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Focused NAFLD Clinic; Improvement and Delay in Progression
a) describe profile of comorbidities associated with NAFLD and b) assess the effect delivering focused care on the control of risk factor for NAFLD. Methods: We retrospectively reviewed NAFLD patients at our center seen and managed at our center between January 2013 and September 2015. Diagnosis of NAFLD was established based on excluding other causes of liver disease, documenting steatosis on ultrasound, and typical NAFLD phenotype with presence of metabolic syndrome. Charts were reviewed for patient demographics, clinical profile, and for associated comorbidities. Patients seen in focused liver clinic (Grp A) were compared with patients seen in other liver clinics (Grp B) for the control of risk factor of NAFLD (HBA1C <7% or weight loss >7%). NAFLD care in focused liver clinic included dedicated time for patient education on control of risk factors and referral to other specialties for control of risk factors of NAFLD and metabolic syndrome. Logistic regression analysis model was built to examine independent effect of focused care on control of risk factors. Results of this analysis are reported as odds ratio with 95% confidence interval. Results: 306 NAFLD patients, (median age 53 years, 62% females, 73% Caucasian, 33% smokers, 1% with cirrhosis, median ALT 42, median BMI 34, and median HB1AC of 6) were analyzed. Comorbidities associated with all 306 NAFLD patients included hypertension 63%, dyslipidemia 54%, GERD 45%, diabetes 40%, gall stones 35%, heart disease 16%, obstructive sleep apnea 15%, hypothyroidism 14%, colonic polyps 12% and extra-hepatic cancer 7.5%. Of 287 patients with available data on the provider details, Grp A (N=86) patients were not different compared to 201 in Grp B. Proportion of patients achieving control of risk factor on follow up was higher among Grp A compared to Grp B patients (36 vs. 13%, P=0.002). On logistic regression analysis, after controlling for demographics such as patient age, sex, race, smoking and cirrhosis, Grp A patients were over 3 fold more likely to control risk factor of NAFLD compared to Grp B patients: 3.23 (1.73-6.00), P=0.002). Conclusion: Outside metabolic syndrome components, gall stone disease is the commonest comorbidity in NAFLD patients. Management of NAFLD patients in a clinic focused to deliver NAFLD care works better in control of the risk factors of NAFLD. Future randomized studies are suggested to examine these findings and the impact of focused NAFLD care on the improvement of liver disease and hard clinical outcomes.
THE ASSOCIATION OF CAFFEINE AND COFFEE CONSUMPTION WITH SEVERITY OF NON-ALCOHOLIC FATTY LIVER DISEASE: A POPULATIONBASED STUDY Hyunseok Kim, Adaugo I. Ike, Mirela Feurdean, Nikolaos T. Pyrsopoulos Objective: Several epidemiological studies suggest that caffeine and coffee consumption may provide hepatic protection. We aimed to investigate the association between total caffeine and regular coffee consumption with NAFLD, using U.S. nationally representative data. Methods: Data was obtained from the Third National Health and Nutrition Examination Survey conducted in 1988-1994. NAFLD was defined by ultrasonographic detection of hepatic steatosis in the absence of other known liver diseases and categorized as normal, mild, moderate, or severe. The severity of hepatic fibrosis was determined by NAFLD fibrosis score (NFS). We obtained information on total caffeine consumption (mg/day) from the total nutrient intake file and calculated the amount of caffeine consumption from regular coffee by multiplying 136mg per cup. We used survey-weighted generalized logistic regression to evaluate the association between caffeine/coffee consumption and degree of NAFLD. The trending of a degree of NAFLD was tested by treating steatosis status and NFS category as an ordinal variable. For all analyses, we used published weights to account for oversampling and nonparticipation in the household interview and physical examination. Results: Among 10,668 people who met our selection criteria and had all available information, 3,922 people (34%) had NAFLD. Based on liver ultrasound findings, there were 1,454 people with mild, 1,665 people with moderate, and 803 people with severe steatosis. Moreover, there were 2,303 people with low NFS (<-1.455, consistent of lack of significant fibrosis), 1,342 people with intermediate NFS, and 277 people with high NFS (>0.676, indicative of advanced fibrosis). The caffeine amount from regular coffee consumption was inversely associated with NAFLD (173 ± 7.4 mg/day in control vs 152 ± 5.8 mg/day in NAFLD, p-value <0.01), while the total caffeine intake had no significant association (275 ± 10 mg/day in control vs 269 ± 12 mg/day in NAFLD, p-value=0.36). In addition, the caffeine amount from coffee consumption was negatively associated with the degree of steatosis based on ultrasound findings (173 ± 7.4 mg/day in normal, 142 ± 7.3 mg/day in mild, 163 ± 10 mg/day in moderate, 152 ± 15 mg/day in severe steatosis, trend p-value=0.02). Both total caffeine intake and caffeine from regular coffee did not show statistical significance with the degree of NFS category. Conclusion: The amount of caffeine from regular coffee consumption, but not the total caffeine intake, is associated with a lower prevalence of NAFLD and inversely correlates with the severity of hepatic steatosis based on ultrasound findings. This may be in part due to the facts that total caffeine intake may also include caffeine from soda or it may be related to other compounds found in coffee such as chlorogenic acid, cafestol and kahweol playing a role in hepatic steatosis.
Tu1580 PSORIASIS IS INDEPENDENTLY ASSOCIATED WITH NON-ALCOHOLIC FATTY LIVER DISEASE Cameron T. Locklear, Pegah Golabi, Natsu Fukui, Leyla de Avila, Munkhzul Otgonsuren, Mariam Afendy, Rebecca Cable, Zobair M. Younossi Introduction: Non-alcoholic fatty liver disease (NAFLD) is one of the leading causes of chronic liver disease worldwide. Patients with NAFLD are at risk for progression to advanced liver disease. NAFLD is strongly associated with obesity and metabolic syndrome. Psoriasis is a chronic systemic inflammatory disease and also linked to obesity and metabolic syndrome. Our aim in this study was to investigate the possible associations between NAFLD and psoriasis in the Medicare population. Methods: In this cross-sectional study, Medicare database was used, which is a federal health insurance program for people who are 65 or older and certain health conditions regardless of age. NAFLD patients were identified from a 5% representative Medicare random sample between 2011and 2014 by using the International Classification of Disease, Ninth Revision (ICD-9) diagnostic codes. An ICD-9 diagnostic code for a health condition was considered to be always present after the outpatient visits in which they were first coded. Exclusion criteria included patients with cancer, human immunodeficiency virus, hepatitis B virus, hepatitis C virus, alcoholic liver disease and other liver diseases and those participants who did not have continuous 12-months Medicare enrollment or who had missing values in total annual Medicare payment. From a total of 5,030,304 Medicare beneficiaries, 3,947,202 were included in the final analysis. Logistic regression model was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for psoriasis while adjusting NAFLD and other risk factors. A p-value of <0.05 was regarded significant. Results: After inclusion and exclusion criteria, 36,830 Medicare recipients with NAFLD (0.9%) and 11,376 Medicare recipients with psoriasis were included. Compared to control group without liver disease, NAFLD was more frequently seen in the psoriasis group than controls (2.7% vs 0.9%, p<0.0001). Similarly, prevalence of obesity (14.6% vs 5.6%), hyperlipidemia (53.1% vs 38.6%), hypertension (66.1% vs 50.9%) and diabetes (35.6% vs 24.8%) were higher in patients with psoriasis than controls (All p<0.0001). Multivariate analysis showed that presence of psoriasis was independently associated with presence of NAFLD (OR: 2.18 [95% CI, 1.95-2.45]), obesity (OR: 2.29 [95% CI, 2.17-2.42]) and diabetes (OR: 1.51 [95% CI, 1.45-1.57]). Conclusions: Medicare patients with psoriasis are at significantly higher risk of NAFLD. This association is independent of obesity and diabetes and suggest a common underlying pathogenic pathway.
Tu1578 CEREBROVASCULAR DISEASE IN PATIENTS WITH CHRONIC LIVER DISEASE: AN ANALYSIS OF UNOS DATABASE Amar Dodda, Kimberly Daniel, Kia Saeian, Achuthan Sourianarayanane Background: Cerebral vascular disease (CVD) is the fifth leading cause of death in the US. Among the many known risk factors for CVD, diseases such as diabetes (DM), coronary artery disease (CAD), and hypertension are also common co-morbidities present in chronic liver disease (CLD). It is unclear if the severity and type of liver disease contributes to CVD risk. Aim: This retrospective review of the UNOS database evaluated various types of liver disease and their association with CVD. Methods: All adult patients listed in the UNOS database for liver transplant from 1996 to 2013 with a diagnosis of CVD were queried. Patients with diagnosis of chronic hepatitis C (HCV), alcoholic liver disease (ALD) or nonalcoholic steatohepatitis (NASH) as the etiology of their CLD were included in analysis. Univariate and multivariate analysis (logistic regression) were performed to assess the effect of patient characteristics on CVD prevalence in CLD. Results: A total of 72441 patients were listed with a diagnosis of ALD (32.6%), HCV (59.2%) or NASH (8.2%) and had complete data available pertaining to the study parameters. Among these patients, 271 had documentation of CVD. On univariate analysis, in patients with NASH, there was a higher prevalence of CVD (1.2% vs 0.6% and 0.4%; p=0.002), CAD (5.8% vs 2.3% and 1.8%; p=<0.001) and DM (52.7% vs 10.1% and 11.3%; p=<0.001) compared to ALD or HCV respectively. NASH patients also exhibited increased incidence of peripheral vascular disease (PVD) and increased BMI. On further univariate analysis among individual liver diseases, occurrence of CVD was not significantly related to age, gender, MELD, Child's-Pugh score, serum creatinine, albumin, or BMI regardless of etiology of CLD. Presence of DM was not associated with increased CVD in NASH (p=0.65) and ALD (p=0.2) but there was a positive relationship in HCV (p=0.001). CAD was not associated with CVD in NASH (p=0.53) but was associated with ALD and HCV (p<0.001). On multivariate analysis, the variables of age (OR 1.04, CI 0.9-0.99), liver disease etiology (OR 6.6, CI 1.4-60.9), PVD (OR 16.8, CI 4.454.6), and CAD (OR 11.5, CI 4.3-27.6) were independently associated with occurrence of CVD. No association was found for BMI, DM, and serum creatinine. On multivariate analysis, when corrected for factors including CAD, BMI, and DM, NASH patients were less likely to have CVD compared to patients with ALD (OR 0.15, CI 0.02-0.73) and HCV (OR 0.16, CI 0.02-0.72). Conclusion: Among those listed for liver transplantation, patients with NASH have a higher prevalence of CVD compared to other etiologies. However, CLD due to NASH was not independently related to increased risk for CVD on multivariate analysis when correcting for effects of DM, CAD, and obesity. Further evaluation of NASH population should be explored to identify additional risk factors for CVD.
Tu1581 PATATIN-LIKE PHOSPHOLIPASE DOMAIN-CONTAINING PROTEIN 3(PNPLA3) GENE POLYMORPHISM HAS A SIGNIFICANTLY STRONGER ASSOCIATION IN DIABETICS WITH ADVANCED LIVER DISEASE AS COMPARED TO DIABETICS WITHOUT LIVER DISEASE Sachet V. Chandak, Deepak Amarapurkar, Sunil Parekh, Nirali Shah Background: The natural history of any chronic liver disease is modulated by a number of emerging risk factors including host genetics.It is now established that all common diseases, including Non Alcoholic Fatty Liver Disease(NAFLD) exhibit a heritable component of susceptibility accounting for 30%-50% of risk. A single nucleotide polymorphism (SNP) in patatin-like phospholipase domain-containing protein 3 gene (PNPLA3) has been implicated in the variation of NAFLD severity in both adults and children.Diabetes is known to be associated with increased risk of Fatty Liver, NASH cirrhosis and Hepatocellular carcinoma.PNPLA3 Polymorphisms has been studied mainly in Caucasians and to some extent in Asians and Africans. However, there are no studies till date reporting a positive association of PNPLA3 (rs738409) polymorphism with liver fibrosis in exclusively Indian diabetic population. Methods: In a prospective study,100 diabetes patients were recruited having a spectrum ranging from diabetes with no liver disease to diabetes with NAFLD/NASH to Liver Cirrhosis. NAFLD/ NASH and Cirrhosis in diabetics was diagnosed on the basis of imaging, biochemistry, exclusion of other liver diseases and liver biopsy in case of doubt.100
Tu1579 FOCUSED NAFLD CLINIC; IMPROVEMENT AND DELAY IN PROGRESSION John Romano, Sumant Arora, Ashwani K. Singal Background: Non-alcoholic fatty liver disease (NAFLD) is rapidly emerging as one of the commonest liver disease in the US, with a potential for progression to end-stage liver disease and cirrhosis, which frequently may need liver transplantation. We performed this study to
S-1205
AASLD Abstracts
AASLD Abstracts
Tu1577
THE ASSOCIATION OF CAFFEINE AND COFFEE CONSUMPTION WITH SEVERITY OF NON-ALCOHOLIC FATTY LIVER DISEASE: A POPULATIONBASED STUDY Hyunseok Kim, Adaugo I. Ike, Mirela Feurdean, Nikolaos T. Pyrsopoulos Objective: Several epidemiological studies suggest that caffeine and coffee consumption may provide hepatic protection. We aimed to investigate the association between total caffeine and regular coffee consumption with NAFLD, using U.S. nationally representative data. Methods: Data was obtained from the Third National Health and Nutrition Examination Survey conducted in 1988-1994. NAFLD was defined by ultrasonographic detection of hepatic steatosis in the absence of other known liver diseases and categorized as normal, mild, moderate, or severe. The severity of hepatic fibrosis was determined by NAFLD fibrosis score (NFS). We obtained information on total caffeine consumption (mg/day) from the total nutrient intake file and calculated the amount of caffeine consumption from regular coffee by multiplying 136mg per cup. We used survey-weighted generalized logistic regression to evaluate the association between caffeine/coffee consumption and degree of NAFLD. The trending of a degree of NAFLD was tested by treating steatosis status and NFS category as an ordinal variable. For all analyses, we used published weights to account for oversampling and nonparticipation in the household interview and physical examination. Results: Among 10,668 people who met our selection criteria and had all available information, 3,922 people (34%) had NAFLD. Based on liver ultrasound findings, there were 1,454 people with mild, 1,665 people with moderate, and 803 people with severe steatosis. Moreover, there were 2,303 people with low NFS (<-1.455, consistent of lack of significant fibrosis), 1,342 people with intermediate NFS, and 277 people with high NFS (>0.676, indicative of advanced fibrosis). The caffeine amount from regular coffee consumption was inversely associated with NAFLD (173 ± 7.4 mg/day in control vs 152 ± 5.8 mg/day in NAFLD, p-value <0.01), while the total caffeine intake had no significant association (275 ± 10 mg/day in control vs 269 ± 12 mg/day in NAFLD, p-value=0.36). In addition, the caffeine amount from coffee consumption was negatively associated with the degree of steatosis based on ultrasound findings (173 ± 7.4 mg/day in normal, 142 ± 7.3 mg/day in mild, 163 ± 10 mg/day in moderate, 152 ± 15 mg/day in severe steatosis, trend p-value=0.02). Both total caffeine intake and caffeine from regular coffee did not show statistical significance with the degree of NFS category. Conclusion: The amount of caffeine from regular coffee consumption, but not the total caffeine intake, is associated with a lower prevalence of NAFLD and inversely correlates with the severity of hepatic steatosis based on ultrasound findings. This may be in part due to the facts that total caffeine intake may also include caffeine from soda or it may be related to other compounds found in coffee such as chlorogenic acid, cafestol and kahweol playing a role in hepatic steatosis.
Tu1580 PSORIASIS IS INDEPENDENTLY ASSOCIATED WITH NON-ALCOHOLIC FATTY LIVER DISEASE Cameron T. Locklear, Pegah Golabi, Natsu Fukui, Leyla de Avila, Munkhzul Otgonsuren, Mariam Afendy, Rebecca Cable, Zobair M. Younossi Introduction: Non-alcoholic fatty liver disease (NAFLD) is one of the leading causes of chronic liver disease worldwide. Patients with NAFLD are at risk for progression to advanced liver disease. NAFLD is strongly associated with obesity and metabolic syndrome. Psoriasis is a chronic systemic inflammatory disease and also linked to obesity and metabolic syndrome. Our aim in this study was to investigate the possible associations between NAFLD and psoriasis in the Medicare population. Methods: In this cross-sectional study, Medicare database was used, which is a federal health insurance program for people who are 65 or older and certain health conditions regardless of age. NAFLD patients were identified from a 5% representative Medicare random sample between 2011and 2014 by using the International Classification of Disease, Ninth Revision (ICD-9) diagnostic codes. An ICD-9 diagnostic code for a health condition was considered to be always present after the outpatient visits in which they were first coded. Exclusion criteria included patients with cancer, human immunodeficiency virus, hepatitis B virus, hepatitis C virus, alcoholic liver disease and other liver diseases and those participants who did not have continuous 12-months Medicare enrollment or who had missing values in total annual Medicare payment. From a total of 5,030,304 Medicare beneficiaries, 3,947,202 were included in the final analysis. Logistic regression model was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for psoriasis while adjusting NAFLD and other risk factors. A p-value of <0.05 was regarded significant. Results: After inclusion and exclusion criteria, 36,830 Medicare recipients with NAFLD (0.9%) and 11,376 Medicare recipients with psoriasis were included. Compared to control group without liver disease, NAFLD was more frequently seen in the psoriasis group than controls (2.7% vs 0.9%, p<0.0001). Similarly, prevalence of obesity (14.6% vs 5.6%), hyperlipidemia (53.1% vs 38.6%), hypertension (66.1% vs 50.9%) and diabetes (35.6% vs 24.8%) were higher in patients with psoriasis than controls (All p<0.0001). Multivariate analysis showed that presence of psoriasis was independently associated with presence of NAFLD (OR: 2.18 [95% CI, 1.95-2.45]), obesity (OR: 2.29 [95% CI, 2.17-2.42]) and diabetes (OR: 1.51 [95% CI, 1.45-1.57]). Conclusions: Medicare patients with psoriasis are at significantly higher risk of NAFLD. This association is independent of obesity and diabetes and suggest a common underlying pathogenic pathway.
Tu1578 CEREBROVASCULAR DISEASE IN PATIENTS WITH CHRONIC LIVER DISEASE: AN ANALYSIS OF UNOS DATABASE Amar Dodda, Kimberly Daniel, Kia Saeian, Achuthan Sourianarayanane Background: Cerebral vascular disease (CVD) is the fifth leading cause of death in the US. Among the many known risk factors for CVD, diseases such as diabetes (DM), coronary artery disease (CAD), and hypertension are also common co-morbidities present in chronic liver disease (CLD). It is unclear if the severity and type of liver disease contributes to CVD risk. Aim: This retrospective review of the UNOS database evaluated various types of liver disease and their association with CVD. Methods: All adult patients listed in the UNOS database for liver transplant from 1996 to 2013 with a diagnosis of CVD were queried. Patients with diagnosis of chronic hepatitis C (HCV), alcoholic liver disease (ALD) or nonalcoholic steatohepatitis (NASH) as the etiology of their CLD were included in analysis. Univariate and multivariate analysis (logistic regression) were performed to assess the effect of patient characteristics on CVD prevalence in CLD. Results: A total of 72441 patients were listed with a diagnosis of ALD (32.6%), HCV (59.2%) or NASH (8.2%) and had complete data available pertaining to the study parameters. Among these patients, 271 had documentation of CVD. On univariate analysis, in patients with NASH, there was a higher prevalence of CVD (1.2% vs 0.6% and 0.4%; p=0.002), CAD (5.8% vs 2.3% and 1.8%; p=<0.001) and DM (52.7% vs 10.1% and 11.3%; p=<0.001) compared to ALD or HCV respectively. NASH patients also exhibited increased incidence of peripheral vascular disease (PVD) and increased BMI. On further univariate analysis among individual liver diseases, occurrence of CVD was not significantly related to age, gender, MELD, Child's-Pugh score, serum creatinine, albumin, or BMI regardless of etiology of CLD. Presence of DM was not associated with increased CVD in NASH (p=0.65) and ALD (p=0.2) but there was a positive relationship in HCV (p=0.001). CAD was not associated with CVD in NASH (p=0.53) but was associated with ALD and HCV (p<0.001). On multivariate analysis, the variables of age (OR 1.04, CI 0.9-0.99), liver disease etiology (OR 6.6, CI 1.4-60.9), PVD (OR 16.8, CI 4.454.6), and CAD (OR 11.5, CI 4.3-27.6) were independently associated with occurrence of CVD. No association was found for BMI, DM, and serum creatinine. On multivariate analysis, when corrected for factors including CAD, BMI, and DM, NASH patients were less likely to have CVD compared to patients with ALD (OR 0.15, CI 0.02-0.73) and HCV (OR 0.16, CI 0.02-0.72). Conclusion: Among those listed for liver transplantation, patients with NASH have a higher prevalence of CVD compared to other etiologies. However, CLD due to NASH was not independently related to increased risk for CVD on multivariate analysis when correcting for effects of DM, CAD, and obesity. Further evaluation of NASH population should be explored to identify additional risk factors for CVD.
Tu1581 PATATIN-LIKE PHOSPHOLIPASE DOMAIN-CONTAINING PROTEIN 3(PNPLA3) GENE POLYMORPHISM HAS A SIGNIFICANTLY STRONGER ASSOCIATION IN DIABETICS WITH ADVANCED LIVER DISEASE AS COMPARED TO DIABETICS WITHOUT LIVER DISEASE Sachet V. Chandak, Deepak Amarapurkar, Sunil Parekh, Nirali Shah Background: The natural history of any chronic liver disease is modulated by a number of emerging risk factors including host genetics.It is now established that all common diseases, including Non Alcoholic Fatty Liver Disease(NAFLD) exhibit a heritable component of susceptibility accounting for 30%-50% of risk. A single nucleotide polymorphism (SNP) in patatin-like phospholipase domain-containing protein 3 gene (PNPLA3) has been implicated in the variation of NAFLD severity in both adults and children.Diabetes is known to be associated with increased risk of Fatty Liver, NASH cirrhosis and Hepatocellular carcinoma.PNPLA3 Polymorphisms has been studied mainly in Caucasians and to some extent in Asians and Africans. However, there are no studies till date reporting a positive association of PNPLA3 (rs738409) polymorphism with liver fibrosis in exclusively Indian diabetic population. Methods: In a prospective study,100 diabetes patients were recruited having a spectrum ranging from diabetes with no liver disease to diabetes with NAFLD/NASH to Liver Cirrhosis. NAFLD/ NASH and Cirrhosis in diabetics was diagnosed on the basis of imaging, biochemistry, exclusion of other liver diseases and liver biopsy in case of doubt.100
Tu1579 FOCUSED NAFLD CLINIC; IMPROVEMENT AND DELAY IN PROGRESSION John Romano, Sumant Arora, Ashwani K. Singal Background: Non-alcoholic fatty liver disease (NAFLD) is rapidly emerging as one of the commonest liver disease in the US, with a potential for progression to end-stage liver disease and cirrhosis, which frequently may need liver transplantation. We performed this study to
S-1205
AASLD Abstracts
AASLD Abstracts
Tu1577