Latin American Association for the study of the liver (ALEH) practice guidance for the diagnosis and treatment of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) currently represents an epidemic worldwide. NAFLD is the most frequently diagnosed chronic liver disease, affecting 20-30% of the general population. Furthermore, its prevalence is predicted to increase exponentially in the next decades, concomitantly with the global epidemic of obesity, type 2 diabetes mellitus (T2DM), and sedentary lifestyle. NAFLD is a clinical syndrome that encompasses a wide spectrum of associated diseases and hepatic complications such as hepatocellular carcinoma (HCC). Moreover, this disease is believed to become the main indication for liver transplantation in the near future. Since NAFLD management represents a growing challenge for primary care physicians, the Asociación Latinoamericana para el Estudio del Hígado (ALEH) has decided to organize this Practice Guidance for the Diagnosis and Treatment of Non-Alcoholic Fatty Liver Disease, written by Latin-American specialists in different clinical areas, and destined to general practitioners, internal medicine specialists, endocrinologists, diabetologists, gastroenterologists, and hepatologists. The main purpose of this document is to improve patient care and awareness of NAFLD. The information provided in this guidance may also be useful in assisting stakeholders in the decision-making process related to NAFLD. Since new evidence is constantly emerging on different aspects of the disease, updates to this guideline will be required in future.

Plasma lipidomic fingerprinting to distinguish among hepatitis C-related hepatocellular carcinoma, liver cirrhosis, and chronic hepatitis C using MALDI-TOF mass spectrometry: a pilot study

BACKGROUND AND AIMS

Hepatitis C (HC) is a major cause of hepatocellular carcinoma (HCC), and a late diagnosis is the main factor for the poor survival of patients. There is an urgent need for identifying sensitive and specific biomarkers for HCC diagnosis. In the present study, plasma lipid patterns of patients with HC-HCC, HC-liver cirrhosis (LC), and chronic HC (CHC) were assessed by matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS).

METHODS

Plasma samples of 25 patients with HC-HCC, 15 patients with HC-LC, and 25 patients with CHC were evaluated by MALDI-MS using a Q-ToF premier (Synapt) mass spectrometer (Waters, Manchester, UK) equipped with a 200-Hz solid-state laser in the mass range between m/z (mass-to-charge ratio) of 700-1200.

RESULTS

A total of 2205 ions were initially obtained and 7 ions (m/z) were highlighted as corresponding to the most important lipids to differentiate HCC patients from LC and CHC patients. The specific lipidomic expression signature generated resulted in an overall predictive accuracy of 93% of HC-HCC and HC-LC, and 100% of HC-HCC and CHC. The 7-peak algorithm distinguished HCC from LC with a sensitivity of 96% and a specificity of 87%, and HCC from CHC with both sensitivity and specificity of 100%.

CONCLUSION

MALDI-MS-specific signature peaks accurately distinguished patients with HC-HCC from those with HC-LC and CHC. The results indicate the potential of MALDI-MS and the selected peaks to improve HCC surveillance in patients with viral C cirrhosis and chronic hepatitis C.

A comparison of prediction equations for the estimation of body fat percentage in non-obese and obese older Caucasian adults in the United States

OBJECTIVES

The predictive capabilities of skinfold regression equations are limited across populations and current equations may not be well suited for the prediction of body fat in older adults or obese Americans. The goal of this study was to compare percent body fat (%BF) predicted by several skinfold regression equations to %BF determined by Dual-Energy X-ray Absorptiometry (DXA) in obese and non-obese Caucasian men and women in the United States over the age of 65 years.

DESIGN

A block design was used with two blocks: obesity (non-obese/obese) and gender (male/female). All subjects underwent the same testing procedures in one visit.

SETTING

University of Pittsburgh Clinical and Translation Research Center.

PARTICIPANTS

Seventy-eight older healthy adults were recruited for participation.

MEASUREMENTS

Actual percent body fat was determined from a whole body DXA scan. Estimated percent body fat (%BF) was calculated using skinfold measurements and established regression equations. The predictive accuracy of the regression equations was evaluated by comparing the estimated %BF to the actual %BF measured with DXA using a within subject ANOVA (α=0.05). This was done within subgroups: obese males, obese females, non-obese males and non-obese females.

RESULTS

Durnin and Womersly and Jackson and Pollock had reasonably good agreement with DXA in older Caucasian American females and males, respectively. The remaining equations significantly overestimated %BF in older Caucasian American males. Mixed results were found in females with Gause-Nilsson and Jackson and Pollock significantly underestimating %BF, while Visser and Kwok overestimated %BF.

CONCLUSION

Numerous factors of a population including age, race, ethnicity, gender and obesity should be considered when selecting a skinfold regression equation to estimate %BF. While Durnin and Womersly and Jackson and Pollock are recommended for predicting %BF in older Caucasian American females and males, respectively, there exists a need to develop accurate regression models that consider obesity, gender, race or ethnicity when predicting %BF in a diverse geriatric American population.

Fibronectina biliar no diagnóstico de estenoses biliares

Introdução: Ainda, não existe método ideal para o diagnóstico diferencial entre estenoses biliares malignas e benignas. Este estudo visa a comparar a concentração de fibronectina biliar nos pacientes com e sem estenose biliar maligna. Métodos: Durante a pancreatocolangiografia retrógrada endoscópica (PCRE), foram coletadas amostras de bile de 50 pacientes com estenose biliar extra-hepática maligna (40), benigna (10) e de 10 doentes sem estenose biliar (grupo controle). A fibronectina total na bile foi determinada por ensaio imunoenzimático. A concentração sérica de bilirrubina direta, fosfatase alcalina, gama glutamiltransferase, aspartato aminotransferase e alanina aminotransferase foi determinada nos pacientes com estenose biliar antes da PCRE. O diagnóstico final foi definido por cirurgia, biópsia ou acompanhamento clínico. Resultados: Os pacientes com neoplasia maligna eram significativamente mais idosos (p= 0,02) e apresentaram níveis mais elevados dos testes bioquímicos relacionados à colestase (p< 0,01). Não houve diferença significativa na concentração de fibronectina biliar entre os pacientes com estenose maligna (694,2 ± 823,5 ng/ml), benigna (828,9 ± 925ng/ml) e grupo controle (466,5 ± 621,5 ng/ml), ou entre os pacientes com (721,2 ± 836,6 ng/ml) e sem estenose (466,5 ± 621,5 ng/ml). Conclusões: As médias de idade e de resultados de exames laboratoriais relacionados à colestase foram mais elevadas nos pacientes com neoplasia maligna. A dosagem apenas da fibronectina total na bile não foi eficaz para diagnóstico diferencial das estenoses biliares.

Peginterferon alfa-2a (40KD) (PEGASYS) plus ribavirin (COPEGUS) in retreatment of chronic hepatitis C patients, nonresponders and relapsers to previous conventional interferon plus ribavirin therapy

Peginterferon alfa plus ribavirin is currently the treatment of choice for chronic hepatitis C. Peginterferon alfa-2a (40KD) plus ribavirin has given an overall sustained virological response of 18% in F3/F4 previous nonresponder US patients. We evaluated the effectiveness of peginterferon alfa-2a (40KD) plus ribavirin in Brazilian patients who were relapsers or nonresponders to previous interferon-based therapy. One-hundred-thirty-four patients with biopsy-proven chronic hepatitis C, HCV RNA positive, elevated ALT and who were either relapsers (n=37) or nonresponders (n=97) to at least 24 weeks of conventional interferon/ribavirin therapy were retreated with peginterferon alfa-2a (40KD) 180mg/qw and ribavirin 800 mg bid for 48 weeks. Efficacy was assessed as virological response (defined as undetectable HCV RNA) at the end of treatment (EoT) and at the end of follow-up (SVR - Sustained Virological Response). Safety assessments consisted of clinical and laboratory evaluations. In the patient sample, 72% were genotype 1 and 34% were cirrhotic. In an intention-to-treat analysis, relapser patients showed 78% EoT response and 51% SVR. Nonresponders showed 57% EoT response and 26% SVR. Positive predictive factors of SVR were non-1 genotype and relapser state. Six percent of the patients interrupted treatment because of adverse events and 45% had dose reduction (mainly associated with leucopenia and anemia). Brazilian patient relapsers and nonresponders to conventional interferon and ribavirin treatment can achieve a sustained virological response when retreated with peginterferon alfa-2a (40KD) and ribavirin. The safety profile is similar to that of naive patients.

Neurohumoral systems in patients with cirrhosis

In order to evaluate the activation of the sympathetic nervous and renin-angiotensin systems and antidiuretic hormone release in the setting of chronic liver disease, we studied 30 patients with cirrhosis who presented normal renal function. The cirrhotic patients were divided into two groups according to Child's score: 20 were Child A and 10 Child B. The control group consisted of 10 normal subjects. Blood samples were collected for determination of norepinephrine (NE), dopamine (DA), angiotensin I and II (AI and AII), and antidiuretic hormone (ADH), using the method of high-performance liquid chromatography (HPLC). No significant differences (p < 0.05) were found in the plasma levels of NE, DA, AI, and AII between the cirrhotic patients and the controls, although the absolute values observed in both groups of cirrhotics were clearly higher than in controls. The ADH levels were higher in Child B in comparison to Child A patients and controls, though this difference was not significant as well. Our results suggest a hormonal activation in cirrhotic patients, even in the early stages of hepatic disease (without ascites). We also noted an increase in ADH levels in Child B patients in relation to Child A and controls, although there was no difference in osmolality, suggesting a non-osmotic ADH release.