ECHO 1. Appreciate the concept and approach of ECHO in general and - - PDF document

1

Introduction to

• Liv

Liver Disea Diseases s & ECHO Ontar ario Liv Liver

Jordan J Feld MD MPH

Toronto Centre for Liver Disease Sandra Rotman Centre for Global Health

Hemant Shah MD MScCH HPTE

Francis Family Liver Clinic @hepatoMD

Dis isclosures

Jordan Feld:

• Research: Abbott, Abbvie, Gilead, Janssen, Merck
• Consulting: Abbvie, Contravir, Gilead, Merck

Hemant Shah:

• Consulting Fees: Abbvie, Gilead, Merck, Intercept, Lupin

Learn arning Obje bjectives

• 1. Appreciate the concept and approach of ECHO in

general and ECHO Liver in particular

• 2. Gain a general understanding of the hepatitis C

virus and the burden of illness caused by chronic hepatitis C virus infection

ECHO

(Extension for Community Health Outcomes) The father of ECHO

Mod Modest Goa

• als

“At ECHO, our mission is to democratize medical knowledge and get best practice care to underserved people all over the world.”

Our goal is to touch the lives of 1 billion people by 2025.

Sanjeev Arora

2

Th The Mo Model It wor

• rks
• Compared outcomes in patients treated in rural NM vs UNM
• Similar cure rates despite tougher-to-cure pop’n in rural areas
• Has spread widely and been replicated throughout the US

Mad Made in in Ne New Me Mexi xico

Primary Care MDs Nurses Other care providers Project ECHO

• Linking PCPs to

specialists

• Facilitates linkage

to care

• Allows people to

be treated by people and in settings they know & trust

Arora NEJM 2011

Perfected in Canada!

Th The Me Methods

 Use Technology to leverage scarce resources  Sharing “best practices” to reduce disparities  Case based learning to master complexity  Web-based database to monitor outcomes

Arora S, Acad Med. 2007 Feb;82(2): 154-60.

ECH CHO in in Ca Canada

• First proposed to do ECHO Hepatitis in Canada
• Limited interest and no support from MOH
• Developed HepC Net program – Hemant Shah – similar model

to support HCV treatment teams around Ontario

• 2014 – ECHO Pain
• Chronic pain team led by Andrea Furlan
• Support from MOH
• Highly successful
• 2016 – Add ECHO Hepatitis + Rheumatology…more in

the works!

• 2018 – ECHO Hepatitis C becomes ECHO Liver

Th The ECHO Hub Hub Team am

• Hepatology: Jordan Feld & Hemant Shah - Toronto
• Family Medicine/Addiction: Craig Kuhn - Niagara
• Nursing: Magdalena Kuczynski
• Pharmacist: Ruifen Su
• ECHO Team:

Rhonda Mostyn – Project Manager Ralph Fabico – Program Coordinator Jane Zhao – Research Coordinator Ashley Grilo - Admin Assistant Shamini Martin – Education Coordinator

3

Th The Sess Sessions

• ‘Didactic session’
• Liver curriculum – 17 topics
• Hub + ‘guest’ speakers – 20-40 min + discussion
• Case presentations
• Community site
• Key points and clear question
• Discussion – community sites + hub
• Collective consensus on best strategies
• Follow-up of previous cases
• Pre + Post questionnaires + survey

‘Curriculum’

Date Topic Presenter S1 – 23-Jul-18 Introduction to Liver Disease and ECHO Liver

• Dr. Jordan Feld

S2 – 30-Jul-18 Who is at risk? Natural History, Screening & Diagnosis

• Dr. Hemant Shah

6-Aug-18 No Session S3 – 13-Aug-18 Initial Assessment, Data Gathering

• Dr. Jordan Feld

S4 -20-Aug-18 Cirrhosis: Management of Key Complications Part 1

• Dr. Jordan Feld

27-Aug-18 No Session (Summer break) 3-Sep-18 No Session (Summer break) S5 -10-Sep-18 Cirrhosis: Management of Key Complications Part 2

• Dr. Hemant Shah

S6 – 17-Sep-18 Epidemiology of Hep B & C &NAFLD in Canada

• Dr. Hemant Shah

S7 – 24-Sep-18 Hep C: Treatment Decision Making, Readiness and Principles, Ontreatment Monitoring

• Dr. Jordan Feld

S8 – 1-Oct-18 Hep C: Best Practice Management of Genotype 1

• Dr. Hemant Shah

8-Oct-18 No Session S9 -15-Oct-18 Hep C: – Best Practice Management of Genotype 2-6

• Dr. Jordan Feld

S10 – 22-Oct-18 Hep C: After Hep C Therapy – Long Term Monitoring & Follow up

• Dr. Hemant Shah

S11 – 29-Oct-18 Hep B: What do the tests mean & Vaccination

• Dr. Hemant Shah

S12 – 5-Nov-18 Hep B: Treatment Options (acute & chronic)

• Dr. Jordan Feld

12-Nov-18 No Session S13 – 19-Nov-18 Hep B: Pregnancy, Children & Immune Suppression

• Dr. Hemant Shah

S14 – 26-Nov-18 Alcoholic liver disease

• Dr. Jordan Feld

S15 – 3-Dec-18 Fatty Liver: Diagnosis, Treatment & Management

• Dr. Jordan Feld

S16 – 10-Dec-18 Symptom Management – Side effects of medications and resources needed for successful treatment Ruifen Su & Magdalena Kuczynski S17 – 17-Dec-18 Treatment Management – Motivational Interviewing: Engaging patients to go

• n and stay on treatment

Richard Yanofsky 24-Dec-18 No Session (Christmas)

Key Areas

• Cirrhosis
• HCV
• HBV
• Fatty Liver
• Alcohol

HCV - Hepatitis C HBV - Hepatitis B

Af After the he Cu Curr rriculum

• Welcome to join any time!
• Bring cases or just participate in the discussion
• With time…the goal is that everyone becomes a

local Liver expert but still value in joining the sessions

• Updates from meetings
• New literature
• Challenging cases

Qu Questions ab about ECHO Liver? In Intr tro to to the Liv Liver

Con Concern rning trends

Mokdad BMC Medicine 2014

Trend in cirrhosis deaths by region 1980 to 2010

4 Why did did we foc

• cus on

n these se dise disease ses?

Mokdad BMC Medicine 2014

Sho Should the he big big 3 3 be be the he big big 4? 4?

Global Burden of Disease Study 2013, Lancet 2015

Deaths (millions) in 2013

Viral hepatitis HIV/AIDS Tuberculosis Malaria

HCV (0.70) HBV (0.69)

A&E (0.06)

Moving in in the he wrong dir directio ion

• 3
• 2
• 1

1 2 3 Male Female

Liver Colorectal Pancreas Lung Prostate Breast Stomach % change annually

Cancer Care Ontario 2015

Liver is a Synthetic Factory

• Protein production – Albumin/clotting factors
• Drug detoxification
• Bile production – digestion/absorption

Man Many cau auses of

• f liv

liver r dise disease…

• Acute
• Viral (Hep A-E, CMV, EBV…)
• Toxin (Drug, alcohol)
• Ischemia (inflow/outflow)
• Autoimmune (autoimmune hepatitis)
• Chronic
• Viral (B, C)
• Fatty liver (NAFLD, Alcohol)
• Inherited (Hemochromatosis, Wilson, A1AT)
• Autoimmune (AIH, PBC, PSC)

More important

Hep – Hepatitis | CMV - Cytomegalovirus | EBV - Epstein–Barr virus AIH – autoimmune hepatitis | PBC - primary biliary cirrhosis | PSC - primary sclerosing cholangitis

Wha hat do do you call all the hese tests?

• ALT (Alanine aminotransferase)
• AST (Aspartate aminotransferase)
• ALP (Alkaline phosphatase)
• GGT (Gamma-glutamyl transferase)

Liver enzymes  NOT LFTs

5

Why?

56 yo man awaiting liver transplant ALT 17 AST 27 GGT 43 ALP 93

“LFTs” are “Normal”!! Actually – not true – LFTs VERY abnormal

INR 2.4 Bilirubin 98 umol/L Albumin 28 g/L

Liver Assessment

• Liver enzymes are not LFTs
• ALT/AST: rate of hepatocellular injury
• ALP/GGT: indication of cholestasis
• Liver function tests
• INR/Albumin: liver synthesis
• Conjugated Bilirubin: transport to caniliculus
• Assessment of portal hypertension
• Platelets: hypersplenism/portal hypertension

INR - International normalized ratio

From the Patient’s Perspective…

 Patients feel perfectly fine!!  Almost always entirely asymptomatic…until it’s too late  Even if they have cirrhosis HCV/HBV/ NASH

Cirrhosis matters: What we are trying to prevent

Jaundice Fluid Retention Ascites Esophageal Varices Hepatic Encephalopathy Liver Cancer

Cirrhosis

Recognizing Cirrhosis

Which one has cirrhosis?

Obvious Not So Obvious

Liver disease catches you by surprise

6

Liver May Look Normal Even with Cirrhosis

Stages F1-3 and even early F4 may “look normal” on imaging A “normal” liver ultrasound does not exclude fibrosis and may miss cirrhosis

The Spectrum of Cirrhosis: From Subtle to Overt

Compensated Cirrhosis

Diagnosis subtle Few or no symptoms

• Possibly fatigue

Subtle or no physical exam abnormalities Subtle or no laboratory abnormalities

• Low platelet count, AST > ALT

Decompensated Cirrhosis

Diagnosis usually obvious Complication(s) of cirrhosis

• Ascites/edema
• Variceal hemorrhage
• Encephalopathy
• Jaundice

Abnormal liver function

• Bilirubin
• Albumin
• INR

INR - International normalized ratio

Too

• ols to
• As

Assess Fi Fibrosis

• Clinical exam
• Normal until and often with cirrhosis (insensitive)
• Suggestive findings: spider angiomata, palmar erythema,

dilated abdominal veins, splenomegaly

• Findings if present, are fairly specific, but very insensitive
• Radiology
• Normal with F0-F3 and often with cirrhosis (insensitive)
• Helpful if shows cirrhosis (fairly specific)
• Nodular liver
• Enlarged caudate lobe
• Enlarged spleen
• Enlarged portal vein

Too

• ols to
• As

Assess Fi Fibrosis

• Laboratory tests
• Liver enzymes (AST/ALT) may be normal even with

advanced fibrosis or cirrhosis – not helpful

• Normal ALT does not mean ‘inactive HCV’
• Liver function (bilirubin, albumin, INR) normal until

advanced cirrhosis

• Tests suggesting advanced fibrosis/cirrhosis
• Platelet count < 150 x 10E9/µl
• AST:ALT ratio > 1 (typically < 1 in HCV)
• Elevated IgG (polyclonal)
• (Abnormal bilirubin, INR, albumin  late finding)

Simple Test: APRI

• Cirrhosis
• Platelets fall
• AST > ALT
• Very useful to exclude

cirrhosis

• Low is good
• <0.5 is good – 98% NPV for

cirrhosis!

• High is bad
• >2.0 – worry about cirrhosis
• Caveat – AST high if active

inflammation

AST/ULN x 100 Platelet count

Castera et al., 2005

ULN - Upper Limit of Normal

Fibrotest

• Age
• Sex
• GGT
• Bilirubin
• Indirect may be up
• α2-Macroglobulin
• Haptoglobin
• Hemolysis
• Apo-Lipoprotein A1

(Castera et al., 2005)

7

Liver Stiffness by Transient Elastography (Fibroscan)

Ultrasound-based technique Determines liver “stiffness” Correlates well with fibrosis No ceiling, ie, increases with worsening cirrhosis → predicts complications (eg, varices) Simple to use – minimal training Other methods in development

Caveats: -Fails in up to 20% (especially in obese patients ) – improved with XL probe.

• Influenced by inflammation – it falsely elevates measurements

Preventing Fibrosis Progression

• Factors associated with progression
• Age
• Sex
• Race (?)
• BMI
• ALCOHOL!!
• Smoking cigarettes (?), marijuana
• HIV co-infection

Modifiable

Cof

• ffee,

, It Doe

• es the

he Liver Goo

• od
• >2 cups caffeinated coffee per day:
• Lower ALT
• Slower progression of fibrosis
• Reduced liver cancer
• Better response to interferon-treatment
• No clear effect of decaf or other caffeinated

beverages…

Ruhl Gastroenterology 2005, Feld Hepatology 2012, Friedman Gastroenterology 2012

Com Compliance Ne Never r See Seems to

• be

be a a Proble lem

PO BID M: 6 m supply Is Cirrhosis s Irreversi sible?

Dogma used to be that “fibrosis” and definitely “cirrhosis” are irreversible…but thinking is changing/has changed

• Poynard. Gastroenterology. 2002.
• Maylin. Gastroenterology. 2008.

ONE WAY

Concept of “Regression of Fibrosis” After cure of HCV - fibrosis improves in > 50% AND 33-67% of cirrhotics are no longer cirrhotic  treat the underlying cause and things may improve

Summary

Liver disease burden is rising Usually asymptomatic  easy to miss Long ‘differential’ but common things are common

• Viral Hep
• Fatty liver (with or without alcohol)

Cirrhosis matters – don’t miss it! Coffee is good for your liver ECHO is a great way to learn about the liver!