Consensus document on acute-on-chronic liver failure (ACLF) established by the Mexican Association of Hepatology.

Acute-on chronic liver failure (ACLF) has been an intensively debated topic mainly due to the lack of a unified definition and diagnostic criteria. The growing number of publications describing the mechanisms of ACLF development, the progression of the disease, outcomes and treatment has contributed to a better understanding of the disease, however, it has also sparked the debate about this condition. As an attempt to provide medical professionals with a more uniform definition that could be applied to our population, the first Mexican consensus was performed by a panel of experts in the area of hepatology in Mexico. We used the most relevant and impactful publications along with the clinical and research experience of the consensus participants. The consensus was led by 4 coordinators who provided the most relevant bibliography by doing an exhaustive search on the topic. The entire bibliography was made available to the members of the consensus for consultation at any time during the process and six working groups were formed to develop the following sections: 1.- Generalities, definitions, and criteria, 2.- Pathophysiology of cirrhosis, 3.- Genetics in ACLF, 4.- Clinical manifestations, 5.- Liver transplantation in ACLF, 6.- Other treatments.

Prognostic performance of an index based on lactic dehydrogenase and transaminases for patients with liver steatosis and COVID-19.

BACKGROUND: Metabolic associated fatty liver disease (MAFLD) is associated with complications and mortality in patients with coronavirus disease 2019 (COVID-19). However, there are no prognostic scores aimed to evaluate the risk of severe disease specifically in patients with MAFLD, despite its high prevalence. Lactate dehydrogenase, aspartate aminotransferase and alanine aminotransferase have been used as markers of liver damage. Therefore, we propose an index based on lactate dehydrogenase, aspartate aminotransferase and alanine aminotransferase for the prediction of complications and mortality in patients with MAFLD and COVID-19. AIM: To evaluate the prognostic performance of an index based on lactate dehydrogenase and transaminases (aspartate aminotransferase/alanine aminotransferase) in patients with COVID-19 and MAFLD [liver fibrosis and nutrition (LNF)-COVID-19 index]. METHODS: In this retrospective cohort study, two cohorts from two different tertiary centers were included. The first was the derivation cohort to obtain the score cutoffs, and the second was the validation cohort. We included hospitalized patients with severe COVID-19 and MAFLD. Liver steatosis was evaluated by computed tomography scan. Area under the receiver operating characteristic (ROC) curve analysis and survival analysis were used. RESULTS: In the derivation cohort, 44.6% had MAFLD; ROC curve analysis yielded a LFN-COVID-19 index > 1.67 as the best cutoff, with a sensitivity of 78%, specificity of 63%, negative predictive value of 91% and an area under the ROC curve of 0.77. In the multivariate analysis, the LFN-COVID-19 index > 1.67 was independently associated with the development of acute kidney injury (odds ratio: 1.8, 95% confidence interval: 1.3-2.5, P < 0.001), orotracheal intubation (odds ratio: 1.9, 95% confidence interval: 1.4-2.4, P < 0.001), and death (odds ratio: 2.86, 95% confidence interval: 1.6-4.5, P < 0.001) in both cohorts. CONCLUSION: LFN-COVID-19 index has a good performance to predict prognosis in patients with MAFLD and COVID-19, which could be useful for the MAFLD population.

Cirrhosis etiology trends in developing countries: Transition from infectious to metabolic conditions. Report from a multicentric cohort in central Mexico.

Background: Cirrhosis is a public health threat associated with high mortality. Alcoholic Liver Disease (ALD) is the leading cause in Latin America and Metabolic Associated Fatty Liver Disease (MAFLD) in western countries. In Mexico, ALD and chronic Hepatitis C Virus infection (HCV) were the most frequent aetiologies during the past decades. We aimed to describe the trends in the aetiologies of cirrhosis in a middle-income country. Methods: We performed a retrospective cohort study including patients diagnosed with cirrhosis between 2000 and 2019 from six different tertiary care hospitals in central Mexico. We collected information regarding cirrhosis etiology, year of diagnosis, hepatocellular carcinoma development, liver transplantation, and death. We illustrated the change in the tendencies of cirrhosis aetiologies by displaying the proportional incidence of each etiology over time stratified by age and gender, and we compared these proportions over time using chi square tests. Findings: Overall, 4,584 patients were included. In 2019, MAFLD was the most frequent cirrhosis etiology (30%), followed by ALD (24%) and HCV (23%). During the study period, MAFLD became the leading etiology, ALD remained second, and HCV passed from first to fourth. When analysed by gender, ALD was the leading etiology for men and MAFLD for women. The annual incidence of HCC was 3·84 cases/100 persons-year, the median survival after diagnosis was 12·1 years, and seven percent underwent LT. Interpretation: Increased alcohol consumption and the obesity epidemic have caused a transition in the aetiologies of cirrhosis in Mexico. Public health policies must be tailored accordingly to mitigate the burden of alcohol and metabolic conditions in developing countries. Funding: None.

Mexican consensus on the diagnosis and management of hepatocellular carcinoma.

INTRODUCTION: There has been an increase in the incidence of hepatocellular carcinoma (HCC) worldwide and information on this disease is limited in Mexico. AIMS: To analyze the available evidence on the diagnosis and treatment of HCC in the Mexican population. MATERIAL AND METHODS: The Mexican Association of Hepatology organized a meeting that 24 medical specialists interested in HCC attended. An electronic database search was carried out to identify documents published from 2000 with the keywords «Hepatocellular carcinoma¼ and «Mexico¼, «epidemiology¼, «diagnosis¼, and «treatment¼. RESULTS: The incidence of HCC in Mexico has increased over the last few decades. The mean age of disease presentation is in patients from 60 to 70 years old, and the man:woman ratio appears to be equal. HCC is frequently associated with underlying hepatopathy and the primary cause reported in our country is chronic hepatitis C virus) infection. Surveillance is recommended for high-risk groups in Child-Pugh stages A and B, and for those in stage C if the patient is on a waiting list or regarded as a candidate for liver transplantation. HCC should be evaluated by a multidisciplinary team of experts in the field. CONCLUSIONS: HCC is a neoplasia that is on the rise in Mexico, with epidemiologic characteristics similar to those of other populations. Diagnosis and treatment should be individualized in accordance with these Consensus guidelines.

[Interferon-alpha and liver fibrosis in patients with chronic damage due to hepatitis C virus]. / Interferón alfa y fibrosis hepática en pacientes con daño crónico por el virus de hepatitis C.

The present review focuses on the published information published regarding the effects of interferon alpha therapy on liver fibrosis in patients with chronic liver damage secondary to hepatitis C infection. Data reviewed included results of the in vitro effects of interferon on hepatic cell line cultures with regards to indirect markers of fibrosis, activation of hepatic stellate cells and oxidative stress response. In the clinical arena, there is current clear evidence of a favorable histological outcome in patients with sustained viral response to interferon therapy. For this reason, the current review focuses more on the histological outcomes regarding liver fibrosis in patients who have not attained viral response to therapy (non-responders) or who already have biopsy defined cirrhosis. Data in these patients were analyzed according to the results of objective testing of fibrosis through the assessment of liver biopsy and its change during time, specially because the morbidity and mortality of this disease is directly related to the complications of liver cirrhosis and not necessarily to the persistence of the hepatitis C virus. Lastly, it is concluded that the process of liver fibrosis/cirrhosis is a dynamic one and that there is some evidence to support the usefulness of interferon alpha therapy as a means to halt or retard the progression of hepatic fibrosis. The result of current clinical trials in which interferon therapy is being used to modify the progression of fibrosis in non-responders or cirrhotic patients is eagerly awaited.

[Endoscopic cholangiography in mild acute biliary pancreatitis: when and for whom?]. / Colangiografía endoscópica en pancreatitis aguda biliar leve: cuándo y a quién.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP), with or without sphincterotomy, has been widely used in patients with severe biliary acute pancreatitis (BAP) or those with cholangitis and/or obstruction of the biliary tree. Its use in subjects with mild BAP is more controversial. AIM: To optimize use of ERCP in patients with mild pancreatitis due to gallstones by identifying clinical and biochemical predictors of choledocholithiasis. MATERIAL AND METHOD: The clinical and biochemical data, images, and outcomes of 83 patients with mild BAP hospitalized at the Instituto Nacional de Ciencias Medicas y Nutricion "Salvador Zubiran" from January 1, 1988 to May 30, 2000 were retrospectively analyzed. All patients received elective cholecystectomy at hospital admission. In 35 cases, ERCP was performed before cholecystectomy (group A). The remaining 48 were operated on without ERCP (group B). In 30, transcystic-cholangiography was done. Forty-seven (57%) were female. Mean age was 47 years (19-90). Mean time between onset of AP and hospital admission was 2.2 days (1-15), and between clinical onset and cholecystectomy, eight days (1-26). Statistical differences were evaluated by non-parametric methods. An univariated and multivariated analysis was performed looking for data to identify choledocholithiasis. RESULTS: Choledocholithiasis was found in 27 cases (32%), 18 from group A (51%), and nine for group B (19%) (RR = 4.58, IC 95% = 1.7-12.25, p = 0.004). ERCP was performed in all cases because of clinical suspicion of choledocholithiasis (jaundice, bilirubin, and alkaline phosphatase alteration and/or choledochal dilation); however, none of the patients of group B in whom choledocholithiasis was operatively diagnosed showed biochemical or radiologic alterations. Subjects with choledocolithiasis presented more frequently a history of biliary pain (RR = 5.75, IC 95% = 1.76-18.7), jaundice (RR = 3.07, IC 95% = 1.15-8.16) and/or alkaline phosphatase elevation (RR = 4.11, IC 95% = 1.3-12.7). CONCLUSION: The high frequency of choledocholithiasis in subjects with mild biliary pancreatitis warranted radiologic exploration of the biliary tree in all patients submitted to cholecystectomy. In those with jaundice, alkaline phosphatase elevation and/or a history of biliary pain, ERCP should be performed prior to the operation; in others, choledocholithiasis can be discharged by operative transcystic cholangiography. Therapeutic measures for treating choledocholithiasis should be adapted to hospital facilities.