Liver International

The increase in Non‐alcoholic Fatty Liver Disease (NAFLD) and the imminent disappearance of chronic viral hepatitis thanks to new and effective therapies is motivating hepatologists to change their clinical approach to chronic liver disease. NAFLD‐cirrhosis or NAFLD‐Hepatocellular Carcinoma (HCC) are now the second cause of liver transplantation in the USA. This short‐review is focused to the epidemiology of NAFLD/Non‐alchoholic Steatohepatitis (NASH), including the definition of this disease which should be revised as well discussing the prevalence, risk factors for progression, natural history and mortality. NAFLD is considered to be the hepatic manifestation of the metabolic syndrome (MS). It affects 25‐30% of the general population and the risk factors are almost identical to those of MS. The natural history involves either the development of cardiovascular diseases or cirrhosis and HCC. HCC can also develop in NASH in the absence of cirrhosis (45% of cases). We conclude that an international consensus conference on the definition, natural history, policies of surveillance and new pharmacological treatments of NAFLD and NASH is urgently needed.

Background: The hepatitis C pandemic has been systematically studied and characterized in North America and Europe, but this important public health problem has not received equivalent attention in other regions.

Aim: The objective of this systematic review was to characterize hepatitis C virus (HCV) epidemiology in selected countries of Asia, Australia and Egypt, i.e. in a geographical area inhabited by over 40% of the global population.

Methodology: Data references were identified through indexed journals and non‐indexed sources. In this work, 7770 articles were reviewed and 690 were selected based on their relevance.

Results: We estimated that 49.3–64.0 million adults in Asia, Australia and Egypt are anti‐HCV positive. China alone has more HCV infections than all of Europe or the Americas. While most countries had prevalence rates from 1 to 2% we documented several with relatively high prevalence rates, including Egypt (15%), Pakistan (4.7%) and Taiwan (4.4%). Nosocomial infection, blood transfusion (before screening) and injection drug use were identified as common risk factors in the region. Genotype 1 was common in Australia, China, Taiwan and other countries in North Asia, while genotype 6 was found in Vietnam and other Southeast Asian countries. In India and Pakistan genotype 3 was predominant, while genotype 4 was found in Middle Eastern countries such as Egypt, Saudi Arabia and Syria.

Conclusion: We recommend implementation of surveillance systems to guide effective public health policy that may lead to the eventual curtailment of the spread of this pandemic infection.

Background/Aims: Diabetic patients have an increased prevalence and severity of non‐alcoholic fatty liver disease (NAFLD). We aimed to investigate the prevalence and the factors associated with the presence of ultrasonographic NAFLD in type‐2 diabetic individuals.

Methods: In a cross‐sectional design study, 180 type‐2 diabetic patients were submitted to a complete clinical and laboratory evaluation and abdominal ultrasonography for NAFLD detection and grading. Statistical analysis included bivariate tests, analysis of variance (anova, for increasing severity of steatosis) and multivariate logistic regression.

Results: The prevalence of ultrasonographic NAFLD was 69.4% [95% confidence interval (CI): 58.3–82.7%]. Patients with NAFLD were more obese, had a higher waist circumference and serum triglyceride and alanine aminotransferase (ALT) levels than those without steatosis. Neither diabetic degenerative complication, nor glycaemic control was associated with liver steatosis. On multivariate analysis, a high serum triglycerides level [>2.82 mmol/L, odds ratio (OR): 3.7–4.1, 95% CI: 1.2–13.3] and a high‐normal ALT level (≥40 U/L, OR: 2.5–2.7, 95% CI: 1.2–5.9) were independently associated with hepatic steatosis, together with either the presence of obesity (OR: 7.1, 95% CI: 3.0–17.0) or of increased waist circumference (OR: 4.8, 95% CI: 1.9–12.2).

Conclusions: Type‐2 diabetic patients have a high prevalence of ultrasonographic NAFLD and its presence is associated with obesity, mainly abdominal, hypertriglyceridaemia and high‐normal ALT levels. Non‐alcoholic fatty liver disease in diabetic patients may develop and progress independent of the diabetes progression itself.

CLDs represent an important, and certainly underestimated, global public health problem. CLDs are highly prevalent and silent, related to different, sometimes associated causes. The distribution of the causes of these diseases is slowly changing, and within the next decade, the proportion of virus‐induced CLDs will certainly decrease significantly while the proportion of NASH will increase. There is an urgent need for effective global actions including education, prevention and early diagnosis to manage and treat CLDs, thus preventing cirrhosis‐related morbidity and mortality. Our role is to increase the awareness of the public, healthcare professionals and public health authorities to encourage active policies for early management that will decrease the short‐ and long‐term public health burden of these diseases. Because necroinflammation is the key mechanism in the progression of CLDs, it should be detected early. Thus, large‐scale screening for CLDs is needed. ALT levels are an easy and inexpensive marker of liver necroinflammation and could be the first‐line tool in this process.

Background/Aims: A large amount of new data on the treatment of chronic hepatitis B has become available such that the 2003 consensus statement requires revision and update.

Methods: New data were presented, discussed and debated in an expert pre‐meeting to draft a revision. The revised contents were finalized after discussion in a general meeting of APASL.

Results: Conceptual background, including the efficacy and safety profile of currently available and emerging drugs, was reviewed. Nineteen recommendations were formed and unresolved issues and areas for further study were suggested.

Conclusion: The current therapy of chronic hepatitis B is modestly effective but not satisfactory. The development of new drugs and new strategies is required to further improve the outcomes of treatment.

Background and Aim: Decisions on public health issues are dependent on reliable epidemiological data. A comprehensive review of the literature was used to gather country‐specific data on risk factors, prevalence, number of diagnosed individuals and genotype distribution of the hepatitis C virus (HCV) infection in selected European countries, Canada and Israel.

Methodology: Data references were identified through indexed journals and non‐indexed sources. In this work, 13 000 articles were reviewed and 860 were selected based on their relevance.

Results: Differences in prevalence were explained by local and regional variances in transmission routes or different public health measures. The lowest HCV prevalence (≤0.5%) estimates were from northern European countries and the highest (≥3%) were from Romania and rural areas in Greece, Italy and Russia. The main risk for HCV transmission in countries with well‐established HCV screening programmes and lower HCV prevalence was injection drug use, which was associated with younger age at the time of infection and a higher infection rate among males. In other regions, contaminated glass syringes and nosocomial infections continue to play an important role in new infections. Immigration from endemic countries was another factor impacting the total number of infections and the genotype distribution. Approximately 70% of cases in Israel, 37% in Germany and 33% in Switzerland were not born in the country. In summary, HCV epidemiology shows a high variability across Europe, Canada and Israel.

Conclusion: Despite the eradication of transmission by blood products, HCV infection continues to be one of the leading blood‐borne infections in the region.

Abstract: Background/Aims: Only a few studies have assessed the epidemiology of non‐alcoholic fatty liver disease (NAFLD). The aim was to evaluate the prevalence of primary NAFLD in a population‐based study in Israel and to determine independent risk factors.

Methods: A cross‐sectional study of a subsample of the Israeli national health survey (n=352). Individuals with a known etiology for secondary NAFLD were excluded. Each participant underwent an abdominal ultrasound, biochemical tests and an anthropometric evaluation.

Results: Three hundred and twenty‐six subjects (53.4% male, mean age 50.5±10.3 standard deviaton [SD]) met the inclusion criteria. The prevalence of primary NAFLD was 30% (25–35% 95% confidence intervals [CI]). NAFLD was more prevalent in men than women (38% vs. 21%; P=0.001). Compared with ultrasonography, the sensitivity of serum alanine transaminase (ALT) for the diagnosis of primary NAFLD was 8.2%. Risk factors independently associated with NAFLD included male gender (odds ratios (OR)=2.8, 95% CI 1.5–5.3), abdominal obesity (OR=2.9, 95% CI 1.3–6.4), homeostasis model assessment (OR=5.8, 95% CI 2.0–17.2), hyperinsulinemia (OR=2.3, 95% CI 1.2–4.3, P=0.01) and hypertriglyceridemia (OR=2.4, 95% CI 1.3–4.5).

Conclusions: NAFLD is prevalent in the general Israeli population and closely related to the metabolic syndrome. The use of ALT as a marker for NAFLD seriously underestimates its prevalence.

Low‐grade or minimal hepatic encephalopathy (MHE) is characterised by relatively mild neurocognitive impairments, and occurs in a substantial percentage of patients with liver disease. The presence of MHE is associated with a significant compromise of quality of life, is predictive of the onset of overt hepatic encephalopathy and is associated with a poorer prognosis for outcome. Early identification and treatment of MHE can improve quality of life and may prevent the onset of overt encephalopathy, but to date, there has been little agreement regarding the optimum method for detecting MHE. The International Society on Hepatic Encephalopathy and Nitrogen Metabolism convened a group of experts for the purpose of reviewing available data and making recommendations for a standardised approach for neuropsychological assessment of patients with liver disease who are at risk of MHE. Specific recommendations are presented, along with a proposed methodology for further refining these assessment procedures through prospective research.