Canadian liver journal最新文献

Background: No Canadian studies examined the economic impact of hepatitis B virus (HBV) using population-based, patient-level data. We determined attributable costs associated with HBV from a health care payer perspective.

Methods: We conducted an incidence-based, matched cohort, cost-of-illness study. We identified infected subjects (positive HBV surface antigen, DNA, or e-antigen) between 2004 and 2014, using health administrative data. The index date was the first positive specimen. The cohort was organized into three groups: no HBV-related complications, HBV-related complications before index date, and HBV-related complications post-index date. To evaluate costs (2017 Canadian dollars), we adopted the phase-of-care approach defining six phases. Mean attributable costs were determined by evaluating mean differences between matched pairs. Hard match variables were sex, age group, index year, rurality, neighbourhood income quintile, comorbidities, and immigrant status. Costs were combined with crude survival data to calculate 1-, 5-, and 10-year costs.

Results: We identified 41,469 infected subjects with a mean age of 44.2 years. The majority were males (54.7%), immigrants (58.4%), and residents of major urban centres (96.8%). Eight percent had HBV-related complications before index date and 11.5% had them post index date. Across groups, mean attributable costs ranged from CAD $27-$19 for pre-diagnosis, CAD $167-$1,062 for initial care, CAD $53-$407 for continuing care, CAD $1,033 for HBV-related complications, CAD $304 for continuing care for complications, and CAD $2,552-$4,281 for final care. Mean cumulative 1-, 5-, and 10-year costs ranged between CAD $253-$3,067, $3,067-$20,349, and $6,128-$38,968, respectively.

Conclusions: HBV is associated with long-term economic burden. These results support decision-making on HBV prevention and monitoring strategies.

Background: Progressive cholestasis of northwestern Quebec (PCNQ) is a rare and severe form of cirrhosis affecting children from Quebec's First Nations. First described by our group in 1981 and historically named North American Indian childhood cirrhosis, such a condition often requires liver transplantation during the pediatric age. This study aimed at suggesting a more culturally sensitive name for the disease and identifying early prognostic factors for an unfavourable outcome.

Methods: We retrospectively collected data of all 14 consecutive patients diagnosed with PCNQ over the last 20 years and compared children listed for liver transplant before 18 years of age (LT, n = 7) to those with milder disease progression (no-LT, n = 7).

Results: Compared with the no-LT group, LT children developed serious complications with an unusually high incidence of gastrointestinal bleeding. Over the first 12 months from presentation, a greater increase of alanine aminotransferase plasma levels, decrease of total bilirubin, and increase of alanine aminotransferase-to-total bilirubin ratio was observed in the LT group. Bone mineral density was lower in LT children independently of vitamin D levels. Patients with PCNQ showed poorer bone health than age-matched children with other cholestatic disorders.

Conclusions: In the name of cultural sensitivity, PCNQ should be the preferred name for this condition. Variation of alanine aminotransferase and total bilirubin plasma levels over the first 12 months from presentation might be used for the early identification of children with PCNQ who are at higher risk of unfavourable outcomes. This might help optimize clinical management to populations that are underserved by health care services.

Background: Liver transplantation (LT) is the only curative treatment for cirrhosis. However, the presence of complications can impact outcomes following LT. Sarcopenia, or muscle mass loss, is highly prevalent in patients with cirrhosis and is associated with longer hospitalization stays and a higher infection rate post-surgery. We aimed to identify patients at higher risk of early sarcopenia post-LT.

Methods: This retrospective study included 79 cirrhotic patients who underwent LT. Muscle mass was evaluated using the third lumbar spine vertebra skeletal muscle index (SMI) and sarcopenia was defined using established cut-off values. Computerized tomography (CT) scans performed within a six-month peri-operative period (three months pre- and post-LT) were included in the study. Complications and comorbidities were collected and correlated to SMI post-LT and predictive models for SMI post-LT were constructed.

Results: The overall prevalence of sarcopenia was 46% and 62% before and after LT, respectively. Newly developed sarcopenia was found in 42% of patients. Post-LT sarcopenia was associated with longer hospital stays (54±37 versus 29±10 days, p = 0.002), higher number of infection (3±1 versus 1±2, p = 0.027), and greater number of complications (5±2 versus 3±2, p < 0.001) compared to absence of sarcopenia. Multivariate analyses showed that the SMI post-LT was independently associated with pre-LT renal function markers, the glomerular filtration rate (GFR) and creatinine (Model 1, GFR: β = 0.33; 95% CI 0.04-0.17; p = 0.003; Model 2, Creatinine: β = -0.29; 95% CI -0.10 to -0.02; p = 0.009).

Conclusions: The present study highlights the potential role of renal dysfunction in the development and persistence of sarcopenia after LT.

Background: Two remote First Nations communities each collaborated with an urban-based liver clinic to organize wide-spread testing, followed by linkage to care for hepatitis C virus (HCV).

Method: Involvement of community members was central to planning and conduct of the programs. Samples were obtained using dry blood spot cards (DBS). A week-long pilot study in Community 1 investigated the effectiveness of the program, using DBS. Community 2, being larger, more remote, and known to be endemic for HCV was more challenging. Three-week-long testing drives plus a stand-alone testing day were used to collect samples over 5 months. Public Health Agency (PHAC)'s National Laboratory for HIV Reference Services (NLHRS) received and tested the DBS samples for HCV and other blood-borne infections. Outcomes were measured by number of people tested, the quality of the tests, and community members' satisfaction with the program and retained knowledge about HCV, based on interviews.

Results: In Community 1, 226 people were tested for HCV over 4 days. 85% agreed to human immunodeficiency virus (HIV) testing as well. In Community 2, 484 people, one-half of the adult population, were tested. Surveys of participants showed food was the most significant draw, and Facebook the most effective way to inform people of the events. Interviews with staff and participants showed a high level of satisfaction.

Conclusion: The results suggest this is an effective approach to testing for HCV in unusually challenging settings. Lessons from the program include the power of community involvement; and the effectiveness of a highly targeted health initiative when developed through collaboration.

Background: With new treatments for non-alcoholic fatty liver disease (NAFLD) on the horizon, it will be important to risk-stratify patients based on degree of fibrosis to allocate treatment to those at highest risk. No studies have examined the complication rates of liver biopsies in patients with NAFLD in the outpatient setting.

Methods: We conducted a retrospective chart review of all outpatient elective liver biopsies for NAFLD at a tertiary care centre over a 10-year period. Demographic variables and stage of fibrosis were recorded. Complications up to 1 week post-procedure were recorded. We used univariate logistic regression models to estimate the odds of major complications by fibrosis stage, age, sex, platelets, and international normalized ratio (INR).

Results: There were 582 biopsies reviewed in total. The mean age was 53 years. There was an even proportion of males to females. The mean fibrosis stage was 1.9; platelet count was 223.9, INR was 1, and partial thromboplastin time (PTT) was 31. Major complications occurred in 8 out of 582 biopsies (1.4%). Bleeding accounted for 6 of the major complications observed, while infection and pneumoperitoneum each occurred once. There were no statistically significant associations between age (odds ratio [OR] 0.97, 95% CI 0.92-1.03), female sex (OR 1.00, 95% CI 0.25-4.04), platelet count <150 (OR 0.59, 95% CI [-inf.], 3.86), INR >1.3 (OR 0.47, 95% CI 0.057-3.85), fibrosis stage, and complication rate.

Conclusions: Our results are consistent with previous studies examining complication rates in other patient populations and clinical settings and support the overall safety of liver biopsies.

Background: Non-alcoholic fatty liver disease (NAFLD) is common with widely ranging severity. Non-invasive risk scores for risk stratification are recommended but misclassify a significant proportion of patients. In situations where non-invasive risk scores do not provide guidance, referral is typically made to a Hepatologist for transient elastography or liver biopsy. Serum ferritin is elevated in many patients with NAFLD related to dysmetabolic and inflammatory hyperferritinemia. Ferritin is widely available and part of a standard workup for chronic liver disease.

Methods: To explore the association of ferritin and risk of fibrosis in NAFLD, we reviewed patients diagnosed with NAFLD at the hepatology clinic of the Vancouver General Hospital between the years of 2015 and 2018. We collected data on 317 patients retrospectively assessing for a relationship between serum ferritin and elastography score.

Results: Two hundred twenty-four patients were included in the final analysis. Median ferritin was 145 µg/L (IQR 62-311). Median liver stiffness was 5.2 kPa with 14.3% of patients having liver stiffness ≥8.7 kPa and 17.4% ≥ 8.0 kPa. ROC curve analysis using a liver stiffness ≥8.0 kPa as a cutoff for F2 fibrosis showed an AUROC of 0.54 for serum ferritin levels. At a cut-off of both 300 µg/L; and 450 µg/L median liver stiffness did not differ significantly in those with ferritin above the cutoff (ferritin ≥300 µg/L; p = 0.099, ferritin ≥450 µg/L; p = 0.12). Ferritin was significantly higher in male patients (198 versus 91 µg/L; p = 0.0001). There was a weak linear association between AST and ferritin levels.

Conclusion: In this cohort of 224 patients with NAFLD, serum ferritin was not predictive of significant liver fibrosis.

Background: Indigenous populations experience higher rates of hepatitis C virus (HCV) infections in Canada. The Extension for Community Health Outcomes+ (ECHO+) telehealth model was implemented in Alberta to support HCV screening and treatment, using Zoom technology to support Indigenous patient access to specialist care closer to home. Our goal was to expand this program to more Indigenous communities in Alberta, using various Indigenous-led or co-designed methods.

Methods: The ECHO+ team implemented a Two-Eyed Seeing framework, incorporating Indigenous wholistic approaches alongside Western treatment. This approach works with principles of respect, reciprocity, and relationality. The ECHO+ team identified Indigenous-specific challenges, including access to liver specialist care, HCV awareness, stigma, barriers to screening and lack of culturally relevant approaches.

Results: Access to HCV care via this program significantly increased HCV antiviral use in the past 5 years. Key lessons learned include Indigenous-led relationship building and development of project outputs in response to community needs influences impact and increases relevant changes increasing access to HCV care. Implementation of ECHO+ was carried out through biweekly telehealth sessions, problem solving in partnership with Indigenous communities, increased HCV awareness, and flexibility resulting from the impacts of COVID-19.

Conclusion: Improving Indigenous patient lives and reducing inequity requires supporting local primary health care providers to create and sustain integrated HCV prevention, diagnosis, treatment, and support services within a culturally safe and reciprocal model. ECHO+ uses telehealth and culturally appropriate methodology and interventions alongside multiple stakeholder collaborations to improve health outcomes for HCV.

Background: Forty percent of hepatitis B carriers have no knowledge of their diagnosis. A prior study in British Columbia suggested high rates of hepatitis B among immigrants. The authors undertook a large-scale screening study to validate these rates.

Methods: Attendees at Asian health fairs without knowledge of their hepatitis B status participated. They completed a questionnaire, and blood was drawn for HBV serologies. Active HBV was defined as HBV surface antigen positive.

Results: Of 2,726 patients, 1,704 (62.5%) were female and 1,022 (37.5%) male. Mean age was 62.7 (SD 22.1) years, and mean time of residing in Canada was 27.5 (SD 15.3) years. Most patients originated from China (1,042 patients, 38.2%) and Hong Kong (871, 31.2%). Fifty-six patients tested positive (seroprevalence rate 2.05%, 95% CI 1.52%-2.59%). Most seropositive patients were from China (28 patients, 50.0%). Mean time of residence in Canada for seropositive patients (23.8 [SD 2.1] y) was less than seronegative patients (27.6 [SD 0.3] y) (p = 0.06). There was a trend towards association of seropositivity with time of residence in Canada (OR 0.98, 95% CI 0.96-1.00, p = 0.09). 8 (14.3%) seropositive patients did not have family doctors, compared with 128 (4.8%) seronegative patients. Lack of a family doctor was strongly associated with seropositivity (OR 3.31, 95% CI 1.32-7.25, χ2 = 10.42, p = 0.001).

Interpretation: The authors have shown that high risk immigrant populations may have seroprevalence rates as high as 2,700 per 100,000. Lack of a family physician was associated with seropositivity. These results should be used to design improved outreach programs.