Association between neck circumference and non-alcoholic fatty liver disease: cross-sectional analysis from ELSA-Brasil

Abstract BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) has become a public health problem worldwide. Neck circumference (NC) is a simple anthropometric adiposity parameter that has been correlated with cardiometabolic disorders like NAFLD. OBJECTIVES: To investigate the association between NC and NAFLD, considering their obesity-modifying effect, among participants from the Longitudinal Study of Adult Health (ELSA-Brasil) baseline study. DESIGN AND SETTINGS: Cross-sectional study at the ELSA-Brasil centers of six public research institutions. METHODS: This analysis was conducted on 5,187 women and 4,270 men of mean age 51.8 (± 9.2) years. Anthropometric indexes (NC, waist circumference [WC] and body mass index [BMI]), biochemical and clinical parameters (diabetes, hypertension and dyslipidemia) and hepatic ultrasound were measured. The association between NC and NAFLD was estimated using multinomial logistic regression, considering potential confounding effects (age, WC, diabetes, hypertension and dyslipidemia). Effect modification was investigated by including the interaction term NC x BMI in the final model. RESULTS: The frequency of NAFLD and mean value of NC were 33.6% and 33.9 (± 2.5) cm in women, and 45.8% and 39.4 (± 2.8) cm in men, respectively. Even after all adjustments, larger NC was associated with a greater chance of moderate/severe NAFLD (1.16; 95% confidence interval [CI] for women; 1.05, 95% CI for men; P < 0.001). Presence of multiplicative interaction between NC and BMI (P < 0.001) was also observed. CONCLUSION: NC was positively associated with NAFLD in both sexes, regardless of traditional adiposity indexes such as BMI and WC. The magnitude of the association was more pronounced among women.

Applied research of ultrasound attenuation parameter in the diagnosis of metabolic dysfunction-associated fatty liver disease / 中华肝脏病杂志

Objective: To evaluate the efficacy, establish a diagnostic model, and value of ultrasound attenuation parameters (UAP) to diagnose hepatic steatosis in metabolic dysfunction-associated fatty liver disease (MAFLD) and its relevant disorders. Methods: 3770 cases were selected from the Health Examination Center of the Third Hospital of Hebei Medical University between October to December 2020. MAFLD diagnosis was based on the Asia-Pacific region MAFLD clinical diagnosis and treatment guidelines. The degree of hepatic steatosis was divided into mild, moderate and severe according to ultrasound imaging. UAP, clinical characteristic indexes, serum biochemical indexes, characteristics of hepatic steatosis and related factors were compared and analyzed in MAFLD patients and healthy controls. Logistic regression method was used to analyze the independent risk factors affecting the progression of hepatic steatosis in MAFLD to establish the diagnostic model. The clinical efficacy of UAP and the new model in diagnosing MAFLD was evaluated by the receiver operating characteristic curve (ROC). One-way ANOVA was used to compare means among multiple groups. Mann-Whitney U test was used to compare non-normally distributed measurement data between the two groups, and rank-sum test was used to compare multiple groups. χ2 test was used to compare count data between groups. Results: Among the 3 770 cases, 650 were MAFLD, with a prevalence rate of 17.24%, and the highest prevalence was 37.23% in the age group of 60-69. The prevalence rate was significantly higher in male than female (30.34% vs. 9.17%). Age-sex analysis showed that the prevalence rate in males aged 30-69 years was 38.26%, and that in females aged over 60 years was 31.94%. UAP was significantly higher in patients with MAFLD than healthy controls (278.55 dB/m vs. 220.90 dB/m, Z=-12.592, P＜0.001), and an increasing trend with increased degree of hepatic steatosis (mild:257.20 dB/m, moderate:286.20 dB/m, and severe: 315.00 dB/m) were observed. The cut-off values of UAP for the diagnosis of mild, moderate and severe hepatic steatosis were 243≤UAP＜258 dB/m, 258≤UAP＜293 dB/m, ≥293 dB/m in MAFLD. The sensitivity and specificity were 67.20%, 93.60%, 95.90%, and 82.10%, 72.00%, and 84.80%, respectively. UAP, alanine aminotransferase and fasting blood glucose were independent risk factors for the progression of hepatic steatosis in MAFLD. The combined MAFLD classification model (UAG model) was established. The AUC of mild, moderate and severe hepatic steatosis in MAFLD were 0.906, 0.907, and 0.946, respectively, and the sensitivity and specificity were 76.50%, 82.10%, 98.00%, and 90.80%, 83.30% and 76.10%, respectively. Conclusion: MAFLD is a common disease in the general population, with a higher incidence in male and elderly female over 30 years of age. UAP can be used as a new noninvasive diagnostic technique to evaluate hepatic steatosis in MAFLD. The UAG model has a good diagnostic efficacy on MAFLD and its relevant disorders, and thus can be used as a guide for evaluating clinical diagnosis and prognosis.

Acoustic radiation force impulse elastography and liver fibrosis risk scores in severe obesity

ABSTRACT Objective: Identifying significant fibrosis is crucial to evaluate the prognosis and therapeutic interventions in patients with nonalcoholic fatty liver disease (NAFLD). We assessed the performance of acoustic radiation force impulse (ARFI) elastography, APRI, FIB-4, Forns, NFS and BARD scores in determining liver fibrosis in severe obesity. Subjects and methods: A prospective study included 108 patients undergoing bariatric surgery. Liver biopsy specimens were obtained intraoperatively and classified according to the NAFLD Activity Score. Patients were assessed with serological markers and shear wave velocity of the liver was measured with the Siemens S2000 ultrasound system preoperatively. Optimal cut-off values were determined using the area under the receiver operating characteristic curves (AUROC). Results: In the entire cohort prevalence of NAFLD was 80.6%, steatohepatitis 25.9% and significant fibrosis 19.4%. The best tests for predicting significant fibrosis were FIB-4 and Forns scores (both AUROC 0.78), followed by APRI (AUROC 0.74), NFS (AUROC 0.68), BARD (AUROC 0.64) and ARFI (AUROC 0.62). ARFI elastography was successful in 73% of the patients. Higher body mass index (BMI) correlated with invalid ARFI measurements. In patients with BMI < 42 kg/m2, ARFI showed 92.3% sensitivity and 82,6% specificity for the presence of significant fibrosis, with AUROC 0.86 and cut-off 1.32 m/s. Conclusions: FIB-4 and Forns scores were the most accurate for the prediction of significant fibrosis in bariatric patients. Applicability and accuracy of ARFI was limited in individuals with severe obesity. In patients with BMI < 42 kg/m2, ARFI elastography was capable for predicting significant fibrosis with relevant accuracy.

Evaluación de la fibrogénesis hepática en pacientes con esteatohepatitis no alcohólica tratados con propóleos rojo oral cubano / Evaluation of hepatic fibrogenesis in patients with nonalcoholic steatohepatitis treated with cuban oral red propolis

Introducción: La enfermedad por depósito graso no alcohólica constituye una pandemia del mundo contemporáneo. Su espectro silente atraviesa estadios de cronicidad y puede llegar a la cirrosis hepática y sobre esta pudiera desarrollarse un hepatocarcinoma. No existen tratamientos y solo se puede actuar sobre los factores de riesgo. Objetivo: Evaluar el efecto citohepatoprotector y antifibrótico del propóleos rojo cubano oral en pacientes con esteatohepatitis no alcohólica. Métodos: Se realizó un estudio longitudinal prospectivo en pacientes seleccionados de las consultas de Gastroenterología, Endocrinología y Medicina Interna del Hospital Clínico Quirúrgico Hermanos Ameijeiras durante el periodo de abril 2017 a abril 2018. El universo de estudio fue de 120 pacientes con diagnóstico imagenológico de hígado graso. La muestra quedó conformada por 70 pacientes con diagnóstico de hígado graso, y que cumplieron criterios de inclusión y exclusión. Las pruebas estadísticas aplicadas fueron análisis de frecuencia y porcentaje para las variables demográficas. La prueba T para las muestras relacionadas evaluó el comportamiento enzimático al inicio y al final del tratamiento y los cambios elastográficos fueron analizados mediante test de Kappa y porcentaje. Resultados: Las variables bioquímicas estudiadas mostraron una disminución estadísticamente significativa al final del tratamiento. Los cambios elastográficos al final del estudio evidenciaron la efectividad del tratamiento, en el cual el 91,4 por ciento de los pacientes evolucionaron hacia el menor grado de fibrosis. Conclusiones: El propóleos rojo cubano demostró ser un apifármaco con acción citohepatoprotectora y antifibrótica de valor terapéutico(AU)

Introduction: Nonalcoholic fat deposition disease is a pandemic in the contemporary world. Its silent spectrum goes through stages of chronicity and it can reach liver cirrhosis and on this a hepatic carcinoma could develop. There are no treatments and medical handling can act on only risk factors. Objective: To evaluate cytohepatoprotective and antifibrotic effect of oral Cuban red propolis in patients with nonalcoholic steatohepatitis. Methods: A prospective longitudinal study was carried out in selected patients from the Gastroenterology, Endocrinology and Internal Medicine consultations at Hermanos Ameijeiras Clinical Surgical Hospital from April 2017 to April 2018. The study universe was 120 patients with imaging diagnosis of fatty liver. The sample consisted of 70 patients with fatty liver diagnosis, who met the inclusion and exclusion criteria. Frequency and percentage analysis for the demographic variables were the statistical tests applied. The T test for the related samples evaluated the enzymatic behavior at the beginning and at the end of the treatment and the elastography changes were analyzed using Kappa and percentage tests. Results: The biochemical variables studied showed statistically significant decrease at the end of the treatment, which evidenced the effectiveness of the treatment. 91.4 percent of the patients progressed to a lower degree of fibrosis. Conclusions: Cuban red propolis proved to be a therapeutic drug with cytohepathoprotective and antifibrotic action(AU)

Caracterización clinicoepidemiológica de pacientes con enfermedad hepática grasa no alcohólica / Clinical epidemiological characterization of patients with non alcoholic fatty hepatic disease

Introducción: La enfermedad hepática grasa no alcohólica se caracteriza por un aumento de la acumulación de lípidos (triglicéridos) de forma macrovesicular, en más de 5 % de los hepatocitos, asociado o no a inflamación y/o fibrosis hepática. Objetivo: Caracterizar a pacientes con enfermedad hepática grasa no alcohólica según variables de interés para el estudio. Método: Se realizó un estudio descriptivo y transversal de 95 pacientes atendidos en el Servicio de Gastroenterología del Hospital General Docente Dr. Juan Bruno Zayas Alfonso de Santiago de Cuba, desde junio hasta diciembre de 2018. Entre las variables figuraron: edad, sexo, factores de riesgo, resultados de exámenes complementarios, ecografía hepática y factores de pronósticos clínicos para la fibrosis. Resultados: En la serie predominaron los grupos etarios de 35-44 y de 45-54 años (65,2 %, respectivamente), el sexo femenino, la obesidad como principal factor de riesgo (50,5 %), la transaminasa glutámico pirúvica-alanina aminotransferasa (39,0 %) entre los exámenes complementario con valores alterados y la esteatosis hepática moderada como hallazgo ecográfico (55,8 %), entre otros. Conclusiones: La enfermedad hepática grasa no alcohólica prevaleció en los pacientes entre 35-54 años, donde la obesidad constituyó el factor de riesgo más importante; asimismo, un mayor número de pacientes presentó cifras elevadas de transaminasa glutámico pirúvica-alanina aminotransferasa y los hallazgos ecográficos revelaron la primacía de la esteatosis moderada. La presencia de 4 o más factores pronósticos constituyó un riesgo para el desarrollo de fibrosis hepática.

Introduction: The non alcoholic fatty hepatic disease is characterized by an increase of the lipids accumulation (triglycerides) in a macrovesicular way, in more than 5 % of the hepatic cells, associated or not with inflammation and/or hepatic fibrosis. Objective: To characterize patients with non alcoholic fatty hepatic disease according to variables of interest for the study. Method: A descriptive and cross-sectional study of 95 patients assisted in the Gastroenterology Service of Dr. Juan Bruno Zayas Alfonso Teaching General Hospital was carried out in Santiago de Cuba, from June to December, 2018. Among the variables figured: age, sex, risk factors, results of complementary exams, hepatic echography and clinical prognosis factors for the fibrosis. Results: In the series there was a prevalence of the 35-44 and 45-54 age groups (65.2 %, respectively), female sex, obesity as main risk factor (50.5 %), transaminase glutamic piruvic-alanineaminotransferase (39.0 %) among the complementary exams with altered values and the moderate fatty liver as echographic finding (55.8 %), among others. Conclusions: The non alcoholic fatty hepatic disease prevailed in patients between 35-54 years, where obesity constituted the most important risk factor; also, a greater number of patients presented high figures of transaminase glutamic piruvic-alanineaminotransferase and the echographic findings revealed the primacy of the moderate steatosis. The presence of 4 or more prognosis factors constituted a risk for the development of hepatic fibrosis.

Relationship between living habits and metabolic diseases in community populations based on ultrasound diagnosis of nafld / Relação entre hábitos de vida e doenças metabólicas em comunidades com base na doença hepática gordurosa não alcoólica (dhgna) diagnosticada por ultrassom / Diagnóstico ultrasónico de la relación entre los hábitos de vida de la comunidad nafld y las enfermedades metabólicas

ABSTRACT As a common metabolic disease, non-alcoholic fatty liver disease (NAFLD) is the most common type of liver disease in western developed countries and an important liver disease in the Asia Pacific region. At present, NAFLD lacks targeted conventional therapy and its basic treatment is the correction of bad living habits. In order to verify the effectiveness of the basic treatment of NAFLD, and explore the prevention methods of NAFLD, this study used ultrasound diagnosis, baseline survey and follow-up survey, and conducted a cross-sectional study on the correlation between nighttime and midday sleep duration and NAFLD, and carried out a prospective study on the correlation between sleep duration and NAFLD. The results showed that there was a negative correlation between the length of sleep at night and the prevalence of NAFLD, while the length of midday sleep was positively correlated with the prevalence of NAFLD. The time of night sleep was an independent factor of NAFLD, and the relationship between midday sleep time and NAFLD was not statistically significant. NAFLD-susceptible people can prevent NAFLD by ensuring adequate sleep at night and reducing midday sleep. This study is expected to provide theoretical reference and data support for the prevention and treatment of NAFLD.

RESUMO Como uma doença metabólica comum, a doença doença hepática gordurosa não alcoólica (DHGNA) é o tipo de doença hepática mais comum nos países desenvolvidos ocidentais e uma doença hepática importante na região Ásia Pacífico. Atualmente, a DHGNA carece de terapia convencional orientada, e seu tratamento básico é a correção de maus hábitos de vida. A fim de verificar a eficácia do tratamento básico da DHGNA e explorar os métodos de prevenção da DHGNA, este estudo, baseado no diagnóstico por ultrassom, através do inquérito de base e do inquérito de acompanhamento, consistiu de estudo transversal sobre a correlação entre a duração do sono à noite e de dia e a DHGNA, e realizou um estudo prospectivo sobre a correlação entre a duração do sono e a DHGNA. Os resultados mostraram que havia uma correlação negativa entre a duração do sono à noite e a prevalência de DHGNA, enquanto a duração do sono de dia estava positivamente correlacionada com a prevalência da DHGNA. A hora do sono noturno foi um fator independente de DHGNA, e a relação entre o sono de dia e DHGNA não foi estatisticamente significativa. As pessoas sensíveis à DHGNA podem prevenir a DHGNA garantindo o sono adequado à noite e reduzindo o sono de dia. Espera-se que este estudo possa fornecer referências teóricas e suporte de dados para a prevenção e tratamento da DHGNA.

RESUMEN Como enfermedad metabólica común, la enfermedad del hígado graso no alcohólico (NAFLD) es el tipo más común de enfermedad hepática en los países desarrollados occidentales y una enfermedad hepática importante en la región de Asia que da al Pacífico. En la actualidad, la EHGNA carece de terapia convencional dirigida y su tratamiento básico es la corrección de los malos hábitos de vida. Con el fin de verificar la efectividad del tratamiento básico y explorar los métodos de prevención de la EHGNA, este estudio utilizó un diagnóstico por ultrasonido, una encuesta de referencia y una encuesta de seguimiento, condujo un estudio transversal sobre la correlación entre la duración del sueño nocturno y la siesta y la EHGNA, y realizó un estudio prospectivo sobre la correlación entre la duración del sueño y la EHGNA. Los resultados mostraron que hubo una correlación negativa entre la duración del sueño por la noche y la prevalencia de EHGNA, mientras que la duración de la siesta se correlacionó positivamente con la prevalencia de EHGNA. El tiempo de sueño nocturno fue un factor independiente de la EHGNA, y la relación entre el tiempo de siesta y la EHGNA no fue estadísticamente significativa. Las personas susceptibles a la EHGNA pueden prevenirla asegurando un sueño adecuado por la noche y reduciendo la siesta. Se espera que este estudio proporcione referencias teóricas y soporte de datos para la prevención y el tratamiento de la EHGNA.

The therapeutic impact of probiotics on nonalcoholic fatty liver disease in pediatrics: a systematic review / Impacto terapêutico dos probióticos na doença hepática gordurosa não alcoólica em pediatria: uma revisão sistemática

ABSTRACT Objective: Evaluate the effects of probiotics use, compared with placebo, in pediatric patients with non-alcoholic fatty liver disease (NAFLD), using laboratorial and ultrasonographic parameters as outcomes. Methods: A systematic review of the literature was performed through MEDLINE and Lilacs databases. The articles selected were randomized controlled clinical trials published until November 2018, without any language restriction, dealing with pediatric patients with NAFLD. Patients were divided into 2 groups. One group received probiotic therapy and the other group, only received placebo. The primary outcome evaluated was the difference between the serum levels of alanine aminotransferase (ALT) before and after receiving probiotics or placebo. The secondary outcomes evaluated were the serum aspartate aminotransferase levels, body mass index, serum triglycerides, waist circumference and level of liver steatosis on the ultrasonography. Results: A total of 46 articles were recovered, and 3 articles were included in the qualitative analysis, totaling 128 patients. Two trials revealed a significant decrease of alanine aminotransferase levels after treatment with probiotics (Lactobacillus rhamnosus for 8 weeks; Bifidobacterium+Lactobacillus for 12 weeks), when compared to the placebo. The other variables did not show a statistically significant difference between both groups. Conclusions: Probiotic therapy has contributed to the reduction of ALT serum levels in pediatric patients with nonalcoholic fatty liver disease, which is in line with results found by other authors in scientific literature. Regarding the secondary outcomes, the use of probiotics did not show benefits or damages compared to placebo.

RESUMO Objetivo: Avaliar os efeitos do uso de probióticos em comparação com placebo, em pacientes pediátricos portadores de doença hepática gordurosa não alcoólica (DHGNA), utilizando parâmetros laboratoriais e ultrassonográficos como desfecho. Métodos: Revisão sistemática da literatura por meio das bases de dados Sistema Online de Busca e Análise de Literatura Médica (MEDLINE) e Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs). Foram selecionados ensaios clínicos controlados randomizados publicados até novembro de 2018, sem restrição de língua, com pacientes pediátricos portadores de DHGNA, divididos em dois grupos. Um grupo foi submetido à terapia probiótica e outro grupo recebeu somente placebo. O desfecho primário avaliado foi a comparação dos níveis de alanina aminotransferase (ALT) ao início e no fim do seguimento entre os grupos probiótico e placebo. Os desfechos secundários avaliados foram os níveis de aspartato aminotransferase sérico, índice de massa corpórea, triglicerídeos totais séricos, circunferência abdominal e grau de esteatose hepática à ultrassonografia abdominal. Resultados: Foram recuperados 46 artigos, sendo três incluídos na análise qualitativa, totalizando 128 pacientes. Dois estudos demonstraram redução significativa dos níveis de ALT com o uso de probiótico (Lactobacillus rhamnosus, por oito semanas; Bifidobacterium+Lactobacillus, por 12 semanas), em comparação ao placebo. As demais variáveis avaliadas não evidenciaram diferença estatisticamente significante ente os dois grupos. Conclusões: O uso de probióticos representou redução nos níveis séricos de ALT na esteatose hepática na infância, indo ao encontro dos resultados obtidos por outros autores da literatura científica vigente. No que se refere às variáveis de desfecho secundário, não foi demonstrado benefício ou dano do tratamento de probióticos em relação ao placebo.

Research Progress of Quantitative Ultrasound Assessment of Liver Steatosis in Non-alcoholic Fatty Liver Disease / 中国医学科学院学报

The incidence of non-alcoholic fatty liver disease(NAFLD)keeps on rise.Without intervention,it may develop to steatohepatitis,cirrhosis,and even hepatocellular carcinoma.Liver biopsy,the gold standard for evaluating the steatosis severity of NAFLD,is invasive and unsuitable for large-scale screening.In recent years,magnetic resonance imaging(MRI)-related examinations have been used as a gold standard only second to liver biopsy,which still have disadvantages in large-scale application.Ultrasound has the advantages of simple operation,low cost,and safety,and may become an important method for accessing NALFD.This review summarizes the current studies about the diagnosis of liver steatosis by quantitative ultrasound assessment,including controlled attenuation parameters,attenuation imaging,ultrasonic liver/kidney intensity ratio and liver attenuation rate,and integrated backscatter.

Avaliação da progressão da fibrose hepática em um grupo de pacientes com doença hepática gordurosa não alcoólica acompanhados por 10 anos / Evaluation of progression of hepatic fibrosis in a group of patients with non-alcoholic fatty liver disease accompanied for 10 years

ABSTRACT BACKGROUND: Non-alcoholic fatty liver disease has been progressively diagnosed in the general population as a consequence of the increased prevalence of obesity and type 2 diabetes mellitus, its main risk factors. It is characterized by accumulation of fat in the hepatocytes associated with lobular inflammation and balonization, which can lead to cirrhosis and hepatocarcinoma. Thus, a characterization and follow-up of a progression of the fibrosis level of these patients becomes important, being that the transient hepatic elastography is a reliable method for this evaluation with a measure of the kapa index. OBJECTIVE: To evaluate the progression of hepatic fibrosis through elastography in patients with non-alcoholic fatty liver disease. METHODS: Patients who had previously performed hepatic biopsy and noninvasive scores for non-alcoholic steatohepatitis (NASH) and fibrosis were included in the study. These same subjects were then submitted to current clinical evaluation, laboratory and liver elastography tests, defining the level of liver fibrosis, about 10 years after the first evaluation. RESULTS: Data were analyzed for 66 patients previously submitted to liver biopsy. Of these, 16 were not found, four could not participate because they were debilitated due to hepatic cirrhosis, two had died from an automobile accident and five from complications of cirrhosis of the liver. Therefore, of the 50 patients with a known history, 9 (18%) had died of cirrhosis or were unable to attend the examination because of their liver disease. The remaining population was predominantly female (61.5%), mean age of 63 years, being overweight, dyslipidemia (76.9%), disorders of the glycemic profile (76.9%), and metabolic syndrome (82.1%). Of the 39 cases evaluated, 35% had the same degree of fibrosis at the initial evaluation (biopsy) and at the current evaluation (elastography), 33% had an increase in the degree of fibrosis and another 30% had a decrease in the degree of fibrosis. Twenty-eight patients had NASH at baseline. Regarding these patients, it was observed in the current evaluation, that 25% remained stable in the degree of fibrosis, 39% progressed, and 35% regressed. CONCLUSION: Despite some limitations of our study, such as the small number of patients, and the use of two different methods of evaluation (biopsy and elastography), the data obtained allow us to conclude that of the 39 evaluated cases, 33% (13) presented progression of fibrosis and the total group of 50 patients, 42% had cirrhosis or died due to liver disease. The presence of NASH on hepatic biopsy did not prove to be, in our study, a predictive of the evolution of hepatic fibrosis in the patients.

RESUMO CONTEXTO: A doença hepática gordurosa não alcoólica vem sendo diagnosticada com frequência progressivamente maior na população geral, como consequência do aumento da prevalência da obesidade e do diabetes mellitus tipo 2, considerados seus principais fatores de risco. Caracteriza-se por acúmulo de gordura nos hepatócitos associada à inflamação lobular e balonização, podendo levar à cirrose e hepatocarcinoma. Desta forma, torna-se importante a caracterização e acompanhamento do nível de fibrose hepática destes pacientes, sendo que a elastografia hepática transitória, tem se mostrado um método confiável para esta avaliação com a medida do índice kapa. OBJETIVO: Avaliar a progressão da fibrose hepática através de elastografia em pacientes com doença hepática gordurosa não alcoólica. MÉTODOS: Foram incluídos no estudo pacientes que haviam realizado anteriormente biópsia hepática e cálculo de escores não invasivos para avaliação de esteato-hepatite não alcoólica (EHNA) e fibrose. Estes mesmos indivíduos foram então submetidos à avaliação clínica, laboratorial e exame de elastografia hepática atuais, definindo o nível de fibrose hepática, cerca de 10 anos após a primeira avaliação. RESULTADOS: Foram analisados dados relativos a 66 pacientes previamente submetidos a biópsia hepática. Destes, 16 não foram localizados, quatro não puderam participar por estarem incapacitados em função de cirrose hepática, dois haviam falecido por acidente automobilístico e cinco, por complicações de cirrose hepática. Portanto, do grupo de 50 pacientes com evolução conhecida, nove (18%) haviam falecido por cirrose ou estavam incapacitados de comparecer ao exame em função de sua doença hepática. A população restante era predominantemente do sexo feminino (61,5%), com idade média de 63 anos, apresentando sobrepeso, dislipidemia (76,9%), distúrbios do metabolismo glicêmico (76,9%) e síndrome metabólica (82,1%). Dos 39 casos avaliados, 35% tiveram o mesmo grau de fibrose na avaliação inicial (biópsia) e na avaliação atual (elastografia), 33% tiveram aumento no grau de fibrose e outros 30% tiveram diminuição no grau de fibrose. Vinte e oito pacientes apresentavam EHNA na avaliação inicial. Em relação a esses pacientes observou-se na avaliação atual que, 25% mantiveram-se estáveis no grau de fibrose, 39% progrediram e, 35% regrediram. CONCLUSÃO: Apesar de algumas limitações do nosso estudo, como o pequeno número de pacientes e o uso de dois métodos diferentes de avaliação (biópsia e elastografia), os dados obtidos nos permitem concluir que dos 39 casos avaliados, 33% apresentaram progressão da fibrose e do grupo total de 50 pacientes, 42% apresentam cirrose ou faleceram em decorrência de doença hepática. A presença de EHNA à biópsia hepática não se mostrou um dado capaz, no nosso estudo, de predizer a evolução da fibrose hepática nos pacientes.

Cuantificación de esteatosis hepática no alcohólica por resonancia magnética / Quantification of liver fat infiltration by magnetic resonance

Background: A simple and inexpensive method is required to assess fatty infiltration of the liver non-invasively. Aim: To develop and compare different methods to quantify liver fat by magnetic resonance and compare it against ultrasound. Material and Methods: Three algorithms were implemented: region growing (RG), graph cuts (GC) and hierarchical (HR), all based on the IDEAL method to obtain water and fat images. Using these images, the proton density fat fraction (PDFF) was calculated. The three methods were tested in phantoms with known fat percentages and later on we acquired images from 20 volunteers with an ultrasound diagnosis of fatty liver disease in different stages. For everyone, the PDFF of the nine liver segments was determined. Results: In phantoms, the mean error between the real fat percentage and the value obtained through the three methods was −1,26, −1 and −0,8 for RG, GC and HR, respectively. The hierarchical method was more precise and efficient to obtain PDFF. The results in volunteers revealed that ultrasound showed errors categorizing the severity of hepatic steatosis in more than 50% of volunteers. Conclusions: We developed a tool for magnetic resonance, which allows to quantify fat in the liver. This method is less operator dependent than ultrasound and describes the heterogeneity in the fat distribution along the nine hepatic segments.

Could semiquantitative analysis of real-time ultrasound elastography distinguish more liver parenchyma alterations of nonalcoholic fatty liver disease in patients with polycystic ovary syndrome?

ABSTRACT Objective: Nonalcoholic fatty liver disease is the commonest diffuse liver disease, of which women with polycystic ovary syndrome are at an increased risk. The aim of the present study was to assess the diagnostic value of the semiquantitative strain parameters of real-time ultrasound elastography for nonalcoholic fatty liver disease in patients with polycystic ovary syndrome. Subjects and methods: Thirty-five polycystic ovary syndrome patients with nonalcoholic fatty liver disease, 70 polycystic ovary syndrome patients without nonalcoholic fatty liver disease, and 70 healthy female controls of reproductive age were included. All participants underwent ultrasonic examination and semiquantitative analysis of real-time ultrasound elastography of the liver. Results: Main semi quantitative strain parameters, such as average strain value, differed significantly among groups polycystic ovary syndrome with nonalcoholic fatty liver disease, polycystic ovary syndrome without nonalcoholic fatty liver disease, and control (87.02 ± 10.16 vs. 96.31 ± 11.44 vs. 104.49 ± 7.28, p < 0.001). Clinical and laboratory parameters differed significantly between the two subgroups with low or high average strain value. For diagnostic value of average strain value for elevated aminotransferase, the area under the curve was 0.808 (range 0.721-0.895). In multiple linear regression analysis, polycystic ovary syndrome, waist circumference, and metabolic syndrome were stand-alone independent factors associated with average strain value among subjects without nonalcoholic fatty liver disease. Conclusion: Semiquantitative real-time ultrasound elastography analysis could distinguish liver parenchyma alterations in patients with polycystic ovary syndrome more sensitively. The diagnostic value of the proposed method for nonalcoholic fatty liver disease need further research.

Evaluation of nonalcoholic fatty liver disease using magnetic resonance in obese children and adolescents / Avaliação de doença hepática gordurosa não alcoólica utilizando ressonância em crianças e adolescentes obesos

Abstract Objective: To determine the frequency of nonalcoholic fatty liver disease using nuclear magnetic resonance as a noninvasive method. Methodology: This was a cross-sectional study conducted on 50 children and adolescents followed up at an outpatient obesity clinic. The subjects were submitted to physical examination, laboratory tests (transaminases, liver function tests, lipid profile, glycemia, and basal insulin) and abdominal nuclear magnetic resonance (calculation of hepatic, visceral, and subcutaneous fat). Results: Nonalcoholic fatty liver disease was diagnosed in 14 (28%) participants, as a severe condition in eight (percent fat >18%), and as non-severe in four (percent fat from 9% to 18%). Fatty liver was associated with male gender, triglycerides, AST, ALT, AST/ALT ratio, and acanthosis nigricans. Homeostasis model assessment of insulin resistance and metabolic syndrome did not show an association with fatty liver. Conclusion: The frequency of nonalcoholic fatty liver disease in the present population of children and adolescents was lower than that reported in the international literature. It is suggested that nuclear magnetic resonance is an imaging exam that can be applied to children and adolescents, thus representing an effective noninvasive tool for the diagnosis of nonalcoholic fatty liver disease in this age range. However, further national multicenter studies with longitudinal design are needed for a better analysis of the correlation between nonalcoholic fatty liver disease and its risk factors, as well as its consequences.

Resumo Objetivo: Determinar a frequência da doença hepática gordurosa não alcoólica utilizando ressonância magnética nuclear como um método não invasivo. Metodologia: Este foi um estudo transversal realizado em 50 crianças e adolescentes acompanhadas em uma Clínica Ambulatorial de Obesidade. Os indivíduos foram submetidos a exame físico, testes de laboratório (transaminases, testes de função hepática, perfil lipídico, glicemia e insulina basal) e ressonância magnética nuclear abdominal (cálculo da gordura hepática, visceral e subcutânea). Resultados: A doença hepática gordurosa não alcoólica foi diagnosticada em 14 (28%) participantes, como uma condição grave em oito (percentual de gordura > 18%) e não grave em quatro (percentual de gordura de 9 a 18%). Fígado gorduroso foi associado a sexo masculino, triglicerídeos, aspartato aminotransferase (AST), alanina aminotransferase (ALT), proporção de AST/ALT e acanthosis nigricans. O Modelo de Avaliação da Homeostase de Resistência à Insulina e a síndrome metabólica não mostraram associação com fígado gorduroso. Conclusão: A frequência da doença hepática gordurosa não alcoólica na população atual de crianças e adolescentes foi inferior à relatada na literatura internacional. Sugerimos que a ressonância magnética nuclear seja um exame de imagem que pode ser aplicado em crianças e adolescentes, representando, assim, uma ferramenta não invasiva eficaz no diagnóstico de doença hepática gordurosa não alcoólica nessa faixa etária. Contudo, estudos multicêntricos nacionais adicionais de modelo longitudinal são necessários para uma melhor análise da correlação entre a doença hepática gordurosa não alcoólica e seus fatores de risco, bem como suas consequências.

Medição do parâmetro de atenuação controlada: um marcador substituto da esteatose hepática em pacientes com doença hepática gordurosa não alcoólica na modificação do estilo de vida - acompanhamento de um estudo prospectivo / Measurement of controlled attenuation parameter: a surrogate marker of hepatic steatosis in patients of nonalcoholic fatty liver disease on lifestyle modification - a prospective follow-up study

ABSTRACT BACKGROUND: Liver biopsy is a gold standard method for hepatic steatosis assessment. However, liver biopsy is an invasive and painful procedure and can cause severe complications therefore it cannot be frequently used in case of follow-up of patients. Non-invasive assessment of steatosis and fibrosis is of growing relevance in non-alcoholic fatty liver disease (NAFLD). To evaluate hepatic steatosis, transient elastography with controlled attenuation parameter (CAP) measurement is an option now days. OBJECTIVE: Aim of this study is to evaluate role of measurement of controlled attenuation parameter, a surrogate marker of hepatic steatosis in patients of nonalcoholic fatty liver disease on lifestyle modification. METHODS: In this study, initially 37 participants were included who were followed up after 6 months with transient elastography, blood biochemical tests and anthropometric measurements. The results were analyzed by Multivariate linear regression analysis and paired samples t-test (Dependent t-test) with 95% confidence interval. Correlation is calculated by Pearson correlation coefficients. RESULTS: Mean CAP value for assessing hepatic steatosis during 1st consultation (278.57±49.13 dB/m) was significantly improved (P=0.03) after 6 months of lifestyle modification (252.91±62.02 dB/m). Only fasting blood sugar (P=0.008), weight (P=0.000), body mass index (BMI) (P=0.000) showed significant positive correlation with CAP. Only BMI (P=0.034) and weight (P=0.035) were the independent predictor of CAP value in NAFLD patients. CONCLUSION: Lifestyle modification improves the hepatic steatosis, and CAP can be used to detect the improvement of hepatic steatosis during follow-up in patients with NAFLD on lifestyle modification. There is no relation between CAP and Fibroscan score in NAFLD patients. Only BMI and weight can predict CAP value independently.

RESUMO CONTEXTO: A biópsia hepática é o método padrão-ouro para avaliação de esteatose hepática. No entanto, é um procedimento invasivo e doloroso que pode causar complicações graves e, portanto, não pode ser usado com frequência em caso de acompanhamento dos pacientes. A avaliação não invasiva de esteatose e fibrose é de crescente relevância na doença hepática gordurosa não alcoólica (DHGNA). Para avaliar a esteatose hepática, a elastografia transitória com parâmetro de atenuação controlada (PAC) é uma opção atual. OBJETIVO: O objetivo deste estudo foi de avaliar o papel da medição do PAC, um marcador substituto da esteatose hepática em pacientes da doença hepática gordurosa não alcoólica, com modificação do estilo de vida. MÉTODOS: Foram incluídos inicialmente neste estudo 37 participantes acompanhados por 6 meses com elastografia transitória, testes bioquímicos no sangue, e medidas antropométricas. Os resultados foram analisados por análise de regressão linear multivariada e emparelhado em amostras-teste t (teste t-dependente) com intervalo de confiança de 95%. A correlação foi calculada pelos coeficientes de correlação de Pearson. RESULTADOS: O valor do PAC para avaliar esteatose hepática durante a primeira consulta (278,57±49,13 dB/m) foi significativamente melhorado (P=0,03) após 6 meses de modificação do estilo de vida (252,91±62,02 dB/m). Somente a glicemia de jejum (P=0,008), o peso (valor de P=0,000), o índice de massa corporal (IMC) (P=0,000) mostraram correlação positiva significativa com PAC. Apenas o IMC (P=0,034) e o peso (P=0,035) foram o preditores independentes de valor de PAC em pacientes com DHGNA. CONCLUSÃO: A modificação do estilo de vida melhora a esteatose hepática, e o PAC pode ser usado para detectar a melhoria da esteatose hepática durante o seguimento em pacientes com DHGNA. Não existe relação entre o PAC e o escore do Fibroscan em pacientes com DHGNA. Só o IMC e o peso podem prever o valor do PAC independentemente.

Prevalencia de esteatosis hepática no alcohólica en pacientes diabéticos tipo 2, con o sin síndrome metabólico / Prevalence of non alcoholic hepatic steatosis in diabetic patients type 2, with or without metabolic syndrome

Recientemente se ha establecido a la esteatosis hepática no alcohólica (EHNA) como un componente más del síndrome metabólico, predictor del desarrollo de diabetes mellitus tipo 2. De los pacientes con EHNA y fibrosis leve a moderada, aproximadamente 13% desarrollan cirrosis en el curso de 4 años. Conocer la prevalencia de esta entidad en población de riesgo de nuestro medio, favorecería tomar algunas conductas diagnósticas y terapéuticas en forma oportuna. OBJETIVO: determinar la prevalencia de esteatosis hepática no alcohólica en pacientes con diabetes mellitus tipo 2. MATERIAL Y METODOS: estudio de corte transversal, que incluye a 95 pacientes con diagnóstico establecido de diabetes mellitus tipo 2, con o sin síndrome metabólico. Se les realizó medición de peso, talla, IMC, perímetro de cintura, área de grasa visceral y porcentaje de grasa corporal mediante impedanciometría, ecografía hepática y glicemia basal. Se realizó el análisis estadístico mediante el paquete S.P.S.S. para Windows, versión 12.0. RESULTADOS: del total de 95 pacientes diabéticos tipo 2 estudiados, 22% (21) fueron varones y 78% (74) mujeres, comprendidos entre los 25 a 74 años, de los cuales 58.9% (56) eran portadores de síndrome metabólico según los criterios de ATP III. 26.3 % (25) pacientes no tenían alteraciones ecográficas compatibles con esteatosis hepática. Presentaron esteatosis leve o grado 1 el 16.8 % (16), 48.4% esteatosis moderada o grado 2, y finalmente 8.4% (8) con esteatosis severa o grado 3. CONCLUSIONES: la prevalencia de esteatosis hepática no alcohólica, diagnosticada mediante ecografía hepática en los pacientes diabéticos de tipo 2 es del 74%, independientemente del diagnóstico de síndrome metabólico, lo que incrementa el riesgo de complicaciones en estos pacientes.

Has recently been established to non-alcoholic hepatic steatosis as one component of metabolic syndrome, predictor of the development of type 2 diabetes mellitus. Patients with NAFLD and mild to moderate fibrosis, approximately 13% develop cirrhosis in the course of 4 years. So you know the prevalence of this institution at risk for our country, it would take some conduct diagnostic and therapeutic in a timely manner. OBJECTIVE: To determine the prevalence of non-alcoholic fatty liver in patients with diabetes mellitus type 2. METHODS: Cross-sectional study, prospective, descriptive, observational and analytical, cut that includes 95 patients with an established diagnosis of diabetes mellitus type 2, with or without metabolic syndrome. He was performed in measurement of weight, height, BMI, perimeter of waist, visceral fat and percentage of body fat by impedance measurement and liver ultrasound and basal glycaemia. He was the statistical analysis using the S.P.S.S. for Windows, version 12.0 package. RESULTS: Of the total of 95 patients diabetic type 2 studied, 22% (21) were males and 78% (74) women, between 25 to 74 years, of which 58.9% (56) were carriers of metabolic syndrome according to the ATP III criteria. 26.3% (25) patients had no alterations compatible with fatty liver ultrasound. They presented mild steatosis or grade 1 the 16.8% (16), 48.4% steatosis moderate grade 2, and finally 8.4% (8) with severe steatosis or grade 3. CONCLUSIONS: the prevalence of non-alcoholic fatty liver, diagnosed by liver ultrasound in type 2 diabetic patients is 74 percent, which increases the risk of complications in these patients.

Consumo alimentar dos portadores de Doença Hepática Gordurosa Não Alcoólica: comparação entre a presença e a ausência de Esteatoepatite Não Alcoólica e Síndrome Metabólica / Dietary intake of patients with Nonalcoholic Fatty Liver Disease: Comparison between the presence and absence of Nonalcoholic Steatosis and Metabolic Syndrome

RESUMO Objetivo O objetivo desse estudo foi avaliar o consumo alimentar de portadores de Doença Hepática Gordurosa Não Alcoólica, comparar com as recomendações nutricionais diárias e analisar a correlação da dieta com a presença de Síndrome Metabólica e com a gravidade da doença, uma vez que estudos sobre os hábitos alimentares dos portadores de Doença Hepática Gordurosa Não Alcoólica ainda são escassos na literatura. Métodos Nesse estudo foram avaliados, inicialmente, 158 pacientes com diagnóstico de Doença Hepática Gordurosa Não Alcoólica. Analisou-se exames laboratoriais, biópsia hepática, dados antropométricos e consumo dietético (registro alimentar de três dias). Dentre os pacientes avaliados, alguns já haviam sido orientados nutricionalmente e foram divididos em dois grupos: "sem dieta" e "com dieta". Para o cálculo de comparações de médias entre os grupos estudados, empregou-se o teste t de Student, considerando o nível de significância de 5% (a£0,05). Resultados Do total inicial de participantes, 59 apresentavam modificação significativa da dieta a partir de alguma orientação nutricional prévia e, por isso, foram excluídos da análise. Dos 99 pacientes restantes, quando confrontados com a ingestão dietética recomendada, 26% apresentavam maior ingestão energética e 80%, de ácidos graxos saturados, além de deficiente ingestão de ácidos graxos poli-insaturados e monoinsaturados, fibras e vitamina E, confirmando estudos prévios nessa mesma população. Entretanto, não foram encontradas diferenças significativas na dieta desses pacientes quando divididos de acordo com a presença ou ausência de Síndrome Metabólica e Esteatoepatite Não Alcoólica. Conclusão Esses dados, à luz dos conhecimentos atuais, sugerem que a dieta, especialmente quando rica em ácidos graxos saturados e deficiente em fibras e vitaminas antioxidantes, pode ter importante papel no aparecimento da Doença Hepática Gordurosa Não Alcoólica, mas que outros fatores exercem papel mais relevante na sua progressão para a Esteatoepatite Não Alcoólica.

ABSTRACT Objective The objective of this study was to assess the food intake of individuals with Nonalcoholic Fatty Liver Disease, compare it with daily nutritional recommendations, and analyze whether diet correlates with the presence of Metabolic Syndrome and disease severity, because studies about the food habits of these individuals are still scarce in the literature. Methods Initially, this study assessed 158 patients diagnosed with Nonalcoholic Fatty Liver Disease. Laboratory tests, liver biopsy, anthropometric data, and food intake (determined by the three-day food record) were analyzed. Some study patients had already received dietary advice, so the sample was divided into two groups, one "without dietary advice" and another "with dietary advice". The Student's t-test compared the means between the groups at a significance level of 5% (a£0.05). Results Of the initial sample, 59 patients changed their diet significantly after receiving dietary advice, so they were excluded from the analysis. The other 99 patients consumed 26% more energy and 80% more saturated fatty acids than recommended and presented low intake of polyunsaturated and monounsaturated fatty acids, fibers, and vitamin E, confirming previous studies in this same population. However, the diets of these patients did not differ significantly by presence or absence of Metabolic Syndrome or Nonalcoholic Steatohepatitis. Conclusion In light of current knowledge, these data suggest that diet, especially when high in saturated fatty acids and low in fiber and antioxidant vitamins, can play an important role in the onset of Nonalcoholic Fatty Liver Disease, but other factors play a more important role in its progression to Nonalcoholic Steatohepatitis.

FT3/FT4 ratio predicts non-alcoholic fatty liver disease independent of metabolic parameters in patients with euthyroidism and hypothyroidism

OBJECTIVE: This study was performed to evaluate the effects of metabolic parameters and thyroid dysfunction on the development of non-alcoholic fatty liver disease (NAFLD). METHODS: The current study evaluated a total of 115 patients, 75 female and 40 male. Physical examination and anthropometric measurements were applied to all participants. Hypothyroidism was considered at a thyroid stimulating hormone level ≥ 4.1 mIU/L. Patients with euthyroidism and patients with hypothyroidism were compared. Abdominal ultrasonography was used to diagnose non-alcoholic fatty liver disease. The participants were further compared with regard to the presence of non-alcoholic fatty liver disease. Logistic regression modeling was performed to identify the relationship between non-alcoholic fatty liver disease and independent variables, such as metabolic parameters and insulin resistance. RESULTS: Non-alcoholic fatty liver disease was identified in 69 patients. The mean waist circumference, body mass index, fasting plasma insulin, HOMA-IR (p<0.001) and FT3/FT4 ratio (p=0.01) values were significantly higher in the patients with NAFLD compared to those without it. Multivariate regression analysis revealed that FT3/FT4 ratio, waist circumference and insulin resistance were independent risk factors for non-alcoholic fatty liver disease. CONCLUSION: Insulin resistance, enlarged waist circumference, elevated body mass index, higher FT3/FT4 ratio and hypertriglyceridemia are independent risk factors for NADLF, whereas hypothyroidism is not directly related to the condition.

Relación entre los hallazgos ecográficos, laparoscópicos e histológicos en pacientes con esteatosis hepática no alcohólica / Relationship between echographical, laparoscopic and histological findings in patients with non-alcoholic steatohepatitis

Se realizó un estudio descriptivo y transversal de 34 pacientes con esteatosis hepática no alcohólica, atendidos en el Servicio de Gastroenterología del Policlínico de Especialidades del Hospital Provincial Docente Clinicoquirúrgico "Saturnino Lora Torres" de Santiago de Cuba, desde octubre del 2011 hasta igual mes del 2013, con vistas a caracterizarles según algunos factores clinicoepidemiológicos y diagnósticos seleccionados, además de estimar la magnitud de la relación entre los hallazgos ecográficos, laparoscópicos y anatomopatológicos de los afectados. Se evidenció una estrecha relación de esta hepatopatía con el sobrepeso, la dislipidemia y la diabetes mellitus, así como una adecuada relación entre las alteraciones hísticas correspondientes a hígado graso no alcohólico con los hallazgos ecográficos y laparoscópicos.

A descriptive and cross-sectional study of 34 patients with non-alcoholic steato-hepatitis, assisted in the Gastroenterology Service of "Saturnino Lora Torres" from the Specialties Polyclinic of the Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba was carried out from October, 2011 to same month of 2013, with the aim of characterizing them according to some clinical and epidemiological factors and selected diagnoses, besides estimating the magnitude of the relationship among the echographical, laparoscopic and pathological findings of those affected. A close relationship of this hepatopathy was evidenced with the overweight, dyslipidemia and diabetes mellitus, as well as an appropriate relationship among the hystic changes corresponding to non-alcoholic fatty liver with the echographical and laparoscopic changes.

Imaging findings of mimickers of hepatocellular carcinoma

Radiological imaging plays a crucial role in the diagnosis of hepatocellular carcinoma (HCC) as the noninvasive diagnosis of HCC in high-risk patients by typical imaging findings alone is widely adopted in major practice guidelines for HCC. While imaging techniques have markedly improved in detecting small liver lesions, they often detect incidental benign liver lesions and non-hepatocellular malignancy that can be misdiagnosed as HCC. The most common mimicker of HCC in cirrhotic liver is nontumorous arterioportal shunts that are seen as focal hypervascular liver lesions on dynamic contrast-enhanced cross-sectional imaging. Rapidly enhancing hemangiomas can be easily misdiagnosed as HCC especially on MR imaging with liver-specific contrast agent. Focal inflammatory liver lesions mimic HCC by demonstrating arterial-phase hypervascularity and subsequent washout on dynamic contrast-enhanced imaging. It is important to recognize the suggestive imaging findings for intrahepatic cholangiocarcinoma (CC) as the management of CC is largely different from that of HCC. There are other benign mimickers of HCC such as angiomyolipomas and focal nodular hyperplasia-like nodules. Recognition of their typical imaging findings can reduce false-positive HCC diagnosis.