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Is Your Liver Well?

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Is Your Liver Well? 10/15/2020 Is Your Liver Well? Marina Roytman MD, FACP Liver Program Director, UCSF Fresno Clinical Professor of Medicine, UCSF October 10, 2020 1 What shall we learn today? What does the liver do? What can damage my liver? What is fatty liver disease? What is Hepatitis C? Who is at risk for liver disease? How can I find out if I have it? What can I do to take improve the health of my liver? 2 1 10/15/2020 Where is My Liver? Liver is located on the right side of your abdomen Healthy liver is completely hidden under the ribs It is about the size of a football 3 What Does My Liver Do? Liver is the body’s factory ◦ It makes proteins that help your blood clot ◦ It makes proteins that help your body be nourished It removes toxic substances from your body 4 2 10/15/2020 What Happens If My Liver Is Damaged? Initially liver may get swollen It may be felt below the ribs More serious or ongoing damage will lead to liver scarring and becoming small and hard This is called CIRRHOSIS = a LOT of scarring 5 What are the Physical Signs of Liver Disease? 6 3 10/15/2020 What Can Damage My Liver? Alcohol: #1 cause of liver damage Viral Hepatitis: infection of the liver ◦ “hepa” = liver ◦ “itis” = inflammation ◦ Types of viral hepatitis A, B, C, D, E Excess weight: may lead to liver damage similar to viral hepatitis or alcoholism 7 Non-alcoholic Fatty Liver Disease: Alphabet soup? NAFLD: Fat in the liver without a good alternative explanation NAFL: NASH: Fat in the liver without Fat in the liver resulting any signs of injury in inflammation and +/- scarring 8 4 10/15/2020 9 Non-alcoholic Fatty Liver Disease: An Emerging American Epidemic 1 in 3 Americans has fatty liver Ultrasound data estimates 50% Up to 50% in diabetics Up to 90% in patients undergoing weight loss surgery 3-10 times more common then Hepatitis C 10 5 10/15/2020 Age-adjusted Prevalence of Obesity and Diagnosed Obesity BMIDiabetes ≥30 kg/m Among2) US Adults 2000 2015 1994 No Data <14.0% 14.0%–17.9% 18.0%–21.9% 22.0%–25.9% > 26.0% Diabetes 2000 2015 1994 No Data <4.5% 4.5%–5.9% 6.0%–7.4% 7.5%–8.9% >9.0% CDC’s Division of Diabetes Translation. United States Surveillance System available at http://www.cdc.gov/diabetes/data 11 Who is at Risk for Fatty Liver Disease? Wong RJ, World J Hepatol 2014;6:263-273 12 6 10/15/2020 Who is at Risk for Fatty Liver Disease? Metabolic syndrome ◦ Diabetes or high blood sugar ◦ High blood pressure ◦ High cholesterol and or triglycerides ◦ Excess fat around the waist line 13 Does Genetics Play a Role? Multiethnic cohort of >59,000 adults in Ontario comparing race, BMI and prevalence of diabetes Chiu M, Diabetes Care 34:1741-48;2011 14 7 10/15/2020 Does Genetics Play a Role? Median hepatic fat content and PNPLA3 rs738409 genotypes in European Americans, African Americans and Hispanics in the Dallas Heart Study (0.23) (0.17) (0.49) Allele Frequency Patients of Hispanic and Asian origin may develop fatty liver disease at a lower weight and a lesser burden of risk factors. Romeo S, Nat Genet 2008 15 What Happens in Fatty Liver Disease? NAFLD NASH NASH with fibrosis ~70 million (25% ) NASH-related cirrhosis 10% of NAFLD NASH- (~7 million) HCC 1% (~700,000) ~4,000 cases/yr 16 8 10/15/2020 Who is at the highest risk of complications of fatty liver disease? Liver Scarring Patients with more severe fibrosis have markedly worse outcomes Controls F0-F2 F3-F4 Prognostic hierarchy from Loomba, et al. Gastroenterology. 2015; Ekstedt et al. Gastroenterology 2015. 17 18 9 10/15/2020 Weight Loss Works! 293 patients with NASH were encouraged to adopt recommended lifestyle changes to reduce their weight over 52 weeks 261 had biopsies at the beginning and at the end of the study 88 (30%) lost >5% body weight Vilar-Gomez, et al. Gastroenterology. 2015. 19 Weight Loss Leads to Reduction in Liver Scarring! Vilar-Gomez, et al. Gastroenterology. 2015 20 10 10/15/2020 21 Eat Yogurt and Drink Coffee! Both improve the health of the bacteria in your gut Healthier gut bacteria decrease inflammation in the liver (that leads to scarring) Coffee is also an appetite suppressant Coffee = black! Yogurt = plain! Avoid probiotics in pill form! 22 11 10/15/2020 Future Therapeutic Targets Thyroid receptor beta agonist Fibroblast growth factor 21 Glucagon-like peptide-1 Combination therapies Duodenal mucosal ablation 23 Do We Have Clinical Trials In Fresno and Can I Participate? Yes! Trials for fatty liver disease are currently running at UCSF Fresno If interested, contact: ◦ Sonia Garcia, Clinical Research Coordinator 559-499-6637 [email protected] 24 12 10/15/2020 What Else Can Damage My Liver? Hepatitis C (+) single stranded linear RNA virus Mimics the cellular mRNA (messenger RNA) molecule Exploits host cellular apparatus to synthesize proteins during replication 25 HCV is Underdiagnosed and Undertreated Cascade of Care in 2018 in the United States 3.0 2,710,935 2.5 2.0 1.5 24% 5% (millions) 1.0 656,007 Number of Individuals Individuals ofNumber 0.5 132,572 125,670 0.0 Viremic Aware Treated in 2018 Cured in 2018 1. Chhatwal J et al. APT. 2019; 2. Zibbell JE, et al. Am J Public Health. 2018;108(2):175-181. 2. Data on file 3. Zibbell JE, et al. Am J Public Health. 2018;108(2):175-181. 26 13 10/15/2020 Chronic Hepatitis C Is a Progressive Disease HEALTHY LIVER FIBROTIC LIVER CIRRHOTIC LIVER Few or no symptoms; can progress without signs for decades Most pts asymptomatic until serious liver complications arise 1. CDC. MMWR Morb Mortal Wkly Rep. 1998;47(RR-19):1-39. 2. Heidelbaugh JJ, et al. Am Fam Physician. 2006;74:756-762. 27 Why is Hepatitis C Curable? • Unlike some other viruses, HCV RNA is only present in the cytoplasm (not in the nucleus) of the host cell1 • Without the stable, genetic-material reservoir of the nucleus created by other viruses, the possibility exists for HCV cure by treatment1 a a cccDNA = covalently closed circular DNA 1. Soriano V, Perelson AS, Zoulim F. Why are there different dynamics in the selection of drug resistance in HIV and hepatitis B and C viruses? J Antimicrob Chemother. 2008;62(1):1-4. 9 28 14 10/15/2020 Age Distribution of New HCV Infections in the US Skews Toward Adolescents and Young Adults 29 Hot off the Press: CDC Update Universal hepatitis C screening: Hepatitis C screening at least once in a lifetime for all adults aged 18 years and older Hepatitis C screening for all pregnant women during each pregnancy 30 15 10/15/2020 How to Diagnose Hepatitis C: Antibody Test It looks for footprints of the virus in your blood If it is positive, patient had been exposed to the virus at some point 15-25% of patients clear the virus on their own Further testing is necessary to determine active infection 31 Hepatitis C RNA: Do I Have Live Virus in Me? Viral Load = PCR Presence of virus = chronic Hepatitis C Viral load DOES NOT correlate to the severity of inflammation, progression of liver disease or chance of cure. 32 16 10/15/2020 What if I am Diagnosed with Hepatitis C? You can be cured with a simple, oral regimen (pills) in as little as 8 to12 weeks! 98% chance of cure! Cure will stop progression of liver disease and allow you liver to heal! 33 SVR Associated With a Reduction in HCC, Liver-Related Mortality, Transplantation, and All-Cause Mortality 30 Hepatocellular Liver-Related Mortality All-Cause Carcinoma or Liver Transplantation Mortality P <0.001 P <0.001 P <0.001 20 Without SVR Without SVR Without SVR 10 Cumulative Incidence (%) Incidence Cumulative With SVR With SVR With SVR 0 012345678910 012345678910 012345678910 Time (y) Time (y) Time (y) International, multicenter, long-term follow-up study of 530 consecutive CHC patients with advanced hepatic fibrosis or cirrhosis, who started an IFN-based treatment regimen between 1990 and 2003. Median follow-up duration 8.4 years Significant reduction of 10-year cumulative incidence of HCC, liver-related mortality or transplantation, and all-cause mortality in patients who achieved SVR van der Meer AJ, et al. JAMA. 2012;308:2584-2593. 34 17 10/15/2020 How do I find out if I have scarring or fat in my liver? 35 The FibroScan Probe Ultrasound “Crystal” (Shear wave speed measurement) Actuator (Shear wave generator) 36 18 10/15/2020 FibroScan = No Needles Needed to Measure Liver Scarring Probe mechanically induces shear wave … Shear Wave 37 Results Disease Significant Cirrhosis F0-F1 F2 Fibrosis F3 F4 HBV < 6.0 > 6.0 > 9.0 > 12.0 HCV < 7.0 > 7.0 > 9.5 > 12.0 HCV-HIV < 7.0 < 10.0 > 11.0 > 14.0 Cholestatic < 7.0 > 7.5 > 10.0 > 17.0 NAFLD/NASH < 7.0 > 7.5 > 10.0 > 14.0 Utilization of FibroScan in Clinical Practice; Bonder S, Afdhal N; Current Gastroenterology Rep, 2014 16-372 38 19 10/15/2020 FibroScan = No Needles Needed to Measure Liver Fat CAP 1 2 Acoustic Impedance 39 Ultrasound Attenuation Rate CAP 40 20 10/15/2020 Results 19 Study Meta-Analysis / 2735 Subjects Grade CAP Cutoff Sensitivity Specificity AUC dB/M S0 vs S1-S3 248 0.69 0.82 0.82 S0-S1 vs S2-S3 268 0.77 0.81 0.86 S0-S2 vs S3 280 0.88 0.78 0.88 Steatosis Grade Affected Hepatocytes CAP Range: 100-400 dB/m S1 < 33 % S2 33 – 66 % S3 > 66 % Karlas et al, 2016 41 What Have We Learnt? Fatty Liver Disease Hepatitis C Exercise! Hepatitis C is Eat healthy! common Eat yogurt! It often does not Drink coffee! cause symptoms Maintain healthy Everyone should be weight! tested! Hepatitis C can be cured in 8-12 weeks! Ask your doctor to check your liver tests! 42 21 10/15/2020 43 22.
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