Is mean platelet volume a simple marker of non-alcoholic fatty liver disease?

BACKGROUND: Due to the increasing prevalence of non-alcoholic fatty liver disease (NAFLD), there was a need to establish non-invasive tests for its detection. Mean platelet volume (MPV) is an inexpensive, practical and easily accessible marker of inflammation in many disorders. Our study was aimed at investigating the relationship between MPV and both NAFLD and liver histology. METHODS: Total 290 patients with biopsy-proven NAFLD (n = 124) and 108 control patients were included in the study. To exclude the effect of other diseases on MPV, we included 156 patient controls in our study. Those whohave liver-related diseases and those who use drugs that may cause fatty liver were not included in the study. Liver biopsy was performed for those whose alanine aminotransferase level persisted for >6 months above the upper limits. RESULTS/CONCLUSION: We found that MPV was significantly higher in the NAFLD group compared with the control group, and MPV had an independent predictive value for the development of NAFLD. We determined that the number of platelets was significantly lower in the NAFLD group compared with that in the control group. We compared MPV values histologically with both stage and grade in all patients with biopsy-proven NAFLD and found that MPV had a significant positive correlation with stage. We observed a positive correlation between MPV and non-alcoholic steatohepatitis grade, but this was not statistically significant. MPV can be useful because it is simple, easy to measure, cost-effective, and routinely tested in daily practice. MPV can be used as a simple marker of NAFLD and an indicator of fibrosis-stage in NAFLD.

Artificial intelligence model with deep learning in nonalcoholic fatty liver disease diagnosis: genetic based artificial neural networks.

Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of chronic liver disease in the world. The NAFLD spectrum includes simple steatosis, steatohepatitis, fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). Genetic, nutritional factors, obesity, insulin resistance, gut microbiota are among the risk factors for NAFLD. The genetic variant Patatin-like phospholipase domain-containing protein 3 (PNPLA3) plays an important role in the development of a number of liver diseases ranging from steatosis, chronic hepatitis, cirrhosis and HCC. Due to the increase in the prevalence of NAFLD, new models are being developed with machine learning, deep learning, artificial neural network (ANN) algorithms in the field of artificial intelligence (AI) to determine low-cost, noninvasive diagnostic methods. Models developed with ANN from AI modules are important in order to examine biochemical and genomic information in detail in the diagnosis of NAFLD. The aim of this study is to develop a simple ANN model using biochemical and genotypic parameters in the diagnosis of NAFLD. A total of 300 patients followed up with the diagnosis of NAFLD and 100 controls were included in the study. The data set was divided into two as training and test set. Genotyping of PNPLA3 (CC, CG, GG) as genomic analysis was performed with real time PCR device. The algorithm used for the diagnosis of NAFLD was designed using age, body mass index (BMI), mean platelet volume (MPV), insulin resistance (IR), alanine aminotransferase (ALT), genotype PNPLA3 (CC, CG, GG) parameters. MLP Classifier algorithm from ANN was used in the development of the model. ANN algorithms are used in python programming language. Statistical analyzes were made in SPSS program. Percent accuracy, area under the ROC curve, confusion matrix, Positive (PPV) and Negative Predicted Value (NPV) values, precision, recall, and f1-score results were determined. The accuracy percentage was determined as 0.979 in the train set and 0.970 in the test set. The Log Loss value was set to 0.09. The developed neural network achieved an accuracy percentage of 97.0% during testing, with an area under the ROC curve value of 0.95. We think that the ANN model developed with genomic and biochemical parameters can be used as a cost-effective, noninvasive new predictive diagnostic model in clinical practice in the diagnosis of NAFLD.

Prognostic factors of elderly patients with hepatocellular carcinoma: should we be more courageous in treatment?

OBJECTIVES: Hepatocellular carcinoma (HCC) is a cancer with a poor prognosis, its incidence increases with age. The risk of developing HCC is highest in the seventh decade. In this study, we aimed to determine the clinicopathological differences, treatment choices, survival times, and effective prognostic factors of HCC in the elderly and young populations. METHODS: All patients aged ≥18 years who were diagnosed histologically between 2016 and 2020 were included in the study. Patients were divided into two groups: <70 years and ≥70 years. The clinicopathological differences, treatment choices, survival times, and effective prognostic factors of HCC were compared in the elderly and young populations. RESULTS: A total of 407 patients were evaluated. There were 164 patients (40.3%) in the geriatric age group. There was no significant difference in the female/male ratio, the laboratory values, survival time between the two groups. There was no significant difference between the two groups in terms of tumor focality and portal vein invasion ( P > 0.05). The presence of NAFLD, maximal tumor diameter (MTD), and portal invasion were found to be significant for survival according to the univariate analysis in elderly group ( P < 0.05). In the multivariate analysis, presence of NAFLD etiologically, and MTD independent risk factors were observed in elderly group ( P < 0.05). CONCLUSION: If the clinicomorphological features of the tumor and prognostic risk factors can be determined by examining the patients in detail, all treatments can be easily applied in the geriatric group.

Metagenomic identification of gut microbiota distribution on the colonic mucosal biopsy samples in patients with non-alcoholic fatty liver disease.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is known to be the most common liver disease in the world, and there are currently no approved pharmacological treatments to prevent or treat this condition. In addition to being associated with an increased risk of hepatocellular carcinoma and cirrhosis, NAFLD has now become the leading cause of liver failure-associated transplantation. The 16S rRNA gene which conserved regions can serve as universal primer binding sites for PCR amplification of gene fragments, while hypervariable regions contain significant sequence diversity useful for prokaryotic identification purposes. 16S rRNA gene sequences can be use by researchers to identify prokaryotic taxonomy found in clinical samples. As a result of increasing microbiota studies with developing technological developments, the role of intestinal microbiota in the pathogenesis of NAFLD is revealed in an important way. In this study, it was aimed to determine the clinical prognostic importance of gut microbiota in the pathogenesis of NAFLD and to determine the microbial composition with intestinal mucosal biopsy samples in NAFLD patients. MATERIAL AND METHOD: We included 20 patients diagnosed with NAFLD as a result of liver function tests, histological, ultrasonographic, biopsy evidence and 20 normal control groups created under exclusion criteria in this study. The healthy control group of the same age and gender as the patients were determined to be equal, and the age, gender, BMI, insulin resistance, AST, ALT levels of the individuals were recorded for analysis. Intestinal mucosal biopsy samples were taken from the individuals included in the study under sterile conditions. Microbial results were obtained as a result of 16S rRNA amplicon metagenomic processes. The region of approximately 1500 bp covering the V1-V9 region of the 16S rRNA gene was targeted to detect microbial diversity. The amplified regions were sequenced using next-generation sequencing. Operational Taxonomic Unit (OTU) value was obtained with bioinformatics software with the obtained sequence data. The analysis of the recorded parameters was done with the SPSS.19 statistical program. RESULTS: In the designed study, 16 phyla, 28 class, 56 order, 128 family, 415 genera, 1041 species microorganisms were analyzed taxonomically in a total of 40 individuals. In our study, Intestinal microbial diversity is lower in NAFLD patients compared to control group individuals. In addition, gram-negative bacteria were found to be more dominant in NAFLD patients. As a phylum, Proteobacteria increased in NAFLD group, Bacteroidetes and Actinobacteria in control group, while Firmicutes had equal distribution in both groups. BMI OR = 6.37, 95 %CI (0.39-0.40) p value was 0.001 in laboratory data, whereas Proteobacteria OR = 1.754, 95% CI (0.901-3.416), p value 0.05 in microbial profile. CONCLUSION: The 16S rRNA metagenomic study of intestinal microbiota using colonic mucosal biopsy samples in NAFLD disease was the first study in the Turkish population, and important data were obtained for other studies. In the data obtained, we think Proteobacteria, Ruminococcaceae, Escherichia coli and Bacilli are very important in both diagnostic and treatment options as a microbial profile in NAFLD.

Paraneoplastic syndrome frequency and prognostic effect in hepatocellular carcinoma patients.

OBJECTIVE: Symptomatic hepatocellular carcinoma (HCC) patients may generally display constitutional symptoms such as abdominal pain, weight loss, anorexia and localized mass, or atypical clinical features of paraneoplastic syndrome (PNS) such as hypercholesterolemia, hypercalcemia, hypoglycemia, erythrocytosis and thrombocytosis. The most common PNS in HCC is hypercholesterolemia, hypercalcemia, hypoglycemia and erythrocytosis. The aim of this study isto evaluate the relationship of PNS in HCC patients. MATERIAL AND METHOD: In this study, the data of 534 patients who were followed up with the diagnosis of HCC between January 2010 and December 2020 in the Gastroenterology clinic were evaluated retrospectively. Clinical data, age, gender, complete blood count of patients with and without PNS, liver biochemistry, alpha-fetoprotein (AFP) level, hepatitis B surface antigen, anti-hepatitis B virus, Child-Pugh score, model for end-stage liver disease score, tumor volume, portal vein thrombosis, liver biopsy histology and radiologic images were taken from the hospital data system and analyzed. RESULTS: Out of the 534 HCC patients, 120 (22.3%) were PNS-positive patients. There was a significant difference between the ages of PNS-positive and PNS-negative patients, and PNS-positive patients were older (64.60±12.97) (P=0.02). PNS-positive HCC was determined as hypoglycemia 5.8%, hypercalcemia 6.3%, erythrocytosis 3.9%, hypercholesterolemia 2.4% and thrombocytosis 3.9%. AFP level (22908 ± 60 ng/ml) and tumor diameter (>10 cm) were higher in the PNS-positive group. Multivariate analysis showed that stage C according to Child-Pugh score and tumor diameter >10 cm were independent predictors of poor prognosis, whereas PNS erythrocytosis and thrombocytosis were independent predictors of better prognosis. CONCLUSION: In PNS-positive HCC patients, hypoglycemia and hypercalcemia were associated with poor prognosis according to Child-Pugh score, whereas erythrocytosis and thrombocytosis were associated with good prognosis.

Prognostic Value of International Normalized Ratio-to-Albumin Ratio and Ferritin Level in Chronic Liver Patients with Hepatocellular Carcinoma.

OBJECTIVE: Hepatocellular carcinoma (HCC) is the sixth among the most common cancers and the fourth among cancer-related causes of death in the world. In the evaluation of liver function in HCC patients, parameters such as albumin-bilirubin, prothrombin time-international normalized ratio (PT-INR) to albumin ratio (PTAR) are used among new methods other than Child-Pugh and MELD scores. Biomarkers are widely used in clinical practice in cases such as diagnosing various diseases, evaluating treatment response and predicting prognosis. We aimed to evaluate the prognostic role of serum ferritin and INR/albumin ratio in patients with chronic liver disease who develop HCC. METHODS: This retrospective study included 534 patients who were followed up with the diagnosis of HCC between 2009 and 2020. The patients with HCC etiology were evaluated in 3 groups (chronic hepatitis B group, chronic hepatitis C group, and other group). When comparing serum ferritin level and prothromin time-international normalized ratio to albumin ratio with Child Pugh score (CTP) in chronic liver patients with HCC, liver functional reserve and its role in predicting prognosis were investigated. RESULTS: The serum ferritin level was 226 ± 334 in the CTP A group, 239 ± 302 in the CTP B group, and 678 ± 966 in the CTP C group, and the p value was 0.001. The PTAR CTP group was 0.35 ± 0.10, the CTP B group was 0.50 ± 0.26, the CTP C group was 1.18 ± 6.01, and the p value was 0.001. Multivariant analysis results showed that ferritin hazard ratio is 1.00, 95% CI 0.99-1.00, and p value was 0.09, and PTAR hazard ratio is 1.38, 95% CI 2.37-8.00, and p value was 0.49. The etiological distribution of HCC was determined as HBV (61.6%), HCV (19.9%), and other etiologies (18.5%). Significant values were determined for age, gender, glucose, GGT, T. cholesterol, and tumor diameter parameters according to etiological distribution. CONCLUSIONS: Serum ferritin level and PTAR score increased in proportion to the severity of liver disease and were associated with poor prognosis. We think that high serum ferritin and PTAR score is a prognostic biomarker in predicting the synthesis function of the liver and mortality in critically ill patients with cirrhosis.

The influence of RS738409 I148M polymorphism of patatin-like phospholipase domain containing 3 gene on the susceptibility of non-alcoholic fatty liver disease.

ABSTRACT: We aimed to elucidate the frequency of polymorphic genotypes and alleles of patatin-like phospholipase domain containing 3 rs738409 polymorphism and its possible associations with non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis in a cohort from Turkey.We enrolled 200 patients diagnosed with NAFLD and genotyped for rs738409 I148M polymorphism by real-time polymerase chain reaction, particularly by melting curve analysis. SPSS analysis software was used for statistical significance. Continuous variable values were expressed as mean ±â€Šstandard deviation. Significant statistical level was chosen as p  = 0.05.Our results demonstrate in a cohort from Turkey that rs738409 C > G polymorphism (I148M) of patatin-like phospholipase domain containing 3 gene is significantly able to affect individuals to have NAFLD in unadjusted regression model.Consistent with the previous studies in other populations, our study group showed a significantly higher risk of having NAFLD in unadjusted regression model but not in the adjusted model indicating that non-genetic factors such as age and sex may be responsible for the association. However, independent studies need to validate our findings with a larger group of NAFLD patients, as well as in different ethnic cohorts.

Serum levels of inflammatory markers CRP, ESR and albumin in relation to survival for patients with hepatocellular carcinoma.

INTRODUCTION: Hepatocellular carcinoma is associated with several chronic inflammatory conditions. It is increasingly understood that the inflammation may be part of the carcinogenic process and prognostically important. OBJECTIVE: To evaluate the serum levels of three inflammation markers in relation to survival in HCC patients. METHODS: We retrospectively examined the serum levels of CRP, albumin and ESR, both singly and in combination, in relation to patient survival. RESULTS: Survival worsened with increase in CRP or ESR or decrease in albumin levels. Combinations of CRP plus albumin or CRP plus ESR were associated with an even greater range of survival (3-fold), together with significant differences in maximum tumor diameter (PVT) and percent of patients with portal vein thrombosis (PVT). The triplet of CRP plus albumin plus ESR was associated with a sevenfold difference in survival, comparing low vs high parameter levels. These significant differences were found in patients with small or large tumors. CONCLUSIONS: Combinations of CRP with albumin or ESR or all three parameters together significantly related to differences in survival and to differences in MTD and percent PVT, in patients with both small and large size HCCs.

The effect of PNPLA3 polymorphism as gain in function mutation in the pathogenesis of non-alcoholic fatty liver disease.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is often associated with metabolic syndrome (type 2 diabetes, hypertension, hypertriglyceridemia, insulin resistance, and obesity). NAFLD is multi-factorial in pathogenesis with some genetic predisposition. The variant patatin-like phospholipase domain-containing protein 3 (PNPLA3) is known to be an independent risk factor for hepatocellular cancer (HCC). The aim of this study was to investigate the role of PNPLA3 polymorphism as the risk factor for NAFLD. METHODOLOGY: Patients had histological, ultrasonographic, biopsy evidence of NAFLD (n=248) and 81 controls were studied for PNPLA3 polymorphism. PNPLA3 genotyping was done from peripheral blood DNA by real-time polymerase chain reaction (RT-PCR). RESULTS: PNPLA3 genotyping of the groups NAFLD (CC [n = 76], CG [n = 83], GG [n = 89]) and control (CC [n= 42], CG [n = 22], GG [n = 17]) was determined. In the patient group, the G allele was 261 (52.63%) and the C allele was 235 (47.37%), whereas in the control group, the G allele was 56 (34.54%) and the C allele was 106 (65.43%). In our study, 53 out of 174 women had GG allele and 54 out of 155 men had GG allele. CONCLUSION: The findings suggest that there is a predominant relationship between men with PNPLA3 I148M variant with NAFLD in women. Patients with NAFLD carrying PNPLA3 rs738409 G>C variant are at higher risk of NAFLD.

Inflammatory markers C-reactive protein and PLR in relation to HCC characteristics.

INTRODUCTION: Several markers of systemic inflammation, including blood C-reactive protein, platelet lymphocyte ratio (PLR) and neutrophil lymphocyte ratio (NLR) have been identified as independent prognosticators for hepatocellular carcinoma (HCC). METHODS: To attempt to understand the significance of these markers, they were examined in relation to 4 tumour parameters, namely maximum tumour diameter (MTD), tumour multifocality, portal vein thrombosis (PVT) and blood alpha-fetoprotein (AFP) levels. RESULTS: Using linear and logistic regression models, we found that C-reactive protein and PLR on single variables, were statistically significantly related to the tumour parameters. In a logistic regression final model, CRP was significantly related to MTD, AFP and PVT, and the Glasgow Index significantly related to MTD and AFP. Results of the area under the receiver operating characteristic curves (ROC), showed that the areas for PLR and CRP were statistically significant for high versus low MTD and for presence versus absence of PVT. CRP alone was significant for high versus low AFP. CONCLUSIONS: These analyses suggest that the prognostic usefulness of the inflammatory markers PLR and CRP (but not NLR) may be due to their reflection of parameter values for tumour growth and invasiveness.

C-Reactive Protein and Platelet-Lymphocyte Ratio as Potential Tumor Markers in Low-Alpha-Fetoprotein Hepatocellular Carcinoma.

The hepatocellular carcinoma (HCC) tumor marker alpha-fetoprotein (AFP) is only elevated in about half of the HCC patients, limiting its usefulness in following the effects of therapy or screening. New markers are needed. It has been previously noted that the inflammation markers C-reactive protein (CRP) and platelet-lymphocyte ratio (PLR) are prognostically important and may reflect HCC aggressiveness. We therefore examined these 2 markers in a low-AFP HCC cohort and found that for HCCs > 2 cm, both markers significantly rise with an increasing maximum tumor diameter (MTD). We calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and Youden index value for each marker, and their area-under-the-curve values for each MTD group. Patients were dichotomized into 2 groups based on the CRP and PLR from the receiver-operating characteristic curve analysis. In the logistic regression models of the 4 different MTD patient groups, CRP and PLR levels were statistically significant to estimate MTD in univariate logistic regression models of MTD groups > 2 cm. CRP and PLR were then combined, and the combination was statistically significant to estimate MTD groups of 3-, 4-, and 5-cm cutoffs. CRP and PLR thus have potential as tumor markers for low-AFP HCC patients, and possibly for screening.

Macroscopic Portal Vein Thrombosis in HCC Patients.

Macroscopic portal vein invasion (PVT) by hepatocellular carcinoma (HCC) in the liver is one of the most important negative prognostic factors for HCC patients. The characteristics of a large cohort of such patients were examined. We found that the percent of patients with PVT significantly increased with increasing maximum tumor diameter (MTD), from 13.7% with tumors of MTD <5cm to 56.4% with tumors of MTD >10cm. There were similar numbers of HCC patients with very large tumors with and without PVT. Thus, MTD alone was insufficient to explain the presence of PVT, as were high AFP levels, since less than 50% of high AFP patients had PVT. However, the percent of patients with PVT was also found to significantly increase with increasing blood alpha-fetoprotein (AFP) levels and tumor multifocality. A logistic regression model that included these 3 factors together showed an odds ratio of 17.9 for the combination of MTD>5.0cm plus tumor multifocality plus elevated AFP, compared to low levels of these 3 parameters. The presence or absence of macroscopic PVT may therefore represent different HCC aggressiveness phenotypes, as judged by a significant increase in tumor multifocality and AFP levels in the PVT positive patients. Factors in addition to MTD and AFP must also contribute to PVT development.

C-reactive protein and hepatocellular carcinoma: analysis of its relationships to tumor factors.

C-reactive protein (CRP) is a blood marker for inflammation and is an independent prognostic factor for many human cancers. Combined with albumin levels, it forms the basis of the Glasgow Index for cancer prognosis. We reviewed the literature on CRP and HCC and also evaluated blood CRP levels and combination CRP plus albumin levels in a large HCC cohort. In order to understand the prognostic significance of CRP, we retrospectively examined a large HCC cohort and examined the relationship of CRP levels to tumor parameters. We report, that CRP alone and CRP plus albumin combined as well, significantly correlated with parameters of HCC aggressiveness, such as maximum tumor dimension (MTD), portal vein thrombosis (PVT) and blood alpha-fetoprotein (AFP) levels, both as individual parameters and all parameters together (Aggressiveness Index). This extends current thinking, to suggest a possible explanation for the usefulness of blood CRP levels in HCC prognostication.

HCC with low- and normal-serum alpha-fetoprotein levels.

A large database of 1773 HCC patients in Turkey was examined. 41.9% had alpha-fetoprotein (AFP) levels <20 IU/ml and an additional 16.123% had values between 20-100 IU/ml. This 58% of the cohort (<100 IU/ml AFP levels) was examined in detail. 66% of patients with small (<5 cm) HCCs had low AFP, compared to 49% of patients with larger (>5 cm) HCCs. The mean diameter (MTD) of larger MTD, low AFP tumors was 8.4cm. Therefore, factors other than AFP must contribute to HCC tumor growth. Larger tumors in low AFP patients had both higher platelet levels and increased PVT percent. Linear regression analysis for both MTD and multifocality showed that platelet numbers and presence of PVT were significant variables; whereas for PVT, significant variables were albumin, alkaline phosphatase and MTD. Comparisons between patients with AFP levels <20, 20-<100, 100-<1000 and >1000 IU/ml showed the most significant tumor finding was an increase in PVT percent between each group, and to a lesser extent, MTD. Thus, low- or normal-AFP HCCs constitute the majority of patients and have slightly lower MTD and much lower PVT percent than HCCs associated with elevated blood AFP levels. New, non-AFP markers are thus needed, especially for small HCCs.