Unggul Budihusodo

Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma

IntroductionThe Asian Pacific Association for the Study of the Liver (APASL) convened an international working party on the management of hepatocellular carcinoma (HCC) in December 2008 to develop consensus recommendations.MethodsThe working party consisted of expert hepatologist, hepatobiliary surgeon, radiologist, and oncologist from Asian-Pacific region, who were requested to make drafts prior to the consensus meeting held at Bali, Indonesia on 4 December 2008. The quality of existing evidence and strength of recommendations were ranked from 1 (highest) to 5 (lowest) and from A (strongest) to D (weakest), respectively, according to the Oxford system of evidence-based approach for developing the consensus statements.ResultsParticipants of the consensus meeting assessed the quality of cited studies and assigned grades to the recommendation statements. Finalized recommendations were presented at the fourth APASL single topic conference on viral-related HCC at Bali, Indonesia and approved by the participants of the conference.

Diagnostic value of a group of biochemical markers of liver fibrosis in patients with non-alcoholic steatohepatitis

OBJECTIVE: The objectives of this study were to investigate the use of non‐invasive biochemical markers to evaluate the severity of liver fibrosis in patients with non‐alcoholic steatohepatitis (NASH).

Seroepidemiology of HBV and HCV infection in Jakarta, Indonesia

A total of 545 serum samples were consecutively collected from patients with acute hepatitis, chronic hepatitis, liver cirrhosis, hepatocellular carcinoma, chronic hemodialysis and voluntary blood donors to study the seroepidemiology of HBV and HCV infection in Jakarta. Fourteen out of 243 or 5.8% samples from blood donors were HBsAg-positive, while HCV-antibodies (anti-C100 and/or anti-CP9 and/or anti-CP10) positivity rate was found in 59 out of 243 or 24.3%. Out of 91 donors aged 29 years or younger, 15 (16.5%) donors turned positive for HCV-antibody (-ies), while out of 152 donors aged 30 years or above, 44 (28.9%) donors were anti-HCV-positive, showing a higher HCV-antibody prevalence among higher age group. Among 88 acute hepatitis patients, 33 (37.5%) cases, 10 (11.4%) cases, 15 (17.0%) cases and 30 (34.1%) cases were diagnosed as hepatitis A, hepatitis B, acute exacerbation of HCV carriers, and NANB hepatitis respectively. HCV-antibodies were found in 15 (45.5%) of hepatitis A cases and 6 (40.0%) of acute exacerbation of HBV carrier cases, but found only in 9 (30.0%) of acute NANB hepatitis cases. Positivity rates of HCV-antibodies among 23 chronic hepatitis, 80 liver cirrhosis and 64 hepatocellular carcinoma cases were 78.3%, 75.0% and 65.6% respectively, while 30.4%, 30.0% and 45.3% of the respective groups were positive for HBs antigen. Among 47 hemodialysis cases, 97.9% and 6.4% were positive for HCV antibodies and HBs antigen respectively. It was concluded that: (1) HBV infection rate is high among blood donors and patients with acute and chronic liver diseases. (2) HCV infection rate is high among blood donors.(ABSTRACT TRUNCATED AT 250 WORDS)

Significant hepatic histopathology in chronic hepatitis B patients with serum ALT less than twice ULN and high HBV-DNA levels in Indonesia

OBJECTIVE:  To study the prevalence of significant hepatic histopathology in chronic hepatitis B (CHB) patients with alanine aminotransferase (ALT) ≤ twice upper limit of normal (ULN) and its association with age, HBeAg status, hepatitis B virus (HBV)‐DNA level and viral genotype.

Effect of L-ornithine-L-aspartate Therapy on Low-Grade Hepatic Encephalopathy in Patients with Liver Cirrhosis

Background: Minimal hepatic encephalopathy (MHE) is an abnormal condition of psychometric testing before hepatic encephalopathy (HE) condition reducing quality of life and survival rate. Impractical instrument, the psychometric hepatic encephalopathy score (PHES), has been recommended in diagnosing MHE. The new critical flicker frequency (CFF) has good precision and accuracy for diagnosing MHE. Oral L-ornithine-L-aspartate (LOLA) may increase ammonia detoxification. The aim of this study was to recognize the effect of oral LOLA on low-grade HE by investigating the mean value of CFF. Method: We included 31 patients with liver cirrhosis and low-grade HE (MHE, HE grade 1 and 2) at the outpatient clinic of hepatology, Cipto Mangunkusumo hospital between November 2009 and March 2010. It was a double-blind, randomized, placebo-controlled clinical trial. Oral LOLA was administered in a dose of 18 g/day, 3 times daily for 14 consecutive days. At the end of the study, there were 27 cirrhotic patients with CFF value < 38 Hz; 14 patients had received LOLA and 13 patients had placebo. Statistic analysis was performed by using the Mann-Whitney U test. Results: The mean value of CFF in LOLA group after treatment (39.3 Hz) was significantly different than the placebo group (36.04 Hz); (p = 0.027). Ammonia level decreased in LOLA group from 118.7 into 109.1 µ mol/L. In placebo group, it increased from 106.9 into 147.5 µ mol/L with p = 0.275 (before); p = 0.052 (after). Conclusion: Oral LOLA may improve the value of CFF and is likely to decrease blood ammonia level in patients with low-grade HE. Keywords: low-grade hepatic encephalopathy, oral LOLA, CFF improvement, ammonia detoxification

Acalculous Cholecystitis Prevalence on Abdominal Ultrasonography Examination of HIV/HCV Co-infection Patients in Cipto Mangunkusumo Hospital

Background: Acalculous cholecystitis is commonly found in patients with human immunodeficiency virus (HIV) compared to general population. Surprisingly, the signs and symptoms are unremarkable. On the other hand, HIV/hepatitis C virus (HCV) co-infection is a common finding. The aim of this study was to evaluate whether HCV infection has any influence to HIV patients concerning acalculous cholecystitis prevalence. Method: A cross-sectional study was performed in HIV/HCV patients who visited AIDS study group clinic at Cipto Mangunkusumo hospital during September 2008 to February 2009. The patients who met the criteria were examined physically and underwent abdominal ultrasonography. Routine blood count, alanine aminotranferase, aspartate aminotransferase, cluster of differentiation 4 (CD4) and serum albumin were recorded. Results: Of 63 patients underwent ultrasonography examination, we found acalculous cholecystitis in 33 patients (52.3%), cholelithiasis and cholecystitis in 2 patients, and 28 patients were considered normal. Patients with CD4 less than 200 cells, tend to have acalculous cholecystitis more than those who had CD4 more than 200 cells. Conclusion: The prevalence of acalculous cholecystitis among HIV/HCV co-infection is higher compared to those with HIV infection alone. Keywords: acalculous cholecystitis, HIV/HCV co-infection, CD4

Effects of BCAA Enteral Nutrition to the Change of Nutritional Status and Hepatic Encephalopathy Parameters in Liver Cirrhosis Patient with Hepatic Encephalopathy

Background: This study was also conducted to determine the effects of high-branched chain amino acid (BCAA) enteral supplementation on altered nutritional status parameters (including plasma prealbumin) and hepatic encephalopathy parameters in liver cirrhosis patients with hepatic encephalopathy. Method: Our study was a randomized, single-blinded experimental study comparing between control group of liver cirrhosis patients with standard hospital liver diet (40 kcal/kgBW/day for male and 35 kcal/kgBW/day for female; protein 1.25 g/kgBW/day) and experimental group of liver cirrhosis patients with liver diet modification high in BCAA supplementation, which had similar protein and calorie calculation as the control group. Results: Subclinical hepatic encephalopathy prevalence was 32%. In the experimental group, prealbumin plasma, arm circumference, body weight and body mass index (BMI) increased; whereas in the control group, prealbumin plasma, arm circumference, body weight and BMI decreased (p < 0.05). In experimental group, the ammonia level significantly decreased (p < 0.01). Clinical hepatic encephalopathy, flapping tremor, the number connection test (NCT) did not show significant changes between the two groups. However, there was worsening trend in the control group. Level of albumin, bilirubin, AST, ALT did not show any significant difference between both groups. Conclusion: High-BCAA enteral supplementation which is administered to liver cirrhosis patients with hepatic encephalopathy for 14 days could improve plasma prealbumin level, arm circumference, body weight, BMI and could decrease the plasma ammonia level. However, it does not improve Fischer ratio, psychometric test and electroencephalography Keywords: malnutrition, liver cirrhosis, BCAA, Fisher ratio

Measuring HBsAg and HBV DNA Levels in Cilegon

Background: Implication of measuring HBsAg level is still not recognized well. The aim of this study to recognize the correlation of serum HBsAg level and serum HBV DNA level between in HBeAg positive patients and HBeAg negative patients. Method: Quantitative serum HBV DNA were collected retrospectively between January 2006 and May 2009. We stratified the patients into four groups, that were; HBeAg positive and (a) ALT > 2 x upper limited normal (UNL) (group A),( b) ALT 2 x UNL (group C) (b) ALT 20,000 IU/mL. In group B, C and D the accuracy to predict serum HBV DNA level were not so good . Conclusion: There were positive correlation between HBsAg titers and HBV DNA levels in HBeAg positive and HBeAg negative patients as demonstrated in the three group stratification; however, the correlation was negative in group HBeAg positive and ALT 2 x UNL with HBsAg cut-off level 7.91 IU/mL and baseline serum HBV DNA cut-off level > 20,0 0 0 IU/mL; while in other groups, the correlation were not so good. Keywords: serum HBsAg level, serum HBV DNA level, hepatitis B, correlation

Protein Energy Malnutrition in Liver Cirrhosis

Protein-energy malnutrition is common in patients with liver cirrhosis, especially in advanced and severe stage. Liver cirrhosis patients with malnutrition have increasing risk to get post-operative complication and mortality. The etiology of malnutrition is multifactorial. Substrate metabolism in liver cirrhosis is characterized by insulin resistance, influencing the transport and elimination of nonoxidative glucose by muscle. Protein turnover occurs in normal rate or it may increase with the increasing of protein degradation. Oxidation and metabolic clearance of fat are normal in patients with liver cirrhosis. Most clinicians used to feed patients with liver disease with a common sense approach, otherwise many investigators suggest the use of nutritional supplements and specialized formulations aggressively, in older to correct pre-existing protein-calorie malnutrition and to stimulate hepatic regeneration. Keywords: malnutrition, liver cirrhosis, branched-chain amino acid