Valid Liver Stiffness Measurement Research Articles

Cumulative methotrexate dose is not associated with liver fibrosis in patients with a history of moderate-to-severe psoriasis.

There are established risk factors for liver fibrosis (LF), but data on the impact of methotrexate on LF in patients with psoriasis are lacking. This cross-sectional study aimed to determine the prevalence of LF in patients with psoriasis and to evaluate the relationship between LF, cumulative methotrexate dose and other LF risk factors. Adults with a history of moderate-to-severe chronic plaque psoriasis were recruited between June 2020 and March 2021. Patients underwent transient elastography to evaluate LF. Three values for liver stiffness measurement (LSM) were assessed, indicating mild or worse LF (≥ 7 kPa), moderate or worse LF (≥ 7.9 kPa) and advanced LF (≥ 9.5kPa). Cumulative methotrexate dose and other potential risk factors for LF were assessed. Overall, 240 patients were recruited and 204 participants with valid LSM values were included in the analysis [median age 48 years [interquartile range (IQR) 37-57]; 51% female sex; 56% body mass index (BMI) ≥ 30 (kg m-2) and a median Alcohol Use Disorders Identification Test (AUDIT) score of 4 (IQR 1-7, 23% score ≥ 8)]. In total, 91% had received methotrexate [median duration 36 months (IQR 14-78)]. Prevalence of LF was 36%, 25% and 17% using LSM ≥ 7 kPa, ≥ 7.9 kPa and ≥ 9.5 kPa, respectively. There was no association between cumulative methotrexate dose [median 2.16 (IQR 0.93-5.2)] and continuous LSM values [unstandardized coefficient 0.16, 95% confidence interval (CI) -0.49 to 0.82, P = 0.626] or using the categorical LSM cutoff values: ≥ 7 kPa [unadjusted odds ratio 1.06 (95% CI 0.97-1.15), P = 0.192], ≥ 7.9 kPa [unadjusted odds ratio 1.03 (95% CI 0.94-1.12), P = 0.577] and ≥ 9.5 kPa (unadjusted odds ratio 1.01, 95% CI 0.91-1.12; P = 0.843). The following risk factors were associated with higher LSM values: BMI (P ≤ 0.001), waist circumference (P ≤ 0.001), metabolic syndrome (P ≤ 0.001), AUDIT score (P = 0.020) and FIB-4 score (P = 0.03). BMI ≥ 28, diabetes and metabolic syndrome were shown to be better predictors of LF compared with FIB-4 score. This study confirms a high prevalence of significant LF in patients with psoriasis. Cumulative methotrexate dose was not associated with LF. Patients with BMI ≥ 28, metabolic syndrome and diabetes are at higher risk for LF. These risk factors may help to identify when a more detailed liver health assessment is needed.

Palm-Sized Wireless Transient Elastography System with Real-Time B-Mode Ultrasound Imaging Guidance: Toward Point-of-Care Liver Fibrosis Assessment.

Transient elastography (TE), recommended by the WHO, is an established method for characterizing liver fibrosis via liver stiffness measurement (LSM). However, technical barriers remain towards point-of-care application, as conventional TE requires wired connections, possesses a bulky size, and lacks adequate imaging guidance for precise liver localization. In this work, we report the design, phantom validation, and clinical evaluation of a palm-sized TE system that enables simultaneous B-mode imaging and LSM. The performance of this system was validated experimentally using tissue-equivalent reference phantoms (1.45-75 kPa). Comparative studies against other liver elastography techniques, including conventional TE and two-dimensional shear wave elastography (2D-SWE), were performed to evaluate its reliability and validity in adults with various chronic liver diseases. Intra- and inter-operator reliability of LSM were established by an elastography expert and a novice. A good agreement was observed between the Young's modulus reported by the phantom manufacturer and this system (bias: 1.1-8.6%). Among 121 patients, liver stiffness measured by this system and conventional TE were highly correlated (r = 0.975) and strongly agreed with each other (mean difference: -0.77 kPa). Inter-correlation of this system with conventional TE and 2D-SWE was observed. Excellent-to-good operator reliability was demonstrated in 60 patients (ICCs: 0.824-0.913). We demonstrated the feasibility of employing a fully integrated phased array probe for reliable and valid LSM, guided by real-time B-mode imaging of liver anatomy. This system represents the first technical advancement toward point-of-care liver fibrosis assessment. Its small footprint, along with B-mode guidance capability, improves examination efficiency and scales up screening for liver fibrosis.

CLivD score modifies FIB-4 performance in liver fibrosis detection in the US general population

Background and aimsSteatotic liver disease (SLD) is a growing global concern. The Chronic Liver Disease (CLivD) risk score predicts liver-related outcomes in the general population using easily accessible variables with...

Prospective comparison of liver stiffness measurement methods in surveillance biopsies after liver transplantation.

Liver stiffness measurements (LSMs) have proven useful for non-invasive detection of fibrosis. Previous studies of LSMs after transplantation were performed in cohorts dominated by hepatitis C reinfections and indication biopsies for the evaluation of graft dysfunction. However, the diagnostic fidelity of LSMs for fibrosis is biased by inflammation e.g., during replicative hepatitis C or rejection. The current study aimed for a head-to-head comparison of two different LSMs, acoustic radiation force impulse (ARFI) and transient elastography (TE), and a determination of cut-off values for the detection of advanced fibrosis (any LAF score component ≥2) in grafts undergoing surveillance biopsies (svLbx) without recurrent hepatitis C. 103 svLbx were paired with valid LSMs at time of biopsy. AUROC analyses showed significant positive correlation with fibrosis for both methods (TE: AUROC = 0.819 (p < 0.001; 95%CI: 0.717-0.921); ARFI: AUROC = 0.771 (p = 0.001; 95%CI: 0.652-0.890). Patients were randomly assigned to training and validation cohorts for both LSM methods. Cut-off values were determined at 1.29 m/s (ARFI) and at 7.5 kPa (TE) in training cohorts. Sensitivity and specificity in training and validation cohorts were: TE: SEN 0.818 and 0.5; SPE 0.742 and 0.885; ARFI: SEN 0.818 and 1.0; SPE 0.75 and 0.586. LSMs were not associated with BANFF criteria for relevant graft injury. LSM is a good non-invasive tool to screen for advanced graft fibrosis but not for relevant graft injury in patients with (near) normal liver enzymes. Fibrosis cut-off values identified and validated in svLbx were lower than in previous cohorts using indication biopsies.

The Prevalence of Liver Fibrosis Stages on More than 23,000 Liver Stiffness Measurements by Vibration-Controlled Transient Elastography: A Single Center Study.

Vibration-controlled transient elastography (VCTE) was the first non-invasive method used for assessing liver fibrosis in patients with chronic liver disease. Over the years, many studies have evaluated its performance. It is now used globally, and, in some countries, it represents the primary step in evaluating liver fibrosis. The aim of this study is to assess the feasibility of VCTE and highlight the prevalence of liver fibrosis stages assessed by VCTE in a large cohort of patients at a single study center. We also aimed to observe the trends in liver stiffness (LS) values over the years according to each type of hepatopathy. A retrospective study was conducted over a period of 13 years (2007-2019) and included patients who presented to our clinic for LS measurements (LSMs), either with known liver diseases or with suspected liver pathology who were undergoing fibrosis screening. The database contained a total of 23,420 measurements. Valid LSMs were obtained in 90.91% (21,291/23,420) of the cases, while 2129 (9.09%) of the measurements were either failed or unreliable. In untreated patients with chronic viral hepatitis, LS values tended to increase during the years, while in patients undergoing antiviral therapy LS values significantly decreased. Our comprehensive study, one of the largest of its kind spanning 13 years, emphasizes the reliability and significance of VCTE in real-world clinical settings.

Dynamic Changes in Liver Stiffness in Patients with Chronic Hepatitis B Undergoing Antiviral Therapy.

This is a retrospective single-center study that included 87 subjects. All subjects had chronic hepatitis B or HBV cirrhosis and underwent nucleos(t)ide analogs (NUC) treatment for more than one year. The study aimed to evaluate the dynamic changes in liver stiffness (LS) measured by transient elastography (TE) during a median interval of 64 months. Patients were assessed prior to starting therapy and followed up annually. Liver stiffness measurements (LSM) were performed annually, and ten valid LSMs were obtained in each session. Reliable LSMs were defined as the median value of 10 measurements with Interquartile range/median (IQR/M) ≤ 30%. A significant decrease in liver stiffness values (p < 0.001) was observed during follow-up. In patients with liver cirrhosis, the LSMs decreased significantly after only one year, 24.6 ± 4.3 kPa vs. 13.5 ± 4.2 kPa (p = 0.007), whereas the decrease in non-cirrhotic patients was not significant, 7.31 ± 3.62 vs. 6.80 ± 2.41 (p = 0.27). Liver stiffness decrease was more significant in patients with initially higher transaminases. Undetectable viral load was achieved in 73.5% of patients in year one, 82.7% in year two, and 90.8% in year three of treatment. In conclusion, our study reveals a decrease in liver stiffness by TE in patients with chronic hepatitis B when undergoing anti-HBV therapy in the first two years. It can be used as a method for follow-up in patients undergoing NUC therapy.

Reduced and more appropriate referrals of patients with type 2 diabetes using liver stiffness measurement compared to FIB-4.

Fatty liver disease and fibrosis are common in patients with type 2 diabetes mellitus (T2DM). Recently published European Association for the Study of the Liver guidelines have suggested screening such patients using liver stiffness measurement (LSM) or fibrosis-4 index (FIB-4) to exclude advanced fibrosis. We initiated a screening programme at the diabetes out-patient clinic to assess the reliability of the suggested approaches and resulting referrals. In this prospective study, consecutive patients attending for T2DM review at an Irish level 3 (district general) hospital between September and November 2021 were screened for liver fibrosis using LSM and had their FIB-4 calculated. The first 100 patients with valid LSM measurements were included in the analysis. Referral rates to the hepatology clinic varied by modality used. If FIB-4 ≥ 1.3 criterion was used, the referral rate to the hepatology clinic was 45%; using LSM < 8kPa to rule out advanced fibrosis resulted in 34% referral rate; using LSM ≥ 10kPa to suggest probable compensated advanced chronic liver disease reduced referral rates to 15%. Combining FIB-4 with LSM in a two-step algorithm led to missed potentially significant liver disease in large numbers. 47% patients with LSM ≥ 8kPa and 33% with LSM ≥ 10kPa had FIB-4 < 1.3. Screening of patients with T2DM using LSM alone rather than FIB-4 leads to reduced numbers of, and more appropriate, referrals to the hepatology clinic. Shifting from an exclusion (LSM < 8kPa) to an inclusion based (LSM ≥ 10kPa) approach may lessen the potential of screening to overwhelm hepatology services.

Inflammatory activity affects the accuracy of liver stiffness measurement by transient elastography but not by two-dimensional shear wave elastography in non-alcoholic fatty liver disease.

BackgroundIn patients with non‐alcoholic fatty liver disease (NAFLD), the impact of the severity of steatosis and inflammatory activity on the accuracy of liver stiffness measurement (LSM) by transient elastography (TE) and by two‐dimensional shear wave elastography (2D‐SWE) in staging liver fibrosis is still debated and scarce. We aimed to focus on this aspect.MethodsWe prospectively studied 104 patients requiring biopsy for the assessment of NAFLD. We used ordinary least squares regression to test for differences in the association between fibrosis and LSM by TE and 2D‐SWE when other factors (steatosis and inflammatory activity) are considered.ResultsAmong 104 patients, 102 had reliable LSM by TE, and 88 had valid LSM by 2D‐SWE. The association between fibrosis based on histology and LSM was significantly stronger when 2D‐SWE assessed LSM compared to TE (Spearman's correlation coefficient of .71; P < .001 vs .51, P < .001; Z = 2.21, P = .027). Inflammatory activity was an independent predictor of LSM by TE but not of LSM by 2D‐SWE. After controlling for fibrosis, age, sex and body mass index, the inflammatory activity and the interaction between inflammatory activity and fibrosis independently explained 11% and 13% of variance in LSM by TE respectively. Steatosis did not affect the association of fibrosis and LSM by either method.ConclusionInflammatory activity on histology significantly affects LSM by TE, but not LSM by 2D‐SWE in NAFLD. LSM by 2D‐SWE reflects liver fibrosis more accurately than LSM by TE. Furthermore, the severity of steatosis on histology did not influence the association of LSM and fibrosis by either elastography method.

Accuracy of Transient Elastography in Assessing Fibrosis at Diagnosis in Naïve Patients With Primary Biliary Cholangitis: A Dual Cut-Off Approach.

Background and AimsLiver fibrosis holds a relevant prognostic meaning in primary biliary cholangitis (PBC). Noninvasive fibrosis evaluation using vibration‐controlled transient elastography (VCTE) is routinely performed. However, there is limited evidence on its accuracy at diagnosis in PBC. We aimed to estimate the diagnostic accuracy of VCTE in assessing advanced fibrosis (AF) at disease presentation in PBC.Approach and ResultsWe collected data from 167 consecutive treatment‐naïve PBC patients who underwent liver biopsy (LB) at diagnosis at six Italian centers. VCTE examinations were completed within 12 weeks of LB. Biopsies were scored by two blinded expert pathologists, according to the Ludwig system. Diagnostic accuracy was estimated using the area under the receiver operating characteristic curves (AUROCs) for AF (Ludwig stage ≥III). Effects of biochemical and clinical parameters on liver stiffness measurement (LSM) were appraised. The derivation cohort consisted of 126 patients with valid LSM and LB; VCTE identified patients with AF with an AUROC of 0.89. LSM cutoffs ≤6.5 and >11.0 kPa enabled to exclude and confirm, respectively, AF (negative predictive value [NPV] = 0.94; positive predictive value [PPV] = 0.89; error rate = 5.6%). These values were externally validated in an independent cohort of 91 PBC patients (NPV = 0.93; PPV = 0.89; error rate = 8.6%). Multivariable analysis found that the only parameter affecting LSM was fibrosis stage. No association was found with BMI and liver biochemistry.ConclusionsIn a multicenter study of treatment‐naïve PBC patients, we identified two cutoffs (LSM ≤6.5 and >11.0 kPa) able to discriminate at diagnosis the absence or presence, respectively, of AF in PBC patients, with external validation. In patients with LSM between these two cutoffs, VCTE is not reliable and liver biopsy should be evaluated for accurate disease staging. BMI and liver biochemistry did not affect LSMs.

Quantification of Liver Fibrosis, Steatosis, and Viscosity Using Multiparametric Ultrasound in Patients with Non-Alcoholic Liver Disease: A "Real-Life" Cohort Study.

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide. This study aimed to evaluate the performance of four ultrasound-based techniques for the non-invasive multiparametric (MPUS) assessment of liver fibrosis (LF), steatosis (HS), and inflammation in patients with NAFLD. We included 215 consecutive adult patients with NAFLD (mean age: 54.9 ± 11.7; 54.5% were male), in whom LF, HS, and viscosity were evaluated in the same session using four new ultrasound-based techniques embedded on the Aixplorer MACH 30 system: ShearWave Elastography (2D-SWE.PLUS), Sound Speed Plane-wave UltraSound (SSp.PLUS), Attenuation Plane-wave UltraSound (Att.PLUS), and Viscosity Plane-wave UltraSound (Vi.PLUS). Transient Elastography (TE) with Controlled Attenuation Parameter (CAP) (FibroScan) were considered as control. All elastographic measurements were performed according to guidelines. Valid liver stiffness measurements (LSM) were obtained in 98.6% of patients by TE, in 95.8% of patients by 2D-SWE.PLUS/Vi.PLUS, and in 98.1% of patients by Att.PLUS/SSp.PLUS, respectively. Therefore, 204 subjects were included in the final analysis. A strong correlation between LSMs by 2D-SWE.PLUS and TE (r = 0.89) was found. The best 2D-SWE.PLUS cut-off value for the presence of significant fibrosis (F ≥ 2) was 7 kPa. Regarding steatosis, SSp.PLUS correlated better than Att.PLUS with CAP values: (r = −0.74) vs. (r = 0.45). The best SSp.PLUS cut-off value for predicting the presence of significant steatosis was 1524 m/s. The multivariate regression analysis showed that Vi.PLUS values were associated with BMI and LSM by 2D-SWE.PLUS. In conclusion, MPUS was useful for assessing fibrosis, steatosis, and inflammation in a single examination in patients with NAFLD.

Direct Comparison of US and MR Elastography for Staging Liver Fibrosis in Patients With Nonalcoholic Fatty Liver Disease

As alternatives to the expensive liver biopsy for assessing liver fibrosis stage in patients with nonalcoholic fatty liver disease (NAFLD), we directly compared the diagnostic abilities of magnetic resonance elastography (MRE), vibration-controlled transient elastography (VCTE), and two-dimensional shear wave elastography (2D-SWE). Overall, 231 patients with biopsy-proven NAFLD were included. Intra- and inter-observer reproducibility was analyzed using intraclass correlation coefficient in a sub-group of 70 participants, in whom liver stiffness measurement (LSM) was performed by an elastography expert and an ultrasound expert who was an elastography trainee on the same day. Valid LSMs were obtained for 227, 220, 204, and 201 patients using MRE, VCTE, 2D-SWE, and all three modalities combined, respectively. Although the area under the curve did not differ between the modalities for detecting stage ≥1, ≥2, and ≥3 liver fibrosis, it was higher for MRE than VCTE and 2D-SWE for stage 4. Sex was a significant predictor of discordance between VCTE and liver fibrosis stage. Skin-capsule distance and the ratio of the interquartile range of liver stiffness to the median were significantly associated with discordance between 2D-SWE and liver fibrosis stage. However, no factors were associated with discordance between MRE and liver fibrosis stage. Intra- and inter-observer reproducibility in detecting liver fibrosis was higher for MRE than VCTE and 2D-SWE. MRE, VCTE, and 2D-SWE demonstrated excellent diagnostic accuracy in detecting liver fibrosis in patients with NAFLD. MRE demonstrated the highest diagnostic accuracy for stage 4 detection and intra- and inter-observer reproducibility. UMIN Clinical Trials Registry No. UMIN000031491.

Serial Transient Elastography Examinations to Monitor Patients With Type 2 Diabetes: A Prospective Cohort Study

Type 2 diabetes is an important risk factor for nonalcoholic fatty liver disease (NAFLD) and advanced fibrosis. Current international guidelines recommend the use of noninvasive tests as initial assessments for NAFLD, but the role of noninvasive tests as monitoring tools has not been established. We aimed to study the role of transient elastography as a monitoring tool in patients with type 2 diabetes. We recruited patients with type 2 diabetes without viral hepatitis or excessive alcohol intake from a complication screening facility in Hong Kong in 2013-2014 and repeated the assessments in 2016-2018. The primary endpoint was an increase of liver stiffness measurement (LSM) to ≥10kPa. The secondary endpoint was the change in the controlled attenuation parameter (CAP). A total of 611 patients with type 2 diabetes and a valid LSM (mean age, 57.7±10.9years; 342 men [56.0%]) were included in this study (568 also had a valid CAP). Overall, there was moderate correlation between the baseline and follow-up LSM (r=0.689, P<0.001). Among 487 patients with a baseline LSM <10kPa, 21 (4.3%) had a follow-up LSM ≥10kPa. Baseline body mass index, alanine aminotransferase (ALT), and ∆ALT were independent factors associated with LSM increase. Among 124 patients with a baseline LSM ≥10kPa, 70 (56.5%) had a follow-up LSM <10kPa. Among 198 patients with a CAP <248dB/m at baseline, 103 (52.0%) had a CAP increased to ≥248dB/m. The prevalence and incidence of NAFLD in patients with type 2 diabetes are high. Although advanced fibrosis is common in this population, few patients progress to advanced fibrosis in 3years. Future studies should define the optimal surveillance interval in patients with diabetes.

Applicability and Results of Liver Stiffness Measurement and Controlled Attenuation Parameter Using XL Probe for Metabolic-Associated Fatty Liver Disease in Candidates to Bariatric Surgery. A Single-Center Observational Study.

Patients with morbid obesity are at high risk of liver fibrosis due to metabolic-associated fatty liver disease. Data on liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) by vibration-controlled transient elastography (VCTE, FibroScan®) XL probe for liver fibrosis and steatosis assessment in morbid obesity are needed. LSM and CAP were measured in candidates to bariatric surgery at a single center during 12months. In patients who underwent an intraoperative liver biopsy, we compared LSM and CAP with histology findings. Comorbidities, body mass index, type of surgery, and infections after surgery were collected and analyzed. Of the eighty-three patients assessed by XL probe, 49 (59%; female in 63%, BMI 42.6 ± 5.1kg/m2) had a valid LSM and CAP measurement. LSM was 7.0 ± 3.9kPa and CAP 329 ± 57dB/m. In the 14 patients undergoing intraoperative liver biopsy, all had steatosis (severe in 50%), 6 (43%) had NASH (NAS ≥ 5), and 4 (29%) showed significant or bridging fibrosis. LSM accurately discriminated between patients with and without significant or severe fibrosis (AUROC 0.833) and CAP well-identified patients with or without ≥S2 steatosis (AUROC 0.896). Nine of 49 patients (18%) tested positive for significant/severe fibrosis by LSM (cut-off 8.9kPa). Applicability of LSM and CAP by XL probe in patients candidate to bariatric surgery was moderate. However, when technically successful, their reliability to diagnose severe steatosis and fibrosis related to MAFLD was good.

Quantification of Steatosis and Fibrosis using a new system implemented in an ultrasound machine.

The study compared the usefulness of 2D-SWE and attenuation measurements obtained using Aplio i800 from Canon together with Transient Elastography (TE) and the Controlled Attenuation Parameter (CAP) as the reference method. We included 112 consecutive adults with reliable LS measurements, 44 healthy subjects and 68 subjects with chronic hepatopathies in whom liver stiffness (LS) and steatosis were evaluated in the same session employing two elastography techniques: Transient Elastography (TE) with Controlled Attenuation Parameter (CAP) implemented on the FibroScan® 530 Compact system and Two Dimensional Shear Wave Elastography (2D-SWE) with Attenuation Imaging (ATI) installed on the Aplio i800 series ultrasound system. Reliable measurements were defined as the median value of 10, respectively 5 valid LS measurements for TE and 2D-SWE, with an interquartile range interval/median ratio (IQR/M) <30%. A very strong positive correlation was found between LS values obtained by TE and 2D-SWE: r=0.88, p<0.0001 and between the attenuation coefficients of steatosis obtained by CAP and ATI, r=0.81, p<0.0001. The best cut-off values by 2DSWE for predicting different stages of liver fibrosis were: for F≥2 - 7.9 kPa and F=4 - 11.7 kPa. Regarding steatosis, the best ATI cut-off values were: for S≥1 - 0.79 dB/cm/mHz and for S3 - 0.86 dB/cm/mHz. 2D-SWE and ATI measurements with the new system strongly correlated with TE and CAP results.

Nonfasted Liver Stiffness Correlates with Liver Disease Parameters and Portal Hypertension in Pediatric Cholestatic Liver Disease.

Elastographic measurement of liver stiffness is of growing importance in the assessment of liver disease. Pediatric experiences with this technique are primarily single center and limited in scope. The Childhood Liver Disease Research Network provided a unique opportunity to assess elastography in a well‐characterized multi‐institutional cohort. Children with biliary atresia (BA), alpha‐1 antitrypsin deficiency (A1ATD), or Alagille syndrome (ALGS) followed in a prospective longitudinal network study were eligible for enrollment in a prospective investigation of transient elastography (FibroScan). Studies were performed in participants who were nonfasted and nonsedated. Liver stiffness measurements (LSMs) were correlated with standard clinical and biochemical parameters of liver disease along with a research definition of clinically evident portal hypertension (CEPH) graded as absent, possible, or definite. Between November 2016 and August 2019, 550 participants with a mean age of 8.8 years were enrolled, 458 of whom had valid LSMs (BA, n = 254; A1ATD, n = 104; ALGS, n = 100). Invalid scans were more common in participants <2 years old. There was a positive correlation between LSM and total bilirubin, international normalized ratio (INR), aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma‐glutamyl transpeptidase (GGT), GGT to platelet ratio (GPR), pediatric end‐stage liver disease score, AST to platelet ratio index, and spleen size, and a negative correlation with albumin and platelet count in BA, with similar correlations for A1ATD (except AST, ALT, and albumin) and ALGS (except for INR, GGT, GPR, and ALT). Possible or definite CEPH was more common in BA compared to ALGS and A1ATD. LSM was greater in definite versus absent CEPH in all three diseases. Disease‐specific clinical and biochemical characteristics of the different CEPH grades were observed. Conclusion: It is feasible to obtain LSMs in children, especially over the age of 2 years. LSM correlates with liver parameters and portal hypertension, although disease‐specific patterns exist.

Absence of colon as the predominant risk factor for liver fibrosis in adults requiring home parenteral nutrition

Liver fibrosis is a well-known complication of long-term use of parenteral nutrition in patients with intestinal failure associated to the nutrient composition in parenteral nutrition. This study investigates the prevalence of significant liver fibrosis and identifies risk factors for liver fibrosis. This was a retrospective study of 35 parenteral nutrition-dependent patients with intestinal failure and 54 patients with intestinal insufficiency and oral nutrition only with a valid liver stiffness measurement obtained with transient elastography from November 2016 to August 2018. Clinical and demographic parameters including age, fat mass index and fat-free mass index, intact colon or colectomy, and nutritional management were analyzed for their association with liver stiffness. A prevalence for liver fibrosis (liver stiffness >7.0 kPa) was established at 37.1% in parenteral nutrition-dependent patients and at 22.2% in patients on oral nutrition. Several factors were significantly and independently associated with liver fibrosis including lipids in home parenteral nutrition (OR 10.66, p= 0.010) and colectomies (OR 3.24, p= 0.036). More than a third of patients receiving home parenteral nutrition have liver fibrosis. Several risk factors were demonstrated such as the amount of lipids and performed colectomies despite current international guidelines for lipids are followed. Our findings emphasize suggest a new perspective to prevent significant hepatic complications: colectomies.

The Complementary Value of Magnetic Resonance Imaging and Vibration-Controlled Transient Elastography for Risk Stratification in Primary Sclerosing Cholangitis

Magnetic resonance (MR) risk scores and liver stiffness (LS) have individually been shown to predict clinical outcomes in primary sclerosing cholangitis (PSC). The aim of this study was to assess their complementary prognostic value. Patients with PSC from 3 European centers with a 3-dimensional MR cholangiography available for central reviewing and a valid LS measurement assessed by vibration-controlled transient elastography by FibroScan performed within a 6-month interval were included in a longitudinal retrospective study. The MR score (Anali) without gadolinium (Gd) was calculated according to the formula: (1 × dilatation of intrahepatic bile ducts) + (2 × dysmorphy) + (1 × portal hypertension). The primary end point was survival without liver transplantation or cirrhosis decompensation. The prognostic values of LS and Anali score without Gd were assessed using Cox proportional hazard models. One hundred sixty-two patients were included. Over a total follow-up of 753 patient-years, 40 patients experienced an adverse outcome (4 liver transplantations, 6 liver-related deaths, and 30 cirrhosis decompensations). LS and Anali score without Gd were significantly correlated (ρ = 0.51, P < 0.001) and were independently associated with the occurrence of an adverse outcome. Optimal prognostic thresholds were 10.5 kPa for LS and 2 for the Anali score without Gd. Hazard ratios (95% confidence interval) were 2.07 (1.06-4.06) and 3.78 (1.67-8.59), respectively. The use in combination of these 2 thresholds allowed us to separate patients into low-, medium-, and high-risk groups for developing adverse outcomes. The 5-year cumulative rates of adverse outcome in these 3 groups were 8%, 16%, and 38% (P < 0.001), respectively. The combined use of MRI and vibration-controlled transient elastography permits easy risk stratification of patients with PSC.

Noninvasive assessment of liver fibrosis in pediatric intestinal failure patients using liver stiffness measurement by Vibration-Controlled Transient Elastography

PurposeThe purpose of this study was to evaluate the diagnostic utility of noninvasive Vibration-Controlled Transient Elastography (VCTE) for assessing liver fibrosis in pediatric intestinal failure (PIF) patients. MethodsData from children with severe intestinal failure (≥90 days parenteral nutrition dependence) who underwent liver stiffness measurement (LSM), as measured by VCTE, at our institution between December 2015 and March 2018 were reviewed. LSM was compared to METAVIR fibrosis score (F0-F4) on liver biopsy performed within 1 year of VCTE. ResultsSeventy children underwent 75 LSM. Sixty-three patients (38% female) had at least one valid LSM, and 63% had a history of cholestasis (direct bilirubin ≥2 mg/dL). Median (IQR) age at first valid LSM was 4.5 years (2.6, 8.7). Sixteen patients had a liver biopsy. LSM differentiated between METAVIR F0-F1 (n = 6) and F2-F4 (n = 10) with an area under the receiver operating characteristic (AUROC) curve of 0.883 (95% CI: 0.686–0.999). The optimal cut-point derived to predict F2-F4 was an LSM ≥6 kPa (sensitivity 80%, specificity 100%). ConclusionLSM as determined by VCTE can distinguish mild (F0-F1) from moderate/severe (F2-F4) liver fibrosis in PIF. VCTE could allow for serial noninvasive monitoring of liver injury, potentially facilitating timely modifications to hepatoprotective management.Type of Study: Study of Diagnostic Test.Level of Evidence: II.

The prevalence of liver fibrosis stages assessed by Transient Elastography: a single center study

Objective The aim of the study was to highlight the prevalence of liver fibrosis stages assessed by means of transient elastography (TE) in large cohort of patients in a single study centre. Material & Method 22400 liver stiffness (LS) assessments by mean of TE have been performed in our Department during an 11 years period (2007-2018). The study included patients with chronic liver diseases of various etiology. In each patient, 10 valid LS measurements were obtained either with M probe or with XL probe. If no valid LS measurements could be obtained, the evaluation was declared as failure. Reliable LSM were defined as median value of 10 measurements with Interquartile range/median (IQR/M) ≤ 30%, and a Success Rate (SR) ≥ 60%. To discriminate between LS stages by TE we used the following cut-offs (1): F2 - 7 kPa; F3 - 9.5 kPa and F4 - 12 kPa. Results The feasibility in our cohort was 90.1%, 2238 of 22400 measurements (9.9%) were failed or unreliable. Based on TE cut-off values, the severity of liver fibrosis in our group was as follows: F Conclusion Transient elastography had a feasibility of 90.1% in this large cohort, almost half of the patients (48.5%) having at most mild fibrosis, and approximately one quarter having cirrhosis (27.4%).

How many HCV cirrhotic patients go below cirrhotic cut-off values in transient elastography after direct acting agents treatment?

Introduction Liver stiffness (LS) measurements by Transient Elastography (TE) has been accepted as a tool for fibrosis assessment. The aim of the study was to evaluate what happens with liver stiffness values after DAA (Direct-acting antivirals) therapy, in patients with compensated HCV cirrhosis, who had sustained virologic response (SVR) and to highlight in how many LS values become lower than the accepted cut-off for cirrhosis. Material & Method A number of 167 patients with compensated HCV cirrhosis who had LS > 12 kPa at baseline, underwent a 12 weeks DAA therapy (Viekirax/Exviera) and had SVR. 56 of them were followed up by TE 24 weeks after EOT (end of treatment) and also 48 weeks after EOT (SVR 48). A subgroup of 28 patients were followed up 96 weeks after EOT (SVR 96). LS values were assessed by means of TE (FibroScan, Echosens) at the start of treatment (ST), at SVR 12 (12 weeks from EOT), SVR 24, SVR 48 and SVR 96, respectively. In each session, 10 valid liver stiffness measurements (LSM) were obtained and reliable LSM were defined as median value of 10 measurements with Interquartile range/median (IQR/M) ≤ 30%. Results LS mean values at SVR12 were significantly lower as compared to ST (16.6 ± 6.87 kPa vs 21.3 ± 8.8, p = 0.002). As compared to SVR12, at SVR24 the mean LS values remained stable (16.6 ± 6.87 vs 16.9 ± 6.87 kPa, p = 0.81) and at SVR48 the values continued to decrease, but without statistical significance (14.6 ± 5.3 vs 16.6 ± 6.87 kPa, p = 0.08). LS was Conclusion In compensated HCV cirrhotic patients, the mean LS values significantly decreased at SVR12, remained stable at SVR24 and decreased at SVR48; 14 % patients had LS values