Diagnostic role of transient elastography in patients with autoimmune liver diseases:A systematic review and meta-analysis

BACKGROUND Noninvasive methods have been developed to detect fibrosis in many liver diseases due to the limits of liver biopsy.However,previous studies have focused primarily on chronic viral hepatitis and nonalcoholic fatty liver disease.The diagnostic value of transient elastography for autoimmune liver diseases(AILDs)is worth studying.AIM To compare the diagnostic accuracy of imaging techniques with serum biomarkers of fibrosis in AILD.METHODS The PubMed,Cochrane Library and EMBASE databases were searched.Studies evaluating the efficacy of noninvasive methods in the diagnosis of AILDs[autoimmune hepatitis(AIH),primary biliary cholangitis(PBC)and primary sclerosing cholangitis(PSC)]were included.The summary area under the receiver operating characteristic curve(AUROC),diagnostic odds ratio,sensitivity and specificity were used to assess the accuracy of these noninvasive methods for staging fibrosis.RESULTS A total of 60 articles were included in this study,and the number of patients with AIH,PBC and PSC was 1594,3126 and 501,respectively.The summary AUROC of transient elastography in the diagnosis of significant fibrosis,advanced fibrosis and cirrhosis in patients with AIH were 0.84,0.88 and 0.90,respectively,while those in patients with PBC were 0.93,0.93 and 0.91,respectively.The AUROC of cirrhosis for patients with PSC was 0.95.However,other noninvasive indices(aspartate aminotransferase to platelet ratio index,aspartate aminotransferase/alanine aminotransferase ratio,fibrosis-4 index)had corresponding AUROCs less than 0.80.CONCLUSION Transient elastography exerts better diagnostic accuracy in AILD patients,especially in PBC patients.The appropriate cutoff values for staging advanced fibrosis and cirrhosis ranged from 9.6 to 10.7 and 14.4 to 16.9 KPa for PBC patients.

To scan or not to scan:Use of transient elastography in an integrated health system

BACKGROUND Non-invasive tests,such as Fibrosis-4 index and transient elastography(com-monly FibroScan),are utilized in clinical pathways to risk stratify and diagnose non-alcoholic fatty liver disease(NAFLD).In 2018,a clinical decision support tool(CDST)was implemented to guide primary care providers(PCPs)on use of FibroScan for NAFLD.AIM To analyze how this CDST impacted health care utilization and patient outcomes.METHODS We performed a retrospective review of adults who had FibroScan for NAFLD indication from January 2015 to December 2017(pre-CDST)or January 2018 to December 2020(post-CDST).Outcomes included FibroScan result,laboratory tests,imaging studies,specialty referral,patient morbidity and mortality.RESULTS We identified 958 patients who had FibroScan,115 before and 843 after the CDST was implemented.The percentage of FibroScans ordered by PCPs increased from 33%to 67.1%.The percentage of patients diagnosed with early F1 fibrosis,on a scale from F0 to F4,increased from 7.8%to 14.2%.Those diagnosed with ad-vanced F4 fibrosis decreased from 28.7%to 16.5%.There were fewer laboratory tests,imaging studies and biopsy after the CDST was implemented.Though there were more specialty referrals placed after the CDST was implemented,multivariate analysis revealed that healthcare utilization aligned with fibrosis score,whereby patients with more advanced disease had more referrals.Very few patients were hospitalized or died.CONCLUSION This CDST empowered PCPs to diagnose and manage patients with NAFLD with appropriate allocation of care towards patients with more advanced disease.

The diagnostic value of transient elastography combined with serum SAA and IL-6 in the degree of hepatitis B liver fibrosis

Objective:To investigat the diagnostic value of transient elastography combined with serum amyloid A and interleukin-6 in the degree of hepatitis B liver fibrosis.Methods:A total of 334 patients with chronic HBV infection that were admitted to the Department of Infectious Diseases of the First Affiliated Hospital of Hainan Medical College from January 2020 to May 2022 with informed consent and underwent liver biopsy puncture were selected.According to the pathological results,they were divided into no obvious fibrosis group,obvious fibrosis group and liver cirrhosis group.Comparison of liver stiffness measurement(LSM),serum amyloid A(SAA0,IL-6 levels between different groups.This study drawed was conducted draw the receiver operating characteristic(ROC)curve of each index to diagnose significant liver fibrosis and liver cirrhosis,and compared the area under the ROC curve(AUC)and diagnostic efficacy of each non-invasive fibrosis diagnostic model.The diagnostic performance of the combined assay was superior to that of APRI and FIB-4 In different degrees of liver fibrosis.Results:According to the degree of liver fibrosis,the levels of SAA,IL-6,and LSM in the no significant fibrosis group(n=140),the significant fibrosis group(n=134),and the cirrhosis group(n=60)were statistically significant difference(All P<0.001).SAA,IL-6 and LSM were significantly correlated with the degree of liver fibrosis(rs=0.456,rs=0.482,rs=0.602,All P<0.001).The AUC of SAA and IL-6 for the diagnosis of significant fibrosis in hepatitis B were 0.738 and 0.809,respectively.And the AUC for the diagnosis of liver cirrhosis were 0.813 and 0.823,respectively.The AUC for the combined diagnosis of significant fibrosis and cirrhosis were 0.930 and 0.964,respectively.The diagnostic performance of the combined assay was superior to that of APRI and FIB-4 in different degrees of liver fibrosis(All P<0.001).Conclusion:LSM combined with serum SAA and IL-6 has great diagnostic value for different degrees of hepatitis B liver fibrosis.

Transient elastography(FibroScan)in critical care:Applications and limitations

FibroScan®is a non-invasive device that assesses the‘hardness’(or stiffness)of the liver via the technique of transient elastography.Because fibrous tissue is harder than normal liver,the degree of hepatic fibrosis can be inferred from the liver hardness.This technique is increasingly being employed to diagnose liver fibrosis,even in critically ill patients.It is now being used not only for diagnosis and staging of liver cirrhosis,but also for outcome prognostication.However,the presence of several confounding factors,especially in critically ill patients,may make interpretation of these results unreliable.Through this review we aim to describe the indications and pitfalls of employing FibroScan in patients admitted to intensive care units.

Transient elastography improves detection of liver cirrhosis compared to routine screening tests

AIM:To investigate the diagnostic significance oftransient elastography(TE) in a daily routine clinical setting in comparison to clinical signs,laboratory parameters and ultrasound.METHODS:TE,ultrasound,laboratory parameters and cutaneous liver signs were assessed in 291 consecutive patients with chronic liver disease of various aetiologies who underwent liver biopsy in daily routine.RESULTS:Sensitivity of TE for the detection of liver cirrhosis was 90.4%,compared to 80.1% for ultrasound,58.0% for platelet count and 45.1% for cutaneous liver signs(P < 0.0001 for comparisons with histology).AUROC for TE was 0.760(95%CI:0.694-0.825).Combination of TE with ultrasound increased sensitivity to 96.1% and AUROC to 0.825(95%CI:0.768-0.882).TE correlated with laboratory parameters of cirrhosis progression like albumin(r =-0.43),prothrombin time(r =-0.44),and bilirubin(r = 0.34; P < 0.001 for each).Particularly,in patients with Child Pugh score A or normal platelet count TE improved sensitivity for the detection of liver cirrhosis compared to ultrasound by 14.1%(P < 0.04) and 16.3%(P < 0.02),respectively.CONCLUSION:Transient elastography is superior to routine diagnostic tests allowing detection of liver cirrhosis in additional 10%-16% of patients with chronic liver disease that would have been missed by clinical examinations.

Transient elastography: A non-invasive tool for assessing liver fibrosis in HIV/HCV patients

AIM: To assess the prevalence of advanced liver fibrosis (ALF) in human immunodeficiency virus (HIV), hepatitis C virus (HCV) and HIV/HCV patients using transient elastography, and to identify factors associated with ALF. METHODS: Between September 2008 and October 2009, 71 HIV mono-infected, 57 HIV/HCV co-infected and 53 HCV mono-infected patients on regular follow-up at our Center were enrolled in this study. Alcohol intake, the main parameters of liver function, presence of HCV-RNA, HIV-RNA, duration of highly active anti-retroviraltherapy (HAART) and CD4 cell count were recorded. ALF was defined as liver stiffness (LS) ≥ 9.5 kPa. To estimate liver fibrosis (LF) a further 2 reliable biochemical scores, aspartate aminotransferase platelet ratio index (APRI) and FIB-4, were also used. RESULTS: LS values of co-infected patients were higher than in either HIV or HCV mono-infected patients (χ 2M H = 4, P < 0.04). In fact, LS ≥ 9.5 was significantly higher in co-infected than in HIV and HCV mono-infected pa-tients (χ 2 = 5, P < 0.03). Also APRI and the FIB-4 index showed more LF in co-infected than in HIV mono-infect-ed patients (P < 0.0001), but not in HCV mono-infected patients. In HIV?HCV co-infected patients, the extent of LS was significantly associated with alcohol intake (P < 0.04) and lower CD4+ cell count (P < 0.02). In HCV pa-tients, LS was correlated with alcohol intake (P < 0.001) and cholesterol levels (P < 0.03). Body mass index, dia-betes, HCV-and HIV-viremia were not significantly cor-related with LS. In addition, 20% of co-infected patients had virologically unsuccessful HAART; in 50% compliance was low, CD4+ levels were < 400 cells/mm 3 and LS was > 9.5 kPa. There was no significant correlation between extent of LF and HAART exposure or duration of HAART exposure, in particular with specific dideoxynucleoside analogues. CONCLUSION: ALF was more frequent in co-infected than mono-infected patients. This result correlated with lower CD4 levels. Protective immunological effects of HAART on LF progression outweigh its hepatotoxic effects.

Shear wave elastography may be sensitive and more precise than transient elastography in predicting significant fibrosis

BACKGROUND Noninvasive measurements including transient elastography(TE)and twodimensional shear wave elastography(SWE)have been used clinically instead of liver biopsy for regular assessment of liver fibrosis in chronic hepatitis B(CHB)patients.AIM To investigate the diagnostic efficiency of SWE compared to TE by assessing independent influencing factors and performance for diagnosing significant fibrosis based on our cohort of treatment-naive CHB patients.METHODS Fifty-four treatment-naive CHB patients who underwent liver biopsy to determine whether to initiate antiviral therapy were enrolled.SWE,TE,serum tests and liver biopsy were performed for all participants.The fibrosis-4 and aspartate aminotransferase to platelet ratio index scores were also calculated.Potential independent influencing factors on SWE and TE values were analyzed.Based on liver pathology results,the agreement and correlation were determined,and a comparison of the two methods was performed.RESULTS There were 27 cases(50%)of mild fibrosis(F0-F2)and 27(50%)cases of significant fibrosis(F3-F6);fibrosis was assessed with the Ishak scoring system.Multivariate linear regression analyses revealed that the fibrosis stage was the only factor that affected the SWE values(P<0.001),whereas the total bilirubin level(P=0.013)and fibrosis stage(P=0.037)were independent factors that affected TE values.Orthogonal partial least squares discriminant analysis showed that the number of independent factors(VIP>1)was higher for TE than SWE.Bland-Altman analysis showed satisfactory agreement between liver stiffness measurements(LSMs)of SWE and TE.Both SWE and TE could significantly discriminate significant fibrosis from mild fibrosis(P<0.001).SWE exhibited a higher correlation with LSMs of liver fibrosis than TE(r=0.65 and 0.50,P<0.001).The diagnostic performance of SWE was better than that of TE for significant fibrosis(F>2).The areas under the receiver operating characteristic curves of SWE and TE were 0.786 and 0.714,respectively.The optimal LSM cutoff values of SWE and TE were 9.05 kPa and 8.15 kPa,respectively.CONCLUSION Compared to the TE value,the SWE value was less affected by other factors.SWE may be more sensitive and precise than TE in predicting significant fibrosis(>F2)in CHB patients.

Longitudinal assessment of liver stiffness by transient elastography for chronic hepatitis C patients

BACKGROUND Liver fibrosis is a common pathway of liver injury and is a feature of most chronic liver diseases.Fibrosis progression varies markedly in patients with hepatitis C virus(HCV).Liver stiffness has been recommended as a parameter of fibrosis progression/regression in patients with HCV.AIM To investigate changes in liver stiffness measured by transient elastography(TE)in a large,racially diverse cohort of United States patients with chronic hepatitis C(CHC).METHODS We evaluated the differences in liver stiffness between patients treated with direct-acting antiviral(DAA)therapy and untreated patients.Patients had≥2 TE measurements and no prior DAA exposure.We used linear regression to measure the change in liver stiffness between first and last TE in response to treatment,controlling for age,sex,race,diabetes,smoking status,human immunodeficiency virus status,baseline alanine aminotransferase,and baseline liver stiffness.Separate regression models analyzed the change in liver stiffness as measured by kPa,stratified by cirrhosis status.RESULTS Of 813 patients,419(52%)initiated DAA treatment.Baseline liver stiffness was 12 kPa in 127(16%).Median time between first and last TE was 11.7 and 12.7 mo among treated and untreated patients,respectively.There was no significant change in liver stiffness observed over time in either the group initiating DAA treatment(0.016 kPa/month;CI:-0.051,0.084)or in the untreated group(0.001 kPa/mo;CI:-0.090,0.092),controlling for covariates.A higher baseline kPa score was independently associated with decreased liver stiffness.CONCLUSION DAA treatment was not associated with a differential change in liver stiffness over time in patients with CHC compared to untreated patients.

Autoimmune Hepatitis Prevalence among Patients from Saudi Arabia with Chronic Liver Disease Referred for Transient Elastography

Background and study aim: Autoimmune hepatitis (AIH) is a chronic liver disease that can lead to progressive liver damage. The prevalence of AIH among the general population and among chronic liver disease (CLD) patients is variable worldwide. Currently, no published data on the prevalence of AIH among Saudi or among liver disease patients from the region. In this study, we aimed to assess the prevalence of AIH among CLD patients who were referred for transient elastography (FibroScan) in Saudi Arabia. Patients and methods: A retrospective study was conducted among CLD patients who had a transient elastography (FibroScan) during the 3-year study period. We obtained demographic data and test results for serum alanine aminotransferase (ALT), bilirubin, hemoglobin (Hgb), platelets, and international normalized ratio (INR) from all patients. We compared the results of the AIH patients to those of the non-AIH patients with CLD. In addition, for AIH patients, we measured serum immunoglobulin G (IgG), antinuclear antibody (ANA), smooth muscle antibody (SMA) and ALT at 2 - 6 weeks and at 3 - 4 months. Results: We included 494 patients, who were predominantly female (271 (60%)) and Saudi (299 (60.5%)). Thirty patients (6.1%) had AIH, which represented the 4th most common liver disease. Compared to non-AIH patients, AIH patients were younger (mean ages 49.9 years, SD 14.22 years, and 40.4 years, SD 13.94 years, respectively, P = 0.001). Patients with AIH had significantly lower Hgb and platelets (P = 0.008 for both) and higher ALT, bilirubin and INR (P = 0.05, 0.047 and 0.019, respectively). More than 50% of the AIH patients had cirrhosis. Older age was not associated with advanced disease stage among the AIH patients (P < 0.001). AIH represents the 4th most common cause of CLD in patients referred for transient elastography in Saudi Arabia. AIH tends to be severe in patients at a young age, with a marked biochemical response to steroids and azathioprine treatment.

Clinical Application of Vibration Controlled Transient Elastography in Patients with Chronic Hepatitis B

Evaluation of the extent and progression of liver fibrosis and cirrhosis is of critical importance in the management and prognosis of patients with chronic hepatitis B.Due to the limitation of liver biopsy,non-invasive methods,especially liver stiffness measurement (LSM) by vibration controlled transient elastography,have been developed and widely applied for liver fibrosis assessment.LSM aims to reduce,but not to substitute,the need for liver biopsy for fibrosis/cirrhosis diagnosis.While LSM may have potential utility in monitoring treatment response,its applications in prediction of liver complications in terms of portal hypertension and esophageal varices,as well as disease prognosis,have been gradually validated.Here,we review the latest clinical applications of LSM in patients with chronic hepatitis B.

Clinical Application of Transient Elastography in the Diagnosis of Liver Fibrosis:an Expert Panel Review and Opinion

Liver fibrosis evaluation is pivotal for treatment decisions and prognosis assessment in patients with chronic liver disease. Liver transient elastography (TE) is a newly developed non-invasive technique for diagnosis of liver fibrosis. It can assess the state of liver fibrosis by liver stiffness measurements, and offers better performance for the diagnosis of liver cirrhosis than serum biological markers. It has now been approved for clinical use in China. The aim of this review is to provide a guide for clinicians to apply this technique appropriately. The recommendations are made under the auspices of China Foundation for Hepatitis Prevention and Control, and have been prepared by a panel experts, who have reviewed and summarized the clinical studies on TE in order to develop these recommendations.

Practical Use of Transient Elastography in Screening for Nonalcoholic Steatohepatitis in a Japanese Population

Background and Aims:Fatty infiltration of liver may induce insulin resistance(IR),and a proportion of patients with nonalcoholic fatty liver disease(NAFLD)is diagnosed with nonalcoholic steatohepatitis.Transient elastography is gaining popularity as a means of non-invasively determining both liver stiffness(fibrosis level)and degree of fatty infiltration,expressed as controlled attenuation parameter(CAP)value.Methods:The aims of this study were to investigate the association between IR and level of fatty liver,and to identify the group at a greater risk of nonalcoholic steatohepatitis using transient elastography and other noninvasive fibrosis markers.A total of 169 patients without chronic hepatitis B and C were analyzed.Results:The CAP value was significantly associated with IR(HOMA-IR≥2.5;AUROC=0.81),and the optimal cut-off to discriminate IR was 264 dB/m.The liver stiffness measurement and aspartate aminotransferase-to-platelet ratio index values were significantly higher for CAP≥264 than in CAP<264.The 9 patients among the overall 169 patients(5.3%)and among the 102 NAFLD patients(8.8%)who showed≥264 dB and≥7.0 kPa in transient elastography could represent good candidates for liver biopsy.Conclusions:Evaluation of NAFLD based on CAP values was useful in diagnosing IR.About 9%of NAFLD patients in a Japanese outpatient clinic with a few metabolic complications might be considered good candidates for liver biopsy to confirm nonalcoholic steatohepatitis.

Ultrasonic elastography in clinical quantitative assessment of fatty liver

AIM: To investigate the clinical application of ultrasonic elastography in quantitative assessment of fatty liver grading. METHODS: A total of 105 patients with fatty liver were divided into mild group (n = 46), moderate group (n = 39), and severe group (n = 20). Forty-five healthy individuals served as a normal control group. All patients who underwent routine ultrasound scan and further ultrasonic elastography were evaluated accordingly to the evaluation standards for ultrasonic elastography. The ratio of surface areas of blue region/total surface area in the desired region was measured. RESULTS: Ultrasonic elastography technique, in comparison to traditional ultrasound, had a rather high consistence in grading of fatty liver [κ value = (95.3%63.6%)/(1%-63.6%) = 0.87, P = 0.001]. The score of ultrasonic elastography increased with the severity of fatty liver with a sensitivity of 97.14% and a specificity of 91.11%. A significant difference was found in the ratio of surface areas of blue regions between different groups (P < 0.05).CONCLUSION: Ultrasonic elastography can be used in quantitative assessment of the severity of fatty liver.

Ultrasound-based elastography for the diagnosis of portal hypertension in cirrhotics

Progressive fibrosis is encountered in almost all chronicliver diseases. Its clinical signs are diagnostic in advanced cirrhosis, but compensated liver cirrhosis is harder to diagnose. Liver biopsy is still considered the reference method for staging the severity of fibrosis, but due to its drawbacks(inter and intra-observer variability, sampling errors, unequal distribution of fibrosis in the liver, and risk of complications and even death), non-invasive methods were developed to assess fibrosis(serologic and elastographic). Elastographic methods can be ultrasound-based or magnetic resonance imaging-based. All ultrasoundbased elastographic methods are valuable for the early diagnosis of cirrhosis, especially transient elastography(TE) and acoustic radiation force impulse(ARFI) elastography, which have similar sensitivities and specificities, although ARFI has better feasibility. TE is a promising method for predicting portal hypertension in cirrhotic patients, but it cannot replace upper digestive endoscopy. The diagnostic accuracy of using ARFI in the liver to predict portal hypertension in cirrhotic patients is debatable, with controversial results in published studies. The accuracy of ARFI elastography may be significantly increased if spleen stiffness is assessed, either alone or in combination with liver stiffness and other parameters. Two-dimensional shearwave elastography, the Elast PQ technique and strain elastography all need to be evaluated as predictors of portal hypertension.

Liver stiffness in pregnant women with intrahepatic cholestasis of pregnancy:A case control study

BACKGROUND Intrahepatic cholestasis of pregnancy(ICP)is a rare but severe complication for both the mother and the unborn child.The diagnosis is primarily based on elevated serum levels of bile acids.In a large ICP cohort,we here study in detail liver stiffness(LS)using transient elastography(TE),now widely used to noninvasively screen for liver cirrhosis within minutes.AIM To specifically explore LS in a large cohort of women with ICP compared to a control group with uncomplicated pregnancy.METHODS LS and hepatic steatosis marker controlled attenuation parameter(CAP)were measured in 100 pregnant women with ICP using TE(Fibroscan,Echosens,Paris,France)between 2010 and 2020.In 17 cases,LS could be measured postpartum.450 women before and 38 women after delivery with uncomplicated pregnancy served as control group.Routine laboratory,levels of bile acids and apoptosis marker caspase-cleaved cytokeratin 18 fragment(M30)were also measured.RESULTS Women with ICP had significantly elevated transaminases but normal gammaglutamyl transferase(GGT).Mean LS was significantly increased at 7.3±3.0 kPa compared to the control group at 6.2±2.3 kPa(P<0.0001).Postpartum LS decreased significantly in both groups but was still higher in ICP(5.8±1.7 kPa vs 4.2±0.9 kPa,P<0.0001),respectively.In ICP,LS was highly significantly correlated with levels of bile acids and M30 but not transaminases.No correlation was seen with GGT that even increased significantly after delivery in the ICP group.Bile acids were mostly correlated with the liver apoptosis marker M30,LS and levels of alanine aminotransferase,aspartate aminotransferase,and bilirubin.In multivariate analysis,LS remained the sole parameter that was independently associated with elevated bile acids.CONCLUSION In conclusion,LS is significantly elevated in ICP which is most likely due to toxic bile acid accumulation and hepatocyte apoptosis.In association with conventional laboratory markers,LS provides additional non-invasive information to rapidly identify women at risk for ICP.

Liver stiffness measurements in patients with HBV vs HCV chronic hepatitis:A comparative study

AIM:To assess the values of liver stiffness (LS) in pa-tients with hepatitis B virus (HBV) chronic hepatitis and to compare them with those in patients with hepatitis C virus (HCV) chronic hepatitis. METHODS: The study included 140 patients with HBV chronic hepatitis, and 317 patients with HCV chronic hepatitis, in which LS was measured (FibroScan-Echo-sens) and liver biopsy was performed in the same session (assessed according to the Metavir score). RESULTS:According to the Metavir score of the 140 HBV patients: one had F0,32 had F1, 67 had F2,33 had F3 and 7 had F4. Of the 317 HCV patients:5 had F0, 34 had F1, 146 had F2, 93 had F3 and 39 had F4. For the same severity of fibrosis, the mean values of LS in HBV patients were similar to those in HCV patients:F1,6.5±1.9 kPa vs 5.8±2.1 kPa (P=0.0889); F2,7.1±2 kPa vs 6.9±2.5 kPa (P = 0.3369); F3,9.1±3.6 kPa vs 9.9±5 kPa (P=0.7038); F4,19.8± 8.6 kPa vs 17.3±6.1 kPa (P=0.6574). A signif icant direct correlation between LS measurements and fibrosis was found in HCV patients (Spearman’s r=0.578, P<0.0001), as well as in HBV patients (r=0.408, P<0.0001). The correlation was more signif icant in HCV than in HBV patients (Fisher’s Z-test,Z= 2.210,P=0.0271). CONCLUSION:In our group, the mean values of LS in patients with chronic B hepatitis were similar to those in patients with chronic HCV hepatitis, for the same stage of f ibrosis. Also, LS was correlated with the severity of fibrosis both in HBV and HCV chronic hepatitis patients.

Prevalence and predictors of nonalcoholic fatty liver disease in South Asian women with polycystic ovary syndrome

BACKGROUND Polycystic ovary disease(PCOS)may be a risk factor for nonalcoholic fatty liver disease(NAFLD)due to common pathogenetic pathways,including insulin resistance and obesity.Both PCOS and NAFLD are more severe in South Asian women.Data on NAFLD in South Asian women with PCOS are lacking.AIM To investigate prevalence and predictors of NAFLD and liver fibrosis in PCOS patients from South Asia.METHODS We conducted an observational routine screening program by means of transient elastography(TE)with associated controlled attenuation parameter(CAP).NAFLD was defined as CAP≥288 decibels per meter.Significant liver fibrosis(stage 2 and higher out of 4)was defined as TE measurement≥8.0 kilopascals.Elevated alanine aminotransferase(ALT)was defined as ALT>24 IU/L,as per upper limit of normal reported in South Asian women.Biochemical hyperandrogenism was defined as free androgen index>5.Predictors of NAFLD were determined by logistic regression analysis.RESULTS 101 PCOS patients(mean age 36.3 years)with no significant alcohol intake or viral hepatitis were included.Prevalence of NAFLD and significant liver fibrosis was 39.6% and 6.9%,respectively.Elevated ALT was observed in 40%and 11.5%of patients with and without NAFLD,respectively.After adjusting for duration of PCOS and insulin resistance measured by homeostasis model for assessment of insulin resistance,independent predictors of NAFLD were higher body mass index[adjusted odds ratio(aOR)1.30,95% confidence interval(CI):1.13-1.52],hyperandrogenism(aOR:5.32,95%CI:1.56-18.17)and elevated ALT(aOR:3.54,95%CI:1.10-11.47).Lifetime cardiovascular risk was higher in patients with NAFLD compared to those without NAFLD(0.31±0.11 vs 0.26±0.13).CONCLUSION Despite their young age,NAFLD diagnosed by TE with CAP is a frequent comorbidity in South Asian women with PCOS and is strongly associated with higher body mass index and hyperandrogenism.Non-invasive screening strategies could help early diagnosis and initiation of interventions,including counselling on weight loss,cardiovascular risk stratification and linkage to hepatology care where appropriate.

Impact of continuous positive airway pressure therapy for nonalcoholic fatty liver disease in patients with obstructive sleep apnea

BACKGROUND Obstructive sleep apnea(OSA)has been suggested as an independent risk factor for nonalcoholic fatty liver disease(NAFLD),and continuous positive airway pressure(CPAP)is the first-line therapy for OSA.AIM To clarify the efficacy of effective CPAP therapy on NAFLD of OSA patients by serum markers and transient elastography(TE)using FibroScan®(Echosens,Paris,France).METHODS We prospectively enrolled 123 consecutive patients with OSA who met the indications for CPAP.Liver fibrosis and steatosis were assessed using TE.Before and after 6 mo of CPAP therapy,serum markers and TE were assessed for all patients.The mean usage rate of CPAP therapy for 6 mo was arbitrarily calculated in each patient and expressed as“mean compliance index”(m-CI).RESULTS In 50 OSA patients with NAFLD,both aspartate aminotransferase(AST)and alanine aminotransferase(ALT)levels were significantly decreased after 6 mo of CPAP therapy.Univariate analysis showed that decreased body weight(BW),decreased body mass index(BMI),decreased AST level,decreased hemoglobin A1c,and high m-CI were significantly related with improved ALT level.In multivariate regression model adjusted for quantities of BW change during 6 mo of CPAP therapy,high m-CI tended to improve ALT level(P=0.051).All 17 OSA patients with NAFLD,high m-CI and no BMI changes showed significant improvements in AST and ALT levels.Meanwhile,no significant changes in TE data or serum fibrosis markers were seen.CONCLUSION Some NAFLD could be associated with chronic intermittent hypoxia due to OSA independent of BW changes.In those cases,adequate reoxygenation from effective CPAP therapy may improve NAFLD.

Liver stiffness reversibly increases during pregnancy and independently predicts preeclampsia

AIM To study liver stiffness(LS) during pregnancy and its association with complications during pregnancy.METHODS In this observational, diagnostic study, 537 pregnant women were prospectively enrolled at the Department of Obstetrics and Gynecology, University hospital Heidelberg and Salem Medical Center. LS was measured using the Fibroscan device(Echosens, Paris) in all women and in 41 cases 24 h after delivery. Clinical and morphological data were recorded and abdominal ultrasound and standard laboratory tests were performed. No complications were observed in 475 women(controls) while preeclampsia and intrahepatic cholestasis of pregnancy(ICP) developed in 22 and 40 women, respectively.RESULTS In controls, LS increased significantly from initially 4.5 ± 1.2 kPa in the second trimester to 6.0 ± 2.3 kPa(P < 0.001) in the third trimester. In the third trimester, 41% of women had a LS higher than 6 kPa. Elevated LS in controls was significantly correlated with alkaline phosphatase, leukocytes, gestational age and an increase in body weight and body mass index(BMI). In women with pregnancy complications, LS was significantly higher as compared to controls(P < 0.0001). Moreover, in multivariate analysis, LS was an independent predictor for preeclampsia with an odds ratio of 2.05(1.27-3.31) and a cut-off value of 7.6 kPa. In contrast, ICP could not be predicted by LS. Finally, LS rapidly decreased in all women within 24 h after delivery from 7.2 ± 3.3 kPa down to 4.9 ± 2.2 kPa(P < 0.001).CONCLUSION During pregnancy, LS significantly and reversibly increases in the final trimester of pregnant women without complications. In women with preeclampsia, LS is significantly elevated and an independent noninvasive predictor.

Nationwide retrospective study of hepatitis B virological response and liver stiffness improvement in 465 patients on nucleos(t)ide analogue

BACKGROUND Hepatitis B virus(HBV)nucleos(t)ide analog(NA)therapy reduces liver disease but requires prolonged therapy to achieve hepatitis B surface antigen(HBsAg)loss.There is limited North American real-world data using non-invasive tools for fibrosis assessment and few have compared 1st generation NA or lamivudine(LAM)to tenofovir disoproxil fumarate(TDF).AIM To assess impact of NA on virological response and fibrosis regression using liver stiffness measurement(LSM)(i.e.,FibroScan®).METHODS Retrospective,observational cohort study from the Canadian HBV Network.Data collected included demographics,NA,HBV DNA,alanine aminotransferase(ALT),and LSM.Patients were HBV monoinfected patients,treatment naïve,and received 1 NA with minimum 1 year follow-up.RESULTS In 465(median 49 years,37%female,35%hepatitis B e antigen+at baseline,84%Asian,6%White,and 9%Black).Percentage of 64(n=299)received TDF and 166 were LAM-treated with similar median duration of 3.9 and 3.7 years,respectively.The mean baseline LSM was 11.2 kPa(TDF)vs 8.3 kPa(LAM)(P=0.003).At 5-year follow-up,the mean LSM was 7.0 kPa in TDF vs 6.7 kPa in LAM(P=0.83).There was a significant difference in fibrosis regression between groups(i.e.,mean-4.2 kPa change in TDF and-1.6 kPa in LAM,P<0.05).The last available data on treatment showed that all had normal ALT,but more TDF patients were virologically suppressed(<10 IU/mL)(n=170/190,89%)vs LAM-treated(n=35/58,60%)(P<0.05).None cleared HBsAg.CONCLUSION In this real-world North American study,approximately 5 years of NA achieves liver fibrosis regression rarely leads to HBsAg loss.