Liver disease: Better monitoring, better prognosis

The latest research in liver disease being presented at Digestive Disease Week® 2009 (DDW®) has important implications for tracking disease development in patients and for current and future transplant recipients. Researchers are making great strides in diagnosing and treating liver disease.

“The research being presented during DDW shows how widespread our efforts are in understanding and treating liver disease,” said Brent Tetri, MD, Saint Louis University. “These studies take us one step closer to better monitoring of liver disease, improving our ability to accurately determine prognosis, more appropriate organ allocation and lower rejection rates in liver transplantation.”

DDW is the largest international gathering of physicians and researchers in the fields of gastroenterology, hepatology, endoscopy and gastrointestinal surgery.

Text Messaging Reduces Rejection in Pediatric Liver Transplant Recipients (Abstract #175)

Text messaging may improve compliance rates in pediatric liver transplant recipients, reduce organ rejection and provide significant cost savings with medications and hospitalizations, according to a new study. Children and adolescents who receive liver transplants often have trouble remembering to take their medication regularly; in addition to being less vigilant than adults, liver patients also suffer memory problems. Missing medication is especially dangerous since their bodies can reject the transplanted liver after only two missed doses of medication. But because young people are generally technologically savvy, researchers sought to determine whether sending text messages would result in improved adherence.

The study looked at 41 young people who were on average 15 years old and at various stages after receiving a liver transplant. The MediM AS system from CareSpeak Communications, which funded the study, was used to decide which time of day patients/or caregivers preferred to receive a medication reminder via text message, which were then sent accordingly. To ensure that patients not only received the message but also took their medication, patients had 15 minutes to send a reply text confirming intake. If they did not, MediM AS system would automatically alert their parents to follow up with their child via another text message. Researchers tracked by computer how many times patients replied, did not reply or had to have parental intervention.

To determine the effectiveness of the text reminders, researchers looked at two factors: the level of medication in the patient’s blood and whether their bodies rejected the liver transplant. Patients who took medication erratically had a higher deviation of medication in their blood, compared to patients who took their medication regularly. In the year prior to the study, 12 of 41 patients experienced rejection that required hospitalization and treatment because the patient’s body rejected the transplant due to improper medication dosage. But one year into this study, just two patients suffered rejection of the liver.

Lead investigator Tamir Miloh, MD, assistant professor in pediatric hepatology and surgery at Mount Sinai Hospital in New York, said that since one liver transplant for graft loss costs a few hundred thousand dollars, and with the costs associated with rejection therapy, the text reminders may help save resources and reduce complications of rejection therapy. “The implications for this study are vast because this practice could be used for many other chronic diseases,” said Dr. Miloh, who is currently conducting another randomized study with more patients.

Previous studies have looked at the effectiveness of text reminders, but not on liver patients and not on a scale of this size.

Dr. Miloh will present these data on Sunday, May 31 at 2:45 p.m. CDT in South Hall, McCormick Place.

The Point of Care 13C Methacetin Breath Test Accurately Predicts Long Term Prognosis with Chronic Liver Disease: A Non-Invasive Liver Function Test (Abstract #S1837)

Researchers at the Hadassah Hebrew University Medical Center in Israel have discovered an effective new tool for assessing the prognosis of patients with chronic liver disease that could have important implications in determining which patients are most appropriate candidates for liver transplantation.

Previously, prognosis in patients with chronic liver disease has been determined by using a combination of blood tests. However, this method is limited to predicting prognosis for up to three months and may only change after a life threatening complication has occurred.

Using a test called the 13C-Methacetin breath test, a rapid, non-invasive procedure, investigators were able to accurately predict the survival of liver disease patients for a period of up to two years. The test is conducted with the patient drinking a cup of water containing a dissolved substrate. The device then measures the appearance of tagged CO2 (the product of the hepatic metabolism of the 13C-Methacetin) in the exhaled breath; the patient does not do anything except sitting and breathing normally.

Studying 575 patients with varying types and degree of liver disease, investigators showed that the breath test can predict which patients will develop complications that will affect their prognosis.

“The potential for this test is tremendous,” said Gadi Lalazar, MD, of the liver unit at the Hadassah Hebrew University Medical School. “Not only can we predict long term prognosis in patients with chronic liver disease, but we can also use it in acute liver disease to determine liver function on a daily basis and determine how well therapy is working. This is something we have never been able to do before.”

Researchers believe that the accuracy of the test, and its capacity to assess liver function, makes the breath test a potentially powerful new tool in predicting prognosis of liver related complications, prioritizing patients for organ transplantation, and predicting their ability to survive surgery.

Dr. Lalazar will present these data on Sunday, May 31 at 8 a.m. CDT in South Hall, McCormick Place.

Cumulative Incidence and Risk Factors of Hepatocellular Carcinoma (HCC) in Patients with End-Stage Liver Disease Secondary to Nonalcoholic Steatohepatitis (Abstract #290)

There is a significant risk of developing of liver cancer in patients with nonalcoholic steatohepatitis, or NASH, according to a study from the Cleveland Clinic. The study also found that mild alcohol consumption may significantly increase the risk of developing liver cancer in patients with end stage liver disease.

NASH is one of two stages of non-alcoholic fatty liver disease, the most common liver disease in the U.S. Unlike the benign stage known as fatty liver, NASH has the potential to cause cirrhosis and liver failure. Until now, evidence linking NASH with liver cancer has been limited and inconsistent.

In a retrospective study of more than 500 patients with either HCV-cirrhosis (hepatitis C) or NASH-cirrhosis over a three year period, researchers found that 20 percent of patients with HCV-cirrhosis and 12.8 percent of patients with NASH-cirrhosis developed hepatocellular carcinoma (liver cancer). The annual risk for developing liver cancer in HCV patients is 4 percent per year and that of NASH patients is 2.6 percent per year. The annual risk for NASH patients was previously unknown. While the rates are higher for patients with HCV, the risk of developing liver cancer for NASH patients is significant.

Investigators also sought to identify modifiable risk factors in effort to potentially reduce the burden of liver cancer in this patient population. They found that even mild alcohol consumption may significantly increase the liver cancer risk in patients with end-stage liver disease.

“This study offers valuable insight into the care of patients with NASH,” said Nizar N. Zein, MD, chief of hepatology and medical director of liver transplantation at the Cleveland Clinic. “Not only do we need to adjust the way we follow these patients, including tracking and preparing for the potential development of liver cancer, but we may also need to counsel this patient population against any alcohol intake given its risk.”

Dr. Zein will present these data on Monday, June 1 at 8:45 a.m. CDT in S105, McCormick Place.

Public Awareness and Attitudes towards Non Alcoholic Fatty Liver Disease (NAFLD) (Abstract #T1006)

Patient awareness of non-alcoholic fatty liver disease (NAFLD) and its complications is poor and must be improved to ensure prevention, detection and treatment of the condition. NAFLD is the most common cause of abnormal liver enzymes and one of the most common causes of cirrhosis of the liver in the U.S. It poses a significant health burden worldwide. In the U.S., chronic liver disease and cirrhosis are the tenth leading cause of death.

Researchers conducted a survey of 5,000 outpatient adults asking about awareness levels of NAFLD and its risk factors. Ninety-eight percent of the patients said their physicians had never talked about NAFLD with them. By contrast, a previous study on colorectal cancer found that 40 percent were aware of that disease and its risk factors.

“It is both disturbing and significant that a surprisingly high number of respondents were uninformed about this silent but deadly disease,” said Sury Anand, MD, chief of gastroenterology at Brooklyn Hospital Center.

The survey also found that 95 percent did not realize that fat in the liver could cause serious health problems and 80 percent had never heard of cirrhosis. Dr. Anand said prevention is especially critical since treatment options for NAFLD are limited. Public awareness of NAFLD must rise to the level of other chronic diseases and conditions, which can best be achieved with the active participation of primary care physicians, pediatricians and other providers in counseling their patients to adopt preventive lifestyle modifications.

He recommends that doctors encourage patients to maintain healthy weight by having a good balanced diet and regular exercise to fend off NAFLD in the similar way that patients need to limit their carbohydrate intake in order to prevent prediabets and diabetes. The study subjects were all from Brooklyn, New York, and Dr. Anand said investigators may consider a follow-up study that surveys a larger group throughout the country. His group intends to survey primary physicians’ and residents’ awareness about NAFLD.

Dr. Nan Sandar will present these data on Tuesday, June 2 at 8 a.m. CDT in South Hall, McCormick Place.

DDW is the largest international gathering of physicians, researchers and academics in the fields of gastroenterology, hepatology, endoscopy and gastrointestinal surgery. Jointly sponsored by the American Association for the Study of Liver Diseases, the AGA Institute, the American Society for Gastrointestinal Endoscopy and the Society for Surgery of the Alimentary Tract, DDW takes place May 30 – June 4, 2009, at the McCormick Place Convention Center. The meeting showcases approximately 5,000 abstracts and hundreds of lectures on the latest advances in GI research, medicine and technology. For more information, visit www.ddw.org.

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