Non-invasive diagnosis and monitoring of liver fibrosis and cirrhosis

The role of bariatric surgery in the management of nonalcoholic steatohepatitis

PURPOSE OF REVIEW

Nonalcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease in the United States and increasing globally. The progressive form of NAFLD, nonalcoholic steatohepatitis (NASH), can lead to cirrhosis and complications of end-stage liver disease. No FDA-approved therapy for NAFLD/NASH exists. Treatment of NAFLD/NASH includes effective and sustained life-style modification and weight loss. This review reports on the recent findings of bariatric surgery in the management of NASH.

RECENT FINDINGS

NAFLD, at all stages, is common in those who meet indication for bariatric surgery. Bariatric surgery resolves NAFLD/NASH and reverses early stages of fibrosis. Although randomized controlled trials of bariatric surgery in NASH are infeasible, studies defining the metabolic changes induced by bariatric surgery, and their effect on NASH, provide insight for plausible pharmacologic targets for the nonsurgical treatment of NASH.

SUMMARY

Resolution of NASH and fibrosis regression can occur after bariatric surgery. Although the exact mechanism(s) underlying the improvement of NASH and hepatic fibrosis following bariatric surgery is not fully elucidated, emerging data on this topic is vitally important for lending insight into the pharmacotherapies for NASH for patients who are not otherwise suitable candidates for bariatric surgery.

The gap between overweight and obesity status in children - (STROBE-compliant article)

Overweight might represent only the early stage of obesity or it might act as a trigger of self-awareness turning into an ideal chance for preventing further obesity development.The aim of this study was to assess the differences between overweight and obese children in terms of anthropometric, low-grade systemic inflammation, liver impairment and atherosclerotic risk.We performed a study on 132 children aged between 5 and 18 years, divided according to the BMI into 2 groups: group 1 to 76 obese children, and group 2 to 56 overweight children, assessing anthropometric, laboratory and elastography parameters.We obtained significantly higher values of anthropometric parameters in obese children versus overweight ones. We found higher levels of leukocytes, lymphocytes, AST, ALT, and E median (P = .0345, P = .0103, P < .0001, P = .0008 and P < .0001) in the obese group as compared to the overweight one. BMI was positively correlated with neutrophils, NLR, ESR, glycemia, anthropometric parameters, and E median (P = .0007/<.0001/.0018/.0044/<.0001/<.0001/<.0001/<.0001/<.0001/.0204); and negatively with lymphocytes and HDL-cholesterol (r = -0.2747/-0.2181, P = .0116/.0120).Our study underlined significant differences between overweight and obese children in terms of inflammatory status and liver impairment suggesting that the risk is directly related to the increase in BMI.

The ALBI Grade is a Good Predictive Model for Very Late Recurrence in Patients with Hepatocellular Carcinoma Undergoing Primary Resection

BACKGROUND

Hepatocellular carcinoma (HCC) patients still have risk for very late recurrence after curative resection. This study assesses prognostic factors in HCC patients with recurrence-free survival (RFS) for 5 years after primary resection.

METHODS

We enrolled 383 HCC patients who received primary tumor resection and achieved more than 5 years without recurrence after resection between January 2001 and April 2013. Predictive factors, including albumin-bilirubin (ALBI) grade, for RFS and overall survival (OS) were analyzed.

RESULTS

After a median follow-up of 103 months, 57 patients (14.9%) had recurrent HCC, and 14 (3.7%) died. Independent predictors for HCC recurrence were male sex (p = 0.035), pre-operative liver cirrhosis (LC) (p = 0.025), serum creatinine  > 1.5 mg/dL (p = 0.045), post-operative 5th-year alpha-fetoprotein (AFP) > 15 ng/ml (p < 0.001), LC (p = 0.004), and ALBI grades 2 and 3 (p < 0.001). I ndependent risk factors for poor survival were age >70 years (p = 0.002), post-operative 5th-year AFP > 15 ng/ml (p = 0.003), and ALBI grades 2 and 3 (p = 0.002). Patients whose deteriorated ALBI grades 5 years after resection had adverse RFS outcomes compared to those with constant (p = 0.056) and improved ALBI grades (p = 0.008). In subgroup analysis, patients with post-operative 5th-year ALBI grades 2 and 3 had significantly poorer RFS and OS (both p < 0.001) than those with grade 1 among patients with low post-operative 5th-year AFP (<15 ng/mL).

CONCLUSION

In HCC patients without recurrence for 5 years after curative resection, post-operative 5th-year ALBI grade is useful for predicting outcomes, even with low AFP during follow-up.

cis-4-[18F]fluoro-L-proline Molecular Imaging Experimental Liver Fibrosis

Introduction: Early-stage liver fibrosis is potentially reversible, but difficult to diagnose. Clinical management would be enhanced by the development of a non-invasive imaging technique able to identify hepatic injury early, before end-stage fibrosis ensues. The analog of the amino acid proline, cis-4-[18F]fluoro-L-proline ([18F]fluoro-proline), which targets collagenogenesis in hepatic stellate cells (HSC), was used to detect fibrosis. Methods: Acute steatohepatitis was induced in experimental animals by liquid ethanol diet for 8 weeks, intra-gastric binge feedings every 10th day along with lipopolysaccharide (LPS) injection. The control animals received control diet for 8 weeks and an equivalent volume of saline on the same schedule as the acute steatohepatitis model. First, in vitro cellular experiments were carried out to assess [3H]proline uptake by HSC, hepatocytes and Kupffer cells derived from rats with acute steatohepatitis (n = 14) and controls (n = 14). Next, ex vivo liver experiments were done to investigate unlabeled proline-mediated collagen synthesis and its associated proline transporter expression in acute steatohepatitis (n = 5) and controls (n = 5). Last, in vivo dynamic and static [18F]fluoro-proline micro-PET/CT imaging was performed in animal models of acute steatohepatitis (n = 7) and control (n = 7) mice. Results: [3H]proline uptake was 5-fold higher in the HSCs of steatohepatitis rats than controls after incubation of up to 60 min. There was an excellent correlation between [3H]proline uptake and liver collagen expression (r-value > 0.90, p < 0.05). Subsequent liver tissue studies demonstrated 2-3-fold higher proline transporter expression in acute steatohepatitis animals than in controls, and proline-related collagen synthesis was blocked by this transporter inhibitor. In vivo micro-PET/CT studies with [18F]fluoro-proline showed 2-3-fold higher uptake in the livers of acute steatohepatitis mice than in controls. There was an excellent correlation between [18F]fluoro-proline uptake and liver collagen expression in the livers of acute steatohepatitis mice (r-value = 0.97, p < 0.001). Conclusion: [18F]fluoro-proline localizes in the liver and correlates with collagenogenesis in acute steatohepatitis with a signal intensity that is sufficiently high to allow imaging with micro-PET/CT. Thus, [18F]fluoro-proline could serve as a PET imaging biomarker for detecting early-stage liver fibrosis.

The assessment of liver fibrosis in children with obesity on two methods: transient and two dimensional shear wave elastography

The aim of this study was to assess the liver stiffness values in children with obesity versus healthy children on 2D-SWE and TE taking into account different laboratory parameters. We performed a case-control study on 287 children aged between 3 to 18 years, admitted in a Romanian Pediatric Tertiary Hospital, which we divided according to the body mass index (BMI) into two groups: the study group-77 children with obesity, and control group-210 children with normal weight. All children underwent anamnesis, clinical exam, laboratory parameters, ultrasound exam, and elastography. Children with obesity presented higher values of platelets, AST, ALT, and AAR as compared to control group (p = 0.0005/p = 0.0065/p < 0.0001/p < 0.0001). We found no significant differences for APRI between the two groups (p = 0.9827), although the values were higher in children with obesity. Significantly higher values of liver stiffness in children with obesity on both 2D-SWE and TE (p = 0.0314/p < 0.0001) were obtained. Similarly, the velocity values measured by 2D-SWE were also significantly higher in the study group (p < 0.0001). Our findings revealed significantly higher levels of platelets, transaminases, AAR, and liver stiffness values on both TE and 2D-SWE in children with obesity. 2D-SWE and TE might represent useful non-invasive methods for predicting liver impairment associated to pediatric obesity.

Tumorigenesis, diagnosis, and therapeutic potential of exosomes in liver cancer

Hepatocellular carcinoma (HCC, also called primary liver cancer) is one of the most fatal cancers in the world. Due to the insidiousness of the onset of HCC and the lack of effective treatment methods, the prognosis of HCC is extremely poor, and the 5-year average survival rate is less than 10%. Exosomes are nano-sized microvesicle and contain various components such as nucleic acids, proteins, and lipids. Exosomes are important carriers for signal transmission or transportation of material from cell to cell or between cells and tissues. In recent years, exosomes have been considered as potential therapeutic targets of HCC. A large number of reports indicate that exosomes play a key role in the establishment of an HCC microenvironment, as well as the development, progression, invasion, metastasis, and even the diagnosis, treatment, and prognosis of HCC. However, the exact molecular mechanisms and roles of exosomes in these processes remain unclear. We believe that elucidation of the regulatory mechanism of HCC-related exosomes and its signaling pathway and analysis of its clinical applications in the diagnosis and treatment of HCC can provide useful clues for future treatment regimens for HCC. This article discusses and summarizes the research progress of HCC-related exosomes and their potential clinical applications.

Tumorigenesis, diagnosis, and therapeutic potential of exosomes in liver cancer

Hepatocellular carcinoma (HCC, also called primary liver cancer) is one of the most fatal cancers in the world. Due to the insidiousness of the onset of HCC and the lack of effective treatment methods, the prognosis of HCC is extremely poor, and the 5-year average survival rate is less than 10%. Exosomes are nano-sized microvesicle and contain various components such as nucleic acids, proteins, and lipids. Exosomes are important carriers for signal transmission or transportation of material from cell to cell or between cells and tissues. In recent years, exosomes have been considered as potential therapeutic targets of HCC. A large number of reports indicate that exosomes play a key role in the establishment of an HCC microenvironment, as well as the development, progression, invasion, metastasis, and even the diagnosis, treatment, and prognosis of HCC. However, the exact molecular mechanisms and roles of exosomes in these processes remain unclear. We believe that elucidation of the regulatory mechanism of HCC-related exosomes and its signaling pathway and analysis of its clinical applications in the diagnosis and treatment of HCC can provide useful clues for future treatment regimens for HCC. This article discusses and summarizes the research progress of HCC-related exosomes and their potential clinical applications.

Use of serum biomarkers in staging of canine hepatic fibrosis

Accurate staging of hepatic fibrosis (HF) is important for treatment and prognosis of canine chronic hepatitis. HF scores are used in human medicine to indirectly stage and monitor HF, decreasing the need for liver biopsy. We developed a canine HF score to screen for moderate or greater HF. We included 96 dogs in our study, including 5 healthy dogs. A liver biopsy for histologic examination and a biochemistry profile were performed on all dogs. The dogs were randomly split into a training set of 58 dogs and a validation set of 38 dogs. A HF score that included alanine aminotransferase, alkaline phosphatase, total bilirubin, potassium, and gamma-glutamyl transferase was developed in the training set. Model performance was confirmed using the internal validation set, and was similar to the performance in the training set. The overall sensitivity and specificity for the study group were 80% and 70% respectively, with an area under the curve of 0.80 (0.71-0.90). This HF score could be used for indirect diagnosis of canine HF when biochemistry panels are performed on the Konelab 30i (Thermo Scientific), using reagents as in our study. External validation is required to determine if the score is sufficiently robust to utilize biochemical results measured in other laboratories with different instruments and methodologies.

B-mode ultrasound for the assessment of hepatic fibrosis: a quantitative multiparametric analysis for a radiomics approach

Hepatic fibrosis and cirrhosis are a growing global health problem with increasing mortality rates. Early diagnosis and staging of hepatic fibrosis represent a major challenge. Currently liver biopsy is the gold standard for fibrosis assessment; however, biopsy requires an invasive procedure and is prone to sampling error and reader variability. In the current study we investigate using quantitative analysis of computer-extracted features of B-mode ultrasound as a non-invasive tool to characterize hepatic fibrosis. Twenty-two rats were administered diethylnitrosamine (DEN) orally for 12 weeks to induce hepatic fibrosis. Four control rats did not receive DEN. B-mode ultrasound scans sampling throughout the liver were acquired at baseline, 10, and 13 weeks. Computer extracted quantitative parameters representing brightness (echointensity, hepatorenal index) and variance (heterogeneity, anisotropy) of the liver were studied. DEN rats showed an increase in echointensity from 37.1 ± SD 7.8 to 53.5 ± 5.7 (10 w) to 57.5 ± 6.1 (13 w), while the control group remained unchanged at an average of 34.5 ± 4.5. The three other features studied increased similarly over time in the DEN group. Histologic analysis showed METAVIR fibrosis grades of F2-F4 in DEN rats and F0-F1 in controls. Increasing imaging parameters correlated with increasing METAVIR grades, and anisotropy showed the strongest correlation (ρ = 0.58). Sonographic parameters combined using multiparametric logistic regression were able to differentiate between clinically significant and insignificant fibrosis. Quantitative B-mode ultrasound imaging can be implemented in clinical settings as an accurate non-invasive tool for fibrosis assessment.

Equal 3-Year Outcomes for Kidney Transplantation Alone in HCV-Positive Patients With Cirrhosis

Kidney transplantation alone in clinically compensated patients with cirrhosis is not well documented. Current guidelines list cirrhosis as a contraindication for kidney transplantation alone. This is an Institutional Review Board-approved retrospective study. We report our experience with a retrospective comparison between transplants in hepatitis C virus-positive (HCV(+)) patients without cirrhosis and HCV(+) patients with cirrhosis. All of the patients were followed for at least a full 3-year period. All of the deaths and graft losses were recorded and analyzed using Kaplan-Meier methodology. One- and three-year cumulative patient survival rates for noncirrhotic patients were 91% and 82%, respectively. For cirrhotic patients, one- and three-year cumulative patient survival rates were 100% and 83%, respectively (P = NS). One- and three-year cumulative graft survival rates censored for death were 94% and 81%, and 95% and 82% for the noncirrhosis and cirrhosis groups, respectively (P = NS). Comparable patient and allograft survival rates were observed when standard kidney allograft recipients were analyzed separately. This study is the longest follow-up document in the literature showing that HCV(+) clinically ompensated patients with cirrhosis may undergo kidney transplantation alone as a safe and viable practice.

Increased sialylation of site specific O-glycoforms of hemopexin in liver disease

Background

Non-invasive monitoring of liver disease remains an important health issue. Liver secreted glycoproteins reflect pathophysiological states of the organ and represent a rational target for serologic monitoring. In this study, we describe sialylated O-glycoforms of liver-secreted hemopexin (HPX) and quantify them as a ratio of disialylated to monosialylated form (S-HPX).

Methods

We measured S-HPX in serum of participants of the HALT-C trial using a LC–MS/MS-MRM assay.

Results

Repeated measurements of S-HPX in the samples of 23 disease-free controls, collected at four different time points, show that the ratio remains stable in the healthy controls but increases with the progression of liver disease. The results of measurement of S-HPX in serum of participants of the HALT-C trial show that it increased significantly (Kruskal–Wallis test, p < 0.01) in liver disease as the stage of fibrosis progressed in liver biopsies. We observed a 1.7-fold increase in fibrosis defined as Ishak score 3–4 (24.9 + 14.2, n = 22) and 4.7-fold increase in cirrhosis defined as Ishak score 5–6 (68.6 + 38.5; n = 24) compared to disease-free controls (14.7 + 6.7, n = 23). S-HPX is correlated with AFP, bilirubin, INR, ALT, and AST while inversely correlated with platelet count and albumin. In an independent verification set of samples, S-HPX separated the Ishak 5–6 (n = 15) from the Ishak 3–4 (n = 15) participants with AuROC 0.84; at the same time, the Ishak 3–4 group was separated from disease-free controls (n = 15) with AuROC 0.82.

Conclusion

S-HPX, a measure of sialylated O-glycoforms of hemopexin, progressively increases in fibrotic and cirrhotic patient of HCV etiology and can be quantified by an LC–MS/MS-MRM assay in unfractionated serum of patients. Quantification of sialylated O-glycoforms of this liver secreted glycoprotein represents a novel measure of the stage of liver disease that could have a role in monitoring the progression of liver pathology.

Electronic supplementary material

The online version of this article (doi:10.1186/s12014-016-9125-x) contains supplementary material, which is available to authorized users.

Utility of Ultrasound, Transaminases, and Visual Inspection to Assess Nonalcoholic Fatty Liver Disease in Bariatric Surgery Patients

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is common in adults with extreme obesity and can impact long-term health and survival. Liver biopsy is the only accurate test for diagnosis and staging, but is invasive and costly. Non-invasive testing offers an attractive alternate, but the overall accuracy remains a significant issue. This study was conducted to determine the accuracy and clinical utility of pre-operative ultrasound and liver transaminase levels, as well as intra-operative hepatic visual inspection, for assessing presence of NAFLD as confirmed by hepatic histology.

METHODS

Data was collected prospectively from 580 morbidly obese adult patients who underwent Roux-en-Y gastric bypass surgery with intraoperative wedge biopsy between January 2004 and February 2009. Complete data for ultrasound, ALT and AST levels, and documented visual inspection was available for 513 patients.

RESULTS

The prevalence of NAFLD was 69 % and that of NASH was 32 %. The individual non-invasive clinical assessments demonstrated low sensitivity, specificity, and accuracy for detecting the presence of steatosis, steatohepatitis, or fibrosis. The combination of normal or abnormal results for all tests improved predictive utility. Abnormal tests with all three assessments had a sensitivity of 95-98 % and a specificity of 28-48 % for major histologic findings in NAFLD/NASH. Normal tests with all three assessments had a sensitivity of 12-22 % and a specificity of 89-97 % for major histologic findings in NAFLD/NASH.

CONCLUSIONS

Although individual clinical tests for NAFLD have limited accuracy, the use of combined clinical tests may prove useful.

More Than Just Accuracy: A Novel Method to Incorporate Multiple Test Attributes in Evaluating Diagnostic Tests Including Point of Care Tests

Current frameworks for evaluating diagnostic tests are constrained by a focus on diagnostic accuracy, and assume that all aspects of the testing process and test attributes are discrete and equally important. Determining the balance between the benefits and harms associated with new or existing tests has been overlooked. Yet, this is critically important information for stakeholders involved in developing, testing, and implementing tests. This is particularly important for point of care tests (POCTs) where tradeoffs exist between numerous aspects of the testing process and test attributes. We developed a new model that multiple stakeholders (e.g., clinicians, patients, researchers, test developers, industry, regulators, and health care funders) can use to visualize the multiple attributes of tests, the interactions that occur between these attributes, and their impacts on health outcomes. We use multiple examples to illustrate interactions between test attributes (test availability, test experience, and test results) and outcomes, including several POCTs. The model could be used to prioritize research and development efforts, and inform regulatory submissions for new diagnostics. It could potentially provide a way to incorporate the relative weights that various subgroups or clinical settings might place on different test attributes. Our model provides a novel way that multiple stakeholders can use to visualize test attributes, their interactions, and impacts on individual and population outcomes. We anticipate that this will facilitate more informed decision making around diagnostic tests.

Diagnostic usefulness of FibroMeter VCTE for hepatic fibrosis in patients with nonalcoholic fatty liver disease

BACKGROUND

Liver fibrosis is an important prognostic determinant in patients with nonalcoholic fatty liver disease (NAFLD). The FibroMeter VCTE is a diagnostic tool comprising both biochemical markers and transient elastography (TE) originally developed for the diagnosis of fibrosis in patients with chronic viral hepatitis. In this pilot study, we investigated the diagnostic performance of the FibroMeter VCTE tool for determining fibrosis in patients with biopsy-proven NAFLD. Its diagnostic accuracy was also compared with those of the NAFLD fibrosis score (NFSA) and TE alone.

PATIENTS AND METHODS

FibroMeter VCTE, NFSA, and TE were determined in 52 patients with NAFLD. The results of liver biopsies were considered the gold standard. Areas under the receiver operating characteristic curve were used to express the diagnostic accuracy of each test.

RESULTS

Significant (F≥2) and severe (F≥3) fibrosis were detected in 20 (38%) and 10 (19%) patients, respectively. The sensitivity of FibroMeter VCTE, NFSA, and TE for detecting significant fibrosis was 70, 65, and 75%, respectively, whereas specificity was 88, 81, and 78%. The sensitivity of FibroMeter VCTE, NFSA, and TE for diagnosing severe fibrosis was 90, 90, and 100%, respectively, whereas specificity was 93, 78, and 76%. Receiver operating characteristic analysis showed that FibroMeter VCTE had a significantly larger areas under the receiver operating characteristic curve (0.968) compared with both NFSA (0.833, P<0.001) and TE (0.922, P<0.05) for the detection of severe fibrosis.

CONCLUSION

Our preliminary findings indicate that FibroMeter VCTE is superior to both NFSA and TE for the diagnosis of severe fibrosis in patients with NAFLD.

Measurements of serum procollagen-III peptide and M30 do not improve the diagnostic accuracy of transient elastography for the detection of hepatic fibrosis in patients with nonalcoholic fatty liver disease

BACKGROUND

Transient elastography (TE) has recently emerged as an accurate noninvasive imaging method for the diagnosis of liver fibrosis in nonalcoholic fatty liver disease (NAFLD). Here, we tested whether adding serum measures of serum procollagen-III peptide (PIIIP) and caspase-cleaved cytokeratin 18 fragment (M30) to TE could improve its diagnostic accuracy in patients with biopsy-proven NAFLD.

PATIENTS AND METHODS

TE was performed in 87 patients with NAFLD. Serum PIIIP and M30 levels were determined by enzyme-linked immunosorbent assay. Liver histology was considered the gold standard. The diagnostic accuracies were assessed by measuring the area under the receiver operating curve.

RESULTS

At histopathological examination, 34 patients (39.1%) had significant fibrosis (F2-F4) and 19 patients (21.8%) had advanced fibrosis (F3-F4). Both TE and serum M30 levels were independent predictors of fibrosis, whereas no association was found with PIIIP. No significant differences in terms of sensitivity and specificity for both significant and advanced fibrosis were evident for TE, serum M30, or their combination. Moreover, the area under the receiver operating curves of serum M30 combined with TE did not differ significantly from those of either test alone.

CONCLUSION

Both TE and serum M30 levels are accurate for the noninvasive diagnosis of fibrosis in NAFLD. However, their combination did not improve the overall diagnostic accuracy.

Comparison of noninvasive scores for the detection of advanced fibrosis in patients with nonalcoholic fatty liver disease

BACKGROUND

The presence of advanced liver fibrosis portends a poor prognosis in nonalcoholic fatty liver disease (NAFLD). We aimed to compare the diagnostic performance of five noninvasive scores [aspartate aminotransferase/platelet ratio (APRI), BARD, FIB-4, NAFLD fibrosis score (NFSA), and FibroMeter] for the assessment of advanced stages of fibrosis (F ≥ 3) in patients with biopsy-proven NAFLD.

METHODS

APRI, BARD, FIB-4, NFSA, and FibroMeter scores were determined in 142 patients with NAFLD. The histopathological analysis of liver biopsies was considered the gold standard. Sensitivity and specificity were calculated for each noninvasive test using receiver operating characteristic (ROC) curve analysis, with a cut-off value of F ≥ 3 for advanced fibrosis. The diagnostic accuracies were assessed by measuring the area under the ROC curve (AUROC). The AUROCs for different noninvasive tests were compared using paired significance tests.

RESULTS

At histopathological examination, 40 patients (28.2%) had a fibrosis stage F0, 50 patients (35.2%) had F1, 22 patients (15.5%) had F2, 20 patients (14.1%) had F3, and 10 patients (7.0%) had F4. The sensitivity of APRI, BARD, FIB-4, NFSA, and FibroMeter scores for advanced fibrosis was 70.0, 73.3, 70.0, 66.7, and 66.7%, respectively, and the specificity was 74.5, 66.4, 71.8, 71.8, and 74.5%, respectively. No significant differences in terms of sensitivity and specificity were evident for the five noninvasive scores. Moreover, the AUROCs did not differ significantly for all scores.

CONCLUSION

Our study suggests that different noninvasive scores have similar accuracy for the diagnosis of advanced hepatic fibrosis in NAFLD.

A comparison of FibroMeter™ NAFLD Score, NAFLD fibrosis score, and transient elastography as noninvasive diagnostic tools for hepatic fibrosis in patients with biopsy-proven non-alcoholic fatty liver disease

BACKGROUND

Noninvasive markers that purport to distinguish patients with non-alcoholic fatty liver disease (NAFLD) with fibrosis from those without must be evaluated rigorously for their classification accuracy. Herein, we seek to compare the diagnostic performances of three different noninvasive methods (FibroMeter™ NAFLD score, NAFLD Fibrosis score (NFSA), and Transient Elastrography [TE]) for the detection of liver fibrosis in NAFLD patients.

METHODS

A total of 88 patients with biopsy-proven NAFLD were included. The Kleiner system was used for grading fibrosis in liver biopsies. The FibroMeter™ NAFLD score was determined using a proprietary algorithm (regression score). The NFSA score was calculated based on age, hyperglycemia, body mass index, platelets, albumin and serum aminotransferase levels. TE was performed using the Fibroscan apparatus.

RESULTS

The sensitivities/specificities for the FibroMeter™ NAFLD score, NFSA, and TE for the diagnosis of significant fibrosis (F2 + F3 + F4 fibrosis) were 38.6%/86.4%, 52.3%/88.6%, and 75.0%/93.2%, respectively. The areas under the receiver operating characteristic curves of TE were significantly higher than those of both the FibroMeter™ NAFLD score and NFSA. No significant differences were found between the FibroMeter™ NAFLD score and NFSA for the detection of significant and severe fibrosis, although the diagnostic performance of the FibroMeter™ NAFLD score was higher than that of the NFSA score for cirrhosis.

CONCLUSIONS

In summary, TE showed the best diagnostic performance for the noninvasive assessment of liver fibrosis in NAFLD patients. The diagnostic performances of the FibroMeter™ NAFLD score and NFSA did not differ significantly for the detection of both significant and severe fibrosis.

Early detection of liver fibrosis in rats using 3-D ultrasound Nakagami imaging: a feasibility evaluation

We investigated the feasibility of using 3-D ultrasound Nakagami imaging to detect the early stages of liver fibrosis in rats. Fibrosis was induced in livers of rats (n = 60) by intraperitoneal injection of 0.5% dimethylnitrosamine (DMN). Group 1 was the control group, and rats in groups 2-6 received DMN injections for 1-5 weeks, respectively. Each rat was sacrificed to perform 3-D ultrasound scanning of the liver in vitro using a single-element transducer of 6.5 MHz. The 3-D raw data acquired at a sampling rate of 50 MHz were used to construct 3-D Nakagami images. The liver specimen was further used for histologic analysis with hematoxylin and eosin and Masson staining to score the degree of liver fibrosis. The results indicate that the Metavir scores of the hematoxylin and eosin-stained sections in Groups 1-4 were 0 (defined as early liver fibrosis in this study), and those in groups 5 and 6 ranged from 1 to 2 and 2 to 3, respectively. To quantify the degree of early liver fibrosis, the histologic sections with Masson stain were analyzed to calculate the number of fiber-related blue pixels. The number of blue pixels increased from (2.36 ± 0.79) × 10(4) (group 1) to (7.68 ± 2.62) × 10(4) (group 4) after DMN injections for 3 weeks, indicating that early stages of liver fibrosis were successfully induced in rats. The Nakagami parameter increased from 0.36 ± 0.02 (group 1) to 0.55 ± 0.03 (group 4), with increasing numbers of blue pixels in the Masson-stained sections (p-value < 0.05, t-test). We concluded that 3-D Nakagami imaging has potential in the early detection of liver fibrosis in rats and may serve as an image-based pathologic model to visually track fibrosis formation and growth.

Biomarkers of liver fibrosis

Liver fibrosis is the final common pathway for almost all causes of chronic liver injury. Liver fibrosis is now known to be a dynamic process having significant potential for resolution. Therefore, fibrosis prediction is an essential part of the assessment and management of patients with chronic liver disease. As such, there is strong demand for reliable liver biomarkers that provide insight into disease etiology, diagnosis, therapy, and prognosis in lieu of more invasive approaches such as liver biopsy. Current diagnostic strategies range from use of serum biomarkers to more advanced imaging techniques including transient elastography and magnetic resonance imaging. In addition to these modalities, there are other approaches including the use of novel, but yet to be validated, biomarkers. In this chapter, we discuss the biomarkers of liver fibrosis including the use of invasive and noninvasive biomarkers and disease-specific biomarkers in various chronic liver diseases.

Evaluating the potential of a new isotope-labelled glyco-ligand for estimating the remnant liver function of schistosoma-infected mice

A new glyco-derivative compound (OCTAM) was developed and labelled with isotope to form (188) Re-OCTAM as a candidate nuclear medicine imaging agent for testing the liver function. We evaluated the potential of isotope-labelled OCTAM for estimating the remnant liver function in vitro and in vivo schistosoma-infected mice. The affinity of OCTAM to liver asialoglycoprotein receptors (ASGPR) was assessed by competitive inhibition assay in vitro. In vivo assessments were performed to score the remnant liver function in mice at different schistosomal infection stages. OCTAM binds specifically to ASGPR and showed competitive inhibition of anti-ASGPR antibody binding to hepatocytes, and was higher than that of other galactosyl ligands. Micro-SPECT/CT images of uninfected mice revealed strong liver uptake. Quantified serial images of mice infected for 9, 12 and 18 weeks showed delayed liver uptake, and the retention of uptake was inversely correlated with stage and grade of schistosoma infection. Pathological and biochemical analysis demonstrated that gradually accumulating liver injury caused by infection significantly influenced uptake of (188) Re-OCTAM. Hepatic ASGPR expression diminished only in the chronic infection stage. This study demonstrated that the isotope-labelled OCTAM could accumulate in the liver, might have potential as an imaging agent for in vivo hepatic function evaluation of schistosomiasis.

Noninvasive diagnosis of liver fibrosis and cirrhosis in chronic hepatitis C patients

BACKGROUND

We aimed to derive a simple noninvasive test for liver-fibrosis staging and then estimate its performance against four simple noninvasive tests in chronic hepatitis C (CHC) patients.

METHODS

CHC patients were divided into two cohorts: an estimation set (n = 324) and a validation set (n = 524). Liver fibrosis was staged according to the METAVIR scoring system. Statistical analysis was done using stepwise linear discriminant analysis and area under receiver-operating characteristic curves (AUCs).

RESULTS

Biotechnology Research Center (BRC) score was constructed combining several blood markers that proved useful to stage liver fibrosis. Aspartate aminotransferase /alanine aminotransferase ratio (AAR), aspartate to platelet ratio index (APRI), Fibro-α, King, and BRC scores correlated with the histological fibrosis stages with correlation coefficient 0.26, 0.36, 0.58, 0.45, and 0.73, respectively. BRC score produced AUCs 0.87, 0.83, and 0.89 for significant (F2-F4), advanced fibrosis (F3-F4), and cirrhosis (F4), respectively. These results were reproduced in the validation study with no significant difference yielding AUCs 0.85 for F2-F4, 0.82 for F3-F4, and 0.88 for F4.

CONCLUSION

BRC score, a novel noninvasive test, is a useful and easy tool to evaluate liver fibrosis in CHC patients and seems more efficient than AAR, APRI, Fibro-α score, and King's score in this group of Egyptian patients.

Classification and staging of chronic liver disease from multimodal data

Chronic liver disease (CLD) is most of the time an asymptomatic, progressive, and ultimately potentially fatal disease. In this study, an automatic hierarchical procedure to stage CLD using ultrasound images, laboratory tests, and clinical records are described. The first stage of the proposed method, called clinical based classifier (CBC), discriminates healthy from pathologic conditions. When nonhealthy conditions are detected, the method refines the results in three exclusive pathologies in a hierarchical basis: 1) chronic hepatitis; 2) compensated cirrhosis; and 3) decompensated cirrhosis. The features used as well as the classifiers (Bayes, Parzen, support vector machine, and k -nearest neighbor) are optimally selected for each stage. A large multimodal feature database was specifically built for this study containing 30 chronic hepatitis cases, 34 compensated cirrhosis cases, and 36 decompensated cirrhosis cases, all validated after histopathologic analysis by liver biopsy. The CBC classification scheme outperformed the nonhierachical one against all scheme, achieving an overall accuracy of 98.67% for the normal detector, 87.45% for the chronic hepatitis detector, and 95.71% for the cirrhosis detector.

Osteopontin contributes to TGF-β1 mediated hepatic stellate cell activation

BACKGROUND AND PURPOSE

Liver fibrosis is characterized by accumulation of extracellular matrix. Our previous study found that osteopontin (OPN) increased in plasma of cirrhotic patients and indicative of cirrhosis staging. The present study was designed to investigate the expression of OPN in liver tissues and plasma of cirrhotic patients and further explore the role of OPN in human hepatic stellate cell (HSC) activation.

METHODS

We used immunohistochemical staining and enzyme-linked immunosorbent assay to evaluate the expression level of OPN in liver tissues and plasma from cirrhotic patients, respectively. We produced lentivirus particles and infected target cell to manipulate OPN expression. Infection efficiency was determined by real-time RT-PCR and western blot. Cell proliferation was determined using CCK8 assay, and phenotypes of HSC activation were determined by real-time RT-PCR. OPN promoter activity was determined by dual luciferase reporter assay.

RESULTS

We found that OPN expression in human cirrhotic liver tissues was upregulated compared to normal controls. In addition, its expression correlated with Child-Pugh classification, MELD score and the occurrence of complications. We further explored OPN level in patients' plasma and showed that its level correlated with transforming growth factor-β1 (TGF-β1). In human HSC cell line LX-2, we found that change of OPN expression level could not only affect the proliferation of cells but also the TGF-β1 mediated HSC activation. Moreover, OPN was increased by TGF-β1 stimulation and regulated by TGF-β1 at transcription level.

CONCLUSIONS

OPN is upregulated in liver tissues and plasma of cirrhotic patients and promotes TGF-β1 mediated HSC activation.

Serum autofluorescence, a potential serum marker for the diagnosis of liver fibrosis in rats

Fluctuations in serum autofluorescence (AF) intensity have recently been widely used as markers of certain diseases such as cancer. To determine the diagnostic value of serum AF intensity for liver fibrosis in rats, we induced liver fibrosis by subcutaneous injection of carbon tetrachloride into rats. The rat serum AF intensities were detected at the excitation wavelength of 337 nm and the emission wavelength of 512 nm. The degree of liver fibrosis was evaluated by Van Gieson’s staining. The relationship between serum AF intensity and the degree of liver fibrosis was analyzed by Spearman and Pearson Correlation. The diagnostic sensitivity and specificity of the serum AF was determined by analyzing the receiver operating characteristic (ROC) curves. Our results show that the serum AF intensity in the rat liver fibrosis model increased when compared with control rats eight weeks and twelve weeks post induction of liver fibrosis. However, there was no significant difference in serum AF intensity between fibrotic and control rats at four week post induction. Furthermore, serum AF intensity correlated positively with the severity of the degree of hepatic fibrosis. ROC analysis further suggested that serum AF intensity is a valid marker for staging fibrosis. Therefore, it may potentially be developed as a novel diagnostic tool for hepatic fibrosis.

Serum TGF-β, Serum MMP-1, and HOMA-IR as non-invasive predictors of fibrosis in Egyptian patients with NAFLD

BACKGROUND/AIM

Non-alcoholic fatty liver disease (NAFLD) is an increasingly prevalent cause of chronic liver disease worldwide. A number of these patients progress to nonalcoholic steatohepatitis (NASH) which carries significant morbidity and mortality. The aim of this study is to evaluate the diagnostic value of serum levels of transforming growth factor beta-1 (TGF-β1) matrix metalloproteinase-1 (MMP-1), and insulin resistance as predictors of fibrosis in Egyptian NAFLD patients.

PATIENTS AND METHODS

Fifty patients with NAFLD and different stages of fibrosis were studied. Serum levels of TGF-β1, MMP-1, and fasting serum insulin were measured; calculation of the homeostasis model assessment for insulin resistance (HOMA-IR) was done.

RESULTS

TGF-β1 gives a sensitivity of 100% and specificity of 94.4% for stage 1 fibrosis, 100% and 93.9%, respectively, for stage 2 fibrosis, and 97.7% and 100%, respectively, for stage 3 fibrosis. MMP-1 showed sensitivity and specificity of 88% and 81.8%, respectively, for stage 2 fibrosis, 90.9% and 55.56%, respectively, for stage 3 fibrosis, but it is of no diagnostic value in stage 1 fibrosis.

CONCLUSION

Serum TGF-β1, MMP-1, and insulin resistance (HOMA-IR) proved to be potentially useful noninvasive markers in predicting fibrosis in NASH patients.

Transient elastography for assessment of fibrosis in paediatric liver disease

The prognosis and management of chronic liver diseases in children largely depend on the extent and progression of liver fibrosis, which is often the most important predictor of disease outcome, and thus influences the indication for potential therapy. Unfortunately, liver biopsy continues to be the gold standard for the staging and grading of fibrosis. Liver biopsy is an invasive and painful technique with several limitations. These limitations have led to the development of alternative noninvasive methods for the accurate assessment of fibrosis and for the maintenance of an acceptable risk/benefit ratio. In the last decades, transient elastography (TE) has received increasing consideration as a means of evaluating disease progression in paediatric chronic liver disease. TE is an accurate and reproducible methodology for identifying subjects without fibrosis or significant fibrosis, or with advanced fibrosis. In this review, we provide an outline of liver fibrosis in paediatric liver diseases, including fibrogenesis, and noninvasive techniques for the diagnosis and follow-up of fibrosis, and then focus on the characteristics of TE and on its strength in the assessment of liver fibrosis, paying particular attention to studies conducted in children.

Usefulness of a novel serum proteome-derived index FI-PRO (fibrosis-protein) in the prediction of fibrosis in chronic hepatitis C

BACKGROUND

Liver biopsy is an imperfect standard for the assessment of chronic hepatitis C liver fibrosis. In this study, the diagnostic role of proteome-derived protein markers and the usefulness of a protein-based index were assessed.

METHODS

Characteristics, clinical biochemistry, and protein markers of patients with chronic hepatitis C from a study (n=62) and validation group (n=73) were statistically assessed according to fibrosis severity. Multivariate models were built using linear discriminant analysis for the prediction of minor fibrosis (F0-F1), moderate fibrosis (F2-F3), and cirrhosis (F4). The best model was validated and diagnostic performance was compared with the aspartate aminotransferase-to-platelet ratio index based on their receiver operator characteristic curves.

RESULTS

Statistical analysis resulted in significant outcomes for both clinical and protein markers. The best multivariate model was based on four protein markers: α-2-macroglobulin (A2M), haptoglobin, hemopexin, and galectin-3-binding protein. A2M and hemopexin were the primary predictors according to this model. A novel index A2M/hemopexin [fibrosis-protein (FI-PRO) index] showed a diagnostic performance rate of 0.80-0.92 for the detection of significant fibrosis (F2-F4) and advanced fibrosis (F3-F4) in the validation group, which was better compared with aspartate aminotransferase-to-platelet ratio index. FI-PRO had an overall positive predictive value of 86% for significant fibrosis and a negative predictive value of at least 90% for advanced fibrosis.

CONCLUSION

Proteome-derived protein markers were successfully implemented in clinical diagnosis of hepatitis C fibrosis, which resulted in the FI-PRO index. The efficiency and usability of FI-PRO should be validated in large-scale, prospective studies.

Fibro-α score as a simple and useful non-invasive test for predicting significant liver fibrosis in chronic hepatitis C patients

BACKGROUND AND STUDY AIMS

Non-invasive methods for the assessment of liver fibrosis are clinically important where hepatitis C virus (HCV) is common in Egypt. Our aim was to evaluate the diagnostic performance of a panel of simple blood markers of liver fibrosis in chronic hepatitis C (CHC) patients.

PATIENTS AND METHODS

A total of 199 patients with CHC evaluated for eligibility for antiviral therapy were included. Liver biochemical profile including transaminases, bilirubin, alkaline phosphatase, serum albumin, complete blood count prothrombin time and AFP were estimated. Liver biopsy was done. Statistical analyses were performed by logistic regression and receiver operating characteristic (ROC) curves to assess and compare diagnostic accuracy of blood markers. A stepwise combination algorithm was developed and validated prospectively in 135 additional patients.

RESULTS

α-Foetoprotein (AFP) was the most efficient marker among other markers tested. The areas under the curves (AUCs) of AFP were 0.77 for significant liver fibrosis (F2-F4), 0.75 for advanced liver fibrosis (F3-F4) and 0.76 for liver cirrhosis (F4). The stepwise multivariate discriminant analysis (MDA) selected a novel non-invasive index for discriminating patients with significant liver fibrosis, named Fibro-α score. Fibro-α score=(1.35 (numeric constant) +AFP (IUml(-1))×0.009584+aspartate aminotransferase (AST)/alanine aminotransferase (ALT)×0.243-platelet count (×10(9)l(-1))×0.001624). The Fibro-α score was used for patients with advanced liver fibrosis and liver cirrhosis. The AUCs of Fibro-α score were 0.82 for patients with advanced liver fibrosis and 0.80 for those with cirrhosis. These results were reproduced in a validation study with no significant difference.

CONCLUSION

While liver biopsy is invasive, expensive and, in some settings, impossible to do, Fibro-α score is simple, cheap, non-invasive and may be useful for predicting significant liver fibrosis.

Liver fibrosis in paediatric liver diseases

Numerous paediatric liver diseases from different origins may be complicated by development of liver fibrosis and progression to cirrhosis. Although fibrogenesis, which represents a major driving force for the development of liver fibrosis, has common tracts whatever the aetiology, liver fibrosis has different histopathological patterns in paediatric liver disease. In these diseases management choices may depend upon the stage of liver fibrosis. Thus, the accurate estimation of histological pattern of liver fibrosis is important for the prevention of the subsequent complications. Liver biopsy has long been considered as a gold standard diagnostic method for assessing liver fibrosis. However, due to its several disadvantages, in the last decades alternative and accurate non-invasive means to estimate fibrosis are developed. In this review, we characterised the most frequent histological patterns of liver fibrosis in paediatric liver diseases. Furthermore, we describe use of liver biopsy in diagnosis and staging of liver fibrosis, list the alternative non-invasive techniques that have an emerging role in the assessment of liver fibrosis, and propose a management algorithm.

Recent advances in imaging hepatic fibrosis and steatosis

Liver disease is an increasing cause of morbidity and mortality worldwide. Currently, the gold standard for diagnosis and assessment of parenchymal disease is histopathological assessment of a percutaneous or transjugular liver biopsy. The risks and limitations of this technique are well recognized and as a result, significant effort has gone into the development of novel noninvasive methods of diagnosis and longitudinal assessment. Imaging techniques have improved significantly over the past decade and new technologies are beginning to enter clinical practice. Ultrasound, computed tomography and MRI are the main modalities currently used, but novel MRI-based techniques will have an increasing role. While there has been extensive research into the imaging of focal liver disease, the evidence base for imaging in diffuse disease has also undergone recent rapid development, particularly in the assessment of fibrosis and steatosis. Both of these abnormalities of the parenchyma can lead to cirrhosis and/or hepatocellular carcinoma and represent an important opportunity for detection of early liver disease. We discuss the recent advances in liver imaging techniques and their role in the diagnosis and monitoring of diffuse liver disease, with a focus on their current and potential clinical relevance and whether they may replace or augment liver biopsy. We also discuss techniques currently under development and their potential clinical applications in the future.

Pathology of chronic hepatitis B and chronic hepatitis C

Histologic evaluation of the liver is a major component in the medical management and treatment algorithm of patients with chronic hepatitis B (HBV) and chronic hepatitis C (HCV). Liver biopsy in these patients remains the gold standard, and decisions on treatment are often predicated on the degree of damage and stage of fibrosis. This article outlines the clinical course and serologic diagnosis of HBV and HCV for the clinician and the pathologist, who together have a close working relationship in managing patients with acute and chronic liver disease. The salient histologic features are elucidated in an attempt to provide the clinician with an understanding of the basic histopathology underlying chronic HCV and HBV.

Galectin-3-binding protein: a serological and histological assessment in accordance with hepatitis C-related liver fibrosis

OBJECTIVES

Invasive liver biopsy is the current method for the assessment of liver fibrosis. In search of noninvasive alternatives, galectin-3-binding protein (G3BP) was introduced as a candidate-marker of hepatitis C-related fibrosis based on serum proteomics. We investigated the role of G3BP as a single-marker of significant fibrosis and cirrhosis by serology and histology and studied the effect of glycosylation on antibody-affinity in hepatitis C and alcoholic cirrhosis.

METHODS

Sera and available biopsies of hepatitis C patients with various fibrosis-grades and patients with alcoholic cirrhosis were used for G3BP-measurements by enzyme-linked immunosorbent assay and immunohistochemistry, respectively. Glycosylation-effect was analyzed by western blot. Data was analyzed in accordance to fibrosis.

RESULTS

G3BP-levels (mean+/-standard deviation) were increased during cirrhosis (22.7+/-10.1 microg/ml) compared to mild (11.3+/-6.4 microg/ml) and moderate fibrosis (13.4+/-8.3 microg/ml) (P<0.001; P=0.004, respectively). Receiver operator characteristic curves showed areas under the curve of 0.68, 0.75 and 0.81 for detection of significant fibrosis, severe fibrosis, and cirrhosis, respectively. Similar findings in hepatic G3BP expression were obtained, in which cirrhosis was associated with diffuse, parenchymal expression (P=0.002). The observed difference between hepatitis C and alcoholic cirrhosis (13.5+/-9.0 microg/ml) (P=0.009) could not be explained by glycosylation.

CONCLUSION

Our recent findings confirm our initial proteome results on serological and histological level as well as the role of G3BP as a marker of hepatitis C-related fibrosis, especially cirrhosis. Implication of this protein in future multi-marker study should be considered.

Systematic review: caspase-cleaved fragments of cytokeratin 18 - the promises and challenges of a biomarker for chronic liver disease

BACKGROUND

Biomarkers hold great promise for detecting chronic liver disease without the use of liver biopsy.

AIM

To review the usefulness of cytokeratin (CK) 18 fragments, a marker of hepatocyte apoptosis, to predict the presence of chronic liver injury.

METHODS

Available literature identified from PubMed was reviewed.

RESULTS

Levels of CK18 fragments have been shown to be elevated in hepatocellular carcinoma, viral hepatitis, alcoholic hepatitis, nonalcoholic fatty liver disease and cholestatic liver disease. In the setting of nonalcoholic fatty liver disease, CK18 fragments may distinguish nonalcoholic steatohepatitis from simple fatty liver.

CONCLUSIONS

Undoubtedly, the most promising application of CK18 fragments is currently in nonalcoholic fatty liver disease, and especially for distinguishing patients with nonalcoholic steatohepatitis vs. those with simple steatosis. Further investigations and technical improvements are required to cross the boundary from research to the clinical application of CK18 fragments as a marker of chronic liver disease.