Ani Kardashian

Cirrhosis affects more than 2 million Americans and drives substantial healthcare utilization, impaired quality of life, and mortality. Because early-stage disease carries a favorable prognosis and decompensated patients can recompensate, systematic delivery of preventive care is essential. Under the auspices of the American College of Gastroenterology Practice Parameters Committee, a writing group of hepatology experts and 2 Grading of Recommendations, Assessment, Development, and Evaluation methodologists developed PICO questions, conducted librarian-assisted searches of PubMed, Embase, and the Cochrane Library, and prioritized systematic reviews, meta-analyses, and randomized trials. The resulting guidance comprises 18 Grading of Recommendations, Assessment, Development, and Evaluation-assessed recommendations and 6 key concept statements spanning 4 domains: prevention of cirrhosis-specific complications, infection prevention, lifestyle factors, and non-liver-specific conditions. Strong recommendations include carvedilol or variceal ligation of high-risk esophageal varices, semiannual hepatocellular carcinoma surveillance, hepatitis A testing and vaccination, influenza, severe acute respiratory syndrome coronavirus 2, respiratory syncytial virus immunization, and smoking-cessation counseling. Conditional recommendations address lactulose for minimal hepatic encephalopathy, adjunctive rifaximin after hospitalization, short-course antibiotic prophylaxis for upper gastrointestinal bleeding, postdischarge behavioral therapy for alcohol use disorder, dietitian-guided nutrition, structured exercise, and bisphosphonates for osteoporosis. Most evidence was of low certainty. We provide an implementation framework of education, stakeholder engagement, and practice integration to translate these recommendations into routine care.

Background and Aim: Significant health disparities persist in alcohol‐associated liver disease (ALD), largely driven by social determinants of health (SDOH). However, the influence of neighbourhood‐level SDOH on ALD outcomes remains underexplored. In this study, we aimed to evaluate how neighbourhood‐level SDOH are associated with disease burden, comorbid conditions, and mortality in individuals with ALD. Methods: We conducted a retrospective cohort study of patients with ALD in the Banner Health System, representing hospitals across Arizona, California, Nevada, Wyoming and Colorado, from January 2012 to October 2024 using ICD codes. Neighbourhood‐level SDOH were quantified using the Social Deprivation Index (SDI). Patients were stratified into quartiles based on SDI score, with Quartile 4 representing the most socioeconomically disadvantaged neighbourhoods. Primary outcomes included incidence of mortality, cirrhosis, major adverse liver outcome (MALO), Type 2 diabetes mellitus, any cancer, and major adverse cardiovascular events (MACE). A multivariable competing risk analysis was performed adjusting for age, sex, race/ethnicity, insurance type, primary language, smoking status, Type 2 diabetes mellitus, hypertension, hyperlipidemia, aspirin use, statin use, alcohol use disorder and a composite mental‐health/substance‐use disorder variable encompassing depression, anxiety disorders, post‐traumatic stress disorder, bipolar disorder, schizophrenia, and non‐alcohol substance use disorders. Results: Among 11,394 patients with ALD and available SDI data, 6747 had ≥ 365 days of follow‐up. The average age was 51 years and 65.6% were female; 68.8% were non‐Hispanic White, 19.7% Hispanic, 5.9% Native American/Alaskan Native (NA), 3.2% Black, and 0.4% Asian/Pacific Islanders. Patients residing in the most disadvantaged neighbourhoods (Quartile 4) were significantly younger, more likely to be female, had a higher median BMI, and more frequently reported a non‐English primary language compared with those in the least disadvantaged areas (Quartile 1). Patients in the most deprived neighbourhoods were more likely to be Hispanic, Black, or Native American/Alaska Native and to be uninsured or on Medicaid, whereas those in the least disadvantaged neighbourhoods predominantly had private insurance. Individuals in Quartile 4 had increased mortality (adjusted hazard ratio [aHR]: 1.48, 95% Confidence Interval [CI]: 1.09–2.01) compared with individuals in Quartile 1. Conclusions: In this large and demographically diverse ALD cohort, residing in socioeconomically disadvantaged neighbourhoods was associated with increased risk of mortality. These findings support the need for contextually tailored clinical interventions and broader treatment strategies that target upstream sociocultural and environmental factors that are associated with health outcomes. Addressing neighbourhood‐level SDOH through community engagement, policy reform, and cross‐sector partnerships to improve collaborative care efforts is needed to reduce health disparities in ALD.

Objective: Food insecurity is a risk factor for metabolic dysfunction-associated steatotic liver disease in the general population. However, little is known about the impact of food insecurity on hepatic steatosis among women with HIV (WWH) and women without HIV (WWOH). Design: We assessed hepatic steatosis by controlled attenuated parameter (CAP) in decibels/meter (dB/m) and food security status using the U.S. Household Food Security Survey in women without viral hepatitis. Women were categorized as being food secure vs. food insecure. Methods: We performed multivariable linear regression analyses to examine the association of food security status with hepatic steatosis. Results: Among 1473 women (1064 WWH, 409 WWOH), 20% reported food insecurity. Food insecurity was associated with lower CAP after adjustment for age, race-ethnicity, income, alcohol intake, BMI, insulin resistance, and HIV [CAP difference: -8.6 dB/m, 95% confidence interval (95% CI): -16.7 to -0.5, P = 0.037]. Each 5 kg/m ² BMI increase was associated with an 18.4 dB/m CAP increase (95% CI: 16.4–20.3, P < 0.001); there was no association of HIV serostatus with steatosis. Additionally, there was a significant interaction between food insecurity and BMI: among women experiencing food insecurity, for every 5 kg/m ² BMI increase, CAP decreased by 6.6 dB/m (95% CI: -12.2 to -1.1, P = 0.02). Conclusion: Food insecurity is prevalent in WWH and, unexpectedly, is associated with less steatosis, in contrast with findings observed in the general population. Additionally, while obesity remains a strong driver of steatosis, food insecurity attenuates the association of BMI with steatosis, particularly at higher BMIs. This study lays the groundwork for future efforts exploring potential mechanistic pathways.

Racial, ethnic, and socioeconomic disparities exist in the prevalence and natural history of chronic liver disease, access to care, and clinical outcomes. Solutions to improve health equity range widely, from digital health tools to policy changes. The current review outlines the disparities along the chronic liver disease health care continuum from screening and diagnosis to the management of cirrhosis and considerations of pre-liver and post-liver transplantation. Using a health equity research and implementation science framework, we offer pragmatic strategies to address barriers to implementing high-quality equitable care for patients with chronic liver disease.

Background: The presence of workplace bias around child-rearing and inadequate parental leave may negatively impact childbearing decisions and sex equity in hepatology. This study aimed to understand the influence of parental leave and child-rearing on career advancement in hepatology. Methods: A cross-sectional survey of physician members of the American Association for the Study of Liver Diseases (AASLD) was distributed through email listserv in January 2021. The 33-item survey included demographic questions, questions about bias, altering training, career plans, family planning, parental leave, and work accommodations. Results: Among 199 US physician respondents, 65.3% were women, and 83.4% (n = 166) were attendings. Sex and racial differences were reported in several domains, including paid leave, perceptions of bias, and child-rearing. Most women (79.3%) took fewer than the recommended 12 paid weeks of parental leave for their first child (average paid leave 7.5 wk for women and 1.7 for men). A majority (75.2%) of women reported workplace discrimination, including 83.3% of Black and 62.5% of Hispanic women. Twenty percent of women were asked about their/their partners’ pregnancy intentions or child-rearing plans during interviews for training. Women were more likely to alter career plans due to child-rearing (30.0% vs. 15.9%, p = 0.030). Women were also more likely to delay having children than men (69.5% vs.35.9%). Conclusions: Women reported sex and maternity bias in the workplace and during training interviews, which was more frequently experienced by Black and Hispanic women. As two-thirds of women had children during training, it is a particularly influential time to reevaluate programmatic support to address long-term gender disparities in career advancement.