Background & Aims:Prior studies demonstrated an association between non-alcoholic fatty liver disease and chronic kidney disease (CKD), though data are conflicting.We examined the association between liver fat and prevalent and incident CKD in the Framingham Heart Study (FHS). Methods:We included FHS participants who underwent computed tomography (CT) from 2002 to 2005 (n = 1315). After excluding heavy alcohol use (n = 211) and missing covariates (n = 117), the final sample included 987 participants. For the incident CKD analysis, we excluded 73 participants with prevalent CKD. Liver fat was measured by the average liver attenuation on CT. Estimated glomerular filtration rate (eGFR) was obtained using the CKD Epidemiology Collaboration Creatinine-Cystatin C equation, and CKD was defined as eGFR < 60 ml/min/1.73 m 2 . Microalbuminuria was defined by sex-specific urinary albumin-creatinine ratio cut-offs. Multivariableadjusted regression models were performed to determine the association between liver fat and CKD. Results:The prevalence of hepatic steatosis and CKD were 19% and 14% respectively (55.9% women, mean age 60 ± 9 years). After adjusting for covariates, we observed no significant associations between liver fat and CKD, microalbuminuria or eGFR in cross-sectional analyses. We observed positive associations between liver fat, incident microalbuminuria and reduced eGFR in age-and sex-adjusted models; these relationships were not significant in multivariable-adjusted models. Conclusions:In this community-based cohort study, we did not observe significant associations between liver fat and prevalent or incident CKD with a median follow-up time of 12.5 years. The association between NAFLD and CKD may be accounted for by shared risk factors; confirmatory studies are needed.
Context.– Coronavirus disease 2019 (COVID-19) has been associated with liver injury, and a small subset of patients recovering from severe disease have shown persistent markedly elevated liver biochemistries for months after infection. Objective.– To characterize persistent biliary injury after COVID-19. Design.– A search of the pathology archives identified 7 post-COVID-19 patients with persistent biliary injury, and the clinical, radiologic, and pathologic features were assessed. Results.– All patients in this cohort presented with respiratory symptoms and had a complicated clinical course with acute elevation of liver biochemistries. Alkaline phosphatase (ALP) was markedly and persistently elevated after discharge (median peak ALP: 1498 IU/L, at a median of 84 days from diagnosis). Magnetic resonance cholangiopancreatography (MRCP) showed 3 patients with irregularity, stricturing, and dilatation of intrahepatic ducts; no radiographic abnormalities were identified in the remaining 4 patients. Liver biopsies showed mild portal changes with features of cholestatic injury in 4 patients (bile duct injury and canalicular cholestasis) and marked biliary obstruction in 2 patients (profound cholestasis, ductular reaction, and bile infarcts), but no SARS-CoV-2 ribonucleic acid (RNA) was identified on in-situ hybridization. On follow-up, most patients had minimal intervention and showed marked improvement of liver biochemistries but with mild persistent elevation of ALP. Conclusions.– A subset of critically ill COVID-19 patients demonstrates marked and persistent cholestatic injury, with radiographic and histologic evidence of secondary sclerosing cholangitis, suggesting that cholestatic liver disease and secondary sclerosing cholangitis may be long-term sequelae of COVID-19 acute illness as a longstanding manifestation of critical illness.
Introduction: Despite high obesity rates nationwide, many medical schools provide insufficient nutrition education. It has been difficult to deliver nutrition education in the Columbia University College of Physicians and Surgeons primary care clerkship given its numerous clinical sites offering varied expertise. We supplemented the clerkship curriculum with an interactive e-learning module designed to provide medical students with knowledge and skills in nutrition and weight management, as well as an understanding of registered dietitians' role. The module was created using Articulate Storyline 2 software and emphasizes active learning and simulated clinical decision-making. Methods: Learning objectives and a curriculum were developed based on a literature review, a student focus group, and the guidance of a multidisciplinary committee. The module integrates narrated content with interactive exercises and utilizes multiple teaching styles. Participants were third-year medical students in the primary care clerkship during January-May 2016 (n = 64). Students completed a web-based evaluation survey after the module. Results: Ninety-two percent of students completed the module in 2 hours or less. Ninety-seven percent agreed that the module was easy to navigate, and 93% agreed that it contributed to their understanding of the topic. Qualitatively, students generally responded positively to the module's active learning component and its use of multiple teaching styles. Discussion: This web-based interactive learning module is an accessible tool that allows educators to simultaneously deliver information and target clinical reasoning skills. Active learning facilitates students' engagement with the content. This module is easily adaptable for other learners, including physicians and patients, and other areas of the curriculum.
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