Clémence M. Canivet

The Periscreen Strip Is Highly Efficient for the Exclusion of Spontaneous Bacterial Peritonitis in Cirrhotic Outpatients

Objectives:We aimed to assess the performance of a new strip (Periscreen) for the rapid diagnosis of spontaneous bacterial peritonitis (SBP).Methods:Ascitic fluid (AF) of cirrhotic patients hospitalized between March 2014 and August 2015 was independently tested by two readers using the new strip, which has four colorimetric graduations (negative, trace, small, and large). SBP was diagnosed on neutrophils in ascites>250/mm3. Ascites not related to portal hypertension were excluded.Results:Overall, 649 patients from 21 French centers were included and 1,402 AF (803 AF samples from 315 outpatients and 599 samples from 334 inpatients) were assessed. Eighty-four AF samples (17 AF in 9 outpatients and 67 AF in 31 inpatients) were diagnosed as SBP. The prevalence of SBP was 6% (2.1% in outpatients vs. 11.2% in inpatients; P<0.001) and 7.2% in patients with symptoms suggestive of SBP (3% in outpatients vs. 11.3% in inpatients; P<0.001). The κ value for inter-reader agreement was 0.81 (95% confidence interval: 0.77–0.84) when using the “trace” threshold. Considering discordant results (n=131) as positive to interpret the diagnostic performance of the strip at the “trace” threshold, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 91.7, 57.1, 12.0, and 99.1%, respectively. At this “trace” threshold, sensitivity and NPV were both 100% in outpatients, and 89.5 and 97.9% in inpatients, respectively. At the “small” threshold, sensitivity, specificity, PPV and NPV were 81.0, 85.9, 25.9 and 98.7%, respectively.Conclusions:The Periscreen strip is a rapid and highly efficient tool for excluding SBP in the outpatient setting.

Severe Vitamin D Deficiency May be an Additional Cofactor for the Occurrence of Alcoholic Steatohepatitis

BACKGROUND Among its pleiotropic effects, vitamin D may protect the liver from fibrosis and/or inflammation. However, the impact of vitamin D on liver pathology in hepatitis C remains unclear, and very few studies including alcoholic patients with liver pathologies have been performed. Here we compared the levels of 25-OH vitamin D in the blood of alcoholic patients with the occurrence of alcoholic steatohepatitis (ASH) or bridging fibrosis. METHODS One hundred and one alcoholic patients were included. All the patients received a liver biopsy, and the levels of 25-OH vitamin D were evaluated with the Liaison 25-OH vitamin D assay. Logistic regression analyses were performed to obtain predictive factors of liver histology. RESULTS Among alcoholic patients, 40.6% presented ASH and 39.6% presented bridging fibrosis. A severe deficiency in 25-OH vitamin D (<10 ng/ml) was seen in 60.4% of patients. This deficiency was frequent in patients with ASH (85.4%) and in those with bridging fibrosis (80%) but was independently associated only with ASH (odds ratio = 8.46 [95% confidence interval 2.05 to 34.89], p = 0.003). CONCLUSIONS In alcoholic patients, a severe deficiency in 25-OH vitamin D was independently associated with the occurrence of ASH.

Safety of sofosbuvir-based regimens after liver transplantation: longitudinal assessment of renal function in the prospective ANRS CO23 CUPILT study

In liver transplant recipients with hepatitis C virus recurrence, there is concern about renal safety of sofosbuvir‐based regimens. Changes in serum creatinine or in the estimated glomerular filtration rate (eGFR) under treatment are used to look for possible renal toxicity. However, serum creatinine and eGFR are highly variable.

Determinants associated with the correction of glomerular hyper-filtration one year after bariatric surgery

BACKGROUND Increased adipokine production and hyperfiltration may explain the links between obesity and chronic kidney disease. Indeed, hyperfiltration may precede a subsequent accelerated decline of kidney function in these patients. Glomerular filtration rate decreases after bariatric surgery in young obese patients with hyperfiltration. OBJECTIVE Our aim was to identify the factors associated with this decrease 1 year after bariatric surgery. SETTING We used data from a prospective cohort of severely obese patients who underwent bariatric surgery in Nice University Hospital. METHODS We analyzed 175 patients before and 1 year after bariatric surgery. Low-grade inflammation was evaluated by serum C-reactive protein levels. Lean body mass and fat body mass were estimated by bioelectric impedance analysis. Body surface area was assessed by the Du Bois formula. Serum creatinine levels were used to estimate glomerular filtration rate by the chronic kidney disease-epidemiology collaboration (CKD-EPI) equation. Glomerular filtration rate was de-adjusted from standard body surface area and then divided by lean body mass to calculate the decrease in hyperfiltration and to separate the patients into 2 groups: above or below the median decrease of hyperfiltration after bariatric surgery. RESULTS The factors associated with a large correction of hyperfiltration were baseline C-reactive protein levels (10.0 ± 5.8 mg/L versus 12.7 ± 7.4 mg/L, P = .01) and brachial circumference (41 ± 4 cm versus 44 ± 5 cm, P = .006). A high fat mass reduction rate was significantly associated with a substantial hyperfiltration reduction after bariatric surgery (P<.001) independently of sex and surgical procedure. CONCLUSIONS The correction of hyperfiltration is associated with a high reduction rate of fat mass after bariatric surgery but may be limited by low-grade inflammation.

Stéatoses hépatiques métaboliques : histoire naturelle, physiopathologie et démarche diagnostique

Les steatoses hepatiques metaboliques (egalement appelees steatopathies dysmetaboliques ou maladie du foie gras non alcoolique, en anglais non-alcoholic fatty liver disease (NAFLD)) sont un probleme de sante publique. La NAFLD regroupe la steatose (en anglais non-alcoholic fatty liver (NAFL)), la steatohepatite non alcoolique (en anglais non-alcoholic steatohepatitis (NASH)) et ses complications que sont la fibrose hepatique, la cirrhose et le carcinome hepatocellulaire. Environ 25 % de la population mondiale aurait une NAFLD et 1,5 a 6,5 % une NASH. Ces fortes prevalences sont liees a l’epidemie de surpoids et d’obesite. Comme l’obesite, la NAFLD est une maladie complexe et heterogene. En effet, la genese, les manifestations cliniques hepatiques et extrahepatiques, et l’evolution de la NAFLD dependent de multiples facteurs environnementaux et genetiques. Le syndrome metabolique, comprenant l’insulino-resistance, joue un role important mais non exclusif dans l’apparition de la NASH. La NAFLD, comme l’obesite et le diabete de type 2, est une maladie multisystemique associee a differentes complications (maladies cardiovasculaires, cancers extrahepatiques et hepatiques, atteinte renale…).La comprehension de la physiopathologie de la NAFLD a permis l’emergence de nombreuses approches therapeutiques medicamenteuses ou non medicamenteuses innovantes en cours d’evaluation.La prise en charge des patients necessite une demarche diagnostique rigoureuse. La biopsie hepatique, qui est l’examen de reference, ne peut pas etre proposee a l’ensemble des sujets a risque de NAFLD. Le developpement et la validation d’outils non-invasifs seriques et/ou physiques evaluant de facon fiable et reproductible, la fibrose mais aussi la NASH et la steatose sont un enjeu majeur. La mise a disposition de ces marqueurs non invasifs permettra de depister, d’evaluer et de suivre les patients.

Maladies cholestatiques et acide ursodésoxycholique : de l’actualité à la pratique

La cirrhose biliaire primitive a beneficie ces dernieres annees d’avancees diagnostiques et therapeutiques. Son diagnostic est evoque precocement lors d’un bilan d’asthenie ou l’exploration d’une perturbation du bilan hepatique. Son diagnostic de certitude repose sur l’association de deux anomalies parmi : une cholestase chronique, la presence d’anticorps anti-mitochondrie (anti-M2), et/ou une cholangite destructrice a la biopsie hepatique. Le traitement de reference est l’acide ursodesoxycholique (AUDC) a la dose de 13-15 mg/kg par jour. L’evaluation de la reponse biochimique (phosphatase alcaline, aspartate-aminotransferase, bilirubine totale) est evaluee precocement, entre 6 et 12 mois, a l’aide des scores de Paris. Dans les formes non decompensees, l’utilisation de l’AUDC a permis l’amelioration du pronostic hepatique et global. Une reponse biochimique incomplete a l’AUDC pourrait, a l’avenir, faire discuter l’instauration d’un traitement adjuvant (acide obeticholique ou bezafibrate). La prise en charge precoce et la stabilisation de la maladie sous AUDC fait que l’evolution vers la cirrhose est rare au point d’amener les experts a vouloir renommer la maladie.Une autre maladie cholestatique recemment identifiee est la cholangite a immunoglobuline (Ig) G4 qui est la manifestation biliaire de la maladie systemique a IgG4. Elle est frequemment associee a la pancreatite a IgG4 (ou auto-immune de type 1). Le diagnostic repose sur des arguments radiologiques, le dosage des IgG4 seriques et une preuve histologique. La cholangite a IgG4 est tres corticosensible, cependant des rechutes sont decrites a l’arret du traitement. Il s’agit d’un diagnostic differentiel a evoquer systematiquement lors de la suspicion d’une cholangite sclerosante primitive, d’un cholangiocarcinome hilaire ou distal ou d’un cancer de la tete du pancreas.

Sudden severe jaundice with high fever in a young woman.

[1] Ramos-Casals M, Brito-Zeron P, Lopez-Guillermo A, et al. Adult haemophagocytic syndrome. Lancet 2014;383:1503–16. A 22-year-old European woman with no previous medical istory and a normal body mass index (19.8 kg/m2), presented ith severe jaundice (total bilirubin 509 mol/l, conjugated 44 mol/l), high fever (39–40 ◦C), hepatomegaly and anaemia haemoglobin 6.9 g/dl). Liver function tests revealed a mild increase