University College London, London, UK
| | - W Greenhalf
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GA, UK
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12
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Bradley C, Scott RA, Cox E, Palaniyappan N, Thomson BJ, Ryder SD, Irving WL, Aithal GP, Guha IN, Francis S. Short-term changes observed in multiparametric liver MRI following therapy with direct-acting antivirals in chronic hepatitis C virus patients. Eur Radiol 2018; 29:3100-3107. [PMID: 30506214 PMCID: PMC6510871 DOI: 10.1007/s00330-018-5788-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 09/04/2018] [Accepted: 09/21/2018] [Indexed: 12/11/2022]
Abstract
Methods We applied multiparametric MRI to assess changes in liver composition, perfusion and blood flow in 17 patients before direct-acting antiviral (DAA) therapy and after treatment completion (within 12 weeks of last DAA tablet swallowed). Results We observed changes in hepatic composition indicated by a reduction in both liver longitudinal relaxation time (T1, 35 ± 4 ms), transverse relaxation time (T2, 2.5 ± 0.8 ms; T2* 3.0 ± 0.7 ms), and liver perfusion (28.1 ± 19.7 ml/100 g/min) which we suggest are linked to reduced pro-inflammatory milieu, including interstitial oedema, within the liver. No changes were observed in liver or spleen blood flow, splenic perfusion, or superior mesenteric artery blood flow. Conclusion For the first time, our study has shown that treatment of HCV with DAAs in patients with cirrhosis leads to an acute reduction in liver T1, T2 and T2* and an increase in liver perfusion measured using MR parameters. The ability of MRI to characterise changes in the angio-architecture of patients with cirrhosis after intervention in the short term will enhance our understanding of the natural history of regression of liver disease and potentially influence clinical decision algorithms. Key Points • DAAs have revolutionised the treatment of hepatitis C and achieve sustained virological response in over 95% of patients, even with liver cirrhosis. • Currently available non-invasive measures of liver fibrosis are not accurate after HCV treatment with DAAs, this prospective single-centre study has shown that MRI can sensitively measure changes within the liver, which could reflect the reduction in inflammation with viral clearance. • The ability of MRI to characterise changes in structural and haemodynamic MRI measures in the liver after intervention will enhance our understanding of the progression/regression of liver disease and could potentially influence clinical decision algorithms.
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Affiliation(s)
- C Bradley
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - R A Scott
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - E Cox
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - N Palaniyappan
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - B J Thomson
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - S D Ryder
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - W L Irving
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - G P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, School of Medicine, the University Of Nottingham, Nottingham, UK
| | - I N Guha
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, School of Medicine, the University Of Nottingham, Nottingham, UK
| | - S Francis
- Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, Nottingham, UK. .,NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.
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13
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Sargeant JA, Gray LJ, Bodicoat DH, Willis SA, Stensel DJ, Nimmo MA, Aithal GP, King JA. The effect of exercise training on intrahepatic triglyceride and hepatic insulin sensitivity: a systematic review and meta-analysis. Obes Rev 2018; 19:1446-1459. [PMID: 30092609 DOI: 10.1111/obr.12719] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 12/12/2022]
Abstract
This systematic review and meta-analysis determined the impact of structured exercise training, and the influence of associated weight loss, on intrahepatic triglyceride (IHTG) in individuals with non-alcoholic fatty liver disease (NAFLD). It also examined its effect on hepatic insulin sensitivity in individuals with or at increased risk of NAFLD. Analyses were restricted to studies using magnetic resonance spectroscopy or liver biopsy for the measurement of IHTG and isotope-labelled glucose tracer for assessment of hepatic insulin sensitivity. Pooling data from 17 studies (373 exercising participants), exercise training for one to 24 weeks (mode: 12 weeks) elicits an absolute reduction in IHTG of 3.31% (95% CI: -4.41 to -2.22%). Exercise reduces IHTG independent of significant weight change (-2.16 [-2.87 to -1.44]%), but benefits are substantially greater when weight loss occurs (-4.87 [-6.64 to -3.11]%). Furthermore, meta-regression identified a positive association between percentage weight loss and absolute reduction in IHTG (β = 0.99 [0.62 to 1.36], P < 0.001). Pooling of six studies (94 participants) suggests that exercise training also improves basal hepatic insulin sensitivity (mean change in hepatic insulin sensitivity index: 0.13 [0.05 to 0.21] mg m-2 min-1 per μU mL-1 ), but available evidence is limited, and the impact of exercise on insulin-stimulated hepatic insulin sensitivity remains unclear.
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Affiliation(s)
- J A Sargeant
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.,National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, UK
| | - L J Gray
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - D H Bodicoat
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, UK.,Diabetes Research Centre, University of Leicester, Leicester, UK
| | - S A Willis
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.,National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, UK
| | - D J Stensel
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.,National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, UK
| | - M A Nimmo
- College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK
| | - G P Aithal
- Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK.,National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - J A King
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK.,National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, UK
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14
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Kasi M, Rashid S, Wallace SAJ, Sujendran V, Griffiths B, Butler A, Gibbs P, Sreedharan L, Zaitoun AM, Venkatachalapathy S, James MW, Aithal GP. Seeding of hepatocellular carcinoma into the stomach wall following endoscopic ultrasound and fine-needle aspiration biopsy. Oxf Med Case Reports 2018; 2018:omy039. [PMID: 30046450 PMCID: PMC6053806 DOI: 10.1093/omcr/omy039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 04/26/2018] [Accepted: 06/01/2018] [Indexed: 01/10/2023] Open
Abstract
Delayed gastrointestinal metastasis is a rare complication of hepatocellular carcinoma (HCC). We present the case of a patient who presented with melaena and microcytic anaemia 6 years after receiving an orthotopic liver transplant for hepatitis B-induced HCC. Oesophagogastroduodenoscopy revealed a fungating gastric mass at the lesser curve and histology from biopsies confirmed metastatic recurrence of HCC in the stomach. The route of metastasis is likely due to iatrogenic seeding of tumour cells during pre-transplant endoscopic ultrasound (EUS) and fine needle aspiration (FNA) biopsy. Subsequent positron emission tomography and magnetic resonance imaging failed to reveal further metastatic disease and the patient was managed with a total gastrectomy. This is the first reported description in the literature of needle-track metastasis in the stomach due to liver EUS-FNA for HCC.
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Affiliation(s)
- M Kasi
- Nottingham Digestive Diseases Centre (NDDC) and NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Samin Rashid
- Liver Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - S A J Wallace
- Division of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Vijayendran Sujendran
- Liver Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Bill Griffiths
- Liver Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Andrew Butler
- Liver Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Paul Gibbs
- Liver Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Loveena Sreedharan
- Liver Unit, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - A M Zaitoun
- Division of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - S Venkatachalapathy
- Nottingham Digestive Diseases Centre (NDDC) and NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - M W James
- Nottingham Digestive Diseases Centre (NDDC) and NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University and Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - G P Aithal
- Nottingham Digestive Diseases Centre (NDDC) and NIHR Nottingham Biomedical Research Centre (BRC), Nottingham University and Nottingham University Hospitals NHS Trust, Nottingham, UK
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15
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Harman DJ, Ryder SD, James MW, Wilkes EA, Card TR, Aithal GP, Guha IN. Obesity and type 2 diabetes are important risk factors underlying previously undiagnosed cirrhosis in general practice: a cross-sectional study using transient elastography. Aliment Pharmacol Ther 2018; 47:504-515. [PMID: 29210096 DOI: 10.1111/apt.14463] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [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: 05/16/2017] [Revised: 07/03/2017] [Accepted: 11/19/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Rising cirrhosis incidence and mortality in the United Kingdom has been attributed predominantly to excess alcohol consumption. However, metabolic risk factors such as Type 2 diabetes and obesity may also be important. AIM To screen at-risk individuals in general practice for undetected cirrhosis using transient elastography and study the risk factors underlying these cases. METHODS The study was undertaken in 4 general practices (adult patient population 20 868) between February 2012 and September 2014. Patients with defined risk factors for chronic liver disease (hazardous alcohol use and/or Type 2 diabetes) were identified from the General Practice electronic records and invited for transient elastography. Elevated liver stiffness was defined as ≥8 kPa. Cirrhosis was confirmed by established histological, radiological and biochemical methods. RESULTS Two thousand three hundred and sixty eight patients were invited for transient elastography and 899/919 who attended (97.8%) had valid measurements. Of these 230 patients had elevated liver stiffness (25.6%) and 27 had cirrhosis (2.9%). Risk factors for new cirrhosis diagnoses were obesity and/or Type 2 diabetes in 16 patients (59.3%), alcohol alone in 3 (11.1%) and both alcohol and obesity and/or diabetes in eight (29.6%). Presence of cirrhosis was significantly increased in obese patients with Type 2 diabetes or hazardous alcohol use compared to non-obese (odds ratio 9.4 [95% CI 2.2-40.9] and 5.6 [95% CI 1.6-19.7] respectively). CONCLUSIONS The number of new cases of cirrhosis diagnosed clearly demonstrates that existing estimates of prevalence are likely to be gross underestimates. Obesity was an important risk factor for cirrhosis within both alcohol users and diabetics.
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Affiliation(s)
- D J Harman
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University Of Nottingham, Nottingham, UK
| | - S D Ryder
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University Of Nottingham, Nottingham, UK
| | - M W James
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University Of Nottingham, Nottingham, UK
| | - E A Wilkes
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University Of Nottingham, Nottingham, UK
| | - T R Card
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University Of Nottingham, Nottingham, UK.,Division of Epidemiology and Public Health, City Hospital Campus, University of Nottingham, Nottingham, UK
| | - G P Aithal
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University Of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - I N Guha
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham University Hospitals NHS Trust, University Of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
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16
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Hariharan D, Wilkes EA, Aithal GP, Travis SJ, Lobo DN. Spontaneous central venous thrombosis and shunt occlusion following peritoneovenous shunt placement for intractable ascites. Ann R Coll Surg Engl 2017; 99:e145-e147. [PMID: 28462645 DOI: 10.1308/rcsann.2017.0058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A 43-year-old man had a peritoneovenous shunt inserted for the treatment of chylous ascites secondary to myelofibrosis. Despite being on anticoagulation for superior mesenteric vein thrombosis, he developed shunt dysfunction within two weeks of insertion. Superior venacavography showed multiple filling defects in the right axillary vein, no filling of the right brachiocephalic and right subclavian vein, and thrombotic occlusion of the internal jugular veins bilaterally. The shunt was removed 11 days after insertion, and there was extensive thrombosis of the venous end of the shunt and the compressible pump chamber. Shunt thrombosis is known to occur but remains a rare complication, with 87% of such obstructions being due to a thrombus at the tip of the venous end of the shunt. Extensive thrombosis of the shunt (as in the present case) is very rare.
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Affiliation(s)
- D Hariharan
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham , UK
| | - E A Wilkes
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham , UK
| | - G P Aithal
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham , UK
| | - S J Travis
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham , UK
| | - D N Lobo
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham , UK
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17
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West J, Card TR, Aithal GP, Fleming KM. Risk of hepatocellular carcinoma among individuals with different aetiologies of cirrhosis: a population-based cohort study. Aliment Pharmacol Ther 2017; 45:983-990. [PMID: 28144999 DOI: 10.1111/apt.13961] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [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] [Received: 03/11/2016] [Revised: 04/04/2016] [Accepted: 01/10/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Among patients with cirrhosis, only those determined to be at risk for hepatocellular carcinoma (HCC) should undergo surveillance. However, little is known about how different aetiologies of cirrhosis affect risk for HCC. AIM To quantify the cumulative incidence of HCC among a representative population of people with cirrhosis of the liver of varying aetiology. METHODS We identified subjects with hepatic cirrhosis from the UK's General Practice Research Database (1987-2006). Diagnoses of HCC were obtained from linked national cancer registries (1971-2006). Cox proportional hazards regression was used to estimate hazard ratios. The predicted 10-year cumulative incidence of HCC for each aetiology of cirrhosis was estimated while accounting for competing risks of death from any cause and liver transplant. RESULTS Among 3107 people with cirrhosis, the adjusted relative risk of HCC was increased twofold to threefold among people with viral and autoimmune/metabolic aetiologies, compared to those with alcohol-associated cirrhosis. The 10-year predicted cumulative incidence estimates of HCC for each aetiology were alcohol, 1.2%; chronic viral hepatitis, 4.0%; autoimmune or metabolic disease, 3.2%; and cryptogenic, 1.1%. CONCLUSIONS In a population-based study in the UK, people with cirrhosis have an estimated cumulative 10-year incidence of HCC of 4% or lower. Cumulative incidence varies with aetiology such that individuals with alcohol or cryptogenic cirrhosis have the lowest risk for HCC. These findings provide important information for cost-effectiveness analyses of HCC surveillance.
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Affiliation(s)
- J West
- Division of Epidemiology and Public Health, The University of Nottingham, Nottingham, UK
| | - T R Card
- Division of Epidemiology and Public Health, The University of Nottingham, Nottingham, UK
- NIHR Nottingham Digestive Diseases Biomedical Research Unit at Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - G P Aithal
- NIHR Nottingham Digestive Diseases Biomedical Research Unit at Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - K M Fleming
- Division of Epidemiology and Public Health, The University of Nottingham, Nottingham, UK
- Public Health Institute, Liverpool John Moores University, Liverpool, UK
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Lewis LC, Lo PCK, Foster JM, Dai N, Corrêa IR, Durczak PM, Duncan G, Ramsawhook A, Aithal GP, Denning C, Hannan NRF, Ruzov A. Dynamics of 5-carboxylcytosine during hepatic differentiation: Potential general role for active demethylation by DNA repair in lineage specification. Epigenetics 2017; 12:277-286. [PMID: 28267381 PMCID: PMC5398770 DOI: 10.1080/15592294.2017.1292189] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Patterns of DNA methylation (5-methylcytosine, 5mC) are rearranged during differentiation contributing to the regulation of cell type-specific gene expression. TET proteins oxidize 5mC to 5-hydroxymethylcytosine (5hmC), 5-formylcytosine (5fC), and 5-carboxylcytosine (5caC). Both 5fC and 5caC can be recognized and excised from DNA by thymine-DNA glycosylase (TDG) followed by the subsequent incorporation of unmodified cytosine into the abasic site via the base excision repair (BER) pathway. We previously demonstrated that 5caC accumulates during lineage specification of neural stem cells (NSCs) suggesting that such active demethylation pathway is operational in this system; however, it is still unknown if TDG/BER-dependent demethylation is used during other types of cellular differentiation. Here we analyze dynamics of the global levels of 5hmC and 5caC during differentiation of human pluripotent stem cells toward hepatic endoderm. We show that, similar to differentiating NSCs, 5caC transiently accumulates during hepatic differentiation. The levels of 5caC increase during specification of foregut, peak at the stage of hepatic endoderm commitment, and drop in differentiating cells concurrently with the onset of expression of α fetoprotein, a marker of committed hepatic progenitors. Moreover, we show that 5caC accumulates at promoter regions of several genes expressed during hepatic specification at differentiation stages corresponding to the beginning of their expression. Our data indicate that transient 5caC accumulation is a common feature of 2 different types (neural/glial and endoderm/hepatic) of cellular differentiation. This suggests that oxidation of 5mC may represent a general mechanism of rearrangement of 5mC profiles during lineage specification of somatic cells in mammals.
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Affiliation(s)
- Lara C Lewis
- a Division of Cancer and Stem Cells , School of Medicine, Centre for Biomolecular Sciences, University of Nottingham , Nottingham , UK
| | - Peggy Cho Kiu Lo
- a Division of Cancer and Stem Cells , School of Medicine, Centre for Biomolecular Sciences, University of Nottingham , Nottingham , UK.,b National Institute for Health Research (NIHR) Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham , Nottingham , UK
| | | | - Nan Dai
- c New England Biolabs, Inc. , Ipswich , USA
| | | | - Paulina M Durczak
- a Division of Cancer and Stem Cells , School of Medicine, Centre for Biomolecular Sciences, University of Nottingham , Nottingham , UK
| | - Gary Duncan
- a Division of Cancer and Stem Cells , School of Medicine, Centre for Biomolecular Sciences, University of Nottingham , Nottingham , UK
| | - Ashley Ramsawhook
- a Division of Cancer and Stem Cells , School of Medicine, Centre for Biomolecular Sciences, University of Nottingham , Nottingham , UK
| | - Guruprasad Padur Aithal
- b National Institute for Health Research (NIHR) Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham , Nottingham , UK
| | - Chris Denning
- a Division of Cancer and Stem Cells , School of Medicine, Centre for Biomolecular Sciences, University of Nottingham , Nottingham , UK
| | - Nicholas R F Hannan
- a Division of Cancer and Stem Cells , School of Medicine, Centre for Biomolecular Sciences, University of Nottingham , Nottingham , UK.,b National Institute for Health Research (NIHR) Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham , Nottingham , UK
| | - Alexey Ruzov
- a Division of Cancer and Stem Cells , School of Medicine, Centre for Biomolecular Sciences, University of Nottingham , Nottingham , UK
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Parker R, Im G, Jones F, Hernández OP, Nahas J, Kumar A, Wheatley D, Sinha A, Gonzalez-Reimers E, Sanchez-Pérez M, Ghezzi A, David MD, Corbett C, McCune A, Aithal GP, Holt A, Stewart S. Clinical and microbiological features of infection in alcoholic hepatitis: an international cohort study. J Gastroenterol 2017; 52:1192-1200. [PMID: 28389732 PMCID: PMC5666044 DOI: 10.1007/s00535-017-1336-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 03/23/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Previous studies have described the clinical impact of infection in alcoholic hepatitis (AH) but none have comprehensively explored the aetiopathogenesis of infection in this setting. We examined the causes, consequences and treatment of infection in a cohort of patients with AH. METHODS We undertook a retrospective cohort study of patients with AH admitted between 2009 and 2014 to seven centres in Europe and the USA. Clinical and microbiological data were extracted from medical records. Survival was analysed with Kaplan-Meier analysis and Cox proportional hazards analysis to control the data for competing factors. Propensity score matching was used to examine the efficacy of prophylactic antibiotics administered in the absence of infection. RESULTS We identified 404 patients with AH. Of these, 199 (49%) showed clinical or culture evidence of infection. Gut commensal bacteria, particularly Escherichia coli and Enterobacter species, were most commonly isolated in culture. Fungal infection was rarely seen. Cultured organisms and antibiotic resistance differed markedly between centres. Infection was an independent risk factor for death (hazard ratio for death at 90 days 2.33, 95% confidence interval 1.63-3.35, p < 0.001). Initiation of antibiotic therapy on admission in the absence of infection did not reduce mortality or alter the incidence of subsequent infections. Corticosteroid use increased the incidence of infection but this did not impact on survival. CONCLUSIONS In this large real-world cohort of patients with AH, infection was common and was associated with reduced short-term survival. Gram-negative, gut commensal bacteria were the predominant infective organisms, consistent with increased translocation of gut bacteria in AH; however, the characteristics of infection differ between centres. Infection should be actively sought and treated, but we saw no benefits of prophylactic antibiotics.
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Affiliation(s)
- Richard Parker
- Centre for Liver Research, Institute of Biomedical Research, College of Medical and Dental Sciences, University of Birmingham, 5th Floor, Birmingham, B15 2TT UK ,University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TH UK
| | - Gene Im
- Mount Sinai Medical Center, 1468 Madison Avenue, New York, NY 10029 USA
| | - Fiona Jones
- Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
| | - Onan Pérez Hernández
- Hospital Universitario de Canarias Carretera de Ofra, 38320 San Cristóbal de La Laguna, Santa Cruz de Tenerife Spain
| | - Jonathan Nahas
- Mount Sinai Medical Center, 1468 Madison Avenue, New York, NY 10029 USA
| | - Aditi Kumar
- New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton Rd, Heath Town, Wolverhampton, WV10 0QP UK
| | - Daniel Wheatley
- New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton Rd, Heath Town, Wolverhampton, WV10 0QP UK
| | - Ashish Sinha
- University Hospitals Bristol NHS Foundation Trust, Marlborough Street, Bristol, BS1 3NU UK
| | - Emilio Gonzalez-Reimers
- Hospital Universitario de Canarias Carretera de Ofra, 38320 San Cristóbal de La Laguna, Santa Cruz de Tenerife Spain
| | - María Sanchez-Pérez
- Hospital Universitario de Canarias Carretera de Ofra, 38320 San Cristóbal de La Laguna, Santa Cruz de Tenerife Spain
| | - Antonella Ghezzi
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Queen′s Medical Centre, E Floor, West Block, Nottingham, NG7 2UH UK
| | - Miruna Delia David
- University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TH UK
| | - Christopher Corbett
- New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton Rd, Heath Town, Wolverhampton, WV10 0QP UK
| | - Anne McCune
- New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton Rd, Heath Town, Wolverhampton, WV10 0QP UK
| | - Guruprasad Padur Aithal
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Queen′s Medical Centre, E Floor, West Block, Nottingham, NG7 2UH UK
| | - Andrew Holt
- University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TH UK
| | - Stephen Stewart
- Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
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Palaniyappan N, Cox E, Bradley C, Scott R, Austin A, O’Neill R, Ramjas G, Travis S, White H, Singh R, Thurley P, Guha IN, Francis S, Aithal GP. Non-invasive assessment of portal hypertension using quantitative magnetic resonance imaging. J Hepatol 2016; 65:1131-1139. [PMID: 27475617 PMCID: PMC5123896 DOI: 10.1016/j.jhep.2016.07.021] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 07/19/2016] [Accepted: 07/21/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Hepatic venous pressure gradient (HVPG) measurement is currently the only validated technique to accurately evaluate changes in portal pressure. In this study, we evaluate the use of non-contrast quantitative magnetic resonance imaging (MRI) as a surrogate measure of portal pressure. METHODS Thirty patients undergoing HVPG measurement were prospectively recruited. MR parameters of longitudinal relaxation time (T1), perfusion of the liver and spleen (by arterial spin labelling), and blood flow in the portal, splanchnic and collateral circulation (by phase contrast MRI) were assessed. We estimated the liver stiffness measurement (LSM) and enhanced liver fibrosis (ELF) score. The correlation of all non-invasive parameters with HVPG was evaluated. RESULTS The mean (range) HVPG of the patients was 9.8 (1-22) mmHg, and 14 patients (48%) had clinically significant portal hypertension (CSPH, HVPG ⩾10mmHg). Liver T1 relaxation time, splenic artery and superior mesenteric artery velocity correlated significantly with HVPG. Using multiple linear regression, liver T1 and splenic artery velocity remained as the two parameters in the multivariate model significantly associated with HVPG (R=0.90, p<0.001). This correlation was maintained in patients with CSPH (R=0.85, p<0.001). A validation cohort (n=10) showed this linear model provided a good prediction of HVPG. LSM and ELF score correlated significantly with HVPG in the whole population but the correlation was absent in CSPH. CONCLUSIONS MR parameters related to both hepatic architecture and splanchnic haemodynamics correlate significantly with HVPG. This proposed model, confirmed in a validation cohort, could replace the invasive HVPG measurement. LAY SUMMARY In patients with cirrhosis, the development and progression of portal hypertension is related to worse outcomes. However, the standard technique of assessing portal pressure is invasive and not widely used in clinical practice. Here, we have studied the use of non-invasive MRI in evaluating portal pressure. The MRI measures of liver architecture and blood flow in the splenic artery correlated well with portal pressure. Therefore, this non-invasive method can potentially be used to assess portal pressure in clinical trials and monitoring treatment in practice.
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Affiliation(s)
- Naaventhan Palaniyappan
- National Institute for Health Research (NIHR) Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, United Kingdom
| | - Eleanor Cox
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
| | - Christopher Bradley
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
| | - Robert Scott
- National Institute for Health Research (NIHR) Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, United Kingdom
| | | | - Richard O’Neill
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Greg Ramjas
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Simon Travis
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Hilary White
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | | | | | - Indra Neil Guha
- National Institute for Health Research (NIHR) Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, United Kingdom
| | - Susan Francis
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
| | - Guruprasad Padur Aithal
- National Institute for Health Research (NIHR) Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, United Kingdom.
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Chikhani M, Evans DL, Blatcher AW, Jackson AP, Guha IN, Aithal GP, Moppett IK. The effect of prone positioning with surgical bolsters on liver blood flow in healthy volunteers. Anaesthesia 2016; 71:550-5. [PMID: 26948476 DOI: 10.1111/anae.13416] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2016] [Indexed: 11/29/2022]
Abstract
This study sought to identify changes in hepatic flood flow and cardiac output during prone positioning on surgical bolsters in awake volunteers, and was prompted by a local incident of significant hepatic dysfunction following surgery in the prone position. Cardiac output was determined using the non-invasive Peñáz technique, and plasma disappearance rate of indocyanine green (ICG-PDR) was measured as a surrogate maker for hepatic blood flow along with serum hepatic enzyme assays. Measurements were made after one hour in supine, prone and returned supine positions. Ten volunteers completed the study. There were significant changes in the disappearance rate of indocyanine green, which decreased this from mean (SD) 31.1 (9.70) supine to 19.6 (4.37)%.min prone, respectively (p = 0.02), increasing on return to the supine position to 24.6 (5.54)%.min (p = 0.019). Cardiac output was also significantly reduced when changing from the supine to the prone position, from mean (SD) 4.7 (1.0 to 3.5 (1.1) (l.min(-1) ), respectively (p = 0.002). We demonstrated an acute and reversible change in both hepatocellular function and cardiac output associated with the prone position.
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Affiliation(s)
- M Chikhani
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
| | - D L Evans
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
| | | | - A P Jackson
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - I N Guha
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - G P Aithal
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - I K Moppett
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
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Bawden SJ, Stephenson MC, Ciampi E, Hunter K, Marciani L, Macdonald IA, Aithal GP, Morris PG, Gowland PA. Investigating the effects of an oral fructose challenge on hepatic ATP reserves in healthy volunteers: A (31)P MRS study. Clin Nutr 2015; 35:645-9. [PMID: 25935852 DOI: 10.1016/j.clnu.2015.04.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 03/02/2015] [Accepted: 04/03/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Impaired homeostasis of hepatic ATP has been associated with NAFLD. An intravenous fructose infusion has been shown to be an effective challenge to monitor the depletion and subsequent recovery of hepatic ATP reserves using (31)P MRS. AIMS The purpose of this study was to evaluate the effects of an oral rather than intravenous fructose challenge on hepatic ATP reserves in healthy subjects. METHODS Self-reported healthy males were recruited. Following an overnight fast, baseline liver glycogen and lipid levels were measured using Magnetic Resonance Spectroscopy (MRS). Immediately after consuming a 500 ml 75 g fructose drink (1275 kJ) subjects were scanned continuously for 90 min to acquire dynamic (31)P MRS measurements of liver ATP reserves. RESULTS A significant effect on ATP reserves was observed across the time course (P < 0.05). Mean ATP levels reached a minimum at 50 min which was markedly lower than baseline (80 ± 17% baseline, P < 0.05). Subsequently, mean values tended to rise but did not reach statistical significance above minimum. The time to minimum ATP levels across subjects was negatively correlated with BMI (R(2) = 0.74, P < 0.005). Rates of ATP recovery were not significantly correlated with BMI or liver fat levels, but were negatively correlated with baseline glycogen levels (R(2) = 0.7, P < 0.05). CONCLUSIONS Depletion of ATP reserves can be measured non-invasively following an oral fructose challenge using (31)P MRS. BMI is the best predictor of postprandial ATP homeostasis following fructose consumption.
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Affiliation(s)
- S J Bawden
- Sir Peter Manfield Imaging Centre, University of Nottingham, Nottingham, UK.
| | - M C Stephenson
- Sir Peter Manfield Imaging Centre, University of Nottingham, Nottingham, UK
| | - E Ciampi
- Unilever Discover, Unilever, Colworth, UK
| | - K Hunter
- Unilever Discover, Unilever, Colworth, UK
| | - L Marciani
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - I A Macdonald
- School of Life Sciences, University of Nottingham, Nottingham, UK
| | - G P Aithal
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | - P G Morris
- Sir Peter Manfield Imaging Centre, University of Nottingham, Nottingham, UK
| | - P A Gowland
- Sir Peter Manfield Imaging Centre, University of Nottingham, Nottingham, UK
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23
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Dawwas MF, Aithal GP. End-stage methotrexate-related liver disease is rare and associated with features of the metabolic syndrome. Aliment Pharmacol Ther 2014; 40:938-48. [PMID: 25185870 DOI: 10.1111/apt.12912] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 05/19/2014] [Accepted: 07/21/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Methotrexate (MTX) is one of the most frequently prescribed drugs in contemporary medicine with a well-recognised hepatotoxic potential, for which stringent laboratory and histological surveillance has long been advocated. AIM To estimate the population burden of end-stage methotrexate-related liver disease (MTX-LD) in the United States and identify independent host risk factors for this disease entity. METHODS We analysed the records of all individuals who had been listed for, and/or received, liver transplantation in the United States, as reported to the Organ Procurement and Transplantation Network between 1 October 1987 and 31 December 2011, and identified those whose liver disease was attributed, wholly or partly, to MTX therapy. We also compared the demographic and clinical characteristics of adult individuals with MTX-LD with those listed and/or transplanted for alcoholic liver disease (ALD, n = 43,285), non-alcoholic steatohepatitis (NASH, n = 7569) and primary sclerosing cholangitis (PSC, n = 8526) using the adjusted odds ratios (AORs) derived from multi-variable logistic regression models. RESULTS Of 158 904 adults who had been listed for, and/or received, liver transplantation during the study period, only 117 (0.07%) had MTX-LD. Compared with individuals with ALD and PSC, those with MTX-LD were more likely to be older (AORs per 5-year increase: 1.27, P < 0.001 and 1.33, P < 0.001 respectively); female (AORs: 1.78, P = 0.003 and 3.87, P < 0.001); Caucasian (AORs: 3.03, P = 0.001 and 2.05, P = 0.04); and diabetic (AORs: 2.76, P < 0.001 and 4.12, P < 0.001). With the exception of Caucasian ethnicity (AOR: 1.94, P = 0.05), the odds of these characteristics did not differ from individuals with NASH. The odds of elevated body mass index among MTX-LD individuals were higher than those with PSC (AOR per 5 kg/m(2) : 1.51, P < 0.001); similar to those with ALD (AOR per 5 kg/m(2) :1.15, P = 0.1); and lower than those with NASH (AOR per 5 kg/m(2) : 0.66, P < 0.001). CONCLUSIONS The United States population burden of end-stage methotrexate-related liver disease is likely to be exceedingly small, suggesting the need for reappraisal of current hepatotoxicity surveillance guidelines. The risk factor profile of methotrexate-related liver disease supports the notion that it may share a common pathogenesis with NASH.
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Affiliation(s)
- M F Dawwas
- National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK; Division of Gastroenterology, Department of Medicine, University of California, Irvine, Orange, CA, USA
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Subramanian V, Johnston RD, Kaye P, Aithal GP. Regional anthropometric measures associated with the severity of liver injury in patients with non-alcoholic fatty liver disease. Aliment Pharmacol Ther 2013; 37:455-63. [PMID: 23293873 DOI: 10.1111/apt.12198] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [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: 12/31/2011] [Revised: 02/02/2012] [Accepted: 12/11/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Not all NAFLD patients are obese and many obese patients do not have NAFLD. Impaired peripheral fat storage may increase the delivery of lipids to the liver and facilitate NAFLD progression. AIM To assess the association of anthropometric measures of regional adiposity including arm fat index (AFI) (upper body fat), waist circumference (visceral fat) and body mass index (total body fat) on liver injury and fibrosis in NAFLD. METHODS One hundred and forty-one patients with histological evidence of NAFLD were included in this study. Multivariate logistic regression models examined the contribution of age, sex, body mass index, AFI, triceps fold thickness (TST), waist and hip circumference to the odds of liver injury (NAS scores ≥3) and fibrosis (fibrosis scores ≥2) by liver biopsy. RESULTS Arm fat index (OR: 0.82, 95% CI: 0.59-0.91) and TST (OR: 0.13, 95% CI: 0.04-0.42) were negatively correlated with NAFLD histological severity. In women, waist circumference was positively correlated with NAFLD severity (OR: 1.21(1.02-1.44). Age (OR: 1.05, 95% CI: 1.01-1.0) and waist circumference (OR: 1.07, 95% CI: 1.00-1.15) were significantly associated with fibrosis risk. In women, AFI (OR: 0.87, 95% CI: 0.76-0.99) and TST (OR: 0.22, 95% CI: 0.05-0.95) were negatively associated with fibrosis risk. CONCLUSIONS Regional anthropometric measures are associated with severity of NAFLD in a sex-specific manner. Men and women with lower arm fat depots and women with bigger waist circumference have a greater likelihood of liver injury. Age and waist circumference seem to be associated with liver fibrosis. Simple anthropometric measurements of peripheral fat deposits may help stratify significant liver injury risk.
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Affiliation(s)
- V Subramanian
- National Institute for Health Research Biomedical Research Unit in Gastrointestinal and Liver Disease, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
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25
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McCorry RB, Palaniyappan N, Chivinge A, Kaye P, James MW, Aithal GP. Development and evaluation of a nurse-led transient elastography service for the staging of hepatic fibrosis in patients with suspected chronic liver disease. QJM 2012; 105:749-54. [PMID: 22408151 DOI: 10.1093/qjmed/hcs043] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [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: 01/07/2023] Open
Abstract
BACKGROUND AND AIMS Establishing the presence of fibrosis and cirrhosis is an essential step in the management of patients with chronic liver diseases (CLD). Liver stiffness measurement (LSM) based on transient elastography (TE) correlates well with the stages of liver fibrosis and has been developed as a non-invasive alternative to liver biopsy. The studies performed to date have used physician operators. With the potential use of TE for screening of community-based populations for liver disease, we aimed to evaluate the performance of nurse operators. DESIGN Retrospective analysis. METHODS We reviewed the reliability and accuracy of LSMs performed by the nurse-led TE service at Queen's Medical Centre, Nottingham between May 2009 and January 2011. Consecutive patients with suspected CLD who underwent LSM were included. RESULTS Over the study period 585 LSMs were performed. Analysis was performed on the 208 patients where LSM could be compared with liver biopsy findings. Of these 11 (5.3%) had unreliable LSM results (less than 10 valid shots or success rate <60%). There were no LSM failures. Inadequate liver biopsy specimen led to exclusion in 26 (12.5%) patients. For the detection of significant fibrosis (Ishak stage >2), a sensitivity of 0.78 and specificity of 0.81 was obtained, with a cut-off value of 8 kPa. Using a cut-off value of 13 kPa for detection of cirrhosis, a sensitivity and specificity of 0.8 and 0.92 was obtained. CONCLUSION We have demonstrated that a nurse-led TE service can produce a low level of unreliable results and LSM failures, with comparable sensitivity and specificity for detecting significant fibrosis and cirrhosis to those reported in the literature. The demands on the use of TE could potentially be eased through the introduction of nurse-led service delivery.
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Affiliation(s)
- R B McCorry
- Department of Hepatology, National Institute of Health Research: Biomedical Research Unit, Nottingham University Hospital NHS Trust, Nottingham NG7 2UH, UK.
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Abstract
BACKGROUND Despite their common use the occurrence and consequences of abnormal liver tests remain unclear. AIMS To estimate the prevalence and mortality associated with abnormal liver tests in people aged 75 years and above. METHODS A cohort study on 13,276 people aged 75 years and above, registered with general practices, with a valid measurement of one or more liver test, calculating the prevalence of abnormal aspartate transaminase (AST), alkaline phosphatase (ALP) or bilirubin. Hazard ratios (HRs) were calculated for all-cause and cause-specific mortality comparing elderly patients with abnormal liver tests to elderly patients with normal liver tests. RESULTS At least one abnormal liver test was found in 2175 subjects (16.1%, 95% CI [15.4%, 16.7%]). The prevalence of a single abnormal liver test was 3.3% (95% CI [3.0%, 3.7%]) for AST, 9.2% (95% CI [8.8%, 9.7%]) for ALP and 5.4% (95% CI [5.1%, 5.9%]) for bilirubin. Abnormal AST, ALP and bilirubin were associated with increased risks of all-cause mortality; adjusted HRs, 1.27(95% CI [1.09, 1.47]), 1.47(95% CI [1.35, 1.61]) and 1.15(95% CI [1.02, 1.30]), respectively. Abnormal AST and ALP were associated with sevenfold and sixfold increased risk of death from liver disease, respectively. Two or more abnormal liver tests were associated with 2-fold and 17-fold increased risk of death from cancer and liver disease, respectively. Of the causes examined, absolute mortality rates were highest for cardiovascular disease in subjects with and without abnormal liver tests. CONCLUSIONS Abnormal liver tests occur commonly in elderly people and are associated with a modest increase in all-cause mortality. There was a strong association with liver disease; however, the majority of deaths were not due to this cause.
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Affiliation(s)
- K M Fleming
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham City Hospital, Nottingham, UK.
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Pirmohamed M, Aithal GP, Behr E, Daly A, Roden D. The phenotype standardization project: improving pharmacogenetic studies of serious adverse drug reactions. Clin Pharmacol Ther 2011; 89:784-5. [PMID: 21593754 DOI: 10.1038/clpt.2011.30] [Citation(s) in RCA: 56] [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] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The ability to predict the risk for serious drug-induced adverse reactions first requires a large patient database for characterization and validation of genetic markers. The Phenotype Standardization Project (PSP) was initiated to standardize phenotypic definitions, thereby facilitating much-needed recruitment without sacrificing the reliability of patient classification. Three phenotypes have been considered in this initial phase: drug-induced liver injury, drug-induced skin injury, and drug-induced torsade de pointes.
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Affiliation(s)
- M Pirmohamed
- Wolfson Centre for Personalised Medicine, University of Liverpool, Liverpool, UK.
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Abstract
BACKGROUND We lack population-based estimates of the rate of decompensation in people with compensated cirrhosis as well as estimates of the manner in which the disease progresses once identified. AIM To determine the rate of decompensation and clinical progression of disease in patients with cirrhosis based upon clinical symptoms recorded electronically in general practice data. METHODS Using Cox proportional hazards regression, we modelled the rate of decompensation for patients from the UK General Practice Research Database with a diagnosis of cirrhosis between 1987 and 2002. We determined the clinical progression in the first year following diagnosis and subsequently categorizing patients through time according to a simple clinical staging system agreed at the Baveno IV consensus conference. RESULTS The rate of decompensation in patients with compensated cirrhosis was found to be 11% overall. The rate of decompensation was higher in the first year (at 31% compared with 7.3% afterwards) and in patients with an alcoholic aetiology. Patients with compensated cirrhosis had a 1-year probability of proceeding directly to death of 7% compared with 20% in patients with decompensated cirrhosis. CONCLUSIONS Using data recorded in general practice records, it is possible to determine the rate of decompensation and the clinical progression of disease in people with cirrhosis.
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Abstract
Alcohol misuse is a common reason for hospital admission. While there is considerable evidence from other areas that provision of specialised alcohol services can reduce alcohol intake, there is currently less evidence for medical departments in an acute hospital setting. Nottingham hospitals initiated such a service in 2002-3 based around two nurse specialists who provided input to inpatients with alcohol-related physical disease and provided links to community-based services for alcohol misuse. This service assessed 3632 patients over five years and has seen a reduction in hospital admissions, violent incidents against staff and primary care attendances. It is believed that this model of care is an effective means of intervening in people with alcohol-related problems.
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Affiliation(s)
- S D Ryder
- Department of Gastroenterology, Queens Medical Centre Campus, Nottingham University Hospitals NHS Trust.
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Thomas T, Gilbert D, Kaye PV, Penman I, Aithal GP, Ragunath K. High-resolution endoscopy and endoscopic ultrasound for evaluation of early neoplasia in Barrett's esophagus. Surg Endosc 2009; 24:1110-6. [PMID: 19915911 DOI: 10.1007/s00464-009-0737-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2009] [Accepted: 08/08/2009] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endoscopic ultrasound (EUS) is useful for detecting depth of invasion and nodal involvement in patients with early Barrett's neoplasia (EBN), precluding endoscopic management. This study aimed to determine whether the lesion morphology of the EBN shown on high-resolution endoscopy predicts EUS and histologic tumor stage. METHODS Retrospective series from two tertiary referral centers were studied. Patients with EBN referred for EUS evaluation before treatment were identified, and data were collected from endoscopies, a database, and case notes. All patients had high-resolution endoscopy followed by radial EUS. RESULTS This study included 50 patients (22 men) with a median age of 69 years (interquartile range, 60-79 years). Visible lesions in the Barrett's segment were described as Paris types 0-1 (n = 9), 0-IIb (n = 12), 0-IIa (n = 12), 0-IIa + IIc (n = 6), and 0-IIc (n = 5). Of the 50 patients, 46 (92%) had either EMR (n = 17), esophagectomy (n = 23), or both (n = 6). All 12 patients (100%) with Paris 0-IIb lesions had T0/T1 m staging on EUS confirmed with resection histology. The sensitivity for EUS T-staging for Paris classification was 71.4% for type 0-I, 100% for type 0-IIb, 83% for type 0-IIa, 66.7% for type 0-IIa + IIc, and 66.7% for type IIc. Overall, 8 (17%) of the 46 patients were understaged and 2 (4%) were overstaged. For detecting submucosal invasion, EUS had a sensitivity of 66%, a specificity of 93%, a negative predictive value of 85%, and a diagnostic accuracy of 84.4%. CONCLUSION Submucosal invasion is detected by EUS for 26% of patients with EBN. The value of EUS staging before resection for type 0-IIb early Barrett's cancer (flat lesions) is limited because 100% of these lesions are limited to the mucosa. For the management algorithm in this selected cohort, the use of EUS should be reconsidered.
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Affiliation(s)
- T Thomas
- Nottingham Digestive Diseases Centre and Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Queens Medical Centre Campus, Nottingham NG7 2UH, UK
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Thomas T, Kaye PV, Ragunath K, Aithal GP. Endoscopic-ultrasound-guided mural trucut biopsy in the investigation of unexplained thickening of esophagogastric wall. Endoscopy 2009; 41:335-9. [PMID: 19340738 DOI: 10.1055/s-0029-1214470] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS Esophageal and/or gastric wall thickening raises the possibility of malignancy. Endoscopic-ultrasound-(EUS-)guided targeted biopsy of the thickened wall is possible. We aimed to evaluate the efficacy and safety of EUS-guided mural trucut biopsies (TCB) in detecting underlying malignancy in patients with thickened esophagogastric wall and negative mucosal biopsies. METHODS Patients with alarm symptoms referred for EUS-guided sampling after negative endoscopy and mucosal biopsy were included in the study. All patients had radial EUS reporting abnormal thickening of the esophageal/gastric wall. A linear-array echoendoscope and a 19-gauge trucut needle were used for sampling. Clinical and investigatory data were collected prospectively between 2004 and 2008. RESULTS Thirty-one patients (20 men) aged 60 - 74 years (median 67 years) were included. All patients had thickened esophageal wall (n = 10), gastric wall (n = 21), or both on radial EUS. Prior to EUS, patients had undergone 1 - 5 endoscopies (median 1.2) and 2 - 8 mucosal biopsies (median 4). The median esophageal and gastric wall thicknesses were 12 and 18 mm respectively. During sampling 1 - 5 needle punctures (median 3) were made. On EUS-TCB, an adequate specimen for histology was obtained in 28/31 patients (90 %). The size of the tissue cores was 4 - 10 mm (median 6mm). Malignancy was confirmed in 16/31 patients (54 %) on histology, and in 11/31 patients (35.4 %) an underlying malignancy was excluded. There was no significant correlation between wall thickness and biopsy size (rho = 0.11, 95 %CI- 0.25 to - 0.45, two-sided P = 0.53). EUS-TCB had sensitivity, specificity, and positive and negative predictive values of 85 %, 100 %, 100 %, and 74 % respectively. There were no immediate or late complications. CONCLUSIONS EUS-guided mural TCB is a safe and effective technique in the investigation of esophagogastric wall thickening in patients with alarm symptoms and has high sensitivity and specificity for the diagnosis of a cancer.
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Affiliation(s)
- T Thomas
- Nottingham Digestive Diseases Centre: BioMedical Research Unit, Nottingham University Hospitals NHS Trust, Queens Medical Centre, United Kingdom
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32
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Johnston RD, Aithal GP, Ryder SD, MacDonald IA. Fast-food hyper-alimentation and exercise restriction in healthy subjects. Gut 2009; 58:469-70; author reply 470. [PMID: 19211862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
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33
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Aithal GP, Anagnostopoulos GK, Tam W, Dean J, Zaitoun A, Kocjan G, Ragunath K, Pereira SP. EUS-guided tissue sampling: comparison of "dual sampling" (Trucut biopsy plus FNA) with "sequential sampling" (Trucut biopsy and then FNA as required). Endoscopy 2007; 39:725-30. [PMID: 17620230 DOI: 10.1055/s-2007-966400] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [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: 02/07/2023]
Abstract
BACKGROUND AND STUDY AIMS Both endoscopic ultrasound- (EUS-) guided tissue sampling techniques, fine-needle aspiration (FNA) and Trucut biopsy, have advantages and limitations. The aim of this study was to develop a strategy of combining these two EUS-guided sampling techniques in order to maximize the diagnostic accuracy and minimize duplication. PATIENTS AND METHODS In this multicenter study we performed "dual sampling" (i. e. with both FNA and Trucut biopsy) in 95 patients during phase 1 of the study and "sequential sampling" (i. e. performing FNA only when Trucut biopsy tissue cores were macroscopically inadequate) in 72 patients during phase 2. RESULTS During the study period, 167/401 patients referred for EUS-guided sampling were eligible for the study; only solid lesions were included. In 143/167 patients (86 %), sampling was performed via the transesophageal or transgastric routes. When the dual sampling strategy was used, an accurate diagnosis was achieved in 78/95 patients by FNA, compared with 85/95 by Trucut biopsy ( P = 0.21). The combined accuracy of the dual sampling strategy was higher than FNA alone (88/95 vs. 78/95, P = 0.048), but was not significantly higher than Trucut biopsy alone (88/95 vs. 85/95, P = 0.61). Using the sequential sampling strategy, an accurate diagnosis was achieved in 66/72 patients (92 %) compared with 88/95 (93 %) for dual sampling ( P = 1.0), and 8/72 patients (11 %) had to undergo FNA after Trucut biopsy failed to obtain an adequate sample. One patient with mediastinal tuberculosis developed a cold abscess following Trucut biopsy. CONCLUSION A sequential sampling strategy, in which EUS-guided Trucut biopsy is attempted first, and FNA performed only when Trucut biopsy fails to obtain a macroscopically adequate sample, achieves a diagnostic accuracy of 92 %, with 11 % of patients requiring both sampling procedures.
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Affiliation(s)
- G P Aithal
- Wolfson Digestive Diseases Centre, Queen's Medical Centre University Hospital, Nottingham, United Kingdom.
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34
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Abstract
BACKGROUND The risk of chronic liver disease is higher in diabetics, and serum alanine transaminase (ALT) is a sensitive predictor of mortality from liver disease. AIM To estimate the prevalence of elevated ALT in type 1 and type 2 diabetes, and identify possible risk factors. METHODS We identified all patients (n = 2077) attending review between September 2002 and August 2003. We excluded those with no ALT measurement (n = 73); those whose alcohol consumption was >14 units/week (women) (n = 276) or >21 units/week (men) (n = 324); and those with a diagnosis of Maturity Onset Diabetes of the Young, secondary diabetes, gestational diabetes or uncertain type of diabetes (n = 51). We calculated the prevalences of elevated ALT in both type 1 and type 2 diabetes patients, and compared the demographic, microvascular risk factors and current drug use between each group using multivariate logistic regression. RESULTS Of 1353 patients included, 836 (61.9%) had type 2 diabetes. Elevated ALT was found in 9.5% (95%CI 7.1-12.3%) of patients with type 1 diabetes, and 12.1% (95%CI 9.9-14.5%) of those with type 2 diabetes. The risk of elevated ALT in patients with type 2 diabetes increased with increasing body mass index (p(trend) = 0.04), and was lower in those taking insulin (OR 0.38, 95%CI 0.22-0.65). DISCUSSION The prevalence of elevated ALT is 3-4 times higher in patients with either type 1 or type 2 diabetes than in the general population. Further studies investigating the aetiology and mechanisms of this elevation may suggest appropriate early interventions.
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Affiliation(s)
- J West
- Division of Epidemiology & Public Health, University of Nottingham Medical School, Nottingham, UK
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35
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Affiliation(s)
- K P Moore
- The UCL Institute of Hepatology, Royal Free and University College Medical School, UCL, Rowland Hill St, London NW3 2PF, UK.
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36
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Abstract
In the last two decades, mortality from primary liver cancer has increased in the UK. We aimed to determine whether the incidence trends for these cancers were similar and in particular if the increasing occurrence of cholangiocarcinoma has continued. We calculated directly age-standardised incidence rates (using the European standard population) by subsite and histological type for all cancers of the liver, gallbladder and biliary tract in England and Wales from 1971 to 2001, using cancer registry data. The incidence of cancers of the liver, gallbladder and biliary tract increased, with the greatest rise, around 12-fold, in intrahepatic bile duct cancers. The rate of liver cell cancer increased by around 45% in males, but by <10% in females. There were marked reductions in the incidence of gallbladder and extrahepatic bile duct cancer. Cholangiocarcinoma increased around 16-fold and became the most common type of primary liver cancer in females, while hepatocellular carcinoma remained the commonest type in males. The age-specific incidence rates showed that intrahepatic bile duct cancer continued to increase throughout the 1990s in those aged 75 and over, while liver cell cancer decreased in the older age groups. In conclusion, there were increases in the incidence of primary liver cancer, which have been particularly dramatic for intrahepatic bile duct cancer, over the last three decades of the 20th century in England and Wales. There has been a halving in the incidence of gallbladder cancer and a reduction of a third in extrahepatic bile duct cancer.
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Affiliation(s)
- J West
- Division of Epidemiology and Public Health, University of Nottingham Medical School, Queen's Medical Centre University Hospital, Nottingham NG7 2UH, UK
| | - H Wood
- National Cancer Intelligence Centre, Office for National Statistics, London, UK
| | - R F A Logan
- Division of Epidemiology and Public Health, University of Nottingham Medical School, Queen's Medical Centre University Hospital, Nottingham NG7 2UH, UK
| | - M Quinn
- National Cancer Intelligence Centre, Office for National Statistics, London, UK
| | - G P Aithal
- Wolfson Digestive Diseases Centre, Queen's Medical Centre University Hospital, D Floor, South Block, Nottingham NG7 2UH, UK
- E-mail:
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37
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Janes SEJ, Zaitoun AM, Catton JA, Aithal GP, Beckingham IJ. Brunner's gland hyperplasia at the ampulla of Vater. J Postgrad Med 2006; 52:38-40. [PMID: 16534163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
Brunner's gland hyperplasia (BGH) is a diagnostic challenge where in the pathophysiology and natural history remain poorly understood. This Case Report describes BGH arising at the ampulla of Vater, causing abdominal pain and vomiting in a 46-year-old man. Owing to the inconclusive nature of imaging studies and suspicious intraoperative findings, a Whipple resection was performed without any complications. Histological analysis showed that the obstructing lesion was BGH, with no evidence of malignancy. This is only the second such case of its kind at the ampulla of Vater to be reported. In addition, we present the previously unreported endoscopic ultrasound findings. The subsequent literature review focuses on the pathophysiology, clinical presentation, diagnosis and management of BGH.
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Affiliation(s)
- S E J Janes
- Department of Surgery, Queens Medical Centre, Nottingham, United Kingdom.
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38
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39
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Abstract
BACKGROUND Population data supporting an association between the autoimmune cholestatic liver diseases, primary biliary cirrhosis and primary sclerosing cholangitis and coeliac disease, is limited and at times contradictory. AIM To explore the relationship between coeliac disease and both primary biliary cirrhosis and primary sclerosing cholangitis within the General Practice Research Database, a UK-based longitudinal primary care database. METHODS We identified 4732 people with diagnosed coeliac disease and 23 620 age- and sex-matched controls within the General Practice Research Database. We calculated the prevalence of primary biliary cirrhosis and primary sclerosing cholangitis for both the coeliac disease and control group. RESULTS There was a higher prevalence of primary biliary cirrhosis in adults with coeliac disease, compared with controls [0.17% vs. 0.05%, odds ratio 3.63 (95% confidence interval: 1.46-9.04)]. Primary sclerosing cholangitis was also more common in the coeliac disease group [0.04% vs. 0%, fishers exact test (P = 0.03)]. CONCLUSIONS There was a threefold or greater increase in risk of both primary biliary cirrhosis and primary sclerosing cholangitis in people with coeliac disease compared with the general population. The association with primary biliary cirrhosis was weaker than in some reports and it is difficult on the basis of this study to justify screening patients with coeliac disease for either primary biliary cirrhosis or primary sclerosing cholangitis.
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Affiliation(s)
- A Lawson
- Wolfson Digestive Disease Foundation, University Hospital, Queen's Medical Centre, Nottingham, UK
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40
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Aithal GP, Haugk B, Das S, Card T, Burt AD, Record CO. Monitoring methotrexate-induced hepatic fibrosis in patients with psoriasis: are serial liver biopsies justified? Aliment Pharmacol Ther 2004; 19:391-9. [PMID: 14871278 DOI: 10.1046/j.1365-2036.2004.01819.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Reports that up to 26% of subjects with psoriasis develop cirrhosis have led to a recommendation of serial liver biopsies after each cumulative dose of 1500 mg of methotrexate. AIM To evaluate the progression of liver injury in patients with psoriasis and the impact of monitoring by liver biopsy on their management. METHODS One hundred and twenty-one liver biopsies from 66 subjects (aged 11-79 years) with psoriasis, receiving a median cumulative dose of 3206 mg of methotrexate over a period of 280.5 weeks, were evaluated. RESULTS The assessment of advanced fibrosis according to the Ishak system (>or= 4) correlated perfectly with that of the Scheuer system (>or= 3) and poorly with that of the Roenigk scale (>or= 3b) (r2 = 1.0 and 0.31, respectively). Two of 24 pre-treatment biopsies showed advanced fibrosis and both subjects were heavy drinkers. The cumulative probabilities of advanced fibrosis (Ishak >or= 4) were 0%, 2.6%, 2.6%, 8.2% and 8.2% at cumulative doses of 1500, 3000, 4500, 5000 and 6000 mg, respectively. None of the subjects developed cirrhosis during follow-up or discontinued therapy on the basis of liver biopsy findings. CONCLUSIONS Advanced hepatic fibrosis with low-dose methotrexate therapy is much less frequent than previously reported. Pre-treatment or monitoring liver biopsies in accordance with the current guidelines have little impact on patient management.
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Affiliation(s)
- G P Aithal
- Queen's Medical Centre University Hospital, Nottingham, UK.
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41
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Affiliation(s)
- E Raw
- Departments of Gastroenterology and 1Neuroradiology, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - L Hudsmith
- Departments of Gastroenterology and 1Neuroradiology, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - G P Aithal
- Departments of Gastroenterology and 1Neuroradiology, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | - T Jaspan
- Departments of Gastroenterology and 1Neuroradiology, Queen's Medical Centre, Nottingham NG7 2UH, UK
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42
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Affiliation(s)
- E Raw
- Department of Gastroenterology, Queen's Medical Centre, Nottingham NG7 2UH, UK.
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43
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44
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Aithal GP, Hoffman BJ. Steering azathioprine safely: lessons from pharmacogenetics. Am J Gastroenterol 2001; 96:3202-3. [PMID: 11721776 DOI: 10.1111/j.1572-0241.2001.05311.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- G P Aithal
- Digestive Disease Center, Medical University of South Carolina, Charleston, USA
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45
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Aithal GP, Craggs A, Day CP, Welfare M, Daly AK, Mansfield JC, Hudson M. Role of polymorphisms in the interleukin-10 gene in determining disease susceptibility and phenotype in inflamatory bowel disease. Dig Dis Sci 2001. [PMID: 11478505 DOI: 10.1023/a: 1010604307776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Interleukin-10 (IL-10) has a key role in regulating mucosal inflammation. The role of functional polymorphisms at positions -627 and -1117 in the IL-10 gene as candidate susceptibility loci in inflammatory bowel disease and their importance in determining disease extent were evaluated in 159 patients with ulcerative colitis (83 left-sided; 76 extensive), 90 patients with Crohn's disease (22 small bowel; 29 large bowel; 39 both), and 227 controls. Genotyping was performed either by PCR-RFLP assays (-627 site) or SSCP analysis (-1117 site). An excess of -627A allele was observed in patients with left-sided colitis (52%) compared with controls (33%; P = 0.004) suggesting that IL-10 may influence the extent of the disease. These results were not replicated in a newly recruited group (N = 100) of patients with UC. We conclude that polymorphisms at -627 and -1117 sites in the IL-10 gene do not contribute to the susceptibility to IBD or determining the extent of the disease in our population.
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Affiliation(s)
- G P Aithal
- Department of Medicine, Medical School, University of Newcastle, Newcastle upon Tyne, UK
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46
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Abstract
Lymphoma complicating inflammatory bowel disease is well described. Whether the risk of lymphoma is increased by immunosuppressive treatment with azathioprine, 6-mercaptopurine or infliximab is a common concern among patients and physicians considering using these agents. This review aims to quantify the lymphoma risk in inflammatory bowel disease and the added risk attributable to these treatments. The evidence from published cases is that lymphomas occur at sites of active inflammatory bowel disease more often than expected for this to be a chance association. Studies on inflammatory bowel disease populations are conflicting, with some follow-up studies from large inflammatory bowel disease clinics showing an increase in lymphoma incidence, while other population-based studies show little or no increase in risk of lymphoma. A small increase in lymphoma risk in inflammatory bowel disease, perhaps 2-3-fold, may be compatible with both sets of data. Studies of the risks associated with immuno- suppression are less satisfactory, with smaller numbers of patients and relatively short follow-up. The available evidence would support a further increase in lymphoma risk associated with immunosuppressive treatment in inflammatory bowel disease of around fivefold compared to no immunosuppressive use, and tenfold compared to the general population. The risks appear to be less than that associated with renal and hepatic transplant-related immunosuppression. Infliximab treatment is still too new to make a full assessment of its long-term safety, but post-marketing surveillance currently suggests that lymphoma risk may not be any greater than that associated with azathioprine and 6-mercaptopurine. Population-wide surveillance for lymphoma in inflammatory bowel disease would be required to narrow the confidence intervals on these estimates of lymphoma risk in inflammatory bowel disease and immunosuppressive treatment.
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Affiliation(s)
- G P Aithal
- Department of Gastroenterology, University of Newcastle, Newcastle upon Tyne, UK
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47
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48
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Aithal GP, Craggs A, Day CP, Welfare M, Daly AK, Mansfield JC, Hudson M. Role of polymorphisms in the interleukin-10 gene in determining disease susceptibility and phenotype in inflamatory bowel disease. Dig Dis Sci 2001; 46:1520-5. [PMID: 11478505 DOI: 10.1023/a:1010604307776] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [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: 12/09/2022]
Abstract
Interleukin-10 (IL-10) has a key role in regulating mucosal inflammation. The role of functional polymorphisms at positions -627 and -1117 in the IL-10 gene as candidate susceptibility loci in inflammatory bowel disease and their importance in determining disease extent were evaluated in 159 patients with ulcerative colitis (83 left-sided; 76 extensive), 90 patients with Crohn's disease (22 small bowel; 29 large bowel; 39 both), and 227 controls. Genotyping was performed either by PCR-RFLP assays (-627 site) or SSCP analysis (-1117 site). An excess of -627A allele was observed in patients with left-sided colitis (52%) compared with controls (33%; P = 0.004) suggesting that IL-10 may influence the extent of the disease. These results were not replicated in a newly recruited group (N = 100) of patients with UC. We conclude that polymorphisms at -627 and -1117 sites in the IL-10 gene do not contribute to the susceptibility to IBD or determining the extent of the disease in our population.
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Affiliation(s)
- G P Aithal
- Department of Medicine, Medical School, University of Newcastle, Newcastle upon Tyne, UK
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49
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Aithal GP, Day CP, Leathart J, Daly AK, Hudson M. Association of single nucleotide polymorphisms in the interleukin-4 gene and interleukin-4 receptor gene with Crohn's disease in a British population. Genes Immun 2001; 2:44-7. [PMID: 11294568 DOI: 10.1038/sj.gene.6363730] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2000] [Revised: 10/16/2000] [Accepted: 11/05/2000] [Indexed: 01/02/2023]
Abstract
Interleukin-4 (IL-4) is an important cytokine in mucosal immunity and plays a critical role in the development of colitis in T-alpha cell receptor mutant mice. Functionally significant polymorphisms have been described in the genes encoding IL-4 and IL-4 receptor. To examine the role of these polymorphisms in disease susceptibility 98 patients with ulcerative colitis, 86 patients with Crohn's disease and 321 healthy controls were genotyped for polymorphisms at position -34 in the IL-4 gene and codon 576 in the IL-4 receptor gene. Thirty-two percent of patients with Crohn's disease carried one or two copies of the variant allele for IL-4 compared with 16% of the controls (P = 0.002). Forty-one percent of patients with Crohn's disease carried one or two copies of the variant IL-4 receptor allele compared with 31% of the controls (P = 0.09). Fifteen percent of patients with Crohn's disease carried combination of both (IL-4 and IL-4 receptor) variant alleles compared with 4% of the controls (P = 0.005). Association with alleles resulting in high IL-4 transcription and enhanced signalling activity suggests that IL-4 may have a role in the pathogenesis of Crohn's disease.
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Affiliation(s)
- G P Aithal
- Centre for Liver Research, Medical School, University of Newcastle upon Tyne, UK.
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Abstract
BACKGROUND/AIM Due to an absence of specific markers, the diagnosis of drug-induced hepatotoxicity is necessarily based on circumstantial evidence and is often inaccurate. We have evaluated the use of the clinical diagnostic scale (CDS) in the causality assessment of hepatotoxic adverse drug reaction (ADR) reports. METHODS 135 hepatic adverse ADRs reported to the Committee on Safety of Medicines in North East England 1992-6 were evaluated. Initially, "International Consensus Criteria" were used to classify reactions as "drug-related", "drug-unrelated" and "indeterminate". Using the CDS, each ADR was then categorised as either definite drug hepatotoxicity (score >17), probable (14-17), possible (10-13), unlikely (6-9), or drug hepatotoxicity excluded (<6). RESULTS 49 ADRs were considered drug-related, 65 unrelated and 21 indeterminate. Reports classified as drug-related by consensus criteria scored higher on the CDS, with a median score of 12, range: 8-15, than either the indeterminate (8; [3-12]) or drug-unrelated reports (5; [2-11]) (p<0.0001). A CDS score of >9, identified 88% of the cases classified as drug-related hepatotoxicity by consensus criteria and excluded 98% of those unrelated to the drugs. CONCLUSIONS CDS scoring correlates well with the international consensus classification and may be a useful tool in the routine evaluation of suspected hepatotoxic drug reactions.
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Affiliation(s)
- G P Aithal
- Centre for Liver Research, University of Newcastle, Newcastle upon Tyne, UK
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