Management of nonalcoholic fatty liver disease:An evidence-based clinical practice review

AIM:To build a consensus among Chilean specialists on the appropriate management of patients with nonalcoholic fatty liver disease(NAFLD)in clinical practice.METHODS:NAFLD has now reached epidemic proportions worldwide.The optimal treatment for NAFLD has not been established due to a lack of evidence-based recommendations.An expert panel of members of the Chilean Gastroenterological Society and the Chilean Hepatology Association conducted a structured analysis of the current literature on NAFLD therapy.The quality of the evidence and the level of recommendations supporting each statement were assessed according to the recommendations of the United States Preventive Services Task Force.A modified three-round Delphi technique was used to reach a consensus among the experts.RESULTS:A group of thirteen experts was established.The survey included 17 open-ended questions that were distributed among the experts,who assessed the articles associated with each question.The levels of agreement achieved by the panel were 93.8%in the first round and 100%in the second and third rounds.The final recommendations support the indication of lifestyle changes,including diet and exercise,for all patients with NAFLD.Proven pharmacological therapies include only vitamin E and pioglitazone,which can be used in nondiabetic patients with biopsy-proven nonalcoholic steatohepatitis(the progressive form of NAFLD),although the long-term safety and efficacy of these therapies have not yet been established.CONCLUSION:Current NAFLD management is rapidly evolving,and new pathophysiology-based therapies are expected to be introduced in the near future.All NAFLD patients should be evaluated using a three-focused approach that considers the risks of liver disease,diabetes and cardiovascular events.

Therapeutic alternatives for the treatment of type 1 hepatorenal syndrome: A Delphi technique-based consensus

AIM To propose several alternatives treatment of type 1 hepatorenal syndrome(HRS-1) what is the most severe expression of circulatory dysfunction on patients with portal hypertension.METHODS A group of eleven gastroenterologists and nephrologists performed a structured analysis of available literature.Each expert was designated to review and answer a question.They generated draft statements for evaluation by all the experts.Additional input was obtained from medical community.In order to reach consensus,a modified three-round Delphi technique method was used.According to United States Preventive Services Task Force criteria,the quality of the evidence and level of recommendation supporting each statement was graded.RESULTS Nine questions were formulated.The available evidence was evaluated considering its quality,number of patients included in the studies and the consistency of its results.The generated questions were answered by the expert panel with a high level of agreement.Thus,a therapeutic algorithm was generated.The role of terlipressin and norepinephrine was confirmed as the pharmacologic treatment of choice.On the other hand the use of the combination of octreotide,midodrine and albumin without vasoconstrictors was discouraged.The role of several other options was also evaluated and the available evidence was explored and discussed.Liver transplantation is considered the definitive treatment for HRS-1.The present consensus is an important effort that intends to organize the available strategies based on the available evidence in the literature,the quality of the evidence and the benefits,adverse effects and availability of the therapeutic tools described.CONCLUSION Based on the available evidence the expert panel was able to discriminate the most appropriate therapeutic alternatives for the treatment of HRS-1.

GOECP/SEOR clinical recommendations for lung cancer radiotherapy during the COVID-19 pandemic

The coronavirus disease 2019 crisis has had a major and highly complex impact on the clinical practice of radiation oncology worldwide.Spain is one of the countries hardest hit by the virus,with devastating consequences.There is an urgent need to share experiences and offer guidance on decision-making with regard to the indications and standards for radiation therapy in the treatment of lung cancer.In the present article,the Oncological Group for the Study of Lung Cancer of the Spanish Society of Radiation Oncology reviews the literature and establishes a series of consensus-based recommendations for the treatment of patients with lung cancer in different clinical scenarios during the present pandemic.