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1.
Hepatology ; 2024 Jul 30.
Artículo en Inglés | MEDLINE | ID: mdl-39212328

RESUMEN

Multidisciplinary clinics (MDCs) are gaining momentum throughout the medical field, having initially been pioneered in oncology clinics due to their inherent ability to streamline complex care and improve both patient outcomes and the patient care experience. Liver transplant and hepatobiliary tumor clinics are examples of established MDCs in hepatology. With the changing landscape of liver disease in regard to etiology and patient complexity and acuity, there is a clear need for efficient, highly coordinated care. These changes highlight opportunities for hepatology MDCs in alcohol-associated liver disease, metabolic dysfunction-associated steatotic liver disease, and palliative care. This review provides practical advice in navigating the complex logistics of establishing and maintaining a hepatology MDC while also reviewing the emerging evidence on clinical outcomes for patients seen in these MDCs. As hepatology looks to the future, establishment of MDCs in key clinical areas will be the cornerstone of patient care.

2.
Am J Gastroenterol ; 119(8): 1496-1505, 2024 Aug 01.
Artículo en Inglés | MEDLINE | ID: mdl-38314748

RESUMEN

INTRODUCTION: The aim of this study is to describe the presenting features, genetic factors, and outcomes of 23 adults who developed liver injury after coronavirus disease 2019 (COVID-19) mRNA vaccination. METHODS: Patients with suspected COVID-19 vaccine hepatitis were enrolled into the Drug-Induced Liver Injury Network. Causality was assessed using the Drug-Induced Liver Injury Network expert opinion score. High-resolution HLA sequencing was undertaken using Illumina platform. RESULTS: Amongst the 16 high causality cases, median time to onset was 16 days, median age was 63 years, and 75% were female. The injury was hepatocellular in 75% with a median alanine aminotransferase of 497 U/L, and 37% had jaundice. An antinuclear antibody and smooth muscle antibody were detectable in 27% and 36%, but only 12% had an elevated immunoglobulin G level. During follow-up, 37% received a short course of corticosteroids, and 88% fully recovered by 6 months with no deaths observed. HLA alleles associated with autoimmune hepatitis were not overrepresented compared with controls, but an ERAP-2 variant (rs1263907) and the ERAP-1 Hap6 haplotype were significantly overrepresented in the high causality cases vs controls ( P = 0.026 and 5 × 10 -5 , respectively). DISCUSSION: Acute liver injury may arise within 8 weeks of COVID-19 mRNA vaccination that is generally mild and self-limited in most patients. The absence of an association with the AIH HLA alleles combined with the significant ERAP-2 and ERAP-1 Hap6 haplotype associations implicates a unique but very rare host immune response to vaccine-derived antigens in the pathogenesis of COVID-19 vaccine hepatotoxicity.


Asunto(s)
Aminopeptidasas , Vacunas contra la COVID-19 , COVID-19 , Enfermedad Hepática Inducida por Sustancias y Drogas , Antígenos de Histocompatibilidad Menor , Humanos , Femenino , Masculino , Persona de Mediana Edad , Enfermedad Hepática Inducida por Sustancias y Drogas/genética , Enfermedad Hepática Inducida por Sustancias y Drogas/etiología , Aminopeptidasas/genética , COVID-19/prevención & control , Anciano , Vacunas contra la COVID-19/efectos adversos , Antígenos de Histocompatibilidad Menor/genética , Antígenos de Histocompatibilidad Menor/inmunología , Estados Unidos/epidemiología , SARS-CoV-2 , Adulto , Vacuna nCoV-2019 mRNA-1273 , Vacunación/efectos adversos , Vacuna BNT162/efectos adversos , Vacunas Sintéticas/efectos adversos
3.
Liver Transpl ; 30(8): 848-861, 2024 Aug 01.
Artículo en Inglés | MEDLINE | ID: mdl-38471008

RESUMEN

Alcohol-associated liver disease poses a significant global health burden, with rising alcohol consumption and prevalence of alcohol use disorder (AUD) contributing to increased morbidity and mortality. This review examines the challenges and opportunities in the care of candidates and recipients of liver transplant (LT) with AUD. Despite advancements in posttransplant patient survival, the risk of disease recurrence and alcohol relapse remains substantial. Several challenges have been identified, including (1) rising disease burden of alcohol-associated liver disease, variable transplant practices, and systemic barriers; (2) disparities in mental health therapy access and the impact on transplant; (3) variable definitions, underdiagnosis, and stigma affecting access to care; and (4) post-LT relapse, its risk factors, and consequential harm. The review focuses on the opportunities to improve AUD care for candidates and recipients of LT through effective biochemical monitoring, behavioral and pharmacologic approaches, creating Centers of Excellence for post-LT AUD care, advocating for policy reforms, and ensuring insurance coverage for necessary services as essential steps toward improving patient outcomes. The review also highlights unmet needs, such as the scarcity of addiction specialists, and calls for further research on personalized behavioral treatments, digital health, and value-based care models to optimize AUD care in the LT setting.


Asunto(s)
Alcoholismo , Hepatopatías Alcohólicas , Trasplante de Hígado , Humanos , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/normas , Hepatopatías Alcohólicas/cirugía , Hepatopatías Alcohólicas/terapia , Hepatopatías Alcohólicas/epidemiología , Hepatopatías Alcohólicas/diagnóstico , Hepatopatías Alcohólicas/etiología , Alcoholismo/complicaciones , Alcoholismo/terapia , Alcoholismo/epidemiología , Factores de Riesgo , Accesibilidad a los Servicios de Salud , Recurrencia , Disparidades en Atención de Salud , Prevalencia , Receptores de Trasplantes/estadística & datos numéricos , Consumo de Bebidas Alcohólicas/efectos adversos , Consumo de Bebidas Alcohólicas/epidemiología , Enfermedad Hepática en Estado Terminal/cirugía , Enfermedad Hepática en Estado Terminal/diagnóstico , Enfermedad Hepática en Estado Terminal/terapia , Enfermedad Hepática en Estado Terminal/complicaciones , Enfermedad Hepática en Estado Terminal/mortalidad
4.
Curr Opin Gastroenterol ; 40(3): 119-125, 2024 05 01.
Artículo en Inglés | MEDLINE | ID: mdl-38353234

RESUMEN

PURPOSE OF REVIEW: The rapid rollout and uptake of novel coronavirus disease 2019 (COVID-19) vaccines has been accompanied by a small yet noticeable accumulation of reports of liver injury occurring after vaccination. This review describes the present evidence surrounding COVID-19 vaccine-induced liver injury (VILI). RECENT FINDINGS: Liver injury occurring after the COVID-19 vaccine often presents clinically similar to autoimmune hepatitis, with positive autoantibodies and a portal and lobular inflammatory infiltrate and varying degrees of necrosis on biopsy. The overwhelming majority of patients recover, often spontaneously or with a limited course of immunosuppression. The overall incidence of this phenomenon appears to be exceedingly low. SUMMARY: Providers should remain vigilant for ongoing reports of VILI after COVID-19 and yet feel reassured by the low incidence and high likelihood of recovery. Ongoing genetic and histological study, as well as longer-term follow-up of presently identified cases, will shed further light on the clinical entity of VILI.


Asunto(s)
COVID-19 , Enfermedad Hepática Crónica Inducida por Sustancias y Drogas , Hepatitis Autoinmune , Humanos , Vacunas contra la COVID-19/efectos adversos , Enfermedad Hepática Crónica Inducida por Sustancias y Drogas/complicaciones , COVID-19/prevención & control , COVID-19/complicaciones , Hepatitis Autoinmune/etiología , Vacunación/efectos adversos
5.
Clin Gastroenterol Hepatol ; 20(1): 183-193, 2022 01.
Artículo en Inglés | MEDLINE | ID: mdl-32927050

RESUMEN

BACKGROUND & AIMS: Hepatocellular carcinoma (HCC) surveillance rates are suboptimal in clinical practice. We aimed to elicit providers' opinions on the following aspects of HCC surveillance: preferred strategies, barriers and facilitators, and the impact of a patient's HCC risk on the choice of surveillance modality. METHODS: We conducted a web-based survey among gastroenterology and hepatology providers (40% faculty physicians, 21% advanced practice providers, 39% fellow-trainees) from 26 US medical centers in 17 states. RESULTS: Of 654 eligible providers, 305 (47%) completed the survey. Nearly all (98.4%) of the providers endorsed semi-annual HCC surveillance in patients with cirrhosis, with 84.2% recommending ultrasound ± alpha fetoprotein (AFP) and 15.4% recommending computed tomography (CT) or magnetic resonance imaging (MRI). Barriers to surveillance included limited HCC treatment options, screening test effectiveness to reduce mortality, access to transportation, and high out-of-pocket costs. Facilitators of surveillance included professional society guidelines. Most providers (72.1%) would perform surveillance even if HCC risk was low (≤0.5% per year), while 98.7% would perform surveillance if HCC risk was ≥1% per year. As a patient's HCC risk increased from 1% to 3% to 5% per year, providers reported they would be less likely to order ultrasound ± AFP (83.6% to 68.9% to 57.4%; P < .001) and more likely to order CT or MRI ± AFP (3.9% to 26.2% to 36.1%; P < .001). CONCLUSIONS: Providers recommend HCC surveillance even when HCC risk is much lower than the threshold suggested by professional societies. Many appear receptive to risk-based HCC surveillance strategies that depend on patients' estimated HCC risk, instead of our current "one-size-fits all" strategy.


Asunto(s)
Carcinoma Hepatocelular , Detección Precoz del Cáncer , Cirrosis Hepática , Neoplasias Hepáticas , Actitud del Personal de Salud , Carcinoma Hepatocelular/diagnóstico , Carcinoma Hepatocelular/epidemiología , Pruebas Diagnósticas de Rutina , Humanos , Cirrosis Hepática/complicaciones , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/epidemiología , Ultrasonografía , Estados Unidos , alfa-Fetoproteínas
10.
Clin Ther ; 45(12): 1177-1188, 2023 12.
Artículo en Inglés | MEDLINE | ID: mdl-37813775

RESUMEN

PURPOSE: Models of integrated, multidisciplinary care are optimal in the setting of complex, chronic diseases and in the overlap of medical and mental health disease, both of which apply to alcohol-related liver disease (ALD). Alcohol use disorder (AUD) drives nearly all cases of ALD, and coexisting mental health disease is common. ALD is a complex condition with severe clinical manifestations and high mortality that can occasionally lead to liver transplantation. As a result, integrated care for ALD is an attractive proposition. The aim of this narrative review was to: (1) review the overlapping and concerning trends in the epidemiology of AUD and ALD; (2) use a theoretical framework for integrated care known as the "five-component model" as a basis to highlight the need for integrated care and the overlapping clinical manifestations and management of the 2 conditions; and (3) review the existing applications of integrated care in this area. METHODS: We performed a narrative review of epidemiology, clinical manifestations, and management strategies in AUD and ALD, with a particular focus on areas of overlap that are pertinent to clinicians who manage each disease. Previously published models were reviewed for integrating care in AUD and ALD, both in the general ALD population and in the setting of liver transplantation. FINDINGS: The incidences of AUD and ALD are rising, with a pronounced acceleration driven by the Coronavirus Disease 2019 pandemic. Hepatologists are underprepared to diagnose and treat AUD despite its high prevalence in patients with liver disease. A patient who presents with overlapping clinical manifestations of both AUD and ALD may not fit neatly into typical treatment paradigms for each individual disease but rather will require new management strategies that are appropriately adapted. As a result, the dimensions of integrated care, including collective ownership of shared goals, interdependence among providers, flexibility of roles, and newly created professional activities, are highly pertinent to the holistic management of both diseases. IMPLICATIONS: Integrated care models have proliferated as recognition grows of the dual pathology of AUD and ALD. Ongoing coordination across disciplines and research in the fields of hepatology and addiction medicine are needed to further elucidate optimal mechanisms for collaboration and improved quality of care.


Asunto(s)
Alcoholismo , Gastroenterología , Hepatopatías Alcohólicas , Trasplante de Hígado , Humanos , Alcoholismo/diagnóstico , Alcoholismo/epidemiología , Alcoholismo/terapia , Hepatopatías Alcohólicas/diagnóstico , Hepatopatías Alcohólicas/epidemiología , Hepatopatías Alcohólicas/terapia , Consumo de Bebidas Alcohólicas
11.
Echocardiography ; 29(4): E100-1, 2012 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-22176492

RESUMEN

Libman-Sacks endocarditis (LSE) is a common manifestation of valve disease in antiphospholipid syndrome. Mitral valve LSE is characterized by verrucous vegetations on the atrial surfaces of valve leaflets. In this report, mitral valve LSE was visualized by real time 3D transesophageal echocardiography (TEE). 3D TEE provides a unique en face view of the mitral valve akin to a surgical or autopsy view that allows for an accurate determination of the size, shape, and location of the vegetations.


Asunto(s)
Ecocardiografía Transesofágica/métodos , Endocarditis no Infecciosa/diagnóstico , Endocarditis no Infecciosa/etiología , Lupus Eritematoso Sistémico/complicaciones , Lupus Eritematoso Sistémico/diagnóstico por imagen , Prolapso de la Válvula Mitral/complicaciones , Prolapso de la Válvula Mitral/diagnóstico por imagen , Anciano , Sistemas de Computación , Ecocardiografía Tridimensional/métodos , Femenino , Humanos
12.
Clin Liver Dis (Hoboken) ; 19(4): 157-160, 2022 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-35505918

RESUMEN

Content available: Author Interview and Author Audio Recording.

13.
Transplant Proc ; 53(8): 2567-2569, 2021 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-34474911

RESUMEN

Thrombocytopenia commonly occurs in patients with advanced liver disease and can be a contraindication in patients needing combined coronary artery bypass grafting (CABG) and liver transplant (LT). Thrombopoietin receptor agonists, including avatrombopag, are part of a novel drug class and stimulate platelet production. Avatrombopag is indicated in the perioperative setting to avoid platelet transfusions, which carry several disadvantages. Avatrombopag was shown to be safe and effective in patients with chronic liver disease. This study describes the successful use of avatrombopag in a patient with thromboembolic risks in preparation for a combined CABG and LT. Larger clinical trials are necessary to validate our results.


Asunto(s)
Trasplante de Hígado , Puente de Arteria Coronaria , Humanos , Tiazoles , Tiofenos
15.
Curr Hepatol Rep ; 19(3): 315-326, 2020 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-33585157

RESUMEN

PURPOSE OF REVIEW: The global burden of non-alcoholic steatohepatitis (NASH) as a major cause of chronic liver disease continues to rise. Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in this patient population. The current review summarizes recent advances in the understanding of CVD in NASH and strategies for screening and management. RECENT FINDINGS: Large genetic epidemiological studies support the intricate role of the metabolic syndrome in the pathophysiology of CVD risk in patients with NASH. Atherosclerotic CVD risk scores can predict elevated CV risk in NASH, but additional work is necessary to refine risk stratification and to guide optimal management. New antidiabetic agents may offer benefit in treating steatosis and reducing CV morbidity in NASH. SUMMARY: Achieving improved outcomes in patients with NASH requires that future efforts focus on optimizing methods for CVD screening and designing clinical trials with long-term cardiovascular endpoints in mind.

16.
Clin Liver Dis (Hoboken) ; 15(4): 153-156, 2020 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-32395242

RESUMEN

http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-4-reading-shroff-maddur a video presentation of this article http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-4-interview-shroff-maddur an interview with the author https://www.wileyhealthlearning.com/Activity/7088613/disclaimerspopup.aspx questions and earn CME.

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