American Association For The Study Of Liver Diseases Guidelines Research Articles

Low treatment rates in patients meeting guideline criteria in diverse practice settings.

Data on usage of antiviral therapy and application of chronic hepatitis B (CHB) management guidelines in different settings are limited. Our goal is to evaluate the proportion of treatment-eligible patients by 6-month follow-up and treatment rate among eligible patients by 12-month follow-up in diverse settings. In this retrospective cohort study, 1,976 treatment-naïve CHB patients were categorized as primary care physician (PCP) group if seen by community PCP (n = 329), gastroenterology (GI) group if seen by community gastroenterologists (n = 1,268), and hepatology group if seen by university hepatologists (n = 379). Treatment eligibility was based on the US Panel 2008 and American Association for the Study of Liver Diseases (AASLD) 2009 guidelines. All groups had similar age, gender, and ethnic distribution. GI and hepatology groups had similar treatment eligibility rates by US Panel (53-54 %) and AASLD guidelines (24-25 %). However, treatment rate was significantly higher in hepatology compared to GI group by the US Panel guideline (59 vs. 45 %, P = 0.001). PCP group had the lowest eligibility and treatment rates by both guidelines. Common reasons for non-treatment were perceived "normal" alanine aminotransferase, desire for further observation, and patient refusal. Male gender, age >50, and subspecialty care predicted treatment initiation in treatment-eligible patients. Less than half of treatment-eligible patients at primary care clinics received treatment. Community gastroenterology and university liver clinics treated about one-half to two-thirds of eligible patients. Patient and provider education should highlight treatment benefits and the new alanine aminotransferase upper limit of normal.

AASLD clinical practice guidelines: A critical review of scientific evidence and evolving recommendations

The American Association for the Study of Liver Diseases (AASLD) practice guidelines provide recommendations in diagnosing and managing patients with liver disease from available scientific evidence in combination with expert consensus opinions. The aim was to systematically review the evolution of recommendations from AASLD guidelines and identify gaps limiting the evidence-based foundations of these guidelines. Initial and current AASLD guidelines published from January 1998 to August 2012 were reviewed. The AGREE II instrument was used to evaluate rigor and transparency of guideline development. The number of recommendations, distribution of grades (strength or certainty), classes (benefit versus risk), and types of recommendations were evaluated. Whenever possible, multiple versions were evaluated for evolving scientific evidence. A total of 991 recommendations from 28 guidelines on 17 topics were evaluated. From initial to current guidelines, the total number of recommendations increased by 36% (512 to 699). The largest increases were from chronic hepatitis B virus (HBV) (+71), liver transplantation (+53), and autoimmune hepatitis (AIH) (+27). Most current recommendations are grade II (44%) and less than 20% are grade I. The AGREE II evaluation showed global improvement in guideline quality. Both HBV and chronic hepatitis C guidelines had greatest increases in grade I recommendations (+383% and +67%, respectively). The greatest increases in treatment recommendations were from HBV (grade I, +1,150%), liver transplantation (grade II, +112%), and AIH (grade III, +105%).Despite significant increases in the numbers of recommendations within AASLD practice guidelines over time, only a minority are supported by grade I evidence, highlighting the need for developing well-designed investigations to provide evidence for areas of uncertainty and improving the quality of future guidelines in hepatobiliary diseases.

The Utilization of Standardized Order Sets Using AASLD Guidelines for Patients With Suspected Cirrhosis and Acute Gastrointestinal Bleeding

To improve the adherence to AASLD (American Association for the Study of Liver Diseases) guidelines for variceal bleeding, we developed and implemented standardized order sets for gastrointestinal bleeding in our hospital on October 1, 2009. We performed medical record reviews of hospitalized patients with gastrointestinal bleeding with suspected cirrhosis from October 2009 to October 2010 to determine the use of octreotide, prophylactic antibiotics, and endoscopy. We reviewed 300 Medical records and identified 26 patients with suspected cirrhosis and gastrointestinal bleeding who had adequate information to determine whether or not the order set was used. Antibiotic was used in 76% of patients, octreotide was used in 76% of patients, and upper endoscopy was completed in 94% of patients within 24 hours. The use of antibiotics was higher than that used in historical controls in our hospital. Implementation of standardized order sets appears to have improved adherence to standard recommendations. However, larger studies with longer follow-ups are needed to evaluate this effect on clinical outcomes and cost of care.

Screening for hepatocellular carcinoma: The rationale for the American Association for the Study of Liver Diseases recommendations

Screening for hepatocellular carcinoma: The rationale for the American Association for the Study of Liver Diseases recommendations

Contrast-Enhanced Ultrasound (CEUS) in the Diagnostic Algorithm of Hepatocellular and Cholangiocellular Carcinoma, Comments on the AASLD Guidelines

Contrast-enhanced ultrasound (CEUS) has long been present in important guidelines and recommendations for the diagnostic work-up of focal liver lesions in patients with cirrhosis. These guidelines have included the guidelines of the American Association for the Study of Liver Diseases (AASLD) 2005, the Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma, the recommendations of the Japanese Society of Hepatology, and the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) guidelines 2004, 2008 and 2012 (in preparation). Recently, the AASLD removed CEUS from their guidelines in part because of the perceived possibility of false-positive hepatocellular carcinoma (HCC) diagnosis in patients with intrahepatic cholangiocarcinoma (ICC), and in part because CEUS is not available in the USA. This latter factor means that published results are not entirely applicable to a North American population. The present manuscript discusses the diagnostic algorithm of hepatocellular carcinoma and provides information on the differential diagnosis between HCC and ICC.

Reactivation of Hepatitis B During Immunosuppressive Therapy: Potentially Fatal Yet Preventable

Reactivation of Hepatitis B During Immunosuppressive Therapy: Potentially Fatal Yet Preventable

Liver transplantation for hepatocellular carcinoma in clinical practice

Hepatocellular carcinoma (HCC) is an established indication for liver transplantation (LT), but the selection criteria and priority are still debated. To ascertain the number and features of patients with HCC who undergo transplantation in a Western country, the number of patients eligible for LT according to the American Association for the Study of Liver Diseases (AASLD) guidelines, the number of patients who actually undergo transplantation and whether adherence affects survival. This is a retrospective analysis from a multicentre Italian database of 2042 cases of HCC, recruited prospectively and consecutively. Kaplan-Meier (log rank) and Cox multivariate analysis estimated survival. Patients who had undergone transplantation (50, 2.5%, with no change over time) had a median survival of 133 months, significantly influenced by the number of lesions and alpha-fetoprotein levels, which were found to be independent predictors of survival on multivariate analysis. Milan criteria were fulfilled in 68%, impacting on survival, whereas 48% fulfilled AASLD guidelines, without such an impact. Two hundred and twenty-eight (11%) patients were eligible for LT according to AASLD; in this group, alpha-fetoprotein levels and Child-Pugh class were independent predictors of survival. Among patients with HCC, those undergoing LT represent a small minority; even fewer (1%) are those who undergo transplantation according to AASLD guidelines, adherence to which only marginally affects survival. Overall, LT impact on HCC patients' treatment is very limited.

IL28B Polymorphism, Explanation for Different Responses to Therapy in Hepatitis C Patients

: Implication for health policy/practice/research/medical education:This article focuses on impact of IL28B polymorphisms on hepatitis C outcomes. This study is recommended to clinicians and researchers in the field of viral hepatitis. Please cite this paper as:Sharafi H, Alavian SM. IL28B polymorphism, explanation for Different Responses to Therapy in Hepatitis C patients. HepatMon. 2011; 11(12):958-9. DoI: 10.5812/kowsar.1735143X.794

Enhancement pattern of small hepatocellular carcinoma (HCC) at contrast-enhanced US (CEUS), MDCT, and MRI: Intermodality agreement and comparison of diagnostic sensitivity between 2005 and 2010 American Association for the Study of Liver Diseases (AASLD) guidelines

ObjectiveTo evaluate agreement between contrast-enhanced ultrasound (CEUS), multi-detector row computed tomography (MDCT) and magnetic resonance imaging (MRI) for the assessment of typical and atypical enhancement patterns of small hepatocellular carcinoma (HCC); and to compare diagnostic sensitivity of 2005 and 2010 American Association for the Study of Liver Diseases (AASLD) guidelines. Materials and methodsBetween January 2008 and December 2009, we included cirrhotic patients with newly diagnosed 10–20mm HCC imaged at two contrast-enhanced imaging techniques among CEUS, MDCT, and MRI. Dynamic studies were reviewed by two radiologists to assess enhancement pattern. Percentage of cases with concordant findings and Cohen coefficient (k) were calculated. McNemar's test was used to compare sensitivity between 2005 and 2010 AASLD guidelines. ResultsThere were 91 patients (69 M; 22 F; mean age, 68 years) with 96 HCCs, studied with a combination of CEUS and MDCT (n=59), CEUS and MRI (n=26), or MDCT and MRI (n=11). Intermodality agreement for assessment of tumor enhancement pattern was 67% (k=0.294, P=0.001). Typical enhancement pattern was detected coincidentally at two imaging modalities in 50 (52%) HCCs. Sensitivity for the diagnosis of HCC increased significantly using the 2010 AASLD (81/96 (84%) vs. 50/96 (52%), P<0.001). ConclusionsAgreement between two imaging modalities for the detection of typical tumor enhancement pattern was reached in 52% of cases. The 2010 AASLD guidelines significantly increased the sensitivity for the diagnosis of HCC.

What is an adequate liver biopsy? a tertiary centre audit

IntroductionLiver biopsy (LB) remains central to the diagnosis and accurate staging of liver disease. It is, however, an invasive procedure with recognised morbidity and mortality. It is imperative that biopsy...

Think twice if you consider entecavir treatment in cases with lamivudine refractoriness

We read with interest the article by Shim et al.1 concerning the efficacy of entecavir (ETV) in patients with chronic hepatitis B resistant to both lamivudine (LAM) and adeofovir (ADV) or to LAM alone. In this study, they indicated that ETV given at 1 mg/day for 48 weeks resulted in lesser hepatitis B virus (HBV) DNA and alanine aminotransferase (ALT) reduction in the LAM/ADV-resistant group than compared with the LAM-resistant group. They also noted that HBV DNA loss was significantly higher in the LAM-resistant group compared with the LAM/ADV-resistant group (34% versus 10%). However, they showed that virological breakthrough was similar in both groups. They also underlined that virological response at 12 weeks determined the degree of HBV DNA reduction over 48 weeks of therapy, regardless of previous antiviral treatment. In their study, Shim et al. underlined the importance of multidrug resistance in cases with inappropriate use of antivirals in HBV infection. The same authors suggested, in the introduction section, that “in terms of salvage therapy for LAM-resistant or ADV-resistant chronic hepatitis B infection, the American Association for the Study of Liver Diseases (AASLD) practice guideline recommended switching to ETV” monotherapy as an optimal strategy. However, according to the current guidelines, including AASLD 2009,2 European Association for the Study of the Liver 2009,3 and Asian Pacific Association for the Study of the Liver 2008,4 what the authors did seemed to be inappropriate to suggest to the readers. The guidelines mentioned above unanimously indicated that ETV can be recommended as a rescue therapy only for ADV-resistant chronic HBV infection having Asp236-to-Thr236 (N236T) and/or Ala181-to-Thr181/Val181 (A181T/V) substitutions. Contrary to what the authors wrote in the introduction section of their article, AASLD guidelines in 20092 on HBV infection clearly indicate that ETV is not an optimal treatment for LAM-refractory HBV. It is clearly known that Leu180-to-Met180 (L180M) + Met204-to-Val204 (M204V) and L180M + M204V + Asn236-to-Thr236 (N236T) mutants behaved 6.25-fold resistant to ETV compared with wild-type HBV.5 We also know that genotypic resistance to ETV will develop at a rate of 43% at the end of 4 years.6 Expectedly, two patients in the series of Shim et al.1 developed virological breakthrough with Ser202-to-Gly202 (S202G) ETV resistance substitutions at 36 weeks of treatment, and one patient developed biochemical breakthrough in the LAM-resistant group of patients. Unfortunately, the readers were not informed in this article how the authors treated these two cases in their series. Another relevant article in this field showed that although HBV DNA suppression was achieved in a higher percentage of patients, there was an emergence of nearly 8% resistance to ETV monotherapy in cases with previous LAM resistance in year 2.7 Thus, this strategy led to selection of multidrug-resistant HBV strains with maximal viral resistance in the near future. Another concern with this article is that the authors also underlined the impact of 1 log HBV DNA reduction at 12 weeks on antiviral efficacy at 48 weeks. However, it would be more valuable if they could provide us with the threshold level of HBV DNA reduction at 12 weeks to achieve HBV undetectability in their cases. As a result, the authors in this article1 tested an approach which is absolutely not valid and nor practical at present. Currently, we believe that ETV monotherapy is not a good alternative as a rescue therapy for cases with LAM and or LAM/ADV resistance, whereas continued treatment resulted in virus suppression in a higher percentage of patients in the series of Shim and colleagues. ETV is obviously not a drug with a high genetic barrier to resistance in the setting of LAM refractoriness. In such situations, we have to admit the effectiveness of other alternative drugs, including tenofovir. Yucel Ustundag*, Omer Topalak , * Zonguldak Karaelmas University School of Medicine, Department of Internal Medicine, Gastroenterology Clinics, Zonguldak, Turkey, Dokuz Eylül University School of Medicine, Department of Internal Medicine, Gastroenterology Clinics, Izmir, Turkey.

Early and very early hepatocellular carcinoma: when and how much do staging and choice of treatment really matter? A multi-center study

BackgroundA consensus on the most reliable staging system for hepatocellular carcinoma (HCC) is still lacking but the most used is a revised Barcelona Clinic Liver Cancer (BCLC) system, adopted by the American Association for the Study of Liver Diseases (AASLD). We investigated how many patients are diagnosed in "very early" and "early" stage, follow the AASLD guidelines for treatment and whether their survival depends on treatment.MethodsData were collected in 530 "very early" and "early" HCC patients recruited by a multicentric Italian collaborative group (ITA.LI.CA). The Kaplan-Meier method was used to estimate overall survival and the log rank to test the statistical significance of difference between groups. Cox's multivariate stepwise regression analysis was used to pinpoint independent prognostic factors and the adjusted relative risks (hazard ratios) were calculated as well. A statistical analysis based on the chi-square test was used to identify significant differences in clinical or pathological features between patients. A P-value < 0.05 was considered statistically significant.Results"Very early" HCC were 3%; Cox multivariate analysis did not identify variables independently associated with survival. The patients following AASLD recommendations (20%) did not show longer survival. In "early" HCC patients (25%), treatment significantly modulated survival (p = 0.0001); the 28% patients treated according to the AASLD criteria survived longer (p = 0,004). The Cox analysis however identified only age, gender, number of lesions and Child class as independent predictors of survival.Conclusionpatients with very early" HCC were very few in this analysis. In most instances they were not treated with the treatment suggested as the most appropriate by the AASLD guidelines and the type of treatment had no impact on survival, even though the number of patients was relatively low and part of the patients were diagnosed before the introduction of the guidelines: this analysis, therefore, might not be considered as conclusive and should be validated. The "early" stage group involved more patients, rarely treated according to the guidelines, both overall and also in those diagnosed after their publication; the survival was in part predicted by the type of treatment, with better results in those treated according to AASLD indications.

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TO TREAT OR NOT TO TREAT: BIAS AND BARRIERS TO HEPATITIS C CARE AMONG THE HOMELESS OF SKID ROW.

Background The prevalence of hepatitis C virus (HCV) among the homeless population occupying the Skid Row District of Los Angeles County is an estimated 54%, compared with a national prevalence of 1.6%. Yet although the need for treatment among the homeless is dire, almost none receive treatment for the disease. Purpose The purpose of this study is to illuminate the systemic barriers to HCV treatment for the homeless. Methods We conducted a secondary analysis of a cross-sectional survey of 534 homeless adults in Skid Row selected by two-stage probability sampling in 2003. Comparing LA County HCV treatment eligibility guidelines to consensus-based guidelines from the American Association for the Study of Liver Diseases (AASLD), our study participants were categorized into four groups: eligible for treatment, eligible for treatment at the provider9s discretion, contraindicated for treatment, and no treatment guidance offered. Results In our sample of 534 homeless patients, 28% were HCV positive. Of these, only 5% would be offered treatment, 33% would be offered treatment at the discretion of the provider, and 32% were deemed ineligible for treatment using AASLD guidelines. For the 30% of patients who were suffering from severe mental illness or drug use without rehabilitation, no recommendations for treatment were offered at all. Not a single homeless person, by contrast, would be deemed eligible for treatment under LA County guidelines. Conclusions Evidence-based revisions to LA County and AALSD guidelines are recommended to better meet the unique treatment needs of the HCV-positive homeless community.

Evaluation for liver transplantation: Adherence to AASLD referral guidelines in a large veterans affairs center

Access of patients to liver transplantation involves three levels: referral for evaluation for transplantation, placement on a waiting list for transplantation, and receipt of a liver transplant. No study has formally evaluated access to liver transplantation at the referral level. Therefore, we sought to estimate the magnitude and determinants of consideration of liver transplantation in patients at a single, large Veterans Affairs medical center. Patients with liver disease were identified between October 2002 and September 2003, and their entire medical records were examined for encounters involving potential indications for liver transplantation according to American Association for the Study of Liver Diseases (AASLD) guidelines, mention of liver transplantation, and potential contraindications. Liver transplantation was mentioned in only 59 (20%) of 300 encounters, constituting 41 (21%) of 199 patients satisfying AASLD guidelines for referral. The significant negative independent determinants of mention of liver transplantation were older age (adjusted odds ratio [OR]: 0.31; 95% confidence interval [CI]: 0.13-0.77, P = 0.01), alcoholic liver disease (adjusted OR: 0.10; 95% CI: 0.02-0.57, P = 0.01), and black race (OR: 0.15; 95% CI: 0.02-0.96, P = 0.045). Most patients had potential contraindications that were inferred (but not documented) as reasons for not being evaluated for transplantation; however, a small but significant proportion (7%) had no recorded evidence of contraindications. In conclusion, we found a low rate of mention of liver transplantation in patients who satisfied AASLD guidelines for referral, particularly among patients with alcoholic liver disease and blacks. Deficiencies at the referral level may lead to disparities at further levels of access to liver transplantation.