Canadian liver journal最新文献

The toxic renal accumulation of bile pigment sparked clinical intrigue almost a century ago. More recently, however, the identification of bile casts within renal tubules in patients with liver dysfunction has been largely overlooked. We have reviewed the literature, including natural history, pathophysiology, and potential treatment of bile cast nephropathy (BCN). We report two cases of acute kidney injury (AKI) associated with acute-on-chronic liver failure in which prolonged hyperbilirubinemia and bile cast identification on renal biopsy evoked the diagnosis of BCN.

Background: With the rate of non-alcoholic fatty liver disease (NAFLD) on the rise, the necessity of identifying patients at risk of cirrhosis and its complications is becoming ever more important. Liver biopsy remains the gold standard for assessing fibrosis, although costs, risks, and availability prohibit its widespread use with at-risk patients. Transient elastography has proven to be a non-invasive and accurate way of assessing fibrosis, although the availability of this modality is often limited in primary care settings. The Fibrosis-4 (FIB-4) and Non-Alcoholic Fatty Liver Disease Fibrosis Score (NFS) are scoring systems that incorporate commonly measured lab parameters and BMI to predict fibrosis.

Method: In this study, we compared FIB-4 and NFS scores with transient elastography scores to assess the accuracy of these inexpensive and readily available scoring systems in detecting fibrosis.

Results: Using an NFS score cut-off of -1.455 and a FibroScan score cut-off of ≥8.7 kPa, the NFS score had a negative predictive value of 94.1%. Using a FibroScan score cut-off of ≥8.7 kPa, the FIB-4 score had a negative predictive value of 91.6%.

Conclusion: The NFS and FIB-4 are non-invasive, inexpensive scoring systems that have high negative predictive value for fibrosis compared with transient elastography scores. These findings suggest that the NFS and FIB-4 can provide adequate reassurance to rule out fibrosis in patients with NAFLD and can be used with select patients to circumvent the need for transient elastography or liver biopsy.

Background: The Canadian Liver Foundation recommends routine hepatitis C (HCV) screening for Canadians born between 1945 and 1975. This study aimed to determine the feasibility and outcomes of targeted birth cohort HCV screening during routine outpatient endoscopic procedures in a tertiary care hospital.

Methods: We conducted a prospective cohort study of individuals born between 1945 and 1975 who attended outpatient endoscopy procedures at Kingston Health Sciences Centre from 2017 to 2019. Patients who consented received the HCV OraSure point-of-care test for the HCV antibody (HCV Ab). If positive, serum for HCV RNA was sent, and patients were linked to care with a hepatologist.

Results: 2,179 patients met birth cohort criteria for HCV screening. Of those, 1,079 (49.5%) were approached for study inclusion, and 160 (15.0%) declined participation, leaving 912 patients who provided consent. The median age was 62 years (IQR 55-67). Overall, 6/912 (0.7%) of participants were HCV Ab positive and 5/912 (0.6%) were HCV RNA positive. Four were linked to care for consideration of direct-acting antiviral (DAA) therapy, 3 received DAA treatment, and all 3 achieved sustained virologic response (SVR).

Conclusions: Birth cohort screening for HCV in an outpatient endoscopy unit identified an HCV prevalence similar to population estimates. In this model, however, 50% of eligible patients were not approached for screening. Linkage to care for assessment of treatment was high at 80%, and of those who received therapy, all achieved SVR. These results suggest this cohort is a suitable population for HCV screening; however, we need strategies to increase recruitment of all eligible individuals.

A 49-year-old woman with no inflammatory bowel disease history presented to our clinic with abnormal liver function tests and right upper quadrant abdominal pain. Blood tests revealed a mixed pattern of liver injury. Abdominal magnetic resonance imaging demonstrated hepatomegaly with periportal edema and hyper-enhancing bile ducts without any sign of biliary obstruction or stricturing. Screening for viral hepatitis and autoimmune liver diseases was negative. An elevated immunoglobulin G (IgG) level suggested the possibility of autoimmune hepatitis (AIH), and a biopsy confirmed the presence of severe interface hepatitis with necrotic areas and focal lymphoid nodular formation. IgG4 staining revealed marked IgG4-positive plasma cell infiltration. A diagnosis of IgG4-associated seronegative AIH was made, and the patient was started on prednisone and azathioprine, with rapid resolution of the enzyme abnormalities. This clinical vignette highlights the potential challenges in establishing a diagnosis of IgG4-associated AIH and cholangitis, as demonstrated by the importance of confirmatory histopathology. Clinicians should maintain a high index of suspicion when confronted with a mixed pattern of liver injury with elevated immunoglobulins but seronegative autoimmune markers.

Background: In Canada, non-alcoholic fatty liver disease (NAFLD) is the most frequently occurring liver disease, affecting one in four Canadians. NAFLD can in turn evolve into non-alcoholic steatohepatitis (NASH) and cirrhosis. No study in Canada has investigated knowledge of NAFLD among physicians.

Methods: Primary care physicians (PCPs); specialists in internal medicine, gastroenterology, and hepatology; and hepatology nurses who were members of the College of Family Physicians of Canada, Canadian Association for the Study of the Liver, or Canadian Association of Hepatology Nurses were invited to participate in this web-based survey.

Results: Of 650 invited physicians and nurses, 214 (33%) responded and 171 (26%) completed the whole survey. Overall, 51% of the respondents were PCPs, 38% were specialists, and 11% were nurses. Of these, 58% of PCPs, 28% of specialists, and 39% of nurses responded that they were only somewhat familiar or unfamiliar with NAFLD. Moreover, 53% of PCPs, 20% of specialists, and 35% of nurses thought the prevalence of NAFLD in Canada was 15% or less. Also, 42% of respondents thought that NASH could be diagnosed by imaging or blood tests. Finally, more than 40% of PCPs, 22% of specialists, and 33% of nurses thought that metformin and statin were treatments for NASH.

Conclusions: This survey shows that a significant proportion of Canadian physicians and nurses managing patients with NAFLD are not very familiar with the disease. This study emphasizes the need for further provider education, national practice guidelines, and improved treatment options.