Liver Biopsy Evaluation Research Articles

2300 Chronic Lymphocytic Leukemia of the Liver: A Rare Cause of Elevated Liver Function Tests

INTRODUCTION: Chronic lymphocytic leukemia is a lymphocytic proliferative malignancy that can infiltrate multiple different organs. It is one of the most common forms of leukemia in the adult population. CLL affecting the liver is historically rare, however since recent it has been becoming more prevalent due to certain advancements in chemotherapy. With metastatic CLL becoming more prevalent, we should focus expansion of research to this subset of patients. CASE DESCRIPTION/METHODS: A 76-year-old male with a past medical history of CLL 13q14 mutation+ and a recent diagnosis of renal insufficiency was evaluated by his Gastroenterologist for elevated liver enzymes. He was found to have an AST of 112 and an ALT of 348. His ferritin was also elevated to 953 with a transferrin saturation of 27%. He was referred to a Hepatologist for a more in-depth workup, which revealed worsening lymphadenopathy on CT scan along with worsening hepatomegaly and splenomegaly on abdominal ultrasound. Blood work was ordered for evaluation of infectious, inflammatory and autoimmune causes of his elevated liver enzymes. The patient’s blood work showed a negative ANA/SMA/AMA, a negative HAV/HBV/HCV. The patient underwent percutaneous liver biopsy for further evaluation. The biopsy showed involvement of his liver with dense lymphoid infiltrate of the portal tracts, consistent with chronic lymphocytic leukemia. The pathology also resulted showing the liver parenchyma showed the same biomarkers as the patients serum studies. The positivity of CD5, CD23 and PAX5 was consistent with the previous serum studies. The patient was initiated on Imbruvica, which provided improvement in his liver function tests. He continues to follow with Oncology for continued treatment on Imbruvica. DISCUSSION: The increased prevalence of liver dysfunction brings up new conversations in CLL treatment. Liver infiltration has not been studied as much as other organ systems and this limits our understanding of this chronic, debilitating disease process. There has been a documented shorter survival for patients diagnosed with liver infiltration of CLL, which limits our patient’s quality of life if we do not better grasp this potential complication of CLL.

1392 Transjugular Liver Biopsy Causing Hemobilia and the Rarely Reported Hemocholecystitis

INTRODUCTION: Transjugular liver biopsy is a safe and effective tool in liver disease patients in whom percutaneous liver biopsy is contraindicated. Serious complications from transjugular liver biopsy are uncommon. Liver biopsy related hemobilia occurs in less than 1% of cases and hemobilia related hemocholecystitis is very rare. CASE DESCRIPTION/METHODS: A 56-year old Asian male with ESRD presented with abdominal pain and melena. 3 days prior to presentation he had undergone a transjugular liver biopsy for evaluation of abnormal LFTs and cirrhotic appearing liver on imaging. Vital signs were normal. Exam was significant for epigastric tenderness. Labs with Hb 10.4 gm/dL, Bili 1.1 mg/dL, ALP 307 U/L, AST 131 U/L, ALT 64 U/L, INR 1, and lipase 5069 U/L. CT abdomen showed a distended gallbladder with ovoid debris within (Figure 1). EGD was with no obvious luminal blood. MRCP showed distended gallbladder with a large sludge ball within, normal CBD, and mild pancreatic head edema. Tagged RBC scan was negative. With continued worsening of LFTs and ongoing gradual decline in Hb, patient was suspected to have intermittent hemobilia and biliary obstruction. ERCP showed bulging major papilla with a trace of blood at the orifice. Cholangiogram showed no obvious filling defects in the bile duct. Gallbladder was un-opacified denoting cystic duct obstruction (Figure 2). Biliary sphincterotomy was performed and balloon sweep of the biliary tree was unremarkable except for some minimal sludge. A plastic stent was placed in the CBD. Patient continued to have worsening right upper quadrant abdominal pain with clinical suspicion for acute cholecystitis. Patient underwent laparoscopic cholecystectomy revealing an edematous and severely inflamed gallbladder. Gallbladder lumen contained bloody bile and blood clots. Microscopic examination of gallbladder revealed extensive wall necrosis and acute inflammation (Figure 3). Patient had an uneventful post-operative course. DISCUSSION: Hemobilia after liver biopsy is rare and occurs in less than 1% cases. Acute cholecystitis from hemobilia (hemocholecystitis) is extremely rare and is due to thrombus obstructing the cystic duct. Diagnosing hemocholecystitis is challenging and clinicians need a high index of suspicion in making this diagnosis and thus prevent delay of much needed definitive treatment. Ultrasound and HIDA scan can be useful in making diagnosis. Risk of gallbladder perforation in these cases is 2-15% from gangrenous cholecystitis. Treatment of hemocholecystitis is early cholecystectomy.

1146 The Use of Liver Biopsy to Determine the Severity of Nonalcoholic Fatty Liver Disease in Children Across the United States

INTRODUCTION: Nonalcoholic fatty liver disease (NAFLD) has become the most common form of chronic liver disease. Determining the severity of NAFLD using the presence of nonalcoholic steatohepatitis (NASH) and stage of liver fibrosis is important, yet liver biopsy remains the gold standard despite limitations to its use. This study surveyed pediatric gastroenterologists across the United States to determine which guidelines are used to determine the severity of NAFLD in children, which patients undergo liver biopsy, and how these guidelines compare to each other and to clinical practice. METHODS: 140 pediatric gastroenterologists were surveyed electronically regarding current diagnostic practices for NAFLD. Responses were reviewed in Survey Monkey and compared to current North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN), American Association for the Study of Liver Diseases (AASLD) and European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines regarding liver biopsy for evaluation of NAFLD. RESULTS: 140 surveys were distributed with 54 responses, a 38.6% response rate. Participants included pediatric gastroenterologists, hepatologists and transplant hepatologists. 96.2% reported familiarity with NASPGHAN guidelines, 22.6% with ESPGHAN and 39.6% with AASLD. 88.7% of responders desired a generalized consensus regarding proper diagnosis. Pediatric gastroenterologists referred obese patients with abnormal liver enzymes suspected to have NAFLD 22% of the time, pediatric hepatologists 27.2%, and transplant hepatologists 39.9% (one-way ANOVA with P-value of 0.324). 61.5% of responders reported using Fibroscan and 59.6% used MR elastography to assess severity of NAFLD and presence of liver fibrosis when not pursuing liver biopsy. 92.5% of responders believed the presence of autoimmune antibodies was important in deciding when to proceed to liver biopsy, as well as 88.7% using abnormal screening labs and 75.5% using imaging suggestive of liver fibrosis. CONCLUSION: Comparison between the criteria that providers believed warranted a liver biopsy versus those included in society guidelines differed. The presence of autoimmune antibodies, abnormal screening labs, and liver fibrosis suggested on imaging all appeared to be important factors regardless of current guidelines. Providers also seem to rely on Fibroscan and MR elastography over liver ultrasound despite the lack of validated cutoff values in children.

Shear-Wave Dispersion Slope from US Shear-Wave Elastography: Detection of Allograft Damage after Liver Transplantation.

Background Allograft damage (hepatic parenchymal damage) after liver transplant is associated with the degree of necroinflammation in graft liver. According to a recent animal study, shear-wave dispersion slope obtained at US shear-wave elastography (SWE) is associated with necroinflammatory activity in the liver. Purpose To evaluate the role of shear-wave dispersion slope in detecting allograft damage after liver transplant. Materials and Methods In this prospective study, 104 liver transplant recipients underwent percutaneous liver biopsy for allograft evaluation from December 2017 to November 2018. All participants underwent allograft SWE examination just before liver biopsy, and liver stiffness and shear-wave dispersion slope were obtained. Allograft damage was diagnosed by histopathologic analysis. Clinical and imaging factors related to liver stiffness and shear-wave dispersion slope were determined by multivariable linear regression analysis. Diagnostic performance of each variable in detecting allograft damage was evaluated by comparing area under the receiver operating curve (AUC) values. Results There were 104 study participants (35 women); median age was 56 years (interquartile range, 50-62 years). Allograft damage was found in 46 of 104 (44.2%) of participants. The median liver stiffness (8.2 kPa vs 6.3 kPa; P < .01) and shear-wave dispersion slope (14.4 [m/sec]/kHz vs 10.4 [m/sec]/kHz; P < .01) were higher in participants with allograft damage than in those without damage, respectively. Fibrosis stage was the only determinant factor for liver stiffness (coefficient, 1.8 kPa per fibrosis stage; 95% confidence interval: 0.1, 3.5; P = .03), whereas both fibrosis stage (coefficient, 1.4 [m/sec]/kHz per fibrosis stage; 95% confidence interval: 0.3, 2.6; P = .02) and necroinflammatory activity (coefficient, 1.6 [m/sec]/kHz per necroinflammatory activity grade; 95% confidence interval: 0.5, 2.7; P < .01) affected shear-wave dispersion slope. The AUC for shear-wave dispersion slope in detecting allograft damage was 0.86, which was higher than that of liver stiffness (AUC, 0.75; P < .01). Conclusion Shear-wave dispersion slope determined at US shear-wave elastography may help in detecting allograft damage after liver transplant. © RSNA, 2019 Online supplemental material is available for this article.

REGENERATE: Design of a pivotal, randomised, phase 3 study evaluating the safety and efficacy of obeticholic acid in patients with fibrosis due to nonalcoholic steatohepatitis

BackgroundNonalcoholic steatohepatitis (NASH) is a chronic, progressive, and severe form of nonalcoholic fatty liver disease. In FLINT, obeticholic acid (OCA) treatment improved multiple histological NASH features. The design and endpoints of REGENERATE, an ongoing phase 3 study, further evaluate OCA treatment in patients with fibrosis due to NASH. AimsThe Month 18 interim analysis assesses the effect of OCA on liver histology, defined as improvement of fibrosis by ≥1 stage with no worsening of NASH or resolution of NASH with no worsening of fibrosis. The end-of-study analyses evaluate the effect of OCA on mortality, liver-related clinical outcomes, and long-term safety. MethodsREGENERATE is a pivotal, long-term study of ~2400 patients with NASH, including ~2100 patients with stage 2 or 3 liver fibrosis. Additionally, ~300 patients with stage 1 fibrosis and ≥1 accompanying comorbidity are included to gather information on the safety of OCA and liver disease progression. Patients are randomised 1:1:1 to receive placebo or OCA (10 or 25 mg). A liver biopsy evaluation occurs at screening, Months 18 and 48, and end of study. The duration of the study is dependent upon accrual of a predetermined number of clinical outcome events. ConclusionsREGENERATE is designed in conjunction with regulatory authorities to support regulatory approvals in NASH. This robust phase 3 study assesses the effect of OCA on liver histology as a surrogate for transplant-free survival and liver-related outcomes, including progression to cirrhosis and mortality, and will ultimately assess clinical benefit through specific evaluation of these outcomes. Clinical trial registrationClinicalTrials.gov with the identifier NCT02548351.

Direct-Acting Antiviral Treatment of Patients with Hepatitis C Resolves Serologic and Histopathologic Features of Autoimmune Hepatitis.

Patients with hepatitis C virus (HCV) often have elevated serum markers and histologic features of autoimmune hepatitis (AIH). We evaluated an HCV‐positive (HCV+) study group that had elevated serum markers of AIH before starting direct‐acting antiviral (DAA) therapy (n = 21) and compared them to an HCV+ control group that did not have laboratory studies suggesting AIH (n = 21). Several patients in the study (17/21) and control (11/21) groups had liver biopsies before DAA treatment, and many were biopsied due to elevated serum markers of AIH. Evaluation of pre‐DAA treatment liver biopsies showed histologic features suggestive of AIH in 64.7% (11/17) of the study group and 45.5% (5/11) of the control group. Patients who were HCV+ with elevated serum markers of AIH had significantly increased hepatitis activity (P < 0.001) and slightly increased fibrosis stages (P = 0.039) in their pretreatment liver biopsies compared to controls. We hypothesized that the elevated serum markers and histologic features of AIH would resolve following DAA treatment. Serum markers of AIH in the study group began decreasing by 6 months posttreatment, and 52.4% (11/21) had complete resolution. Alanine aminotransferase levels significantly decreased into the normal range for all patients (21/21). Even patients that had persistence of serum markers of AIH after DAA treatment had normal transaminases. Six patients from the study patient group and 4 patients from the control group had follow‐up liver biopsies after DAA treatment, and all biopsies showed resolution of the histologic features of AIH. Conclusion: The majority of HCV+ patients that have serum markers and/or histopathologic features of AIH should initially be treated with DAA.

Comparison of liver stiffness assessment by transient elastography and shear wave elastography using six ultrasound devices.

Transient elastography (TE) is the gold standard for measurement of liver stiffness. The usefulness of shear wave elastographies (SWE) is well accepted. However, the measurement values cannot be equivalently compared because cut-off values for the diagnosis of liver fibrosis are different among those devices. We aimed to clarify correlations, to generate the regression equations between TE and SWEs, and to compare the diagnostic ability of each device to diagnose liver fibrosis. A total of 109 patients with chronic liver disease who underwent liver biopsy and same-day evaluation of liver stiffness using six ultrasound devices were analyzed. The diagnostic ability of liver stiffness from each ultrasound device and correlations between TE and each SWE were analyzed. Liver stiffness measured by all six ultrasound devices increased significantly as liver fibrosis stage advanced (P < 0.001). Receiver operating characteristic (ROC) curve analysis for predicting significant fibrosis (≥F2) and cirrhosis yielded area under the ROC curve (AUROC) values based on TE of 0.830 (95% confidence interval [CI], 0.755-0.905) and 0.959 (95% CI, 0.924-0.995), respectively. The AUROCs for predicting significant fibrosis (≥F2) and cirrhosis (F4) based on SWE from all five ultrasound devices were over 0.8 and 0.9, respectively. Furthermore, the correlation coefficients between TE values and SWE values from five ultrasound devices were all over 0.8, indicating a strong relationship. Our study showed strong correlations between TE and SWEs with high correlation coefficients. The regression equations between TE and SWEs demonstrated the ability to compare the measurement values in each device equivalently.

Clinical practice guidelines for the provision of renal service in Hong Kong: Potential Kidney Transplant Recipient Wait-listing and Evaluation, Deceased Kidney Donor Evaluation, and Kidney Transplant Postoperative Care.

Clinical practice guidelines for the provision of renal service in Hong Kong: Potential Kidney Transplant Recipient Wait-listing and Evaluation, Deceased Kidney Donor Evaluation, and Kidney Transplant Postoperative Care.

Regional Variation in Utilization and Outcomes of Liver Allografts From Donors With High Body Mass Index and Graft Macrosteatosis: A Role for Liver Biopsy.

Obesity, defined as a high body mass index (hBMI) of 30 kg/m or greater, is a growing epidemic worldwide and is associated with multiple comorbidities. High BMI individuals account for an increasing portion of potential liver donors. Here we evaluate trends in the utilization and outcomes of hBMI donors on a national and regional level and the potential role of liver biopsy in donor evaluation. United Network for Organ Sharing Standard Transplant Analysis and Research database was evaluated for deceased donor liver transplants between 2006 and 2016 across 11 Organ Procurement and Transplantation Network regions. High BMI donors were compared with lower BMI counterparts and evaluated for biopsy rates, utilization rates and allograft outcomes. Univariate and multivariable analyses were performed. Seventy-seven thousand fifty potential donors were identified and 60 200 transplants were evaluated. Utilization rates for hBMI donors were 66.1% versus 78.1% for lower BMI donors (P < 0.001). Pretransplant biopsy was performed more frequently in hBMI donors (52.1% vs 33.1%, P < 0.001) and macrosteatosis of 30% or greater was identified more often (21.1% vs 12.2%, P < 0.001). Biopsy performance increased utilization rate of hBMI donors in 7 of 11 Organ Procurement and Transplantation Network regions. region 6 showed the highest rate of biopsy performance, high rate of hBMI donor utilization, and highest 5-year estimated graft survival rates of all regions. High BMI donors have not previously been associated with worse graft survival in multivariable analyses; however, they are used much less frequently. Liver biopsy may increase the utilization rate of hBMI donors and improve donor selection. Further evaluation of regions with high rates of utilization and good outcomes is warranted.

Noinvasive fibrosis assessment in fatty liver disease in diabetes patients

Background and Aim Noninvasive tools are well accepted by patients for fibrosis assessment in chronic liver diseases, including nonalcoholic fatty liver disease (NAFLD). Transient elastography (TE) is an accepted alternative to liver biopsy for fibrosis evaluation. NAFLD is quite frequent in clinical practice and it is difficult to identify those patients who have nonalcoholic steatohepatitis (NASH). The aim of this study was to assess the value of simple biological tests (APRI, FIB 4 Index and BARD score) for ruling out the presence of significant and severe fibrosis and their correlation with TE in diabetic patients with NAFLD. Material and Method We conducted a prospective study which included 469 diabetic patients (p) out of which 454 had steatosis (average age 61 ± 9.3 years, 55.1% female), evaluated both by serum markers (TGO, TGP, platelets) and by TE-Fibroscan (Echosens,Paris, France), with incorporated CAP function. Based on specific formulas we calculated APRI, FIB4 index and BARD score. Liver stiffness measurements (LSM) were considered reliable if 10 valid values with an IQR/median 8.5 kPa, severe fibrosis > 10.1kPa, and for steatosis we considered: S1(mild)-230-275 db/m, S2 (moderate)-275-300 db/m, S3 (severe) > 300 db/m. Results We tried to rule out significant fibrosis by using APRI Regarding FIB4 score, we found that 94%p had FIB4 18.3% of patients had a BARD score Conclusion simple tests such as APRI score

Non-invasive prediction of fibrosis in chronic hepatitis B

Aim: To date, the main diagnostic tool for assessing the liver fibrosis stage has been liver biopsy. Despite the advantages in patient prognosis prediction and disease management, the application of liver biopsy is hampered by its limitations. The limitations of liver biopsy have led to a need for the development of a non- invasive scoring system that is simple to use, reliable, and cheap. The aim of this study was to evaluate the accuracy of APRI (AST to Platelet Ratio Index) and FIB-4 (Fibrosis-4) scores in the prediction of liver fibrosis in Chronic Hepatitis B patients.Material and Methods: A retrospective assessment was made of the electronic medical records to identify patients who underwent liver biopsy for evaluation of fibrosis related to CHB (Chronic Hepatitis B). A total of 352 patients were included in the study. Laboratory parameters that were measured within 7 days of the liver biopsy day were considered suitable for the calculation of the formulae. The APRI and FIB-4 scores was calculated. Liver biopsy reports, which were eligible for inclusion in the study, were assessed retrospectively. The fibrosis stage and histological acitvity index were used as previously described by Ishak. Analyses were performed using SPSS 22 (IBM SPSS Statistics 22, SPSS inc., an IBM Co., Somers, NY).Results: APRI was well correlated with fibrosis and HAI score (r=0.280, p0.05; r=0.22, p0.05) respectively. The FIB-4 correlation between fibrosis and HAI was significant (r=0.433, p0.05; r=0.34, p0.05) respectively.Conclusion: Inexpensive, non-invasive, and reliable fibrosis assessement models for CHC should be applied in clinical practice.Keywords: Chronic hepatitis B; liver fibrosis; APRI, FIB-4.

Real-world management of juvenile autoimmune liver disease.

Background and aimsJuvenile autoimmune liver disease (JAILD) includes paediatric forms of autoimmune hepatitis (AIH) and autoimmune sclerosing cholangitis (ASC). Since evidence is scarce, there are currently no evidence-based management guidelines for juvenile AIH. This survey was carried out amongst the paediatric members of the International AIH Group (IAIHG) to describe their practices in the management of JAILD.MethodsAn online survey questionnaire was distributed to members of the IAIHG with active practice (https://www.surveymonkey.de/r/Juvenile_AILD). The questionnaire consisted of four clinical scenarios on different presentations of AIH.ResultsFifty-eight surveys were sent to the IAIHG members, out of which 43 (74%, 22 countries, four continents) were returned. None reported budesonide as a first-line induction agent for the acute presentation of AIH. Sixteen (37%) routinely perform liver biopsy at three years of biochemical remission. Thirty-five respondents (81%) perform magnetic resonance cholangiography (MRC) at presentation. Ciclosporin is the most widely used second-line agent (number of patients treated = ∼360, 21 centres). Mycophenolate mofetil (n = ∼225, 31 centres), tacrolimus (n = ∼130, 21 centres) and sirolimus (n = ∼5, 3 centres) are less often reported. Rescue therapy with infliximab and rituximab has been tried in eight centres (n = ∼19) and nine centres (n = ∼16), respectively.ConclusionsPrednisolone remains the preferred first-line induction agent in JAILD. MRC at presentation is performed by the large majority of participants. Participants reported a wide variation in performing liver biopsy for therapy evaluation during follow-up. Within the paediatric members of the IAIHG there is considerable experience with second-line therapeutic agents.

Immune Reconstitution Syndrome with Initiation of Treatment of HBV/HIV Co-infection: Activity Flare associated with E antigen Seroconversion

Immune reconstitution syndrome is a recognized complication with initiation of highly active antiretroviral therapy for acquired immune deficiency syndrome patients co-infected with hepatitis B. Hepatitis B flares are seen in 20%-25% of patients after initiation of highly active antiretroviral therapy, an estimated 1%-5% of whom develop clinical hepatitis. We present a case of highly active antiretroviral therapy initiation for HIV that led to a flare of HBV activity despite antiviral therapy directed towards both. Liver biopsy and longitudinal serologic evaluation lend support to the hypothesis that the flare in activity was representative of IRIS. Importantly, we document eAg/eAb seroconversion with the IRIS phenomenon.

Liver Biopsy Results in Potential Donor Evaluation in Living Related Liver Transplantation

Introduction Living donor liver transplantation has been increasing due to the growing discrepancy between the number of patients in waiting lists for liver transplant and the availability of deceased-donors. The evaluation of potential liver donors should ensure the safety of the surgical procedure for the donor. In addition to this, preoperative tests should identify donor grafts that pose risks for the recipient. Liver biopsy is the gold standard for selecting optimal donors. Our aim in this study is to evaluate the results of preoperative liver biopsy of potential donors. Materials and Methods Between December 1988 and October 2017, we performed 580 LT procedures at our centers (age range, 6 mo – 64 y). We evaluated the demographic features of 612 living related liver donor candidates that we performed liver biopsy between January 2001-June 2017. The histological analyses were examined. Body mass index and gender were compared in predicting the degree of histologically determined steatosis. Results We performed liver biopsy in 612 liver donor candidates (328 male, 284 female) (age range 18-69 years). Among these candidates, 416 liver biopsy were reported as normal (68%); 196 liver biopsies had pathological findings (32%). Of 196 donors with pathological findings; 86 (44%) had fatty changes, 24 (12%) had portal inflammation, 86 (44%) had other pathological findings (like fibrosis, hepatitis, focal spotty necrosis). The mean BMI with steatosis were much more higher than the mean BMI without steatosis (29.7± 3.6 vs 24.8 ± 4.2) ( p<.001). 25% of male and 15% of female donor candidates had steatosis. Conclusion The high rate of pathological findings in liver biopsy of donor candidates with healthy-appearing livers pointed the importance of liver biopsy in preoperative evaluation of donors.

Noninvasive Biomarkers in Assessment of Liver Fibrosis in Patients with HBeAg Negative Chronic Hepatitis B.

BACKGROUND:Liver biopsy for evaluation of liver fibrosis has several adverse effects, for which reason noninvasive tests have been developed.AIM:To evaluate the usefulness of noninvasive biomarkers, qHBsAg and HBV DNA levels in predicting liver fibrosis in patients with hepatitis Be antigen (HBeAg) negative chronic hepatitis B (CHB).MATERIAL AND METHODS:This prospective study included 50 patients with HBeAg negative CHB. All patients underwent laboratory and serology testing, quantification of HBV DNA and HBs antigen. The liver stiffness was measured with elastography. The patients were analysed for APRI and FIB-4, quantitative hepatitis Bs antigen and HBV DNA.RESULTS:Logistic regression analysis showed that greatest significance in predicting liver fibrosis has FIB-4 (Wald = 3.24, P = 0.07), followed by HBV DNA ≥ 2 000 IU/ml ≤ 20 000 IU/ml (Wald = 2.86, P = 0.09), qHBsAg (Wald = 2.17, P = 0.14), HBV DNA > 20 000 IU/ml (Wald = 0.58, P = 0.45), APRI (Wald = 0.04, P = 0.84).CONCLUSION:the FIB-4 index has the greatest value in predicting liver fibrosis while APRI has the lowest; the more advanced liver disease is associated with lower serum level of quantitative HBs antigen. Combination of noninvasive blood biomarkers and imaging tests can provide better diagnostic accuracy and exclude the need for liver biopsy.

Diagnostic Performance of Shear Wave Elastography in Patients With Autoimmune Liver Disease.

To assess performance of shear wave elastography for evaluation of fibrosis and the histologic stage in patients with autoimmune liver disease (ALD) and to validate previously established advanced fibrosis cutoff values in this cohort. Shear wave elastography was performed on patients with ALD with an Aixplorer ultrasound system (SuperSonic Imagine, Aix-en-Provence, France) using an SC6-1 transducer. The median estimated tissue Young modulus was calculated from sets of 8 to 10 elastograms. A blinded, subspecialty-trained pathologist reviewed biopsy specimens. The METAVIR classification was used to stage liver fibrosis and necroinflammation. Steatosis was graded from 0 to 4+. The Kendall τ-b correlation test was performed to identify the correlation between the estimated tissue Young modulus and fibrosis, steatosis, and the necroinflammatory score. The Spearman correlation test was performed to identify the correlation between the estimated tissue Young modulus and clinical data. The diagnostic performance of shear wave elastography for differentiating METAVIR stage F2 or higher from F0 and F1 fibrosis was evaluated by a receiver operating characteristic (ROC) curve analysis. Fifty-one patients with ALD were analyzed. The estimated tissue Young modulus was positively correlated with the fibrosis stage and necroinflammation score (r = 0.386; P < .001; r = 0.338; P = .002, respectively) but not steatosis (r = -0.091; P = .527). Serum aspartate aminotransferase, alanine aminotransferase, and total bilirubin values were positively correlated with the estimated tissue Young modulus (r = 0.501; P < .001; r = 0.44; P = .001; r = 0.291; P = .038). The serum albumin value was negatively correlated (r = -0.309; P = .033). The area under the ROC curve was 0.781 (95% confidence interval, 0.641-0.921) for distinguishing F2 or greater fibrosis from F0 and F1 fibrosis. Based on the ROC curve, an optimal cutoff value of 9.15 kPa was identified (sensitivity, 83.3%; specificity, 72.7%). Shear wave elastography is a novel noninvasive adjunct to liver biopsy in evaluation and staging of patients with ALD, showing the potential for serial evaluations of disease progression and treatment responses.

Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is defined by the pathologic accumulation of fat in more than 5% of hepatocytes in the absence of significant alcohol consumption (daily intake &lt; 20 g in women and &lt; 30 g in men) and by excluding secondary causes of hepatic steatosis. NAFLD can be categorized into two principal phenotypes: nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH). NAFL is defined by the presence of macrovesicular steatosis without inflammation, whereas NASH sees inflammation and hepatocyte ballooning injury, is associated with varying degrees of fibrosis, and can progress to cirrhosis and end-stage liver disease. This review addresses the epidemiology, etiology, pathophysiology, diagnosis, treatment, and prognosis of NAFLD. Figures show the spectrum of fatty liver disease, hepatic consequences of insulin resistance, role of liver biopsy in evaluation of NAFLD, histologic features of NASH, and principles of NAFLD. Tables list risk factors and clinical manifestations for NAFLD, physical examination findings in NAFLD, comparison of imaging modalities, and noninvasive fibrosis markers. This review contains 6 figures, 5 tables and 166 references Key words: Nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, non-invasive assessment, vibration controlled transient elastography, magnetic resonance elastography, diet and lifestyle treatment

Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is defined by the pathologic accumulation of fat in more than 5% of hepatocytes in the absence of significant alcohol consumption (daily intake &lt; 20 g in women and &lt; 30 g in men) and by excluding secondary causes of hepatic steatosis. NAFLD can be categorized into two principal phenotypes: nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH). NAFL is defined by the presence of macrovesicular steatosis without inflammation, whereas NASH sees inflammation and hepatocyte ballooning injury, is associated with varying degrees of fibrosis, and can progress to cirrhosis and end-stage liver disease. This review addresses the epidemiology, etiology, pathophysiology, diagnosis, treatment, and prognosis of NAFLD. Figures show the spectrum of fatty liver disease, hepatic consequences of insulin resistance, role of liver biopsy in evaluation of NAFLD, histologic features of NASH, and principles of NAFLD. Tables list risk factors and clinical manifestations for NAFLD, physical examination findings in NAFLD, comparison of imaging modalities, and noninvasive fibrosis markers. This review contains 6 figures, 5 tables and 166 references Key words: Nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, non-invasive assessment, vibration controlled transient elastography, magnetic resonance elastography, diet and lifestyle treatment

Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is defined by the pathologic accumulation of fat in more than 5% of hepatocytes in the absence of significant alcohol consumption (daily intake &lt; 20 g in women and &lt; 30 g in men) and by excluding secondary causes of hepatic steatosis. NAFLD can be categorized into two principal phenotypes: nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH). NAFL is defined by the presence of macrovesicular steatosis without inflammation, whereas NASH sees inflammation and hepatocyte ballooning injury, is associated with varying degrees of fibrosis, and can progress to cirrhosis and end-stage liver disease. This review addresses the epidemiology, etiology, pathophysiology, diagnosis, treatment, and prognosis of NAFLD. Figures show the spectrum of fatty liver disease, hepatic consequences of insulin resistance, role of liver biopsy in evaluation of NAFLD, histologic features of NASH, and principles of NAFLD. Tables list risk factors and clinical manifestations for NAFLD, physical examination findings in NAFLD, comparison of imaging modalities, and noninvasive fibrosis markers. This review contains 6 figures, 5 tables and 166 references Key words: Nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, non-invasive assessment, vibration controlled transient elastography, magnetic resonance elastography, diet and lifestyle treatment

Relationship among biomarkers of iron metabolism and severity of underlying nonalcoholic steatohepatitis (NASH)

Background: In obese subjects with nonalcoholic steatohepatitis (NASH), hepatic iron load may be associated with the risk of toxicity, acting as a comorbidity factor involved in fibrogenesis and carcinogenesis. To evaluate the relationship among biomarkers of iron metabolism and the severity of NASH in adult obese subjects. Methods: Eighty-eight adult subjects with histological diagnosis of non-alcoholic fatty liver disease (NAFLD) were evaluated in a prospective study for the biomarkers of iron metabolism: serum iron, transferrin and ferritin, as well as transferrin saturation index (TSI). Iron deposition in the liver, the intensity of steatosis and fibrosis were assessed in liver biopsies. Results: Increased serum levels of ferritin were found in 31/88 (35.2%) subjects and 12/88 (13.6%) had values of TSI above 45%. Histological evaluation of liver biopsies showed the presence of fibrosis in 48/88 cases (54.5%) being 23.8% mild and 30.7% moderate/severe. Analysis of stainable iron in liver biopsies by Perls method, demonstrated fine granular deposits in the cytoplasm of hepatocytes in 17/88 biopsies (19.3%). There was no association between the presence of iron deposits in the liver parenchyma and the intensity of fibrosis. Multiple logistic regression analysis identified type 2 diabetes mellitus (T2DM) or fasting glucose >100 mg/dL and dyslipidemia as factors independently associated with fibrosis. Conclusions: The findings from our study did not confirm the association between the presence of iron in the hepatic parenchyma and the severity of NASH in obese subjects.