GP73 level in patients with chronic hepatitis B: Relationship with liver biopsy, levels of ALT, AST and HBV DNA

BACKGROUND/AIMS

In this study, we investigated the Golgi protein 73 (GP73) level in Hepatitis B and determined the correlation between Hepatitis B virus (HBV) DNA, alanine aminotransferase (ALT), aspartate aminotransferase (AST) levels, and liver histopathology. Materials and.

METHODS

GP73 levels were estimated by enzyme-linked immunosorbent assay in serum samples from patients. Liver biopsy specimens were examined by the same pathologist.

RESULTS

: This study included a total of 127 patients who underwent liver biopsy. Of patients, 85% were HBeAg negative. HBV DNA level was median 134667 IU/mL (2247-170000000 IU/mL), Liver biopsy results revealed a mean Histological Activity Index (HAI) grade of 7.7 ± 3.4 and a mean fibrosis stage of 2.25 ± 1.06 gr/dL. GP73 was as follows: a mean of 14.8 ± 7.9 ng/mL and a median of 12.9 (4.8-50.1) ng/mL. A weak correlation between GP73 level and AST (r = 0.236, P = 0.11), fibrosis stage (r = 0.287, P = 0.002), and HAI grade (r = 0.218, P = 0.016) was noted. No statistically significant correlation was detected between GP73 and ALT (r = 0.16, P = 0.08), HBV DNA (r = 0.13, P = 0.08).

CONCLUSION

Although recent studies revealed a strong correlation and increased GP73 levels in accordance with HAI scores and the fibrosis grade of liver, we detected a weak correlation between serum GP73 levels and HAI scores, fibrosis stage, and AST. This may be due to the insufficient number of patients with higher HAI grading and fibrosis staging in our study. Therefore, we concluded that, in cases of low-moderate fibrosis and HAI grading, GP73 seemed not to be useful and a reliable marker to replace liver biopsy.

Using vibration controlled transient elastography and FIB-4 to assess liver cirrhosis in a hepatitis C virus infected population

We assessed the performance characteristics of the Fibrosis-4 (FIB-4) score in a veteran population with chronic hepatitis C virus (HCV) infection and used vibration controlled transient elastography (VCTE) as the gold standard.All VCTE studies were performed by a single operator on United States veterans with HCV infection presenting for care at the Atlanta VA Medical Center (AVAMC) over a 2 year period. VCTE liver stiffness measurements (LSM) were categorized as cirrhotic if LSM was >12.5 kPa and non-cirrhotic if LSM was ≤12.5 kPa. FIB-4 scores ≤3.25 were considered non-cirrhotic and scores >3.25 were considered cirrhotic. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for the FIB-4 score. A second analysis was done which identified and excluded indeterminate FIB-4 scores, defined as any value between 1.45 and 3.25.When FIB-4 was used to screen for liver cirrhosis using VCTE as the gold standard, sensitivity was 42%, specificity was 88%, PPV was 62%, and NPV was 76%. When indeterminate FIB-4 scores were excluded from the analysis, sensitivity was 95%, specificity was 61%, PPV was 62%, and NPV was 94.4%. In a veteran population with chronic HCV infection, we found the sensitivity of the FIB-4 score to be unacceptably low for ruling out liver cirrhosis when using a binary cutoff at 3.25. Using a second staging method like VCTE may be an effective way to screen for liver cirrhosis in persons with chronic HCV, especially when the FIB-4 score is in the indeterminate range.

Clinical significance of serum human epididymis protein 4 in liver fibrosis: An experimental study

BACKGROUND

Human epididymis protein 4 (HE4) has been identified as marker for renal fibrosis. Present study aimed to investigate the clinical significance of serum HE4 in liver fibrosis.

METHODS

Serum from 65 liver fibrosis patients, 68 hepatic patients without fibrosis, and 50 controls was collected respectively. Serum HE4 levels were measured by chemiluminescence immunoassay and compared among the groups. The relationships between serum HE4 levels and the clinical characteristics of liver fibrosis were also analyzed. A receiver operator characteristic curve was plotted to investigate the diagnostic efficacy of serum HE4 for liver fibrosis. Child-Pugh (C-P) score and liver fibrosis score were also evaluated. Data were analyzed by statistical software 13.0.

RESULTS

Serum HE4 levels were significantly higher in liver fibrosis than that of controls [105.35 (82.64, 164.18) vs 46.2 (39.9, 58.9) pmol L, P = .00] and hepatic patients without liver fibrosis [105.35 (82.64, 164.18) vs 51.00 (44.02, 65.65) pmol L, P < .01]; Serum HE4 levels in liver fibrosis patients with C-P class C were significantly higher than those with C-P class A [143.75 (106.50, 186.08) vs 81.42 (69.73, 99.26) pmol L, P = .005] and C-P class B [143.75 (106.50, 186.08) vs 113.10 (88.92, 169.50) pmol L, P = .01]; the diagnostic sensitivity and specificity of serum HE4 levels for liver fibrosis detection were 87.5% and 81.1%, at a cutoff value of 69 pmol L; Serum HE4 levels in alcoholic liver fibrosis were higher than that of liver fibrosis with hepatitis B virus infection [131.30 (100.67, 228.35) vs 89.46 (73.74, 116.45) pmol L, P < .01].

CONCLUSION

Serum HE4 was closely correlated with C-P class and might be a potential marker for liver fibrosis.

Image Processing Pipeline for Liver Fibrosis Classification Using Ultrasound Shear Wave Elastography

The purpose of this study was to develop an automated method for classifying liver fibrosis stage ≥F2 based on ultrasound shear wave elastography (SWE) and to assess the system's performance in comparison with a reference manual approach. The reference approach consists of manually selecting a region of interest from each of eight or more SWE images, computing the mean tissue stiffness within each of the regions of interest and computing a resulting stiffness value as the median of the means. The 527-subject database consisted of 5526 SWE images and pathologist-scored biopsies, with data collected from a single system at a single site. The automated method integrates three modules that assess SWE image quality, select a region of interest from each SWE measurement and perform machine learning-based, multi-image SWE classification for fibrosis stage ≥F2. Several classification methods were developed and tested using fivefold cross-validation with training, validation and test sets partitioned by subject. Performance metrics were area under receiver operating characteristic curve (AUROC), specificity at 95% sensitivity and number of SWE images required. The final automated method yielded an AUROC of 0.93 (95% confidence interval: 0.90-0.94) versus 0.69 (95% confidence interval: 0.65-0.72) for the reference method, 71% specificity with 95% sensitivity versus 5% and four images per decision versus eight or more. In conclusion, the automated method reported in this study significantly improved the accuracy for ≥F2 classification of SWE measurements as well as reduced the number of measurements needed, which has the potential to reduce clinical workflow.

Nonalcoholic Fatty Liver Disease: An Important Consideration for Primary Care Providers in Hawai'i

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide. NAFLD is a broad term for both non-alcoholic fatty liver (NAFL), which describes simple fatty liver without inflammation, and non-alcoholic steatohepatitis (NASH), the more severe phenotype with hepatocellular inflammation. The population of Hawai'i is particularly vulnerable to the NAFLD and obesity epidemics due to its large proportions of high-risk ethnic minorities exposed to varying degrees of westernization. Unfortunately, primary care providers (PCPs) often face a lack of awareness on the diagnosis and disease spectrum of NAFLD. Early initiation of treatment for NAFLD is crucial to slow its progression and prevent liver-related morbidity and mortality. This review aims to raise awareness for NAFLD among PCPs in Hawai'i by summarizing the disease's epidemiology, diagnosis, and treatment. The diagnostic workup of NAFLD in the primary care setting involves exclusion of other liver disease etiologies and staging assessment of fibrosis and steatosis through non-invasive means such as serum biomarkers or elastography. Patients with overt signs and symptoms of cirrhosis or a high likelihood of advanced hepatic fibrosis should be referred to liver disease specialists. The role of PCPs in NAFLD management involves facilitating weight loss through therapeutic lifestyle modifications and treatment of comorbid cardiovascular conditions. Evidence-based pharmacologic therapies for NAFLD are available, such as vitamin E and pioglitazone, with more currently in development.

Prevalence of steatosis and fibrosis in young adults in the UK: a population-based study

BACKGROUND

The estimated worldwide prevalence of non-alcoholic fatty liver disease (NAFLD) in adults is 25%; however, prevalence in young adults remains unclear. We aimed to identify the prevalence of steatosis and fibrosis in young adults in a sample of participants recruited through the Avon Longitudinal Study of Parents and Children (ALSPAC), based on transient elastography and controlled attenuation parameter (CAP) score.

METHODS

In this population-based study, we invited active participants of the ALSPAC cohort to our Focus@24+ clinic at the University of Bristol (Bristol, UK) between June 5, 2015, and Oct 31, 2017, for assessment by transient elastography with FibroScan, to determine the prevalence of steatosis and fibrosis. FibroScan data were collected on histologically equivalent fibrosis stage (F0-F4) and steatosis grade (S0-S3); results with an IQR to median ratio of 30% or greater were excluded for median fibrosis results greater than 7·1 kPa, and CAP scores for steatosis were excluded if less than ten valid readings could be obtained. Results were collated with data on serology (including alanine aminotransferase, aspartate aminotransferase, and γ-glutamyl transferase) and exposures of interest: alcohol consumption (via the Alcohol Use Disorder Identification Test for Consumption [AUDIT-C] and the Diagnostic and Statistical Manual of Mental Disorders-5 criteria for alcohol use disorder), body-mass index (BMI), waist-to-height ratio, socioeconomic status (based on predefined ALSPAC markers), and sex. We used logistic regression models to calculate odds ratios (ORs) for the effect of exposures of interest on risk of steatosis and fibrosis, after dichotomising the prevalences of fibrosis and steatosis and adjusting for covariates (excessive alcohol intake [hazardous drinking, AUDIT-C score ≥5; or harmful drinking, evidence of alcohol use disorder], social class, smoking, and BMI).

FINDINGS

10 018 active ALSPAC participants were invited to our Focus@24+ clinic, and 4021 attended (1507 men and 2514 women), with a mean age of 24·0 years (IQR 23·0-25·0). 3768 CAP scores were eligible for analysis. 780 (20·7% [95% CI 19·4-22·0]) participants had suspected steatosis (S1-S3; ≥248 dB/m), with 377 (10·0%) presenting with S3 (severe) steatosis (≥280 dB/m). A BMI in the overweight or obese range was positively associated with steatosis when adjusted for excessive alcohol consumption, social class, and smoking (overweight BMI: OR 5·17 [95% CI 4·11-6·50], p<0·0001; obese BMI: 27·27 [20·54-36·19], p<0·0001). 3600 participants had valid transient elastography results for fibrosis analysis. 96 participants (2·7% [95% CI 2·2-3·2]) had transient elastography values equivalent to suspected fibrosis (F2-F4; ≥7·9 kPa), nine of whom had values equivalent to F4 fibrosis (≥11·7 kPa). Individuals with alcohol use disorder and steatosis had an increased risk of fibrosis when adjusted for smoking and social class (4·02 [1·24-13·02]; p=0·02).

INTERPRETATION

One in five young people had steatosis and one in 40 had fibrosis around the age of 24 years. The risk of fibrosis appears to be greatest in young adults who have harmful drinking patterns and steatosis. A holistic approach to the UK obesity epidemic and excessive drinking patterns is required to prevent an increasing health-care burden of adults with advanced liver disease in later life.

FUNDING

Medical Research Council UK, Alcohol Change UK, David Telling Charitable Trust.

Management and Outcomes of Acute Appendicitis in the Presence of Cirrhosis: A Nationwide Analysis

Best management for acute appendicitis (AA) in adults with liver cirrhosis is controversial and needs more investigation. We aimed to examine the impact of different treatment modalities on outcomes in this complex patient population. The Nationwide Inpatient Sample database from 2012 to 2014 was queried to identify AA patients with no cirrhosis, compensated cirrhosis (CC), and decompensated cirrhosis (DC). Each cohort was further stratified according to the treatment type: nonoperative management, open appendectomy, and laparoscopic appendectomy (LA). Chi-square, ANOVA, and binary regression analyses were used to determine differences between groups and risk factors for mortality and complications, with P < 0.05 considered statistically significant. A total of 108,289 AA patients were analyzed; of those, 304 with CC and 134 with DC were identified. Compared with CC and no cirrhosis, DC patients had significantly higher mortality, higher cost, and longer hospital length of stay. LA is accompanied by higher survival, lower cost, shorter duration of hospitalization, and lower incidence of complications across all groups. We conclude that LA is the best management strategy for AA in cirrhotic patients. Even in decompensated cirrhotics, which are associated with worse clinical outcomes, LA is still a favorable option over open appendectomy and nonoperative management.

Serum Wisteria floribunda agglutinin-positive Mac-2-binding protein levels predict the presence of fibrotic nonalcoholic steatohepatitis (NASH) and NASH cirrhosis

OBJECTIVE

The race for finding effective treatments for nonalcoholic fatty liver disease (NAFLD) has been slowed down by the high screen-failure rate for including patients in trials due to the lack of a noninvasive biomarker that can identify patients with significant disease. Recently, Wisteria floribunda agglutinin-positive Mac-2-binding protein (WFA+ -M2BP) has shown promise in predicting liver fibrosis. The aims of this study were to evaluate the utility of WFA+ -M2BP as a biomarker to sub-classify patients with NAFLD according to their disease severity and to assess its correlation with histologic features of NAFLD.

METHODS

Patients undergoing biopsy for clinical suspicion of NAFLD and healthy controls were included. Patients with NAFLD were classified into: NAFL, early NASH (F0-F1), fibrotic NASH (F2-F3), and NASH cirrhosis (F4). Levels of WFA+ -M2BP in sera was measured by a HISCL™ M2BPGi™ assay kit using an automated immunoanalyzer (HISCL™-800; Sysmex, Kobe, Japan). Analysis of covariance was used to assess difference in WFA+ -M2BP between the groups and Spearman's correlation coefficients were used to assess correlation with histological features.

RESULTS

Our cohort consisted of 20 healthy controls and 198 patients with biopsy-proven NAFLD divided as follows: 52 with NAFL, 62 with early NASH, 52 with fibrotic NASH, and 32 with NASH cirrhosis. WFA+ -M2BP level was found to be significantly increased in the fibrotic NASH and NASH cirrhosis groups compared to healthy controls and those with early NAFLD after adjusting for age, gender and BMI. Furthermore, patients with NASH cirrhosis had significantly higher WFA+ -M2BP levels (2.4[1.5, 4.2] C.O.I (Cut-off Index)) than those with fibrotic NASH (1.2[0.79, 1.9]), p < 0.001. WFA+ -M2BP level had moderate correlation with inflammation, ballooning and NAFLD activity score and strong correlation with fibrosis stage. Additionally, ROC curve analysis demonstrated that WFA+ -M2BP accurately differentiated F2-4 from F0-F1.

CONCLUSION

In a large cohort of patients with the full spectrum of NAFLD, WFA+ -M2BP levels predicted the presence of advanced disease and correlated strongly with fibrosis stage.

Diagnostic accuracy of point shear wave elastography and transient elastography for staging hepatic fibrosis in patients with non-alcoholic fatty liver disease: a meta-analysis

OBJECTIVE

This study aimed to assess the accuracy of staging liver fibrosis in patients with non-alcoholic fatty liver disease (NAFLD) usingpoint shear wave elastography (pSWE) and transient elastography (TE).

SETTING

Relevant records on NAFLD were retrieved from PubMed, Embase, Web of Science and the China National Knowledge Infrastructure databases up to 20 December 2017. A bivariate mixed-effects model was conducted to combine sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and area under the summary receiver operating characteristic curve (AUC) between pSWE and TE. A sensitivity analysis was implemented to explore the source of heterogeneity.

PARTICIPANTS

Patients with NAFLD who had a liver stiffness measurement using pSWE and TE before liver biopsy were enrolled according to the following criteria: 2×2 contingency tables can be calculated via the reported number of cases; sensitivity and specificity were excluded according to the following criteria: history of other hepatic damage, such as chronic hepatitis C, concurrent active hepatitis B infection, autoimmune hepatitis, suspicious drug usage and alcohol abuse.

RESULTS

Nine pSWE studies comprising a total of 982 patients and 11 TE studies comprising a total of 1753 patients were included. For detection of significant fibrosis, advanced fibrosis and cirrhosis, the summary AUC was 0.86 (95% CI 0.83 to 0.89), 0.94 (95% CI 0.91 to 0.95) and 0.95 (95% CI 0.93 to 0.97) for pSWE, and the summary AUC was 0.85 (95% CI 0.82 to 0.88), 0.92 (95% CI 0.89 to 0.94) and 0.94 (95% CI 0.93 to 0.97) for TE, respectively. The proportion of failure measurement was over tenfold as common with TE using an M probe compared with pSWE.

CONCLUSION

pSWE and TE, providing precise non-invasive staging of liver fibrosis in NAFLD, are promising techniques, particularly for advanced fibrosis and cirrhosis.

Evaluation of the Behavior of Carcinoembryonic Antigen in Cirrhotic Patients

Benign liver diseases are a cause of increased serum levels of CEA. We studied the behavior of CEA in 86 patients with liver cirrhosis who underwent extensive clinical and laboratory evaluation. We found abnormal CEA levels in 38.4% of the patients (28.6% Child's grade A, 40.6% Child's B, and 42.4% Child's C) with a mean of 4.75 ng/ml. Significant differences were found between patients and controls. There was a trend towards higher levels of CEA in more severe cirrhosis according to Child's classification, although this was not significant. We found significant correlations between CEA and some liver tests, including glycocholic acid (r = 0.264., p = 0.012), a marker of severity in liver diseases. The increase of CEA in these patients is probably due to alterations in its metabolic processing caused by hepatocellular dysfunction. Moderate elevations of serum CEA can be expected in cirrhotic patients independently of malignancy.

Liver cirrhosis in England-an observational study: are we measuring its burden occurrence correctly?

OBJECTIVES

Mortality due to liver disease (of which cirrhosis is the end stage) is increasing more than any other chronic condition in the UK. This study aims to demonstrate that (1) exclusive reliance on mortality rates may not reveal the true burden of liver cirrhosis, and (2) diverse use of diagnostic coding may produce misleading estimates.

DESIGN

Observational study.

SETTING

The Office for National Statistics death registry was interrogated to investigate liver cirrhosis mortality trends in England and Wales from 1968 to 2011.

MAIN OUTCOME

Standardised mortality trends according to three different definitions of liver cirrhosis based on the specificity of diagnostic codes were calculated: 1 (chronic liver diseases), 2 (alcoholic and unspecified cirrhosis only) and 3 (cirrhosis as end-stage liver disease). The mortality trends were compared with incidence rates established in a previous population-based study (based on definition 3), from 1998 to 2009, to investigate discrepancies between these two measures.

RESULTS

Over the study period, the overall standardised liver cirrhosis mortality rates were 8.8, 5,1 and 5.4 per 100 000 person-years for definitions 1, 2 and 3, respectively. The mortality rates for definition 3 in 1998 and 2009 were 6.2 and 5.9 per 100 000 person-years, respectively; while the equivalent incidence rates were at least threefold and sixfold higher: 23.4 and 35.9 per 100 000 person-years, respectively. This discrepancy between incidence and mortality rates was also at least threefold in men and women separately and across age groups.

CONCLUSION

Mortality rates underestimated the incidence of liver cirrhosis by at least threefold between 1998 and 2009 and varied with differing definitions of disease. Mortality data should not be used exclusively as an indicator for the occurrence of liver cirrhosis in the population. Routinely collected healthcare data are available to measure occurrence of this disease. Careful consideration should be taken when selecting diagnostic codes for cirrhosis.

[Cardiac Surgery for Patients with Liver Cirrhosis]

Liver cirrhosis has emerged as a serious risk factor for cardiac surgery due to the higher mortality and morbidity that these patients display compared with the non-cirrhotic cardiac surgery population. Child-Pugh classification and model for end-stage liver disease score( MELD) score are useful to assess perioperative risk in patients with cirrhosis. According to recent research, cardiac surgery could be offered to patients with Child-Pugh A and a low MELD score with only mild increase in the risk of mortality. However, for patients with more advanced cirrhosis, risk of mortality is extremely high. To decrease mortality, careful patient selection, meticulous consideration of surgical strategy and perioperative treatment are vital for the recovery of cirrhotic patients.

Evaluation of Acoustic Radiation Force Impulse (ARFI) for Fibrosis Staging in Chronic Liver Diseases

BACKGROUND

acoustic radiation force impulse (ARFI) is a new proposed noninvasive method for liver fibrosis staging. Integrated with B-mode ultrasonography, ARFI can be used to assess liver tissue condition. However its diagnostic accuracy is still being continuously evaluated. Also, there is lack of data regarding the utilization of ARFI in our population. This study aimed to evaluate the diagnostic value of ARFI as an alternative noninvasive modality for fibrosis staging in chronic hepatitis B and hepatitis C patients in our population.

METHODS

we conducted cross-sectional comparison of ARFI imaging and transient elastography on patients who underwent liver biopsy at Cipto Mangunkusumo Hospital. Fibrosis staging using METAVIR scoring system presented as standard reference. A total of 43 patients underwent liver biopsy was evaluated by ARFI imaging and transient elastography. Cut-off values were determined using receiver-operating characteristic (ROC).

RESULTS

both liver stiffness determined by ARFI and transient elastography (TE) were moderately correlated with METAVIR score with value of 0.581 and 0.613, respectively (both P<0.01). Diagnostic accuracy of ARFI predicted significant fibrosis (F≥2) with area under receiver operating characteristic curve (AUROC) of 0.773 (95% CI 0.616-0.930) and even better for cirrhosis (F4 fibrosis), expressed as AUROC of 0.856 (95% CI 0.736-0.975). Transient elastography was better for significant fibrosis with AUROC of 0.761 (95% CI 0.601-0.920) and was best for prediction of cirrhosis, expressed as AUROC of 0.845 (95% CI 0.722-0.968).

CONCLUSION

ARFI is provided with more convenient evaluation of liver tissue condition, and its diagnostic accuracy is not significantly different from TE for staging liver fibrosis.

Safety, Tolerability, and Efficacy of Sofosbuvir Plus Ribavirin in Elderly Patients Infected with Hepatitis C Virus Genotype 2

BACKGROUND

An interferon-free regimen including sofosbuvir and ribavirin (RBV) for patients with hepatitis C virus (HCV) genotype 2 (G2) infection leads to a drastic improvement of sustained virological response (SVR). However, the safety, tolerability, and efficacy in patients aged 75 or older have not been completely understood.

SUMMARY

Fifty-six patients with HCV G2 infection who were treated with sofosbuvir and weight-based dose of RBV were enrolled. Thirty-seven patients aged ≥75 and 19 patients aged ≤74 were classified as the aged and non-aged groups, respectively. The aged group was characterized by significantly more number of women, history of hepatocellular carcinoma, low serum albumin (ALB) level, low hemoglobin (Hb) concentration, low estimated glomerular filtration rate (eGFR), and high fibrosis-4 index (p = 0.0029). Forty-one patients were evaluated for SVR at 12 weeks after the end of therapy (SVR12); of them, all but one completed the treatment scheduled for 12 weeks. The aged group showed lower SVR12 rate than the non-aged group (81.3% for aged and 96.0% for non-aged groups). Although the Hb concentration and eGFR are significantly lower in the aged group throughout the clinical course, all patients in the aged group completed the 12-week treatment with a gradual increase of serum ALB level. Key Messages: The combination of sofosbuvir plus RBV is tolerable and beneficial in patients aged >75. However, intensive management of anemia by dose reduction of RBV is necessary, which could lead to a low SVR12 rate compared to that observed in patients younger than 75 years.

From Child-Pugh to Model for End-Stage Liver Disease: Deciding Who Needs a Liver Transplant

This article reviews the historical evolution of the liver transplant organ allocation policy and the indications/contraindications for liver transplant, and provides an overview of the liver transplant evaluation process. The article is intended to help internists determine whether and when referral to a liver transplant center is indicated, and to help internists to counsel patients whose initial evaluation at a transplant center is pending.

Suitability of using serum hialuronic acid concentrations in the diagnosis of canine liver fibrosis

There are multiple dynamic changes associated with the metabolism of the extracellular matrix (ECM) which occur in the course of liver fibrosis. Therefore, the evaluation of parameters reflecting the deposition of ECM, the activity of myofibroblasts and the synthesis and degradation of collagen may aid in the diagnosis of liver fibrosis. Hyaluronic acid is considered to be a marker of ECM deposition. It is a glycosaminoglycan synthesized by hepatic stellate cells and degraded by hepatic sinusoidal endothelial cells. The aim of this study was to evaluate the concentration of hyaluronic acid in dogs with different degrees of liver fibrosis. The study was carried out on 29 dogs with liver disease. A core needle biopsy of the liver was performed in order to assess the degree of hepatic inflammation. Then, hyaluronic acid serum concentrations were measured. The dogs were divided into five groups based on the histopathological examination and the evaluation of the degree of hepatic fibrosis. The study showed that serum hyaluronic acid concentrations were low in patients with first stage liver fibrosis and in controls, while they were twice as high as control values in the group of dogs with second stage liver fibrosis. These concentrations were three-fold greater than control values in patients with third stage liver fibrosis, and seven-fold greater in patients with liver cirrhosis. Based on the results, it was concluded that serum hyaluronic acid is a useful marker of liver fibrosis and may aid in determining the degree of its advancement.

Laparoscopic splenectomy for patients with liver cirrhosis: Improvement of liver function in patients with Child-Pugh class B

BACKGROUND

We aimed to assess the short-term outcomes of laparoscopic splenectomy (LS) and liver function at 1 year after splenectomy in the patients with liver cirrhosis.

METHODS

Forty-five patients with liver cirrhosis and hypersplenism underwent LS. We reviewed electronic medical records regarding the liver functional reserve, the etiology of liver cirrhosis, and the presence of hepatocellular carcinoma and esophago-gastric varices. Prospectively collected data of perioperative variables, postoperative complications, and long-term liver function were analyzed.

RESULTS

Forty-five patients had a chronic liver disease classified into Child-Pugh classes (A/B/C: 23/20/2). The etiologies of disease were hepatitis C virus infection in 34 patients, hepatitis B virus infection in 4, and others in 7. Fourteen patients underwent procedures in addition to LS, including hepatectomy (n = 7) and devascularization for esophagogastric varices (n = 8). Postoperative complications occurred in 11 patients (24%). Neither postoperative liver failure nor in-hospital mortality occurred. White blood cell and platelet counts determined 7 days, 1 month, and 1 year after LS doubled or increased more than twice compared with the preoperative values (P < .001). One year after LS, patients who had been classified preoperatively into Child-Pugh class B had decreased total serum bilirubin levels (P = .03), and increased prothrombin activity (P = 003) and decreased Child-Pugh scores (P = .001). The Child-Pugh classifications improved in 14 of 18 patients (78%) who had Child-Pugh class B preoperatively.

CONCLUSION

LS is a safe and feasible procedure for hypersplenism in patients with liver cirrhosis. In addition, LS most likely ameliorates liver function at 1 year after LS in patients with Child-Pugh class B liver cirrhosis.

Acute-on-chronic liver failure: A new syndrome that will re-classify cirrhosis

Acute-on-chronic liver failure (ACLF) is a recently recognized syndrome characterized by acute decompensation (AD) of cirrhosis and organ/system failure(s) (organ failure: liver, kidney, brain, coagulation, circulation and/or respiration) and extremely poor survival (28-day mortality rate 30-40%). ACLF occurs in relatively young patients. It is especially frequent in alcoholic- and untreated hepatitis B associated-cirrhosis, in addition it is related to bacterial infections and active alcoholism, although in 40% of cases no precipitating event can be identified. It may develop at any time during the course of the disease in the patient (from compensated to long-standing cirrhosis). The development of ACLF occurs in the setting of a systemic inflammation, the severity of which correlates with the number of organ failures and mortality. Systemic inflammation may cause ACLF through complex mechanisms including an exaggerated inflammatory response and systemic oxidative stress to pathogen- or danger/damage-associated molecular patterns (immunopathology) and/or alteration of tissue homeostasis to inflammation caused either by the pathogen itself or through a dysfunction of tissue tolerance. A scoring system composed of three scores (CLIF-C OFs, CLIF-C AD, and CLIF-C ACLFs) specifically designed for patients with AD, with and without ACLF, allows a step-wise algorithm for a rational indication of therapy. The management of ACLF should be carried out in enhanced or intensive care units. Current therapeutic measures comprise the treatment for associated complications, organ failures support and liver transplantation.

Stratification of patients with liver fibrosis using dual-energy CT

Assessing the severity of liver fibrosis has direct clinical implications for patient diagnosis and treatment. Liver biopsy, typically considered the gold standard, has limited clinical utility due to its invasiveness. Therefore, several imaging-based techniques for staging liver fibrosis have emerged, such as magnetic resonance elastography (MRE) and ultrasound elastography (USE), but they face challenges that include limited availability, high cost, poor patient compliance, low repeatability, and inaccuracy. Computed tomography (CT) can address many of these limitations, but is still hampered by inaccuracy in the presence of confounding factors, such as liver fat. Dual-energy CT (DECT), with its ability to discriminate between different tissue types, may offer a viable alternative to these methods. By combining the "multi-material decomposition" (MMD) algorithm with a biologically driven hypothesis we developed a method for assessing liver fibrosis from DECT images. On a twelve-patient cohort the method produced quantitative maps showing the spatial distribution of liver fibrosis, as well as a fibrosis score for each patient with statistically significant correlation with the severity of fibrosis across a wide range of disease severities. A preliminary comparison of the proposed algorithm against MRE showed good agreement between the two methods. Finally, the application of the algorithm to longitudinal DECT scans of the cohort produced highly repeatable results. We conclude that our algorithm can successfully stratify patients with liver fibrosis and can serve to supplement and augment current clinical practice and the role of DECT imaging in staging liver fibrosis.

[Scoring methods for liver tissue fibrosis based on ultrasound radio frequency time series]

Trying to provide ultrasonic image-aid measures for quantitative diagnosis and dynamic monitoring of liver fibrosis, we propose two scoring methods for liver fibrosis tissue in vivo , based on ultrasound radio frequency (RF) time series in this paper. Firstly, RF echo signals of human liver were recorded in this study. Then one of the recorded frame RF data was demodulated to be B model image. After that, a region of interest (ROI) in the B model image was selected. For each point in the ROI, its all frame data were acquired so that RF time series were formed. An SMR (size measure relationship) fractal dimension and six spectral features were extracted from RF time series in the ROI. With relative deviation and Fisher's discriminant ratio, seven features were weighted and summed so that the liver tissues' scores were obtained, Score-rd and Score-fisher, respectively. Area under ROC curve (AUC) and a support vector machine (SVM) were used to evaluate whether these scoring methods would be useful in distinguishing normal and cirrhosis tissues. Experimental results are shown as follows: Score-rd's AUC was 0.843, while Score-fisher was 0.816, SVM classification accuracies were both up to 87.5%. This proved that our proposed scoring methods were effective in distinguishing normal and cirrhosis tissues. Score-rd and Score-fisher have potential for clinical applications. They can also provide quantitative references for liver fibrosis diagnosis.

MELD scores and Child-Pugh classifications predict the outcomes of ERCP in cirrhotic patients with choledocholithiasis: a retrospective cohort study

Endoscopic retrograde cholangiopancreatography (ERCP) is challenging in cirrhotic patients with choledocholithiasis. We evaluated the safety and efficacy of ERCP in cirrhotic patients with choledocholithiasis and accessed the model for end-stage liver disease (MELD) scores and Child-Pugh classifications for prediction of morbidity and mortality.From January 2000 to June 2014, 77 ERCP operations were performed in cirrhotic patients with choledocholithiasis. The data on operative complications were analyzed. MELD scores and Child-Pugh classifications were calculated and associated with operative outcomes and survival. Telephone follow-up was performed to determine survival situations.No death, perforation, or hemorrhage caused by gastroesophageal varices occurred as a result of the procedure. The rate of intraoperative hemorrhage was 13.0%, and the rate of postoperative morbidity was 27.3% including hemorrhage (18.2%), post-ERCP pancreatitis (6.1%), aggravated infection of the biliary tract (1.3%), hepatic encephalopathy (1.3%), and respiratory failure (1.3%). Four (5.2%) patients had both intraoperative and postoperative hemorrhage. Receiver operating characteristic analysis identified MELD scores higher than 11.5 as the best cutoff value for predicting complication incidence (95% confidence interval = 0.63-0.87). Twenty-one (44.7%) patients with a MELD score above 11.5 developed a complication, and 3 (10%) patients who had a lower MELD score developed a complication (P = 0.001). Both MELD score and Child-Pugh classification had prognostic value in patients without jaundice, although sex may result in different prognostic values based on the 2 scores. The rate of complications was not significantly different among patients with different Child-Pugh classifications. No significant difference was observed in patients with different MELD scores or Child-Pugh classifications in terms of median survival times.ERCP is an effective and safe procedure in cirrhotic patients with choledocholithiasis. MELD scores can predict the risk of operative complications, but Child-Pugh classification system scores do not predict the risk of complications.

Role of cystatin C and renal resistive index in assessment of renal function in patients with liver cirrhosis

AIM: To evaluate the clinical significance of cystatin C and renal resistive index for the determination of renal function in patients with liver cirrhosis.

METHODS: We conducted a study of 63 patients with liver cirrhosis. A control group comprised of 30 age and gender-matched healthy persons. Serum cystatin C was determined in all study subjects and renal Doppler ultrasonography was made. Estimated glomerular filtration rate from serum creatinine (GFR_Cr) and cystatin C (GFR_Cys) was calculated.

RESULTS: We confirmed significant differences in values of cystatin C between patients with different stages of liver cirrhosis according to Child-Pugh (P = 0.01), and a significant correlation with model of end stage liver disease (MELD) score (r_s = 0.527, P < 0.001). More patients with decreased glomerular filtration rate were identified based on GFR_Cys than on GFR_Cr (P < 0.001). Significantly higher renal resistive index was noted in Child-Pugh C than in A (P < 0.001) and B stage (P = 0.001). Also, a significant correlation between renal resistive index and MELD score was observed (r_s = 0.607, P < 0.001). Renal resistive index correlated significantly with cystatin C (r_s = 0.283, P = 0.028) and showed a negative correlation with GFR_Cys (r_s = -0.31, P = 0.016).

CONCLUSION: Cystatin C may be a more reliable marker for assessment of liver insufficiency. Additionally, cystatin C and renal resistive index represent sensitive indicators of renal dysfunction in patients with liver cirrhosis.

Nationwide longitudinal analysis of acute liver failure in taiwan

Acute liver failure (ALF) is uncommon but fatal. Current management is based mostly on clinical experience. We aimed to investigate the incidence, etiology, outcomes, and prognostic factors of ALF in Taiwan. Patients with the admission diagnosis of ALF between January 2005 and September 2007 were identified from the Longitudinal Health Insurance Database of Taiwan. ALF was further confirmed by disease severity based on laboratory orders, prescriptions, and duration of hospital stay, and acute onset without prior liver disease. Prognostic factors were identified using Cox regression analysis. During the study period, 218 eligible cases were identified from 28,078 potential eligible ALF patients. The incidence was 80.2 per million person-years in average and increased with age. The mean age was 57.9 ± 17.1 years and median survival was 171 days. The most common etiologies were viral (45.4%, mainly hepatitis B virus) and followed by alcohol/toxin (33.0%). Independent prognostic factors included alcohol consumption (hazard ratio, HR, 1.67 [1.01-2.77]), malignancy (HR 2.90 [1.92-4.37]), frequency of checkups per week for total bilirubin (HR 1.57 [1.40-1.76]), sepsis (HR 1.85 [1.20-2.85]), and the use of hemodialysis/hemofiltration (HR 2.12 [1.15-3.9]) and proton pump inhibitor (HR 0.94 [0.90-0.98]). Among the 130 patients who survived ≥90 days, 66 (50.8%) were complicated by liver cirrhosis. Eight (3.7%) were referred for liver transplantation evaluation, but only 1 received transplantation and survived. ALF in Taiwan is mainly due to viral infection. Patients with malignancy and alcohol exposure have worst prognosis. The use of proton pump inhibitor is associated with improved survival. Half of the ALF survivors have liver cirrhosis.

Staging chronic hepatitis C in seven categories using fibrosis biomarker (FibroTest™) and transient elastography (FibroScan®)

BACKGROUND & AIMS

FibroTest™ (FT) and Transient Elastography (TE) have been validated as non-invasive markers of METAVIR fibrosis stages from F0 to F4 using biopsy, and as prognostic markers of liver related mortality in patients with chronic hepatitis C. The aim was to extend the validation of FT and TE as markers of critical steps defined by occurrence of cirrhosis without complications (F4.1), esophageal varices (F4.2), and severe complications (F4.3): primary liver cancer, variceal bleeding, or decompensation (ascites, encephalopathy, or jaundice).

METHODS

The updated individual data of 3927 patients (1046 cirrhotics) without complications at baseline were pooled from three prospective cohorts called "EPIC", "Paris", and "Bordeaux" cohorts.

RESULTS

At 5 years, among 501 patients without varices at baseline (F4.1) varices occurred in 19 patients [F4.2 incidence of 4.0% (95% CI 2.2-5.8)]. The predictive performance (AUROC) of FT was 0.77 (0.66-0.84; p<0.001). At 10 years severe complications occurred in 203 patients, [F4.3 incidence of 13.4% (9.6-17.1)], including primary liver cancer in 84 patients [6.4% (3.5-9.3)]. FT was predictive (Cox adjusted on treatment) of severe complications [AUROC 0.79 (76-82); p<0.0001], including primary liver cancer [AUROC 0.84 (80-87); p<0.0001]. Similarly TE was predictive of severe complications [AUROC 0.77 (72-81); p<0.0001], including primary liver cancer [AUROC 0.86 (81-90); p<0.0001].

CONCLUSIONS

FibroTest™ and TE increase were associated with the occurrence of all severe complications including hepatocellular carcinoma, hepatic insufficiency, and variceal bleeding. FibroTest™ increase was also associated with the occurrence of esophageal varices.

[Correlation between levels of liver fibrosis and liver fibrosis biochemical parameters of advanced schistosomiasis patients]

OBJECTIVE

To explore the correlation between the levels of liver fibrosis and liver fibrosis biochemical parameters of advanced schistosomiasis patients.

METHODS

A total of 48 advanced schistosomiasis patients were investigated and they were examined by the liver biopsy and B ultrasound imaging. At the same time, the liver fibrosis biochemical parameters, including glutamine transpeptidase (GGT), alkaline phosphatase (AKP), procollagen III (PC-III), collagen type IV (IV-C), hyaluronic acid (HA) and laminin (LN), were detected. The liver fibrosis levels were classified by the liver biopsy and B ultrasound imaging, respectively, and the correlation between the levels of liver fibrosis and liver fibrosis biochemical parameters were analyzed statistically.

RESULTS

There was no correlation between the liver fibrosis levels classified by the liver biopsy and all the liver fibrosis biochemical parameters; there was a weak correlation between the liver fibrosis levels classified by the B ultrasound imaging and GGT, AKP, LN and PC-III, respectively; there was a significant correlation between the liver fibrosis levels classified by the B ultrasound imaging and HA and IV-C, respectively.

CONCLUSIONS

B ultrasound examination is a better, noninvasive fibrosis inspection method. Liver fibrosis biochemical parameters combined with the B ultrasound examination may better reflect the overall condition of liver fibrosis.

[Clinical observation on abnormal glucose metabolism of cirrhosis of different classified child-pugh in schistosomiasis patients]

OBJECTIVE

To study the abnormal glucose metabolism of cirrhosis of different classified Child-Pugh in schistosomiasis patients.

METHODS

A total of 90 schistosomiasis patients with different classified Child-Pugh cirrhosis were investigated for their fasting blood glucose (FBG), 2-hour blood glucose (2hBG), 3-hour blood glucose (3hBG), free insulin (FINS), insulin release index (IRI) and insulin resistance index (IRI).

RESULTS

With the increasing of classified Child-Pugh, the abnormal glucose metabolism of the 90 schistosome cirrhosis patients aggravates, but most of FBS was normal or increases slightly. There was only one female patient in 7 patients with diabetes mellitus of liver.

CONCLUSION

The ratio of abnormal glucose metabolism of schistosomiasis cirrhosis patients is less, and most of them are younger males.

Genetic polymorphisms of ICAM 1 and IL28 as predictors of liver fibrosis severity and viral clearance in hepatitis C genotype 4

BACKGROUND AND OBJECTIVES

Intercellular adhesion molecule-1 (ICAM-1) is located on chromosome 19p13.2, and this protein plays an important role in the pathogenesis of the hepatitis C virus (HCV). The rs12979860 polymorphism of the IL-28B gene participates in HCV clearance. This study investigated the association of the genetic markers (SNPs), rs5496, rs281437 and rs12979860 polymorphisms, with viral clearance and the progression of hepatic fibrosis in HCV genotype 4 patients who were treated with pegylated interferon and ribavirin.

METHODS

Thirty consecutive HCV genotype 4 patients who were treated with pegylated interferon and ribavirin therapy for 48 weeks were grouped into responders (control group) and non-responders (case group). The severity of fibrosis was classified according to the Scheuer Score. SNP genotyping of rs5496 [A/G], rs281437 [C/T] and rs12979860 [C/T] were performed using the 5' nuclease assay with a TaqMan MGB probe in an ABI 7500 Fast Real-Time PCR System (Applied Biosystems).

RESULTS

All SNPs exhibited Hardy-Weinberg Equilibrium (HWE). The patients with the C allele of rs12979860 exhibited an approximately eight times higher risk of SVR compared to patients with the T allele (aOR=7.98; CI: 1.07-59.36, P=0.012). No significant association of rs5496 and rs281437 with treatment response was detected (P=0.185 and P=0.123, respectively). Patients with the T allele of rs281437 exhibited an approximately 13 times higher risk of severe fibrosis compared to patients with the C allele (aOR=13.0; CI: 1.32-128.11, P= 0.028). No significant association of the other genetic variants with the degree of fibrosis in the study subjects was detected for rs5496 and rs12979860.

CONCLUSION

The present study revealed associations between the ICAM-1 gene marker, rs281437, and the progression of hepatic fibrosis in HCV genotype 4 and rs12979860 of the IL-28 B gene with viral clearance.

Pharmacokinetics of E5564, a Lipopolysaccharide Antagonist, in Patients with Impaired Hepatic Function

E5564 is a structural analog of the Lipid A portion of lipopolysaccharide (LPS). E5564 has been tested in several in vitro and in vivo models and has demonstrated its effectiveness against LPS. It is intended to be an antagonist of LPS to reduce the morbidity and mortality associated with sepsis syndrome. This study assessed the pharmacokinetics (PK) of E5564 in patients with impaired hepatic function. E5564 was administered via intermittent intravenous infusion every 12 hours for six times to 24 hepatic-impaired patients (12 each to Child-Pugh Classifications A and B) and 24 matching healthy volunteers. Plasma samples were analyzed by LC/MS/MS. A one-compartment model resulted in good and comparable fits for all volunteers. Regardless of liver disease state, none of the PK parameters compared (i.e., Cmax (0-12),tmax (0-12),CL,t1/2, Vss, AUC(0-12), AUC(0-last), AUC(0-infinity), C(ss,min), C(ss,max), and C(ss,av)) exhibited any difference between these two groups. This suggested that the exposure of E5564 in volunteers was independent of hepatic function. Thus, no dose adjustment is needed in patients with hepatic impairment classified as Child-Pugh A and B.

Outcome of laparoscopic cholecystectomy for gallstones disease in patients with liver cirrhosis

BACKGROUND

Laparoscopic cholecystectomy (LC), a gold standard procedure for cholelithiasis, is associated with higher incidence of bile duct injuries and perioperative bleeding. These complications are of further concern when LC is carried out on patients with liver cirrhosis. Although LC is now increasingly being performed for cholelithiasis in cirrhotic patients, the safety of the procedure is debatable in this group of patients.

METHODS

We retrospectively analysed 82 LCs, performed between January 2002 and December 2011. in cirrhotic patients with gall stone disease for perioperative complications. Patients were sub-classified into Class A, B and C based on child-Pugh classification of severity of liver cirrhosis. Intergroup comparisons were carried out using ANOVA, and p < or = 0.05 was considered significant.

RESULTS

LC was successfully completed in all but 3 patients (3.7%). None of the cirrhotic patients had bile duct injury. Class C patients (n = 27) had higher frequency of perioperative bleeding than Class B and A (p = 0.03). Class C patients had comparatively longer stay (5.42 days: range 4-8 days) than Class B (3 days; range 2-6) and Class A (2.74 days; range 2-4), (p = 0.01). There was no mortality in our series.

CONCLUSION

The outcome in Child A and B cirrhosis is comparable to noncirrhotic patients undergoing LC for gall stone disease. Conversion rate and perioperative bleeding in these groups of patients is acceptable in relevance to LC in non-cirrhotic patients. Child C patients however need careful assessment and determination of operative risk versus advantages.

Potential proteomic biomarkers in assessing liver fibrosis using SELDI-TOF MS

BACKGROUND/AIMS

The accurate assessment of the severity of liver fibrosis is of paramount importance in determining treatment strategies, response to treatment and prognosis in patients with chronic liver disease. The aim of this study was to investigate potential proteomic biomarkers for assessing stages of hepatic fibrosis.

METHODS

Serum samples of 83 patients with chronic liver disease (using METAVIR index, 17 F0, 30 F1, 6 F2, 9 F3, and 21 F4 patients) and 29 healthy controls were analyzed using surface-enhanced laser desorption/ionization time-of- flight mass spectrometry on IMAC30 ProteinChip arrays. Discriminatory peaks between groups were identified using Mann-Whitney U non-parametric test. Comparison of mild (F0, F1) and severe fibrosis (F2, F3, F4) was performed using tree classification (cross-validation) with the Biomarker Patterns Software, version 5.0 (Ciphergen Biosystems, US).

RESULTS

No statistically significant discriminatory peak was evident between F0, F1 and F2 fibrosis. More than 30 peaks were found to be discriminatory between patients with cirrhosis (F4) and all other stages of liver fibrosis, including F2 and F3. Six surface-enhanced laser desorption/ionization proteomic features were found to be discriminative for mild (F0, F1) vs. advanced (F2, F3, F4) fibrosis (AUROC ≥0.8, p<0.05, Mann-Whitney test). The decision tree (m/z 4280, 10453 and 6376) yielded a sensitivity of 83.3% (30/36), a specificity of 85.1% (40/47), a positive predictive value of 81.1%, and a negative predictive value of 86.9%, with an AUROC of 0.94.

CONCLUSIONS

The results of this study revealed discriminatory peaks between the protein profiles of patients with cirrhosis and other stages of liver fibrosis. Potential proteomic biomarkers can be notably determined for discriminating mild and advanced fibrosis using surface-enhanced laser desorption/ionization time-of- flight mass spectrometry.

Hepatic vein waveform in liver cirrhosis: correlation with child's class and size of varices

OBJECTIVE

To determine the correlation of hepatic venous waveform changes with severity of hepatic dysfunction and grading of oesophageal varices.

METHODS

A cross-sectional analytical study was conducted at Jinnah Postgraduate Medical Centre, Karachi, Medical Unit-III, Ward-7 from January 2009 to December 2009. Cirrhotic patients with portal hypertension were included in study. Patients presented with acute variceal bleeding, previous treatment with beta blockers or nitrates, sclerotherapy endoscopic band ligation, portal vein thrombosis, severe clotting defects, hepatic encephalopathy grade III or IV and noncirrhotic portal hypertension; were excluded from the study. Upper G I endoscopy was carried out in all patients after informed consent. Oesophageal varices were classified according to Baveno III while hepatic function was assessed and grouped by Child-Pugh classification. Colour Doppler ultrasound was carried out on all patients. Their waveforms were classified as monophasic, biphasic triphasic and the correlation of these hepatic vein waveforms with Child-Pugh class and size of oesophageal varices was evaluated. Statistical significance was defined as P?0.05.

RESULTS

Total of 65 patients who met the inclusion criteria and included in the study with mean age of 47.39 +/- 10.91 (range 23-70) years. Among these 51 (78.5%) were males while 14 (21.5%) were females. On the basis of hepatic function 32 (49.2%) patients presented in Child-Pugh Class A, 23 (35.4%) with Class B and 10 (15.4%) patients had Class C. Hepatic venous waveform was triphasic in 5 (7.7%), biphasic in 18 (27.7%), and monophasic in 42 (64.6%) cases. The relationship of these waveforms had significant relation with hepatic dysfunction (p < 0.012) while insignificant with grading of oesophageal varices (p 0.29). Upper GI endoscopy revealed large grade varices in 37 (56.9%) patients, 17 (26.2%) patients had small grade varices while no varices were found in 11 (16.9%) patients.

CONCLUSION

Hepatic venous waveform pressure changes have significant relation with severity of hepatic dysfunction but insignificant relation with grading of oesophageal varices. Further studies using a combination of various Doppler parameters are required to create indices with a better predictive value.

Relationship of liver disease stage and antiviral therapy with liver-related events and death in adults coinfected with HIV/HCV

CONTEXT

Human immunodeficiency virus (HIV) accelerates hepatitis C virus (HCV) disease progression; however, the effect of liver disease stage and antiviral therapy on the risk of clinical outcomes is incompletely understood.

OBJECTIVE

To determine the incidence of end-stage liver disease (ESLD), hepatocellular carcinoma (HCC), or death according to baseline hepatic fibrosis and antiviral treatment for HIV/HCV coinfected individuals.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort of 638 coinfected adults (80% black, 66% men) receiving care at the Johns Hopkins HIV clinic and receiving a liver biopsy and who were prospectively monitored for clinical events between July 1993 and August 2011 (median follow-up, 5.82 years; interquartile range, 3.42-8.85 years). Histological specimens were scored for hepatic fibrosis stage according to the METAVIR scoring system.

MAIN OUTCOME MEASURE

Incidence of composite outcome of ESLD, HCC, or death.

RESULTS

Patients experienced a graded increased risk in incidence of clinical outcomes based on baseline hepatic fibrosis stage (classification range, F0-F4): F0, 23.63 (95% CI, 16.80-33.24); F1, 36.33 (95% CI, 28.03-47.10); F2, 53.40 (95% CI, 33.65-84.76); F3, 56.14 (95% CI, 31.09-101.38); and F4, 79.43 (95% CI, 55.86-112.95) per 1000 person-years (P < .001). In multivariable negative binomial regression, fibrosis stages F2 through F4 and antiretroviral therapy were independently associated with composite ESLD, HCC, or all-cause mortality after adjustment for demographic characteristics, injection drug use, and CD4 cell count. Compared with F0, the incidence rate ratio (RR) for F2 was 2.31 (95% CI, 1.23-4.34; P = .009); F3, 3.18 (95% CI, 1.47-6.88; P = .003); and F4, 3.57 (95% CI, 2.06-6.19; P < .001). Human immunodeficiency virus treatment was associated with fewer clinical events (incidence RR, 0.27; 95% CI, 0.19-0.38; P < .001). For the 226 patients who underwent HCV treatment, the incidence of clinical events did not significantly differ between treatment nonresponders and untreated patients (incidence RR, 1.27; 95% CI, 0.86-1.86; P = .23). In contrast, no events were observed in the 51 patients with sustained virologic response (n = 36) and relapse (n = 15), including 19 with significant fibrosis.

CONCLUSION

In this cohort of patients with HIV/HCV coinfection, hepatic fibrosis stage was independently associated with a composite outcome of ESLD, HCC, or death.

Noninvasive assessment of liver fibrosis with acoustic radiation force impulse imaging: increased liver and splenic stiffness in patients with liver fibrosis and cirrhosis

PURPOSE

To evaluate acoustic radiation force impulse imaging (ARFI) of the liver and spleen as a new method for the noninvasive assessment of liver fibrosis (LF).

MATERIALS AND METHODS

Three groups of 58 examinees were studied: (A) 20 healthy volunteers; (B) 18 patients with chronic viral hepatitis (CVH) B or C having liver fibrosis stages F 1 - 4 (assessed by liver biopsy; Ishak classification); and (C) 20 patients with liver cirrhosis (LC). All participants were examined using the Siemens ACUSON S 2000 Ultrasound Virtual Touch Tissue Quantification system. Ten measurements were performed on both liver lobes and three measurements on the spleen, and the obtained mean values (shear wave velocities [SWV] expressed in m/s) were compared between the groups. In 20 patients the splenic artery pulsatility index (SAPI) was also measured and correlated to the liver and splenic ARFI and histological stage of LF.

RESULTS

Hepatic ARFI measurements demonstrated a significant correlation to LB results (Spearman's ρ = 0.766; ρ < 0.001) and SWV cut-off values of 1.3 (AUC 0.96) and 1.86 (AUC 0.99) could reliably differentiate between healthy (A) and non-cirrhotic CVH (B), as well as between non-cirrhotic CVH (B) and LC (C). Splenic SWV cut-off value of 2.73 (AUC 0.82) could differentiate between the patients with LC and non-cirrhotic CVH. A significant correlation was also observed between the SAPI and liver ARFI results (ρ = 0.56; p = 0.013).

CONCLUSION

The hepatic and splenic SWV measured by ARFI increase with the LF stage, and the hepatic SWV correlate well with SAPI. This new technology enables simultaneous morphological, Doppler and elastometric examinations and might improve the accuracy of noninvasive liver fibrosis assessment.

Alpha-fetoprotein above normal levels as a risk factor for the development of hepatocellular carcinoma in patients infected with hepatitis C virus

BACKGROUND

Noninvasive risk factors are required for predicting the development of hepatocellular carcinoma (HCC) not only in patients with cirrhosis but also in those with chronic hepatitis who are infected with hepatitis C virus (HCV).

METHODS

A total of 707 patients with chronic HCV infection without other risks were evaluated for the predictive value of noninvasive risk factors for HCC, including age, sex, viral load, genotype, fibrosis stage, aspartate and alanine aminotransferase levels, bilirubin, albumin, platelet count, and alpha-fetoprotein (AFP) at entry to the study, as well as interferon (IFN) therapy they received.

RESULTS

The ten-year cumulative incidence rates of HCC for patients with fibrosis stages F0/F1, F2, F3, and F4 were 2.5, 12.8, 19.3, and 55.9%, respectively. Multivariate analysis identified age ≥57 years [hazard ratio (HR) 2.026, P = 0.004], fibrosis stage F4 (HR 3.957, P < 0.001), and AFP 6-20 ng/mL (HR 1.942, P = 0.030) and ≥20 ng/mL (HR 3.884, P < 0.001), as well as the response to IFN [relative risk (RR) 0.099, P < 0.001], as independent risk factors for the development of HCC. The ten-year cumulative incidence rates of HCC in the patients with AFP levels of <6, 6-20, and ≥20 ng/mL at entry were 6.0, 24.6, and 47.3%, respectively.

CONCLUSIONS

Not only high (>20 ng/mL), but also even slightly elevated (6-20 ng/mL) AFP levels, could serve as a risk factor for HCC to complement the fibrosis stage. In contrast, AFP levels <6 ng/mL indicate a low risk of HCC development in patients infected with HCV, irrespective of the fibrosis stage.

Optimization and robustness of blood tests for liver fibrosis and cirrhosis

OBJECTIVES

To optimize the performance and feasibility of fibrosis blood tests and evaluate their robustness.

DESIGN AND METHODS

The derivation population included 1056 HCV patients with liver biopsy and blood markers. Validation populations included 984 patients with various viral hepatitis causes, and Fibroscan and/or liver biopsy and/or blood markers.

RESULTS

The bootstrap method validated the markers of the original FibroMeter(2G), but not those of Fibrotest and Hepascore, and provided a hyaluronate-free FibroMeter(3G). AUROCs for significant fibrosis were: FibroMeter(2G): 0.853 vs. FibroMeter(3G): 0.851, p=0.489. Compared to FibroMeter(2G), FibroMeter(3G) had a significantly higher patient rate with predictive values ≥90% for significant fibrosis. Accuracy for fibrosis stage classification was: Fibrotest: 37.9%, FibroMeter(2G): 74.9%, and FibroMeter(3G): 86.9% (p<10(-3)).

CONCLUSION

The bootstrap method validated FibroMeter(2G) and provided a cheaper and more feasible hyaluronate-free FibroMeter(3G) with comparable performance. Compared to binary diagnosis, fibrosis stage classification increased discrimination, with an increased accuracy to 87% for FibroMeter(3G).

Risk assessment for the development of hepatocellular carcinoma: according to on-treatment viral response during long-term lamivudine therapy in hepatitis B virus-related liver disease

BACKGROUND & AIMS

To assess the risk for the development of hepatocellular carcinoma (HCC) according to the underlying liver status and on-treatment viral response during long-term lamivudine therapy in patients with hepatitis B virus-related liver disease.

PATIENTS AND METHODS

Between March 1997 and February 2005, a total of 872 patients were treated with lamivudine for more than one year. Between 1983 and 1998, a total of 699 patients were enrolled as historical controls.

RESULTS

For patients with compensated cirrhosis, HCC occurred in 4.9% (5/103) of cases with sustained viral suppression (persistently <141,500 copies/ml), 11.8% (20/170) in cases with viral breakthrough, and 19.4% (7/36) in cases with a suboptimal response (persistently 141,500 copies/ml): the mean follow-up was 5.1+/-2.7, 5.4+/-2.3, and 3.7+/-1.8 years, respectively. For the control group, HCC developed in 25.0% (37/148) of the cases during a mean follow-up of 6.1+/-4.3 years. Thus, the annual incidence of HCC was 0.95%, 2.18%, 5.26%, and 4.10% in patients with sustained viral suppression, viral breakthrough, suboptimal response, and the control group, respectively. The cumulative incidence of HCC in patients with sustained viral suppression was significantly lower than in patients with a suboptimal response and the controls (p=0.002 and p=0.005, respectively). In patients without cirrhosis and with decompensated cirrhosis, the preventive effects of lamivudine on the development of HCC were not observed (p=0.446 and p=0.123, respectively).

CONCLUSION

Lamivudine therapy reduced the incidence of HCC in patients with compensated cirrhosis when the viral suppression was sustained.

[Prognostic indices in liver cirrhosis and transplant assessment]

In view of growing disproportion between the number of organ donors and recipients awaiting transplantation the issue of an appropriate allocation of organs is becoming more and more important. The Child-Turcotte-Pugh Scale (CTP), which has been used for many years, has proved limited in many aspects. Hence, MELD Score (Model for End-Stage Liver Disease) was first introduced in the US in 2002 and later on in numerous other countries. This has led to a decrease in mortality among patients waiting for a liver transplant. Research into constructing new prognostic scales or improving the old ones are being continued. Various modifications of both MELD and CTP score have been evaluated. In this article we review recently tested scores and discuss their potential applications.

[Functional MR study of hepatic fibrosis]

The accurate diagnosis and staging of hepatic fibrosis is crucial for treatment and prognosis of liver disease. The current gold standard is liver biopsy, but it cannot be used in population-based screening, and has well known drawbacks if used for monitoring of disease progression or treatment results. Functional MR, as a non-invasive method, is increasingly used in hepatic fibrosis and became the current hot spot. Most recently available functional MR imaging techniques including diffusion weighted imaging, perfusion weighted imaging and MR spectroscopy can detect cirrhosis or fibrosis reasonably accurately. However, to date only MR elastography has been able to stage fibrosis or diagnose mild disease. MR diffusion weighted appears next most promising.

Surgery in the patient with liver disease

Surgery is performed in patients with liver disease more frequently now than in the past, in part because of the long-term survival of patients with cirrhosis. Recent work has focused on estimating perioperative risk in patients with liver disease. Hemodynamic instability in the perioperative period can worsen liver function in patients with liver disease. Operative risk correlates with the severity of the underlying liver disease and the nature of the surgical procedure. Thorough preoperative evaluation is necessary prior to elective surgery. Surgery is contraindicated in patients with certain conditions, such as acute hepatitis, acute liver failure, and alcoholic hepatitis. Estimation of perioperative mortality is inexact because of the retrospective nature of and biased patient selection in available clinical studies. The Child-Pugh classification (Child-Turcotte-Pugh score) and particulary the Model for End-Stage Liver Disease (MELD) score provide reasonable estimations of perioperative mortality but do not replace the need for careful preoperative preparation and postoperative monitoring, as early detection of complications is essential for improving outcomes. Medical therapy for specific manifestations of hepatic disease, including ascites, encephalopathy, and renal dysfunction, should be optimized preoperatively or, if necessary, administered in the postoperative period.

[Repeat endovascular interventions after transjugular intrahepatic portosystemic shunt (tips) procedures]

The authors share their experience with transjugular intrahepatic portosystemic shunt (TIPS) procedures preformed in a total of fifty-nine patients diagnosed with and hence operated on for class B and C hepatocirrhosis (according to the Child-Turcotte-Pugh classification), portal hypertension, grade 3 varicosely dilated oesophageal veins, or ascites. Of these, there were 12 women and 47 men (average age 56.3 years). Three types of stents were used: matrix stents (PERICO), self-expanding (ZA-stents, OptiMedsinus-SuperFlex- Visualstents, Zilverstents, SMART), and coated self-expanding stents (Gore Viatorr TIPS Endoprosthesis). Six (11 %) TIPS procedures ended in failure. Of the remaining 53 successful TIPS attempts, thirteen patients developed an in-stent thrombosis at various terms postoperatively, with one patient having experienced it twice Within four postoperative days, thrombosis occurred in three patients, at terms varying from one month to three months in five patients, and from 6 to 12 months in a further five patients. More often thromboses were encountered with the matrix stents (n = 3) 23.0% (PERICO) and self-expanding stents (n = 8) in 61.0% (OptiMed sinus-SuperFlex-Visual). Thromboses were clinically manifested by oesophageal variceal haemorrhage. An in-stent thrombosis was confirmed by means of ultrasonographic duplex scanning (lack of arterial blood flow). The primary stent patency rate following TIPS procedures amounted to 67%. with the secondary assisted graft patency rate equalling 89%. Restoration of the stent's lumen after TIPS procedures by means of endovascular recanalization, rheolytic thrombectomy, balloon angioplasty, and a stent-in-stent technique appears to be a minimally invasive, rather efficient method and virtually the only way to preserve the stent's patency. This technique makes it possible to decrease the rate of recurrent oesophageal variceal haemorrhage.

Age dependency of regional impedance indices regardless of clinical stage in patients with cirrhosis of the liver

PURPOSE

To prospectively assess if ageing itself induces modifications of the impedance indices (resistance and pulsatility indexes) of hepatic, splenic, superior mesenteric and renal arteries in patients with liver cirrhosis.

MATERIALS AND METHODS

78 consecutive patients with cirrhosis (41 males, 37 females, Child-Pugh score 7 [range 5 - 12]) were studied by colour-Doppler ultrasound. The resistance index (RI) and pulsatility index (PI) were determined in the main hepatic artery, intraparenchymal branches of hepatic, splenic, and renal arteries, and superior mesenteric artery; clinical data were simultaneously collected. Logistic regression analysis was performed to assess the relative impact of age, severity of liver disease and other relevant variables on the increase of impedance indices. Linear regression analysis was used to identify a coefficient to adjust RIs and PIs to age.

RESULTS

Resistance and pulsatility indices of all the vessels studied except of the superior mesenteric artery showed a direct correlation with age (e. g. splenic artery RI: R = 0.520, p < 0.0001), and correlated most strongly with Child-Pugh score (e. g. right renal artery PI: R = 0.462, p < 0.0001). Age was associated independently with increased PI and RI in hepatic, splenic and renal arterial districts. In these vessels, the RI threshold of normality can be adjusted to the decade of age adding a correction of 0.03.

CONCLUSION

Ageing itself induces an increase of hepatic, splenic and renal impedance indices in cirrhotic patients. The threshold of normality for these indices in cirrhosis should be adjusted according to the patients' age.

Definition and natural history of metabolic steatosis: clinical aspects of NAFLD, NASH and cirrhosis

Metabolic steatosis or non-alcoholic fatty liver (NAFLD) is the most common cause of chronic liver injury in Western countries. Histological signs of necroinflammation, indicating the presence of non-alcoholic steatohepatitis (NASH), are present in 20-30% of cases. While steatosis on its own has a benign course, NASH may be associated with fibrosis and may progress to cirrhosis, terminal liver failure and hepatocellular carcinoma. NAFLD is closely associated with the metabolic syndrome, its prevalence reaching 50-90% in obese patients. The clinical impact of NAFLD has been demonstrated in large cohort studies by the overprevalence of cirrhosis and hepatocellular carcinoma in obese and diabetic patients. In terms of survival, liver disease is the third most common cause of mortality in patients with NAFLD. When associated with other causes of liver disease such as alcohol consumption or hepatitis C infection, metabolic steatosis may be a major risk factor for disease progression.