Fibroscan and Low-Density Lipoprotein Versus Non-invasive Markers (APRI test and FIB-4) As Determinants of Severe Liver Fibrosis in Egyptian Diabetic Patients With Non-Alcoholic Fatty Liver Disease.

INTRODUCTION

Non-alcoholic fatty liver disease (NAFLD) is one of the most frequent causes of liver disease around the world. It is expected to overcome alcoholic liver disease as the most frequent reason for end-stage hepatic disease in the next ten years.¹

It includes a wide range of clinical and histological signs,  starting from simple steatosis to steatohepatitis, fibrosis, and cirrhosis. ²

NAFLD is associated with an abnormal buildup of fat in the liver that is not caused by excessive alcohol usage, viral hepatitis, or drugs which be able to cause fatty liver. ³

 There are Important risk factors for NAFLD as type 2 diabetes (T2DM), hypertension, hypertriglyceridemia, hyperlipidemia and obesity. ⁴

The liver is a major cause of insulin resistance which is   a key part of how type 2diabetes develops and how it gets worse. NAFLD is mostly happen if you have diabetes, and about 70 percent of people with T2DM have NAFLD. ⁵

A leading reason for chronic liver disease is NAFLD which frequently has severe effects as decompensated hepatic cirrhosis and hepatocellular cancer. ⁶

Only 24% of people with high cholesterol have NAFLD. This happens more often with persons who have hypertriglyceridemia and mixed hyperlipidemia, where the rates are 50% and 60%, respectively. Hypertriglyceridemia, low HDL-C, more dense and small LDL-C are all linked to NAFLD. About 60% to 70% of people with NAFLD also have dyslipidemia. ⁷

Abdominal ultrasonography, measurement of the lipid profile and liver functions, excluding the presence of hepatitis B and C ,alcohol poisoning, and testing for insulin resistance (IR) are all required  for primary assessment  of early stages of fatty liver. ⁸

liver biopsy is the best way to find out if someone has NAFLD, although it occasionally causes complications, including bleeding, bile leakage, infections, and other potentially catastrophic problems. ⁹

New non-invasive laboratory and radiographic diagnostic methods have developed during the previous ten years to avoid  the problems of  liver biopsies when finding out  hepatic fibrosis in NAFLD. ¹⁰

Numerous researches had indicated the use of imaging and serological markers as non-invasive techniques for assessing fibrosis in NAFLD. ¹¹

Recent research demonstrates that the ultrasound-based controlled attenuation parameter value applied  in the TE method may be used to predict the extent of steatosis in NAFLD patients. ¹⁰

Aim of the study to evaluate the role of non-invasive scores (APRI score  and FIB-4), fibroscan and low-density lipoprotein in predicting Egyptian patients with NAFLD who have severe liver fibrosis.

PATIENTS AND METHODS

A prospective cohort study  was carried out  in the heptogastroentrology and infectious disease Al-Hussien University  Hospital  and The National Hepatology and Tropical Research Institute (NHTMRI). Ninty patients attended  the outpatient clinic who had NAFLD over a 3-years period

FIB-4            = age (year) × AST (IU/L)/platelet count (×10⁹/L) × √ALT (IU/L). ¹²

APRI Score = (AST/Upper Limit Normal AST) x 100] / Platelets (10⁹/L). ¹³

Inclusions Criteria: Age (18-70 years), gender (male or female), diabetes mellitus (fasting blood sugar levels more than 126 g/dL), nondiabetic patients, patients identified as having NAFLD based on abdominal ultrasound examination (Hyperechoic liver, in which the liver echo-texture was brighter than that of the kidney, with indistinct vascular boundaries and a significant decrease in ultrasound signal), and cases who agreed to take part in the research.

Exclusions Criteria: Patients with alcoholic liver disease, patients taking Hepatotoxic drugs like methotrexate and corticosteroids, patients with advanced hepatic disease, cardiac failure, and hepatic congestion, patients patients that could not do a fibroscan examination due to a very high body mass index (BMI).and other causes of liver disease as viral, metabolic, autoimmune diseases

Ethical Considerations:  before enrollment, each participant gave their signed, informed permission. Written consents were approved by the ethical committee of Al Hussein Hepatology , Gastroenterology department and the National Hepatology and Tropical Medicine Research Institute (NHTMRI).

Methods

Initial Assessment: The outpatient clinic was the first place where all patients were checked. A comprehensive investigation and evaluation were conducted.This included:

History: Name, age, gender, place of residence, employment, marital status, certain behaviors of medical and surgical relevance are all examples of demographic information.

Examination: General examination for vital signs are heart rate, respiratory rate, blood pressure, and temperature. other systems examination, local examination of the liver was done to show site, size, surface, border, and presence of lymph node metastases. Physical examination included: BMI: Weight (Kg) / Height (m)2 (Normal: <25) waist Circumference, which is calculated horizontally at the level of the navel without compressing the skin (Normal: Males 78:94 cm, Females 64:80 cm).

Laboratory investigations: Complete blood count (CBC) is including total leucocytic count ( Total and Differential), red blood cells (RBCs), hemoglobin (Hb), and platelet count, among the laboratory tests that were performed. Bilirubin (total and direct), total proteins, serum albumin, alanine transferase (ALT), aspartate transferase (AST), and alkaline phosphatase (ALP) are all included in the list of liver function tests (LFTs), kidney function tests (KFTs), such as serum urea and creatinine. Prothrombin time (PT) and the International Normalization Ratio are two components of the coagulation profile (INR). Lipid profile is including Serum cholesterol, triglycerides and low-density lipoproteins (LDL), viral markers like hepatitis B surface antigen (HBsAg) and hepatitis C antibodies (HCV Ab).

Abdominal Ultrasonography: Equipment: Philips Envisor C HD

Fibroscan:

Study Procedures: (Fibro Scan 502, Echosens, and Paris, France)

The Fibroscan 502 touch has two probes, M+ and XL+, and can be used to measure LSM and CAP at any participating medical center (TBRI). Each study was conducted by a devoted study coordinator who followed the manufacturer set of rules (Fibro Scan 502, Echosens, and Paris, France).

Statistical analysis: Statistical Package for the Social Sciences (SPSS) version 22 for Microsoft Windows was used to code, process, and analyze the data (IBM SPSS Inc, Chicago, IL, USA). The normality of the data distribution was determined using the Shapiro-Wilk test. We utilized frequency counts and relative percentages to demonstrate qualitative data. Use the chi-square test to discover differences between two or more sets of qualitative variables (2). A ROC curve is utilized to determine a cutoff for a certain outcome. The quantitative data were reported as mean ± standard deviation (Standard deviation). Using the independent samples t-test, two sets of normally distributed variables with independent distributions were compared (parametric data). P values below 0.05 were considered significant.  

RESULTS

This study included 90 cases divided into (50 Diabetic and 40 non Diabetic) with NAFLD. As regards age, the mean age of all studied patients was 41.878 ±8.828 years. As regards sex, there were 28 males(31.11%) and 62 females(68.89%) in all the studied patients

Table 1: Description of symptoms of all studied patients

This table shows that : 10% of patients with NAFLD are asymptomatic, 40% complaining of right quadrant pain,20% complaining of fatigue,15%complaining of malaise, and 5% have nausea

Table 2:        this table shows that: there was non significant comparison between two groups as regrard clinical symptoms(P-value=0.478)

Table 3:  baseline demographic data of the whole studied patients      

this table shows that : there was significant increase in age in diabetic patients (p value 0.002)

Table 4: Comparison between  diabetic and non-diabetic patients  as regard lab investigations

This table shows: There was significantly decrease LDL in diabetic patients(p value <0.001)and significantly high AST in diabetic patients (p value <0.001)

Table 5: Comparison of APRI score in diabetic and nondiabetic patients

This table shows: There was non significant comparison between two groups as regard APRI titre (P-value=0.481) and APRI grades(P-value=0.557)

Table 6: Comparison of Fib-4 in diabetic and nondiabetic patients

This table shows: there was a significant comparison between two groups as regard FIB-4 titre (P-value =0.022 )and non significant comparison between two groups as regard FIB-4 grades (p =0.335)

Table 7: Comparison of Fibrosis by LSM and fibrosis grades in diabetic and nondiabetic patients

This table shows: there was a significant comparison between two groups as regard Fibrosis LSM  (P-value <0.001)and fibrosis grades (P-value <0.001)

Table 8: Relation  between APRI grades and (FIB-4grades, gender, BMI Group, fibrosis grades, and steatosis grades)

This table shows: there was a significant comparison between two groups as regard(fib-4 grades (p value<0.001) and fibrosis grades (p value=0.002) and non significant comparison between two groups  as regard (gender ,BMI  group and steatosis grades )

Table 9: Relation between FIB-4 grades and (gender, fibrosis grades, and steatosis grades)

This table shows: there was statistically significant comparison between two groups as regard fibrosis grades ((P-value<0.001), and There was non significant comparison between FIB-4 grades as regard (Gender and Steatosis grades)       

Table 10: Correlation between APRI score and (FIB-4, fibrosis LSM and steatosis and lab tests) and Correlation between Fib-4 and (fibrosis LSM, steatosis CAP and lab tests)

This table shows: there was a significant positive correlation  between APRI as regard (FIB-4, fibrosis LSM, ASTand  ALT) and significant  negative correlation  as regard (platelet and FBS) and a significant positive correlation between  FIB-4 as regard (fibrosis LSM, age and AST) and significant  negative correlation  as regard  (platelet and urea)

Fig. 1: receiving operating characteristic curve for apri score in diabetic and non diabetic patients (Cutoff >0.5 ) Sens.= 50 Spec.= 75 Accuracy=58.2%

Fig.2: receiving operating characteristic curve for FIB-4 in diabetic and non diabetic patients (Cutoff >2 ) Sens.= 42 Spec.= 85 Accuracy=64.4%

Fig.3: receiving operating characteristic curve for  Fibrosis LSM in diabetic and non diabetic patients                     (Cutoff >0.5 ) Sens.= 86 Spec.= 72.5 Accuracy=83.1%