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1. MELD 3.0 adequately predicts mortality and renal replacement therapy requirements in patients with alcohol-associated hepatitis

Author

Luis Antonio Díaz, Eduardo Fuentes-López, Gustavo Ayares, Francisco Idalsoaga, Jorge Arnold, María Ayala Valverde, Diego Perez, Jaime Gómez, Rodrigo Escarate, Alejandro Villalón, Carolina A. Ramírez, Maria Hernandez-Tejero, Wei Zhang, Steve Qian, Douglas A. Simonetto, Joseph C. Ahn, Seth Buryska, Winston Dunn, Heer Mehta, Rohit Agrawal, Joaquín Cabezas, Inés García-Carrera, Berta Cuyàs, Maria Poca, German Soriano, Shiv K. Sarin, Rakhi Maiwall, Prasun K. Jalal, Saba Abdulsada, Fátima Higuera-de-la-Tijera, Anand V. Kulkarni, P. Nagaraja Rao, Patricia Guerra Salazar, Lubomir Skladaný, Natália Bystrianska, Ana Clemente-Sanchez, Clara Villaseca-Gómez, Tehseen Haider, Kristina R. Chacko, Gustavo A. Romero, Florencia D. Pollarsky, Juan Carlos Restrepo, Susana Castro-Sanchez, Luis G. Toro, Pamela Yaquich, Manuel Mendizabal, Maria Laura Garrido, Sebastián Marciano, Melisa Dirchwolf, Victor Vargas, César Jiménez, Alexandre Louvet, Guadalupe García-Tsao, Juan Pablo Roblero, Juan G. Abraldes, Vijay H. Shah, Patrick S. Kamath, Marco Arrese, Ashwani K. Singal, Ramon Bataller, and Juan Pablo Arab

Subjects
End-stage liver disease, Alcoholic hepatitis, Alcohol, Cirrhosis, Female, Outcome prediction, Diseases of the digestive system. Gastroenterology, RC799-869
Abstract

Background & Aims: Model for End-Stage Liver Disease (MELD) score better predicts mortality in alcohol-associated hepatitis (AH) but could underestimate severity in women and malnourished patients. Using a global cohort, we assessed the ability of the MELD 3.0 score to predict short-term mortality in AH. Methods: This was a retrospective cohort study of patients admitted to hospital with AH from 2009 to 2019. The main outcome was all-cause 30-day mortality. We compared the AUC using DeLong's method and also performed a time-dependent AUC with competing risks analysis. Results: A total of 2,124 patients were included from 28 centres from 10 countries on three continents (median age 47.2 ± 11.2 years, 29.9% women, 71.3% with underlying cirrhosis). The median MELD 3.0 score at admission was 25 (20–33), with an estimated survival of 73.7% at 30 days. The MELD 3.0 score had a better performance in predicting 30-day mortality (AUC:0.761, 95%CI:0.732–0.791) compared with MELD sodium (MELD-Na; AUC: 0.744, 95% CI: 0.713–0.775; p = 0.042) and Maddrey’s discriminant function (mDF) (AUC: 0.724, 95% CI: 0.691–0.757; p = 0.013). However, MELD 3.0 did not perform better than traditional MELD (AUC: 0.753, 95% CI: 0.723–0.783; p = 0.300) and Age-Bilirubin-International Normalised Ratio-Creatinine (ABIC) (AUC:0.757, 95% CI: 0.727–0.788; p = 0.765). These results were consistent in competing-risk analysis, where MELD 3.0 (AUC: 0.757, 95% CI: 0.724–0.790) predicted better 30-day mortality compared with MELD-Na (AUC: 0.739, 95% CI: 0.708–0.770; p = 0.028) and mDF (AUC:0.717, 95% CI: 0.687–0.748; p = 0.042). The MELD 3.0 score was significantly better in predicting renal replacement therapy requirements during admission compared with the other scores (AUC: 0.844, 95% CI: 0.805–0.883). Conclusions: MELD 3.0 demonstrated better performance compared with MELD-Na and mDF in predicting 30-day and 90-day mortality, and was the best predictor of renal replacement therapy requirements during admission for AH. However, further prospective studies are needed to validate its extensive use in AH. Impact and implications: Severe AH has high short-term mortality. The establishment of treatments and liver transplantation depends on mortality prediction. We evaluated the performance of the new MELD 3.0 score to predict short-term mortality in AH in a large global cohort. MELD 3.0 performed better in predicting 30- and 90-day mortality compared with MELD-Na and mDF, but was similar to MELD and ABIC scores. MELD 3.0 was the best predictor of renal replacement therapy requirements. Thus, further prospective studies are needed to support the wide use of MELD 3.0 in AH.

Published
2023
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2. Clinical and microbiological characteristics of bacterial infections in patients with cirrhosis. A prospective cohort study from Argentina and Uruguay

Author

Carolina Vazquez, María Nelly Gutierrez-Acevedo, Sabrina Barbero, Lorena del Carmen Notari, Marina Agozino, José Luis Fernandez, María Margarita Anders, Nadia Lorena Grigera, Florencia Antinucci, Orlando Nicolas Federico Orozco-Ganem, María Dolores Murga, María Daniela Perez, Ana Gracia Palazzo, Liria Martinez Rejtman, Ivonne Giselle Duarte, Julio Daniel Vorobioff, Victoria Trevizan, Sofía Bulaty, Fernando Bessone, Marcelo Valverde, Martín Elizondo, Silvia Mabel Borzi, Teodoro Eduardo Stieben, Adriano Carlos Masola, Sebastian Eduardo Ferretti, Diego Arufe, Ezequiel Demirdjian, María Pia Raffa, Mirta Peralta, Hugo Alberto Fainboim, Cintia Elizabet Vazquez, Pablo Marcelo Ruiz, José Emanuel Martínez, Leandro Alfredo Heffner, Andrea Odzak, Melisa Dirchwolf, Astrid Smud, Manuel Mendizabal, Pablo Anibal Calzetta, Ana Martinez, Jesica Tomatis, Andres Bruno, Agñel Ramos, Josefina Pages, Silvina Tevez, Adrian Carlos Gadano, Diego Hernan Giunta, and Sebastián Marciano

Subjects
Multidrug resistance, Antibiotics, Antimicrobial agents, Specialties of internal medicine, RC581-951
Abstract

Introduction and Objectives: there is insufficient data regarding bacterial infections in patients with cirrhosis to support recommendations for empiric antibiotic treatments, particularly in Latin America. This study aimed to evaluate bacterial infection's clinical impact and microbiological characteristics, intending to serve as a platform to revise current practices. Materials and Methods: multicenter prospective cohort study of patients with cirrhosis and bacterial infections from Argentina and Uruguay. Patient and infection-related information were collected, focusing on microbiology, antibiotic susceptibility patterns, and outcomes. Results: 472 patients were included. Spontaneous bacterial infections and urinary tract infections (UTIs) were registered in 187 (39.6%) and 116 (24.6%) patients, respectively, representing the most common infections. Of the 256 culture-positive infections, 103 (40.2%) were caused by multidrug-resistant organisms (reaching 50% for UTI), and 181 (70.7%) received adequate initial antibiotic treatment. The coverage of cefepime and ceftriaxone was over 70% for the empirical treatment of community-acquired spontaneous infections, but ceftazidime´s coverage was only 40%. For all UTI cases and for healthcare-associated or nosocomial spontaneous bacterial infections, the lower-spectrum antibiotics that covered at least 70% of the isolations were imipenem and meropenem. During hospitalization, a second bacterial infection was diagnosed in 9.8% of patients, 23.9% required at least one organ support, and 19.5% died. Conclusions: short-term mortality of bacterial infections in patients with cirrhosis is very high, and a high percentage were caused by multidrug-resistant organisms, particularly in UTIs. The information provided might serve to adapt recommendations, particularly related to empirical antibiotic treatment in Argentina and Uruguay. The study was registered in Clinical Trials (NCT03919032).

Published
2023
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3. O-21 EVIDENCE OF SUBOPTIMAL PUBLIC HEALTH POLICIES ON HEPATOCELLULAR CARCINOMA IN THE AMERICAS: A HUGE DEBT OF OUR REGION

Author

Luis Antonio Díaz, Gustavo Ayares, Francisco Idalsoaga, Jorge Arnold, Blanca Norero, Oscar Corsi, Gonzalo Pizarro, Sergio García, Eduardo Fuentes-López, Edmundo Martinez, Patricia Guerra Salazar, Roberta C. Araújo, Mario Reis Alvares-Da-Silva, Florencia D. Pollarsky, Nelia Hernandez, Juan Carlos Restrepo, Mirtha Infante, Enrique Carrera, Abel Sanchez, Marcos Girala, Martín Padilla, Javier Díaz, Martín Tagle, Melisa Dirchwolf, Manuel Mendizabal, Mariana Lazo, Catterina Ferreccio, Thomas G. Cotter, Mayur Brahmania, Nahum Méndez-Sánchez, Juan Pablo Roblero, Winston Dunn, Patrick S. Kamath, Ashwani K. Singal, Ramón Bataller, Marco Arrese, and Juan Pablo Arab

Subjects
Specialties of internal medicine, RC581-951
Abstract

Introduction and Objectives: Although most cases of HCC occur in patients with advanced liver disease and there are effective screening methods, health policies aimed at preventing and detecting HCC are not often on the agenda of government initiatives and policies. This study aimed to explore HCC-related population-wide public health policies, treatment availability, epidemiological surveillance, and awareness campaigns in the Americas. Materials and Methods: We conducted a 43-item survey about HCC among experts from 12 countries. Questions were classified into four categories: policies and civil society (18 questions), clinical guidelines (5 questions), epidemiology (7 questions), and care management (13 questions). The survey was administered using an electronic form in May 2022. Data was collected in a spreadsheet, revised by two independent reviewers, and contrasted with governmental institutions. Results: We obtained 22 responses from 15 out of the 18 countries targeted. A total of 7 (47%) countries had a written national cancer strategy or action plan. Only 4 (27%) countries had a specific written national HCC strategy or action plan, including Argentina, Brazil, Mexico, and the United States. These same four countries also had national clinical guidelines on HCC. HCC is managed by various providers, including Hepatologists (80%), Oncologists (80%), Gastroenterologists (60%), Surgeons (47%), and Palliative medicine (20%). There were important differences in the availability of treatments among countries in the Americas (Figure). Of note, 60% of countries had liver transplantation available for HCC, but only 67% of them had this therapy outside the capital city. Nine (60%) countries had a national disease registry that included HCC. However, only Brazil (7%) had governmental funded awareness campaigns on HCC prevention or screening. Conclusions: Implementation of public health policies on HCC is scarce in the Americas. Important differences in treatments were observed across countries, especially in curative therapies. Our results strongly encourage developing public health policies on HCC in the Americas.

Published
2023
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4. O-25 ASSESSMENT OF MODELS FOR PREDICTING RESPONSE TO CORTICOIDS TREATMENT IN ALCOHOL-ASSOCIATED HEPATITIS: A GLOBAL COHORT STUDY

Author

Francisco Idalsoaga, Luis Antonio Díaz, Gustavo Ayares, Jorge Arnold, Winston Dunn, Yanming Li, Ashwani Singal, Doug Simonetto, María Ayala-Valverde, Diego Perez, Jaime Gomez, Rodrigo Escarate, Eduardo Fuentes-López, Carolina A Ramirez, Dalia Morales-Arraez, Wei Zhang, Steve Qian, Joseph Ahn, Seth Buryska, Heer Mehta, Muhammad Waleed, Horia Stefanescu, Adelina Horhat, Andreea Bumbu, Bashar Attar, Rohit Grawal, Joaquín Cabezas, Inés García-Carrera, Berta Cuyàs, Maria Poca, German Soriano Pastor, Shiv K Sarin, Rakhi Maiwall, Prasun K Jalal, María Fátima Higuera-De La Tijera, Anand Kulkarni, Nagaraja Rao P, Patricia Guerra Salazar, Lubomir Skladaný, Natália Bystrianska, Veronica Prado, Ana Clemente-Sanchez, Diego Rincón, Tehseen Haider, Kristina R Chacko, Gustavo A Romero, Florencia D Pollarsky, Juan Carlos Restrepo, Luis G Toro, Pamela Yaquich, Manuel Mendizabal, Maria Laura Garrido, Sebastian Marciano, Melisa Dirchwolf, Victor Vargas, Cesar Jimenez, Guadalupe García-Tsao, Guillermo Ortiz, Juan G Abraldes, Patrick Kamath, Marco Arrese, Vijay Shah, Ramon Bataller, and Juan Pablo Arab

Subjects
Specialties of internal medicine, RC581-951
Abstract

Introduction and Objectives: Alcohol-associated hepatitis (AH) is a severe entity associated with high mortality. Corticosteroids might be used in cases with severe disease and several dynamic models can predict mortality and response to corticosteroids in AH patients. However, there is no consensus on the best of them. This study aimed to evaluate dynamic models to predict response to corticosteroid treatment based on short-term mortality in patients with severe AH based on a worldwide cohort. Materials and Methods: A retrospective cohort study of patients with severe AH (between 2009 – 2019). We included patients who received corticosteroid treatment and calculated the Lille model of day 4 (Lille-4), day 7 (Lille-7) (cut-off value ≥0.45), and the Trajectory of Serum Bilirubin (TSB)(cut-off value ≥0.8 of the ratio between bilirubin at admission and day 7) to predict mortality. We estimated up to 30-day survival using Kaplan-Meier curves, and we performed multivariable analyzes using Cox regression. Specifically, we constructed two models to compare Lille-4 vs. TSB and Lille-7 vs. TSB, adjusting by well-known clinical variables associated with higher mortality in AH (age, sex, and creatinine at admission). Results: 1,066 patients were included (30 centers, 10 countries), age 47.7 ± 10.9 years, 30% women. The MELD score on admission was 25 [21-30]. Responders were considered by Lille-4 49.1%, Lille-7 46.6%, and TSB 55.4%. In the first Cox regression, we observed that Lille-4 and TSB predicted 30-day mortality (HR 3.0, 95%CI: 1.7-5.1; p

Published
2023
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5. OP-5 ALCOHOL-ASSOCIATED HEPATITIS IN LATIN AMERICA: RESULTS FROM THE AH-LATIN STUDY

Author

Luis Antonio Díaz, Jorge Arnold, Francisco Idalsoaga, Gustavo Ayares, María Ayala-Valverde, Diego Perez, Jaime Gomez, Rodrigo Escarate, Juan Pablo Roblero, Blanca Norero, José Antonio Velarde, Janett Jacobo, Jesús Varela, Scherezada Mejía Loza, Jacqueline Córdova, Rita Silva, Cristina Melo Rocha, Roberta C. Araujo, Gustavo Henrique Pereira, Claudia Couto, Fernando Bessone, Mario Tanno, Gustavo Romero, Manuel Mendizabal, Sebastián Marciano, Melisa Dirchwolf, Pedro Montes, Patricia Guerra Salazar, Geraldine Ramos, Juan Carlos Restrepo, Gabriel Díaz, Luis Guillermo Toro, Enrique Carrera, Brahmania Mayur, Singal Ashwani, Bataller Ramon, Shah Vijay, Kamath Patrick S., Marco Arrese, and Juan Pablo Arab

Subjects
Specialties of internal medicine, RC581-951
Abstract

Introduction and Objectives: Severe alcohol-associated hepatitis (AH) is an entity with high morbidity and mortality; however, data in Latin America is limited. We aimed to characterize patients hospitalized for AH in a multinational cohort in Latin America. Materials and Methods: Multicenter prospective cohort study. We included patients admitted with severe AH between 2015-2022. Sociodemographic and clinical information was recorded. The analysis included survival analysis using Kaplan-Meier curves. This study was approved by the institutional ethics committee. Results: 470 patients from 24 centers (8 countries: Mexico, Chile, Argentina, Brazil, Peru, Bolivia, Colombia, and Ecuador) were included. Age 49.8 ± 10.6 years, 85.6% of men and 45% had a previous diagnosis of cirrhosis. Median MELD at admission was 26.9 [22-32] points. 26.5% met SIRS criteria and 34.3% had an acute kidney injury (AKI) on admission. Only 36.8% of patients were treated with corticosteroids. Survival at 30 days was 75.0% (95%CI: 70.1-79.3%) and 62.8% (95%CI: 57.1-68.0%) at 90 days. A total of 191 (45.8%) patients presented infections, 31.4% at admission and 24.9% during hospitalization. The most frequent locations of community-acquired infections were respiratory (33.5%), urinary (32.1%), spontaneous bacterial peritonitis (14.9%), and skin (10.5%), while the most frequent pathogens were Escherichia coli (40%), Klebsiella pneumoniae (12%), and Enterococcus (6%). The presence of infection at admission was associated with a decreased survival at 90-days (66.9% versus 48.1%, p=0.0002). AKI at admission was also associated with decreased survival at 90-days (86.8% versus 51.3%, p

Published
2023
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6. P-6 PATTERNS OF ANTIBIOTIC RESISTANCE IN PATIENTS WITH CIRRHOSIS AND SPONTANEOUS BACTERIAL INFECTIONS: ANALYSES OF THE MULTICENTER STUDY FROM ARGENTINA AND URUGUAY

Author

Sebastián Marciano, Maria Nelly Gutierrez Acevedo, Sabrina Barbero, Lorena del Carmen Notari, Marina Agozino, Jose Luis Fernandez, Maria Margarita Anders, Nadia Grigera, Florencia Antinucci, Orlando Federico Orozco Ganem, Maria Dolores Murga, Daniela Perez, Ana Palazzo, Liria Martinez Rejtman, Ivonne Giselle Duarte, Julio Vorobioff, Victoria Trevizan, Sofía Bulaty, Fernando Bessone, Marcelo Valverde, Martín Elizondo, José Daniel Bosia, Silvia Mabel Borzi, Teodoro E. Stieben, Adriano Masola, Sebastian Eduardo Ferretti, Diego Arufe, Ezequiel Demirdjian, Maria Pia Raffa, Mirta Peralta, Hugo Alberto Fainboim, Cintia Elizabet Vazquez, Pablo Ruiz, José Emanuel Martínez, Leandro Alfredo Heffner, Andrea Odzak, Melisa Dirchwolf, Astrid Smud, Manuel Mendizabal, Carla Bellizzi, Ana Martinez, Jesica Tomatis, Andres Bruno, Agñel Ramos, Josefina Pages, Silvina Tevez, Diego Giunta, and Adrian Gadano

Subjects
Specialties of internal medicine, RC581-951
Abstract

Introduction and Objectives: Selecting an empiric antibiotic treatment in patients with cirrhosis and spontaneous bacterial infections is challenging. It is of paramount importance to have local epidemiological data to maximize pathogen coverage while minimizing the unnecessary use of broad-spectrum antibiotics. This study aimed to describe the patterns of antibiotic resistance of spontaneous bacterial infections according to the site of acquisition. Materials and Methods: Analysis of the multicenter prospective cohort study of cirrhotic patients with bacterial infections in Argentina and Uruguay (NCT03919032). Only culture-positive spontaneous infections were included in this study: spontaneous bacterial peritonitis (SBP), spontaneous bacterial empyema (SBE), and spontaneous bacteremia (SB). We estimated the proportion of infections that were sensitive to various antibiotics according to where the infection was acquired: community-acquired (CA), healthcare-associated (HCA), or nosocomial (NOS). Approximately 80% coverage is advisable for empiric treatments in stable patients and 90% for critically-ill patients. Results: The main cohort included 472 patients, of whom 97 presented culture-positive spontaneous infections and were included: with 57 (59%) SBP, 34 (35%) SB, and 4 (6%) SBE. Regarding the site of acquisition, 43% were CA, 36% NOS, and 21% HCA. Gram-positive and negative bacteria were found in 53% and 47% of the infections. The most frequent isolations were Streptococcus spp (26%), E coli (20), K pneumonia (15%), S Aureus (10%), E. faecium (6%) and E. faecalis (4%). Multidrug-resistant organisms (MDROs) were isolated in 35% of the patients. As shown in the table, cefepime and ceftriaxone offer the most rational coverage for CA and HCA infections, and imipenem or meropenem for NOS infections. However, in critically-ill patients, broader-spectrum antibiotics are needed to achieve a coverage closer to 90% (table). Conclusions: We present, for the first time in our region, evidence-based recommendations for the empirical treatment of spontaneous bacterial infections. Prior colonization and/or infections by MDROs might refine even more the antibiotic selection and should be explored.

Published
2023
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7. Outbreak of hepatitis A in a post-vaccination era: High rate of co-infection with sexually transmitted diseases

Author

Sebastián Marciano, Diego Arufe, Leila Haddad, Manuel Mendizabal, Adrián Gadano, Luis Gaite, Margarita Anders, Laura Garrido, Ana Alicia Martinez, Damián Conte, Martin Barrabino, Lucrecia Rovey, Maria Del Valle Aubone, Natalia Ratusnu, Hugo Tanno, Hugo Fainboim, Angel Oyervide, Lucia de Labra, Andrés Ruf, and Melisa Dirchwolf

Subjects
Hepatitis A, Outbreak, Men who have sex with Men, Sexually transmitted disease, Specialties of internal medicine, RC581-951
Abstract

Introduction and objectives: After hepatitis A (HAV) mandatory immunization in 2005 in Argentina, the incidence of HAV declined drastically. However, several new autochthonous cases of HAV have been reported since 2017. We aimed to evaluate the clinical and epidemiological characteristics and possible transmission routes of affected patients. Patients or Materials and methods: We performed a cross-sectional study of patients residing in Argentina with acute hepatitis A between 30.06.2017 and 31.12.2018. Results: 66 cases of HAV were registered. Fifty-six patients (86%) were males, with a mean age of 34 ± 12 years old. The most likely routes of transmission were sexual intercourse of men with men, reported by 31 patients. Additionally, 23% and 26% of patients tested positive for HIV and syphilis, respectively. In total, 35% of patients required hospitalization. When assessing outcomes, 79% had a mild presentation and 21% had a severe/fulminant presentation: one patient underwent liver transplantation, and one patient died. Conclusions: Our study describes that during the study period, HAV infection affected predominantly young adults, particularly men who have sex with men. An elevated proportion of them was diagnosed with a concomitant sexually transmitted disease, and several patients had a severe presentation of the disease.

Published
2020
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8. Latin American Association for the study of the liver (ALEH) practice guidance for the diagnosis and treatment of non-alcoholic fatty liver disease

Author

Juan Pablo Arab, Melisa Dirchwolf, Mário Reis Álvares-da-Silva, Francisco Barrera, Carlos Benítez, Marlene Castellanos-Fernandez, Graciela Castro-Narro, Norberto Chavez-Tapia, Daniela Chiodi, Helma Cotrim, Kenneth Cusi, Claudia Pinto Marques Souza de Oliveira, Javier Díaz, Eduardo Fassio, Solange Gerona, Marcos Girala, Nelia Hernandez, Sebastián Marciano, Walter Masson, Nahum Méndez-Sánchez, Nathalie Leite, Adelina Lozano, Martín Padilla, Arturo Panduro, Raymundo Paraná, Edison Parise, Marlene Perez, Jaime Poniachik, Juan Carlos Restrepo, Andrés Ruf, Marcelo Silva, Martín Tagle, Monica Tapias, Kenia Torres, Eduardo Vilar-Gomez, José Eduardo Costa Gil, Adrian Gadano, and Marco Arrese

Subjects
Steatosis, NAFLD, NASH, Fatty liver, Clinical practice guidance, Nonalcoholic fatty liver disease, Specialties of internal medicine, RC581-951
Abstract

Non-alcoholic fatty liver disease (NAFLD) currently represents an epidemic worldwide. NAFLD is the most frequently diagnosed chronic liver disease, affecting 20–30% of the general population. Furthermore, its prevalence is predicted to increase exponentially in the next decades, concomitantly with the global epidemic of obesity, type 2 diabetes mellitus (T2DM), and sedentary lifestyle. NAFLD is a clinical syndrome that encompasses a wide spectrum of associated diseases and hepatic complications such as hepatocellular carcinoma (HCC). Moreover, this disease is believed to become the main indication for liver transplantation in the near future. Since NAFLD management represents a growing challenge for primary care physicians, the Asociación Latinoamericana para el Estudio del Hígado (ALEH) has decided to organize this Practice Guidance for the Diagnosis and Treatment of Non-Alcoholic Fatty Liver Disease, written by Latin-American specialists in different clinical areas, and destined to general practitioners, internal medicine specialists, endocrinologists, diabetologists, gastroenterologists, and hepatologists. The main purpose of this document is to improve patient care and awareness of NAFLD. The information provided in this guidance may also be useful in assisting stakeholders in the decision-making process related to NAFLD. Since new evidence is constantly emerging on different aspects of the disease, updates to this guideline will be required in future.

Published
2020
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9. From Child-Pugh to MELD score and beyond: Taking a walk down memory lane

Author

Andres Ruf, Melisa Dirchwolf, and Richard B. Freeman

Subjects
End-stage liver disease, Liver transplantation, Organ allocation, Specialties of internal medicine, RC581-951
Abstract

The Child-Turcotte-Pugh (CTP) and the MELD (Model for End-Stage Liver Disease) scores were designed to predict the outcome of decompressive therapy for portal hypertension. They were prospectively validated to predict mortality risk in patients with a wide spectrum of liver disease etiology and severity. Unlike the CTP score, the MELD score was derived from prospectively gathered data. Its calculation was based on serum bilirubin, serum creatinine, international normalized ratio (INR) and etiology of liver disease. Instituting a continuous disease severity score that de-emphasizes waiting time resulted in better categorization of waiting patients and enhanced transparency. The US instituted the MELD system in 2002 and soon thereafter, MELD-based liver allocation was adopted throughout the world including Latin America. The most significant impact of MELD-based policies has been the reduction of waiting-list mortality. In the years after implementation of the MELD system, several options have been proposed to improve the MELD score's accuracy. Adding serum sodium (MELD-Na) increased the accuracy of the score in predicting waiting list mortality, thus completing the original MELD score as a prognostic model in liver allocation. On the 20th anniversary of the creation of MELD score we present a brief account of its development, its use to stratify patients on the waiting list for liver transplantation as well as its adoption as liver allocation system .

Published
2022
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10. Argentinian clinical practice guideline for surveillance, diagnosis, staging and treatment of hepatocellular carcinoma

Author

Federico Piñero, Mario Tanno, Gabriel Aballay Soteras, Matías Tisi Baña, Melisa Dirchwolf, Eduardo Fassio, Andrés Ruf, Silvia Mengarelli, Silvia Borzi, Nora Fernández, Ezequiel Ridruejo, Valeria Descalzi, Margarita Anders, Guillermo Mazzolini, Virginia Reggiardo, Sebastián Marciano, Florencia Perazzo, Juan Carlos Spina, Lucas McCormack, Martín Maraschio, Cecilia Lagues, Adrián Gadano, Federico Villamil, Marcelo Silva, Fernando Cairo, and Beatriz Ameigeiras

Subjects
Liver cancer, Practice guideline, Latin America, Argentina, Specialties of internal medicine, RC581-951
Abstract

The A.A.E.E.H has developed this guideline for the best care of patients with hepatocellular carcinoma (HCC) from Argentina. It was done from May 2018 to March 2020. Specific clinical research questions were systematically searched. The quality of evidence and level of recommendations were organized according to GRADE. HCC surveillance is strongly recommended with abdominal ultrasound (US) every six months in the population at risk for HCC (cirrhosis, hepatitis B or hepatitis C); it is suggested to add alpha-feto protein (AFP) levels in case of inexeperienced sonographers. Imaging diagnosis in patients at risk for HCC has high specificity and tumor biopsy is not mandatory. The Barcelona Clinic Liver Cancer algorithm is strongly recommended for HCC staging and treatment-decision processes. Liver resection is strongly recommended for patients without portal hypertension and preserved liver function. Composite models are suggested for liver transplant selection criteria. Therapies for HCC with robust clinical evidence include transarterial chemoembolization (TACE) and first to second line systemic treatment options (sorafenib, lenvatinib, regorafenib, cabozantinib and ramucirumab). Immunotherapy with nivolumab and pembrolizumab has failed to show statistical benefit but the novel combination of atezolizumab plus bevacizumab has recently shown survival benefit over sorafenib in frontline.

Published
2020
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11. Failure in all steps of hepatocellular carcinoma surveillance process is frequent in daily practice

Author

Melisa Dirchwolf, Sebastián Marciano, Andres E. Ruf, Amit G. Singal, Vanina D'Ercole, Paola Coisson, Alina Zerega, Federico Orozco, Ana Palazzo, Eduardo Fassio, Diego Arufe, Margarita Anders, Claudia D'Amico, Luis Gaite, Marcos Thompson, Daniela Perez, Leila Haddad, Ezequiel Demirdjian, Moira Zunino, Adrián Gadano, María Dolores Murga, Carla Bermudez, Jesica Tomatis, Nadia Grigera, Florencia Antinucci, Manuel Baravalle, Maria Mercedes Rodriguez Gazari, Melina Ferreiro, Manuel Barbero, Andrea Curia, Manuel Demonte, and Gisela Gualano

Subjects
Liver cancer, Screening, Failure, Alpha fetoprotein, Cirrhosis, Specialties of internal medicine, RC581-951
Abstract

Introduction and objectives: Failures at any step in the hepatocellular carcinoma (HCC) surveillance process can result in HCC diagnostic delays and associated worse prognosis. We aimed to estimate the prevalence of surveillance failure and its associated risk factors in patients with HCC in Argentina, considering three steps: 1) recognition of at-risk patients, 2) implementation of HCC surveillance, 3) success of HCC surveillance. Methods: We performed a multi-center cross-sectional study of patients at-risk for HCC in Argentina seen between10.01.2018 and 10.30.2019. Multivariable logistic regression analysis was used to identify correlates of surveillance failure. Results: Of 301 included patients, the majority were male (74.8%) with a mean age of 64 years old. At the time of HCC diagnosis, 75 (25%) patients were unaware of their diagnosis of chronic liver disease, and only 130 (43%) patients were under HCC surveillance. Receipt of HCC surveillance was significantly associated with follow-up by a hepatologist. Of 119 patients with complete surveillance, surveillance failure occurred in 30 (25%) patients. Surveillance failure was significantly associated with alpha fetoprotein ≥20 ng/mL (OR 4.0, CI 95% 1.43−11.55). Conclusions: HCC surveillance failure was frequent in all the evaluated steps. These data should help guide strategies to improve the implementation and results of HCC surveillance in our country.

Published
2021
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12. NAFLD: Challenges and opportunities to address the public health problem in Latin America

Author

Juan Pablo Arab, Luis Antonio Díaz, Melisa Dirchwolf, Henry E. Mark, Jeffrey V. Lazarus, Elly Vaughan, Nahum Méndez-Sánchez, Claudia P. Oliveira, Adrián Gadano, and Marco Arrese

Subjects
Non-alcoholic steatohepatitis, NASH, Non-alcoholic fatty liver disease, NAFLD, MAFLD, Public policies, Specialties of internal medicine, RC581-951
Abstract

Non-alcoholic fatty liver disease (NAFLD) is reaching epidemic proportions worldwide. Collectively, Latin American countries have some of the highest obesity rates in the world and the fastest-growing prevalence of type 2 diabetes mellitus (T2DM). Since obesity and T2DM are intrinsically linked with NAFLD, epidemiological projections are worrisome. In addition to this adverse epidemiological setting, the region of Latin America faces unique challenges and obstacles to addressing the growing burden of NAFLD. In this article, on the occasion of the International NASH Day on June 10, 2021, we describe the main challenges and opportunities to improve care of people living with NAFLD in Latin America. Among the major challenges to be tackled are: lack of disease awareness, limited educational opportunities for healthcare personnel and general public, health system fragmentation, and lack of effective strategies for the prevention and effective treatment of NAFLD and common comorbidities, namely obesity and T2DM. Wide dissemination of current concepts on NAFLD, and extensive collaboration between scientific societies, governments, non-governmental organizations, pharmaceutical industry, and other stakeholders is urgently needed to advance the NAFLD public health policies agenda that allows us to address this disease with a whole of society approach.

Published
2021
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13. P-53 FAILURE IN ALL STEPS OF HEPATOCELLULAR CARCINOMA SURVEILLANCE PROCESS IS FREQUENT IN DAILY PRACTICE.

Author

Melisa Dirchwolf, Sebastián Marciano, Andres E. Ruf, Amit G. Singal, Vanina D'Ercole, Paola Coisson, Alina Zerega, Federico Orozco, Ana Palazzo, Eduardo Fassio, Diego Arufe, Margarita Anders, Claudia D'Amico, Luis Gaite, Marcos Thompson, Daniela Perez, Leila Haddad, Ezequiel Demirdjian, Moira Zunino, Adrián Gadano, María Dolores Murga, Carla Bermudez, Jesica Tomatis, Nadia Grigera, Florencia Antinucci, Manuel Baravalle, Maria Mercedes Rodriguez Gazari, Melina Ferreiro, Manuel Barbero, Andrea Curia, Manuel Demonte, and Gisela Gualano

Subjects
Specialties of internal medicine, RC581-951
Abstract

Introduction: Failures at any step in the hepatocellular carcinoma (HCC) surveillance process can result in HCC diagnostic delays and associated worse prognosis. Objectives: We aimed to estimate the prevalence of surveillance failure and its associated risk factors in patients with HCC in Argentina, considering three steps: 1) recognition of at-risk patients, 2) implementation of HCC surveillance, 3) success of HCC surveillance. Methods: We performed a multi-center cross-sectional study of patients at-risk for HCC in Argentina seen between10.01.2018 and 10.30.2019. Multivariable logistic regression analysis was used to identify correlates of surveillance failure. Results: Of 301 included patients, the majority were male (74.8%) with a mean age of 64 years old. At the time of HCC diagnosis, 75 (24.9%) patients were unaware of their diagnosis of chronic liver disease, and only 130 (43.2%) patients were under HCC surveillance. Receipt of HCC surveillance was significantly associated with follow-up by a hepatologist. Of 119 patients with complete surveillance, surveillance failure occurred in 30 (25.2%) patients. Patients under complete surveillance were significantly more likely to be diagnosed within Milan criteria than those without surveillance (75% vs. 50%, p

Published
2021
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14. P-68 FREQUENCY AND FACTORS ASSOCIATED WITH ANTIBIOTIC DE-ESCALATION IN PATIENTS WITH CIRRHOSIS AND BACTERIAL INFECTIONS

Author

Maria Nelly Gutierrez Acevedo, Sabrina Barbero, Lorena del Carmen Notari, Marina Agozino, Jose Luis Fernandez, Silvina Tevez, Maria Margarita Anders, Nadia Grigera, Florencia Antinucci, Orlando Orozco Ganem, Maria Dolores Murga, Daniea Perez, Ana Palazzo, Liria Martinez Rejtman, Ivonne Giselle Duarte, Julio Vorobioff, Victoria Trevizan, Sofía Bulaty, Fernando Bessone, José Daniel Bosia, Silvia Mabel Borzi, Teodoro E. Stieben, Adriano Masola, Sebastian Eduardo Ferretti, Agñel Ramos, Diego Arufe, Ezequiel Demirdjian, Maria Pia Raffa, Cintia Elizabet Vazquez, Pablo Ruiz, José Emanuel Martínez, Hugo Fainboim, Mirta Peralta, Leandro Alfredo Heffner, Andrea Odzak, Andres Bruno, Melisa Dirchwolf, Jesica Tomatis, Astrid Smud, Manuel Mendizabal, Josefina Pages, Carla Bellizzi, Ana Martinez, Diego Giunta, Marcelo Valverde, Martin Elizondo, Ezequiel Mauro, Adrian Gadano, and Sebastián Marciano

Subjects
Specialties of internal medicine, RC581-951
Abstract

Background: Antibiotic de-escalation is considered a safe strategy that reduces costs and the risk of multi-drug resistant infections. However, its prevalence and associated factors in real-life practice were not reported in patients with cirrhosis in Latin-America. Aims: To estimate the prevalence of antibiotic de-escalation in patients with cirrhosis in real life-practice, and to explore its associated factors. Methods: We performed an analysis of the multicenter prospective cohort study of cirrhotic patients with bacterial infections throughout Argentina and Uruguay (clinicatrials.gov NCT03919032). Patients who died in the first 72 hs from the diagnosis of the infection were excluded. In accordance with guidelines, de-escalation was defined as changing the initially antimicrobials to a narrower spectrum regimen, or suspending one or more of the empirical antibiotics, according to culture results or to other clinical reasons, either in patients with culture-positive or culture-negative bacterial infections. We used inverse probability weighting (IPW) of having a culture-positive infection to estimate its causal effect on de-escalation. Results: We included 450 patients. Most frequent infections were SBP (30.4%), and urinary tract infection (12.9%). Overall, 243 (54%) infections were culture-positive, and 207 (46%) culture-negative. De-escalation was reported in 85 patients (18.9%: 95% CI 15%-22%) at a mean of 3.3 ± 2.4 days from treatment initiation and was more frequent in culture-positive than culture-negative infections (28.4% vs 7.7%, p< 0.001). The table shows the crude analyses of variables associated with de-escalation. Culture-positive infection was strongly and independently associated with de-escalation (ORIPW 6.08; 95% CI: 2.90-12.70; p < 0.001). Conclusions: Antibiotic de-escalation was reported in one-fifth of in-patients with cirrhosis. Given that having a culture-positive infection had a strong effect on de-escalation, efforts should be made to increase the likelihood of obtaining adequate culture samples in a timely manner.

Published
2021
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15. O-9 COMPARISON OF THE PERFORMANCE OF DIFFERENT SCORES FOR THE PREDICTION OF IN-HOSPITAL MORTALITY IN PATIENTS WITH CIRRHOSIS AND BACTERIAL INFECTIONS

Author

Agustina Martinez Garmendia, Maria Nelly Gutierrez Acevedo, Sabrina Barbero, Lorena del Carmen Notari, Marina Agozino, Jose Luis Fernandez, Maria Margarita Anders, Nadia Grigera, Florencia Antinucci, Orlando Orozco Ganem, Maria Dolores Murga, Daniea Perez, Ana Palazzo, Liria Martinez Rejtman, Ivonne Giselle Duarte, Julio Vorobioff, Victoria Trevizan, Sofía Bulaty, Fernando Bessone, José Daniel Bosia, Silvia Mabel Borzi, Teodoro E. Stieben, Adriano Masola, Sebastian Eduardo Ferretti, Diego Arufe, Ezequiel Demirdjian, Maria Pia Raffa, Cintia Elizabet Vazquez, Pablo Ruiz, José Emanuel Martínez, Hugo Fainboim, Mirta Peralta, Leandro Alfredo Heffner, Andrea Odzak, Melisa Dirchwolf, Astrid Smud, Manuel Mendizabal, Carla Bellizzi, Diego Giunta, Marcelo Valverde, Martin Elizondo, Ezequiel Mauro, Ana Martinez, Jesica Tomatis, Andres Bruno, Agñel Ramos, Josefina Pages, Silvina Tevez, Salvatore Piano, Adrian Gadano, and Sebastián Marciano

Subjects
Specialties of internal medicine, RC581-951
Abstract

Background: Predicting short-term mortality in patients with cirrhosis and bacterial infections is challenging. Aims: To compare the performance of various scores in predicting in-hospital mortality in this population. Methods: We performed an analysis of the multicenter prospective cohort study of patients with cirrhosis with bacterial infections throughout Argentina and Uruguay (clinicatrials.gov.NCT03919032). Patients were classified according to the CLIF criteria as having ACLF or mere acute decompensation (AD). We evaluated the performance of scores of liver disease and infection severity in predicting in-hospital mortality. MELD, MELD-Na, and Quick SOFA (qSOFA) were computed in all patients. CLIF-AD was only computed in patients without ACLF, and CLIF-ACLF only in patients with ACLF. We plotted ROC curves and estimated their area under the curve (AUROC). Results: We included 472 patients: 66% male, mean age 57 ± 12 years. Most frequent infections: SBP (30%) and urinary tract infection (25%). Overall, 332 (70%) patients had acute decompensation, and 140 (30%) ACLF. In-hospital mortality rate was 19%: 41% in patients with ACLF vs 10% in patients with AD (p

Published
2021
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16. Biomarkers in Hepatocellular Carcinoma: Diagnosis, Prognosis and Treatment Response Assessment

Author

Federico Piñero, Melisa Dirchwolf, and Mário G. Pessôa

Subjects
liver cancer, biological, markers, Cytology, QH573-671
Abstract

Hepatocellular carcinoma (HCC) is one of the main cancer-related causes of death worldwide. Thus, there is a constant search for improvement in screening, diagnosis, and treatment strategies to improve the prognosis of this malignancy. The identification of useful biomarkers for surveillance and early HCC diagnosis is still deficient, with available serum biomarkers showing low sensitivity and heterogeneous specificity despite different cut-off points, even when assessed longitudinally, or with a combination of serum biomarkers. In contrast, HCC biomarkers used for prognostic (when associated with clinical outcomes) or predictive purposes (when associated with treatment response) may have an increased clinical role in the near future. Furthermore, some serum biomarkers are already implicated as a treatment selection tool, whether to provide access to certain therapies or to assess clinical benefit after treatment. In the present review we will discuss the clinical utility and foreseen future of HCC biomarkers implicated in surveillance, diagnosis, prognosis, and post-treatment assessment.

Published
2020
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17. The Clinical Features of Patients with Chronic Hepatitis C Virus Infections Are Associated with Killer Cell Immunoglobulin-Like Receptor Genes and Their Expression on the Surface of Natural Killer Cells

Author

Ariel Podhorzer, Melisa Dirchwolf, Andrés Machicote, Santiago Belen, Silvina Montal, Silvia Paz, Hugo Fainboim, Luis G. Podestá, and Leonardo Fainboim

Subjects
chronic HCV, liver, killer cell immunoglobulin-like receptor, natural killer cells, T cells, Immunologic diseases. Allergy, RC581-607
Abstract

Killer cell immunoglobulin-like receptor (KIR) genes are known to play a role in the acute phase of hepatitis C virus (HCV) infection. The present study investigated their roles in chronic HCV (CHCV) infection by analyzing the phenotypes and function of natural killer (NK) and T cells that express KIRs. T cells from CHCV patients showed a more differentiated phenotype, and NK cells exhibited an activated profile. These observations are consistent with the increased expression of the degranulation marker CD107a observed after PMA stimulation. We explored the correlations between the expression of KIR genes and lectin type-C receptors with clinical factors that predict progression to fibrosis and cirrhosis. The expression levels of KIR2DS3 and the functional alleles of KIR2DS4-FL were increased in patients with intermediate and high viral loads. Homozygous KIR2DS4 was also associated with the presence of cirrhosis. In the group of individuals with a shorter infection time who developed cirrhosis, we detected decreased expression of KIR3DL1 in CD56dim NK cells in the presence of its ligand. Similarly, in the group of patients with late CHCV infections complicated with cirrhosis, we detected lower expression of the strong inhibitory receptor NKG2A in CD56bright NK cells. We also detected an increase in NKG2C expression in CD56dim NK cells in CHCV patients who displayed high necroinflammatory activity. Decreased KIR3DL2 expression in CD56dim and CD56bright NK cells was associated with a high body mass index, and KIR3DL2 expression may be one factor associated with the more rapid progression of CHCV to fibrosis in patients.

Published
2018
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19. Norfloxacin prophylaxis effect on multidrug resistance in patients with cirrhosis and bacterial infections

Author

Sebastián Marciano, Maria N. Gutierrez-Acevedo, Sabrina Barbero, Lorena del C. Notari, Marina Agozino, Jose L. Fernandez, Maria M. Anders, Nadia Grigera, Florencia Antinucci, Orlando F. Orozco Ganem, Maria D. Murga, Daniela Perez, Ana Palazzo, Liria Martinez Rejtman, Ivonne G. Duarte, Julio Vorobioff, Victoria Trevizan, Sofía Bulaty, Fernando Bessone, Marcelo Valverde, Martín Elizondo, José D. Bosia, Silvia M. Borzi, Teodoro E. Stieben, Adriano Masola, Sebastian E. Ferretti, Diego Arufe, Ezequiel Demirdjian, Maria P. Raffa, Mirta Peralta, Hugo A. Fainboim, Cintia E. Vazquez, Pablo Ruiz, José E. Martínez, Leandro A. Heffner, Andrea Odzak, Melisa Dirchwolf, Astrid Smud, Manuel Mendizabal, Carla Bellizzi, Ana Martinez, Jesica Tomatis, Andres Bruno, Agñel Ramos, Josefina Pages, Silvina Tevez, Adrian C. Gadano, and Diego H. Giunta

Subjects
Microbiology (medical), Infectious Diseases, General Medicine
Published
2023

20. Use of statins after liver transplantation is associated with improved survival: results of a nationwide study

Author

Chiara, Becchetti, Melisa, Dirchwolf, Jonas, Schropp, Giulia, Magini, Beat, Müllhaupt, Franz, Immer, Jean-François, Dufour, Vanessa, Banz, Annalisa, Berzigotti, Jaume, Bosch, Patrick, Yerly, University of Zurich, and Bosch, Jaume

Subjects
Adult, Male, 610 Medicine & health, 360 Social problems & social services, Risk Factors, Humans, 2736 Pharmacology (medical), 2715 Gastroenterology, Pharmacology (medical), Aged, Retrospective Studies, Hepatology, Graft Survival, 360 Soziale Probleme, Sozialdienste, Gastroenterology, Middle Aged, Liver Transplantation, Treatment Outcome, 10219 Clinic for Gastroenterology and Hepatology, 10036 Medical Clinic, 10032 Clinic for Oncology and Hematology, 10209 Clinic for Cardiology, 2721 Hepatology, Hydroxymethylglutaryl-CoA Reductase Inhibitors, 10178 Clinic for Pneumology, 610 Medizin und Gesundheit
Abstract

BACKGROUND There is limited information on the effects of statins on the outcomes of liver transplantation (LT), regarding either their use by LT recipients or donors. AIM To analyse the association between statin exposure and recipient and graft survival. METHODS We included adult LT recipients with deceased donors in a nationwide prospective database study. Using a multistate modelling approach, we examined the effect of statins on the transition hazard between LT, biliary and vascular complications and death, allowing for recurring events. The observation time was 3 years. RESULTS We included 998 (696 male, 70%, mean age 54.46 ± 11.14 years) LT recipients. 14% of donors and 19% of recipients were exposed to statins during the study period. During follow-up, 141 patients died; there were 40 re-LT and 363 complications, with 66 patients having two or more complications. Treatment with statins in the recipient was modelled as a concurrent covariate and associated with lower mortality after LT (HR = 0.35; 95% CI 0.12-0.98; p = 0.047), as well as a significant reduction of re-LT (p = 0.004). However, it was not associated with lower incidence of complications (HR = 1.25; 95% CI = 0.85-1.83; p = 0.266). Moreover, in patients developing complications, statin use was significantly associated with decreased mortality (HR = 0.10; 95% CI = 0.01-0.81; p = 0.030), and reduced recurrence of complications (HR = 0.43; 95% CI = 0.20-0.93; p = 0.032). CONCLUSIONS Statin use by LT recipients may confer a survival advantage. Statin administration should be encouraged in LT recipients when clinically indicated.

Published
2022

21. A multi-society Delphi consensus statement on new fatty liver disease nomenclature

Author

Rinella, Mary E, Lazarus, Jeffrey V, Ratziu, Vlad, Francque, Sven M, Sanyal, Arun J, Kanwal, Fasiha, Romero, Diana, Abdelmalek, Manal F, Anstee, Quentin M, Arab, Juan Pablo, Arrese, Marco, Bataller, Ramon, Beuers, Ulrich, Boursier, Jerome, Bugianesi, Elisabetta, Byrne, Christopher, Castro Narro, Graciela E, Chowdhury, Abhijit, Cortez-Pinto, Helena, Cryer, Donna, Cusi, Kenneth, El-Kassas, Mohamed, Klein, Samuel, Eskridge, Wayne, Fan, Jiangao, Gawrieh, Samer, Guy, Cynthia D, Harrison, Stephen A, Kim, Seung Up, Koot, Bart, Korenjak, Marko, Kowdley, Kris, Lacaille, Florence, Loomba, Rohit, Mitchell-Thain, Robert, Morgan, Timothy R, Powell, Elisabeth, Roden, Michael, Romero-Gómez, Manuel, Silva, Marcelo, Singh, Shivaram Prasad, Sookoian, Silvia C, Spearman, C Wendy, Tiniakos, Dina, Valenti, Luca, Vos, Miriam B, Wong, Vincent Wai-Sun, Xanthakos, Stavra, Yilmaz, Yusuf, Younossi, Zobair, Hobbs, Ansley, Villota-Rivas, Marcela, Newsome, Philip NVeeral Ajmeral, William Alazawi, Maryam Alkhatry, Naim Alkhouri, Alina Allen, Michael Allison, Khalid Alswat, Mario R Alvares-da-Silva, Michele Alves-Bezerra, Matthew J Armstrong, Diego Arufe, Pablo Aschner, Gyorgy Baffy, Meena Bansal, Pierre Bedossa, Renata Belfort, Thomas Berg, Annalisa Berzigotti, Michael Betel, Cristiana Bianco, Clifford Brass, Carol L Brosgart, Elizabeth Matthews Brunt, Maria Buti, Steve Caldwell, Rotonya Carr, Teresa Casanovas, Laurent Castera, Cyrielle Caussy, Eira Cerda, Naga Chalasani, Wah Kheong Chan, Phunchai Charatcharoenwitthaya, Michael Charlton, Amanda Cheung, Daniela Chiodi, Ray Chung, David Cohen, Kathleen Corey, Helma P Cotrim, Javier Crespo, Anuradha Dassanayake, Nicholas Davidson, Robert De Knegt, Victor De Ledinghen, Münevver Demir, Sebastian Diaz, Anna Mae Diehl, Bruce Dimmig, Melisa Dirchwolf, Ajay Duseja, Karel Dvorak, Mattias Ekstedt, Reda El Wakil, María Lucía Ferraz, Scott Friedman, Michael Fuchs, Amalia Gastaldelli, Anja Geerts, Andreas Geier, Marcos Girala, George Goh, Nicolas Goossens, Isabel Graupera, Hannes Hagström, Zachary Henry, Bela Hunyady, Alan Hutchison, Scott Isaacs, François Jornayvaz, Cynthia Kemp, Denise Kile, Won Kim, David Kleiner, Rohit Kohli, Marcelo Kugelmas, Joel Lavine, Mariana Lazo, Nathalie Leite, Adelina Lozano, Panu Luukkonen, Paula Macedo, Dina Mansour, Christos Mantzoros, Giulio Marchesini, Sebastián Marciano, Kim Martinez, Lyudmila Vladimirova Mateva, Jose M Mato, Alexis McCary, Luca Miele, Ivana Mikolasevic, Veronica Miller, Rosalba Moreno, Cynthia Moylan, Atsushi Nakajima, Jean Charles Nault, Suzanne Norris, Mazen Noureddin, C P Oliveira, Arlin Ong, Martín Padilla, Raluca Pais, Arturo Panduro, Manas K Panigrahi, George Papatheodoridis, Serena Pelusi, Marlene Pérez, Juanita Perez Escobar, Gianluca Perseghin, Mario Pessoa, Salvatore Petta, Massimo Pinzani, Monica Platon Lupsor, Atoosa Rabiee, Stefano Romeo, Yaron Rotman, Ian Rowe, Riina Salupere, Sanjaya Satapathy, Jörn M Schattenberg, Wendy Schaufert, Bernd Schnabl, Lynn Seim, Lawrence Serfaty, David Shapiro, Ashwani K Singal, Lubomir Skladany, Norbert Stefan, Jonathan Stine, Shikha Sundaram, Gianluca Svegliati-Baroni, Gyonzgi Szabo, Frank Tacke, Tawesak Tanwandee, Giovanni Targher, Norah Terrault, Brent Tetri, Maja Thiele, Baron Tisthammer, Aldo Torre Delgadillo, Michael Trauner, Emmanuel Tsochatzis, Laurens Van Kleef, Saskia Van Mil, Lisa VanWagner, Jose Antonio Velarde Ruiz Velasco, Mette Vesterhus, Eduardo Vilar-Gomez, Kymberly Watt, Julia Wattacheril, Fonda Wilkins, José Willemse, Amany Zekry, Shira Zelber-Sagi, Mary E, R, Jeffrey V, L, Vlad, R, Sven M, F, Arun J, S, Fasiha, K, Diana, R, Manal F, A, Quentin M, A, Juan Pablo, A, Marco, A, Ramon, B, Ulrich, B, Jerome, B, Elisabetta, B, Christopher, B, Graciela E, C, Abhijit, C, Helena, C, Donna, C, Kenneth, C, Mohamed, E, Samuel, K, Wayne, E, Jiangao, F, Samer, G, Cynthia D, G, Stephen A, H, Seung Up, K, Bart, K, Marko, K, Kris, K, Florence, L, Rohit, L, Robert, M, Timothy R, M, Elisabeth, P, Michael, R, Manuel, R, Marcelo, S, Shivaram Prasad, S, Silvia C, S, C Wendy, S, Dina, T, Luca, V, Miriam B, V, Vincent, W, Stavra, X, Yusuf, Y, Zobair, Y, Ansley, H, Marcela, V, Newsome, NVeeral Ajmeral, P, Alazawi, W, Alkhatry, M, Alkhouri, N, Allen, A, Allison, M, Alswat, K, R Alvares-da-Silva, M, Alves-Bezerra, M, J Armstrong, M, Arufe, D, Aschner, P, Baffy, G, Bansal, M, Bedossa, P, Belfort, R, Berg, T, Berzigotti, A, Betel, M, Bianco, C, Brass, C, L Brosgart, C, Matthews Brunt, E, Buti, M, Caldwell, S, Carr, R, Casanovas, T, Castera, L, Caussy, C, Cerda, E, Chalasani, N, Kheong Chan, W, Charatcharoenwitthaya, P, Charlton, M, Cheung, A, Chiodi, D, Chung, R, Cohen, D, Corey, K, P Cotrim, H, Crespo, J, Dassanayake, A, Davidson, N, De Knegt, R, De Ledinghen, V, Demir, M, Diaz, S, Mae Diehl, A, Dimmig, B, Dirchwolf, M, Duseja, A, Dvorak, K, Ekstedt, M, El Wakil, R, Lucía Ferraz, M, Friedman, S, Fuchs, M, Gastaldelli, A, Geerts, A, Geier, A, Girala, M, Goh, G, Goossens, N, Graupera, I, Hagström, H, Henry, Z, Hunyady, B, Hutchison, A, Isaacs, S, Jornayvaz, F, Kemp, C, Kile, D, Kim, W, Kleiner, D, Kohli, R, Kugelmas, M, Lavine, J, Lazo, M, Leite, N, Lozano, A, Luukkonen, P, Macedo, P, Mansour, D, Mantzoros, C, Marchesini, G, Marciano, S, Martinez, K, Vladimirova Mateva, L, M Mato, J, Mccary, A, Miele, L, Mikolasevic, I, Miller, V, Moreno, R, Moylan, C, Nakajima, A, Charles Nault, J, Norris, S, Noureddin, M, P Oliveira, C, Ong, A, Padilla, M, Pais, R, Panduro, A, K Panigrahi, M, Papatheodoridis, G, Pelusi, S, Pérez, M, Perez Escobar, J, Perseghin, G, Pessoa, M, Petta, S, Pinzani, M, Platon Lupsor, M, Rabiee, A, Romeo, S, Rotman, Y, Rowe, I, Salupere, R, Satapathy, S, M Schattenberg, J, Schaufert, W, Schnabl, B, Seim, L, Serfaty, L, Shapiro, D, K Singal, A, Skladany, L, Stefan, N, Stine, J, Sundaram, S, Svegliati-Baroni, G, Szabo, G, Tacke, F, Tanwandee, T, Targher, G, Terrault, N, Tetri, B, Thiele, M, Tisthammer, B, Torre Delgadillo, A, Trauner, M, Tsochatzis, E, Van Kleef, L, Van Mil, S, Vanwagner, L, Antonio Velarde Ruiz Velasco, J, Vesterhus, M, Vilar-Gomez, E, Watt, K, Wattacheril, J, Wilkins, F, Willemse, J, Zekry, A, Zelber-Sagi, S, and Vincent Wai-Sun, W

Subjects
steatotic liver disease, MASLD, alcohol, steatohepatiti, MetALD, NASH, nonalcoholic, Delphi, Fatty liver disease, NAFLD, cardiometabolic, nomenclature, mafld, type 2 diabetes, MED/13 - ENDOCRINOLOGIA
Abstract

Unlabelled: The principal limitations of the terms nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are the reliance on exclusionary confounder terms and the use of potentially stigmatising language. This study set out to determine if content experts and patient advocates were in favour of a change in nomenclature and/or definition. Methods: A modified Delphi process was led by three large pan-national liver associations. Consensus was defined a priori as a supermajority (67%) vote. An independent committee of experts external to the nomenclature process made the final recommendation on the acronym and its diagnostic criteria. Results: A total of 236 panellists from 56 countries participated in four online surveys and two hybrid meetings. Response rates across the 4 survey rounds were 87%, 83%, 83% and 78%, respectively. 74% of respondents felt that the current nomenclature was sufficiently flawed to consider a name change. The terms 'non-alcoholic' and 'fatty' were felt to be stigmatising by 61% and 66% of respondents, respectively. Steatotic liver disease (SLD) was chosen as an overarching term to encompass the various aetiologies of steatosis. The term steatohepatitis was felt to be an important pathophysiological concept that should be retained. The name chosen to replace NAFLD was metabolic dysfunction-associated steatotic liver disease (MASLD). There was consensus to change the definition to include the presence of at least one of five cardiometabolic risk factors. Those with no metabolic parameters and no known cause were deemed to have cryptogenic SLD. A new category, outside pure MASLD, termed MetALD was selected to describe those with MASLD who consume greater amounts of alcohol per week (140 to 350g/week and 210 to 420g/week for females and males respectively). Conclusions: The new nomenclature and diagnostic criteria are widely supported, non-stigmatising and can improve awareness and patient identification.

Published
2023

22. Evaluación de fibrosis en pacientes con enfermedad por hígado graso no alcohólico: adherencia a los algoritmos propuestos y barreras para cumplir con ellos

Author

Maria C Torres, Claudia D'Amico, B. García, Sebastián Marciano, Alfredo Martínez, Melisa Dirchwolf, Ezequiel Mauro, M.N. Anselmo, Natalia Ratusnu, Adrián Narvaez, Sanjeev Arora, E. Sirotinsky, E. Hurtado, C. Bellizzi, M.A. Peche, J. Allevato, C. García Dans, Adrián Gadano, Luis Gaite, B. Ríos, Florencia Pollarsky, and Leila Haddad

Subjects
Gynecology, medicine.medical_specialty, Steatosis, business.industry, Gastroenterology, NASH, RC799-869, Diseases of the digestive system. Gastroenterology, medicine.disease, Noninvasive, Fibrosis, 03 medical and health sciences, 0302 clinical medicine, 030228 respiratory system, NAFLD, Nonalcoholic fatty liver disease, medicine, In patient, 030212 general & internal medicine, business, ECHO
Abstract

Resumen: Introducción y objetivos: La estadificación de la fibrosis en pacientes con enfermedad por hígado graso no alcohólico (EHGNA) se realiza aplicando distintos algoritmos. Sin embargo, hay pocos reportes de cómo se utilizan en la vida real. Nuestro objetivo fue estimar la proporción de pacientes con EHGNA que teniendo riesgo indeterminado o alto de fibrosis según scores no-invasivos se someten a estudios adicionales de estadificación. Materiales y métodos: Estudio de corte transversal multicéntrico de pacientes con EHGNA evaluados por hepatólogos del 1 de junio del 2018 al 31 de julio del 2018. Se calcularon FIB-4 y NAFLD fibrosis score en todos los pacientes y se consideró que, si al menos uno de los scores sugería riesgo indeterminado o alto de fibrosis, el paciente debería haberse sometido a estudios adicionales de estadificación. Resultados: Se incluyeron 238 pacientes. La mediana de tiempo entre el diagnóstico de EHGNA y la inclusión en el estudio fue de 12.2 (IQR 3.0-36.5) meses. En total, 128 (54%) pacientes tuvieron al menos una evaluación con score no-invasivo que sugería riesgo indeterminado o alto de fibrosis. Sin embargo, solamente 72 (56%) se realizaron estudios para confirmar el grado de fibrosis (elastografía, biopsia, etc.). Las principales barreras encontradas por los médicos para aplicar los algoritmos de estadificación fueron relacionadas a cobertura de salud y a costos. Conclusiones: Un alto porcentaje de pacientes con EHGNA tiene riesgo indeterminado o alto de fibrosis, de acuerdo con los resultados obtenidos con scores no invasivos. Sin embargo, solamente la mitad se realizó estudios adicionales, evidenciando una baja adherencia a las recomendaciones actuales. Abstract: Introduction and aims: Fibrosis staging in patients with nonalcoholic fatty liver disease (NAFLD) is carried out through the application of stepwise algorithms but there is little real-world data on their use. Our aim was to calculate the number of patients with NAFLD and indeterminate or high risk for fibrosis, assessed through noninvasive scores, that consequently underwent further staging evaluation. Materials and methods: A cross-sectional multicenter cohort study was conducted on patients with NAFLD evaluated by hepatologists within the time frame of June 1 and July 31, 2018. The FIB-4 and NAFLD fibrosis scores were calculated in all the patients, and if at least one of the scores suggested indeterminate or high risk for fibrosis, we believed the patient should have undergone additional fibrosis staging assessment. Results: The study included 238 patients. The median time interval from NAFLD diagnosis and inclusion in the analysis was 12.2 months (IQR 3.0-36.5). A total of 128 (54%) patients had at least one noninvasive score that suggested indeterminate or high risk for fibrosis but studies to confirm the fibrosis grade (elastography, biopsy, etc.) were performed on only 72 (56%). The main barriers encountered by the physicians for applying the staging algorithms were related to health insurance coverage and imaging study costs. Conclusions: A high percentage of patients with NAFLD were at indeterminate or high risk for fibrosis, according to noninvasive scores, but additional studies were carried out on only half of them, showing low adherence to current recommendations.

Published
2022

25. The Latin American Association for the Study of the Liver (ALEH) position statement on the redefinition of fatty liver disease

Author

Juan Pablo Arab, Javier Diaz-Ferrer, Marcos Girala, Marcelo Silva, Eduardo Fassio, Juan Carlos Restrepo, Melisa Dirchwolf, Martín Padilla-Machaca, Marlen Ivón Castellanos Fernández, Mario G. Pessoa, Claudia P. Oliveira, Aldo Torre, Ezequiel Ridruejo, Lucy Dagher, Helma Pinchemel-Cotrim, Misael Uribe, Marco Arrese, Manuel Gatica, Norberto C. Chávez-Tapia, Adrián Gadano, Nahum Méndez-Sánchez, and Blanca Olaechea

Subjects
Nosology, medicine.medical_specialty, Consensus, Latin Americans, MEDLINE, Disease, 03 medical and health sciences, 0302 clinical medicine, Non-alcoholic Fatty Liver Disease, Risk Factors, Terminology as Topic, Internal medicine, Prevalence, medicine, Humans, Health policy, Hepatology, business.industry, Public health, Fatty liver, Gastroenterology, medicine.disease, Latin America, 030220 oncology & carcinogenesis, Family medicine, 030211 gastroenterology & hepatology, business
Abstract

The Latin American Association for the Study of the Liver (Asociación Latinoamericana para el Estudio del Hígado; ALEH) represents liver professionals in Latin America with the mission of promoting liver health and quality patient care by advancing the science and practice of hepatology and contributing to the development of a regional health policy framework. Fatty liver disease associated with metabolic dysfunction is of specific concern in the ALEH region, where its prevalence is one of the highest globally, second only to the Middle East. A recent consensus from an international panel recommended a new definition of fatty liver disease associated with metabolic dysfunction, including a shift in name from non-alcoholic fatty liver disease (NAFLD) to metabolic-associated fatty liver disease (MAFLD), and adoption of a set of positive criteria to diagnose the disease, independent of alcohol intake or other liver diseases. Given, the importance of this proposal, ALEH invited leading members of regional nations to come to a consensus on it from a local perspective. We reached a consensus to endorse the proposal that the disease should be renamed as MAFLD and that the disease should be diagnosed by the proposed simple and easily applicable criteria. We expect that this change in nosology will result in improvements in disease awareness and in advances in scientific, economic, public health, political, and regulatory aspects of the disease.

Published
2021

26. Outbreak of hepatitis A in a post-vaccination era: High rate of co-infection with sexually transmitted diseases

Author

Diego Arufe, Maria Del Valle Aubone, L. Gaite, Angel Oyervide, Martín Barrabino, Sebastián Marciano, Laura Garrido, Leila Haddad, Manuel Mendizabal, Ana Alicia Martinez, Adrián Gadano, Lucia de Labra, Natalia Ratusnu, Margarita Anders, Andrés Ruf, Lucrecia Rovey, Hugo Fainboim, Damián Conte, Hugo Tanno, and Melisa Dirchwolf

Subjects
Adult, Male, Sexually transmitted disease, Pediatrics, medicine.medical_specialty, Argentina, Sexually Transmitted Diseases, Specialties of internal medicine, Disease Outbreaks, Men who have sex with men, Young Adult, 03 medical and health sciences, 0302 clinical medicine, Risk Factors, Epidemiology, medicine, Humans, Homosexuality, Male, Young adult, Men who have sex with Men, Hepatitis A Vaccines, Hepatology, Coinfection, Transmission (medicine), business.industry, Incidence (epidemiology), Hepatitis A, Outbreak, General Medicine, Middle Aged, medicine.disease, Cross-Sectional Studies, RC581-951, 030220 oncology & carcinogenesis, Female, 030211 gastroenterology & hepatology, Syphilis, business
Abstract

Introduction and objectives After hepatitis A (HAV) mandatory immunization in 2005 in Argentina, the incidence of HAV declined drastically. However, several new autochthonous cases of HAV have been reported since 2017. We aimed to evaluate the clinical and epidemiological characteristics and possible transmission routes of affected patients. Patients or Materials and methods We performed a cross-sectional study of patients residing in Argentina with acute hepatitis A between 30.06.2017 and 31.12.2018. Results 66 cases of HAV were registered. Fifty-six patients (86%) were males, with a mean age of 34 ± 12 years old. The most likely routes of transmission were sexual intercourse of men with men, reported by 31 patients. Additionally, 23% and 26% of patients tested positive for HIV and syphilis, respectively. In total, 35% of patients required hospitalization. When assessing outcomes, 79% had a mild presentation and 21% had a severe/fulminant presentation: one patient underwent liver transplantation, and one patient died. Conclusions Our study describes that during the study period, HAV infection affected predominantly young adults, particularly men who have sex with men. An elevated proportion of them was diagnosed with a concomitant sexually transmitted disease, and several patients had a severe presentation of the disease.

Published
2020

27. Global multi-stakeholder endorsement of the MAFLD definition

Author

Nahum Méndez-Sánchez, Elisabetta Bugianesi, Robert G Gish, Frank Lammert, Herbert Tilg, Mindie H Nguyen, Shiv K Sarin, Núria Fabrellas, Shira Zelber-Sagi, Jian-Gao Fan, Gamal Shiha, Giovanni Targher, Ming-Hua Zheng, Wah-Kheong Chan, Shlomo Vinker, Takumi Kawaguchi, Laurent Castera, Yusuf Yilmaz, Marko Korenjak, C Wendy Spearman, Mehmet Ungan, Melissa Palmer, Mortada El-Shabrawi, Hans-Juergen Gruss, Jean-François Dufour, Anil Dhawan, Heiner Wedemeyer, Jacob George, Luca Valenti, Yasser Fouad, Manuel Romero‐Gomez, Mohammed Eslam, Maria Lorena Abate, Bahaa Abbas, Ahmed Amr Abbassy, Waleed Abd El Ghany, Amira Abd Elkhalek, Emad Abd ElMajeed, Mohammad Abdalgaber, Mohamed AbdAllah, Marwa Abdallah, Nourhan Abdallah, Shereen Abdelaleem, Yasser Abdelghani, Wael Abdelghany, Safaa Mohamed Abdelhalim, Wafaa Abdelhamid, Nehal Abdelhamid, Nadia A. Abdelkader, Elsayed Abdelkreem, Aly Mohamed Abdelmohsen, Awny Ali Abdelrahman, Sherief M Abd-elsalam, Doaa Abdeltawab, Abdulbaset Abduh, Nada Abdulhakam, Maheeba Abdulla, Navid Abedpoor, Ludovico Abenavoli, Fredrik Åberg, Omala Ablack, Mostafa Abo elftouh, Yousry Esam-Eldin Abo-Amer, Ashraf Aboubkr, Alaa Aboud, Amr M. Abouelnaga, Galal A. Aboufarrag, Ashraf Aboutaleb, Leticia Abundis, Gupse Adalı, Enrique Adames, Leon Adams, Danjuma Adda, Noor Adel, Nada Adel, Muhammad Adel Sayed, Taiba Jibril Afaa, Nawal Afredj, Gulnara Aghayeva, Alessio Aghemo, Carlos A. Aguilar-Salinas, Golo Ahlenstiel, Walid Ahmady, Wafaa Ahmed, Amira Ahmed, Samah Nasser Ahmed, Heba Mostafa Ahmed, Rasha Ahmed, Elmar Aigner, Mesut Akarsu, Maisam Akroush, Umit Akyuz, Mamun Al Mahtab, Tahani Al Qadiri, Yusriya Al Rawahi, Razzaq AL rubaee, Muna Al Saffar, Shahinul Alam, Zaid Al-Ani, Agustín Albillos, Mohamed Alboraie, Said Al-Busafi, Mohamed Al-Emam, Jawaher Alharthi, Kareem Ali, Basma Abdelmoez Ali, Mohammad Ali, Raja Affendi Raja Ali, Anna Alisi, Ali Raad AL-Khafaji, Maryam Alkhatry, Rocio Aller, Yahya Almansoury, Khalid Al-Naamani, Alaa Alnakeeb, Anna Alonso, Saleh A. Alqahtani, Leina Alrabadi, Khalid Alswat, Mahir Altaher, Turki Altamimi, Jose Altamirano, Mario R. Alvares-da-Silva, Elsragy Adel M. Aly, Amgad Alzahaby, Ahmed Alzamzamy, Keisuke Amano, Maysa A. Amer, Mona A. Amin, Sayed A. Amin, Ashraf A. Amir, Javier Ampuero, Noha Anas, Pietro Andreone, Soa Fy Andriamandimby, Mahmoud Anees, Peltec Angela, Manal Antonios, Wael Arafat, Jose Moreno Araya, Juan Armendariz-Borunda, Matthew J. Armstrong, Hassan Ashktorab, Patricia Aspichueta, Fathia Assal, Mira Atef, Dina Attia, Hoda Atwa, Reham Awad, Mohyeldeen Abd Elaziz Awad, Sally Awny, Obafemi Awolowo, Yaw Asante Awuku, Ibrahim Ayada, Than Than Aye, Sherif Ayman, Hedy Ayman, Hesham Ayoub, Hosny M. Azmy, Romiro P. Babaran, Omneya Badreldin, Ahmed Badry, İbrahim Halil Bahçecioğlu, Amira Bahour, Jiajia Bai, Yasemin Balaban, Muthuswamy Balasubramanyam, Khaled Bamakhrama, Jesus M Banales, Babu Bangaru, Jianfeng Bao, Jorge Suazo Barahona, Salma Barakat, Sandra Maria Barbalho, Bikwa Barbra, Beatriz Barranco, Francisco Barrera, Ulrich Baumann, Shamardan Bazeed, Eva Bech, Aourarh Benayad, Andreas Benesic, David Bernstein, Fernando Bessone, Susie Birney, Cyrille Bisseye, Martin Blake, Bilal Bobat, Leonilde Bonfrate, Dmitry S Bordin, Francisco Bosques-Padilla, Jerome Boursier, Boushab Mohamed Boushab, David Bowen, Patricia Medina Bravo, Paul N Brennan, Bisi Bright, Ilse Broekaert, Xabier Buque, Diego Burgos-Santamaría, Julio Burman, Luca Busetto, Chris D. Byrne, Patricia Anne I. Cabral-Prodigalidad, Guillermo Cabrera-Alvarez, Wei Cai, Francesca Cainelli, Ali Riza Caliskan, Ali Canbay, Ana Cano-Contreras, Hai-Xia Cao, Zhujun Cao, Andres Carrion, Francesca Carubbi, Teresa Casanovas, Marlen Ivón Castellanos Fernández, Jin Chai, Siew Pheng Chan, Phunchai Charatcharoenwitthaya, Norberto Chavez-Tapia, Kazuaki Chayama, Jinjun Chen, Lin Chen, Zhong-Wei Chen, Huiting Chen, Sui-Dan Chen, Qiang Chen, Yaxi Chen, Gang Chen, En-Quang Chen, Fei Chen, Pei-Jer Chen, Robert Cheng, Wendy Cheng, Jack Tan Wei Chieh, Imad Chokr, Evangelos Cholongitas, Ashok Choudhury, Abhijit Chowdhury, Evaristus Sunday Chukwudike, Stefano Ciardullo, Michelle Clayton, Karine Clement, Marie Michelle Cloa, Cecilia Coccia, Cristina Collazos, Massimo Colombo, Arif Mansur Cosar, Helma Pinchemel Cotrim, Joris Couillerot, Alioune Coulibaly, Gonzalo Crespo, Javier Crespo, Maria Cruells, Ian Homer Y. Cua, Hesham K. Dabbous, George N Dalekos, Patricia D'Alia, Li Dan, Viet Hang Dao, Mostafa Darwish, Christian Datz, Milagros B Davalos-Moscol, Heba Dawoud, Blanca Olaechea de Careaga, Robert de Knegt, Victor de Ledinghen, Janaka de Silva, Nabil Debzi, Marie Decraecker, Elvira Del Pozo, Teresa C Delgado, Manuel Delgado-Blanco, Łukasz Dembiński, Adilson Depina, Moutaz Derbala, Hailemichael Desalegn, Christèle Desbois-Mouthon, Mahmoud Desoky, Anouk Dev, Agostino Di Ciaula, Moisés Diago, Ibrahima Diallo, Luis Antonio Díaz, Melisa Dirchwolf, Paola Dongiovanni, Andrriy Dorofeyev, Xiaoguang Dou, Mark W. Douglas, Michael Doulberis, Cecil K. Dovia, Adam Doyle, Ivana Dragojević, Joost PH Drenth, Xuefei Duan, Audrius Dulskas, Dan L Dumitrascu, Oliver Duncan, Vincent Dusabejambo, Rev. Shem N.A. Dwawhi, Sho Eiketsu, Doaa El Amrousy, Ahmed El Deeb, Ghada El Deriny, Hesham Salah El Din, Salwa El Kamshishy, Mohamed El Kassas, Maissa El Raziky, Osama A Elagamy, Wafaa Elakel, Dina Elalfy, Hanaa Elaraby, Heba ElAwady, Reda Elbadawy, Hanaa Hassan Eldash, Manal S. Eldefrawy, Carol Lezama Elecharri, Amel Elfaramawy, Mohammed Elfatih, Mahmoud Elfiky, Mohamed Elgamsy, Mohamed Elgendy, Mohamed A. El-Guindi, Nagi Elhussieny, Ahmed Maher Eliwa, Zeineb Elkabbany, Hesham El-Khayat, Nehal M. El-Koofy, Alaa Elmetwalli, Amr Elrabat, Fathiya El-Raey, Fatma Elrashdy, Medhat Elsahhar, Esraa M. Elsaid, Shimaa Elsayed, Hany Elsayed, Aly Elsayed, Amr M. Elsayed, Hamdy Elsayed, Magdy El-Serafy, Ahmed M. Elsharkawy, Reem Yehia Elsheemy, Eman Elsayed Elshemy, Sara Elsherbini, Naglaa Eltoukhy, Reda Elwakil, Ola Emad, Shaimaa Emad, Mohamed Embabi, Ilkay Ergenç, Tatiana Ermolova, Gamal Esmat, Doaa M. Esmat, Enrique Carrera Estupiñan, Said Ettair, Tcaciuc Eugen, Mohammed Ezz-Eldin, Lidia Patricia Valdivieso Falcón, Yu-Chen Fan, Samah Fandari, Mahmoud Farag, Taghreed Mohamed Farahat, Eman M. Fares, Michael Fares, Eduardo Fassio, Hayam Fathy, Dina Fathy, Wael Fathy, Soheir Fayed, Dan Feng, Gong Feng, Miguel Fernández-Bermejo, Cristina Targa Ferreira, Javier Díaz Ferrer, Alastair Forbes, Rabab Fouad, Hanan M. Fouad, Tove Frisch, Hideki Fujii, Shuhei Fukunaga, Shinya Fukunishi, Hacer Fulya, Masato Furuhashi, Yasmine Gaber, Augusto Jose G. Galang, Jacqueline Cordova Gallardo, Rocío Galloso, Mahmoud Gamal, Reham Gamal, Hadeel Gamal, Jian Gan, Anar Ganbold, Xin Gao, George Garas, Tony Garba, Miren García-Cortes, Carmelo García-Monzón, Javier García-Samaniego, Amalia Gastaldelli, Manuel Gatica, Elizabeth Gatley, Tamar Gegeshidze, Bin Geng, Hasmik Ghazinyan, Salma Ghoneem, Luca Giacomelli, Gianluigi Giannelli, Edoardo G. Giannini, Matthew Giefer, Pere Ginès, Marcos Girala, Pablo J Giraudi, George Boon-Bee Goh, Ahmed Ali Gomaa, Benbingdi Gong, Dina Hilda C. Gonzales, Humberto C. Gonzalez, Maria Saraí Gonzalez-Huezo, Isabel Graupera, Ivica Grgurevic, Henning Grønbæk, Xuelian Gu, Lin Guan, Ibrahima Gueye, Alice Nanelin Guingané, Ozen Oz Gul, Cuma Bulent Gul, Qing Guo, Pramendra Prasad Gupta, Ahmet Gurakar, Juan Carlos Restrepo Gutierrez, Ghada Habib, Azaa Hafez, Emilia Hagman, Eman Halawa, Osama Hamdy, Abd Elkhalek Hamed, Dina H. Hamed, Saeed Hamid, Waseem Hamoudi, Yu Han, James Haridy, Hanan Haridy, David C H Harris Harris, Michael Hart, Fuad Hasan, Almoutaz Hashim, Israa Hassan, Ayman Hassan, Essam Ali Hassan, Adel Ahmed Hassan, Magda Shehata Hassan, Fetouh Hassanin, Alshymaa Hassnine, John Willy Haukeland, Amr Ismael M. Hawal, Jinfan He, Qiong He, Yong He, Fang-Ping He, Mona Hegazy, Adham Hegazy, Osama Henegil, Nelia Hernández, Manuel Hernández-Guerra, Fatima Higuera-de-la-Tijera, Ibrahim Hindy, Keisuke Hirota, Lee Chi Ho, Alexander Hodge, Mohamed Hosny, Xin Hou, Jiao-Feng Huang, Yan Huang, Zhifeng Huang, Yuan Huang, Ang Huang, Xiao-Ping Huang, Sheng Hui-ping, Bela Hunyady, Mennatallah A. Hussein, Osama Hussein, Shahinaz Mahmoud Hussien, Luis Ibáñez-Samaniego, Jamal Ibdah, Luqman Ibrahim, Miada Ibrahim, Ibrahim Ibrahim, Maria E. Icaza-Chávez, Sahar Idelbi, Ramazan Idilman Idilman, Mayumi Ikeda, Giuseppe Indolfi, Federica Invernizzi, Iram Irshad, Hasan Mohamed Ali Isa, Natacha Jreige Iskandar, Abdulrahman Ismaiel, Mariam Ismail, Zulkifli Ismail, Faisal Ismail, Hideki Iwamoto, Kathryn Jack, Rachael Jacob, Fuad Jafarov, Wasim Jafri, Helen Jahshan, Prasun K Jalal, Ligita Jancoriene, Martin Janicko, Hiruni Jayasena, Meryem Jefferies, Vivekanand Jha, Fanpu Ji, Yaqiu Ji, Jidong Jia, Changtao Jiang, Ni Jiang, Zong-zhe Jiang, Xing Jin, Yi Jin, Xu Jing, Qian Jingyu, Maia Jinjolava, FX Himawan Haryanto Jong, Alina Jucov, Ibecheole Julius, Mona Kaddah, Yoshihiro Kamada, Abobakr kamal, Enas Mohamed Kamal, Ashraf Sayed Kamel, Jia-Horng Kao, Maja Karin, Thomas Karlas, Mohammad Kashwaa, Leolin Katsidzira, Eda Kaya, M.Azzam Kayasseh, Bernadette Keenan, Caglayan Keklikkiran, William Keml, Deia K. Khalaf, Rofida Khalefa, Sherin Khamis, Doaa Khater, Hamed khattab, Anatoly Khavkin, Olga Khlynova, Nabil Khmis, Nazarii Kobyliak, Apostolos Koffas, Kazuhiko Koike, Kenneth Y.Y. Kok, Tomas Koller, Narcisse Patrice Komas, Nataliya V. Korochanskaya, Yannoula Koulla, Shunji Koya, Colleen Kraft, Bledar Kraja, Marcin Krawczyk, Mohammad Shafi Kuchay, Anand V Kulkarni, Ashish Kumar, Manoj Kumar, Sulaiman Lakoh, Philip Lam, Ling Lan, Naomi F. Lange, Kamran Bagheri Lankarani, Nicolas Lanthier, Kateryna Lapshyna, Sameh A. Lashen, Konang Nguieguia Justine Laure, Leonid Lazebnik, Didier Lebrec, Samuel S. Lee, Way Seah Lee, Yeong Yeh Lee, Diana Julie Leeming, Nathalie Carvalho Leite, Roberto Leon, Cosmas Rinaldi Adithya Lesmana, Junfeng Li, Qiong Li, Jun Li, Yang-Yang Li, Yufang Li, Lei Li, Min Li, Yiling li, Huiqing Liang, Tang Lijuan, Seng Gee Lim, Lee-Ling Lim, Shumei Lin, Han-Chieh Lin, Rita Lin, Rania Lithy, Yaru Liu, Yuanyuan Liu, Xin Liu, Wen-Yue Liu, Shourong Liu, Ken Liu, Tian Liu, Amedeo Lonardo, Mariana Bravo López, Eva López-Benages, Patricio Lopez-Jaramillo, Huimin Lu, Lun Gen Lu, Yan Lu, John Lubel, Rashid Lui, Iulianna Lupasco, Elena Luzina, Xiao-Hui Lv, Kate Lynch, Hong-Lei Ma, Mariana Verdelho Machado, Nonso Maduka, Katerina Madzharova, Russellini Magdaong, Sanjiv Mahadeva, Amel Mahfouz, Nik Ritza Kosai Nik Mahmood, Eman Mahmoud, Mohamed Mahrous, Rakhi Maiwall, Ammar Majeed, Avik Majumdar, Loey Mak, Madiha M Maklouf, Reza Malekzadeh, Claudia Mandato, Alessandra Mangia, Jake Mann, Hala Hussien Mansour, Abdellah Mansouri, Alessandro Mantovani, Jun qian Mao, Flor Maramag, Giulio Marchesini, Claude Marcus, Rui António Rocha Tato Marinho, Maria L Martinez-Chantar, Antonieta A. Soares Martins, Rana Marwan, Karen Frances Mason, Ghadeer Masoud, Mohamed Naguib Massoud, Maria Amalia Matamoros, Rosa Martín Mateos, Asmaa Mawed, Jean Claude Mbanya, Charles Mbendi, Lone McColaugh, Duncan McLeod, Juan Francisco Rivera Medina, Ahmed Megahed, Mai Mehrez, Iqbal Memon, Shahin Merat, Randy Mercado, Ahmed Mesbah, Taoufik Meskini, Mayada Metwally, Rasha Metwaly, Lei Miao, Eileen Micah, Luca Miele, Vladimir Milivojevic, Tamara Milovanovic, Yvonne L. Mina, Milan Mishkovik, Amal Mishriki, Tim Mitchell, Alshaimaa Mohamed, Mona Mohamed, Sofain Mohamed, Shady Mohammed, Ahmed Mohammed, Viswanathan Mohan, Sara Mohie, Aalaa Mokhtar, Reham Moniem, Mabel Segura Montilla, Jose Antonio Orozco Morales, María María Sánchez Morata, Jose Maria Moreno-Planas, Silvia Morise, Sherif Mosaad, Mohamed Moselhy, Alaa Mohamed Mostafa, Ebraheem Mostafa, Nezha Mouane, Nasser Mousa, Hamdy Mahfouz Moustafa, Abeer Msherif, Kate Muller, Christopher Munoz, Ana Beatriz Muñoz-Urribarri, Omar Alfaro Murillo, Feisul Idzwan Mustapha, Emir Muzurović, Yehia Nabil, Shaymaa Nafady, Ayu Nagamatsu, Atsushi Nakajima, Dan Nakano, Yuemin Nan, Fabio Nascimbeni, Mirella S. Naseef, Nagwa Nashat, Taran Natalia, Francesco Negro, Alexander V. 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Peltekian, Xuebin Peng, Liang Peng, Ying Peng, Rahul Pengoria, Martina Perez, José Luis Pérez, Norma Marlene Pérez, Marcello Persico, Mário Guimarães Pessoa, Salvatore Petta, Mathew Philip, Maria Corina Plaz Torres, Naveen Polavarapu, Jaime Poniachik, Piero Portincasa, Chunwen Pu, Tuğrul Pürnak, Edhie Purwanto, Xiaolong Qi, Xingshun Qi, Zibing Qian, Zhao Qiang, Zengpei Qiao, Liang Qiao, Alberto Queiroz, Atoosa Rabiee, Manal Radwan, Alain Marcel Rahetilahy, Yasmin Ramadan, Dina Ramadan, Anis Safura Ramli, Grant A. Ramm, Ao Ran, Ivan Rankovic, Huiying RAO, Sara Raouf, Sayantan Ray, Nancy Reau, Ahmed Refaat, Thomas Reiberger, Jose M Remes-Troche, Eira Cerda Reyes, Ben Richardson, Ezequiel Ridruejo, Sergio Riestra Jimenez, Ibrahim Rizk, Stuart Roberts, Juan Pablo Roblero, Jorge Alberto Prado Robles, Don Rockey, Manuel Rodríguez, Heriberto Rodríguez Hernández, Eva Román, Fernando Gomes Romeiro, Stefano Romeo, Jose Miguel Rosales-Zabal, Georgina R. 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Xu, A, Xu, C, Yan, H, Yang, J, Yang, R, Yang, Y, Yang, Q, Yang, N, Yao, J, Yara, J, Yaras, S, Yilmaz, N, Younes, R, Younes, H, Young, S, Youssef, F, Yu, Y, Yu, M, Yuan, J, Yue, Z, Yuen, M, Yun, W, Yurukova, N, Zakaria, S, Zaky, S, Zaldastanishvili, M, Zapata, R, Zare, N, Zerem, E, Zeriban, N, Zeshuai, X, Zhang, H, Zhang, X, Zhang, Y, Zhang, W, Zhang, Z, Zhao, J, Zhao, R, Zhao, H, Zheng, C, Zheng, Y, Zheng, R, Zheng, T, Zheng, K, Zhou, X, Zhou, Y, Zhou, H, Zhou, L, Zhu, L, Zhu, Y, Zhu, P, Ziada, E, Ziring, D, Ziyi, L, Zou, S, Zou, Z, Zou, H, Zuart Ruiz, R, and Global Multi-Stakeholder Consensus on the Redefinition of Fatty Liver Disease

Subjects
Renal disorders Radboud Institute for Molecular Life Sciences [Radboudumc 11], Hepatology, Non-alcoholic Fatty Liver Disease, NAFLD, consensu, Gastroenterology, MAFLD, definition, Humans, MAFLD, NAFLD, Human medicine
Abstract

Contains fulltext : 252162.pdf (Publisher’s version ) (Closed access)

Published
2022

28. The establishment of public health policies and the burden of non-alcoholic fatty liver disease in the Americas

Author

Luis Antonio Díaz, Eduardo Fuentes-López, Gustavo Ayares, Francisco Idalsoaga, Jorge Arnold, Andrea Márquez-Lomas, Carolina A Ramírez, María Paz Medel, Francisca Viñuela, Lucas Lacalle, Juan Pablo Roblero, Catterina Ferreccio, Mariana Lazo, Mayur Brahmania, Ashwani K Singal, Melisa Dirchwolf, Nahum Méndez-Sánchez, Norberto Chavez-Tapia, Patricia Guerra, Juan Carlos Restrepo, Claudia P Oliveira, Julissa Lombardo, Abel Sánchez, Martín Elizondo, Martín Tagle, Martín Padilla, Marco Sánchez, Enrique Carrera, Marcos Girala, Omega Chery, Marlen Castellanos-Fernández, Francisco Barrera, Jeffrey V Lazarus, Patrick S Kamath, Ramon Bataller, Marco Arrese, and Juan Pablo Arab

Subjects
Hepatology, Non-alcoholic Fatty Liver Disease, Risk Factors, Health Policy, Gastroenterology, non-alcoholic fatty liver diseases, Humans, nutritional and metabolic diseases, Obesity, Public Health, Americas, the Americas, digestive system diseases
Abstract

Non-alcoholic fatty liver disease (NAFLD) affects 20-25% of the general population and is associated with morbidity, increased mortality, and elevated health-care costs. Most NAFLD risk factors are modifiable and, therefore, potentially amenable to being reduced by public health policies. To date, there is no information about NAFLD-related public health policies in the Americas. In this study, we analysed data from 17 American countries and found that none have established national public health policies to decrease NAFLD-related burden. There is notable heterogeneity in the existence of public health policies to prevent NAFLD-related conditions. The most common public health policies were related to diabetes (15 [88%] countries), hypertension (14 [82%] countries), cardiovascular diseases (14 [82%] countries), obesity (nine [53%] countries), and dyslipidaemia (six [35%] of countries). Only seven (41%) countries had a registry of the burden of NAFLD, and efforts to raise awareness in the Americas were scarce. The implementation of public health policies are urgently needed in the Americas to decrease the burden of NAFLD.

Published
2022

29. Argentinian clinical practice guideline for surveillance, diagnosis, staging and treatment of hepatocellular carcinoma

Author

Juan Carlos Spina, Mario Tanno, Cecilia Lagues, Ezequiel Ridruejo, Margarita Anders, Silvia Borzi, Matías Tisi Baña, Adrián Gadano, Andrés Ruf, Melisa Dirchwolf, Federico Piñero, Marcelo Silva, Guillermo Mazzolini, Nora Fernández, Eduardo Fassio, Martín Maraschio, Florencia Perazzo, Beatriz Ameigeiras, Lucas McCormack, Valeria Descalzi, Gabriel Aballay Soteras, Sebastián Marciano, Silvia Mengarelli, Virginia Reggiardo, Federico G. Villamil, and Fernando Cairo

Subjects
Oncology, Biopsy, Specialties of internal medicine, Medical Oncology, 0302 clinical medicine, Risk Factors, purl.org/becyt/ford/3.2 [https], LIVER CANCER, Ultrasonography, ARGENTINA, Evidence-Based Medicine, Liver Neoplasms, General Medicine, Hepatitis C, Treatment Outcome, RC581-951, 030220 oncology & carcinogenesis, Hepatocellular carcinoma, 030211 gastroenterology & hepatology, purl.org/becyt/ford/3 [https], Liver cancer, Algorithms, medicine.drug, Sorafenib, medicine.medical_specialty, Practice guideline, Carcinoma, Hepatocellular, Consensus, Clinical Decision-Making, Argentina, Risk Assessment, LATIN AMERICA, Ramucirumab, Decision Support Techniques, 03 medical and health sciences, Atezolizumab, Predictive Value of Tests, Internal medicine, medicine, Humans, neoplasms, Neoplasm Staging, Hepatology, business.industry, Guideline, medicine.disease, digestive system diseases, Latin America, PRACTICE GUIDELINE, Liver function, business
Abstract

The A.A.E.E.H has developed this guideline for the best care of patients with hepatocellular carcinoma (HCC) from Argentina. It was done from May 2018 to March 2020. Specific clinical research questions were systematically searched. The quality of evidence and level of recommendations were organized according to GRADE. HCC surveillance is strongly recommended with abdominal ultrasound (US) every six months in the population at risk for HCC (cirrhosis, hepatitis B or hepatitis C); it is suggested to add alpha-feto protein (AFP) levels in case of inexeperienced sonographers. Imaging diagnosis in patients at risk for HCC has high specificity and tumor biopsy is not mandatory. The Barcelona Clinic Liver Cancer algorithm is strongly recommended for HCC staging and treatment-decision processes. Liver resection is strongly recommended for patients without portal hypertension and preserved liver function. Composite models are suggested for liver transplant selection criteria. Therapies for HCC with robust clinical evidence include transarterial chemoembolization (TACE) and first to second line systemic treatment options (sorafenib, lenvatinib, regorafenib, cabozantinib and ramucirumab). Immunotherapy with nivolumab and pembrolizumab has failed to show statistical benefit but the novel combination of atezolizumab plus bevacizumab has recently shown survival benefit over sorafenib in frontline. Fil: Piñero, Federico. Universidad Austral. Hospital Universitario Austral; Argentina Fil: Tanno, Mario. Universidad Nacional de Rosario. Facultad de Ciencias Médicas. Hospital Nacional del Centenario; Argentina Fil: Aballay Soteras, Gabriel. Ministerio de Defensa. Ejército Argentino. Hospital Militar Central Cirujano Mayor "Dr. Cosme Argerich"; Argentina Fil: Tisi Baña, Matías. Universidad Austral. Hospital Universitario Austral; Argentina Fil: Dirchwolf, Melisa. Hospital Privado de Rosario; Argentina Fil: Fassio, Eduardo. Hospital Nacional Profesor Alejandro Posadas.; Argentina Fil: Ruf, Andrés. Hospital Privado de Rosario; Argentina Fil: Mengarelli, Silvia Estela. Gobierno de la Provincia de Entre Rios. Hospital San Roque.; Argentina Fil: Borzi, Silvia. Hospital Privado de Cordoba; Argentina Fil: Fernández, Nora. Hospital Británico de Buenos Aires; Argentina Fil: Ridruejo, Ezequiel. Universidad Austral. Hospital Universitario Austral; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. CEMIC-CONICET. Centro de Educaciones Médicas e Investigaciones Clínicas "Norberto Quirno". CEMIC-CONICET; Argentina Fil: Descalzi, Valeria. Fundación Favaloro; Argentina Fil: Anders, Margarita. Hospital Alemán; Argentina Fil: Mazzolini, Guillermo. Universidad Austral; Argentina Fil: Reggiardo, Virginia. Gobierno de la Ciudad Autónoma de Buenos Aires. Hospital General de Agudos Doctor Cosme Argerich; Argentina Fil: Marciano, Sebastian. Hospital Italiano. Departamento de Medicina.; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Perazzo, Florencia. Hospital Británico de Buenos Aires; Argentina Fil: Spina, Juan Carlos. Hospital Italiano; Argentina Fil: McCormack, Lucas. Hospital Alemán; Argentina Fil: Maraschio, Martín Alejandro. Hospital Privado de Cordoba; Argentina Fil: Lagues, Cecilia. Universidad Austral; Argentina Fil: Gadano, Adrián Carlos. Hospital Italiano. Departamento de Medicina.; Argentina Fil: Villamil, Federico. Hospital Italiano. Departamento de Medicina.; Argentina. Hospital Británico de Buenos Aires; Argentina Fil: Silva, Marcelo. Universidad Austral. Hospital Universitario Austral; Argentina Fil: Cairo, Fernando. Hospital Británico de Buenos Aires; Argentina Fil: Ameigeiras, Beatriz. Gobierno de la Ciudad de Buenos Aires. Hospital General de Agudos "Ramos Mejía"; Argentina

Published
2020

30. Diagnosis and treatment of non-alcoholic fatty liver disease. Argentine Association for the Study of Liver Diseases, year 2019

Author

Eduardo Fassio, Melisa Dirchwolf, and Fernando J. Barreyro

Subjects
lcsh:Immunologic diseases. Allergy, clinical guidelines, treatment, diagnosis, lcsh:R, non-alcoholic fatty liver disease, lcsh:Medicine, lcsh:RC109-216, non-alcoholic steatohepatitis, lcsh:RC581-607, lcsh:Infectious and parasitic diseases
Abstract

Nonalcoholic fatty liver disease (NAFLD) is the most frequent chronic liver disease worldwide, with an estimated global prevalence of approximately 25%, that is much higher in patients with overweight, obesity and type 2 diabetes. NAFLD is considered as the hepatic manifestation of metabolic syndrome. It has a wide spectrum, from simple steatosis to steatohepatitis, fibrosis, cirrhosis and its complications, such as hepatocellular carcinoma. Most of the affected patients will not evolve to advanced fibrosis or cirrhosis. Despite this, it has been described that the hepatic disease is the third cause of death among patients with nonalcoholic fatty liver, after cardiovascular and malignant diseases. Among the huge number of patients affected, the main challenge is to identify those who are at risk of developing cirrhosis or its complications and to recognize the diagnostic and treatment options. In this Guideline, endorsed by the Argentine Association for the Study of Liver Diseases, the definitions, epidemiological aspects, natural history and a practical approach to possible algorithms to estimate the severity of liver disease in the individual patient are reviewed; in addition to analyzing advances in treatment and proposing recommendations for follow-up. It is important to note that no data on the incidence or prevalence of the disease have been published in the general population of Argentina, and it is encouraged to carry them out.

Published
2020

31. The MELD upgrade exception: a successful strategy to optimize access to liver transplantation for patients with high waiting list mortality

Author

Melisa Dirchwolf, Chiara Becchetti, Sarah G. Gschwend, Christian Toso, Philipp Dutkowski, Franz Immer, Franziska Beyeler, Simona Rossi, Jonas Schropp, Jean-François Dufour, Vanessa Banz, Patrizia Amico, Andres Axel, John-David Aubert, Beckmann Sonja, Guido Beldi, Christian Benden, Christoph Berger, Isabelle Binet, Pierre-Yves Bochud, Sanda Branca, Heiner Bucher, Thierry Carrel, Emmanuelle Catana, Yves Chalandon, Sabina de Geest, Olivier de Rougemont, Michael Dickenmann, Joëlle L. Dreifuss, Michel Duchosal, Thomas Fehr, Sylvie Ferrari-Lacraz, Christian Garzoni, Paola G. Soccal, Christophe Gaudet, Emiliano Giostra, Déla Golshayan, Karine Hadaya, Jörg Halter, Dimitri Hauri, Dominik Heim, Christoph Hess, Sven Hillinger, Hans Hirsch, Patricia Hirt, Günther Hofbauer, Uyen Huynh-Do, Michael Koller, Bettina Laesser, Brian Lang, Roger Lehmann, Alexander Leichtle, Christian Lovis, Oriol Manuel, Hans-Peter Marti, Pierre Y. Martin, Michele Martinelli, Katell Mellac, Aurélia Merçay, Karin Mettler, Pascal Meylan, Nicolas Mueller, Antonia Müller, Thomas Müller, Ulrike Müller-Arndt, Beat Müllhaupt, Mirjam Nägeli, Manuel Pascual, Klara Posfay-Barbe, Juliane Rick, Anne Rosselet, Silvia Rothlin, Frank Ruschitzka, Urs Schanz, Stefan Schaub, Aurelia Schnyder, Macé Schuurmans, Federico Simonetta, Katharina Staufer, Susanne Stampf, Jürg Steiger, Guido Stirniman, Ueli Stürzinger, Christian Van Delden, Jean-Pierre Venetz, Jean Villard, Julien Vionnet, Madeleine Wick, Markus Wilhlem, and Patrick Yerly

Subjects
Adult, Cohort Studies, Hepatology, Waiting Lists, Gastroenterology, Humans, Severity of Illness Index, Switzerland, Liver Transplantation
Abstract

MELD exceptions are designed to equipoise liver transplant waiting list survival. We aimed to analyze the impact of the MELD Upgrade rule and all other MELD exceptions on the liver transplant waiting list outcomes during 2012-2017 in Switzerland.We conducted a nationwide cohort study including all adult patients registered on the Swiss liver transplant waiting list between 2012 and 2017. Waiting list mortality and access to transplantation were analyzed, considering MELD exceptions as time-dependent covariates.730 patients were included. Patients with MELD Upgrade exceptions had a higher risk of dying while on the waiting list (OR 2.13; CI 95% 1.30-3.47) and also an increased likelihood of receiving a liver transplantation, when compared to patients without MELD exceptions. Patients with any type of MELD exceptions were more likely to be transplanted when compared to patients without MELD exceptions. The proportion of patients with MELD exceptions increased from 2012 to 2017 (44% vs 88%). Allocation MELD at the time of transplantation showed an annual increase (23 ± 8 points vs 32 ± 5 points, p 0.001).Only patients with MELD Upgrade exceptions had the expected combination of higher waiting list mortality and quicker access to liver transplantation.

Published
2021

32. Alcohol associated hepatitis in Latin America: results from the AH-LATIN study

Author

Jorge Arnold, Luis Antonio Diaz, Francisco Idalsoaga, Gustavo Ayares, Eduardo Fuentes, Carolina Ramirez, María Paz Medel, Catterina Ferreccio, Mariana Lazo, Juan Pablo Roblero, Mayur Brahmania, Rodolfo Carbonetti, Sebastián Marciano, Manuel Mendizabal, Fernando Bessone, Gustavo Romero, Ana Palazzo, Estela Florencia Manero, Melisa Dirchwolf, Diego Piombino, María Ayala Valverde, Fernando Cairo, Maria Alejandra Gracia Villamil, Maria Mercedes Rodriguez Gazari, Patricia Gallardo, Geraldine Ramos, Patricia Guerra, Fabio Silveira, Roberta Chaves, Giovanni Silva, Cirley Lobato, Jozelda Lemos, Rogério Alves, Gustavo Pereira, Rita de Cássia Martins Alves da Silva, Liliana Sampaio Costa Mendes, Cláudia Alves Couto, Cristina Melo Rocha, Raul Lazarte, Pamela Yaquich, Blanca Norero, Camila Jure, Alejandra Dominguez, Marta Mac Vicar, Violeta Rivas, Juan Pablo Arancibia, Armando Sierralta, Jose Valera, Sebastian Diaz, Carlos Sanchez, Luis Toro, Adrian Varon, Elizabeth Correa, Juan Carlos Restrepo, Monica Tapias, Ricardo Aguilera Rosales, Mirtha Infante, Galo Pazmiño, Xiimena Armijos, Enrique Carrera, Regina Ligoria, Gerson Avila, Abel Sanchez, Marco Sánchez, Scherezada Mejia, Jacqueline Cordova, Maria De Fatima Higuera de La Tijera, Raul Contreras, Francisco Solis, Jesus Varela, Janett Jacobo, Jose Antonio Velarde-Ruiz Velasco, Julissa Lombardo Quezada, Esther Veramendi, Victor Vela, Claudia Pamo, Donny Puma, Julio Marcelo, Laura Tenorio, Maria Cabrera, Jose Rivera, Pedro Montes, Ramon Bataller, Alexandre Louvet, Vijay Shah, Patrick S. Kamath, Ashwani Singal, Marco Arrese, and Juan Pablo Arab

Subjects
Hepatology
Published
2022

33. From Child-Pugh to MELD score and beyond: Taking a walk down memory lane

Author

Melisa Dirchwolf, Richard B. Freeman, and Andrés Ruf

Subjects
Waiting time, medicine.medical_specialty, Waiting Lists, medicine.medical_treatment, Specialties of internal medicine, Liver transplantation, Severity of Illness Index, Serum bilirubin, End Stage Liver Disease, Liver disease, Disease severity, medicine, Humans, In patient, Hepatology, business.industry, Organ allocation, General Medicine, End-stage liver disease, medicine.disease, Prognosis, Liver Transplantation, body regions, RC581-951, ROC Curve, Emergency medicine, Prognostic model, Portal hypertension, business
Abstract

The Child-Turcotte-Pugh (CTP) and the MELD (Model for End-Stage Liver Disease) scores were designed to predict the outcome of decompressive therapy for portal hypertension. They were prospectively validated to predict mortality risk in patients with a wide spectrum of liver disease etiology and severity. Unlike the CTP score, the MELD score was derived from prospectively gathered data. Its calculation was based on serum bilirubin, serum creatinine, international normalized ratio (INR) and etiology of liver disease. Instituting a continuous disease severity score that de-emphasizes waiting time resulted in better categorization of waiting patients and enhanced transparency. The US instituted the MELD system in 2002 and soon thereafter, MELD-based liver allocation was adopted throughout the world including Latin America. The most significant impact of MELD-based policies has been the reduction of waiting-list mortality. In the years after implementation of the MELD system, several options have been proposed to improve the MELD score's accuracy. Adding serum sodium (MELD-Na) increased the accuracy of the score in predicting waiting list mortality, thus completing the original MELD score as a prognostic model in liver allocation. On the 20th anniversary of the creation of MELD score we present a brief account of its development, its use to stratify patients on the waiting list for liver transplantation as well as its adoption as liver allocation system .

Published
2021

34. NAFLD: Challenges and opportunities to address the public health problem in Latin America

Author

Henry E. Mark, Melisa Dirchwolf, Claudia Pinto Marques Souza de Oliveira, Luis Antonio Díaz, Elly Vaughan, Juan Pablo Arab, Adrián Gadano, Nahum Méndez-Sánchez, Jeffrey V. Lazarus, and Marco Arrese

Subjects
medicine.medical_specialty, Economic growth, Latin Americans, MAFLD, Specialties of internal medicine, Public policy, Disease, Public policies, digestive system, 03 medical and health sciences, 0302 clinical medicine, Non-alcoholic Fatty Liver Disease, NAFLD, Health care, Epidemiology, medicine, Humans, Obesity, Non-alcoholic steatohepatitis, Pharmaceutical industry, Hepatology, business.industry, Public health, Health Policy, NASH, 1. No poverty, nutritional and metabolic diseases, General Medicine, medicine.disease, digestive system diseases, 3. Good health, Latin America, RC581-951, Diabetes Mellitus, Type 2, 13. Climate action, 030220 oncology & carcinogenesis, 030211 gastroenterology & hepatology, business, Delivery of Health Care
Abstract

Non-alcoholic fatty liver disease (NAFLD) is reaching epidemic proportions worldwide. Collectively, Latin American countries have some of the highest obesity rates in the world and the fastest-growing prevalence of type 2 diabetes mellitus (T2DM). Since obesity and T2DM are intrinsically linked with NAFLD, epidemiological projections are worrisome. In addition to this adverse epidemiological setting, the region of Latin America faces unique challenges and obstacles to addressing the growing burden of NAFLD. In this article, on the occasion of the International NASH Day on June 10, 2021, we describe the main challenges and opportunities to improve care of people living with NAFLD in Latin America. Among the major challenges to be tackled are: lack of disease awareness, limited educational opportunities for healthcare personnel and general public, health system fragmentation, and lack of effective strategies for the prevention and effective treatment of NAFLD and common comorbidities, namely obesity and T2DM. Wide dissemination of current concepts on NAFLD, and extensive collaboration between scientific societies, governments, non-governmental organizations, pharmaceutical industry, and other stakeholders is urgently needed to advance the NAFLD public health policies agenda that allows us to address this disease with a whole of society approach.

Published
2021

35. Spontaneous bacterial peritonitis in patients with cirrhosis: incidence, outcomes, and treatment strategies

Author

Adrián Gadano, Melisa Dirchwolf, Juan M Diaz, and Sebastián Marciano

Subjects
medicine.medical_specialty, Cirrhosis, medicine.drug_class, Antibiotics, Drug resistance, Review, 03 medical and health sciences, 0302 clinical medicine, Spontaneous bacterial peritonitis, Internal medicine, Ascites, Medicine, Antibiotic prophylaxis, drug resistance, Hepatology, business.industry, antibiotic prophylaxis, Incidence (epidemiology), Acute kidney injury, medicine.disease, bacterial infections, acute kidney injury, 030220 oncology & carcinogenesis, 030211 gastroenterology & hepatology, medicine.symptom, acute-on-chronic liver failure, business
Abstract

Spontaneous bacterial peritonitis is the most frequent bacterial infection in patients with cirrhosis. The reported incidence varies between 7% and 30% in hospitalized patients with cirrhosis and ascites, representing one of their main complications. Outcomes in patients with spontaneous bacterial peritonitis are poor since acute kidney injury, acute-on-chronic liver failure, and death occur in as much as 54%, 60%, and 40% of the patients, respectively, at midterm. Early antibiotic treatment of spontaneous bacterial peritonitis is crucial. However, the landscape of microbiological resistance is continuously changing, with an increasing spread of multidrug-resistant organisms that make its current management more challenging. Thus, the selection of the empirical antibiotic treatment should be guided by the severity and location where the infection was acquired, the risk factors for multidrug-resistant organisms, and the available information on the local expected bacteriology. The use of albumin as a complementary therapy for selected high-risk patients with spontaneous bacterial peritonitis is recommended in addition to antibiotics. Even though antibiotic prophylaxis has proven to be effective to prevent spontaneous bacterial peritonitis, a careful selection of high-risk candidates is crucial to avoid antibiotic overuse. In this article we review the pathogenesis, risk factors, and prognosis of spontaneous bacterial peritonitis, as well as the current evidence regarding its treatment and prophylaxis.

Published
2019

36. Unresolved issues in the prophylaxis of bacterial infections in cirrhosis patients

Author

Melisa Dirchwolf, Andrés Ruf, José Emanuel Martínez, and Sebastián Marciano

Subjects
First episode, Gastrointestinal bleeding, medicine.medical_specialty, Cirrhosis, Hepatology, business.industry, medicine.drug_class, Antibiotics, medicine.disease, 03 medical and health sciences, 0302 clinical medicine, Spontaneous bacterial peritonitis, 030220 oncology & carcinogenesis, Internal medicine, Epidemiology, medicine, 030211 gastroenterology & hepatology, In patient, Antibiotic prophylaxis, business
Abstract

Bacterial infections are highly prevalent and a frequent cause of hospitalization and short-term mortality in patients with cirrhosis. Due to their negative impact on survival, antibiotic prophylaxis for bacterial infections in high-risk subgroups of patients with cirrhosis has been the standard of care for decades. Patients with prophylaxis indications include those at risk for a first episode of spontaneous bacterial peritonitis (SBP) due to a low ascitic fluid protein count and impaired liver and kidney function, patients with a prior episode of SBP and those with an episode of gastrointestinal bleeding. Only prophylaxis due to gastrointestinal bleeding has a known and short-time duration. All other indications imply long-lasting exposure to antibiotics - once the threshold requirement for initiating prophylaxis is met - without standardized criteria for re-assessing antibiotic interruption. Despite the fact that the benefit of antibiotic prophylaxis in reducing bacterial infections episodes and mortality has been thoroughly reported, the extended use of antibiotics in patients with cirrhosis has also had negative consequences, including the emergence of multi-drug resistant bacteria. Currently, it is not clear whether restricting the use of broad and fixed antibiotic regimens, tailoring the choice of antibiotics to local bacterial epidemiology or selecting non-antibiotic strategies will be the preferred antibiotic prophylaxis strategy for patients with cirrhosis in the future.

Published
2018

37. Identification of optimal therapeutic window for steroid use in severe alcohol-associated hepatitis: A worldwide study

Author

Gustavo Romero, Pierre-Emmanuel Rautou, Saba Abdulsada, Kristina R. Chacko, Roberta Chaves Araújo, Won Kim, Rohit Agrawal, Germán Soriano, Juan Pablo Arab, Inés García-Carrera, Wei Zhang, Juan Pablo Arancibia, Seth Buryska, Andreea Bumbu, Richard D. Parker, Diego Rincón, Pamela Yaquich, Alexandre Louvet, Douglas A. Simonetto, Aldo Torre, Patrick S. Kamath, Tazime Issoufaly, Susana Castro-Sanchez, Felipe Zamarripa, Juan Pablo Roblero, Manuel Mendizabal, Vijay H. Shah, Zohaib Syed Haque, Fernando Bessone, Tej I Mehta, Julio Santiago Marcelo, Ramon Bataller, Carolina A. Ramírez, Tehseen Haider, Muhammad Majeed, Virginia Clark, Veronica Prado, Natalia Baeza, Natalia Bystrianska, Prasun K. Jalal, Rakhi Maiwall, Elizabeth C. Verna, Horia Stefanescu, Michael R. Lucey, Philippe Mathurin, Patricia Guerra Salazar, Berta Cuyàs, Ana Clemente-Sanchez, Maria Laura Garrido, Maria A. Poca, Adelina Horhat, A. Rojo, Luis G. Toro, Luis Antonio Díaz, Juan Carlos Restrepo, Francisco Idalsoaga, Lubomir Skladaný, Dalia Morales-Arraez, Diego Piombino, Guadalupe Garcia-Tsao, Florencia Pollarsky, Juan G. Abraldes, Joseph C. Ahn, Jorge Arnold, María de Fátima Higuera de la Tijera, Edilmar Alvarado-Tapias, Ashwani K. Singal, Eduardo Fuentes-López, Shiv Kumar Sarin, Marcela de Sousa Coelho, Victor Vargas, Robert S. Brown, Winston Dunn, Bashar M. Attar, Joaquín Cabezas, Melisa Dirchwolf, Meritxell Ventura-Cots, Jose A Gonzalez, José Altamirano, Adrián Narvaez, P. Nagaraja Rao, Marco Arrese, Anand V. Kulkarni, and Fernando Cairo

Subjects
0301 basic medicine, Adult, Male, medicine.medical_specialty, Alcoholic liver disease, Cirrhosis, Time Factors, Alcohol Drinking, Alcoholic hepatitis, alcoholic hepatitis, Severity of Illness Index, Hepatitis, corticosteroids, Maddrey discriminant function, Cohort Studies, 03 medical and health sciences, Liver disease, 0302 clinical medicine, Internal medicine, medicine, Humans, Retrospective Studies, Hepatology, business.industry, alcohol, cirrhosis, Hazard ratio, Middle Aged, medicine.disease, alcohol-associated liver disease, MELD, 030104 developmental biology, Methylprednisolone, Prednisolone, 030211 gastroenterology & hepatology, Female, Steroids, business, medicine.drug, alcoholic liver disease, steroids
Abstract

Background & Aims: Corticosteroids are the only effective therapy for severe alcohol-associated hepatitis (AH), defined by a model for end-stage liver disease (MELD) score >20. However, there are patients who may be too sick to benefit from therapy. Herein, we aimed to identify the range of MELD scores within which steroids are effective for AH. Methods: We performed a retrospective, international multi-center cohort study across 4 continents, including 3,380 adults with a clinical and/or histological diagnosis of AH. The main outcome was mortality at 30 days. We used a discrete-time survival analysis model, and MELD cut-offs were established using the transform-the-endpoints method. Results: In our cohort, median age was 49 (40-56) years, 76.5% were male, and 79% had underlying cirrhosis. Median MELD at admission was 24 (19-29). Survival was 88% (87-89) at 30 days, 77% (76-78) at 90 days, and 72% (72-74) at 180 days. A total of 1,225 patients received corticosteroids. In an adjusted-survival-model, corticosteroid use decreased 30-day mortality by 41% (hazard ratio [HR] 0.59; 0.47-0.74; p 51. The type of corticosteroids used (prednisone, pred-nisolone, or methylprednisolone) was not associated with sur-vival benefit (p = 0.247). Conclusion: Corticosteroids improve 30-day survival only among patients with severe AH, especially with MELD scores between 25 and 39. Lay summary: Alcohol-associated hepatitis is a condition where the liver is severely inflamed as a result of excess alcohol use. It is associated with high mortality and it is not clear whether the most commonly used treatments (corticosteroids) are effective, particularly in patients with very severe liver disease. In this worldwide study, the use of corticosteroids was associated with increased 30-day, but not 90-or 180-day, survival. The maximal benefit was observed in patients with an MELD score (a marker of severity of liver disease; higher scores signify worse disease) between 25-39. However, this benefit was lost in patients with the most severe liver disease (MELD score higher than 51). (C) 2021 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

Published
2021

39. Medical management of metabolic and cardiovascular complications after liver transplantation

Author

C. Becchetti, Jean-François Dufour, Vanessa Banz, and Melisa Dirchwolf

Subjects
medicine.medical_specialty, medicine.medical_treatment, 610 Medicine & health, Review, Liver transplantation, End Stage Liver Disease, 03 medical and health sciences, Liver disease, Postoperative Complications, 0302 clinical medicine, Solid organ transplantation, Risk Factors, Humans, Medicine, Obesity, Intensive care medicine, Fulminant hepatitis, Metabolic Syndrome, Post-transplantation metabolic syndrome, business.industry, Gastroenterology, General Medicine, medicine.disease, Liver Transplantation, Survival Rate, Transplantation, surgical procedures, operative, Cardiovascular Diseases, New-onset diabetes after transplantation, 030220 oncology & carcinogenesis, Hepatocellular carcinoma, Hypertension, Etiology, 030211 gastroenterology & hepatology, Metabolic syndrome, Orthotopic liver transplantation, business, Dyslipidemia
Abstract

Liver transplantation represents the only curative option for patients with end-stage liver disease, fulminant hepatitis and advanced hepatocellular carcinoma. Even though major advances in transplantation in the last decades have achieved excellent survival rates in the early post-transplantation period, long-term survival is hampered by the lack of improvement in survival in the late post transplantation period (over 5 years after transplantation). The main etiologies for late mortality are malignancies and cardiovascular complications. The latter are increasingly prevalent in liver transplant recipients due to the development or worsening of metabolic syndrome and all its components (arterial hypertension, dyslipidemia, obesity, renal injury, etc.). These comorbidities result from a combination of pre-liver transplant features, immunosuppressive agent side-effects, changes in metabolism and hemodynamics after liver transplantation and the adoption of a sedentary lifestyle. In this review we describe the most prevalent metabolic and cardiovascular complications present after liver transplantation, as well as proposing management strategies.

Published
2020
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40. Latin American Association for the study of the liver (ALEH) practice guidance for the diagnosis and treatment of non-alcoholic fatty liver disease

Author

Edison Roberto Parise, Norberto C. Chávez-Tapia, Claudia P. Oliveira, Walter Masson, Juan Pablo Arab, Marco Arrese, Arturo Panduro, Adrián Gadano, Nahum Méndez-Sánchez, Marlene Perez, Andrés Ruf, Marlene Castellanos-Fernandez, Eduardo Vilar-Gomez, Daniela Chiodi, Javier Diaz, Sebastián Marciano, Jaime Poniachik, Juan Carlos Restrepo, Helma Pinchemel Cotrim, Marcos Girala, Mário Reis Álvares-da-Silva, Kenneth Cusi, José E Costa Gil, Adelina Lozano, Marcelo Silva, Solange Gerona, Carlos Benítez, Martín Tagle, Kenia Torres, Francisco Barrera, Melisa Dirchwolf, Graciela Castro-Narro, Nelia Hernández, Nathalie C. Leite, Raymundo Paraná, Eduardo Fassio, Martín Padilla, and Monica Tapias

Subjects
medicine.medical_specialty, Clinical practice guidance, Cirrhosis, Steatosis, medicine.medical_treatment, Population, Specialties of internal medicine, MAFLD, Disease, Liver transplantation, Chronic liver disease, 03 medical and health sciences, 0302 clinical medicine, Non-alcoholic Fatty Liver Disease, NAFLD, Fatty liver, Nonalcoholic fatty liver disease, medicine, Humans, Nonalcoholic steatohepatitis, education, Intensive care medicine, education.field_of_study, Hepatology, business.industry, purl.org/pe-repo/ocde/ford#3.02.19 [https], NASH, nutritional and metabolic diseases, General Medicine, Guideline, medicine.disease, digestive system diseases, Latin America, RC581-951, 030220 oncology & carcinogenesis, 030211 gastroenterology & hepatology, business, Algorithms
Abstract

Non-alcoholic fatty liver disease (NAFLD) currently represents an epidemic worldwide. NAFLD is the most frequently diagnosed chronic liver disease, affecting 20-30% of the general population. Furthermore, its prevalence is predicted to increase exponentially in the next decades, concomitantly with the global epidemic of obesity, type 2 diabetes mellitus (T2DM), and sedentary lifestyle. NAFLD is a clinical syndrome that encompasses a wide spectrum of associated diseases and hepatic complications such as hepatocellular carcinoma (HCC). Moreover, this disease is believed to become the main indication for liver transplantation in the near future. Since NAFLD management represents a growing challenge for primary care physicians, the Asociación Latinoamericana para el Estudio del Hígado (ALEH) has decided to organize this Practice Guidance for the Diagnosis and Treatment of Non-Alcoholic Fatty Liver Disease, written by Latin-American specialists in different clinical areas, and destined to general practitioners, internal medicine specialists, endocrinologists, diabetologists, gastroenterologists, and hepatologists. The main purpose of this document is to improve patient care and awareness of NAFLD. The information provided in this guidance may also be useful in assisting stakeholders in the decision-making process related to NAFLD. Since new evidence is constantly emerging on different aspects of the disease, updates to this guideline will be required in future.

Published
2020

41. The Importance of Knowing the Local Epidemiology When a Patient With Cirrhosis Acquires a Bacterial Infection

Author

Sebastián Marciano, Marcelo Valverde, Melisa Dirchwolf, Maria N Gutierrez-Acevedo, and Adrián Gadano

Subjects
medicine.medical_specialty, Cirrhosis, Hepatology, business.industry, Epidemiology, medicine, ComputingMethodologies_IMAGEPROCESSINGANDCOMPUTERVISION, Reviews, Intensive care medicine, medicine.disease, business
Abstract

Watch a video presentation of this article.

Published
2019

42. Evaluación del acceso a antivirales para el tratamiento de la hepatitis C en un país con recursos limitados

Author

M.N. Anselmo, Luis Gaite, M.C. Aparicio, M.S. Frola, R. Hansen, C. García Dans, M.B. García Rosales, Silvia Borzi, Natalia Ratusnu, Adrián Gadano, Leila Haddad, Sebastián Marciano, B. Ríos, M.V. Aubone, M. Ibáñez Duran, Omar Galdame, Claudia D'Amico, Melisa Dirchwolf, T.M. Strella, M.E. Sirotinsky, L. de Labra, M.A. Peche, and S. De Filippi

Subjects
0301 basic medicine, 03 medical and health sciences, 030104 developmental biology, 0302 clinical medicine, Gastroenterology, lcsh:Diseases of the digestive system. Gastroenterology, 030211 gastroenterology & hepatology, lcsh:RC799-869
Abstract

Resumen: Objetivos: Estimar la proporción de pacientes que acceden al tratamiento de la hepatitis C con antivirales de acción directa (AAD) en Argentina, y evaluar factores asociados a la falta de acceso. Métodos: Estudio de cohorte transversal que incluyó la totalidad de prescripciones consecutivas de AAD realizadas entre enero de 2016 y febrero de 2017 por centros de salud que participan en el proyecto de telemedicina ECHOTM dirigido por el Hospital Italiano de Buenos Aires. Resultados: Se incluyeron 143 prescripciones de tratamiento. El acceso global fue del 70% (IC 95%: 62-77%). Pertenecer al sistema de salud público fue el único factor independiente asociado con la falta de acceso al tratamiento [OR 4.98 (IC95% 2.05-12.09)]. Conclusión: Los pacientes con hepatitis C pertenecientes al sistema de salud público tienen 4 veces más chances de no acceder a tratamiento con AAD que los pacientes con dependencia de otros sistemas de salud (medicina privada u obras sociales). Abstract: Aims: To estimate the number of patients that have access to treatment of hepatitis C with direct-acting antivirals in Argentina and evaluate the factors associated with the lack of access. Materials and methods: A cross-sectional cohort study was conducted that included all the consecutive prescriptions of direct-acting antivirals issued at health centers that participated in the ECHOTM telemedicine project directed by the Hospital Italiano de Buenos Aires, within the time frame of January 2016 and February 2017. Results: A total of 143 treatment prescriptions were included and overall access was 70% (95% CI 62-77%). The only independent factor associated with a lack of treatment access was coverage by a public healthcare system (OR 4.98 [95% CI 2.05- 12.09]). Conclusion: Patients with hepatitis C that were covered by a public healthcare system had a 4 times higher chance of not having access to treatment with direct-acting antivirals than patients covered by other healthcare systems (private insurance or the social welfare system). Palabras clave: Antivirales de acción directa, Acceso, Hepatitis C, Sistemas de salud, Barreras, Keywords: Direct-acting antiviral agents, Access, Hepatitis C, Healthcare systems, Barriers

Published
2018

43. Access to direct-acting antivirals for the treatment of hepatitis C in a country with limited resources

Author

M.V. Aubone, R. Hansen, T.M. Strella, Melisa Dirchwolf, M.E. Sirotinsky, Natalia Ratusnu, Silvia Borzi, M. Ibáñez Duran, Sebastián Marciano, B. Ríos, M.B. García Rosales, Luis Gaite, Omar Galdame, M.S. Frola, Adrián Gadano, L. de Labra, M.N. Anselmo, Claudia D'Amico, S. De Filippi, M.A. Peche, Leila Haddad, M.C. Aparicio, and C. García Dans

Subjects
0301 basic medicine, medicine.medical_specialty, Argentina, Social Welfare, DIRECT ACTING ANTIVIRALS, Antiviral Agents, Health Services Accessibility, 03 medical and health sciences, 0302 clinical medicine, Time frame, Humans, Medicine, lcsh:RC799-869, Medical prescription, Developing Countries, business.industry, General Medicine, Hepatitis C, Hepatitis C, Chronic, medicine.disease, Cross-Sectional Studies, 030104 developmental biology, Family medicine, lcsh:Diseases of the digestive system. Gastroenterology, 030211 gastroenterology & hepatology, business, Limited resources, Healthcare system, Cohort study
Abstract

Aims: To estimate the number of patients that have access to treatment of hepatitis C with direct-acting antivirals in Argentina and evaluate the factors associated with the lack of access. Materials and methods: A cross-sectional cohort study was conducted that included all the consecutive prescriptions of direct-acting antivirals issued at health centers that participated in the ECHOTM telemedicine project directed by the Hospital Italiano de Buenos Aires, within the time frame of January 2016 and February 2017. Results: A total of 143 treatment prescriptions were included and overall access was 70% (95% CI 62-77%). The only independent factor associated with a lack of treatment access was coverage by a public healthcare system (OR 4.98 [95% CI 2.05- 12.09]). Conclusions: Patients with hepatitis C that were covered by a public healthcare system had a 4 times higher chance of not having access to treatment with direct-acting antivirals than patients covered by other healthcare systems (private insurance or the social welfare system). Resumen: Objetivos: Estimar la proporción de pacientes que acceden al tratamiento de la hepatitis C con antivirales de acción directa (AAD) en Argentina, y evaluar factores asociados a la falta de acceso. Métodos: Estudio de cohorte transversal que incluyó la totalidad de prescripciones consecutivas de AAD realizadas entre enero de 2016 y febrero de 2017 por centros de salud que participan en el proyecto de telemedicina ECHOTM dirigido por el Hospital Italiano de Buenos Aires. Resultados: Se incluyeron 143 prescripciones de tratamiento. El acceso global fue del 70% (IC95%: 62-77%). Pertenecer al sistema de salud público fue el único factor independiente asociado con la falta de acceso al tratamiento [OR 4.98 (IC95% 2.05-12.09)]. Conclusión: Los pacientes con hepatitis C pertenecientes al sistema de salud público tienen 4 veces más chances de no acceder a tratamiento con AAD que los pacientes con dependencia de otros sistemas de salud (medicina privada u obras sociales). Keywords: Direct-acting antivirals, Access, Hepatitis C, Healthcare systems, Barriers, Palabras clave: Antivirales de acción directa, Acceso, Hepatitis C, Sistemas de salud, Barreras

Published
2018

44. Spontaneous bacteremia and spontaneous bacterial peritonitis share similar prognosis in patients with cirrhosis: a cohort study

Author

Laura Barcan, Sebastián Marciano, Astrid Smud, Adrián Gadano, Leila Haddad, Carla Bermudez, Melisa Dirchwolf, María Lourdes Posadas-Martínez, Federico Genre Bert, Natalia Sobenko, and Diego Giunta

Subjects
medicine.medical_specialty, Cirrhosis, Hepatology, business.industry, Mortality rate, Acute kidney injury, Retrospective cohort study, medicine.disease, Gastroenterology, 03 medical and health sciences, 0302 clinical medicine, Spontaneous bacterial peritonitis, 030220 oncology & carcinogenesis, Internal medicine, Bacteremia, medicine, 030211 gastroenterology & hepatology, Cumulative incidence, business
Abstract

Spontaneous bacteremia is a poorly characterized infection in patients with cirrhosis. We compared the incidence of mortality and acute kidney injury in patients with spontaneous bacterial peritonitis and spontaneous bacteremia, and identified risk factors for mortality and acute kidney injury in patients with spontaneous bacteremia. We performed a retrospective cohort study of patients with cirrhosis and spontaneous bacteremia or spontaneous bacterial peritonitis from 2008 to 2016 at Hospital Italiano, Buenos Aires. We compared the cumulative incidence of acute kidney injury and death between the two infections, and identified risk factors for these outcomes in patients with spontaneous bacteremia. Seventy-one patients with spontaneous bacteremia and 55 patients with spontaneous bacterial peritonitis were included. Most infections were nosocomial. Overall, 26% of bacteria were resistant and 11% multi-resistant. We found no significant association between acute kidney injury [subhazard ratio (sHR) 1.05 (95% confidence interval, CI 0.67–1.63, p = 0.83)] or death [sHR 1.15 (95% CI 0.60–2.20, p = 0.68)] and type of spontaneous infection in multivariate analyses adjusting for basal Model for End-Stage Liver Disease (MELD) score. In patients with spontaneous bacteremia, baseline MELD score was independently associated with acute kidney injury [sHR 1.07 (95% CI 1.03–1.11, p = 0.001)] and death [sHR 1.07 (95% CI 1.02–1.15, p = 0.03)]. Short-term acute kidney injury and mortality rates were similar in patients with spontaneous bacteremia and spontaneous bacterial peritonitis. Risk assessment of patients with spontaneous bacteremia can be performed with baseline MELD score.

Published
2017

45. O-9 COMPARISON OF THE PERFORMANCE OF DIFFERENT SCORES FOR THE PREDICTION OF IN-HOSPITAL MORTALITY IN PATIENTS WITH CIRRHOSIS AND BACTERIAL INFECTIONS

Author

Carla Bellizzi, Diego Giunta, Maria Pia Raffa, Andres Bruno, Lorena del Carmen Notari, Manuel Mendizabal, Ezequiel Mauro, Maria Dolores Murga, Salvatore Piano, Adriano Masola, Agustina Martinez Garmendia, Martin Elizondo, Pablo Ruiz, Teodoro E. Stieben, Fernando Bessone, Ivonne Giselle Duarte, Liria Martinez Rejtman, Silvia Borzi, José L. Fernández, Victoria Trevizan, Maria Nelly Gutierrez Acevedo, Andrea Odzak, Ezequiel Demirdjian, Melisa Dirchwolf, Florencia Antinucci, Silvina Tevez, Leandro Alfredo Heffner, Ana Palazzo, Sofía Bulaty, Sebastián Marciano, Nadia Grigera, Josefina Pages, Sebastián Ferretti, Jesica Tomatis, José Emanuel Martínez, Agñel Ramos, Mirta Peralta, Hugo Fainboim, Daniea Perez, Marcelo Valverde, Astrid Smud, Sabrina Barbero, Maria Margarita Anders, Diego Arufe, José Daniel Bosia, Julio Vorobioff, Marina Agozino, Ana Martínez, Adrián Gadano, Cintia Elizabet Vazquez, and Orlando Orozco Ganem

Subjects
medicine.medical_specialty, Cirrhosis, RC581-951, Hepatology, In hospital mortality, business.industry, Internal medicine, medicine, Specialties of internal medicine, In patient, General Medicine, business, medicine.disease
Abstract

Background: Predicting short-term mortality in patients with cirrhosis and bacterial infections is challenging. Aims: To compare the performance of various scores in predicting in-hospital mortality in this population. Methods: We performed an analysis of the multicenter prospective cohort study of patients with cirrhosis with bacterial infections throughout Argentina and Uruguay (clinicatrials.gov.NCT03919032). Patients were classified according to the CLIF criteria as having ACLF or mere acute decompensation (AD). We evaluated the performance of scores of liver disease and infection severity in predicting in-hospital mortality. MELD, MELD-Na, and Quick SOFA (qSOFA) were computed in all patients. CLIF-AD was only computed in patients without ACLF, and CLIF-ACLF only in patients with ACLF. We plotted ROC curves and estimated their area under the curve (AUROC). Results: We included 472 patients: 66% male, mean age 57 ± 12 years. Most frequent infections: SBP (30%) and urinary tract infection (25%). Overall, 332 (70%) patients had acute decompensation, and 140 (30%) ACLF. In-hospital mortality rate was 19%: 41% in patients with ACLF vs 10% in patients with AD (p

Published
2021

46. P-68 FREQUENCY AND FACTORS ASSOCIATED WITH ANTIBIOTIC DE-ESCALATION IN PATIENTS WITH CIRRHOSIS AND BACTERIAL INFECTIONS

Author

Hugo Fainboim, Maria Dolores Murga, Ezequiel Mauro, Marcelo Valverde, José Daniel Bosia, Maria Nelly Gutierrez Acevedo, Silvina Tevez, Leandro Alfredo Heffner, Marina Agozino, Teodoro E. Stieben, Julio Vorobioff, Cintia Elizabet Vazquez, Adriano Masola, Mirta Peralta, Ana Martínez, Ana Palazzo, Maria Margarita Anders, Adrián Gadano, Astrid Smud, Orlando Orozco Ganem, Carla Bellizzi, Fernando Bessone, Silvia Borzi, Andres Bruno, Diego Arufe, Nadia Grigera, Liria Martinez Rejtman, José L. Fernández, Jesica Tomatis, Sebastián Ferretti, Ivonne Giselle Duarte, Martin Elizondo, Agñel Ramos, Ezequiel Demirdjian, Manuel Mendizabal, Andrea Odzak, Sabrina Barbero, Victoria Trevizan, Florencia Antinucci, Sofía Bulaty, Pablo Ruiz, Sebastián Marciano, Josefina Pages, José Emanuel Martínez, Lorena del Carmen Notari, Daniea Perez, Melisa Dirchwolf, Diego Giunta, and Maria Pia Raffa

Subjects
medicine.medical_specialty, Cirrhosis, Hepatology, business.industry, medicine.drug_class, Antibiotics, Specialties of internal medicine, General Medicine, medicine.disease, RC581-951, Internal medicine, Medicine, In patient, business, De-escalation
Abstract

Background: Antibiotic de-escalation is considered a safe strategy that reduces costs and the risk of multi-drug resistant infections. However, its prevalence and associated factors in real-life practice were not reported in patients with cirrhosis in Latin-America. Aims: To estimate the prevalence of antibiotic de-escalation in patients with cirrhosis in real life-practice, and to explore its associated factors. Methods: We performed an analysis of the multicenter prospective cohort study of cirrhotic patients with bacterial infections throughout Argentina and Uruguay (clinicatrials.gov NCT03919032). Patients who died in the first 72 hs from the diagnosis of the infection were excluded. In accordance with guidelines, de-escalation was defined as changing the initially antimicrobials to a narrower spectrum regimen, or suspending one or more of the empirical antibiotics, according to culture results or to other clinical reasons, either in patients with culture-positive or culture-negative bacterial infections. We used inverse probability weighting (IPW) of having a culture-positive infection to estimate its causal effect on de-escalation. Results: We included 450 patients. Most frequent infections were SBP (30.4%), and urinary tract infection (12.9%). Overall, 243 (54%) infections were culture-positive, and 207 (46%) culture-negative. De-escalation was reported in 85 patients (18.9%: 95% CI 15%-22%) at a mean of 3.3 ± 2.4 days from treatment initiation and was more frequent in culture-positive than culture-negative infections (28.4% vs 7.7%, p< 0.001). The table shows the crude analyses of variables associated with de-escalation. Culture-positive infection was strongly and independently associated with de-escalation (ORIPW 6.08; 95% CI: 2.90-12.70; p < 0.001). Conclusions: Antibiotic de-escalation was reported in one-fifth of in-patients with cirrhosis. Given that having a culture-positive infection had a strong effect on de-escalation, efforts should be made to increase the likelihood of obtaining adequate culture samples in a timely manner.

Published
2021

47. A Dynamic Definition of Acute Kidney Injury Does not Improve Prognosis Assessment in Acutely Decompensated Patients with Cirrhosis

Author

Diego Giunta, María Emilia Debernardi, Melisa Dirchwolf, Liliana Paloma Rojas, Adrián Gadano, Sebastián Marciano, Vanina Pagotto, and Ezequiel Mauro

Subjects
0301 basic medicine, medicine.medical_specialty, Cirrhosis, Hepatology, business.industry, Liver failure, Acute kidney injury, medicine.disease, 03 medical and health sciences, 030104 developmental biology, 0302 clinical medicine, Model for End-Stage Liver Disease, Internal medicine, medicine, Kidney injury, Retrospective analysis, Original Article, 030211 gastroenterology & hepatology, Decompensation, In patient, Intensive care medicine, business
Abstract

Background/objectives to compare the prognostic accuracy for 28 and 90-day transplant-free mortality of a modified CLIF-SOFA score (including a dynamic definition of acute kidney injury) with that of the classic CLIF-SOFA score and KDIGO score for acute kidney injury in patients with acute decompensation of cirrhosis. Methods A retrospective analysis of all admissions of acutely decompensated patients with cirrhosis was carried out from January 2012 to December 2014. Classic and modified CLIF-SOFA scores were analyzed, as well as acute kidney injury diagnosis using the KDIGO score regarding their accuracy for 28- and 90-day transplant free mortality prediction. Results 108 admissions were analyzed. Acute kidney injury diagnosis was met in 37 (34%) patients. Acute-on-chronic liver failure was diagnosed in 59 (55%) patients using the classic CLIF-SOFA score; and in 64 (59%) patients using the modified CLIF-SOFA score. Both CLIF-SOFA scores were highly effective in predicting 28-day transplant-free mortality (AUCROC 0.93 and 0.92, p =0.34) as well as 90-day transplant-free mortality (AUCROC 0.79 and 0.78, p =0.78). Acute kidney injury diagnosis had significantly lower accuracy in mortality assessment (28 and 90-day transplant free mortality AUCROC 0.67 [ p =0.002] and 0.63 [ p =0.02]). Conclusions To our knowledge, this is the first evidence of the limited impact of modifying the fixed kidney injury definition currently used for acute-on-chronic liver failure.

Published
2017

48. Clinical epidemiology of acute hepatitis C in South America

Author

Silvia Borzi, Ezequiel Ridruejo, Daniela Chiodi, Andrés Ruf, Rodolfo Carbonetti, Melisa Dirchwolf, Pablo Maximiliano Plaza, Teresa Schroder, Margarita Anders, Hugo Fainboim, Luciana Tadey, Carolina Shulman, Sebastián Marciano, Ezequiel Mauro, Néstor Gill Petta, Federico Tanno, Fernando Barreyro, and Lucrecia Rezzonico

Subjects
medicine.medical_specialty, business.industry, Hepatitis C virus, Retrospective cohort study, Hepatitis C, Hepatology, medicine.disease_cause, medicine.disease, Virology, 03 medical and health sciences, 0302 clinical medicine, Infectious Diseases, Internal medicine, Cohort, Epidemiology, medicine, 030211 gastroenterology & hepatology, 030212 general & internal medicine, Risk factor, Fulminant hepatitis, business
Abstract

There is scarce data pertaining to acute hepatitis C (aHC) infection in South America. We aimed to describe clinical characteristics and evolution of aHC in a South American cohort. A retrospective survey was conducted at 13 hepatology units. All patients ≥16 years old with aHC diagnosis were included. Demographic, clinical and outcome information were registered in a standardized ad hoc questionnaire. Sixty-four patients were included. The majority were middle-aged (median age: 46 years) and female (65.6%); most of them were symptomatic at diagnosis (79.6%). HCV-1 was the most prevalent genotype (69.2%). Five patients had liver failure: three cases of severe acute hepatitis, one case of fulminant hepatitis and one case of acute-on-chronic liver failure. Nosocomial exposure was the most prevalent risk factor. Evolution was assessed in 46 patients. In the untreated cohort, spontaneous resolution occurred in 45.8% and was associated with higher values of AST/ALT and with the absence of intermittent HCV RNA viremia (P = 0.01, 0.05, and 0.01, respectively). In the treated cohort, sustained virological response was associated with nosocomial transmission and early treatment initiation (P = 0.04 each). The prevalence of nosocomial transmission in this South-American cohort of aHC stresses the importance of following universal precautions to prevent HCV infection. J. Med. Virol. 89:276-283, 2017. © 2016 Wiley Periodicals, Inc.

Published
2016

49. Impact of acute-on-chronic liver failure on post-transplant survival and on kidney outcomes

Author

Melisa Dirchwolf, Maria N Gutierrez-Acevedo, Sebastián Marciano, Florencia Pollarsky, Maria C Torres, Carla Bermudez, Juan M Diaz, Adrián Narvaez, Diego Giunta, Ezequiel Mauro, Adrián Gadano, Jorge Ortíz, Liliana P Rojas-Saunero, and Epidemiology

Subjects
Adult, Liver Cirrhosis, Male, medicine.medical_specialty, Gastroenterology, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, Humans, Medicine, Survival rate, Retrospective Studies, Kidney, Hepatology, business.industry, Graft Survival, Hazard ratio, Acute-On-Chronic Liver Failure, Retrospective cohort study, Odds ratio, Middle Aged, medicine.disease, Confidence interval, Liver Transplantation, Survival Rate, Transplantation, Treatment Outcome, medicine.anatomical_structure, 030220 oncology & carcinogenesis, Kidney Failure, Chronic, Female, 030211 gastroenterology & hepatology, business, Kidney disease
Abstract

Objectives We aimed to evaluate the effect of acute-on-chronic liver failure (ACLF) on patients’ 1-year post-liver transplant (LT) survival. In addition, we evaluated the effect of ACLF on the development of post-LT chronic kidney disease (CKD) and early allograft dysfunction (EAD). Patients and methods A retrospective cohort of patients who underwent transplantation from 2010 to 2016 was studied. EASL-CLIF’s definition of ACLF was used. The risk of post-LT death, CKD, and EAD was estimated with regression models weighted by inverse probability weighting considering the recipients’ characteristics. Donor’s BMI and donor risk index were included in the models as well. Results A total of 185 patients were included: 125 (67.6%) without ACLF and 60 (32.4%) with ACLF. The 1-year post-LT survival rate was 91.2% [95% confidence interval (CI): 84.6–95.1%] in patients without ACLF versus 84.9% (95% CI: 73.1–91.9%) in patients with ACLF. Post-LT CKD occurred in 43 (38.7%) patients without ACLF versus 26 (52.0%) patients with ACLF. EAD occurred in 40 (32.3%) patients without ACLF versus 15 (28.8%) patients with ACLF. No effect of ACLF was found on survival (hazard ratio 1.75; 95% CI: 0.64–4.75, P =0.272), CKD (odds ratio: 1.31; 95% CI: 0.60–2.86; P= 0.491), or EAD (odds ratio: 0.74; 95% CI: 0.38–1.66, P=0.473). Conclusion In this study, which included mainly patients with grade 1 ACLF at the time of LT, its presence had no impact on post-LT survival or on the occurrence of CKD or EAD. Eur J Gastroenterol Hepatol 31: 1157–1164 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Published
2019

50. Spontaneous bacterial peritonitis recurrence in patients with cirrhosis receiving secondary prophylaxis with norfloxacin

Author

Laura Barcan, Diego Giunta, Carla Bermudez, Sebastián Marciano, Adrián Gadano, Melisa Dirchwolf, Juan M Diaz, Astrid Smud, and Maria N Gutierrez-Acevedo

Subjects
Adult, Liver Cirrhosis, Male, medicine.medical_specialty, Cirrhosis, Peritonitis, 03 medical and health sciences, 0302 clinical medicine, Spontaneous bacterial peritonitis, Recurrence, Internal medicine, medicine, Bacteriology, Secondary Prevention, Humans, In patient, Antibiotic prophylaxis, Norfloxacin, Aged, Retrospective Studies, Hepatology, business.industry, Gastroenterology, Secondary prophylaxis, Retrospective cohort study, Bacterial Infections, Antibiotic Prophylaxis, Middle Aged, medicine.disease, Anti-Bacterial Agents, 030220 oncology & carcinogenesis, 030211 gastroenterology & hepatology, Female, business, circulatory and respiratory physiology, medicine.drug
Abstract

Few studies carried out more than 20 years ago have evaluated spontaneous bacterial peritonitis (SBP) recurrence in patients receiving secondary antibiotic prophylaxis. These studies reported a 1-year recurrence rate of 20-26%. Changes in the bacteriology of SBP over the last few years might have negative effects on secondary prophylaxis. Our primary aim was to estimate the incidence of SBP recurrence in patients with cirrhosis receiving secondary prophylaxis with norfloxacin and to explore the factors associated with SBP recurrence.This was a retrospective cohort study of patients receiving norfloxacin for the secondary prophylaxis of SBP from 1 March 2003 to 31 March 2016. Follow-up was performed for 365 days after secondary prophylaxis was started. A competing risk analysis approach was used.A total of 115 patients were included. The prevalence of quinolone-resistant and multiresistant bacteria in the first episode of SBP among patients with culture-positive SBP was 70.96% [95% confidence interval (CI): 51.96-85.77%] and 12.90% (95% CI: 3.63-29.83%), respectively. The cumulative incidence of SBP recurrence was 28.53% (95% CI: 20.15-37.45%) after 365 days. Male patients showed an estimated subhazard ratio of SBP recurrence of 2.52 (95% CI: 1.07-5.91, P=0.034). No other risk factors for SBP recurrence were identified. The overall cumulative incidence of death after 365 days was 21.57% (95% CI: 14.14-30.04%), without significant differences among patients with or without SBP recurrence.Even though changes in the bacteriology of SBP occurred over time, its recurrence rate in patients receiving norfloxacin remains similar to what was reported in the initial studies.

Published
2018

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