1
|
Armandi A, Merizian T, Werner MM, Coxson HO, Sanavia T, Birolo G, Gashaw I, Ertle J, Michel M, Galle PR, Labenz C, Emrich T, Schattenberg JM. Variability of transient elastography-based spleen stiffness performed at 100 Hz. Eur Radiol Exp 2023; 7:79. [PMID: 38087079 PMCID: PMC10716091 DOI: 10.1186/s41747-023-00393-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/11/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Spleen stiffness measurement (SSM) performed by transient elastography at 100 Hz is a novel technology for the evaluation of portal hypertension in advanced chronic liver disease, but technical aspects are lacking. We aimed to evaluate the intraexamination variability of SSM and to determine the best transient elastography protocol for obtaining robust measurements to be used in clinical practice. METHODS We analyzed 253 SSM exams with up to 20 scans for each examination, performed between April 2021 and June 2022. All SSM results were evaluated according to different protocols by dividing data into groups of n measurements (from 2 to 19). Considering as reference the median SSM values across all the 20 measurements, we calculated the distribution of the absolute deviations of each protocol from the reference median. This analysis was repeated 1,000 times by resampling the data. Distributions were also stratified by etiology (chronic liver disease versus clinically significant portal hypertension) and different SSM ranges: < 25 kPa, 25-75, and > 75 kPa. RESULTS Overall, we observed that the spleen stiffness exam had less variability if it exceeded 12 measurements, i.e., absolute deviations ≤ 5 kPa at 95% confidence. For exams with higher SSM values (> 75 kPa), as seen in clinically significant portal hypertension, at least 15 measurements are highly recommendable. CONCLUSIONS Fifteen scans per examination should be considered for each SSM exam performed at 100 Hz to achieve a low intraexamination variability within a reasonable time in clinical practice. RELEVANCE STATEMENT Performing at least 15 scans per examination is recommended for 100 Hz SSM in order to achieve a low intraexamination variability, in particular for values > 75 kPa compatible with clinically significant portal hypertension. KEY POINTS • Spleen stiffness measurement by transient elastography is used for stratification in patients with portal hypertension. • At 100 Hz, this method may have intraexamination variability. • A minimum of 15 scans per examination achieves a low intraexamination variability.
Collapse
Affiliation(s)
- Angelo Armandi
- Division of Gastroenterology and Hepatology, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, Turin, 10126, Italy
- Metabolic Liver Disease Research Program, I. Department of Medicine, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, Mainz, 55131, Germany
| | - Talal Merizian
- Metabolic Liver Disease Research Program, I. Department of Medicine, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, Mainz, 55131, Germany
| | - Merle Marie Werner
- Metabolic Liver Disease Research Program, I. Department of Medicine, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, Mainz, 55131, Germany
| | - Harvey O Coxson
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach & Ingelheim, Germany
| | - Tiziana Sanavia
- Computational Biomedicine Unit, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, Turin, 10126, Italy
| | - Giovanni Birolo
- Computational Biomedicine Unit, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, Turin, 10126, Italy
| | - Isabella Gashaw
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach & Ingelheim, Germany
| | - Judith Ertle
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Maurice Michel
- Metabolic Liver Disease Research Program, I. Department of Medicine, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, Mainz, 55131, Germany
| | - Peter R Galle
- Metabolic Liver Disease Research Program, I. Department of Medicine, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, Mainz, 55131, Germany
| | - Christian Labenz
- Metabolic Liver Disease Research Program, I. Department of Medicine, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, Mainz, 55131, Germany
| | - Tilman Emrich
- Department of Radiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, Mainz, 55131, Germany
| | - Jörn M Schattenberg
- Metabolic Liver Disease Research Program, I. Department of Medicine, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, Mainz, 55131, Germany.
| |
Collapse
|
2
|
Rinaldi L, Giorgione C, Mormone A, Esposito F, Rinaldi M, Berretta M, Marfella R, Romano C. Non-Invasive Measurement of Hepatic Fibrosis by Transient Elastography: A Narrative Review. Viruses 2023; 15:1730. [PMID: 37632072 PMCID: PMC10459581 DOI: 10.3390/v15081730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/04/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
Transient elastography by FibroScan® (Echosens, Paris, France) is a non-invasive method that can provide a reliable measurement of liver fibrosis through the evaluation of liver stiffness. Despite its limitations and risks, liver biopsy has thus far been the only procedure able to provide data to quantify fibrosis. Scientific evidence and clinical practice have made it possible to use FibroScan® in the diagnostic work-up of several liver diseases to monitor patients' long-term treatment response and for complication prevention. For these reasons, this procedure is widely used in clinical practice and is still being investigated for further applications. The aim of this narrative review is to provide a comprehensive overview of the main applications of transient elastography in the current clinical practice.
Collapse
Affiliation(s)
- Luca Rinaldi
- Department of Advanced Medical and Surgical Sciences, “Luigi Vanvitelli” University of Campania, 80131 Naples, Italy; (L.R.); (R.M.)
| | - Chiara Giorgione
- Department of Advanced Medical and Surgical Sciences, “Luigi Vanvitelli” University of Campania, 80131 Naples, Italy; (L.R.); (R.M.)
| | - Andrea Mormone
- Department of Advanced Medical and Surgical Sciences, “Luigi Vanvitelli” University of Campania, 80131 Naples, Italy; (L.R.); (R.M.)
| | - Francesca Esposito
- Department of Advanced Medical and Surgical Sciences, “Luigi Vanvitelli” University of Campania, 80131 Naples, Italy; (L.R.); (R.M.)
| | - Michele Rinaldi
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II” University of Naples, 80131 Naples, Italy;
| | - Massimiliano Berretta
- Department of Clinical and Experimental Medicine, University of Messina, 98121 Messina, Italy;
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, “Luigi Vanvitelli” University of Campania, 80131 Naples, Italy; (L.R.); (R.M.)
| | - Ciro Romano
- Department of Advanced Medical and Surgical Sciences, “Luigi Vanvitelli” University of Campania, 80131 Naples, Italy; (L.R.); (R.M.)
| |
Collapse
|
3
|
Ljungquist O, Olinder J, Tverring J, Kjölvmark C, Torisson G. Agreement and reliability of hepatic transient elastography in patients with chronic hepatitis C: A cross‐sectional test–retest study. Health Sci Rep 2023; 6:e1184. [PMID: 37021011 PMCID: PMC10069238 DOI: 10.1002/hsr2.1184] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/26/2023] [Accepted: 02/16/2023] [Indexed: 04/05/2023] Open
Abstract
Background and Aims Transient elastography (TE) has largely replaced liver biopsy to evaluate fibrosis stage and cirrhosis in chronic hepatitis C. Previous studies have reported excellent reliability of TE but agreement metrics have not been reported. This study aimed to assess interrater agreement and reliability of repeated TE measurements. Methods Two operators performed TE independently, directly after each other. The primary outcome was disagreement, defined as a difference in TE results between operators of ≥33%, as well as the smallest detectable change, SDC95 (i.e., the difference between measurements needed to state with 95% certainty that there is a difference in underlying stiffness). Secondary outcomes included reliability, measured as intraclass correlation (ICC), and patient and examination characteristics associated with the agreement. Results In total, 65 patients were included, with a mean liver stiffness of 9.7 kPa. Of these, 21 (32%) had a disagreement in TE results of ≥33% between the two operators. The SDC95 on the log scale was 1.97, indicating that an almost twofold increase or decrease in liver stiffness would be required to confidently represent a change in the underlying fibrosis. Reliability, estimated using the ICC, was acceptable at 0.86. In a post hoc analysis, fasting less than 5 h before TE was associated with a higher degree of disagreement (48% vs. 19%, p = 0.03). Conclusions In our clinical setting, interrater agreement in directly repeated TE measurements was surprisingly low. It is essential to further investigate the reliability and agreement of TE to determine its validity and usefulness.
Collapse
Affiliation(s)
- Oskar Ljungquist
- Department of Infectious DiseasesHelsingborg HospitalHelsingborgSweden
- Division of Infection Medicine, Department of Clinical SciencesLund UniversityLundSweden
| | - Jon Olinder
- Department of Infectious DiseasesHelsingborg HospitalHelsingborgSweden
- Division of Infection Medicine, Department of Clinical SciencesLund UniversityLundSweden
| | - Jonas Tverring
- Department of Infectious DiseasesHelsingborg HospitalHelsingborgSweden
- Division of Infection Medicine, Department of Clinical SciencesLund UniversityLundSweden
| | | | - Gustav Torisson
- Clinical Infection Medicine, Department of Translational Medicine, Faculty of MedicineLund UniversityMalmöSweden
- Department of Infectious DiseasesSkåne University HospitalMalmöSweden
| |
Collapse
|
4
|
Carmiel Haggai M, Sgayer I, Bornstein J, Odeh M, Lowenstein L, Frank Wolf M. Liver stiffness and steatosis in preeclampsia as shown by transient elastography-a prospective cohort study. Am J Obstet Gynecol 2022; 227:515.e1-515.e9. [PMID: 35500613 DOI: 10.1016/j.ajog.2022.04.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Preeclampsia is a multisystem disorder and the leading cause of severe morbidity and death in pregnancy. Liver involvement in preeclampsia ranges from elevated liver enzyme levels to hepatic infarction or rupture. Endothelial dysfunction leads to changes in blood flow and congestion and may be involved in the pathophysiology of preeclampsia. Changes in splanchnic blood flow and portal congestion can lead to altered liver stiffness. Transient elastography is a noninvasive, ultrasound-based technique that measures organ stiffness and steatosis and is therefore widely used in clinical hepatology. Previous studies reported elevated liver stiffness and liver steatosis, as measured by transient elastography, in women with preeclampsia. OBJECTIVE This study followed changes in liver stiffness and steatosis, as measured by transient elastography, from the antepartum period to 1-week postpartum among women with preeclampsia compared with healthy controls and evaluated the association between preeclampsia severity and transient elastography results. STUDY DESIGN This prospective cohort study was conducted from 2017 through 2021. The study group comprised women with preeclampsia, and the control group comprised healthy pregnant women hospitalized for other reasons. All the participants underwent transient elastography either on diagnosis of preeclampsia (study group) or on hospital admission (control group) and again in the postpartum period. Liver stiffness measurements are expressed in kilopascals (kPa) in the range of 2.5 to 75 kPa, and liver steatosis is expressed by controlled attenuation parameter in the range of 100 to 400 dB/m. RESULTS The study group comprised 36 women and the control group 37. Liver stiffness scores were significantly elevated in the study when compared with the control group, both in the antepartum period (P<.001) and the postpartum period (P=.025). Liver stiffness scores decreased significantly after delivery in the study and control groups (P<.001 and P=.002, respectively). Liver steatosis scores were higher in the study group than in the control group both in the antepartum and postpartum periods (P<.001 and P<.02, respectively). In the multivariable analysis, the diagnosis of preeclampsia correlated with higher antepartum liver stiffness scores (P=.005). For the study group, postpartum liver stiffness and liver steatosis scores were increased among those with vs those without severe features of preeclampsia (P=.03 and P=.04, respectively) CONCLUSION: Reductions in liver stiffness and steatosis from the antepartum to the postpartum period were documented in both the preeclampsia and control groups. However, both these measures were higher in the preeclampsia group and correlated with preeclampsia severity. Larger studies may be able to determine whether transient elastography can predict the severity of preeclampsia or other related metabolic conditions that correlate with chronic hypertension.
Collapse
|
5
|
Novel albumin, bilirubin and platelet criteria for the exclusion of high-risk varices in compensated advanced chronic liver disease: A validation study. Clin Res Hepatol Gastroenterol 2021; 45:101598. [PMID: 33780835 DOI: 10.1016/j.clinre.2020.101598] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/27/2020] [Accepted: 12/01/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Availability of transient elastography (TE) limits the application of Baveno-VI criteria. In a derivation study, the ABP criteria (Albumin >40 g/l, Bilirubin <22 μmol/l and Platelet >114,000/μl) had been shown to perform well in identifying compensated advanced chronic liver disease (cACLD) patients without high-risk varices (HRV). We aim to externally validate this novel ABP criteria for the exclusion of HRVs among cACLD patients. METHODS Data was retrospectively collected from consecutive cACLD patients with paired TE and esophagogastroduodenoscopy (EGD) performed between 2011 and 2017 in Changi General Hospital, Singapore. We estimate the discriminative ability of ABP criteria in validation cohort using AUROC and calibration-in-the-large. We subsequently compare the performance between ABP and Baveno-VI criteria in the validation cohort. RESULTS Among 314 patients included in our validation cohort, 32 (10.2%) had HRV on screening EGD. Application of ABP criteria within this validation cohort has increased discriminative ability than the derivation cohort. The AUROC of validation and derivation cohort were 0.68 (0.60-0.76) and 0.66 (0.60-0.76), respectively. The mean and standard error for calibration-in-the-large and calibration slope were -0.08 (0.22) and 0.93 (0.26) respectively. The ABP criteria had excellent performance in excluding HRV and will spare more screening EGDs than the Baveno-VI criteria (39.2% vs 27.4%, p < 0.001), without missing more HRVs. CONCLUSION We validated the performance of ABP criteria for the exclusion of HRVs in cACLD patients. ABP criteria is superior to Baveno-VI criteria by sparing more screening EGD without the need of TE.
Collapse
|
6
|
Syed T, Chadha N, Kumar D, Gupta G, Sterling RK. Non-Invasive Assessment of Liver Fibrosis and Steatosis in End-Stage Renal Disease Patients Undergoing Renal Transplant Evaluation. Gastroenterology Res 2021; 14:244-251. [PMID: 34527094 PMCID: PMC8425797 DOI: 10.14740/gr1445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/02/2021] [Indexed: 12/19/2022] Open
Abstract
Background Non-alcoholic fatty liver disease (NAFLD) has an increased prevalence in end-stage renal disease (ESRD) due to similar risk factors. The aim of this study was to assess non-invasive testing including transient elastography (TE) for liver stiffness (LS), controlled attenuated parameter (CAP) for steatosis, Fibrosis-4 (FIB-4) score, aspartate aminotransferase (AST) to platelet ratio index (APRI) and NAFLD fibrosis score (NFS), for evaluation of NAFLD along with advanced fibrosis (AF) in patients with ESRD undergoing renal transplant evaluation. Methods Data were retrospectively collected within 12 weeks of TE. Primary outcomes were AF, defined by LS ≥ 9 kPa compared to APRI > 1.5, FIB-4 > 2.67, and NFS of 0.675, and ≥ 5% steatosis by CAP ≥ 263 dB/m compared to liver histology when available. Results A total of 171 patients were evaluated: mean age 56, 65% male, 36% obese, 47% had diabetes, 96% hypertension, and 56% dyslipidemia. Mean LS was 6.5 kPa with 21% having AF. Mean CAP was 232 dB/m, with 25% having steatosis. Those with AF were older with higher NFS. Those with steatosis were obese and had diabetes without higher LS or fibrosis scores. Only NFS was associated with LS ≥ 9 kPa. In those with liver histology, AF was associated with LS ≥ 9 kPa but not with APRI, FIB-4, or NFS. Conclusions Despite normal liver enzymes, non-invasive assessment via TE in ESRD patients exhibited high prevalence of AF and steatosis not detected by APRI or FIB-4 scores. This high prevalence was secondary to the common risk factors such as obesity and diabetes, among patients with NAFLD and ESRD.
Collapse
Affiliation(s)
- Taseen Syed
- Department of Gastroenterology, Nutrition and Hepatology, Virginia Commonwealth University, Richmond, VA, USA.,Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Nikita Chadha
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Dhiren Kumar
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, VA, USA.,Department of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Gaurav Gupta
- Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, VA, USA.,Department of Nephrology, Virginia Commonwealth University, Richmond, VA, USA
| | - Richard K Sterling
- Department of Gastroenterology, Nutrition and Hepatology, Virginia Commonwealth University, Richmond, VA, USA.,Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, VA, USA.,Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| |
Collapse
|
7
|
Piedade J, Pereira G, Guimarães L, Duarte J, Victor L, Baldin C, Inacio C, Santos R, Chaves Ú, Nunes EP, Grinsztejn B, Veloso VG, Fernandes F, Perazzo H. Liver stiffness regression after sustained virological response by direct-acting antivirals reduces the risk of outcomes. Sci Rep 2021; 11:11681. [PMID: 34083617 PMCID: PMC8175552 DOI: 10.1038/s41598-021-91099-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 05/20/2021] [Indexed: 12/11/2022] Open
Abstract
The role of liver stiffness measurement (LSM) after sustained virological response (SVR) in HCV patients treated by direct-acting antivirals (DAAs) remains unclear. We aimed to evaluate LSM regression value after SVR and to identify risk factors associated with liver related complications (LRC) or death. This retrospective study analyzed patients with LSM ≥ 10 kPa with LSM by transient elastography pre-DAAs and post-SVR. Patients with previous hepatic decompensation were excluded. Medical records were reviewed to identify primary outcomes. Kaplan-Meier curves and time-to-event Cox proportional-hazard models were performed. 456 patients [65% female, 62 years (IQR 57-68)] were included. During a follow-up of 2.3 years (IQR 1.6-2.7), 28 patients developed 37 outcomes [rate = 29.0 (95% CI 20.0-42.0) per 1000 person-years]. The cumulative incidence of outcomes was significantly lower in patients who regressed LSM ≥ 20% [3.4% (95% CI 1.8-7.0) vs. 9.0% (5.5-14.5), p = 0.028]. In a multivariate Cox-model [HR(95% CI)], male gender [HR = 3.00 (1.30-6.95), p = 0.010], baseline albumin < 3.5 mg/dL [HR = 4.49 (1.95-10.34), p < 0.001] and baseline unfavorable Baveno-VI [HR = 4.72 (1.32-16.83), p = 0.017] were independently associated and LSM regression ≥ 20% after SVR had a trend to reduce the risk of LRC or death [HR = 0.45 (0.21-1.02), p = 0.058]. The use of simple parameters before DAAs and repetition of LSM post-SVR can identify patients with different risks for severe outcome after HCV eradication.
Collapse
Affiliation(s)
- Juliana Piedade
- Oswaldo Cruz Foundation (FIOCRUZ), Evandro Chagas National Institute of Infectious Diseases (INI), Rio de Janeiro, Brazil.,Hepatology Department, Bonsucesso Federal Hospital, Rio de Janeiro, Brazil
| | - Gustavo Pereira
- Hepatology Department, Bonsucesso Federal Hospital, Rio de Janeiro, Brazil.,School of Medicine, Estacio de Sa University, Rio de Janeiro, Brazil
| | - Lívia Guimarães
- Hepatology Department, Bonsucesso Federal Hospital, Rio de Janeiro, Brazil
| | - Joana Duarte
- Hepatology Department, Bonsucesso Federal Hospital, Rio de Janeiro, Brazil
| | - Lívia Victor
- Hepatology Department, Bonsucesso Federal Hospital, Rio de Janeiro, Brazil
| | - Caroline Baldin
- Hepatology Department, Bonsucesso Federal Hospital, Rio de Janeiro, Brazil
| | - Cintia Inacio
- Oswaldo Cruz Foundation (FIOCRUZ), Evandro Chagas National Institute of Infectious Diseases (INI), Rio de Janeiro, Brazil
| | - Ricardo Santos
- Oswaldo Cruz Foundation (FIOCRUZ), Evandro Chagas National Institute of Infectious Diseases (INI), Rio de Janeiro, Brazil
| | - Úrsula Chaves
- Oswaldo Cruz Foundation (FIOCRUZ), Evandro Chagas National Institute of Infectious Diseases (INI), Rio de Janeiro, Brazil
| | - Estevão P Nunes
- Oswaldo Cruz Foundation (FIOCRUZ), Evandro Chagas National Institute of Infectious Diseases (INI), Rio de Janeiro, Brazil
| | - Beatriz Grinsztejn
- Oswaldo Cruz Foundation (FIOCRUZ), Evandro Chagas National Institute of Infectious Diseases (INI), Rio de Janeiro, Brazil
| | - Valdilea G Veloso
- Oswaldo Cruz Foundation (FIOCRUZ), Evandro Chagas National Institute of Infectious Diseases (INI), Rio de Janeiro, Brazil
| | - Flavia Fernandes
- Hepatology Department, Bonsucesso Federal Hospital, Rio de Janeiro, Brazil
| | - Hugo Perazzo
- Oswaldo Cruz Foundation (FIOCRUZ), Evandro Chagas National Institute of Infectious Diseases (INI), Rio de Janeiro, Brazil.
| |
Collapse
|
8
|
MR elastography of the liver: comparison of three measurement methods. Clin Radiol 2020; 75:715.e1-715.e7. [DOI: 10.1016/j.crad.2020.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 05/07/2020] [Indexed: 02/07/2023]
|
9
|
Perazzo H, Cardoso SW, Yanavich C, Nunes EP, Morata M, Gorni N, da Silva PS, Cardoso C, Almeida C, Luz P, Veloso VG, Grinsztejn B. Predictive factors associated with liver fibrosis and steatosis by transient elastography in patients with HIV mono-infection under long-term combined antiretroviral therapy. J Int AIDS Soc 2018; 21:e25201. [PMID: 30394678 PMCID: PMC6216177 DOI: 10.1002/jia2.25201] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 10/08/2018] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Non-alcoholic fatty liver disease is characterized by the presence of hepatic steatosis and can be associated with fibrosis progression, development of cirrhosis and liver-related complications. Data on the prevalence of liver fibrosis and steatosis in HIV patients remain contradictory in resource-limited settings. We aimed to describe the prevalence and factors associated with liver fibrosis and steatosis in patients with HIV mono-infection under long-term antiretroviral therapy (ART) in Rio de Janeiro, Brazil. METHODS Clinical assessment, fasting blood collection and liver stiffness measurement (LSM)/controlled attenuation parameter (CAP) by transient elastography were performed on the same day for this cross-sectional study (PROSPEC-HIV study; NCT02542020). Patients with viral hepatitis co-infection, ART-naïve or missing data were excluded. Liver fibrosis and steatosis were defined by LSM ≥ 8.0 kPa and CAP ≥ 248 dB/m respectively. HIV history, cumulative and current ART regimens were evaluated. Multivariate logistic regression models adjusted for age and gender were performed. RESULTS In total, 395 patients (60% female; median age of 45 (IQR, 35 to 52) years, body mass index = 25.7 (23.2 to 29.4) kg/m2 , alanine aminotransferase = 30 (23 to 42) IU/L, duration of ART for 7 (4 to 14) years) were included. LSM and CAP were reliable in 93% (n = 367) and 87% (n = 344) respectively. The prevalence of fibrosis and steatosis were 9% (95% confidence interval (CI), 7 to 13) and 35% (95% CI, 30 to 40) respectively. The following factors were associated with fibrosis (odds ratio (OR) (95% CI)): older age (per 10 years; 1.80 (1.27 to 2.55); p = 0.001) and CD4+ count <200 cells/mm3 (7.80 (2.09 to 29.09), p = 0.002). Type 2 diabetes had a trend towards the presence of liver fibrosis (2.67 (0.96 to 7.46), p = 0.061). Central obesity (10.74 (4.40 to 26.20), p < 0.001), type 2 diabetes (9.74 (3.15 to 30.10), p < 0.001), dyslipidaemia (2.61 (1.35 to 5.05), p = 0.003) and metabolic syndrome (4.28 (2.45 to 7.46), p < 0.001) were associated with steatosis. A dominant backbone ART regimen of zidovudine (AZT), d4T, ddI or ddC was associated with steatosis (1.90 (1.07 to 3.38), p = 0.028) independently of metabolic features. CONCLUSION Integrated strategies for preventing non-communicable diseases in people with HIV mono-infection are necessary to decrease the burden of liver diseases. Clinical Trial Number: NCT02542020.
Collapse
Affiliation(s)
- Hugo Perazzo
- Laboratory of Clinical Research in STI/AIDS (LAPCLIN‐AIDS)National Institute of Infectious Diseases Evandro Chagas‐Oswaldo Cruz Foundation (INI/FIOCRUZ)Rio de JaneiroBrazil
| | - Sandra W Cardoso
- Laboratory of Clinical Research in STI/AIDS (LAPCLIN‐AIDS)National Institute of Infectious Diseases Evandro Chagas‐Oswaldo Cruz Foundation (INI/FIOCRUZ)Rio de JaneiroBrazil
| | - Carolyn Yanavich
- Laboratory of Clinical Research in STI/AIDS (LAPCLIN‐AIDS)National Institute of Infectious Diseases Evandro Chagas‐Oswaldo Cruz Foundation (INI/FIOCRUZ)Rio de JaneiroBrazil
| | - Estevão P Nunes
- Laboratory of Clinical Research in STI/AIDS (LAPCLIN‐AIDS)National Institute of Infectious Diseases Evandro Chagas‐Oswaldo Cruz Foundation (INI/FIOCRUZ)Rio de JaneiroBrazil
| | - Michelle Morata
- Laboratory of Clinical Research in STI/AIDS (LAPCLIN‐AIDS)National Institute of Infectious Diseases Evandro Chagas‐Oswaldo Cruz Foundation (INI/FIOCRUZ)Rio de JaneiroBrazil
- Plataform of Clinical ResearchNational Institute of Infectious Diseases Evandro Chagas‐Oswaldo Cruz Foundation (INI/FIOCRUZ)Rio de JaneiroBrazil
| | - Nathalia Gorni
- Department of NutritionNational Institute of Infectious Diseases Evandro Chagas‐Oswaldo Cruz Foundation (INI/FIOCRUZ)Rio de JaneiroBrazil
| | - Paula Simplicio da Silva
- Department of NutritionNational Institute of Infectious Diseases Evandro Chagas‐Oswaldo Cruz Foundation (INI/FIOCRUZ)Rio de JaneiroBrazil
| | - Claudia Cardoso
- Department of NutritionNational Institute of Infectious Diseases Evandro Chagas‐Oswaldo Cruz Foundation (INI/FIOCRUZ)Rio de JaneiroBrazil
| | - Cristiane Almeida
- Department of NutritionNational Institute of Infectious Diseases Evandro Chagas‐Oswaldo Cruz Foundation (INI/FIOCRUZ)Rio de JaneiroBrazil
| | - Paula Luz
- Laboratory of Clinical Research in STI/AIDS (LAPCLIN‐AIDS)National Institute of Infectious Diseases Evandro Chagas‐Oswaldo Cruz Foundation (INI/FIOCRUZ)Rio de JaneiroBrazil
| | - Valdilea G Veloso
- Laboratory of Clinical Research in STI/AIDS (LAPCLIN‐AIDS)National Institute of Infectious Diseases Evandro Chagas‐Oswaldo Cruz Foundation (INI/FIOCRUZ)Rio de JaneiroBrazil
| | - Beatriz Grinsztejn
- Laboratory of Clinical Research in STI/AIDS (LAPCLIN‐AIDS)National Institute of Infectious Diseases Evandro Chagas‐Oswaldo Cruz Foundation (INI/FIOCRUZ)Rio de JaneiroBrazil
| |
Collapse
|
10
|
Shiha GE, El-Etreby S, Bahgat M, Hamed M, El Sherbini M, Ghoneem EA, Zalata K, Soliman RE, El Basiouny MA, Mikhail NN. Chronic Hepatitis C Patients with Obesity: Do we Need two Operators for Accurate Evaluation of Liver Stiffness? Ann Hepatol 2018; 17:795-801. [PMID: 30145567 DOI: 10.5604/01.3001.0012.3138] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM Transient elastography is gaining popularity as a non-invasive method for predicting liver fibrosis, but inter observer agreement and factors influencing reproducibility have not been adequately assessed. MATERIAL AND METHODS This cross-sectional study was conducted at Specialized Medical Hospital and the Egyptian Liver Foundation, Mansoura, Egypt. The inclusion criteria were: age older than 18 years and chronic infection by hepatitis C. The exclusion criteria were the presence of ascites, pacemaker or pregnancy. Three hundred and fifty-six patients participated in the study. Therefore, 356 pairs of exams were done by two operators on the same day. RESULTS The overall inter observer agreement ICC was 0.921. The correlation the two operators was excellent (Spearman's value q = 0.808, p < 0.001). Inter-observer reliability values were κ = 0.557 (p < 0.001). A not negligible discordance of fibrosis staging between operators was observed (87 cases, 24.4%). Discordance of at least one stage and for two or more stages of fibrosis occurred in 60 (16.9%) and 27 cases (7.6%) respectively. Obesity (BMI ≥ 30 kg/m2) is the main factor associated with discordance (p = 0.002). CONCLUSION Although liver stiffness measurement has had an excellent correlation between the two operators, TE presented an inter-observer variability that may not be negligible.
Collapse
Affiliation(s)
- Gamal E Shiha
- Egyptian Liver Research Institute and Hospital (ELRIH), Sherbin, El Mansoura, Egypt
| | - Shahira El-Etreby
- Hepatology and Gastroenterology Unit, Internal Medicine. Department, Faculty of Medicine, Mansoura University, Egypt
| | - Mounir Bahgat
- Hepatology and Gastroenterology Unit, Internal Medicine. Department, Faculty of Medicine, Mansoura University, Egypt
| | - Magdy Hamed
- Hepatology and Gastroenterology Unit, Internal Medicine. Department, Faculty of Medicine, Mansoura University, Egypt
| | - Mohamed El Sherbini
- Hepatology and Gastroenterology Unit, Internal Medicine. Department, Faculty of Medicine, Mansoura University, Egypt
| | - Elsayed A Ghoneem
- Hepatology and Gastroenterology Unit, Internal Medicine. Department, Faculty of Medicine, Mansoura University, Egypt
| | - Khaled Zalata
- Pathology Department, Faculty of Medicine, Mansoura University, Egypt
| | - Reham E Soliman
- Egyptian Liver Research Institute and Hospital (ELRIH), Sherbin, El Mansoura, Egypt
| | | | - Nabiel Nh Mikhail
- Egyptian Liver Research Institute and Hospital (ELRIH), Sherbin, El Mansoura, Egypt
| |
Collapse
|
11
|
Dong H, Xu C, Zhou W, Liao Y, Cao J, Li Z, Hu B. The combination of 5 serum markers compared to FibroScan to predict significant liver fibrosis in patients with chronic hepatitis B virus. Clin Chim Acta 2018; 483:145-150. [PMID: 29709450 DOI: 10.1016/j.cca.2018.04.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 04/24/2018] [Accepted: 04/26/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND We evaluated the performance of serum hyaluronan (HA), procollagen type III N-terminal peptide (PIIINP), type IV collagen (IVC), laminin (LN), alanine aminotransferase (ALT), and aspartate aminotransferase (AST), compared to transient elastography (FibroScan) in predicting significant liver fibrosis. METHODS We therefore determined 4 serum fibrosis markers, FibroScan and liver biopsy in 70 consecutive adult patients with chronic hepatitis B. According to a modified Scheuer scoring system, significant fibrosis was defined as fibrosis stage ≥S2. We compared serum fibrosis markers to histological staging and FibroScan results using Spearman correlation analysis and area under receiver operating characteristic (ROC) curves (AUROCs). RESULTS Of the 212 patients who had the results of FibroScans and four serum fibrosis markers for HBV, 70 had concurrent liver biopsy. Significant liver fibrosis was found in 24/70 patients. The serum levels of HA, PIIINP, IVC, LN, ALT, AST was all positively correlated with fibrosis stage of Liver biopsy. The coefficients with stages were respectively 0.468, 0.392, 0.538, 0.213, 0.350, 0.375. There was a significant difference between mild fibrosis (<S2) and significant fibrosis (≥S2), excluding LN, in the levels of these 5 serum makers (P < .05). AUROC for FibroScans and HA, PIIINP, IVC, LN, ALT, AST to correctly allocate patients to histological fibrosis stage ≥ S2 was 0.866, 0.784, 0.738, 0.827, 0.630, 0.713 and 0.728 respectively. Since LN shows the worst performance of the others. We decided to check the performance of the combination of HA, PIIINP, CIV, ALT, AST, excluding LN, to distinguish fibrosis stages. The index of the histological fibrosis stage ≥ S2, combining the 5 serum markers, significantly improved diagnostic performance (AUROC = 0.861) compared to the use of 5 serum markers alone in all HBV patients. CONCLUSION The combination of the 5 serum markers and FibroScan performed equally well in predicting significant fibrosis. The combination of the 5 serum markers is a reliable noninvasive method to predict significant liver fibrosis in patients with CHB. So, it provide another choice rather than FibroScan in predicting significant liver fibrosis.
Collapse
Affiliation(s)
- Huimin Dong
- Department of Laboratory Medicine, Third Affiliated Hospital, Sun Yat-sen University, PR China
| | - Changzhi Xu
- Department of Laboratory Medicine, Third Affiliated Hospital, Sun Yat-sen University, PR China
| | - Wenying Zhou
- Department of Laboratory Medicine, Third Affiliated Hospital, Sun Yat-sen University, PR China
| | - Yuan Liao
- Department of Laboratory Medicine, Third Affiliated Hospital, Sun Yat-sen University, PR China
| | - Junyan Cao
- Department of Laboratory Medicine, Third Affiliated Hospital, Sun Yat-sen University, PR China
| | - Zhaoxia Li
- Department of Laboratory Medicine, Third Affiliated Hospital, Sun Yat-sen University, PR China.
| | - Bo Hu
- Department of Laboratory Medicine, Third Affiliated Hospital, Sun Yat-sen University, PR China.
| |
Collapse
|
12
|
Regression of liver fibrosis over a 24-week period after completing direct-acting antiviral therapy in patients with chronic hepatitis C receiving care within the national hepatitis C elimination program in Georgia: results of hepatology clinic HEPA experience. Eur J Gastroenterol Hepatol 2017; 29:1223-1230. [PMID: 28857900 DOI: 10.1097/meg.0000000000000964] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We assessed the impact of direct-acting antiviral (DAA) therapy on liver fibrosis regression measured by transient elastography (TE) in patients with chronic hepatitis C virus (HCV) infection. PATIENTS AND METHODS A prospective cohort study was carried out in HCV monoinfected patients with advanced liver fibrosis or cirrhosis receiving interferon (IFN)-containing or IFN-free DAA therapy. Liver stiffness (LS) score more than 14.5 kPa indicated LS-defined cirrhosis. The primary outcome was improvement in liver stiffness measurement (LSM) at week 24 after treatment measured as (a) decrease in the median LS compared with baseline and (b) at least a 20% decrease in LSM compared with baseline. A multivariate logistic regression model was utilized to identify the factors associated with at least a 20% improvement in LSM. RESULTS Of a total of 304 patients, 172 (56.6%) had LS-defined cirrhosis before treatment. LSM decreased from the baseline median value of 16.9 (interquartile range: 11.8-27.7) kPa to a post-treatment week 24 score of 11.9 (interquartile range: 8.2-20.9) kPa (P<0.0001). Of a total of 304 patients, 198 (65.1%) achieved at least a 20% reduction in LS. In multivariate logistic regression analysis, sustained virological response (SVR) was associated significantly with this reduction (P<0.0001). The addition of IFN to the treatment regimen had no impact on the decrease in LSM. Despite decreasing baseline LSM, more than half of the LS-defined cirrhotic patients remained cirrhotic at week 24 after treatment. CONCLUSION In patients with advanced fibrosis, pretreatment LS significantly reduced during DAA therapy. SVR was the only independent factor associated with the regression in LSM. However, irrespective of achieving SVR, liver damage still persisted in a substantial proportion of patients. Thus, early treatment of HCV-infected patients can significantly prevent residual liver damage.
Collapse
|
13
|
Ragazzo TG, Paranagua-Vezozzo D, Lima FR, de Campos Mazo DF, Pessoa MG, Oliveira CP, Alves VAF, Carrilho FJ. Accuracy of transient elastography-FibroScan®, acoustic radiation force impulse (ARFI) imaging, the enhanced liver fibrosis (ELF) test, APRI, and the FIB-4 index compared with liver biopsy in patients with chronic hepatitis C. Clinics (Sao Paulo) 2017; 72:516-525. [PMID: 29069254 PMCID: PMC5629733 DOI: 10.6061/clinics/2017(09)01] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/15/2017] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Although liver biopsy is the gold standard for determining the degree of liver fibrosis, issues regarding its invasiveness and the small amount of liver tissue evaluated can limit its applicability and interpretation in clinical practice. Non-invasive evaluation methods for liver fibrosis can address some of these limitations. The aim of this study was to evaluate the accuracy of transient elastography-FibroScan®, acoustic radiation force impulse (ARFI), enhanced liver fibrosis (ELF), the aspartate aminotransferase-to-platelet ratio index (APRI), and the FIB-4 index compared with liver biopsy in hepatitis C. METHODS We evaluated chronic hepatitis C patients who were followed at the Division of Clinical Gastroenterology and Hepatology, Hospital das Clínicas, Department of Gastroenterology of University of São Paulo School of Medicine, São Paulo, Brazil, and who underwent liver biopsy. The accuracy of each method was determined by a receiver operating characteristic (ROC) curve analysis, and fibrosis was classified as significant fibrosis (≥F2), advanced fibrosis (≥F3), or cirrhosis (F4). The Obuchowski method was also used to determine the diagnostic accuracy of each method at the various stages of fibrosis. In total, 107 FibroScan®, 51 ARFI, 68 ELF, 106 APRI, and 106 FIB-4 analyses were performed. RESULTS A total of 107 patients were included in the study. The areas under the ROC curve (AUROCs) according to fibrosis degree were as follows: significant fibrosis (≥F2): FibroScan®: 0.83, FIB-4: 0.76, ELF: 0.70, APRI: 0.69, and ARFI: 0.67; advanced fibrosis (≥F3): FibroScan®: 0.85, ELF: 0.82, FIB-4: 0.77, ARFI: 0.74, and APRI: 0.71; and cirrhosis (F4): APRI: 1, FIB-4: 1, FibroScan®: 0.99, ARFI: 0.96, and ELF: 0.94. The accuracies of transient elastography, ARFI, ELF, APRI and FIB-4 determined by the Obuchowski method were F0-F1: 0.81, 0.78, 0.44, 0.72 and 0.67, respectively; F1-F2: 0.73, 0.53, 0.62, 0.60, and 0.68, respectively; F2-F3: 0.70, 0.64, 0.77, 0.60, and 0.67, respectively; and F3-F4: 0.98, 0.96, 0.82, 1, and 1, respectively. CONCLUSION Transient elastography remained the most effective method for evaluating all degrees of fibrosis. The accuracy of all methodologies was best at F4.
Collapse
Affiliation(s)
- Taisa Grotta Ragazzo
- Divisao de Gastroenterologia e Hepatologia Clinica, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Denise Paranagua-Vezozzo
- Divisao de Gastroenterologia e Hepatologia Clinica, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fabiana Roberto Lima
- Divisao de Gastroenterologia, Faculdade de Ciencias Medicas, Universidade Estadual de Campinas, Campinas, SP, BR
| | - Daniel Ferraz de Campos Mazo
- Divisao de Gastroenterologia e Hepatologia Clinica, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Divisao de Gastroenterologia, Faculdade de Ciencias Medicas, Universidade Estadual de Campinas, Campinas, SP, BR
| | - Mário Guimarães Pessoa
- Divisao de Gastroenterologia e Hepatologia Clinica, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Claudia Pinto Oliveira
- Divisao de Gastroenterologia e Hepatologia Clinica, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Flair José Carrilho
- Divisao de Gastroenterologia e Hepatologia Clinica, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| |
Collapse
|
14
|
Latent Class Analysis of Noninvasive Methods and Liver Biopsy in Chronic Hepatitis C: An Approach without a Gold Standard. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8252980. [PMID: 29057268 PMCID: PMC5615978 DOI: 10.1155/2017/8252980] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 07/30/2017] [Accepted: 08/03/2017] [Indexed: 12/11/2022]
Abstract
Aims To evaluate the applicability of the Latent Class Analysis (LCA) and accuracy of transient elastography (TE), aspartate-to-platelet-ratio-index (APRI), enhanced liver fibrosis (ELF), and liver biopsy (LB) for liver fibrosis assessment in a model without a gold standard. Methods Significant fibrosis was defined as TE ≥ 7.1 kPa, APRI ≥ 1.5, ELF ≥ 9.37, or LB METAVIR F ≥ 2. Cirrhosis was defined as TE ≥ 12.5 kPa, APRI ≥ 2.0, ELF ≥ 10.31, or LB as METAVIR F = 4. Results 117 patients with chronic hepatitis C were included. In the LCA, for significant fibrosis the sensitivities and specificities (95% CI) were 0.92 (0.86–0.98) and 0.79 (0.72–0.86) for TE; 0.47 (0.40–0.54) and 0.99 (0.95–1.00) for APRI; 0.81 (0.74–0.88) and 0.78 (0.71–0.85) for ELF; and 0.86 (0.68–1.00) and 0.91 (0.79–1.00) for LB. For cirrhosis, the sensitivities and specificities were 0.92 (0.76–1.00) and 0.94 (0.91–0.97) for TE; 0.57 (0.37–0.77) and 0.97 (0.93–1.00) for APRI; 0.94 (0.84–1.00) and 0.88 (0.82–0.94) for ELF; and 0.30 (0.12–0.48) and 1.00 for LB. Conclusion LCA was useful to evaluate accuracy of methods for liver fibrosis staging. Sensitivities and specificities of noninvasive methods were increased in LCA compared to the use of LB as the gold standard.
Collapse
|
15
|
Kim G, Kim KJ, Rhee Y, Lim SK. Significant liver fibrosis assessed using liver transient elastography is independently associated with low bone mineral density in patients with non-alcoholic fatty liver disease. PLoS One 2017; 12:e0182202. [PMID: 28759632 PMCID: PMC5536288 DOI: 10.1371/journal.pone.0182202] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 07/16/2017] [Indexed: 02/07/2023] Open
Abstract
Background Metabolic bone disorders frequently occur in patients with chronic liver disease; however, the association between liver fibrosis and bone mineral density in patients with non-alcoholic fatty liver disease (NAFLD) is unclear. Methods This is a cross-sectional analysis of 231 asymptomatic subjects (160 women, 61.6 years old) from a university hospital setting, between February 2012 and December 2014. Bone mineral density (BMD) was measured at the lumbar spine, femur neck, and total hip using dual-energy X-ray absorptiometry (DXA). Liver fibrosis and steatosis were assessed using transient elastography. Results Among a total of 231 individuals, 129 subjects (55.8%) had NAFLD. BMDs at lumbar spine, femur neck, and total hip were significantly lower in patients having NAFLD with significant fibrosis, compared with patients having NAFLD without significant fibrosis (Ps<0.005). In patients with NAFLD, significant liver fibrosis revealed marked negative correlations with BMD at the lumber spine (r = –0.19, P = 0.032), femur neck (r = –0.19, P = 0.034), and total hip (r = –0.21, P = 0.016). A multivariate linear regression analysis revealed that significant liver fibrosis was independently correlated with low BMD at the femur neck (β = –0.18, P = 0.039) and total hip (β = –0.21, P = 0.005) after adjustment for age, sex, BMI, fasting plasma glucose, alanine aminotransferase, high-density lipoprotein cholesterol, and liver steatosis among patients with NAFLD. Using multivariable logistic regression, significant liver fibrosis was independently associated with overall osteopenia and osteoporosis in subjects having NAFLD (OR = 4.10, 95% CI = 1.02–16.45). Conclusion The presence of significant liver fibrosis assessed via TE was independently associated with low BMD in NAFLD subjects.
Collapse
Affiliation(s)
- Gyuri Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kwang Joon Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yumie Rhee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-Kil Lim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- * E-mail:
| |
Collapse
|
16
|
Couto I, Victoria M, Veloso VG, Rodrigues L, Grinsztejn B, Lacerda M, Victoria F, Perazzo H. Prevalence and predictors for compensated Advanced Chronic Liver Disease (c-ACLD) in patients with chronic Hepatitis Delta Virus (HDV) infection. PLoS One 2017; 12:e0174453. [PMID: 28329027 PMCID: PMC5362235 DOI: 10.1371/journal.pone.0174453] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 03/09/2017] [Indexed: 02/07/2023] Open
Abstract
Objective The study aimed to evaluate the prevalence and predictor factors for compensated advanced chronic liver disease (c-ACLD) in patients with hepatitis Delta virus (HDV) infection. Methods This cross-sectional study included consecutive HDV-infected patients defined by positive anti-HDV. Patients with hepatitis C coinfection, liver transplantation or presence of conditions that limit liver (LSM) or spleen stiffness measurement (SSM) were excluded. Blood tests, abdominal ultrasound, SSM and LSM by transient elastography (FibroScan®) were performed at the same day. Alcohol consumption was quantified using the AUDIT score and c-ACLD was defined by LSM ≥ 15 kPa performed by an experimented operator blinded for clinical and laboratory data. Results 101 patients were eligible and few patients were excluded due to negative anti-HDV (n = 7), hepatitis C coinfection (n = 2), liver transplantation (n = 10) and limitation for LSM or SSM (n = 5). Therefore, 77 patients [61% male, age = 43 (IQR,36–52) years] were included. The prevalence of c-ACLD was 57% (n = 44/77). Patients with c-ACLD had a higher rate of detectable HBV viral load (p = 0.039), higher levels of transaminases, GGT, alkaline phosphatases, total bilirubin and INR (p<0.001 for all), as well as lower platelet count and albumin levels (p>0.001 for both) compared to those without c-ACLD. Patients with c-ACLD had higher SSM [65.2 (IQR,33.8–75.0) vs 21.8 (16.5–32.0) kPa; p<0.001] and higher splenic volume [475 (IQR,311–746) vs 154 (112–283) cm3; p<0.001] compared to those without. Detectable HBV viral load (>10 UI/ml), alkaline phosphatase (per IU/L) and GGT levels (per IU/L) were independently associated with c-ACLD in all multivariate models. Splenic volume [per cm3,OR = 1.01 (95%CI,1.01–1.02);p = 0.002], SSM [per kPa, OR = 1.04 (1.01–1.07);p = 0.012] and splenomegaly [yes vs no,OR = 28.45 (4.42–182.95);p<0.001] were independently associated with c-ACLD. Conclusions The prevalence of c-ACLD was high in patients with chronic HDV infection in western Amazon basin. HBV viral load, liver enzymes and splenic features can be used to predict severe liver disease in HDV-infected patients.
Collapse
Affiliation(s)
- Ingrid Couto
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT HVD), Manaus, Amazonas, Brazil
| | - Marilu Victoria
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT HVD), Manaus, Amazonas, Brazil
| | - Valdiléa G. Veloso
- Laboratório de Pesquisa Clínica em DST/AIDS (LAPCLIN-AIDS), Instituto Nacional de Infectologia Evandro Chagas - Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Lorena Rodrigues
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT HVD), Manaus, Amazonas, Brazil
| | - Beatriz Grinsztejn
- Laboratório de Pesquisa Clínica em DST/AIDS (LAPCLIN-AIDS), Instituto Nacional de Infectologia Evandro Chagas - Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Marcus Lacerda
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT HVD), Manaus, Brazil
- Instituto de Pesquisas Leônidas & Maria Deane - Fundação Oswaldo Cruz (FIOCRUZ), Manaus, Brazil
| | - Flamir Victoria
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT HVD), Manaus, Amazonas, Brazil
| | - Hugo Perazzo
- Laboratório de Pesquisa Clínica em DST/AIDS (LAPCLIN-AIDS), Instituto Nacional de Infectologia Evandro Chagas - Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
- * E-mail: ,
| |
Collapse
|
17
|
Han MAT, Saouaf R, Ayoub W, Todo T, Mena E, Noureddin M. Magnetic resonance imaging and transient elastography in the management of Nonalcoholic Fatty Liver Disease (NAFLD). Expert Rev Clin Pharmacol 2017; 10:379-390. [PMID: 28277807 DOI: 10.1080/17512433.2017.1299573] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease and cirrhosis worldwide and the second most common cause of liver transplantation in major medical centers. Because liver steatosis and fibrosis severity are related to disease morbidity and mortality, the extent of disease, and disease progression, they need to be assessed and monitored. In addition, innovation with new drug developments requires disease staging and monitoring in both phase 2 and 3 clinical trials. Currently, disease assessment in both clinical practice and research is mostly performed by liver biopsy, an invasive, procedure with risks. Noninvasive, highly accurate tests are needed that could be used in clinical trials as surrogate endpoints and in clinical practice for monitoring patients. Area Covered: We discuss noninvasive tests, transient elastography (TE) with controlled attenuation parameter (CAP), magnetic resonance imaging (MRI), and MR elastography (MRE), summarize the available evidence of their usefulness for assessing steatosis and fibrosis. Therefore they could be used as clinical trials outcomes and in disease monitoring in clinical practice. Expert Commentary: TE with CAP, MRI and MRE are highly accurate noninvasive diagnostic tools for quantifying hepatic steatosis and fibrosis. Therefore they could be used as clinical trials outcomes and in disease monitoring in clinical practice.
Collapse
Affiliation(s)
- Ma Ai Thanda Han
- a Division of Digestive and Liver Diseases , Cedars-Sinai Medical Center , Los Angeles , California , USA
| | - Rola Saouaf
- b Department of Radiology , Cedars-Sinai Medical Center , Los Angeles , California , USA
| | - Walid Ayoub
- c Fatty Liver Program, Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center , Los Angeles , California , USA.,d Comprehensive Transplant Center, Cedars-Sinai Medical Center , Los Angeles , California , USA
| | - Tsuyoshi Todo
- d Comprehensive Transplant Center, Cedars-Sinai Medical Center , Los Angeles , California , USA
| | - Edward Mena
- e California Liver Research Institute , Pasadena , California , USA
| | - Mazen Noureddin
- c Fatty Liver Program, Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center , Los Angeles , California , USA.,d Comprehensive Transplant Center, Cedars-Sinai Medical Center , Los Angeles , California , USA
| |
Collapse
|
18
|
Friedrich-Rust M, Poynard T, Castera L. Critical comparison of elastography methods to assess chronic liver disease. Nat Rev Gastroenterol Hepatol 2016; 13:402-11. [PMID: 27273167 DOI: 10.1038/nrgastro.2016.86] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Staging of liver fibrosis and diagnosis, or exclusion, of early compensated liver cirrhosis are important in the treatment decisions and surveillance of patients with chronic liver disease. Good diagnostic accuracy, increased availability and the possibility to perform follow-up examinations led to the implementation of noninvasive methods into clinical practice. Noninvasive tests are increasingly included in national and international guidelines, leaving liver biopsy reserved for patients with unexplained discordance or suspected additional aetiologies of liver disease. In addition to staging of liver fibrosis, data on the prognostic value of these methods have increased in the past few years and are of great importance for patient care. This Review focuses on elastography methods for noninvasive assessment of liver fibrosis, disease severity and prognosis. Although liver elastography started with transient elastography, at present all large ultrasonography companies offer an elastography technique integrated in their machines. The goal of this Review is to summarize the methodological problems of noninvasive tests in general, in addition to providing an overview on currently available techniques and latest developments in liver elastography.
Collapse
Affiliation(s)
- Mireen Friedrich-Rust
- Department of Internal Medicine, J.W. Goethe-University Hospital, Theodor-Stern-Kai 7, Frankfurt 60590, Germany
| | - Thierry Poynard
- Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Hepatology Department, 47-83 Boulevard de l'Hôpital, Paris 75013, France.,Université Pierre et Marie Curie, INSERM, UMR-S 938, 57 Boulevard de l'Hôpital, Paris 75013, France
| | - Laurent Castera
- Department of Hepatology, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, 100 Boulevard du General Leclerc, Clichy 92110, France.,Université Paris VII, INSERM UMR 1149, Centre de Recherche sur l'Inflammation, 16 Rue Huchard, Paris 75018, France
| |
Collapse
|
19
|
Perazzo H, Fernandes FF, Soares JC, Fittipaldi J, Cardoso SW, Grinsztejn B, Veloso VG. Learning curve and intra/interobserver agreement of transient elastography in chronic hepatitis C patients with or without HIV co-infection. Clin Res Hepatol Gastroenterol 2016; 40:73-82. [PMID: 26056050 DOI: 10.1016/j.clinre.2015.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 03/18/2015] [Accepted: 04/28/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Liver stiffness measurement (LSM) by transient elastography has been validated as a noninvasive method to stage liver fibrosis. Few studies have evaluated the learning curve of this method and its reproducibility has led to controversy results. We aimed to evaluate the intra- and interobserver agreement of transient elastography as well as its learning curve for definition of an experimented operator. METHODS We retrospectively analyzed 922 examinations performed in 544 patients during a training program of transient elastography. Patients with chronic hepatitis C with or without HIV co-infection that had two examinations by the training operator (intraobserver analysis; n=125) or examination by both training and experimented operators (interobserver analysis; n=151) in the same day were included. LSM was converted to METAVIR score: <7.1 as F0F1, 7.1-9.4 as F2, 9.5-12.4, as F3 and >12.4 kPa as F4. RESULTS The overall intra- and interobserver intraclass correlation coefficient [ICC 95% CI] were 0.926 (0.901-0.951) and 0.912 (0.885-0.939), respectively. Measurements were correlated [Spearman's] in intra- [0.906, P<0.0001] and interobserver [0.907, P<0.0001] analysis. Reliability values [kappa (SE)] were k=0.74 (0.09) and k=0.85 (0.08) for fibrosis stages F ≥ 2 and k=0.77 (0.09) and k=0.75 (0.08) for cirrhosis in intra- and interobserver analysis, respectively. Agreement was improved when operator's experience was higher than 100 exams. However, it was observed discordance for fibrosis staging between examinations in a quarter of patients. CONCLUSION Although there was a considerable discrepancy on fibrosis staging between examinations and a small power, transient elastography had an acceptable reproducibility in our population. Performance of at least 100 examinations should be used to define an experimented operator.
Collapse
Affiliation(s)
- Hugo Perazzo
- National Institute of Infectious Disease - Fundação Oswaldo Cruz, Laboratory of clinical research on STD/AIDS, Rio de Janeiro, Brazil.
| | - Flavia F Fernandes
- Bonsucesso Federal Hospital, Gastroenterology Department, Rio de Janeiro, Brazil
| | - João Carlos Soares
- National Institute of Infectious Disease - Fundação Oswaldo Cruz, Laboratory of clinical research on STD/AIDS, Rio de Janeiro, Brazil
| | - Juliana Fittipaldi
- National Institute of Infectious Disease - Fundação Oswaldo Cruz, Laboratory of clinical research on STD/AIDS, Rio de Janeiro, Brazil
| | - Sandra W Cardoso
- National Institute of Infectious Disease - Fundação Oswaldo Cruz, Laboratory of clinical research on STD/AIDS, Rio de Janeiro, Brazil
| | - Beatriz Grinsztejn
- National Institute of Infectious Disease - Fundação Oswaldo Cruz, Laboratory of clinical research on STD/AIDS, Rio de Janeiro, Brazil
| | - Valdiléa G Veloso
- National Institute of Infectious Disease - Fundação Oswaldo Cruz, Laboratory of clinical research on STD/AIDS, Rio de Janeiro, Brazil
| |
Collapse
|
20
|
Perazzo H, Veloso VG, Grinsztejn B, Hyde C, Castro R. Factors That Could Impact on Liver Fibrosis Staging by Transient Elastography. Int J Hepatol 2015; 2015:624596. [PMID: 26770833 PMCID: PMC4684863 DOI: 10.1155/2015/624596] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 11/09/2015] [Accepted: 11/26/2015] [Indexed: 12/15/2022] Open
Abstract
Transient elastography (TE) based on liver stiffness measurement (LSM) is one of the most validated noninvasive methods for liver fibrosis staging in patients with chronic liver diseases. This method is painless, has no potential complications, is rapid (<10 min), and can be performed at the patient's bedside. However, several points should be considered when interpreting TE results. This review aims to discuss the critical points that might influence liver stiffness and TE results. Spectrum bias and the impact of the prevalence of fibrosis stages should be taken into account when interpreting the studies that validated this method using liver biopsy as a gold-standard. LSM might be influenced by nonfasting status, flare of transaminases, heart failure, extrahepatic cholestasis, presence of steatosis, aetiology of liver disease, type and position of probe, and operator's experience. In addition, interobserver variability can impact on the management of patients with chronic liver diseases. TE should be performed by an experienced operator (>100 exams), in a 3-hour fasting status, and its results should be handled by specialist clinicians that are aware of the limitations of this method.
Collapse
Affiliation(s)
- Hugo Perazzo
- Evandro Chagas National Institute of Infectious Disease (INI), Oswaldo Cruz Foundation (FIOCRUZ), Laboratory of Clinical Research on STD/AIDS, Avenida Brasil 4365, 21040-900 Manguinhos, RJ, Brazil
| | - Valdilea G. Veloso
- Evandro Chagas National Institute of Infectious Disease (INI), Oswaldo Cruz Foundation (FIOCRUZ), Laboratory of Clinical Research on STD/AIDS, Avenida Brasil 4365, 21040-900 Manguinhos, RJ, Brazil
| | - Beatriz Grinsztejn
- Evandro Chagas National Institute of Infectious Disease (INI), Oswaldo Cruz Foundation (FIOCRUZ), Laboratory of Clinical Research on STD/AIDS, Avenida Brasil 4365, 21040-900 Manguinhos, RJ, Brazil
| | - Chris Hyde
- Institute of Health Research, Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis and Modelling for Health Improvement (ESMI), University of Exeter Medical School, University of Exeter, St. Luke's Campus, South Cloisters, EX1 2LU Exeter, UK
| | - Rodolfo Castro
- Evandro Chagas National Institute of Infectious Disease (INI), Oswaldo Cruz Foundation (FIOCRUZ), Laboratory of Clinical Research on STD/AIDS, Avenida Brasil 4365, 21040-900 Manguinhos, RJ, Brazil
| |
Collapse
|
21
|
Castro R, Perazzo H, Grinsztejn B, Veloso VG, Hyde C. Chronic Hepatitis C: An Overview of Evidence on Epidemiology and Management from a Brazilian Perspective. Int J Hepatol 2015; 2015:852968. [PMID: 26693356 PMCID: PMC4677022 DOI: 10.1155/2015/852968] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 11/03/2015] [Accepted: 11/11/2015] [Indexed: 02/06/2023] Open
Abstract
Chronic hepatitis C remains one of the main causes of chronic liver disease worldwide and presents a variable natural history ranging from minimal changes to advanced fibrosis and cirrhosis and its complications, such as development of hepatocellular carcinoma. Approximately, 1.45 million people are estimated to be infected by HCV in Brazil representing a major public health issue. The aim of this paper was to review the epidemiology and management of chronic hepatitis C from a Brazilian perspective. The management of chronic hepatitis C has been challenged by the use of noninvasive methods to stage liver fibrosis as an alternative to liver biopsy and the high cost of new interferon-free antiviral treatments. Moreover, the need of cost-effectiveness analysis in hepatitis C and the recent changes in treatment protocols were discussed.
Collapse
Affiliation(s)
- Rodolfo Castro
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Laboratory of Clinical Research on STD/AIDS, Avenida Brasil 4365, 21040-900 Manguinhos, RJ, Brazil
| | - Hugo Perazzo
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Laboratory of Clinical Research on STD/AIDS, Avenida Brasil 4365, 21040-900 Manguinhos, RJ, Brazil
| | - Beatriz Grinsztejn
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Laboratory of Clinical Research on STD/AIDS, Avenida Brasil 4365, 21040-900 Manguinhos, RJ, Brazil
| | - Valdilea G. Veloso
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Laboratory of Clinical Research on STD/AIDS, Avenida Brasil 4365, 21040-900 Manguinhos, RJ, Brazil
| | - Chris Hyde
- Institute of Health Research, Peninsula Technology Assessment Group (PenTAG), Evidence Synthesis and Modelling for Health Improvement (ESMI), University of Exeter Medical School, University of Exeter, St Luke's Campus, South Cloisters, Exeter EX1 2LU, UK
| |
Collapse
|
22
|
Comparison of Histochemical Stainings in Evaluation of Liver Fibrosis and Correlation with Transient Elastography in Chronic Hepatitis. Anal Cell Pathol (Amst) 2015; 2015:431750. [PMID: 26665101 PMCID: PMC4664783 DOI: 10.1155/2015/431750] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 08/05/2015] [Accepted: 08/12/2015] [Indexed: 02/05/2023] Open
Abstract
Background and Aim. The best staining to evaluate liver fibrosis in liver hepatitis is still a debated topic. This study aimed to compare Masson's trichrome (MT), Sirius Red (SR), and orcein stainings in evaluating liver fibrosis in chronic HCV hepatitis (CHC) with semiquantitative and quantitative methods (Collagen Proportionate Area (CPA) by Digital Image Analysis (DIA)) and correlate them with transient elastography (TE). Methods. Liver stiffness evaluation of 111 consecutive patients with CHC was performed by TE. Semiquantitative staging by Metavir score system and CPA by DIA were assessed on liver biopsy stained with MT, SR, and orcein. Results. MT, SR, and orcein staining showed concordant results in 89.6% of cases in staging CHC, without significant difference in both semiquantitative and quantitative evaluations of fibrosis. TE values were concordant with orcein levels in 86.5% of the cases and with MT/RS in 77.5% (P < 0.001). No significant correlation between the grade of necroinflammatory activity and TE values was found. Conclusion. In CHC, SR/MT and orcein stainings are almost concordant and when discordant, orcein staining is better related to TE values than MT/RS. This suggests that elastic fibers play a more important role than reticular or collagenous ones in determining stiffness values in CHC.
Collapse
|
23
|
Perazzo H, Fernandes FF, Castro Filho EC, Perez RM. Points to be considered when using transient elastography for diagnosis of portal hypertension according to the Baveno's VI consensus. J Hepatol 2015. [PMID: 26206072 DOI: 10.1016/j.jhep.2015.06.036] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Hugo Perazzo
- Evandro Chagas National Institute of Infectious Disease (INI) - Oswaldo Cruz Foundation (FIOCRUZ), Laboratory of Clinical Research on STD/AIDS, Rio de Janeiro, Brazil.
| | - Flavia F Fernandes
- Bonsucesso Federal Hospital, Gastroenterology Department, Rio de Janeiro, Brazil
| | - Elio C Castro Filho
- University of the State of Rio de Janeiro (UERJ), Gastroenterology Department, Rio de Janeiro, Brazil
| | - Renata M Perez
- University of the State of Rio de Janeiro (UERJ), Gastroenterology Department, Rio de Janeiro, Brazil; Federal University of Rio de Janeiro (UFRJ), Internal Medicine Department, Rio de Janeiro, Brazil; D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil
| |
Collapse
|