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.

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.

Transient elastography(Fibro Scan~?) with controlled attenuation parameter in the assessment of liver steatosis and fibrosis in patients with nonalcoholic fatty liver disease- Where do we stand?

Non-alcoholic fatty liver disease(NAFLD) is the most common cause of chronic liver disease worldwide. Currently, the routinely used modalities are unable to adequately determine the levels of steatosis and fibrosis(laboratory tests and ultrasonography) or cannot be applied as a screening procedure(liver biopsy). Among the non-invasive tests, transient elastography(Fibro Scan?, TE) with controlled attenuation parameter(CAP) has demonstrated good accuracy in quantifying the levels of liver steatosis and fibrosis in patients with NAFLD, the factors associated with the diagnosis and NAFLD progression. The method is fast, reliable and reproducible, with good intra- and interobserver levels of agreement, thus allowing for population-wide screening and disease follow-up. The initial inability of the procedure to accurately determine fibrosis and steatosis in obese patients has been addressed with the development of the obese-specific XL probe. TE with CAP is a viable alternative to ultrasonography, both as an initial assessment and during follow-up of patients with NAFLD. Its ability to exclude patients with advanced fibrosis may be used to identify low-risk NAFLD patients in whom liver biopsy is not needed, therefore reducing the risk of complications and the financial costs.

Performance of transient elastography in assessing liver fibrosis in patients with autoimmune hepatitis-primary biliary cholangitis overlap syndrome

AIM To investigate the performance of transient elastography(TE) for diagnosis of fibrosis in patients with autoimmune hepatitis-primary biliary cholangitis(AIHPBC) overlap syndrome.METHODS A total of 70 patients with biopsy-proven AIH-PBC overlap syndrome were included. Spearman correlation test was used to analyze the correlation of liver stiffness measurement(LSM) and fibrosis stage. Independent samples Student's t-test or one-way analysis of variance was used to compare quantitative variables. Receiver operating characteristics(ROC) curve was used to calculate the optimal cut-off values of LSM for predicting individual fibrosis stages. A comparison on the diagnostic accuracy for severe fibrosis was made between LSM and other serological scores.RESULTS Patients with AIH-PBC overlap syndrome had higher median LSM than healthy controls(11.3 ± 6.4 k Pa vs 4.3 ± 1.4 k Pa, P < 0.01). LSM was significantly correlated with fibrosis stage(r = 0.756, P < 0.01). LSM values increased gradually with an increased fibrosis stage. The areas under the ROC curves of LSM for stages F ≥ 2, F ≥ 3, and F4 were 0.837(95%CI: 0.729-0.914), 0.910(0.817-0.965), and 0.966(0.893-0.995), respectively. The optimal cut-off values of LSM for fibrosis stages F ≥ 2, F ≥ 3, and F4 were 6.55, 10.50, and 14.45 k Pa, respectively. LSM was significantly superior to fibrosis-4, glutaglumyl-transferase/platelet ratio, and aspartate aminotransferase-to-platelet ratio index scores in detecting severe fibrosis(F ≥ 3)(0.910 vs 0.715, P < 0.01; 0.910 vs 0.649, P < 0.01; 0.910 vs 0.616, P < 0.01, respectively).CONCLUSION TE can accurately detect hepatic fibrosis as a noninvasive method in patients with AIH-PBC overlap syndrome.

Non-invasive assessment of liver fibrosis using twodimensional shear wave elastography in patients with autoimmune liver diseases

AIM To determine the diagnostic accuracy of two-dimensional shear wave elastography(2D-SWE) for the noninvasive assessment of liver fibrosis in patients with autoimmune liver diseases(AILD) using liver biopsy as the reference standard.METHODS Patients with AILD who underwent liver biopsy and 2D-SWE were consecutively enrolled. Receiver operating characteristic(ROC) curves were constructed to assess the overall accuracy and to identify optimal cut-off values.RESULTS The characteristics of the diagnostic performance were determined for 114 patients with AILD. The areas under the ROC curves for significant fibrosis, severe fibrosis, and cirrhosis were 0.85, 0.85, and 0.86, respectively, and the optimal cut-off values associated with significant fibrosis(≥ F2), severe fibrosis(≥ F3), and cirrhosis(F4) were 9.7 k Pa, 13.2 k Pa and 16.3 k Pa, respectively. 2D-SWE showed sensitivity values of 81.7% for significant fibrosis, 83.0% for severe fibrosis,and 87.0% for cirrhosis, and the respective specificity values were 81.3%, 74.6%, and 80.2%. The overall concordance rate of the liver stiffness measurements obtained using 2D-SWE vs fibrosis stages was 53.5%.CONCLUSION2D-SWE showed promising diagnostic performance for assessing liver fibrosis stages and exhibited high cut-off values in patients with AILD. Low overall concordance rate was observed in the liver stiffness measurements obtained using 2D-SWE vs fibrosis stages.

Noninvasive assessment of alcoholic liver disease using unidimensional transient elastography(Fibroscan~)

Unidimensional transient elastography(TE) is a noninvasive technique, which has been increasingly used in the assessment of diffuse liver diseases. This paper focuses on reviewing the existing data on the use of TE in the diagnosis of fibrosis and in monitoring disease progression in alcoholic liver disease, on the factors that may influence the result of fibrosis prediction, and last but not least, on its potential use in assessing the steatosis degree. Therefore, this field is far from being exhausted and deserves more attention. Further studies are required, on large groups of biopsied patients, in order to find answers to all the remaining questions in this field.

Transient elastography compared to liver biopsy and morphometry for predicting fibrosis in pediatric chronic liver disease: Does etiology matter?

AIM: To evaluate transient elastography (TE) as a noninvasive tool in staging liver fibrosis compared with liver biopsy and morphometry in children with different chronic liver diseases.METHODS: A total of 90 children [50 with chronic hepatitis C virus (HCV), 20 with autoimmune hepatitis (AIH) and 20 with Wilson disease] were included in the study and underwent liver stiffness measurement (LSM) using TE. Liver biopsies were evaluated for fibrosis, qualitatively, by Ishak score and quantitatively by fibrosis area fraction (FAF) using digital image analysis (morphometry). LSM was correlated with fibrosis and other studied variables using spearman correlation. A stepwise multiple regression analysis was also performed to examine independent factors associated with LSM. Different cut-off values of LSM were calculated for predicting individual fibrosis stages using receiver-operating characteristic curve. Cut-off values with optimal clinical performance (optimal sensitivity and specificity simultaneously) were selected.RESULTS: The majority of HCV group had minimal activity (80%) and no/mild fibrosis (72%). On the other hand, the majority of AIH group had mild to moderate activity (70%) and moderate to severe fibrosis (95%) and all Wilson disease group had mild to moderate activity (100%) and moderate to severe fibrosis (100%). LSM correlated significantly with both FAF and Ishak scores and the correlation appeared better with the latter (r = 0.839 vs 0.879, P &#x0003c; 0.0001 for both). LSM discriminated individual stages of fibrosis with high performance. Sensitivity ranged from 81.4% to 100% and specificity ranged from 75.0% to 97.2%. When we compared LSM values for the same stage of fibrosis, they varied according to the different etiologies. Higher values were in AIH (16.15 &#x000b1; 7.23 kPa) compared to Wilson disease (8.30 &#x000b1; 0.84 kPa) and HCV groups (7.43 &#x000b1; 1.73 kPa). Multiple regression analysis revealed that Ishak fibrosis stage was the only independent variable associated with higher LSM (P &#x0003c; 0.0001).CONCLUSION: TE appears reliable in distinguishing different stages of liver fibrosis in children. However, its values vary according to the disease type. For that, a disease-specific estimation of cut-off values for fibrosis staging is worthy.

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.

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.

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.

Overview and developments in noninvasive diagnosis of nonalcoholic fatty liver disease

High prevalence of non-alcoholic fatty liver disease (NAFLD) and very diverse outcomes that are related to disease form and severity at presentation have made the search for noninvasive diagnostic tools in NAFLD one of the areas with most intense development in hepatology today.Various methods have been investigated in the recent years,including imaging methods like ultrasound and magnetic resonance imaging,different forms of liver stiffness measurement,various biomarkers of necroinflammatory processes (acute phase reactants,cytokines,markers of apoptosis),hyaluronic acid and other biomarkers of liver fibrosis.Multicomponent tests,scoring systems and diagnostic panels were also developed with the purposes of differentiating non-alcoholic steatohepatitis from simple steatosis or discriminating between various fibrosis stages.In all of the cases,performance of noninvasive methods was compared with liver biopsy,which is still considered to be a gold standard in diagnosis,but is by itself far from a perfect comparative measure.We present here the overview of the published data on various noninvasive diagnostic tools,some of which appear to be very promising,and we address as well some of still unresolved issues in this interesting field.

Utility of FibroScan-based scoring systems to narrow the risk group of nonalcoholic fatty liver disease with comorbidities

BACKGROUND Vibration-controlled transient elastography(VCTE)is proposed as a second step of examination to assess liver fibrosis in patients with nonalcoholic fatty liver disease(NAFLD)after triaging by the fibrosis-4(FIB-4)index.Recently,VCTEbased scoring systems,including FibroScan-AST(FAST),Agile 3+,and Agile 4,emerged to determine the status of NAFLD.However,the significance of these scoring systems remains unknown in narrowing the high-risk group of NAFLD patients with comorbidities,including hepatocellular carcinoma(HCC)and esophagogastric varices(EGV).AIM To clarify the significance of VCTE-based scoring systems to narrow the high-risk group of NAFLD patients with comorbidities.METHODS We performed a cross-sectional study to investigate the usefulness of VCTE-based scoring systems and other fibrosis markers to narrow the high-risk group of patients with NAFLD.FIB-4 index was used for the first triage.Risk groups of FAST,Agile 3+,and Agile 4 were stratified according to the published data.Among the 191 patients with NAFLD,there were 26(14%)and 25 patients(13%)with HCC and EGV,respectively.RESULTS When 1.3 was used as a cutoff value,the FIB-4 index narrowed the risk group to 120 patients,in which all patients with HCC and/or EGV were included.High risk group of Agile 3+could subsequently narrow the risk group.The prevalence of HCC and EGV at this step were 33%(26/80)and 31%(25/80),respectively.In further narrowing of EGV,Agile 4 aggregated the patients with EGV into 43 patients,of whom 23(53%)had EGV.FAST failed to narrow the risk group of patients with comorbidities.When 2.6 was used as a cutoff value of the FIB-4 index,three patients with HCC and two patients with EGV were missed at the first triage.CONCLUSION Agile 3+and Agile 4 are useful to narrow the NAFLD patient group,in which patients may have HCC and/or EGV.

超声瞬时弹性成像检测受控衰减参数评估非酒精性脂肪性肝病患者肝脂肪变程度价值研究

目的分析应用超声瞬时弹性成像检测的受控衰减参数(CAP)评估非酒精性脂肪性肝病(NAFLD)患者肝脂肪变程度的价值。方法2020年5月~2022年5月我院诊治的NAFLD患者78例,均接受肝脏超声检查和超声瞬时弹性成像检查,绘制受试者工作特征曲线(ROC)并计算曲线下面积(AUC)评估CAP诊断NAFLD患者肝脂肪变程度的效能。结果肝脏超声检查结果显示,78例NAFLD患者中包括轻度肝脂肪变41例、中度肝脂肪变23例和重度肝脂肪变14例;重度肝脂肪变患者血清ALT和AST水平分别为(77.2±14.9)U/L和(59.1±11.7)U/L,显著高于中度肝脂肪变患者【分别为(40.1±8.3)U/L和(35.9±6.2)U/L,P<0.05】或轻度肝脂肪变患者【分别为(26.7±5.5)U/L和(23.3±4.8)U/L,P<0.05】;重度肝脂肪变患者血清TG水平和CAP分别为(3.5±0.7)mmol/L和(317.7±27.6)dB/m,显著高于轻度肝脂肪变患者【分别为(1.6±0.6)mmol/L和(259.9±27.5)dB/m,P<0.05】或中度肝脂肪变患者【分别为(2.7±0.6)mmol/L和(292.1±30.7)dB/m,P<0.05】,而血清HDL-C水平为(0.8±0.4)mmol/L,显著低于轻度肝脂肪变患者【(1.3±0.3)mmol/L,P<0.05】或中度肝脂肪变患者【(1.1±0.3)mmol/L,P<0.05】;以CAP>285.4dB/m为截断点,诊断NAFLD患者中度肝脂肪变,以CAP>309.1dB/m为截断点,诊断NAFLD患者重度肝脂肪变,结果发现轻度肝脂肪变39例,中度肝脂肪变22例,重度肝脂肪变17例,其AUC、敏感度和特异度分别为0.783(95%CI:0.669~0.896)、78.3%和75.6%,和0.696(95%CI:0.515~0.876)、78.6%和69.6%(P<0.05)。结论应用CAP诊断NAFLD患者肝脂肪变程度可能比超声检查更准确,有很大的临床应用价值。

点剪切波弹性成像与瞬时弹性成像评估非酒精性脂肪肝患者肝纤维化分期的Meta分析

目的应用Meta分析系统评价点剪切波弹性成像(pSWE)与瞬时弹性成像(TE)对非酒精性脂肪肝(NAFLD)患者肝纤维化分期的诊断效能。方法计算机检索万方数据库、中国生物医学文献数据库、中国知网、PubMed、Web of Science、Embase和Cochrane Library数据库,搜索关于pSWE和TE诊断NAFLD患者肝纤维化分期的相关文献,检索时间均为建库至2023年2月1日。由两名研究人员分别独立筛选文献、提取资料并进行偏倚风险评估,采用I2检验探索各研究间的异质性;采用双变量混合效应模型分析并比较两种方法对NAFLD患者肝纤维化分期的诊断效能。结果最终纳入14篇文献,其中应用TE检测8篇,应用pSWE检测3篇,同时应用TE和pSWE检测3篇,TE与pSWE检测失败率比较差异有统计学意义(10.2%vs.0.9%,P<0.05)。Meta分析结果显示,pSWE诊断NAFLD患者≥F2、≥F3、F4期肝纤维化的综合受试者工作特征曲线的曲线下面积分别为0.85[95%CI(可信区间):0.82~0.88]、0.95(95%CI:0.91~0.97)、0.93(95%CI:0.91~0.96);TE的曲线下面积分别为0.83(95%CI:0.82~0.85)、0.90(95%CI:0.89~0.93)、0.94(95%CI:0.91~0.96),两种方法的曲线下面积比较差异均无统计学意义。剔除引起异质性的异常数据后,亚组分析显示,pSWE诊断≥F2、≥F3、F4期肝纤维化的合并阳性似然比和阴性似然比分别为2.69、2.24、2.68和0.07、0.28、0.21,TE的合并阳性似然比和阴性似然比分别为3.22、6.27、11.28和0.31、0.24、0.11。Deeks’漏斗图显示,pSWE和TE诊断肝纤维化不同分期的文献数据均无明显的发表偏倚(均P>0.05)。结论pSWE和TE均可无创、准确地诊断NAFLD患者肝纤维化分期,尤其对≥F3、F4期肝纤维化具有较高的诊断效能。

磁共振及超声瞬时弹性成像对代谢相关脂肪性肝病定量评估的研究进展

代谢相关脂肪性肝病(MAFLD)会导致脂肪性肝炎、肝硬化及肝细胞性癌。肝穿刺是诊断MAFLD的金标准。然而,有创检查不能广泛应用于临床实践中,无创诊断MAFLD是未来发展趋势。目前主要的检查方法有超声瞬时弹性成像、磁共振质子密度脂肪分数、磁共振波谱成像、磁共振弹性成像等。因此,本文就MRI及超声瞬时弹性成像技术在MAFLD定量评估中的研究进展进行综述,旨在为临床精准诊疗提供影像标记物。

不同中医证型酒精性肝病患者的临床特点分析

【目的】探讨不同中医证型酒精性肝病患者的临床特点。【方法】回顾性收集2018~2022年在佛山市中医院就诊的符合纳入、排除标准的129例酒精性肝病患者的一般资料、中医证型以及就诊时的肝肾功能、血脂、肝脏瞬时弹性成像等临床数据,分析酒精性肝病患者的中医证型分布,探讨不同中医证型酒精性肝病患者的临床特点。【结果】(1)一般资料方面,129例患者中,男性128例(99.22%),女性1例(0.78%);平均年龄为(48.71±11.50)岁;平均体质量指数(BMI)为(23.82±3.98)kg·m^(-2)。(2)中医证型分布方面,以湿热蕴结证最常见,共70例(54.26%),其余分别为肝郁脾虚证24例(18.60%)、痰湿内阻证22例(17.05%)、肝肾不足证7例(5.43%)、痰瘀互结证3例(2.33%)、瘀血内结证3例(2.33%)。(3)临床特点方面,经非参数秩和检验分析,不同中医证型酒精性肝病患者的BMI、饮酒量、天冬氨酸氨基转移酶(AST)、谷氨酰转肽酶(GGT)、总胆红素(TBIL)、碱性磷酸酶(ALP)、甘油三酯(TG)、肝脏硬度测量值(LSM)以及反映肝脏脂肪含量的受控衰减参数值(CAP)比较,差异均有统计学意义(P<0.05或P<0.01)。其中较为突出的特征是,仅有肝郁脾虚证、痰湿内阻证、痰瘀互结证及瘀血内结证等4型患者的BMI超标(>24 kg·m^(-2)),而样本量占比高达54.26%的湿热蕴结证和肝肾不足证患者的BMI均在正常范围(分别为23.03 kg·m^(-2)和21.42 kg·m^(-2)),且此两种证型的BMI与痰湿内阻证(26.44 kg·m^(-2))均存在显著性差异(P<0.01),提示酒精性肝病有超过一半以上患者不会出现超重现象;另外,BMI最高的痰湿内阻证患者在血清TG(2.69 mmol/L)、CAP(292 db/m)等指标中也同样呈现出最高数值,提示痰湿内阻证患者的肥胖及肝脏脂肪浸润程度相对于其他证型严重;而代表肝脏慢性炎症损伤的AST和胆管细胞损伤的GGT,在湿热蕴结证和肝肾不足证中均有显著性升高,且此两型患者的LSM值也是所有证型分组里最高的,差异均有统计学意义(P<0.05或P<0.01)。【结论】湿热蕴结证是酒精性肝病的主要中医临床证型;酒精性肝病的肝脏脂肪浸润程度和体质量超标与病情严重程度并不呈一致性关系;不同中医证型酒精性肝病患者的临床异常指标存在一定差异,临床辨证时可将中医四诊资料与临床指标相互参照,这将有助于提高中医临床诊断的准确性。

实时剪切波弹性成像联合血清IL-6/IL-22水平与自身免疫性肝病肝纤维化的相关性

目的探讨实时剪切波弹性成像(SWE)联合血清白细胞介素-6(IL-6)/白细胞介素-22(IL-22)水平与自身免疫性肝病(AILD)患者肝纤维化(HF)的评估价值。方法选择海安市中医院2021年6月—2022年9月收治AILD患者130例作为研究对象,行SWE检查和测定血常规、肝生化指标、肝纤维化四项、IL-6、IL-22水平。根据肝活检和Metavir分级进行HF分期,在F1~4期的108例患者中,原发性胆汁性胆管炎(PBC)患者采用熊去氧胆酸联合泼尼松龙治疗,自身免疫性肝炎(AIH)采用泼尼松片联合硫唑嘌呤片口服,疗程6个月。比较HF各期的杨氏模量值和血清IL-6/IL-22水平,Pearson分析杨氏模量值和血清IL-6/IL-22水平与肝纤维化四项和FIB-4的相关性,绘制受试者工作特征曲线(ROC)分析杨氏模量值联合血清IL-6/IL-22水平的诊断效能;观察治疗6个月时不同疗效的的杨氏模量值和血清IL-6/IL-22水平。结果肝硬化组的杨氏模量值和IL-6/IL-22水平为(14.50±3.92)kPa和2.46±0.35,高于进展期HF组的(11.17±2.78)kPa和2.15±0.31,明显HF组的(7.29±1.56)kPa和1.92±0.28,无HF组的(4.93±0.71)kPa和1.67±0.24,差异有统计学意义(t=34.681,13.275,均P<0.05)。Pearson分析显示,AILD患者的杨氏模量值和血清IL-6/IL-22水平与层黏蛋白(LN)、透明质酸(HA)、Ⅲ型前胶原(PC-Ⅲ)、Ⅳ型胶原(Ⅳ-C)等肝纤维化四项和FIB-4呈显著正相关(P<0.01)。AILD合并HF患者治疗后显效组的杨氏模量值和血清IL-6/IL-22水平为(6.90±1.48)kPa和1.78±0.23,低于有效组的(8.35±1.87)kPa和1.90±0.27,无效组的(9.51±2.24)kPa和2.04±0.29,差异有统计学意义(t=17.256,9.037,均P<0.05)。ROC曲线显示,杨氏模量值联合IL-6/IL-22水平诊断AILD患者HF分期的AUC、敏感度和特异度均高于任一单项效能(P<0.05)。结论SWE联合血清IL-6/IL-22水平与AILD患者的HF严重程度密切相关,能客观反映和动态观察治疗效果和疾病预后。

Controlled attenuation parameter for evaluating liver steatosis in chronic viral hepatitis

AIM: To assess the performance of controlled attenuation parameter (CAP) in patients with chronic viral hepatitis.

Ultrasound findings in autoimmune hepatitis

Ultrasound findings in autoimmune hepatitis(AIH) have not been reported systematically so far. The use of reliable and accurate noninvasive methods for determining fibrosis stage is important in evaluation of treatment efficacy and fibrosis regression in AIH. Imaging plays an important role in detection of complications and ruling out other possible causes of chronic liver diseases. Ultrasound elastography cutoff values in AIH patients are not the same as those in patients with chronic viral hepatitis or non-alcoholic fatty liver disease. AIH is characterized by wide fluctuations in inflammatory activity. Here we report on current knowledge of ultrasound findings in AIH.

Primary liver injury and delayed resolution of liver stiffness after alcohol detoxification in heavy drinkers with the PNPLA3 variant I148M

AIMTo investigate the influence of PNPLA3 genotype in heavy drinkers on serum markers and liver stiffness (LS) during alcohol withdrawal and its association with histology. METHODSCaucasian heavy drinkers (n = 521) with a mean alcohol consumption of 192.1 g/d (median alcohol consumption: 169.0 g/d; 95%CI: 179.0-203.3) were enrolled at the Salem Medical Center, University of Heidelberg. LS was measured by transient elastography (Fibroscan, Echosens SA, Paris, France). LS and serum markers were prospectively studied in these patients with all stages of alcoholic liver disease (steatosis, steatohepatitis, fibrosis) prior and after alcohol detoxification with a mean observation interval of 6.2 &plusmn; 3.2 d. A liver biopsy with histological analysis including the Kleiner score was obtained in 80 patients. RESULTSThe PNPLA3 rs738409 genotype distribution for CC, CG and GG was 39.2%, 52.6% and 8.2%. GG genotype primarily correlated with histological steatohepatitis (r = 0.404, P r = 0.319, P r = 0.264, P r = 0.828, P r = 0.516, P r = 0.319, P vs 6%) with 3.8% more CC carriers while 3.7% less were seen in the F4 cirrhosis group. Thus, about 20% of patients with alcoholic liver cirrhosis would be attributable to PNPLA3 G variants. The OR to develop cirrhosis corrected for age, gender and body mass index was 1.295 (95%CI: 0.787-2.131) for CG + GG carriers. CONCLUSIONIn heavy drinkers, PNPLA3 GG primarily correlates with ballooning/steatohepatitis but not steatosis resulting in a delayed inflammation-associated resolution of LS. Consequently, sustained ballooning-associated LS elevation seems to be a potential risk factor for fibrosis progression in PNPLA3 GG carriers.