Cardiovascular disease in cirrhosis--a point-prevalence study in relation to glucose tolerance

Characterization and stratification of risk factors of stroke in people living with HIV: A theory-informed systematic review

BACKGROUND

Identification and stratification of risk factors for stroke among individuals living with HIV (PLWH) will facilitate primary prevention and prognostication, as well as strategies aimed at optimizing neurorehabilitation. This review sought to characterize and stratify the risk factors associated with stroke in PLWH.

METHODS

The review was structured in accordance with the preferred items for reporting systematic reviews and meta-analysis (PRISMA) checklist. The epidemiological triangle, Bradford criteria, and Rothman causality model further informed the review. The review outcomes encompassed cardiovascular factors, HIV-related factors, and personal and extrinsic factors associated with stroke in PLWH. We conducted searches in PubMed, Scopus, Medline, Web of Science, Cumulative Index for Nursing and Allied Health Literature, and African Journal (SABINET). Data screening and extraction were independently performed utilizing predefined eligibility criteria and a data-extraction template. Narrative synthesis and risk stratification were employed to analyze the results.

RESULTS

Thirty studies (22 cohorts and eight case-control) with a sample size of 353,995 participants were included in this review. The mean age of the participants was 45.1 ± 10.7 years. The majority of the participants (72.4%) were male. Risk factors for stroke in PLWH include cardiovascular factors (advanced age, tobacco use, hypertension, diabetes, atrial fibrillation, etc.), HIV-related factors (high viral load and low nadir CD4 count), personal factors (advanced age and female sex), and comorbidities (hepatitis C virus infection, chronic kidney disease, coronary artery disease, and liver fibrosis or cirrhosis). Diabetes, atrial fibrillation, smoking habits, hypertension, age, and viral load demonstrated a high likelihood of association with stroke in PLWH and should be prioritized when constructing clinical prediction algorithms for HIV-related stroke.

CONCLUSIONS

The most important factors were hypertension and chronic kidney disease, followed by smoking, dyslipidemia, diabetes, HCV, HBV, CD4 count, use of ART, TB, and substance use (cocaine). The least important factors were age, sex, ethnicity, obesity, alcohol use, ART duration, and viral load. The predictive significance of these factors is still evolving, given the average moderate certainty of evidence. Predictive and preventative models should target factors with a high causality index and low investigative costs.

TRIAL REGISTRATION

The review is part of a larger review registered with the PROSPERO (ID: CRD42024524494).

Risk of Coronary Artery Disease in Patients with Liver Cirrhosis: A Systematic Review and Meta-analysis

BACKGROUND AND AIMS

Coronary artery disease (CAD) is increasingly observed in patients with liver cirrhosis. However, data on the incidence and prevalence of CAD in cirrhotic patients are heterogeneous, and the association remains uncertain. In this study, we aimed to conduct a systematic review and meta-analysis to address these issues.

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched. Incidence, prevalence, and factors associated with CAD were pooled using a random-effects model. Risk ratio (RR) and odds ratio (OR), with their 95% confidence interval (CI), were calculated to evaluate differences in CAD incidence and prevalence between patients with and without liver cirrhosis.

RESULTS

Fifty-one studies were included. The pooled incidences of CAD, acute coronary syndromes, and myocardial infarction (MI) were 2.28%, 2.02%, and 1.80%, respectively. Liver cirrhosis was not significantly associated with CAD incidence (RR = 0.77; 95% CI = 0.46-1.28) or MI (RR = 0.87; 95% CI = 0.49-1.57). The pooled prevalence of CAD, acute coronary syndromes, and MI was 18.87%, 12.54%, and 6.12%, respectively. Liver cirrhosis was not significantly associated with CAD prevalence (OR = 1.29; 95% CI = 0.83-2.01) or MI (OR = 0.58; 95% CI = 0.28-1.22). Non-alcoholic steatohepatitis, hepatitis C virus, advanced age, male sex, diabetes mellitus, hypertension, hyperlipidemia, smoking history, and family history of CAD were significantly associated with CAD in cirrhotic patients.

CONCLUSIONS

CAD is common in cirrhotic patients, but cirrhosis itself may not be associated with an increased CAD risk. In addition to traditional risk factors, non-alcoholic steatohepatitis and hepatitis C virus infection are also associated with CAD presence in cirrhotic patients.

Ischemic Heart Disease in Chronic Hepatitis B: A Danish Nationwide Cohort Study

Objective

Data on the risk of ischemic heart disease (IHD) in patients with chronic hepatitis B virus (CHB) are conflicting. Our objective was to address the rate of IHD in patients with CHB compared with individuals without CHB (control-persons) from the general population.

Study Design and Setting

We conducted a cohort study of prospectively obtained data from Danish nationwide registries. We produced cumulative incidence curves and calculated the unadjusted incidence rate ratio (IRR) of IHD in persons with and without CHB. The adjusted association between having CHB and developing IHD was examined using a cause-specific Cox regression model.

Results

In total, 6472 persons with CHB and 62,251 age- and sex-matched individuals from the general population were followed for 48,840 and 567,456 person-years, respectively, during which 103 (1,59%) with CHB and 1058 (1,70%) control-persons developed IHD. The crude IRR was 1.13 (95% CI: 0.91–1.39). CHB did not have a statistically significant effect on the rate of IHD after adjusting for several confounding factors (adjusted hazard ratio: 0.96, 95% CI: 0.76–1.21).

Conclusion

In this nationwide cohort study, we did not find any difference between rate of IHD in persons with CHB in comparison with the general population.

Metformin use and cirrhotic decompensation in patients with type 2 diabetes and liver cirrhosis

AIMS

To compare the risks of all-cause mortality, hepatic outcomes, major adverse cardiovascular events between metformin users and nonusers for patients with diabetes and cirrhosis.

METHODS

From the Taiwan's National Health Insurance Research Database, we selected propensity-score matched metformin users and nonusers from the cohorts of type 2 diabetes mellitus with compensated (n = 26 164) or decompensated liver cirrhosis (n = 15 056) between 1 January 2000 and 31 December 2009, and followed them until 31 December 2010. Cox proportional hazards models with robust sandwich standard error estimates were used to assess risk of investigated outcomes for metformin users.

RESULTS

The incidence rates of mortality during follow-up were 3.8 and 3.3 per 100 patient-years (adjusted hazard ratio [aHR] 1.13, 95% confidence interval 1.01-1.25) for metformin users and nonusers, respectively. The incidence rates of cirrhotic decompensation during follow-up were 5.9 and 4.9 per 100 patient-years (aHR 1.15, 95% confidence interval 1.04-1.27) for metformin users and nonusers. The risk of death (P for trend <.01) and cirrhotic decompensation (P for trend <.0001) associated with metformin use was significant for those taking metformin for >40 defined daily doses in 90 days or >1000 mg/d. The outcomes of metformin use vs nonuse for type 2 diabetes mellitus with decompensated liver cirrhosis were not statistically different, except that metformin users had higher risk of mortality (aHR 1.15).

CONCLUSION

Metformin use was associated with higher risks of mortality and cirrhotic decompensation in patients with compensated liver cirrhosis. Prospective studies are required to confirm our results.

Is insulin the preferred treatment in persons with type 2 diabetes and liver cirrhosis?

BACKGROUND

Insulin is highly recommended for diabetes management in persons with liver cirrhosis. However, few studies have evaluated its long-term effects in these persons. We conducted this study to compare the risks of mortality, liver-related complications, and cardiovascular events in persons with type 2 diabetes mellitus (T2DM) and compensated liver cirrhosis.

METHODS

From January 1, 2000, to December 31, 2012, we selected 2047 insulin users and 4094 propensity score-matched nonusers from Taiwan's National Health Insurance Research Database. Cox proportional hazard models were used to assess the risks of outcomes.

RESULTS

The mean follow-up time was 5.84 years. The death rate during the follow-up period was 5.28 and 4.07 per 100 person-years for insulin users and nonusers, respectively. In insulin users, the hazard ratios and 95% confidence intervals (CIs) of all-cause mortality, hepatocellular carcinoma, decompensated cirrhosis, hepatic failure, major cardiovascular events, and hypoglycemia were 1.31 (1.18-1.45), 1.18 (1.05-1.34), 1.53 (1.35-1.72), 1.26 (1.42-1.86), 1.41 (1.23-1.62), and 3.33 (2.45-4.53), respectively.

CONCLUSIONS

This retrospective cohort study indicated that among persons with T2DM and compensated liver cirrhosis, insulin users were associated with higher risks of death, liver-related complications, cardiovascular events, and hypoglycemia compared with insulin nonusers.

Comorbid hepatitis C does not modulate prevalence or severity of diabetic retinopathy

Purpose

There are limited and conflicting data regarding the impact of comorbid hepatitis C virus (HCV) infection on diabetic retinopathy (DR). This study sought to compare the prevalence and severity of DR among patients with diabetes mellitus (DM) with and without HCV.

Patients and methods

This was a retrospective, case–control study of patients with DM comparing 120 patients with comorbid HCV and 120 age-matched controls. DR prevalence and several measures of severity were compared between groups. Subgroup analyses were performed among HCV patients with cirrhosis, comorbid HIV, or history of treatment with interferon. Statistical analysis for between-group comparisons utilized both univariate and multivariate analyses.

Results

Cases and controls exhibited similar baseline characteristics: average hemoglobin A1c, DM duration, and age (p>0.05). Among cases and controls, there was no difference in DR prevalence (35.8% versus 42.5%, respectively, p=0.29) or severity (p>0.05). Within the HCV subgroup, DR severity was reduced in patients with HIV or cirrhosis. However, multivariate analysis identified reduced DM duration in these subgroups as the primary contributor to lesser DR severity, rather than HIV or cirrhosis.

Conclusion

In this study, comorbid HCV did not modulate the prevalence or severity of DR among patients with DM. These findings may inform clinical monitoring among HCV-positive diabetics undergoing ophthalmic evaluation.

Prevalence of diabetes in liver cirrhosis: A systematic review and meta-analysis

An association between diabetes mellitus (DM) and liver cirrhosis is well-known, but estimates of the prevalence of DM in patients with liver cirrhosis vary widely. A systematic review was undertaken to determine the prevalence of DM in adult patients with liver cirrhosis. The Medline, EMBASE, and Cochrane Library databases were searched for peer-reviewed studies published in English (1979-2017) that investigated the prevalence of diabetes in adult patients with cirrhosis. Pooled estimates of prevalence of DM were determined for all eligible patients and according to aetiology and severity of liver disease. Fifty-eight studies satisfied criteria for inclusion, with 9705 patients included in the pooled prevalence analysis. The overall prevalence of DM was 31%. The prevalence of DM was highest in patients with nonalcoholic fatty liver disease (56%), cryptogenic (51%), hepatitis C (32%), or alcoholic (27%) cirrhosis. For assessing prevalence of DM as a function of severity of liver disease, evaluable data were available only for hepatitis C and hepatitis B cirrhosis. DM may be more prevalent in cirrhosis than previously thought. This has implications for prognosis and treatment in these patients.

Viral infection and atherosclerosis

Several risk factors have been described for the pathogenesis of atherosclerosis. Infectious diseases are suggested to be a causative factor, and some viruses have been studied for their relation with atherosclerotic diseases. Studies report two hypotheses, direct and indirect effects, for the role of viral infections in atherogenesis. Viruses are able to initiate atherosclerosis by two different pathways. They can exert their direct effects on atherogenesis by infecting vascular cells and then inducing inflammation in the endothelium and smooth muscle cells. Alternatively, they can also apply indirect effects by infecting non-vascular cells and inducing systemic inflammation. In this review, we consider the available data about the effects and correlations of DNA and RNA viruses on atherosclerosis.

Chronic Hepatitis C Association with Diabetes Mellitus and Cardiovascular Risk in the Era of DAA Therapy

Patients with chronic hepatitis C have both higher prevalence of diabetes mellitus type 2 (T2DM) and increased cardiovascular risk compared to never infected people. Sustained viral response (SVR) achievement led to decreasing incidence and prevalence of T2DM during the interferon era of HCV treatment. Currently, direct-acting antiviral drugs (DAA) are the gold standard for treating HCV infection, while yielding SVR in nearly all patients. In chronic HCV patients with T2DM (prediabetes most likely too), DAA therapy is associated with both better fasting glucose and glycated hemoglobin (HbA1C) controls; thus reducing pharmacotherapy in a certain part of patients is possible. Papers mentioned in the review confirmed DAA role in both total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) increase. This alteration was accompanied by an increase in high-density lipoprotein cholesterol (HDL-C) and a decrease in triglycerides (TG) verified by most of the studies. However, the clinical significance of lipoprotein alterations caused by DAA therapy has not been explained yet. Moreover, DAA treatment of chronic hepatitis C improves hypertension control and atherosclerotic plaques. It is very likely that DAA therapeutic regimens will decrease both T2DM prevalence and cardiovascular risk in chronic hepatitis C patients; further research, however, is needed.

Hepatitis B virus infection and decreased risk of stroke: a meta-analysis

Several studies have reported that hepatitis B virus (HBV) infection may decrease the risk of stroke. However, its association is controversial. Thus, we conducted a systematic review and meta-analysis to investigate the relationship between hepatitis B virus (HBV) infection and the risk of stroke. Relevant studies published before May 2017 were identified by searching PubMed, EMBASE, and ISI Web of Science. The relationships between HBV infection and the risk of stroke were assessed using odds ratio (OR)/risk ratio (RR) values and the corresponding 95% confidence intervals (CIs). We used the random effects model proposed by DerSimonian and Laird to quantify the relationship. Five articles, including 834,75 HBV-infected patients and 593,949 uninfected controls, were included in the meta-analysis. The risk of stroke was significantly lower in HBV-infected patients than in uninfected controls (summary OR = 0.78; 95% CI = 0.70–0.86; I² = 0%). However, this inverse relationship was only observed in cohort studies (OR = 0.77; 95% CI = 0.69–0.86), rather than cross-sectional study (OR = 1.10; 95% CI = 0.55–2.19). In summary, HBV infection was associated with lower risk of developing stroke.

MELD-Na score predicts incident major cardiovascular events, in patients with nonalcoholic fatty liver disease (NAFLD)

Cardiovascular disease (CVD) is the leading cause of mortality among adults with nonalcoholic fatty liver disease (NAFLD); however, accurate tools for identifying NAFLD patients at highest CVD risk are lacking. Using a validated algorithm, we identified a retrospective cohort of 914 NAFLD patients without known CVD. Fibrosis severity was estimated using the fibrosis‐4 index. Patients were followed for 5 years for the development of a major adverse cardiovascular event (MACE); a composite of cardiovascular death, myocardial infarction, or unstable angina; urgent coronary revascularization; or stroke. Using an adjusted Cox proportional hazard regression model, NAFLD‐specific biomarkers of CVD risk were identified. Discrimination was compared to that of the Framingham Risk Score (FRS) using the area under the receiver operating characteristic curve. Among 914 patients, the mean age was 53.4 years and 60.6% were female. Over 5 years, 288 (31.5%) experienced MACE. After adjustment for traditional cardiometabolic risk factors and underlying FIB‐4 index score, each 1‐point increase in the model for end‐stage liver disease integrating sodium (MELD‐Na) was associated with a 4.2% increased risk of MACE (hazard ratio, 1.042; 95% confidence interval, 1.009‐1.075; P = 0.011). Compared to patients in the lowest MELD‐Na quartile (<7.5), those in the highest quartile (≥13.2) had a 2.2‐fold increased risk of MACE (adjusted hazard ratio, 2.21; 95% confidence interval, 1.11‐4.40; P = 0.024; P trend = 0.004). Incorporating MELD‐Na with the FRS significantly improved discrimination of future CVD risk (combined C‐statistic 0.703 versus 0.660 for the FRS alone; P = 0.040). Conclusion: Among patients with NAFLD, the MELD‐Na score accurately stratifies the risk for patients according to future CVD event risk. The addition of the MELD‐Na score to the FRS may further improve discrimination of NAFLD‐related CVD risk. (Hepatology Communications 2017;1:429–438)

Prevalence of pre-transplant electrocardiographic abnormalities and post-transplant cardiac events in patients with liver cirrhosis

Background

Although cardiovascular disease is thouht to be common in cirrhosis, there are no systematic investigations on the prevalence of electrocardiographic (ECG) abnormalities in these patients and data on the occurrence of post-transplant cardiac events in comparison with the general population are lacking. We aimed to study the prevalence and predictors of ECG abnormalities in patients with cirrhosis undergoing liver transplantation and to define the risk of cardiac events post-transplant compared to the general population.

Methods

Cirrhotic patients undergoing first-time liver transplantation between 1999–2007 were retrospectively enrolled. ECGs at pre-transplant evaluation were reviewed using the Minnesota classification and compared to healthy controls. Standardized incidence ratios for post-transplant cardiac events were calculated.

Results

234 patients with cirrhosis were included, 186 with an available ECG (36% with alcoholic and 24% with viral cirrhosis; mean follow-up 4 years). Cirrhotics had a prolonged QTc interval, a Q wave, abnormal QRS axis deviation, ST segment depression and a pathologic T wave more frequently compared to controls (p < 0.05 for all). Arterial hypertension, older age, cirrhosis severity and etiology were related to ECG abnormalities. Compared to the general Swedish population, patients were 14 times more likely to suffer a cardiac event post-transplant (p < 0.001). A prolonged QTc interval and Q wave were related to post-transplant cardiac events (p < 0.05 for all).

Conclusions

Pre-transplant ECG abnormalities are common in cirrhosis and are associated with cardiovascular risk factors and cirrhosis severity and etiology. Post-transplant cardiac events are more common than in the general population.

Prevalence of diabetes and incidence of angiopathy in patients with chronic viral liver disease

Patients with chronic liver disease (CLD) often develops glucose intolerance. We explored the prevalence of diabetes mellitus in viral CLD, and analyzed factors profoundly affecting the diabetic angiopathies. 229 CLD patients (124 chronic hepatitis and 105 liver cirrhosis) entered the study. The diagnosis of diabetes was made with the criteria by World Health Organization. Laboratory investigation included serum asparate aminotransferase, alanine aminotransferase, albumin, fasting blood sugar, hemoglobin A1c (HbA1c), fasting immunoreactive insulin, and HOMA-R (FBS*IRI/405). The incidence of macro- and microangiopathy were also examined. Forty (17.5%) CLD patients were diagnosed diabetes, giving a significantly higher incidence than that of general cohort (5.3%) (p<0.001). Among them, 12 (30%) had the triopathy, significantly lower than that in a matched group of diabetic patients without CLD (65%) (p<0.001). Significantly increased levels of HbA1c and HOMA-R were observed in diabetic CLD with angiopathy compared with diabetic CLD without. Incidence of diabetes was increased in viral CLD patients. The rate of diabetic angiopathies in CLD, however, was relatively low, this could be explained by low coagulability in these patients. Poor control of hyperglycemia, partly due to insulin resistance, might explain the onset of angiopathy in diabetic CLD.

Insulin resistance and chronic liver disease

Increased insulin resistance is frequently associated with chronic liver disease and is a pathophysiological feature of hepatogenous diabetes. Distinctive factors including hepatic parenchymal cell damage, portal-systemic shunting and hepatitis C virus are responsible for the development of hepatogenous insulin resistance/diabetes. Although it remains unclear whether insulin secretion from pancreatic beta cells is impaired as it is in type 2 diabetes, retinopathic and cardiovascular risk is low and major causes of death in cirrhotic patients with diabetes are liver failure, hepatocellular carcinoma and gastrointestinal hemorrhage. Hemoglobin A1c is an inaccurate marker for the assessment and management of hepatogenous diabetes. Moreover, exogenous insulin or sulfonylureas may be harmful because these agents may promote hepatocarcinogenesis. Thus, pathogenesis, cause of death, assessment and therapeutic strategy for hepatogenous insulin resistance/diabetes differ from those for lifestyle-related type 2 diabetes. In this article, we review features of insulin resistance in relationship to chronic liver disease. We also discuss the impact of anti-diabetic agents on interferon treatment and hepatocarcinogenesis.

Systemic abnormalities in liver disease

Systemic abnormalities often occur in patients with liver disease. In particular, cardiopulmonary or renal diseases accompanied by advanced liver disease can be serious and may determine the quality of life and prognosis of patients. Therefore, both hepatologists and non-hepatologists should pay attention to such abnormalities in the management of patients with liver diseases.

Dysmetabolic changes associated with HCV: a distinct syndrome?

Although not associated with the metabolic syndrome, HCV is linked with impaired insulin signalling, insulin resistance, hypocholesterolemia and steatosis which represent a distinct HCV-associated dysmetabolic syndrome. Insulin resistance affects the development of diabetes, fibrosis, impaired response to antivirals and perhaps hepatocellular carcinoma risk. HCV infection is associated with hypocholesterolemia and steatosis reversible after sustained virologic response. A "viral", and a "metabolic" steatosis exist as function of viral genotypes. Little is known about the possible role of HCV in further components of the metabolic syndrome such as atherosclerosis, obesity, arterial hypertension, hyperuricemia and thrombotic risk factors.

Prognostic significance of glycaemic control in patients with HBV and HCV-related cirrhosis and diabetes mellitus

AIMS

Diabetes mellitus (DM) is frequently observed in patients with cirrhosis, particularly that due to hepatitis C virus (HCV) infection. However, no studies have focused on the clinical significance of glycaemic control in cirrhotic patients because of their short life expectancy and poor hepatic function. The aim of this study was to evaluate the prognostic impact of glycaemic control in patients with hepatitis B virus (HBV) and HCV-related cirrhosis and DM.

METHODS

A total of 434 patients with HCV-related (HCV group, n = 88) or HBV-related (HBV group, n = 346) cirrhosis were studied retrospectively. We determined the prevalence of DM and treatment methods for hyperglycaemia and status of glycaemic control, and the patients' outcome.

RESULTS

The prevalence of DM was 43.2% (38/88) in the HCV group and 19.7% (68/346) in the HBV group. Patients in the HCV group were older with a female preponderance. DM was detected before the diagnosis of cirrhosis or simultaneously in 92% and 79% in the HCV and HBV groups, respectively. Most patients were treated with insulin or oral hypoglycaemic agents. However, blood glucose levels were maintained within the normal range in 34.2% of the HCV group and in 23.5% of the HBV group. Forty-six patients died during the observation period in both groups. Hepatic failure was the most common cause of death, and sepsis and variceal bleeding were more frequent in the HCV group than in the HBV group. Multivariate analysis showed that Child-Pugh class was the most important factor for survival in both groups. In the HCV group, the status of glycaemic control was a significant independent factor of survival (P = 0.018). In the HBV group, age and the development of spontaneous bacterial peritonitis were significant.

CONCLUSION

DM is more frequent in patients with HCV-related cirrhosis than in patients with HBV. Strict control of blood glucose levels could improve survival in HCV patients. A precise assessment of the risks and benefits of glycaemic control is required to reduce the mortality and morbidity of patients with cirrhosis and DM.

Reduced prevalence of ischemic events and abnormal supraortic flow patterns in patients with liver cirrhosis

BACKGROUND

A reduced prevalence of cardiovascular diseases has been reported in liver cirrhosis. However, studies focusing on supraortic district of cirrhotic patients are lacking.

METHODS

By ultrasound duplex scanning, the presence and severity of atherosclerotic plaques and flow pattern abnormalities were assessed in carotid and vertebral arteries of 118 cirrhotics aged 60.7 +/- 12.8 (1 standard deviation) years, and in 236 controls matched with cirrhotic patients according to age, sex and cigarette smoking.

RESULTS

Previous ischemic strokes were significantly less numerous in cirrhotic patients than in controls (0.8% vs. 10.5%; P = 0.0009); also the prevalence of myocardial infarction was significantly reduced (1.7% vs. 6.4%; P = 0.0532). Moreover, cirrhotic patients differed from controls for a lower prevalence of hypertension and hypercholesterolemia, and for a greater proportion of diabetics. Although the presence and severity of atherosclerotic plaques was similar in the two groups, liver cirrhosis was associated with a lower prevalence of abnormal flow patterns (13.6% vs. 29.2%; P = 0.0011). The inverse association of hemodynamic changes with liver cirrhosis persisted after all main risk factors were simultaneously taken into account by multiple logistic regression. However, in the presence of hypertension, hypercholesterolemia and cigarette smoking, the 'protective' effect of cirrhosis on the occurrence of abnormal flow patterns was no longer detectable.

CONCLUSIONS

Advanced liver disease is associated with a reduced prevalence of ischemic stroke, which seems to be related to a decreased prevalence of abnormal flow patterns in the supraortic vessels, especially among non-smokers.

Hepatic steatosis is associated with an increased risk of carotid atherosclerosis

AIM: Although an association between hepatic steatosis and vascular risk factors has been described, direct relationships between fatty liver and atherosclerosis have not yet been investigated. The aim of the present study has been to investigate those relationships.

METHODS: The Study of Health in Pomerania examined a random population sample aged between 20 and 79 years. A study population of 4222 subjects without hepatitis B and C infections and without liver cirrhosis was available for the present analysis. Hepatic steatosis was defined sonographically and intima-media thickness (IMT) as well as plaque prevalence were estimated by carotid ultrasound.

RESULTS: The prevalence rate of hepatic steatosis was 29.9%. Among subjects aged ≥45 years, an association between hepatic steatosis and IMT of the carotid arteries was found in bivariate analysis, but not after adjustment for atherosclerotic risk factors. Individuals with fatty liver had more often carotid plaques than persons without fatty liver (plaque prevalence rate 76.8% vs 66.6%; P<0.001). This association persisted after adjustment for confounding factors and was predominantly present in subjects with no to mild alcohol consumption.

CONCLUSION: There is an independent association between hepatic steatosis and carotid atherosclerotic plaques. Metabolic changes due to nonalcoholic fatty liver disease may explain this relationship.

Hepatitis B virus infection and coronary atherosclerosis: Results from a population with relatively high prevalence of hepatitis B virus

AIM: To investigate the possible association between hepatitis B virus (HBV) infection and angiographically proven coronary artery disease (CAD) in a population with relatively high prevalence of HBV.

METHODS: Sera from 434 patients who underwent coronary angiography were tested for HBV antigens (HBsAg, HBeAg) and antibodies (Anti-HBs, Anti-HBc and Anti-HBe) by ELISA.

RESULTS: Seventy-seven percent (224/291) of the patients with CAD and 73.4% (105/143) of the patients without angiographic evidence of atherosclerosis were seropositive for HBV (P>0.05). However, C-reactive protein (CRP) levels were significantly higher in patients with CAD (P = 0.008), while lower in HBV seropositive population (P = 0.043 and P = 0.021 after adjustment for conventional risk factors).

CONCLUSION: Our results suggested HBV infection negatively correlates with CRP levels, but seems not to be associated with coronary atherosclerosis.

Prevalence and determinants of diabetes mellitus among Iranian patients with chronic liver disease

BACKGROUND: Alterations in carbohydrate metabolism are frequently observed in cirrhosis. We conducted this study to define the prevalence of diabetes mellitus (DM) and impaired glucose tolerance (IGT) in Iranian patients with chronic liver disease (CLD), and explore the factors associated with DM in these patients. METHODS: One hundred and eighty-five patients with CLD were enrolled into the study. Fasting plasma glucose and two-hour plasma glucose were measured in patients' sera. DM and IGT were diagnosed according to the latest American Diabetes Association criteria. RESULTS: The subjects included 42 inactive HBV carriers with a mean age of 42.2 +/- 12.0 years, 102 patients with HBV or HCV chronic hepatitis with a mean age of 41.2 +/- 10.9 years, and 41 cirrhotic patients with a mean age of 52.1 +/- 11.4 years. DM and IGT were diagnosed in 40 (21.6%) and 21 (11.4%) patients, respectively. Univariate analysis showed that age (P = 0.000), CLD status (P = 0.000), history of hypertension (P = 0.007), family history of DM (P = 0.000), and body mass index (BMI) (P = 0.009) were associated with DM. Using Multivariate analysis, age (OR = 4.7, 95%CI: 1.8-12.2), family history of DM (OR = 6.6, 95%CI: 2.6-17.6), chronic hepatitis (OR = 11.6, 95%CI: 2.9-45.4), and cirrhosis (OR = 6.5, 95%CI: 2.4-17.4) remained as the factors independently associated with DM. When patients with cirrhosis and chronic hepatitis were analyzed separately, higher Child-Pugh's score in cirrhotic patients (OR = 9.6, 95%CI: 1.0-88.4) and older age (OR = 7.2, 95%CI: 1.0-49.1), higher fibrosis score (OR = 59.5, 95%CI: 2.9-1211.3/ OR = 11.9, 95%CI: 1.0-132.2), and higher BMI (OR = 30.3, 95%CI: 3.0-306.7) in patients with chronic hepatitis were found to be associated with higher prevalence of DM. CONCLUSIONS: Our findings indicate that patients with cirrhosis and chronic hepatitis are at the increased risk of DM occurrence. Older age, severe liver disease, and obesity were associated with DM in these patients.

Nutrition in hepatic failure and liver transplantation

Protein-energy malnutrition (PEM) is a common problem in patients with end-stage liver disease, and it is universally present in patients undergoing orthotopic liver transplantation. Although PEM is an independent risk factor for morbidity and mortality, it need not be considered an absolute contraindication for liver transplantation. The etiology of PEM in liver disease is multifactorial and includes decreased nutrient and calorie intake, alterations in intestinal malabsorption and/or maldigestion, and diverse abnormalities of carbohydrate, fat, and protein metabolism. This article reviews the prevalence of malnutrition, its pathophysiology, different modalities for assessment of body composition, and general guidelines for nutritional support in patients with liver disease and liver transplantation.