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Ferraioli G, Barr RG, Berzigotti A, Sporea I, Wong VWS, Reiberger T, Karlas T, Thiele M, Cardoso AC, Ayonrinde OT, Castera L, Dietrich CF, Iijima H, Lee DH, Kemp W, Oliveira CP, Sarin SK. WFUMB Guidelines/Guidance on Liver Multiparametric Ultrasound. Part 2: Guidance on Liver Fat Quantification. ULTRASOUND IN MEDICINE & BIOLOGY 2024; 50:1088-1098. [PMID: 38658207 DOI: 10.1016/j.ultrasmedbio.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/26/2024]
Abstract
The World Federation for Ultrasound in Medicine and Biology (WFUMB) has promoted the development of this document on multiparametric ultrasound. Part 2 is a guidance on the use of the available tools for the quantification of liver fat content with ultrasound. These are attenuation coefficient, backscatter coefficient, and speed of sound. All of them use the raw data of the ultrasound beam to estimate liver fat content. This guidance has the aim of helping the reader in understanding how they work and interpret the results. Confounding factors are discussed and a standardized protocol for measurement acquisition is suggested to mitigate them. The recommendations were based on published studies and experts' opinion but were not formally graded because the body of evidence remained low at the time of drafting this document.
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Affiliation(s)
- Giovanna Ferraioli
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Richard Gary Barr
- Department of Radiology, Northeastern Ohio Medical University, Youngstown, OH, USA
| | - Annalisa Berzigotti
- Department for Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ioan Sporea
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Center for Advanced Research in Gastroenterology and Hepatology, "Victor Babeș" University of Medicine and Pharmacy, Timișoara, Romania
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, Medical Data Analytics Centre, The Chinese University of Hong Kong, Hong Kong, China; State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Thomas Karlas
- Department of Medicine II, Division of Gastroenterology, Leipzig University Medical Center, Leipzig, Germany
| | - Maja Thiele
- Center for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Department for Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ana Carolina Cardoso
- Hepatology Division, School of Medicine, Federal University of Rio de Janeiro, Clementino, Fraga Filho Hospital, Rio de Janeiro, RJ, Brazil
| | - Oyekoya Taiwo Ayonrinde
- Department of Gastroenterology and Hepatology, Fiona Stanley Hospital, Murdoch, WA, Australia; Medical School, The University of Western Australia, Crawley, WA, Australia; Curtin Medical School, Curtin University, Bentley, WA, Australia
| | - Laurent Castera
- Université Paris-Cité, Inserm UMR1149, Centre de Recherche sur l'Inflammation, Paris, France; Service d'Hépatologie, Hôpital Beaujon, Assistance-Publique Hôpitaux de Paris, Clichy, France
| | - Christoph Frank Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem and Permancence, Bern, Switzerland
| | - Hiroko Iijima
- Department of Gastroenterology, Division of Hepatobiliary and Pancreatic Disease, Hyogo Medical University, Nishinomiya, Hyogo, Japan; Ultrasound Imaging Center, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Dong Ho Lee
- Department of Radiology, College of Medicine, Seoul National University Hospital, Seoul National University, Seoul, Republic of Korea
| | - William Kemp
- Department of Gastroenterology, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Claudia P Oliveira
- Gastroenterology Department, Laboratório de Investigação (LIM07), Hospital das Clínicas de São Paulo, HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Pyo JH, Cho SJ, Choi SC, Jee JH, Yun J, Hwang JA, Park G, Kim K, Kang W, Kang M, Byun YH. Diagnostic performance of quantitative ultrasonography for hepatic steatosis in a health screening program: a prospective single-center study. Ultrasonography 2024; 43:250-262. [PMID: 38898634 PMCID: PMC11222130 DOI: 10.14366/usg.24040] [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: 03/14/2024] [Revised: 05/29/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024] Open
Abstract
PURPOSE This study compared the diagnostic performance of quantitative ultrasonography (QUS) with that of conventional ultrasonography (US) in assessing hepatic steatosis among individuals undergoing health screening using magnetic resonance imaging-derived proton density fat fraction (MRI-PDFF) as the reference standard. METHODS This single-center prospective study enrolled 427 participants who underwent abdominal MRI and US. Measurements included the attenuation coefficient in tissue attenuation imaging (TAI) and the scatter-distribution coefficient in tissue scatter-distribution imaging (TSI). The correlation between QUS and MRI-PDFF was evaluated. The diagnostic capabilities of QUS, conventional B-mode US, and their combined models for detecting hepatic fat content of ≥5% (MRI-PDFF ≥5%) and ≥10% (MRI-PDFF ≥10%) were compared by analyzing the areas under the receiver operating characteristic curves. Additionally, clinical risk factors influencing the diagnostic performance of QUS were identified using multivariate linear regression analyses. RESULTS TAI and TSI were strongly correlated with MRI-PDFF (r=0.759 and r=0.802, respectively; both P<0.001) and demonstrated good diagnostic performance in detecting and grading hepatic steatosis. The combination of QUS and B-mode US resulted in the highest areas under the ROC curve (AUCs) (0.947 and 0.975 for detecting hepatic fat content of ≥5% and ≥10%, respectively; both P<0.05), compared to TAI, TSI, or B-mode US alone (AUCs: 0.887, 0.910, 0.878 for ≥5% and 0.951, 0.922, 0.875 for ≥10%, respectively). The independent determinants of QUS included skinliver capsule distance (β=7.134), hepatic fibrosis (β=4.808), alanine aminotransferase (β=0.202), triglyceride levels (β=0.027), and diabetes mellitus (β=3.710). CONCLUSION QUS is a useful and effective screening tool for detecting and grading hepatic steatosis during health checkups.
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Affiliation(s)
- Jeung Hui Pyo
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo Jin Cho
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Chul Choi
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hwan Jee
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeeyeong Yun
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Ah Hwang
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Goeun Park
- Biomedical Statistics Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Kyunga Kim
- Biomedical Statistics Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
- Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Korea
| | - Wonseok Kang
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Korea
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mira Kang
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Korea
- Digital Transformation Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young hye Byun
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Chan WK, Wong VWS, Adams LA, Nguyen MH. MAFLD in adults: non-invasive tests for diagnosis and monitoring of MAFLD. Hepatol Int 2024:10.1007/s12072-024-10661-x. [PMID: 38913148 DOI: 10.1007/s12072-024-10661-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 02/13/2024] [Indexed: 06/25/2024]
Abstract
Metabolic dysfunction-associated fatty liver disease (MAFLD) is the liver manifestation of a metabolic syndrome and is highly prevalent in the general population. There has been significant progress in non-invasive tests for MAFLD, from the diagnosis of fatty liver and monitoring of liver fat content in response to intervention, to evaluation of liver fibrosis and its change over time, and from risk stratification of patients within the context of clinical care pathways, to prognostication. Various non-invasive tests have also been developed to assess for fibrotic metabolic dysfunction-associated steatohepatitis, which has emerged as an important diagnostic goal, particularly in the context of clinical trials. Non-invasive tests can be used to diagnose clinically significant portal hypertension so that intervention can be administered to reduce the risk of decompensation. Furthermore, the use of risk stratification algorithms can identify at-risk patients for hepatocellular carcinoma surveillance. Beyond the liver, various tests that evaluate cardiovascular disease risk, assess sarcopenia and measure patient reported outcomes, can be utilized to improve the care of patients with MAFLD. This review provides an up-to-date overview of these non-invasive tests and the limitations of liver biopsy in the management of patients with MAFLD.
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Affiliation(s)
- Wah-Kheong Chan
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
| | - Vincent Wai-Sun Wong
- Medical Data Analytics Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
- State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Leon A Adams
- Medical School, University of Western Australia, Perth, Australia
- Department of Hepatology, Sir Charles Gairdner Hospital, Perth, Australia
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Stanford, CA, USA
- Department of Epidemiology and Population Health, Stanford University Medical Center, Palo Alto, CA, USA
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Hobeika C, Ronot M, Guiu B, Ferraioli G, Iijima H, Tada T, Lee DH, Kuroda H, Lee YH, Lee JM, Kim SY, Cassinotto C, Maiocchi L, Raimondi A, Nishimura T, Kumada T, Kwon EY, Jang JK, Correas JM, Valla D, Vilgrain V, Dioguardi Burgio M. Ultrasound-based steatosis grading system using 2D-attenuation imaging: An individual patient data meta-analysis with external validation. Hepatology 2024:01515467-990000000-00856. [PMID: 38652643 DOI: 10.1097/hep.0000000000000895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/07/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND AND AIMS Noninvasive tools assessing steatosis, such as ultrasonography-based 2D-attenuation imaging (ATI), are needed to tackle the worldwide burden of steatotic liver disease. This one-stage individual patient data (IPD) meta-analysis aimed to create an ATI-based steatosis grading system. APPROACH AND RESULTS A systematic review (EMBASE + MEDLINE, 2018-2022) identified studies, including patients with histologically or magnetic resonance imaging proton-density fat fraction (MRI-PDFF)-verified ATI for grading steatosis (S0 to S3). One-stage IPD meta-analyses were conducted using generalized mixed models with a random study-specific intercept. Created ATI-based steatosis grading system (aS0 to aS3) was externally validated on a prospective cohort of patients with type 2 diabetes and metabolic dysfunction-associated steatotic liver disease (n=174, histologically and MRI-PDFF-verified steatosis). Eleven enrolled studies included 1374 patients, classified into S0, S1, S2, and S3 in 45.4%, 35.0%, 9.3%, and 10.3% of the cases. ATI was correlated with histological steatosis ( r = 0.60; 95% CI: 0.52, 0.67; p < 0.001) and MRI-PDFF ( r = 0.70; 95% CI: 0.66, 0.73; p < 0.001) but not with liver stiffness ( r = 0.03; 95% CI: -0.04, 0.11, p = 0.343). Steatosis grade was an independent factor associated with ATI (coefficient: 0.24; 95% CI: [0.22, 0.26]; p < 0.001). ATI marginal means within S0, S1, S2, and S3 subpopulations were 0.59 (95% CI: [0.58, 0.61]), 0.69 (95% CI [0.67, 0.71]), 0.78 (95% CI: [0.76, 0.81]), and 0.85 (95% CI: [0.83, 0.88]) dB/cm/MHz; all contrasts between grades were significant ( p < 0.0001). Three ATI thresholds were calibrated to create a new ATI-based steatosis grading system (aS0 to aS3, cutoffs: 0.66, 0.73, and 0.81 dB/cm/MHz). Its external validation showed Obuchowski measures of 0.84 ± 0.02 and 0.82 ± 0.02 with histologically based and MRI-PDFF-based references. CONCLUSIONS ATI is a reliable, noninvasive marker of steatosis. This validated ATI-based steatosis grading system could be valuable in assessing patients with metabolic dysfunction-associated steatotic liver disease.
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Affiliation(s)
- Christian Hobeika
- Department of HPB Surgery and Liver Transplantation, AP-HP, Hôpital Beaujon, Clichy, France
- Université Paris Cité, Inserm, CArcinose Péritoine Paris-Technologies, Paris, France
- Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Maxime Ronot
- Department of Radiology, Hôpital Beaujon, AP-HP.Nord, Clichy, France
- Université Paris Cité, Inserm, Centre de recherche sur l'inflammation, Paris, France
| | - Boris Guiu
- Department of Radiology, St-Eloi University Hospital, Montpellier, France
| | - Giovanna Ferraioli
- Dipartimento di Scienze Clinico-Chirurgiche, Diagnostiche e Pediatriche, University of Pavia, Pavia, Italy
| | - Hiroko Iijima
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Hyogo Medical University, Hyogo, Japan
| | - Toshifumi Tada
- Department of Internal Medicine, Japanese Red Cross Society Himeji Hospital, Hyogo, Japan
| | - Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hidekatsu Kuroda
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Iwate Medical University, Iwate, Japan
| | - Young Hwan Lee
- Department of Radiology, Wonkwang University School of Medicine and Hospital, Iksan, Korea
| | - Jeong Min Lee
- Department of Radiology, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, Korea
| | - So Yeon Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | | | - Laura Maiocchi
- Ultrasound Unit, Dipartimento Servizi Diagnostici e per Immagini Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Ambra Raimondi
- Dipartimento di Scienze Clinico-Chirurgiche, Diagnostiche e Pediatriche, University of Pavia, Pavia, Italy
- Ultrasound Unit, Dipartimento Servizi Diagnostici e per Immagini Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Takashi Nishimura
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Hyogo Medical University, Hyogo, Japan
| | - Takashi Kumada
- Department of Nursing, Gifu Kyoritsu University, Gifu, Japan
| | - Eun Young Kwon
- Department of Radiology, Wonkwang University School of Medicine and Hospital, Iksan, Korea
| | - Jong Keon Jang
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jean-Michel Correas
- AP-HP, Hôpital Necker Enfants Malades, Service d'Imagerie Adulte, Paris, France
- Sorbonne Université, CNRS, INSERM Laboratoire d'Imagerie Biomédicale, Paris, France
| | - Dominique Valla
- Université Paris Cité, Inserm, Centre de recherche sur l'inflammation, Paris, France
- Service d'hépatologie, Hôpital Beaujon, Clichy, France
| | - Valérie Vilgrain
- Department of Radiology, Hôpital Beaujon, AP-HP.Nord, Clichy, France
- Université Paris Cité, Inserm, Centre de recherche sur l'inflammation, Paris, France
| | - Marco Dioguardi Burgio
- Department of Radiology, Hôpital Beaujon, AP-HP.Nord, Clichy, France
- Université Paris Cité, Inserm, Centre de recherche sur l'inflammation, Paris, France
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Kumada T, Toyoda H, Ogawa S, Gotoh T, Suzuki Y, Imajo K, Sugimoto K, Kakegawa T, Kuroda H, Yasui Y, Tamaki N, Kurosaki M, Izumi N, Akita T, Tanaka J, Nakajima A. Advanced fibrosis leads to overestimation of steatosis with quantitative ultrasound in individuals without hepatic steatosis. Ultrasonography 2024; 43:121-131. [PMID: 38316132 PMCID: PMC10915114 DOI: 10.14366/usg.23194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/11/2023] [Accepted: 12/11/2023] [Indexed: 02/07/2024] Open
Abstract
PURPOSE The effect of hepatic fibrosis stage on quantitative ultrasound based on the attenuation coefficient (AC) for liver lipid quantification is controversial. The objective of this study was to determine how the degree of fibrosis assessed by magnetic resonance (MR) elastography affects AC based on the ultrasound-guided attenuation parameter according to the grade of hepatic steatosis, using magnetic resonance imaging (MRI)-derived proton density fat fraction (MRIderived PDFF) as the reference standard. METHODS Between February 2020 and April 2021, 982 patients with chronic liver disease who underwent AC and MRI-derived PDFF measurement as well as MR elastography were enrolled. Multiple regression was used to investigate whether AC was affected by the degree of liver stiffness. RESULTS AC increased as liver stiffness progressed in 344 patients without hepatic steatosis (P=0.009). In multivariable analysis, AC was positively correlated with skin-capsule distance (P<0.001), MR elastography value (P=0.037), and MRI-derived PDFF (P<0.001) in patients without hepatic steatosis. In 52 of 982 patients (5%), the correlation between AC and MRIderived PDFF fell outside the 95% confidence interval for the regression line slope. Patients with MRI-derived PDFF lower than their AC (n=36) had higher fibrosis-4 scores, albumin-bilirubin scores, and MR elastography values than patients with MRI-derived PDFF greater than their AC (n=16; P=0.018, P=0.001, and P=0.011, respectively). CONCLUSION AC is affected by liver fibrosis (MR elastography value ≥6.7 kPa) only in patients without hepatic steatosis (MRI-derived PDFF <5.2%). These values should be interpreted with caution in patients with advanced liver fibrosis.
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Affiliation(s)
- Takashi Kumada
- Department of Nursing, Faculty of Nursing, Gifu Kyoritsu University, Ogaki, Japan
| | - Hidenori Toyoda
- Department of Gastroenterology and Hepatology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Sadanobu Ogawa
- Department of Imaging Diagnosis, Ogaki Municipal Hospital, Ogaki, Japan
| | - Tatsuya Gotoh
- Department of Imaging Diagnosis, Ogaki Municipal Hospital, Ogaki, Japan
| | - Yasuaki Suzuki
- Department of Gastroenterology, Nayoro City General Hospital, Nayoro, Japan
| | - Kento Imajo
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- Department of Gastroenterology, Shin-yurigaoka General Hospital, Kawasaki, Japan
| | - Katsutoshi Sugimoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Tatsuya Kakegawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Hidekatsu Kuroda
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University, Morioka, Japan
| | - Yutaka Yasui
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Musashino-shi, Japan
| | - Nobuharu Tamaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Musashino-shi, Japan
| | - Masayuki Kurosaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Musashino-shi, Japan
| | - Namiki Izumi
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Musashino-shi, Japan
| | - Tomoyuki Akita
- Department of Epidemiology, Infectious Disease Control, and Prevention, Hiroshima University Institute of Biomedical and Health Sciences, Hiroshima, Japan
| | - Junko Tanaka
- Department of Epidemiology, Infectious Disease Control, and Prevention, Hiroshima University Institute of Biomedical and Health Sciences, Hiroshima, Japan
| | - Atsushi Nakajima
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Ayres ABS, Carneiro CRG, Gestic MA, Utrini MP, Chaim FDM, Callejas-Neto F, Chaim EA, Cazzo E. Identification of Predictors of Non-alcoholic Steatohepatitis and Its Severity in Individuals Undergoing Bariatric Surgery. Obes Surg 2024; 34:456-466. [PMID: 38097891 DOI: 10.1007/s11695-023-06986-5] [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: 09/20/2023] [Revised: 11/28/2023] [Accepted: 12/06/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND As obesity reached epidemic proportions, non-alcoholic fatty liver disease (NAFLD) also had a worrisome parallel increase. The non-invasive differentiation of non-alcoholic steatohepatitis (NASH) from uncomplicated NAFLD remains an important challenge in current clinical practice. OBJECTIVE To identify predictors of the occurrence and severity of NAFLD and NASH. METHODS This is an analytical cross-sectional study which included individuals undergoing bariatric surgery. Participants were histologically classified according to the presence NASH and severity of NAFLD. Demographic, clinical, anthropometric, and biochemical aspects were analyzed and compared. RESULTS Out of 171 individuals, 87.7% were female and the mean age was 38.4±9.3 years. The average BMI was 38±3.0 kg/m2. NAFLD was histologically confirmed in 74.9%; the commonest histopathological abnormalities were macrovesicular steatosis (74.9%) and ballooning (40.4%). Simple steatosis occurred in 30.4%, 44.4% presented with NASH, and 31% had severe NAFLD. NASH associated with higher levels of ALT (0.03), ALP (0.02), and glucose (0.02). Cutoff values were, respectively, 23 U/L, 67 U/L, and 81 mg/dL. Their concomitant use provided an 83.1% specificity for NASH. Severe NAFLD associated with diabetes (p=0.02), higher BMI (p=0.01), AST (p=0.04), ALT (p<0.01), ALP (p=0.01), glucose (p=0.02), and ferritin (p<0.01). BMI over 39.3 kg/m2 and ferritin over 178 ng/mL concomitantly provided a 70.5% accuracy for severe NAFLD. CONCLUSIONS NASH and severe NAFLD associated with higher levels of ALT, ALP, and glucose. Severe NAFLD associated with higher BMI and higher ferritin levels in this group. The concomitant evaluation of these laboratory tests could help ruling out NASH and safely screening severe NAFLD.
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Affiliation(s)
- Arthur Balestra Silveira Ayres
- Dept. of Surgery-School of Medical Sciences-State University of Campinas (UNICAMP), Rua Alexander Fleming, s/no, Campinas, (SP), Brazil
| | | | - Martinho Antonio Gestic
- Dept. of Surgery-School of Medical Sciences-State University of Campinas (UNICAMP), Rua Alexander Fleming, s/no, Campinas, (SP), Brazil
| | - Murillo Pimentel Utrini
- Dept. of Surgery-School of Medical Sciences-State University of Campinas (UNICAMP), Rua Alexander Fleming, s/no, Campinas, (SP), Brazil
| | - Felipe David Mendonça Chaim
- Dept. of Surgery-School of Medical Sciences-State University of Campinas (UNICAMP), Rua Alexander Fleming, s/no, Campinas, (SP), Brazil
| | - Francisco Callejas-Neto
- Dept. of Surgery-School of Medical Sciences-State University of Campinas (UNICAMP), Rua Alexander Fleming, s/no, Campinas, (SP), Brazil
| | - Elinton Adami Chaim
- Dept. of Surgery-School of Medical Sciences-State University of Campinas (UNICAMP), Rua Alexander Fleming, s/no, Campinas, (SP), Brazil
| | - Everton Cazzo
- Dept. of Surgery-School of Medical Sciences-State University of Campinas (UNICAMP), Rua Alexander Fleming, s/no, Campinas, (SP), Brazil.
- Cidade Universitária Zeferino Vaz, Campinas, (SP), CEP 13085-000, Brazil.
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Hänni O, Ruby L, Paverd C, Frauenfelder T, Rominger MB, Martin A. Confounders of Ultrasound Attenuation Imaging in a Linear Probe Using the Canon Aplio i800 System: A Phantom Study. Diagnostics (Basel) 2024; 14:271. [PMID: 38337786 PMCID: PMC10855333 DOI: 10.3390/diagnostics14030271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 02/12/2024] Open
Abstract
There have been studies showing attenuation imaging (ATI) with ultrasound as an approach to diagnose liver diseases such as steatosis or cirrhosis. So far, this technique has only been used on a convex probe. The goal of the study was to investigate the feasibility of ATI measurements using the linear array on a canon Aplio i800 scanner on certified phantoms. Three certified liver tissue attenuation phantoms were measured in five different positions using a linear probe. The effects of positioning and depth were explored and compared. The values were compared to the certified expected value for each phantom as well as the different measurement values for each measurement position. The ATI measurements on phantoms showed significant effect for the different probe positions and region of interest (ROI) depths. Values taken in the center with the probe perpendicular to the phantom were closest to certified values. Median values at 2.5-4.5 cm depth for phantoms 1 and 2 and 0.5-2.5 cm for phantom 3 were comparable with certified values. Measurements taken at a depth greater than 6 cm in any position were the least representative of the certified values (p-value < 0.01) and had the widest range throughout the different sessions. ATI measurements can be performed with the linear probe in phantoms; however, careful consideration should be given to depth dependency, as it can significantly affect measurement values. Remaining measurements at various depths within the 0.5-6.0 cm range showed deviation from the certified values of approximately 25%.
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Affiliation(s)
- Olivia Hänni
- Faculty of Medicine, University of Zurich, Dekanat Pestalozzistrasse 3, 8032 Zurich, Switzerland
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland (M.B.R.)
| | - Lisa Ruby
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland (M.B.R.)
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Catherine Paverd
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland (M.B.R.)
| | - Thomas Frauenfelder
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland (M.B.R.)
| | - Marga B. Rominger
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland (M.B.R.)
| | - Alexander Martin
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland (M.B.R.)
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Zhu Y, Yin H, Zhou D, Zhao Q, Wang K, Fan Y, Chen K, Han H, Xu H. A prospective comparison of three ultrasound-based techniques in quantitative diagnosis of hepatic steatosis in NAFLD. Abdom Radiol (NY) 2024; 49:81-92. [PMID: 37950767 DOI: 10.1007/s00261-023-04078-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 11/13/2023]
Abstract
PURPOSE To investigate the correlation between different ultrasound attenuation-based techniques and to compare their diagnostic performances using proton magnetic resonance spectroscopy (1H-MRS) as a reference standard. METHODS Participants who had clinical suspicion of nonalcoholic fatty liver disease (NAFLD) were prospectively recruited. Each subject had ultrasound with attenuation imaging (ATI) or quantitative ultrasound including tissue attenuation imaging (TAI) and tissue scatter-distribution imaging (TSI), and controlled-attenuation parameter (CAP) and 1H-MRS if available. The technical success rates, intra-observer repeatabilities of attenuation and backscattering coefficient were evaluated. ATI, TAI and CAP were three attenuation-based techniques. Spearman coefficient was used to test correlations among them and 1H-MRS. In addition, the diagnostic performances of these parameters for detecting ≥ 5% or 10% hepatic steatosis were evaluated. RESULTS 130 participants had ultrasound scanning. Among them, 67 had CAP and 48 had 1H-MRS. The technical success rates were all 100%. The intra-observer repeatabilities of them were also excellent (ICCs > 0.90) and AC-ATI correlated well with AC-TAI (r = 0.752). AC-ATI, AC-TAI showed moderate correlation with CAP, (rATI = 0.623, 95% CI 0.446-0.752, P < 0.001; rTAI = 0.573, 95% CI 0.377-0.720, P < 0.001). For correlation with 1H-MRS, ATI and TAI performed better than CAP(rATI = 0.587; rTAI = 0.712; r CAP = 0.485). The AUCs of ATI, TAI, TSI and CAP for detecting ≥ 5% hepatic steatosis were 0.883, 0.862, 0.870 and 0.868, respectively. The AUC improved to 0.907 when TAI and TSI were combined (P < 0.05). When detecting ≥ 10% hepatic steatosis, the AUCs were 0.855, 0.702, 0.822 and 0.838, respectively. CONCLUSION Different ultrasound attenuation-based techniques were well correlated and exhibited good diagnostic performances in quantitative diagnosis of hepatic steatosis, however, the threshold values were different. Combinations of multiple parameters may improve the diagnostic performance in detecting hepatic steatosis. TRIAL REGISTRATION The study has been registered online ( https://www.chictr.org.cn ; unique identifier: ChiCTR2300069459).
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Affiliation(s)
- Yuli Zhu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
| | - Haohao Yin
- Department of Ultrasound, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
- Shanghai Institute of Medical Imaging, Fudan University, Shanghai, 200032, China
- Institute of Ultrasound in Medicine and Engineering, Fudan University, Shanghai, 200032, China
| | - Da Zhou
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Qiannan Zhao
- Department of Ultrasound, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
| | - Kun Wang
- Department of Ultrasound, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
| | - Yunling Fan
- Department of Ultrasound, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
| | - Kailing Chen
- Department of Ultrasound, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China
| | - Hong Han
- Department of Ultrasound, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China.
| | - Huixiong Xu
- Department of Ultrasound, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai, 200032, China.
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9
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Torkzaban M, Wessner CE, Halegoua-DeMarzio D, Lyshchik A, Nam K. Diagnostic Performance of Quantitative Ultrasound Parameters in Non-alcoholic Fatty Liver Disease. Acad Radiol 2024; 31:199-211. [PMID: 37507328 DOI: 10.1016/j.acra.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/27/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023]
Abstract
RATIONALE AND OBJECTIVES Marked liver steatosis, steatohepatitis, and significant fibrosis are risk factors for unfavorable outcomes in non-alcoholic fatty liver disease (NAFLD). In this study, the diagnostic performance of attenuation coefficient (AC), liver stiffness (LS), and dispersion slope (DS) was evaluated separately and combined in the diagnosis of liver steatosis and fibrosis in NAFLD suspects using biopsy or magnetic resonance imaging (MRI) as a reference standard. MATERIALS AND METHODS Seventy-four NAFLD suspects were prospectively imaged with an Aplio i800 ultrasound scanner (Canon Medical Systems, Tustin, CA). AC, LS, and DS measurements were obtained from the right liver lobe. RESULTS Thirty-four patients underwent liver biopsy, and 40 had MRI. There were 32 patients (43%) with liver steatosis and fibrosis (S + F), 22 (30%) with steatosis (S), 5 (7%) with fibrosis (F), and 15 (20%) with normal liver (N). Mean ACs were significantly higher in steatotic livers (n = 54) than in non-steatotic livers (n = 20) (P < 0.0001). LS and DS were significantly higher in patients with liver fibrosis (n = 37) compared to non-fibrotic livers (n = 37) (P = 0.0004 and P = 0.0002, respectively). In detecting (S + F), the area under the receiver operating characteristic curve (AUROCC) was 0.87 for combined ultrasound parameters of LS and AC (negative predictive value [NPV]: 75%, positive predictive value [PPV]: 77%, P < 0.0001). In detecting patients with liver steatosis and fibrosis stage ≥2, LS had an AUROCC of 0.93 (NPV: 87%, PPV: 82%, P < 0.0001). In the biopsy group, 32% (11/34) were diagnosed with non-alcoholic steatohepatitis (NASH). DS values showed a significant difference among patients with (n = 23) or without (n = 11) hepatocellular ballooning (P = 0.02). AUROCC was 0.87 for combined ultrasound parameters of AC, LS, and DS with body mass index (BMI) in detecting NASH (NPV: 80%, PPV: 87%, P = 0.0006). CONCLUSION AC and LS showed high diagnostic value in detecting liver steatosis and fibrosis, respectively. The combined AC and LS values further improved the diagnostic accuracy in detecting NAFLD and high-risk NAFLD patients.
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Affiliation(s)
- Mehnoosh Torkzaban
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA 19107 (M.T., C.E.W., A.L., K.N.)
| | - Corinne E Wessner
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA 19107 (M.T., C.E.W., A.L., K.N.)
| | - Dina Halegoua-DeMarzio
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania (D.H.)
| | - Andrej Lyshchik
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA 19107 (M.T., C.E.W., A.L., K.N.)
| | - Kibo Nam
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA 19107 (M.T., C.E.W., A.L., K.N.).
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Song K, Kim HS, Chae HW. Nonalcoholic fatty liver disease and insulin resistance in children. Clin Exp Pediatr 2023; 66:512-519. [PMID: 36634667 PMCID: PMC10694550 DOI: 10.3345/cep.2022.01312] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/19/2022] [Accepted: 12/29/2022] [Indexed: 01/11/2023] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD), a spectrum of liver diseases characterized by excessive fat accumulation, is the leading cause of chronic liver disease. The global prevalence of NAFLD is increasing in both adults and children. In Korea, the prevalence of pediatric NAFLD increased from 8.2% in 2009 to 12.1% in 2018 according to a national surveillance study. For early screening of pediatric NAFLD, laboratory tests including aspartate aminotransferase and alanine aminotransferase; biomarkers including hepatic steatosis index, triglyceride glucose index, and fibrosis-4 index; and imaging studies including ultrasonography and magnetic resonance imaging are required. Insulin resistance plays a major role in the pathogenesis of NAFLD, which promotes insulin resistance. Thus, the association between NAFLD and insulin resistance, diabetes mellitus, and metabolic syndrome has been reported in many studies. This review addresses issues related to the epidemiology and investigation of NAFLD as well as the association between NAFLD and insulin resistance and metabolic syndrome with focus on pediatric NAFLD.
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Affiliation(s)
- Kyungchul Song
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Ho-Seong Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Wook Chae
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
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11
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Ozturk A, Kumar V, Pierce TT, Li Q, Baikpour M, Rosado-Mendez I, Wang M, Guo P, Schoen S, Gu Y, Dayavansha S, Grajo JR, Samir AE. The Future Is Beyond Bright: The Evolving Role of Quantitative US for Fatty Liver Disease. Radiology 2023; 309:e223146. [PMID: 37934095 PMCID: PMC10695672 DOI: 10.1148/radiol.223146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a common cause of morbidity and mortality. Nonfocal liver biopsy is the historical reference standard for evaluating NAFLD, but it is limited by invasiveness, high cost, and sampling error. Imaging methods are ideally situated to provide quantifiable results and rule out other anatomic diseases of the liver. MRI and US have shown great promise for the noninvasive evaluation of NAFLD. US is particularly well suited to address the population-level problem of NAFLD because it is lower-cost, more available, and more tolerable to a broader range of patients than MRI. Noninvasive US methods to evaluate liver fibrosis are widely available, and US-based tools to evaluate steatosis and inflammation are gaining traction. US techniques including shear-wave elastography, Doppler spectral imaging, attenuation coefficient, hepatorenal index, speed of sound, and backscatter-based estimation have regulatory clearance and are in clinical use. New methods based on channel and radiofrequency data analysis approaches have shown promise but are mostly experimental. This review discusses the advantages and limitations of clinically available and experimental approaches to sonographic liver tissue characterization for NAFLD diagnosis as well as future applications and strategies to overcome current limitations.
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Affiliation(s)
- Arinc Ozturk
- From the Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital, 101 Merrimac St, 3rd Floor, 323G, Boston, MA 02114 (A.O., V.K., T.T.P., Q.L., M.B., P.G., S.S., Y.G., S.D., A.E.S.); Harvard Medical School, Boston, Mass (A.O., V.K., T.T.P, Q.L., A.E.S.); Departments of Medical Physics and Radiology, University of Wisconsin, Madison, Wis (I.R.M.); GE HealthCare, Milwaukee, Wis (M.W.); and Department of Radiology, University of Florida, Gainesville, Fla (J.R.G.)
| | - Viksit Kumar
- From the Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital, 101 Merrimac St, 3rd Floor, 323G, Boston, MA 02114 (A.O., V.K., T.T.P., Q.L., M.B., P.G., S.S., Y.G., S.D., A.E.S.); Harvard Medical School, Boston, Mass (A.O., V.K., T.T.P, Q.L., A.E.S.); Departments of Medical Physics and Radiology, University of Wisconsin, Madison, Wis (I.R.M.); GE HealthCare, Milwaukee, Wis (M.W.); and Department of Radiology, University of Florida, Gainesville, Fla (J.R.G.)
| | - Theodore T Pierce
- From the Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital, 101 Merrimac St, 3rd Floor, 323G, Boston, MA 02114 (A.O., V.K., T.T.P., Q.L., M.B., P.G., S.S., Y.G., S.D., A.E.S.); Harvard Medical School, Boston, Mass (A.O., V.K., T.T.P, Q.L., A.E.S.); Departments of Medical Physics and Radiology, University of Wisconsin, Madison, Wis (I.R.M.); GE HealthCare, Milwaukee, Wis (M.W.); and Department of Radiology, University of Florida, Gainesville, Fla (J.R.G.)
| | - Qian Li
- From the Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital, 101 Merrimac St, 3rd Floor, 323G, Boston, MA 02114 (A.O., V.K., T.T.P., Q.L., M.B., P.G., S.S., Y.G., S.D., A.E.S.); Harvard Medical School, Boston, Mass (A.O., V.K., T.T.P, Q.L., A.E.S.); Departments of Medical Physics and Radiology, University of Wisconsin, Madison, Wis (I.R.M.); GE HealthCare, Milwaukee, Wis (M.W.); and Department of Radiology, University of Florida, Gainesville, Fla (J.R.G.)
| | - Masoud Baikpour
- From the Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital, 101 Merrimac St, 3rd Floor, 323G, Boston, MA 02114 (A.O., V.K., T.T.P., Q.L., M.B., P.G., S.S., Y.G., S.D., A.E.S.); Harvard Medical School, Boston, Mass (A.O., V.K., T.T.P, Q.L., A.E.S.); Departments of Medical Physics and Radiology, University of Wisconsin, Madison, Wis (I.R.M.); GE HealthCare, Milwaukee, Wis (M.W.); and Department of Radiology, University of Florida, Gainesville, Fla (J.R.G.)
| | - Ivan Rosado-Mendez
- From the Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital, 101 Merrimac St, 3rd Floor, 323G, Boston, MA 02114 (A.O., V.K., T.T.P., Q.L., M.B., P.G., S.S., Y.G., S.D., A.E.S.); Harvard Medical School, Boston, Mass (A.O., V.K., T.T.P, Q.L., A.E.S.); Departments of Medical Physics and Radiology, University of Wisconsin, Madison, Wis (I.R.M.); GE HealthCare, Milwaukee, Wis (M.W.); and Department of Radiology, University of Florida, Gainesville, Fla (J.R.G.)
| | - Michael Wang
- From the Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital, 101 Merrimac St, 3rd Floor, 323G, Boston, MA 02114 (A.O., V.K., T.T.P., Q.L., M.B., P.G., S.S., Y.G., S.D., A.E.S.); Harvard Medical School, Boston, Mass (A.O., V.K., T.T.P, Q.L., A.E.S.); Departments of Medical Physics and Radiology, University of Wisconsin, Madison, Wis (I.R.M.); GE HealthCare, Milwaukee, Wis (M.W.); and Department of Radiology, University of Florida, Gainesville, Fla (J.R.G.)
| | - Peng Guo
- From the Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital, 101 Merrimac St, 3rd Floor, 323G, Boston, MA 02114 (A.O., V.K., T.T.P., Q.L., M.B., P.G., S.S., Y.G., S.D., A.E.S.); Harvard Medical School, Boston, Mass (A.O., V.K., T.T.P, Q.L., A.E.S.); Departments of Medical Physics and Radiology, University of Wisconsin, Madison, Wis (I.R.M.); GE HealthCare, Milwaukee, Wis (M.W.); and Department of Radiology, University of Florida, Gainesville, Fla (J.R.G.)
| | - Scott Schoen
- From the Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital, 101 Merrimac St, 3rd Floor, 323G, Boston, MA 02114 (A.O., V.K., T.T.P., Q.L., M.B., P.G., S.S., Y.G., S.D., A.E.S.); Harvard Medical School, Boston, Mass (A.O., V.K., T.T.P, Q.L., A.E.S.); Departments of Medical Physics and Radiology, University of Wisconsin, Madison, Wis (I.R.M.); GE HealthCare, Milwaukee, Wis (M.W.); and Department of Radiology, University of Florida, Gainesville, Fla (J.R.G.)
| | - Yuyang Gu
- From the Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital, 101 Merrimac St, 3rd Floor, 323G, Boston, MA 02114 (A.O., V.K., T.T.P., Q.L., M.B., P.G., S.S., Y.G., S.D., A.E.S.); Harvard Medical School, Boston, Mass (A.O., V.K., T.T.P, Q.L., A.E.S.); Departments of Medical Physics and Radiology, University of Wisconsin, Madison, Wis (I.R.M.); GE HealthCare, Milwaukee, Wis (M.W.); and Department of Radiology, University of Florida, Gainesville, Fla (J.R.G.)
| | - Sunethra Dayavansha
- From the Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital, 101 Merrimac St, 3rd Floor, 323G, Boston, MA 02114 (A.O., V.K., T.T.P., Q.L., M.B., P.G., S.S., Y.G., S.D., A.E.S.); Harvard Medical School, Boston, Mass (A.O., V.K., T.T.P, Q.L., A.E.S.); Departments of Medical Physics and Radiology, University of Wisconsin, Madison, Wis (I.R.M.); GE HealthCare, Milwaukee, Wis (M.W.); and Department of Radiology, University of Florida, Gainesville, Fla (J.R.G.)
| | - Joseph R Grajo
- From the Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital, 101 Merrimac St, 3rd Floor, 323G, Boston, MA 02114 (A.O., V.K., T.T.P., Q.L., M.B., P.G., S.S., Y.G., S.D., A.E.S.); Harvard Medical School, Boston, Mass (A.O., V.K., T.T.P, Q.L., A.E.S.); Departments of Medical Physics and Radiology, University of Wisconsin, Madison, Wis (I.R.M.); GE HealthCare, Milwaukee, Wis (M.W.); and Department of Radiology, University of Florida, Gainesville, Fla (J.R.G.)
| | - Anthony E Samir
- From the Center for Ultrasound Research & Translation, Department of Radiology, Massachusetts General Hospital, 101 Merrimac St, 3rd Floor, 323G, Boston, MA 02114 (A.O., V.K., T.T.P., Q.L., M.B., P.G., S.S., Y.G., S.D., A.E.S.); Harvard Medical School, Boston, Mass (A.O., V.K., T.T.P, Q.L., A.E.S.); Departments of Medical Physics and Radiology, University of Wisconsin, Madison, Wis (I.R.M.); GE HealthCare, Milwaukee, Wis (M.W.); and Department of Radiology, University of Florida, Gainesville, Fla (J.R.G.)
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12
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Torkzaban M, Wessner CE, Halegoua-DeMarzio D, Rodgers SK, Lyshchik A, Nam K. Diagnostic Performance Comparison Between Ultrasound Attenuation Measurements From Right and Left Hepatic Lobes for Steatosis Detection in Non-alcoholic Fatty Liver Disease. Acad Radiol 2023; 30:1838-1845. [PMID: 36586759 PMCID: PMC10307925 DOI: 10.1016/j.acra.2022.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 11/21/2022] [Accepted: 12/16/2022] [Indexed: 12/30/2022]
Abstract
RATIONALE AND OBJECTIVES Non-alcoholic fatty liver disease (NAFLD) is currently diagnosed by liver biopsy or MRI proton density fat fraction (MRI-PDFF) from left hepatic lobe (LTHL) and/or right hepatic lobe (RTHL). The objective of this study was to compare the diagnostic value of ultrasound attenuation coefficients (ACs) from RTHL and LTHL in detecting hepatic steatosis using biopsy or MRI-PDFF as a reference standard. MATERIALS AND METHODS Sixty-six patients with suspected NAFLD were imaged with an Aplio i800 ultrasound scanner (Canon Medical Systems, Tustin, CA). Five AC measurements from RTHL and LTHL were averaged separately and together to be compared with the reference standard. RESULTS Forty-seven patients (71%) were diagnosed with NAFLD. Mean ACs were significantly higher in fatty livers than non-fatty livers (RTHL: 0.73 ± 0.10 vs. 0.63 ± 0.07 dB/cm/MHZ; p < 0.0001, LTHL: 0.78 ± 0.11 vs. 0.63 ± 0.06 dB/cm/MHz; p < 0.0001, RTHL & LTHL: 0.76 ± 0.09 vs. 0.63 ± 0.05 dB/cm/MHz; p < 0.0001). Biopsy steatosis grades (n =31) were better correlated with the mean ACs of RTHL & LTHL (r = 0.72) compared to LTHL (r = 0.67) or RTHL (r = 0.61). Correlation between MRI-PDFF (n = 35) and mean ACs was better for LTHL (r = 0.69) compared to the RTHL & LTHL (r = 0.66) or RTHL (r = 0.45). Higher diagnostic accuracy was shown for the mean ACs of RTHL & LTHL (AUC 0.89, specificity 94%, sensitivity 78%) compared to LTHL (AUC 0.89, specificity 88%, sensitivity 82%) or RTHL (AUC 0.81, specificity 89%, sensitivity 68%). CONCLUSION Ultrasound ACs from RTHL and LTHL showed comparable diagnostic values in detection of hepatic steatosis with the highest diagnostic accuracy when they were averaged together.
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Affiliation(s)
- Mehnoosh Torkzaban
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Corinne E Wessner
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Dina Halegoua-DeMarzio
- Department of Medicine, Division of Gastroenterology & Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Shuchi K Rodgers
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Andrej Lyshchik
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kibo Nam
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania.
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13
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Collin R, Magnin B, Gaillard C, Nicolas C, Abergel A, Buchard B. Prospective study comparing hepatic steatosis assessment by magnetic resonance imaging and four ultrasound methods in 105 successive patients. World J Gastroenterol 2023; 29:3548-3560. [PMID: 37389233 PMCID: PMC10303516 DOI: 10.3748/wjg.v29.i22.3548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/04/2023] [Accepted: 05/12/2023] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is becoming a major health problem, resulting in hepatic, metabolic and cardio-vascular morbidity.
AIM To evaluate new ultrasonographic tools to detect and measure hepatic steatosis.
METHODS We prospectively included 105 patients referred to our liver unit for NAFLD suspicion or follow-up. They underwent ultrasonographic measurement of liver sound speed estimation (SSE) and attenuation coefficient (AC) using Aixplorer MACH 30 (Supersonic Imagine, France), continuous controlled attenuation parameter (cCAP) using Fibroscan (Echosens, France) and standard liver ultrasound with hepato-renal index (HRI) calculation. Hepatic steatosis was then classified according to magnetic resonance imaging proton density fat fraction (PDFF). Receiver operating curve (ROC) analysis was performed to evaluate the diagnostic performance in the diagnosis of steatosis.
RESULTS Most patients were overweight or obese (90%) and had metabolic syndrome (70%). One third suffered from diabetes. Steatosis was identified in 85 patients (81%) according to PDFF. Twenty-one patients (20%) had advanced liver disease. SSE, AC, cCAP and HRI correlated with PDFF, with respective Spearman correlation coefficient of -0.39, 0.42, 0.54 and 0.59 (P < 0.01). Area under the receiver operating characteristic curve (AUROC) for detection of steatosis with HRI was 0.91 (0.83-0.99), with the best cut-off value being 1.3 (Se = 83%, Sp = 98%). The optimal cCAP threshold of 275 dB/m, corresponding to the recent EASL-suggested threshold, had a sensitivity of 72% and a specificity of 80%. Corresponding AUROC was 0.79 (0.66-0.92). The diagnostic accuracy of cCAP was more reliable when standard deviation was < 15 dB/m with an AUC of 0.91 (0.83-0.98). An AC threshold of 0.42 dB/cm/MHz had an AUROC was 0.82 (0.70-0.93). SSE performed moderately with an AUROC of 0.73 (0.62-0.84).
CONCLUSION Among all ultrasonographic tools evaluated in this study, including new-generation tools such as cCAP and SSE, HRI had the best performance. It is also the simplest and most available method as most ultrasound scans are equipped with this module.
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Affiliation(s)
- Remi Collin
- Gastroenterology and Endoscopy Unit, Dupuytren University Hospital, Limoges 87000, France
- Department of Hepatology and Gastroenterology, Clermont-Ferrand University Hospital, Clermont-Ferrand 63000, France
| | - Benoit Magnin
- Department of Radiology, Clermont-Ferrand University Hospital, Clermont-Ferrand 63000, France
| | - Constance Gaillard
- Department of Radiology, Clermont-Ferrand University Hospital, Clermont-Ferrand 63000, France
| | - Carine Nicolas
- Department of Hepatology and Gastroenterology, Clermont-Ferrand University Hospital, Clermont-Ferrand 63000, France
| | - Armand Abergel
- Department of Hepatology and Gastroenterology, Clermont-Ferrand University Hospital, Clermont-Ferrand 63000, France
| | - Benjamin Buchard
- Department of Hepatology and Gastroenterology, Clermont-Ferrand University Hospital, Clermont-Ferrand 63000, France
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14
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Nehring P, Szeligowska J, Przybyłkowski A. Elastography of the Liver in Wilson's Disease. Diagnostics (Basel) 2023; 13:diagnostics13111898. [PMID: 37296749 DOI: 10.3390/diagnostics13111898] [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: 04/12/2023] [Revised: 05/22/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
Staging of liver fibrosis is of special significance in Wilson's disease as it determines the patient's prognosis and treatment. Histopathological examination is a standard method for fibrosis assessment; however, non-invasive methods like transient elastography and share wave elastography are believed to be reliable and repetitive and are expected to replace liver biopsy in Wilson's disease. This article presents a short description of available elastography techniques and the results of the most recent studies on elastography of the liver in patients with Wilson's disease.
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Affiliation(s)
- Piotr Nehring
- Department of Gastroenterology and Internal Medicine, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
| | - Jowita Szeligowska
- Department of Gastroenterology and Internal Medicine, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
| | - Adam Przybyłkowski
- Department of Gastroenterology and Internal Medicine, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
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15
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Fetzer DT, Rosado-Mendez IM, Wang M, Robbin ML, Ozturk A, Wear KA, Ormachea J, Stiles TA, Fowlkes JB, Hall TJ, Samir AE. Pulse-Echo Quantitative US Biomarkers for Liver Steatosis: Toward Technical Standardization. Radiology 2022; 305:265-276. [PMID: 36098640 PMCID: PMC9613608 DOI: 10.1148/radiol.212808] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 04/07/2022] [Accepted: 04/14/2022] [Indexed: 11/11/2022]
Abstract
Excessive liver fat (steatosis) is now the most common cause of chronic liver disease worldwide and is an independent risk factor for cirrhosis and associated complications. Accurate and clinically useful diagnosis, risk stratification, prognostication, and therapy monitoring require accurate and reliable biomarker measurement at acceptable cost. This article describes a joint effort by the American Institute of Ultrasound in Medicine (AIUM) and the RSNA Quantitative Imaging Biomarkers Alliance (QIBA) to develop standards for clinical and technical validation of quantitative biomarkers for liver steatosis. The AIUM Liver Fat Quantification Task Force provides clinical guidance, while the RSNA QIBA Pulse-Echo Quantitative Ultrasound Biomarker Committee develops methods to measure biomarkers and reduce biomarker variability. In this article, the authors present the clinical need for quantitative imaging biomarkers of liver steatosis, review the current state of various imaging modalities, and describe the technical state of the art for three key liver steatosis pulse-echo quantitative US biomarkers: attenuation coefficient, backscatter coefficient, and speed of sound. Lastly, a perspective on current challenges and recommendations for clinical translation for each biomarker is offered.
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Affiliation(s)
| | | | - Michael Wang
- From the Department of Radiology, University of Texas Southwestern
Medical Center, Dallas, Tex (D.T.F.); Departments of Medical Physics (I.M.R.M.,
T.J.H.) and Radiology (I.M.R.M.), University of Wisconsin, Institutes for
Medical Research, 1111 Highland Ave, Room 1005, Madison, WI 53705; General
Electric Healthcare, Milwaukee, Wis (M.W.); Department of Radiology, University
of Alabama at Birmingham, Birmingham, Ala (M.L.R.); Department of Radiology,
Massachusetts General Hospital, Boston, Mass (A.O.); U.S. Food and Drug
Administration, Silver Spring, Md (K.A.W.); Department of Electrical and
Computer Engineering, University of Rochester, Rochester, NY (J.O.); Department
of Natural Sciences, Kettering University, Flint, Mich (T.A.S.); Departments of
Biomedical Engineering and Radiology, University of Michigan, Ann Arbor, Mich
(J.B.F.); RSNA Quantitative Imaging Biomarkers Alliance (T.J.H.); and Center for
Ultrasound Research & Translation, Department of Radiology, Massachusetts
General Hospital, Harvard Medical School, Boston, Mass (A.E.S.)
| | - Michelle L. Robbin
- From the Department of Radiology, University of Texas Southwestern
Medical Center, Dallas, Tex (D.T.F.); Departments of Medical Physics (I.M.R.M.,
T.J.H.) and Radiology (I.M.R.M.), University of Wisconsin, Institutes for
Medical Research, 1111 Highland Ave, Room 1005, Madison, WI 53705; General
Electric Healthcare, Milwaukee, Wis (M.W.); Department of Radiology, University
of Alabama at Birmingham, Birmingham, Ala (M.L.R.); Department of Radiology,
Massachusetts General Hospital, Boston, Mass (A.O.); U.S. Food and Drug
Administration, Silver Spring, Md (K.A.W.); Department of Electrical and
Computer Engineering, University of Rochester, Rochester, NY (J.O.); Department
of Natural Sciences, Kettering University, Flint, Mich (T.A.S.); Departments of
Biomedical Engineering and Radiology, University of Michigan, Ann Arbor, Mich
(J.B.F.); RSNA Quantitative Imaging Biomarkers Alliance (T.J.H.); and Center for
Ultrasound Research & Translation, Department of Radiology, Massachusetts
General Hospital, Harvard Medical School, Boston, Mass (A.E.S.)
| | - Arinc Ozturk
- From the Department of Radiology, University of Texas Southwestern
Medical Center, Dallas, Tex (D.T.F.); Departments of Medical Physics (I.M.R.M.,
T.J.H.) and Radiology (I.M.R.M.), University of Wisconsin, Institutes for
Medical Research, 1111 Highland Ave, Room 1005, Madison, WI 53705; General
Electric Healthcare, Milwaukee, Wis (M.W.); Department of Radiology, University
of Alabama at Birmingham, Birmingham, Ala (M.L.R.); Department of Radiology,
Massachusetts General Hospital, Boston, Mass (A.O.); U.S. Food and Drug
Administration, Silver Spring, Md (K.A.W.); Department of Electrical and
Computer Engineering, University of Rochester, Rochester, NY (J.O.); Department
of Natural Sciences, Kettering University, Flint, Mich (T.A.S.); Departments of
Biomedical Engineering and Radiology, University of Michigan, Ann Arbor, Mich
(J.B.F.); RSNA Quantitative Imaging Biomarkers Alliance (T.J.H.); and Center for
Ultrasound Research & Translation, Department of Radiology, Massachusetts
General Hospital, Harvard Medical School, Boston, Mass (A.E.S.)
| | - Keith A. Wear
- From the Department of Radiology, University of Texas Southwestern
Medical Center, Dallas, Tex (D.T.F.); Departments of Medical Physics (I.M.R.M.,
T.J.H.) and Radiology (I.M.R.M.), University of Wisconsin, Institutes for
Medical Research, 1111 Highland Ave, Room 1005, Madison, WI 53705; General
Electric Healthcare, Milwaukee, Wis (M.W.); Department of Radiology, University
of Alabama at Birmingham, Birmingham, Ala (M.L.R.); Department of Radiology,
Massachusetts General Hospital, Boston, Mass (A.O.); U.S. Food and Drug
Administration, Silver Spring, Md (K.A.W.); Department of Electrical and
Computer Engineering, University of Rochester, Rochester, NY (J.O.); Department
of Natural Sciences, Kettering University, Flint, Mich (T.A.S.); Departments of
Biomedical Engineering and Radiology, University of Michigan, Ann Arbor, Mich
(J.B.F.); RSNA Quantitative Imaging Biomarkers Alliance (T.J.H.); and Center for
Ultrasound Research & Translation, Department of Radiology, Massachusetts
General Hospital, Harvard Medical School, Boston, Mass (A.E.S.)
| | - Juvenal Ormachea
- From the Department of Radiology, University of Texas Southwestern
Medical Center, Dallas, Tex (D.T.F.); Departments of Medical Physics (I.M.R.M.,
T.J.H.) and Radiology (I.M.R.M.), University of Wisconsin, Institutes for
Medical Research, 1111 Highland Ave, Room 1005, Madison, WI 53705; General
Electric Healthcare, Milwaukee, Wis (M.W.); Department of Radiology, University
of Alabama at Birmingham, Birmingham, Ala (M.L.R.); Department of Radiology,
Massachusetts General Hospital, Boston, Mass (A.O.); U.S. Food and Drug
Administration, Silver Spring, Md (K.A.W.); Department of Electrical and
Computer Engineering, University of Rochester, Rochester, NY (J.O.); Department
of Natural Sciences, Kettering University, Flint, Mich (T.A.S.); Departments of
Biomedical Engineering and Radiology, University of Michigan, Ann Arbor, Mich
(J.B.F.); RSNA Quantitative Imaging Biomarkers Alliance (T.J.H.); and Center for
Ultrasound Research & Translation, Department of Radiology, Massachusetts
General Hospital, Harvard Medical School, Boston, Mass (A.E.S.)
| | - Timothy A. Stiles
- From the Department of Radiology, University of Texas Southwestern
Medical Center, Dallas, Tex (D.T.F.); Departments of Medical Physics (I.M.R.M.,
T.J.H.) and Radiology (I.M.R.M.), University of Wisconsin, Institutes for
Medical Research, 1111 Highland Ave, Room 1005, Madison, WI 53705; General
Electric Healthcare, Milwaukee, Wis (M.W.); Department of Radiology, University
of Alabama at Birmingham, Birmingham, Ala (M.L.R.); Department of Radiology,
Massachusetts General Hospital, Boston, Mass (A.O.); U.S. Food and Drug
Administration, Silver Spring, Md (K.A.W.); Department of Electrical and
Computer Engineering, University of Rochester, Rochester, NY (J.O.); Department
of Natural Sciences, Kettering University, Flint, Mich (T.A.S.); Departments of
Biomedical Engineering and Radiology, University of Michigan, Ann Arbor, Mich
(J.B.F.); RSNA Quantitative Imaging Biomarkers Alliance (T.J.H.); and Center for
Ultrasound Research & Translation, Department of Radiology, Massachusetts
General Hospital, Harvard Medical School, Boston, Mass (A.E.S.)
| | - J. Brian Fowlkes
- From the Department of Radiology, University of Texas Southwestern
Medical Center, Dallas, Tex (D.T.F.); Departments of Medical Physics (I.M.R.M.,
T.J.H.) and Radiology (I.M.R.M.), University of Wisconsin, Institutes for
Medical Research, 1111 Highland Ave, Room 1005, Madison, WI 53705; General
Electric Healthcare, Milwaukee, Wis (M.W.); Department of Radiology, University
of Alabama at Birmingham, Birmingham, Ala (M.L.R.); Department of Radiology,
Massachusetts General Hospital, Boston, Mass (A.O.); U.S. Food and Drug
Administration, Silver Spring, Md (K.A.W.); Department of Electrical and
Computer Engineering, University of Rochester, Rochester, NY (J.O.); Department
of Natural Sciences, Kettering University, Flint, Mich (T.A.S.); Departments of
Biomedical Engineering and Radiology, University of Michigan, Ann Arbor, Mich
(J.B.F.); RSNA Quantitative Imaging Biomarkers Alliance (T.J.H.); and Center for
Ultrasound Research & Translation, Department of Radiology, Massachusetts
General Hospital, Harvard Medical School, Boston, Mass (A.E.S.)
| | - Timothy J. Hall
- From the Department of Radiology, University of Texas Southwestern
Medical Center, Dallas, Tex (D.T.F.); Departments of Medical Physics (I.M.R.M.,
T.J.H.) and Radiology (I.M.R.M.), University of Wisconsin, Institutes for
Medical Research, 1111 Highland Ave, Room 1005, Madison, WI 53705; General
Electric Healthcare, Milwaukee, Wis (M.W.); Department of Radiology, University
of Alabama at Birmingham, Birmingham, Ala (M.L.R.); Department of Radiology,
Massachusetts General Hospital, Boston, Mass (A.O.); U.S. Food and Drug
Administration, Silver Spring, Md (K.A.W.); Department of Electrical and
Computer Engineering, University of Rochester, Rochester, NY (J.O.); Department
of Natural Sciences, Kettering University, Flint, Mich (T.A.S.); Departments of
Biomedical Engineering and Radiology, University of Michigan, Ann Arbor, Mich
(J.B.F.); RSNA Quantitative Imaging Biomarkers Alliance (T.J.H.); and Center for
Ultrasound Research & Translation, Department of Radiology, Massachusetts
General Hospital, Harvard Medical School, Boston, Mass (A.E.S.)
| | - Anthony E. Samir
- From the Department of Radiology, University of Texas Southwestern
Medical Center, Dallas, Tex (D.T.F.); Departments of Medical Physics (I.M.R.M.,
T.J.H.) and Radiology (I.M.R.M.), University of Wisconsin, Institutes for
Medical Research, 1111 Highland Ave, Room 1005, Madison, WI 53705; General
Electric Healthcare, Milwaukee, Wis (M.W.); Department of Radiology, University
of Alabama at Birmingham, Birmingham, Ala (M.L.R.); Department of Radiology,
Massachusetts General Hospital, Boston, Mass (A.O.); U.S. Food and Drug
Administration, Silver Spring, Md (K.A.W.); Department of Electrical and
Computer Engineering, University of Rochester, Rochester, NY (J.O.); Department
of Natural Sciences, Kettering University, Flint, Mich (T.A.S.); Departments of
Biomedical Engineering and Radiology, University of Michigan, Ann Arbor, Mich
(J.B.F.); RSNA Quantitative Imaging Biomarkers Alliance (T.J.H.); and Center for
Ultrasound Research & Translation, Department of Radiology, Massachusetts
General Hospital, Harvard Medical School, Boston, Mass (A.E.S.)
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Song K, Son NH, Chang DR, Chae HW, Shin HJ. Feasibility of Ultrasound Attenuation Imaging for Assessing Pediatric Hepatic Steatosis. BIOLOGY 2022; 11:biology11071087. [PMID: 36101465 PMCID: PMC9313139 DOI: 10.3390/biology11071087] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022]
Abstract
We investigated the feasibility of ultrasound attenuation imaging (ATI) for assessing pediatric hepatic steatosis. A total of 111 children and adolescents who underwent liver ultrasonography with ATI for suspected hepatic steatosis were included. Participants were classified into the normal, mild, or moderate−severe fatty liver group according to grayscale US findings. Associations between clinical factors, magnetic resonance imaging proton density fat fraction, steatosis stage and ATI values were evaluated. To determine the cutoff values of ATI for staging hepatic steatosis, areas under the curve (AUCs) were analyzed. Factors that could cause measurement failure with ATI were assessed. Of 111 participants, 88 had successful measurement results. Median ATI values were significantly increased according to steatosis stage (p < 0.001). Body mass index (BMI) was a significant factor for increased ATI values (p = 0.047). To differentiate fatty liver from normal liver, a cutoff value of 0.59 dB/cm/MHz could be used with an AUC value of 0.853. To differentiate moderate to severe fatty liver from mild fatty liver, a cutoff value of 0.69 dB/cm/MHz could be used with an AUC value up to 0.91. ATI can be used in children as an effective ultrasonography technique for quantifying and staging pediatric hepatic steatosis.
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Affiliation(s)
- Kyungchul Song
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul 03722, Korea; (K.S.); (H.W.C.)
| | - Nak-Hoon Son
- Department of Statistics, Keimyung University, Daegu 42601, Korea;
| | - Dong Ryul Chang
- Department of Radiology, Research Institute of Radiological Science and Center for Clinical Imaging Data Science, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si 16995, Korea;
| | - Hyun Wook Chae
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul 03722, Korea; (K.S.); (H.W.C.)
| | - Hyun Joo Shin
- Department of Radiology, Research Institute of Radiological Science and Center for Clinical Imaging Data Science, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si 16995, Korea;
- Correspondence: ; Tel.: +82-31-5189-8321; Fax: +82-31-5189-8377
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Cassinotto C, Jacq T, Anselme S, Ursic-Bedoya J, Blanc P, Faure S, Belgour A, Guiu B. Diagnostic Performance of Attenuation to Stage Liver Steatosis with MRI Proton Density Fat Fraction as Reference: A Prospective Comparison of Three US Machines. Radiology 2022; 305:353-361. [PMID: 35819322 DOI: 10.1148/radiol.212846] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background US tools to quantify liver fat content have recently been made clinically available by different vendors, but comparative data on their accuracy are lacking. Purpose To compare the diagnostic performances of the attenuation parameters of US machines from three different manufacturers (vendors 1, 2, and 3) in participants who underwent liver fat quantification with the MRI-derived proton density fat fraction (PDFF). Materials and Methods From July 2020 to June 2021, consecutive participants with chronic liver disease were enrolled in this prospective single-center study and underwent MRI PDFF quantification (reference standard) and US on the same day. US was performed with two different machines from among three vendors assessed. Areas under the receiver operating characteristic curve (AUCs) for the staging of liver steatosis (MRI PDFF: ≥5.5% for grade ≥S1 and ≥15.5% for grade ≥S2) were calculated in test and validation samples and then compared between vendors in the study sample. Results A total of 534 participants (mean age, 60 years ± 13 [SD]; 320 men) were evaluated. Failure of measurements occurred in less than 1% of participants for all vendors. Correlation coefficients with the MRI PDFF were 0.71, 0.73, and 0.54 for the attenuation coefficients of vendors 1, 2, and 3, respectively. In the test sample, AUCs for diagnosis of steatosis grade S1 and higher and grade S2 and higher were 0.89 and 0.93 for vendor 1 attenuation, 0.88 and 0.92 for vendor 2 attenuation, and 0.79 and 0.79 for vendor 3 attenuation, respectively. In the validation sample, a threshold value of 0.65 for vendor 1 and 0.66 for vendor 2 yielded sensitivity of 77% and 84% and specificity of 78% and 85%, respectively, for diagnosis of grade S1 and higher. Vendor 2 attenuation had greater AUCs than vendor 3 attenuation (P = .001 and P = .003) for diagnosis of grade S1 and higher and grade S2 and higher, respectively, and vender 2 had greater AUCs for attenuation than vendor 1 for diagnosis of grade S2 and higher (P = .04). For all vendors, attenuation was not associated with liver stiffness (correlation coefficients <0.05). Conclusion To stage liver steatosis, attenuation coefficient accuracy varied among US devices across vendors when using MRI proton density fat fraction quantification as the reference standard, with some demonstrating excellent diagnostic performance and similar cutoff values. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Dubinsky in this issue.
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Affiliation(s)
- Christophe Cassinotto
- From the Departments of Diagnostic and Interventional Radiology (C.C., T.J., S.A., A.B., B.G.), Hepatology A (J.U.B., S.F.), and Hepatology B (P.B.), Saint-Eloi Hospital, University Hospital of Montpellier, 80 Avenue Augustin Fliche, 34090 Montpellier, France; and Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, Montpellier University, Montpellier, France (C.C., B.G.)
| | - Tony Jacq
- From the Departments of Diagnostic and Interventional Radiology (C.C., T.J., S.A., A.B., B.G.), Hepatology A (J.U.B., S.F.), and Hepatology B (P.B.), Saint-Eloi Hospital, University Hospital of Montpellier, 80 Avenue Augustin Fliche, 34090 Montpellier, France; and Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, Montpellier University, Montpellier, France (C.C., B.G.)
| | - Sophie Anselme
- From the Departments of Diagnostic and Interventional Radiology (C.C., T.J., S.A., A.B., B.G.), Hepatology A (J.U.B., S.F.), and Hepatology B (P.B.), Saint-Eloi Hospital, University Hospital of Montpellier, 80 Avenue Augustin Fliche, 34090 Montpellier, France; and Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, Montpellier University, Montpellier, France (C.C., B.G.)
| | - José Ursic-Bedoya
- From the Departments of Diagnostic and Interventional Radiology (C.C., T.J., S.A., A.B., B.G.), Hepatology A (J.U.B., S.F.), and Hepatology B (P.B.), Saint-Eloi Hospital, University Hospital of Montpellier, 80 Avenue Augustin Fliche, 34090 Montpellier, France; and Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, Montpellier University, Montpellier, France (C.C., B.G.)
| | - Pierre Blanc
- From the Departments of Diagnostic and Interventional Radiology (C.C., T.J., S.A., A.B., B.G.), Hepatology A (J.U.B., S.F.), and Hepatology B (P.B.), Saint-Eloi Hospital, University Hospital of Montpellier, 80 Avenue Augustin Fliche, 34090 Montpellier, France; and Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, Montpellier University, Montpellier, France (C.C., B.G.)
| | - Stéphanie Faure
- From the Departments of Diagnostic and Interventional Radiology (C.C., T.J., S.A., A.B., B.G.), Hepatology A (J.U.B., S.F.), and Hepatology B (P.B.), Saint-Eloi Hospital, University Hospital of Montpellier, 80 Avenue Augustin Fliche, 34090 Montpellier, France; and Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, Montpellier University, Montpellier, France (C.C., B.G.)
| | - Ali Belgour
- From the Departments of Diagnostic and Interventional Radiology (C.C., T.J., S.A., A.B., B.G.), Hepatology A (J.U.B., S.F.), and Hepatology B (P.B.), Saint-Eloi Hospital, University Hospital of Montpellier, 80 Avenue Augustin Fliche, 34090 Montpellier, France; and Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, Montpellier University, Montpellier, France (C.C., B.G.)
| | - Boris Guiu
- From the Departments of Diagnostic and Interventional Radiology (C.C., T.J., S.A., A.B., B.G.), Hepatology A (J.U.B., S.F.), and Hepatology B (P.B.), Saint-Eloi Hospital, University Hospital of Montpellier, 80 Avenue Augustin Fliche, 34090 Montpellier, France; and Institut Desbrest d'Epidémiologie et de Santé Publique, IDESP UMR UA11 INSERM, Montpellier University, Montpellier, France (C.C., B.G.)
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Dubinsky TJ. Evaluating Hepatic Steatosis with MRI as the Reference Standard: Different Performances of Three US Machines. Radiology 2022; 305:362-363. [PMID: 35819330 DOI: 10.1148/radiol.221177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Theodore J Dubinsky
- From the Department of Radiology, University of Washington Harborview Medical Center, 325 Ninth Ave, Box 359728, Seattle, WA 98104-2499
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Yoon H, Kim J, Lim HJ, Kamiyama N, Oguri T, Koh H, Lee MJ. Attenuation Coefficient Measurement Using a High-Frequency (2-9 MHz) Convex Transducer for Children Including Fatty Liver. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:1070-1077. [PMID: 35296397 DOI: 10.1016/j.ultrasmedbio.2022.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 01/14/2022] [Accepted: 02/07/2022] [Indexed: 06/14/2023]
Abstract
We evaluated the measurement feasibility and diagnostic ability of an ultrasound-guided attenuation parameter (UGAP) using a high-frequency convex transducer in children. This retrospective study included all consecutive children who underwent abdomen ultrasonography from July to December 2020. Attenuation coefficients (ACs) of the liver were measured using both 1- to 6-MHz (AC1-6) and 2- to 9-MHz (AC2-9) probes of the LOGIQ E10 system (GE Healthcare). t-Tests and Pearson's or partial correlation analyses were performed, and AC cutoff values for diagnosing fatty liver were obtained from receiver operating characteristic curve analyses. Finally, 118 patients (M:F = 83:35, mean age: 10.2 ± 4.1 y) were evaluated, and the measurement success rate was 98.3% (116/118) for AC2-9. AC1-6 was available in children with a liver depth greater than 9 cm. The ratio of interquartile range to median of the AC2-9 was lower than that of the AC1-6 (4.3 vs. 8.5, p < 0.001). In the normal group (n = 41), the AC2-9 values were not associated with age, sex or body mass index. For the evaluation of steatosis, the AC2-9 values exhibited a positive correlation with the MR fat fraction (coefficient = 0.498, p < 0.001). The cutoff value of 0.699 dB/cm/MHz had 90.2% sensitivity and 100% specificity for diagnosing fatty liver. In conclusion, measurements of ACs using a high-frequency convex transducer are feasible even in small children, with lower measurement variability. The AC2-9 values also had good diagnostic performance for pediatric fatty liver.
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Affiliation(s)
- Haesung Yoon
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; Severance Pediatric Liver Disease Research Group, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jisoo Kim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; Severance Pediatric Liver Disease Research Group, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Ji Lim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; Severance Pediatric Liver Disease Research Group, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | - Takuma Oguri
- Ultrasound General Imaging, GE Healthcare, Hino, Tokyo, Japan
| | - Hong Koh
- Severance Pediatric Liver Disease Research Group, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea; Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Mi-Jung Lee
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; Severance Pediatric Liver Disease Research Group, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea.
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20
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Alves VPV, Dillman JR, Tkach JA, Bennett PS, Xanthakos SA, Trout AT. Comparison of Quantitative Liver US and MRI in Patients with Liver Disease. Radiology 2022; 304:660-669. [PMID: 35608446 DOI: 10.1148/radiol.212995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Quantitative US techniques can be used to identify changes of liver disease, but data regarding their diagnostic performance and relationship to MRI measures are sparse. Purpose To define associations between quantitative US and MRI measures of the liver in children, adolescents, and young adults with liver disease and to define the predictive ability of quantitative US measures to detect abnormal liver stiffening and steatosis defined with MRI. Materials and Methods In this prospective study, consecutive patients aged 8-21 years and known to have or suspected of having liver disease and body mass index less than 35 kg/m2 underwent 1.5-T MRI and quantitative liver US during the same visit at a pediatric academic medical center between April 2018 and December 2020. Acquired US parameters included shear-wave speed (SWS) and attenuation coefficient, among others. US parameters were compared with liver MR elastography and liver MRI proton density fat fraction (PDFF). Pearson correlation, multiple logistic regression, and receiver operating characteristic curve analyses were performed to assess associations and determine the performance of US relative to that of MRI. Results A total of 44 study participants (mean age, 16 years ± 4 [SD]; age range, 8-21 years; 23 male participants) were evaluated. There was a positive correlation between US SWS and MR elastography stiffness (r = 0.73, P < .001). US attenuation was positively correlated with MRI PDFF (r = 0.45, P = .001). For the prediction of abnormal (>2.8 kPa) liver shear stiffness, SWS (1.56 m/sec [7.3 kPa] cutoff) had an area under the receiver operating characteristic curve (AUC) of 0.95 with 91% sensitivity (95% CI: 71, 99) (20 of 22 participants) and 95% specificity (95% CI: 76, 99) (20 of 21 participants). For the prediction of abnormal (>5%) liver PDFF, US attenuation (0.55 dB/cm/MHz cutoff) had an AUC of 0.75 with a sensitivity of 73% (95% CI: 39, 94) (eight of 11 participants) and a specificity of 73% (95% CI: 55, 86) (24 of 33 participants). Conclusion In children, adolescents, and young adults with known or suspected liver disease, there was moderate to high correlation between US shear-wave speed (SWS) and MR elastography-derived stiffness. US SWS predicted an abnormal liver shear stiffness with high performance. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Khanna and Alazraki in this issue.
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Affiliation(s)
- Vinicius P V Alves
- From the Department of Radiology (V.P.V.A, J.R.D., J.A.T., P.S.B., A.T.T.) and Division of Gastroenterology, Hepatology and Nutrition (S.A.X.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Kasota Building MLC 5031, Cincinnati, OH 45226; and Departments of Radiology (J.R.D., A.T.T.) and Pediatrics (S.A.X., A.T.T.), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan R Dillman
- From the Department of Radiology (V.P.V.A, J.R.D., J.A.T., P.S.B., A.T.T.) and Division of Gastroenterology, Hepatology and Nutrition (S.A.X.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Kasota Building MLC 5031, Cincinnati, OH 45226; and Departments of Radiology (J.R.D., A.T.T.) and Pediatrics (S.A.X., A.T.T.), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jean A Tkach
- From the Department of Radiology (V.P.V.A, J.R.D., J.A.T., P.S.B., A.T.T.) and Division of Gastroenterology, Hepatology and Nutrition (S.A.X.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Kasota Building MLC 5031, Cincinnati, OH 45226; and Departments of Radiology (J.R.D., A.T.T.) and Pediatrics (S.A.X., A.T.T.), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Paula S Bennett
- From the Department of Radiology (V.P.V.A, J.R.D., J.A.T., P.S.B., A.T.T.) and Division of Gastroenterology, Hepatology and Nutrition (S.A.X.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Kasota Building MLC 5031, Cincinnati, OH 45226; and Departments of Radiology (J.R.D., A.T.T.) and Pediatrics (S.A.X., A.T.T.), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Stavra A Xanthakos
- From the Department of Radiology (V.P.V.A, J.R.D., J.A.T., P.S.B., A.T.T.) and Division of Gastroenterology, Hepatology and Nutrition (S.A.X.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Kasota Building MLC 5031, Cincinnati, OH 45226; and Departments of Radiology (J.R.D., A.T.T.) and Pediatrics (S.A.X., A.T.T.), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Andrew T Trout
- From the Department of Radiology (V.P.V.A, J.R.D., J.A.T., P.S.B., A.T.T.) and Division of Gastroenterology, Hepatology and Nutrition (S.A.X.), Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Kasota Building MLC 5031, Cincinnati, OH 45226; and Departments of Radiology (J.R.D., A.T.T.) and Pediatrics (S.A.X., A.T.T.), University of Cincinnati College of Medicine, Cincinnati, Ohio
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21
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Kim PH, Cho YA, Yoon HM, Bak B, Lee JS, Jung AY, Oh SH, Kim KM. Accuracy of attenuation imaging in the assessment of pediatric hepatic steatosis: correlation with the controlled attenuation parameter. Ultrasonography 2022; 41:761-769. [PMID: 35765803 PMCID: PMC9532206 DOI: 10.14366/usg.21246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/05/2022] [Indexed: 11/03/2022] Open
Abstract
PURPOSE This study evaluated the accuracy of attenuation imaging (ATI) for the assessment of hepatic steatosis in pediatric patients, in comparison with the FibroScan vibration-controlled transient elastography controlled attenuation parameter (CAP). METHODS Consecutive pediatric patients referred for evaluation of obesity who underwent both ATI and FibroScan between February 2020 and September 2021 were included. The correlation between attenuation coefficient (AC) and CAP values was assessed using the Spearman test. The AC cutoff value for discriminating hepatic steatosis corresponding to a CAP value of 241 dB/m was calculated. Multivariable linear regression analysis was performed to estimate the strength of the association between AC and CAP. The diagnostic accuracy of AC cutoffs was estimated using the imperfect gold-standard methodology based on a two-level Bayesian latent class model. RESULTS Seventy patients (median age, 12.5 years; interquartile range, 11.0 to 14.0 years; male:female, 58:12) were included. AC and CAP showed a moderate-to-good correlation (ρ =0.646, P<0.001). Multivariable regression analysis affirmed the significant association between AC and CAP (P<0.001). The correlation was not evident in patients with a body mass index ≥30 kg/m2 (ρ=-0.202, P=0.551). Linear regression revealed that an AC cutoff of 0.66 dB/cm/MHz corresponded to a CAP of 241 dB/m (sensitivity, 0.93; 95% confidence interval [CI], 0.85 to 0.98 and specificity, 0.87; 95% CI, 0.56 to 1.00). CONCLUSION ATI showed an acceptable correlation with CAP values in a pediatric population, especially in patients with a body mass index <30 kg/m2. An AC cutoff of 0.66 dB/cm/MHz, corresponding to a CAP of 241 dB/m, can accurately diagnose hepatic steatosis.
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Affiliation(s)
- Pyeong Hwa Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Ah Cho
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Mang Yoon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Boram Bak
- University of Ulsan Foundation for Industry Cooperation, Ulsan, Korea
| | - Jin Seong Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ah Young Jung
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seak Hee Oh
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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22
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Lee SB, Park BJ, Lee YJ, Jung DH. Early Chronic Kidney Disease (G1-G3a) in Combination with Steatosis as a Predictor of Incident Ischemic Heart Disease: A Longitudinal Study in Non-Diabetic Koreans. Biomedicines 2021; 9:biomedicines9101358. [PMID: 34680475 PMCID: PMC8533481 DOI: 10.3390/biomedicines9101358] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/25/2021] [Accepted: 09/28/2021] [Indexed: 12/26/2022] Open
Abstract
Hepatic steatosis and chronic kidney disease (CKD) in the advanced stages are closely related to cardiovascular diseases. Despite the potential connection between early CKD (G1-G3a) and hepatic steatosis on cardiometabolic risks, few studies have revealed their causal link to ischemic heart disease (IHD). We prospectively investigated the combined effect of CKD in earlier stages and hepatic steatosis on incident IHD risk in large-scale, non-diabetic Koreans. Data were assessed from 16,531 participants without diabetes from the Health Risk Assessment Study (HERAS) and Korea Health Insurance Review and Assessment (HIRA) data. We divided the study population into four groups according to the existence of early CKD and hepatic steatosis: controls, early CKD only, hepatic steatosis only, and both early CKD and hepatic steatosis. We prospectively assessed hazard ratios (HRs) with 95% confidence intervals (CIs) for IHD using multivariate Cox proportional-hazard regression models over a 50-month period. During the follow-up period, 326 (2.0%) patients developed IHD. HRs of IHD in the four groups were 1.00 (controls), 1.26 (95% CI 0.72–2.19), 1.19 (95% CI 0.90–1.57) and 1.76 (95% CI 1.04–2.97), respectively, after adjusting for potential confounding variables. Even less than stage 3A, CKD could precede and predict IHD in patients with hepatic steatosis.
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Affiliation(s)
- Sung-Bum Lee
- Department of Health Check-up, Yongin Severance Hospital, Yongin-si 16995, Korea;
| | - Byoung-Jin Park
- Department of Family Medicine, Yongin Severance Hospital, Yongin-si 16995, Korea;
| | - Yong-Jae Lee
- Department of Family Medicine, Gangnam Severance Hospital, Seoul 06273, Korea;
| | - Dong-Hyuk Jung
- Department of Family Medicine, Yongin Severance Hospital, Yongin-si 16995, Korea;
- Correspondence:
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