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Spectrum, Screening, and Diagnosis of Alcohol-related Liver Disease. J Clin Exp Hepatol 2023; 13:75-87. [PMID: 36647416 PMCID: PMC9840079 DOI: 10.1016/j.jceh.2022.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022] Open
Abstract
Alcohol-related liver disease (ALD) represents one of the leading causes of chronic liver disease and is a major cause of liver-related deaths worldwide. ALD encompasses a range of disorders including simple steatosis, alcoholic steatohepatitis, fibrosis, cirrhosis, and hepatocellular carcinoma. Patients with underlying ALD and continued heavy alcohol consumption can also develop an episode of acute-on-chronic liver injury called alcohol-associated hepatitis, the most severe form of the disease, which portends a poor prognosis. The most important risk factor for the development of ALD is the amount of alcohol consumed. Individual susceptibility to progression to advanced fibrosis among heavy drinkers is likely determined by a combination of behavioral, environmental, genetic, and epigenetic factors, but the mechanisms are largely unknown. The only effective therapy for ALD is prolonged alcohol abstinence. Diagnosis of ALD involves assessing patients for alcohol use disorder and signs of advanced liver disease. In clinical practice, the histological assessment for ALD diagnosis is uncommon, and it is usually based on the medical history, clinical manifestations, and laboratory and imaging tests. Several promising biomarkers that can have both diagnostic and prognostic value in patients with ALD have been identified in recent years. This review provides an overview of the clinical spectrum of ALD, the diagnostic approach of the disease from different perspectives as well as current diagnostic and prognostic biomarkers.
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Key Words
- AH, alcohol-associated hepatitis
- ALD, alcohol-related liver disease
- ASH, alcoholic steatohepatitis
- AST, aspartate aminotransferase
- AUD, alcohol use disorder
- AUDIT, Alcohol Use Disorders Identification Test
- CAGE, Cut down, Annoyed, Guilty, and Eye-opener
- DSM-5, Diagnostic and Statistical Manual of Mental Disorders Fifth edition
- GGT, gamma-glutamyl transferase
- HCC, hepatocellular carcinoma
- INR, international normalized ratio
- LSM, liver stiffness measurement
- NAFLD, non-alcoholic fatty liver disease
- PCF, pericellular fibrosis
- SFS, SALVE fibrosis stages
- SHG, SALVE Histopathology Group
- TE, transient elastography
- WHO, World Health Organization
- alcohol-associated hepatitis
- alcohol-related liver cirrhosis
- alcohol-related liver disease
- alcoholic steatohepatitis
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The Impact of the COVID-19 Epidemic on Hospital Admissions for Alcohol-related Liver Disease and Pancreatitis in Western Sydney. GASTRO HEP ADVANCES 2023; 2:424-425. [PMID: 36624832 PMCID: PMC9812465 DOI: 10.1016/j.gastha.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/13/2022] [Accepted: 12/19/2022] [Indexed: 01/06/2023]
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Abstract
BACKGROUND/AIMS Alcohol-related liver disease (ALD) is the medical manifestation of alcohol use disorder, a prevalent psychiatric condition. Acute and chronic manifestations of ALD have risen in recent years especially in young people and ALD is now a leading indication of liver transplantation (LT) worldwide. Such alarming trends raise urgent and unanswered questions about how medical and psychiatric care can be sustainably integrated to better manage ALD patients before and after LT. METHODS Critical evaluation of the interprofessional implications of broad and multifaceted ALD pathophysiology, general principles of and barriers to interprofessional teamwork and care integration, and measures that clinicians and institutions can implement for improved and integrated ALD care. RESULTS The breadth of ALD pathophysiology, and its numerous medical and psychiatric comorbidities, ensures that no single medical or psychiatric discipline is adequately trained and equipped to manage the disease alone. CONCLUSIONS Early models of feasible ALD care integration have emerged in recent years but much more work is needed to develop and study them. The future of ALD care is an integrated approach led jointly by interprofessional medical and psychiatric clinicians.
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Poor Outcomes after Recidivism in Living Donor Liver Transplantation for Alcohol-Related Liver Disease. J Clin Exp Hepatol 2022; 12:37-42. [PMID: 35068783 PMCID: PMC8766539 DOI: 10.1016/j.jceh.2021.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 04/04/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Recidivism in patients who underwent liver transplantation for alcohol-related liver disease (ALD) is shown to be associated with poor survival in some studies. METHODS Living donor liver transplantation (LDLT) recipients for ALD with at least 2 years of follow-up and history of significant alcohol relapse were included. The recipients underwent LDLT from June 2010 to December 2016, and data were analyzed until June 2019. The cohort had a median follow-up of 54 (33-78 IQR) months. Recidivism (significant alcohol intake) was defined as >21 units per week. RESULTS A total of 27 of 463 (5.8%) LDLT recipients (all men), aged 43.5 ± 9.6 years, had significant alcohol intake. A liver biopsy was performed on demand in 14 patients (in the presence of raised levels of liver enzymes or jaundice). The histological diagnoses in these patients were as follows: alcoholic hepatitis in 7 (50%), alcoholic hepatitis and acute cellular rejection or chronic rejection in 4 (28.5%), cirrhosis in 2 (14.2%), and acute cellular rejection and cirrhosis in 1 (7.1%) patient. Four of 5 patients with a biopsy diagnosis of acute or chronic rejection were noncompliant with immunosuppression. Six of these patients died. The mortality after 1 year of transplant was significantly more in patients with recidivism. CONCLUSION Recidivism was associated with significant morbidity and mortality after liver transplantation.
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Postreperfusion Liver Biopsy as Predictor of Early Graft Dysfunction and Survival After Orthotopic Liver Transplantation. J Clin Exp Hepatol 2022; 12:1133-1141. [PMID: 35814514 PMCID: PMC9257905 DOI: 10.1016/j.jceh.2021.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 12/26/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Postreperfusion liver biopsy (PRB) can assess the degree of ischemia/reperfusion injury (IRI) after orthotopic liver transplantation (OLT). The influence of IRI on graft outcomes and overall survival is controversial. AIM To determine the correlation between the severity of IRI in PRB and overall graft and patient survival and, secondarily, to identify factors on PRB that predict poor graft outcomes. METHODS This is a retrospective analysis of all patients who underwent OLT using donation after brain death (DBD) with PRB. The severity of IRI in PRB was graded. Predictors of IRI were assessed using univariate and multivariate analysis and the Kaplan-Meier with log rank test for the graft and overall survival, respectively. RESULTS We included 280 OLTs (64.7%). The histopathological assessment of IRI severity was as follows: no IRI (N = 96, 34.3%), mild IRI (N = 65; 23.2%), moderate IRI (N = 101; 36.1%), and severe IRI (N = 18; 6.4%). The incidence rates of initial good graft function (IGGF), primary nonfunction and early allograft dysfunction (EAD) were 32.5%, 3.9%, and 18.6%, respectively. Severe IRI was associated with a lower incidence of IGGF (OR: 0.34, 95% CI 0.12-0.92; P = 0.03). Patients with severe IRI tended to have a higher incidence of EAD (33.2% vs. 18.6, P = 0.23). The cold ischemia time was an independent predictor of severe IRI on the multivariate analysis. Severe IRI was associated with poor 1- and 5-year overall survival rates (67% and 44%, respectively, compared with 84 and 68% in nonsevere IRI). Patients with severe IRI exhibited worse graft and overall survival. CONCLUSIONS Cold ischemia time predicts the development of severe IRI. Patients with severe IRI show worse graft and overall survival and a lower incidence of IGGF, suggesting that histopathological findings could be useful for identifying patients at high risk of worse outcomes after OLT.
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Key Words
- ALD, alcohol-related liver disease
- ALF, acute liver failure
- ALT, alanine aminotransferase
- CIHD, chronic ischaemic heart disease
- CNI, calcineurin inhibitors
- COPD, chronic obstructive pulmonary disease
- DBD, donation after brain death
- EAD, early allograft dysfunction
- H&E, hematoxylin and eosin
- HBV, hepatitis B virus
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- IGGF, initial good graft function
- IQR, interquartile range
- IRI, ischaemia/reperfusion injury
- MELD, Model for End-stage Liver Disease
- OLT, orthotopic liver transplantation
- ONT, Organización Nacional de Transplantes
- PBC, primary biliary cholangitis
- PNF, primary nonfunction
- PRB, postreperfusion liver biopsy
- SD, standard deviation
- STROBE, Strengthening the Reporting of Observational studies in Epidemiology
- cold ischemia time
- early allograft dysfunction
- ischemia reperfusion injury
- liver transplantation
- postreperfusion biopsy
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Barriers for Liver Transplant in Patients with Alcohol-Related Hepatitis. J Clin Exp Hepatol 2022; 12:13-19. [PMID: 35068780 PMCID: PMC8766699 DOI: 10.1016/j.jceh.2021.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/13/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Liver transplantation (LT) for alcohol-related liver disease has historically been reserved for patients who have been six months abstinent. Given the increasing incidence of alcohol-related hepatitis (AH) and dismal survival in patients who fail medical therapy, transplant centers are extending their acceptance criteria for patients with less than 6 months of sobriety. We sought to determine the barriers for listing. METHODS We conducted a retrospective chart review of all inpatient LT referrals for a diagnosis of AH between September 2019 and December 2020. LT evaluations were performed by a multidisciplinary team. Descriptive statistics were reported using mean and standard deviation (SD) or percentage where appropriate. RESULTS During our study period, 82 patients were evaluated for LT. Of these 82 patients, 62 were declined for liver transplantation. The mean (SD) age of the 62-patient cohort was 44 years (10.7), and most patients were men. The mean (SD) number of reasons for denial was 2 (0.97). Four patients had medical contraindications for transplant. Twenty-seven (44%) and 35 (56%) patients lacked insight and were at risk of alcohol relapse, respectively. Forty-three (69%) and fourteen (22.5%) patients had insufficient social support and an inability to maintain a therapeutic relationship with the transplant team, respectively. CONCLUSION Patients are more likely denied for psychosocial factors than medical comorbidities. The majority were due to lack of insight, insufficient social support, and inability to maintain a therapeutic relationship with the transplant team. Resources should be allocated to address these issues.
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Abstract
Patients with chronic liver disease (CLD) with or without cirrhosis remain at risk of developing hepatic decompensation when infected with viral or bacterial pathogens. The Advisory Committee on Immunization Practices (ACIP) currently recommends vaccination in CLD against hepatitis A virus (HAV), hepatitis B virus (HBV), influenza, pneumococcus, herpes zoster, tetanus, diphtheria, pertussis, and SARS-CoV-2. Inactivated vaccines are preferred over live attenuated ones, especially in transplant recipients where live vaccines are contraindicated. As the severity of the liver disease progresses, vaccine efficacy declines, and therefore, vaccines should be ideally administered early in the disease course for optimal immune response. Despite the strong recommendations, overall vaccination coverage in CLD remains poor; however, it is encouraging to note that in recent years coverage against influenza and pneumococcus has shown some improvement. Inadequate access to healthcare, lack of information on vaccine safety, poor financial reimbursement for healthcare providers, and vaccine misinformation are often responsible for low immunization rates. This review summarizes the impact of vaccine-preventable illness in those with CLD, updated vaccine guidelines, seroconversion rates in the vaccinated, and barriers faced by healthcare professionals in immunizing those with liver disease.
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Key Words
- ACIP, Advisory Committee on Immunization Practices
- ACLF, acute on chronic liver failure
- ALD, alcohol-related liver disease
- CLD, Chronic liver disease
- CLIF-C, Chronic Liver Failure Consortium
- DAA, direct-acting antiviral drugs
- HAV, hepatitis A virus
- HBV, hepatitis B virus
- HCV, hepatitis C virus
- LT, liver transplant
- NAFLD, nonalcoholic fatty liver disease
- SARS-CoV-2
- SOFA, sequential organ failure assessment
- chronic liver disease
- immunization
- vaccines
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External validation of the Toronto hepatocellular carcinoma risk index in a Swedish population. JHEP Rep 2021; 3:100343. [PMID: 34611618 PMCID: PMC8476346 DOI: 10.1016/j.jhepr.2021.100343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/11/2021] [Accepted: 07/29/2021] [Indexed: 11/28/2022] Open
Abstract
Background & Aims The Toronto hepatocellular carcinoma (HCC) risk index (THRI) is a predictive model to determine the risk of HCC in patients with cirrhosis. This study aimed to externally validate the THRI in a Swedish setting to investigate whether it could identify patients not requiring HCC surveillance. Methods From 2004-2017, 2,491 patients with cirrhosis at the Karolinska University Hospital were evaluated. Patients were classified into low-, intermediate- and high-risk groups for future HCC according to the THRI. Harrell’s C-index, calibration-in-the-large, calibration slope and goodness-of-fit estimates were calculated to assess model discrimination and calibration. Cox proportional hazards regression was used to determine the risk of HCC. Results Most patients were male (n = 1,638, 66%). The most common etiologies of cirrhosis were steatohepatitis (n = 1,182, 48%) followed by viral hepatitis (n = 987, 40%). In all, 131 patients (5.3%) were designated as low risk for HCC. Harrell’s C-index was 0.69. Calibration-in-the-large (0.11), calibration slope (1.24, not different from 1, p = 0.66) and goodness-of-fit showed good model calibration. Patients in the high-risk group had a 7.1-fold (95% CI 2.9–17.2) higher risk of HCC and patients in the intermediate-risk group had a 2.5-fold (95% CI 1.0–6.3) higher risk compared to the low-risk group. Conclusions In a Swedish setting, the THRI could differentiate between low- and high-risk of HCC development. However, because the low-risk group was relatively small (5.3%), the clinical applicability of the THRI could be limited. Lay summary The Toronto hepatocellular carcinoma (HCC) risk index (THRI) is a novel prediction model used to stratify patients with cirrhosis based on future risk of HCC. In this study, the THRI was validated in an external cohort using the TRIPOD guidance. Few patients were identified as low-risk, and the THRI had a modest discriminative ability, limiting its clinical applicability. The THRI is a simple and non-invasive method to estimate 5- and 10-year HCC risk. This was the largest validation of the THRI to date. The THRI had a modest discriminative ability and was well-calibrated. However, the THRI could only identify few patients at low risk of HCC, limiting its clinical use.
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Comprehensive lipidomics reveals phenotypic differences in hepatic lipid turnover in ALD and NAFLD during alcohol intoxication. JHEP Rep 2021; 3:100325. [PMID: 34401690 PMCID: PMC8350545 DOI: 10.1016/j.jhepr.2021.100325] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/26/2021] [Accepted: 06/16/2021] [Indexed: 12/17/2022] Open
Abstract
Background & Aims In experimental models, alcohol induces acute changes in lipid metabolism that cause hepatocyte lipoapoptosis and inflammation. Here we study human hepatic lipid turnover during controlled alcohol intoxication. Methods We studied 39 participants with 3 distinct hepatic phenotypes: alcohol-related liver disease (ALD), non-alcoholic fatty liver disease (NAFLD), and healthy controls. Alcohol was administrated via nasogastric tube over 30 min. Hepatic and systemic venous blood was sampled simultaneously at 3 time points: baseline, 60, and 180 min after alcohol intervention. Liver biopsies were sampled 240 min after alcohol intervention. We used ultra-high performance liquid chromatography mass spectrometry to measure levels of more than 250 lipid species from the blood and liver samples. Results After alcohol intervention, the levels of blood free fatty acid (FFA) and lysophosphatidylcholine (LPC) decreased, while triglyceride (TG) increased. FFA was the only lipid class to decrease in NAFLD after alcohol intervention, whereas LPC and FFA decreased and TG increased after intervention in ALD and healthy controls. Fatty acid chain uptake preference in FFAs and LPCs were oleic acid, linoleic acid, arachidonic acid, and docosahexaenoic acid. Hepatic venous blood FFA and LPC levels were lower when compared with systemic venous blood levels throughout the intervention. After alcohol intoxication, liver lipidome in ALD was similar to that in NAFLD. Conclusions Alcohol intoxication induces rapid changes in circulating lipids including hepatic turnaround from FFA and LPC, potentially leading to lipoapoptosis and steatohepatitis. TG clearance was suppressed in NAFLD, possibly explaining why alcohol and NAFLD are synergistic risk factors for disease progression. These effects may be central to the pathogenesis of ALD. Clinical Trials Registration The study is registered at Clinicaltrials.gov (NCT03018990). Lay summary We report that alcohol induces hepatic extraction of free unsaturated fatty acids and lysophosphatidylcholines, hepatotoxic lipids which have not been previously associated with alcohol-induced liver injury. We also found that individuals with non-alcoholic fatty liver disease have reduced lipid turnover during alcohol intoxication when compared with people with alcohol-related fatty liver disease. This may explain why alcohol is particularly more harmful in people with non-alcoholic fatty liver and why elevated BMI and alcohol have a synergistic effect on the risk of liver-related death. Alcohol intoxication induces rapid changes in the profile of circulating lipids. Alcohol has a profound effect on monosaturated fatty acids. Triglyceride clearance is suppressed in NAFLD during alcohol intoxication. Hepatic lipid turnover differentiates ALD and NAFLD during alcohol intoxication. A suppressed metabolic response may explain why alcohol is particularly harmful in NAFLD.
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Key Words
- ALD, alcohol-related liver disease
- ALT, alanine aminotransferase
- AST, asparagine aminotransferase
- Alcohol
- CTL, healthy control
- Cer, ceramide
- DG, diglyceride
- Ethanol
- FFA, free fatty acid
- Fatty acids
- GGT, gamma-glutamyl transferase
- HOMA-IR, Homeostatic Model Assessment of Insulin Resistance
- Heavy drinking
- HexCer, hexosylceramide
- LPC, lysophosphatidylcholine
- LPE, lysophosphatidylethanolamine
- LacCer, lactosylceramides
- Lipidomics
- Liver disease
- Lysophosphatidylcholines
- NAFLD, non-alcoholic fatty liver disease
- P-glucose, plasma glucose
- PC, phosphatidylcholine
- PE, phosphatidylethanolamine
- PI, phosphatidylinositol
- PLA2, phospholipase A2
- QC, quality control
- SHexCer, sulfatides hexosylceramide
- SM, sphingomyelin
- TE, transient elastography
- TG, triglyceride
- Triglycerides
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Epidemiology of non-alcoholic fatty liver disease and hepatocellular carcinoma. JHEP Rep 2021; 3:100305. [PMID: 34189448 PMCID: PMC8215299 DOI: 10.1016/j.jhepr.2021.100305] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/07/2021] [Accepted: 05/01/2021] [Indexed: 02/07/2023] Open
Abstract
The prevalence of hepatocellular carcinoma (HCC) is increasing worldwide, whereas that of most other cancers is decreasing. Non-alcoholic fatty liver disease (NAFLD), which has increased with the epidemics of obesity and type 2 diabetes, increases the risk of HCC. Interestingly, NAFLD-associated HCC can develop in patients with or without cirrhosis. A lack of awareness about NAFLD-related HCC has led to delays in diagnosis. Therefore, a large number of patients with HCC are diagnosed with advanced-stage HCC with low 5-year survival. In this context, increasing awareness of NAFLD and NAFLD-related HCC may lead to earlier diagnosis and more effective interventions.
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Key Words
- ALD, alcohol-related liver disease
- CVD, cardiovascular disease
- ELF, enhanced liver fibrosis
- FIB-4, fibrosis-4
- HCC, hepatocellular carcinoma
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- PDGF, platelet-derived growth factor
- STAT3, signal transducer and activator of transcription 3
- TNF, tumour necrosis factor-α
- VEGF, vascular endothelial growth factor
- awareness
- cirrhosis
- natural history
- non-cirrhosis
- surveillance
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Impact of alcohol abstinence on survival after hepatic resection for hepatocellular carcinoma in patients with alcohol-related liver disease. Ann Med Surg (Lond) 2021; 68:102644. [PMID: 34386231 PMCID: PMC8346358 DOI: 10.1016/j.amsu.2021.102644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/28/2021] [Accepted: 07/28/2021] [Indexed: 12/03/2022] Open
Abstract
Background This study aimed to evaluate the prognostic impact of alcohol abstinence on survival after hepatic resection for hepatocellular carcinoma (HCC) in patients with alcohol-related liver disease (ALD). Patients and methods In total, 92 patients with ALD-HCC who underwent initial and curative hepatic resection were identified, including 56 and 36 patients with and without alcohol abstinence, respectively. Results The 3-, 5-, and 7-year recurrence-free survival (RFS) were 46%, 43%, and 37% in the abstinence group, and 61%, 36%, and 36% in the non-abstinence group, respectively (p = 0.71). The 3-, 5-, and 7-year overall survival (OS) were 91%, 76%, and 66% in the abstinence group, and 87%, 57%, and 44% in the non-abstinence group, respectively (p = 0.023). Multivariate analysis revealed that non-abstinence was an independent prognostic factor for OS (P = 0.026). The incidence rate of liver-related death including HCC-specific death, liver failure, and renal failure in cirrhosis (hepatorenal syndrome) between the non-abstinence and abstinence groups were 41.7% vs. 19.6% (p = 0.032). Worsening of the Child–Pugh grade at intrahepatic recurrence was more frequently observed in the non-abstinence (33.3%) than that in the abstinence group (6.5%) (p = 0.039). Conclusions Alcohol abstinence might improve the long-term survival of patients with ALD-HCC undergoing hepatic resection. Non-abstinence after surgery was an independent prognostic factor for overall survival with a 2.2-fold increased risk. Worsening of Child–Pugh grade at intrahepatic recurrence was less frequently observed in the abstinent patients. Hepatic resection tended to be more frequently performed for the treatment of HCC recurrence in the abstinent patients. The incidence rate of liver-related death was significantly lower in the abstinent patients.
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Key Words
- ALD, alcohol-related liver disease
- ALT, alanine aminotransferase
- APRI, aspartate aminotransferase-to-platelet ratio index
- AST, aspartate aminotransferase
- Alcohol abstinence
- Alcohol-related liver disease
- BMI, body mass index
- FIB-4, fibrosis index based on four factors
- GGT, gamma-glutamyl transpeptidase
- HBV, hepatitis B virus
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- Hepatocellular carcinoma
- OS, overall survival
- RFS, recurrence-free survival
- TACE, transcatheter arterial chemoembolization
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Abstract
The recently identified novel cytosolic DNA sensor cyclic GMP-AMP synthase (cGAS) activates the downstream adaptor protein stimulator of interferon genes (STING) by catalysing the synthesis of cyclic GMP-AMP. This in turn initiates an innate immune response through the release of various cytokines, including type I interferon. Foreign DNA (microbial infection) or endogenous DNA (nuclear or mitochondrial leakage) can serve as cGAS ligands and lead to the activation of cGAS-STING signalling. Therefore, the cGAS-STING pathway plays essential roles in infectious diseases, sterile inflammation, tumours, and autoimmune diseases. In addition, cGAS-STING signalling affects the progression of liver inflammation through other mechanisms, such as autophagy and metabolism. In this review, we summarise recent advances in our understanding of the role of cGAS-STING signalling in the innate immune modulation of different liver diseases. Furthermore, we discuss the therapeutic potential of targeting the cGAS-STING pathway in the treatment of liver diseases.
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Key Words
- AIM2, absent in melanoma 2
- ALD, alcohol-related liver disease
- APCs, antigen-presenting cells
- CDNs, cyclic dinucleotides
- DAMPs, damage-associated molecular patterns
- DCs, dendritic cells
- ER, endoplasmic reticulum
- GVHD, graft-versus-host disease
- HCC, hepatocellular carcinoma
- HSCs, hepatic stellate cells
- IFN-I, type I interferon
- IL, interleukin
- IRF3, interferon regulatory factor 3
- IRI, ischaemia refusion injury
- KCs, Kupffer cells
- LSECs, liver sinusoidal endothelial cells
- MHC, major histocompatibility complex
- NAFLD, non-alcoholic fatty liver disease
- NK cells, natural killer cells
- NPCs, non-parenchymal cells
- PAMPs, pathogen-associated molecular patterns
- PD-1, programmed cell death protein-1
- PD-L1, programmed cell death protein ligand-1
- PPRs, pattern recognition receptors
- SAVI, STING-associated vasculopathy with onset in infancy
- STING, stimulator of interferon genes
- TBK1, TANK-binding kinase 1
- TGF-β1, transforming growth factor-β1
- TLR, Toll-like receptor
- TNF, tumour necrosis factor
- XRCC, X-ray repair cross complementing
- aHSCT, allogeneic haematopoietic stem cell transplantation
- cGAMP, cyclic guanosine monophosphate-adenosine monophosphate
- cGAS, cyclic guanosine monophosphate-adenosine monophosphate synthase
- cGAS-STING signalling
- dsDNA, double-strand DNA
- hepatocellular carcinoma
- innate immune response
- liver injury
- mTOR, mammalian target of rapamycin
- mtDNA, mitochondrial DNA
- nonalcoholic fatty liver disease
- siRNA, small interfering RNA
- ssRNA, single-stranded RNA
- viral hepatitis
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NAFLD and MAFLD as emerging causes of HCC: A populational study. JHEP Rep 2021; 3:100231. [PMID: 33748726 PMCID: PMC7957147 DOI: 10.1016/j.jhepr.2021.100231] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 12/14/2020] [Accepted: 01/06/2021] [Indexed: 12/29/2022] Open
Abstract
Background & Aims There are conflicting data regarding the epidemiology of hepatocellular carcinoma (HCC) arising in the context of non-alcoholic and metabolic-associated fatty liver disease (NAFLD and MAFLD). We aimed to examine the changing contribution of NAFLD and MAFLD, stratified by sex, in a well-defined geographical area and highly characterised HCC population between 1990 and 2014. Methods We identified all patients with HCC resident in the canton of Geneva, Switzerland, diagnosed between 1990 and 2014 from the prospective Geneva Cancer Registry and assessed aetiology-specific age-standardised incidence. NAFLD-HCC was diagnosed when other causes of liver disease were excluded in cases with type 2 diabetes, metabolic syndrome, or obesity. Criteria for MAFLD included one or more of the following criteria: overweight/obesity, presence of type 2 diabetes mellitus, or evidence of metabolic dysregulation. Results A total of 76/920 (8.3%) of patients were diagnosed with NAFLD-HCC in the canton of Geneva between 1990 and 2014. Between the time periods 1990–1994 and 2010–2014, there was a significant increase in HCC incidence in women (standardised incidence ratio [SIR] 1.83, 95% CI 1.08–3.13, p = 0.026) but not in men (SIR 1.10, 95% CI 0.85–1.43, p = 0.468). In the same timeframe, the proportion of NAFLD-HCC increased more in women (0–29%, p = 0.037) than in men (2–12%, p = 0.010) while the proportion of MAFLD increased from 21% to 68% in both sexes and from 7% to 67% in women (p <0.001). From 2000–2004 to 2010–2014, the SIR of NAFLD-HCC increased to 1.92 (95% CI 0.77–5.08) for men and 12.7 (95% CI 1.63–545) in women, whereas it decreased or remained stable for other major aetiologies of HCC. Conclusions In a populational cohort spanning 25 years, the burden of NAFLD and MAFLD associated HCCs increased significantly, driving an increase in HCC incidence, particularly in women. Lay summary Hepatocellular carcinoma (HCC) is the most common type of liver cancer, increasingly arising in patients with liver disease caused by metabolic syndrome, termed non-alcoholic fatty liver disease (NAFLD) or metabolic-associated fatty liver disease (MAFLD). We assessed all patients with HCC between 1990 and 2014 in the canton of Geneva (western Switzerland) and found an increase in all HCC cases in this timeframe, particularly in women. In addition, we found that HCC caused by NAFLD or MAFLD significantly increased over the years, particularly in women, possibly driving the increase in overall HCC cases. The burden of HCC arising in the context of non-alcoholic and metabolic-associated fatty liver disease (NAFLD and MAFLD) remains unclear. We assessed all HCC cases between 1990 and 2014 in an area of western Switzerland. We found a significant increase in overall HCC incidence in women but not in men. The proportion of NAFLD- and MAFLD-HCC increased in both sexes, particularly in women. Liver function of MAFLD patients was intermediate between ‘pure’ NAFLD and non-MAFLD individuals.
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Key Words
- AFP, alpha-foetoprotein
- ALD, alcohol-related liver disease
- ALT, alanine transaminase
- ASI, age-standardised incidence
- AST, aspartate aminotransferase
- Fatty liver
- GGT, gamma-glutamyltransferase
- HCC, hepatocellular carcinoma
- HR, hazard ratio
- Hepatocellular carcinoma
- INR, international normalised ratio
- Liver cancer
- MAFLD, metabolic-associated fatty liver disease
- MELD, model for end-stage liver disease
- Metabolic syndrome
- NAFLD, non-alcoholic fatty liver disease
- SIR, standardised incidence ratio
- TACE, transarterial chemoembolisation
- Women’s health
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Case-finding strategies in non-alcoholic fatty liver disease. JHEP Rep 2020; 3:100219. [PMID: 33659890 PMCID: PMC7896150 DOI: 10.1016/j.jhepr.2020.100219] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/18/2020] [Accepted: 11/23/2020] [Indexed: 12/18/2022] Open
Abstract
Among the large population of patients with non-alcoholic fatty liver disease (NAFLD), identifying those with advanced disease remains challenging. Many patients are diagnosed late, following the development of liver-related complications, leading to poor clinical outcomes. Accumulating evidence suggests that using non-invasive tests for liver fibrosis in patients with metabolic risk factors improves the detection of patients in need of specialised management and is cost-effective. Because of the vast number of patients requiring evaluation, the active participation of general practitioners and physicians who manage patients with metabolic disorders, such as diabetologists, is crucial; this calls for the increased awareness of NAFLD beyond liver clinics. Non-invasive case-finding strategies will need to be further validated and generalised for upcoming drug therapies to have the required impact on the worldwide burden of NAFLD.
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Key Words
- ALD, alcohol-related liver disease
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- Awareness
- Case-finding
- Cirrhosis
- Cost-effectiveness
- ELF, enhanced liver fibrosis
- Elastography
- FIB-4
- FIB-4, fibrosis-4
- GP, general practitioner
- Liver fibrosis
- NAFLD, non-alcoholic fatty liver disease
- NAS, NAFLD activity score
- NASH, non-alcoholic steatohepatitis
- NFS, NAFLD fibrosis score
- NICE, National Institute of Clinical Excellence
- NIT, non-invasive test
- Patient pathway
- Primary care
- QALY, quality-adjusted life year
- Screening
- T2DM, type 2 diabetes mellitus
- TE, transient elastography
- Type 2 diabetes mellitus
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Abstract
The organoid model represents a major breakthrough in cell biology that has revolutionised biomedical research. Organoids are 3D physiological in vitro structures that recapitulate morphological and functional features of in vivo tissues and offer significant advantages over traditional cell culture methods. Liver organoids are of particular interest because of the pleiotropy of functions exerted by the human liver, their utility to model different liver diseases, and their potential application as cell-based therapies in regenerative medicine. Moreover, because they can be derived from patient tissues, organoid models offer new perspectives in personalised medicine and drug discovery. In this review, we discuss the current liver organoid models for the study of liver disease.
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Key Words
- 3D cultures
- A1AT, alpha-1 antitrypsin
- ALD, alcohol-related liver disease
- CCA, cholangiocarcinoma
- CFTR, cystic fibrosis transmembrane conductance regulator
- CHC, combined hepato-cholangiocarcinoma
- CLD, chronic liver disease
- CTLN1, citrullinemia type 1
- Chol-orgs, cholangiocyte organoids
- Disease modelling
- EGF, epidermal growth factor
- ER, endoplasmic reticulum
- ESCs, embryonic stem cells
- FFAs, free fatty acids
- HCC, hepatocellular carcinoma
- HUVEC, human umbilical vein endothelial cells
- Hep-orgs, hepatocyte organoids
- IL-, interleukin-
- Liver disease
- MSC, mesenchymal stem cell
- NAFLD, non-alcoholic fatty liver disease
- Organoids
- PDO, patient-derived organoid
- PDX, patient-derived xenograft
- PHH, primary human hepatocyte
- PSC, primary sclerosing cholangitis
- Personalised medicine
- Preclinical models
- iPSC, induced pluripotent stem cell
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Abstract
While metabolic syndrome and alcohol consumption are the two main causes of chronic liver disease, one of the two conditions is often predominant, with the other acting as a cofactor of morbimortality. It has been shown that obesity and alcohol act synergistically to increase the risk of fibrosis progression, hepatic carcinogenesis and mortality, while genetic polymorphisms can strongly influence disease progression. Based on common pathogenic pathways, there are several potential targets that could be used to treat both diseases; based on the prevalence and incidence of these diseases, new therapies and clinical trials are needed urgently.
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Key Words
- ACC, acetyl-CoA carboxylase
- ALD
- ALD, alcohol-related liver disease
- ASH
- ASH, alcohol-related steatohepatitis
- ASK-1, apoptosis signal-regulating kinase 1
- Alcohol
- BMI, body mass index
- CLD, chronic liver disease
- CPT, carnitine palmitoyltransferase
- DNL, de novo lipogenesis
- EASL, European Association for the Study of the Liver
- ER, endoplasmic reticulum
- FXR, farnesoid X receptor
- HCC, hepatocellular carcinoma
- HSD17B13, hydroxysteroid 17-beta dehydrogenase 13
- IL, interleukin
- LPS, lipopolysaccharide
- MBOAT7, membrane bound O-acyl transferase 7
- MELD, model for end-stage liver disease
- NAFLD
- NAFLD, non-alcoholic fatty liver disease
- NASH
- NASH, non-alcoholic steatohepatitis
- OR, odds ratio
- PAMP, pathogen-associated molecular pattern
- PI3K, phosphatidylinositol-3-kinase
- PIP3, phosphatidylinositol 3,4,5-triphosphate
- PNPLA3, palatin-like phospholipase domain-containing 3
- PRKCE, protein kinase C Epsilon
- ROS, reactive oxygen species
- SREBP-1c, sterol regulatory element binding protein-1c
- TLR, Toll-like receptor
- TM6SF2, transmembrane 6 superfamily member 2
- TNF-α, tumour necrosis factor-α
- WHO, World Health Organization
- diabetes
- metabolic syndrome
- obesity
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17
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Beta-blockers in cirrhosis: Evidence-based indications and limitations. JHEP Rep 2020; 2:100063. [PMID: 32039404 PMCID: PMC7005550 DOI: 10.1016/j.jhepr.2019.12.001] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 02/07/2023] Open
Abstract
Non-selective beta-blockers (NSBBs) are the mainstay of treatment for portal hypertension in the setting of liver cirrhosis. Randomised controlled trials demonstrated their efficacy in preventing initial variceal bleeding and subsequent rebleeding. Recent evidence indicates that NSBBs could prevent liver decompensation in patients with compensated cirrhosis. Despite solid data favouring NSBB use in cirrhosis, some studies have highlighted relevant safety issues in patients with end-stage liver disease, particularly with refractory ascites and infection. This review summarises the evidence supporting current recommendations and restrictions of NSBB use in patients with cirrhosis.
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Key Words
- ACLF
- ACLF, acute-on-chronic liver failure
- AKI, acute kidney injury
- ALD, alcohol-related liver disease
- ARD, absolute risk difference
- AV, atrioventricular
- EBL, endoscopic band ligation
- GOV, gastroesophageal varices
- HRS, hepatorenal syndrome
- HVPG, hepatic venous pressure gradient
- IGV, isolated gastric varices
- IRR, incidence rate ratio
- ISMN, isosorbide mononitrate
- MAP, mean arterial pressure
- NASH, non-alcoholic steatohepatitis
- NNH, number needed to harm
- NNT, number needed to treat
- NR, not reported
- NSBBs
- NSBBs, non-selective beta-blockers
- OR, odds ratio
- PH, portal hypertension
- PHG, portal hypertensive gastropathy
- RCT, randomised controlled trials
- RR, risk ratio
- SBP, spontaneous bacterial peritonitis
- SCL, sclerotherapy
- TIPS, transjugular intrahepatic portosystemic shunt
- ascites
- cirrhosis
- portal hypertension
- spontaneous bacterial peritonitis
- varices
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Prevalence of Minimal Hepatic Encephalopathy in Patients With Liver Cirrhosis: A Cross-Sectional, Clinicoepidemiological, Multicenter, Nationwide Study in India: The PREDICT Study. J Clin Exp Hepatol 2019; 9:476-483. [PMID: 31516264 PMCID: PMC6728606 DOI: 10.1016/j.jceh.2018.09.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 09/19/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The study aimed at assessing the prevalence and clinical profile of minimal hepatic encephalopathy (MHE) in patients with cirrhosis using neuropsychological assessment and at understanding the management practices of MHE in the Indian clinical setting. METHODS This cross-sectional, clinicoepidemiological study conducted at 20 sites enrolled liver cirrhosis patients with Grade 0 hepatic encephalopathy according to West-Haven Criteria. Patients were subjected to mini-mental state examination and those with a score of ≥24 were assessed using psychometric hepatic encephalopathy score. Short Form-36 questionnaire was administered to assess the impact on health-related quality of life. RESULTS Of the 1260 enrolled patients, 1114 were included in the analysis. The mean age was 49.5 years and majority were males (901 [81%]). The prevalence of MHE was found to be 59.7% (665/1114) based on the psychometric hepatic encephalopathy score of ≤-5. Alcohol-related liver disease was the most common etiology (482 [43.27%]) followed by viral infection (239 [21.45%]). Past smokers as well as those currently smoking were more likely to have MHE than nonsmokers. A significant association was found between tobacco chewing, smoking, alcohol consumption, diabetes, and the presence of MHE. Multivariable analysis revealed smoking as the only parameter associated with MHE. A total of 300 (26.9%) patients were on prophylaxis with lactulose/lactitol or rifaximin. These patients were less likely to have MHE as compared to those not on prophylaxis (odds ratio, 0.67; 95% confidence interval, 0.50-0.88; P = 0.005). CONCLUSION The disease burden of MHE is quite substantial in patients with cirrhosis with no apparent cognitive defect. Smoking, whether past or current, has significant association with the presence of MHE. Although MHE has been shown to adversely affect quality of life, prophylaxis for MHE is not routinely practiced in the Indian setting.The study has been registered under clinical trials registry of India (CTRI/2014/01/004306).
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Key Words
- ALD, alcohol-related liver disease
- CI, confidence interval
- DST, Digit Symbol Test
- FCT, figure connection test
- HE, hepatic encephalopathy
- HRQL, health-related quality of life
- MCS, mental component summary
- MELD, model for end-stage liver disease
- MHE, minimal hepatic encephalopathy
- MMSE, mini-mental state examination
- NCT, number connection test
- PCS, physical component summary
- PHES
- PHES, psychometric hepatic encephalopathy score
- SF-36, Short Form-36
- cirrhosis
- covert hepatic encephalopathy
- hepatic encephalopathy
- lactulose
- minimal hepatic encephalopathy
- quality of life
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