Elastografik fibrozis ve steatozun demografik, klinik ve laboratuvar belirleyicileri

Öz

Giriş ve Amaç: Viral hepatitler tüm dünyada en önemli karaciğer hastalığı nedeni olma özelliğini sürdürmektedir. Bunun yanında alkolik ve nonalkolik karaciğer hastalıklarına da artan sıklıkta rastlanmaktadır. Obezite ve diyabet sıklığı ile alkol tüketimindeki artışlar, bu faktörlerin önümüzdeki yıllarda kronik karaciğer hastalıkları etiyolojisinde daha önemli olacağını düşündürmektedir. Karaciğer fibrozisi ve sonucunda gelişen siroz, kronik karaciğer hastalığının başlıca morbidite ve mortalite sebebidir. Çalışmada elastografi ile elde edilen fibrozis ve steatozis sonuçlarının biyokimyasal ve antropometrik parametrelerle olan ilişkisinin incelenmesi amaçlandı. Gereç ve Yöntem: Karadeniz Teknik Üniversitesi Tıp Fakültesi Hastanesi Gastroenteroloji Kliniği’ne başvuran ve elastografi yapılan 50 hasta çalışmaya dâhil edildi. Hastaların biyokimyasal parametreleri ve beden kitle indeksi ile elastografik steatoz ve fibrozis skorları arasındaki ilişki değerlendirildi. Elastografi kontrollü atenüasyon parametresi değerleri Li’nin skalası baz alınarak S0-S3 arasında; fibrozis/elastisite değerleri ise Petroff’un skalası baz alınarak F0-F4 arasında sınıflandırıldı. Bulgular: Çalışmaya dâhil edilen 50 hastanın 26’sı erkek, 24’ü kadındı. Ortalama yaş 49.9 ± 13.4 yıldı. Vücut kitle indeksi için ortanca değer 29.4 kg/m2 olarak saptandı. En sık eşlik eden hastalıklar hipertansiyon (n = 19, %38), diyabetes mellitus (n = 19, %38), hiperlipidemi (n = 11, %22) ve hipotiroidi (n = 7, %14) idi. Hastaların transient elastografi ile ölçülen fibrozis skorları; F0-1 %84 (n = 42), F2 %4 (n = 2), F3 %4 (n = 2 ve F4 %8 (n = 4); elastografi kontrollü atenüasyon parametresi değerleri ise S0 %61.2 (n = 30), S1 %2 (n = 1), S2 %10.2 (n = 5), S3 %6.1 (n = 3), S4 %20.4 (n = 10) şeklinde idi. Steatoz derecesi ≥ S2 olanlarda vücut kitle indeksi ve trigliserit düzeyi anlamlı olarak daha yüksekti (p < 0.05). Fibrozis düzeyi ≥ F2 olanlarda total kolesterol, yüksek dansiteli lipoprotein, alanin aminotransferaz ve gama glutamil transpeptidaz değerleri anlamlı olarak yüksekti (p < 0.05). Alıcı işlem karakteristikleri eğrisi kullanılarak yapılan analiz sonucunda steatoz derecesi ≥ S2 varlığını ön gördüren vücut kitle indeksi değerinin 29.6 kg/m2 olduğu saptanmıştır (%73.7 duyarlılık, %65.5 özgüllük, eğrinin altında kalan: 0.808, %95 güven aralığı: 0.687-0.028). Sonuç: Elastografik olarak karaciğer steatoz ve fibrozisinin belirlenmesi, hastaların rutin takiplerinde klinik durumu, prognozu ve tedavi cevabının değerlendirilmesi açısından faydalı ve etkin bir yöntemdir. Ekonomik nedenlerle uygulanamadığı durumlarda noninvaziv testlerin kullanımı ihmal edilmemelidir.

Anahtar Kelimeler

• Nonalkolik yağlı karaciğer hastalığı
• fibrozis
• steatozis
• transient elastografi
• elastografi kontrollü atenüasyon parametresi
• CAP

Demographic, clinical and laboratory predictors of hepatic steatosis and fibrosis by elastography

Öz

Background and Aims: Viral hepatitis continues to be the most important cause of liver disease all over the world. In addition, alcoholic and non-alcoholic liver diseases are also encountered with increasing frequency. The prevalence of obesity and diabetes and the increase in alcohol consumption suggest that these factors will be more important in the etiology of chronic liver diseases in the coming years. Liver fibrosis and associated cirrhosis are the main causes of morbidity and mortality in chronic liver disease. In our study, we aimed to examine the relationship between fibrosis and steatosis results obtained by elastography and biochemical and anthropometric parameters. Materials and Method: Fifty patients who applied to Karadeniz Technical University Medical Faculty Hospital Gastroenterology Clinic and underwent elastography were included in the study. The relationship between the patients' biochemical parameters and body mass index, and elastographic steatosis and fibrosis scores were evaluated. Elastography controlled attenuation parameter values are between S0 and S3 based on the scale of Li; fibrosis/elasticity values were classified between F0-F4 based on Petroff's scale. Results: Of the 50 patients included in the study, 26 were male and 24 were female. The mean age was 49.9 ± 13.4 years. The median value for body mass index was 29.4 kg/m2. The most common comorbidities were hypertension (n = 19, 38%), diabetes mellitus (n = 19, 38%), hyperlipidemia (n = 11, 22%) and hypothyroidism (n = 7, 14%). Fibrosis scores of patients measured by transient elastography; F0-1 was 84% (n = 42), F2 4% (n = 2), F3 4% (n = 2), and F4 8% (n = 4). Elastography controlled attenuation parameter values are S0 61.2% (n = 30), S1 2% (n = 1), S2 10.2% (n = 5), S2-3 6.1% (n = 3), S4 20.4% (n = 10). In those with a degree of steatosis ≥ S2; body mass index and triglyceride levels were significantly higher (p < 0.05). Total cholesterol, high density lipoprotein, alanine aminotransferase and gamma glutamyl transferase values were significantly higher in patients with fibrosis level ≥ F2 (p < 0.05). As a result of the analysis using the receiver operating characteristic curve, the body mass index value predicting the presence of steatosis degree ≥ S2 was found to be 29.6 kg/m2 (73.7% sensitivity, 65.5% specificity, under the curve: 0.808, 95% confidence interval: 0.687-0.028). Conclusion: Elastographic determination of liver steatosis and fibrosis is a useful and effective method in the routine follow-up of patients, in terms of evaluating the clinical status, prognosis and treatment response. The use of non-invasive tests based on biochemical parameters should not be neglected in cases where device-dependent noninvasive tests cannot be applied for economic reasons.

Anahtar Kelimeler

• Non-alcoholic fatty liver disease
• fibrosis
• steatosis
• transient elastography
• elastography controlled attenuation parameter
• CAP

Kaynakça

1. 1. Younossi Z, Anstee QM, Marietti M, et al. Global burden of NAFLD and NASH: Trends, predictions, risk factors and prevention. Nat Rev Gastroenterol Hepatol 2018;15:11-20.
2. 2. Sanyal AJ, Chalasani N, Kowdley K V, et al. Pioglitazone, vitamin E, or placebo for nonalcoholic steatohepatitis. N Engl J Med 2010;362:1675-85.
3. 3. Angulo P. Nonalcoholic fatty liver disease. N Engl J Med [Internet]. 2002 Apr 18;346(16):1221–31.
4. 4. Adams LA, Anstee QM, Tilg H, et al. Non-alcoholic fatty liver disease and its relationship with cardiovascular disease and other extrahepatic diseases. Gut [Internet] 2017;66:1138-53.
5. 5. Pisto P, Santaniemi M, Bloigu R, et al. Fatty liver predicts the risk for cardiovascular events in middle-aged population: a population-based cohort study. BMJ Open [Internet]. 2014 Mar 15;4(3):e004973.
6. 6. Eslam M, Newsome PN, Sarin SK, et al. A new definition for metabolic dysfunction-associated fatty liver disease:An international expert consensus statement. J Hepatol 2020;73:202-9.
7. 7. Eslam M, Sanyal AJ, George J, International Consensus Panel. MAFLD: A Consensus-driven proposed nomenclature for metabolic associated fatty liver disease. Gastroenterology 2020;158:1999-2014.
8. 8. Alkol Dışı Yağlı Karaciğer Hastalığı (NAFLD) Klinik Rehberi, Türk Karaciğer Araştırmalar Derneği Yayını, 2021, Ankara.

9. 9. Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases. Hepatology 2018;67:328-57.
10. 10. Marchesini G, Day CP, Dufour JF, et al. EASL-EASD-EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. J Hepatol. 2016;64(6):1388-402.
11. 11. Petroff D, Blank V, Newsome PN, et al. Assessment of hepatic steatosis by controlled attenuation parameter using the M and XL probes: an individual patient data meta-analysis. Lancet Gastroenterol Hepatol [Internet] 2021;6:185-98.
12. 12. Eddowes PJ, Sasso M, Allison M, et al. Accuracy of FibroScan controlled attenuation parameter and liver stiffness measurement in assessing steatosis and fibrosis in patients with nonalcoholic fatty liver disease. Gastroenterology 2019;156:1717-30.
13. 13. Sterling RK, Lissen E, Clumeck N, et al. Development of a simple noninvasive index to predict significant fibrosis in patients with HIV/HCV coinfection. Hepatology [Internet] 2006;43:1317-25.
14. 14. Lee JH, Kim D, Kim HJ, et al. Hepatic steatosis index: A simple screening tool reflecting nonalcoholic fatty liver disease. Dig Liver Dis [Internet] 2010;42:503-8.
15. 15. Fabbrini E, Magkos F, Mohammed BS, et al. Intrahepatic fat, not visceral fat, is linked with metabolic complications of obesity. Proc Natl Acad Sci U S A. 2009;106(36):15430-5.
16. 16. Chon YE, Jung KS, Kim SU, et al. Controlled attenuation parameter (CAP) for detection of hepatic steatosis in patients with chronic liver diseases: A prospective study of a native Korean population. Liver Int 2014;34:102-9.
17. 17. Friedrich-Rust M, Hadji-Hosseini H, Kriener S, et al. Transient elastography with a new probe for obese patients for non-invasive staging of non-alcoholic steatohepatitis. Eur Radiol 2010;20:2390-6.
18. 18. DeFilippis AP, Blaha MJ, Martin SS, et al. Nonalcoholic fatty liver disease and serum lipoproteins: the Multi-Ethnic Study of Atherosclerosis. Atherosclerosis [Internet] 2013;227:429-36.
19. 19. Alberto CCL, Iaarah MG, Eugenia ICM, et al. Clinical relevance of lipid panel and aminotransferases in the context of hepatic steatosis and fibrosis as measured by transient elastography (fibroscan®). J Med Biochem 2021;40:40-66.
20. 20. Patton H, Lavine JE, Van Natta ML, et al. Clinical correlates of histopathology in pediatric nonalcoholic steatohepatitis (NASH). Gastroenterology 2008;135:1961-71.e2.
21. 21. Younossi ZM, Gramlich T, Matteoni CA, et al. Nonalcoholic fatty liver disease in patients with type 2 diabetes. Clin Gastroenterol Hepatol 2004;2:262-5.
22. 22. Demir M, Deyneli O, Yılmaz Y. Screening for hepatic fibrosis and steatosis in Turkish patients with type 2 diabetes mellitus: A transient elastography study. Turkish J Gastroenterol 2019;30:266-70.
23. 23. Labenz C, Huber Y, Kalliga E, et al. Predictors of advanced fibrosis in non-cirrhotic non-alcoholic fatty liver disease in Germany. Aliment Pharmacol Ther 2018;48:1109-16.
24. 24. McPherson S, Hardy T, Henderson E, et al. Evidence of NAFLD progression from steatosis to fibrosing-steatohepatitis using paired biopsies: Implications for prognosis and clinical management. J Hepatol 2015;62:1148-55.
25. 25. Trivedi HD, Suri J, Oh D, et al. The presence of diabetes impacts liver fibrosis and steatosis by transient elastography in a primary care population. Ann Hepatol. 2021;24:100336.