Comparison of liver biopsy and transient elastography based on clinical relevance

A Tense Race: Correlation of Liver Stiffness with Ultrasound Elastography and Hemodynamics in Fontan Patients

Background

Patients with Fontan physiology are predisposed to congestive hepatopathy, progressive liver fibrosis, and end-stage liver disease. Ultrasound-based shear wave elastography (SWE) is a non-invasive tool to diagnose and monitor liver fibrosis. We sought to determine whether the degree of hemodynamic derangement prior to and after the Fontan operation is associated with increased liver stiffness measured by SWE.

Methods

A single-center retrospective study of patients with Fontan circulation who underwent ultrasound elastography between 2008 and 2024 was conducted. Liver stiffness was measured by SWE and reported as velocity in m/s. Hemodynamic assessment with cardiac catheterization and echocardiograms were collected before and after the Fontan operation. Data was analyzed as a continuous (linear regression model) and a dichotomous variable (t-test).

Results

78 post-Fontan ultrasound elastography studies performed in 56 patients were analyzed. Pre-Fontan hemodynamics included median effective pulmonary flow of 2.45 L/min/m2 [2.21, 3.16] (p = 0.46), ventricular end-diastolic pressure of 10 mmHg [8, 10.5] (p = 0.77), and median Glenn pressure of 12 mmHg [13, 15] (p = 0.83). Post-Fontan median systemic cardiac index was 2.80 L/min/m2 [2.4, 3.34] (p = 0.93), median ventricular end-diastolic pressure of 12 mmHg [13.5, 14] (p = 0.99), median systemic saturation of 93% [87, 96] (p = 0.77), median indexed pulmonary vascular resistance of 1.80 WU·m2 [1.49, 2.37] (p = 0.93), and median Fontan pressure of 18 mmHg [16, 21] (p = 0.86). No correlation was found between SWE and hemodynamics. On echocardiography, no correlation was found between SWE and systemic ventricular systolic function (p = 0.35) or degree of systemic atrioventricular valve regurgitation (p = 0.35).

Conclusions

The degree of liver stiffness by SWE in this cohort did not correlate with pre- and post-Fontan hemodynamics on cardiac catheterization, degree of ventricular dysfunction, or severity of atrioventricular valve regurgitation by echocardiography.

Imaging-based noninvasive liver disease assessment for staging liver fibrosis in chronic liver disease: A systematic review supporting the AASLD Practice Guideline

BACKGROUND AND AIMS

Transient elastography (TE), shear wave elastography, and/or magnetic resonance elastography (MRE), each providing liver stiffness measurement (LSM), are the most studied imaging-based noninvasive liver disease assessment (NILDA) techniques. To support the American Association for the Study of Liver Diseases guidelines on NILDA, we summarized the evidence on the accuracy of these LSM methods to stage liver fibrosis (F).

APPROACH AND RESULTS

A comprehensive search for studies assessing LSM by TE, shear wave elastography, or MRE for the identification of significant fibrosis (F2-4), advanced fibrosis (F3-4), or cirrhosis (F4), using histopathology as the standard of reference by liver disease etiology in adults or children from inception to April 2022 was performed. We excluded studies with <50 patients with a single disease entity and mixed liver disease etiologies (with the exception of HCV/HIV coinfection). Out of 9447 studies, 240 with 61,193 patients were included in this systematic review. In adults, sensitivities for the identification of F2-4 ranged from 51% to 95%, for F3-4 from 70% to 100%, and for F4 from 60% to 100% across all techniques/diseases, whereas specificities ranged from 36% to 100%, 74% to 100%, and 67% to 99%, respectively. The largest body of evidence available was for TE; MRE appeared to be the most accurate method. Imaging-based NILDA outperformed blood-based NILDA in most comparisons, particularly for the identification of F3-4/F4. In the pediatric population, imaging-based NILDA is likely as accurate as in adults.

CONCLUSIONS

LSM from TE, shear wave elastography, and MRE shows acceptable to outstanding accuracy for the detection of liver fibrosis across various liver disease etiologies. Accuracy increased from F2-4 to F3-4 and was the highest for F4. Further research is needed to better standardize the use of imaging-based NILDA, particularly in pediatric liver diseases.

Transient elastography and diffusion-weighted magnetic resonance imaging for assessment of liver fibrosis in children with chronic hepatitis C

BACKGROUND

Chronic hepatitis C (CHC) is a health burden with consequent morbidity and mortality. Liver biopsy is the gold standard for evaluating fibrosis and assessing disease severity and prognostic purposes post-treatment. Noninvasive alternatives for liver biopsy such as transient elastography (TE) and diffusion-weighted magnetic resonance imaging (DW-MRI) are critical needs.

AIM

To evaluate TE and DW-MRI as noninvasive tools for predicting liver fibrosis in children with CHC.

METHODS

This prospective cross-sectional study initially recruited 100 children with CHC virus infection. Sixty-four children completed the full set of investigations including liver stiffness measurement (LSM) using TE and measurement of apparent diffusion coefficient (ADC) of the liver and spleen using DW-MRI. Liver biopsies were evaluated for fibrosis using Ishak scoring system. LSM and liver and spleen ADC were compared in different fibrosis stages and correlation analysis was performed with histopathological findings and other laboratory parameters.

RESULTS

Most patients had moderate fibrosis (73.5%) while 26.5% had mild fibrosis. None had severe fibrosis or cirrhosis. The majority (68.8%) had mild activity, while only 7.8% had moderate activity. Ishak scores had a significant direct correlation with LSM (P = 0.008) and were negatively correlated with both liver and spleen ADC but with no statistical significance (P = 0.086 and P = 0.145, respectively). Similarly, histopathological activity correlated significantly with LSM (P = 0.002) but not with liver or spleen ADC (P = 0.84 and 0.98 respectively). LSM and liver ADC were able to significantly discriminate F3 from lower fibrosis stages (area under the curve = 0.700 and 0.747, respectively) with a better performance of liver ADC.

CONCLUSION

TE and liver ADC were helpful in predicting significant fibrosis in children with chronic hepatitis C virus infection with a better performance of liver ADC.

Effect of cranberry supplementation on liver enzymes and cardiometabolic risk factors in patients with NAFLD: a randomized clinical trial

Background

We aimed to evaluate the effect of cranberry supplementation on serum liver enzymes, hepatic steatosis, and cardiometabolic risk factors in patients with non-alcoholic fatty liver (NAFLD).

Methods

In the present parallel-designed randomized controlled clinical trial, 110 patients with NAFLD were enrolled. The patients were randomized to receive 144 mg cranberry capsule or placebo for 6 months. The primary efficacy of the treatment was lipid profile, glycemic measurements, and liver enzyme levels.

Results

The data were reported for 46 in the supplementation group and 48 in the placebo group. The patient’s mean (SD) age was 43.16 (11.08) years. No significant differences between groups were observed regarding the post-intervention level of liver enzyme. The mean after-intervention levels of total cholesterol (p < 0.001) and triglyceride (p = 0.01) were significantly lower in the intervention group compared with the placebo group. At the end of the study, the mean insulin and HOMA-IR levels were significantly lower in the cranberry group compared with the placebo group. Significantly more patients in the cranberry group experienced a decrease in steatosis level compared with the control group.

Conclusion

The results of the present study showed that cranberry supplementation had a positive effect on some lipid profiles, insulin resistance, and hepatic steatosis in patients with NAFLD.

Trial registration

IRCT20200725048200N1; first registration date: 11.8.2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-021-03436-6.

Evaluation of ultrasonic fibrosis diagnostic system using convolutional network for ordinal regression

PURPOSE

Diagnosis of liver fibrosis is important for establishing treatment and assessing the risk of carcinogenesis. Ultrasound imaging is an excellent diagnostic method as a screening test in terms of non-invasiveness and simplicity. The purpose of this study was to automatically diagnose liver fibrosis using ultrasound images to reduce the burden on physicians.

METHODS

We proposed and implemented a system for extracting regions of liver parenchyma utilizing U-Net. Using regions of interest, the stage of fibrosis was classified as F0, F1, F2, F3, or F4 utilizing CORALNet, an ordinal regression model based on ResNet18. The effectiveness of the proposed system was verified.

RESULTS

The system implemented using U-Net had a maximum mean Dice coefficient of 0.929. The results of classification of liver fibrosis utilizing CORALNet had a mean absolute error (MAE) of 1.22 and root mean square error (RMSE) of 1.60. The per-case results had a MAE of 1.55 and RMSE of 1.34.

CONCLUSION

U-Net extracted regions of liver parenchyma from the images with high accuracy, and CORALNet showed effectiveness using ordinal information to classify fibrosis in the images. As a future task, we will study a model that is less dependent on teaching data.

Association Between Transient Elastography and Controlled Attenuated Parameter and Liver Ultrasound in Children With Cystic Fibrosis

Methods to identify children with cystic fibrosis (CF) at risk for development of advanced liver disease are lacking. We aim to determine the association between liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE) with research ultrasound (US) patterns and conventional hepatic markers as a potential means to follow liver disease progression in children with CF. ELASTIC (Longitudinal Assessment of Transient Elastography in CF) is a nested cohort of 141 patients, ages 7-21, enrolled in the Prediction by US of Risk of Hepatic Cirrhosis in CF (PUSH) Study. We studied the association between LSM with research-grade US patterns (normal [NL], heterogeneous [HTG], homogeneous [HMG], or nodular [NOD]) and conventional hepatic markers. In a subgroup (n = 79), the association between controlled attenuation parameter (CAP) and US pattern was explored. Among 133 subjects undergoing VCTE, NOD participants (n = 26) had a significantly higher median (interquartile range) LSM of 9.1 kPa (6.3, 15.8) versus NL (n = 72, 5.1 kPa [4.2, 7.0]; P < 0.0001), HMG (n = 17, 5.9 kPa [5.2, 7.8]; P = 0.0013), and HTG (n = 18, 6.1 kPa [4.7, 7.0]; P = 0.0008) participants. HMG participants (n = 14) had a significantly higher mean CAP (SD) (270.5 dB/m [61.1]) compared with NL (n = 40, 218.8 dB/m [46.5]; P = 0.0027), HTG (n = 10, 218.1 dB/m [60.7]; P = 0.044), and NOD (n = 15, 222.7 dB/m [56.4]; P = 0.041) participants. LSM had a negative correlation with platelet count (r_s =  - 0.28, P = 0.0071) and positive correlation with aspartate aminotransferase-to-platelet ratio index (r_s = 0.38, P = 0.0002), Fibrosis-4 index (r_s = 0.36, P = 0.0007), gamma-glutamyltransferase (GGT; r_s = 0.35, P = 0.0017), GGT-to-platelet ratio (r_s = 0.35, P = 0.003), and US spleen size z-score (r_s = 0.27, P = 0.0073). Conclusion: VCTE is associated with US patterns and conventional markers in patients with liver disease with CF.

Intravoxel incoherent motion parameters in the evaluation of chronic hepatitis B virus-induced hepatic injury: fibrosis and capillarity changes

OBJECTIVE

To evaluate the diagnostic efficacy of intravoxel incoherent motion (IVIM) parameters in hepatitis B virus (HBV)-induced hepatic fibrosis using different calculation methods and to investigate histopathologic origins.

MATERIALS AND METHODS

Liver biopsies from 37 prospectively recruited chronic hepatitis B patients were obtained. Twelve b-value (0-1000 s/mm²) diffusion-weighted imaging (DWI) was performed with a 1.5 T scanner and was followed by blinded percutaneous liver biopsy. All biopsy specimens were evaluated with Ishak staging, and the microvascular density (MVD) was calculated. Patients were classified as having no/mild (F0-1), moderate (F2-3), or marked (F4-5) fibrosis. Pseudodiffusion (D*), the perfusion fraction (f), and the apparent diffusion coefficient (ADC) were calculated using all b-values, while true diffusion (D) was calculated using all b-values [D_0-1000] and b-values greater than 200 s/mm² [D_200-1000]. Three concentric regions of interest (ROIs) (5, 10, and 20 mm) centered on the biopsy site were used.

RESULTS

D* was correlated with the MVD (p = 0.015, Pearson's r = 0.415), but f was not (p = 0.119). D_0-1000 was inversely correlated with Ishak stage (p = 0.000, Spearman's r_s =  - 0.685) and was significantly decreased in all the fibrosis groups; however, only the no/mild and marked fibrosis groups had significantly different D_200-1000 values. A pairwise comparison of receiver operating characteristic (ROC) curves of D_0-1000 and D_200-1000 showed significant differences (p = 0.039). D* was the best at discriminating early fibrosis (AUC = 0.861), while the ADC best discriminated advanced fibrosis (AUC = 0.964).

CONCLUSION

D* was correlated with the MVD and is a powerful parameter to discriminate early hepatic fibrosis. D significantly decreased with advanced fibrosis stage when using b-values less than 200 s/mm² in calculations.

Therapeutic Effects of Garlic on Hepatic Steatosis in Nonalcoholic Fatty Liver Disease Patients: A Randomized Clinical Trial

BACKGROUND AND AIMS

Emerging evidence suggests that garlic (Allium sativum L.) and its bioactive components can mitigate hepatic steatosis by the modulation of hepatic lipid metabolism. We aimed to assess the efficacy of the garlic administration on hepatic steatosis in patients with NAFLD.

PATIENTS AND METHODS

This clinical trial was conducted on adult patients with ultrasound-diagnosed NAFLD. Eligible participants were randomly assigned, with the use of the stratified blocked procedure, to receive 800 mg garlic or placebo for 15 weeks. The primary outcome was the improvement in the hepatic steatosis diagnosed by ultrasound technique after 15 weeks of intervention.

RESULTS

A total of 110 patients underwent randomization, and 98 patients completed the trial. Twenty-four (51.1%) patients in the garlic group achieved improvement in the hepatic steatosis compared to eight (15.7%) patients in the placebo group with the relative risk of 5.6 (95% CI: 2.17 to 14.5; P=0.001), which remained significant after adjusting for baseline value of hepatic steatosis. There were significant reductions in weight and serum ALT, AST, FBS, Hb A1C, total cholesterol, LDL-cholesterol, and TG concentration with the garlic intake compared to placebo (P<0.05). The results were also significant after adjusting for weight change, energy intake, and physical activity. No serious adverse effects were observed with the garlic intake.

CONCLUSION

The intake of garlic powder was accompanied by a significant improvement in the hepatic steatosis and comorbidity related to this condition among subjects with NAFLD.

Role of gut microbiota and oxidative stress in the progression of non-alcoholic fatty liver disease to hepatocarcinoma: Current and innovative therapeutic approaches

Non-alcoholic fatty liver disease (NAFLD) represents the most common chronic liver disease in industrialized countries. NAFLD progresses through the inflammatory phase of non-alcoholic steatohepatitis (NASH) to fibrosis and cirrhosis, with some cases developing liver failure or hepatocellular carcinoma (HCC). Liver biopsy remains the gold standard approach to a definitive diagnosis of NAFLD and the distinction between simple steatosis and NASH. The pathogenesis of NASH is still not clear. Several theories have been proposed ranging from the "Two Hit Theory" to the "Multiple Hit Theory". However, the general consensus is that the gut microbiota, oxidative stress, and mitochondrial damage play key roles in the pathogenesis of NASH. The interaction between the gut epithelia and some commensal bacteria induces the rapid generation of reactive oxygen species (ROS). The main goal of any therapy addressing NASH is to reverse or prevent progression to liver fibrosis/cirrhosis. This problem represents the first "Achilles' heel" of the new molecules being evaluated in most ongoing clinical trials. The second is the inability of these molecules to reach the mitochondria, the primary sites of energy production and ROS generation. Recently, a variety of non-pharmacological and pharmacological treatment approaches for NASH have been evaluated including vitamin E, the thiazolidinediones, and novel molecules related to NASH pathogenesis (including obeticholic acid and elafibranor). Recently, a new isoform of human manganese superoxide dismutase (MnSOD) was isolated and obtained in a synthetic recombinant form designated rMnSOD. This protein has been shown to be a powerful antioxidant capable of mediating ROS dismutation, penetrating biological barriers via its uncleaved leader peptide, and reducing portal hypertension and fibrosis in rats affected by liver cirrhosis. Based on these distinctive characteristics, it can be hypothesized that this novel recombinant protein (rMnSOD) potentially represents a new and highly efficient adjuvant therapy to counteract the progression from NASH to HCC.

Transient elastography in clinical detection of liver cirrhosis: A systematic review and meta-analysis

BACKGROUND/AIMS

Transient elastography is a noninvasive method for measuring liver fibrosis. This meta-analysis assesses the diagnostic performance of transient elastography of detecting liver cirrhosis in patients with liver disease.

PATIENTS AND METHODS

We searched MEDLINE, Cochrane, EMBASE databases until Jan 31, 2015, using the following search terms: elastography and liver cirrhosis. Included studies assessed patients with a diagnosis of liver cirrhosis, with an index test of transient elastography, and with the reference standard being a histopathological exam by liver biopsy. Sensitivity analysis and assessment of risk of bias and publication bias were performed.

RESULTS

Fifty-seven studies were included in the meta-analysis with a total of 10,504 patients. The pooled estimate for the sensitivity of transient elastography for detecting liver fibrosis was 81% and the specificity was 88%. The imputed diagnostic odds ratio (DOR) was 26.08 and the area under the receiver-operating characteristic (AUROC) curve was 0.931.

CONCLUSION

Our findings indicate that transient elastography shows good sensitivity, specificity and a high accuracy for detecting liver cirrhosis. Transient elastography can be used as an additional method for the clinical diagnosis of liver fibrosis and cirrhosis.

Ultrasound elastography: liver

Ultrasound elastography, also termed sonoelastography, is being used increasingly in clinical practice to aid the diagnosis and management of diffuse liver disease. Elastography has been shown to be capable of differentiating advanced and early-stage liver fibrosis, and consequently a major application in clinical liver care includes progression to cirrhosis risk stratification through (1) assessment of liver fibrosis stage in HCV and HBV patients, (2) distinguishing non-alcoholic steatohepatitis from simple steatosis in non-alcoholic fatty liver disease patients, and (3) prognostic evaluation of liver disease is autoimmune liver disease. In addition, elastographic characterization of focal liver lesions and evaluation of clinically significant portal hypertension have the potential to be clinically useful and are areas of active clinical research.

Liver stiffness measurement for risk assessment of hepatocellular carcinoma

AIM

Liver fibrosis is a risk factor for hepatocellular carcinoma (HCC), but at what fibrotic stage the risk for HCC is increased has been poorly investigated quantitatively. This study aimed to determine the appropriate cut-off value of liver stiffness for HCC concurrence by FibroScan, and its clinical significance in hepatitis B virus (HBV), hepatitis C virus (HCV) and non-B, non-C (NBNC) liver disease.

METHODS

Subjects comprised 1002 cases (246 with HCC and 756 without HCC) with chronic liver disease (HBV, 104; HCV, 722; and NBNC, 176).

RESULTS

Liver stiffness was significantly greater in all groups with HCC, and the determined cut-off value for HCC concurrence was more than 12.0 kPa in those with HCV, more than 8.5 kPa in those with HBV and more than 12.0 kPa in those with NBNC. Liver stiffness of more than 12.0 kPa was an independent risk factor for new HCC development in HCV. For HCV, risk factors for HCC concurrence were old age, male sex, low albumin, low platelets and liver stiffness, while for HBV they were old age, low platelets and liver stiffness, and for NBNC they were old age, elevated α-fetoprotein and liver stiffness.

CONCLUSION

Liver stiffness cut-off values and their association with HCC concurrence were different depending on the etiology. In HCV, liver stiffness of more than 12.0 kPa was an independent risk factor for new HCC development. Collectively, determining the fibrotic cut-off values for HCC concurrence would be important in evaluating HCC risks.

A health technology assessment of transient elastography in adult liver disease

BACKGROUND

An estimated one in 10 Canadians have some form of liver disease. The reference standard for staging and monitoring liver fibrosis is percutaneous liver biopsy--an invasive procedure associated with risks and complications. Transient elastography (TE) represents a noninvasive, ultrasound-based alternative.

OBJECTIVE

To assess the efficacy of TE compared with liver biopsy for fibrosis staging in adults with five common types of liver disease: hepatitis B, hepatitis C, nonalcoholic fatty liver disease, cholestatic liver disease and complications post-liver transplantation.

METHODS

A systematic review of published and grey literature from 2001 to June 2011 was conducted. Included were observational studies evaluating the accuracy of TE using liver biopsy as the comparator. An economic model was developed to estimate the cost per correct diagnosis gained with liver biopsy compared with TE. Identification of moderate fibrosis (stages 2 to 4) and cirrhosis (stage 4) were considered.

RESULTS

Fifty-seven studies were included in the review. The diagnostic accuracy of TE for the five clinical subgroups had sensitivities ranging from 0.67 to 0.92 and specificities ranging from 0.72 to 0.95. Liver biopsy was associated with an additional $1,427 to $7,030 per correct diagnosis gained compared with TE. The model was sensitive to the sensitivity and specificity of TE and the prevalence of fibrosis.

CONCLUSIONS

TE is an accurate diagnostic method in patients with moderate fibrosis or cirrhosis. TE is less effective but less expensive than liver biopsy. Systemic implementation of TE should be considered for the noninvasive assessment of liver fibrosis.

Invasive and non-invasive techniques for detecting portal hypertension and predicting variceal bleeding in cirrhosis: a review

Portal hypertension is a severe syndrome that may derive from pre-sinusoidal, sinusoidal, and post-sinusoidal causes. As a consequence, several complications (i.e. ascites, oesophageal varices) may develop. In sinusoidal portal hypertension, hepatic venous pressure gradient (HVPG) is a reliable method for defining the grade of portal pressure, establishing the effectiveness of the treatment, and predicting the occurrence of complications; however, some questions exist regarding its ability to discriminate bleeding from non-bleeding varices in cirrhotic patients. Other imaging techniques (transient elastography, endoscopy, endosonography, and duplex Doppler sonography) for assessing causes and complications of portal hypertensive syndrome are available and may be valuable for the management of these patients. In this review, we evaluate invasive and non-invasive techniques currently employed to obtain a clinical prediction of deadly complications, such as variceal bleeding in patients affected by sinusoidal portal hypertension, in order to create a diagnostic algorithm to manage them. Again, HVPG appears to be the reference standard to evaluate portal hypertension and monitor the response to treatment, but its ability to predict several complications and support management decisions might be further improved through the diagnostic combination with other imaging techniques.

Acoustic radiation force elasticity imaging in diagnostic ultrasound

The development of ultrasound-based elasticity imaging methods has been the focus of intense research activity since the mid-1990s. In characterizing the mechanical properties of soft tissues, these techniques image an entirely new subset of tissue properties that cannot be derived with conventional ultrasound techniques. Clinically, tissue elasticity is known to be associated with pathological condition and with the ability to image these features in vivo; elasticity imaging methods may prove to be invaluable tools for the diagnosis and/or monitoring of disease. This review focuses on ultrasound-based elasticity imaging methods that generate an acoustic radiation force to induce tissue displacements. These methods can be performed noninvasively during routine exams to provide either qualitative or quantitative metrics of tissue elasticity. A brief overview of soft tissue mechanics relevant to elasticity imaging is provided, including a derivation of acoustic radiation force, and an overview of the various acoustic radiation force elasticity imaging methods.

Performance of liver stiffness measurements by transient elastography in chronic hepatitis

AIM

To compare results of liver stiffness measurements by transient elastography (TE) obtained in our patients population with that used in a recently published meta-analysis.

METHODS

This was a single center cross-sectional study. Consecutive patients with chronic viral hepatitis scheduled for liver biopsy at the outpatient ward of our Infectious Diseases Department were enrolled. TE was carried out by using FibroScan™ (Echosens, Paris, France). Liver biopsy was performed on the same day as TE, as day case procedure. Fibrosis was staged according to the Metavir scoring system. The diagnostic performance of TE was assessed by using receiver operating characteristic (ROC) curves and the area under the ROC curve analysis.

RESULTS

Two hundred and fifty-two patients met the inclusion criteria. Six (2%) patients were excluded due to unreliable TE measurements. Thus, 246 (171 men and 75 women) patients were analyzed. One hundred and ninety-five (79.3%) patients had chronic hepatitis C, 41 (16.7%) had chronic hepatitis B, and 10 (4.0%) were coinfected with human immunodeficiency virus. ROC curve analysis identified optimal cut-off value of TE as high as 6.9 kPa for F ≥ 2; 7.9 kPa for F ≥ 3; 9.6 kPa for F = 4 in all patients (n = 246), and as high as 6.9 kPa for F ≥ 2; 7.3 kPa for F ≥ 3; 9.3 kPa for F = 4 in patients with hepatitis C (n = 195). Cut-off values of TE obtained by maximizing only the specificity were as high as 6.9 kPa for F ≥ 2; 9.6 kPa for F ≥ 3; 12.2 kPa for F = 4 in all patients (n = 246), and as high as 7.0 kPa for F ≥ 2; 9.3 kPa for F ≥ 3; 12.3 kPa for F = 4 in patients with hepatitis C (n = 195).

CONCLUSION

The cut-off values of TE obtained in this single center study are comparable to that obtained in a recently published meta-analysis that included up to 40 studies.

Elastography for the diagnosis of severity of fibrosis in chronic liver disease: a meta-analysis of diagnostic accuracy

BACKGROUND & AIMS

Transient elastography is a non-invasive method, for the assessment of hepatic fibrosis, developed as an alternative to liver biopsy. We studied the performance of elastography for diagnosis of fibrosis using meta-analysis.

METHODS

MEDLINE, EMBASE, SCI, Cochrane Library, conference abstracts books, and article references were searched. We included studies using biopsy as a reference standard, with the data necessary to calculate the true and false positive, true and false negative diagnostic results of elastography for a fibrosis stage, and with a 3-month maximum interval between tests. The quality of the studies was rated with the QUADAS tool.

RESULTS

We identified 40 eligible studies. Summary sensitivity and specificity was 0.79 (95% CI 0.74-0.82) and 0.78 (95% CI 0.72-0.83) for F2 stage and 0.83 (95% CI 0.79-0.86) and 0.89 (95% CI 0.87-0.91) for cirrhosis. After an elastography result at/over the threshold value for F2 or cirrhosis ("positive" result), the corresponding post-test probability for their presence (if pre-test probability was 50%) was 78%, and 88% respectively, while, if values were below these thresholds ("negative" result), the post-test probability was 21% and 16%, respectively. No optimal stiffness cut-offs for individual fibrosis stages were validated in independent cohorts and cut-offs had a wide range and overlap within and between stages.

CONCLUSIONS

Elastography theoretically has good sensitivity and specificity for cirrhosis (and less for lesser degrees of fibrosis); however, it should be cautiously applied to everyday clinical practice because there is no validation of the stiffness cut-offs for the various stages. Such validation is required before elastography is considered sufficiently accurate for non-invasive staging of fibrosis.

Shear wave velocity is a useful marker for managing nonalcoholic steatohepatitis

AIM

To investigate whether a noninvasive measurement of tissue strain has a potential usefulness for management of nonalcoholic steatohepatitis (NASH).

METHODS

In total 26 patients, 23 NASHs and 3 normal controls were enrolled in this study. NASH was staged based on Brunt criterion. At a region of interest (ROI), a shear wave was evoked by implementing an acoustic radiation force impulse (ARFI), and the propagation velocity was quantified.

RESULTS

Shear wave velocity (SWV) could be reproducibly quantified at all ROIs in all subjects except for 4 NASH cases, in which a reliable SWV value was not calculated at several ROIs. An average SWV of 1.34 +/- 0.26 m/s in fibrous stage 0-1 was significantly slower than 2.20 +/- 0.74 m/s and 2.90 +/- 1.01 m/s in stages 3 and 4, respectively, but was not significantly different from 1.79 +/- 0.78 m/s in stage 2. When a cutoff value was set at 1.47 m/s, receiver operating characteristic analysis showed significance to dissociate stages 3 and 4 from stage 0-1 (P = 0.0092) with sensitivity, specificity and area under curve of 100%, 75% and 94.2%, respectively. In addition, the correlation between SWV and hyaluronic acid was significant (P < 0.0001), while a tendency toward negative correlation was observed with serum albumin (P = 0.053).

CONCLUSION

The clinical implementation of ARFI provides noninvasive repeated evaluations of liver stiffness at an arbitrary position, which has the potential to shed new light on NASH management.

Clinical features of Vibrio vulnificus infections in the coastal areas of the Ariake Sea, Japan

Vibrio vulnificus infection can result in necrotizing fasciitis and sepsis and is associated with high mortality. Most patients infected with this microbe have liver dysfunction as an underlying disease. However, because of the sporadic nature of outbreaks and unidentified cases, extensive evaluation of clinical features and identification of factors affecting prognosis have not been performed. We retrospectively analyzed 37 cases in Japan from 1984 to 2008 to review clinical features and to identify risk factors associated with prognosis. Statistical differences between clinical features (patient's characteristics, initial clinical laboratory data, symptoms upon admission, and other risk indicators) and prognosis were analyzed by use of the chi(2) test or the Mann-Whitney U test. Multivariate logistic regression analysis was also performed to assess factors which potentially affect hospital mortality. The mortality rate was 64.9%. An underlying liver disease was observed in 91.6% of the patients. The presence of liver cirrhosis tended to be related to hospital mortality; however, statistical significance was not achieved. Advanced age, lower platelet counts, and the presence of extensive skin lesions at onset affected outcomes with statistical significance. The prognosis of this disease is poor, because septic shock and necrotizing fasciitis often develop within a few days. Early diagnosis and treatment are needed to improve the prognosis of V. vulnificus infection.