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Rashidi-Alavijeh J, Nuruzade N, Frey A, Huessler EM, Hörster A, Zeller AC, Schütte A, Schmidt H, Willuweit K, Lange CM. Implications of anaemia and response to anaemia treatment on outcomes in patients with cirrhosis. JHEP Rep 2023; 5:100688. [PMID: 36926273 PMCID: PMC10011825 DOI: 10.1016/j.jhepr.2023.100688] [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: 08/03/2022] [Revised: 12/29/2022] [Accepted: 01/12/2023] [Indexed: 01/30/2023] Open
Abstract
Background & Aims Anaemia is frequently observed in patients with cirrhosis and was identified as a predictor of adverse outcomes, such as increased mortality and occurrence of acute-on-chronic liver failure. To date, the possible effects of iron supplementation on these adverse outcomes are not well described. We therefore aimed to assess the role of iron supplementation in patients with cirrhosis and its capability to improve prognosis. Methods Laboratory diagnostics were performed in consecutive outpatients with cirrhosis admitted between July 2018 and December 2019 to the University Hospital Essen. Associations with transplant-free survival were assessed in regression models. Results A total of 317 outpatients with cirrhosis were included, of whom 61 received a liver transplant (n = 19) or died (n = 42). In multivariate Cox regression analysis, male sex (hazard ratio [HR] = 3.33, 95% CI [1.59, 6.99], p = 0.001), model for end-stage liver disease score (HR = 1.19, 95% CI [1.11, 1.27], p <0.001) and the increase of haemoglobin levels within 6 months (ΔHb6) (HR = 0.72, 95% CI [0.63, 0.83], p <0.001) were associated with transplant-free survival. Regarding the prediction of haemoglobin increase, intake of rifaximin (beta = 0.50, SD beta = 0.19, p = 0.007) and iron supplementation (beta = 0.79, SD beta = 0.26, p = 0.003) were significant predictors in multivariate analysis. Conclusions An increase of haemoglobin levels is associated with improvement of transplant-free survival in patients with cirrhosis. Because the prediction of haemoglobin increase significantly depends on rifaximin and iron supplementation, application of these two medications can have an important impact on the outcome of these patients. Impact and implications Anaemia is very common in patients with cirrhosis and is known to be a predictor of negative outcomes, but little is known about the effect of iron substitution in these individuals. In our cohort, increase of haemoglobin levels improved transplant-free survival of patients with cirrhosis. The increase of haemoglobin levels was mainly induced by iron supplementation and was even stronger in the case of concomitant use of iron and rifaximin. Clinical trial registration UME-ID-10042.
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Key Words
- ACLF, acute-on-chronic liver failure
- AIH, autoimmune hepatitis
- ALT, alanine aminotransferase
- AP, alkaline phosphatase
- AST, aspartate aminotransferase
- CRP, C-reactive protein
- Haemoglobin
- INR, international normalised ratio
- Iron deficiency
- Iron supplementation
- LT, liver transplantation
- Liver transplantation
- MELD, model for end-stage liver disease
- NASH, non-alcoholic steatohepatitis
- NSBBs, non-selective beta blockers
- PBC, primary biliary cholangitis
- PSC, primary sclerosing cholangitis
- Rifaximin
- SSC, secondary sclerosing cholangitis
- TIPS, transjugular intrahepatic portosystemic shunt
- aPTT, activated partial thromboplastin time
- ΔHb3, difference of haemoglobin levels after 3 months
- ΔHb6, difference of haemoglobin levels after 6 months
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Affiliation(s)
- Jassin Rashidi-Alavijeh
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Nargiz Nuruzade
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Alexandra Frey
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Eva-Maria Huessler
- Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), University of Duisburg-Essen, Duisburg, Germany
| | - Anne Hörster
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Amos Cornelius Zeller
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Andreas Schütte
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Hartmut Schmidt
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Katharina Willuweit
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
| | - Christian Markus Lange
- Department of Gastroenterology, Hepatology and Transplant Medicine, Medical Faculty, University of Duisburg-Essen, Duisburg, Germany
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Abstract
Acute-on-chronic liver failure (ACLF) is a clinical syndrome that occurs in patients with cirrhosis and is characterised by acute deterioration, organ failure and high short-term mortality. Alcohol is one of the leading causes of ACLF and the most frequently reported aetiology of underlying chronic liver disease. Among patients with alcoholic hepatitis (AH), ACLF is a frequent and severe complication. It is characterised by both immune dysfunction associated to an increased risk of infection and high-grade systemic inflammation that ultimately induce organ failure. Diagnosis and severity of ACLF determine AH prognosis, and therefore, ACLF prognostic scores should be used in severe AH with organ failure. Corticosteroids remain the first-line treatment for severe AH but they seem insufficient when ACLF is associated. Novel therapeutic targets to contain the excessive inflammatory response and reduce infection have been identified and are under investigation. With liver transplantation remaining one of the most effective therapies for severe AH and ACLF, adequate organ allocation represents a growing challenge. Hence, a clear understanding of the pathophysiology, clinical implications and management strategies of ACLF in AH is essential for hepatologists, which is narrated briefly in this review.
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Key Words
- ACLF, Acute-on-chronic liver failure
- AH, alcoholic hepatitis
- ALT, alanine aminotransferase
- APASL, Asian Pacific Association for the Study of the Liver
- AST, aspartate aminotransferase
- DAMPs, damage-associated molecular patterns
- EASL-CLIF, European Association for the Study of the Liver – Chronic Liver Failure Consortium
- GAHS, Glasgow alcoholic hepatitis score
- IL, interleukin
- INR, international normalised ratio
- MELD, model for end-stage liver disease
- NAC, N-acetylcysteine
- NACSELD, North American Consortium for the Study of End-Stage Liver Disease
- PAMPs, pathogen-associated molecular patterns
- TNF, tumour necrosis factor
- WGO, World Gastroenterology Organization
- acute-on-chronic liver failure
- alcoholic hepatitis
- cirrhosis
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Affiliation(s)
- Maria Pilar Ballester
- Digestive Disease Department, University Clinic Hospital of Valencia, Blasco Ibañez Av, 17, Valencia, 46010, Spain
- INCLIVA Biomedical Research Institute, Menéndez y Pelayo St., 4, Valencia, 46010, Spain
| | - Richard Sittner
- Department of Hepatology and Gastroenterology, Campus Virchow-Klinikum, Charitéplatz 1 Berlin, 10117, Germany
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Disease Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, United Kingdom
- European Foundation for the Study of Chronic Liver Failure (EF Clif) and the European Association for the Study of the Liver–Chronic Liver Failure (EASL-CLIF) Consortium, Travessera de Gràcia St., 11, Barcelona, 08021, Spain
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Reißing J, Lutz P, Frissen M, Ibidapo-Obe O, Reuken PA, Wirtz TH, Stengel S, Quickert S, Rooney M, Große K, Zimmermann HW, Trautwein C, Stallmach A, Bruns T. Immunomodulatory receptor VSIG4 is released during spontaneous bacterial peritonitis and predicts short-term mortality. JHEP Rep 2021; 4:100391. [PMID: 34917912 PMCID: PMC8666561 DOI: 10.1016/j.jhepr.2021.100391] [Citation(s) in RCA: 1] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 10/01/2021] [Accepted: 10/20/2021] [Indexed: 12/13/2022]
Abstract
Background & Aims V-set Ig-domain-containing 4 (VSIG4) is an immunomodulatory macrophage complement receptor modulating innate and adaptive immunity and affecting the resolution of bacterial infections. Given its expression on peritoneal macrophages (PMs), we hypothesised a prognostic role of peritoneal VSIG4 concentrations in patients with spontaneous bacterial peritonitis (SBP). Methods We isolated PMs from patients with cirrhosis and analysed VSIG4 expression and release by flow cytometry, quantitative real-time PCR, ELISA, and confocal microscopy. We measured soluble VSIG4 concentrations in ascites from 120 patients with SBP and 40 patients without SBP and investigated the association of soluble VSIG4 in ascites with 90-day survival after SBP using Kaplan–Meier statistics, Cox regression, and competing-risks regression analysis. Results VSIG4 expression was high on resting, large PMs, which co-expressed CD206, CD163, and tyrosine-protein kinase Mer (MERTK). VSIG4 gene expression in PMs decreased in patients with SBP and normalised after resolution. During SBP, VSIG4hi PMs were depleted (25% vs. 57%; p <0.001) and soluble VSIG4 in ascites were higher in patients with SBP than in patients without (0.73 vs. 0.35 μg/ml; p <0.0001). PM activation by Toll-like receptor (TLR) agonists or infection with live bacteria in vitro resulted in a loss of surface VSIG4 and the release of soluble VSIG4. Mechanistically, shedding of VSIG4 from PMs was protease-dependent and susceptible to microtubule transport inhibition. Soluble VSIG4 in ascites exceeded serum concentrations and correlated with serum creatinine, model for end-stage liver disease score and C-reactive protein during SBP. Concentrations of 1.0206 μg/ml or higher indicated increased 90-day mortality (hazard ratio 1.70; 95% CI 1.01–2.86; p = 0.046). Conclusions VSIG4 is released from activated PMs into ascites during SBP. Higher peritoneal VSIG4 levels indicate patients with organ failure and poor prognosis. Lay summary Patients with liver cirrhosis who develop ascites have an increased risk of infection and mortality. Our study shows that in patients with infected ascites, the complement receptor VSIG4 is released by resident macrophages into the abdominal fluid where it can be measured. Patients with elevated levels of this protein in ascites are at high risk of dying within 90 days. VSIG4 expression is high on human resting, large peritoneal macrophages (PMs) that co-express CD206, CD163, and MERTK. PM activation by TLR agonists or infection results in the loss of surface VSIG4 and release of soluble VSIG4 (sVSIG4). Ascites sVSIG4 correlates with organ dysfunction and inflammation during SBP. Higher ascitic fluid sVSIG4 concentrations indicated increased risk of 90-day mortality in 120 patients with SBP. Addition of an antibody binding to the extracellular domain of VSIG4 enhanced phagocytosis of bacteria in vitro.
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Key Words
- AF, ascitic fluid
- BSA, bovine serum albumin
- Bacterial infection
- Biomarker
- C3, complement component 3
- CCR2, C-C chemokine receptor type 2
- EEA1, early endosome antigen 1
- FCS, foetal calf serum
- FMO, fluorescence minus one
- HLA-DR, human leucocyte antigen-DR isotype
- IMC, isotype-matched control
- INR, international normalised ratio
- LAMP2, lysosome-associated membrane protein 2
- LPS, lipopolysaccharide
- MACS, magnet-activated cell sorting
- MELD, model for end-stage liver disease
- MERTK, tyrosine-protein kinase Mer
- MFI, median fluorescence intensity
- MMP, matrix metalloproteinase
- MOI, multiplicity of infection
- MPLA, monophosphoryl lipid A
- PAMP, pathogen-associated molecular pattern
- PD-L1, programmed cell death 1 ligand 1
- PFA, paraformaldehyde
- PM, peritoneal macrophage
- Prognostic factor
- Risk of death
- SBP, spontaneous bacterial peritonitis
- TAPI-2, tumour necrosis factor protease inhibitor 2
- TLR, Toll-like receptor
- TNF, tumour necrosis factor
- VSIG4, V-set Ig-domain-containing 4
- qRT-PCR, quantitative real-time PCR
- sVSIG4, soluble V-set Ig-domain-containing 4
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Affiliation(s)
- Johanna Reißing
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Philipp Lutz
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
- German Center for Infection Research, University of Bonn, Bonn, Germany
| | - Mick Frissen
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Oluwatomi Ibidapo-Obe
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Philipp A. Reuken
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany
| | - Theresa H. Wirtz
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Sven Stengel
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany
| | - Stefanie Quickert
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany
| | - Michael Rooney
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany
| | - Karsten Große
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Henning W. Zimmermann
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Christian Trautwein
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Andreas Stallmach
- Department of Internal Medicine IV (Gastroenterology, Hepatology, and Infectious Diseases), Jena University Hospital, Jena, Germany
| | - Tony Bruns
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
- Corresponding author. Address: Department of Internal Medicine III, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany. Tel.: +49-241-80-80-866; Fax: +49-3641-9-32-42-22
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Kerbert AJC, Gupta S, Alabsawy E, Dobler I, Lønsmann I, Hall A, Nielsen SH, Nielsen MJ, Gronbaek H, Amoros À, Yeung D, Macnaughtan J, Mookerjee RP, Macdonald S, Andreola F, Moreau R, Arroyo V, Angeli P, Leeming DJ, Treem W, Karsdal MA, Jalan R. Biomarkers of extracellular matrix formation are associated with acute-on-chronic liver failure. JHEP Rep 2021; 3:100355. [PMID: 34805815 PMCID: PMC8581571 DOI: 10.1016/j.jhepr.2021.100355] [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] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/03/2021] [Accepted: 08/17/2021] [Indexed: 12/24/2022]
Abstract
Background & Aims Acute-on-chronic liver failure (ACLF) is characterised by organ failure(s), high short-term mortality, and, pathophysiologically, deranged inflammatory responses. The extracellular matrix (ECM) is critically involved in regulating the inflammatory response. This study aimed to determine alterations in biomarkers of ECM turnover in ACLF and their association with inflammation, organ failures, and mortality. Methods We studied 283 patients with cirrhosis admitted for acute decompensation (AD) with or without ACLF, 64 patients with stable cirrhosis, and 30 healthy controls. A validation cohort (25 ACLF, 9 healthy controls) was included. Plasma PRO-C3, PRO-C4, PRO-C5, PRO-C6, and PRO-C8 (i.e. collagen type III–VI and VIII formation) and C4M and C6M (i.e. collagen type IV and VI degradation) were measured. Immunohistochemistry of PRO-C6 was performed on liver biopsies (AD [n = 7], ACLF [n = 5]). A competing-risk regression analysis was performed to explore the prognostic value of biomarkers of ECM turnover with 28- and 90-day mortality. Results PRO-C3 and PRO-C6 were increased in ACLF compared to AD (p = 0.089 and p <0.001, respectively), whereas collagen degradation markers C4M and C6M were similar. Both PRO-C3 and PRO-C6 were strongly associated with liver function and inflammatory markers. Only PRO-C6 was associated with extrahepatic organ failures and 28- and 90-day mortality (hazard ratio [HR; on log-scale] 6.168, 95% CI 2.366–16.080, p <0.001, and 3.495, 95% CI 1.509–8.093, p = 0.003, respectively). These findings were consistent in the validation cohort. High PRO-C6 expression was observed in liver biopsies of patients with ACLF. Conclusions This study shows, for the first time, evidence of severe net interstitial collagen deposition in ACLF and makes the novel observation of the association between PRO-C6 and (extrahepatic) organ failures and mortality. Further studies are needed to define the pathogenic significance of these observations. Lay summary This study describes a disrupted turnover of collagen type III and VI in Acute-on-chronic liver failure (ACLF). Plasma biomarkers of these collagens (PRO-C3 and PRO-C6) are associated with the severity of liver dysfunction and inflammation. PRO-C6, also known as the hormone endotrophin, has also been found to be associated with multi-organ failure and prognosis in acute decompensation and ACLF. Collagen type III and VI formation is increased in ACLF compared to AD. PRO-C3 and PRO-C6 correlate with the severity of liver dysfunction and inflammation in AD and ACLF. High PRO-C6 levels were found to be indicative for the presence of multi-organ failure and worse survival.
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Key Words
- ACLF, acute-on-chronic liver failure
- AD, acute decompensation
- CLIF-C ACLF, CLIF Consortium Acute-on-Chronic Liver
- CLIF-C AD, CLIF Consortium Acute Decompensation
- CLIF-C OF, CLIF Consortium Organ Failure
- CPE, concordance probability estimate
- Collagen
- DAMP, danger-associated molecular pattern
- ECM, extracellular matrix
- HC, healthy control
- HR, hazard ratio
- HSC, hepatic stellate cell
- IHC, immunohistochemistry
- INR, international normalised ratio
- K18, keratin 18
- Liver cirrhosis
- MELD, model for end-stage liver disease
- MMP, matrix metalloproteinase
- Multi-organ failure
- NGAL, neutrophil gelatinase-associated lipocalin
- NIS, noninterventional Study
- PAMP, pathogen-associated molecular pattern
- Prognosis
- ROC, receiver operating characteristic
- SC, stable cirrhosis
- TLR, toll-like receptor
- UCL, University College London
- UCLH, University College London Hospitals
- WCC, white cell count
- cK18, caspase-cleaved keratin 18
- α-SMA, alpha-smooth muscle actin
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Affiliation(s)
- Annarein J C Kerbert
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
| | - Saurabh Gupta
- Translational and Biomarker Research, GI-DDU, Takeda Pharmaceuticals International Co., Cambridge, MA, USA
| | - Eman Alabsawy
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK.,Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Iwona Dobler
- Statistical and Quantitative Sciences, Takeda Pharmaceuticals International Co., Cambridge, MA, USA
| | - Ida Lønsmann
- Biomarkers and Research, Nordic Bioscience, Herlev, Denmark
| | - Andrew Hall
- Sheila Sherlock Liver Centre, Royal Free London NHS Foundation Trust, London, UK
| | - Signe Holm Nielsen
- Biomarkers and Research, Nordic Bioscience, Herlev, Denmark.,Department of Biomedicine and Biotechnology, Technical University of Denmark, Lyngby, Denmark
| | | | - Henning Gronbaek
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Àlex Amoros
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Dave Yeung
- Translational and Biomarker Research, GI-DDU, Takeda Pharmaceuticals International Co., Cambridge, MA, USA
| | - Jane Macnaughtan
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
| | - Rajeshwar P Mookerjee
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK.,Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Stewart Macdonald
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
| | - Fausto Andreola
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
| | - Richard Moreau
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.,Inserm and Université de Paris, Centre de Recherche sur l'Inflammation (CRI), Paris, France.,Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Vicente Arroyo
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, DIMED, University of Padova, Padua, Italy
| | | | - William Treem
- Clinical Science, GI-TAU, Takeda Pharmaceuticals International Co., Cambridge, MA, USA
| | | | - Rajiv Jalan
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
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Emamaullee J, Khan S, Weaver C, Goldbeck C, Yanni G, Kohli R, Genyk Y, Zhou S, Shillingford N, Sullivan PM, Takao C, Detterich J, Kantor PF, Cleveland JD, Herrington C, Ram Kumar S, Starnes V, Badran S, Patel ND. Non-invasive biomarkers of Fontan-associated liver disease. JHEP Rep 2021; 3:100362. [PMID: 34693238 DOI: 10.1016/j.jhepr.2021.100362] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/12/2021] [Accepted: 09/05/2021] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Fontan-associated liver disease (FALD) has emerged as an important morbidity following surgical palliation of single ventricle congenital heart disease. In this study, non-invasive biomarkers that may be associated with severity of FALD were explored. Methods A retrospective cohort of paediatric patients post-Fontan who underwent liver biopsy at a high volume at a paediatric congenital heart disease centre was reviewed. Results Among 106 patients, 66% were male and 69% were Hispanic. The mean age was 14.4 ± 3.5 years, and biopsy was performed 10.8 ± 3.6 years post-Fontan. The mean BMI was 20.8 ± 5 kg/m2, with 27.4% meeting obesity criteria. Bridging fibrosis was observed in 35% of patients, and 10.4% of all patients had superimposed steatosis. Bridging fibrosis was associated with lower platelet counts (168.3 ± 58.4 vs. 203.9 ± 65.8 K/μl for congestive hepatic fibrosis score [CHFS] 0–2b, p = 0.009), higher bilirubin (1.7 ± 2.2 vs. 0.9 ± 0.7 mg/dl, p = 0.0090), higher aspartate aminotransferase-to-platelet ratio index [APRI] and fibrosis-4 [FIB-4] scores (APRI: 0.5 ± 0.3 vs. 0.4 ± 0.1, p <0.01 [AUC: 0.69] and FIB-4: 0.6 ± 0.4 vs. 0.4 ± 0.2, p <0.01 [AUC: 0.69]), and worse overall survival (median 2 years follow-up post-biopsy, p = 0.027). Regression modelling of temporal changes in platelet counts before and after biopsy correlated with fibrosis severity (p = 0.005). Conclusions In this large, relatively homogeneous adolescent population in terms of age, ethnicity, and Fontan duration, bridging fibrosis was observed in 35% of patients within the first decade post-Fontan. Bridging fibrosis was associated with worse survival. Changes in platelet counts, even years before biopsy, and APRI/FIB-4 scores had modest discriminatory power in identifying patients with advanced fibrosis. Steatosis may represent an additional risk factor for disease progression in obese patients. Further prospective studies are necessary to develop strategies to screen for FALD in the adolescent population. Lay summary In this study, the prevalence of Fontan-associated liver disease (FALD) in the young adult population and clinical variables that may be predictive of fibrosis severity or adverse outcomes were explored. Several lab-based, non-invasive markers of bridging fibrosis in FALD were identified, suggesting that these values may be followed as a prognostic biomarker for FALD progression in the adolescent population. FALD is universal within 10 years post-Fontan, with 35% of patients having bridging fibrosis. Of our adolescent patient population, 10% had concomitant hepatic steatosis, which was associated with obesity. Regression modelling demonstrates that temporal changes in platelet counts correlate with severity of fibrosis in FALD. AST-to-platelet ratio index and FIB-4 scores correlate with bridging fibrosis with a high specificity. Bridging fibrosis in FALD is associated with worse survival.
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Key Words
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- APRI, AST-to-platelet ratio index
- AST, aspartate aminotransferase
- BMI, body mass index
- BNP, brain natriuretic peptide
- BUN, blood urea nitrogen
- CBC, complete blood count
- CHFS, congestive hepatic fibrosis score
- CHLT, combined heart–liver transplantation
- CVP, central venous pressure
- Congenital heart disease
- Congestive hepatopathy
- ECMO, extracorporeal membrane oxygenation
- FALD, Fontan-associated liver disease
- FIB-4, fibrosis-4
- GFR, glomerular filtration rate
- GGT, gamma-glutamyl transferase
- INR, international normalised ratio
- IQR, interquartile range
- LVAD, left ventricular assist device
- MELD, model of end-stage liver disease
- MELD-Na, MELD-sodium
- MELD-XI, MELD without INR
- NAFLD, non-alcoholic fatty liver disease
- PELD, paediatric end-stage liver disease
- PT, prothrombin time
- PTT, partial thromboplastin time
- TTE, transthoracic echocardiograms
- Univentricular heart disease
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Fossdal G, Mjelle AB, Wiencke K, Bjørk I, Gilja OH, Folseraas T, Karlsen TH, Rosenberg W, Giil LM, Vesterhus M. Fluctuating biomarkers in primary sclerosing cholangitis: A longitudinal comparison of alkaline phosphatase, liver stiffness, and ELF. JHEP Rep 2021; 3:100328. [PMID: 34485881 PMCID: PMC8403583 DOI: 10.1016/j.jhepr.2021.100328] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 05/25/2021] [Accepted: 06/16/2021] [Indexed: 02/08/2023] Open
Abstract
Background & Aims Primary sclerosing cholangitis (PSC) is a progressive liver disease characterised by fluctuating liver biochemistries and highly variable disease progression. The Enhanced Liver Fibrosis (ELF®) test and liver stiffness measurements (LSMs) reflect fibrosis and predict clinical outcomes in PSC; however, longitudinal assessments are missing. We aimed to characterise the systematic change in ELF and LSM over time in a prospective cohort of patients with PSC, along with their longitudinal relationship to alkaline phosphatase (ALP) and bilirubin. Methods We included 113 non-transplant PSC patients (86 males [76.1%]; mean age 43.3 ± 15.7 years) with annual study visits between 2013 and 2019 at 2 Norwegian centres. ELF test, LSM, clinical data, liver biochemistries, and revised Mayo risk score were measured. We used linear mixed-effects models to estimate change over time, intraclass correlations (ICCs), and their relationship with ALP and bilirubin. Results At baseline, the median (range) ELF test was 9.3 (7.5–12.9) and median LSM 1.26 m/s (0.66–3.04 m/s). ELF and LSM increased over time (0.09 point/year, 95% CI [0.03, 0.15], p = 0.005, vs. 0.12 point/year, 95% CI [0.03, 0.21], p = 0.009). Between-patient effects explained 78% of ELF variation (ICC 0.78) and 56% of LSM variation (ICC 0.56). ALP also increased and showed the highest ICC (0.86). Conclusions ELF and LSM increased over a 5-year period. Longitudinal analyses demonstrated differences regarding within- and between-patient effects, suggesting that the ELF test may have superior reliability for risk stratification compared with LSM in PSC. Lay summary Primary sclerosing cholangitis (PSC) is characterised by substantial disease variability between patients and fluctuating liver biochemistries. Hence, new biomarkers are needed to identify individuals with an increased risk of developing end-stage liver disease. We explore the change over time of 2 putative prognostic biomarkers in PSC, the serum Enhanced Liver Fibrosis (ELF®) test and LSMs by ultrasound, demonstrating differences that may reflect differing abilities to discriminate risk. ELF and LSM increased in patients with PSC, but only in patients with ALP >1.5× ULN. ELF may be more reliable for PSC risk stratification (low within-patient variation). A subgroup showed concomitant spontaneous reduction in ALP, ELF, and LSM.
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Key Words
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- Alkaline phosphatase
- Biomarker
- CRP, C-reactive protein
- ELF, enhanced liver fibrosis
- Elastography
- Enhanced liver fibrosis test
- FIB-4, Fibrosis-4 Index for Liver Fibrosis
- GGT, gamma-glutamyl transferase
- HA, hyaluronic acid
- ICC, intraclass correlation
- INR, international normalised ratio
- IgG4, immunoglobulin G4
- LSM, liver stiffness measurement
- Liver stiffness
- PIIINP, propeptide of type III procollagen
- PSC, primary sclerosing cholangitis
- Primary sclerosing cholangitis
- ROI, region of interest
- Risk stratification
- TE, transient elastography
- TIMP-1, tissue inhibitor of metalloproteinases-1
- UDCA, ursodeoxycholic acid
- ULN, upper limit of normal
- pSWE, point shear wave elastography
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Affiliation(s)
- Guri Fossdal
- Norwegian PSC Research Centre, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Anders B Mjelle
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kristine Wiencke
- Norwegian PSC Research Centre, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Section of Gastroenterology, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Ida Bjørk
- Department of Radiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Odd Helge Gilja
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,National Centre for Ultrasound in Gastroenterology, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Trine Folseraas
- Norwegian PSC Research Centre, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Section of Gastroenterology, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Tom Hemming Karlsen
- Norwegian PSC Research Centre, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Section of Gastroenterology, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - William Rosenberg
- UCL Institute for Liver and Digestive Health, University College London & Royal Free London NHS Foundation Trust, London, UK
| | - Lasse M Giil
- Department of Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Mette Vesterhus
- Norwegian PSC Research Centre, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway
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7
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Laschtowitz A, Zachou K, Lygoura V, Pape S, Derben F, Jaeckel E, Oller-Moreno S, Weidemann S, Krech T, Piecha F, Schön G, Liebhoff AM, Al Tarrah M, Heneghan M, Drenth JP, Dalekos G, Taubert R, Lohse AW, Schramm C. Histological activity despite normal ALT and IgG serum levels in patients with autoimmune hepatitis and cirrhosis. JHEP Rep 2021; 3:100321. [PMID: 34381983 PMCID: PMC8333110 DOI: 10.1016/j.jhepr.2021.100321] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 10/27/2020] [Revised: 05/14/2021] [Accepted: 05/31/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND & AIMS In autoimmune hepatitis (AIH), normal levels of transaminases and IgG define biochemical remission and are considered the best surrogate markers for histological remission. This study assessed whether this also applies to patients with AIH cirrhosis. METHODS In this European multicentric study, we included 125 biopsies from 113 patients with AIH and histologically proven cirrhosis; 105 biopsies from 104 patients with AIH without cirrhosis served as controls. Biochemical parameters were available within 4 weeks of biopsy. AIH activity was graded according to the modified Hepatitis Activity Index (mHAI), with mHAI ≥4/18 considered to indicate risk of disease progression. RESULTS In total, 47 out of 125 liver biopsies were obtained from patients with AIH cirrhosis and normal ALT levels at time of biopsy. Only 26% (12/47) of those livers showed histological remission (mHAI <4/18), whereas 36% (17/47) showed moderate to high histological activity (mHAI ≥6/18). In patients with noncirrhotic AIH, 88% (46/52 biopsies) of cases with normal ALT levels had histological remission and only 4% (2/52) had an mHAI ≥6/18 (p <0.001). The addition of IgG to define complete biochemical remission only slightly improved the association with histological remission in the limited number of patients with AIH cirrhosis available for analysis [29% (5/17) of biopsies with mHAI <4/18]. ALT correlated closely with mHAI in AIH without cirrhosis but poorly in AIH with cirrhosis. CONCLUSIONS In contrast to patients with noncirrhotic AIH, in patients with AIH cirrhosis, who are at risk of disease progression, normal ALT levels and potentially also complete biochemical remission are poor surrogate markers of histological remission. Thus, new biomarkers are needed to monitor disease activity and progression in patients with AIH cirrhosis. LAY SUMMARY Autoimmune hepatitis (AIH) is an inflammatory disease of the liver that usually responds to immunosuppressive therapy. Serum transaminases and IgG levels within the normal ranges define complete biochemical remission and are considered as surrogate markers for histological disease activity. Here, we show that those biochemical markers are not sufficient to indicate low disease activity in patients with AIH and already established cirrhosis. Consequently, until better biomarkers for disease activity are found, only liver biopsy can reliably indicate disease activity in the presence of cirrhosis. Additional investigations, such as measurements of liver stiffness, should be undertaken to monitor non-invasively for disease progression in patients with AIH and established cirrhosis.
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Key Words
- AIH, autoimmune hepatitis
- ALD, alcoholic liver disease
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- Autoimmune hepatitis
- Biochemical remission
- Cirrhosis
- EASL, European Association for the Study of the Liver
- Histological activity
- ICC, intraclass correlation coefficient
- INR, international normalised ratio
- LLN, lower limit of normal
- Liver biopsy
- MELD, model for end-stage liver disease
- NAFLD, non-alcoholic fatty liver disease
- TE, transient elastography
- TIPS, transjugular intrahepatic portosystemic shunt
- ULN, upper limit of normal
- gamma-GT, gamma glutamyl transferase
- mHAI
- mHAI, modified Hepatitis Activity Index
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Affiliation(s)
- Alena Laschtowitz
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
| | - Kalliopi Zachou
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Centre of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Vasiliki Lygoura
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Centre of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Simon Pape
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Finn Derben
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Elmar Jaeckel
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Sergio Oller-Moreno
- Institute of Medical Systems Biology, Centre for Molecular Neurobiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Sören Weidemann
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
- Department of Pathology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Till Krech
- Department of Pathology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Felix Piecha
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Anna-Maria Liebhoff
- Institute of Medical Systems Biology, Centre for Molecular Neurobiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Munira Al Tarrah
- Institute of Liver Studies and Transplantation, King´s College Hospital, London, UK
| | - Michael Heneghan
- Institute of Liver Studies and Transplantation, King´s College Hospital, London, UK
| | - Joost P.H. Drenth
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - George Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Centre of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Richard Taubert
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Ansgar Wilhelm Lohse
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
- German Centre for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Hamburg, Germany
- Hamburg Centre for Translational Immunology (HCTI), University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Schramm
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- European Reference Network for Hepatological Diseases (ERN-RARE LIVER)
- Hamburg Centre for Translational Immunology (HCTI), University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
- Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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8
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Reddy MS, Rajakumar A, Mathew JS, Venkatakrishnan L, Jothimani D, Sudhindran S, Jacob M, Narayanasamy K, Venugopal R, Mohanka R, Kaliamoorthy I, Varghese J, Panackel C, Mohamed Z, Vij M, Sachan D, Pillay V, Saigal S, Dhiman R, Soin AS, Gupta S, Wendon J, Rela M, Sarin SK. Liver Transplantation Society of India Guidelines for the Management of Acute Liver Injury Secondary to Yellow Phosphorus-Containing Rodenticide Poisoning Using the Modified Delphi Technique of Consensus Development. J Clin Exp Hepatol 2021; 11:475-483. [PMID: 34276154 PMCID: PMC8267358 DOI: 10.1016/j.jceh.2020.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/28/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Acute liver failure caused by the ingestion of yellow phosphorus-containing rodenticide has been increasing in incidence over the last decade and is a common indication for emergency liver transplantation in Southern and Western India and other countries. Clear guidelines for its management are necessary, given its unpredictable course, potential for rapid deterioration and variation in clinical practice. METHODS A modified Delphi approach was used for developing consensus guidelines under the aegis of the Liver Transplantation Society of India. A detailed review of the published literature was performed. Recommendations for three areas of clinical practice, assessment and initial management, intensive care unit (ICU) management and liver transplantation, were developed. RESULTS The expert panel consisted of 16 clinicians, 3 nonclinical specialists and 5 senior advisory members from 11 centres. Thirty-one recommendations with regard to criteria for hospital admission and discharge, role of medical therapies, ICU management, evidence for extracorporeal therapies such as renal replacement therapy and therapeutic plasma exchange, early predictors of need for liver transplantation and perioperative care were developed based on published evidence and combined clinical experience. CONCLUSION Development of these guidelines should help standardise care for patients with yellow phosphorus poisoning and identify areas for collaborative research.
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Key Words
- ALF, acute liver failure
- ALI, acute liver injury
- DDLT, deceased donor liver transplantation
- ICU, intensive care unit
- INR, international normalised ratio
- KCC, Kings College Criteria
- LDLT, living donor liver transplantation
- LT, liver transplantation
- LTSI, Liver Transplantation Society of India
- MELD, model for end-stage liver disease
- RRT, renal replacement therapy
- TPE, therapeutic plasma exchange
- YP, yellow phosphorus
- acute liver failure
- consensus guidelines
- liver transplantation
- rat killer poison
- yellow phosphorus
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Affiliation(s)
- Mettu S. Reddy
- Institute of Liver Disease & Transplantation, Dr Rela Institute & Medical Center, Chennai, India
| | - Akila Rajakumar
- Department of Liver Anesthesia & Intensive Care, Dr Rela Institute & Medical Center, Chennai, India
| | - Johns S. Mathew
- Department of Liver Transplantation & Gastrointestinal Surgery, Amrita Hospitals, Kochi, India
| | | | - Dinesh Jothimani
- Department of Hepatology, Dr Rela Institute & Medical Center, Chennai, India
| | - S. Sudhindran
- Department of Liver Transplantation & Gastrointestinal Surgery, Amrita Hospitals, Kochi, India
| | - Mathew Jacob
- Multiorgan Transplantation & Hepatobiliary Surgery, Aster Medicity, Kochi, India
| | | | - Radhika Venugopal
- Department of Hepatology, Dr Rela Institute & Medical Center, Chennai, India
| | - Ravi Mohanka
- Department of Liver Transplantation & HPB Surgery, Global Hospital, Mumbai, India
| | - Ilankumaran Kaliamoorthy
- Department of Liver Anesthesia & Intensive Care, Dr Rela Institute & Medical Center, Chennai, India
| | - Joy Varghese
- Department of Hepatology & Liver Transplantation, Gleneagles Global Hospital & Health City, Chennai, India
| | - Charles Panackel
- Department of Hepatology & Liver Transplantation, Aster Medicity, Kochi, India
| | - Zubair Mohamed
- Department of Anesthesiology & Critical Care Medicine, Amrita Hospitals, Kochi, India
| | - Mukul Vij
- Department of Pathology & Laboratory Medicine, Dr Rela Institute & Medical Center, Chennai, India
| | - Deepti Sachan
- Department of Transfusion Medicine, Dr Rela Institute & Medical Center, Chennai, India
| | - V.V. Pillay
- Department of Forensic Medicine & Toxicology, Amrita Hospitals, Kochi, India
| | - Sanjiv Saigal
- Department of Hepatology & Liver Transplantation, Medanta Medicity, Gurgaon, India
| | - Radhakrishna Dhiman
- Department of Hepatology & Liver Transplantation, Post-graduate Institute of Medical Education & Research, Chandigarh, India
| | - Arvinder S. Soin
- Department of Liver Transplantation & Regenerative Medicine, Medanta Medicity, Gurgaon, India
| | - Subhash Gupta
- Centre for Liver & Biliary Sciences, Max Super Specialty Hospital, Saket, Delhi, India
| | - Julia Wendon
- Institute of Liver Studies, Kings College Hospital, London, UK
| | - Mohamed Rela
- Institute of Liver Disease & Transplantation, Dr Rela Institute & Medical Center, Chennai, India
| | - Shiv K. Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences, New Delhi, India
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9
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Dajti E, Marasco G, Ravaioli F, Colecchia L, Ferrarese A, Festi D, Colecchia A. Risk of hepatocellular carcinoma after HCV eradication: Determining the role of portal hypertension by measuring spleen stiffness. JHEP Rep 2021; 3:100289. [PMID: 34095798 PMCID: PMC8165428 DOI: 10.1016/j.jhepr.2021.100289] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/06/2021] [Accepted: 03/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND & AIMS Hepatitis C virus (HCV) eradication with direct-acting antivirals (DAAs) reduces but does not eliminate the risk for hepatocellular carcinoma (HCC). The development of surveillance strategies for HCC after the sustained virologic response (SVR) is therefore warranted. We aimed to evaluate the role of spleen stiffness measurement (SSM) in the prediction of HCC risk in a cohort of patients with advanced chronic liver disease (ACLD) treated with DAAs. METHODS This is a retrospective cohort study of 140 patients with HCV-related ACLD successfully treated with DAAs in our centre between 2015 and 2017. Patients with available liver stiffness (LSM) and SSM before treatment and 6 months after (SVR24) were included. A Cox regression model investigated the association between SSM and HCC development. RESULTS During a median follow-up of 41.5 (IQR 32-49) months, 20 patients presented with HCC. SSM at SVR24 predicted HCC development in univariate and adjusted multivariate analysis (hazard ratio: 1.025; 95% CI: 1.001-1.050); the best cut-off was 42 kPa. Patients with LSM-SVR24 ≤10 kPa were at the lowest risk of HCC. In patients with LSM-SVR24 >10 kPa, HCC incidence was not further influenced by LSM values (10-20 kPa vs. >20 kPa), but only by SSM-SVR24 values (≤42 vs. >42 kPa). CONCLUSIONS Portal hypertension, as evaluated by SSM, plays a significant role in liver carcinogenesis after DAA treatment. We proposed a new algorithm based on post-treatment values of LSM and SSM for the stratification of HCC risk after SVR achievement. LAY SUMMARY Spleen stiffness predicts the development of hepatocellular carcinoma after viral eradication, especially in patients with post-treatment liver stiffness values >10 kPa. An algorithm based on liver and spleen stiffness can stratify for the risk of liver cancer development and guide the surveillance strategies after treatment with direct-acting antivirals.
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Key Words
- ACLD, advanced chronic liver disease
- ALT, alanine aminotransferase
- DAA
- DAA, direct-acting antiviral
- Direct-acting antiviral
- HCC
- HCC, hepatocellular carcinoma
- HCV, hepatitis C virus
- INR, international normalised ratio
- LSM, liver stiffness measurement
- Liver stiffness
- MELD, model for end-stage liver disease
- SSM, spleen stiffness measurement
- SVR, sustained virologic response
- Spleen stiffness
- TE, transient elastography
- Transient elastography
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Affiliation(s)
- Elton Dajti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Giovanni Marasco
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Federico Ravaioli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Luigi Colecchia
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Alberto Ferrarese
- Unit of Gastroenterology, Borgo Trento University Hospital of Verona, Verona, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Antonio Colecchia
- Unit of Gastroenterology, Borgo Trento University Hospital of Verona, Verona, Italy
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10
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Nevens F, Gustot T, Laterre PF, Lasser LL, Haralampiev LE, Vargas V, Lyubomirova D, Albillos A, Najimi M, Michel S, Stoykov I, Gordillo N, Vainilovich Y, Barthel V, Clerget-Chossat N, Sokal EM. A phase II study of human allogeneic liver-derived progenitor cell therapy for acute-on-chronic liver failure and acute decompensation. JHEP Rep 2021; 3:100291. [PMID: 34169246 PMCID: PMC8207211 DOI: 10.1016/j.jhepr.2021.100291] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/16/2021] [Accepted: 04/07/2021] [Indexed: 02/06/2023] Open
Abstract
Background & Aims Human allogeneic liver-derived progenitor cells (HALPC, HepaStem®; Promethera Biosciences, Mont-Saint-Guibert, Belgium) are an advanced therapy medicinal product that could potentially alleviate systemic inflammation and ameliorate liver function in patients with acute-on-chronic liver failure (ACLF) or acute decompensation of cirrhosis (AD). Methods This open-label phase II study was conducted in 9 centres in Belgium, Spain, and Bulgaria between 2016 and 2019. The primary objective was to assess the safety of HALPC therapy up to Day 28 and the secondary objectives were to assess its safety and preliminary efficacy up to Month 3. Results The 24 treated patients (mean age: 51 years) were mostly male with an alcoholic cirrhosis. On pre-infusion Day 1, 15 patients had ACLF and 9 patients had AD. Two of the 3 initial patients treated with high HALPC doses (∼5×106 cells/kg body weight [BW]) had severe adverse bleeding events attributed to treatment. In 21 patients subsequently treated with lower HALPC doses (0.6 or 1.2×106 cells/kg BW, 1 or 2 times 7 days apart), no serious adverse events were related to treatment, and the other adverse events were in line with those expected in patients with ACLF and AD. Overall, markers of systemic inflammation and altered liver function decreased gradually for the surviving patients. The Day-28 and Month-3 survival rates were 83% (20/24) and 71% (17/24), and at Month 3, no patient had ACLF. Conclusions The treatment of patients with ACLF or AD with up to 2 doses of 1.2×106 HALPC/kg BW appeared safe. The results of this study support the initiation of a proof-of-concept study in a larger cohort of patients with ACLF to further confirm the safety and evaluate the efficacy of HALPC therapy. Clinical Trials Registration EudraCT 2016-001177-32. Lay summary Patients with liver cirrhosis may suffer from the rapid onset of organ failure or multiple organ failure associated with a high risk of death in the short term. This clinical study of 24 patients suggests that an advanced therapy based on the intravenous infusion of low doses of human allogeneic liver-derived progenitor cells is safe and supports the next phase of clinical development of this type of therapy.
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Key Words
- ACLF, acute-on-chronic liver failure
- AD, acute decompensation of liver cirrhosis
- AE, adverse event
- AESI, AE of special interest
- ATMP, advanced therapy medicinal product
- Alcoholic liver disease
- BW, body weight
- CRP, C-reactive protein
- EASL-CLIF, European Association for the Study of Chronic Liver Failure
- HALPC, human allogeneic liver-derived progenitor cells
- INR, international normalised ratio
- Liver regenerative medicine
- MELD, model for end-stage liver disease
- MSC, mesenchymal stem cells
- SAE, serious AE
- SAS, safety analysis set
- SUSAR, suspected unexpected serious adverse reaction
- Stem cell
- TEG, thromboelastography
- TGT, thrombin generation test
- i.v., intravenous
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Affiliation(s)
- Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospitals, KU Leuven, Belgium
| | - Thierry Gustot
- Department of Gastroenterology and Hepato-Pancreatology, C.U.B. Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Luc L Lasser
- Gastroenterology Clinic, CHU Brugmann, Brussels, Belgium.,Department of Hepatogastroenterology, CHU Brugmann, Brussels, Belgium
| | - Lyudmil E Haralampiev
- Department of Internal Diseases, Multiprofile Hospital for Active Treatment (MEDICA), Ruse, Bulgaria
| | - Victor Vargas
- Liver Unit, Hospital Vall d'Hebron, Universitat Autònoma Barcelona, CIBERehd, Barcelona, Spain
| | - Desislava Lyubomirova
- Department of Clinical Gastroenterology with Hepatology, Gastroenterology Clinic, University Multiprofile Hospital for Active Treatment "Georgi Stranski", Pleven, Bulgaria
| | - Agustin Albillos
- Gastroenterology and Hepatology, University Hospital Ramón y Cajal, Madrid, Spain
| | - Mustapha Najimi
- UCLouvain, Institute of Experimental and Clinical Research (IREC), Laboratory of Pediatric Hepatology and Cell Therapy (PEDI), Brussels, Belgium
| | | | | | | | | | | | | | - Etienne M Sokal
- UCLouvain, Institute of Experimental and Clinical Research (IREC), Laboratory of Pediatric Hepatology and Cell Therapy (PEDI), Brussels, Belgium.,Promethera Biosciences, Mont-Saint-Guibert, Belgium.,Cliniques Universitaires Saint-Luc, UCLouvain, Pediatric Hepatology & Gastroenterology Unit, Brussels, Belgium
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11
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Sessa A, Allaire M, Lebray P, Medmoun M, Tiritilli A, Iaria P, Cadranel JF. From congestive hepatopathy to hepatocellular carcinoma, how can we improve patient management? JHEP Rep 2021; 3:100249. [PMID: 33665589 PMCID: PMC7902554 DOI: 10.1016/j.jhepr.2021.100249] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 12/09/2020] [Accepted: 12/19/2020] [Indexed: 02/06/2023] Open
Abstract
Heart failure and liver disease often coexist because of systemic disorders and diseases that affect both organs as well as complex cardio-hepatic interactions. Heart failure can cause acute or chronic liver injury due to ischaemia and passive venous congestion, respectively. Congestive hepatopathy is frequently observed in patients with congenital heart disease and after the Fontan procedure, but also in older patients with chronic heart failure. As congestive hepatopathy can evolve into cirrhosis and hepatocellular carcinoma, screening for liver injury should be performed in patients with chronic cardiac diseases and after Fontan surgery. Fibrosis starts in the centro-lobular zone and will extend progressively to the portal area. Chronic liver injury can be reversible if heart function improves. However, in the case of terminal heart failure, uncontrolled by medical resources or by assistive device support, the combination of heart and liver transplants must be discussed in patients with chronic advanced liver fibrosis. In this review of the literature, we will focus on congestive hepatopathy and its complications, such as liver fibrosis and hepatocellular carcinoma, with the aim of improving the management and surveillance of patients experiencing these complications.
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Key Words
- ACE, angiotensin-converting enzyme
- AFP, α-fetoprotein
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- AST, aspartate amino transferase
- BNP, B-type natriuretic peptide
- Combined heart and liver transplant
- Congestive hepatopathy
- FALD, Fontan-associated liver disease
- FIB-4, Fibrosis-4 index
- Fontan-associated liver disease
- GGT, gamma-glutamyltransferase
- HCC, hepatocellular carcinoma
- INR, international normalised ratio
- MELD, model for end-stage liver disease
- NAFLD, non-alcoholic fatty liver disease
- NFS, NAFLD fibrosis score
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Affiliation(s)
- Anna Sessa
- Sorbonne Université, Service d’Hépatologie, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, AP-HP, Paris, France
- Department of Hepatology and Gastroenterology, Policlinico Federico II, Napoli, Italy
| | - Manon Allaire
- Sorbonne Université, Service d’Hépatologie, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, AP-HP, Paris, France
- Inserm U1149, Centre de Recherche sur l’Inflammation, France Faculté de Médecine Xavier Bichat, Université Paris Diderot, Paris, France
| | - Pascal Lebray
- Sorbonne Université, Service d’Hépatologie, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, AP-HP, Paris, France
| | - Mourad Medmoun
- Service d 'Hépato-Gastroentérologie de nutrition et d’Alcoologie, Groupe Hospitalier Public du Sud de l'Oise, Creil, France
| | - Alberto Tiritilli
- Service de Cardiologie, Groupe Hospitalier Public du Sud de l'Oise, Creil, France
| | - Pierre Iaria
- Service de Cardiologie, Groupe Hospitalier Public du Sud de l'Oise, Creil, France
| | - Jean-François Cadranel
- Service d 'Hépato-Gastroentérologie de nutrition et d’Alcoologie, Groupe Hospitalier Public du Sud de l'Oise, Creil, France
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Lovato CM, Thévenot T, Borot S, Di Martino V, Qualls CR, Urban FK, Dorin RI. Decreased maximal cortisol secretion rate in patients with cirrhosis: Relation to disease severity. JHEP Rep 2021; 3:100277. [PMID: 34027338 PMCID: PMC8121968 DOI: 10.1016/j.jhepr.2021.100277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 02/13/2021] [Accepted: 03/07/2021] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Hepatic enzymes play a major role in the metabolic elimination of cortisol, and reduced rates of cortisol clearance have been consistently observed in patients with chronic liver disease. It is less clear whether there are concomitant abnormalities of adrenocortical function in patients with cirrhosis. In the present study, we sought to assess adrenocortical function in patients with cirrhosis using measures of free cortisol appearance and elimination rates that are independent of serum concentrations of cortisol binding proteins. Methods Post hoc analysis used computer-assisted numerical and modelling methods with serial total and free cortisol concentration data to obtain rates of free cortisol appearance and elimination. Rate parameters were obtained in 114 patients with chronic liver disease, including Child-Pugh (CP) ≤8 (n = 53) and CP >8 (n = 61). Results Maximal cortisol secretion rate (CSRmax) was significantly decreased (p = 0.01) in patients with cirrhosis with CP >8 (0.28 nM/s; 95% CI 0.24–0.34) compared with those with CP ≤8 (0.39 nM/s; 95% CI 0.33–0.46), and CSRmax was negatively correlated with CP score (r = −0.19, p = 0.01). Free cortisol elimination rate was significantly (p = 0.04) decreased in the CP >8 group (0.16 ± 0.20 min−1) compared with that in the CP ≤8 group (0.21 ± 0.21 min−1), and free cortisol elimination rates were negatively correlated with CP score (r = −0.23, p = 0.01). A significant correlation between CSRmax and free cortisol elimination rate (r = 0.88, p <0.001) was observed. Conclusions CSRmax and free cortisol elimination rates were significantly reduced according to severity of cirrhosis. In contrast to stimulated total cortisol concentrations, CSRmax estimates were independent of cortisol-binding protein concentrations. Results provide additional evidence of subnormal adrenocortical function in patients with cirrhosis. Lay summary We applied numerical analytic methods to characterise adrenocortical function in patients with varying stages of chronic liver disease. We found that patients with more severe cirrhosis have decreased rate of free cortisol elimination and decreased maximal cortisol secretion rate, which is a measure of adrenocortical function. In contrast to conventional measures of adrenocortical function, those obtained using numerical methods were not affected by variation in corticosteroid binding globulin and albumin concentrations. We conclude that patients with cirrhosis demonstrate measurable abnormalities of adrenocortical function, evidence of which supports aspects of the hepatoadrenal syndrome hypothesis. Free cortisol appearance and elimination rates were obtained by computer-assisted numerical analysis. Maximal cortisol secretion rates, a measure of adrenocortical function, were inversely related to severity of cirrhosis. Variation in concentrations of cortisol binding proteins bias measures of adrenocortical function that rely on total cortisol. Chronically reduced rate of free cortisol elimination in patients with cirrhosis may contribute to the pathophysiology of subnormal adrenocortical function. Evidence of subnormal adrenocortical function supports the hepatoadrenal syndrome hypothesis.
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Key Words
- ACLF, acute-on-chronic liver failure
- ACTH, adrenocorticotrophin
- AI, adrenal insufficiency
- Adrenal insufficiency
- CBG, corticosteroid-binding globulin
- CIRCI, critical illness-related corticosteroid insufficiency
- CP, Child-Pugh
- CPR, cortisol production rate
- CRP, C-reactive protein
- CRT, corticosteroid replacement therapy
- CSR, cortisol secretion rate
- CSRbase, basal CSR (before ACTH stimulation)
- CSRmax, maximal CSR
- Computer-assisted numerical analysis
- HPA, hypothalamic–pituitary–adrenal
- HSD, hydroxysteroid dehydrogenase
- Hydrocortisone
- INR, international normalised ratio
- Liver disease
- MCR, metabolic clearance rate
- MELD, model for end-stage liver disease
- Metabolic clearance rate
- PAI, primary adrenal insufficiency
- RAI, relative adrenal insufficiency
- RCT, randomised clinical trial
- SAI, secondary adrenal insufficiency
- SCOTCH, Supplemental Corticosteroids in Cirrhotic Hypotensive Patients With Suspicion of Sepsis
- STB, standardised beta
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Affiliation(s)
- Christina M Lovato
- Department of Internal Medicine/Endocrinology, Diabetes and Metabolism, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Thierry Thévenot
- Service d'Hépatologie et de Soins Intensifs Digestifs, Hôpital Universitaire Jean Minjoz, Besançon, France
| | - Sophie Borot
- Service d'Endocrinologie-Métabolisme et Diabétologie-Nutrition, Hôpital Jean Minjoz, Besançon, France
| | - Vincent Di Martino
- Service d'Hépatologie et de Soins Intensifs Digestifs, Hôpital Universitaire Jean Minjoz, Besançon, France
| | - Clifford R Qualls
- Department of Mathematics and Statistics, University of New Mexico, Albuquerque, NM, USA.,New Mexico Veterans Affairs Healthcare System, Albuquerque, NM, USA
| | - Frank K Urban
- Department of Electrical and Computer Engineering, Florida International University, Miami, FL, USA
| | - Richard I Dorin
- Department of Internal Medicine/Endocrinology, Diabetes and Metabolism, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.,New Mexico Veterans Affairs Healthcare System, Albuquerque, NM, USA
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13
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Nephew LD, Zia Z, Ghabril M, Orman E, Lammert C, Kubal C, Chalasani N. Sex disparities in waitlisting and liver transplant for acute liver failure. JHEP Rep 2021; 3:100200. [PMID: 33511336 PMCID: PMC7817503 DOI: 10.1016/j.jhepr.2020.100200] [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: 03/27/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND & AIMS Sex disparities in liver transplantation (LT) for chronic liver disease have been described. It is unclear if similar disparities exist for acute liver failure (ALF). METHODS Adults waitlisted for LT from 2002 to 2016 with ALF were investigated using the United Network of Organ Sharing database. Clinical characteristics and causative aetiologies were compared between men and women who were waitlisted Status-1. Differences in LT, waitlist removal, and 1-year post-transplant survival were explored. RESULTS Of 8,408 patients waitlisted for LT with ALF, 41.3% of men and 63.9% of women were waitlisted Status-1 (p <0.001). Women had significantly higher international normalised ratio, higher frequency of grade 3-4 hepatic encephalopathy, and different aetiologies of ALF than men. On univariable analysis, women were less likely to undergo LT (subdistribution hazard ratio [SHR] 0.90; 95% CI 0.84-0.97) and were more likely to die or be removed from the waitlist as a result of clinical deterioration (SHR 1.14; 95% CI 1.002-1.30) than men. The disparities in LT (HR 0.95; 95% CI 0.87-1.03) and death/clinical deterioration (SHR 1.13; 95% CI 0.99-1.29) were no longer significant on multivariable analysis. On multivariable analysis, there was no difference in 1-year post-transplant survival between men and women. CONCLUSIONS Women with ALF are more likely to be waitlisted Status-1 than men. There were no clear disparities in LT or waitlist removal. Sex differences in LT and waitlist removal were attenuated on fully adjusted models, suggesting that these disparities may in part be mitigated by Status-1 listing. LAY SUMMARY Women with acute liver failure appear to be sicker than men and more often require urgent Status-1 waitlisting. There were no sex disparities in waitlist removal because of clinical deterioration or liver transplantation. This is in contrast to chronic liver disease, where sex disparities exist. The Status-1 waitlisting that women with acute liver failure receive may in part mitigate sex disparities in liver transplantation.
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Key Words
- AIH, autoimmune hepatitis
- ALF, acute liver failure
- APAP, acetaminophen
- Allocation
- Fulminant
- Gender
- HE, hepatic encephalopathy
- HR, hazard ratio
- INR, international normalised ratio
- LT, liver transplantation
- MELD, model for end-stage liver disease
- SHR, subdistribution hazard ratio
- SRTR, Scientific Registry of Transplant Recipients
- Status-1
- UNOS, United Network of Organ Sharing
- Women
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Affiliation(s)
- Lauren D. Nephew
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Zahra Zia
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Marwan Ghabril
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eric Orman
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Craig Lammert
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chandrashekhar Kubal
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Naga Chalasani
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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14
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Myers S, Neyroud-Caspar I, Spahr L, Gkouvatsos K, Fournier E, Giostra E, Magini G, Frossard JL, Bascaron ME, Vernaz N, Zampaglione L, Negro F, Goossens N. 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] [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: 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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Affiliation(s)
- Shuna Myers
- Medical Faculty, University of Geneva, Geneva, Switzerland
| | | | - Laurent Spahr
- Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | | | - Evelyne Fournier
- Geneva Cancer Registry, University of Geneva, Geneva, Switzerland
| | - Emiliano Giostra
- Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Giulia Magini
- Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
- Division of Transplantation, Geneva University Hospital, Geneva, Switzerland
| | - Jean-Louis Frossard
- Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Marie-Eve Bascaron
- Division of Palliative Medicine, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Nathalie Vernaz
- Medical Directorate, Geneva University Hospital, Geneva, Switzerland
| | - Lucia Zampaglione
- Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Francesco Negro
- Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
- Clinical Pathology, Geneva University Hospital, Geneva, Switzerland
| | - Nicolas Goossens
- Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
- Department of Medicine, University of Geneva, Geneva, Switzerland
- Corresponding author. Address: Division of Gastroenterology and Hepatology, Department of Medicine, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland. Tel.: +41 22 372 9350; fax: +41 22 372 9021.
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Abstract
Autoimmune hepatitis is associated with varied clinical presentations and natural history, as well as somewhat unpredictable treatment responses. Understanding how to stratify patients who require further escalation of therapy will help clinicians manage these patients. The presentation of acute severe autoimmune hepatitis (AS-AIH) is relatively uncommon, although its prevalence is potentially greater than currently perceived. Previous studies consist of small retrospective single-centre series and are not directly comparable due to the diversity of presentations, disease definitions and non-standardised treatment regimens. We define AS-AIH as those who present acutely with AIH and are icteric with an international normalised ratio ≥1.5 and no evidence of hepatic encephalopathy. Those with hepatic encephalopathy should be defined as having AS-AIH with acute liver failure. In this review, we provide a structured practical approach for diagnosing and managing this unique group of patients.
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Key Words
- ACLF, acute-on-chronic liver failure
- AIH, autoimmune hepatitis
- ALF, acute liver failure
- ALI, acute liver injury
- ALT, alanine aminotransferase
- ANA, anti-nuclear antibody
- AS-AIH, acute severe autoimmune hepatitis
- ASMA, anti-smooth muscle antibody
- AST, aspartate aminotransferase
- AUROC, analysis of area under the receiver operator characteristic curve
- Acute liver failure
- Acute severe presentation
- Autoimmune hepatitis
- CT, computed tomography
- Corticosteroids
- DILI, drug-induced liver injury
- EBV, Epstein-Barr virus
- HE, hepatic encephalopathy
- HLA, human leukocyte antigen
- IAIHG, International Autoimmune Hepatitis Group
- INR, international normalised ratio
- LT, liver transplantation
- Liver transplantation
- MELD, model for end-stage liver disease
- MELD-Na, model for end-stage liver disease-sodium
- MHN, massive hepatic necrosis
- NAC, N-acetylcysteine
- PT, prothrombin time
- UKELD, United Kingdom end-stage liver disease
- USALF, United States Acute Liver Failure
- anti-LC-1, anti-liver cytosol-1
- anti-LKM, anti-liver kidney microsomal
- anti-SLA/LP, anti-soluble liver antigen/liver pancreas
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Affiliation(s)
- Mussarat N. Rahim
- Institute of Liver Studies, King's College Hospital, London, SE5 9RS, UK
| | - Rosa Miquel
- Liver Histopathology Laboratory, King's College Hospital, London, SE5 9RS, UK
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16
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Vesterhus M, Nielsen MJ, Hov JR, Saffioti F, Manon-Jensen T, Leeming DJ, Moum B, Boberg KM, Pinzani M, Karlsen TH, Karsdal MA, Thorburn D. Comprehensive assessment of ECM turnover using serum biomarkers establishes PBC as a high-turnover autoimmune liver disease. JHEP Rep 2020; 3:100178. [PMID: 33225252 PMCID: PMC7666353 DOI: 10.1016/j.jhepr.2020.100178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 08/21/2020] [Accepted: 08/25/2020] [Indexed: 02/08/2023] Open
Abstract
Background & Aims Primary sclerosing cholangitis (PSC), primary biliary cholangitis (PBC) and autoimmune hepatitis (AIH) are phenotypically distinct autoimmune liver diseases that progress to cirrhosis and liver failure; however, their histological fibrosis distribution differs. We investigated the extracellular matrix (ECM) profiles of patients with PSC, PBC, and AIH to establish whether the diseases display differential patterns of ECM turnover. Methods Serum samples were retrospectively collected from the UK (test cohort; PSC n = 78; PBC n = 74; AIH n = 58) and Norway (validation cohort; PSC n = 138; PBC n = 28; AIH n = 27). Patients with ulcerative colitis without liver disease (n = 194) served as controls. We assessed specific serological biomarkers of ECM turnover: type III and V collagen formation (PRO-C3, PRO-C5), degradation of type III and IV collagen (C3M, C4M), biglycan (BGM) and citrullinated vimentin (VICM). Results Most of the ECM markers showed elevated serum levels in PBC compared with PSC or AIH (p <0.01). PRO-C3 correlated well with liver stiffness and showed the most striking differences between advanced and non-advanced liver disease; several of the other ECM markers were also associated with stage. PRO-C3 and other ECM markers were inversely associated with ursodeoxycholic acid treatment response in PBC and remission in AIH. All ECM remodelling markers were significantly elevated (p <0.05) in patients with PSC, PBC, or AIH compared with ulcerative colitis. Conclusions In this first study comparing ECM turnover in autoimmune liver diseases, we found increased ECM turnover in PBC compared with either PSC or AIH. The study indicates that ECM remodelling is different in PSC, PBC, and AIH, suggesting differing opportunities for therapeutic intervention. Lay summary The level of scarring is linked to prognosis in autoimmune liver diseases such as primary sclerosing cholangitis, primary biliary cholangitis, and autoimmune hepatitis; hence, the scarring process is a possible target for novel therapy. Investigating the scarring process using highly specific technology, we show that the scarring process is different between the 3 autoimmune liver diseases, and this may have important implications for the development of medical treatment. Serological biomarkers specifically targeting extracellular matrix remodelling enable evaluation of the dynamics of fibrosis evolution. ECM turnover was increased in PBC compared with PSC and AIH. ECM markers, particularly PRO-C3, were associated with disease stage in the autoimmune liver diseases and with clinical outcome in PSC.
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Key Words
- AIH, autoimmune hepatitis
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- APRI, AST to platelet ratio index
- AST, aspartate aminotransferase
- AUROC, area under the receiver operator characteristics curve
- BGM, marker of biglycan degradation
- Biomarker
- C3M, marker of type III collagen degradation
- C4M, marker of type IV collagen degradation
- CI, confidence interval
- ECM, extracellular matrix
- ELF, enhanced liver fibrosis
- Fibrosis
- GGT, gamma glutamyltransferase
- HYA, hyaluronic acid
- IBD, inflammatory bowel disease
- INR, international normalised ratio
- LSM, liver stiffness measurement
- PBC, primary biliary cholangitis
- PIIINP, N-terminal procollagen type III
- PRO-C3
- PRO-C3, marker of type III collagen formation
- PRO-C5, marker of type V collagen formation
- PSC, primary sclerosing cholangitis
- Primary biliary cholangitis
- Primary sclerosing cholangitis
- TE, transient elastography
- TIMP-1, tissue inhibitor of metalloproteinase
- UC, ulcerative colitis
- VICM, marker of citrullinated vimentin degradation
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Affiliation(s)
- Mette Vesterhus
- Norwegian PSC Research Center, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Department of Internal Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Johannes Roksund Hov
- Norwegian PSC Research Center, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Section of Gastroenterology, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Francesca Saffioti
- UCL Institute for Liver and Digestive Health, Division of Medicine, University College London & Royal Free Hospital, London, UK.,Department of Clinical and Experimental Medicine, Division of Clinical and Molecular Hepatology, University of Messina, Messina, Italy
| | | | | | - Bjørn Moum
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Division of Medicine, Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Kirsten Muri Boberg
- Norwegian PSC Research Center, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Section of Gastroenterology, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Massimo Pinzani
- UCL Institute for Liver and Digestive Health, Division of Medicine, University College London & Royal Free Hospital, London, UK
| | - Tom Hemming Karlsen
- Norwegian PSC Research Center, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Section of Gastroenterology, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | | | - Douglas Thorburn
- UCL Institute for Liver and Digestive Health, Division of Medicine, University College London & Royal Free Hospital, London, UK
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Zaccherini G, Weiss E, Moreau R. Acute-on-chronic liver failure: Definitions, pathophysiology and principles of treatment. JHEP Rep 2020; 3:100176. [PMID: 33205036 PMCID: PMC7652714 DOI: 10.1016/j.jhepr.2020.100176] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/29/2020] [Accepted: 08/18/2020] [Indexed: 12/11/2022] Open
Abstract
The term acute-on-chronic liver failure (ACLF) defines an abrupt and life-threatening worsening of clinical conditions in patients with cirrhosis or chronic liver disease. In recent years, different definitions and diagnostic criteria for the syndrome have been proposed by the major international scientific societies. The main controversies relate to the type of acute insult (specifically hepatic or also extrahepatic), the stage of underlying liver disease (cirrhosis or chronic hepatitis) and the concomitant extrahepatic organ failure(s) that should be considered in the definition of ACLF. Therefore, different severity criteria and prognostic scores have been proposed and validated. Current evidence shows that the pathophysiology of ACLF is closely associated with an intense systemic inflammation sustained by circulating pathogen-associated molecular patterns and damage-associated molecular patterns. The development of organ failures may be a result of a combination of tissue hypoperfusion, direct immune-mediated damage and mitochondrial dysfunction. Management of ACLF is currently based on the supportive treatment of organ failures, mainly in an intensive care setting. For selected patients, liver transplantation is an effective treatment that offers a good long-term prognosis. Future studies on potential mechanistic treatments that improve patient survival are eagerly awaited.
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Key Words
- AARC, APASL ACLF Research Consortium
- ACLF, acute-on-chronic liver failure
- AKI, acute kidney injury
- APASL, Asian Pacific Association for the Study of the Liver
- Acute decompensation
- Bacterial infections
- Bacterial translocation
- CLIF, Chronic Liver Failure-Consortium
- COSSH, Chinese Group on the Study of Severe Hepatitis
- DAMPs, damage-associated molecular patterns
- EASL, European Association for the Study of the Liver - Chronic Liver
- ER, endoplasmic reticulum
- HMGB1, high mobility group box 1
- ICU, intensive care unit
- INR, international normalised ratio
- Immunopathology
- Inflammatory response
- MELD, model for end-stage liver disease
- Metabolism
- Multiorgan failure
- NACSELD, North American Consortium for the Study of End-stage Liver Disease
- NO, nitric oxide
- OF, organ failure
- PAMPs, pathogen-associated molecular patterns
- PRR, pattern-recognition receptors
- Sterile inflammation
- TLR, Toll-like receptor
- UNOS, United Network for Organ Sharing
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Affiliation(s)
- Giacomo Zaccherini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain
| | - Emmanuel Weiss
- European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain.,Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, Paris, France.,Inserm et Université de Paris, Centre de Recherche sur l'Inflammation (CRI), Paris, France
| | - Richard Moreau
- European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain.,Inserm et Université de Paris, Centre de Recherche sur l'Inflammation (CRI), Paris, France.,Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France
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18
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De Martin E, Michot JM, Rosmorduc O, Guettier C, Samuel D. Liver toxicity as a limiting factor to the increasing use of immune checkpoint inhibitors. JHEP Rep 2020; 2:100170. [PMID: 33205034 PMCID: PMC7648167 DOI: 10.1016/j.jhepr.2020.100170] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [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: 06/06/2020] [Revised: 07/23/2020] [Accepted: 07/30/2020] [Indexed: 02/07/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) improve clinical outcomes in patients suffering from different types of cancer. Liver toxicity is one of the immune-related adverse events associated with immunotherapy; although not common, its management is challenging as it is extremely heterogeneous in terms of presentation and severity. Differences in the development and evolution of ICI-related toxicity in healthy or cirrhotic livers have not yet been elucidated. Assessing causality is key to diagnosing ICI-induced liver toxicity; liver biopsies can assist not only in the differential diagnosis but also in assessing the severity of histological liver damage. The current classification of severity overestimates the grade of liver injury and needs to be revised to reflect the views of hepatologists. Spontaneous improvements in ICI-related liver toxicity have been reported, so corticosteroid therapy should probably be individualised not systematic. The reintroduction of ICIs in a patient with previous immune-mediated hepatitis may be possible, but the risk/benefit ratio should be considered, as the risk factors for hepatitis recurrence are currently unclear. The management of these patients, requiring a balance between efficacy, toxicity and specific treatments, necessitates multidisciplinary collaboration. The incidence of immune-related liver toxicity will continue to rise based on the increasing use of ICIs for most cancers, mandating improved understanding and management of this complication.
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Key Words
- AIH, autoimmune hepatitis
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- AMA, anti-mitochondrial antibodies
- ANA, anti-nuclear antibodies
- ASMA, anti-smooth muscles antibodies
- AST, aspartate aminotransferase
- CTLA-4, cytotoxic T lymphocyte-associated protein 4
- Corticosteroid therapy
- DCR, disease control rate
- DILI, drug-induced liver injury
- GGT, gamma-glutamyltransferase
- HCC, hepatocellular carcinoma
- ICI, immune checkpoint inhibitor
- INR, international normalised ratio
- Immune-mediated hepatitis
- Immunotherapy
- Liver biopsy
- MMF, mycophenolate mofetil
- ORR, objective response rate
- OS, overall survival
- PD-1, programmed cell death 1
- PD-L1-2, programmed cell death ligands 1-2
- PFS, progression-free survival
- TKI, tyrosine kinase inhibitor
- UDCA, ursodeoxycholic acid
- ULN, upper limit of normal
- anti-LC1, anti-liver cytosol type-1 antibodies
- anti-LKM, anti-liver-kidney microsomal antibodies
- anti-SLA, anti-soluble liver antigen antibodies
- irAE, immune-related adverse event
- trAE, treatment-related adverse event
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Affiliation(s)
- Eleonora De Martin
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, Univ Paris-Sud, Université Paris-Saclay, FHU Hépatinov, Villejuif, F-94800, France
| | - Jean-Marie Michot
- Département d'innovation thérapeutique et d'Essais Précoces (DITEP), Institut Gustave-Roussy, Université Paris Saclay, Villejuif, France
| | - Olivier Rosmorduc
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, Univ Paris-Sud, Université Paris-Saclay, FHU Hépatinov, Villejuif, F-94800, France.,Sorbonne-Université
| | - Catherine Guettier
- AP-HP Hôpital Bicêtre, Laboratoire Anatomie Pathologique, Le Kremlin-Bicêtre, France, Univ Paris-Sud, UMR-S 1193, Université Paris-Saclay, France
| | - Didier Samuel
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, Univ Paris-Sud, Université Paris-Saclay, FHU Hépatinov, Villejuif, F-94800, France
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García-Pagán JC, Saffo S, Mandorfer M, Garcia-Tsao G. Where does TIPS fit in the management of patients with cirrhosis? JHEP Rep 2020; 2:100122. [PMID: 32671331 PMCID: PMC7347999 DOI: 10.1016/j.jhepr.2020.100122] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 04/20/2020] [Accepted: 05/11/2020] [Indexed: 02/06/2023] Open
Abstract
In this review, we summarise the current knowledge on the indications and contraindications of transjugular intrahepatic portosystemic shunt (TIPS) placement for the treatment of the complications of portal hypertension in cirrhosis, specifically variceal haemorrhage and ascites. Moreover, we discuss the role of TIPS for the treatment of portal vein thrombosis (PVT) and the prevention of complications after extrahepatic surgery ('preoperative TIPS') in patients with cirrhosis. The position of TIPS in the treatment hierarchy depends on the clinical setting and on patient characteristics. In acute variceal haemorrhage, preemptive TIPS is indicated in patients at a high risk of failing standard therapy, that is those with a Child-Pugh score of 10-13 points or Child-Pugh B with active bleeding at endoscopy, although the survival benefit in the latter group still remains to be established. Non-preemptive TIPS is a second-line therapy for the prevention of recurrent variceal haemorrhage and for the treatment of ascites. Of note, TIPS may also improve sarcopenia. Contraindications to TIPS placement, independent of clinical setting, include very advanced disease (Child-Pugh >13 points), episodes of recurrent overt hepatic encephalopathy without an identifiable precipitating factor, heart failure, and pulmonary hypertension. In patients with PVT, TIPS placement not only controls complications of portal hypertension, but also promotes portal vein recanalisation. Although the severity of portal hypertension correlates with poor outcomes after extrahepatic surgery, there is no evidence to recommend preoperative TIPS placement.
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Key Words
- ACLF, acute-on-chronic liver failure
- AKI, acute kidney injury
- ARR, absolute risk reduction
- AVB, acute variceal bleeding
- Ascites
- BNP, brain natriuretic peptide
- BRTO, balloon-occluded retrograde transvenous obliteration
- Bleeding
- CHF, chronic heart failure
- CLD, chronic liver disease
- CSPH, clinically significant portal hypertension
- Cirrhosis
- EVL, endoscopic variceal ligation
- GOV, gastro-oesophageal varices
- HCC, hepatocellular carcinoma
- HE, hepatic encephalopathy
- HVPG, hepatic venous pressure gradient
- Haemorrhage
- ICA, International Club of Ascites
- IGV, isolated gastric varices
- INR, international normalised ratio
- ISMN, isosorbide mononitrate
- LVP+A, LVP with albumin
- LVP, large-volume paracenteses
- MELD, model for end-stage liver disease
- NNT, number needed to treat
- NSBB, non-selective beta blocker
- OS, overall survival
- PCI, percutaneous coronary intervention
- PFTE, polytetrafluoroethylene
- PLT, platelet count
- PSE, portosystemic encephalopathy
- PV, portal vein
- PVT, portal vein thrombosis
- Portal hypertension
- Portal vein thrombosis
- RA, refractory ascites
- RCTs, randomised controlled trials
- SBP, spontaneous bacterial peritonitis
- SEMS, self-expandable metallic stent
- TFS, transplant-free survival
- TIPS, transjugular intrahepatic portosystemic shunt
- Transjugular intrahepatic portosystemic shunt
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Affiliation(s)
- Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Saad Saffo
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Mattias Mandorfer
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Barcelona, Spain
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, VA-Connecticut Healthcare System, West Haven, CT, USA
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
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Zermatten MG, Fraga M, Calderara DB, Aliotta A, Moradpour D, Alberio L. Biomarkers of liver dysfunction correlate with a prothrombotic and not with a prohaemorrhagic profile in patients with cirrhosis. JHEP Rep 2020; 2:100120. [PMID: 32715285 PMCID: PMC7369360 DOI: 10.1016/j.jhepr.2020.100120] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/08/2020] [Accepted: 04/21/2020] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Different liver dysfunction biomarkers are used to assess the bleeding risk of patients with cirrhosis, either as such or included in bleeding risk assessment scores. Since the current model of coagulation in patients with cirrhosis describes a procoagulant tendency with increasing severity according to Child-Pugh stage, we decided to investigate the relation between liver dysfunction biomarkers and thrombin generation. Our aim was to verify their adequacy for bleeding risk assessment. Methods We performed a prospective single-centre study including 260 patients with liver cirrhosis. Thrombin generation was measured using ST Genesia® Thrombin Generation System without and with thrombomodulin in order to assess the role of proteins C and S. Relations between thrombin generation and Child-Pugh/model for end-stage liver disease (MELD) scores, prothrombin time (PT)/international normalised ratio (INR), activated partial thromboplastin time (aPTT), factor V activity, albumin, and total bilirubin were assessed. Results Thrombomodulin-mediated inhibition of thrombin generation was significantly decreased in patients with liver cirrhosis compared with healthy donors (p <0.0001) and in Child-Pugh B and C compared with A (p <0.0001 [A–B], 0.4515 [B–C], <0.0001 [A–C]). Thrombomodulin-mediated inhibition significantly decreased with increasing PT/INR, aPTT, and total bilirubin levels and with decreasing factor V activity and albumin levels. Conclusions Worsening liver dysfunction biomarkers reflect an increasing prothrombotic profile in patients with liver cirrhosis. In particular, prolonged PT/INR and aPTT as well as decreasing factor V activity are related to an increasing thrombotic risk and not to an increasing bleeding risk. These parameters should not be used to assess bleeding risk due to haemostatic anomalies in patients with liver cirrhosis. Alternative biomarkers for bleeding risk assessment in patients with liver cirrhosis need to be developed. Lay summary We demonstrate that the laboratory parameters used to assess bleeding risk of patients with liver disease, e.g. prothrombin time/international normalised ratio (PT/INR) and activated partial thromboplastin time (aPTT), are inadequate for this purpose because they are correlated with a prothrombotic coagulation profile. In this article, we highlight the need for alternative parameters to assess bleeding risk in patients with liver disease. Patients with cirrhosis display a prothrombotic coagulation profile. This is due to a relative decrease of natural anticoagulants compared with procoagulants. In cirrhosis, PT and aPTT correlate with a prothrombotic state, and are inadequate as bleeding risk biomarkers.
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Affiliation(s)
- Maxime G Zermatten
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Montserrat Fraga
- Division of Gastroenterology and Hepatology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Debora Bertaggia Calderara
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alessandro Aliotta
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Darius Moradpour
- Division of Gastroenterology and Hepatology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
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Alix P, Val-Laillet D, Turlin B, Ben Mosbah I, Burel A, Bobillier E, Bendavid C, Delpy E, Zal F, Corlu A, Boudjema K. Adding the oxygen carrier M101 to a cold-storage solution could be an alternative to HOPE for liver graft preservation. JHEP Rep 2020; 2:100119. [PMID: 32695967 DOI: 10.1016/j.jhepr.2020.100119] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 12/16/2022] Open
Abstract
Background & Aims Hypothermic oxygenated machine perfusion (HOPE) is a promising technique for providing oxygen to the liver during graft preservation; however, because of associated logistical constraints, addition of an oxygen transporter to static cold-storage solutions (SCS) might be easier. M101 is marine worm haemoglobin that has been shown to improve kidney preservation in the clinic when added to SCS. This study evaluated the effects of the addition of M101 to SCS on the quality of pig liver graft preservation. Methods Pig liver grafts were preserved using SCS, HOPE, or SCS+M101, and the liver functions were compared during cold preservation and after orthotopic allotransplantation (OLT) in pigs. Results During preservation of the liver grafts, mitochondrial function, ATP synthesis, antioxidant capacities, and hepatocyte architecture were better preserved, and free radical production, antioxidant activities, and inflammatory mediators were lower, with HOPE or SCS+M101 than with SCS alone. However, after 1 h of preservation, liver functions with HOPE were superior to those with SCS+M101. After 6 h of preservation and OLT, blood levels of aspartate and alanine aminotransferases and lactate dehydrogenase increased with a peak effect at Day 1 post-transplant; values were similar with HOPE and SCS+M101, and were significantly lower than those in the SCS group. At Days 1 and 3, tumor necrosis factor α levels remained lower with HOPE and SCS+M101 vs. SCS. At Day 7, liver cell necrosis and inflammation were less marked in both oxygenated groups. Conclusions When added to SCS, M101 effectively oxygenates liver grafts during preservation, preventing post-transplant injury; although graft performances are below those achieved with HOPE. Lay summary When transported between donors and recipients, even cold-stored liver grafts need oxygen to maintain their viability. To provide them with oxygen, we added a marine worm super haemoglobin (M101) to the cold-storage solution UWCS. Using a pig liver transplant model, we revealed that livers cold stored with UWCS+M101 showed improved oxygenation compared with simple cold-storage solutions, but did not reach the oxygenation level achieved with machine perfusion.
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Key Words
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- Cell necrosis
- DCD, deceased after circulatory death
- DGF, delayed graft function
- HOPE, hypothermic oxygenated machine perfusion
- Haemoglobin
- Hepatocyte
- INR, international normalised ratio
- IRI, ischaemia-reperfusion injury
- Inflammation
- Liver transplantation
- Oxidative stress
- PT, prothrombin time
- SCS, simple cold-storage solutions
- UWCSS, University of Wisconsin cold-storage solution
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Shribman S, Webb G, Taylor R, Warner TT, Duckworth A, Gimson A, Shenoy A, Griffiths W. Liver transplantation for late-onset presentations of acute liver failure in Wilson's disease: The UK experience over 2 decades. JHEP Rep 2020; 2:100096. [PMID: 32322813 PMCID: PMC7163315 DOI: 10.1016/j.jhepr.2020.100096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/04/2020] [Accepted: 02/22/2020] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Acute liver failure as the initial presentation of Wilson’s disease is usually associated with onset in childhood, adolescence or early adulthood. Outcomes after transplantation for late-onset presentations, at or after 40 years, are seldom reported in the literature. Methods We report a case, review the literature and provide unpublished data from the UK Transplant Registry on late-onset acute liver failure in Wilson's disease. Results We describe the case of a 62-year-old man presenting with acute liver failure who was successfully treated with urgent liver transplantation. We identified 7 cases presenting at age 40 years or over in the literature, for which individual outcomes were reported; 3 were treated with transplantation and 2 survived. We identified a further 8 cases listed for transplantation in the UK between 1995 and 2014; 7 were treated with transplantation and 6 survived. One patient was de-listed for unknown reasons. Conclusions Wilson's disease should be considered in older adults presenting with acute liver failure. We suggest that urgent liver transplantation has good outcomes for late-onset presentations and recommend that urgent transplantation should always be considered in Wilson's disease presenting as acute liver failure. Lay summary Wilson's disease is a rare inherited disease that causes copper accumulation in the liver and brain and usually manifests during childhood, adolescence or early adulthood. We report the case of a 62-year-old who developed acute liver failure and was successfully treated with urgent liver transplantation. We discuss the outcomes of other late-onset cases of acute liver failure due to Wilson's disease in the literature and provide additional data from the UK Transplant Registry. We describe the case of a 62-year-old transplanted for acute liver failure in Wilson's disease. Outcomes after transplantation were previously reported in 3 late-onset cases. We describe a further 7 late-onset cases from the UK Transplant Registry. Wilson's disease should be considered in acute liver failure presenting at any age. Transplantation should always be considered in acute liver failure presentations.
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Affiliation(s)
- Samuel Shribman
- Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, London, UK
| | - Gwilym Webb
- Cambridge Liver Unit, Addenbrooke's Hospital, Cambridge, UK
| | | | - Thomas T Warner
- Reta Lila Weston Institute, UCL Queen Square Institute of Neurology, London, UK
| | - Adam Duckworth
- Cambridge Liver Unit, Addenbrooke's Hospital, Cambridge, UK
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Thomsen KL, Robertson FP, Holland-Fischer P, Davidson BR, Mookerjee RP, Møller HJ, Jalan R, Grønbæk H. The Macrophage Activation Marker Soluble CD163 is Associated With Early Allograft Dysfunction After Liver Transplantation. J Clin Exp Hepatol 2019; 9:302-11. [PMID: 31360022 DOI: 10.1016/j.jceh.2018.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 06/18/2018] [Accepted: 09/26/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/OBJECTIVES Soluble CD163 (sCD163), a macrophage activation marker, is upregulated in conditions of macrophage proliferation and activation. Elevated sCD163 levels have been associated with liver disease severity and progression. During liver transplantation, the implanted liver is exposed to ischaemia and reperfusion injury, resulting in an acute inflammatory response and macrophage activation. The relationship between sCD163 levels during liver transplantation and the development of early allograft dysfunction (EAD) has not been investigated. METHODS We included 27 cirrhosis patients (age 55 [range 32-72] years, 23 men) on the waiting list for liver transplantation. Alcohol consumption and viral hepatitis were the most frequent causes for cirrhosis. Patients were characterised by standard biochemical analysis and based on clinical disease severity scores. Information about donor, graft and course of the liver transplantation was recorded. sCD163 levels were measured at the time of liver transplantation before surgery, 2 h after reperfusion, and then at 24 h after transplantation. RESULTS We observed above-normal sCD163 levels at baseline (5.9 mg/L [4.7-8.8]). Two hours after reperfusion, sCD163 levels increased significantly from baseline (8.4 mg/L [7.4-10.9]; P < 0.01). Twenty-four hours after transplantation, sCD163 levels were significantly reduced compared with baseline (3.7 mg/L [2.9-5.5]; P < 0.01). However, in patients with EAD (n = 16), sCD163 levels were increased compared with patients without EAD (4.1 [3.2-7.4] vs. 3.1 [2.8-3.8] mg/L; P = 0.03). CONCLUSIONS We observed elevated sCD163 levels in patients with EAD after liver transplantation, confirming macrophage activation to play a role in EAD. Thus, sCD163 may be used as an early marker for EAD after liver transplantation, but larger studies are warranted to validate these findings.
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Key Words
- ALK, alkaline phosphatase
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- BMI, body mass index
- CIT, cold ischaemic time
- CRP, C-reactive protein
- DBD, deceased brain death
- DCD, deceased cardiac death
- EAD, Early allograft dysfunction
- ELISA, enzyme-linked immunosorbent assay
- Hb, haemoglobin
- I/R, ischaemia/reperfusion
- IL, interleukin
- INR, international normalised ratio
- IQR, interquartile range
- MELD, Model for End-Stage Liver Disease
- NAFLD, nonalcoholic fatty liver disease
- NF-κB, nuclear factor- κB
- PT, prothrombin time
- TNF-α, tumour necrosis factor α
- WBC, white blood cell
- WIT, warm ischaemic time
- graft dysfunction
- liver transplantation
- macrophages
- sCD163
- sCD163, soluble CD163
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Mehta G, Rousell S, Burgess G, Morris M, Wright G, McPherson S, Frenette C, Cave M, Hagerty DT, Spada A, Jalan R. A Placebo-Controlled, Multicenter, Double-Blind, Phase 2 Randomized Trial of the Pan-Caspase Inhibitor Emricasan in Patients with Acutely Decompensated Cirrhosis. J Clin Exp Hepatol 2018; 8:224-234. [PMID: 30302038 PMCID: PMC6175779 DOI: 10.1016/j.jceh.2017.11.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 11/15/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cirrhosis and acute-on-chronic liver failure (ACLF) are associated with systemic inflammation, and caspase-mediated hepatocyte cell death. Emricasan is a novel, pan-caspase inhibitor. Aims of this study were to assess the pharmacokinetics, pharmacodynamics, safety and clinical outcomes of emricasan in acute decompensation (AD) of cirrhosis. METHODS This was a phase 2, multicentre, double-blind, randomized trial. The primary objective was to evaluate the pharmacokinetics, pharmacodynamics and safety of emricasan in patients with cirrhosis presenting with AD and organ failure. AD was defined as an acute decompensating event ≤6 weeks' duration. Patients were randomized proportionately to emricasan 5 mg bid, emricasan 25 mg bid, emricasan 50 mg bid or placebo. Treatment was continued to 28 days, or voluntary discontinuation. RESULTS Twenty-three subjects were randomized, of whom 21 were dosed (placebo n = 4; 5 mg n = 5; 25 mg n = 7; 50 mg n = 5). Pharmacokinetic data showed 5 mg dose was associated with low plasma levels (<50 ng/ml), and 25 mg and 50 mg doses showed comparable pharmacokinetic profiles. Therefore, for analysis of secondary endpoints, placebo and 5 mg groups were merged into a 'placebo/low-dose' group, and 25 mg and 50 mg groups were merged into a 'high-dose' group. Five deaths occurred amongst the 21 patients, all due to progression of liver disease (2 in placebo/low-dose, 3 in high-dose). No statistically significant changes from baseline MELD score or CLIF-C ACLF score were noted between placebo/low-dose and high-dose groups at day 7 (MELD -1 vs -1, CLIF-C ACLF 0.7 vs 0.8). An initial reduction in cleaved keratin M30 fragment was noted between placebo/low-dose and high-dose groups (percent relative change: day 2: -11.6 vs -42.6, P = 0.017, day 4: -3.5 vs -38.9 P = 0.017) although this did not persist to day 7 (-3.1 vs -20.8, P = 0.342). CONCLUSION This study demonstrates that emricasan is safe and well tolerated in advanced liver disease. However, this study fails to provide proof-of-concept support for caspase inhibition as a treatment strategy for ACLF. TRIAL REGISTRATION EudraCT 2012-004245-33.
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Key Words
- ACLF, acute-on-chronic liver failure
- AD, acute decompensation
- ALT, alanine aminotransferase
- ANCOVA, analysis of covariance
- AST, aspartate aminotransferase
- Bid, Bis in die (twice a day)
- DL, decilitre
- HCV, hepatitis C virus
- INR, international normalised ratio
- MELD, model for end-stage liver disease
- Mg, milligrams
- TNF, tumour necrosis factor
- TRAIL, tumour necrosis factor-related apoptosis-inducing ligand
- apoptosis
- cell death
- cirrhosis
- liver failure
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Affiliation(s)
- Gautam Mehta
- Institute for Liver and Digestive Health, Royal Free Campus, UCL, London, UK,Address for correspondence: Gautam Mehta, Institute for Liver and Digestive Health, Royal Free Campus, UCL, London, UK.
| | | | | | | | - Gavin Wright
- Department of Gastroenterology, Basildon and Thurrock University Hospitals NHS Foundation Trust, Basildon, UK
| | - Stuart McPherson
- Liver Unit, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Catherine Frenette
- Department of Organ Transplantation, Scripps Green Hospital, San Diego, USA
| | - Matthew Cave
- Department of Medicine, University of Louisville School of Medicine, Louisville, USA
| | | | | | - Rajiv Jalan
- Institute for Liver and Digestive Health, Royal Free Campus, UCL, London, UK
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El-Shaer W, Abou-Taleb A, Kandeel W. Transurethral bipolar plasmakinetic vapo-enucleation of the prostate: Is it safe for patients on chronic oral anticoagulants and/or platelet aggregation inhibitors? Arab J Urol 2017; 15:347-354. [PMID: 29234539 PMCID: PMC5717451 DOI: 10.1016/j.aju.2017.09.005] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/20/2017] [Accepted: 09/16/2017] [Indexed: 02/02/2023] Open
Abstract
Objectives To assess the safety and efficacy of bipolar plasmakinetic enucleation and resection of the prostate (PKERP) for the management of benign prostatic hyperplasia (BPH) in patients on oral anticoagulant (OAC) therapy and/or platelet aggregation inhibitors (PAIs). Patients and methods In all, 91 patients were recruited and underwent PKERP whilst they were receiving PAIs (aspirin, 56 patients; clopidogrel, three; aspirin and clopidogrel, 11). In all, 15 patients were receiving an OAC drug perioperatively, whilst another six patients were on dual PAIs and OACs. The primary outcomes were the perioperative morbidity and mortality rates. The secondary outcomes were functional outcomes including maximum urinary flow rate (Qmax), International Prostate Symptoms Score (IPSS), and post-void residual urine volume (PVR). Results The mean (SD) age of the patients was 65 (5.9) years, preoperative adenoma volume was 80.9 (30.4) mL, and the operative time was 67 (23) min. No patient developed serious perioperative cardiovascular complications. The mean (SD) duration of hospital stay was 1.79 (1) days and the postoperative catheterisation time was 1.14 (0.76) days. The mean (SD) haemoglobin drop was 0.74 (0.61) g/dL, blood transfusion rate was 2.2%, and the clot retention rate was 2.2%. The mean (SD) postoperative Qmax was 18.6 (4.37) mL/s as compared to 7.2 (3.2) mL/s preoperatively (P < 0.001), and the preoperative IPSS was reduced from 24.3 (6.1) to 5.7 (2.3) postoperatively (P < 0.05). Prostate volume measured by transrectal ultrasonography was significantly reduced from a mean (SD) of 80.9 (30.4) mL preoperatively to 29.5 (10.6) mL postoperatively (P < 0.001). Conclusion Minimally invasive PKERP may be considered as a safe and effective treatment option for managing patients with BPH receiving OAC/PAI drugs.
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Key Words
- Anticoagulant
- BPH
- Hb, haemoglobin
- HoLEP, holmium laser enucleation of the prostate
- INR, international normalised ratio
- LUTS
- M-TURP, monopolar TURP
- OA, oral anticoagulant
- PAI, platelet aggregation inhibitor
- PKERP
- PKERP, plasmakinetic enucleation and resection of the prostate
- PVR, post-void residual urine volume
- Qmax, maximum urinary flow rate
- ThuVARP, thulium vaporesection of the prostate
- ThuVEP, thulium vapoenucleation of the prostate
- UI, urinary incontinence
- US, ultrasonography
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Affiliation(s)
- Waleed El-Shaer
- Department of Urology, Banha University Hospital, Banha, Egypt
| | | | - Wael Kandeel
- Department of Urology, Banha University Hospital, Banha, Egypt
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Voukalis C, Lip GYH, Shantsila E. Emerging Tools for Stroke Prevention in Atrial Fibrillation. EBioMedicine 2016; 4:26-39. [PMID: 26981569 PMCID: PMC4776061 DOI: 10.1016/j.ebiom.2016.01.017] [Citation(s) in RCA: 8] [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: 12/01/2015] [Revised: 01/07/2016] [Accepted: 01/14/2016] [Indexed: 02/02/2023] Open
Abstract
Ischaemic strokes resulting from atrial fibrillation (AF) constitute a devastating condition for patients and their carers with huge burden on health care systems. Prophylactic treatment against systemic embolization and ischaemic strokes is the cornerstone for the management of AF. Effective stroke prevention requires the use of the vitamin K antagonists or non-vitamin K oral anticoagulants (NOACs). This article summarises the latest developments in the field of stroke prevention in AF and aims to assist physicians with the choice of oral anticoagulant for patients with non-valvular AF with different risk factor profile. Vitamin K antagonists (VKA) or non-VKA oral anticoagulants should be used for stroke prevention in atrial fibrillation. Antiplatelet agents should not be prescribed solely for thromboprophylaxis in atrial fibrillation. Stroke risk should be assessed using the CHA2DS2-VASc score, and bleeding risk with the HAS-BLED score. The net clinical benefit favours oral anticoagulation with non-VKA oral anticoagulants in presence of at least 1 risk factor.
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Key Words
- Atrial fibrillation
- CKD, chronic kidney disease
- CrCl, creatinine clearance
- DM, diabetes mellitus
- ESRF, end stage renal failure
- HF, heart failure
- HTN, hypertension
- ICH, intracranial haemorrhage
- INR, international normalised ratio
- LV, left ventricle
- NCB, net clinical benefit
- NICE, National institute for Health and Care Excellence
- NVAF, non-valvular atrial fibrillation
- Net clinical benefit
- Non-vitamin K oral anticoagulants
- Oral anticoagulation
- PCI, percutaneous coronary intervention
- RSM, risk stratification model
- Risk stratification
- SE, systemic embolism
- Stroke prevention
- TE, thromboembolic episode
- TIA, transient ischaemic attack
- TTR, time in therapeutic range
- eGFR, estimated glomerular filtration rate
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Affiliation(s)
- Christos Voukalis
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK
| | - Gregory Y H Lip
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK
| | - Eduard Shantsila
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK
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Vasudevan A, Spanger M, Lubel JS. Abdominal Pain Following Drug-eluting Bead Transarterial Chemoembolization. J Clin Exp Hepatol 2015; 5:93-4. [PMID: 25941438 PMCID: PMC4415190 DOI: 10.1016/j.jceh.2015.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 01/03/2015] [Indexed: 12/12/2022] Open
Affiliation(s)
- Abhinav Vasudevan
- Department of Gastroenterology, Eastern Health, Melbourne, Victoria, Australia,Address for correspondence: Abhinav Vasudevan, Department of Gastroenterology, Eastern Health Clinical School, Monash University, Level 2, 5 Arnold Street, Box Hill, Victoria, 3128, Australia. Tel.: +61 3 98953333; fax: +61 3 9899 9137.
| | - Manfred Spanger
- Department of Radiology, Eastern Health, Melbourne, Victoria, Australia,Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - John S. Lubel
- Department of Gastroenterology, Eastern Health, Melbourne, Victoria, Australia,Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
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28
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Goh GBB, Pagadala MR, Dasarathy J, Unalp-Arida A, Sargent R, Hawkins C, Sourianarayanane A, Khiyami A, Yerian L, Pai RK, Dasarathy S, McCullough AJ. Clinical spectrum of non-alcoholic fatty liver disease in diabetic and non-diabetic patients. BBA Clin 2014; 3:141-5. [PMID: 26675585 PMCID: PMC4661498 DOI: 10.1016/j.bbacli.2014.09.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 09/05/2014] [Accepted: 09/11/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND While non-alcoholic fatty liver disease (NAFLD) has been well characterised in patients with diabetes mellitus (DM), less is known about NAFLD in non-DM patients. We investigated the clinical characteristics of NAFLD patients with and without DM and accuracy of the NAFLD fibrosis score (NFS) in these two NAFLD groups. METHODS Clinical, biochemical and histological variables were evaluated in this prospective cross-sectional study of 503 patients with biopsy proven NAFLD. Comparisons between patients with and without DM were analysed. NFS was correlated with liver histology to assess its robustness in patients with and without DM. RESULTS There were 503 biopsy proven NAFLD patients with 48% of the cohort being diabetic. Relative to patients without DM, patients with DM were older (52 vs. 46 years, p < 0.001), with higher proportion of females (70% vs. 54%, p < 0.001), higher BMI (37 vs. 35, p = 0.009), higher prevalence of hypertension (73% vs. 44%, p < 0.001), higher prevalence of NASH (80.2% vs. 64.4%; p < 0.001) and advanced fibrosis (40.3% vs. 17.0%; p < 0.001). A considerable amount of patients without DM still had NASH (64%) and advanced fibrosis (17%). The clinical utility of the NFS differed between NAFLD patients with and without DM, with sensitivity to exclude advanced fibrosis being 90% of NAFLD patients with DM but only 58% of patients without DM. CONCLUSION Patients with DM have more severe NAFLD based on histology. However, NASH and advanced fibrosis also occur in a considerable proportion of NAFLD patients without DM. The lower utility of the NFS in NAFLD patients without DM emphasises the heterogeneous nature of the NAFLD phenotype.
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Key Words
- ACE-I, angiotensin-converting enzyme-inhibitor
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- ARB, angiotensin receptor blocker
- AST, aspartate aminotransferase
- BMI, body mass index
- CIs, confidence intervals
- Chol, total cholesterol
- DM, type 2 diabetes mellitus
- Diabetic
- ER, endoplasmic reticulum
- FFAs, free-fatty acids
- HDL, high density lipoprotein cholesterol
- HOMA-IR, Homeostatic model assessment—insulin resistance
- INR, international normalised ratio
- LDL, low density lipoprotein cholesterol
- NAFLD
- NAFLD fibrosis score
- NAFLD, non-alcoholic fatty liver disease
- NAS, NAFLD activity score
- NASH CRN, Non-alcoholic Steatohepatitis Clinical Research Network
- NASH, non-alcoholic steatohepatitis
- NFS, NAFLD fibrosis score
- Non-diabetic
- ORs, odd ratios
- SDs, standard deviations
- TGs, triglycerides
- VLDL, very-low-density lipoproteins
- apoB-100, apolipoprotein B-100
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Affiliation(s)
| | | | | | | | - Ruth Sargent
- Department of Gastroenterology at Cleveland Clinic, USA
| | | | | | | | - Lisa Yerian
- Department of Pathology at Cleveland Clinic, USA
| | - Rish K Pai
- Department of Pathology at Cleveland Clinic, USA
| | - Srinivasan Dasarathy
- Department of Gastroenterology at Cleveland Clinic, USA ; Department of Pathobiology at Cleveland Clinic, USA
| | - Arthur J McCullough
- Department of Gastroenterology at Cleveland Clinic, USA ; Department of Pathobiology at Cleveland Clinic, USA
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