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Dunn W, Li Y, Singal AK, Simonetto DA, Díaz LA, Idalsoaga F, Ayares G, Arnold J, Ayala-Valverde M, Perez D, Gomez J, Escarate R, Fuentes-López E, Ramirez-Cadiz C, Morales-Arraez D, Zhang W, Qian S, Ahn JC, Buryska S, Mehta H, Dunn N, Waleed M, Stefanescu H, Bumbu A, Horhat A, Attar B, Agrawal R, Cabezas J, Echavaría V, Cuyàs B, Poca M, Soriano G, Sarin SK, Maiwall R, Jalal PK, Higuera-de-la-Tijera F, Kulkarni AV, Rao PN, Guerra-Salazar P, Skladaný L, Kubánek N, Prado V, Clemente-Sanchez A, Rincon D, Haider T, Chacko KR, Romero GA, Pollarsky FD, Restrepo JC, Toro LG, Yaquich P, Mendizabal M, Garrido ML, Marciano S, Dirchwolf M, Vargas V, Jiménez C, Hudson D, García-Tsao G, Ortiz G, Abraldes JG, Kamath PS, Arrese M, Shah VH, Bataller R, Arab JP. An artificial intelligence-generated model predicts 90-day survival in alcohol-associated hepatitis: A global cohort study. Hepatology 2024:01515467-990000000-00843. [PMID: 38607809 DOI: 10.1097/hep.0000000000000883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/14/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND AIMS Alcohol-associated hepatitis (AH) poses significant short-term mortality. Existing prognostic models lack precision for 90-day mortality. Utilizing artificial intelligence (AI) in a global cohort, we sought to derive and validate an enhanced prognostic model. APPROACH AND RESULTS The Global AlcHep initiative, a retrospective study across 23 centers in 12 countries, enrolled AH patients per NIAAA criteria. Centers were partitioned into derivation (11 centers, 860 patients) and validation cohorts (12 centers, 859 patients). Focusing on 30 and 90-day post-admission mortality, three AI algorithms (Random Forest, Gradient Boosting Machines, and eXtreme Gradient Boosting) informed an ensemble model, subsequently refined via Bayesian updating, integrating the derivation cohort's average 90-day mortality with each center's approximate mortality rate to produce post-test probabilities. The ALCoholic Hepatitis Artificial INtelligence (ALCHAIN) Ensemble score integrated age, gender, cirrhosis, and 9 laboratory values, with center-specific mortality rates. Mortality was 18.7% (30-day) and 27.9% (90-day) in the derivation cohort, versus 21.7% and 32.5% in the validation cohort. Validation cohort 30 and 90-day AUCs were 0.811 (0.779 - 0.844) and 0.799 (0.769 - 0.830), significantly surpassing legacy models like Maddrey's Discriminant Function, MELD variations, ABIC, Glasgow, and modified Glasgow Scores (p<0.001). ALCHAIN Ensemble score also showcased superior calibration against MELD and its variants. Steroid use improved 30-day survival for those with an ALCHAIN Ensemble score>0.20 in both derivation and validation cohorts. CONCLUSIONS Harnessing AI within a global consortium, we pioneered a scoring system excelling over traditional models for 30 and 90-day AH mortality predictions. Beneficial for clinical trials, steroid therapy, and transplant indications, it's accessible at: https://aihepatology.shinyapps.io/ALCHAIN/.
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Affiliation(s)
| | - Yanming Li
- University of Kansas Medical Center, KS, USA
| | - Ashwani K Singal
- Department of Gastroenterology and Hepatology, University of Louisville, Louisville, KY, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Luis A Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Idalsoaga
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gustavo Ayares
- Servicio Medicina Interna, Hospital El Pino, Santiago, Chile
| | - Jorge Arnold
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Diego Perez
- Servicio Medicina Interna, Hospital El Pino, Santiago, Chile
| | - Jaime Gomez
- Servicio Medicina Interna, Hospital El Pino, Santiago, Chile
| | | | - Eduardo Fuentes-López
- Department of Health Sciences, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carolina Ramirez-Cadiz
- Department of Anesthesiology and Perioperative Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
| | - Dalia Morales-Arraez
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Wei Zhang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
- Center for Liver Disease and Liver Transplantation, Columbia University, New York, NY, USA
| | - Steve Qian
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - Joseph C Ahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Seth Buryska
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Heer Mehta
- University of Kansas Medical Center, KS, USA
| | | | - Muhammad Waleed
- Department of Gastroenterology and Hepatology, University of Louisville, Louisville, KY, USA
| | - Horia Stefanescu
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Andreea Bumbu
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Adelina Horhat
- University of Medicine and Pharmacy "Iuliu Hatieganu" Cluj-Napoca, Romania
| | - Bashar Attar
- Division of Gastroenterology & Hepatology, Cook County Health, and Hospital Systems, Chicago, Illinois, USA
| | - Rohit Agrawal
- Division of Gastroenterology and Hepatology, University of West Virginia, West Virginia, USA
| | - Joaquín Cabezas
- Gastroenterology and Hepatology Department. University Hospital Marqués de Valdecilla. Santander. Spain; Clinical and Translational Research in Digestive Diseases, Research Institute Valdecilla (IDIVAL). Santander, Spain
| | - Victor Echavaría
- Gastroenterology and Hepatology Department. University Hospital Marqués de Valdecilla. Santander. Spain; Clinical and Translational Research in Digestive Diseases, Research Institute Valdecilla (IDIVAL). Santander, Spain
| | - Berta Cuyàs
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Institut de Recerca Hospital de Sant Pau-IIB Sant Pau, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - Maria Poca
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Institut de Recerca Hospital de Sant Pau-IIB Sant Pau, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - German Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Institut de Recerca Hospital de Sant Pau-IIB Sant Pau, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Prasun K Jalal
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Fátima Higuera-de-la-Tijera
- Servicio de Gastroenterología y Hepatología, Hospital General de México "Dr. Eduardo Liceaga"; Facultad de Medicina, Universidad Nacional Autónoma de México, México
| | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - P Nagaraja Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | | | - Lubomir Skladaný
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University, F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Natália Kubánek
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University, F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | | | - Ana Clemente-Sanchez
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
- Liver Unit, Department of Digestive Diseases Hospital General Universitario Gregorio Marañón, Madrid, Spain
- CIBERehd Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | - Diego Rincon
- Liver Unit, Department of Digestive Diseases Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Tehseen Haider
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, Bronx, NY, USA
| | - Kristina R Chacko
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, Bronx, NY, USA
| | - Gustavo A Romero
- Sección Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Florencia D Pollarsky
- Sección Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Juan C Restrepo
- Unidad de Hepatología del Hospital Pablo Tobon Uribe, Grupo de Gastrohepatología de la Universidad de Antioquia, Medellín, Colombia
| | - Luis G Toro
- Hepatology and Liver Transplant Unit, Hospitales de San Vicente Fundación de Medellín y Rionegro, Colombia
| | - Pamela Yaquich
- Departamento de Gastroenterología, Hospital San Juan de Dios, Santiago, Chile
| | - Manuel Mendizabal
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Buenos Aires, Argentina
| | | | | | - Melisa Dirchwolf
- Unidad de Hígado, Hospital Privado de Rosario, Rosario, Argentina
| | - Victor Vargas
- Liver Unit, Hospital Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - César Jiménez
- Liver Unit, Hospital Vall d'Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - David Hudson
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
| | - Guadalupe García-Tsao
- Section of Digestive Diseases, Yale University School of Medicine/VA-CT Healthcare System, New Haven, CT, USA
| | - Guillermo Ortiz
- Section of Digestive Diseases, Yale University School of Medicine/VA-CT Healthcare System, New Haven, CT, USA
| | - Juan G Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, Canada
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Marco Arrese
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Ramon Bataller
- Liver Unit, Hospital Clinic, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Juan P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada
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Arab JP, Dunn W, Im G, Singal AK. Changing landscape of alcohol-associated liver disease in younger individuals, women, and ethnic minorities. Liver Int 2024. [PMID: 38578107 DOI: 10.1111/liv.15933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 03/06/2024] [Accepted: 03/28/2024] [Indexed: 04/06/2024]
Abstract
Alcohol use is the most important determinant of the development of alcohol-associated liver disease (ALD) and of predicting long-term outcomes in those with established liver disease. Worldwide, the amount, type, and pattern of use of alcohol vary. Alcohol use and consequent liver disease have been increasing in certain ethnic groups especially Hispanics and Native Americans, likely due to variations in genetics, cultural background, socio-economic status, and access to health care. Furthermore, the magnitude and burden of ALD have been increasing especially in the last few years among females and young adults who are at the prime of their productivity. It is critical to recognize the problem and care for these patients integrating cultural aspects in liver clinics. At the federal level, a societal approach is needed with the implementation of public health policies aiming to reduce alcohol consumption in the community. By addressing these challenges and promoting awareness, we can strive to reduce the burden of ALD, especially in high-risk demographic groups to improve their long-term health outcomes. Finally, we need studies and quality research examining these changing landscapes of demographics in ALD as a basis for developing therapeutic targets and interventions to reduce harmful drinking behaviours in these high-risk demographic groups.
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Affiliation(s)
- Juan P Arab
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Winston Dunn
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Gene Im
- Division of Gastroenterology and Hepatology, Department of Medicine, Mount Sinai Medical School, New York, New York, USA
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Louisville, Louisville, Kentucky, USA
- Health Research, VA Medical Center, Sioux Falls, South Dakota, USA
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3
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Díaz LA, Fuentes-López E, Idalsoaga F, Ayares G, Corsi O, Arnold J, Cannistra M, Vio D, Márquez-Lomas A, Ramirez-Cadiz C, Medel MP, Hernandez-Tejero M, Ferreccio C, Lazo M, Roblero JP, Cotter TG, Kulkarni AV, Kim W, Brahmania M, Louvet A, Tapper EB, Dunn W, Simonetto D, Shah VH, Kamath PS, Lazarus JV, Singal AK, Bataller R, Arrese M, Arab JP. Association between public health policies on alcohol and worldwide cancer, liver disease and cardiovascular disease outcomes. J Hepatol 2024; 80:409-418. [PMID: 37992972 DOI: 10.1016/j.jhep.2023.11.006] [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: 04/28/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND & AIMS The long-term impact of alcohol-related public health policies (PHPs) on disease burden is unclear. We aimed to assess the association between alcohol-related PHPs and alcohol-related health consequences. METHODS We conducted an ecological multi-national study including 169 countries. We collected data on alcohol-related PHPs from the WHO Global Information System of Alcohol and Health 2010. Data on alcohol-related health consequences between 2010-2019 were obtained from the Global Burden of Disease database. We classified PHPs into five items, including criteria for low, moderate, and strong PHP establishment. We estimated an alcohol preparedness index (API) using multiple correspondence analysis (0 lowest and 100 highest establishment). We estimated an incidence rate ratio (IRR) for outcomes according to API using adjusted multilevel generalized linear models with a Poisson family distribution. RESULTS The median API in the 169 countries was 54 [IQR 34.9-76.8]. The API was inversely associated with alcohol use disorder (AUD) prevalence (IRR 0.13; 95% CI 0.03-0.60; p = 0.010), alcohol-associated liver disease (ALD) mortality (IRR 0.14; 95% CI 0.03-0.79; p = 0.025), mortality due to neoplasms (IRR 0.09; 95% CI 0.02-0.40; p = 0.002), alcohol-attributable hepatocellular carcinoma (HCC) (IRR 0.13; 95% CI 0.02-0.65; p = 0.014), and cardiovascular diseases (IRR 0.09; 95% CI 0.02-0.41; p = 0.002). The highest associations were observed in the Americas, Africa, and Europe. These associations became stronger over time, and AUD prevalence was significantly lower after 2 years, while ALD mortality and alcohol-attributable HCC incidence decreased after 4 and 8 years from baseline API assessment, respectively (p <0.05). CONCLUSIONS The API is a valuable instrument to quantify the robustness of alcohol-related PHP establishment. Lower AUD prevalence and lower mortality related to ALD, neoplasms, alcohol-attributable HCC, and cardiovascular diseases were observed in countries with a higher API. Our results encourage the development and strengthening of alcohol-related policies worldwide. IMPACT AND IMPLICATIONS We first developed an alcohol preparedness index, an instrument to assess the existence of alcohol-related public policies for each country. We then evaluated the long-term association of the country's alcohol preparedness index in 2010 with the burden of chronic liver disease, hepatocellular carcinoma, other neoplasms, and cardiovascular disease. The strengthening of alcohol-related public health policies could impact long-term mortality rates from cardiovascular disease, neoplasms, and liver disease. These conditions are the main contributors to the global burden of disease related to alcohol use. Over time, this association has not only persisted but also grown stronger. Our results expand the preliminary evidence regarding the importance of public health policies in controlling alcohol-related health consequences.
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Affiliation(s)
- Luis Antonio Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Observatorio Multicéntrico de Enfermedades Gastrointestinales, OMEGA, Santiago, Chile
| | - Eduardo Fuentes-López
- Observatorio Multicéntrico de Enfermedades Gastrointestinales, OMEGA, Santiago, Chile; Departamento de Ciencias de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Idalsoaga
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gustavo Ayares
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Oscar Corsi
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Arnold
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Macarena Cannistra
- Escuela de Medicina, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Danae Vio
- Escuela de Medicina, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Carolina Ramirez-Cadiz
- Department of Anesthesiology, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - María Paz Medel
- Departamento de Medicina Familiar, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Catterina Ferreccio
- Public Health Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Advanced Center for Chronic Diseases, ACCDis, Santiago, Chile
| | - Mariana Lazo
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA; Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA; Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Juan Pablo Roblero
- Sección Gastroenterología, Hospital Clínico Universidad de Chile, Escuela de Medicina Universidad de Chile, Santiago, Chile
| | - Thomas G Cotter
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Won Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Mayur Brahmania
- Univeristy of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Alexandre Louvet
- Hôpital Claude Huriez, Services des Maladies de l'Appareil Digestif, CHRU Lille, and Unité INSERM 995, Lille, France
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA; Gastroenterology Section, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | | | - Douglas Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey V Lazarus
- CUNY Graduate School of Public Health and Health Policy (CUNY SPH), New York, NY, USA; Barcelona Institute for Global Health (ISGlobal), Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Ashwani K Singal
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | | | - Marco Arrese
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Observatorio Multicéntrico de Enfermedades Gastrointestinales, OMEGA, Santiago, Chile
| | - Juan Pablo Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Observatorio Multicéntrico de Enfermedades Gastrointestinales, OMEGA, Santiago, Chile; Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada.
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4
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Díaz LA, Fuentes-López E, Ayares G, Idalsoaga F, Arnold J, Valverde MA, Perez D, Gómez J, Escarate R, Villalón A, Ramírez CA, Hernandez-Tejero M, Zhang W, Qian S, Simonetto DA, Ahn JC, Buryska S, Dunn W, Mehta H, Agrawal R, Cabezas J, García-Carrera I, Cuyàs B, Poca M, Soriano G, Sarin SK, Maiwall R, Jalal PK, Abdulsada S, Higuera-de-la-Tijera F, Kulkarni AV, Rao PN, Salazar PG, Skladaný L, Bystrianska N, Clemente-Sanchez A, Villaseca-Gómez C, Haider T, Chacko KR, Romero GA, Pollarsky FD, Restrepo JC, Castro-Sanchez S, Toro LG, Yaquich P, Mendizabal M, Garrido ML, Marciano S, Dirchwolf M, Vargas V, Jiménez C, Louvet A, García-Tsao G, Roblero JP, Abraldes JG, Shah VH, Kamath PS, Arrese M, Singal AK, Bataller R, Arab JP. MELD 3.0 adequately predicts mortality and renal replacement therapy requirements in patients with alcohol-associated hepatitis. JHEP Rep 2023; 5:100727. [PMID: 37456675 PMCID: PMC10339256 DOI: 10.1016/j.jhepr.2023.100727] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 07/18/2023] Open
Abstract
Background & Aims Model for End-Stage Liver Disease (MELD) score better predicts mortality in alcohol-associated hepatitis (AH) but could underestimate severity in women and malnourished patients. Using a global cohort, we assessed the ability of the MELD 3.0 score to predict short-term mortality in AH. Methods This was a retrospective cohort study of patients admitted to hospital with AH from 2009 to 2019. The main outcome was all-cause 30-day mortality. We compared the AUC using DeLong's method and also performed a time-dependent AUC with competing risks analysis. Results A total of 2,124 patients were included from 28 centres from 10 countries on three continents (median age 47.2 ± 11.2 years, 29.9% women, 71.3% with underlying cirrhosis). The median MELD 3.0 score at admission was 25 (20-33), with an estimated survival of 73.7% at 30 days. The MELD 3.0 score had a better performance in predicting 30-day mortality (AUC:0.761, 95%CI:0.732-0.791) compared with MELD sodium (MELD-Na; AUC: 0.744, 95% CI: 0.713-0.775; p = 0.042) and Maddrey's discriminant function (mDF) (AUC: 0.724, 95% CI: 0.691-0.757; p = 0.013). However, MELD 3.0 did not perform better than traditional MELD (AUC: 0.753, 95% CI: 0.723-0.783; p = 0.300) and Age-Bilirubin-International Normalised Ratio-Creatinine (ABIC) (AUC:0.757, 95% CI: 0.727-0.788; p = 0.765). These results were consistent in competing-risk analysis, where MELD 3.0 (AUC: 0.757, 95% CI: 0.724-0.790) predicted better 30-day mortality compared with MELD-Na (AUC: 0.739, 95% CI: 0.708-0.770; p = 0.028) and mDF (AUC:0.717, 95% CI: 0.687-0.748; p = 0.042). The MELD 3.0 score was significantly better in predicting renal replacement therapy requirements during admission compared with the other scores (AUC: 0.844, 95% CI: 0.805-0.883). Conclusions MELD 3.0 demonstrated better performance compared with MELD-Na and mDF in predicting 30-day and 90-day mortality, and was the best predictor of renal replacement therapy requirements during admission for AH. However, further prospective studies are needed to validate its extensive use in AH. Impact and implications Severe AH has high short-term mortality. The establishment of treatments and liver transplantation depends on mortality prediction. We evaluated the performance of the new MELD 3.0 score to predict short-term mortality in AH in a large global cohort. MELD 3.0 performed better in predicting 30- and 90-day mortality compared with MELD-Na and mDF, but was similar to MELD and ABIC scores. MELD 3.0 was the best predictor of renal replacement therapy requirements. Thus, further prospective studies are needed to support the wide use of MELD 3.0 in AH.
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Affiliation(s)
- Luis Antonio Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo Fuentes-López
- Departamento de Ciencias de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gustavo Ayares
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Idalsoaga
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Arnold
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Diego Perez
- Servicio Medicina Interna, Hospital El Pino, Santiago, Chile
| | - Jaime Gómez
- Servicio Medicina Interna, Hospital El Pino, Santiago, Chile
| | | | - Alejandro Villalón
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Departamento de Ciencias Médicas, Facultad de Medicina y Odontología, Universidad de Antofagasta, Antofagasta, Chile
| | - Carolina A. Ramírez
- Department of Anesthesia & Perioperative Medicine, Western University, London, ON, Canada
| | - Maria Hernandez-Tejero
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
- Liver Unit, Hospital Clinic, Barcelona, Spain
| | - Wei Zhang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
- Gastroenterology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Steve Qian
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | | | - Joseph C. Ahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Seth Buryska
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Heer Mehta
- University of Kansas Medical Center, KS, USA
| | - Rohit Agrawal
- Division of Gastroenterology and Hepatology, University of Illinois, Chicago, IL, USA
| | - Joaquín Cabezas
- Gastroenterology and Hepatology Department. University Hospital Marqués de Valdecilla, Santander, Spain
- Research Institute Valdecilla (IDIVAL), Santander, Spain
| | - Inés García-Carrera
- Gastroenterology and Hepatology Department. University Hospital Marqués de Valdecilla, Santander, Spain
- Research Institute Valdecilla (IDIVAL), Santander, Spain
| | - Berta Cuyàs
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Institut de Recerca Hospital de Sant Pau-IIB Sant Pau, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - Maria Poca
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Institut de Recerca Hospital de Sant Pau-IIB Sant Pau, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - German Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Institut de Recerca Hospital de Sant Pau-IIB Sant Pau, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - Shiv K. Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Prasun K. Jalal
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Saba Abdulsada
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Fátima Higuera-de-la-Tijera
- Servicio de Gastroenterología, Hospital General de México ‘Dr. Eduardo Liceaga’, Facultad de Medicina, Universidad Nacional Autónoma de México, México City, Mexico
| | - Anand V. Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - P. Nagaraja Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | | | - Lubomir Skladaný
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University, F.D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Natália Bystrianska
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University, F.D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Ana Clemente-Sanchez
- Liver Unit, Department of Digestive Diseases Hospital General Universitario Gregorio Marañón Madrid, Madrid, Spain
- CIBERehd Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas Madrid, Madrid, Spain
| | - Clara Villaseca-Gómez
- Liver Unit, Department of Digestive Diseases Hospital General Universitario Gregorio Marañón Madrid, Madrid, Spain
- CIBERehd Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas Madrid, Madrid, Spain
| | - Tehseen Haider
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, Bronx, NY, USA
| | - Kristina R. Chacko
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, Bronx, NY, USA
| | - Gustavo A. Romero
- Sección Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Florencia D. Pollarsky
- Sección Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Juan Carlos Restrepo
- Unidad de Hepatología del Hospital Pablo Tobon Uribe, Grupo de Gastrohepatología de la Universidad de Antioquia, Medellín, Colombia
| | - Susana Castro-Sanchez
- Unidad de Hepatología del Hospital Pablo Tobon Uribe, Grupo de Gastrohepatología de la Universidad de Antioquia, Medellín, Colombia
| | - Luis G. Toro
- Hepatology and Liver Transplant Unit, Hospitales de San Vicente Fundación de Medellín y Rionegro, Medellín, Colombia
| | - Pamela Yaquich
- Departamento de Gastroenterología, Hospital San Juan de Dios, Santiago, Chile
| | - Manuel Mendizabal
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Buenos Aires, Argentina
| | | | | | - Melisa Dirchwolf
- Unidad de Hígado, Hospital Privado de Rosario, Rosario, Argentina
| | - Victor Vargas
- Liver Unit, Hospital Vall d’Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autonoma Barcelona, CIBEREHD, Barcelona, Spain
| | - César Jiménez
- Liver Unit, Hospital Vall d’Hebron, Vall d'Hebron Research Institute (VHIR), Universitat Autonoma Barcelona, CIBEREHD, Barcelona, Spain
| | - Alexandre Louvet
- Hôpital Claude Huriez, Services des Maladies de l'Appareil Digestif, CHRU Lille, and Unité INSERM 995, Lille, France
| | - Guadalupe García-Tsao
- Section of Digestive Diseases, Yale University School of Medicine/VA-CT Healthcare System, New Haven/West Haven, CT, USA
| | - Juan Pablo Roblero
- Sección Gastroenterología, Hospital Clínico Universidad de Chile, Escuela de Medicina Universidad de Chile, Santiago, Chile
| | - Juan G. Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, AB, Canada
| | - Vijay H. Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Patrick S. Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Marco Arrese
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ashwani K. Singal
- Department of Medicine, University of South Dakota Sanford School of Medicine and Transplant Hepatology, Avera Transplant Institute, Sioux Falls, SD, USA
| | | | - Juan Pablo Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, ONT, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, ONT, Canada
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5
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Mischel AK, Liao Z, Cao F, Dunn W, Lo JC, Newton KP, Goyal NP, Yu EL, Schwimmer JB. Prevalence of Elevated ALT in Adolescents in the US 2011-2018. J Pediatr Gastroenterol Nutr 2023; 77:103-109. [PMID: 37084344 PMCID: PMC10330162 DOI: 10.1097/mpg.0000000000003795] [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] [Indexed: 04/23/2023]
Abstract
OBJECTIVE The objective of this study is to characterize suspected nonalcoholic fatty liver disease (NAFLD) using elevated alanine aminotransferase (ALT) in a diverse and nationally representative cohort of adolescents and to characterize higher ALT elevation in adolescents with obesity. METHODS Data from the National Health and Nutrition Examination Survey 2011-2018 were analyzed for adolescents 12-19 years. Participants with causes for elevated ALT other than NAFLD were excluded. Race and ethnicity, sex, body mass index (BMI), and ALT were examined. Elevated ALT was defined as >22 U/L (females) and >26 U/L (males) using the biologic upper normal limit (ULN). Elevated ALT thresholds up to 2X-ULN were examined among adolescents with obesity. Multivariable logistic regression was used to determine the association of race/ethnicity and elevated ALT, adjusting for age, sex, and BMI. RESULTS Prevalence of elevated ALT in adolescents was 16.5% overall and 39.5% among those with obesity. For White, Hispanic, and Asian adolescents, prevalence was 15.8%, 21.8%, and 16.5% overall, 12.8%, 17.7%, and 27.0% in those with overweight, and 43.0%, 43.5%, and 43.1% in those with obesity, respectively. Prevalence was much lower in Black adolescents (10.7% overall, 8.4% for overweight, 20.7% for obesity). Prevalence of ALT at 2X-ULN was 6.6% in adolescents with obesity. Hispanic ethnicity, age, male sex, and higher BMI were independent predictors of elevated ALT. CONCLUSIONS Prevalence of elevated ALT in U.S. adolescents is high, affecting 1 in 6 adolescents during 2011-2018. The risk is highest in Hispanic adolescents. Asian adolescents with elevated BMI may comprise an emerging risk group for elevated ALT.
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Affiliation(s)
- Anna K. Mischel
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA, 92093, USA
| | - Zhengxu Liao
- Division of Biostatistics and Bioinformatics, Department of Family Medicine and Public Health, University of California San Diego School of Medicine, La Jolla, CA, 92093, USA
| | - Fangyi Cao
- Division of Biostatistics and Bioinformatics, Department of Family Medicine and Public Health, University of California San Diego School of Medicine, La Jolla, CA, 92093, USA
| | - Winston Dunn
- Gastroenterology and Hepatology, the University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA
| | - Joan C. Lo
- Department of Medicine, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, Ca, 94611, USA
- Division of Research, Kaiser Permanente Northern California, 2000- Broadway, Oakland, CA, 94612, USA
| | - Kimberly P. Newton
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA, 92093, USA
- Department of Gastroenterology, Rady Children’s Hospital San Diego, San Diego, CA, 92123, USA
| | - Nidhi P. Goyal
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA, 92093, USA
- Department of Gastroenterology, Rady Children’s Hospital San Diego, San Diego, CA, 92123, USA
| | - Elizabeth L. Yu
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA, 92093, USA
- Department of Gastroenterology, Rady Children’s Hospital San Diego, San Diego, CA, 92123, USA
| | - Jeffrey B. Schwimmer
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California San Diego School of Medicine, La Jolla, CA, 92093, USA
- Department of Gastroenterology, Rady Children’s Hospital San Diego, San Diego, CA, 92123, USA
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6
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Mehta H, Dunn W. Determining Prognosis of ALD and Alcohol-associated Hepatitis. J Clin Exp Hepatol 2023; 13:479-488. [PMID: 37250869 PMCID: PMC10213842 DOI: 10.1016/j.jceh.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Abstract
Alcohol-associated hepatitis has a poor prognosis in terms of short-term mortality and often presents with symptoms, such as jaundice, acute renal failure, and ascites. There are many prognostic models that have been developed to predict short-term and long-term mortality in these patients. Current prognostic models can be divided into static scores, which are measured at admission, and dynamic models, which measure baseline and after a certain amount of time. The efficacy of these models in predicting short-term mortality is disputed. Numerous studies across the world have compared prognostic models, such as the Maddrey's discriminant function, the model for end-stage liver disease score, model for end-stage liver disease score-Na, Glasgow alcohol-associated hepatitis score, and the age-bilirubin-international normalized ratio-creatinine (ABIC) score, to each other to determine which score is more useful for a particular context. There are also prognostic markers such as liver biopsy, breath biomarkers, and acute kidney injury that are able to predict mortality. The accuracy of these scores is a key to determining when treatment with corticosteroids is futile since there is an increased risk of infection in those treated with it. Furthermore, although these scores are helpful in predicting short-term mortality, the only factor that is able to predict long-term mortality in patients with alcohol-related liver disease is abstinence. Numerous studies have proven that even though corticosteroids provide a treatment for alcohol-associated hepatitis, it is a temporary one, at best. The purpose of this paper is to compare the historical models to current ones in their ability to predict mortality in patients with alcohol-related liver disease by analyzing multiple studies that have examined these prognostic markers. This paper also isolates the knowledge gaps in the ability to delineate which patients would benefit from corticosteroids and patients who would not and provides potential models for the future that could narrow this gap.
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Affiliation(s)
- Heer Mehta
- University of Missouri–Kansas City School of Medicine, USA
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7
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Dunn W, Castera L, Loomba R. Roles of Radiological Tests in Clinical Trials and the Clinical Management of Nonalcoholic Fatty Liver Disease. Clin Liver Dis 2023; 27:363-372. [PMID: 37024213 PMCID: PMC10792514 DOI: 10.1016/j.cld.2023.01.020] [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] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Radiological testing is now routinely used for clinical trial prescreening, diagnosis, and treatment and referral. The CAP performs well in detecting fatty liver but is unable to grade and track longitudinal changes. MRI-PDFF is a better technique for evaluating longitudinal changes and is used as a primary endpoint in trials of antisteatotic agents. The probability of detecting liver fibrosis using radiological testing techniques is high when performed at referral centers, and reasonable imaging strategies include the combination of FIB-4 and VCTE, the FAST Score, MAST, and MEFIB. The strategy currently recommended is the sequential application of FIB-4 and VCTE.
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Affiliation(s)
- Winston Dunn
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA.
| | - Laurent Castera
- Université de Paris, UMR1149 (CRI), INSERM, Paris, France; Service d'Hépatologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Beaujon, Clichy, France
| | - Rohit Loomba
- Division of Gastroenterology and Hepatology, Department of Medicine, NAFLD Research Center, University of California San Diego, La Jolla, CA, USA
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Yarra P, Dunn W, Younossi Z, Kuo YF, Singal AK. Association of Previous Gastric Bypass Surgery and Patient Outcomes in Alcohol-Associated Cirrhosis Hospitalizations. Dig Dis Sci 2023; 68:1026-1034. [PMID: 35788931 DOI: 10.1007/s10620-022-07591-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 06/04/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Roux-En-Y gastric bypass (RYGB) is associated with risk of alcohol use disorder. The impact of RYGB among patients with alcohol-associated liver disease (ALD) remains unknown. METHODS A retrospective cohort from National Inpatient Sample (01/2006-09/2015) database on 421,156 admissions with alcohol-associated cirrhosis (AC) was stratified for non-primary discharge diagnosis of previous RYGB. Admissions with RYGB (cases) were matched 1:3 to without RYGB (controls) based on propensity score on demographics, calendar year, socioeconomic status (insurance and zip code income quartile), obesity, diabetes, anxiety, and alcohol use disorder. Primary outcome was concomitant discharge diagnosis of alcoholic hepatitis (AH) or development of acute on chronic liver failure (ACLF). RESULTS Of 10,168 admissions (mean age 49 yrs., 75% females, 79% whites), cases (N = 2542) vs. controls had higher prevalence of concomitant AH (18.8 vs. 17%, P = 0.032), hepatic encephalopathy (31 vs. 25%), infection (28 vs. 24%), and grade 3 ACLF (13 vs. 5%), P < 0.001. Conditional logistic regression models showed higher odds for AH, hepatic encephalopathy, and infection among cases. In-hospital mortality of 6.3% (43% in ACLF) was lower in cases, but similar in the sub-cohorts of AH (N = 1768) or ACLF (N = 768). Results were similar in a sensitivity analysis of matched cohort of 2016 hospitalizations (504 cases) with primary discharge diagnosis of AC. CONCLUSION Among patients with AC, previous RYGB is associated with increased likelihood of concomitant AH, hepatic encephalopathy, and infection, but similar in-hospital mortality. Prospective studies are needed to validate, determine causality, and understand mechanisms of these findings among patients with alcohol-associated cirrhosis.
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Affiliation(s)
- Pradeep Yarra
- Department of Medicine, University of Kentucky, Lexington, KY, USA
| | - Winston Dunn
- Division of Gastroenterology and Hepatology, Department of Medicine, Kansa University Medical Center, Kansas City, KS, USA
| | - Zobair Younossi
- Center for Liver Diseases and Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Yong-Fang Kuo
- Department of Biostatistics and Preventive Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Ashwani K Singal
- Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, 57105, USA.
- Division of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, SD, USA.
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9
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Dunn W, Song X, Koestler D, Grdinovac K, Al‐hihi E, Chen J, Taylor R, Wilson J, Weinman SA. Patients with type 2 diabetes and elevated fibrosis-4 are under-referred to hepatology and have unrecognized hepatic decompensation. J Gastroenterol Hepatol 2022; 37:1815-1821. [PMID: 35613944 PMCID: PMC9543724 DOI: 10.1111/jgh.15900] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/05/2022] [Accepted: 05/22/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM The American Association for the Study of Liver Diseases recommends a high index of suspicion for nonalcoholic steatohepatitis and advanced fibrosis in patients with type 2 diabetes (T2D) and an elevated fibrosis-4 index (FIB-4). We investigated the referral pattern of patients with T2D and FIB4 > 3.25 to the hepatology clinic and evaluated the clinical benefits to the patient. METHODS We included patients aged 18-80 years with T2D and a FIB4 score >3.25 who had visited the internal medicine, family medicine, endocrinology clinic from 01/01/2014-5/31/2019. The first time point of high-risk FIB-4 was identified as the baseline for time-to-event analysis. The patients were classified based on whether they had visited the hepatology clinic (referred vs not referred). RESULTS Of the 2174 patients, 290 (13.3%) were referred to the hepatology clinic, and 1884 (86.7%) were not referred. In multivariate analyses, the referred patients had a lower overall mortality risk (Hazard Ratio: 0.57; 95% CI: 0.38-87). Notably, the referred patients had the same rate of biochemical decompensation, as measured by progression to MELD ≥ 14, but a substantially higher rate of diagnosis in cirrhosis (27, 19-38) and cirrhosis complications, including ascites (2.9, 2.0-4.1), hepatic encephalopathy (99, 13-742), and liver cancer (14, 5-38). CONCLUSIONS We found that patients with T2D and high-risk FIB4 are associated with better overall survival after referral to a hepatology clinic. We speculate that the survival difference is due to the increased recognition of cirrhosis and cirrhosis complications in the referred populations.
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Affiliation(s)
- Winston Dunn
- Department of Internal MedicineUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Xing Song
- Center for Medical Informatics and Enterprise AnalyticsUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Devin Koestler
- Department of Biostatistics and Data ScienceUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Kristine Grdinovac
- Department of Internal MedicineUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Eyad Al‐hihi
- Department of Internal MedicineUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - John Chen
- Center for Medical Informatics and Enterprise AnalyticsUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Ryan Taylor
- Department of Internal MedicineUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Jessica Wilson
- Department of Internal MedicineUniversity of Kansas Medical CenterKansas CityKansasUSA
| | - Steven A. Weinman
- Department of Internal MedicineUniversity of Kansas Medical CenterKansas CityKansasUSA
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10
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Kezer CA, Buryska SM, Ahn JC, Harmsen WS, Dunn W, Singal AK, Arab JP, Díaz LA, Arnold J, Kamath PS, Shah VH, Simonetto DA. The Mortality Index for Alcohol-Associated Hepatitis: A Novel Prognostic Score. Mayo Clin Proc 2022; 97:480-490. [PMID: 35181163 DOI: 10.1016/j.mayocp.2021.10.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/17/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To develop a new scoring system that more accurately predicts 30-day mortality in patients with alcohol-associated hepatitis (AH). METHODS A cohort of consecutive adults diagnosed with AH at a single academic center from January 1, 1998, to December 31, 2018, was identified for model derivation. Multivariate logistic regression was used to create a new scoring system to predict 30-day mortality. External validation of this score was performed on a multicenter retrospective cohort. RESULTS In the derivation cohort of 266 patients, the 30-day mortality rate was 19.2%. The following variables were found to be significantly associated with mortality on multivariate analysis: age (P=.002), blood urea nitrogen (P=.003), albumin (P=.01), bilirubin (P=.02), and international normalized ratio (P=.001). A model incorporating these variables, entitled the Mortality Index for Alcohol-Associated Hepatitis (MIAAH), achieved a C statistic of 0.86. Comparison of the accuracy of the MIAAH to existing prognostic models, including the Model for End-Stage Liver Disease and Maddrey Discriminant Function, showed that the highest concordance was achieved by the MIAAH and that this difference was significant. In the validation cohort of 249 patients, the MIAAH C statistic decreased to 0.73 and was found to be significantly superior to the Maddrey Discriminant Function but not to the Model for End-Stage Liver Disease. CONCLUSION The MIAAH competes with the current prognostication models and is at a minimum as accurate as these existing scores in identifying patients with AH at high risk of short-term mortality. Furthermore, the MIAAH demonstrates advantageous performance characteristics in its ability to increasingly accurately dichotomize patients into those at highest risk of death and those likely to survive.
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Affiliation(s)
| | - Seth M Buryska
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Joseph C Ahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Winston Dunn
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City
| | - Ashwani K Singal
- University of South Dakota Sanford School of Medicine and Transplant Hepatologist, Avera Transplant Institute, Sioux Falls
| | - Juan P Arab
- Department of Gastroenterology and Hepatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis A Díaz
- Department of Gastroenterology and Hepatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Arnold
- Department of Gastroenterology and Hepatology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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11
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Arab JP, Díaz LA, Baeza N, Idalsoaga F, Fuentes-López E, Arnold J, Ramírez CA, Morales-Arraez D, Ventura-Cots M, Alvarado-Tapias E, Zhang W, Clark V, Simonetto D, Ahn JC, Buryska S, Mehta TI, Stefanescu H, Horhat A, Bumbu A, Dunn W, Attar B, Agrawal R, Haque ZS, Majeed M, Cabezas J, García-Carrera I, Parker R, Cuyàs B, Poca M, Soriano G, Sarin SK, Maiwall R, Jalal PK, Abdulsada S, Higuera-de la Tijera MF, Kulkarni AV, Rao PN, Guerra Salazar P, Skladaný L, Bystrianska N, Prado V, Clemente-Sanchez A, Rincón D, Haider T, Chacko KR, Cairo F, de Sousa Coelho M, Romero GA, Pollarsky FD, Restrepo JC, Castro-Sanchez S, Toro LG, Yaquich P, Mendizabal M, Garrido ML, Narvaez A, Bessone F, Marcelo JS, Piombino D, Dirchwolf M, Arancibia JP, Altamirano J, Kim W, Araujo RC, Duarte-Rojo A, Vargas V, Rautou PE, Issoufaly T, Zamarripa F, Torre A, Lucey MR, Mathurin P, Louvet A, García-Tsao G, González JA, Verna E, Brown RS, Roblero JP, Abraldes JG, Arrese M, Shah VH, Kamath PS, Singal AK, Bataller R. Identification of optimal therapeutic window for steroid use in severe alcohol-associated hepatitis: A worldwide study. J Hepatol 2021; 75:1026-1033. [PMID: 34166722 PMCID: PMC11090180 DOI: 10.1016/j.jhep.2021.06.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/18/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Corticosteroids are the only effective therapy for severe alcohol-associated hepatitis (AH), defined by a model for end-stage liver disease (MELD) score >20. However, there are patients who may be too sick to benefit from therapy. Herein, we aimed to identify the range of MELD scores within which steroids are effective for AH. METHODS We performed a retrospective, international multicenter cohort study across 4 continents, including 3,380 adults with a clinical and/or histological diagnosis of AH. The main outcome was mortality at 30 days. We used a discrete-time survival analysis model, and MELD cut-offs were established using the transform-the-endpoints method. RESULTS In our cohort, median age was 49 (40-56) years, 76.5% were male, and 79% had underlying cirrhosis. Median MELD at admission was 24 (19-29). Survival was 88% (87-89) at 30 days, 77% (76-78) at 90 days, and 72% (72-74) at 180 days. A total of 1,225 patients received corticosteroids. In an adjusted-survival-model, corticosteroid use decreased 30-day mortality by 41% (hazard ratio [HR] 0.59; 0.47-0.74; p <0.001). Steroids only improved survival in patients with MELD scores between 21 (HR 0.61; 0.39-0.95; p = 0.027) and 51 (HR 0.72; 0.52-0.99; p = 0.041). The maximum effect of corticosteroid treatment (21-30% survival benefit) was observed with MELD scores between 25 (HR 0.58; 0.42-0.77; p <0.001) and 39 (HR 0.57; 0.41-0.79; p <0.001). No corticosteroid benefit was seen in patients with MELD >51. The type of corticosteroids used (prednisone, prednisolone, or methylprednisolone) was not associated with survival benefit (p = 0.247). CONCLUSION Corticosteroids improve 30-day survival only among patients with severe AH, especially with MELD scores between 25 and 39. LAY SUMMARY Alcohol-associated hepatitis is a condition where the liver is severely inflamed as a result of excess alcohol use. It is associated with high mortality and it is not clear whether the most commonly used treatments (corticosteroids) are effective, particularly in patients with very severe liver disease. In this worldwide study, the use of corticosteroids was associated with increased 30-day, but not 90- or 180-day, survival. The maximal benefit was observed in patients with an MELD score (a marker of severity of liver disease; higher scores signify worse disease) between 25-39. However, this benefit was lost in patients with the most severe liver disease (MELD score higher than 51).
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Affiliation(s)
- Juan Pablo Arab
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Luis Antonio Díaz
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Natalia Baeza
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Idalsoaga
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo Fuentes-López
- Department of Health Sciences, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jorge Arnold
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Servicio Medicina Interna, Hospital El Pino, Santiago, Chile
| | | | - Dalia Morales-Arraez
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Meritxell Ventura-Cots
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Edilmar Alvarado-Tapias
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Wei Zhang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - Virginia Clark
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, FL, USA
| | - Douglas Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Joseph C Ahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Seth Buryska
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Tej I Mehta
- Division of Gastroenterology and Hepatology, Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA; The Johns Hopkins Hospital, Department of Interventional Radiology, Baltimore, MD, USA
| | - Horia Stefanescu
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Adelina Horhat
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Andreea Bumbu
- Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | | | - Bashar Attar
- Division of Gastroenterology & Hepatology, Cook County Health and Hospital Systems, Chicago, Illinois, USA
| | - Rohit Agrawal
- Division of Gastroenterology and Hepatology, University of Illinois, Chicago, Illinois, USA
| | - Zohaib Syed Haque
- Division of Gastroenterology & Hepatology, Cook County Health and Hospital Systems, Chicago, Illinois, USA
| | - Muhammad Majeed
- Division of Gastroenterology & Hepatology, Cook County Health and Hospital Systems, Chicago, Illinois, USA
| | - Joaquín Cabezas
- Gastroenterology and Hepatology Department, University Hospital Marques de Valdecilla, Santander, Spain; Research Institute Valdecilla (IDIVAL), Santander, Spain
| | - Inés García-Carrera
- Gastroenterology and Hepatology Department, University Hospital Marques de Valdecilla, Santander, Spain; Research Institute Valdecilla (IDIVAL), Santander, Spain
| | - Richard Parker
- Leeds Liver Unit, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Berta Cuyàs
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, CIBERehd, Barcelona, Spain
| | - Maria Poca
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, CIBERehd, Barcelona, Spain
| | - German Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, CIBERehd, Barcelona, Spain
| | - Shiv K Sarin
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Prasun K Jalal
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Saba Abdulsada
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | | | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - P Nagaraja Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | | | - Lubomir Skladaný
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University, Slovak Republic; F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | - Natália Bystrianska
- Division of Hepatology, Gastroenterology and Liver Transplantation, Department of Internal Medicine II, Slovak Medical University, Slovak Republic; F. D. Roosevelt University Hospital, Banska Bystrica, Slovak Republic
| | | | - Ana Clemente-Sanchez
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA; Liver Unit, Department of Digestive Diseases Hospital General Universitario Gregorio Marañón Madrid, Spain; CIBERehd Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas Madrid, Spain
| | - Diego Rincón
- Liver Unit, Department of Digestive Diseases Hospital General Universitario Gregorio Marañón Madrid, Spain; CIBERehd Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas Madrid, Spain
| | - Tehseen Haider
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, Bronx, NY, USA
| | - Kristina R Chacko
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, Bronx, NY, USA
| | - Fernando Cairo
- Liver Transplant Unit, Hospital El Cruce, Florencio Varela, Buenos Aires, Argentina
| | | | - Gustavo A Romero
- Sección Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Florencia D Pollarsky
- Sección Hepatología, Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo, Buenos Aires, Argentina
| | - Juan Carlos Restrepo
- Unidad de Hepatología del Hospital Pablo Tobon Uribe, Grupo de Gastrohepatología de la Universidad de Antioquia, Medellín, Colombia
| | - Susana Castro-Sanchez
- Unidad de Hepatología del Hospital Pablo Tobon Uribe, Grupo de Gastrohepatología de la Universidad de Antioquia, Medellín, Colombia
| | - Luis G Toro
- Hepatology and Liver Transplant Unit, Hospitales de San Vicente Fundación de Medellín y Rionegro, Colombia
| | - Pamela Yaquich
- Departamento de Gastroenterología, Hospital San Juan de Dios, Santiago, Chile
| | - Manuel Mendizabal
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Buenos Aires, Argentina
| | | | - Adrián Narvaez
- Liver Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Fernando Bessone
- Hospital Provincial del Centenario, Universidad Nacional de Rosario, Rosario, Argentina
| | | | - Diego Piombino
- Servicio de Medicina Interna del Hospital de Emergencias Dr Clemente Alvarez de Rosario, Santa Fe, Argentina
| | - Melisa Dirchwolf
- Unidad de Hígado, Hospital Privado de Rosario, Rosario, Argentina
| | - Juan Pablo Arancibia
- Departamento de Gastroenterología y Hepatología, Clínica Santa María, Santiago, Chile
| | - José Altamirano
- Department of Internal Medicine, Hospital Quironsalud, Barcelona, Spain
| | - Won Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, South Korea
| | - Roberta C Araujo
- Gastroenterology Division, Ribeirão Preto Medical School, University of São Paulo, 14048-900 Ribeirão Preto, SP, Brazil
| | - Andrés Duarte-Rojo
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
| | - Victor Vargas
- Liver Unit, Hospital Vall d'Hebron, Universitat Autonoma Barcelona, CIBEREHD, Barcelona, Spain
| | - Pierre-Emmanuel Rautou
- Université de Paris, Centre de recherche sur l'inflammation, Inserm, U1149, CNRS, ERL8252, F-75018 Paris, France; Service d'Hépatologie, DHU Unity, DMU Digest, Hôpital Beaujon, AP-HP, Clichy, France; Centre de Référence des Maladies Vasculaires du Foie, French Network for Rare Liver Diseases (FILFOIE), European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Belgium
| | - Tazime Issoufaly
- Université de Paris, Centre de recherche sur l'inflammation, Inserm, U1149, CNRS, ERL8252, F-75018 Paris, France; Service d'Hépatologie, DHU Unity, DMU Digest, Hôpital Beaujon, AP-HP, Clichy, France; Centre de Référence des Maladies Vasculaires du Foie, French Network for Rare Liver Diseases (FILFOIE), European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Belgium
| | | | - Aldo Torre
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubiràn", Mexico City, Mexico
| | - Michael R Lucey
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Philippe Mathurin
- Hôpital Claude Huriez, Services des Maladies de l'Appareil Digestif, CHRU Lille, and Unité INSERM 995, Lille, France
| | - Alexandre Louvet
- Hôpital Claude Huriez, Services des Maladies de l'Appareil Digestif, CHRU Lille, and Unité INSERM 995, Lille, France
| | - Guadalupe García-Tsao
- Section of Digestive Diseases, Yale University School of Medicine/VA-CT Healthcare System, New Haven/West Haven, USA
| | - José Alberto González
- Gastroenterology Department, Hospital Universitario "Dr José E González" Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Elizabeth Verna
- Division of Digestive and Liver Diseases, Department of Medicine and Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, NY, USA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY
| | - Juan Pablo Roblero
- Sección Gastroenterología, Hospital Clínico Universidad de Chile, Escuela de Medicina Universidad de Chile, Santiago, Chile
| | - Juan G Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, Canada
| | - Marco Arrese
- Department of Gastroenterology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA
| | - Ramon Bataller
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA, USA
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Im GY, Mellinger JL, Winters A, Aby ES, Lominadze Z, Rice J, Lucey MR, Arab JP, Goel A, Jophlin LL, Sherman CB, Parker R, Chen PH, Devuni D, Sidhu S, Dunn W, Szabo G, Singal AK, Shah VH. Provider Attitudes and Practices for Alcohol Screening, Treatment, and Education in Patients With Liver Disease: A Survey From the American Association for the Study of Liver Diseases Alcohol-Associated Liver Disease Special Interest Group. Clin Gastroenterol Hepatol 2021; 19:2407-2416.e8. [PMID: 33069880 PMCID: PMC8291372 DOI: 10.1016/j.cgh.2020.10.026] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/28/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS While abstinence-promoting behavioral and pharmacotherapies are part of the therapeutic foundation for alcohol use disorder (AUD) and alcohol-associated liver disease (ALD), these therapies, along with alcohol screening and education, are often underutilized. Our aim was to examine provider attitudes and practices for alcohol screening, treatment and education in patients with liver disease. METHODS We conducted a survey of primarily (89%) hepatology and gastroenterology providers within (80%) and outside the United States (20%). Surveys were sent to 921 providers with 408 complete responses (44%), of whom 343 (80%) work in a tertiary liver transplant center. RESULTS While alcohol screening rates in liver disease patients was nearly universal, less than half of providers reported practicing with integrated addiction providers, using alcohol biomarkers and screening tools. Safe alcohol use by liver disease patients was felt to exist by 40% of providers. While 60% of providers reported referring AUD patients for behavioral therapy, 71% never prescribed AUD pharmacotherapy due to low comfort (84%). Most providers (77%) reported low addiction education and 90% desired more during GI/hepatology fellowship training. Amongst prescribers, baclofen was preferred, but with gaps in pharmacotherapy knowledge. Overall, there was low adherence to the 2019 AASLD practice guidance for ALD, although higher in hepatologists and experienced providers. CONCLUSIONS While our survey of hepatology and gastroenterology providers demonstrated higher rates of alcohol screening and referrals for behavioral therapy, we found low rates of prescribing AUD pharmacotherapy due to knowledge gaps from insufficient education. Further studies are needed to assess interventions to improve provider alignment with best practices for treating patients with AUD and ALD.
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Affiliation(s)
- Gene Y Im
- Division of Liver Diseases, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Jessica L Mellinger
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Adam Winters
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - Elizabeth S Aby
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Zurabi Lominadze
- Division of Gastroenterology, Department of Medicine, University of Maryland, Baltimore, Maryland
| | - John Rice
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Michael R Lucey
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Juan P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Aparna Goel
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Loretta L Jophlin
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Courtney B Sherman
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, California
| | - Richard Parker
- Leeds Liver Unit, St James's University Hospital, Leeds, United Kingdom
| | - Po-Hung Chen
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Deepika Devuni
- Division of Gastroenterology, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sandeep Sidhu
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
| | - Winston Dunn
- Department of Internal Medicine, The University of Kansas Medical Center, Kansas City, Kansas
| | - Gyongyi Szabo
- Division of Gastroenterology and Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ashwani K Singal
- Division of Gastroenterology and Hepatology, Department of Medicine, Avera McKennan University Hospital Transplant Institute, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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13
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Singal AK, Arsalan A, Dunn W, Arab JP, Wong RJ, Kuo YF, Kamath PS, Shah VH. Editorial: trends in alcohol use and alcohol-associated liver disease in the US population-authors' reply. Aliment Pharmacol Ther 2021; 54:513-514. [PMID: 34331802 DOI: 10.1111/apt.16520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Ashwani K Singal
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA.,Division of Gastroenterology and Hepatology, Avera Transplant Institute, Sioux Falls, SD, USA
| | - Arshad Arsalan
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA
| | - Winston Dunn
- Division of Gastroenterology and Hepatology, Kansas University Medical Center, Kansas City, KS, USA
| | - Juan P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Palo Alto VA Medical Center, Stanford University, Stanford, CA, USA
| | - Yong-Fang Kuo
- Department of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Singal AK, Arsalan A, Dunn W, Arab JP, Wong RJ, Kuo YF, Kamath PS, Shah VH. Alcohol-associated liver disease in the United States is associated with severe forms of disease among young, females and Hispanics. Aliment Pharmacol Ther 2021; 54:451-461. [PMID: 34247424 DOI: 10.1111/apt.16461] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/12/2021] [Accepted: 05/18/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Alcohol use and alcohol-associated liver disease (ALD) burden are increasing in young individuals. AIM To assess host factors associated with this burden. METHODS National Health and Nutrition Examination Survey (NHANES), National Inpatient Sample (NIS), and United Network for Organ Sharing (UNOS) databases (2006-2016) were used to identify individuals with harmful alcohol use, ALD-related admissions, and ALD-related LT listings respectively. RESULTS Of 15 981 subjects in NHANES database, weighted prevalence of harmful alcohol use was 17.7%, 29.3% in <35 years (G1) versus 16.9% in 35-64 years (G2) versus 5.1% in ≥65 years (G3). Alcohol use was about 11 and 4.7 folds higher in G1 and G2 versus G3, respectively. Male gender and Hispanic race associated with harmful alcohol use. Of 593 600 ALD admissions (5%, 77%, and 18% in G1-G3 respectively), acute on chronic liver failure (ACLF) occurred in 7.2%, (7.2 in G2 vs 6.7% in G1 and G3, P < 0.001). After controlling for other variables, ACLF development among ALD hospitalizations was higher by 14% and 10% in G1 and G2 versus G3, respectively. Female gender and Hispanic race were associated with increased ACLF risk by 8% and 17% respectively. Of 20,245 ALD LT listings (3.4%, 84.4%, and 12.2% in G1-G3 respectively), ACLF occurred in 28% candidates. Risk of severe (grade 2 or 3) ACLF was higher by about 1.7 fold in G1, 1.5 fold in females and 20% in Hispanics. CONCLUSION Young age, female gender, and Hispanic race are independently associated with ALD-related burden and ACLF in the United States. If these findings are validated in prospective studies, strategies will be needed to reduce alcohol use in high risk individuals to reduce burden from ALD.
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Affiliation(s)
- Ashwani K Singal
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA.,Division of Gastroenterology and Hepatology, Avera Transplant Institute, Sioux Falls, SD, USA
| | - Arshad Arsalan
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA
| | - Winston Dunn
- Division of Gastroenterology and Hepatology, Kansas University Medical Center, Kansas City, KS, USA
| | - Juan P Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Palo Alto VA Medical Center, Stanford University, Stanford, CA, USA
| | - Yong-Fang Kuo
- Department of Biostatistics, University of Texas Medical Branch, Galveston, TX, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Vijay H Shah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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15
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Kim D, Adeniji N, Latt N, Kumar S, Bloom PP, Aby ES, Perumalswami P, Roytman M, Li M, Vogel AS, Catana AM, Wegermann K, Carr RM, Aloman C, Chen VL, Rabiee A, Sadowski B, Nguyen V, Dunn W, Chavin KD, Zhou K, Lizaola-Mayo B, Moghe A, Debes J, Lee TH, Branch AD, Viveiros K, Chan W, Chascsa DM, Kwo P, Dhanasekaran R. Predictors of Outcomes of COVID-19 in Patients With Chronic Liver Disease: US Multi-center Study. Clin Gastroenterol Hepatol 2021; 19:1469-1479.e19. [PMID: 32950749 PMCID: PMC7497795 DOI: 10.1016/j.cgh.2020.09.027] [Citation(s) in RCA: 158] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Chronic liver disease (CLD) represents a major global health burden. We undertook this study to identify the factors associated with adverse outcomes in patients with CLD who acquire the novel coronavirus-2019 (COVID-19). METHODS We conducted a multi-center, observational cohort study across 21 institutions in the United States (US) of adult patients with CLD and laboratory-confirmed diagnosis of COVID-19 between March 1, 2020 and May 30, 2020. We performed survival analysis to identify independent predictors of all-cause mortality and COVID-19 related mortality, and multivariate logistic regression to determine the risk of severe COVID-19 in patients with CLD. RESULTS Of the 978 patients in our cohort, 867 patients (mean age 56.9 ± 14.5 years, 55% male) met inclusion criteria. The overall all-cause mortality was 14.0% (n = 121), and 61.7% (n = 535) had severe COVID-19. Patients presenting with diarrhea or nausea/vomiting were more likely to have severe COVID-19. The liver-specific factors associated with independent risk of higher overall mortality were alcohol-related liver disease (ALD) (hazard ratio [HR] 2.42, 95% confidence interval [CI] 1.29-4.55), decompensated cirrhosis (HR 2.91 [1.70-5.00]) and hepatocellular carcinoma (HCC) (HR 3.31 [1.53-7.16]). Other factors were increasing age, diabetes, hypertension, chronic obstructive pulmonary disease and current smoker. Hispanic ethnicity (odds ratio [OR] 2.33 [1.47-3.70]) and decompensated cirrhosis (OR 2.50 [1.20-5.21]) were independently associated with risk for severe COVID-19. CONCLUSIONS The risk factors which predict higher overall mortality among patients with CLD and COVID-19 are ALD, decompensated cirrhosis and HCC. Hispanic ethnicity and decompensated cirrhosis are associated with severe COVID-19. Our results will enable risk stratification and personalization of the management of patients with CLD and COVID-19. Clinicaltrials.gov number NCT04439084.
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Affiliation(s)
| | | | - Nyann Latt
- Ochsner Medical Center, New Orleans, Louisiana
| | | | | | - Elizabeth S. Aby
- Hennepin County Medical Center, Minneapolis, Minnesota,University of Minnesota, Minneapolis, Minnesota
| | | | - Marina Roytman
- University of California San Francisco, Fresno, California
| | - Michael Li
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | | | | | | | | | | | | | | | | | - Winston Dunn
- University of Kansas Medical Center, Kansas City, Kansas
| | | | - Kali Zhou
- University of Southern California, Los Angeles, California
| | | | - Akshata Moghe
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - José Debes
- Hennepin County Medical Center, Minneapolis, Minnesota,University of Minnesota, Minneapolis, Minnesota
| | | | | | | | - Walter Chan
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Paul Kwo
- Stanford University, Stanford, California
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16
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Wozniak AL, Adams A, King KE, Dunn W, Christenson LK, Hung WT, Weinman SA. The RNA binding protein FMR1 controls selective exosomal miRNA cargo loading during inflammation. J Cell Biol 2021; 219:152116. [PMID: 32970791 PMCID: PMC7659717 DOI: 10.1083/jcb.201912074] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [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: 12/12/2019] [Revised: 04/22/2020] [Accepted: 07/09/2020] [Indexed: 12/16/2022] Open
Abstract
Cells respond to inflammatory disease states by releasing exosomes containing highly specific protein and RNA cargos, but how inflammation alters cargo specificity and secretion of exosomes is unknown. We show that increases in exosome secretion induced by either viral infection or LPS/ATP exposure result from inflammasome activation and subsequent caspase-1–dependent cleavage of the trafficking adaptor protein RILP. This cleaved form of RILP promotes the movement of multivesicular bodies toward the cell periphery and induces selective exosomal miRNA cargo loading. We have identified a common short sequence motif present in miRNAs that are selectively loaded into exosomes after RILP cleavage. This motif binds the RNA binding protein FMR1 and directs miRNA loading into exosomes via interaction with components of the ESCRT (endosomal sorting complex required for transport) pathway. These results indicate that inflammasome-mediated RILP cleavage, and sequence-specific interactions between miRNAs and FMR1, play a significant role in exosome cargo loading and enhanced secretion during cellular inflammatory responses.
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Affiliation(s)
- Ann L Wozniak
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS.,Liver Center, University of Kansas Medical Center, Kansas City KS
| | - Abby Adams
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS.,Liver Center, University of Kansas Medical Center, Kansas City KS
| | - Kayla E King
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS.,Liver Center, University of Kansas Medical Center, Kansas City KS
| | - Winston Dunn
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS.,Liver Center, University of Kansas Medical Center, Kansas City KS
| | - Lane K Christenson
- Department of Molecular & Integrative Physiology, University of Kansas Medical Center, Kansas City KS
| | - Wei-Ting Hung
- Department of Molecular & Integrative Physiology, University of Kansas Medical Center, Kansas City KS.,Center for Systems Biology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Steven A Weinman
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS.,Liver Center, University of Kansas Medical Center, Kansas City KS
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17
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Rabiee A, Sadowski B, Adeniji N, Perumalswami PV, Nguyen V, Moghe A, Latt NL, Kumar S, Aloman C, Catana AM, Bloom PP, Chavin KD, Carr RM, Dunn W, Chen VL, Aby ES, Debes JD, Dhanasekaran R, Roytman M, Viveiros K, Chan W, Li M, Vogel A, Wegerman K, Lee T, Zhou K. Liver Injury in Liver Transplant Recipients With Coronavirus Disease 2019 (COVID-19): U.S. Multicenter Experience. Hepatology 2020; 72:1900-1911. [PMID: 32964510 PMCID: PMC7537191 DOI: 10.1002/hep.31574] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/19/2020] [Accepted: 09/07/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Coronavirus disease 2019 (COVID-19) is associated with liver injury, but the prevalence and patterns of liver injury in liver transplantation (LT) recipients with COVID-19 are open for study. APPROACH AND RESULTS We conducted a multicenter study in the United States of 112 adult LT recipients with COVID-19. Median age was 61 years (interquartile range, 20), 54.5% (n = 61) were male, and 39.3% (n = 44) Hispanic. Mortality rate was 22.3% (n = 25); 72.3% (n = 81) were hospitalized and 26.8% (n = 30) admitted to the intensive care unit (ICU). Analysis of peak values of alanine aminotransferase (ALT) during COVID-19 showed moderate liver injury (ALT 2-5× upper limit of normal [ULN]) in 22.2% (n = 18) and severe liver injury (ALT > 5× ULN) in 12.3% (n = 10). Compared to age- and sex-matched nontransplant patients with chronic liver disease and COVID-19 (n = 375), incidence of acute liver injury was lower in LT recipients (47.5% vs. 34.6%; P = 0.037). Variables associated with liver injury in LT recipients were younger age (P = 0.009; odds ratio [OR], 2.06; 95% confidence interval [CI], 1.20-3.54), Hispanic ethnicity (P = 0.011; OR, 6.01; 95% CI, 1.51-23.9), metabolic syndrome (P = 0.016; OR, 5.87; 95% CI, 1.38-24.99), vasopressor use (P = 0.018; OR, 7.34; 95% CI, 1.39-38.52), and antibiotic use (P = 0.046; OR, 6.93; 95% CI, 1.04-46.26). Reduction in immunosuppression (49.4%) was not associated with liver injury (P = 0.156) or mortality (P = 0.084). Liver injury during COVID-19 was significantly associated with mortality (P = 0.007; OR, 6.91; 95% CI, 1.68-28.48) and ICU admission (P = 0.007; OR, 7.93; 95% CI, 1.75-35.69) in LT recipients. CONCLUSIONS Liver injury is associated with higher mortality and ICU admission in LT recipients with COVID-19. Hence, monitoring liver enzymes closely can help in early identification of patients at risk for adverse outcomes. Reduction of immunosuppression during COVID-19 did not increase risk for mortality or graft failure.
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Affiliation(s)
- Atoosa Rabiee
- Division of GastroenterologyVA Medical CenterWashingtonDC
| | - Brett Sadowski
- Division of GastroenterologyGeorgetown UniversityWashingtonDC
| | - Nia Adeniji
- Division of GastroenterologyStanford UniversityStanfordCA
| | | | | | - Akshata Moghe
- Division of GastroenterologyUniversity of Pittsburgh Medical CenterPA
| | - Nyan L. Latt
- Division of GastroenterologyOchsner Medical CenterLA
| | - Sonal Kumar
- Division of GastroenterologyWeill Cornell MedicineNY
| | - Costica Aloman
- Division of GastroenterologyRush University Medical CenterIL
| | | | | | - Kenneth D. Chavin
- Division of Transplant and Hepatobiliary SurgeryUniversity Hospitals Cleveland Medical CenterOH
| | | | - Winston Dunn
- Division of GastroenterologyKansas University Medical CenterKS
| | | | - Elizabeth S. Aby
- Division of GastroenterologyUniversity of MinnesotaMN,Division of GastroenterologyHennepin County Medical CenterMN
| | - Jose D. Debes
- Division of GastroenterologyUniversity of MinnesotaMN,Division of GastroenterologyHennepin County Medical CenterMN
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18
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Abstract
The prevalence of nonalcoholic fatty liver disease (NAFLD) is estimated to be 26.3% among the US population. A subset of this population exhibits an aggressive histological phenotype, nonalcoholic steatohepatitis (NASH) with ≥ stage 2 fibrosis, which may progress to cirrhosis. The definition of NAFLD excludes excessive alcohol intake, which is well known to cause alcoholic liver disease and will not be discussed here. Most NAFLD clinical trials use ~14 drinks per week as the cutoff for excessive alcohol intake. Alcohol consumption below this threshold, which we define as moderate alcohol consumption, is common in the US. According to the 2012 Behavioral Risk Factor Surveillance System (BRFSS), 56% of the US adult population consume alcohol, but only 8.2% report drinking heavily and 18.3% report binge drinking. The American Association for the Study of Liver Diseases (AASLD) Practice Guidance of 2018 states that there are insufficient data to make a recommendation with regard to moderate alcohol consumption in patients with NAFLD, citing a lack of longitudinal studies that examine the impact of moderate alcohol consumption on disease progression and its extrahepatic harms versus benefits, specifically in individuals with established NAFLD. NAFLD prevalence studies have generally noted a negative correlation between modest alcohol consumption and NAFLD. However, prevalence studies have limited application to patients with established NAFLD who present to the clinic. There can also be many confounding factors, because modest alcohol consumption is also negatively associated with some NAFLD risk factors, and those risk factors may not be adequately adjusted for in analyses. The prevalence of NASH with significant fibrosis (≥ F2) is more important because this is the group that is believed to have progressive disease. Thus, cohort studies of disease progression are more important from the patient's standpoint. Because these patients have already developed NAFLD or NASH, their interest lies in their odds of disease progression if they have moderate alcohol consumption compared to abstinence. It is also noteworthy that cardiovascular disease is the most important cause of death among patients with NAFLD. Moderate alcohol consumption has been associated with a reduction in overall mortality, but mostly in cardiovascular mortality. However, this protective effect has not been demonstrated specifically in patients with NAFLD.
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Affiliation(s)
- Gong Weng
- Department of Internal Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Winston Dunn
- Department of Internal Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
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19
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Hamilton JL, Eways KR, Fohn S, Dunn W. Multicultural Awareness and a Comprehensive Team Approach to Liver Transplantation: A Case Report. J Clin Psychol Med Settings 2019; 26:282-290. [PMID: 31201654 DOI: 10.1007/s10880-019-09638-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 11/28/2022]
Abstract
Patients being considered for a liver transplant undergo a rigorous evaluation process to identify the medical and psychosocial factors that may impact transplant success. The American Association for the Study of Liver Disease outlines recommendations for medical factors, but guidelines for psychosocial factors, such as multiculturalism, are less clear. The aim of this unique case study was to highlight the importance of multicultural awareness in the context of liver transplantation. More specifically, the report follows an American Indian man from initial diagnosis through psychological assessment and transplantation in order to illustrate the benefits of a comprehensive, multicultural team approach. Various components of multiculturalism are discussed, including the patient's ethnicity, intellectual functioning, socioeconomic status, and mental health history. Consideration of these factors by the patient's treatment team ultimately led to the patient's candidacy for transplant, as well as effective psychosocial support throughout the transplant process and recovery. Incorporation more specific psychosocial recommendations into national liver transplantation guidelines would likely improve the evaluation process and outcomes.
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Affiliation(s)
- Jessica L Hamilton
- Department of Psychiatry and Internal Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA.
| | - Kalon R Eways
- Department of Psychology, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Sara Fohn
- Department of Psychiatry and Internal Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA
| | - Winston Dunn
- Department of Psychiatry and Internal Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS, 66160, USA
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20
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Dunn W, Vittal A, Zhao J, He J, Chakraborty S, Whitener M, Fohn S, Ash R, Taylor RM, Olyaee M, Olson JC, Todd N, Floyd BN, Pandya P, Laycock M, Schmitt T, Weinman SA. PNPLA3 gene predicts clinical recovery after sustained virological response in decompensated hepatitis C cirrhosis. BMJ Open Gastroenterol 2019; 6:e000241. [PMID: 30997139 PMCID: PMC6441264 DOI: 10.1136/bmjgast-2018-000241] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/08/2018] [Accepted: 11/16/2018] [Indexed: 12/14/2022] Open
Abstract
Background Patients with decompensated hepatitis C virus (HCV) cirrhosis experience various outcomes after sustained virological response (SVR), ranging from clinical recovery to further deterioration. We hypothesised that the genetic risk for steatosis, namely the polymorphisms rs738409 of Patatin-like Phospholipase Domain-Containing 3 (PNPLA3), rs58542926 of Transmembrane-6-Superfamily-2 (TM6SF2), and rs641738 of Membrane-bound O-acyltransferase Domain-Containing 7 (MBOAT7), is predictive of recovery. Methods We prospectively enrolled 56 patients with Child-Pugh (CPT) B/C cirrhosis who underwent antiviral therapy. The primary outcome was change in CPT score at 12, 24, and 48 weeks after SVR. We used a linear mixed-effects model for analysis. Results Forty-five patients (PNPLA3: 21 CC, 19 CG, 5 GG) survived to the first endpoint without liver transplantation. The mean change in CPT score at 12, 24, and 48 weeks was −1.57 (SE=0.30), –1.76 (SE=0.32), and −2.0 (SE=0.36), respectively, among the patients with the PNPLA3 CC genotype and −0.50 (SE=0.20), –0.41 (SE=0.25), and −0.24 (SE=0.27), respectively, among the other 24 patients. After adjustment for baseline characteristics, the PNPLA3 CG/GG genotypes were associated with a 1.29 (SE=0.30, p<0.0001) point higher CPT score. Most of the difference came from differences in hepatic encephalopathy and bilirubin. The results for rs58542926 and rs641738 were not significant. Conclusion The PNPLA3 CG/GG genotypes could identify a subgroup of patients with decompensated HCV cirrhosis that had suboptimal clinical recovery despite SVR. An understanding of the genetic factors that influence clinical outcomes will help target patients for liver transplant based on individual genetic risk factors and provide insight leading to new therapeutic approaches.
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Affiliation(s)
- Winston Dunn
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Anusha Vittal
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Missouri, USA.,NIH/NIDDK, Bethesda, MD, United States
| | - Jie Zhao
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Jianghua He
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Shweta Chakraborty
- Liver Transplant Center, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Melissa Whitener
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Sara Fohn
- Liver Transplant Center, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Ryan Ash
- Department of Diagnostic Radiology, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Ryan M Taylor
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Mojtaba Olyaee
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Jody C Olson
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Nancy Todd
- Liver Transplant Center, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Beth N Floyd
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Prashant Pandya
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Missouri, USA.,Department of Internal Medicine, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Melissa Laycock
- Liver Transplant Center, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Timothy Schmitt
- Department of Surgery, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Steven A Weinman
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Missouri, USA
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21
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Dunn W, Chalasani N. Advice Regarding Alcohol Use by Individuals With Nonalcoholic Fatty Liver Disease: Primum non nocere. Hepatology 2019; 69:9-11. [PMID: 30175408 DOI: 10.1002/hep.30245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 08/27/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Winston Dunn
- The University of Kansas Medical Center, Kansas City, KS
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22
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Hulme CH, Stevens A, Dunn W, Heazell AEP, Hollywood K, Begley P, Westwood M, Myers JE. Identification of the functional pathways altered by placental cell exposure to high glucose: lessons from the transcript and metabolite interactome. Sci Rep 2018; 8:5270. [PMID: 29588451 PMCID: PMC5869594 DOI: 10.1038/s41598-018-22535-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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: 08/09/2017] [Accepted: 02/19/2018] [Indexed: 02/06/2023] Open
Abstract
The specific consequences of hyperglycaemia on placental metabolism and function are incompletely understood but likely contribute to poor pregnancy outcomes associated with diabetes mellitus (DM). This study aimed to identify the functional biochemical pathways perturbed by placental exposure to high glucose levels through integrative analysis of the trophoblast transcriptome and metabolome. The human trophoblast cell line, BeWo, was cultured in 5 or 25 mM glucose, as a model of the placenta in DM. Transcriptomic analysis using microarrays, demonstrated 5632 differentially expressed gene transcripts (≥± 1.3 fold change (FC)) following exposure to high glucose. These genes were used to generate interactome models of transcript response using BioGRID (non-inferred network: 2500 nodes (genes) and 10541 protein-protein interactions). Ultra performance-liquid chromatography-mass spectrometry (MS) and gas chromatography-MS analysis of intracellular extracts and culture medium were used to assess the response of metabolite profiles to high glucose concentration. The interactions of altered genes and metabolites were assessed using the MetScape interactome database, resulting in an integrated model of systemic transcriptome (2969 genes) and metabolome (41 metabolites) response within placental cells exposed to high glucose. The functional pathways which demonstrated significant change in response to high glucose included fatty acid β-oxidation, phospholipid metabolism and phosphatidylinositol phosphate signalling.
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Affiliation(s)
- C H Hulme
- Maternal and Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, M13 9WL, UK.,Maternal and Fetal Health Research Centre, Central Manchester University Hospitals NHS Foundation Trust, St Mary's Hospital, Manchester Academic Health sciences Centre, Manchester, M13 9WL, UK
| | - A Stevens
- Division of Developmental Biology & Medicine, Faculty of Biology, Medicine & Health University of Manchester, Manchester Academic Health Sciences Centre, Manchester, M13 9WL, UK
| | - W Dunn
- Centre for Advanced Discovery and Experimental Therapeutics (CADET), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, M13 9WL, UK.,Centre for Endocrinology and Diabetes, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester, M13 9WL, UK.,School of Biosciences, Phenome Centre Birmingham and Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - A E P Heazell
- Maternal and Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, M13 9WL, UK.,Maternal and Fetal Health Research Centre, Central Manchester University Hospitals NHS Foundation Trust, St Mary's Hospital, Manchester Academic Health sciences Centre, Manchester, M13 9WL, UK
| | - K Hollywood
- Centre for Advanced Discovery and Experimental Therapeutics (CADET), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, M13 9WL, UK.,Centre for Endocrinology and Diabetes, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester, M13 9WL, UK.,Manchester Institute of Biotechnology and School of Chemistry, University of Manchester, 131 Princess Street, Manchester, M1 7DN, UK
| | - P Begley
- Centre for Advanced Discovery and Experimental Therapeutics (CADET), Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, M13 9WL, UK.,Centre for Endocrinology and Diabetes, Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester, M13 9WL, UK
| | - M Westwood
- Maternal and Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, M13 9WL, UK.,Maternal and Fetal Health Research Centre, Central Manchester University Hospitals NHS Foundation Trust, St Mary's Hospital, Manchester Academic Health sciences Centre, Manchester, M13 9WL, UK
| | - J E Myers
- Maternal and Fetal Health Research Centre, Division of Developmental Biology & Medicine, School of Medical Sciences, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, M13 9WL, UK. .,Maternal and Fetal Health Research Centre, Central Manchester University Hospitals NHS Foundation Trust, St Mary's Hospital, Manchester Academic Health sciences Centre, Manchester, M13 9WL, UK.
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23
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Dunn W. WITHDRAWN: Nonalcoholic steatohepatitis therapies. Liver Research 2018. [DOI: 10.1016/j.livres.2017.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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25
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Abstract
Alcoholic liver disease encompasses the progressive stages of liver dysfunction that culminates in alcoholic cirrhosis (AC) and in severe cases alcoholic hepatitis (AH). Currently, prognostic scores have limited specificity and sensitivity. Plasma keratin-18 (K18) levels are elevated during liver disease and may be biomarkers of outcome. The objective of this study was to determine if total K18 (M65) or caspase-cleaved K18 (M30) levels were different between AC and AH patients. M65 and M30 levels were measured in the plasma of consented healthy controls and patients with AC and AH. Cell death was assessed by TUNEL staining and caspase activity. M65 and M30 values were significantly higher in AC patients compared to healthy controls and further increased in AH patients. The M65 values and the M30/M65 ratios of nonsurviving AH patients were significantly elevated above their surviving counterparts and healthy controls. Statistical analysis indicated that M30/M65 ratios outperformed current indices for accurately distinguishing the prognosis of AH patients. These scores occurred with minimal increase in plasma cell death markers such as ALT and AST. Serum caspase activity, TUNEL staining, and M30 immunohistochemistry in biopsies indicated that serum and tissue values may not correlate well with overall cell death. In conclusion, both M65 and M30 differentiate AH from AC patients, and M65 values and the M30/M65 ratio are capable of predicting early stage mortality; however, they may not accurately reflect pure hepatocyte cell death in these populations, as they do not strongly correlate with traditional cell death markers.
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Affiliation(s)
- Benjamin L. Woolbright
- *Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Brian W. Bridges
- †Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Winston Dunn
- †Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jody C. Olson
- †Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Steven A. Weinman
- †Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Hartmut Jaeschke
- *Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, KS, USA
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Al-Hihi E, Shankweiler C, Stricklen D, Gibson C, Dunn W. Electronic medical record alert improves HCV testing for baby boomers in primary care setting: adults born during 1945-1965. BMJ Open Qual 2017; 6:e000084. [PMID: 29209663 PMCID: PMC5704105 DOI: 10.1136/bmjoq-2017-000084] [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] [Received: 04/14/2017] [Revised: 08/25/2017] [Accepted: 09/24/2017] [Indexed: 11/09/2022] Open
Abstract
METHOD This project aims to implement the HCV birth cohort screening guidelines over a 9-month period in the primary care setting at the University of Kansas Health System General Internal Medicine Division. The project team measured the number of patients in the baby boomer population who received a one-time screen for HCV. An electronic medical record (EMR) intervention was implemented to identify baby boomers who did not have an HCV screening or diagnosis. Additionally, education was provided to all primary care providers in the clinic to increase awareness of the HCV birth cohort screening. RESULTS The quality improvement methods increased the percentage of baby boomers who obtained a one-time screening test for HCV from a baseline of 30% to a 55% screening rate during the nine-month project period. CONCLUSION Identifying the HCV screening needs and creating a visual reminder in the EMR can be used to facilitate sustainable awareness and improvement of screening rates. The project team recognizes that continued work is required to close the HCV screening care gaps in the primary care setting.
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Affiliation(s)
- Eyad Al-Hihi
- Department of General and Geriatric Medicine, The University of Kansas Health System, Kansas, USA
| | - Caylin Shankweiler
- Department of General and Geriatric Medicine, The University of Kansas Health System, Kansas, USA
| | - David Stricklen
- Department of Organizational Improvement, The University of Kansas Health System, Kansas, USA
| | - Cheryl Gibson
- Department of Internal Medicine, The University of Kansas Medical Center, Kansas, USA
| | - Winston Dunn
- Department of Gastroenterology and Hepatology, The University of Kansas Health System, Kansas, USA
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Haraldsdottir K, Brickson S, Sanfilippo J, Dunn W, Watson A. In-season changes in heart rate recovery are inversely related to time to exhaustion but not aerobic capacity in rowers. Scand J Med Sci Sports 2017. [PMID: 28649720 DOI: 10.1111/sms.12934] [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: 10/19/2022]
Abstract
To determine if in-season changes in heart rate recovery (HRR) are related to aerobic fitness and performance in collegiate rowers. Twenty-two female collegiate rowers completed testing before and after their competitive season. Body fat percentage (BF%) was determined by dual-energy X-ray absorptiometry. Maximal aerobic capacity (VO2max ) and time to exhaustion (Tmax ) were determined during maximal rowing ergometer testing followed by 1 minute of recovery. HRR was expressed absolutely and as a percentage of maximal HR (HRR%1 min ). Variables were compared using paired Wilcoxon tests. Multivariable regression models were used to predict in-season changes in HRR using changes in VO2max and Tmax , while accounting for changes in BF%. From preseason to post-season, VO2max and BF% decreased (3.98±0.42 vs 3.78±0.35 L/min, P=.002 and 23.8±3.4 vs 21.3±3.9%, P<.001, respectively), while Tmax increased (11.7±1.3 vs 12.6±1.3 min, P=.002), and HRR%1 min increased (11.1±2.7 vs 13.8±3.8, P=.001). In-season changes in VO2max were not associated with HRR%1 min (P>.05). In-season changes in Tmax were related to changes in HRR%1 min (β=-1.67, P=.006). In-season changes in BF% were not related to changes in HRR (P>.05 for all). HRR1 min and HRR%1 min were faster preseason to post-season, although the changes were unrelated to VO2max . Faster HRR%1 min post-season was inversely related to changes in Tmax . This suggests that HRR should not be used as a measure of aerobic capacity in collegiate rowers, but is a promising measure of training status in this population.
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Affiliation(s)
- K Haraldsdottir
- Department of Pediatrics, University of Wisconsin, Madison, WI, USA.,Department of Kinesiology, University of Wisconsin, Madison, WI, USA
| | - S Brickson
- Department of Orthopedics, University of Wisconsin, Madison, WI, USA
| | - J Sanfilippo
- Department of Orthopedics, University of Wisconsin, Madison, WI, USA
| | - W Dunn
- Department of Orthopedics, University of Wisconsin, Madison, WI, USA
| | - A Watson
- Department of Orthopedics, University of Wisconsin, Madison, WI, USA
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Little LM, Dean E, Tomchek SD, Dunn W. Classifying sensory profiles of children in the general population. Child Care Health Dev 2017; 43:81-88. [PMID: 27545764 DOI: 10.1111/cch.12391] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 07/09/2016] [Accepted: 07/10/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to subtype groups of children in a community sample with and without developmental conditions, based on sensory processing patterns. METHODS We used latent profile analysis to determine the number of sensory subtypes in a sample of n = 1132 children aged 3-14 years with typical development and developmental conditions, including autism spectrum disorder (ASD), attention-deficit hyperactivity disorder and learning disabilities. RESULTS A five-subtype solution was found to best characterize the sample, which differed on overall degree and differential presentation of sensory processing patterns. Children with and without developmental conditions presented across subtypes, and one subtype was significantly younger in age than others (P < 0.05). CONCLUSIONS Our results show that sensory subtypes include both children with typical development and those with developmental conditions. Sensory subtypes have previously been investigated in ASD only, and our results suggest that similar sensory subtypes are present in a sample reflective of the general population of children including those largely with typical development. Elevated scores on sensory processing patterns are not unique to ASD but rather are reflections of children's abilities to respond to environmental demands.
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Affiliation(s)
- L M Little
- Department of Occupational Therapy, University of Kansas Medical Center, Kansas City, KS, USA
| | - E Dean
- Department of Occupational Therapy, University of Kansas Medical Center, Kansas City, KS, USA
| | - S D Tomchek
- Department of Occupational Therapy, University of Kansas Medical Center, Kansas City, KS, USA.,Department of Pediatrics, University of Louisville, Weisskopf Child Evaluation Center, Louisville, KY, USA
| | - W Dunn
- Department of Occupational Therapy, University of Kansas Medical Center, Kansas City, KS, USA
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Abstract
Alcoholic liver disease includes a broad clinical-histological spectrum from simple steatosis, cirrhosis, acute alcoholic hepatitis with or without cirrhosis to hepatocellular carcinoma as a complication of cirrhosis. The pathogenesis of alcoholic liver disease can be conceptually divided into (1) ethanol-mediated liver injury, (2) inflammatory immune response to injury, (3) intestinal permeability and microbiome changes. Corticosteroids may improve outcomes, but this is controversial and probably only impacts short-term survival. New pathophysiology-based therapies are under study, including antibiotics, caspase inhibition, interleukin-22, anakinra, FXR agonist and others. These studies provide hope for better future outcomes for this difficult disease.
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Affiliation(s)
- Winston Dunn
- Gastroenterology & Hepatology, The University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS USA
| | - Vijay H. Shah
- Gastroenterology Research Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN USA
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Wu C, Dunn W. Is it worthy of switching to PegIFN alfa-2a in patients achieving virological suppression with entecavir? J Hepatol 2015; 62:1439-40. [PMID: 25703083 DOI: 10.1016/j.jhep.2015.01.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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] [Received: 10/16/2014] [Accepted: 01/11/2015] [Indexed: 01/08/2023]
Affiliation(s)
- Chuanghong Wu
- Department of Infectious Diseases, Shekou People's Hospital, Shenzhen, China.
| | - Winston Dunn
- Department of Infectious Diseases, Shekou People's Hospital, Shenzhen, China; Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, United States
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Velazquez ER, Narayan V, Grossmann P, Dunn W, Gutman D, Aerts H. TU-CD-BRB-04: Automated Radiomic Features Complement the Prognostic Value of VASARI in the TCGA-GBM Dataset. Med Phys 2015. [DOI: 10.1118/1.4925589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Rios Velazquez E, Meier R, Dunn W, Alexander B, Wiest R, Bauer S, Gutman D, Reyes M, Aerts H. TU-AB-BRA-11: Evaluation of Fully Automatic Volumetric GBM Segmentation in the TCGA-GBM Dataset: Prognosis and Correlation with VASARI Features. Med Phys 2015. [DOI: 10.1118/1.4925516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Dunn W, O'Neil M, Zhao J, Wu CH, Roberts B, Chakraborty S, Sherman C, Weaver B, Taylor R, Olson J, Olyaee M, Gilroy R, Schmitt T, Wan YJY, Weinman SA. Donor PNPLA3 rs738409 genotype affects fibrosis progression in liver transplantation for hepatitis C. Hepatology 2014; 59:453-60. [PMID: 24123231 PMCID: PMC7224311 DOI: 10.1002/hep.26758] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 08/12/2013] [Accepted: 09/17/2013] [Indexed: 12/18/2022]
Abstract
UNLABELLED The rs738409 G>C single nucleotide polymorphism occurring in the patatin-like phospholipase 3 gene has been identified as a novel genetic marker for hepatic steatosis. Recent studies also associated rs738409 with fibrosis in hepatitis C (HCV). Therefore, we sought to determine the impact of donor and recipient rs738409 genotype on the progression of fibrosis after liver transplantation for HCV. This cohort study included 101 patients infected with HCV who underwent liver transplantation between January 2008, and June 2011. Donor and recipient rs738409 genotypes were determined from donor wedge biopsies and recipient explants. The time to Ishak stage 3 fibrosis, or HCV-related mortality/graft loss was analyzed by the Cox model adjusting for HCV-Donor Risk Index, warm ischemic time, pretransplant Model for Endstage Liver Disease (MELD) and viral load. The rs738409 CC variant was present in 56% of donors and 57% of recipients. The median follow-up period was 620 days. A total of 39 patients developed the primary outcome of ≥stage 3 fibrosis or HCV-related mortality/graft loss, the time to which differed by donor (P = 0.019) but not recipient (P = 0.89) genotype. In the multivariate model, donor GC or GG variants had 2.53 times the risk (95% confidence interval [CI] 1.25-5.02, P = 0.008) compared to CC variants. In the alternative endpoint: stage 3 fibrosis or all-cause mortality/graft loss, the effect of donor genotype was attenuated but remained significant at 1.98 (95% CI 1.11-3.53). CONCLUSIONS The rs738409 genotype is an important predictor of posttransplant outcome in HCV. Liver, and not adipocytes, is the site at which this effect occurs. Our finding may be useful in donor selection for liver transplantation with HCV, and may guide decisions regarding early antiviral treatment.
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Affiliation(s)
- Winston Dunn
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Maura O'Neil
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Jie Zhao
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Chuang Hong Wu
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Benjamin Roberts
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Shweta Chakraborty
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Craig Sherman
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Brandy Weaver
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Ryan Taylor
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Jody Olson
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Mojtaba Olyaee
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Richard Gilroy
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Timothy Schmitt
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Yu-Jui Yvonne Wan
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
| | - Steven A. Weinman
- Department of Internal Medicine; University of Kansas Medical Center; Kansas City KS
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Adachi K, Sasaki H, Nagahisa S, Yoshida K, Hattori N, Nishiyama Y, Kawase T, Hasegawa M, Abe M, Hirose Y, Alentorn A, Marie Y, Poggioli S, Alshehhi H, Boisselier B, Carpentier C, Mokhtari K, Capelle L, Figarella-Branger D, Hoang-Xuan K, Sanson M, Delattre JY, Idbaih A, Yust-Katz S, Anderson M, Olar A, Eterovic A, Ezzeddine N, Chen K, Zhao H, Fuller G, Aldape K, de Groot J, Andor N, Harness J, Lopez SG, Fung TL, Mewes HW, Petritsch C, Arivazhagan A, Somasundaram K, Thennarasu K, Pandey P, Anandh B, Santosh V, Chandramouli B, Hegde A, Kondaiah P, Rao M, Bell R, Kang R, Hong C, Song J, Costello J, Bell R, Nagarajan R, Zhang B, Diaz A, Wang T, Song J, Costello J, Bie L, Li Y, Li Y, Liu H, Luyo WFC, Carnero MH, Iruegas MEP, Morell AR, Figueiras MC, Lopez RL, Valverde CF, Chan AKY, Pang JCS, Chung NYF, Li KKW, Poon WS, Chan DTM, Wang Y, Ng HAK, Chaumeil M, Larson P, Yoshihara H, Vigneron D, Nelson S, Pieper R, Phillips J, Ronen S, Clark V, Omay ZE, Serin A, Gunel J, Omay B, Grady C, Youngblood M, Bilguvar K, Baehring J, Piepmeier J, Gutin P, Vortmeyer A, Brennan C, Pamir MN, Kilic T, Krischek B, Simon M, Yasuno K, Gunel M, Cohen AL, Sato M, Aldape KD, Mason C, Diefes K, Heathcock L, Abegglen L, Shrieve D, Couldwell W, Schiffman JD, Colman H, D'Alessandris QG, Cenci T, Martini M, Ricci-Vitiani L, De Maria R, Larocca LM, Pallini R, de Groot J, Theeler B, Aldape K, Lang F, Rao G, Gilbert M, Sulman E, Luthra R, Eterovic K, Chen K, Routbort M, Verhaak R, Mills G, Mendelsohn J, Meric-Bernstam F, Yung A, MacArthur K, Hahn S, Kao G, Lustig R, Alonso-Basanta M, Chandrasekaran S, Wileyto EP, Reyes E, Dorsey J, Fujii K, Kurozumi K, Ichikawa T, Onishi M, Ishida J, Shimazu Y, Kaur B, Chiocca EA, Date I, Geisenberger C, Mock A, Warta R, Schwager C, Hartmann C, von Deimling A, Abdollahi A, Herold-Mende C, Gevaert O, Achrol A, Gholamin S, Mitra S, Westbroek E, Loya J, Mitchell L, Chang S, Steinberg G, Plevritis S, Cheshier S, Gevaert O, Mitchell L, Achrol A, Xu J, Steinberg G, Cheshier S, Napel S, Zaharchuk G, Plevritis S, Gevaert O, Achrol A, Chang S, Harsh G, Steinberg G, Cheshier S, Plevritis S, Gutman D, Holder C, Colen R, Dunn W, Jain R, Cooper L, Hwang S, Flanders A, Brat D, Hayes J, Droop A, Thygesen H, Boissinot M, Westhead D, Short S, Lawler S, Bady P, Kurscheid S, Delorenzi M, Hegi ME, Crosby C, Faulkner C, Smye-Rumsby T, Kurian K, Williams M, Hopkins K, Faulkner C, Palmer A, Williams H, Wragg C, Haynes HR, Williams M, Hopkins K, Kurian KM, Haynes HR, Crosby C, Williams H, White P, Hopkins K, Williams M, Kurian KM, Ishida J, Kurozumi K, Ichikawa T, Onishi M, Fujii K, Shimazu Y, Oka T, Date I, Jalbert L, Elkhaled A, Phillips J, Chang S, Nelson S, Jensen R, Salzman K, Schabel M, Gillespie D, Mumert M, Johnson B, Mazor T, Hong C, Barnes M, Yamamoto S, Ueda H, Tatsuno K, Aihara K, Jalbert L, Nelson S, Bollen A, Hirst M, Marra M, Mukasa A, Saito N, Aburatani H, Berger M, Chang S, Taylor B, Costello J, Popov S, Mackay A, Ingram W, Burford A, Jury A, Vinci M, Jones C, Jones DTW, Hovestadt V, Picelli S, Wang W, Northcott PA, Kool M, Reifenberger G, Pietsch T, Sultan M, Lehrach H, Yaspo ML, Borkhardt A, Landgraf P, Eils R, Korshunov A, Zapatka M, Radlwimmer B, Pfister SM, Lichter P, Joy A, Smirnov I, Reiser M, Shapiro W, Mills G, Kim S, Feuerstein B, Jungk C, Mock A, Geisenberger C, Warta R, Friauf S, Unterberg A, Herold-Mende C, Juratli TA, McElroy J, Meng W, Huebner A, Geiger KD, Krex D, Schackert G, Chakravarti A, Lautenschlaeger T, Kim BY, Jiang W, Beiko J, Prabhu S, DeMonte F, Lang F, Gilbert M, Aldape K, Sawaya R, Cahill D, McCutcheon I, Lau C, Wang L, Terashima K, Yamaguchi S, Burstein M, Sun J, Suzuki T, Nishikawa R, Nakamura H, Natsume A, Terasaka S, Ng HK, Muzny D, Gibbs R, Wheeler D, Lautenschlaeger T, Juratli TA, McElroy J, Meng W, Huebner A, Geiger KD, Krex D, Schackert G, Chakravarti A, Zhang XQ, Sun S, Lam KF, Kiang KMY, Pu JKS, Ho ASW, Leung GKK, Loebel F, Curry WT, Barker FG, Lelic N, Chi AS, Cahill DP, Lu D, Yin J, Teo C, McDonald K, Madhankumar A, Weston C, Slagle-Webb B, Sheehan J, Patel A, Glantz M, Connor J, Maire C, Francis J, Zhang CZ, Jung J, Manzo V, Adalsteinsson V, Homer H, Blumenstiel B, Pedamallu CS, Nickerson E, Ligon A, Love C, Meyerson M, Ligon K, Mazor T, Johnson B, Hong C, Barnes M, Jalbert LE, Nelson SJ, Bollen AW, Smirnov IV, Song JS, Olshen AB, Berger MS, Chang SM, Taylor BS, Costello JF, Mehta S, Armstrong B, Peng S, Bapat A, Berens M, Melendez B, Mollejo M, Mur P, Hernandez-Iglesias T, Fiano C, Ruiz J, Rey JA, Mock A, Stadler V, Schulte A, Lamszus K, Schichor C, Westphal M, Tonn JC, Unterberg A, Herold-Mende C, Morozova O, Katzman S, Grifford M, Salama S, Haussler D, Nagarajan R, Zhang B, Johnson B, Bell R, Olshen A, Fouse S, Diaz A, Smirnov I, Kang R, Wang T, Costello J, Nakamizo S, Sasayama T, Tanaka H, Tanaka K, Mizukawa K, Yoshida M, Kohmura E, Northcott P, Hovestadt V, Jones D, Kool M, Korshunov A, Lichter P, Pfister S, Otani R, Mukasa A, Takayanagi S, Saito K, Tanaka S, Shin M, Saito N, Ozawa T, Riester M, Cheng YK, Huse J, Helmy K, Charles N, Squatrito M, Michor F, Holland E, Perrech M, Dreher L, Rohn G, Goldbrunner R, Timmer M, Pollo B, Palumbo V, Calatozzolo C, Patane M, Nunziata R, Farinotti M, Silvani A, Lodrini S, Finocchiaro G, Lopez E, Rioscovian A, Ruiz R, Siordia G, de Leon AP, Rostomily C, Rostomily R, Silbergeld D, Kolstoe D, Chamberlain M, Silber J, Roth P, Keller A, Hoheisel J, Codo P, Bauer A, Backes C, Leidinger P, Meese E, Thiel E, Korfel A, Weller M, Saito K, Mukasa A, Nagae G, Nagane M, Aihara K, Takayanagi S, Tanaka S, Aburatani H, Saito N, Salama S, Sanborn JZ, Grifford M, Brennan C, Mikkelsen T, Jhanwar S, Chin L, Haussler D, Sasayama T, Tanaka K, Nakamizo S, Nishihara M, Tanaka H, Mizukawa K, Kohmura E, Schliesser M, Grimm C, Weiss E, Claus R, Weichenhan D, Weiler M, Hielscher T, Sahm F, Wiestler B, Klein AC, Blaes J, Weller M, Plass C, Wick W, Stragliotto G, Rahbar A, Soderberg-Naucler C, Sulman E, Won M, Ezhilarasan R, Sun P, Blumenthal D, Vogelbaum M, Colman H, Jenkins R, Chakravarti A, Jeraj R, Brown P, Jaeckle K, Schiff D, Dignam J, Atkins J, Brachman D, Werner-Wasik M, Gilbert M, Mehta M, Aldape K, Terashima K, Shen J, Luan J, Yu A, Suzuki T, Nishikawa R, Matsutani M, Liang Y, Man TK, Lau C, Trister A, Tokita M, Mikheeva S, Mikheev A, Friend S, Rostomily R, van den Bent M, Erdem L, Gorlia T, Taphoorn M, Kros J, Wesseling P, Dubbink H, Ibdaih A, Sanson M, French P, van Thuijl H, Mazor T, Johnson B, Fouse S, Heimans J, Wesseling P, Ylstra B, Reijneveld J, Taylor B, Berger M, Chang S, Costello J, Prabowo A, van Thuijl H, Scheinin I, van Essen H, Spliet W, Ferrier C, van Rijen P, Veersema T, Thom M, Meeteren ASV, Reijneveld J, Ylstra B, Wesseling P, Aronica E, Kim H, Zheng S, Mikkelsen T, Brat DJ, Virk S, Amini S, Sougnez C, Chin L, Barnholtz-Sloan J, Verhaak RGW, Watts C, Sottoriva A, Spiteri I, Piccirillo S, Touloumis A, Collins P, Marioni J, Curtis C, Tavare S, Weiss E, Grimm C, Schliesser M, Hielscher T, Claus R, Sahm F, Wiestler B, Klein AC, Blaes J, Tews B, Weiler M, Weichenhan D, Hartmann C, Weller M, Plass C, Wick W, Yeung TPC, Al-Khazraji B, Morrison L, Hoffman L, Jackson D, Lee TY, Yartsev S, Bauman G, Zheng S, Fu J, Vegesna R, Mao Y, Heathcock LE, Torres-Garcia W, Ezhilarasan R, Wang S, McKenna A, Chin L, Brennan CW, Yung WKA, Weinstein JN, Aldape KD, Sulman EP, Chen K, Koul D, Verhaak RGW. OMICS AND PROGNSTIC MARKERS. Neuro Oncol 2013; 15:iii136-iii155. [PMCID: PMC3823898 DOI: 10.1093/neuonc/not183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023] Open
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Bi L, Chiang JYL, Ding WX, Dunn W, Roberts B, Li T. Saturated fatty acids activate ERK signaling to downregulate hepatic sortilin 1 in obese and diabetic mice. J Lipid Res 2013; 54:2754-62. [PMID: 23904453 DOI: 10.1194/jlr.m039347] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [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: 12/20/2022] Open
Abstract
Hepatic VLDL overproduction is a characteristic feature of diabetes and an important contributor to diabetic dyslipidemia. Hepatic sortilin 1 (Sort1), a cellular trafficking receptor, is a novel regulator of plasma lipid metabolism and reduces plasma cholesterol and triglycerides by inhibiting hepatic apolipoprotein B production. Elevated circulating free fatty acids play key roles in hepatic VLDL overproduction and the development of dyslipidemia. This study investigated the regulation of hepatic Sort1 in obesity and diabetes and the potential implications in diabetic dyslipidemia. Results showed that hepatic Sort1 protein was markedly decreased in mouse models of type I and type II diabetes and in human individuals with obesity and liver steatosis, whereas increasing hepatic Sort1 expression reduced plasma cholesterol and triglycerides in mice. Mechanistic studies showed that the saturated fatty acid palmitate activated extracellular signal-regulated kinase (ERK) and inhibited Sort1 protein by mechanisms involving Sort1 protein ubiquitination and degradation. Consistently, hepatic ERK signaling was activated in diabetic mice, whereas blocking ERK signaling by an ERK inhibitor increased hepatic Sort1 protein in mice. These results suggest that increased saturated fatty acids downregulate liver Sort1 protein, which may contribute to the development of dyslipidemia in obesity and diabetes.
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Affiliation(s)
- Lipeng Bi
- Department of Pharmacology, Toxicology, and Therapeutics and Liver Center, University of Kansas Medical Center, Kansas City, KS 66160; and
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Dunn W, Zeng Z, O'Neil M, Zhao J, Whitener M, Yu-Jui Wan Y, Mitchell EK, Handler M, Weinman SA. The interaction of rs738409, obesity, and alcohol: a population-based autopsy study. Am J Gastroenterol 2012; 107:1668-74. [PMID: 23032985 PMCID: PMC6677545 DOI: 10.1038/ajg.2012.285] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [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 The objective of this study was to access the prevalence of alcoholic liver disease (ALD) and nonalcoholic fatty liver disease (NAFLD) histology in the general population, which had been otherwise difficult to access because of inherent misclassification bias in surrogate marker studies and referral bias in patient case series. The interaction among rs738409, obesity, and alcohol remains controversial. This population-based autopsy study investigated the histological prevalence of ALD and NAFLD, and interactions among rs738409, obesity, and alcoholism. METHODS A total of 170 alcoholic and 235 nonalcoholic cases were selected from 1,034 adult car accident autopsies in 17 Kansas and Missouri counties from 2000 to 2010. The nonalcoholic group had undetectable blood alcohol concentration, while the alcoholic group had a blood alcohol concentration ≥0.08%. RESULTS The age-standardized prevalences of hepatic steatosis, steatohepatitis, and advanced fibrosis were 56, 6, and 18% among alcoholics and 36, 4, and 6% in nonalcoholics, respectively. The interaction terms among alcohol, body mass index (BMI), and genotype were not significant. rs738409 GC or GG genotype was associated with 1.9-fold odds (95% confidence interval (CI), 1.2-2.9) of a higher NAFLD Activity Score (NAS). Alcohol had 3.5-fold odds (95% CI, 2.0-5.9), while every 5-unit increase in BMI had 1.9-fold odds (95% CI, 1.7-2.5). A negative interaction between alcohol and BMI towards fibrosis had been observed (P=0.045). Every 5-unit increase in BMI had 2.2-fold odds (95% CI, 1.5-2.5) of fibrosis among nonalcoholics, but not in alcoholics. CONCLUSIONS This study assessed the prevalence of fatty liver histology in the general population from an autopsy study perspective. The finding of an additive interaction among rs738409, obesity, and alcohol towards NAS may be useful in targeting preventative care to patients at highest risk for ALD. The negative interaction between alcohol and obesity towards fibrosis supported previous findings and suggests the need for future research to explore potential mechanisms that may improve treatment of nonalcoholic steatohepatitis-related fibrosis.
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Affiliation(s)
- Winston Dunn
- Division of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas 66160, USA.
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Dunn W, Sanyal AJ, Brunt EM, Unalp-Arida A, Donohue M, McCullough AJ, Schwimmer JB. Modest alcohol consumption is associated with decreased prevalence of steatohepatitis in patients with non-alcoholic fatty liver disease (NAFLD). J Hepatol 2012; 57:384-91. [PMID: 22521357 PMCID: PMC3399018 DOI: 10.1016/j.jhep.2012.03.024] [Citation(s) in RCA: 183] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 03/08/2012] [Accepted: 03/12/2012] [Indexed: 12/25/2022]
Abstract
BACKGROUND & AIMS Non-alcoholic fatty liver disease (NAFLD) is a cardiovascular risk factor. Although modest alcohol consumption may reduce the risk for cardiovascular mortality, whether patients with NAFLD should be allowed modest alcohol consumption remains an important unaddressed issue. We aimed to evaluate the association between modest alcohol drinking and non-alcoholic steatohepatitis (NASH), among subjects with NAFLD. METHODS In a cross-sectional analysis of adult participants in the NIH NASH Clinical Research Network, only modest or non-drinkers were included: participants identified as (1) drinking >20 g/day, (2) binge drinkers, or (3) non-drinkers with previous alcohol consumption were excluded. The odds of having a histological diagnosis of NASH and other histological features of NAFLD were analyzed using multiple ordinal logistic regression. RESULTS The analysis included 251 lifetime non-drinkers and 331 modest drinkers. Modest drinkers compared to non-drinkers had lower odds of having a diagnosis of NASH (summary odds ratio 0.56, 95% CI 0.39-0.84, p=0.002). The odds of NASH decreased as the frequency of alcohol consumption increased within the range of modest consumption. Modest drinkers also had significantly lower odds for fibrosis (OR 0.56 95% CI 0.41-0.77) and ballooning hepatocellular injury (OR 0.66 95% CI 0.48-0.92) than lifetime non-drinkers. CONCLUSIONS In a large, well-characterized population with biopsy-proven NAFLD, modest alcohol consumption was associated with lesser degree of severity as determined by lower odds of the key features that comprise a diagnosis of steatohepatitis, as well as fibrosis. These findings demonstrate the need for prospective studies and a coordinated consensus on alcohol consumption recommendations in NAFLD.
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Affiliation(s)
- Winston Dunn
- Departments of Pediatrics and Medicine, University of California, San Diego, La Jolla, CA,Gastroenterology and Hepatology, Department of Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Arun J. Sanyal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, VA
| | - Elizabeth M. Brunt
- John Cochran VA Medical Center, Saint Louis and Division of Gastroenterology, Saint Louis University School of Medicine, Saint Louis, MO
| | - Aynur Unalp-Arida
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Michael Donohue
- Division of Biostatics and Bioinformatics, Department of Family and Preventive Medicine, University of California, San Diego, La Jolla, CA
| | | | - Jeffrey B. Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics University of California, San Diego, CA,Department of Gastroenterology, Rady Children’s Hospital, San Diego, CA
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Ebah L, Oveland E, Read I, Summers A, Nikam M, Sayce A, Chaloner C, Dunn W, Wiig H, Brenchley P, Mitra S, Lindley E, Keane D, Charlie B, Jill H, Linda J, Jayne O, Elizabeth G, Perez de Jose A, Abad Esttebanez S, Verdalles Guzman U, Vega Martinez A, Bucalo Mana L, Rincon Bello A, Barraca D, Yuste Lozano C, Lopez-Gomez JM, Mancini E, Bolasco P, Severi S, Corazza L, Santoro A, Agar B, Leypoldt K, Akonur A, Hutchcraft A, Culleton B. Dialysis techniques and adequacy. Nephrol Dial Transplant 2012. [DOI: 10.1093/ndt/gfs200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in children. Liver disease can be a cause of low bone mineral density. Whether or not NAFLD influences bone health is not known. AIM To evaluate bone mineral density in obese children with and without NAFLD. METHODS Thirty-eight children with biopsy-proven NAFLD were matched for age, gender, race, ethnicity, height and weight to children without evidence of liver disease from the National Health and Nutrition Examination Survey. Bone mineral density was measured by dual energy X-ray absorptiometry. Age and gender-specific bone mineral density Z-scores were calculated and compared between children with and without NAFLD. After controlling for age, gender, race, ethnicity and total per cent body fat, the relationship between bone mineral density and the severity of histology was analysed in children with NAFLD. RESULTS Obese children with NAFLD had significantly (P < 0.0001) lower bone mineral density Z-scores (-1.98) than obese children without NAFLD (0.48). Forty-five per cent of children with NAFLD had low-bone mineral density for age, compared to none of the children without NAFLD (P < 0.0001). Among those children with NAFLD, children with NASH had a significantly (P < 0.05) lower bone mineral density Z-score (-2.37) than children with NAFLD who did not have NASH (-1.58). CONCLUSIONS The NAFLD was associated with poor bone health in obese children. More severe disease was associated with lower bone mineralisation. Further studies are needed to evaluate the underlying mechanisms and consequences of poor bone mineralisation in children with NAFLD.
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Affiliation(s)
- Perrie E. Pardee
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego, San Diego, California,Department of Medicine, University of California, San Diego, La Jolla, California
| | - Winston Dunn
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Kansas Medical Center, San Diego, California
| | - Jeffrey B. Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego, San Diego, California,Department of Gastroenterology, Rady Children’s Hospital San Diego, San Diego, California,Liver Imaging Group, Department of Radiology, University of California, San Diego, San Diego, California
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Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in children. Liver disease can be a cause of low bone mineral density. Whether or not NAFLD influences bone health is not known. AIM To evaluate bone mineral density in obese children with and without NAFLD. METHODS Thirty-eight children with biopsy-proven NAFLD were matched for age, gender, race, ethnicity, height and weight to children without evidence of liver disease from the National Health and Nutrition Examination Survey. Bone mineral density was measured by dual energy X-ray absorptiometry. Age and gender-specific bone mineral density Z-scores were calculated and compared between children with and without NAFLD. After controlling for age, gender, race, ethnicity and total per cent body fat, the relationship between bone mineral density and the severity of histology was analysed in children with NAFLD. RESULTS Obese children with NAFLD had significantly (P < 0.0001) lower bone mineral density Z-scores (-1.98) than obese children without NAFLD (0.48). Forty-five per cent of children with NAFLD had low-bone mineral density for age, compared to none of the children without NAFLD (P < 0.0001). Among those children with NAFLD, children with NASH had a significantly (P < 0.05) lower bone mineral density Z-score (-2.37) than children with NAFLD who did not have NASH (-1.58). CONCLUSIONS The NAFLD was associated with poor bone health in obese children. More severe disease was associated with lower bone mineralisation. Further studies are needed to evaluate the underlying mechanisms and consequences of poor bone mineralisation in children with NAFLD.
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Affiliation(s)
- P E Pardee
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego, 92123, USA
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Harvie M, Wright C, Pegington M, Mitchell E, Evans DG, Jebb S, Clarke R, Goodacre R, Dunn W, Mattson M, Howell A. P3-09-02: Intermittent Dietary Carbohydrate Restriction Enables Weight Loss and Reduces Breast Cancer Risk Biomarkers. Cancer Res 2011. [DOI: 10.1158/0008-5472.sabcs11-p3-09-02] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Energy restriction is a potential strategy for breast cancer prevention but is difficult to achieve and maintain. We found that intermittent energy restriction (2 days strict dieting week) is comparable to the standard approach of moderate daily restriction for weight loss and marginally better for improving insulin sensitivity, but no easier to follow1. In this follow on study we wished to test whether 2 novel intermittent low carbohydrate/low energy diets were feasible and easier to follow than a standard daily energy restriction. Design: Randomised comparison of 3 dietary types over 4 months in 115 overweight or obese (mean body mass index 31.0 [±5.3 SD] kg/m2) women at increased risk of breast cancer (lifetime risk > 1 in 6).
Diets:
1. A restricted low carbohydrate diet (RLCD): 650 kcal and <50g carbohydrate / day for 2 days per week
2. Ad lib low carbohydrate diet (ALCD): <50g / day for 2 days per week with other food types (e.g. protein) ad lib
3. A standard daily restricted Mediterranean diet (DRMD): ∼ 1500kcal/day for 7 days per week
Methods: Weight, anthropometrics, blood markers for breast cancer; insulin resistance, oxidative stress markers, leptin, adiponectin, lipids, inflammatory markers IGF-1 were assessed at baseline, 1, 3 and 4 months.
Results: 88/114 completed the study (77%, drop outs 6 RLCD, 8 ALCD 12 DRMD). Last observation carried forward analyses show both intermittent low carbohydrate diets were superior to standard daily restriction for reducing weight and body fat: mean (95% confidence interval [CI]) change in body fat for RLCD was −4.3 (−5.6 to −3.0) kg, for ALCD −4.1 (−5.2 to −3.1) kg vs. −2.4 (−3.4 to −1.2) kg for DRMD (P value for difference between groups = 0.02). The intermittent groups had greater improvement in insulin resistance: mean (95% CI) change for RLCD was −22 (−35 to −11) %, ALCD −14 (−27 to −5%) % vs. −4 (−16 to 9) % for DRMD (P = 0.02). Other biomarkers are being assayed currently.
Conclusion: Greater weight loss, fewer drop outs and greater reductions in insulin resistance with the novel intermittent low carbohydrate diets indicate that these are alternative approaches for energy restriction for potentially reducing risk of breast cancer and other diseases.
Reference:
1Harvie MN, Pegington M, Mattson MP, Frystyk J, Dillon B, Evans G et al. The effects of intermittent or continuous energy restriction on weight loss and metabolic disease risk markers: a randomized trial in young overweight women. Int.J Obes (Lond) 35; 714–27, 2011. This study is funded by the Genesis Breast Cancer Prevention Appeal: www.genesisuk.org
Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-09-02.
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Affiliation(s)
- M Harvie
- 1University Hospital of South Manchester, Manchester, United Kingdom; MRC Human Nutrition Research Group, Cambridge, United Kingdom; University of Manchester, Manchester, United Kingdom; National Institute of Aging, Baltimore
| | - C Wright
- 1University Hospital of South Manchester, Manchester, United Kingdom; MRC Human Nutrition Research Group, Cambridge, United Kingdom; University of Manchester, Manchester, United Kingdom; National Institute of Aging, Baltimore
| | - M Pegington
- 1University Hospital of South Manchester, Manchester, United Kingdom; MRC Human Nutrition Research Group, Cambridge, United Kingdom; University of Manchester, Manchester, United Kingdom; National Institute of Aging, Baltimore
| | - E Mitchell
- 1University Hospital of South Manchester, Manchester, United Kingdom; MRC Human Nutrition Research Group, Cambridge, United Kingdom; University of Manchester, Manchester, United Kingdom; National Institute of Aging, Baltimore
| | - DG Evans
- 1University Hospital of South Manchester, Manchester, United Kingdom; MRC Human Nutrition Research Group, Cambridge, United Kingdom; University of Manchester, Manchester, United Kingdom; National Institute of Aging, Baltimore
| | - S Jebb
- 1University Hospital of South Manchester, Manchester, United Kingdom; MRC Human Nutrition Research Group, Cambridge, United Kingdom; University of Manchester, Manchester, United Kingdom; National Institute of Aging, Baltimore
| | - R Clarke
- 1University Hospital of South Manchester, Manchester, United Kingdom; MRC Human Nutrition Research Group, Cambridge, United Kingdom; University of Manchester, Manchester, United Kingdom; National Institute of Aging, Baltimore
| | - R Goodacre
- 1University Hospital of South Manchester, Manchester, United Kingdom; MRC Human Nutrition Research Group, Cambridge, United Kingdom; University of Manchester, Manchester, United Kingdom; National Institute of Aging, Baltimore
| | - W Dunn
- 1University Hospital of South Manchester, Manchester, United Kingdom; MRC Human Nutrition Research Group, Cambridge, United Kingdom; University of Manchester, Manchester, United Kingdom; National Institute of Aging, Baltimore
| | - M Mattson
- 1University Hospital of South Manchester, Manchester, United Kingdom; MRC Human Nutrition Research Group, Cambridge, United Kingdom; University of Manchester, Manchester, United Kingdom; National Institute of Aging, Baltimore
| | - A Howell
- 1University Hospital of South Manchester, Manchester, United Kingdom; MRC Human Nutrition Research Group, Cambridge, United Kingdom; University of Manchester, Manchester, United Kingdom; National Institute of Aging, Baltimore
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Abstract
OBJECTIVE To compare the Model for End-Stage Liver Disease (MELD) with the modified model including sodium (MELDNa) for predicting 180-day mortality in patients with alcoholic hepatitis (AH) and determine the subset in whom serum sodium may enhance 180-day mortality prediction. PATIENTS AND METHODS We examined 26 patients with AH enrolled in a prospective trial between June 1, 2004, and June 30, 2007, at Mayo Clinic. Logistic regression analysis was done to assess the effect of MELD and MELDNa scores on 180-day mortality. The C statistic was derived to compare MELD with MELDNa in patients with and without ascites. RESULTS MELD (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.05-1.47; P = .007; C statistic, 0.81) and MELDNa (OR, 1.24; 95% CI, 1.05-1.56; P = .008; C statistic, 0.78) were significant predictors of 180-day mortality in patients with AH. A MELD score of 27.0 and a MELDNa score of 28.0 had sensitivity of 76.5% and 87.5% and specificity of 64.9% and 52.5%, respectively. In patients with AH and ascites, MELDNa (OR, 2.27; 95% CI, 1.22-36.68; P = .008; C statistic, 0.97) was a better predictor of 180-day mortality than MELD (OR, 1.37; 95% CI, 1.07-2.12; P = .006; C statistic, 0.90). A MELD score of 29.0 and a MELDNa score of 34.0 had sensitivity of 85.7% and 83.3% and specificity of 31.0% and 16.7%, respectively. CONCLUSION MELD and MELDNa were similar predictors of 180-day mortality; however, MELDNa was a better predictor of mortality than MELD in patients with ascites. Hyponatremia in patients with AH without ascites is not a predictor of mortality because it may have a dilutional basis secondary to excessive intake of low-osmolar alcohol.
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Affiliation(s)
| | | | | | | | - Vijay H. Shah
- Individual reprints of this article are not available. Address correspondence to Vijay H. Shah, MD, Gastroenterology Research Unit and Advanced Liver Disease Study Group, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ()
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Schwimmer JB, Dunn W, Norman GJ, Pardee PE, Middleton MS, Kerkar N, Sirlin CB. SAFETY study: alanine aminotransferase cutoff values are set too high for reliable detection of pediatric chronic liver disease. Gastroenterology 2010; 138:1357-64, 1364.e1-2. [PMID: 20064512 PMCID: PMC2846968 DOI: 10.1053/j.gastro.2009.12.052] [Citation(s) in RCA: 318] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Revised: 12/14/2009] [Accepted: 01/04/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS The appropriate alanine aminotransferase (ALT) threshold value to use for diagnosis of chronic liver disease in children is unknown. We sought to develop gender-specific, biology-based, pediatric ALT thresholds. METHODS The Screening ALT for Elevation in Today's Youth (SAFETY) study collected observational data from acute care children's hospitals, the National Health and Nutrition Examination Survey (NHANES, 1999-2006), overweight children with and without non-alcoholic fatty liver disease (NAFLD), and children with chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infections. The study compared the sensitivity and specificity of ALT thresholds currently used by children's hospitals vs study-derived, gender-specific, biology-based, ALT thresholds for detecting children with NAFLD, HCV, or HBV. RESULTS The median upper limit of ALT at children's hospitals was 53 U/L (range, 30-90 U/L). The 95th percentile levels for ALT in healthy weight, metabolically normal, liver disease-free, NHANES pediatric participants were 25.8 U/L (boys) and 22.1 U/L (girls). The concordance statistics of these NHANES-derived thresholds for liver disease detection were 0.85 (95% confidence interval [CI]: 0.74-0.96) in boys and 0.91 (95% CI: 0.83-0.99) in girls for NAFLD, 0.80 (95% CI: 0.70-0.91) in boys and 0.79 (95% CI: 0.69-0.89) in girls for HBV, and 0.86 (95% CI: 0.77-0.95) in boys and 0.84 (95% CI: 0.75-0.93) in girls for HCV. Using current children's hospitals ALT thresholds, the median sensitivity for detection of NAFLD, HBV, and HCV ranged from 32% to 48%; median specificity was 92% (boys) and 96% (girls). Using NHANES-derived thresholds, the sensitivities were 72% (boys) and 82% (girls); specificities were 79% (boys) and 85% (girls). CONCLUSIONS The upper limit of ALT used in children's hospitals varies widely and is set too high to reliably detect chronic liver disease. Biology-based thresholds provide higher sensitivity and only slightly less specificity. Clinical guidelines for use of screening ALT and exclusion criteria for clinical trials should be modified.
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Affiliation(s)
- Jeffrey B. Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, California
,Department of Gastroenterology, Rady Children’s Hospital San Diego, San Diego, California
,Liver Imaging Group, Department of Radiology, University of California, San Diego School of Medicine, San Diego, California
| | - Winston Dunn
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Gregory J. Norman
- Department of Family and Preventive Medicine, University of California, San Diego, La Jolla, California
| | - Perrie E. Pardee
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego School of Medicine, San Diego, California
| | - Michael S. Middleton
- Liver Imaging Group, Department of Radiology, University of California, San Diego School of Medicine, San Diego, California
| | - Nanda Kerkar
- Department of Pediatrics, Division of Pediatric Hepatology, Mount Sinai School of Medicine, New York, New York
,Recanati Miller Transplant Institute, Department of Surgery, Mount Sinai School of Medicine, New York, New York
| | - Claude B. Sirlin
- Liver Imaging Group, Department of Radiology, University of California, San Diego School of Medicine, San Diego, California
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Dunn W, Xu R, Wingard DL, Rogers C, Angulo P, Younossi ZM, Schwimmer JB. Suspected nonalcoholic fatty liver disease and mortality risk in a population-based cohort study. Am J Gastroenterol 2008. [PMID: 18684196 DOI: 10.1111/j.1572-0241.2008.02034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Case series suggest that nonalcoholic fatty liver disease (NAFLD) is associated with increased all-cause and cardiovascular mortality. The current study compared the survival of subjects with and without suspected NAFLD in a population-based cohort, and placed the finding in the context of previously published case series. METHODS Primary analysis assessed mortality for NHANES-III participants with and without suspected NAFLD using the National Death Index. Suspected NAFLD was based upon unexplained ALT elevation. The Olmsted County and Cleveland Clinic case series were also used for comparison. Survivals were compared using Proportional Hazards Model and direct age standardization. RESULTS The NHANES cohort included 980 with and 6,594 subjects without suspected NAFLD. Over a mean of 8.7 yr, suspected NAFLD had a hazards ratio of 1.37 (95% CI 0.98-1.91) for all-cause mortality. In the 45-54 age group, suspected NAFLD had significantly higher all-cause (4.40 95% CI 1.27-13.23) and cardiovascular mortality (8.15, 95% CI 2.00-33.20) after adjusting for conventional cardiovascular risk factors. The age-standardized rate per 10,000 per year was 129 (95% CI 118-140) for the NHANES non-NAFLD cohort, 154 (95% CI 116-198) for the NHANES suspected NAFLD cohort, 214 (95% CI 157-279) for the Olmsted County series, and 426 (95% CI 298-573) for the Cleveland Clinic series. CONCLUSION The magnitude of mortality risk in NAFLD depends on the setting and method of ascertainment. Suspected NAFLD in the 45-54 age group is a strong independent risk factor for cardiovascular death and warrants further cardiovascular risk management guidelines.
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Affiliation(s)
- Winston Dunn
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California, USA
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Dunn W, Xu R, Wingard DL, Rogers C, Angulo P, Younossi ZM, Schwimmer JB. Suspected nonalcoholic fatty liver disease and mortality risk in a population-based cohort study. Am J Gastroenterol 2008; 103:2263-71. [PMID: 18684196 PMCID: PMC2574666 DOI: 10.1111/j.1572-0241.2008.02034.x] [Citation(s) in RCA: 235] [Impact Index Per Article: 14.7] [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: 12/11/2022]
Abstract
OBJECTIVE Case series suggest that nonalcoholic fatty liver disease (NAFLD) is associated with increased all-cause and cardiovascular mortality. The current study compared the survival of subjects with and without suspected NAFLD in a population-based cohort, and placed the finding in the context of previously published case series. METHODS Primary analysis assessed mortality for NHANES-III participants with and without suspected NAFLD using the National Death Index. Suspected NAFLD was based upon unexplained ALT elevation. The Olmsted County and Cleveland Clinic case series were also used for comparison. Survivals were compared using Proportional Hazards Model and direct age standardization. RESULTS The NHANES cohort included 980 with and 6,594 subjects without suspected NAFLD. Over a mean of 8.7 yr, suspected NAFLD had a hazards ratio of 1.37 (95% CI 0.98-1.91) for all-cause mortality. In the 45-54 age group, suspected NAFLD had significantly higher all-cause (4.40 95% CI 1.27-13.23) and cardiovascular mortality (8.15, 95% CI 2.00-33.20) after adjusting for conventional cardiovascular risk factors. The age-standardized rate per 10,000 per year was 129 (95% CI 118-140) for the NHANES non-NAFLD cohort, 154 (95% CI 116-198) for the NHANES suspected NAFLD cohort, 214 (95% CI 157-279) for the Olmsted County series, and 426 (95% CI 298-573) for the Cleveland Clinic series. CONCLUSION The magnitude of mortality risk in NAFLD depends on the setting and method of ascertainment. Suspected NAFLD in the 45-54 age group is a strong independent risk factor for cardiovascular death and warrants further cardiovascular risk management guidelines.
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Affiliation(s)
- Winston Dunn
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Ronghui Xu
- Department of Family and Preventive Medicine and Department of Mathematics, University of California, San Diego, La Jolla, California
| | - Deborah L. Wingard
- Department of Family and Preventive Medicine, University of California, San Diego, La Jolla, California
| | | | - Paul Angulo
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Zobair M. Younossi
- Center for Liver Diseases at Inova Fairfax Hospital, Inova Health System, Falls Church, Virginia
| | - Jeffrey B. Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego, San Diego, California
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Abstract
UNLABELLED People at risk for coronary heart disease are often at risk for nonalcoholic fatty liver disease (NAFLD). The association of modest wine consumption with NAFLD has not been studied and the recommendation of wine for patients at risk for both diseases is controversial. The aim is to test the hypothesis that modest wine consumption is associated with decreased prevalence of NAFLD. We included Third National Health and Nutrition Examination Survey participants who either reported no alcohol consumption or preferentially drinking wine with total alcohol consumption up to 10 g per day. Suspected NAFLD was based on unexplained serum alanine aminotransferase (ALT) elevation over the cut point of the reference laboratory (ALT > 43) and the cut point based on the 95th percentile of healthy subjects (ALT > 30 for men; ALT > 19 for women). Multivariate analysis was adjusted for age, gender, race, neighborhood, income, education, caffeine intake, and physical activity. A total of 7,211 nondrinkers and 945 modest wine drinkers comprised the study sample. Based on the reference laboratory cut point, suspected NAFLD was observed in 3.2% of nondrinkers and 0.4% of modest wine drinkers. The adjusted odds ratio was 0.15 (95% confidence interval, 0.05-0.49). Using the healthy subject cut point, suspected NAFLD was observed in 14.3% of nondrinkers and 8.6% of wine drinkers. The adjusted odds ratio was 0.51 (95% confidence interval, 0.33-0.79). CONCLUSION Modest wine consumption is associated with reduced prevalence of suspected NAFLD. The current study supports the safety of one glass of wine per day for cardioprotection in patients at risk for both coronary heart disease and NAFLD.
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Affiliation(s)
- Winston Dunn
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, San Diego, CA
| | - Ronghui Xu
- Department of Family and Preventive Medicine and Department of Mathematics, University of California, San Diego, San Diego, CA
| | - Jeffrey B. Schwimmer
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego, San Diego, CA
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Abstract
Childhood obesity is a worldwide health problem associated with an increase in the prevalence and severity of nonalcoholic fatty liver disease (NAFLD). This review covers the progress made between 2005 and 2007 in understanding the epidemiology, histology, and treatment of pediatric NAFLD. The number of children with NAFLD presents a major public health crisis. Noninvasive diagnostic tools offer future promise, but currently are unable to grade and stage disease. Therefore, pediatric NAFLD remains a clinico-pathological diagnosis requiring direct demonstration of liver steatosis and the exclusion of other causes of fatty liver and/or hepatitis. There are currently no proven therapies for NAFLD in children; however, TONIC (Treatment of Nonalcoholic Fatty Liver Disease in Children), the first multicenter clinical trial of pediatric NAFLD, is currently in progress. Such studies are imperative to address fundamental questions regarding cause and cure.
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Affiliation(s)
- Winston Dunn
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego Medical Center, 200 West Arbor Drive, San Diego, CA 92103, USA
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Murphy JG, Cremonini F, Kane GC, Dunn W. Is simulation based medicine training the future of clinical medicine? Eur Rev Med Pharmacol Sci 2007; 11:1-8. [PMID: 17405343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
The training of physician in the art and science of clinical medicine presents several challenges that are well suited to simulation based medical education (SBME). Modern patient centered medical education seeks to provide comprehensive "hands-on" clinical exposure for physicians in training, while simultaneously providing maximum individual patient comfort and safety. The ethical conundrum is obvious: direct patient contact is needed in order to educate the best clinical physicians and surgeons, but patients have an expectation to be treated and have surgery performed only by highly trained healthcare personnel. This is the kernel of the "medical educators dilemma". Simulation based medical education can partially solve "the medical educators dilemma" by providing realistic medical education in a safe, error tolerant environment with convenience and advantages over conventional "bedside" training but is it real medicine or make believe!
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Affiliation(s)
- J G Murphy
- Mayo Multidisciplinary Simulation Center, Mayo Clinic College of Medicine, Rochester, MN, USA.
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