Performance of the aspartate aminotransferase-to-platelet ratio index for the staging of hepatitis C-related fibrosis: an updated meta-analysis

Aspartate aminotransferase-to-platelet ratio index as a novel predictor of early mortality in heat stroke patients: a multi-centre retrospective study

BACKGROUND

The aspartate aminotransferase-to-platelet ratio index (APRI) is an effective non-invasive marker for chronic liver dysfunction. Given that heat stroke patients often suffer from poor prognosis due to multi-organ involvement, with liver injury and coagulation dysfunction being of particular concern, this study aims to investigate whether APRI can comprehensively reflect liver injury and coagulation dysfunction in heat stroke patients and explore its relationship with 28-day mortality.

METHODS

This retrospective study analysed electronic medical records from patients treated at 57 grade A tertiary hospitals in China from May 2005 to May 2024. The primary outcome was 28-day mortality, and the secondary outcome was 7-day mortality. Restricted cubic splines (RCS) were utilized to visualize the relationship between APRI and 28-day mortality risk. The independent association between APRI and outcomes was assessed using Cox proportional hazards models, with multivariable analyses controlling for confounding factors. The predictive ability of APRI for outcomes was evaluated using receiver operating characteristic (ROC) curves.

RESULTS

A total of 450 eligible patients were included, with 71 deaths occurring within 28 days. RCS analysis showed a positive correlation between APRI and 28-day mortality. Participants were divided into higher (APRI ≥ 15.14) and lower (APRI < 15.14) APRI groups. Cox proportional hazards models indicated that individuals with higher APRI had a significantly increased 28-day mortality rate (HR 5.322, 95% confidence interval [CI] 2.642-10.720, p < 0.0001). Subgroup and interaction analyses confirmed the robustness of the core findings. Additionally, the areas under the ROC (AUROC) for APRI predicting 28-day mortality was 0.823 (95% CI 0.772-0.875), significantly higher than the AST to ALT ratio (0.526, 95% CI 0.448-0.605) and total bilirubin (0.694, 95% CI 0.623-0.765).

CONCLUSION

APRI is an independent predictor of early mortality risk in heat stroke.

Synergistic impact of serum uric acid and ferritin on MAFLD risk: A comprehensive cohort analysis

The characterization of Metabolic Dysfunction-Associated Fatty Liver Disease (MAFLD) underscores metabolic anomalies as critical in fatty liver disease progression. Serum uric acid is increasingly recognized as a determinant for fatty liver diseases due to its association with metabolic disorders. Ferritin, in parallel, serves as an inflammatory marker closely tied to metabolic syndrome and insulin resistance. Our study explores the combined influence of serum uric acid and ferritin on MAFLD prevalence. We conducted a retrospective cohort analysis at Samsung Changwon Hospital's Health Screening Center (2011-2018), encompassing 7,818 individuals post-exclusion criteria. Participants were stratified into gender-specific quartiles based on serum uric acid and ferritin levels. Utilizing multivariable Cox proportional hazard models alongside Kaplan-Meier analysis, we assessed the incidence of MAFLD and its relationship with these serum biomarkers, also performing subgroup assessments by gender, age, and BMI. Over 41,819 person-years with an average observation period of 5.35 ± 2.06 years, 1,073 incident cases of MAFLD were recorded. The risk of MAFLD was notably higher within the upper quartiles of serum uric acid (HR: 2.17, 95% CI: 1.70-2.78). Each increment in natural logarithmic serum uric acid level correlated with an increased risk (HR: 3.65, 95% CI: 2.32-5.74). Serum ferritin also indicated an enhanced risk, albeit less pronounced. The simultaneous presence of elevated levels of both uric acid and ferritin correlated with the highest MAFLD risk (HR: 3.89, 95% CI: 2.41-6.28). Our findings affirm that high serum uric acid levels significantly escalate the risk of MAFLD, with serum ferritin levels contributing to a lesser yet substantial degree. The concurrent elevation of both biomarkers magnifies MAFLD risk, reinforcing the need for their combined assessment in MAFLD risk evaluation.

Volatomics for Diagnosis and Risk Stratification of MASLD: A Proof-Of-Concept Study

BACKGROUND AND AIMS

Human breath contains numerous volatile organic compounds (VOCs) produced by physiological and metabolic processes or perturbed in pathological states. Electronic nose (eNose) technology has been extensively validated as a non-invasive diagnostic tool for respiratory disease. Using eNose-derived exhaled breath signals, we investigated whether it could discriminate patients with metabolic dysfunction-associated steatotic liver disease (MASLD) from healthy volunteers and identify patients at high risk of disease progression.

METHODS

In a prospective single-centre study, exhaled breath VOCs were analysed using an eNose, in a well-characterised cohort comprising patients with Child-Turcotte-Pugh class A MASLD cirrhosis (n = 30), non-cirrhotic MASLD (n = 30) and healthy volunteers (n = 30). An unbiased machine learning clustering technique was applied. Longitudinal clinical data were collected over 5 years for the patient cohort. Logistic regression and univariable analysis were performed to identify risk factors for disease progression, liver-related outcomes, and all-cause mortality.

RESULTS

Principal component analysis of breath VOCs discriminated patients with MASLD from healthy volunteers with 100% sensitivity (p < 0.001, cross-validation verification of 96%), independent of age and gender. The eNose breath profile classified patients with MASLD into three distinct subgroups with similar baseline clinical and demographic characteristics but markedly different prognoses. During the 5-year follow-up period, Cluster 2 was identified as a higher-risk subgroup for progression (42%, p = 0.03), liver-related decompensation events (17%, p = 0.06), and all-cause mortality (12.5%).

CONCLUSION

eNose can discriminate patients with MASLD from healthy volunteers and, using unbiased clustering analysis, identify patients with a significantly worse prognosis. These results warrant prospective validation in independent MASLD populations.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02950610.

The role of the AST-to-platelet ratio index (APRI) score on outcomes following robotic minor, technically major, & major hepatectomy for liver tumors

Predictive capability of aspartate transaminase-to-platelet ratio index (APRI) in assessing liver fibrosis/cirrhosis. This study aims to evaluate the correlation between APRI scores and perioperative outcomes following robotic hepatectomy. Data of 530 consecutive patients undergoing robotic hepatectomy were analyzed. Patients were classified based on an APRI score threshold of 0.7 and extent of resection. Data are presented as median (mean ± SD). Of 530 patients, 166 (31%) underwent major resection. Expectedly, major resections were associated with higher expert-level operations based on IWATE system. While having statistically similar APRI scores, patients undergoing major resection had larger tumor size (p = 0.003), longer operative duration (p < 0.0001), and higher blood loss (p = 0.0002). Patients undergoing minor/technically major resections, 100 (27%) patients had an elevated APRI, which was associated with higher MELD score (p = 0.0001), Child-Pugh score (p = 0.0001), cirrhosis (p < 0.0001), and neoplastic diseases (p < 0.0001). Patients undergoing major resections, 48 (29%) had elevated APRI, which was also associated with higher Child-Pugh Score (p < 0.0001), cirrhosis (p = 0.0008), and neoplastic diseases (p = 0.001). Elevated APRI levels were indicative of cirrhosis and higher MELD score; however, outcomes following robotic major hepatectomy remain unaffected by the index.

Interpretable machine learning model for predicting post-hepatectomy liver failure in hepatocellular carcinoma

Post-hepatectomy liver failure (PHLF) is a severe complication following liver surgery. We aimed to develop a novel, interpretable machine learning (ML) model to predict PHLF. We enrolled 312 hepatocellular carcinoma (HCC) patients who underwent hepatectomy, and 30% of the samples were utilized for internal validation. Variable selection was performed using the least absolute shrinkage and selection operator regression in conjunction with random forest and recursive feature elimination (RF-RFE) algorithms. Subsequently, 12 distinct ML algorithms were employed to identify the optimal prediction model. The area under the receiver operating characteristic curve, calibration curves, and decision curve analysis (DCA) were utilized to assess the model's predictive accuracy. Additionally, an independent prospective validation was conducted with 62 patients. The SHapley Additive exPlanations (SHAP) analysis further explained the extreme gradient boosting (XGBoost) model. The XGBoost model exhibited the highest accuracy with AUCs of 0.983 and 0.981 in the training and validation cohorts among 12 ML models. Calibration curves and DCA confirmed the model's accuracy and clinical applicability. Compared with traditional models, the XGBoost model had a higher AUC. The prospective cohort (AUC = 0.942) further confirmed the generalization ability of the XGBoost model. SHAP identified the top three critical variables: total bilirubin (TBIL), MELD score, and ICG-R15. Moreover, the SHAP summary plot was used to illustrate the positive or negative effects of the features as influenced by XGBoost. The XGBoost model provides a good preoperative prediction of PHLF in patients with resectable HCC.

Gut Microbiota and Genetic Polymorphisms Appear to Drive Disease Expression of Nonalcoholic Fatty Liver Disease in Lean Individuals

Background/Objectives

There are very few comparative studies worldwide between 'lean' and 'nonlean/obese nonalcoholic fatty liver disease (NAFLD)' patients analyzing the differences in gut microbiome, genotype, and serum bile acids. Our aim was to compare the genotype, gut microbiome, bile acid profile, and metabolic patterns of lean NAFLD and obese NAFLD patients with special reference to hepatic fibrosis.

Methods

Both lean and obese NAFLD patients diagnosed by ultrasonography along with matched controls were included. Genotyping, fecal microbiome analysis and estimation of serum total bile acid levels were done for patients as well as controls.

Results

Biochemical and metabolic patterns of lean and obese NAFLD patients were comparable. Lean NAFLD patients had lower fasting plasma glucose (FPG) and homoeostasis model assessment-insulin resistance (HOMA-IR), although the proportions of patients having elevated HOMA-IR and metabolic syndrome (MS) were comparable. Noninvasive scores of liver fibrosis were also comparable. A greater proportion of lean NAFLD patients had the PNPLA3 rs738409 (G/G) genotype. However, there was no association of genetic polymorphisms with steatosis or fibrosis. Nonlean and lean NAFLD patients had comparable serum total bile acid levels. On microbiome analysis, lean NAFLD patients were found to have distinct expression of bacterial species while beta diversity was found to be significantly different across all groups.

Conclusion

Lean NAFLD patients were found to have the PNPLA3 rs738409 (G/G) genotype. Lean NAFLD patients were also found to have unique gut microbial signatures, while beta diversity significantly differed across all groups. Differential expression of gut microbiota and genetic polymorphisms could underlie the pathogenesis of lean NAFLD.

Long-Term Risk of Hepatic and Extrahepatic-Related Events After Direct Antiviral Therapy for Chronic Hepatitis C: A Prospective Long-Term Study Cohort

Novel direct antiviral-acting (DAA) molecules significantly improved efficacy and ameliorated outcomes of patients with chronic hepatitis C (CHC). The extensive use of DAA from 2015, due to large access to therapy, maximized rates of viral eradication with a safety profile in the majority of cases.

AIMS

We evaluated risk factors and the incidence of related clinical events and hepatocellular carcinoma (HCC) in cases with sustained virologic response (SVR) after DAA. We also aimed to apply a score assessment to identify the individual patient with unfavorable outcomes during an average follow-up (FU) of five years.

METHODS

In total, 470 cases consecutively recruited with CHC have been compared by non-invasive tests (NIT), as APRI, FORNS, FIB-4, LSPS, and transient elastography (TE) liver stiffness measurement (LSM), to identify cutoff related to major event onset.

RESULTS

Grouping of cases without or with related events development of both types hepatic (HE) (i.e., HCC or further cirrhosis decompensation or/with hospitalized septic state) or extrahepatic (EHE) (i.e., other tumors, bleeding, or thrombotic episodes and other organs pathologic conditions not liver related)allowed us to select the parameters to propose a novel risk stratification system (RISS) for the identification of the remnant individual patient's risk for HCC occurrence, orthotopic liver transplant (OLT) need, or death during long-term follow-up (FU).

CONCLUSIONS

Patients with cirrhosis and portal hypertension (PH) maintained a higher LSM mean value (>25 kPa), showed the lowest reduction of NIT scores, and developed events in 80/108 (74%) cases (67 and 13 of HE and EHE type), even after long-term successful DAA therapy. Furthermore, cases with RISS score ≥ 8 demonstrated a significant incidence of HCC (37/46, 80.4%) and a reduction in survival rate to 65.4% at 5-year FU.

Simple Clinical Prediction Rules for Identifying Significant Liver Fibrosis: Evaluation of Established Scores and Development of the Aspartate Aminotransferase-Thrombocytopenia-Albumin (ATA) Score

Background: Existing non-invasive tests (NITs) for liver fibrosis offer moderate precision and accessibility but are often limited by complexity, reducing their practicality in routine clinical use. This study aimed to evaluate the diagnostic performance of current fibrosis assessment methods and develop a novel, simplified scoring system-the Aspartate Aminotransferase (AST)-Thrombocytopenia-Albumin (ATA) score-to enhance ease of use and clinical applicability. Methods: This study examined past cases of patients with chronic liver disease (CLD) by using magnetic resonance elastography (MRE) to evaluate fibrosis stages. Serum biomarkers were collected, and common fibrosis scores were calculated. Logistic regression identified potential predictors of significant fibrosis, forming the ATA score. Diagnostic performance was assessed, and internal validation was conducted via bootstrap resampling. Results: Among 70 patients, 31.4% had significant fibrosis. Hepatitis B was the most common cause (60.0%), followed by hepatitis C (18.6%) and nonalcoholic fatty liver disease (NAFLD, 15.7%). The ATA score demonstrated an area under the receiver operating characteristic curve (AUROC) of 0.872, comparable to the AST-to-platelet ratio index (APRI; 0.858) and fibrosis-4 index (FIB-4; 0.847). The recommended cut-offs for identifying high-risk patients were ATA score ≥ 2 (specificity 95.8%, sensitivity 50.0%), APRI ≥ 0.50 (specificity 89.6%, sensitivity 68.2%), and FIB-4 ≥ 1.3 (specificity 58.3%, sensitivity 90.9%). Internal validation confirmed model robustness, with an optimism-corrected AUROC of 0.8551. Conclusions: The ATA score offers a straightforward and efficient method for detecting significant fibrosis, demonstrating comparable diagnostic capability to APRI and FIB-4, while being more user-friendly in clinical practice. A score of 0-1 indicates low risk, suitable for clinical follow-up, whereas a score of ≥2 suggests high risk, warranting further evaluation. Integrating the ATA score into clinical workflows can enhance early detection, optimize resource utilization, and improve patient care.

Novel integrative models to predict the severity of inflammation and fibrosis in patients with drug-induced liver injury

Background and aims

Drug-induced liver injury (DILI) is becoming a worldwide emerging problem. However, few studies focus on the diagnostic performance of non-invasive markers in DILI. This study aims to develop novel integrative models to identify DILI-associated liver inflammation and fibrosis, and compare the predictive values with previously developed indexes.

Methods

A total of 72 DILI patients diagnosed as DILI through liver biopsy were enrolled in this study. Patients were divided into absent-mild (S0-S1, G0-G1) group and moderate-severe (S2-S4, G2-G4) group based on the histological severity of inflammation and fibrosis. We used the area under the receiver operating characteristics curves (AUC) to test the model performances. Backward stepwise regression, best subset and logistic regression models were employed for feature selection and model building. Prediction models were presented with nomogram and evaluated by AUC, Brier score, calibration curves and decision curve analysis (DCA).

Results

For diagnosing moderate-severe inflammation and fibrosis, we calculated the AUC of gamma-glutamyl transpeptidase-to-platelet ratio (GPR), aspartate aminotransferase-to-platelet ratio index (APRI), fibrosis-4 index (FIB-4) and fibrosis-5 index (FIB-5), which were 0.708 and 0.676, 0.778 and 0.667, 0.822 and 0.742, 0.831 and 0.808, respectively. Then, backward stepwise regression, best subset and logistic regression models were conducted for predicting significant liver inflammation and fibrosis. For the prediction of ≥G2 inflammation grade, the AUC was 0.856, 0.822, 0.755, and for the prediction of ≥S2 fibrosis grade, the AUC was 0.889, 0.889, 0.826. Through Brier score, calibration curves and DCA, it was further demonstrated that backward stepwise regression model was highly effective to predict both moderate-severe inflammation and fibrosis for DILI.

Conclusion

The backward stepwise regression model we proposed in this study is more suitable than the existing non-invasive biomarkers and can be conveniently used in the individualized diagnosis of DILI-related liver inflammation and fibrosis.

The Triglyceride-Glucose Index as a Biomarker for Insulin Resistance Following Hepatitis C Virus Eradication: A Prospective Cohort Study

Background: The triglyceride-glucose (TyG) index has emerged as a novel surrogate marker of insulin resistance, but its changes after hepatitis C virus (HCV) eradication remain unclear. This study aimed to evaluate changes in the TyG index following direct-acting antiviral (DAA) treatment. Methods: HCV-infected patients achieving sustained virological response 12 weeks post-treatment (SVR12) were prospectively enrolled from May 2015 to June 2023. Exclusion criteria included the following: (1) failure to achieve SVR12; (2) use of anti-diabetes or anti-hyperlipidemia medications; and (3) hepatitis B virus or human immunodeficiency virus co-infection. Changes in lipid profiles, TyG index, and homeostasis model assessment of insulin resistance (HOMA-IR) were evaluated from baseline to SVR12. Insulin resistance was defined as HOMA-IR ≥ 2.5. The optimal TyG index cut-off for predicting insulin resistance was determined using the Youden Index. Results: A total of 111 patients (median age: 61.0 years; 45.9% male) were included. The TyG index correlated positively with HOMA-IR (Pearson's r = 0.32, p < 0.001). Among patients with pre-existing insulin resistance, significant improvements were observed at SVR12 in both HOMA-IR (4.0 [IQR: 3.1-5.4] vs. 2.5 [IQR: 2.0-3.9]; p < 0.001) and TyG index (8.47 [IQR: 8.08-8.68] vs. 8.36 [IQR: 8.00-8.71]; p = 0.028). Using 8.27 as the optimal TyG index cut-off, similar improvements were noted in HOMA-IR (2.8 [IQR: 2.0-4.3] vs. 2.3 [IQR: 1.5-3.8]; p = 0.031) and TyG index (8.62 [IQR: 8.46-8.83] vs. 8.52 [IQR: 8.27-8.89]; p = 0.003). Conclusions: The TyG index is a valuable tool for monitoring changes in insulin resistance after HCV eradication, particularly in patients with baseline insulin resistance.

Prognostic value of liver fibrosis scores in ambulatory patients with heart failure

OBJECTIVES

To investigate the association of four liver fibrosis scores - Fibrosis-4 (FIB-4), AST/ALT ratio, AST-to-platelet ratio index (APRI) and Gamma-glutamyl transferase-to-platelet ratio index (GPRI) - and clinical outcomes in ambulatory patients with heart failure (HF).

METHODS

We conducted a retrospective study involving 2379 patients with HF referred to a specialized clinic from January 2010 to June 2022. We used multivariable Cox´s regression models to study the association between liver fibrosis scores and long-term clinical outcomes (all-cause death and the combined endpoints all-cause death or HF hospitalization and cardiovascular death or heart transplantation). Areas under receiver-operator curves were used to evaluate the discriminative capacity of each score for predicting 1-year clinical outcomes, as well as to analyze their incremental predictive value in addition to the broadly validated MAGGIC risk score.

RESULTS

Median follow up was 1568 days. GPRI was identified as an independent predictor of all-cause death or HF hospitalization (HR 1.12, 95% CI 1.07-1.18), all-cause death (HR 1.14, 95% CI 1.08-1.20) and cardiovascular death or heart transplantation (HR 1.10, 95% CI 1.03-1.17). FIB-4 and AST/ALT ratios were also independently associated with all-cause mortality. According to receiver-operator curve analyses, GPRI showed the best discriminative capacity among the four liver fibrosis scores evaluated in the study to predict 1-year clinical outcomes. The predictive value of GPRI was incremental to the one of the MAGGIC risk score.

CONCLUSIONS

Liver fibrosis scores are associated with long-term clinical outcomes in ambulatory patients with HF. In our study, the predictive capacity of GPRI outperformed the one of FIB-4, APRI and AST/ALT and was incremental to the one of the MAGGIC risk score.

Prediction of chronic severe intestinal failure-associated liver disease by current criteria in adults: A descriptive cohort study

INTRODUCTION

Intestinal failure-associated liver disease covers a spectrum of conditions from mild to end-stage disease. Currently, there are 9 diagnostic criteria divided to four categories: cholestasis, steatosis, fibrosis, and unclassified. Our aim was to evaluate the application of these criteria to patients with chronic severe liver disease in patients with intestinal failure.

METHODS

This was a cross-sectional study of patients attending the home parenteral nutrition clinic of a national UK reference intestinal failure center from March 2015 to December 2019. Exclusion criteria included active malignancy, home parenteral nutrition for <6 months duration, and liver transplantation. Clinically significant intestinal failure-associated liver disease was defined as moderate-severe fibrosis or cirrhosis on liver biopsy and/or radiological imaging compatible with liver cirrhosis.

RESULTS

Two hundred and twenty-one patients were included (age at home parenteral nutrition initiation: 50 ± 16.0 years; 63.6% female). There was a wide range of intestinal failure-associated liver disease point prevalence depending on the established criteria used (2.9%-35.1%). Twenty-three patients (9.5%) were diagnosed with clinically significant intestinal failure-associated liver disease, but no patient with clinically significant intestinal failure-associated liver disease met all diagnostic criteria, and 6 of 23 (26.1%) did not fit any of the established criteria.

CONCLUSIONS

Intestinal failure-associated liver disease is a poorly defined medical condition, and current noninvasive diagnostic methods are unreliable in predicting disease severity. Further studies are needed to develop the definition to reflect that intestinal failure-associated liver disease is a spectrum of disease that includes chronic severe liver disease and improve methods of disease diagnosis.

Aspartate aminotransferase-to-platelet ratio index outperforms Fibrosis-4 in 2843 Korean patients with metabolic dysfunction-associated steatotic liver disease

AIM

The definition of metabolic dysfunction-associated steatotic liver disease (MASLD) has recently been proposed. We aim to investigate the diagnostic efficacy of noninvasive fibrosis markers in predicting liver fibrosis in patients with nonalcoholic fatty liver disease (NAFLD), metabolic dysfunction-associated fatty liver disease (MAFLD), and MASLD.

METHODS

This retrospective study involved 2843 patients diagnosed with steatotic liver disease at six tertiary hospitals in South Korea. Liver fibrosis was assessed using vibration-controlled transient elastography, and various noninvasive markers, including the aspartate aminotransferase-to-platelet ratio index (APRI), Fibrosis-4 index (FIB-4), NAFLD fibrosis score (NFS), and serum Mac-2-binding protein glycosylation isomer were analyzed.

RESULTS

Among 1106 patients, 79.9% met criteria for NAFLD, MAFLD, and MASLD. The APRI had area under the receiver operating characteristic curve (AUC) values of 0.819, 0.821, and 0.818 for liver fibrosis ≥F2, and 0.819, 0.824, and 0.884 for liver fibrosis ≥F3, and 0.890, 0.884, and 0.889 for fibrosis ≥F4 in NAFLD, MAFLD, and MASLD, respectively. The FIB-4 index showed AUC values of 0.776, 0.793, and 0.778 for fibrosis ≥F2, 0.788, 0.814, and 0.79 for fibrosis ≥F3, and 0.846, 0.859, and 0.856 for fibrosis ≥F4. The APRI consistently had the highest AUC values, except in individuals older than 64 years for fibrosis ≥F4.

CONCLUSIONS

The APRI was the most effective noninvasive fibrosis marker across NAFLD, MAFLD, and MASLD, particularly in age-stratified analyses. Further research is needed to establish standardized cut-off values and enhance the clinical utility of these markers in managing liver fibrosis.

Biliary Metaplasia and Macrophage Activation Define the Cellular Landscape of Cardiogenic Liver Disease

Right heart failure significantly impacts liver remodeling and function, a process referred to as cardiogenic liver disease. Although recognized as a risk factor for adverse outcomes, little is understood about the cellular and molecular players that contribute to liver disease in heart failure. Using human liver biopsy samples from patients with heart failure and a mouse model of liver congestion, we unraveled a nexus of macrophages, hepatic stellate cells, and biliary metaplastic cells that shape the pathologic environment of cardiogenic liver disease.

Evaluation of the Aspartate Aminotransferase to Platelet Ratio Index for Predicting In-Hospital Mortality in Cardiogenic Shock Patients Admitted to the Intensive Care Unit

Backgrounds

This study aimed to investigate the conceivable utility of the aspartate aminotransferase to platelet ratio index (APRI) in prognostic prediction for patients with cardiogenic shock (CS) hospitalized in the intensive care unit (ICU).

Methods

Data for patients diagnosed with CS were obtained from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database and categorized into groups based on the APRI quartiles. The primary endpoint encompassed in-hospital and ICU mortality rates. The secondary outcomes included sepsis and acute kidney injury (AKI). Kaplan-Meier survival analysis was utilized to assess differences in main endpoints among groups categorized by their APRI.

Results

This study collected data from 1808 patients diagnosed with CS. Multivariate Cox regression analysis indicated that an elevated APRI was independently correlated with a heightened risk of in-hospital mortality (hazard ratio (HR) 1.005 [95% confidence interval (CI) 1.003-1.007]; p < 0.001) and ICU mortality (HR 1.005 [95% CI 1.003-1.007]; p < 0.001). Multivariate logistic regression analysis demonstrated that APRI was independently correlated with a heightened risk of sepsis (odds ratio (OR) 1.106 [95% CI 1.070-1.144]; p < 0.001) and AKI (OR 1.054 [95% CI 1.035-1.073]; p < 0.001).

Conclusions

An increased APRI was linked to worse clinical outcomes in critically ill patients with cirrhosis. Nevertheless, further extensive prospective investigations are needed to validate these findings.

Characteristics and Survival Outcomes of Hepatocellular Carcinoma After the Fontan Operation

BACKGROUND

The Fontan operation is a surgical procedure to palliate single ventricle congenital heart disease. Hepatocellular carcinoma (HCC) is a rare complication of Fontan-associated liver disease (FALD).

OBJECTIVES

The authors aim to examine characteristics of individuals with Fontan circulation diagnosed with HCC and to describe tumor characteristics, treatment, and survival outcomes of these patients.

METHODS

This was a multicenter retrospective case-control study of adults with Fontan circulation between 2005 and 2021. HCC cases were included based on histology or imaging-based diagnosis. Controls were randomly selected in a 3:1 ratio from the center in which the case was derived. Descriptive statistics were used to compare groups and Kaplan-Meier survival analysis was performed.

RESULTS

There were 58 cases of HCC diagnosed at a median age of 31 (IQR: 26-38) years. Diagnosis was made at very early or early stage disease in 68%. Compared to controls, cases had higher prevalence of advanced FALD including varices, ascites, splenomegaly, and decreased platelets. Treatment with curative intent (combined heart-liver transplantation, resection, or ablation) was performed in 41%. Survival at 1 year was 78.9% and highest among those diagnosed at very early or early stage. Over half were undergoing active surveillance at diagnosis, which showed a nonsignificant trend toward higher survival (P = 0.088).

CONCLUSIONS

We describe the clinical characteristics, treatment, and survival in patients with FALD-HCC. Results suggest that adults with FALD-HCC diagnosed with early stage disease may have survival benefit. Our findings underscore the importance of HCC screening for early detection in individuals after the Fontan operation.

The Value of Clinical Decision Support in Healthcare: A Focus on Screening and Early Detection

In a rapidly changing technology landscape, "Clinical Decision Support" (CDS) has become an important tool to improve patient management. CDS systems offer medical professionals new insights to improve diagnostic accuracy, therapy planning, and personalized treatment. In addition, CDS systems provide cost-effective options to augment conventional screening for secondary prevention. This review aims to (i) describe the purpose and mechanisms of CDS systems, (ii) discuss different entities of algorithms, (iii) highlight quality features, and (iv) discuss challenges and limitations of CDS in clinical practice. Furthermore, we (v) describe contemporary algorithms in oncology, acute care, cardiology, and nephrology. In particular, we consolidate research on algorithms across diseases that imply a significant disease and economic burden, such as lung cancer, colorectal cancer, hepatocellular cancer, coronary artery disease, traumatic brain injury, sepsis, and chronic kidney disease.

Deep proteome profiling of metabolic dysfunction-associated steatotic liver disease

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) affects roughly 1 in 3 adults and is a leading cause of liver transplants and liver related mortality. A deeper understanding of disease pathogenesis is essential to assist in developing blood-based biomarkers.

METHODS

Here, we use data-independent acquisition mass spectrometry to assess disease-state associated protein profiles in human liver, blood plasma, and white adipose tissue (WAT).

RESULTS

In liver, we find that MASLD is associated with an increased abundance of proteins involved in immune response and extracellular matrix (ECM) and a decrease in proteins involved in metabolism. Cell type deconvolution of the proteome indicates liver endothelial and hepatic stellate cells are the main source of ECM rearrangements, and hepatocytes are the major contributor to the changes in liver metabolism. In the blood, profiles of several MASLD-associated proteins correlate with expression in WAT rather than liver and so could serve as suitable liver disease predictors in a multi-protein panel marker. Moreover, our proteomics-based logistic regression models perform better than existing methods for predicting MASLD and liver fibrosis from human blood samples.

CONCLUSIONS

Our comprehensive proteomic analysis deepens the understanding of liver function and MASLD pathology by elucidating key cellular mechanisms and multi-organ interactions, and demonstrates the robustness of a proteomics-based biomarker panel to enhance diagnosis of MASLD and significant fibrosis.

Feasibility of implementing viral hepatitis services into a correctional service facility in Cape Town, South Africa

BACKGROUND

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are estimated to be of the most prevalent infectious diseases in correctional settings worldwide. However, viral hepatitis services have not been routinely integrated into South African correctional facilities. We aimed to assess prevalence of HBV infection and HCV infection among people accessing HIV services and assess the feasibility of viral hepatitis service integration in a South African correctional centre.

METHODS

Voluntarily participating people in a correctional services facility were offered free hepatitis B surface antigen (HBsAg) and anti-HCV point-of-care testing in addition to routine HIV testing and treatment services on a first-come, first-served basis during June 2021-March 2022. Off-site laboratory testing (HBV and HCV molecular testing and non-invasive liver fibrosis staging) and screening for hepatocellular carcinoma informed further management. A general practitioner at the facility managed participants, with virtual support from hepatologists. Data on age and history of injecting was collected and point-of-care and laboratory results were recorded. Data were analysed using descriptive statistics.

RESULTS

The median age of the 765 people who participated was 32.5 years (IQR 27.5 - 38.2), with 2.2% (17/765) reporting having ever injected a drug. The sample prevalence was 3.9% (30/765) for HBV infection, 0.5% (3/665) for HCV infection, and 1.2% (9/765) for HIV-HBV coinfection. Thirty people had reactive HBsAg point-of-care tests. Among those with reactive HBsAg point-of-care tests 90.0% (27/30) received work-up, among whom 48.1% (13/27) were monitored, 44.4% (12/27) were placed on treatment and two people were released before a management plan could be finalised. Of those treated 33.3% (4/12) started tenofovir/emtricitabine and 66.7% (8/12) antiretroviral therapy. Of the eligible participants, 27.3% (201/735) received at least one hepatitis B vaccine dose and 26.9% (54/201) received three doses. All three participants who had confirmed HCV infection were started on direct-acting antivirals. Of the two completing treatment one achieved sustained virological response at 12 weeks (SVR12), one person was released before SVR12 was done. One person was lost to follow-up. No clinical adverse events were reported.

CONCLUSION

There was a notable viral hepatitis burden among people in this correctional centre and integration of viral hepatitis services into the existing HIV services was acceptable and feasible. Further efforts to sustain and expand access to viral hepatitis services in South African correctional centres could catalyse national viral hepatitis elimination efforts.

Disparities in Alcohol-Associated Liver Disease Hospital Encounters Amongst a Texas-Based Cohort of Patients

INTRODUCTION

Alcohol-associated liver disease (ALD) disproportionately impacts men, racial and ethnic minorities, and individuals of low socioeconomic status; however, it's unclear how recent increases in ALD burden have impacted these disparities. We aimed to describe trends in racial, ethnic and socioeconomic disparities in alcohol-associated hospital encounters.

METHODS

We conducted a retrospective cohort study of adult hospital encounters with alcohol-associated diagnoses from three health systems between January 2016 and December 2021. The cohort was divided into three eras: a 'Historical Era,' (Oct 2016-June 2018, used only for trends); 'Era 1' (July 2018-March 2020); and 'Era 2' (April 2020-December 2021). Kaplan Meier and Cox regression analyses were performed to identify factors associated with overall survival.

RESULTS

We identified 19,295 individuals with alcohol-associated encounters (44.7% White, 29.8% Hispanic, and 21.8% non-Hispanic Black (NHB) individuals), with a greater increase observed between eras 1 and 2 than the historical era and Era 1 (8.7% vs. 5.0%, p < 0.01). By age and sex, the greatest increases in encounters were observed in the youngest and oldest females but only the oldest males. By race and ethnicity, Hispanic individuals had greater increases in encounters compared to Black and White individuals (14.8% vs. 7.5% and 6.3%, p < 0.01). Older age (aSHR: 1.03, 95% CI: 1.03-1.0), higher MELD (aSHR: 1.08, 95% CI: 1.0-1.09), hepatic encephalopathy (aSHR: 1.42, 95% CI: 1.06-1.90), and hepatocellular carcinoma (HCC) (aSHR: 3.20, 95% CI: 2.29-4.49) were associated with increased mortality.

CONCLUSION

The highest increases of alcohol-associated encounters were observed amongst young Hispanic and NHB women, highlighting variation in trends by age, sex, race and ethnicity. These disparities merit further investigation to elucidate underlying mechanisms and develop tailored interventions to improve ALD burden and outcomes.

Annual biological variation and personalized reference intervals of 8 serum liver enzymes and 3 noninvasive tests in fatty liver patients

BACKGROUND

The liver function tests and noninvasive tests (NITs) play important roles in the follow-up and monitoring of fatty liver disease (FLD). Our aim is to establish annual biological variation (BV) and personalized reference intervals (prRIs) of liver function tests for the first time in order to accurately assess the status and progress of FLD.

METHODS

67 fatty liver patients who participated in regular physical examination once a year for six consecutive years, were enrolled. Based on these patients, we calculated annual BV and derived parameters, including reference change value (RCV), index of individuality (II), and total variation around the true homeostatic set point (TVset) which could further be used to derive prRI.

RESULTS

We calculated the annual within-subject BV (CVI), within-person BV (CVP), RCV, II, TVset of 8 liver function tests and 3 NITs for fatty liver patients. CVI estimates of fatty liver patients for half of liver function tests were significantly lower than those of healthy people and these could lead to a lower RCV. IIs of all measurands were < 1.4 except for total bile acids (TBA). The mean of CVP is similar to the CVI; however, there is a significant heterogeneity in CVP among different subjects. Annual TVset estimates for 7 measurands were lower and prRI was also narrower in fatty liver patients than that of healthy people.

CONCLUSION

Annual BV and their derived parameters based on fatty liver patients can provide an objective basis for the monitoring and follow-up of FLD, a global epidemic disease.

Fontan-Associated Liver Disease

Fontan-associated liver disease (FALD) occurs in all patients who have undergone Fontan palliation for functional single ventricle congenital heart defects. While liver fibrosis is universal in patients who have undergone Fontan palliation, FALD may lead to more serious consequences including portal hypertension, cirrhosis, and hepatocellular carcinoma. Scientific studies of the pathophysiology and clinical management of FALD have been limited to date by the heterogeneous nature of the disease, relatively small population of patients with Fontan physiology, and inaccuracy of noninvasive staging tests. As survival after the Fontan procedure improves, the population of adults with Fontan physiology is growing, leading to more severe extracardiac complications related to the Fontan circulation and growing demand for heart and liver transplantation. The accurate evaluation, staging, and management of FALD comprises a clinical challenge which requires expert multidisciplinary input.

Clinical- and Cost-Effectiveness of Liver Disease Staging in Hepatitis C Virus Infection: A Microsimulation Study

BACKGROUND

Liver disease assessment is a key aspect of chronic hepatitis C virus (HCV) infection pre-treatment evaluation but guidelines differ on the optimal testing modality given trade-offs in availability and accuracy. We compared clinical outcomes and cost-effectiveness of common fibrosis staging strategies.

METHODS

We simulated adults with chronic HCV receiving care at US health centers through a lifetime microsimulation across five strategies: (1) no staging or treatment (comparator), (2) indirect serum biomarker testing (Fibrosis-4 index [FIB-4]) only, (3) transient elastography (TE) only, (4) staged approach: FIB-4 for all, TE only for intermediate FIB-4 scores (1.45-3.25), and (5) both tests for all. Outcomes included infections cured, cirrhosis cases, liver-related deaths, costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). We used literature-informed loss to follow-up (LTFU) rates and 2021 Medicaid perspective and costs.

RESULTS

FIB-4 alone generated the best clinical outcomes: 87.7% cured, 8.7% developed cirrhosis, and 4.6% had liver-related deaths. TE strategies cured 58.5%-76.6%, 16.8%-29.4% developed cirrhosis, and 11.6%-22.6% had liver-related deaths. All TE strategies yielded worse clinical outcomes at higher costs per QALY than FIB-4 only, which had an ICER of $12 869 per QALY gained compared with no staging or treatment. LTFU drove these findings: TE strategies were only cost-effective with no LTFU. In a point-of-care HCV test-and-treat scenario, treatment without any staging was most clinically and cost-effective.

CONCLUSIONS

FIB-4 staging alone resulted in optimal clinical outcomes and was cost-effective. Treatment for chronic HCV should not be delayed while awaiting fibrosis staging with TE.

Role of noninvasive tests in the prognostication of metabolic dysfunction-associated steatotic liver disease

In managing metabolic dysfunction-associated steatotic liver disease, which affects over 30% of the general population, effective noninvasive biomarkers for assessing disease severity, monitoring disease progression, predicting the development of liver-related complications, and assessing treatment response are crucial. The advantage of simple fibrosis scores lies in their widespread accessibility through routinely performed blood tests and extensive validation in different clinical settings. They have shown reasonable accuracy in diagnosing advanced fibrosis and good performance in excluding the majority of patients with a low risk of liver-related complications. Among patients with elevated serum fibrosis scores, a more specific fibrosis and imaging biomarker has proved useful to accurately identify patients at risk of liver-related complications. Among specific fibrosis blood biomarkers, enhanced liver fibrosis is the most widely utilized and has been approved in the United States as a prognostic biomarker. For imaging biomarkers, the availability of vibration-controlled transient elastography has been largely improved over the past years, enabling the use of liver stiffness measurement (LSM) for accurate assessment of significant and advanced fibrosis, and cirrhosis. Combining LSM with other routinely available blood tests enhances the ability to diagnose at-risk metabolic dysfunction-associated steatohepatitis and predict liver-related complications, some reaching an accuracy comparable to that of liver biopsy. Magnetic resonance imaging-based modalities provide the most accurate quantification of liver fibrosis, though the current utilization is limited to research settings. Expanding their future use in clinical practice depends on factors such as cost and facility availability.

FIB-4 Index Can Predict Mortality in Hospitalized Patients with COVID-19 Infection, Independent of CT Severity Score

BACKGROUND

The fibrosis 4 (FIB-4) index is typically used in assessing liver fibrosis, and has shown potential in predicting the outcome in various diseases. This study aims to evaluate the predictive power of the FIB-4 index for mortality in COVID-19 patients admitted to a reference hospital in Tehran, Iran.

METHODS

In this prospective cohort study, 387 patients with COVID-19 without diabetes, were categorized into deceased and surviving groups. We compared anthropometric and demographic data, liver function tests, CT scores, and FIB-4 indices between the groups. Multivariate logistic regression assessed the independent association of FIB-4 with mortality.

RESULTS

Among the 387 patients, (all non-diabetics), 58 (15%) died, with a higher mortality rate observed in patients with a FIB-4 index≥2.6 (63.4%) compared to those with FIB-4<2.6 (29.7%). Deceased patients were considerably older and more likely to be hypertensive (P values<0.001). After adjustment of confounding factors, a FIB-4 index≥2.6 was found to be independently associated with increased mortality (OR: 13.511, 95% CI: 1.356-134.580, P=0.026).

CONCLUSION

The FIB-4 index, calculable by routine laboratory tests, may be a valuable prognostic factor for COVID-19 mortality. This easily obtainable marker could help identify high-risk patients early, potentially allowing for more rapid intervention and treatment prioritization.

The relationship between dose of methotrexate and incidence of liver fibrosis in patients with rheumatoid arthritis

Introduction

Methotrexate (MTX) is a chemotherapy agent and immune system suppressant that can cause liver fibrosis in long-term usage. This study aimed to investigate the relationship between the dose of MTX and the incidence of liver fibrosis in patients with rheumatoid arthritis (RA).

Material and methods

This cohort study was conducted on RA patients with normal liver function who took MTX. Liver FibroScan and laboratory tests, including α2-macroglobulin, total bilirubin, g-glutamyltransferase, apolipoprotein A1, haptoglobin, and alanine transaminase was performed. The patients were divided into 2 groups regarding their cumulative dose of MTX and the rate of liver fibrosis incidence was compared between the 2 groups.

Results

In total, 60 RA patients with the mean age of 55.2 ±11.8 years were enrolled. The mean duration of MTX use in patients was 6.9 ±3.8 years, and it was higher in the higher cumulative dose MTX group (> 2 g) than in the lower cumulative dose group (< 2 g; p < 0.0001). The overall prevalence of grade 3 fibrosis was 3.33%. The prevalence of second- and third-degree liver fibrosis in patients receiving a lower cumulative dose was respectively 9 (28.1%) and 1 (3.1%), and in patients receiving a higher cumulative dose it was 7 (25%) and 1 (3.6%), respectively. There was no statistically significant difference between the 2 groups regarding the prevalence of liver fibrosis (p = 0.88). Both aspartate aminotransferase to platelet ratio index and Fibrosis Index Based on 4 Factors indices showed no significant difference between the 2 groups (p = 0.594, p = 0.232).

Conclusions

These results suggest that long-term treatment with a higher cumulative dose of MTX is not associated with a higher incidence of liver fibrosis in RA patients.

A model based on chitinase 3-like protein for expecting liver severity of hepatitis B virus infections in the immune tolerance phase

BACKGROUND

The question of whether to treat patients with chronic hepatitis B (CHB) during the immune tolerance (IT) period is a matter of ongoing debate, as it is difficult to discern different levels of liver disease severity. We created and assessed a novel diagnostic model for identifying significant liver tissue damage in individuals with CHB in IT phase.

METHODS

From November 2018 to December 2022, a cross-sectional study of 311 patients with chronic hepatitis B virus infection (HBV DNA > 30 IU/mL) at Ningbo No. 2 Hospital, Ningbo, China, who underwent liver biopsy, including 44 patients in IT phase. Utilizing univariate regression analyses and logistics analysis, and model was developed and validated to predict the severity of hepatic inflammatory and fibrosis in CHB patients and in IT phase.

RESULTS

Chitinase 3-like Protein (CHI3L1), albumin (ALB), alanine transaminase (ALT) / aspartate aminotransferase (AST) were identified as independent predictors of liver lesion severity in CHB patients with IT. The three were combined to build the model (named as CAA index), which demonstrated good performance. The CAA index achieved an area under the receiver operating characteristic curve (AUC) of 0.916 (95 % CI, 0.820-1.000) and AUC of validation group was 0.875 (95 % CI, 0.683-1.000).

CONCLUSIONS

CHI3L1 serves as an independent measure of liver fibrosis and inflammation in CHB. This diagnostic model has some value in assessing the severity of the patient's liver lesion severity and may be a reliable non-invasive diagnostic model helping determine whether treatment is necessary among CHB patients in IT phase.

Endoscopic Ultrasound-Guided Portosystemic Pressure Gradient Correlates with Clinical Parameters and Liver Histology

BACKGROUND AND AIMS

Endoscopic ultrasound-guided portosystemic pressure gradient measurement (EUS-PPG) is a novel technique to evaluate for portal hypertension (PH), a diagnosis that can prognosticate and guide therapy for patients. This study evaluated the safety and efficacy of EUS-PPG and correlation with clinical parameters and liver histology.

METHODS

We conducted a multicenter, retrospective study of patients undergoing EUS-PPG from January 2020 to December 2022 for suspected liver disease or PH. Linear regression was used to examine the relationship between EUS-PPG and clinical parameters of PH, and the chi-square test, Fisher's exact test, and Wilcoxon rank sum test described correlation with liver biopsy histology and noninvasive markers of fibrosis (Fibrosis-4, APRI [aspartate aminotransferase-to-platelet ratio index]). Logistic regression was performed to identify the strongest predictor of histologic cirrhosis.

RESULTS

Across 8 centers, 385 patients were enrolled and 373 had successful EUS-PPG (technical success 97%). Higher median PPGs were observed in patients with than without esophageal varices (11.6 mm Hg vs 4.1 mm Hg), portal hypertensive gastropathy (10.5 mm Hg vs 3.3 mm Hg), and thrombocytopenia (7.6 mm Hg vs 4.4 mm Hg) (P < .001). Individuals with PH and clinically significant PH (PPG ≥10) were 6.7 and 3.8 times more likely to have cirrhosis on histology, respectively. EUS-PPG was the best overall predictor of biopsy-proven cirrhosis (area under the curve 0.84) compared with Fibrosis-4 (0.72), and APRI (0.54). There were 2 minor adverse events related to PPG (postprocedural pain).

CONCLUSIONS

EUS-PPG measurement was technically feasible and safe and demonstrated a strong correlation with clinical parameters of PH and liver histology. The strongest predictor of cirrhosis was EUS-PPG >5 mm Hg, which outperformed noninvasive markers of fibrosis.

The associations between diet-induced inflammation and the improvement or worsening of hepatic steatosis and fibrosis: a longitudinal analysis of RaNCD cohort study

BACKGROUND

Persistent inflammation plays a crucial role in the pathogenesis of metabolic dysfunction-associated steatotic liver disease (MASLD). We aimed to scrutinize the associations of diet-induced inflammation with the improvement or worsening of hepatic steatosis and fibrosis in MASLD.

METHODS

This longitudinal study involved 2,537 participants from the Ravanser Non-Communicable Disease (RaNCD) cohort (2015-2023). Dietary intake was assessed using the 118-item food frequency questionnaire (FFQ), and diet-induced inflammation was determined using the dietary inflammatory index (DII). The AST to platelet ratio index (APRI) and Fibrosis-4 (FIB-4) were used as confirmed predictive indicators for hepatic fibrosis and the hepatic steatosis index (HSI) was used for hepatic steatosis.

RESULTS

Adherence to an inflammatory diet independently increases the risk of worsening hepatic steatosis (RR:1.39; 95%CI: 1.02-1.93; P-value: 0.04) and reduces the risk of improving hepatic steatosis (RR: 66; 95% CI: 0.48-0.98; P-value: 0.01) compared to an anti-inflammatory diet. The DII scores did not show any connection to hepatic fibrosis, as determined by FIB-4 (β: - 1.08; 95%CI: - 2.43 to 0.27; P-value: 0.12) and APRI (β: 0.22; 95%CI: - 1.51 to 1.95; P-value: 0.80).

CONCLUSIONS

These results underscore the importance of dietary composition in managing hepatic steatosis and highlight the need for further research to explore the mechanisms underlying these associations.

The role of noninvasive biomarkers for monitoring cell injury in advanced liver fibrosis

INTRODUCTION

Accurate and reliable diagnosis and monitoring of hepatic fibrosis is increasingly important given the variable natural history in chronic liver disease (CLD) and expanding antifibrotic therapeutic options targeting reversibility of early-stage cirrhosis. This highlights the need to develop more refined and effective noninvasive techniques for the dynamic assessment of fibrogenesis and fibrolysis.

AREAS COVERED

We conducted a literature review on PubMed, from 1 December 1970, to 1 November 2024, to evaluate and compare available blood-based and imaging-based noninvasive tools for hepatic fibrosis diagnosis and monitoring. Simple scores such as FIB-4 and NAFLD fibrosis score are suitable for excluding significant or advanced fibrosis, while tertiary centers should adopt complex scores and liver stiffness measurement as part of a secondary diagnostic and more comprehensive evaluation. Moreover, the advent of multiomics for high-resolution molecular profiling, and integration of artificial intelligence for noninvasive diagnostics holds promise for revolutionizing fibrosis monitoring and treatment through novel biomarker discovery and predictive omics-based algorithms.

EXPERT OPINION

The increased shift toward noninvasive diagnostics for liver fibrosis needs to align with personalized medicine, enabling more effective, tailored management strategies for patients with liver disease in the future.

Rapid identification and phenotyping of nonalcoholic fatty liver disease patients using a machine-based approach in diverse healthcare systems

Nonalcoholic fatty liver disease (NAFLD) is the most common global cause of chronic liver disease and remains under-recognized within healthcare systems. Therapeutic interventions are rapidly advancing for its inflammatory phenotype, nonalcoholic steatohepatitis (NASH) at all stages of disease. Diagnosis codes alone fail to recognize and stratify at-risk patients accurately. Our work aims to rapidly identify NAFLD patients within large electronic health record (EHR) databases for automated stratification and targeted intervention based on clinically relevant phenotypes. We present a rule-based phenotyping algorithm for efficient identification of NAFLD patients developed using EHRs from 6.4 million patients at Columbia University Irving Medical Center (CUIMC) and validated at two independent healthcare centers. The algorithm uses the Observational Medical Outcomes Partnership (OMOP) Common Data Model and queries structured and unstructured data elements, including diagnosis codes, laboratory measurements, and radiology and pathology modalities. Our approach identified 16,006 CUIMC NAFLD patients, 10,753 (67%) previously unidentifiable by NAFLD diagnosis codes. Fibrosis scoring on patients without histology identified 943 subjects with scores indicative of advanced fibrosis (FIB-4, APRI, NAFLD-FS). The algorithm was validated at two independent healthcare systems, University of Pennsylvania Health System (UPHS) and Vanderbilt Medical Center (VUMC), where 20,779 and 19,575 NAFLD patients were identified, respectively. Clinical chart review identified a high positive predictive value (PPV) across all healthcare systems: 91% at CUIMC, 75% at UPHS, and 85% at VUMC, and a sensitivity of 79.6%. Our rule-based algorithm provides an accurate, automated approach for rapidly identifying, stratifying, and sub-phenotyping NAFLD patients within a large EHR system.

ICOSL deficiency promotes M1 polarization to alleviate liver fibrosis in schistosomiasis mice

The expression of inducible co-stimulator ligand (ICOSL) on macrophage (Mφ) implies their ability to interact with inducible co-stimulator (ICOS)-expressing T cells, thereby modulating immune responses within the liver microenvironment. This study aimed to elucidate the mechanism underlying ICOS/ICOSL signaling in the regulation of Mφ polarization during Schistosomiasis-induced liver fibrosis. To investigate this, ICOSL-knock out (KO) and wildtype (WT) C57BL/6 mice were infected with Schistosoma japonicum (S. japonicum) to examine the dynamic changes in Mφ phenotype and observe the pathology alterations in the liver. There was significantly decreased expression of ICOSL both in monocytes of cirrhosis patients and the liver tissue of mice infected with S. japonicum. Furthermore, ICOSL-KO mice exhibited reduced liver granuloma formation and fibrosis during S. japonicum infection. Simultaneously, Mφ in ICOSL-KO mice polarized towards M1-type and induced apoptosis of hepatic stellate cells (HSCs). Overall, the blockade of ICOSL signaling could promote M1 polarization, induce HSCs apoptosis, and ameliorate hepatic fibrosis, suggesting that ICOSL may serve as a potential biomarker for prognosis and therapeutic target for schistosomiasis-induced hepatic fibrosis.

Targeted Plasma Bile Acid Metabolomic Analysis in Metabolic Dysfunction-Associated Steatohepatitis and Alcoholic Hepatitis

Background: Even though many metabolic liver diseases can now be diagnosed using blood tests and diagnostic imaging, early diagnosis remains difficult. Understanding mechanisms contributing to the progression from Metabolic Dysfunction-Associated Steatohepatitis (MASH) and Alcoholic Hepatitis (AH) to cirrhosis is critical to reduce the burden of end-stage liver disease. Monitoring individual bile acids has been proposed as a way to distinguish various liver disorders. Methods: This study explored bile acid profiles in patients with MASH and AH. Plasma samples from patients with MASH, AH, and a control group were analyzed using liquid chromatography-tandem mass spectrometry (LC-MS/MS) to quantify bile acid concentrations. Targeted metabolomic analysis was performed to compare bile acid levels between the hepatitis and control groups. Results: Concentrations of ursodeoxycholic acid (UDCA), chenodeoxycholic acid (CDCA), taurocholic acid (TCA), tauroursodeoxycholic acid (TUDCA), taurochenodeoxycholic acid (TCDCA), glycoursodeoxycholic acid (GUDCA), glycochenodeoxycholic acid (GCDCA), and glycocholic acid (GCA) were significantly elevated in the hepatitis group. Correlation analysis revealed strong positive relationships between the total and direct bilirubin levels and TUDCA and GCDCA. Aspartate aminotransferase (AST) showed strong positive correlations with TCDCA and GCDCA. Child-Pugh score, Fibrosis-4 index, and non-alcoholic fatty liver disease fibrosis score were positively correlated with GCA, whereas the aspartate aminotransferase-to-platelet ratio correlated with TCA, TCDCA, and GCA. The model for end-stage liver disease (MELD) score showed a strong positive correlation with GCDCA. Implications: GCDCA may serve as a predictive biomarker for liver damage, potentially enabling early diagnosis and targeted intervention in patients with MASH and AH.

Decreased liver volume after bariatric surgery and its positive impact on liver function tests and lipid profile

BACKGROUND

Obesity is associated with a higher incidence of fatty liver disease, intrahepatic triglyceride content, and hepatic fibrosis. These abnormalities could progress to severe liver disease.

OBJECTIVES

To evaluate the effects of bariatric surgery (BaS)-induced weight loss on liver volume, hepatic function tests, and lipid profile.

SETTING

Academic Hospital, United States.

METHODS

We conducted a retrospective review of an institutional review board (IRB)-approved database on patients who underwent BaS from 2006 to 2018. To determine changes in liver volume, we reviewed abdominal computed tomography scans before BaS (Group 1) and up to 18 months after (Group 2). Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and lipid profiles were collected before and after BaS.

RESULTS

Seventy-three patients met the inclusion criteria. Patients were predominantly females 78.1% (57), with an average age of 51.29+12.54 years. The liver volume was 1870.73 + 638.5 mm3 before and 1555.15 + 464.8 after BaS (P = .004). ALT was 36.9 + 25.3 before versus 23.8 + 19.3 after BaS (P = .024).Triglyceride levels changed from 135.62 + 69.98 before to 97.50 + 47.33 after BaS (P = .009). Low-density lipoprotein decreased from 107.9 + 38.1 to 89.6 + 32.8 (P = .048).

CONCLUSIONS

BaS-induced weight loss determines significant liver shrinkage by reducing liver volume, and coincides with improvements in hepatic function tests and lipid profile. Our results suggest that BaS might contribute to reduction of the progression of fatty liver disease to fibrosis.

Real-World Experience, Effectiveness, and Safety of Direct-Acting Antivirals for the Treatment of Hepatitis C in Oman: A Cross-Sectional, Multicenter Study

Background: The advent of direct-acting antiviral (DAA) therapy has revolutionized the treatment landscape of the hepatitis C virus (HCV) infection. This study aimed to provide a comprehensive research study of the real-world effectiveness and safety of DAA treatment, representing the first study conducted in the Omani population. Methods: A cross-sectional study was conducted including 375 HCV patients with different genotypes, treated using different DAA regimens, with or without ribavirin, between January 2012 and December 2020 at the Sultan Qaboos University Hospital and the medical city for military and security services, two tertiary hospitals in Muscat, Oman. The rate of sustained virologic response 12 weeks after completing the regimen (SVR-12) was analyzed as the primary outcome. Secondary outcomes included treatment safety and adverse events related to DAA therapy, as reported by patients and treating physicians. Results: A total of 375 patients were included in the study, with a mean age of 47.3 ± 15.4 years. Most were male (59.2%) and treatment-naïve (71.7%). The prevalence of liver cirrhosis was 19.7%, while 4.0% had hepatocellular carcinoma (HCC). The SVR-12 rate among treatment-naïve and treatment-experienced patients was 95.0% and 93.4%, respectively. Several parameters were associated with DAA treatment failure, including liver cirrhosis (p = 0.004) and active HCC (p = 0.009). Following SVR-12, significant improvements were observed in alanine transaminase, bilirubin, and albumin levels, Fibrosis-4 Index, and liver stiffness measurements compared to baseline (p <0.001 each). No significant adverse effects were reported. Conclusions: Based on our real-world experience, DAAs are highly effective in treating patients with HCV infection in Oman, with an excellent tolerability and safety profile.

Intra- and inter-patient diversity in hepatocellular carcinoma based on phosphorylation profiles-A pilot study in a single institution

BACKGROUND

Recent studies have addressed the efficacy of targeted drugs against hepatocellular carcinoma. However, most tumors escape a single kinase inhibition; co-inhibition of additional signaling pathways re-sensitizes resistant cancer cells to targeted drugs, thus reinforcing the importance of combination therapy for drug-resistant tumors. This study aimed to clarify the phosphorylation profiles of representative cancer-related tyrosine kinases in hepatocellular carcinoma to focus on potential therapeutic targets and to investigate the possibility of expanding combination therapy options using targeted drugs.

MATERIALS AND METHODS

Patients' whole blood, hepatocellular carcinoma tissue, and adjacent hepatic tissues were obtained during surgeries from 10 patients. All patients showed negative results for hepatitis B and hepatitis C RNA and none had a history of heavy drinking. The activation of receptor tyrosine kinases (RTKs) was analyzed by using a human RTK phosphorylation antibody array.

RESULTS

Among 62 different phospho-RTKs, 26 were activated in tumor tissues, of which ACK1, Dtk, Fyn, and Lyn were positive in 9 out of 10 cases. The median concordance rates of activated tumor and serum RTKs in each patient was 50 %. There was an inter- and intra-patient diversity of phosphorylation profiles in the serum, tumor of resected specimens, and non-tumor tissue of resected specimens in the same patients.

CONCLUSION

There was an intra- and inter- patient diversity in the activation of important and representative cancer-related RTKs. Expanding on this approach will allow us to learn how to predict the best combination of targets for each patient and to prioritize those combinations for clinical testing.

Comparison of different noninvasive scores for assessing hepatic fibrosis in a cohort of chronic hepatitis C patients

The continuous search for simple, noninvasive methods for assessing liver fibrosis remains very important to help risk-stratify and follow-up patients with chronic hepatitis C virus (HCV). This study aimed to evaluate the diagnostic performance and accuracy of six serological noninvasive scores for the assessment of liver fibrosis in comparison to liver histopathology. This retrospective cohort study included data from 19501 patients with chronic HCV infection who had liver biopsies as an HCV treatment prerequisite within the Egyptian national HCV treatment program. Six noninvasive scores (FIB-4, APRI, King's score, Fibro-Q, fibrosis index, Fibro-α score) were evaluated and compared to liver histopathology data in assessing different stages of liver fibrosis. The diagnostic performance for each score was assessed using the area under the receiver-operating characteristic curve (AUROC). All six noninvasive scores were statistically significant for predicting different stages of liver fibrosis. Four scores (FIB-4, King's score, APRI, and Fibro Q) had a better diagnostic performance for predicting different fibrosis stages. FIB-4, followed by the King's score, performs better in identifying patients with advanced fibrosis at cutoffs of 2.01 and 16.7, respectively, with AUROC of 0.71 for both, and in predicting cirrhosis at cutoffs of 2.21 and 17.4, respectively with AUROC 0.82 for both. Using noninvasive scores for fibrosis assessment is very important, especially in limited resource settings, to rapidly stratify patients who need more specialized care.

Effectiveness of sofosbuvir-based treatments for patients with hepatitis C virus genotype 6 infection: a real-world study from East China

Background

Over the past decade, the proportion of hepatitis C virus (HCV) genotypes (GT) 1 and 2 has decreased in almost all regions of China, while GT 3 and 6 have emerged as new challenges. GT 6 is unique in many respects, like high genetic variability and emerging resistant variants. This study aims to assess the efficacy of sofosbuvir (SOF)-based treatments in patients with GT 6 chronic hepatitis C (CHC).

Methods

A retrospective analysis was conducted on patients with GT 6 HCV infection, who were diagnosed between July 2018 and May 2023. All patients received a 12-week course of SOF-based treatments. The primary efficacy endpoint was sustained virologic response (SVR), which is defined as having undetectable HCV RNA at 12 weeks after treatment completion (SVR12). The efficacy data for SVR12 were analyzed using both the evaluated population (EP) and per-protocol population (PP). For the PP populations, efficacy data were stratified using Forrester plots.

Results

A total of 201 patients were included in the study. In PP population, the end of treatment virological response rate was 99.48% (190/191), the SVR12 rate was 99.31% (143/144), and the SVR24 rate was 100.00% (75/75). Only one patient with genotype 6a experienced a relapse 12 weeks after the completion of treatment, but her HCV RNA was undetectable both at the end of treatment and 24 weeks after the end of treatment. Additionally, the normalization rates of alanine transaminase (ALT) and aspartate aminotransferase (AST) were significantly higher at the end of treatment (EOT) compared to baseline (27.36% vs. 93.03%, 36.32% vs. 95.02%, p < 0.001). Significant improvements were observed in the levels of total bilirubin, ALT, AST, albumin, globulin, albumin/globulin ratio, gamma-glutamyl transferase, alkaline phosphatase, platelet, fibrosis-4 (FIB-4), and aspartate transaminase to platelet ratio index (APRI) between baseline and EOT (p < 0.05).

Conclusion

SOF-based treatments achieved high virological and biochemical response rates in patients with HCV GT 6 infection.

[Serological Markers to Assess Liver Fibrosis and Their Roles]

Chronic liver disease is a significant public health issue worldwide, with the degree of liver fibrosis and its progression significantly influencing the treatment and prognosis. A liver biopsy is the standard diagnostic method, but it is invasive and presents various issues. Therefore, numerous non-invasive diagnostic methods have been developed. Serum markers are categorized into indirect markers, which reflect liver damage, inflammation, or functional changes, and direct markers, which measure the components released into the bloodstream during fibrosis. In addition, various kinds of formulas that combined direct/indirect markers and demographic variables were developed and validated with encouraging outcomes. Nevertheless, despite their convenience, serum indicators require cautious interpretation because they are affected by a number of factors. More research will be needed to determine if the clinical course of chronic liver disease under a disease-specific treatment could be monitored appropriately using serological markers.

Impact of sociodemographic disparities on sarcopenia, telomere length, and mortality in patients with liver disease in the US population

BACKGROUND & AIMS

Sarcopenia is common in patients with liver disease and both sarcopenia and short telomeres are associated with mortality, however their relationship in patients with liver disease remains unknown.

METHODS

A cohort of 16,072 adults from the National Health and Nutrition Examination Survey from 1999 to 2006 was analyzed. Liver disease was defined by aminotransferases and classified into etiology-based categories. Sarcopenia was defined by dual-energy x-ray absorptiometry. All analyses were conducted separately on each multiple imputation data set and combined via Rubin's rules. P-values for group comparisons were calculated by testing logistic regression parameter estimates. Cox proportional hazards regression was used for mortality analysis with mortality data available until 2015.

RESULTS

Sarcopenia was present in 9.5% of patients with liver disease. Age, race, income, education, physical inactivity, and certain medical comorbidities were associated with sarcopenia. Patients with liver disease and sarcopenia had significantly shorter telomeres than patients with liver disease without sarcopenia when unadjusted for age. The interaction between telomere length and sarcopenia was significantly associated with all-cause mortality.

CONCLUSIONS

The implications of telomere length on all-cause mortality in patients with liver disease varied by age and sarcopenia status. Shorter telomeres appear to be more highly associated with increased mortality in older patients without sarcopenia.

Assessment of the Fibrosis Score and the Child-Turcotte-Pugh (CTP) Score in Patients With Chronic Liver Disease in India

OBJECTIVE

 This study aimed to evaluate the severity of liver fibrosis in chronic liver disease patients using aspartate aminotransferase-to-platelet ratio index (APRI), fibrosis-4 (FIB-4), FibroScan, and the Child-Turcotte-Pugh (CTP) score. It emphasized assessing fibrosis progression toward cirrhosis (F4 stage) and exploring the correlation between non-invasive markers and the CTP score for liver function and prognosis.

METHODOLOGY

This observational cross-sectional study was conducted over one calendar year in the Department of Medicine at Baba Raghav Das (BRD) Medical College, Gorakhpur, India. A total of 200 patients with chronic liver disease were selected. Fibrosis scores were calculated using FibroScan, APRI, and FIB-4, while the modified CTP score was determined for each participant. Pearson's correlation was used to assess relationships between variables, while logistic regression evaluated the association of non-invasive methods (APRI, FIB-4, FibroScan) with severe fibrosis (F4). Odds ratios (ORs), sensitivity, specificity, and AUC were calculated, and ROC curves visualized their discriminative ability. Statistical significance was defined as p < 0.05.

RESULTS

 The study revealed a predominance of advanced fibrosis (F4) in males (82.5%) and patients with ethanol-induced liver disease (84.6%). FIB-4 had the strongest predictive value for advanced fibrosis with an OR of 3.8 (95% CI: 3.0-4.5) and AUC of 0.743, followed by APRI with an OR of 2.5 (95% CI: 1.9-3.1) and AUC of 0.757. CTP showed the highest sensitivity (95.45%) but a lower AUC (0.697), indicating its clinical value in correlating fibrosis severity with liver dysfunction. Hemoglobin, platelets, and INR showed no significant correlation with fibrosis, while total bilirubin was elevated in advanced CTP classes. A moderate positive correlation (r = 0.481, p < 0.001) was observed between fibrosis scores and CTP, linking fibrosis severity with liver dysfunction. These findings emphasize FIB-4's superior predictive accuracy, while APRI and CTP remain valuable complementary tools for liver disease prognosis.

CONCLUSION

 In conclusion, FIB-4 is the most accurate for staging advanced fibrosis, while APRI excels in initial screening due to its higher sensitivity. FibroScan effectively assesses direct fibrosis, and the CTP score adds prognostic value, making these methods complementary for managing chronic liver diseases.

Benchmarking clinical risk prediction algorithms with ensemble machine learning for the noninvasive diagnosis of liver fibrosis in NAFLD

BACKGROUND AND AIMS

Ensemble machine-learning methods, like the superlearner, combine multiple models into a single one to enhance predictive accuracy. Here we explore the potential of the superlearner as a benchmarking tool for clinical risk prediction, illustrating the approach to identifying significant liver fibrosis among patients with NAFLD.

APPROACH AND RESULTS

We used 23 demographic/clinical variables to train superlearner(s) on data from the NASH-clinical research network observational study (n = 648) and validated models with data from the FLINT trial (n = 270) and National Health and Nutrition Examination Survey (NHANES) participants with NAFLD (n = 1244). Comparing the superlearner's performance to existing models (Fibrosis-4 [FIB-4], NAFLD fibrosis score, Forns, AST to Platelet Ratio Index [APRI], BARD, and Steatosis-Associated Fibrosis Estimator [SAFE]), it exhibited strong discriminative ability in the FLINT and NHANES validation sets, with AUCs of 0.79 (95% CI: 0.73-0.84) and 0.74 (95% CI: 0.68-0.79) respectively.

CONCLUSIONS

Notably, the SAFE score performed similarly to the superlearner, both of which outperformed FIB-4, APRI, Forns, and BARD scores in the validation data sets. Surprisingly, the superlearner derived from 12 base models matched the performance of one with 90 base models. Overall, the superlearner, being the "best-in-class" machine-learning predictor, excelled in detecting fibrotic NASH, and this approach can be used to benchmark the performance of conventional clinical risk prediction models.

Machine Learning-Based Models for Advanced Fibrosis and Cirrhosis Diagnosis in Chronic Hepatitis B Patients With Hepatic Steatosis

BACKGROUND AND AIMS

The global rise of chronic hepatitis B (CHB) superimposed on hepatic steatosis (HS) warrants noninvasive, precise tools for assessing fibrosis progression. This study leveraged machine learning (ML) to develop diagnostic models for advanced fibrosis and cirrhosis in this patient population.

METHODS

Treatment-naive CHB patients with concurrent HS who underwent liver biopsy in 10 medical centers were enrolled as a training cohort and an independent external validation cohort (NCT05766449). Six ML models were implemented to predict advanced fibrosis and cirrhosis. The final models, derived from SHAP (Shapley Additive exPlanations), were compared with Fibrosis-4 Index, nonalcoholic fatty liver disease Fibrosis Score, and aspartate aminotransferase-to-platelet ratio index using the area under receiver-operating characteristic curve (AUROC) and decision curve analysis (DCA).

RESULTS

Of 1,198 eligible patients, the random forest model achieved AUROCs of 0.778 (95% confidence interval [CI], 0.749-0.807) for diagnosing advanced fibrosis (random forest advanced fibrosis model) and 0.777 (95% CI, 0.748-0.806) for diagnosing cirrhosis (random forest cirrhosis model) in the training cohort, and maintained high AUROCs in the validation cohort. In the training cohort, the random forest advanced fibrosis model obtained an AUROC of 0.825 (95% CI, 0.787-0.862) in patients with hepatitis B virus DNA ≥105 IU/mL, and the random forest cirrhosis model had an AUROC of 0.828 (95% CI, 0.774-0.883) in female patients. The 2 models outperformed Fibrosis-4 Index, nonalcoholic fatty liver disease Fibrosis Score, and aspartate aminotransferase-to-platelet ratio index in the training cohort, and also performed well in the validation cohort.

CONCLUSIONS

The random forest models provide reliable, noninvasive tools for identifying advanced fibrosis and cirrhosis in CHB patients with concurrent HS, offering a significant advancement in the comanagement of the 2 diseases.

CLINICALTRIALS

gov, Number: NCT05766449.

Assessment of the Child-Pugh Score, Model for End-Stage Liver Disease Score, Fibrosis-4 Index, and AST to Platelet Ratio Index as Non-endoscopic Predictors of the Presence of Esophageal Varices and Variceal Bleeding in Chronic Liver Disease Patients

Background Esophageal varices (EVs) develop as a complication of chronic liver disease and, when left unaddressed, can lead to variceal hemorrhage manifesting as severe hematemesis and occasionally, melena. Due to its frequent negative associations, early diagnosis and the implementation of non-selective beta blocker primary prophylaxis are imperative. Although upper gastrointestinal endoscopy has historically been used to image and identify EVs, patients frequently find this intrusive treatment to be uncomfortable and burdensome. It can also be expensive and challenging for patients who live in remote places and healthcare deserts, where access to healthcare is limited. Therefore, it is crucial to identify non-invasive markers for the prediction of variceal bleeding and EVs in individuals with chronic liver disease. Methodology A cross-sectional observational study was done at Osmania General Hospital, a tertiary healthcare center in Hyderabad, India. The study sample consisted of patients with chronic liver disease who underwent upper gastrointestinal endoscopy during the study period in keeping with the inclusion and exclusion criteria. In a sample of 103 patients, the mean age was 10.72±45.55 years, with 22 females (21.4%) and 81 males (78.6%). The majority (85, 82.5%) had alcoholic chronic liver disease, while 14 (13.6%) had other etiologies, and four (3.9%) had infectious causes. Data were collected to calculate the Child-Pugh score, AST to platelet ratio index (APRI), model for end-stage liver disease (MELD) score, and fibrosis-4 (FIB-4) index. The patients were observed and followed up for a duration of three months. The data were evaluated using chi-squared tests and independent t-tests, chosen according to their relevance, to assess the utility of these scores as non-endoscopic predictors of EVs and esophageal variceal bleeding (EVB). Results The results indicated that only the FIB-4 index was found to be a significant predictor of Grade 2 or higher grades of EV according to the Pacquet classification. The FIB-4 index was significantly higher in the Grade 2 or higher EV group (p = 0.029) with t(101) = 1.98. Conclusion Thus, the study demonstrates that ≥ Grade 2 EV on upper gastrointestinal endoscopy can be predicted using the FIB-4 index. Even though our study shows that the FIB-4 index is a useful noninvasive predictor of EV, large-scale studies with bigger sample sizes and longer follow-up times are necessary to ensure accurate clinical application.

Non-invasive visualization of liver fibrosis with [68Ga]Ga-DOTA-FAPI-04 PET from preclinical insights to clinical translation

PURPOSE

The reversibility of early liver fibrosis highlights the need for improved early detection and monitoring techniques. Fibroblast activation protein (FAP) is a promising theranostics target significantly upregulated during fibrosis. This preclinical and preliminary clinical study investigated a FAP-targeted probe, gallium-68-labeled FAP inhibitor 04 ([68Ga]Ga-DOTA-FAPI-04), for its capability to visualize liver fibrosis.

METHODS

The preclinical study employed [68Ga]Ga-DOTA-FAPI-04 micro-positron emission tomography (PET)/computed tomography (CT) on carbon tetrachloride-induced mice model (n = 34) and olive oil-treated control group (n = 26), followed by validation of the probe's biodistribution. Hepatic uptake was correlated with fibrosis and inflammation levels, quantified through histology and serum assays. FAP and α-smooth muscle actin expression were determined by immunohistochemistry, as well as immunofluorescence. The subsequent clinical trial enrolled 26 patients with suspected or confirmed liver fibrosis to undergo [68Ga]Ga-DOTA-FAPI-04 PET/magnetic resonance imaging or PET/CT. Key endpoints included correlating [68Ga]Ga-DOTA-FAPI-04 uptake with histological inflammation grades and fibrosis stages, and evaluating its diagnostic and differential efficacy compared to established serum markers and liver stiffness measurement (LSM).

RESULTS

[68Ga]Ga-DOTA-FAPI-04 mean uptake in mice livers was notably higher than in control mice, increasing from week 6 [0.70 ± 0.11 percentage injected dose per cubic centimeter (%ID/cc)], peaking at week 10 (0.97 ± 0.15%ID/cc) and slightly reducing at week 12 (0.89 ± 0.28%ID/cc). The hepatic biodistribution and FAP expression showed a consistent trend. In the patient cohort, hepatic [68Ga]Ga-DOTA-FAPI-04 uptake presented moderate correlations with inflammation grades (r = 0.517 to 0.584, all P < 0.05) and fibrosis stages (r = 0.653 to 0.698, all P < 0.01). The average SUVmax to background ratio in the liver showed superior discriminative ability, especially between stage 0 and stage 1, outperforming LSM (area under curve 0.984 vs. 0.865).

CONCLUSION

[68Ga]Ga-DOTA-FAPI-04 PET shows significant potential for non-invasive visualization and dynamic monitoring of liver fibrosis in both preclinical experiment and preliminary clinical trial, especially outperforming other common clinical indicators in the early stage.

TRIAL REGISTRATION

NCT04605939. Registered October 25, 2020, https://clinicaltrials.gov/study/NCT04605939.

Liver fibrosis prediction models in a population of Latina and White women

Point-of-care tools to assess advanced liver fibrosis, including the NFS, BARD, FIB-4, and APRI, are of major interest due to their noninvasive nature. However, these tools have not been investigated extensively in the Latina population. Given that the highest rate of NAFLD in Latinos and the most severe presentation of non-alcoholic fatty liver disease (NAFLD) is more common in women, we hypothesize that ethnicity may play a role in predicting liver fibrosis, particularly in women. We determined whether ethnicity alone or in association with other parameters can predict the severity of fibrosis in women with NAFLD when included in four tools. We retrospectively included 562 Latina and 133 White Caucasian women with a history of NAFLD. Associations between ethnicity and liver fibrosis severity using the four fibrosis predictor models were studied using backward selection multinomial logistic regression. Latina women compared to White showed lower body mass index (p < 0.001), higher HbA1c (p < 0.001), lower prevalence of bariatric surgery (p < 0.001), lower likelihood to smoke (p = 0.003), and higher prevalence of chronic kidney disease stages 3-5 (p = 0.01). Some clinical variables were associated with fibrosis but not univocally in each tool. We did not find differences in the outcome of the four models when holding all other factors and examining ethnicity alone between Latina and White women. Although we did not include data on liver histology, this is the first study examining the role of ethnicity in predicting the severity of fibrosis using established noninvasive scores and documenting no association between Latina ethnicity and the severity of fibrosis in women with NAFLD.

Intestinal failure-associated liver disease: Current challenges in screening, diagnosis, and parenteral nutrition considerations

Intestinal failure-associated liver disease (IFALD) is a serious life-limiting complication that can occur throughout the clinical course of intestinal failure and its management by parenteral nutrition (PN). Despite this, there is a lack of a standardized definition for IFALD, which makes this insidious condition increasingly difficult to screen and diagnose in clinical practice. Attenuating the progression of liver disease before the onset of liver failure is key to improving morbidity and mortality in these patients. This requires timely detection and promptly addressing reversible factors. Although there are various noninvasive tools available to the clinician to detect early fibrosis or cirrhosis in various chronic liver disease states, these have not been validated in the patient population with IFALD. Such tools include biochemical composite scoring systems for fibrosis, transient elastography, and dynamic liver function tests. This review article aims to highlight the existing real need for an accurate, reproducible method to detect IFALD in its early stages. In addition, we also explore the role PN plays in the pathogenesis of this complex multifactorial condition. Various aspects of PN administration have been implicated in the etiology of IFALD, including the composition of the lipid component, nutrient excess and deficiency, and infusion timing. We aim to highlight the clinical relevance of these PN-associated factors in the development of IFALD and how these can be managed to mitigate the progression of IFALD.

Ensemble for evaluating diagnostic efficacy of non-invasive indices in predicting liver fibrosis in untreated hepatitis C virus population

BACKGROUND

Hepatitis C virus (HCV) infection progresses through various phases, starting with inflammation and ending with hepatocellular carcinoma. There are several invasive and non-invasive methods to diagnose chronic HCV infection. The invasive methods have their benefits but are linked to morbidity and complications. Thus, it is important to analyze the potential of non-invasive methods as an alternative. Shear wave elastography (SWE) is a non-invasive imaging tool widely validated in clinical and research studies as a surrogate marker of liver fibrosis. Liver fibrosis determination by invasive liver biopsy and non-invasive SWE agree closely in clinical studies and therefore both are gold standards.

AIM

To analyzed the diagnostic efficacy of non-invasive indices [serum fibronectin, aspartate aminotransferase to platelet ratio index (APRI), alanine aminotransferase ratio (AAR), and fibrosis-4 (FIB-4)] in relation to SWE. We have used an Artificial Intelligence method to predict the severity of liver fibrosis and uncover the complex relationship between non-invasive indices and fibrosis severity.

METHODS

We have conducted a hospital-based study considering 100 untreated patients detected as HCV positive using a quantitative Real-Time Polymerase Chain Reaction assay. We performed statistical and probabilistic analyses to determine the relationship between non-invasive indices and the severity of fibrosis. We also used standard diagnostic methods to measure the diagnostic accuracy for all the subjects.

RESULTS

The results of our study showed that fibronectin is a highly accurate diagnostic tool for predicting fibrosis stages (mild, moderate, and severe). This was based on its sensitivity (100%, 92.2%, 96.2%), specificity (96%, 100%, 98.6%), Youden's index (0.960, 0.922, 0.948), area under receiver operating characteristic curve (0.999, 0.993, 0.922), and Likelihood test (LR+ > 10 and LR- < 0.1). Additionally, our Bayesian Network analysis revealed that fibronectin (> 200), AAR (> 1), APRI (> 3), and FIB-4 (> 4) were all strongly associated with patients who had severe fibrosis, with a 100% probability.

CONCLUSION

We have found a strong correlation between fibronectin and liver fibrosis progression in HCV patients. Additionally, we observed that the severity of liver fibrosis increases with an increase in the non-invasive indices that we investigated.

Ensemble for evaluating diagnostic efficacy of non-invasive indices in predicting liver fibrosis in untreated hepatitis C virus population

BACKGROUND

Hepatitis C virus (HCV) infection progresses through various phases, starting with inflammation and ending with hepatocellular carcinoma. There are several invasive and non-invasive methods to diagnose chronic HCV infection. The invasive methods have their benefits but are linked to morbidity and complications. Thus, it is important to analyze the potential of non-invasive methods as an alternative. Shear wave elastography (SWE) is a non-invasive imaging tool widely validated in clinical and research studies as a surrogate marker of liver fibrosis. Liver fibrosis determination by invasive liver biopsy and non-invasive SWE agree closely in clinical studies and therefore both are gold standards.

AIM

To analyzed the diagnostic efficacy of non-invasive indices [serum fibronectin, aspartate aminotransferase to platelet ratio index (APRI), alanine aminotransferase ratio (AAR), and fibrosis-4 (FIB-4)] in relation to SWE. We have used an Artificial Intelligence method to predict the severity of liver fibrosis and uncover the complex relationship between non-invasive indices and fibrosis severity.

METHODS

We have conducted a hospital-based study considering 100 untreated patients detected as HCV positive using a quantitative Real-Time Polymerase Chain Reaction assay. We performed statistical and probabilistic analyses to determine the relationship between non-invasive indices and the severity of fibrosis. We also used standard diagnostic methods to measure the diagnostic accuracy for all the subjects.

RESULTS

The results of our study showed that fibronectin is a highly accurate diagnostic tool for predicting fibrosis stages (mild, moderate, and severe). This was based on its sensitivity (100%, 92.2%, 96.2%), specificity (96%, 100%, 98.6%), Youden’s index (0.960, 0.922, 0.948), area under receiver operating characteristic curve (0.999, 0.993, 0.922), and Likelihood test (LR+ > 10 and LR- < 0.1). Additionally, our Bayesian Network analysis revealed that fibronectin (> 200), AAR (> 1), APRI (> 3), and FIB-4 (> 4) were all strongly associated with patients who had severe fibrosis, with a 100% probability.

CONCLUSION

We have found a strong correlation between fibronectin and liver fibrosis progression in HCV patients. Additionally, we observed that the severity of liver fibrosis increases with an increase in the non-invasive indices that we investigated.

A FAPα-activated MRI nanoprobe for precise grading diagnosis of clinical liver fibrosis

Molecular imaging holds the potential for noninvasive and accurate grading of liver fibrosis. It is limited by the lack of biomarkers that strongly correlate with liver fibrosis grade. Here, we discover the grading potential of fibroblast activation protein alpha (FAPα) for liver fibrosis through transcriptional analysis and biological assays on clinical liver samples. The protein and mRNA expression of FAPα are linearly correlated with fibrosis grade (R2 = 0.89 and 0.91, respectively). A FAPα-responsive MRI molecular nanoprobe is prepared for quantitatively grading liver fibrosis. The nanoprobe is composed of superparamagnetic amorphous iron nanoparticles (AFeNPs) and paramagnetic gadoteric acid (Gd-DOTA) connected by FAPα-responsive peptide chains (ASGPAGPA). As liver fibrosis worsens, the increased FAPα cut off more ASGPAGPA, restoring a higher T1-MRI signal of Gd-DOTA. Otherwise, the signal remains quenched due to the distance-dependent magnetic resonance tuning (MRET) effect between AFeNPs and Gd-DOTA. The nanoprobe identifies F1, F2, F3, and F4 fibrosis, with area under the curve of 99.8%, 66.7%, 70.4%, and 96.3% in patients' samples, respectively. This strategy exhibits potential in utilizing molecular imaging for the early detection and grading of liver fibrosis in the clinic.