Fátima Aparecida Ferreira Figueiredo

Impact of nutritional status on outcomes after liver transplantation.

Background. Poorpreoperative nutritional status has been reported to be associated with adverse outcomes after liver transplantation. Published data are, however, conflicting, with methods of preoperative nutritional assessment and postoperative outcomes varying between studies. Methods. We prospectively studied the predictive value of preoperative nutritional status for adverse outcomes after liver transplantation. Assessment of preoperative nutritional status included: body cell mass determination, subjective global assessment, anthropometry, handgrip dynamometry, biochemical and amino acid profile, Child’s score, and dual-energy x-ray absorptiometry. Death, intensive care unit (ICU) length of stay ≥4 days, hospital length of stay ≥15 days, blood usage ≥36 U of blood products, infection, rejection, and global resource utilization (an index of cost) greater than the median were considered poor outcomes. Results. Fifty-three patients were studied. Longer ICU stay was associated with lower handgrip strength (P <0.01) and lower aromatic amino acid levels (P <0.01). Longer total hospital stay and the development of infections were associated with lower branched chain amino acid levels (P <0.01 and <0.001, respectively). Acute cellular rejection was associated with lower total body fat (P <0.001) and higher triglyceride levels (P <0.02). Neither death nor higher global resource utilization was associated with any preoperative nutritional parameter. Conclusions. Lower preoperative handgrip strength and branched chain amino acid levels are associated with longer ICU stays and increased likelihood of posttransplant infections. In our program, in which nutritional support was provided to potential recipients exhibiting malnourishment, none of the measured nutritional parameters were associated with mortality or greater global resource utilization.

Enhanced liver fibrosis panel as a predictor of liver fibrosis in chronic hepatitis C patients.

Background: Evaluation of fibrosis is crucial in the assessment of chronic hepatitis C (CHC). The enhanced liver fibrosis (ELF) is a serological panel including hyaluronic acid (HA), tissue inhibitor of matrix metalloproteinases-1 (TIMP-1), and amino-terminal propeptide of type III procollagen (PIIINP) that has shown good results in predicting liver fibrosis in distinct scenarios of chronic liver diseases. Aims: We aimed to assess the performance of ELF on the detection of fibrosis and cirrhosis in a CHC patient cohort and to compare the results of ELF and transient elastography (TE—Fibroscan) using liver biopsy as reference. Patients and Methods: One hundred twenty patients were prospectively evaluated by TE and ELF using an ADVIA Centaur automated system. The ELF score was calculated using the manufacturer’s algorithm. Biopsies were classified according to the METAVIR score. Receiver operator characteristic curve analyses were performed to evaluate the accuracy of ELF and TE. Results: The area under the receiver operator characteristic curve (AUROC) of ELF for the diagnosis of significant fibrosis was 0.81 [95% confidence interval (CI), 0.73-0.87], for advanced fibrosis was 0.82 (95% CI, 0.74-0.88), and for cirrhosis was 0.78 (95% CI, 0.70-0.85). Using the proposed cutoffs, ELF overestimated fibrosis in 66% (81/120) of cases and underestimated in 3% (3/120). We found no statistically significant difference when comparing the AUROC of ELF and TE for diagnosing fibrosis or cirrhosis. Conclusions: ELF panel is a good noninvasive fibrosis marker and showed similar results to TE in CHC patients. However, new cutoff points need to be established to improve its performance on patients with CHC.

Interobserver variability in transient elastography analysis of patients with chronic hepatitis C.

Transient elastography based on liver stiffness measurement is a non‐invasive method to assess hepatic fibrosis. However, interobserver variability has led to controversy over its use in fibrosis evaluation. To evaluate the interobserver variation in transient elastography in chronic hepatitis C.

Low bone mineral density in noncholestatic liver cirrhosis: prevalence, severity and prediction

BACKGROUND Metabolic bone disease has long been associated with cholestatic disorders. However, data in noncholestatic cirrhosis are relatively scant. AIMS To determine prevalence and severity of low bone mineral density in noncholestatic cirrhosis and to investigate whether age, gender, etiology, severity of underlying liver disease, and/or laboratory tests are predictive of the diagnosis. PATIENTS/METHODS Between March and September/1998, 89 patients with noncholestatic cirrhosis and 20 healthy controls were enrolled in a cross-sectional study. All subjects underwent standard laboratory tests and bone densitometry at lumbar spine and femoral neck by dual X-ray absorptiometry. RESULTS Bone mass was significantly reduced at both sites in patients compared to controls. The prevalence of low bone mineral density in noncholestatic cirrhosis, defined by the World Health Organization criteria, was 78% at lumbar spine and 71% at femoral neck. Bone density significantly decreased with age at both sites, especially in patients older than 50 years. Bone density was significantly lower in post-menopausal women patients compared to pre-menopausal and men at both sites. There was no significant difference in bone mineral density among noncholestatic etiologies. Lumbar spine bone density significantly decreased with the progression of liver dysfunction. No biochemical variable was significantly associated with low bone mineral density. CONCLUSIONS Low bone mineral density is highly prevalent in patients with noncholestatic cirrhosis. Older patients, post-menopausal women and patients with severe hepatic dysfunction experienced more advanced bone disease. The laboratory tests routinely determined in patients with liver disease did not reliably predict low bone mineral density.

Transient elastography evaluation of hepatic and spleen stiffness in patients with hepatosplenic schistosomiasis.

Background Hepatosplenic schistosomiasis (HES) has not been evaluated by transient elastography so far and its correlation with ultrasound variables remains to be defined. Aims The aim of this study was to describe the parameters of liver and spleen stiffness in HES assessed by transient elastography in comparison with cirrhotics and controls evaluating its correlation with ultrasonographic data. Patients and methods HES, hepatitis C virus-cirrhotic, and control patients were included in this sectional study. Liver and spleen stiffness were compared among the three groups. The ultrasonographic parameters were compared with transient elastography in HES patients. Results Thirty HES, 30 hepatitis C virus-cirrhotic patients, and 17 controls were included. Those with HES presented liver stiffness that was significantly higher than the controls and lower than the cirrhotics: 9.7 (3.6–75.0) versus 3.7 (2.8–5.4) versus 27.0 (14.7–61.5) kPa (P<0.001). Spleen stiffness values were comparable between hepatosplenic and cirrhotics: 66.4 (25.7–75.0) versus 69.1 (18.0–75.0) kPa (P=0.78) and were significantly higher than the controls 16.5 kPa (6.3–34.3) (P<0.001). In patients with HES, high spleen stiffness was associated with right liver lobe diameter (P=0.015), splenic artery resistance index (P=0.002), portal vein diameter (P=0.021), portal vein area (P=0.008), portal vein congestion index (P=0.035), splenic vein diameter (P=0.013), and spleen diameter (P=0.021). Conclusion Liver stiffness may be a useful tool to differentiate portal hypertension related to cirrhosis from that of HES. High spleen stiffness is a potential surrogate marker of portal hypertension in this population.