METABOLIC DYSFUNCTION ASSOCIATED STEATOTIC LIVER DISEASE - ASSESSMENT OF PATIENTS WITH OBESITY AND METABOLIC SYNDROME - GUIDELINE FROM THE BRAZILIAN SOCIETY OF BARIATRIC AND METABOLIC SURGERY / Doença Hepática Esteatótica Associada à Disfunção Metabólica - Avaliação de pacientes portadores de obesidade e síndrome metabólica - Guideline da Sociedade Brasileira de Cirurgia Bariátrica e Metabólica

Introduction: Metabolic Dysfunction Associated Steatotic Liver Disease (MASLD) is the most prevalent chronic liver disease in the world and has recently been renamed to emphasize its metabolic component. This article seeks to fill the gap in specific guidelines for patients with obesity and MASLD who will undergo bariatric surgery. Methods: A systematic search for guidelines was carried out on the PubMed and Embase platforms. Results: Were found 544 articles, of which 11 were selected according to inclusion/exclusion criteria. All 11 guidelines are from clinical societies and therefore do not include some necessary interpretations for bariatric patients. Conclusions: We recommend that every patient undergoing bariatric and metabolic surgery be screened initially with the Fibrosis-4 (FIB-4) score, followed by transient hepatic elastography (Vibration-controlled Transient Elastography - VCTE), especially for those with FIB4 > 1.3. However, the interpretation of VCTE results in obese patients requires further studies to define the real cutoff values. Enhanced Liver Fibrosis® (ELF®) shows promise, but its availability is limited. The indication for liver biopsy during surgery needs to be individualized but is recommended for those with changes in FIB4 and/or VCTE. Family screening is recommended for relatives of young patients with advanced fibrosis. Liver transplantation is an option for patients with advanced MASLD, but the optimal timing for bariatric surgery in relation to transplantation is still unclear. Regular follow-up and VCTE examination are recommended to monitor disease progression after surgery.  

Introdução: A Doença Hepática Esteatótica Associada à Disfunção Metabólica (MASLD) é a doença hepática crônica mais prevalente no mundo e foi recentemente renomeada para enfatizar seu componente metabólico. Este artigo busca preencher a lacuna de diretrizes específicas para pacientes portadores de obesidade e MASLD que irão ser submetidos à cirurgia bariátrica. Método: Foi realizado uma busca sistemática por guidelines nas plataformas PubMed e Embase. Resultados: Foram encontrados 544 artigos, dos quais 11 foram selecionados conforme critérios de inclusão/exclusão. Todos os 11 guidelines são de sociedades clínicas, portanto, não contemplam algumas interpretações necessárias para o paciente bariátrico. Conclusões: Recomendamos que seja feito o rastreio de todo paciente que será submetido a cirurgia bariátrica e metabólica inicialmente com o score Fibrosis-4 (FIB-4), seguido da elastografia hepática transitória (Vibration-controlled Transient Elastography - VCTE), principalmente para aqueles com FIB4> 1,3. No entanto, a interpretação dos resultados do VCTE em pacientes obesos necessita de mais estudos para delimitar os reais valores de cortes. O Enhanced Liver Fibrosis® (ELF®) mostra-se promissor, mas sua disponibilidade é limitada. A indicação da biópsia hepática durante a cirurgia, precisa ser individualizada, porém é recomendada para aqueles com alteração do FIB4 e/ou da VCTE. O rastreio familiar é recomendado para parentes de pacientes jovens já com fibrose avançada. O transplante hepático é uma opção para pacientes com MASLD avançada, mas o momento ideal para a cirurgia bariátrica em relação ao transplante ainda não está claro. O acompanhamento regular e o exame VCTE são recomendados para monitorar a progressão da doença após a cirurgia.

Incidence and Risk Factors of Hepatocellular Carcinoma in Patients with Chronic Hepatitis C Treated with Direct-Acting Antivirals.

BACKGROUND: Conflicting data regarding the incidence of hepatocellular carcinoma (HCC) after cure of HCV infection with direct-acting antivirals (DAAs) remains. We investigated the incidence and risk factors to HCC after treatment with DAAs followed up for five years. METHODS: A total of 1075 HCV patients ≥ 18 years were treated with DAAs from 2015 to 2019 and followed until 2022. Ultrasonography was performed before DAAs and each 6 months thereafter. RESULTS: Of the total, 51/1075 (4.7%) developed HCC in the median of 40 (IQR 25-58) months: 26/51 (51%) male, median age 60 (IQR 54-66) years, alpha-fetoprotein (AFP) 12.2 (IQR 6.1-18.8) ng/mL, 47/51 (92.1%) cirrhotic 78.7%, 8/51 (15.7%) without sustained virological response (SVR). Seventeen percent had non-characterized nodules before DAAs. Cumulative HCC incidence was 5.9% in 5 years. Overall incidence was 1.46/100 patient-years (PY) (95% CI = 1.09-1.91), being 2.31/100 PY (95% CI = 1.70-3.06), 0.45/100 PY (95% CI = 0.09-1.32) and 0.20/100 PY (95% CI 0.01-1.01) in METAVIR F4, F3 and F2, respectively, and the main risks to HCC were non-characterized nodule, cirrhosis, high AFP values and non-SVR. CONCLUSION: HCV cure reduced risk for HCC, but it still occurred particularly in cirrhotic patients. Some risk factors can be identified to predict early HCC diagnosis.

Pacientes cirróticos com escore Child-Pugh C apresentam intervalos QT mais longo / Cirrhotic patients with Child-Pugh C have longer QT intervals

Fundamento e objetivos: A cardiomiopatia cirrótica tem sido usada para descrever a disfunção cardíaca crônica em pacientes cirróticos sem doença cardíaca estrutural prévia. Além disso, o prolongamento do intervalo QT é uma das alterações cardíacas mais importantes relacionadas à cirrose. Estudos prévios sugerem que o prolongamento QT está associado com uma taxa de mortalidade mais alta em pacientes cirróticos. O objetivo deste estudo foi analisar intervalos QTs segundo a gravidade da cirrose, medida pela classificação Child-Plugh. Materiais e métodos: Em um estudo transversal, um total de 67 pacientes com cirrose não alcoólica submeteu-se à avaliação clínica e eletrocardiográfica. A gravidade da cirrose foi classificada de acordo com o escore Child-Pugh. O intervalo QT foi medido por um eletrocardiograma de 12 derivações. Resultados: Os intervalos QTs foram mais longos em pacientes no grupo Child-Plugh C que nos grupos Child-Pugh A e B (459 ± 33 vs 436 ± 25 e 428 ± 34 ms, respectivamente, p = 0,004). Houve uma correlação positiva entre o intervalo QT e o escore Child-Pugh em indivíduos com escore Child-Pugh ≥ 7 (r = 0,50; p < 0,05) e intervalos QT ≥ 440 ms (r = 0,46, p < 0,05). Conclusão: O presente estudo mostrou que pacientes com cirrose Child-Plugh C apresentam intervalos QTs mais longos, o que reforçou a relação entre a gravidade da cirrose e achados eletrocardiográficos da cardiomiopatia cirrótica. Além disso, esse resultado foi encontrado em pacientes sem sintomas cardíacos, o que destacou a importância de um método simples e não invasivo, como o eletrocardiograma, para identificar pacientes cirróticos com cardiomiopatia

Background and aims: Cirrhotic cardiomyopathy has been used to describe chronic cardiac dysfunction in cirrhotic patients with no previous structural heart disease. Additionally, QT prolongation is one of the most important cardiac alterations related to cirrhosis. Previous studies suggest that QT prolongation is associated with a higher mortality rate among cirrhotic patients. The aim of this study was to analyze QT intervals according to cirrhosis severity as measured by the Child-Pugh classification. Materials and methods: In a cross-sectional study, a total of 67 patients with nonalcoholic cirrhosis underwent clinical and electrocardiographic evaluation. Cirrhosis severity was classified according to the Child-Pugh score. The QT interval was measured by a 12-lead electrocardiogram. Results: The QT intervals were longer in patients in the Child-Pugh C group than those in the Child-Pugh A and B groups (459 ± 33 vs 436 ± 25 and 428 ± 34 ms, respectively, p=0.004). There was a positive correlation between the QT interval and the Child-Pugh score in individuals with Child-Pugh scores ≥ 7 (r=0.50, p<0.05) and QT intervals ≥ 440 ms (r=0.46, p<0.05). Conclusion: The present study showed longer QT intervals in patients with Child-Pugh C cirrhosis, which reinforced the relationship between the severity of cirrhosis and electrocardiographic findings of cirrhotic cardiomyopathy. Moreover, this finding emerged in patients with no cardiac symptoms, which highlighted the importance of a simple and noninvasive method (ECG) to identify cirrhotic patients with cardiomyopathy

The Correlation Between Obesity-Related Diseases and Non-alcoholic Fatty Liver Disease in Women in the Pre-operative Evaluation for Bariatric Surgery Assessed by Transient Hepatic Elastography.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is a common, severe disease in obese patients. However, NAFLD is usually underestimated by ultrasonography. Liver biopsy is not routinely done in bariatric surgery or during the follow-up. This study therefore examined the correlation between metabolic syndrome and NAFLD in morbidly obese patients based on an assessment using transient hepatic elastography (THE). MATERIAL AND METHODS: This study involved 50 female patients in the pre-operative phase for bariatric surgery. Before surgery, we collected clinical, laboratory, and anthropometric variables. THE measurements were obtained using a FibroScan® device (Echosens, Paris, France), and steatosis was quantified using Controlled Attenuation Parameter software (CAP). Statistical analyses were done using linear correlation and the Kruskal-Wallis test. RESULTS: The mean of THE and CAP values were 7.56 ± 4.78 kPa and 279.94 ± 45.69 dB/m, respectively, and there was a significant linear correlation between the two measurements (r = 0.651; p < 0.001). The numbers of metabolic syndrome parameters did not influence the THE (p = 0.436) or CAP (p = 0.422) values. HbA1c and HOMA-IR showed a strong linear correlation with CAP (r = 0.643, p = 0.013 and r = 0.668, p = 0.009, respectively) and a tendency to some linear correlation with THE (r = 0.500, p = 0.05 and r = 0.500, p = 0.002, respectively). CONCLUSION: Morbidly obese women submitted to FibroScan® presented a high prevalence of severe steatosis and advanced fibrosis in our sample. Insulin resistance parameters were correlated with steatosis, but less with fibrosis.