Serum Biglycan as a Diagnostic Marker for Non-Alcoholic Steatohepatitis and Liver Fibrosis.

BACKGROUND: Non-alcoholic steatohepatitis (NASH) has risen in prevalence substantially through the years. Although course and progression of the disease are variable, fibrosis is the most important factor. We intended to explore utility of serum biglycan (BGN) in NASH and its capacity in anticipating liver fibrosis. METHODS: Serum tests of consecutive patients with biopsy-confirmed NASH and age, gender-matched healthy volunteers were utilized to evaluate serum BGN levels using ELISA kits. The correlation between BGN and histopathological highlights of NASH was examined. While patients with fibrosis scores < 2 were assembled in mild and scores of (≥ 2) were in significant fibrosis groups. Univariate/multivariate regression analyses were performed to assess the independent predictive variables of liver fibrosis. Receiver operating characteristics (ROC) were applied to locate the best cutoff values of BGN for NASH and fibrosis. RESULTS: Seventy patients with NASH and 70 controls were recruited in the study. BGN levels were lower in NASH patients contrasted with controls 137.70 ± 33.12 pg/mL vs. 259.61 ± 187.34 pg/mL, respectively, and p < 0.001. In correlation, serum BGN was related to liver fibrosis and inflammation. The comparison between mild and significant fibrosis groups regarding BGN was as follows 155.92 ± 49.97 pg/mL vs. 390.07 ± 214.746 pg/mL, respectively, (p < 0.001). In multivariate analyses, BGN was an independent predictive factor of significant fibrosis (OR, 1.030; 95% CI: 1.011 - 1.048; p < 0.001). ROC analysis revealed that BGN was statistically significant in determination of significant fibrosis (AUROC, 0.955; 95% CI, 0.877 - 0.990; p < 0.001). Best cutoff value was 189.58 pg/mL with the best sensitivity (93.55%) and specificity (87.18%). CONCLUSIONS: Serum BGN may be a new non-invasive indicative marker for the presence of NASH, significant fibrosis, and a treatment goal in the disease process.

The importance of serum biglycan levels as a fibrosis marker in patients with chronic hepatitis B.

BACKGROUND: Liver biopsy is recommended in the majority of patients with chronic viral hepatitis for fibrosis evaluation. Because of the potential risks of liver biopsy, many studies related to non-invasive biomarkers of hepatic fibrosis have been performed. We aimed to assess the diagnostic value of serum biglycan as a non-invasive fibrosis marker in chronic hepatitis B patients. METHODS: This study included 120 patients with biopsy-proven hepatitis B patients and 60 healthy controls. Fibrosis stage and necroinflammatory activity were assessed in liver biopsy specimens. Biglycan level was measured using an ELISA assay. RESULTS: Serum biglycan levels of chronic hepatitis B patients were found to be significantly higher than those of healthy controls (337.3±363.0 pg/mL vs 189.1±61.9 pg/mL, respectively, P<.001). There was a statistically significant positive correlation between serum biglycan level and fibrosis stage (P=.004; r=.213). Besides, a statistically significant positive correlation was found between serum biglycan level and necroinflammatory activity (P<.001; r=.271). The AUROC of BGN levels was 0.702 for fibrosis stage, differentiating patients from healthy controls with statistical significance (P<.001). The AUROC of BGN levels was 0.632 for necroinflammatory activity score, differentiating patients from healthy controls with statistical significance (P=.004). CONCLUSIONS: Serum biglycan might be used as a non-invasive marker of liver fibrosis. Further studies are needed to evaluate the usefulness of this marker.

Association between Plasma Endothelin-1, Transforming Growth Factor-ß, Fibroblast Growth Factor, and Nitric Oxide Levels and Liver Injury in Hematopoietic Stem Cell Transplantation Recipients with Persistent Iron Overload after Transplantation.

Graft-versus-host disease, iron overload, and infections are the major causes of liver dysfunction in allogeneic hematopoietic stem cell transplantation (AHSCT) recipients. We investigated the relationship between serum iron parameters and the levels of transforming growth factor-ß (TGF-ß), fibroblast growth factor (FGF), endothelin-1 (ET-1), and nitric oxide (NO) as predictors of chronic liver injury in 54 AHSCT recipients who survived at least a year after transplantation. Serum samples from patients were obtained for the evaluation of ET-1, TGF-ß, FGF, NO, and nontransferrin bound iron at the first year follow-up visit using commercially available ELISA kits. Patients were categorized depending on serum ferritin and transferrin saturation levels. The parameters were compared between the groups, and survival analysis was also performed. Most of the AHSCT recipients (81.5%) were in complete remission during the study. After a median follow-up time of 73 months (range, 13 to 109 months), 72.2% of the patients were alive. Mean serum levels of ET-1, NO, TGF-ß, and FGF were 81.54 ± 21.62 µmol/mL, 31.82 ± 26.42 µmol/mL, 2.56 ± 0.77 ng/mL, and 50.31 ± 32.69 pg/mL, respectively. Nineteen patients (35.2% of the cohort) had serum ferritin levels higher than 1000 ng/mL. Mean serum levels of ET-1, NO, TGF-ß, and FGF were similar in patients with serum ferritin levels below or above 1000 ng/mL (P > .05). Serum ferritin levels were positively correlated with serum alanine aminotransferase (r = .284, P = .042) and γ-glutamyl transferase (r = .271, P = .05) levels and were negatively correlated with serum albumin levels (r = .295, P = .034). There was a significant positive correlation between serum transferrin saturation and alanine aminotransferase levels (r = .305, P = .03). Serum ET-1 level was positively correlated with alkaline phosphatase levels (r = .304, P = .026). In univariate Cox regression analysis serum levels of iron parameters, ET-1, NO, TGF-ß, and FGF did not have an impact on overall survival (P > .05). The probability of progression-free survival was also similar in patients with ferritin levels above or below 1000 ng/mL (P = .275). The probability of survival was similar in patients with transferrin saturation ≥70% and <70% (P > .05). Serum iron parameters showed a positive correlation with liver injury. However, there was no correlation between fibrogenic cytokines and liver transaminases. Our results suggest that iron overload at least with the current levels of ferritin might have a relatively benign course. Prospective randomized trials will guide the actual role of iron chelation in the post-transplantation setting.

Role of serum toll-like receptors 2 and 4 in non-alcoholic steatohepatitis and liver fibrosis.

BACKGROUND AND AIM: Non-alcoholic fatty liver disease is a common cause of chronic liver disease, including non-alcoholic steatohepatitis (NASH). Our aim was to investigate whether serum toll-like receptors 2 and 4 (TLR2 and TLR4) levels are correlated with NASH and able to predict liver fibrosis, as well as to compare these markers with other non-invasive fibrosis scores (aspartate aminotransferase [AST] to alanine aminotransferase ratio, AST to platelet ratio index, fibrosis index, fibrosis 4, and fibrosis cirrhosis index). METHODS: Serum samples were obtained from consecutive biopsy proven NASH patients and healthy controls. Serum TLR2 and TLR4 were measured using ELISA. Stage of fibrosis was evaluated using the Brunt Criteria. The different non-invasive fibrosis scores were compared using areas under the curve. RESULTS: Fifty-seven patients with NASH and 57 healthy individuals were enrolled in the study. Serum TLR2 levels were not significantly different between the healthy controls and NASH patients. The medians were 3.88 ng/mL ± 0.29 versus 3.81 ng/mL ± 0.32, respectively (P = 0.587). In comparing the levels of TLR4 between groups, the medians were 1.05 ng/mL ± 0.13 versus 1.46 ng/mL ± 0.27, respectively (P < 0.001). In NASH patients, the levels of serum TLR4 increased with the stage of fibrosis: TLR4 medians were F0:1.01, F1:1.46, F2:2.14, F3:3.74, F4:5.83 (P < 0.001). TLR4 produced AUCs for ≥ F1, ≥ F2, and ≥ F3 of 0.862, 0.810, and 0.905, respectively (P < 0.001). TLR4 levels were more predictive than other non-invasive fibrosis scores in liver fibrosis. CONCLUSION: Serum TLR4 levels but not TLR2 were elevated in NASH patients in comparison with healthy controls. And in NASH patients, serum TLR4 levels both correlated with and were able to predict liver fibrosis.

Can serum pin1 level be regarded as an indicative marker of nonalcoholic steatohepatitis and fibrotic stages?

BACKGROUND: We aimed to investigate serum Pin1 as an indicator of the presence of nonalcoholic steatohepatitis (NASH) and its association with the histopathological liver fibrosis stages. METHODS: Serum samples were collected from consecutive biopsy-proven NASH patients and healthy controls, and then serum levels of Pin1 were measured. The correlations between clinical and histopathological features of NASH and Pin1 were evaluated. Patients who had fibrotic stages <2 were termed mild fibrosis group and those who had ≥ 2 as advanced fibrosis group. We performed univariate and multivariate logistic regression analyses to evaluate the independent predicting factors for the presence of liver fibrosis caused by NASH. RESULTS: Fifty-six consecutive NASH patients and 56 age- and sex-matched healthy controls were enrolled in the study. Serum Pin1 levels were significantly higher in NASH patients (39.24 ± 30.94) than in controls (27.7 ± 9.56, p < 0.001). In NASH patients, serum Pin1 levels were correlated with the histopathological features. Patients with advanced fibrosis had higher serum Pin1 levels than the mild fibrosis group (53.42 ± 33.8 vs. 33.24 ± 20.90, respectively; p < 0.001). In multivariate analysis, Pin1 remained an independent predicting factor of advanced liver fibrosis (OR: 1.051, 95% CI: 1.013-1.089, p < 0.05). CONCLUSION: Serum Pin1 level can be used as a potential independent marker of the presence of the NASH and advanced fibrotic scores.

Low serum vitamin D levels are associated with severe histological features and poor response to therapy in patients with autoimmune hepatitis.

BACKGROUND AND AIM: 25-Hydroxyvitamin D [25(OH)D] has an important role in fibrosis progression and inflammatory response in patients with various etiologies of chronic liver disease. However, its influence on autoimmune hepatitis (AIH) has not been investigated. We evaluated the association of serum 25(OH)D levels with clinical, biochemical and histological features and response to therapy in AIH. MATERIALS AND METHODS: Serum 25(OH)D levels were quantified in 68 therapy naïve AIH patients and 34 healthy controls. RESULTS: Mean serum 25(OH)D levels were significantly lower in AIH compared to healthy controls (16.8 ± 9.2 vs. 35.7 ± 13.6, p < 0.0001). Low levels of 25(OH)D (<30 µg/L) were independently associated with advance fibrosis and severe interface hepatitis in AIH patients [p = 0.014; odds ratio (OR) 0.12, 95% confidence interval (CI) 0.02-0.65 and p = 0.020; OR 0.17, 95% CI 0.04-0.76, respectively]. Severe 25(OH)D deficiency (<10 µg/L) was associated with advance fibrosis, severe interface hepatitis, low platelet counts and sampling time in a univariate analysis. Only interface hepatitis and fibrosis scores were independently associated with 25(OH)D deficiency in a multiple regression analysis (p = 0.005; OR 0.12, 95% CI 0.03-0.53 and p = 0.022; OR 0.15, 95% CI 0.03-0.75, respectively). Mean serum 25(OH)D levels were lower in non-responders compared to responders (9.2 ± 4.8 vs. 17.1 ± 9.4, p = 0.015), and 25(OH)D deficiency was more commonly observed in non-responders than the responders (80 vs. 43%, p = 0.036). CONCLUSIONS: Low 25(OH)D levels are associated with advance fibrosis and severe inflammation in AIH. Our study suggests that vitamin D may be a potential biomarker that predicts response to therapy and histological features in AIH.

HBV-related events after allogeneic hematopoetic stem cell transplantation in a center from Turkey.

To investigate the frequency of hepatitis B virus (HBV)-related events after allogeneic HCT in a moderate endemic area for HBV infection. The data of 197 patients who underwent allogeneic hematopoetic stem cell transplatation (HCT) from September 2003 through December 2010 were reviewed retrospectively with respect to HBV-related events. Resolved HBV infection was described as negative HBsAg, positive HBcAb, and positive HBsAb. Latent HBV infection was defined in patients with HBcAb positivity in the abscence of HBV DNA and HBsAb. Hepatitis B naive patients are defined as the patiens with no serological or molecular marker related to HBV. Seropositive patients were the patients with positive HBsAg and HBV-DNA. Median age was 28 (range, 15-64) years, with 128 male and 69 female patients. Median follow-up of the cohort was 8 (range, 0.5-78) months. We detected HBV-related events in 7 (3.6 %) recipients after allogeneic HCT. Five (71.4 %) of these events were HBV reactivation, while two cases (28.6 %) had acute hepatitis B infection. Four of the five reactivations were in the seropositive group (80 %), while one ocurred in a patient with resolved hepatitis. Two patients who developed acute hepatitis B were HBV naive and previously immunized patients, respectively. Hepatitis B virus reactivation remains a problem in seropositive patients and might require more effective treatment strategies.

Diagnostic potential of serum direct markers and non-invasive fibrosis models in patients with chronic hepatitis B.

AIM: Liver biopsy is recommended in the majority of patients with chronic viral hepatitis for fibrosis evaluation. Because of the disadvantages of liver biopsy, many studies related to non-invasive biomarkers and scores have been performed. In this study, we aimed to assess the diagnostic value of serum direct markers and non-invasive fibrosis models to predict liver fibrosis in the treatment-naive chronic hepatitis B (CHB) patients and to compare their diagnostic performance. METHODS: This study included 58 patients with a diagnosis of CHB virus infection and 30 healthy controls. Hyaluronic acid, tissue inhibitor of matrix metalloproteinase 1 and amino-terminal propeptide of type III procollagen were measured by enzyme-linked immunosorbent assay; and the Original European Liver Fibrosis panel, the Enhanced Liver Fibrosis (ELF) panel, PP score, aspartate aminotransferase to platelet ratio index (APRI) and FIB-4 indexes were calculated using the formulas taken from previous publications. Fibrosis stage was determined using Ishak's scoring system. RESULTS: The fibrosis stages identified upon liver biopsy was F0 in 12 patients (20.7%), F1-2 in 36 (62.1%) and F3-5 in 10 (17.2%). The diagnostic value of all the non-invasive indices was low to detect mild fibrosis. We demonstrated that the diagnostic accuracy of HA is the best for predicting fibrosis of F3 or more (area under the receiver-operator curve, 0.902). In our study, the results from a combination of tests showed that ELF and APRI had the highest diagnostic value sensitivity of 90%, specificity of 100%, positive predictive value of 100% and negative predictive value of 96.4% for detection of fibrosis of F3 or more. CONCLUSION: In CHB patients, combination of ELF and APRI has a better diagnostic value in predicting fibrosis of F3 or more.

Serum liver fatty acid binding protein shows good correlation with liver histology in NASH.

BACKGROUND/AIMS: Simple, reproducible and non-invasive tests that can be used to determine the severity of non-alcoholic steatohepatitis (NASH) are needed. Liver-type fatty acid binding protein (L-FABP) plays a key role in the fatty acid metabolism of the liver. We aimed to determine whether serum L-FABP levels in patients with NASH were different from those in healthy controls, and if so, whether this was associated with the degree of fibrosis, steatosis and inflammatory activity. METHODOLOGY: Forty-seven patients with histologically confirmed NASH and 41 healthy controls were included in the study. Serum L-FABP levels were measured in all participants. RESULTS: Mean L-FABP levels were significantly higher in patients with NASH compared to the control group (2703.19±1603.47 vs. 1684.58±860.19, p<0.001). Serum L-FABP levels showed a significant positive correlation with NAS score (p=0.03, r=0.312), the degree of fibrosis (p=0.02, r=0.324) and inflammation (p=0.03, r=0.312), BMI (p=0.05, r=0.303), serum ALT (p=0.01, r=0.28), AST (p=0.04, r=0.315), and triglyceride levels (p=0.03, r=0.328). CONCLUSIONS: Serum L-FABP levels are elevated in NASH and this elevation is positively correlated with the degree of fibrosis and inflammation. L-FABP levels may aid as a non-invasive marker in determining the severity of fibrosis and inflammation in patients with NASH.

Diagnostic performance of 2D shear wave elastography in predicting liver fibrosis in patients with chronic hepatitis B and C: a histopathological correlation study.

PURPOSE: In this study, we investigated the diagnostic efficacy of 2D-Shear Wave Elastography (2D-SWE) in detecting stages of liver fibrosis and determining the disease-specific cut-off values in patients with chronic hepatitis B and C infection, using histopathological analysis as the reference method. METHOD: Our study included 103 consecutive adult patients with chronic hepatitis B and C infection (CHB and CHC) who had liver biopsy within three months of elastography examination. A real-time 2D-SWE was performed using the LOGIQ E9 system (GE Medical Systems, Wisconsin, USA). The correlation between the liver stiffness measurements and the METAVIR scores was evaluated. The diagnostic performance of 2D-SWE was assessed, and cut-off values were set. RESULTS: We found a statistically significant positive correlation between elastography values and the degree of liver fibrosis (Spearman's correlation coefficient = 0.76 and 0.83 for CHB and CHC; respectively) (p = 0.0001). The stiffness cut-off values were F ≥ 1: 5.92 kPa, F ≥ 2: 7.69 kPa, F ≥ 3: 8.97 kPa, F ≥ 4: 12.15 kPa in CHB; and F ≥ 1: 6.09 kPa, F ≥ 2: 7.81 kPa, F ≥ 3: 9.0 kPa, F ≥ 4: 12.47 kPa in CHC patients. CONCLUSION: 2D-SWE is reliable and accurate for the diagnosis of liver fibrosis. In selected patients, 2D-SWE may be useful in reducing the need for liver biopsy when staging fibrosis. Further studies in larger prospective series are needed to confirm these results and determine the most appropriate cut-off values for each stage of liver fibrosis.

The prevalence of metabolic-associated fatty liver disease in the Turkish population: A multicenter study.

Background and Aim: The objective of the present study was to investigate the prevalence of metabolic-associated fatty liver disease (MAFLD) in patients with dyspepsia. Materials and Methods: A total of 909 consecutive patients who presented with dyspepsia at 8 tertiary care centers in Turkey between March 2019 and December 2019 were included. Results: The median age was 47 years. Among them, 30.3% of the patients were obese, 18.8% had type 2 diabetes mellitus (T2DM), 35.1% had metabolic syndrome, 84.8% had dyslipidemia, and 23.9% had hypertension. The prevalence of MAFLD was 45.5%. Among the patients with MAFLD, the prevalence of obesity, T2DM, metabolic syndrome, dyslipidemia, and hypertension was 43.3%, 24.9%, 52.5%, 92.3%, and 31.9%, respectively. MAFLD was significantly associated with all of the metabolic comorbidities (p<0.001). The median Fibrosis-4 Index score of the MAFLD patients was 0.88 (range: 0.1-9.5). Of note, 53 patients with hepatic steatosis did not meet the MAFLD criteria. Conclusion: The results of the present study indicated that there was a significantly high prevalence of MAFLD observed in daily clinical practice in Turkey. Early diagnosis and prevention efforts should be implemented to reduce disease progression, and a region-based strategy is recommended.

Characteristics of Newly Diagnosed Hepatocellular Carcinoma Patients Across Turkey: Prospective Multicenter Observational 3K Registry Study.

AIMS: To evaluate patient profile for epidemiological and clinicopathological characteristics and potential risk/prognostic factors in newly diagnosed hepatocellular carcinoma (HCC) patients across Turkey. METHODS: A total of 547 patients (mean (SD) age 62.6 (10.3) years, 81.9% were males) were included in this registry study. Data on patient characteristics, etiologies of HCC, laboratory values, and tumor characteristics and stages were recorded at study enrollment. RESULTS: HBV infection (68.2%) was the leading etiology, followed by HCV infection (17.2%), HDV infection (5.5%), alcohol (6.4%), and NAFLD (3.5%), as the major etiologies. Considering that 51.6% of the patients had >5 cm HCC, 44% were Child-Pugh B/C and 57% were BCLC B-D, it appears that a significant group of HCC patients were diagnosed at advanced stages. Of 540 patients, 271 (50.2%) were referred or applied with the diagnosis of HCC. Patients with HCC at presentation had larger tumor size (median (min-max) 6.6 (0-30) vs. 4.8 (0-90) cm, P < .001) and more advanced BCLC stage (Stage C-D in 40.8% vs. 26.4%, respectively, P = .005), compared to patients who were diagnosed during follow-up. CONCLUSIONS: Our findings revealed that HBV infection was the leading etiology and a moderate-to-advanced disease was evident in more than half of patients at the time of diagnosis. HCC patients diagnosed at follow-up had smaller tumor size and earlier BCLC stage.

Evaluation of Plasma Urokinase-Type Plasminogen Activator Receptor (UPAR) in Patients With Chronic Hepatitis B, C and Non-Alcoholic Fatty Liver Disease (NAFLD) as Serological Fibrosis Marker.

BACKGROUND/AIMS: Progressive hepatic fibrosis is the main predictor of outcome and prognosis in chronic liver diseases. The importance of the coagulation cascade has been defined in liver fibrosis; however, the role of the fibrinolytic pathway has not been clear yet. We aimed to evaluate the association between the plasma levels of soluble urokinase Plasminogen Activator Receptor (uPAR) and the severity of liver fibrosis in chronic hepatitis B, C and Non-Alcoholic Fatty Liver Disease (NAFLD). METHODS: 96 chronic hepatitis B, 22 chronic hepatitis C and 11 NAFLD patients together with 47 healthy controls were enrolled in the study. uPAR plasma levels were detected by Enzyme-Linked Immunosorbent Assay (ELISA) method. RESULTS: The plasma levels of uPAR in patients with chronic hepatitis B and C significantly exceeded those of healthy controls (P < 0.001) while mean uPAR levels in patients with NAFLD were not different from healthy controls. Mean uPAR levels in chronic viral hepatitis patients with F1-F3 fibrosis and F4-F6 fibrosis were higher than those of control group (P < 0.001). Mean uPAR level in patients with F4-F6 fibrosis was significantly higher than that of patients with F1-F3 fibrosis (P < 0.001). CONCLUSION: This is the first study that investigated uPAR as a fibrosis marker in NAFLD and chronic hepatitis B patients. It is suggested that plasma levels of uPAR are closely related to the fibrosis stage in chronic hepatitis B and C and that uPAR might be a noninvasive marker of liver fibrosis.

Evaluation of serum procollagen C-proteinase enhancer 1 level as a fibrosis marker in patients with chronic hepatitis B.

AIM: Although liver biopsy has long been considered the gold standard for staging fibrosis, because of the disadvantages and risks of biopsy, several noninvasive processes such as serum biomarkers have been introduced for the assessment of liver fibrosis. The aim of this study was to assess the diagnostic value of serum procollagen C-proteinase enhancer 1 (PCPE-1) as a noninvasive fibrosis marker in treatment-naive chronic hepatitis B patients. PATIENTS AND METHODS: This study included 126 patients with biopsy-proven hepatitis B and 50 healthy controls. Fibrosis stage was determined using the Ishak scoring system. The PCPE-1 level was measured using the enzyme-linked immunosorbent assay assay, and the aspartate aminotransferase to platelet ratio index and the FIB-4 index were calculated using the formulas described in Appendix 1 (Supplemental digital content 1, http://links.lww.com/EJGH/A277). RESULTS: Serum PCPE-1 levels of chronic hepatitis B patients were found to be significantly lower than those of the healthy control group (4.49±2.74 vs. 42.9±59.6 pg/ml, respectively, P<0.001). There was a statistically significant negative correlation between serum PCPE-1 level and fibrosis stage (P=0.011; r=-0.226). A statistically significant negative correlation was found between serum PCPE-1 level and necroinflammatory activity (P=0.030; r=-0.194). PCPE-1 levels of patients with liver fibrosis scores of F1-2 were statistically significantly lower than those of the healthy control group (P<0.001) (area under the receiver operating characteristic: 0.955). The area under the receiver operating characteristic of the PCPE-1 level was 0.615 for the prediction of fibrosis (F0 vs. F1-6) (P=0.039). CONCLUSION: Serum PCPE-1 might be used as a noninvasive marker of liver fibrosis. Further animal and human studies are needed to assess the utility of this marker.

Serum ß-trophin level as a new marker for noninvasive assessment of nonalcoholic fatty liver disease and liver fibrosis.

OBJECTIVE: Nonalcoholic fatty liver disease (NAFLD) is a common chronic liver disease and evaluation of fibrosis is important. We aimed to investigate the utility of serum ß-trophin in NAFLD and its ability to predict liver fibrosis. PATIENTS AND METHODS: Serum samples of consecutive patients with biopsy-proven NAFLD and age-matched and sex-matched healthy controls were used to measure ß-trophin using ELISA. Correlations between histopathological features of NAFLD and ß-trophin were analyzed. Whereas patients with fibrosis scores less than 2 were grouped in the mild fibrosis group, patients with scores of 2 or more were grouped in the significant fibrosis group. Univariate/multivariate logistic regression analyses were carried out to evaluate the independent predicting factors of liver fibrosis. Receiver operating characteristics (ROCs) were assessed to determine the best cut-off values for NAFLD and fibrosis. RESULTS: Sixty-nine patients with NAFLD and 69 healthy controls were enrolled in the study. Serum ß-trophin levels were lower in NAFLD patients compared with the controls (2.34±0.06 vs. 1.94±0.09 ng/ml, respectively, P<0.001). In NAFLD, serum ß-trophin was related to liver fibrosis and inflammation. The mild fibrosis group had higher serum ß-trophin levels than the significant fibrosis group (2.11±0.12 vs. 1.72±0.11, respectively, P<0.001). In multivariate analysis, ß-trophin remained an independent predictor of significant fibrosis (odds ratio, 0.237; 95% confidence interval, 0.059-0.949; P<0.001). ROC analysis showed that serum ß-trophin was statistically significant in the identification of significant fibrosis (area under receiver operating characteristic, 0.844; 95% confidence interval, 0.718-0.970; P<0.001). The best cut-off value was 1.786, with the best sensitivity (71.43%) and specificity (95.65%). CONCLUSION: Serum ß-trophin may be a potential noninvasive marker for the identification of NAFLD and significant liver fibrosis.

Comparative diagnostic accuracy of red cell distribution width-to-platelet ratio versus noninvasive fibrosis scores for the diagnosis of liver fibrosis in biopsy-proven nonalcoholic fatty liver disease.

OBJECTIVE: Nonalcoholic fatty liver disease (NAFLD) is a chronic liver disease and assessment of liver fibrosis is important. We aimed to investigate the performance of red cell volume distribution width-to-platelet ratio (RPR) in predicting liver fibrosis in patients with NAFLD and to compare it with well-known noninvasive predicting fibrosis scores (alanine aminotransferase ratio, aspartate aminotransferase platelet ratio index, fibrosis index, fibrosis 4, and fibrosis, cirrhosis index). MATERIALS AND METHODS: Serum samples of consecutive biopsy-proven NAFLD patients were used to calculate the RPR index. Fibrosis stages were evaluated using the Brunt Criteria. Area under receiver operating characteristics curve was used to calculate predicting performance and compare with other noninvasive fibrosis scores. RESULTS: One hundred and twenty-three consecutive patients with biopsy-confirmed NAFLD were recruited; 54 patients (43.9%) were women. The median age of the patients was 49 years. Fibrosis scores were F0-1, F2, F3, and F4 in 79 (64.2%), 27 (22%), 11 (8.9%), and 6 (4.9%) patients, respectively. The median RPR increased as the fibrosis scores progressed: F0, 0.0524; F1, 0.0534; F2, 0.0606; F3, 0.0815; and F4 0.2022. Area under receiver operating characteristics curve of the RPR was 0.69 in predicting significant fibrosis (≥ F2), 0.81 in advanced fibrosis (≥ F3), and 0.85 in F4, and all were statistically significant (P<0.001). Comparisons with other noninvasive fibrosis scores were not statistically significant (P>0.05). RPR was correlated with fibrosis r: 0.37, 95% confidence interval: (0.21-0.52), P<0.001. RPR was an independent predicting factor for identifying both significant and advanced fibrosis in regression analysis (P<0.05). CONCLUSION: RPR was both correlated and able to predict liver fibrosis and may be suggested to reduce liver biopsy in NAFLD.

Impact of hepatic immunoreactivity of angiotensin-converting enzyme 2 on liver fibrosis due to non-alcoholic steatohepatitis.

BACKGROUND: We aimed to evaluate the hepatic immunoreactivity of angiotensin-converting enzyme 2 (ACE2) in non-alcoholic steatohepatitis (NASH) patients, elucidate its association with the clinicopathological characteristics and also determine its role in fibrosis progression. METHODS: The consecutive biopsy proven NASH patients were subdivided into two groups according to their fibrosis score. Fibrotic stages<3 in mild fibrosis group and fibrotic stages ≥ 3 in advanced fibrosis depending on the presence of bridging fibrosis. Liver biopsy specimens were immunohistochemically stained for ACE2 immunoreactivity. Demographics and clinical properties were compared between the groups. Univariate and multivariate analysis were also performed to evaluate the independent predicting factors for the presence of advanced liver fibrosis caused by NASH. RESULTS: One hundred and eight patients were enrolled in the study. Out of this, ninety-four patients representing 87% were classified as mild fibrosis group, whilst fourteen representing 13% were in advanced fibrosis group. We compared high hepatic immunoreactivity of ACE2 between mild and advanced fibrosis groups and found a statistically significant difference 65.9% vs 28.5%, respectively and P=0.008. Hepatic ACE2 immunoreactivity was inversely correlated with the fibrosis score (r: -0.337; P<0.001). The significant variables in the univariate analysis were then evaluated in multivariate logistic regression analysis and hepatic ACE2 immunoreactivity was an independent predicting factor of liver fibrosis [odds ratio (OR): 0.194; 95% confidence interval (CI): 0.082-0.897, P=0.036]. CONCLUSION: Hepatic immunoreactivity of ACE2 was inversely correlated with the liver fibrosis among biopsy proven NASH patients and it was also an independent predicting factor of advanced fibrosis.

Angiotensin-converting enzyme for noninvasive assessment of liver fibrosis in autoimmune hepatitis.

BACKGROUND AND AIM: There are no validated noninvasive markers of liver fibrosis in autoimmune hepatitis (AIH). An activated renin-angiotensin system (RAS) and its key element angiotensin-converting enzyme (ACE) have been implicated in the pathogenesis of hepatic fibrogenesis. We aimed to study the assumed role of activated RAS in the fibrogenic process and whether the serum concentration of ACE can predict different fibrosis stages in AIH. PATIENTS AND METHODS: Serum samples of 73 consecutive patients who were diagnosed with AIH were analysed for ACE concentration. All patients underwent a liver biopsy. RESULTS: Serum ACE levels increased significantly for each fibrosis score. The median ACE was 45 U/l in patients with fibrosis score I, 54 U/l in patients with fibrosis score II, 68 U/l in patients with fibrosis score III and 87 U/l in patients with fibrosis score IV. For significant fibrosis (≤F2), a 56 U/l cut-off value of ACE had 95.5% sensitivity and 74.5% specificity, and receiver-operating characteristic curves showed an area under the curve (AUC) of 0.89. For advanced fibrosis (≤F3), a 64 U/l cut-off level of ACE had 85.2% sensitivity and 94.8% specificity, and AUC was 0.91. For cirrhosis, a 68 U/l cut-off level of ACE had 100% sensitivity and 84.4% specificity, and AUC was 0.95. CONCLUSION: Our results suggest that activated RAS may sustain hepatic fibrogenesis in AIH. Measurement of serum ACE offers an easy, accurate and inexpensive noninvasive method that differentiates significant from nonsignificant liver fibrosis in AIH. Blockade of RAS may exert beneficial effects on fibrosis progression in AIH.

Vitamin E treatment in patients with nonalcoholic steatohepatitis: A six-month, open-label study of sixteen patients.

BACKGROUND: Free radicals have a pivotal role in the pathogenesis of nonalcoholic steatohepatitis (NASH). Decreasing oxidative stress might have beneficial effects on the biochemical and histologic progression of this disease. OBJECTIVE: We aimed to determine the therapeutic effect of vitamin E, a potent antioxidant, on liver enzymes and histology in NASH. METHODS: This 6-month, open-label study was conducted at the Departments of Gastroenterology and Pathology, Gazi University School of Medicine (Ankara, Turkey). Patients aged 18 to 70 years with biopsy-proven NASH were included in the study. All patients received vitamin E 800 U/d in 2 divided doses, orally (capsules) for 6 months. Patients were not advised to change their exercise or dietary habits. Body mass index (BMI) was calculated at months 0 (baseline) and 6. Histologic scoring of steatosis, necroinflammatory grade, and fibrosis stage was performed at 0 and 6 months. Liver enzyme activities (alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase [ALP], and gamma-glutamyltransferase [GGT]) were monitored monthly. Control biopsy specimens were obtained at the end of the treatment. All of the liver biopsies were read by a single pathologist (G.A.) who was blinded to the clinical, laboratory, and histopathologic data, as well as the sequence of liver biopsies. Assessments of compliance and tolerability of treatment were performed using a pill count and patient interview, respectively, at the end of each month. RESULTS: Sixteen patients (12 men, 4 women; mean [SD] age, 45.5 [6.9] years [range, 37-60 years]) were enrolled. All patients completed 6 months of treatment. Mean BMI did not change significantly from baseline. Significant improvements in mean (SD) serum liver enzyme activities were observed at 6 months compared with baseline (ALT: 38.6 [16.3] U/L vs 84.8 [22.1] U/L, respectively, P = 0.001; AST: 29.8 [15.4] U/L vs 46.0 [16.0] U/L, respectively, P = 0.001; ALP: 154.6 [64.1] U/L vs 211.5 [70.4] U/L, respectively, P= 0.011; and GGT: 49.8 [38.5] U/L vs 64.7 [54.4] U/L, respectively, P = 0.002), as well as in total cholesterol level (176.2 [42.0] mg/dL vs 199.6 [60.6] mg/dL; P = 0.02). Posttreatment liver biopsy was available in 13 patients (81%). Significant improvements in the mean (SD) scores of steatosis (1.46 [0.66] vs 2.43 [0.62]; P = 0.002) and necroinflammatory grade (0.84 [0.24] vs 1.31 [0.51]; P= 0.006) were observed at 6 months compared with baseline, respectively. However, no significant change was noted in the mean (SD) score of fibrosis stage (0.77 [0.33] vs 1.12 [0.59], respectively). None of the patients reported any adverse effects. CONCLUSION: In this small, 6-month, open-label study, vitamin E treatment was safe and well tolerated and led to potential biochemical and histologic improvements (except in fibrosis) in patients with NASH.

The association between indirect bilirubin levels and liver fibrosis due to chronic hepatitis C virus infection.

We proposed to evaluate the association between serum indirect bilirubin levels and liver fibrosis in patients with chronic hepatitis C (CHC) genotype 1b. Biopsy proven CHC genotype 1b patients' demographics, clinical and histopathological characteristics were evaluated. Logistic regression analysis was done to evaluate the clinical, laboratory and demographic features of the histologically proven liver fibrosis in CHC patients. A total of 112 biopsy proven CHC genotype 1b patients were enrolled into the study. Liver fibrosis scores were measured by using Ishak fibrosis scores and were divided into two groups; fibrosis scores ≤ 2 were categorized as mild fibrosis, 82 patients (73.2%), whereas fibrosis scores >2 were categorized as advanced fibrosis group, 30 patients (26.8%). Patients with advanced fibrosis had lower indirect bilirubin levels than the mild fibrosis group (0.28 ± 0.02 mg/dl vs. 0.44 ± 0.032 mg/dl, p<0.001, respectively). Indirect bilirubin level was negatively correlated with advanced fibrosis scores (r=-0.416 and p<0.001). In multivariate logistic regression analysis, low indirect bilirubin level was an independent predicting factor of advanced liver fibrosis (OR: 0.001, 95% CI: 0.0-0.005, p<0.001). There is an inverse relationship between indirect bilirubin levels and advanced liver fibrosis caused by CHC genotype 1b.