Background and Aims
HCC is a leading cause of mortality in patients with advanced liver disease and is associated with significant morbidity. Despite multiple available curative and palliative ...treatments, there is a lack of systematic evaluation of patient‐reported outcomes (PROs) in HCC.
Approach and Results
The American Association for the Study of Liver Diseases Practice Metrics Committee conducted a scoping review of PROs in HCC from 1990 to 2021 to (1) synthesize the evidence on PROs in HCC and (2) provide recommendations on incorporating PROs into clinical practice and quality improvement efforts. A total of 63 studies met inclusion criteria investigating factors associated with PROs, the relationship between PROs and survival, and associations between HCC therapy and PROs. Studies recruited heterogeneous populations, and most were cross‐sectional. Poor PROs were associated with worse prognosis after adjusting for clinical factors and with more advanced disease stage, although some studies showed better PROs in patients with HCC compared to those with cirrhosis. Locoregional and systemic therapies were generally associated with a high symptom burden; however, some studies showed lower symptom burden for transarterial radiotherapy and radiation therapy. Qualitative studies identified additional symptoms not routinely assessed with structured questionnaires. Gaps in the literature include lack of integration of PROs into clinical care to guide HCC treatment decisions, unknown impact of HCC on caregivers, and the effect of palliative or supportive care quality of life and health outcomes.
Conclusion
Evidence supports assessment of PROs in HCC; however, clinical implementation and the impact of PRO measurement on quality of care and longitudinal outcomes need future investigation.
The burden of HCC is substantial. To address gaps in HCC care, the American Association for the Study of Liver Diseases (AASLD) Practice Metrics Committee (PMC) aimed to develop a standard set of ...process‐based measures and patient‐reported outcomes (PROs) along the HCC care continuum. We identified candidate process and outcomes measures for HCC care based on structured literature review. A 13‐member panel with content expertise across the HCC care continuum evaluated candidate measures on importance and performance gap using a modified Delphi approach (two rounds of rating) to define the final set of measures. Candidate PROs based on a structured scoping review were ranked by 74 patients with HCC across 7 diverse institutions. Out of 135 measures, 29 measures made the final set. These covered surveillance (6 measures), diagnosis (6 measures), staging (2 measures), treatment (10 measures), and outcomes (5 measures). Examples included the use of ultrasound (± alpha‐fetoprotein AFP) every 6 months, need for surveillance in high‐risk populations, diagnostic testing for patients with a new AFP elevation, multidisciplinary liver tumor board (MLTB) review of Liver Imaging‐Reporting and Data System 4 lesions, standard evaluation at diagnosis, treatment recommendations based on Barcelona Clinic Liver Cancer staging, MLTB discussion of treatment options, appropriate referral for evaluation of liver transplantation candidacy, and role of palliative therapy. PROs include those related to pain, anxiety, fear of treatment, and uncertainty about the best individual treatment and the future. The AASLD PMC has developed a set of explicit quality measures in HCC care to help bridge the gap between guideline recommendations and measurable processes and outcomes. Measurement and subsequent implementation of these metrics could be a central step in the improvement of patient care and outcomes in this high‐risk population.
Nonalcoholic steatohepatitis (NASH) is common in morbidly obese persons. Liver biopsy is diagnostic but technically challenging in such individuals. This study was undertaken to develop a clinically ...useful scoring system to predict the probability of NASH in morbidly obese persons, thus assisting in the decision to perform liver biopsy. Consecutive subjects undergoing bariatric surgery without evidence of other liver disease underwent intraoperative liver biopsy. The outcome was pathologic diagnosis of NASH. Predictors evaluated were demographic, clinical, and laboratory variables. A clinical scoring system was constructed by rounding the estimated regression coefficients for the independent predictors in a multivariate logistic model for the diagnosis of NASH. Of 200 subjects studied, 64 (32%) had NASH. Median body mass index was 48 kg/m2 (interquartile range, 43‐55). Multivariate analysis identified six predictive factors for NASH: the diagnosis of hypertension (odds ratio OR, 2.4; 95% confidence interval CI, 1‐5.6), type 2 diabetes (OR, 2.6; 95% CI, 1.1‐6.3), sleep apnea (OR, 4.0; 95% CI, 1.3‐12.2), AST > 27 IU/L (OR, 2.9; 95% CI, 1.2‐7.0), alanine aminotransferase (ALT) > 27 IU/L (OR, 3.3; 95% CI, 1.4‐8.0), and non‐Black race (OR, 8.4; 95% CI, 1.9‐37.1). A NASH Clinical Scoring System for Morbid Obesity was derived to predict the probability of NASH in four categories (low, intermediate, high, and very high). Conclusion: The proposed clinical scoring can predict NASH in morbidly obese persons with sufficient accuracy to be considered for clinical use, identifying a very high‐risk group in whom liver biopsy would be very likely to detect NASH, as well as a low‐risk group in whom biopsy can be safely delayed or avoided. (HEPATOLOGY 2008.)
To evaluate how often general pediatricians, pediatric endocrinologists, and gastroenterologists diagnose children as overweight and how often interventions are provided, including nutritional ...counseling and screening for nonalcoholic fatty liver disease (NAFLD) and metabolic syndrome.
The study was a retrospective chart review of outpatient visits at 2 academic hospitals.
A total of 2256 patient visits were analyzed, including 715 visits by overweight children. Of those 715 visits, 31% resulted in a diagnosis of overweight. Diagnosis of overweight and nutritional counseling were least likely to occur during gastroenterology visits (22% and 13%, respectively,
P < .01). Screening for metabolic syndrome was most likely to occur during endocrinology visits (34%;
P < .01). Screening for NAFLD was most likely to occur during gastroenterology visits (23%;
P < .01). Children age < 5 years and those with a body mass index percentile (BMI%) of 85% to 94% were least likely to receive diagnosis and intervention for overweight.
The majority of overweight children were not diagnosed and did not receive relevant and recommended evaluations and interventions. Specific attention should be focused on providing diagnosis and interventions for overweight children, especially those age < 5 years and with a BMI% of 85% to 94%.
Background/Aims The precise prevalence of risk factors for atherosclerosis in NASH-related cirrhosis is unknown. The aims of this study were: (1) to compare the prevalence of major risk factors for ...atherosclerosis between subjects who underwent liver transplantation for NASH-related cirrhosis and those with cirrhosis of other aetiologies and (2) to compare pathologic changes of atherosclerosis within the explants hepatic hilar arteries between the groups. Methods Sixty subjects with NASH-related cirrhosis and 60 subjects with cirrhosis of other aetiologies were reviewed retrospectively. Demographic and clinical characteristics related to atherosclerosis were analyzed and compared. The hepatic hilar arteries of the explanted livers were examined for pathologic changes. Results The prevalence of all coronary artery disease (CAD) risk factors and the metabolic syndrome was significantly higher in NASH-related cirrhosis group compared to cirrhosis of other aetiologies. The proportion of patients with a diagnosis of CAD was also significantly higher in the NASH-related cirrhosis group (21.6% vs. 5%, p = 0.005). Pathological examination of hilar arteries showed possible atherosclerotic changes in only 4 cases (3 NASH-related cirrhosis; 1 HCV). Conclusions Major risk factors for atherosclerosis are significantly more prevalent in subjects with NASH-related cirrhosis than in subjects with cirrhosis of other aetiologies and are predictive of an increased prevalence of CAD. This study suggests that NASH-related cirrhosis is not protective against atherosclerosis.
In the absence of surrogate markers, the evaluation of suspected nonalcoholic fatty liver disease (NAFLD) is highly dependent on histological examination. The extent of sampling variability affecting ...the reliability of a single liver biopsy in patients with suspected NAFLD is poorly characterized. This prospective study aimed to correlate precise histological findings in paired biopsies—right and left lobe—in the diagnosis of NAFLD in morbidly obese subjects undergoing bariatric surgery employing both Brunt and Matteoni classifications and the NAFLD Activity Score (NAS). We also aimed to determine whether the composite histopathological findings of the two biopsies would improve diagnostic accuracy. Consecutive subjects had an intraoperative biopsy from both right and left lobes, evaluated and scored in a blinded manner. Intraobserver agreement was also assessed. Kappa coefficients of agreement were calculated. Forty‐one subjects had acceptable biopsies. Agreement for steatosis was excellent and moderate for fibrosis. Concordance was only fair for most features of necroinflammation. Intraobserver agreement was only moderate for lobular inflammation. Excellent agreement was seen for the diagnosis of NASH using Brunt criteria and good agreement when using Matteoni and NAS scoring systems. Composite biopsy data particularly improved identification of hepatocyte ballooning. The diagnostic accuracy also improved substantially when composite features were compared with single‐sided biopsy features, especially for the Matteoni and NAS scoring systems. In conclusion, significant sampling variability occurs in NAFLD, particularly for features of necroinflammation. This should be factored into the design of clinical trials and studies of the natural history of the disease. (HEPATOLOGY 2006;44:874–880.)
Nonalcoholic fatty liver disease (NAFLD) has been referred to as the hepatic manifestation of the metabolic syndrome. There is a lower prevalence of metabolic syndrome in individuals with higher ...health‐related fitness (HRF) and physical activity (PA) participation. The relationship between NAFLD severity and HRF or PA is unknown. Our aim was to compare measures of HRF and PA in patients with a histological spectrum of NAFLD severity. Thirty‐seven patients with liver biopsy–confirmed NAFLD (18 women/19 men; age = 45.9 ± 12.7 years) completed assessment of cardiorespiratory fitness (CRF, VO2peak), muscle strength (quadriceps peak torque), body composition (%fat), and PA (current and historical questionnaire). Liver histology was used to classify severity by steatosis (mild, moderate, severe), fibrosis stage (stage 1 versus stage 2/3), necroinflammatory activity (NAFLD Activity Score; ≤4 NAS1 versus ≥5 NAS2) and diagnosis of NASH by Brunt criteria (NASH versus NotNASH). Analysis of variance and independent t tests were used to determine the differences among groups. Fewer than 20% of patients met recommended guidelines for PA, and 97.3% were classified at increased risk of morbidity and mortality by %fat. No differences were detected in VO2peak (x = 26.8 ± 7.4 mL/g/min) or %fat (x = 38.6 ± 8.2%) among the steatosis or fibrosis groups. Peak VO2 was significantly higher in NAS1 versus NAS2 (30.4 ± 8.2 versus 24.4 ± 5.7 mL/kg/min, P = 0.013) and NotNASH versus NASH (34.0 ± 9.5 versus 25.1 ± 5.7 mL/kg/min, P = 0.048). Conclusion: Patients with NAFLD of differing histological severity have suboptimal HRF. Lifestyle interventions to improve HRF and PA may be beneficial in reducing the associated risk factors and preventing progression of NAFLD. (HEPATOLOGY 2008.)
To determine if the concordance of magnetic resonance (MR) imaging and MR spectroscopic data with histologic measures of steatosis is affected by histologic magnification level, tissue heterogeneity, ...or assessment of tissue area versus that of hepatocytes.
This study was institutional review board approved and HIPAA compliant. Written informed consent was obtained. In- and out-of-phase MR imaging and MR spectroscopic measures of steatosis were compared in 33 patients with nonalcoholic fatty liver disease and in 15 healthy volunteers. Concordance of MR imaging and MR spectroscopic data with histologic findings was assessed for (a) histologic examination at standard (×40 and ×100) versus high magnification (×200 and ×400), (b) heterogeneity and homogeneity of livers, and (c) percentage of tissue and hepatocytes that contained lipids. Evaluations included linear regression and Fisher exact tests.
In- and out-of-phase MR imaging and MR spectroscopic data were well correlated (R2=0.93) and generally concordant with histologic measures. Patients in whom MR fat fractions were higher than expected compared with steatosis grades at standard magnification histologic examination were upgraded significantly more often when high magnification was used than were the remaining patients (100% 10 of 10 vs 47% 7 of 15, P<.01). MR imaging and MR spectroscopic data of homogeneous livers were significantly more likely than those of heterogeneous livers to be concordant with steatosis grades when high magnification was used (81% 13 of 16 vs 47% 8 of 17, P<.05). For all patients, percentage of fat in tissue was lower than that in hepatocytes, which affected individual patients, but not the overall correlation.
MR imaging and MR spectroscopic data were generally concordant with histologic measures of steatosis. Discordance between them may reflect differences in magnification at histologic examination and in liver heterogeneity.
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