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Ferraioli G, Barr RG, Berzigotti A, Sporea I, Wong VWS, Reiberger T, Karlas T, Thiele M, Cardoso AC, Ayonrinde OT, Castera L, Dietrich CF, Iijima H, Lee DH, Kemp W, Oliveira CP, Sarin SK. WFUMB Guideline/Guidance on Liver Multiparametric Ultrasound: Part 1. Update to 2018 Guidelines on Liver Ultrasound Elastography. ULTRASOUND IN MEDICINE & BIOLOGY 2024:S0301-5629(24)00142-X. [PMID: 38762390 DOI: 10.1016/j.ultrasmedbio.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 05/20/2024]
Abstract
The World Federation for Ultrasound in Medicine and Biology (WFUMB) endorsed the development of this document on multiparametric ultrasound. Part 1 is an update to the WFUMB Liver Elastography Guidelines Update released in 2018 and provides new evidence on the role of ultrasound elastography in chronic liver disease. The recommendations in this update were made and graded using the Oxford classification, including level of evidence (LoE), grade of recommendation (GoR) and proportion of agreement (Oxford Centre for Evidence-Based Medicine [OCEBM] 2009). The guidelines are clinically oriented, and the role of shear wave elastography in both fibrosis staging and prognostication in different etiologies of liver disease is discussed, highlighting advantages and limitations. A comprehensive section is devoted to the assessment of portal hypertension, with specific recommendations for the interpretation of liver and spleen stiffness measurements in this setting.
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Affiliation(s)
- Giovanna Ferraioli
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Richard Gary Barr
- Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio, USA; Southwoods Imaging, Youngstown, Ohio, USA
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ioan Sporea
- Division of Gastroenterology and Hepatology, Department of Internal Medicine II, Center for Advanced Research in Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, Timișoara, Romania
| | - Vincent Wai-Sun Wong
- Medical Data Analytics Centre, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China; State Key Laboratory of Digestive Disease, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong, China
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Thomas Karlas
- Division of Gastroenterology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Maja Thiele
- Center for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Department for Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ana Carolina Cardoso
- Hepatology Division, School of Medicine, Federal University of Rio de Janeiro, Clementino, Fraga Filho Hospital, Rua Prof. Rodolpho Paulo Rocco, Cidade Universitária da Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Oyekoya Taiwo Ayonrinde
- Department of Gastroenterology and Hepatology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia; Medical School, University of Western Australia, Crawley, Western Australia, Australia; Curtin Medical School, Curtin University, Kent Street, Bentley, Western Australia, Australia
| | - Laurent Castera
- Université Paris-Cité, Inserm UMR1149, Centre de Recherche sur l'Inflammation, Paris, France; Service d'Hépatologie, Hôpital Beaujon, Assistance-Publique Hôpitaux de Paris, Clichy, France
| | - Christoph Frank Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem and Permancence, Bern, Switzerland
| | - Hiroko Iijima
- Division of Hepatobiliary and Pancreatic Disease, Department of Gastroenterology, Hyogo Medical University, Nishinomiya, Hyogo, Japan; Ultrasound Imaging Center, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - William Kemp
- Department of Gastroenterology, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Claudia P Oliveira
- Gastroenterology Department, Laboratório de Investigação (LIM07), Hospital das Clínicas de São Paulo, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
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Israelsen M, Rungratanawanich W, Thiele M, Liangpunsakul S. Non-invasive tests for alcohol-associated liver disease. Hepatology 2024:01515467-990000000-00841. [PMID: 38607723 DOI: 10.1097/hep.0000000000000885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 03/23/2024] [Indexed: 04/14/2024]
Abstract
Alcohol consumption is a global phenomenon and a major contributor to alcohol-associated liver disease (ALD). Detecting individuals at risk of ALD has been challenging, with only a small fraction of patients being identified at early stages compared to other chronic liver diseases. In response to this challenge, non-invasive tests (NITs) have become essential tools for the detection of ALD, offering opportunities for early identification and intervention to mitigate the disease burden. Noninvasive alcohol consumption biomarkers are crucial in estimating individuals' recent alcohol intake, providing valuable insights into their drinking patterns. Various NITs have been investigated for the initial screening of asymptomatic individuals at risk of ALD, as well as for identifying specific stages of the disease. These NITs are applied in 2 main clinical scenarios: population-based stratification for identifying and predicting liver-related symptoms and diagnosing and prognosticating compensated cirrhosis or advanced chronic liver disease in secondary or tertiary care settings. Moreover, NITs play a significant role in the prognostic assessment of patients with various manifestations of ALD, including alcohol-associated hepatitis (AH), decompensated cirrhosis, and metabolic-associated and ALD. These tests guide appropriate treatment decisions and predict outcomes. In this review, various NITs for the early detection and monitoring of alcohol consumption were discussed. Additionally, the evaluation of NITs for screening and predicting ALD and liver complications was addressed comprehensively. Future perspectives of NITs for ALD were explored, alongside a thorough discussion of the opportunities and challenges associated with NITs for ALD screening.
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Affiliation(s)
- Mads Israelsen
- Department of Gastroenterology and Hepatology, Fibrosis Fatty Liver and Steatohepatitis Research Centre, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Wiramon Rungratanawanich
- Section of Molecular Pharmacology and Toxicology, National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland, USA
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Fibrosis Fatty Liver and Steatohepatitis Research Centre, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Suthat Liangpunsakul
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Roudebush Veterans Administration Medical Center, Indianapolis, Indiana, USA
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3
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Kataria S, Juneja D, Singh O. Transient elastography (FibroScan) in critical care: Applications and limitations. World J Meta-Anal 2023; 11:340-350. [DOI: 10.13105/wjma.v11.i7.340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/28/2023] [Accepted: 09/22/2023] [Indexed: 12/14/2023] Open
Abstract
FibroScan® is a non-invasive device that assesses the ‘hardness’ (or stiffness) of the liver via the technique of transient elastography. Because fibrous tissue is harder than normal liver, the degree of hepatic fibrosis can be inferred from the liver hardness. This technique is increasingly being employed to diagnose liver fibrosis, even in critically ill patients. It is now being used not only for diagnosis and staging of liver cirrhosis, but also for outcome prognostication. However, the presence of several confounding factors, especially in critically ill patients, may make interpretation of these results unreliable. Through this review we aim to describe the indications and pitfalls of employing FibroScan in patients admitted to intensive care units.
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Affiliation(s)
- Sahil Kataria
- Department of Critical Care Medicine, Holy Family Hospital, New Delhi 110025, India
| | - Deven Juneja
- Department of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - Omender Singh
- Department of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
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Johannessen A, Stockdale AJ, Henrion MYR, Okeke E, Seydi M, Wandeler G, Sonderup M, Spearman CW, Vinikoor M, Sinkala E, Desalegn H, Fall F, Riches N, Davwar P, Duguru M, Maponga T, Taljaard J, Matthews PC, Andersson M, Mboup S, Sombie R, Shimakawa Y, Lemoine M. Systematic review and individual-patient-data meta-analysis of non-invasive fibrosis markers for chronic hepatitis B in Africa. Nat Commun 2023; 14:45. [PMID: 36596805 PMCID: PMC9810658 DOI: 10.1038/s41467-022-35729-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 12/20/2022] [Indexed: 01/05/2023] Open
Abstract
In sub-Saharan Africa, simple biomarkers of liver fibrosis are needed to scale-up hepatitis B treatment. We conducted an individual participant data meta-analysis of 3,548 chronic hepatitis B patients living in eight sub-Saharan African countries to assess the World Health Organization-recommended aspartate aminotransferase-to-platelet ratio index and two other fibrosis biomarkers using a Bayesian bivariate model. Transient elastography was used as a reference test with liver stiffness measurement thresholds at 7.9 and 12.2kPa indicating significant fibrosis and cirrhosis, respectively. At the World Health Organization-recommended cirrhosis threshold (>2.0), aspartate aminotransferase-to-platelet ratio index had sensitivity (95% credible interval) of only 16.5% (12.5-20.5). We identified an optimised aspartate aminotransferase-to-platelet ratio index rule-in threshold (>0.65) for liver stiffness measurement >12.2kPa with sensitivity and specificity of 56.2% (50.5-62.2) and 90.0% (89.0-91.0), and an optimised rule-out threshold (<0.36) with sensitivity and specificity of 80.6% (76.1-85.1) and 64.3% (62.8-65.8). Here we show that the World Health Organization-recommended aspartate aminotransferase-to-platelet ratio index threshold is inappropriately high in sub-Saharan Africa; improved rule-in and rule-out thresholds can optimise treatment recommendations in this setting.
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Affiliation(s)
- Asgeir Johannessen
- Department of Infectious Diseases, Vestfold Hospital, Tønsberg, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Alexander J Stockdale
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Marc Y R Henrion
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Edith Okeke
- Faculty of Medical Sciences, University of Jos, Jos, Nigeria
| | - Moussa Seydi
- Service de Maladies Infectieuses et Tropicales, Centre Regional de Recherche et de Formation, Centre Hospitalier National Universitaire de Fann, Dakar, Senegal
| | - Gilles Wandeler
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Sonderup
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - C Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Michael Vinikoor
- Department of Internal Medicine, University of Zambia, Lusaka, Zambia
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Edford Sinkala
- Department of Internal Medicine, University of Zambia, Lusaka, Zambia
| | - Hailemichael Desalegn
- Department of Infectious Diseases, Vestfold Hospital, Tønsberg, Norway
- Medical Department, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Fatou Fall
- Department of Hepatology and Gastroenterology, Hopital Principal de Dakar, Dakar, Senegal
| | - Nicholas Riches
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Pantong Davwar
- Faculty of Medical Sciences, University of Jos, Jos, Nigeria
| | - Mary Duguru
- Faculty of Medical Sciences, University of Jos, Jos, Nigeria
| | - Tongai Maponga
- Division of Medical Virology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Jantjie Taljaard
- Division of Infectious Diseases, Department of Medicine, Tygerberg Hospital and Stellenbosch University, Cape Town, South Africa
| | - Philippa C Matthews
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- The Francis Crick Institute, London, UK
- University College London, London, UK
| | - Monique Andersson
- Division of Medical Virology, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Souleyman Mboup
- L'Institut de Recherche en Santé, de Surveillance Épidémiologique et de Formations (IRESSEF), Dakar, Senegal
| | - Roger Sombie
- Yalgado Ouédraogo University Hospital Center, Ouagadougou, Burkina Faso
| | - Yusuke Shimakawa
- Unité d'Epidémiologie des Maladies Emergentes, Institut Pasteur, Paris, France
| | - Maud Lemoine
- Department of Metabolism, Digestion and Reproduction, Division of Digestive Diseases, Hepatology section, Imperial College London, London, UK
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Ferraioli G, Roccarina D. Update on the role of elastography in liver disease. Therap Adv Gastroenterol 2022; 15:17562848221140657. [PMID: 36506750 PMCID: PMC9730016 DOI: 10.1177/17562848221140657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 11/05/2022] [Indexed: 12/12/2022] Open
Abstract
The diagnosis of liver fibrosis and the assessment of its severity are important to provide appropriate management, to determine the prognosis or the need for surveillance. Currently, for fibrosis staging, liver stiffness measurement (LSM) with the shear wave elastography (SWE) techniques is considered a reliable substitute for liver biopsy in several clinical scenarios. Nonetheless, it should be emphasized that stiffness value is a biomarker of diffuse liver disease that must be interpreted taking into consideration anamnesis, clinical and laboratory data. In patients with diffuse liver disease, it is more clinically relevant to determine the likelihood of advanced disease rather than to obtain an exact stage of liver fibrosis using a histologic classification. In this regard, a 'rule of five' for LSMs with vibration-controlled transient elastography (VCTE) and a 'rule of four' for LSMs with the acoustic radiation force impulse (ARFI)-based techniques have been proposed. In patients with advanced chronic liver disease (CLD), the risk of liver decompensation increases with increasing liver stiffness value. SWE has been proposed as a tool to predict the risk of death or complications in patients with CLD. LSM by VCTE combined with platelets count is a validated non-invasive method for varices screening, with very good results in terms of invasive procedures being spared. ARFI-based techniques also show some promising results in this setting. LSM, alone or combined in scores or algorithms with other parameters, is used to evaluate the risk of hepatocellular carcinoma occurrence. Due to the high prevalence of CLD, screening the population at risk is of interest but further studies are needed.
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Affiliation(s)
| | - Davide Roccarina
- Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK,Internal Medicine Consultant, SOD Medicina Interna ed Epatologia, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
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Legros L, Bardou-Jacquet E, Turlin B, Michalak S, Hamonic S, Le Gruyer A, Aziz K, Lemoine C, Bouvard N, Chavagnat JJ, Silvain C, Kerjean J, Le Dréau G, Lacave-Oberti N, Oberti F, Le Lan C, Guyader D, Moirand R. Transient Elastography Accurately Screens for Compensated Advanced Chronic Liver Disease in Patients With Ongoing or Recent Alcohol Withdrawal. Clin Gastroenterol Hepatol 2022; 20:1542-1552.e6. [PMID: 33588101 DOI: 10.1016/j.cgh.2021.02.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/28/2021] [Accepted: 02/08/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Liver stiffness measurement by transient elastography (TE) is a promising method for staging fibrosis in alcohol-related liver disease, but uncertainties remain regarding the influence of alcohol consumption and thus the ideal timing for TE performance. We evaluated the performance of TE compared with liver biopsy to exclude compensated advanced chronic liver disease (cACLD) in patients hospitalized for alcohol detoxification. METHODS Patients were recruited prospectively at 6 in-patient addiction centers in France. Eligible patients had increased aspartate aminotransferase levels, and no history or signs of overt cirrhosis. TE, histology, and biochemistry measurements were obtained within a median of 6 days after alcohol withdrawal. TE and biochemistry were repeated 1 and 2 months later. RESULTS The study included 259 patients for per-protocol analysis, of whom 45 (17%) had cACLD. TE identified patients with high accuracy at inclusion and at the 1- and 2-month follow-up evaluation, with area under the curve values of 0.96 (95% CIs, 0.94-0.99), 0.96 (95% CIs, 0.92-0.99), and 0.93 (95% CIs, 0.85-1.00), respectively. In 84% of patients, cACLD was ruled out when liver stiffness was less than 10 kPa (negative predictive value, 99% (95% CIs, 98%-100%)) or ruled in when greater than 25 kPa (positive predictive value, 93% (95% CI, 83%-102%)). Algorithms based on aminotransferase levels and/or bilirubin did not add to the diagnostic performance of TE in this period. Among patients with initial liver stiffness of 10 to 25 kPa, more than half of those with no cACLD showed liver stiffness of less than 10 at 1- and 2-month follow-up testing. CONCLUSIONS TE performed during the first 2 months after alcohol cessation is an excellent method for excluding alcohol-related cACLD. CLINICAL TRIAL NUMBER NCT01789008.
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Affiliation(s)
| | - Edouard Bardou-Jacquet
- Service des Maladies du Foie, Rennes, France; Université (Univ) Rennes, Institut National de Recherche pour l'Agriculture, l'Alimentation et l'Environnement (INRAE) INSERM, Centre Hospitalier Universitaire (CHU) Rennes, Institut NUMECAN (Nutrition Metabolisms and Cancer), Rennes, France
| | | | - Sophie Michalak
- Department of Pathology, University Hospital, Angers, France
| | - Stéphanie Hamonic
- Epidemiology and Public Health Department, Rennes University Hospital, Rennes, France
| | | | - Karim Aziz
- Yves Le Foll Hospital, Saint-Brieuc, France
| | | | | | | | | | | | - Gérard Le Dréau
- Service d'Hépato-gastro-enterologie, Hopital de Lorient, France
| | - Natacha Lacave-Oberti
- Addiction and Psychiatry Department, Angers, France; Hemodynamique, Interaction Fibrose et Invasivite Tumorales Hepatiques (HIFIH) Laboratory, Unité Propre à l'Enseignement Supérieur (UPRES) Equipe Associée (EA)3859, Angers, France
| | - Frederic Oberti
- Hemodynamique, Interaction Fibrose et Invasivite Tumorales Hepatiques (HIFIH) Laboratory, Unité Propre à l'Enseignement Supérieur (UPRES) Equipe Associée (EA)3859, Angers, France; Hepato-gastroenterology Department, Angers University Hospital, Angers, France
| | | | | | - Romain Moirand
- Université (Univ) Rennes, Institut National de Recherche pour l'Agriculture, l'Alimentation et l'Environnement (INRAE) INSERM, Centre Hospitalier Universitaire (CHU) Rennes, Institut NUMECAN (Nutrition Metabolisms and Cancer), Rennes, France; Unité Fonctionelle (UF) Addictologie, Rennes, France.
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Garbuzenko DV. Principles of diagnosis and treatment of alcohol-induced liver fibrosis. MEDITSINSKIY SOVET = MEDICAL COUNCIL 2022. [DOI: 10.21518/2079-701x-2022-16-7-104-114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Alcohol-related liver diseases are one of the leading causes of death worldwide, primarily due to complications of liver cirrhosis (LC). Early detection of alcohol-induced liver fibrosis (LF) is a difficult task, since often alcoholic liver disease (ALD) is clinically manifested only at late stages. Given that not all alcoholic suffer from ALD, the widespread use of liver biopsy to verify the diagnosis is not advisable. Despite the variety of proposed non-invasive methods for assessing the severity of LF in patients with ALD, none of them has sufficient validation and therefore cannot be recommended for widespread use in clinical practice. The most well-studied transient elastography, due to its suboptimal specificity, can be effectively used only to exclude clinically significant LF or LC. The only proven approach to treat ALD is persistent and total alcohol abstinence. While the therapeutic options for patients with severe forms of acute hepatitis remain unchanged since the 70s of the last century and are based mainly on the use of corticosteroids, currently, there are no approaches to antifibrotic therapy of ALD approved by the guidelines. At the same time, modern achievements in understanding the pathophysiological mechanisms of this disease have served as an impetus for the development of ways to solve the problem. In particular, providing intestinal eubiosis may be an important goal for the prevention and treatment of alcohol-induced LF. Randomized controlled multicenter trials involving a large number of patients are needed to confirm this and other hypotheses related to antifibrotic therapy of ALD and to accept them as a standard of medical care.
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Krag A, Roskams T, Pinzani M, Mueller S. Diagnostic challenges in patients with alcohol-related liver disease. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:45-57. [PMID: 35042253 DOI: 10.1055/a-1713-4372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Alcohol is globally the leading risk factor for cirrhosis and is subsumed under the term alcohol-related liver disease (ALD). However, only ca. 10% of people with harmful alcohol consumption (>40 gram alcohol per day) develop cirrhosis, while 15% have normal liver histology. Unfortunately, laboratory parameters and ultrasound hold little value to neither rule-in nor rule out alcohol related liver fibrosis. While several indices with combinations of liver associated markers such as FIB4 seem to be promising, non-invasive test strategies are urgently needed with cut-off's that can be applied to guide clinical decision making. The aims of this review article are to highlight novel developments for the diagnosis of ALD and to identify topics of controversy and potential future directions. In the last 15 years, elastography to measure liver stiffness (LS) has significantly improved our screening strategies for cirrhosis. LS values below 6 kPa are considered as normal and exclude ALD. LS of 8 and 12.5 kPa represent generally accepted cut-off values for F3 and F4 fibrosis. Especially, transient elastography (TE) has been assessed in numerous studies, but similar performance can be obtained with point shear wave elastography, 2 SD shear wave elastography or MR elastography. Important confounders of elevated LS such as inflammation should also be considered and alcohol withdrawal not only improves liver inflammation but also LS. Liver stiffness measurement has signficiantly improved early diagnosis and follow-up of fibrosis in patients with ALD and patients with diagnosed manifest but clinically compensated cirrhosis should undergo further clinical examinations to rule out complications of portal hypertension. In addition, surveillance for the occurrence of hepatocellular carcinoma is recommended in all cirrhotic patients.
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Affiliation(s)
- Aleksander Krag
- Centre for Liver Research/Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Tania Roskams
- Department of Imaging and Pathology, University of Leuven, Leuven, Netherlands
| | - Massimo Pinzani
- University College London Institute for Liver and Digestive Health, Royal Free Hospital, London, United Kingdom of Great Britain and Northern Ireland
| | - Sebastian Mueller
- Centre of Alcohol Research, University of Heidelberg, Heidelberg, Germany.,Department of Medicine, Salem KH, Heidelberg, Germany
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Boursier J, Decraecker M, Bourlière M, Bureau C, Ganne-Carrié N, de Lédinghen V. Quality criteria for the measurement of liver stiffness. Clin Res Hepatol Gastroenterol 2022; 46:101761. [PMID: 34325013 DOI: 10.1016/j.clinre.2021.101761] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 07/23/2021] [Indexed: 02/04/2023]
Abstract
Liver elastography offers the possibility of a quick, non-invasive, and painless evaluation of the liver with immediate results at bedside. Transient elastography is the most validated technology, and many others such as point shear wave elastography, 2D-shear wave elastography, or magnetic resonance elastography have been developed. To ensure the best evaluation, several conditions of examination must be respected for liver stiffness measurement. Indeed, patient, operator and examination characteristics have all been shown to influence the result of liver stiffness measurement. Food intake increases liver stiffness, whereas withdrawal in alcoholics is associated with a decrease in elastography results. Inter-observer reproducibility of the measurement seems suboptimal, and the influence of the operator experience is still being debated. The measurement site and the FibroScan® probe must be correctly chosen. Finally, the intrinsic characteristics and quality criteria of the measurement, especially the interquartile range/median ratio, must be carefully checked to avoid overestimation of liver stiffness. Most of the results come from studies which have evaluated transient elastography, with less data available for the other technologies. Liver stiffness measurement could appear as a simple way to explore the liver, but several conditions must be met before deciding the patient management according to its result.
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Affiliation(s)
- Jérôme Boursier
- Laboratoire HIFIH, UPRES EA3859, SFR ICAT 4208, Université d'Angers, Angers, France.
| | - Marie Decraecker
- Service d'hépato-gastroentérologie, Hôpital Haut-Lévêque, CHU Bordeaux, pessac & INSERM U1053, Université de Bordeaux, Bordeaux, France
| | - Marc Bourlière
- Service d'hépato-gastroentérologie, Hôpital Saint Joseph & INSERM UMR 1252 IRD SESSTIM Aix Marseille Université, Marseille, France
| | - Christophe Bureau
- Service d'hépatologie, Hôpital Rangueil, CHU Toulouse, Toulouse, France
| | - Nathalie Ganne-Carrié
- Service d'hépatologie, Hôpital Avicenne, APHP, Université Sorbonne Paris Nord, Bobigny & INSERM UMR 1138, Centre de Recherche des Cordeliers, Université de Paris, France
| | - Victor de Lédinghen
- Service d'hépato-gastroentérologie, Hôpital Haut-Lévêque, CHU Bordeaux, pessac & INSERM U1053, Université de Bordeaux, Bordeaux, France
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EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis - 2021 update. J Hepatol 2021; 75:659-689. [PMID: 34166721 DOI: 10.1016/j.jhep.2021.05.025] [Citation(s) in RCA: 659] [Impact Index Per Article: 219.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 05/28/2021] [Indexed: 02/07/2023]
Abstract
Non-invasive tests are increasingly being used to improve the diagnosis and prognostication of chronic liver diseases across aetiologies. Herein, we provide the latest update to the EASL Clinical Practice Guidelines on the use of non-invasive tests for the evaluation of liver disease severity and prognosis, focusing on the topics for which relevant evidence has been published in the last 5 years.
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Rhodes F, Cococcia S, Panovska-Griffiths J, Tanwar S, Westbrook RH, Rodger A, Rosenberg WM. Uncovering unsuspected advanced liver fibrosis in patients referred to alcohol nurse specialists using the ELF test. BMC Gastroenterol 2021; 21:143. [PMID: 33789586 PMCID: PMC8011169 DOI: 10.1186/s12876-021-01728-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 03/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND AIMS Alcohol use disorders (AUD) cause 7.2% of UK hospital admissions/year. Most are not managed by hepatologists and liver disease may be missed. We used the Enhanced Liver Fibrosis (ELF) test to investigate prevalence and associations of occult advanced liver fibrosis in AUD patients not known to have liver fibrosis. METHODS Liver fibrosis was assessed using ELF in prospective patients referred to the Royal Free Hospital Alcohol Specialist Nurse (November 2018-December 2019). Known cases of liver disease were excluded. Patient demographics, blood tests, imaging data and alcohol histories recorded. Advanced fibrosis was categorised as ELF ≥ 10.5. RESULTS The study included 99 patients (69% male, mean age 53.1 ± 14.4) with median alcohol intake 140 units/week (IQR 80.9-280), and a mean duration of harmful drinking of 15 years (IQR 10-27.5). The commonest reason for admission was symptomatic alcohol withdrawal (36%). The median ELF score was 9.62, range 6.87-13.78. An ELF score ≥ 10.5 was recorded in 28/99 (29%) patients, of whom 28.6% had normal liver tests. Within previous 5-years, 76% had attended A&E without assessment of liver disease. The ELF score was not associated with recent alcohol intake (p = 0.081), or inflammation (p = 0.574). CONCLUSION Over a quarter of patients with AUD had previously undetected advanced liver fibrosis assessed by ELF testing. ELF was not associated with liver inflammation or recent alcohol intake. The majority had recent missed opportunities for investigating liver disease. We recommend clinicians use non-invasive tests to assess liver fibrosis in patients admitted to hospital with AUD.
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Affiliation(s)
- Freya Rhodes
- Institute for Liver and Digestive Health, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, Hampstead, London, NW3 2PF, UK.,Institute for Liver and Digestive Health, UCL Division of Medicine, Royal Free Campus, London, NW3 2QG, UK
| | - Sara Cococcia
- Institute for Liver and Digestive Health, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, Hampstead, London, NW3 2PF, UK.,First Department of Internal Medicine, San Matteo Hospital Foundation, University of Pavia, Pavia, Italy.,Institute for Liver and Digestive Health, UCL Division of Medicine, Royal Free Campus, London, NW3 2QG, UK
| | - Jasmina Panovska-Griffiths
- Department of Applied Health Research, University College London, London, UK.,Institute for Global Health, University College London, London, UK
| | - Sudeep Tanwar
- Institute for Liver and Digestive Health, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, Hampstead, London, NW3 2PF, UK.,Barts Health NHS Trust, London, UK
| | - Rachel H Westbrook
- Institute for Liver and Digestive Health, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, Hampstead, London, NW3 2PF, UK.,Institute for Liver and Digestive Health, UCL Division of Medicine, Royal Free Campus, London, NW3 2QG, UK
| | - Alison Rodger
- Institute for Global Health, University College London, London, UK
| | - William M Rosenberg
- Institute for Liver and Digestive Health, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, Hampstead, London, NW3 2PF, UK.
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12
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Ryu SR, Yoo JJ, Kang SH, Jeong SW, Kim MY, Cho YK, Chang Y, Kim SG, Jang JY, Kim YS, Baik SK, Kim YJ, Park SY, Baymbajav B. The cut-off value of transient elastography to the value of hepatic venous pressure gradient in alcoholic cirrhosis. Clin Mol Hepatol 2020; 27:197-206. [PMID: 33317252 PMCID: PMC7820198 DOI: 10.3350/cmh.2020.0171] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/06/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/AIMS The hepatic venous pressure gradient (HVPG) reflects portal hypertension, but its measurement is invasive. Transient elastography (TE) is a noninvasive method for evaluating liver stiffness (LS). We investigated the correlation between the value of LS, LS to platelet ratio (LPR), LS-spleen diameter-to-platelet ratio score (LSPS) and HVPG according to the etiology of cirrhosis, especially focused on alcoholic cirrhosis. METHODS Between January 2008 and March 2017, 556 patients who underwent HVPG and TE were consecutively enrolled. We evaluated LS, LPR, and LSPS according to the etiology of cirrhosis and analyzed their correlations with HVPG. RESULTS The LS value was higher in patients with alcoholic cirrhosis than viral cirrhosis based on the HVPG (43.5 vs. 32.0 kPa, P<0.001). There were no significant differences in the LPR or LSPS between alcoholic and viral cirrhosis groups, and the areas under the curves for the LPR and LSPS in subgroups according to HVPG levels were not superior to that for LS. In alcoholic cirrhosis, the LS cutoff value for predicting an HVPG ≥10 mmHg was 32.2 kPa with positive predictive value (PPV) of 94.5% and 36.6 kPa for HVPG ≥12 mmHg with PPV of 91.0%. CONCLUSION The LS cutoff value should be determined separately for patients with alcoholic and viral cirrhosis. In alcoholic cirrhosis, the LS cutoff values were 32.2 and 36.6 kPa for predicting an HVPG ≥10 and ≥12 mmHg, respectively. However, there were no significant differences in the LPR or LSPS between alcoholic and viral cirrhosis groups.
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Affiliation(s)
- Se Ri Ryu
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jeong-Ju Yoo
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Seong Hee Kang
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Soung Won Jeong
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Young Kyu Cho
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Young Chang
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jae Young Jang
- Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Young Seok Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yong Jae Kim
- Department of Radiology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Su Yeon Park
- Department of Biostatistics, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
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13
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Carrier P, Girard M, Debette-Gratien M, Ouedraogo N, Loustaud-Ratti V, Nubukpo P. Liver elastometry and alcohol withdrawal: Median-term follow-up in a psychiatric unit. Alcohol 2020; 89:49-56. [PMID: 32711035 DOI: 10.1016/j.alcohol.2020.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 07/07/2020] [Accepted: 07/16/2020] [Indexed: 12/16/2022]
Abstract
The measurement of liver stiffness (LS) shows promise as a follow-up tool after alcohol withdrawal, but it has mainly been studied in the early phase or in patients with severe liver disease. A 6-month ancillary study of a specific psychiatric cohort of alcoholic patients without known liver disease followed after withdrawal was conducted (Clinical Trial NCT01491347). Clinical and biological data and LS values were collected every 2 months. A total of 129 patients were included in the study; 93 had an LS assessment within the first 7 days, and 37 had all four LS measurements. Only seven (7.5%) patients had an initial LS > 12.1 kPa, the threshold used to define severe fibrosis. Abstinence was not associated with changes in LS at the various median-term follow-up periods. However, LS of abstinent subjects decreased significantly relative to that of non-abstinent subjects between M0 and M2. CAP™ values were not associated with abstinence. The systematic median-term follow-up of withdrawn patients does not appear to be contributory. However, LS could help to detect relapse in the first 2 months after withdrawal for subjects treated in a psychiatric hospital for dependence. It thus could serve as a motivation tool. Prospective studies with various and higher baseline LS values are warranted for simultaneous longitudinal assessment, including for very short- and long-term LS after withdrawal.
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Affiliation(s)
- Paul Carrier
- Fédération d'Hépatologie, Service d'Hépato-gastroentérologie, Centre Hospitalier Universitaire Dupuytren, Avenue Martin Luther King, Limoges, 87025, France; INSERM Unité S-1248 Faculté de Médecine et de Pharmacie, Rue Docteur Marcland, Limoges, 87025, France; Pôle Universitaire d'Addictologie, Centre Hospitalier Esquirol, Rue du Docteur Marcland, Limoges, 87025, France
| | - Murielle Girard
- Unité de Recherche et de Neurostimulation, Centre Hospitalier Esquirol, Rue du Docteur Marcland, Limoges, 87025, France; INSERM UMR 1094/NET Faculté de Médecine et de Pharmacie, Rue Docteur Marcland, Limoges, France.
| | - Marilyne Debette-Gratien
- Fédération d'Hépatologie, Service d'Hépato-gastroentérologie, Centre Hospitalier Universitaire Dupuytren, Avenue Martin Luther King, Limoges, 87025, France; INSERM Unité S-1248 Faculté de Médecine et de Pharmacie, Rue Docteur Marcland, Limoges, 87025, France; Pôle Universitaire d'Addictologie, Centre Hospitalier Esquirol, Rue du Docteur Marcland, Limoges, 87025, France
| | - Natacha Ouedraogo
- Pôle Universitaire d'Addictologie, Centre Hospitalier Esquirol, Rue du Docteur Marcland, Limoges, 87025, France
| | - Véronique Loustaud-Ratti
- Fédération d'Hépatologie, Service d'Hépato-gastroentérologie, Centre Hospitalier Universitaire Dupuytren, Avenue Martin Luther King, Limoges, 87025, France; INSERM Unité S-1248 Faculté de Médecine et de Pharmacie, Rue Docteur Marcland, Limoges, 87025, France
| | - Philippe Nubukpo
- Pôle Universitaire d'Addictologie, Centre Hospitalier Esquirol, Rue du Docteur Marcland, Limoges, 87025, France; Unité de Recherche et de Neurostimulation, Centre Hospitalier Esquirol, Rue du Docteur Marcland, Limoges, 87025, France; INSERM UMR 1094/NET Faculté de Médecine et de Pharmacie, Rue Docteur Marcland, Limoges, France
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14
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Giuffrè M, Campigotto M, Colombo A, Visintin A, Budel M, Aversano A, Navarria L, Piccin A, Cavalli CA, Sigon R, Balestra R, Tinè F, Abazia C, Masutti F, Crocè LS. The role of elastography in alcoholic liver disease: fibrosis staging and confounding factors, a review of the current literature. Minerva Gastroenterol (Torino) 2020; 67:112-121. [PMID: 33222430 DOI: 10.23736/s2724-5985.20.02777-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Alcohol-related liver disease (ALD) was estimated to have a prevalence of 2% among the USA population. Since severe fibrosis in compensated patients is the main predictor of long-term survival, it is of utmost importance to early detect patients with severe fibrosis before decompensation occurs. Liver elastography has been used to stage liver fibrosis. However, there is a widespread lack in guidelines for the correct use of liver stiffness (LS) in ALD. EVIDENCE ACQUISITION A structured search was carried out on MEDLINE/PubMed database. From the original 225 research articles identified, only 12 studies met the inclusion criteria, with 10 studies being eventually included. EVIDENCE SYNTHESIS According to reported data, patients with aspartate aminotransferase (AST)>100 IU/L and 50 IU/L showed significantly higher values of LS if compared to patients with the same fibrosis stage. Also, excessive alcohol consumption greatly influences elastography, leading to false fibrosis staging. When LS values >5-6 kPa are detected, several aspects should be taken into account. First of all, the patient should be asked about the current alcohol consumption (i.e. active vs. abstinence, determination of abstinence period, and quantification of alcohol intake), and if the patient is an active drinker, liver elastography can be repeated after a complete abstinence period of at least two weeks. and if the patient is an active drinker, liver elastography can be repeated after a complete abstinence period of at least two weeks. Secondly, clinicians should check liver transaminases level, and if AST are above 100 IU/L, they should be aware of a possible overestimation of fibrosis. However, whether transaminases-adapted cut-off values should be used for ad-hoc decisions in patients with no time or option to withdraw from alcohol consumption is still a matter of debate. CONCLUSIONS We hope that our review article may serve as a reference point in the prospect of futures guidelines.
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Affiliation(s)
- Mauro Giuffrè
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy - .,Italian Liver Foundation, Basovizza, Trieste, Italy - .,Pathologies of the Liver Clinic, A.S.U. Giuliano Isontina, Trieste, Italy -
| | - Michele Campigotto
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Anna Colombo
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Alessia Visintin
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Martina Budel
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Alessandro Aversano
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Luca Navarria
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Anna Piccin
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Carolina A Cavalli
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Riccardo Sigon
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | | | - Fabio Tinè
- Pathologies of the Liver Clinic, A.S.U. Giuliano Isontina, Trieste, Italy
| | - Cristiana Abazia
- Pathologies of the Liver Clinic, A.S.U. Giuliano Isontina, Trieste, Italy
| | - Flora Masutti
- Pathologies of the Liver Clinic, A.S.U. Giuliano Isontina, Trieste, Italy
| | - Lory S Crocè
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.,Italian Liver Foundation, Basovizza, Trieste, Italy.,Pathologies of the Liver Clinic, A.S.U. Giuliano Isontina, Trieste, Italy
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15
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Damiris K, Tafesh ZH, Pyrsopoulos N. Efficacy and safety of anti-hepatic fibrosis drugs. World J Gastroenterol 2020; 26:6304-6321. [PMID: 33244194 PMCID: PMC7656211 DOI: 10.3748/wjg.v26.i41.6304] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/30/2020] [Accepted: 10/20/2020] [Indexed: 02/06/2023] Open
Abstract
Recent progress in our understanding of the pathways linked to progression from hepatic insult to cirrhosis has led to numerous novel therapies being investigated as potential cures and inhibitors of hepatic fibrogenesis. Liver cirrhosis is the final result of prolonged fibrosis, which is an intimate balance between fibrogenesis and fibrinolysis. A number of these complex mechanisms are shared across the various etiologies of liver disease. Thankfully, investigation has yielded some promising results in regard to reversal of fibrosis, particularly the indirect benefits associated with antiviral therapy for the treatment of hepatitis B and C and the farnesoid receptor agonist for the treatment of primary biliary cholangitis and metabolic associated fatty liver disease. A majority of current clinical research is focused on targeting metabolic associated fatty liver disease and its progression to metabolic steatohepatitis and ultimately cirrhosis, with some hope of potential standardized therapeutics in the near future. With our ever-evolving understanding of the underlying pathophysiology, these therapeutics focus on either controlling the primary disease (the initial trigger of fibrogenesis), interrupting receptor ligand interactions and other intracellular communications, inhibiting fibrogenesis, or even promoting resolution of fibrosis. It is imperative to thoroughly test these potential therapies with the rigorous standards of clinical therapeutic trials in order to ensure the highest standards of patient safety. In this article we will briefly review the key pathophysiological pathways that lead to liver fibrosis and present current clinical and experimental evidence that has shown reversibility of liver fibrosis and cirrhosis, while commenting on therapeutic safety.
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Affiliation(s)
- Konstantinos Damiris
- Department of Medicine, Rutgers-New Jersey Medical School, Newark, NJ 07103, United States
| | - Zaid H Tafesh
- Medicine-Gastroenterology and Hepatology, Rutgers-New Jersey Medical School, Newark, NJ 07103, United States
| | - Nikolaos Pyrsopoulos
- Medicine-Gastroenterology and Hepatology, Rutgers-New Jersey Medical School, Newark, NJ 07103, United States
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16
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Hadefi A, Degré D, Trépo E, Moreno C. Noninvasive diagnosis in alcohol-related liver disease. Health Sci Rep 2020; 3:e146. [PMID: 32166191 PMCID: PMC7060960 DOI: 10.1002/hsr2.146] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/10/2019] [Accepted: 12/17/2019] [Indexed: 12/14/2022] Open
Abstract
Background Alcohol‐related liver disease (ALD) represents a major cause of death worldwide, and unfortunately, most patients are diagnosed at an advanced stage of the disease, which is related to poorer outcomes. Liver biopsy has historically been the gold standard for identifying advanced hepatic fibrosis, but this approach has several limitations, including invasiveness, low applicability, sampling variability, and cost. Main Text In order to detect earlier features of advanced liver fibrosis, surrogate biomarkers and techniques have been developed. While these were initially developed for chronic liver diseases such as viral hepatitis and nonalcoholic fatty liver disease (NAFLD), their performance in ALD has also been recently studied. Among the noninvasive surrogate markers and techniques used to detect liver fibrosis, the Enhanced Liver Fibrosis test, FibroTest, and Transient Elastography are the most accurate and validated techniques. In this review, we summarize the current status of the noninvasive assessment of liver disease in ALD and provide a synthesis of how these noninvasive tools can be used in clinical practice. Finally, we briefly outline novel biomarkers that are currently being investigated and discuss future directions and new opportunities in the noninvasive diagnosis of ALD.
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Affiliation(s)
- Alia Hadefi
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology CUB Hôpital Erasme, Université Libre de Bruxelles Brussels Belgium.,Laboratory of Experimental Gastroenterology Université Libre de Bruxelles Brussels Belgium
| | - Delphine Degré
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology CUB Hôpital Erasme, Université Libre de Bruxelles Brussels Belgium.,Laboratory of Experimental Gastroenterology Université Libre de Bruxelles Brussels Belgium
| | - Eric Trépo
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology CUB Hôpital Erasme, Université Libre de Bruxelles Brussels Belgium.,Laboratory of Experimental Gastroenterology Université Libre de Bruxelles Brussels Belgium
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology CUB Hôpital Erasme, Université Libre de Bruxelles Brussels Belgium.,Laboratory of Experimental Gastroenterology Université Libre de Bruxelles Brussels Belgium
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17
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Patel K, Sebastiani G. Limitations of non-invasive tests for assessment of liver fibrosis. JHEP Rep 2020; 2:100067. [PMID: 32118201 PMCID: PMC7047178 DOI: 10.1016/j.jhepr.2020.100067] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 01/05/2020] [Accepted: 01/08/2020] [Indexed: 02/07/2023] Open
Abstract
The diagnostic assessment of liver injury is an important step in the management of patients with chronic liver disease (CLD). Although liver biopsy is the reference standard for the assessment of necroinflammation and fibrosis, the inherent limitations of an invasive procedure, and need for repeat sampling, have led to the development of several non-invasive tests (NITs) as alternatives to liver biopsy. Such non-invasive approaches mostly include biological (serum biomarker algorithms) or physical (imaging assessment of tissue stiffness) assessments. However, currently available NITs have several limitations, such as variability, inadequate accuracy and risk factors for error, while the development of a newer generation of biomarkers for fibrosis may be limited by the sampling error inherent to the reference standard. Many of the current NITs were initially developed to diagnose significant fibrosis in chronic hepatitis C, subsequently refined for the diagnosis of advanced fibrosis in patients with non-alcoholic fatty liver disease, and further adapted for prognostication in CLD. An important consideration is that despite their increased use in clinical practice, these NITs were not designed to reflect the dynamic process of fibrogenesis, differentiate between adjacent disease stages, diagnose non-alcoholic steatohepatitis, or follow longitudinal changes in fibrosis or disease activity caused by natural history or therapeutic intervention. Understanding the strengths and limitations of these NITs will allow for more judicious interpretation in the clinical context, where NITs should be viewed as complementary to, rather than as a replacement for, liver biopsy.
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Key Words
- AGA, American Gastroenterology Association
- ALT, alanine aminotransferase
- APRI, AST-platelet ratio index
- AST, aspartate aminotransferase
- AUC, area under the curve
- BMI, body mass index
- Biomarkers
- CAP, controlled attenuation parameter
- CHB, chronic hepatitis B
- CHC, chronic hepatitis C
- CLD, chronic liver disease
- CPA, collagen proportionate area
- DAA, direct-acting antiviral
- ELF, enhanced liver fibrosis
- Elastography
- FIB-4, fibrosis-4
- FLIP, fatty liver inhibition of progression
- HCC, hepatocellular carcinoma
- IFN, interferon
- LSM, liver stiffness measure
- Liver biopsy
- MR, magnetic resonance
- MRE, magnetic resonance elastography
- NAFLD, non-alcoholic fatty liver disease
- NFS, NAFLD fibrosis score
- NITs, non-invasive tests
- Non-alcoholic fatty liver disease
- SVR, sustained virologic response
- US, ultrasound
- VCTE, vibration-controlled transient elastography
- Viral hepatitis
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Affiliation(s)
- Keyur Patel
- Division of Gastroenterology, University Health Network Toronto, Toronto General Hospital, Toronto, ON, Canada
- Corresponding author. Address: Division of Gastroenterology, University of Toronto Health Network, Toronto General Hospital, 200 Elizabeth Street, 9EN, Toronto, ON M5G 2C4.
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology, McGill University Health Center, Montreal, QC, Canada
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18
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Crabb DW, Im GY, Szabo G, Mellinger JL, Lucey MR. Diagnosis and Treatment of Alcohol-Associated Liver Diseases: 2019 Practice Guidance From the American Association for the Study of Liver Diseases. Hepatology 2020; 71:306-333. [PMID: 31314133 DOI: 10.1002/hep.30866] [Citation(s) in RCA: 410] [Impact Index Per Article: 102.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 12/12/2022]
Affiliation(s)
- David W Crabb
- Indiana University School of Medicine, Indianapolis, IN
| | - Gene Y Im
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gyongyi Szabo
- University of Massachusetts Medical School, Worcester, MA
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19
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Elshaarawy O, Mueller J, Guha IN, Chalmers J, Harris R, Krag A, Madsen BS, Stefanescu H, Farcau O, Ardelean A, Procopet B, Thiele M, Mueller S. Spleen stiffness to liver stiffness ratio significantly differs between ALD and HCV and predicts disease-specific complications. JHEP Rep 2019; 1:99-106. [PMID: 32039357 PMCID: PMC7001583 DOI: 10.1016/j.jhepr.2019.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/01/2019] [Accepted: 05/12/2019] [Indexed: 12/17/2022] Open
Abstract
Background & Aims Both liver stiffness (LS) and spleen stiffness (SS) are widely used to non-invasively assess liver fibrosis and portal hypertension, respectively. We aimed to identify the impact of disease etiology, namely the localization of inflammation (portal vs. lobular), on the SS/LS ratio. Methods In this multicenter study, LS and SS were prospectively assessed in 411 patients with alcohol-related liver disease (ALD) or hepatitis C virus (HCV) using FibroScan® (Echosens, Paris); changes in these parameters were also studied in response to treatment (alcohol withdrawal, HCV therapy). LS and spleen length (SL) were further analyzed in a retrospective cohort of 449 patients with long-term data on decompensation/death. Results Both, SS and SL were significantly higher in HCV compared to ALD (42.0 vs. 32.6 kPa, p≪0.0001, 15.6 vs. 11.9 cm, p≪0.0001) despite a lower mean LS in HCV. Consequently, the SS to LS ratio and the SL to LS ratio were significantly higher in HCV (3.8 vs. 1.72 and 1.46 vs. 0.86, p≪0.0001) through all fibrosis stages. Notably, SL linearly increased with SS and the relation between SS and SL was identical in HCV and ALD. In contrast, livers were much larger in ALD at comparable LS. After treatment, LS significantly decreased in both diseases without significant changes to the SS/LS ratio. In the prognostic cohort, patients with ALD had higher LS values (30.5 vs. 21.3 kPa) and predominantly presented with jaundice (65.2%); liver failure was the major cause of death (p≪0.01). In contrast, in HCV, spleens were larger (17.6 vs. 12.1 cm) while variceal bleeding was the major cause of decompensation (73.2%) and death (p≪0.001). Conclusion Both SS/LS and SL/LS ratios are significantly higher in patients with portal HCV compared to lobular ALD. Thus, combined LS and SS or SL measurements provide additional information about disease etiology and disease-specific complications. Lay summary Herein, we show that patients with hepatitis C virus infection (HCV) have higher spleen stiffness and portal pressure than patients with alcohol-related liver disease (ALD), within the same fibrosis stage and matched to liver stiffness. Thus, the spleen stiffness to liver stiffness ratio is significantly higher in patients with HCV compared to ALD. Additionally, patients with HCV more commonly progress to portal hypertension-related complications (e.g. variceal bleeding), while patients with ALD more commonly progress to liver failure (e.g. jaundice). The spleen stiffness to liver stiffness ratio is a useful tool to confirm disease etiology and predict disease-specific complications. SS/LS ratio is significantly higher in patients with portal HCV compared to lobular ALD. Patients with HCV have higher SS and portal pressure than patients with ALD and the same LS. Patients with HCV die earlier from portal hypertension-related complications. Patients with ALD die earlier from liver failure. Combined LS and SS measurements provide extra information about disease etiology and disease-specific complications.
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Affiliation(s)
- Omar Elshaarawy
- Department of Medicine and Center for Alcohol Research, Salem Medical Center, University of Heidelberg, Zeppelinstraße 11-33, 69121 Heidelberg, Germany
| | - Johannes Mueller
- Department of Medicine and Center for Alcohol Research, Salem Medical Center, University of Heidelberg, Zeppelinstraße 11-33, 69121 Heidelberg, Germany
| | - Indra Neil Guha
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Jane Chalmers
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Rebecca Harris
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology and Odense Patient data Exploratory Network, OPEN, Odense University Hospital, Odense, Denmark
| | - Bjørn Stæhr Madsen
- Department of Gastroenterology and Hepatology and Odense Patient data Exploratory Network, OPEN, Odense University Hospital, Odense, Denmark
| | - Horia Stefanescu
- Department of Hepatology and Liver Research Club, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Oana Farcau
- Department of Hepatology and Liver Research Club, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Andreea Ardelean
- Department of Hepatology and Liver Research Club, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Bogdan Procopet
- Department of Hepatology and Liver Research Club, Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Maja Thiele
- Department of Gastroenterology and Hepatology and Odense Patient data Exploratory Network, OPEN, Odense University Hospital, Odense, Denmark
| | - Sebastian Mueller
- Department of Medicine and Center for Alcohol Research, Salem Medical Center, University of Heidelberg, Zeppelinstraße 11-33, 69121 Heidelberg, Germany
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20
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Abstract
Alcoholic hepatitis is a unique type of alcohol-associated liver disease characterized by acute liver inflammation caused by prolonged heavy alcohol use. Treatment is mostly supportive. The short-term prognosis of acute alcoholic hepatitis depends on liver recovery, and ranges widely from rapid improvement to grim multiorgan failure despite treatment. Refinement of scoring systems have enhanced prognostication to guide clinical decision making in alcoholic hepatitis. Recent advances in the treatment of alcoholic hepatitis have solidified corticosteroids as the cornerstone of treatment to enhance short-term survival, but not intermediate or long-term survival.
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Affiliation(s)
- Gene Y Im
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, Recanati-Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029, USA.
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21
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Moreno C, Mueller S, Szabo G. Non-invasive diagnosis and biomarkers in alcohol-related liver disease. J Hepatol 2019; 70:273-283. [PMID: 30658728 DOI: 10.1016/j.jhep.2018.11.025] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 11/29/2018] [Accepted: 11/29/2018] [Indexed: 12/14/2022]
Abstract
Even though alcohol-related liver disease (ALD) is a major cause of severe liver disease worldwide, most patients with ALD are diagnosed at the decompensation stage. Liver biopsy is still considered the gold standard for establishing a definite diagnosis and assessing the fibrosis stage of ALD, but it is an invasive procedure, associated with significant morbidity. During the last decade, non-invasive tests have been developed to estimate the severity of liver fibrosis and steatosis. Measurement of liver stiffness by transient elastography has become the most commonly used non-invasive parameter to evaluate fibrosis. In ALD, transient elastography has been demonstrated to have an excellent performance to detect advanced fibrosis and cirrhosis. However, aspartate aminotransferase levels must be considered when interpreting liver stiffness cut-offs. Non-invasive biological tests have also been evaluated to assess liver fibrosis in ALD. The commercially available Enhanced Liver Fibrosis test and FibroTest have comparable performance for the diagnosis of advanced fibrosis in ALD, with studies suggesting that they are better than other biological tests (i.e. FIB-4 and APRI). Although ultrasound is still accepted as an initial screen for fatty liver diagnosis, new methods have recently been developed to detect steatosis. Magnetic resonance spectroscopy and magnetic resonance imaging techniques are highly accurate and reproducible, with superior sensitivities and specificities for detecting histological steatosis than ultrasound. However, low availability and high cost limit the use of magnetic resonance techniques in routine clinical practice. More recently, controlled attenuation parameter was developed as a novel tool to non-invasively assess liver steatosis; performed in combination with transient elastography, it was suggested to be superior to regular ultrasound for detecting steatosis and was shown to have acceptable diagnostic accuracy. New serum biomarkers are under investigation to non-invasively diagnose more severe forms of ALD and to predict prognosis of patients.
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Affiliation(s)
- Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.
| | - Sebastian Mueller
- Salem Medical Center and Center for Alcohol Research, University of Heidelberg, Zeppelinstraße 11-33, 69121 Heidelberg, Germany
| | - Gyongyi Szabo
- Department of Medicine, LRB-208, University of Massachusetts Medical School, 364 Plantation Street, Worcester, MA 01605, USA
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22
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Ferraioli G, Wong VWS, Castera L, Berzigotti A, Sporea I, Dietrich CF, Choi BI, Wilson SR, Kudo M, Barr RG. Liver Ultrasound Elastography: An Update to the World Federation for Ultrasound in Medicine and Biology Guidelines and Recommendations. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:2419-2440. [PMID: 30209008 DOI: 10.1016/j.ultrasmedbio.2018.07.008] [Citation(s) in RCA: 292] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/02/2018] [Accepted: 07/13/2018] [Indexed: 06/08/2023]
Abstract
The World Federation for Ultrasound in Medicine and Biology has produced these guidelines for the use of elastography techniques in liver diseases. For each available technique, the reproducibility, results and limitations are analyzed, and recommendations are given. This set of guidelines updates the first version, published in 2015. Since the prior guidelines, there have been several advances in technology. The recommendations are based on the international published literature, and the strength of each recommendation is judged according to the Oxford Centre for Evidence-Based Medicine. The document has a clinical perspective and is aimed at assessing the usefulness of elastography in the management of liver diseases.
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Affiliation(s)
- Giovanna Ferraioli
- Ultrasound Unit, Department of Clinical Sciences and Infectious Diseases, Fondazione IRCCS Policlinico San Matteo, School of Medicine, University of Pavia, Pavia, Italy
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong
| | - Laurent Castera
- Service d'Hepatologie, Hopital Beaujon, Clichy, Assistance Publique-Hopitaux de Paris, INSERM UMR 1149 CRI, Universite Denis Diderot Paris-VII, Paris, France
| | - Annalisa Berzigotti
- Swiss Liver Center, Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Switzerland
| | - Ioan Sporea
- Department of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Timisoara, Romania
| | | | - Byung Ihn Choi
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Stephanie R Wilson
- Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University School of Medicine, Osaka Sayama, Japan
| | - Richard G Barr
- Department of Radiology, Northeastern Ohio Medical University and Southwoods Imaging, Youngstown, Ohio, USA.
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23
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Nguyen-Khac E, Thiele M, Voican C, Nahon P, Moreno C, Boursier J, Mueller S, de Ledinghen V, Stärkel P, Gyune Kim S, Fernandez M, Madsen B, Naveau S, Krag A, Perlemuter G, Ziol M, Chatelain D, Diouf M. Non-invasive diagnosis of liver fibrosis in patients with alcohol-related liver disease by transient elastography: an individual patient data meta-analysis. Lancet Gastroenterol Hepatol 2018; 3:614-625. [DOI: 10.1016/s2468-1253(18)30124-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/02/2018] [Accepted: 04/06/2018] [Indexed: 02/08/2023]
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24
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EASL Clinical Practice Guidelines: Management of alcohol-related liver disease. J Hepatol 2018; 69:154-181. [PMID: 29628280 DOI: 10.1016/j.jhep.2018.03.018] [Citation(s) in RCA: 474] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 03/20/2018] [Indexed: 12/12/2022]
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25
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Ebrahimi H, Naderian M, Sohrabpour AA. New Concepts on Reversibility and Targeting of Liver Fibrosis; A Review Article. Middle East J Dig Dis 2018; 10:133-148. [PMID: 30186577 PMCID: PMC6119836 DOI: 10.15171/mejdd.2018.103] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 06/10/2018] [Indexed: 12/12/2022] Open
Abstract
Currently, liver fibrosis and its complications are regarded as critical health problems.
With the studies showing the reversible nature of liver fibrogenesis, scientists have focused
on understanding the underlying mechanism of this condition in order to develop new
therapeutic strategies. Although hepatic stellate cells are known as the primary cells
responsible for liver fibrogenesis, studies have shown contributing roles for other cells,
pathways, and molecules in the development of fibrosis depending on the etiology of
liver fibrosis. Hence, interventions could be directed in the proper way for each type of
liver diseases to better address this complication. There are two main approaches in clinical
reversion of liver fibrosis; eliminating the underlying insult and targeting the fibrosis
process, which have variable clinical importance in the treatment of this disease. In this
review, we present recent concepts in molecular pathways of liver fibrosis reversibility
and their clinical implications.
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Affiliation(s)
- Hedyeh Ebrahimi
- The Liver, Pancreatic, and Biliary Diseases Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Naderian
- The Liver, Pancreatic, and Biliary Diseases Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Ali Sohrabpour
- Associate Professor, The Liver, Pancreatic, and Biliary Diseases Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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26
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Stickel F, Datz C, Hampe J, Bataller R. Pathophysiology and Management of Alcoholic Liver Disease: Update 2016. Gut Liver 2017; 11:173-188. [PMID: 28274107 PMCID: PMC5347641 DOI: 10.5009/gnl16477] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 10/14/2016] [Indexed: 12/13/2022] Open
Abstract
Alcoholic liver disease (ALD) is a leading cause of cirrhosis, liver cancer, and acute and chronic liver failure and as such causes significant morbidity and mortality. While alcohol consumption is slightly decreasing in several European countries, it is rising in others and remains high in many countries around the world. The pathophysiology of ALD is still incompletely understood but relates largely to the direct toxic effects of alcohol and its main intermediate, acetaldehyde. Recently, novel putative mechanisms have been identified in systematic scans covering the entire human genome and raise new hypotheses on previously unknown pathways. The latter also identify host genetic risk factors for significant liver injury, which may help design prognostic risk scores. The diagnosis of ALD is relatively easy with a panel of well-evaluated tests and only rarely requires a liver biopsy. Treatment of ALD is difficult and grounded in abstinence as the pivotal therapeutic goal; once cirrhosis is established, treatment largely resembles that of other etiologies of advanced liver damage. Liver transplantation is a sound option for carefully selected patients with cirrhosis and alcoholic hepatitis because relapse rates are low and prognosis is comparable to other etiologies. Still, many countries are restrictive in allocating donor livers for ALD patients. Overall, few therapeutic options exist for severe ALD. However, there is good evidence of benefit for only corticosteroids in severe alcoholic hepatitis, while most other efforts are of limited efficacy. Considering the immense burden of ALD worldwide, efforts of medical professionals and industry partners to develop targeted therapies in ALF has been disappointingly low.
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Affiliation(s)
- Felix Stickel
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich,
Switzerland
| | - Christian Datz
- Department of Internal Medicine, Hospital Oberndorf, Teaching Hospital of the Paracelsus Private University of Salzburg, Oberndorf,
Austria
| | - Jochen Hampe
- Medical Department 1, University Hospital Dresden, TU Dresden, Dresden,
Germany
| | - Ramon Bataller
- Division of Gastroenterology and Hepatology, Department of Medicine and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC,
USA
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Gianni E, Forte P, Galli V, Razzolini G, Bardazzi G, Annese V. Prospective Evaluation of Liver Stiffness Using Transient Elastography in Alcoholic Patients Following Abstinence. Alcohol Alcohol 2016; 52:42-47. [PMID: 27542989 DOI: 10.1093/alcalc/agw053] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 06/30/2016] [Indexed: 12/28/2022] Open
Abstract
AIMS Fibroscan® is a non-invasive method to evaluate liver stiffness (LS), however, its accuracy in alcohol-related liver diseases (ALD) especially with respect to active or stopped alcohol drinking is largely unknown. We prospectively evaluated the LS changes in patients with ALD following alcohol withdrawal. METHODS Sixty-four patients were evaluated by FibroScan® and lab tests at baseline and after 4 weeks of abstinence. RESULTS At baseline, 21 patients (33%) had an abnormal LS (> 7 kPa) and 32 patients (50%) had abnormal liver function tests. More specifically, 3 and 11 subjects had a LS higher than 9.6 kPa and 12.5 kPa, respectively. The LS significantly declined in abstinent from 9.2 ± 10.1 (M±SD) at the baseline to 6.9 ± 6.1 kPa at 4 weeks (P = 0.03), respectively, while did not change significantly in drinkers. In addition, 80% of abstainers had a significant LS reduction (-2.6 ± 5.5 kPa), compared to drinkers (2.2 ± 3.6 kPa) (P = 0.004). After 6 months, 27 patients accepted a further evaluation: 22 abstinent and 5 relapsed to drink. At the final evaluation, only 4 out of 22 abstainers had still a LS higher than 7 kPa. CONCLUSIONS During active drinking LS is probably overestimated by Fibroscan® in ALD, since 1 month after abstinence it is dramatically reduced, especially in subjects with baseline values higher than 7 kPa. SHORT SUMMARY We prospectively evaluated liver stiffness by Fibroscan® in patients with alcohol-related liver disease at baseline and following abstinence. After 1 month of abstinence, the LS is dramatically reduced, especially when values are greater than 7 kPa and transaminase elevated at baseline.
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Affiliation(s)
- Elena Gianni
- Unit of Gastroenterology, University Hospital Careggi, Florence, Italy
| | - Paolo Forte
- Unit of Gastroenterology, University Hospital Careggi, Florence, Italy
| | | | - Giulia Razzolini
- Unit of Gastroenterology, University Hospital Careggi, Florence, Italy
| | | | - Vito Annese
- Unit of Gastroenterology, University Hospital Careggi, Florence, Italy
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28
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Stumpf S, Jaeger H, Graeter T, Oeztuerk S, Schmidberger J, Haenle MM, Kratzer W. Influence of age, sex, body mass index, alcohol, and smoking on shear wave velocity (p-SWE) of the pancreas. Abdom Radiol (NY) 2016; 41:1310-6. [PMID: 26880176 PMCID: PMC4912593 DOI: 10.1007/s00261-016-0661-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Purpose A variety of elastographic techniques have been developed to facilitate the non-invasive assessment of tissue properties. The goal of the study was to examine the influence of gender, age, BMI, alcohol consumption, and smoking in healthy volunteers. Methods Of the 263 participants who met all the study inclusion criteria, 234 had successful measurements. The examination was performed with the Siemens Acuson S3000 (Siemens Healthcare, Erlangen, Germany), using the 6C1 curved array transducer with the virtual touch tissue quantification (VTQ) method. Results The values determined with the curved array in the head of the pancreas were 1.44 ± 0.39 m/s for women and 1.19 ± 0.29 m/s for men; in the body, the results were 1.49 ± 0.37 m/s for women and 1.26 ± 0.30 m/s for men; in the tail, the corresponding values were 1.29 ± 0.36 m/s for women and 1.05 ± 0.30 m/s for men. Comparison of gender showed that men have significantly lower mean values than women. There were significantly higher values in all parts of the organ with the increasing age of the participants (p < 0.0001). For BMI, there was a significant correlation with the values only when considering the BMI in continuous form. Alcohol consumption and smoking did not have any significant effects. Conclusions ARFI-VTQ is qualified for use on pancreatic tissue. Further studies are required to examine the influence of other factors in larger populations.
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29
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Thiele M, Madsen BS, Krag A. Reply. Gastroenterology 2016; 150:1252-1253. [PMID: 27025670 DOI: 10.1053/j.gastro.2016.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Bjørn Stæhr Madsen
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
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30
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Mueller S, Englert S, Seitz HK, Badea RI, Erhardt A, Bozaari B, Beaugrand M, Lupșor-Platon M. Inflammation-adapted liver stiffness values for improved fibrosis staging in patients with hepatitis C virus and alcoholic liver disease. Liver Int 2015; 35:2514-21. [PMID: 26121926 DOI: 10.1111/liv.12904] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 06/20/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS It is well known that inflammation increases liver stiffness (LS) in patients with chronic hepatitis C (HCV) and alcoholic liver disease (ALD) independent of fibrosis stage, but no inflammation-adapted cut-off values have been settled so far. An early identification of rapid fibrosers, however, is essential to decide whom to treat first with the novel but expensive antiviral drugs. METHODS Liver stiffness, biopsy-proven fibrosis stages F0-F4 (METAVIR or Kleiner score) and routine laboratory parameters were studied in 2068 patients with HCV (n = 1391) and ALD (n = 677). RESULTS Among the routine parameters for liver damage, AST correlated best with LS (HCV: r = 0.54, P < 0.0001 and ALD: r = 0.34, P < 0.0001). In the absence of elevated transaminases, cut-off values were almost identical between HCV and ALD for F1-2, F3 and F4 (HCV: 5.1, 9.0 and 11.9 kPa vs ALD: 4.9, 8.1 and 10.5 kPa). These cut-off values increased exponentially as a function of median AST level. The impact of AST on LS was higher in lobular-pronounced ALD as compared to portal tract-localized HCV. Most notably, Cohen's weighted Kappa displayed an improved agreement of the novel AST-dependent cut-off values with histological fibrosis stage both for HCV (0.68 vs 0.65) and ALD (0.80 vs 0.76). CONCLUSIONS The novel AST-adapted cut-off values improve non-invasive fibrosis staging in HCV and ALD and may be also applied to other liver diseases. Especially in HCV, they could help to decide whom to treat first with the novel but expensive antiviral drugs.
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Affiliation(s)
- Sebastian Mueller
- Department of Internal Medicine, Salem Medical Center, Heidelberg, Germany.,Center for Alcohol Research, University of Heidelberg, Heidelberg, Germany
| | - Stefan Englert
- Institute of Medical Biometry und Informatics, University of Heidelberg, Heidelberg, Germany
| | - Helmut K Seitz
- Department of Internal Medicine, Salem Medical Center, Heidelberg, Germany.,Center for Alcohol Research, University of Heidelberg, Heidelberg, Germany
| | - Radu I Badea
- Department of Ultrasonography, University of Medicine and Pharmacy, Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor", Cluj-Napoca, Romania
| | - Andreas Erhardt
- Department of Internal Medicine II, Petrus Hospital, Wuppertal, Germany
| | - Bita Bozaari
- Department of Internal Medicine I, University of Tübingen, Tübingen, Germany
| | - Michel Beaugrand
- Liver Unit Jean Verdier Hospital, Université Paris 13, Paris, France
| | - Monica Lupșor-Platon
- Department of Ultrasonography, University of Medicine and Pharmacy, Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor", Cluj-Napoca, Romania
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31
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Lupsor-Platon M, Badea R. Noninvasive assessment of alcoholic liver disease using unidimensional transient elastography (Fibroscan ®). World J Gastroenterol 2015; 21:11914-11923. [PMID: 26576080 PMCID: PMC4641113 DOI: 10.3748/wjg.v21.i42.11914] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 07/27/2015] [Accepted: 09/14/2015] [Indexed: 02/06/2023] Open
Abstract
Unidimensional transient elastography (TE) is a noninvasive technique, which has been increasingly used in the assessment of diffuse liver diseases. This paper focuses on reviewing the existing data on the use of TE in the diagnosis of fibrosis and in monitoring disease progression in alcoholic liver disease, on the factors that may influence the result of fibrosis prediction, and last but not least, on its potential use in assessing the steatosis degree. Therefore, this field is far from being exhausted and deserves more attention. Further studies are required, on large groups of biopsied patients, in order to find answers to all the remaining questions in this field.
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32
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Diagnostic and Prognostic Values of Noninvasive Predictors of Portal Hypertension in Patients with Alcoholic Cirrhosis. PLoS One 2015. [PMID: 26196942 PMCID: PMC4511411 DOI: 10.1371/journal.pone.0133935] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Portal hypertension is a direct consequence of hepatic fibrosis, and several hepatic fibrosis markers have been evaluated as a noninvasive alternative to the detection of portal hypertension and esophageal varices. In the present study, we compared the diagnostic and prognostic values of the noninvasive fibrosis markers in patients with alcoholic cirrhosis. A total of 219 consecutive alcoholic cirrhosis patients were included. Biochemical scores and liver stiffness (LS) were compared with hepatic venous pressure gradient (HVPG). For the detection of clinically significant portal hypertension (CSPH; HVPG≥10 mmHg) in compensated patients, LS and LS–spleen diameter to platelet ratio score (LSPS) showed significantly better performance with area under the curves (AUCs) of 0.85 and 0.82, respectively, than aspartate aminotransferase-to-platelet ratio index, FIB-4, Forns’ index, Lok index, (platelet count)2/[monocyte fraction (%) × segmented neutrophil fraction (%)], and platelet count-to-spleen diameter ratio (all P<0.001). However, for the detection of high-risk varices, none of the non-invasive tests showed reliable performance (AUCs of all investigated tests < 0.70). During a median follow-up period of 42.6 months, 46 patients with decompensated cirrhosis died. Lok index (hazard ratio [HR], 1.13; 95% confidence interval [CI], 1.05–1.22; P = 0.001) and FIB-4 (HR, 1.06; 95% CI, 1.01–1.10; P = 0.009) were independently associated with all-cause death in decompensated patients. Among the tested noninvasive markers, only Lok index significantly improved discrimination function of MELD score in predicting overall survival. In conclusion, LS and LSPS most accurately predict CSPH in patients with compensated alcoholic cirrhosis. In the prediction of overall survival in decompensated patients, however, Lok index is an independent prognostic factor and improves the predictive performance of MELD score.
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33
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Legros L, Bardou-Jacquet E, Latournerie M, Guillygomarc'h A, Turlin B, Le Lan C, Désille Y, Lainé F, Moirand R, Brissot P, Deugnier Y, Guyader D. Non-invasive assessment of liver fibrosis in C282Y homozygous HFE hemochromatosis. Liver Int 2015; 35:1731-8. [PMID: 25495562 DOI: 10.1111/liv.12762] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 12/10/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS C282Y homozygotes with serum ferritin (SF) levels >1000 μg/L and/or increased serum transaminase levels are at risk of severe F3/F4 fibrosis. Current practical guidelines recommend liver biopsy in such individuals. This prospective observational cohort study aimed to evaluate non-invasive alternative means such as hyaluronic acid (HA) and transient elastography (TE) for the assessment of severe fibrosis in patients with SF >1000 μg/L or elevated transaminases. METHODS Between September 2005 and April 2013, 77 patients diagnosed C282Y homozygotes underwent a liver biopsy because of SF >1000 μg/L and/or increased transaminases according to current guidelines, with concomitant TE. All of them had clinical and biological evaluation, including HA measurement in 52 cases. RESULTS A total of 19.5% of patients had F3-F4 severe fibrosis. HA was higher in patients with severe fibrosis, but did not accurately predict severe fibrosis. TE was significantly higher in patients with severe fibrosis (17.2 vs. 4.9 kPa; P < 0.05) and was able to accurately predict fibrosis stage in 47/61 (77%) patients with valid measurement using a lower threshold of 6.4 kPa and an upper threshold of 13.9 kPa. Efficient assessment of severe fibrosis was not possible in patients with intermediate TE values. CONCLUSION An algorithm that successively employed SF and TE can accurately classify severe fibrosis in 61% of patients, restricting the need for liver biopsy to the 39% of patients with intermediate or unvalid TE values. This algorithm should be validated in independent cohorts before extended use.
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Affiliation(s)
- Ludivine Legros
- Liver disease unit and National reference center for rare iron overload diseases of genetic origin, CHU de Rennes, Rennes, France.,Inserm UMR991, CHU de Rennes, Rennes, France
| | - Edouard Bardou-Jacquet
- Liver disease unit and National reference center for rare iron overload diseases of genetic origin, CHU de Rennes, Rennes, France.,Inserm UMR991, CHU de Rennes, Rennes, France.,University of Rennes 1, CHU de Rennes, Rennes, France
| | - Marianne Latournerie
- Liver disease unit and National reference center for rare iron overload diseases of genetic origin, CHU de Rennes, Rennes, France
| | - Anne Guillygomarc'h
- Liver disease unit and National reference center for rare iron overload diseases of genetic origin, CHU de Rennes, Rennes, France
| | - Bruno Turlin
- University of Rennes 1, CHU de Rennes, Rennes, France.,Department of Pathology, CHU de Rennes, Rennes, France
| | - Caroline Le Lan
- Liver disease unit and National reference center for rare iron overload diseases of genetic origin, CHU de Rennes, Rennes, France
| | - Yoann Désille
- Liver disease unit and National reference center for rare iron overload diseases of genetic origin, CHU de Rennes, Rennes, France
| | - Fabrice Lainé
- Clinical Investigation Unit, Inserm CIC0203, CHU de Rennes, Rennes, France
| | - Romain Moirand
- Liver disease unit and National reference center for rare iron overload diseases of genetic origin, CHU de Rennes, Rennes, France.,Inserm UMR991, CHU de Rennes, Rennes, France.,University of Rennes 1, CHU de Rennes, Rennes, France
| | - Pierre Brissot
- Liver disease unit and National reference center for rare iron overload diseases of genetic origin, CHU de Rennes, Rennes, France.,Inserm UMR991, CHU de Rennes, Rennes, France.,University of Rennes 1, CHU de Rennes, Rennes, France
| | - Yves Deugnier
- Liver disease unit and National reference center for rare iron overload diseases of genetic origin, CHU de Rennes, Rennes, France.,University of Rennes 1, CHU de Rennes, Rennes, France
| | - Dominique Guyader
- Liver disease unit and National reference center for rare iron overload diseases of genetic origin, CHU de Rennes, Rennes, France.,University of Rennes 1, CHU de Rennes, Rennes, France
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Mathurin P, Bataller R. Trends in the management and burden of alcoholic liver disease. J Hepatol 2015; 62:S38-46. [PMID: 25920088 PMCID: PMC5013530 DOI: 10.1016/j.jhep.2015.03.006] [Citation(s) in RCA: 209] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 03/05/2015] [Accepted: 03/05/2015] [Indexed: 12/16/2022]
Abstract
Alcoholic liver disease (ALD) is the most prevalent cause of advanced liver disease in Europe and is the leading cause of death among adults with excessive alcohol consumption. There is a dose-response relationship between the amount of alcohol consumed and the risk of ALD. The relative risk of cirrhosis increases in subjects who consume more than 25 g/day. The burden of alcohol-attributable liver cirrhosis and liver cancer is high and is entirely preventable. Health agencies should develop population-based policies to reduce the prevalence of harmful and/or hazardous alcohol consumption and foster research in this field to provide new diagnostic and therapeutic tools. Disease progression of patients with ALD is heavily influenced by both genetic and environmental factors. Non-invasive methods for the diagnosis of fibrosis have opened new perspectives in the early detection of advanced ALD in asymptomatic patients. Alcoholic hepatitis, the most severe form of ALD, carries a high short-term mortality (around 30-50% at 3 months). Corticosteroids improve short-term survival in patients with severe alcoholic hepatitis but duration of therapy should be adapted to early response. Liver transplantation is the best option for patients with severe liver dysfunction. However, alcohol relapse after transplantation remains a critical issue and drinking habits of transplanted patients need to be routinely screened.
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Affiliation(s)
- Philippe Mathurin
- Service Maladie de l'Appareil Digestif and INSERM U995, Univ Lille 2, CHRU Lille, France.
| | - Ramon Bataller
- Departments of Medicine and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Tapper EB, Castera L, Afdhal NH. FibroScan (vibration-controlled transient elastography): where does it stand in the United States practice. Clin Gastroenterol Hepatol 2015; 13:27-36. [PMID: 24909907 DOI: 10.1016/j.cgh.2014.04.039] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 04/01/2014] [Accepted: 04/01/2014] [Indexed: 02/07/2023]
Abstract
With widespread screening and increasingly effective treatments for patients with viral hepatitis as well as the increasing prevalence of nonalcoholic fatty liver disease, the population presenting to the care of gastroenterologists and hepatologists is certain to increase. Assessment of advanced liver disease is traditionally invasive and expensive. Vibration-controlled transient elastography, commonly delivered by the FibroScan device, is an option recently approved by the Food and Drug Administration for the noninvasive assessment of liver disease at the point of care. Herein, we review the promise and pitfalls of vibration-controlled transient elastography with the aim of providing clinicians with a framework to interpret its results and apply this technology to the changing needs of our patients.
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Affiliation(s)
- Elliot B Tapper
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Laurent Castera
- Department of Hepatology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, INSERM U773, University of Paris-VII, Clichy, France
| | - Nezam H Afdhal
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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Vonghia L, Michielsen P, Dom G, Francque S. Diagnostic challenges in alcohol use disorder and alcoholic liver disease. World J Gastroenterol 2014; 20:8024-8032. [PMID: 25009373 PMCID: PMC4081672 DOI: 10.3748/wjg.v20.i25.8024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/07/2014] [Accepted: 02/17/2014] [Indexed: 02/06/2023] Open
Abstract
Alcohol use disorders represent a heterogeneous spectrum of clinical manifestations that have been defined by the Diagnostic and Statistical Manual of Mental Disorders-5. Excessive alcohol intake can lead to damage of various organs, including the liver. Alcoholic liver disease includes different injuries ranging from steatosis to cirrhosis and implicates a diagnostic assessment of the liver disease and of its possible complications. There is growing interest in the possible different tools for assessing previous alcohol consumption and for establishing the severity of liver injury, especially by non-invasive methods.
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Morishita N, Hiramatsu N, Oze T, Harada N, Yamada R, Miyazaki M, Yakushijin T, Miyagi T, Yoshida Y, Tatsumi T, Kanto T, Takehara T. Liver stiffness measurement by acoustic radiation force impulse is useful in predicting the presence of esophageal varices or high-risk esophageal varices among patients with HCV-related cirrhosis. J Gastroenterol 2014; 49:1175-82. [PMID: 24005957 DOI: 10.1007/s00535-013-0877-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 08/23/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Screening and periodic surveillance for esophageal varices (EVs) by esophagogastroduodenoscopy (EGD) are recommended for cirrhotic patients. We investigated non-invasive liver stiffness measurement using acoustic radiation force impulse (ARFI) for the diagnosis of EV presence and high-risk EVs among patients with HCV-related cirrhosis. METHODS Among 181 consecutive patients with HCV-related cirrhosis, we studied 135 patients who had received EGD and ARFI. Serum fibrosis markers [platelet count, FIB-4, and aspartate aminotransferase-to-platelet ratio index (APRI)] were measured in a training set of 92 patients and compared with ARFI in the diagnostic performance for EV presence and high-risk EVs. Furthermore, the obtained optimal cutoff values of ARFI were prospectively examined in a validation set of 43 patients. RESULTS In the training set, the ARFI value increased with the EV grade (p < 0.001). The ARFI value for high-risk EVs was significantly higher than that for low-risk EVs (p < 0.001). AUROC values for diagnosis of EV presence and high-risk EVs by ARFI were 0.890 and 0.868, which had the highest diagnostic performance among factors including serum fibrosis markers. The optimal cutoff value of ARFI for EV presence was 2.05 m/s with good sensitivity (83%), specificity (76%), PPV (78%), and NPV (81%), and that for high-risk EVs was 2.39 m/s with good sensitivity (81%), specificity (82%), PPV (69%), and NPV (89%). These cutoff values obtained in the training cohort also showed excellent performance in the validation set. CONCLUSIONS Liver stiffness measurement by ARFI is useful in predicting EV presence or high-risk EVs among patients with HCV-related cirrhosis.
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Affiliation(s)
- Naoki Morishita
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan,
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Abstract
Alcoholism results in about 2.5 million deaths annually worldwide, representing 4% of all mortality. Although alcoholism is associated with more than 60 diseases, most mortality from alcoholism results from alcoholic liver disease (ALD). ALD includes alcoholic steatosis, alcoholic hepatitis, and alcoholic cirrhosis, in order of increasing severity. Important scoring systems of ALD severity include: Child-Pugh, a semi-quantitative scoring system useful to roughly characterize clinical severity; model for end-stage liver disease, a quantitative, objective scoring system used for prognostication and prioritization for liver transplantation; and discriminant function, used to determine whether to administer corticosteroids for alcoholic hepatitis. Abstinence is the cornerstone of ALD therapy. Psychotherapies, including twelve-step facilitation therapy, cognitive-behavioral therapy, and motivational enhancement therapy, help support abstinence. Disulfiram decreases alcohol consumption by causing unpleasant sensations after drinking alcohol from accumulation of acetaldehyde in serum, but disulfiram can be hepatotoxic. Adjunctive pharmacotherapies to reduce alcohol consumption include naltrexone, acamprosate, and baclofen. Nutritional therapy helps reverse muscle wasting, weight loss, vitamin deficiencies, and trace element deficiencies associated with ALD. Although reduced protein intake was previously recommended for advanced ALD to prevent hepatic encephalopathy, a diet containing 1.2-1.5 g of protein/kg per day is currently recommended to prevent muscle wasting. Corticosteroids are first-line therapy for severe alcoholic hepatitis (discriminant function ≥ 32), but proof of their efficacy in decreasing mortality remains elusive. Pentoxifylline is an alternative therapy. Complications of advanced ALD include ascites, spontaneous bacterial peritonitis, esophageal variceal bleeding, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, and portopulmonary hypertension. Alcoholic cirrhotics have increased risk of developing hepatomas. Liver transplantation is the ultimate therapy for severe ALD, but generally requires 6 mo of proven abstinence for eligibility. Alcoholic cirrhotics who maintain abstinence generally have a relatively favorable prognosis after liver transplantation.
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Utilisation de l’élastométrie hépatique comme outil de dépistage de la fibrose hépatique dans un service d’addictologie. Presse Med 2014; 43:e17-31. [DOI: 10.1016/j.lpm.2013.07.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 07/09/2013] [Accepted: 07/15/2013] [Indexed: 12/11/2022] Open
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Mueller S. Noninvasive assessment of patients with alcoholic liver disease. Clin Liver Dis (Hoboken) 2013; 2:68-71. [PMID: 30992827 PMCID: PMC6448623 DOI: 10.1002/cld.186] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Sebastian Mueller
- Department of Internal Medicine, Salem Medical Center and Center for Alcohol Research, University of Heidelberg, Heidelberg, Germany
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Bardou-Jacquet E, Legros L, Soro D, Latournerie M, Guillygomarc’h A, Lan CL, Brissot P, Guyader D, Moirand R. Effect of alcohol consumption on liver stiffness measured by transient elastography. World J Gastroenterol 2013; 19:516-522. [PMID: 23382630 PMCID: PMC3558575 DOI: 10.3748/wjg.v19.i4.516] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 01/10/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the evolution of transient elastography (TE) in patients with alcoholic liver disease according to alcohol cessation or continuation.
METHODS: We retrospectively selected in our local database all patients who had two TE between June 2005 and November 2010 with chronic alcohol excessive consumption and excluded those with associated cause of liver disease. TE was performed at least one week apart by senior operator. TE examinations with less than ten successful measures or with an interquartile range above 30% were excluded. We retrospectively reviewed file of all patients to include only patient followed up by trained addictologist and for which definite information on alcohol consumption was available. Concomitant biological parameters [aspartate amino transferase (AST), alanine amino transferase and gamma-glutamyl transpeptidase (GGT)] within 4 wk of initial and final TE were recorded. Putative fibrosis score according to initial and final TE were determined with available cut-off for alcoholic liver disease and hepatitis C. Initial and final putative fibrosis score were compared according to alcohol consumption during follow-up.
RESULTS: During the study period 572 patients had TE examination for alcoholic liver disease and 79 of them had at least two examinations. Thirty-seven patients met our criteria with a median follow-up of 32.5 wk. At the end of the study, 13 (35%) were abstinent, and 24 (65%) relapsers. Eight patients had liver biopsy during follow-up. TE decreased significantly during follow-up in 85% of abstinent patients [median (range): -4.9 (-6.1,-1.9)], leading to a modification of the putative fibrosis stage in 28%-71% of patient according to different cut-off value. In relapsers TE increased in 45% and decreased in 54% of patient. There was no statistical difference between initial and final TE in relapsers. In the overall population, using 22.6 kPa as cut-off for cirrhosis, 4 patients had cirrhosis at initial TE and 3 patients had cirrhosis at final TE. Using 19.5 kPa as cut-off for cirrhosis, 7 patients had cirrhosis at initial TE and 5 patients had cirrhosis at final TE. Using 12.5 kPa as cut-off for cirrhosis, 16 patients had cirrhosis at initial TE and 15 patients had cirrhosis at final TE. Evolution of biological data was in accordance with the relapse or abstinent status: abstinence ratio (duration of abstinence/duration follow-up) was correlated with AST ratio (r = -0.465, P = 0.007) and GGT ratio (r = -0.662, P < 0.0001). GGT was correlated with initial (r = 0.488, P = 0.002) and final TE (r = 0.49, P < 0.005). Final TE was correlated with AST (r = 0.362, P < 0.05). Correlation between TE ratio and AST ratio (r = 0.44, P = 0.01) revealed that TE varied proportionally to AST for all patients irrespective of their alcohol status. The same relationship was observed between TE ratio and GGT ratio (r = 0.65, P < 0.0001). Evolution of TE was significantly correlated with the ratio of time of abstinence to observation time (r = -0.387, P = 0.016) and the evolution of liver enzymes.
CONCLUSION: TE significantly decreased with abstinence. Results of TE in alcoholic liver disease cannot be interpreted without taking into account alcohol consumption and liver enzymes.
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Bensamoun SF, Leclerc GE, Debernard L, Cheng X, Robert L, Charleux F, Rhein C, Latrive JP. Cutoff values for alcoholic liver fibrosis using magnetic resonance elastography technique. Alcohol Clin Exp Res 2012; 37:811-7. [PMID: 23216352 DOI: 10.1111/acer.12025] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 09/04/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Due to the lack of cutoff values validated for specific liver diseases, the purpose of this study was to set up specific magnetic resonance elastography (MRE) cutoff values for asymptomatic liver fibrosis in alcoholic patients. METHODS Ninety patients underwent 3 clinical exams. The liver stiffness was measured locally with the Fibroscan, and globally through cartographies of shear modulus generated with MRE. The Fibroscan method was chosen as the gold standard to classify the fibrosis. The liver score was also obtained with the Fibrometer A, and the diagnostic performance of the methods was analyzed with receiver-operating characteristic (ROC) curves and cutoff values were calculated. RESULTS Spearman correlation and area under the ROC curve revealed that MRE is a better diagnostic method than the Fibrometer A, to identify various levels of fibrosis. The results showed that the Fibrometer A was adapted for severe fibrosis. The MRE cutoff values are F1:2.20 kPa, F2:2.57 kPa, F3:3.31 kPa, and F4:4 kPa and were not influenced by the glutamic oxaloacetic transaminase level. By using the ultrasound cutoff values attributed for alcoholism, 66% of patients had a similar liver fibrosis diagnosis as the MRE cutoffs. However, both imaging techniques did not provide the same distribution for minor fibrosis. CONCLUSIONS None of the imaging techniques (Fibroscan, MRE) could replace the gold standard of the biopsy. However, due to the risk and the unnecessary procedure for the present recruited alcoholic patients, the Fibroscan method was chosen as the reference. Since MRE is currently being used as a clinical exam, the present MRE cutoffs could aid clinicians with their diagnosis of liver fibrosis for alcoholism disease.
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Affiliation(s)
- Sabine F Bensamoun
- Biomechanics and Bioengineering Laboratory, UMR CNRS 7338, UTC, Compiègne, France.
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Leclercq S, Cani PD, Neyrinck AM, Stärkel P, Jamar F, Mikolajczak M, Delzenne NM, de Timary P. Role of intestinal permeability and inflammation in the biological and behavioral control of alcohol-dependent subjects. Brain Behav Immun 2012; 26:911-8. [PMID: 22521198 DOI: 10.1016/j.bbi.2012.04.001] [Citation(s) in RCA: 207] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 03/16/2012] [Accepted: 04/02/2012] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND AIMS Mood and cognition alterations play a role in the motivation for alcohol-drinking. Lipopolysaccharides are known to stimulate inflammation that was shown to induce mood and cognitive changes in rodents and humans. Enhanced intestinal permeability and elevated blood LPS characterize alcohol-dependent mice. However, no data have been published in non-cirrhotic humans. Our first goal was to test whether intestinal permeability, blood LPS and cytokines are increased in non-cirrhotic alcohol-dependent subjects before withdrawal and if they recover after withdrawal. Our second goal was to test correlations between these biochemical and the behavioral variables to explore the possibility of a role for a gut-brain interaction in the development of alcohol-dependence. METHODS Forty alcohol-dependent-subjects hospitalized for a 3-week detoxification program were tested at onset (T1) and end (T2) of withdrawal and compared for biological and behavioral markers with 16 healthy subjects. Participants were assessed for gut permeability, systemic inflammation (LPS, TNFα, IL-6, IL-10, hsCRP) and for depression, anxiety, alcohol-craving and selective attention. RESULTS Intestinal permeability and LPS were largely increased in alcohol-dependent subjects at T1 but recovered completely at T2. A low-grade inflammation was observed at T1 that partially decreased during withdrawal. At T1, pro-inflammatory cytokines were positively correlated with craving. At T2 however, the anti-inflammatory cytokine IL-10 was negatively correlated with depression, anxiety and craving. CONCLUSION Leaky gut and inflammation were observed in non-cirrhotic alcohol-dependent subjects and inflammation was correlated to depression and alcohol-craving. This suggests that the gut-brain axis may play a role in the pathogenesis of alcohol-dependence.
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Affiliation(s)
- Sophie Leclercq
- Department of Adult Psychiatry and Institute of Neurosciences, Université catholique de Louvain, Brussels, Belgium
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EASL clinical practical guidelines: management of alcoholic liver disease. J Hepatol 2012; 57:399-420. [PMID: 22633836 DOI: 10.1016/j.jhep.2012.04.004] [Citation(s) in RCA: 431] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 04/04/2012] [Indexed: 12/12/2022]
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Trabut JB, Thépot V, Nalpas B, Lavielle B, Cosconea S, Corouge M, Vallet-Pichard A, Fontaine H, Mallet V, Sogni P, Pol S. Rapid decline of liver stiffness following alcohol withdrawal in heavy drinkers. Alcohol Clin Exp Res 2012; 36:1407-11. [PMID: 22404692 DOI: 10.1111/j.1530-0277.2012.01737.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 12/05/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Measurement of liver stiffness (LS) using real-time elastography appears as a promising tool to evaluate the severity of chronic liver diseases. Previous studies in patients with alcoholic liver disease have suggested that fibrosis was the only histological parameter to influence LS. To challenge this hypothesis, we have prospectively tested the short-term impact of alcohol withdrawal on LS value. METHODS Patients hospitalized for alcohol withdrawal in our Liver and Addiction Unit between 2007 and 2010 had an LS determination at entry (D0) and 7 days after alcohol withdrawal (D7). LS value was given as the median of 10 measurements performed with a FibroScan(®) device. For a given patient, variation of LS was considered as significant when the comparison of the 10 measurements at D0 and at D7 yielded a p-value under 0.05 (Wilcoxon test). RESULTS One hundred and thirty-seven patients were included in the study (median alcohol consumption: 150 g/d; hepatitis C: n = 21 [15.6%]). Considering all patients, median LS value decreased from 7.2 to 6.1 kPa between D0 and D7 (p = 0.00001, paired Wilcoxon test). LS decreased significantly in 62 patients (45.3%), and there was a reduction in the estimated stage of fibrosis in 32 (23.3%). LS increased significantly in 16 patients (11.7%). Subgroup analyses revealed that the decrease in LS was still significant in patients with or without hepatitis C infection, and aspartate transaminase level below or above 100 UI/l. CONCLUSIONS LS decreases significantly in nearly half of heavy drinkers after only 7 days of abstinence. This result strongly suggests that nonfibrotic lesions (such as the presence of alcoholic hepatitis) may influence LS. From a practical point of view, it also shows that variation of alcohol consumption must be taken into account for the interpretation of LS value.
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Affiliation(s)
- Jean-Baptiste Trabut
- Unité d'Hépatologie et d'Addictologie, Hôpital Cochin, Assitance Publique - Hôpitaux de Paris, France.
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