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Recent efforts to reclassify non-alcoholic fatty liver disease (NAFLD) as metabolic dysfunction-associated fatty liver disease (MAFLD) and metabolic dysfunction-associated steatotic liver disease (MASLD) are intended to divert attention to the metabolic basis of the disease rather than to alcohol consumption. This reclassification recognizes the role of obesity, sedentary lifestyles and poor dietary habits in the development of the disease, leading to a better understanding of its etiology. Nevertheless, the transition has posed its own challenges, particularly with regard to communication between patient and healthcare professional. Many healthcare professionals report difficulty in explaining the nuanced concepts, especially the term "steatosis". In addition, the change in terminology has not yet removed the stigma, with ongoing debates about the appropriateness of the terms "fatty" and "steatotic". Surveys suggest that while "obesity" may be perceived as more stigmatizing, the medical term "steatotic liver disease" is not considered as stigmatizing, indicating a disconnect in perceptions between healthcare professionals and patients.
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Enfermedad del Hígado Graso no Alcohólico , Estigma Social , Humanos , Enfermedad del Hígado Graso no Alcohólico/psicología , Terminología como Asunto , Obesidad/psicología , Estereotipo , Actitud del Personal de Salud , Factores de Riesgo , Conocimientos, Actitudes y Práctica en Salud , Hígado Graso/psicologíaRESUMEN
BACKGROUND: Liaoning score has been developed and validated to predict the risk of esophageal varices in liver cirrhosis. This study aimed to further modify the Liaoning score by combining clinical and laboratory parameters to predict the long-term outcome of cirrhotic patients. METHODS: First, 474 cirrhotic patients were retrospectively enrolled from Shenyang, China as the training cohort. Independent predictors for death were identified by competing risk analyses, and then a new prognostic model, called as modified Liaoning score, was developed. Its performance was externally validated at three centers from Fuzhou, China (n = 1944), Jinan, China (n = 485), and São Paulo, Brazil (n = 221). RESULTS: Age, total bilirubin (TBIL), albumin (ALB), serum creatinine (SCr), and Liaoning score were independently associated with death in the training cohort. Modified Liaoning score = 0.159×Liaoning score + 0.010×TBIL(µmol/L)+0.029×age(years)+0.011×SCr(µmol/L)-0.037×ALB(g/L). The area under curve of modified Liaoning score was 0.714 (95%CI = 0.655-0.773), which was higher than that of Child-Pugh score (0.707, 95%CI = 0.645-0.770), MELD score (0.687, 95%CI = 0.623-0.751), and Liaoning score (0.583, 95%CI = 0.513-0.654). A modified Liaoning score of ≥ 1.296 suggested a higher cumulative incidence of death in liver cirrhosis (p < 0.001). Modified Liaoning score still had the highest prognostic performance in Chinese and Brazilian validation cohorts. CONCLUSIONS: Modified Liaoning score can be considered for predicting the long-term outcome of cirrhotic patients.
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Cirrosis Hepática , Humanos , Estudios Retrospectivos , Brasil , Cirrosis Hepática/complicaciones , Pronóstico , Índice de Severidad de la EnfermedadRESUMEN
Impairments in liver function lead to different complications. As chronic liver disease progresses (CLD), hypoalbuminemia and alterations in bile acid compositions lead to changes in gut microbiota and, therefore, in the host-microbiome interaction, leading to a proinflammatory state. Alterations in gut microbiota composition and permeability, known as gut dysbiosis, have important implications in CLD; alterations in the gut-liver axis are a consequence of liver disease, but also a cause of CLD. Furthermore, gut dysbiosis plays an important role in the progression of liver cirrhosis and decompensation, particularly with complications such as hepatic encephalopathy and spontaneous bacterial peritonitis. In relation to this, antibiotics play an important role in treating CLD. While certain antibiotics have specific indications, others have been subjected to continued study to determine whether or not they have a modulatory effect on gut microbiota. In contrast, the rational use of antibiotics is important, not only because of their disrupting effects on gut microbiota, but also in the context of multidrug-resistant organisms. The aim of this review is to illustrate the role of gut microbiota alterations in CLD, the use and impact of antibiotics in liver cirrhosis, and their harmful and beneficial effects.
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Non-alcoholic fatty liver disease (NAFLD) represents a global public health burden. Despite the increase in its prevalence, the disease has not received sufficient attention compared to the associated diseases such as diabetes mellitus and obesity. In 2020 it was proposed to rename NAFLD to metabolic dysfunction-associated fatty liver disease (MAFLD) in order to recognize the metabolic risk factors and the complex pathophysiological mechanisms associated with its development. Furthermore, along with the implementation of the proposed diagnostic criteria, the aim is to address the whole clinical spectrum of the disease, regardless of BMI and the presence of other hepatic comorbidities. As would it be expected with such a paradigm shift, differing viewpoints have emerged regarding the benefits and disadvantages of renaming fatty liver disease. The following review aims to describe the way to the MAFLD from a historical, pathophysiological and clinical perspective in order to highlight why MAFLD is the approach to follow.
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Background: Hepatic epithelioid hemangioendothelioma (HEHE) is a rare neoplastic disease of varied presentation and unspecific radiological signs in the early stages. The diagnostic delay can lead to metastatic disease, thus increasing the tumor burden and reducing the treatment options. HEHE is usually deemed a slow-growing tumor, but its speed of growth is poorly reported and still unknown. Case Description: In this case report, we documented a HEHE diagnosed in a young woman who had complaints of abdominal pain, weight loss and bloating for a long time. The typical findings observed in histological studies were not promptly recognized in the histological analyzes, even after two laparoscopic-guided liver biopsies, delaying the diagnosis until extrahepatic tumor spreading. Findings observed in computed tomography, magnetic resonance imaging and histological studies are presented. The coalescence of nodules and the rising of giant masses, occupying large parts of the liver in a specific time span, were registered and quantified. As opposed to prior reports, the results show that hepatic HEHE can grow rapidly, reinforcing the need of early diagnosis, thus avoiding the complications presented herein. Conclusions: The findings observed via radiological and histological imaging that could have avoided the diagnosis delay are depicted and discussed, showing that HEHE can rise faster than previously documented.
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BACKGROUND: Common variable immunodeficiency (CVID) is a rare disease that affects children and adults and is often difficult to diagnose. Despite being one of the most frequent causes of immunodeficiency, involving gastrointestinal (GI), respiratory, and hematological systems, the disease onset can have heterogeneous and intermittent symptoms, frequently leading to diagnostic delay. GI symptoms are common and can include diarrhea, but the asymptomatic periods lead to overlooking the recurrent pattern. The same can occur with respiratory infections, thus delaying CVID suspicion. The starting point for CVID diagnosis is the decreased gamma globulin levels in serum protein electrophoresis (SPE), also observed through direct immunoglobulin's dosage. CASE PRESENTATION: The patient is a 38 years-old man who had intermittent diarrhea and recurrent airway infections for 19 years, but the CVID diagnosis was achieved only after SPE was carried out. At that time, he was already malnourished, and developed other complications related to CVID in a short period. CONCLUSIONS: SPE is readily available and inexpensive, but is not part of the laboratory approach in diarrhea. According to the case presented herein, it can be useful for patients with recurrent infections or other clues of the disease.
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Inmunodeficiencia Variable Común , Diagnóstico Tardío , Adulto , Proteínas Sanguíneas , Inmunodeficiencia Variable Común/complicaciones , Inmunodeficiencia Variable Común/diagnóstico , Diagnóstico Tardío/efectos adversos , Diarrea/etiología , Electroforesis , Humanos , MasculinoRESUMEN
BACKGROUND Metabolic dysfunction-associated fatty liver disease (MAFLD) is now the term used for hepatic steatosis in patients who are overweight or obese, have type 2 diabetes mellitus (T2DM), or evidence of metabolic dysregulation. The prevalence of MAFLD among morbidly obese subjects is 65-93%. Hepatic dendritic cells (hDCs) are antigen-presenting cells that induce T cell-mediated immunity. MAFLD pathogenesis involves numerous immune cell-mediated inflammatory processes, while the particular role of hDCs is yet to be well defined. This study aimed to identify hDCs in liver biopsies from 128 patients with MAFLD associated with obesity. MATERIAL AND METHODS In this cross-sectional study, 128 liver biopsies from 128 patients with MAFLD (diagnosed as presence of hepatic steatosis, plus T2DM, metabolic dysregulation or overweight/obesity) were collected and assessed for CD11c⺠immunoreactivity degree (CD11c as dendritic cell biomarker), through antigen retrieval, reaction with CD11c antibodies (primary), and marking with diaminobenzidine chromogen. RESULTS Among the 128 patients with MAFLD, 64 (50%) had MAFLD and fibrosis and 72 (56.2%) positively expressed hDCs (CD11câº). Among morbidly obese patients, 49 (64.5%) positively expressed hDCs (CD11câº) in liver tissue; from patients with obesity grade I- grade II (GI-II), 18 (54.5%) positively expressed hDCs (CD11câº) in liver tissue; and from non-obese patients with MAFLD, 5 (26.3%) positively expressed hDCs (CD11câº) in liver tissue. CONCLUSIONS hDC expression increases significantly in morbidly obese patients with MAFLD compared with non-obese patients, independent of the degree of fibrosis, suggesting the role of adaptive changes within hDCs in the perpetuation of inflammatory insults in chronic liver diseases.
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Diabetes Mellitus Tipo 2 , Hígado Graso , Hepatopatías , Enfermedad del Hígado Graso no Alcohólico , Obesidad Mórbida , Biopsia , Estudios Transversales , Células Dendríticas/metabolismo , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/patología , Hígado Graso/complicaciones , Hígado Graso/metabolismo , Fibrosis , Humanos , Hepatopatías/patología , Enfermedad del Hígado Graso no Alcohólico/complicaciones , Enfermedad del Hígado Graso no Alcohólico/patología , Obesidad Mórbida/complicaciones , Sobrepeso/complicacionesRESUMEN
BACKGROUND: Bisphosphonates are the mainstay of osteoporosis treatment, but their use for patients with esophageal varices has been avoided due to the risk of esophagitis, which may cause variceal bleeding. Since most clinical trials assessing osteoporosis treatment last 2-3 years, this study aimed to evaluate a 2-year risedronate treatment for patients with esophageal varices and liver cirrhosis. METHODS: The study received Institutional Review Board approval, and the sample was divided into two groups according to bone mineral density (BMD). Cirrhosis severity and endoscopic findings at baseline were similar between the groups. The intervention group had 51 patients with osteoporosis, who received oral risedronate 35 mg weekly plus calcium and vitamin D supplements. The control group had 51 patients with osteopenia, receiving only the supplements. Scheduled esophagogastroduodenoscopies and BMD measurements were carried out. RESULTS: The adjusted esophagitis risk was higher in the intervention group; however, none of the subjects had digestive bleeding. Lumbar spine BMD increased in the intervention group (- 3.06 ± 0.71 to - 2.33 ± 0.90; p < 0.001) and in the control group (- 1.38 ± 0.77 to - 1.10 ± 1.05; p = 0.012). Femoral neck BMD did not change in the intervention group (- 1.64 ± 0.91 to - 1.71 ± 0.95; p = 0.220), but tended to decrease in the control group (- 1.00 ± 0.74 to - 1.09 ± 0.82; p = 0.053). CONCLUSION: Oral risedronate was effective and did not cause gastrointestinal bleeding in cirrhotic patients with esophageal varices under endoscopic surveillance.
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Conservadores de la Densidad Ósea , Várices Esofágicas y Gástricas , Esofagitis , Osteoporosis , Humanos , Ácido Risedrónico/uso terapéutico , Várices Esofágicas y Gástricas/complicaciones , Conservadores de la Densidad Ósea/uso terapéutico , Conservadores de la Densidad Ósea/efectos adversos , Hemorragia Gastrointestinal/complicaciones , Osteoporosis/complicaciones , Osteoporosis/tratamiento farmacológico , Osteoporosis/inducido químicamente , Densidad Ósea , Cirrosis Hepática/complicaciones , Cirrosis Hepática/tratamiento farmacológico , Esofagitis/inducido químicamente , Esofagitis/complicaciones , Esofagitis/tratamiento farmacológicoRESUMEN
Background: Hepatocellular carcinoma is a relevant cause of mortality worldwide, mainly among patients who have a prior liver disease. In spite of clear recommendations regarding surveillance and screening methods, most patients are still diagnosed only when they are no longer candidates to curative treatment modalities, while others do not achieve the goals of such treatments, thus increasing the need of anticancer drugs. Moreover, when cirrhotic patients begin to receive these drugs, many types of adverse events are seen as a reason to withdrawal, even when there are findings suggesting a good response to the treatment. Case Summary. This case report is about a cirrhotic patient who received many types of treatment, from surgery and chemoembolization during early stages to first- and second-line systemic therapy when the disease turned to be advanced. Since he had no signs of liver dysfunction and suffered tumor progression during sorafenib treatment, regorafenib was initiated. The main findings that make this case important are the adverse events after taking this second-line agent, which would certainly be considered unacceptable and would lead to the drug withdrawal. The reasons why regorafenib was maintained are explained based on clinical and imaging findings, showing how this decision led to an excellent response. Conclusions: The knowledge of the main adverse events described in the pilot clinical trials can avoid unnecessary withdrawal of regorafenib. In addition, some clinical and imaging findings can be deemed as predictors of good response to tyrosine kinase inhibitors.
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Carcinoma Hepatocelular , Neoplasias Hepáticas , Carcinoma Hepatocelular/tratamiento farmacológico , Humanos , Neoplasias Hepáticas/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Compuestos de Fenilurea/uso terapéutico , Piridinas/uso terapéuticoRESUMEN
OBJECTIVE: The aim of this study was to compare the effects of muscle wasting according to measures obtained by different limb muscle mass indexes, to find the best mortality predictor among outpatients with cirrhosis. METHODS: Patients with liver cirrhosis (N = 210) were submitted to dual-energy x-ray absorptiometry (DXA). Appendicular muscle mass (AMM), AMM index (AMMI), upper limb muscle mass (ULMM), and ULMM index (ULMMI) were calculated. The Model for End-Stage Liver Disease, anthropometric measures, and the presence of ascites and edema were also registered. Multiple logistic regressions were performed to determine mortality predictors; the area under the receiver operating characteristic curve was used to establish the best cutoff point to predict mortality. RESULTS: The mean follow-up duration was 49 ± 15.59 mo. ULMM and ULMMI were clearly associated with mortality (P = 0.007 and 0.001, respectively), whereas AMM and AMMI were not. After calculating the cutoff points for men and women, the presence of a depleted ULMMI as a categorical variable was associated with a mortality risk 2.5 times higher. CONCLUSIONS: The results suggest that using ULMMI is better than AMMI for predicting mortality of outpatients with cirrhosis, thus offering a better measure to detect muscle wasting in this population using DXA.
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Enfermedad Hepática en Estado Terminal , Sarcopenia , Absorciometría de Fotón , Femenino , Humanos , Cirrosis Hepática/diagnóstico por imagen , Masculino , Músculo Esquelético , Pacientes Ambulatorios , Estudios Retrospectivos , Sarcopenia/diagnóstico por imagen , Índice de Severidad de la EnfermedadRESUMEN
Background: Nonalcoholic fatty liver disease (NAFLD) is a serious worldwide health problem, with an estimated global prevalence of 24%; it has a notable relationship with other metabolic disorders, like obesity and type 2 diabetes mellitus (T2DM). Nonalcoholic steatohepatitis (NASH) is one of the most important clinical entities of NAFLD, which is associated with an increased risk of progression to liver cirrhosis and hepatocellular carcinoma (HCC). Mexico is one of the countries with the highest prevalence of metabolic diseases; therefore, we sought to investigate the impact that these clinical entities have in the progression to advanced fibrosis in Mexican patients with NASH. Methods: We performed a multicenter retrospective cross-sectional study, from January 2012 to December 2017. A total of 215 patients with biopsy-proven NASH and fibrosis were enrolled. NASH was diagnosed according NAS score and liver fibrosis was staged by the Kleiner scoring system. For comparing the risk of liver fibrosis progression, we divided our sample into two groups. Those patients with stage F0-F2 liver fibrosis were included in the group with non-significant liver fibrosis (n=178) and those individuals with F3-F4 fibrosis were included in the significant fibrosis group (n=37). We carried out a multivariate analysis to find risk factors associated with liver fibrosis progression. Results: From the 215 patients included, 37 had significant liver fibrosis (F3-4). After logistic regression analysis T2DM (p=0.044), systemic arterial hypertension (p=0.014), cholesterol (p=0.041) and triglycerides (p=0.015) were the main predictor of advanced liver fibrosis. Conclusions: In a Mexican population, dyslipidemia was the most important risk factor associated with advanced liver fibrosis and cirrhosis.
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Dislipidemias/complicaciones , Cirrosis Hepática/epidemiología , Enfermedad del Hígado Graso no Alcohólico , Adulto , Anciano , Carcinoma Hepatocelular , Estudios Transversales , Diabetes Mellitus Tipo 2 , Femenino , Humanos , Cirrosis Hepática/complicaciones , Neoplasias Hepáticas , Masculino , México/epidemiología , Persona de Mediana Edad , Enfermedad del Hígado Graso no Alcohólico/complicaciones , Enfermedad del Hígado Graso no Alcohólico/epidemiología , Estudios Retrospectivos , Factores de RiesgoRESUMEN
Acute portomesenteric vein thrombosis is potentially lethal. In the present paper, a cirrhotic patient with a previous history of esophageal variceal bleeding presented with acute occlusive portomesenteric vein thrombosis, but achieved complete recanalization by low-molecular-weight heparin followed by rivaroxaban. Notably, no bleeding episode occurred during anticoagulation therapy. This case supported early initiation of anticoagulation in such patients.
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Várices Esofágicas y Gástricas/terapia , Inhibidores del Factor Xa/uso terapéutico , Hemorragia Gastrointestinal/terapia , Hemostasis Endoscópica , Heparina de Bajo-Peso-Molecular/uso terapéutico , Cirrosis Hepática Alcohólica/complicaciones , Venas Mesentéricas , Vena Porta , Rivaroxabán/uso terapéutico , Trombosis de la Vena/tratamiento farmacológico , Enfermedad Aguda , Várices Esofágicas y Gástricas/diagnóstico , Várices Esofágicas y Gástricas/etiología , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiología , Hemostasis Endoscópica/efectos adversos , Humanos , Cirrosis Hepática Alcohólica/diagnóstico , Masculino , Venas Mesentéricas/diagnóstico por imagen , Persona de Mediana Edad , Vena Porta/diagnóstico por imagen , Resultado del Tratamiento , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/etiologíaRESUMEN
Despite the high prevalence of osteoporosis in liver cirrhosis, the indication of bisphosphonates for patients with esophageal varices has been avoided due to risk of digestive mucosal damage. Therefore, this study aimed to evaluate the safety profile of risedronate treatment for patients with osteoporosis, liver cirrhosis and esophageal varices with low risk of bleeding. A total of 120 patients were allocated into two groups according to their bone mineral density measured by dual-energy X-ray absorptiometry. In the intervention group, 57 subjects with osteoporosis received oral risedronate at 35 mg weekly plus daily calcium and vitamin D supplementation. In the control group, 63 subjects with osteopenia received only calcium and vitamin D. The groups received the treatment for one year and underwent surveillance endoscopies at six and 12 months, as well as a control dual-energy X-ray absorptiometry after a 12-month follow-up. The study received Institutional Review Board approval. The groups had not only comparable Model for End-stage Liver Disease score and esophageal varices degree, but also similar incidence of digestive adverse effects. A significant improvement was achieved in the intervention group in the lumbar spine T score (p < 0.001). The results suggest that risedronate may be safely used in liver cirrhosis and esophageal varices with low bleeding risk under endoscopic surveillance, thus allowing bone mass recovery.
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Várices Esofágicas y Gástricas/tratamiento farmacológico , Cirrosis Hepática/tratamiento farmacológico , Osteoporosis/tratamiento farmacológico , Ácido Risedrónico/administración & dosificación , Absorciometría de Fotón , Adulto , Anciano , Calcio/administración & dosificación , Calcio/efectos adversos , Várices Esofágicas y Gástricas/complicaciones , Várices Esofágicas y Gástricas/patología , Femenino , Estudios de Seguimiento , Humanos , Cirrosis Hepática/complicaciones , Cirrosis Hepática/patología , Masculino , Persona de Mediana Edad , Osteoporosis/etiología , Osteoporosis/patología , Estudios Prospectivos , Ácido Risedrónico/efectos adversos , Vitamina D/administración & dosificación , Vitamina D/efectos adversosAsunto(s)
Colestasis/diagnóstico , Enfermedad de Gilbert/diagnóstico , Hiperbilirrubinemia/etiología , Ictericia/etiología , Cirrosis Hepática/diagnóstico , Enfermedad del Hígado Graso no Alcohólico/diagnóstico , Bilirrubina/metabolismo , Colestasis/complicaciones , Diagnóstico Diferencial , Enfermedad de Gilbert/complicaciones , Humanos , Ictericia Obstructiva/etiología , Cirrosis Hepática/complicaciones , Pruebas de Función Hepática , Enfermedad del Hígado Graso no Alcohólico/complicacionesRESUMEN
AIM: The present study aimed to identify variables associated with sarcopenia in cirrhotic outpatients using clinical data, anthropometric measures and lab tests. In a single centre prospective study, 261 cirrhotic outpatients were followed on average for 2 years. The diagnostic criteria of sarcopenia were applied according to the current guidelines, combining muscle strength and appendicular muscle mass index. METHODS: Age, sex, liver disease aetiology and the Model of End-Stage Liver Disease score were included as independent variables, as well as mid-arm circumference (MAC), body mass index and triceps skinfold. Multiple logistic regression was applied including all independent variables (maximum model). Then, the analysis was performed only with the variables that were significant in the first analysis (parsimonious model). Once the variable most related to sarcopenia was determined by the two models, the area under the receiver operator characteristic curve was calculated. Mortality rates were described for patients with and without sarcopenia. RESULTS: Sarcopenia was diagnosed in 14 subjects (5.36%), and the variable best associated with sarcopenia was MAC (P < 0.01). The 1-year mortality rate of 35.71% found among subjects with sarcopenia was not significantly higher (P = 0.07) than the 15.38% observed among those without this condition. CONCLUSIONS: Before examinations requiring ionising radiation, patients with cirrhosis can be submitted to simple screening tools to identify those who have a high risk of sarcopenia, thus promoting a cost-effective assessment.
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Cirrosis Hepática/complicaciones , Pacientes Ambulatorios , Sarcopenia/epidemiología , Antropometría , Brasil/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Fuerza Muscular , Evaluación Nutricional , Estudios Prospectivos , Sarcopenia/complicaciones , Sarcopenia/mortalidad , Índice de Severidad de la EnfermedadRESUMEN
INTRODUCTION: With the successes of antiretroviral therapy, patients infected with human immunodeficiency virus (HIV) living longer. Regarding this, the common diseases of HIV population (i.e., opportunistic infections) are now losing ground in front of metabolic alterations. This phenomenon is related to the delay in progression to acquired immune deficiency syndrome (AIDS), making it so that patients live in a chronic inflammatory state which, combined with other mechanisms such infectious ones, cause metabolic diseases. Areas covered: Considering a high prevalence of metabolic alterations, the relationship between metabolic syndrome (MetS) with nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH), and liver diseases as a major cause of death in the HIV-infected population, this paper aims to overview the mechanisms and prevalence of NAFLD and NASH as they relate to the developed metabolic diseases of HIV patients. Expert opinion: The pathways underlying MetS include the effects of HIV and ART on the liver, adipose tissue, and muscle. These mechanisms result in liver damage, consequently leading to NAFLD and its more severe form NASH. These conditions have increased in HIV-infected population in recent years and since their life expectancy is improving it is important to be ready to attend their new emerging diseases.