Editorial: How often can we get the right diagnosis after bone marrow transplant in patients with abnormal liver function tests? Authors' reply

This article is linked to Dezan et al papers. To view these articles, visit https://doi.org/10.1111/apt.17756 and https://doi.org/10.1111/apt.17840

Hepatobiliary disease after bone marrow transplant: A cross-sectional study of 377 patients

BACKGROUND

Bone marrow transplantation (BMT) is a standard treatment for several haematologic conditions. Following BMT, patients may develop hepatobiliary complications that impact morbidity and mortality. The differential diagnosis may include drug-induced liver injury (DILI), sepsis-associated liver injury (SALI), sinusoidal obstruction syndrome (SOS), graft-versus-host disease (GVHD), viral hepatitis, ischaemic hepatitis, and fulminant hepatitis.

AIMS

To evaluate the frequency, clinical characteristics, and outcomes of patients with hepatobiliary alterations associated with BMT in a tertiary referral centre.

METHODS

This was a cross-sectional study with data collected from the medical records of patients undergoing BMT between January 2017 and June 2022. We diagnosed hepatobiliary complications based on established criteria.

RESULTS

We included 377 patients; 55.7% had hepatobiliary complications. Female gender, pre-BMT hepatobiliary alteration, and haploidentical allogeneic transplantation were associated with increased risk with odds ratios (OR) of 1.8 (p = 0.005), 1.72 (p = 0.013) and 3.25 (p = 0.003), respectively. Patients with hepatobiliary complications spent longer in the hospital than those without (27.7 × 19.3 days, respectively; p < 0.001). Among 210 patients with hepatobiliary complications, 28 died compared to 5 of 167 without complications (OR 4.98; p = 0.001).

CONCLUSIONS

Hepatobiliary complications are frequent in patients undergoing BMT. There is a greater risk of their occurrence in women, people with pre-BMT liver alterations, and in haploidentical transplants. The occurrence of these complications increases the length of stay and is associated with a higher risk of death.

Brazilian evidence-based guideline for screening, diagnosis, treatment, and follow-up of metabolic dysfunction-associated steatotic liver disease (MASLD) in adult individuals with overweight or obesity: A joint position statement from the Brazilian Society of Endocrinology and Metabolism (SBEM), Brazilian Society of Hepatology (SBH), and Brazilian Association for the Study of Obesity and Metabolic Syndrome (Abeso)

Introduction

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as Nonalcoholic fatty liver disease (NAFLD), is one of the most common hepatic diseases in individuals with overweight or obesity. In this context, a panel of experts from three medical societies was organized to develop an evidence-based guideline on the screening, diagnosis, treatment, and follow-up of MASLD.

Material and methods

A MEDLINE search was performed to identify randomized clinical trials, meta-analyses, cohort studies, observational studies, and other relevant studies on NAFLD. In the absence of studies on a certain topic or when the quality of the study was not adequate, the opinion of experts was adopted. Classes of Recommendation and Levels of Evidence were determined using prespecified criteria.

Results

Based on the literature review, 48 specific recommendations were elaborated, including 11 on screening and diagnosis, 9 on follow-up,14 on nonpharmacologic treatment, and 14 on pharmacologic and surgical treatment.

Conclusion

A literature search allowed the development of evidence-based guidelines on the screening, diagnosis, treatment, and follow-up of MASLD in individuals with overweight or obesity.

Non-alcoholic fatty liver disease and periodontal disease: A systematic review and meta-analysis of cross-sectional studies

Non-alcoholic fatty liver disease (NAFLD) is a chronic liver disease, comprising hepatic steatosis, and non-alcoholic steatohepatitis. Periodontal disease (PD) may be a risk factor for the evolution of liver cirrhosis. This study aimed to evaluate the association between NAFLD and PD.We searched in Pubmed, Scopus, Cochrane, and Lilacs databases with descriptors (Non-alcoholic Fatty Liver Disease OR (non-alcoholic AND Fatty Liver AND disease) OR Nonalcoholic Steatohepatitis) AND (Periodontal Disease OR Gingivitis OR Periodontitis) from January 2021 to September 2021. We selected, by the abstract, cross-sectional, cohort (prospective and retrospective), and case-control studies that address periodontal disease in patients with Non-alcoholic Fatty Liver Disease, and aged ≥ 18 years. The search was without the restriction of language and publication time.The search resulted in 954 articles. After applying the selection criteria, five cross-sectional studies remained. A metanalysis combined the study estimates of periodontal disease in NAFLD, by using the random effects. The Odds Ratio (1.91; 95% CI 1.21-3.02; P = 0.006) indicates that the chance of presenting Periodontal disease is 91% higher in individuals with NAFLD when compared with individuals without NAFLD. There are few studies with appropriate methodology to produce sound evidence about the causal relationship between the use of NAFLD and PD, however, studies support the association. So, dental staff must be aware of this association for better management of periodontal disease in patients with NAFLD.

From Nonalcoholic Steatohepatits to Steatotic Liver Disease: A Long Way

In 1980, Ludwig et al [...].

Hepatobiliary disease after bone marrow transplant

INTRODUCTION

Bone marrow transplantation (BMT) is the standard treatment for several hematologic pathologies. Post-BMT patients may develop hepatobiliary complications that impact morbidity and mortality. The differential diagnosis may include drug-induced liver injury (DILI), sepsis-associated liver injury (SALI), sinusoidal obstruction syndrome (SOS), graft-versus-host disease (GVHD), viral hepatitis, ischemic and fulminant hepatitis, among others.

AREA COVERED

Defining the etiology of hepatobiliary injury is challenging due to the overlapping symptoms. Thus, it is necessary to be aware of and understand the clinical characteristics of these hepatobiliary complications and provide adequate management with possible better outcomes. We reviewed the scientific literature focused on early hepatobiliary complications associated with BMT. We searched the PubMed database using the following descriptors: hepatic complications, drug-induced liver disease, graft-versus-host disease, cholestasis, sepsis, sinusoidal obstruction syndrome, cytomegalovirus, viral hepatitis, bone marrow transplantation, and hematopoietic stem cell transplantation.

EXPERT OPINION

Post-BMT hepatobiliary complications comprise several differential diagnoses and are challenges for the hepatologist's clinical practice. When evaluating these patients, it is necessary to consider the temporality between the use of certain medications, the increase in liver enzymes, and the presence of infection, in addition to applying diagnostic criteria and complementary tests for a specific diagnosis.

Prevalence of sarcopenia using different methods in patients with non-alcoholic fatty liver disease

BACKGROUND

Sarcopenia is a clinical condition associated with several liver diseases and it includes non-alcoholic fatty liver disease (NAFLD) in its broad spectrum as steatosis, steatohepatitis and fibrosis. However, the criteria to define sarcopenia are diverse, and even those established in consensus have been discussed regarding their performance in making an accurate diagnosis.

AIM

To evaluate the prevalence of sarcopenia, using different methods, in patients with NAFLD, and its association with clinical-anthropometric parameters.

METHODS

This was an observational study of outpatients with NAFLD. Sarcopenia was defined by the European Working Group Consensus on Sarcopenia in Older People of 2010 (EWGSOP1) and 2018 (EWGSOP2). The skeletal muscle index was used to estimate muscle mass, handgrip strength was assessed using the dynamometer and physical performance by walking a distance of four meters at usual walking speed. The non-invasive fibrosis scores, fibrosis-4 (FIB-4) index and Aspartate aminotransferase to platelet ratio index (APRI), were used to assess the absence and presence of fibrosis.

RESULTS

Fifty-seven individuals with NAFLD were evaluated, the mean age (SD) was 52.7 (11.3) years and 75.4% were female. Fibrosis assessed by FIB-4 and APRI was observed in 3.7% and 16.6% of patients with NAFLD, respectively. The diagnosis of sarcopenia was identified only by EWGSOP1 in 3.5% of NAFLD patients, and the prevalence of probable/pre-sarcopenia was higher using the EWGSOP2 consensus at 26.3%, when compared to 1.8% with EWGSOP1. Sarcopenia defined by EWGSOP1, was associated with grade I steatosis, but without overweight (P < 0.05). An association between sarcopenia and fibrosis was not observed (P > 0.05). EWGSOP2 showed a greater number of patients with probable sarcopenia, and who were overweight (12 (80.0%)), with a higher degree of steatosis [11 (73.3%) and presence of fibrosis (1 (6.7%), FIB-4 and 3 (20.0%), APRI] compared to EWGSOP1 [1 (100%), 0 (0.0%), 0 (0.0%), FIB-4 and 0 (0.0%), APRI, respectively].

CONCLUSION

The present study showed that sarcopenia in NAFLD was not predominant in patients without fibrosis, by both diagnostic methods. In addition, the prevalence of probable sarcopenia also depends on the method applied.

Diet and intestinal bacterial overgrowth: Is there evidence?

The intestinal microbiota and its role in health and disease processes have been the subject of several studies. It is known that changes in the intestinal microbiota occur due to several factors, such as the use of medication, age, lifestyle and diseases, which can modify intestinal homeostasis and lead to excessive growth of bacteria in the small intestine, triggering a clinical condition called small bowel bacterial overgrowth (SIBO). Individuals with SIBO may present gastrointestinal symptoms ranging from nausea, diarrhea and/or constipation, and flatulence to distension and abdominal pain, resulting from poor absorption of nutrients or changes in intestinal permeability. The gold-standard treatment is based on the use of antibiotics to eradicate bacterial overgrowth. Some studies have evaluated diets in the treatment of SIBO; however, the studies are of low methodological quality, making extrapolation of the results to clinical practice unfeasible. Thus, there is still not enough scientific evidence to support a specific type of diet for the treatment of SIBO.

Anthropometric clinical indicators of visceral adiposity as predictors of nonalcoholic fatty liver disease

OBJECTIVE

This study aims to evaluate the role of anthropometric clinical indicators of visceral adiposity as predictors of NAFLD, identifying the cutoff points based on gender.

METHODS

This was a cross-sectional study conducted in patients with or without NAFLD. Waist circumference (WC), body mass index (BMI), waist-to-height ratio (WHtR), Conicity Index (C Index), and lipid accumulation product (LAP) were evaluated.

RESULTS

A total of 107 individuals were evaluated, of which 46.7% were diagnosed with NAFLD. Individuals with NAFLD presented higher values of WC, BMI, C Index, LAP, and WHtR when compared with those without NAFLD (p<0.05). For the total sample, the indicators WC, BMI, WHtR, LAP, and C Index had an area under the receiver operator characteristic curve (AUC) above 0.87, with no difference in the prediction of NAFLD in both sexes. WHtR (AUC=0.934) was the indicator of visceral adiposity with the best discriminatory power for NAFLD, followed by LAP (0.919), WC (0.912), C Index (0.907), and BMI (0.877).

CONCLUSIONS

The anthropometric clinical indicators of visceral adiposity showed high performance, especially the WHtR indicator, as NAFLD predictors.

Muscle mass and cellular membrane integrity assessment in patients with nonalcoholic fatty liver disease

OBJECTIVE

To evaluate the association between muscle mass depletion and compromising of the cell membrane integrity and clinical-anthropometric characteristics in patients with nonalcoholic fatty liver disease.

METHODS

This observational study evaluated waist circumference, body mass index, and waist-to-height ratio in patients with nonalcoholic fatty liver disease. Skeletal mass index corrected by weight and impairment of cell membrane integrity were assessed using bioelectrical impedance analysis.

RESULTS

In 56 patients, muscle mass depletion was observed in 62.5% and cell membrane impairment in 28.6%. The metabolic syndrome and elevated aspartate aminotransferase were the only clinical factors associated with mass depletion (p<0.05). The linear regression analysis showed association between skeletal mass index and waist-to-height ratio and waist circumference, after adjustments (p<0.05). The phase angle value was not different between those with and without mass depletion, and also it did not have correlation with skeletal mass index and clinical parameters (p>0.05).

CONCLUSIONS

The prevalence of mass depletion and cell membrane impairment was higher in patients with nonalcoholic fatty liver disease. The muscle mass depletion was associated with central obesity, aspartate aminotransferase elevated, and metabolic syndrome; however, the phase angle is not associated with clinical and anthropometric data.

Anthropometric indicators of visceral adiposity as predictors of non-alcoholic fatty liver disease: A review

The objective was to critically analyze studies that evaluated the predictive capacity of indicators of visceral adiposity in non-alcoholic fatty liver disease (NAFLD). The bibliographic research was carried out using the electronic database PubMed, LILACS and SciELO, references of selected articles. Although we found few studies, they have already used several indicators of visceral adiposity as waist circumference, waist-to-hip ratio, waist-to-height ratio, Lipid accumulation product, Body Shape Index, Body Roundness Index and most them were good predictors of NAFLD. Thus, the anthropometric indicators may contribute for the diagnosis of NAFLD in a simple, low-cost and non-invasive way, allowing early therapeutic measures to prevent the evolution to non-alcoholic steatohepatitis.

Hyperferritinemia in patients with nonalcoholic fatty liver disease

Objective:

In liver diseases, hyperferritinemia (HYF) is related to injured cells in acquired and genetic conditions with or without iron overload. It is frequent in patients with nonalcoholic fatty liver disease (NAFLD), in which it is necessary to define the mean of HYF to establish the better approach for them. The present study evaluated the significance of elevated ferritin in patients with NAFLD and steatohepatitis (NASH).

Method:

The review was performed using search instruments of indexed scientific material, including MEDLINE (by PubMed), Web of Science, IBECS and LILACS, to identify articles published in Portuguese, English and Spanish, from 2005 to May, 2016. Studies eligible included place and year of publication, diagnose criteria to NAFLD, specifications of serum ferritin measurements and/or liver histopathologic study. Exclusion criteria included studies with patients with alcohol consumption ≥ 20 g/day and other liver diseases.

Results:

A total of 11 from 30 articles were selected. It included 3,564 patients and they were cross-sectional, retrospective, case series and case-control. The result's analyses showed in 10 of these studies a relationship between ferritin elevated serum levels and NAFLD/NASH with and without fibrosis and insulin resistance.

Conclusion:

Hyperferritinemia in patients with NAFLD/NASH is associated more frequently with hepatocellular injury than hemochromatosis. These data suggest the relevance to evaluate carefully HYF in patients with NAFLD/NASH to establish appropriate clinical approach.

Nonalcoholic fatty liver disease in patients with coronary disease from a Brazil northeast area

Background Nonalcoholic fatty liver disease (NAFLD) is the most frequent chronic liver injury around the world. It is associated with metabolic syndrome and cardiovascular diseases. Objective To evaluate the frequency and relevance of NAFLD in patients with coronary artery disease (CAD). Methods Patients from a Brazil Northeast area, who underwent elective coronary angiography (CAG) from 2009 to 2010 were included. All of them had suspicion of CAD. Criteria to CAD: presence of obstructive lesions in the epicardial coronary arteries, or in their major branches. NAFLD criteria: presence of hepatic steatosis on ultrasound; exclusion of other liver diseases; ethanol intake ≤ 20g/day. Statistics analysis included Independent t-test, Mann-Whitney and Pearson's chi-squared test. Multivariate regression analysis measured the relationship between the risk factors and the concomitant presence of CAD and NAFLD. Results A total of 244 patients were evaluated: 63.5% had CAD and 42.2% had NAFLD. NAFLD was observed in 43.9% of the CAD patients. The regression analysis showed that the relationship between CAD and NAFLD was positively correlated with HOMA-IR ≥3.0 or insulin resistance and overweight/obesity. Conclusion NAFLD was frequent among CAD patients; insulin resistance and overweight/obesity were the most relevant risk factors related to the association NAFLD and CAD. The results suggest that patients with CAD should be evaluated for NAFLD.

Recreational Anabolic-Androgenic Steroid Use Associated With Liver Injuries Among Brazilian Young Men

BACKGROUND

The recreational use of anabolic-androgenic steroids (AAS) has reached alarming levels among healthy people. However, several complications have been related to consumption of these drugs, including liver disorders.

OBJECTIVE

To evaluate the prevalence of liver injuries in young Brazilian recreational AAS users.

METHODS

Between February/2007 and May/2012 asymptomatic bodybuilders who were ≥18 years old and reported AAS use for ≥6 months were enrolled. All had clinical evaluations, abdominal ultrasound (AUS), and blood tests.

RESULTS

182 individuals were included in the study. The median age (interquartile range) was 26.0 years (22.0-30.0) and all were male. Elevated liver enzyme levels were observed in 38.5% (n = 70) of AAS users, and creatine phosphokinase was normal in 27.1% (n = 19) of them. Hepatic steatosis was observed by AUS in 12.1% of the sample. One individual had focal nodular hyperplasia and another had hepatocellular adenoma. One case each of hepatitis B and C virus infection was found. A diagnosis of toxic liver injury was suggested in 23 (12.6%) AAS users without a history of alcohol or other medications/drugs consumption, or evidence of other liver diseases.

CONCLUSIONS/IMPORTANCE

Young Brazilian recreational AAS users presented a wide spectrum of liver injuries that included hepatotoxicity, fatty liver, and liver neoplasm. They also presented risk factors for liver diseases such as alcohol consumption and hepatitis B and C virus infection. The results suggest that the risk of AAS use for the liver may be greater than the esthetic benefits, and demonstrate the importance of screening AAS users for liver injuries.

The influence of concomitant use of alcohol, tobacco, cocaine, and anabolic steroids on lipid profiles of Brazilian recreational bodybuilders

Anabolic-androgenic steroids (AAS) are used to enhance physical performance and/or appearance. The aim of this study was to evaluate the influence of the concomitant use of alcohol, tobacco, cocaine, and AAS on blood lipid profiles of 145 asymptomatic male bodybuilders from the Northeast region of Brazil. Interviews, clinical exams, and serological evaluations were performed on all participants between 2007 and 2009. All subjects' self-reported use of testosterone or its derivatives, 118 individuals reported alcohol intake, 27-reported cigarette smoking, and 33 confirmed cocaine use. Four subjects were users of all drugs at the same time. Higher levels of total cholesterol and LDL-cholesterol were observed among concomitant users of alcohol, tobacco, cocaine, and AAS. The study's limitations are noted.

Nonalcoholic fatty liver disease in menopausal women

CONTEXT

Nonalcoholic Fatty Liver Disease (NAFLD) is common in postmenopausal women. It is associated with metabolic syndrome. However, the influence of hormone replacement therapy in NAFLD development in these women needs to be investigated. This study aimed to describe the clinical characteristics of NAFLD in postmenopausal women, and the relationship between hormone replacement therapy and this disease.

METHODS

From April 2009 to April 2011, 292 postmenopausal women from National Health System from Northeast of Brazil were selected, and 251 were included in this study. Menopause was defined as the absence of menstruation for 12 consecutive months in otherwise healthy women. Criteria to NAFLD included: presence of steatosis on abdominal ultrasound; history of alcohol consumption less than 20 g/day and exclusion of other liver diseases. All women underwent a clinical evaluation. Standard univariate and multivariate analyses were performed to evaluate the results.

RESULTS

The mean age was 56.5 ± 6.7 years. Hormone replacement therapy was referred by 21.1% (53) women and 78.9% (198) was not. Prevalence of NAFLD was 37.1% (93/251) in postmenopausal women, 26,4% (14/53) in the group with hormone replacement therapy and 39,9% (79/198) without hormone replacement therapy. Gamma-glutamyl transpeptidase (P = 0.001), alanine transaminase (P<0.01), ferritin (P<0.001) and insulin resistance (homeostatic model assessment of insulin resistance ≥3) (P<0.001) were higher in the group of women with NAFLD diagnosis who did not referred the use of hormone replacement therapy. Metabolic syndrome was also more frequent in women with NAFLD, who did not refer hormone replacement therapy.

CONCLUSION

In conclusion this data suggests elevated prevalence of NAFLD in postmenopausal women; negative association of hormone replacement therapy and NAFLD.

Dopplerfluxometria da veia hepática em pacientes com esteatose não alcoólica

OBJETIVO: Avaliar a correlação entre a dopplerfluxometria da veia hepática direita e o grau de esteatose, inflamação e fibrose à biópsia na doença hepática gordurosa não alcoólica. MATERIAIS E MÉTODOS: Foi realizada ultrassonografia com Doppler em 80 pacientes, sendo 40 portadores de doença hepática gordurosa não alcoólica, também submetidos à biópsia. Quarenta controles normais saudáveis, sem fatores risco para doença hepática gordurosa não alcoólica foram submetidos a ultrassonografia com Doppler. O padrão ao Doppler da veia hepática direita foi classificado em trifásico, bifásico e monofásico. Os espécimes de biópsia foram classificados conforme o grau de esteatose, inflamação e fibrose. RESULTADOS: O fluxo foi trifásico em 38 (95%) dos controles e em 9 (56,3%) dos pacientes com esteatose discreta, enquanto nos com esteatose acentuada o padrão foi monofásico em 60%. Encontrou-se diferença significante na distribuição dos padrões ao Doppler (p < 0,01). Houve correlação negativa e significante entre o padrão ao Doppler da veia hepática direita e grau de esteatose (r = -0,57; p < 0,01). CONCLUSÃO: A alteração do padrão ao Doppler da veia hepática direita em pacientes com doença hepática gordurosa não alcoólica pode sugerir redução da complacência vascular consequente a infiltração gordurosa.

Nonalcoholic fatty liver disease in asymptomatic Brazilian adolescents

AIM

To evaluate the prevalence and clinical characteristics of Nonalcoholic fatty liver disease (NAFLD) among asymptomatic Brazilian adolescents.

METHODS

Transversal observational study included asymptomatic adolescents with central obesity from private and public schools in Salvador-Bahia, northeastern Brazil. The children answered a questionnaire that included age, gender, race, and medical history, and were submitted to a complete physical exam and abdominal ultrasound. Biochemical exams included: ALT, AST, GGT, C reactive protein (CRP), fasting glucose, insulin, cholesterol and triglycerides. Criteria for NAFLD included: the presence of steatosis in ultrasound and/or high level of ALT, negative or occasional historic of intake of alcohol (<or= 140 g/wk), negative investigation for hepatitis A, B, C, auto-immune hepatitis, Wilson disease and hemochromatosis.

RESULTS

From October, 2005 to October, 2006, the study included 1801 subjects between 11 and 18 years of age and a mean age of 13.7+/-2.0 years. One hundred ninety-nine had central obesity. The prevalence of NAFLD was 2.3%, most of whom were male and white. Insulin resistance (IR) was observed in 22.9% of them and had positive correlations with ALT and GGT (P<0.05). Elevated CRP was observed in 6.9% of the cases; however, it was not associated with WC, IR or liver enzymes.

CONCLUSION

The prevalence of NAFLD in Brazilian adolescents was low. The ethnicity may have influence this frequency in the population studied, which had a large proportion of African descendents.

Fatty liver disease in severe obese patients: Diagnostic value of abdominal ultrasound

AIM: To evaluate the sensitivity and specificity of abdominal ultrasound (US) for the diagnosis of hepatic steatosis in severe obese subjects and its relation to histological grade of steatosis.

METHODS: A consecutive series of obese patients, who underwent bariatric surgery from October 2004 to May 2005, was selected. Ultrasonography was performed in all patients as part of routine preoperative time and an intraoperative wedge biopsy was obtained at the beginning of the bariatric surgery. The US and histological findings of steatosis were compared, considering histology as the gold standard.

RESULTS: The study included 105 patients. The mean age was 37.2 ± 10.6 years and 75.2% were female. The histological prevalence of steatosis was 89.5%. The sensitivity and specificity of US in the diagnosis of hepatic steatosis were, respectively, 64.9% (95% CI: 54.9-74.3) and 90.9% (95% CI: 57.1-99.5). The positive predictive value and negative predictive value were, respectively, 98.4% (95% CI: 90.2-99.9) and 23.3% (95% CI: 12.3-39.0). The presence of steatosis on US was associated to advanced grades of steatosis on histology (P = 0.016).

CONCLUSION: Preoperative abdominal US in our series has not shown to be an accurate method for the diagnosis of hepatic steatosis in severe obese patients. Until another non-invasive method demonstrates better sensitivity and specificity values, histological evaluation may be recommended to these patients undergoing bariatric surgery.

Alteração de enzimas hepáticas em trabalhadores de refinaria de petróleo

OBJETIVO: A exposição ocupacional típica de uma refinaria de petróleo pode alterar a função hepática de seus trabalhadores. Assim, o objetivo do estudo foi identificar fatores de risco de alterações em enzimas hepáticas em trabalhadores de uma refinaria de petróleo. MÉTODOS: Os trabalhadores de uma refinaria de petróleo, localizada em São Francisco do Conde, Estado da Bahia, eram submetidos a exames periódicos anuais de 1982 a1998. O estudo caso-controle investigou todos os 150 casos de indivíduos com alteração simultânea de gama-glutamil transferase e de alanino amino transferase, de pelo menos 10% acima do valor de referência. Como controles, foram selecionados 150 indivíduos sem quaisquer alterações de enzimas hepáticas ou de bilirrubinas, desde a sua admissão. Foram calculadas as razões de chance e respectivos intervalos de confiança de 95% a partir de modelos de regressão logística. RESULTADOS: Em todos os setores de produção, o risco de alteração de enzimas hepáticas foi significantemente mais elevado do que no setor administrativo (RC=5,7; IC 95%: 1,7-18,4), estando controlados os efeitos do álcool, obesidade e antecedentes médicos de hepatite. No período 1992-1994 foram registrados 89 casos, 88 deles provieram dos diversos setores da produção. CONCLUSÕES: A exposição ocupacional desempenha papel importante na determinação de alterações de enzimas hepáticas em trabalhadores do refino de petróleo, além dos fatores de risco eminentemente biológicos e/ou comportamentais como obesidade e o consumo de álcool.

Trimethoprim-sulfamethoxazole versus norfloxacin in the prophylaxis of spontaneous bacterial peritonitis in cirrhosis

BACKGROUND

The prognosis of patients with chronic liver disease and spontaneous bacterial peritonitis is poor, being of great importance its prevention.

AIM

To compare the effectiveness of trimethoprim-sulfamethoxazole versus norfloxacin for prevention of spontaneous bacterial peritonitis in patients with cirrhosis and ascites.

PATIENTS AND METHODS

Fifty seven patients with cirrhosis and ascites were evaluated between March 1999 and March 2001. All of them had a previous episode of spontaneous bacterial peritonitis or had ascitic fluid protein concentration < or = 1 g/dL and/or serum bilirubin > or = 2.5 mg/dL. The patients were randomly assigned to receive either 800/160 mg/day of trimethoprim-sulfamethoxazole 5 days a week or 400 mg of norfloxacin daily. The mean time of observation was 163 days for the norfloxacin group and 182 days for the trimethoprim-sulfamethoxazole group. In the statistical analysis, differences were considered significant at the level of 0.05.

RESULTS

According to the inclusion criteria, 32 patients (56%) were treated with norfloxacin and 25 (44%) with trimethoprim-sulfamethoxazole. Spontaneous bacterial peritonitis occurred in three patients receiving norfloxacin (9.4%) and in four patients receiving trimethoprim-sulfamethoxazole (16.0%). Extraperitoneal infections occurred in 10 patients receiving norfloxacin (31.3%) and in 6 patients receiving trimethoprim-sulfamethoxazole (24.0%). Death occurred in seven patients (21.9%) who received norfloxacin and in five (20.0%) who received trimethoprim-sulfamethoxazole. Side effects occurred only in the trimethoprim-sulfamethoxazole group.

CONCLUSION

In spite of the reduced number of patients and time of observation, trimethoprim-sulfamethoxazole and norfloxacin were equally effective in spontaneous bacterial peritonitis prophylaxis, suggesting that trimethoprim-sulfamethoxazole is a valid alternative to norfloxacin.

Body mass index and waist circumference in non-alcoholic fatty liver disease

OBJECTIVE

To evaluate the association of anthropometric indexes (body mass index and waist circumference) in patients with non-alcoholic fatty liver disease (NAFLD), and its association with insulin resistance (IR), metabolic syndrome (MS) and histological findings.

METHODS

From August 2003 to July 2004 a case series of 81 outpatients with clinic and/or histological diagnosis of NAFLD were selected at the Bahia University Gastro-Hepatology Clinic, Brazil. Liver function tests, lipid profile, glucose and insulin were performed in all patients. Body mass index (BMI) and waist circumference (WC) were determined according to WHO criteria. IR was measured by means of the homeostasis model assessment (HOMA) and IR was considered with HOMA > or =3. MS was defined according to the Adult Treatment Panel III (ATP III). Liver biopsy was performed in 37 cases.

RESULTS

Body mass index > or = 30 kg m(-2) (obesity) was found in 39% of the cases and BMI > or = 25-29.9 kg m(-2) (overweight) in 53%. BMI was correlated with IR (r = 0.29; P = 0.02) and WC with ALT (r = 0.02; P = 0.03). Increased WC also was related to IR and to MS. The presence of steatohepatitis with fibrosis on liver biopsy was associated with overweight (68%) and increase of WC (41%).

CONCLUSIONS

Body mass index and WC are frequent associated with MS, IR and histological findings (steatohepatitis and fibrosis) in patients with NAFLD.

[Liver changes in workers at an oil refinery and in a reference population in the state of Bahia, Brazil]

OBJECTIVE

To determine the prevalence of liver changes in workers at an oil refinery located in the state of Bahia, Brazil, as compared to a reference population with no occupational exposure to chemical products, and to describe the factors associated with the observed differences in prevalence.

METHODS

We studied workers at the refinery and at the company's central management office located in the city of Salvador, which is the state capital. Blood samples of 692 refinery workers and 377 workers from the reference population were analyzed. Cases were defined as individuals presenting high serum levels of both gammaglutamyltransferase (GGT) and alanine aminotransferase (ALT) (GGT > 50 U/L for males and > 32 U/L for females; ALT > 50 U/L). Data were collected on age, sex, weight, height, years working for the company, use of alcohol, smoking habits, physical exercise, occupational exposure to chemical products, use of personal safety equipment, and medical history of hepatitis, jaundice, and obesity.

RESULTS

The prevalence of liver changes among refinery workers was 15.3% (95% CI: 12.5 to 18.1), vs. 3.8% (95% CI: 1,8 to 5,8) in the reference population. According to multiple logistic regression analysis, the prevalence of liver changes among refinery workers was 3.56 times greater (95% CI: 1,99 to 6,38) than in the reference population, regardless of the presence of other relevant co-variables, such as obesity, exercise, smoking, and alcohol consumption.

CONCLUSIONS

These results suggest that occupational exposure may play a major role in the development of liver changes among workers at the oil refinery where the study was carried out.

[Antibodies to hepatitis C virus in patients undergoing hemodialysis in Salvador, BA, Brazil]

BACKGROUND

Hepatitis C infection in hemodialysis units has been evaluated in different geographic regions.

AIMS

The prevalence of anti-HCV in patients undergoing hemodialysis program in the city of Salvador, State of Bahia, Brazil, was studied and its association with transfusions, duration of hemodialysis and ALT elevation.

METHOD

During a period of 17 months, all patients undergoing dialytic treatment, were evaluated. The total number of patients was 395, all of whom completed a questionnaire and provided serum samples for laboratory analysis. Serological levels were measured for ALT and the samples were tested for anti-HCV using ELISA II with a further confirmation using RIBA III.

RESULTS

Anti-HCV was positive in 23.8% (94/395). The presence of transfusions was associated with anti-HCV and as the number of transfusions used increased, so did the frequency of anti-HCV. Of the patients who never received transfusions, 12.5% (6/48) were anti-HCV positive. The duration of dialytic treatment lasted from 53.44 +/- 36.45 months in the anti-HCV positive group and 22.10 +/- 22.75 months for the group testing negative. ALT elevation was more frequent in the anti-HCV positive group. Positivity for the RIBA III fractions was 79.8%, 100%, 80.9% and 52.1%, for c100-3, c33, c22 and NS5, respectively. The anti-NS5 was even less frequent in the group with elevated ALT.

CONCLUSIONS

The prevalence of anti-HCV in patients undergoing chronic hemodialysis in Salvador, Bahia, is elevated and it is associated with transfusions, a longer duration of dialytic treatment and ALT elevation.

HCV infection in northeastern Brazil: unexpected high prevalence of genotype 3a and absence of African genotypes

The genomic diversity of HCV embraces 6 genotypes and at least 52 subtypes with clinical and epidemiological correlations. There is a paucity of studies assessing HCV genotypes and biomolecular epidemiology in Brazil. We studied genotype distribution and epidemiological aspects in 232 HCV carriers, 133 (57.9%) males and 99 (42.1%) females, followed in the liver disease referral unit in Salvador, BA, northeastern Brazil. All of them were anti-HCV positive by 3rd generation ELISA assay, and HCV-RNA positive by RT-PCR. Genotyping was performed by INNOLIPA. Assessment of risk factors for HCV infection showed that 93 (40%) had past blood transfusion, 14 (6%) intravenous drug use, 19 (8%) inhalation of cocaine, 28 (12%) tattooing, 15 (7%) were health care workers, 5 (2%) had reused disposable syringes, 5 (2%) had multiple risk factors and in 53 (23%) no risk factor was determined. Genotype 1a was observed in 75 (32%), 1b in 72 (31%), 3a in 61 (26%), 2ab in 14 (6%); 5 (2.5%) had mixed genotypes and 5 (2.5%) were undetermined. Patients with genotype 1 had a higher mean age (P < 0.05) and no particular risk factors were associated with a specific genotype. Genotype 1 largely predominates in northeast Brazil followed by genotype 3 which, in this population, does not seem to be related to intravenous drug abuse, in contrast to some European studies. Although 80% of the Salvador population comprises African-Brazilians, no African genotype was identified, which may mean that HCV was introduced into this region via European immigration. This study demonstrated some peculiarities of HCV epidemiology in Brazil and strongly suggests that HCV introduction to this region was probably related to European immigration.

Nonalcoholic steatohepatitis: a toxic liver disease in industrial workers

AIMS

Occupational/environmental exposure to hepatotoxins has recently been implicated in nonalcoholic steatohepatitis (NASH). The aims of this study were to determine the presence and frequency of NASH in a large group of workers chronically exposed to several volatile petrochemical products in an industrial area in north-east Brazil and to observe its course in workers removed from the work environment.

METHODS

1500 asymptomatic workers were screened with standard liver blood tests during 1994-5. Those with elevated transaminases (>3x normal) on 3 occasions were evaluated further both clinically and with serum HBsAg, anti-HCV, ferritin, lipids and autoantibody determination. Patients with either no etiological diagnosis, positive HBsAg/anti-HCV serology and/or excess alcohol intake underwent liver biopsy. Those with obesity, diabetes or an isolated abnormal GGT were excluded. Of workers diagnosed as having NASH (compatible histology and no excess alcohol intake), a proportion were removed from the work environment and evaluated monthly with liver blood tests and a repeat liver biopsy 8-14 months later.

RESULTS

112 workers had abnormal transaminases and 32 fulfilled the criteria for liver biopsy. 20 of these were classified as NASH, the remainder had viral hepatitis (n = 6), alcoholic liver disease (n = 5) or portal vein thrombosis (n = 1). In all of the 10/20 who were removed from the work environment, their aminotransferases and GGT gradually decreased and their histology improved.

CONCLUSIONS

These results demonstrate that NASH can occur following chronic exposure to volatile petrochemical substances in the workplace. Exposed workers should be regularly screened for the presence of liver damage and ideally removed from the work environment where possible.

Prevalence of hepatitis E virus IgG antibodies in patients from a referral unit of liver diseases in Salvador, Bahia, Brazil

Hepatitis E virus (HEV) is prevalent in Asia and Africa. Recently, it was also described in Mexico, but epidemiologic data from other Latin American countries are scarce. The seroprevalence of anti-HEV in a referral hepatology unit in northern Brazil was determined by testing for anti-HEV IgG in 701 serum samples from our serum bank. Specimens analyzed were from 200 blood donors, 79 patients with acute viral hepatitis (AVH), 392 hemodialyzed patients, and 30 carriers of schistosomiasis. Duplicate test results for anti-HEV were positive in four (2%) of 200 of the blood donors, three (10%) of the 30 carriers of schistosomiasis, and in none of the 392 hemodialyzed patients. Fourteen (17.7%) of the AVH patients were positive, as were six (25%) of 24 with hepatitis A virus, three (11%) of 26 with hepatitis B virus, 0 (0%) of 12 with hepatitis C virus, and five (29%) of 17 with non-A, non-B, non-C hepatitis viruses. Among AVH cases, those with hepatitis A virus had a higher frequency of anti-HEV positivity compared with all other hepatotropic viruses (P < 0.0003). We conclude that HEV is prevalent in northern Brazil. The higher prevalence in patients compared with blood donors could be explained by the lower social condition of patients who sought public health service in this area, in contrast with the heterogeneous socioeconomic distribution of blood donors. Patients with AVH due to hepatitis A had a greater frequency of anti-HEV, probably because of similar routes of transmission for both hepatitis A and E viruses. Finally, the absence of anti-HEV in the hemodialyzed group could be explained by a lower immunologic response found in patients with chronic renal failure.

[Prevalence of hepatitis C virus in urban and rural populations of northeast Brazil-pilot study]

Hepatitis C virus can be found in all continents. However, differences exist with respect to its prevalence. In Brazil, epidemiological data are scarce, and are based, in their majority, on information obtained from blood donors and not from the general population. Our objective is to show the prevalence of anti-HCV in two distinct populations: one rural and one urban: Salvador, a metropolis, and Castro Alves, a rural village with very little contact with other populations. Eight hundred individuals from Salvador and 800 from Castro Alves were randomly visited. After obtaining consent, we collected blood samples for serology tests and determination of ALT levels. The anti-HCV antibody was tested using ELISA II (ABBOTT Labs), and confirmed by RIBA III (Chiron). We studied the prevalence of anti-HCV in two populations and its distribution with respect to age group and sex and ALT level. chi 2 and Fisher exact were used for the statistical analysis. Of the 800 individuals from Salvador, 44% were women and 56% were men. The age group varied from 10 to 70 years, with an average age of 42. Ten (1.25%) individuals were anti-HCV positive in the urban population and none in the rural population (P < 0.001). No evident correlation was found regarding sex and ALT level, between anti-HCV positive and anti-HCV negative individuals in the urban population. In conclusion, our results suggest a higher prevalence of HCV infection in the urban population probably due to a high level of exposure. The sero-epidemiological studies using blood donors do not reflect the epidemiological reality of HCV in Brazil due to selection bias which could overestimate its seroprevelence.

[Paracentesis associated to dextran-70 in the treatment of ascites in patients with chronic liver diseases: a randomized therapeutic study]

The treatment of ascites of large volume in chronic liver disease patients was evaluated in the present study. We compared diuretics with paracentesis and an infusion of Dextran-70. Therapeutic efficacy, complications and length of hospital stay were the variables studied. Of the 38 patients, 20 were selected randomly. They were evaluated using clinical, laboratory and/or histological criteria: 10 patients in the paracentesis group with Dextran-70 and 10 in the diuretic group. The groups were similar with respect to age, diagnosis and Child-Pugh classification. However, there was a greater number of males in the paracentesis group with Dextran-70. In each paracentesis, an average of 9.41 liters (4.5 to 14.1) of ascitic fluid was collected. The average hospitalization period in the paracentesis group with Dextran-70 was 10.5 days (8-14), significantly less when compared to the diuretic group: 24.4 days (14-48). In the diuretic group one patient presented complications such as hyperkalemia, increased urea and creatinine levels, while in the paracentesis group with Dextran-70 one patient presented a temperature above 38 degrees C during treatment. The results suggest that paracentesis associated with Dextran-70 could be a therapeutic alternative for chronic liver disease patients with ascites in our population. It was effective; it had no significant side effects; it reduced the length of hospital stay and therefore should decrease the cost and the risk of complications in patients requiring prolonged hospitalization periods.

[Hepatitis B virus markers in peripheral blood mononuclear cells]

Recent studies have shown tropism of the hepatitis B virus (HBV) by peripheral blood mononuclear cells (PBMC). The consequences of this phenomenon and their clinical use are not yet clear, however. Seventy-nine patients were studied between March 1989 and October 1990. Sixty-nine patients had chronic liver disease with histological evaluations, and 10 were vaccinated for HBV. The following markers were determined: serum: HBsAg, HBeAg, anti-HBe, antitotal-HBc, anti-HBs, anti-HCV, HBV-DNA; lysated PMBC cells: HBsAg, HBeAg. Hepatic tissue: HBsAg, HBcAg. Four groups were formed according to serology. Group I--positive HBsAg patients (n = 25) HBsAg was observed in the lysated of PBMC in 19 (76%) of the patients. HBeAg in PBMC was detected in 8 (32%), all of them showed evidence of viral replication (presence of HBcAg and/or HBV-DNA in the serum HBcAg in the tissue). Group II--antitotal HBc/anti-HBs positive (n = 14), HBsAg in PBMC was found in 5 (36%) and HBeAg in 1 (7.0%). In this patient replication markers in the serum and in the tissue (HBV-DNA, HBcAg) was also present. Three patients out of 9 anti-HBs positive had HBsAg in PBMC. Group III--seronegative patients for HBV. HBsAg was present in PBMC in 2 (6.6%) of the patients, but was absent in all of them. There was concomitant presence of HBsAg in MN and the hepatic tissue in 1 patient. Replication markers were not observed in the group. Group IV--10 asymptomatic individuals vaccinated for HBV. Except anti-HBs in serum, no other HBV marker could be identified in serum or in PBMC.(ABSTRACT TRUNCATED AT 250 WORDS)

[Forms of hepatic disease in alcoholic patients in Salvador, BA]

This study was carried out to evaluate the relative importance of various patterns in liver in patients followed with chronic ethylism at the Hepatology Unit Care Service of the Hospital Prof. Edgard Santos--University Federal of Bahia, Brazil. Ninety six individuals were submitted to liver biopsy. Of those, 69 (71.9%) presented with alcoholic lesions and 27 (28.1%) had other histologic features of liver disease not commonly related to alcoholism. These data suggested that the presence of other types of liver diseases are prevalent in alcoholic patients in Bahia and showed that, in addition to clinic and laboratorial evaluation, it is essential to perform the histological study to complete the diagnostic of the patients, and detect other liver diseases not associated to alcohol.