Browsing by Subject "Liver Cirrhosis"
Now showing 1 - 13 of 13
- Results Per Page
- Sort Options
Item Acute-on-chronic liver failure(2019-06-07) O'Leary, Jacqueline G.Item Biliary cirrhosis(1962-10-11) Combes, BurtonItem Cardiovascular changes in cirrhosis of the liver(1966-12-08) Bashour, Fouad A.Item HCC Surveillance Is Associated with Potential Harms(2015-01-26) Muffler, Adam; Atiq, Omair; Yopp, Adam; Singal, Amit G.BACKGROUND: Hepatocellular carcinoma (HCC) is the 3rd leading cause of cancer death worldwide and leading cause of death in patients with cirrhosis. HCC surveillance is recommended in patients with cirrhosis to improve early detection rates. A comprehensive assessment of HCC surveillance should weigh both benefits and harms; however, no study to date has assessed potential harms. Although ultrasound and alpha fetoprotein (AFP) have minimal direct harms, there are potential downstream harms from follow-up tests that should be considered. Objective: To quantify and characterize potential harms of HCC surveillance among a large cohort of patients with cirrhosis METHODS: We conducted a retrospective cohort study among patients with cirrhosis followed at a large safety-net health system. We recorded all surveillance abdominal imaging and/or alpha fetoprotein (AFP) testing between January 2010 and December 2013. We defined a false positive surveillance test as a suspicious liver mass on ultrasound or AFP >20 ng/mL, without HCC development during follow-up. We recorded CT or MRI scans, biopsies, or any procedures performed as a direct result of surveillance testing. Predictors of harm were identified using logistic regression, with significance being defined as p<0.05. RESULTS: We identified 571 patients with cirrhosis, with median follow-up of 2.8 years. HCC surveillance was performed at least once in 551 (96%) patients. Surveillance testing led to diagnostic CT or MRI testing in 123 (21.5%) patients - 74 with one CT/MRI and 49 with multiple studies. Rates of unnecessary diagnostic testing increased from 15% if followed for ≤1 year to 25% if followed for 1-2 years to 37% if followed for ≥2 years. An additional two patients had a biopsy and one patient angiogram for false positive surveillance tests. Follow-up tests were performed due to false positive ultrasound in 47 cases, false positive AFP in 35 cases, and indeterminate ultrasound results in 41 cases. In multivariate analysis, surveillance harm was associated with viral liver disease (OR 1.60, 95%CI 1.04-2.46), receipt of hepatology subspecialty care (OR 2.32, 95%CI 1.52-3.59), and coverage by Parkland Health Plus (OR 2.21, 95%CI 1.45- 3.40). CONCLUSION: This study is the first to demonstrate HCC surveillance can be associated with potential harms. One in five patients have at least one unnecessary diagnostic test, and nearly 10% have multiple tests. Better HCC surveillance tools, with a higher positive predictive value, are urgently needed.Item Hepatorenal syndrome: a nephrologist's perspective(2012-03-02) Quinones, HenryItem Infectious complications of cirrhosis(2000-08-24) Thiele, Dwain L.Item [Liver cirrhosis and viral hepatitis](1959-12-17) UnknownItem Liver Fibrosis and Steatosis in HIV-Infected Patients: Impact of Race/Ethnicity, Gender, BMI, and ART(2019-04-02) Rucker, Danielle; Cutrell, James; Bedimo, Roger; Luque, AmnerisBACKGROUND: The advent of antiretroviral therapy (ART) led to a decline in morbidity and mortality related to AIDS and its related complications. With this decline, an increasing proportion of morbidity and mortality in people living with HIV (PLWH) is secondary to liver and cardiovascular disease. Previous studies have shown that PLWH have traditional risk factors for these diseases, such as obesity, as well as risk factors that are unique to their population, including direct metabolic effects of HIV and ART. Several factors, such as race, ethnicity, gender, and BMI, have been shown to have an impact on the course of liver steatosis and fibrosis in general population. The impact of these factors on the course of liver steatosis and fibrosis in the setting of hepatitis B and C co-infections in PLWH have been studied, but there is a paucity of literature detailing the impact in the absence of viral hepatitis co-infection. NAFLD, APRI, and FIB-4 scores have been shown to be effective noninvasive markers for clinically significant liver steatosis and fibrosis. However, these non-invasive markers have not been validated for use in patients without viral hepatitis co-infection. This study aims to determine if race, ethnicity, gender, BMI, and the specific ART regimen have a differential impact on non-invasive markers of liver steatosis and fibrosis in PLWH. OBJECTIVE: Determine if race, ethnicity, gender, BMI, and specific ART regimen will modulate changes in non-invasive markers of liver steatosis and fibrosis. METHODS: All patients initiating ART at the Parkland Memorial Hospital HIV clinic from 2009-2017 were analyzed. Exposure to ART was defined as concurrent receipt of at least two nucleoside reverse transcriptase inhibitor (NRTI) drugs plus at least one protease inhibitor (PI), non-nucleoside reverse transcriptase inhibitor (NNRTI), or integrase inhibitor (INSTI). The existing patient database includes demographics (notably, gender, race, and ethnicity), CD4 and HIV RNA levels, co-morbidities, laboratory values (most notably, liver function tests), ART regimen, and body mass index (BMI). An analysis of yearly changes in BMI was calculated based on specific ART drugs, and differences between groups stratified by gender or race/ethnicity were compared. For subjects who meet certain pre-determined liver function test minimums, non-invasive markers for liver fibrosis (APRI, NAFLD, and FIB-4 scores) will be utilized and trended over time. Manual chart extraction will be examined for patients with clinically-indicated imaging (abdominal ultrasound, computed tomography, or magnetic resonance imaging) to estimate the incidence and prevalence of liver fibrosis or steatosis in this population and to determine whether race/ethnicity or gender modifies these risks. RESULTS: The difference in yearly BMI change was statistically significant for the INSTI dolutegravir (DTG; p=<0.01) between Blacks and non-Hispanic whites (NHW) but not for any other ART drugs tested. The difference in yearly BMI change showed a trend for statistical significance for DTG (p=0.06) between Hispanics and NHW but not for any other ART drugs tested. The difference in yearly BMI change by ART drug in men versus women was statistically significant for atazanavir (ATV; p=0.03), darunavir (DRV;p=<0.01), lopinavir (LPV; p=0.03), and dolutegravir (DTG; p=<0.01) but not with elvitegravir (EVG; p=0.72). CONCLUSIONS AND NEXT STEPS: Our preliminary results indicate that particular ART drugs, principally the INSTI DTG, appear to be associated with greater BMI gains than other agents. Additionally, in PLWH on ART, women demonstrated greater BMI gains than men, and Blacks and Hispanics demonstrated greater BMI gains than NHW in our cohort. The next steps will be to analyze the trends of APRI, FIB-4, and NAFLD scores over time in our cohort as non-invasive markers of liver fibrosis and to determine the demographic, HIV, and ART-related factors associated with higher rates of liver fibrosis. We will also conduct a review of clinically-indicated abdominal imaging for evidence of hepatic fibrosis in a subset of our cohort to validate the use of these non-invasive markers in PLWH without viral hepatitis. Given that HIV has been transformed into a chronic disease and that PLWH are now living decades on these ART regimens, it is of paramount importance to determine the long-term metabolic and hepatic consequences of these medications to better inform patient care and practice guidelines. We believe that our large cohort of demographically diverse PLWH on contemporary ART regimens and with detailed clinical follow-up data offers an important population to further our understanding of these critical issues.Item Liver transplantation: what an internist needs to know(2018-07-06) Kerr, Thomas A.Item Sensitivity of Ultrasound and Alpha Fetoprotein for Detection of Hepatocellular Carcinoma in Patients with Cirrhosis(2017-01-17) Sasiponganan, Chayanit; Singal, Amit G.BACKGROUND: Hepatocellular carcinoma (HCC) is the fastest growing cause of cancer related mortality in the United States. Prognosis is strongly tied to early detection, which facilitates curative treatment and long-term survival. Therefore, HCC screening is recommended in at risk patients, i.e. those with cirrhosis. Although ultrasonography is routinely used to screen at-risk patients for HCC, it is operator dependent and its sensitivity outside of prospective cohort studies is poorly described. Further, the benefit of adding serum biomarkers, such as alpha fetoprotein, has also been poorly studied. The aim of our study was to quantify the effectiveness of ultrasound and AFP for HCC detection in patients with cirrhosis. METHODS: We performed a retrospective chart review of patients newly diagnosed with HCC at UT Southwestern and Parkland Health and Hospital System between January 2009 and December 2015. We excluded patients who did not have at least one ultrasound within 12 months prior to HCC diagnosis. Ultrasounds were categorized as positive if there was a suspicious mass > 1 cm and AFP as positive if ≥20 ng/mL, the most common cut-off in clinical practice. Sensitivity was compared between ultrasound alone and combination of ultrasound + AFP using the chi-square test, with statistical significance defined as p<0.05. RESULTS: Of the 925 patients diagnosed with HCC between January 2009 and December 2015, 521 patients had an ultrasound within 12 months prior to HCC diagnosis. The overall sensitivity of ultrasound for HCC detection was 77.5% n=404/521). Of the 521 included patients, 400 had at least one AFP within 12 months of HCC diagnosis. There were 154 patients who had both positive ultrasound and AFP, 143 with positive ultrasound alone, 59 with positive AFP alone, and 44 with negative ultrasound and AFP. The sensitivity of ultrasound alone was 74.3% compared to 89.0% with ultrasound and AFP p<0.001). CONCLUSION: Ultrasound alone has suboptimal sensitivity for HCC detection in clinical practice, highlighting the need for better screening tools. Adding serum biomarkers, such as AFP, can significantly improve HCC detection in clinical practice.Item [Southwestern News](2005-09-29) Rian, RussellItem Spontaneous bacterial peritonitis(1988-04-28) Cuthbert, Jennifer A.Item Therapeutic approaches to the prevention of variceal hemorrhage in cirrhotic patients(1989-03-16) Thiele, Dwain L.