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The relationship between liver disease stage and liver fibrosis: A tangled web
Abstract
Germani G, Burroughs A K & Dhillon A P (2010) Histopathology57, 773–784
The relationship between liver disease stage and liver fibrosis: a tangled web
The structural consequences of chronic liver disease are described as a series of liver disease ‘stages’ with scarring and architectural change that eventually destroys and replaces the normal lobular structure of the liver. Fibrosis (‘excess collagen’) and stage have been confused in histological staging systems. Fibrosis is part of increasing liver disease stage, but fibrosis and stage are different. Staging liver disease is important in routine histopathological assessment. Measurement of liver fibrosis is another process. The collagenous proportion of a liver biopsy [collagen proportionate area (CPA)] correlates with hepatic venous pressure gradient (HVPG), which is of recognized prognostic value. CPA at 1 year post-transplantation in hepatitis C virus-infected patients predicts subsequent clinical decompensation. CPA in cirrhotic patients predicts decompensation more accurately than staging or HVPG. The ‘cirrhosis’ stage category has poor prognostic power, and CPA effectively substages cirrhosis. CPA improves the description of liver disease stage. Proper validation of antifibrotic treatments and ‘non-invasive markers of liver fibrosis’ requires measurement of liver fibrosis (and not liver biopsy stage scores). It is unacceptable for the words ‘fibrosis’ and ‘score’ to remain next to each other. There are benefits to properly understanding liver fibrosis and liver disease stage and properly assessing each of them.
... Additionally, in advanced liver disease, each of the descriptive morphological stages contains a wide range of quantitative fibrosis values, another limitation of the current morphological category is that no subclassification was contained. 13 Collagen proportionate area (CPA) calculated by digital image analysis (DIA) was established to assess the proportion of collagen to tissue, have been confirmed as an appropriate a measurement to assess the fibrosis degree continuously in advanced stage liver disease, substages cirrhosis effectively as well as improves the description of liver disease stage. [14][15][16][17][18] Currently, although there have studies that focused on the clinical significance of serum quantitative HBsAg on liver histology, it is still unclear about the association between quantitative HBsAg and CPA at any specific time point. ...
... Liver stage and fibrosis have always been confused in histological assessment, liver disease staging is necessary for routine histopathological assessment while liver fibrosis measurement is another process. 13 The "number" of the stage score is neither continuous variable nor quantitatively related so that cannot be used as a measurement. For example, METAVIR stage 1 does not equivalent to half as much fibrosis as stage 2. ...
Background:
Quantitative serum hepatitis B surface antigen (HbsAg) has been widely used as a biomarker for treatment response and prognosis in chronic hepatitis B infection, and has recently been found associated with liver histology in e-antigen positive patients. A histological measurement as a continuous variable-collagen proportionate area (CPA)-is appropriate to assess liver fibrosis degree and substages cirrhosis. We, therefore, aimed to explore the association between serum quantitative HBsAg and CPA in e antigenpositive hepatitis B cirrhosis.
Methods:
Liver fibrosis staging was evaluated by METAVIR semiquantitative scoring system, only patients with METAVIR fibrosis stage 4 were included. All liver sections were stained with picroSirius red for determination of collagen quantification by digital image analysis.
Results:
Mean CPA value was 23.46%. The percentage of patients with different classification of CPA (30%) were 25.8%, 57.8%, and 16.4%, respectively. A modest correlation was found between CPA and serum HBsAg level (r = -0.306, P =.001). Hepatitis B surface antigen level is independently associated with CPA in multivariable linear regression analyses.
Conclusion:
Serum HBsAg levels can predict liver fibrosis determined by CPA in HBeAg-positive hepatitis B cirrhosis.
... "0 = fibrosis not present, 1 = small portal area expansion with/ without septa, 2 = fibrous expansion of most portal areas with/without septa, 3 = most portal area fibrous expansion fibrous with infrequent portal to portal bridging, 4 =fibrous dilatation of most portal areas with portal to portal and portal to central bridging, 5 = signified bridging with formation of nodules (partial cirrhosis), 6 = cirrhosis evident or definite. [22,23] Digital images were acquired from Sirius red-stained sections using a digital camera linked to the microscope at magnification x400 (n=4/group). Measurements were represented as a percentage fibrotic area to the total surface area using Leica Image analysis software. ...
... The Ishaq scoring system was used to stage the animals based on the percentage of fibrotic surface area. [22,23] ...
... However, the two items have always been confused which led to misinterpretation of data in the literature. Furthermore, each of the descriptive morphological stages of chronic liver disease, especially for advanced liver disease, contains a wide range of quantitative values for brosis, a signi cant limitation of current morphological category is that it contains no sub-classi cation [13]. Thus, a histological technique that measures the amount of brosis properly in advanced-stage liver disease is of great interest in liver pathology. ...
... Liver brosis and stage have always been confused in histological staging systems, staging liver disease is important in routine histopathological assessment while measurement of liver brosis is another process [13]. CPA as a continuous variable is a suitable histological measurement to assess the degree of brosis and substage cirrhosis, as an improvement of liver disease stage description. ...
Background: Quantitative serum HBsAg has been widely used as a biomarker for treatment response and prognosis in chronic hepatitis B, and recently been found associated with liver histology in HBeAg positive patients. Collagen proportionate area (CPA) as a continuous variable is a appropriate histological measurement to assess the degree of fibrosis and substages cirrhosis. We aimed to explore the association of serum HBsAg level with CPA in e antigen positive hepatitis B cirrhosis.
Methods: Liver fibrosis staging was evaluated semiquantitatively according to the Metavir scoring system, only patients with METAVIR stage 4 were included. All liver biopsies were restained with picroSirius red for collagen quantification and determination of CPA by digital image analysis.
Results: Mean collagen proportionate area value was 23.46%. The percentage of patients with different classification of CPA (< 20%, 20%-30%, >30%) were 25.8%, 57.8%, and 16.4%, respectively. A modest correlation was observed between CPA and serum HBsAg (r = -0.306, p = 0.001). HBsAg level is independently associated with collagen proportionate area in multivariable linear regression analyses.
Conclusion: Serum HBsAg levels can predict liver fibrosis determined by CPA in e antigen positive hepatitis B cirrhosis.
... Semi-quantitative stages describe the architectural changes, but they do not quantify the actual amount of collagen fibers, which is the main factor that both indicates fibrosis progression and influences hepatic stiffness. Several authors recently suggested that the current histopathological scoring for staging liver fibrosis needs to be critically reassessed, and some even described it as "a tarnished gold standard" that must be improved [8][9][10]. ...
... Furthermore, CPA has greater mathematical and statistical meaning than routine stage scores. Fibrosis staging is one kind of representative shorthand symbol, which does not reflect any fibrosis-related substance measurements or have any mathematical relevance (e.g., liver fibrosis stage 4 does not mean the severity is twice that of stage 2) [9]. And obviously, it is not a rigorous scientific method using the highest grade F4 or F6 to cover all levels of cirrhosis [23]. ...
... In chronic liver disease, the main histological feature is the accumulation of connective tissue. This results in a harmful process, which occurs in the liver and leads to necrosis/apoptosis of hepatic or biliary cells [12]. Accumulation of connective tissue makes the liver stiffer, which can be quantified by ultrasound based elastography. ...
... Elastography is particularly reliable when it comes to ruling-in significant fibrosis (stage F≥2 to METAVIR classification) and the ruling-out of cirrhosis (stage F=4 to METAVIR). However, once cirrhosis presents, the pathophysiological processes in the liver are underway in the molecular, histological, macroscopic and clinical phenotypes [3,12,14,15]. It is well known that cirrhosis can be divided into clinical stages, according to the Child-Pugh classification. ...
Liver stiffness measurement (LSM) by ultrasound-based elastography may be used to non-invasively discriminate between the stages of liver fibrosis, rule out cirrhosis and follow its evolution, including the prediction of the presence of oesophageal varices. The same is possible in order to diagnose clinically significant portal hypertension, referring primarily to transient elastography and LSM values ≥20-25 kPa. The same approach may be used to reliably rule out the presence of oesophageal varices (LSM <20 kPa + platelets >150x109/L). These recommendations refer primarily to patients with viral aetiology of chronic liver disease (hepatitis C), while additional studies are required for other aetiologies. While spleen stiffness measurement (SSM) also poses a logical choice in this indication, controversial results have nevertheless been published on this issue. It should be emphasized, however, that more recent data indicate that this parameter should be included in the diagnostic algorithm for portal hypertension, if not as the sole then as a part of a sequential algorithm, combined with LSM. Until now, transient elastography has been most extensively studied and founded on scientific evidence, although the results of other ultrasound-based elastography techniques demonstrate the same trend for the non-invasive assessment of portal hypertension.
... also induce large accuracy bias to the results [5]. The semiquantitative parameter currently used to assess liver fibrosis, collagen proportionate area (CPA), has been deemed more objective and accurate for assessing the quantity of excessive extracellular matrix (ECM) deposition, and correlates better with prognosis than the Ishak staging system [6][7][8]. However, calculation of the CPA is also based on an invasive LB. ...
... The sections were then deparaffinized and hydrated for subsequent Sirius red staining to stage fibrosis and calculate the CPA. Each specimen was categorized into one of seven fibrotic stages (0-6) according to the Ishak scoring system [7,17]. All specimens were evaluated by a well-trained medical student and a qualified histopathologist with 10 years of experience. ...
Objective:
Scintigraphy using 99mTc-3PRGD2 targeting integrin αvβ3 could assess activation of hepatic stellate cells (HSCs). Liver fibrogenesis is intimately associated with activation of HSCs, and the fibrolytic process is accompanied by the reduction of the activated HSCs. In this study, we aimed to evaluate the feasibility of this method to assess the severity of liver fibrosis and the reversal after the fibrotic stimulus withdrawal.
Methods:
Liver fibrosis of different stages was induced by thioacetamide (TAA) injection for 2, 4 and 6 weeks (n = 6 for each time point). Another 6 rats with 8-week TAA administration (the 8-week group) and 6 rats which were injected with TAA for 6 weeks, and then withdrawn of TAA for 2 weeks (spontaneous recovery rats, SRR) were designed. The ratios of radioactivity detected in the liver vs. the heart at 30 min post-injection of (99m)Tc-3PRGD2 (L/H30min), the collagen proportionate area (CPA), the protein and mRNA levels of integrin αv, integrin β3 were analyzed and compared among groups.
Results:
The Ishak stage scores of the livers in the control and 2, 4, 6-week groups increased when the TAA administration period was extended. L/H30min increased with the upgrading of liver fibrosis and the differences between each pair of groups were statistically significant (p 30 min in the 8-week group was similar to that in the 6-week group (p > 0.05), but was significantly higher than that in the SRR group (p = 0.005).
Conclusions:
Scintigraphy using (99m)Tc-3PRGD2 may provide a non-invasive method for grading liver fibrosis and assessing liver fibrosis reversal.
... Th e traditional histological staging systems are semiquantitative methods, assigning numerical algorithms without quantitative relation to the underlying liver disease [77]. Despite their recognized value in routine histopathological practice they are inadequate to sub-classify cirrhosis [66]. ...
... All systems appoint "numerical" scores to each stage. However, the use of numerical calculations for a continuous variable, as is fi brosis, is now thought conceptually inexact, as already noted in the Introduction [77]. ...
Hepatic fibrogenesis may gradually result to cirrhosis due to the accumulation of extracellular matrix components as a response to liver injury. Thus, therapeutic decisions in chronic liver disease, regardless of the cause, should first and foremost be guided by an accurate quantification of hepatic fibrosis. Detection and assessment of the extent of hepatic fibrosis represent a challenge in modern Hepatology. Although traditional histological staging systems remain the “best standard”, they are not able to quantify liver fibrosis as a dynamic process and may not accurately substage cirrhosis. This review aims to compare the currently used non-invasive methods of measuring liver fibrosis and provide an update in current tissue-based digital techniques developed for this purpose, that may prove of value in daily clinical practice.
... 2,9 However, liver fibrosis assessment and performance of non-invasive tests should really be evaluated in the context of other histopathological metrics on biopsy such as quantitative measures of collagen. 10 Despite sampling issues, given the nonlinear increase in collagen deposition with advancing disease, quantitative morphometry may detect changes in fibrosis that are not apparent using standard grading systems. 11 In addition, no studies have previously quantified alpha smooth muscle actin (a-SMA) expression (as a marker of hepatic stellate cell activation) in relation to non-invasive biomarker assessment of fibrosis. ...
... Given the nonlinear association of quantitative collagen with Ishak stage we assessed for disproportionate changes in collagen and a-SMA from baseline Ishak stages 2, 3 or 4. There were no significant differences in mean change (D) from baseline in log 10 ...
Background:
Assessment of fibrosis progression in chronic liver disease relies upon non-invasive tools and changes in semi-quantitative histopathology scores that may not be reliable.
Aim:
To assess the diagnostic performance of the FibroSURE (FS) index and collagen/alpha smooth muscle actin (α-SMA) morphometry in relation to longitudinal changes in fibrosis on paired biopsies.
Methods:
The study cohort included 201 chronic hepatitis C (CHC) nonresponders enrolled in a prior phase II anti-fibrotic study. Serum FS and paired biopsies, with both collagen and α-SMA morphometry, were evaluated at baseline and week 52.
Results:
Study patients were mostly male (67%) and Caucasian (77%), with Ishak stages 2 (n = 79), 3 (n = 88) and 4 (n = 30), excluded (n = 4 stage 1 or 5). Mean biopsy length was 22.9 mm. For baseline Ishak 2/3 vs. 4, there were no significant differences in AUROCs for collagen (0.71), SMA (0.66) or FS (0.70). At week 52, 62% of patients had no change in Ishak stage, but collagen/α-SMA increased by 34-51% (P < 0.0001), and FS decreased by 5% (P = 0.008). Among the 33% of patients with +/-1 Ishak stage change, FS changes were not significant, but α-SMA increased 29-72%, and collagen increased by 12-38% (P = 0.01 for +1 only).
Conclusions:
Longitudinal changes in collagen and α-SMA morphometry are apparent prior to change in histological stage or FibroSURE in CHC nonresponders with intermediate fibrosis. This likely reflects quantitative morphological differences that are not detected by routine histological staging or serum markers such as FibroSURE.
... Quantitative digital morphometric analysis (DMA) provides a standardized, objective evaluation of fibrosis offering digital images of liver biopsy samples, providing accurate measurements of the collagen and remaining liver tissue areas, and calculating the proportion of the biopsy specimen that is occupied by collagen (collagen proportion area -CPA) [4,5]. There are significant correlations between CPA and histological stage as well as CPA and liver stiffness (LS) or other serum markers of liver fibrosis and hepatic venosus pressure gradient [4][5][6][7]. ...
... Quantitative digital morphometric analysis (DMA) provides a standardized, objective evaluation of fibrosis offering digital images of liver biopsy samples, providing accurate measurements of the collagen and remaining liver tissue areas, and calculating the proportion of the biopsy specimen that is occupied by collagen (collagen proportion area -CPA) [4,5]. There are significant correlations between CPA and histological stage as well as CPA and liver stiffness (LS) or other serum markers of liver fibrosis and hepatic venosus pressure gradient [4][5][6][7]. ...
Prognosis and treatment of liver diseases mainly depend on the precise evaluation of the fibrosis. Comparisons were made between the results of Metavir fibrosis scores and digital morphometric analyses (DMA), liver stiffness (LS) values and aminotransferase-platelet ratio (APRI) scores, respectively. Liver biopsy specimens stained with Sirius red and analysed by morphometry, LS and APRI measurements were taken from 96 patients with chronic liver diseases (56 cases of viral hepatitis, 22 cases of autoimmune- and 18 of mixed origin). The strongest correlation was observed between Metavir score and DMA (r = 0.75 p < 0.05), followed in decreasing order by LS and Metavir (r = 0.61), LS and DMA (r = 0.47) LS and APRI (r = 0.35) and Metavir and APRI (r = 0.24), respectively. DMA is a helpful additional tool for the histopathological evaluation of fibrosis, even when the sample size is small and especially in case of advanced fibrosis. The non-invasive methods showed good correlation with the histopathological methods; LS proved to be more accurate than APRI. The stronger correlation between LS values and Metavir scores, as well as the results of DMA in case of appropriate sample size were remarkable.
... Collagen, a superfamily of extracellular matrix proteins with a triple helix structure, is vital for maintaining tissue structure and stability, and it plays a crucial role in mediating physiological processes such as tissue regeneration and wound healing [1][2][3][4][5]. The dysregulation of collagen remodeling has been widely recognized as a key underlying factor contributing to a variety of severe diseases such as tumors and fibrosis [6][7][8][9]. The aberrant synthesis and degradation of type I and type IV collagen have been closely implicated in the multifaceted processes of tumor progression, invasion, and metastasis [10][11][12][13]. ...
The accurate detection of multiplex collagen biomarkers is vital for diagnosing and treating various critical diseases such as tumors and fibrosis. Despite the attractive optical properties of quantum dots (QDs), it remains technically challenging to create stable and specific QDs-based probes for multiplex biological imaging. We report for the first time the construction of multi-color QDs-based peptide probes for the simultaneous fingerprinting of multiplex collagen biomarkers in connective tissues. A bipeptide system composed of a glutathione (GSH) host peptide and a collagen-targeting guest peptide (CTP) has been developed, yielding CTP-QDs probes that exhibit exceptional luminescence stability when exposed to ultraviolet irradiation and mildly acidic conditions. The versatile bipeptide system allows for facile one-pot synthesis of high-quality multicolor CTP-QDs probes, exhibiting superior selectivity in targeting critical collagen biomarkers including denatured collagen, type I collagen, type II collagen, and type IV collagen. The multicolor CTP-QDs probes have demonstrated remarkable efficacy in simultaneously fingerprinting multiple collagen types in diverse connective tissues, irrespective of their status, whether affected by injury, diseases, or undergoing remodeling processes. The innovative multicolor CTP-QDs probes offer a robust toolkit for the multiplex fingerprinting of the collagen suprafamily, demonstrating significant potential in the diagnosis and treatment of collagen-related diseases.
... The Sirius Red-positive areas were quantified using ImageJ software. To evaluate the degree of fibrosis in the liver specimens, fibrosis scores were assigned based on the Ishak stage score ranging from 0 to 6, as previously reported [21]. ...
Although alcohol is a well-known causal factor associated with liver diseases, challenges remain in inducing liver fibrosis in experimental rodent models. These challenges include rodents’ natural aversion to high concentrations of alcohol, rapid alcohol metabolism, the need for a prolonged duration of alcohol administration, and technical difficulties. Therefore, it is crucial to establish an experimental model that can replicate the features of alcoholic liver fibrosis. The objective of this study was to develop a feasible rat model of alcoholic liver fibrosis that emulates human drinking patterns and combines low-dose chemicals within a relatively short time frame. We successfully developed an 8-week rat model of alcoholic liver fibrosis that mimics chronic and heavy drinking patterns. Rats were fed with a control liquid diet, an alcohol liquid diet, or alcohol liquid diet combined with multiple binges via oral gavage. To accelerate the progression of alcoholic liver fibrosis, we introduced low-dose carbon tetrachloride (CCl4) through intraperitoneal injection. This model allows researchers to efficiently evaluate potential therapeutics in preclinical studies of alcoholic liver fibrosis within a reasonable time frame.
... The automated analysis of liver brosis was based on the continuous measurement of the collagen proportionate area (CPA) i.e., the ratio of area of PSR-stained collagen bers versus area of liver section as described before [14,15]. Other studies in rodents [8, 19,35,36] and human biopsies [21,[36][37][38][39] used CPA to report on the amount of collagen deposit in the liver. In these previous studies, CPA measurement still involved a number of manual procedures, for example to select relevant area or exclude artefacts, unlike the present study in which it was fully automated from native images to statistical analysis. ...
Current literature highlights the need for precise histological quantitative assessment of fibrosis which cannot be achieved by conventional scoring systems, inherent to their discontinuous values and reader-dependent variability. Here we used an automated image analysis software to quantitate fibrosis deposition in two relevant preclinical models of liver fibrosis, and established correlation with other quantitative fibrosis descriptors. Longitudinal quantification of liver fibrosis was carried out during progression of post-necrotic (CCl 4 -induced) and metabolic (HF-CDAA feeding) models of chronic liver disease in mice. Whole slide images of picrosirius red-stained liver sections were analyzed in fully automated, unsupervised manner by our software. Fibrosis was characterized by a significant increase of collagen proportionate area (CPA) at weeks 3 (CCl 4 ) and 8 (HF-CDAA) with a progressive increase up to week 18 and 24, respectively. CPA was compared to collagen content assessed biochemically by hydroxyproline assay (HYP) and standard histological staging systems. CPA showed a high correlation with HYP content for CCl 4 (r = 0.8268) and HF-CDAA (r = 0.6799) models. High correlations were also found with Ishak score or its modified version (r = 0.9705) for CCl 4 and HF-CDAA (r = 0.9062) as well as with NASH CRN for HF-CDAA (r = 0.7937). Such correlations support the use of automated digital analysis as a reliable tool to evaluate the dynamics of liver fibrosis and efficacy of antifibrotic drug candidates in preclinical models.
... Presently the Ishak's scoring has been utilized to evaluate liver fibrosis. Where zero means absence of fibrosis, score one = expansion of some portal areas with connective tissue septa or without connective tissue septa, score two=expansion of most portal areas with connective tissue septa or without connective tissue septa, score three = expansion of majority of the portal areas with portalto-portal bridging, score four= expansion of most portal areas with portal to portal and portal to central bridging, while score five = bridging with occasional nodules, and finally score 6 means cirrhosis [46] . In the current study, fibrosis was detected, crossing from one portal area to the adjacent one (Ishak's score three by using the Masson's trichrome in group III. ...
... 8 Liver injury caused by virus infection can result in fibrogenesis, where the stage of liver fibrosis decides the clinical prognosis and the line of treatment of HCV infection. 9 However, assessment of liver fibrosis is a big problem as it depends on liver biopsy which is an invasive method and prone to sampling error. 10 Novel biomarkers, such as microRNAs (miRNAs), are suggested to be ideal potential non-invasive indicators for liver fibrosis and hepatic disease progression due to their stability in the circulation, in addition to sensitivity to detection by quantitative PCR. ...
... 8 Liver injury caused by virus infection can result in fibrogenesis, where the stage of liver fibrosis decides the clinical prognosis and the line of treatment of HCV infection. 9 However, assessment of liver fibrosis is a big problem as it depends on liver biopsy which is an invasive method and prone to sampling error. 10 Novel biomarkers, such as microRNAs (miRNAs), are suggested to be ideal potential non-invasive indicators for liver fibrosis and hepatic disease progression due to their stability in the circulation, in addition to sensitivity to detection by quantitative PCR. ...
... 8 Liver injury caused by virus infection can result in fibrogenesis, where the stage of liver fibrosis decides the clinical prognosis and the line of treatment of HCV infection. 9 However, assessment of liver fibrosis is a big problem as it depends on liver biopsy which is an invasive method and prone to sampling error. 10 Novel biomarkers, such as microRNAs (miRNAs), are suggested to be ideal potential non-invasive indicators for liver fibrosis and hepatic disease progression due to their stability in the circulation, in addition to sensitivity to detection by quantitative PCR. ...
Background
MicroRNA (miRNAs) are small noncoding molecules play an important role in hepatitis C virus (HCV) replication and liver diseases progression. The current study aimed to evaluate serum miRNAs as potential biomarkers for diagnosis, monitoring of fibrosis progression and prediction of responses to direct acting antivirals (sofosbuvir + daclatasvir + ribavirin) in HCV genotype 4‐ patients.
Methods
The serum levels of four miRNAs (miRNA‐21, 199, 448 and 181c) were assessed in 150 HCV‐ patients and 50 healthy controls using quantitative real‐time PCR. The diagnostic accuracy was determined using receiver operating characteristic (ROC) curve.
Results
The 4 studied miRNAs showed significant upregulation in HCV‐ patients compared to controls. There were significant upregulation of MiR‐199 and significant downregulation of miR‐448 in late stages of fibrosis with high diagnostic accuracy (area under the curve “AUC” = 0. 989%; p < 0.001) and (AUC = 0. 0.672; p> 0.001) respectively. Regarding response to treatment, only miR‐199 showed a significant upregulation in non‐ responders‐ patients with high diagnostic accuracy (AUC= 0.968; p<0.001).
Conclusion
miR‐199 and miR‐448 could serve as valuable non‐invasive biomarkers for assessment of liver fibrosis progression. Additionally, miR‐199 could be also a potential biomarker for assessment of treatment efficacy among HCV‐ patients. Therefore, miR‐199 and miR‐448 serum levels should be considered during the treatment of HCV genotype4‐ patients in Egypt and the world.
... [4][5][6][7] Irregular accumulation of collagen has been widely found in fibrosis-related diseases, which leads to the disruption of normal tissue architecture and the impairment of proper organ function. [8][9][10] The anomalous distribution of different types of collagen has been demonstrated to be closely correlated with the growth, invasion and metastasis of tumor. [11][12][13] Furthermore, excessive degradation of Type II collagen, the principle component of articular cartilage, has been considered as the determinant factor for inducing rheumatoid arthritis and osteoarthritis. ...
The efficient detection of pathological collagen plays an essential role in the diagnosis, prognosis, and treatment of various critical diseases such as arthritis and tumors. Peptide probes with the (Gly‐Pro‐Hyp)n sequences have been recently discovered to recognize pathological collagen; however, their staining efficacy severely suffers from their strong trimerizing tendency. An intrinsically nontrimerizing peptide probe F‐GOP‐10 has been constructed for the first time to specifically target pathological collagen. F‐GOP‐10 consists of the repetitive (Gly‐Hyp‐Pro)n sequences, and displays the single stranded conformation at 0 °C. F‐GOP‐10 has been demonstrated to selectively recognize pathological, but not intact collagen in various mouse connective tissues, and it has been successfully applied to detect pathological collagen in osteoarthritis, liver fibrosis, and various cancer tissues. Compared with the common Masson's trichrome staining method, F‐GOP‐10 displays unique selectivity to only bind to pathological collagen without the interference of intact collagen. Notably, peptide probes with different lengths of the Gly‐Hyp‐Pro triplets all maintain the single stranded conformation, demonstrating their intrinsically non‐trimerizing nature. This pure‐peptide, pure monomer probe allows the accurate concentration determination and the elimination of harmful pretreatment, which has great potential in histopathology staining and other clinical applications. An intrinsically nontrimerizing peptide probe is developed for specific recognition of pathological collagen without the interference of intact collagen. It always maintains the single stranded conformation, and has been successfully applied to target pathological collagen in various tissues including osteoarthritis, liver fibrosis, and cancer. This pure‐peptide, pure monomer probe has great potential in histopathology staining and other clinical applications.
... Histological assessment was performed by a blinded observer, who scored the liver sections to assess hepatocellular death and inflammation using the following criteria Normal histology ''0''; minor hepatocellular death and inflammation ''1''; widely distributed patchy necrosis and inflammation ''2''; complete disruption with panlobular necrosis and inflammation ''3''; mortality ''4''. To assess liver fibrosis, the scoring system of Ishak et al. [16] was used where 0 = no fibrosis, 1 = expansion of some portal areas with/without septa, 2 = expansion of most portal areas with/without septa, 3 = expansion of most portal areas with portal-portal bridging, 4 = expansion of most portal areas with portal-portal and portal-central bridging, 5 = bridging with occasional nodules, 6 = cirrhosis probable or definite. ...
Background:
The extracellular vesicles (EVs) secreted by bone marrow-derived mesenchymal stem cells (MSCs) hold significant potential as a novel alternative to whole-cell therapy. We herein compare the therapeutic potential of BM-MSCs versus their EVs (MSC-EVs) in an experimental Carbon tetrachloride (CCl4)-induced liver damage rat model.
Methods:
Rats with liver damage received a single IV injection of MSC-EVs, 1 million MSCs, or 3 million MSCs. The therapeutic efficacy of each treatment was assessed using liver histopathology, liver function tests and immunohistochemistry for liver fibrosis and hepatocellular injury.
Results:
Animals that received an injection of either MSCs-EVs or 3 million MSCs depicted significant regression of collagen deposition in the liver tissue and marked attenuation of hepatocellular damage, both structurally and functionally.
Conclusion:
Similar to high doses of MSC-based therapy (3 million MSCs), MSC-EVs mitigated the fibrogenesis and hepatocellular injury in a rat model of CCl4-induced liver fibrosis. The anti-fibrinogenic effect was induced by attenuating hepatic stellate cell activation. Therefore, the administration of MSC-EVs could be considered as a candidate cell-free therapeutic strategy for liver fibrosis and hepatocellular damage.
... 30 Germani et al suggests that non-invasive scores must be validated with proper measurement of liver fibrosis by measuring the CPA (collagen proportionate area) which correlates with HVPG(Hepatic venous pressure gradient) rather than validating the scores using liver biopsy stage scores. 10 Though the non-invasive markers are less accurate in predicting fibrosis, they can still serve as useful tools in centres with limited facilities since they are objective and readily calculated from the available laboratory variables. ...
... Fibrosis is currently measured semiquantitatively, using a score with a scale of 0 to 4 that takes into account both architectural changes and fibrosis. 27 Assigned scores are overall simple descriptors and do not have a quantitative relation with each other, as also confirmed in the present study. Therefore, progression or regression through stages might not be observed in the relative short duration of trials, while subtle changes in fibrosis might be missed. ...
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.
Aims
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.
... In patients with chronic liver disease (CLD) liver fibrosis has been consistently reported as the most important indicator of the disease severity and predictor of the rate and dynamics of development of liver related complications and overall mortality (1,2). Cirrhosis as the distinctive advanced histological stage and clinical entity represents a turning point in the natural history of CLD (3,4). ...
Background: Liver Stiffness (LS) assessed by Sonoelastography (SE), has been demonstrated as reliable non-invasive indicator of liver fibrosis stage in patients with Chronic Liver Diseases (CLD). Sonoelastography performs best in ruling-out cirrhosis (F=4) and ruling-in signifficant fibrosis (F≥2). However, it is insufficiently accurate to replace endoscopy for detection of Esophageal Varices (EV), being able to only ruling-out large EV. LS ≥ 25 kPa by Transient Elastography (TE) is considered highly suggestive for the presence of Clinically Significant Portal Hypertension (CSPH). Higher liver and spleen stiffness have been asociated with adverse clinical outcomes in CLD. Two-dimensional shear wave elastography (2D-SWE), the latest developed SE method, allows both visualisation and quantification of liver elasticity in real time superimposed over B-mode ultrasound image. Discussion: Meta-analysis of studies with Supersonic Shear Imaging (SSI) revealed comparable performance of this 2D-SWE to TE in fibrosis staging, with AUROCs 0.85 for F≥2 (LS cut-off 8.04 kPa) and 0.93 for F=4 (LS cut-off 11.12 kPa). Few studies reported very good performance of 2DSWE (SSI) to rule-in CSPH (AUROCs 0.79-0.95; LS cut-offs 15-25 kPa). While conflicting data exist with respect to its performance in predicting the presence of EV, prognostic utility of 2D-SWE (SSI) was demonstrated in a single study that reported 3.4-fold (P=0.026) higher risk of adverse outcome in patients with baseline LS≥21.5 kPa followed over 28 months. Conclusion: 2D-SWE (SSI) might be used to stage liver fibrosis in CLD, identify patients with compensated cirrhosis under risk of adverse outcomes and potentially stratify risk of having CSPH and EV.
... 4 Additionally, there is debate as to whether the assignment of a fibrosis stage on pathologic examination accurately reflects the degree of overall scarring within the liver. 5 Collagen deposition within the liver, in response to cumulative injury, contributes to fibrosis stage, and will affect the physical properties of the parenchyma, particularly its viscosity. However, this is not a linear relationship and there is an exponential increase in collagen deposition seen in advanced stages of fibrosis. ...
Objectives
The purpose of this study was to compare the reliability and agreement of 2 methods of 2‐dimensional (2D) shear wave elastography (SWE) on liver stiffness in healthy volunteers. We also assessed effects of the prandial state and operator experience on measurements.
Methods
Two operators, 1 experienced and 1 novice, independently examined 20 healthy volunteers with 2D SWE on 2 ultrasound machines (Aixplorer [SuperSonic Imagine, Aix‐en‐Provence, France] and Aplio 500 [Canon Medical Systems Corporation, Otawara, Japan]). Volunteers were scanned 8 times by the operators using both machines in fasting and postprandial states. Agreement was evaluated by a Bland‐Altman analysis, and the correlation was assessed by the Pearson correlation and intraclass correlation coefficients (ICCs). An analysis of variance was conducted to determine the contribution of the machine, prandial state, and operator experience to the variability.
Results
Agreement assessed by Bland‐Altman plots showed no statistically significant difference in measured liver stiffness between the machines (mean difference, –0.8%; 95% confidence interval, –3.7%, 2.1%), with a critical difference of 1.36 kPa. The correlation was good to excellent for both the crude overall Pearson coefficient and the ICC, both measuring 0.88 (95% confidence interval, 0.82, 0.92). Subclass ICCs for the fasting state, postprandial state, novice operator, and experienced operator were 0.89, 0.88, 0.90, and 0.86, respectively. The 2‐way mixed effect analysis of variance showed that the volunteers accounted for 86.3% of variation in median liver stiffness, with no statistically significant contribution from operator experience, the prandial state, or the machine (P = .108, .067, and .296, respectively).
Conclusions
Our study showed that the 2D SWE techniques had a high degree of reliability and agreement in measurement of liver stiffness in a healthy population. Operator experience and the prandial state did not impart significant variability to stiffness measurements.
... The stage of liver fibrosis progression decides the clinical manifestation progression and the line of management for CHC infection. 7 However, monitoring development of liver fibrosis is problematic and bulky as it depends on an invasive liver biopsy process, which is still the gold-trend for detecting changes in liver fibrosis. 8 A group of small noncoding regulatory RNAs (microRNA [miRNA]), which are 20 to 24 nucleotides, were being examined as possible serum markers for various human diseases, because of their relative stability. ...
Egypt is one of the highest prevalence rates of hepatitis C virus (HCV) infection worldwide. HCV is among major reasons for chronic liver diseases. microRNA (miRNAs), small non‐coding regulatory molecules play key role in the pathogenesis of liver. Circulating miRNAs represent potential non‐invasive biomarkers for diagnosis and monitoring patients with liver diseases progression. To investigate the potential role of circulating miRNAs for surveillance of liver disease progression, we assessed the expression of 20 liver‐related miRNAs in sera of 47 chronic hepatitis C Egyptian patients compared with 25 controls using qRT‐PCR assay. The sensitivity and specificity were evaluated using receiver operating characteristic (ROC) curve. The correlations between their levels and the clinico‐pathological features were assessed. Fourteen miRNAs showed up‐regulation and 6 miRNAs showed down‐regulation. ROC curve analyses revealed that the explored miRNAs could serve as valuable biomarkers for chronic hepatitis with an AUC ranged from 0.708 (95% CI: 0.587 – 0.829; P = 0.004) for miR‐199 up to 0.974 (95% CI: 0.943 – 1.00; P < 0.001) for miR‐23b. Expression level of miR‐21 demonstrated significant correlation with age, liver enzymes (AST/ALT), and AFP level. AST level was directly correlated with miR‐122, while an inversely correlated with miR‐23b. Fibrosis and steatosis stages possessed positive correlation with miR‐199 expression and negative correlation with miR‐27a and miR‐93. Conclusion, miR‐23b and miR‐106 might be useful biomarker for CHC. miR‐27a, miR‐93, and miR‐199 might have potential role in progression of liver diseases. Unravel the role of these miRNAs in CHC patients might lead to precise prognosis and management.
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... 4 Additionally, there is debate as to whether the assignment of a fibrosis stage on pathologic examination accurately reflects the degree of overall scarring within the liver. 5 Collagen deposition within the liver, in response to cumulative injury, contributes to fibrosis stage, and will affect the physical properties of the parenchyma, particularly its viscosity. However, this is not a linear relationship and there is an exponential increase in collagen deposition seen in advanced stages of fibrosis. ...
Objective:
To determine the accuracy of shear-wave elastography (SWE) to differentiate low from advanced degrees of liver fibrosis in hepatitis C patients.
Material & method:
Consented native/transplant hepatitis C patients underwent SWE using a C1-6 MHz transducer before ultrasound (US)-guided liver biopsy. Five interpretable SWE samples were obtained from the right lobe of the liver immediately before US-guided random biopsy of the right lobe. Average kilopascal (kPa) values were compared to the meta-analysis of histological data in viral hepatitis (METAVIR) fibrosis grading. SWE values were correlated with the degree of inflammation and fatty infiltration.
Results:
Study population consisted of 115 patients (63 with transplant, and 52 with native liver) including 29 women and 86 men, with a mean ± SD age of 56 ± 8.7 years. Mean ± SD SWE values were 7.9 ± 3 kPa in 83 patients with METAVIR scores of 0-2 and 13.2 ± 5.9 kPa in 32 patients with METAVIR scores of 3 or 4 (P < .001). Area under curve (AUC) of a Receiver Operating Characteristics curve for advanced degrees of fibrosis was 0.81 (95% CI: 0.71, 0.90) (P < .001). AUCs of transplant versus native livers (0.78 [CI:0.62, 0.94] versus 0.85 [CI: 0.73, 0.96]), degree of inflammation (0.81 [CI: 0.65, 0.97] versus 0.72 [0.56, 0.88]), or degree of fat deposition (0.81 [CI:0.70, 0.92] versus 0.80 [CI:0.61, 1]) were not statistically different (P > .05). for kPa threshold of SWE value of 10.67 kPa to differentiate advanced from low degree of fibrosis had a sensitivity of 59% (CI: 41%-76%) and specificity of 90% (CI: 82%-96%).
Conclusion:
Liver stiffness evaluated by SWE can differentiate low from advanced liver fibrosis.
... Le stade F2 désigne une fibrose légère, le stade F3, une fibrose sévère. A partir du stade F4, on l'appelle cirrhose(Germani et al. 2010) (Figure 74).La fibrose change l'architecture du foie sur le plan anatomique mais aussi sur le plan fonctionnel. Au plan clinique, la cirrhose au stade initial est dite compensée, stade où il y a une absence de complications dues à la maladie. ...
L’actine est impliquée dans de nombreuses fonctions cellulaires physiologiques et pathologiques. Au cours de ma thèse j'ai analysé le rôle de l'actine i) lors de l’invasion tumorale et ii) dans la formation des fenêtres des cellules endothéliales sinusoïdales hépatiques. i) Les cellules tumorales forment des structures d’actine permettant la dégradation de la matrice extracellulaire (MEC) nommés invadosomes. Mes travaux ont permis de démontrer que la RhoGTPase Cdc42 régule la formation de la structure d’actine qu’est l’invadosome, tandis que la protéine d’échafaudage Tks5 est requise pour l’activité de dégradation aboutissant à un invadosome fonctionnel. Ces deux molécules constituent la signature moléculaire minimale des invadosomes. Nous avons établi que le collagène de type I qui est surexprimé dans le microenvironnement tumoral induit la formation d’invadosomes linéaires (Lis). Nous avons identifié le récepteur à domaine discoïdine 1 (DDR1) comme spécifiquement responsable de la formation des Lis. Son interaction avec le collagène fibrillaire permet le recrutement du facteur d’échange des RhoGTPases, Tuba et l’activation de la Cdc42 conduisant à la formation d’un Li. DDR1 est impliqué dans l’invasion tumorale et sa surexpression est de mauvais pronostic dans plusieurs cancers comme le poumon ou encore le sein. Le récepteur DDR1 est également impliqué dans la cohésion cellulaire au cours de la migration collective des cellules tumorales. Nous avons démontré que dans un contexte riche en collagène de type I, DDR1 a une double localisation et donc différents rôles associés dans la migration collective. D’une part un rôle de cohésion cellulaire et d’autre part un rôle dans la dégradation de la MEC. Nous tentons de démontrer que ces différentes fonctions impliquent différentes isoformes de DDR1. Nous souhaitons par la suite déterminer les mécanismes moléculaires qui régulent l’expression, la localisation et la signalisation associées aux différentes isoformes de DDR1. ii) Dans un contexte physiologique, les capillaires sanguins du foie présentent des pores transcellulaires ou fenêtres, qui permettent les échanges bidirectionnels entre le sang et les hépatocytes pour assurer la fonction de filtration de cet organe. Au cours du processus de fibrose ces fenêtres sont perdues, réduisant les échanges. Nous avons démontré le caractère réversible de la perte des fenêtres mais aussi que l’actine n’était pas impliquée dans la formation de ces structures. Nous avons développé une méthode de visualisation en microscopie haute résolution STED de ces structures, permettant pour la première fois une analyse sur cellule vivante. Par une approche de spectrométrie de masse couplée à notre nouvelle méthode d’observation en STED, nous voulons valider la co-localisation des fenêtres avec des marqueurs potentiels identifiés.
... A large number of studies have compared CPA to the various clinical pathology grading schemes and other laboratory variables. Earlier publications tended to stress comparison of CPA to grading; however, fibrosis content and pathologist grading are not interchangeable [16]. CPA correlates with hepatic venous pressure gradient (HVPG) [6,54], which is of useful prognostic value. ...
... 6 Recently, methods to quantify liver fibrosis through a computer-based technology, called quantitative digital image analysis (DIA), have been developed. 7,8 DIA measures the collagen and remaining liver tissue areas and calculates the collagen proportional area (CPA), defined as the proportion of the biopsy area that is occupied by collagen. Unlike traditional histological staging systems, which mainly depend on the degree of architectural distortion, DIA measures the amount of fibrosis as a continuous variable. ...
Background and aim:
Quantitative digital imaging analysis to evaluate liver fibrosis is accurate, but its clinical use is limited by its high cost and lack of standardization. We aimed to validate an inexpensive digital imaging analysis technique for fibrosis quantification in chronic hepatitis B patients.
Material and methods:
In total, 142 chronic hepatitis B patients who underwent liver biopsy and analysis of serum fibrosis markers were included. Images of Sirius red stain sections were captured and processed using Adobe Photoshop CS3 software. The percentage of fibrosis (fibrosis index) was determined by the ratio of the fibrosis area to the total sample area, expressed in pixels, and calculated automatically.
Results:
A strong correlation between the fibrosis index and the Ishak, Metavir, and Laennec histological staging systems were observed (r = 0.83, 0.86, and 0.84, respectively; < 0.001). The cutoff value associated with cirrhosis was 7.7% with an area under the receiver operating characteristic curve (AUROC) of 0.95 (95% confidence interval [CI], 0.92-0.99, p < 0.001). Furthermore, the fibrosis index yielded a cutoff value of 8.9% (AUROC, 0.74; 95% CI, 0.66-0.86), 12% (AUROC, 0.84; 95% CI, 0.75-0.93), and 14% (AUROC, 0.97; 95% CI, 0.92-1.0) for the diagnosis of cirrhosis 4a, 4b, and 4c, respectively. No serum markers or fibrosis models were correlated with the fibrosis index in Metavir F2-F4.
Conclusions:
The present digital imaging analysis technique is reproducible and available worldwide, allowing its use in clinical practice, and can be considered as a complementary tool to traditional histological methods.
... From the results of our study, the first question that comes to mind is what potential interest does P-SHG has with regard to several other methodologies routinely used to quantify liver fibrosis (for review see 34 ). The gold standard histological activity index method commonly used by clinicians and hepatopathologists for scoring, grading and staging chronic hepatitis is based on the staining of histological sections by Masson trichrome and picrosirius red dyes. ...
Polarization dependence second harmonic generation (P-SHG) microscopy is gaining increase popularity for in situ quantification of fibrillar protein architectures. In this report, we combine P-SHG microscopy, new linear least square (LLS) fitting and modeling to determine and convert the complex second-order non-linear optical anisotropy parameter ρ of several collagen rich tissues into a simple geometric organization of collagen fibrils. Modeling integrates a priori knowledge of polyhelical organization of collagen molecule polymers forming fibrils and bundles of fibrils as well as Poisson photonic shot noise of the detection system. The results, which accurately predict the known sub-microscopic hierarchical organization of collagen fibrils in several tissues, suggest that they can be subdivided into three classes according to their microscopic and macroscopic hierarchical organization of collagen fibrils. They also show, for the first time to our knowledge, intrahepatic spatial discrimination between genuine fibrotic and non-fibrotic vessels. CCl4-treated livers are characterized by an increase in the percentage of fibrotic vessels and their remodeling involves peri-portal compaction and alignment of collagen fibrils that should contribute to portal hypertension. This integrated P-SHG image analysis method is a powerful tool that should open new avenue for the determination of pathophysiological and chemo-mechanical cues impacting collagen fibrils organization.
... Therefore, in disease affecting the liver in a diverse way, the histologic findings of biopsy specimen may not be representative of the pathologic process. However, most cases of chronic liver disease causing fibrosis, such as viral and autoimmune hepatitis, as well as nonalcoholic steatohepatitis (NASH), affect the liver in a relatively uniform pattern [63]. Then the extent, to which the biopsy will be representative, will depend greatly on the size of the specimen obtained. ...
... A brief overview of these systems is shown inFigure 1Band 1C. The Laennec staging is a modified METAVIR system subdividing stage 4 into 4A, 4B and 4C based on thickness of septa and nodule size, that is validated to correlate with HVPG, severity of cirrhosis, decompensation events, and hepatoma occurrence better than other systems.[28][29][30][31][32]Even though not fully defined, incomplete septal cirrhosis is a form of macronodular cirrhosis comprising of fine and incomplete septa, which delimit rudimentary regeneration nodules. ...
Cirrhosis is a dynamic process that leads to progressive liver failure with development of portal hypertension and associated complications. Our current understanding of cirrhosis has come a long way from the time Rene Laennec first coined the term. Cirrhosis can be diagnosed with conformity utilizing histology, a trend that is changing in the current era of hemodynamic studies. To understand cirrhosis and its evolutionary stages, we must first understand fibrosis, its subsequent progression and associated hemodynamic changes at each level. In this review, we discuss stages of cirrhosis from an investigational, imaging, histological and hemodynamic point of view; discuss the diagnosis of cirrhosis within the same aspects and in keeping with current changing scenarios.
... Instead, histological scoring is based on the subjective visual interpretation of architectural changes of fibrosis, without quantifying fibrosis as a continuous variable, but rather report as a semi-quantitative numerical stage. These numbers are not arithmetically proportionate, i.e., stage 2 is not half of stage 4 (19,20). The need for an objective method, has led to the inceasing use of digital image analysis (DIA) technology with collagen quantification using collagen proportionate area (CPA) for liver fibrosis assessment (21)(22)(23)(24)(25). ...
Chronic hepatitis B virus (HBV) infection is a major cause of liver morbidity and mortality worldwide. While a proportion of the 250 million individuals chronically infected with HBV will not come to significant harm or require therapy, many others risk developing complications of the end-stage liver disease such as decompensated cirrhosis and hepatocellular carcinoma (HCC), without intervention. Due to the complex natural history of HBV infection, patients require an expert assessment to interpret biochemistry, viral serology and appropriately stage the disease, and to initiate monitoring and/or therapy where indicated. The detection and quantification of liver fibrosis is a key factor for disease management and prognostication for an individual with HBV. The reliance on invasive liver biopsy to stage disease is diminishing with the advent of robust non-invasive blood- and imaging-based algorithms which can reliably stage disease in many cases. These tests are now incorporated into International guidelines for HBV management and relied upon daily to inform clinical judgement. Both blood- and imaging-based approaches have advantages over liver biopsy, including minimal risks, lower cost, better patient acceptance and speed of results, while disadvantages include lower diagnostic accuracy in intermediate disease stages and variability with co-existing hepatic inflammation or steatosis. This review outlines the methods of fibrosis assessment in chronic HBV infection and focuses on the most commonly used blood- and imaging-based non-invasive tests, reviewing their diagnostic performance and applicability to patient care.
... The Laennec staging is a modified METAVIR system subdividing stage 4 into 4A, 4B and 4C based on thickness of septa and nodule size, that is validated to correlate with HVPG, severity of cirrhosis, decompensation events, and hepatoma occurrence better than other systems. [28][29][30][31][32] Even though not fully defined, incomplete septal cirrhosis is a form of macronodular cirrhosis comprising of fine and incomplete septa, which delimit rudimentary regeneration nodules. It is found to be associated with various diseases such as idiopathic portal hypertension, regenerative nodular hyperplasia, and partial non-cirrhotic nodular transformation and is also seen with progression or regression of cirrhosis of any etiology. ...
Cirrhosis is a dynamic process that leads to progressive liver failure with development of portal hypertension and associated complications. Our current understanding of cirrhosis has come a long way from the time Rene Laennec first coined the term. Cirrhosis can be diagnosed with conformity utilizing histology, a trend that is changing in the current era of hemodynamic studies. To understand cirrhosis and its evolutionary stages, we must first understand fibrosis and the subsequent changes that occur, leading to cirrhosis at the histological level, correlate this with the investigational changes, and ultimately, know regarding hemodynamic progression. In this review, we discuss stages of cirrhosis from an investigational, imaging, histological and hemodynamic point of view; discuss the diagnosis of cirrhosis within the same aspects and in keeping with current changing scenarios.
... Publicaciones incluidas en el metaanálisis: Turan y colaboradores, (26) Railton y colaboradores. (27) ...
Cada ano se realizan en el mundo aproximadamente 200 millones de cirugias no cardiacas, de las cuales unos 100 millones se llevan a cabo en sujetos mayores de 45 anos. 1 Por esta razon la evaluacion preoperatoria de riesgo cardiovascular es una consulta frecuente para los medicos clinicos, cardiologos y anestesiologos. Alrededor de 2 millones de pacientes fallecen dentro de los 30 dias postoperatorios debido a diferentes complicaciones, siendo las de origen cardiovascular las mas frecuentes, particularmente relacionadas a eventos isquemicos agudos. 2-3 Como consecuencia, la evaluacion del riesgo cardiovascular ocupa un lugar central para mejorar los resultados clinico-quirurgicos mediante distintos tipos de medidas perioperatorias. Desde hace varios anos las sociedades cientificas internacionales han generado y renovado recomendaciones, muchas veces basadas en criterios fisiopatologicos, en la extrapolacion de decisiones desde el contexto clinico no-operatorio, y en estudios observacionales que poseen sesgos y tamanos muestrales insuficientes. En este consenso se observara lo dificil que ha resultado generar recomendaciones en el periodo perioperatorio, dado la escasez o calidad suboptima de la evidencia cientifica existente. Como siempre, es importante destacar que un consenso es una guia de recomendaciones que no son dogmaticas y que constituyen consejos frente al paciente “promedio”, sin la intencion de reemplazar el criterio del medico frente al paciente “individual”. Las medidas diagnosticas y terapeuticas recomendadas puede verse afectadas por la disponibilidad y la experiencia del medio en que se encuentre el medico actuante y puede sufrir cambios en el tiempo de acuerdo con la aparicion de nuevas evidencias cientificas.
... Digital image analysis can be used to accurately measure the collagen proportionate area (CPA) in liver biopsies [8]. This type of analysis yields a quantitative value, thereby reducing the inter-and intraobserver variation found with semiquantitative methods [9]. ...
The extent of fibrosis is a major determinant of the clinical outcome in patients with chronic liver diseases. We undertook this study to explore the degree of fibrosis in baseline liver biopsies to predict clinical outcomes in chronic hepatitis B (CHB) patients. Fibrosis quantification was done by image analysis on Masson's trichrome stained sections and correlated with clinical and biochemical parameters, liver stiffness and hepatic vein pressure gradient (HVPG, n=96). Follow-up information collected related to clinical outcome. A total 964 cases analyzed. Median quantitative fibrosis (QF) was 3.7% {interquartile range (IQR): 1.6-9.7%} with substantial variation in various stages. Median QF was F0, 1% (0.7% -1.65%); F1, 3.03% (2.07-4.0%); F2, 7.1% (5.6-8.7%); F3, 12.7% (10.15-16.7%); F4, 26.9% (20.3-36.4%). QF positively correlated with METAVIR staging, liver stiffness measurement, and HVPG. Eighty-nine cases developed liver-related events: decompensation, hepatocellular carcinoma (HCC), liver transplantation and death. Cox-regression analysis after adjusting for METAVIR staging- QF, albumin and AST for composite events; QF and albumin for decompensation and only QF for HCC, were found significant predictors of clinical outcomes. QF categorized into five stages: QF1, 0-5%; QF2, 5.1-10%; QF3, 10.1-15%; QF4, 15.1-20%; QF5, > 20.1%. In patients with advanced stages of QF, a probability of event-free survival found to be low. Quantitative fibrosis in baseline liver biopsy predicts progression of the disease and disease outcome in CHB patients. QF defines the probability of event-free survival in CHB cases.
... Publicaciones incluidas en el metaanálisis: Turan y colaboradores, (26) Railton y colaboradores. (27) ...
... A large number of studies have compared CPA to the various clinical pathology grading schemes and other laboratory variables. Earlier publications tended to stress comparison of CPA to grading; however, fibrosis content and pathologist grading are not interchangeable [16]. CPA correlates with hepatic venous pressure gradient (HVPG) [6,54], which is of useful prognostic value. ...
Fibrosis plays a role in a wide number of diseases and organs, including pulmonary fibrosis, liver cirrhosis, pancreatic cancer, cardiovascular and kidney diseases, macular degeneration, cancer metastasis, and chronic organ transplant rejection. Despite many efforts to develop effective and accurate noninvasive diagnostic and prognostic techniques, histopathology remains the gold standard. This chapter discusses the use of quantitative histology and alternative non-histological measurements, including serum protein and recently identified microRNA markers, as complementary approaches for the diagnosis and staging of liver fibrosis in pharmacological and clinical studies.
... Based on these findings, LC is nowadays considered an evolving entity as opposed to a previous dogma of it being a final and stationary stage of chronic liver disease (19). Accumulation of fibrosis is one of the most prominent hallmarks of chronic liver disease, tightly related to deterioration of liver functions and clinical outcomes, and for these reasons it has been used for staging purposes (20,21). Cirrhosis is characterized by continuous changes at the molecular level, fibrosis accumulation, scar consolidation, architectural distortion, and neovascularization along with development of portal hypertension and reduction in liver function (22). ...
Aim
Primary: to evaluate predictivity of liver stiffness (LS), spleen stiffness (SS), and their ratio assessed by real-time 2D shear wave elastography (RT-2D-SWE) for adverse outcomes (hepatic decompensation, hepatocellular carcinoma or death; “event”) in compensated liver cirrhosis (LC) patients. Secondary: to evaluate ability of these measures to discriminate between cirrhotic patients with/without esophageal varices (EV).
Methods
Predictivity of LS, SS, and LS/SS was assessed in a retrospectively analyzed cohort of compensated LC patients (follow-up cohort) and through comparison with incident patients with decompensated cirrhosis (DC) (cross-sectional cohort). Both cohorts were used to evaluate diagnostic properties regarding EV.
Results
In the follow-up cohort (n = 44) 18 patients (40.9%) experienced an “event” over a median period of 28 months. LS≥21.5 kPa at baseline was independently associated with 3.4-fold (95% confidence interval [CI] 1.16-10.4, P = 0.026) higher risk of event. Association between SS and outcomes was weaker (P = 0.056), while there was no association between LS/SS ratio and outcomes. Patients with DC (n = 43) had higher LS (35.3 vs 18.3 kPa, adjusted difference 65%, 95% CI 43%-90%; P < 0.001) than compensated patients at baseline. Adjusted odds of EV increased by 13% (95% CI 7.0%-20.0%; P < 0.001) with 1 kPa increase in LS. At cut-offs of 19.7 and 30.3 kPa, LS and SS had 90% and 86.6% negative predictive value, respectively, to exclude EV in compensated patients.
Conclusion
This is the first evaluation of RT-2D-SWE as a prognostic tool in LC. Although preliminary and gathered in a limited sample, our data emphasize the potential of LS to be a reliable predictor of clinical outcomes and the presence of EV in LC patients.
... 23 Moreover, computer assisted image analysis associated to properly stained liver sections is the recommended method for measuring fibrosis morphologically using digital image segmentation to assess the area of collagen and the area of tis- sue. 24,25 Image analysis do not enable evaluation of the architectural changes included in stage scoring systems (nodularity, fibrous portal linking and por- tal-central fibrous bridging), thus this technique must be applied as a complementary tool together with histopathological analysis to quantify and eval- uate fibrosis progression. To date, image analyses have been used infrequently in clinical settings. ...
The prediction of intermediate stage of fibrosis in chronic hepatitis C represents a prognostic factor for disease progression. Studies evaluating biopsy performance in intermediate stage considering current patterns of liver samples and pathologists' variability are scarce. We aimed to evaluate the effect of optimal liver specimens (≥ 20 mm and/or ≥ 11 portal tracts) and pathologists' expertise on agreement for intermediate stage of fibrosis in chronic hepatitis C.
Guided biopsies with large TruCut needle were initially scored by four pathologists with different expertise in liver disease and posteriorly reviewed by a reference hepatopathologist to evaluate fibrosis agreement.
Of the 255 biopsies initially selected, 240 met the criteria of an optimal fragment (mean length 24 ± 5 mm; 16 ± 6 portal tracts) and were considered for analysis. The overall agreement among all fibrosis stages was 77% (κ = 0.66); intraobserver and interobserver agreement was, respectively, 97% (k = 0.96) and 73% (κ = 0.60). Excluded samples (< 20 mm and < 11 portal tracts) presented a lower agreement (40%; κ = 0.24). Stratifying fibrosis stages, an interobserver agreement of 42% was found in intermediate stage (F2), ranging from 0 to 56% according to pathologists' expertise, compared to 97% in mild (F0-F1) and 72% in advanced fibrosis (≥ F3) (p < 0.001). Of the 23% misclassified cases, fibrosis understaging occurred in 82% of specimens, predominantly in F2, even when evaluated by a hepatopathologist.
Liver biopsy presents intrinsic limitations to assess intermediate stage of fibrosis not overcome by optimal samples and experienced pathologists' analysis, and should not be considered the gold standard method to evaluate intermediate fibrosis in chronic hepatitis C.
... In addition, studies in natural history of chronic viral hepatitis indicated that the progression of pathophysiology conditions of patients with chronic hepatitis B is often accompanied with the histological changes of hepatic fibrosis instead of necroinflammation. [25] Thus, changes of fibrotic structure potentially could be more reliable and accurate for monitoring and predicting the pathophysiological conditions of CLD than the other clinical parameters. ...
The present mini-review updated the progress in methodologies based on using liver biopsy.
Articles for study of liver fibrosis, liver biopsy or fibrosis assessment published on high impact peer review journals from 1980 to 2014.
Key articles were selected mainly according to their levels of relevance to this topic and citations.
With the recently mounting progress in chronic liver disease therapeutics, comes by a pressing need for precise, accurate, and dynamic assessment of hepatic fibrosis and cirrhosis in individual patients. Histopathological information is recognized as the most valuable data for fibrosis assessment. Conventional histology categorical systems describe the changes of fibrosis patterns in liver tissue; but the simplified ordinal digits assigned by these systems cannot reflect the fibrosis dynamics with sufficient precision and reproducibility. Morphometric assessment by computer assist digital image analysis, such as collagen proportionate area (CPA), detects change of fibrosis amount in tissue section in a continuous variable, and has shown its independent diagnostic value for assessment of advanced or late-stage of fibrosis. Due to its evident sensitivity to sampling variances, morphometric measurement is feasible to be taken as a reliable statistical parameter for the study of a large cohort. Combining state-of-art imaging technology and fundamental principle in Tissue Engineering, structure-based quantitation was recently initiated with a novel proof-of-concept tool, qFibrosis. qFibrosis showed not only the superior performance to CPA in accurately and reproducibly differentiating adjacent stages of fibrosis, but also the possibility for facilitating analysis of fibrotic regression and cirrhosis sub-staging.
With input from multidisciplinary innovation, liver biopsy assessment as a new "gold standard" is anticipated to substantially support the accelerated progress of Hepatology medicine.
... However, the changes described in the histopathological scoring categories are largely architectural, with little reference to the quantity, quality and distribution of fibrosis 3,4 and, also, current scoring systems only have one 'stage' for cirrhosis and no sub-classification is established. 4,5 Moreover, routine fibrosis assessment is usually carried out on a trichrome or reticulin stain. These are not specific collagen stains, and no measurement of the actual amount of collagen in the liver is made. ...
Background
It is unclear whether the course of cirrhosis and its prognosis are related to the amount of collagen in the liver.AimTo determine whether fibrosis, assessed by collagen proportionate area (CPA) in patients with compensated cirrhosis, is associated with the presence of oesophageal varices, and predict disease decompensation during the follow-up period.Methods
We prospectively evaluated 118 consecutive patients with compensated cirrhosis to correlate fibrosis, assessed by CPA in liver biopsies, with the presence of oesophageal varices (OV) and with the rate of liver decompensation (LD) development during a median follow-up of 72 months.ResultsAt baseline 38 (32.2%) patients had OV and during the follow-up (median 72 months, IQR 47–91), 17 patients (14.4%) developed LD. The mean CPA value was different in patients with and without OV (14.8 ± 5.9% vs. 21.6 ± 9.5%, P < 0.001). The best CPA cut-off for OV by area under the receiver operating characteristic (AUROC) was ≥14% and with multivariate logistic analysis CPA was the only variable associated with OV (OR: 28.32, 95% CI: 6.30–127.28; P < 0.001). By AUROC analysis the best CPA cut-off to predict LD was 18.0%. By Cox regression multivariate analysis CPA ≥18% (HR: 3.99, 95% CI: 1.04–11.45; P = 0.036), albumin (HR: 0.12, 95% CI: 0.04–0.43; P = 0.001) and presence of OV (HR: 8.15, 95% CI: 2.31–28.78; P = 0.001) were independently associated with LD.Conclusion
Quantification of fibrosis by collagen proportionate area allows identification of patients with compensated HCV cirrhosis with a higher likelihood of clinically relevant portal hypertension and a higher risk of decompensation.
... Histological staging systems are semi-quantitative and defined by morphological changes, rather than total amount of liver fibrosis, and lack assessment of fibrous septa thickness or subsinusoidal fibrosis (SSF). In contrast, measurement of the proportion of liver biopsy occupied by collagen [collagen proportional area (CPA)] provides a quantitative assessment of liver fibrosis with less inter-and intra-observer variability (15,16). To our knowledge, correlation of the ELF score with CPA or SSF has not been evaluated. ...
Background and AimsThere is increasing need to identify individuals with advanced liver fibrosis, who are at risk of complications such as hepatocellular carcinoma. The commercially available Enhanced Liver Fibrosis (ELF) test provides a non-invasive assessment of fibrosis severity. This study was designed to determine the diagnostic accuracy of the manufacturer's cut-off value (≥9.8) in identifying advanced fibrosis.Methods
The relationship between ELF score and fibrosis was examined using serum collected at time of liver biopsy for investigation of liver disease, particularly viral hepatitis. Fibrosis was staged using a modified METAVIR score. If available, liver tissue was recut and stained with Sirius red to determine collagen proportional area and subsinusoidal fibrosis.ResultsELF score ≥9.8 had a sensitivity of 74.4% and specificity 92.4% for detecting advanced fibrosis. In the whole cohort (n=329), ELF score was more likely to incorrectly classify individuals if age was ≥45 years and METAVIR inflammatory grade was 2 or 3 (adjusted OR 3.71 and 2.62 respectively). In contrast, ELF score was less likely to misclassify individuals in the presence of steatosis (OR 0.37). Neither subsinusoidal fibrosis nor collagen proportional area explained the discordance in ELF score for patients with or without advanced fibrosis.Conclusion
Although ELF score ≥9.8 reliably identifies advanced fibrosis in patients with chronic liver disease, both age and inflammatory activity need to be considered when interpreting the result. Importantly, ELF score performed well in the presence of steatosis and could thus be helpful in the assessment of fatty liver disease.This article is protected by copyright. All rights reserved.
Results from the interferon era have demonstrated reversibility of cirrhosis following viral eradication, but only for patients in the initial stage of cirrhosis. Although direct-acting antivirals (DAA) represent revolutionary treatment of hepatitis C, there are currently no studies showing histological effects of therapy on a large number of cirrhotic patients. However, studies involving transient elastography demonstrated a rapid decrease in liver stiffness after successful DAA therapy, probably due to resolution of inflammation, rather than fibrosis regression, as the latter requires a longer period of time. Reversal of fibrosis and cirrhosis upon viral eradication is a prerequisite for the reduction of portal pressure, but this effect has only been observed for the subclinical stage of portal hypertension (PH). On the other hand, the majority of patients with clinically significant PH remain at risk of decompensation and death, despite hepatitis C virus cure, as PH remains high in this setting. This calls for novel therapeutic approaches.
Infection with the Hepatitis C virus (HCV) leads to liver inflammation and fibrosis, which progresses to cirrhosis. Cirrhosis leads to complications including hepatocellular carcinoma (HCC), end-stage liver disease, the necessity for liver transplantation, or death. In fact, HCV is the leading cause of liver transplantation, accounting for more than 40 % of liver transplants in the United States (Organ Procurement and Transplantation Network 2010). Because of the extended interval between infection and the emergence of complications, the proportion of HCV-infected patients with cirrhosis is expected to reach 45 % by 2030 (Davis et al. 2010). Fibrosis stage predicts morbidity, including liver-related deaths (Everhart et al. 2010). Patients with cirrhosis from HCV infection have an increased risk of developing HCC, estimated at 1–3 % per year (Fattovich et al. 1997), and the risk increases when comparing patients with cirrhosis relative to those with bridging fibrosis (Lok et al. 2009). With an estimated 180 million people infected by HCV worldwide, fibrosis and its progression to cirrhosis represent a major global problem (Rosen HR 2011).
Alcoholic liver disease (ALD) consists of a broad spectrum of disorders, ranging from simple steatosis to alcoholic steatohepatitis and cirrhosis. Fatty liver develops in more than 90% of heavy drinkers, however only 30%-35% of them develop more advanced forms of ALD. Therefore, even if the current "gold standard" for the assessment of the stage of alcohol-related liver injury is histology, liver biopsy is not reasonable in all patients who present with ALD. Currently, although several non-invasive fibrosis markers have been suggested as alternatives to liver biopsy in patients with ALD, none has been sufficiently validated. As described in other liver disease, the diagnostic accuracy of such tests in ALD is acceptable for the diagnosis of significant fibrosis or cirrhosis but not for lesser fibrosis stages. Existing data suggest that the use of non-invasive tests could be tailored to first tier screening of patients at risk, in order to diagnose early patients with progressive liver disease and offer targeted interventions for the prevention of decompensation. We review these tests and critically appraise the existing evidence.
Purpose:
To evaluate the feasibility of using supersonic shear-wave elastography (SSWE) in children and normal values of liver stiffness with the use of control patients of different ages (from neonates to teenagers) and the diagnostic accuracy of supersonic shear wave elastography for assessing liver fibrosis by using the histologic scoring system as the reference method in patients with liver disease, with a special concern for early stages of fibrosis.
Materials and methods:
The institutional review board approved this prospective study. Informed consent was obtained from parents and children older than 7 years. First, 51 healthy children (from neonate to 15 years) were analyzed as the control group, and univariate and multivariate comparisons were performed to study the effect of age, transducer, breathing condition, probe, and position on elasticity values. Next, 45 children (from 1 month to 17.2 years old) who underwent liver biopsy were analyzed. SSWE measurements were obtained in the same region of the liver as the biopsy specimens. Biopsy specimens were reviewed in a blinded manner by a pathologist with the use of METAVIR criteria. The areas under the receiver operating characteristics curve (AUCs) were calculated for patients with fibrosis stage F0 versus those with stage F1-F2, F2 or higher, F3 or higher, and F4 or higher.
Results:
A successful rate of SSWE measurement was 100% in 96 patients, including neonates. Liver stiffness values were significantly higher when an SC6-1 probe (Aixplorer; SuperSonic Imagine SA, Aix-enProvence, France) was used than when an SL15-4 probe (Aixplorer) was used (mean ± standard deviation, 6.94 kPa ± 1.42 vs 5.96 kPa ± 1.31; P = .006). There was no influence of sex, the location of measurement, or respiratory status on liver elasticity values (P = .41-.93), although the power to detect such a difference was low. According to the degree of liver fibrosis at liver biopsy, 88.5%-96.8% of patients were correctly classified, with AUCs of 0.90-0.98 (95% confidence interval [CI]: 0.8, 1.0). The AUC for patients with stage F0 versus stage F1-F2 was 0.93 (95% CI: 0.87, 0.99).
Conclusion:
SSWE allows accurate assessment of liver fibrosis, even in children with early stage (F1-F2) disease, and the choice of transducer influences liver stiffness values.
It is estimated that up to 10% of patients with HIV have chronic hepatitis C (HCV)-HIV coinfection in the Western world. Assessment of liver disease is essential in such patients in order to diagnose cirrhosis at an early stage, prioritize for anti-HCV treatment but also assess fibrosis regression after sustained viral response (SVR). In this review, we present a critical appraisal of liver disease assessment in patients with HIV-HCV co-infection.
Liver biopsy has largely been replaced by noninvasive fibrosis assessment in most coinfected patients, although it is still of value if there are concerns of additional diagnoses. Noninvasive assessment includes serum markers and liver stiffness measurement using elastography-based techniques. Certain serum markers, such as FIB-4, SHASTA index, and Fibrometer HIVC have been specifically developed in patients with HIV-HCV coinfection. Transient elastography has advantages over serum markers, as it is not influenced by concomitant antiretroviral medication, HIV replication, CD4 cell count, or nonliver inflammatory processes.
Noninvasive markers are increasingly used for clinical decision-making and predicting clinical outcomes in HIV-HCV coinfected patients. The concept of residual risk for liver-related events after SVR needs to be further explored with noninvasive fibrosis tools in prospective studies.
Liver fibrosis staging provides prognostic value, although hampered by observer variability. We used digital analysis to develop diagnostic morphometric scores for significant fibrosis, cirrhosis and fibrosis staging in chronic hepatitis C.
We automated the measurement of 44 classical and new morphometric descriptors. The reference was histological METAVIR fibrosis (F) staging (F0 to F4) on liver biopsies. The derivation population included 416 patients and liver biopsies ≥20 mm-length. Two validation population included 438 patients.
In the derivation population, the area under the receiver operating characteristic (AUROC) for clinically significant fibrosis (F stage ≥2) of a logistic score combining 5 new descriptors (stellar fibrosis area, edge linearity, bridge thickness, bridge number, nodularity) was 0.957. The AUROC for cirrhosis of 6 new descriptors (edge linearity, nodularity, portal stellar fibrosis area, portal distance, granularity, fragmentation) was 0.994. Predicted METAVIR F staging combining 8 morphometric descriptors agreed well with METAVIR F staging by pathologists: κ = 0.868. Morphometric score of clinically significant fibrosis had a higher correlation with porto-septal fibrosis area (r s = 0.835) than METAVIR F staging (r s = 0.756, P < 0.001) and the same correlations with fibrosis biomarkers, e.g., serum hyaluronate: r s = 0.484 versus r s = 0.476 for METAVIR F (P = 0.862). In the validation population, the AUROCs of clinically significant fibrosis and cirrhosis scores were, respectively: 0.893 and 0.993 in 153 patients (biopsy < 20 mm); 0.955 and 0.994 in 285 patients (biopsy ≥ 20 mm). The three morphometric diagnoses agreed with consensus expert reference as well as or better than diagnoses by first-line pathologists in 285 patients, respectively: significant fibrosis: 0.733 versus 0.733 (κ), cirrhosis: 0.900 versus 0.827, METAVIR F: 0.881 versus 0.865.
The new automated morphometric scores provide reproducible and accurate diagnoses of fibrosis stages via "virtual expert pathologist."
Background:
Liver biopsy is the reference standard for diagnosing the extent of fibrosis in chronic liver disease; however, it is invasive, with the potential for serious complications. Alternatives to biopsy include non-invasive liver tests (NILTs); however, the cost-effectiveness of these needs to be established.
Objective:
To assess the diagnostic accuracy and cost-effectiveness of NILTs in patients with chronic liver disease.
Data sources:
We searched various databases from 1998 to April 2012, recent conference proceedings and reference lists.
Methods:
We included studies that assessed the diagnostic accuracy of NILTs using liver biopsy as the reference standard. Diagnostic studies were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Meta-analysis was conducted using the bivariate random-effects model with correlation between sensitivity and specificity (whenever possible). Decision models were used to evaluate the cost-effectiveness of the NILTs. Expected costs were estimated using a NHS perspective and health outcomes were measured as quality-adjusted life-years (QALYs). Markov models were developed to estimate long-term costs and QALYs following testing, and antiviral treatment where indicated, for chronic hepatitis B (HBV) and chronic hepatitis C (HCV). NILTs were compared with each other, sequential testing strategies, biopsy and strategies including no testing. For alcoholic liver disease (ALD), we assessed the cost-effectiveness of NILTs in the context of potentially increasing abstinence from alcohol. Owing to a lack of data and treatments specifically for fibrosis in patients with non-alcoholic fatty liver disease (NAFLD), the analysis was limited to an incremental cost per correct diagnosis. An analysis of NILTs to identify patients with cirrhosis for increased monitoring was also conducted.
Results:
Given a cost-effectiveness threshold of £20,000 per QALY, treating everyone with HCV without prior testing was cost-effective with an incremental cost-effectiveness ratio (ICER) of £9204. This was robust in most sensitivity analyses but sensitive to the extent of treatment benefit for patients with mild fibrosis. For HBV [hepatitis B e antigen (HBeAg)-negative)] this strategy had an ICER of £28,137, which was cost-effective only if the upper bound of the standard UK cost-effectiveness threshold range (£30,000) is acceptable. For HBeAg-positive disease, two NILTs applied sequentially (hyaluronic acid and magnetic resonance elastography) were cost-effective at a £20,000 threshold (ICER: £19,612); however, the results were highly uncertain, with several test strategies having similar expected outcomes and costs. For patients with ALD, liver biopsy was the cost-effective strategy, with an ICER of £822.
Limitations:
A substantial number of tests had only one study from which diagnostic accuracy was derived; therefore, there is a high risk of bias. Most NILTs did not have validated cut-offs for diagnosis of specific fibrosis stages. The findings of the ALD model were dependent on assuptions about abstinence rates assumptions and the modelling approach for NAFLD was hindered by the lack of evidence on clinically effective treatments.
Conclusions:
Treating everyone without NILTs is cost-effective for patients with HCV, but only for HBeAg-negative if the higher cost-effectiveness threshold is appropriate. For HBeAg-positive, two NILTs applied sequentially were cost-effective but highly uncertain. Further evidence for treatment effectiveness is required for ALD and NAFLD.
Study registration:
This study is registered as PROSPERO CRD42011001561.
Funding:
The National Institute for Health Research Health Technology Assessment programme.
Imaging of supramolecular structures by multiphoton microscopy offers significant advantages for studying specific fibrillar compounds in biological tissues. In this study, we aimed to demonstrate the relevance of Second Harmonic Generation (SHG) for assessing and quantifying, without staining, fibrillar collagen in liver fibrosis.
We first showed the relationship between SHG signal and collagen forms over-produced and accumulated during fibrosis progression. Taking this property into consideration, we developed an innovative method to precisely quantify the fibrosis area in histological slices by scoring of fibrillar collagen deposits (Fibrosis-SHG index).
The scoring method was routinely applied to 119 biopsies from patients with chronic liver disease allowing a fast and accurate measurement of fibrosis correlated with the Fibrosis-Metavir score (rho=0.75, p<0.0001). The technique allowed discriminating patients with advanced (moderate to severe) fibrosis (AUROC=0.88, p<0.0001) and cirrhosis (AUROC=0.89, p<0.0001). Taking advantage of its continuous gradation, the Fibrosis-SHG index also allowed the discrimination of several levels of fibrosis within the same F-Metavir stage. The SHG process presented several advantages such as a high reliability and sensitivity that lead to a standardized evaluation of hepatic fibrosis in liver biopsies without staining and pathological examination.
Second harmonic microscopy emerges as an original and powerful tool in the assessment of liver fibrosis and offers new possibilities for the evaluation of experimental protocols. We expect that this technology could easily be applicable in the study of other fibro-proliferative pathologies.
For more than a century and a half, the description of a liver as “cirrhotic” was sufficient to connote both a pathological and clinical status, and to assign the prognosis of a patient with liver disease. However, as our interventions to treat advanced liver disease have progressed (e.g., antiviral therapies), the inadequacy of a simple one-stage description for advanced fibrotic liver disease has become increasingly evident. Until recently, refining the diagnosis of cirrhosis into more than one stage hardly seemed necessary when there were no interventions available to arrest its progression. Now, however, understanding the range of potential outcomes based on the severity of cirrhosis is essential in order to predict outcomes and individualize therapy. This position paper, rather than providing clinical guidelines, attempts to catalyze a reformulation of the concept of cirrhosis from a static to a dynamic one, creating a template for further refinement of this concept in the future.
Hepatitis C virus (HCV) allograft cirrhosis may progress rapidly requiring re-transplantation but its course is little studied. We evaluated serially biopsied patients who developed HCV-related allograft cirrhosis. We assessed outcome of graft cirrhosis in 55 out of 234 consecutive patients and predictors of decompensation and mortality, including hepatic venous pressure gradient (HVPG) in 38. Allograft cirrhosis (Ishak stage 6, 60%; stage 5, 40%) was diagnosed between 12 and 172 months (median, 52) from transplantation; subsequent follow up was 22 (1-78) months. Faster development (<or=48 months) was associated with tacrolimus and nonuse of azathioprine and prednisolone. Decompensation occurred in 22% with a probability of not developing decompensation reaching 60% at 5 years. Survival among compensated patients was 77% at 5 years, but fell rapidly after decompensation (12% at 1 year). Decompensation and mortality were independently associated with HVPG >or= 10 mmHg, Child-Pugh score >or= 7, and albumin levels <or= 32 g/dl but not with fibrosis stage 5 or 6, HCV genotype (1b, 34%) or immunosuppression used after diagnosis of cirrhosis. In conclusion, Ishak stage 5 and 6 HCV-related cirrhosis have similar prognosis after liver transplantation. An HVPG >or= 10 mmHg, in addition to liver dysfunction, gives independent prognostic information prior to decompensation, allowing early relisting before prognosis becomes extremely poor.
This memorandum provides guidelines on the definition, nomenclature, and classification of cirrhosis, chronic hepatitis, and hepatic fibrosis. These are considered according to morphological characteristics and aetiology. It is hoped that this system will serve as a standard for diagnostic, research, and epidemiological purposes. The relationship of cirrhosis to liver cell carcinoma is briefly discussed and the possible morphological markers of an increased risk of malignancy are defined.
The aim was to assess the validity of a digitally computed fibrosis ratio as a measure of fibrosis stage in liver biopsy specimens. We scored 230 liver biopsy specimens from patients with chronic hepatitis C for fibrosis using modified Knodell criteria; fibrosis ratios were computed from digital images that encompassed the complete trichrome-stained section of each case. Although an overall correlation between fibrosis ratio and ordinal score was present, subset analysis showed that this correlation existed only among biopsy specimens with high scores (3-6, early bridging fibrosis to established cirrhosis). There was no correlation or difference between category means found among biopsy specimens with low scores (0-3, normal to early bridging fibrosis). Furthermore, concordance by both estimates in direction of fibrosis change among serial liver biopsy specimens was found in only 11 (30%) of 37 pairs compared. The findings suggest that a qualitative assessment of the computerized fibrosis pattern is necessary for the interpretation of computerized fibrosis ratio measurements, particularly in patients with early stage fibrosis.
Chronic hepatitis C is a major healthcare problem. The response to antiviral therapy for patients with chronic hepatitis C has previously been defined biochemically and by PCR. However, changes in the hepatic venous pressure gradient (HVPG) may be considered as an adjunctive end point for the therapeutic evaluation of antiviral therapy in chronic hepatitis C. It is a validated technique which is safe, well tolerated, well established, and reproducible. Serial HVPG measurements may be the best way to evaluate response to therapy in chronic hepatitis C.
Nonalcoholic steatohepatitis (NASH) can be regarded as manifestation of the metabolic syndrome in the liver. Parallel to the obesity epidemic NASH shows the greatest increase among liver diseases. NASH is not always a benign disease because in an number of patients it tends to progress to cirrhosis of the liver with all the well known complications including hepatocellular cancer. In precirrhotic stages patients usually either feel well or report unspecific complains like fatigue. Clinically the liver appears enlarged, in addition patients often present with other symptoms of the metabolic syndrome. Biochemistry reveals an hepatitic pattern with aminotransferases showing more pronounced elevations than alkaline phosphatase. In early stages ALT values exceed those of AST while in more advanced stages the ALT/AST ratio shows an inverse pattern. Ultrasound examination detects diffuse hyperechogenicity of the enlarged liver, thereby signs of cirrhosis should be carefully sought. Histopathology, however, is the only method to confirm the diagnosis of NASH after chronic alcoholisms has been excluded. On microscopic analysis there are changes similar to alcoholic hepatitis (ASH). Moreover histopathology exclusively can quantify the inflammatory activity (grading) as well as the degree of fibrosis or even cirrhosis (staging) thereby providing prognostic information, to.
Determining a relationship between specific histological parameters in cirrhosis and hepatic venous pressure gradient can be used to subclassify cirrhosis.
To determine the relationship between hepatic venous pressure gradient and specific histological parameters in cirrhosis.
Forty-seven patients (mean age: 46.2 +/- 13.6 years; 36 male) with biopsy-proven cirrhosis and hepatic venous pressure gradient measurements within 1 month of biopsy were studied. The following histological parameters were scored semiquantitatively: nodule size, loss of portal tracts and central veins, portal inflammation, periportal inflammation, bile duct proliferation, lobular inflammation, ballooning, fatty change, cholestasis and septal thickness.
On multiple ordinal regression analysis, small nodule size (odds ratio: 21.0; 95% confidence interval: 2.1-208.2, P = 0.009) and thick septa (OR: 42.6; CI: 2.3-783.7, P = 0.011) were significantly associated with the presence of clinically significant portal hypertension. A score was assigned to each of the two parameters (nodule size: large = 1, medium = 2, small = 3 and septal thickness: thin = 1, medium = 2, thick = 3). Two subcategories were devised based on the composite score: category A (n = 12): score 1-3 and category B (n = 35): score 4-6. On ordinal regression, subcategory B (OR: 15.5; CI: 3.3-74.2, P = 0.001) was significantly associated with clinically significant portal hypertension.
Small nodularity and thick septa are independent predictors of the presence of clinically significant portal hypertension.
Liver biopsy is used as the “gold standard” for the assessment of the stage and degree of activity in chronic hepatitis C and is of major importance in evaluating the effects of treatment. Because numerous therapeutic trials are undertaken with histological control, the reproducibility of liver biopsy interpretation appears essential. Therefore the aim of this study was to estimate intraobserver and interobserver variations in the assessment of features, classification, and numerical scoring of chronic viral hepatitis C among 10 pathologists specializing in liver diseases. These pathologists independently reviewed 30 liver biopsy specimens of viral hepatitis C and completed a histological form for each of the specimens. Five pairs of pathologists then were randomly designated. They independently reviewed the biopsy specimens and filled out a new coding form. The interobserver variation was calculated for each item among the 10 individuals and then among the five pairs with the intraclass correlation coefficient or ϰ statistics. Five features showed an almost perfect or a substantial degree of concordance among the 10 observers (i.e., cirrhosis, fibrosis, fibrosis grading of Knodell index, steatosis, portal lymphoid aggregates). The 17 other indicators showed a weaker concordance with, for instance, a moderate degree of concordance for piecemeal necrosis, disease activity, Knodell index, a fair degree of concordance for lobular necrosis, and only a slight degree of concordance for six items. Five items had a higher concordance when viewed by a pair of pathologists than when studied by only one pathologist (i.e., steatosis, periportal necrosis grading of Knodell index, lobular necrosis grading of Knodell index, centrilobular fibrosis, and ductular proliferation). Two showed a significant decrease, and the others were unchanged. This study reveals that certain features of major importance in assessing disease activity show significant observer variation. The acceptable degree of concordance of the Knodell index was related mainly to the substantial degree of concordance of the fibrosis score, whereas other numerical items displayed substantial observer variations. Simultaneous observation by two pathologists increased the reproducibility of numerical scoring and of certain viral hepatitis C lesions. A classification of chronic hepatitis C based on dissociated semiquantitative assessment of necroinflammatory lesions and fibrosis offered more reproducibility than the use of a global numerical index. (Hepatology 1994;20:15–20.)
A Histology Activity Index has been developed which generates a numerical score for liver biopsy specimens obtained from patients with asymptomatic chronic active hepatitis. Biopsies are graded in four categories: periportal necrosis, intralobular necrosis, portal inflammation, and fibrosis. Under code, three pathologists and three hepatologists evaluated 14 liver biopsy specimens obtained from five patients with asymptomatic chronic active hepatitis. Good correlation was seen between severity of liver biopsy lesions as judged by conventional histological descriptions and Histology Activity Index scores. Significant differences in Histology Activity Index score occurred in only 2 of 28 duplicate scorings of biopsy specimens by two observers. This system provides definitive endpoints for statistical analysis of serial changes in liver histology and offers an alternative to the use of conventional pathological descriptions in following the natural history and treatment responses of asymptomatic chronic active hepatitis.
Collagen content was measured in 38 needle liver biopsies (8 steatosis, 8 chronic hepatitis, 7 fibrosis and 15 cirrhosis) by a new colorimetric method based on the selective capacity of Sirius red and Fast green to bind to collagen and noncollagenous proteins, respectively. The values were compared with those obtained after determination of the degree of fibrosis by morphometry in the same tissue.In biopsies with cirrhosis and fibrosis, there was a higher amount of collagen than in biopsies with chronic hepatitis and steatosis. Furthermore, there was a highly significant direct correlation between the collagen content measured colorimetrically and the degree of fibrosis determined morphometrically (r = 0.77, p < 0.001), suggesting that this new colorimetric method is useful in measuring the degree of fibrosis in needle liver biopsies.
Hepatic venous pressure gradient (HVPG) measurement is not a routinely used technique, despite its therapeutic and prognostic value.
To review the role of HVPG from published literature.
Systematic literature review.
In acute variceal bleeding, HVPG is prognostic identifying 'difficult to treat' group, which now has defined clinical correlations. In secondary prevention of portal hypertensive bleeding, a reduction to < or = 12 mmHg confers near complete protection against rebleeding. The target of > or = 20% HVPG reduction from baseline needs prospective assessment to test a change of therapy, if no reduction occurs. The acute HVPG response to beta-blockade needs further assessment. In primary prevention, the cost-effectiveness of HVPG measurement is not favourable given the efficacy of medical therapy. In chronic liver disease, wedge hepatic venous pressure (WHVP) is prognostic for survival. Pharmacological reduction in portal pressure decreases complications and improves survival, possibly independent of a concomitant improvement in liver function. This latter requires urgent confirmation as it is clinically very relevant. HVPG monitoring can be used to assess anti-viral therapy particularly in cirrhosis, ergonomically combined with transjugular biopsy.
The prognostic and therapeutic value of HVPG is established beyond portal hypertensive bleeding for which there are some clinical surrogates. HVPG measurement should now be part of everyday clinical practice.
Unlabelled:
Fibrosis progression in chronic liver disease has usually been evaluated by liver biopsy using insensitive semiquantitative numerical scores. An alternative to this is to measure fibrous tissue quantitatively using morphometric image analysis. The aim of this study was to quantify fibrosis progression in a cohort of patients with treatment-refractory chronic hepatitis C enrolled in a placebo-controlled clinical trial of interferon gamma-1b (IFN-gamma 1b) for the treatment of advanced hepatic fibrosis. We used morphometry to quantify the amount of fibrous tissue in liver biopsies performed at baseline and after 48 weeks in 245 patients who had paired unfragmented, adequate-sized specimens and correlated the results with clinical and laboratory parameters. Eighty-seven patients were treated with placebo and 158 with IFN-gamma 1b. No effect of the drug on fibrosis was found in the trial, and so data from all 245 patients were combined for analysis. At baseline, 78% had cirrhosis; 22%, bridging fibrosis. The mean morphometrically determined collagen content increased by 58% between baseline and 48 weeks. There were statistically significant but weak correlations of fibrosis with platelet count, albumin, bilirubin, INR, and hyaluronic acid; however, changes in these did not correlate with or predict changes in fibrosis in the liver biopsy.
Conclusion:
In advanced chronic hepatitis C, fibrosis increases at a rapid pace that can only be detected by morphometry. This technique can be used in future therapeutic trials of agents to inhibit fibrosis progression.
Liver fibrosis is mainly evaluated by qualitative histological examination. Although histological semi-quantitative scores and quantitative determination with image analysis are now possible, these methods have not been fully validated and compared. Therefore, we evaluated these two methods prospectively in 243 patients with chronic liver disease.
The semi-quantitative fibrosis score was evaluated by two independent pathologists, using the Knodell fibrosis score and a 6-grade score derived from the Metavir score; the area of fibrosis was measured by image analysis. The serum levels of hyaluronate, N-terminal peptide of procollagen III, laminin, transforming growth factor-beta1, alpha2-macroglobulin, apolipoprotein A1, PGA score and prothrombin index were measured.
There was a good correlation between the semi-quantitative fibrosis score and the area of fibrosis (r=0.84, p<10(-4)). Using multiple regression analysis, the semi-quantitative score was predicted by the 8 serum markers with R2=0.69 (R2=0.59 for hyaluronate at the 1st step) while the area of fibrosis was predicted with R2=0.79 (R2=0.76 for hyaluronate at the 1st step), and the Knodell fibrosis score was predicted with R2=0.65 (R2=0.31 for hyaluronate at the 1st step).
The area of fibrosis, as determined by image analysis, and the semi-quantitative score are well correlated. However, for serum markers the correlation is higher with the area of fibrosis than with the semi-quantitative score. Other characteristics such as reproducibility, rapidity, simplicity, adaptability, and exhaustiveness also favor image analysis.
Unlabelled:
Significant liver fibrosis (F >or= 2) and portal hypertension (hepatic venous pressure gradient [HVPG] >or= 6 mmHg) at 1 year after liver transplantation (LT) identify patients with severe hepatitis C recurrence. We evaluated whether repeated liver stiffness measurements (LSM) following LT can discriminate between slow and rapid "fibrosers" (fibrosis stage F2-F4 at 1 year after LT). Eighty-four patients who had undergone LT and who were infected with hepatitis C virus (HCV) and 19 LT controls who were not infected with HCV underwent LSM at 3, 6, 9, and 12 months after LT. All HCV-infected patients underwent liver biopsy 12 months after LT (paired HVPG measurements in 74); 31 (37%) were rapid fibrosers. Median LSM (in kilopascal) at months 6, 9, and 12 were significantly higher in rapid fibrosers (9.9, 9.5, 12.1) than in slow fibrosers (6.9, 7.5, 6.6) (P < 0.01 all time points). The slope of liver stiffness progression (kPa x month) in rapid fibrosers (0.42) was significantly greater than in slow fibrosers (0.05) (P < 0.001), suggesting two different speeds of liver fibrosis progression. Figures were almost identical for patients with HVPG >or= 6 mmHg or HVPG < 6 mmHg at 1 year after LT. Multivariate analysis identified donor age, bilirubin level, and LSM as independent predictors of fibrosis progression and portal hypertension in the estimation group (n = 50) and were validated in a second group of 34 patients. The areas under the receiver operating characteristic curve that could identify rapid fibrosers and patients with portal hypertension as early as 6 months after LT were 0.83 and 0.87, respectively, in the estimation group and 0.75 and 0.80, respectively, in the validation group.
Conclusion:
Early and repeated LSM following hepatitis C recurrence in combination with clinical variables discriminates between rapid and slow fibrosers after LT.
Significant fibrosis (fibrosis stage [F] >or= 2) and portal hypertension (hepatic venous pressure gradient [HVPG] >or= 6 mm Hg) in patients 1 year after liver transplantation indicate progressive hepatitis C recurrence. This study evaluated whether serum fibrosis markers can predict hepatitis C recurrence during the first year after liver transplantation.
Hyaluronic acid, amino-terminal propeptide of type-III-procollagen, tissue inhibitor of matrix metalloproteinase type-1 concentrations were measured in serum samples from 133 patients infected with hepatitis C virus (HCV) at 3, 6, and 12 months after liver transplantation; routine laboratory tests were also performed. Liver biopsy samples (n = 133) and HVPGs (n = 94) were analyzed 1 year after transplantation. Sixteen patients who were not infected with HCV served as controls.
An algorithm, including the 3 markers (3-M-ALG) and 3 published scores (aspartate aminotransferase [AST]-to-alanine aminotransferase ratio, AST-to-platelet ratio index, and Benlloch) were analyzed. One year after liver transplantation, 50 patients (38%) had significant fibrosis (F >or= 2) and 31 (32%) had an HVPG >or= 6 mm Hg. The area under the receiver operator characteristic curve of the 3-M-ALG used to identify F >or= 2 at 3, 6, and 12 months after transplantation (0.67, 0.77, and 0.78) and of those with HVPG >or= 6 at the same time points (0.75, 0.87, and 0.90) were significantly higher than values obtained with the 3 published scores. At 12 months, a 3-M-ALG >or= 2 identified most patients at risk of decompensation/death.
Serum markers can accurately discriminate between patients with mild and progressive hepatitis C recurrence after liver transplantation.
Lamivudine improves liver histology in patients with chronic hepatitis B (CHB), but its effects on portal pressure remain unknown. We evaluated the effect of lamivudine monotherapy on hepatic venous pressure gradient (HVPG) in CHB-related cirrhosis with significant portal hypertension.
We studied 19 patients with cirrhosis due to HBeAg-negative CHB and HVPG >or=10 mm Hg treated with oral lamivudine (100mg daily). Liver biochemistry, Child-Pugh and MELD score were determined every 3 months, alpha-fetoprotein and HBV DNA every 6 months and HVPG at baseline and at 12 months after lamivudine initiation. Diuretics, beta-blockers, antibiotics and/or endoscopic therapy were used for routine indications.
At 12 months, a significant reduction was observed in ALT (p=0.001), HBV DNA (p=0.002), Child-Pugh (p=0.012) and MELD score (p=0.006). Four patients developed virological breakthrough during treatment. At 12 months, HVPG decreased in all but one patient [baseline: 14.4+/-3.9 and 12 months: 12.4+/-3.3 mm Hg (p=0.007)]. HVPG decreased >20% or below the 12 mm Hg threshold in 10 of 13 patients with baseline HVPG >or=12 mm Hg. HVPG increased in a patient with hepatic flare after virological breakthrough.
In conclusion, in patients with cirrhosis due to HBeAg-negative CHB, lamivudine monotherapy reduces HVPG, especially when virological suppression and biochemical remission is achieved.
Unlabelled:
Histopathological scoring of disease stage uses descriptive categories without measuring the amount of fibrosis. Collagen, the major component of fibrous tissue, can be quantified by computer-assisted digital image analysis (DIA) using histological sections. We determined relationships between DIA, Ishak stage, and hepatic venous pressure gradient (HVPG) reflecting severity of fibrosis. One hundred fifteen patients with hepatitis C virus (HCV) who had undergone transplantation had 250 consecutive transjugular liver biopsies combined with HVPG (median length, 22 mm; median total portal tracts, 12), evaluated using the Ishak system and stained with Sirus red for DIA. Liver collagen was expressed as collagen proportionate area (CPA). Median CPA was 6% (0.2-45), correlating with Ishak stage (stage 6 range, 13%-45%), and with HVPG (r = 0.62; P < 0.001). Median CPA was 4.1% when HVPG was less than 6 mm Hg and 13.8% when HVPG was 6 mm Hg or more (P < 0.0001) and 6% when HVPG was less than 10 mm Hg and 17.3% when HVPG was 10 mm Hg or higher (P < 0.0001). Only CPA, not Ishak stage/grade, was independently associated by logistic regression, with HVPG of 6 mm Hg or more [odds ratio, 1.206; 95% confidence interval (CI), 1.094-1.331; P < 0.001], or HVPG of 10 mm Hg or more (odds ratio, 1.105; 95% CI, 1.026-1.191; P = 0.009). CPA increased by 50% (3.6%) compared with 20% in HVPG (1 mm Hg) in 38 patients with repeated biopsies.
Conclusion:
CPA assessed by DIA correlated with Ishak stage scores and HVPG measured contemporaneously. CPA was a better histological correlate with HVPG than Ishak stage, had a greater numerical change when HVPG was low, and resulted in further quantitation of fibrosis in cirrhosis.
This paper is a speculative review of the irreversibility of cirrhosis of the liver. Experimental studies dealing with the specific issue of irreversibility of the process are summarized, and the following three general propositions are derived: 1. All experimental models of cirrhosis are reversible, provided the inciting agent is removed and sufficient time is allowed for the return to normal liver structure. 2. Experimental cirrhosis of the liver goes through two successive stages, differing (among many other features) in the time and completeness of their reversibility. 3. Increased reticulum fibers are more easily and completely resorbed than thick collagenous bundles. Human cases of cirrhosis of the liver in which the fact of regression appears to be sufficiently documented are also summarized. Most of them seem to fulfil the three conditions derived from the analysis of experimental data, namely, withdrawal of the etiologic agent at an early stage in their development (with a predominance of reticulum over collagen fibers) and allowance of sufficient time to document the disappearance of the disease. Experimental studies on the mechanisms of collagen degradation in general, and in the liver of mammals in particular, are also reviewed. It is concluded that much remains to be done but that the outcome is by no means hopeless.
By means of staining with Sirius Red F3BA in a saturated picric acid solution, the collagen contents of rat livers with varying degrees of fibrosis have been measured quantitatively in fixed and sectioned material, using both histophotometry in situ and extraction of bound dye with colorimetric analysis. These findings have been correlated with chemical assays of the hydroxyproline content in homogenates from the same livers. It appears that a highly significant correlation exists between both section-based analysis methods and the hydroxyproline content, the Spearman-Rank correlation coefficients being virtually identical. For analysis of collagen accumulation in rat liver, both section-based methods seem to be useful and reliable, the extraction method giving the quickest results for large-scale screening, and the histophotometric method being more appropriate to take readings in selected areas. With human liver material, indications have been obtained for the existence of large sampling errors due to inhomogeneous distribution of collagen deposits. Using the extraction method, no significant changes could be observed in the volume density of collagen during postnatal growth from 1 week to 21 months in rat liver: only on the third day after birth was a higher value of collagen/total protein obtained, possibly due to a higher water content of the hepatocytes. Partial hepatectomy was found to have no influence at all on the collagen content of rat liver during the period of restorative growth or after it.
A simple, sensitive, and quantitative procedure is described for the measurement of collagen and protein content in tissue sections prepared from formalin-fixed paraffin-embedded samples. The method can detect as little as 5.7 micrograms of collagen per mg of protein. It is based on the selective binding of Sirius red F3BA and Fast green FCF to collagen and noncollagenous components, respectively, when the sections are stained with both dyes dissolved in aqueous saturated picric acid. Both dyes are eluted readily and simultaneously with NaOH-methanol and the absorbances obtained at 540 and 605 nm can be used to determine the amount of collagen and protein. The color equivalence of each dye was determined after destaining the sections and measuring the collagen content by hydroxyproline analysis and the amount of protein by the micro-Kjeldahl procedure. When several sections prepared from five rat tissues were analyzed first by the dye binding method and then by the chemical procedure, comparable results were obtained. This method could be of use in measuring collagen in tissue specimens and could be helpful in assessing the degree of fibrosis in tissue samples and in evaluating the effects of antifibrogenic drugs currently in use.
Wedged hepatic venous pressure recording and venography were investigated to assess histologic reflection of the stage of chronic liver disease. Forty-nine patients were studied. The four main groups and the means of the pressure gradients (WHVP - FHVP) with their 95% confidence limits were chronic active hepatitis (n = 12), 6 mm Hg (4.35-7.65); chronic hepatitis in transition to cirrhosis (n = 9), 10.3 mm Hg (6.6-14.1); and established cirrhosis (n = 8), 15.4 mm Hg (9.4-21.4); but only 3.4 mm Hg (2.2-4.6) in near-normal liver (n = 8). A pressure gradient of more than 5 mm Hg was always associated with significant liver disease on liver biopsy. In 25 patients venographies were assessed. Whereas patients with near-normal biopsy specimens had normal appearances, patients with more severe disease showed increasingly severe changes. The techniques applied should not replace liver biopsy. However, they provide relevant supplementary information, might have a place in follow-up studies to assess progression of disease, and occasionally reduce the need for liver biopsy.
Previous studies of picro-dye reactions demonstrated wide variations in the binding of different dyes. Picro-Sirius Red F3BA was recommended because it colors all collagens intensely and is suitable for polarization microscopy. Recent publications on quantitative uses of this stain were surprising. To obtain further information on the chemical mechanisms of dye binding by proteins, 94 sulfonated azo dyes were tested under the conditions of the picro-Sirius Red F3BA reaction. Reaction patterns varied widely, from failure to compete successfully with picrate ions for binding sites to strong coloration of all tissue structures. Only a few dyes stained collagen, reticulum fibers and basement membranes intensely and selectively. The reactivity of dyes was determined by their molecular configuration and the nature and position of substituents. Correlation with physico-chemical data showed that dye binding is due to non-ionic interactions, i.e. van der Waals and dispersion forces and hydrophobic bonding. Coulomb forces do not impart affinity - increasing sulfonation actually decreases dye uptake - but draw dyes within reach of non-ionic sites. Bound dyes form aggregates with additional dye ions; the aggregation number can range from 2 to many powers of 10. Clearly, dye binding by proteins is not stoichiometric.
Histopathologic monitoring of the liver is mandatory during methotrexate (MTX) treatment. Fibrosis is an important histologic feature of liver damage.
Our purpose was to supply an independent measure to histopathologic grading of hepatic changes in MTX-treated patients with psoriasis.
Forty-six liver biopsy specimens from 26 patients with psoriasis evaluated for or treated with MTX were histopathologically classified and their collagen content quantified by image analysis after staining with Sirius Red F3BA.
Fibrosis in normal liver biopsy specimens (controls) amounted to 0.9% +/- 0.1% and in patients with psoriasis varied between 9.3% +/- 1.4% and 24.0% +/- 4.9%. An effect of MTX on liver fibrosis was not discerned. No correlation was obtained between fibrosis and histologic grades, intake of alcohol, lean tissue mass, or age of the patient.
Two changes occurred in the psoriatic liver; the collagen content was increased at least tenfold when compared with controls, and significant heterogeneity in collagen content was present among patients (p < 0.001).
The evaluation of hepatic fibrosis on histological sections is of great interest for the staging and follow-up of chronic liver disease. Because no reliable scoring system is yet available, we have designed a semiquantitative scoring system in which the four main sites of fibrotic deposit--centrilobular vein, portal tract and perisinusoidal space, together with width and number of septa when present--are analyzed. These different items have been previously settled from comparison with morphometric measurements to evaluate surface density of total collagen performed on the same liver needle biopsy specimens stained with picro-sirius. The score has been tested on samples from 200 consecutive patients with various liver diseases and compared with the surface density of total collagen and Knodell scoring system. For observer variation study, the features by three independent pathologists were coded on 20 cases. There was a good interobserver (Kendall's tau-b = 0.75) and intraobserver (tau-B = 0.73) reproducibility. Each component of the fibrosis scoring system and total collagen surface density were significantly linearly related (one-way polynomial analysis, p < 10(-4); the correlation between semiquantitative scoring system and surface density of total collagen was 0.73 (p < 10(-5). Our semiquantitative scoring system, simple and reproducible, describes both liver architecture and fibrotic deposit. It is better related to morphometric measurement of fibrosis than each of its constituents or than the fibrosis item of the Knodell scoring system. It represents a reliable and convenient method for fibrosis evaluation, which is mandatory for clinical use.
The aim of this study was to evaluate the effect of interferon-alpha on liver fibrosis with an established quantitative histochemical method for determining collagen as a marker. 59 patients (31 men, 28 women; 47 +/- 14 yr) with chronic non-A, non-B hepatitis (92% with hepatitis C virus antibody) received subcutaneous injections of 3 or 1 MU recombinant interferon-alpha 2b or placebo thrice weekly for 24 wk. Needle-biopsy sections taken before and after interferon treatment were examined for histological evaluation and collagen quantitation. Values were compared with results obtained by means of morphometrical analysis of liver collagen and Knodell scoring histological index. The index of periportal and/or bridging necrosis was the only component of Knodell's histological score significantly decreased (p < 0.05) in patients treated with 3 MU interferon compared with placebo-treated controls. The fibrosis score was not significantly changed. In contrast, liver total collagen variations measured colorimetrically and morphometrically were significantly decreased in patients treated with 3 MU and 1 MU compared with the increase observed in the placebo-treated controls (p < 0.05). From these results, we conclude that a 6-mo course of 3 MU or 1 MU interferon-alpha 2b causes slight but nonetheless significant regression of liver fibrosis as assessed on the basis of quantitative estimation of liver collagen, irrespective of other response criteria, whereas progression of liver fibrosis can be observed in the absence of treatment.
To clarify the characteristics of fibrosis developed in the process from chronic hepatitis C to cirrhosis, a morphometric analysis of liver biopsy samples was conducted on 25 chronic hepatitis C patients and 20 chronic hepatitis B patients (controls). Hepatitis C patients were followed up for 3 to 23 years. The mean number of liver biopsies performed on these patients was 3.8. Each biopsy was evaluated for the degree of fibrosis by using two methods: a semiquantitative method with a staging scoring system, and morphometry using a computed image analysis system. A significant correlation was observed between the Stage and the area of fibrosis (AF = the ratio of the area of fibrosis to that of the entire tissue specimen). The AF in cirrhosis was significantly higher in hepatitis C patients than in hepatitis B patients. The ratio of AF in the last biopsy sample to AF in the initial biopsy sample was significantly higher in hepatitis C patients than in hepatitis B patients. Evolution from chronic hepatitis C to cirrhosis occurred more frequently in patients aged > or = 50 years, and this time period was 1.8 times shorter than that in patients aged < 50 years. AF in the initial biopsy related significantly to the period of evolution from chronic hepatitis C to cirrhosis. AF in the initial biopsy might be a predictive factor for prognosis.
The aims of the study were to determine, in patients with chronic hepatitis C treated with alpha interferon: (i) changes in the morphometric evaluation of liver fibrosis at the end of treatment and 6, 12 and 18 months after treatment; (ii) the predictive value of histologic lesions for the response to treatment, in particular the predictive value of morphometric evaluation of liver fibrosis.
Seventy patients with chronic hepatitis C who participated in two trials of recombinant interferon alpha 2b treatment were studied. Liver specimens were obtained before and at the end of treatment and 6, 12 or 18 months later. Histologic lesions were assessed according to the Knodell system. Quantitative study of total fibrosis and of Disse space collagen was done by the computerized automated morphometric method.
A significant decrease in morphometric Disse space collagen was observed at the end of treatment and 6 months later. This decrease was also observed, although it was not significant, 12 and 18 months after treatment. There was no relationship between this decrease and the biochemical and virological responses or the dose of interferon. The pretreatment Knodell activity score, but not the morphometric evaluation of fibrosis, was a significant predictor of sustained response.
A decrease in Disse space collagen, as assessed by the sensitive morphometric method, was observed at the end of and 6 months after treatment. This observation is consistent with an anti-fibrogenetic effect of alpha interferon. Mild or moderate histologic activity was associated with a sustained response to therapy.
The proliferation and differentiation of stellate (Ito, or fat-storing) cells into myofibroblast-like cells is responsible for the development of liver fibrosis. Using computer image analysis, we evaluated the changes of alpha smooth muscle actin-positive stellate cells and liver fibrosis after interferon-alpha or -beta (IFN-alpha, beta) therapy in patients with chronic hepatitis C.
Patients with chronic hepatitis C were treated with IFN-alpha or -beta and were divided into three groups on the basis of clinical criteria; a complete responder group (CR, 18 of 51), a partial responder group (PR, 17 to 51), and a nonresponder group (NR, 16 of 51). Liver fibrosis was assessed from specimens stained with Sirius red and was quantitated by computer image analysis. We also evaluated alpha-smooth muscle actin expression in the liver before and after IFN therapy by a semiquantitative scoring method (the alpha-smooth muscle actin index).
Before IFN therapy, a large number of stellate cells expressing a-smooth muscle actin were present in the liver biopsy specimens. There was a significant correlation (r = 0.699, p < 0.05) between the change in the percent area of fibrosis and the alpha-smooth muscle actin index before and after IFN therapy in all groups. The complete responder group also showed a significant reduction of a-smooth muscle actin-expressing cells that was correlated with the reduction of serum ALT (r = 0.686, p < 0.05).
These results suggest a-smooth muscle actin-expressing cells are responsible for liver fibrosis, and the elimination of factors stimulating matrix synthesis (e.g., hepatitis virus) may decrease liver fibrosis.
The effect of interferon on the reduction of liver fibrosis is controversial. We aimed to compare semiquantitative methods with a quantitative digital image analysis system to assess liver fibrosis in biopsies from patients with chronic hepatitis and different responses to interferon.
We studied 98 liver biopsies with chronic hepatitis C before and after recombinant interferon alfa-2 treatment, using conventional histological assessment, grading of histological activity, scoring/staging of fibrosis (Knodell and Scheuer), and quantification of fibrosis with image analysis (FibroQuant).
Sustained-responders to interferon showed a significant reduction in histological lesions and in their Knodell and Scheuer activity indexes. The semiquantitative systems showed no reduction in fibrosis. The FibroQuant application showed a significant reduction in porto-periportal and septal areas among sustained-responders (P < 0.001) and non-responders (P < 0.05), and in porto-periportal and septal fibrosis areas only in sustained-responders (P < 0.001), whereas the percentage of fibrosis increased in non-responders (P < 0.001).
The Scheuer system is useful for the daily evaluation of fibrosis, but the FibroQuant application provides more objective data on the anti-fibrogenic effects of interferon, which include a reduction in the porto-periportal area in sustained-responders and non-responders, accompanied by a reduction in the area of fibrosis only when the viral replication has ceased.
Background/Methods: In order to evaluate the progression of liver fibrosis associated with Hepatitis C virus (HCV) infection, two liver biopsy specimens obtained prior to antiviral therapy from 98 patients with HCV were scored and evaluated using statistical methods appropriate for ordered categorical data.
Results/conclusions: Greater progression of fibrosis was seen with increasing time between the biopsies. Likewise, the change in fibrosis score was significantly more pronounced in the 11 patients whose first biopsy was obtained within the first year after acquiring HCV. A multivariate logistic regression analysis of possible explanatory factors for the fibrosis outcome showed that interface hepatitis in both biopsies, the time interval between the biopsies, and age at first biopsy were associated with change in the fibrosis score. In addition we found that higher age at the time of infection was associated with development of cirrhosis, that moderate intake of alcohol was associated with fibrosis progression, and that an inflammatory response in the form of moderate interface hepatitis in the first biopsy was not necessarily associated with greater progression of fibrosis if the second biopsy showed mild interface hepatitis. However, having moderate interface hepatitis later in the course of infection as reflected by the second biopsy may be detrimental. If moderate interface hepatitis early in the course of the disease is followed by less interface hepatitis later there is less fibrosis; and if moderate interface hepatitis persists, there is more fibrosis eventually.
Objective methods are needed to quantitatively assess the burden of fibrous tissue in liver biopsy specimens and its changes after treatment. The aim of this study was to assess the validity of a computer-assisted morphometric method in the evaluation of liver fibrosis in patients with chronic hepatitis C. Sixty-nine liver biopsy specimens stained with Sirius red were evaluated by two independent observers with a computer-assisted morphometric method to measure the percentage of fibrous tissue in the optic fields examined (fibrosis ratio). Furthermore, 11 pairs of liver biopsy specimens obtained before and after treatment from patients with chronic hepatitis C were evaluated with morphometry by two independent observers in order to assess in which direction fibrosis changed. In the 69 patients, the correlation of the morphometry-measured fibrosis ratio pairs by the two observers was high (r = 0.781). However, the differences between paired values were large, reaching +/- 5% in 95% of instances. The fibrosis ratios observed with morphometry by the two examiners correlated poorly with the Ishak's staging score. The two examiners agreed in 10 out of 11 instances in judging in which direction fibrosis had changed. In conclusion, using our present technique of computer-assisted morphometry, the quantitative assessment of the percentage extension of fibrous tissue was not sufficiently accurate. However, computer-assisted morphometry proved to be useful when evaluating the direction of fibrous changes in pairs of liver biopsy specimens from patients with chronic hepatitis C before and after treatment.
Fibrosis is a common endpoint of clinical trials in chronic hepatitis C, and liver biopsy remains the gold standard for fibrosis evaluation. However, variability in the distribution of fibrosis within the liver is a potential limitation. Our aim was to assess the heterogeneity of liver fibrosis and its influence on the accuracy of assessment of fibrosis with liver biopsy. Surgical samples of livers from patients with chronic hepatitis C were studied. Measurement of fibrosis was performed on the whole section by using both image analysis and METAVIR score (reference value). From the digitized image of the whole section, virtual biopsy specimens of increasing length were produced. Fibrosis was assessed independently on each individual virtual biopsy specimen. Results were compared with the reference value according to the length of the biopsy specimen. By using image analysis, the coefficient of variation of fibrosis measurement with 15-mm long biopsy specimens was 55%; and for biopsy specimens of 25-mm length it was 45%. By using the METAVIR scoring system, 65% of biopsies 15 mm in length were categorized correctly according to the reference value. This increased to 75% for a 25-mm liver biopsy specimen without any substantial benefit for longer biopsy specimens. Sampling variability of fibrosis is a significant limitation in the assessment of fibrosis with liver biopsy. In conclusion, this study suggests that a length of at least 25 mm is necessary to evaluate fibrosis accurately with a semiquantitative score. Sampling variability becomes a major limitation when using more accurate methods such as automated image analysis.
Accurate histological assessment of liver fibrosis is essential in the management of chronic hepatitis B (CHB). Although semi-quantitative scoring systems describe well the pathological patterns of hepatic structure, they produce fibrosis evaluation that is not very precise. Image analysis or morphometry has the theoretical advantage of providing truly quantitative data.
The present study aimed at validating a new image analysis system, Bioquant Nova Prime, in estimating collagen content in liver biopsy samples from patients with CHB. The biopsies were stained with picrosirius red and the areas of collagen were measured. The results were correlated with laboratory parameters and Ishak modified histological scores. Discriminative reliability of morphometry was determined using receiver operating characteristics (ROC) analysis.
There was excellent interobserver agreement (r=0.84-0.94, P<0.01) in the morphometric analysis. Significant correlations between the quantitative morphometric data and the semi-quantitative score (Spearman's r=0.68-0.78, P<0.001) were also demonstrated. Excellent discriminative power of morphometry in differentiating mild from advanced fibrosis and cirrhosis from absence of cirrhosis was shown by the ROC analysis.
Our results validated the use of Bioquant Nova Prime in estimating collagen content in liver biopsies. We showed that morphometry is a sensitive method of liver fibrosis quantification in CHB and complements semi-quantitative histological scoring system. This tool, with its reliable intraassay variability, could be of special value in assessing histological response to treatment after anti-viral or anti-fibrotic therapy.
Recurrent hepatitis C is a frequent event in liver transplantation (LT). Serial liver biopsies remain the best way of monitoring disease progression. Due to the limitations of a liver biopsy, there is an interest in developing noninvasive markers of liver fibrosis. While several models for predicting fibrosis have been constructed in patients who have not undergone transplantation, these are lacking in the transplant population. The aim of this study was to construct one simple model based on routine laboratory data to predict fibrosis in hepatitis C virus (HCV)-infected LT patients. A total of 510 yearly protocol liver biopsies performed in 188 LT patients (67% male; median age 54 years) were divided into 2 groups: training set (n = 414) and validation set (n = 96). Laboratory variables at time of biopsies were recorded. Multivariate analysis identified 4 variables as independent predictors of fibrosis: prothrombin time (PT), albumin/total protein ratio, aspartate aminotransferase (AST), and time since LT. The area under the receiver operating characteristic (ROC) curves (AUCs) were 0.80 and 0.84 for the training and the validation set, respectively. In the training set, using a cutoff of 0.2, the model had a sensitivity, specificity, positive predictive value, and negative predictive value of 74%, 69%, 42%, and 90%, respectively, to differentiate significant (bridging fibrosis and cirrhosis) from mild fibrosis (none or portal). In the validation cohort, these values increased to 87%, 71%, 49%, and 95%, respectively. In conclusion, in the LT setting, a simple fibrosis index is useful to select HCV-infected patients with a very low risk of significant fibrosis in whom protocol liver biopsies may be avoided.
While the definitive diagnosis of cirrhosis is histological, it is the degree of portal hypertension, as determined by the hepatic venous pressure gradient (HVPG), that is an important determinant of the severity of cirrhosis. An HVPG > or =10 mmHg (termed clinically significant portal hypertension or CSPH) is predictive of the development of complications of cirrhosis, including death. This study aimed to determine the relationship between specific histological parameters and HVPG in cirrhosis.
Forty-three patients with biopsy-proven cirrhosis and HVPG measurements within 6 months of the biopsy were included in the study. The following parameters were scored semiquantitatively and without knowledge of HVPG results: sinusoidal fibrosis, septal thickness, loss of portal tracts and central veins, nodule size, inflammation, steatosis, and iron.
Septal thickness (p=0.03), small nodularity (p=0.003), loss of portal tracts (p=0.01), inflammation (p=0.04) and alcoholic etiology (p=0.01) correlated with the presence of CSPH. However, small nodularity and septal thickness were the only parameters independently predictive of CSPH (r=0.658, p<0.05).
We describe a subclassification of histological cirrhosis based on the severity of portal hypertension that consists of a combination of nodule size and septal thickness, with small nodularity and thick septa being independent predictors of the presence of CSPH.
The necessity of liver biopsy for staging fibrosis and its quantification in patients with chronic hepatitis C (CHC) remains controversial. Semiquantitative scoring of fibrosis is considered more subjective and less objective than digital quantification by image analysis. However, measurement of fibrosis using digital image analysis is thought to be less reliable in determining early stage fibrosis as compared with advanced fibrosis or cirrhosis. Our aims were to correlate all Ishak stages of fibrosis (0-6) with fibrosis percentage (%) using computerized digital image analysis, and thereby seek to improve discrimination between varying levels of liver fibrosis.
Fibrosis % data were obtained by image analysis on 164 trichrome-stained liver biopsies from untreated patients with CHC, representing all Ishak stages of fibrosis.
Digital analysis of fibrosis % was highly correlated with Ishak scores of fibrosis (Kendall's tau-beta=0.86, P<0.001). Receiver-operator characteristic curves showed reliable discriminative capability of our digital image measurement of fibrosis when compared with semiquantitative assessments of fibrosis. Excellent interobserver reliability was found.
Recent advances in digital quantification of fibrosis have resulted in improved discrimination between the varying stages of liver fibrosis, including mild fibrosis. This method is reproducible, can detect early as well as advanced fibrosis or cirrhosis, may prove to be the best assessment of mild fibrosis, and may be more precise than semiquantitative estimation of changes for monitoring fibrosis progression or regression during clinical therapeutic trials.
Liver biopsy is essential in the follow-up of HCV-infected liver transplant recipients. The aim of this study was to prospectively compare percutaneous (PLB) versus transjugular liver biopsy (TLB) in the assessment of liver damage. We also explored the diagnostic value of hepatic venous pressure gradient (HVPG) to identify patients at risk of severe HCV disease recurrence after liver transplantation (LT). One hundred sixteen paired PLB and TLB (with HVPG measurement) were performed 3 or 12 months after LT in 80 patients. Concordance for necroinflammation and fibrosis was fair or good, particularly 1 year after LT (kappa > or = 0.6). At this point, a significant positive association was seen between the median HVPG and the fibrosis stage (2.5 mm Hg for F0; 5 mm Hg for F1, 6 mm Hg for F2, and 11.5 mm Hg for F3; Kruscal-Wallis < 0.001). Despite this strong association, portal hypertension (HVPG > or = 6 mm Hg) was detected in 1 (5%) of 22, 4 (16%) of 25, and 6 (60%) of 10 patients with fibrosis stages 0, 1, and 2, respectively. After a median follow-up of 38 months, clinical decompensation occurred in 15 (19%) of 80 patients. Although the presence of significant fibrosis (F2-F3) 1 year after transplantation was good to predict clinical decompensation (AUC: 0.80), an HVPG of 6 mm Hg or greater was extremely accurate at identifying patients at risk of disease progression (AUC: 0.96). In conclusion, HVPG determination is a valuable tool for follow-up in patients with HCV recurrence after LT.
One of the most important aspects of the histopathological assessment of liver biopsies in the setting of chronic liver disease is determination of the degree of fibrosis and architectural change. Most of the work in this regard has been concerned with chronic viral hepatitis. This article attempts to assess critically our current and historical biopsy practice, from subjective fibrosis scoring systems to biopsy sample size; and the appropriate use of the data that scoring systems
generate in the research and clinical setting. An understanding of the limitations of each of the components of the fibrosis assessment process can help to devise appropriate protocols to ensure that the information obtained is optimised, and its degree of reliability appreciated. It is only from this starting point that recently promulgated antifibrotic medications and ‘‘non-invasive’’ liver fibrosis assessment techniques can be evaluated properly.<br /