Related Chronic Liver Disease Research Articles

A Rare Case Hepatocellular Carcinoma Metastasis to Calcaneum Bone

Hepatocellular carcinoma (HCC) represents one of the most common causes of cancer related deaths worldwide. Bone metastases from HCC are infrequent, with a reported incidence ranging from 3 to 20% with extremely poor prognosis. HCC with bone metastases is very aggressive with a low incidence rate of detection. Here we report a HCV related chronic liver disease with s/p EVL, presenting with a history of pain over his heel which on further evaluation diagnosed to be a calceneum metastasis from a primary hepatocellular carcinoma.

Technical Challenges in Simultaneous Living Donor Liver Transplantation and Domino Orthotopic Liver Transplantation

Liver transplantation is the ideal treatment of choice for Familial amyloid polyneuropathy (FAP). It is known that during transplantation surgery, this explant liver which will be removed from amyloid patient can be used as a domino graft for another suitable recipient. Even after successful results of domino liver transplantation in deceased donation setting this procedure is always seen with a fear of putting both the recipients at risk due to technical challenge. With living donor as the liver donor for the amyloid patient, the challenges faced are even higher. Only few centres have done similar surgeries and there are no standard guidelines for the same. The anatomical prerequisites, technique, and indications of domino orthotopic liver transplant (D-OLT) in live donation settling are still evolving. We here report a case of live donor liver transplant from a 38 year old with a Right lobe graft for a 40 year old with FAP along with D-OLT for a 52 year old with HBV related decompensated chronic liver disease with HCC. We have described the technical challenges and learnings in our first case which is one of few cases done in the Indian Subcontinent.

Deciphering the liver enigma: distinguishing drug-induced liver injury and metabolic dysfunction-associated steatotic liver disease—a comprehensive narrative review

Drug-induced liver injury (DILI) poses a complex and heterogeneous clinical challenge, which often resembles non-drug related acute or chronic liver diseases, such as metabolic dysfunction-associated steatotic liver disease (MASLD). Furthermore, certain drugs can induce hepatic steatosis, which is considered a rare variant of hepatotoxicity. Additionally, the detection and diagnosis of DILI in patients with non-alcoholic liver disease present additional challenges that require attention. The importance of achieving an accurate diagnosis is highlighted by the different therapeutic approaches needed for each of these diseases. Nonetheless, as definitive diagnostic tests and distinct biomarkers often remain elusive, the differential diagnosis must rely on a combination of clinical, biochemical, histological, and immunophenotypic profiling. The diagnosis of hepatotoxicity is predicated upon the temporal nexus between the administration of a potentially hepatotoxic drug and the onset of hepatic injury, concomitantly excluding alternative hepatic pathologies. More frequently, this condition presents an acute course, with a more pronounced elevation of cytolytic and cholestatic parameters as compared to fatty liver disease. Advances in elucidating the underlying mechanisms hold promise for bolstering the diagnosis and management of these conditions. This article aims to thoroughly examine and emphasize the currently available scientific evidence to provide valuable insights into the diagnostic strategies for DILI, metabolic-associated liver disease, and drug-induced steatosis (DIS).

Clinical study on the efficacy of hepatitis B vaccination in hepatitis C virus related chronic liver diseases in Egypt

BackgroundChronic hepatitis B (HBV) and C virus (HCV) infections represent significant public health issues internationally. HBV vaccination has high sero-conversion rates in patients with mild to moderate chronic liver disease but has reduced efficacy in advanced stages. Aimto evaluate the efficacy of hepatitis B vaccination in HCV-related chronic liver disease and identify possible factors that may contribute to hypo-responsiveness in those patients. MethodsOur study was a retrospective observational clinical study carried out at the tropical medicine department. It was conducted on 500 individuals (400 chronic HCV patients and 100 healthy controls). Individuals were divided into 5 groups: A (control group), B (cirrhotic patient not receiving treatment), C (chronic hepatitis patients receiving treatment), D (cirrhotic patients receiving treatment), and E (HCC patients receiving treatment). All individuals were subjected for comprehensive history taking, clinical examination, laboratory investigations, and assessment of anti-HBs titer. ResultsThere is an inverse relationship between the level of anti-HBs Abs and the duration of vaccine. Diabetes and presence of cirrhosis have statistically significant relationship with serum anti-HBs Abs titer (P = 0.007). Oral DAAs therapy is associated with reduced response to HBV vaccine (only 31.75% of the patients were protected). ConclusionHCV infection and its complications significantly impair HBV vaccine response. Levels of anti-HBs Abs decline progressively with increasing duration from the last dose in immunization schedule of HBV vaccine. Diabetes and presence of cirrhosis being the main risk factors for vaccine hypo-responsiveness, also oral DAAs therapy is associated with reduced response to HBV vaccine.

Association of lipid profile with severity of hepatitis B virus related chronic liver disease in adult

Background: Chronic liver disease (CLD) is a major health problem and contributes to a common cause of hepatocellular carcinoma, disability and death worldwide. Hepatitis B virus (HBV) is the leading cause of CLD in our country. Abnormal lipid profile is expected in those with severe liver dysfunction.
 Objective: The objective of the study was to determine the alteration of lipid profile (total cholesterol, triglyceride, LDL-C and HDL-C) in HBV positive adult CLD patients and to correlate with severity of liver damage.
 Methods: This case control study was conducted for one year between January 2018 to December 2018. One hundred and three patients, >18 years old, admitted with HBV positive CLD in Dhaka Medical College Hospital were recorded as case and 103 age and sex matched, healthy population, were recorded as control. A standard case record form including demographics, histories, clinical examinations and different investigations were completed for each group. Then lipid profile values of cases were compared to controls and different Child-Pugh and MELD scores, were used to see severity of liver damage in CLD patients.
 Results: In patients with HBV positive adult CLD, there were a significant decrease in serum total cholesterol. LDL-C and HDL-C levels compared to the control group (mean 131.4 vs 179.3, 72.5 vs 109.6, and 31.0 vs 40.4 mg/dl, respectively; p<0.001). Comparison of lipid profile with pathologic progression of CLD revealed that these values were diminished gradually with progression of liver damage. Overall triglyceride level was decreased marginally in cases when compared to controls (mean 139.2 vs 146.6 and p=0.047) and this reduction was observed in only advanced stage.
 Conclusion: Serum total cholesterol, LDL-C and HDL-C level in HBV positive CLD patients were low and diminished gradually with severity of liver damage. Triglyceride level was marginally significant and diminished in advanced CLD.
 Bang Med J Khulna 2021; 54 : 08-12

THU151 - Altered fecal microbiome and metabolome in hepatitis B related chronic liver diseases

THU151 - Altered fecal microbiome and metabolome in hepatitis B related chronic liver diseases

CLINICAL PROFILE OF ACUTE KIDNEY INJURY IN CHRONIC LIVER DISEASE, AND ITS EFFECT ON IN HOSPITAL MORTALITY

Introduction - Chronic liver disease (CLD) is a common clinical condition affecting mankind.Its association with the diseases of other important organs like kidney makes it a more devastating disease. Acute kidney injury (AKI) considerably affects the prognosis and outcome of patients with CLD, hence it is important to prevent the development of AKI and identify the precipitating factors as early as possible, so that early interventions can be done.1 A prospective observational study was done on 100 chronic liver disease patients admitted in J. A. group ofMaterial and methods - hospitals Gwalior, over a period of 22 months from Nov. 2019 to June 2021. Detailed history and physical examination, biochemical and radiological investigations were performed and data was collected using a standardised proforma. Out of the 100 patients 70 are patientsResults - are male and 30 are females. Most of the patients belonged to Child - Pugh class C (60%), followed by class B (39%) and class A (1%).Overall, alcohol was found to be the most common cause of chronic liver disease (59%), followed by hepatitis B virus infection (20%), Hepatitis C virus infection(6%), NASH related CLD(2%), portal vein thrombosis(5%), Wilson's disease (1%), unknown etiology (7%). In males, the most common cause of CLD was found to be chronic alcoholism(84.3%), followed by hepatitis B virus infection(8.6%), portal vein thrombosis and NASH related hepatitis in 2.8% each and Wilson's disease (1.4%). In females most common cause of CLD was found to be hepatitis B virus infection (46.6%),followed by hepatitis c virus infection (20%), portal vein thrombosis(10%), unknown etiology (23.3%). Ascites (78%) was the most common sign of hepatic decompensation, followed by pedal edema (67%), jaundice (52%), altered sensorium(20%), GI bleed ( 22%), dilated abdominal veins(18%), alopecia(10%). palmar erythema ( 8 %) and testicular atrophy(4%). Prevalence of AKI in CLD was found to be 30%, out of which maximum no. of patients were in AKIN stage 3(48%), frequency of stage 1 & 2 AKI was 26.6% each. The most common cause of AKI in CLD was found to be sepsis (40%), followed by GI bleed (26.7%), inappropriate use of diuretics (13. 3%), Paracentesis (6.6%)and diarrhea(10%) severe vomiting ( 3. 3%). The in hospital mortality in the patients who developed AKI was considerably higher (56.6%) than the patients who did not developed AKI (8.5%), signicant at p <0.05. CLD patients are at increased risk of developing AKI , and mortality rates areConclusion - signicantly higher in patients of CLD complicated by AKI.

Efficacy of Direct Acting Anti-Viral Agents in Patients Infected with Chronic Hepatitis C Virus: A Single Center Experience

Background: Hepatitis virus C (HCV) infection is affecting millions of people globally with an estimated prevalence in Pakistan ranging from 4.5 to 8%. Advent of oral direct acting antiviral agents (DAAs) in combination therapy has made possible the treatment of decompensated cirrhosis secondary to hepatitis C (HCV) infection. Therefore, this study focused to evaluate safety and efficacy of direct antiviral agents (DAAs) in compensated and decompensated cirrhotic patients.
 Materials and Methods: This cross sectional study was conducted in the Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation (SIUT) Karachi, from 1st September 2017 to 30th June 2018. Patients diagnosed with HCV, presenting in outpatient department were enrolled. All patients received Daclatasavir, Sofosbuvir and Ribavirin combination. Patient without cirrhosis and with cirrhosis received treatment for 12 and 24 weeks, respectively. End of treatment response was taken as primary end point. Statistical analysis was performed by SPSS version 20.0.
 Results: Out of 180 patients, 88(48.9%) were male and 92(51.1%) were female, with mean age of 44.59±11.29 years. Majority had genotype 3 i.e., 145(80.6%). In this study population, 97(53.9%) patients were non-cirrhotic and received 3 months treatment while 83(46.1%) cirrhotic patient got 6 months treatment. Post- stratification observed that young patients have better treatment response rate than older individuals (p-=0.031) On the other hand, statistical insignificant association was observed between end of treatment response with regards to gender, duration of treatment, history of hepatic encephalopathy and ascites.
 Conclusion: This study concluded that treatment with direct antiviral agents of Hepatitis C virus related chronic liver disease is effectual and has shown equivalent response in cirrhotic and non-cirrhotic patients. Age is an important factor affecting treatment response i.e, better response achieved in patient with less than 45 years.

Evaluation of portal vein velocity in non alcoholic fatty liver disease by Doppler ultrasound

Nonalcoholic fatty liver disease is being increasingly recognized as one of the major causes of chronic liver disease. It is associated with various metabolic condition including obesity and diabetes. As the incidence of diabetes and obesity is increasing every day due to change in lifestyle, the incidence of nonalcoholic fatty liver disease is also increasing and so does its related chronic liver disease. Doppler ultrasound is easily available, noninvasive modality to see the hemodynamics of portal vein in various diffuse liver diseases. Our objective in our study is to show the correlation between the nonalcoholic fatty liver disease and Doppler findings of portal vein. The study was conducted in Department of Radiology of College of medical sciences, Bharatpur. Total 70 participants with in group of 30-60 years were included in our study (50 patients with fatty liver disease and 20 with normal liver parenchyma). All ultrasound examination performed with the Toshiba Aplio 500 with convex array deep probe of frequency 3.5MHZ. Prospective cross-sectional study was conducted over the period of one year between September 2020 to August 2021. The mean age of our patients with fatty liver was 42.1 ± 8.4 years, mean BMI was 30.6 ± 3.6 similarly mean V_min and V_max of portal vein is 20.0 ± 7.7cm/s and 24.6 ± 7.4cm/s respectively. Same way the control group without fatty liver had 40.6 ± 9.7 years mean age, 23.55 ± 4.8cm/s mean BMI, 30.05 ± 5.1cm/s mean V_min and 34 ± 5.0cm/s mean V_max. There is statistically significant difference of mean BMI (p<0.001), Minimum Portal Vein Velocity (p<0.001) and Maximum Portal Vein Velocity (p<0.001) among the patients having fatty liver disease and not having fatty liver. Our findings suggest that patients with nonalcoholic fatty liver have lower portal venous velocities than normal healthy study participants.

Hepatitis E virus infection in a patient with alcohol related chronic liver disease: a case report of acute-on-chronic liver failure

BackgroundThe hepatitis E virus (HEV) infection has been described as a causing factor for acute-on-chronic-liver-failure (ACLF) in patients with underlying chronic liver disease (CLD), such as chronic hepatitis or cirrhosis, which could end in the failure of one or more organs and high short-term mortality. There are scarce data about the association of HEV in patients with chronic liver disorders in South America.Case presentationA 56-year-old hypertensive male with a history of type 2 diabetes was diagnosed with alcohol-related-liver cirrhosis in February 2019. A year later, the patient was admitted to hospital due to fatigue, jaundice and acholia. No evidence of hepatitis A virus, hepatitis B virus, hepatitis C virus, Epstein–Barr virus, herpes zoster virus and cytomegalovirus infections were found. Nevertheless, in February and March, 2020 the patient was positive for HEV-IgM and HEV-IgG, and HEV genotype 3 RNA was detected in sera. Afterwards, he presented grade I hepatic encephalopathy and, therefore, was diagnosed with acute hepatitis E-on-chronic liver disease. The patient reported a recent travel to the Argentine coast, where he consumed seafood. Besides, he reveled to have consumed pork meat and had no history of blood transfusion.ConclusionThis report describes a unique case of hepatitis E virus infection in a patient with alcohol-related cirrhosis. This is the first report of a patient with HEV-related ACLF in Argentina and it invokes the importance of HEV surveillance and treatment among patients with CLD, such as alcohol-related cirrhosis.

Study of occurrence of HBeAg among Hepatitis- B surface antigen positive cases

Hepatitis is a universal concept that mean inflammation of the liver and infection with 1 of the 5 viruses called hepatitis A, B, C, D and E viruses is the almost common cause. The 5 viral cause’s hepatitis-B infection is the worldly almost common hepatic infection, which is cause by hepatitis-B (HBV). HBV is a DNA virus. It is 42–47 nm in diameter and enters the liver through with blood stream. HBV is highly contagious and is 60–100 times more than HIV. It is transmissible throughly with blood cell and all body fluid or mucosa membranous. It is transmitted almost normally by unsafe physical sexual contact, contaminated blood transfusions and unsterilized use needles from mother to baby, close household touch and in the midst of children in early childhood. Study of occurrence of HBeAg among Hepatitis- B surface antigen positive cases; 1. Identification of Hepatitis B Surface Antigen positive cases; 2. Occurrence of HBeAg among Hepatitis- B surface antigen positive cases. 5ml blood was collected from anterior cubital vein by Venipuncture from recruited patient. Samples were collected after proper consent and aseptic precautions. Then every blood sample was transfer overhead a tagged tube plane vial The study was conducted in Department of Microbiology, Teerthanker Mahaveer Hospital. Blood sample from 106 patients including both male and female were collected from various department of the Hospital for the analysis purpose. Out of them, 38 (36%) cases were HBeAg positive and 68 (64%) cases were HBeAg negative: The result of our study put up valuable information and connection in HBeAg positive cases. In this little sample size 106 analysis of the patients at Uttar Pradesh Teerthanker Mahaveer Medical College, the prevalence of HBeAg (positive results) in the department of medical microbiology, while the negative result is 68(64%).Males 29(76%) were more affected by the HBV (HBeAg) infection as compare to Female 9(24%).An important preventive measure is the screening for HBV in blood donors. Hepatitis-B related chronic liver disease and hepatocellular carcinoma are best prevented by universal childhood immunization. In non-infected people, HBV infection can be avoided by HBV vaccination.Injections Sequence 3 at 0, 1 and 6 months. In over 90% of recipients vaccination is successful.

A CASE REPORT ON A RARE COMPLICATION OF HMG-COA REDUCTASE INHIBITORS.

Rhabdomyolysis is the rare adverse effect of statin therapy. It is a condition characterized by the damage and breakdown of skeletal muscle. A 66 years old male patient was admitted to the hospital with the chief complaint of pain and weakness in both lower and upper limbs for ve days and was diagnosed with statin-induced rhabdomyolysis. The signicance of statin-induced rhabdomyolysis in a patient with recent Hepatitis B related Decompensated Chronic Liver Disease with portal Hypertension, and Severe Mitral Regurgitation is highlighted here. Based on this case report, we recommend that clinicians should inform regular follow-up to the patients when prescribing statins.

Evaluation of Metabolic Changes in HCV Diabetic Patients Treated With Direct Acting Antiviral Agents

Abstract Background Viral hepatitis is a major public health problem in need of urgent response. The prevalence of hepatitis C virus (HCV) infection in Egypt is the highest in the world. Seroprevalence was modeled to 10.6% and viraemic prevalence to 7.3% in 2014. The association between hepatitis C virus (HCV) infection and diabetes has been widely postulated. Prospective studies have demonstrated a higher risk of developing type 2 diabetes mellitus (T2DM) and insulin resistance in the HCV population. Objective to evaluate metabolic changes in HCV-positive diabetic patients following combination therapy of hepatitis C, clarifying the role of DAAs in these changes. Patients and Methods This study was conducted in Ain Shams University Hospital outpatient clinics who attended from March to December 2018. our study included 70 patients, and were subdivided into the following two groups: Group I: Easy to treat group. Contains 35 diabetic patients with HCV related chronic liver disease treated with sofosbuvir, daclatasvir. Group II: Difficult to treat group. Contains 35 diabetic patients with HCV related chronic liver disease treated with sofosbuvir and daclatasvir and ribavirin. Results Treatment was considered successful when patients became non-viraemic as identified by negative HCV RNA serum PCR at 12 weeks from the end of the treatment regimens (SVR). It was found that diabetic patients treated with DAAs achieved reduction of HbA1C by mean of (0.724±0.3%). The mean increase of serum uric acid level was (0.607±0.4 mg/dL). There were increases in Cholesterol (by mean of 16.85±3.4), HDL (by mean of 5.34±2.1) and LDL (by mean of 13.91±4.2) as well as a decrease in TG (by mean of 13.56±5.1). Conclusion Our study concludes that HCV eradication in diabetic patients leads to various metabolic changes in the form of: Reduction of serum HbA1c level. Elevation of serum uric acid. Elevation of serum cholesterol, HDL, LDL as well as a decrease in TG. Further and larger studies are needed to evaluate the full magnitude of RBV effects on the patients’ metabolism.

Handgrip strength in prediction of sarcopenia in Chronic HCV patient

Abstract Background HCV is one of the major causes of morbidity and mortality in the world and especially in Egypt. However, there is numerous complications to HCV infection (e.g. liver cirrhosis, ascites, portal hypertension, encephalopathy …. etc.) but there is multiple unseen complication (e.g. sarcopenia, loss of electrolytes, loss of protein …etc.) Objective To evaluate value of handgrip strength in assessment of sarcopenia in HCV related chronic liver disease patients Patients and Methods This study was conducted on 64 adult persons older than 18 years. They were randomly collected from the outpatient clinics at department of internal Medicine in Ain Shams University during the period from June 2018 to August 2019. Results In our study there was a great significance relation between handgrip strength and child score in evaluating nutritional status more than anthropometric parameter. Therefore, even that several methods to evaluate nutritional and functional capacity status in patients with cirrhosis have been tested, they have reported diverse results. Conclusion Our study we can conclude that HGS is a simple, easy to be applied and more accurate method in evaluation of sarcopenia in chronic HCV patients.

Comparing the Efficacy of Double Dose Hepatitis B Vaccine with Conventional Dose Hepatitis B Vaccine in CLD Patients

Aim: To compare the efficacy of double dose hepatitis B vaccine with conventional dose hepatitis B vaccine in hepatitis C related chronic liver disease patients. Study design: Interventional study (randomized controlled clinical trial) Place and duration of study: Outpatient Department of Medicine, Services Hospital, Lahore from 12th August 2019 to 12th February 2020. Methodology: One hundred and ten patients of both male and female age group 30 to 70 years diagnosed with chronic liver disease on the basis of changed liver echo texture on ultrasound were included. Patients were divided into two groups, each group having 55 patients. One group was given double dose (2ml) while the other was given conventional dose (1ml). Both groups were compared for efficacy in terms of prevention of CLD. Results: The mean age of conventional group was 33.8±9.6 years while 33.7±9.1 years in the double dose group with male predominance (69.10%). Hypo-responsiveness was detected in 23.6% and 32.7% of conventional low dose group and double dose group respectively. There were gender variations in mean Anti-HBs levels. It was 129.80±70.53 mIU/mL in males and 113.26±75.57 mIU/mL in female patients (P= 0.039). Mean titers of anti-HBs in conventional dose group and high dose group were 127.82±67.59 mIU/mL and 121.56±77.00 mIU/mL, respectively (P= 0.52). Conclusion: Double dose hepatitis B vaccination in chronic HCV infected patients efficiently increases the response rate and hence protection against chronic hepatitis B. Keywords: Double dose hepatitis B vaccine, conventional hepatitis B vaccine, chronic hepatitis.

Proximal Hip Geometry, Trabecular Bone Score, Bone Mineral Density and Bone Mineral Parameters in Patients With Cryptogenic and Hepatitis B Related Cirrhosis- A Study From the Indian Subcontinent

The impact of cryptogenic cirrhosis on skeleton has not been studied in Indian context. So this study investigated bone health in male patients with early cryptogenic cirrhosis as defined by Child-Turcot-Pugh A (CTP-A) categorization and compared it with patients diagnosed to have hepatitis B related chronic liver disease (CLD) on treatment and age, sex-matched healthy controls. It was a cross-sectional study, in which thirty male subjects were recruited in each group. Bone mineral density (BMD), trabecular bone score (TBS), hip structural analysis (HSA) and bone mineral parameters were assessed. The mean ±SD age of the study subjects was 39.3 ± 9.2 years. The mean 25-hydroxy vitamin D was significantly lower in subjects with cryptogenic cirrhosis as compared to controls (p = 0.001). Subjects with cryptogenic cirrhosis had significantly lower (1.297 ± 0.099) TBS as compared to hepatitis-B related CLD (1.350 ± 0.094) control subjects (1.351 ± 0.088) (p = 0.04). BMD at the hip and lumbar spine was also significantly lower in subjects with cryptogenic cirrhosis as compared to hepatitis-B related CLD and healthy age matched controls (p < 0.05). Most components of HSA were significantly affected in subjects with cryptogenic cirrhosis as compared to control subjects (p < 0.05). Patients with cryptogenic cirrhosis had significantly low TBS and BMD lumbar spine and hip as well as poor proximal hip geometry which may be good predictor of future fragility fractures.

Interleukin-9: Investigating Its Possible Role in Liver Cirrhosis Progression and in Tumour Promotion of Hepatocellular Carcinoma in Chronic HCV Infected Patients, A Single Centre Study

Background: Cytokines play an essential role in the pathogenesis of hepatitis C virus (HCV) related cirrhosis and hepatocellular carcinoma (HCC). Interleukin-9 (IL-9) participates in inflammation, autoimmunity and tumor immunity. IL-9 was reported to affect liver fibrosis, severity and prognosis of HCV related diseases.Aim of the study: To assess the potential correlation of serum IL-9 level and its receptor with the progression and prognosis of patients having HCV related chronic liver disease and its probable association with hepatocellular carcinoma.Methods: Sixty-eight patients having HCV chronic liver disease and 20 apparently healthy controls (HCs) were enrolled in the study. The patients were grouped into 3 groups: 18 patients having compensated chronic liver disease (CCLD), 18 patients having decompensated chronic liver disease, and 32 patients having hepatocellular carcinoma (HCC). Serum IL-9 level was estimated by ELISA and IL-9 receptor (IL-9R) gene expression was assessed by RT-PCR in HCC group and HCs.Results: IL-9 level was significantly higher in patients in comparison to HCs and there was statistically significant difference between the 3 patients’ groups (p 1600pg/ml, IL-9 had the ability to differentiate between CCLD group and HCC group with 75% sensitivity and 94.44% specificity. There was a highly significant statistical difference between HCC group and HCs in IL-9R gene expression (p < 0.001).Conclusion: Serum IL-9 level is higher in chronic HCV infected patients than in HCs. IL-9R gene expression is higher among HCC patients than in HCs.

Serum copeptin level is a biomarker associated with ascites retention and the formation of a portosystemic shunt in chronic liver disease.

Copeptin is a stable cleavage product of the arginine vasopressin precursor and is equimolarly secreted with arginine vasopressin. We aimed to assess whether copeptin is the surrogate marker for complications related chronic liver disease (CLD) such as ascites, hepatic encephalopathy (HE), portosystemic shunts (PSSs), and all causes of mortality in CLD. Serum copeptin was measured in 170 CLD patients upon hospital admission. The association of copeptin levels with liver enzymes, liver functional reserve, and clinical parameters was investigated. Cox proportional hazard regression, logistic regression, and Kaplan-Meier analyses were performed to evaluate the associations of copeptin and ascites, HE and PSS formation, and prognostic factors with short-term (1year) and long-term (4years) mortality. Serum copeptin levels were significantly correlated with liver and renal function, elevated in parallel with liver disease progression, and also associated with HE. Serum copeptin, albumin-bilirubin score and hepatocellular carcinoma were independent predictors of PSS formation and decreased rate of survival. Serum copeptin and albumin-bilirubin scores were independent predictors of ascites retention. The short-term and long-term cumulative mortality rate was significantly decreased in patients with serum copeptin >5.5 or >4.8pmol/mL compared with patients in whom serum copeptin levels were <5.5 or <4.8pmol/mL (P<0.0001; P<0.0001). Serum copeptin level is a predictor for ascites retention and HE and PSS formation associated with portal hypertension. Moreover, serum copeptin level may be useful in predicting the rate of survival in patients with CLD.

New frontiers in liver resection for hepatocellular carcinoma.

SummaryLiver resection is one of the main curative options for early hepatocellular carcinoma (HCC) in patients with cirrhosis and is the treatment of choice in non-cirrhotic patients. However, careful patient selection is required to balance the risk of postoperative liver failure and the potential benefit on long-term outcomes. In the last decades, improved surgical techniques and perioperative management, as well as better patient selection, have enabled the indications for liver resection to be expanded. In this review, we aim to describe the main indications for liver resection in the management of HCC, its role compared to percutaneous ablation and liver transplantation in the therapeutic algorithm, as well as the recent advances in liver surgery that could be used to improve the prognosis of patients with HCC.

Presentations, Causes and Outcomes of Drug-Induced Liver Injury in Egypt

Drug-induced liver injury (DILI) is a frequent cause of liver injury and acute liver failure. We aimed to review all hospitalized DILI cases in a tertiary Egyptian center from January 2015 through January 2016. Cases with elevated alanine aminotransferase more than 3-fold and/or alkaline phosphatase more than 2-fold the upper limit of normal value were prospectively recruited and followed for one year. Drug history, liver biopsy whenever feasible and application of Roussel Uclaf Causality Assessment Method (RUCAM) were the diagnostic prerequisites after exclusion of other etiologies of acute liver injury. In order of frequency, the incriminated drugs were: Diclofenac (31 cases, 41.3%), amoxicillin-clavulanate (14 cases, 18.7%), halothane toxicity (8 cases, 10.7%), ibuprofen (4 cases, 5.3%), Khat (3 cases, 4%), tramadol (3 cases, 4%), Sofosbuvir with ribavirin (2 cases, 2.7%), and acetylsalicylic acid (2 cases, 2.7%) with one offending drug in 93.3% of cases. Forty-four cases (58.7%) were males; while 56 cases (74.7%) had HCV related chronic liver disease. Thirty-two cases (42.7%) presented with pattern of hepatocellular injury, while 23 cases (30.7%) were with cholestasis, and 20 cases (20.7%) with a mixed hepatocellular/cholestatic injury. One case received a transplant (0.75%), 7 cases died (9.3%), 23 cases (30.6%) developed liver decompensation (hepatic encephalopathy and ascites), and 44 cases completely resolved (58.7%). In conclusion, Diclofenac is the commonest offender in DILI occurrence in an Egyptian cohort. Age and prothrombin concentration were the only predictors of unfavorable outcomes of DILI.