Publications by authors named "Robert J Wong"

163 Publications

Trends in the Prevalence of Hepatitis C Virus Infection based on the Insurance Status in the United States from 2013 to 2018.

Liver Int 2021 Nov 24. Epub 2021 Nov 24.

Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, United States.

Background & Aims: With the recent improvement in the treatment of hepatitis C virus (HCV) infection, a better understanding of the infection burden is needed. We aimed to (1) estimate the trends in the national prevalence of HCV infection based on the type of health insurance coverage and (2) identify at-risk populations for HCV infection in the United States (US) general population.

Methods: Population-based analyses using the National Health and Nutrition Examination Survey (2013-2018) were performed with a focus on HCV infection. We analyzed the prevalence of HCV infection based on the health insurance status before the direct-acting antiviral (DAA) era (2013-2014) and during the DAA era (2015-2018).

Results: The age-adjusted prevalence of active HCV infection (HCV RNA [+]) was 0.92% (95% confidence interval [CI], 0.71%-1.19%) in the US non-institutionalized civilian population. While the prevalence of active HCV infection has remained stable, the prevalence of resolved HCV infection has increased after the introduction of DAA. In terms of health insurance coverage, the prevalence of active HCV infection decreased, and the prevalence of resolved HCV infection increased among individuals who had health insurance, especially private health insurance. The independent risk factors of active HCV infection were 40-69 years group, male, less than high school education, unmarried, below poverty status, being born in the US, history of blood transfusion, and not having private health insurance.

Conclusion: The burden of active HCV infection has decreased among individuals who had health insurance, especially private health insurance, during the DAA era.
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http://dx.doi.org/10.1111/liv.15113DOI Listing
November 2021

Closing the gap to achieve HBV elimination by 2030: A global pursuit fueled by regional successes.

Authors:
Robert J Wong

Lancet Reg Health West Pac 2021 Nov 25;16:100254. Epub 2021 Aug 25.

Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford. CA.

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http://dx.doi.org/10.1016/j.lanwpc.2021.100254DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8406021PMC
November 2021

Primary biliary cholangitis has the highest waitlist mortality in patients with cirrhosis and acute on chronic liver failure awaiting liver transplant.

Clin Transplant 2021 Sep 12:e14479. Epub 2021 Sep 12.

Department of Biostatistics and Preventive Medicine, University of Texas Medical Branch, Galveston, USA.

Background: Data are sparse on etiology specific outcomes on waitlist (WL) and post-transplant outcomes among patients with acute on chronic liver failure (ACLF).

Methods And Results: In a retrospective cohort of 14,774 adults from United network for organ sharing (UNOS) database listed for Liver transplantation (LT) with cirrhosis and ACLF (January 2013-June 2019), 40% were due to alcohol-associated liver disease (ALD), followed by hepatitis C virus (HCV) at 20%, non-alcoholic steatohepatitis (19%), cryptogenic cirrhosis (7%), autoimmune hepatitis (5%), primary sclerosing cholangitis (PSC) at 3%, and 2% each for hepatitis B, primary biliary cholangitis (PBC), and metabolic etiology. Using competing risk analysis, cumulative risk of WL mortality was highest for PBC at 20.5% and lowest for PSC at 13.3%, P < .001. Compared with ALD as reference, WL mortality was higher for PBC (1.45 [1.16-1.82]), and similar for other etiologies, P < .001. Of this cohort, 9650 (65.3%) patients received LT, with 1-year. patient survival of 91.6% for PBC, worst for cryptogenic cirrhosis (89.5%) and best for PSC and ALD (93.4%), P < .001.

Conclusion: Among listed candidates with ACLF, those with PBC have highest WL mortality 1-year. post-transplant survival was excellent among recipients for PBC. If these findings are validated in prospective studies, liver disease etiology should be considered for LT selection among patients in ACLF.
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http://dx.doi.org/10.1111/ctr.14479DOI Listing
September 2021

Prevalence of hepatitis E infection among adults with concurrent chronic liver disease.

J Viral Hepat 2021 Nov 26;28(11):1643-1655. Epub 2021 Aug 26.

Tuberculosis Section, Division of Communicable Disease Control and Prevention, Alameda County Public Health Department, San Leandro, California, USA.

While hepatitis E virus (HEV) infection can increase the risk of liver decompensation and death in patients with underlying chronic liver disease (CLD), prevalence of HEV in this cohort is not well reported. Using data from the 2011-2018 National Health and Nutrition Examination Survey, we aim to evaluate seroprevalence of HEV IgG among adults with non-alcoholic fatty liver disease (NAFLD), alcoholic liver disease (ALD), chronic hepatitis C virus (HCV) and chronic hepatitis B virus (HBV). HEV IgG seroprevalence between groups was evaluated with chi-square testing, and adjusted multivariate logistic regression models evaluated for predictors of seropositivity for HEV IgG. Seroprevalence of HEV IgG was 6.58% in ALD, 8.66% in HCV, 8.81% in NAFLD and 19.86% in HBV. We observed increasing HEV IgG seroprevalence over time in our study period, and in 2015-2018, seroprevalence was highest among the individuals with HCV (10.00%) and HBV (30.30%). Older age and being born outside of the United States were associated with seropositivity for HEV IgG in ALD, NAFLD, HBV, and for HCV, older age and being at or below poverty level were associated with seroprevalence for HEV IgG. In conclusion, we observed a relatively high prevalence of HEV among adults with CLD. These data highlight the need for greater awareness and education about the role of HEV in patients with underlying CLD, improving HEV test diagnostics, and revisiting the discussion about the potential role of HEV vaccines in CLD patients who are at higher risk of decompensation and death from acute HEV infection.
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http://dx.doi.org/10.1111/jvh.13597DOI Listing
November 2021

Diagnosis and Treatment of Latent Tuberculosis Infection.

Am J Gastroenterol 2021 11;116(11):2155-2158

Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA.

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http://dx.doi.org/10.14309/ajg.0000000000001398DOI Listing
November 2021

Editorial: trends in alcohol use and alcohol-associated liver disease in the US population-authors' reply.

Aliment Pharmacol Ther 2021 08;54(4):513-514

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.

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http://dx.doi.org/10.1111/apt.16520DOI Listing
August 2021

Alcohol-associated liver disease in the United States is associated with severe forms of disease among young, females and Hispanics.

Aliment Pharmacol Ther 2021 08 11;54(4):451-461. Epub 2021 Jul 11.

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.

Background: Alcohol use and alcohol-associated liver disease (ALD) burden are increasing in young individuals.

Aim: To assess host factors associated with this burden.

Methods: National Health and Nutrition Examination Survey (NHANES), National Inpatient Sample (NIS), and United Network for Organ Sharing (UNOS) databases (2006-2016) were used to identify individuals with harmful alcohol use, ALD-related admissions, and ALD-related LT listings respectively.

Results: Of 15 981 subjects in NHANES database, weighted prevalence of harmful alcohol use was 17.7%, 29.3% in <35 years (G1) versus 16.9% in 35-64 years (G2) versus 5.1% in ≥65 years (G3). Alcohol use was about 11 and 4.7 folds higher in G1 and G2 versus G3, respectively. Male gender and Hispanic race associated with harmful alcohol use. Of 593 600 ALD admissions (5%, 77%, and 18% in G1-G3 respectively), acute on chronic liver failure (ACLF) occurred in 7.2%, (7.2 in G2 vs 6.7% in G1 and G3, P < 0.001). After controlling for other variables, ACLF development among ALD hospitalizations was higher by 14% and 10% in G1 and G2 versus G3, respectively. Female gender and Hispanic race were associated with increased ACLF risk by 8% and 17% respectively. Of 20,245 ALD LT listings (3.4%, 84.4%, and 12.2% in G1-G3 respectively), ACLF occurred in 28% candidates. Risk of severe (grade 2 or 3) ACLF was higher by about 1.7 fold in G1, 1.5 fold in females and 20% in Hispanics.

Conclusion: Young age, female gender, and Hispanic race are independently associated with ALD-related burden and ACLF in the United States. If these findings are validated in prospective studies, strategies will be needed to reduce alcohol use in high risk individuals to reduce burden from ALD.
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http://dx.doi.org/10.1111/apt.16461DOI Listing
August 2021

Epidemiology and Prevention of Tuberculosis and Chronic Hepatitis B Virus Infection in the United States.

J Immigr Minor Health 2021 Dec 23;23(6):1267-1279. Epub 2021 Jun 23.

Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA.

Tuberculosis (TB) and chronic hepatitis B virus (CHB) infection can be prevented with treatment and vaccination, respectively. We reviewed epidemiology and guidelines for TB and CHB to inform strategies for reducing United States (U.S.) burden of both infections. Non-U.S.-born, compared to U.S.-born, persons have a 15-, 6-, and 8-fold higher TB incidence and latent TB infection (LTBI) and CHB prevalence, respectively; all infections disproportionately impact non-U.S.-born Asians. TB and CHB each are associated with ~ 10% mortality that results in 7- and 14-years per life lost, respectively. LTBI and CHB have significant gaps in their care cascade as 40% of LTBI and 20% of CHB patients are diagnosed, and 20% of LTBI and CHB diagnosed patients receive treatment. Reducing TB and CHB burden will require healthcare provider-, system-, and policy-level interventions, and increased funding and collaboration between public health departments and healthcare systems.Institutional Review Board Statement: Since this review article did not include primary data on patients and only focused on reviewing published data, approval by an institutional review board was not needed.
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http://dx.doi.org/10.1007/s10903-021-01231-6DOI Listing
December 2021

Prevalence of Latent Tuberculosis Infection Among Persons with Chronic Hepatitis B Virus Infection: A Systematic Review and Meta-Analysis.

Dig Dis Sci 2021 May 30. Epub 2021 May 30.

Tuberculosis Section, Division of Communicable Disease Control and Prevention, Alameda County Public Health Department, 1000 San Leandro Blvd., San Leandro, CA, 94577, USA.

Background: Tuberculosis (TB) and chronic hepatitis B virus infection (HBV) can be prevented through latent tuberculosis infection (LTBI) treatment and HBV vaccination, respectively. Prevalence of LTBI and HBV are six- and ninefold higher among non-US-born compared to US-born persons, respectively. Few studies have described the prevalence of LTBI-HBV co-infection.

Aims: In this study, we estimated LTBI prevalence among persons with chronic HBV.

Methods: We conducted a systematic review and meta-analysis using PubMed from inception through September 1, 2019, and identified and reviewed studies that provided data regarding LTBI prevalence among adults with chronic HBV. Pooled LTBI prevalence among adults with HBV was calculated using a random-effects meta-analysis model.

Results: A total of 1,205 articles were identified by systematic review of the published literature. Six studies were included in the meta-analysis; five studies were conducted in North America, and one was in China. LTBI prevalence among adults with chronic HBV was estimated to be 34.25% (95% confidence interval: 17.88-50.62%).

Conclusion: LTBI prevalence among adults with chronic HBV was two times higher than the LTBI prevalence among all non-US-born persons. The high LTBI prevalence and increased risk of hepatotoxicity with TB medications among persons with chronic HBV may warrant consideration of routine screening for HBV among persons who are tested for LTBI. Reducing morbidity and mortality associated with TB and chronic HBV may require healthcare systems and public health to ensure that persons at risk of both infections are screened and treated for LTBI and chronic HBV.
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http://dx.doi.org/10.1007/s10620-021-07056-5DOI Listing
May 2021

Estimating Prevalence of Hepatitis B Virus Coinfection Among Adults With Tuberculosis: A Systematic Review With Meta-analysis.

J Clin Gastroenterol 2021 Apr 9. Epub 2021 Apr 9.

Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto Department of Medicine, Alameda Health System-Highland Hospital Medical Library Services, Alameda Health System, Oakland Department of Family and Community Medicine, University of California, San Francisco, CA Tuberculosis Section, Division of Communicable Disease Control and Prevention, Alameda County Public Health Department, San Leandro, CA.

Background: While patients with hepatitis B virus (HBV) infection and tuberculosis (TB) have similar risk factors, little is known regarding the prevalence of HBV and TB coinfection. We aim to evaluate the prevalence of HBV among patients with TB across world regions.

Methods: We systematically reviewed the literature using PubMed from inception through September 1, 2019, to identify studies that provided data to calculate HBV coinfection prevalence among adults with TB infection. Prevalence estimates of HBV coinfection among TB patients were stratified by world regions and calculated using meta-analyses with random-effects models.

Results: A total of 36 studies met inclusion criteria (4 from the Africa region, 6 from the Americas region, 5 from the Eastern Mediterranean region, 2 from European region, 6 from Southeast Asia region, and 13 from the Western Pacific region). On meta-analysis, overall pooled HBV coinfection prevalence among TB patients was 7.1%, but varied by world region. Region-specific pooled HBV prevalence among TB patients was highest in Africa region [11.4%, 95% confidence interval (CI): 3.45-19.31] and Western Pacific region (10.8%, 95% CI: 8.68-12.84), and was lowest in the Americas (2.2%, 95% CI: 0.78-3.53). Sensitivity analyses yielded similar HBV prevalence estimates across world regions.

Conclusions: In this meta-analysis, we observed HBV coinfection prevalence among TB patients to be 38% to 450% higher than published estimates from the Polaris group of region-specific overall HBV prevalence. Timely identification of HBV infection among TB patients will improve patient outcomes by allowing for closer clinical monitoring and management, which may reduce the risk of liver dysfunction and liver failure related to TB treatment.
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http://dx.doi.org/10.1097/MCG.0000000000001533DOI Listing
April 2021

ACG Clinical Guideline: Diagnosis and Management of Idiosyncratic Drug-Induced Liver Injury.

Am J Gastroenterol 2021 05;116(5):878-898

University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Idiosyncratic drug-induced liver injury (DILI) is common in gastroenterology and hepatology practices, and it can have multiple presentations, ranging from asymptomatic elevations in liver biochemistries to hepatocellular or cholestatic jaundice, liver failure, or chronic hepatitis. Antimicrobials, herbal and dietary supplements, and anticancer therapeutics (e.g., tyrosine kinase inhibitors or immune-checkpoint inhibitors) are the most common classes of agents to cause DILI in the Western world. DILI is a diagnosis of exclusion, and thus, careful assessment for other etiologies of liver disease should be undertaken before establishing a diagnosis of DILI. Model for end-stage liver disease score and comorbidity burden are important determinants of mortality in patients presenting with suspected DILI. DILI carries a mortality rate up to 10% when hepatocellular jaundice is present. Patients with DILI who develop progressive jaundice with or without coagulopathy should be referred to a tertiary care center for specialized care, including consideration for potential liver transplantation. The role of systemic corticosteroids is controversial, but they may be administered when a liver injury event cannot be distinguished between autoimmune hepatitis or DILI or when a DILI event presents with prominent autoimmune hepatitis features.
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http://dx.doi.org/10.14309/ajg.0000000000001259DOI Listing
May 2021

Low Rates of Hepatitis B Virus Treatment Among Treatment-Eligible Patients in Safety-Net Health Systems.

J Clin Gastroenterol 2021 Mar 17. Epub 2021 Mar 17.

*Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Healthcare System, Palo Alto †Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford ‡Division of Gastroenterology and Hepatology, Alameda Health System-Highland Hospital, Oakland, CA §Division of Infectious Diseases, University of Texas Southwestern Medical Center ∥Parkland Health and Hospital System, Dallas, TX ¶Multi-Organ Transplant Institute, Ochsner Health System, New Orleans, LA #Division of Gastroenterology and Hepatology, MetroHealth System, Cleveland, OH **Medical Technology and Practice Patterns Institute, Bethesda, MD.

Background: Timely initiation of antiviral therapy in chronic hepatitis B virus (CHB) reduces risk of disease progression. We evaluate overall treatment rates and predictors of treatment among treatment-eligible safety-net CHB patients.

Methods: We retrospectively evaluated adults with CHB from 2010 to 2018 across 4 large safety-net health systems in the United States. CHB was identified with ICD-9/10 diagnosis coding and confirmed with laboratory data. Treatment eligibility was determined using American Association for the Study of Liver Diseases (AASLD) guidelines. Comparison of CHB treatment rates among treatment-eligible patients were performed using χ testing, Kaplan Meier methods and log-rank testing. Adjusted multivariate Cox proportional hazards models evaluated independent predictors of receiving treatment among eligible patients.

Results: Among 5157 CHB patients (54.7% male, 34.6% African American, 22.3% Asian), 46.8% were treatment-eligible during the study period. CHB treatment rates were 48.4% overall and 37.3% among CHB patients without human immunodeficiency virus. Significantly lower odds of treatment were observed in females versus males (odds ratio: 0.40, 95% confidence interval: 0.33-0.49, P<0.001) and patients age 65 years or above versus age below 45 years (odds ratio: 0.68, 95% confidence interval: 0.51-0.92, P=0.012). Conversely, significantly greater odds of treatment were observed in African American and Asians versus non-Hispanic whites, CHB patients with indigent care versus commercially insured patients, and non-English speaking versus English speaking patients.

Conclusion: Among a large multicentered, safety-net cohort of CHB patients, 46.8% of treatment-eligible CHB patients overall and 37.3% of treatment-eligible CHB patients without human immunodeficiency virus received antiviral therapy. Improving CHB treatment rates among treatment-eligible patients represents "low hanging fruit," given the clear benefits of antiviral therapy in mitigating disease progression.
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http://dx.doi.org/10.1097/MCG.0000000000001530DOI Listing
March 2021

Low Prevalence of Vaccination or Documented Immunity to Hepatitis A and Hepatitis B Viruses Among Individuals with Chronic Liver Disease.

Am J Med 2021 07 26;134(7):882-892. Epub 2021 Mar 26.

Tuberculosis Section, Division of Communicable Disease Control and Prevention, Alameda County Public Health Department, San Leandro, CA.

Background: Despite national guidelines emphasizing the importance of vaccination or documenting immunity to hepatitis A virus and hepatitis B virus for patients with chronic liver disease, the success of adhering to these recommendations is suboptimal. We aim to evaluate the prevalence of vaccination or documented reactivity to hepatitis A antibody and hepatitis B surface antibody among US adults with chronic liver disease.

Methods: Using 2011-2018 National Health and Nutritional Examination Survey data, adults with nonalcoholic fatty liver disease, alcoholic liver disease, hepatitis B, and hepatitis C were evaluated to determine prevalence of vaccination (self-reported completion) and hepatitis A antibody reactivity or hepatitis B surface antibody reactivity.

Results: Overall prevalence of vaccination or hepatitis A antibody reactivity was lowest among individuals with nonalcoholic fatty liver disease (60.8%; 95% confidence interval [CI], 57.9-63.6) and alcoholic liver disease (61.8%; 95% CI, 59.0-64.6), and highest among individuals with hepatitis B (82.9%; 95% CI, 76.8-89.0). Prevalence of vaccination or hepatitis B surface antibody reactivity was much lower: 38.6% (95% CI, 35.7-41.4) in nonalcoholic fatty liver disease, 40.7% (95% CI, 34.4-47.0) in chronic hepatitis C virus, and 47.1% (95% CI, 44.3-49.9) in alcoholic liver disease.

Conclusion: Among US adults with chronic liver disease, prevalence of vaccination or documented reactivity to hepatitis A antibody and hepatitis B surface antibody was alarmingly low. These observations are particularly concerning given that underlying chronic liver disease increases risks of severe liver injury and decompensation from acute hepatitis A or hepatitis B infections.
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http://dx.doi.org/10.1016/j.amjmed.2021.02.008DOI Listing
July 2021

Ethnicity and Insurance-Specific Disparities in the Model for End-Stage Liver Disease Score at Time of Liver Transplant Waitlist Registration and its Impact on Mortality.

J Clin Exp Hepatol 2021 Mar-Apr;11(2):188-194. Epub 2020 Aug 8.

Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.

Background And Aims: Disparities in timely referral to liver transplantation (LT) evaluation persist. We aim to examine race/ethnicity and insurance-specific differences in the Model for End-Stage Liver Disease (MELD) score at time of waitlist (WL) registration and its impact on WL survival.

Methods: We retrospectively evaluated U.S. adults listed for LT using 2005-2018 United Network for Organ Sharing LT registry. Multiple linear regression methods examined factors associated with MELD at listing, and Fine-Gray competing risks regression were used to analyze WL mortality.

Results: Among 144,163 WL registrants (median age = 56 years, 65.3% male, 56.4% private insurance, 23.3% Medicare, 15.7% Medicaid), mean WL MELD at listing was higher in African Americans versus non-Hispanic whites (2.57 points higher, 95%CI: 2.40-2.74, < 0.001). Compared with patients with private insurance, adjusted mean WL MELD was higher among those with no insurance, Medicare, or Medicaid ( < 0.001 for all). After correcting for differences in MELD at listing, Asians had lower risk of WL death versus non-Hispanic whites (subhazard ratio (SHR): 0.92, 95% CI: 0.86-1.00,  = 0.04), but no difference was observed in African Americans or Hispanics. Compared with patients with private insurance, higher risk of WL death was observed in patients with no insurance (SHR: 1.33, 95%CI: 1.14-1.56, < 0.001), Medicare (SHR: 1.20, 95%CI: 1.16-1.25, < 0.001), or Medicaid (SHR: 1.22, 95%CI: 1.17-1.27, < 0.001).

Conclusion: Higher MELD scores at listing among African Americans did not translate into increased WL mortality. Patients with Medicare, Medicaid, or uninsured had significantly higher WL mortality than privately insured patients, even after correcting for disparities in MELD scores at listing.
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http://dx.doi.org/10.1016/j.jceh.2020.07.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7953015PMC
August 2020

The Association Between Nonalcoholic Fatty Liver Disease and Risk of Cardiovascular Disease, Stroke, and Extrahepatic Cancers.

J Clin Exp Hepatol 2021 Jan-Feb;11(1):45-81. Epub 2020 May 20.

Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland, CA, USA.

Background & Aims: Although primarily a disease with liver-specific complications, nonalcoholic fatty liver disease (NAFLD) is a systemic disease with extrahepatic complications. We aim to evaluate the association between NAFLD and cardiovascular disease (CVD), stroke and cerebrovascular disease, and extrahepatic cancers.

Methods: We searched MEDLINE, EMBASE, and Cochrane Systematic Review Database from January 1, 2000 to July 1, 2019 to identify peer-reviewed English language literature using predefined keywords for NAFLD, CVD, stroke and cerebrovascular disease, and extrahepatic cancers among adults. Two reviewers independently selected studies for inclusion. Measures of association between NAFLD and CVD, stroke and cerebrovascular disease, and extrahepatic cancers were extracted. Quality assessed using Newcastle-Ottawa scale and Grading of Recommendations Assessment, Development and Evaluation (GRADE).

Results: Thirty studies were included evaluating CVD, 16 studies evaluating stroke or cerebrovascular disease, and 13 studies evaluating extrahepatic cancers. On pooled meta-analysis assessment, NAFLD was associated with increased risk of CVD (risk ratio [RR]: 1.78; 95% confidence interval [CI]: 1.52-2.08) and stroke or cerebrovascular disease (RR: 2.08, 95% CI: 1.72-2.51). Significant heterogeneity in assessing extrahepatic cancers prevented applying meta-analysis methods, but NAFLD seemed to be associated with increased risk of breast and colorectal cancers. Overall level of quality of studies were very low by GRADE.

Conclusions: NAFLD is associated with increased risks of CVD and stroke or cerebrovascular disease among adults. There appears to be increased risk of breast and colorectal cancers. Given low quality of evidence, it is premature to make any strong conclusions to modify CVD, stroke, or cancer screening policies in patients with NAFLD.
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http://dx.doi.org/10.1016/j.jceh.2020.04.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897860PMC
May 2020

Ethnicity-Specific Differences in Liver Transplant Outcomes Among Adults With Primary Sclerosing Cholangitis: 2005-2017 United Network for Organ Sharing/Organ Procurement and Transplantation Network.

J Clin Exp Hepatol 2021 Jan-Feb;11(1):30-36. Epub 2020 Jun 15.

Division of Gastroenterology and Hepatology, Alameda Health System - Highland Hospital, Oakland, CA, USA.

Background & Aims: Lack of effective medical therapies for primary sclerosing cholangitis (PSC) leads to continued disease progression to end-stage liver disease requiring liver transplantation (LT). Few studies have specifically evaluated whether ethnic disparities in LT outcomes exist among adults awaiting LT. We aimed to evaluate ethnicity-specific differences in LT outcomes among adults with PSC in the US.

Methods: We retrospectively evaluated US adults (aged ≥ 18 years) with PSC without hepatocellular carcinoma listed for LT using the 2005-2017 United Network for Organ Sharing database. Ethnicity-specific differences in overall waitlist survival and probability of receiving LT were evaluated using competing risks regression analyses and adjusted multivariable Cox proportional hazards models. Overall survival after LT was evaluated with Kaplan-Meier methods and multivariable Cox proportional hazards models.

Results: Among 4046 patients with PSC listed for LT (69.2% men, 82.2% non-Hispanic white, 12.4% African American, 3.9% Hispanic, 1.6% Asian), significantly higher risk of waitlist death was men vs. women (Standardized hazard ratio (SHR) = 1.50, 95% CI: 1.05-2.12,  = 0.025), but no ethnicity-specific differences were observed. Compared with non-Hispanic whites, Hispanics had significantly lower probability of receiving LT (SHR = 0.73, 95% CI: 0.54-0.98,  = 0.035). Among patients with PSC and end-stage liver disease who underwent LT, African Americans had significantly higher risk of post-LT death compared with non-Hispanic whites (SHR = 1.68, 95% CI: 1.21-2.32,  = 0.002).

Conclusions: Among a large cohort of US adults with PSC awaiting LT, significant ethnicity-specific disparities in LT outcomes were observed. Lower probability of LT in Hispanics and significantly higher risk of post-LT death in African Americans were observed.
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http://dx.doi.org/10.1016/j.jceh.2020.06.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897847PMC
June 2020

Antiviral Therapy Reduces Risk of Cirrhosis in Noncirrhotic HBV Patients Among 4 Urban Safety-Net Health Systems.

Am J Gastroenterol 2021 07;116(7):1465-1475

Medical Technology and Practice Patterns Institute, Bethesda, Maryland, USA.

Introduction: To evaluate the impact of chronic hepatitis B virus infection (CHB) treatment on risk of cirrhosis, liver-related outcomes, and death among a diverse CHB cohort with a large proportion of African Americans.

Methods: Adults with noncirrhotic CHB without human immunodeficiency virus from 2010 to 2018 were retrospectively evaluated across 4 US safety-net health systems. CHB was identified with International Classification of Diseases, Ninth Revision/Tenth Revision diagnosis coding and confirmatory laboratory data. Propensity-score matching, Kaplan-Meier methods, and adjusted Cox proportional hazards models were used to evaluate impact of CHB treatment on risk of cirrhosis, hepatocellular carcinoma (HCC), death, and composite of cirrhosis, HCC, or death.

Results: Among 4,064 CHB patients (51.9% female, 42.0% age <45 years, 31.6% African American, 26.6% Asian, 26.7% Hispanic), 23.2% received CHB antiviral therapy and 76.8% did not. Among the propensity score-matched cohort (428 treated and 428 untreated), CHB treatment was associated with lower risk of cirrhosis (hazards ratio 0.65, 95% confidence interval 0.46-0.92, P = 0.015) and composite of cirrhosis, HCC, or death (hazards ratio 0.67, 95% confidence interval 0.49-0.94, P = 0.023). Females vs males and African Americans vs non-Hispanic whites had significantly lower risk of cirrhosis. When treatment effects were stratified by age, sex, and ethnicity, the benefits of antiviral therapies in reducing risk of cirrhosis were seen primarily in CHB patients who were females, age <45 years, and of Asian ethnicity.

Discussion: Our propensity score-matched cohort of noncirrhotic CHB patients demonstrated significant reductions in risk of cirrhosis due to CHB treatment.
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http://dx.doi.org/10.14309/ajg.0000000000001195DOI Listing
July 2021

An Updated Assessment of Chronic Hepatitis B Prevalence Among Foreign-Born Persons Living in the United States.

Hepatology 2021 Aug 26;74(2):607-626. Epub 2021 May 26.

Hepatitis B Foundation, Doylestown, PA.

Background And Aims: Although prevalence of chronic hepatitis B (CHB) in the USA includes 0.42 million (range, 0.28-0.67) U.S.-born persons, foreign-born (FB) persons contribute a substantially larger number to the burden of CHB in the USA. Over the past decade, patterns of U.S. immigration have changed and many countries have implemented HBV prevention programs. This study aims to estimate the number of FB persons with CHB in the USA by country of origin, updating our 2011 study.

Approach And Results: We performed systematic searches for articles published in 2009-2019 reporting HBsAg seroprevalence in emigrants and in-country populations of 117 countries. Data meeting inclusion criteria were combined with data from our 2011 study to calculate pooled prevalence estimates for 99 countries using meta-analyses (total 2,800 surveys involving 112 million subjects). Combining country-specific CHB rate estimates with the number of FB in the USA in 2018, by country of origin from the U.S. Census Bureau, we estimate that the number of FB with CHB in the USA in 2018 was 1.47 million (95% CI, 1.21-1.73), substantially higher than previously reported. The weighted average CHB prevalence for all FB in the USA in 2018 was 3.07%. Approximately 59% of FB with CHB in the USA in 2018 emigrated from Asia, 19% from the Americas, and 15% from Africa. Subgroup analyses found that for many countries, CHB rates are higher in males than females and have declined over the past three decades, but no consistent pattern is observed between emigrant and in-country rates.

Conclusions: Including FB and U.S.-born persons, the total prevalence of CHB in the USA may be as high as 2.4 million.
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http://dx.doi.org/10.1002/hep.31782DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8453838PMC
August 2021

Delays and Gaps in Progressing Through the Hepatitis C Virus Cascade of Care: An Underserved Safety-net Hospital Experience.

J Transl Int Med 2020 Dec 31;8(4):261-267. Epub 2020 Dec 31.

Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA.

Background And Objective: While highly effective hepatitis C virus (HCV) therapies exist, gaps in the cascade of care remain. Disparities in the HCV cascade are prominent among underserved safety-net populations. We aim to evaluate the HCV cascade among an urban safety-net cohort of HCV patients.

Methods: We retrospectively evaluated adults with chronic HCV to determine rates of linkage to care (LTC), retention to care, and receiving HCV treatment from 2002 to 2018. Comparisons between groups utilized Chi-square testing; comparisons of median time to LTC and HCV treatment were evaluated with Student's -test and analysis of variance.

Results: Among 600 chronic HCV patients (60.7% male, 20.7% non-Hispanic white, 49.2% African American, 92.5% treatment naïve, 26.8% cirrhosis), successful LTC within one year of HCV diagnosis was 57.7%, among which, 91.6% were successfully retained into care. In those with successful LTC, 72.6% received HCV treatment, 91.8% completed treatment, and 89% achieved SVR12. Women with HCV experienced longer delays from LTC to HCV treatment (331 . 206 days in men, < 0.05), as did African Americans (280 . 165 days in non-Hispanic whites, < 0.05). Compared to the non-Hispanic whites, HCV treatment was lower in African Americans (70.4% . 74.4%, < 0.05).

Conclusion: Women with HCV experienced significant delays along the HCV cascade, with median time of over 2 years from diagnosis to treatment. African Americans also experienced significant delays along the HCV cascade of care. However, sex and race/ethnicity were not found to be significant predictors of overall LTC or treatment.
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http://dx.doi.org/10.2478/jtim-2020-0039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7805291PMC
December 2020

Trends in the Prevalence of Metabolic Dysfunction-Associated Fatty Liver Disease in the United States, 2011-2018.

Clin Gastroenterol Hepatol 2021 Jan 22. Epub 2021 Jan 22.

Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Healthcare System, Stanford University School of Medicine, Palo Alto, California.

Nonalcoholic fatty liver disease (NAFLD) affects more than 25% of the adult population worldwide and is associated with significant clinical and economic burden. However, heterogeneous definitions and inaccurate terminology contribute to variations in prevalence estimates and may not comprehensively incorporate complex metabolic dysfunctions that exist. An international expert panel consensus proposed updated nomenclature, metabolic dysfunction-associated fatty liver disease (MAFLD), and associated criteria to more accurately capture this complex multisystem metabolic disorder. Although it has not replaced NAFLD, the term MAFLD has been positively received given it more comprehensively incorporates the metabolic derangements that contribute to risk of fatty liver and it may be more practical for clinicians to identify patients with fatty liver. We describe prevalence of MAFLD among US adults based on these recently proposed nomenclature and definition..
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http://dx.doi.org/10.1016/j.cgh.2021.01.030DOI Listing
January 2021

Validating a novel score based on interaction between ACLF grade and MELD score to predict waitlist mortality.

J Hepatol 2021 06 14;74(6):1355-1361. Epub 2020 Dec 14.

Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA; Division of Transplant Hepatology, Avera Transplant Institute, Sioux Falls, SD, USA. Electronic address:

Background & Aims: Among candidates listed for liver transplant (LT), the model for end-stage liver disease (MELD) score may not capture acute-on-chronic liver failure (ACLF) severity. Data on the interaction between ACLF and MELD score in predicting waitlist mortality are scarce.

Methods: We analyzed the UNOS database (01/2002 to 06/2018) for LT listings in adults with cirrhosis and ACLF (without hepatocellular carcinoma). ACLF grades 1, 2, 3a, and 3b- were defined using the modified EASL-CLIF criteria.

Results: Of 18,416 candidates with ACLF at listing (mean age 54 years, 69% males, 63% Caucasians), 90-day waitlist mortality (patient death or being too sick for LT) was 21.6% (18%, 20%, 25%, and 39% for ACLF grades 1, 2, 3a, and 3b, respectively). Using a Fine and Gray regression model, we identified an interaction between MELD and ACLF grade, with ACLF having a higher impact at lower MELD scores. Other variables included candidate's age, sex, liver disease etiology, listing MELD, ACLF grade, obesity, and performance status. A score developed using parameter estimates from the interaction model on the derivation cohort (n = 9,181) stratified the validation cohort (n = 9,235) into quartiles: Q1 (score <10.42), Q2 (10.42-12.81), Q3 (12.82-15.50), and Q4 (>15.50). Waitlist mortality increased with each quartile from 13%, 18%, 23%, and 36%, respectively. Observed vs. expected waitlist mortality deciles in the validation cohort showed good calibration (goodness of fit p = 0.98) and correlation (R = 0.99).

Conclusion: Among selected candidates who have ACLF at listing, MELD score and ACLF interact in predicting cumulative risk of 90-day waitlist mortality, with higher impact of ACLF grade at lower listing MELD score. Validating these findings in large prospective studies will support consideration of both MELD and ACLF when prioritizing transplant candidates and allocating liver grafts.

Lay Summary: In patients with cirrhosis listed for liver transplantation, the presence of multiorgan failure, a condition referred to as acute-on-chronic liver failure, is associated with high waiting list mortality rates. Current organ allocation policy disadvantages patients with this condition. This study describes and validates a new scoring method that performs better than the currently available scoring systems. Further validation of this approach may reduce the deaths of patients with cirrhosis and acute-on-chronic liver failure on the transplant waiting list.
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http://dx.doi.org/10.1016/j.jhep.2020.12.003DOI Listing
June 2021

Lower Likelihood of Post-transplant Graft Failure, Death, and Retransplantation in the Era of Direct-Acting Antivirals.

J Clin Exp Hepatol 2020 Nov-Dec;10(6):581-589. Epub 2020 Feb 21.

Alameda Health System, Highland Hospital, Division of Gastroenterology and Hepatology, USA.

Background: Direct-acting antivirals (DAAs) are expected to improve outcomes for patients with hepatitis C virus (HCV) infection after liver transplantation (LT). We aim to evaluate trends in post-LT outcomes with availability of DAAs.

Methods: We retrospectively evaluated US adults transplanted from January 1, 2002, to March 31, 2018, using the United Network for Organ Sharing Registry, stratified by pre-DAA (January 1, 2002- to December 31, 2013) vs. post-DAA (January 1, 2014-, to March 31, 2018) eras. Adjusted multivariate Cox regression analyses and competing risk models evaluated likelihood of graft failure, death, and retransplantation (re-LT).

Results: Among 97,147 patients, 30.2% had HCV infection and 19.4% had hepatocellular carcinoma (HCC). Of all patients, 31.9% experienced graft failure, 27.1% died after LT, and 4.7% underwent re-LT. The post-DAA era experienced lower likelihood of graft failure (hazard ratio [HR] = 0.69, p < 0.001). Although patients with HCV infection (HR = 1.18, p < 0.001) and HCC (HR = 1.11, p < 0.001) had higher likelihood of graft failure in the pre-DAA era, no differences were seen in the post-DAA era. Although patients with HCV infection (HR = 1.20, p < 0.001) and HCC (HR = 1.17, p < 0.001) had higher likelihood of death after LT in the pre-DAA era, no differences were seen in the post-DAA era. The post-DAA era had lower likelihood of post-LT death when stratified by non-HCC (HR = 0.70, p < 0.001) and HCC cohorts (HR = 0.67, p < 0.001) or by non-HCV (HR = 0.73, p < 0.001) and HCV (HR = 0.58, p < 0.001) cohorts.

Conclusion: Although patients with HCV infection and HCC had higher risk of post-LT graft failure and death in the pre-DAA era, the disparity disappeared in the post-DAA era independently of each other. This likely reflects impact of DAAs on improving post-LT outcomes among patients with HCV infection and improved selection of patients with HCC for LT after 2014.
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http://dx.doi.org/10.1016/j.jceh.2020.02.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719962PMC
February 2020

Trends in mortality in hepatitis C infection and alcoholic liver disease based on drug overdose in the United States.

J Viral Hepat 2021 02 18;28(2):436-439. Epub 2020 Nov 18.

Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA.

We examined trends in mortality from hepatitis C virus (HCV) infection and alcoholic liver disease (ALD) in the setting of drug overdose. Using US Census and national mortality records (2009-2018), we identified deaths with HCV infection, ALD and drug overdose. HCV-related mortality without drug overdose increased up to 2014, followed by a marked decrease. Mortality from HCV and drug overdose increased significantly. Whereas ALD-related mortality without drug overdose continued to rise, no significant trend from ALD with drug overdose was noted. HCV-related mortalities reduced after the introduction of DAA agents, while drug overdose-related mortality in HCV was constantly increased.
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http://dx.doi.org/10.1111/jvh.13435DOI Listing
February 2021

The Effect of Hospital Safety-Net Burden and Patient Ethnicity on In-Hospital Mortality Among Hospitalized Patients With Cirrhosis.

J Clin Gastroenterol 2021 08;55(7):624-630

Toronto Centre for Liver Disease, University Health Network, Toronto General Hospital, University of Toronto, Canada.

Background: Over 2.1 million individuals in the United Stats have cirrhosis, including 513,000 with decompensated cirrhosis. Hospitals with high safety-net burden disproportionately serve ethnic minorities and have reported worse outcomes in surgical literature. No studies to date have evaluated whether hospital safety-net burden negatively affects hospitalization outcomes in cirrhosis. We aim to evaluate the impact of hospitals' safety-net burden and patients' ethnicity on in-hospital mortality among cirrhosis patients.

Methods: Using National Inpatient Sample data from 2012 to 2016, the largest United States all-payer inpatient health care claims database of hospital discharges, cirrhosis-related hospitalizations were stratified into tertiles of safety-net burden: high (HBH), medium (MBH), and low (LBH) burden hospitals. Safety-net burden was calculated as percentage of hospitalizations per hospital with Medicaid or uninsured payer status. Multivariable logistic regression evaluated factors associated with in-hospital mortality.

Results: Among 322,944 cirrhosis-related hospitalizations (63.7% white, 9.9% black, 15.6% Hispanic), higher odds of hospitalization in HBHs versus MBH/LBHs was observed in blacks (OR, 1.26; 95%CI, 1.17-1.35; P<0.001) and Hispanics (OR, 1.63; 95% CI, 1.50-1.78; P<0.001) versus whites. Cirrhosis-related hospitalizations in MBHs or HBHs were associated with greater odds of in-hospital mortality versus LBHs (HBH vs. LBH: OR, 1.05; 95% CI, 1.00-1.10; P=0.044). Greater odds of in-hospital mortality was observed in blacks (OR, 1.27; 95% CI, 1.21-1.34; P<0.001) versus whites.

Conclusion: Cirrhosis patients hospitalized in HBH experienced 5% higher mortality than those in LBH, resulting in significantly greater deaths in cirrhosis patients. Even after adjusting for safety-net burden, blacks with cirrhosis had 27% higher in-hospital mortality compared with whites.
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http://dx.doi.org/10.1097/MCG.0000000000001452DOI Listing
August 2021

Patients with hepatocellular carcinoma from more rural and lower-income households have more advanced tumor stage at diagnosis and significantly higher mortality.

Cancer 2020 01 26;127(1):45-55. Epub 2020 Oct 26.

Division of Gastroenterology and Hepatology, University of South Dakota, Sioux Falls, South Dakota.

Background: Patients from rural and low-income households may have suboptimal access to liver disease care, which may translate into worse HCC outcomes. The authors provide a comprehensive update of HCC incidence and outcomes among US adults, focusing on the effect of rural geography and household income on tumor stage and mortality.

Methods: The authors retrospectively evaluated adults with HCC using Surveillance, Epidemiology, and End Results data from 2004 to 2017. HCC incidence was reported per 100,000 persons and was compared using z-statistics. Tumor stage at diagnosis used the Surveillance, Epidemiology, and End Results staging system and was evaluated with multivariate logistic regression. HCC mortality was evaluated using Kaplan-Meier and multivariate Cox proportional hazards methods.

Results: HCC incidence plateaued for most groups, with the exception of American Indians/Alaska Natives (2004-2017: APC, 4.17%; P < .05) and patients in the lowest household income category (<$40,000; 2006-2017: APC, 2.80%; P < .05). Compared with patients who had HCC in large metropolitan areas with a population >1 million, patients in more rural regions had higher odds of advanced-stage HCC at diagnosis (odds ratio, 1.10; 95% CI, 1.00-1.20; P = .04) and higher mortality (hazard ratio, 1.05; 95% CI, 1.01-1.08; P = .02). Compared with the highest income group (≥$70,000), patients with HCC who earned <$40,000 annually had higher odds of advanced-stage HCC (odds ratio, 1.15; 95% CI, 1.01-1.32; P = .03) and higher mortality (hazard ratio, 1.23; 95% CI, 1.16-1.31; P < .001).

Conclusions: Patients from rural regions and lower-income households had more advanced tumor stage at diagnosis and significantly higher HCC mortality. These disparities likely reflect suboptimal access to consistent high-quality liver disease care, including HCC surveillance.
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http://dx.doi.org/10.1002/cncr.33211DOI Listing
January 2020

Understanding Gaps in the Hepatocellular Carcinoma Cascade of Care: Opportunities to Improve Hepatocellular Carcinoma Outcomes.

J Clin Gastroenterol 2020 Nov/Dec;54(10):850-856

Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford.

Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality. Existing studies have highlighted significant disparities in HCC outcomes, particularly among vulnerable populations, including ethnic minorities, safety-net populations, underinsured patients, and those with low socioeconomic status and high risk behaviors. The majority of these studies have focused on HCC surveillance. Although HCC surveillance is one of the most important first steps in HCC monitoring and management, it is only one step in the complex HCC cascade of care that evolves from surveillance to diagnosis and tumor staging that leads to access to HCC therapies. In this current review, we explore the disparities that exist along this complex HCC cascade of care and further highlight potential interventions that have been implemented to improve HCC outcomes. These interventions focus on patient, provider, and system level factors and provide a potential framework for health systems to implement quality improvement initiatives to improve HCC monitoring and management.
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http://dx.doi.org/10.1097/MCG.0000000000001422DOI Listing
June 2021

Chronic Kidney Disease in Patients with Chronic Liver Disease: What Is the Price Tag?

Hepatol Commun 2020 Oct 30;4(10):1389-1391. Epub 2020 Sep 30.

Division of Gastroenterology and Hepatology Veterans Affairs Palo Alto Health Care System Palo Alto CA.

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http://dx.doi.org/10.1002/hep4.1583DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527759PMC
October 2020

Rural-Urban Geographical Disparities in Hepatocellular Carcinoma Incidence Among US Adults, 2004-2017.

Am J Gastroenterol 2021 02;116(2):401-406

Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, California, USA.

Introduction: To evaluate impact of urbanicity and household income on hepatocellular carcinoma (HCC) incidence among US adults.

Methods: HCC incidence was evaluated by rural-urban geography and median annual household income using 2004-2017 Surveillance, Epidemiology, and End Results data.

Results: Although overall HCC incidence was highest in large metropolitan regions, average annual percent change in HCC incidence was greatest among more rural regions. Individuals in lower income categories had highest HCC incidence and greatest average annual percent change in HCC incidence.

Discussion: Disparities in HCC incidence by urbanicity and income likely reflect differences in risk factors, health-related behaviors, and barriers in access to healthcare services.
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http://dx.doi.org/10.14309/ajg.0000000000000948DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8136433PMC
February 2021

Acute on Chronic Liver Failure From Nonalcoholic Fatty Liver Disease: A Growing and Aging Cohort With Rising Mortality.

Hepatology 2021 May 25;73(5):1932-1944. Epub 2021 Mar 25.

Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA.

Background And Aims: We assessed the burden of nonalcoholic fatty liver disease (NAFLD)-related acute on chronic liver failure (ACLF) among transplant candidates in the United States, along with waitlist outcomes for this population.

Approach And Results: We analyzed the United Network for Organ Sharing registry from 2005 to 2017. Patients with ACLF were identified using the European Association for the Study of the Liver/Chronic Liver Failure criteria and categorized into NAFLD, alcohol-associated liver disease (ALD), and hepatitis C virus (HCV) infection. We used linear regression and Chow's test to determine significance in trends and evaluated waitlist outcomes using Fine and Gray's competing risks regression and Cox proportional hazards regression. Between 2005 and 2017, waitlist registrants for NAFLD-ACLF rose by 331.6% from 134 to 574 candidates (P < 0.001), representing the largest percentage increase in the study population. ALD-ACLF also increased by 206.3% (348-1,066 registrants; P < 0.001), whereas HCV-ACLF declined by 45.2% (P < 0.001). As of 2017, the NAFLD-ACLF population consisted primarily of persons aged ≥60 years (54.1%), and linear regression demonstrated a significant rise in the proportion of patients aged ≥65 in this group (β = 0.90; P = 0.011). Since 2014, NAFLD-ACLF grade 1 was associated with a greater risk of waitlist mortality relative to ALD-ACLF (subhazard ratio [SHR] = 1.24; 95% confidence interval [CI], 1.05-1.44) and HCV-ACLF (SHR = 1.35; 95% CI, 1.08-1.71), among patients aged ≥60 years. Mortality was similar among the three groups for patients with ACLF grade 2 or 3.

Conclusions: NAFLD is the fastest rising etiology of cirrhosis associated with ACLF among patients listed in the United States. As the NAFLD population continues to grow and age, patients with NAFLD-ACLF will likely have the highest risk of waitlist mortality.
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http://dx.doi.org/10.1002/hep.31566DOI Listing
May 2021

Real-world Comorbidity Burden, Health Care Utilization, and Costs of Nonalcoholic Steatohepatitis Patients With Advanced Liver Diseases.

J Clin Gastroenterol 2021 Nov-Dec 01;55(10):891-902

Department of Gastroenterology and Hepatology, Henry Ford Hospital, Wayne State University School of Medicine, Detroit, MI.

Goals: This study evaluates the real-world comorbidity burden, health care resource utilization (HRU), and costs among nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH) patients with advanced liver diseases [compensated cirrhosis (CC), decompensated cirrhosis (DCC), liver transplantation (LT), hepatocellular carcinoma (HCC)].

Background: NAFLD/NASH is a leading cause of liver diseases.

Materials And Methods: Adult NAFLD/NASH patients were identified retrospectively from MarketScan Commercial claims (2006-2016). Following initial NAFLD/NASH diagnosis, advanced liver diseases were identified using the first diagnosis as their index date. Mean annual all-cause HRU and costs (2016 USD) were reported. Adjusted costs were estimated through generalized linear models. Cumulative costs were illustrated for patient subsets with variable follow-up for each stage.

Results: Within the database, 485,774 NAFLD/NASH patients met eligibility criteria. Of these, 93.4% (453,564) were NAFLD/NASH patients without advanced liver diseases, 1.6% (7665) with CC, 3.3% (15,833) with DCC, 0.1% (696) with LT, and 0.1% (428) with HCC. Comorbidity burden was high and increased as patients progressed through liver disease severity stages. Compared with NAFLD/NASH without advanced liver diseases (adjusted costs: $23,860), the annual cost of CC, DCC, LT, and HCC were 1.22, 5.64, 8.27, and 4.09 times higher [adjusted costs: $29,078, $134,448, $197,392, and $97,563 (P<0.0001)]. Inpatient admissions significantly drove increasing HRU.

Conclusion: Study findings suggest the need for early identification and effective management of NAFLD/NASH patients to minimize comorbidity burden, HRU, and costs in the privately insured US population.
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http://dx.doi.org/10.1097/MCG.0000000000001409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8500367PMC
October 2021
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