José Antonio Mujika Alustiza

PNPLA3 p.I148M variant is associated with greater reduction of liver fat content after bariatric surgery.

BACKGROUND Obesity is the major trigger of nonalcoholic fatty liver disease (NAFLD). NAFLD is further favored by the patatin-like phospholipase domain-containing 3 (PNPLA3) p.I148M, transmembrane 6 superfamily member 2 (TM6SF2) p.E167K, and membrane-bound O-acyltransferase domain containing 7 (MBOAT7) rs641738 variants. OBJECTIVES To investigate the relationship between the PNPLA3, TM6SF2, and MBOAT7 genotypes and the outcomes of bariatric surgery. SETTING University hospital. METHODS Prospectively we monitored 84 obese individuals (body mass index 35-64 kg/m2) scheduled for bariatric surgery. The PNPLA3 p.I148M, TM6SF2 p.E167K, and MBOAT7 rs641738 variants were genotyped using restriction fragment length polymorphism analysis and TaqMan assays. Hepatic steatosis was determined before surgery using analysis of liver biopsy samples and a novel magnetic resonance imaging-based equation. One year later, steatosis was reevaluated by magnetic resonance imaging. RESULTS The presence of the PNPLA3 allle [M] was associated with increased hepatic triglyceride content (P = .03), steatosis detected by magnetic resonance imaging (P = 0.04), and decreased serum glucose concentrations (P = .04). Neither variant TM6SF2 nor MBOAT7 increased hepatic steatosis (all P>.05); however, the MBOAT7 polymorphism was associated with increased triglyceride, total cholesterol, low density lipoprotein, and serum glucose levels (all P<.05). Patients carrying the prosteatotic PNPLA3 allele [M] lost more weight (P<.01) and liver fat (P = .04) one year after surgery, as compared to individuals having the common genotype. The PNPLA3 genotype and initial grade of steatosis, but not the TM6SF2 or MBOAT7 variants, were independent predictors of NAFLD improvement (P = .03 and P<.01, respectively). CONCLUSION In obese patients, the presence of the PNPLA3 p.I148M allele might be associated with greater improvement of hepatic steatosis after bariatric surgery in comparison to carriers of PNPLA3 wild-type alleles.

Non-invasive methods for liver fibrosis prediction in hemochromatosis: One step beyond

Advances in recent years in the understanding of, and the genetic diagnosis of hereditary hemochromatosis (HH) have changed the approach to iron overload hereditary diseases. The ability to use a radiologic tool (MRI) that accurately provides liver iron concentration determination, and the presence of non-invasive serologic markers for fibrosis prediction (serum ferritin, platelet count, transaminases, etc), have diminished the need for liver biopsy for diagnosis and prognosis of this disease. Consequently, the role of liver biopsy in iron metabolism disorders is changing. Furthermore, the irruption of transient elastography to assess liver stiffness, and, more recently, the ability to determine liver fibrosis by means of MRI elastography will change this role even more, with a potential drastic decline in hepatic biopsies in years to come. This review will provide a brief summary of the different non-invasive methods available nowadays for diagnosis and prognosis in HH, and point out potential new techniques that could come about in the next years for fibrosis prediction, thus avoiding the need for liver biopsy in a greater number of patients. It is possible that liver biopsy will remain useful for the diagnosis of associated diseases, where other non-invasive means are not possible, or for those rare cases displaying discrepancies between radiological and biochemical markers.

Novel equation to determine the hepatic triglyceride concentration in humans by MRI: diagnosis and monitoring of NAFLD in obese patients before and after bariatric surgery.

BackgroundNon-alcoholic fatty liver disease (NAFLD) is caused by abnormal accumulation of lipids within liver cells. Its prevalence is increasing in developed countries in association with obesity, and it represents a risk factor for non-alcoholic steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma. Since NAFLD is usually asymptomatic at diagnosis, new non-invasive approaches are needed to determine the hepatic lipid content in terms of diagnosis, treatment and control of disease progression. Here, we investigated the potential of magnetic resonance imaging (MRI) to quantitate and monitor the hepatic triglyceride concentration in humans.MethodsA prospective study of diagnostic accuracy was conducted among 129 consecutive adult patients (97 obesity and 32 non-obese) to compare multi-echo MRI fat fraction, grade of steatosis estimated by histopathology, and biochemical measurement of hepatic triglyceride concentration (that is, Folch value).ResultsMRI fat fraction positively correlates with the grade of steatosis estimated on a 0 to 3 scale by histopathology. However, this correlation value was stronger when MRI fat fraction was linked to the Folch value, resulting in a novel equation to predict the hepatic triglyceride concentration (mg of triglycerides/g of liver tissue = 5.082 + (432.104 * multi-echo MRI fat fraction)). Validation of this formula in 31 additional patients (24 obese and 7 controls) resulted in robust correlation between the measured and estimated Folch values. Multivariate analysis showed that none of the variables investigated improves the Folch prediction capacity of the equation. Obese patients show increased steatosis compared to controls using MRI fat fraction and Folch value. Bariatric surgery improved MRI fat fraction values and the Folch value estimated in obese patients one year after surgery.ConclusionsMulti-echo MRI is an accurate approach to determine the hepatic lipid concentration by using our novel equation, representing an economic non-invasive method to diagnose and monitor steatosis in humans.

Accurate fat fraction quantification by multiecho gradient-recalled-echo magnetic resonance at 1.5 T in rats with nonalcoholic fatty liver disease

AIM To assess the diagnostic accuracy of a new reconstruction technique for gradient-recalled-echo magnetic resonance (MR) sequences that provides a full decomposition of the water and fat content inside a voxel for nonalcoholic fatty liver disease (NAFLD) in rats. MATERIAL AND METHODS Rats were randomized into two groups. A control group (n = 10) was given free access to regular dry rat chow for 4 weeks. The steatosis (n = 40) group was given free access to feed and water 4 days per week, and fasted for the remaining 3 days for 4 weeks. All rats were killed at 4 weeks and assessed for fatty infiltration and biochemical method. RESULTS The average fat content using the gold standard method was 2.65 g (2.20-3.05) of fat/100g liver for the control group and 4.14 g (1.95-8.60) of fat/100g of liver for the overfed group (p<0.05). The average fat-fraction obtained from the MR was 0.016 (0.01-0.02) for the control group and 0.057 (0.00-0.18) for the overfed group. The Pearson correlation coefficient between the samples was r(2) = 0.87. CONCLUSION Multi-echo MR is a good technique to quantify liver fat in rats.

Effect of Neoadjuvant Chemotherapy in Hepatic Steatosis

Chemotherapy drugs often produce side effects in the liver. In recent years, there has been speculation about the ability to produce hepatic steatosis in patients treated with 5-fluorouracil and oxaliplatin. This prospective study examines whether these drugs can produce steatosis in patients with neoadjuvant treatment who were operated on for liver tumors. Purpose: Our objective was to assess the effect of neoadjuvant chemotherapy (NAC) on the development of hepatic steatosis in the healthy liver. Patients and Methods: This was a prospective study based on 32 patients divided into two groups. The presence of steatosis was assessed using a histological score (Kleiner classification) and a biochemical method (Folch method) for patients from both groups. Results: A total of 14 patients (44%) had hepatic steatosis and half of these were in each group. The steatosis was moderate to severe (grades 2–3) in 4 patients (13%), 2 in each group. The mean levels of triglycerides in the liver were 33.38 and 29.94 mg/g in group I and group II, respectively, with the difference not being statistically significant. Conclusions: Almost half of the patients treated with NAC for liver neoplasia developed steatosis. Nevertheless, NAC does not seem to increase the risk of hepatic steatosis.

Mild hepatic iron overload in dysmetabolic hyperferritinemia: MRI may overestimate the liver iron concentration values.

Dear Editor, It is with interest that we read the article “Dysmetabolic hyperferritinemia is associated with normal transferrin saturation, mild hepatic iron overload, and elevated hepcidin” by Chen et al. [1]. This paper claims that seven of the ten cases presented in the study had “mild” hepatic overload, with a median of 75 μmol/g, determined by MRI [2]. The results state that mild hepatic iron overload is defined as liver iron concentration (LIC) greater than 35 μmol/g and less than 150 μmol/g. The median value for the seven cases was 75 μmol/g, with a range of 40–120. Two patients had hepatic iron indexes of 1.9 and one, greater than 1.9. Is this “mild” liver iron overload? We would like to point out that normal iron concentration is between 10 and 36 μmol/g [3]; high iron overload is universally considered to be in excess of 80 μmol/g (in one study, above 71 μmol/g [4]). The authors have used Gandons MRI method [2] for LIC calculation. We recently demonstrated that this method has a tendency to overestimate LIC [5]. One must take care when labelling as “mild” a 120-μmol/g LIC and explain why this is the case (the authors were using a method that tends to overestimate). When using a validated method for LIC determination by MRI with a good correlation [6], there is no need to explain why an elevated value is considered as mild, because the value will be very similar to that obtained by liver biopsy.

La utilización del espacio en la ocupación de la cueva de Praileaitz I (Deba, Gipuzkoa, Euskal Herria)

The spatial occupation of the Praileaitz I cave (Deba) shows differences and similarities depending on the moments in which it was inhabited by human beings. In this paper, the usages that the different spaces of the cavity had from the Gravetian to its abandonment in the Epipaleolithic are reviewed. The importance of the Lower Magdalenian period is highlighted. (1) Departamento de Arqueología Prehistórica. Sociedad de Ciencias Aranzadi. Zorroagaina, z.g. 20014 Donostia. praileaitz@gmx.com (2) Departamento de Arqueología Prehistórica. Sociedad de Ciencias Aranzadi (3) Facultad de Letras (UPV-EHU) La excavación del yacimiento de Praileaitz I a lo largo de una década se ha extendido a zonas muy amplias del mismo, lo que ha permitido profundizar en las características de las efímeras ocupaciones que se han sucedido a lo largo del Paleolítico Superior (Solutrense, distintas fases del Magdaleniense) y Epipaleolítico (PEÑALVER, 2014b, PEÑALVER et al., 2017). Sin embargo, hay que señalar que no se ha alcanzado la roca madre en ninguna de las áreas de la cavidad, a excepción de en la plataforma exterior existente a un lado de la entrada. Las intervenciones reiniciadas en 2012, y que no son objeto de estudio en esta memoria, se centran en la zona noroeste del vestíbulo (cuadros 6F y 8F), en la segunda sala interior (cuadros 12J’, 14J’ y 16J’), y sobre todo en la prolongación de la galería noroeste hacia el oeste (PEÑALVER, 2013 y 2014a). El objetivo principal de estos trabajos es identificar aquellas ocupaciones anteriores al Solutrense, y más concretamente el origen de algunos restos de aspecto musteriense cuya presencia se ha constatado en el vestíbulo, en el contacto con la galería noroeste. La potencia de los diferentes niveles varía según la zona. El mayor espesor se detectó en el vestíbulo (Fig. 1), donde los sedimentos procedentes de la “chimenea” allí existente, y aquellos otros acarreados por escorrentía ladera abajo se acumulaban principalmente bajo el dintel. Prueba de ello es que el nivel de colgantes atribuible al Magdaleniense Inferior se detecta en el vestíbulo a -129 cm bajo la superficie (cuadro 10G) mientras que en el tránsito de aquí a la primera sala se sitúa a -51 cm (cuaXabier Peñalver, Sonia San JoSe, JoSe antonio MuJika-aluStiza 122 Munibe Monographs. Anthropology and Archaeology Series • 1 (2017) • 121-133 • Donostia-San Sebastián • ISSN 2530-4720 eISSN 2530-4739 dro 12B) y a tan solo -20 cm bajo la capa de concreción que cubría esta sala. La datación más antigua que disponemos (35010± 280 BP) es la obtenida a partir de una ulna de Pantera pardus, hallada en el rellano exterior existente bajo un pequeño abrigo ubicado a un lado de la entrada a la cueva en la que se han excavado 16 m2. Los restos faunísticos aquí eran frecuentes, pero no así los de carácter industrial que eran escasos y poco característicos, siendo reseñable únicamente la detección de alguna fugaz ocupación humana durante el Aziliense o el Magdaleniense Final. Es el vestíbulo y su entorno –zona de tránsito a la primera sala interior– el sector de Praileaitz I que más vestigios estratificados ha aportado, aunque todos ellos corresponden a fugaces y recurrentes ocupaciones. Cronológicamente, las dos dataciones más antiguas (25320±140 y 22900±110 BP) nos retrotraen al Gravetiense, aunque por ahora no se han identificado restos industriales característicos de esta época, por lo que tampoco se puede descartar que se relacionen con restos de animales ajenos a la ocupación humana. También hay que indicar que no se ha profundizado en extensión, hasta la fecha, en cotas inferiores del vestíbulo (por debajo de los primeros indicios solutrenses), y los restos que indican mayor antigüedad se han localizado en el contacto entre éste y la galería noroeste. Ésta última galería estaba casi colmatada en su totalidad y sellada por una potente capa estalagmítica, constatándose ocasionalmente objetos de sílex, quizás descontextualizados o en posición secundaria, y cuyo origen habría que buscar en el otro extremo de la galería. Por otra parte, no es descartable que en el vestíbulo hayan desaparecido parte de estos niveles más antiguos a causa de un vaciado posterior. El Solutrense es uno de los periodos culturales mejor representados (Figs. 2 y 3), a pesar de no haberse excavado en su totalidad en amplias zonas de la cueva, gracias a la presencia de un número significativo de objetos muy característicos, de retoques planos, en las distintas zonas de la cavidad (vestíbulo, primera sala interior y extremo norte de la segunda sala interior). Esta cronología se ve sustentada también por varias dataciones (19330±150, 17760±70 y 17530±70 BP). Hay que advertir que estos restos estaban en contacto, casi entremezclándose, con los de las ocupaciones del Magdaleniense Inferior que se le superpone. La ocupación de la cavidad durante el Magdaleniense Inferior está datada en torno al 15500 BP, y es sin duda la más importante de todas las detectadas hasta hoy en Praileaitz I, y no sólo por la relevancia de los materiales hallados, sino por la ordenación del espacio en Fig. 1. Vestíbulo iluminado por la cercana boca de la cueva (X. Otero). / Vestibule iluminated by the near entrance of the cave (X. Otero). 123 LA UTILIZACIóN DEL ESPACIO EN LA OCUPACIóN DE LA CUEVA DE PRAILEAITZ I (DEBA, GIPUZkOA, EUSkAL HERRIA) Munibe Monographs. Anthropology and Archaeology Series • 1 (2017) • 121-133 • Donostia-San Sebastián • ISSN 2530-4720 eISSN 2530-4739 ese momento, y su estructuración en torno a un hogar, un posible asiento y sobre un suelo empedrado intencionadamente (Figs. 4 y 5). Los 29 colgantes recogidos en las distintas zonas de la cueva son un claro testimonio del área frecuentada, aunque la estancia, al igual que la de otros momentos cronológicos, parece que fue temporal y no muy duradera, si nos basamos en el número y características de los restos arqueológicos recuperados. El hogar parece responder a una fogata, o a una serie de ellas prendidas en un breve periodo en el mismo punto. No se observaron hogares yuxtapuestos, ni superpuestos a distintas cotas, como se ha descrito en otros asentamientos estacionales y como sucede en los niveles VI y VII de Ekain, donde se determinaron distintas situaciones: así, se detectaron hasta cuatro hogares, uno de ellos tras preparar una pequeña hondonada y junto al mismo había “un gran bloque apto para sentarse” además de casi todos los útiles, así como numerosas lascas y restos faunísticos. En el más antiguo, que estaba cerca de la pared interior, existía una acumulación de clastos y allí se concentraban también la mayoría de las piezas (ALTUNA, MERINO, 1984: 33-34). Las áreas más intensamente frecuentadas a lo largo del Magdaleniense Inferior fueron el vestíbulo –la zona más luminosa–, la primera sala interior –de un ambiente Fig. 2-3. Elementos solutrenses: buril sobre truncadura transversal en soporte laminar con retoques planos dorsales (J.A. Mujika) y fragmento de bastón perforado (X. Otero). / Solutrean elements: burin over transversal truncation on laminar basis with dorsal flat retouches (J.A. Mujika) and fragment of perforated baton (X. Otero). en penumbra– y el “túnel” de tránsito entre estos dos espacios, de aproximadamente 1 m de altura y 1,50 m de anchura. La totalidad de esta superficie comprende 89 m2 y presenta características diferentes según el sector. El vestíbulo, con una superficie de 34 m2, muestra un suelo relativamente horizontal –la diferencia máxima de las cotas de los ejes longitudinal y transversal se sitúa en unos 20 cm – formado por pequeños clastos de calizas que parecen circunscribirse a él, ya que apenas se adentran en la galería noroeste y en la zona de tránsito a la primera sala interior (PEÑALVER, MUJIkA, 2003 y 2005b). Los cantos muestran unas dimensiones muy homogéneas (de unos 10 cm), llegando a constituir una capa irregular de unos 3 cm de espesor (subnivel IV.II). Probablemente, la colocación de carácter antrópico de estos clastos tuvo la intencionalidad de preparar un piso bien drenado, y pudieron haber sido recogidos en el entorno de la propia cavidad, donde no faltan zonas abruptas a cuyos pies se pudieron formar acumulaciones de clastos. La existencia de suelos preparados en asentamientos magdalenienses está documentada en varios yacimientos. En la cueva de Isturitz, en la base del nivel magdaleniense de la Sala San Martín, se describe una capa casi continua de piedras planas de dimensiones variables (25-30 cm), cuyo carácter antrópico no se señala, pero que quizás no habría que desechar (SAINT-PÉRIER, 1930). También al norte de los Pirineos podemos citar en el Magdaleniense Superior-Final de Bourrouilla (Arancou) la existencia de un hogar y una estructura subcircular conformada por losas calizas, al parecer relacionada con actividades de fabricación y arreglos del instrumental de caza (DACHARY et al., 2008). En los yacimientos de la falaise de Pastou también se señalan otras estructuras. En concreto en Duruthy, Xabier Peñalver, Sonia San JoSe, JoSe antonio MuJika-aluStiza 124 Munibe Monographs. Anthropology and Archaeology Series • 1 (2017) • 121-133 • Donostia-San Sebastián • ISSN 2530-4720 eISSN 2530-4739 Arambourou (1978, 147 ss) describe en el Magdaleniense VI el transporte de cantos rodados, entre los que se intercalan otros restos desprendidos de las paredes y trozos de plaquetas de arenisca, para sanear y crear un encachado, además de algún murete con bloques dipuestos de canto, y sobre todo trabajos de acondicionamiento del pronunciado talud existente bajo la falaise, creando al menos seis aterrazamientos. En estos encachados se han observado, además, agujeros de postes a fin de construir alguna estructura parcialmente aérea (tienda, paravientos, etc.) (p. 27 ss.). En los niveles del Magdaleniense IV (p. 47 ss, 148), en las proximidades de un hogar, se apreciaron abundantes plaquetas de arenisca, algunas enrojecidas por el fuego, que pavimentaban el suelo, aunque el sediment

Dysmetabolic iron overload syndrome. The need for an accurate liver iron concentration determination by MRI

We have read with great interest the article by Lain e et al. They concluded that in dysmetabolic iron overload syndrome patients, iron depletion by phlebotomy did not improve metabolic and hepatic features, was not well tolerated, and was associated with weight gain. In their study, dysmetabolic iron overload syndrome patients had a liver iron concentration (LIC) >50 lmol/g by magnetic resonance imaging. Our group has published a study that provides further evidence that LIC is not raised in patients with hyperferritinemia and metabolic syndrome. Patients with dysmetabolic hyperferritinemia (metabolic syndrome and hyperferritinemia) have a mean LIC within normal values, and LIC in patients with dysmetabolic hyperferritinemia have no significant differences from patients with hyperferritinemia and without metabolic syndrome. This points toward the importance of ferritin as a marker of inflammation rather than clinically important hepatic iron deposition and provides caution when interpreting these values and making subsequent clinical management decisions, for example, whether to perform a phlebotomy. The LIC determination in Lain e et al.’s study was performed by magnetic resonance imaging, using Rennes University’s calculation model. This method has a tendency to overestimate LIC, which limits the diagnostic performance and accuracy for clinical practice. In a study with 171 biopsied patients, 43% of patients with no iron overload were diagnosed using MRI as having liver iron overload and 45% of patients with moderate iron overload were diagnosed as having high iron overload. The specificity for the absence of liver iron overload was 57%. We can expect that an important group of Lain e et al.’s 274 patients may have been overestimated for LIC values. Probably, the real LIC values were lower than those published.

Dysmetabolic iron overload syndrome: The need for an accurate liver iron concentration determination by magnetic resonance imaging: CORRESPONDENCE

We have read with great interest the article by Lain e et al. They concluded that in dysmetabolic iron overload syndrome patients, iron depletion by phlebotomy did not improve metabolic and hepatic features, was not well tolerated, and was associated with weight gain. In their study, dysmetabolic iron overload syndrome patients had a liver iron concentration (LIC) >50 lmol/g by magnetic resonance imaging. Our group has published a study that provides further evidence that LIC is not raised in patients with hyperferritinemia and metabolic syndrome. Patients with dysmetabolic hyperferritinemia (metabolic syndrome and hyperferritinemia) have a mean LIC within normal values, and LIC in patients with dysmetabolic hyperferritinemia have no significant differences from patients with hyperferritinemia and without metabolic syndrome. This points toward the importance of ferritin as a marker of inflammation rather than clinically important hepatic iron deposition and provides caution when interpreting these values and making subsequent clinical management decisions, for example, whether to perform a phlebotomy. The LIC determination in Lain e et al.’s study was performed by magnetic resonance imaging, using Rennes University’s calculation model. This method has a tendency to overestimate LIC, which limits the diagnostic performance and accuracy for clinical practice. In a study with 171 biopsied patients, 43% of patients with no iron overload were diagnosed using MRI as having liver iron overload and 45% of patients with moderate iron overload were diagnosed as having high iron overload. The specificity for the absence of liver iron overload was 57%. We can expect that an important group of Lain e et al.’s 274 patients may have been overestimated for LIC values. Probably, the real LIC values were lower than those published.

Dysmetabolic iron overload syndrome: The need for an accurate liver iron concentration determination by magnetic resonance imaging

We have read with great interest the article by Lain e et al. They concluded that in dysmetabolic iron overload syndrome patients, iron depletion by phlebotomy did not improve metabolic and hepatic features, was not well tolerated, and was associated with weight gain. In their study, dysmetabolic iron overload syndrome patients had a liver iron concentration (LIC) >50 lmol/g by magnetic resonance imaging. Our group has published a study that provides further evidence that LIC is not raised in patients with hyperferritinemia and metabolic syndrome. Patients with dysmetabolic hyperferritinemia (metabolic syndrome and hyperferritinemia) have a mean LIC within normal values, and LIC in patients with dysmetabolic hyperferritinemia have no significant differences from patients with hyperferritinemia and without metabolic syndrome. This points toward the importance of ferritin as a marker of inflammation rather than clinically important hepatic iron deposition and provides caution when interpreting these values and making subsequent clinical management decisions, for example, whether to perform a phlebotomy. The LIC determination in Lain e et al.’s study was performed by magnetic resonance imaging, using Rennes University’s calculation model. This method has a tendency to overestimate LIC, which limits the diagnostic performance and accuracy for clinical practice. In a study with 171 biopsied patients, 43% of patients with no iron overload were diagnosed using MRI as having liver iron overload and 45% of patients with moderate iron overload were diagnosed as having high iron overload. The specificity for the absence of liver iron overload was 57%. We can expect that an important group of Lain e et al.’s 274 patients may have been overestimated for LIC values. Probably, the real LIC values were lower than those published.