Validity of FibroScan values for predicting hepatic fibrosis stage in patients with chronic HCV infection

Evaluation of skeletal muscle elasticity using color Doppler shear wave imaging

PURPOSE

This study aimed to (1) assess the precision and reproducibility of color Doppler shear wave imaging (CD SWI) by comparing it with shear wave elastography (SWE) via elasticity phantom measurements, and (2) investigate the potential clinical applications of CD SWI in the upper limb muscles by assessing the reproducibility of skeletal muscle elasticity evaluations.

METHODS

Four elastography phantoms of different stiffness (6.0-7.5 wt%) were used to assess the precision and reproducibility of CD SWI (compared with SWE) at depths. Typical upper limb muscles of 24 men were also assessed for this comparison.

RESULTS

At superficial depths (0-2 cm), the phantom measurements obtained using CD SWI and SWE were similar at all levels of stiffness. Furthermore, both methods were highly reliable, with almost perfect intra- and inter-operator reliabilities. At greater depths (2-4 cm), measurements obtained using both methods were similar at all stiffness levels. Although standard deviations (SDs) of the phantom measurements obtained using both methods at lower stiffness were similar, those at higher stiffness were different. The SD of the CD SWI measurements was < 50% of that of the SWE measurements. However, both methods were highly reliable in the phantom test, with almost perfect intra- and inter-operator reliabilities. The intra- and inter-operator reliabilities of the shear wave velocity measurements for typical muscles of the upper limbs were also substantial in clinical settings.

CONCLUSION

CD SWI is a valid method for measuring elasticity, with precision and reliability as high as those of SWE.

Impact of COVID-19 on epidemic trend of hepatitis C in Henan Province assessed by interrupted time series analysis

OBJECTIVE

Hepatitis C presents a profound global health challenge. The impact of COVID-19 on hepatitis C, however, remain uncertain. This study aimed to ascertain the influence of COVID-19 on the hepatitis C epidemic trend in Henan Province.

METHODS

We collated the number of monthly diagnosed cases in Henan Province from January 2013 to September 2022. Upon detailing the overarching epidemiological characteristics, the interrupted time series (ITS) analysis using autoregressive integrated moving average (ARIMA) models was employed to estimate the hepatitis C diagnosis rate pre and post the COVID-19 emergence. In addition, we also discussed the model selection process, test model fitting, and result interpretation.

RESULTS

Between January 2013 and September 2022, a total of 267,968 hepatitis C cases were diagnosed. The yearly average diagnosis rate stood at 2.42/100,000 persons. While 2013 witnessed the peak diagnosis rate at 2.97/100,000 persons, 2020 reported the least at 1.7/100,000 persons. The monthly mean hepatitis C diagnosed numbers culminated in 2291 cases. The optimal ARIMA model chosen was ARIMA (0,1,1) (0,1,1)12 with AIC = 1459.58, AICc = 1460.19, and BIC = 1472.8; having coefficients MA1=-0.62 (t=-8.06, P < 0.001) and SMA1=-0.79 (t=-6.76, P < 0.001). The final model's projected step change was - 800.0 (95% confidence interval [CI] -1179.9 ~ -420.1, P < 0.05) and pulse change was 463.40 (95% CI 191.7 ~ 735.1, P < 0.05) per month.

CONCLUSION

The measures undertaken to curtail COVID-19 led to a diminishing trend in the diagnosis rate of hepatitis C. The ARIMA model is a useful tool for evaluating the impact of large-scale interventions, because it can explain potential trends, autocorrelation, and seasonality, and allow for flexible modeling of different types of impacts.

Safety and Efficacy of Direct-acting Antiviral Therapies for Chronic HCV Infection in Hemodialysis Patients

BACKGROUND/AIM

The aim of this study was to determine the safety and efficacy of a direct-acting antiviral treatment, ombitasvir/paritaprevir/ritonavir and dasabuvir, without ribavirin, in a real-life setting.

PATIENTS AND METHODS

We performed a prospective observational study including 108 patients undergoing hemodialysis for end-stage kidney disease, referred to our clinic for antiviral therapy for chronic hepatitis C virus infection. Patients received treatment with ombitasvir/paritaprevir/ritonavir and dasabuvir, for 12 weeks. Sustained virologic response (SVR) was defined as undetectable viremia at 12 weeks after the end of therapy. For safety analysis, we monitored serum levels of hemoglobin, albumin, total bilirubin, alanine-aminotransferase and aspartate- aminotransferase at the beginning and end of therapy, as well as at SVR. Verbal Numeric Rating Scale was used to assess the presence of nausea, headaches and fatigue.

RESULTS

We noted a high prevalence of diabetic and hypertensive nephropathy as the underlying cause of chronic kidney disease. Most of the patients had F2 and F3 liver fibrosis (32.40% and 34.25%, respectively). The SVR rate was 96.2% (103/107 patients). We recorded an unrelated death after the completion of antiviral therapy. We found increased levels of nausea, headaches and fatigue at the end of therapy compared to at initiation, The presence and degree of symptoms did not correlate with the underlying cause of renal disease (p=0.72) nor with the degree of fibrosis (p=0.08). Minimal increases in transaminases and bilirubin were recorded at the end of treatment, with no statistical significance.

CONCLUSION

Oral antiviral therapy with ombitasvir/paritaprevir/ritonavir and dasabuvir can be safely used in hemodialysis patients, with similar response rates compared to the general population.

Potential role of noninvasive biomarkers during liver fibrosis

Various types of liver disease exist, such as hepatitis and alcoholic liver disease. These liver diseases can result in scarring of liver tissue, cirrhosis, and finally liver failure. During liver fibrosis, there is an excess and disorganized accumulation of extracellular matrix (ECM) components which cause the loss of normal liver cell functions. For patients with chronic liver disease, fibrosis prediction is an essential part of the assessment and management. To diagnose liver fibrosis, several invasive and noninvasive markers have been proposed. However, the adoption of invasive markers remains limited due to their inherent characteristics and poor patient acceptance rate. In contrast, noninvasive markers can expedite the clinical decision through informed judgment about disease stage and prognosis. These noninvasive markers are classified into two types: Imaging techniques and serum biomarkers. However, the diagnostic values of biomarkers associated with liver fibrosis have also been analyzed. For example, the serum levels of ECM proteins can react to either matrix accumulation or degradation. During virus-host interactions, several regulatory steps take place to control gene expression, such as the change in cellular microRNA expression profiles. MicroRNAs are a class of non-coding RNAs (18-20 long nucleotides) that function by post-transcriptional regulation of gene expression. Although various noninvasive markers have been suggested in recent years, certain limitations have restricted their clinical applications. Understanding the potential of non-invasive biomarkers as a therapeutic option to treat liver fibrosis is still in progress.

Liver Fibrosis Evaluated With Transient Elastography in 35 Children With Chronic Hepatitis C Virus Infection

BACKGROUND

The aim of this prospective study was to analyze liver fibrosis in teenagers with chronic hepatitis C (CHC) using noninvasive methods.

METHODS

Thirty-five patients with CHC, 12-17 years of age (mean 14.2 ± 1.8 years; 22/35, 63% male) were included. Most of them (29/35, 83%) were infected vertically, 21/35 (60%) were treatment-naive, 30/35 (86%) were infected with genotype 1 and 5/35 (14%) were infected with genotype 4 HCV. In all patients, evaluation of liver fibrosis was performed using transient elastography (TE) and measurement of the following serum biomarkers: aspartate transaminase-to-platelet ratio index (APRI) and Fibrosis-4 index (FIB-4). Using liver stiffness measurement (LSM) results as a reference, the diagnostic performance of APRI and FIB-4 was assessed by calculating area under the receiver operating characteristics curve.

RESULTS

Transient elastography results revealed no or mild fibrosis (F0/1 in METAVIR scale) in 31/35 (89%) patients. In 4/35 (11%) patients, significant fibrosis was observed (F ≥ 2), including 3/35 (9%) with cirrhosis (F4). The median APRI was 0.32, and the median FIB-4 was 0.32. LSM was associated with both APRI and FIB-4 [r = 0.61, 95% confidence interval (CI) 0.35-0.79, P = 0.0001; and r = 0.60, 95% CI 0.32-0.78, P = 0.0002, respectively]. For the diagnosis of significant fibrosis, the area under the receiver operating characteristics (95% CI) for both APRI and FIB-4 was 0.855 (0.695-0.951). APRI, with a cutoff >0.374, predicted significant fibrosis, with 100% sensitivity and 67.7% specificity, whereas FIB-4, with a cutoff >0.402, predicted significant fibrosis, with 75.0% sensitivity and 90.3% specificity.

CONCLUSIONS

Significant fibrosis, including cirrhosis, may occur in teenagers with CHC. Serum biomarkers (APRI, FIB-4) correlate positively with LSM.

The Role of Elastography in Non-Alcoholic Fatty Liver Disease

The most common liver disease in developing countries is non-alcoholic fatty liver disease (NAFLD). This involves the abnormal accumulation of lipids in the liver, the pathogenesis of the disease being related to dyslipidemia, obesity, insulin resistance and type 2 diabetes. Most often, the diagnosis of NAFLD is incidental, when performing routine blood tests or when performing a transabdominal ultrasound. The NAFLD spectrum ranges from simple forms of hepatic steatosis to the most advanced form of the disease, steatohepatitis (NASH), which in evolution can cause inflammation, fibrosis, cirrhosis of the liver and even liver cancer. For the evaluation of the prognosis and the clinical evolution, the most important parameter to define is the degree of liver fibrosis. Currently, the gold standard remains the liver biopsy, the differentiation between NAFLD and NASH being made only on the basis of histological analysis. However, liver biopsy is an invasive procedure, with numerous risks such as bleeding, lesions of the other organs and complications related to anesthesia, which significantly reduces its widespread use. Moreover, the risk of a false negative result and the increased costs of the procedure further limits its use in current practice. For this reason, non-invasive methods of evaluating the degree of liver fibrosis have gained ground in recent years. Imaging techniques such as elastography have shown promising results in evaluating and staging NAFLD. The aim of this article is to review the current status of the non-invasive tests for the assessment of NAFLD with a focus on the ultrasound-based elastography techniques.

Liver fibrosis assessment by FibroScan compared with pathological findings of liver resection specimen in hepatitis C infection

AIM

FibroScan is a tool for the non-invasive diagnosis of hepatic fibrosis. Previous studies have compared liver stiffness to percutaneous liver biopsy findings, but no study has compared liver stiffness to liver resection specimen findings. The aim of this study was to compare FibroScan measurements to resected liver specimen findings.

METHODS

From April 2011 to November 2015, a total of 114 patients with liver tumor and hepatitis C were enrolled. We divided them into two groups, the training set and validation set. Liver stiffness was measured by FibroScan before surgery, and specimens obtained by liver resection were evaluated according to the METAVIR system.

RESULTS

Using Spearman's rank correlation analysis, a positive correlation between liver stiffness measurement and liver fibrosis stage was observed (r = 0.786, P ≤ 0.0001). In the training set, the area under receiver operating curves for diagnosis of F ≥ 2 was 0.971 (95% confidence interval, 0.928-1.000; cut-off value, 5.9), for diagnosis of F ≥ 3 was 0.911 (0.825-0.997, 9.8), and for diagnosis of F = 4 was 0.917 (0.849-0.985, 15.5). In the validation set, at a cut-off value of 5.9 kPa, sensitivity, specificity, positive predictive values, and negative predictive values for F ≥ 2 were 95.7%, 0.0%, 97.8%, and 0.0%, respectively, of 9.8 kPa for F ≥ 3 were 86.2%, 52.6%, 73.5%, and 71.4%, and of 15.5 kPa for F = 4 were 100%, 71.8%, 45.0%, and 100%.

CONCLUSIONS

The stage of stiffness graded by FibroScan has a good correlation with the liver fibrosis of resected liver specimens. It has the ability to diagnose fibrosis stage non-invasively.

Influence of subjects' characteristics and technical variables on muscle stiffness measured by shear wave elastosonography

PURPOSE

The aim of this study is to quantitatively assess lower limbs muscle elasticity in a court of healthy subjects and to evaluate the influence of technical variables (e.g., diameter of the ROI-region of interest) and examined subjects' characteristics (e.g., sex, levels of physical activity, side evaluated) on muscle stiffness.

MATERIALS AND METHODS

54 healthy subjects (48 men, 6 women) were evaluated for a total of 108 lower limbs. Shear wave elastography was performed with a multifrequency linear probe (15-4 MHz). Two radiologists performed the evaluation of lower limbs from left to right side (first calf and then thigh). The measures were taken on gastrocnemius and on femoral biceps muscle belly. We chose to place for this study two ROIs of 4 and 2 mm of diameter.

RESULTS

The mean muscle stiffness was 1.98 ± 0.48 (range between 1.89 ± 0.36 and 2.15 ± 0.57 m/s). The difference in muscle stiffness between left and right side of the body and between different levels of physical activity never became statistically significant (p value between 0.314 and 0.915). Only in one test out of eight the difference of muscle stiffness between male and female resulted statistically significant (p value 0.020). When comparing the measurement obtained with a 2 and 4 mm diameter ROIs the values were statistically different only for the left thigh (p value 0.028).

CONCLUSION

Our study, despite its limitations (low sample and low female population), seems to give some clear advice: physiological or technical factors do not determine statistically significant differences on passive muscle stiffness.

Non-invasive assessment of liver fibrosis in chronic viral hepatitis

BACKGROUND

Hyaluronic acid (HA), ASAT to Platelet Ratio Index (APRI), ASAT/ALAT ratio, Fibrosis 4 score (FIB4) and FibroScan were studied as non-invasive markers of liver fibrosis (F) in chronic viral hepatitis B (CHB) and C (CHC), in an attempt to avoid the complications of liver puncture biopsy, considered the gold standard in the evaluation of F. The aim of our research was to study whether HA, APRI, ASAT/ALAT ratio, FIB4 and FibroScan are useful non-invasive markers in predicting severe F in Romanian patients.

PATIENTS AND METHODS

This was a prospective multicenter transversal and observational study, which included 76 patients with CHB/CHC. The independent effect of studied markers was tested using multiple binary logistic regression.

RESULTS

In patients with CHB and CHC, the APRI cut-off value for F4 was 0·70 ng/mL (Se = 77%, Sp = 78%), the FIB4 cut-off value was 2·01 (Se = 77%, Sp = 69%), and the FibroScan cut-off value was 13·15 (Se = 92%, Sp = 88%). For patients with CHB/CHC, there was a significant linear positive correlation between F and HA (r = 0·42, P = 0·001), FibroScan (r = 0·67, P < 0·001), APRI (r = 0·46, P < 0·001) and FIB4 (r = 0·51, P < 0·001). Considering age, sex and body mass index as possible confounding factors or covariates in multivariable logistic modelling, FibroScan was the unique test that able to significantly highlight the presence of F4 score in CHB/CHC patients (P = 0·009) while FIB4 test seems to have a tendency to statistical significance.

CONCLUSION

FibroScan, APRI and FIB4 are useful non-invasive tests for the evaluation of F4 in patients with CHB and CHC.

Serum hyaluronic acid in chronic viral hepatitis B and C: a biomarker for assessing liver fibrosis in chronic hemodialysis patients

PURPOSE

Serum hyaluronic acid (sHA) is studied as a noninvasive marker of liver fibrosis (F) in chronic B and C viral hepatitis in general population but less in end-stage renal disease patients undergoing hemodialysis.

METHODS

We evaluated sHA as a noninvasive biomarker of F in a multicenter prospective, transversal, and observational study which included 52 end-stage renal disease patients with chronic B (14) and C (38) viral hepatitis (age 55.57 ± 14.46 years, dialysis vintage 132.59 ± 86.02 months).

RESULTS

Of the noninvasive tests analyzed, only sHA, APRI, and FIB4 index were able to differentiate patients with F1 (sHA p = 0.006; APRI p = 0.031; FIB4 p = 0.016). No statistically significant differences were found between sHA and APRI, ASAT/ALAT ratio, and FIB4 index in detecting F1 a (p > 0.02). sHA seemed to be more efficient than APRI, ASAT/ALAT ratio, and FIB4 index, having the highest estimated AUC value. The sHA threshold value for F1 was equal to 33.46 ng/mL, with the following estimated values of the performance indicators: Se 88.46 % and Sp 50 %. sHA was the only noninvasive test of the studied tests that could determine F2 (p = 0.002), with a threshold value of 80.24 ng/mL (Se 63 %, Sp 88 %), and F3 (p = 0.008), with a threshold value of 88.54 ng/mL (Se 60 %, Sp 84 %). None of the studied noninvasive tests could determine F4.

CONCLUSIONS

In patients with chronic B and C viral hepatitis undergoing hemodialysis, sHA may be a useful biomarker for the liver fibrosis grades: F1-mild, F2-moderate, and F3-severe, but it does not differentiate between chronic hepatitis (F1-F3) and liver cirrhosis (F4).

Improvement of glucose and lipid metabolism with pegylated interferon-a plus ribavirin therapy in Chinese patients chronically infected with genotype 1b hepatitis C virus

BACKGROUND

Many epidemiological studies have demonstrated a significant association between Type 2 diabetes mellitus and abnormal lipid profiles with chronic HCV genotype 1 (GT1) infection. We examined the impact on glucose and lipid profiles of treating Chinese patients using pegylated interferon (Peg-IFN)-a and ribavirin (RBV).

METHODS

We conducted a hospital-based clinical study of Chinese patients chronically infected with GT1b HCV. All the patients were treated for 48 weeks (PR48) with Peg-IFN-a (180 micro g once per week) or Peg-IFN-a (1.5 micro g/kg once per week) plus RBV (15 mg/kg per day). Fasting blood glucose (FBG), postprandial blood glucose (PBG-2h), glycosylated hemoglobin (HbA1c), total cholesterol (TC) and triglyceride (TG) levels, were measured at baseline, during therapy, at the end of therapy and at follow-up. In addition, liver stiffness (LS) by transient elastography, HCV RNA and ALT levels were also measured.

RESULTS

We enrolled 116 patients. At the end of treatment (EOT) (week 48), HCV RNA was negative in all patients, 77.6% (90/116) of patients achieved sustained virologic response (SVR) 24 weeks after EOT, and 22.4% (26/116) did not achieve SVR. All parameters associated with liver inflammation, liver fibrosis, glucose and lipid metabolism had decreased significantly compared with baseline (P < .05) in SVR patients. However, there were no obvious changes in lipid metabolism in non-SVR patients.

CONCLUSION

PR48 therapy is still the primary treatment for Chinese patients with GT1b HCV infection and will remain so until oral anti-HCV agents are approved. It is beneficial in amelioration of liver histological status and glucose metabolism regardless of post-treatment virologic response.

Transient elastography in hepatitis C virus-infected patients with beta-thalassemia for assessment of fibrosis

AIM

We sought to evaluate the performance of transient elastography (TE) for the assessment of liver fibrosis in chronic hepatitis C (CHC) patients with beta-thalassemia.

METHODS

Seventy-six CHC patients with beta-thalassemia underwent TE, liver biopsy, T2 -weighted magnetic resonance imaging (MRI) for the assessment of liver iron content (LIC) and laboratory evaluation. The accuracy of TE and its correlation with the other variables was assessed.

RESULTS

TE values increased proportional to fibrosis stage (r = 0.404, P < 0.001), but was independent of T2 -weighted MRI-LIC (r = 0.064, P = 0.581). In multivariate analysis, fibrosis stage was still associated with the log-transformed TE score(standardized β = 0.42 for F4 stage of METAVIR, P = 0.001). No correlation was noted between LIC and TE score (standardized β = 0.064, P = 0.512). The area under the receiver operating characteristic curve for prediction of cirrhosis was 80% (95% confidence interval, 59-100%). A cut-off TE score of 11 had a sensitivity of 78% and specificity of 88.1% for diagnosing cirrhosis. The best cut-off values for "TE-FIB-4 cirrhosis score" comprising TE and FIB-4 and "TE-APRI cirrhosis score" combining TE with aspartate aminotransferase-to-platelet ratio index (APRI) both had 87.5% sensitivity and 91.04% specificity for the diagnosis of cirrhosis.

CONCLUSION

Regardless of LIC, TE alone or when combined with FIB-4 or APRI, is a diagnostic tool with moderate to high accuracy to evaluate liver fibrosis in CHC patients with beta-thalassemia. However, because splenectomy in a proportion of our subjects might have affected the platelet count, the scores utilizing APRI and FIB-4 should be interpreted cautiously.

Diagnostic value of fibronectin discriminant score for predicting liver fibrosis stages in chronic hepatitis C virus patients

BACKGROUND

Several noninvasive predictive models were developed to substitute liver biopsy for fibrosis assessment.

AIM

To evaluate the diagnostic value of fibronectin which reflect extracellular matrix metabolism and standard liver functions tests which reflect alterations in hepatic functions.

MATERIAL AND METHODS

Chronic hepatitis C (CHC) patients (n = 145) were evaluated using ROC curves and stepwise multivariate discriminant analysis (MDA) and was validated in 180 additional patients. Liver biochemical profile including transaminases, bilirubin, alkaline phosphatase, albumin, complete blood count were estimated. Fibronectin concentration was determined using monoclonal antibody and ELISA.

RESULTS

A novel index named fibronectin discriminant score (FDS) based on fibronectin, APRI and albumin was developed. FDS produced areas under ROC curves (AUC) of 0.91 for significant fibrosis and 0.81 for advanced fibrosis. The FDS correctly classified 79% of the significant liver fibrosis patients (F2-F4) with 87% sensitivity and 75% specificity. The relative risk [odds ratio (OR)] of having significant liver fibrosis using the cut-off values determined by ROC curve analyses were 6.1 for fibronectin, 4.9 for APRI, and 4.2 for albumin. FDS predicted liver fibrosis with an OR of 16.8 for significant fibrosis and 8.6 for advanced fibrosis. The FDS had similar AUC and OR in the validation group to the estimation group without statistically significant difference.

CONCLUSION

FDS predicted liver fibrosis with high degree of accuracy, potentially decreasing the number of liver biopsy required.

Evaluation of curative effect of autologous bone marrow stem cell transplantation on decompensated cirrhosis by Fibroscan

AIM: To evaluate the efficacy of autologous bone marrow stem cell transplantation in the treatment of decompensated cirrhosis by Fibroscan combined with multiple parameters.

METHODS: A total of 58 patients with decompensated cirrhosis were divided into transplantation group (n = 27) and control group (n = 31). Baseline examinations, including liver biopsy and Fibroscan, were performed before therapy. Both groups underwent routine medical treatment, and the transplantation group additionally underwent autologous bone marrow stem cell transplantation. At 2, 4, 8, 12, 24 and 48 wk after therapy, liver function and coagulation function were measured. Fibroscan and FIB-4 tests were performed at 12, 24 and 48 wk. At 48 wk after therapy, some patients underwent a liver biopsy. Then the efficacy of autologous bone marrow stem cell transplantation in the treatment of cirrhosis and the role of Fibroscan in evaluation of the curative effect were analyzed comprehensively.

RESULTS: Successful transplantation was achieved in all the 27 patients. Seven patients from each group underwent a liver biopsy, and they were clearly diagnosed with cirrhosis by histopathology. At 8 wk after therapy, the improvement in symptoms and physical signs in the transplantation group was better than that in the control group. The liver function and coagulation function improved in both groups, and the improvement was more significant in the transplantation group than in the control group. The liver stiffness values in the transplantation group did not differ significantly between before treatment and 12 and 24 wk after transplantation (31.66 kPa ± 6.97 kPa vs 31.98 kPa ± 7.36 kPa, 31.35 kPa ± 6.73 kPa, both P > 0.05), but were significantly higher at 48 wk than at other time points (31.78 kPa ± 7.35 kPa, P < 0.05). The liver stiffness values in the control group increased gradually from 32.05 kPa ± 9.09 kPa at pretreatment to 36.39 kPa ± 9.39 kPa at 48 wk after therapy (P < 0.05), and there was a statistical difference in the liver stiffness values between the two groups at 48 wk. The level of HA in the transplantation group decreased more significantly than that in the control group (P < 0.05 at 24 wk).

CONCLUSION: Autologous bone marrow stem cell transplantation can significantly improve symptoms and liver function in patients with decompensated cirrhosis. Fibroscan is an important means of evaluating the curative effect of autologous bone marrow stem cell transplantation on decompensated cirrhosis.

Cost-effectiveness and population outcomes of general population screening for hepatitis C

BACKGROUND

Current US guidelines recommend limiting hepatitis C virus (HCV) screening to high-risk individuals, and 50%-75% of infected persons remain unaware of their status.

METHODS

To estimate the cost-effectiveness and population-level impact of adding one-time HCV screening of US population aged 20-69 years to current guidelines, we developed a decision analytic model for the screening intervention and Markov model with annual transitions to estimate natural history. Subanalyses included protease inhibitor therapy and screening those at highest risk of infection (birth year 1945-1965). We relied on published literature and took a lifetime, societal perspective.

RESULTS

Compared to current guidelines, incremental cost per quality-adjusted life year gained (ICER) was $7900 for general population screening and $4200 for screening by birth year, which dominated general population screening if cost, clinician uptake, and median age of diagnoses were assumed equivalent. General population screening remained cost-effective in all one-way sensitivity analyses, 30 000 Monte Carlo simulations, and scenarios in which background mortality was doubled, all genotype 1 patients were treated with protease inhibitors, and most parameters were set unfavorable to increased screening. ICER was lowest if screening was applied to a population with liver fibrosis similar to 2010 estimates. Approximately 1% of liver-related deaths would be averted per 15% of the general population screened; the impact would be greater with improved referral, treatment uptake, and cure.

CONCLUSIONS

Broader screening for HCV would likely be cost-effective, but significantly reducing HCV-related morbidity and mortality would also require improved rates of referral, treatment, and cure.

A secreted form of the asialoglycoprotein receptor, sH2a, as a novel potential noninvasive marker for liver fibrosis

BACKGROUND AND AIM

The human asialoglycoprotein receptor is a membrane heterooligomer expressed exclusively in hepatocytes. A soluble secreted form, sH2a, arises, not by shedding at the cell surface, but by intracellular cleavage of its membrane-bound precursor, which is encoded by an alternatively spliced form of the receptor H2 subunit. Here we determined and report that sH2a, present at constant levels in serum from healthy individuals is altered upon liver fibrosis, reflecting the status of hepatocyte function.

METHODS

We measured sH2a levels in serum using a monoclonal antibody and an ELISA assay that we developed, comparing with routine liver function markers. We compared blindly pretreatment serum samples from a cohort of 44 hepatitis C patients, which had METAVIR-scored biopsies, with 28 healthy individuals.

RESULTS

sH2a levels varied minimally for the healthy individuals (150±21 ng/ml), whereas the levels deviated from this normal range increasingly in correlation with fibrosis stage. A simple algorithm combining sH2a levels with those of alanine aminotransferase allowed prediction of fibrosis stage, with a very high area under the ROC curve of 0.86.

CONCLUSIONS

sH2a has the potential to be a uniquely sensitive and specific novel marker for liver fibrosis and function.

Noninvasive evaluation of hepatic fibrosis using acoustic radiation force-based shear stiffness in patients with nonalcoholic fatty liver disease

BACKGROUND & AIMS

Nonalcoholic fatty liver disease (NAFLD), the most common form of chronic liver disease in developed countries, may progress to nonalcoholic steatohepatitis (NASH) in a minority of people. Those with NASH are at increased risk for cirrhosis and hepatocellular carcinoma. The potential risk and economic burden of utilizing liver biopsy to stage NAFLD in an overwhelmingly large at-risk population are enormous; thus, the discovery of sensitive, inexpensive, and reliable noninvasive diagnostic modalities is essential for population-based screening.

METHODS

Acoustic Radiation Force Impulse (ARFI) shear wave imaging, a noninvasive method of assessing tissue stiffness, was used to evaluate liver fibrosis in 172 patients diagnosed with NAFLD. Liver shear stiffness measures in three different imaging locations were reconstructed and compared to the histologic features of NAFLD and AST-to-platelet ratio indices (APRI).

RESULTS

Reconstructed shear stiffnesses were not associated with ballooned hepatocytes (p=0.11), inflammation (p=0.69), nor imaging location (p=0.11). Using a predictive shear stiffness threshold of 4.24kPa, shear stiffness distinguished low (fibrosis stage 0-2) from high (fibrosis stage 3-4) fibrosis stages with a sensitivity of 90% and a specificity of 90% (AUC of 0.90). Shear stiffness had a mild correlation with APRI (R(2)=0.22). BMI>40kg/m(2) was not a limiting factor for ARFI imaging, and no correlation was noted between BMI and shear stiffness (R(2)=0.05).

CONCLUSIONS

ARFI imaging is a promising imaging modality for assessing the presence or absence of advanced fibrosis in patients with obesity-related liver disease.

Early detection of nonalcoholic steatohepatitis in patients with nonalcoholic fatty liver disease by using MR elastography

PURPOSE

To investigate the diagnostic accuracy (area under the receiver operating characteristic curve [AUROC]) of magnetic resonance (MR) elastography for the early detection of nonalcoholic steatohepatitis (NASH) among patients with nonalcoholic fatty liver disease (NAFLD).

MATERIALS AND METHODS

An institutional review board-approved and HIPAA-compliant retrospective study was conducted in 58 NAFLD patients. Informed consent was waived by the review board. Hepatic stiffness, relative fat fraction, inflammation grade, and fibrosis stage were assessed from MR elastography, in-phase and out-of-phase gradient-echo imaging, and liver biopsy histopathologic review, respectively. Pairwise t testing, receiver operating characteristic analysis, and partial correlation analysis were performed.

RESULTS

The mean hepatic stiffness for patients with simple steatosis (2.51 kPa) was less (P = .028) than that for patients with inflammation but no fibrosis (3.24 kPa). The mean hepatic stiffness for patients with inflammation but no fibrosis was less (P = .030) than that for patients with hepatic fibrosis (4.16 kPa). Liver stiffness had high accuracy (AUROC = 0.93) for discriminating patients with NASH from those with simple steatosis, with a sensitivity of 94% and a specificity 73% by using a threshold of 2.74 kPa.

CONCLUSION

In patients with NAFLD, hepatic stiffness measurements with MR elastography can help identify individuals with steatohepatitis, even before the onset of fibrosis; NAFLD patients with inflammation but no fibrosis have greater liver stiffness than those with simple steatosis and lower mean stiffness than those with fibrosis.

Early detection of nonalcoholic steatohepatitis in patients with nonalcoholic fatty liver disease by using MR elastography

PURPOSE

To investigate the diagnostic accuracy (area under the receiver operating characteristic curve [AUROC]) of magnetic resonance (MR) elastography for the early detection of nonalcoholic steatohepatitis (NASH) among patients with nonalcoholic fatty liver disease (NAFLD).

MATERIALS AND METHODS

An institutional review board-approved and HIPAA-compliant retrospective study was conducted in 58 NAFLD patients. Informed consent was waived by the review board. Hepatic stiffness, relative fat fraction, inflammation grade, and fibrosis stage were assessed from MR elastography, in-phase and out-of-phase gradient-echo imaging, and liver biopsy histopathologic review, respectively. Pairwise t testing, receiver operating characteristic analysis, and partial correlation analysis were performed.

RESULTS

The mean hepatic stiffness for patients with simple steatosis (2.51 kPa) was less (P = .028) than that for patients with inflammation but no fibrosis (3.24 kPa). The mean hepatic stiffness for patients with inflammation but no fibrosis was less (P = .030) than that for patients with hepatic fibrosis (4.16 kPa). Liver stiffness had high accuracy (AUROC = 0.93) for discriminating patients with NASH from those with simple steatosis, with a sensitivity of 94% and a specificity 73% by using a threshold of 2.74 kPa.

CONCLUSION

In patients with NAFLD, hepatic stiffness measurements with MR elastography can help identify individuals with steatohepatitis, even before the onset of fibrosis; NAFLD patients with inflammation but no fibrosis have greater liver stiffness than those with simple steatosis and lower mean stiffness than those with fibrosis.

Is spleen circulation impaired in systemic sclerosis and what is the role of liver fibrosis?

AIM

To investigate the spleen vascular involvement and the presence of liver fibrosis in a population of subjects with established systemic sclerosis (SSc).

METHODS

In a cross-sectional fashion, 17 patients with SSc were compared with 18 patients suffering from hepatitis C virus (HCV)-related liver cirrhosis, grade A and B Child-Pugh classification. Eighteen non elderly subjects, apparently healthy, were used as the control group. Splenic artery resistivity index (SARI) at Doppler ultrasound, transient elastography of liver and nailfold capillaroscopy were the main outcomes.

RESULTS

Transient elastography values of SSc patients were similar to those of controls; 5.2 ± 1.1 vs 4.5 ± 1, (P = 0.07). Median Alanine amino transferase (ALT) concentrations of cirrhotic patients were greater than those of controls and SSc patients, i.e. 66.5 (36-89) U/L vs 29 (22-34) U/L and 31 (22-41) U/L, respectively, (P = 0.005). SARI determinations in cirrhotic patients, although significantly higher than those found in controls and SSc patients, showed some degree of overlap with SSc patients, i.e. 0.59 vs 0.52 and 0.57, respectively, (P = 0.04). Mean systolic blood pressure was significantly higher in SSc patients than in cirrhotics and controls, i.e. 142 mmHg vs 128.2 mmHg and 127 mmHg, respectively, (P = 0.005). Mean diastolic blood pressure behaved in a similar fashion, i.e. 84 mmHg vs 72.2 mmHg and 76.9 mmHg (P = 0.005). Nailfold Capillaroscopy grades and diastolic blood pressure values correlated well with SARI results.

CONCLUSION

An enhanced resistivity of the splenic artery was found in patients suffering from SSc; they did not have evidence of splenomegaly as well as no liver fibrosis or any other form of liver damage.

A brief review on molecular, genetic and imaging techniques for HCV fibrosis evaluation

Background

Chronic HCV is one of the major causes of morbidity and mortality in the present day world. The assessment of disease progression not only provides useful information for diagnosis and therapeutic supervision judgment but also for monitoring disease. Different invasive and non invasive methods are applied to diagnose the disease from initial to end stage (mild fibrosis to cirrhosis). Although, liver biopsy is still considered as gold standard to identify liver histological stages, an assessment of the disease development based on non-invasive clinical findings is also emerging and this may replace the need of biopsy in near future. This review gives brief insight on non-invasive methods currently available for predicting liver fibrosis in HCV with their current pros and cons to make easier for a clinician to choose better marker to assess liver fibrosis in HCV infected patients.

Methods

More than 200 studies regarding invasive and noninvasive markers available for HCV liver disease diagnosis were thoroughly reviewed. We examined year wise results of these markers based on their sensitivity, specificity, PPV, NPV and AUROCs.

Results

We found that in all non-invasive serum markers for HCV, FibroTest, Forn's Index, Fibrometer and HepaScore have high five-year predictive value but with low AUROCs (0.60~0.85) and are not comparable to liver biopsy (AUROC = 0.97). Even though from its beginning, Fibroscan is proved to be best with high AUROCs (> 0.90) in all studies, no single noninvasive marker is able to differentiate all fibrosis stages from end stage cirrhosis. Meanwhile, specific genetic markers may not only discriminate fibrotic and cirrhotic liver but also differentiate individual fibrosis stages.

Conclusions

There is a need of marker which accurately determines the stage based on simplest routine laboratory test. Genetic marker in combination of imaging technique may be the better non invasive diagnostic method in future.

The Diagnostic Value of Ultrasound Elastography in Patients with Hepatitis B Virus Infection: A Prospective Study

The aim of this prospective study was to investigate the diagnostic value of ultrasound elastography for evaluating liver stiffness measurement (LSM) in 74 patients with hepatitis B virus (HBV) infection, treated with telbivudine (22 with chronic HBV infection, 32 with compensated cirrhosis and 20 with decompensated cirrhosis). Each patient underwent ultrasound elastography measurements and serum liver marker assays before and after 6 months' treatment with 600 mg telbivudine, orally, once daily. In the 22 patients with chronic HBV infection, LSM values measured by ultrasound elastography decreased significantly following the treatment period compared with baseline. The LSM values were significantly higher in the 20 patients with decompensated cirrhosis than in the 32 patients with compensated cirrhosis after treatment. Significant decreases in serum hepatic fibrosis indices occurred in all patients following treatment. The correlation between fibrosis index, hyaluronic acid level and LSM was statistically significant in all patients, whereas the correlation between alanine aminotransferase and LSM was not. The findings suggest that liver stiffness in patients with HBV can be measured simply with ultrasound elastography and that it is reduced within 6 months by treatment with telbivudine. The main adverse events noted during the study period were that creatine kinase levels were increased in seven patients and that seven patients had influenza-like symptoms.

Acute liver failure is associated with elevated liver stiffness and hepatic stellate cell activation

Acute liver failure (ALF) is associated with massive short-term cell death, whereas chronic liver injury is accompanied by continuous cell death. Hepatic stellate cells (HSCs) contribute to tissue repair and liver fibrosis in chronic liver injury, although their role in ALF remains unexplained. Twenty-nine patients (median age = 43 years, 17 females and 12 males) with ALF according to the Acute Liver Failure Study Group criteria were included. Upon the diagnosis of ALF and after 7 days, we determined liver stiffness (LS) with FibroScan, standard laboratory parameters, and serum levels of matrix metalloproteinase 1 (MMP-1), MMP-2, MMP-9, tissue inhibitor of metalloproteinases 1 (TIMP-1), TIMP-2, hyaluronic acid, and markers of overall cell death (M65) and apoptosis (M30). Stellate cell activation and progenitor response were analyzed immunohistochemically in biopsy samples of 12 patients with alpha-smooth muscle actin (alpha-SMA), keratin-17, and keratin-19 staining, respectively. Cell death markers (M30 level = 2243 +/- 559.6 U/L, M65 level = 3732 +/- 839.9 U/L) and fibrosis markers (TIMP-1 level = 629.9 +/- 69.4 U/mL, MMP-2 level = 264 +/- 32.5 U/mL, hyaluronic acid level = 438.5 +/- 69.3 microg/mL) were significantly increased in patients versus healthy controls. This was paralleled by collagen deposition, elevated alpha-SMA expression, and higher LS (25.6 +/- 3.0 kPa). ALF was associated with ductular progenitor proliferation.

CONCLUSION

Our results demonstrate HSC activation and a progenitor response in ALF. Positive correlations between LS, the degree of liver cell damage, and the intensity of HSC activation suggest that fibrosis is a response to ALF in an attempt to repair damaged tissue.

Recent advances in the use of Fibroscan for diagnosis of liver fibrosis

In recent years, non-invasive methods for assessment of liver fibrosis have attracted worldwide attention. However, although many biochemical markers and imaging examinations have been used for evaluation of liver fibrosis, their sensitivity and specificity are low. Fibroscan (transient elastography) is a new non-invasive technology to assess the degree of liver fibrosis by measuring liver stiffness. Although Fibroscan has been extensively used to evaluate chronic hepatitis C and its complications in other countries, its use is uncommon in China. In this article, we will review its working principle, diagnostic value, and application status.