BACKGROUND AND AIMS:Hepatitis D virus (HDV) underdiagnosis remains common. We assessed the HDV screening and prevalence rates in HBsAg-positive patients seen at tertiary liver centres throughout Greece as well as factors affecting HDV diagnosis.METHODS:All adult HBsAg-positive patients seen within the last 5 years were included. Non-screened patients who visited or could be recalled to the clinics over a 6-month period were prospectively tested for anti-HDV.RESULTS:Of 5079 HBsAg-positive patients, 53% had anti-HDV screening (41% before and 12% after study initiation). Pre-study (8%-88%) and total screening rates (14%-100%) varied widely among centres. Screening rates were associated with older age, known risk group, elevated ALT, centre location and size and period of first visit. Anti-HDV prevalence was 5.8% without significant difference in patients screened before (6.1%) or after study initiation (4.7%, p = 0.240). Anti-HDV positivity was associated with younger age, parenteral drug use, born abroad, advanced liver disease and centre location. Overall, HDV RNA detectability rate was 71.6% being more frequent in anti-HDV-positive patients with elevated ALT, advanced liver disease and hepatitis B therapy.CONCLUSIONS:Anti-HDV screening rates and recall capabilities vary widely among Greek liver clinics being higher in HBsAg-positive patients of known risk group with active/advanced liver disease seen at smaller centres, while non-medical factors are also important. Anti-HDV prevalence varies throughout Greece being higher in patients born abroad with younger age, parenteral drug use and advanced liver disease. Viremia is more frequently but not exclusively detected in anti-HDV-positive patients with elevated ALT and advanced liver disease.

Background:PNPLA3(I148M) and TM6SF2(E167K) variants are determinants of inter-individual and ethnicity-related differences in hepatic fat content and NAFLD progression.

Background: NAFLD is dramatically increasing in parallel with the pandemic of Type 2 Diabetes Mellitus.

Background: NAFLD is dramatically increasing in parallel with the pandemic of Type 2 Diabetes Mellitus (T2DM). Objectives: We aimed to assess the performance of the most commonly used non-invasive blood biomarkers for liver fibrosis in subjects with T2DM.

Nonalcoholic fatty liver disease (NAFLD) is dramatically increasing in parallel with the pandemic of type 2 diabetes. Here, the authors aimed to assess the performance of the most commonly used noninvasive, blood-based biomarkers for liver fibrosis (FibroTest, NAFLD fibrosis score, BARD score, and FIB-4 Index) in subjects with type 2 diabetes. Liver stiffness measurement was estimated by two-dimensional shear wave elastography. Finally, the authors assessed the diagnostic role of ActiTest and NashTest 2 in liver fibrosis in the examined population.

SummaryBackgroundTenofovir alafenamide (TAF) has exhibited a favourable safety profile on estimated glomerular filtration (eGFR) and bone mineral density (BMD), but has not been extensively studied in patients with renal impairment and/or BMD disorders.AimsTo assess predictors of eGFR changes and other safety and efficacy outcomes during 24‐month TAF therapy in patients with chronic hepatitis B with renal and/or BMD disorders/risks.MethodsAdult patients who started TAF at 13 clinics throughout Greece were prospectively included. Main exclusion criteria were hepatitis D, active malignancy and bisphosphonates recent use. MDRD formula was used for eGFR estimation.ResultsTAF was initiated in 176 patients (91% switched from another agent). At 12 and 24 months, HBV DNA was undetectable in 97% and 100%, and ALT was normal in 96% and 95% of patients. Median ALT decreased from baseline to month 12/24 (p < 0.001). Mean eGFR decreased from previous treatment initiation to baseline (p < 0.001), increased at 12 months and remained stable at 24 months (p ≤ 0.001). An increase in eGFR of >3 ml/min at 12 month was observed in 50% of patients and was associated mainly with baseline eGFR 30–60 ml/min. In patients with baseline phosphate <2.5 mg/dl, mean serum phosphate increased at month‐12/24 (p < 0.001). Median BMD did not change significantly from baseline to 12 months but improved at 24 months (p = 0.001).ConclusionsIn mostly switched patients with renal and/or BMD disorders/risks, eGFR improved after 12‐24 months of TAF treatment, especially in patients with baseline eGFR 30–60 ml/min. TAF may also improve low serum phosphate, BMD and ALT, whereas it maintains or induces virological suppression.

Objectives: Nonalcoholic fatty liver disease is dramatically increasing in parallel with the pandemic of type 2 diabetes mellitus. We investigated factors associated with hepatic steatosis (HS) in adult Greek individuals with established type 2 diabetes mellitus. Materials and Methods: We investigated 120 consecutive people with type 2 diabetes attending the Diabetic Outpatient Clinic at an Academic Hospital in Athens, Greece. All of them had demographic, clinical, and biochemical data recorded. HS was estimated by magnetic resonance imaging determined by proton density fat fraction software and defined as the percentage of total liver fat divided by the liver volume. HS of >5% was considered abnormal. The PNPLA3 (I148M) variant was evaluated as a genetic factor by standard molecular techniques. FibroMax™ was also calculated. Results: Of the 120 participants, median age was 61.7, 46% were females, diabetes duration was 10 years, and HbA1c (glycated hemoglobin) was 6.7%. The median value of HS was 7.8. The PNPLA3 rs738409 CC/CG/GG genotype frequencies were 54.2%, 35%, and 10.8%, respectively. In multivariate analysis, PNPLA3 rs738409 (β = 0.425, P = 0.001), waist circumference (β = 2.448, P = 0.001), and female sex (β = 0.419, P = 0.002) had a direct association with HS, while duration of diabetes (β = -0.179, P = 0.011) had an inverse association with HS. Conclusions: HS in type 2 diabetes is the sum of interplay of various factors exerting a direct or an inverse association, the most prominent among them being abdominal obesity and PNPLA3 molecular variability.

A case of combined acute and chronic liver injury related to consumption of multi-ingredient nutritional oral supplements containing Aloe Vera gel and vitamin A among other vitamins, minerals and dietary elements such as fish and calamari oil in a 59-year-old female with unexplained hypertransaminasemia is reported. A unique complex liver injury was diagnosed on liver biopsy combining histological features of protracted acute hepatitis, mild manifestation of hypervitaminosis A and lipogranulomatous reaction attributed to Aloe Vera, vitamin A and lipids, respectively. Normalization of liver tests was achieved after discontinuation of all nutritional supplements. Updated Roussel Uclaf Causality Assessment Method (RUCAM) score (+8, probable) further supported herb-induced liver injury. The present case highlights the increasing incidence of complex histological liver injury linked to the constantly growing consumption of multi-ingredient dietary supplements and alternative medications.

We evaluated keratin 7 (K7) hepatocellular expression in 92 patients with common types of acute and chronic cholestatic diseases caused by bile duct obstruction/destruction or parenchymal lesions [acute hepatitis ( n =20), mixed/pure cholestasis ( n =16), primary biliary cholangitis-PBC ( n =35), primary sclerosing cholangitis-PSC ( n =10), vanishing bile duct syndrome ( n =3), complete large bile duct obstruction due to space-occupying lesions ( n =8)]. K7 immunohistochemical hepatocellular expression and ductular reaction (DR) were semi-quantitatively assessed. Results were correlated with liver enzyme serum levels, cholestasis type, histological features, hepatocellular Ki67 labelling index (LI) and HepPar1 expression. Hepatocellular K7 expression was detected in 87% (81/92) cases and in all cholestatic disease types with lowest incidence in pure/mixed cholestasis and highest in incomplete bile duct obstruction (iBDO), reaching 100% in PSC. K7-positive hepatocytes had low Ki67 LI (0-5%) retaining HepPar1 expression, irrespective of disease type. PSC cases had high K7 hepatocellular expression even with intact bile ducts, a feature that may aid differential diagnosis of cholestatic syndromes. K7 hepatocellular expression significantly correlated with cholestasis type, bile duct loss and fibrosis stage. It was higher in milder acute cholestatic hepatitis showing inverse correlation with hepatocyte proliferation and serum transaminase levels. In iBDO, younger age independently correlated with high K7 expression, while serum GGT levels showed a nearly significant correlation. Correlation with DR findings implied that K7-positive hepatocytes may result through metaplasia. In conclusion, K7 hepatocellular expression is a sensitive though non-specific marker of cholestasis. It may represent a cytoprotective reaction of resting hepatocytes in cholestasis of longer duration especially in younger patients.

BACKGROUND AND AIMS:Liver stiffness measurements (LSMs) by 2-dimensional-shear-wave elastography (LSM2D-SWE) are now widely used in hepatology. However, relevant information for primary biliary cholangitis (PBC) is scant. We compare LSM2D-SWE with liver biopsy (LB) in a cohort of PBC patients in Greece.METHODS:Data of 68 LBs from 53 PBC patients were retrospectively analyzed and fibrosis stage was compared to LSM2D-SWE. Forty-six patients (86.8%) were females and at the time of LBx median (IQR) age was 62.6 (53.2-72.1). Demographic, UDCA treatment, histological and B-mode ultrasound data were tested for their influence on LSM2D-SWE estimates.RESULTS:Liver fibrosis stages F0-F4 were found in 4, 19, 19, 16 and 10 cases, respectively. Across stages F0-F4, the LSM2D-SWE was 5.6 (5.1-6.1), 7.0 (5.8-7.7), 9.1 (7.3-11.5), 10.8 (9.9-12.2) and 14.5 (11.9-25.7) kPa, respectively, with highly significant difference (p<.001). The LSM2D-SWE differed also significantly between F0 vs. F1 (p=.027), F1 vs. F2 (p=.005) and F3 vs. F4 (p=.017). The discriminatory ability of LSM2D-SWE for mild, significant, severe fibrosis and cirrhosis was highly significant in all comparisons (p<.001), with AUC2D-SWE 95.3%, 87.4%, 85.3% and 95.3% and accuracy 89.7%, 85.3%, 80.9% and 86.8%, respectively. Among 21 parameters tested, significant predictors of LSM2D-SWE by multiple linear regression were fibrosis stage, portal inflammation and parenchymal heterogeneity. The portal inflammation grade accounted for 32.2% of LSM variation with adjusted R2 0.428.CONCLUSIONS:In patients with PBC, LSM measurements by 2D-SWE can reliably discriminate between mild, significant, severe fibrosis and cirrhosis. Measurements are significantly affected by portal inflammation grade.

BACKGROUND & AIMS:Discontinuation of nucleos(t)ide analogues (NA) remains a debatable issue in HBeAg-negative chronic hepatitis B (CHB). This study aimed to address the outcome of HBeAg-negative CHB patients who discontinued NA therapy.METHODS:This prospective study included 57 non-cirrhotic HBeAg-negative Caucasian CHB patients who discontinued NA therapy after median virological remission of 6 years. All patients had regular blood tests. Virological relapse was defined as HBV DNA > 2000 IU/mL or >20 000 IU/mL and biochemical relapse as ALT > ULN (40 IU/mL) or >2xULN. All patients with retreatment predefined criteria restarted entecavir or tenofovir.RESULTS:Of the 57 patients, 29 remained without retreatment after median follow-up of 65 months (range: 36-87) following treatment discontinuation. At 3, 6, 12, 24, 36 and 48 months, cumulative rates of retreatment were 16%, 20%, 32%, 35%, 46% and 50%, while the proportion of patients with HBV DNA < 2000 IU/mL and ALT < ULN were 73%, 60%, 52%, 52%, 47% and 37% respectively. All patients had virological and biochemical response after retreatment. No patient developed liver failure, hepatocellular carcinoma or death. Cumulative rates of HBsAg loss were 2%, 4%, 7%, 10% and 20% at 3, 6, 12, 24 and 36 months. HBsAg levels < 100 IU/mL at the end of NA treatment could predict HBsAg loss (P = .001).CONCLUSIONS:Our study supports that NA therapy can be safely stopped in non-cirrhotic patients with HBeAg-negative CHB. Over a median follow-up of more than 5 years, half of the patients remained without retreatment with a substantial proportion of them achieving functional cure.

Non-alcoholic fatty liver disease (NAFLD) is closely correlated to metabolic syndrome, which is a marker of increased cardiovascular risk. Aortic stiffness and intima media thickness (IMT) are independent prognostic factors of cardiovascular risk. We investigated whether NAFLD is associated with increased atherosclerotic damage. 46 patients (mean age 55±13 yrs, 24M/22F) with increased serum alanine aminotransferase levels and abdominal ultrasound and/or biopsy evidence of NAFLD, and 40 age, gender, body-mass index, and cardiovascular risk factors adjusted controls were studied. Carotid-femoral pulse wave velocity (PWV), an established index of aortic stiffness, was calculated using a validated noninvasive device (Complior®). Higher values of PWV indicate stiffer aorta and vice versa. Mean IMT of common carotid arteries was determined as a marker of generalized early atherosclerosis using B-mode ultrasound imaging. NAFLD subjects had significantly increased carotid-femoral PWV (8.5±1.7 vs 7.9±1.5 m/s, p < 0.05) and mean value of carotid IMT (0.98±0.3 vs 0.77±0.2 mm, p < 0.05) compared to controls. Systolic, diastolic and pulse pressure were not different among the two groups. Interestingly enough, patients with increasing fibrosis stage (ALT/AST ratio of greater than 1, n = 21) had increased carotid-femoral PWV and mean carotid IMT compared to patients with ratio lower than 1, after adjusting for age and systolic blood pressure (9.2±1.6 vs. 8.2±1.5 m/s, p < 0.01 and 1.08±0.37 vs 0.83±0.21 mm, p < 0.05, respectively). Patients with NAFLD have increased aortic stiffness and IMT, indicating both functional and structural changes in large arteries. These findings are important to further characterize the increase of cardiovascular risk in such patients.

BACKGROUND:Collagen proportionate area (CPA) measurement is a technique that quantifies fibrous tissue in liver biopsies by measuring the amount of collagen deposition as a proportion of the total biopsy area. CPA predicts clinical outcomes in patients with HCV and can sub-classify cirrhosis.AIM:To test the ability of CPA to quantify fibrosis and predict clinical outcomes in patients with NAFLD.METHODS:We assessed consecutive patients with biopsy-proven NAFLD from three European centres. Clinical and laboratory data were collected at baseline and at the time of the last clinical follow-up or death. CPA was performed at two different objective magnifications, whole biopsy macro and ×4 objective magnification, named standard (SM) and high (HM) magnification respectively. The correlation between CPA and liver stiffness was assessed in a sub-group of patients.RESULTS:Of 437 patients, 32 (7.3%) decompensated and/or died from liver-related causes during a median follow-up of 103 months. CPA correlated with liver stiffness and liver fibrosis stage across the whole spectrum of fibrosis. HM CPA was significantly higher than SM CPA in stages F0-F3 but similar in cirrhosis, reflecting a higher ability to capture pericellular/perisinusoidal fibrosis at early stages. Age at baseline (HR: 1.04, 95% CI: 1.01-1.08), HM CPA (HR: 1.04 per 1% increase, 95% CI: 1.01-1.08) and presence of advanced fibrosis (HR: 15.4, 95% CI: 5.02-47.84) were independent predictors of liver-related clinical outcomes at standard and competing risk multivariate Cox-regression analysis.CONCLUSIONS:CPA accurately measures fibrosis and is an independent predictor of clinical outcomes in NAFLD; hence it merits further evaluation as a surrogate endpoint in clinical trials.

Background: Recent data suggest that chronic systemic inflammation impairs vascular function and plays a critical role in cardiovascular disease. Aortic stiffness and wave reflections are independent markers and prognosticators of cardiovascular risk. The present study was undertaken to assess whether chronic infection with hepatitis B virus (HBV) or hepatitis C virus (HCV) affects aortic stiffness and wave reflections. Methods: We determined aortic stiffness and wave reflections in 26 consecutive patients (mean age: 49±16 yrs, 9M/17F) positive for HCV infection and 14 patients (mean age: 52±11 yrs, 9M/5F) with HBV infection, who had never been treated with interferon. 40 healthy individuals were recruited to compare each of the two subgroups and they were matched for age, gender, body-mass index and risk factors. Aortic stiffness was evaluated with carotid-femoral pulse wave velocity (PWV) and wave reflections with augmentation index (AIx) of the aortic pressure waveform. Results: Patients with HCV infection had higher carotid-femoral PWV than controls, indicating increased aortic stiffness (7.5±1.3 vs. 6.7±1.3m/s, P < 0.05), while AIx did not differ (25±15 vs. 27±15%, P=NS). Carotid-femoral PWV and AIx in the subjects with HBV infection were similar to those in the control subjects. There were not differences as regard systolic, diastolic pressures and heart rate between patients with hepatitis and controls. Conclusions: Patients with HCV have impaired aortic elastic properties, whereas HBV does not influence aortic stiffness. These findings are important to further characterize the increase of cardiovascular risk in patients with hepatitis C virus seropositivity.