Prospective evaluation of non-alcoholic fatty liver disease by elastographic methods of liver steatosis and fibrosis; controlled attenuation parameter and liver stiffness measurements.

AIMS: To examine the temporal changes of both controlled attenuation parameter (CAP) and liver stiffness measurements (LSM), assessed by Fibroscan, in a large sample of patients with non-alcoholic fatty liver disease (NAFLD). METHODS: In this prospective, observational study, we consecutively enrolled 507 adult individuals with Fibroscan-defined NAFLD who were followed for a mean period of 21.2 ±â€¯11.7 months. RESULTS: During the follow-up period, 84 patients (16.5%) had a progression of CAP of at least 20% with a median time of 39.93 months, while 201 (39.6%) patients had a progression of LSM of at least 20% with median time of 30.46 months. There were significant differences in the proportion of LSM progression across body mass index (BMI) categories, with obese patients having the highest risk of progression over the follow-up (hazard ratio 1.66; 95%CI 1.23-2.25). Multivariable regression analysis showed that BMI and serum creatinine levels were the strongest predictors for CAP progression in the whole population, while HOMA-estimated insulin resistance was an independent predictor of LSM progression over time in the subgroup of obese patients. CONCLUSION: This prospective study shows for the first time that the progression risk of both liver steatosis and fibrosis, detected non-invasively by Fibroscan, is relevant and shares essentially the same metabolic risk factors that are associated with NAFLD progression detected by other invasive methods.

Non-alcoholic fatty liver disease and colorectal cancer.

As a significant cause of cancer death worldwide, colorectal cancer (CRC) is still one of the most common cancers in the world. The most efficient strategies to reduce CRC incidence include identifying risk factors for CRC and performing a preventive colonoscopy in high-risk populations. Some well-established risk factors for CRC development include hereditary syndromes and inflammatory bowel disease. Of note, in recent years, attention has been given to new evidence indicating that more than 75%-95% of CRC occurs in individuals with little or no genetic risk. For these individuals, the risk for CRC is associated with their lifestyle and dietary factors, including central obesity, overweight and physical inactivity. Recently, evidence demonstrated a connection between non-alcoholic fatty liver disease (NAFLD) and CRC. Insulin resistance and metabolic syndrome (MetS) are common risks that NAFLD and colorectal neoplasms share. The incidence of NAFLD is increasing in parallel with an increasing prevalence of MetS and obesity. Consequently, the question arises: will the incidence of CRC increase together with this dramatic increase in obesity, MetS and ultimately NAFLD prevalence? Recent studies of adenomatous polyps, CRC and NAFLD are discussed in this manuscript.

Nonalcoholic fatty liver and the severity of acute pancreatitis.

AIM: To explore the effect of nonalcoholic fatty liver as a hepatic manifestation of metabolic syndrome on the severity of acute pancreatitis. We hypothesized that patients with nonalcoholic fatty liver would have a more severe form of acute pancreatitis. PATIENTS AND METHODS: We retrospectively analyzed 822 patients hospitalized with acute pancreatitis. We diagnosed acute pancreatitis and determined its severity according the revised Atlanta classification criteria from 2012. We assessed nonalcoholic fatty liver with computed tomography. RESULTS: There were 198 (24.1%) patients out of 822 analyzed who had nonalcoholic fatty liver. Patients with nonalcoholic fatty liver had statistically higher incidence of moderately severe (35.4% vs. 14.6%; p=0.02) and severe acute pancreatitis (20.7% vs. 9.6%; p<0.001) compared to patients without nonalcoholic fatty liver. At the admission patients with nonalcoholic fatty liver had higher values of C-reactive protein as well as at day three, higher APACHE II score at admission and significantly higher incidence of organ failure and local complications as well as higher values of computed tomography severity index compared to patients without nonalcoholic fatty liver. We found independent association between the occurrence of moderately severe and severe acute pancreatitis and nonalcoholic fatty liver (OR 2.13, 95%CI 1.236-3.689). Compared to patients without nonalcoholic fatty liver, patients with nonalcoholic fatty liver had a higher death rate, however not statistically significant (5.6% vs. 4.3%; p=NS). CONCLUSION: Presence of nonalcoholic fatty liver at admission can indicate a higher risk for developing more severe forms of acute pancreatitis and could be used as an additional prognostic tool.

Metabolic syndrome and acute pancreatitis.

AIM: The aim of our study was to investigate the influence of metabolic syndrome on the course of acute pancreatitis determined by disease severity, the presence of local and systemic complications and survival rate. PATIENTS AND METHODS: 609 patients admitted to our hospital in the period from January 1, 2008 up to June 31, 2015 with the diagnosis of acute pancreatitis were analyzed. The diagnosis and the severity of acute pancreatitis were made according to the revised Atlanta classification criteria from 2012. RESULTS: Of 609 patients with acute pancreatitis, 110 fulfilled the criteria for metabolic syndrome. Patients with metabolic syndrome had statistically significantly higher incidence of moderately severe (38.2% vs. 28.5%; p=0.05) and severe (22.7% vs. 12.8%; p=0.01) acute pancreatitis in comparison to those without metabolic syndrome, while patients without metabolic syndrome had higher incidence of mild acute pancreatitis in comparison to those patients with metabolic syndrome (58.7% vs. 39.1%; p<0.001). Patients with metabolic syndrome had a higher number of local and systemic complications, and higher APACHE II score in comparison to patients without metabolic syndrome. In multivariable logistic regression analysis, the presence of metabolic syndrome was independently associated with moderately severe and severe acute pancreatitis. Comparing survival rates, patients suffering from metabolic syndrome had a higher death rate compared to patients without metabolic syndrome (16% vs. 4.5%; p<0.001). CONCLUSION: The presence of metabolic syndrome at admission portends a higher risk of moderately severe and severe acute pancreatitis, as well as higher mortality rate.

Is there a relationship between hypomagnesemia and proton-pump inhibitors in patients on chronic hemodialysis?

AIM: We investigated the association among long-term proton-pump inhibitors (PPIs) use with serum magnesium (Mg) levels in chronic hemodialysis (HD) patients, as well as possible association among PPI use and increased risk of cardiovascular (CVD) morbidity in HD patients. METHODS: Of 418 HD patients that were screened for inclusion, 136 were excluded due to incomplete medical data, duration of renal replacement therapy (RRT) for less than 12months, use of Mg-based-phosphate binders or other Mg-based medications or either to presence of chronic increased GI losses. Among 282 patients included in the study, 170 patients were on PPIs. RESULTS: Serum Mg levels were significantly lower among PPI users vs. non-users (0.94±0.2 vs. 1.03±0.2mmol/L; p<0.0001). The median duration of PPI use was 27±9.6months (range from 12 to 108) and it was not significantly associated with Mg levels (r=0.116; p=0.167). Additionally, residual renal function didn't show a significant correlation with Mg concentration (r=-0.102; p=NS) in both groups of patients. The use of PPIs was an independent and strong predictor of low Mg concentrations even in multivariate analysis (OR 3.05; 95% CI 1.2498-7.4594, p=0.01). On the other hand, the daily dose of PPIs was not associated with low Mg levels. PPI users had a higher rate of adverse CVD events during the 1 year of follow-up in comparison to non-PPI users but that difference wasn't statistically significant (17.6% vs. 10.7%; p=0.110). CONCLUSION: We have found a significant association between PPI use and lower serum Mg levels in chronic HD patients.

Body mass index: short- and long-term impact on kidney transplantation.

AIM: The topic of pretransplantation body mass index (BMI) is still a matter of controversy. The aim of this study was to investigate the influence of pretransplant BMI on short- and long-term outcomes in patients receiving kidney transplant. METHODS: We have analysed 521 renal transplant recipients (RTRs). BMI was categorised as follows: less than or equal to 20, more than 20 to less than or equal to 25, more than 25 to less than or equal to 30 and more than 30 RESULTS: The distribution of the RTRs per category of BMI at baseline was: ≤ 20 (14.4%), > 20 to ≤ 25 (50.9%), > 25 ≤ 30 (26.9%) and > 30 (7.9%). In further analysis, the patients were stratified into four groups according to their pretransplant BMI values. There was no difference in the rates of delayed graft function between the four analysed groups of patients. Recipients with normal pre-transplant BMI were less likely to develop wound complications in comparison to the recipients with high BMI (p = 0.04) and obese recipients (p = 0.0001). RTRs with normal BMI were less likely to develop lymphoceles in comparison to the recipients with high BMI (p = 0.0003). Obese patients were more likely to develop lymphocele in comparison to the recipients with high BMI (p = 0.01). Obese recipients had a longer mean length of hospital stay in comparison to the recipients with normal BMI (p = 0.04). There was no significant difference regarding 1-year graft and patient survival, as well as because of acute rejection crisis between the investigated groups of recipients. We did not find any significant difference in 5-year patients and graft survival between those RTRs with BMI > 20 to ≤ 25 and to those recipients with BMI > 25. CONCLUSION: Overweight and obese transplant candidates should not be excluded from kidney transplantation.

Outcomes following renal transplantation in older renal transplant recipients: a single-center experience and "Croatian senior program".

BACKGROUND/OBJECTIVE: Outcomes of kidney transplantation in older patients have not, however, been fully defined. The aims of this study were to analyze the number of new end-stage renal disease (ESRD) patients ≥65 years of age who were managed with kidney transplantation and their survival through the study period. In addition, we have analyzed post-transplantation outcomes in younger and older renal transplant recipients (RTRs). METHODS: We have analyzed the mean age of 505 RTRs transplanted between January 1990 and December 2013. Older people were defined as aging 65 years or older. Of 505 RTRs, there were 73 (14.5 %) patients who were ≥65 years of age. Therefore, in further analysis, patients were divided into two subgroups: younger recipients (younger than 65 years) and older recipients (aging 65 years or older). RESULTS: In the period from 1990 to 2001, patients who were 65 years of age and older were only sporadically treated with kidney transplantation in Croatia. Since 2002, the number of patients older than 65 years undergoing renal transplantation has been increasing. The older recipients were more likely to receive organs from older donors (52.6 ± 16.8 vs. 45.8 ± 13.2; p = 0.0001). There were no significant differences due to HLA mismatch between the two groups of analyzed patients. There was no difference in the rates of DGF between the older and younger recipients. Older recipients were less likely than younger recipients to have acute rejection crisis during the first-ear after transplantation (16.4 vs. 34.7 %; p = 0.03). There were no significant differences due to readmission rates in the first-year post-transplantation between the two groups. There was no significant difference due to graft function and 1-year graft and patient's survival between young and older recipients. Serum creatinine values at 1 year were higher in older recipients who received kidneys from elderly donor. CONCLUSION: Our experience supports the use of kidney transplantation in the population of older ESRD patients. We can increase patients and graft survivals in elderly individuals with careful pre-transplant evaluation and HLA matching. "Croatian senior program" that includes HLA matching represents a good approach for kidney transplantation in older ESRD patients.