AASLD 2020 | Prof. Jorge A. Bezerra: Turn challenges into opportunities! chronic disease management and scientific research in epidemic situation

In the face of COVID - 19 pandemic, liver area the last game in 2020 - the United States to liver disease (AASLD2020) online adjustment, which made the whole turn challenges into opportunities, both stick to the office will promote liver communication purpose, and further expand the coverage, more rare is also for delegates who won the Nobel Prize winner in 2020 chance of face-to-face communication.

Hepatology Digest invited Professor Jorge A. Bezerra, PRESIDENT of AASLD2020 and medical Center of Cincinnati Children's Hospital, USA, to share with us the adjustment of AASLD2020 in the epidemic, the impact of the epidemic on the diagnosis and treatment of liver disease in the United States, and the latest research progress in the field of biliary atrexia in children, which is his major research direction.

Hepatology Digest: The Liver Meeting is the annual must-attend event bringing together attendees from around the world, what adjustments have been made to the meeting by the organizing committee due to the outbreak of novel coronavirus disease-2019? 

Prof. Jorge A. Bezerra：First and foremost, I wish that you and those watching this interview are well and working together to promote health and safety among your friends and loved ones. You are right. The liver meeting is the annual event where members and all hepatology providers and investigators present the latest advances in the field. They learn about newest clinical protocols, listen to key opinion leaders present new discoveries, and lectures on hot topics in hepatology. It is also where they meet with colleagues, make new friends, and really establish new collaborations. The pandemic fragmented our plan for the meeting as we knew it. But it did not change our resolve to have the annual liver meeting and to maintain our commitment to the hepatology community. So, we decided that the liver meeting must go on. The reality is that hepatology remains a vibrant field. Despite the pandemic, hepatology has new discoveries and ongoing clinical trials that ultimately improve the health of patients with liver disease. Therefore, we made a series of efforts to turn the challenge into a major opportunity for the field. We gave clinicians and researchers more time to complete their work and submit abstracts by delaying the deadline for submission of abstracts. Then, we worked with the scientific program committee to redesign our program and put it in a digital platform in a way that also enabled interaction among the participants. Aware of the socio-economic impact of the pandemic, we also lowered the registration price so that more could participate in the meeting. More than ever, we felt we needed to share new knowledge more broadly – all over the world. Last but not least, we took two other steps to make the liver meeting really special. First, we developed a new sessions focused on COVID-19 and the liver and invited Dr. Anthony Fauci, a leader who has given consistent national advice on the pandemic in the United States, to talk about the new developments on COVID-19. At the end of the meeting, the AASLD gave a gift to all participants by a special hour-long interview with with the three recipients of the 2020 Nobel Prize for Physiology or Medicine: Drs. Harvey J. Alter, Michael Houghton, Charles M. Rice. 

Hepatology Digest: How about the latest progresses in the research of biliary atresia communicated at this meeting?

Prof. Jorge A. Bezerra：Biliary atresia is indeed a disease of severe consequences to the health of affected children. We are moving closer to understanding the cause of the disease and identifying new biomarkers to monitor the course of disease, screen for complications, and hopefully use as endpoints for clinical trials. At the liver meeting, a group of investigators from my hospital, Cincinnati Children's Hospital, reported their ability to engineer a biliary organoid directly liver biopsies of babies with biliary atresia. They called it multi-lineage biliary organoid. Then they studied these organoid and found that epithelium and peribiliary glands are presented if the biopsies come from a normal patient. But if it comes from a patient with biliary atresia, the epithelium is delayed and abnormal and the peribiliary glands are not very well formed. Therefore, they provide the evidence there is a delay of the epithelium development as one of the main causes for biliary atresia.

I'll tell you about two other stories. A group of investigators from Texas Children's Hospital reported the results of two studies supported by the Childhood Liver Disease Research Network. This is a multi-center consortium funded by the National Institutes of Health in the United States. In the first study, they reported serum bile acids in children with good biliary drainage after the Kasai procedure which is the initial surgery for biliary atresia. If they have good biliary drainage and low serum bile acids, they have the best outcome. In contrast, if they have surgery and good biliary drainage, but high concentrations of serum bile acids, they have lower survival with the native liver and require liver transplantation for long-term survival. In the second study, they analyzed a group of patients with biliary atresia, Alagille syndrome, and alpha-1 antitrypsin deficiency, three important pediatric liver diseases. They correlated serum biomarkers with the liver stiff measurement. They found that in patients with biliary atresia, there was a correlation between the concentration of three biomarkers, MMP-7 (matrix metalloproteinase-7), IL-8 (interleukin-8) and endoglin with high liver stiffness measurement. They also found that for Alagille disease, there is correlation between IL-8 and high liver stiffness measurement. For alpha-1 antitrypsin deficiency, it was high level of connective tissue growth factor and liver stiffness. So, these studies show the importance of discoveries of biomarkers for specific diseases, and that the biology of portal hypertension and fibrosis is not the same role for all diseases. 

Hepatology Digest: The COVID-19 pandemic has caused significant impact on global health, what is its impact on the management of chronic liver diseases in high-prevalence areas?

Prof. Jorge A. Bezerra：You're absolutely right. The pandemic has imposed new challenges in the management of all patients with chronic liver disease. First, there is a real potential for COVID-19 to worsen preexisting liver disease in a vulnerable population, such as those with NASH or non-alcoholic steatohepatitis, those with decompensated cirrhosis, and those requiring immune suppression. Even when there is no direct effect of the virus in the liver, the virus may injure the endothelium of the blood vessels and the sinusoid, cause secondary lesion in the liver with inflammation, and decrease bile flow. It's also clear that patients with very high liver enzymes and bilirubin, which usually reflect severe liver disease, have severe COVID-19 disease. 

The second is that the pandemic has also had an indirect effect in patients with liver diseases, who have decreased access to care in areas of high prevalence and high transmission rates of coronavirus. Sometimes the patients and family members are afraid to seek help because they are concerned they may get infected if they seek medical care at a hospital or physician’s office. The good news is that hospitals and clinics are taking extra steps to keep the environment safe. Health care providers, whenever possible, will recommend that the patients seek proper care, wherever they are, in the United States, in China and in other countries. The patients may also not seek care because they have lost health insurance. This really shows how the pandemic has impacted different socio-economic status of the patients. Patients with diseases like cancer need to be evaluated regularly to prevent progression of the disease. Otherwise, they may have more difficult outcomes. 

The pandemic also impacted patients with chronic or acute liver failure that need liver transplantation. With a large number of occupied beds at major transplant centers, even when a new liver is available, the surgeons and hepatologists have to make decisions based on the availability of ICU, medical, and surgical beds. We are glad that the community continues to be creative and work together to still perform liver transplantation while keeping patiences safe.