Ultrasound Methods for the Assessment of Liver Steatosis: A Critical Appraisal.

The prevalence of the non-alcoholic fatty liver disease has reached major proportions, being estimated to affect one-quarter of the global population. The reference techniques, which include liver biopsy and the magnetic resonance imaging proton density fat fraction, have objective practical and financial limitations to their routine use in the detection and quantification of liver steatosis. Therefore, there has been a rising necessity for the development of new inexpensive, widely applicable and reliable non-invasive diagnostic tools. The controlled attenuation parameter has been considered the point-of-care technique for the assessment of liver steatosis for a long period of time. Recently, many ultrasound (US) system manufacturers have developed proprietary software solutions for the quantification of liver steatosis. Some of these methods have already been extensively tested with very good performance results reported, while others are still under evaluation. This manuscript reviews the currently available US-based methods for diagnosing and grading liver steatosis, including their classification and performance results, with an appraisal of the importance of this armamentarium in daily clinical practice.

Assessment of clinically significant portal hypertension by two-dimensional shear wave elastography.

BACKGROUND AND AIMS: To evaluate two-dimensional shear wave elastography (2DSWE) in parallel with transient elastography (TE) for diagnosing clinically significant portal hypertension (CSPH) and high-risk varices (HRV) in patients with chronic liver disease. PATIENTS AND METHODS: Consecutive patients with suspicion of compensated advanced chronic liver disease (cACLD) [liver stiffness measurement (LSM) ≥ 10 kPa by TE, or morphological signs suggestive of cACLD on imaging], with no history of liver decompensation, underwent hepatic venous pressure gradient (HVPG) measurement, transjugular liver biopsy and esophagogastroduodenoscopy, which served as the reference methods for diagnosing CSPH, cACLD and HRV. All patients underwent LSM and spleen stiffness measurements (SSM) by 2DSWE and TE. RESULTS: Seventy-six (76) patients were included (78% men, mean age 62 years, body mass index 28.3 kg/m2 , 36.8% alcoholic, 30.3% non-alcoholic fatty liver disease, 14.5% viral hepatitis). Of them, 80.3%, 69.7%, 52.6% and 22.4% had cACLD, cirrhosis, CSPH and HRV respectively. LSM performed better than SSM in diagnosing CSPH and HRV. For CSPH, AUROCs (0.926 vs. 0.866), optimal cut-offs (20.1 vs. 20.2 kPa) and sensitivity/specificity (80.5%/94.3% vs. 77.5% /86.1%) were comparable for 2DSWE and TE. Ruling-out of CSPH by 2DSWE (LSM at cut-off with ≥90% sensitivity (13.5 kPa) and platelets ≥ 150 x 109 /L) performed comparably to TE, with 1/24 cases falsely classified as negative. For HRV, AUROCs were similar (0.875 2DSWE, 0.851 TE) with similar optimal LSM cut-offs enabling 100% sensitivity and ruling-out HRV. CONCLUSION: Liver stiffness measurement by 2DSWE appears to perform equally well as TE for diagnosing CSPH and ruling-out HRV in compensated chronic liver disease.

Assessment of Steatosis and Fibrosis in Liver Transplant Recipients Using Controlled Attenuation Parameter and Liver Stiffness Measurements.

Aim: The primary objective of this study was to evaluate the prevalence of increased controlled attenuation parameter (CAP) and liver stiffness measurements (LSM) as surrogate markers of liver steatosis and fibrosis in liver transplant recipient (LTR). Secondary objectives were to determine the predictors of increased CAP and LSM in population of LTR. Methods: In this prospective, cross-sectional study, we have evaluated 175 LTRs' mean age as 61 (53-65) with a functioning graft for more than one year who came for regular outpatient examinations to the Department of Gastroenterology, University Hospital (UH) Merkur, Zagreb, Croatia. Results: Of 175 analyzed LTRs, 34.28% had obesity, 64.00% had hypertension, 38.28% had diabetes, and 58.85% had hyperlipidemia. The prevalence of liver steatosis was 68.57%, while the prevalence of severe liver steatosis was 46.85%. On multivariate analysis, independent factors associated with liver steatosis were male gender, total cholesterol as positive predictor, and HDL as negative predictor, and independent factors positively associated with severe liver steatosis were higher body mass index (BMI) and higher triglyceride levels. The prevalence of moderate liver fibrosis was 54.85%, while the prevalence of advanced liver fibrosis was 24%. On multivariate analysis, independent factors positively associated with moderate fibrosis were gamma-glutamyl transferase (GGT) and CAP, while the independent factor positively associated with advanced fibrosis was GGT. Conclusion: Our study showed high prevalence of increased CAP and LSM measurements as surrogate markers of liver steatosis and fibrosis. Metabolic syndrome components were highly present and were associated with CAP and LSM values as well as in the pretransplant setting. Due to high prevalence of metabolic comorbidities and nonalcoholic fatty liver disease in LTRs and the lack of the abnormal liver test in a significant number of these patients, TE with CAP may be a reasonable initial assessment for LTRs with one or more components of the metabolic syndrome.

Young GI Societies in Europe: 2019 update.

BACKGROUND: One of the aims of the Young Talent Group (YTG) is to make United European Gastroenterology (UEG) more attractive to young fellows interested in gastroenterology (GI), and to actively involve them in UEG activities and the activities of their respective national societies. In 2017, we conducted a survey among the Friends of the UEG YTG with the aim of identifying the state of organization and needs of Young GI Sections (YGISs) throughout Europe, highlighting areas for further development and improvement. AIMS: The aim of the current web-based survey was to assess the progress of YGISs over 1 year, and persisting hurdles in forming and running a YGIS. RESULTS: Overall, 38 of 42 Friends answered the survey (91%). The number of YGISs has increased significantly from 12 in 2017 to 25 in 2019. Young gastroenterologists remained supported, but not influenced, by national societies. Results of the survey suggest that a lack of dedicated and motivated fellows has replaced a lack of funding as the most prevalent hurdle in forming these types of sections. CONCLUSION: Our survey shows that the development of YGISs has improved markedly within the last 2 years. However, several limitations, like underrepresentation in subcommittees of national societies, remain and need to be addressed in order to involve young gastroenterologists in their respective national societies and within UEG, to pave the way for future research, education and excellent quality of care, and reduce health inequalities across Europe.

Transient elastography (FibroScan(®)) with controlled attenuation parameter in the assessment of liver steatosis and fibrosis in patients with nonalcoholic fatty liver disease - Where do we stand?

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide. Currently, the routinely used modalities are unable to adequately determine the levels of steatosis and fibrosis (laboratory tests and ultrasonography) or cannot be applied as a screening procedure (liver biopsy). Among the non-invasive tests, transient elastography (FibroScan(®), TE) with controlled attenuation parameter (CAP) has demonstrated good accuracy in quantifying the levels of liver steatosis and fibrosis in patients with NAFLD, the factors associated with the diagnosis and NAFLD progression. The method is fast, reliable and reproducible, with good intra- and interobserver levels of agreement, thus allowing for population-wide screening and disease follow-up. The initial inability of the procedure to accurately determine fibrosis and steatosis in obese patients has been addressed with the development of the obese-specific XL probe. TE with CAP is a viable alternative to ultrasonography, both as an initial assessment and during follow-up of patients with NAFLD. Its ability to exclude patients with advanced fibrosis may be used to identify low-risk NAFLD patients in whom liver biopsy is not needed, therefore reducing the risk of complications and the financial costs.

[Assessment of nutritional status in patients with chronic kidney disease on maintance hemodialysis]. / Procjena nutricijskog statusa u bolesnika s kronicnom bubreznom bolesti koji se lijece redovitom hemodijalizom.

INTRODUCTION: It is well established that nutritional status is an important factor affecting the outcome and recovery from disease or injury. Assessment of nutritional status is an integral part of care for patients with chronic kidney disease, especially for those treated with dialysis procedures. According to available literature, 18%-80% of patients on dialysis have some form of nutritional deficiency. Furthermore, in patients treated with dialysis procedures there is a rule called 'reverse epidemiology', according which patients with better nutritional status have better survival rate. Therefore, nutritional assessment should detect malnutrition and rate the overall nutritional status of each patient through clinical data categories: medical history, physical examination, nutrition physical examination, psychosocial history, demographics, physical activity, and current medical/surgical issues. Consequently, the main aim of our study was to analyze the nutritional status of our patients treated with hemodialysis procedures. Another aim was to analyze the applicability of measuring skinfold by caliper as a method of nutritional status assessment. SUBJECTS AND METHODS: During a six-month period, we analyzed 129 patients (57.4% of men and 42.6% of women), mean age 68.1 ± 12.4 years, treated with hemodialysis procedures (24.8% of patients were treated with online hemodiafiltration and 75.2% with standard, conventional hemodialysis) as the method of choice of renal replacement therapy (RRT) for more than 6 months. All patients were dialyzed three times a week for four hours on biocompatible synthetic membranes. The patients treated with online hemodiafiltration were dialyzed on high-flux helixone membranes, while those treated with standard, conventional hemodialysis were dialyzed on polysulfone membranes and helixone low-flux membranes. The mean time of RRT was 71.2 ± 56.7 months. During the study period, in each patient we followed medical history, and clinical and laboratory parameters of nutritional status at 3 and 6 months. To assess the nutritional status, we used dry weight (DW), body mass index (BMI), skinfold caliper measurement (result is correlated with total body fat, FAT), and common laboratory indicators of nutritional status (serum albumin and cholesterol). RE- SULTS: Analyzing the efficiency of skinfold thickness measurement with caliper, we found that the FAT obtained by caliper showed a statistically significant positive correlation with clinical indicators of nutritional status, and with BMI (r = 0.364, p < 0.0001), DW (r = 0.206, p = 0.005) and volume of muscle circumference (r = 0.399, p < 0.0001). Also, FAT showed statistically significant positive correlation with laboratory indicators of nutritional status, including serum albumin (r = 0.299, p = 0.01) and cholesterol (r = 0.225, p = 0.002). There was no statistically significant correlation between the duration of RRT and FAT (p = NS). CONCLUSION: In clinical practice, as well as for regular evaluation of nutritional status, it is important that the method we used proved efficient, precise, relatively fast and posing less economic burden. From our experience, the measurement of skinfold with caliper is an applicable, relatively quick and inexpensive method for regular assessment of nutritional status in patients treated with hemodialysis proce- dures. Therefore, all patients treated with RRT should undergo nutritional screening and expert help should be available from dietitians or nutritional support teams in order to identify this problem properly in its early stage and to reduce its high prevalence.

BCM--body composition monitor: a new tool for the assessment of volume-dependent hypertension in patients on maintenance haemodialysis.

Hypertension is a common finding in end-stage renal disease patients with the prevalence between 20 to 85%. Although the etiology of arterial hypertension (AH) in this patient group is multifactorial, sodium and volume excess leading to extracellular volume overload are one of the most important and potentially adjustable causes. Control of volume status can either normalize the blood pressure (BP) or make the AH easier to control in the great majority of dialysis patients. Heavy reliance is placed on the dialysis procedure to gradually remove fluid over a period of days to weeks until a stable dry weight is achieved. Numerous attempts have been made to utilize alternative methods to more accurately assessment of dry weight, and the newest and most interesting method is multifrequency bioelectrical impedance spectroscopy (BIS). In this prospective study we used BIS in 65 haemodialysis (HD) patients in order to detect those with volume-dependent hypertension and to further investigate the role of dry weight management in BP control. Dry weight was corrected at the beginning, and after 1, and 3 months. Final data were collected after six months. Our data showed that assessment of fluid overload using BIS provides better management of fluid status and BP control in the patients on maintenance HD, and that dry weight correction can lead to significantly better control of volume-dependent hypertension in this patient group.