EASL-ALEH Clinical Practice Guidelines: Non-invasive tests for evaluation of liver disease severity and prognosis

The histological grading of fibrosis in Budd-Chiari syndrome: A chronic liver disease, different from others

INTRODUCTION

Budd-Chiari syndrome (BCS) is an uncommon disease caused by hepatic venous outflow obstruction. They can result in centrilobular fibrosis, nodular regenerative hyperplasia and cirrhosis. Assessing liver fibrosis is crucial for determining the stage of BCS, predicting disease progression and guiding treatment decisions. Although this pathology has been known for decades, no useful grading system was assigned. This study aims to introduce a histologic fibrosis grading system for BCS patients.

METHODOLOGY

All patients from 2017 to 2022 (Sanjay Gandhi Postgraduate Institute of Medical Sciences [SGPGIMS]), Lucknow diagnosed with BCS for whom liver biopsy was performed were included in the study. The Budd-Chiari syndrome-Hepatic Fibrosis system (BCS-HFS) was implemented to grade fibrosis. The fibrosis grade was compared with the fibrosis percentage area and a correlation was found with the hemodynamic variables (hepatic venous pressure gradient [HVPG]) and the prognostic scores.

RESULTS

There were 56 patients with BCS. The median age was 27 years, with a male-female ratio of 1.8:1. There was a significant difference in the fibrosis percentage, hemorrhage percentage and model for end-stage liver disease (MELD) score among the BCS-HFS grades (p < 0.05). There was a significant correlation between BCS-HFS and HVPG (ρ = 0.699, p < 0.001) and the MELD prognostic score (ρ = 0.474, p < 0.001).

CONCLUSION

BCS-HFS is applicable for grading fibrosis in BCS. It can help in uniform histopathology reporting and for further prospective and comparative studies.

The Role of Endoscopic Ultrasound in Assessing Portal Hypertension: A State-of-the-Art Literature Review and Evolving Perspectives

BACKGROUND

Portal hypertension (PH) is a critical complication in patients with hepatic diseases. Its accurate evaluation is essential for early diagnosis, risk stratification, and management. Endoscopic ultrasound (EUS) has emerged as a promising diagnostic tool, offering high-resolution imaging of the portal venous system, hepatic vasculature, and surrounding structures.

AIMS

This review aims at providing an overview of the evolving role of EUS in PH evaluation in patients with liver disease.

MATERIALS AND METHODS

A systematic search was conducted in PubMed and Google Scholar until 31 May 2024. Relevant studies were identified using keywords related to EUS and PH. Additional references were included based on expert knowledge and citation analysis. Only full-length papers and abstracts in English were considered.

RESULTS

EUS demonstrates significant utility in PH assessment, offering high-resolution imaging and advanced tools like contrast enhancement (CE) and shear-wave elastography (SWE) for evaluating liver stiffness and correlating it with PH severity. EUS-guided portal pressure gradient (PPG) measurement provides a less invasive method for evaluating PH, potentially offering a safer alternative to conventional techniques.

DISCUSSION

EUS offers unique advantages in PH assessment, enabling comprehensive evaluation in a single session. Despite its potential, limitations such as invasiveness, sedation-related variability, and restricted availability persist. Emerging techniques require further validation in larger cohorts and standardised training.

CONCLUSION

EUS is a valuable diagnostic tool for PH evaluation, with the potential to improve outcomes through earlier diagnosis and better stratification. Addressing its limitations through further research and standardised protocols is critical to optimize its clinical utility.

TRIAL REGISTRATION

NCT04115046, NCT05728697, NCT05097963 and NCT03155282.

Non-invasive liver fibrosis markers are increased in obese individuals with non-alcoholic fatty liver disease and the metabolic syndrome

The need for early non-invasive diagnostic tools for chronic liver fibrosis is growing, particularly in individuals with obesity, non-alcoholic fatty liver disease (NAFLD), and the metabolic syndrome (MetS) since prevalence of these conditions is increasing. This case-control study compared non-invasive liver fibrosis markers in obesity with NAFLD and MetS (NAFLD-MetS, n = 33), in obese (n = 28) and lean (n = 27) control groups. We used MRI (T1 relaxation times (T1) and liver stiffness), circulating biomarkers (CK18, PIIINP, and TIMP1), and algorithms (FIB-4 index, Forns score, FNI, and MACK3 score) to assess their potential in predicting liver fibrosis risk. We found that T1 (892 ± 81 ms vs. 818 ± 64 ms, p < 0.001), FNI (15 ± 12% vs. 9 ± 7%, p = 0.018), CK18 (166 ± 110 U/L vs. 113 ± 41 U/L, p = 0.019), and MACK3 (0.18 ± 0.15 vs. 0.05 ± 0.04, p < 0.001) were higher in the NAFLD-MetS group compared with the obese control group. Moreover, correlations were found between CK18 and FNI (r = 0.69, p < 0.001), CK18 and T1 (r = 0.41, p < 0.001), FNI and T1 (r = 0.33, p = 0.006), MACK3 and FNI (r = 0.79, p < 0.001), and MACK3 and T1 (r = 0.50, p < 0.001). We show that liver fibrosis markers are increased in obese individuals with NAFLD and MetS without clinical signs of liver fibrosis. More studies are needed to validate the use of these non-invasive biomarkers for early identification of liver fibrosis risk.

Use of Hepatoscope 2DTE for non-invasive assessment of liver stiffness among Mexican immigrant adults in a community-based setting

PURPOSE

Mexican-origin adults have one of the highest rates of metabolic dysfunction-associated steatotic liver disease (MASLD) and its severe form metabolic dysfunction steatohepatitis (MASH) in the US. Given the costs and invasiveness of liver biopsy, this study assessed the application of Hepatoscope® 2DTE, the latest-generation transient elastography for liver stiffness in Mexican adult immigrants from Southern Arizona and compared it with FibroScan® VCTE™.

METHODS

Participants (n = 199) from a cross-sectional community-based study completed anthropometric measures, demographic information, a blood draw, and liver stiffness measurements (LSM) with FibroScan VCTE and the ultraportable Hepatoscope 2DTE. LSM2DTE and LSMVCTE were compared using Spearman's correlation and Bland-Altman analysis. The number of at-risk for fibrosis participants as assessed using each system was compared according to FIB-4.

RESULTS

A total of 122 participants were considered for this sub-analysis which consisted of 71.3 % women. Mean age was 51.9 ± 12.1 years, BMI was 30.7 ± 5.7 kg/m², 43.4 % of participants had obesity, and 19.7 % were diabetic. Mean FIB-4 was 1.00 ± 0.53, and median LSM were 5.6 [4.7 - 6.7] and 5.3 [4.1 - 5.8] kPa for 2DTE and VCTE, respectively. 2DTE significantly correlated with VCTE (r = 0.53, p < 0.0001) and there was no systematic bias between the two LSM. There was no difference in the number of at-risk for fibrosis participants between the two LSM per FIB-4 categories.

CONCLUSION

Hepatoscope can be used for point-of-care liver stiffness assessment and risk stratification of adults at risk of liver fibrosis in community-based settings.

Hepatocellular Carcinoma After HCV Eradication with Direct-Acting Antivirals: A Reappraisal Based on New Parameters to Assess the Persistence of Risk

Approximately 95% of patients with chronic hepatitis C achieve viral eradication through direct-acting antiviral (DAA) treatment. Ensuing clinical benefits include halting liver fibrosis, thereby reducing the need for liver transplantation, and decreasing both liver-related and overall mortality. It is well established that, although ameliorated, the risk of developing hepatocellular carcinoma (HCC) persists, particularly among patients with pre-treatment advanced fibrosis/cirrhosis. Current guidelines recommend indefinite HCC surveillance in these patients. However, a recent Markov model evaluation shows that HCC surveillance is cost-effective only for patients with cirrhosis but not so for those with F3 fibrosis, a finding which points out the need to better define the risk of HCC in hepatitis C patients after cure and further characterize pre- and post-treatment factors that might affect the incidence of HCC in this setting. We reviewed the literature analyzing this aspect. Here we summarize the main findings: male gender and older age are independent predictors of increased risk of post-cure HCC development. Moreover, non-invasive tests for hepatic fibrosis, namely FIB4, APRI, and liver stiffness, measured before and after treatment and their post-therapy change, contribute to better stratifying the risk of HCC occurrence. Furthermore, low serum albumin, as well as an AFP above 7 ng/mL prior to and after DAA therapy, also constitute independent predictors of HCC development. Considering these findings, we propose to classify patients with HCV viral eradication and advanced fibrosis/cirrhosis into groups of low, medium, or high risk of HCC and to adopt adequate surveillance strategies for each group, including protocols for abbreviated magnetic resonance imaging (MRI) for those at the highest risk.

Liver stiffness measurement trajectory analysis for prognosis in patients with chronic hepatitis B and compensated advanced chronic liver disease

INTRODUCTION AND OBJECTIVES

Liver stiffness measurements (LSMs) offer a noninvasive method for monitoring liver disease development. This study evaluated the prognostic value of different LSM trajectories in chronic hepatitis B (CHB) and compensated advanced chronic liver disease (cACLD) patients.

MATERIALS AND METHODS

We retrospectively analyzed 1272 CHB and cACLD patients with at least two LSMs, applied group-based trajectory modeling (GBTM) to identify distinct LSM trajectories, and used a Cox model to analyze their associations with liver-related events (LREs) and mortality risk.

RESULTS

Patients were categorized into five groups with distinct LSM trajectories: 67 (8.5 %), 13 (11 %), 36 (23.5 %), 34 (27.6 %) and 23 (25.0 %) developed LREs in Groups 1-5. The low stable trajectory (Group 3), the medium gradual decrease trajectory (Group 4) and high quickly decrease followed by increase trajectory (Group 5) had higher LREs risks than the low gradual decrease trajectory (Group 1) (adjusted HRs 2.26, 2.39, 2.67; 95 % CIs 1.50-3.40, 1.57-3.66, 1.61-4.43, respectively). Similar elevated risks were observed for hepatic decompensation, hepatocellular carcinoma (HCC), liver-related and all-cause mortality, except that there was no significant difference in the risk of HCC between Groups 4 and 1 (aHR 0.66, 0.36-1.23). When comparing Group 1 with the medium quickly decrease trajectory (Group 2), no significant differences were noted in the prognosis (P > 0.05). Notably, age over 40, high LSM, low PLT, and high total bilirubin were linked to high-risk trajectories (Groups 3-5).

CONCLUSIONS

Monitoring LSM trajectories improves prognostic prediction in CHB and cACLD compared with single measurements and may guide personalized treatment strategies.

The Value of Clinical Decision Support in Healthcare: A Focus on Screening and Early Detection

In a rapidly changing technology landscape, "Clinical Decision Support" (CDS) has become an important tool to improve patient management. CDS systems offer medical professionals new insights to improve diagnostic accuracy, therapy planning, and personalized treatment. In addition, CDS systems provide cost-effective options to augment conventional screening for secondary prevention. This review aims to (i) describe the purpose and mechanisms of CDS systems, (ii) discuss different entities of algorithms, (iii) highlight quality features, and (iv) discuss challenges and limitations of CDS in clinical practice. Furthermore, we (v) describe contemporary algorithms in oncology, acute care, cardiology, and nephrology. In particular, we consolidate research on algorithms across diseases that imply a significant disease and economic burden, such as lung cancer, colorectal cancer, hepatocellular cancer, coronary artery disease, traumatic brain injury, sepsis, and chronic kidney disease.

Non-invasive assessment of severe liver fibrosis in patients with Fontan-associated liver disease: The VALDIG-EASL FONLIVER cohort

BACKGROUND & AIMS

Fontan-type surgery is a palliative procedure for congenital heart disease with univentricular physiology that may, in the long term, lead to advanced chronic liver disease. Herein, we assessed the accuracy of conventional non-invasive models for assessing liver fibrosis in the context of Fontan circulation and developed a new risk score employing non-invasive tools.

METHODS

A prospective, cross-sectional, observational study was conducted across five European centers and encompassing all consecutive adult patients with Fontan circulation, liver biopsy and non-invasive tests (e.g. elastography, APRI, and FIB-4). The primary outcome was the identification of severe liver fibrosis on biopsy. Multivariable logistic regression identified non-invasive predictors of severe fibrosis, leading to the development and internal validation of a new scoring model named the FonLiver risk score.

RESULTS

In total, 217 patients (mean [SD] age, 27.9 [8.9] years; 50.7% males) were included. Severe liver fibrosis was present in 47.9% (95% CI 41.2%-54.5%) and correlated with a lower functional class, protein-losing enteropathy, and compromised cardiopulmonary and systemic hemodynamics. The final FonLiver risk score incorporated liver stiffness measurement using transient elastography and platelet count, and demonstrated strong discrimination and calibration (AUROC of 0.81). The FonLiver risk score outperformed conventional prediction models (e.g. APRI and FIB-4), which all exhibited worse performance in our cohort (AUROC <0.70 for all).

CONCLUSION

Severe liver fibrosis is prevalent in adults following Fontan-type surgery and can be effectively estimated using the novel FonLiver risk score. This scoring system can be easily incorporated into the routine assessment of patients with Fontan circulation.

IMPACT AND IMPLICATIONS

Fontan-type surgery is used as a palliative procedure for congenital heart disease with univentricular physiology that may, in the long term, lead to advanced chronic liver disease. The severity of liver fibrosis progression has been proposed as a surrogate for failing Fontan hemodynamics as well as worse outcomes after heart transplantation. The development of FALD screening protocols would facilitate the early detection of advanced fibrosis and anticipate interventions to optimize the Fontan circulation, thereby improving outcomes. In our international series, we have developed the FonLiver risk score to predict severe fibrosis, that can be easily incorporated into the routine assessment of patients with Fontan circulation.

The relationship between the ratio of non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol (NHHR) and both MASLD and advanced liver fibrosis: evidence from NHANES 2017-2020

Background

The non-HDL-C to HDL-C ratio (NHHR) is a dependable lipid marker linked to atherosclerotic traits. This study examines the potential relationship between NHHR and both metabolic dysfunction-associated steatotic liver disease (MASLD) and advanced liver fibrosis.

Methods

This study investigated the relationship between NHHR levels and both MASLD and advanced liver fibrosis using data from the 2017-2020 National Health and Nutrition Examination Survey (NHANES) in the United States. First, we conducted a baseline characteristics analysis of the population based on NHHR quartiles. Second, we employed multivariable weighted linear regression models to examine the associations between NHHR and MASLD, as well as advanced liver fibrosis. Third, we utilized restricted cubic splines (RCS) to assess potential non-linear relationships. Fourth, we performed subgroup analyses. Finally, ROC curve analysis was conducted to evaluate the effectiveness of NHHR.

Results

In the main analysis, this study included a total of 9,864 participants. Following multivariable logistic regression and comprehensive adjustments, elevated NHHR levels in the Q3 and Q4 groups were significantly linked to MASLD, with odds ratios of 1.59 (95% CI: 1.20-2.11) and 1.83 (95% CI: 1.40-2.39), respectively (P for trend < 0.0001). Elevated NHHR levels in the Q2 and Q3 groups remained significantly linked to a decreased risk of advanced liver fibrosis, with odds ratios of 0.61 (95% CI 0.40-0.94, P = 0.03) and 0.64 (95% CI 0.47-0.89, P = 0.01), respectively. RCS analysis revealed a U-shaped nonlinear association between NHHR and both MASLD (P = 0.000; P for nonlinear = 0.029) and advanced liver fibrosis (P = 0.0001; P for nonlinear = 0.000). In the subgroup analysis, we found that this relationship was significant only in certain subgroups. The ROC curve analysis revealed that NHHR exhibited the best predictive performance for diagnosing MASLD based on the fatty liver index (FLI). The optimal cutoff point for NHHR in predicting MASLD using FLI was determined to be 2.476, with sensitivity and specificity values of 0.589 and 0.698, respectively.

Conclusion

NHHR may serve as a predictive marker for MASLD and advanced liver fibrosis, highlighting its potential significance in risk assessment and prevention strategies.

Association of MASLD Phenotypes With Liver Fibrosis in Hepatitis C: The Role of Cardiometabolic Risk Factors

Steatotic liver disease is prevalent among people with hepatitis C virus (HCV). The new definition of metabolic dysfunction-associated steatotic liver disease (MASLD) emphasises the metabolic drivers of steatosis and recognises its frequent coexistence with other chronic liver diseases, including HCV. We aimed to evaluate the association of coexisting MASLD and HCV with liver fibrosis. Individuals with HCV who underwent transient elastography (TE) with associated controlled attenuation parameter (CAP) were included from two clinical centres. MASLD and significant liver fibrosis were defined as the presence of steatosis (CAP ≥ 275 dB/m) with at least one cardiometabolic risk factor, and liver stiffness measurement (LSM) ≥ 7.1 kPa measured by TE, respectively. Associated cofactors of significant liver fibrosis were determined using stepwise regression and cross-validation by LASSO models to select confounders. Among 590 participants, 31% were diagnosed with MASLD. The prevalence of significant liver fibrosis was the highest among people with MASLD (58%) followed by HCV-related steatosis (45%) and the non-steatosis group (39%). After adjusting for potential confounders, MASLD was associated with significant liver fibrosis (adjusted odds ratio [aOR] 2.29, 95% confidence interval [CI] 1.07-4.87). Furthermore, specific MASLD phenotypes including diabetes, hypertension and overweight were associated with significant liver fibrosis, with aORs of 4.76 (95% CI 2.16-10.49), 3.44 (95% CI 1.77-6.68) and 2.54 (95% CI 1.27-5.07), respectively. In conclusion, MASLD is associated with liver fibrosis in people with HCV, specifically the diabetes, overweight and hypertensive phenotypes. Beyond pursuing a virological cure, healthcare providers should prioritise managing metabolic conditions, particularly diabetes, hypertension and obesity.

Optimization of the Use of APRI and FIB-4 for Ruling Out Liver Cirrhosis in Chronic Hepatitis B Patients With Normal Alanine Aminotransferase

The exclusion of cirrhosis is important in chronic hepatitis B (CHB) patients with normal alanine aminotransferase (ALT). We aimed to optimise the performance of the aspartate aminotransferase to platelet ratio index (APRI) and fibrosis score based on four factors (FIB-4) to exclude cirrhosis in these patients. Five hundred and eighty four patients with normal ALT who underwent liver biopsy were included in the study. The patients were divided into derivation and external validation sets. A grid search method was used to identify new cut-offs with a negative predictive value (NPV) of > 95% and a sensitivity of > 90% for detecting cirrhosis. The proportion of patients with cirrhosis in the derivation and validation sets was 19.4% and 7.5%, respectively. The conventional cut-offs of APRI (77.6%) and FIB-4 (41.8%) had high rates of cirrhosis misclassification. A new APRI cut-off of 0.21 had a sensitivity of 97.0% and an NPV of 95.6%, and only two (3.0%) patients with cirrhosis were misclassified in the derivation set. Using a new FIB-4 cut-off of 0.53, with a sensitivity of 98.5% and NPV of 96.2%, only one (1.5%) patient with cirrhosis was misclassified. External validation showed similar results. Using the new cut-offs of APRI and FIB-4, cirrhosis could be completely excluded for HBeAg-positive patients or those aged > 40 years. The conventional cut-offs had high misclassification rates for cirrhosis. The new cut-offs of APRI (≤ 0.21) and FIB-4 (≤ 0.53) could be used to exclude cirrhosis in CHB patients with normal ALT levels with a low misclassification rate.

Prognostic Implications of Cardiac Geometry in Cirrhosis: Findings From a Large Cohort

BACKGROUND AND AIMS

Cirrhosis is characterised by hyperdynamic circulation, which contributes to cirrhotic cardiomyopathy (CCM). However, the expert consensus on CCM did not initially include cardiac structure because of scant evidence. Therefore, this study investigated the associations of cardiac chamber geometry with mortality and CCM.

METHODS

We retrospectively included 2514 cirrhotic patients from 2011 to 2023. In accordance with the guidelines for echocardiography, left ventricular (LV) hypertrophy (LVH) and LV, left atrial (LA), right ventricular (RV), and right atrial (RA) enlargement were evaluated. Cox and logistic regression analyses were performed to examine the relationships among cardiac chamber, all-cause mortality, and CCM.

RESULTS

The prevalence rates of LV hypertrophy and LV, LA, RV, and RA enlargement were 21.9%, 21.3%, 30.4%, 5.9%, and 10.9%, respectively. Concentric LVH (HR: 1.305, 95% confidence interval (CI): 1.153-1.466), eccentric LVH (HR: 1.272, 95% CI: 1.139-1.426), LV enlargement (HR: 1.305, 95% CI: 1.153-1.466), and LA enlargement (HR: 1.254, 95% CI: 1.130-1.379) were significantly associated with mortality during the median follow-up of 2.1 years. In a subcohort of 1898 individuals, CCM, with a prevalence of 29.0%, was independently associated with concentric LVH (OR: 1.834, 95% CI: 1.214-2.707), eccentric LVH (OR: 3.063, 95% CI: 2.379-3.903), LV enlargement (OR: 2.519, 95% CI: 2.150-2.977), LA enlargement (OR: 3.559, 95% CI: 2.770-4.321), and RA enlargement (OR: 1.416, 95% CI: 1.025-1.915). LV abnormalities showed 90% specificity and 35% sensitivity for CCM diagnosis.

CONCLUSIONS

Geometric pattern changes in the LV and LA are prevalent and independently associated with all-cause mortality and CCM. These indicators have potential for hazard stratification and CCM redefinition.

Comparison of the diagnostic accuracy of shear wave elastography with transient elastography in adult nonalcoholic fatty liver disease: a systematic review and network meta-analysis of diagnostic test accuracy

PURPOSE

To compare the diagnostic test accuracy (DTA) of shear wave elastography (SWE) to that of transient elastography (TE) for liver fibrosis grade assessment in nonalcoholic fatty liver disease adults.

METHODS

MEDLINE, The Cochrane Library, and Web of Science were searched. Inclusion criteria were primary studies examining DTA of TE, point SWE (pSWE), two-dimensional SWE (2D-SWE), or magnetic resonance elastography (MRE) with liver biopsy. Network meta-analysis was conducted using a Bayesian bivariate mixed-effects model.

RESULTS

For fibrosis grade 2 or higher, 15 studies with 25 observations (16 observations for TE, 1 for MRE, 4 for pSWE and 2D-SWE; 2,066 patients) were included; the pooled sensitivity and specificity were 0.79 (95% credible interval (CrI) 0.70-0.86; 95% prediction interval (PI) 0.36-0.96) and 0.73 (95% CrI 0.62-0.82; 95% PI 0.23-0.96) for TE, 0.68 (95% CrI 0.48-0.83; 95% PI 0.23-0.94) and 0.75 (95% CrI 0.53-0.88; 95% PI 0.24-0.97) for pSWE, 0.85 (95% CrI 0.70-0.93; 95% PI 0.40-0.98) and 0.72 (95% CrI 0.49-0.86; 95% PI 0.20-0.96) for 2D-SWE, respectively. The proportion of studies classified as unclear in QUADAS-2 was high, and the results were heterogeneous.

CONCLUSION

2D-SWE could be recommended as TE is for liver fibrosis assessment. The protocol of this systematic review and network meta-analysis has been registered in PROSPERO (CRD42022327249). All included primary papers have already been published and the information and data can be used freely.

Precision in Liver Diagnosis: Varied Accuracy Across Subgroups and the Need for Variable Thresholds in Diagnosis of MASLD

BACKGROUND AND AIMS

The performance of non-invasive liver tests (NITs) is known to vary across settings and subgroups. We systematically evaluated whether the performance of three NITs in detecting advanced fibrosis in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) varies with age, sex, body mass index (BMI), type 2 diabetes mellitus (T2DM) status or liver enzymes.

METHODS

Data from 586 adult LITMUS Metacohort participants with histologically characterised MASLD were included. The diagnostic performance of the Fibrosis-4 Index (FIB-4), enhanced liver fibrosis (ELF) and vibration-controlled transient elastography liver stiffness measurement (VCTE LSM) was evaluated. Performance was expressed as the area under the receiver operating characteristics curve (AUC). Thresholds for detecting advanced fibrosis (≥F3) were calculated for each NIT for fixed (high) sensitivity, specificity and predictive values.

RESULTS

Differences in AUC between all subgroups were small and statistically not significant, indicating comparable performance in detecting ≥F3, irrespective of these clinical factors. However, different thresholds were needed to achieve the same level of accuracy with each test. For example, for a fixed sensitivity and specificity, the thresholds for all three NITs were higher in patients with T2DM. Effects for sex, age and liver enzymes were less pronounced.

CONCLUSIONS

Performance of the selected NITs in detecting advanced liver fibrosis does not vary substantially with clinical characteristics. However, different thresholds have to be selected to achieve the same sensitivity, specificity and predictive values in the respective subgroups. Large prospective studies are called for to study NIT accuracy considering multiple patient characteristics.

Performance of spleen stiffness measurement to rule out high-risk varices in patients with porto-sinusoidal vascular disorder

BACKGROUND AND AIMS

Baveno VII consensus suggests that screening endoscopy can be spared in patients with compensated cirrhosis when spleen stiffness measurement (SSM) by vibration-controlled transient elastography (VCTE) is ≤40 kPa as they have a low probability of high-risk varices (HRV). Conversely, screening endoscopy is required in all patients with porto-sinusoidal vascular disorder (PSVD). This study aimed to evaluate the performance of SSM-VCTE to rule out HRV in patients with PSVD and signs of portal hypertension.

APPROACH AND RESULTS

We retrospectively included patients with PSVD, ≥1 sign of portal hypertension, without a history of variceal bleeding, who underwent an SSM-VCTE within 2 years before or after an upper endoscopy in 21 VALDIG centers, divided into a derivation and a validation cohort. One hundred fifty-four patients were included in the derivation cohort; 43% had HRV. By multivariable logistic regression analysis, SSM-VCTE >40 kPa and serum bilirubin ≥1 mg/dL were associated with HRV. SSM-VCTE ≤40 kPa combined with bilirubin <1 mg/dL had a sensitivity of 96% to rule out HRV and could spare 38% of screening endoscopies, with 4% of HRV missed, and a 95% negative predictive value. In the validation cohort, including 155 patients, SSM combined with bilirubin could spare 21% of screening endoscopies, with 4% of HRV missed and a 94% negative predictive value.

CONCLUSIONS

This study gathering a total of 309 patients with PSVD showed that SSM-VCTE ≤40 kPa combined with bilirubin <1 mg/dL identifies patients with PSVD and portal hypertension with a probability of HRV <5%, in whom screening endoscopy can be spared.

Imaging-based noninvasive liver disease assessment for staging liver fibrosis in chronic liver disease: A systematic review supporting the AASLD Practice Guideline

BACKGROUND AND AIMS

Transient elastography (TE), shear wave elastography, and/or magnetic resonance elastography (MRE), each providing liver stiffness measurement (LSM), are the most studied imaging-based noninvasive liver disease assessment (NILDA) techniques. To support the American Association for the Study of Liver Diseases guidelines on NILDA, we summarized the evidence on the accuracy of these LSM methods to stage liver fibrosis (F).

APPROACH AND RESULTS

A comprehensive search for studies assessing LSM by TE, shear wave elastography, or MRE for the identification of significant fibrosis (F2-4), advanced fibrosis (F3-4), or cirrhosis (F4), using histopathology as the standard of reference by liver disease etiology in adults or children from inception to April 2022 was performed. We excluded studies with <50 patients with a single disease entity and mixed liver disease etiologies (with the exception of HCV/HIV coinfection). Out of 9447 studies, 240 with 61,193 patients were included in this systematic review. In adults, sensitivities for the identification of F2-4 ranged from 51% to 95%, for F3-4 from 70% to 100%, and for F4 from 60% to 100% across all techniques/diseases, whereas specificities ranged from 36% to 100%, 74% to 100%, and 67% to 99%, respectively. The largest body of evidence available was for TE; MRE appeared to be the most accurate method. Imaging-based NILDA outperformed blood-based NILDA in most comparisons, particularly for the identification of F3-4/F4. In the pediatric population, imaging-based NILDA is likely as accurate as in adults.

CONCLUSIONS

LSM from TE, shear wave elastography, and MRE shows acceptable to outstanding accuracy for the detection of liver fibrosis across various liver disease etiologies. Accuracy increased from F2-4 to F3-4 and was the highest for F4. Further research is needed to better standardize the use of imaging-based NILDA, particularly in pediatric liver diseases.

Application of ultrasound elastography and splenic size in predicting post-hepatectomy liver failure: Unveiling new clinical perspectives

In this article, we discuss the study by Cheng et al, published in the World Journal of Gastroenterology, focusing on predictive methods for post-hepatectomy liver failure (PHLF). PHLF is a common and serious complication, and accurate prediction is critical for clinical management. The study examines the potential of ultrasound elastography and splenic size in predicting PHLF. Ultrasound elastography reflects liver functional reserve, while splenic size provides additional predictive value. By integrating these factors with serological markers, we developed a comprehensive prediction model that effectively stratifies patient risk and supports personalized clinical decisions. This approach offers new insights into predicting PHLF. These methods not only assist clinicians in identifying high-risk patients earlier but also provide scientific support for personalized treatment strategies. Future research will aim to validate the model's accuracy with larger sample sizes, further enhancing the clinical application of these non-invasive indicators.

Prognostic performance of the two-step clinical care pathway in metabolic dysfunction-associated steatotic liver disease

BACKGROUND & AIMS

Current guidelines recommend a two-step approach for risk stratification in patients with metabolic dysfunction-associated steatotic liver disease (MASLD) involving Fibrosis-4 index (FIB-4) followed by liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE) or similar second-line tests. This study aimed to examine the prognostic performance of this approach.

METHODS

The VCTE-Prognosis study was a longitudinal study of patients with MASLD who had undergone VCTE examinations at 16 centres from the US, Europe and Asia with subsequent follow-up for clinical events. The primary endpoint was incident liver-related events (LREs), defined as hepatic decompensation and/or hepatocellular carcinoma.

RESULTS

Of 12,950 patients (mean age 52 years, 41% female, 12.1% LSM >12 kPa), baseline FIB-4, at cut-offs of 1.3 (or 2.0 for age ≥65) and 2.67, classified 66.3% as low-risk and 9.8% as high-risk, leaving 23.9% in the intermediate-risk zone. After classifying intermediate FIB-4 patients as low-risk if LSM was <8.0 kPa and high-risk if LSM was >12.0 kPa, 81.5%, 4.6%, and 13.9% of the full cohort were classified as low-, intermediate-, and high-risk, respectively. At a median (IQR) follow-up of 47 (23-72) months, 248 (1.9%) patients developed LREs. The 5-year cumulative incidence of LREs was 0.5%, 1.0% and 10.8% in the low-, intermediate- and high-risk groups, respectively. Replacing LSM with Agile 3+, Agile 4, and FAST did not reduce the intermediate-risk zone or improve event prediction. Classifying intermediate FIB-4 patients by LSM <10 kPa (low-risk) and >15 kPa (high-risk) reduced the intermediate-risk zone while maintaining predictive performance.

CONCLUSIONS

The non-invasive two-step approach of FIB-4 followed by LSM is effective in classifying patients at different risks of LREs.

IMPACT AND IMPLICATIONS

Metabolic dysfunction-associated steatotic liver disease (MASLD) is emerging as one of the leading causes of cirrhosis and hepatocellular carcinoma worldwide, but only a minority of patients will develop these complications. Therefore, it is necessary to use non-invasive tests instead of liver biopsy for risk stratification. Additionally, as most patients with MASLD are seen in primary care instead of specialist settings, cost and availability of the tests should be taken into consideration. In this multicentre study, the use of the Fibrosis-4 index followed by liver stiffness measurement by vibration-controlled transient elastography effectively identified patients who would later develop liver-related events. The results support current recommendations by various regional guidelines on a clinical care pathway based on non-invasive tests to diagnose advanced liver fibrosis.

Performance of Noninvasive Indices for Discrimination of Metabolic Dysfunction-Associated Steatotic Liver Disease in Young Adults

Background/Aims

Although numerous noninvasive steatosis indices have been developed to assess hepatic steatosis, whether they can be applied to young adults in the evaluation of metabolic dysfunction-associated steatotic liver disease (MASLD) remains uncertain.

Methods

Data from patients under 35 years of age who visited the Liver Health Clinic at the Armed Forces Goyang Hospital between July 2022 and January 2024 were retrospectively collected. Steatosis was diagnosed on the basis of a controlled attenuation parameter score ≥250 dB/m. MASLD was defined as the presence of steatosis in patients with at least one cardiometabolic risk factor.

Results

Among the 1,382 study participants, 901 were diagnosed with MASLD. All eight indices for diagnosing steatosis differed significantly between the MASLD and non-MASLD groups (p<0.001). Regarding the predictive performance, the hepatic steatosis index (HSI), fatty liver index (FLI), Framingham steatosis index, Dallas steatosis index, Zhejiang University index, lipid accumulation product, visceral adiposity index, and triglyceride glucose-body mass index exhibited an area under the curve of 0.898, 0.907, 0.899, 0.893, 0.915, 0.869, 0.791, and 0.898, respectively. The cutoff values for the FLI and HSI were re-examined, indicating a need for alternative cutoff values for the HSI, with a rule-in value of 42 and a rule-out value of 36 in this population.

Conclusions

This study presents novel findings regarding the predictive performance of established steatosis markers in young adults. Alternative cutoff values for the HSI in this population have been proposed and warrant further validation.

Golgi protein 73 in liver fibrosis

Golgi protein 73 (GP73) is implicated in key pathogenic processes, particularly those related to inflammation and fibrogenesis. In the last years, its measurement has emerged as a promising biomarker for detection of liver fibrosis (LF), a common consequence of chronic liver disease that can progress to cirrhosis and eventually hepatocellular carcinoma. GP73 concentrations in blood appear significantly increased in LF patients, correlating with disease severity, making this biomarker a possible non-invasive alternative for detecting and monitoring this condition regardless of etiology. Understanding the molecular mechanisms involving GP73 expression could also lead to new therapeutic strategies aimed at modulating its synthesis or function to prevent or reverse LF. Despite its clinical potential, GP73 as a LF biomarker faces several challenges. The lack of demonstrated comparability among different assays as well as the lack of knowledge of individual variability can make difficult the result interpretation. Further research is therefore needed focusing on robust clinical validation of GP73 as a LF biomarker. Addressing analytical, biological, and clinical limitations will be critical to exploiting its potential for improving detection and monitoring of advanced LF.

Acute kidney injury is associated with liver-related outcomes in patients with hepatitis B virus infection: a retrospective cohort study

BACKGROUND

The effects of acute kidney injury (AKI) on liver-related outcomes in patients with hepatitis B virus (HBV) infection remain unclear. The study aimed to evaluate the association between AKI with liver-related mortality and complications in patients with HBV infection.

METHODS

The multicenter, retrospective cohort study included Chinese adults with HBV infection from 24 regional central hospitals between January 2000 and December 2022. AKI was defined as a ≥ 26.5 μmol/l increase in serum creatinine concentration within 48 h, or a ≥ 50% increase over the baseline within 7 days. The primary outcome was post-discharge liver-related mortality, while the secondary outcome was a composite of new-onset liver cirrhosis and hepatocellular carcinoma. Cox proportional hazard model was employed for analyses.

RESULTS

Of the 86,204 inpatients with HBV infection and without liver cancer or cirrhosis at baseline, 4407(5.1%) patients experienced AKI. During a mean follow-up of 4.6 ± 2.4 years, 334 (0.4%) patients died of liver-related events. After adjustment, AKI during hospitalization was significantly associated with a higher risk of liver-related mortality after discharge (adjusted hazard ratio (HR), 1.78; 95% confidence intervals (CI), 1.26-2.51, P = 0.001), especially in those with severe AKI. Similarly, AKI was associated with a higher risk of cirrhosis or new-onset hepatocellular carcinoma (adjusted HR, 1.33; 95%CI, 1.10-1.60, P = 0.004). The association between AKI and liver-related outcomes remained consistent across different subgroups.

CONCLUSIONS

AKI during hospitalization was associated with substantial increased risk of liver-related mortality and incident liver-related complication. Our findings highlight the importance of monitoring AKI in patients with HBV infection for tailoring personalized treatments.

Multisociety consensus recommendations on hepatitis delta virus infection

ABSTRACT

Hepatitis D virus (HDV) prevalence data and country-specific HDV guidelines are not widely available in the Gulf Cooperation Council (GCC) states. We developed consensus recommendations to guide healthcare professionals, policymakers, and researchers in improving HDV management and patient health outcomes in three GCC states: Kuwait, Saudi Arabia, and the United Arab Emirates. A consensus panel comprising hepatology experts (n = 6) from the three GCC societies was formed. The panel identified two broader areas related to clinical practice (screening and diagnosis, and treatment and management), addressed critical questions, and developed draft recommendations in February 2024. The strength of the final set of recommendations was subjected to consensus voting in March 2024. A majority was defined apriori with a two-thirds vote (67%). The paper outlines those recommendations alongside showcasing the current epidemiology of HDV in the GCC states, emphasizing the variability in prevalence, demographic patterns, and region-specific risk factors. It also highlights the current state of screening and diagnosis practices, identifying key obstacles, such as access to advanced screening protocols and diagnostic tools. Furthermore, HDV treatment landscape and preventative strategies are outlined, focusing on vaccination, public health initiatives, and the crucial role of public awareness and education. Ethical and sociocultural considerations are discussed, underscoring the importance of culturally sensitive healthcare practices. These recommendations present a comprehensive overview of the challenges and strategies for managing HDV in these states. Policy recommendations are provided to support HDV management, including standardizing care protocols and promoting public health measures.

Obesity in Prediabetic Patients: Management of Metabolic Complications and Strategies for Prevention of Overt Diabetes

Obesity and prediabetes affect a substantial part of the general population, but are largely underdiagnosed, underestimated, and undertreated. Prediabetes differs from diabetes only in the degree of hyperglycaemia consequent to the progressive decline in residual beta-cell function. Both prediabetes and diabetes occur as a consequence of insulin resistance that starts several years before the clinical onset of overt diabetes. Macrovascular complications in patients with diabetes are mainly caused by insulin resistance. This is why in prediabetes, the overall cardiovascular risk is, by all means, similar to that in patients with diabetes. It is important, therefore, to identify prediabetes and treat patients not only to prevent or delay the onset of diabetes, but to reduce the cardiovascular risk associated with prediabetes. This review provides an overview of the pathophysiology of prediabetes in patients with obesity and the progression toward overt diabetes. We have reviewed nutritional and pharmacological approaches to the management of obesity and reduced glucose tolerance, and the treatment of the major comorbidities in these patients, including hypertension, dyslipidaemia, and Metabolic dysfunction-associated Steatotic Liver Disease (MASLD), has also been reviewed. In patients with obesity and prediabetes, the nutritional approach is similar to that adopted for patients with obesity and diabetes; treatments of dyslipidaemia and hypertension also have the same targets compared to patients with diabetes. MASLD is a critical issue in these patients; in the prediabetic state, MASLD rarely progresses into fibrosis. This highlights the importance of the early recognition of this pathological condition before patients become diabetic when the risk of fibrosis is much higher. It is necessary to raise awareness of the clinical relevance of this pathological condition in order to prompt early intervention before complications occur. The single most important therapeutic goal is weight loss, which must be early and persistent.

Prospective comparative diagnostic performance of quantitative ultrasound parameters for the measurement of hepatic steatosis in a biopsy-proven metabolic dysfunction associated steatotic liver disease cohort

OBJECTIVES

The aim of this study was to compare the diagnostic performance of attenuation imaging (ATI), shear wave elastography (SWE), and shear wave dispersion (SWD) for detecting and grading hepatic steatosis in patients with metabolic dysfunction associated steatotic liver disease (MASLD).

METHODS

Sixty-six patients with MASLD confirmed histopathologically and 34 healthy volunteers who were age/sex-matched were prospectively enrolled in this study. ATI, SWE, and SWD examinations were performed. Fibrosis stage, necroinflammatory activity, and steatosis grade were confirmed histopathologically. Steatosis was graded as follows: S0 (<5%); S1 (5%-32%); S2 (33%-66%) to S3 (>66%). We compared the diagnostic performance of ATI, SWE, and SWD for detecting and grading hepatic steatosis.

RESULTS

Both attenuation coefficient (AC) and SWD values were significantly different among the different hepatic steatosis, and both were correlated with hepatic steatosis. ATI had better diagnostic performance than SWD for detecting and grading hepatic steatosis. The area under the receiver operating characteristic (ROC) curve of ATI for detecting ≥S1, ≥S2, and =S3 were 0.917 (cut-off value of 0.69 dB/cm/MHz), 0.933 (cut-off value of 0.74 dB/cm/MHz), and 0.870 (cut-off value of 0.82 dB/cm/MHz), respectively. The area under the ROC curve of SWD value was 0.758 (cut-off value of 10.79 m/s/kHz), 0.685 (cut-off value of 12.64 m/s/kHz), and 0.722 (cut-off value of 13.24 m/s/kHz), respectively.

CONCLUSIONS

ATI technology is a reliable method for detecting and grading hepatic steatosis in patients with MASLD than SWE and SWD.

ADVANCES IN KNOWLEDGE

We compared the diagnostic performance of ATI, SWE, SWD for detecting and grading hepatic steatosis in patients with MASLD in order to find the best diagnostic parameters.

Application of a deep learning algorithm for the diagnosis of HCC

Background & Aims

Hepatocellular carcinoma (HCC) is characterized by a high mortality rate. The Liver Imaging Reporting and Data System (LI-RADS) results in a considerable number of indeterminate observations, rendering an accurate diagnosis difficult.

Methods

We developed four deep learning models for diagnosing HCC on computed tomography (CT) via a training-validation-testing approach. Thin-slice triphasic CT liver images and relevant clinical information were collected and processed for deep learning. HCC was diagnosed and verified via a 12-month clinical composite reference standard. CT observations among at-risk patients were annotated using LI-RADS. Diagnostic performance was assessed by internal validation and independent external testing. We conducted sensitivity analyses of different subgroups, deep learning explainability evaluation, and misclassification analysis.

Results

From 2,832 patients and 4,305 CT observations, the best-performing model was Spatio-Temporal 3D Convolution Network (ST3DCN), achieving area under receiver-operating-characteristic curves (AUCs) of 0.919 (95% CI, 0.903-0.935) and 0.901 (95% CI, 0.879-0.924) at the observation (n = 1,077) and patient (n = 685) levels, respectively during internal validation, compared with 0.839 (95% CI, 0.814-0.864) and 0.822 (95% CI, 0.790-0.853), respectively for standard of care radiological interpretation. The negative predictive values of ST3DCN were 0.966 (95% CI, 0.954-0.979) and 0.951 (95% CI, 0.931-0.971), respectively. The observation-level AUCs among at-risk patients, 2-5-cm observations, and singular portovenous phase analysis of ST3DCN were 0.899 (95% CI, 0.874-0.924), 0.872 (95% CI, 0.838-0.909) and 0.912 (95% CI, 0.895-0.929), respectively. In external testing (551/717 patients/observations), the AUC of ST3DCN was 0.901 (95% CI, 0.877-0.924), which was non-inferior to radiological interpretation (AUC 0.900; 95% CI, 0.877--923).

Conclusions

ST3DCN achieved strong, robust performance for accurate HCC diagnosis on CT. Thus, deep learning can expedite and improve the process of diagnosing HCC.

Impact and implications

The clinical applicability of deep learning in HCC diagnosis is potentially huge, especially considering the expected increase in the incidence and mortality of HCC worldwide. Early diagnosis through deep learning can lead to earlier definitive management, particularly for at-risk patients. The model can be broadly deployed for patients undergoing a triphasic contrast CT scan of the liver to reduce the currently high mortality rate of HCC.

Cholate Shunt, Oral Cholate Challenge and Endoscopic Lesions of Portal Hypertension: The SHUNT-V Study

BACKGROUND

The accuracy of current criteria for ruling out large oesophageal varices (LEV) and other endoscopic lesions of portal hypertension (PH) may be compromised by obesity and MASLD/MASH.

AIMS

In the US multicentre SHUNT-V study, we evaluated the disease severity index (DSI) for detecting LEV and other lesions of PH at endoscopy.

METHODS

Subjects were adults with compensated cirrhosis scheduled for endoscopy to screen for varices. DSI was calculated from clearances of labelled cholates after oral and intravenous administration. DSI ≤ 18.3 was evaluated as a cut-off for ruling out LEV with acceptance criteria of negative likelihood ratio < 0.52 and sensitivity > 85%.

RESULTS

SHUNT-V enrolled 306 subjects; 275 had both DSI and endoscopy, and 238 had Child-Pugh A cirrhosis (52.1% MASLD/MASH, 25.2% chronic hepatitis C and 15.6% alcoholic liver disease; 87% were overweight, 64% were obese and 54% had diabetes). AUROCs for DSI ranged from 0.81 to 0.82 for LEV and 0.79 to 0.80 for all significant PH lesions. DSI 18.3 had sensitivity 96.3%-100% for LEV and 97.3%-100% for all significant PH lesions. If DSI ≤ 18.3 were used as the sole determinant to defer EGD, 27%-35% of EGDs could have been avoided with 0%-3.7% of LEV and 0%-2.7% of all significant PH lesions missed.

CONCLUSIONS

HepQuant DSI predicts the likelihood of LEV and significant PH lesions across a spectrum of patient characteristics and disease aetiologies. DSI, based on liver function and portal-systemic shunting, can aid in the decision to defer endoscopy for varices in patients with Child-Pugh A cirrhosis.

TRIAL REGISTRATION

The SHUNT-V study was registered at ClinicalTrials.gov (NCT03583996).

The evolving role of liver biopsy: Current applications and future prospects

Histopathologic evaluation of liver biopsy has played a longstanding role in the diagnosis and management of liver disease. However, the utility of liver biopsy has been questioned by some, given the improved imaging modalities, increased availability of noninvasive serologic tests, and development of artificial intelligence over the past several years. In this review, we discuss the current and future role of liver biopsy in both non-neoplastic and neoplastic liver diseases in the era of improved noninvasive laboratory, radiologic, and digital technologies.

Noninvasive assessment of hepatic steatosis grades by ultrasound derived fat fraction in metabolic dysfunction associated steatotic liver disease

To evaluate the diagnostic performance of ultrasound-derived fat fraction (UDFF) and clinical prediction models in assessing hepatic steatosis grades in MASLD patients, with liver biopsy as reference standard.A total of 85 obese patients who were found to have fatty liver by B-mode ultrasound and underwent UDFF measurement, with liver biopsy available, were enrolled. The diagnostic performance of UDFF, clinical prediction models including fatty liver index (FLI), hepatic steatosis index (HSI), ZheJiang University index (ZJU index) and lipid accumulation product (LAP) for hepatic steatosis was assessed. The areas under receiver operating characteristics curves (AUROCs) were utilized to determine the diagnostic efficacy. DeLong test was used to compare the diagnostic performance of different noninvasive methods for hepatic steatosis. The UDFF values of S1, S2 and S3 groups were 17.53 ± 7.49%, 25.00 ± 5.41% and 27.58 ± 6.55%, respectively (P < 0.001). UDFF values were significantly positively correlated with histologic steatosis grades (r = 0.531, P < 0.001). In the ≥ S2 group, the AUROC of UDFF was higher than that of FLI and LAP (P < 0.05), but not significantly different from that of HSI and ZJU index (P > 0.05). In the ≥ S3 group, the AUROC of UDFF was higher than that of FLI, ZJU index and LAP (P < 0.05), but not significantly different from that of HSI (P > 0.05). The UDFF proves effective in assessing hepatic steatosis in patients with MASLD, and its diagnostic efficacy exceeded that of FLI and LAP, but there was no significant difference with HSI, ZJU index in the ≥ S2 group, and with HSI in the ≥ S3 group.

Prevalence and associated factors of MAFLD in adults with type 2 diabetes

To estimate the prevalence and associated factors of hepatic steatosis and fibrosis in adults with type 2 diabetes (T2DM) in the United States.Data were retrieved from the 2017‒March 2020 prepandemic cycle of the National Health and Nutritional Examination and Survey (NHANES). The study population included patients with T2DM. The controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) were used to assess hepatic steatosis and fibrosis, respectively. A total of 1,290 T2DM patients were included, 85.2% (1044 patients) of whom presented with hepatic steatosis (CAP>248 dB/m). Among the 1044 T2DM patients with metabolically associated fatty liver disease (MAFLD), 29.5% developed hepatic fibrosis (LSM>8 kPa). Non-Hispanic black individuals (adjusted OR = 0.4008), BMI (adjusted OR = 1.1627), HbA1c (adjusted OR = 1.1450), TG (adjusted OR = 1.2347), HDL (adjusted OR = 0.4981), ALT (adjusted OR = 1.0227), AST (adjusted OR = 0.9396), and albumin (adjusted OR = 1.7030) were independently associated with steatosis. Age (adjusted OR = 1.0300), female sex (adjusted OR = 0.6655), BMI (adjusted OR = 1.1324), AST (adjusted OR = 1.0483), and GGT (adjusted OR = 1.0101) were independently associated with fibrosis. Heart failure was an independent factor associated with advanced fibrosis (adjusted OR = 1.9129) and cirrhosis (adjusted OR = 2.228). In the United States, hepatic steatosis is highly prevalent among T2DM patients, with 29.5% of these patients developing hepatic fibrosis. Some components of metabolic syndrome are related to hepatic steatosis and fibrosis. Moreover, heart failure is an independent factor associated with advanced fibrosis and cirrhosis.

Diagnostic Efficacy of Vibration-Controlled Transient Elastography in Patients With Metabolic Dysfunction-Associated Liver Disease and Chronic Hepatitis B

Aim of the Study: HBV-infected individuals are also presenting with MASLD. However, the value of VCTE for detecting hepatic fibrosis and steatosis in CHB patients concurrent with MASLD is unclear. In patients with combined CHB and MASLD, we intend to assess the diagnostic efficacy of VCTE in determining the extent of fibrosis and steatosis. Methods: This retrospective study involved 368 patients diagnosed with chronic HBV infection combined with MASLD who received liver biopsy and VCTE at Xiamen City Traditional Chinese Medicine Hospital from June 2018 to June 2023. The cutoff values for liver stiffness measurement (LSM) and controlled attenuation parameter (CAP) were determined via the use of the cross-validated area under the receiver operating characteristic (AUROC) curve analyses to identify pairwise fibrosis stage and grade, respectively. The diagnostic statistics were calculated with a 90% fixed sensitivity and 90% specificity. Results: An AUROC of 0.86 (95% CI: 0.76-0.95) was determined by a LSM cutoff value of 11.25 to identify patients with cirrhosis. Patients have the following values: sensitivity, 0.79; specificity, 0.90; PPV, 0.89; and NPV, 0.81. An AUROC of 0.84 (95% CI: 0.76-0.95) was determined by a CAP cutoff value of 313 to identify patients with severe steatotic liver. Patients have the following values: sensitivity, 0.86; specificity, 0.82; PPV, 0.82; and NPV, 0.85. Conclusion:In this investigation of adult patients diagnosed with CHB with MASLD, VCTE demonstrated a robust capability to differentiate cirrhosis and severe steatotic liver.

Primary sclerosing cholangitis: Is qualitative and quantitative 3 T MR imaging useful for the evaluation of disease severity?

Purpose

To analyze the role of qualitative and quantitative 3 T MR imaging assessment as a non-invasive method for the evaluation of disease severity in patients with primary sclerosing cholangitis (PSC).

Methods

A series of 26 patients, with histological diagnosis of PSC undergoing 3 T MRI and hepatological evaluation, was retrospectively enrolled. All MR examinations included diffusion-weighted imaging (DWI), T2-weighted (T2w) and T1-weighted (T1w) sequences, before and after administration of Gd-EOB-DTPA with the acquisition of both dynamic and hepato-biliary phase (HBP). Qualitative analysis was performed by assessment of liver parenchyma and biliary tract changes, also including biliary excretion of gadoxetic acid on HBP. Quantitative evaluation was conducted on liver parenchyma by measurement of apparent diffusion coefficient (ADC) and relative enhancement (RE) on 3-minute delayed phase and on HBP. Results of blood tests (ALT, ALP, GGT, total and direct bilirubin, albumin, and platelets) and transient elastography-derived liver stiffness measurements (TE-LSM) were collected and correlated with qualitative and quantitative MRI findings.

Results

Among qualitative and quantitative findings, fibrosis visual assessment and RE had the best performance in estimating disease severity, showing a statistically significant correlation with both biomarkers of cholestasis and TE-LSM. Statistical analysis also revealed a significant correlation of gadoxetic acid biliary excretion with ALT and direct bilirubin, as well as of ADC with total bilirubin.

Conclusion

Qualitative and quantitative 3 T MR evaluation is a promising non-invasive method for the assessment of disease severity in patients with PSC.

A Multi-Institutional Study on Ultrasound Image Analysis for Staging HBV-Derived Liver Fibrosis: A Potential Noninvasive Alternative to Liver Stiffness Measurement

INTRODUCTION

Liver stiffness measurement is principal for staging liver fibrosis but not included in routine examinations. We investigated whether comparable diagnostic performance can be achieved by mining ultrasound images and developing a novel serum index (NSI).

METHODS

Texture features were extracted from ultrasound images. Spearman correlation and logistics regression selected independent variables for significant (F ≥ 2) and advanced (F ≥ 3) fibrosis. We compared the diagnostic performance of transient elastography (TE), ultrasound image biomarker, conventional serum indices (aspartate aminotransferase-to-platelet ratio index, fibrosis-4 index, gamma-glutamyl transpeptidase-to-platelet ratio), and NSI in 365 patients with chronic hepatitis B.

RESULTS

Among patients, 52.1% had significant fibrosis and 24.2% had advanced fibrosis. PLT, gamma-glutamyl transferase, prealbumin, and globulin were incorporated into NSI. In the validation group, TE achieved the best performance (area under the curve [AUC]: 0.765 [0.690-0.849] for significant fibrosis; 0.812 [0.745-0.878] for advanced fibrosis), followed by ultrasound image biomarker (AUC: 0.712 [0.629-0.795]; 0.678 [0.595-0.763]) and NSI (AUC: 0.630 [0.534-0.725]; 0.659 [0.572-0.745]), outperforming conventional indices.

DISCUSSION

Texture analysis enhances ultrasound's diagnostic utility, but TE remains superior. When TE is unavailable, ultrasound image analysis and NSI, incorporating prealbumin, can serve as alternative tools for fibrosis staging.

Predictors of liver fibrosis changes assessed by paired liver biopsies in chronic hepatitis C patients treated with direct-acting antivirals

BACKGROUND/PURPOSE

There are limited studies performing paired liver biopsies in chronic hepatitis C (CHC) patients treated with direct-acting antivirals (DAA). We aimed to investigate the predictors of liver fibrosis changes assessed by paired liver biopsies in these patients.

METHODS

From March 2017 to March 2020, 113 CHC patients were prospectively enrolled to receive DAA therapy at our hospital. Paired liver biopsies were performed at baseline and 12 weeks after the end of treatment.

RESULTS

Among the entire cohort, the rate of sustained virological response (SVR) was 100%. Four baseline variables independently predicted fibrosis regression, including age <65 years [odds ratio (OR) = 2.725, p = 0.036], fibrosis stages (METAVIR scores) < 3 (OR = 4.874, p = 0.040), hemoglobin levels ≥12.5 g/dL (OR = 3.538, p = 0.029), and platelet counts ≥160 103/μL (OR = 2.958, p = 0.023). Besides, five independent predictors of fibrosis progression included baseline age ≥66 years (OR = 16.351, p = 0.024), body mass index (BMI) ≥26.5 kg/m2 (OR = 21.666, p = 0.009), sofosbuvir/ribavirin use (OR = 29.465, p = 0.031), platelet counts <119 103/μL (OR = 33.739, p = 0.026), and the absence of alanine aminotransferase (ALT) levels declining from >35 U/L at baseline to ≤35 U/L at 4 weeks after baseline (OR = 284.534, p = 0.026).

CONCLUSION

For DAA-treated CHC patients, those with baseline age <65 years, fibrosis stages <3, hemoglobin levels ≥12.5 g/dL, or platelet counts ≥160 103/μL are more likely to attain fibrosis regression. There is a higher risk of fibrosis progression in those with baseline age ≥66 years, BMI ≥26.5 kg/m2, sofosbuvir/ribavirin use, platelet counts <119 103/μL, or the absence of early ALT normalization at 4 weeks after baseline.

Relevance of combined influence of nutritional and inflammatory status on non-alcoholic fatty liver disease and advanced fibrosis: A mediation analysis of lipid biomarkers

BACKGROUND AND AIM

This study aimed to investigate the relationship between advanced lung cancer inflammation index (ALI) and non-alcoholic fatty liver disease (NAFLD) and advanced liver fibrosis (AF).

METHODS

A total of 5642 individuals from the National Health and Nutrition Examination Survey (NHANES) between 2017 and 2020 were examined. Limited cubic spline regression model, and weighted logistic regression were employed to determine if ALI levels were related to the prevalence of NAFLD and AF. Additionally, a mediating analysis was conducted to investigate the role of lipid biomarkers, such as total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C), in the effects of ALI on the prevalence of NAFLD and AF.

RESULTS

After adjusting for potential confounders, a significant positive association was found between ALI with NAFLD and AF prevalence. Compared with those in ALI Tertile 1, participants in Tertile 3 had higher odds of NAFLD prevalence (odds ratio [OR]: 3.16; 95% confidence interval [CI]: 2.52-3.97) and AF (OR: 3.17; 95% CI: 2.30-4.36). Participants in both Tertile 2 and Tertile 3 had lower odds of developing AF (P for trend = 0.005). Moreover, we discovered a nonlinear association between ALI and NAFLD. An inflection point of 74.25 for NAFLD was identified through a two-segment linear regression model. Moreover, TC and HDL-C levels mediated the association between ALI and NAFLD by 10.2% and 4.2%, respectively (both P < 0.001).

CONCLUSION

Our findings suggest that higher ALI levels are positively associated with an increased prevalence of NAFLD and AF, partly mediated by lipid biomarkers.

Follow-up post-HCV virological response to DAA in advanced chronic liver disease

Direct-acting antivirals (DAA) achieve high virological response rates with minimal side effects for many patients. Despite their significant impact on the progression and epidemiology of hepatitis C virus (HCV) associated liver disease, the global annual incidence of chronic infections is expected to remain relatively constant, averaging 1.42 million new cases each year until 2030. Furthermore, by 2030, there will be a 14-17% increase in end-stage liver disease outcomes such as liver-related deaths, hepatocellular carcinoma (HCC), and decompensated cirrhosis in adults aged 18 years and over. Although reductions in liver decompensation, HCC occurrence, and mortality have been shown in patients with advanced liver disease who achieved sustained virological response (SVR) with DAA, these benefits may be less significant in those with decompensated liver cirrhosis. This review aims to summarise the impact of the virological response to DAA on liver disease progression and outcomes in patients with advanced chronic liver disease, which appears to be crucial for defining patient-specific follow-up.

Non-invasive prediction nomogram for predicting significant fibrosis in patients with metabolic-associated fatty liver disease: a cross-sectional study

BACKGROUND AND AIM

This study aims to validate the efficacy of the conventional non-invasive score in predicting significant fibrosis in metabolic-associated fatty liver disease (MAFLD) and to develop a non-invasive prediction model for MAFLD.

METHODS

This cross-sectional study was conducted among 7701 participants with MAFLD from August 2018 to December 2023. All participants were divided into a training cohort and a validation cohort. The study compared different subgroups' demographic, anthropometric, and laboratory examination indicators and conducted logistic regression analysis to assess the correlation between independent variables and liver fibrosis. Nomograms were created using the logistic regression model. The predictive values of noninvasive models and nomograms were evaluated using receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA).

RESULTS

Four nomograms were developed for the quantitative analysis of significant liver fibrosis risk based on the multivariate logistic regression analysis results. The nomogram's area under ROC curves (AUC) was 0.710, 0.714, 0.748, and 0.715 in overall MAFLD, OW-MAFLD, Lean-MAFLD, and T2DM-MAFLD, respectively. The nomogram had a higher AUC in all MAFLD participants and OW-MAFLD than the other non-invasive scores. The DCA curve showed that the net benefit of each nomogram was higher than that of APRI and FIB-4. In the validation cohort, the AUCs of the nomograms were 0.722, 0.750, 0.719, and 0.705, respectively.

CONCLUSION

APRI, FIB-4, and NFS performed poorly predicting significant fibrosis in patients with MAFLD. The new model demonstrated improved diagnostic accuracy and clinical applicability in identifying significant fibrosis in MAFLD.

Regression of liver fibrosis after HBsAg loss: A prospective matched case-control evaluation using transient elastography and serum enhanced liver fibrosis test

BACKGROUND AND AIM

We assessed the effect of hepatitis B surface antigen (HBsAg) seroclearance (HBsAg-loss) on liver fibrosis regression in patients with chronic hepatitis B (CHB) infection.

METHOD

CHB patients with recent documented HBsAg-loss were age- and gender-matched with treatment-naïve HBeAg-negative CHB infection. Paired assessment with transient elastography and enhanced liver fibrosis (ELF) measurements were performed and repeated at 3 years. Fibrosis regression was arbitrarily defined as decrease in ≥ 1 fibrosis stage by ELF, or combining with reduction > 30% in liver stiffness.

RESULTS

A total of 142 HBsAg-loss and 142 CHB subjects were recruited (median age 58.1 years, 51.4% male). A total of 1.8% (1.4% HBsAg-loss vs 2.1% CHB) achieved combined endpoint of fibrosis regression at 3 years. When ELF-only definition of fibrosis regression was used, 14.5% HBsAg-loss and 16.9% CHB subjects achieved this endpoint, which was significantly associated with baseline ELF (hazard ratio (HR) 1.827, 95% confidence interval (CI) 1.085-3.075) and time since HBsAg-loss (HR 2.688, 95% CI 1.257-5.748). While increasing time since HBsAg-loss increased the proportion of ELF-defined fibrosis regression, increasing age was also associated with significant fibrosis. Age of achieving HBsAg-loss (ageSC) was independently associated with high baseline ELF values. Up to 52.3% and 63.8% subjects with ageSC > 50 had advanced fibrosis/cirrhosis at baseline and 3 years, respectively, compared with 5.9% and 20.6% in subjects with ageSC < 50.

CONCLUSION

Fibrosis regression occurred in a minority of subjects achieving HBsAg-loss, which was not significantly different compared with subjects with persistent overt CHB. Subjects after achieving HBsAg-loss, especially among those with ageSC > 50, should receive ongoing surveillance for liver-related complications.

Plasma microRNA-15a/16-1 serves as a non-invasive indicator of liver fibrosis severity in individuals with chronic hepatitis B

Background

The lack of effective non-invasive diagnostic methods for liver fibrosis hinders timely treatment for chronic hepatitis B (CHB) patients, leading to the progression of advanced liver disease. Circulating microRNAs offer a non-invasive approach to fibrosis assessment. MicroRNA-15a/16-1 (miR-15a/16) was reported to be implicated in fibrosis development, but the role of plasma miR-15a/16 in liver fibrosis assessment remains poorly understood. This study explored the importance of plasma miR-15a/16 in assessing liver fibrosis severity of CHB patients.

Methods

Quantitative PCR was utilized to measure the levels of plasma miR-15a/16 in 435 patients with CHB and 74 healthy controls. We assessed the correlation between plasma miR-15a/16 levels and liver fibrosis and cirrhosis using Pearson correlation coefficients, multivariate linear and logistic regression models, and smooth curve fitting. Utilizing the receiver operating characteristic (ROC) curve, we examined the diagnostic potential of plasma miR-15a/16 in severe fibrosis and cirrhosis.

Results

Plasma levels of miR-15a/16 in patients with CHB were significantly reduced compared to those in healthy controls. In the CHB cohort, levels were notably decreased in individuals with severe fibrosis or cirrhosis compared to those without severe fibrosis or cirrhosis. Plasma miR-15a/16 levels exhibited a negative relationship with the severity of liver fibrosis, gradually decreasing as the histological fibrosis stage progressed from S0 to S4. Reduced levels of plasma miR-15a/16 were linked to an elevated risk of severe liver fibrosis (miR-15a: odds ratio [OR] = 0.243; 95 % confidence interval [CI]: 0.138, 0.427; miR-16: OR = 0.201; 95 % CI: 0.097, 0.417) and cirrhosis (miR-15a: OR = 0.153; 95 % CI: 0.079, 0.298; miR-16: OR = 0.064; 95 % CI: 0.025, 0.162). MiR-15a achieved an area under the ROC curve of 0.886 and 0.832 for detecting moderate-to-severe fibrosis (S2-S4) and cirrhosis, respectively. MiR-16 demonstrated similar diagnostic values.

Conclusion

Plasma miR-15a/16 levels were negatively correlated with the severity of liver fibrosis in CHB patients and could serve as a new non-invasive indicator in evaluating liver fibrosis.

Comparison of different noninvasive scores for assessing hepatic fibrosis in a cohort of chronic hepatitis C patients

The continuous search for simple, noninvasive methods for assessing liver fibrosis remains very important to help risk-stratify and follow-up patients with chronic hepatitis C virus (HCV). This study aimed to evaluate the diagnostic performance and accuracy of six serological noninvasive scores for the assessment of liver fibrosis in comparison to liver histopathology. This retrospective cohort study included data from 19501 patients with chronic HCV infection who had liver biopsies as an HCV treatment prerequisite within the Egyptian national HCV treatment program. Six noninvasive scores (FIB-4, APRI, King's score, Fibro-Q, fibrosis index, Fibro-α score) were evaluated and compared to liver histopathology data in assessing different stages of liver fibrosis. The diagnostic performance for each score was assessed using the area under the receiver-operating characteristic curve (AUROC). All six noninvasive scores were statistically significant for predicting different stages of liver fibrosis. Four scores (FIB-4, King's score, APRI, and Fibro Q) had a better diagnostic performance for predicting different fibrosis stages. FIB-4, followed by the King's score, performs better in identifying patients with advanced fibrosis at cutoffs of 2.01 and 16.7, respectively, with AUROC of 0.71 for both, and in predicting cirrhosis at cutoffs of 2.21 and 17.4, respectively with AUROC 0.82 for both. Using noninvasive scores for fibrosis assessment is very important, especially in limited resource settings, to rapidly stratify patients who need more specialized care.

[Noninvasive Imaging Test to Assess Liver Fibrosis: Vibration-controlled Transient Elastography]

Liver fibrosis refers to the formation of scar tissue in the liver when inflammation persists over a long period. Assessing liver fibrosis is crucial for predicting the prognosis of chronic liver disease and managing patients with these conditions. Although a liver biopsy remains the gold standard for assessing liver fibrosis, it is limited by its invasive nature. Consequently, continuous efforts have been made to develop non-invasive methods for evaluating liver fibrosis, including imaging techniques and serum biomarkers. Vibration-controlled transient elastography (VCTE), a representative non-invasive imaging technique, has been used widely for liver fibrosis assessment since its introduction in 2003. This paper discusses the principles and methods of measurement, the advantages and disadvantages, and the considerations for interpreting VCTE based on the 2024 KASL Clinical Practice Guidelines for Non-invasive Tests to Assess Liver Fibrosis in Chronic Liver Disease. In addition, the diagnostic utility of VCTE in chronic viral hepatitis is reviewed.

Explainable machine learning model for predicting the risk of significant liver fibrosis in patients with diabetic retinopathy

BACKGROUND

Diabetic retinopathy (DR), a prevalent complication in patients with type 2 diabetes, has attracted increasing attention. Recent studies have explored a plausible association between retinopathy and significant liver fibrosis. The aim of this investigation was to develop a sophisticated machine learning (ML) model, leveraging comprehensive clinical datasets, to forecast the likelihood of significant liver fibrosis in patients with retinopathy and to interpret the ML model by applying the SHapley Additive exPlanations (SHAP) method.

METHODS

This inquiry was based on data from the National Health and Nutrition Examination Survey 2005-2008 cohort. Utilizing the Fibrosis-4 index (FIB-4), liver fibrosis was stratified across a spectrum of grades (F0-F4). The severity of retinopathy was determined using retinal imaging and segmented into four discrete gradations. A ten-fold cross-validation approach was used to gauge the propensity towards liver fibrosis. Eight ML methodologies were used: Extreme Gradient Boosting, Random Forest, multilayer perceptron, Support Vector Machines, Logistic Regression (LR), Plain Bayes, Decision Tree, and k-nearest neighbors. The efficacy of these models was gauged using metrics, such as the area under the curve (AUC). The SHAP method was deployed to unravel the intricacies of feature importance and explicate the inner workings of the ML model.

RESULTS

The analysis included 5,364 participants, of whom 2,116 (39.45%) exhibited notable liver fibrosis. Following random allocation, 3,754 individuals were assigned to the training set and 1,610 were allocated to the validation cohort. Nine variables were curated for integration into the ML model. Among the eight ML models scrutinized, the LR model attained zenith in both AUC (0.867, 95% CI: 0.855-0.878) and F1 score (0.749, 95% CI: 0.732-0.767). In internal validation, this model sustained its superiority, with an AUC of 0.850 and an F1 score of 0.736, surpassing all other ML models. The SHAP methodology unveils the foremost factors through importance ranking.

CONCLUSION

Sophisticated ML models were crafted using clinical data to discern the propensity for significant liver fibrosis in patients with retinopathy and to intervene early.

PRACTICE IMPLICATIONS

Improved early detection of liver fibrosis risk in retinopathy patients enhances clinical intervention outcomes.

Sodium taurocholate cotransporting polypeptide (NTCP) polymorphisms may influence HDV RNA load and early response to bulevirtide

BACKGROUND & AIMS

Genetic polymorphisms in the sodium taurocholate cotransporting peptide (NTCP encoded by SLC10A1) have been described, but their role in untreated and treated patients with chronic hepatitis delta (CHD) remains unknown. Virological response (VR) to the NTCP inhibitor bulevirtide (BLV) was achieved at week 48 by >70% of patients with CHD, but nearly 15% experienced virological non-response (VNR) or partial response (PR). This study aimed to evaluate whether NTCP genetic polymorphisms affect baseline HDV RNA load and response to BLV in patients with CHD.

METHODS

BLV-untreated and -treated patients were enrolled in a retrospective cross-sectional and longitudinal study. Clinical and virological characteristics were collected at baseline and up to 96 weeks in the BLV-treated patients. NTCP genetic polymorphisms were identified by Sanger sequencing.

RESULTS

Of the six NTCP polymorphisms studied in 209 untreated patients with CHD, carriers of the rs17556915 TT/CC (n = 142) compared to CT (n = 67) genotype presented with higher median HDV RNA levels (5.39 vs. 4.75 log10 IU/ml, p = 0.004). Of 209 patients receiving BLV monotherapy at 2 mg/day, 76 were evaluated at week 24 and 40 up to week 96. Higher mean baseline HDV RNA levels were confirmed in TT/CC (n = 43) compared to CT (n = 33) carriers (5.38 vs. 4.72 log10 IU/ml, p = 0.010). Although 24-week VR was comparable between TT/CC and CT carriers (25/43 vs. 17/33, p = 0.565), the former group presented VNR more often than PR (9/11 vs. 9/23, p = 0.02) at week 24. 7/9 TT/CC genotype carriers remained VNR at week 48 of BLV treatment.

CONCLUSIONS

The NTCP rs17556915 C>T genetic polymorphisms may influence baseline HDV RNA load both in BLV-untreated and -treated patients with CHD and may contribute to identifying patients with different early virological responses to BLV.

IMPACT AND IMPLICATIONS

Although several sodium taurocholate cotransporting polypeptide (NTCP) genetic polymorphisms have been described, no data are available on their potential role in modifying HDV RNA load or treatment response to bulevirtide (BLV) in patients with chronic hepatitis delta (CHD). In this study, we demonstrated that patients with CHD, either treated or untreated, carrying NTCP rs17556915 TT/CC, presented higher baseline HDV RNA levels compared to those with the CT genotype. Higher HDV RNA levels in TT/CC carriers compared to CT carriers were also confirmed in patients with CHD treated with BLV monotherapy up to 96 weeks. Furthermore, carriers of TT/CC, compared to CT genotype, more frequently showed viral non-response (VNR) than partial response (PR) at week 24 of BLV treatment, and 7/9 TT/CC genotype carriers remained VNR at week 48 of BLV treatment. This is the first study demonstrating a potential role of NTCP genetic polymorphisms in influencing HDV viral load and early virological response to BLV monotherapy. Since no direct HDV resistance to BLV has been described so far, if confirmed in larger studies, the genetic polymorphisms in NTCP may help identify patients with different patterns of early virological response to BLV.

A preoperative model to predict overall survival in patients with hepatoma undergoing resection

BACKGROUND

We aimed to develop a preoperative model to predict overall survival (OS) in patients with hepatoma undergoing liver resection (LR).

METHODS

Patients who underwent LR for Barcelona Clinic Liver Cancer (BCLC) stage 0, A, or B hepatoma were enrolled. Tumor burden score (TBS) scores were determined using the following equation: TBS (Pinna et al., 2018) 2 = (largest tumor size [in cm])(Pinna et al., 2018) 2 ​+ ​(tumor number) (Pinna et al., 2018) 22. The cutoff values for radiographic TBS were based on our recently published paper: low, <2.6; medium, 2.6-7.9; high, >7.9.

RESULTS

Multivariate analysis showed that radiographic TBS (low: referent; medium: HR ​= ​2.89; 95 ​% CI: 1.60-5.21; p ​< ​0.001; high, HR ​= ​7.60; 95 ​% CI: 3.80-15.2; p ​< ​0.001), AFP (<400 ​ng/mL: referent; ≧400 ​ng/mL: HR ​= ​1.67, 95 ​% CI: 1.11-2.52, p ​= ​0.014), and cirrhosis (absence: referent; presence: HR ​= ​1.88, 95 ​% CI: 1.30-2.72, p ​< ​0.001) were associated with OS. A simplified risk score was superior to BCLC system in concordance index (0.688 vs. 0.623).

CONCLUSIONS

We have developed a preoperative model that performs better in predicting OS than the BCLC system.

Imaging of Cirrhosis and Hepatocellular Carcinoma: Current Evidence

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related deaths worldwide. Early detection of HCC is a key factor in enabling curative therapies and improving overall survival. Worldwide, several guidelines are available for surveillance of at-risk populations and diagnosis of HCC. This article provides a current comprehensive update on screening and diagnosis of HCC.

Prediction of Hepatocellular Carcinoma and Liver-related Events in Anti-hepatitis D Virus-positive Individuals

BACKGROUND & AIMS

Chronic hepatitis D (CHD) is the most severe form of chronic viral hepatitis, with a high risk of developing hepatocellular carcinoma (HCC) and liver-related mortality. Risk stratification is needed to guide HCC surveillance strategies and to prioritize treatment with antiviral agents.

METHODS

We conducted a multicenter retrospective cohort of anti-hepatitis D virus (HDV)-positive individuals managed at sites in the Netherlands and the United Kingdom. We studied the 5-year cumulative incidences of HCC and liver-related events (first of HCC, liver transplantation, and liver-related mortality), in the overall cohort and among relevant subgroups.

RESULTS

We analyzed 269 anti-HDV-positive individuals with a median follow-up of 4.3 years in which 47 first events occurred. The 5-year cumulative incidences of HCC and liver-related events were 3.8% and 15.6% in the overall cohort. The 5-year cumulative incidence of HCC and liver-related events for individuals without cirrhosis was 0% and 0.9% compared with 12% and 41.3% for individuals with cirrhosis (P < .001). The 5-year cumulative incidence of HCC and liver-related events was 0% and 2.1% among individuals with low PAGE-B scores, compared to 3.2% and 21.1% with intermediate and 25.4% and 45.5% with high-risk scores (P < .001). We found comparable results for the Fibrosis-4 score. Findings were consistent regardless of cirrhosis or detectable HDV RNA (P < .001).

CONCLUSION

Anti-HDV-positive individuals are at high risk of adverse liver-related outcomes. The incidence of HCC was negligible among individuals without cirrhosis and among individuals with low baseline PAGE-B and/or Fibrosis-4 scores. Therefore, these scores can be used to guide HCC surveillance strategies and potentially also for treatment prioritization.

Risk factors for significant histological changes in both HBeAg positive and negative treatment-naive chronic hepatitis B with persistently normal alanine aminotransferase level

BACKGROUND

Chronic hepatitis B virus (HBV) infection remains a serious health issue, and determining the optimal time for antiviral therapy is challenging. We aimed to assess liver histological changes in patients with HBeAg-positive chronic hepatitis B (CHB) and those with HBeAg-negative CHB who had persistently normal alanine aminotransferase and to determine the association between significant liver injury and various clinical parameters.

METHODS

We retrospectively included, in this study, 339 treatment-naïve patients with chronic HBV infections who had persistently normal alanine aminotransferase and underwent liver biopsy from 2013 to 2023. Histologic assessment was based on the Metavir scoring system to evaluate the association between clinical characteristics and the severity of liver inflammation and fibrosis.

RESULTS

Among the included participants, 138 were HBeAg-positive and 201 were HBeAg-negative. Lower hepatitis B surface antigen (HBsAg) (P = 0.003) and higher aspartate aminotransferase (AST) (P = 0.002) levels were associated with significant necroinflammation, whereas increasing age (P = 0.004) and lower HBV DNA (P < 0.001) levels were associated with significant fibrosis in HBeAg-positive patients with normal ALT levels. Higher HBV-DNA (P = 0.001) and AST levels(P < 0.001) were associated with significant necroinflammation, and higher AST(P < 0.001) levels were associated with significant fibrosis in HBeAg-negative patients.

CONCLUSIONS

A substantial proportion of patients with HBV infection who had normal ALT presented significant liver injury. HBsAg and AST were independent predictive factors for evaluating inflammation, while HBV DNA load and age were independent predictive factors for evaluating fibrosis in the HBeAg-positive group. HBV DNA load and AST were independent predictive factors for evaluating inflammation, while AST were independent predictive factors for evaluating fibrosis in the HBeAg-negative group.

Meta-analysis: accuracy of the Baveno VI criteria for the diagnosis of high-risk varices in patients with hepatocellular carcinoma

Background and aim

Diagnosing high-risk varices (HRV) is crucial for determining the prognosis and treatment strategy in patients with hepatocellular carcinoma (HCC). Although the Baveno VI consensus guidelines have been validated for assessing HRV in patients with liver cirrhosis, their applicability to those with HCC remains uncertain. This study aims to evaluate the effectiveness of the Baveno VI criteria in screening for HRV in patients with HCC.

Methods

We searched for English-language articles related to Baveno criteria and HCC across PubMed, Embase, Web of Science, and Cochrane databases, covering publications from their inception until April 19, 2024. Our meta-analysis was conducted using STATA 14.0 and Meta-Disc 1.4 software. We assessed the quality of the included studies using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. We analyzed pooled sensitivity (SEN), specificity (SPE), diagnostic odds ratio (DOR), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) using a random-effects model and constructed a summary receiver operating characteristic (SROC) curve. Based on established consensus, the favorable Baveno VI criteria were defined as a liver stiffness measurement (LSM) < 20 kPa and a platelet count (PLT) > 150×109/L to exclude HRV. This study is registered with PROSPERO under the registration number CRD42024533946.

Results

We finally brought four studies, including 1277 patients with HCC, into this meta-analysis. The SEN, SPE, DOR, and AUC of favorable Baveno VI criteria in screening HRV in patients with HCC were 0.90 (95% CI: 0.81-0.95), 0.33 (95% CI: 0.25-0.41), 4.44 (95% CI: 2.14-9.22), and 0.59 (95% CI: 0.55-0.64), respectively. The LR+ and LR- of the favorable Baveno VI criteria were 1.34 (95% CI: 1.19-1.50) and 0.30 (95% CI: 0.16-0.58), respectively. Subgroup and meta-regression analyses indicated that BCLC and Child-Pugh stages likely contribute to the heterogeneity in the SPE.

Conclusions

The favorable Baveno VI criteria may not effectively screen HRV in patients with HCC. However, the current evidence is insufficient, and further studies with larger sample sizes and detailed patient subgroups are needed.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024533946.

Prognostic significance of dynamic changes in liver stiffness measurement in patients with chronic hepatitis B and compensated advanced chronic liver disease

BACKGROUND AND AIM

Liver stiffness measurements (LSMs) are promising for monitoring disease progression or regression. We assessed the prognostic significance of dynamic changes in LSM over time on liver-related events (LREs) and death in patients with chronic hepatitis B (CHB) and compensated advanced chronic liver disease (cACLD).

METHODS

This retrospective study included 1272 patients with CHB and cACLD who underwent at least two measurements, including LSM and fibrosis score based on four factors (FIB-4). ΔLSM was defined as [(follow-up LSM - baseline LSM)/baseline LSM × 100]. We recorded LREs and all-cause mortality during a median follow-up time of 46 months. Hazard ratios (HRs) and confidence intervals (CIs) for outcomes were calculated using Cox regression.

RESULTS

Baseline FIB-4, baseline LSM, ΔFIB-4, ΔLSM, and ΔLSM/year were independently and simultaneously associated with LREs (adjusted HR, 1.04, 95% CI, 1.00-1.07; 1.02, 95% CI, 1.01-1.03; 1.06, 95% CI, 1.03-1.09; 1.96, 95% CI, 1.63-2.35, 1.02, 95% CI, 1.01-1.04, respectively). The baseline LSM combined with the ΔLSM achieved the highest Harrell's C (0.751), integrated AUC (0.776), and time-dependent AUC (0.737) for LREs. Using baseline LSM and ΔLSM, we proposed a risk stratification method to improve clinical applications. The risk proposed stratification based on LSM performed well in terms of prognosis: low risk (n = 390; reference), intermediate risk (n = 446; HR = 3.38), high risk (n = 272; HR = 5.64), and extremely high risk (n = 164; HR = 11.11).

CONCLUSIONS

Baseline and repeated noninvasive tests measurement allow risk stratification of patients with CHB and cACLD. Combining baseline and dynamic changes in the LSM improves prognostic prediction.