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Duseja A, Singh S, De A, Madan K, Rao PN, Shukla A, Choudhuri G, Saigal S, Shalimar, Arora A, Anand AC, Das A, Kumar A, Eapen CE, Devadas K, Shenoy KT, Panigrahi M, Wadhawan M, Rathi M, Kumar M, Choudhary NS, Saraf N, Nath P, Kar S, Alam S, Shah S, Nijhawan S, Acharya SK, Aggarwal V, Saraswat VA, Chawla YK. Indian National Association for Study of the Liver (INASL) Guidance Paper on Nomenclature, Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease (NAFLD). J Clin Exp Hepatol 2023; 13:273-302. [PMID: 36950481 PMCID: PMC10025685 DOI: 10.1016/j.jceh.2022.11.014] [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: 03/24/2022] [Revised: 11/16/2022] [Accepted: 11/29/2022] [Indexed: 03/24/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a major cause of chronic liver disease globally and in India. The already high burden of NAFLD in India is expected to further increase in the future in parallel with the ongoing epidemics of obesity and type 2 diabetes mellitus. Given the high prevalence of NAFLD in the community, it is crucial to identify those at risk of progressive liver disease to streamline referral and guide proper management. Existing guidelines on NAFLD by various international societies fail to capture the entire landscape of NAFLD in India and are often difficult to incorporate in clinical practice due to fundamental differences in sociocultural aspects and health infrastructure available in India. A lot of progress has been made in the field of NAFLD in the 7 years since the initial position paper by the Indian National Association for the Study of Liver on NAFLD in 2015. Further, the ongoing debate on the nomenclature of NAFLD is creating undue confusion among clinical practitioners. The ensuing comprehensive review provides consensus-based, guidance statements on the nomenclature, diagnosis, and treatment of NAFLD that are practically implementable in the Indian setting.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- ALD, alcohol-associated liver disease
- ALT, alanine aminotransferase
- APRI, AST-platelet ratio index
- AST, aspartate aminotransferase
- BMI, body mass index
- CAP, controlled attenuation parameter
- CHB, chronic Hepatitis B
- CHC, chronic Hepatitis C
- CK-18, Cytokeratin-18
- CKD, chronic kidney disease
- CRN, Clinical Research Network
- CVD, cardiovascular disease
- DAFLD/DASH, dual etiology fatty liver disease or steatohepatitis
- EBMT, endoscopic bariatric metabolic therapy
- ELF, enhanced liver fibrosis
- FAST, FibroScan-AST
- FIB-4, fibrosis-4
- FLIP, fatty liver inhibition of progression
- FXR, farnesoid X receptor
- GLP-1, glucagon-like peptide-1
- HCC, hepatocellular carcinoma
- INASL, Indian National Association for Study of the Liver
- LAI, liver attenuation index
- LSM, liver stiffness measurement
- MAFLD
- MAFLD, metabolic dysfunction-associated fatty liver disease
- MR-PDFF, magnetic resonance – proton density fat fraction
- MRE, magnetic resonance elastography
- MetS, metabolic syndrome
- NAFL:, nonalcoholic fatty liver
- NAFLD, nonalcoholic fatty liver disease
- NAS, NAFLD activity score
- NASH
- NASH, nonalcoholic steatohepatitis
- NCD, noncommunicable diseases
- NCPF, noncirrhotic portal fibrosis
- NFS, NAFLD fibrosis score
- NHL, non-Hodgkin's lymphoma
- NPCDCS, National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke
- OCA, obeticholic acid
- PPAR, peroxisome proliferator activated receptor
- PTMS, post-transplant metabolic syndrome
- SAF, steatosis, activity, and fibrosis
- SGLT-2, sodium-glucose cotransporter-2
- SWE, shear wave elastography
- T2DM, DM: type 2 diabetes mellitus
- USG, ultrasound
- VAT, visceral adipose tissue
- VCTE, vibration controlled transient elastography
- fatty liver
- hepatic steatosis
- nonalcoholic steatohepatitis
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Affiliation(s)
- Ajay Duseja
- Departmentof Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S.P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, India
| | - Arka De
- Departmentof Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kaushal Madan
- Max Centre for Gastroenterology, Hepatology and Endoscopy, Max Hospitals, Saket, New Delhi, India
| | - Padaki Nagaraja Rao
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Akash Shukla
- Department of Gastroenterology, Seth GSMC & KEM Hospital, Mumbai, India
| | - Gourdas Choudhuri
- Department of Gastroenterology and Hepato-Biliary Sciences, Fortis Memorial Research Institute, Gurugram, India
| | - Sanjiv Saigal
- Max Centre for Gastroenterology, Hepatology and Endoscopy, Max Hospitals, Saket, New Delhi, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Anil Arora
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Anil C. Anand
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Ashim Das
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Kumar
- Institute of Liver, Gastroenterology and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | | | - Krishnadas Devadas
- Department of Gastroenterology, Government Medical College, Trivandrum, India
| | | | - Manas Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Manav Wadhawan
- Institute of Liver & Digestive Diseases, BLK Super Speciality Hospital, Delhi, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Neeraj Saraf
- Department of Hepatology, Medanta, The Medicity, Gurugram, India
| | - Preetam Nath
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Sanjib Kar
- Department of Gastroenterology and Hepatology, Gastro Liver Care, Cuttack, India
| | - Seema Alam
- Department of PediatricHepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Samir Shah
- Department of Hepatology, Institute of Liver Disease, HPB Surgery and Transplant, Global Hospitals, Mumbai, India
| | - Sandeep Nijhawan
- Department of Gastroenterology, Sawai Man Singh Medical College, Jaipur, India
| | - Subrat K. Acharya
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Vinayak Aggarwal
- Department of Cardiology, Fortis Memorial Research Institute, Gurugram, India
| | - Vivek A. Saraswat
- Department of Hepatology, Pancreatobiliary Sciences and Liver Transplantation, Mahatma Gandhi University of Medical Sciences and Technology, Jaipur, India
| | - Yogesh K. Chawla
- Department of Gastroenterology and Hepatology, Kalinga Institute of Medical Sciences, Bhubaneswar, India
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Simão AL, Palma CS, Izquierdo-Sanchez L, Putignano A, Carvalho-Gomes A, Posch A, Zanaga P, Girleanu I, Henrique MM, Araújo C, Degre D, Gustot T, Sahuco I, Spagnolo E, Carvalhana S, Moura M, Fernandes DA, Banales JM, Romero-Gomez M, Trifan A, Russo FP, Stauber R, Berenguer M, Moreno C, Gonçalves J, Cortez-Pinto H, Castro RE. Cirrhosis is associated with lower serological responses to COVID-19 vaccines in patients with chronic liver disease. JHEP Rep 2023;:100697. [PMID: 36844943 DOI: 10.1016/j.jhepr.2023.100697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/10/2023] [Accepted: 01/21/2023] [Indexed: 02/22/2023] Open
Abstract
Background & Aims The response of patients with chronic liver disease (CLD) to COVID-19 vaccines remains unclear. Our aim was to assess the humoral immune response and efficacy of two-dose COVID-19 vaccines among CLD patients of different etiologies and disease stages. Methods 357 patients were recruited in clinical centers from 6 European countries. 132 healthy volunteers served as controls. Serum IgG, IgM (nM) and neutralizing antibodies (NAb; %) against the Wuhan-Hu-1, B.1.617 and B.1.1.529 SARS-CoV-2 spike proteins were determined prior to vaccination (T0), 14 days (T2) and 6 months (T3) after second dose vaccination. Patients fulfilling inclusion criteria at T2 (n=212) were stratified into "low" or "high" responders according to IgG levels. Infection rates and severity were collected throughout the study. Results Wuhan-Hu-1 IgG, IgM and neutralization levels significantly increased from T0 to T2 in patients vaccinated with either BNT162b2 (70.3%), mRNA-1273 (18.9%) or ChAdOx1 (10.8%). In multivariate analysis, age, cirrhosis and type of vaccine (ChAdOx1 > BNT162b2 > mRNA-1273) predicted "low" humoral response, while viral hepatitis and antiviral therapy predicted "high" humoral response. Comparing with Wuhan-Hu-1, B.1.617 and, further, B.1.1.529 IgG levels were significantly lower at both T2 and T3. Compared with healthy individuals, CLD patients presented with lower B.1.1.529 IgGs at T2 with no additional key differences. No major clinical or immune IgG parameters associated with SARS-COV-2 infection rates or vaccine efficacy. Conclusions Patients with CLD and cirrhosis exhibit lower immune responses to COVID-19 vaccination, irrespective of disease etiology. The type of vaccine leads to different antibody responses, that appear not to associate with distinct efficacy, although this needs validation in larger cohorts with a more balanced representation of all vaccines. Lay summary In patients with CLD vaccinated with two-dose vaccines, age, cirrhosis and type of vaccine (Vaxzevria > Pfizer BioNTech > Moderna) predict a "lower" humoral response, while viral hepatitis etiology and prior antiviral therapy predict a "higher" humoral response. This differential response appears not to associate with SARS-COV-2 infection incidence or vaccine efficacy. Still, compared with Wuhan-Hu-1, humoral immunity was lower for the Delta and Omicron variants, and all decreased after 6 months. As such, patients with CLD, particularly those older and with cirrhosis, should be prioritized for receiving booster doses and/or recently approved adapted vaccines.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- ACE2, Angiotensin-Converting Enzyme 2
- AIH, autoimmune hepatitis
- CAID, cirrhosis-associated immune dysfunction
- CHB, chronic hepatitis B
- CLD, chronic liver disease
- COVID-19 vaccine
- Chronic liver disease
- Cirrhosis
- EASL, European Association for the Study of the Liver
- Humoral immunity
- IQR, interquartile range
- MRFLD, metabolic related fatty liver disease
- NAFLD, non-alcoholic fatty liver disease
- NAb, neutralizing antibodies
- OR, odds ratio
- PBC, primary biliary cholangitis
- PSC, primary sclerosing cholangitis
- SARS-CoV-2
- yo, years old
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Anstee QM, Hallsworth K, Lynch N, Hauvespre A, Mansour E, Kozma S, Marino JP, Bottomley J, Piercy J, Higgins V. Real-world management of non-alcoholic steatohepatitis differs from clinical practice guideline recommendations and across regions. JHEP Rep 2022; 4:100411. [PMID: 34977520 DOI: 10.1016/j.jhepr.2021.100411] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 10/20/2021] [Accepted: 11/09/2021] [Indexed: 12/20/2022]
Abstract
Background & Aims Despite availability of diagnostic and management reference guidelines outlining standard of care for patients with non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH), national and regional guidelines are lacking, resulting in variations in patient management between regions. We retrospectively analyzed patient characteristics and management data from the Adelphi Real World NASH Disease Specific Programme™ for patients with NASH in the EU5, Canada, and the Middle East to identify gaps between real-world practice and that advocated by reference guidelines, irrespective of clinician awareness or consultation of guidelines. Methods We performed an analysis of physicians (hepatologists, gastroenterologists, diabetologists) and their patients diagnosed with NASH. Physicians completed patient record forms for the next 5 consulting patients, collecting information on patient care, including diagnosis and disease management. Results A total of 429 physicians provided data for 2,267 patients with NASH (EU5, n = 1,844; Canada, n = 130; Middle East, n = 293). Patient age, physician-defined fibrosis stage, comorbidities and symptoms, and diagnostic testing practices highlighted statistically significant differences across regions. Substantial disconnects between reference guidelines and real-world practice were observed. Use of liver function tests, non-invasive tests (e.g. ultrasound and transient elastography), and tests to exclude other conditions was suboptimal. Although lifestyle advice was widely provided, patients were less commonly referred to diet, exercise, and lifestyle specialists. Two-thirds of patients were receiving off-label treatment for NASH or associated underlying conditions with the aim of improving NASH, most commonly statins, metformin, and vitamin E. Conclusion Real-world NASH management approaches differ across regions and from proposed standard of care represented by reference multidisciplinary guidelines. Establishment and awareness of, and adherence to regional and national guidelines may improve identification and management of patients with NASH and potentially improve outcomes in this population. Lay summary Although reference guidelines are available to guide the management of patients with NASH, these are not widely used and there is a lack of national guidelines. Our study shows how clinical practice in the EU, Canada, and Middle East differs from proposed standard of care, particularly relating to how patients are diagnosed and treated. Wider establishment of, awareness of, and reference to guidelines may improve how physicians identify and manage patients with NASH. Reference guidelines exist for the diagnosis and management of patients with NASH. This analysis compared reference guidelines and real-world practice in 3 regions. Substantial deviations from reference guidelines were seen in testing and treatment. Referral to diet, exercise, and lifestyle specialists was suboptimal. Establishment, awareness, and adherence to national guidelines is needed.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- EASD, European Association for the Study of Diabetes
- EASL, European Association for the Study of the Liver
- EASO, European Association for the Study of Obesity
- EU5, France, Germany, Italy, Spain and United Kingdom
- FIB-4, Fibrosis-4
- HbA1c, glycated hemoglobin
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- NIT, non-invasive test
- Non-alcoholic steatohepatitis
- T2DM, type 2 diabetes mellitus
- VCTE, vibration-controlled transient elastography
- clinical practice guidelines
- diagnostic pathways
- liver disease
- patient management
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Stainbrook T, Elliott K, Powell A, Simpson MA, Bash M. Hepatitis C identification and treatment in rural Pennsylvania, USA. Prev Med Rep 2021; 24:101526. [PMID: 34976603 PMCID: PMC8683873 DOI: 10.1016/j.pmedr.2021.101526] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/30/2021] [Accepted: 08/12/2021] [Indexed: 11/15/2022] Open
Abstract
The opioid epidemic in the United States has led to increases in hepatitis C virus (HCV) infection especially in rural communities. It is recommended that persons who inject drugs undergo screening and treatment. We initiated HCV screening and treatment within a mostly rural area of Pennsylvania by targeting medicated-assisted treatment (MAT) facilities and community events. Screening was conducted in 43 rural and 13 urban counties by a clinical team. At MAT facilities, the clinical team performed HCV screening between 4:30am and 1:00pm using the OraQuick HCV test free of charge. Participants with a positive screen were linked to treatment. In all, 3,051 screening tests were conducted among 2,995 unique participants, who were mostly white (2821, 94%) and from rural counties (2597, 87%). Participants were most frequently 25-to-34 years old (798, 27%). A total of 730 patients were HCV screen positive, 371 patients received an HCV RNA PCR test, and 272 were HCV RNA positive. Of them, 249 met with a healthcare provider, 102 initiated treatment, and 50 completed SVR testing, with 49 achieving SVR. Anti-HCV positivity was more frequent among MAT facility versus non-MAT patients (41% versus 5%) (p < .001). Non-MAT participants were more likely to begin treatment for HCV (91% [21/23] versus 30% [81/272]) and achieve SVR (71% versus 43%). In HCV screening and treatment among high-risk patients, substantial numbers of participants were lost at every point of care between screening and follow-up testing. Specific screening, treatment, and follow-up strategies for persons in rural communities may be needed.
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Affiliation(s)
| | - Kelsey Elliott
- TruCare Internal Medicine & Infectious Diseases, DuBois, PA, USA
| | - Amy Powell
- TruCare Internal Medicine & Infectious Diseases, DuBois, PA, USA
| | - Mary A. Simpson
- TruCare Internal Medicine & Infectious Diseases, DuBois, PA, USA
| | - Maddy Bash
- TruCare Internal Medicine & Infectious Diseases, DuBois, PA, USA
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Moctezuma-Velázquez C, Lewis S, Lee K, Amodeo S, Llovet JM, Schwartz M, Abraldes JG, Villanueva A. Non-invasive imaging criteria for the diagnosis of hepatocellular carcinoma in non-cirrhotic patients with chronic hepatitis B. JHEP Rep 2021; 3:100364. [PMID: 34712933 PMCID: PMC8531662 DOI: 10.1016/j.jhepr.2021.100364] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 01/12/2021] [Revised: 08/25/2021] [Accepted: 08/30/2021] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Criteria defined by the European Association for the Study of the Liver (EASL) and Liver Imaging Reporting and Data System (LI-RADS) enable hepatocellular carcinoma (HCC) diagnosis based on imaging in cirrhosis. Non-cirrhotic patients require biopsy given the lower pre-test probability of HCC. The objective of our study was to assess the performance of EASL and LI-RADS criteria for the diagnosis of HCC in non-cirrhotic patients with chronic HBV infection. Methods This was a cross-sectional study performed at a referral center. We included all patients with HBV without cirrhosis with focal liver lesions who underwent contrast-enhanced CT or MRI at our clinic between 2005-2018. Studies were reviewed by 2 radiologists blinded to the diagnosis. Results We included 280 patients, median age was 56.8 (IQR 48.2-65.45) years and 223 (80%) were male. In 191 (79%) cases the lesion was found as a result of screening. Cirrhosis was excluded based on pathology in 252 (90%) cases. We assessed 338 nodules: 257 (76%) HCC, 40 (12%) non-HCC malignant lesions, and 41 (12%) benign lesions. EASL criteria and LR-5/LR-tumor-in-vein (TIV) categories had a 100% agreement in categorizing lesions as HCC, and 226 nodules (67%) were classified as HCCs. The sensitivity, specificity, positive predictive value, and negative predictive value were 82.1 (76.9-86.6), 81.5 (71.3-89.2), 93.4 (89.3-96.2), and 58.9 (49.2-68.1), respectively. When the pre-test probability of HCC is >70%, estimated as a PAGE-B score above 9, and EASL or LR-5/LR-TIV criteria are met, post-test probability would be >90%. Conclusions EASL criteria and LR-5/LR-TIV categories show a positive predictive value in patients with HBV without cirrhosis that is comparable to that seen in patients with cirrhosis. These criteria can be used when the pre-test probability of HCC is >70%. Lay summary Current guidelines recommend performing a biopsy to confirm the diagnosis of presumed hepatocellular carcinoma (HCC) in patients without cirrhosis. We showed that specific imaging criteria had a 100% agreement for categorizing lesions as HCC, with a positive predictive value of 93.4%. These imaging criteria could be used to diagnose HCC in HBV patients without cirrhosis with a pre-test probability of HCC of ≥70%, avoiding the need for a liver biopsy. Imaging criteria defined by the EASL and LI-RADS enable the diagnosis of HCC without biopsy in patients with cirrhosis. A biopsy is recommended in all patients without cirrhosis. Imaging criteria had a good performance in patients with HBV infection without cirrhosis when pre-test probability was >70%. HCC may be diagnosed based solely on imaging criteria in patients with HBV subject to HCC screening (i.e. PAGE-B score >9).
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Affiliation(s)
- Carlos Moctezuma-Velázquez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, Mexico City, Mexico
- Liver Cancer Translational Research Group, Liver Unit, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sara Lewis
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Karen Lee
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Salvatore Amodeo
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Josep M. Llovet
- Mount Sinai Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, USA
- Liver Cancer Translational Research Group, Liver Unit, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Catalonia, Spain
| | - Myron Schwartz
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Juan G. Abraldes
- Division of Gastroenterology (Liver Unit), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Augusto Villanueva
- Mount Sinai Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, USA
- Corresponding author. Address: Icahn School of Medicine at Mount Sinai, 1425 Madison Ave, Box 1123, Room 11-70E, New York, NY 10029, USA; Tel.: +1-212-659-9392.
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Sharma P, Kumar A, Anikhindi S, Bansal N, Singla V, Shivam K, Arora A. Effect of COVID-19 on Pre-existing Liver disease: What Hepatologist Should Know? J Clin Exp Hepatol 2021; 11:484-493. [PMID: 33398223 PMCID: PMC7774459 DOI: 10.1016/j.jceh.2020.12.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 12/24/2020] [Indexed: 02/07/2023] Open
Abstract
COVID-19 is characterized by predominant respiratory and gastrointestinal symptoms. Liver enzymes derangement is seen in 15-55% of the patients. Advanced age, hypertension, diabetes, obesity, malignancy, and cardiovascular disease predispose them to severe disease and the need for hospitalization. Data on pre-existing liver disease in patients with COVID-19 is limited, and most studies had only 3-8% of these patients. Patients with metabolic dysfunction-associated fatty liver (MAFLD) had shown a 4-6 fold increase in severity of COVID-19, and its severity and mortality increased in patients with higher fibrosis scores. Patients with chronic liver disease had shown that cirrhosis is an independent predictor of severity of COVID-19 with increased hospitalization and mortality. Increase in Child Turcotte Pugh (CTP) score and model for end-stage liver disease (MELD) score increases the mortality in these patients. Few case reports had shown SARS-CoV-2 as an acute event in the decompensation of underlying chronic liver disease. Immunosuppression should be reduced prophylactically in patients with autoimmune liver disease and post-transplantation with no COVID-19. Hydroxychloroquine and remdesivir is found to be safe in limited studies in a patient with cirrhosis and COVID-19. For hepatologists, cirrhosis with COVID-19 is a pertinent issue as the present pandemic will have severe disease in patients with chronic liver disease leading to more hospitalization and decompensation.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- ACE2, Angiotensin-Converting Enzyme 2
- AIH, Autoimmune Hepatitis
- ALP, Alkaline Phosphatase
- AST/ALT, Aspartate and Alanine Aminotransferase
- CHF, Congestive Heart Failure
- CKD, Chronic Kidney Disease
- CLD, Chronic Liver Disease
- CLIF-OC, Chronic Liver Failure Organ Cirrhosis
- CLIF-OF, Chronic Liver Failure Organ Failure
- COVID-19
- CRP, C Reactive Protein
- CTP, Child Turcotte Pugh
- Cirrhosis
- DILI, Drug-Induced Liver Injury
- EASL, European Association for the Study of Liver
- HBC, Hepatitis C
- HBV, Hepatitis B
- HCC, Hepatocellular Carcinoma
- HCQ, Hydoxycholoroquine
- LT, Liver Transplantation
- Liver disease
- MAFLD, Metabolic Associated Fatty Liver Disease
- MELD, Model for End-stage Liver Disease
- NAFLD, Nonalcoholic Fatty Liver Disease
- PPE, Personal Protection Kit
- RR, Relative Risk
- RTPCR, Reverse Transcription-Polymerase Chain Reaction
- Severity
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Affiliation(s)
- Praveen Sharma
- Department of Gastroenterology Sir Ganga Ram Hospital New Delhi, India
| | - Ashish Kumar
- Department of Gastroenterology Sir Ganga Ram Hospital New Delhi, India
| | | | - Naresh Bansal
- Department of Gastroenterology Sir Ganga Ram Hospital New Delhi, India
| | - Vikas Singla
- Department of Gastroenterology Sir Ganga Ram Hospital New Delhi, India
| | - Khare Shivam
- Department of Gastroenterology Sir Ganga Ram Hospital New Delhi, India
| | - Anil Arora
- Department of Gastroenterology Sir Ganga Ram Hospital New Delhi, India
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Malik F, Bailey H, Chan P, Collins IJ, Mozalevskis A, Thorne C, Easterbrook P. Where are the children in national hepatitis C policies? A global review of national strategic plans and guidelines. JHEP Rep 2021; 3:100227. [PMID: 33665586 PMCID: PMC7898178 DOI: 10.1016/j.jhepr.2021.100227] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 10/14/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND & AIMS It is estimated that 3.26 million children and adolescents worldwide have chronic HCV infection. To date, the global response has focused on the adult population, but direct-acting antiviral (DAA) regimens are now approved for children aged ≥3 years. This global review describes the current status of policies on HCV testing and treatment in children, adolescents, and pregnant women in WHO Member States. METHODS We identified national strategic plans and/or clinical practice guidelines (CPGs) for HCV infection from a World Health Organization (WHO) database of national policies from Member States as of August 2019. A standardised proforma was used to abstract data on polices or recommendations on testing and treatment in children, adolescents and pregnant women. Analysis was stratified according to the country-income status and results were validated through WHO regional focal points through August 2020. RESULTS National HCV policies were available for 122 of the 194 WHO Member States. Of these, the majority (n = 71/122, 58%) contained no policy recommendations for either testing or treatment in children or adolescents. Of the 51 countries with policies, 24 had specific policies for both testing and treatment, and were mainly from the European region; 18 countries for HCV testing only (12 from high- or upper-middle income); and 9 countries for treatment only (7 high- or upper-middle income). Twenty-one countries provided specific treatment recommendations: 13 recommended DAA-based regimens for adolescents ≥12 years and 6 still recommended interferon/ribavirin-based regimens. CONCLUSIONS There are significant gaps in policies for HCV-infected children and adolescents. Updated guidance on testing and treatment with newly approved DAA regimens for younger age groups is needed, especially in most affected countries. LAY SUMMARY To date, the predominant focus of the global response towards elimination of hepatitis C has been on the testing and treatment of adults. Much less attention has been paid to testing and treatment among children and adolescents, although in 2018 an estimated 3.26 million were infected with HCV. Our review shows that many countries have no national guidance on HCV testing and treatment in children and adolescents. It highlights the urgent need for advocacy and updated policies and guidelines specific for children and adolescents.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- APASL, Asian Pacific Association for the Study of the Liver
- Adolescents
- CPGs, clinical practice guidelines
- Children
- Clinical practice guidelines
- DAAs, direct-acting antivirals
- EASL, European Association for the Study of the Liver
- ESPGHAN, European Society for Paediatric Gastroenterology Hepatology and Nutrition
- GHSS, Global Health Sector Strategy
- GLE, glecaprevir
- GT, genotype
- Hepatitis C
- IDU, injecting drug use
- IFN, interferon
- LED, ledipasvir
- LMICs, low- and middle-income countries
- MoH, ministries of health
- NASPGHAN, North American Society for Pediatric Gastroenterology Hepatology and Nutrition
- NSPs, national strategic plans
- National strategic plans
- PIB, pibrentasvir
- Policies
- Policy review
- Pregnancy
- RBV, ribavirin
- SOF, sofosbuvir
- VEL, velpatasvir
- WHO, World Health Organization
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Affiliation(s)
- Farihah Malik
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Heather Bailey
- UCL Institute for Global Health, University College London, London, UK
| | - Polin Chan
- World Health Organization Regional Office for the Western Pacific, Manila, Philippines
| | - Intira Jeannie Collins
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | | | - Claire Thorne
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Philippa Easterbrook
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
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Abstract
Sickle hepatopathy is an umbrella term describing various pattern of liver injury seen in patients with sickle cell disease. The disease is not uncommon in India; in terms of prevalence, India is second only to Sub-Saharan Africa where sickle cell disease is most prevalent. Hepatic involvement in sickle cell disease is not uncommon. Liver disease may result from viral hepatitis and iron overload due to multiple transfusions of blood products or due to disease activity causing varying changes in vasculature. The clinical spectrum of disease ranges from ischemic injury due to sickling of red blood cells in hepatic sinusoids, pigment gall stones, and acute/chronic sequestration syndromes. The sequestration syndromes are usually episodic and self-limiting requiring conservative management such as antibiotics and intravenous fluids or packed red cell transfusions. However, rarely these episodes may present with coagulopathy and encephalopathy like acute liver failure, which are life-threatening, requiring exchange transfusions or even liver transplantation. However, evidence for their benefits, optimal indications, and threshold to start exchange transfusion is limited. Similarly, there is paucity of the literature regarding the end point of exchange transfusion in this scenario. Liver transplantation may also be beneficial in end-stage liver disease. Hydroxyurea, the antitumor agent, which is popularly used to prevent life-threatening complications such as acute chest syndrome or stroke in these patients, has been used only sparingly in hepatic sequestrations. The purpose of this review is to provide insights into epidemiology of sickle cell disease in India and pathogenesis and classification of hepatobiliary involvement in sickle cell disease. Finally, various management options including exchange transfusion, liver transplantation, and hydroxyurea in hepatic sequestration syndromes will be discussed in brief.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- ACLF, Acute on chronic liver failure
- ALF, Acute liver failure
- ALT, Alanine transaminase
- AST, Aspartate transaminase
- FFP, Fresh frozen plasma
- GIT, Gastrointestinal tract
- HAV, Hepatitis A virus
- HBV, Hepatitis B virus
- HCV, Hepatitis C virus
- HEV, Hepatitis E virus
- HIC, Hepatic iron content
- HbS, Sickle hemoglobin
- HbSS, Sickle cell disease homozygous
- INR, International normalized ratio
- PT, Prothrombin time
- RUQ, Right upper quadrant
- SC, Scheduled caste
- SCD, Sickle cell disease
- SCIC, Sickle cell intrahepatic cholestasis
- ST, Scheduled tribe
- TJLB, Transjugular liver biopsy
- UDCA, Ursodeoxycholic acid
- cholelithiasis
- intrahepatic cholestasis
- sickle cell hepatopathy
- sickle cholangiopathy
- sickle hepatic crisis
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Affiliation(s)
| | - Anil C. Anand
- Address for correspondence. Anil C Anand, Professor and Head, Department of Gastroenterology & Hepatology, Kalinga Institute of Medical Sciences, Bhubneshwar, India.
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Marot A, Singal AK, Moreno C, Deltenre P. Granulocyte colony-stimulating factor for alcoholic hepatitis: A systematic review and meta-analysis of randomised controlled trials. JHEP Rep 2020; 2:100139. [PMID: 32775975 PMCID: PMC7396826 DOI: 10.1016/j.jhepr.2020.100139] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/06/2020] [Accepted: 06/08/2020] [Indexed: 12/11/2022] Open
Abstract
Background & Aims Granulocyte colony-stimulating factor (G-CSF) treatment has been proposed as a therapeutic option for patients with severe alcoholic hepatitis (AH). The aim of this study was to synthesise available evidence on the efficacy of G-CSF in AH. Methods This is a meta-analysis of randomised controlled trials evaluating the risk of death at 90 days and the risk of infection. Results Seven studies were included. Of a total of 396 patients, 336 had AH, 197 patients were treated with G-CSF, and 199 received placebo or pentoxifylline. In overall meta-analysis, G-CSF therapy was associated with a reduced risk of death at 90 days (odds ratio [OR] 0.28; 95% CI 0.09–0.88; p = 0.03). There was high heterogeneity between studies (p <0.001; I2 = 80%). Five studies were performed in Asia and 2 in Europe. In the subgroup analysis of studies performed in Asia, G-CSF was associated with a reduced risk of death (OR 0.15; 95% CI 0.08–0.28; p <0.001; heterogeneity: p = 0.5, I2 = 0%). In European studies, G-CSF tended to increase mortality compared with controls, although the difference was not significant (OR 1.89; 95% CI 0.90–3.98; p = 0.09; heterogeneity: p = 0.8, I2 = 0%). In Asian studies, occurrence of infection was less frequent in G-CSF patients than in controls (OR 0.12; 95% CI 0.06–0.23; p <0.001; heterogeneity: p = 0.7, I2 = 0%), whilst in European studies, this occurrence was not statistically different (OR 0.92; 95% CI 0.50–1.68; p = 0.78; heterogeneity: p = 0.5, I2 = 0%). In sensitivity analyses, excluding studies that included patients with acute-on-chronic liver failure (ACLF) other than AH, patients with less severe AH, or patients with non-response to corticosteroids, results were similar to those of overall analyses, both for mortality and occurrence of infection. Conclusions Granulocyte colony-stimulating factor therapy may improve the prognosis of patients with severe AH. However, owing to the high heterogeneity observed in the overall analysis caused by conflicting results between the Asian and European studies, G-CSF cannot currently be recommended for AH, particularly in Europe. Whether these differences can be explained by ethnic differences or disparities in patient selection and disease severity remains unclear. Lay summary The main finding of this meta-analysis is that the use of granulocyte colony-stimulating factor (G-CSF) is associated with a mortality reduction of more than 70% at 3 months amongst patients with alcoholic hepatitis (AH) compared with controls who did not receive this therapy. However, owing to the high heterogeneity observed in the overall analysis caused by conflicting results between the Asian and European studies, G-CSF cannot currently be recommended for patients with AH, particularly in Europe. Whether these differences can be explained by ethnic differences or disparities in patient selection and disease severity remains unclear. This meta-analysis reports pooled data from 7 studies on the use of G-CSF in patients with alcoholic hepatitis. The favourable effect of G-CSF was only encountered in Asian not European studies. Additional data are needed to clarify the usefulness of G-CSF in severe alcoholic hepatitis, particularly in Europe.
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Affiliation(s)
- Astrid Marot
- Department of Gastroenterology and Hepatology, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
- Corresponding author. Address: Department of Gastroenterology and Hepatology, CHU UCL Namur, Université Catholique de Louvain, avenue Gaston Thérasse, 1, 5530 Yvoir, Belgium. Tel.: +32 81 42 32 72; fax: +32 81 42 32 54.
| | - Ashwani K. Singal
- Division of Transplant Hepatology, Avera Transplant Institute and Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre Deltenre
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
- Department of Gastroenterology and Hepatology, Clinique St Luc, Bouge, Belgium
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Gaur N, Malhotra V, Agrawal D, Singh SK, Beniwal P, Sharma S, Jhorawat R, Rathore V, Joshi H. Sofosbuvir-Velpatasvir Fixed Drug Combination for the Treatment of Chronic Hepatitis C Infection in Patients With End-Stage Renal Disease and Kidney Transplantation. J Clin Exp Hepatol 2020; 10:189-193. [PMID: 32405174 PMCID: PMC7212294 DOI: 10.1016/j.jceh.2019.10.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 10/23/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION India is witnessing high hepatitis C virus (HCV) infection burden in patients of chronic kidney disease. Due to unavailability of costly Kidney Disease Improving Global Outcomes-recommended directly acting antiviral drugs, a widely available pan-genotypic combination of Sofosbuvir and Velpatasvir can become an economical option. Data regarding treatment experience of sofosbuvir-velpatasvir combination in chronic kidney disease is scarce. No data from India have been published in patients on renal replacement therapies till now. METHODS This retrospective analysis included all patients of end-stage renal disease on maintenance hemodialysis with treatment-naïve chronic HCV infection treated with sofosbuvir (400 mg) and velpatasvir (100 mg) fixed-dose combination. Pretreatment routine investigations were performed, which included HCV viral load, genotype, fibro scan, endoscopy for esophageal varices, and portal vein Doppler. The patients were followed up with HCV viral load to declare sustained virologic response. RESULT patients were included with a mean age of 39.8 ± 10.8 years, and 77.4% were male. Genotype 1 was found to be most prevalent (67.7%), with a median viral load of 106copies/ml. Six (19.3%) patients had hepatitis B virus co-infection. Three (9.7%) patients had cirrhosis. Sustained virologic response (SVR12) was achieved in 30 (96.8%) patients, and one (3.2%) patient had relapse. Furthermore, 14 (45.2%) patients underwent renal transplantation, and none of them had relapsed. Dyspepsia (9.7%) was the most common side effect observed with no major adverse effect. CONCLUSION Our study showed excellent efficacy with the safety profile of this drug combination in end-stage renal disease patients. However, larger prospective studies and multicenter randomized controlled trials are needed for further confirmation.
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Affiliation(s)
- Nisha Gaur
- SMS Medical College and Hospital, Jaipur, Rajasthan, India
| | - Vinay Malhotra
- SMS Medical College and Hospital, Jaipur, Rajasthan, India
| | | | | | - Pankaj Beniwal
- SMS Medical College and Hospital, Jaipur, Rajasthan, India
| | - Sanjeev Sharma
- SMS Medical College and Hospital, Jaipur, Rajasthan, India
| | | | - Vinay Rathore
- SMS Medical College and Hospital, Jaipur, Rajasthan, India
| | - Harshal Joshi
- SMS Medical College and Hospital, Jaipur, Rajasthan, India
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11
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Nguyen-Vu T, Malvar C, Chin YK, Kaltenbach T, Liu A, Myint T, Asokkumar R, Shergill A, Soetikno R. Simulation-based mastery learning (SBML) for rapid acquisition of upper endoscopy knowledge and skills-initial observation. VideoGIE 2020; 5:222-225. [PMID: 32529151 PMCID: PMC7280157 DOI: 10.1016/j.vgie.2020.02.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Key Words
- AASLD, American Association for the Study of Liver Diseases
- APC, argon plasma coagulation
- ASA, American Society of Anesthesiologists
- EOE, eosinophilic esophagitis
- GE, gastroesophageal
- IEE, image-enhanced endoscopy
- NVUGIB, nonvariceal upper GI bleeds
- TTS, through the scope
- UGI, upper gastrointestinal
- VUGIB, variceal upper GI bleeds
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Affiliation(s)
- Tiffany Nguyen-Vu
- Section of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA.,Department of Medicine, University of California, San Francisco, California, USA
| | - Carmel Malvar
- Section of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA.,Department of Medicine, University of California, San Francisco, California, USA
| | - Yung Ka Chin
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Tonya Kaltenbach
- Section of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA.,Department of Medicine, University of California, San Francisco, California, USA
| | - Andy Liu
- California Pacific Medical Center, San Francisco, California, USA
| | - Thomas Myint
- California Pacific Medical Center, San Francisco, California, USA
| | | | - Amandeep Shergill
- Section of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA.,Department of Medicine, University of California, San Francisco, California, USA
| | - Roy Soetikno
- Section of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA.,Academy of Endoscopy, Woodside, California, USA
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12
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Wang D, Chen F, Zeng T, Tang Q, Chen B, Chen L, Dong Y, Li X. Comprehensive biological function analysis of lncRNAs in hepatocellular carcinoma. Genes Dis 2020; 8:157-167. [PMID: 33997162 PMCID: PMC8099694 DOI: 10.1016/j.gendis.2019.12.013] [Citation(s) in RCA: 4] [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] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/16/2019] [Accepted: 12/31/2019] [Indexed: 12/19/2022] Open
Abstract
Thousands of long non-coding RNAs (lncRNAs) have been discovered in human genomes by gene chip, next-generation sequencing, and/or other methods in recent years, which represent a significant subset of the universal genes involved in a wide range of biological functions. An abnormal expression of lncRNAs is associated with the growth, invasion, and metastasis of various types of human cancers, including hepatocellular carcinoma (HCC), which is an aggressive, highly malignant, and invasive tumor, and a poor prognosis in China. With a more in-depth understanding of lncRNA research for HCC and the emergence of new molecular-targeted therapies, the diagnosis, treatment, and prognosis of HCC will be considerably improved. Therefore, this review is expected to provide recommendations and directions for future lncRNA research for HCC.
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Affiliation(s)
- Dan Wang
- Department of Clinical Laboratory, People's Hospital of Rongchang District, Chongqing, Rongchang 402460, PR China.,Key Laboratory of Molecular Biology of Infectious Diseases, Ministry of Education, Chongqing Medical University, Chongqing, 400016, PR China
| | - Fengjiao Chen
- Key Laboratory of Molecular Biology of Infectious Diseases, Ministry of Education, Chongqing Medical University, Chongqing, 400016, PR China
| | - Tao Zeng
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Sichuan Province, Chengdu, 611731, PR China
| | - Qingxia Tang
- Department of Clinical Laboratory, People's Hospital of Rongchang District, Chongqing, Rongchang 402460, PR China
| | - Bing Chen
- Department of Clinical Laboratory, People's Hospital of Rongchang District, Chongqing, Rongchang 402460, PR China
| | - Ling Chen
- Key Laboratory of Molecular Biology of Infectious Diseases, Ministry of Education, Chongqing Medical University, Chongqing, 400016, PR China
| | - Yan Dong
- Clinical Molecular Medicine Testing Center, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, PR China
| | - Xiaosong Li
- Clinical Molecular Medicine Testing Center, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, PR China
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13
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Ahmed IA, Mikail MA, Mustafa MR, Ibrahim M, Othman R. Lifestyle interventions for non-alcoholic fatty liver disease. Saudi J Biol Sci 2019; 26:1519-1524. [PMID: 31762620 PMCID: PMC6864195 DOI: 10.1016/j.sjbs.2018.12.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [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: 10/02/2017] [Revised: 12/29/2018] [Accepted: 12/31/2018] [Indexed: 12/11/2022] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a multi-factorial disease and the most common of chronic liver diseases worldwide. The four clinical-pathological entities which are usually followed by NAFLD course include non-alcoholic steatosis, non-alcoholic steatohepatitis, advanced fibrosis/cirrhosis, and hepatocellular carcinoma. The cornerstones of NAFLD management and treatment, however, are healthy lifestyles such as dietary modifications, regular physical activity, and gradual weight loss. At present, no drugs or pharmacological agents have been approved for long-term treatment of NAFLD. Therefore, lifestyle modification is considered the main clinical recommendation and an initial step for the management of NAFLD.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- ALA, alpha-linolenic acid
- DDT, dichlorodiphenyltrichloroethane
- DHA, docosahexaenoic acid
- Diet
- EASD, European Association for the Study of Diabetes
- EASL, European Association for the Study of the Liver
- EASO, European Association for the Study of Obesity
- EPA, eicosapentaenoic acid
- Exercise
- Lifestyle
- Liver disease
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- Weight loss
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Affiliation(s)
- Idris Adewale Ahmed
- The Center for Natural Products Research and Drug Discovery (CENAR), Wellness Research Cluster, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Maryam Abimbola Mikail
- Department of Biomedical Science, Faculty of Science, Lincoln University College, Malaysia
| | - Mohammad Rais Mustafa
- The Center for Natural Products Research and Drug Discovery (CENAR), Wellness Research Cluster, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Muhammad Ibrahim
- International Islamic University Malaysia, Kuantan Campus, Malaysia
| | - Rozana Othman
- The Center for Natural Products Research and Drug Discovery (CENAR), Wellness Research Cluster, University of Malaya, 50603 Kuala Lumpur, Malaysia
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14
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Nagral A, Sarma MS, Matthai J, Kukkle PL, Devarbhavi H, Sinha S, Alam S, Bavdekar A, Dhiman RK, Eapen CE, Goyal V, Mohan N, Kandadai RM, Sathiyasekaran M, Poddar U, Sibal A, Sankaranarayanan S, Srivastava A, Thapa BR, Wadia PM, Yachha SK, Dhawan A. Wilson's Disease: Clinical Practice Guidelines of the Indian National Association for Study of the Liver, the Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition, and the Movement Disorders Society of India. J Clin Exp Hepatol 2019; 9:74-98. [PMID: 30765941 PMCID: PMC6363961 DOI: 10.1016/j.jceh.2018.08.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 08/25/2018] [Indexed: 12/12/2022] Open
Abstract
Clinical practice guidelines for Wilson's disease (WD) have been published by the American Association for the Study of Liver Diseases and European Association for the Study of the Liver in 2008 and 2012, respectively. Their focus was on the hepatic aspects of the disease. Recently, a position paper on pediatric WD was published by the European Society of Pediatric Gastroenterology Hepatology and Nutrition. A need was felt to harmonize guidelines for the hepatic, pediatric, and neurological aspects of the disease and contextualize them to the resource-constrained settings. Therefore, experts from national societies from India representing 3 disciplines, hepatology (Indian National Association for Study of the Liver), pediatric hepatology (Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition), and neurology (Movement Disorders Society of India) got together to evolve fresh guidelines. A literature search on retrospective and prospective studies of WD using MEDLINE (PubMed) was performed. Members voted on each recommendation, using the nominal voting technique. The Grades of Recommendation, Assessment, Development and Evaluation system was used to determine the quality of evidence. Questions related to diagnostic tests, scoring system, and its modification to a version suitable for resource-constrained settings were posed. While ceruloplasmin and 24-h urine copper continue to be important, there is little role of serum copper and penicillamine challenge test in the diagnostic algorithm. A new scoring system - Modified Leipzig score has been suggested with extra points being added for family history and serum ceruloplasmin lower than 5 mg/dl. Liver dry copper estimation and penicillamine challenge test have been removed from the scoring system. Differences in pharmacological approach to neurological and hepatic disease and global monitoring scales have been included. Rising bilirubin and worsening encephalopathy are suggested as indicators predicting need for liver transplant but need to be validated. The clinical practice guidelines provide recommendations for a comprehensive management of WD which will be of value to all specialties.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- ACLF, Acute on Chronic Liver Failure
- ALF, Acute Liver Failure
- ALT, Alanine Transaminase
- AST, Aspartate Transaminase
- Cu, Copper
- DP, D-Penicillamine
- EASL, European Association for the Study of the Liver
- GAS for WD, Global Assessment Scale for Wilson's Disease
- HCC, Hepatocellular Carcinoma
- INR, International Normalized Ratio
- KF, Kayser-Fleischer
- LT, Liver Transplantation
- MARS, Molecular Absorption Recirculating System
- MELD, Model for End-Stage Liver Disease
- MRI, Magnetic Resonance Imaging
- NGS, Next-Generation Sequencing
- NWI, New Wilson's Index
- PELD, Pediatric end stage liver disease
- TPE, Total Plasma Exchange
- TTM, Tetrathiomolybdate
- WD, Wilson's Disease
- Wilson's disease scoring
- genetic disorder
- modified Leipzig scoring
- rare disease
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Affiliation(s)
- Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, India,Department of Gastroenterology, Apollo Hospitals, Navi Mumbai, India,Address for correspondence: Aabha Nagral, 7, Snehasagar, Prabhanagar, Prabhadevi, Mumbai 400025, India.
| | - Moinak S. Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - John Matthai
- Department of Paediatric Gastroenterology, Masonic Medical Centre for Children, Coimbatore, India
| | | | - Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, India
| | - Sanjib Sinha
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Vinay Goyal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Neelam Mohan
- Department of Pediatric Gastroenterology, Hepatology & Liver Transplantation, Medanta – The Medicity Hospital, Gurgaon, India
| | - Rukmini M. Kandadai
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Malathi Sathiyasekaran
- Department of Pediatric Gastroenterology, Kanchi Kamakoti Childs Trust Hospital Chennai, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anupam Sibal
- Department of Pediatric Gastroenterology and Hepatology, Indraprastha Apollo Hospitals, New Delhi, India
| | | | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Baburam R. Thapa
- Department of Gastroenterology & Pediatric Gastroenterology, MM Medical Institute of Medical Sciences and Research, Mullana, Ambala, India
| | - Pettarusp M. Wadia
- Department of Neurology, Jaslok Hospital and Research Centre, Mumbai, India
| | - Surendra K. Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anil Dhawan
- Department of Pediatrics and Pediatric Liver GI and Nutrition Center and Mowat Labs, King's College Hospital, London, UK
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15
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Rout G, Nayak B, Patel AH, Gunjan D, Singh V, Kedia S, Shalimar. Therapy with Oral Directly Acting Agents in Hepatitis C Infection Is Associated with Reduction in Fibrosis and Increase in Hepatic Steatosis on Transient Elastography. J Clin Exp Hepatol 2019; 9:207-214. [PMID: 31024203 PMCID: PMC6477071 DOI: 10.1016/j.jceh.2018.06.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 06/10/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/AIMS Direct-Acting Antivirals (DAAs) are now the standard of care for management of Chronic Hepatitis C (CHC) infection. The aim of this study was to evaluate change in Liver Stiffness Measurement (LSM) and Controlled Attenuation Parameter (CAP) by transient elastography (FibroScan®) after completion of DAA therapy. METHODS LSM and CAP were measured serially (baseline pre-treatment, at 12 weeks post therapy, and one year after completion of therapy) in a prospective cohort of 372 CHC patients treated with DAAs. Patients with at least two FibroScan measurements were included. RESULTS The mean age was 38.1 ± 12.6 years; 58.3% males. Cirrhosis as defined by biopsy or fibroscan measurement (≥12.5) kPa was found in 25.5%. On paired analysis (n = 317), LSM (IQR) decreased from a baseline value 7.1 (5.3-13.8) kPa to 6.2 (4.8-11.2) kPa 12 weeks post therapy with a median decline 0.7 (-0.6-2.6) kPa, P < 0.001. Similarly, on paired analysis (n = 160), LSM decreased from baseline 6.9 (5.1-12.7) kPa to 6.1 (4.8-9.4) kPa after one year of treatment with median decline 0.9 (-0.6-3.2) kPa, P < 0.001. In contrast, on paired analysis (n = 317), CAP increased from baseline of 213.0 (180.0-254.5) dB/m to 225.0 (190.0-269.0) dB/m at 12 weeks post therapy with median increase 7.0 (-23.5-45.5), P = 0.001. Similarly, on paired analysis (n = 160), CAP increased from baseline of 210.0 (180.3-260.8) dB/m to 234.0 (204.0-282.0) dB/m at one year post therapy with median increase 25.0 (-12.5-61.5) dB/m, P < 0.001. On multivariate linear regression analysis, low baseline CAP value and low albumin were significantly associated with increase in CAP values. CONCLUSION Treatment with DAAs reduces liver stiffness, but is associated with increase in hepatic steatosis.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- ALT, Alanine Aminotransferase
- AST, Aspartate Aminotransferase
- BMI, Body Mass Index
- CAP, Controlled Attenuation Parameter
- CHC, Chronic Hepatitis C
- DAAs, Directly-Acting Antivirals
- F0-4, METAVIR Fibrosis Stage 0 to 4
- Fibroscan
- HCV, Hepatitis C Virus
- HIV, Human Immunodeficiency Virus
- IFN, Interferon
- IQR, Interquartile Range
- LSM, Liver Stiffness Measurement
- NAFLD, Non-alcoholic Fatty Liver Disease
- SD, Standard Deviation
- SVR12
- SVR12, Sustained Viral Response at 12 Weeks
- TE, Transient Elastography
- controlled attenuation parameter
- liver stiffness measurement
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Affiliation(s)
- Gyanranjan Rout
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Baibaswata Nayak
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Arpan H. Patel
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Deepak Gunjan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Vishwajeet Singh
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India,Address for correspondence: Shalimar, Associate Professor, Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India. Tel.: +91 11 26596643.
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Hafeez QUA, Butt AS, Ahmed F. Management of Chronic Hepatitis B: Knowledge and Practices of Physicians in Pakistan. J Clin Exp Hepatol 2018; 8:342-351. [PMID: 30563995 PMCID: PMC6286432 DOI: 10.1016/j.jceh.2017.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 12/23/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In Pakistan, approximately 4.5 million people are afflicted with chronic hepatitis B (CHB). The compliance with hepatitis B virus (HBV) management guidelines is still unknown. This was the first study from Pakistan in which the knowledge and practices of treating physicians were compared with three standardized guidelines (Asia Pacific Association for the Study of the Liver (APASL) 2012/European Association for the Study of the Liver (EASL) 2012/American Association for the Study of Liver Diseases (AASLD) 2009). METHODS A cross-sectional study was conducted during 2014-2015 at four tertiary care teaching hospitals of Karachi, Pakistan. The study participants were internists, gastroenterologist, senior residents who were involved in the management of CHB patients. All participants were offered to fill the study questionnaire. RESULTS A total of 179 physicians (103 residents, 76 consultants) participated. Mean age of participant was 35 ± 9.3 years. Approximately one-third of them followed AASLD (27.3%) and EASL (24.0%) guidelines. Entecavir, tenofovir or Peg IFN ∞ 2a were considered as first line therapy by 43%, 38.5% and 30.2% respectively. However, 17.9% preferred entecavir with tenofovir for rescue therapy, 25.7% and 23.5% preferred tenofovir or entecavir as both first line and rescue therapy respectively. Serum HBV DNA, alanine transaminase levels were used to monitor during oral antivirals therapy by 45.3%. hepatocellular carcinoma screening was considered for all HBV cases by 51.4% using ultrasound (55.3%) and alfa fetoprotein (52.5%) every 6 months.Overall 40.2% participants had poor knowledge about indication of liver biopsy, treatment initiation and antiviral prophylaxis. Significant association was found between grades of knowledge and gender, age group, designation and specialty (P < 0.05). Younger physicians, consultants (age 25-40 years) and those who were practicing gastroenterology/hepatology were more likely to have higher knowledge scores in compliance with the guidelines as compared to others. CONCLUSION Our study highlighted the gaps in knowledge and practices in managing CHB patients according to guidelines. Efforts to improve knowledge, refresher courses and appropriate coordination between gastroenterologists and internal medicine physicians could enable management and follow-up of patients with CHB effectively.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- ADV, adefovir
- APASL, Asia Pacific Association for the Study of the Liver
- CHB, chronic hepatitis B
- EASL, European Association for the Study of the Liver
- ESLD, end stage liver disease
- ETV, entecavir
- HBIg, hepatitis B immunoglobulin
- HCC, hepatocellular carcinoma
- LAM, lamivudine
- NAs, nucleoside/nucleotide analogs
- PMDC, Pakistan Medical and Dental Council
- Peg IFN, pegylated interferon
- TDF, tenofovir
- chronic hepatitis B
- compliance
- guidelines
- knowledge
- practices
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Affiliation(s)
| | - Amna S. Butt
- Address for correspondence: Amna Subhan Butt, Consultant Gastroenterologist, Section of Gastroenterology, Department of Medicine, The Aga Khan University, Stadium Road, Karachi 74800, Pakistan. Tel.: +92 21 34864508; fax: +92 21 34934294.
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Agrawal S, Rana BS, Mitra S, Duseja A, Das A, Dhiman RK, Chawla Y. A Case of Acute-on-Chronic Liver Failure (ACLF) Due to An Uncommon Acute And Chronic Event. J Clin Exp Hepatol 2018; 8:95-97. [PMID: 29743800 PMCID: PMC5938333 DOI: 10.1016/j.jceh.2017.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 08/25/2017] [Indexed: 12/12/2022] Open
Abstract
Acute on Chronic Liver Failure (ACLF) is an acute worsening of patients with chronic liver disease resulting in liver failure. Usually these patients have cirrhosis as the underlying liver disease with alcohol being the most common etiology. Common hepatitic illnesses causing acute worsening in Indian patients of ACLF include alcoholic hepatitis, acute viral hepatitis related to hepatitis E virus and acute flare in chronic hepatitis B. We report an adult case of ACLF due acute viral hepatitis related to hepatitis A virus infection superimposed on nonalcoholic steatohepatitis without cirrhosis.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- ACLF
- ACLF, Acute on Chronic Liver Failure
- ALT, Alanine Aminotransferase
- APASL, Asia-Pacific Association for the Study of Liver
- AST, Aspartate Aminotransferase
- EASL, European Association for the Study of the Liver
- HAV, Hepatitis A Virus
- HCV, Hepatitis C Virus
- NAFLD
- NAFLD, Nonalcoholic Fatty Liver Disease
- NASH
- NASH, Nonalcoholic Steatohepatitis
- ULN, Upper Limit of Normal
- USG, Ultrasonography
- cryptogenic cirrhosis
- hepatitis A virus
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Affiliation(s)
- Swastik Agrawal
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Baldev S. Rana
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Suvradeep Mitra
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence: Ajay Duseja, Professor, Department of Hepatology, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, India. Tel.: +91 172 2756336; fax: +91 172 2744401.
| | - Ashim Das
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Radha K. Dhiman
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Yogesh Chawla
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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18
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Arora A, Singh SP, Kumar A, Saraswat VA, Aggarwal R, Bangar M, Bhaumik P, Devarbhavi H, Dhiman RK, Dixit VK, Goel A, Goswami B, Kapoor D, Madan K, Narayan J, Nijhawan S, Pandey G, Rai RR, Sahu MK, Saraf N, Shalimar, Shenoy T, Thomas V, Wadhawan M. INASL Position Statements on Prevention, Diagnosis and Management of Hepatitis B Virus Infection in India: The Andaman Statements. J Clin Exp Hepatol 2018; 8:58-80. [PMID: 29743798 PMCID: PMC5938334 DOI: 10.1016/j.jceh.2017.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 12/09/2017] [Indexed: 12/12/2022] Open
Abstract
Hepatitis B Virus (HBV) infection is one of the major causes of morbidity, mortality and healthcare expenditure in India. There are no Indian consensus guidelines on prevention, diagnosis and management of HBV infection. The Indian National Association for Study of the Liver (INASL) set up a taskforce on HBV in 2016, with a mandate to develop consensus guidelines for diagnosis and management of HBV infection, relevant to disease patterns and clinical practices in India. The taskforce first identified contentious issues on various aspects of HBV management, which were allotted to individual members of the taskforce who reviewed them in detail. A 2-day round table discussion was held on 11th and 12th February 2017 at Port Blair, Andaman & Nicobar Islands, to discuss, debate, and finalize the consensus statements. The members of the taskforce reviewed and discussed the existing literature threadbare at this meeting and formulated the 'INASL position statements' on each of the issues. The evidence and recommendations in these guidelines have been graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system with minor modifications. The strength of recommendations (strong: 1, weak: 2) thus reflects the quality (grade) of underlying evidence (A, B, C, D). We present here the INASL position statements on prevention, diagnosis and management of HBV in India.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- ADV, adefovir dipivoxil
- ALT, alanine aminotransferase
- APASL, Asian Pacific Association for the Study of the Liver
- ART, antiretroviral therapy
- AST, aspartate aminotransferase
- Anti-HBe, antibodies to hepatitis B envelope antigen
- CBC, complete blood count
- CDC, Center for Disease Control
- CHB, chronic hepatitis B
- CU-HCC, Chinese University-Hepatocellular Carcinoma
- DAA, direct-acting antiviral
- DILI, drug induced liver injury
- DNA, deoxyribonucleic acid
- EASL, European Association for the Study of the Liver
- ETV, entecavir
- GAG-HCC, Guide with Age, Gender, HBV DNA, Core Promoter Mutations and Cirrhosis-Hepatocellular Carcinoma
- GGT, gamma-glutamyl transferase
- GRADE, Grading of Recommendations Assessment Development and Evaluation
- HBIG, hepatitis B immune globulin
- HBV, hepatitis B virus
- HBeAg, hepatitis B envelope antigen
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- HDV, hepatitis D virus
- HIV, human immunodeficiency virus
- IFN-α, interferon alpha
- INASL, Indian National Association for Study of the Liver
- INR, international normalized ratio
- KASL, Korean Association for the Study of the Liver
- LAM, lamivudine
- NA, nucleos(t)ide analogue
- PAGE-B, platelets, age, gender—hepatitis B
- PVNR, primary virological non-response
- PVR, partial virological response
- PegIFN-α, pegylated interferon alpha
- RCT, randomized controlled trial
- REACH-B, risk estimation for hepatocellular carcinoma in chronic hepatitis B
- SOVR, sustained off-therapy virological response
- TAF, tenofovir alafenamide
- TDF, tenofovir disoproxil fumarate
- TDV, telbivudine
- TSH, thyroid-stimulating hormone
- VR, virologic response
- WHO, World Health Organization
- anti-HBs, antibody to hepatitis B surface antigen
- cccDNA, covalently closed circular DNA
- chronic hepatitis
- cirrhosis
- eGFR, estimated glomerular filtration rate
- hepatitis B
- jaundice
- liver failure
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Affiliation(s)
- Anil Arora
- Director, Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Ganga Ram Institute for Postgraduate Medical Education & Research (GRIPMER), Sir Ganga Ram Hospital, New Delhi, India
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Moudgil S, Kalra N, Prabhakar N, Dhiman RK, Behera A, Chawla YK, Khandelwal N. Comparison of Contrast Enhanced Ultrasound With Contrast Enhanced Computed Tomography for the Diagnosis of Hepatocellular Carcinoma. J Clin Exp Hepatol 2017; 7:222-229. [PMID: 28970709 PMCID: PMC5620356 DOI: 10.1016/j.jceh.2017.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 03/01/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS The most common primary malignant tumor of liver is hepatocellular carcinoma (HCC). The highest risk of developing HCC is seen in patients of cirrhosis. Ultrasound is used for surveillance in these patients. This study evaluates the role of contrast enhanced ultrasound (CEUS) in the diagnosis of HCC and compares CEUS to contrast enhanced computed tomography (CECT). MATERIALS AND METHODS This prospective study included 22 patients with cirrhosis and suspected to have HCC on the basis of gray scale ultrasound or elevated Alpha-fetoprotein. Multiphasic CECT and CEUS were done. On both CECT and CEUS, arterial phase enhancement patterns of the lesions were classified as heterogeneously hyperenhancing, homogeneously hyperenhancing, isoenhancing or nonenhancing. The enhancement patterns of the lesions in portal venous phase were classified as hyperenhancing, isoenhancing, washout or nonenhancing. Presence or absence of neovascularity and peripheral capsule were also noted. The diagnosis of HCC was made as per American Association for the Study of Liver Diseases (AASLD) guidelines. RESULTS There was moderate degree of agreement between the two modalities in characterizing the enhancement pattern in arterial phase, as calculated by using kappa test (k = 0.59, P < 0.05). Substantial agreement between them, for demonstrating the neovascularity, was also seen (k = 0.772, P < 0.05). CEUS was found to be superior to CECT in demonstrating portal venous phase wash out and peripheral capsule. Only fair agreement was seen between them, with kappa value for portal venous washout being k = 0.38 (P < 0.05) and for peripheral capsule being k = 0.328 (P < 0.05). CONCLUSION CEUS is comparable to CECT in demonstrating the arterial phase enhancement pattern of HCC and the neovascularity. CEUS was found to be better than CECT in demonstrating the portal venous phase washout and peripheral capsule.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- CECT, contrast enhanced computed tomography
- CEMR, contrast enhanced magnetic resonance
- CEUS, contrast enhanced ultrasound
- CT, computed tomography
- HCC, hepatocellular carcinoma
- MI, mechanical index
- MRI, magnetic resonance imaging
- OPD, outpatient department
- RFA, radiofrequency ablation
- UCA, ultrasound contrast agents
- US, ultrasound
- k, kappa value
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Affiliation(s)
- Sandeep Moudgil
- Department of Radio Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Naveen Kalra
- Department of Radio Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence: Naveen Kalra, Department of Radiodiagnosis, PGIMER, Chandigarh, India. Tel.: +91 7087009388.Department of Radiodiagnosis, PGIMERChandigarhIndia
| | - Nidhi Prabhakar
- Department of Radio Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Radha Krishan Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arunanshu Behera
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Yogesh Kumar Chawla
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Niranjan Khandelwal
- Department of Radio Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Owens RE, Snyder HS, Twilla JD, Satapathy SK. Pharmacologic Treatment of Alcoholic Hepatitis: Examining Outcomes Based on Disease Severity Stratification. J Clin Exp Hepatol 2016; 6:275-281. [PMID: 28003716 PMCID: PMC5157883 DOI: 10.1016/j.jceh.2016.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 07/12/2016] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Maddrey discriminant function (MDF) score is a measure of disease prognosis in alcoholic hepatitis (AH) used to identify patients at highest risk of mortality and determine the need for initiation of pharmacologic treatment. The purpose of this study was to evaluate the effects of pharmacologic therapy for hospitalized AH patients as stratified by MDF score. METHODS A retrospective review of patients with an AH diagnosis admitted to a Methodist LeBonheur Healthcare adult hospital between 06/2009 and 06/2014 was conducted. Patients ≥18 years of age with an ICD-9 code for AH were evaluated. RESULTS Of the 493 patients screened, 234 met the inclusion criteria, comprised of 62 patients with an MDF ≥ 32 (treatment, n = 42 vs. no treatment, n = 20) and 172 patients with an MDF < 32 (treatment, n = 15 vs. no treatment, n = 157). For the patients with an MDF ≥ 32, there was no statistically significant difference between the treatment group vs. non-treatment group regarding 28-day mortality (31% vs. 11%, respectively; P = 0.18) and 6-month mortality (45% treatment vs. 38% non-treatment; P = 0.75). For the patients with an MDF <32, there was no statistically significant difference between the treatment group vs. non-treatment group regarding 28-day mortality (0% vs. 7%, respectively; P > 0.99) and 6-month mortality (11% treatment vs. 13% non-treatment; P > 0.99). There was no difference in incidence of acute kidney injury, hepatorenal syndrome, development of infection or hepatic encephalopathy between the treatment vs. non-treatment groups. CONCLUSIONS Pharmacologic treatment showed no survival benefit, regardless of disease severity. Given the mortality risk seen in mild-moderate AH patients not receiving treatment and concern for a possible treatment ceiling effect in severe AH patients, more data are needed to adequately assess the utility of MDF in selecting appropriate candidates for AH treatment.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- AH, alcoholic hepatitis
- AKI, acute kidney injury
- ALD, alcoholic liver disease
- ARR, absolute risk reduction
- GI, gastrointestinal
- HRS, hepatorenal syndrome
- INR, international normalized ratio
- MDF, Maddrey discriminant function
- MELD, Model for End-Stage Liver Disease
- Maddrey discriminant function
- PT, prothrombin time
- SCr, serum creatinine
- SD, standard deviation
- eGFR, estimated glomerular filtration rate
- pentoxifylline
- prednisolone
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Affiliation(s)
- Ryan E. Owens
- University of Oklahoma College of Pharmacy, Department of Pharmacy, Clinical and Administrative Sciences, 1110 North Stonewall Avenue, Oklahoma City, OK 73117, USA,Address for correspondence: Ryan E. Owens, Department of Pharmacy, Clinical and Administrative Sciences, 1110 North Stonewall Avenue, Oklahoma City, OK 73117, USA.Department of Pharmacy, Clinical and Administrative Sciences1110 North Stonewall AvenueOklahoma CityOK73117USA
| | - Heather S. Snyder
- Methodist University Hospital, Department of Pharmacy, 1265 Union Avenue, Memphis, TN 38104, USA
| | - Jennifer D. Twilla
- Methodist University Hospital, Department of Pharmacy, 1265 Union Avenue, Memphis, TN 38104, USA
| | - Sanjaya K. Satapathy
- Methodist University Hospital Transplant Institute, University of Tennessee Health Sciences Center, Division of Surgery, Transplant Hepatology, 1265 Union Avenue, Memphis, TN 38104, USA
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22
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Abstract
Hepatocellular carcinoma (HCC) is one of the major causes of morbidity, mortality and healthcare expenditure in patients with chronic liver disease. The management of HCC is evolving because of recently introduced novel therapeutic approaches. Optimal outcome requires an early and accurate assessment of tumor response to therapy. Current imaging modalities, such as computed tomography (CT) and magnetic resonance (MR) imaging; provide reliable and reproducible anatomical data in order to demonstrate tumor burden changes. However, in the setting of novel targeted therapies and liver directed treatments, simple tumor anatomical changes can be less informative and usually appear later than biological changes. There has been a growing interest to monitor the therapeutic response, at an early phase of treatment, by measuring tumor viability and/or perfusion. Therefore the importance of tumor viability assessment is increasingly being recognized. The tumor viability measurement guidelines have recently been amended to include the measurement of only the longest diameter of the enhancing tumors to formally amend RECIST to modified RECIST (mRECIST). Viable tumor should be defined as uptake of contrast agent in the arterial phase. In this review, we discuss criteria of response evaluation in HCC and further follow-up of patients receiving curative and palliative treatment.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- CR, complete response
- CT, computed tomography
- DWI, diffusion weighted imaging
- EASL, European Association for the Study of the Liver
- GI, gastro-intestinal
- HCC, hepatocellular carcinoma
- MR, magnetic resonance
- PD, progressive disease
- PET, positron emission tomography
- PR, partial response
- RECIST, response evaluation criteria in solid tumors
- RFA, radiofrequency ablation
- SD, stable disease
- TACE, trans-arterial chemoembolization
- WHO, World Health Organization
- liver cancer
- mRECIST, modified response evaluation criteria in solid tumors
- radiofrequency ablation
- targeted therapy
- trans-arterial chemoembolization
- transplant
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Affiliation(s)
- Anil Arora
- Address for correspondence: Dr Anil Arora, Chairman, Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India.
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Kumar A. Current practices in management of hepatocellular carcinoma in India: results of an online survey. J Clin Exp Hepatol 2014; 4:S140-6. [PMID: 25755606 DOI: 10.1016/j.jceh.2014.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 07/05/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Prior to INASL guidelines, there were no Indian guidelines for management of hepatocellular carcinoma (HCC) in India. The guidelines given by other societies like AASLD, EASL etc are not uniform and not tailored for Indian patients. Hence management practices for HCC in India largely depended on physicians' individual preferences. This survey aimed to study current practices in management of HCC in India. METHODS An online survey was conducted from the platform of a survey portal (www.surveymonkey.com), from December 2012 to April 2013. Invitation to participate in the survey was sent to 1383 doctors of India who were expected to be involved in management of patients of HCC. The survey was of 10 min duration and consisted of questions on how the respondents diagnosed and managed patients of HCC. RESULTS Three hundred and seventy-seven doctors answered the survey questions (72% gastroenterologists, 95% working in India). The important points which emerged from the survey are following: (i) The incidence of HCC is increasing in India; (ii) The most common etiologic agent is Hepatitis B responsible for 43% cases; (iii) Only 14% patients present in early stage when curative treatment is possible (BCLC-A); (iv) 90% of these respondents screen for HCC when they first evaluate a cirrhotic patient; (v) While following a patient of cirrhosis most respondents screen for HCC by ultrasound and AFP at every 6 months to 1 year; and (vi) Most (82%) respondents follow some international guideline for staging and treatment of HCC. The respondents also suggested that there is a need for spreading awareness about HCC in public as well as in medical fraternity, and there is a need for a national registry of HCC. CONCLUSIONS This is the first survey on management practices on HCC. With the publication of the INASL guidelines on HCC, the diagnosis and treatment of HCC will be more uniform and protocol based. Further such surveys should be carried out at periodic interval to track increasing awareness and better management practices for HCC in India.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- AFP, alpha–fetoprotein
- BCLC, Barcelona clinic liver cancer
- CECT, contrast enhanced computerized tomography
- CTP, Child Turcotte Pugh
- EASL, European Association for the Study of the Liver
- ESDO, European Society of Digestive Oncology
- FNAC, fine needle aspiration cytology
- GI, gastro-intestinal
- HBV, hepatitis B virus
- HCC, hepatocellular carcinoma
- INASL, Indian National Association for the Study of Liver
- MBBS, Bachelor of Medicine, Bachelor of Surgery
- SOL, space occupying lesion
- TACE, transcatheter arterial chemoembolization
- guidelines
- hepatocellular carcinoma
- liver cancer
- management practices
- survey
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Abstract
The current American Association for the Study of Liver Diseases (AASLD) guideline provides strategies for achieving the diagnosis of hepatocellular carcinoma (HCC) based on the size of liver nodules seen on surveillance imaging. For lesions less than 1 cm in size, follow-up surveillance imaging is recommended. Lesions larger than 2 cm require typical radiological hallmark on dynamic imaging. Lesions of 1-2 cm in size require typical imaging features including intense uptake of contrast during arterial phases followed by decreased enhancement during portal venous phases on at least 2 imaging modalities. In cases of atypical radiological features of the suspected lesion, tissue diagnosis either by fine needle aspiration or biopsy should be obtained. Although fine needle aspiration could give a smaller risk of seeding than biopsy, biopsy has been preferred over cytology. Percutaneous biopsy of HCC carries a potential risk of tumor seeding along the needle tract. However the risk is low and there is no clear evidence of post transplant recurrence due to needle tract seeding. Histopathologic assessment can differentiate between premalignant lesions such as dysplastic nodules and early HCC. Atypical variants of HCC can be recognized morphologically which may have associated prognostic value.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- AFP, alpha-fetoprotein
- CK7, cytokeratin 7
- CT, computed tomography
- DN, dysplastic nodules
- EASL, European Association for the Study of the Liver
- EMA, epithelial membrane antigen
- EpCAM, epithelial cell adhesion molecule
- FNA, fine needle aspiration
- GPC-3, glypican-3
- GS, glutamine synthetase
- HBV, hepatitis B virus
- HCC
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- HSP70, heat shock protein 70
- MRI, magnetic resonance imaging
- USG, ultrasonography
- pCEA, polyclonal carcinoembryonic antigen
- pathology
- tissue diagnosis
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Affiliation(s)
- Deepali Jain
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
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