We present here the first update of the 2013 EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) Guidelines and Recommendations on the clinical use of elastography with a focus on the assessment of diffuse liver disease. The short version provides clinical information about the practical use of elastography equipment and interpretation of results in the assessment of diffuse liver disease and analyzes the main findings based on published studies, stressing the evidence from meta-analyses. The role of elastography in different etiologies of liver disease and in several clinical scenarios is also discussed. All of the recommendations are judged with regard to their evidence-based strength according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence. This updated document is intended to act as a reference and to provide a practical guide for both beginners and advanced clinical users.

/pdf/efsumb-guidelines-and-recommendations-on-the-clinical-use-of-q0y0yhaqko.pdf

EFSUMB Guidelines and Recommendations on the Clinical Use of Liver Ultrasound Elastography, Update 2017 (Long Version)

https://archive-ouverte.unige.ch/unige:112949/ATTACHMENT01

EASL Clinical Practice Guidelines on nutrition in chronic liver disease

ESPEN guideline on clinical nutrition in liver disease.

https://www.cghjournal.org/article/S1542-3565(16)30198-7/pdf

A Model to Identify Sarcopenia in Patients With Cirrhosis

https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.26370

The nutritional management of hepatic encephalopathy in patients with cirrhosis: International society for hepatic encephalopathy and nitrogen metabolism consensus

Liver cirrhosis affects the results of many of the traditional techniques currently used to evaluate nutritional status. Our aim was to compare the traditional two-compartment model (subjective global assessment and anthropometry and blood tests) of nutritional assessment with a multicompartmental model (body composition analysis) in patients with cirrhosis. Seventy-nine patients and 17 control subjects were studied. Subjective global assessment, anthropometry and blood tests, and body composition analysis were performed for each. The two most important compartments were body cell mass and total body fat. The subjects were classified by each method as well nourished or moderately or severely malnourished. Twenty-five patients (31.6%) were malnourished according to the subjective global assessment, 2 (6.3%) with Child's class A cirrhosis, 10 (34.5%) with class B, and 13 (72.2%) with class C, whereas 24 (30.4%) were malnourished according to the traditional model, 5 (15.6%) in the Child's A group, 8 (27.6%) in B, and 11 (61.1%) in C. According to the multicompartmental model, 48 patients (60.1%) were malnourished, 11 (34.4%) in Child's A, 20 (69%) in B, and 17 (94.4%) in C. The use of the multicompartmental model increased the prevalence of malnutrition by more than 60% in Child's classes A and B patients and by more than 20% in Child's class C patients. Traditional nutritional assessment, although easier, underestimated the prevalence and severity of malnutrition in patients with cirrhosis. The underestimation was more pronounced in Child's class A and B patients.

Comparison of three methods of nutritional assessment in liver cirrhosis: subjective global assessment, traditional nutritional parameters, and body composition analysis.

Background and Aims:  Malnutrition is common in liver cirrhosis patients. However, it is under-diagnosed because liver disease affects the traditional nutritional assessment. An understanding of changes in body composition and the establishment of the tissue-loss pattern in liver cirrhosis patients could help practitioners to better manage malnutrition in this setting. The aims of this study were: to quantify body composition changes, to determine tissue loss pattern, and to assess the relation of these to the severity of hepatic dysfunction.



Methods:  Seventy-nine patients and 17 controls were studied. Total body water and extracellular water were measured using dilution techniques. Intracellular water and body cell mass were calculated from these parameters. Total body fat was obtained using absorptiometry.



Results:  Extracellular water was increased and intracellular water was decreased in patients. The two major compartments (body cell mass and body fat) were significantly reduced, mainly in patients with moderate and severe disease. However, significant losses occurred even in Child–Pugh class A patients. We established a tissue-loss pattern. In Child–Pugh class A patients body fat loss predominated. Child–Pugh class B patients had losses in at least one of the two compartments. Most Child–Pugh class C patients had simultaneous depletion in both compartments.



Conclusions:  Liver cirrhosis was characterized by a significant reduction in body cell mass and body fat and by a redistribution of body water. Significant losses occurred even in patients with mild disease. There was a more pronounced loss of fat in the initial stages, followed by an accelerated loss of body cell mass in the advanced stages of liver cirrhosis.



© 2004 Blackwell Publishing Asia Pty Ltd

Effect of liver cirrhosis on body composition: Evidence of significant depletion even in mild disease

Background and Aims:  Patients undergoing hemodialysis are at risk of infection with both hepatitis B virus (HBV) and hepatitis C virus (HCV). Occult HBV infection is usually associated with low levels of HBV and is frequently detected in HCV-infected patients. The aims of the present study were to compare the prevalence of occult HBV infection among anti-HCV-positive and anti-HCV-negative patients undergoing hemodialysis, and characterize the molecular patterns of HBV isolates from patients with occult infection.



Methods:  Serum samples from 100 patients negative for hepatitis B surface antigen undergoing hemodialysis, half of whom were positive for anti-HCV antibodies, were tested for the presence of HBV-DNA using semi-nested polymerase chain reaction (PCR). PCR products of the S gene were directly sequenced.



Results:  HBV-DNA was detected in 15 samples. There were no significant differences in HCV status, sex, age, time of dialysis, alanine aminotransferase levels or HBV serological markers between patients with or without occult HBV infection, with the exception of antibody to hepatitis B core antigen (anti-HBc)-only serological marker (P = 0.003). All six HBV isolates that could be sequenced were of genotype A/subgenotype A1. Four of these six HBV isolates contained mutations associated with lamivudine resistance in the DNA polymerase (two with L180M/M204V and two with rt173V/180M/204V) and a specific substitution (Y100C) in the HBV small surface protein.



Conclusions:  HBV isolates with the identified substitutions have the potential to spread silently by nosocomial transmission within the hemodialysis unit. These results have potential implications for the management of patients with occult HBV infection undergoing hemodialysis.

Occult hepatitis B virus infection and lamivudine-resistant mutations in isolates from renal patients undergoing hemodialysis.

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 (PIIIN

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

Background & Aims
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.

Methods
We performed a cross-sectional study, analysing findings from two experienced operators who each assessed 195 patients by transient elastography on the same day. Liver stiffness measurement used to define fibrosis stages, based on METAVIR score, was: 12.4 kPa as F4. We also assessed interobserver variation in identification of potential oesophageal varices screening based on transient elastography.

Results
The interobserver intraclass correlation coefficient was 0.940 (95% CI 0.863–0.967) and measurements made by operators correlated [Spearman's ρ = 0.924; P < 0.001]. However, the median liver stiffness measurement assessed by first operators was higher (11.5 vs 9.8 kPa; P < 0.001). The discordance between operators was 35% for at least one stage of fibrosis and 5% for two or more stages. Interobserver reliability values were κ = 0.61 for fibrosis stages F ≥ 2 and κ = 0.80 for cirrhosis. Among the 74 patients determined to have cirrhosis by at least one operator, there was considerable discordance in identification of those with indication for oesophageal varices screening (κ values from 0.13 to 0.61) according to several cut-offs.

Conclusion
Although a high correlation of liver stiffness measurement between operators, interobserver variability in transient elastography was not negligible. This method should not be used as the only screening tool for oesophageal varices in chronic hepatitis C.

Fatima Aparecida Ferreira Figueiredo

Papers

Comparison of three methods of nutritional assessment in liver cirrhosis: subjective global assessment, traditional nutritional parameters, and body composition analysis.

Effect of liver cirrhosis on body composition: Evidence of significant depletion even in mild disease

Occult hepatitis B virus infection and lamivudine-resistant mutations in isolates from renal patients undergoing hemodialysis.

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

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