Fibrosis-4 stage of liver fibrosis predicts cardiovascular outcomes in acute coronary syndrome patients with and without type 2 diabetes mellitus

AIMS

We aim to analyze the effect of liver fibrosis, assessed by the Fibrosis-4 (FIB-4) index, on cardiovascular events in acute coronary syndrome (ACS) patients with and without type 2 diabetes mellitus (T2DM).

METHODS

6563 ACS patients undergoing PCI were analyzed in this study. Patients were divided into three groups according to literature-based FIB-4 cut-offs: < 1.45, 1.45-3.25, and ≥ 3.25.

RESULTS

During the median 2.4-year follow-up, 270 major adverse cardiac and cerebrovascular events (MACCE) and 194 major bleeding were recorded. Intermediate or high FIB-4 scores were significantly associated with an elevated risk of MACCE, mortality, and MI but not associated with ischemic stroke and major bleeding. Further restricted cubic spline analysis showed that FIB-4 as a continuous variable was positively associated with an increased adjusted risk of MACCE. The results were consistent in subgroups with and without T2DM.

CONCLUSIONS

Liver fibrosis staged by FIB-4 was correlated with an increased risk of MACCE, mortality, and MI in ACS patients who underwent PCI with and without T2DM. FIB-4 index may help risk stratification of ACS patients independent of T2DM status.

Antibody to hepatitis B virus core antigen positivity is a predictor of non-alcoholic fatty liver disease severity

Insufficient information is available about co-factors favoring the progression of non-alcoholic fatty liver disease (NAFLD) toward cirrhosis. We aimed to evaluate the impact of a limited alcohol intake and of occult hepatitis B virus (HBV) infection (OBI) on the severity of NAFLD. Three-hundred-seventy-four alcohol non-abusers and HBV surface antigen negative NAFLD patients (223 males; mean age 55.4 years), consecutively admitted to the outpatients clinic of a referral liver unit from January 1st, 2018 to December 31st, 2019, were studied. Anti-HBV core antigen antibody [(anti-HBc), a surrogate marker of OBI] was assessed in all patients. Patients were distinguished between teetotal and moderate alcohol consumers (intake of less than 30 g and 20 g if males or females, respectively). Liver fibrosis was non-invasively assessed by FIB-4 and transient elastography. Uni- and multivariate analyses were performed to identify predictors of advanced fibrosis. Patients had a mean BMI of 28.5 kg/m², and the majority presented metabolic and cardio-vascular comorbidities [258 patients (69%) had insulin resistance/diabetes, 249 (66.6%) dyslipidemia, 200 (53.5%) arterial hypertension]. Multivariate analysis showed that anti-HBc positivity (p = 0.046, OR 2.153) was a factor associated with advanced fibrosis at FIB-4 score testing, whereas moderate alcohol intake was not associated with severe NAFLD both at FIB-4 and transient elastography evaluations. The study showed that a moderate alcohol intake has no impact on NAFLD severity and suggested that OBI might negatively affect the NAFLD outcome.

Liver Function Tests and FIB-4 Score as Predictors of Severity in COVID-19 Patients from the South-West of Romania

Background: The coronavirus disease 2019 pandemic (COVID-19) is the most important global health crisis to date. In this study, we performed an analysis to find the association between liver damage, FIB-4 score and the severity of COVID-19 disease. Methods: We included a total of 580 patients that tested positive for SARS-CoV-2 infection and were hospitalized. No patient included had any known history of liver disease. Liver function tests were performed, and FIB-4 score was calculated in order to assess their involvement in the disease progression. Results: More than half of the patients had elevated liver function tests. Age, high body mass index, associated heart disease and diabetes were associated with poor outcome. Corticosteroids, antibiotics, and anticoagulants strongly correlated with liver injuries. Liver impairment and injury, as well as a FIB-4 score higher than 3.5, also correlated with higher degrees of disease severity. Conclusion: Liver injury and elevated FIB-4 score were associated with poor clinical outcome and disease severity, as well as being a valuable tool to predict COVID-19-related mortality.

Increased Natural Killer Cells Are Associated with Alcohol Liver Fibrosis and with T Cell and Cytotoxic Subpopulations Change

Natural killer (NK) cells play a therapeutic role in liver fibrosis (LF). We aimed to analyze NK cells in heavy drinkers without cirrhosis or decompensated liver disease and establish correlations with other related subpopulations. Data on sociodemographic characteristics, alcohol consumption, laboratory parameters, and immunophenotyping of NK (CD16⁺/CD56⁺), T (CD3⁺), B (CD19⁺), NKT (CD16⁺/CD56⁺/CD3⁺), and cytotoxic (CD3^-CD8⁺) cells were collected. Fibrosis-4 (FIB-4) scores were used to compare patients without (FIB-4 < 1.45) and with (FIB-4 > 3.25) advanced LF (ALF). We included 136 patients (76% male) with a mean age of 49 years who had a 15-year alcohol use disorder (AUD) and alcohol consumption of 164 g/day. Patients with ALF (n = 25) presented significantly lower absolute total lymphocyte, T cell, B cell, and NKT cell numbers than patients without LF (n = 50; p < 0.01). However, the NK cells count was similar (208 ± 109 cells/µL vs. 170 ± 105 cells/µL) in both groups. The T cells percentage was lower (80.3 ± 5.6% vs. 77 ± 7%; p = 0.03) and the NK cells percentage was higher (9.7 ± 5% vs. 13 ± 6%; p = 0.02) in patients with ALF than in those without LF. The percentages of NK cells and T cells were inversely correlated in patients without (r = –0.65, p < 0.01) and with ALF (r = −0.64; p < 0.01). Additionally, the NK cells and CD3^-CD8⁺ cell percentages were positively correlated in patients without (r = 0.87, p < 0.01) and with (r = 0.92; p < 0.01) ALF. Conclusions: Heavy drinkers without decompensated liver disease showed an increase in NK cells related to T cells lymphopenia and an increase in cytotoxic populations. The interaction of NK cells with other subpopulations may modify alcohol-related liver disease progression.

Liver Fibrosis is Associated with Clinical Outcomes in Patients with Intracerebral Hemorrhage

BACKGROUND

Recent studies have reported the predictive value of liver fibrosis indices for hematoma enlargement in patients with intracerebral hemorrhage (ICH). However, little is known about the precise association between fibrosis and ICH prognosis. Thus, our study was designed to investigate the relevance of liver fibrosis, as evaluated by fibrosis-4 (FIB-4) score and poor outcomes after ICH.

METHODS

We used data from a prospective, multi-center and registry-based database. In this study, patients were stratified by the higher cut-off value of a FIB-4 score ≥2.67. The two groups of patients were then compared with regard to baseline characteristics, ICH severity and follow-up outcomes. We performed univariable and multivariable logistic regression analysis to determine the prognostic value of a FIB-4 score ≥2.67 for major disability or death. Kaplan-Meier survival curves were used to analyze the association between different FIB-4 scores and survival rate.

RESULTS

Our present study included 839 patients from 13 hospitals in Beijing. Participants with FIB-4 scores ≥2.67 had a larger baseline hematoma volume and a higher score on the modified Rankin Scale at follow-up (all p values <0.05). In the logistic regression analysis, liver fibrosis defined by a FIB-4 score ≥2.67 was independently associated with poor clinical outcomes at discharge and at 1 year (at discharge: adjusted odds ratio [95% CI] = 1.894 [1.120-3.202], p = 0.0172; at 1 year: adjusted odds ratio [95% CI] = 1.694 [1.021-2.809], p = 0.0412). However, this association was not observed at 3 months. During the follow-up period, patients with a FIB-4 score ≥2.67 also had a significantly lower survival rate according to Kaplan-Meier survival analysis.

CONCLUSION

Our study suggests that liver fibrosis defined by a FIB-4 score ≥2.67 is associated with poor clinical outcomes and lower survival rates in patients with mild to moderate ICH. These data provide reliable evidence for detecting fibrosis and managing related risk factors to improve prognosis after ICH.

Early Elevation of Fibrosis-4 Liver Fibrosis Score Is Associated With Adverse Outcomes Among Patients With Coronavirus Disease 2019

Background

Limited prior data suggest that pre-existing liver disease was associated with adverse outcomes among patients with COVID-19. FIB-4 is a noninvasive index of readily available laboratory measurements that represents hepatic fibrosis. We sought to evaluate the association between FIB-4 at an early stage of infection and COVID-19 outcomes.

Methods

FIB-4 was evaluated at admission in a cohort of 267 patients admitted with early-stage COVID-19 confirmed through RT-PCR. Hazard of ventilator use and of high-flow oxygen was estimated using Cox regression models controlled for covariates. Risk of progress to severe cases and of death/prolonged hospitalization (>30 days) were estimated using logistic regression models controlled for same covariates.

Results

Forty-one (15%) patients progressed to severe cases, 36 (14%) required high-flow oxygen support, 10 (4%) required mechanical ventilator support, and 1 died. Patients with high FIB-4 score (>3.25) were more likely to be older with pre-existing conditions. FIB-4 between 1.45-3.25 was associated with over 5-fold (95% CI: 1.2-28) increased hazard of high-flow oxygen use, over 4-fold (95% CI: 1.5-14.6) increased odds of progress to severe stage, and over 3-fold (95% CI: 1.4-7.7) increased odds of death or prolonged hospitalization. FIB-4>3.25 was associated with over 12-fold (95% CI: 2.3-68. 7) increased hazard of high-flow oxygen use and over 11-fold (95% CI: 3.1-45) increased risk of progress to severe disease. All associations were independent of sex, number of comorbidities, and inflammatory markers (D-dimer, C-reactive protein).

Conclusions

FIB-4 at early-stage of COVID-19 had an independent and dose-dependent association with adverse outcomes during hospitalization. FIB-4 provided significant prognostic value to adverse outcomes among COVID-19 patients.

Associated Factors of Liver Disease After Fontan Operation in Relation to Ultrasound Liver Elastography

Although the Fontan operation can improve outcomes, surviving patients still face Fontan-associated liver disease (FALD). The aim of this study was to determine the associated factors of FALD in relation to ultrasound liver elastography. A cross-sectional study was conducted for all patients on whom an ultrasound upper-abdomen and ultrasound liver elastography was performed at more than 1 year after the Fontan operation. The data consisted of the age at operation, type of Fontan operation, and laboratory data such as gamma-glutamyl transferase (GGT), aspartate aminotransferase-to-platelet ratio index (APRI), and fibrosis-4 (FIB-4) score. Cardiovascular evaluations included echocardiography and cardiac catheterization. Eighty patients with a median age of 12 years (range 5-36 years) were eligible for the study. The prevalence of FALD was 41%. For the purpose of univariate logistic regression analysis, the age at the Fontan operation, time elapsed since the Fontan operation, previous Glenn shunt, presence of fenestration, mean pulmonary artery pressure and IVC pressure post-Fontan operation, platelet count, GGT, and FIB-4 score were considered to be factors significantly associated with FALD. Following an adjustment by multivariate logistic regression analysis, age greater than 7 years at the time of Fontan procedure, time elapsed of more than 9 years since the procedure, and GGT level > 130 U/L were found to be significantly associated with FALD. Patients with these factors should be investigated for FALD.

FIB-4 Regression With Direct-Acting Antiviral Therapy in Patients With Hepatitis C Infection: A Safety-Net Hospital Experience

Background: Liver fibrosis stage determines the risk of morbidity and mortality from chronic hepatitis C virus (HCV) infection. The majority of HCV-infected patients are underserved and have other comorbid conditions that lead to more progressive liver disease such as cirrhosis and hepatocellular carcinoma. Safety net hospitals are the prime location to treat these patients. Direct acting antiviral (DAA) agents are highly effective in virus eradication.

Aim: We aimed to evaluate the effect of treatment with DAAs on FIB-4 index.

Methods: We identified 343 patients who initiated HCV treatment with DAAs from 2016 to 2018 and achieved a sustained virologic response (SVR) in Metrohealth Medical Center, a safety net hospital system. We compared the severity of hepatic fibrosis before and 1 year after SVR was attained. We evaluated whether the presence of other comorbid conditions influenced liver fibrosis regression. All analyses were performed using SAS software.

Results: There was a statistically significant drop in mean FIB-4 score from baseline to post-SVR (3.47 ± 2.84 vs. 2.28 ± 1.60, P < 0.001). One hundred seventeen patients had baseline FIB-4 scores ≥3.25, 56% had FIB-4 scores <3.25 after SVR. Alcohol use disorder was associated with a higher baseline FIB-4 score compared to low level drinking (3.85 ± 0.20 vs. 3.15 ± 0.16). These patients showed greater improvement in FIB-4 scores after treatment when compared to those without alcohol use disorder (1.44 ± 0.15 vs. 0.97 ± 0.13, P = 0.02).

Conclusion: FIB-4 index is a useful non-invasive tool for monitoring fibrosis regression after antiviral therapy. Patients with a history of alcohol abuse had the greatest reduction in FIB-4 score post-SVR.

Liver stiffness measurements and FIB-4 are predictors of response to sofosbuvir-based treatment regimens in 7256 chronic HCV patients

Objectives: To assess the role of baseline liver stiffness (LS) by Transient elastography (TE) and FIB-4 in the prediction of virological response to sofosbuvir - based regimens in chronic HCV patients.Methods: A retrospective, multicenter study including 7256 chronic HCV patients who received different sofosbuvir-based regimens. Baseline demographic and laboratory data were recorded. TE was performed with FIB-4 calculation at baseline.Results: Sustained virological response at week 12 post-treatment (SVR12) was 91.4%. Pretreatment TE values and FIB-4 were significantly lower among sustained responders (17.8 ± 11.5 kPa, 2.66 ± 1.98, respectively) versus relapsers (24.5 ± 13.9 kPa, 4.02 ± 3.3, respectively). Best cutoff levels for LS by TE and FIB-4 score for prediction of failure to treatment response were 16.7 kPa and 2.4, respectively. Among different treatment protocol, patients with FIB-4 > 2.4, TE values >16.7 kPa are more prone to treatment failure except when using SOF/SIM treatment regimens.Conclusion: Baseline LS by TE and FIB-4 score may be useful for predicting treatment outcome in the new era of DAAs and could be integrated into pretreatment assessment of chronic HCV patients for better optimization of patient management.

Prevalence of prolonged QT interval in patients with HCV-related chronic liver disease

Background

Hepatitis C virus (HCV) is a common disease in Egypt with a high socioeconomic burden and extra-hepatic manifestations as QT prolongation, but previous studies included mainly patients with advanced liver disease, so in this study, we aimed to delineate the prevalence of QT prolongation in early-stage HCV patients.

Results

The study included 874 HCV patients with early cirrhosis; in Child’s class A, 57 (6.5%) patients had prolonged QT interval corrected (QTc). There was significant higher proportion of cirrhotic patients in the prolonged QTc group (31.6%) vs. in the normal QTc group (11.5%). QTc was 424.39 ± 36.6 vs. 411.51 ± 32.89 ms in cirrhotic and non-cirrhotic patients, respectively (P, 0.001). There was significant higher proportion of Fibrosis 4 (FIB-4) ≥ 1.45 score in the prolonged QTc (77.2%) vs. in the normal QTc group (56.8%) (P, 0.003). QTc interval was 417.76 ± 34.12 ms in patients with FIB-4 score ≥ 1.45 vs. 406.78 ± 31.95 ms in those with FIB-4 < 1.45 (P, < 0.001). FIB-4 score value of 2.108 predicted prolonged QTc with a sensitivity of 63.2% and a specificity of 64.5% (P, < 0.001). Twenty-four patients of long QTc group sent ECGs after HCV eradication, and 19 patients (79%) showed QTc normalization.

Conclusions

HCV is associated with QTc prolongation even in patients with early chronic liver disease stages without significant fibrosis. Also, it is related to the degree of fibrosis and cirrhosis. At a cutoff value of 2.108, FIB-4 score can predict prolonged QTc. HCV eradication is associated with a high incidence of QTc normalization.

The association between a non-invasive hepatic fibrosis score and urolithiasis among non-alcoholic fatty liver disease (NAFLD) patients in China: a cross-sectional study

OBJECTIVE

Mounting data now support a strong link between the presence of non-alcoholic fatty liver disease (NAFLD) and an increased risk of urolithiasis. However, little is known on the association between hepatic fibrosis and the risk of urolithiasis among NAFLD patients. Therefore, this study aimed to investigate the prevalence of urolithiasis among NAFLD patients and determine whether the Fibrosis-4 (FIB-4) score, a surrogate marker of hepatic fibrosis, is associated with urolithiasis among NAFLD patients.

DESIGN

Cross-sectional studies.

SETTING

China.

METHODS

A total of 2058 adult patients with NAFLD were included in this study. Logistic regression analysis was used to detect the association between FIB-4 score and urolithiasis. Receiver operating characteristic (ROC) curve analysis was used to assess the diagnostic value of FIB-4 score for the detection of urolithiasis among NAFLD patients.

RESULTS

200 (9.7%) individuals had ultrasonography-diagnosed urolithiasis among 2058 NAFLD patients. FIB-4 score (OR=1.58; 95% CI 1.06 to 2.31), age (OR=1.11; 95% CI 1.08 to 1.13), obesity (OR=3.16; 95% CI 2.29 to 4.39) and hyperuricemia (OR=3.79; 95% CI 2.67 to 5.36) were independent factors associated with urolithiasis among NAFLD patients. Moreover, a novel algorithm including multiple variables (FIB-4 score, age, obesity and hyperuricemia) showed an area under a ROC curve of 0.813 (95% CI 0.795 to 0.829) for identifying urolithiasis among NAFLD patients. The optimal cut-off value of > -2.23 for the multivariate model provides a sensitivity of 76% and a specificity of 74% for predicting urolithiasis among NAFLD patients.

CONCLUSION

Urolithiasis among NAFLD patients is associated with FIB-4 score. Further, a novel algorithm based on FIB-4 score could serve as a useful tool for identifying individuals with a higher risk of urolithiasis among NAFLD patients, although prospective cohort studies are still needed in the future.

Cytokines, Hepatic Fibrosis, and Antiretroviral Therapy Role in Neurocognitive Disorders HIV Related

The HIV may trigger a process of neuronal loss and axonal degeneration throughout the brain, which is carried on by the immune system releasing of proinflammatory cytokines, so that chronic inflammation associated with dysregulated innate immune response, glial cell dysfunction, and adverse antiretroviral therapy (ART) effect play an important role causing milder HIV-associated neurocognitive disorders or asymptomatic neurocognitive impairment. All patients have been tested for neurocognitive functioning through a comprehensive, five-domain neuropsychological battery performed in the study. Human cytokine (interleukin [IL]-6, IL-8, IL-18, and tumor necrosis factor [TNF]-α) and brain-derived neurotrophic factor serum levels were quantified using ELISAs, and the hepatic fibrosis was estimated using the noninvasive Fibrosis 4 (FIB-4) score. The study showed a group of 40 HIV-infected individuals and it was observed that almost 40% of HIV⁺ individuals, even if clinically asymptomatic, displayed some degree of neurocognitive dysfunction, compared to normative performance standards, at least in two cognitive areas. The functions affected the most were memory, attention, executive function, and psychomotor processing speed. Three cytokines (IL-6, IL-8, and IL-18) to be significantly linked to test results in specific neurocognitive domain were found. Treatments with nucleoside reverse transcriptase inhibitor plus non-nucleoside reverse transcriptase inhibitor alone were instead associated with poor neurocognitive outcome, especially in verbal fluency, fine motility, and Zung Depression Scale. Elevated value of FIB-4 score showed an opposite connection with cognitive performance as well, underlining the direct association between hepatic steatosis and neurocognitive deficit. The cytokine panel and the FIB-4 score can predict presence or worsening of neurocognitive functions in HIV-infected individuals. An ART switch can be suggested according to the neurocognitive domain involved the most, advising a therapy with protease inhibitors or/and integrase inhibitors to improve fluency, executive functions, and to prevent depression.

Elevated red cell distribution width is associated with advanced fibrosis in NAFLD

Background/Aims

The red-blood-cell distribution width (RDW) is a newly recognized risk marker in patients with cardiovascular disease, but its role in nonalcoholic fatty liver disease (NAFLD) has not been well defined. The aim of the present study was to determine the association between RDW values and the level of fibrosis in NAFLD according to BARD and FIB-4 scores.

Methods

This study included 24,547 subjects who had been diagnosed with NAFLD based on abdominal ultrasonography and questionnaires about alcohol consumption. The degree of liver fibrosis was determined according to BARD and FIB-4 scores. The association between RDW values and the degree of fibrosis in NAFLD was analyzed retrospectively.

Results

After adjusting for age, hemoglobin level, mean corpuscular volume, history of hypertension, history of diabetes, and high-sensitivity C-reactive protein, the RDW values were 12.61±0.41% (mean±SD), 12.70±0.70%, 12.77±0.62%, 12.87±0.82%, and 13.25±0.90% for those with BARD scores of 0, 1, 2, 3, and 4, respectively, and 12.71±0.72%, 12.79±0.66%, and 13.23±1.52% for those with FIB-4 scores of <1.30, 1.31-2.66, and ≥2.67, respectively (P<0.05). The prevalence of advanced fibrosis (BARD score of 24 and FIB-4 score of ≥1.3) increased with the RDW [BARD score: 51.1% in quartile 1 (Q1) vs. 63.6% in Q4; FIB-4 score: 6.9% in Q1 vs. 10.5% in Q4; P<0.001]. After adjustments, the odds ratio of having advanced fibrosis for those in Q4 compared to Q1 were 1.76 (95%CI=1.55-2.00, P<0.001) relative to BARD score and 1.69 (95%CI=1.52-1.98, P<0.001) relative to FIB-4 score.

Conclusions

Elevated RDW is independently associated with advanced fibrosis in NAFLD.