bluuebunny/crossref_metadata_2025 huggingface dataset:
989 Clinicians Fail to Screen for HDV in Patients With HBV Despite Guideline Recommendations
Authors: Moore Andrew , Mitchell Justin , Reau Nancy
Published: October 2019

INTRODUCTION:

Hepatitis D virus (HDV) requires the presence of the hepatitis B virus (HBV) for replication. Due to limited access to testing and lack of reporting, it is unknown how many HBV patients are co-infected with HDV, but estimates state that anywhere from 5% to 42% of those with chronic HBV are also co-infected with HDV. HBV-HDV co-infection is considered one of the most aggressive forms of viral hepatitis as it leads to cirrhosis and hepatocellular carcinoma more rapidly and results in fulminant liver failure in up to 5% of those affected. EASL recommends that in patients with HBV, other causes of chronic liver disease, including HDV, should be tested for. Additionally, AASLD recommends the testing of HBsAg+ positive persons at increased risk for HDV, specifically HIV+ and HCV-Ab+ individuals. We hypothesized that adherence to these guidelines is poor.

METHODS:

339 patients who were HBsAg+ were seen at our tertiary academic institution between January 1, 2014, and January 1, 2019. Demographic information including age, sex, and race was captured by chart review as was co-infection with HIV or HCV. We evaluated if patients were ever screened for HDV using the HDV-Ab.

RESULTS:

339 patients were HBsAg+, of which 82 were also HBeAg+. 90 (27%) were screened for HDV with only 1 patient (0.3%) testing positive for HDV; 249 (73%) were never screened for hepatitis D. Only 1 of 9 patients (11%) who tested positive for HIV was screened for HDV, and only 1 of 13 patients (8%) who tested positive for HCV was screened for HDV. With respect to race, 111 patients were black, 117 were Asian, 56 were Caucasian, and 55 were other/unknown. The highest rate of screening was noted among Asians at 32%.

CONCLUSION:

Guidelines recommend screening for HDV in patients with HBV, especially those coinfected with HIV or HCV. Unfortunately, adherence to these guidelines was poor, with the lowest screening rates in those with HIV and HCV who are considered highest risk. With an expected prevalence of 5–42%, many HDV-HBV coinfected patients remain unrecognized and at risk for aggressive liver disease. Lack of awareness to guideline recommendations may contribute to poor screening rates, and it is evident that reflexive screening for patients who have HBV needs to be emphasized.
994 The Performance of the NAFLD Fibrosis Score in Hispanics With Type 2 Diabetes and Biopsy-Proven NAFLD
Authors: Barbara Mary , Annunziata Giuseppe , Noureddin Mazen , Alkhouri Naim
Published: October 2019

INTRODUCTION:

In patients with nonalcoholic fatty liver disease, Hispanic ethnicity and the presence of type 2 diabetes mellitus (T2DM) are associated with advanced fibrosis (AF). The NAFLD fibrosis score (NFS) is a noninvasive test that has been validated to predict AF but was originally developed in mainly a Caucasian population. The aim of our study was to assess the performance of NFS in Hispanic patients with T2DM and biopsy proven NAFLD

METHODS:

This was a single institutional study in south Texas. Using ICD 9/ ICD 10 codes, a retrospective chart review between 2010–2017 identified 55,670 patients with T2DM between ages 18–80. 479 out of 55,670 patients had a liver biopsy. The stage of liver fibrosis was scored from F0 to F4 with (F0-2) defined as early fibrosis and (F3-4) as advanced fibrosis (AF). NFS was calculated and patients were divided into three groups: low score (<-1.45), intermediate score ( -1.45-0.676) and high score consistent with advance fibrosis (>0.676). Analysis was performed using Stata IC 15. A P value < 0.05 was considered statistically significant. Area under the ROC curve (AUC) analysis was done to determine NFS accuracy

RESULTS:

After excluding patients with missing data to calculate NFS and those with liver transplant, total of 311 patients were included in the study. The mean age was 55.15 ± 9 years, 55.31% were females, mean BMI 33.16 ± 7.9 kg/m2, mean AST 45.56 ± 44.78 U/L, ALT 52.03 ± 38.75 U/L, albumin 3.44 ± 0.60 g/dl, platelets 203.97 ± 84.61 KuL, and the mean NFS was 0.627 ± 1.78. 40% of the patients (125 out of 311) had AF proven by liver biopsy. AF was more predominant among females (43% vs 35%). AUC for NFS to predict AF was 0.73, SE 0.02, 95% CL [0.68-0.79], P < 0.001. At the low cutoff point; sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 97%, 11 %, 42 % and 78%, respectively and 67%,72%, 61% and 76% at the high cutoff point ( >0.676). Interestingly, 47% of the cohort was in the intermediate score, 24% of the intermediate group had AF (F3-4) vs 76 % had early fibrosis (F0-2)

CONCLUSION:

NFS had a fair diagnostic accuracy for predicting the presence of AF in Hispanic patients with NAFLD and T2DM with AUC of 0.73. A large percentage of our cohort was in the intermediate zone indicating the need for sequential testing with other noninvasive tests to improve accuracy
1005 Worse Functional Status at Time of Liver Transplant Waitlist Registration Is Associated With Significantly Greater Prevalence of Hepatic Encephalopathy, Ascites, and Spontaneous Bacterial Peritonitis
Authors: McCabe Patrick , Hirode Grishma , Liu Benny , Bhuket Taft , Wong Robert
Published: October 2019

INTRODUCTION:

Poor functional status (FS) is associated higher liver transplant (LT) waitlist mortality. Whether this higher risk of death is mediated by higher prevalence of cirrhosis complications is not clear. We aim to evaluate the impact of FS at time LT waitlist registration on odds of hepatic encephalopathy (HE), ascites, and spontaneous bacterial peritonitis (SBP) among adults listed for LT.

METHODS:

Using 2003-2018 United Network for Organ Sharing LT data, we retrospectively evaluated the impact of FS on prevalence of HE, ascites, and SBP among U.S. adults listed for LT using Karnofsky Performance Status categories (KPS-1: FS 80-100%, KPS-2: 60-70%, KPS-3: 40-50%, KPS-4: 10-30%). We further stratified patients by etiology: hepatitis C (HCV), nonalcoholic steatohepatitis (NASH), alcoholic liver disease (ALD), and combined HCV/ALD. Comparisons of HE, ascites, and SBP prevalence between groups utilized chi-squared methods and adjusted multivariate logistic regression.

RESULTS:

Among 101,249 adults listed for LT (70.1% male, 72.7% non-Hispanic white, 20.3% HCC) 38.2% were KPS-1, 35.6% KPS-2, 14.5% KPS-3, and 11.7% KPS-4. Patients with worse FS were more likely to have HE, ascites, and SBP at time of waitlist registration (HE: 82% (KPS-4) vs. 52% (KPS-1); ascites: 68% (KPS-1) vs. 93% (KPS-4); SBP: 4% (KPS-1) vs. 17% (KPS-4), P < 0.001 for all)) (Figure 1). On multivariate regression, worse FS was associated with greater odds of HE (KPS-4 vs. KPS-1: OR 1.62, 95% CI 1.52-1.73, P < 0.01), ascites (KPS-4 vs. KPS-1: OR 1.41, 95% CI 1.29-1.54, P < 0.01), and SBP (KPS-4 vs. KPS-1: 2.12, 95% CI 1.93-2.33, P < 0.01). Compared to HCV patients, greater odds of HE and ascites were observed in NASH (ascites, OR 1.32, 95% CI 1.25-1.39, P < 0.01), ALD (ascites, OR 1.58, 95% CI 1.52-1.65, P < 0.01), and HCV/ALD (ascites, OR 1.40, 95% CI 1.32-1.49, P < 0.01). While ALD and HCV/ALD patients also had greater odds of SBP vs. HCV, NASH patients had lower odds of SBP (OR 0.92, 95% CI 0.85-0.99, P = 0.03). When stratified by etiology, similar trends were observed, with worse FS strongly associated with greater odds of HE, ascites, and SBP across all etiologies.

CONCLUSION:

Worse FS is associated with higher odds of cirrhosis complications including ascites, HE, and SBP, which was observed across all liver disease etiologies. Disease-specific comparisons showed higher odds of ascites, HE, and SBP in HCV vs. other etiologies, with the exception of lower odds of SBP in NASH patients vs. HCV.
1007 Sex-Specific and Ethnicity-Specific Disparities in Receipt of Hepatocellular Carcinoma (HCC) Treatment Among a Cohort of Patients Who Developed HCC Recurrence
Authors: Zhang Julia A. , Hirode Grishma , Wong Robert
Published: October 2019

INTRODUCTION:

Despite receiving cancer-directed therapies, there is a high rate of cancer recurrence among patients with hepatocellular carcinoma (HCC). Our study aims to focus on the subset of patients with HCC recurrence to evaluate sex- and ethnicity-specific disparities in receipt of treatment.

METHODS:

Adults with HCC who developed HCC recurrence were identified using 1973-2015 U.S. National Cancer Institute’s Surveillance, Epidemiology, and End Results cancer registry. HCC tumor stage was assessed with the SEER historic staging system (localized, regional, distant) and HCC treatment received was assessed with SEER’s site-specific surgery variable (no treatment, locoregional therapy, surgical resection, and liver transplantation (LT)). Comparisons of tumor stage at diagnosis and receipt of HCC treatment between groups were assessed using chi-square testing and multivariate logistic regression models.

RESULTS:

Among 275 patients with recurrence of HCC (76.7% male, 48.7% non-Hispanic Whites, 14.9% Hispanic, 27.6% Asian/Pacific Islanders), 24.6% did not receive any HCC-directed surgical treatment, 21.9% received locoregional therapies, 42.3% surgical resection, and 11.2% LT. Compared to women, men were significantly less likely to receive any HCC treatment after initial diagnosis of HCC (OR 0.33, 95% CI 0.14-0.76, P = 0.01), including surgical resection or LT (OR 0.53, 95% CI 0.29-0.96, P = 0.037). Compared to non-Hispanic Whites, significantly lower rates of any HCC treatment were observed in Hispanics (OR 0.40, 95% CI 0.19-0.84, P = 0.015) and higher rates of treatment were seen in Asian/Pacific Islanders (OR 2.28, 95% CI 1.02-5.12, P = 0.045). On multivariate analysis, there were significantly lower odds of receiving any therapy for the initial HCC diagnosis in men vs. women (OR 0.27, 95% CI 0.11-0.68, P < 0.01) and in Hispanics vs. non-Hispanic Whites (OR 0.32, 95% CI 0.15-0.72, P < 0.01). Asian/Pacific Islanders were more likely to receive treatment compared to non-Hispanic Whites (OR 2.72, 95% CI 1.15-6.44, P = 0.023). There were no significant differences in receipt of treatment for the HCC recurrence based on sex or ethnicity.

CONCLUSION:

Among U.S. adults with HCC who developed HCC recurrence, nearly one quarter did not receive any HCC-directed surgical therapies at initial diagnosis. Men and Hispanics were significantly less likely to receive any HCC-directed therapies for the initial HCC diagnosis.
1009 The Use of a “Pop Up” Identification System Can Lead to the Identification and a High Percentage of Treatment of Patients With Chronic Hepatitis C
Authors: Snyder Ned , Curry Curtis , Jerrels Leon
Published: October 2019

INTRODUCTION:

The World health Assembly has set as a goal the elimination of hepatitis C (HCV) as a public health threat by 2030. In the United States, a problem with elimination of HCV is that many patients that are infected are not identified, and the majority who screen positive for HCV, for a variety of reasons, do not receive treatment. In Texas, it has been estimated that only 25% of patients identified as infected actually receive treatment. The cost of treatment has decreased significantly, and lack of coordinated care may partially account for the low treatment rates. The majority of patients with chronic HCV were born 1945-1965, and it has been recommended that patients in this birth cohort be routinely screened with hepatitis c antibody. Kelsey-Seybold Clinic is an accountable health care organization that has about 1 1/2 million patient visits a year. At least 2/3's of the patients receive essentially all their care in our system. currently, there is a pop up message in the electronic medical records of patients in the 1945-1965 cohort when they are seen by their primary care physician as a reminder to check the HCV antibody if not previously done. We wanted to determine if this coordinated system led to a higher percentage of patients being treated than historically reported.

METHODS:

Utilizing the appropriate codes, we examined the data base for 2018 to see 1) what number of patients in this birth cohort with a positive HCV antibody had a HCV RNA performed 2) what number were referred for treatment 3)what number received treatment.

RESULTS:

A total of 8902 patients in the cohort were screened, and 136 (1.5%) were positive for HCV antibody. 113 of the 136 (83.1%) had a positive HCV RNA. At this time, 97 of the 113 have been seen by gastroenterology and hepatology and 85 have so far received anti-viral therapy for a treatment rate of 75.2%. At the time of presentation, updated treatment numbers and response rates will be available.

CONCLUSION:

Utilizing a system of coordinated care, we have been able to identify a large number of patients in the 1945-1965 birth cohort, and subsequently treat a higher percentage of actively infected patients than has been previously noted.
1012 Impact of Treatment With Direct Anti Viral Agents on Health Related Quality of Life Using Chronic Liver Disease Questionnaire in Chronic Hepatitis C Patients
Authors: Khan Shoaib Ahmed , Hanif Farina , Laeeq Syed Mudassir , Luck Nasir Hassan , Majid Zain , Mehmood Nasir , Kumar Sandeep
Published: October 2019

INTRODUCTION:

Health related quality of life (HRQOL) is important for the physical and psychosocial wellbeing of patients with chronic illnesses. The Chronic Liver Disease Questionnaire (CLDQ) is validated to assess HRQOL. We aim to determine the effect on HRQOL and associated predictive factors in patients treated with direct antiviral agent for Hepatitis C.

METHODS:

Patients receiving sofosbuvir, daclatasvir and ribavirin combination for 12 weeks for Hepatitis C eradication were enrolled. CLDQ consisted of 29 questions assessed on a seven point Likert scale, consisting of 6 domains; Abdomen symptoms, Fatigue, Systemic symptoms, Activity, Emotional function and Worry. Higher score was indicative of minimum symptoms.

RESULTS:

In 168 patients, majority were females (53 %) with mean age of 45.6 ± 10.8 yrs. Most of study population were uneducated (47 %) and had a low socioeconomic status (60.1%). End of treatment response was achieved in all participants. Mean CLDQ score before and after HCV treatment was 3.8 ± 1.0 and 5.2 ± 1.7, respectively (P = 0.00). Median Child score before and after treatment was 10 and 9, respectively. (P = 0.00) Similarly, MELD score improved from 13 to 10 after treatment. (P = 0.00) Statistical significant improvement in all domain of CLDQ score was also observed after treatment. (P = 0.00) On multiple regression analysis pretreatment systemic and activity score showed statistical significant association with post treatment CLDQ score.

CONCLUSION:

We report positive impact of HRQOL in hepatitis C patients treated with direct antiviral agents. Pre-treatment Systemic and Activity scores are statistically significant predictors of improvements in HRQOL.
1013 The Effect of Steatosis on the Clinical Course of Autoimmune Hepatitis
Authors: Davis Ashley , Assis David , Celli Romulo , Gurung Ananta , Dhanpat Jain
Published: October 2019

INTRODUCTION:

Nonalcoholic Fatty Liver Disease (NAFLD) is a common liver disease in western developed countries. NAFLD is increasingly encountered alongside other chronic liver diseases, such as autoimmune hepatitis (AIH). The impact of NAFLD on the clinical course of AIH is unclear and one recent single center study suggested a worse clinical outcome for patients with AIH and concurrent steatohepatitis. We aimed to determine the frequency of steatosis and steatohepatitis in patients with AIH and the effect on treatment outcomes.

METHODS:

The cohort consisted of 61 AIH patients from a single, large, tertiary referral center with pre-treatment liver biopsies and available clinical data. Biliary overlap syndromes were excluded. Two liver pathologists recorded histological findings, including quantification of steatosis and steatohepatitis. One clinical reviewer recorded 96 clinical/laboratory variables. Non-parametric (Spearman rho) tests were used and correlations with P < 0.05 were deemed significant. Non parametric t-tests were used to compare various degrees of steatosis (none, mild/moderate) with clinical variables and P < 0.05 were deemed significant.

RESULTS:

Patients were followed for mean of 3.1 ± 3 years after diagnosis. Mean age at diagnosis was 49.9 ± 19.1 years and mean BMI at diagnosis was 28.3 ± 7. In this cohort, 31.7% of patients had steatosis on histology, and out of those 75.0% had mild and 25.0% had moderate degree of steatosis. Strikingly, there were no cases of steatohepatitis. The degree of steatosis was positively correlated with increasing age and BMI, (r = 0.44, CI 0.17-0.65, P ≤ 0.001and r = 0.49, CI 0.15-0.73, P = 0.01, respectively). However, there was no correlation between degree of steatosis and initial treatment failure, ALT at 12 months of treatment, chances of biochemical remission, development of cirrhosis, or the dose of steroid required for biochemical remission. Furthermore, there was no difference in these outcomes when those with versus without steatosis were compared.

CONCLUSION:

Data from this single center study suggest that AIH patients with mild and moderate steatosis have the same clinical course and response to treatment as those without steatosis.. The increasing prevalence of superimposed NAFLD in AIH warrants longitudinal observational multi-center studies focused on the frequency of steatohepatitis, and the impact of steatosis on the natural history of AIH.
1015 Fibroscan Is a Feasible and Useful Point-Of-Care Tool to Assess Nonalcoholic Fatty Liver Disease Severity in Children Texas Liver Institute, University of Texas (UT) Health San Antonio, San Antonio, TX
Authors: Cummings-John Oladuni D. , Geistweidt Stephenie , Okubote Toluwalase C. , Ascher Bartlett Johanna M. , Filo Jean , Betancourt Amanda , Alkhouri Naim , Lawitz Eric , Angueira Candice
Published: October 2019

INTRODUCTION:

Estimating the severity of liver steatosis by controlled attenuation parameter (CAP) and liver fibrosis by transient elastography (TE) using the FibroscanTM machine provides a noninvasive method to establish the presence of nonalcoholic fatty liver disease (NAFLD) and assess its severity. The use of CAP/TE is becoming routine practice in adults yet limited data exists in children with suspected NAFLD. The aim of this study was to assess the feasibility and utility of measuring CAP/TE by FibroscanTM in a cohort of children with suspected NAFLD.

METHODS:

All children referred with a clinical suspicion of NAFLD (elevated alkaline phosphatase (ALT) or fatty infiltration on ultrasonography) who had CAP/TE measured were included. FibroscanTM testing was performed on a standardized machine with an experienced operator utilizing a medium (M) or extra-large (XL) probe. Standard criteria for having valid measurements were applied (IQR < 30% with >70% success rate). Severity of steatosis was evaluated based on the following cutoffs for CAP: <225 db/m (no steatosis), 225-250 db/m (mild steatosis), 250-300 db/m (moderate steatosis), >300 db/m (severe steatosis). Severity of liver stiffness was evaluated using the following TE cutoffs: <6 kPa (no fibrosis), 6-10 kPa (mild to moderate fibrosis), >10 kPa (advanced fibrosis). Baseline clinical and laboratory parameters were also collected.

RESULTS:

119 children with suspected NAFLD were referred to the clinic between May 2017 and April 2019. The mean age at time of assessment was 13.0 (± 3.0) years. The majority were males (68%), obese (87%) and of Hispanic ethnicity (77%). The M probe was used to successfully complete 64% of scans whereas the XL probe was required for 36% of scans. 4/116 (3%) had a CAP < 225 indicating no steatosis. 15/116 (13%) of patients fell within the mild steatosis range (CAP 225-250), 31/116 (27%) with moderate steatosis (CAP 250-300) and the majority, 66/116 (57%), of patients having severe steatosis with CAP values > 300. On TE, 50% had no fibrosis, 45% with mild to moderate fibrosis and 7% with advanced fibrosis. Linear regression analysis demonstrated a weakly positive correlation between baseline ALT and TE measurements (correlation coefficient (r) was 0.24; P value < 0.05; Figure 1.1).

CONCLUSION:

CAP/TE provides a reliable way to confirm the diagnosis of NAFLD and assess its severity in children. Larger pediatric studies that assess the correlation with liver histology and disease progression are needed.
1016 Lusutrombopag Is a Safe Treatment Option for Thrombocytopenia in Patients With Chronic Liver Disease Undergoing a Scheduled Invasive Procedure: Pooled Safety Analysis From 3 Studies
Authors: Brown Robert S. , Izumi Namiki , Kano Takeshi , Ochiai Toshimitsu , Kurosaki Masayuki , Violi Francesco , Shrestha Pomy
Published: October 2019

INTRODUCTION:

Lusutrombopag is a thrombopoietin receptor agonist (TPO-RA) approved in Japan (2015) and the US (2018) for treatment of thrombocytopenia (TCP), and in the EU (2019) for severe TCP, associated with chronic liver disease (CLD) in patients undergoing a planned invasive procedure. In an integrated analysis of two Phase 3 studies, lusutrombopag reduced the need for platelet transfusions compared to placebo. Treatment with TPO-RAs has been associated with an increased risk of thrombotic events in patients with CLD; thus, a thorough safety assessment of new agents is critical. A pooled retrospective analysis of 3 clinical studies was performed to assess safety of lusutrombopag.

METHODS:

Safety data from 3 double-blind, randomized, placebo-controlled studies in patients with CLD and TCP undergoing a planned invasive procedure (Phase 2b: M0626 [Japan; JapicCTI-121944], Phase 3: L-PLUS 1 [Japan; JapicCTI-132323] and L-PLUS 2 [global; NCT02389621]) were pooled. Adults with platelet counts <50 × 109/L at baseline received lusutrombopag 3 mg or placebo for up to 7 days before a procedure planned 9-14 days after randomization. Platelet transfusion was given if the platelet count remained <50 × 109/L no more than 2 days prior to procedure. Adverse event (AE) data were collected from signing of informed consent until the end of the post-treatment period or early termination.

RESULTS:

The pooled safety population included 341 patients (n = 171, lusutrombopag; n = 170, placebo). Approximately 65% of patients in the lusutrombopag and placebo groups experienced an AE (Table 1). Thrombotic and thromboembolic AEs occurred in 1.8% (3/171) of lusutrombopag patients (cardiac ventricular thrombosis, n = 1 [patient had prior history of cardiac ventricular thrombosis]; portal vein thrombosis, n = 2) and 2.4% (4/170) of placebo patients (mesenteric vein thrombosis, n = 2; portal vein thrombosis, n = 2). Overall, bleeding-related AEs occurred in less lusutrombopag vs placebo patients (15 [8.8%] vs 27 [15.9%]), respectively. The 3 AEs leading to death among patients taking lusutrombopag were not considered treatment-related but due to the progression of underlying disease.

CONCLUSION:

In this pooled safety analysis, lusutrombopag was safe and well-tolerated in patients with TCP and CLD undergoing planned invasive procedures. Approximately 50% fewer bleeding-related AEs and no increased risk of thrombotic and thromboembolic AEs were observed in patients treated with lusutrombopag vs placebo.
1018 Patients With Cirrhosis Have Worse Outcomes When Hospitalized With Influenza
Authors: Sobotka Lindsay , Hinton Alice , Mumtaz Khalid , Conteh Lanla
Published: October 2019

INTRODUCTION:

The Centers for Disease Control and Prevention estimates that approximately 48 million patients were affected by influenza during the 2017 and 2018 flu season, resulting in 100,000 hospitalizations and 80,000 deaths. Previous studies on infections in patients with decompensated cirrhosis noted worse hospital outcomes as compared to patients without cirrhosis. This study aims to evaluate hospital outcomes in patients with cirrhosis who are hospitalized for influenza.

METHODS:

Utilizing the Nationwide Inpatient Sample, a retrospective database analysis was performed on adult patients admitted with influenza between 2005 and 2013. Patients were identified by ICD-9 codes. Multivariate analyses assessed patient and hospital outcomes including length of stay, inpatient mortality, cost of admission and influenza complications in patients with cirrhosis as compared to those without liver disease. Further, a subset analysis was conducted among patients with cirrhosis to evaluate the impact of decompensated cirrhosis on influenza outcomes.

RESULTS:

A total 236,513 patients were included, 234,960 without liver disease and 1,553 with cirrhosis. On multivariable analysis, patients with cirrhosis had higher costs [$1,030, 95% CI 710, 1,351] and longer length of stay [0.24 days, 95% CI 0.07, 0.41] however no significant differences were observed for mortality or influenza complications. Of the patients with cirrhosis, 76% (n: 1,176) had compensated cirrhosis and 24% (n: 377) had decompensated cirrhosis. After adjusting for confounders, patients with decompensated cirrhosis were noted to have a longer length of stay [1.92 days, 95% CI 1.63, 2.21], higher costs [$5,005, 95% CI 4,459, 5,551], and increased rates of influenza complications [OR 2.56, 95% CI 1.32, 4.93].

CONCLUSION:

Patients with decompensated cirrhosis have worse outcomes when admitted with influenza than patients with compensated cirrhosis. Further studies should be completed to determine interventions that can improve influenza outcomes within the population of patients with decompensated cirrhosis.
1020 The Effect of Metabolic Syndrome Components on Liver Stiffness Measurement Values After HCV Eradication
Authors: Asaad Imad , Eisa Mohamed , Lee Tae Hoon , Hamid Osama , Sandhu Annumeet A. , Calderon Amy
Published: October 2019

INTRODUCTION:

The availability of noninvasive fibrosis measures coupled with high sustained viral response (SVR) rates has shifted the paradigm in the management of HCV infection in the direct-acting antiviral (DAA) era. Although these noninvasive tests are valuable in evaluating hepatic fibrosis prior to HCV therapy, use of these measures in monitoring fibrosis regression after HCV eradication is currently limited. There is evidence that patients who achieve SVR after therapy have a reduced risk of liver-related complications.1 This is likely attributed to the regression of fibrosis after HCV eradication.2 Other comorbidities, such as obesity, nonalcoholic steatohepatitis and diabetes mellitus may also contribute to liver-related complications.3-4 The aim of this study is to evaluate the effect of metabolic syndrome components on liver stiffness measurement (LSM) after HCV eradication.

METHODS:

A retrospective study of 65 HCV monoinfected patients who received DAA and achieved SVR located in a safety net hospital in Cleveland. All Patients had pretreatment LSM of more than 7k Pa. Patient’s with Fibrosis stage F4 had CP class A. Fibrosis was evaluate within 12 months before treatment and 12-24 months after SVR using Transient Elastography. Other collected parameters included BMI, history of DM, HLD and HTN, HbA1c, LDL, HDL and TGs. Demographics and hepatitis C genotype (GT) were also collected. Statistical analysis was performed using descriptive analysis, Anova, Univariate regression and Multivariate regression to compare variables for statistical significance.

RESULTS:

Among all subjects (n = 65). 64.6% were male. 61.5% had Genotype 1a, 26.2% had genotype 1b and 6.2% had genotype 2. 33.8% were diabetic, 64.6% had hyperlipidemia, and 66.2% patients had hypertension. The mean pre-treatment LSM was 14.4kPa (SD 10.0) and the mean post-treatment LSM was 9.33 kPa (SD 5.3). The mean of delta-stiffness was 5.1 kPa (SD 9.7). 53.8% patients dropped their LSM by 3 kPa or more after SVR. In univariate logistic regression, age (P = 0.675), race (P = 0.11), genotype (P = 0.688), BMI (P = 0.709), diabetes (P = 0.661), hyperlipidemia (P = 0.743), and hypertension (P = 0.545) failed to show any significant correlation with significant drop (≥3kPa) in liver stiffness measurement.

CONCLUSION:

Sustained viral response after direct-acting antiviral (DAA) therapy leads to significant improvement in LSM within 48 months of therapy completion. Metabolic syndrome components has no significant effect on LSM improvement after SVR.
1026 High SVR Rates in HCV-Infected Patients With Multiple Co-Morbid Medical Conditions Treated With HCV DAAs in Community Practice Using a Specialized Pharmacy Team
Authors: Hanysak Bryan , Mann Jena , Ramirez Ruben , Kim Jae , Guerrero Richard , Van Frank Timothy , Mitchell Robert , Hinojosa Kim , Christensen Kimberley , Landaverde Carmen , Loo Nicole , Alkhouri Naim , Wells Jennifer , Rodas Fabian , Lawitz Eric , Pedicone Lisa D. , Poordad Fred
Published: October 2019

INTRODUCTION:

Approved HCV DAA regimens can cure nearly all patients; however, barriers to care in community practices include patients with a large number of medical co-morbidities, advanced liver damage and insurance approval of DAA regimens. This study assesses medical conditions, liver staging methods, and the drug prior auth process in HCV-infected patients managed in community practices partnered with a dedicated pharmacy team with expertise in liver disorders.

METHODS:

This IRB-approved, ongoing study captures outcomes on a cohort of 705 patients from community practices across Texas. Patients had chronic hepatitis C and were treated with DAA regimens selected by the physician. Insurance carrier and prior auth process data were also captured.

RESULTS:

96% of prior auth requests to Medicare and Medicaid were accepted upon first request; however, only 84% of requests to private insurance were accepted upon first request and did not require an appeal. This cohort included many patients with complicated medical histories including HCC (4.4%), ESRD (2.7%), liver transplant (2.1%) and seizure disorders (4.5%). Liver staging was done via Fibrotest (71%), Fibroscan (22%), Fibrosure (13%) and liver biopsy (0.6%). Medicaid patients had proportionately more advanced disease (79% F3/F4) and were less likely to be previously treated with DAA therapy (1.6%). The most common co-morbid conditions were hypertension (66%), diabetes (28%), GERD (23%), depression (20%), anxiety (16%) dyslipidemia (16%), renal disease (9%) and COPD (9%). Medicaid patients had the highest rates of dyslipidemia, obesity, renal disease and COPD. Overall, 90% of patients had undetectable virus at week 4, 96.7% completed follow-up and 97% achieved SVR, regardless of health insurance type. All patients with ESRD or with seizure disorders treated with oxcarbazepine achieved SVR as did 87% of patients with prior liver transplant. SVR was also achieved in 86% of patients with a history of HCC.

CONCLUSION:

HCV treatment in the community setting resulted in 97% cure. This cohort includes a wide variety of patients including those on dialysis or post-liver transplant. Partnership with a dedicated and liver focused pharmacy team resulted in 90% approval of first-time prior auth requests. Knowledge of and management of co-morbid conditions is critical for maximizing overall patient adherence, compliance and outcomes. Close monitoring through a chronic care management model can lead to better overall patient management.
1028 Treatment of Chronic HBV in African American Patients With and Without Co-Infection With HIV
Authors: Rahim Usman , Benjaram Sindhuri , Ameen Wadah , Ehrinpreis Murray N. , Mutchnick Milton , Naylor Paul
Published: October 2019

INTRODUCTION:

TThe prevalence of Hepatitis B virus (HBV) infection in the US is estimated at 2 million and remains a public health challenge. The incidence of HBV is high in African Americans (AA), but most studies on HBV are in Asian population. Majority of patients in our Gastroenterology academic clinics are AA. We aimed to evaluate characteristics and treatment outcomes of chronic HBV in AA patients with or without co-infection with HIV.

METHODS:

We identified 149 patients with a visit between 2016-2018. Majority (124/149 = 83%) of patients had one previous visit at least two years prior, such that outcomes of treatment could be evaluated (25 patients excluded). All HIV-HBV co-infected patients were treated with tenofovir containing HART regimens and the majority of mono-infected were also treated with tenofovir.

RESULTS:

There were 62 AA and 2 non-AA patients with HIV coinfection, and 53 AA, 14 Asian, and 18 non-AA/non-Asian patients who were treated. Coinfected patients were more likely to be male (90% vs. 54%). The liver relevant data at entry for the 115 AA patients reported in this study is shown in Table 1. Co-infected and Mono-infected had patients who were on treatment or projected to be treated had had greater degrees of elevated HBV DNA, Inflammation, and fibrosis compared to HBV patients who were not subsequently treated. Co-infected and mono-infected patients were equally likely to be treated. In evaluation of response to treatment, only patients treated for at least 2 years were included (18 patients were excluded). Response to treatment is shown in Table 2. The number of patients with HBV DNA >2000 I.U. (Hi HBV DNA) and high ALT declined significantly in both treatment groups. Fibrosis defined by APRI and FIB-4 also declined but was only statistically significant in the co-infected patients. When correlating decline with time on therapy, only ALT (P < 0.01) declined in HIV-HBV co infected patients. ALT, APRI and FIB-4 all declined with time on treatment in mono-infected patients, although only Fib-4 was significant at P < 0.05

CONCLUSION:

AA individuals with HBV, regardless of co-infection with HIV, respond to anti-viral therapy with a decline in HBV DNA, ALT, APRI and FIB-4. Further studies evaluating outcomes as defined by continued assessment of liver by ultrasound, serum based fibrosis specific assays, and fibroscan are required to more accurately define the positive effects of anti-viral therapy, especially in HIV coinfected AA.
1030 Screening for Steatosis and Fibrosis in a General Population With Fatty Liver Using Transient Elastography (Fibroscan)
Authors: Wong Peter W. , Dharel Narayan , Wong Corinne C.
Published: October 2019

INTRODUCTION:

Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are increasingly common in the United States and the Western World. In the United States, NAFLD and NASH are estimated to affect 1/3 and 1/10 Americans, respectively putting large proportion of the U.S. population at risk of advanced liver disease, cirrhosis and liver cancer. Transient Elastography or Fibroscan was approved in the United States in 2013 by the FDA as a non-invasive diagnostic test for the detection of steatosis and fibrosis in a variety of liver diseases including NAFLD. Until recently, access to Fibroscan has been limited primarily to academic research centers and tertiary care hospitals with the true status of NAFLD in the community and general U.S. population largely unknown. In this study, we report the status of NAFLD in a suburban community practice as identified by Fibroscan.

METHODS:

In this retrospective study, steatosis and fibrosis scores were analyzed in 489 NAFLD patients that had a Fibroscan (Fibroscan Compact 530) in a community hospital from February to November 2018. All the patients were referred for Fibroscan by gastroenterologists due to a fatty liver found on prior imaging studies by abdominal ultrasounds and / or CT scans. Patients with significant alcohol use (more than 2 drinks a day) and chronic liver disease (hepatitis B, Hepatitis C, autoimmune liver diseases and etc) were excluded from the analysis.

RESULTS:

Number of patient (percentage %). 1. *Steatosis score : S0 = 46 (9.40%), S1 = 15 (3.06%), S2 = 37 (7.56%) and S3 = 391 (79.95%). 2.** Fibrosis score : F0-F1 = 205 (41.92%), F2 = 148 (30.26%), F3 = 68 (13.90%) and F4 = 68 (13.90%). *Steatosis scoring: S0 = no fat, S1 = mild fat, S2 = moderate fat, S3 = severe fat. **Fibrosis scoring: F0-F1 = none to minimal scarring, F2 = moderate scarring, F3 = severe scarring, F4 = advanced fibrosis / cirrhosis.

CONCLUSION:

In this general population with incidental fatty liver, an alarming number of patients of nearly 80% have severe fatty liver disease (S3) and nearly a third (27.80%) have severe to advanced fibrosis / cirrhosis. With the higher than expected significant abnormal findings from this observational study, we recommend Transient Elastography (Fibroscan) as a screening tool to all clinicians managing patients with fatty liver disease. To confirm the validity of advanced liver disease found on Fibroscan, a liver biopsy should be considered in patients with severe or advanced (S3/4) liver fibrosis.
1036 Liver Transplant Referral Patterns for Severe Alcoholic Hepatitis With Recent Alcohol Use
Authors: Hsu Angela , Choden Tenzin , Hsu Christine
Published: October 2019

INTRODUCTION:

Liver transplant is the most effective treatment to optimize survivorship in severe alcoholic hepatitis which has a six month mortality rate of 70%. In recent years, multi-center data demonstrated a drastic mortality benefit of early liver transplant and questions the six month alcohol sobriety requirement at some transplant centers. The purpose of this study is to determine whether or not community gastroenterology (GI) providers are aware of the survival benefits of early liver transplant in severe alcoholic hepatitis and to examine what factors impact their decision to refer.

METHODS:

This study was designed as a cross sectional survey targeting GI providers and fellows within the Washington, DC area. The surveys were distributed both in paper and electronic form via email and local academic meetings. Data was analyzed using Chi-Squared analysis and two sample T-test to detect statistically significant differences between groups.

RESULTS:

Forty-five surveys were completed by GI physicians (34 attendings, 11 fellows). There was a wide range in the number of years since completion of academic training (range = 0-45 years, average = 14 years). Overall, 40% (17/42) of all participants stated that an active drinking status made them less likely to refer for transplant. Participants who completed training >10 years ago overestimated the rate of alcohol recidivism compared to their counterparts (P = 0.005); however, there was no statistically significant difference in their likelihood to refer active alcohol users for transplant. Although not statistically significant, participants who were more likely to refer active drinkers for transplant completed their last academic training more recently than their counterparts (10 vs 17 years ago, P = 0.14). Factors associated with a higher tendency to refer active users for liver transplant included working for a liver transplant center (P = 0.007) and awareness that peak mortality occurs within two months of last drink (P = 0.001).

CONCLUSION:

Despite the survival benefits of early liver transplant in severe alcoholic hepatitis, 40% of gastroenterologists surveyed state they are less likely to refer active alcohol users for liver transplant. Education regarding low recidivism rates and drastic benefits in survival outcomes even in patients with less than six months of alcohol sobriety should be disseminated to community gastroenterologists, especially at non-transplant centers.
1039 Hepatic Steatosis as an Indicator of Chronic Hepatitis B Virus Infection Severity
Authors: Lim Huei-Wen , Qiu He , Khuwaja Samreen , Liu Audrey , Lee Tai-Ping
Published: October 2019

INTRODUCTION:

Chronic hepatitis B virus (HBV) infection is a leading cause of liver-related morbidity and mortality affecting 248 million individuals worldwide. Non-alcoholic fatty liver disease (NAFLD) is a common occurrence in chronic HBV infection. It ranges from simple steatosis to active inflammation of nonalcoholic steatohepatitis, and subsequent fibrosis, cirrhosis and an increase risk of hepatocellular carcinoma. Our study aims to assess the causal effect of NAFLD among chronic HBV patients.

METHODS:

We performed a retrospective chart review of all treated and untreated chronic HBV patients at Sandra Atlas Bass Center for Liver Diseases over the past 5 years. Medical records of study subjects with a diagnosis of NAFLD age ≥ 18 years and <90 years were reviewed. Patients were stratified into the following two groups: (1) mild-moderate steatosis (S0-S2) and (2) severe steatosis (S3). Patients with other co-existing chronic liver diseases were excluded. Clinical data as shown on Table 1 were analyzed. Continuous variables were statistically analyzed with student’s T-test. Categorical variables were analyzed with Pearson’s chi-squared test.

RESULTS:

We identified 110 patients with HBV infection and NAFLD, of which 68 (61.8%) patients had severe hepatic steatosis. Co-morbidities and ethnicities did not significantly differ among the two studied groups. Patients in the mild-moderate steatosis group had statistically higher HDL level (53.4 vs 46.6mg/dL, P = 0.033) and a lower ALT level (31.0 vs 47.7U/L, P = 0.027) than that observed in the severe steatosis group. Thirty-one percent of patients with severe steatosis were also found to have F2-F4 disease compared to 7% in the mild-moderate steatosis group (P = 0.013). Sixty-three percent of patients in the severe steatosis group required treatment with HBV anti-viral therapy compared to 31% in the mild-moderate steatosis group (P = 0.001). Tenofovir alafenamide (48.2%) was the HBV anti-viral therapy most commonly used.

CONCLUSION:

Our study showed that patients with severe steatosis tend to have lower HDL but higher ALT and fibrosis stage, and are twice as likely to require anti-HBV therapy. Hepatic steatosis may be an indicator of the severity of chronic HBV infection. Further studies are warranted to understand the correlation between NAFLD and chronic HBV infection.
1042 Direct-Acting Antivirals for the Treatment of Hepatitis C Genotypes 1 to 5 in Sub-Saharan Africa
Authors: Sultan Amir , Braimoh Grace , Bane Abate , Debes Jose D.
Published: October 2019

INTRODUCTION:

The use of direct-acting antivirals (DAAs) for the treatment of hepatitis C virus infection (HCV) has exposed the possibility of global elimination of the virus worldwide. However, a large number of HCV-infected individuals reside in resource-limited settings such as sub-Saharan Africa (SSA). There is very limited knowledge of the use of DAAs in SSA

METHODS:

We developed a single-arm prospective study to assess response to DAAs in 164 individuals infected with HCV genotypes 1 to 5 in Addis Ababa, Ethiopia. The majority of patients were treated with Ledipasvir/Sofosbuvir (LDP/SOF) with or without Ribavirin (RBV) or Sofosbuvir with Ribavirin (SOF/RBV). Before initiation of treatment, every patient underwent an abdominal ultrasound, evaluation of liver function markers and calculation of aspartate transaminase to Platelet Ratio Index (APRI) to determine fibrosis status. HCV RNA levels were determined at baseline and 12 weeks after end of treatment.

RESULTS:

HCV treatment with DAAs was completed by all 164 enrolled individuals. The median age of patients was 52 years (IQR 42-60) and 55% of them were females. Seventy-six percent of individuals had genotype 4, 14% genotype 2, 6% genotype 1, 2.5% genotype 5 and 1.5% genotype 3. The median HCV RNA level before treatment was 1.300.555 IU/L (IQR: 649825-3182800), and the median APRI score was 1.49 (IQR 1.13-2.24) with 19 % of participants showing evidence of cirrhosis on imaging. Sixty-seven percent of patients were treated using LDP/SOF, 18.5% using LDP/SOF/RBV and 14.6% using SOF/RBV, all for a total of 12 weeks. The sustained virologic response (SVR) rate across all genotypes was 98.8%. In those individuals with cirrhosis, SVR was 93.5% and in non-cirrhotics 100% regardless of APRI-based fibrosis level. Two patients failed to achieve SVR. Both showed evidence of decompensated cirrhosis and one had failed previous therapy with interferon. Among reported side effects, fatigue was the most commonly reported at 11%, followed by nausea in 1.2% of subjects. All side effected subsidized after end of treatment.

CONCLUSION:

Our study demonstrates for the first time successful treatment of HCV with DAAs among different viral genotypes in Sub-Saharan Africa, demonstrating the feasibility of HCV elimination in resource-limited settings.
1044 The Prevalence of Liver Fibrosis in Hispanic Adolescents With Nonalcoholic Fatty Liver Disease Is High and Independent of the Presence of Prediabetes and Diabetes
Authors: Sandhu Sanjeet
Published: October 2019

INTRODUCTION:

Prediabetes and Type 2 diabetes (T2DM) are risk factors for nonacloholic fattty liver disease (NAFLD), an increasing cause of liver disease in the United States. Hispanics develop NAFLD and may progress to liver fibrosis at a younger age when compared to non-Hispanic whites. Relying on Serum Alanine Aminotransferase (ALT) levels are inaccurate to determine the presence of fibrosis. We sought to compare the prevalence of fibrosis in Hispanic children with NAFLD and insulin resistance compared to Hispanic children with NAFLD but without insulin resistance

METHODS:

Adolescent Hispanics (8-17 years of age) with overweight or obesity who were referred for suspected NAFLD based on the presence of elevated ALT or fatty infiltration on ultrasonography were included. Shear wave transient elastography was used to determine suspected fibrosis in those with A1c ≥ 5.7% compared to a control group with A1c < 5.7%. A value of >5.1kPa was used to define suspected fibrosis. Statistical analysis was done using R Core Team Statistical Software. P value < 0.05 was considered statistically significant.

RESULTS:

The study cohort consisted of of 67 patients with mean age of 13.71 years old with 55.2% male. Mean BMI Standard Deviation was 2.44 and the mean ALT was 93.6 U/L. There were 34 patients with A1c < 5.7% with mean liver stiffness of 5.68 kPa and 33 patients with A1c ≥ 5.7 with mean liver stiffness of 5.41 kPa (P = 0.44). The prevalence of suspected fibrosis (>5.1kPa) in obese, Hispanic adolescents presenting for suspected NAFLD was 62.7% with no significant correlation to A1c value (P = 0.69) or degree of obesity as determined by BMI percentile (P = 0.37). ALT (r = 0.13, P = .35) or AST (r = 0.15, P = .28) were not good predictors of liver stiffness either.

CONCLUSION:

Liver fibrosis should be suspected in all obese, Hispanic adolescents presenting with suspected NAFLD independent of the degree of obesity, A1c, ALT or AST values. Earlier intervention in this high risk population is crucial to long term hepatic health.