The Calculation and Evaluation of an Ultrasound-Estimated Fat Fraction in Non-Alcoholic Fatty Liver Disease and Metabolic-Associated Fatty Liver Disease

We aimed to develop a non-linear regression model that could predict the fat fraction of the liver (UEFF), similar to magnetic resonance imaging proton density fat fraction (MRI-PDFF), based on quantitative ultrasound (QUS) parameters. We measured and retrospectively collected the ultrasound attenuation coefficient (AC), backscatter-distribution coefficient (BSC-D), and liver stiffness (LS) using shear wave elastography (SWE) in 90 patients with clinically suspected non-alcoholic fatty liver disease (NAFLD), and 51 patients with clinically suspected metabolic-associated fatty liver disease (MAFLD). The MRI-PDFF was also measured in all patients within a month of the ultrasound scan. In the linear regression analysis, only AC and BSC-D showed a significant association with MRI-PDFF. Therefore, we developed prediction models using non-linear least squares analysis to estimate MRI-PDFF based on the AC and BSC-D parameters. We fitted the models on the NAFLD dataset and evaluated their performance in three-fold cross-validation repeated five times. We decided to use the model based on both parameters to calculate UEFF. The correlation between UEFF and MRI-PDFF was strong in NAFLD and very strong in MAFLD. According to a receiver operating characteristics (ROC) analysis, UEFF could differentiate between <5% vs. ≥5% and <10% vs. ≥10% MRI-PDFF steatosis with excellent, 0.97 and 0.91 area under the curve (AUC), accuracy in the NAFLD and with AUCs of 0.99 and 0.96 in the MAFLD groups. In conclusion, UEFF calculated from QUS parameters is an accurate method to quantify liver fat fraction and to diagnose ≥5% and ≥10% steatosis in both NAFLD and MAFLD. Therefore, UEFF can be an ideal non-invasive screening tool for patients with NAFLD and MAFLD risk factors.

[The significance of omega-3 fatty acids in the treatment of non-alcoholic fatty liver disease]

Today, non-alcoholic fatty liver disease is the most common chronic liver disease, yet there is no clearly accepted effective therapy. What is certain is that the number of people suffering from the disease is increasing, making prevention, treatment and recognition of co-morbidities of paramount importance. Current evidence suggests that the development of non-alcoholic fatty liver disease may be due to pathological factors of different origins. The main risk factors include genetic factors, acquired environmental influences and lifestyle. Lifestyle modification, i.e., the elimination or reduction of these harmful factors, can reverse liver damage, depending on the stage of the disease. In this summary statement, we review the pathophysiology of non-alcoholic fatty liver disease, risk factors and therapeutic options, within that in particular lifestyle modification (dietary changes, increasing physical activity, weight loss). Furthermore, we also show the importance of omega-3 fatty acids such as eicosapentaenoic acid and docosahexaenoic acid in detail. With our knowledge, the personalized treatment of non-alcoholic fatty liver disease can be elaborated. Orv Hetil. 2023; 164(33): 1294-1299.

Hypocalcemia on Admission Is a Predictor of Disease Progression in COVID-19 Patients with Cirrhosis: A Multicenter Study in Hungary

Hypocalcemia is a common condition in liver cirrhosis and is associated with the severity of SARS-CoV-2 infection. However, there is a lack of data demonstrating the prognostic value of hypocalcemia in COVID-19 patients with cirrhosis. This study aimed to evaluate the prognostic value of hypocalcemia for COVID-19 severity, mortality and its associations with abnormal liver function parameters. We selected 451 COVID-19 patients in this retrospective study and compared the laboratory findings of 52 COVID-19 patients with cirrhosis to those of 399 COVID-19 patients without cirrhosis. Laboratory tests measuring albumin-corrected total serum calcium were performed on admission, and the levels were monitored during hospitalization. The total serum calcium levels were significantly lower in cirrhosis cases (2.16 mmol/L) compared to those without cirrhosis (2.32 mmol/L). Multivariate analysis showed that hypocalcemia in COVID-19 patients with cirrhosis was a significant predictor of in-hospital mortality, with an OR of 4.871 (p < 0.05; 95% CI 1.566-15.146). ROC analysis showed the AUC value of total serum calcium was 0.818 (95% CI 0.683-0.953, p < 0.05), with a sensitivity of 88.3% and a specificity of 75%. The total serum calcium levels showed a significant negative correlation with the Child-Turcette-Pugh score (r = -0.400, p < 0.05). Hypocalcemia on admission was a significant prognostic factor of disease progression in COVID-19 patients with cirrhosis.

The Nobel prize in physiology and medicine - 2022

The Nobel Assembly at Karolinska Institutet awarded the 2022 Nobel Prize in Physiology or Medicine to a Swedish geneticist, Svante Pääbo, for his discoveries concerning the genomes of extinct hominins and human evolution, for the sequencing of the genome of the Neanderthal, the discovery of a previously unknown hominin, Denisova, and the establishment of a new scientific discipline, paleogenomics.

Effectiveness of COVID-19 Vaccination with mRNA Vaccines for Patients with Cirrhosis in Hungary: Multicentre Matched Cohort Study

Patients with cirrhosis are vulnerable to hepatic decompensation events and death following COVID-19 infection. Therefore, primary vaccination with COVID-19 vaccines is fundamental to reducing the risk of COVID-19 related deaths in patients with cirrhosis. However, limited data are available about the effectiveness of mRNA vaccines compared to other vaccines. The aim of our study was to investigate the efficacy of mRNA vaccines versus other vaccines in cirrhosis. In this retrospective study, we compared clinical characteristics and vaccine effectiveness of 399 COVID-19 patients without cirrhosis (GROUP A) to 52 COVID-19 patients with cirrhosis (GROUP B). 54 hospitalised cirrhosis controls without COVID-19 (GROUP C) were randomly sampled 1:1 and matched by gender and age. Of the cirrhosis cases, we found no difference (p = 0.76) in mortality rates in controls without COVID-19 (11.8%) compared to those with COVID-19 (9.6%). However, COVID-19 patients with cirrhosis were associated with higher rates of worsening hepatic encephalopathy, ascites and esophageal varices. Patients with cirrhosis receiving mRNA vaccines had significantly better survival rates compared to viral vector or inactivated vaccines. Primary vaccination with the BNT162b2 vaccine was the most effective in preventing acute hepatic decompensating events, COVID-19 infection requiring hospital admission and in-hospital mortality.

Tápcsatornai endoszkópos eljárásokkal összefüggő infekciós kockázat a SARS-CoV-2-járvány idején

Bevezetés: A COVID–19-pandémia jelentősen befolyásolta az endoszkópos laboratóriumok működését. Az endoszkópos vizsgálatok nagy vírusátviteli rizikójúnak számítanak. Célkitűzés: A koronavírus-járványnak a magyarországi endoszkópos laborok működésére kifejtett hatásának és az endoszkópos személyzet SARS-CoV-2-fertőzésben való érintettségének felmérése a 2020-as évben. Módszerek: Országos szintű, keresztmetszeti, kérdőíves tanulmányunk során magyarországi endoszkópos laboratóriumok vezetőit kerestük meg online formában. Vizsgáltuk a 2020-ban elvégzett felső és alsó tápcsatornai endoszkópiák számát a 2019-es referenciaévhez viszonyítva (átlag [95%-os konfidenciaintervallum]), továbbá a SARS-CoV-2-fertőzéssel érintett dolgozók számát és fertőződésük potenciális forrását. Eredmények: A megkeresett intézmények 30%-ából érkeztek válaszok (33/111). A referenciaévhez képest sem a felső (1593 [743–1514] vs. 1129 [1020–2166], p = 0,053), sem az alsó tápcsatornai endoszkópos vizsgálatok száma (1181 [823–1538] vs. 871 [591–1150], p = 0,072) nem csökkent, bár a vírushullámoknak megfelelően mindkét vizsgálattípus esetén 80%-ot meghaladó vizsgálatszám-csökkenést tapasztaltunk. Dedikáltan fertőző betegek vizsgálatára kialakított helyiség az intézetek 12%-ában állt rendelkezésre. A védőfelszerelések az első és a második hullám alatt 70%-ban, illetve 82%-ban voltak mennyiségileg és minőségileg megfelelőek. A vizsgálat előtt fertőzöttségirizikó-stratifikáció az intézetek 85%-ában, míg PCR-vizsgálat csupán 42%-ukban történt minden esetben. Az első és második járványhullám alatt a dolgozói létszám az orvosoknál 33%-kal, illetve 26%-kal, az asszisztenseknél 19%-kal, illetve 21%-kal csökkent, elsősorban életkori korlátozás, COVID-ellátásba való áthelyezés miatt. Az asszisztensek 32%-a, az orvosok 41%-a esett át COVID-fertőzésen, 16%-ban, illetve 18%-ban nem megfelelő védőfelszerelés-használattal összefüggésben. Következtetés: A járványhullámok alatti restrikciók feloldását követően a vizsgálati terhelés emelkedik. A SARS-CoV-2-vakcinák elérhetősége előtt az endoszkópos laborok dolgozóit érintő COVID-fertőzések 15%-a nem megfelelő védőfelszerelés-használattal volt összefüggésbe hozható. Orv Hetil. 2022; 163(46): 1814–1822.

The Elevated De Ritis Ratio on Admission Is Independently Associated with Mortality in COVID-19 Patients

Liver damage in COVID-19 patients was documented as increased alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels or an elevated AST/ALT ratio, known as the De Ritis ratio. However, the prognostic value of the elevated De Ritis ratio in COVID-19 patients is still unknown. The aim of our study was to evaluate the prognostic value of the De Ritis ratio compared to other abnormal laboratory parameters and its relation to mortality. We selected 322 COVID-19 patients in this retrospective study conducted between November 2020 and March 2021. The laboratory parameters were measured on admission and followed till patient discharge or death. Of the 322 COVID-19 patients, 57 (17.7%) had gastrointestinal symptoms on admission. The multivariate analysis showed that the De Ritis ratio was an independent risk factor for mortality, with an OR of 29.967 (95% CI 5.266-170.514). In ROC analysis, the AUC value of the the De Ritis ratio was 0.85 (95% CI 0.777-0.923, p < 0.05) with sensitivity and specificity of 80.6% and 75.2%, respectively. A De Ritis ratio ≥1.218 was significantly associated with patient mortality, disease severity, higher AST and IL-6 levels, and a lower ALT level. An elevated De Ritis ratio on admission is independently associated with mortality in COVID-19 patients, indicating liver injury and cytokine release syndrome.

Tissue attenuation imaging and tissue scatter imaging for quantitative ultrasound evaluation of hepatic steatosis

We aimed to assess the feasibility of ultrasound-based tissue attenuation imaging (TAI) and tissue scatter distribution imaging (TSI) for quantification of liver steatosis in patients with nonalcoholic fatty liver disease (NAFLD). We prospectively enrolled 101 participants with suspected NAFLD. The TAI and TSI measurements of the liver were performed with a Samsung RS85 Prestige ultrasound system. Based on the magnetic resonance imaging proton density fat fraction (MRI-PDFF), patients were divided into ≤5%, 5-10%, and ≥10% of MRI-PDFF groups. We determined the correlation between TAI, TSI, and MRI-PDFF and used multiple linear regression analysis to identify any association with clinical variables. The diagnostic performance of TAI, TSI was determined based on the area under the receiver operating characteristic curve (AUC). The intraclass correlation coefficient (ICC) was calculated to assess interobserver reliability. Both TAI (rs = 0.78, P < .001) and TSI (rs = 0.68, P < .001) showed significant correlation with MRI-PDFF. TAI overperformed TSI in the detection of both ≥5% MRI-PDFF (AUC = 0.89 vs 0.87) and ≥10% (AUC = 0.93 vs 0.86). MRI-PDFF proved to be an independent predictor of TAI (β = 1.03; P < .001), while both MRI-PDFF (β = 50.9; P < .001) and liver stiffness (β = -0.86; P < .001) were independent predictors of TSI. Interobserver analysis showed excellent reproducibility of TAI (ICC = 0.95) and moderate reproducibility of TSI (ICC = 0.73). TAI and TSI could be used successfully to diagnose and estimate the severity of hepatic steatosis in routine clinical practice.

Altered element homeostasis and transmethylation ability in short-term polyphenol rich supplementation in hyperlipidemic animal model

Non-alcoholic fatty liver disease is one of the most common chronic liver diseases with unclarified pathomechanism and without evidence-proven therapy. Dietary polyphenols, targeting oxidative stress, are at the center of investigations. Our aim was to examine the effects of a polyphenol rich extract on metal element homeostasis and transmethylation ability in non-alcoholic fatty liver model. A ten-day rat model was used (control group, hyperlipidemic group with fat-rich diet, hyperlipidemic group with fat-rich diet and polyphenol supplementation, N = 8 in each group). The hyperlipidemic diet increased the concentration of the majority of the elements with significantly higher contents of B, Co, Cu, Fe, Mg, Mn, Na, Ni, P, Se, Si, and Zn in the liver. Further elevation of Al, Pb, and Sn concentrations could be observed in polyphenol supplemented animals. The polyphenol supplement unexpectedly decreased the transmethylation ability of the liver (132.00 vs. 114.15 vs. 92.25 HCHO μg g−1) further. The results emphasize the possible role of altered metal and non-metal element concentrations and decreased transmethylation ability in the pathomechanism of fatty liver disease. Dietary supplementation with natural compounds may have undesirable effect as well, there is the necessity to improve the efficacy of polyphenol formulations because of their low oral bioavailability.

The Nobel Prize in Physiology or Medicine-2020

At the time of COVID-19 coronavirus pandemia, the Nobel Prize of Physiology or Medicine 2020 was awarded jointly to three researchers Harvey J. Alter, Charles M. Rice, and Michael Houghton for the discovery of Hepatitis C virus. Their works contributed to the isolation of the blood-borne virus, causing chronic hepatitis in 80% of infected person, resulting in cirrhosis, and in elevated risk of liver failure and hepatocellular carcinoma formation. Their results created the basis of HCV screening of blood, and blood products, achieving more than 95% cure of infected people without nearly side effects with direct-acting antiviral agents, supporting the goal of the WHO targeting the elimination of viral hepatitis by 2030.

Impact of milk thistle (Silybum marianum) on the mycotoxin caused redox-homeostasis imbalance of ducks liver

The Fusarium mycotoxins deoxynivalenol (DON) and zearalenone (ZEA) frequently contaminate grain crops, especially maize, the basis of poultry's feed. Mycotoxins enter the food chain and induce pathological changes in edible tissues. Milk thistle (Silybum marianum) has been used for the treatment of liver disease in humans because of its antioxidant and hepatoprotective effects, but its utility in veterinary use is poorly examined. To investigate possible protective properties against mycotoxin caused oxidative stress in poultry, pressed form of milk thistle seed (0.5%) was tested in white, female, Hungarian ducks over a feeding period of 47 days. Ducks were separated into 3 groups. The first group was fed with normal diet. The second group was fed with normal diet contaminated with DON (4.9 mg/kg) and ZEA (0.66 mg/kg). The third group received mycotoxin contaminated feed with milk thistle supplementation. Histological examination, markers of the redox status and metal element concentration measurements were carried out. The results showed alterations in the histological examination and in the redox homeostasis markers as a short-term effect by strengthening the antioxidant system. Acute exposure of mycotoxins caused an oxidative stress, which induced an effective antioxidant defensive response of the organism indicated by the free sulfhydryl group content (from 0.72 ± 0.06 to 0.77 ± 0.11) and the reducing power (0.49 ± 0.06 to 0.52 ± 0.08) elevation. The short-term free radical injury may be compensated by the liver resulting in decreased lipid peroxidation markers (malondialdehyde concentration: from 16.86 ± 0.49 to 0.94 ± 0.15, conjugated diene concentration: from 0.21 ± 0.07 to 0.17 ± 0.03). Silymarin further strengthtened the antioxidant defense by the elevation of sulfhydryl groups concentration and reducing power property resulted in decreased total scavenger capacity. However the concentration of lipid peroxidation markers were further elevated by the used antioxidant treatment (MDA: 5.2 ± 0.35, DC: 0.26 ± 0.08). In conclusion, the mycotoxin-contamination activated effectively the antioxidant system. The milk thistle supplementation has cytoprotective effects according to the histological findings, activated the antioxidant system, however the elevation of lipid peroxidation products need further explanation.

Factors affecting liver disease progression, with emphasis on the role of free radical reactions

Chronic liver disorders are the main leading cause of morbidity and mortality data. Viral infection, toxic injury, metabolic, autoimmun, storage disorders, in the case of ongoing presence of the etiological factors, could result in fibrotic remodelling in the liver. The process is complex, not fully understood in details; cells, cytokines, chemokines release, altered secretion of hepatokines, lipotoxicity, innate immun system, gut microbiom, metal ions and free radical reactions all have a role in it. Chronic liver disorders are often symptomless, diagnosed in the stage of fibrotic tissue accumulation, liver failure or hepatocellular carcinoma formation, when the prognosis is poor, treatment options are narrow. Noninvasive, properly sensitive and specific biomarkers are the targets of studies, with them the necessity of liver biopsies can be decreased, through the follow-up of processes, progression and treatment efficacy. Authors review the processes taking part in the progression of the most frequent chronic liver disorders, emphasizing the parameters of pro/antioxidant balance, and the necessity of a combined reliable biomarker. Orv Hetil. 2020; 161(35): 1441-1448.

The potential role of organic and conventional yoghurt consumption in the treatment of non-alcoholic fatty liver disease

INTRODUCTION

Health is an important motivation for the consumption of both organic and functional foods. Organic food contains fewer pesticide residues and statistically more selected health-related compounds such as polyphenols in plant products and polyunsaturated fatty acids in milk and meat products. Recent studies suggest that the gut-liver axis plays an important role in the pathogenesis of non-alcoholic fatty liver disease, so probiotics could be a therapeutic tool. Comparing the health effects of yoghurt from organic origin with so-called conventional yoghurt is difficult, because there is no biomarker that would signal the difference with good specificity and sensitivity.

AIM

The aim of this study was to investigate numerous biomarkers to evaluate the difference between yoghurt from conventional and organic origin and their health effects in NAFLD.

PATIENTS AND METHOD

We performed a prospective, cohort study consisting of 37 (age = 51.73 ± 11.82, male = 21, female = 16) patients with NAFLD at the 2nd Department of Internal Medicine of the Semmelweis University, Budapest. Diagnosis of NAFLD was based on ultrasonography and the exclusion of other etiololgy. The patients were examined also with shear wave elastography to evaluate the hepatic fibrosis stage. We divided the patients randomly into two groups. The patients consumed individually daily 300 grams of yoghurt from organic (n = 21) or conventional (n = 16) origin for 8 weeks. We collected 37 routine laboratory data, measured 4 cytokines, 3 markers of the redox-homeostasis and 14 body composition values before, after, and 12 weeks after the yoghurt consumption.

RESULTS

We found a mild elevation of vitamin D and a minimal reduction of LDL after the yoghurt consumption, but in the other 35 routine laboratory data there was no statistical difference. Adiponectin and leptin levels were elevated after the yoghurt consumption in the "conventional group". In contrast, we found significant decrease of adiponectin levels in the "organic group" after the treatment. Only the adiponectin tendency was different in the two groups. The induced free radical content was also statistically lower after the yoghurt consumption. In the body composition measurements, there were no significant differences.

CONCLUSION

These data suggest that adiponectin could be a possible biomarker to evaluate the effectiveness of probiotic treatment in non-alcoholic fatty liver disease. Our work can serve as a basis for future studies investigating relationships between organic yoghurt consumption and health outcomes. Orv Hetil. 2020; 161(35): 1466-1474.

Changes in endogenous metal element concentrations in various aetiologies of chronic liver disease

Our body contains physiologically many metal ions used for its metabolic processes and function. Metal ion changes can start pathological processes, however, the pathological processes may also lead to changes in metal ion concentration. In this study, the authors summarize the physiologically present metal ions' change in liver diseases with various aetiologies, the consequences are discussed as well as the connections with the progression. Further, the authors point out the element concentration changes as diagnostic or prognostic values for the liver diseases as well. Orv Hetil. 2020; 161(22): 917-923.

[Hepatitis C virus infection and hepatocarcinogenesis]

Hepatitis C virus infection causes approximately 4 million new infections worldwide, and 399 000 deaths due to its complications, cirrhosis and hepatocellular carcinoma (HCC). Microenvironmental changes, chronic inflammation, oxidative stress, endoplasmic reticulum stress caused by HCV infection, via genetic and epigenetic changes can result in primary liver cancer during decades. The direct oncogenic property of HCV is wellknown. The transforming effect of four HCV proteins (core, NS3, NS4B, NS5A) has been proven. Effective antiviral therapy, sustained viral response decreases the HCV-related general and liver-related mortality. Interferon-based therapy reduces the risk of HCC development. Shorter therapy with direct acting antiviral agents (DAA) has higher efficacy, fewer side-effects. Publications have reported the unexpected effects of DAA. The authors review the articles focusing on the occurrence of HCC in connection with DAA therapies. There is a need for prospective, multicentric studies with longer follow-up to examine the risk of HCC formation. After antiviral therapy, HCC surveillance is of high importance which means abdominal ultrasound every 3-6-12 months in sustained viral response patients as well. Orv Hetil. 2019; 160(22): 846-853.

[The role of gut microbiota in chronic liver diseases, and treatment possibilities]

The community of microorganisms in the intestine, namely gut microbiome lives in symbiosis with the host, contributing to its homeostasis and influencing it simultaneously. It can be suspected that gut microbiome plays a central role in the pathophysiology of intestinal and extraintestinal diseases: determining their development, progress and complications. Recently, intestinal microbiome has become a highlighted field of interest and important topic in research, especially in hepatology. It is in the focus of relevant research as the liver is the organ which meets nutrients, bacterial components, toxins and metabolites at first, as a filter. The evolvement of different liver diseases - just like alcoholic and non-alcoholic fatty liver disease, steatohepatitis, cirrhosis or hepatocellular carcinoma - correlates with the changed composition and activity of gut microbiome. Thus, it can be hypothesized that pre-, pro- and antibiotics could have an impact on the treatment of these diseases. In our review article, the relationship between intestinal flora and liver diseases with different etiologies as well as therapeutic possibilities are discussed. Orv Hetil. 2018; 159(36): 1465-1474.

[Extrahepatic manifestations in chronic hepatitis C infected patients]

The importance of chronic hepatitis C infection is significant. 3% of the World's population is infected. There is at least one extrahepatic manifestation in 50% of HCV patients, which makes the prognosis and mortality worse. The pathomechanisms included are cryoglobulin production, immunmechanisms, and direct viral effects. The authors summarize the main extrahepatic manifestations, as well as treatment possibilities. The aim is to draw attention to this colourful infection in order to improve the recognition in the era of the new effective direct antiviral agents. Orv. Hetil., 2017, 158(16), 603-612.

[Antioxidants--antioxidative stress: facts and questions, 2015]

In the past years great importance has been attributed to antioxidant therapy in the prevention and treatment of disorders developed in connection with oxidative stress. After initial success, undesirable effects, toxicities, and prooxidant effects of antioxidants were reported [CARET, ATBC study]. In addition, metaanalyses failed to confirm the role of antioxidant supplementation in the primary and secondary prevention. The authors review the prooxidant effects of antioxidants, and their role in cell signalling and cell process modulation. Finally, the authors summarize possible explanations why combined use of antiooxidants is more favourable.

[Various pathways leading to the progression of chronic liver diseases]

As the result of various effects (viruses, metabolic diseases, nutritional factors, toxic agents, autoimmune processes) abnormal liver function, liver steatosis and connective tissue remodeling may develop. Progression of this process is complex including various pathways and a number of factors. The authors summarize the factors involved in the progression of chronic liver disease. They describe the role of cells and the produced inflammatory mediators and cytokines, as well as the relationship between the disease and the intestinal flora. They emphasize the role of oxidative stress, mitochondrial dysfunction and cell death in disease progression. Insulin resistance and micro-elements (iron, copper) in relation to liver damage are also discussed, and genetic and epigenetic aspects underlying disease progression are summarized. Discovery of novel treatment options, assessment of the effectiveness of treatment, as well as the success and proper timing of liver transplantation may depend on a better understanding of the process of disease progression.

[Non-invasive assessment of fatty liver]

As the result of various harmful effects (infectious agents, metabolic diseases, unhealthy diet, obesity, toxic agents, autoimmune processes) hepatic damage may develop, which can progress towards liver steatosis, and fibrosis as well. The most common etiological factors of liver damages are hepatitis B and C infection, alcohol consumption and non-alcoholic fatty liver disease. Liver biopsy is considered as the gold standard for the diagnosis of chronic liver diseases. Due to the dangers and complications of liver biopsy, studies are focused on non-invasive markers and radiological imaging for liver steatosis, progression of fatty liver, activity of the necroinflammation and the severity of the fibrosis. Authors review the possibilities of non-invasive assessment of liver steatosis. The statistical features of the probes (positive, negative predictive values, sensitivity, specificity) are reviewed. The role of radiological imaging is also discussed. Although the non-invasive methods discussed in this article are useful to assess liver steatosis, further studies are needed to validate to follow progression of the diseases and to control therapeutic response.

Options of non-invasive assessment of liver fibrosis based on the clinical data

Liver cirrhosis is one of the leading causes of death worldwide. Liver biopsy is considered as the gold standard for the diagnosis of chronic liver diseases. Studies have focused on non-invasive markers for liver fibrosis because of the dangers and complications of liver biopsy. The authors review the non-invasive direct as well as indirect methods for liver fibrosis assessment and present the positive and negative predictive value, sensitivity and specificity of those. Clinical utilities of transient elastography (Fibrsocan) is also reviewed. Non-invasive methods are useful in the assessment of liver fibrosis, monitoring disease progression and therapeutic response. Their accuracy can be increased by the combined or sequential use of non-invasive markers. Orv. Hetil., 2015, 156(2), 43–52.

[Review of overlap syndromes in autoimmune liver diseases. Diagnostic and therapeutic difficulties]

Overlap syndromes are biochemical, serological, histological and radiological overlaps across the classic autoimmune liver diseases in the presence of autoimmun hepatitis and primary biliary cirrhosis or primary sclerosing cholangitis. The exact prevalence of the disease is not known, but it may vary between 5% and 20%. Because it has no generally accepted diagnostic criteria, clinical signs, biochemical, serological, radiological and histological findings are evaluated together. Treatment depends on the predominant feature of the overlap syndrome; ursodeoxycholic acid and/or immunsuppressive (corticosteroid) treatment are used, based on observations from retrospective, non-randomized studies.

[Data for the decrease of "voluntary childlessness" in inflammatory bowel disease]

Inflammatory bowel disease is a chronic disorder affecting young adults in their reproductive years, hence its populational consequences are not negligible. While fertility in inflammatory bowel disease is the same as in the general population (except for male patients with sulphasalazine treatment and females with ileum-pouch anal anastomosis), "voluntary childlessness" is higher, 14-18%. Patients require accurate counseling addressing fertility, pregnancy course and outcome. They need to be informed appropriately about risks and benefits of medications in inflammatory bowel disease in order to assist their decision making, decrease "voluntary childlessness" and improve compliance. Authors review the issues related to fertility, outcome of pregnancy, medical treatment options before and during pregnancy as well as during breastfeeding in inflammatory bowel disease.

Update on the pharmacogenomics of proton pump inhibitors

Proton pump inhibitors (PPIs) are widely used for the treatment of gastroesophageal reflux disease as well as other acid-related disorders. PPIs are metabolized primarily via the CYP2C19 and CYP3A4 isoenzymes; their activity is influenced both by exogenous and endogenous (pharmacogenetic) factors. The CYP2C19 polymorphism affects the metabolism of PPIs, causing large individual pharmacokinetic variations. Differences in the CYP2C19-mediated metabolism can produce marked interpatient variability in acid suppression, in drug-interaction potential and in clinical efficacy. Understanding the pharmacokinetic properties of PPIs and examining the pharmacogenetic alterations may help clinicians optimize PPI therapy and administer individual treatment, especially to nonresponder patients with gastroesophageal reflux disease or ulcer or after failed eradication therapy.

[Tomato peel: rare cause of biliary tract obstruction]

Foreign bodies in the biliary tree are rare causes of obstructive jaundice. Food bezoars are infrequent as well. They can cause biliary obstruction after biliary tract interventions, or in the presence of biliary-bowel fistula or duodenum diverticulum. Food bezoars usually pass the gastrointestinal tract without any symptoms, but they can cause abdominal pain and obstructive jaundice in the case of biliary tract obstruction. Endoscopic retrograde cholangio-pancreatography has the major role in the diagnosis and the treatment of the disease. Authors summarize the medical history of a 91-year-old female patient, who developed vomiting and right subcostal pain due to the presence of tomato peel within the ductus choledochus.

[Idiopathic retroperitoneal fibrosis. Pitfalls and challenges--experience with two cases]

Retroperitoneal fibrosis is the chronic, nonspecific inflammation of the retroperitoneum. About 75% of the cases are idiopathic. The pathomechanism of the disorder is not clearly defined. Autoimmune inflammation and secondary fibrosis are the main suspected mechanisms against an unknown factor possibly related to atherosclerosis. Symptoms and laboratory parameters are nonspecific which make the diagnosis difficult. At the time of the diagnosis complications are often present. After the urological and surgical management of the complications, the aim of the medical treatment is immunosuppression. Corticosteroids are usually used for treatment, although the optimal dosage and the duration of the treatment are not known. After therapy cessation relapse may occur, requiring repeated steroid therapy or addition of steroid sparing drugs. Predicting factors for treatment response, corticosteroid demand or relapse are not known. Authors review the medical history of two patients with retroperitoneal fibrosis and discuss diagnostic difficulties of this disorder.

Lymphoid aggregates may contribute to the migration and epithelial commitment of bone marrow-derived cells in colonic mucosa

AIMS

Colonic inflammation is followed by regeneration supported by bone marrow-derived cells (BMDCs) including multipotent cells. They migrate to the colonic epithelial layer and may transdifferentiate into epithelial-like cells or keep their stem cell characteristics and produce progenies. The aim was to study the role of lymphoid aggregates in the migration and transition of BMDCs in both healthy colons and non-specific colitis (NSC).

METHODS

Samples of normal colon (n=5) and NSC (n=5) from female patients who were initially transplanted with male bone marrow were studied. After detecting XY chromosomes using fluorescent in situ hybridisation, tissue sections were digitalised, the coverslips were eliminated and the samples were double stained for CD45 and cytokeratin with immunofluorescence. Then CDX2 expression, as a sign of intestinal epithelial commitment of Musashi-1+ stromal BMDCs, was also tested with both immunoperoxidase and parallel immunofluorescence stainings. The slides were digitalised again and analysed simultaneously.

RESULTS

A significant increase in intraepithelial CD45-BMDCs was found in regions adjacent to lymphoid aggregates (median: 1.01) compared with healthy epithelial regions (median: 0.0175) or NSC (median: 0.04) samples. The stromal Musashi-1+ cells were positive for CDX2 as well, as a sign of epithelial differentiation. The CDX2+ cells bearing the Y chromosome proved the epithelial commitment of several stromal BMDCs.

CONCLUSION

Elevated number of intraepithelial CD45-BMDCs at lymphoid aggregates suggests that BMDCs play a role in epithelial regeneration and that lymphoid aggregates serve as their migration route.

Fatty liver and hepatitis C virus infection

Hepatitis C virus infection is a common liver disease worldwide, leading to the development of steatosis, cirrhosis and hepatocellular carcinoma. In patients with chronic hepatitis C virus infection the prevalence of steatosis has been estimated to be about 55%. Development of steatosis is due to both viral and metabolic factors. Hepatitis C virus proteins moderate a number of intracellular pathways, however, further studies are required to understand these mechanisms. Obesity and insulin resistance may allow the virus to resist antiviral treatment. This review discusses the relationship among steatosis, insulin resistance and the response to antiviral therapy. Orv. Hetil., 2011, 152, 1513–1519.

[New possibilities of targeted therapy in the treatment of hepatocellular carcinoma with the help of molecular biology]

Hepatocellular carcinoma (HCC) has a poor prognosis. Approximately 85% of patients are not candidates for curative treatments at the time of diagnosis; hence palliative modalities (transcatheter arterial chemoembolisation, radiofrequency ablation, systemic chemotherapy) are used. Systemic chemotherapies have disappointing results. The increasing knowledge in the molecular biology of HCC will increase the possibilities of targeted therapy. The multi-tyrosine kinase inhibitor sorafenib is the only drug which has approved. The VEGF-inhibitors (bevacizumab, sunitinib), EGFR-blocker agents (erlotinib), as well as the inhibition of mTOR (rapamycin) are promising. Combination of sorafenib or other anti-angiogenic agents with local ablative procedure (transcatheter arterial chemoembolisation, radiofrequency ablation), or with curative hepatectomy also can be favorable. Alteration of Wnt pathway, retinoid compounds, inhibition of the cell cycle as well as the proteosome, and epigenetic therapy can be other potential promising targets in HCC.

Non-alcoholic steatosis/steatohepatitis – 2010

A nem alkoholos eredetű zsírmáj és a steatohepatitis a kóros májműködés leggyakoribb oka. A szerzők áttekintik a kórkép fő kóroki tényezőit, kialakulásának lehetséges hátterét, klinikumát, valamint a kórisme felállításának nehézségeit. Nagy az igény olyan, nem invazív biomarkerek (TNF-α adiponektin, lipidperoxidáció termékei, citokeratin-18, hialuronsav), pontrendszerek (Fibrotest, APRI), vizsgálatok (Fibroscan) kidolgozására, amelyek a betegség előrehaladását, a gyulladást és a fibrosist jelzik. Mind ez idáig megfelelően hatékony kezelés nem ismert. A terápia részben a kiváltó tényezők eliminálását (testsúlycsökkentés), az anyagcserezavar (diabetes mellitus, hyperlipidaemia) kezelését célozza meg, részben a májvédelmet (antioxidánsok) helyezi előtérbe. Orv. Hetil., 2010, 47, 1940–1945.

[Peptic ulcer: facts and questions -- 2010]

Etiology and clinical manifestation of the peptic ulcer keep changes nowadays. Helicobacter pylori-infection, nonsteroidal anti-inflammatory drugs and small dosage acetic acid treatment are the main etiological factors. Helicobacter pylori positive peptic ulcer can be treated with eradication of the bacterium. Prevention of the NSAID-ulcer and the prescription of the acid suppressive therapy depend on the gastrointestinal and cardiovascular risk factors of patient. Despite of the effective therapies, there are still questions to answer. The number of Helicobacter pylori and NSAID negative ulcers is likely to increase, their therapy must be clarified. There's a fall in the eradication rate of Helicobacter pylori infection, the optimal treatment is missing.

[Role of the endocrine system in the pathogenesis of non-alcoholic fatty liver disease]

The most frequent liver disorder in metabolic syndrome is the nonalcoholic fatty liver disease. Its pathogenesis is a complex, multifactorial process, characterized by insulin resistance and involvement of the endocrine system. Hypothyroidism may lead to nonalcoholic steatohepatitis via hyperlipidemia and obesity. Adult patients with growth hormone deficiency have a metabolic syndrome-like phenotype with obesity and many characteristic metabolic alterations. The chronic activation of the hypothalamic-pituitary-adrenal axis results in metabolic syndrome as well. Cushing's syndrome has also features of metabolic syndrome. Mild elevation of transaminase activities is commonly seen in patients with adrenal failure. Non-alcoholic steatosis is twice as common in postmenopusal as in premenopausal women and hormonal replacement therapy decreases the risk of steatosis. Insulin resistance, diabetes mellitus type 2, sleeping apnoe syndrome, cardiovascular disorders and non-alcoholic fatty liver disease are more frequent in polycystic ovary syndrome. Hypoandrogenism in males and hyperandrogenism in females may lead to fatty liver via obesity and insulin resistance. Adipokines (leptin, acylation stimulating protein, adiponectin) have a potential role in the pathogenesis of nonalcoholic fatty liver. The alterations of endocrine system must be considered in the background of cryptogenic liver diseases. The endocrine perspective may help the therapeutic approaches in the future.

[Appearing of bone marrow derived stem cells in healthy and regenerating colonic epithelium]

In the process of regeneration following colon inflammation mesenchymal stem cells (MSC) of bone marrow origin may also take part besides their local counterparts. These cells migrate in the colon epithelium where they may contribute to epithelial regeneration or form progeny for keeping up local stem cell pool. MSC cells probably leave circulation around lymphoid aggregates to then migrate into nearby crypts. During migration they change their phenotype upon the influence of local microenvironment.

AIMS

In this study epithelial migration and transition of bone marrow stem cells were examined. Samples from normal healthy individuals and from aspecific inflammation were used. The possible role of lymphoid aggregates in the epithelial regeneration was also studied.

MATERIALS AND METHODS

Samples of normal colon (2) and those showing mild aspecific colitis (3) from female patients who were initially transplanted with male bone marrow were studied. First we detected gender chromosomes with fluorescent in situ hybridization (FISH) and the samples were archived with digital scanning. Then CD45 and cytokeratin (CK) double immunofluorescent reactions (IF) were made followed by digitalization again. Digitalized samples were estimated simultaneously with virtual microscopy (Mirax Viewer).

RESULTS

Significant elevation of CD45 negative/Y-FISH positive potential MSCs were found in crypts locating to the neighborhood of lymphoid aggregates (1,075%) compared with both normal (0,027%, p = 0,002) and mild colitis (0,045%, p = 0,004) samples.

CONCLUSION

Local stem cells probably have enough regeneration capacity in case of minor inflammation. However, in aspecific inflammation the number of MSCs contributing to epithelial regeneration was elevated, suggesting their facilitated contribution to the repair process with less probable forming of local stem cell progeny.

[Risk factors for esophageal cancer, and possible genetic background]

Esophageal cancer is the sixth most common cancer mortality, with increasing incidence. 95% of the esophageal cancer is squamous cell carcinoma or adenocarcinoma. Although they differ in histology and epidemiology, some of their risk factors (smoking, dietary factors) and their pathogenesis are the same. More than 90% of esophageal cancer is diagnosed in late stage. Despite the development of diagnostic and therapeutic techniques, esophageal cancer has poor prognosis, with 5-year survival rates between 10-13%. Understanding the exact pathogenesis can help the prevention of this highly aggressive cancer, with the use of natural substances and nonsteroid inflammatory drugs.

The effect of body weight reduction on the effectivity of combined peginterferon and ribavirin treatment in chronic HCV hepatitis

Idült C-vírus-hepatitisben a túlsúly/elhízás a zsírmáj kialakulásának független kóroki tényezője. A kombinált pegilált interferon + ribavirin kezelés hatástalansága hepatitis C-vírus 1-es genotípusa esetében a derékkörfogattal, a testtömegindexszel (BMI), a szénhidrát-anyagcsere zavarával, a steatosissal, a fibrosis súlyosságával áll összefüggésben. Az elhízás a kezelésre adott elégtelen válasz önálló negatív prediktív tényezője. Esetismertetés: A szerzők egy 59 éves, elhízott (BMI = 46,47 kg/m 2 ), krónikus HCV-fertőzött férfi beteg esetét ismertetik, akinél a testsúlycsökkenés – kétszeri sikertelen kombinált antivirális kezelés után – a peginterferon-alfa-2a + ribavirin kezelésre adott biokémiai és virológiai választ segítette. A beteg a korszerű interferon és ribavirin kombinált kezelések között amantadin- és szilimarinterápiában részesült. Megbeszélés: A szerzők esetükkel összefüggésben áttekintik a zsírmáj, illetve az inzulinrezisztencia jelentőségét idült HCV-hepatitisben, valamint ismertetik a testsúlycsökkentés és az inzulinrezisztencia csökkentésének jelentőségét. Következtetés: A testsúlycsökkentés és a hepatoprotectiv szerek elősegíthették a peginterferon és ribavirin kombinált kezelés antivirális hatásának növelését és így a tartós immunválasz kialakítását.

[The new aspects of the eradication of Helicobacter pylori and the importance of bacterial resistance]

The first line treatment of Helicobacter pylori infection is a 7-day PPI-based (PPI+clarithromycin+amoxycillin or metronidazole) combined therapy. Success of first eradication attempts in the literature is around 80-90%, while in Hungary 75%. Repeated eradication is needed in 10-25% of cases. The second and third line treatments are successful only in 36% and 20% of cases. Treatment failure is increasing worldwide with the higher rates of bacterial, especially clarithromycin resistance. Patients' noncompliance, pharmacogenetic and pharmacokinetic properties of the applied drugs are important as well. The eradication success rates are unacceptable in populations with higher metronidazole and clarithromycin resistance, that is why there is a need for newer combinations. A possible solution is the application of sequential therapy, or using newer antibiotics (levofloxacin). The importance of new natural substances (lactoferrin, probiotics, plant drugs) must be further investigated.

[Stem cell transplantation in the treatment of gastrointestinal diseases]

The stem cells with self-renewal ability are capable to form one or more cell types. They will be in the target of cell and gene therapy because of their multipotency and easy retrieval. Application of adult mesenchymal, neuronal, epidermal and haematopoietic stem cell can be favourable in the treatment of cardiac (myocardial infarction), bone (osteoarthritis), neurological (Parkinson's, Alzheimer's) and hematological (hemophilia, thrombocytopenia) disorders. Authors summarize the knowledge in connection with their application in the therapy of gastrointestinal diseases. Haematopoietic stem cell transplantation has been successful for the treatment of refractory Crohn's disease, as well as in selected group of celiac patients. Mesenchymal stem cell transplantation has been proved beneficial in the prevention of liver fibrotic process. It will gain more grounds in the treatment of autoimmune liver diseases: autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis in the future. Well-designed, multicentric, prospective studies are needed to confirm the results of case reports and clinical studies with small group of patients.

[Epidemiology, risk factors and molecular pathogenesis of primary liver cancer]

Primary liver cancer is the fifth most common cancer worldwide. Hepatocellular carcinoma accounts for 85-90% of primary liver cancers. Distribution of hepatocellular carcinoma shows variations among geographic regions and ethnic groups. Males have higher liver cancer rates than females. Hepatocellular carcinoma occurs within an established background of chronic liver disease and cirrhosis (70-90%). Major causes (80%) of hepatocellular carcinoma are hepatitis B, C virus infection, and aflatoxin exposition. Its development is a multistep process. We have a growing understanding on the molecular pathogenesis. Genetic and epigenetic changes activate oncogenes, inhibit tumorsuppressor genes, which result in autonomous cell proliferation. The chromosomal instability caused by telomere dysfunction, the growth-retrained environment and the alterations of the micro- and macroenvironment help the expansion of the malignant cells. Understanding the molecular mechanisms could improve the screening of patients with chronic liver disease, or cirrhosis, and the prevention as well as treatment of hepatocellular carcinoma.

[Role of obesity in colorectal carcinogenesis]

The obesity is the second most frequent cause of death which can be prevented. It elevates the risk of cardiovascular diseases, diabetes mellitus type 2, cancers and premature mortality. Overweight and obesity responsible for 14% of cancer caused death in males, and 20% in females, respectively. Authors review the connection between obesity, metabolic syndrome and related metabolic alterations with colorectal cancers. They summarize the role of inflammation, hyperinsulinemia, insulin-like growth factor-I and adipokines in the colorectal carcinogenesis.

Genetic background of esophageal squamous cell carcinoma

A nyelőcsőrák a kilencedik leggyakoribb rosszindulatú daganat. Több mint 90%-ban előrehaladott állapotban kerül felismerésre. A sebészi beavatkozás, a kemo-, illetve radioterápia lehetőségei korlátozottak. Napjainkban a génterápia került az érdeklődés előterébe. A szerzők a nyelőcsőlaphámrák genetikai és molekuláris hátterét és a génterápiával elért kezdeti tapasztalatokat tekintik át. Ismertetik a komplementer nukleinsavak (antisense terápia), a génpótlás, a kis interferáló RNS-k alkalmazásának lehetőségeit.

[Stem cell theory of colorectal cancer and its connection with molecular-biological data]

Colorectal cancer is the second leading cause of death in Hungary as well as in the developed countries. The high cancer prevalence of the gastrointestinal tract is the result of the rapid turnover of epithelial cells and exposure to dietary toxins. Adult stem cells are in the lime-light of the medicine. The adult stem cells and tumor cells resemble to each other on the basis of their properties, like self-renewal and proliferation. Cancer is believed to be a disease of stem cells. Recent years have seen major advances in our understanding of location (niche), life cycle, regulation (Wnt/beta-catenin signaling pathway) and markers (mathusashi-1, beta-catenin) of gastrointestinal stem cells. The exact role of adult stem cells in intestinal carcinogenesis is open for debate. New works suggest the role for inflammation-induced engraftment of circulating marrow-derived stem cells in colorectal carcinogenesis. The causes of malignant transformation of local or engrafting bone marrow-derived stem cells are mutations (APC, MMR genes) or methylation (CDKN2A, p16/INK4a, MGMT, MLH1). The spread of dysplastic cells (bottom-up, top-down hypothesis) is also ambiguous.

Genetic background of the multifactorial liver and bile duct diseases

The majority of liver diseases, are complex. They are the results of interactions between several genes and environmental factors. Familial aggregation and higher concordance rate of monozygotic twins compared to those of dizygotic twins provide evidence for the importance of genetic factors in the pathogenesis. There are only limited data in connection with the genetic background of multifactorial liver diseases. In the future, the genetic background may permit prevention, early, accurate diagnosis, prediction of disease course, complications, prognosis, as well as treatment response.

[Inflammatory bowel disease and colorectal cancer]

The colorectal cancer is one of the most serious complication of inflammatory bowel disease. Longer duration of the disease, extensive colitis, primary sclerosing cholangitis, family history of colorectal cancer are the main risk factors. The relative risk of colorectal cancer in ulcerative colitis is increased, however, there're marked geographically differences. Relative risk of colorectal cancer is 2.5 and small bowel cancer risk is 31.2 in Crohn's disease. There aren't prospective, randomized, controlled trials that definitively prove the benefit of surveillance of colorectal cancer in IBD. Colonoscopy improve the 5-year survival rate, however, there is no evidence for the reduction of mortality. Meta-analysis showed efficacy of mesalamine in the reduction of risk of colorectal cancer, but prospective trials have been missed. Chemoprotective role of other immunomodulators has not been proven yet.

[Alopecia areata caused by extreme solar abuse]

The Authors present a female patient who suffered from alopecia areata caused by extreme solar abuse. Biological effects of ionizing radiation, the damages by free radicals and protection against oxidative damage are summarized. The main forms and risk factors of UV-radiation, skin damages by UV-light as well as the pathogenesis of the alopecia areata are reviewed.

[Genetic background of irritable bowel syndrome]

Irritable bowel syndrome (IBS) is a functional disorder which affects the 20% of the population. The exact origin is unknown. IBS is the result of interaction of genes and environmental factors. Familial aggregation and higher concordance rate of monozygotic twins compared to dizygotic twins provide evidence for the importance of genetic factors in the pathogenesis of IBS. Interest has focused on genetic variants of serotonin transporter and receptors, because of their role in gut motility, visceral sensitivity, immune processes and mood. Firm conclusions about the role of serotonin system, as well as other neuroreceptors, G-proteins, cytokine polymorphisms in the pathogenesis of IBS cannot be made.

[The genetics of obesity]

Obesity is a major health problem. It increases the risk of cardiovascular diseases, 2-type diabetes mellitus, cancers, and premature mortality. Apart from some monogenic forms, it's a polygenic disorder, the result of interaction of genes and environmental factors. Genetic variants of proteins taking part in the regulation of food intake or thermogenesis and tissue mediators produced by the adipose tissue are responsible the genetic components of obesity. Identification of the genetic background of the obesity will help to understand the exact molecular mechanism of the pathogenesis, make possible the prevention, as well as individual therapeutic interventions.

[The Human Genome Project, genetic viability and genetic epidemiology]

The goal of the Human Genome Project to elucidate the complete sequence of the human genome has been achieved. The aims of the "post-genome" era are explaining the genetic information, characterisation of functional elements encoded in the human genome and mapping the human genetic variability as well. Two unrelated human beings also share 99.9% of their genomic sequence. The difference of 0.1% is the result of genetic polymorphisms: single nucleotide polymorphisms, repetitive sequences and insertion/deletion. The genetic differences, coupled with environmental exposures will determine the phenotypic variation we observe in health or disease. The disease-causing genetic variants can be identified by linkage analysis or association studies. The knowledge of human genome and application of multiple biomarkers will improve our ability to identify individuals at risk, so that preventive interventions can be applied, earlier diagnosis can be made and treatment can be optimized.