Table of Content

31 August 2020, Volume 25 Issue 8

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Liver Fibrosis & Cirrhosis

Prospective study on the risk factors and the treatment response of acute renal injury in liver cirrhotic patients

YIN Wei, LI Cheng-zhong

2020, 25(8):  791-796. 

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Objective To prospectively observe the risk of morbidity and the therapeutic effect of acute kidney injury in patients with cirrhosis based on 2015 International Ascites Club (IAC) diagnostic criteria. Methods A prospective, observational and open method was used to observe the hospitalized patients with decompensated cirrhosis. Once acute kidney injury (AKI) occurred, the patients were diagnosed and treated according to the new ICA-AKI guideline. Data were collected during the treatment period to evaluate the therapeutic response. The risk factors for AKI complication and the influencing factors for the treatment were analyzed by logistic regression. Results A total of 804 patients with decompensated cirrhosis were included in the study. 213 patients(26.5%, 213/804) were complicated with AKI during hospitalization or had AKI at admission, of which 68.1%(145/213)、25.3%(54/213)and 6.6%(14/213)were AKI stage 1, 2 and 3, respectively. The 2015 dagnostic criteria of HRS was shown to improve the diagnostic sensitivity. A missed diagnosis rate of 20.9%(14/67)were found in these patients if using the 2007 standard. Multivariate analysis showed that age, MELD score (P=0.004), infection(P=0.000) and upper gastrointestinal bleeding (P=0.000)were the main risk factors of AKI in decompensated cirrhotic patients. After personalized treatment according to AKI stage, 86.9% (185/213) of the patients with AKI were improved. Multivariate analysis showed that only the preliminary stage of AKI was the main factor affecting the prognosis of the AKI patients (P=0.000). If the initial AKI stage increased, the proportion of responsive treatment decreased. The treatment responsive rate in AKI stages 1, 2 and 3 were 94.5% (137/145), 70.4% (38/54) and 28.6% (4/14), respectively. Conclusion The updated diagnostic and management procedure by ICA improves the diagnostic sensitivity and treatment responsive rate of AKI in decompensated cirrhotic patients, This enables some previously neglected patients to be treated timely. By using the new guideline a higher responsive rate can be achieved but the intervention is required to initiate at a lower AKI stage.

Clinical effect of triple-lumen and two-capsule catheter assisted by emergency endoscopy in the treatment of esophageal gastric varices bleeding in patients with hemorrhagic shock and under mechanical ventilation

ZHANG Jun-chang, LIN Fang, CHEN Su-hong, MU Jin-song

2020, 25(8):  797-799. 

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Objective To explore the clinical effect of triple-lumen and two-capsule catheter assisted by emergency endoscopy in the treatment of ruptured esophageal and gastric varices bleeding with hemorrhagic shock during mechanical ventilation. Methods fifteen patients with ruptured esophageal and gastric varices bleeding admitted in our hospital from May 2017 to March 2019 were selected as the research objects. Results in 15 patients with hemorrhagic shock, endoscopic hemostasis or insertion of the three-chamber and two-sac tubes during mechanical ventilation failed. insertion of triple-lumen and two-capsule catheter assisted by emergency endoscopy was successful. The hemostatic effect was definite in 12 cases. 1 cases were successfully treated with emergency Tips to stop the bleeding when their condition was stable. 2 cases died clinically. Conclusion The treatment of ruptured esophageal and gastric varices bleeding with triple-lumen and two-capsule catheter assisted by emergency endoscopy has a high success rate,the hemostatic effect is definite, it can be popularized and implemented in clinic.

A comparison of different intravascular approaches for measuring hepatic venous pressure gradient

CHEN Guang, WANG Yu, JIN Long, WEI Jian-an, HU Yue-feng, CAO Sha-sha

2020, 25(8):  800-802. 

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Objective To investigate an optimized method for measuring hepatic venous pressure gradient (HVPG). The consuming time and the incidence of complications between the transjugular and the modified transfemoral methods were compared. Methods Sixty patients who received HVPG measurement at Beijing Friendship Hospital, Capital Medical University between December 2017 to December 2019 were studied. They were divided into two groups (with 30 cases in each group) according to a random number table. The HVPG in one group of patients were measured with the modified transfemoral method, using 7F RDC guiding catheter in combination with 5.5F double-lumen balloon catheter. The consuming time of catheterization and the incidence of complications between the transjugular group and the modified transfemoral group were compared. Results HVPG was successfully measured in all 60 subjects. The average catheterization time (145±25)s in the modified transfemoral group was less than that in the transjugular group (227±34)s(t=10.511,P=0.000),The incidence rate of supraventricular tachycardia in the modified transfemoral group (3.33%) was lower than that in the transjugular group (36.67%)(χ²=21.600,P=0.000), The incidence rate of anxiety in the modified transfemoral group (6.67%) was lower than that in the transjugular group (23.33%)(χ²=29.400,P=0.000, all have statistical significant differences. Conclusion For measuring HVPG, the modified transfemoral method may shorten the operating time, and therefore is a safety and clinically desirable approach.

The role of advanced dynamic flow imaging in evaluating the stent patency of transjugular intrahepatic portosystemic shunt

LI Yong-sheng, LIANG Xiao-feng, MA Yan

2020, 25(8):  803-805. 

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Objective To study on the value of advanced dynamic flow imaging (ADF) in evaluating the stent patency of transjugular intrahepatic portosystemic shunt (TIPS). Methods Sixty-four patients with TIPS therapy who were admitted to our hospital from July 2017 to July 2019 were included in the study. All patients underwent ADF examination. The results of contrast-enhanced ultrasonography (CEUS) were used as gold standard to compare ADF with CEUS in the evaluation of TIPS stent patency. The consistency between ADF and CEUS results was analyzed. Results ADF detected 0 case with 0 grade, CEUS detected 0 case with 0 grade, the diagnostic coincidence rate was 100.00%; ADF detected 4 cases with grade 1, CEUS detected 3 cases with grade 1, the diagnostic coincidence rate was 98.44%; ADF detected 4 cases with grade 2, CEUS detected 4 cases with grade 2, the diagnostic coincidence rate was 100.00%; ADF detected 56 cases with grade 3, CEUS detected 57 cases with grade 3, the diagnostic coincidence rate was 95.31%. The sensitivity, specificity, accuracy, positive predictive value, negative predictive value and Kappa value of ADF in the evaluation of TIPS stent patency were 85.71%, 96.49%, 95.31%, 75.00%, 98.21% and 0.77, respectively. Conclusion The stent patency of TIPS can be displayed in time by ADF. It is therefore important in evaluating TIPS function, and worthy of clinical promotion.

Effects of non-selective beta blockers on hemodynamics and incidence of hepatorenal syndrome in liver cirrhotic patients complicated with gastric varices

GAO Shu-juan, GENG Xi-lin

2020, 25(8):  806-809. 

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Objective To investigate the effect of non-selective beta blockers (NSBBs) on circulation and incidence of hepatorenal syndrome (HRS) in patients with cirrhosis complicated with esophageal and gastric varices. Methods 135 patients with cirrhosis complicated with esophageal and gastric varices and treated in our hospital from January 2017 to March 2019 were divided into NSBBs group (n=85) and routine group (n=50) according to different treatment schemes. The general data, laboratory parameters, hemodynamic parameters [resting heart rate (RHR), arterial systolic pressure (SAP), mean arterial pressure (MAP)], and the incidence of HRS were collected. Results After treatment, RHR was decreased in both groups, and SAP and MAP were increased in both groups, moreover, NSBBs group had lower SAP and MAP than those in routine group (P<0.05). The incidence of HRS in NSBBs group was higher than that in routine group (P<0.05). Varicose and ascites severity, SAP, MAP and NSBBs treatment were high risk factors for HRS (P<0.05). Conclusion NSBBs can damage the circulatory system of cirrhosis patients with gastric varices, and may increase the incidence of HRS during the treatment due to the increased severity degrees.

The application value of serum 25(OH)D in the evaluation of progressive liver fibrosis in diabetic patients with nonalcoholic fatty liver disease

WEN Qiong-hua, TANG Min-yun, WEI Yu

2020, 25(8):  810-812. 

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Objective To study on the application value of serum 25-hydroxyvitamin D [25(OH)D] in the evaluation of progressive liver fibrosis in patients with type 2 diabetes mellitus (T2DM) and nonalcoholic fatty liver disease (NAFLD). Methods The clinical data of 265 T2DM patients with NAFLD enrolled in our hospital from May 2015 to May 2019 were retrospectively analyzed for their status of liver fibrosis progression. Multi-factor Logistic regression analysis was applied to investigate the independent factors, and to determine the predictive value of serum 25(OH)D for progressive liver fibrosis. Results Of the 265 patients, 80 (30.19%) had progressive liver fibrosis. In addition to age, the course of diabetes mellitus, body mass index, hemoglobin, albumin, alanine aminotransferase, ratio of aspartate aminotransferase and alanine aminotransferase, serum creatinine, cystatin C and 24-hour urinary microalbumin, serum 25(OH)D was also an independent predictive factor associated with liver fibrosis progression (P<0.05) with the area under curve (ROC)of 0.831. Conclusion Serum 25(OH)D plays an important role in the assessment of progressive liver fibrosis in patients with T2DM accompanied with NAFLD.

Liver Cancer

A retrospective analysis of 5-year post-operative survival rate of hepatocellular carcinoma patients with different AFP levels

ZHANG Zhi-sheng, KONG Qing-li, LIANG Zhi-peng

2020, 25(8):  813-815. 

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Objective To study on the differences of 5-year post-operative survival rate of hepatocellular carcinoma (HCC) patients with various serum alpha fetoprotein (AFP) levels prior to the operation. Methods The clinical data of 135 patients who received surgical resection in our hospital from November 2011 to November 2014 were retrospectively analyzed. According to their serum AFP levels before operation, the patients were divided into group A (51 cases, with AFP≤20 ng/mL), group B (36 cases, with 20 ng/mL < AFP≤400 ng/mL) and group C (48 cases, with AFP > 400 ng/mL). Parameters of platelet (PLT), alanine aminotransferase (ALT), gamma glutamyltransferase (GGT), total bilirubin (TBil), albumin (Alb), and prothrombin time (PT) were compared, and the relapse-free survival rate and overall survival rate were analyzed at 1, 3 and 5 years after operation. Results There were no significant differences in PLT, ALT, GGT, TBil, Alb and PT among these three groups (P>0.05). The recurrence free survival rates at 1, 3 and 5 years after operation in group C were 54.2% (26/48), 33.3% (16/48), 27.1% (13/48), respectively, which were significantly lower than 78.4% (40/51), 58.8% (30/51), 41.2% (21/51) in group A, and 69.4% (25/36), 41.7% (15/36), 33.3% (12/36) in group B (P<0.05). The overall postoperative survival rates at 1, 3 and 5 years in group C were 81.3% (39/48), 52.1% (25/48), 35.4% (17/48), respectively, which were significantly lower than 94.1% (48/48), 82.4% (42/51), 62.7% (32/51) in group A, and 91.7% (33/36), 75.0% (27/36), 52.8% (19/36) in group B (P<0.05). Conclusion Preoperative serum AFP levels are closely associated with the prognosis of HCC.

The application value of liver imaging-reporting and data system (LI-RADS) of contrast-enhanced ultrasound in LR-3, LR-4 and LR-5 lesions

YANG Da-cai, WU Hong, ZHU Ting-ling

2020, 25(8):  816-818. 

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Objective To explore the application value of liver imaging-reporting and data system (LI-RADS) of contrast-enhanced ultrasound (CEUS) in LR-3, LR-4 and LR-5 lesions. Methods From January 2013 to January 2019, 122 patients including 87 males and 35 females with liver focal lesions at risk of hepatocellular carcinoma (HCC) were collected, with an average age of 53.1±8.4 years. The diagnostic performance of CEUS LI-RADS classification was evaluated, with liver pathology as the diagnostic gold standard. The comparison of measurement data (x+s) were performed with t test, and the comparison of counting data (%) were analyzed with chi-square test. Results There were 146 lesions in these patients, of which 120 (82.2%) were pathologically confirmed HCC and 26 (17.8%) were benign liver lesions. 5 were classified as LR-1, 3 were LR-2, all were benign;16 were classified as LR-3, 32 were LR-4 and 90 were LR-5. The LR-1, LR-2 lesions were considered as negative, whereas the LR-3, LR-4 and LR-5 lesions were positive. The sensitivity, specificity and accuracy of LR-3+LR-4+LR-5 in the diagnosis of HCC were 95.8%, 30.8% and 84.2%. Regardless of LR-3 lesions, the sensitivity, specificity and accuracy of LR-4+LR-5 in the diagnosis of HCC were 100%, 53.3% and 94.6%,. Regardless of LR-3 and LR-4 lesions, the sensitivity, specificity and accuracy of LR-5 in the diagnosis of HCC were 100%, 80.0% and 98.0%. The specificity of LR-3+LR-4+LR-5 (30.8%) in the diagnosis of HCC was significantly lower than that of LR-4+LR-5 (53.3%, P<0.05) and LR-5 (80.0%, P<0.05). Meanwhile, the specificity of LR-4+LR-5 (53.3%) was significantly lower than LR-5 (80.0%, P<0.05). The diagnostic accuracy of LR-3+LR-4+LR-5 (84.2%) was significantly lower than that of LR-4+LR-5 (94.6%, P<0.05) and LR-5 (98.0%, P<0.05). However, there was no significant difference in the diagnostic sensitivity between LR-3+LR-4+LR-5, LR-4+LR-5 and LR-5 (P>0.05). Conclusion CEUS LI-RADS classification standard has high diagnostic accuracy for LR-3, LR-4, LR-5 HCC lesions, especially for LR-5 lesions.

Effect of argon knife in hepatic resection for hepatocellular carcinoma on postoperative recurrence and survival rate

LI De-fu, XIA Yong-hong, MA Ying

2020, 25(8):  819-821. 

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Objective To study the effect of argon knife dealing with liver cross section in hepatic resection for hepatocellular carcinoma on postoperative recurrence and survival rate. Methods A total of 144 patients with hepatocellular carcinoma admitted to our hospital from January 2014 to August 2016 received non-radical palliative resection and hepatic portal occlusion. The patients were randomly divided into 2 groups, 72 in each. The liver cross section was treated with traditional electric knife in the control group and argon knife in the observation group. The intraoperative and postoperative conditions (the residual hepatic cross section area, operation time, intraoperative blood loss, intraoperative blood transfusion volume, hepatic portal occlusion time, the total postoperative drainage volume, drainage days, and the postoperative hospital stay time) of the 2 groups were analyzed. The 6-month, 1-year, 2-year, 3-year survival rate, and 6-month, 9-month, 1-year, 2-year recurrence rate after operation were compared between the 2 groups. Results The intraoperative blood loss and transfusion volume in the observation group were significantly less than those in the control group (P<0.05). The postoperative 6-month, 1-year, 2-year and 3-year survival rates in the observation group were 91.67%, 62.50%, 27.78% and 13.89%, respectively, which were significantly higher than those in the control group (79.17%, 45.83%, 12.50% and 8.33%, respectively, P<0.05). The 6-month, 9-month, 1-year and 2-year recurrence rates after operation in the observation group were 31.94%, 63.89%, 77.78% and 86.11%, which were significantly lower than those in the control group (58.33%, 79.17%, 90.28% and 95.83%, respectively, P<0.05). Conclusion In the resection for hepatocellular carcinoma, argon knife can reduce the intraoperative blood loss and blood transfusion, lower the tumor recurrence, and improve the survival rate of patients.

Feasibility study of contrast-enhanced ultrasound LI-RADS in the diagnosis of primary hepatocellular carcinoma

LI Ming-hui TANG Rong CHEN Sun-bin

2020, 25(8):  822-824. 

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Objective To study the feasibility of contrast-enhanced ultrasound (CEUS) liver imaging reporting and data system (LI-RADS) in the diagnosis of primary hepatocellular carcinoma. Methods Clinical data of high-risk patients with primary hepatocellular carcinoma admitted to our department from June 2016 to June 2019 were collected. The diagnosis of the disease was in accordance with the 2015 edition of practice guidelines for pathological diagnosis of primary liver cancer. The ultrasound contrast agent is SonoVue (Bracco Company, Italy). The 2017 edition of CEUS LI-RADS was adopted. In this study, pathological results were used as the diagnostic gold standard. LI-RADS class 1 (LR-1) and LI-RADS class 2 (LR-2) were defined as negative results, LI-RADS 3 (LR-3), LI-RADS 4 (LR-4) and LI-RADS 5 (LR-5) as positive ones. The diagnostic value was analyzed by receiver operator characteristic (ROC) curve. Results There were 74 patients enrolled in the study, including 52 males and 22 females, with an average age of (54.2 ± 11.4) years. A total of 86 lesions were detected. The diameter of the lesions ranged from 0.6 to 9.2 cm, with an average of (2.6 ± 1.4) cm. The pathological results included primary hepatocellular carcinoma (72), cholangiocarcinoma (3), focal nodular hyperplasia (6), hepatic hemangioma (3) and inflammatory lesions (2). Based on CEUS LI-RADS, there were 4 cases of LR-1, 5 cases of LR-2, 16 cases of LR-3, 25 cases of LR-4 and 36 cases of LR-5. The area under the ROC curve was 0.86 (95% confidence interval: 0.80-0.91). The diagnostic indexes of CEUS LI-RADS for primary hepatocellular carcinoma were as follows: the accuracy of 94.2% (81/86), the sensitivity of 100% (72/72), the specificity of 64.3% (9/14), the positive predictive value of 91.1% (72/79), and the negative predictive value of 100% (9/9). When LR-3 was not taken into account, the adjusted diagnostic indexes were as follows: the accuracy of 97.1% (68/70), the sensitivity of 100% (59/59), the specificity of 81.8% (9/11), the positive predictive value of 96.7% (59/61), and the negative predictive value of 100% (9/9). Conclusion CEUS LI-RADS performs well in the diagnosis of primary hepatocellular carcinoma, which has clinical feasibility.

Value of preoperative serum AFP and NLR levels in predicting prognosis of HCC patients

ZHANG Hai-ye, PENG Yi, LU Yue-jiu, HE Li-feng

2020, 25(8):  825-827. 

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Objective To evaluate the predictive value of preoperative serum alpha-fetoprotein (AFP) level and neutrophil-to-lymphocyte ratio (NLR) in the prognosis of patients with hepatocellular carcinoma (HCC). Methods The clinical data of 88 patients with HCC who underwent surgery in our hospital from February 2014 to February 2016 were retrospectively analyzed. According to the prognosis, they were divided into a good prognosis group and a poor prognosis group. The gender, age, the tumor, node, metastasis (TNM) stage, tumor diameter, lymph node metastasis, hepatitis B virus infection, AFP, and NLR between the 2 groups were compared. The value of AFP and NLR in predicting poor prognosis of HCC patients was analyzed by receiver operator characteristic curve. And risk factors for poor prognosis of HCC were identified by multivariate logistic regression analysis. Results There was no difference between the 2 groups in sex, age or the incidence of hepatitis B virus infection (P>0.05). In poor prognosis group, cases of TNM stage III or IV, tumor diameter ≥ 60 mm and lymph node metastasis were significantly more than those in good prognosis group (P<0.05). AFP and NLR in poor prognosis group were significantly higher than those in good prognosis group (P<0.05). The area under the curve of AFP and NLR predicting the poor prognosis of HCC patients was 0.839 and 0.815, respectively (P<0.05). Multivariate logistic regression analysis confirmed that TNM stage III or IV, tumor diameter ≥ 60 mm, lymph node metastasis, AFP ≥ 444.26 ng/mL, NLR ≥ 2.65 were risk factors for poor prognosis of HCC patients (P<0.05). Conclusion The prognosis of HCC is affected by many factors. When AFP ≥ 444.26 ng/mL or NLR ≥ 2.65, the prognosis of HCC patients tends to be poor, which should be paid attention to in clinical treatment.

The relationship between CT perfusion parameters and pathological grade microvascular invasion of hepatocellular carcinoma

LI Kun, HE Hai-lin

2020, 25(8):  828-830. 

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Objective To study the relationship between computed tomography (CT) perfusion parameters and pathological grade, microvascular invasion of hepatocellular carcinoma (HCC). Methods The clinical data of 170 patients with HCC undergoing CT perfusion imaging from March 2017 to March 2019 were retrospectively analyzed. The mean transit time (MTT), hepatic artery perfusion (HAP) and hepatic artery perfusion index (HAPI) were recorded. The relationship between perfusion parameters and HCC pathological grade, microvascular invasion was analyzed. Results There were significant differences in MTT, HAP and HAPI among HCC patients of different pathological degrees (P<0.05). MTT in microvascular invasion group was significantly shorter than that in non-microvascular invasion group (P<0.05). HAP and HAPI in microvascular invasion group were significantly higher than those in non-microvascular invasion group. (P<0.05). The receiver operator characteristic curve showed that MTT, HAP and HAPI had high application value in the diagnosis of poorly differentiated HCC (P<0.05). Conclusion MTT, HAP and HAPI of CT perfusion imaging are closely related to microvascular invasion, which are helpful to identify poorly differentiated HCC from HCC of other pathological degrees.

Preventive value of coolant perfusion via PTCD and ENBD catheter against bile duct thermal injury induced by microwave ablation for hepatocellular carcinoma

LIN Tao, GAO Chun-yun, LI Yong-nian, ZHAO Shi-min

2020, 25(8):  831-834. 

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Objective To study on the preventive value of coolant perfusion via catheter systems of percutaneous transhepatic cholangial drainage (PTCD) and endoscopic nasobiliary drainage (ENBD) on bile duct thermal injury induced by microwave ablation for hepatocellular carcinoma. Methods Ninety-two patients with hepatocellular carcinoma in portal area underwent microwave ablation were randomly divided into two groups, with 46 cases in each group. The observation group was perfused with PTCD catheter, while the control group was perfused with ENBD catheter for microwave ablation of HCC. The cooling effects of operation and the incidences of complications during follow-up period of time in patients of these two groups were analyzed. Results The time of microwave ablation in the observation group was significantly longer than that in the control group (P<0.05). The incidence of complications in the observation group was 17.39%, which was significantly lower than 43.48% in the control group (P<0.05). The in-situ recurrence rate, intrahepatic recurrence rate, mortality rate and 3-year cumulative survival rate were 8.69%, 41.30%, 32.61%, 67.39% in the observation group, and 8.69%, 36.96%, 28.26%, 71.74% in the control group, respectively, without significant differences between these two groups (P>0.05). Conclusion Both coolant perfusion via PTCD and ENBD catheter systems can prevent bile duct thermal injury induced by microwave ablation for hepatocellular carcinoma in portal area, but coolant perfusion via PTCD catheter is better in safety.

The value of contrast-enhanced ultrasound with SonoVue in the differential diagnosis of atypical focal hepatic lesions

HU Su-ling, LI Hong-jiang

2020, 25(8):  835-836. 

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Objective To assess the value of contrast-enhanced ultrasound (CEUS) with SonoVue in the diagnosis of atypical focal hepatic lesions. Methods A total of 64 patients with liver tumors examined by CEUS using SonoVue in our hospital from March 2016 to March 2019 were selected, including 38 males and 26 females, with an average age of (49.1 ± 10.2) years. A total of 76 atypical focal lesions were diagnosed by imaging examination (MRI and/or CT) or liver histopathology, including 55 malignant lesions (32 primary hepatocellular carcinomas, 6 primary intrahepatic cholangiocarcinomas and 17 metastatic liver cancers) and 21 benign lesions (14 hepatic hemangiomas, 5 focal nodular hyperplasias and 2 hepatic abscesses), with the diameter ranging from 1.9 cm to 7.6 cm. The measurement data were expressed as (±s), compared by t test, and the count data were expressed as absolute values and compared by chi-square test. Results In CEUS, the initial enhancement time of malignant atypical liver focal lesions [(17.2 ± 3.3) s] was significantly earlier than that of benign focal lesions [(26.8 ± 6.7) s, P<0.05]. The initial enhancement washout time of malignant focal lesions [(77.8 ± 12.7) s] was significantly earlier than that of benign focal lesions [(228.4 ± 29.4) s, P<0.05]. The enhancement duration of malignant focal lesions [(43.6 ± 9.3) s] was significantly shorter than that of benign focal lesions [(172.1 ± 22.7) s, P<0.05]. There was no significant difference in the enhancement rate or washout rate between primary and metastatic liver cancers (P>0.05), but there was significant difference in the enhancement pattern and degree (P<0.05). Conclusion CEUS with SonoVue can accurately distinguish the malignant from benign atypical focal hepatic lesions, and primary from metastatic liver cancers.

Elasticity score and strain rate ratio of ultrasound elastography in the identification of hepatic nodules

LIU Ke, HUANG Yan-zhuo

2020, 25(8):  837-839. 

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Objective To investigate the value of elasticity score and strain rate (SR) ratio of ultrasound elastography (UE) in differentiating hepatic nodules. Methods A total of 110 patients with hepatic nodules admitted to our hospital from July 2017 to July 2019 underwent UE. According to the pathology, the patients were divided into benign group and malignant group. The elasticity score and SR value were compared between the 2 groups. The receiver operator characteristic curve was drawn to evaluate the discrimination value of elasticity score and SR value between benign and malignant hepatic nodules. The area under the curve (AUC), the best cut-off value, sensitivity and specificity were determined. The kappa test was used to assess the diagnostic consistency of elasticity score and SR value with pathology. Results Among 110 patients, 67 (60.91%) were benign, including 2 (2.99%) cases of liver abscess, 53 (79.10%) cases of hepatic hemangioma and 12 (17.91%) cases of hepatic hemangioendothelioma. Forty-three (39.09%) cases were malignant, including 32 (74.42%) cases of primary hepatocellular carcinoma, 8 (18.60%) cases of metastatic hepatocellular carcinoma and 3 (6.98%) cases of cholangiocarcinoma. The elasticity scores of benign group and malignant group were (1.63 ± 0.12) and (3.68 ± 0.45), respectively. The SR values of benign group and malignant group were (3.09 ± 1.12) and (10.62 ± 3.75), respectively. The elasticity scores and SR values of benign group were significantly lower than those of malignant group (P<0.05). The AUC of elasticity score, SR value and combination were 0.802, 0.788 and 0.863, respectively. The kappa values of elasticity score, SR value and combination were 0.667, 0.532 and 0.811, respectively. Conclusion The elasticity score and SR value are valuable in the differential diagnosis of hepatic nodules. And the combined application has better accuracy.

Liver Injury

The expression of type 3 innate lymphocytes in blood may have potential differential diagnosis value between drug-induced liver injury and autoimmune hepatitis

LI Qing, ZHOU Tian-hui, MO Rui-dong, XIANG Xiao-gang, ZHAO Gang-de, ZHOU Hui-juan, XU Yu-min, CAI Wei, WANG Hui, XIE Qing, LAI Rong-tao

2020, 25(8):  840-844. 

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Objective The pathogenesis of drug-induced liver injury (DILI) is not yet fully understood. Clinical diagnosis relies on the scores of RUCAM scale. In particular, it is often confused with the diagnosis of autoimmune hepatitis (AIH) in clinical practice. Therefore, the search for early warning signs of DILI is of great significance for clinical diagnosis of DILI. Based on our previous work, this study further explored the expression of ILC3 cells in drug-induced liver injury. Methods 30 patients with DILI, 10 patients with AIH and 10 patients with healthy control (HC) were included in the diagnosis and treatment guidelines for drug-induced liver injury in 2015. Peripheral blood was collected and clinical demographic information was described. Peripheral blood mononuclear cells (PBMC) of patients and healthy subjects were isolated by Ficoll density gradient centrifugation. After antibody staining, flow cytometry was used to count the frequency of lin-CD127⁺NKP46⁺ILC3 in each group, and analyze the correlation between DILI and AIH. Results (1) The mean cell frequency percentages of NKp46⁺ILC3 in PBMC in DILI group and AIH group were 0.011%±0.002% and 0.019%±0.004%, which were significantly lower than those in HC healthy group (0.041%±0.003%, P<0.001). (2) The mean cell frequency percentage of NKp46⁺ILC3 in PBMC of DILI group was significantly lower than that of AIH group, with statistically significant difference (P<0.01). (3) The frequency percentage of NKp46⁺ILC3 in DILI group increased gradually with the improvement of the disease, while the frequency percentage of NKp46⁺ILC3 cells in AIH group showed no significant change during the same period of treatment. (4) The frequency percentage of ILCs in DILI and AIH group was 0.060%±0.006% and 0.074±0.009, which were significantly lower than those in healthy group (0.162±0.015) (P<0.001). However, there was no significant difference of ILCs between DILI and AIH group (P=0.03). (5) The mean cell frequency percentage of NKp46⁺ILC3 in DILI patients was not correlated with the liver function level of aspartate aminotransferase (AST), glutamate aminotransferase (ALT) and total bilirubin (TBil). Conclusion The frequency of ILC3 cells in the peripheral blood of DILI patients was significantly decreased, which was significantly lower than that of AIH group and healthy control group. The cell frequency was related to the progression of disease, but was irrelevant to transaminase, total bilirubin and other biochemical markers.

The incidence and clinical characters of drug-induced liver injury in patients after liver transplantation

ZHOU Xia, SUN Yan-ling, GAO Yin-jie, HE Xi, WANG Hong-bo, ZHANG Da-li, LIU Zhen-wen, LIU Hong-ling

2020, 25(8):  845-847. 

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Objective To investigate the incidence and clinical characteristics of drug-induced liver injury (DILI) in patients after liver transplantation (LTx). Methods The patients who received LTx in our center from January 2005 to December 2015 were enrolled. The pathological and clinical data were analyzed to determine the incidence and clinical characteristics of DILI in post-LTx patients. Results A total of 21 (3.77%) cases were diagnosed DILI from 557 post-LTx patients. There were 3 patterns (hepatocellular, cholestatic, and mixed), cholestatic pattern predominant (n = 11, 52.4%). Of these DILI cases, 16 (76.2%) were mild, 4 (19%) were moderate. DILI attacked in 5 cases (23.8%) within 3 months after transplantation, and in 13 cases (61.9%) within 1 year. The major agents inducing DILI were immunosuppressive agents (n = 11, 52.4%), especially tacrolimus. Besides, antifungal agents (n = 2, 9.5%), antituberculotics (n = 2, 9.5%), and Chinese herb (n = 3, 14.3%) were also causative agents. After symptomatic treatment, the liver function of 17 patients was significantly improved. Conclusion The incidence of DILI is low in patients after LTx. Antifungal drugs and tacrolimus are the main causes. The disease is relatively mild and mostly attacks within 1 year after LTx.

Clinical significance of circulating hypoxia inducible factor-1α and cycloxygenase-2 in patients with drug-induced liver injury

LI Liang, TAO Ying-min, ZHANG Xue-min, XIE Juan, CHEN Yuan

2020, 25(8):  848-852. 

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Objective To investigate the diagnostic values of levels of circulating hypoxia inducible factor-1α (HIF-1α) and cyclooxygenase-2 (COX-2) for drug-induced liver injury (DILI) as noninvasive methods. Methods A total of 60 DILI patients in our department from March 2017 to March 2020 were enrolled in the study. The levels of circulating HIF-1α and COX-2 were detected in these 60 DILI patients and 30 healthy controls by enzyme-linked immunosorbent assay. The diagnostic values were analyzed by receiver operator characteristic (ROC) curve. Results The serum levels of HIF-1α and COX-2 were significantly higher in DILI patients than those in healthy controls [(6.41 ± 1.08) vs (4.77 ± 1.57) μg/L, (25.95 ± 5.39) vs (19.35 ± 5.48) ng/L, both P<0.01]. In DILI patients, there was no significant difference in serum HIF-1α and COX-2 levels among hepatocellular, cholestatic and mixed types (all P > 0.05). There were no significant differences in serum HIF-1α and COX-2 levels among various age and sex, either. There was a linear relationship between HIF-1α and COX-2 expression (P<0.05). The area under the ROC curve of HIF-1α and COX-2 was 0.894 and 0.820, respectively. The cut-off value of HIF-1α for predicting DILI was 5.2 μg/L, with a sensitivity of 85.00% and a specificity of 86.67%. And the cut-off value of COX-2 was 19.31 ng/L, with a sensitivity of 96.67% and a specificity of 63.33%. After combining HIF-1α and COX-2, 4.5 μg/L and 25 ng/L were identified as the cut-off values, respectively. And the area under the ROC curve was 0.906, with a sensitivity of 91.67% and a specificity of 83.33%. Conclusion The serum levels of HIF-1α and COX-2 can serve as useful noninvasive predictive markers for the diagnosis of DILI, but not as reference for DILI classification. And the combination of the 2 has better diagnostic value.

Comparative study of preservative effect of normothermic machine perfusion on porcine liver with warm ischemia injury between portal vein pressure- and flow-controlled mode

HE Xi-ran, TAN Xiao-yu, ZHANG Lin, KUANG Wei-jian, LIU Hua-min, CHEN Su-ping, GUO Jia-xing, LIANG Ming-ju, ZHOU Wei-jin, HUO Feng

2020, 25(8):  853-856. 

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Objective To compare the protective effect of portal vein pressure-controlled and flow-controlled mode in porcine livers with warm ischemia by normothermic machine perfusion (NMP) system ex vivo. Methods Female Bama miniature swine were used as both blood and liver donors. The livers with 60-minute warm ischemia time were divided into 2 groups, one group was perfused in a portal vein constant pressure-controlled mode (n = 6), the other was perfused in a portal vein constant flow-controlled mode (n = 6), each group was perfused for 6 hours with NMP equipment. The perfusion parameters, blood gas parameters, biochemical indicators, and histopathology of livers were analyzed. Results There was no statistical difference in cold ischemic time between the 2 groups before perfusion (P > 0.05). After 6 hours of NMP, the hepatic artery flow in the constant pressure-controlled group [(0.13 ± 0.08) mL/min/g (liver weight)] was lower than that in the constant flow-controlled group [(0.25 ± 0.09) mL/min/g (liver weight)] (P<0.05). Between the 2 groups, there was no difference in perfusate pH, lactate level, glucose level, and blood urea nitrogen level (except for the 2nd hour) (P>0.05). There was no statistical difference in hepatocellular enzymes or total bilirubin level between the 2 groups at the end of perfusion either (P>0.05). The volume of bile produced in the constant flow-controlled group [(54.47 ± 15.63) mL] was more than that in the constant pressure-controlled group [(6.98 ± 3.20) mL] (P<0.05). In hepatic histopathological score, there were no differences between the 2 groups (P>0.05). Conclusion The constant flow-controlled mode was more beneficial to the blood supply of hepatic artery, thus promoted the bile synthesis in liver. It is suggested that the portal vein flow-controlled mode may be a better perfusion method, which requires further animal liver transplantation experiments and clinical liver transplantation trials.

Viral Hepatitis

The clinical significance of hepatitis B virus C region variation in OBI patients

SHAO Shu-guang, SUN Hai-xia, FENG Liu-fang

2020, 25(8):  857-859. 

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Objective To study the clinical significance of variation of hepatitis B virus C region in patients with occult hepatitis b virus infection (OBI). Methods Clinical data of 80 OBI patients admitted and treated in our hospital from March 2017 to March 2019 were retrospectively analyzed. After admission (before treatment), 7mL of fasting venous blood was extracted 2 ~ 3 days in the morning to detect hepatitis b E antigen (HBeAg), HBV-DNA, core antibody (anti-HBc) and hepatitis b virus C region variation. Analysis of hepatitis b virus C region variation of HBeAg (+) and HBeAg (-) patients, as well as hepatitis b virus C region variation in patients with different HBV-DNA content HBeAg (-). Finally, the distribution of anti-HBc (+) in HBeAg (-) hepatitis b virus variant patients was analyzed. Results In 80 patients with OBI, HBeAg (+) accounted for 55.00% and HBeAg (-) 45.00%.The mutation rate of HBeAg (-) group was 75.00%, which was significantly higher than that of HBeAg (+) group (34.09%, P<0.05). The variation rates of hepatitis b virus C region in patients with different HBV-DNA content HBeAg (-) were 100.00%, 78.95%, and 16.67% respectively, with statistically significant differences between each group (P<0.05). The anti -HBc (+) rate was 81.48% in 27 patients with HBeAg (-) hepatitis b virus variant in region C. Conclusion HBV C region mutation in OBI patients is closely related to disease progression and prognosis, so we should pay attention to HBV C region mutation in the diagnosis and treatment of OBI.

Other Liver Diseases

Clinical analysis of 4 cases of POEMS syndrome and literature review

LI Lu, YANG Xian-shan, KONG Ming, ZHENG Su-jun, CHEN Yu

2020, 25(8):  860-862. 

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Objective To improve the understanding of POEMS syndrome and reduce the incidence of misdiagnosis. Methods 4 patients who were treated in our department from January 2017 to August 2019 were collected. According to the causes of the disease, clinical features and examination results, relevant misdiagnosis analysis and literature review of the above patients were conducted to summarize their characteristics. Results 1 case had peripheral nerve and other 3 cases had ascites or hepatosplenomegaly as the first symptom on admission. 3 cases were Ig A lamda positive, one was IgG lamda positive. The VEGF levels of them were higher than 800 pg/ml, and no fibrosis in liver tissue pathology. Conclusion POEMS syndrome is a multi-systemic disease with low incidence and high misdiagnosis rate. Hepatomegaly and splenomegaly with peritoneal effusion may be the first symptom of some patients with POEMS syndrome. Clinicians should pay attention to multi-system inspection to reduce misdiagnosis and improve clinical diagnosis rate.

Efficacy and safety of granulocyte colony-stimulating factor in treatment of patients with hepatic failure: A Meta-analysis

YU Cong, ZHOU Pei

2020, 25(8):  863-866. 

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Objective To systematically review the clinical efficacy and safety of G-CSF (granulocyte colony-stimulating factor) in treatment of patients with hepatic failure. Methods We searched PubMed, WanFang Database, the Cochrane Library, CNKI, CBM, VIP databases to collect RCTs (randomized clinical trials) of G-CSF in treatment of patients with hepatic failure, which were published before January, 2018. RCTs comparing the use of any regimen of G-CSF against placebo or no intervention in patients with ACLF were included. Primary outcomes included overal mortality, mortality due organ failure, and adverse events. We selected the retrieved studies according to the predefined inclusion and exclusion criteria, and evaluated the quality of included studies, a total of 5 studies involving 279 patients with hepatic failure were included. Results The results of meta-analysis showed that the survival rate in G-CSF group was significantly higher than that in control group [RR=1.94,95%CI=1.37-2.26,P<0.0001]. Conclusion G-CSF is more effective than the general supporting treatment for patients with hepatic failure, as it can increase the survival rate and has fewer adverse events. Although the evidence is still limited, the apparent benefit is observed that the use of G-CSF in ACLF patients as a reasonable alternative when liver transplantation is contraindicated or unavailable.

Research on the construction and development of hepatology hospital based on the disease spectrum of inpatients

PAN Yun-he, HU Chen-bo

2020, 25(8):  867-869. 

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Objective To explore the composition and changes of disease spectrum of patients with liver diseases in Pudong New Area Nanhua Hospital in recent five years. To provide reference for the treatment of patients with liver diseases and the development and construction of specialized hospitals for liver diseases. Methods It was a retrospective study of the disease composition of the inpatients with liver disease in our hospital from January 2015 to December 2019. According to the annual statistics of the number of inpatients with various liver diseases, we compared the composition of infectious and non-infective liver diseases, and analyzed the dynamic changes of the composition of liver disease in the past five years. Results The percentage of infective liver disease was decreasing year by year, but it was still the main cause of liver disease hospitalization, among which chronic hepatitis B was still the first cause. The incidence of non-infective liver disease continues to rise, among which non-alcoholic fatty liver disease was the first. Conclusion The number of inpatients with infective liver disease were declining, and non-infective liver disease were on the rise. The construction and development of liver disease specialist hospital may need multidisciplinary cross cooperation.

Relationship between signal transducer and activator of transcription-3 in placenta and perinatal outcome in patients with intrahepatic cholestasis of pregnancy

PEI Guang-li, XIE Jie, LIU De-rong, XU Jin'e

2020, 25(8):  870-872. 

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Objective To investigate the relationship between signal transduction and transcriptional activator 3 (STAT3) in placenta and delivery outcome in pregnant women with intrahepatic cholestasis (ICP) during pregnancy. Methods 126 ICP pregnant women admitted to our hospital from January 2016 to January 2020 were selected as the observation group, and 102 healthy pregnant women admitted to our hospital at the same time were selected as the control group. The expression of STAT3 in placenta was determined by immunohistochemical streptomycin (SP) and western blot.The positive rate of STAT3 cells, the average optical density and the expression of STAT3 protein in placenta of the two groups were compared, and the relationship between the expression of STAT3 in placenta and the delivery outcome of ICP pregnant women was analyzed. Results The positive rate, mean optical density and STAT3 protein expression in the placenta of the observation group were significantly higher than that of the control group (all P<0.001).Among the 126 ICP pregnant women, natural delivery accounted for 30.95% and cesarean section for 69.05%.The positive rate and the average optical density of STAT3 cells in the placenta of the parturient were significantly lower than those of the cesarean section (all P<0.001). Conclusion STAT3 in placenta is closely related to the delivery outcome of ICP pregnant women.

Clinical value of ultrasound shear wave elastography in the diagnosis of biliary atresia in children

GENG Xing-lan, WANG Ke-jun, KANG You-liang

2020, 25(8):  873-875. 

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Objective To explore the clinical value of ultrasonic shear wave elastography (SWE) in the diagnosis of infantile biliary atresia (BA). Methods From January 2017 to July 2019, 72 suspected cases of cholestatic liver disease were treated in our hospital, including 42 males and 30 females, aged from 25 days to 160 days, with an average age of (82.6 ±16.8) days. 60 healthy patients were selected as control group. The measurement data were expressed as (±s), the t-test was used for comparative analysis, the counting data was expressed as absolute value, and the chi-square test was used for comparative analysis. The diagnostic indexes were obtained by drawing ROC curve. Results Among the 72 suspected cases of cholestatic liver disease, 38 cases of BA (BA group) were confirmed by operation, and the remaining 34 cases were included in non-BA group. There were 26 males and 12 females in BA group, with an average age of (84.3±19.8) days, while in non-BA group, there were 22 males and 12 females with an average age of (78.9±26.4) days. There was no significant difference in sex composition and age among BA group, non-BA group and control group. The average value of liver stiffness weasurement (LSM) in BA group was (14.6±6.2) kPa, the average value of LSM in non-BA group was (8.3±2.3) kPa, the average value of LSM in control group was (5.8±1.1) kPa,. There was significant difference in LSM among the three groups (P<0.05). There was no significant difference in the average value of LSM between male and female patients in the three groups (P>0. 05). The average value of LSM in BA group within 30 days was significantly lower than that in 90 days (P<0.05), but there was no significant difference in LSM between non-BA group and control group within 30 days and 90 days (P>0. 05). After drawing the ROC curve, the optimal critical value of LSM in the diagnosis of BA was 12.8 KPA, the sensitivity was 73.4% and the specificity was 88.7%, and the area under the Roc curve was 0.83. Conclusion SWE can accurately reflect the changes of LSM in infantile BA patients, and has important clinical value for the differential diagnosis of infantile BA patients.

Study on function of rHepLPCs cultured on decellularized human umbilical cord-derived scaffolds

JING Hong-shu, PENG Yuan, WANG Zhen-yu, LI Wei-jian, YUAN Tian-jie, Zhang Hong-dan, YAN He-xin, ZHAI Bo

2020, 25(8):  876-880. 

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Objective This study aimed to fabricate and to characterize decellularized human umbilical cord-derived scaffolds (dHUCS), to evaluate the function of rodent hepatocyte-derived liver progenitor-like cells (rHepLPCs) cultured on 3-dimensional (3D) scaffolds, and to provide a novel liver tissue engineering protocol. Methods Hepatocytes were isolated from mice by a 2-step collagenase perfusion method, expanded in vitro and labeled with Dil. The dHUCS was characterized by detection of component, Masson staining and hematoxylin and eosin staining. The function of 3D-cultured rHepLPCs was analyzed by quantitative polymerase chain reaction and biochemical assays. Results After decellularization, the nucleic acid residue of umbilical cord-derived scaffolds was 60.20 ± 1.42 ng/mg (dry weight), and the removal rate of nucleic acids was 90.5%. Matrix component were rich. After 2-week culture, albumin, glucose-6-phosphatase and carbamoyl-phosphate synthetase 1 expression levels of hepatocytes were upregulated by 10.1 ± 2.3, 34.4 ± 1.3 and 42.0 ± 22.0 times, respectively. As for ammonia metabolism, the ammonia clearance and urea synthesis levels were 5.7 ± 0.9 mg/(dL·million cells·day) and 7.1 ± 2.5 mg/(dL·million cells·day) in 2-dimensional-cultured rHepLPCs, 26.7 ± 4.5 mg/(dL·million cells·day) and 42.1 ± 7.0 mg/(dL·million cells·day) in 3D-cultred rHepLPCs, respectively. Conclusion The dHUCS is an ideal liver tissue engineering material. The 3D cultured rHepLPCs could have better function, which have potential therapeutic effect on acute liver failure characterized by elevated serum ammonia.