Correlation between ultrasonographic and pathologic diagnosis of liver fibrosis due to chronic virus hepatitis

Potential alternative and novel biomarkers for paediatric MAFLD: exploratory evidence from a Chinese cohort

BACKGROUND

While the associations between pediatric non-obese metabolic dysfunction-associated fatty liver disease (MAFLD) and multiple diagnostic biomarkers are well-established, the role of a broader range of blood-based, urine-based, and body composition-based biomarkers for monitoring MAFLD are needed.

METHODS

A pediatric cohort was established in Wuxi, China. We measured body composition biomarkers, blood-based and urine-based biomarkers, and liver stiffness in participants to diagnose MAFLD and identify alternative and novel potential biomarkers for MAFLD. Body mass index (BMI), high-density lipoprotein cholesterol (HDLC), triglycerides, glucose, systolic blood pressure (SBP), diastolic blood pressure (DBP), and waist perimeter were used as MAFLD diagnostic biomarkers. To identify alternative biomarkers, we performed correlation analysis to determine biomarkers exhibited strong correlation (|r| > 0.8, p-value < 0.05) with diagnostic biomarkers. To identify novel potential biomarkers, we performed regression analysis to determine biomarkers associated with MAFLD (p-value < 0.05 in stepwise multivariate regression) among the remaining biomarkers that are not related to the diagnostic biomarkers.

RESULTS

Out of 1,108 participants who completed all examinations (N biomarker = 91), 113 participants were diagnosed with MAFLD (prevalence: 14.99% in boys and 5.18% in girls). 27 biomarkers that were strongly correlated with diagnostic biomarkers were identified as alternative biomarkers. A multivariate logistic regression analysis identified 9 novel potential biomarkers including 5 blood-based biomarkers (plateletocrit, calcium, insulin, AST/ALT ratio, total bilirubin), urine pH, and body fat measurements in the arm, leg, and thigh.

CONCLUSIONS

This study illustrated the characteristics and potential alternative and novel biomarkers of MAFLD based on a Chinese paediatric cohort. These findings posed new paths in guiding the prevention and early diagnosis and prevention.

TRIAL REGISTRATION

This trial was registered in the Chinese Clinical Trials Registry (ChiCTR2400080508). The date of first registration, 01/31/2024. Retrospectively registered.

Protocol for a Longitudinal Cohort Study to Understand Characteristics and Risk Factors Underlying Vibration-Controlled Transient Elastography-Diagnosed Metabolic Dysfunction-Associated Fatty Liver Disease Children

Background

Metabolic-associated steatotic liver disease (MASLD) is a novel term proposed in 2023 to replace non-alcoholic fatty liver disease (NAFLD) with the aim of better reflecting its pathogenesis and clinical manifestations. Vibration-controlled transient elastography (VCTE) is an evidence-based, non-invasive imaging device used to evaluate liver fat deposition and fibrosis. It can effectively detect liver fat infiltration greater than 5%, which is much higher than the previous ultrasound detection rate (it is difficult to detect liver fat deposition below 30%). Nevertheless, the prevalence and characteristics of MASLD children diagnosed based on these updated criteria are currently not well established.

Methods

Currently, a prospective multi-center population-based cohort study is being conducted in Wuxi, China, spanning from 2023 to 2035, involving 5600 children from four primary schools. Throughout the study's baseline and follow-up periods, yearly physical examinations, laboratory tests, VCTE assessments, and bioelectrical impedance analysis are being conducted to measure MASLD-related biomarkers. Additionally, a questionnaire is being administered to inquire about dietary habits. MASLD is being diagnosed based on clinical and laboratory criteria, and the corresponding prevalence is being assessed.

Results

Recruitment began in March 13, 2023. To date, 1475 participants have completed the physical examination and questionnaire survey.

Discussion

Our study investigated the prevalence of MASLD and its influencing factors in Chinese school-age children and adolescents. By collecting and analyzing data from physical examinations and survey questionnaires, it may propose new avenues for guiding the treatment and early-stage prevention of MASLD in children.

Trial Registration

Chinese Clinical Trials Registry (NO. ChiCTR2400080508).

Artificial Intelligence and Image Analysis-Assisted Diagnosis for Fibrosis Stage of Metabolic Dysfunction-Associated Steatotic Liver Disease Using Ultrasonography: A Pilot Study

BACKGROUND/OBJECTIVES

Elastography increased the diagnostic accuracy of liver fibrosis. However, several challenges persist, including the widespread utilization of equipment, difficulties in measuring certain cases, and the influence of viscosity factors. A rough surface and a blunted hepatic margin have long been acknowledged as valuable characteristics indicative of hepatic fibrosis. The objective of this study was to conduct an image analysis and quantitative assessment of the contour of the sagittal section of the left lobe of the liver.

METHODS

Between February and October 2020, 486 consecutive outpatients underwent ultrasound examinations at our hospital. A total of 214 images were manually annotated by delineating the liver contour to create annotation images. U-Net was employed for liver segmentation, with the dataset divided into training (n = 128), testing (n = 42), and validation (n = 44) subsets. Additionally, 43 Metabolic Dysfunction Associated Steatotic Liver Disease (MASLD) cases with pathology data from between 2015 and 2020 were included. Segmentation was performed using the program developed in the first step. Subsequently, shape analysis was conducted using ImageJ.

RESULTS

Liver segmentation exhibited high accuracy, as indicated by Dice loss of 0.044, Intersection over Union of 0.935, and an F score of 0.966. The accuracy of the classification of the liver surface as smooth or rough via ResNet 50 was 84.6%. Image analysis showed MinFeret and Minor correlated with liver fibrosis stage (p = 0.046, 0.036, respectively). Sensitivity, specificity, and AUROC of Minor for ≥F3 were 0.571, 0.862, and 0.722, respectively, and F4 were 1, 0.600, and 0.825, respectively.

CONCLUSION

Deep learning segmentation of the sagittal cross-sectional contour of the left lobe of the liver demonstrated commendable accuracy. The roughness of the liver surface was correctly judged by artificial intelligence. Image analysis showed the thickness of the left lobe inversely correlated with liver fibrosis stage.

Computed Tomographic Findings of Liver Cirrhosis in Dogs: Comparison between Compensated and Decompensated Cirrhosis

This study aimed to describe computed tomography (CT) characteristics of histologically confirmed cirrhosis and to compare these CT characteristics between compensated and decompensated cirrhosis. Sixteen dogs who underwent contrast CT and histopathological examinations were included; eleven dogs were assigned to the compensated group, and five dogs were assigned to the decompensated group. Irregular hepatic contours with a diffuse nodular distribution and hepatic lymph node enlargement are common concomitant features of cirrhotic livers on CT images. The enhancement patterns of the regenerative nodules and hepatic parenchyma were not significantly different from each other. Hypoattenuating areas with delayed contrast enhancement indicating fibrotic tissue were confirmed in 56.3% of cases. Hypoattenuating wedge-shaped area or nodule with minor or no contrast enhancement (histopathologically confirmed as focal necrosis) were confirmed in 37.5% of cases. Among CT variables, only normalized liver volume and portal vein-to-aorta ratio were significantly lower (p = 0.038 and 0.003, respectively) in the decompensated group. In conclusion, this study presented the CT features of cirrhosis and identified CT features that can discriminate between compensated and decompensated cirrhosis. Specifically, lower normalized liver volume and the portal vein-to-aorta ratio might be useful indicators for the progression of cirrhosis to the decompensated phase.

US-based Sequential Algorithm Integrating an AI Model for Advanced Liver Fibrosis Screening

Background Noninvasive tests can be used to screen patients with chronic liver disease for advanced liver fibrosis; however, the use of single tests may not be adequate. Purpose To construct sequential clinical algorithms that include a US deep learning (DL) model and compare their ability to predict advanced liver fibrosis with that of other noninvasive tests. Materials and Methods This retrospective study included adult patients with a history of chronic liver disease or unexplained abnormal liver function test results who underwent B-mode US of the liver between January 2014 and September 2022 at three health care facilities. A US-based DL network (FIB-Net) was trained on US images to predict whether the shear-wave elastography (SWE) value was 8.7 kPa or higher, indicative of advanced fibrosis. In the internal and external test sets, a two-step algorithm (Two-step#1) using the Fibrosis-4 Index (FIB-4) followed by FIB-Net and a three-step algorithm (Three-step#1) using FIB-4 followed by FIB-Net and SWE were used to simulate screening scenarios where liver stiffness measurements were not or were available, respectively. Measures of diagnostic accuracy were calculated using liver biopsy as the reference standard and compared between FIB-4, SWE, FIB-Net, and European Association for the Study of the Liver guidelines (ie, FIB-4 followed by SWE), along with sequential algorithms. Results The training, validation, and test data sets included 3067 (median age, 42 years [IQR, 33-53 years]; 2083 male), 1599 (median age, 41 years [IQR, 33-51 years]; 1124 male), and 1228 (median age, 44 years [IQR, 33-55 years]; 741 male) patients, respectively. FIB-Net obtained a noninferior specificity with a margin of 5% (P < .001) compared with SWE (80% vs 82%). The Two-step#1 algorithm showed higher specificity and positive predictive value (PPV) than FIB-4 (specificity, 79% vs 57%; PPV, 44% vs 32%) while reducing unnecessary referrals by 42%. The Three-step#1 algorithm had higher specificity and PPV compared with European Association for the Study of the Liver guidelines (specificity, 94% vs 88%; PPV, 73% vs 64%) while reducing unnecessary referrals by 35%. Conclusion A sequential algorithm combining FIB-4 and a US DL model showed higher diagnostic accuracy and improved referral management for all-cause advanced liver fibrosis compared with FIB-4 or the DL model alone. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Ghosh in this issue.

Contribution of Aflatoxin B1 Exposure to Liver Cirrhosis in Eastern Ethiopia: A Case-Control Study

Background

Liver cirrhosis is a global health problem due to a large number of disability-associated life years and mortality. However, evidence is scarce on its causes in Eastern-Ethiopia, a place where there is a high prevalence of liver cirrhosis of unknown etiology. This study attempted to identify the risk factors related to liver cirrhosis in the area.

Methods

A case-control study was conducted at a tertiary care hospital from January 2020 to July 2021. Following diagnoses using an ultrasound-based cirrhosis scale, a total of 127 cases were identified and compared with 253 control patients. A structured questionnaire and data abstraction form were used to collect demographic, lifestyle, and clinical information. A blood sample was also taken from each participant for clinical chemistry, hepatitis B virus (HBV), and hepatitis C virus tests as well as for an aflatoxin B1 (AFB1) albumin adduct (AF-alb) assay. Binary logistic regression analysis was used to determine predictors of liver cirrhosis.

Results

AF-alb levels were detected in 75% of the cases and 64% of the controls, with a median (IQR) level of 11 pg/mg (5.5-25) and 7.0 pg/mg (4.3-20.5), respectively (p<0.05). Moreover, the number of subjects with high AF-alb levels (≥8.6 pg/mg) was greater in cases (45%, p<0.05)) than controls (28%). Age ≥55 years (adjusted odds ratio (AOR)=0.4; 95% CI: 0.2, 0.8), being a farmer (AOR= 3.0; 95% CI: 1.5, 6.0), family history of liver disease (AOR= 2.9; 95% CI: 1.1, 7.9), HBV seropositivity (AOR=4.0; 95% CI: 1.9, 8.8), and exposure to high levels of AF-alb (AOR=2.0; 95% CI: 1.1, 3.7) were significantly associated with liver cirrhosis.

Conclusion

This study found a strong link between AFB1 exposure and liver cirrhosis. Mitigation of aflatoxin exposure and a better understanding of additional environmental risk factors like pesticides may be necessary to reduce the disease burden in Ethiopia.

Grading Bleomycin-Induced Pulmonary Fibrosis in ex vivo Mouse Lungs Using Ultrasound Image Analysis

OBJECTIVES

The aim of this study was to assess bleomycin-induced pulmonary fibrosis on ex vivo mouse lungs using ultrasound image grading and texture analysis.

METHODS

Excised mouse lungs were divided into 3 groups: control, mild fibrosis, and severe fibrosis based on the monitored indicators of health. B-mode ultrasound images were obtained via scanning the mouse lungs ex vivo. The surface smoothness, echo density, and angle of lesions or the lung margin were graded, and the imaging contrast, correlation, homogeneity, and entropy were assessed via texture analysis.

RESULTS

The grades of surface smoothness, echo density, and angle were statistically higher for the severe fibrosis group compared with those of the control and mild fibrosis groups (P < .05). In addition, statistically significant differences in the contrast, correlation, and homogeneity between mild and severe fibrosis groups were observed (P < .05).

CONCLUSIONS

The results obtained in this study suggest that ultrasound image grading and texture analysis are valuable and meaningful methods for assessing pulmonary fibrosis in a bleomycin mouse model.

Diagnostic Accuracy of FibroScan and Factors Affecting Measurements

Evaluating liver steatosis and fibrosis is important for patients with non-alcoholic fatty liver disease. Although liver biopsy and pathological assessment is the gold standard for these conditions, this technique has several disadvantages. The evaluation of steatosis and fibrosis using ultrasound B-mode imaging is qualitative and subjective. The liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) determined using FibroScan are the evidence-based non-invasive measures of liver fibrosis and steatosis, respectively. The LSM and CAP measurements are carried out simultaneously, and the median values of more than ten valid measurements are used to quantify liver fibrosis and steatosis. Here, we demonstrate that the reliability of the LSM depends on the interquartile range to median ratio (IQR/Med), but CAP values do not depend on IQR/Med. In addition, the LSM is affected by inflammation, congestion, and cholestasis in addition to fibrosis, while CAP values are affected by the body mass index in addition to steatosis. We also show that the M probe provides higher LSM values but lower CAP values than the XL probe in the same population. However, there was no statistically significant difference between the diagnostic accuracies of the two probes. These findings are important to understand the reliability of FibroScan measurements and the factors influencing measurement values for all patients.

Advances in Imaging of Diffuse Parenchymal Liver Disease

There are >1.5 billion people with chronic liver disease worldwide, causing liver diseases to be a significant global health issue. Diffuse parenchymal liver diseases, including hepatic steatosis, fibrosis, metabolic diseases, and hepatitis cause chronic liver injury and may progress to fibrosis and eventually hepatocellular carcinoma. As early diagnosis and treatment of these diseases impact the progression and outcome, the need for assessment of the liver parenchyma has increased. While the current gold standard for evaluation of the hepatic parenchymal tissue, biopsy has disadvantages and limitations. Consequently, noninvasive methods have been developed based on serum biomarkers and imaging techniques. Conventional imaging modalities such as ultrasound, computed tomography scan, and magnetic resonance imaging provide noninvasive options for assessment of liver tissue. However, several recent advances in liver imaging techniques have been introduced. This review article focuses on the current status of imaging methods for diffuse parenchymal liver diseases assessment including their diagnostic accuracy, advantages and disadvantages, and comparison between different techniques.

Accuracy of liver stiffness measurement and controlled attenuation parameter using FibroScan® M/XL probes to diagnose liver fibrosis and steatosis in patients with nonalcoholic fatty liver disease: a multicenter prospective study

BACKGROUND

Few studies have evaluated both liver fibrosis and steatosis in patients with nonalcoholic fatty liver disease (NAFLD) using both FibroScan^® M and XL probes. This study was performed to investigate the accuracy of both FibroScan^® probes to diagnose liver fibrosis and steatosis in patients with NAFLD.

METHODS

We prospectively enrolled 137 consecutive patients with clinically suspected NAFLD in our joint-research facilities. Liver biopsies, liver stiffness measurements (LSMs), and controlled attenuation parameter (CAP) measurements were performed, and 122 patients with NAFLD diagnosed pathologically by central pathologists were included in the final analysis.

RESULTS

Reliable LSM results were obtained in 85.2% (M) and 89.3% (XL) of patients, and CAP was reliable in 90.2% (M) and 90.2% (XL). The median LSM was significantly lower with the XL than M probe, and CAP was significantly higher with the XL than M probe. The optimal cut-off values for diagnosing the fibrosis stage were lower for LSM with the XL than M probe (stage ≥ 2, 6.7 vs. 7.0; stage ≥ 3, 8.2 vs. 10.8; stage 4, 14.3 vs. 16.8, respectively), whereas those of CAP were higher for the XL than M probe (score of ≥ 2, 273 vs. 267; score of 3, 302 vs. 286, respectively). There were no significant differences in accuracy of the LSM and CAP between the probes.

CONCLUSIONS

Liver fibrosis and steatosis could be equally evaluated with FibroScan^® M and XL probes in patients with NAFLD. There was no significant difference in diagnostic accuracy between the two probes using probe-specific cut-off values.

Cumulative incidence and risk factors for the development of hepatocellular carcinoma in patients with chronic hepatitis B who achieved sustained disappearance of viremia by nucleos(t)ide analog treatment

AIM

Nucleos(t)ide analog (NA) therapy has been reported to reduce the risk of hepatocellular carcinoma (HCC). However, some patients who achieve hepatitis B virus (HBV)-DNA disappearance from serum by NA develop HCC. In this study, we investigated the cumulative incidence and risk factors for HCC in patients with chronic hepatitis B (CHB) who achieved sustained disappearance of viremia by NA treatment.

METHODS

A total of 133 CHB patients (median age, 51 years; 79 men [59%]; 28 with cirrhosis [21%]) who received NA therapy and achieved HBV-DNA disappearance from serum were analyzed retrospectively. We evaluated the cumulative incidence of HCC and risk factors associated with HCC based on data collected at the time of HBV-DNA disappearance.

RESULTS

Thirteen patients developed HCC during the follow-up period. The 1-, 3-, and 5-year cumulative incidence of HCC was 0.0%, 7.8%, and 11.1%, respectively. In multivariate analysis, advanced age (hazard ratio [HR], 4.601; 95% confidence interval [CI], 1.220-17.351; P = 0.024), liver cirrhosis (HR, 5.563; 95% CI, 1.438-21.519; P = 0.013), and higher HBV core-related antigen (HBcrAg) levels (HR, 13.532; 95% CI, 1.683-108.815; P = 0.014) at the time of HBV-DNA disappearance were significantly associated with the development of HCC.

CONCLUSION

Our findings indicate the importance of continuous HCC surveillance especially in patients with advanced age, cirrhosis, and/or higher serum levels of HBcrAg, even if they achieve HBV-DNA disappearance.

Noninvasive Clinical Predictors of Portal Hypertensive Gastropathy in Patients with Liver Cirrhosis

BACKGROUND AND OBJECTIVES

Portal hypertensive gastropathy (PHG) is described endoscopically as "mosaic-like appearance" of gastric mucosa with or without the red spots. It can only be diagnosed by upper gastrointestinal (GI) endoscopy. The aim of this study was to determine the diagnostic accuracy of platelet count to spleen diameter ratio (PSR) and right liver lobe diameter to albumin ratio (RLAR) in the detection of PHG using upper GI endoscopy as a gold standard in patients with liver cirrhosis.

MATERIAL AND METHODS

This cross-sectional study was conducted in the Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi. All consecutive patients with ages 18-65 years who were screened using esophagogastroduodenoscopy (EGD) to exclude esophageal varices were enrolled. At the same time, findings related to PHG were noted. After informed consent, all the patients had blood tests including platelet count and albumin and abdominal ultrasound determining spleen diameter and right liver lobe diameter.

RESULTS

Out of 111 patients, 59 (53.15%) were males with a mean age of 44 ± 12.61 years. Rate of PHG was observed in 84.68% (94/111) cases confirmed by EGD. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of PSR were 87.23%, 5.88%, 83.67%, 7.69%, and 74.7%, respectively, and those of RLAR were 28.72%, 70.59%, 84.38%, 15.19%, and 35.14%, respectively.

CONCLUSION

PSR is better predictor of PHG than RLAR but at the expense of relatively lower specificities and NPV likely because of underlying pathophysiology (portal hypertension) which is similar for esophageal varices, PHG, and ascites.

Asian-Pacific Association for the Study of the Liver (APASL) consensus guidelines on invasive and non-invasive assessment of hepatic fibrosis: a 2016 update

Hepatic fibrosis is a common pathway leading to liver cirrhosis, which is the end result of any injury to the liver. Accurate assessment of the degree of fibrosis is important clinically, especially when treatments aimed at reversing fibrosis are being evolved. Despite the fact that liver biopsy (LB) has been considered the "gold standard" of assessment of hepatic fibrosis, LB is not favored by patients or physicians owing to its invasiveness, limitations, sampling errors, etc. Therefore, many alternative approaches to assess liver fibrosis are gaining more popularity and have assumed great importance, and many data on such approaches are being generated. The Asian Pacific Association for the Study of the Liver (APASL) set up a working party on liver fibrosis in 2007, with a mandate to develop consensus guidelines on various aspects of liver fibrosis relevant to disease patterns and clinical practice in the Asia-Pacific region. The first consensus guidelines of the APASL recommendations on hepatic fibrosis were published in 2009. Due to advances in the field, we present herein the APASL 2016 updated version on invasive and non-invasive assessment of hepatic fibrosis. The process for the development of these consensus guidelines involved review of all available published literature by a core group of experts who subsequently proposed consensus statements followed by discussion of the contentious issues and unanimous approval of the consensus statements. The Oxford System of the evidence-based approach was adopted for developing the consensus statements using the level of evidence from one (highest) to five (lowest) and grade of recommendation from A (strongest) to D (weakest). The topics covered in the guidelines include invasive methods (LB and hepatic venous pressure gradient measurements), blood tests, conventional radiological methods, elastography techniques and cost-effectiveness of hepatic fibrosis assessment methods, in addition to fibrosis assessment in special and rare situations.

Computer-aided Characterization and Diagnosis of Diffuse Liver Diseases Based on Ultrasound Imaging: A Review

Diffuse liver diseases, such as hepatitis, fatty liver, and cirrhosis, are becoming a leading cause of fatality and disability all over the world. Early detection and diagnosis of these diseases is extremely important to save lives and improve effectiveness of treatment. Ultrasound imaging, a noninvasive diagnostic technique, is the most commonly used modality for examining liver abnormalities. However, the accuracy of ultrasound-based diagnosis depends highly on expertise of radiologists. Computer-aided diagnosis systems based on ultrasound imaging assist in fast diagnosis, provide a reliable "second opinion" for experts, and act as an effective tool to measure response of treatment on patients undergoing clinical trials. In this review, we first describe appearance of liver abnormalities in ultrasound images and state the practical issues encountered in characterization of diffuse liver diseases that can be addressed by software algorithms. We then discuss computer-aided diagnosis in general with features and classifiers relevant to diffuse liver diseases. In later sections of this paper, we review the published studies and describe the key findings of those studies. A concise tabular summary comparing image database, features extraction, feature selection, and classification algorithms presented in the published studies is also exhibited. Finally, we conclude with a summary of key findings and directions for further improvements in the areas of accuracy and objectiveness of computer-aided diagnosis.

Prediction of development of hepatocellular carcinoma using a new scoring system involving virtual touch quantification in patients with chronic liver diseases

BACKGROUND

This study aimed to establish a new scoring system that combined several risk factors, including virtual touch quantification (VTQ) values and fasting plasma glucose (FPG) levels, for predicting the development of hepatocellular carcinoma (HCC) in patients with chronic liver disease.

METHODS

A total of 1808 chronic liver disease patients who underwent VTQ measurement were analyzed. Risk factors for developing HCC were selected by multivariate Cox proportional hazards models.

RESULTS

VTQ (>1.33 m/s), FPG (≥110 mg/dl), sex (male), age (≥55 years), and α-fetoprotein (AFP) level (≥5 ng/ml) were independently selected as risk factors for HCC development by multivariate analysis. Using these parameters, we established a new scoring system (0 to 5 points), based on VTQ, FPG, sex, age, and AFP level, named VFMAP. As compared with the low VFMAP score group (0 or 1 point), the hazard ratio for the incidence of HCC was 17.37 [95 % confidence interval (CI), 2.35-128.40] in the intermediate-score group (2 or 3 points) and 66.82 (95 % CI, 9.01-495.80) in the high-score group (4 or 5 points). The area under the receiver operating characteristic curve of the VFMAP score for predicting HCC development within 5 years was 0.82 (95 % CI, 0.76-0.87), indicating a moderate diagnostic value. A VFMAP cutoff value of 3 excluded HCC within 5 years with a high negative predictive value (98.2 %).

CONCLUSION

The VFMAP score accurately predicted HCC in patients with chronic liver disease.

Echocardiography as a Screening Test for Myocardial Scarring in Children with Hypertrophic Cardiomyopathy

Introduction. Hypertrophic cardiomyopathy (HCM) is burdened with morbidity and mortality including tachyarrhythmias and sudden cardiac death. These complications are attributed in part to the formation of proarrhythmic scars in the myocardium. The presence of extensive LGE is a risk factor for adverse outcomes in HCM. Late gadolinium enhancement (LGE) cardiac magnetic resonance imaging (cMRI) is the standard for the noninvasive evaluation of myocardial scars. However, echocardiography represents an attractive screening tool for myocardial scarring. The aim of this study was to compare the suitability of echocardiography to detect myocardial scars to the standard of cMRI-LGE. Methods. The cMRI studies and echocardiograms from 56 consecutive children with HCM were independently evaluated for the presence of cMRI-LGE and echocardiographic evidence of scarring by expert readers. Results. Echocardiography had a high sensitivity (93%) and negative predictive value (94%) in comparison to LGE. The false positive rate was high, leading to a low specificity (37%) and a low positive predictive value (35%). Conclusions. Given the poor specificity and positive predictive value, echocardiography is not a suitable screening test for the presence of myocardial scarring in children with HCM. However, children without echocardiographic evidence of myocardial scarring may not need to undergo cardiac magnetic resonance imaging to “rule in” LGE.

Four-dimensional flow magnetic resonance imaging in cirrhosis

Since its introduction in the 1970’s, magnetic resonance imaging (MRI) has become a standard imaging modality. With its broad and standardized application, it is firmly established in the clinical routine and an essential element in cardiovascular and abdominal imaging. In addition to sonography and computer tomography, MRI is a valuable tool for diagnosing cardiovascular and abdominal diseases, for determining disease severity, and for assessing therapeutic success. MRI techniques have improved over the last few decades, revealing not just morphologic information, but functional information about perfusion, diffusion and hemodynamics as well. Four-dimensional (4D) flow MRI, a time-resolved phase contrast-MRI with three-dimensional (3D) anatomic coverage and velocity encoding along all three flow directions has been used to comprehensively assess complex cardiovascular hemodynamics in multiple regions of the body. The technique enables visualization of 3D blood flow patterns and retrospective quantification of blood flow parameters in a region of interest. Over the last few years, 4D flow MRI has been increasingly performed in the abdominal region. By applying different acceleration techniques, taking 4D flow MRI measurements has dropped to a reasonable scanning time of 8 to 12 min. These new developments have encouraged a growing number of patient studies in the literature validating the technique’s potential for enhanced evaluation of blood flow parameters within the liver’s complex vascular system. The purpose of this review article is to broaden our understanding of 4D flow MRI for the assessment of liver hemodynamics by providing insights into acquisition, data analysis, visualization and quantification. Furthermore, in this article we highlight its development, focussing on the clinical application of the technique.

Radiographical findings in patients with liver cirrhosis and hepatic encephalopathy

Background and aims: Hepatic encephalopathy is a common complication encountered in patients with liver cirrhosis. Hepatic encephalopathy is not reflected in the current liver transplant allocation system. Correlation was sought between hepatic encephalopathy with findings detected on radiographic imaging studies and the patient’s clinical profile.

Methods: A retrospective analysis was conducted of patients with cirrhosis, who presented for liver transplant evaluation in 2009 and 2010. Patients with hepatocellular carcinoma, ejection fraction less than 60% and who had a TIPS (transjugular intrahepatic portosystemic shunting) procedure or who did not complete the evaluation were excluded. Statistical analysis was performed and variables found to be significant on univariate analysis (P < 0.05) were analysed by a multivariate logistic regression model.

Results: A total of 117 patients met the inclusion criteria and were divided into a hepatic encephalopathy group (n = 58) and a control group (n = 59). Univariate analysis found that a smaller portal vein diameter, smaller liver antero-posterior diameter, liver nodularity and use of diuretics or centrally acting medications showed significant correlation with hepatic encephalopathy. This association was confirmed for smaller portal vein, use of diuretics and centrally acting medications in the multivariate analysis.

Conclusion: A decrease in portal vein diameter was associated with increased risk of encephalopathy. Identifying patients with smaller portal vein diameter may warrant screening for encephalopathy by more advanced psychometric testing, and more aggressive control of constipation and other factors that may precipitate encephalopathy.

Utility of real-time shear wave elastography for assessing liver fibrosis in patients with chronic hepatitis C infection without cirrhosis: Comparison of liver fibrosis indices

AIM

To clarify the diagnostic impact of liver fibrosis except for cirrhosis identified using shear wave elastography (SWE) in chronic hepatitis C (CHC) patients, and to compare the performance in diagnosing liver fibrosis among SWE and liver fibrosis indices.

METHODS

A total of 55 CHC patients who underwent liver biopsy were analyzed. The diagnostic performance for identifying significant liver fibrosis (F2-F3) for SWE, FIB-4 index, aspartate aminotransferase-to-platelet ratio index (APRI) and Forns' index was assessed using receiver-operator curve (ROC) analysis.

RESULTS

The median SWE elasticity value, FIB-4 index, APRI and Forns' index in the F0-F1 and F2-F3 groups were 6.3 kPa and 13.1 kPa; 1.52 and 4.45; 0.41 and 1.43; and 7.69 and 8.85, respectively (P < 0.001 for all four methods). Multivariate analysis showed that SWE was independently associated with the presence of significant liver fibrosis (odds ratio, 2.52; 95% confidence interval, 1.49-4.28; P < 0.001). The area under the ROC curve for SWE in diagnosing significant liver fibrosis was 0.94, indicating high diagnostic value, compared with 0.86, 0.88 and 0.83, for the FIB-4 index, APRI and Forns' index, respectively, which corresponds to moderate diagnostic value. The accuracy of SWE, FIB-4 index, APRI and Forns' index for diagnosing significant liver fibrosis was 90.9%, 76.4%, 74.5% and 67.2%, respectively.

CONCLUSION

SWE has excellent ability for diagnosing significant liver fibrosis in CHC even when patients with cirrhosis are excluded. The diagnostic performance of SWE is superior to that of three liver fibrosis indices.

Long-term prognosis of patients with hepatitis B infection: causes of death and utility of nucleos(t)ide analogue therapy

BACKGROUND

Long-term nucleos(t)ide analogue (NA) therapy for chronic hepatitis B (CHB) patients has been reported to reduce the risk of hepatocellular carcinoma (HCC) development. However, survival rates and causes of death in CHB patients either treated or not treated with NA therapy are unclear. Therefore, we investigated the prognosis of CHB in both of these groups.

METHODS

A total of 919 CHB patients who were treated (n = 189) or not treated (n = 730) with NA therapy were enrolled; of these, 135 were selected from each group by propensity score matching. Survival, mortality from both HCC and non-liver related diseases, and causes of death were analyzed.

RESULTS

In all patients (n = 919), cumulative survival and mortality from both HCC and non-liver related diseases did not differ significantly according to NA therapy status. Of 66 patients who died during the follow-up period, 59.1% died due to liver-related diseases (including HCC); of the remainder, 48.1% died of non-liver related malignancies. In patients selected by propensity score matching (n = 270), cumulative survival and mortality from HCC were significantly improved in those who received NA therapy compared with those who did not (p = 0.015 and 0.018, respectively). Cox proportional hazards models indicated that NA therapy was independently associated with survival of CHB patients (hazard ratio, 0.286; 95% confidence interval, 0.122-0.668; p = 0.004).

CONCLUSIONS

Approximately 40% of CHB patients died of non-liver-related diseases. Additionally, in patients who required anti-viral therapy for CHB, NA therapy improved survival and mortality from HCC.

Cost-effectiveness of non-invasive methods for assessment and monitoring of liver fibrosis and cirrhosis in patients with chronic liver disease: systematic review and economic evaluation

BACKGROUND

Liver biopsy is the reference standard for diagnosing the extent of fibrosis in chronic liver disease; however, it is invasive, with the potential for serious complications. Alternatives to biopsy include non-invasive liver tests (NILTs); however, the cost-effectiveness of these needs to be established.

OBJECTIVE

To assess the diagnostic accuracy and cost-effectiveness of NILTs in patients with chronic liver disease.

DATA SOURCES

We searched various databases from 1998 to April 2012, recent conference proceedings and reference lists.

METHODS

We included studies that assessed the diagnostic accuracy of NILTs using liver biopsy as the reference standard. Diagnostic studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Meta-analysis was conducted using the bivariate random-effects model with correlation between sensitivity and specificity (whenever possible). Decision models were used to evaluate the cost-effectiveness of the NILTs. Expected costs were estimated using a NHS perspective and health outcomes were measured as quality-adjusted life-years (QALYs). Markov models were developed to estimate long-term costs and QALYs following testing, and antiviral treatment where indicated, for chronic hepatitis B (HBV) and chronic hepatitis C (HCV). NILTs were compared with each other, sequential testing strategies, biopsy and strategies including no testing. For alcoholic liver disease (ALD), we assessed the cost-effectiveness of NILTs in the context of potentially increasing abstinence from alcohol. Owing to a lack of data and treatments specifically for fibrosis in patients with non-alcoholic fatty liver disease (NAFLD), the analysis was limited to an incremental cost per correct diagnosis. An analysis of NILTs to identify patients with cirrhosis for increased monitoring was also conducted.

RESULTS

Given a cost-effectiveness threshold of £20,000 per QALY, treating everyone with HCV without prior testing was cost-effective with an incremental cost-effectiveness ratio (ICER) of £9204. This was robust in most sensitivity analyses but sensitive to the extent of treatment benefit for patients with mild fibrosis. For HBV [hepatitis B e antigen (HBeAg)-negative)] this strategy had an ICER of £28,137, which was cost-effective only if the upper bound of the standard UK cost-effectiveness threshold range (£30,000) is acceptable. For HBeAg-positive disease, two NILTs applied sequentially (hyaluronic acid and magnetic resonance elastography) were cost-effective at a £20,000 threshold (ICER: £19,612); however, the results were highly uncertain, with several test strategies having similar expected outcomes and costs. For patients with ALD, liver biopsy was the cost-effective strategy, with an ICER of £822.

LIMITATIONS

A substantial number of tests had only one study from which diagnostic accuracy was derived; therefore, there is a high risk of bias. Most NILTs did not have validated cut-offs for diagnosis of specific fibrosis stages. The findings of the ALD model were dependent on assuptions about abstinence rates assumptions and the modelling approach for NAFLD was hindered by the lack of evidence on clinically effective treatments.

CONCLUSIONS

Treating everyone without NILTs is cost-effective for patients with HCV, but only for HBeAg-negative if the higher cost-effectiveness threshold is appropriate. For HBeAg-positive, two NILTs applied sequentially were cost-effective but highly uncertain. Further evidence for treatment effectiveness is required for ALD and NAFLD.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001561.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Changes in portal hemodynamics after TIPS in liver cirrhosis and portal hypertension

OBJECTIVE

The objective of this study is to analyze the changes in portal hemodynamics that occurs in portal hypertension before and after transjugular intrahepatic portosystemic shunt (TIPS), to investigate the relationship between these changes and portal pressure (PP) and to determine the significance of sonographic parameters in measuring PP.

METHODS

Ultrasonography of the portal and splenic veins and direct measurement of the PP were performed in 92 patients before and after TIPS. The differences observed in the portal and splenic vein diameters, the blood flow velocity in the portal and splenic veins and the PP were measured, and the correlations between PP and the other parameters were assessed using the SPSS 13 (SPSS Inc., Chicago, IL, USA). P < 0.05 was considered statistically significant.

RESULTS

We observed a significant decrease in the PP and the diameters of the portal and splenic veins compared to preoperative conditions (p < 0.001). The velocity of blood flow in the portal and splenic veins was significantly increased after TIPS (p < 0.001). The PP correlated with the diameter and velocity of blood flow in portal (r = 0.46, p = 0.020; r = 0.47, p = 0.017) and splenic vein (r = 0.57, p = 0.003; r = 0.33, p = 0.003) only in Child's A and was absent in Child's B cirrhosis patients.

CONCLUSION

The PP is influenced by the complex interaction between intrahepatic vascular resistance, collaterals and the amount of portal blood flow, which varies considerably between individuals. Once a certain pressure threshold is reached, collaterals form, and the correlation between the ultrasonographic parameters and PP becomes limited.

Effect of nucleos(t)ide analogue therapy on hepatocarcinogenesis in chronic hepatitis B patients: a propensity score analysis

BACKGROUND & AIMS

Some patients with chronic hepatitis B virus (HBV) infection progress to hepatocellular carcinoma (HCC). However, the long-term effect of nucleos(t)ide analogue (NA) therapy on progression to HCC is unclear.

METHODS

Therefore, we compared chronic hepatitis B patients who received NA therapy to those who did not, using a propensity analysis.

RESULTS

Of 785 consecutive HBV carriers between 1998 and 2008, 117 patients who received NA therapy and 117 patients who did not, were selected by eligibility criteria and propensity score matching. Factors associated with the development of HCC were analyzed. In the follow-up period, HCC developed in 57 of 234 patients (24.4%). Factors significantly associated with the incidence of HCC, as determined by Cox proportional hazards models, include higher age (hazard ratio, 4.36 [95% confidence interval, 1.33-14.29], p=0.015), NA treatment (0.28 [0.13-0.62], p=0.002), basal core promoter (BCP) mutations (12.74 [1.74-93.11], p=0.012), high HBV core-related antigen (HBcrAg) (2.77 [1.07-7.17], p=0.036), and high gamma glutamyl transpeptidase levels (2.76 [1.49-5.12], p=0.001).

CONCLUSIONS

NA therapy reduced the risk of HCC compared with untreated controls. Higher serum levels of HBcrAg and BCP mutations are associated with progression to HCC, independent of NA therapy.

Characteristics of elderly hepatitis C virus-associated hepatocellular carcinoma patients

BACKGROUND AND AIM

The average age of hepatitis C virus (HCV)-related hepatocellular carcinoma (HCC) patients has been rising in Japan. We evaluate characteristics of HCV-positive patients who develop HCC in older age to determine an optimal surveillance strategy.

METHODS

A total of 323 patients with three or more years of follow-up before HCC diagnosis and 323 propensity-matched controls without HCC were studied. HCC patients were classified into four groups according to age at the time of HCC diagnosis: group A (≤ 60 years, n = 36), group B (61-70 years, n = 115), group C (71-80 years, n = 143), and group D (> 80 years, n = 29). Clinical and laboratory data were compared.

RESULTS

Platelet counts were significantly higher in the older groups at HCC diagnosis (P < 0.0001). The rate of platelet counts decline was lower in older groups (P = 0.0107). The average integration value of serum alanine aminotransferase (ALT) in groups A, B, C, and D were 80.9 IU/L, 62.3 IU/L, 59.0 IU/L, and 44.9 IU/L, respectively (P < 0.0001). In older patients (≥ 65 years old), cirrhosis and average integration value of ALT were significantly associated with hepatocarcinogenesis, but platelet count was not.

CONCLUSION

Elderly HCV-positive patients (≥ 65 years old) with low ALT values developed HCC regardless of their platelet counts. These findings should be taken into account when designing the most suitable HCC surveillance protocol for this population.

Predictive value of tumor markers for hepatocarcinogenesis in patients with hepatitis C virus

BACKGROUND

Increases in tumor markers are sometimes seen in patients with chronic liver disease without hepatocellular carcinoma (HCC). The aim of this study was to determine the relationship between the levels of three tumor markers [alpha-fetoprotein (AFP), Lens culinaris agglutinin-reactive fraction of AFP (AFP-L3%), and des-γ-carboxy prothrombin (DCP)] and hepatic carcinogenesis to identify hepatitis C virus (HCV) carriers at high risk for cancer development.

METHODS

A total of 623 consecutive HCV carriers with follow-up periods of >3 years were included. The average integration values were calculated from biochemical tests, and tumor markers, including AFP, AFP-L3%, and DCP, and factors associated with the cumulative incidence of HCC were analyzed.

RESULTS

HCC developed in 120 (19.3%) of the 623 patients. Age >65 years [adjusted relative risk, 2.303 (95% confidence interval, 1.551-3.418), P < 0.001], low platelet count [3.086 (1.997-4.768), P < 0.001], high aspartate aminotransferase value [3.001 (1.373-6.562), P < 0.001], high AFP level [≥10, <20 ng/mL: 2.814 (1.686-4.697), P < 0.001; ≥20 ng/mL: 3.405 (2.087-5.557), P < 0.001] compared to <10 ng/mL, and high AFP-L3% level [≥5, <10%: 2.494 (1.291-4.816), P = 0.007; ≥10%: 3.555 (1.609-7.858), P < 0.001] compared to <5% were significantly associated with an increased incidence of HCC on multivariate analysis.

CONCLUSIONS

Increased AFP or AFP-L3% levels were significantly associated with an increased incidence of HCC. Among HCV carriers, patients with ≥10 ng/mL AFP or patients with ≥5% AFP-L3% are at very high risk for the development of HCC even if AFP is less than 20 ng/mL or AFP-L3% is less than 10%, which are the most commonly reported cutoff values.

Previously unrecognized advanced liver disease unveiled by transient elastography in patients with Haemophilia and chronic hepatitis C

Before the introduction of viral inactivation procedures and viral screening of plasma-products, haemophiliacs were at high risk of infection with HCV. Those who acquired HCV infection in the 1980s, and are still alive today, may have developed significant liver fibrosis or cirrhosis. However, liver biopsy has not routinely been utilized in the evaluation of haemophiliacs with HCV in Denmark. The aim of this study was to investigate the prevalence of significant fibrosis/cirrhosis among haemophiliacs as evaluated by transient elastography (TE). Cross-sectional investigation of adult patients with haemophilia A or B. TE with liver stiffness measurements (LSM) ≥ 8 kPa were repeated after 4-6 weeks. Significant fibrosis and cirrhosis was defined as measurements ≥ 8 kPa or ≥ 12 kPa respectively. Among 307 patients with haemophilia A or B registered at the two Haemophilia centres, 141(46%) participate in this study. Forty (28.4%) had chronic hepatitis C, 33 (23.4%) past hepatitis C and 68 (48.2%) had never been infected, at screening LSM ≥ 8 kPa were found in 45.7%, 24.7% and 4.6% respectively. Among patients with chronic hepatitis C significant fibrosis was confirmed in 17.1% and cirrhosis in 2.9% by repeated LSM ≥ 8 and ≥ 12 kPa respectively. The median TE-value in never HCV-infected haemophiliacs was comparable with what has been found in healthy non-haemophiliacs. In Danish haemophiliacs where liver biopsy has not routinely been used for assessing severity of liver fibrosis, LSM identified advanced liver disease in one-fifth of cases that had not been recognized during clinical follow-up.

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.

Prediction of compensated liver cirrhosis by ultrasonography and routine blood tests in patients with chronic viral hepatitis

BACKGROUND/AIMS

Liver biopsy is a standard method for diagnosis of liver cirrhosis in patients with chronic hepatitis. Because liver biopsy is an invasive method, non-invasive methods have been used for diagnosis of compensated liver cirrhosis in patients with chronic hepatitis. The current study was designed to evaluate the usefulness of ultrasonography and routine blood tests for diagnosis of compensated liver cirrhosis in patients with chronic viral hepatitis.

METHODS

Two hundred three patients with chronic viral hepatitis who underwent liver biopsy were included in this study and ultrasonography and routine blood tests were analyzed retrospectively. Ultrasonographic findings, including surface nodularity, parenchyma echogenecity, and spleen size, were evaluated. The diagnostic accuracy of ultrasonography and routine blood tests were examined.

RESULTS

Discriminant analysis with forward stepwise selection of variables showed that liver surface nodularity, platelet count, and albumin level were independently associated with compensated liver cirrhosis (p<0.05). Cross-tabulation revealed that the following 4 variables had >95% specificity: platelet count <100,000 /uL; albumin level <3.5 g/dL; INR >1.3; and surface nodularity. If at least one of the four variables exists in a patient with chronic viral hepatitis, we can predict liver cirrhosis with 90% specificity and 61% sensitivity.

CONCLUSIONS

These results suggest that four variables (platelet count <100,000 /uL, albumin level <3.5 g/dL, INR >1.3, and surface nodularity) can be used for identification of liver cirrhosis in patients with chronic viral hepatitis with high specificity.

Prognostic analysis of acute exacerbations of hepatitis-B after chemotherapy in combination with rituximab in 19 patients with lymphoma

The prognosis and management of acute exacerbations of hepatitis-B in patients with lymphoma after chemotherapy in combination with rituximab remain unclear. Here, we describe 19 Chinese patients with lymphoma who suffered this complication, in order to analyze their clinical characteristics. Receiver operating characteristic analysis and Kaplan-Meier survival analysis were utilized to determine potential prognostic factors. We found that key prognostic factors included the peak prothrombin time (PT), international normalized ratio (INR), and total bilirubin (TB), as well as the PT and INR on admission and the interval between acute exacerbation of hepatitis-B and the last cycle of chemotherapy. Moreover, our data suggested that shorter interval between the last cycle of rituximab and acute exacerbation of hepatitis-B might be another prognostic indicator of inferior survival. Our results revealed that the severity of hepatic damage and the interval between the last cycle of chemotherapy and hepatitis flare were the major prognostic factors of an acute exacerbation of hepatitis-B induced by immunochemotherapy. Prophylactic antiviral and rescue antiviral therapy remain to be further characterized.

Accuracy of ultrasound to identify chronic liver disease

AIM: To identify and assess studies reporting the diagnostic performance of ultrasound imaging for identifying chronic liver disease (CLD) in a high risk population.

METHODS: A search was performed to identify studies investigating the diagnostic accuracy of ultrasound imaging for CLD. Two authors independently used the quality assessment of diagnostic accuracy studies (QUADAS) checklist to assess the methodological quality of the selected studies. Inter-observer reliability of the QUADAS tool was assessed by measuring the degree of agreement (percent agreement, κ statistic) between the reviewers for each assessment prior to a consensus meeting. The characteristics of each study population, sensitivity and specificity results for the index tests, and results of any testing for observer agreement were extracted from the reports. Receiver Operator Characteristic plots were generated using Microsoft Excel 2003 software and used to graphically display the diagnostic performance data and to explore the relationships between the reported ultrasound techniques and study characteristics, and methodology quality.

RESULTS: Twenty-one studies published between 1991 and 2009 were retained for data extraction, analysis and assessment for methodological quality. Assessment of methodology quality was performed on the 21 selected studies by two independent reviewers (RA & KT) using the QUADAS assessment tool. Across all studies the mean number of responses within the QUADAS assessment tool was 10 (range 7-13) for “Yes”, 1 (range 0-3) for “No” and 3 (range 0-6) for “unclear”. Inter-rater agreement for assessment of methodology quality was significantly greater than chance when assessing for representative spectrum, clear selection criteria, appropriate delay between reference and index tests, adequate descriptions of the index and reference tests, reference and index test blinding, and if relevant clinical information was provided. Seven studies reported moderate to high observer agreement for ultrasound techniques. Studies which clearly reported blinding performed better than the other studies for diagnostic accuracy, and lower diagnostic accuracy was evident for populations with lower prevalence of disease. Assessment of the liver surface using ultrasound consistently had moderate diagnostic accuracy across studies which demonstrated good research methodology. Other techniques demonstrated variable or poor to fair diagnostic accuracy.

CONCLUSION: Ultrasound of the liver surface is a useful diagnostic tool in patients at risk of CLD when assessing whether they should undergo a liver biopsy.

Incidence of hepatocellular carcinoma in hepatitis C carriers with normal alanine aminotransferase levels

BACKGROUND/AIMS

This study sought to identify the independent risk factors involved in the development of hepatocellular carcinoma (HCC) in patients with chronic hepatitis C virus (HCV) infection who have normal alanine aminotransferase (ALT) levels.

METHODS

A total of 519 patients with average ALT integration values less than or equal to 40 IU/L over 10 years were included. Baseline ultrasound was done in all patients and 68 patients underwent liver biopsy at the start of this study. Factors associated with the cumulative incidence of HCC were determined.

RESULTS

HCC occurred in 48 of 519 patients (9.2%). The following factors were significantly associated with the incidence of HCC: age>65 years (adjusted hazard ratio: 2.006 [95% confidence interval: 1.078-3.733]), ALT>20 IU/L (6.242 [1.499-25.987]), platelet count<15.0x10(4)/m(3) (2.675 [1.407-5.085]), total bilirubin>1.2mg/dL (2.798 [1.257-6.228]), ALP>338 IU/L (2.486 [1.327-4.657]), and total albumin<3.5g/dl (2.707 [1.177-6.223]). The 5- and 10-year cumulative incidences of HCC were 4.4% and 26.5% in patients with ALT>20 IU/L and platelet count<15.0x10(4)/m(3), respectively.

CONCLUSIONS

High ALT level and low platelet count are closely associated with the development of hepatocarcinogenesis. Therefore, individuals within this group are candidates for antiviral therapy.

Effect of body weight and lifestyle changes on long-term course of nonalcoholic fatty liver disease in Koreans

BACKGROUND

Although the prevalence of nonalcoholic fatty liver disease (NAFLD) has been increasing, there have been few studies of long-term changes in NAFLD in large numbers of subjects. This study was performed to assess the long-term changes in severity of fatty liver and to analyze the association with changes in body weight and lifestyle factors.

METHODS

We analyzed lifestyle factors, biochemical data, and abdominal ultrasonography in subjects who underwent voluntary medical checkups at a 5-year interval. Fatty liver on ultrasonography was graded as normal, mild, moderate, or severe by the degree of echogenicity.

RESULTS

The analyzed population consisted of 2895 subjects of age 47+/-8.7 years (range, 20-79 years). Among the 1938 subjects who had normal livers at baseline, 374 subjects (19%) developed fatty liver 5 years later. Those who developed fatty liver showed more weight gain, increase of aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma glutamyl transferase (gamma-GT), and glucose levels during the 5-year period. Among the 930 subjects who had fatty liver at baseline, 263 (28%) subjects showed a decrease in grade and 209 (22%) progressed to a higher grade of fatty liver after 5 years. The group with a lower grade lost -2.2+/-4.3 kg of body weight from baseline, and reduction in hepatic steatosis grade was associated with decreased serum AST, ALT, triglycerides, gamma-GT, and fasting glucose levels.

CONCLUSIONS

Even a small weight reduction was associated with improvements in NAFLD and related metabolic abnormalities such as dyslipidemia and hyperglycemia. Subjects with fatty liver should be advised to lose weight through lifestyle modifications.

Can imaging modalities diagnose and stage hepatic fibrosis and cirrhosis accurately?

The accurate diagnosis and staging of hepatic fibrosis is crucial for prognosis and treatment of liver disease. The current gold standard, liver biopsy, cannot be used for population-based screening, and has well known drawbacks if used for monitoring of disease progression or treatment success. Our objective was to assess performance and promise of radiologic modalities and techniques as alternative, noninvasive assessment of hepatic fibrosis. A systematic review was conducted. Six hundred twenty-eight studies were identified via electronic search. One hundred fifty-three papers were reviewed. Most described techniques that could differentiate between cirrhosis or severe fibrosis and normal liver. Accurate staging of fibrosis or diagnosis of mild fibrosis was often not achievable. Ultrasonography is the most common modality used in the diagnosis and staging of hepatic fibrosis. Elastographic measurements, either ultrasonography-based or magnetic resonance-based, and magnetic resonance diffusion weighted imaging, show the most promise for accurate staging of hepatic fibrosis. Most currently available imaging techniques can detect cirrhosis or significant fibrosis reasonably accurately. However, to date only magnetic resonance elastography has been able to stage fibrosis or diagnose mild disease. Utrasonographic elastography and magnetic resonance diffusion weighted appear next most promising.

Aflatoxin exposure and viral hepatitis in the etiology of liver cirrhosis in the Gambia, West Africa

BACKGROUND

Cirrhosis of the liver is thought to be a major cause of morbidity and mortality in sub-Saharan Africa, but few controlled studies on the etiology of cirrhosis have been conducted in this region.

OBJECTIVES

We aimed to elucidate the association between environmental and infectious exposures and cirrhosis in The Gambia.

METHODS

Ninety-seven individuals were diagnosed with cirrhosis using a validated ultrasound scoring system and were compared with 397 controls. Participants reported demographic and food frequency information. Blood samples were tested for hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), hepatitis C virus (HCV) antibody, HCV RNA, and the aflatoxin-associated 249(ser) TP53 mutation.

RESULTS

HBsAg seropositivity was associated with a significant increase in risk of cirrhosis [odds ratio (OR) = 8.0; 95% confidence interval (CI), 4.4-14.7] as was the presence of HBeAg (OR = 10.3; 95% CI, 2.0-53.9) and HCV infection (OR = 3.3; 95% CI, 1.2-9.5). We present novel data that exposure to aflatoxin, as assessed both by high lifetime groundnut (peanut) intake and by the presence of the 249(ser) TP53 mutation in plasma, is associated with a significant increase in the risk for cirrhosis (OR = 2.8; 95% CI, 1.1-7.7 and OR = 3.8; 95% CI, 1.5-9.6, respectively). Additionally, aflatoxin and hepatitis B virus exposure appeared to interact synergistically to substantially increase the risk of cirrhosis, although this was not statistically significant.

CONCLUSIONS

Our results suggest that the spectrum of morbidity associated with aflatoxin exposure could include cirrhosis.

Diagnosis of liver cirrhosis by transit-time analysis at contrast-enhanced ultrasonography

PURPOSE

The aims of this prospective study were to evaluate analysis of sulfur-hexafluoride-filled microbubble contrast agent (Sonovue) transit times as a tool for differentiating liver cirrhosis from the noncirrhotic stage of liver disease and to compare its performance with that of conventional B-mode and Doppler ultrasonography (US).

MATERIALS AND METHODS

Contrast-enhanced hepatic ultrasonography with the US contrast agent Sonovue was performed on 38 patients with diagnoses of hepatic cirrhosis based on unequivocal clinical signs or liver biopsy findings (Child-Pugh classes A in 19, B in 16 and C in three), 31 patients with noncirrhotic diffuse liver disease (biopsy confirmed) and 14 controls without diffuse liver disease. Time curves of hepatic-vein signal intensity were analysed using objective criteria to determine the time of enhancement onset (hepatic-vein arrival time) and peak enhancement (hepatic-vein peak enhancement). Accuracy in diagnosing cirrhosis was compared with that based on B-mode and Doppler data.

RESULTS

Hepatic-vein arrival time in cirrhotic patients was significantly shorter (p < 0.01) than in noncirrhotic (chronic liver disease and controls) patients. Peak enhancement times in these three groups were not significantly different. An arrival-time cutoff of 17 s distinguished cirrhotic from noncirrhotic patients with high accuracy (100% sensitivity, 93.3% specificity, positive and negative predictive values 92.6% and 100%, respectively) and excellent reproducibility (kappa coefficients of 1.0 and 0.93 for intraand interobserver agreement). Contrast-enhanced US showed better sensitivity than the B-mode and Doppler data.

CONCLUSIONS

Analysis of the time of onset of US contrast enhancement of the hepatic vein appears to be a potentially useful noninvasive supplement to conventional sonography and Doppler in the follow-up of patients with chronic diffuse liver disease.

Ultrasonography in differentiation between chronic viral hepatitis and compensated early stage cirrhosis

AIM

To assess the value of gray scale (GS) and colour Doppler ultrasonography (CDU) in differentiating the progression of chronic viral hepatitis (CVH) and compensated liver cirrhosis (CIR).

METHODS

Seventy-two patients and 32 normal individuals who were used as controls were studied. Forty-four patients suffered from CVH and 28 from CIR. All patients were underwent to liver biopsy. Multiple qualitative and quantitative variables were studied in liver, portal vein (PV), hepatic artery (HA) and spleen with GS and CDU. On the basis of the obtained CDU data, several known indexes were calculated. In addition, alternative indices [PV diameter (D)/time average mean velocity (VTAM), HA/PV VTAM ratio] were calculated and studied.

RESULTS

ROC analysis showed that PV congestion index, PV D/VTAM and HA/PV VTAM indices had the best sensitivity and specificity in discriminating CVH from CIR. Stepwise discriminant analysis showed that 88.9% of the originally grouped cases could be correctly classified by the three qualitative and four quantitative variables selected as statistically significant predictors. Among the CVH patients who underwent to biopsy, statistically significant changes were found in those at fibrosis stage 5 compared to fibrosis stages 1-4.

CONCLUSION

Simple GS and CDU parameters discriminate CVH from CIR. The alternative Doppler indexes can accurately differentiate chronic virus hepatitis from cirrhosis. These indexes can be used in monitoring chronic virus hepatitis and avoiding unnecessary biopsies.

Transient elastography for patients with chronic hepatitis B and C virus infection: Non-invasive, quantitative assessment of liver fibrosis

AIM/METHODS

The aim of the present study was to compare the diagnostic performance of transient elastography (FibroScan) with that of serum fibrosis markers and stages of hepatic fibrosis by biopsy in 68 patients with chronic hepatitis B virus (HBV) and in 161 patients with hepatitis C virus (HCV) infection.

RESULTS

The serum levels of hyaluronic acid (r = 0.601) and type IV collagen (r = 0.663) significantly positively associated with the FibroScan values (all P < 0.05). Classified by fibrosis stages, the median values of FibroScan were 3.5 kPa for F0, 6.4 kPa for F1, 9.5 kPa for F2, 11.4 kPa for F3, and 15.4 kPa forF4 in patients with chronic HBV infection, and were 6.3 kPa for F0, 6.7 kPa for F1, 9.1 kPa for F2, 13.7 kPa for F3, and 26.4 kPa for F4 in those with chronic HCV infection. The values were significantly correlated with fibrosis stage for both (HBV, r = 0.559, P = 0.0093, and HCV, r = 0.686, P < 0.0001).

CONCLUSION

These results suggest that FibroScan is an efficient and simple method for evaluating liver fibrosis in patients with chronic infection, both for HBV and HCV.

Predictors of graft and patient survival in hepatitis C virus (HCV) recipients: model to predict HCV cirrhosis after liver transplantation

BACKGROUND

Hepatitis C virus (HCV) recurrence after liver transplantation (LT) is almost universal, but the natural history of recurrent HCV in the allograft is highly variable. Our study had two aims: 1) to assess the impact of different pre- and postLT factors on graft and patient survival in HCV transplant recipients and 2) to create a model which may predict the patients at risk for HCV-related graft cirrhosis at 5 years postLT.

METHODS

A total of 168 LTs were considered for this study. Univariate and multivariate Cox proportional hazards regression model was used, as well as logistic regression analysis to create a model of prediction of HCV cirrhosis within 5 years after LT.

RESULTS

Predictive factors for both decreased graft and patient survival included patients recently transplanted (2000-2004), induction without azathioprine, short-term therapy with mycophenolate mofetil and prednisone (< or =6 months), presence of early cholestasis, histologically proven early recurrence of hepatitis C. Recipient human leukocyte antigen DR3 positivity, presence of early cholestasis, and donor age >50 years were identified as independent predictors of graft cirrhosis within 5 years. A predictive model was established in order to calculate at 6 months a risk score for graft HCV cirrhosis within 5 years postLT using a formula that included the identified independent predictors. The area under receiver operating characteristic curve was 0.83, indicating a good ability to predict medium-term HCV allograft cirrhosis.

CONCLUSION

This model may be a useful tool for better identifying high-risk HCV patients who should be selected for early initiation of antiviral therapy.

Improvement in the routine diagnostic assessment of the liver by high-resolution sonography: an analysis of 999 cases

OBJECTIVE

High-frequency ultrasound transducers have been helpful in certain settings of transabdominal ultrasound examination, and their role in the evaluation of the liver surface in patients with cirrhosis is well documented. However, their value in the routine assessment of the liver has not yet been analysed systematically. The aim of this pilot study was to clarify whether the additional use of high-frequency ultrasound as compared to the standard 3.5 MHz-transducer is of any benefit.

MATERIAL AND METHODS

A total of 999 patients from a tertiary care medical centre were examined with a wideband 3.5 MHz- and a high-frequency transducer (band width 4.5 to 10 MHz) with tissue harmonic imaging using one of two high-end ultrasound machines (Siemens Sonoline Elegra or Hitachi EUB-8500). Findings on hepatic pathologies were collected on a standardized documentation sheet and were evaluated using descriptive statistics.

RESULTS

In all, 948 patients showed a plain liver surface when the 3.5 MHz transducer was used, whereas this was only true for 862 patients examined with the high-frequency probe. Using the 7.5 MHz probe, the structure of the liver parenchyma appeared to be homogeneous (n=800; 80.1%) less often than when the 3.5 MHz probe (n=822; 82.3%) was used. More cases of liver cirrhosis were suspected with the high-frequency probe (n=66; 6.6% as compared with n=49; 4.9%). In 85 patients (8.5%) new hepatic pathologies were described which had not been detected with the 3.5 MHz probe. The examiners judged the high-frequency examination to be helpful in 284 cases. The time needed for the additional examination ranged between 0.5 and 10 min (mean: 2.2 min).

CONCLUSIONS

This study demonstrates that the additional use of a high-frequency transducer during routine abdominal examinations reveals new hepatic pathologies in a significant proportion of examined patients, without substantial prolongation of the overall examination period.