Prospective evaluation of outcomes in cirrhosis of different etiologies: impact of HIV infection and simvastatin therapy

慢性肝病，主要是肝硬化，仍然是65岁以下成年人死亡的第六大原因。 美国的尽管在诊断和治疗方面取得了进展，但肝硬化的死亡率并未改变 在过去的40年里，这一数字显著增加，仍然是一个重大的公共卫生负担。我们和其他人使用了 建模和数据库评估显示，酒精相关性肝病（ALD）和非酒精性脂肪肝 肝病（NAFLD）是美国肝硬化的两个主要原因。治疗潜在病因 肝硬化的逆转可能有助于纤维化的消退，但肝硬化是否可逆尚未确定。是否纤维化 一旦确定肝硬化的诊断，并且如果这种进展与失代偿有关， 或肝细胞癌（HCC）也是未知的。肝硬化的各种并发症，肌肉减少症 由于收缩功能受损而导致的身体虚弱是频繁的、渐进的，并对临床产生不利影响 结果。尽管有很高的临床意义，但目前还没有关于其发展、进展和预后的前瞻性研究。 以及肝硬化患者肌肉减少和虚弱的预测因子。合并症，特别是感染人类免疫系统- 缺乏病毒（HIV）使肝硬化患者处于纤维化进展、失代偿和 肌肉减少症/虚弱综合征。肠道微生物组及其代谢产物（异代谢物）在肠道微生物中起着重要的作用。 在肝损伤和肝硬化并发症（包括HCC和肌肉减少症）中的作用， 人类患者的前瞻性研究。大多数关于进展、长期并发症、合并症的影响、 肝硬化的发病率和结局是横断面的，受试者数量较少，并且不翻译 肝硬化及其并发症发生机制的研究进展。 因此，在特征明确的肝硬化中进行前瞻性研究对于发展有效的治疗至关重要 战略和改善成果。越来越多的人对他汀类药物用于治疗 肝硬化由于抗炎和抗纤维化作用，可以防止失代偿和HCC。的 克利夫兰诊所卫生系统是最大的临床项目之一，有大量的患者， 由于我们的专业知识，肝硬化患者被转诊接受长期治疗，包括肝移植 在创新的方法，病人护理，包括远程访问和应用数字健康纳入 整合电子病历。作为对RFA PAR DK-20-003的回应，我们建议成为 肝硬化网络建立肝硬化患者纵向队列，主要是酒精相关和 非酒精性脂肪性肝病合并症包括HIV感染。我们将建立一个数据库， 特征的患者和这些患者的生物储存库，以促进我们对 肝硬化的进展，并发症的发展，并确定新的生物标志物和治疗，以改善 临床结果。我们还将进行一项使用辛伐他汀/安慰剂的前瞻性随机临床试验， 将肝硬化患者作为网络的一部分，以确定临床反应和安全性。

Chronic liver disease, primarily cirrhosis, remains the 6th leading cause of death in adults younger than 65y in the United States. Despite advances in diagnostics and therapies, mortality in cirrhosis has not changed significantly over the last 40y and remains a major significant public health burden. We and others have used modeling and database evaluations to show that alcohol related liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD) are the 2 major causes of cirrhosis in the United States. Treating the underlying etiology of cirrhosis may help fibrosis regress but whether cirrhosis is reversible is not yet established. Whether fibrosis progresses once a diagnosis of cirrhosis is established and if such a progression is related to decompensation or hepatocellular carcinoma (HCC) are also not known. Of the various complications of cirrhosis, sarcopenia and physical frailty due to impaired contractile function are frequent, progressive and adversely impact clinical outcomes. Despite the high clinical significance, there are no prospective studies on development, progression and predictors of sarcopenia and frailty in cirrhosis. Co-morbidities especially infection with human immune- deficiency virus (HIV) places patients with cirrhosis at high risk of progression of fibrosis, decompensation, and sarcopenia/frailty syndrome. The gut microbiome and their metabolites (xenometabolites) play a mechanistic role in hepatic injury and complications of cirrhosis including HCC and sarcopenia but there are very limited prospective studies in human patients. Most studies on the progression, long term complications, impact of co- morbidities and outcomes in cirrhosis are cross-sectional, have small number of subjects, and do not translate advances in mechanistic understanding of development of cirrhosis or its complications into clinical practice. Therefore, prospective studies in well characterized cirrhosis are critical to develop effective management strategies and improve outcomes. There is increasing interest in the use of statins in the management of cirrhosis due to anti-inflammatory and antifibrotic effects that may prevent decompensation and HCC. The Cleveland Clinic Health System is one of the largest clinical programs with a large population of patients with cirrhosis who are referred for long-term management including liver transplantation, because of our expertise in innovative approaches to patient care including televisits and applications of digital health incorporated into integrated electronic medical records. In response to the RFA PAR DK-20-003, we propose to be a part of a Liver Cirrhosis Network to establish a longitudinal cohort of patients with cirrhosis, primarily alcohol related and non-alcoholic fatty liver disease with co-morbidities including HIV infection. We will develop a database of well characterized patients and a biorepository from these patients to advance our mechanistic understanding of progression of cirrhosis, development of complications and identify novel biomarkers and therapies to improve clinical outcomes. We will also conduct a prospective randomized clinical trial using simvastatin/placebo in well characterized patients with cirrhosis as part of the network to determine clinical responses and safety.