Amaddeo, G

Biasi, L

BRONTE, Fabrizio

Bruno, R

CALVARUSO, Vincenza

CRAXI, Antonio

DI MARCO, Vito

Iacò, A

Prestini, K

Puoti, M

Sacchi, P

Squadrito, G

Iacò, A

Archivio istituzionale della ricerca - Università di Palermo

LETTERSLiver stiffness measurement bytransient elastography predictsearly recovery from acutehepatitisWe read with interest the lead article byCasterà and Pinzani,1 particularly thecomment regarding the role of transientelastography (TE) in the context of acutehepatitis (AH).The assumption that liver stiffness isdetermined exclusively by hepatic ﬁbrosishas been challenged by evidence thatpatients with AH can have high values ofliver stiffness measurement (LSM) by TE.2AH is a suitable model for studying thekinetics of LSM, since inﬂammation andnecrosis increase rapidly and sometimesmassively, but may revert with equal speed.We evaluated 92 consecutive patients(mean age 41.8616.3 years, 71.7% males)with symptomatic AH to assess how LSMwas inﬂuenced by aetiology, and whetherLSM kinetics correlated with the clinicalcourse of AH. Twelve patients (13%)had acute hepatitis A virus (AHAV), 34(37%) acute hepatitis B virus (AHBV), 26(28.3%) acute hepatitis C virus (AHCV) and20 (21.7%) drug-induced liver injury (DILI).TE was performed at the onset of symptomsof AH, and at 4, 8 and 12 weeks. At the onsetof AH, all patients had values of serumalanine aminotransferase (ALT) at least 10times above the upper normal limit, andjaundice was present in 70, 60, 42 and 27%of patients with AHBV, DILI, AHAV andAHCV, respectively (p¼0.009). The medianvalue of LSM was 12.2 kPa (range 3.6e45.0),and LSM correlated with ALT (r¼0.346,p¼0.001) and bilirubin (r¼0.349, p¼0.001).LSM was signiﬁcantly different in the fourgroups of patients (p¼0.003), and LSM>12 kPa, the predictive cut-off for the diag-nosis of cirrhosis, was observed in 64, 46, 40and 8% of patients with AHBV, AHCV, DILIand AHAV, respectively (p¼0.010). Fourpatients with severe acute AHBV receivedlamivudine, one with severe DILI receivedsteroids, and 20 with AHCV received inter-feron treatment. A progressive and signiﬁ-cant reduction in LSM was observed in allgroups of patients during follow-up. In thefourth week, 27, 38, 40 and 100% of patientswith AHBV, AHCV, DILI and AHAV,respectively, had LSM <7 kPa. At week 8, thepercentage of patients with LSM <7 kPa was37, 50 and 50% for AHBV, AHCV and DILI,respectively. At week 12, the percentage ofpatients with LSM <7 kPa was 44, 58 and66% for AHBV, AHCVand DILI, respectively(ﬁgure 1). To identify whether biochemicalparameters and LSM predict the clinicalcourse of AH, patients were analysed forearly clinical recovery from AH (normalserum ALT values at week 4). By logisticregression analysis LSM was the onlyvariable at presentation associated withearly clinical recovery (OR 0.727, 95% CI0.599 to 0.882, p¼0.001). The receiver oper-ating characteristic (ROC) analysis forthe model was 0.84, and the best cut-off ofLSM for identifying patients with earlyclinical recovery was 9.5 kPa (sensitivity83%, speciﬁcity 70%, positive predictivevalue 41%, negative predictive value 96%,positive likelihood ratio (LR) 2.86 and nega-tive LR 0.16).We concluded that LSM has a wide rangeof values in AH, reﬂecting different mecha-nisms of liver injury. In patients with AHAVwho have prevalently a necrotic injury withscarce portal and periportal lymphocyticinﬁltration,3 LSM rarely increases up to thevalues observed in patients with cirrhosis.Conversely, severe immune-mediatedlymphocytic inﬁltration4 5 can be thesubstrate for the increase in LSM in patientswith AHBV or AHCV, and both inﬂamma-tory mechanisms and cholestasis6 canincrease LSM in patients with DILI. Finally,LSM is independently associated with earlyclinical recovery and could be used tomonitor patients with AH.Vito Di Marco,1 Vincenza Calvaruso,1Alessandra Iaco`,1 Fabrizio Bronte,1 Luciano Biasi,2Katiela Prestini,2 Paolo Sacchi,3 GiulianaAmaddeo,4 Giovanni Squadrito,4 Raffaele Bruno,3Massimo Puoti,2 Antonio Craxı`11Sezione di Gastroenterologia e Epatologia (Di.Bi.M.I.S.),University of Palermo, Italy; 2Unita` complessa di MalattieInfettive, AO Niguarda-Ca` Granda, Milano Dipartimentodi Malattie Infettive, University of Brescia, Italy;3Divisione di Malattie Infettive, University di Pavia, Italy;4Unita` di Epatologia Clinica e Biomolecolare, University ofMessina, ItalyCorrespondence to Vito Di Marco, DipartimentoBiomedico diMedicina Interna e Specialistica, (Di.Bi.M.I.S.),University of Palermo, Piazza delle Cliniche 2, 90127Palermo, Italy; vito.dimarco@tin.itCompeting interests None.Patient consent Obtained.Provenance and peer review Not commissioned; notexternally peer reviewed.Published Online First 9 December 2010Gut 2011;60:1023. doi:10.1136/gut.2010.228478REFERENCES1. Castera L, Pinzani M. Biopsy and non-invasivemethods for the diagnosis of liver fibrosis: does it taketwo to tango? Gut 2010;59:861e6.2. Arena U, Vizzutti F, Corti G, et al. Acute viral hepatitisincreases liver stiffness values measured by transientelastography. Hepatology 2008;47:380e4.3. Masada CT, Shaw BW Jr, Zetterman RK, et al.Fulminant hepatic failure with massive necrosis asa result of hepatitis A infection. J Clin Gastroenterol1993;17:158e62.4. Ishii S, Koziel MJ. Immune responses during acuteand chronic infection with hepatitis C virus. ClinImmunol 2008;128:133e47.5. Sprengers D, van der Molen RG, Kusters JG, et al.Analysis of intrahepatic HBV-specific cytotoxic T-cellsduring and after acute HBV infection in humans.J Hepatol 2006;45:182e9.6. Ramachandran R, Kakar S. Histological patterns indrug-induced liver disease. J Clin Pathol2009;62:481e92.Immediate effect on fertility ofa gluten-free diet in women withuntreated coeliac diseaseIn a recent paper inGut, describing a Swedishpopulation-based cohort, Zugna et al found56065505540453035202510150560655055404530352025101505606550554045303520251015056065505540453035202510150VCHAVBHAVAHAILIDLSM (kPa)LSM (kPa)LSM (kPa)LSM (kPa)10.0 = p720.0 = p500.0 = p100.0 < p4enilesaBht8keewht21keewhtkeew 4enilesaBht8keewht21keewhtkeewenilesaB 4ht8keewht21keewhtkeew4enilesaBht8keewht21keewhtkeewFigure 1 Kinetics of liver stiffness measurement (LSM) during the clinical course of the differentgroups. AHAV, acute hepatitis A virus; AHBV, acute hepatitis B virus; AHCV, acute hepatitis Cvirus; DILI, drug-induced liver injury.Gut July 2011 Vol 60 No 7 1023PostScript group.bmj.com on May 24, 2013 - Published by gut.bmj.comDownloaded from doi: 10.1136/gut.2010.228478 2011 60: 1023 originally published online December 9, 2010Gut Vito Di Marco, Vincenza Calvaruso, Alessandra Iacò, et al. acute hepatitiselastography predicts early recovery from Liver stiffness measurement by transient http://gut.bmj.com/content/60/7/1023.1.full.htmlUpdated information and services can be found at: These include:References http://gut.bmj.com/content/60/7/1023.1.full.html#ref-list-1This article cites 6 articles, 2 of which can be accessed free at:serviceEmail alertingthe box at the top right corner of the online article.Receive free email alerts when new articles cite this article. Sign up inNotes http://group.bmj.com/group/rights-licensing/permissionsTo request permissions go to: http://journals.bmj.com/cgi/reprintformTo order reprints go to: http://group.bmj.com/subscribe/To subscribe to BMJ go to: group.bmj.com on May 24, 2013 - Published by gut.bmj.comDownloaded from 

Liver stiffness measurement by transient elastography predicts early recovery from acute hepatitis

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Liver stiffness measurement by transient elastography predicts early recovery from acute hepatitis

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